Helicobacter pylori eradication does not cause reflux oesophagitis in functional dyspeptic patients: a randomized, investigator-blinded, placebo-controlled trial.

BACKGROUND: The protective role of Helicobacter pylori in gastro-oesophageal reflux disease has been widely discussed. AIM: To assess the risk of reflux oesophagitis in patients with functional dyspepsia after treatment for H. pylori infection. METHODS: A randomized, placebo-controlled, investigator-blinded trial was carried out on 157 functional dyspeptic patients. Patients were randomized to receive lansoprazole, amoxicillin and clarithromycin (antibiotic group) or lansoprazole and identical antibiotic placebos (control group). Upper gastrointestinal endoscopy was performed at baseline, 3 and 12 months after randomization. The primary aim was to detect the presence of reflux oesophagitis. Analyses were performed on an intention-to-treat basis. RESULTS: A total of 147 patients (94%) and 133 (85%) completed 3 months and 12 months follow-up, respectively. The eradication rate of H. pylori was 90% in the antibiotic group (74 of 82) and 1% (one of 75) in the control group. At 3 months, reflux oesophagitis was diagnosed in 3.7% (three of 82) in the antibiotic group and 4% (three of 75) in the control group (P > 0.2). At 12 months, diagnosis was established in five new cases within the first group and in four within the second (P > 0.2). No difference was found in heartburn symptoms. CONCLUSIONS: H. pylori eradication does not cause reflux oesophagitis in this western population of functional dyspeptic patients.

Non-invasive diagnosis of a congenital coronary artery fistula.

This report describes a large congenital coronary artery fistula of the left circumflex artery draining into the coronary sinus in a 46 year old woman. The fistula was initially diagnosed by cross-sectional and transesopha-geal echocardiography using multiplane probe. Additionally, the entire course of the fistula was visualised in electron beam tomography. Angiography confirmed echocardiographic and tomographic findings.

Consumo de benzodiazepínicos em Porto Alegre / Benzodiazepinics comsumption in Porto Alegre

Os benzodiazepínicos (BDZ) vêm sendo utilizados em larga escala para o controle da ansiedade e outras condiçöes clínicas desde que foi introduzida sua comercializaçäo na década de 60. Nos últimos anos, diversos estudos têm apontando seu uso indiscriminado, contribuindo para aumentar a morbidade associada, bem como a busca por outras substâncias calmamente de acesso mais fácil. OBJETIVO. Estimar a prevalência do uso de benzodiazepínicos e calmantes caseiros na populaçäo adulta de Porto Alegre, TS. MÉTODOS. 480 habitantes do município de Porto Alegre, RS, com idade igual ou superior a 18 anos, selecionados através de amostragem aleatória por conglomerados (setores censitários do IBGE), foram entrevistados em seus domicílios durante o mês de junho de 1991. RESULTADOS. As prevalências do uso de BDZ na vida, no último ano e no último mês, foram, respectivamente, 46,7 por cento, 21,3 por cento e 13,1 por cento. Entre as mulheres e os viúvos ou separados a prevalência foi significativamente maior. A maioria dos indivíduos que usaram BDZ no último mês o fizeram, no mínimo, 2 a 3 dias por semana. Mais de 40 por cento dos entrevistados relataram uso freqüente de substâncias caseiras para "acalmar", sendo 28,8 por cento a prevalência do uso no último mês. CONCLUSAO. O uso de substâncias químicas para aliviar a ansiedade e outros sintomas está difundido entre a populaçäo. A legislaçäo, nem sempre respeitada, tem sido insuficiente para disciplinar o uso. É necessário compreender a complexidade de razöes para que a situ-açäo se mantenha e investir em medidas para educar médicos e populaçäo quanto ao uso adequado dos BDZ, além de buscar reguladoras ao nível da lei que sejam mais eficientes

[Benzodiazepine consumption in Porto Alegre]. / Consumo de benzodiazepínicos em Porto Alegre.

Benzodiazepines has been largely used to control anxiety and other clinical pictures since it began to be traded in the 60's. In recent years, many studies have shown that they are used indiscriminately, contributing to increase associated morbidity, and to search for other more accessible tranquilizers. PURPOSE--To estimate the prevalence of benzoadiazepine and over-the-counter tranquilizers use in adults living in Porto Alergre-RS, Brazil. METHODS--480 inhabitants of Porto Alegre, aged 18 or older, selected through a random cluster sampling procedure (sectors of the Brazilian Census), were interviewed in their homes during June, 1991. RESULTS--The prevalence for BDZ use during life, in the past year and in the past month was, respectively, 46.7%, 21.3% and 13.11%. Prevalence was significantly higher among women and widowers or divorced. The majority of those who used BDZ during the past month did so at least 2 or 3 days per week. More than 40% reported frequent over-the-counter substances use to "tranquilize", with a 28.8% prevalence for past month use. CONCLUSION--Chemical substance use to alleviate anxiety and other symptoms is generally spread. Legislation, not always respected, has been insufficient to discipline its use. Understanding the complexity of reasons for the situation to be unchanged is needed. Also necessary is the investment in education on adequate use of BDZ, both for physicians and population, and the search for legal measures that should be more efficient.

Cardiodynamic changes during passive tilt and acute nitrate therapy.

In six patients with normal left ventricles and seven post-myocardial infarction patients cardiodynamic changes during tilt and acute nitrate medication were investigated. The conductance catheter was used for on-line registration of left ventricular volumes and a microtip manometer for high-fidelity pressure recordings. We analysed left ventricular end-diastolic volume index (EDVI) ejection fraction (EF), cardiac index (CI), heart rate (HR), end-systolic pressure (ESP) and end-diastolic pressure (EDP) in the supine position and 30 s after passive upright tilt. Supine and standing measurements were performed without medication and 2 min after acute nitrate medication (0.8 mg sublingual nitroglycerin). After unloading by upright tilt there was a similar reduction of average EDVI in the control group (-18 +/- 7 ml.m2) and in the post-infarction group (-21 +/- 18 ml.m2). The effect of nitroglycerin on EDVI (-12 +/- 4 ml.m2 control, -7 +/- 6 ml.m2 post-infarction) was less than the effect of upright tilt. EF in the control group improved by +8 +/- 5% (in absolute values) during passive tilt; the combined effect of tilt and nitrate was +12 +/- 6% EF (p < 0.05). In the post-infarction group EF did not change significantly during tilt and/or nitrate therapy. In the patients with normal regional ventricular function, CI during tilt was maintained at a constant level. In the post-infarction group the reduction in CI was not significant. Although the reduction in EDVI was similar in the control and infarction groups, the infarction group did not respond to the cardiodynamic change by increasing EF.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular performance in relation to heart rate and AV delay at rest.

The influence of heart rate (HR) and AV delay (AVD) on left ventricular haemodynamics was studied in 12 patients classified as having coronary heart disease (CHD), hypertensive heart disease (HHD), dilated cardiomyopathy (DCM) or who served as controls. Using the conductance catheter technique, haemodynamics were measured during pacing rates of 80 to 180 beat.min-1 at AV delays of 0 to 240 ms. A 3-D linear regression analysis of the data quantified the influence of HR and AVD in principle for each group. An increase in HR resulted in a rise in the cardiac index without changing ejection fraction in the control group only, but led to a decrease in these parameters in HHD and DCM; cardiac index remained constant in CHD. CHD patients frequently had a more pronounced left ventricular end-diastolic pressure (LVEDP) elevation with higher HR, whereas left ventricular end-diastolic volume (LVEDV) and stroke volume decreased. In patients with HHD, lengthening of the AVD resulted in an increase in LVEDV and a decrease in LVEDP and left ventricular end-systolic volume (LVESV) leading to a higher ratio of stroke volume to LVEDP than in the other subsets. In DCM, longer AVD also resulted in a higher SV/LVEDP ratio, but in contrast to HHD the influence of AVD variation on LVEDP and therefore on the LVEDV/LVEDP ratio was missing.

Haemodynamic analysis of atrioventricular tachycardia.

The aim of the study was to delineate the influence of the ventriculo-atrial interval (VAI) in tachycardia with regard to the underlying heart disease. Haemodynamic studies were performed by the conductance catheter technique during paced tachycardia with a HR of 140, 160 and 180 beat.min-1 at various VAI in 10 patients; three with coronary heart disease (CHD), three with hypertensive heart disease (HHD) and four serving as controls. The influence of the VAI accounted for an overall change in cardiac index (CI) of 30 +/- 14%. Alterations in left ventricular peak systolic pressure (LVPSP) depending on VAI were significantly higher (P < 0.01) in CHD patients (32 +/- 9%) than in other groups (14 +/- 9% in the controls and 17 +/- 8% in HHD patients). The influence of VAI on left ventricular end-diastolic pressure (LVEDP) did not differ between the subgroups and accounted for a mean overall change of 32 +/- 14%. Atrial activation during the last third of the cardiac cycle led to the highest values of CI, LVEDP and LVPSP in the control group, whereas in HHD and CHD groups minimal values of CI were correlated with maxima of LVEDP and LVPSP. Conversely, with atrial activation during the medium third of the cardiac cycle minima of CI and LVEDP were observed in the controls, whereas in HHD and CHD patients the highest cardiac index coincided with the lowest LVEDP. Thus tachycardias have different haemodynamic effects depending on the nature of myocardial impairment and the timing of AV coupling.

Chronotherapy in coronary heart disease: comparison of two nitrate treatments.

The purpose of this study was to assess the ischemic burden and the hemodynamic changes during daily activities in patients with coronary heart disease. Three exercise tests were performed during the day (10:00 a.m., 2:00 p.m., 6:00 p.m.), recording ST-segment depression, pulmonary artery pressure, pulmonary wedge pressure, and cardiac output as well as heart rate and systemic blood pressure during placebo and nitrate therapy. With placebo as well as nitrate therapy there was a gradual increase of ischemia and preload and a decrease of cardiac output during the day. High nitrate concentrations led to a significant reduction of both preload and ST depression with a marked circadian phase dependency of cardiovascular effects.

Circadian variation of cardiac performance in coronary heart disease.

To study the circadian variation of cardiac performance in patients with coronary heart disease, three exercise tests on a bicycle ergometer were performed during the active part of the day (10 a.m., 2 p.m. and 6 p.m.), recording ST-segment depression and pulmonary capillary wedge pressure. Ten male patients with angiographically documented coronary heart disease underwent bicycle ergometry during placebo and during nitrate therapy (placebo controlled, double-blind crossover 2 x 20 mg IS-5-MN and 1 x 120 mg ISDN sustained release). During placebo as well as during nitrate therapy there was a gradual decrease of cardiac performance during the day, documented by the increase in ST-depression and pulmonary capillary wedge pressure at equal work loads. High nitrate concns led to a significant reduction of both ST-depression and preload with a marked circadian-phase dependency of cardiovascular effects.

[Ambulatory invasive and noninvasive blood pressure monitoring]. / Ambulantes invasives und nichtinvasives Blutdruckmonitoring.

Indirect arterial blood pressure measurement has not changed substantially since its introduction by Riva-Rocci in 1986, Korotkoff in 1905 and Recklinghausen in 1906. Random measurements in the clinic or practice reflect only incompletely the dynamic nature of the blood pressure. Blood pressure recordings by patients themselves have provided more information through better temporal resolution, however, exact characterization of the pressure response throughout the entire day and, in particular, during physical exertion are not enabled; the latter are especially important with regard to diagnosis and treatment of hypertension. In 1966, therefore, radiotelemetric transmission of direct, continuously-measured arterial blood pressure was developed which enabled beat-to-beat registration of blood pressure, outside the laboratory, during normal daily life and sport activities. The initial results showed a marked variability of the blood pressure during the course of the day (Figure 1). Excessive blood pressure increases were observed during exposure to cold, static and dynamic exercise and to a lesser degree during automobile driving and exposure to heat (Figure 3). Recording of the pressure curves via transmission by radiotelemetry shows a high degree of accuracy and temporal resolution, spatial and situational freedom but is invasive and costly in terms of personnel. The same holds true for direct continuous blood pressure registration and storage on a portable tape recorder. Portable, automatic blood pressure measuring units for ambulatory monitoring employ indirect auscultatory or oscillometric recording with a cuff. As compared with the radiotelemetric direct continuous blood pressure measuring method, the indirect method has subordinate temporal resolution, that is, the measurements are only intermittent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Afterload reduction by long-term nitrate therapy]. / Nachlastsenkung unter Langzeit-Nitrattherapie.

Tolerance to arterial and venous effects is a common problem in longterm-therapy with nitrates when dosing schemes with multiple, regulary timed intervals throughout the day are applied. A balanced effect on preload and afterload is essential for a successful therapy of congestive heart failure. Interval therapy, the once daily medication of a nitrate, has a proven tolerancefree effect on preload. This study addresses the problem of afterload reduction under longterm interval therapy with nitrates. Nine patients with coronary heart disease NYHA II-III with congestion under exercise where included in the study. After a washout period they where treated with once-daily 120 mg ISDN s.r. Measuring mean arterial pressure and cardiac output, we compared the effect of the first dose (acute) with the effect after 5 weeks 1 x 1 120 mg ISDN s.r. (chronic). After acute therapy the mean arterial pressure under exercise was reduced by 14% from 121 +/- 12 mmHg to 104 +/- 11 mmHg. The average reduction of blood pressure under exercise was unchanged during chronic therapy (105 +/- 8 mmHg). Peripheral resistance was reduced by 21% from 914 +/- 266 to 722 +/- 190 dynsec/cm5 after the first dose. The afterload reduction was maintained during chronic therapy (727 +/- 176 dynsec/cm5).

Circadian investigation of interval therapy with isosorbide dinitrate in coronary heart disease.

One of the most promising concepts in nitrate therapy is interval therapy, a dosage scheme with marked changes of nitrate concentrations in the 24-h interval. In a single-blind, placebo-controlled study in patients with coronary heart disease we investigated the circadian anti-ischaemia and haemodynamic response to interval therapy with isosorbide dinitrate (120 mg sustained release 1 X 1). 10 male patients (46-75 years, mean 60 years) with chronic stable angina and ST-segment depression during exercise entered the trial. At the end of a 10-day placebo period (medication at 8 am) three exercise tests were performed (10 am, 2 pm, 6 pm), recording ST-segment changes, pulmonary capillary wedge pressure (PCP) and cardiac index (CI). Spontaneous ischaemic events were detected by Holter monitoring until 8 am the next day. After three weeks of therapy with isosorbide dinitrate, the protocol was repeated (statistics: paired t-test, *P less than 0.05). PCP was reduced by 8.3 mmHg* at 10 am, 8.0 mmHg at 2 pm, 2.9 mmHg (NS) at 6 pm with a concomitant increase of cardiac index (+0.8,* +0.7*, +0.3 NS l min-1 m-2). While the haemodynamic improvement was maximal in the morning the anti-ischaemia effect (reduction of ST-depression) was constant during the active day (-0.40*, -0.50*, -0.43* mm). Four transient ischaemia episdodes at night were recorded under placebo, none under isosorbide dinitrate. In conclusion, all parameters studied demonstrate the effectiveness of chronic interval therapy with isosorbide dinitrate.

[Hemodynamics and coronary dynamics under ISDN long-term therapy]. / Hämodynamik und Koronardynamik unter ISDN-Langzeittheraie.

Although nitrates are among the oldest drugs in cardiology the problem of tolerance is a scientific challenge of today. We examined and compared the effects of initial and chronic therapy (4 weeks) with 1 X 1 ISDN 120 mg sustained release in 9 patients with coronary heart disease and impaired left ventricular function. At intraindividually identical workloads (average 50 +/- 12 watt) there was a reduction of PCWPm from 32.5 +/- 9.5 to 19.7 +/- 9.8 mm Hg. This reduction of PCWPm during bicycle ergometry was fully achieved in long-term therapy. With the first dose of ISDN cardiac index (CI) at maximum workload increased from 6.0 +/- 1.2 to 6.8 +/- 1.3 l/min/m2; during chronic therapy cardiac index improved from 5.3 +/- 1.3 to 6.6 +/- 1.1 l/min/m2. Exercise capacity during bicycle ergometry in the sitting position increased concomitantly from 414 to 686 watt X min. In long-term therapy there was a further significant improvement to 772 watt X min. ST-segment depression, measured as sum of ST-depression in all 12 standard ECG leads decreased from 0.63 mV before medication to 0.11 mV after the first dose and to 0.16 mV in long-term therapy. The investigation of ventricular function during ventriculography and the investigation of coronary vasomotion during coronary angiography after ergonovine maleate i.v. and ISDN s.l. also demonstrated the full nitrate effect in long-term therapy.