Pregnant Women's Acceptability of Alcohol, Tobacco, and Drug Use Screening and Willingness to Disclose Use in Prenatal Care.

PURPOSE: Despite the prevalence of alcohol, tobacco, and other drug (ATOD) use screening as part of prenatal care, pregnant women's perspectives on screening are largely absent from research and clinical practice. This study examines pregnant women's acceptability of ATOD screening and willingness to disclose their ATOD use in prenatal care. METHODS: Pregnant women completed a self-administered survey and structured interview at four prenatal care facilities in Louisiana and Maryland (N = 589). Participants reported the acceptability of screening and their willingness to honestly disclose their ATOD use to their provider. Data were analyzed through descriptive statistics, tests of proportions, simple regression models, and coding of open-ended responses. RESULTS: Nearly all pregnant women found screening acceptable for alcohol (97%), tobacco (98%), and other drug use (97%) during prenatal care. The acceptability of alcohol use screening was higher among those who reported binge drinking (98% vs. 96%; p = .002) and risky alcohol consumption (99% vs. 96%; p = .018). The acceptability of screening for other drugs was higher among women reporting binge drinking (98% vs. 96%; p = .032) and other drug use (98% vs. 96%; p = .058). Almost all pregnant women indicated that they were willing to disclose their alcohol (99%), tobacco (99%), and other drug use (98%) to their provider. CONCLUSIONS: Almost all women considered verbal screening for ATOD use during prenatal care acceptable and indicated that they were willing to honestly disclose their ATOD use. Verbal screening may allow for the opportunity to initiate safe, nonjudgmental conversations about women's substance use, risk, and goals for their ATOD use, pregnancy, and parenting.

Role of non-invasive imaging in the management of coronary artery disease: an assessment of likely change over the next 10 years. A report from the British Cardiovascular Society Working Group.

Coronary angiography has been the gold standard for determining the severity, extent and prognosis of coronary atheromatous disease for the past 15-20 years. However, established non-invasive testing (such as myocardial perfusion scintigraphy and stress echocardiography) and newer imaging modalities (multi-detector x ray computed tomography and cardiovascular magnetic resonance) now need to be considered increasingly as a challenge to coronary angiography in contemporary practice. An important consideration is the degree to which appropriate use of such techniques impacts on the need for coronary angiography over the next 10-15 years. This review aims to determine the role of the various investigation techniques in the management of coronary artery disease and their resource implications, and should help determine future service provision, accepting that we are in a period of significant technological change.

Balloon pulmonary valvuloplasty in carcinoid syndrome.

Half of all patients with carcinoid syndrome develop cardiac involvement. Patients who have cardiac involvement have a significantly worse prognosis than those without, and death can occur directly as a result of cardiac involvement. A case of carcinoid syndrome in a 38 year old woman with lesions in the liver, who presented with right sided valvar abnormalities, a dilated right ventricle, and right ventricular pressure overload, is presented. In order to palliate the patient's symptoms and to decrease right sided pressures before major abdominal surgery, balloon pulmonary valvuloplasty was performed at the time of cardiac catheterisation. This resulted in a reduction in the pulmonary gradient and right ventricular pressure. Following the procedure, the patient's symptoms were completely relieved. She went on to laparotomy where the lesions in the liver were excised without complication.

Clinical evaluation is better: myoglobin estimation used singly as a discriminant for early acute myocardial infarction does not well identify patients who will benefit from thrombolytic therapy.

We have examined the use of serum myoglobin concentration in the management of cases of suspected acute myocardial infarction (AMI). In a series of 51 patients myoglobin, used as a discriminant, correctly identified 97% (28/29) of cases as AMI with one false positive. Initial clinical judgement based on history, examination and the electrocardiogram correctly identified 66% (19/29) of cases with one false positive. These patients were given streptokinase. However, in these further identified AMI patients, 78% (7/9) had small enzyme rises with non-Q wave infarction and/or non-ST elevation and therefore may not have benefited from thrombolytic therapy in contrast to the Q wave/raised ST segment infarcts with large enzyme rises identified by clinical means. Enthusiasm for myoglobin estimation, where used as a discriminant for AMI, as a direct pointer to thrombolysis in the early diagnosis of AMI should be tempered by this finding.

The effect of impaired renal function on the pharmacokinetics of metoprolol after single administration of a 14/190 metoprolol OROS system.

Renal function is known to sometimes have a significant effect on the pharmacokinetics of drugs or drug metabolites, which are eliminated in appreciable amounts by the kidneys. For this reason, we conducted a study to compare the plasma concentration profiles of metoprolol and its metabolite, alpha-hydroxymetoprolol (OH-metoprolol), in healthy volunteers and in renally impaired patients. Following a single oral dose of a 14/190 metoprolol OROS (oral osmotic) tablet, plasma metoprolol profiles were shown to be similar for both subject groups. However, in renally impaired patients, renal clearance of OH-metoprolol was reduced and mean plasma levels of OH-metoprolol were increased approximately two- to threefold in comparison with healthy volunteers. The accumulation of OH-metoprolol in plasma, however, is unlikely to contribute to the beta-blocking effect of metoprolol, since OH-metoprolol possesses only one tenth the activity of its parent compound.

Acute hemodynamic effects of single-dose nicorandil in coronary artery disease.

Fifteen patients undergoing routine cardiac catheterization for investigation of chest pain were given a single dose of 40 mg of nicorandil either sublingually (8 patients) or orally (7 patients). Fourteen patients had angina (11 effort, 3 atypical) and 1 had palpitations but all had normal left ventricular (LV) function (mean LV end-diastolic pressure 7.4 mm Hg). Hemodynamic evaluations and plasma drug concentrations were performed at baseline and 5, 15, 30, 45 and 60 minutes after dosing. In addition, venous compliance was determined at baseline, 15 and 45 minutes using forearm venous occlusion plethysmography. Significant (p less than 0.05) central and peripheral hemodynamic changes occurred within 15 minutes. A reduction in preload was apparent from a decrease in LV end-diastolic pressure (from 7.4 +/- 1.7 to -2.6 +/- 1.5 mm Hg [p less than 0.05]) and a simultaneous decrease in mean pulmonary artery pressure (from 10.8 +/- 0.7 to 5.1 +/- 0.6 mm Hg [p less than 0.05]) at 60 minutes after dosing. This reduction in preload may reflect the venous vasodilatory activity of the drug as indicated by significant (p less than 0.05) increases in venous capacitance at 15 and 45 minutes. Total peripheral resistance decreased to a maximum of 19% (p less than 0.05) at 30 minutes and then began to return toward baseline. This effect in reducing afterload led to a substantial decrease (p less than 0.05) in systolic and diastolic aortic blood pressures, which was maximal at 45 minutes (34 and 21%, respectively). Transient increases in heart rate (p less than 0.05) and cardiac contractility indexes (p less than 0.05) were also observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise capacity after single and twice-daily doses of nicorandil in chronic stable angina pectoris.

In a double-blind parallel group study, 46 patients with chronic stable angina were randomized, after a 2-week placebo washout period, to 1 of 3 treatment groups for an additional 2 weeks. Groups 1 and 2 received nicorandil (5 mg, n = 5; 10 mg, n = 10) twice daily, respectively, increasing to 10 and 20 mg (n = 20) twice daily after 1 week of treatment; group 3 continued to receive placebo. A symptom-limited Bruce protocol exercise test was performed before and 2 hours after the initial dose and, after 2 weeks of treatment, 2 and 12 hours after administration. The following parameters were measured: resting, peak exercise and recovery blood pressure and heart rate, exercise duration, time to onset of angina and time to 1 mm of ST-segment depression. After initial dosing, there were significant increases in exercise duration (16%--n = 5, n = 10 vs -2% [placebo]) and time to onset of angina (20%, n = 5; 26%, n = 10 vs 5% [placebo]) (p less than 0.05). Time to onset of 1 mm of ST-segment depression increased in the nicorandil-treated groups compared with that in the placebo group (27%, n = 5; 25%, n = 10 vs 8% [placebo]). Calculated total exercise work increased in both nicorandil groups compared with exercise work in the placebo group (30%, n = 5; 19%, n = 10 vs 3% [placebo]). A decrease in resting systolic blood pressure (12%) in the 10-mg group was the only significant alteration in the hemodynamic parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic relapsing pericarditis and dilated cardiomyopathy: serological evidence of persistent enterovirus infection.

By means of two different IgM-capture assays, enterovirus-specific IgM responses were shown in 9 of 14 (64%) patients with chronic relapsing pericarditis. This finding suggests persistent enterovirus infection, particularly coxsackie B virus infection. IgM responses persisted for at least 1 year and for up to 10 years after onset of symptoms. In contrast, patients with acute enterovirus infections, including acute pericarditis, had transient responses. Among patients with acute pericarditis, the level of IgM antibody was significantly higher in those who subsequently relapsed (mean 1.21, range 0.6-2.0 optical density [OD] units) than in those who did not (0.4, 0.2-0.9 OD units; p less than 0.01). Of 86 patients with dilated cardiomyopathy, 28 (33%) showed enterovirus-specific IgM responses which were present for up to 19 months before transplantation and persisted up to 4 years afterwards. Although the distribution of HLA types in these patients was similar to that in the general population, the frequency of the HLA A2 haplotype was significantly higher in those who were IgM positive. IgM antibody was significantly more common in those who had had symptoms for longer than a year before transplantation than in those with a shorter duration of symptoms (1 of 21 vs 8 of 23; p less than 0.02). Persistent virus-specific serum IgA responses were also shown in patients with chronic cardiac disease.

Enhanced pressor sensitivity to oral tyramine challenge following high dose selegiline treatment.

Blood pressure and heart rate responses to oral tyramine have been measured in healthy volunteers before and after administration of the selective monoamine oxidase B inhibitor selegiline at high dosage (30 mg/day). Treatment brought about a 2 to 4-fold increase in tyramine sensitivity and a concomitant small but significant reduction in plasma 4-hydroxy-3-methoxyphenylglycol concentration, pointing to the emergence of some degree of monoamine oxidase A inhibition. It is suggested that patients treated with selegiline 30 mg/day or more should be placed on a tyramine-free diet.

Acute haemodynamic and metabolic effects of dopexamine, a new dopaminergic receptor agonist, in patients with chronic heart failure.

Dopexamine, a new compound with postjunctional dopamine receptor activating and beta adrenoceptor agonist properties, was given to 10 patients with chronic heart failure at diagnostic cardiac catheterisation to investigate its acute haemodynamic and metabolic effects. The drug was administered by intravenous infusion in three incremental doses and produced significant dose related increases in cardiac index, stroke volume index, and heart rate and falls in systemic vascular resistance and left ventricular end diastolic pressure; aortic and pulmonary artery pressures were unchanged. Isovolumic phase (max dP/dt and KVmax) and ejection phase (peak aortic blood velocity, maximum acceleration of blood, and maximum rate of change of power with time during ejection) indices of myocardial contractility were all increased by dopexamine but these changes were hard to interpret in the presence of an increase in heart rate. Myocardial efficiency and ejection fraction were both increased and left ventricular end diastolic and end systolic volumes fell. These largely beneficial changes were achieved without a statistically significant increase in myocardial oxygen consumption or disturbance of myocardial metabolic function. Dopexamine was well tolerated but tremor was reported by two patients at the intermediate dose and mild chest pain by two patients at the high dose.

Cardiac pacing in children.

Twenty patients aged between 12 months and 13 years underwent permanent pacemaker implantation. The main indication for pacing was post-surgical atrioventricular block. The complication rate was high and related mainly to infections and lead system problems. The use of small multiprogrammable pacemakers is expected to reduce the reoperation rate for system malfunction and elective replacement. Newer methods of electrode insertion and active fixation devices in smaller diameter leads make endocardial pacing a practical alternative to epicardial pacing in the larger child who did not require a pacing system at the time of surgery.