Differences in guideline-recommended heart failure medication between Dutch heart failure clinics: an analysis of the CHECK-HF registry.

BACKGROUND: Heart failure (HF) is associated with poor prognosis, high morbidity and mortality. The prognosis can be optimised by guideline adherence, which also can be used as a benchmark of quality of care. The purpose of this study was to evaluate differences in use of HF medication between Dutch HF clinics. METHODS: The current analysis was part of a cross-sectional registry of 10,910 chronic HF patients at 34 Dutch outpatient clinics in the period of 2013 until 2016 (CHECK-HF), and focused on the differences in prescription rates between the participating clinics in patients with heart failure with reduced ejection fraction (HFrEF). RESULTS: A total of 8,360 HFrEF patients were included with a mean age of 72.3 ± 11.8 years (ranging between 69.1 ± 11.9 and 76.6 ± 10.0 between the clinics), 63.9% were men (ranging between 54.3 and 78.1%), 27.3% were in New York Heart Association (NYHA) class III/IV (ranging between 8.8 and 62.1%) and the average estimated glomerular filtration rate (eGFR) was 59.6 ± 24.6 ml/min (ranging between 45.7 ± 23.5 and 97.1 ± 16.5). The prescription rates ranged from 58.9-97.4% for beta blockers (p < 0.01), 61.9-97.1% for renin-angiotensin system (RAS) inhibitors (p < 0.01), 29.9-86.8% for mineralocorticoid receptor antagonists (MRAs) (p < 0.01), 0.0-31.3% for ivabradine (p < 0.01) and 64.9-100.0% for diuretics (p < 0.01). Also, the percentage of patients who received the target dose differed significantly, 5.9-29.1% for beta blockers (p < 0.01), 18.4-56.1% for RAS inhibitors (p < 0.01) and 13.2-60.6% for MRAs (p < 0.01). CONCLUSIONS: The prescription rates and prescribed dosages of guideline-recommended medication differed significantly between HF outpatient clinics in the Netherlands, not fully explained by differences in patient profiles.

Design of self-cleansing sanitary sewer systems with the use of flushing devices.

Many European countries tend to shift from constructing combined sewer systems to separate ones, in order to optimise wastewater treatment efficiency and reduce CSO impact on surface waters. An economic design minimises maintenance requirements by aiming at self-cleansing pipes. However, providing the necessary slopes for self-cleansing sanitary sewer pipes often is unfeasible in flat regions, resulting in an increased risk of loss of hydraulic capacity or blocking. To reduce these risks, flushing tanks can be installed in the sewer system. Where most other researchers contribute to a better understanding of the hydraulics of flushing, this paper rather tries to formulate a methodology to design and test flushing devices in sanitary sewer systems using standards and hydrodynamic simulations. Therefore, several aspects that require consideration when incorporating flushing devices into a sanitary sewer system are discussed. For instance, when flushing sanitary sewers the increase in discharge has to be explicitly considered. A Belgian case study is used to investigate the suitability of the developed methodology. Although the pipe slopes in the methodology are derived assuming uniform flow, the simulation results comply with it. Furthermore, pressurisation of the conduits due to multiple flushing waves remains within acceptable limits.

Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction.

OBJECTIVES: The study assessed the value of the electrocardiogram (ECG) as predictor of the left anterior descending coronary artery (LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1) in patients with acute anterior myocardial infarction (AMI). BACKGROUND: In anterior AMI, determination of the exact site of LAD occlusion is important because the more proximal the occlusion the less favorable the prognosis. METHODS: One hundred patients with a first anterior AMI were included. The ECG showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site as determined by coronary angiography. RESULTS: ST-elevation in lead aVR (ST elevation(aVR)), complete right bundle branch block, ST-depression in lead V5 (ST depression(V5)) and ST elevation(V1) > 2.5 mm strongly predicted LAD occlusion proximal to S1, whereas abnormal Q-waves in V4-6 were associated with occlusion distal to S1 (p = 0.000, p = 0.004, p = 0.009, p = 0.011 and p = 0.031 to 0.005, respectively). Abnormal Q-wave in lead aVL was associated with occlusion proximal to D1, whereas ST depression(aVL) was suggestive of occlusion distal to D1 (p = 0.002 and p = 0.022, respectively). For both the S1 and D1, inferior ST depression > or = 1.0 mm strongly predicted proximal LAD occlusion, whereas absence of inferior ST depression predicted distal occlusion (p < or = 0.002 and p < or = 0.020, respectively). CONCLUSIONS: In anterior AMI, the ECG is useful to predict the LAD occlusion site in relation to its major side branches.

Early referral for intentional rescue PTCA after initiation of thrombolytic therapy in patients admitted to a community hospital because of a large acute myocardial infarction.

BACKGROUND: If no in-house facilities for percutaneous transluminal coronary angioplasty (PTCA) are present, thrombolytic therapy is the treatment of choice for acute myocardial infarction (AMI). A few studies have shown benefit from rescue PTCA in patients directly admitted to centers with PTCA facilities. The obvious question arises whether patients with AMI initially admitted to a community hospital can benefit from early transfer for intentional rescue PTCA. METHODS AND RESULTS: One hundred sixty-five patients were transferred early for intentional rescue PTCA from a community hospital at a distance of 20 miles. On arrival at the angioplasty center, bedside markers were used to determine reperfusion. In case of obvious reperfusion, no invasive procedure was done; otherwise, coronary angiography and rescue PTCA, if necessary, was performed. During transfer, 1 (1%) patient died and 15 (9%) patients had arrhythmic or hemodynamic problems. Median time delay between onset of chest pain and arrival at the community hospital and the PTCA center was 61 minutes (range 0 to 413) and 150 minutes (range 28 to 472), respectively. In 66 (40%) patients, reperfusion was diagnosed by noninvasive reperfusion criteria on arrival at the PTCA center (group 1). Ninety-eight (59%) patients without evident noninvasive criteria of reperfusion underwent angiography 187 median minutes after the onset of chest pain. Forty-one (25%) patients had Thrombolysis In Myocardial Infarction grade 3 flow, and no further intervention was performed (group 2). In the remaining 57 (35%) patients, rescue PTCA was performed, which was successful in 96% (group 3). In-hospital mortality rate was lowest in group 1 compared with the other 2 groups (0% vs 7% vs 11%; P <.05). Reinfarction was highest in group 1 compared with the other groups (17% vs 5% vs 2%; P <.01). No significant differences were found in coronary artery bypass grafting, stroke, or bleeding complications. The 1-year follow-up data showed low revascularization rates; 2 (1%) patients died after discharge from the hospital. CONCLUSIONS: Early transfer of patients with large AMI for intentional rescue PTCA can be done with acceptable safety and is feasible within therapeutically acceptable time limits and results in additional early reperfusion in 33% of patients. A large, randomized, multicenter trial is needed to compare efficacy of intravenous thrombolytic treatment in a community hospital versus early referral for either rescue or primary PTCA.

Determination of carbaryl as its primary metabolite, 1-naphthol, by reversed-phase high-performance liquid chromatography with fluorometric detection.

Carbaryl and its hydrolysis product, 1-naphthol, are determined simultaneously, and in a mixture of other pesticides, by reversed-phase high-performance liquid chromatography (HPLC). Fluorometric detection affords a higher degree of selectivity than absorbance detection, while providing detection limits of 1.0 ng ml(-1) and 1.4 mg ml(-1) for 1-naphthol and carbaryl, respectively. The described method requires no enrichment of samples and includes a simple hydrolysis step. Additionally, enhancement of fluorescence detection signal intensity is explored through HPLC solvent composition effects as well as through formation of cyclodextrin inclusion complexes. The method described in this report is a selective and fast alternative to the currently accepted U.S. Environmental Protection Agency (EPA) method of detection carbaryl in ground water.

Myocardial rupture after myocardial infarction is related to the perfusion status of the infarct-related coronary artery.

Acute or subacute myocardial rupture is a serious and often lethal complication of acute myocardial infarction. The role of an occluded or open culprit coronary artery on the occurrence of this complication is not clear. We therefore reviewed the perfusion status of the infarct-related coronary artery retrospectively in 57 patients who had an initially nonfatal rupture (group A) and 28 patients (including 9 patients from group A) with a postmortem diagnosis of myocardial rupture (group B). In 35 of the 57 patients in group A, a coronary angiogram was available. Complete occlusion or ineffective reperfusion was present in 30 (89%) of 35 patients. The remaining 22 patients of group A showed no clinical signs of reperfusion. All 28 patients of group B had inadequate reperfusion of the infarcted area on postmortem angiography and macroscopic examination of the coronary artery. Our observations suggest that myocardial rupture typically occurs in an infarcted area without reperfusion.

Differences in the intestinal microflora of normal and dystrophic BIO 8262 Nij Syrian hamsters.

The microflora of the gastro-intestinal tract of dystrophic BIO 8262 Nij Syrian hamsters and Kun:Sh Syrian hamsters as controls was investigated by means of culturing techniques and scanning electron microscopy. The oesophagus, forestomach, stomach, small intestine, coecum and faeces were assessed for the presence of Enterobacteriaceae, Staphylococci, Lactobacilli, Streptococci, Clostridia, Bacteroides and yeasts. The normal hamsters showed low levels of yeasts in the oesophagus, forestomach and stomach; yeasts were not present in the other compartments. Relatively low levels of Staphylococci and Enterobacteriaceae were found in all gut segments; also Bacteroides was found in low levels in the upper part of the gut. The other groups of bacteria showed relatively high levels in all segments. In dystrophic BIO 8262 Nij hamsters no Enterobacteriaceae and yeasts have been detected in the gut. Scanning electron microscopy showed no difference in adhesion between both hamsters strains.

Ultraviolet spectrometric detection for gas chromatography of polynuclear aromatic compounds with repetitive spectral scans using absorbance and concurrent fluorescence measurements.

A computer-controlled ultraviolet spectrometric detection system for gas chromatography (GC) is described which acquires absorption spectra of gas-phase GC effluents at rates up to two 62-nm scans per s. Concurrent fluorescence measurements enhance the selectivity of this detection system, providing additional qualitative information. The system has been designed to preserve chromatographic resolution and is selective for aromatic compounds. This multi-mode GC detection is demonstrated through GC separations of polynuclear aromatic compounds with limits of detection ranging from 30 to 70 ng for absorbance measurements. The spectral information obtained with this detection system may be used for compound identification, enhancement of the selectivity and for resolving co-eluting GC eluites.

Assembly of Agrostemma githago (corn-cockle) storage proteins and their precursor proteins into oligomers.

The major fraction of seed storage proteins of Agrostemma githago (corn-cockle), a non-leguminous dicot, occurs as material with S20,w values of approximately 11S and approximately 2S, and a minor fraction as oligomers with S20,w values of approximately 6.5S. The 11S proteins are of the legumin type and consist of disulphide-linked alpha- and beta-subunits of Mr approximately 39 000 and approximately 23 000 respectively. The oligomeric assembly of the precursor polypeptides of the 11S proteins was examined. The approximately 65 000-Mr precursor polypeptides of two 11S proteins, which consist of 38 000-25 000-Mr subunits and 36 000-22 000-Mr subunits respectively, were assembled into oligomers of approximately 7S and subsequently cleaved. Thereafter the 11S oligomer was formed. The 88 000-Mr precursor of a third 11S protein, which consists of 41 000-23 000-Mr subunits, was assembled into an approximately 8S oligomer and then cleaved, yielding two disulphide-linked intermediates of Mr 59 000 and 24 000. Thereafter, the 11S oligomer was formed. Processing of the 59 000-Mr to the 41 000-Mr polypeptide occurred both in the 8S and in the 11S form.