Leadless cardiac pacemaker in elderly patients: How old for a new technology?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Leadless transcatheter pacemakers are considered as a safe and effective option for cardiac pacing in patients (pts) at higher risk of complications with conventional transvenous cardiac pacing.

Purpose

Our aim was to assess the clinical "real-life" feasibility and outcomes of leadless pacing in elderly pts in a high-volume center over a mid-term follow-up (FU) period.

Methods

Elderly pts (aged ≥ 75 years) who underwent leadless MICRA® system pacemaker implantation with a FU period above 3 months were included in this retrospective monocentric study.

Results

130 pts were included (84 ± 5.6 years old, male 66.2%). Indications were: Atrioventricular block (permanent 15.4%; transient 27.7%), atrial fibrillation bradycardia 50% and sinus node dysfunction 6.9%. Leadless system pacing was preferred over conventional pacing in pts with: transvenous pacemaker extractions due to infectious 18.5% or vascular 1.5% complications; active systemic infection and urgent need for cardiac stimulation 20%; complex conventional vascular approach 21.6%; severe tricuspid valve disease 1.5%; deterioration of general condition and clinical frailty 22.3%; shortly after transvalvular aortic valve replacement 8.5%. Among the pts, 6.2% had previous leadless Nanostim® device implantation with dysfunction of the system. Pts had either local anesthesia 13.2% or deep sedation 86.8%. The average fluoroscopy time was 4.3±2.9 minutes and number of device deployments before the final position ranged from 1 to 7 with a mean value of 1.5±1 positions. Pacing threshold during implant was 0.5±0.4 V at 0.24ms, only 4 pts (3%) had an implant threshold of >1.0 V at 0.24 ms. Two postoperative deaths were observed: 1 cardiac arrest related to myocardial dysfunction and consequent pulmonary edema in a patient with advanced heart failure, and 1 death secondary to myocardial perforation with need for surgical repair that occurred among the first implantations with an apical device position and a patient with multiple comorbidities. The total rate of major complications was 2.3% with only 1 vascular complication at the femoral puncture site. The median time from the leadless pacemaker implant procedure to discharge was 5±6.5 days (minimum 1 and maximum 40 days): 55.6% pts were able to leave the cardiology department within the first 72 hours. The mean FU period was 17 months ± 15 months with a mortality rate of 12.3% (cardiovascular impairment 5.4%; non cardiovascular-related deaths 6.9%). Increase in pacing thresholds was noted in 4 pts with subsequent stabilization; 92.2% of pts presented with thresholds lower than 1V at 0.24 ms. All pts remained free of infections during FU with no cases of device dislodgement observed.

Conclusion

Elderly pts are at higher risk of complications; our experience confirms their clinical frailty and underlines the favorable safety profile of leadless system pacing with a low rate of complications and stable pacing thresholds.

Serum ghrelin level is associated with cardiovascular risk score

Ghrelin, a newly discovered bioactive peptide, was originally reported to induce growth hormone release. Recent studies have shown beneficial hemodynamic effects of ghrelin in the cardiovascular system to support the wide distribution of its receptors in cardiovascular tissues. The aim of the study was to determine whether cardiovascular risk factors influence plasma ghrelin levels.

METHODS

We evaluated in the Rehabilitation Hospital Cluj-Napoca, Cardiology-Department 88 consecutive subjects, 65 (73.86%) being women, with mean age 61.7 +/- 10.33 years. We assessed the presence of cardiovascular risk factors (obesity, arterial hypertension, diabetes mellitus, metabolic syndrome, smoking and lipid fractions). Plasma ghrelin levels were determined with a commercial ELISA kit (pg/ml).

RESULTS

After the evaluation of cardiovascular risk factors, we found no statistically significant difference between ghrelin levels in the patients with vs those without cardiovascular risk factors (p>0.05). A negative correlation was found between ghrelin levels and age, r = -0.32 (p <0.05). Using the HeartScore Internet tool we calculated the cardiovascular risk for each patient according to the risk score system (SCORE) for high cardiovascular risk countries. Statistically, the risk of fatal cardiovascular events in the next 10 years was indirectly correlated with the ghrelin levels in each patient-correlation between ghrelin levels and SCORE system r = -0.25, p=0.015. In conclusion, low serum ghrelin concentrations are associated with an increased global cardiovascular risk, calculated based on the European SCORE scale. However, we could not demonstrate a direct relationship between any of the major risk factors and ghrelin.

Isolated Bell's palsy - an unusual presentation of dengue infection

Dengue fever is a very common arthropod - borne infection in tropical countries. Neurological complications in dengue fever are relatively uncommon and among these, isolated cranial neuropathies have been reported only very rarely. We present an unusual neurological complication of Bell's palsy (lower motor neuron 7 th nerve palsy) associated with dengue infection. To the best of our knowledge, there have been very few documented cases of Flavivirus causing isolated Bell's palsy.

Activation of the Cardiac Proteasome During Pressure Overload Promotes Ventricular Hypertrophy

BACKGROUND

The adaptation of cardiac mass to hemodynamic overload requires an adaptation of protein turnover, ie, the balance between protein synthesis and degradation. We tested 2 hypotheses: (1) chronic left ventricular hypertrophy (LVH) activates the proteasome system of protein degradation, especially in the myocardium submitted to the highest wall stress, ie, the subendocardium, and (2) the proteasome system is required for the development of LVH.

METHODS AND RESULTS

Gene and protein expression of proteasome subunits and proteasome activity were measured separately from left ventricular subendocardium and subepicardium, right ventricle, and peripheral tissues in a canine model of severe, chronic (2 years) LVH induced by aortic banding and then were compared with controls. Both gene and protein expressions of proteasome subunits were increased in LVH versus control (P<0.05), which was accompanied by a significant (P<0.05) increase in proteasome activity. Posttranslational modification of the proteasome was also detected by 2-dimensional gel electrophoresis. These changes were found specifically in left ventricular subendocardium but not in left ventricular subepicardium, right ventricle, or noncardiac tissues from the same animals. In a mouse model of chronic pressure overload, a 50% increase in heart mass and a 2-fold increase in proteasome activity (both P<0.05 versus sham) were induced. In that model, the proteasome inhibitor epoxomicin completely prevented LVH while blocking proteasome activation.

CONCLUSIONS

The increase in proteasome expression and activity found during chronic pressure overload in myocardium submitted to higher stress is also required for the establishment of LVH.

Effect of treatment with nebivolol on parameters of oxidative stress in type 2 diabetics with mild to moderate hypertension

AIM

The aim of this study was to examine the effect of the cadioselective B(1)-adrenoceptor blocker nebivolol on glycaemic control, lipid profile and markers of oxidative stress in patients with type 2 diabetes over a 6-month period.

METHODS

Twenty-six patients with mild to moderate hypertension (140-160 mmHg systolic, 90-105 mmHg diastolic) confirmed on 24-h blood pressure monitoring, were treated with nebivolol 5 mg daily for 6 months. Total serum cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) subfractions, lipid hydroperoxides (LHPs) and total antioxidant capacity (TAC) were measured before and after 6 months of treatment.

RESULTS

Nebivolol, as expected, reduced mean daytime systolic and diastolic pressures on ambulatory monitoring (149 +/- 9 to 140 +/- 13 mmHg, P = 0.02 and 84 +/- 7 to 77 +/- 9 mmHg, P < 0.001). There were no significant changes in serum cholesterol or triglycerides following treatment but a significant increase in HDL cholesterol was noted (1.12 +/- 0.19 to 1.25 +/- 0.36 mmol/L, P = 0.008). Patients showed a highly significant reduction in TAC from 501 +/- 57 to 422 +/- 29 trolox equivalent (P < 0.001). Baseline LHPs were very high and showed no significant change over the 6-month period (18.7 +/- 7.4 and 18.7 +/- 10.9 micromol/L). The LDL score increased significantly from 1.7 +/- 0.7 to 2.3 +/- 0.7 (P = 0.0002) at 6 months suggesting a change to a more atherogenic lipid profile. Neither weight nor glycaemic control changed during treatment.

CONCLUSION

Nebivolol appears to be lipid neutral and may even have a positive effect on HDL cholesterol. Despite this it may promote the formation of potentially atherogenic LDL subfractions possibly as a result of reduced antioxidant defences. Further studies are needed to clarify the changes observed in parameters of oxidative stress.

Peripheral blood and BM CD34+ CD38− cells show better resistance to cryopreservation than CD34+ CD38+ cells in autologous stem cell transplantation

BACKGROUND

We and others have shown a critical role for CD34+ CD38- cells in hematopoietic recovery after autologous stem cell transplantation (ASCT), in particular for platelet reconstitution. Thus a routine assessment of CD34+ CD38- cells in freezing-thawing procedures for autografting could represent an important tool for predicting poor engraftment.

METHODS

To compare the impact of cryopreservation on CD34+ CD38+ and CD34+ CD38- hematopoietic stem cell subsets, 193 autograft products collected in 84 patients with malignancies were assessed before controlled-rate cryopreservation in 10% DMSO and after thawing for autografting.

RESULTS

Cell counts after thawing were significantly different from the pre-freezing counts for total CD34+ (P<0.0001) and CD34+ CD38+ (P<0.0001) cells, but not for CD34+ CD38- cells (P=0.252). Median losses for CD34+, CD34+ CD38+ and CD34+ CD38- cells were, respectively, 11.8%, 11.4% and 0.0%. The magnitude of fresh/post-thawing percentage cell variation was significantly different when comparing between the CD34+ CD38+ and CD34+ CD38- cell subsets (P<0.001). Moreover, CD34+ CD38- cells exhibited recovery values > or =100% in 85/160 graft products, compared with 51/193 in CD34+ CD38+ cells (P<0.0001). Also, recovery values > or =90% were significantly better in the CD34+ CD38- (98/160 grafts) than in the CD34+ CD38+ subsets (89/193 grafts) (P<0.01).

DISCUSSION

In this work we have demonstrated that CD34+ cells that do not express the CD38 Ag show a significantly better resistance to cryopreservation. This could represent another example of the particular ability of less committed progenitor cells to overcome environmental injuries. Moreover, we consider routine assessment of CD34+ CD38- cells before freezing as clinically relevant, but post-thawing controls may be avoided because of their good resistance to freezing.

Insulin resistance--the new goal!

Diabetes mellitus is a well-recognized risk-factor for coronary artery disease (CAD). Epidemiological studies have shown that the risk of CAD increases two to sixfold in patients with type 2 diabetes compared with those without the disease. Furthermore the prevalence of diabetes in the UK has increased by 30% since 1991 and the world population of people with diabetes in 2010 is expected to be twice that of 1990. In addition whilst the mortality from CAD in patients without diabetes has declined over the past 20 years the mortality in men with type 2 diabetes has not changed and in women may have increased. UKPDS and other studies have shown a significant improvement in the onset and course of microvascular complications with good diabetic control. However the same is not true for macrovascular complications for which there is no good evidence of improvement with better diabetic control. This apparent lack of benefit from improved care of diabetic patients has led to many different approaches. These include attempts to achieve even better glycaemic control, greater emphasis on other risk factors particularly hypertension and interestingly attention to the prediabetic state characterized by insulin resistance (IR). The latter is associated with a number of abnormalities which could play a causative role in the development of cardiovascular disease. This article will review the concept of IR and the possible interventions available to tackle it.

gamma-Hydroxybutyrate ligands possess antidopaminergic and neuroleptic-like activities

The action of agonists or antagonists at the gamma-hydroxybutyrate (GHB) receptor represents a possibility to modulate dopaminergic activities in brain. In the present study, GHB and six structural analogs were tested for their ability to displace [3H] GHB binding from striatal membranes. All the analogs tested exhibited higher affinity for GHB as compared with GHB itself. Parallel experiments were carried out on striatal slices in order to determine IC50 values for inhibition of dopamine release in the presence of these compounds. All substances inhibited dopamine release with higher potency as compared with GHB itself. These antidopaminergic activities were confirmed in several neuropharmacological tests, usually used to predict neuroleptic activities in vivo. There appears to be a relationship between the affinity for the GHB striatal low-affinity receptor and the inhibition of dopamine release on one hand, and the antidopaminergic activity (as revealed by the in vivo tests) on the other hand. Thus, it is suggested that GHB agonists possessing antidopaminergic activities, may represent potential drugs endowed with neuroleptic properties.

Parkinsonism and acquired hydrocephalus

Left hemiparkinsonism was the first symptom of increased intracranial pressure in a 14-year-old girl. The parkinsonism resolved when the increased intracranial pressure was relieved by a ventriculo-peritoneal shunt. This is the first case of parkinsonism associated with hydrocephalus caused by non-neoplastic aqueductal stenosis.

[Incidence of asymptomatic gallstones in hospital patients]

A total of 1512 hospital patients was screened by ultrasound to evaluate the prevalence of asymptomatic gallstones. Before ultrasound examination each patient filled in a form about his or her symptoms. In 1122 subjects no gallstones were found. 134 subjects had been cholecystectomized, 165 subjects had symptomatic and 91 subjects had asymptomatic gallstones, respectively. An asymptomatic gallstone was prospectively defined being "silent" when no abdominal complaints had occurred. Women had gallstones or cholecystectomy twice as often as men. 34% of the gallstones in men and 36% of the gallstones in women being asymptomatic. Seventy nine percent of the subjects with an asymptomatic stone did not know about their gallstones. The fraction of subjects with gallstones or cholecystectomy and the fraction of gallstones being asymptomatic, both increased with age. Nausea occurred in 5% of the subjects with asymptomatic gallstones, but in 39% of those with symptomatic gallstones or cholecystectomy. Subjects with asymptomatic gallstones complained about food intolerance significantly less often than subjects with symptomatic gallstones or subjects after cholecystectomy.

[Preoperative diagnosis of intra-abdominal diseases. Reliability of sonography and computer tomography]

In a retrospective study the reliability of ultrasound and computed tomography was compared and evaluated using the subsequent intraoperative findings. The analysis comprised ultrasound and computed tomography data of 111 consecutive patients in whom both investigations were performed within one week and whose diagnoses could be ascertained intraoperatively within two weeks. The correct diagnosis was made preoperatively in 80 out of 111 patients by ultrasound (sensitivity 72%) and in 95 out of 111 patients by computed tomography (sensitivity 85%). The results show that computed tomography is superior to ultrasound in preoperative diagnosis of intraabdominal diseases (P less than 0.025). In particular, liver and adrenal tumours and diseases of the air-filled gastrointestinal tract can be diagnosed more reliably preoperatively by computed tomography than by ultrasound.

Salivary secretion in reflux esophagitis

It has been speculated that impaired salivary flow and contents contribute to abnormal acid clearance in patients with reflux esophagitis. To test this hypothesis, salivary secretion of volume, bicarbonate, and N-acetylneuraminic acid was measured in patients with reflux esophagitis, in age- and sex-matched controls, and in healthy young volunteers. Resting saliva was collected by permitting the saliva to drip into a flask every 30 s. Parotid saliva was collected by means of a Lashley capsule during stimulation by oral infusion of 1 ml/min of 2% citric acid. Total mixed saliva was collected by a dental sucker during esophageal perfusion with water and 10-mM hydrochloric acid. The volume of resting saliva and its concentration of bicarbonate were similar in the three groups. The concentration and the output of N-acetylneuraminic acid were higher in the young volunteers than in the two other groups. The volume flow and the composition of stimulated parotid saliva were similar in the three groups of subjects. Volume of total mixed saliva and concentration of bicarbonate and N-acetylneuraminic acid during esophageal perfusion with water were higher in patients with reflux esophagitis than in age- and sex-matched controls and were similar to the values found in young healthy volunteers. Acid perfusion increased the secreted volume of total mixed saliva by 150% and the concentration of bicarbonate by 30% in healthy young volunteers, but not in patients with reflux esophagitis and in the healthy age- and sex-matched controls; the concentration of N-acetylneuraminic acid was left unaffected by acid perfusion in all three groups. These findings disprove the hypothesis of impaired salivation in reflux esophagitis. The age-related loss of salivary response to acidic esophageal perfusion might be the reason why reflux esophagitis with peptic lesions affects predominantly elder people.

Detection of Crohn's disease by ultrasound

The target appearance of grey scale ultrasound is thought to be a characteristic sign of gastrointestinal wall thickening. It consists of a strong echogenic center surrounded by a sonolucent rim. In a prospective controlled study, the sensitivity and specificity of the ultrasonic B-scan for Crohn's disease were investigated. Fifty-one patients with Crohn's disease and 124 control subjects were studied. Sensitivity and specificity of the ultrasonic target appearance for Crohn's disease were 76% and 88%, respectively. When additional ultrasonic signs of inflammatory bowel disease were considered, sensitivity and specificity rose to 84% and 91%, respectively. Both colon and ileum were affected in 85% of the true-positive and in 8% of the false-negative targets. The Crohn's disease activity index was 213 +/- 136 in patients with true-positive targets and 167 +/- 118 in patients with false-negative target appearances. Most false-positive target phenomena arose from gastrointestinal tumors. It is concluded that ultrasound is a suitable complementary method for the detection of Crohn's disease.

Predictors of duodenal ulcer healing and relapse

Predictors of duodenal ulcer healing and relapse were examined in a population known to have a high healing incidence. Two double-blind prospective studies were performed in 134 patients over 4 wk and in 66 patients over 1 yr, respectively. Short-term treatment consisted either of cimetidine 1 g/day, pirenzepine 75 mg/day, or placebo. In a multiple stepwise linear regression analysis the following factors proved to increase healing incidence in decreasing order of importance: female sex, moderate alcohol consumption, abstinence from smoking, young age, and cimetidine treatment. The following factors had no influence on duodenal ulcer healing: number and total area of peptic lesions, concomitant disease, relatives with duodenal ulcer, duration of duodenal ulcer disease, and status as a migrant worker. In the long-term study, treatment consisted either of cimetidine 400 mg at bedtime, pirenzepine 30 mg at bedtime, or placebo. Cimetidine prevented ulcer relapse. Smoking favored duodenal ulcer relapse in the placebo group, but not in the cimetidine and pirenzepine group. For all the other factors no statistically significant effect was found. It is concluded that in a population with high spontaneous healing incidence (a) factors other than drug treatment such as sex, alcohol intake, smoking, and age are at least as important predictors of the outcome of short-term treatment as the drug treatment itself; (b) moderate alcohol intake might favor ulcer healing; (c) the unfavorable effect of smoking on ulcer relapse is overcome by low-dose, long-term, antisecretory treatment.

[Is the sonographic diagnosis of hepatic cirrhosis and hepatic metastases reliable (author's transl)]

In a prospective study the reliability of the sonographic diagnosis of hepatic cirrhosis and metastases was investigated in 101 patients. Sonographic diagnoses were checked by laparoscopy. Hepatic cirrhosis was accurately diagnosed in 78% of the cases and hepatic metastases were correctly diagnosed in 92% of cases. The absence of cirrhosis or metastases was correctly recognised in 93% and 98%, respectively. The sonographic diagnosis of liver cirrhosis is based on five criteria: convexity of the ventral surface, caudal margin greater than 45%, rigid contours on palpation diffuse density of the internal structure, and splenomegaly. The most important criterium for the diagnosis of metastases is the presence of circumscribed contour changes. In 32 patients with cirrhosis and in 12 patients with metastases one diagnosis was incorrect. Thus sonography has a high accuracy in the diagnosis of hepatic cirrhosis and metastases.

[Prevention of duodenal ulcer recurrence with cimetidine (author's transl)]

The effect of long-term prophylaxis of duodenal ulceration with cimetidine was tested in a double blind trial. In 20 patients treated with cimetidine there was a four-fold reduction in the relapse rate when compared with 18 placebo-treated patients. However, treatment of the acute phase of ulceration with cimetidine increased the recurrence rate more than five-fold when compared with placebo treatment. Slow healing of ulceration was followed by a two-fold incidence of recurrence when compared with rapid healing. From the results it is concluded that recurrence occurs in patients after slow healing and (or) previous cimetidine treatment if long-term prophylaxis with cimetidine is not carried out.

[Cimetidine in the treatment of duodenal ulcer (author's transl)]

In a double-blind trial of patients with duodenal ulcer at three centres the healing rate after a four-week course of treatment (1 g cimetidine daily) was 79% (30 out of 38 patients), compared with 58% (23 out of 40 patients) on placebos. Cimetidine did not effect subjective symptoms or the need for antacids to relieve pain, except for a minor beneficial effect on diurnal ulcer symptoms during the second week of treatment. Results of long-term administration suggest that cimetidine at 400 mg daily prevent s relapses, but the possibility of an increased relapse rate after cimetidine withdrawal can not as yet be excluded.

Transport of radioactivity from primary auditory neurons beyond the cochlear nuclei

Transneuronal degeneration in secondary brainstem auditory nuclei has been described following cochlear lesions, and Marchi studies have revealed degeneration in the trapezoid body after such lesions. These findings support the view of some early neuroanatomists that primary auditory afferents project beyond the cochlear nuclei. Silver impregnation studies of degenerating cochlear afferents have failed to support this claim, leaving the question unresolved. Using [3H] amino acids auditory projections in the monkey were traced autoradiographically from labeled ganglion cells: (1) in all portions of the spiral ganglion, (2) in apical and middle turns of the cochlea and (3) primarily in the basal turn of the cochlea. Labeling of the entire spiral ganglion resulted in profuse transport of isotope to parts of all cochlear nuclei [anteroventral (AVCN), posteroventral (PVCN), and dorsal (DCN) cochlear nuclei]. Labeled axons entering the trapezoid body (TB) projected ipsilaterally to: (1) the lateral trapezoid nuclei (LTN), (2) the lateral superior olivary nucleus (LSO), (3) the dorsal dendritic zone of the medial superior olivary nucleus (MSO), and (4) the pericollicular or cortical nucleus of the inferior colliculus (IC). Auditory fibers crossing the midline in the TB projected contralaterally to: (1) the medial trapezoid nucleus (MTN), (2) the ventral dendritic zone of the MSO, (3) the ventral nucleus of the lateral lemniscus (VNLL), and (4) the central nucleus of the inferior colliculus (CNIC). Selective labeling of cells in the apical and middle ganglionic turns ofthe cochlea resulted in a similar pattern of centripetal transport. Selective [3H] uptake primarily by ganglion cells in the basal turn of the cochlea resulted in: (1) labeling of restricted parts of all cochlear nuclei, and (2) a considerable reduction of isotope transported beyond the cochlear nuclei. Labeled fibers in the TB were distributed sparsely in the ipsilateral LTN, LSO and dorsal dendritic zone of the MSO. Fibers in the TB were not labeled contralaterally in these animals. Interpretation of these data considers the possibility of transneuronal isotope transport. The pattern of isotope transported beyond the cochlear nuclei does not correspond to the secondary projections of any individual cochlear nucleus, although it bears some resemblance to that of the AVCN. The current study suggests that some primary auditory afferents project beyond the cochlear nuclei.

[Controlled trials of premedication of fiberendoscopy (author's transl)]

In four controlled studies on 771 consecutive patients we tested the value of premedication before passing a fiberendoscope. Following local anaesthesia of the throat, 10 mgs of diazepam in patients less than 60 years and 5 mgs in those over 60 years quickly injected intravenously caused a sufficient premedication for fiberendoscopy. Premedication with diazepam is better than placebo. We fell that omission of premedication is not justifiable. Flunitrazepam, for premedication, in doses of 1-2 mgs did not prove to be suitable. 20 patients were radiologically controlled for signs of aspiration following premedication and endoskopy. They showed no signs of aspiration.

Treatment of acute viral hepatitis with (+)-cyanidanol-3

A double-blind trial of (+)-cyanidanol-3 (2 g/day) versus placebo tablets was carried out in 100 patients with acute viral hepatitis. 51 received the drug and 49 placebo. (+)-Cyanidanol-3 accelerated the disappearance of HBsAg from the blood, lowered serum-bilirubin, and relieved symptoms such as anorexia, nausea, and pruritus. The drug was well tolerated. None of the patients had a relapse of acute hepatitis. Chronic active hepatitis developed in 1 of the placebo-treated patients. Thus, (+)-cyanidanol-3 seems to be of benefit in acute viral hepatitis.

[Postoperative stress hemorrhage: ineffective prevention with pepsin inhibitor and deglycyrrhizinized licorice extract. Prospective study]

A double blind controlled study on prophylaxis of postoperative gastrointestinal bleeding from stress lesions was performed. Both tragant sulfate, a pepsin inhibitor, and deglycyrrhizinized liquorice extract proved to be without prophylactic effect.

[A prospective study of post-operative bleeding from stress lesions. I. Epidemiology (author's transl)]

Among 5776 patients operated on under general anaesthesia there was an increased risk of postoperative gastro-intestinal bleeding from stress lesions among those aged over 70 years, after major surgery, or with complications such as hypovolaemia, septicaemia or respiratory failure (n = 551). In this group of patients the incidence of fatal haemorrhage was 0.5%. Stress lesions were a certain cause of bleeding from the gastro-intestinal tract in 5.1% and a probable one in 5.1%. Time of year, sex, past history of peptic ulcer, or anticoagulation did not increase the risk of bleeding.

[Diagnosis of chronic pancreatitis]

The fact that a large number of pancreatic explorations have been proposed shows that now are really satisfactory. Generally speaking, it is true that instrumental techniques are relatively affirmative, whereas less aggressive methods are more uncertain. It is shown that a proper association of simple tests offers the general practitioner a 75% certainty of diagnosing pancreatic disease. Scintiscanning, zonography, angiography and retrograde pancreatography have been proposed in recent years, but they are complicated and demand considerable experience. In combination, they permit certain diagnosis in about 95% of cases. An experimenter may specialise in one or several of these techniques. Diagnosis of pancreatic disease is beyond the capacity of the general practitioner and requires the cooperation of several specialists, or examination at a large medical centre.

[Oesophageal function in patiensts with angina (author's transl)]

Oesophageal functions were measured in 18 patients with angina, 13 healthy volunteers and 29 age-matched patients with reflux disease. Acid clearance was as abnormal in angina patients (88 +/- 46 swallows) as in those with reflux disease (97 +/- 45). The pressure in the lower oesophageal sphincter was low in patients with angina (13 +/- 8 mm Hg). The incidence of hiatal hernia, subjective symptoms during acidification of the oesophagus and results of the reflux provocation test were similar in patients with angina pectoris and healthy controls.

The effect of difenoxin on the lower esophageal sphincter pressure in man

Difenoxin, a new antidiarrheal agent, had no effect on lower esophageal sphincter pressure in man when given at an oral dose of 2 mg. Thus, this drug does not appear to cause or aggravate symptoms of gastro-esophageal reflux and may safely be used in reflux patients.