[Agreement between observers with different experience in the interpretation of the stress myocardial perfusion electrocardiogram in SPECT]. / Concordancia entre observadores con distinta experiencia en interpretación de electrocardiograma de esfuerzo en SPECT de perfusión miocárdica.

UNLABELLED: Coronary artery disease (CAD) is the leading cause of death in many countries. Stress electrocardiogram (ECG) is able to detect myocardial ischemia and also has prognostic value, which may be impaired in presence of electrical baseline abnormalities. Stress myocardial single photon emission tomography (SPECT) has recognized utility yield in assessment of CAD, requiring independent interpretation of ECG and myocardial images. PURPOSE: To analyze stress ECG interpretation reproducibility among observers with different training level, including pre- and post-graduate medical students, compared to an experienced cardiologist and also with SPECT. METHOD: We studied 95 patients under CAD evaluation, mean age 61+/-9.3 years (range: 42-85), 56% male. Interobserver correlation kappa (k) between perfusion gated (99m)Tc-Sestamibi SPECT and exercise ECG were calculated as normal/abnormal, presence of necrosis, ischemia or mixed pattern. Interobserver kappa (k) analysis was made. RESULTS: 49.5% stress ECG and 45% SPECT studies were abnormal at the initial report with 62.1% concordance (k: 0.24) for normal/abnormal and 58.9% for ischemia (k: 0.14). Agreement between stress ECG initial report and independent cardiologist was 89.5% (k: 0.78). The correlation between independent observers and the initial report ranged between 62.1% and 48.4%, for baseline ECG between 41.1% and 90.5% considering normal/abnormal, and between 80% and 93.7% (k: 0.59-0.87) for the presence of ischemia. CONCLUSION: Stress ECG interpretation presented adequate interobserver reproducibility with greater agreement in the most experienced observers, confirming the importance of training.

Concordancia entre observadores con distinta experiencia en interpretación de electrocardiograma de esfuerzo en SPECT de perfusión miocárdica / Agreement between observers with different experience in the interpretation of the stress myocardial perfusion electrocardiogram in SPECT

ResumenLa enfermedad coronaria (EC) es la principal causa de muerte en muchos países. El electrocardiograma (ECG) de esfuerzo permite evaluar la isquemia miocárdica y agrega valor pronóstico, con rendimiento limitado en presencia de alteraciones eléctricas basales. La SPECT (single photon emission computed tomography ‘tomografía computarizada por emisión de fotón único’) en esfuerzo se utiliza para evaluación de EC, con reconocido buen rendimiento, que requiere interpretación independiente del ECG y de las imágenes miocárdicas.ObjetivoAnalizar la concordancia en la interpretación del ECG de esfuerzo entre observadores en entrenamiento, incluyendo alumnos de pre y posgrado de Medicina, con un cardiólogo experimentado y con SPECT miocárdica.MétodoSe incluyeron 95 pacientes enviados para evaluación de EC, edad: 61 ± 9,3 años (rango: 42–85), 56%: hombres. Se calculó la concordancia entre la SPECT de perfusión sincronizada con 99mTc-Sestamibi y ECG de esfuerzo según resultado normal/anormal, necrosis, isquemia o patrón mixto. Se efectuó un análisis interobservador kappa (k).ResultadosFueron anormales el 49,5% de los ECG de esfuerzo según informe inicial y el 45% de los estudios SPECT; la concordancia para normal/anormal fue del 62,1% (κ: 0,24) y para isquemia del 58,9% (κ: 0,14). La concordancia entre informe ECG de esfuerzo inicial y el del cardiólogo independiente fue del 89,5% (κ: 0,78). Las concordancias interobservador con este informe variaron entre el 62,1 y el 48,4%; para ECG basal, entre el 41,1 y el 90,5% considerando normal/anormal; y entre el 80 y el 93,7% (κ: 0,59–0,87) para isquemia entre éste y otros observadores.ConclusiónEn la interpretación del ECG de esfuerzo se encontró adecuada reproducibilidad entre observadores, con mayor acuerdo en los más experimentados, lo que confirma la importancia del entrenamiento(AU9

AbstractCoronary artery disease (CAD) is the leading cause of death in many countries. Stress electrocardiogram (ECG) is able to detect myocardial ischemia and also has prognostic value, which may be impaired in presence of electrical baseline abnormalities. Stress myocardial single photon emission tomography (SPECT) has recognized utility yield in assessment of CAD, requiring independent interpretation of ECG and myocardial images.PurposeTo analyze stress ECG interpretation reproducibility among observers with different training level, including pre- and post-graduate medical students, compared to an experienced cardiologist and also with SPECT.MethodWe studied 95 patients under CAD evaluation, mean age 61±9.3 years (range: 42–85), 56% male. Interobserver correlation kappa (k) between perfusion gated 99mTc-Sestamibi SPECT and exercise ECG were calculated as normal/abnormal, presence of necrosis, ischemia or mixed pattern. Interobserver kappa (k) analysis was made.Results49.5% stress ECG and 45% SPECT studies were abnormal at the initial report with 62.1% concordance (k: 0.24) for normal/abnormal and 58.9% for ischemia (k: 0.14). Agreement between stress ECG initial report and independent cardiologist was 89.5% (k: 0.78). The correlation between independent observers and the initial report ranged between 62.1% and 48.4%, for baseline ECG between 41.1% and 90.5% considering normal/abnormal, and between 80% and 93.7% (k: 0.59–0.87) for the presence of ischemia.ConclusionStress ECG interpretation presented adequate interobserver reproducibility with greater agreement in the most experienced observers, confirming the importance of training(AU)

201Tl myocardial SPECT detects significant coronary artery disease between 50% and 75% angiogram stenosis.

UNLABELLED: Coronary angiography is the "gold standard" for the diagnosis of coronary artery disease (CAD). The aim of this work was to compare 201Thallium SPECT with different coronary angiographic cutoff values. METHODS: Data pertaining to 145 patients were tabulated. All patients underwent stress ECG, 201Thallium SPECT and coronary angiography. To assess the cutoff impact, two criteria for coronary angiography diagnosis were used: a) > or = 50% and b) > or = 75% stenosis, and applied to data from patients and vessels. RESULTS: On a patient basis, 201Thallium SPECT sensitivity, specificity and accuracy were 87%, 57% and 81% with > or = 50% cutoff and 93%, 51% and 79% with > or = 75% cutoff, respectively (NS). When performing individual vessel analysis, sensitivity, specificity and accuracy were 59%, 78% and 68% for > or = 50% cutoff and 70%, 75% and 74% for > or = 75% cutoff, respectively (p < 0.029 for sensitivity). As expected, the severer the stenosis the higher the detection rate. There were 19 patients who had stenosis between 50% and 74%. Of these, 21% had abnormal stress ECG and 58% abnormal Thallium-201 SPECT. CONCLUSION: 201Thallium SPECT results support the use of > or = 50% stenosis cutoff criteria for CAD diagnosis and evaluation. Combined with coronary angiography, myocardial SPECT offers an excellent management strategy to patients.

201Tl myocardial SPECT detects significant coronary artery disease between 50 % and 75 % angiogram stenosis

La angiografía coronaria es el estándar de oro para diagnosticar enfermedad coronaria. El objetivo de este trabajo fue comparar los resultados del SPECT con Talio 201 con los diversos valores de estenosis coronaria a la angiografía. Métodos: Se tabularon resultados de 145 pacientes. A todos ellos se les realizó una prueba de esfuerzo, SPECT de perfusión miocárdica con Talio 201 y angiografía coronaria. Para hacer la valoración se utilizaron 2 criterios angiográficos para estenosis coronaria: a) >= 50 % b) >= 75 %, los que se aplicaron a los pacientes y vasos coronarios estudiados por individual. Resultados: En una evaluación individual por paciente la sensibilidad (S), especificidad (E) y exactitud (Ex) fue de 87 %, 57 % y 81 % con criterio de estenosis de >= 50 % y de 93 %, 51 % y 79 % usando criterio de >= 75 %, respectivamente (NS). Al analizar los vasos individualmente la S, E y Ex fue de 59 %, 78 % y 68 % para criterio >= 50 % y 70 %, 75 % y 74 % para criterio >= 75 % (p < 0,029 para S). Como era esperado a mayor severidad de estenosis, mayor incidencia de detección. Hubo 19 pacientes que presentaron estenosis entre 50 y 74 %. De ellos 21 % presentó prueba de esfuerzo anormal y 58 % SPECT de perfusión miocárdica anormal. Conclusión: Los resultados con el estudio de perfusión miocárdica con Talio 201 avalan el uso del valor de 50 % o más de estenosis en el diagnóstico y evaluación de enfermedad coronaria. En conjunto con la angiografía coronaria el SPECT miocárdico ofrece una excelente estrategia para el manejo de los pacientes

Coronary angiography is the "gold standard" for the diagnosis of coronary artery disease (CAD). The aim of this work was to compare 201Thallium SPECT with different coronary angiographic cutoff values. Methods: Data pertaining to 145 patients were tabulated. All patients underwent stress ECG, 201Thallium SPECT and coronary angiography. To assess the cutoff impact, two criteria for coronary angiography diagnosis were used: a) >= 50 % and b) >= 75 % stenosis, and applied to data from patients and vessels. Results: On a patient basis, 201Thallium SPECT sensitivity, specificity and accuracy were 87 %, 57 % and 81 % with >= 50 % cutoff and 93 %, 51 % and 79 % with >= 75 % cutoff, respectively (NS). When performing individual vessel analysis, sensitivity, specificity and accuracy were 59 %, 78 % and 68 % for >= 50 % cutoff and 70 %, 75 % and 74 % for >= 75 % cutoff, respectively (p = 50 % stenosis cutoff criteria for CAD diagnosis and evaluation. Combined with coronary angiography, myocardial SPECT offers an excellent management strategy to patients

[Oral health screening: evaluation of implementation of a national programme]. / Evaluation de la réalisation du bilan bucco-dentaire (BBD) conventionnel.

BACKGROUND: The first national French oral health screening was implemented in 1998 toward young people aged from 15 to 18 Years. These adolescents were invited every year to a free dental check up performed by their dentist. The aim of this study, carried out for self-employed persons insured by compulsory national health insurance, was to measure the rate of dental checks during years 1998-1999-2000, to estimate the oral health status, to assess the factors related to the dental care consumption in 1998, and the predictive factors for a successive dental check. METHODS: We included seventy four French counties. Every teenager born in 1983 (23.874) was invited. We collected data from both the health insurance databases and the form filled in by the consulted dental surgeons. We selected four variables: gender, residence place, social, and occupational group to study the consumption in 1998. RESULTS: In 1998, 10% (2462) of teenagers have got a dental check up (EXP1). Only 0,7% participated in the three screenings (1998-1999-2000). We noted a higher female consumption and disparities between the main categories of self-employed persons. Participation by boys was higher than girls. The lowest participation rates concerned the Ile of France area and adolescents living with single parents. In 1998 (EXP1), 57% of teenagers had at least one decayed tooth. Only 69% of them received appropriate curative dental treatments in the following six-Months period. However, among teenagers followed during the three years, higher rates of care reaching 90% were observed on the second and third EXP. CONCLUSION: This small participation rate may be related to the recent implementation of screening. It should lead to optimize screening and to associate other partners in particular the state education system. It should also be helpful in focusing the oral health prevention policy toward the population with a high risk of decay.

[Antihypertensive effects of valsartan. National multicentric study]. / Efecto antihipertensivo del valsartán. Estudio multicéntrico nacional.

BACKGROUND: Valsartan is an angiotensin AT1 receptor antagonist. Clinical studies have shown that this is an effective and well tolerated drug. AIM: To compare valsartan with other commonly used antihypertensives in a National multicentric study. MATERIAL AND METHODS: Between 1997 and 1998, a pharmacological surveillance of patients with mild or moderate hypertension, coming from different regions of the country, was carried out. Patients were followed during 8 weeks. In the group treated with valsartan, the initial dose was 80 mg/day. After four weeks of therapy, and according to patient's response the dose of valsartan or of the other antihypertensives was modified. RESULTS: Five hundred ninety three patients, aged 59 years old as a mean, were included in the study. Of these 434 (265 female) received valsartan and 159 (101 female) other antihypertensive drugs. Fifteen percent of patients treated with valsartan and 25% of patients with other medications required a dose change at four weeks, due to lack of response (p < 0.01). At week eight, 1.5% of patients with valsartan and 17.4% of patients with other medications reported adverse effects such as cough, headache, edema or flushing (p < 0.01). CONCLUSIONS: In this Chilean observational multicentric study, valsartan proved to be more effective and to cause less adverse effects than commonly used medications in hypertensive patients.

[Comparative effects of policosanol and two HMG-CoA reductase inhibitors on type II hypercholesterolemia]. / Efecto comparativo de policosanol con dos inhibidores de la HMG-CoA reductasa en el tratamiento de la hipercolesterolemia tipo II.

BACKGROUND: Policosanol is a new cholesterol lowering agent derived from sugar cane. AIM: To compare the cholesterol lowering efficacy of policosanol with HMG CoA inhibitors. PATIENTS AND METHODS: Patients with a LDL cholesterol over 160 mg/dl were studied. If, after 6 weeks of diet, cholesterol persisted elevated, they were doubly blind randomized to receive policosanol 10 mg/day (55 patients), lovastatin 20 mg/day (26 patients) or simvastatin 10 mg/day (25 patients). Serum cholesterol was measured again after 8 weeks of therapy. RESULTS: Initial demographic and laboratory data were similar among treatment groups. A 24% LDL cholesterol reduction was obtained with policosanol, compared with a 22% reduction with lovastatin and a 15% reduction with simvastatin. HDL cholesterol significantly increased in patients on policosanol and did not change in the other treatment groups. Adverse effects of policosanol were mild and unspecific. No changes in hepatic enzymes were observed. CONCLUSIONS: Policosanol is a safe and effective cholesterol reducing agent.

[Outbreak of methicillin-resistant Staphylococcus aureus in general hospital intensive care unit]. / Epidémie à Staphylococcus aureus résistant à la méticilline dans une réanimation polyvalente d'un hôpital général.

Mantes' hospital polyvalent intensive care unit (ICU) experienced an outbreak episode caused by methicillin resistant Staphylococcus aureus (MRSA). Suspicion of physicians was strengthened by observing the weekly reading of multiresistant germs and the significative increase of MRSA carriers incidence rate, compared with the number of admission in the ICU: 5.5% to 11.3%. This outbreak was surprising: it happened immediately after the installation in a new hospital and the reinforcement of nosocomial infection surveillance (systematic screening of every patient admitted to the I.U.C., his isolation if he presents risk factors to multiresistant germs, increasing of handwashing stations). The overlapping period of hospitalisation concerning the 13 patients being reported as SARM carrier, having the same antibiogram, and the epidemic curve suggested a cross contamination. The index case was a MRSA carrier the day of her admission and have had a recent hospitalisation in a high risk unit. MRSA has always been isolated in nasal swab. Six patients among the thirteen carriers developed an infection and have been treated by vancomycin: two systemic infections and four pulmonary infections. The mortality rate was 33% and only one of them seemed to be directly due to MRSA. Area samples were all negative. The clinical staff have been screened with nasal swab. We identified only one nasal MRSA carrier. The pulsed-field gel electrophoresis study showed that 9/11 which have been analysed were identical. This outbreak brought about staff, more sensibilisation to the nosocomial infection and updating of plain hygien rules leaded to its stop five months later.

[Recommendations for the use of ambulatory blood pressure monitoring. Consensus document of the Chilean Hypertension Society]. / Recomendaciones sobre el uso de la monitorización ambulatoria de presión arterial. Documento de consenso de la Sociedad Chilena de Hipertensión.

Continuous ambulatory blood pressure monitoring is a diagnostic technique devised as a consequence of the great variations in blood pressure measurements. It allows multiple daily measurements, nocturnal monitoring, avoids the stress of blood pressure measurements, gives a picture of pressure behavior during 24 hours and reduces observer related errors. The equipment used must be accurate and validated using international protocols. Accepted indications for continuous ambulatory blood pressure monitoring are white coat hypertension, episodic hypertension, resistance to medications and assessment of symptoms or autonomic dysfunction. Other indications with less clear cut usefulness, are high risk cardiac, renal or pregnant patients and an accurate blood pressure control. We describe equipment calibration, elements that must be considered in the reports, result interpretation and conclusions. Normal blood pressure ranges for children and pregnant women are also reported.

Is ouabain produced by the adrenal gland?

1. Ouabain or a related stereoisomer, termed endogenous ouabain, has been identified in adrenal cortex tissue and culture medium from adrenocortical cells. 2. Angiotensin II and adrenocorticotropin, the main activators of aldosterone secretion from adrenal glomerulosa cells appear to increase the production of this compound. 3. The purpose of this review is to briefly discuss recent available experimental evidence suggesting that endogenous ouabain is secreted by the zona glomerulosa of the adrenal gland.

[Predictive value of the ergometric test stress parameters for myocardial ischemia according to SPECT thallium-201 scintigraphy]. / Valor de los parámetros de la prueba ergométrica para predecir isquemia miocárdica de acuerdo a cintigrafía SPECT con Talio 201.

BACKGROUND: Exercise EKG is used as the test of choice in the diagnosis of coronary artery disease. Classical parameters are angor and ST depression representing myocardial ischemia. AIM: To correlate exercise EKG parameters with SPECT 201Thallium to know their likelihood ratios for ischemia. PATIENTS AND METHODS: Two hundred seventy four patients (171 men), aged 58 years old as a mean, were studied. Of these, 23% had a prior myocardial infarction. The likelihood ratios for the presence of ischemia of ST depression, failure to increase blood systolic pressure, the presence of angor and its duration during stress testing were calculated according to the results of SPECT 201Thallium. Seventy one patients were also subjected to a coronary angiography. RESULTS: Among men, likelihood ratios for the presence of angor, failure to increase systolic pressure, ST alterations and duration of angor were 6.9, 6.15, 1.77 and 1.27 respectively. Among women, the figures were 5.45, 1.77, 0.58 and 1.4 respectively. The diagnostic accuracy of SPECT 201Thallium, when correlated with the results of coronary angiography, was 85%. CONCLUSIONS: Among men, the best exercise EKG predictors for myocardial ischemia were the failure to increase systolic blood pressure and the presence of angor. Among women the only significant predictor was the presence of angor.

[Clinical effectiveness of and tolerance to ramipril in the treatment of essential arterial hypertension phase 1 and 2. Results of a multicenter study]. / Eficacia clínica y aceptabilidad de ramipril en el tratamiento de la hipertensión arterial esencial etapas 1 y 2. Resultados de un estudio multicéntrico.

BACKGROUND: In the last two decades, angiotensin converting enzyme inhibitors have become first line medications in the treatment of hypertension. AIM: To assess the tolerance and effectiveness of ramipril as monotherapy in the treatment of essential hypertension. PATIENTS AND METHODS: One hundred eighty eight hypertensive patients, aged 21 to 80 years-old, coming from 4 Chilean hospitals were studied. Using an open non controlled design; they were treated with placebo for two weeks and with the active drug during eight weeks, in initial doses of 2.5 mg/day that were adjusted to 5 mg/day if diastolic blood pressure did not drop below 90 mm Hg or if its reduction was less than 10 mm Hg. RESULTS: During the active drug treatment period, systolic blood pressure decreased from 164.8 +/- 7.2 to 147.3 +/- 4.8 mm Hg. Diastolic blood pressure dropped from 102.3 +/- 3.1 to 87.8 +/- 3.0 mm Hg. Seventy percent of patients achieved a diastolic blood pressure of less than 90 mm Hg, 56.9% with 2.5 mg/day and 13.8% with 5 mg/day. Dizziness, cough and headache were the main adverse reactions, observed in 3.7, 3.2 and 2.1% of patients respectively. Adherence to treatment was 98%. There were no changes in laboratory values during the treatment period. CONCLUSIONS: Ramipril is effective and well tolerated in the treatment of essential hypertension.

[The antihypertensive response to prazosin, a selective vascular alpha blocker. A multicenter study]. / Respuesta antihipertensiv a al prazosin, un alfa bloqueador vascular selectivo. Estudio multicéntrico.

The efficacy and safety of oral prazosin was assessed in 108 ambulatory mild (91-104 mmHg diastolic pressure) to moderate (104-114 mmHg) essential hypertensive patients. After a 2 week no-drug control period, prazosin, 2, 4, 8 or 10 mg per day was given in 2 weeks periods as needed to obtain control of blood pressure. A seating diastolic pressure of < or = 90 mmHg was defined as adequate response. Satisfactory blood pressure response was obtained in 86% of patients, with doses of 4 mg or less in 70%. Treatment results were not related to initial blood pressure level, but obese patients were more resistant to drug effect (p < 0.05). Heart rate and laboratory parameters did not change. Adverse effects, mainly headache, dizziness and palpitations, were noticed in 46 patients (43%) and occurred with the lower dose in 78% of them. Adverse effects were slight or moderated and lasted from 1 day to 2 weeks in most patients. Treatment was discontinued in 2 patients, one because of persistent dizziness which was promptly relieved after stopping the drug and another due to syncope occurring immediately after a dose increase. We conclude that oral prazosin at low doses is an effective and well-tolerated drug which should be considered in the treatment of mild to moderate hypertension.