The nitura study--effect of nitroglycerin or urapidil on hemodynamic, metabolic and respiratory parameters in hypertensive patients with pulmonary edema.

OBJECTIVE: To assess the effects of nitroglycerin or urapidil on hemodynamic, respiratory and metabolic parameters in hypertensive patients with pulmonary edema. DESIGN: Open, randomized and prospective clinical study. SETTING: Out-of-hospital setting and Emergency Department in a 2000-bed hospital. PATIENTS: Hundred twelve patients with evidence of hypertensive crises with pulmonary edema (systolic blood pressure (SBP) > 200 mmHg and/or diastolic blood pressure (DBP) > 100 mm Hg and rales over both lungs) at the time when the emergency physician arrived. INTERVENTIONS: The out-of-hospital treatment consisted of oxygen via face mask, 80 mg furosemide i.v., 10 mg morphium s.c., and either nitroglycerin sublingually (initial dose: 0.8 mg; repetitive administration of 0.8 mg every 10 min to a cumulative dose of 3.2 mg) or urapidil (initial dose: 12.5 mg i.v.; repetitive administration every 15 min to a cumulative dose of 50 mg). If SBP was more than 180 mm Hg and/or DBP more than 90 mm Hg on admission, antihypertensive treatment was continued with nitroglycerin (0.3-3 mg/h) or urapidil (5-50 mg/h). MEASUREMENTS AND RESULTS: Blood pressure (BP) was measured every 5 min with the use of an automatic oscillometric device. Serum lactate, PO2, pH value, and base excess (BE) were evaluated on admission and 6 h later. Blood pressure, serum lactate and BE on admission were significantly lower (SBP: 155 +/- 30 vs 179 +/- 33 mm Hg; p = 0.0002; DBP: 82 +/- 17 vs 93 +/- 19 mmHg; p = 0.001; lactate: 2.2 +/- 1.6 vs 3.9 +/- 2.7; p = 0.0001; BE: -1.9 +/- 3.9 vs -4.4 +/- 1.7; p = 0.0005) and PO2 and pH values were significantly higher in the urapidil group compared to the nitroglycerin group (PO2: 75 +/- 25 vs 66 +/- 17; p = 0.036; pH: 7.33 +/- 0.08 vs 7.29 +/- 0.09; p = 0.042). After 6 h no differences between the two groups were observed. CONCLUSION: The more pronounced BP reduction in the urapidil group was associated with an improved respiratory and metabolic situation in hypertensive patients with pulmonary edema. Therefore, urapidil is a valuable alternative to nitroglycerin in patients with pulmonary edema and systemic hypertension.

Mortality of opiate users in Vienna, Austria.

The purpose of this study was to investigate whether there are differences in overall and cause-specific mortality rates of opiate users in maintenance treatment and of opiate users not in any drug treatment program in Vienna, Austria. A cohort of opiate-users enrolled in maintenance treatment in Vienna and a cohort of individuals involved in opiate-related emergencies from 1995 to 1997 were retrospectively analyzed. The standardized mortality rate of opiate-users enrolled in maintenance treatment was 12.1 and that of individuals involved in opiate-related emergencies was 48.8. Excess mortality was found for all categories for both groups. In the face of the extremely high excess mortality of opiate users involved in opiate-related emergencies, measures have to be taken to get these individuals in drug treatment programs as soon as possible.

Analysing calls by lay persons reporting cardiac arrest.

Prior to establishing a protocol for pre-arrival instructions for cardio-pulmonary resuscitation in the Vienna emergency medical system dispatch centre, a study was performed to determine whether any problems exist which may compromise guidance for basic life-support on the telephone. To evaluate the feasibility of prearrival instructions, a retrospective analysis of cardiac arrest calls was performed. We reviewed the Vienna emergency medical services dispatch centre tape recordings, ambulance run sheets and the hospital charts of 114 patients suffering from atraumatic cardiac arrest. Analysis showed that in 59 cases the arrest occurred in the victim's home. The telephone and the patient were either in the same or in adjoining rooms in 55% of the calls. We did not experience any technical or language difficulties. The caller and victim were related in 51 cases. The callers were completely calm in 77% and fairly calm in an additional 15%. Not one caller was distraught. Our data show that most objections to the feasibility of pre-arrival instructions can be refuted. We conclude that in Vienna the setting and location of arrest will impose few problems on the performance of bystander-cardio-pulmonary resuscitation using pre-arrival instructions given by dispatchers.

Prediction of survival after out-of-hospital cardiac arrest: results of a community-based study in Vienna.

The objective of this study was the assessment of out-of-hospital cardiac arrest and the definition of possible predictive factors for final hospital discharge. Out of a database of 89,557 consecutive missions of the Vienna emergency medical system (EMS) during 1990, there were 623 missions due to a collapse of non-traumatic origin: in 374 cases (60.0%) the patients were declared dead without further attempts at resuscitation. The remaining 249 patients were analysed for predictive factors at site. Survival to hospital admission: 109 patients survived to hospital admission (43.7%); bystander support had a small impact (P < 0.05) on survival to hospital arrival whereas age and gender had no predictive power. Most patients with ventricular tachycardia/fibrillation (VT/VF) survived primarily (69 of 117, i.e. 59.0%). Survival to hospital discharge: 27 patients were discharged from hospital care (10.8%). ECG findings on arrival of the EMS physician at the site proved to be the only powerful predictor for survival: 24 of 117 patients with VT/VF survived compared with only one of 81 with primary asystole, two of 39 with severe bradycardia, and no patient with electromechanical dissociation.

Ocular penetration of oral clarithromycin in humans.

Clarithromycin has a wide spectrum of activity against many gram-positive and gram-negative organisms, intracellular pathogens, and opportunistic pathogens. To examine the penetration of clarithromycin in the ocular tissues, 21 patients who underwent elective cataract surgery (Group I) received a single 500-mg dose of clarithromycin orally either 4, 8, 10, 12, or 22 hours before cataract surgery, and 21 patients who underwent elective retina/vitreous surgery (Group II) received 500 mg every 12 hours orally for 3 days before the surgery with the last dose given either 3, 6, 8, 11, or 24 hours before the surgery. Serum from all patients was assayed for clarithromycin prior to drug administration and at the time ocular specimen was taken. Aqueous, iris, and vitreous samples were also assayed for clarithromycin concentration. The concentrations of clarithromycin in the aqueous fluid 4, 8, 10, 12, and 22 hours after administration were: (mean +/- SD) 0.13+/-0.05, 0.137+/-0.11, 0.074+/-0.03, 0.06+/-0.02, and 0.074+/-0.04 microg/ml, respectively. Concentration of clarithromycin in vitreous 3, 6, 8, 11, and 24 hours after administration were: (mean +/- SD) 0.11+/-0.02, 0.257+/-0.13, 0.27+/-0.21, 0.307+/-0.26 and 0.108+/-0.07 microg/ml, respectively. The mean concentration of clarithromycin in the iris was 6.2 microg/g. In conclusion, this data suggest that clarithromycin widely penetrates and adequately concentrates in the aqueous humor, vitreous humor, and iris tissue after oral administration and therefore is effective in the management of many infectious ocular conditions.

Kohl - the traditional eyeliner: Use and analysis.

Kohl is a traditional powder-like mixture used as an eyeliner and to treat eye disease in many Middle and Far East countries. We studied kohl use among 360 individuals selected at random in Riyadh, Saudi Arabia. Kohl was used by 13% of males and 26% of females, especially the elderly and illiterate. Forty percent of females with children applied kohl to the eyes of their children during the first postnatal month. Analysis of five commercially available traditional kohl samples showed that some preparations have a high pH and a high lead concentration (88%), indicating that most preparations are lead-based rather than antimony-based. It is interesting to find that some kohl preparation have a weak antimicrobial effect against Streptococcus, Staphylococcus and Proteus species. The use of lead-based kohl is still a common and serious practice and should be discouraged, especially in children. The role of traditional kohl use in the pathogenesis of common ocular external diseases prevalent in Middle and Far East countries merits in investigation.

Ocular manifestations of endemic syphilis (bejel).

Bejel or nonvenereal syphilis is a treponemal infection that is still endemic in many parts of the world including Saudi Arabia. The authors have examined 17 patients with clinical findings consistent with bejel. All patients had positive serologic tests for bejel. There were 11 male and six female patients, with a mean age of 54 years (range, 37-73 years). Results of clinical examination showed uveitis in nine patients, optic atrophy in six, and chorioretinitis scars in six. In four patients who needed intraocular surgery, two aqueous specimens showed positive antibodies for Treponema pallidum.

[Sublingual nitroglycerin or intravenous enalaprilat in preclinical treatment of hypertensive patients with pulmonary edema]. / Sublinguales Nitroglyzerin oder intravenöses Enalaprilat in der präklinischen Behandlung von hypertensiven Patienten mit Lungenödem.

In a prospectively designed randomized study, we compared the efficacy of sublingual nitroglycerine and intravenous enalaprilat in the out-of-hospital treatment of 46 hypertensive patients with pulmonary edema (defined as rales over both lungs and systolic blood pressure > 200 mm Hg and diastolic blood pressure > 100 mg). The out-of-hospital treatment consists of oxygen (6 Ll/min) via a face mask, furosemide 80 mg i.v., opioids 10 mg s.c., and either sublingual nitroglycerine (n = 23; initial dose: 0.8 mg; repetitive application of 0.8 mg every 10 min until a cumulative dose of 3.2 mg) or intravenous enalaprilat (initial dose: 2.5 mg; repetitive application of 2.5 mg every 30 min until a cumulative dose of 10 mg). The aim of the antihypertensive treatment was a reduction of systolic blood pressure below 160 mm Hg and diastolic blood pressure below 90 mm Hg until admission to the emergency department. In the emergency room, an arterial and venous blood sample was taken to determine the respiratory (pO2, pCO2) and metabolic status (pH value; base-excess; serum lactate) of the patient. Successful antihypertensive treatment was observed in 13/23 (57%) patients of the enalaprilat group and 15/23 (65%) patients of the nitroglycerine group (p = 0.54). Systolic and diastolic blood pressure on admission were similar in both treatment groups (systolic RR: enalaprilat: 179 [31] mm Hg; nitroglycerine: 184 [38] mm Hg; p = 0.59; diastolic RR: enalaprilat: 96 [14] mm Hg; nitroglycerine: 101 [14] mm Hg; p = 0.12). No significant differences were observed between the enalaprilat and the nitroglycerine groups concerning respiratory and metabolic parameters on admission (pO2: 67 [15] vs. 64 [17] mm Hg; p = 0.50; pCO2: 46 [9] vs. 47 [13]; p = 0.75; pH value: 7.27 [0.12] vs. 7.27 [0.09]; p = 0.98; BE: -4.2 [3.7] vs. -5.7 [4.1]; p = 0.23; lactate: 4.2 [3.3] vs. 4.2 [2.7]; p = 0.98). Intravenous enalaprilat did not exhibit any advantage compared to nitroglycerine in terms of blood pressure reduction or respiratory and metabolic parameters on admission to the emergency room. We conclude that enalaprilat is no substitute for nitroglycerine in the out-of-hospital treatment of hypertensive patients with pulmonary edema.

The long-tube single plate Molteno implant for the treatment of recalcitrant glaucoma.

One hundred cases of recalcitrant glaucoma were operated with a long tube single-plate Molteno implant (LSMI). At the median follow-up of 15 months an intraocular pressure of less than or equal to 19 mm Hg was obtained in 64 of the 87 eyes (73%) which have a minimum follow-up of 6 months (secondary non-neovascular glaucomas = 19; congenital glaucomas = 26; secondary neovascular glaucomas = 12). The interval probability (percentage +/- standard error) of obtaining a successful result (IOP less than or equal to 19 mm Hg) was 79% (+/- 13) at twelve months from surgery, and 53% (+/- 24) at the eighteen month interval. The least favorable results were obtained in the secondary non-neovascular glaucomas. Complications observed included choroidal detachment (24%), tube exposure (4%), tube-endothelium contact (6%), plus band keratopathy, fibrous ingrowth, traction retinal detachment and corneal ulcers. Seventeen cases needed repeated surgery for the management of complications. In order to decrease the post-operative hypotony, we have been using a tourniquet suture around the tube at the time of implantation to occlude it temporarily and limit the outflow.

Exophiala jeanselmei keratitis.

We present the case of a 42-year-old Saudi male with a fungal corneal abscess in his left eye. The aetiological agent was found to be the dematiaceous fungus Exophiala jeanselmei. The patient was treated with topical natamycin, miconazole, and also amphotericin B. During the course of the infection corneal perforation occurred which was treated with cyanocrylate glue. Secondary glaucoma resulted from peripheral anterior synechia which necessitated trabeculectomy. At the end of the course the infection was successfully eradicated, the complications were cured, and vision improved from counting fingers in front of the face at presentation to 20/80. There was no recurrence of the infection in a follow-up period of 2 years.

Prehospital opiate emergencies in Vienna.

To establish baseline data on prehospital emergencies caused by opiates during a 4-month period, a retrospective analysis of run records of the Emergency Medical System in Vienna, the capital of Austria, was conducted. During the study period, there were 308 opioid emergencies involving 240 persons, an average of 2.5 overdoses per day. Severely compromised patients were treated in 67.8% of the 308 emergencies, and 79.3% of emergencies were transported to hospital; 52.5% of the involved persons were younger than 22 years of age. Sex distribution and periodicity and frequency of emergencies differed among age groups. A subgroup of individuals involved repeatedly in emergencies was identified, partly showing temporal clustering of fatal and nonfatal overdoses. Persons involved in opiate emergencies belong to heterogenous subgroups. At a local level, research should be initiated to clarify the pattern and impact of these emergencies on overall drug abuse prevention.

Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest. A clinical feasibility trial. Hypothermia After Cardiac Arrest (HACA) Study Group.

BACKGROUND AND PURPOSE: Recent animal studies showed that mild resuscitative hypothermia improves neurological outcome when applied after cardiac arrest. In a 3-year randomized, prospective, multicenter clinical trial, we hypothesized that mild resuscitative cerebral hypothermia (32 degrees C to 34 degrees C core temperature) would improve neurological outcome after cardiac arrest. METHODS: We lowered patients' temperature after admission to the emergency department and continued cooling for at least 24 hours after arrest in conjunction with advanced cardiac life support. The cooling technique chosen was external head and total body cooling with a cooling device in conjunction with a blanket and a mattress. Infrared tympanic thermometry was monitored before a central pulmonary artery thermistor probe was inserted. RESULTS: In 27 patients (age 58 [interquartile range [IQR] 52 to 64] years; 7 women; estimated "no-flow" duration 6 [IQR 1 to 11] minutes and "low-flow" duration 15 [IQR 9 to 23] minutes; admitted to the emergency department 36 [IQR 24 to 43] minutes after return of spontaneous circulation), we could initiate cooling within 62 (IQR 41 to 75) minutes and achieve a pulmonary artery temperature of 33+/-1 degrees C 287 (IQR 42 to 401) minutes after cardiac arrest. During 24 hours of mild resuscitative hypothermia, no major complications occurred. Passive rewarming >35 degrees C was accomplished within 7 hours. CONCLUSIONS: Mild resuscitative hypothermia in patients is feasible and safe. A clinical multicenter trial might prove that mild hypothermia is a useful method of cerebral resuscitation after global ischemic states.

Cumulative incidence of retinoblastoma in Riyadh, Saudi Arabia.

A survey of all hospitals in the city of Riyadh for retinoblastoma cases presenting during the period 1982-1986 was performed; 22 cases (16 females and six males) were identified. The cumulative live births in the city of Riyadh for the same period numbered 254,780. The authors report the cumulative incidence of retinoblastomas in Riyadh, Saudi Arabia as 1:11580 live births per year.

Retinoblastoma: the Saudi Arabian experience.

During the period March 1983-May 1987, 74 cases of retinoblastoma were evaluated at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. 60% of the cases were unilateral with a female preponderance of 59.4% noted for this series. Additionally, the mean age at diagnosis was 22 months, and delay of retinoblastoma diagnosis since the first symptoms were observed ranged from two days to 36 months. Fifty-seven eyes were enucleated, and in 21 of these patients, this was the sole form of therapy. The remainder of patients were treated with radiotherapy alone or combined with chemotherapy, cryotherapy/photocoagulation. Overall, two-year survival statistics of this group of Saudi patients is 80% which compares favorably to other reports in the West. Emphasis is placed on management of the retinoblastoma patients by a multi-disciplinary group, and public educational efforts are imperative.

Heparin surface-modified intraocular lenses in patients with inactive uveitis or diabetes.

OBJECTIVE: This study aimed to determine whether heparin surface-modified (HSM) intraocular lenses (IOLs) with a hydrophilic surface would reduce cell adherence and other postoperative changes compared with the conventional polymethylmethacrylate (PMMA) IOLs in patients with either diabetes mellitus or inactive uveitis. DESIGN: The study design was a randomized, double-masked, clinical trial. PARTICIPANTS: Twenty-five patients with bilateral cataracts, 14 with inactive anterior uveitis and 11 with diabetes, with an age range of 11 to 81 years (mean, 52.8 years) participated. INTERVENTION: Bilateral cataract extraction with posterior chamber IOL implantation was measured, each patient receiving an HSM lens in one eye and a PMMA lens in the other. Pharmacia one-piece HSM and PMMA IOLs were used. Postoperative ocular changes were evaluated at regular intervals for 24 months in patients with inactive uveitis and for 6 months in patients with diabetes. Patients and physicians alike were unaware of which eye contained which lens until postoperative results were compiled. Records were kept by a study coordinator. MAIN OUTCOME MEASURES: Comparisons of posterior synechiae, IOL cellular deposits, and posterior capsular fibrosis between PMMA and HSM IOLs were measured. RESULTS: Using the chi-square test, no statistically significant difference was found between the HSM and PMMA IOLs in the number of cellular deposits found on the anterior IOL surface, the number of adhesions between the iris and IOL, or the incidence of capsular opacification. CONCLUSION: The HSM and PMMA IOLs showed similar postoperative results in patients with inactive uveitis or diabetes mellitus.