Will an orange a day keep the doctor away?

An 80 year old man, who relied on a home based meals-on-wheels service was admitted to hospital with non-specific symptoms, but had clinical and biochemical evidence of scurvy. Subsequently, all new admissions (n=37) to the department over a three week period were assessed for evidence of undernutrition. It was found that 73% had hypovitaminosis C, with 30% having concentrations suggestive of scurvy. There were no significant associations between level of vitamin C and type of accommodation, food provision, or age. The commonest symptom associated with vitamin C deficiency was anorexia, but overall, there was a paucity of clinical signs associated with vitamin C deficiency. The possible associations of vitamin C deficiency in the elderly are discussed.

Acute loss of capture due to flecainide acetate.

Antiarrhythmic drugs increase pacing threshold, but this is rarely of clinical significance. Administration of flecainide acetate in a 75-year-old woman with an implanted AAIR pacemaker because of sick sinus syndrome caused an abrupt rise of pacing threshold and failure of pacing. Pacing threshold returned to the normal value a few days after flecainide treatment was stopped.

Lead insertion by supraclavicular approach of the subclavian vein puncture.

Total occlusion of the left subclavian vein was diagnosed in a 76-year-old patient, 6 years after implantation of an ICD with VVI pacing backup. Replacement of the ICD included upgrading of the ICD system because of the presence of pacemaker syndrome when the patient was VVI paced. Insertion of an atrial lead through the ipsilateral vein system was made possible by using the supraclavicular approach of the subclavian, enabling puncturing of the left subclavian vein medially to the obstruction.

Stents in total occlusion for restenosis prevention. The multicentre randomized STOP study. The Israeli Working Group for Interventional Cardiology.

AIMS: This multicentre randomized study set out to evaluate whether coronary stenting improves the results of successful balloon angioplasty for chronic total occlusion. Balloon angioplasty for chronic total occlusion has a high restenosis rate. Several reports have suggested that coronary stenting may decrease the likelihood of restenosis and reocclusion. METHODS AND RESULTS: Patients with total coronary artery occlusions who had an optimal PTCA result were randomized either to no further treatment or additional stent implantation. The AVE microstent was used and all patients were scheduled for a 1-, 3-, and 6-month clinical follow-up. Repeat coronary angiography to assess the rate and pattern of restenosis was performed at 6 months or earlier if clinically indicated. Ninety-six patients were enrolled in this study. The mean age was 59. 3+/-10.3 years and 15 were females. Forty-eight patients were randomized to the stent arm, receiving 52 stents (lengths 18-39 mm). Stent implantation was successful in all and there were no major procedure-related complications. Sixty-nine patients (72%) were restudied after 6 months. The binary restenosis rates (50%), in the PTCA arm were 70.9% with a minimal lumen diameter of 1.01+/-0.79 mm compared to 42.1% in the stent arm with a minimal lumen diameter of 1.63+/-1.02 mm (P=0.034). Reocclusion occurred in 7.9% in the stent group compared to 16.1% in the PTCA group. Restenosis in the PTCA group was focal in 88% of patients and occurred at the point of total obstruction (within 5 mm), compared to diffuse instent restenosis, which occurred in 54% of the patients in the stent group. CONCLUSION: Coronary stenting can significantly decrease the rate of restenosis and reocclusion of total occlusions. As restenosis in the stent group was more diffuse, care should be taken to implant short stents at the site of occlusion.

Effect of isosorbide-5-mononitrate on exercise performance and clinical status in patients with congestive heart failure. Results of the Nitrates in Congestive Heart Failure (NICE) Study.

BACKGROUND AND AIMS: Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied. METHODS: Oral isosorbide-5-mononitrate (ISMN) (50 mg once daily) or placebo was administered to 136 patients (NYHA Class 2-3) treated for heart failure, all receiving captopril and most also furosemide. Endpoints were treadmill exercise time at 12 weeks by modified Naughton protocol (primary), with an additional 12-week follow-up period. Secondary endpoints included left ventricular dimensions, ejection fraction, cardiothoracic ratio, functional class, quality of life, hospitalizations and plasma norepinephrine and atrial natriuretic peptide in a four-center substudy. RESULTS: Intention-to-treat analysis showed that mean change in treadmill exercise duration tended to be greater in patients receiving ISMN than placebo (treatment difference +42 s, 95% CI -5, +90 s at 12 weeks and +21 s, 95% CI -25, +74 s after 24 weeks) (NS). Treatment difference was greater in the prespecified subgroup with ejection fraction 31-40% (+55 s, 95% CI -11, +136 s at 12 weeks and +65 s, 95% CI +3, +147 s) (p = 0.035) at 24 weeks. No deleterious effects (i.e. hypotension) were observed with ISMN, although headache was reported in 19% of the active treatment group (p = 0.0001). CONCLUSIONS: ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant.

Implantation of permanent dual chamber pacemaker in a pregnant woman by transesophageal echocardiographic guidance.

A 37-year-old woman complained of fatigue and dizziness because of intermittent sinus arrest and asystole up to 5.2 seconds. She was 3 months into her pregnancy and a dual chamber permanent pacemaker was implanted by transesophageal echocardiographic guidance.

[Propafenone dose for emergency room conversion of paroxysmal atrial fibrillation].

Paroxysmal atrial fibrillation (AF), a frequent cause of repeated hospitalization, is effectively treated with propafenone. The time to conversion to sinus rhythm is a consideration when managing AF in the emergency room. We investigated the conversion rates of paroxysmal AF by 3 different oral propafenone (P) regimens, in terms of time to conversion. 188 patients with onset of AF within 48 hours were treated with propafenone (P): 48 received 600 mg as a first oral dose followed after 8 hrs by 150 mg (Group A); 82 received 300 mg as a first dose, followed by the same dose 3 and again 8 hrs later (B); 58 received 150 mg every 3 hrs, up to a total dose of 600 mg (C). P was stopped when sinus rhythm was achieved. Rates of conversion to sinus rhythm after 3 hrs in the 3 groups were: 46%, 41% and 26% respectively; after 8 hrs: 77%, 78% and 70%; and after 12 hrs: 81%, 84% and 76%. Treatment was discontinued in 8. There was excessive QRS widening (> 25% of the basal value) in 1 in group A, 1 in group B and 2 in group C; wide-QRS tachycardia occurred in 4 in group B. In Group A there was a higher rate of early successful conversion, with a lower incidence of side-effects than with the other regimens.

Failure of left-sided implantable cardioverter defibrillator implantation due to absence of left brachiocephalic vein.

Implantation of an implantable cardioverter defibrillator by the transvenous approach was impossible from the left side in a patient with on absence of the left brachiocephalic vein; the left subclavian vein was connected by a large left superior intercostal vein to the accessory hemiazygos vein that joined the azygos vein; then the blood flowed into the superior vena cava. Implantation was successfully attempted using the right-sided venous access.

Treatment and outcome of patients with acute myocardial infarction and prior cerebrovascular events in the thrombolytic era: the Israeli Thrombolytic National Survey.

BACKGROUND: Patients with a history of stroke presenting with acute myocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are available on the risks vs the benefits of thrombolysis in patients with an acute MI and a prior cerebrovascular event (PCE). METHODS: Data were derived from 2 nationwide surveys of 2012 consecutive patients with acute MI admitted to all 25 coronary care units in Israel during 1992 and 1994. Thrombolytic therapy was given to patients with a PCE at the discretion of the treating physicians. Outcomes were compared between patients with an acute MI with and without a PCE and between patients with a PCE treated with or excluded from thrombolysis. RESULTS: Patients with a PCE (n = 115 [6%]) were older, with higher rates of atherosclerotic risk factors and in-hospital complications than their counterparts without a prior event (n = 1897). They were treated less often with thrombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P<.01), but not after multivariate adjustments for clinical characteristics (adjusted hazard ratio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acute MI and a PCE who were treated with thrombolysis (n = 29 [25%]) were compared with 46 patients found ineligible for thrombolysis primarily because of their PCE. The timing of the PCE was comparable in both groups (one fifth in the preceding year), while prior transient ischemic attacks were more prevalent among patients who had undergone thrombolysis. The patients who were treated with thrombolysis (n = 29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and beta-blockers more often than their counterparts (n= 46). In-hospital intracranial hemorrhage did not occur in either group. The 1-year mortality rates were 2-fold higher among patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64). CONCLUSIONS: These findings, derived from 2 nationwide surveys of consecutive patients with acute MI, suggest that patients with PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our preliminary data, may be beneficial in selected patients with an acute MI with a nonrecent PCE.

Insulation lead failure: is it a matter of insulation coating, venous approach, or both?

Lead insulation material and implant route have a major impact on lead reliability and durability. We compare the incidence of lead insulation failure resulting from both the venous approach and insulation type. Two hundred ninety consecutive leads were followed for a mean period of 57 +/- 30 months; leads with < 1 year follow-up were excluded. There were 116 Silicone Rubber insulated leads and 174 with polyurethane (151 Pellethane 80A and 23 Pellethane 55D) insulation; 279 leads were bipolar and 11 unipolar; 274 leads were implanted in the ventricle and 66 in the atrium. The venous route was the subclavian vein for 170 leads (58%) and the cephalic vein for 120 leads (42%). Insulation failure was diagnosed when a single sign of oversensing, undersensing, failure to capture, early pulse battery depletion, and lead impedance < 250 omega was present. Measurement of lead impedance was performed intraoperatively at implantation and during lead revision or pulse generator replacement. Lead failure caused by conductor coil fracture was not considered. There were 13 lead insulation failures, all among leads with polyurethane insulation (12 Pellethane 80A and 1 Pellethane 55D). Eleven failures (10%) occurred when the subclavian vein and 2 (3%) when the cephalic vein approach was used. The cumulative survival rate of polyurethane and silicone rubber insulated leads was 88.7% and 100%, respectively (P = 0.02); the cumulative survival rate of polyurethane insulated leads was 83.2% when the subclavian vein and 95.1% when the cephalic vein were used (P = 0.03). The mean time to polyurethane lead failure when the subclavian vein approach was used was 54 +/- 17 months and when the cephalic route was 73 +/- 4 months (P < 0.02). By multivariate analysis, the route of entry was found to be a significant variable related to polyurethane insulated lead failure (P < 0.05). At lead revision failure to capture was present in 7, oversensing in 4, and undersensing in 2 instances; impedance was < 250 omega in all cases. Pellethane 80A insulated leads are prone to insulation failure, but more when the subclavian vein is used, rather than the cephalic vein.

Deglutition syncope associated with carotid sinus hypersensitivity.

A 78-year-old patient complained of syncope, near syncope, and dizziness when eating; complete atrioventricular block, with ventricular asystole for 3.6 seconds, was recorded on continuous electrocardiographic monitoring. Left and right carotid sinus massage produces sinus arrest and ventricular asystole lasting 6.4 and 4.8 seconds, respectively. These phenomena were prevented by atropine administration. The symptoms were completely relieved by permanent pacing, but the patient died 6 months later because of large cell undifferentiated carcinoma of the lower third of the esophagus.

Implantation of dual chamber pacemaker in a patient with persistent left superior vena cava.

A 35-year-old patient underwent permanent pacemaker implantation because of symptomatic sinus bradycardia. During the procedure, persistent left superior vena cava was found. The ventricular lead crossed the tricuspid valve only after curving the stylet to form a loop in the right atrium (RA); subsequently, the curved stylet was changed to a straight one and the lead was positioned and screwed into the right ventricular apex. The atrial lead positioning was possible when the stylet was slightly curved and the lead could reach the anterior wall of the RA. At 18 months, a follow-up revealed normal pacemaker function and stable lead position.

Alterations in connexin expression and cell communication in healing corneal epithelium.

PURPOSE: The aim of this study was to examine cell-to-cell metabolite transfer and connexin distribution in the rabbit corneal epithelium, in the stationary state, and during wound healing. METHODS: Rabbit corneas were wounded with a surgical tool, producing a 3-mm-wide elongated debridement. Corneas were allowed to heal in vivo for up to 45 hours. Monoclonal antibodies against connexins Cx 26, Cx 32, Cx 43, and Cx 50 were used to stain cryostat sections. Cell-to-cell metabolite transfer capacity was assessed by a modification of the scrape-loading technique using lucifer yellow as the organic ion tracer. RESULTS: The rabbit corneal epithelium contains Cx 43 and Cx 50, localized in the cell's plasma membrane, as shown previously for other species. Cx 26 and Cx 32 are not detectable. Tracer transfer occurred in both basal and suprabasal cell layers. After wounding, the migrating epithelial monolayer lacked Cx 43 and Cx 50. This change was apparent 6 hours after injury and persisted until complete wound closure (approximately 24 hours). The Cx 50 membrane stain was increased elsewhere, in particular in the transition zone between monolayered and multilayered epithelium. Consistent with the expression changes, migrating cells displayed no or minimal cell-to-cell tracer transfer, whereas in the periphery of the wound, tracer transfer was enhanced in comparison to the control specimen. CONCLUSIONS: Corneal epithelial healing involves biphasic changes in the expression of connexins and cell-to-cell communications. These alterations may be critical for the optimization of the healing response.

[Balloon mitral valvuloplasty].

Since March 1990 we performed 100 balloon mitral valvuloplasties (BMV) in 82 females and 18 males (mean age 37 +/- 1 years; range 16 - 81) Initially we used the single shaft, dual or triple balloon system, while during the past 3 years we have been using the Inoue balloon system with step-wise inflation, monitoring with trans-thoracic echo (TTE) for immediate evaluation of mitral valve area (MVA) and/or severity of mitral regurgitation (MR), with 93% technical success. Hemodynamic data before and immediately after the procedure are in table below: [table: see text] C.O. cardiac output, DGR diastolic gradient, LAP left atrial pressure, MVA mitral valve area; all differences significant, p < 0.05. Acute complications included cardiac tamponade in 4/100; severe, acute MR in 2/100; only 5 were referred for urgent surgery. Neither cardiac tamponade nor severe MR were noted in the past 3 years. There was no periprocedural mortality in the past 5 years. Of 93 patients followed for 27 +/- 6 months (range 0-60), 90 (96%) were in NYHA classes I and II, 5 had late MVR, 2 underwent repeated BMV, and there was 1 death 16 months after the procedure. Immediate hemodynamic improvement followed BMV in most patients with pliable mitral stenosis. The Inoue system, with step-wise inflation and monitoring by TTE, proved to be a safe procedure. Symptomatic improvement continues during more than 4 years of follow-up.

Calcium antagonists and mortality in patients with coronary artery disease: a cohort study of 11,575 patients.

OBJECTIVES: This study sought to establish the risk ratio for mortality associated with calcium antagonists in a large population of patients with chronic coronary artery disease. BACKGROUND: Recent reports have suggested that the use of short-acting nifedipine may cause an increase in overall mortality in patients with coronary artery disease and that a similar effect may be produced by other calcium antagonists, in particular those of the dihydropyridine type. METHODS: Mortality data were obtained for 11,575 patients screened for the Bezafibrate Infarction Prevention study (5,843 with and 5,732 without calcium antagonists) after a mean follow-up period of 3.2 years. RESULTS: There were 495 deaths (8.5%) in the calcium antagonist group compared with 410 in the control group (7.2%). The age-adjusted risk ratio for mortality was 1.08 (95% confidence interval [CI] 0.95 to 1.24). After adjustment for the differences between the groups in age and gender and the prevalence of previous myocardial infarction, angina pectoris, hypertension, New York Heart Association functional class, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and current smoking, the adjusted risk ratio declined to 0.97 (95% CI 0.84 to 1.11). After further adjustment for concomitant medication, the risk ratio was estimated at 0.94 (95% CI 0.82 to 1.08). CONCLUSIONS: The current analysis does not support the claim that calcium antagonist therapy in patients with chronic coronary artery disease, whether myocardial infarction survivors or others harbors an increased risk of mortality.

[Transseptal left heart catheterization: a new application of an old invasive technique].

In this evolving era of balloon mitral valvotomy (BMV), radiofrequency ablation (RF) of left-sided bypass tracts via catheter, and hemodynamic evaluation of aortic mechanical prostheses, there has been renewed interest in transseptal left heart catheterization (TSLHC). In the 3 years 1990-1994, 122 consecutive patients were referred for TSLHC to our institute (which lacks thoracic surgical facilities). 12 patients were excluded; 10 with a LA mass proven by transesophageal echocardiography (TEE), 1 with a vascularized thrombus in the circumflex coronary system and 1 with congenital interruption of the inferior vena cava with azygous continuity. In the remaining 110 cases TSLHC was performed for interventions in 90 cases (82%) of BMV, and for left-sided catheter radiofrequency (RF) ablation in 3 (3%). For diagnostic purposes it was performed in 17 (15%) cases for hemodynamic evaluation of mechanical aortic valve prostheses. Using the Brockenbrough needle, the adult Mullins sheath system (MSS) and single plane fluoroscopy, 100% technical success was achieved. Needle puncture was not needed in 30 (27%) due to direct crossing with the MSS through a stretched foramen ovale. In 2 we had to perform SVC dye injection for better interatrial septum localization. There were no complications when TSLHC was only used for diagnostic procedures. 1 patient had perforation of the LA due to right lower pulmonary vein laceration following septal dilatation. Following stabilization by immediate pericardiocentesis, the patient was transferred for open heart surgery. There were no great vessel perforations, systemic embolization or periprocedural deaths. TSLHC can be performed quite safely with single-plane fluoroscopy without an onsight surgical team, as with an experienced staff this procedure has very low morbidity and mortality.