Influence of mitral regurgitation on the response to captopril therapy for congestive heart failure caused by idiopathic dilated cardiomyopathy.

To assess the influence of mitral regurgitation (MR) on the response to captopril therapy for congestive heart failure (CHF), 30 patients with idiopathic dilated cardiomyopathy in New York Heart Association functional class III were studied. Left ventricular end-diastolic diameter and stroke volume were measured by Doppler echocardiography, and exercise tolerance by exercise testing before and at 1, 3 and 12 months after treatment. Patients were classified into 2 groups: those with (n = 14) and those without (n = 16) MR. No significant differences were observed between the 2 groups in pretreatment studies. Exercise tolerance increased significantly in the group with MR (p less than 0.001) during the year of follow-up, from 514 +/- 193 seconds at baseline study to 671 +/- 178 seconds (p less than 0.0005) at 1 month, 688 +/- 127 seconds (p less than 0.0005) at 3 months and 690 +/- 108 seconds (p less than 0.01) at 12 months. The group without MR had no significant changes. Stroke volume increased significantly only in the MR group during follow-up (p less than 0.01), changing from 43 +/- 9 ml at baseline study to 52 +/- 11 ml (p less than 0.01) at 1 and 49 +/- 11 ml (p less than 0.01) at 3 months. At 12 months the increase was not statistically significant. Left ventricular end-diastolic diameter decreased more in the group with than without MR, although the differences were not significant. Thus, the presence of dynamic MR appears to be an important factor in the therapeutic response to captopril therapy for CHF.

Specific aspects of erectile function in urology/andrology.

The urologist/andrologist is the specialist responsible for diagnosis and treatment of health problems related to the genitourinary tract, and his or her participation in comprehensive care for a patient with erectile dysfunction (ED) is fundamental and often indispensable. The urologists/andrologists should characterize the origin of ED because of their knowledge and familiarity of all diagnostic tests and second- and third-line therapy. The origin of ED is important to determine for various reasons, such as young people suitable for etiologic treatment, medicolegal reasons, or patients' wishes for a better understanding of their condition. A review of the diagnostic tests available as well as indications for second- and third-line therapy is presented. The close relationship between ED and urological disorders, such as benign prostatic hyperplasia, prostate cancer and their treatments, and renal failure, in association with penile conditions like Peyronie's disease, priapism, and possible androgen deficiency in men older than 50 years, places the urologist at the center of integrated treatment of male ED.

An evidence-based programme for smoking cessation: effectiveness in routine general practice.

BACKGROUND: Smoking cessation clinical practice guidelines are based on randomised clinical trials reporting outcomes in persons who participate in these studies. However, many practitioners are sceptical about the effectiveness of these recommendations when applied to the general population in everyday routine consultation. AIM: To evaluate the results of a comprehensive smoking cessation programme in routine primary care practice. METHOD: All smokers consulting in 10 general practices during one year participated in a non-randomised controlled trial. The percentages of subjects in the intervention (n = 1203, seven practices) and control (n = 565, three practices) groups who reported sustained abstinence between six and 12 months follow-up and were validated biochemically were compared. The effect of the programme was adjusted to baseline differences in both groups by multiple logistic regression analyses. RESULTS: The programme resulted in an increase of five percentage points (95% CI = 3.1%-6.8%) in the validated and sustained one-year abstinence probability, with 7.1% for all of the intervention practices (adjusted OR = 3.7, 95% CI = 2.4-5.7). CONCLUSION: Programmes that combine advice to stop smoking to all smokers attending general practices with the offering of support, follow-up, and nicotine patches to those willing to stop are feasible and effective in routine practice, as primary care clinicians need only identify 20 smokers to get one additional success attributable to the programme.

Echocardiographic findings in pannus ingrowth on an omniscience mitral prosthesis.

Serial echocardiographic findings in a patient with an Omniscience mitral prosthesis presenting progressive perivalvular pannus ingrowth are described. The first echocardiographic study was carried out one year after prosthesis implantation and showed decreased prosthetic opening velocity. As prosthetic thrombosis was suspected, hemodynamic study was performed, which proved normal. The patient remained in functional grade II for a year and a half prior to the onset of progressive dyspnea and dizzy spells. Echocardiogram was thus repeated and revealed the presence of multiple dense echoes behind the prosthetic disc. Three months after this last study, the patient presented acute pulmonary edema and reduction of disc excursion and opening and closing velocities. Hemodynamic study suggested prosthetic obstruction. Surgery revealed the presence of perivalvular pannus trapping the prosthetic disc. The prosthesis was subsequently replaced by a Björk-Sorin. This case emphasizes the usefulness of echocardiography in the early detection of perivalvular pannus ingrowth revealing prosthetic mobility anomalies, even before hemodynamic changes occur.

[Atypical sinus node dysfunction. Usefulness of implantable Holter. A case report]. / Disfunción sinusal atípica. Utilidad del Holter implantable. A propósito de un caso.

We present an 84 year-old female patient with repeated syncopes/presyncopes in the last nine years. All diagnosis tests were negative, including ECG, 24-hour Holter, tilt table test and EP study. Therefore, a subcutaneous insertable loop recorder was implanted (Reveal). The recording of three episodes showed the association of presyncope with the onset of atrial fibrilation and, in two syncopes, with an atrial pause between AF episodes. Probably an abnormal prolonged sinus node recovery time (more than 6 s) allowed AF to restart before the sinus rhythm.

[Adverse effects of dobutamine stress echocardiography]. / Efectos secundarios de la ecocardiografía de estrés con dobutamina.

OBJECTIVES: To study the side effects of dobutamine echocardiography and to define the protocol with less side effects. PATIENTS AND METHODS: Since June 1992 to November 1994 dobutamine echocardiography was performed on two different groups of patients. In the first, the test was preoperatively done to evaluate the surgical risk. The remaining were patients with angina. Dobutamine was started at a dose of 5 micrograms/kg/min and increased up to a total dose of 40 micrograms/kg/min. Since March 1993 atropine was added if the heart rate was under 90 beats/min. RESULTS: One hundred and forty one patients were included (76 for a preoperatory appraisal and 65 with angina). Echocardiography test was not performed on 3 patients (2 with pulmonary disease and 1 with a therapeutic neumothorax). Among the remaining 138 patients, side effects appeared in 53 patients (38%) and test had to be prematurely interrupted in 11 (8%) of them. Side effects presented during the test in 9 (7%) although it could be finished and at the end of the test in 33 (24%). The most frequent side effects were arrhythmias that appeared in 28 patients (20%) and were considered significant in 17: 7 with supraventricular tachycardia, 7 with more than 6 ventricular premature systoles per minute, 2 with ventricular tachycardia and 1 with multifocal supraventricular premature systoles. These arrhythmias were observed when the dose of dobutamine was 20 micrograms/kg/min or more (p < 0.05). Hypotension developed in 11 patients (8%) and noncardiac effects in 13 (9%). The dobutamine test was interrupted for arrhythmias in 4% of cases, noncardiac side effects in 2% and poor image quality in 3%. A steady increment of heart rate 5 minutes after infusion of atropine was detected in 12 patients (maximal: 93 +/- 23 beats per minute; after five minutes: 94 +/- 19) and side effects were encountered in only one of these patients (hypotension). CONCLUSIONS: Intravenous administration of dobutamine during echocardiography can be finished in the majority of patients with good tolerance in spite of its side effects. Arrhythmias with dose over 20 micrograms/kg/min, poor image quality and chronotropic insufficiency are the most frequently encountered limitations.

[Diabetic ketoacidosis as the first manifestation of acromegaly]. / Cetoacidosis diabética como primera manifestación de una acromegalia.

Diabetes mellitus is a frequent manifestation in patients with acromegaly and it can show up even before the latter manifests. Typically, the diabetes mellitus in these patients does not tend to develop ketosis. We present the case of a patient hospitalized due to diabetic ketoacidosis associated to a perianal abscess. Diabetes mellitus type I was rejected and the presence of insulin-resistance was verified. She required insulin therapy just for three months. The clinical, hormonal and radiological evaluation showed, three years latter, the presence of a hypophyseal tumor producing growth hormone. After performing a trans-sphenoidal adenomectomy, the insulin-therapy could be removed with a normal glycemic profile. This case of acromegaly demonstrates the relationship between growth hormone and glucose metabolism. It can be considered that the ketoacidosis was the first manifestation of the acromegaly, which is exceptional.

[Can we help our patients to stop smoking?: the experience of the Smoking Cessation Program]. / Podemos ayudar a nuestros pacientes a dejar de fumar?: la experiencia del Programa de Abandono del Tabaco.

OBJECTIVE: To describe the process and results of the Smoking Cessation Program in order to answer this question: Does the lack of time and resources justify poor involvement of physicians in helping patients to stop smoking? METHODS: Prospective series of cases that included all smokers (n = 1203) who for any reason attended seven general practices over a period of one year. The behaviour of smokers when the program was offered as well as the workload generated by the implementation of the process are described. Subjects who stopped smoking were those who did not smoke two years after enrolment in a sustained and validated form for least 12 months. RESULTS: A total of 7.3% of all smokers quit (95% confidence interval [CI]: 5.9-8.9). Enrolment of subjects caused an increase in the consultation time of 23 seconds and decreased from a mean of 30 new smokers per month per practice during the first three months to 12 at the end of the first year. All received advise to stop smoking (mean increase of 3 min and 33 s) but only 17.5% accepted the therapeutic plan during the first year (95% CI: 15.4-19.9) that had a duration of 72:11 min and generated a mean of six programmed appointments a month in each practice. Twenty percent of subjects who participated in the therapeutic plan stopped smoking (95% CI: 14.8-26.1). CONCLUSIONS: Identification and universal advice to smokers, together with treatment of those who are motivated to quit, achieved important success rates without increasing excessively ordinary work loads.

[Knowledge and attitudes of practice of health workers in Bizkaia health centers toward diet and cholesterol]. / Conocimientos y actitudes prácticas de los sanitarios de los centros de salud de Bizkaia ante la dieta y el colesterol.

OBJECTIVE: Analyze the extent to which criteria and practice of the Sanitary Personnel approximate the recommendations of the Consensus on the Control of Hypercholesterolemia in Spain, find out how extensive their dietary knowledge in and how skillful they are to interview and counsel a patient with hyperlipidemia. DESIGN: Transversal study with simple aleatory sampling using a questionnaire. PARTICIPANTS AND LOCATION: 101 physicians and 95 nurses working in Primary Health Care Teams in Bizkaia, during the monthly of June 1991; deputies for periods inferior to 3 months were excluded. MEASUREMENTS AND MAIN RESULTS: 82% of physicians (P) counselled dietetic treatment for cholesterolemic levels coinciding with those set in the Consensus and 70% demanded excessive analytical controls for hypercholesterolemic patients under treatment already normalized; 37% (P) and 12% of nurses (N) knew that the polyunsaturated/saturated fat ratio is the main dietetic factor; various errors were detected in questions relating to olive oil, unsaturated fat in fish and fibre values of legume; accurate responses between 13-54% (N) and 23-77% (P). CONCLUSIONS: The "mediterranean diet" is not sufficiently known; our ability for the dietetic interview and personalized counsel needs to be improved. In the light of the above and taking into accounted the gaps and deviations existing between our practice and the Consensus and its applications, we consider a better diffusion of the cited document is necessary among Primary Health Care Teams.

Skewed X inactivation in a female MZ twin results in Duchenne muscular dystrophy.

One of female MZ twins presented with muscular dystrophy. Physical examination, creatine phosphokinase levels, and muscle biopsy were consistent with Duchenne muscular dystrophy (DMD). However, because of her sex she was diagnosed as having limb-girdle muscular dystrophy. With cDNA probes to the DMD gene, a gene deletion was detected in the twins and their mother. The de novo mutation which arose in the mother was shown by novel junction fragments generated by HindIII, PstI, or TaqI when probed with cDNA8. Additional evidence of a large gene deletion was given by novel SfiI junction fragments detected by probes p20, J-Bir, and J-66 on pulsed-field gel electrophoresis (PFGE). Immunoblot analysis of muscle from the affected twin showed dystrophin of normal size but of reduced amount. Immunofluorescent visualization of dystrophin revealed foci of dystrophin-positive fibers adjacent to foci of dystrophin-negative fibers. These data indicate that the affected twin is a manifesting carrier of an abnormal DMD gene, her myopathy being a direct result of underexpression of dystrophin. Cytogenetic analysis revealed normal karyotypes, eliminating the possibility of a translocation affecting DMD gene function. Both linkage analysis and DNA fingerprint analysis revealed that each twin has two different X chromosomes, eliminating the possibility of uniparental disomy as a mechanism for DMD expression. On the basis of methylation differences of the paternal and maternal X chromosomes in these MZ twins, we propose uneven lyonization (X chromosome inactivation) as the underlying mechanism for disease expression in the affected female.