Emergency department use of aspirin in patients with possible acute myocardial infarction

OBJECTIVE: To determine the relevance of the functional affinity of IgM rheumatoid factor (RF) to the clinical and serological characteristics of patients with rheumatoid arthritis. METHODS: The functional affinity of IgM RF of 57 seropositive rheumatoid arthritis patients was evaluated by an enzyme linked immunosorbent assay based on the use of a chaotropic agent. The inhibition index was taken as an estimate of functional affinity. The patient group was divided into high functional affinity subgroup 1 (functional affinity < 0.5, n = 37) and low functional affinity subgroup 2 (functional affinity > 0.5, n = 20). The medical records of all patients were reviewed with a particular note of the disease activity and the articular damage score. RESULTS: The disease duration was shorter (P < 0.01) in subgroup 1 patients [7.9 (SD 6.4) years] than in subgroup 2 patients [13.4 (11.29) years], so that Ritchie's, Lee's, and Steinbrocker's indices were lower in the former than in the latter (P < 0.01, 0.001, and 0.01, respectively). In contrast, erythrocyte sedimentation rates, C reactive protein concentrations, antinuclear antibody, and HLA DR4 prevalences were similar in the two subgroups. CONCLUSIONS: Different forms of RF are present during progression of the disease.     

Short-term versus long-term use of nitrates in acute myocardial infarction

While previous experimental and small-scaled clinical studies have shown intravenous administration of nitroglycerin in the setting of acute myocardial infarction reduced infarct size and diminished the frequency of mechanical complications, its effect on short-term and long-term outcome has not been established. Recently, two large-scaled clinical trials, GISSI-3 and ISIS-4, have demonstrated unexpected neutral effect of nitrates on subacute phase mortality after myocardial infarction. Long-term nitrate treatment, however, has been indicated by three independent clinical studies that it may increase cardiac events in patients with healed myocardial infarction. Although a large-scaled randomized clinical trial is required to confirm the deleterious effect of nitrates on long-term outcome after myocardial infarction, routine use of nitrates in chronic phase of coronary heart disease cannot be recommended.     

Metallothionein, zinc and copper levels: relationship with acute myocardial infarction

BACKGROUND: Laparoscopy is increasingly used in patients with intraabdominal bacterial infection although pneumoperitoneum may increase bacteremia by elevated intraabdominal pressure. METHODS: The influence of laparotomy and laparoscopy on bacteremia, endotoxemia, and postoperative abscess formation was investigated in a rat model. Rats received intraperitoneally a standardized fecal inoculum and underwent laparotomy (n = 20), or laparoscopy (n = 20), or no further manipulation in the control group (n = 20). RESULTS: Bacteremia and endotoxemia were higher after laparotomy and laparoscopy compared to the control group (p = 0.01) 1 h after intervention. One hour after intervention, aerobic and anaerobic bacterial species were detected in the laparotomy group while only anaerobic bacteria were found in the other two groups. Although bacteremia and endotoxemia did not differ among the three groups after 1 week, the mean number of intraperitoneal abscesses was significantly higher (p < 0.05) after laparotomy (n = 10) compared with laparoscopy (n = 6) and control group (n = 5). CONCLUSION: Laparoscopy does not increase bacteremia and intraperitoneal abscess formation compared to laparotomy in an animal model of peritonitis.     

Evaluation of biopsy classification for rejection: relation to detection of myocardial damage by monoclonal antimyosin antibody imaging

OBJECTIVES: This study sought to compare the histologic grades of rejection in endomyocardial biopsy specimens with the global estimate of myocardial transplant-related cardiac damage detected by myocardial uptake of monoclonal antimyosin antibodies. BACKGROUND: The diagnosis and treatment of acute cardiac allograft rejection is based on the interpretation of endomyocardial biopsies. Because allograft rejection is a multifocal process and biopsy is obtained from a small area of the right ventricle, sampling error may occur. Global assessment of myocardial damage associated with graft rejection is now possible with the use of antimyosin scintigraphy. The present study was undertaken to compare the histologic grades of rejection in endomyocardial biopsy specimens with the global assessment of transplant-related myocardial damage detected by antimyosin scintigraphy. METHODS: Biopsies (n=395) from 112 patients were independently interpreted by three pathologists in a blinded manner according to the original Stanford four-grade (normal, mild, moderate and severe) and the current International Society of Heart and Lung Transplantation (ISHLT) seven-grade (0, 1A, 1B, 2, 3A, 3B and 4) classifications. The results were correlated with 395 antimyosin studies performed at the time of the biopsies. The heart/lung ratio of antimyosin antibody uptake was used to assess the severity of myocardial damage. RESULTS: In the Stanford biopsy grade classification, significantly higher antimyosin uptake, indicating increasing degrees of myocardial damage, were associated with normal (1.78+/-0.26), mild (1.88+/-0.31) and moderate (1.95+/-0.38) biopsy classifications for rejection (p < 0.01). In the ISHLT classification, significant differences were detected only for antimyosin uptake associated with grades 0 (1.77+/-0.26) and 3A (1.98+/-0.39) but not for intermediate scores (1A, 1B and 2). In view of the similar intensity of antibody uptake among the various grades, ISHLT biopsy scores were regrouped: normal biopsies in grade A; 1A and 1B as grade B; and 2 and 3A as grade C. Antimyosin uptake in grades A, B and C was 1.78+/-0.26, 1.88+/-0.31, 1.95+/-0.38, respectively (p < 0.01). CONCLUSIONS: The current ISHLT seven-grade scoring system does not reflect the progressive severity of myocardial damage associated with heart transplant rejection. Because myocardial damage constitutes the basis of treatment for allograft rejection, there is a need to reevaluate the ISHLT grading system, given its importance for multicenter trials.     

The use of hormone replacement therapy in women with acute myocardial infarction: an audit of current practice

We undertook criterion-based audit of the current practice of prescribing hormone replacement therapy for women with acute myocardial infarction; the audit included 181 consecutive women admitted to one hospital with this diagnosis in one calendar year. The set standard was that, barring any contraindication, all postmenopausal women with acute myocardial infarction should be prescribed hormone replacement therapy before discharge from hospital. The evidence base of this standard derives from more than 30 epidemiological and clinical studies and a large body of biological data. Only 4.7% of the women were current users of hormone replacement therapy and the set standard was met in only 3% of eligible nonusers. Professionals caring for women who have had a myocardial infarction need to consider hormone replacement therapy as a secondary prophylaxis of myocardial infarction. Gynaecologists should liaise with colleagues in other specialties and general practice to ensure that information on the nongynaecological benefits of hormone replacement therapy is widely disseminated.     

Clinical picture of acute myocardial infarction depending on the use of pharmacologic treatment schemes

The aim of the work was a retrospective comparison of the clinical course of acute myocardial infarction depending on the applied schema of pharmacological treatment: streptokinase, heparin, antiplatelet drugs. The analysis included 409 patients (261 men and 148 women aged 31-85 years; mean age 61 years). Twelve-lead ECG records were analysed: 24 hours, 48 hours, 72 hours, 7 days and 14 days after the onset of the disease. The sum of ST segment elevations, sum of Q wave amplitude and the sum of R wave amplitude in the leads showing signs of infarction were taken into account. The mean was calculated from the highest values of AspAT and AlAT. The haemodynamic, arrhythmic and other early and late complications occurring during the treatment were subjected to analysis; the per cent index of deaths in each group was also calculated. In the patients treated with streptokinase, in comparison to the patients treated with heparin and antiplatelet drugs, earliest stabilization was observed of the ECG pattern in the form of: reduction of ST segment elevation, reduction of R wave height, and formation of a stable Q wave. AspAT and AlAT values were highest in the group of patients treated with streptokinase in relation to the remaining groups of patients. Arrhythmic and haemodynamic complications occurred less frequently in the patients treated with streptokinase and heparin than in those treated with antiplatelet drugs. On the other hand, late and other early complications were observed less frequently in the patients treated with antiplatelet drugs. The mortality during hospitalization period was similar in individual groups of patients, being 7.2% for the patients treated with streptokinase, 7.5% for those treated with antiplatelet drugs, and 9% for those treated with heparin.     

In-hospital and follow-up mortality of patients with acute myocardial infarction

Patients with definite acute MI who were admitted to Songkla University Hospital between 1982 and 1990 were studied. The 195 patients and 202 admissions were nearly equally distributed between these 65 and older versus those younger than 65. Three quarters were males. The in-hospital mortality was 19.5 per cent and 76.3 per cent of the deaths were from heart failure. Neither age nor gender determined the mortality once corrected for the Killip's staging. There was no difference in mortality when comparing Q versus non-Q MI, anterior versus inferior wall MI or males versus females. One hundred and thirty-eight patients could be followed for and average of 27.1 months. First year mortality was 11 per cent and the first 2 years was 14 per cent. The in-hospital mortality, representing the prethrombolytic era, appeared to be similar to values reported from the Thai and Western literature. The predominance of death from heart failure rather than from arrhythmia may be a consequence of delayed admission whence arrhythmic death had already occurred or patients will seek hospital advice only if highly symptomatic.     

Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction

The Studies of Left Ventricular Dysfunction (SOLVD) assessed the effect of enalapril in patients with systolic left ventricular dysfunction (LVD). We performed retrospective analyses of the association between calcium channel blocker (CCB) use and fatal and nonfatal myocardial infarction (MI) in these patients. MI occurred in 11.5% of 845 patients receiving CCBs versus 7.5% of 2551 patients not receiving CCBs in the enalapril group and in 14.4% of 874 patients receiving CCBs versus 9.3% of 2527 patients not receiving CCBs in the placebo group. By multivariate Cox regression analysis, adjusting for comorbidity, cause and severity of LVD, heart failure, and concomitant drug use, CCB use was an independent predictor of MI (relative risk [RR] 1.37, confidence interval [CI] 1.14 to 1.63). The increase in MI risk was greater among patients with a higher heart rate (RR 1.46, CI 1.14 to 1.86) and lower blood pressure (RR 1.45, CI 1.14 to 1.86). The adjusted risk ratio for all-cause mortality associated with CCB use was 1.14 (CI 1.00 to 1.28; p = 0.0454). In this analysis of patients with LVD, CCB use was associated with significantly increased risk of fatal or nonfatal MI.     

Etiopathogenesis of acute myocardial infarction: role of early leukocytosis]

Ultrasonic standing wave chambers with acoustic pathlengths of 1.1 and 0.62 mm have been constructed. The chambers were driven at frequencies over the range 0.66-12.2 MHz. The behaviour of 2 microns diameter latex microparticles and 5 microns diameter yeast in the chambers has been elucidated. One (flow) chamber had a downstream laminar flow expansion section to facilitate observation of concentrated particle bands formed in the ultrasonic field. A second (microscopy) chamber allowed direct observation of band formation in the field and their characterisation by confocal scanning laser microscopy. Clear band formation occurs when the chamber pathlength is a multiple of half wavelengths at the driving frequency, so that the chamber rather than the transducer resonance has the most influence on band formation in this system. Band formation occurred in half-wavelength steps from a position one quarter of a wavelength off the transducer to a band at a similar distance from the reflector. Ordered band formation was preserved by the laminar flow in the expansion chamber, although bands that formed very close to the wall were dissipated downstream. The microscopy chamber provided evidence of significant lateral particle concentration within bands in the pressure nodal planes. The approaches described will be applicable to the manipulation of smaller particles in narrower chambers at higher ultrasonic frequencies.     

Incidence of hibernating myocardium after acute myocardial infarction treated with thrombolysis

OBJECTIVE: To establish the incidence of hibernating myocardium after myocardial infarction treated with thrombolysis and to observe differences in the clinical outcome between patients with and without hibernating tissue. METHODS: 41 patients underwent gated positron emission tomography with 18-fluorodeoxyglucose and 13N-ammonia at a median of eight days after first myocardial infarction. RESULTS: All 41 subjects had a matched perfusion-metabolism deficit in the region of myocardium indicated as the site of infarction by an electrocardiograph; 32 patients (78%) had scans which also showed at least one area of reduced blood flow and contraction with a concomitant increase in glucose uptake, representing hibernating myocardium. Patients were followed up at a median of six months: all 41 were alive and none had sustained a further infarct or cardiac arrhythmia; 17 subjects with hibernating tissue (53.1%) and two without (25%) reported chest pain after myocardial infarction. CONCLUSIONS: Hibernating myocardium is relatively common shortly after myocardial infarction treated with thrombolysis. It does not influence mortality or the incidence of postinfarction chest pain.     

Randomized, double-blind placebo-controlled trial of coenzyme Q10 in patients with acute myocardial infarction

Adherence with inhaled beta-agonists and corticosteroids in 24 asthmatic children was tracked over 3 months utilizing the metered-dose inhaler chronolog (MDIC). Patients seldom took all of their medications as prescribed, and failed to take any inhaled corticosteroid doses on a median of 41.8% of days or inhaled beta-agonists on 28.1% of days despite prescribed daily use. Medication nonadherence was correlated with lower levels of asthma knowledge (Asthma Knowledge Questionnaire) and family dysfunction (Family Assessment Device), but not child behavior disorder (Child Behavior Checklist). Patients tended to dramatically over-report medication use. Improved identification of the markers of nonadherence can directly facilitate more efficient targeting of behavioral interventions, resulting in improved adherence, better illness control, and less requirement of urgent medication intervention.     

In vivo comparison of three different porous materials intended for use in a keratoprosthesis

OBJECTIVE: To determine whether low airloss hydrotherapy reduces the incidence of new skin lesions associated with incontinence in hospitalized patients and results in more rapid healing of existing pressure sores compared with standard care. To assess subjectively patient and nursing satisfaction related to using low airloss hydrotherapy beds. DESIGN: Randomized, prospective, unblinded study. SETTING: Acute and chronic hospital wards. PARTICIPANTS: A total of 116 newly admitted, incontinent, hospitalized patients with and without existing pressure sores. INTERVENTION: Low airloss hydrotherapy compared with treatment on hospital beds and mattresses ordered by the patient's attending physician. MEASUREMENTS: Incidence rates of new skin lesion development, e.g., pressure sores, candidiasis, and chemical irritation; improvement in existing pressure sore size, volume, and status; subjective assessment of patient and nursing satisfaction. RESULTS: Possible hypothermia was identified in two patients during the first week of the study, and patient and nursing dissatisfaction with low airloss hydrotherapy remained high throughout the first months of the study. Therefore, two major modifications in the initial protocol were made: (1) increased patient temperature monitoring for hypothermia was initiated in Week 2 of the study and (2) increased staff resources for in-service training on bed use began in Week 18 of the study. After the latter change, 58 subjects were randomized to low airloss hydrotherapy and 58 to standard care. Subjects were old (median age > or = 80 years), and almost all were bedbound or nonambulatory. The median (range) length of follow-up for subjects in the treatment group was significantly shorter than for those in the control group (4 (1-60) days versus 6 (1-62) days, respectively, P = .017) because there were more dropouts from the treatment group (24 (36%) of 58 versus 2 (3%) of 58, P = .0001). The major reasons dropout occurred were patient or family dissatisfaction (12 (21%)), new or worsened skin lesions thought to be related to bed use (4 (7%)), and hypothermia < 97 degrees F (4 (7%)). The total cumulative incidence of new truncal skin lesions within 9 days of enrollment was greater in the treatment than in the control group (48% versus 14%, respectively, P < 0.01). Too few patients with existing pressure sores were treated for too short a period of time to assess the effect of low airloss hydrotherapy on pressure sore healing. Because only 10 patients treated on low airloss hydrotherapy beds were able to complete satisfaction surveys meaningfully, interpretation of these data is difficult. Only nine (21%) of 44 nurses subjectively reported overall satisfaction using the low airloss hydrotherapy bed. CONCLUSIONS: This study shows the value of a rigorously designed clinically based evaluation of a new product developed for older patients. The results of the study led to re-engineering of the prototype low airloss hydrotherapy bed as well as a change in marketing strategy. Studies of products targeted to the prevention and treatment of pressure sores in older patients should be undertaken before generalized marketing begins.     

ISIS 4: clinical controversy regarding magnesium infusion, thrombolytic therapy, and acute myocardial infarction

Magnesium (Mg) infusions over 24 hours were given to patients with suspected acute myocardial infarction (AMI) at least 2 hours after thrombolysis. Patients showed no benefit and even some increased risk in contrast to reduction in mortality obtained by Mg therapy in smaller trials. Results of all of the studies were pooled and statistically analyzed, according to a fixed-effects model that is inappropriate for studies of different protocols. The panel concluded that further study of Mg in AMI is not needed. This conclusion has been questioned.     

A retrospective study of sexual life in women with acute myocardial infarction

Nitrofurazone (N), povidone-iodine (P), and silver sulfadiazine (S) were compared in the emergency department outpatient treatment of 84 patients suffering second degree burns over less than 15% (adults) or 5% (children) of their total body surface area. Indices of healing were percent of healing, degree of dryness, crust separation, eschar separation, tissue granulation, and wound pain. Statistical analysis indicates that healing in N-treated patients was superior to that in S-treated patients: tissue granulation began sooner, crusts separated more rapidly, wounds were dryer, and the amount of healing at two weeks was greater. Results in P-treated patients were equivalent to those in N-treated when cases with complications were excluded from analysis. Among patients with less serious burns, N-treated patients suffered less pain than S-treated, but there was no significant difference in pain between N and P or between P and S. In patients with more serious second-degree burns there was more pain with P than with N, but neither P nor N differed significantly from S in this regard.     

Treatment of acute myocardial infarction with sodium nitroprusside (author's transl)

In 12 patients with acute myocardial infarction, seven of whom had high and five low blood pressure measurements, sodium nitroprusside infusions were given to reduce the myocardial oxygen consumption. The dosage was between 20 and 300 mug/min. Sodium nitroprusside led to a considerable reduction of the systemic arterial pressure, while the left ventricular filling pressure was less influenced. In normotensive patients the filling pressure could often not be sufficiently lowered as a too severe reduction of arterial pressure occurred beforehand. In hypertensive patients the relationship between left ventricular filling pressure and arterial pressure was better: in all patients the arterial pressure could be lowered to normal values and the filling pressure also became normal in most cases. Angina pectoris improved markedly in all patients. These results show that sodium nitroprusside has a satisfactory effect on the haemodynamics in hypertensive infarct patients, whereas it is less suitable for the treatment of normo- or hypotensive patients.