The efficacy of bupivacaine infiltration along nephrostomy tract on postoperative pain control and opioid consumption after PCNL: a prospective randomized controlled trial

OBJECTIVE

Percutaneous nephrolithotomy (PCNL) is a common endourological procedure for patients with large kidney stones, but the management of postoperative pain is still a major challenge. The aim of this clinical trial was to evaluate the efficacy of 0.25% bupivacaine infiltration along the nephrostomy tract on postoperative pain scores and analgesia consumption in patients who underwent PCNL.

PATIENTS AND METHODS

A total of 50 patients who underwent PCNL were enrolled in this prospective, randomized controlled trial (NCT04160936). Patients were prospectively randomized into two equal groups: the study group (n=25) received 20 mL of 0.25% bupivacaine infiltration along the nephrostomy tract, whereas patients in the control group (n=25) did not. Postoperative pain as the primary outcome was assessed by using a visual analogue scale (VAS) and a dynamic visual analogue scale (DVAS) at different time points. The secondary outcomes were the time for first opioid demands, the number of opioid demands, and the total opioid consumption over the 48 h postoperatively.

RESULTS

There were no significant differences between the two groups regarding demographics, surgery, and stone characteristics. Patients in the study group had significantly less VAS and DVAS pain scores compared to the control group. The mean time of the first opioid demand in the study group was significantly longer as compared to the control group (7.1 ± 2.5h vs. 3.2 ± 1.8 h, p<0.001). The mean number of doses and total consumption of opioids were significantly less in the study group compared to the control group over 48 h (1.5 ± 0.8 vs. 2.9 ± 0.7 and 122.82 ± 62.5 mg vs. 223 ± 70 mg, respectively) (p<0.0001).

CONCLUSIONS

Local anesthetic infiltration of 0.25% bupivacaine along the nephrostomy tract is efficient in alleviating post-operative pain and reducing opioid consumption after PCNL.

Pathological gait in partial foot amputation versus peripheral neuropathy

Partial foot amputation (PFA) is a common surgical loss of part of either the forefoot or mid-foot. It is usually the sequel to a cascade of physiological foot dysfunction such as peripheral neuropathy (PN). The gait compensation mechanisms associated with these foot disorders aren't well understood yet.

PURPOSE

The aim of the study was to evaluate pathological gait compensation mechanisms in PFA due to PN versus PN alone through a comprehensive gait analysis.

METHODS

Plantar pressure, GRF, load distribution, footprint length and area, foot progression angle, step length, percentage of double limb support, and stance time were measured on 53 participants assigned into two well-matched groups: (A) 25 subjects with healed unilateral PFA and (B) 28 subjects with PN without ulcer. The gait analysis was conducted at a self-preferred walking speed using the FREEMED baropodometric platform and FREESTEP software.

RESULTS

The PFA group showed a significant decrease in load over the remaining toes and metatarsal heads compared to the PN group (p = .001 and p = .003, respectively). Conversely, the PFA group showed a significant increase in load over the mid-foot and peak plantar pressure during mid-stance (p = .007 and p = .016, respectively). All other measured variables showed no significant difference between the two groups (p > .05).

CONCLUSION

Individuals with PFA and PN or PN alone tend to shift their body loads posteriorly and redistribute their loads to compensate for the insufficient support from the forefoot. The PFA group was worse than the PN group. Furthermore, the PFA may not be the primary cause of the altered gait but rather the underlying systemic disease. The PFA surgery only worsens the compensatory mechanism.

Efficacy of different approaches on quality of upper extremity function, dexterity and grip strength in hemiplegic children: a randomized controlled study

OBJECTIVE

To investigate the effect of mirror therapy (MT) together with taping compared to modified constraint-induced movement therapy (mCIMT) and MT alone on the quality of upper extremity (UE) function, dexterity, and grip strength in children with hemiplegic cerebral palsy (CP).

PATIENTS AND METHODS

Sixty children with hemiplegic CP ranging in age from 6 to 8 years were enrolled. The participants were randomly distributed into three groups. The three groups underwent the same suggested upper limb (UL) exercise programme for 1h/5 days/week for 12 successive weeks. Group A performed the programme with MT and taping. Group B performed the same programme using mCIMT alone, while group C performed this programme with MT alone. In addition, the three groups underwent a routine physical therapy programme for 1 h. The quality of UE function, dexterity, and grip strength was measured using the Quality of Upper Extremity Skills Test (QUEST), Box and Block Test (BBT), and hand-held dynamometer before and after 12 successive weeks of treatment.

RESULTS

After treatment, the measurement of all variables in the three groups showed significant improvements with superior effects seen in group A.

CONCLUSIONS

Based on the results obtained in this study, MT with taping, mCIMT alone, and MT alone are good supplements to traditional physical therapy programmes in improving the quality of UE function, dexterity, and grip strength in children with hemiplegic CP with more superior effects seen after using MT together with taping.

Does acetabular coverage influence the clinical outcome of arthroscopically treated cam-type femoroacetabular impingement (FAI)?

Aims

What represents clinically significant acetabular undercoverage in patients with symptomatic cam-type femoroacetabular impingement (FAI) remains controversial. The aim of this study was to examine the influence of the degree of acetabular coverage on the functional outcome of patients treated arthroscopically for cam-type FAI.

Patients and Methods

Between October 2005 and June 2016, 88 patients (97 hips) underwent arthroscopic cam resection and concomitant labral debridement and/or refixation. There were 57 male and 31 female patients with a mean age of 31.0 years (17.0 to 48.5) and a mean body mass index (BMI) of 25.4 kg/m² (18.9 to 34.9). We used the Hip2Norm, an object-oriented-platform program, to perform 3D analysis of hip joint morphology using 2D anteroposterior pelvic radiographs. The lateral centre-edge angle, anterior coverage, posterior coverage, total femoral coverage, and alpha angle were measured for each hip. The presence or absence of crossover sign, posterior wall sign, and the value of acetabular retroversion index were identified automatically by Hip2Norm. Patient-reported outcome scores were collected preoperatively and at final follow-up with the Hip Disability and Osteoarthritis Outcome Score (HOOS).

Results

At a mean follow-up of 2.7 years (1 to 8, sd 1.6), all functional outcome scores significantly improved overall. Radiographically, only preoperative anterior coverage had a negative correlation with the improvement of the HOOS symptom subscale (r = -0.28, p = 0.005). No significant difference in relative change in HOOS subscale scores was found according to the presence or absence of radiographic signs of retroversion.

Discussion

Our study demonstrated the anterior coverage as an important modifier influencing the functional outcome of arthroscopically treated cam-type FAI. Cite this article: Bone Joint J 2018;100-B:831-8.

Zoledronic acid in children with osteogenesis imperfecta and Bruck syndrome: a 2-year prospective observational study

Treatment with zoledronic acid (ZA) over 2 years, among 33 children with osteogenesis imperfecta (OI) and five Bruck syndrome cases, showed reduction in fracture rates, pain, and improvement in bone mineral density (BMD) and motor milestones of development. This is the first study reporting the use of bisphosphonates in patients with Bruck syndrome (BS).

INTRODUCTION

OI and BS are genetic disorders that result in bone fragility and reduced BMD. There is little literature describing the efficacy and safety of ZA in this population. In this study, we assess the response to treatment with ZA at six monthly intervals in Egyptian children with OI and BS for a period of 2 years.

METHODS

Thirty-three patients with OI and five patients with BS were treated with 0.1 mg/kg ZA intravenously every 6 months for 2 years during which they were followed up using different parameters. A clinical severity score (CSS) was applied to the patients before and 2 years after the start of therapy. Comparison of disease severity and response to ZA treatment between autosomal-dominant (AD) and autosomal-recessive (AR) OI patients was also done.

RESULTS

After 6 months of treatment, OI and BS patients showed a significant increase in BMD Z-scores (P < 0.003 in the spine and P < 0.004 in the hip), together with a significant drop in fracture rate (P < 0.001), relief of pain (P < 0.001), and improvement in ambulation (P < 0.001). CSS was significantly reduced after 2 years of treatment in both OI and BS patients. AR-OI patients were more severely affected than AD-OI patients and showed more significant improvement.

CONCLUSION

Zoledronic acid proved to be safe and effective in the treatment of OI and BS. The biannual infusion protocol was convenient to patients. There was a positive correlation between disease severity and benefits of the treatment. The use of the CSS proved to be of value in the assessment of the degree of severity in OI, and with some modifications, it was a valuable tool for the assessment of response to treatment.

UCP2 protects against amyloid beta toxicity and oxidative stress in primary neuronal culture

AD is a common neurodegenerative disease characterized by aggregated amyloid-beta (Aβ) peptide, and oxidative stress, while uncoupling protein 2 (UCP2) is a member of the anion carrier family, predicted the existence of a protein-regulated proton leak with the main purpose of controlling mitochondrial oxidative stress, reduce the generation of superoxide anion. we use the primary hippocampal neurons and add the different doses of Aβ1-40, then observe the change of UCP2 at different concentrations of Aβ, activity of LDH and the content of NO. Our results provide novel insight that UCP2 may protect hippocampal neurons exposed to amyloid β protein through decreasing ROS production. 20μmol/L Aβ1-40 significantly increased the activity of LDH and the content of NO. According to the correlation analysis, NO was significantly correlation with LDH, and UCP2 was significantly correlation with NO. These results suggest the potential of UCP2 as a therapeutic candidate for treating neurodegenerative diseases such as AD.

Lycopene attenuates dichlorvos-induced oxidative damage and hepatotoxicity in rats

Because of the widespread use of dichlorvos (DDVP) for domestic applications, evaluation of their toxic effects is of major concern to public health. Lycopene may lower oxidative stress by a mechanism that is not fully elucidated. The present study was undertaken to evaluate the protective efficacy of lycopene in terms of normalization of altered biochemical parameters following DDVP treatment in rats. Animals were divided into four groups. The first group was used as control, while groups 2, 3, and 4 were orally treated with lycopene (10 mg kg−1 body weight (b.w.)), DDVP (1.6 mg kg−1 b.w.), and DDVP plus lycopene, respectively. Results showed that oral administration of DDVP for 30 days increased the levels of lipid peroxidation markers such as malondialdehyde, 4-hydroxynonanal, and protein carbonyl content in liver. Also, a decrease in levels of vitamin C, vitamin E, and reduced glutathione was detected due to DDVP administration. These were accompanied by a decrease in the activities of antioxidant enzymes superoxide dismutase, catalase, glutathione peroxidase, and glutathione- S-transferase in the liver tissue. Moreover, DDVP increased the activities of serum transaminases, alkaline phosphatase, lactate dehydrogenase, and lipoxygenase, and the levels of bilirubin, total cholesterol, low-density lipoprotein cholesterol, triglyceride and DNA–protein crosslinks, and 8-hydroxy-2-deoxyguanosine, while decreased the level of high-density lipoprotein cholesterol. Our results provide new insights into the biochemical studies of relation between DDVP hepatotoxicity and lycopene treatment. Administration of lycopene to DDVP-treated rats reverted the status of hepatic markers to near-normal levels. These data suggest that lycopene can protect against the liver damage induced by DDVP.

Photocatalytic activity of nanostructured ZnO-ZrO₂ binary oxide using fluorometric method

Evaluation of the photocatalytic activity of ZnO-ZrO2 nanomaterials using fluorescence based technique has rarely been reported. In the present work, ZnO-ZrO2 mixed oxides coupled with various ZnO dosages (0, 10, 30, 50, 70wt%) were prepared by impregnation method. These nanomaterials were characterized by studying their structural, surface and optical properties. The photocatalytic activity in term of quantitative determination of the active oxidative species (OH) produced on the surface of binary oxide was evaluated using fluorescent probe method. The interaction between ZnO and ZrO2 was affected on the photocatalytic efficiency of mixture. The results show that, the addition of ZnO to ZrO2 decreased the electron-hole recombination and increased the rate of OH radicals formation. 50 wt% ZnO-ZrO2 photocatalyst exhibited much higher photocatalytic activity. The profound effect of binary oxide catalyst was generally considered due to the high surface area, small particle size, high monoclinic phase of ZrO2 content, low band gap and the presence of surface OH groups.

Enoyl-coenzyme A hydratase in cancer

Enoyl-CoA hydratase (Ech) catalyzes the second step in the physiologically important beta-oxidation pathway of fatty acid metabolism. The enzyme was reported to be associated with the progression, metastasis and drug resistance of cancers. It might function as a tumor promoter or a tumor suppressor for certain cancers depending on the particular type or stage of tumor cells/tissues. In this review, Ech's association with malignant tumors as well as its potential mechanisms is discussed and summarized. The enzyme might be useful in the diagnosis, treatment and prognosis determination of certain tumors.

Evaluation of the photocatalytic activity of Ln3+-TiO2 nanomaterial using fluorescence technique for real wastewater treatment

Evaluation the photocatalytic activity of different Ln(3+) modified TiO2 nanomaterials using fluorescence based technique has rarely been reported. In the present work, xmol Ln(3+) modified TiO2 nanomaterials (Ln = Nd(3+), Sm(3+), Eu(3+), Gd(3+), Dy(3+) and Er(3+) ions; x = 0.005, 0.008, 0.01, 0.02 and 0.03) were synthesized by sol-gel method and characterized using different advanced techniques. The photocatalytic efficiency of the modified TiO2 expressed in the charge carrier separation and OH radicals formation were assigned using TiO2 fluorescence quenching and fluorescence probe methods, respectively. The obtained fluorescence measurements confirm that doping treatment significantly decreases the electron-hole recombination probability in the obtained Ln(3+)/TiO2. Moreover, the rate of OH radicals formation is increased by doping. The highly active nanoparticles (0.02Gd(3+)/TiO2 and 0.01Eu(3+)/TiO2) were applied for industrial wastewater treatment using solar radiation as a renewable energy source.

Synthesis, insecticidal, and fungicidal screening of some new synthetic quinoline derivatives

This paper describes the synthesis of a series of quinolines graphted with hydrazones, pyrazoles, pyridazine, phthalazine, triazepinone, semicarbazide, and thiomorpholide moieties and four metal complexes. These derivatives were screened against Fusarium oxysporum and the red palm weevil (RPW) Rhynchophorus ferrugineus Oliver (coleopteran: Curculionidae) as palm pathogens. Only chlorinated quinolines were active against these organisms with hydrazones being good fungicides, while those modified with pyrazoles and pyrazines showed moderate insecticidal activity. A unique trihydroxylated hydrazone was active against both organisms, while another hydrazone, the most potent fungicide in this series, exhibited insecticidal activity only upon com- plexation with Zn2+ ions.

Synthesis of highly active thin film based on TiO2 nanomaterial for self-cleaning application

Highly active self-cleaning surfaces were prepared from hydrothermally treated TiO2 nanomaterials for different times (0, 12, 24 and 36 h) under acidic condition. TiO2 thin films were characterized by X-ray diffraction (XRD), transmission electron microscope (TEM) and scanning electron microscope (SEM). TiO2 thin film (hydrothermal 24h) exhibited hybrid morphology from accumulated plates, clusters, rods and spheres. The photo self-cleaning activity in term of quantitative determination of the active oxidative species (OH) produced on the thin film surfaces was evaluated using fluorescent probe method. The results show that, the highly active thin film is the hydrothermally treated for 24 h at 200 °C. The structural, morphology and photoactivity properties of nano-TiO2 thin films make it promising surfaces for self-cleaning application. Mineralization of commercial textile dye (Remazol Red RB-133, RR) from highly active TiO2 thin film surface was applied. Moreover, the durability of this nano-TiO2 thin film (hydrothermal 24h) was studied.

Prevalence and site preferences of heterophyid metacercariae in Tilapia zilli from Ismalia fresh water canal, Egypt

Factors affecting prevalence and site preferences of heterophyid metacercariae (MC) were investigated in this study. A total of 173 specimens of a freshwater fish, Tilapia zilli were collected during autumn 2008, winter 2009 and summer 2009, from Ismailia fresh water canal, Egypt. Results showed that the total prevalence of heterophyid MC was 95.37%. The heterophyid MC consisted of Haplorchis yokogawi (47.4%), Pygidiopsis genata (21.4%), and Phagicola ascolonga (93.64%). H. yokogawi MC was detected in striated muscles, P. ascolonga in liver and kidney while, P. genata was detected in muscles, liver and kidney. The aggregation indices showed that all MC were aggregated and the P. genata was the most highly aggregated followed by H. yokogawi and then P. ascolonga. Responses of the heterophyid MC to host sex, weight and season greatly varied according to species of MC. Different responses of interaction for heterophyid MC intensity were found by GLIM analysis and this variation dependant on the type of infection (single or mixed infections). Factors affecting site preference of heterophid MC infection were discussed and further studies in other locations are required to examine the factors affecting site preference.

Abstract P1-11-08: A Multicenter Prospective Phase II Trial of Neo-Adjuvant (FEC 100)/Cisplatin-Docetaxel with or without Trastuzumab in Locally Advanced Breast Cancer. Gulf Oncology Research Group (G0RG-001)

BACKGROUND: To evaluate the efficacy and safety profile of the (FEC100) followed by cisplatin/docetaxel with or without trastuzumab as primary chemotherapy for patients with locally advanced breast cancer (LABC T2&gt; 4cm, N0-2, M0).

METHODS: Eighty (80) patients with LABC (T2-T4, No-N2, M0) received 4 cycles of FEC (100) followed by 4 cycles of cisplatin/docetaxel, followed by definitive surgery and locoregional radiotherapy with or without hormonal therapy. Patients with HER2 positive received trastuzumab concurrently with cisplatin docetaxel for a total of 8 cycles (for a total of 6 months). The primary end point was pathologic complete response (pCR) in breast and/or axilla for HER2 negative and HER2 positive. RESULTS: Seventy nine (79) patients were evaluable for analysis: median age: 43yrs, Premenopausal: 83%, median tumor size: 7.0cm (≥4 - 10), Stage IIB: 24% and IIIA/IIIB: 76%, both ER/PR positive: 56%, Her2/neu (3+) by IHC staining: 39%. Clinical response was 65% complete response and 28% partial response. Breast conserving surgery was performed in: 10 % and MRM in: 90%.Three (3) patients suffered an asymptomatic and reversible decrease in left ventricular ejection fraction. Pathological complete response (pCR) can b summarized as follow: Overall pCR in breast: 37%, in Axilla: 65%, Breast and axilla: 33%. In patients with HER2 Negative: pCR in breast: 19%, in Axilla: 56%, Breast and axilla: 17%.In patients with HER2 positive: pCR in breast: 65%, in Axilla: 77%, Breast and axilla: 58%.Overall the DFS & OS at 3 years were 88% and 98% respectively.

CONCLUSIONS: This sequential combination is a safe, feasible and active combination, which associated with high clinical and pathologic response rates, the addition of trastuzumab increased pCR rate in HER2 positive tumors with promising and encouraging outcomes, further investigation of this combination are warranted.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-11-08.

An unusual cause of pelvic pain: struma ovarii

A 22 year old female patient presented with a three month history of pelvic discomfort and dysmenorrhoea. A pelvic MRI demonstrated a large mass measuring 10 x 6 cm in size. On T1 and T2 weighted images the mass was noted to be predominantly cystic. The mass also contained peripheral solid components as well as a large fat fluid level. Following excision, histological examination revealed a lesion with mature teratomatous elements but with a significant component (> 50%) being composed of mature thyroid tissue. A 2cm area within the lesion had the morphological pattern of a classical papillary thyroid carcinoma. A diagnosis of struma ovarii was made. Struma ovarii is a rare ovarian neoplasm generally arising in a teratoma and accounts for less than 1% all ovarian neoplasms. Here we present the above case of struma ovarii in a young patient and discuss the radiological characteristics of the disease.

Relationship between organizational climate and empowerment of nurses in Menoufiya hospitals, Egypt

One factor influencing the outcome of care may be the nursing staffs experience of organizational work climate. We compared organizational climate and nurse's empowerment in specialty units at 2 hospitals in Egypt. Data were collected from 164 diploma school staff nurses using 2 tools: the situational outlook questionnaire to assess organizational climate and the psychological empowerment in the workplace questionnaire. There was no statistically significant difference in the level of organizational climate between the 2 hospitals, which the majority of nurses classified as moderate. Most nurses reported a moderate level of empowerment in both hospitals and there was a statistically significant positive correlation between organizational climate and nurse's empowerment.

Prevalence and intensity of Angiostrongylus cantonensis in freshwater snails in relation to some ecological and biological factors

The purpose of the study was to record different intermediate hosts of A. cantonensis and to determine the infection prevalence and intensity of this parasite in freshwater snails in relation to some ecological and biological factors. The study was conducted at Al-Salam irrigation Canal and Al-Abtal village (north Sinai) for one year, from March 2004 to February 2005. Thirteen species of freshwater snails of nine families were examined for A. cantonensis infection. Six species were found infected with A. cantonensis larvae. These species were L. carinatus, C. bulimoides, C. cyclostomoides, B. alexandrina, L. natalensis and M. tuberculta. The infection prevalence of A. cantonensis in the examined snails ranged from 0.63 to 2.24%. L. carinatus snail had the highest prevalence, mean abundance and mean intensity of A. cantonensis infection. Positive correlations were found between both prevalence and mean abundance of A. cantonensis and host size in L. carinatus and M. tuberculata. Negative correlations were detected between salinity and prevalence, mean abundance and mean intensity of larvae of A. cantonensis. The results demonstrated seasonal and spatial variation in the prevalence, mean abundance and mean intensity of infection among examined snails. In this study, A. cantonensis larvae were found in a wide range of freshwater snails and M. tuberculata snail was recorded as a new intermediate host for the first time. In conclusion, further investigations in other areas and controlled laboratory experiments of infection approaches are required to evaluate the possible threat of this parasite on humans.

Factors affecting helminths community structure of the Egyptinan lizard Chalcides ocellatus (Forskal, 1775)

The variation in the component community structure of intestinal helminths in the lizard Chalcides ocellatus (Forskal, 1775) was studied in relation to the seasonal variation and host weight and sex. 120 lizards were collected seasonally during year 2004, from Al Firdan, Ismailia governorate, Egypt. The helminths community consisted of six species (five nematodes and one cestode). The various helminths differed according to host sex. The prevalence of total helminths infection was 67.6 % while the prevalences of Thelandros schusteri, Pharyngodon mamillatus, Parapharyngodon bulbosus, Cosmocerca vrcibradici, Spauligodon petersi and Oochoristica maccoyi were 43.4%, 3.9 %, 13.2%, 5.3%, 6.6%, and 14.3%, respectively. The results showed that the season was the main factor affecting infracommunity species richness and parasite abundance. Moreover, there was interaction between season and host sex on abundance of P. bulbosus. The prevalence of intestinal helminths varied significantly in relation to host weight classes and sex in some species. Helminths abundance and intensity were independent from host sex. In addition, correlations were found between total helminths abundance and host weight. In conclusion, the helminths community of C. ocellatus was depauperate and the influence of the studied factors varied from species to another one. We cannot say if the low species richness and infection rates observed in the present study are typical of the host species or if they are due to characteristics of the study area, since no available data on parasite assemblages exist for other C. ocellatus populations.

Nucleophilic reaction by carbonic anhydrase model zinc compound: characterization of intermediates for CO2 hydration and phosphoester hydrolysis

The partially hydrophilic and hydrophobic tripodal ligands, tris(hydroxy-2-benzimidazolylmethyl)amine L1h and tris(2-benzimidazolyl)amine L1 were used for the preparation of biomimetic complex of carbonic anhydrase. The CO(2) hydration using [L1hZn(OH)]ClO(4).1.5H(2)O provided the zinc-bound and free HCO(3)(-)s, which were formed by nucleophilic attack of Zn-OH toward CO(2) in dimethyl sulfoxide (DMSO). The phenolic OH in L1h can recognize water molecules through hydrogen bonds to facilitate the collection of the water molecules around a biomimetic zinc compound; the molecular structure of [L1hZn(OH)](+) was revealed. The packing diagram has demonstrated the all the water molecules are hydrogen bonded to each phenolic OH. The nucleophilic attack of zinc-bound OH(-) to substrate is used to catalyze the CO(2) hydration and phosphoester hydrolysis. The carbonic anhydrase model compound [L1Zn(OH(2))](2+) was applied for the hydrolysis of phosphoesters, parathion and bis(p-nitrophenyl)phosphate (BNPP(-)). The low reactivity of [L1Zn(OH)](+) for parathion hydrolysis is attributed to the stability of the intermediate [L1Zn(OP(S)(OEt)(2))](+). Since the structures of the intermediates [L1Zn(OH(2))](BNPP)(2) (1) and [L1Zn(OP(S)(OEt)(2))]ClO(4) (2) formed on the way of hydrolysis are too stable to realize the catalytic cycle and are not active for hydrolysis, carbonic anhydrase model compound [L1Zn(OH(2))](2+) was not suitable for phosphoester hydrolysis; the zinc model compound surrounded by three benzimidazolyl groups is used to have the steric hindrance for bulky substrate, such as parathion and BNPP(-).

Allodynia and hyperalgesia produced by specific inhibition of spinal c-fos expression: lack of correlation with dynorphin content

Inhibition of spinal Fos expression increases formalin-induced nociception and decreases spinal prodynorphin messenger ribonucleic acid (mRNA), suggesting that Fos modulates nociception by inducing dynorphin synthesis. This study tests the hypothesis that Fos modulates sensitivity to other somatic stimuli, such that inhibition of Fos expression will result in tactile allodynia and thermal hyperalgesia. In addition, it correlates the somatosensory effects of inhibition of Fos expression with spinal dynorphin content. Antisense oligodeoxynucleotide (ODN) to c-fos mRNA was administered by intrathecal infusion. Tactile sensitivity was tested by probing the hindpaw with von Frey filaments. Thermal sensitivity was quantitated by using withdrawal latency to radiant heat. Two percent formalin was injected into the dorsal hindpaw, and flinches were quantitated. Fos was quantitated by counting immunoreactive cells. Dynorphin was measured by immunoassay. Intrathecal antisense, but not mismatch, ODN resulted in tactile allodynia, thermal hyperalgesia, and hyperalgesia to formalin-induced nociception. Antisense ODN decreased Fos-like immunoreactivity after formalin injection but did not alter Jun-like immunoreactivity. Antisense ODN had differing effects on spinal dynorphin content, depending on the method of administration. These experiments show a role of Fos in modulating somatosensory sensitivity and suggest that induction of dynorphin synthesis is not the sole mechanism by which Fos does so.

Malaria in the first 6 months of life in urban African infants with anemia

A total of 446 infants in the first 6 months of life who presented at an urban children's hospital with complaints of any illness whatsoever were recruited into a study with the aim of determining the contribution of malaria to infant morbidity in a malaria-endemic urban area in Nigeria. Sixty-eight of the infants were in their first month of life and 79, 77, 61, 97, and 64 were in their second, third, fourth, fifth and sixth month of life, respectively. Overall, 107 (24.0%) infants were clinically diagnosed as having malaria. This included 3 who were in the first month of life, 12 in the second, 15 in the third, 17 in the fourth, 33 in the fifth, and 27 in the sixth months of life (4.4, 15.2, 19.5, 27.9, 34.0, and 42.1%, respectively). Laboratory investigations confirmed 35 (32.7%) of those clinically diagnosed and 86 (25.4%) of those not clinically diagnosed (n = 339) as having malaria parasitemia, giving an overall malaria parasite rate of 27.1% among the infants. Acute respiratory infection was the major diagnosis (41.3%) among those that were not initially diagnosed as malaria but turned out to have malaria parasitemia followed by gastroenteritis (11.8%) and failure to growth (1.5%). Overall geometric mean parasite density was 202.5 parasites/microL of blood (range, 12-65,317 parasites/microL of blood). The mean hematocrit of infants with parasites (33.0%) was significantly lower (P < 0.005) than that of infants without parasites (35.1%). The mean hematocrit of infants with malaria parasites in each age group was lower than that of infants without malaria parasites in the corresponding age group. Among the infants with malaria parasites, those aged 2 to 2.9 months recorded the lowest mean hematocrit (30.1%), and those aged < 1 month recorded the highest mean hematocrit (42.7%). Axillary temperature increased and hematocrit decreased with increase in parasite density. The percentage of infants with anemia likewise increased as the parasite density increased. Plasmodium falciparum was present in all infected infants, but mixed infection with P. malariae was present in only 2.5% of infections. Analysis of our data suggests an urgent need for health education of caretakers and for training of clinicians for increased awareness of malaria as an important cause of illness and anemia in infants aged < 6 months so as to reduce children's wasting due to an easily preventable and treatable disease.

Cardiovascular risk factors in normotensive and hypertensive Egyptians

OBJECTIVES

To define the prevalence of cardiovascular risk factors and their relation to the level of blood pressure, in Egyptians.

METHODS

Data were collected during the Egyptian National Hypertension project, a national hypertension survey in Egypt. During phase I of the survey, hypertensive (HT) patients were identified. In phase II, clinical and laboratory evaluations were made on HT and gender-matched normotensives (NT). A total of 2313 individuals were examined, 311 NT males, 443 NT females, 670 HT males and 889 HT females.

RESULTS

The prevalence of obesity was 33 and 47% in hypertensive men and women, respectively. After adjusting for age, HT men had significantly higher heart rate, total cholesterol (TC), triglycerides (TG), fasting blood sugar (FBS), post-prandial blood sugar (PBS), body mass index and waist/hip (W/H) ratio than their NT counterparts. In addition, HT women had higher low-density lipoprotein cholesterol (LDL-C). The prevalence of elevated LDL-C and FBS increased with age. The prevalence of hypertriglyceridemia, elevated FBS and obesity rose with increasing level of blood pressure (BP). From the 25-34 to the 55-64 age group, the percentage of hypertensives with > or = 2 risk factors rose from 42.9 to 60.6% in men, and from 9.4 to 46.2% in women. All risk factors were more prevalent in urban populations.

CONCLUSION

This is one of the few reports on the prevalence of cardiovascular risk factors in a developing country. Risk factors cluster with rising level of BP and with ageing. Obesity is very prevalent, particularly in hypertensive Egyptian women. Health efforts directed at the prevention and treatment of obesity should be a high priority.

Gender and the relationship between resting heart rate and left ventricular geometry

OBJECTIVES

Heightened mortality is common to both an elevated resting heart rate and left ventricular hypertrophy (LVH). We examined the relationship between resting heart rate and left ventricular geometry.

METHODS

We analysed resting heart rate and echocardiographic data on 1,685 individuals aged 25-93 years, 756 males and 929 females, without heart failure. The study population, 719 normotensives and 966 untreated hypertensives, was derived from the Egyptian National Hypertension Project (1991-94); a cross-sectional study of the prevalence of hypertension and cardiovascular risk factors in Egyptians. The mean of the last two of three heart rate readings was used to represent the resting heart rate.

RESULTS

Left ventricular mass index (LVMI) was weakly inversely related to heart rate in total males (r= -0.14, P< 0.0005) and total females (r= -0.1, P= 0.007) after controlling for age and blood pressure. The relative wall thickness (RWT) of the left ventricle was positively associated with heart rate in females. Resting heart rate increased linearly from 83.8 to 89 b.p.m. (P= 0.03) from the lowest (< or = 0.33) to highest (> or = 0.47) RWT quintiles in hypertensive females after adjusting for age and blood pressure. In both those with and without LVH (defined as LVMI > 125 g/m2), hypertensive females with RWT > 0.45 compared to those with RWT < or = 0.45 had consistently higher resting heart rate (93.8 b.p.m. versus 84.2 b.p.m., P = 0.047 and 88.9 b.p.m. versus 85 b.p.m., P = 0.005, respectively) after adjusting for age and blood pressure. No such relationship was found in males.

CONCLUSIONS

Among hypertensive females, an elevated resting heart rate is associated with abnormal left ventricular geometry, namely, concentric left ventricular remodelling and hypertrophy.

Serum ferritin and other haematological measurements in apparently healthy adults with malaria parasitaemia in Lagos, Nigeria

We studied 300 apparently healthy residents of Lagos aged 16-57 years. Their mean ferritin levels were 99.6 +/- 50.5 microg/l (men aged 20-57) and 66.5 +/- 44 microg/l (women aged 20-53) in aparasitaemic individuals. In parasitaemic subjects, mean ferritin levels were 133.1 +/- 48.3 microg/l (men aged 20-56) and 114.8 +/- 51.1 microg/l (women aged 16-50). Mean haematocrit values for aparasitaemic males were 45.7 +/- 5.6% and 37.9 +/- 5% for females, while mean haemoglobin levels were 153.2 +/- 1.5 microg/l and 124 +/- 3 microg/l, respectively. The mean values for MCV (mean corpuscular volume), MCH (mean corpuscular haemoglobin), MCHC (mean corpuscular haemoglobin concentration) were 101.7 +/- 8fl, 30.6 +/- 2.2 pg, 335 +/- 0.4 g/l and 99.8 +/- 10.1fl, 29.1 +/- 6.5 pg, 335 +/- 6 g/l. Serum iron levels were 34.2 +/- 5 micromol/l and 29.5 +/- 77 micromol/l. All haematological parameters measured were similar in both malaria parasitaemia positive and negative subjects, except ferritin level which was significantly higher in parasitaemic individuals (P < 0.05). Ferritin concentration and malaria density (r = 0.76 in males, r = 0.74 in females, P < 0.05) were positively correlated. Ferritin levels of subjects infected with Plasmodium falciparum were significantly higher than of those infected with P. malariae (P < 0.05). Hence ferritin estimation without examination for malaria parasitaemia in a malaria-endemic region such as Nigeria is not reliable. Asymptomatic malaria parasitaemia increases the ferritin level. Considering the mean ferritin level we found in normal subjects on a balanced diet, routine iron supplementation may not be necessary in the treatment of malaria-induced anaemia in Nigeria.

Relationship between skin color and blood pressure in egyptian adults: results from the national hypertension project

In many, but not all societies, dark skin color is associated with high blood pressure. Whether the association between skin color and blood pressure is independent of known determinants of blood pressure remains controversial. We examined the association between skin color and blood pressure in 835 Egyptian adults (370 men and 465 women) participating in the National Hypertension Project, a national survey of hypertension prevalence and blood pressure-related complications conducted in Egypt during 1991-1993. Skin color was assessed by measuring the concentration of cutaneous melanin in an unexposed area with the use of reflectance spectrophotometry. Higher concentrations of melanin were associated with lower body mass index, less education, manual labor (among men), and a lower urinary sodium-to-potassium ratio (among women). In multivariate regression analyses adjusted for age, body mass index, and education, there was a significant nonlinear association between blood pressure and skin color among women; in the lower to intermediate range of skin pigmentation, both systolic and diastolic blood pressures were higher in women with greater concentrations of cutaneous melanin. In men, blood pressure was not associated with skin color. When we used a subjective assessment of skin color, there was no significant difference in blood pressure between black-skinned Egyptians (predominantly of Nubian descent) and fair-skinned Egyptians for either gender. While the significant relationship in women appeared to be independent of known risk factors for hypertension, residual confounding may explain the association.

Myocardial perfusion abnormalities in treated hypertensive patients without known coronary artery disease

OBJECTIVE

Myocardial perfusion abnormalities may occur in hypertensive patients in absence of significant coronary artery disease. However, it is not well established whether hypertensive patients without known coronary artery disease have a higher prevalence or extent of myocardial perfusion abnormalities compared with normotensive patients with similar clinical features.

DESIGN

This study compares the prevalence and extent of rest and stress-induced myocardial perfusion abnormalities in patients with and without hypertension.

METHODS

Dobutamine (up to 40 microg/kg per min) stress technetium-99m myocardial perfusion SPECT imaging was performed for evaluation of myocardial ischaemia in 350 patients (mean age = 60+/-13 years, 146 men) without known coronary artery disease. One hundred and forty-eight patients were hypertensive. Rest SPECT images were acquired 24 h after the test Abnormal perfusion was defined as the presence of reversible or fixed perfusion defects.

RESULTS

No significant difference was detected between patients with and without hypertension regarding gender, prevalence of symptoms, risk factors, pretest probability of coronary artery disease (52+/-28 versus 53+/-29%), peak rate pressure product (21040+/-4755 versus 20774+/-4865) or number of patients achieving the target heart rate during stress (85 versus 86%). Hypertensive patients were significantly older (62+/-11 versus 58+/-13 years, P = 0.005) and were receiving beta-blockers more frequently (34 versus 18%, P = 0.0001). The prevalence of myocardial perfusion abnormalities was similar in patients with and without hypertension (28 versus 31% in patients with low, 38 versus 33% in patients with intermediate and 60 versus 58% in patients with high pretest probability of coronary artery disease, respectively). No significant difference was detected between the two groups regarding stress perfusion defect score (1.45+/-2.5 versus 1.50+/-2.6) or rest score (0.72+/-1.8 versus 0.68+/-1.6).

CONCLUSION

Treated hypertensive patients without known coronary artery disease have a similar prevalence and severity of myocardial perfusion abnormalities at rest and at dobutamine stress compared with normotensive patients with similar clinical characteristics.

Risperidone-induced increase of plasma norepinephrine is not correlated with symptom improvement in chronic schizophrenia

BACKGROUND

Previous studies have shown an increase in plasma levels of norepinephrine (NE) after clozapine treatment of schizophrenia. This effect has been suggested to relate to improvement in symptoms.

METHODS

To test whether other novel antipsychotic drugs have such an effect, the present experiment examined schizophrenic symptoms and plasma levels of NE before and after 5 weeks of treatment with risperidone or haloperidol.

RESULTS

Risperidone, but not haloperidol, significantly increased plasma NE; however, there was no correlation of this effect with clinical improvement on any symptom scale.

CONCLUSIONS

This finding suggests that risperidone shares similar properties with clozapine in enhancing peripheral NE, but that these changes in plasma NE may not be a consistent indicator of atypical antipsychotic drug efficacy.

The functional significance of chronotropic incompetence during dobutamine stress test

OBJECTIVE

To investigate the functional significance of chronotropic incompetence during dobutamine stress echocardiography.

PATIENTS AND METHODS

The functional significance of chronotropic incompetence was evaluated during dobutamine stress echocardiography in 512 patients without beta blocker treatment who underwent dobutamine stress echocardiography (up to 40 microg/kg/min) and completed the protocol or reached the target heart rate. Mean (SD) age was 60 (12) years (313 men, 199 women). Chronotropic incompetence was defined as failure to achieve 85% of the maximum exercise heart rate predicted for age and sex (220 - age in men; 200 - age in women) at maximum dobutamine dose.

RESULTS

Chronotropic incompetence occurred in 196 patients (38%). Affected patients were significantly younger, more likely to be men (both p << 0.001) and smokers (p < 0.05), had a higher prevalence of previous myocardial infarction (p < 0.005) and resting wall motion abnormalities (p < 0. 05), and had a lower resting heart rate (p << 0.001) and systolic blood pressure (p << 0.001) than patients without chronotropic incompetence, but there was no difference in the overall prevalence of ischaemia and significant coronary artery disease. By multivariate analysis, independent predictors of chronotropic incompetence were a lower resting heart rate (p << 0.001), younger age (p << 0.001), and male sex (p << 0.001).

CONCLUSIONS

The relations among sex, age, and chronotropic incompetence show the need to titrate the dobutamine dose using specific data based on age and sex related heart rate responses to dobutamine rather than to an exercise stress test. Obtaining specific heart rate criteria is necessary to determine whether chronotropic incompetence represents a real failure to achieve a normal response or is the result of applying an inappropriate gold standard.

Living conditions of children at risk for noma: Nigerian experience

The study reported in this paper was carried out in the Northwestern and Southwestern regions of Nigeria, between October 1996 and April 1998. The study examined the possible contributory role of living conditions in the development of acute necrotizing gingivitis (ANG) or noma from oral lesions. Questionnaire data obtained from 42 fresh noma cases seen in the Northwest and four fresh cases seen in the Southwest were examined. In addition 46 cases of advanced ANG from the Southwest were included. The main focus was to compare some of the environmental living conditions of cases with advanced ANG and those with noma in these regions. All the noma and ANG cases were seen in children aged 2-12 years. The level of good oral hygiene practices and general environmental living conditions were significantly higher in the Southwest than in the Northwest. Data also showed that living in close proximity with livestock was significantly higher in the Northwest than in the Southwest (P < 0.05). The environmental living conditions of children in the Northwest were further compounded by poor sanitary faecal disposal practices as well as minimal access to potable water. The overall data indicated that living in substandard accommodations, exposure to debilitating childhood diseases, living in close proximity to livestock, poor oral hygiene, limited access to potable water and poor sanitary disposal of human and animal faecal waste could have put the children in the Northwest at higher risk for noma than the children in the Southwest. These could have been responsible for the higher prevalence of noma in the Northwest than in the Southwest.

Noninvasive diagnosis of coronary artery stenosis in women with limited exercise capacity: comparison of dobutamine stress echocardiography and 99mTc sestamibi single-photon emission CT

OBJECTIVES

To compare the accuracy of dobutamine stress echocardiography (DSE) and simultaneous 99mTc sestamibi (MIBI) single-photon emission CT (SPECT) imaging for the diagnosis of coronary artery stenosis in women.

PATIENTS

Seventy women with limited exercise capacity referred for evaluation of myocardial ischemia.

METHODS

DSE (up to 40 microg/kg/min) was performed in conjunction with stress MIBI SPECT. Resting MIBI images were acquired 24 h after the stress test. Ischemia was defined as new or worsened wall motion abnormalities confirmed by DSE and as reversible perfusion defects confirmed by MIBI. Significant coronary artery disease was defined as > or = 50% luminal diameter stenosis.

RESULTS

DSE was positive for ischemia in 35 of 45 patients with coronary artery stenosis and in 2 of 25 patients without coronary artery stenosis (sensitivity = 78% CI, 68 to 88; specificity = 92% CI, 85 to 99; and accuracy = 83% CI, 74 to 92). A positive MIBI study for ischemia occurred in 29 patients with coronary artery stenosis and in 7 patients without coronary artery stenosis (sensitivity = 64% CI, 53 to 76; specificity = 72% CI, 61 to 83; and accuracy = 67% CI, 56 to 78 [p < 0.05 vs DSE]). In the 59 vascular regions with coronary artery stenosis, the regional sensitivity of DSE was higher than MIBI (69% CI, 62 to 77 vs 51% CI, 42 to 59, p < 0.05), whereas specificity in the 81 vascular regions without significant stenosis was similar (89% CI, 84 to 94 vs 88% CI, 82 to 93, respectively).

CONCLUSION

DSE is a useful noninvasive method for the diagnosis of coronary artery stenosis in women and provides a higher overall and regional diagnostic accuracy than dobutamine MIBI SPECT in this particular population.

Closed tibia fracture. "The effect of an intact fibula and the location of tibia fracture on fracture union"

Tibial fractures are common and complications occur more frequently than any other long bone fractures. The effect of fibula and location of fracture on union of Tibia fracture remain controversial. A retrospective study of unilateral closed tibial shaft fractures without any associated injury was done. From 1988 to 1992, 74 out of 103 patients were available for the study. There were 60 males and 14 females with the age ranges from 3 to 75 years with an average of 29.7 years. The differences of fractures healing were analyses with respect to the status of the fibula and the location of the tibial fracture. This study concludes that the location of the fracture and the status of the fibula have no significant influence on healing (p > 0.05).

Altered expression of mitochondrial 16S ribosomal RNA in p53-deficient mouse embryos revealed by differential display

Inactivation of the tumor suppressor p53 is associated with neural tube defects and altered teratogenicity in early embryos. To gain insight into the function of p53 during early embryogenesis, RNA profiles of wild-type p53(+/+) and p53(-/-) null mutant mouse embryos were compared at the head-fold stage (day 8 post coitum) using HPLC-based mRNA differential display. The results of this screen revealed a deficiency of mitochondrial 16S ribosomal RNA in p53(-/-) embryos. RT-PCR showed abnormalities in 16S rRNA levels relative to some representative nuclear (COIV, beta-actin) and mitochondrial (COIII) transcripts in p53(-/-) embryos, and that 16S rRNA expression increased with development of p53(+/+) embryos during neurulation. Embryos that lack p53 also displayed weakened cytochrome c oxidase staining and reduced ATP content. During neurulation, the mouse embryo switches from an anaerobic (glycolytic) to an aerobic (oxidative) metabolism. The preliminary results of the present study suggest that p53 may be involved, directly or indirectly, in this transition.

The impact of short stature on child morbidity in a rural African community

This study was undertaken to assess whether short stature in children under 5 years of age is associated with an increased risk of acute or persistent diarrhoea, acute respiratory infection, or indeed any illness, taking account of possible confounding factors such as whether breastfed, water quality, degree of household crowding, age and gender. After initial anthropometric assessment, the morbidity and diet of a cohort of 403 Somali children were recorded for 1 year at 2-week intervals. In multivariate analyses of the findings, adjustments were made for the possible confounding factors listed. Short stature was associated with an increased incidence of acute diarrhoea (< -2 SD score, RR 1.7, 95% CI 1.3-2.2) and with a risk of developing persistent diarrhoea, but not with the incidence of acute respiratory infections. When adjusting for age only, short stature increased the risk of developing any illness, but this association was not shown when adjusting for the other possible confounding factors. There was a dose-effect relationship between different degrees of short stature and acute diarrhoea, with an increased incidence of acute diarrhoea among the shortest children. Efforts were made to account for the possibility of reverse causality, which seemed not to change the main findings. Thus, short stature seemed to increase the risk of subsequent acute diarrhoea in children under 5 years of age.

Impaired systolic blood pressure response to dobutamine stress testing: a marker of more severe functional abnormalities in patients with myocardial infarction

Dobutamine-induced hypotension has been disregarded as a marker of more severe functional abnormalities in patients with suspected coronary artery disease. However, its functional significance in patients with myocardial infarction has not been studied. The aim of this study was to define the predictors of systolic blood pressure (SBP) response to dobutamine in patients with previous myocardial infarction. Dobutamine stress (up to 40 microg/kg per minute) echocardiography was performed in 326 patients with prior myocardial infarction referred for evaluation of myocardial ischemia. A 16-segment, four-grade score model was used to assess left ventricular function. Wall motion score index was derived by summation of wall motion score divided by 16. SBP and heart rate increased from rest to peak dobutamine stress (127 +/- 22 vs 134 +/- 27 mm Hg and 72 +/- 14 vs 122 +/- 24 bpm, p < 0.00001 in both). An increase of SBP > or = 30 mm Hg occurred in 50 patients (15%). By multivariate analysis, independent predictors of failure of SBP increase were higher peak wall motion score index (p < 0.001), higher resting SBP (p < 0.01), and medication with calcium channel blockers (p < 0.05). SBP drop > or = 20 mm Hg occurred in 54 patients (17%). Independent predictors of SBP drop were higher resting wall motion score index (p < 0.001), higher resting SBP (p < 0.0001), and older age (p < 0.05). In patients with myocardial infarction, left ventricular function and baseline systolic blood pressure are powerful predictors of SBP response to dobutamine stress testing.

Gender differences in the accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease

The accuracy of dobutamine stress echocardiography (DSE) for the diagnosis of coronary artery disease (CAD) has not been yet evaluated in women. We studied the effect of gender on the accuracy of DSE for the diagnosis of CAD in 306 consecutive patients (210 men and 96 women) with limited exercise capacity and suspected myocardial ischemia who underwent coronary angiography within 3 months of DSE. There were no serious complications during DSE. Men had a higher prevalence of nonsustained ventricular tachycardia (7% vs 0.03%, p <0.05) and supraventricular tachycardia (9% vs 0.03%, p <0.05) during the test compared with women. Peak stress rate-pressure product was not different in men and women (18,140 +/- 4,187 vs 18,543 +/- 4,223). Significant CAD (> or =50% luminal diameter stenosis) was present in 171 men (81%) and in 62 women (65%, p <0.005). The sensitivity, specificity, and accuracy of ischemic pattern at DSE for the diagnosis of significant CAD were 76% (confidence interval [CI] 67 to 84), 94% (CI 89 to 99), and 82% (CI 75 to 90) in women and 73% (CI 67 to 79), 77% (CI 71 to 83), and 74% (CI 68 to 80) in men, respectively. Overall specificity was higher in women than in men (p <0.05). Regional accuracy of DSE was significantly higher in women than in men in the 3 arterial regions (84% [CI 79 to 88] vs 75% [CI 72 to 79], p <0.005). It is concluded that DSE is a safe and feasible method for the diagnosis of CAD in women. The overall specificity and the regional accuracy of DSE are higher in women than in men. Further studies are required to evaluate the functional significance of these findings and their reproducibility in different patient populations.

Hypertension surveys in the developing world. Lessons from the Egyptian National Hypertension Project (NHP)

Accurate national estimates of the prevalence of hypertension in developing countries are lacking. Inadequate funds, inexperience and lack of infrastructure are also important barriers to hypertension research. The aim of this review is to help investigators from the developing countries, with limited resources, to design and conduct national hypertension surveys. The information is mostly based on the experience gained during the Egyptian National Hypertension Project (NHP) which can serve as a model for similar surveys elsewhere. The review addresses a number of important questions: (1) Why conduct a national hypertension survey in a developing country; (2) What kind of data are needed; (3) Where to start and how to raise funds; (4) Who will carry out the survey; (5) How to design your sample and where to survey; (6) How to organize and perform field operations; (7) How to collect accurate data and do quality control measures; and (8) How to handle the data?

Safety and feasibility of dobutamine-atropine stress testing in hypertensive patients

Dobutamine stress testing is increasingly used for the diagnosis and functional evaluation of coronary artery disease. The aim of this study was to assess the hemodynamic profile, safety, and feasibility of dobutamine stress testing in hypertensive patients. Dobutamine (up to 40 micrograms/kg per minute)-atropine (up to 1 mg) stress echocardiography was performed for the detection of myocardial ischemia in 1164 patients with limited exercise capacity (age, 60 +/- 12 years; 761 men); 446 patients were known to have hypertension. The test was considered feasible when 85% of the maximal heart rate and/or an ischemic end point (new or worsened wall motion abnormalities, ST segment depression, or angina) was achieved. No myocardial infarction or death occurred during the test. Dobutamine induced a significant increase of heart rate in patients with and without hypertension (59 +/- 25 and 63 +/- 23 beats per minute, respectively). Peak rate pressure product was similar in patients with and without hypertension (18,566 +/- 4584 and 18,230 +/- 4508). Hypotension (systolic pressure drop > 40 mm Hg) during the test was more frequent in hypertensive patients (7% versus 4% in normotensive, P < .05). Independent predictors of hypotension were baseline systolic pressure greater than 140 mm Hg (odds ratio, 6.9; 95% confidence interval, 3.4 to 14), older age (odds ratio, 1.04; 95% confidence interval, 1.01 to 1.07), and medication with calcium channel blockers (odds ratio, 1.8; 95% confidence interval, 1.1 to 3.5). The prevalence of ventricular tachycardia was similar (4.1%) in both groups. Episodes of 10 beats or more (0.06% of patients) were terminated promptly by intravenous metoprolol administration. Dobutamine stress testing was considered feasible in 91% of patients with and 92% of patients without hypertension. Dobutamine-atropine stress echocardiography is a safe and feasible method for the assessment of hypertensive patients referred for evaluation of myocardial ischemia. Despite the higher prevalence of dobutamine-induced hypotension in these patients, the feasibility of the test is comparable to that in individuals without hypertension.

Impact of severity of coronary artery stenosis and the collateral circulation on the functional outcome of dyssynergic myocardium after revascularization in patients with healed myocardial infarction and chronic left ventricular dysfunction

The aim of this study was to assess the influence of the severity of coronary artery stenosis and the grade of collateral circulation on myocardial viability in patients with chronic left ventricular (LV) dysfunction undergoing coronary artery bypass grafting. Forty patients (age 59 +/- 8 years) with old myocardial infarction were studied by dobutamine stress echocardiography (DSE) before coronary artery bypass grafting. LV function was assessed using a 16-segment, 5-grade score model. Viability and functional recovery were respectively defined as a reduction in wall motion score > or = 1 at low-dose DSE and at follow-up echocardiograms obtained 3 months after surgery. There were 56 stenotic coronary arteries subtending severely dyssynergic myocardial segments, of which 38 were occluded. Among 186 severely dyssynergic segments, functional recovery occurred in 42 (23%). There was no significant difference between myocordial regions with patent or occluded coronary arteries with respect to prevalence of viability or functional recovery and percentage of viable or recovered segments relative to the total number of dyssynergic segments. In patients with total occlusion, these parameters were not different between regions with different collateral grades. Sensitivity, specificity, and accuracy of low-dose DSE for prediction of regional functional recovery were 71%, 90%, and 86%, respectively. It is concluded that in patients with chronic LV dysfunction, the presence of total occlusion of coronary arteries supplying severely dyssynergic regions does not imply a lower prevalence or extent of functional recovery after revascularization, regardless of the grade of angiographically visualized collaterals. Low-dose DSE can identify myocardial regions with a high probability of functional improvement after revascularization regardless of the severity of underlying coronary stenosis or collateralization of the involved coronary vessel.

Dobutamine 99Tcm-MIBI SPET myocardial perfusion scintigraphy in the prediction of restenosis after percutaneous transluminal coronary angioplasty in patients unable to perform an exercise stress test

After successful percutaneous transluminal coronary angioplasty (PTCA), restenosis occurs in a relatively high proportion of patients. Exercise thallium scintigraphy is a useful method for the detection of restenosis. In patients unable to exercise, dobutamine perfusion scintigraphy may represent a feasible alternative. However, its diagnostic accuracy in this clinical setting has not been evaluated. We studied 40 patients (29 males, 11 females) aged 57 +/- 9 years, at a mean of 185 +/- 80 days after successful PTCA with a high-dose dobutamine (up to 40 micrograms kg-1 min-1) stress test, in conjunction with 99Tcm-methoxyisobutyl isonitrile (99Tcm-MIBI) single photon emission tomography (SPET). Significant restenosis was defined as > or = 50% luminal diameter stenosis of a coronary segment with previous PTCA and was predicted on the basis of the occurrence of reversible perfusion defects in the corresponding territories. Reversible perfusion defects occurred in 20 of 29 arteries with and in 4 of 17 arteries without restenosis. The sensitivity of dobutamine MIBI for the detection of restenosis in arteries with previous PTCA was 69% (CI = 56-82), the specificity 76% (CI = 64-89), the positive predictive value 83% (CI = 73-94), the negative predictive value 59% (CI = 45-73) and accuracy 72% (CI = 59-85). The overall sensitivity of 99Tcm-MIBI SPET for the diagnosis of significant coronary stenosis (including arteries without previous PTCA) on a patient basis was 79% (CI = 67-92), the specificity 82% (CI = 70-94) and accuracy 80% (CI = 68-92). The sensitivity of 99Tcm-MIBI SPET was significantly higher than that of electrocardiography (79 vs 38%, P < 0.005). It is concluded that dobutamine 99Tcm-MIBI SPET is a useful method for the detection of restenosis after PTCA in patients unable to perform an exercise stress test.

Relation between ST segment elevation during dobutamine stress test and myocardial viability after a recent myocardial infarction

OBJECTIVE

To assess the relation between ST segment elevation during the dobutamine stress test and late improvement of function after acute Q wave myocardial infarction.

PATIENTS AND DESIGN

70 patients were studied a mean (SD) 8 (3) days after acute myocardial infarction with high dose dobutamine-atropine stress echocardiography and a follow up echocardiogram at 85 (10) days. A score model based on 16 segments and four grades was used to assess left ventricular function. Functional improvement was defined as a reduction of wall motion score > or = 1 in > or = 1 segments at follow up.

INTERVENTION

Myocardial revascularisation was performed in 23 patients (33%) before follow up studies.

RESULTS

ST segment elevation occurred in 40 patients (57%). Late functional improvement occurred in 35 patients (50%). Functional improvement was more common in patients with ST segment elevation (68% v 30%, P < 0.005) and they had a higher mean (SD) number of improved segments at follow up (1.9 (2.2) v 0.5 (1.1), P < 0.005). The wall motion score index decreased between baseline and follow up in patients with ST segment elevation (1.54 (0.50) v 1.48 (0.43), P < 0.05) but not in patients without ST segment elevation (1.39 (0.60) v 1.45 (0.47)). The accuracy of ST segment elevation for the prediction of functional improvement was similar to that of low dose dobutamine echocardiography in patients with anterior infarction (80% v 83%) and in patients who underwent revascularisation (78% v 83% respectively).

CONCLUSION

In patients with a recent Q wave myocardial infarction, dobutamine-induced ST segment elevation is a valuable marker of myocardial viability particularly when the test is performed without or with suboptimal echocardiographic imaging.

Comparison of dobutamine stress echocardiography and 99m-technetium sestamibi SPECT myocardial perfusion scintigraphy for predicting extent of coronary artery disease in patients with healed myocardial infarction

This study compares the value of dobutamine stress echocardiography and 99m-technetium methoxyisobutyl-isonitrile (MIBI) single-photon emission computed tomography (SPECT) in the assessment of extent and location of coronary narrowing in patients with healed myocardial infarction. Dobutamine (up to 40 microg/kg/ min)-atropine (up to 1 mg) stress echocardiography (DSE) in conjunction with MIBI SPECT was performed in 72 patients (52 men, mean age 57 +/- 11 years) with healed myocardial infarction referred for evaluation of myocardial ischemia. Ischemia was defined as new or worsened wall motion abnormalities at DSE and reversible perfusion defects at MIBI SPECT. Significant stenosis (> or = 50% luminal diameter stenosis) of the infarct-related artery was detected in 45 patients and of other coronary arteries in 22 patients. Sensitivity and specificity of remote ischemia for diagnosis of remote coronary stenosis were 68% (95% confidence interval [CI] 57 to 80) and 93% (CI 86 to 99) for DSE, and 64% (CI 52 to 76), and 90% (CI 83 to 98) for MIBI SPECT, respectively. The positive predictive value and specificity of peri-infarction ischemia for the diagnosis of infarct-related artery stenosis were 89% (CI 81 to 97) and 82% (CI 73 to 92) for DSE, and 87% (CI 79 to 95) and 82% (CI 73 to 92) for SPECT, respectively. The agreement between both techniques was higher for the diagnosis of remote than peri-infarction ischemia (84% vs 66%, p = 0.02). It is concluded that in patients with myocardial infarction undergoing dobutamine stress testing, both echocardiography and MIBI SPECT are clinically useful methods for the diagnosis of remote and infarct-related coronary artery stenosis.

Dobutamine thallium-201 SPECT imaging for assessment of peri-infarction and remote myocardial ischemia

This study assessed the value of dobutamine 201Tl scintigraphy for detecting significant disease of infarct-related and remote coronary arteries in myocardial infarction patients.

METHODS

Dobutamine (up to 40 micrograms/kg/min)/atropine (up to 1 mg) stress test in conjunction with stress-reinjection 200Tl SPECT was performed in 71 symptomatic patients with left ventricular dysfunction > 3 mo after myocardial infarction. Ischemia was defined as reversible perfusion defects.

RESULTS

Significant coronary artery stenosis (> or = 50% luminal diameter stenosis) was detected in all patients. Sensitivity, specificity and accuracy of regional ischemia for the diagnosis of remote coronary artery stenosis were 74% (95% Cl 63-86), 80% (Cl 70-90) and 76% (Cl 65-87), respectively. Those for infarct-related artery stenosis were 71% (Cl 60-81), 83% (Cl 75-92) and 72% (Cl 61-82), respectively. Ischemic perfusion score was higher in patients with multiversus single-vessel disease (1056 +/- 1021 versus 423 +/- 633, p < 0.01).

CONCLUSION

Dobutamine thallium scintigraphy is valuable for assessing the extent of coronary stenosis on the basis of reversible hypoperfusion in symptomatic patients late after myocardial infarction.

Hemodynamic and 24-h blood pressure profile of amlodipine monotherapy

OBJECTIVES

To test the therapeutic efficacy, hemodynamic profile, changes in arterial compliance, left ventricular mass and side effects of amlodipine monotherapy in hypertensive Egyptians.

BACKGROUND

Amlodipine is a dihydropyridine calcium antagonist with prolonged duration of action. Its hemodynamic and hypotensive effects were not reported in hypertensive Egyptians. Hypertension is a major health problem in Egypt. Racial differences in hypotensive efficacy of some drugs have been described.

METHODS

Thirty-two hypertensive patients in stages I and II WHO were recruited from a hypertension clinic. Following 2-4 weeks placebo period 23 patients satisfied inclusion criteria of DBP 95-115 mm Hg. Active amlodipine therapy 5-10 mg was given once daily. Office BP was measured at monthly intervals for 3 months. Ambulatory 24-h blood pressure (ABP) and echo-Doppler studies were performed at the end of placebo and after amlodipine therapy.

RESULTS

Twenty patients completed the 3 months active treatment period, their age ranged from 30-63 years; 13 were males, body mass index (BMI) was 31 +/- 14 kg/m2 (mean +/- s.d.). Office systolic (S) BP decreased from 152 +/- 14 to 133 +/- 8 mm Hg, diastolic (D) BP from 104 +/- 6 to 89 +/- 8 mm Hg, BP was normalised ( < 140/90 mm Hg) in 13 patients. Heart rate did not change. ABP 24 h, day-time, night time and early morning readings decreased significantly. Amlodipine attenuated SBP rises ( > 140 mm Hg) from 62% to 28% (P < 0.001) and DBP ( > 90 mm Hg) from 73% to 46% (P < 0.001). Cardiac index and left ventricle (LV) functional shortening did not change while systemic vascular resistance decreased from 35 to 29.8 units (P < 0.001). LV mass index decreased from 101 to 96 gm/m2 (NS) and arterial compliance increased from 0.97 to 0.99 ml/mm Hg (NS). Oedema of lower limbs developed in six patients and was the only side effect.

CONCLUSION

Amlodipine effectively lowered BP when given as monotherapy to hypertensive Egyptians. It did not influence heart rate, cardiac index or myocardial contractility. Change in LV mass and arterial compliance were not significant.

Assessment of patients after coronary artery bypass grafting by dobutamine stress echocardiography

Dobutamine stress echocardiography is an accurate method for the diagnosis and localization of vascular compromise in patients evaluated after coronary artery bypass graft surgery. The test provides useful data for selection of patients for whom coronary angiography may be indicated.

The Egyptian National Hypertension Project (NHP): preliminary results

The prevalence of hypertension (HTN), its cardiovascular complications, the role of environmental and demographic factors were examined in a cross-sectional national survey of 7915 individuals--25 years and older--in 21 sampling locations in six Egyptian governorates. Sample had a stratified, multistage, probability design. The weighted national estimate of HTN (SBP > or = 140 mmHg, DBP > or = 90 mmHg or on medications) was 26%. Hypertension was more prevalent in the following groups: unemployed (49.7% vs 25.3%), socially isolated--living alone (59.7% vs 29.9%), low educated 34.1% vs 24.2%) and in the obese (BMI > 31 kg/m2: 39.8% vs 26.5%). Hypertension prevalence increased progressively with age and was more prevalent in urban than rural areas.

Child mortality in a collapsing African society

A cohort study of mortality among under-5-year-olds was carried out in two Somali villages in 1987-89, a period of economic and political collapse in the rural parts of the country. Analysed was the relative importance of the social characteristics for under-5-year-old mortality against a background of deteriorating political and economic conditions. Mortality increased among under-5-year-olds from 1987 (211 per 1000) to 1988 (323 per 1000) to 1989 (414 per 1000). The mortality risk was more pronounced for boys than girls and was more so for infants than children aged 1-4 years. The major signs prior to death were respiratory infections, diarrhoeal diseases, fever/malaria and tetanus in the neonatal period. Over the 3-year study period mortality rates for diarrhoeal diseases increased significantly, while those for respiratory infections and diseases preventable by immunization increased more slowly. The increasing trend in under-5-year-old mortality was more pronounced in instances when the mother derived her major income from sources other than farming and in larger households.