Organization of intensive cardiac care units in Europe: Results of a multinational survey.

BACKGROUND: The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe. METHODS: A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14). RESULTS: A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries. CONCLUSION: More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Radiation doses in a newly founded Interventional Cardiology department.

Coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA) radiation doses were investigated in a recently founded Interventional Cardiology (IC) department. The study includes 336 procedures (177 CAs and 159 PTCAs) carried out with a Philips digital flat detector monoplane system. Patient dose was measured in terms of kerma-area product (KAP) and cumulative dose. Using appropriate conversion factors, peak skin dose (PSD) and effective dose (E) were estimated. Median values of KAP (Gy cm(2)), PSD (mGy) and E (mSv) were: 34 478 and 6.1, respectively for CA and 80 885 and 14.4 for PTCA, within European and international reference levels. Only 1.5 % of patients received radiation dose over the 2 Gy threshold (PTCA procedures) for deterministic effects and none reported any skin effect. Radiation doses were within international standards and comparable with other radiological examinations. The percentage of the high-risk patients for radiation skin effects is extremely low.

Evaluation of radiation dose during pacemaker implantations.

The purpose was to evaluate patient radiation doses and compare with other interventional procedures. One hundred and twenty-eight procedures were carried out with a recently installed mobile undercouch C-arm machine with a 23-cm diameter image intensifier. The radiation dose is provided by the X-ray machine, in terms of cumulative dose (CD). Kerma-Area product (KAP) was then estimated from CD and the X-ray field size. Other patient parameters recorded were patient weight, age, kilovolt, milliampere and fluoroscopy time (T). Median (range) CD, KAP and T were 15.2 mGy (3.2-110 mGy), 6.3 Gy cm(2) (1.3-45.7 Gy cm(2)) and 5.2 (1.5-27.4 min) min, respectively. Median E was 1.1 mSv (conversion factor: 0.18 mSv per Gy cm(2)), which corresponds to approximately one lumbar spine X-ray radiography. The effective dose is much lower than a coronary angiography (8 mSv) or an electrophysiology study (6 mSv). Radiation dose is low compared with other interventional cardiology procedures.

Temperature-dependent low electric field charging of Si nanocrystals embedded within oxide-nitride-oxide dielectric stacks.

In this work we examine the current peaks and the negative differential resistance that appear in the low electric field regime of oxide-nitride-oxide structures with a two-dimensional band of silicon nanocrystals embedded in a nitride layer. The silicon nanocrystals were synthesized by low energy ion implantation (1 keV, 1.5 x 10(16) Si(+) cm(-2)) and subsequent thermal annealing (950 degrees C, 30 min). Electrical examination was performed at temperatures from 20 to 100 degrees C using constant voltage ramp-rate current measurements. This approach enables us to determine the origin of the observed current peaks as well as to extract the trapping location of the injected carriers within the dielectric stack. The results confirm that the carriers are trapped within the Si nanocrystal band, verifying that this region corresponds to energy minima of the dielectric stack.

Cardiac troponin I in patients with acute upper and lower limb ischemia.

BACKGROUND: The aim of this study was to investigate the presence, etiology and clinical significance of elevated troponin I in patients with acute upper or lower limb ischemia. The high sensitivity and specificity of cardiac troponin for the diagnosis of myocardial cell damage suggested a significant role for troponin in the patients investigated for this condition. The initial enthusiasm for the diagnostic potential of troponin was limited by the discovery that elevated cardiac troponin levels are also observed in conditions other than acute myocardial infarction, even conditions without obvious cardiac involvement. PATIENTS AND METHODS: 71 consecutive patients participated in this study. 31 (44%) of them were men and mean age was 75.4 +/- 10.3 years (range 44-92 years). 60 (85%) patients had acute lower limb ischemia and the remaining (11; 15%) had acute upper limb ischemia. Serial creatine kinase (CK), isoenzyme MB (CK-MB) and troponin I measurements were performed in all patients. RESULTS: 33 (46%) patients had elevated peak troponin I (> 0.2 ng/ml) levels, all from the lower limb ischemia group (33/60 vs. 0/11 from the acute upper limb ischemia group; p = 0.04). Patients with lower limb ischemia had higher peak troponin I values than patients with upper limb ischemia (0.97 +/- 2.3 [range 0.01-12.1] ng/ml vs. 0.04 +/- 0.04 [0.01-0.14] ng/ml respectively; p = 0.003), higher peak CK values (2504 +/- 7409 [range 42-45 940] U/ml vs. 340 +/- 775 [range 34-2403] U/ml, p = 0.002, respectively, in the two groups) and peak CK-MB values (59.4 +/- 84.5 [range 12-480] U/ml vs. 21.2 +/- 9.1 [range 12-39] U/ml, respectively, in the two groups; p = 0.04). Peak cardiac troponin I levels were correlated with peak CK and CK-MB values. CONCLUSIONS: Patients with lower limb ischemia often have elevated troponin I without a primary cardiac source; this was not observed in patients presenting with acute upper limb ischemia. It is very important for these critically ill patients to focus on the main problem of acute limb ischemia and to attempt to treat the patient rather than the troponin elevation per se. Cardiac troponin elevation should not prevent physicians from providing immediate treatment for limb ischaemia to these patients, espescially when signs, symptoms and electrocardiographic findings preclude acute cardiac involvement.

Effects of different N fertilizers on the activity of Glomus mosseae and on grapevine nutrition and berry composition.

Grapevine N fertilization may affect and be affected by arbuscular mycorrhizal (AM) fungal colonization and change berry composition. We studied the effects of different N fertilizers on AM fungal grapevine root colonization and sporulation, and on grapevine growth, nutrition, and berry composition, by conducting a 3.5-year pot study supplying grapevine plants with either urea, calcium nitrate, ammonium sulfate, or ammonium nitrate. We measured the percentage of AM fungal root colonization, AM fungal sporulation, grapevine shoot dry weight and number of leaves, nutrient composition (macro- and micronutrients), and grapevine berry soluble solids (total sugars or degrees Brix) and total acidity. Urea suppressed AM fungal root colonization and sporulation. Mycorrhizal grapevine plants had higher shoot dry weight and number of leaves than non-mycorrhizal and with a higher growth response with calcium nitrate as the N source. For the macronutrients P and K, and for the micronutrient B, leaf concentration was higher in mycorrhizal plants. Non-mycorrhizal plants had higher concentration of microelements Zn, Mn, Fe, and Cu than mycorrhizal. There were no differences in soluble solids ( degrees Brix) in grapevine berries among mycorrhizal and non-mycorrhizal plants. However, non-mycorrhizal grapevine berries had higher acid content with ammonium nitrate, although they did not have better N nutrition and vegetative growth.

Swallow syncope in a patient with esophageal stenosis caused by an ascending aorta aneurysm: differential diagnosis from postprandial hypotension: a case report.

Swallow syncope is usually caused by organic or functional disorders of the esophagus due to abnormal vasovagal reflex. In elderly patients this situation could be confused with postprandial hypotension. We present a case of an elderly patient who presented with swallow syncope that was caused by a waist in the midportion of esophagus induced by an ascending aorta aneurysm.

Brain natriuretic peptide increases acutely and much more prominently than atrial natriuretic peptide during coronary angioplasty.

BACKGROUND: Increased levels of plasma brain natriuretic peptide (BNP) are observed in patients with congestive heart failure, hypertension, left ventricular hypertrophy, and acute myocardial infarction. However, there are no data on serial changes in plasma levels of BNP in patients undergoing coronary angioplasty. HYPOTHESIS: The study was undertaken to examine plasma concentrations of BNP together with those of atrial natriuretic peptide (ANP) in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). METHODS: Plasma concentrations of BNP and ANP were examined in 13 patients with stable angina pectoris and good left ventricular function undergoing PTCA. Blood samples were taken from the femoral vein at baseline, after the first balloon inflation, after the end of the procedure, and 4 h thereafter. RESULTS: Plasma BNP levels were 14 +/- 4 at baseline, 22 +/- 10 after the first balloon inflation, 28 +/- 12 at the end of the procedure, and 15 +/- 4 pgr/ml 4 h thereafter (F = 13.05, p < 0.00001). Plasma ANP levels were 80 +/- 15, 86 +/- 14, 90 +/- 24, and 75 +/- 6 fmol/l (F = 5.95, p = 0.002), respectively. The increase of BNP at the end of the procedure was related to the increase of ANP (r = 0.78, p = 0.002). CONCLUSION: Plasma BNP levels increase acutely and much more prominently than those of plasma ANP during coronary angioplasty; however, plasma BNP levels return to baseline values shortly after the end of the procedure.

Intracoronary ketanserin augments coronary collateral blood flow and decreases myocardial ischemia during balloon angioplasty.

AIMS: To test the hypothesis that ketanserin augments coronary collateral blood flow and decreases myocardial ischemia during balloon angioplasty. METHODS AND RESULTS: Forty-four patients with single vessel disease and stable angina were studied. Collateral flow was determined during balloon inflations, based on the distal velocity time integral (13 patients) or on coronary wedge/mean arterial pressure measurements (10 patients). The 2nd and 3rd inflations lasted the same time and between them 1.5 mg intracoronary ketanserin in 10 ml normal saline was administered over 3 min. In 21 control subjects normal saline alone was given. In the flow velocity group the velocity time integral was 78.5+/-53.1 mm during the 2nd inflation and 106.0+/-43.2 mm during the 3rd (p<.05), while the ST deviation was 1.1+/-.7 and .7+/-.7 mm, respectively (p<.05). In the intracoronary pressure group the CWP/MBP was .40+/-.10 during the 2nd inflation and .45+/-.11 during the 3rd (p<.05), while the ST deviation was 1.2+/-.8 and .8+/-.8 mm respectively (p<.05). In the controls no variables changed during the tested inflations. CONCLUSION: Intracoronary administration of ketanserin augments coronary collateral flow and decreases myocardial ischemia during balloon angioplasty. This could be of clinical significance in the management of acute ischemic syndromes.

Effect of rotational coronary atherectomy on peripheral endothelin-1, atrial natriuretic peptide, and cyclic adenosine monophosphate plasma levels.

We investigated the effects of coronary rotational atherectomy (PTCRA) on plasma levels of endothelin-1 (ET-1), atrial natriuretic peptide (ANP), and cyclic adenosine monophosphate (cAMP). We studied 14 patients undergoing PTCRA and compared them with 14 patients undergoing plain balloon angioplasty. Blood samples were taken from the femoral vein at baseline, after the end of the atherectomy, after the first balloon inflation, after the end of the procedure, and 4 hours later. ET-1 increased in the angioplasty group from 6.3 +/- 3.2 pmol/L at baseline to 8.5 +/- 3.9 pmol/L at the end of the procedure (F = 3.83, P = .02), whereas it did not change in the PTCRA group. ANP increased in the PTCRA group from 78.1 +/- 15.7 pmol/L at baseline to 89.7 +/- 24.0 pmol/L at the end of the procedure (F = 6.75, P = .0001), whereas it did not change in the angioplasty group. cAMP decreased in the PTCRA group, whereas it did not change in the angioplasty group. In conclusion, ET-1 increases less, ANP increases more, and cAMP decreases more during atherectomy than during plain balloon angioplasty.

Beta-adrenergic blockade decreases coronary collateral blood flow in patients with coronary artery disease.

The effect of beta-adrenergic blockade on coronary collateral blood flow has not been clarified. We examined the acute effects of beta-adrenergic blockade on coronary collateral blood flow. Fifteen patients (Part A) with stable angina were studied while undergoing coronary angioplasty. According to the protocol, all patients underwent a minimum of three balloon inflations. Collateral flow velocity was determined during balloon inflations using the Doppler flow guidewire positioned distally to the lesion. The two tested balloon inflations, the second and third, were maintained for the same length of time. Between the second and third balloon inflations, 1 mg of propranolol was administered IC into the treated artery. Ten controls were studied following saline infusion. In 10 other patients (Part B), the effect of 1 mg IC propranolol on the coronary artery area distal to the lesion was studied, and five patients served as controls. In the treated group, in Part A blood pressure remained stable during the balloon inflations tested. Heart rate decreased from 79 +/- 11 to 73 +/- 12 beats/min (P < .05), velocity time integral from 9.6 +/- 8.2 to 6.6 +/- 4.1 cm (P < .05), and ST elevation from 1.3 +/- .9 to .9 +/- 1.0 mV (P < .05) between the second and third balloon inflations. In the controls the variables examined did not change during the balloon inflations tested. In Part B, neither propranolol nor normal saline had any significant effect on coronary artery lumen area. Thus, IC administration of beta-adrenergic blockade decreases coronary collateral blood flow, and this potentially worsens the ischemic zone. However, beta-adrenergic blockade ameliorates myocardial ischemia during coronary angioplasty.

Estrogen replacement therapy and exercise performance in postmenopausal women with coronary artery disease.

We treated 10 postmenopausal women with stable angina, positive exercise test, and documented coronary artery disease with oral conjugated equine estrogen (0.625 mg/day of Premarin) or placebo for 4 weeks, in random order, with crossover after a 4-week washout period. Exercise tests, performed after each treatment period while the patients were taking their usual antianginal drugs showed no differences; thus, short-term estrogen does not improve exercise-induced ischemia compared with placebo.

Mental symptoms, hostility features and stressful life events in people with cancer.

Hostility features, mental symptoms, and stressful life events were investigated in 100 patients (59 men and 41 women) suffering from cancer. Fifty-seven healthy men (n = 26) and women (n = 31) were used for comparison purposes. The assessment instruments were the Hostility and Direction of Hostility Questionnaire, the Delusions Symptoms States Inventory/states of anxiety and depression and a modified version of the Schedule of Life Experiences. Women patients reported lower scores than healthy women on total hostility, but men patients reported higher scores than healthy men. Introverted hostility was increased in both male and female patients, but due to different patterns: in women due to lower scores on extroverted hostility subscales, especially acting-out hostility, whereas in men due to higher scores on introverted hostility subscales, especially guilt. Female patients, compared with healthy women, reported significantly higher scores on the depressive and anxiety subscales, whereas in the man the differences were not statistically significant even though patients reported higher scores than normals. On the Schedule of Life Experiences, female patients reported statistically significant higher scores than healthy women.

Volume loading in predominant right ventricular infarction: bedside haemodynamics using rapid response thermistors.

Intravenous fluid loading is commonly used for the treatment of low cardiac output (CO) syndrome complicating severe right ventricular infarction (RVMI). We prospectively evaluated the effectiveness of this method in 11 consecutive patients (age 66 +/- 14 years) with severe RVMI, using a newer thermodilution method with rapid response thermistors. Volume loading was performed until pulmonary wedge pressure (PWP) reached 18 to 24 mmHg. Right atrial pressure (RAP), pressures of the right ventricle (RV) and pulmonary artery (PA), PWP, RV volumes, RV ejection fraction (RVEF), stroke volume (SV), CO, pulmonary vascular resistance (PVR) and RAP/PWP ratio were measured before and after volume loading. RAP rose from 12 +/- 4 to 19 +/- 5 mmHg (P < 0.0001) and its tracing showed a non-compliant pattern in all patients. RV end-diastolic pressure rose from 13 +/- 4 to 20 +/- 5 mmHg (P < 0.0001) and PWP from 14 +/- 3 to 20 +/- 6 mmHg (P < 0.0001). Mean PA pressure rose from 20 +/- 3 to reach 25 +/- 6 mmHg (P < 0.001), while PVR did not change significantly (117 +/- 39 vs 101 +/- 49 dyn.s.cm-5, P ns). RAP/PWP ratio rose from 0.85 +/- 0.14 to 1.05 +/- 0.07 (P < 0.01). The end-diastolic RV volume increased from 95 +/- 26 to 113 +/- 24 ml.m-2 (P < 0.001); however, RV end-systolic volume increased from 65 +/- 28 to 83 +/- 29 ml.m-2 (P < 0.01), thus SV did not change significantly (30 +/- 6 vs 30 +/- 8 ml.beat-1.m-2, P ns). RVEF decreased from 32 +/- 11 to 28 +/- 11% (P < 0.001). CO did not improve significantly (2.3 +/- 0.42 vs 2.4 +/- 0.62 l.min-1.m-2, P ns) neither did the clinical status.(ABSTRACT TRUNCATED AT 250 WORDS)

Neglected cases of papillary and follicular thyroid carcinoma. Occurrence of subcutaneous scalp metastases.

Three cases, two follicular and one of papillary thyroid carcinoma are reported. All three patients presented with subcutaneous cystic scalp metastases; they had a long-standing history of thyroid cancer, although two had never sought medical attention. We discuss this unusual clinical manifestation in patients with untreated well differentiated thyroid carcinoma.

Is androgen substitution necessary in hypogonadal patients when they are treated with chemotherapy for malignant diseases?

A patient with hypogonadotropic hypogonadism owing to endogenous gonadotropin releasing hormone deficiency, who developed Hodgkin's disease is described. Chemotherapy administration caused prolonged and life-threatening myelosuppression; androgen substitution seemed to reverse bone marrow function and to maintain normal peripheral blood counts. Whether or not androgens are a necessary substitution in hypogonadal patients suffering from cancer and undergoing chemotherapy is discussed.