Global constructive work is associated with ventricular arrhythmias after cardiac resynchronization therapy

AIMS

Non-invasive left ventricular (LV) pressure-strain loops provide a novel method for quantifying myocardial work by incorporating LV pressure in measurements of myocardial deformation. Early studies suggest that myocardial work parameters such as global constructive work (GCW) could be useful and reliable in arrhythmia prediction, particularly in patients undergoing cardiac resynchronization therapy (CRT). The aim of this study was to evaluate whether the magnitude of GCW was associated with the occurrence of ventricular arrhythmias in patients after CRT.

METHODS AND RESULTS

Patients on guideline-recommended treatment with a CRT defibrillator (CRT-D) were evaluated by 2D speckle-tracking echocardiography including measurements of GCW at least 6 months after implantation. The primary outcome was a composite of appropriate defibrillator therapy and sustained ventricular arrhythmia under the monitor zone. A total of 162 patients [mean age 66 years (±10), 122 males (75%)] were included. Sixteen (10%) patients experienced the primary outcome during a median follow-up of 18 months (interquartile range: 12-25) after the performance of index echocardiography. Patients with a below-median GCW (<1473 mmHg%) had a hazard ratio (HR) for the outcome of 8.14 [95% confidence interval (CI): 1.83-36.08], P = 0.006 compared with patients above the median in a univariate model and remained an independent predictor after multivariate adjustment for the estimated glomerular filtration rate and QRS duration [HR 4.75 (95% CI: 1.01-22.28), P < 0.05].

CONCLUSION

In patients treated with CRT-D, a GCW below median level was associated with a five-fold increase in the risk of ventricular arrhythmias.

86Coronary CT angiography as the first-line diagnostic strategy in patients with non-ST-segment Elevation Acute Coronary Syndrome - The VERDICT trial

Background

In patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) coronary pathology may range from structurally normal vessels to severe coronary artery disease. Current guidelines recommend early invasive coronary angiography (ICA) to guide management strategy.

Purpose

We tested the hypothesis that a strategy of first-line coronary computed tomography angiography (CCTA) may be used to differentiate between significant and nonsignificant coronary artery stenosis in patients with NSTE-ACS.

Methods

We included patients with NSTE-ACS confirmed by ischaemic ECG changes and/or elevated biomarkers of myocardial ischaemia, in whom ICA was feasible within 12 hours. Patients were randomised 1:1 to ICA within 12 hours (Very Early) or 48–72 hours (Standard) and CCTA was conducted prior to ICA. The primary endpoint was the ability of CCTA to rule out significant coronary artery stenosis (≥50% stenosis) expressed as the negative predictive value (NPV) using ICA as the reference standard. The VERDICT trial is registered with ClinicalTrials.gov number NCT02061891.

Results

CCTA was conducted in 1023 patients – Very Early, 2.5 (IQR 1.8, 4.2) hours, N=583 and Standard, 59.9 (IQR 38.9, 86.7) hours, N=440 after establishment of the diagnosis. Significant coronary stenosis was found by ICA in 67.4% of the patients. NPV of CCTA (95% CI) was 90.9% (86.8%-94.1%) and the positive predictive value, sensitivity and specificity were 87.9% (85.3–90.1%), 96.5 (94.9–97.8%) and 72.4 (67.2–77.1%), respectively. False negative patients (24/1023, 2.3%) mostly had lesions in coronary segments with a luminal diameter ≤2.5 mm. NPV was not influenced by patient characteristics or clinical risk profile, including abnormal cardiac troponin, ischaemic ECG changes, or a GRACE risk score>140. CCTA accuracy parameters were similar in Very Early and the Standard strategy group.

Conclusions

First-line CCTA may be used to rule out clinically significant coronary artery disease in patients with NSTE-ACS and thus potentially guide patient management.

Acknowledgement/Funding

This study was funded by the Danish Agency for Science, Technology, and Innovation and the Danish Council for Strategic Research (grant no. 09–066994)

3335First-line coronary computed tomography predicts long-term clinical outcome in patients with Non-ST-segment elevation acute coronary syndrome - The VERDICT trial

Background

In patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) coronary pathology may range from structurally normal vessels to severe coronary artery disease. Current guidelines recommend early invasive coronary angiography (ICA) for risk assessment and choice of treatment strategy.

Purpose

We tested the hypothesis that 1) a first-line coronary computed tomography angiography (CCTA) predicts long term clinical outcome in patients with NSTE-ACS and 2) adding ICA to CCTA does not improve prediction of cardiovascular events.

Methods

We included patients with NSTE-ACS confirmed by ischaemic ECG changes and/or elevated biomarkers of myocardial ischaemia, in whom both CCTA and ICA were feasible within 12 hours. According to the VERDICT study protocol (ClinicalTrials.gov number NCT02061891) patients were randomised 1:1 to evaluation within 12 hours (Very Early) or 48–72 hours (Standard). CCTA was conducted prior to ICA and patients with an event between tests were excluded. Based on CCTA and ICA, patients were categorized according to European Society of Cardiology (ESC) guidelines as having prognostic indication for coronary revascularization ESCprog (left main stenosis, proximal left anterior descending artery stenosis or multivessel disease) or no prognostic indication – ESCnon-prog. The primary endpoint was a combined endpoint of all-cause mortality, non-fatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia or hospital admission for left sided heart failure. Discrimination of 1.5-year outcomes was assessed by time-dependent area under the receiver operating characteristic curve (AUC).

Results

CCTA and ICA was conducted in 979 patients. During a median follow-up time of 4.2 (IQR 2.7–5.5) years the primary endpoint occurred in 209 (21.3%) patients. Patients with ESCprog as defined by CCTA had a hazard ratio of 1.53 (95% CI 1.16–2.03) for occurrence of the primary endpoint. AUC for the prediction of the primary endpoint by CCTA was 68.6 (95% CI: 62.7–74.5) as compared to 68.6 (95% CI: 62.8–74.5), when adding ICA to the model. Similar findings were noted in patients randomized to either Very Early or Standard treatment strategy.

Conclusions

Long-term risk assessment in patients with NSTE-ACS may be conducted using a first-line CCTA strategy and may thus potentially guide patient management. Adding invasive coronary angiography to CCTA does not improve risk assessment.

Acknowledgement/Funding

This study was funded by the Danish Agency for Science, Technology, and Innovation and the Danish Council for Strategic Research (grant no. 09–066994)

Module-detection approaches for the integration of multilevel omics data highlight the comprehensive response of Aspergillus fumigatus to caspofungin

Background

Omics data provide deep insights into overall biological processes of organisms. However, integration of data from different molecular levels such as transcriptomics and proteomics, still remains challenging. Analyzing lists of differentially abundant molecules from diverse molecular levels often results in a small overlap mainly due to different regulatory mechanisms, temporal scales, and/or inherent properties of measurement methods. Module-detecting algorithms identifying sets of closely related proteins from protein-protein interaction networks (PPINs) are promising approaches for a better data integration.

Results

Here, we made use of transcriptome, proteome and secretome data from the human pathogenic fungus Aspergillus fumigatus challenged with the antifungal drug caspofungin. Caspofungin targets the fungal cell wall which leads to a compensatory stress response. We analyzed the omics data using two different approaches: First, we applied a simple, classical approach by comparing lists of differentially expressed genes (DEGs), differentially synthesized proteins (DSyPs) and differentially secreted proteins (DSePs); second, we used a recently published module-detecting approach, ModuleDiscoverer, to identify regulatory modules from PPINs in conjunction with the experimental data. Our results demonstrate that regulatory modules show a notably higher overlap between the different molecular levels and time points than the classical approach. The additional structural information provided by regulatory modules allows for topological analyses. As a result, we detected a significant association of omics data with distinct biological processes such as regulation of kinase activity, transport mechanisms or amino acid metabolism. We also found a previously unreported increased production of the secondary metabolite fumagillin by A. fumigatus upon exposure to caspofungin. Furthermore, a topology-based analysis of potential key factors contributing to drug-caused side effects identified the highly conserved protein polyubiquitin as a central regulator. Interestingly, polyubiquitin UbiD neither belonged to the groups of DEGs, DSyPs nor DSePs but most likely strongly influenced their levels.

Conclusion

Module-detecting approaches support the effective integration of multilevel omics data and provide a deep insight into complex biological relationships connecting these levels. They facilitate the identification of potential key players in the organism’s stress response which cannot be detected by commonly used approaches comparing lists of differentially abundant molecules.

Electronic supplementary material

The online version of this article (10.1186/s12918-018-0620-8) contains supplementary material, which is available to authorized users.

Effect of ribavirin on junin virus infection in guinea pigs

Junin virus (JUNV) is the aetiological agent of Argentine haemorrhagic fever. The pathogenesis of the infection is not well understood, no licensed vaccines exist and no specific antiviral therapy is available. Previous studies have demonstrated the ability of ribavirin to delay and reduce JUNV disease and virus burden in guinea pigs without preventing death. Based on available data, we performed three different studies to determine the efficacy of ribavirin against JUNV in the guinea pig model with a focus on survival. Different doses and treatment schedules of ribavirin were tested in a lethal model of JUNV infection. Our results show that prolonged treatment with high doses of ribavirin significantly reduces the mortality in guinea pigs infected with JUNV. These results may be useful in future experimental studies or clinical testing.

Off-pump versus on-pump CABG in high-risk patients: Short- and mid-term outcome

OBJECTIVE

During recent years Conventional Coronary Artery Bypass Grafting (cCABG) and Off-Pump Coronary Bypass (OPCAB) have been compared in several randomised and non-randomised studies. Focus has been on postoperative outcome with short-term follow-up in low-risk patients and therefore little is known of the effectiveness of OPCAB in high-risk patients. Furthermore, it is unknown if a potential beneficial short-term outcome is consistent over time.

DESIGN

In 2001, 217 patients with a Euroscore > or =5 were included in an observational cohort study; 162 patients were operated by cCABG and 55 by OPCAB. Follow-up data were retrieved from the Danish national person registry. The study includes a mid-term follow-up, with a mean follow-up time of 3.97 years+/-0.32.

RESULTS

No differences in mortality between OPCAB and cCABG were found. In-hospital mortality was 5.5% in the OPCAB group vs 5.6% in the cCABG group and mid-term mortality was 21.8% in the OPCAB group vs 24.7% in the cCABG group; p = 0.71. During the follow-up period 41.5% of patients with an EF < or =35% at the time of surgery and 43.3% of patients with a Euroscore >8 died. Seven percent in the cCABG group had a perioperative AMI vs none in the OPCAB group; p < 0.05. In 74.5% cCABG's allogenic transfusions of blood components was necessary vs only 55.6% OPCAB's (p < 0.05). No significant differences in CNS complications or atrial fibrillation could be demonstrated.

CONCLUSION

A similar outcome between OPCAB in cCABG in high-risk patients with respect to mortality was found. OPCAB seems to have a beneficial effect on morbidity. A cautious approach to patients with a combined high Euroscore and low ejection fraction should be the strategy of choice.

Controlled clinical trial of treatment with cimetidine for non-ulcer dyspepsia

The effect of cimetidine (1 g daily) and placebo was studied in a controlled clinical trial comprising 50 patients with non-ulcer dyspepsia in whom an organic abnormality responsible for the dyspeptic symptoms was not disclosed by a standardized and extensive examination programme. Reduction of symptoms occurred in 13 (54%) out of 24 patients treated with cimetidine and in 16 (62%) out of 26 treated with placebo. The difference was insignificant, as were the alterations in the individual dyspeptic symptoms between the groups. Only 6 patients (25%) on cimetidine and 8 (31%) on placebo treatment had a total relief of symptoms. Of these, all cimetidine-treated patients remained free from symptoms during the successive 3-month observation period, while the dyspeptic symptoms relapsed in 3 (38%) placebo-treated patients. Subsequent resumption of placebo treatment reduced the symptoms in all 3 patients, but only one became free from symptoms. Cimetidine does not seem to be superior to placebo in the treatment of non-ulcer dyspepsia in patients without any previous history of ulcer or without any sign on endoscopy of an active or previous ulcer disease.

Changes in plasma fatty acid composition after intake of a standardised breakfast in prepubertal obese children

Obese patients typically show a pattern of dyslipidaemia and changes in plasma fatty acid composition reflecting abnormalities in lipoprotein metabolism and dietary habits. Animals and obese adults have been widely studied; however, contradictory results have been published in children. The objective was to assess changes in plasma fatty acid composition in total plasma lipids and plasma lipid fractions in obese prepubertal children compared with those of normal weight and to evaluate changes in postprandial plasma fatty acids during a 3 h period after intake of a standardised breakfast. The study was a case-control study with thirty-four obese and twenty normal-weight prepubertal children (Tanner 1). Anthropometric and metabolic variables and fatty acid concentrations were measured in plasma and its fractions. Liquid chromatography was used to separate lipid fractions and GLC to quantify fatty acids. Plasma total fatty acids (TFA), SFA, MUFA and PUFA concentrations were higher in obese than in control children. Except for 18 : 0, 18 : 3n-3, 20 : 4n-6 and n-3 PUFA, all fatty acids in TAG were also elevated in the obese group. Fatty acids 16 : 1n-7, 18 : 0, 18 : 1n-9, 20 : 2n-6, TFA and MUFA significantly decreased between the 2nd and 3rd hour in normal-weight v. obese children. The concentration of 16 : 1n-7 was positively and the proportion of 20 : 4n-6 inversely associated with a significant increase in risk of obesity. Obese prepubertal children show an altered plasma fatty acid profile and concentrations, mainly related to the TAG fatty acid profile, with a lower clearance of fatty acids v. normal-weight prepubertal children.

Ingesta de una fórmula láctea suplementada con hierro como medida preventiva del déficit de hierro en niños de 1 a 3 años de edad

OBJECTIVE

Low iron status is a well known risk factor for iron deficiency anemia in infants and young children. The aim of the present study was to evaluate the influence of an iron-fortified toddler formula on iron status in 1-3 year-olds.

PATIENTS AND METHODS

Thirty-three healthy infants and young children were assigned to two groups that received 500 mL/day of and iron-fortified toddler formula or 500 mL/day of unmodified cow's milk for 4 months. Allocation was random and double-blind. Daily dietary intake was calculated by dietary evaluation, and iron nutritional status was assessed (hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, serum iron, ferritin, and transferrin).

RESULTS

At enrollment, no anemia was found in either group, although hemoglobin concentration and hematocrit were significantly lower in the toddler formula group than in the unmodified cow's milk group. However, these differences disappeared at the end of the intervention period. After 4 months, the toddler formula group showed significantly higher serum ferritin and lower serum transferrin concentrations than the cow's milk group.

CONCLUSION

Intake of iron-supplemented toddler formula for 4 months in 1-3 year-olds is more effective in maintaining iron nutritional status than cow's milk.

Postprandial response of trans fatty acids in prepubertal obese children

OBJECTIVES

To evaluate the intake, plasma concentrations and postprandial response of trans fatty acids in obese and control children at prepubertal age in order to detect potential associations with childhood obesity.

DESIGN

Case-control study, clinical dietary intervention with a 428 kcal standardized breakfast and longitudinal 3 h postprandial follow-up for trans fatty acid plasma levels.

SUBJECTS

Fifty-four children aged 6-13 years of both sexes, 34 obese (body mass index >97th percentile for age and sex) and 20 non-obese (control group) at prepubertal period (Tanner I).

MEASUREMENTS

Various anthropometric parameters and sex hormones, fasting insulin and glucose, estimation of dietary trans fatty acid intake and their plasma quantitation in fasting conditions, and for 3 h following intake of a standardized breakfast.

RESULTS

Dietary trans fatty acid intake was less than 0.4% of total energy in both groups, with a trend towards higher intake in obese children. Fasting plasma trans fatty acid concentrations and percentages were similar in both groups. However, trans fatty acid levels at +3 h were significantly higher than at 0 h in obese children, but not in controls (obese, 0 h: 2.38+/-0.29; 3 h: 3.62+/-0.45; controls, 0 h: 2.29+/-0.24; 3.14+/-0.49 mg/dl); cis monounsaturated fatty acid concentrations were not significantly affected by the postprandial interval. Obese children exhibited hyperinsulinemia and insulin resistance; however, trans fatty acid intake or their plasma levels were not associated with them.

CONCLUSION

There is a low intake of trans fatty acids in Southern Spanish children, which is supported by their low concentrations in plasma. No difference in trans fatty acid intake is observed between obese and control children, although plasma levels remain higher in obese than in control children after 3 h of a meal. A marked insulin resistance is seen in obese, but it is not correlated with either trans fatty acid intake or plasma concentration.

Pharmacological treatment for prevention of restenosis

Coronary artery disease (CAD) is the leading cause of mortality and morbidity among adults in the Western world. Coronary artery bypass grafting and percutaneous coronary interventions (PCI) have gained widespread acceptance for the treatment of symptomatic CAD. There has been an explosive growth worldwide in the utilisation of PCI, such as balloon angioplasty and stenting, which now accounts for over 50% of coronary revascularisation. Despite the popularity of PCI, the problem of recurrent narrowing of the dilated artery (restenosis) continues to vex investigators. In recent years, significant advances have occurred in the understanding of restenosis. Two processes seem to contribute to restenosis: remodelling (vessel size changes) and intimal hyperplasia (vascular smooth muscle cell [VSMC] proliferation and extracellular matrix [ECM] deposition). Despite considerable efforts, pharmacological approaches to decrease restenosis have been largely unsuccessful and the only currently applied modality to reduce the restenosis rate is stenting. However, stenting only prevents remodelling and does not inhibit intimal hyperplasia. Several potential targets for inhibiting restenosis are currently under investigation including platelet activation, the coagulation cascade, VSMC proliferation and migration, and ECM synthesis. In addition, new approaches for local drug therapy, such as drug eluting stents, are currently being evaluated in preclinical and clinical studies. In this article, we critically review the current status of drugs that are being evaluated for restenosis at various stages of development (in vitro, preclinical animal models and human trials).

Localization of L11 protein on the ribosome and elucidation of its involvement in EF-G-dependent translocation

L11 protein is located at the base of the L7/L12 stalk of the 50 S subunit of the Escherichia coli ribosome. Because of the flexible nature of the region, recent X-ray crystallographic studies of the 50 S subunit failed to locate the N-terminal domain of the protein. We have determined the position of the complete L11 protein by comparing a three-dimensional cryo-EM reconstruction of the 70 S ribosome, isolated from a mutant lacking ribosomal protein L11, with the three-dimensional map of the wild-type ribosome. Fitting of the X-ray coordinates of L11-23 S RNA complex and EF-G into the cryo-EM maps combined with molecular modeling, reveals that, following EF-G-dependent GTP hydrolysis, domain V of EF-G intrudes into the cleft between the 23 S ribosomal RNA and the N-terminal domain of L11 (where the antibiotic thiostrepton binds), causing the N-terminal domain to move and thereby inducing the formation of the arc-like connection with the G' domain of EF-G. The results provide a new insight into the mechanism of EF-G-dependent translocation.

[Carcinoid--advances in diagnosis and treatment]

Carcinoid is one of the most frequently diagnosed neuroendocrine tumours. It develops slowly but grows by infiltration and has the ability to give metastases in distant organs. The clinical picture is very diverse and in 10% of cases the signs called carcinoid syndrome develop. Not infrequently it produces also peptide hormones. In the present paper the most modern diagnostic methods, possibilities of surgical and pharmacological treatment of this extremely interesting neoplasm are discussed.

Effect of enalapril on proteinuria after kidney transplantation

We studied the effect of enalapril, an inhibitor of angiotensin-converting enzyme (iACE), on proteinuria and renal function in recipients of renal allografts. Twenty-two patients with post-transplant nephrotic syndrome were treated with incremental doses of enalapril for 1 year. Urinary protein excretion decreased after 2 months of treatment from a mean of 8.9 g/day (range 4.0-18.9 g/day) to 4.5 g/day (range 0.4-10.0 g/day; P < 0.01) and remained significantly low for the rest of the study. However, in the same period, creatinine clearance did not change significantly; it went from 47.8 ml/min (range 17.1-110.3 ml/min) before treatment to 44.2 ml/min (range 16.5-88.5 ml/min) after 2 months of iACE therapy. Analysis of individual data showed that there was a significant reduction in proteinuria in 14 of the 22 patients and that the rate of deterioration of renal function did not increase in 17 of the 22 patients. We did not observe any serious side effects of enalapril administration. The results of our study prove that iACE can be used safely and effectively to reduce post-transplant proteinuria.

School placement for human immunodeficiency virus-infected children: the Baltimore City experience

Over the past 6 years, the city of Baltimore has successfully implemented a school placement policy for human immunodeficiency virus (HIV)-infected children and children with acquired immunodeficiency syndrome (AIDS). Both policy and specific procedures are based on nationally promulgated guidelines. School placement policy is part of an overall AIDS policy that includes education of students and staff and adoption of universal precautions to prevent transmission of communicable diseases in school. Implementation has been marked by excellent collaboration between the departments of health and education. Important policy components include expedited clinical investigation of each case, an interagency review panel, strict protection of confidentiality, a restricted setting for certain children, a school site visit for each placement, and continued monitoring of the school placement by school nurses. Many HIV-infected students need special educational services and/or school health services. The Baltimore City school placement process has avoided the exaggerated publicity endured by some communities, where media reporting has aggravated community fears and invaded the lives of families with HIV-infected children. Baltimore City has succeeded in ensuring access to education, protecting families' confidentiality, and providing special care for HIV-infected students. Local communities should emphasize national guidelines in designing school placement policies for HIV-infected children. School placement policies work best in the context of a comprehensive policy incorporating AIDS education and care.

Colonic epithelial dysplasia or carcinoma in a regional group of patients with ulcerative colitis of more than 15 years duration

Colonoscopic screening for neoplasia was performed in a regional group of ulcerative colitis patients with a disease duration of greater than or equal to 15 years. A total of 121 patients, aged less than 80 years, were invited to participate, of whom 100 (83%) accepted colonoscopy, including biopsies in 15 standard locations of the entire colon, plus additional biopsies from all visible lesions. Unequivocal dysplasia was found in one patient with extensive colitis and a disease duration of 31 years. A polyp with highly differentiated adenocarcinoma was found in the sigmoid colon of a patient with intermittent rectum involvement, 37 years after the ulcerative colitis diagnosis had been made. Biopsy specimens from the remaining 98 patients showed no signs of dysplasia or cancer. Thus the frequency of pre-malignant or malignant changes is very low compared with the results of similar studies, and the rationale for general colonoscopic surveillance programmes for such patients is open to question.

Acyclovir in the prevention of duodenal ulcer recurrence

This study tests the hypothesis that reactivation of a latent herpes simplex virus infection may be a cause of recurrent duodenal ulceration. Patients with recently healed duodenal ulcer were entered into a double blind, randomised study of maintenance treatment with the antiviral drug acyclovir (400 mg bid) versus placebo, to determine if suppression of herpes virus infection would influence the natural history of the ulcer disease. One hundred and fifteen patients entered the trial and 76 patients completed it according to the protocol. Endoscopy was performed when ulcer symptoms recurred and at the end of the 25 week trial period. In the acyclovir group the cumulated relapse rate was 63% compared with 56% in the placebo group (NS). This result suggests that reactivation of herpes simplex virus is not a cause of recurrent duodenal ulcer.

Evaluation of a new leukocyte labeling procedure with 99mTc-HMPAO

A technique for labeling leukocytes with 99mTc using hexamethylpropylene-amineoxime (HMPAO) was evaluated in vitro. The labeling procedure resulted in a cell bound fraction of radioactivity of 56% after 99mTc incubation and 96% after 1 washing of cells. In the final cell suspension 84% of the radioactivity was attached to the polymorphonuclear (PMN) leukocytes constituting 94% of white cells. Only 5% was bound to residual red blood cells. The stability evaluated in autologous plasma showed a decline of cell bound activity from 96% to 84% over 3 h. The chemotactic function of PMN leukocytes was unaffected by the labeling procedure. These findings demonstrate that HMPAO, albeit cell unspecific, is efficient for labeling PMN leukocytes with 99mTc. The stability of the labeling procedure is high and the technique does not affect cell function. No other current 99mTc leukocyte labeling technique possesses all these qualities.

Effect of omeprazole and cimetidine on prepyloric gastric ulcer: double blind comparative trial

We conducted a six week double blind randomised study of 176 patients with prepyloric gastric ulcer to determine whether the proton pump inhibitor, omeprazole 30 mg daily would accelerate healing and pain relief, as compared with cimetidine 1 g daily. At two, four, and six weeks after entry ulcers healed in a larger percentage of patients treated with omeprazole (54, 81, and 86%) than of those treated with cimetidine (39, 73, and 78%) ('intention to treat' cohort; p less than 0.05 at two weeks). A higher proportion of patients on omeprazole became free of pain during the first week of treatment (p less than 0.05). No major clinical or biochemical side effects were noted. Omeprazole is an efficient treatment for patients with prepyloric gastric ulcers.

Effect of omeprazole and cimetidine on duodenal ulcer. A double-blind comparative trial

We conducted a double-blind randomized study of 132 patients to determine whether the new, investigational proton-pump inhibitor, omeprazole (30 mg per day), would accelerate healing and pain relief, as compared with cimetidine (1 g per day), in patients with duodenal ulcer. After two weeks of treatment, which was completed by all patients, the healing rates were 73 per cent in the omeprazole group and 46 per cent in the cimetidine group (P less than 0.01). After four weeks of treatment, which was completed by 118 patients, the corresponding figures were 92 and 74 per cent (P less than 0.05). In the omeprazole group 55 per cent of the patients were free of pain after the first week, as compared with 40 per cent of those treated with cimetidine (P greater than 0.05). No major clinical or biochemical side effects of omeprazole or cimetidine were noted. A six-month follow-up study revealed no significant difference between the recurrence rates after omeprazole and after cimetidine treatment. In May 1984 clinical trials with omeprazole were temporarily suspended, since a study of long-term toxicity in rats had shown the development of gastric carcinoid tumors.

Osteoporosis in hyperthyroidism estimated by photon absorptiometry

The degree of osteoporosis in hyperthyroidism before and during treatment with carbimazole was studied by photon absorption technique of the right forearm and calcaneus. In addition serum total calcium, serum ionized calcium, serum phosphorus and serum alkaline phosphatase were determined. A group of 96 patients suffering from untreated hyperthyroidism (85 women and 11 men) was studied (79 of these patients were also followed during treatment) and compared to a control group of 157 persons (107 women and 50 men). The women were divided into two groups: less than or equal to 45 years old and more than 45 years old. In all groups untreated hyperthyroid patients showed lower bone densities compared to the control group, but this was only significant in women. During treatment all groups showed a significant increase in density. After 3-6 months of treatment bone density in the calcaneus increased 12% and in the forearm 1.5%; after 6 months - 3 years 33% and 31%, respectively. At that time bone density was normalized. There was no correlation between bone density in hyperthyroid patients and duration and severity of the disease. The biochemical changes were characterised by increases in serum alkaline phosphatase (26%), serum total calcium (16%) and serum ionized calcium concentration (17%) in cases of untreated hyperthyroidism. Serum phosphorus concentration did not change. A correlation was found between elevation of the alkaline phosphatase and decreased bone density.

Diabetes and hypoglycemia in chronic pancreatitis

Fifty-nine patients with chronic pancreatitis were studied in retrospect. The incidence of overt diabetes was high, 36/59. Half of the diabetics were insulin-dependent, and among these labile diabetes with hyperglycemia and high amounts of glucose in the urine was not uncommon. Hypoglycemic episodes were noted in 14 of the 18 insulin-treated patients, and in 3 patients severe hypoglycemia was believed to be the cause of death. Mechanisms leading to such disastrous hypoglycemia are discussed, and a hypothesis regarding lack of glucagon as the cause of severe hypoglycemic attacks was experimentally tested by measuring pancreatic glucagon in plasma in two patients with pancreatic diabetes and severe brain damage following hypoglycemic coma. Low basal glucagon values were found, and the normal rise upon insulin-induced hypoglycemia was not seen. From these results it may be justified to suggest, firstly that glucagon should be used in the management of severe hypoglycemia in chronic pancreatitis, and secondly that a certain degree of hyperglycemia should be allowed in the treatment of diabetes in these patients.