Continuous blood pressure monitoring during stress ECG

This paper describes the process of narrative analysis as undertaken within a nursing study on scholars and scholarship. If follows an earlier paper titled: Theoretical perspectives on narrative inquiry that described the influencing ideas of Bruner (1987) and Roof (1994) upon the same study. Analysis procedures are described here in sufficient detail for other researchers wishing to implement a similar approach to do so. The process as described has two main components: (A) strategies of 'core story creation' and 'employment'; and (B) issues and dilemmas of narrative analysis, especially relating to rigour. The ideas of Polkinghorne (1988), Mishler (1986), and Labov (in Mishler 1986a) are introduced in so far as they impinge upon the analysis process. These relate especially to the development of key terms, and to the analysis strategies of core story creation and employment. Outcomes of the study in question are termed 'Signposting the lived-world of scholarship'.     

The ECG diagnosis of acute myocardial infarction in the presence of left bundle branch block

The electrocardiographic diagnosis of ischemic heart disease is made more difficult in the setting of confounding patterns, including left bundle branch block (LBBB). The electrocardiographic detection of abnormalities arising from acute ischemic cardiac disease in this setting is possible in certain cases, contrary to popular medical opinion. Several strategies are available to assist in the correct interpretation of the electrocardiogram (ECG) with LBBB and potential acute ischemia, including: (1) a knowledge of the anticipated ST segment-T wave morphologies of LBBB and, consequently, the ability to recognize ischemic changes; (2) the performance of serial ECGs demonstrating dynamic change; and (3) a comparison to previous ECGs. The first strategy, an awareness of the anticipated ST segment morphologies of LBBB, is the most important and not dependent on additional diagnostic testing or past medical records.     

Non-atherosclerotic acute myocardial infarction

AIM: The aim of the study is to analyse the benefits and risks of PEE in patients, cared for by a team with many years experience. PATIENTS AND METHODS: From 16. 2. 1988 until 31. 12. 1993 246 PEEs (229 gastrostomies, 6 duodenostomies, 7 jejunostomies, 4 attempts) were performed on 234 patients (56% male, 44% female, mean age 68.3 years). 117 patients had tumorous and 117 neurological diseases. We used the pull technique with the Fresenius Freka PEG-system. Analysis was performed using a standardised documentation sheet which was filled out until the end of tube feeding. In total, we registered 39,678 days of tube feeding, 4513 of which were in hospitalized patients. RESULTS: The mean intubation time was 192.6 days (maximum 1496). In 8 cases, the tube could be explanted before the patient was discharged; 68 patients were discharged to a nursing home and 71 patients were allowed to go home. The tube-independent hospital lethality was 36.64%. A PEE-specific lethality had not been registered. Complications arose in a total of 37 patients (15.04%), 4 of which were severe (1.63%) Fifty-nine patients (25.43%) reported short-term feelings of ill health (vomiting, diarrhoea, pain). CONCLUSION: PEE is an effective and low-risk method of long-term nutrition. The advantages are simple insertion, safe handling by patients and relatives/nursing staff and the low cost.     

Stent implantation in acute myocardial infarction

Analysis of the data from 7188 cases seen in the 1980s two general hospitals in Shanghai and comparison of the data with those in the 1950s, 1960s and 1970s revealed that the percentage of heart diseases among the inpatients in medical wards increased in each decades, from 9.89%, 15.69% 20.91% to 23.54% respectively. The constituent ratios of different etiologic types of heart diseases changed. Coronary heart disease constituted the largest proportion, next in number was rheumatic heart disease and congenital heart disease was in the third place. The incidence of congenital heart diseases, myocarditis, cardiac dysrhythmias without organic heart diseases, cardiomyopathy and endocarditis increased and that of rheumatic heart disease, pulmonary heart disease and hypertensive heart disease apparently decreased, syphilitic heart disease was rarely encountered.     

Precordial mapping in acute myocardial infarction

Serial precordial mapping was done in 30 patients with acute anterior myocardial infarction, 27 transmural and 3 subendorcardial. The sum of ST elevations in the 48 lead map was designated as sigma ST. Normal sigma ST was calculated as 27.1+/-3.1 in males and 14.3+/-2.8 in females. In infarction it was 100.4+/-58.2 in males and 84.8+/-50.9 in females on the 1st day of admission. Sigma ST was elevated on day 1 and tended to fall gradually. In 6 patients it was normal by day 7 and in 7 it was still abnormal by day 21. This fall roughly correlated with fall in SGOT and CPK levels. Significant elevation of sigma ST occurred in 14 of 27 cases after day 1. In 10 of 27 cases significant re-elevation occurred on day 4 or after i.e. when the patient was outside the ICCU. In 10 of the 14 re-elevations there was pain or worsening of clinical picture and in 12 there was re-elevation of SGOT. This elevation presumably implied infarct extension. There was a tendency to more arrhythmias in the patients with higher sigma ST and of the 4 deaths in the series 3 had very high sigma ST and high levels of SGOT. The patient with the highest sigma ST 295 died in cardiogenic shock. The number of risk factors was found to be higher in the high sigma ST group.     

Atrial tachyarrhythmias in acute myocardial infarction

Causative factors, clinical consequences and treatment of atrial tachyarrhythmias were reviewed in 917 monitored patients with definite acute myocardial infarction. Significant atrial tachyarrhythmias were found in 104 (11 per cent) of them and included atrial fibrillation in 67, atrial flutter in 29 and paroxysmal atrial tachycardia in 33. These episodes were single in 79 patients and multiple in 25, and began within the first four days of acute myocardial infarction in 90 per cent of the patients. Fifty per cent of these atrial tachyarrhythmias were heralded by premature atrial contractions. The incidence of atrial tachyarrhythmia was not related to the location of the acute myocardial infarction or to the presence or degree of power failure; however, atrial tachyarrhythmias were significantly more frequent in patients with pericarditis. Atrial tachyarrhythmias were well tolerated in almost one fifth of the patients, caused marginal compromise in almost two thirds and led to severe clinical deterioration in one fifth. Paroxysmal atrial tachycardia rarely required specific treatment, atrial fibrillation was best managed with intravenous administration of digoxin except when associated with severe clinical compromise, and atrial flutter generally required cardioversion or rapid intravenous therapy and usually caused severe clinical deterioration. Over-all, atrial tachyarrhythmia was not associated with a significantly increased mortality, and in those who died, death was not related specifically to the atrial tachyarrhythmia but rather to the severity of the underlying acute myocardial infarction. However, persisting atrial tachyarrhythmias, particularly atrial flutter which tends to be refractory to both heart rate control and cardioversion, may contribute indirectly to morbidity and mortality.     

Intracoronary stenting in acute myocardial infarction

Stent implantation into an infarct-related artery during acute myocardial infarction is generally contraindicated because of the risk of stent thrombosis. We report on 3 patients who had successful stenting for an acute occlusive dissection that developed during direct infarct coronary angioplasty and was refractory to conventional prolonged balloon dilatation, with good long-term clinical and angiographic results. The prerequisites for success include proper premedication, presence of only a minimal amount of thrombus in the infarct-related artery, liberal use of intracoronary thrombolytic therapy, as perfect an angiographic result as possible, as well as careful and aggressive post-stenting anticoagulation.     

Percutaneous transluminal coronary angioplasty in acute myocardial infarction. A prospective controlled study

In the present study we compared the outcome of primary percutaneous coronary angioplasty (PTCA) (PTCA without prior or concomitant administration of thrombolytic drugs) in 82 consecutive patients with acute myocardial infarction (AMI) with the outcome of 82 AMI patients, who were treated with intravenous thrombolysis. The thrombolysis patients were prospectively matched to the angioplasty patients regarding age, sex, duration of symptoms and infarct localisation. The in-hospital mortality was 3.7% in the PTCA group versus 4.9% in the thrombolysis group. Thrombolysis-treated patients had increased use of diuretics and ACE-inhibitors as compared to PTCA-treated patients. The mean ejection fraction was 52 +/- 11% in the PTCA group versus 47 +/- 10% (p = 0.01) in the thrombolysis group. We conclude that initial Danish experience with primary PTCA is promising, and that this treatment may favourably affect the outcome of acute myocardial infarction.     

Decaffeinated coffee and acute myocardial infarction. A case-control study in Italian women

The relationship between consumption of decaffeinated coffee and acute myocardial infarction was analyzed in a case-control study conducted in Italy between 1983 and 1992. Case patients were 433 women with acute myocardial infarction, aged 24 to 69 years (median age, 52 years), and control subjects included 869 women in hospital for a wide spectrum of acute conditions, other than cardiovascular, neoplastic, digestive, and hormone-related diseases or conditions associated with long-term modification of diet. Regular use of decaffeinated coffee was reported by 11% of the case patients and 7% of the control subjects. Compared with women who did not drink decaffeinated coffee, the relative risk (RR) was 1.3 (95% confidence interval (CI), 0.8 to 2.2) for one cup/d and 2.1 (95% CI, 1.1 to 3.9) for 2 or more cups (chi 2(1) for trend = 5.62, P = 0.02). The estimates were somewhat higher after allowance for education, marital status, body mass index, and smoking status (RR for > or = 2 cups of decaffeinated coffee per day, 2.5; 95% CI, 1.2 to 4.9), and somewhat lower after further allowance for diabetes, hypertension, and hyperlipidemia (RR, 1.7; 95% CI, 0.8 to 3.6). There was no association between duration of use of decaffeinated coffee and infarction risk. The relationship between decaffeinated coffee and infarction was consistent across strata of age, education, smoking, and history of hyperlipidemia. Thus, a relationship of marginal significance was observed in this study between decaffeinated coffee and myocardial infarction, of similar magnitude to that described for caffeinated coffee. This indicates that (i) caffeine is unlikely to be a relevant factor in any potential coffee-myocardial infarction relationship, and (ii) shifting from caffeinated to decaffeinated coffee is unjustified in order to reduce any possible coffee-related infarction risk.     

Thrombolysis for acute myocardial infarction

Thrombolytic therapy has been a major advance in the management of acute myocardial infarction. Unfortunately, it continues to be underused or is administered later than is optimal. Thrombolytic therapy works by lysing infarct artery thrombi and achieving reperfusion, thereby reducing infarct size, preserving left ventricular function, and improving survival. The most effective thrombolytic regimens achieve angiographic epicardial infarct-artery patency in only approximately 50% of patients within 90 minutes. Bleeding requiring transfusion occurs in approximately 5% of patients and stroke in approximately 1.8% with these regimens, which include adjunctive aspirin and intravenous heparin. There are several ways in which reperfusion rates and thus patient outcomes might be improved, such as different dosing regimens of established agents; combinations of different agents; improved adjunctive therapy such as direct antithrombin agents, low-molecular-weight heparin, or glycoprotein IIb/IIIa receptor antagonists; or the development of novel thrombolytic agents with enhanced fibrin specificity, resistance to native inhibitors, or prolonged half-lives allowing bolus administration. All of these strategies are being tested in clinical trials. The best approach currently is to administer thrombolytic therapy as soon as possible to all patients without contraindications who present within 12 hours of symptom onset and have ST-segment elevation on the ECG or new-onset left bundle-branch block, unless an alternative reperfusion strategy is planned.     

Can ECG changes predict the long-term outcome in patients admitted to hospital for suspected acute myocardial infarction?

SETTING: The activity of KRM 1648 (KRM), a new benzoxazinorifamycin, and rifabutin (RBT), alone or in combination with clarithromycin (CLA), was evaluated against Mycobacterium avium complex (MAC) that multiplied in human alveolar macrophages (AM). DESIGN: AM were recovered by bronchoalveolar lavage, incubated in RPMI 1640 medium with 10% human AB serum, infected with four strains of MAC (of non-acquired immune deficiency syndrome [AIDS] origin), and then treated with each drug alone or in combination. After incubation for 7 days, colony forming units in each well were counted on 7H10 agar. RESULTS: Although concentrations between 0.2 microgram/ml and 20 micrograms/ml of both rifamycins showed clear dose-dependent activities against all MAC strains tested, only 20 micrograms/ml of each drug had modest bactericidal effect. In combination with 2.0 micrograms/ml of CLA, however, 0.2 microgram/ml of both drugs caused a bactericidal response against two of the four MAC strains examined. CONCLUSION: According to this human alveolar macrophage model of MAC infection, KRM and RBT in combination with CLA was found to be a promising candidate against human pulmonary MAC infection, and deserves clinical evaluation.     

Nonsurgical infarctectomy in acute experimental myocardial infarction

This study examines whether a catheter mounted left intraventricular balloon may prevent left ventricular (LV) dysfunction following acute experimental myocardial infarction. In 10 anesthetized pigs, multiple coronary arterial ligations were applied around the apex of the heart. LV end-diastolic pressure (LVEDP), aortic flow (AF), and LV long and short axis fractional shortening (FS) were measured before and at 15 min intervals after ligations. At the 60th min after ligation, the LV long axis FS and AF decreased by 7.2 +/- 2.6% (p < 0.05) and 13.25 +/- 2.68% (p < 0.01), respectively, and the LVEDP increased by 4.3 +/- 1.1 mm Hg (p < 0.01) while no change was noted in the LV short axis FS. An intraventricular catheter mounted nonpulsating balloon was positioned over the endocardium of the infarcted area at the LV apex. Inflation of the nonpulsating balloon to an optimal volume, which was found to be equal to 8-10% of the LV end-diastolic volume, resulted in a reduction (by 3.8 +/- 1.2 mm Hg, p < 0.01) of the already increased LVEDP and in an increase (by 6.6 +/- 2.1%, p < 0.05) in the LV short axis FS while no statistically significant change was noted in the AF and LV long axis FS. It is concluded that an intraventricular catheter mounted balloon patch positioned over the endocardium of the infarcted area may ameliorate early LV dysfunction, possibly by interfering with the functional geometry of the LV contraction.