Screening-Guided Spironolactone Treatment of Subclinical Left Ventricular Dysfunction for Heart Failure Prevention in At-risk Patients

BACKGROUND

Subclinical left ventricular dysfunction (LVD) is a prelude to symptomatic heart failure (HF). We hypothesised that screening-guided treatment with spironolactone would prevent incident HF in at-risk patients.

METHODS

We randomised asymptomatic, community-dwelling subjects aged ≥65 years old, with at least one non-ischaemic HF risk factor (hypertension, type 2 diabetes mellitus or obesity) to echocardiography-guided therapy or usual care. Spironolactone therapy was triggered by the detection of subclinical LVD (GLS ≤16% or diastolic abnormalities (at least one of E/e'>15, E/e' >10 with left atrial enlargement [LAE] or impaired relaxation [E/A <0.8, IR], LAE with IR), or borderline GLS (17%) with IR or borderline GLS with LAE. The primary outcome was incident HF at 24 months. Secondary outcomes were change in 6-minute walk test (6MWT) and change in LV function.

RESULTS

LVD was identified in 161 (46%) of 349 participants (age 70 years [68-73], 201 (58%) women). The trial was stopped because of a 55% rate of spironolactone discontinuation, due primarily to decline in renal function. Incident HF developed in 11 (3.5%) of 310 participants completing follow-up, with no difference between usual care and intervention (4 [2.5%] vs. 7 [4.7%], p=0.29), decline in 6MWT distance (p=0.28), persistent or new LVD (p=0.58), nor change in GLS with intervention (p=0.15). A per-protocol analysis of 131 patients with baseline LVD and a follow-up echocardiogram, showed resolution of LVD with spironolactone therapy (61% vs 33%, p=0.01).

CONCLUSION

The study was underpowered to determine whether screening-guided spironolactone therapy reduced incident HF because spironolactone was frequently discontinued due to renal function criteria. However, LVD resolved in more patients treated with spironolactone than in untreated patients. Future trials should use less conservative renal criteria for spironolactone discontinuation.

The impact of intensive care in a private hospital on patients aged 80 and over: health-related quality of life, functional status and burden versus benefit

BACKGROUND

Greater numbers of persons aged over 80 years are admitted to intensive care units (ICU) compared with 15 years ago. Outcomes other than death such as physical dependence and cognitive impairment and treatment burden are important to older people.

AIMS

The aims of this study were to determine the long-term outcomes of functional impairment, health-related quality of life (HRQoL) and the self-reported burden of treatment in a sample of patients aged 80 years and above admitted to ICU. Half of the cohort were admitted for elective cardiac surgery, the rest for non-cardiac surgery and medical conditions.

METHODS

In this longitudinal cohort study, in a tertiary level ICU, we measured HRQoL using the SF-36 and functional status using the modified Barthel Index at several time points over a 2-year follow-up period. We also assessed treatment burden by asking participants whether they thought the episode of care was worthwhile.

RESULTS

A total of 348 patients was recruited into the study. One-fifth of the cohort had died by the 2-year follow-up data collection point. There was an improvement in physical functioning in the cardiac surgery group at 6 months which was not sustained. There was no change in HRQoL at 2 years in either group. The majority valued the episode of care.

CONCLUSION

We demonstrated that HRQoL and previous lifestyle is preserved in the majority following ICU admission, associated with a high level of patient valuation of the episode of care.

Team approach to teaching participatory group process involving natural resources and agriculture

Contemporary issues are defined by people who share diverse and often strongly defended views about the topic. In Oregon, citizens are increasingly being asked or expected to participate in complex decisions that require a consensus. Rather than teach one professor's synthesis of a contemporary natural resource issue, faculty from six disciplines coach group process, interactive learning skills, and systems thinking as a way to address complex issues from multiple perspectives. Students learn by grappling with a natural resource issue of their choice within groups based on a diversity among majors, degree status, and gender. Students define situation (S), brainstorm new or different targets (T), and analyze two or more pathways (P), using an STP learning and action process. Exploring potential pathways involves defining possible consequences, stakeholder views, feasibility (ecological, social, economic, and political), and planning that includes expected behavior of the improved system over time. Students present their topics and improvements showing systemic relationships, systematic analysis, and integration of scientific facts and secondary data at midterm and during finals. Reflective learning is fostered throughout the course with prompted questions in a journal notebook. Grading criteria promote meaningful inquiry and participation in group process combined with integration of scientific facts and reflective learning.

Lengthy hospitalization associated with vertebral fractures despite control for comorbid conditions

This study established whether length of hospital stay (LOS) in Canadians 50 years and older is attributable to their vertebral fractures versus comorbid conditions. The study used a case-control design and data in the Canadian Institute for Health Information (CIHI) database on hospital discharges in Ontario, Alberta, and British Columbia between April 1, 1996 and March 31, 1997. Patients with vertebral fractures were identified by International Classification of Diseases (ICD-9) codes. LOS constituted the dependent measure in a multivariate linear regression that calculated the independent contributions to LOS by vertebral fractures while controlling for: age, gender, province, discharged deceased, hip fractures, all other fractures, motor vehicle accidents, all other injuries, and the major disorder classifications in ICD-9. Mean LOS for all patients admitted for vertebral fractures was 10.1 days. LOS attributed solely to vertebral fractures was 4.8 days based on a 50-year-old woman with no comorbid conditions, and 6.1 days based on a 75-year-old woman. Of 18 health conditions, vertebral fractures were among the top 3 in accounting for LOS, along with hip fractures and mental disorders which accounted for 5.9 days and 6.1 days in a 50-year-old woman. Among patients admitted for other problems, comorbid vertebral fractures added 2.1 days. These findings indicate that hospital stays for vertebral fractures are lengthy despite control for comorbidity.

Comparison of erosion of dental enamel by four drinks using an intra-oral applicance

There are several causes of erosion - acidic foods and drinks have been implicated and reducing their erosive potential would seem an important area of research. Calcium-citrate-malate (CCM) appeared to have potentially useful properties as an anti-erosion additive. The study aims were to test the ability of an intra-oral enamel slab system to measure erosion and to compare the erosive potential of a citric acid-based orange juice drink either with or without added CCM and a positive and negative control. Eleven adults wore an upper removable appliance for four periods each of 6 days. Each appliance held two enamel slabs which were inserted into the test drinks for 15 min 4 times a day for 6 days. Loss of enamel was quantified by profiling casts of the enamel slabs taken before and after the test period. Loss of enamal was greatest during exposure to a diet phosphoric acid-based cola drink (p < 0.001) but was similar during exposure to the two citric acid-based orange drinks, with or without CCM, and distilled water. The loss of surface enamel measured from a scanning electron micrograph agreed well with the measurement obtained by profilometry. It can be concluded that (a) the intra-oral enamel slab system was able to discriminate between drinks in their erosive potential, and (b) it was not possible to determine if CCM had any potential for reduction in erosion in an acid beverage as the level of erosion observed for both the critic acid-based orange drinks was not statistically significantly different from that observed with distilled water.

Foliar Interception and Retention Values after Pesticide Application. A Proposal for Standardized Values for Environmental Risk Assessment (Technical Report)

In performing risk assessments for plant protection products by applicants or regulators in relation to the registration of the products, an important aspect to take into account is the foliar interception and retention of the active substance of the product on the plant. An overview is given of the approaches to this item in several parts of the world. The relevant circumstances and influencing variables, such as growth phase, planting density, and some physicochemical characteristics (e.g., vapor pressure and Henry's coefficient) are dealt with. Finally, a proposal is presented for how to take into account the phenomenon of foliar interception and retention in the initial phase, first tier, of the risk assessment process.

Adult cutaneous Langerhans cell histiocytosis

A 24-year-old male presented with a 4 year history of a crusted erythematous papular eruption of the scalp and external auditory meati and a 12 month history of painful perianal ulceration. A diagnosis of Langerhans cell histiocytosis was made and confirmed by skin histology. Extensive investigation revealed no systemic involvement. Rapid improvement occurred after intravenous 2-chlorodeoxyadenosine but relapse of perianal lesions occurred within 5 months. Local radiotherapy to the perianal region resulted in a complete remission sustained over 12 months.

Visual impairment in very low birthweight children

AIMS

To compare the visual function of a cohort of very low birthweight (VLBW) children in early adolescence with that of their normal birthweight peers; to correlate visual impairment in this group with available perinatal data; and to examine the relation between the visual ability of VLBW children and their cognitive and motor skills.

METHODS

As part of a long term neurodevelopmental study, 137 VLBW children and 163 normal birthweight controls were visually assessed between the ages of 11 and 13 years. Their eyes were examined for strabismus and movement disorders, and the use of visual correction for refractive errors was noted. Measures were made of visual acuity, stereopsis, and contrast sensitivity. All children had standardised tests of motor ability and cognitive skills. Perinatal data, including cranial ultrasonography results, had been obtained from the children's notes. No data were available however, regarding retinopathy of prematurity as screening was not established when these infants were born.

RESULTS

On all measures, the visual function of the VLBW children was poorer than that of the controls. Reduced visual function was present in 63.5% of VLBW children compared with 36% of controls. Poor contrast sensitivity and strabismus were predictive of poor motor skills in the VLBW children. Poor contrast sensitivity and poor visual acuity (at 0.3 metres) were predictive of lower IQ. Low birthweight, intraventricular haemorrhage, intrauterine growth retardation and low 1 minute Apgar scores predicted reduced visual function.

CONCLUSIONS

VLBW children have a high incidence of impaired vision. Stereopsis and contrast sensitivity are useful additions to the screening of this high risk group. They identified impaired vision that was not detected by normal screening and were related to impaired neurodevelopmental outcome.

Spontaneous recovery rates for unilateral sixth nerve palsies

Two hundred and thirteen patients with unilateral isolated sixth nerve palsies were assessed to determine what proportion of them underwent spontaneous recovery and over what period of time this recovery occurred. All were primary ophthalmic referrals from which trauma was excluded. In all, 78.4% of patients experienced spontaneous recovery of their palsy, 36.6% recovering by 8 weeks and 73.7% by 24 weeks. Only 16.4% failed to recover. Of this group, however, nearly 40% had serious underlying pathology accounting for their palsy.

Suprasellar cavernous angioma causing pituitary and hypothalamic dysfunction

A case of suprasellar cavernous angioma causing pituitary and hypothalamic dysfunction is presented. A literature review confirms this as a most unusual location and highlights the value of magnetic resonance imaging in the diagnosis of this condition.

Human immunodeficiency virus (HIV) sero-prevalence in sexually transmitted disease clinic populations

Two HIV sero-prevalence surveys conducted during 1989 in public sexually transmitted disease clinics in the Kansas City SMSA tested 1,561 males and 1.043 females. There were 23 sero-positive males; no sero-positive females. The rate for males using the Missouri clinic was nearly triple that of males using the Kansas clinic. Among males the sero-prevalence rate for white males was 8.4 times that for black males. Of the 14 HIV sero-positive males for whom risk factor information was available, 12 were gay or bisexual and two were heterosexual intravenous drug users.

Evidence that coupling factor B is bound to the matrix side of the inner mitochondrial membrane

Rotenone-sensitive NADH dehydrogenase activity and Lubrol stimulation of cytochrome oxidase activity were measured to assess the opposite membrane polarity of beef heart mitoplast and inside-out particle preparations. The ATP-Pi exchange activity of mitoplasts was not affected by their incubation at pH 8.9 in the presence of 5 mM EDTA (a treatment known to extract coupling factor B (F beta) from submitochondrial particles), nor was it stimulated by the addition of F beta to intact and alkaline treated mitoplast preparations. In contrast, the exchange activity of inside-out particles was decreased 18 fold by the alkaline/EDTA treatment and was almost completely restored by the addition of F beta to F beta-depleted particles. From these results it is concluded that in beef heart mitochondria, the coupling factor F beta is bound to the matrix-side of the inner mitochondrial membrane.

Acute spontaneous subdural haematoma of arterial origin

Spontaneous arterial subdural haematoma is arguably a rare condition. We report on three patients who presented with progressive neurological deficit or coma and who had been initially diagnosed as strokes. Explanations for the development of this condition are reviewed and it is suggested that it is not as rare as previously thought.

Hippocampal and renal type I receptors are differentially regulated

Previously, we have shown that renal mineralocorticoid receptors and hippocampal "corticosterone-perferring" sites have identical intrinsic steroid specificity in vitro. Others have shown that the aldosterone binding species in kidney and hippocampus have identical trypsin fragmentation patterns on isoelectric focusing. To further explore possible areas of identity, we determined levels of type I receptors in hippocampus, renal outer medulla cortex, and renal inner medulla papilla from 22 min to 16 days after adrenalectomy. Available type I sites in kidney fractions increased postadrenalectomy to plateau levels in 22 (inner medulla papilla) or 90 min (outer medulla cortex). In contrast, available hippocampal receptors attained maximal levels 24-48 h postadrenalectomy. Animals, 24-h adrenalectomized, showed no differences in steroid uptake or washout between kidney and hippocampus, determined by in vitro tracer binding 22 or 90 min after intravenous aldosterone or corticosterone. We interpret the marked difference in receptor levels between kidney and hippocampus postadrenalectomy as evidence for tissue-specific differences in the control of receptor levels by endogenous steroids.

A method for the purification of Leishmania promastigotes from infected phlebotomine sandflies

We describe a method for the purification of Leishmania promastigotes, isolated from infected sandflies (Lutzomyia longipalpis) using a discontinuous density centrifugation gradient (Percoll/Homem). The sandflies, infected seven days previously with Leishmania donovani chagasi or Leishmania mexicana mexicana from culture, were homogenized and centrifuged on a Percoll discontinuous gradient. Five interface bands were formed, and most of the promastigotes settled out at the interface between the (30% and 40%) Percoll concentrations. An extraction of 3.5 x 10(4) promastigotes from 90 female flies was achieved using this technique.

Ontogeny of renal mineralocorticoid receptors and urinary electrolyte responses in the rat

We examined the ontogeny of cytosol mineralocorticoid receptors in renal inner medulla-papilla (IM-PAP) and outer medulla-cortex (OM-CX) and of a biological response to administered corticosteroids (urinary K+/Na+ ratio). Rats at early (7-9 days), intermediate (13-15 days), and late (23-30 days) stages of maturation were used. Young rats were found to be essentially insensitive to aldosterone, in contrast to rats aged 13-15 days and older. Scatchard analysis of IM-PAP and OM-CX cytosol showed equivalent high-affinity aldosterone binding sites at all ages. The affinity of these sites was constant (Kd, 4 degrees C approximately 0.5 nM) and their concentration varied only slightly over maturation. In a series of in vivo nuclear transfer studies, the hyposensitivity to aldosterone in young rats did not seem to be due to a difference in the nuclear binding of aldosterone-receptor complexes. The resistance of the immature (7-9 days) rat kidney to aldosterone thus appears to be a postreceptor phenomenon. The maturational events allowing expression of mineralocorticoid-inducible genes in the kidney remain to be determined.

Extravascular CBG-like sites in rat kidney and mineralocorticoid receptor specificity

To determine the intrarenal distribution of extravascular corticosteroid-binding globulin- (CBG) like sites, we measured the specific binding of [3H]corticosterone to supernatants prepared from papilla-inner medulla, outer medulla, and cortex from adrenalectomized rats. Renal papilla-inner medulla of exhaustively perfused kidneys contained 8-20 times higher concentrations of such sites than cortex or outer medulla. The ontogeny and steroid specificities of such sites were identical to those of plasma CBG; their molar concentration in the inner medulla-papilla was 4 times that of plasma CBG, consistent with local accumulation of CBG. Cytosols from all three zones bound [3H]aldosterone in the presence of RU-26988, a highly specific synthetic glucocorticoid, with high affinity (Kd 4 degrees C, 0.3-0.4 X 10(-9) M) and limited capacity (papilla-inner medulla, 23-34; outer medulla, 15-16; cortex, 12-17 fmol/mg). In papilla-inner medulla the apparent specificity of such [3H]aldosterone binding sites was aldosterone greater than corticosterone greater than dexamethasone, in contrast to aldosterone = corticosterone greater than dexamethasone in outer medulla and cortex. We propose that extravascular CBG confers mineralocorticoid specificity on the papilla-inner medulla [3H]aldosterone binding sites. In addition, given the higher levels of extravascular than intravascular CBG and the recurrent vascular architecture of the renal medulla-papilla, a countercurrent exchange model is proposed for renewable sequestration of corticosterone in the region.

A computer-compatible method for observing falling asleep behavior of hospitalized children

A family-organizational linkage framework was used to conceptualize the nighttime separation behaviors of 18 hospitalized children, ages 3 to 8, whose parents did not room-in. All children were observed for three consecutive nights during the falling asleep period. A bedtime story, tape recorded by the parent, was played on the second and third nights for one group. Frequency and duration of falling asleep behaviors were recorded and analyzed with the Senders Signals and Receivers System, a computer-compatible method of recording behavioral data. Eight conceptual behavioral categories emerged from the data: sleepy, contact, active, inactive, neutral, communication, distress, and pleasure. The story-children fell asleep sooner (23 minutes vs. 28 minutes), exhibited more sleepy behaviors, and displayed fewer active behaviors. Duration of contact behaviors also was greater in this group (22 minutes vs. 14 minutes). Hospitalized children who hear a bedtime story recorded by a parent appear to use self-soothing behaviors to cope with the separation experience.

Biogenesis of mitochondria. Defective assembly of the proteolipid into the mitochondrial adenosine triphosphatase complex in an oli2 mit- mutant of Saccharomyces cerevisiae

A single mutation in the oli2 region of the mitochondrial DNA causes a charge alteration in a mitochondrially translated subunit of the mitochondrial ATPase (subunit 6; apparent Mr 20 000; apparent pI 6.9 and 7.1). This alteration leads to the defective assembly of the proteolipid subunit into the enzyme complex. The mutant, which is able to grow only very slowly by oxidative metabolism at 28 degrees C offers new possibilities for studying the assembly of the membrane sector (F0) into the mitochondrial ATPase complex and the role of subunit 6 in this process.

mit-Mutations in the structural gene of subunit III of cytochrome oxidase in Saccharomyces cerevisiae

Two-dimensional electrophoretic analysis of the mitochondrial translation products of four mit-mutants indicate that subunit III of cytochrome oxidase is the only mitochondrial translation product affected by mutations in the oxi2 region of the mtDNA. Mitochondria of two of these mutants synthesize new products which coprecipitate with an anticytochrome oxidase antiserum and produce proteolytic digests similar to those of subunit III of the enzyme complex. These data strongly support the suggestion that the oxi2 region of the yeast mtDNA contains the structural gene of subunit III of cytochrome oxidase.

Biogenesis of mitochondria. Two-dimensional electrophoretic analysis of mitochondrial translation products in yeast

1. Mitochondrial translation products of yeast Saccharomyces cerevisiae were separated according to charge as well as molecular weight by a highly resolving two dimensional electorphoretic technique (isoelectric focusing in the first dimension ana SDS-electrophoresis in the second dimension). 2. The major protein components (the oligomeric form of subunit 9 of mitochondrial ATPase, var 1, cytochrome oxidase subunits I, II and III, subunit 6 of mitochondrial ATPase and cytochrome b apoprotein) were identified either from their mobility in SDS-electrophoresis or by using mit- mutants defective in certain mitochondrially made polypeptides. 3. This method allowed the separation of subunit III of cytochrome oxidase and subunit 6 of mitochondrial ATPase which cannot be resolved by conventional SDS-polyacrylamide gel electrophoresis. 4. Subunit II of cytochrome oxiodase resolves in two spots of similar pI values and subunit 6 of mitochondrial ATPase resolves in two spots of similar molecular weight. In both cases the double spots disappear simultaneously following a single mutation in the coresponding structural gene. 5. Total mitochondrial proteins were also resolved two-dimensionally revealing over 100 components. The mitochondrial translation products, with the exception of subunit 9 of mitochondrial ATPase, could be easily recognized among the other mitochondrial proteins.

Behavioral issues and the computer

Rapid advances in technology are making computers available to even the smallest organizations. Hopefully, this will prove to be a great boon to human resources management, and not one of its biggest boondoggles.