MB's Articles of Interest - MAY '99

TITLE: The future: screening and effective intervention. Am J Med (United States), Jun 22 1998, 104(6A) p54S-59S Brunton SA Department of Family Medicine, Long Beach Memorial Medical Center, California 90806, USA. JOURNAL ARTICLE; REVIEW (43 references); REVIEW, TUTORIAL
ABSTRACT: Despite an increased understanding of risk factors for cardiovascular disease and the development of new programs, procedures, and medications to reduce risk, effective large-scale primary and secondary prevention have remained difficult to achieve. Large-scale, primarily educational, community-based programs aimed at detecting and reducing risk can be effective, particularly when they are aimed at specific populations at increased risk. However, the long-term benefits of these programs have been modest. Recent studies have demonstrated that lipid-lowering therapy is a critical adjunct to dietary and lifestyle changes. The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors in particular are highly effective in reducing cardiovascular risk in both primary and secondary prevention programs that combine lifestyle modification and aggressive medical therapy. The ability of these drugs to produce rapid improvements in endothelial function and increase coronary perfusion also supports their use in the medical rather than surgical management of at least some patients with cardiovascular disease who are candidates for percutaneous transluminal coronary angioplasty.

TITLE: Lessons from hypertension trials. Am J Med (United States), Jun 22 1998, 104(6A) p50S-53S Hennekens CH Harvard Medical School and the Division of Preventive Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02215-1204, USA. JOURNAL ARTICLE; REVIEW (30 references); REVIEW, TUTORIAL
ABSTRACT: Hypertension is a well-established risk factor for stroke, myocardial infarction (MI), and premature cardiovascular death. Even mild elevations of blood pressure (i.e., diastolic blood pressure 90 and 110 mm Hg) yield increased risk. In fact, mild-to-moderate hypertension is more common than severe hypertension and accounts for a greater proportion of the deaths and serious nonfatal vascular events. The treatment goal is to make optimal use of antihypertensive drug therapy while encouraging patients to implement lifestyle changes such as weight loss, sodium restriction, decreased alcohol intake, and increased exercise. Pharmacologic therapy of mild-to-moderate hypertension can significantly reduce the incidence of stroke, MI, coronary artery disease, vascular mortality, and total mortality. Beta blockers and diuretics should continue to be used as first-line therapy until there is direct and reliable evidence from large-scale randomized trials with clinical endpoints for newer agents such as calcium antagonists and angiotensin-converting enzyme inhibitors.

TITLE: The lipoprotein and coronary atherosclerosis study (LCAS): lipid and metabolic factors related to atheroma and clinical events. Am J Med (United States), Jun 22 1998, 104(6A) p42S-49S Herd JA Baylor College of Medicine, Houston, Texas 77030, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Studies of lipid-lowering therapy are usually conducted in patients with severely elevated cholesterol levels. However, most individuals who develop clinically significant coronary artery disease (CAD) have total cholesterol levels 240 mg/dL and low-density lipoprotein (LDL) cholesterol levels similar to individuals who do not develop significant CAD. The Lipoprotein and Coronary Atherosclerosis Study (LCAS) was conducted to determine whether lipid-lowering therapy with fluvastatin would reduce the progression or induce the regression of coronary atherosclerotic lesions and/or reduce new lesion formation in patients with CAD and mildly to moderately elevated LDL cholesterol. The LCAS was the first angiographically monitored trial of this 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor. All 429 men and women (mean age, 58.8 years) had angiographic evidence of CAD and LDL cholesterol levels of 115-190 mg/dL (mean 145.6 mg/dL). Patients were randomized to fluvastatin 20 mg twice daily or placebo. Patients whose prerandomization LDL cholesterol was or = 160 mg/dL also received open-label cholestyramine. Lipid-lowering therapy with fluvastatin significantly slowed CAD progression. After 2.5 years, the mean LDL cholesterol decreased by 23.9% in all fluvastatin-treated patients (+/-cholestyramine) and by 22.5% in patients treated with fluvastatin monotherapy. There was significantly less lesion progression in fluvastatin versus placebo-treated patients (p 0.01). There also were fewer clinical events in fluvastatin-treated patients. Findings suggest that fluvastatin may improve arterial and arteriolar function within a few weeks of beginning therapy.

TITLE: Current thinking in lipid lowering. Am J Med (United States), Jun 22 1998, 104(6A) p33S-41S Ballantyne CM Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (66 references); REVIEW, TUTORIAL
ABSTRACT: In addition to elevated low-density lipoprotein (LDL) cholesterol, which has been conclusively proven to play a critical role in atherogenesis and coronary artery disease (CAD), other lipoprotein abnormalities are associated with CAD, such as reduced high-density lipoprotein (HDL) cholesterol; increased triglyceride-rich lipoproteins (very low density and intermediate-density lipoproteins); increased lipoprotein(a); small, dense LDL; and LDL with increased susceptibility to oxidation. Other, nonlipid factors such as homocysteine, fibrinogen, C-reactive protein, and soluble cell adhesion molecules may also have a role in risk stratification. The present US treatment guidelines, which focus on LDL cholesterol, stratify risk assessment and intensity of treatment by the presence of CAD; therefore, noninvasive imaging techniques such as ultrafast computed tomography and positron-emission tomography (PET) of the heart, which enable early detection of CAD, are useful in risk assessment. Because the influence of risk factors depends on their severity and combination, global risk assessment provides a necessary guide to the appropriate intensity of treatment. Agents are available that reduce LDL cholesterol and triglyceride and increase HDL cholesterol; although lipoprotein(a), LDL particle size, LDL oxidation, and homocysteine can also be altered, the clinical effects of such alterations are not known. Combination therapy that simultaneously improves multiple components of the lipid profile may provide additional benefit compared with monotherapy. To provide cost-effective treatment to the most patients, high-risk patients must be identified through systematic screening. Then each patient should be treated with the most cost-effective agent(s) that will enable achievement of the lipid levels recommended in the guidelines.

TITLE: Lessons from cholesterol-lowering trials. Am J Med (United States), Jun 22 1998, 104(6A) p28S-32S Smith SC Jr Division of Cardiology, Center for Cardiovascular Disease, University of North Carolina, Chapel Hill 27599-7075, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (20 references); REVIEW, TUTORIAL
ABSTRACT: More than 13 million individuals have coronary artery disease (CAD), and in approximately 2 million patients with congestive heart failure, CAD is the underlying cause. The cost of treating cardiovascular disease has spiraled, yet only a small percentage of the total cost is spent on preventive medical therapies and lifestyle changes that can reduce the morbidity, mortality, and disability caused by heart disease. Recent trials of cholesterol-lowering therapies have clearly shown that this treatment approach, particularly the use of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, can significantly reduce mortality from cardiovascular events and the need for expensive hospitalization and revascularization procedures. The challenge for clinicians is to apply the important lessons learned from these clinical trials to patient care. Recent data indicate that less than half of patients with CAD receive cholesterol-lowering therapy, and few meet the low-density lipoprotein (LDL) cholesterol goal. Clinicians treating CAD need to emphasize primary and secondary prevention and recognize the key role of cholesterol-lowering therapy.

TITLE: How dead is the federal constitutional right to assisted suicide? Am J Med (United States), Jun 1998, 104(6) p565-8 Paola FA. Department of Internal Medicine, University of South Florida College of Medicine, Tampa 33612-4799, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (09 references); REVIEW, TUTORIAL
ABSTRACT: The US Supreme Court recently upheld state laws in New York and Washington that prohibit assisted suicide. In both cases, the judgment of the Court was unanimous. Closer scrutiny of the opinions in the cases, however, suggests that we may not have seen the last of a federal constitutional right to assisted suicide.

TITLE: Prostate cancer screening and beliefs about treatment efficacy: a national survey of primary care physicians and urologists Comment in: Am J Med 1998 Jun; 104(6):602-4. Am J Med (United States), Jun 1998, 104(6) p526-32. Fowler FJ Jr; Bin L; Collins MM; Roberts RG; Oesterling JE; Wasson JH; Barry MJ. Center for Survey Research, University of Massachusetts, Boston, 02125, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: To describe practice patterns and beliefs of primary care physicians and urologists regarding early detection and treatment of prostate cancer. SUBJECTS AND METHODS: National probability samples of primary care physicians (n=444) and urologists (n=394) completed mail survey instruments in 1995. Physicians were asked about their use of prostate-specific antigen (PSA) testing for men of different ages and their beliefs about the value of radical prostatectomy, external-beam radiation therapy, and watchful waiting for men with differing life expectancies. RESULTS: Most primary care physicians report doing PSA tests during routine examination of men older than 50 years of age. The majority say they continue to do them on patients over 80 years and to refer men with abnormal values for biopsy. In contrast, only a minority of urologists would recommend PSA tests or biopsy for abnormal values for men over 75 years of age. More than 80% of primary care physicians and urologists doubt the value of radical prostatectomy for men with 10 years of life expectancy; more primary care physicians than urologists see probable survival benefit in radiation therapy for patients with life expectancy 10 years (48% versus 36%) or 10 years (67% versus 53%). Thirteen percent of primary care physicians and only 3% of urologists consider watchful waiting to be as appropriate as aggressive therapy for men with 10 years of life expectancy. CONCLUSIONS: Primary care physicians are more aggressive about PSA testing and referral for biopsy than most urologists recommend. Both groups recommend PSA testing and believe that aggressive treatment is more beneficial than existing evidence indicates.

TITLE: High rates of prostate-specific antigen testing in men with evidence of benign prostatic hyperplasia [see comments. Comment in: Am J Med 1998 Jun; 104(6):602-4 . Am J Med (United States), Jun 1998, 104(6) p517-25. Meigs JB; Barry MJ; Giovannucci E; Rimm EB; Stampfer MJ; Kawachi I. Massachusetts General Hospital, and the Department of Medicine, Harvard Medical School, Boston 02114, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: Benign prostatic hyperplasia is common among men who may be candidates for prostate cancer screening using prostate-specific antigen (PSA) testing. Patterns of PSA testing among men with evidence of benign prostatic hyperplasia have not been studied. METHODS: We examined the prevalence and correlates of a self-reported history of PSA testing. In 1994, 33,028 US health professionals without prostate cancer aged 47 to 85 years provided information on prior PSA testing, lower urinary tract symptoms characteristic of benign prostatic hyperplasia, history of prostatectomy, and prostate cancer risk factors. In 1995, a subset of 7,070 men provided additional information on diagnosis and treatment of benign prostatic hyperplasia. RESULTS: From 39% of men in their 50s to 53% of men in their 80s reported PSA testing in the prior year (P 0.0001 for trend with age). Men were more likely to report PSA testing if they had lower urinary tract symptoms characteristic of benign prostatic hyperplasia (age-adjusted odds ratio for severe symptoms 2.2, 95% confidence interval 1.8 to 2.6), a prior history of prostatectomy (age-adjusted odds ratio 1.1, 95% confidence interval 1.02 to 1.2), or a physician diagnosis of benign prostatic hyperplasia (odds ratio 1.9, 95% confidence interval 1.7 to 2.2; adjusted for age, signs or symptoms of benign prostatic hyperplasia, and prostate cancer risk factors). CONCLUSIONS: These US health professionals reported preferential use of PSA testing among men least likely to benefit from early cancer detection (older men) and among men most likely to have a false-positive PSA result (men with benign prostatic hyperplasia). Physician and patient education are needed to promote more rational and selective use of this screening test.

TITLE: Prostate cancer screening: practice what the evidence preaches. Comment on: Am J Med 1998 Jun; 104(6):517-25; Comment on: Am J Med 1998 Jun; 104(6):526-32. Am J Med (United States), Jun 1998, 104(6) p602-4. Wilt TJ
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Free PSA for detecting prostate cancer [letter] JAMA (United States), Dec 2 1998, 280(21) p1825-6. Peirce JC; Hoffman RM
PUBLICATION TYPE: LETTER

TITLE: How you look determines what you find: severity of illness and variation in blood transfusion for hip fracture. E: Am J Med (United States), Sep 1998, 105(3) p198-206. Poses RM; Berlin JA; Noveck H; Lawrence VA; Huber EC; O'Hara DA; Spence RK; Duff A; Strom BL; Carson JL. Department of Medicine, Brown University School of Medicine, Providence, Rhode Island, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT (Cut) The outcome of interest was postoperative blood transfusion. "Trigger hemoglobin" was the lowest hemoglobin recorded before transfusion or recorded at any time during the week before or after surgery for patients who were not transfused. RESULTS: There was considerable variation in transfusion among hospitals postoperatively (range 31.2% to 54.0%, P = 0.001). Trigger hemoglobin also varied considerably among hospitals. In unadjusted analyses, four of nine teaching and two of nine nonteaching hospitals had postoperative transfusion rates significantly higher than the reference (teaching) hospital, while one nonteaching hospital had a lower rate. In an analysis controlling for trigger hemoglobin and multiple clinical variables, one of nine teaching and four of nine nonteaching hospitals had rates higher than the reference hospital, while four teaching hospitals and one nonteaching hospital had lower rates. CONCLUSIONS: The apparent pattern of variation of transfusion among hospitals varies according to how one adjusts for relevant patient characteristics. Utilization report cards that fail to adjust for these characteristics may be misleading.

TITLE: The etiology of obesity: relative contribution of metabolic factors, diet, and physical activity. Am J Med (United States), Aug 1998, 105(2) p145-50. Weinsier RL; Hunter GR; Heini AF; Goran MI; Sell SM. Department of Nutrition Sciences, University of Alabama at Birmingham, 35294, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (67 references); REVIEW, TUTORIAL
ABSTRACT: Three major factors modulate body weight: metabolic factors, diet, and physical activity, each influenced by genetic traits. Despite recent advances in these areas, the prevalence of obesity in Westernized societies has increased. In contrast to monogenic animal models and rare human genetic syndromes, predisposition to common forms of obesity is probably influenced by numerous susceptibility genes, accounting for variations in energy requirements, fuel utilization, muscle metabolic characteristics, and taste preferences. Although recent increases in obesity prevalence cannot be explained by changes in the gene pool, previously "silent" genetic variants may now play important permissive roles in modern societies. Available data suggest that variations in resting energy expenditure, thermic effect of food, and fuel utilization exist but, by themselves, are unlikely to explain the onset of obesity. Regarding diet, the best available trend survey data indicate that fat and energy intake have fallen, in this and other Westernized countries. Diverging trends of decreasing energy intake and increasing body weight suggest that reduced physical activity may be the most important current factor explaining the rising prevalence of obesity. Subsistence in modern societies requires extreme adaptations in previously useful energy-conserving diet and exercise behaviors. Recognizing the difficulties in sustaining energy-restricted diets in the presence of fast foods and social feasts, the current trend toward increasing body weight is not likely to be reversed solely through recommendations for further reductions in energy intake. In all likelihood, activity levels will have to increase in response to an environment engineered to be more physically demanding.

TITLE: The needs of a patient in pain.. Am J Med (United States), Jul 27 1998, 105(1B) p2S-7S. Katz WA. Division of Rheumatology, University of Pennsylvania Health System, Presbyterian Medical Center, Philadelphia 19104, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (36 references); REVIEW, TUTORIAL
ABSTRACT: Pain affects everyone at some point in their life. However, everyone experiences pain in a highly individualized way, and therefore, the management of pain must also be customized. Of the 3 general types of pain-acute, chronic malignant, and chronic nonmalignant-the latter is the least predictable and, therefore, can be the most difficult to treat. General principles of pain management can be summarized as (1) respecting the pain and the patient; (2) recognizing and addressing the psychosocial aspects of pain; and (3) treating the pain-and the underlying cause-appropriately and in a timely fashion. The best success in pain management relies on a multidisciplinary approach that includes patient education, medications, physical medicine, and psychological counseling. Although a number of effective analgesic drugs are available, all are associated with adverse events. To reduce the risk of these side effects, the patient's specific needs and medical history must be considered before initiating therapy. Central to effective management of chronic pain is a positive physician-patient relationship. Several strategies are discussed to help in building such a connection.

TITLE: Non-narcotic analgesics: renal and gastrointestinal considerations. Introduction.. Am J Med (United States), Jul 27 1998, 105(1B) p1S. Hamilton FA. National Institute of Diabetes and Digestive Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892-6600, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

TITLE: Hume Memorial lecture. Prevention of spinal cord complications in aortic surgery. Am J Surg (United States), Aug 1998, 176(2) p92-101. Connolly JE. Department of Surgery, University of California Irvine Medical Center, Orange 92868, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (63 references); REVIEW, TUTORIAL
ABSTRACT: Paraplegia or paraparesis after operations on the thoracic and abdominal aorta is a devastating event, both for the patient and the surgeon. While its incidence varies from under 1% with operations at the top and bottom of the aorta, its occurrence in the midportion of the aorta, just above the diaphragm, even in the best of hands exceeds 10%. Over a decade ago, Crawford et al (J Vasc Surg. 1986; 3:389-404) introduced the use of inclusion and sequential clamping techniques for thoracoabdominal aneurysmectomy, lowering both morbidity and neurologic sequelae. Although these techniques have been widely adopted, newer ancillary adjuncts have been recommended by a number of investigators. This paper summarizes the possible causes of paraplegia secondary to the various operations on the aorta and analyzes the status and value of the various ancillary techniques in its prevention.

TITLE: Peripherally inserted central catheters revisited. Am J Surg (United States), Aug 1998, 176(2) p208-11. Smith JR; Friedell ML; Cheatham ML; Martin SP; Cohen MJ; Horowitz JD. Department of Surgery, Orlando Regional Medical Center, Florida 32806, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: This study compares central venous catheters (CVC) and peripherally inserted central catheters (PICC) for indications for insertion, complications, and economic impact. METHODS: A retrospective review of 838 (283 CVC, 555 PICC) consecutively placed venous catheters reflected 49,365 CVC and 11,814 PICC days. RESULTS: There were 57 (20%) complications in the CVC group, 197 (35%) complications in the PICC group. PICC were associated with a statistically significant increase in the incidence of catheter malfunction (P = 0.0005), arm vein phlebitis (P = 0.0004), and overall complications (P = 0.00001). A higher complication rate was noted in PICC inserted for chemotherapy (P = 0.00001) and parenteral hyperalimentation administration (P = 0.04). Charges for inpatient insertion of PICC and CVC were $500 and $2,500, respectively. CONCLUSIONS: PICC have a significantly higher complication rate than CVC. PICC provide cost-effective central access of 2 to 3 weeks' duration, reserving operatively placed CVC for longer access requirements.

TITLE: Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature. Comment in: Acta Anaesthesiol Scand 1998 Jul; 42(6):609-13. Acta Anaesthesiol Scand (Denmark), Jul 1998, 42(6) p614-20. Kindler CH; Seeberger MD; Staender SE. Department of Anesthesia, Kantonsspital, University of Basel, Switzerland.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (61 references); REVIEW OF REPORTED CASES
ABSTRACT: BACKGROUND: Epidural abscess is a serious complication of epidural block. Because of its low incidence, the risk factors and the symptoms and cause of epidural abscess related to epidural anesthesia and analgesia are not well known by anesthesiologists. METHODS: A computer-assisted search of the literature on epidural catheter-related abscess was performed to describe the clinical course and bacteriology of this complication, to determine possible risk factors, and to assess the index of suspicion among physicians. RESULTS: Forty-two patients with a catheter-related epidural abscess were identified. Only in 15 patients was the correct diagnosis considered initially. The time from insertion of the epidural catheter to symptoms varied between 1 and 60 d. Initial symptoms included back pain, fever, and leukocytosis. The time from symptoms to treatment was a few hours to 108 d. Interval from first symptoms to treatment was significantly longer in patients with persistent neurologic deficits compared with patients who completely recovered. Staphylococcus aureus was the most common etiologic agent. Outcome was reported in 39 patients, but only 19 made a full recovery. CONCLUSION: The index of suspicion among anesthesiologists, other physicians and nurses taking care of patients with epidural catheters must be increased for this complication; this should shorten the interval from symptoms to treatment and lower the incidence of neurological sequelae.

TITLE: Neurological complications in association with spinal and epidural analgesia&emdash;again. Comment on: Acta Anaesthesiol Scand 1998 Jul; 42(6):614-20; Comment on: Acta Anaesthesiol Scand 1998 Jul; 42(6):727-31; Comment on: Acta Anaesthesiol Scand 1998 Jul; 42(6):732-5. Acta Anaesthesiol Scand (Denmark), Jul 1998, 42(6) p609-13. Breivik H
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Long term relative survival after surgery for abdominal aortic aneurysm in western Australia: population based study. : BMJ (England), Sep 26 1998, 317(7162) p852-6. Norman PE; Semmens JB; Lawrence-Brown MM; Holman CD. University Department of Surgery, Fremantle Hospital, PO Box 480, Fremantle, Western Australia 6959, Australia. pnorman@cyllene.uwa.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.

TITLE: Growth rates and risk of rupture of abdominal aortic aneurysms. Br J Surg (England), Dec 1998, 85(12) p1674-80. Vardulaki KA; Prevost TC; Walker NM; Day NE; Wilmink AB; Quick CR; Ashton HA; Scott RA. Institute of Public Health, University of Cambridge, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: The study provides a more accurate assessment of the risk of aneurysm rupture without surgery and helps to define rescreening intervals for those with an enlarged aortic diameter

TITLE: Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants. Comment in: Lancet 1998 Nov 21; 352(9141):1642-3. Lancet (England), Nov 21 1998, 352(9141) p1649-55
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: Ultrasonographic surveillance for small abdominal aortic aneurysms is safe, and early surgery does not provide a long-term survival advantage. Our results do not support a policy of open surgical repair for abdominal aortic aneurysms of 4.0-5.5 cm in diameter.
MB. What about endoluminals?

TITLE: Facts, at last, on management of small infrarenal aortic aneurysms. Comment on: Lancet 1998 Nov 21; 352(9141):1649-55; Comment on: Lancet 1998 Nov 21; 352(9141):1656-60. Lancet (England), Nov 21 1998, 352(9141) p1642-3. Pretre R; Turina MI. Department of Cardiovascular Surgery, University Hospital, Zurich, Switzerland.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

TITLE: Flushing away the fat. Weight loss during trials of orlistat was significant, but over half was due to diet. Comment on: BMJ 1998 Sep 26; 317(7162):835. BMJ (England), Sep 26 1998, 317(7162) p830-1. Garrow J
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Albumin: don't confuse us with the facts. Rather than fulminating, seek to answer the questions raised [editorial] . BMJ (England), Sep 26 1998, 317(7162) p829-30. McClelland B
PUBLICATION TYPE: EDITORIAL

TITLE: The rise and fall of viagra. BMJ (England), Sep 19 1998, 317(7161) p824. Berger A. General practitioner, London.
PUBLICATION TYPE: JOURNAL ARTICLE

TITLE: Regulation of doctors and the Bristol inquiry. Both need to be credible to both the public and doctors. Comment on: BMJ 1998 Dec 5; 317(7172):1577-9; Comment on: BMJ 1998 Dec 5; 317(7172):1579-80; Comment on: BMJ 1998 Dec 5; 317(7172):1581-2. BMJ (England), Dec 5 1998, 317(7172) p1539-40. Smith R
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis. Comment in: BMJ 1998 Nov 28; 317(7171):1468. BMJ (England), Nov 28 1998, 317(7171) p1477-80 Benavente O; Moher D; Pham B Department of Medicine, Division of Neurology, University of Texas Health Science Center, San Antonio, TX 78284-7883, USA. benavente@uthscsa.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSION: Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.

TITLE: Carotid endarterectomy for asymptomatic carotid stenosis. Better data, but the case is still not convincing [editorial; comment]
COMMENTS: Comment on: BMJ 1998 Nov 28; 317(7171):1477-80 BMJ (England), Nov 28 1998, 317(7171) p1468 Warlow C
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Recent advances: control of chronic pain. BMJ (England), Nov 21 1998, 317(7170) p1438-41 Nurmikko TJ; Nash TP; Wiles JR Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool L9 1AE, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (40 references); REVIEW, TUTORIAL

TITLE: Safer non-cardiac surgery for patients with coronary artery disease. Medical treatment should be optimised to improve outcome. [editorial] BMJ (England), Nov 21 1998, 317(7170) p1400-1. Sonksen J; Gray R; Hickman PH
PUBLICATION TYPE: EDITORIAL

TITLE: Nuts to you (...and you, and you). Eating nuts may be beneficial-though it is unclear why. Comment on: BMJ 1998 Nov 14; 317(7169):1341-5. BMJ (England), Nov 14 1998, 317(7169) p1332-3. Tunstall-Pedoe H
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Height, early energy intake, and cancer. Evidence mounts for the relation of energy intake to adult malignancies. Comment on: BMJ 1998 Nov 14; 317(7169):1350-1; Comment on: BMJ 1998 Nov 14; 317(7169):1351-2. BMJ (England), Nov 14 1998, 317(7169) p1331-2. Albanes D
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Efficient management of randomised controlled trials: nature or nurture.. BMJ (England), Oct 31 1998, 317(7167) p1236-9. Farrell B. Institute of Health Sciences, Oxford OX3 7LF.. Barbara.Farrell@ndm.ox.ac.uk.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (3 references); REVIEW, TUTORIAL

TITLE: ABC of oxygen: assessing and interpreting arterial blood gases and acid-base balance.BMJ (England), Oct 31 1998, 317(7167) p1213-6. Williams AJ. Lane-Fox Respiratory Unit, St. Thomas's Hospital, London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (0 references); REVIEW, TUTORIAL

TITLE: Magic bullet for obesity. BMJ (England), Oct 24 1998, 317(7166) p1136-8. Hirsch J. Rockefeller University, New York, NY 10021-6399 USA. Hirsch@raockvax.rockefeller.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (8 references); REVIEW, TUTORIAL

TITLE: Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. Comment in: BMJ 1998 Oct 24; 317(7166):1097-8. BMJ (England), Oct 24 1998, 317(7166) p1111-6; discussion 1116-7. McManus IC. Centre for Health Informatics and Multi-professional Education, Royal Free and University College Medical School, University College London, Whittington Hospital Campus, London N19 5NF. i.mcmanus@ucl.ac.uk.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The data released by the Council of Heads of Medical Schools allow a detailed analysis of the selection process at individual medical schools. The results suggest several areas in which some candidates are disadvantaged, in particular those from ethnic minority groups. Similar data in the future will allow monitoring of changes in selection processes.

TITLE: Is medical school selection discriminatory? New data should be used as a catalyst for. Comment on: BMJ 1998 Oct 24; 317(7166):1111-6; discussion 1116-7. BMJ (England), Oct 24 1998, 317(7166) p1097-8. Abbasi K
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Is the FDA approving drugs too fast?. Probably not--but drug recalls have sparked debate [editorial] BMJ (England), Oct 3 1998, 317(7163) p899. Kleinke JD; Gottlieb S
PUBLICATION TYPE: EDITORIAL

TITLE: The European Medicines Evaluation Agency: open to criticism. Transparency must be coupled with greater rigour [editorial] BMJ (England), Oct 3 1998, 317(7163) p898. Abbasi K; Herxheimer A
PUBLICATION TYPE: EDITORIAL

TITLE: Intraoperative heparin flushes and subsequent acute heparin-induced thrombocytopenia.. Anesthesiology (United States), Dec 1998, 89(6) p1567-9. Ling E; Warkentin TE. Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada. linge@fhs.mcmaster.ca.
PUBLICATION TYPE: JOURNAL ARTICLE

TITLE: Efficacy and costs of patient-controlled analgesia versus regularly administered intramuscular opioid therapy. Anesthesiology (United States), Dec 1998, 89(6) p1377-88 Choiniere M; Rittenhouse BE; Perreault S; Chartrand D; Rousseau P; Smith B; Pepler C. Department of Anesthesia, Faculty of Medicine, University of Montreal, Quebec, Canada. choiniem@ere.umontreal.ca.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Compared with regularly scheduled intramuscular dosing, PCA is more costly and does not have clinical advantages for pain management after hysterectomy. Because of the comparable outcomes, the general use of PCA in similar patients should be questioned.

TITLE: Effect of various lithotomy positions on lower-extremity blood pressure. Anesthesiology (United States), Dec 1998, 89(6) p1373-6. Halliwill JR; Hewitt SA; Joyner MJ; Warner MA. Department of Physiology and Biophysics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
CONCLUSIONS: Although lower-extremity systolic blood pressures in the young, healthy volunteers correlated with predicted values, there was an additional reduction in pressure associated with the lithotomy position. This surprising finding suggests that a lengthy procedure necessitating the use of a lithotomy position for only a portion should be planned so the remainder of the procedure can take place before establishing the position or so the position can be changed to an alternative position when it is no longer needed.

TITLE: Multicenter study of contaminated percutaneous injuries(CPIs) in anesthesia personnel. Anesthesiology (United States), Dec 1998, 89(6) p1362-72. Greene ES; Berry AJ; Jagger J; Hanley E; Arnold WP 3rd; Bailey MK; Brown M; Gramling-Babb P; Passannante AN; Seltzer JL; Southorn P; Van Clief MA; Venezia RA. Department of Anesthesiology, Albany Medical College, New York 12208, USA. elliott_greene@ccgateway.amc.edu.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY
CONCLUSIONS: Performance of anesthesia tasks is associated with CPIs from blood-contaminated hollow-bore needles. Thirty percent of all CPIs would have been high-risk for bloodborne pathogen transmission if the source patients were infected. Most CPIs were potentially preventable, and fewer than half were reported to hospital health services. The results identify devices and mechanisms responsible for CPIs, provide estimates of risk levels, and permit formulation of strategies to reduce risks.

TITLE: Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Comment in: Anesthesiology 1998 Dec; 89(6):1309-10. Anesthesiology (United States), Dec 1998, 89(6) p1313-21. Tavernier B; Makhotine O; Lebuffe G; Dupont J; Scherpereel P. Department of Anesthesia 2, University Hospital, Lille, France. btavernier@chru-lille.fr.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
CONCLUSION: The dDown component of the systolic pressure variation is a sensitive indicator of the response of cardiac output to volume infusion in patient with sepsis-induced hypotension who require mechanical ventilation.

TITLE: Blood volume measurement: the next intraoperative monitor? Comment on: Anesthesiology 1998 Dec; 89(6):1322-8; Comment on: Anesthesiology 1998 Dec; 89(6):1329-35. Anesthesiology (United States), Dec 1998, 89(6) p1310-2. Barker SJ
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Assessing fluid responsiveness by the systolic pressure variation in mechanically ventilated patients. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Comment on: Anesthesiology 1998 Dec; 89(6):1313-21. Anesthesiology (United States), Dec 1998, 89(6) p1309-10. Perel A
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Blood volume measurement at the bedside using ICG pulse spectrophotometry: Comment in: Anesthesiology 1998 Dec; 89(6):1310-2. Anesthesiology (United States), Dec 1998, 89(6) p1322-8. Haruna M; Kumon K; Yahagi N; Watanabe Y; Ishida Y; Kobayashi N; Aoyagi T. Division of Surgical Intensive Care, National Cardiovascular Center, Suita, Osaka, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
CONCLUSIONS: In most patients, the pulse method provides bedside measurement of BV without blood sampling (except for hemoglobin determination), with an estimated error less than 10%. In 10-30% of tests the method failed because of motion distortion of the record during the 10-min data collection period or because of insufficient pulse amplitude in the test tissue.

TITLE: Spontaneous recovery after discontinuation of intraoperative cardiopulmonary resuscitation: case report. Anesthesiology (United States), Nov 1998, 89(5) p1252-3. Frolich MA. Department of Anesthesiology and Intensive Care Medicine, University of Ludwig Maximillians, Grosshadern Clinic, Munich, Germany. froelich@anest1.ufl.edu.
PUBLICATION TYPE: JOURNAL ARTICLE

TITLE: Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology (United States), Nov 1998, 89(5) p1147-56; discussion 9A-10A. Kain ZN; Mayes LC; Wang SM; Caramico LA; Hofstadter MB. Department of Anesthesiology, and Child Study Center and the Children's Clinical Research Center, Yale University School of Medicine, New Haven, Connecticut 06510, USA. zeev.kain@yale.edu.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Under the conditions of this study, oral midazolam is more effective than either parental presence or no intervention for managing a child's and parent's anxiety during the preoperative period.
MB. I am sure that the individual anaesthetist would be another variable.

TITLE: Effects of mild perioperative hypothermia on cellular immune responses. Anesthesiology (United States), Nov 1998, 89(5) p1133-40. Beilin B; Shavit Y; Razumovsky J; Wolloch Y; Zeidel A; Bessler H. Department of Anesthesiology, Rabin Medical Center, Campus Golda, Petah Tiqva, Israel.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Mild perioperative hypothermia suppressed mitogen-induced activation of lymphocytes and reduced the production of certain cytokines, IL-1beta and IL-2, and in this way may contribute to the immune alterations observed in the perioperative period.

TITLE: A primer for EEG signal processing in anesthesia [see comments]: Anesthesiology 1998 Oct; 89(4):815-7 Anesthesiology (United States), Oct 1998, 89(4) p980-1002 Rampil IJ Department of Anesthesia, University of California, San Francisco 94143-0648, USA. ira_rampil@vaxine.ucsf.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (61 references); REVIEW, TUTORIAL

TITLE: EEGs, EEG processing, and the bispectral index Comment on: Anesthesiology 1998 Oct; 89(4):980-1002 Anesthesiology (United States), Oct 1998, 89(4) p815-7 Todd MM
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Third-generation cephalosporins and vancomycin as risk factors for postoperative vancomycin-resistant enterococcus infection. Arch Surg (United States), Dec 1998, 133(12) p1343-6 Dahms RA; Johnson EM; Statz CL; Lee JT; Dunn DL; Beilman GJ Department of Surgery, University of Minnesota Medical School, Minneapolis 55455, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: This matched control study showed that use of 3GCs, alone (P=.05) or concurrently with vancomycin (P=.05), was a risk factor for VRE infection in surgical patients. Judicious administration of third-generation antibiotics is warranted in surgical patients with other risk factors for VRE.
MB. Some surgeons have not read this.

TITLE: Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis. JAMA (United States), Dec 23-30 1998, 280(24) p2105-10. Halpern SH; Leighton BL; Ohlsson A; Barrett JF; Rice A. Department of Anaesthesia, University of Toronto and Women's College Hospital, Ontario, Canada. halpern@ftn.net.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.

TITLE: Techniques to improve physicians' use of diagnostic tests: a new conceptual framework: Comment in: JAMA 1998 Dec 16; 280(23):2036. JAMA (United States), Dec 16 1998, 280(23) p2020-7. Solomon DH; Hashimoto H; Daltroy L; Liang MH. Department of Medicine, Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA 02115, USA. dhsolomon@bics.bwh.harvard.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results.

TITLE: Changing physician behavior in ordering diagnostic tests. Comment on: JAMA 1998 Dec 16; 280(23):2020-7; Comment on: JAMA 1998 Dec 16; 280(23):2038-33. JAMA (United States), Dec 16 1998, 280(23) p2036. Lundberg GD
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Techniques to improve physicians' use of diagnostic tests: a new conceptual framework: Comment in: JAMA 1998 Dec 16; 280(23):2036. JAMA (United States), Dec 16 1998, 280(23) p2020-7. Solomon DH; Hashimoto H; Daltroy L; Liang MH. Department of Medicine, Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA 02115, USA. dhsolomon@bics.bwh.harvard.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results. Intensive lifestyle changes for reversal of coronary heart disease. JAMA (United States), Dec 16 1998, 280(23) p2001-7. Ornish D; Scherwitz LW; Billings JH; Gould KL; Merritt TA; Sparler S; Armstrong WT; Ports TA; Kirkeeide R L; Hogeboom C; Brand RJ. Department of Medicine, California Pacific Medical Center, San Francisco, USA. DeanOrnish@aol.com.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACTDESIGN: Randomized controlled trial conducted from 1986 to 1992 using a randomized invitational design. PATIENTS: Forty-eight patients with moderate to severe coronary heart disease were randomized to an intensive lifestyle change group or to a usual-care control group, and 35 completed the 5-year follow-up quantitative coronary arteriography.. CONCLUSIONS: More regression of coronary atherosclerosis occurred after 5 years than after 1 year in the experimental group. In contrast, in the control group, coronary atherosclerosis continued to progress and more than twice as many cardiac events occurred.

TITLE: Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. Comment in: JAMA 1998 Dec 9; 280(22):1949-50. JAMA (United States), Dec 9 1998, 280(22) p1930-5. He J; Whelton PK; Vu B; Klag MJ. Department of Biostatistics and Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA. jhe@mailhost.tcs.tulane.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: These results indicate that aspirin therapy increases the risk of hemorrhagic stroke. However, the overall benefit of aspirin use on myocardial infarction and ischemic stroke may outweigh its adverse effects on risk of hemorrhagic stroke in most populations.
MB. They found the same think about 15 yago==
Impact of hospital volume on operative mortality for major cancer surgery. Comment in: JAMA 1998 Nov 25; 280(20):1783-4. JAMA (United States), Nov 25 1998, 280(20) p1747-51. Begg CB; Cramer LD; Hoskins WJ; Brennan MF. Department of Epidemiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. beggc@mskcc.org.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: These data support the hypothesis that when complex surgical oncologic procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower.

TITLE: Hospital volume and patient outcomes in major cancer surgery: a catalyst for quality assessment and concentration of cancer services Comment on: JAMA 1998 Nov 25; 280(20):1747-51. JAMA (United States), Nov 25 1998, 280(20) p1783-4. Hillner BE; Smith TJ
PUBLICATION TYPE: COMMENT; EDITORIAL== MB. The Healt Dept does not seem to realise that.

TITLE: Severe pneumothorax after intercostal nerve blockade. A case report. Acta Anaesthesiol Scand (Denmark), Oct 1998, 42(9) p1124-6. Holzer A; Kapral S; Hellwagner K; Eisenmenger-Pelucha A; Preis C. Department of Anesthesiology and General Intensive Care, University of Vienna, Austria.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Extra caution should be used in applying this procedure to patients with underlying chronic lung disease, especially on the opposite side. Our case demonstrates that in all patients undergoing intercostal nerve blockade preference should be given to the approach at the dorsal angulation of the rib in the lateral or prone position due to its lower risk of pneumothorax.

TITLE: Comparison of the haemodynamic actions of desflurane/N2O and isoflurane/N2O anaesthesia in vascular surgical patients.. Acta Anaesthesiol Scand (Denmark), Oct 1998, 42(9) p1057-62. Zubicki A; Gostin X; Miclea D; Riou B; Buy E; Richer C; Coriat P. Department of Anesthesiology and Intensive Care, Hopital de la Pitie-Salpetriere, Paris, France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: We conclude that sympathetic hyperactivity previously reported during desflurane anaesthesia in healthy volunteers is not frequent in clinical practice in elderly vascular surgical patients under desflurane/N2O anaesthesia, since it occurs at an anaesthetic depth which cannot be reached in these patients because of the lowering arterial blood pressure effects of desflurane, which are similar to those of isoflurane.

TITLE: A comparison of three fluid-vasopressor regimens used to prevent hypotension during subarachnoid anaesthesia in the elderly.. Anaesth Intensive Care (Australia), Oct 1998, 26(5) p497-502. Yap JC; Critchley LA; Yu SC; Calcroft RM; Derrick JL. Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We aimed to compare the efficacy of fluid preloading with two recently recommended fluid-vasopressor regimens for maintaining blood pressure during subarachnoid anaesthesia in the elderly. Sixty elderly patients requiring surgery for traumatic hip fractures received subarachnoid anaesthesia using 0.05 ml/kg of 0.5% heavy bupivacaine. Hypotension, i.e. systolic arterial pressure < 75% of baseline, was prevented or treated by: A--normal saline 16 ml/kg plus intravenous ephedrine boluses (0.1 mg/kg); B--normal saline 8 ml/kg plus intramuscular depot ephedrine (0.5 mg/kg); or C--Haemaccel 8 ml/kg plus metaraminol infusion. Systolic arterial pressure and heart rate were recorded using custom-written computer software (Monitor, version 1.0). Systolic arterial pressure decreased in all groups after five minutes (P < 0.001). Decreases were greatest in group A (P < 0.05). Heart rate increased by 7% group A and decreased by 9% in group C (P < 0.05). During the first hour, hypotension was present for 47%, 25% and 20% of the time in groups A, B and C respectively and overcorrection of systolic arterial pressure occurred in 19% of the time in group C. We conclude that treatment A was inadequate in preventing hypotension. Treatments B and C were more effective but were associated with an increased heart rate and overcorrection of systolic arterial pressure respectively.
MB. Recipes are no good. CVP & urinary output might help. As would taking notice of the monitors

TITLE: Labour ward midwifery staff epidural knowledge and practice.. Anaesth Intensive Care (Australia), Aug 1998, 26(4) p411-9. Vandendriesen NM; Lim W; Paech MJ. Royal Perth Hospital, Western Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A survey was conducted amongst labour ward midwives at our hospital to evaluate education, knowledge and attitudes toward the management of epidural analgesia in labour. Sixty of 80 distributed forms were returned, giving a 75% response rate. Forty-two per cent of respondents had more than ten years' practice experience. Only 51% achieved a predetermined pass score for knowledge about epidural analgesia. Though most had received formal education about epidural analgesia, 35% felt postgraduate education was insufficient. A majority of midwives supported epidural analgesia on demand (78%), during established labour (74%), or for women at increased risk of caesarean section (82%). Midwives with lower knowledge levels were more likely to recommend epidural analgesia early in labour to multiparous women (P = 0.001) and to women with either a small or a large baby (P = 0.06). The majority of midwives (93%, 70% and 65%) would "almost always" top-up women with cardiac or medical diseases, multiple pregnancy or hypertensive disease, respectively. A clear requirement for ongoing education, with input from the anaesthetic department, was identified, irrespective of personal experience. Practice patterns are discussed and recommendations made with respect to improvement of epidural analgesia management and continuing education.

TITLE: Induction of anaesthesia with sevoflurane, preprogrammed propofol infusion or combined sevoflurane/propofol for laryngeal mask insertion: cardiovascular, movement and EEG bispectral index responses. Anaesth Intensive Care (Australia), Aug 1998, 26(4) p360-5. Blake DW; Hogg MN; Hackman CH; Pang J; Bjorksten AR. Royal Melbourne Hospital, Victoria, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Inhalation induction with sevoflurane was compared with propofol or sevoflurane/propofol in 60 unpremedicated adults. Target concentrations for the three groups (with 60% nitrous oxide) were 3% end-tidal sevoflurane, 12 mg/l propofol and 1.5% sevoflurane/6 mg/l propofol respectively, prior to insertion of a laryngeal mask airway (LMA) at 10 minutes. Induction of anaesthesia was satisfactory in each group, but movement response to LMA insertion was observed in 20 patients (least in the sevoflurane group). Cardiovascular responses were similar except for a lower heart rate in the sevoflurane group. EEG bispectral index suggested a greater depth of anaesthesia in the inhalation induction group. A bispectral index of 60 separated patients responding to LMA insertion from nonresponders (P = 0.006), and had a sensitivity of 68% and specificity 70%. Movement response was not predicted by cardiovascular changes.

TITLE: Mortality and light to moderate alcohol consumption after myocardial infarction. Comment in: Lancet 1998 Dec 12; 352(9144):1873. Lancet (England), Dec 12 1998, 352(9144) p1882-5. Muntwyler J; Hennekens CH; Buring JE; Gaziano JM. Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
INTERPRETATION: Men with previous myocardial infarction who consume small to moderate amounts of alcohol have a lower total mortality.

TITLE: Randomised trial of efficacy and safety of inhaled zanamivir in treatment of influenza A and B virus infections. The MIST (Management of Influenza in the Southern Hemisphere Trialists) Study Group Comment in: Lancet 1998 Dec 12; 352(9144):1872-3. Lancet (England), Dec 12 1998, 352(9144) p1877-81
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Influenza affects many people worldwide each year and has many troublesome symptoms. We investigated the efficacy and safety of the inhaled antiviral agent zanamivir as a treatment for influenza A and B infection. METHODS: In a randomised, double-blind, placebo-controlled trial, we recruited 455 patients aged 12 years and older with influenza-like symptoms of 36 h duration or less who lived in Australia, New Zealand, and South Africa. Eligible patients were randomly assigned 10 mg inhaled zanamivir (n=227) or placebo (n=228) twice daily for 5 days. All patients recorded symptoms on diary cards four times daily during treatment and twice daily for 9 days after treatment. We analysed all patients by intention to treat, influenza-positivity, and high risk of developing complications. FINDINGS: Compared with placebo, zanamavir relieved influenza symptoms a median of 1.5 days earlier in the intention-to-treat population (p=0.011), in influenza-positive patients (p=0.004), and in patients who were febrile at entry (p<0.001). In high-risk patients treated with zanamivir, symptoms were alleviated a median of 2.5 days earlier (p=0.048), fewer had complications (p=0.004), and fewer used complication-associated antibiotics (p=0.025) compared with placebo. The adverse event profiles were similar for zanamivir and placebo. INTERPRETATION: Zanamivir was well-tolerated and effective in shortening the duration and severity of influenza symptoms and, in high-risk patients, the rate of complications. Our findings need to be confirmed in future studies because of the small number of patients.
MB. My shares went down when the FDA did not approve it. I knew they always do that with foreign drugs.

TITLE: Treating influenza with zanamivir Comment on: Lancet 1998 Dec 12; 352(9144):1877-81 Lancet (England), Dec 12 1998, 352(9144) p1872-3 Read RC Sheffield University Medical School, and Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, UK.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

TITLE: In-flight incidents [editorial]. Lancet (England), Nov 28 1998, 352(9142) p1719
PUBLICATION TYPE: EDITORIAL

TITLE: Adverse effects of cannabis. Comment in: Lancet 1998 Nov 14; 352(9140):1565. Lancet (England), Nov 14 1998, 352(9140) p1611-6. Hall W; Solowij N. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (50 references); REVIEW, TUTORIAL
ABSTRACT: Cannabis is the most widely used illicit drug in many developed societies. Its health and psychological effects are not well understood and remain the subject of much debate, with opinions on its risks polarised along the lines of proponents' views on what its legal status should be. An unfortunate consequence of this polarisation of opinion has been the absence of any consensus on what health information the medical profession should give to patients who are users or potential users of cannabis. There is conflicting evidence about many of the effects of cannabis use, so we summarise the evidence on the most probable adverse health and psychological consequences of acute and chronic use. This uncertainty, however, should not prevent medical practitioners from advising patients about the most likely ill-effects of their cannabis use. Here we make some suggestions about the advice doctors can give to patients who use, or are contemplating the use, of this drug.

TITLE: Dangerous habits [editorial comment] on: Lancet 1998 Nov 14; 352(9140):1611-6. Lancet (England), Nov 14 1998, 352(9140) p1565
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Making sense of hepatitis C [editorial]. Lancet (England), Nov 7 1998, 352(9139) p1485
PUBLICATION TYPE: EDITORIAL

TITLE: Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet (England), Oct 24 1998, 352(9137) p1347-51. Forette F; Seux ML; Staessen JA; Thijs L; Birkenhager WH; Babarskiene MR; Babeanu S; Bossini A; Gil-Extremera B; Girerd X; Laks T; Lilov E; Moisseyev V; Tuomilehto J; Vanhanen H; Webster J; Yodfat Y; Fagard R. Department of Geriatrics, Hopital Broca, University of Paris V, France. francoise.forette@brc.ap-hop-paris.fr.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: In elderly people with isolated systolic hypertension, antihypertensive treatment was associated with a lower incidence of dementia. If 1000 hypertensive patients were treated with antihypertensive drugs for 5 years 19 cases of dementia might be prevented.

TITLE: Malignant hyperthermia. Lancet (England), Oct 3 1998, 352(9134) p1131-6 Denborough M Division of Biochemistry and Molecular Biology, John Curtin School of Medical Research, Australian National University, Canberra ACT. M.Denborough@anu.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (57 references); REVIEW, TUTORIAL
ABSTRACT: A specific inherited muscle membrane disorder predisposes to a variety of clinical problems. The most common is malignant hyperthermia (MH), a dangerous hypermetabolic state after anaesthesia with suxamethonium and/or volatile halogenated anaesthetic agents. MH may also be triggered in susceptible individuals by severe exercise in hot conditions, infections, neuroleptic drugs, and overheating in infants. Inbred pigs have provided a helpful model, and experiments on these animals and in MH-susceptible patients have shown that the essential biochemical abnormality is an increase in calcium ions in the muscle cells. This knowledge has led to a specific muscle test to identify susceptibility to MH and to a specific treatment, dantrolene; and as a result the case-fatality rate in MH has fallen from 70% in the 1970s to 5% today. In pigs susceptibility to MH is caused by a single mutation in the ryanodine receptor (RYR) in skeletal muscle. In man the genetics is more complex and three clinical myopathies that predispose to MH have been defined. By far the most common is inherited as a mendelian dominant characteristic and at present mutations in the human RYR account for no more than 20% of susceptible families.

TITLE: Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet (England), Oct 3 1998, 352(9134) p1097-102 Kissane DW; Street A; Nitschke P. University of Melbourne Centre for Palliative Care, Kew, Victoria, Australia. dwk@rubens.its.unimelb.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: During the 9 months between July, 1996, and March, 1997, the provision of euthanasia for the terminally ill was legal in the Northern Territory of Australia. Seven patients made formal use of the Rights of the Terminally Ill (ROTI) Act; four died under the Act. We report their clinical details and the decision-making process required by the Act. METHODS: We taped in-depth interviews with the general practitioner who provided euthanasia. Further information was available from public texts created by patients, the media, and the coroner. FINDINGS: All seven patients had cancer, most at advanced stages. Three were socially isolated. Symptoms of depression were common. Having met criteria of the Act, some patients deferred their decision for a time before proceeding with euthanasia. Medical opinions about the terminal nature of illness differed. INTERPRETATION: Provision of opinions about the terminal nature of illness and the mental health of the patient, as required by the ROTI Act, created problematic gatekeeping roles for the doctors involved.

TITLE: Adverse effects of extradural and intrathecal opiates: report of a nationwide survey in Sweden. 1982 [classical article] : Br J Anaesth (England), Jul 1998, 81(1) p86-93; discussion 85 Gustafsson LL; Schildt B; Jacobsen K
PUBLICATION TYPE: BIOGRAPHY; CLASSICAL ARTICLE; HISTORICAL ARTICLE; JOURNAL ARTICLE

TITLE: Factors influencing the arterial oxygen tension during anaesthesia with artificial ventilation. 1965 [classical article] Br J Anaesth (England), Jun 1998, 80(6) p860-76; discussion 858-9 Nunn JF; Bergmann NA; Coleman AJ
PUBLICATION TYPE: BIOGRAPHY; CLASSICAL ARTICLE; HISTORICAL ARTICLE; JOURNAL ARTICLE

TITLE: Haemodynamic responses to extubation after cardiac surgery with and without continued sedation. Br J Anaesth (England), Jun 1998, 80(6) p834-6 Conti J; Smith D Shackleton Department of Anaesthesia, Southampton General Hospital.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We studied the haemodynamic response to cessation of mechanical ventilation and removal of the tracheal tube in 84 patients after coronary artery bypass grafting. Patients were sedated on the ICU with propofol 1-3 mg kg-1 h-1, and randomly allocated to extubation while awake or while still sedated. Systolic and diastolic blood pressures and heart rate increased significantly faster in the awake group as mechanical ventilation was stopped; systolic blood pressure 6.1 (3.0) vs 0.7 (1.8) mm Hg min-1, diastolic blood pressure 2.1 (1.6) vs 0.2 (0.9) mm Hg min-1, heart rate 2.1 (1.7) vs 0.2 (0.5) beats min-2; P < 0.01 in each case. Treatment was required for systolic hypertension during discontinuation of mechanical ventilation in 20 patients (53%) in the awake group and in three patients (7.5%) in the sedated group (P < 0.001). No patient in the sedated group had any new ischaemic ECG changes. Significant new ST segment changes did not occur in the sedated group but were present in five patients in the awake group (P = 0.013), one of whom suffered a perioperative myocardial infarction. Removal of the tracheal tube while patients are still sedated after coronary artery bypass grafting is safe, and reduces the incidences of haemodynamic disturbance and myocardial ischaemia during extubation.

TITLE: Myocardial ischaemia during tracheal extubation in patients after cardiac surgery: an observational study. Br J Anaesth (England), Jun 1998, 80(6) p832-3 Barham NJ; Boomers OW; Sherry KM; Locke TJ Department of Anaesthesia, Northern General Hospital Trust, Sheffield.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: This study examines whether there is a temporal relationship between tracheal extubation and myocardial ischaemia in haemodynamically stable patients extubated within 6 h of cardiac surgery. Fifty-two patients were studied during three time periods: 1, from 2 h until 30 min before extubation (90 min); 2, from 30 min before until 30 min after extubation (60 min); 3, from 30 min until 2 h after extubation (90 min). Significant ST segment changes were defined as a reversible ST segment depression of 2 mm or greater or an elevation of 3 mm or greater from baseline, lasting for 1 min or more. Fourteen patients (26.9%) had ST segment changes. The ischaemic burden in periods 2 and 3 was increased compared with that in period 1; the mean (SD) was: period 1, 19.2 (18.8) min; period 2, 35.4 (24.9) min; period 3, 39.6 (24.5) min; however, the mean ST deviation (mm) did not change. ST segment changes were associated with an increased heart rate; they were not related to arterial pressure. We conclude that there is a temporal relationship between ST segment changes and tracheal extubation after cardiac surgery.

TITLE: Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth (England), Jun 1998, 80(6) p767-75 : Asai T; Koga K; Vaughan RS Department of Anaesthetics and Intensive Care Medicine, University Hospital of Wales, Cardiff.
PUBLICATION TYPE: JOURNAL ARTICLE
We conclude that the incidence of respiratory complications associated with tracheal extubation may be higher than that during tracheal intubation.
MB. They think coughing is a complication.

TITLE: Effect of pre-treatment with intravenous atropine or glycopyrrolate on cardiac arrhythmias during halothane anaesthesia for adenoidectomy in children. Br J Anaesth (England), Jun 1998, 80(6) p756-60 Annila P; Rorarius M; Reinikainen P; Oikkonen M; Baer G University of Tampere, Medical School, Finland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
The use of anticholinergics did not influence the incidence of ventricular arrhythmias during halothane anaesthesia in children. Bradycardia was more common in the placebo group than in the atropine group.

TITLE: Postoperative hypoxaemia: continuous extradural infusion of bupivacaine and morphine vs patient-controlled analgesia with intravenous morphine. Br J Anaesth (England), Jun 1998, 80(6) p742-7 Motamed C; Spencer A; Farhat F; Bourgain JL; Lasser P; Jayr C Departement de Chirurgie, Institut Gustave Roussy, Villejuif, France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
No significant difference was found for patient sedation and satisfaction.

TITLE: Do the pharmacokinetics of vecuronium change during prolonged administration in critically ill patients Br J Anaesth (England), Jun 1998, 80(6) p715-9 Segredo V; Caldwell JE; Wright PM; Sharma ML; Gruenke LD; Miller RD Department of Anesthesia, University of California, San Francisco 94143-0648, USA. ? [Comment in: Br J Anaesth 1998 Jun; 80(6):707-9== PUBLICATION TYPE: JOURNAL ARTICLE
During prolonged administration, vecuronium clearance increased in three and decreased in two patients. This change ranged from a 61% decrease to a 58% increase, and was not linked to any clinical factor. The steady-state volume of distribution (range 368-1765 ml kg-1; median 494 ml kg-1) did not change in any patient during the study. The change in clearance of vecuronium during its prolonged administration in critically ill patients suggests that future studies of neuromuscular blocking drugs in the ICU should take account of their changing pharmacokinetics over the course of administration.

TITLE: Interaction of a subanaesthetic concentration of isoflurane with midazolam: effects on responsiveness, learning and memory [see comments] Br J Anaesth (England), May 1998, 80(5) p581-Ghoneim MM; Block RI; Dhanaraj VJ Department of Anesthesia, College of Medicine, University of Iowa, Iowa City 52242, USA.Comment in: Br J Anaesth 1998 May; 80(5):575-6== PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: There are situations in which "light" anaesthesia combined with neuromuscular block is the only anaesthetic regimen that can be tolerated safely by the patient. Benzodiazepines have hypnotic and specific amnesic effects. Therefore, we have examined the interaction of midazolam with a subanaesthetic dose of isoflurane (0.2% end-expired concentration) in 28 healthy volunteers. Thereafter, 15 subjects received midazolam 0.03 mg kg-1 i.v. and 13 subjects received midazolam 0.06 mg kg-1 in a random, double-blind manner. Word lists were administered and response to commands was tested before and after administration of midazolam. After 1 h of recovery, memory for word lists was tested by word completion, free recall and forced choice recognition tasks. After administration of midazolam, recall and, to a lesser degree, implicit memory were absent. Recognition was also absent after administration of midazolam 0.06 mg kg-1 and at the 3-min and 15-min assessments after administration of midazolam 0.03 mg kg-1. Responsiveness was more frequent with midazolam 0.03 mg kg-1 than with 0.06 mg kg-1 and increased over time. We conclude that a larger dose of midazolam or isoflurane, or both, may be necessary to abolish responsiveness.
MB. Surprise, surprise.

TITLE: Is amnesia for intraoperative events good enough? Br J Anaesth (England), May 1998, 80(5) p575-6 Andrade J; Jones JG
editorial; Comment on: Br J Anaesth 1998 May; 80(5):581-7== PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Convulsions, ataxia and hallucinations following propofol. Acta Anaesthesiol Scand (Denmark), Jul 1998, 42(6) p739-41 Bendiksen A; Larsen LM Department of Anaesthesiology, Vejle Hospital, Denmark.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A 6-year-old fit girl experienced convulsions 44 h after an otherwise uneventful anaesthesia with propofol, alfentanil and nitrous oxide. As an underlying pathology was suspected, the child was kept sedated for 6.5 h for further investigations. During this period she received a continuous infusion of propofol amounting in total to 1600 mg. After having regained consciousness, she was strikingly ataxic and remained so for 5 days. During this period she also experienced two episodes of hallucinations lasting about 2 h. Investigations including lumbar puncture, EEG, cerebral CT and MR scan could not explain the neurological symptoms. She recovered without long-term sequelae.

TITLE: Comparison of spontaneous frontal EMG, EEG power spectrum and bispectral index to monitor propofol drug effect and emergence.
Acta Anaesthesiol Scand (Denmark), Jul 1998, 42(6) p628-36
Struys M; Versichelen L; Mortier E; Ryckaert D; De Mey JC; De Deyne C; Rolly G Department of Anaesthesia, University Hospital of Gent, Belgium.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The BIS might be an accurate measure to monitor depth of anaesthesia and hypnotic drug effect. Other neurophysiologic measures have limited value to monitor depth of anaesthesia and hypnotic drug effect.

TITLE: Managed care for congestive heart failure: influence of payer status on process of care, resource utilization, and short-term outcomes. Am Heart J (United States), Sep 1998, 136(3) p553-61 Philbin EF; Di Salvo TG Heart Failure and Transplantation Center, Massachusetts General Hospital, and Harvard Medical School, Boston, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Though insuring only a small proportion of New Yorkers hospitalized for CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is uncertain and deserves wider prospective study.
558

TITLE: Emotional distress before coronary bypass grafting limits the benefits of surgery. Am Heart J (United States), Sep 1998, 136(3) p510-7Perski A; Feleke E; Anderson G; Samad BA; Westerlund H; Ericsson CG; Rehnqvist N Division of Preventive Medicine, Karolinska Institute, Soder Hospital, Stockholm, Sweden.
CONCLUSIONS: Systematic evaluation and treatment of emotional distress in the candidates for coronary revascularization may be expected to result in more optimal subjective results and a reduction in the number of serious cardiac events after surgery.

TITLE: Reproducibility of the six-minute walking test in patients with chronic congestive heart failure: practical implications. Am J Cardiol (United States), Jun 15 1998, 81(12) p1497-500 Opasich C; Pinna GD; Mazza A; Febo O; Riccardi PG; Capomolla S; Cobelli F; Tavazzi L Department of Biomedical Engineering, S. Maugeri Foundation, Institute of Care and Scientific Research Medical Center of Montescano, Italy.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: This study assesses the reproducibility of the 6-minute walking test in patients with chronic heart failure using 2 different measurement protocols. Practical suggestions for the clinical setting are given.

TITLE: Does the 6-minute walk test predict the prognosis in patients with NYHA class II or III chronic heart failure? Am Heart J (United States), Sep 1998, 136(3) p449-57 Roul G; Germain P; Bareiss P Cardiology Department, Hopitaux Universitaires de Strasbourg, Hopital de Hautepierre, France. COMMENTS: Comment in: Am Heart J 1998 Sep; 136(3):371-2
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: We prospectively evaluated the potential of the 6-minute walk test compared with peak VO2 in predicting outcome of patients with New York Heart Association (NYHA) class II or III heart failure.. CONCLUSIONS: A distance walked in 6 minutes < or =300 m can predict outcome. Moreover, in these cases there is a significant correlation between the 6-minute walk test and peak VO2 demonstrating the potential of this simple procedure as a first-line screening test for this subset of patients.

TITLE: Is 6-minute walk test of value in congestive heart failure? [editorial; comment] Comment on: Am Heart J 1998 Sep; 136(3):449-57: Am Heart J (United States), Sep 1998, 136(3) p371-2 Schaufelberger M; Swedberg K
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Physical examination of venous pressure: a critical review [see comments] COMMENTS: Comment in: Am Heart J 1998 Jul; 136(1):6-9 Am Heart J (United States), Jul 1998, 136(1) p10-8 McGee SR Seattle Veterans Affairs Medical Center, University of Washington, 98108, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (78 references); REVIEW, TUTORIAL
CONCLUSIONS: Clinicians should avoid making decisions about degrees of CVP elevation that are imprecise and difficult to reproduce. Instead, they should determine during physical diagnosis merely whether the CVP is elevated. Until further research is done, the best definition of elevated CVP is that of Sir Thomas Lewis-when the top of the external or internal jugular veins is 3 cm of vertical distance above the sternal angle, the CVP is abnormally high.

TITLE: The jugular veins: knowing enough to look [editorial; comment]
Comment on: Am Heart J 1998 Jul; 136(1):10-8 Am Heart J (United States), Jul 1998, 136(1) p6-9 Economides E; Stevenson LW
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (13 references); REVIEW, TUTORIAL

TITLE: Relative efficacy of medical therapy and revascularization for improving exercise capacity in patients with chronic left ventricular dysfunction. Am Heart J (United States), Jul 1998, 136(1) p57-62
Williams MJ; Luthern L; Blackburn G; Lytle BW; Marwick TH== Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In patients with severe left ventricular dysfunction improvements of exercise capacity are more marked after coronary revascularization than may be obtained after maximization of medical therapy.

TITLE: Low-molecular-weight heparins in non-ST-segment elevation ischemia: the ESSENCE trial. Efficacy and Safety of Subcutaneous Enoxaparin versus intravenous unfractionated heparin, in non-Q-wave Coronary Events. Am J Cardiol (United States), Sep 10 1998, 82(5B) p19L-24L Cohen M; Demers C; Gurfinkel EP; Turpie AG; Fromell GJ; Goodman S; Langer A; Califf RM; Fox KA; Premmereur J; Bigonzi F Division of Cardiology, Allegheny University of the Health Sciences-Hahnemann Division, Philadelphia, Pennsylvania 19102-1192, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Combination antithrombotic therapy with heparin plus aspirin decreases the risk of recurrent ischemic events in patients with acute coronary syndromes without persistent ST-segment elevation. Compared with standard unfractionated heparin, low-molecular-weight heparin (LMWH) has a more predictable antithrombotic effect, is easier to administer, and does not require coagulation monitoring. At 176 hospitals in 3 continents, 3,171 patients with rest unstable angina or non-wave myocardial infarction were randomly assigned to either enoxaparin (a LMWH), 1 mg/kg twice daily subcutaneously, or to continuous intravenous unfractionated heparin, for a minimum of 48 hours to a maximum of 8 days. Trial medication was administered in a double-blind, placebo-controlled fashion. At 14 days, the primary endpoint, the composite risk of death, myocardial infarction, or recurrent angina with electrocardiographic changes or prompting intervention, was significantly lower in patients assigned to enoxaparin compared with heparin (16.6% vs 19.8%; odds ratio [OR] 1.24; 95% confidence interval [CI] 1.04-1.49; p = 0.019). At 30 days, the composite risk of death, myocardial infarction, or recurrent angina remained significantly lower in the enoxaparin group compared with the unfractionated heparin group (19.8% vs 23.3%, OR 1.23; 95% CI 1.0-1.46, p = 0.016). The rate of revascularization procedures at 30 days was also significantly lower in patients assigned to enoxaparin (27.1% vs 32.2%, p = 0.001). The 30-day incidence of major bleeding complication was 6.5% versus 7.0% (p = not significant), but the incidence of minor bleeding was significantly higher in the enoxaparin group (13.8% vs 8.8%, p <0.001) due primarily to injection-site ecchymosis. Thus, combination antithrombotic therapy with enoxaparin plus aspirin is more effective than unfractionated heparin plus aspirin in decreasing ischemic outcomes in patients with unstable angina or non-Q-wave myocardial infarction in the early (30 days) phase. The lower recurrent ischemic event rate seen with the LMWH, enoxaparin, is achieved without an increase in major bleeding, but with an increase in minor bleeding complications due mainly to injection-site ecchymosis.

TITLE: Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (The second National Registry of Myocardial Infarction). Am J Cardiol (United States), Aug 1 1998, 82(3) p259-64 Goldberg RJ; Mooradd M; Gurwitz JH; Rogers WJ; French WJ; Barron HV; Gore JM
Department of Medicine, University of Massachusetts Medical School, Worcester 01655, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: This study examines the association between time to treatment with thrombolytic therapy and hospital outcomes in patients with acute myocardial infarction (AMI) enrolled in a national registry. A total of 71,253 patients hospitalized with AMI from June 1994 to July 1996 who received tissue plasminogen activator (t-PA) therapy in 1,474 United States hospitals were studied. In this study sample, approximately 39% of patients presented to participating hospitals within 2 hours of acute symptom onset and received t-PA; 36% were treated within 2.1 to 4 hours, 12% between 4.1 to 6 hours, and the remaining 13% thereafter. After controlling for potentially confounding factors, in-hospital death rates increased progressively with increasing delays in time of administration of t-PA. The lowest risk for dying during acute hospitalization was seen for those treated with t-PA within 2 hours of acute symptoms. No significant association was seen between time of administration of t-PA and in-hospital risk of recurrent AMI, myocardial ischemia, cardiogenic shock, major bleeding episodes, or stroke and/or intracranial bleeding. The incidence of sustained ventricular arrhythmias declined with progressively longer time to administration of t-PA. The results of this multihospital observational study suggest that patients with AMI treated earlier with t-PA are significantly more likely to survive the acute hospitalization than patients treated later. These data reinforce the benefits to be gained by treatment with t-PA as soon as possible following the onset of acute ischemic symptoms, and for community-wide efforts to reduce the duration of prehospital delay in patients with acute coronary disease.

TITLE: Effect of intravenous procainamide on direct-current cardioversion of atrial fibrillation.
Am J Cardiol (United States), Jul 15 1998, 82(2) p241-2 Jacobs LO; Andrews TC; Pederson DN; Donovan DJ : Department of Cardiology/Division of Medicine, Wilford Hall Medical Center, Lackland Air Force Base, Texas, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL

TITLE: Eugene Braunwald, MD: a conversation with the editor [interview by William Clifford Roberts] : Am J Cardiol (United States), Jul 1 1998, 82(1) p93-108 Braunwald E
PUBLICATION TYPE: INTERVIEW

TITLE: Validation of death certificate diagnosis of out-of-hospital sudden cardiac death. Am J Cardiol (United States), Jul 1 1998, 82(1) p50-3 Iribarren C; Crow RS; Hannan PJ; Jacobs DR Jr; Luepker RV Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The validity of death certificate diagnosis of out-of-hospital sudden cardiac death (OOH-SCD) was studied among 108,676 30- to 74-year-old residents in 5 Minnesota communities using 6-year mortality data (1985 to 1990). Among 4,244 total deaths, location of death was listed on the certificate as out of hospital in 2,035 cases. Of those, 911 were judged not to have OOH-SCD because they had actually been admitted to the hospital or were noncardiovascular deaths. Among the remaining 1,124, 254 were diagnosed as OOH-SCD using a thorough, physician-based procedure that used clinical records, autopsy reports, and an informant (next-of-kin) interview. We used only death certificate information to define OOH-SCD simply and inexpensively as ICD-9 code 427.5 (cardiac arrest) plus location of death listed as out-of-hospital. Compared with the physician diagnosis, sensitivity was only 24%, whereas specificity was 85%. When the definition of OOH-SCD was expanded to include ICD codes 410-414 (acute myocardial infarction and chronic coronary artery disease), sensitivity improved to 87%, whereas specificity became 66%. However, even with this higher sensitivity and specificity, only 27% of the cases labeled OOH-SCD by death certificate agreed with the physician diagnosis. Death certificate diagnosis of OOH-SCD included many erroneous cases, and may not have been suitable for study of etiologic factors, such as cardiac dysrhythmias. Death certificate diagnosis may be useful to assess population time trends in OOH-SCD, provided that misclassification (false-positive rate) remains constant over time.

TITLE: Twenty-two-year follow-up in the VA Cooperative Study of Coronary Artery Bypass Surgery for Stable Angina. Am J Cardiol (United States), Jun 15 1998, 81(12) p1393-9 Peduzzi P; Kamina A; Detre K Department of Veterans Affairs Cooperative Studies Program Coordinating Center, Veterans Affairs Connecticut Healthcare System, West Haven 06516, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We evaluated the 22-year results of initial coronary artery by pass surgery with saphenous vein grafts compared with initial medical therapy on survival, incidence of myocardial infarction, reoperation, and symptomatic status in 686 patients (average age 51) with stable angina in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery. Between 1972 and 1974, 354 patients were assigned to medical treatment and 332 to surgical revascularization. In the surgical cohort, 312 patients underwent operation (operative mortality 5.8%) and 25% subsequently underwent repeat operation (operative mortality 10.3%). In the medical cohort, 160 patients crossed over to surgery (operative mortality 4.4%) and 21% of these patients had reoperation (operative mortality 9.1%). Neither crossover nor reoperation was predictable by angiographic or clinical risk factors measured at baseline. The overall 22-year cumulative survival rates were 25% and 20% in the medical and surgical cohorts (p = 0.24). Corresponding rates in low-risk patients who had 1 or 2 vessels diseased, or 3 vessels diseased with normal left ventricular function were 31% and 24% (p = 0.024). Although significant at 10 years, there was also no long-term survival benefit for high-risk patients assigned to bypass surgery. The probabilities of remaining free of myocardial infarction and of being alive without infarction were significantly higher with initial medical therapy, 57% versus 41% (p = 0.02) and 18% versus 11% (p = 0.0031), respectively. This trial provides strong evidence that initial bypass surgery did not improve survival for low-risk patients, and that it did not reduce the overall risk of myocardial infarction. Although there was an early survival benefit with surgery in high-risk patients (up to a decade), long-term survival rates became comparable in both treatment groups. In total, there were twice as many bypass procedures performed in the group assigned to surgery without any long-term survival or symptomatic benefit.
MB, The results don’t seem to have changed since their earlier report.

TITLE: Effects of ergotamine on myocardial blood flow in migraineurs without evidence of atherosclerotic coronary artery disease.
Am J Cardiol (United States), May 1 1998, 81(9) p1165-8 Gnecchi-Ruscone T; Lorenzoni R; Anderson D; Legg N; Tousoulis D; Winter PD; Crisp A; Camici PG MRC Cyclotron Unit, Imperial College School of Medicine, Hammersmith Hospital, London, United Kingdom.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: The effects of intravenous ergotamine (0.25 mg) on basal and hyperemic (dipyridamole) myocardial blood flow (MBF), measured with positron emission tomography and H2(15)O, were assessed in 15 migraineurs in a double-blind, randomized, placebo controlled, crossover study. Ergotamine produced a 27% reduction in hyperemic MBF (2.62 +/- 0.11 vs 3.72 +/- 1.05 ml x min(-1) x g(-1); p 0.05), a 31% reduction in the coronary vasodilator reserve (1.81 +/- 0.50 vs 2.71 +/- 1.15; p 0.01), and a 55% increase in minimal coronary resistance (42.2 +/- 15 vs 26.7 +/- 8 mm Hg x min x ml(-1) x g(-1); p 0.001), suggesting vasoconstriction of the coronary microcirculation.

TITLE: Guidelines for approval of anti-obesity drugs affecting atherosclerosis and/or lipids. The international union of pharmacology (IUPHAR). Am J Cardiol (United States), Apr 23 1998, 81(8A) p29F-30F Anderson JW Metabolic Research Group, Veterans Affairs Medical Center and University of Kentucky, Lexington, USA.
PUBLICATION TYPE: GUIDELINE; JOURNAL ARTICLE; REVIEW (10 references); REVIEW, TUTORIAL

TITLE: The worth of controlling plasma lipids [editorial; comment]Comment on: Am J Cardiol 1998 Apr 15; 81(8):1045-6 Am J Cardiol (United States), Apr 15 1998, 81(8) p1047-9 Kannel WB
PUBLICATION TYPE: COMMENT; EDITORIAL
ABSTRACT: The worth of controlling plasma lipids is well established; clearly, it is better to prevent atherosclerosis than wait to treatit after it has reached an advanced stage.

TITLE: Influence of myocardial infarction, coronary artery bypass surgery, and stroke on cognitive impairment in late life.: Am J Cardiol (United States), Apr 15 1998, 81(8) p1017-21 Petrovitch H; White L; Masaki KH; Ross GW; Abbott RD; Rodriguez BL; Lu G; Burchfiel CM; Blanchette PL; Curb JD Honolulu-Asia Aging Study and Honolulu Heart Program, Kuakini Medical Center, Hawaii 96813, USA. .
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Relations between cognitive test scores in later life and prior myocardial infarction (MI), coronary artery bypass graft surgery (CABG), and stroke were examined for this study. Subjects were 3,734 Japanese-American men (80% of surviving Honolulu Heart Program cohort) aged 71 to 93 years at the time of cognitive testing. Impairment was defined as scoring below the 16th percentile on a validated cognitive assessment scale. Prior MI, stroke, and CABG were established using hospital surveillance, history, and record review. After adjustment for age, years of education, and years of childhood spent in Japan, men with prior stroke were significantly more likely than others to have poor cognitive performance (odds ratio 4.4, 95% confidence limits 3.0 to 6.7). History of 1 stroke was associated with an odds ratio of 50 (95% confidence limits 10.5 to 238.3). There was no significant association between cognitive performance and or = 1 prior MI or history of CABG. Time between events and cognitive function testing did not affect results. Analyses support a significant association between clinical stroke and persistent cognitive impairment, but fail to implicate CABG or MI.

TITLE: Combined carotid endarterectomy and coronary artery bypass grafting in asymptomatic carotid artery stenosis. Am Surg (United States), Oct 1998, 64(10) p993-7 ): Terramani TT; Rowe VL; Hood DB; Eton D; Nuno IN; Yu H; Yellin AE; Starnes VA; Weaver FA
Department of Surgery, University of Southern California School of Medicine, Los Angeles 90033, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (14 references); REVIEW, TUTORIAL
This study demonstrates the safety of combined CEA/CABG for coexistent coronary and asymptomatic carotid disease. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.

TITLE: Treatment of hepatocellular carcinoma associated with cirrhosis in the era of liver transplantation. Ann Intern Med (United States), Oct 15 1998, 129(8) p643-53 Mor E; Kaspa RT; Sheiner P; Schwartz M Rabin Medical Center, Petah-Tikva, Israel. eytanmor@mail.netvision.net.il.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (94 references); REVIEW, TUTORIAL
CONCLUSIONS: The efficacy of liver transplantation for hepatocellular carcinoma has been proven mainly in patients with advanced cirrhosis and small lesions. Future studies may clarify the role of approaches combining neoadjuvant chemotherapy with transplantation for large (stage III) tumors.

TITLE: Cumulative epinephrine dose during cardiopulmonary resuscitation and neurologic outcome. Comment in: Ann Intern Med 1998 Sep 15; 129(6):501-2 : Ann Intern Med (United States), Sep 15 1998, 129(6) p450-6 Behringer W; Kittler H; Sterz F; Domanovits H; Schoerkhuber W; Holzer M; Mullner M; Laggner AN University of Vienna Medical School, Austria.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The results indicate that an increasing cumulative dose of epinephrine administered during resuscitation is independently associated with unfavorable neurologic outcome after ventricular fibrillation cardiac arrest.

TITLE: The next chapter in the high-dose epinephrine story: unfavorable neurologic outcomes? Comment on: Ann Intern Med 1998 Sep 15; 129(6):450-6 Ann Intern Med (United States), Sep 15 1998, 129(6) p501-2 Cummins RO; Hazinski MF
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Opening the black box: how do physicians communicate about advance directives? : Ann Intern Med (United States), Sep 15 1998, 129(6) p441-9 Tulsky JA; Fischer GS; Rose MR; Arnold RM Durham Veterans Affairs Medical Center and Duke University, North Carolina 27705, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.

TITLE: Near-fatal heat stroke during the 1995 heat wave in Chicago. Ann Intern Med (United States), Aug 1 1998, 129(3) p173-81 Dematte JE; O'Mara K; Buescher J; Whitney CG; Forsythe S; McNamee T; Adiga RB; Ndukwu IM Michael Reese Hospital and Medical Center, University of Illinois at Chicago, 60521, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Near-fatal classic heat stroke is associated with multiorgan dysfunction. A high percentage of patients had infection at presentation. A high mortality rate was observed during acute hospitalization and at 1 year. In addition, substantial functional impairment at discharge persisted 1 year. The degree of functional disability correlated highly with survival at 1 year.

TITLE: Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg (United States), Sep 1998, 228(3) p429-38 Sosa JA; Bowman HM; Gordon TA; Bass EB; Yeo CJ; Lillemoe KD; Pitt HA; Tielsch JM; Cameron JL Department of Surgery, Robert Wood Johnson Clinical Scholars Program, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205-2196, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.

TITLE: Long-term results of pediatric liver transplantation: an analysis of 569 transplants. : Ann Surg (United States), Sep 1998, 228(3) p411-20 Goss JA; Shackleton CR; McDiarmid SV; Maggard M; Swenson K; Seu P; Vargas J; Martin M; Ament M; Brill J; Harrison R; Busuttil RW Dumont-UCLA Transplant Center, Department of Surgery, UCLA School of Medicine, Los Angeles, California 90095, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Liver transplantation in the pediatric patient is a durable procedure that provides excellent long-term survival. Although there have been overall improvements in patient outcome with increased experience, the effect is most pronounced for patients younger than 1 year of age. Retransplantation, although effective in a meaningful number of patients, continues to carry a progressive decrement in survival with the number of allografts performed. Use of living-related and in situ split-liver allografts has dramatically reduced waiting times for small children and has improved patient survival.

TITLE: Complications in 100 living-liver donors. Ann Surg (United States), Aug 1998, 228(2) p214-9 Grewal HP; Thistlewaite JR Jr; Loss GE; Fisher JS; Cronin DC; Siegel CT; Newell KA; Bruce DS; Woodle ES; Brady L; Kelly S; Boone P; Oswald K; Millis JM Section of Transplantation, University of Chicago, Illinois 60637, USA.
CONCLUSIONS: Although the procedure is safe, many LDLT donors have a perisurgical complication. Surgical experience and technical modifications have resulted in a significant reduction in these complications, however. To minimize the risks for these healthy donors, LDLT should be performed at institutions with extensive experience.

TITLE: Split-liver transplantation. Br J Surg (England), Jul 1998, 85(7) p881-3 Rela M; Heaton ND Institute of Liver Studies, King's College Hospital, London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE

TITLE: Internal bioartificial liver with xenogeneic hepatocytes prevents death from acute liver failure: an experimental study.Comment in: Ann Surg 1998 Jul; 228(1):14-5 Ann Surg (United States), Jul 1998, 228(1) p1-7 Roger V; Balladur P; Honiger J; Baudrimont M; Delelo R; Robert A; Calmus Y; Capeau J; Nordlinger B Research Unit 402 of INSERM, the Department of Surgery, Hospital Saint-Antoine, Paris, France.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The implantable bioartificial liver was able to prevent death in this model of acute liver failure. This could be an important step toward clinical application of the method.

TITLE: Support of the acutely failing liver: state of the art: Comment on: Ann Surg 1998 Jul; 228(1):1-7; Comment on: Ann Surg 1998 Jul; 228(1):8-13 : Ann Surg (United States), Jul 1998, 228(1) p14-5
Demetriou AA
PUBLICATION TYPE: COMMENT; EDITORIAL

TITLE: Early experience with day-case transthoracic endoscopic sympathectomy. Br J Surg (England), Sep 1998, 85(9) p1266 Grabham JA; Raitt D; Barrie WW The Minimal Access Surgery Trent Training Centre, Leicester General Hospital, UK.
PUBLICATION TYPE: JOURNAL ARTICLE

TITLE: Central venous pressure and its effect on blood loss during liver resection. Br J Surg (England), Aug 1998, 85(8) p1058-60 Jones RM; Moulton CE; Hardy KJ University of Melbourne Department of Surgery, Victoria, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Any strategy to reduce blood loss in liver resection and decrease blood transfusion would be of benefit to the patient and surgeon. This study evaluates the association of central venous pressure (CVP) with blood loss and blood transfusion during liver resection. METHODS: One hundred consecutive hepatic resections in the period 1986-1996 were studied prospectively concerning CVP, volume of blood lost, and volume of blood transfused. Blood loss volume and blood transfusion were analysed for those with a CVP less than or equal to 5 cmH2O, and greater than 5 cmH2O. A multivariate analysis assessed potential confounding factors in the comparison. RESULTS: The median blood loss in patients with a CVP of 5 cmH2O or less was 200 ml (n=40) and that in those with a CVP above 5 cmH2O was 1000 ml (n=52) (P=0.0001). Only two of 40 patients with a CVP of 5 cmH2O or less had a blood transfusion whereas 25 of 52 patients with a CVP greater than 5 cmH2O required a transfusion (P=0.0008). A multivariate analysis did not show confounding factors. CONCLUSION: The volume of blood lost during liver resection correlates with the CVP. Lowering the CVP to less than 5 cmH2O is a simple and effective way to reduce blood loss during liver surgery.
MB. Low CVP increases risk of air embolus. We have had a death due to that.

TITLE: Dose-related cardiovascular and endocrine effects of transdermal nicotine. Clin Pharmacol Ther (United States), Jul 1998, 64(1) p87-95 Zevin S; Jacob P 3rd; Benowitz NL Division of Clinical Pharmacology and Experimental Therapeutics, San Francisco General Hospital Medical Center, CA, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Transdermal nicotine in doses up to 21 mg/24 hr is used to facilitate smoking cessation. However, this dose does not achieve the nicotine plasma levels seen among heavy smokers, and underdosing may be one of the reasons for the limited efficacy of transdermal nicotine. There are some concerns about the adverse cardiovascular effects of nicotine, especially with concomitant smoking. Treatment with higher doses of transdermal nicotine has been proposed for highly dependent smokers, but the effects of such treatment on the cardiovascular system have not been determined. The objective of this study was to determine the cardiovascular effects of high-dose transdermal nicotine with concomitant smoking. METHODS: Twelve healthy male smokers received three doses of transdermal nicotine (21, 42, and 63 mg/24 hr) and placebo, each for 5 days, in a balanced order. The subjects smoked during the first 4 days of each treatment and abstained from smoking during the fifth day. Ambulatory 24-hour daytime and nighttime heart rate and blood pressure values were determined for each treatment; plasma nicotine, cotinine, and carboxyhemoglobin levels and urinary catecholamines with aldosterone were measured on days 4 and 5. The data were compared by means of repeated-measures ANOVA. RESULTS: There was no difference in heart rate or blood pressure and no changes in the pattern of circadian variations with various transdermal nicotine doses compared with smoking alone, consistent with the development of tolerance. Urinary epinephrine level was significantly higher (p 0.05) with transdermal nicotine compared with no nicotine but was not higher with transdermal nicotine and smoking compared with smoking alone. No change was found in fibrinogen and lipid profiles with different nicotine doses. CONCLUSIONS: High-dose nicotine treatment, even with concomitant smoking, caused no short-term adverse effects on the cardiovascular system.

TITLE: Intermittent dobutamine treatment in patients with chronic refractory congestive heart failure: a randomized, double-blind, placebo-controlled study.: Clin Pharmacol Ther (United States), Jun 1998, 63(6) p682-5 Elis A; Bental T; Kimchi O; Ravid M; Lishner M
Department of Medicine, Meir Hospital, Kfar-Saba, Israel.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Intermittent dobutamine infusions in patients with refractory CHF have no effect on the need for hospitalization or on survival.