Developing a mobile health application for wound telemonitoring: a pilot study on abdominal surgeries post-discharge care

BACKGROUND

Many early signs of Surgical Site Infection (SSI) developed during the first thirty days after discharge remain inadequately recognized by patients. Hence, it is important to use interactive technologies for patient support in these times. It helps to diminish unnecessary exposure and in-person outpatient visits. Therefore, this study aims to develop a follow-up system for remote monitoring of SSIs in abdominal surgeries.

MATERIAL AND METHODS

This pilot study was carried out in two phases including development and pilot test of the system. First, the main requirements of the system were extracted through a literature review and exploration of the specific needs of abdominal surgery patients in the post-discharge period. Next extracted data was validated according to the agreement level of 30 clinical experts by the Delphi method. After confirming the conceptual model and the primary prototype, the system was designed. In the pilot test phase, the usability of the system was qualitatively and quantitatively evaluated by the participation of patients and clinicians.

RESULTS

The general architecture of the system consists of a mobile application as a patient portal and a web-based platform for patient remote monitoring and 30-day follow-up by the healthcare provider. Application has a wide range of functionalities including collecting surgery-related documents, and regular assessment of self-reported symptoms via systematic tele-visits based on predetermined indexes and wound images. The risk-based models embedded in the database included a minimum set with 13 rules derived from the incidence, frequency, and severity of SSI-related symptoms. Accordingly, alerts were generated and displayed via notifications and flagged items on clinicians' dashboards. In the pilot test phase, out of five scheduled tele-visits, 11 (of 13) patients (85%), completed at least two visits. The nurse-centered support was very helpful in the recovery stage. Finally, the result of a pilot usability evaluation showed users' satisfaction and willingness to use the system.

CONCLUSION

Implementing a telemonitoring system is potentially feasible and acceptable. Applying this system as part of routine postoperative care management can provide positive effects and outcomes, especially in the era of coronavirus disease when more willingness to telecare service is considered.

Cancer in Iran 2008 to 2025: Recent incidence trends and short-term predictions of the future burden

Policymakers require estimates of the future number of cancer patients in order to allocate finite resources to cancer prevention, treatment and palliative care. We examine recent cancer incidence trends in Iran and present predicted incidence rates and new cases for the entire country for the year 2025. We developed a method for approximating population-based incidence from the pathology-based data series available nationally for the years 2008 to 2013, and augmented this with data from the Iranian National Population-based Cancer Registry (INPCR) for the years 2014 to 2016. We fitted time-linear age-period models to the recent incidence trends to quantify the future cancer incidence burden to the year 2025, delineating the contribution of changes due to risk and those due to demographic change. The number of new cancer cases is predicted to increase in Iran from 112 000 recorded cases in 2016 to an estimated 160 000 in 2025, a 42.6% increase, of which 13.9% and 28.7% were attributed to changes in risk and population structure, respectively. In terms of specific cancers, the greatest increases in cases are predicted for thyroid (113.8%), prostate (66.7%), female breast (63.0%) and colorectal cancer (54.1%). Breast, colorectal and stomach cancers were the most common cancers in Iran in 2016 and are predicted to remain the leading cancers nationally in 2025. The increasing trends in incidence of most common cancers in Iran reinforce the need for the tailored design and implementation of effective national cancer control programs across the country.

Clinical and Epidemiological Characteristics of Hospitalized COVID-19 Patients in Hormozgan, Iran: A Retrospective, Multicenter Study

BACKGROUND

To better manage the COVID-19 pandemic, it is necessary to carefully study information about patients with COVID-19. Objective: To report clinical and epidemiological characteristics of COVID-19 patients in southern Iran.

METHODS

This cross-sectional retrospective study was conducted based on data extracted from the COVID-19 registry of Hormozgan. Data from patients with confirmed COVID-19 based on CT-scan results or real-time reverse transcriptase-polymerase chain reaction (RT-PCR) results until September 25, 2020, were analyzed for this study (2351 inpatients). We reported demographics, signs and symptoms on admission, comorbidities, and treatments, as well as clinical outcomes, hospital stay, and intensive care unit (ICU) admission.

RESULTS

Most of patients were men (1235/2351; 52.5%) and the most common signs and symptoms included cough (1343/2351; 57.1%), shortness of breath (1224/2351; 52.1%) and fever. The most common comorbidities included hypertension (410/2351 (17.4%), diabetes (343/2351; 14.6%) and chronic cardiac disease (282/2351; 12%). Also, 228 patients (9.7%) were hospitalized in the ICU. The mortality rate was 12.5% (295/2351) among all patients and 64.5% (147/228) in ICU wards, respectively. The number of cases with comorbidities including hypertension, chronic cardiac disease, diabetes, chronic neurological disorders, chronic kidney disease, chronic hematologic disease, malignant neoplasm, moderate or severe liver disease, dementia and fauvism in the ICU was significantly higher than the general wards.

CONCLUSION

Most characteristics of our patients were similar to those reported in other studies; however, our patients were younger and suffered from a less severe disease. The mortality rate in the ICU was higher than other studies.

Optimized Patients' Length of Hospital Stay with Interventions Based on Health Information Technology: A Review Study

BACKGROUND

Information and communications technologies (ICTs) may facilitate shorting length of stay (LOS) of patients through the optimization of processes and delivery services.

OBJECTIVES

This study aims to provide technology-based solutions and interventions based on health information technology (HIT) that have optimization potentials of patients' LOS.

METHODS

This review study searched papers in PubMed, Scopus as well as Google Scholar without presuming time limits by the end of 2019. English and Persian Papers were included, which addressed an association between the ICT and LOS as well as its positive effect in shortening LOS.

RESULTS

Identified technologies were finally classified into eleven groups. Based on the findings, common health technologies such as health information systems, telemedicine especially tele-consultation, electronic discharge planning tools, and visual analytical dashboards in order to expedite the process and help to optimize LOS seem appropriate.

CONCLUSIONS

HIT-based interventions have potential that may support better management of processes related to patients' admission, hospitalization, and discharge. However consistently evaluation along with using any new technology is necessary.

Surgical Patients Follow-Up by Smartphone-Based Applications: A Systematic Literature Review

BACKGROUND

Telemedicine technology with the development of mobile applications (apps) has provided a new approach for the follow-up of patients.

OBJECTIVES

This study aims to carry out an overview of the studies related to the use of mobile apps in the follow-up of surgical patients.

METHODS

In this study, an electronic search of four databases included PubMed, Scopus, Embase, and web of science was carried out. It included studies in the English language from the beginning of 2009 to June 2019.

RESULTS

Twenty-three articles were selected for the final analysis, that all of them were published from 2015 onwards. In most studies, fourteen to thirty-days follow-up period for different outpatient and inpatient surgeries was planned. Apps' components in the studies mostly include indexes for evaluation of recovery quality, pain level, and the surgical site infection. The most important achievement of studies included feasibility, early detection of complications, reducing unscheduled in-person visits, patients' self-efficiency, and satisfaction.

CONCLUSIONS

Our review showed that mHealth-based interventions have potential that may support better management of post-discharge systematic follow-up of surgery patients.

Implementation of regional COVID-19 registry in Hormozgan (RCovidRH), Iran: Rationale and study protocol

Background: The rapid outbreak of COVID-19 has resulted in a global pandemic in 2020. Information sources such as disease registries through accessing quality, valid, accurate, and timely data empower researchers and health authorities to study and develop appropriate actions. Our study describes the protocol for implementation of regional COVID-19 registry in Hormozgan province (RCovidRH). Methods: We followed approved phases for the development of RCovidRH to cover the population in Hormozgan. Missioned to develop and implement the protocol, the registry's steering committee was made up of 10 members from subject fields of the registry at the core and 5 subgroups. The main purpose of the registry is to provide a comprehensive information profile of demographic, clinical, laboratory, imaging, and treatment data of confirmed and probable COVID-19 patients in Hormozgan. The data is retrospectively and prospectively collected. Case report form (CRF) was mainly based on International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) CRF. A web-based, 2-language software was also developed to facilitate data collection and storage. Data analysis is to be conducted with collaboration of clinical physicians, data-mining specialists, and epidemiologists after reaching appropriate sample size. Results: We included data related to demographic and identification, onset and admission, signs and symptoms at hospital admission, admission signs and symptoms, comorbidities, pathogen testing, assessment, laboratory, imaging, complications, treatment and medication, and outcomes. We found this registry was limited by incomplete clinical data for small fraction of outpatients, incomplete or inaccurate address by referred people due to fear of social rejection, delay in data entry at the facilities due to workload. Conclusion: This registry via organizing clinical and epidemiological COVID-19 data increases the potentiality of joint studies. Recognition and coordination of a registry is highly important to solve its limitations to collect data. Other universities and provinces can apply our model to develop COVID-19 registries or data sets for this disease.

Cancer incidence in Iran in 2014: Results of the Iranian National Population-based Cancer Registry

BACKGROUND

We aimed to report, for the first time, the results of the Iranian National Population-based Cancer Registry (INPCR) for the year 2014.

METHODS

Total population of Iran in 2014 was 76,639,000. The INPCR covered 30 out of 31 provinces (98% of total population). It registered only cases diagnosed with malignant new primary tumors. The main sources for data collection included pathology center, hospitals as well as death registries. Quality assessment and analysis of data were performed by CanReg-5 software. Age standardized incidence rates (ASR) (per 100,000) were reported at national and subnational levels.

RESULTS

Overall, 112,131 new cancer cases were registered in INPCR in 2014, of which 60,469 (53.9%) were male. The diagnosis of cancer was made by microscopic confirmation in 76,568 cases (68.28%). The ASRs of all cancers were 177.44 and 141.18 in male and female, respectively. Cancers of the stomach (ASR = 21.24), prostate (18.41) and colorectum (16.57) were the most common cancers in men and the top three cancers in women were malignancies of breast (34.53), colorectum (11.86) and stomach (9.44). The ASR of cervix uteri cancer in women was 1.78. Our findings suggested high incidence of cancers of the esophagus, stomach and lung in North/ North West of Iran.

CONCLUSION

Our results showed that Iran is a medium-risk area for incidence of cancers. We found differences in the most common cancers in Iran comparing to those reported for the World. Our results also suggested geographical diversities in incidence rates of cancers in different subdivisions of Iran.

The Comparison of the Minimum Data Set for Elderly Health in Selected Countries

INTRODUCTION

Ongoing increase in the elderly population in many developed countries has drawn attention to health of this age group. Recording adequate and relevant data for the elderly is considered as the basis for future planning for this segment of society. So this study was conducted to compare minimum data about elderly health in selected countries.

METHODS

This review study was conducted through Internet and library studies. Key words were extracted from search engines and data bases including Google, Yahoo, Google Scholar, PubMed, ProQuest and Iranian National Medical Digital Library. Inclusion criteria included English language with no time limits. All articles, research projects, theses, guidelines and progress reports were retrieved from the United States, Sweden, Japan and Iran and reviewed. Also, websites of organizations responsible for elderly health in selected countries were visited and their documents were reviewed. Results from this search were provided narratively and finally were presented within comparison tables.

FINDINGS

The findings of this study showed that elderly data in the selected countries are collected around four axis including minimum demographic data, medical histories, health assessment and financial data of elderly health.

DISCUSSION AND CONCLUSION

Given the importance of the minimum data set of elderly health for future planning, the use of experiences of leading countries in elderly health seems necessary; however, localization of it according to the country's needs is inevitable.

Health Information Management System for Elderly Health Sector: A Qualitative Study in Iran

Background:

There are increasing change and development of information in healthcare systems. Given the increase in aging population, managers are in need of true and timely information when making decision.

Objectives:

The aim of this study was to investigate the current status of the health information management system for the elderly health sector in Iran.

Materials and Methods:

This qualitative study was conducted in two steps. In the first step, required documents for administrative managers were collected using the data gathering form and observed and reviewed by the researcher. In the second step, using an interview guide, the required information was gathered through interviewing experts and faculty members. The convenience, purposeful and snowball sampling methods were applied to select interviewees and the sampling continued until reaching the data saturation point. Finally, notes and interviews were transcribed and content analysis was used to analyze them.

Results:

The results of the study showed that there was a health information management system for the elderly health sector in Iran. However, in all primary health care centers the documentation of data was done manually; the data flow was not automated; and the analysis and reporting of data are also manually. Eventually, decision makers are provided with delayed information.

Conclusions:

It is suggested that the steward of health in Iran, the ministry of health, develops an appropriate infrastructure and finally puts a high priority on the implementation of the health information management system for elderly health sector in Iran.

Aspergillus colonization in patients with chronic obstructive pulmonary disease

Background and Purpose:

Chronic obstructive pulmonary disease (COPD) has been recognized as a risk factor for invasive aspergillosis. Airway colonization by Aspergillus species is a common feature of chronic pulmonary diseases. Nowadays, the incidence of COPD has increased in critically ill patients. The aim of the present study was to isolate and identify Aspergillus colonies in the respiratory tract of COPD patients.

Materials and Methods:

This study was performed on 50 COPD patients, who were aged above 18 years, and were in intensive care units of three hospitals in Sari, Iran, for at least six days. All the samples obtained from sputum, bronchoalveolar lavage, and tracheal aspirates were cultured for fungi each week. According to the conventional techniques, Aspergillus isolates were initially based on growth and standard morphological characteristics. To confirm the identification of grown Aspergillus, the partial beta-tubulin gene was sequenced using specific primers.

Results:

A total of 50 patients, who met our inclusion criteria, were enrolled in the study during 2012-14. The results showed that 27 (54%) and 23 (46%) of the participants were male and female, respectively. The majority of the patients developed dyspnea followed by hemoptysis, chest pain, and high fever. Corticosteroids and broad-spectrum antibacterial agents were administered to 75% and 80% of the patients, respectively. Based on the conventional and molecular approaches, A. fumigatus (seven cases; 43.7%), A. flavus (five cases; 31.2%), A. niger (one case; 6.2%), A. terreus (one case; 6.2%), A. orezea (one case; 6.2%), and A. tubingensis (one case; 6.2%) were recovered.

Conclusion:

Recovery of Aspergillus species from the respiratory tract of COPD patients with pneumonia indicates two possibilities: either colonization or invasive aspergillosis.

Information technology governance domains in hospitals: a case study in Iran

IT governance is a set of organizational structures ensuring decision-making rights and responsibilities with regard to the organization’s IT assets. This qualitative study was carried out to identify the IT governance domains in teaching hospitals affiliated to Iran University of Medical Sciences. There were 10 heads of IT departments and 10 hospital directors. Semi structured interviews used for data collection. To analyze the data content analysis was applied. All the interviewees (100%) believed that decisions upon hospital software needs could be made in a decentralized fashion by the IT department of the university. Most of the interviewees (90%) believed that there were policies for logistics and maintenance of networks, purchase and maintenance, standards and general policies in the direction of the policies of the ministry of health and medical education. About 80% of the interviewees believed that the current emphasis of the hospital’s IT unit and the hospital management for outsourcing of services were in the format of specialized contracts and under supervision of the university Statistic and IT department. A hospital strategic committee is an official organizational group consisting of hospital executives, heads of IT and multiple functional areas and business units in a hospital. In this committee, “the head of hospital” acts as the director of IT activities and ensures that IT strategies are alignment with the hospital business strategies.

The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

Introduction:

Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians’ performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS).

Methods:

This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians’ knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test.

Results:

Change in physicians’ knowledge before and after education was not statistically significant (p = 0.15). Residents’ behavior did not have statistically significant changes during three phases of the study.

Conclusion:

Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians’ behavior about chart documentation.

Frontal sinus mucopyelocele with intracranial and intraorbital extension

This case is related to a 52-year-old lady with proptosis, diplopia and diminution of vision due to a mass lesion in upper medial quadrant of the orbit. CT scan revealed a well defined mass in basi-frontal area with intra-orbital and intracranial extension. On exploring it was found to be mucopyocele of the frontal sinus. Surgical excision was done by external approach. The symptoms and signs resolved completely within a week. Frontal sinus mucopyoceles are benign and curable. Early recognition and management of them is of paramount importance because they can expand and cause local, orbital or intracranial complications.

Vector ecology and susceptibility in a malaria-endemic focus in southern Islamic Republic of Iran

This study aimed to carry out a malaria situation analysis, species composition and susceptibility levels of the main malaria vector, Anopheles stephensi, to different insecticides in Bashagard. A longitudinal survey was conducted in 2 randomly selected villages in Bashagard. Malaria vectors were sampled by dipping method for the larvae and hand catch, night-biting catch, total catch, and shelter pit collection for the adults. Standard WHO susceptibility tests were used for a variety of insecticides on F1 progeny of An. stephensi reared from wild-caught females. In total, 693 adult anopheline mosquitoes and 839 third and fourth-instar larvae were collected and identified. They comprised 7 species; the most abundant adult and larvae anopheline mosquito was An. dthali (40.7% and 30.5% respectively). An. culicifacies (24.2%) and An. stephensi (16.7%) were the next most common species for adult mosquitoes. An. stephensi was fully susceptible to malathion and pyrethroid insecticides but resistant to DDT and tolerant to dieldrin.

Entomological and epidemiological attributes for malaria transmission and implementation of vector control in southern Iran

Bashagard is an important malaria endemic area in south of Iran. An epidemiological and entomological survey was performed during 2002-2010. The aim of study was to determine malaria situation, species composition of anopheline mosquitoes and susceptibility status of main vectors to insecticides/larvicides. A total of 13,490 malaria cases were recorded, Plasmodium vivax (99.64%), P. falciparum (0.35%) and mix cases (0.01%). The highest and lowest Annual Parasite Incidence (API) were observed in 2007 (145.72/1000) and 2009 (6.29/1000), respectively. Anopheles culicifacies, An. dthali, An. stephensi, An. superpictus, An. fluviatilis, An. moghulensis, An. turkhudi and An. apoci were collected from the area. Two peak activities occur in April and October. The first five species were confirmed as malaria vectors in Iran. No indication of sporozoite in mosquitoes using molecular method was performed. Susceptibility tests using diagnostic dose of insecticides and larvicides showed only resistance of An. stephensi to DDT. Tolerance in An. stephensi to deltamethrin and bendiocarb is reported. The same phenomenon was observed in An. culicifacies to DDT, propoxur and deltamethrin, and in An. dthali to malathion and deltamethrin. Larvae of vectors were susceptible to all larvicides, except for An. stephensi that exhibited tolerance to fenthion. In conclusion it should be emphasized that malaria transmission is a complex process in Bashagard. This event is attributed to five proven vectors with different behaviors which are active in the area. Regarding tolerance of vectors to deltamethrin, resistance management is suggested by using new insecticide with novel mode of action.

The Occurrence of Red-Back Spider Latrodectus hasselti (Araneae: Theridiidae) in Bandar Abbas, Southern Part of Iran

BACKGROUND

Due to importance and fatal affect of Red-back spiders, Latrodectus hasselti, a faunistic survey for presence of this spider in Bandar Abbas has been conducted. This animal is considerably the most medically importance spiders all over the world.

METHODS

Live adult spider specimens were collected from Bandar Abbas town using hand catch conventional method and transferred to the laboratory throughout the summer of 2008. They were identified based on morphological characteristics and taxonomic keys and confirmed by some external experts.

RESULTS

Results showed the occurrence of the red-back spider, L. hasselti from Bandar Abbas, southern port of Iran. Two female specimens were found. The spider had specific morphological characters including black color with an obvious orange to red longitudinal strip on its upper parts of abdomen.

CONCLUSION

Although the specimens were collected from south of the country, however since the region is an important harbor and port and goods come form different parts of world we assume the possibility of arrival from its origin and native breeding sites of the world. Therefore further investigation is needed to clarify the presence of this species in different parts of Iran.

Bionomics of Anopheles stephensi Liston in the malarious area of Hormozgan province, southern Iran, 2002

Anopheles stephensi Liston is an important malaria vector in Hormozgan province, where it is the most prevalent anopheline mosquito. It shows two annual activity peaks, one in spring and another in the autumn. In mountainous areas the second peak starts earlier than in coastal regions. Adults are endophilic and endophagic, but in the hot season when people sleep outside buildings they frequently bite outdoors. Larvae are found in a wide-range of habitats, both natural and man-made. All three biological forms of the species, occur in the province, i.e. An. stephensi stephensi (type form), An. stephensi mysorensis, and the intermediate form. An. stephensi mysorensis is found only in rural-mountainous areas, whereas the type and intermediate forms occur in urban-coastal regions and the rural plains, with the type form predominant. The presence of the type form in urban areas and mysorensis in rural areas is consistent with the available epidemiological data for malaria in the region and with the finding in India that the type form is an efficient malaria vector inhabiting urban areas whereas mysorensis is rural and has a lower vectorial capacity. Insecticide susceptibility tests on field collected adult mysorensis and adults from laboratory strains of the type and intermediate forms were carried out according to WHO standard methods. These showed that all three forms are susceptible to bendiocarb, propoxur, malathion, fenitrothion, deltamethrin, permethrin, cyfluthrin, and lambdacyhalothrin, but are resistant to DDT and show low level of tolerance to dieldrin. Examination of the larvicidal activity of malathion, fenitrothion, temephos and chlorpyrifos at diagnostic doses showed that these stephensi forms are susceptible to all larvicides except fenitrothion. Irritability tests to pyrethroid insecticides showed high levels of irritability to permethrin and lambdacyhalothrin, but low irritability to cyfluthrin and deltamethrin. The importance of these findings for the epidemiology and control of malaria in the region are discussed.

ELECTIVE EXPERIENCES OF FOREIGN MEDICAL STUDENTS AT THE TEACHING HOSPITAL OF TRIBHUVAN UNIVERSITY INSTITUTE OF MEDICINE, NEPAL

This paper has attempted to document and analyze the trend and experiences of foreignmedical students enrolled in the elective programme organized by the MedicalEducation Department (MED) at the Teaching Hospital of the Tribhuvan University(TUTH), Institute of Medicine in Kathmandu. Elective documents have been analyzedfor the period between 1997-2000 and a written questionnaire survey has beenadministered to a total of 73 foreign medical students who completed elective in theyear 2000. Over a period of four years a total of 268 students had undergone electiveposting in various departments of TUTH. More than half of the students (55%) camefrom European universities. More than 60% of respondents (n=73) considered theopportunity to see variety of patients as the main strength of the elective programme.Overwhelming majority of respondents (95%) rated the learning experience as goodor excellent. The most favoured department was the Internal Medicine. The studydemonstrates the unique value of elective in enriching student learning in medicaleducation. The traditional belief that all students should have a uniform curriculumthroughout their training has been largely challenged.1The insights gained couldperhaps, inspire medical schools to seriously think about introducing elective provisionas an essential component of their undergraduate curricula.1. Medical Education Department, TU Institute of Medicine.Address for correspondence : Dr. D. S. Pant, MD, MHPED,Assistant Director & Elective Programme Coordinator,Medical Education Department, TU Institute of Medicine,P.O. Box: 1524, Kathmandu, Nepal.Email: dspant@healthnet.org.np, Home Page: www.nchped.org.npKey Words: Elective terms, overseas elective, elective experience in developingcountries, core and elective options, undergraduate medical elective.

A rapid troponin-I-based protocol for assessing acute chest pain

In a prospective randomized open trial with 30-day follow-up, we compared a troponin-I-based protocol to 'standard management' for the diagnosis and risk stratification of patients with acute non-ST-elevation chest pain. Patients with acute chest pain (n=400) were randomized to standard diagnostic tests and management, or a protocol based on the admission ECG and the troponin-I result 6 h after onset of chest pain. Low-risk patients were discharged early from CCU; high-risk patients were treated with medical therapy or referred for in-patient angiography as appropriate. We measured length of CCU stay, and followed all patients for major adverse cardiac events (MACE) of death, non-fatal myocardial infarction (MI), or urgent revascularization during the admission and for 30 days post-discharge. The troponin protocol allowed earlier discharge in the low-risk group (10 vs. 30 h, p<0.001) with no excess of adverse events compared to standard management (3% vs. 5%, p=0.32). It identified a group of patients at moderate risk of cardiac events (15% MACE rate during admission and 30-day follow-up), and a high-risk group (75% MACE rate) more accurately than did standard management. The prognostic power of troponin testing in combination with the admission ECG was higher than with either test used alone. The protocol improved the efficiency of low-risk patient management, and improved patient risk stratification. This study adds to the evidence favouring troponin evaluation as part of the management of acute coronary syndromes.

Improvement in midwall myocardial shortening with regression of left ventricular hypertrophy

Despite normal indices of left ventricular (LV) chamber function, patients with LV hypertrophy (LVH) due to hypertension are thought to have depressed midwall systolic shortening compared with normotensives. The aims of the present study were (1) to confirm this observation and (2) to assess the effects of antihypertensive therapy that cause regression of LVH on LV systolic function assessed at both the midwall and endocardium. Thirty-eight previously untreated hypertensive subjects with LVH underwent echocardiography and were compared with 38 normotensive control subjects. Comparisons between the group with LVH and the control group revealed no significant differences in cardiac output (4. 32+/-0.23 versus 4.55+/-0.21 L/min), ejection fraction (62.5+/-2% versus 66.4+/-1.07%), or endocardial fractional shortening (34.5+/-1.45% versus 37.0+/-0.82%), but shortening assessed at the midwall was significantly less in the group with LVH (17.9+/-1.11% versus 21.6+/-0.63%, P<0.01). Subsequently, 32 patients with uncontrolled hypertension (24 previously untreated and 8 on existing antihypertensive therapy) underwent treatment with ramipril, with the addition of felodipine and bendrofluazide if required, to reduce blood pressure to <140/90 mm Hg. These 32 patients underwent echocardiography at baseline, after blood pressure control, and after an additional 6 months of tight blood pressure control. Good blood pressure control was achieved after 6 months compared with baseline (143/86+/-2.8/1.4 versus 174/103+/-4.1/1.9 mm Hg; P<0.01) with significant regression of LV mass index (124+/-3.4 versus 145+/-3.8 g/m(2), P<0.01). LV fractional shortening assessed at the midwall improved with regression of LVH (21.9+/-0.84 and 18.7+/-1. 19%, P<0.05), with posttreatment midwall shortening being similar to that of the normal control subjects evaluated in the first study. Hypertensive patients with LVH have depressed midwall systolic shortening despite normal indices of LV chamber function. Regression of LVH after good blood pressure control improved midwall shortening to normal levels.

Randomised comparison of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation

We designed a prospective, randomised, single-blind trial to compare the relative efficacy of antero-lateral versus antero-posterior paddle positions for DC cardioversion of persistent atrial fibrillation. A total of 59 patients were randomised to cardioversion using standard gel pads placed either in the antero-lateral (AL) or antero-posterior (AP) positions. The first synchronised shock was given at 360 J; if this was unsuccessful, a second shock of 360 J was given in the alternative position. We compared cardioversion success rate and energy requirements with each strategy. With the first 360 J DC shock, a significantly greater proportion of patients were restored to sinus rhythm from the antero-lateral position (18/30) compared to the antero-posterior position (10/29) (P=0.048). For those patients remaining in atrial fibrillation, there was no difference in the proportions cardioverted from the antero-lateral position (4/19) compared to the antero-posterior position (5/12) with the second 360 J DC shock (P=0. 22). The total cardioversion success rate was 23/30 (77%) for antero-lateral followed by antero-posterior shocks compared to a success rate of 14/29 (48%) for antero-posterior followed by antero-lateral shocks, and this difference was significant (P=0.024). There was no significant difference in the mean energy delivered for patients randomised to an initial antero-lateral shock (504 J), compared to patients given an initial antero-posterior shock (583 J) (P=0.1). We conclude that the antero-lateral paddle position appears more effective for DC cardioversion of persistent atrial fibrillation.

Randomised double blind trial of oral versus intravenous flecainide for the cardioversion of acute atrial fibrillation

OBJECTIVE

To investigate whether an oral loading dose of flecainide is as safe and effective as intravenous flecainide for the cardioversion of acute atrial fibrillation.

DESIGN

Prospective, randomised, double blind, double placebo study.

SETTING

Cardiac care unit of a large district general hospital in the UK.

PATIENTS AND METHODS

79 patients presenting with symptomatic acute atrial fibrillation: patients were given either intravenous flecainide (n = 39) or a solution of oral flecainide (n = 40), with appropriate placebos. All patients were heparinised during the study.

PRIMARY OUTCOME MEASURES

Safety; mean time to cardioversion; proportion of patients restored to sinus rhythm at two hours and eight hours after treatment. Analysis was by intention to treat.

RESULTS

There were no differences in baseline characteristics between the oral and intravenous groups. Both forms of flecainide were well tolerated, with no adverse clinical events during the study. The mean time to cardioversion was 110 minutes in the oral group and 52 minutes in the intravenous group (p = 0.002). Two hours after treatment, 27 of the 40 patients in the oral group (68%) and 25 of the 39 in the intravenous group (64%) had reverted to sinus rhythm (p = 0.74). Eight hours after treatment, 30 patients in the oral group (75%) and 28 in the intravenous group (72%) had reverted to sinus rhythm (p = 0.76).

CONCLUSIONS

Intravenous flecainide restored sinus rhythm more rapidly than oral flecainide, but at two hours and eight hours after treatment there was no difference in the proportion of patients cardioverted by the two approaches. These results suggest a role for oral loading doses of flecainide in the treatment of acute or symptomatic paroxysmal atrial fibrillation.

Absence of sympathetic overactivity in Afro-Caribbean hypertensive subjects studied by heart rate variability

Black hypertensives present a greater prevalence of left ventricular hypertrophy and an increased mortality compared to white hypertensives. Differences in sympathetic activity might contribute to explain these racial differences in hypertension. Nevertheless, previous laboratory studies did not show any increase of sympathetic activity direct to the heart in black subjects. The aim of the present study was to investigate the cardiac sympatho-vagal balance in black and white hypertensives analysing heart rate variability, during the entire 24 h. We analysed Holter recordings of 52 essential hypertensive patients, who had never received antihypertensive treatment, 26 of whom were black and 26 were white. Consecutive series of 300 beats, with 150 beats overlapped (approximately 600 series/day), were considered for the analysis in time and frequency domain. The mean 24-h value of the power of the low frequency spectral component (0.04-0.15 Hz), expressed in normalised units, ie a marker of sympathetic modulation, was significantly lower in the group of black patients compared to whites (respectively 40.0 +/- 2.1 vs 53.6 +/- 3.6 nu, P < 0.01). Similar results were observed for the LF/HF ratio, an index of the sympatho-vagal balance (respectively 4.11 +/- 0.58 vs 5.98 +/- 0.79; P < 0.05). In a multiple linear regression analysis, considering diastolic blood pressure, left ventricular mass index, race and age as independent variables, only race (P < 0.002) and age (P < 0.01) could independently predict the normalised low frequency power or the LF/HF ratio, as dependent variables. The results of this study suggest some blunting of the cardiac sympathetic neural modulation in black hypertensives compared to white hypertensives, during the entire 24 h.

QT dispersion in athletic left ventricular hypertrophy

OBJECTIVE

To assess whether physiologic left ventricular hypertrophy as a result of physical training is associated with an increased QT length or dispersion.

METHODS

Thirty-three subjects were assessed. These consisted of a group of international endurance athletes (including 8 rowers, 2 cyclists, and 1 triathlete), a group of 12 professional soccer players, and a further group of 10 control subjects. Each underwent 2-dimensional echocardiography and 12-lead electrocardiographic examination.

RESULTS

Left ventricular mass index was considerably greater in both the endurance athlete (163.3 +/- 14.4 g/m2; P <.01) and soccer player groups (144.2 +/- 5.5 g/m 2; P <.05) compared with the controls (109.2 +/- 6.3 g/m2). In spite of these large differences in cardiac structure there were no significant differences in QT parameters between the groups (QT dispersion 56.9 +/- 5.5, 68.5 +/- 9.5, and 67.2 +/- 12.6 ms; QTc dispersion 61.4 +/- 9.2, 69.4 +/- 13.3, and 54.2 +/- 6.5 ms; maximum QT 402 +/- 10.3, 404 +/- 9.6, and 392 +/- 14.0 ms; and maximum QTc 404 +/- 7.0, 413 +/- 9.3, and 399 +/- 9.9 ms among endurance athletes, soccer players, and controls, respectively).

CONCLUSION

Left ventricular hypertrophy occurring as a consequence of athletic training does not appear to be associated with a major increase in QT length or QT dispersion.

Influence of sub valvular pathology on immediate results and follow up events of Inoue balloon mitral valvotomy

We evaluated the influence of sub valvular pathology (SVP) on the immediate results and follow up events of Inoue Balloon Mitral Valvotomy (IBMY) in 206 patients with severe SVP (Group I) and compared their outcome with 206 age and sex matched patients selected from the rest of 619 patients having mild/moderate SVP (Group II). Pre-procedure echocardiographic recordings were reviewed and mitral valve morphology was evaluated using U.S. California Score. The severe SVP group had lower mitral valve areas (MVA) (0.7 cm2 vs. 0.8 cm2) and higher mean pulmonary artery pressure (MPAP) (46.3+/-16.9 mmHg vs. 40.7+/-16.25 mmHg) and mean pulmonary capillary wedge pressure (PCWP) (27.5+/-7.3 mmHg vs. 25.7+/-8.0 mmHg) (p<0.001). IBMV was done using standard technique. The procedure was technically successful in 192/206 patients (93.2%) in group I and 187/206 (91%) in group II (p=ns). The mean transmitral gradient decreased from 24.8+/-7.6 mmHg to 7.46+/-3.4 mmHg while mean PCWP fell from 27.5+/-7.3 mmHg to 12.2+/-5.6 mmHg and MPAP fell from 46.3+/-16.9 mmHg to 23.6+/-12.2 mmHg (p=<0.001). MVA increased from 0.7+/-0.2 cm2 to 1.7+/-0.4 cm2 (p=<0.001). Severe mitral regurgitation (MR) occurred in 2 patients out of which one patient, who had associated coronary artery disease, died post operatively, and moderate MR occurred in 8 patients. The results achieved in patients with severe SVP were not statistically different from those with mild/moderate SVP. The benefits achieved immediate post IBMV were sustained in 184 patients with severe SVP who were available for follow up at a mean duration of 15.2 months (range 3 months to 51 months). Thus IBMV is safe and effective in patients with severe SVP. This group of patients with severe SVP are more hemodynamically deranged pre-BMV and also achieve better hemodynamic benefit compared to those with mild/moderate SVP. Severe SVP does not have any adverse effect either on immediate results (success/occurrence of MR) or on intermediate term follow up.

The effect of reduction of door-to-needle times on the administration of thrombolytic therapy for acute myocardial infarction

Optimal management of acute myocardial infarction requires rapid administration of thrombolytic therapy. However, only patients who fulfill the following specific criteria are likely to benefit from this treatment: admission within 12 hours of the onset of symptoms, no contraindications, ST elevation or possible new-onset left bundle branch block on the admission electrocardiogram. We employed an aggressive policy to reduce the delay between admission to hospital and the administration of thrombolysis (the 'door-to-needle time'), and investigated whether this approach affected the accuracy of administration of thrombolysis. Patients admitted to the cardiac care unit with acute myocardial infarction, or who were thrombolysed, were identified retrospectively over two equivalent 4-month periods before and after implementation of our policy. Patients were considered eligible for thrombolysis if they fulfilled the criteria mentioned above. The mean (SD) door-to-needle time for all patients who received thrombolysis on admission decreased from 61(70) to 19(20) minutes (p = 0.0004). The proportion of patients eligible for thrombolysis who received treatment increased from 24/38 to 30/30 (p = 0.0002). However, the proportion of patients receiving thrombolysis who did not fulfill our criteria also increased, from 3/27 to 11/41 (p = 0.1). There were no complications of thrombolysis in the first study period, but two cerebrovascular accidents in the second period; both patients fulfiled our criteria for treatment. We conclude that simple educational measures greatly reduced door-to-needle times and led to a higher proportion of eligible patients receiving thrombolysis. However, greater pressure on medical staff to make rapid management decisions increased the proportion of patients being thrombolysed inappropriately.

Ethnic differences in the hypertensive heart and 24-hour blood pressure profile

Black hypertensive persons have been observed to have a greater degree of left ventricular hypertrophy than white hypertensives. However, previous studies have matched groups for blood pressure (BP) measured in the clinic, and it has been demonstrated that black hypertensives have an attenuated nocturnal BP dip. Clinic BPs may thus underestimate mean 24-hour BP in this group. To investigate whether the differences in left ventricular hypertrophy can be accounted for by the greater mean 24-hour BP in black hypertensives, 92 previously untreated hypertensives were studied with 24-hour ambulatory BP monitoring and echocardiography. The 46 black hypertensives (24 men and 22 women) were matched with the 46 white hypertensives for age, gender, and mean 24-hour BP. Despite similar mean 24-hour BPs (blacks, 142/93 mm Hg; whites, 145/92 mm Hg; P=.53/.66), the black group had a smaller mean nocturnal dip than the white group (blacks, 8/8 mm Hg; whites, 16/13 mm Hg; P<.01). In addition, mean left ventricular mass index (LVMI) was greater (blacks, 130 g/m2; whites, 107 g/m2; P<.001). Mean 24-hour systolic BP was significantly related to LVMI in both groups (blacks, r=.45, P<.01; whites, r=.56, P<.01). However, systolic BP dip correlated inversely with LVMI only in the black group (blacks, r=-.30, P<.04; whites, r=.05, P=.76). In a multiple regression model, LVMI was independently related to both mean daytime BP and mean nocturnal BP dip in black subjects but only to mean daytime BP in white subjects. In conclusion, the increased left ventricular hypertrophy observed in black hypertensives compared with white hypertensives is not accounted for by differences in mean 24-hour BP. However, LVMI in black hypertensives appears to be more dependent on nocturnal BP than that in white hypertensives; this, coupled with the attenuated BP dip in black hypertensives, suggests that the BP profile rather than 24-hour BP may be important in determining the differences in left ventricular hypertrophy.

Immediate and follow up results of Inoue balloon mitral valvotomy in juvenile rheumatic mitral stenosis

BACKGROUND AND AIMS OF THE STUDY

Juvenile rheumatic mitral stenosis (MS) with severe pulmonary venous and arterial hypertension (PAH) is a relatively common occurrence in developing countries. The study objectives were to evaluate the safety, efficacy and follow up of Inoue balloon mitral valvotomy (IBMV) in juveniles with rheumatic MS.

METHODS

A total of 193 patients with juvenile rheumatic MS were analyzed and compared with adults, with specific reference to the effect of IBMV on hemodynamics and pulmonary vasculature in patients with severe PAH.

RESULTS

Mitral valve areas were smaller (0.76 +/- 0.22 versus 0.81 +/- 0.22 cm2), while mean pulmonary arterial pressure (MPAP) (44.5 +/- 16.5 versus 38.4 +/- 15.1 mmHg) and pulmonary vascular resistance (PVR) (5.5 +/- 4.6 versus 4.41 +/- 4.04 Wood units) were greater in juvenile patients when compared with adults. There was a 99% procedural success. Juvenile patients showed an overall greater fall in MPAP and PVR when compared with adults. The incidence of severe PAH was much higher (32%) among juveniles than adults (16%). Only 5% of patients with juvenile MS with severe PAH had residual severe PAH immediately after IBMV, compared with 17% in older patients. Hemodynamic benefits (echocardiographic mean transvalvular gradient and mitral valve area) were sustained at a mean follow up of 29 months, and there was no documented case of restenosis after successful IBMV.

CONCLUSIONS

We conclude that IBMV is safe and effective in juvenile rheumatic MS and provides greater hemodynamic benefit compared with adults; such benefit is sustained during a mean follow up of 29 months.

Left ventricular geometry in presenting untreated hypertension

In order to investigate the spectrum of geometry in our patient population, 63 untreated hypertensives underwent two-dimensional echocardiography. Left ventricular (LV) mass index and relative wall thickness, a measure of wall thickness in relation to cavity size, were calculated from the M-mode strip. In addition, to assess the sphericity of the left ventricle the ratio of LV minor to major hemiaxis was calculated. The subjects comprised 41 men (17 Caucasian, 22 Afro-Caribbean and two Oriental), and 21 women (five Caucasian, 12 Afro-Caribbean and two Oriental). Concentric hypertrophy was present in 46% of subjects, concentric remodelling in 32% of subjects, eccentric hypertrophy in only 6% of subjects and a normal left ventricular shape in 16% of subjects. The degree of sphericity of the left ventricle was similar among the four groups, suggesting that it does not change in uncomplicated hypertension. In contrast to the previously published combined series from Sassari and New York we had a low proportion of patients with either eccentric hypertrophy or normal left ventricular geometry. This is probably due to the high proportion of Afro-Caribbean subjects in our clinic population who are more likely to have left ventricular hypertrophy.

Left ventricular hypertrophy, blood pressure and ACE genotype in untreated hypertension

It has been suggested that the deletion polymorphism of the angiotensin-converting enzyme (ACE) genotype may be important in the development of left ventricular hypertrophy (LVH). In order to test this hypothesis we investigated the interaction between blood pressure (BP), LVH and ACE genotype in 86 previously untreated hypertensive patients. Each underwent two-dimensional and Doppler echocardiography and ACE genotyping. There were no significant differences in BP, the parameters of left ventricular structure (including left ventricular mass index) or diastolic function between the three genotype groups. Additionally, there were no significant differences in the relationship between systolic BP and left ventricular mass index among the three genotype groups (II genotype, r = 0.46, P = 0.02; ID genotype, r = 0.42, P = 0.01; DD genotype, r = 0.34, P = 0.10; F = 0.38). In contrast to some previous studies, we have found in this group of previously untreated hypertensive subjects no evidence to suggest that the deletion polymorphism of the ACE genotype is important in the development of LVH.

Platelet aggregability and occurrence of restenosis following coronary angioplasty

Restenosis following percutaneous coronary angioplasty (PTCA) is a complex medical problem occurring in nearly a third of the patients undergoing PTCA with no single definite predictor demonstrated in an individual patient. Platelets are known to play an important role in the pathogenesis of the restenotic process. However, no known parameter of platelet function or activity has been studied as a risk factor predicting the occurrence of restenosis. We prospectively assessed platelet activation in twenty two consecutive patients with stable angina who underwent a successful PTCA for single vessel coronary artery disease. Platelet activation levels were measured using aggregability curves derived from unclotted blood samples on a platelet aggregometer using varying concentrations of adenosine di-phosphate (ADP) in the following time sequence: (1) Basal i.e. pre-PTCA, (2) post-PTCA day 1, (3) post-PTCA day 7, and (4) post-PTCA day 28. Occurrence of restenosis was studied using angiographic follow-up in all patients. At follow-up, seven of the twenty two patients studied developed restenosis. There was no significant difference or any specific trend noted over time in the levels of platelet aggregability in the study group as a whole (basal: 30.0 +/- 15.4%, post-PTCA day 1: 32.5 +/- 16.1%, post-PTCA day 7: 34.6 +/- 15.4% and post-PTCA day 28: 32.6 +/- 16.1%). However, when the patients were subgrouped into those with and without restenosis, the patients with restenosis had a significantly higher basal platelet aggregability (38.7 +/- 16.3%) versus those who did not develop restenosis (25.0 +/- 12.1%), p = 0.0128. We conclude that patients developing restenosis after PTCA have a significantly higher basal platelet aggregability and this could be used as a marker for its occurrence in an individual patient.

Absent conal septum in tetralogy of Fallot. An angiographic study

Absent conal septum in tetralogy of Fallot (TF) is usually noted intraoperatively when the ventricular septal defect (VSD) is found abutting the pulmonary valve, its superior rim being nearly inaccessible transatrially, and the posterior rim being separated from the tricuspid valve (TV) by a muscular ridge. The authors retrospectively analyzed angiograms of 208 consecutive patients with TF seen at their center from July 1989 to December 1995 for absence of the conal septum and the presence of an interval between the TV and the margin of the VSD in 30 degrees right anterior oblique view. In 13 (6%) patients, angiograms were inadequate or of poor quality for assessment and were excluded. Twenty-two of the remaining 195 (11%) patients had a large muscular interval between the tricuspid annulus and the margin of the VSD, which was associated with an absent conal septum in 14 (7.2%) and a diminutive septum in 8 (4%) patients. Nine of the 14 patients with an absent conal septum at angiography underwent surgery, and this finding was confirmed in all. The authors conclude that absent conal septum is not uncommon in TF and constitutes an important variation in its anatomy that can be identified preoperatively at angiography for optimal surgical management.

The effects on cardiac arrhythmias of antihypertensive therapy causing regression of left ventricular hypertrophy

To examine the effects of antihypertensive therapy causing regression of left ventricular hypertrophy on cardiac arrhythmias, 26 hypertensive subjects were treated with ramipril with felodipine if required, and followed for 6 months after blood pressure control. Compared with baseline, left ventricular mass index (LVMI) was significantly reduced both at blood pressure control and after a further 6 months of treatment (baseline, blood pressure control, 6 months after blood pressure control; LVMI 142 +/- 3.6, 131 +/- 3.4, 123 +/- 3.8* g/m2, *P < .01 compared with baseline). There was a significant relationship between the decrease in systolic blood pressure and the decrease in LVMI after 6 months of blood pressure control compared with baseline (r = 0.41, P = .05). Compared with baseline, the average total number of ventricular ectopics decreased after blood pressure was controlled (88 +/- 59 and 21 +/- 12 respectively); however this reduction was not maintained after 6 months of further treatment, either before (78 +/- 50) or after drug washout (86 +/- 40). Compared with baseline (639 +/- 590) supraventricular ectopic total was not initially reduced after blood pressure control (650 +/- 604), but was reduced after a further 6 months of treatment (294 +/- 261). This reduction was maintained after drug washout (267 +/- 254), although this did not reach statistical significance. Radionuclide scanning at baseline was not a predictor of patients with the highest risk of arrhythmia and there was no correlation between improvement or worsening of a defect with changes in ventricular ectopic total. In conclusion, antihypertensive therapy with ramipril and felodipine, although causing regression of left ventricular hypertrophy did not lead to a sustained reduction in ventricular ectopic total.

Left ventricular hypertrophy and QT dispersion in hypertension

The interlead variation in QT length on a standard electrocardiograph reflects regional repolarization differences in the heart. To investigate the association between this interlead variation (QT dispersion) and left ventricular hypertrophy, we subjected 100 untreated subjects to 12-lead electrocardiography and echocardiography. Additionally, 24 previously untreated subjects underwent a 6-month treatment study with ramipril and felodipine. In the cross-sectional part of the study, QT dispersion corrected for heart rate (QTc dispersion) was significantly correlated with left ventricular mass index (r = .30, P < .01), systolic pressure (r = .30, P < .01), the ratio of peak flow velocity of the early filling wave to peak flow velocity of the atrial wave (E/A ratio) (r = -.22, P = .02), isovolumic relaxation time (r = .31, P < .01), and age (r = .21, P < .04). In the treatment part of the study, lead-adjusted QTc dispersion decreased from 24 to 19 milliseconds after treatment, and after a subsequent 2 weeks of drug washout remained at 19 milliseconds (P < .01). The changes in left ventricular mass index at these stages were 144, 121, and 124 g/m2 (P < .01). Systolic pressure decreased from 175 to 144 mm Hg and increased again to 164 mm Hg after drug washout (P < .01). The E/A ratio (0.97, 1.02, and 1.02; P = 69) and isovolumic relaxation time (111, 112, and 112; P = .97) remained unchanged through the three assessment points. In conclusion, QT dispersion is increased in association with an increased left ventricular mass index in hypertensive individuals. Antihypertensive therapy with ramipril and felodipine reduced both parameters. If an increased QT dispersion is a predictor of sudden death in this group of individuals, then the importance of its reduction is evident.

Transesophageal dobutamine-atropine stress echocardiography: diagnostic accuracy for coronary stenosis detection and localization

Transesophageal echocardiography with dobutamine-atropine stress (TE-DASE) is a recently described technique for evaluation of coronary artery disease (CAD). We undertook this study prospectively to determine the feasibility, reliability and safety of this procedure in patients with known CAD and to evaluate its diagnostic accuracy for coronary stenoses of varying severity. Thirty-seven patients who underwent coronary arteriography (CART) and TE-DASE within a 3-month interval without intervening ischemic events or revascularisation were included in the study CART and stress echograms were independently evaluated by different observers. Stenosis was measured with calipers and a > or = 50% lumen diameter stenosis was considered significant. A reduction or lack of endocardial motion and/or wall thickening on progressive incremental stress was considered an abnormal response. TE-DASE could be successfully completed in 33/37 (90%) patients. Using a modified 16-segment model of the left ventricle (LV), 15.2 +/- 0.8 segments/patient and 501/528 (95%) segments overall could be optimally evaluated. Inter-observer concordance for an abnormal response was 94%. Predictive accuracies for one-vessel disease (1-VD), two-vessel disease (2-VD) and three-vessel disease (3-VD) were 88, 58 and 23% respectively. Overall sensitivity for detection of a significant (> or = 50%) stenosis was 72% (32% for moderate (50-69%), 90% for severe (> or = 70%) stenosis) and specificity was 96%. Diagnostic accuracy for localisation of significant stenosis was 95% for the left anterior descending artery (LAD), 86% for the left circumflex artery (LCX) and 88% for the right coronary artery (RCA). There were no major complications. We conclude that TE-DASE is a safe, reliable and easily-performed procedure and provides excellent visualisation of myocardial segments. Diagnostic accuracy for detection of severe stenosis and its localisation is excellent.

Plasma mediated neutrophil stimulation during coronary angioplasty: autocrine effect of platelet activating factor

BACKGROUND

Polymorphonuclear neutrophils are involved in the development of myocardial injury during ischaemia and reperfusion. Coronary angioplasty has been shown to result in neutrophil activation. This may be a result of contact with ligands expressed by endothelial cells or response to soluble stimuli released from ischaemic tissue into the plasma or both.

OBJECTIVE

To investigate plasma mediated neutrophil activation during angioplasty.

METHODS AND RESULTS

Plasma samples were collected from the coronary sinus, femoral artery, and femoral vein of 14 patients undergoing angioplasty, before and after the first balloon inflation and at the end of the procedure. Plasma samples were incubated with washed neutrophils isolated from healthy donors. Expression of the adhesion molecules CD18 integrin and L-selectin (Leu-8) was measured by flow cytometry, and superoxide anion production was measured by chemiluminescence. Plasma samples from the coronary sinus and femoral artery but not from the peripheral vein induced increased expression of neutrophil CD18 after balloon deflation. Modification of the expression of L-selectin was not noted. Production of superoxide anion by neutrophils was stimulated by plasma samples from the coronary sinus, but not by those from the femoral artery or vein. This plasma mediated neutrophil stimulation was prevented when the neutrophils were pretreated with platelet activating factor receptor antagonists BN52021 or BN50739. The platelet activating factor concentration detected in the coronary sinus was not higher than in control plasma.

CONCLUSION

Brief ischaemia during coronary angioplasty leads to the release of soluble stimuli capable of inducing neutrophil integrin expression and free oxygen radical production. Platelet activating factor may act as an autocrine neutrophil stimulus under these conditions.

The effects of antihypertensive therapy on carotid vascular structure in man

OBJECTIVE

An increased carotid intima-media thickness (IMT) has been found to be associated with a number of cardiovascular risk factors such as age, hypertension, cigarette smoking, hypercholesterolaemia and left ventricular hypertrophy. Our objective was to assess whether carotid intima-media thickness in hypertensive patients could be reduced by antihypertensive therapy.

METHODS

13 hypertensive patients, 10 previously untreated, were examined using carotid ultrasonography and echocardiography at baseline and then at 8 weeks and 39 weeks after commencement of antihypertensive therapy with ramipril and the second-line addition of felodipine.

RESULTS

By the end of the study significant regression of IMT (0.1(0.05-0.16) mm, F-value 10.2, P < 0.01) and left ventricular mass index had occurred (25(10.7-39.3) g/m2, F-value 9.7, P < 0.01). The reduction in IMT was significantly related to the reduction in mean arterial pressure, r = 0.55, P = 0.05).

CONCLUSION

Antihypertensive therapy with ramipril and felodipine causes regression of IMT in hypertensive patients, probably chiefly through blood pressure reduction. Large prospective studies are required to assess whether a reduction in IMT results in a reduction in morbidity and mortality.

Left ventricular diastolic function in hypertension: a 4 year follow-up study

In order to assess the long term effects of antihypertensive treatment on left ventricular diastolic function, 26 hypertensive patients were followed up for a mean of 4.25 years with two-dimensional and Doppler echocardiography. A significant reduction in left ventricular mass index was first apparent after 9 months of therapy (mean (S.D.) 124 (22) vs. 114 (18) g/m2, P < 0.01), and this was maintained over the 4.25 year period (124 (22) vs. 117 (17) g/m2, p < 0.05). At 9 months there was no change in either isovolumic relaxation time (108 (26) vs. 108 (17) ms, P = N.S.) or left ventricular filling as assessed by peak flow velocity E/A ratio (0.94 (0.22) vs. 0.95 (0.27), P = N.S.). However, after 4.25 years there was a significant improvement in IVRT (108 (26) vs. 83 (11) ms, P < 0.01) with a trend towards an improved peak flow velocity E/A ratio, although this did not reach statistical significance (0.95 (0.27) vs. 1.02 (0.26), P = N.S.). Of the 14 patients who had an abnormal isovolumic relaxation time at baseline, 12 normalised and 2 improved. These findings suggest that left ventricular diastolic dysfunction in hypertension may be reversed by prolonged antihypertensive treatment.