Hyperbaric oxygen therapy attenuates central sensitization induced by a thermal injury in humans.

BACKGROUND: Hyperbaric oxygen (HBO2 ) treatment has in animal experiments demonstrated antinociceptive effects. It was hypothesized that these effects would attenuate secondary hyperalgesia areas (SHAs), an expression of central sensitization, after a first-degree thermal injury in humans. METHODS: Seventeen healthy volunteers were examined during two sessions using a randomized crossover design. Volunteers were studied during control conditions (ambient pressure, FI O2 = 0.21) and during HBO2 (2.4 standard atmosphere, FI O2 = 1.0, 90 min) conditions in a pressure chamber. Quantitative sensory testing, including assessment of SHAs was performed. RESULTS: A statistically significant overall attenuation of SHAs was seen during the HBO2 sessions compared with the control-sessions (P = 0.011). In the eight volunteers starting with the HBO2 session, no difference in SHAs compared with control was demonstrated. However, in the nine volunteers starting with the control session, a statistical significant attenuation of SHAs was demonstrated in the HBO2 session (P = 0.004). CONCLUSIONS: The results indicate that HBO2 therapy in humans attenuates central sensitization induced by a thermal skin injury, compared with control. These new and original findings in humans corroborate animal experimental data. The thermal injury model may give impetus to future human neurophysiological studies exploring the central effects of hyperbaric oxygen treatment.

Heart valve disease associated with treatment with ergot-derived dopamine agonists: a clinical and echocardiographic study of patients with Parkinson's disease.

OBJECTIVE: To elucidate the association between treatment with ergot-derived dopamine agonists (EDDA) and valvular abnormalities amongst patients with idiopathic Parkinson's disease (IPD) and secondly, to analyse the yield of clinical screening for valvular heart disease. DESIGN: A cross-sectional controlled study. SETTING: The cohort of IPD patients treated in the outpatient clinic, Department of Neurology, Aarhus University Hospital, Denmark. SUBJECTS: A total of 138 IPD patients [median age 64 (39-87) years, 62% men] treated with either EDDA (n = 85) or non-EDDA (n = 53) for at least 6 months. Interventions. Patients were screened for valvular heart disease by clinical means and by examiner-blinded echocardiography. Main outcome measure was valvular regurgitation revealed by echocardiography. RESULTS: Severe aortic regurgitation (n = 4) or moderate aortic (n = 12), mitral (n = 3) or tricuspidal valve regurgitation (n = 5) was found in 22 EDDA patients (25.9%). Two patients had coexistent moderate mitral and tricuspid valvular regurgitation. Two non-EDDA patients had moderate valve insufficiency (3.8%, P < 0.05). The adjusted relative risk for at least moderate valve insufficiency in the EDDA patients was 7.2% (P < 0.05). The sensitivity of detecting at least moderate valvular disease by cardiac murmur, dyspnoea, or the heart failure marker NT-proBNP (natriuretic peptide) was 62% for the neurologists and 93% for the cardiologist but with equally low specificity (30-35%). CONCLUSION: EDDA was associated with a clinically important and statistically significant risk of at least moderate valve regurgitation. Clinical screening for valve disease was inadequate and it seems advisable to offer EDDA patients control with echocardiography.

Effect of organic loading rate on a wastewater treatment process combining moving bed biofilm and membrane reactors.

The effect of moving bed biofilm reactor (MBBR) loading rate on membrane fouling rate was studied in two parallel units combining MBBR and membrane reactor. Hollow fiber membranes with molecular weight cut-off of 30 kD were used. The HRTs of the MBBRs varied from 45 min to 4 h and the COD loading rates ranged from 4.1 to 26.6 g COD m(-2) d(-1). The trans-membrane pressure (TMP) was very sensitive to fluxes for the used membranes and the experiments were carried out at relatively low fluxes (3.3-5.6 l m(-2) h(-1)). Beside the test with the highest flux, there were no consistent differences in fouling rate between the low- and high-rate reactors. Also, the removal efficiencies were quite similar in both systems. The average COD removal efficiencies in the total process were 87% at 3-4 h HRT and 83% at 0.75-1 h HRT. At high loading rates, there was a shift in particle size distribution towards smaller particles in the MBBR effluents. However, 79-81% of the COD was in particles that were separated by membranes, explaining the relatively small differences in the removal efficiencies at different loading rates. The COD fractionation also indicated that the choice of membrane pore size within the range of 30 kD to 0.1 microm has very small effect on the COD removal in the MBBR/membrane process, especially with low-rate MBBRs.

High-rate wastewater treatment combining a moving bed biofilm reactor and enhanced particle separation.

Many cities around the world are looking for compact wastewater treatment alternatives since space for treatment plants is becoming scarce. In this paper development of a new compact, high-rate treatment concept with results from experiments in lab-scale and pilot-scale are presented. The idea behind the treatment concept is that coagulation/floc separation may be used to separate suspended and colloidal matter (resulting in > 70% organic matter removal in normal wastewater) while a high-rate biofilm process (based on Moving Bed biofilm reactors) may be used for removing low molecular weight, easily biodegradable, soluble organic matter. By using flotation for floc/biomass separation, the total residence time for a plant according to this concept will normally be < 1 hour. A cationic polymer combined with iron is used as coagulant at low dosages (i.e. 1-2 mg polymer/l, 5-10 mg Fe/l) resulting in low sludge production (compared to conventional chemical treatment) and sufficient P-removal.

Temporal changes in clinic and ambulatory blood pressure during cyclic post-menopausal hormone replacement therapy.

OBJECTIVE: Post-menopausal hormone replacement (HRT) might protect against cardiovascular disease, possibly by arterial vasodilation and reduced blood pressure. Progestogens are needed to avoid endometrial disease but vascular effects are controversial. The objective was to assess temporal changes in blood pressure (BP) by two measurement techniques during a cyclic hormone replacement regimen. DESIGN AND METHODS: Sixteen healthy and normotensive post-menopausal women (age 55 +/- 3 years) were studied in a placebo-controlled, randomized crossover study, and were randomized to 17beta-oestradiol plus cyclic norethisterone acetate (NETA) or placebo in two 12-week periods separated by a 3-month washout Clinic blood pressure was measured sitting by the same observer with a mercury manometer at four visits in each period. Twenty-four hour ambulatory blood pressure was measured at baseline and in the ninth weeks of treatment in both periods. RESULTS: Clinic systolic and diastolic BP were reduced after 10 days of oestradiol (-5.1 and -3.2 mmHg respectively, P < or = 0.05). After 9 weeks of cyclic HRT, prior to progestogen addition, clinic BP returned to baseline. During addition of NETA, diastolic blood pressure was again reduced (-3.6 mmHg, P= 0.037). Mean 24 h ambulatory systolic and diastolic blood pressures were significantly lower than clinic measurements (-15.7 and -5.9 mmHg, P < 0.001) but were unaffected by HRT. CONCLUSIONS: Clinic blood pressure is reduced during a cyclic HRT regimen but the reduction varies with the HRT regimen, which might explain the diversity in previous BP findings during HRT. Norethisterone acetate might possess additive blood pressure-lowering effects in postmenopausal women.

Verapamil and angiotensin-converting enzyme inhibitors in patients with coronary artery disease and reduced left ventricular ejection fraction.

Verapamil is effective as antianginal medication but contraindicated in patients with congestive heart failure. Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure but have limited effect on patients with angina pectoris. No studies have been published on the combined treatment with verapamil and ACE inhibitors in patients with stable angina pectoris and left ventricular dysfunction. We performed an open study in 14 patients with angina pectoris and ejection fraction < 40%. The patients received verapamil 180 mg and trandolapril 2 mg twice daily for 3 months. We found a significant increase in ejection fraction from 28 +/- 6 to 35 +/- 11 (p < 0.03), wall motion index from 1.0 +/- 0.3 to 1.2 +/- 0.3 (p < 0.03), exercise duration from 6.9 +/- 2.5 to 7.7 +/- 2.9 minutes (p < 0.01), and ratio of exercise to rest rate-pressure product from 2.2 +/- 0.4 to 2.5 +/- 0.6 (p < 0.02). Use of nitroglycerin and number of angina pectoris attacks were both significantly reduced after 3 months of treatment. These findings support the hypothesis that the combination of verapamil and trandolapril is useful in patients with attenuated left ventricular function and angina pectoris.

Cardiovascular and respiratory changes and convalescence in laparoscopic colonic surgery: comparison between carbon dioxide pneumoperitoneum and gasless laparoscopy.

HYPOTHESIS: Gasless laparoscopy produces smaller cardiopulmonary and systemic changes than carbon dioxide (CO2) laparoscopy during colonic surgery. DESIGN: Prospective randomized trial. SETTING: Department of Surgery in a university hospital. PATIENTS: Twenty-two patients scheduled for laparoscopic colonic resection; 5 patients were excluded because of conversion to open surgery (N = 17). INTERVENTIONS: Patients were randomized to either gasless (n = 9) or conventional CO2 (n = 8) surgery. MAIN OUTCOME MEASURES: Intraoperative assessment of hemodynamic factors and pulmonary function, and postoperative assessment of pain, pulmonary function, convalescence, and various injury factors were done several times until 30 days after surgery. Surgical complications were noted. RESULTS: Descending aorta blood flow after 30 minutes (P=.03) and heart rate after 150 minutes were higher in the CO2 group (P=.009). Central venous pressure, PaCO2 inspiration pressure, and end tidal CO2 level were significantly higher in the CO2 group (P = .05, .03, .04, and .01, respectively). Patients in the CO2 group had less pain during mobilization and coughing (P = .008 and .006, respectively), and were significantly more fatigued (P = .04). No other important differences were observed in intraoperative hemodynamic factors, postoperative convalescence, immunocompetence, or pulmonary function. CONCLUSION: No clinically important differences in cardiovascular and systemic response were observed between patients undergoing CO2 or gasless laparoscopy for colonic disease.

Effect of specific thromboxane-synthetase inhibition on thromboxane and prostaglandin synthesis in stable angina induced by exercise test.

14 patients with effort induced angina pectoris were treated with a specific TxB2 inhibitor Dazoxiben or verapamil for two weeks with a wash-out period of 14 days between the two regimens. A sub-maximal bicycle test was performed before treatment and at the end of each treatment period. The bicycle test induced a significant increase in serum TxB2 in patients without treatment and during verapamil therapy. This increase was significantly inhibited by Dazoxiben treatment. No alterations in plasma TxB2 or 6-keto-PGF1 alpha were observed on either regimen. Dazoxiben had no clinical effect, while verapamil caused a highly significant prolongation of exercise time.

Predictors of sudden death and death from pump failure in congestive heart failure are different. Analysis of 24 h Holter monitoring, clinical variables, blood chemistry, exercise test and radionuclide angiography.

One hundred and ninety consecutive patients discharged with congestive heart failure were examined with clinical evaluation, blood chemistry, 24 h Holter monitoring, exercise test and radionuclide angiography. Median left ventricular ejection fraction was 0.30, 46% were in New York Heart Association class II and 44% in III. Total mortality after 1 year was 21%, after 2 years 32%. Of 60 deaths, 33% were sudden and 49% due to pump failure. Multivariate analyses identified totally different risk factors for sudden death: ventricular tachycardia, s-sodium < or = 137 mmol/l, s-magnesium < or = 0.80 mmol/l, s-creatinine > 121 mumol/l, and maximal change in heart rate during exercise < or = 35 min-1, and for death from progressive pump failure: New York Heart Association class III + IV, delta heart rate over 24 h < or = 50 min-1, low ejection fraction, high resting p-noradrenaline, s-urea > 7.6 mmol/l, s-potassium < 3.5 mmol/l, and maximal exercise duration < or = 4 min. In conclusion, this study demonstrated different risk factors for sudden death and for death from progressive pump failure.

The prevalence of myocardial ischemia six months after thrombolytic treatment of acute coronary episodes. A subset of a placebo controlled, randomised trial, the ASSET Study.

The purpose of this prospectively conducted study was to determine the prevalence of transient myocardial ischemia, evaluated from 24 h continuous ECG monitoring and exercise test, 6 months after inclusion in the Anglo Scandinavian Study of Early Thrombolysis (the ASSET trial, a randomised, placebo controlled study of alteplase for survival in patients with suspected acute myocardial infarction (AMI)), and to relate these findings to development of cardiac events. Of the 58 consecutively studied patients ischemic responses were found in 13 (45%) of 29 patients initially treated with placebo, and in 21 (72%) of 29 alteplase treated patients (P = 0.03). After another 6 months, i.e. 12 months after the acute event, two patients were dead, two had non-fatal reinfarctions and three had coronary artery by-pass surgery in the group with ischemic response; no events were recorded in patients without ischemia (P < 0.05). Alteplase treated patients more often had late myocardial ischemia, and cardiac events were found in patients with ischemia. Since the ASSET trial has demonstrated significantly higher short- and long-term survival rate in the alteplase treated group, it was indicated (1) that alteplase treated patients were better positioned for sustaining subsequent ischemia and thus cardiac events due to preservation of viable myocardial tissue, and (2) that late ischemia in the setting of initial alteplase treatment may convey other information than ischemia occurring in placebo treated patients.

Prognostic implications of ventricular ectopy one week, one month, and sixteen months after an acute myocardial infarction. Danish Study Group on Verapamil in Myocardial Infarction.

BACKGROUND: Ventricular ectopy early after an acute myocardial infarction (AMI) has previously been demonstrated to predict mortality. Less information is available about the prognostic implications of ventricular ectopy occurring late after an AMI, and no information is available about the prognostic implication of the development of ventricular ectopy during the first year after an AMI. HYPOTHESIS: The purpose of the present prospectively conducted trial, a part of the Danish Verapamil Infarction Trial II (DAVIT II), was to evaluate the prognostic implication of (1) ventricular premature complexes (VPCs) recorded by 24-h Holter monitoring 1 week, 1 month, and 16 months after an AMI; and (2) development of > 10 VPCs/h or of any complex ventricular ectopy, that is, pairs, more than two types of VPCs, ventricular tachycardia, or > 10 VPCs/h during follow-up after an AMI. METHODS: Patients were monitored 1 week (n = 250), 1 month (n = 210), and 16 months (n = 201) after AMI. RESULTS: Multivariate analyses based on history, clinical findings, and ventricular ectopy showed the following results: After 1 week, > 10 VPCs/h (p = 0.0006) and heart failure (p < 0.007); after 1 month, > 10 VPCs/h (p = 0.003) and resting heart rate (p < 0.02); and after 16 months, ventricular tachycardia (p = 0.002) independently predicted long-term mortality. Mortality was significantly predicted by the development of > 10 VPCs/h from 1 week to 1 month (p = 0.003) and 16 months (p = 0.03), and from 1 to 16 months (p = 0.007) after AMI, as well as by the development of any complex ventricular ectopy from 1 week to 1 month (p = 0.02) and 16 months (p = 0.01), and from 1 to 16 months (p = 0.04) after AMI. CONCLUSION: The present study demonstrated that 1 week and 1 month after an AMI the quantity of VPCs, that is, > 10 VPCs/h, predicted mortality, whereas 16 months after an AMI the quality of VPCs, that is, ventricular tachycardia, predicted mortality.

Propafenone versus quinidine slow-release for the treatment of chronic ventricular arrhythmias.

The efficacy and side-effects of oral propafenone 300 mg b.i.d. were compared to those of quinidine slow-release 800 mg b.i.d. in a randomized double-blind placebo controlled cross-over study in 12 patients with symptomatic premature ventricular complexes (PVCs). Furthermore during steady-state the plasma levels of propafenone and quinidine were measured repeatedly over an 8-hour period and correlated to the numbers of PVCs. In 6 patients both drugs reduced PVCs by 80%. In 2 patients this effect was obtained by propafenone and not by quinidine, while the reverse was found in another 2 patients. In 2 patients neither of the drugs was able to reduce PVCs by 80%. During treatment with quinidine 4 patients experienced diarrhoea and 1 patient suffered headaches taking propafenone. The plasma levels showed great variation. No correlation between the plasma levels expressed as area under the concentration-time curve and the reduction of PVCs was found.

Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography.

OBJECTIVE: To evaluate the effect of metoprolol, a beta adrenergic blocking drug, on the occurrence of myocardial ischaemia during endoscopic cholangiopancreatography. DESIGN: Double blind, randomised, controlled trial. SETTING: University Hospital. SUBJECTS: 38 (two groups of 19) patients scheduled for endoscopic cholangiopancreatography. INTERVENTIONS: Metoprolol 100 mg or placebo as premedication two hours before endoscopy. MAIN OUTCOME MEASURES: Heart rate, arterial oxygen saturation by continuous pulse oximetry, ST segment changes during endoscopic cholangiopancreatography (an ST segment deviation > 1 mV was defined as myocardial ischaemia), electrocardiogram monitored continuously with a Holter tape recorder. RESULTS: All patients had increased heart rate during endoscopy compared with rate before endoscopy, but heart rate during endoscopy was significantly lower in the metoprolol group compared with the placebo group (P = 0.0002). Twenty one patients (16 placebo, 5 metoprolol; P = 0.0008) developed tachycardia (heart rate > 100/min) during the procedure, and 11 patients (10 placebo, 1 metoprolol; P = 0.003) developed myocardial ischaemia. One patient in the placebo group had an acute inferolateral myocardial infarction. In the 10 other patients with signs of myocardial ischaemia during endoscopy the ST deviation disappeared when the endoscope was retracted. In all patients myocardial ischaemia was related to increases in heart rate, and 10 of the 11 patients had tachycardia coherent with myocardial ischaemia. CONCLUSIONS: Metoprolol prevented myocardial ischaemia during endoscopic cholangiopancreatography, probably through lowering the heart rate. Thus, tachycardia seems to be a key pathogenic factor in the development of myocardial ischaemia during endoscopy.

Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial.

OBJECTIVE: To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day. DESIGN: Randomised controlled trial. SETTING: Copenhagen, Denmark. SUBJECTS: 42 alcoholic patients without liver disease admitted for elective colorectal surgery. INTERVENTIONS: Withdrawal from alcohol consumption for 1 month before operation (disulfiram controlled) compared with continuous drinking. MAIN OUTCOME MEASURES: Postoperative complications requiring treatment within the first month after surgery. Perioperative immunosuppression measured by delayed type hypersensitivity; myocardial ischaemia and arrhythmias measured by Holter tape recording; episodes of hypoxaemia measured by pulse oximetry. Response to stress during the operation were assessed by heart rate, blood pressure, serum concentration of cortisol, and plasma concentrations of glucose, interleukin 6, and catecholamines. RESULTS: The intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm2 v 12 mm2, P=0.04), but not after surgery (3 mm2 v 3 mm2). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P

The roots of nursing: teaching caring based on Watson.

Caring is the root of nursing. Therefore, care must be a core component of any nursing programme. Watson (1985) developed 10 carative factors that she considers central to the caring process. These carative factors, which 'form a structure for studying and understanding nursing as the science of caring' (Watson 1985), shaped a unit of study at a School of Nursing in a tertiary institution in Western Australia. This paper describes how Watson's carative factors were used as a framework for teaching caring to Semester I undergraduate students.

[Predictors of sudden death and death from heart failure in patients with heart insufficiency are different]. / Praediktorer for pludselig død og for død pga. pumpesvigt er forskellige hos patienter med hjerteinsufficiens.

The purpose was to identify risk factors for the two most common modes of death in chronic congestive heart failure (CHF) in 190 consecutive patients discharged with CHF. They were examined with clinical evaluation, blood chemistry, chest X-ray, exercise testing, echocardiography, isotope ventriculography and Holter monitoring. Mortality after one year was 21%, after two years 32%. Of 60 deaths, 33% were sudden and 49% due to pump failure. Multivariate analyses identified totally different risk factors for sudden death: ventricular tachycardia, S-sodium < or = 137 mmol/l, S-magnesium < or = 0.80 mmol/l, S-creatinine > 121 mumol/l, and maximal change in heart rate during exercise < or = 35/min. For death from progressive pump failure: New York Heart Association class 3 + 4, delta heart rate over 24 h < or = 50/min, low ejection fraction, high resting P-noradrenaline, S-urea > 7.6 mmol/l, S-potassium < 3.5 mmol/l, and maximal exercise duration < or = 4 min.

[Metoprolol prevents myocardial ischemia during endoscopic retrograde cholangiopancreatography]. / Metoprolol forebygger myokardieiskaemi under endoskopisk retrograd kolangiopankreatikografi.

The aim of our study was to evaluate the effect of metoprolol on the occurrence of myocardial ischaemia during endoscopic cholangiopancreatography. Thirty-eight (2 x 19) patients scheduled for endoscopic cholangiopancreatography received either metoprolol 100 mg or placebo two hours before endoscopy. During endoscopy, arterial oxygen saturation was measured by continuous pulse oximetry, and the electrocardiogram was monitored continuously with a Holter tape recorder. Myocardial ischaemia was defined as an ST segment deviation > 1 mV from baseline. Heart rate during endoscopy was significantly lower in the metoprolol group compared with the placebo group (p = 0.0002). Twenty-one patients (16 placebo versus five metoprolol, p = 0.0008) developed tachycardia (heart rate > 100/min) during the procedure. A total of eleven patients (ten placebo versus one metoprolol, p = 0.003) developed myocardial ischaemia during the procedure, and myocardial ischaemia was always related to increases in heart rate. In conclusion, metoprolol prevented myocardial ischaemia during endoscopic cholangiopancreatography, probably through a heart rate lowering effect. Thus, tachycardia seems to be a key pathogenic factor in the development of myocardial ischaemia during endoscopy.

[Episodic hypoxemia and coinciding ECG changes after acute myocardial infarction]. / Episodisk hypoksaemi og samtidige ekg-forandringer efter akut myokardieinfarkt.

This study was conducted to document the trend in arterial hypoxaemia and electrocardiographic (ECG) abnormalities on second to sixth night after acute myocardial infarction (AMI). Nineteen consecutive patients with AMI were monitored continuously during the night with a Holter tape recorder and a pulse oxymeter. Five patients had > 30 episodic oxygen desaturations of > or = 5%, and many patients had episodes with oxygen desaturations < 80% ranging from 46-61% (from 7/15-11/18) during the nights of monitoring. Constant hypoxaemia was found in 11-13% of the patients. Many patients had simultaneous occurrence of episodic hypoxaemia and episodic sinustachycardia, ST-deviation and arrhythmias, giving a summarized simultaneous occurrence of episodic hypoxaemia and ECG-abnormalities ranging from 13/18 (72%) patients on the third night to 7/15 (46%) patients on the sixth night. Episodic and constant hypoxaemia are thus common during the first week after AMI. Episodic hypoxaemia was associated with ECG-abnormalities in the majority of patients.