Femoral bone mineral density in patients with heart failure.

INTRODUCTION: Heart failure and osteoporosis are common conditions in older, frail individuals. It is important to investigate interactions of the common problems in the aging population to devise relevant interventions. METHODS: Sixty individuals (43 men, mean age 77+/-9 years, and 17 women, mean age 78+/-12 years) with heart failure (HF) and 23 age- and gender-matched non-HF controls (15 men, eight women; mean age 77+/-9 years) underwent hip and bone mineral density (BMD) assessments; frailty assessment; physical performance assessment including 6-min walk, grip strength, and self-reported physical activity; and biochemical assessment including calcium, parathyroid hormone (PTH), 25-hydroxy vitamin D (25-OHD), estradiol, creatinine (Cr), and blood urea nitrogen levels (BUN). RESULTS: Significant differences between HF and control groups were found for BMD Z-scores of the femoral neck, total femur, and trochanteric region at the femur (p<.05). Further differences between groups included frailty score (p=.02), 6-min walking distance (p<.001), and self-reported physical activity (p=.001). In addition, several differences between groups were present for calcium (p=.054), PTH (p<.001), 25-OHD (p=.01), Cr (p=.04), and BUN (p=.01). In regression analysis, HF (defined as case, by ejection fraction, or by New York Heart Association class), frailty status, and vitamin D were significant predictors of lower bone mass at the femur. CONCLUSIONS: Individuals with HF have lower BMD, in part related to lower vitamin D status and higher frailty rates. Interventions to optimize vitamin D and physical activity should be explored to prevent bone loss in individuals with heart failure.

Prevention of perinatal group B streptococcal infection: current controversies.

Group B streptococcus (GBS) is the most frequent cause of neonatal sepsis in the United States. The Centers for Disease Control and Prevention (CDC) issued guidelines for its prevention in 1996. This article details areas of controversy with those guidelines and offers recommendations for resolution. We recommend that a prevention policy be adopted by all hospitals. If a screening-based policy is chosen, compliance is essential. Penicillin is the antibiotic of choice for GBS prevention. Increasing resistance to clindamycin and erythromycin might eliminate them as alternative choices in patients allergic to penicillin. Group B streptococcal prophylaxis might not be necessary in women who have repeat elective cesarean delivery. In asymptomatic women, a positive urine culture for GBS should be considered clinically equivalent to a positive vaginal or rectal sample for screening. Neonatal sepsis caused by organisms other than GBS must be monitored carefully by all hospitals providing obstetrics services.

Unrecognized bulimia nervosa: a potential cause of perioperative cardiac dysrhythmias.

PURPOSE: To report serious cardiac dysrhythmias in two patients whose bulimia nervosa was not revealed during preoperative screening. CLINICAL REPORT: Case #1: A 25-yr-old woman with preoperative hypokalemia (K+ = 3.1 mEq x l(-1)) required anesthesia for removal of a wrist ganglion. She claimed the hypokalemia was of unknown etiology, and denied other medical problems. Shortly after induction of anesthesia with thiopental and isoflurane, the ECG revealed two runs of torsades de pointes. This was successfully treated by decreasing pulmonary ventilation, allowing P(ET)CO2 to increase from 32 to 45 mm Hg. Case #2: A 39-yr-old woman who denied any medical problems received propofol, rocuronium sevoflurane and N2O during general anesthesia for breast augmentation. In the PACU, the patient complained of light-headedness, and the ECG revealed a heart rate of 44 bpm with P-R interval of 0.42 sec. Following 0.5 mg atropine, the heart rate increased but the P-R interval remained prolonged (0.36 sec) and the corrected Q-T interval was 0.51 sec. Treatment with 2.5 g MgSO4, 20 mEq KCl, and 9.4 mEq calcium gluconate i.v. normalized the Q-T interval, and decreased the P-R interval to 0.22 sec. Upon specific questioning, she admitted to a remote history of bulimia, but denied any bulimic behavior for the last 16 yr. CONCLUSION: Two patients with histories of eating disorders failed to disclose this information during preoperative evaluation. Perioperative cardiac dysrhythmias developed in these patients, even though they claimed that eating behavior had returned to normal.

Teaching senior medical students in an office setting: the apprentice system revisited: a cardiologist's perspective.

The recent changes in medical school curricula, brought about by insurance companies, government agencies, and market forces have shifted the focus of patient care from hospital bedside to office or clinic. Classic approaches to the teaching of medical students in the subspecialties have become confused and inadequate. Students' confidence in their own clinical expertise has been hampered by lack of teaching and guidance, and these functions cannot be filled by higher technology. We have completed a successful four year project for fourth year students utilizing a busy practice of cardiology/internal medicine in monthly electives. Among the objectives were to share the real life practice of medicine primarily in an office setting thereby decentralizing patient care and teaching outside of the medical school; to help students gain experience and confidence in the clinical skills of diagnosis and to help them choose "high tech" procedures that are appropriate, and have acceptable cost/benefit ratios; and to recruit an enlightened teaching faculty from practicing physicians who will become medical student advocates, facilitators, and role models, especially for the difficult years of managed care ahead. The elective met with enthusiastic support from all students, whose follow-up letters from residencies confirmed the practical value of the course in clinical skills as well as in choice of appropriate higher technology. Although poorly compensated at present, a few plausible suggestions are offered. If structured and coordinated efficiently this practical experience for students can be a real incentive for continued education, inspiration, and pleasure for the faculty monitor, without compromising his or time or income.

Absence of a deleterious effect of calcium channel blockers in patients with left ventricular dysfunction after myocardial infarction: The SAVE Study Experience. SAVE Investigators. Survival and Ventricular Enlargement.

BACKGROUND: As a result of randomized controlled trials with calcium channel blockers after myocardial infarction, concern has developed that these agents are associated with an increased risk of cardiovascular events, particularly in the presence of left ventricular dysfunction. METHODS: To test the hypothesis that calcium channel blockers increase cardiovascular events in such patients, the incidence of all-cause mortality, cardiovascular death, severe heart failure, and recurrent infarction was examined in 940 patients taking calcium channel blockers and 1180 not taking them 24 hours before randomization to placebo or captopril in the Survival and Ventricular Enlargement (SAVE) Trial. All patients had an ejection fraction < or =40%. Relative risks for calcium channel blocker users versus nonusers and the 95% confidence intervals were computed with univariate and multivariate Cox regressions. Adjustments were made for differences in baseline covariates. RESULTS: For all causes of mortality, the relative risk for calcium channel blocker users versus nonusers was 0.96, with the 95% confidence interval of 0.78 to 1.17. In the SAVE placebo and captopril groups, the relative risks for the development of severe heart failure among the calcium channel block users versus nonusers were 0.95 and 1.23, with the 95% confidence interval of 0.72 to 1.25 and 0.88 to 1.71, respectively. A similar neutral result held for patients with and without a history of hypertension. Furthermore, calcium channel blockers did not alter the benefit of the angiotensin converting enzyme inhibitor, captopril. CONCLUSIONS: This analysis of the nonrandomized clinical use of calcium channel blockers in the postmyocardial infarction population with left ventricular dysfunction did not identify either a clinical deterioration or improvement with respect to subsequent cardiovascular events.

Assessment of office-based care of sexually transmitted diseases and vaginitis and antibiotic decision-making by obstetrician-gynecologists.

OBJECTIVE: Survey office-based obstetric-gynecologic practitioners regarding their knowledge of infectious disease care and antibiotic use. METHODS: A survey questionnaire of multiple-choice questions was mailed to Fellows of the American College of Obstetricians and Gynecologists about clinical entities for which recommendations have undergone recent changes or about which there was a lack of consensus in a prior similar survey (Gibbs RS, McGregor JA, Mead PB, et al.: Obstet Gynecol 83:631-636, 1994). RESULTS: Respondents indicated that oral metronidazole was their most frequent choice to treat bacterial vaginosis. Ampicillin (57%) was used more often than penicillin (39%) for intrapartum group B streptococcus prophylaxis. Azithromycin was preferred (61%) over erythromycin-base (38%) for chlamydia treatment during pregnancy. There were several modes of practice that deviated from accepted care: 27% and 29% did not screen for chlamydia and gonorrhea, respectively, in pregnancy; 17% used cultures for Gardnerella vaginalis to diagnose bacterial vaginosis; 25% considered quinolones to be safe in pregnancy; 93% felt metronidazole should never be used in pregnancy; and the majority (66%) would send a patient treated successfully for pelvic cellulitis home with an oral antibiotic. CONCLUSION: Respondents' infectious disease knowledge and practices in obstetrics and gynecology is appropriate in treating sexually transmitted diseases, bacterial vaginosis, and group B streptococcus. Numerous deficiencies still exist in screening for sexually transmitted diseases in pregnancy and diagnosing bacterial vaginosis, as well as in the choice of antibiotics to use or avoid for certain infections.

Treatment of sporadic acute puerperal mastitis.

OBJECTIVE: The purposes of this study were to compare the efficacy of amoxicillin and cephradine for the treatment of sporadic acute puerperal mastitis (SAPM) and to evaluate the microbiology and clinical parameters of this infection. METHODS: We conducted a prospective, randomized, single-blinded study comparing amoxicillin, 500 mg orally q 8 h for 7 days, and cephradine, 500 mg orally q 6 h for 7 days. The diagnostic criteria for SAPM included a temperature of > or =37.56 (> or =99.6) and erythema and tenderness of the breast(s). RESULTS: Twenty-seven consecutive outpatients with SAPM were evaluated for admission to the study, and 25 of these were enrolled. The mean temperature at enrollment was 38.17 (100.7), with a mean WBC count of 11,440/microl. The most frequent bacterial isolates from expressed milk were Staphylococcus aureus (7), staphylococcal species (coagulase negative) (8), and alpha-hemolytic streptococci (4). There were no significant differences between the 2 antibiotic regimens in cure rate, mean days to resolution of symptoms, or recurrence within 30 days. Both of the treatment failures and 1 of the 3 recurrences within 30 days were amoxicillin-treated patients whose cultures grew S. aureus. CONCLUSIONS: Oral amoxicillin and cephradine appear equally effective in the treatment of SAPM. Staphylococci were the most frequent isolates from the milk of women with mastitis.

Percutaneous removal of infected permanent pacemaker leads using a simple coaxial dilating system.

A simple traction-countertraction technique using common and readily available materials was successfully used to remove infected pacemaker leads from two patients. The specific methodology is presented. Although somewhat technically demanding, this approach appears safe and cost-effective. This method provides another way to remove pacemaker leads without resorting to thoracotomy.

A survey of practices in infectious diseases by obstetrician-gynecologists.

OBJECTIVE: To survey current practices among obstetricians and gynecologists concerning a wide range of infectious diseases to guide future efforts in continuing medical education. METHODS: A survey questionnaire of multiple-choice questions was mailed to 2500 physicians, under age 65, randomly selected from the American Medical Association specialty list of obstetrician-gynecologists. The first 500 returns constituted the data set and were analyzed by computer. RESULTS: We found many clinical areas in which practice patterns were deemed appropriate, including antibiotic selection, universal screening for hepatitis B, and follow-up of urinary tract infection in pregnancy. In other areas, marked by controversy among "experts," practice patterns varied widely. These areas included management of premature rupture of the membranes and premature labor, and universal screening for group B streptococci. Areas in need of further continuing medical education efforts include management of perinatal viral infections and diagnosis and treatment of sexually transmitted diseases. CONCLUSIONS: Although this survey indicated that practice patterns of American obstetricians and gynecologists are appropriate in many clinical areas relevant to infectious diseases, there are other clinical conditions requiring future efforts in continuing medical education.

Metronidazole.

Metronidazole has proven to be a useful and inexpensive antibiotic for the treatment of T. vaginalis and bacterial vaginosis. Few alternatives exist for these two specific indications, and metronidazole will continue to play a primary role in therapy. Oral metronidazole continues to be a very inexpensive alternative to oral vancomycin for the treatment of C. difficile-induced pseudomembranous colitis. For the treatment of moderate to severe mixed aerobic/anaerobic pelvic infections, metronidazole should be considered secondarily in patients who have failed other multiple- or single-drug regimens or in patients who are infected. with anaerobic organisms resistant to other commonly used agents including clindamycin, cefoxitin, cefotetan, or ampicillin/sulbactam. Metronidazole is not a first line drug of choice for antibiotic prophylaxis in obstetric and gynecologic patients.

Nonimmune hydrops fetalis associated with maternal infection with syphilis.

Intrauterine infection with syphilis was diagnosed by reactive maternal serologic studies, ultrasonographic findings, and exclusion of other causes in three hydropic fetuses at 31, 34, and 35 weeks' gestation. With penicillin therapy and preterm delivery all infants survived through the perinatal period. Intrauterine infection that follows syphilis is a potentially treatable cause of nonimmune hydrops.

Amyloid heart disease manifested by systemic arterial thromboemboli.

Amyloid heart disease characteristically produces a stiff heart syndrome whereby diastolic filling is impaired yet systolic function is well preserved. We report two patients with this pattern of amyloid heart disease, both of whom developed cardiogenic thromboemboli. The rarity of this complication is striking given the pathophysiologic bases of amyloid heart disease. Investigation of contributing causes revealed that the phenomena appeared to represent the cumulative effects of disorders producing stasis, endothelial disturbance, and probable abnormalities in blood coagulability, the classic Virchow's triad revisited. Understanding of the pathophysiologic basis of this event leads to specific suggestions for workup and management in this patient population.

Effects of diltiazem on recurrent myocardial infarction in patients with non-Q wave myocardial infarction.

Diltiazem has been reported to reduce the short-term in-hospital reinfarction rate in patients with a non-Q wave myocardial infarction. In the long-term Multicenter Diltiazem Postinfarction Trial, there were 514 patients with non-Q wave myocardial infarction; 279 patients were randomized to the placebo group and 235 to the treatment group. The average follow-up period was 25 months. There was no difference in baseline clinical characteristics between the two groups. Early reinfarction (less than or equal to 6 months) occurred in 17 patients in the placebo group and in 2 patients in the diltiazem group (p less than 0.001). Late reinfarction (greater than 6 months) occurred in 13 patients in the placebo group and in 14 patients in the diltiazem group (p = NS). Initial and reinfarction electrocardiograms (ECGs) were analyzed by using a coding system that permitted identification of standard anatomic areas involved in the infarction process. Thirty-one of the 46 patients had a localized infarction on index and reinfarction ECGs. In the early reinfarction group, 10 (77%) of 13 infarctions occurred in the same ECG region in which the initial infarction had occurred; all 10 were in patients in the placebo group. Among the 18 patients with late reinfarction, the site of the second infarction was the same as that of the first in 9 patients and differed in 9. There was no difference between the placebo and diltiazem groups with respect to location of the infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Choice of antibiotic in nonelective cesarean section.

The use of antibiotics for prophylaxis against infection among women undergoing nonelective cesarean section has become the standard of care in the United States. Many different antibiotics have been used successfully. Single-dose regimens administered after the cord is clamped have proven just as effective as multiple-dose regimens. Although the most frequently used class of antibiotics is the cephalosporin family, the single best agent has not been determined. This study was a double-blind, randomized trial in which we compared a narrow-spectrum cephalosporin (cefazolin; n = 63) with an expanded-spectrum cephamycin (cefoxitin; n = 66) and with a broad-spectrum cephalosporin (cefotaxime; n = 60) used as a single-dose prophylaxis in patients undergoing a nonelective cesarean section. Of the 194 patients enrolled in the study, 189 were evaluable. There was no significant difference between the groups in mean age, gravidity, parity, duration of labor, duration of ruptured membranes, number of vaginal examinations, or socioeconomic status (socioeconomic status was defined by third-party coverage). There was no significant difference among the antibiotics in the incidence of immediate or delayed postoperative infections. These data indicate that a less expensive, narrow-spectrum cephalosporin is as effective as more expensive, broader-spectrum cephamycins and cephalosporins as prophylaxis for patients undergoing nonelective cesarean section.

Relation between beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure. The Multicenter Diltiazem Post-Infarction Research Group.

This study examined the relations among beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure in patients after myocardial infarction. The study was performed with the placebo group of the Multicenter Diltiazem Post-Infarction Trial. Ejection fraction data were available in 1,084 patients; of these, 557 were receiving a beta-blocker and 527 were not. In addition to ejection fraction, other correlates of left ventricular function included the presence or absence of pulmonary rales, chest X-ray film evidence of pulmonary congestion and the presence of an S3 gallop. Beta-blocker use was less frequent in patients with an ejection fraction less than 30%, rales, an S3 gallop and pulmonary congestion on chest X-ray film. Twenty-one percent of patients with an ejection fraction less than 30%, 42% of patients with rales, 28% of patients with an S3 gallop and 28% of patients with pulmonary congestion were receiving beta-blocker therapy. For every correlate of left ventricular function, the chance of developing congestive heart failure was greater in patients with diminished left ventricular function than in those without. For each level of left ventricular function, the chance of developing congestive heart failure requiring treatment was greater in patients not taking a beta-blocker.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic complications of acute myocardial infarction.

These complications can be broken down into three major categories: the direct effects of ischemia, the effects of myocardial rupture or similar structural loss secondary to ischemic insult, and the effects of inhibitory autonomic reflexes triggered by infarction. It is critical to correlate the hemodynamic problem with its etiology in order to choose the appropriate treatment.

Efficacy of oral antibiotics following parenteral antibiotics for serious infections in obstetrics and gynecology.

Patients with serious soft-tissue infections in obstetrics and gynecology are frequently treated with parenteral antibiotics until afebrile and clinically well for 48-72 hours, and then discharged on a broad-spectrum oral antibiotic. To evaluate the efficacy of this type of management, we designed a prospective, randomized single-blinded study comparing a group of patients who received oral antibiotics after hospital discharge (N = 80) with a group who did not (N = 83). No significant differences in age, race, parity, diagnosis, or pathogen isolated were observed between the patients in the two groups. No significant difference was noted in delayed morbidity between those who did and those who did not take oral antibiotics (P greater than .06). In light of the cost of oral antibiotics and the chance of drug-induced side effects, the data suggest that oral antibiotics after parenteral antibiotics are not indicated.