The role of attentional deployment during distancing in adolescents with major depression

Individuals with major depression (MD) show deficits in cognitive reappraisal. It is yet unexplored how the act of directing visual attention away from/towards emotional aspects impacts on cognitive reappraisal in MD. Thus, we examined the role of attentional deployment during cognitive reappraisal (specifially during distancing) in adolescent MD. 36 MD adolescents and 37 healthy controls (12-18 years) performed a cognitive reappraisal task during which they a) down-regulated self-reported negative affective responses to negative pictures via distancing, or b) simply attended to the pictures. During the task, attentional focus was systematically varied by directing participants' gaze to emotional vs. non-emotional picture aspects. The validity of this experimental manipulation was checked by continuous eye-tracking during the task. Across groups and gaze focus conditions, distancing diminished negative affective responses to the pictures. Regulation success significantly differed between groups dependent on gaze focus: MD adolescents showed relatively less regulation success than controls in the emotional gaze focus condition, while the reverse was true for the non-emotional gaze focus condition. The results suggest that in MD adolescents, an emotional context might interfere with emotion regulatory aims. The findings can provide an important starting point for the development of innovative training regimes that target deficient reappraisal processes in adolescents suffering from MD.

Neonatal murine macrophages show enhanced chemotactic capacity upon toll-like receptor stimulation

BACKGROUND

The neonatal surgical patient is threatened by exuberant inflammatory reactions. Neonatal macrophages are key players in this process. We investigated the ability of neonatal macrophages to initiate a local inflammatory reaction upon exposure to different bacterial or viral ligands to toll-like receptors (TLRs).

METHODS

Peritoneal wash outs from neonatal (<24 h) and adult (42 days) C57BL/6J mice were gained by peritoneal lavages. In a first set of experiments, macrophages were purified and stimulated for 6 h by four different TLR ligands. mRNA was extracted for transcriptome analysis. In a second set of experiments, lipopolysaccharide was applied into peritoneal cavities. After 6 h of incubation, the cellular composition of the inflamed cavities was evaluated by cytological staining as well as chipcytometry.

RESULTS

Neonatal murine peritoneal macrophages differed significantly in the expression of pro- and anti-chemotactic genes. Functional assignment of these genes revealed enhanced chemotactic potential of neonatal macrophages and was confirmed by a higher influx of pro-inflammatory cells into neonatal peritoneal cavities.

CONCLUSION

Neonatal peritoneal macrophages demonstrated an enhanced chemotactic potential upon stimulation with four TLR ligands. This was associated with an increased influx of inflammatory cells to the peritoneal cavity. This might contribute to the strong inflammatory responses of neonates and preterms.

Efficacy and safety of an oral fixed low-dose perindopril 2 MG/indapamide 0.625 MG combination: a randomized, double-blind, placebo-controlled study in elderly patients with mild to moderate hypertension

The efficacy and safety of 12 weeks treatment with an oral fixed low-dose perindopril 2 mg + indapamide 0.625 mg (Per/Ind) combination in elderly and very elderly patients (65-85 years) with mild to moderate systolic and diastolic hypertension (SDH) or isolated systolic hypertension (ISH) were investigated vs placebo. This trial was a multinational randomized double-blind study with doubling of active drug dosage in nonresponders. Intention to treat analysis was performed in 383 patients (age 72.4 years; ISH 32%). 58.5% remained on their initial dosage. Per/Ind decreased supine diastolic and systolic blood pressure (sDBP/sSBP) by 13.2+/-8.0 mm Hg and 22.5+/-13.9 mm Hg (P <.0001) versus placebo -7.3+/-9.0 mm Hg and -12.3+/-15.2 mm Hg, respectively. In ISH (n = 123), Per/Ind decreased sSBP by 23.0+/-11.8 mm Hg (P <.0001). Overall response and normotension rates was 81.3% with Per/Ind (P <.0001). Adverse event rates (including hypokalemia) were similarly low in both groups. Analysis in the over-75 year subgroup showed similar safety and efficacy results. Fixed low-dose Per/Ind is a safe and effective treatment of hypertension including isolated systolic hypertension in the elderly.

Prognostic value of thrombolysis, coronary artery patency, signal-averaged electrocardiography, left ventricular ejection fraction, and Holter electrocardiographic monitoring for life-threatening ventricular arrhythmias after a first acute myocardial infarction

Prognostic studies after acute myocardial infarction (AMI) have mainly been performed in the prethrombolytic era. Despite the fact that modern management of AMI has reduced mortality rates, the occurrence of malignant ventricular arrhythmias in the late phase of AMI remains an important issue. We prospectively studied 244 consecutive patients (97 treated with thrombolytics) who survived a first AMI. All patients underwent time domain signal-averaged electrocardiography (vector magnitude: measurements of total QRS duration, terminal low [<40 microV] amplitude signal duration, and root-mean-square voltage of the last 40 ms of the QRS complex), Holter electrocardiographic monitoring, and cardiac catheterization. Late life-threatening ventricular arrhythmias were recorded. Eighteen arrhythmic events occurred during a mean follow-up period of 57 +/- 18 months. Three independent factors were associated with a higher risk of arrhythmic events: (1) left ventricular ejection fraction (odds ratio 1.9/0.10 decrease), (2) terminal low-amplitude signal duration (odds ratio 1.5/5 ms increase), and (3) absence of thrombolytic therapy (odds ratio 3.9). Low-amplitude signal duration sensitivity for sudden cardiac death was low (30%). Left ventricular ejection fraction had the highest positive predictive value for sudden cardiac death (10%). Thus, thrombolysis decreases both the incidence of ventricular tachycardia and sudden cardiac death with a higher reopening rate of the infarct-related vessel. Signal averaging predicts the occurrence of ventricular tachycardia and an impaired left ventricular ejection fraction predicts the occurrence of sudden cardiac death.

Additional predictive value of both left and right ventricular ejection fractions on long-term survival in idiopathic dilated cardiomyopathy

BACKGROUND

In idiopathic dilated cardiomyopathy, long-term outcome is poor and left ventricular ejection fraction is a major powerful predictor of survival. However, right ventricular function might also play an important role in the long-term prognosis of this disease.

AIM

The aim of this study was to determine the role of right ventricular parameters, mainly right ventricular ejection fraction, on survival in idiopathic cardiomyopathy.

METHODS

We prospectively assessed long-term follow-up and predictors of survival in 62 consecutive patients referred from 1990 to 1992 for evaluation of idiopathic dilated cardiomyopathy, including haemodynamic evaluation, thermodilution right ventricular ejection fraction and volume measurements.

RESULTS

At the time of catheterization, dyspnoea class III or IV was present in 60% of the patients, atrial fibrillation in 19% and complete left bundle branch block in 35%. Left ventricular ejection fraction was 30 +/- 10% and right ventricular ejection fraction was 30 +/- 16%. During follow-up (2.2 +/- 1.3 years), 15 patients (24%) had heart transplantation and nine (14%) died before cardiac transplantation. Cumulative survival rate without heart transplantation was 74% and 56% at 1 and 4 years, respectively. In univariate analysis, survival was related to: dyspnoea class I or II (P < 0.04), absence of complete left bundle branch block (P < 0.05), administration of lower doses of furosemide (P < 0.01), high left ventricular ejection fraction (P < 0.001), low pulmonary artery pressure (P < 0.002), high cardiac index (P < 0.006), and low right ventricular volumes (P < 0.001). Multivariate analysis showed only two independent predictors of survival: left ventricular ejection fraction (P < 0.001) and right ventricular ejection fraction (P < 0.004).

CONCLUSION

In addition to left ventricular ejection fraction, right ventricular ejection fraction appears to be a complementary predictor of survival in idiopathic dilated cardiomyopathy, suggesting the importance of assessing right ventricular function in this disease.

Frequencies of five genetic polymorphisms in coronarographed patients and effects on lipid levels in a supposedly healthy population

Allele frequencies of genetic polymorphisms were compared between supposedly healthy subjects and angiographically proven coronary artery disease patients. The polymorphic candidate loci investigated were the apolipoprotein (apo) B signal peptide and XbaI polymorphism, the apo E polymorphism and two polymorphism of lipoprotein lipase (LPL) gene: Hind/III and PvuII. Apo B signal peptide and HindIII/LPL polymorphisms showed significant differences in allele partition between cases and controls; the rare alleles of both polymorphisms were less frequent (p < 0.05) in cases. We looked for associations between the polymorphisms and lipid concentration variability in a supposedly healthy population (145 men and 144 women). Apo B signal peptide, apo E and PvuII/LPL polymorphisms seem to influence some lipid metabolism parameters significantly. Apo AI and LpCIII levels were significantly different among apo B signal peptide genotypes: Del homozygotes had the highest concentrations of both variables. The epsilon 4 allele of apo E polymorphism was associated with increased concentrations of total cholesterol, LDL cholesterol and apo B. Increased LpAI:AII levels observed in E3 homozygotes (p < 0.01) have not previously been reported. LpAI:AII concentration was also influenced by PvuII/LPL polymorphisms.

Influence of cigarette smoking on rate of reopening of the infarct-related coronary artery after myocardial infarction: a multivariate analysis

OBJECTIVES

This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both.

BACKGROUND

In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients.

METHODS

We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [+/- SD] 6.7 +/- 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade > or = 2. Four cardiovascular risk factors--smoking, hypertension, hypercholesterolemia and diabetes mellitus--and eight different variables-age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography--were recorded in all patients.

RESULTS

Thrombolysis in current smokers and anterior infard location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infard vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location.

CONCLUSIONS

These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas nonsmokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.

Beneficial cumulative role of both nitroglycerin and dobutamine on right ventricular systolic function in congestive heart failure patients awaiting heart transplantation

End-stage idiopathic dilated cardiomyopathy or ischemic heart disease usually present with very low cardiac output and severe ventricular dysfunction which may require pharmacological support before heart transplantation. Right ventricular ejection fraction might be an important factor of functional capacity and survival in congestive heart failure. In order to test the immediate response of right ventricular hemodynamic parameters to nitroglycerin and dobutamine usually used to treat severe left ventricular dysfunction, we studied 17 congestive heart failure patients (15 men, two women; mean age 55 +/- 13 years) with end-stage idiopathic dilated cardiomyopathy (n = 10) or end-stage ischemic heart disease (n = 7), left ventricular ejection fraction < 35% (mean 22 +/- 8%), and sinus rhythm. A well validated thermodilution technique using a dedicated catheter with a fast catheter-computer response, permitting instantaneous measurements of right ventricular ejection fraction, was used. Right ventricular hemodynamic parameters were recorded at baseline, after an intravenous bolus injection of 3 mg nitroglycerin and after an intravenous infusion of dobutamine administered after nitroglycerin until normalization of cardiac index or a maximal dose of 15 micrograms/kg/min. Pulmonary artery mean pressure significantly decreased after nitroglycerin (43 +/- 9 mmHg at baseline vs. 31 +/- 10 mmHg after nitroglycerin, P < 0.0001) and did not subsequently change after dobutamine (32 +/- 10 mmHg after dobutamine, ns). Cardiac index was not affected by nitroglycerin (1.7 +/- 0. l/min/m2 at baseline vs. 2.0 +/- 0.3 l/min/m2 after nitroglycerin, ns), but dramatically increased after dobutamine (3.0 +/- 1.0 l/min/m2 after dobutamine, P < 0.0001). Concomitantly to the changes of these two parameters, right ventricular ejection fraction progressively increased (14 +/- 8% at baseline vs. 20 +/- 10% after nitroglycerin (P < 0.0006) vs. 28 +/- 13% after dobutamine (P < 0.0001)). Progressive increase of right ventricular ejection fraction after administration of nitroglycerin followed by administration of dobutamine suggests the beneficial cumulative role of both medications on right ventricular systolic function in severe congestive heart failure.

[Is percutaneous transluminal coronary angioplasty in chronic total coronary occlusion justified? Long term results in a series of 201 patients]

Percutaneous transluminal coronary angioplasty of chronic total coronary occlusions has a low primary success rate and is associated with a high percentage of restenosis. The aim of this retrospective study was to assess the long-term benefits of these procedures. In a series of 201 patients with 203 chronic total occlusions, the technical success rate was 51%, the clinical success rate was 46% with 3% of major complications. The only factor associated with a favourable outcome was the presumed duration of the occlusion. The clinical follow-up period was established at 6 years. The result of the initial procedure was used to establish two groups of patients: group I, clinical success, and group II, clinical failure. Patients in group I had a probability of survival greater than that of those in group II (97 vs 92%; p < 0.05); survival without coronary bypass surgery was also significantly better (89 vs 74%; p < 0.003). On the other hand, the probability without angioplasty was less in group I (70 vs 77%; p < 0.01), the result of a high restenosis rate (48%). A Cox analysis identified clinical success of angioplasty as a good prognostic factor for survival. Moreover, the clinical status at long-term was significantly better in patients in group I. These results indicate that in patients with chronic total coronary occlusions, the success of angioplasty has a favourable effect on long-term outcome both in terms of survival and in quality of life. They must be interpreted in the light of the limitations inherent in a retrospective study and should be confirmed by prospective trials.

Long-term prediction of major ischemic events by exercise thallium-201 single-photon emission computed tomography. Incremental prognostic value compared with clinical, exercise testing, catheterization and radionuclide angiographic data

OBJECTIVES

This study sought to evaluate the prognostic role of exercise thallium-201 (Tl-201) single-photon emission computed tomography (SPECT) in patients with known or suspected coronary artery disease.

BACKGROUND

Compared with planar Tl-201 scintigraphy, Tl-201 SPECT allows enhanced assessment of myocardial perfusion abnormalities. However, the long-term prognostic value of exercise Tl-201 SPECT has not been ascertained and compared with that of other techniques of investigation.

METHODS

Predictors of ischemic events were sought in 217 patients with known or suspected coronary artery disease who underwent exercise Tl-201 SPECT, coronary angiography and rest radionuclide angiography and who initially received medical therapy. Predictive values were determined using Cox proportional hazards regression models.

RESULTS

During a mean (+/- SD) follow-up period of 70 +/- 19 months, 29 patients had a major ischemic event (cardiac death or myocardial infarction). Total extent of exercise defects was the best independent predictor by Tl-201 SPECT of major events (p < 0.001) and provided additional prognostic information compared with clinical, exercise testing and catheterization variables (p < 0.02). Extent of reversible Tl-201 SPECT perfusion defects provided additional prognostic information compared with extent of irreversible defects (p < 0.001) and was the sole Tl-201 SPECT variable providing additional prognostic information compared with radionuclide left ventricular ejection fraction (p < 0.02).

CONCLUSIONS

Total extent of exercise Tl-201 SPECT defects is a powerful long-term predictor of major ischemic events that enhances the prediction provided by clinical, exercise testing and coronary angiographic data. In view of its prognostic significance, extent of reversible Tl-201 SPECT defects might provide original information about improving prognosis by coronary revascularization.

[Comparative outcome of aortic valve endocarditis with or without annular abscess]

Annular abscess is a not uncommon but serious complication of aortic valve endocarditis. The aim of this retrospective study was to evaluate the prognosis of aortic valve endocarditis with and without annular abscess. Between January 1981 and 1989, 122 consecutive cases of aortic endocarditis fulfilling the diagnostic criteria of Duke University were admitted to hospital. Group I included 40 cases with aortic ring abscess confirmed at surgery, in 35 patients; group II comprised 43 cases of operated aortic valve endocarditis without annular abscess in 41 patients and group III comprised 38 cases of aortic valve endocarditis treated medically without echocardiographic or angiographic signs of annular abscess in 36 patients. The patients in group III were significantly older than those in group I (57 +/- 14 years vs 44 +/- 17 years; p < 0.001). From the clinical point of view, endocarditis of prosthetic valves was slightly more common, but without reaching statistical significance, in group I, but the abscess was associated with more severe cardiac failure. Systemic embolism, atrioventricular block and pericardial effusion were equally common in the three groups. On the other hand, endocarditis with annular abscess was more often the result of infection with streptococci A, B, C or pneumoniae, than forms without abscess (22.5% vs 5% and 3% respectively in the 3 groups; p < 0.05). Of the patients treated surgically, destructive lesions of the valves were more common in cases of abscess (57.5% vs 35%; p < 0.05): the hospital mortality was higher in cases of abscess (17.5% vs 7%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of calculation of the kappa coefficient in the evaluation of an imaging method]

Radiologists are often confronted to the choice of the most appropriate statistic tool for evaluating diagnostic imaging methods. Using a radiological literature example, the Kappa agreement test is herein described and its applications are determined. Although widely performed to determine the inter-rater agreement, this test is also suited for the confrontation of two or more diagnostic imaging methods applied on the same subjects and providing categorical data. It procures the degree of agreement between the different methods.

Predictive value for treatment outcome in acute myeloid leukemia of cellular daunorubicin accumulation and P-glycoprotein expression simultaneously determined by flow cytometry

To evaluate the clinical relevance of multidrug resistance (MDR) phenotype, the intracellular daunorubicin accumulation (IDA) and P-glycoprotein (P-gp) expression were investigated in 87 adult patients with acute leukemia: 69 patients with de novo acute myeloid leukemia (AML), 10 with AML at relapse, and eight with secondary leukemia to myelodysplastic syndromes (MDS-AML). IDA and P-gp expression were determined by double-labeling flow cytometry analysis. Of 87 patients, 36 expressed P-gp (41%). P-gp expression was more frequently observed in AML at relapse and MDS-AML as compared with de novo AML (P = .0001). P-gp expression was significantly associated with CD34 expression (P = .0003) and chromosome 7 abnormalities (P = .027). A significantly reduced IDA was observed in P-gp+ as compared with P-gp- patients (P = .0007). Of the 87 patients, 51 achieved complete remission (CR). A reduced IDA was observed in patients in failure as compared with patients in CR (22% +/- 17% v 42% +/- 21%; P = 10(-4). Twelve of 36 P-gp+ patients as compared with 40 of 51 P-gp- patients achieved CR (33% v 78%; P = 10(-4). The prognostic value of IDA and P-gp expression was confirmed in multivariate analysis. These data suggest that the determination of IDA and P-gp expression may be useful in designing therapy for patients with AML.

Refractory anemia with excess of blasts: a multivariate analysis of prognostic factors in 91 patients and a simplified scoring system for predicting survival

Prognosis in myelodysplastic syndromes is extremely variable. The prognostic value of the FAB classification has been demonstrated in many studies. However, within the same FAB subtype, some patients may experience prolonged survival, whereas others die in a few weeks. This prognostic heterogeneity makes the therapy decision difficult. In an attempt to identify significant prognostic factors for survival in refractory anemia with excess of blasts (RAEB), clinical and hematological characteristics were analyzed in 91 patients. Multivariate regression analysis showed that bone marrow total blast cells percentages, sex and hemoglobin level were the characteristics significantly associated with survival. A scoring index based upon these three characteristics may be proposed and had a great prognostic value (p < 0.00001). It allows us to separate patients into three groups with low, intermediate and high score with a median survival of 239, 133 and 45 days for each group respectively. This scoring index may be useful in the design of therapy and analysis of future clinical trials. However, its predictive value needs to be confirmed in other series.

[Transluminal coronary angioplasty in patients with left ventricular dysfunction; immediate and long term results]

Transluminal coronary angioplasty is increasingly performed in patients with left ventricular dysfunction. However, there is little data available concerning the outcome of these patients. The aim of this retrospective study was to assess the immediate and long-term results in 90 patients (76 men and 14 women) with left ventricular ejection fractions < or = 35% (average 29 +/- 5%) undergoing angioplasty between 1980 and December 1992. Eighty-seven patients (96%) had a history of infarction, 27 (30%) had already at least one episode of left ventricular failure and 34 (38%) had unstable angina at the time of angioplasty. The coronary disease was usually multi-vessel. A total of 118 lesions were dilated with a primary success rate of 77% (91/118): 86% (82/95) in non-occlusive stenoses and 39% (9/23) in complete obstructions. The total success rate per procedure was 72% (65/90) with a hospital mortality rate of 5.5% (5 cases). The mean follow-up period was 53 +/- 47 months. Twelve patients died during this period and two were lost to follow-up. The total and cardiovascular mortality at the end of the study was 19% (17/88). Eight of the 71 survivors underwent another revascularisation procedure (4 bypasses and 4 angioplasties); 21 (29%) have stable angina, 50 (71%) have no anginal pain and 61 (86%) have antianginal treatment. The probability of survival at one and four years was 81 +/- 4% and 79 +/- 5%, respectively. A multivariate analysis using the Cox model showed three independent prognostic factors for long-term mortality: triple coronary vessel disease, the best predictive factor, left ventricular ejection fraction and female gender.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence and risk factors for latent sensitization to chymopapain: predictive skin-prick tests in 700 candidates for chemonucleolysis

Seven hundred patients were investigated prospectively before undergoing chemonucleolysis. A past history of allergy and/or previous exposure to papain, either in food, beverages or drugs, was sought, and a skin-prick test with chymopapain was performed. Based on the results obtained, the subjects were classified into four groups: Group I--225 non-atopic non-papain-exposed subjects; Group II--285 non-atopic papain-exposed subjects; Group III--69 atopic non-papain-exposed subjects; and Group IV--121 atopic papain-exposed subjects. Latent sensitization to papain was observed in 0.4% of subjects in Group I, 3.16% in Group II, 5.8% in Group III and 7.4% in Group IV. The odds ratios were 13.8 for atopy and 7.3 for exposure to papain. Interaction between atopy and papain exposure did not result in a significantly greater risk. Neither sex nor age nor a history of a previous drug reaction were risk factors. Only one patient out of the 23 who were sensitive to papain had no risk factor. The 677 skin-test negative patients then underwent chemonucleolysis and none of them had an anaphylactic reaction. This was significantly less frequent: (P = 0.04) than the incidence in a random population (0.45%). Prick tests performed 6 weeks and 6 months after chemonucleolysis revealed newly acquired sensitization in 36% of the patients. Atopy was not a risk factor for this event.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up after coronary angioplasty in patients younger than 40 years of age

Over an 11-year period, the initial and late outcomes of percutaneous transluminal coronary angioplasty (PTCA) were studied in 140 consecutive patients younger than 40 years of age (mean, 34 +/- 3 years; range, 23 to 39 years; 132 men). Before the procedure, 28% of the patients had unstable angina, and 44% had a history of prior myocardial infarction. Mean left ventricular ejection fraction was 64% +/- 10%, and 75% of the patients had one-vessel disease. Primary success was 86% (77% for the first 70 patients vs 93% for the last 70, p < 0.02). Complications were nine periprocedural myocardial infarctions, eight emergency coronary surgical procedures, and no deaths. During follow-up (mean, 6 +/- 3 years; range, 1 to 12 years), 39 (28%) of the 104 patients who had repeat coronary angiography had angiographic restenosis (all < 6 months after PTCA). Late events were 13 elective coronary surgical procedures (11 for restenosis, one for failed PTCA, and one for progression of coronary artery disease), 13 PTCAs on a new site, five deaths, and four nonfatal myocardial infarctions. Ten-year survival was 96% +/- 1%, and 10-year event-free survival (without myocardial infarction, elective coronary surgery, or repeat PTCA) was 58% +/- 6%. Among survivors, 88% were free of angina, and 93% had returned to work. In patients younger than 40 years of age, PTCA yields excellent long-term survival, provided that the eventuality of repeat procedures during the first months is accepted. In addition, PTCA for progression on a new site is not unusual after several years.

Prognosis of stroke patients undergoing mechanical ventilation

OBJECTIVE

to determine the outcome of stroke patients undergoing mechanical ventilation.

DESIGN

retrospective chart review and follow-up telephone interview.

SETTING

medical ICU in a multidisciplinary university hospital.

PATIENTS AND PARTICIPANTS

199 stroke patients from 1984-1989 where the final diagnosis was stroke.

INTERVENTIONS

all patients were admitted for the need of mechanical ventilation.

MEASUREMENTS AND RESULTS

demographic information, previous relevant diseases, stroke type, general clinical and neurological data, biochemical variables, severity of illness were recorded for the first 24 h following ICU admission. A 1-year follow-up was performed, including mortality and functional status of survivors. Of 170 eventually analyzable patients, 123 (72.4%) died during their ICU stay and 156 (91.8%) during the first year. Three variables were independently associated with one-year mortality: Glasgow score < 10 (p < 0.03), bradycardia (p < 0.001), absence of brainstem reflexes (p < 0.0004).

CONCLUSION

overall prognosis of stroke needing mechanical ventilation is poor, strongly linked to symptoms of neurological impairment.

[Estimation with bacteriology of the evolution of nosocomial infections between 1989 and 1991 in an university hospital]

The bacteriological laboratory data base was studied with an original software (Bacterio) and an appropriate method ("doubles" and early samples are not taken in account) to estimate the nosocomial infections. The incidence rates for 100 hospitalizations at the University hospital of Nancy are 9.2, 8.2 et 8.2 for respectively 1989, 90 et 91. These values are corrected while taking into account a method's sensibility of 65%. The 1000 days of hospitalization's rates allow a better comparison between the medical departments. For the whole hospital, the results are respectively of 7.9, 7.2 and 7.5%. Even if the many bias described cannot always been checked, the method gives some evolutivity indicators which are very useful for the hygienists.

Prospective study of risk factors in natural rubber latex hypersensitivity

Five hundred sixty-nine subjects routinely underwent skin prick tests for latent sensitization to latex. The study of risk factors included skin tests to inhalant allergens, to diagnose atopy, and a questionnaire aimed at revealing frequent exposure to latex such as the wearing of gloves, multiple surgical procedures, or urinary catheterization. The subjects were categorized into five groups: group I, subjects with no risk factor (n = 272); group II, nonatopic subjects exposed to latex (n = 73); group III, atopic subjects not exposed (n = 180); group IV, exposed atopic subjects (n = 44); and group V, subjects with a history of intraoperative anaphylactic shock caused by latex (n = 13). Twenty-five subjects had spina bifida and were in either group II (14 subjects) or group IV (11 subjects). The questionnaire identified a probable allergy to latex in 18 subjects: 16 cases were confirmed by skin test, but responses were not informative in 23 patients who were sensitive to latex. Positive prick tests to latex were obtained in 0.37% of group I, 6.85% of group II, 9.44% of group III, and 36.36% of group IV. Of the children with spina bifida, 32% had positive skin test results. As risk factors, atopy and exposure were synergistic. We recommend predictive prick tests not only in children with spina bifida but also in any atopic subject or in any patient with a history of frequent exposure to latex. Latex could be considered a habitual allergen. The use of latex urinary catheters should be avoided in patients who are catheterized on a daily basis.

[Peri-ungual capillaroscopy. Value in the diagnosis of systemic diseases]

The diagnostic value of nailfold capillaroscopy was assessed through blind analysis of a continuous series of 354 examinations. Major and minor dystrophies and capillary bed abnormalities are the best criteria, especially in patients presenting with vascular disorders of the upper extremities. A systemic disease (specificity: 82.7 percent; negative predictive value (NPV): 90.2 percent) and specifically a systemic scleroderma (sensitivity: 97.1 percent and NPV: 99.4 percent) is improbable in case of normal capillaroscopy. First component analysis distinguished patients with definite systemic disease from normal subjects. Its value is dubious in other connective tissue diseases systemic lupus erythematosus, rheumatoid arthritis, Sjögren's disease, etc.).

[Immediate and long-term results of coronary transluminal angioplasty in patients under 35 years of age]

Over an eleven year period, 57 patients under 35 years of age underwent percutaneous transluminal coronary angioplasty (PTCA). The features of the study population were: 55 men and 2 women, average age 32 +/- 3 years; unstable angina in 30%, previous myocardial infarction in 53%, average left ventricular ejection fraction 59 +/- 12%, single vessel disease in 84%. A total of 63 vessels were dilated. The primary success rate was 81% (72% in the first 29 patients compared with 89% in the latter 28 patients, p = 0.1). The following complications were observed: peri-procedural infarction (4 cases), emergency coronary bypass surgery (4 cases), no fatalities. During follow-up (average 6 +/- 3 years), of the 43 patients who underwent control coronary angiography in the last 6 months, 14 (33%) had angiographic restenosis. The long-term outcome was marked by 5 coronary bypass operations (3 for restenosis, 1 after failure of PTCA and 1 for progression of the coronary disease), 8 PTCAs for a new lesion due to progression of the coronary disease, 2 deaths and 2 non-lethal infarctions. The 10 year survival was 96 +/- 3% and the survival rate without cardiac events (infarction, surgical revascularisation or repeat PTCA) was 62 +/- 10% at 10 years. Of the 54 survivors, 50 (92%) have no angina, and 44 (81%) continue to take antiischaemic drug therapy. Of the 50 patients who were in full employment, 37 (74%) have gone back to full-time working and 8 (16%) have taken part-time jobs. (ABSTRACT TRUNCATED AT 250 WORDS)

Results of percutaneous transluminal coronary angioplasty of either the left anterior descending or left circumflex coronary artery in patients with chronic total occlusion of the right coronary artery

The acute and long-term results of percutaneous transluminal coronary angioplasty (PTCA) of the left coronary artery in 106 patients (group 1) with chronic occlusion of the right coronary artery were compared with those of 106 patients matched for sex (92 male) and age (56 +/- 10 years) undergoing left PTCA with a normal right coronary artery (group 2). Before the procedure, group 1 had more unstable angina (42 vs 29%; p < 0.05), more frequent prior myocardial infarction (80 vs 25%; p < 0.001), and a lower left ventricular ejection fraction (56 +/- 10% vs 65 +/- 11%; p < 0.005). Acute results were not different in the 2 groups with respect to primary success (group 1: 93%; and group 2: 89%) and complications (group 1: 2 with emergency coronary surgery, and 4 with periprocedural myocardial infarction and no death; and group 2: 1 with emergency coronary surgery, 1 death, and 3 with periprocedural myocardial infarction). At 6 months, 79 patients in group 1 and 71 patients in group 2 had reangiography; the rate of restenosis was 35% in group 1 and 42% in group 2. In both groups, left ventricular ejection fraction increased significantly in patients without restenosis (58 +/- 12% vs 63 +/- 10%, p < 0.001 [n = 44] in group 1; and 66 +/- 9% vs 70 +/- 10%, p < 0.001 [n = 29] in group 2). In group 1, improvement was significant only for patients without collaterals to the occluded right coronary artery (59 +/- 10% vs 66 +/- 7%; p < 0.003 [n = 24]).(ABSTRACT TRUNCATED AT 250 WORDS)

[Nutritional and trace elements status in cardiomyopathies in the elderly]

Nutritionnal status remain poor in hospitalized elderly for cardiopathy compared to healthy controls, secondary to bad general status. Selenium rate appears significantly lower in ischemic cardiomyopathy than in valvular or hypertension cardiopathy.

[Modalities of detection of abnormal blood level of thyroid hormones in hospitalized aged patients]

In a continuous series of 3836 patients over 60 years old, 24.1% have abnormal tests, 1.28% present hyperthyroidism and 1.98% hypothyroidism. Screening with TSH alone and T4 if abnormality, appears as the most helpful and costless method in order to detect thyroid dysfunction in hospitalised elderly patients.

[Transluminal coronary angioplasty in patients over 75 years of age. Immediate and long-term results]

Over a 4-year period, 120 transluminal coronary angioplasties were performed in 102 patients older than 75 years. There were 56 men and 46 women aged from 75 to 89 years (mean: 78 +/- 3 years) presenting with the following characteristics: left ventricular ejection fraction 60 +/- 11 percent; severe angina (class III or IV) 86 percent; history of myocardial infarction 43 percent; one-vessel lesion 39 percent; 66 percent of the arteries dilated were calcified. Altogether, 158 vessels (1.3 per procedure) were dilated: 1 vessel in 74 percent of the patients, 2 in 20 percent and 3 in 6 percent. The primary success rate was 80 percent per lesion (126/158 lesions) and 77 percent per procedure (92/120 procedures). This primary success rate was significantly higher when the stenosis dilated was not calcified (88 versus 75 percent, P < 0.05) and in cases with stenosis rather than complete occlusion (83 versus 53 percent, P < 0.01). Three patients died (3 percent) and 9 (7.5 percent) developed infarction with Q wave, but no emergency bypass was needed. The first 79 patients could be followed up for a mean period of 23 +/- 13 months (range: 8-61 months), and no patient was lost sight of. During that period, 11 patients died (including 7 of cardiac cause), 2 had a non-lethal infarction, 7 underwent distant aortocoronary bypass and 18 had a second angioplasty for restenosis. The long-term survival rate (Kaplan-Meier) was 83 +/- 6 percent at 4 years (90 percent when the angioplasty was successful and 73 percent when it failed; P < 0.02). Among the 65 survivors, 73 percent no longer had angina, 96 percent are in the New York Heart Association class I or II, and 92 percent are still on oral anti-angina therapy. Thus, transluminal coronary angioplasty can be performed in very old patients with good efficacy and an acceptable complication rate. The improvement obtained persists for a long time when the angioplasty is successful.

Percutaneous transluminal coronary angioplasty in patients more than 75 years old: early and long-term results

Over 4 yr, 102 consecutive patients more than 75 yr old (56 men, 46 women; mean age 78 +/- 3 years, range: 76-89 years) underwent 120 percutaneous transluminal coronary angioplasty procedures. At baseline, 86% had severe anginal symptoms (Canadian class III or IV), 43% had a history of prior myocardial infarction; 61% had multivessel coronary artery disease, and mean left ventricular ejection fraction was 60 +/- 11%. Calcifications were observed on 66% of the dilated arteries. A total of 158 vessels (1.3 vessel per procedure) were attempted: 1 vessel in 89 procedures (74%), 2 vessels in 24 (20%) and 3 vessels in 7 (6%). The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). Complications included 3 deaths (3%), 9 Q-wave infarctions (7.5%) and there was no emergency coronary bypass surgery. The primary success rate was significantly related to the absence of coronary calcifications on the dilated segment (88% versus 75%, p < 0.05) and to the initial patency of the dilated artery (subtotal stenosis: 83% versus total occlusion: 53%, p < 0.05). Follow-up data were obtained in the 79 consecutive patients with a duration of follow-up exceeding 8 months. The mean duration of follow-up was 23 +/- 13 months (range 8 to 61 months). No patient was lost to follow-up; 11 patients died (cardiac causes: 7), 2 had a non-fatal infarction, 7 had aortocoronary bypass surgery and 18 had repeat percutaneous transluminal coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary transluminal angioplasty after 70 years of age. Multivariate analysis of parameters influencing immediate results and long-term prognosis]

Between January 1986 and July 1990, 186 patients over 70 years of age underwent 215 transluminal coronary angioplasties. The patients' characteristics were: 117 men and 69 women; mean age 75.5 +/- 4 years (70-89 years): left ventricular ejection fraction 62 +/- 12%: 40% had previous myocardial infarction; 48% had single vessel disease; 80% had severe angina (19% Class III and 61% Class IV) and 58% of dilated vessels had calcification. In all, 276 vessels (1.3 patient) were dilated: one vessel in 77%, 2 vessels in 18% and 3 or more in 5% of patients. The primary success rate defined as a reduction of the diameter of stenosis below 50% was 81% (174/215 procedures) (85%-215/253 stenosis--in dilatations and 65%-15/23 obstructions--in attempted disobliterations). There were 4 deaths (2.1%), 12 Q wave infarcts (5.5%) and 5 non Q wave infarcts (2.3%), 2 emergency bypass grafts procedures and no cerebrovascular accidents. A multivariate analysis identified two factors which reduced the primary success rate: coronary calcification (p less than 0.02) and a history of previous infarction (p less than 0.02). Three factors were associated with an increased risk of perioperative infarction: the female sex, age greater than 75 years (p less than 0.01) and previous infarction (p less than 0.03). The first 154 patients were followed up for 25 +/- 14 months (8-61 months) without any patients being lost to follow-up. In this period, 16 patients died (11 of cardiac causes), 2 had non-fatal infarction, 13 underwent secondary aortocoronary bypass surgery and 30 patients (20%) developed an angiographic restenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bacterio-expert: an integrated system for assisting in the validation of antibiotic sensitivity tests. Retrospective application in 4053 Staphylococcus]

Bacterio-expert is a simple expert system for assisting in the validation of antibiotic sensitivity testing. This system is incorporated in a data acquisition and editing program for bacteriologic test (Bacterio program written in Turbo-Pascal for personal computer users by the same authors). The principles of this system are explained and results with 4,053 antibiotic sensitivity tests on Staphylococcus aureus isolates are reported. Approximately 10% of tests required corrections.