[Cryptosporidium parvum and Giardia lamblia--incidence in surface and drinking water--significance and detection]. Cryptosporidium parvum and Giardia lamblia are protozoan parasites which can cause gastroenteritis in man and animal. Surface water and drinking-water play an important role in transmission of the disease. The parasites can be detected by extensive and time-consuming procedures only. In this paper we describe a new way to isolate C. parvum and G. lamblia from water by a modification of essential steps of the original method of Rose. The new method applies the separation by flow centrifugation, the purification by different filters and the parasite isolation by percoll density gradient centrifugation. The modified method allows reproducible and by 20% increased recovery rates of cysts. Due to this fast and easy technique this procedure can be integrated in routine examinations.


[Data protection and data access (I): federal data protection law and the social welfare code with reference to carrying out occupational medicine epidemiologic studies in Germany]. The regulations applicable to research in occupational epidemiology are the federal data protection (confidentiality) law (BDSG), the social welfare code (SGB), medical professional secrecy regulations and the federal statistics law (BStatG). The SGB, medical professional secrecy, and BStatG codes take precedence over BDSG rulings. This paper discusses BDSG and SGB. Medical professional secrecy and BStatG will be the topic of another publication (Datenschutz and Datenzugang II). The BDSG permits processing and utilization of personal data only if 1. this is permitted by BDSG or a law with higher priority, or 2. if the individual concerned has given her or his informed consent. According to the BDSG private research institutes can have access to personal data collected within non-public institutions only via section 28 (2) without consent of the individual. The "research paragraph" section 40 governs the processing and utilisation of personal data by research institutions. As a rule, the SGB permits access to epidemiological data sources only with the informed consent of the individuals concerned. The exception is section 75 SGBX. This paragraph permits disclosure of personal data without the individual's consent by the relevant public institution only if public interest considerably outweighs the private concerns. To our knowledge, however, this clause has had no practical significance. The concept of "informed consent" is discussed in detail, including the requirements for a legal form for informed consent. The legal codes of the BDSG, professional secrecy, and BStatG permit the transfer of personal data if the individuals concerned remain anonymous. This paper deals in detail with the concept of "anonymity".(ABSTRACT TRUNCATED AT 250 WORDS)


[Drug-assisted treatment of substance dependence (Drug and Alcohol Symposium, Basel 1992)]. The report on the symposium is an interim account of the treatment of drug addiction in Switzerland. The spread of drugs could not be halted by prohibition. The ideal of a drug-free society does not seem to be translatable into reality. Hence, it is unrealistic to set up continence or sobriety as a goal in the treatment of all addicts, for a proportion of drug dependents or addicts is bypassed or not addressed at all. New approaches based on pharmaceuticals an assisting medication, combined with a diversified allocation of drugs, are under discussion.


[Social medicine aspects of persistent somatoform pain disorder]. Persistent somatoform pain disorder is a mental disease the symptom of which--namely, physical pain--cannot be satisfactorily explained by physical findings. This is a frequently occurring disease. But it is often not identified or at least not recognised at an early stage. This leads to negative effects on the patient (e.g. chronification) and on the national social welfare system (for example, costs can mount up to thousands of million DM for medical and social welfare measures). To reduce these problems as far as possible, it is imperative to recognise the disease at an early stage. In particular, those doctors who are mainly engaged in the medical treatment of organs must be familiar with the possibility of functional pain arising from psychic factors, and they must be able to identify it in individual cases, at least as a tentative diagnosis.


[Courses in health education as interventions in industry]. Following a brief overview of approaches to workplace health promotion and more specifically of health education courses the paper describes the objectives, contents and methods of a new health course for workers at elevated health risk. This course was developed as part of a comprehensive workplace intervention programme. It comprises three consecutive modules, coping with stress, nutrition, and fitness, each consisting of five 75-minute lessons. Due to intervals of several months between the modules the whole course takes about a year. Course objectives are to improve awareness of own health-related life-style, to mobilise health resources and to develop potentials for health action. Instructional methods include teaching of relevant knowledge, exchange of experience, observational tasks as well as practical exercises.


[Secondary data analysis within the scope of occupational medicine epidemiology]. The analysis of large administrative data sets plays an important rôle in occupational epidemiology in Germany. In this article, examples of such data sets and their use in epidemiologic investigations are presented. The validity of administrative data is discussed.


[Basic requirements of documentation in school preadmission examination]. Health screening, health counselling, promotion of pupils and health reporting are the principal marks of school doctor's precautionary health care examinations. The appropriate documentation form must meet the basic requirements of the pupil, of the medical officer and of the evaluation programme. The general concept is realized in three steps: first, definition of the contents, second, operationalisation of the individual items and third, the definition of conventional documenting.


[Legionella and other bacteria in air humidifiers and cooling systems of air conditioning units--a survey]. Air humidifiers using cold water and cooling towers of air-conditioning systems provide the best settings for the growth of bacteria. Hence, we investigated 90 water samples for humidifiers and 15 water samples from cooling towers of hospitals, authorities, schools, and factories. The colony forming units/ml at 20 degrees C and 36 degrees C, the biological activity of added biocidal substances, and the occurrence of legionella were determined. About 90 percent of the samples showed no activity of the biocidal substance added, suggesting the uselessness of such substances. Furthermore, they exercised neither an influence on the CFU of the water samples nor on the occurrence of legionella. Legionella were isolated in 7 per cent of the humidifiers investigated, in 3 per cent of air conditioned buildings, respectively. 13 per cent of the cooling towers contained legionella. The risk of infection by air conditioning systems, humidifiers, cooling towers, and other emitters of infections agents should be controlled by the public health service.


[Toxic adverse effects of oxygen therapy in patients with chronic obstructive bronchitis]. Seventy-eight patients aged 16-78 (48 males and 30 females) in whom COB ran with respiratory insufficiency stage II and III (51 and 27 patients, respectively) and cor pulmonale stage II-A, II-B and III (28, 26 and 8 patients, respectively) received normal-pressure oxygen for 10 min. Posttreatment examinations were performed for pulmonary function, acid and alkaline reactions, oxygen metabolism and blood flow rate. The frequency and intensity of PaCO2 rise in COB patients on oxygen therapy are shown to correlate with severity of restrictive respiratory insufficiency (RRI) and hypoxemia, to relate to reduced capacity of oxygenated hemoglobin for CO2 transport, being independent of the lost hypoxemic stimulus on the respiratory center. Elevated PaCO2 in COB patients on oxygen therapy is not a contraindication to its administration, though dictates its short duration (10-15 min 1-2 times an hour). Complete intolerance to oxygen therapy arose in 5.1% of the COB patients with manifest RRI (VC of due VC being 21.1 +/- 4.13%) and hypoxemia (% HBO2 being 52.6 +/- 8.01%). In effective treatment these patients diminished RRI and restored tolerance to oxygen therapy.


[Zinc metabolism in duodenal ulcer].

[Zinc metabolism in duodenal ulcer]. Zinc concentrations were measured in blood and gastroduodenal mucosa of patients with duodenal ulcer in remission and exacerbation. These were found reduced in plasma but elevated in gastroduodenal mucosa. Healing of the ulcer lesion was associated with positive shifts in zinc metabolism which recovered normal values in ulcer remission. It is concluded that plasma and gastroduodenal levels of zinc reflect the stage of the pathological process in peptic ulcer.


[The use of CO2-laser and blood loss during mastectomy]. The problem of radical treatment of breast cancer which largely contributes nowadays to overall cancer incidence in female population is far from being solved. In view of the significance of surgical treatment of breast cancer, the study was initiated to clear up relations between blood loss and kind of surgery. Three groups of patients were assessed for blood loss: subjected to standard mastectomy, modified mastectomy and mastectomy with application of CO2-laser. The blood loss reached 351.2 +/- 11.2 ml, 303.0 +/- 10.8 ml and 155.0 +/- 12.4 ml, respectively. The results evidence the advantage of CO2-laser application in mastectomy in respect to reducing blood loss.


[Specific IgE antibodies in brucellosis]. Specific IgE antibodies and sensitization were assessed in patients with brucellosis in various forms. IgE antibodies were determined with enzyme immunoassay which demonstrated high specificity and sensitivity with conjugate against IgE antibodies in 509 serum samples. Specific IgE antibodies were present in most patients with acute, subacute or chronic brucellosis. Their synthesis seems to be a normal component of humoral immunity in response to brucellosis agent invasion. Allergy in brucellosis seems to arise without participation of the IgE antibodies as there is no correlation between the antibodies levels, the response to Burnet's allergic test and specific leukocytolysis activity.


[T-cell immunity and immunomodulators in the comprehensive treatment of diffuse toxic goiter]. Age-specific and related to DTG severity lowering of T-lymphocyte count, active and autologous T-lymphocyte number, thymic serum activity were found in 83 DTG patients. These shifts made justified the use of immunomodulator tactivin in 32 DTG patients. The drug was administered in daily subcutaneous doses (1 ml of 0.01% solution) for 5 days. As a result, the T-cell immunity returned to normal values. The highest response occurred in young subjects with moderate hyperthyroidism. Because a single tactivin course failed to bring up a persistent effect, repeat courses are needed to achieve good clinical and immunologic responses.


[In vivo analysis of the morphofunctional state of myocardial blood supply in ischemic heart disease]. The patency of coronary arteries and morphofunctional features of myocardial microhemocirculation were studied in 40 males with coronary heart disease (CHD) aged 36-59 using intravital coronary angiography, intraoperative left ventricular biopsies assessed electron-microscopically and by semithin sections. In spite of various impairment of the coronary arteries, there was similar clinical presentation. It was found that in addition to atherosclerosis stenosing the main subepicardial vessels in CHD, there appeared a peripheral barrier for the tissue circulation with defective permeability of the myocardial microvessels. Intramyocardial vascular disorders were characterized by noticeable changes in blood rheology, reactivity of resistive vessels and angiosclerosis. The role of multifactor endothelial deformities rose significantly as well as of extravasal compression of the microvessels in interstitial edema and sclerosis, in affected cardiomyocytes. Moreover, the permeability of the histohematic barrier came to be destroyed. The above changes can be considered as reversible, irreversible and amenable to correction. The findings led the investigators to the conclusion on a role of the dysfunction of the intramyo cardial vascular bed as an essential mechanism of CHD pathogenesis responsible for realization of the functional factors.


Mixed-bed polymeric o-nitrobenzophenone reagents for the on-line derivatization of amines in high performance liquid chromatography. Several polymer-bound o-nitrobenzophenone reagents containing different detector-sensitive tags have been combined in the same reactor for the on-line derivatization of amine samples. The formation of multiple derivatives allows numerous opportunities for quantitation from the same injection, and also allows improved identification from the retention times of the multiple derivatives. Changing the reaction conditions changes the ratio of the products formed, so that changes in the ratio of peak heights and areas can also be used for analyte identification. In this work, propylamine was derivatized in acetonitrile on-line, precolumn. Changing the reaction conditions, of reaction time, temperature, solvent, presence of catalyst and the components of the reactor, changed the ratio of the derivatives formed. These changes in product formation with changing reaction conditions were applied to the identification and quantitation of amphetamine and methamphetamine in urine. The drugs were identified by the retention times of their derivatives, the ratio of the peak areas of the derivatives and the change in the ratios after changing reaction conditions. Each derivative was also used for quantitation of levels of spiked concentrations of amphetamine and methamphetamine, with relative errors less than 8%.


An automated method for the determination of a new potential antiepileptic agent (CGP 33101) in human plasma using high performance liquid chromatography. An automated analytical method utilizing laboratory robotics has been developed and validated for quantifying concentrations of a new antiepileptic drug candidate (CGP 33101) in human plasma. The robotic system aliquots the biological sample, adds the internal standard (CGP 23901) and pH 12 buffer, extracts the compounds from the basified matrix into an organic phase (methyl-t-butyl ether:dichloromethane, 2:1) and concentrates the extracts for reversed-phase, high performance liquid chromatographic (HPLC) analysis. The robotic system is directly interfaced with the HPLC system. Separation is achieved on a Hypersil 3 microns C18 column (4.6 x 50 mm) with ultraviolet detection of the analytes at 230 nm. Specificity was demonstrated by the lack of interfering peaks at the retention times for both the drug and internal standard. Recovery and reproducibility assessments indicated good accuracy (overall mean relative recovery of 102.7%) and precision (coefficient of variation of 4.4 to 7.7%) for CGP 33101 over the concentration range of 50-4000 ng/mL. The limit of quantification (LOQ) is 50 ng/mL. The method has been successfully applied to a clinical study in which normal volunteers received single oral doses of 400-1200 mg of this new drug candidate.


A selective HPLC/RIA for dexamethasone and its prodrug dexamethasone-21-sulphobenzoate sodium in biological fluids. A combined high performance liquid chromatography/radioimmunoassay procedure is described for the simultaneous determination of dexamethasone (DEX) and its prodrug dexamethasone-21-sulphobenzoate sodium (DSS) in plasma. After precipitation of the plasma proteins by acetonitrile, the protein-free supernatant was injected onto a C18 reversed phase liquid chromatographic system and DSS- and DEX-containing fractions were collected. Hydrolysis of DSS by 0.01 N NaOH, followed by fractions extraction of both hydrolysed DSS and DEX fractions with ethyl acetate allowed the use of a dexamethasone-specific radioimmunoassay for the selective determination of both compounds. The method is accurate and reproducible (intraday variability for DSS and DEX < 6%, interday variability for DEX 14%), allowing quantification of DEX and DSS as low as 0.3 ng/mL and 0.7 ng/mL, respectively.


Measurement of recombinant interferon levels by high performance immunoaffinity chromatography in body fluids of cancer patients on interferon therapy. The technique of high performance immunoaffinity chromatography was used to measure the levels of recombinant interferon in chronic lymphocytic leukaemia patients enrolled in a phase II recombinant interferon clinical trial. The technique employed a short high pressure chromatography column packed with minute glass beads which had monoclonal antibody, directed against recombinant alpha interferon, immobilized to their surface. This system was used to measure interferon levels in a variety of different human body fluids. A good correlation was found when interferon levels, detected by chromatographic separation, were compared to levels obtained by a conventional radioimmunoassay.


A high performance liquid chromatographic method for the determination of albuterol enantiomers in human serum using solid phase extraction and chemical derivatization. A high performance liquid chromatographic method was developed for the simultaneous assay of R(-)- and S(+)-albuterol in human serum. The assay involves solid phase extraction as a sample clean-up step and derivatization of racemic albuterol to its diastereomeric thioureas with 2,3,4,6-tetra-O-acetyl-alpha-D-glucopyranosyl isothiocyanate. Chromatographic separation was accomplished under isocratic conditions using an octadecylsilane column and a mobile phase consisting of 29:71 acetonitrile:distilled water containing 0.1% triethylamine, pH 4.0 (adjusted with concentrated phosphoric acid) at a flow rate of 0.8 mL/min. The diastereomers were detected using a fluorescence detector set at 223 nm excitation and no emission filter. Racemic bamethane was used as internal standard. Drug to internal standard peak-height ratios were linear over a 2-20 ng/mL range for each enantiomer. The limit of detection of each analyte was 1.0 ng/mL (S/N = 3).


Determination of MDL 201,012 at femtomole/millilitre levels in human plasma by liquid chromatography with electrochemical detection. A sensitive and selective liquid chromatographic method to quantitate MDL 201,012 in human plasma was developed and validated. MDL 201,012 (I), diethyl-MDL 201,012 (internal standard, II) and desmethyldiol-MDL 201,012 (masking agent, III) were isolated from basified plasma (2 mL) by solid phase extraction using Bond-Elut C-18 cartridges. Endogenous components were selectively removed prior to eluting the analytes from the sorbent. Components were separated using on-line LC column switching with a cyanopropyl precolumn and a phenyl analytical column. The analytical column effluent was monitored electrochemically at a glassy carbon electrode at a potential of +1025 mV vs. Ag/AgCl. Peak-height ratios were proportional to the amount of MDL 201,012 added to plasma over the range 125-7500 pg/mL MDL 201,012. Absolute recovery of MDL 201,012 from human plasma was > 94% across the calibration range. The minimum quantitation limit was 125 pg/mL. Assay precision (%RSD) ranged from 5.2 to 13% based on the analysis of quality control standards containing 125, 250, 500, 1000, 2500, 5000 and 7500 pg/mL MDL 201,012. Corresponding assay accuracy (% relative error) was +/- 8.5%. The method has been successfully used to quantitate MDL 201,012 in samples from acute dose tolerance studies in human volunteers.


Solid phase extraction and simultaneous high performance liquid chromatographic determination of antipyrine and its major metabolites in urine. A reversed phase gradient high performance liquid chromatographic method utilizing solid phase extraction has been described for the simultaneous determination of antipyrine (AP), 4-hydroxyantipyrine (4-OHAP), norantipyrine (NorAP) and 3-hydroxymethylantipyrine (3-OHMAP) in human urine after hydrolysis with beta-glucuronidase. The C-18 sorbent cartridges were conditioned and urine samples were applied, washed with 1 x 4 mL of phosphate buffer and eluted with 3 x 100 microL of 20% v/v of acetonitrile in methylene chloride. The eluent was evaporated to dryness, reconstituted in 100 microL phosphate buffer and injected. The calibration ranges were 2.0-250 micrograms/mL (AP), 2.5-250 micrograms/mL (NorAP), 2.0-250 micrograms/mL (3-OHMAP) and 5.0-500 micrograms/mL (4-OHAP) with regression coefficients of 0.998 or greater. Specificity was indicated by the absence of interferences in chromatogram of blank urine from normal as well as cirrhotic patients. The average recovery was 86.7% for AP, 90.5% for NorAP, 85.2% for 4-OHAP and 74.2% for 3-OHMAP. The within-assay precision as indicated by the reproducibility of the assayed spiked urine was less than 9% in all cases and the between-assay precision was less than 12%. The method was applied to studies on antipyrine metabolism in stable cirrhotic patients. Following administration of a single oral dose of about 1000 mg to nine stable cirrhotic patients and eight age-matched healthy volunteers, the cumulative account excreted in the urine up to 48 h for AP and the three metabolites was comparable to other literature reports.


Cinderella and the four learning theories. This paper explores the underlying assumptions about teaching, learning and knowledge as it relates to the four learning theories--behaviourist, cognitive, humanist and critical. The assumptions of these four theories are exposed with metaphorical adaptive use of the Cinderella story. It is this author's intention to provoke discussion and arouse interest regarding the four approaches to teaching and learning.


Analysis of chlortetracycline by high performance liquid chromatography with postcolumn alkaline-induced fluorescence detection. A high performance liquid chromatographic method for the analysis of chlortetracycline (CTC) using postcolumn fluorescence detection has been developed. After chromatographic separation of CTC on a polystyrene-divinylbenzene copolymer column, a highly fluorescent derivative isochlortetracycline (iso-CTC) was formed postcolumn in an on-line reaction coil with the addition of 25% NaOH (w/v). Chromatographic separation was achieved on a PRP-1 column, 15 cm x 4.6 mm, with 27:73 acetonitrile:0.2% perchloric acid (v/v), at 1.0 mL/min. Fluorescence derivatization was achieved by the on-line addition of 25% NaOH (w/v), at a flow rate of 0.2 mL/min, into the column eluant in a post-column reaction coil. The reaction coil was 9 m of teflon (1/16 in o.d., 0.3 mm i.d.) knitted into a six-sided coil. The fluorescent derivative was detected at lambda ex 355 nm and lambda em > 389 nm. Using this method after a simple sample cleanup, CTC can be detected in milk at 0.04 micrograms/mL, which is comparable to that obtained by microbiological assays. The detection method was linear between 0.02 micrograms/mL and 4 micrograms/mL. Because of the chromatographic separation, the method is more selective than microbiological assays and more sensitive than ultraviolet detection. With the chromatographic system described, the keto tautomeric forms of CTC and 4-epi-CTC are separated in a system which minimizes their formation on-column. In acidic aqueous organic solutions, the keto tautomer of CTC is the only product formed to any significant amount.


Robotic solid phase extraction and high performance liquid chromatographic analysis of ranitidine in serum or plasma. A fully automated assay for the analysis of ranitidine in serum and plasma, with and without an internal standard, was validated. It utilizes robotic solid phase extraction with on-line high performance liquid chromatographic (HPLC) analysis. The ruggedness of the assay was demonstrated over a three-year period. A Zymark Py Technology II robotic system was used for serial processing from initial aspiration of samples from original collection containers, to final direct injection onto the on-line HPLC system. Automated serial processing with on-line analysis provided uniform sample history and increased productivity by freeing the chemist to analyse data and perform other tasks. The solid phase extraction efficiency was 94% throughout the assay range of 10-250 ng/mL. The coefficients of variation for within- and between-day quality control samples ranged from 1 to 6% and 1 to 5%, respectively. Mean accuracy for between-day standards and quality control results ranged from 97 to 102% of the respective theoretical concentrations.


Computers and nurses.

Computers and nurses. This paper will consider some of the reasons why nurses must become computer literate and be both aware of, and able to use, information technology. There are advantages for nurses in professional standing, research opportunities and assistance with management problems. Without nursing involvement the use of computers will be imposed on nurses, and it is possible that such an imposition could limit nursing autonomy, exclude nurses from decision making and increase the nurse's workload without benefit. There is a rapid expansion of information and its electronic storage and processing. Are we as nurses aware of the implications of this? Do we really want to know about it? And are we ready to cope with the changes it could make in the way we practice? These are essential questions for curriculum planners now.


Community based nurse case managers: a model to meet New Zealand's changing health care needs. Policy-makers are concerned to find ways to improve the quality, accessibility and continuity of care, contain costs and ultimately to reduce the rate of institutionalisation. The health reform in New Zealand proposes to open up the way for nurses to be more extensively and effectively involved in primary and community based care in order to meet these needs. The role of nurses as community based nurse case managers in the United States is reviewed and demonstrates very clearly not only is the quality of health care enhanced but also the client and fiscal outcomes improved. The challenge from the reform is for nurses to see the opportunities and to take the initiative before it is taken by other disciplines.


Why Londoners have low death rates from ischaemic heart disease and stroke. To explain the low death rates from cardiovascular disease in London. London and the other counties of England and Wales. Women living in London during 1901-10 and people in London dying during 1968-78. At the beginning of the twentieth century young women aged 15-34 in London had remarkably low death rates, largely because of low rates for tuberculosis and other infectious diseases and low mortality during childbirth. Their low death rates contrasted with the high rates in girls under 15 years. Large numbers of young women had migrated into London from agricultural counties in southern England and went into domestic service, where the diet was usually very good. Recent findings suggest that a mother's nutrition and health has a major effect on the risk of cardiovascular disease in the next generation. The low cardiovascular mortality in London is consistent with this, and contrasts with the high mortality from other common diseases.


Noise and the classical musician.

Noise and the classical musician. To test the hypothesis that noise exposure may cause hearing loss in classical musicians. Comparison of hearing levels between two risk groups identified during the study by measuring sound levels. Symphony orchestra and occupational health department in the west Midlands. Hearing level as measured by clinical pure tone audiometry. Trumpet and piccolo players received a noise dose of 160% and 124%, respectively, over mean levels during part of the study. Comparison of the hearing levels of 18 woodwind and brass musicians with 18 string musicians matched for age and sex did not show a significant difference in hearing, the mean difference in the hearing levels at the high (2, 4, and 8 KHz) audiometric frequencies being 1.02 dB (95% confidence interval -2.39 to 4.43). This study showed that there is a potential for occupational hearing loss in classical orchestral musicians.


Does earwax lose its pathogens on your auriscope overnight? To describe the organisms cultured from general practitioners' auriscope earpieces; and to explore general practitioners' perceptions of the possibility of cross infection from contaminated auriscope earpieces and of how their auriscope earpieces are cleaned. Microbiological survey of auriscope earpieces in two general practices and a semistructured questionnaire sent to 105 general practitioners. General practitioners served by one district general hospital microbiology laboratory in the north of England. Organisms were cultured from 41 (93%) of 44 auriscope earpieces, of which 14 (32%) carried potential pathogens; four (9%) were heavily contaminated. Of the 85 (81%) general practitioners who responded, 72 (85%) believed that contaminated auriscope earpieces could cause serious infection, 66 (78%) did not clean earpieces between patients, and 70 (82%) thought that patients would mind if they knew that dirty earpieces were used. Almost a third of auriscope earpieces were contaminated by pathogenic bacteria. Although general practitioners suspected this, most did not ensure that a clean earpiece was used for each patient.


[Determination of level of expansion and incidence of rupture of abdominal aortic aneurysms]. We studied 114 patients (out of a cohort of 797 consecutive patients admitted with abdominal aortic aneurysm) who were denied any immediate operation because of patient's refusal, high surgical risk, or small transverse diameter as assessed by CT scanning and ultrasonography. All patients not operated on, underwent from two to six repeated examinations during an average follow-up period of 16.8 months (range, 3 to 132). Forty-seven patients (41.2%) were subsequently operated on electively because of marked increase of transverse diameter of the aneurysm (n = 44) or for other reasons (n = 3), with a death rate of 0%. Eighteen other patients underwent emergency operation for leaking or ruptured aneurysms, and there were five deaths. The incidence of rupture was clearly related to the final diameter value, rising from 0% in aneurysms less than 40 mm to 22% in large size aneurysms (> or = 50 mm). Among the 49 patients not operated on, one died of rupture before operation and five of causes unrelated to the disease. Using individual serial measurements, we determined the linear expansion rate of the aneurysm, which proved to be related to initial diameter values: 5.3 mm/year for diameters less than 40 mm (n = 49), 6.9 mm/year in the 40 to 49 mm group (n = 41), and 7.4 mm/year for diameters of 50 mm or more (n = 24). We also fitted an exponential model to the patient data and determined in each case an "exponential" expansion rate expressed in year-1. The overall mean was equal to 0.129 year-1, and individual values were found to be independent of initial diameter size. The superiority of the exponential model over the linear model was shown to be statistically significant. Our study confirms that expansion of aneurysms is related to initial diameter values and shows that the time evolution of the disease process can be adequately described by an exponential model. It also suggests that rupture of aneurysms is not only related to their size but also to their rate of expansion.


[Trans-laparoscopy surgery, a passing fashion or progress?]. Since the first laparoscopic cholecystectomy performed in 1987 by Philippe Mouret in Lyon (France), there has been a real revolution in the field of visceral surgery: more and more operations are performed by this mini-invasive surgical method: lithiasis of the common bile duct, Nissen and Heller procedure, truncal vagotomies, abdominal and thoracic, supra-selective vagotomies, hernia, appendectomy, band sections during intestinal occlusion, resection of the colon and rectum, oesophagectomies ... In Belgium, more than 3,000 cholecystectomies have been listed in a national registry in which the modalities and complications of this laparoscopic approach have been scrutinized. During the years to come, there will be an important technological development which will make this procedure easier, safer and quicker. Consequences of this new approach cannot completely be foreseen but there are some drawbacks: possible simplification of well established surgical techniques in order to facilitate the laparoscopic approach, causing a deterioration of the long term results, teaching and training difficulties for young and older surgeons, very costly equipment.


[Soft tissue ossification: mechanism].

[Soft tissue ossification: mechanism]. Three experiments: cardiac ligature, subcutaneous implantation of glass diaphragm and regenerated calcaneus tendon transplantation, produce new bone with marrow. The mechanism proceeds in two steps: 1) after trauma or local irritation, mesenchymal fibroblasts enter in division; this young population remains fibrous indefinitely; 2) those young reactive cells, submitted to local oxygen deficiency, build new substances called "stress proteins". Under anoxia, a potent stressor, transplanted new calcaneus tendon ossifies and marrow develops in its core. No immigrant cells participate in this ossicle as it is rejected in a foreign host. Ectopic ossification is an active phenomenon, young fibroblast population building its own inductor, quite different from passive osteogenesis in which inductive message is produced outside the responsive cell. Fracture repair proceeds by an osteogenic reaction from both periosteum and marrow. A third factor is delivered by the cortex: osteogenin or BMP inductor. A fourth osteogenic factor is to be considered: "autoinduction by local stress anoxia".


[European Organization for Research and Treatment of Cancer (EORTC): objectives, realizations and future perspectives]. The objectives and realizations of the EORTC are described. The activities of the treatment branch are centralized at the EORTC Data Center located in Brussels. Approximately 6000 patients are included every year within clinical trials run by EORTC, involving active participation of more than 2000 physicians distributed in 350 institutions in Europe. 80% of patients included in EORTC trials are located in EC countries. Recently, new cooperative groups have been created in order to study cancers in elderly, tumors related to AIDS as well as invasive fungal infections in cancer patients. New perspectives and further developments include cost evaluations of new therapeutic modalities in oncology as well as quality of life of cancer patients. Furthermore, EORTC promotes the creation of a meta-analysis unit. A fellowship program to allow training of medical doctors and statisticians at the EORTC Data Center including scientists coming from Eastern and Central Europe is also encouraging. Every year, EORTC activities lead to at least 40 publications and more than 80 scientific communications allowing rapid diffusion of the results of researches performed.


The assessment of carotid and vertebral arteries: a comparison of CFM duplex ultrasound with intravenous digital subtraction angiography. The use of duplex ultrasound with colour flow mapping is compared with that of intravenous digital subtraction angiography (IVDSA) in the investigation of carotid and vertebral artery disease. Ninety-nine carotid and vertebral arteries were examined independently by IVDSA and ultrasound for location and degree of disease in 30 men (mean age 58) and 20 women (mean age 53). For purposes of comparison the carotid tree was divided into six segments. In 46% of cases no disease was detected by either modality. In 36% of cases where disease was found, ultrasound found mild disease in arteries reported as normal by IVDSA. Both modalities detected the six cases of total occlusion found in the study. IVDSA underestimated five cases of major disease found by ultrasound at the bifurcation or in the bulb. Overall agreement in grading vessel segments was good, with 74.5% in complete agreement and 90.3% grading stenoses to within +/- 25% of the other modality. There was good qualitative agreement in the findings for vertebral arteries. In four patients conventional arteriography was also available for comparison.


Comparison of a subjective and a quantitative assessment of the neonatal chest radiograph. The aim of this study was to assess if quantitative classification of the chest radiograph appearance at 7 days predicted chronic oxygen dependency (oxygen dependency beyond 8 weeks of age) more accurately than did subjective classification at 28 days of age. Thirty preterm infants, median gestational age 27 weeks, who had chest radiographs taken for clinical purposes at 7 and 28 days of age, were recruited into the study. The 7-day chest radiograph was scored according to the lung volume, presence of opacification, interstitial changes, pulmonary interstitial emphysema and cystic elements. The range of chest radiograph scores was from 0-18, a score of 18 indicating the most abnormal appearance. The 28-day chest radiograph was classified as Type I or Type II chronic lung disease (CLD), according to the presence or absence, respectively, of coarse reticulation. The median chest radiograph score at 7 days of the 30 infants was 5 (range 2-14). In predicting chronic oxygen dependency, a chest radiograph score of 5 at 7 days had 83% sensitivity and 75% specificity, but a diagnosis of Type II CLD at 28 days of age had only 67% sensitivity and 67% specificity. We conclude that a quantitative assessment of the chest radiograph appearance at 7 days is more useful than a subjective assessment at 28 days of age.


Myocardial damage following coronary bypass surgery: assessment with antimyosin antibody uptake. To assess the role of 111In antimyosin antibody (AbAm) in the delineation of myocardial damage following coronary bypass surgery, we studied 51 consecutive patients who underwent coronary surgery, 27 of whom had a history of prior myocardial infarction. All patients underwent a diagnostic protocol comprising: (1) 99Tcm pyrophosphate (PYP) and AbAm injection 48 h after surgery (AbAm imaging 24 and 48 h post-injection) (myocardial/background and myocardial/lung ratios were obtained respectively from the computer image); (2) Radioimmunoassay (RIA) serum CK-B levels from samples obtained immediately before surgery, and 24 and 48 h later; (3) clinical and ECG follow-up. Twenty-five patients showed positive AbAm studies, 10 had positive PYP images, and 21 had CK-B levels above normal limits at 24 h. One patient with abnormal AbAm, PYP and CK-B studies had new Q waves on the ECG after surgery. This patient was considered to have sustained a peri-operative myocardial infarction. The large number of positive AbAm studies probably reflects myocardial damage frequently associated with coronary bypass surgery.


Computed tomographic appearances of the pelvis following hindquarter amputation. Bilateral and midline symmetry of the normal pelvic anatomy is an aid to the interpretation of computed tomographic (CT) examinations. Following hindquarter amputation (HQA) or partial hemipelvectomy (PHP) the normal anatomical relationships are disturbed. The CT examinations of 15 patients who had undergone either an HQA or a PHP for an advanced musculoskeletal malignancy are reviewed. The new "normal" anatomy revealed displacement of the bladder and small bowel to the side of surgery in one third of patients, more commonly in the PHP cases. There were varying degrees of wasting of the ipsilateral musculature, gluteus maximus muscle flap, erector spinae and psoas muscles, etc., because of partial denervation and disruption of their origin or insertion. Recurrent tumour was identified in eight of 10 cases in which it was clinically suspected prior to the CT examination. Invariably the recurrence arose within the muscle flap at the resection margin. Bone involvement by direct tumour spread was present in three cases. Pitfalls in differentiating recurrent tumour from scar tissue are discussed.


Assessment of mammographic film processor performance in a hospital and mobile screening unit. In contrast to the majority of mammographic breast screening programmes, film processing at this centre occurs on site in both hospital and mobile trailer units. Initial (1989) quality control (QC) sensitometric tests revealed a large variation in film processor performance in the mobile unit. The clinical significance of these variations was assessed and acceptance limits for processor performance determined. Abnormal mammograms were used as reference material and copied using high definition 35 mm film over a range of exposure settings. The copies were than matched with QC film density variation from the mobile unit. All films were subsequently ranked for spatial and contrast resolution. Optimal values for processing time of 2 min (equivalent to film transit time 3 min and developer time 46 s) and temperature of 36 degrees C were obtained. The widespread anomaly of reporting film transit time as processing time is highlighted. Use of mammogram copies as a means of measuring the influence of film processor variation is advocated. Careful monitoring of the mobile unit film processor performance has produced stable quality comparable with the hospital based unit. The advantages of on site film processing are outlined. The addition of a sensitometric step wedge to all mammography film stock as a means of assessing image quality is recommended.


The influence of needle size on post-myelography headache: a controlled trial. This study aimed to test the hypothesis that the use of fine rather than larger calibre needles for myelography reduces the incidence of post-procedural headache. 160 patients were randomized in a prospective controlled trial of 22 gauge versus 26 gauge needles. The incidence and overall severity of headache as measured at 1, 4 and 21 days after myelography was not significantly different in the two groups.


Does myodil introduced for ventriculography lead to symptomatic lumbar arachnoiditis? Although there is a substantial body of evidence implicating Myodil or Pantopaque as a cause of lumbar arachnoiditis, assessment of the clinically based evidence is complicated by the additional potentially causative factors present in a high proportion of cases. These include pre-existing spinal pathology, traumatic lumbar puncture and surgery. The aim of this retrospective study was to attempt to ascertain whether Myodil introduced via ventricular catheter was associated with subsequent development of symptomatic lumbar arachnoiditis. In 222 patients in whom clinical records were reviewed there was no excess of back pain following ventriculography compared to the general population. Myodil ventriculography does not appear to be a major cause of symptomatic lumbar arachnoiditis. Several unavoidable problems with the methodology of this study are discussed.


Clearance of iopamidol, a non-ionic contrast medium, by CAPD in patients with end-stage renal failure. In normal healthy subjects radiographic contrast media are cleared by the kidneys with a half-life of approximately 2 h and a total body clearance of 8 l/h. The mechanism of contrast clearance has not been previously investigated in chronic renal failure patients undergoing continuous ambulatory peritoneal dialysis (CAPD). A study was undertaken to investigate the pharmacokinetics of a non-ionic water soluble radiographic contrast medium (iopamidol) in 10 patients stabilized on CAPD. All patients (eight male, two female) aged 22-68 years (median 53 years) had injection of 30 ml of iopamidol 300 via a forearm vein to investigate subclavian vein patency following previous cannulation for haemodialysis. Venous blood samples, CAPD dialysate and urine were collected for seven days post injection. The mean plasma half-life was 37.9 h (SD 10.6) (range 24.1-57.2 h) for the CAPD patients and was greatly prolonged in comparison to healthy subjects. The total body clearance of iopamidol was also greatly reduced (0.377 l/h). CAPD removed an average of 53.6% of the administered dose (range 36.3-80.8%) whilst an average of 26.9% was excreted in the urine (range 1.3-56.3%). The combined renal and dialysate clearance was up to 93% of the administered dose over the period of the study. There is therefore some evidence for a small extra renal clearance of iopamidol in end-stage renal failure patients. This study has shown for the first time that patients with end-stage renal failure undergoing CAPD have significantly delayed elimination of contrast medium. This should be taken into consideration when extensive or prolonged investigations using contrast medium are proposed.


Influence of radiologist grade on fluoroscopic patient dose. The effect of radiologist grade on patient dose during fluoroscopic barium studies was assessed over a one-year period in a large teaching hospital using area-kerma measurements made with a Diamentor M2 system. The number of studies investigated was 164 for barium swallows, 274 for barium meals and 1288 for barium enemas. The patient's AP thickness was assessed at the abdominal level from a formula combining the patient's estimated height and weight. For each study there was no significant change in AP thickness as a function of radiologist grade. For all barium studies there was a trend for both the screening time and the patient dose to fall to a minimum for the grades third-year registrar/first-year senior registrar. From this group to consultant level the dose and screening time rose.


Comparison of the effect of different reference data on Lunar DPX and Hologic QDR-1000 dual-energy X-ray absorptiometers. We have investigated whether the Lunar DPX (software 3.4) and Hologic QDR-1000 dual-energy X-ray absorptiometers have comparable normal reference databases for the spine and femur of white UK and USA subjects. After conversion for systematic differences in absolute bone density values between the two systems, the reference databases were very similar for the spine in young subjects, but there were clear differences in the femur databases of young females and males of all ages. These differences were confirmed by comparing the percent age-matched and young values determined by the two systems for subjects scanned on both systems. Thus the diagnosis and management of a patient could differ, depending on the system used for the bone density measurements.


La langue et les Lèvres: cross-language influences on bimodal speech perception. Previous research in speech perception has yielded two sets of findings which are brought together in the present study. First, it has been shown that normal hearing listeners use visible as well as acoustical information when processing speech. Second, it has been shown that there is an effect of specific language experience on speech perception such that adults often have difficulty identifying and discriminating non-native phones. The present investigation was designed to extend and combine these two sets of findings. Two studies were conducted using six consonant-vowel syllables (/ba/, /va/, /alpha a/, /da/, /3a/, and /ga/ five of which occur in French and English, and one (the interdental fricative /alpha a/) which occurs only in English. In Experiment 1, an effect of specific linguistic experience was evident for the auditory identification of the non-native interdental stimulus by French-speakers. In Experiment 2, it was shown that the effect of specific language experience extends to the perception of the visible information in speech. These findings are discussed in terms of their implications for our understanding of cross-language processes in speech perception and for our understanding of the development of bimodal speech perception.


Neural and behavioural effects of domoic acid, an amnesic shellfish toxin, in the rat. To examine the neurotoxic effects of domoic acid, an amnesic shellfish toxin, electroencephalographic and behavioural experiments were conducted on 38 rats. Injection of domoic acid (0.5-1.0 mg/kg intravenously, or 0.04-0.08 microgram intraventricularly) caused seizure discharges in the hippocampus, tonic-clonic convulsions, and death within a few days. Convulsions and ensuing death were prevented by diazepam. Animals pretreated with diazepam (5 mg/kg, ip) tolerated intraventricular dose of domoic acid 0.4 microgram, but showed a loss of pyramidal neurons mainly in the CA3, CA4, and a part of CA1 areas of the dorsal hippocampus. Learning of a radial maze task was severely impaired in naive rats after intraventricular injection of domoic acid (and diazepam, ip). In the animals previously trained on the maze task, domoic acid interfered with relearning of the same task. These effects appear similar to those of kainic acid and are analogous to the symptoms observed in humans who ingested mussels tainted with domoic acid.


Forty year trends in Canadian tobacco sales. Despite high taxes, the price of tobacco products continues to be a "bargain" for smokers. This paper presents trends since 1950 in real tobacco price index, per capita real disposable income, smoking prevalence, and sales of cigarettes and fine-cut tobaccos. In addition, an "effective tobacco price index", which is the ratio of the real tobacco price index to per capita (age 15+) real disposable income, indexed to a base year (1950) is discussed. This index gives the price of tobacco products as a fraction of real disposable income. The data indicate that, in 1991, the "effective tobacco price" is only 78% of 1950 values.


Restrictions on smoking: changes in knowledge, attitudes and predicted behaviour in metropolitan Toronto from 1983 to 1988. To describe recent changes in knowledge, attitudes and behaviour with regard to restrictions on smoking, we compared the findings of population-based surveys conducted in Metropolitan Toronto in 1983 and 1988. In both surveys identical questions and similar data collection procedures were used. There were no changes in knowledge scores regarding the health effects of active smoking or environmental tobacco smoke (ETS), nor in smoking behaviour. In contrast, there were marked changes in attitudes. The population favoured more restrictions on smoking, including prohibition in specific locations, and there was greater support for restrictions on sales and advertising, for differential insurance rates favouring nonsmokers, and for higher taxes on cigarettes. Fewer 1988 respondents reported smoking among their associates and more reported being bothered by others' smoking. The implications for public health education and policy development are discussed.


The impact of the decreased prevalence of smoking in Canada. Using data on the prevalence of smoking among different age and gender groups, we estimated the impact of the prevalence of smoking on the present and future mortality of Canadians. In 1989, the life expectancy of male smokers at the age of 45 was 7 years less than non-smokers, among female smokers life expectancy was 4 years less than non-smokers. The total number of smoking-attributable deaths from all causes was estimated for every decade from 1969 to 2019. A decrease in smoking prevalence from 1989 levels to 10% overall in 1999 would result in 15,000 and 6,000 fewer smoking-attributable deaths among women and men, respectively. Continuing the existing pattern of smoking among men and women will result in an increase in the total number of smoking-attributable deaths among women and an increase in the smoking-attributable deaths from lung cancer in both sexes.


Survey of smoking prevalence among Canadian nursing students and registered nurses. Patterns of tobacco use are described for members of the Canadian Nurses Association, and students enrolled in the graduating classes of Canadian nursing schools outside Quebec. Seventeen percent of the RNs and 30% of students reported being current smokers. Forty-six of RNs and 10% of students started smoking in nursing school. Although RNs' smoking rates are lower than in any previous survey, students' rates remain high. Smoking prevention and cessation programs are needed in educational institutions.


Validation of a survey instrument to measure the extent to which physician and dentist office environments discourage smoking. The health professional's office environment has been identified as one of the potential influences on smoking behaviour of patients. This study compared characteristics of office smoking policies and environments of 30 physicians and 30 dentists using both telephone survey and site visit. The site visit was considered the 'gold standard'. The sequence of interview presentation was randomly reversed for half the physicians and half the dentists to control for order effects. Kappa estimates and two-way Analysis of Variance were used on categorical and continuous variables, respectively. The results show there was a high agreement between the two modes of surveying. Physicians and dentists do not differ in level of agreement and in the consistency of responses obtained by telephone and site visit. We conclude that a telephone survey is a valid method to obtain smoking-related information from health professional offices.


Smoking and oral health in older adults. This paper examines the relationship between smoking and oral health in older adults. The data are taken from a cross-sectional study of oral health and treatment needs among persons aged 50 years and over living independently in four Ontario communities. Data were obtained from 907 subjects. Half of these reported a history of smoking and one fifth were current smokers. Current smokers were more likely to have lost all their natural teeth than those who had never smoked. Among those retaining one or more natural teeth, current smokers had fewer teeth, fewer functional units, more crown surfaces with decay and more decayed root surfaces. Periodontal indicators showed that the extent and severity of periodontal disease were more marked among current smokers when compared with those who had never smoked. Current smokers also showed a higher prevalence of mucosal disorders and needed more dental treatment. Regression analysis suggested that the links between smoking and oral disorders differ according to the disease in question.


A comparison between instructional experience and performance of teachers and nurses delivering a smoking prevention program. This paper focuses on the implementation evaluation strategy of a smoking prevention program and examines differences in instructional experience and implementation of the grade six curriculum in relation to provider type. Arbaseline, nurses (n = 40), compared with teachers (n = 39), reported (a) less previous classroom teaching experience, (b) greater reliance on lecturing and audio/visual materials, (c) less use of small group classroom activities, and (d) less confidence using small group and role playing methods in the classroom. More nurses than teachers believed smoking to be a significant problem in the schools. Nurses had less confidence than teachers in their ability to teach the smoking prevention curriculum. Nonetheless, behavioural observation indicated that nurses implemented the curriculum more completely. However, teachers, at least those who received workshop training, showed some evidence of greater utilization of teaching styles thought to be desirable.


Modifiable cardiac risk factors of smoking, elevated serum cholesterol and hypertension: a community survey. This descriptive study assessed the prevalence, perceptions and practices of community residents concerning three risk factors most commonly associated with coronary heart disease: smoking behaviour, hypertension and elevated blood cholesterol/dietary factors. One thousand questionnaires were randomly mailed to residents with a response rate of 48.1%. Results indicated that residents identify smoking and dietary factors as major risks for the development of heart disease. Although the prevalence of hypertension and the frequency of blood pressure screening was similar to other provincial and community surveys that investigated cardiac behaviours, differences were found with the prevalence of smoking behaviour, the frequency of blood cholesterol screening, and knowledge and practices of dietary behaviour. As a result of the study, target groups have been identified and programs have been recommended to meet community needs.


Measuring alcohol abuse in the community: consumption, binge-drinking, and alcohol-related consequences ("alcoholism"). This study reported and compared community health indicators for the measurement of alcohol abuse. Using data from the 1989 Hamilton-Wentworth Health Survey, similar rates were found for four differing definitions of alcohol abuse: 1) drinking everyday (5.7%, 95% confidence limit (CL) = 3.8-7.7%), 2) drinking at least 14 drinks in the past seven days (12.1%, 95% CL = 9.2-15.1%), 3) frequent binging on 10 drinks or more (9.4%, 95% CL = 6.9-11.8%), and 4) "alcoholism" as defined by the Michigan Alcoholism Screening Test (MAST) (7.4%, 95% CL = 5.1-9.7%). Binging on five drinks or more occurred frequently (37.0, 95% CL = 32.8-41.1%). All indicators of alcohol abuse from the survey were significantly higher for males as compared to females (p < 0.05), and demonstrated varying distributions by age. Estimates of drinking consumption based on the sale of alcoholic beverages in the community were also examined and found to estimate consumption levels nearly double that of the self-reported survey data. Relevance to public health planning and monitoring is discussed.


The experience of an occupational health centre during a prolonged work stoppage. We describe the experience of the occupational health centre at the Sarnia Division of Dow Chemical Canada prior to, during and after a work stoppage of seven months duration. A descriptive analysis was performed of the occupational health case load during the work stoppage compared to the same period one year earlier. Total visits as well as those for dermatologic, upper respiratory, musculoskeletal and those associated with a non-occupationally related situation (e.g., sunburn) exceeded normal frequencies during the first ten weeks of the work stoppage. In particular, there was a peak number of visits during the first two weeks when a 'lock-in' prevented employees from visiting their own physicians except for emergency situations. In the Discussion section, recommendations are outlined to lessen the chance of adverse health effects in workers responsible for operating a chemical plant during a work stoppage.


Occupational health nursing in Canada: its social foundation and future. Our purpose in examining the social foundation of occupational health nursing is to better determine the future direction of the profession and its impact on a diverse workforce. Part of what makes up the profession of occupational health nursing is found in its definition: a process that is determined by the interaction between the occupational health nurse, worker, work and workplace; its goal is to assist the worker to achieve his or her optimal level of functioning, primarily through health education, health promotion, prevention of disease and injury and crisis intervention. Much of occupational health nursing is also based on its history and the traditions that have been established. A true understanding, then, of what occupational health nursing's future can be comes from a solid understanding of the history of the profession. As social trends in the past affected the profession, so will they in the future.


The clinical nurse specialist as a consultant for play on the pediatric bone marrow transplant unit. A theory of consultation is reviewed and the practical ways in which to implement the consultation role of the pediatric CNS are discussed. A case study is presented to facilitate understanding of the role of the CNS as a consultant in medical play on a pediatric bone marrow transplant unit.


Moving on: recovering from the death of a spouse. Grieving is a complex multidimensional process in response to loss. The grief work involved in coping with a loved one's death does not end when the loved one dies. Rather, the grief work continues through a series of recovery stages. Six stages of recovery--loss, protest, searching, despair, reorganization, and reinvestment--are illustrated and discussed using a case study that highlights a wife's recovery from the death of her husband. Recognition of the stages of grief recovery after a death are significant for health care professionals so that bereavement support may be provided throughout the entire recovery process.


A metaphysical journey in a comatose state. This paper is about the intense experience of being in the hospital in a comatose state resulting from an aneurysm with a massive brain hemorrhage and two subsequent surgeries. The event begins with a premonition of what will happen from a street name. The experience of brain surgeries, along with the fine care of the nurses, left me with a truly memorable impression. This paper describes the various feelings and strong emotions that I experienced while in a comatose state. It suggests that a patient in a comatose state can exist in a deep state of emotions close to ecstasy. The paper concludes with gratefulness to all the people who followed me step by step on this journey.


Increasing practice-based research: doctorally prepared clinical nurse specialists may be the answer. The CNS role is proposed as an expert practitioner, educator, consultant, and research within a specialty area. The role, as originally envisioned, was to bridge the gap between practice and research. The research component of the role is frequently given the least emphasis in actual practice. This is problematic for a practice discipline building its scientific base. Many have proposed collaborative practice models to remedy this situation. This paper proposes that a CNS, prepared at the doctoral level, may be the more appropriate solution. Because CNSs maintain a strong practice base, they directly observe problems in the practice setting. With the appropriate research preparation, doctorally prepared CNSs can be in a position to solve clinical problems and advance the science of nursing.


A community health nursing curriculum and Healthy People 2000. The School of Nursing at the University of Alabama at Birmingham recently revised its graduate level community health nursing curriculum based on the priority areas and health objectives in Healthy People 2000. Health priority areas are presented as class topics and provide direction for the students' fieldwork. This paper provides background on the national strategy used to develop the national health objectives, suggestions on how nursing can be at the forefront of influencing the health of the nation, and specifics involved in implementing a community health nursing curriculum using the year 2000 health objectives.


Increasing the impact of the clinical nurse specialist through activity in a shared governance organization. For the CNS frustrated by traditional placement in an organization, participation in a shared governance organization increases opportunities to improve nursing practice and staff satisfaction. CNSs provide nursing expertise and leadership skills for specific committees as they assist staff nurses in meeting committee objectives. The authors also propose the use of a shared governance organization committee structure as a mechanism for CNSs to increase meaningful interaction with staff nurses and influence their professional development. Their model displays four pathways for CNS-staff nurse interaction through shared governance organization activities: examination of the goals of the profession, evaluation of personal needs and goals, assessment of the characteristics of one's work, and transmission of information. The support provided by the CNS in dealing with these issues increases the staff nurses' sense of a "professional self" and, it is postulated, enhances job satisfaction, decision making, and commitment to the organization's goals.


The art of the consultation note.

The art of the consultation note. Inherent in the consultation process is the ability to communicate effectively, yet little emphasis is placed on written communication through consultation notes. The art of writing a consultation note is learned primarily through trial and error or by master/apprentice relationships with senior practitioners. This paper reviews the types of consultations in which advanced practitioners are involved and presents a format for preparing a comprehensive consultation note.


Value of Holter monitoring in patients with the long QT syndrome. The idiopathic long QT syndrome (LQTS) is an infrequently occurring disorder. It has major clinical impact as patients are prone to syncope, ventricular tachyarrhythmias and sudden arrhythmogenic cardiac death. This paper reports the value of ambulatory electrocardiogram (ECG) monitoring as a diagnostic tool to establish the diagnosis of LQTS. 14 patient with idiopathic LQTS were studied. The results were compared to those of 14 age- and sex-matched healthy control individuals. A 24-hour ambulatory ECG tracing was obtained in each individual. 5/14 patients with LQTS had pathological findings during ambulatory ECG monitoring (2 patients with episodes of torsade de pointes tachycardia, 2 patients with T-wave alternans and 1 patient with bradycardia due to an intermittent SA block), whereas all control persons had normal ambulatory ECG recordings (p < 0.03). Thus, ambulatory ECG recordings may contribute significant diagnostic information in patients with suspected LQTS.


Reduced left ventricular diastolic asynchrony after captopril in single vessel coronary artery disease. Impaired left ventricular diastolic function is often found preceding systolic functional abnormality in coronary artery disease. To assess whether captopril improves diastolic function, radionuclide ventriculography was performed before and 1 h after captopril administration in 10 stable effort angina patients with severe isolated stenosis of the left anterior descending coronary artery and in 8 controls. Resting global peak filling rate (PFR) was significantly (p < 0.05) reduced in association with significantly (p < 0.01) increased left ventricular diastolic asynchronous index (delta t) in patients with angina pectoris. Neither global PFR nor regional cardiac function was affected by captopril, although delta t was significantly (p < 0.05) reduced from 70 +/- 18 (SD) to 51 +/- 25 ms in patients with angina pectoris. A significant (p < 0.01) correlation was observed between percentage changes in peak ejection rate and in PFR in all subjects. Thus, captopril improves left ventricular asynchrony in patients with stable angina, although global diastolic function affected by systolic function remains unchanged.


Ibopamine as a valuable adjunct and substitute for dopamine in bridging therapy before heart transplantation. Ibopamine is an active dopamine analogue leading to improved renal perfusion and afterload reduction in heart failure. This report describes casuistic experiences in patients with severe heart failure awaiting heart transplantation. All patients could be stabilized, intravenous catecholamines be discontinued, and diuretics be reduced. Six of seven patients could be successfully transplanted. No major side effects were noted. Thus ibopamine can be a suitable adjunct for patients with endstage heart failure.


Placebo treatment in congestive heart failure. In order to evaluate the effect of placebo treatment in congestive heart failure, we retrospectively studied 24 patients with moderately severe congestive heart failure who participated in heart failure treatment trials performed over the past 10 years in the Ohio State University Heart Failure Research Laboratory. Placebo-treated patients from 4 placebo-controlled trials comprised the placebo treatment group (n = 15), while one natural course-controlled trial provided patients for the non-placebo control group (n = 9). Changes in symptoms, left ventricular function and exercise duration were assessed following an 8-week course of therapy. Chronic placebo therapy resulted in an 81-second improvement in exercise duration which was statistically significant when compared to pretreatment baseline and to the duration achieved by the nonplacebo control group. Clinically, functional class improved significantly by 27% above baseline only for the placebo treatment group. Indices of left ventricular function did not change for either group. The salient feature of this study is that the placebo treatment effect, while believed to exist in congestive heart failure, has never been demonstrated in a manner which controlled for the natural course and variability of the disease process. The operative components of the placebo effect remain unknown, and further investigation will be necessary to elucidate the underlying mechanisms involved. However, the importance of this phenomenon lies not only with the response to and effects of placebo therapy but also in the role that the placebo effect plays in what is generally presumed to be the predominant responses, effects and benefits of active drug therapy.


Characteristics and prognosis of patients with acute myocardial infarction in relation to whether they were treated in the coronary care unit or in another ward. The characteristics and the prognosis in 921 consecutive patients with acute myocardial infarction (AMI) admitted to one single hospital are described and related to whether they were treated in the coronary care unit or not. Patients treated in the coronary care unit (n = 779) had a 1-year mortality rate of 26% as compared with 41% for patients treated in general wards (n = 115; p < 0.001) and 74% for patients treated in the intensive care unit (n = 27; p < 0.001). Patients treated outside the coronary care unit had a different risk factor pattern including a higher age and a higher prevalence of a previous cardiovascular disease. Independent clinical risk indicators for death among patients in the coronary care unit were in order of significance, high age (p < 0.001), arrhythmia on admission (p < 0.01), acute congestive heart failure on admission (p < 0.01) and a history of diabetes mellitus (p < 0.05). In patients treated in general wards, the only risk indicator for death was a history of congestive heart failure.


Continuous vectorcardiography in patients with chest pain indicative of acute ischemic heart disease. To assess the clinical usefulness of continuous on-line vectorcardiography (VCG), we studied 61 patients admitted to the coronary care unit (CCU) with chest pain, supposedly ischemic. Continuous VCG was performed for 24 h, monitoring QRS vector difference (QRS-VD), ST-change vector magnitude (STC-VM) and ST vector magnitude (ST-VM) measured 20 and 60 ms after the termination of the QRS complex. The patients were divided into four groups based on the final diagnosis; group A, 15 patients with normal exercise tests and extracardiac causes of chest pain; group B, 15 patients with unstable angina; group C, 15 patients with non-Q-wave myocardial infarction (MI); group D, 16 patients with Q-wave MI. Treatment was given according to a normal routine. Of 31 patients with MI, 16 received treatment with streptokinase. Groups A and B showed no significant permanent changes in QRS-VD, STC-VM or ST-VM. However, group B showed a higher occurrence of transient episodes (duration: 2 min-6 h) of a significant change of QRS-VD by > 15 microVs and of STC-VM, ST-VM 20 and ST-VM 60 by > 0.1 mV. Groups C and D showed both permanent changes and transient episodes for the studied vector parameters. Transient episodes were significantly fewer in group D than in group B. In patients with MI, the permanent change of vector parameters evolved more rapidly and reached a plateau earlier in those treated with streptokinase (QRS-VD: 178 +/- 82 vs. 293 +/- 100 min, p < 0.001; ST-VM 20: 142 +/- 75 vs. 293 +/- 89 min, p < 0.005). The magnitude of the end value for QRS-VD correlated with infarct size estimated by the maximal value of creatine kinase (r = 0.89; p < 0.001). We conclude that in patients admitted to the CCU with chest pain, continuous VCG monitoring early differentiates patients suffering from ischemic heart disease (IHD) from patients without IHD. It also differentiates patients with unstable angina from patients with MI.


Kinetics of technetium-99m-Sestamibi and thallium-201 in a transient ischemic myocardium animal model: insight into the 'redistribution' phenomenon. This study was designed to determine the redistribution potential for technetium-99m (99mTc)-hexakis-2-methoxy isobutyl isonitrile (99mTc-Sestamibi) as compared to thallium-201 (201Tl) in a transiently ischemic swine heart model. The left anterior descending coronary artery (LAD) was totally occluded for 10 min. One minute prior to the release of the LAD, 99mTc-Sestamibi, 201Tl and a set of 95Nb-radiolabeled microspheres (15 microns) were injected. A second set of 51Cr-radiolabeled microspheres was injected prior to sacrifice in order to document reflow. Animals were sacrificed at different times post-LAD release (ranging from 1 min to 4 h). The left ventricle was sectioned into 0.2- to 0.5-gram pieces for the gamma spectroscopic counting of the 99mTc-Sestamibi, 201Tl and radiolabeled microspheres. Linear regression analysis of radiotracer localization versus microsphere-determined regional myocardial blood flow (rMBF) demonstrates an initial slight filling in of 99mTc-Sestamibi into transiently ischemic zones, with subsequent stable kinetics up to 4 h (i.e., it does not further redistribute). In comparison, the ischemic to normal ratios for 201Tl activity increase progressively in a time-dependent manner. These differences between 99mTc-Sestamibi and 201Tl might be explained on the basis of their blood clearance kinetics and/or their net clearance from normal and ischemic zones of the heart. It is concluded that 99mTc-Sestamibi is a stable and reliable indicator for rMBF over time, and that the lack of normalization of 99mTc-Sestamibi into transient ischemic zones will necessitate two separate injections for differentiation between ischemia and persistent defects.


The value of chest pain during the exercise tolerance test in predicting coronary artery disease. The predictive power of 10 common exercise test parameters compared with coronary angiography was studied. Only the exercise electrocardiogram (EXECG), maximal rate pressure product (MAXRPP), and exercise chest pain (EXCP) contributed unique predictive information with the emergence of two interactions involving EXCP (EXCP.EXECG and EXCP.MAXRPP). (1) EXCP appears to be a more serious finding only in those higher risk individuals with either a positive EXECG or lower MAXRPP; (2) EXCP and its interactions may help discriminate between anginal and nonanginal, exertional chest pain, and (3) the contradictory results found when EXCP was allowed to interact may explain conflicting results in previous multivariate models regarding the predictive significance of EXCP.


Influence of ocular tropicamide on exercise testing. This study was aimed to evaluate the effects of tropicamide 0.5% eye drops on cardiovascular parameters during exercise testing. The study group included 154 healthy subjects (mean age: 44.7 +/- 8 years). The subjects were divided into three groups according to the size of the pupils at the onset of exercise: A: pupils not dilated (n = 27), B: pupils partially dilated (n = 90) and C: pupils widely dilated (n = 37). They were compared to 66 healthy controls (age 43.8 +/- 8) who did not receive the drops. Rest and exercise parameters were affected in groups A and B, while the results of group C resembled those of the controls: (a) resting heart rate -66.7, 66.6, 70.9 and 69.3, respectively (p = 0.03); (b) heart rate at 50 and 100 W - 104, 107, 110 and 111 (p = 0.01) and 131, 131, 137, 139, respectively (p = 0.01); and (c) peak systolic blood pressure - 192, 186, 183, 175; respectively (p = 0.004). Reanalyzing the data by scoring of visual impairment gave identical results. As a whole, the study group achieved higher work loads than the controls (126 vs. 119 W; p = 0.03). We conclude that the instillation of ocular tropicamide has definite effects on cardiovascular parameters, both at rest and during exercise. Mainly, patients showed a lower heart rate at the initial levels of exercise. However, at symptom-limited level, tropicamide does not influence a patient's ability to achieve the target heart rate, and stress testing results are not altered by the drug.


Right atrial myxoma presenting with recurrent episodes of pulmonary embolism. We observed a right atrial myxoma presenting with recurrent episodes of pulmonary embolism, the diagnosis of which was made approximately 2 years after the initial symptoms appeared. We emphasize the importance of prompt recognition and subsequent surgical treatment of cardiac myxoma because embolism by tumor fragments is a potentially fatal complication of this condition.


Percutaneous balloon mitral valvotomy in pregnancy using the Inoue balloon catheter. Percutaneous balloon mitral valvotomy (PBMV) using the Inoue balloon catheter was performed successfully in 2 patients with severe mitral stenosis refractory to medical treatment during pregnancy. Because of its unique design and ease of manipulation, we recommend the Inoue balloon catheter for performing PBMV in selected patients with mitral stenosis during pregnancy, as procedure and fluoroscopy times can be significantly shortened.


Effect of smoking on the oxidative processes of cardiomyocytes. The effect of prolonged (14 days) passive smoking on the respiration of isolated cardiomyocytes in rabbits using various substrates (pyruvate, glutamate, succinate) was studied. The endogenous respiration of cardiomyocytes was not affected whereas stimulated respiration as well as the ratio of stimulated to endogenous respiration significantly decreased. These results complement previous studies in which the effect of smoking on the metabolic processes of heart muscle mitochondria was measured. In conclusion, prolonged smoking may provoke myocardial dysfunction and in this way may contribute to the development of heart failure in chronic smokers.


Effect of pacing on epinephrine-stimulated atrial natriuretic factor release. Previous in vitro studies showed that epinephrine stimulation can induce atrial natriuretic factor (ANF) release only form the right atrium but not from the left. In addition, sinus node has been shown to play an important role in the release of ANF. In vitro studies were done in isolated left and right rat atria to determine if pacing can induce the left atria to release ANF during epinephrine stimulation. ANF concentrations in the perfusate were measured by a radioimmunoassay method. Epinephrine increased ANF release in the right atria (from 6.3 +/- 0.8 to 10.8 +/- 0.9 pg/min/mg), but not in the unpaced left atria (4.2 +/- 0.4 and 4.2 +/- 0.3 pg/min/mg). However, when the atria were paced, ANF release rose in both the left (from 6.2 +/- 0.5 to 11.5 +/- 1.4 pg/min/mg) and right (from 8.4 +/- 1.15 to 16.6 +/- 1.8 pg/min/mg) atria with epinephrine addition. These results suggest that atrial contraction and tension play an important role in epinephrine-stimulated ANF release.


Effects of cloricromene on ischemia-reperfusion myocardial damage in the rabbit. Cloricromene, a compound with several biological activities which suggest a therapeutic role in thrombosis or ischemic disease, has been studied for its effects on the extension of myocardial damage and the production of oxygen free radicals during periods of ischemia and reperfusion. In twenty rabbits the left anterior descending coronary artery (LAD) was occluded and cloricromene (3.6 micrograms/kg/min; n = 10) or placebo (n = 10) were continuously infused. After 50 min the artery was reopened and after 20 min of reperfusion a biopsy was obtained from the anterior wall of the heart in the LAD area and from the posterior wall (control myocardium) prior to sacrifice. Both samples were used for chemiluminescence measurement (free-radical production) and ultrastructural studies. In the placebo group all rabbits showed ST-segment changes during ischemia and reperfusion arrhythmias, while in the cloricromene group there were transient ST elevations in 4 animals which reverted at higher infusion rates of the drug. The chemiluminescence values were 18,017 +/- 1,956 and 8,583 +/- 918 cpm/mg protein (p < 0.001) in the anterior and posterior walls of the left ventricle, respectively, for the placebo group, and 7,767 +/- 992 and 8,333 +/- 832 cpm/mg protein (NS), respectively, for the cloricromene group. The ratio between the anterior and posterior wall was 2.27 +/- 0.37 for the placebo group versus 0.95 +/- 0.11 for the cloricromene group (p < 0.001). In ultrastructural studies, the anterior wall in the placebo group showed irreversible myocyte injury and infarction as well as mitochondrial damage. Samples from the cloricromene-treated group showed, in general, preservation of myocyte architecture or minor signs of injury. These results illustrate clearly the protective effect of cloricromene during damage induced by ischemia and reperfusion in the rabbit.


Endometriosis: recurrence and retreatment. Endometriosis, a condition in which endometrial tissue sheds and becomes attached to extrauterine sites, appears to be a progressive or recurrent disease. Although there are a variety of treatment options, the only cure for endometriosis is total abdominal hysterectomy with bilateral oophorectomy. For women who wish to preserve fertility, however, this is not a desirable choice. Because the symptoms of endometriosis suggest a hormonal relationship, pharmacologic management entails inducing anovulation. A concern of both physicians and patients is recurrence of endometriosis after initial response to therapy. Whether symptoms represent recurrent disease or progression of preexisting implants is still unknown. A repeat course of therapy with danazol, a synthetic androgen, may be tried for retreatment of endometriosis. Another option is the progestins. Conservative surgery (ie, laparoscopy) is also an option, but often must be repeated for pain control; combination pharmacologic/surgical therapy, although in widespread use, is not without disadvantages and requires further investigation.


The effects of immune globulin on endotoxemia. Ten patients (mean age, 40 years; 2 women) with endotoxemia received 2.5 gm of immune globulin daily for 4 days or 5 gm daily for 2 days. In all patients, plasma endotoxin levels decreased to normal levels (< or = 9.8 pg/ml) within a mean of 3.2 days after starting immune globulin treatment, and body temperatures decreased to < 37 degrees C within 4.5 days. In 10 antibiotic-treated (control) patients with endotoxemia who did not receive immune globulin, plasma endotoxin levels declined to normal levels in 6 and their body temperatures dropped to normal levels within 5.0 days; no changes in body temperature were noted in the 4 patients whose plasma endotoxin levels did not decrease.


Comparison of etodolac and diclofenac in osteoarthritis of the knee. This study compared the efficacy and safety of etodolac, a new nonsteroidal anti-inflammatory drug of the pyranocarboxylic class, with that of diclofenac in patients with osteoarthritis of the knee. A total of 172 patients entered this double-blind, parallel study and were randomly assigned to receive etodolac 600 mg/day (n = 85) or diclofenac 150 mg/day (n = 87) for 8 weeks. Both treatment groups showed a statistically significant reduction in pain at the second week and significant improvement (P < or = 0.05) from baseline in all efficacy assessments for the remainder of the study. Seventeen (20%) patients in the etodolac group and 21 (24%) patients in the diclofenac group reported at least one adverse event. Seven (8%) patients treated with etodolac and eight (9%) of those receiving diclofenac withdrew prematurely from the trial. One diclofenac-treated patient had a significant increase in alanine aminotransferase at the final evaluation. The results of this study indicate that etodolac was well tolerated and as effective as diclofenac in relieving the signs and symptoms of osteoarthritis.


Glyburide versus glipizide in the treatment of patients with non-insulin-dependent diabetes mellitus. Thirty-four adults with non-insulin-dependent diabetes mellitus were randomly assigned to receive either oral glyburide or oral glipizide in a multicenter comparative trial. Fasting blood glucose and hemoglobin A1c (HbA1c) were assessed at the beginning of the titration phase, the beginning of maintenance therapy, and the end of maintenance therapy. Maintenance therapy lasted approximately 3 months. The initial mean total dose of glyburide (5.4 mg) was significantly lower than that of glipizide (10.6 mg) (P = 0.04) and remained significantly lower at the beginning of maintenance therapy (7.8 mg versus 15.3 mg; P < 0.01) and at the end of the trial (10 mg versus 16.8 mg; P = 0.05). Although significant differences were not detected for fasting blood glucose or HbA1c, patients received higher total doses of glipizide compared with glyburide at the middle and final evaluations to maintain the fasting blood glucose between 3.9 and 10 mmol/L and HbA1c at < 9%. No serious adverse reactions were observed in any patient. These results indicate that doses of glipizide required to maintain blood glucose between 3.9 and 10 mmol/L and HbA1c at < 9% increased over time. Seventy-five percent of patients receiving glyburide were controlled with once-daily dosing compared with 29.4% of those treated with glipizide. Both glyburide and glipizide provide safe and effective treatment for patients with non-insulin-dependent diabetes mellitus, but more patients will benefit from once-daily therapy with glyburide.


Effects of manidipine and delapril on serum lipids, lipoproteins, and apolipoproteins in patients with mild to moderate essential hypertension: a randomized trial with one-year follow-up. Forty-five patients with mild to moderate essential hypertension were randomly assigned to receive 10 to 40 mg of manidipine HCl or 15 to 60 mg of delapril daily for 12 months. In the manidipine-treated group were 13 women and 5 men (mean age, 48.2 years) and in the delapril-treated group 11 women and 11 men (mean age, 53.7 years). Blood samples were taken at baseline and after 6 and 12 months of treatment and again at 2 months after treatment discontinuation. Significant reductions in blood pressure were observed in both treatment groups. The reduction in diastolic blood pressure was significantly greater in the manidipine-treated patients than in the delapril-treated patients; no significant between-groups differences in systolic blood pressure were noted. Heart rate increased significantly in the manidipine group. No changes in serum levels of total cholesterol, triglycerides, and high-density and low-density lipoprotein cholesterol were noted during or after treatment. In the manidipine group, a small but significant decrease in apolipoprotein (apo) A-I and an increase in lipoprotein(a) were found at 6 months and a significant increase in apo A-II and apo E at 12 months; in the delapril group a significant decrease in apo A-I was found at 6 months. The results indicate that both manidipine and delapril are lipid-neutral antihypertensive drugs, since neither drug greatly affected serum lipid metabolism.


Effects of temperature, solution composition, and type of container on the stability and absorption of carmustine. The stability and absorption of carmustine were studied comparatively in glass flasks and Stedim 6 bags. Stedim 6 is a new, multilayer, polyethylene-lined film. When stored at room temperature (22 degrees C +/- 2 degrees C) in the dark, carmustine decomposed in 5% dextrose solution and more so in 0.9% sodium chloride solution. When stored at 4 degrees C +/- 0.5 degrees C, the losses were identical in the glass flasks and Stedim 6 bags (about 11% after 72 hours). As long as they are kept in the dark at 4 degrees C, carmustine admixtures can be prepared up to 48 hours before administration, in either dextrose or sodium chloride isotonic solutions, and stored in either glass flasks or Stedim 6 bags.


Enoxacin in the treatment of typhoid fever. Enoxacin 400 mg twice daily was given orally to 40 patients who had Salmonella typhi- or Salmonella paratyphi-positive blood or bone marrow cultures. One patient was switched to parenteral therapy within 48 hours of study enrollment, but the remaining 39 patients were given enoxacin for 10 to 14 days. All 39 patients were cured by enoxacin, even though 23 (58.9%) strains were resistant to cotrimoxazole and 16 (41%) strains were multiply resistant to ampicillin, chloramphenicol, and cotrimoxazole. No adverse events necessitated the interruption of therapy. In this study, enoxacin was well tolerated and efficacious in the treatment of typhoid fever.


Hypercoagulable state in patients with hypercholesterolemia: effects of pravastatin. Molecular markers of the coagulation system and the effects of pravastatin on lipid levels and the coagulation markers were studied in 48 patients (mean age, 55 years) with hypercholesterolemia (plasma total cholesterol levels > 280 mg/dl). Each patient received 10 mg of pravastatin daily for 3 months. Plasma total cholesterol and low-density lipoprotein cholesterol levels decreased significantly during treatment and high-density lipoprotein cholesterol levels increased significantly. Above-normal plasma levels of thrombin-antithrombin III complex, fibrinopeptide A, FDP-D-dimer, plasminogen activator inhibitor-I, and thrombomodulin were found in the patients before treatment; each of these was reduced significantly during treatment. The findings suggest the presence of a hypercoagulable state in hypercholesterolemia and that pravastatin might prevent the hypercoagulable state by reducing hypercholesterolemia.


Enalapril and verapamil in the treatment of isolated systolic hypertension in the elderly. A prospective, investigator-blinded, randomized study was conducted to compare the efficacy and tolerability of enalapril and verapamil in the treatment of isolated systolic hypertension in elderly patients. Of the 115 patients who completed the study, 58 received enalapril and 57 verapamil. The goal of treatment was a systolic blood pressure < 160 mmHg and a reduction of at least 20 mmHg below baseline. The initial daily dose of enalapril was 5 mg, and of verapamil 240 mg. The dosage was titrated upward until the goal blood pressure was achieved. At the end of the titration period, systolic and diastolic blood pressures were significantly decreased (P < 0.001) in both patient groups. Blood pressure remained significantly decreased (P < 0.001) in both groups during the 8-week maintenance treatment period. There were no significant differences between groups. Two patients in the enalapril group and nine patients in the verapamil group were withdrawn from the study because of adverse effects. The results of this study demonstrate that enalapril and verapamil are well tolerated and effective in the treatment of isolated systolic hypertension in the elderly.


Assessing health-related quality of life: application to drug therapy. There is growing awareness among the principal stakeholders in health care that health outcomes data should be used in the evaluation of medical care interventions. Health-related quality of life is a patient-reported health outcome that is gaining increasing attention. In fact, in certain diseases, quality of life may be the most important health outcome to consider in assessing treatment efficacy. Quality of life is a construct commonly viewed as having several dimensions or domains. Although the terminology may differ depending on the author, the basic dimensions of health-related quality of life are physical status and functioning, emotional/psychological status, social functioning, and disease- or treatment-related symptomatology. There are a number of methodologic issues in the measurement of quality of life that must be carefully considered when designing a study or evaluating existing research. These issues include general or disease-specific measures, index or profile outcome measures, dimensions measured, relative importance of dimensions, reliability of the measure, and validity of the measure. This paper provides a brief overview of health-related quality of life and its measurement in the context of drug therapy.


Reversal of central nervous system effects by flumazenil after intravenous conscious sedation with midazolam: report of a multicenter clinical study. The Flumazenil in Intravenous Conscious Sedation with Midazolam Multicenter Study Group I. Flumazenil, a benzodiazepine antagonist, reverses the residual central nervous system effects of benzodiazepines. In this US double-blind, multicenter study, the efficacy of flumazenil was compared with that of placebo in antagonizing the effects of midazolam, a benzodiazepine used to induce intravenous conscious sedation. The mean dose of flumazenil was 0.7 mg, administered intravenously. At 5 minutes posttreatment, 82% of 131 flumazenil-treated patients, compared with 15% of 65 placebo-treated patients, demonstrated complete reversal of sedation. In 85% of patients who responded to flumazenil, this reversal of sedation was maintained throughout the 180-minute observation period. Psychomotor performance returned to prestudy levels 5 minutes posttreatment in 87% of the flumazenil-treated patients, compared with 28% of the placebo-treated patients. At the doses administered, flumazenil was less effective in reversing midazolam-induced amnesia, with only 60% of patients demonstrating partial recovery of memory. It was, nevertheless, more effective than placebo. Flumazenil was well tolerated. Dizziness (10%) and nausea (9%) were the most frequently reported adverse effects. Results of this study demonstrate that flumazenil antagonizes the central nervous system effects of midazolam after intravenous conscious sedation.


Reversal of central benzodiazepine effects by intravenous flumazenil after conscious sedation with midazolam and opioids: a multicenter clinical study. The Flumazenil in Intravenous Conscious Sedation with Midazolam Multicenter Study Group II. The efficacy and safety of flumazenil in antagonizing the central effects of the benzodiazepine midazolam was demonstrated in patients in whom conscious sedation was induced with midazolam plus an opioid (fentanyl, meperidine, or morphine). In a double-blind, multicenter study, 240 patients were administered flumazenil postoperatively at an average intravenous dose of 0.7 mg (7 ml) and 114 patients were administered an average dose of 9 ml placebo. Complete reversal of sedation was observed in 80% of flumazenil-treated patients and 30% of placebo-treated patients 5 minutes posttreatment. In 87% of patients who responded to flumazenil, the level of alertness was maintained throughout the 180-minute observation period. Midazolam-impaired psychomotor performance returned to normal 5 minutes posttreatment in 80% of the flumazenil-treated patients and 28% of the placebo-treated patients. Flumazenil was less effective in reversing midazolam-induced amnesia, with only 70% of flumazenil-treated patients (and 15% of placebo-treated patients) able to recall the picture shown them at the 5-minute assessment, and fewer patients able to recall pictures shown at later times. Flumazenil was well tolerated, although adverse effects were reported slightly more often than in the placebo group. The most frequent adverse events in both groups were dizziness and nausea. Vital signs were not affected.


Reversal of central benzodiazepine effects by flumazenil after conscious sedation produced by intravenous diazepam. The Flumazenil in Intravenous Conscious Sedation with Diazepam Multicenter Study Group I. Flumazenil is a competitive benzodiazepine antagonist that rapidly reverses the residual effects of benzodiazepines following intravenous conscious sedation. In a double-blind, multicenter study, postoperative patients who had been sedated with intravenous diazepam were randomly allocated to receive intravenous doses of flumazenil (0.4 mg to 1 mg) or placebo. Levels of sedation and psychomotor impairment were evaluated prestudy, at baseline, and at 6 intervals from 5 to 180 minutes posttreatment. A global evaluation of effectiveness was made at the 5-minute assessment, and memory was assessed at the 180-minute assessment. Flumazenil (mean dose: 0.73 mg [7.3 ml]) was significantly more effective than placebo (mean dose: 8.9 ml) in reversing sedation, psychomotor impairment, and amnesia within 5 minutes after the start of administration. At the 5-minute posttreatment assessment, 84% of 102 flumazenil-treated patients (compared with 42% of 52 placebo-treated patients) experienced complete reversal of sedation. Ninety-two percent of 93 flumazenil-treated patients (compared with 41% of 46 placebo-treated patients) had normal psychomotor function. Reversal of amnesia at the 5-minute assessment was achieved in 75% of 101 flumazenil-treated patients and in 20% of 51 placebo-treated patients. Statistically significant differences between flumazenil and placebo were also observed at the 15-minute assessment. Thereafter there were no significant differences between the two treatment groups. Most (70%) flumazenil-treated patients exhibited no recurrence of sedation during the 180-minute assessment period. The most frequent adverse reaction in the flumazenil group was dizziness (6%). There were no serious adverse experiences related to the test drug. Flumazenil provided prompt, controlled reversal of residual effects, especially sedation, in the majority (84%) of patients recovering from intravenous conscious sedation induced by diazepam. For most (70%) of these flumazenil-treated patients, the reversal was maintained throughout the 180-minute assessment.