Nerium oleander could be used for sustainable management of traffic-borne elemental-enriched roadside soils

Metal pollutants released from motor vehicles are deposited in roadside environments. Metals are non-biodegradable and biomagnify in the food chain causing significant health hazards at all levels of the ecosystem. Hence, management of contaminated roadside verges is critically important and should be kept in mind while planning specific management strategies of such areas. Native vegetation could help to decontaminate heavy metal polluted soils in the best sustainable way. Therefore, this study was designed to assess the potential of Nerium oleander to accumulate heavy metals commonly released by automobiles such as Pb, Cd, Ni, and Zn along with various C and N compounds from five different locations along a busy road in Punjab, Pakistan, during summer and winter seasons. N. oleander showed the ability to absorb C, N, and heavy metals Pb and Cd; the maximum concentration of Pb and Cd was 8.991 mg kg-1 and 0.599 mg kg-1, respectively. These pollutants negatively affected photosynthetic pigments, gas exchange attributes, soluble proteins, and free amino acids. But antioxidant activity of N. oleander was found to be increased in both seasons. The metal accumulation in the plant was higher in the summer though. We highly recommend that by growing N. oleander at roadside verges for decontamination of vehicular pollutants could lead to sustainable management of these corridors.

Group B Streptococcus (GBS) colonisation is dynamic over time, whilst GBS capsular polysaccharides-specific antibody remains stable

Group B Streptococcus (GBS) is a leading cause of adverse pregnancy outcomes due to invasive infection. This study investigated longitudinal variation in GBS rectovaginal colonization, serum and vaginal GBS capsular polysaccharide (CPS)-specific antibody levels. Non-pregnant women were recruited in the UK and were sampled every 2 weeks over a 12-week period. GBS isolates were taken from recto-vaginal swabs and serotyped by polymerase chain reaction. Serum and vaginal immunoglobulin G (IgG) and nasal immunoglobulin A (IgA) specific to CPS were measured by Luminex, and total IgG/A by ELISA. Seventy women were enrolled, of median age 26. Out of the 66 participants who completed at least three visits: 14/47 (29.8%) women that were GBS negative at screening became positive in follow-up visits and 16/19 (84.2%) women who were GBS positive at screening became negative. There was 50% probability of becoming negative 36 days after the first positive swab. The rate of detectable GBS carriage fluctuated over time, although serum, vaginal, and nasal CPS-specific antibody levels remained constant. Levels of CPS-specific antibodies were higher in the serum of individuals colonized with GBS than in non-colonized, but similar in the vaginal and nasal mucosa. We found correlations between antibody levels in serum and the vaginal and nasal mucosa. Our study demonstrates the feasibility of elution methods to retrieve vaginal and nasal antibodies, and the optimization of immunoassays to measure GBS-CPS-specific antibodies. The difference between the dynamics of colonization and antibody response is interesting and further investigation is required for vaccine development.

Assessment of Lead and Cadmium Pollution in Soil and Wild Plants at Different Functional Areas of Sialkot

Heavy metal pollution is a great hazard to the environment that enters the ecosystem through different natural and anthropogenic sources. A study was performed to evaluate concentrations of Cd and Pb in selected plants, Ricinus communis and Parthenium hysterophorus, and soils from different functional sites in Sialkot. Maximum fresh and dry weights of R. communis were recorded from control and field sites. Highest concentrations of Cd in P. hysterophorus (33.5 mg kg^-1) and R. communis (24.36 ± 2.83 mg kg^-1) were recorded at residential and industrial sites, respectively. However, road site samples showed maximum concentrations of Pb both in R. communis (9.06 ± 0.35 mg kg^-1) and P. hysterophorus (7.90 ± 0.36 mg kg^-1). Soil from the road site were found to be highly acidic (pH 4.75 ± 0.04), while the field site showed highest EC (494 ± 3.60) and TDS (509 ± 3.00) values. Generally, there were reductions in chlorophyll a and carotenoids, but an increase in chlorophyll b was observed in both plants at all sites compared to the control.

'We need to share our stories': the lives of Pakistanis with intellectual disability and their guardians

INTRODUCTION

The experiences of Pakistanis with intellectual disabilities (IDs) and their family members have been underexplored empirically.

METHOD

The present study sought to address this gap by understanding the lives of five Special Olympics Pakistan athletes and their guardians through PhotoVoice.

FINDINGS

Through thematic analysis, we present the primary theme concerning Pakistan's cultural context that provides an empirical exploration of cultural beliefs about intellectual disability, cultural expectations and support received by people with intellectual disabilities and their guardians.

DISCUSSION

We discuss implications for research and practice.

The significance of petroleum bitumen in ancient Egyptian mummies

Mummification was practised in ancient Egypt for more than 3000 years, emerging from initial observations of buried bodies preserved by natural desiccation. The use of organic balms (and other funerary practices) was a later introduction necessitated by more humid burial environments, especially tombs. The dark colour of many mummies led to the assumption that petroleum bitumen (or natural asphalt) was ubiquitous in mummification; however, this has been questioned for more than 100 years. We test this by investigating 91 materials comprising balms, tissues and textiles from 39 mummies dating from ca 3200 BC to AD 395. Targeted petroleum bitumen biomarker (steranes and hopanes) analyses by gas chromatography-mass spectrometry selected ion monitoring (GC-MS SIM, m/z 217 and 191) showed no detectable bitumen use before the New Kingdom (ca 1550-1070 BC). However, bitumen was used in 50% of New Kingdom to Late Period mummies, rising to 87% of Ptolemaic/Roman Period mummies. Quantitative determinations using (14)C analyses reveal that even at peak use balms were never more than 45% w/w bitumen. Critically, the dark colour of balms can be simulated by heating/ageing mixtures of fats, resins and beeswax known to be used in balms. The application of black/dark brown balms to bodies was deliberate after the New Kingdom reflecting changing funerary beliefs and shifts in religious ideology.This article is part of the themed issue 'Quantitative mass spectrometry'.

Functional redundancy and/or ongoing pseudogenization among F-box protein genes expressed in Arabidopsis male gametophyte

F-box protein genes family is one of the largest gene families in plants, with almost 700 predicted genes in the model plant Arabidopsis. F-box proteins are key components of the ubiquitin proteasome system that allows targeted protein degradation. Transcriptome analyses indicate that half of these F-box protein genes are found expressed in microspore and/or pollen, i.e., during male gametogenesis. To assess the role of F-box protein genes during this crucial developmental step, we selected 34 F-box protein genes recorded as highly and specifically expressed in pollen and isolated corresponding insertion mutants. We checked the expression level of each selected gene by RT-PCR and confirmed pollen expression for 25 genes, but specific expression for only 10 of the 34 F-box protein genes. In addition, we tested the expression level of selected F-box protein genes in 24 mutant lines and showed that 11 of them were null mutants. Transmission analysis of the mutations to the progeny showed that none of the single mutations was gametophytic lethal. These unaffected transmission efficiencies suggested leaky mutations or functional redundancy among F-box protein genes. Cytological observation of the gametophytes in the mutants confirmed these results. Combinations of mutations in F-box protein genes from the same subfamily did not lead to transmission defect either, further highlighting functional redundancy and/or a high proportion of pseudogenes among these F-box protein genes.

Natural variation of Arabidopsis response to nitrogen availability

Our understanding of plant growth in response to nitrogen (N) supply is mainly based on studies of mutants and transformants. This study explored the natural variability of Arabidopsis thaliana first to find out its global response to N availability and secondly to characterize the plasticity for growth and N metabolism among 23 genetically distant accessions under normal (N+), limited (N-), and starved (N0) N supplies. Plant growth was estimated by eight morphological traits characterizing shoot and root growth and 10 metabolic parameters that represented N and carbon metabolism. Most of the studied traits showed a large variation linked to genotype and nutrition. Furthermore, Arabidopsis growth was coordinated by master traits such as the shoot to root ratio of nitrate content in N+, root fresh matter and root amino acids in N-, and shoot fresh matter together with root thickness in N0. The 23 accessions could be gathered into four different groups, according to their growth in N+, N-, and N0. Phenotypic profiling characterized four different adaptative responses to N- and N0. Class 1 tolerated N limitation with the smallest decrease in shoot and root biomass compared with N+, while class 2 presented the highest resistance to N starvation by preferential increased root growth, huge starch accumulation, and high shoot nitrate content. In contrast, class 3 plants could tolerate neither N limitation nor N starvation. Small plants of class 4 were different, with shoot biomass barely affected in N- and root biomass unaffected in N0.

Effects of nifedipine and nitroglycerin on left ventricular systolic dysfunction and impaired diastolic filling after exercise-induced ischemia in humans

OBJECTIVES

This study sought to determine whether calcium antagonist, compared with nitroglycerin, administration attenuates left ventricular dysfunction after exercise-induced ischemia in humans.

BACKGROUND

Exercise-induced ischemia impairs left ventricular systolic function and diastolic filling after exercise. The mechanism of this phenomenon is unknown but may relate to intracellular calcium overload.

METHODS

Echocardiography was performed in 131 patients before and 30 min, 2 h and 4 h after exercise stress test. Ischemia was defined as a reversible thallium stress defect. No medication, sublingual nitroglycerin or nifedipine was randomly given to each patient at peak exercise.

RESULTS

Isovolumetric relaxation time was significantly prolonged from rest (100 +/- 19 ms [mean +/- SD]) to 30 min (118 +/- 20 ms, p < 0.0005), 2 h (117 +/- 18 ms, p < 0.0005) and 4 h (110 +/- 22 ms, p < 0.05) after exercise in 21 patients with exercise-induced ischemia who received no medication (ischemia-none group). Isovolumetric relaxation time similarly increased after exercise in 23 patients who received nitroglycerin and had exercise-induced ischemia (ischemia-NTG group) but was unchanged in 20 patients with exercise-induced ischemia who received nifedipine (ischemia-nifedipine group). Peak early filling velocity decreased in the ischemia-none and ischemia-NTG groups from rest to 30 min and 2 h after exercise, but peak early filling velocity was unchanged in the ischemia-nifedipine group. Ejection fraction decreased from rest to 30 min after exercise in the ischemia-none group (59 +/- 12% vs. 51 +/- 13%, p < 0.025) and ischemia-NTG group (59 +/- 14% vs. 49 +/- 14%, p < 0.005) but was unchanged in the ischemia-nifedipine group (60 +/- 19% vs. 64 +/- 18%, p = NS). A new regional left ventricular wall motion abnormality occurred more frequently 30 min after exercise in the ischemia-none group (11 [52%] of 21) and ischemia-NTG group (9 [39%] of 23) compared with the ischemia-nifedipine group (2 [10%] of 20, both p < 0.05). No change occurred in left ventricular systolic function and diastolic filling after exercise in the control groups.

CONCLUSIONS

Exercise-induced ischemia impairs systolic function and diastolic filling after exercise. Sublingual nifedipine but not nitroglycerin attenuates this process and suggests that altered calcium homeostasis may play a role in left ventricular dysfunction that occurs after exercise-induced ischemia.

Early repair of postinfarction ventricular septal defect with gelatin-resorcin-formol biological glue

BACKGROUND

Early surgical repair of postinfarction ventricular septal defect has improved early mortality rate. Mortality remains high in patients presenting within 1 week of infarction, or when rupture has occurred in the inferior part of the septum.

METHODS

We describe a surgical technique for repair of postinfarction ventricular septal defect that involves no infarctectomy: continuous suturing of a bovine pericardial patch to healthy myocardium around the infarcted area and use of gelatin-resorcin-formol biological glue as a sealant between the patch and the interventricular septum.

RESULTS

We have used this technique successfully in 3 consecutive patients in whom repair was performed within 1 week of myocardial infarction. The rupture of the interventricular septum was located anteriorly in 2 patients and inferiorly in the other. They all made an uneventful recovery, and at follow-up there was no evidence of residual shunt.

CONCLUSIONS

This technique can be a useful adjunct to the surgical management of this difficult group of patients.

Can an echocardiographic score predict who will benefit clinically from balloon dilation of the mitral valve?

Deciding whether a patient with sub-optimal mitral valve anatomy will benefit from percutaneous mitral valvotomy remains a demanding clinical problem. We assessed the ability of an established echo score applied to transoesophageal images to predict absolute increases in mitral valve area and improvement in exercise capacity. Twenty five consecutive patients undergoing routine percutaneous mitral valvotomy were studied. Changes in exercise tolerance were measured by serial cardiorespiratory treadmill exercise testing. Before the procedure, exercise duration was directly related to mitral valve area (rs = 0.44, P < 0.05). Following percutaneous mitral valvotomy there was an increase in valve area (0.9 +/- 0.2 to 1.4 +/- 0.3 cm2, P < 0.0001) and repeat exercise testing demonstrated increases in exercise duration (470 +/- 220 to 610 +/- 240 s, P < 0.001) and peak VO2 (12.6 +/- 4.2 to 15.1 +/- 4.5 ml/kg/min, P < 0.01). There was an inverse correlation between the echo score and the increase in valve area (rs = -0.52, P < 0.05) but no relationship between the echo score and the increase in exercise duration or peak minute oxygen consumption (VO2). These data demonstrate that a score applied to transoesophageal images echocardiographic images can predict changes in mitral valve area but that the score fails to predict functional improvement for an individual patient. This suggests, therefore, that patients without contraindications to valvotomy whose valves have a high echo score should still be considered for valvotomy as they may benefit considerably from the procedure.

Transoesophageal echocardiography as the sole diagnostic investigation in patients with suspected thoracic aortic dissection

OBJECTIVES

To assess the value and limitations of using transoesophageal echocardiography as the sole diagnostic test in patients with suspected thoracic aortic dissection.

DESIGN

Retrospective data review over a two year period.

SETTING

A regional cardiothoracic centre.

PATIENTS

Data were compiled from admission records, surgical records, and lists of patients undergoing diagnostic investigations in the hospital. Patient's notes were used to identify presentation, management, and outcome.

INTERVENTIONS

Patients were managed according to the policy of our unit, which is to treat patients with dissection affecting the ascending aorta by an operation. Patients with uncomplicated dissection sparing the ascending aorta are initially managed medically.

MAIN OUTCOME MEASURES

In hospital and two year follow-up of patients who were investigated by transoesophageal echocardiography alone.

RESULTS

Of 48 patients referred, 45 underwent transoesophageal echocardiography. Dissection was confirmed in 22 patients. Transoesophageal echocardiography showed the proximal extent of the dissection in 21/22 (96%) and only one patient required a further diagnostic investigation. Ten patients with dissection of the ascending aorta underwent graft replacement of the ascending aorta; operative mortality was 10% and their two year survival was 80%. Of the eight patients with dissection of the descending aorta, six were discharged home, and five were alive at two years. No patient without evidence of dissection on their initial transoesophageal echocardiographic examination required re-investigation into possible dissection in the two years after discharge.

CONCLUSIONS

In patients with suspected thoracic dissection transoesophageal echocardiography rapidly and safely gives all the necessary diagnostic information. Further investigations, including coronary angiography, before surgery are unnecessary.

Echocardiographic evidence of persistent pericardial effusion after open heart surgery

Cross-sectional and M-mode echocardiography were used to review 33 patients 6-28 months (mean 19 months) after open heart surgery. Eleven patients had had echocardiographic signs of pericardial effusion during the first week after open heart surgery (Group A), and 22 had not (Group B). At review, pericardial effusion was found in 73% of subjects in Group A compared with 18% of those in Group B (P < 0.01). On average, posterior effusions were small (mean dimension in systole 0.9 cm) but they were detected reproducibly (interobserver agreement 97%). Anterior echo-free spaces (< 0.5 cm) were found frequently, but interobserver variation in their detection was high (agreement in 68%). Symptoms did not correlate with the presence of a late post-operative effusion but the groups were not matched for rhythm or ventricular function. Five patients in Group A had developed atrial fibrillation in association with their early post-operative effusion, and four of these had persisting atrial fibrillation at this review. These results suggest that echo-free spaces around the heart, suggestive of small pericardial effusions, may persist for many months after open heart surgery.

Abnormalities of left ventricular flow following mitral valve replacement: a colour flow Doppler study

Left ventricular flow patterns were studied at rest by colour flow Doppler echocardiography in 33 patients with mitral tilting-disc prostheses (group 1), in 38 patients with mitral tissue prostheses (group 2) and in 18 healthy volunteers (controls). A 'crossed' flow pattern was seen in 14 patients with mechanical (42%) and in 15 patients with tissue prostheses (39%). The remaining patients and all controls had either 'parallel' or 'intermediate' flow patterns which were classified as 'normal'. There was a significant correlation between the type of flow pattern and the position of the mitral prosthesis in both study groups. The presence of a crossed flow pattern, however, was not related to functional status (assessed clinically by NYHA class) or to abnormalities on the electrocardiogram. Left atrial size was greater in patients with crossed flow than in those without, but all other echocardiographic parameters were similar. Eight patients with crossed and eight with normal flow patterns underwent treadmill exercise testing; there was no difference between the two groups with regard to exercise performance as determined by exercise duration, maximum oxygen consumption and the ventilatory response to exercise. The results of this study indicate that the pattern of blood flow within the left ventricle may be fundamentally altered by the orientation of both mechanical and tissue prostheses. The presence of a crossed flow pattern is not, however, accompanied by significant deleterious haemodynamic or functional consequences.

Tricuspid regurgitation following mitral valve replacement: an echocardiographic study

The development of late tricuspid regurgitation following mitral valve replacement is accompanied by a severe reduction in exercise capacity and a poor functional outcome. In this study, we compared the clinical and echocardiographic characteristics of two matched groups with (n = 13) and without (n = 13) clinically significant tricuspid regurgitation. The preoperative pulmonary artery pressures and symptom durations were similar, but tricuspid regurgitation at palpation was detected only in patients who later developed severe tricuspid regurgitation (5/13 vs. 0/13; p < 0.02). None of the patients had echocardiographic evidence of rheumatic tricuspid valve disease at the time of the study, but the tricuspid annular diameter (3.7 +/- 0.5 cm vs. 3.2 +/- 0.4 cm; p < 0.05) and right ventricular diameter (4.9 +/- 0.4 cm vs. 4.0 +/- 0.8 cm; p < 0.01) were greater in patients who had developed severe late tricuspid regurgitation. Echocardiographic parameters of left ventricular function and Doppler estimated pulmonary artery systolic pressures were similar in the two groups, and no evidence of prosthetic dysfunction or aortic valve disease was found. These results imply that late tricuspid regurgitation following mitral valve replacement develops as a result of dilation of the tricuspid annulus associated with right ventricular decompensation. The persistence of uncorrected tricuspid incompetence would seem to be an important contributory factor, and its accurate detection and correction at the time of initial surgery may prove to be the most effective means of preventing the development of this important complication of mitral valve replacement.

Emergency mitral valve replacement immediately following caesarean section

Cardiopulmonary bypass immediately post-partum could carry the risk of severe uterine bleeding. We report the case of a woman who successfully underwent emergency replacement of a thrombosed mitral prosthesis immediately after Caesarean section.

Palaeoepidemiology of Schistosoma infection in mummies

Images

Reduced exercise capacity in patients with tricuspid regurgitation after successful mitral valve replacement for rheumatic mitral valve disease

OBJECTIVE

To determine how severe tricuspid regurgitation influences exercise capacity and functional state in patients who have undergone successful mitral valve replacement for rheumatic mitral valve disease.

DESIGN

9 patients in whom clinically significant tricuspid regurgitation developed late after mitral valve replacement were compared with 9 patients with no clinical evidence of tricuspid regurgitation. The two groups were matched for preoperative clinical and haemodynamic variables. Patients were assessed by conventional echocardiography, Doppler echocardiography, and a maximal treadmill exercise test in which expired gas was monitored by mass spectrometry.

SETTING

University Hospital of Wales, Cardiff.

SUBJECTS

18 patients who had been reviewed regularly since mitral valve replacement.

MAIN OUTCOME MEASURE

Objective indices of exercise performance including exercise duration, maximal oxygen consumption, anaerobic threshold, and ventilatory response to exercise.

RESULTS

Mitral valve prosthetic function was normal in all patients and estimated pulmonary artery systolic pressure and left ventricular function were similar in the two groups. Right ventricular diameter (median (range) 5.0 (4.3-5.6) v 3.7 (3.0-5.4) cm, p less than 0.01) and the incidence of paradoxical septal motion (9/9 v 3/9, p less than 0.01) were greater in the group with severe tricuspid regurgitation. Exercise performance--assessed by exercise duration (6.3 (5.0-10.7) v 12.7 (7.2-16.0) min, p less than 0.01), maximum oxygen consumption (11.2 (7.3-17.8) v 17.7 (11.8-21.4) ml min-1 kg-1, p less than 0.01), and anaerobic threshold (8.3 (4.6-11.4) v 0.7 (7.3-15.5) ml min-1 kg-1, p less than 0.05)--was significantly reduced in the group with severe tricuspid regurgitation. The ventilatory response to exercise was greater in patients with tricuspid regurgitation (minute ventilation at the same minute carbon dioxide production (41.0 (29.9-59.5) v 33.6 (26.8-39.3) l/min, p less than 0.01).

CONCLUSIONS

Clinically significant tricuspid regurgitation may develop late after successful mitral valve replacement and in the absence of residual pulmonary hypertension, prosthetic dysfunction, or significant left ventricular impairment. Patients in whom severe tricuspid regurgitation developed had a considerable reduction in exercise capacity caused by an impaired cardiac output response to exercise and therefore experienced a poor functional outcome. The extent to which this was attributable to the tricuspid regurgitation itself or alternatively to the consequences of right ventricular dysfunction was not clear and requires further investigation.

Straddle embolus--imminent paradoxical embolus diagnosed by echocardiography and treated surgically

Paradoxical embolus, the passage of an embolus from the right to the left side of the circulation, was formerly recognised as a postmortem diagnosis. More recently, survivors with paradoxical embolus have been described. A case of paradoxical embolus is described in which the diagnosis was made clinically, and an imminent further embolus visualised by transoesophageal echocardiography, which was successfully treated surgically. Treatment strategies are discussed.

Biopharmaceutical studies of 3-substituted isatin derivatives

The metabolic fate of isatin hydrazone (Ia), isatin-3-thiosemicarbazone (Ib), isatin-3-semicarbazone (Ic), isatin-3-phenylhydrazone (Id), isatin oxime (Ie) and 3-hydroxy-3-acetonyl oxindole (II) was studied in rabbits. The compounds were administered orally in the dose of 300 mg/kg body wt. Isatin anthranilic acid, tryptophan and nicotinic acid were identified as the major metabolites excreted in urine. The 3-hydroxy-3-acetonyl oxindole (II) gave on additional metabolite, oxindole. The major metabolites were separated and identified unambiguously on thin layer silica gel plate. Metabolic pathways have been proposed to explain the biotransformation of the compounds investigated.

Brucellosis: an unusual cause of fever in Kentucky

Human infection with brucellosis appears to be very uncommon in Kentucky. Only three cases have been reported to the Kentucky Department of Health, Frankfort, in the last 4 years. It is suspected, however, that brucellosis is severely underdiagnosed and under-reported in the United States. A patient recently diagnosed with acute systemic brucellosis reminds us that this illness may still be seen in the Commonwealth.

Emergency angioplasty of the left main coronary artery

During urgent cardiac catheterization total occlusion of a severe left main coronary artery stenosis occurred, leading to profound cardiogenic shock. The patient survived, after prompt left main coronary angioplasty was performed, followed by emergency coronary bypass surgery.

Left atrial ball thrombus: echocardiographic features and clinical implications

The echocardiographic features of left atrial ball thrombus associated with mitral stenosis are reviewed, and some previously unpublished cross-sectional echocardiographic findings presented. In one patient who had a large free-floating ball thrombus there was variation in its echocardiographic appearance; the thrombus was removed uneventfully at surgery. In another patient who had a pedunculated but immobile ball thrombus, a stalk was identified which attached it to the inter-atrial septum; this patient died suddenly before surgery could be performed, due to detachment of the thrombus and obstruction of the mitral valve orifice. Cross-sectional echocardiography is clearly superior to M-mode imaging in the detection of atrial thrombi, and variable appearances may help differentiation of thrombus from myxoma. Whether or not a ball thrombus appears mobile, emergency thrombectomy and mitral valve replacement is indicated, because of the risk of obstruction of the mitral valve.

Treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex

A controlled trial in 149 patients admitted to a district hospital with probable myocardial infarction tested the effect of 30 units of anisoylated plasminogen streptokinase activator complex (APSAC) on indices of infarct size. Patients were grouped prospectively according to whether they entered the trial within two and a half hours (early entry) or between two and a half and four hours (late entry) after onset of the symptoms. Sixty seven of 73 patients in the control group showed increased plasma activity of myocardial creatine kinase isoenzyme that was diagnostic of infarction compared with only 60 of 76 who received APSAC. The difference was significant overall but occurred predominantly in the early entry group. The patients who received APSAC had more early ventricular arrhythmias, compatible with reperfusion, and showed greater preservation of R waves during admission to hospital. Unwanted effects were generally minor and more common in the actively managed group than the control group (26% v 3%). After nine to 12 months of follow up 12 patients in the control group had died compared with seven in the actively managed group. The ease of administration and the apparent efficacy of APSAC suggest that it is suitable for use in a district hospital for patients with suspected acute myocardial infarction.