17-year trends in incidence and prognosis of cardiogenic shock in patients with acute myocardial infarction in western Sweden.

BACKGROUND: Cardiogenic shock remains the leading cause of in hospital death in acute myocardial infarction (AMI) and is associated with a mortality rate of approximately 50%. Here we investigated the 17-year trends in incidence and prognosis of AMI-induced cardiogenic shock in Västra Götaland in western Sweden, an area with approximately 1.6 million inhabitants. The study period includes the transition from thrombolysis to primary percutaneous coronary intervention (PCI) as the region-wide therapy of choice for patients with ST-elevation myocardial infarction (STEMI). METHODS: Data on patients hospitalized in cardiac care units in Västra Götaland, Sweden between 1995 and 2013 were obtained from the Swedish Websystem for Enhancement of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). We determined the incidence of cardiogenic shock among patients diagnosed with AMI and the risk of death associated with developing cardiogenic shock. We fitted logistic regression models to study which factors predicted post-AMI cardiogenic shock. Analyses were performed on complete case data as well as after multiple imputation of missing data. RESULTS: Incidence of cardiogenic shock as a complication of AMI declined in western Sweden in the past decade, from 14% in 1995 to 4% in 2012. The risk of dying once cardiogenic shock had developed increased during the study period (p<0.01). Patients presenting with STEMI were more likely to develop cardiogenic shock than patients presenting with non STEMI (p<0.001). CONCLUSIONS: The incidence of cardiogenic shock has declined but cardiogenic shock carries a worse prognosis today than in 1995.

Angiographic findings and survival in patients undergoing coronary angiography due to sudden cardiac arrest in western Sweden.

AIM: Sudden cardiac arrest (SCA) accounts for more than half of all deaths from coronary heart disease. Time to return of spontaneous circulation is the most important determinant of outcome but successful resuscitation also requires percutaneous coronary intervention in selected patients. However, proper selection of patients is difficult. We describe data on angiographic finding and survival from a prospectively followed SCA patient cohort. METHODS: We merged the RIKS-HIA registry (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) and SCAAR (Swedish Coronary Angiography and Angioplasty Registry) for patients hospitalized in cardiac care units in Western Sweden between January 2005 and March 2013. We performed propensity score-adjusted logistic and Cox proportional-hazards regression analyses on complete-case data as well as on imputed data sets. RESULTS: 638 consecutive patients underwent coronary angiography due to SCA. Severity of coronary artery disease was similar among SCA patients and patients undergoing coronary angiography due to suspected coronary artery disease (n=37,142). An acute occlusion was reported in the majority of SCA patients and was present in 37% of patients who did not have ST-elevation on the post resuscitation ECG. 31% of SCA patients died within 30 days. Long-term risk of death among patients who survived the first 30 days was higher in patients with SCA compared to patients with acute coronary syndromes (P<0.001). CONCLUSIONS: Coronary artery disease and acute coronary occlusions are common among patients who undergo coronary angiography after sudden cardiac arrest. These patients have a substantial mortality risk both short- and long-term.

Long-term mortality in patients with type 2 diabetes undergoing coronary angiography: the impact of glucose-lowering treatment.

AIMS/HYPOTHESIS: The aim of this study was to analyse whether the increased mortality rates observed in insulin-treated patients with type 2 diabetes and coronary artery disease are explained by comorbidities and complications. METHODS: A retrospective analysis of data from two Swedish registries of type 2 diabetic patients (n = 12,515) undergoing coronary angiography between the years 2001 and 2009 was conducted. The association between glucose-lowering treatment and long-term mortality was studied after extensive adjustment for cardiovascular- and diabetes-related confounders. Patients were classified into four groups, according to glucose-lowering treatment: diet alone; oral therapy alone; insulin in combination with oral therapy; and insulin alone. RESULTS: After a mean follow-up time of 4.14 years, absolute mortality rates for patients treated with diet alone, oral therapy alone, insulin in combination with oral therapy and insulin alone were 19.2%, 17.4%, 22.9% and 28.1%, respectively. Compared with diet alone, insulin in combination with oral therapy (HR 1.27; 95% CI 1.12, 1.43) and insulin alone (HR 1.62; 95% CI 1.44, 1.83) were associated with higher mortality rates. After adjustment for baseline differences, insulin in combination with oral glucose-lowering treatment (HR 1.22; 95% CI 1.06, 1.40; p < 0.005) and treatment with insulin only (HR 1.17; 95% CI 1.02, 1.35; p < 0.01) remained independent predictors for long-term mortality. CONCLUSIONS/INTERPRETATION: Type 2 diabetes patients treated with insulin and undergoing coronary angiography have a higher long-term mortality risk after adjustment for measured confounders. Further research is needed to evaluate the optimal glucose-lowering treatment for these high-risk patients.

Patients with a history of diabetes have a lower survival rate after in-hospital cardiac arrest.

AIM: To describe the association between a history of diabetes and outcome among patients suffering an in-hospital cardiac arrest. METHOD: All patients suffering an in-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted at Sahlgrenska University Hospital in Göteborg between 1994 and 2006 and at nine further hospitals in Sweden between 2005 and 2006. RESULTS: In all, 1810 patients were included in the survey, 395 (22%) of whom had a previous history of diabetes. Patients with a history of diabetes differed from those without such a history by having a higher prevalence of previous myocardial infarction, stroke, heart failure and renal disease. They were more frequently treated with anti-arrhythmic drugs during resuscitation. Whereas immediate survival did not differ between groups (51.7% and 53.1%, respectively), patients with diabetes were discharged alive from hospital (29.3%) less frequently compared with those without diabetes (37.6%). When correcting for dissimilarities at baseline, the adjusted odds ratio for being discharged alive (diabetes/no diabetes) was 0.57 (95% CL 0.40-0.79). CONCLUSION: Among patients suffering an in-hospital cardiac arrest in Sweden in whom CPR was attempted, 22% had a history of diabetes. These patients had a lower survival rate, which cannot simply be explained by different co-morbidity.

Admission glycaemia and outcome after acute coronary syndrome.

BACKGROUND: Acute phase hyperglycaemia has been associated with increased mortality in patients with acute coronary syndrome. We investigated whether the predictive value of admission hyperglycaemia for mortality differs between diabetics and non-diabetics with acute coronary syndrome. METHODS: Patients with acute coronary syndrome (n=1957) were followed up prospectively for 45 months. Patients were stratified into quartile groups defined by admission plasma glucose and hyperglycaemia was defined as plasma glucose of >9.4 mmol/l, which was the cut-off value for the 4th quartile. The relationship between admission hyperglycaemia and short-term (< or =30 day) and late (>30 day) mortality was analysed. RESULTS: Of 1957 patients, 22% had a history of diabetes. Among patients without diabetes, those with hyperglycaemia had both a higher 30-day mortality rate (20.2% vs. 3.5%, p<0.0001) and late mortality rate (19.1% vs. 11.7%, p=0.007). Hyperglycaemic patients with diabetes had a higher late mortality rate than diabetic patients with plasma glucose of < or =9.4 mmol/l (29.3% vs. 14.9%, p=0.001). Of patients with hyperglycaemia at admission, those without diabetes had a higher 30-day mortality rate compared with those with diabetes (p=0.002). CONCLUSION: Admission hyperglycaemia is a strong risk factor for mortality in patients with acute coronary syndrome and may be even stronger than a previous history of diabetes. Hyperglycaemic patients without recognised diabetes have a higher short-term mortality risk than hyperglycaemic patients with known diabetes.

Association between glycometabolic status in the acute phase and 21/2 years after an acute coronary syndrome.

OBJECTIVES: To evaluate the association between glycometabolic status in the acute phase and 21/2 years later in patients with acute coronary syndrome (ACS). METHODS: Non-diabetic patients (n = 762) presenting with ACS were prospectively followed up for 21/2 years. Patients were stratified by admission plasma glucose (<6.1 mmol/l, 6.1 - 6.9 mmol/l and >or=7.0 mmol/l) and HbA1c (or=5.5%). The predictive value of glucose levels >or= 7.0 mmol/l and HbA1c >or= 5.5% for glycometabolic disturbance (i.e. diabetes or impaired fasting glycaemia (IFG)) was analysed. RESULTS: Of 762 patients, 13% had a diagnosis of diabetes and 16% had IFG at follow-up. The prevalence of glycometabolic disturbance at follow-up increased with increasing plasma glucose at admission, from 19% in patients with < 6.1 mmol/l to 42% in patients with >or= 7.0 mmol/l. Sixty-one percent of patients with HbA1c >or= 5.5% had glycometabolic disturbance after 21/2 years compared to only 25% of those with HbA1c < 5.5%. CONCLUSION: Non-diabetic patients with ACS and hyperglycaemia are at high risk for developing glycometabolic disturbance. HbA1c may be an even stronger predictor of glycometabolic disturbance than plasma glucose.

Speckle reduction in laser projection systems by diffractive optical elements.

In laser projection systems the observer in the far field of the image points on the screen will recognize serious speckle noise. There are many methods to reduce or eliminate speckles in the near field by reducing or eliminating temporal or spatial coherence of the laser. But for the far field it is hardly possible to change the coherence properties of laser sources so that speckles will disappear. We propose a new method for eliminating speckles in the far field by using a diffractive optical element. The intensity modulation depth in the far-field speckle pattern can be reduced to a few percent while good beam quality is preserved.

What determines a family doctor's prescribing habits for antibiotics? A comparative study on a doctor's own behaviour in two different settings.

OBJECTIVE: To compare the author's prescribing habits for antibiotics in two different work settings and to study the reasons for the observed different trends. DESIGN: A retrospective database study of computer-based patient records. The author's 55,261 patient contacts during a nine-year period were investigated. SETTING: A solo practice in a small isolated fishing village, Bolungarvík, in 1984-1987, and a group practice in the town of Akureyri in 1987-1992, where the people had a free choice of doctors. SUBJECT: The author himself was the subject of the study. MAIN OUTCOME MEASURE: Type and number of prescriptions of antibiotics. The predictive variables were number and type of contacts, number of listed patients, age and sex of the patients, diagnosis, and the use of laboratory investigations. RESULTS: From 1984 to 1986 the author reduced the number of his prescriptions of antibiotics from 82.9 to 63.8 per 1000 contacts (p < 0.001) in his solo practice. In the group practice the number increased from 82.6 in 1988 to 90.5 in 1992 (NS). There was an increase in the workload during the study periods, especially the latter, with a looser affiliation to the patient group. The incidence of respiratory diseases seemed to be in accordance with the frequency of prescriptions. CONCLUSIONS: In affluent societies many family physicians should be able to reduce their number of prescriptions of antibiotics to some extent, if they are interested in doing so and have a well established relationship with their patients. A computer-based quality control is essential for that purpose, because the expectations of the patients, the surroundings of the doctor, and his work environment determine to a great extent his antibiotic prescribing habits.

[Physicians faced with reporting in campaign against doping]. / Doktor inför rätta för kamp mot doping.

Despite its geographic isolation Iceland has not escaped the advent of problems with illicit drug-taking and abuse of hormones and other agents, in athletics and in other contexts. Denial of abuse, both by individuals and by athletics clubs, is facilitated by the secrecy surrounding usage and a certain insouciance among physicians with regard to the occurrence of abuse and the health risks involved, paired with a tendency to put confidentiality before the obligation to report incipient signs of health hazards and epidemiological trends. Good relations with the mass media, open factual discussions, and the civil courage to sound the alarm as early as possible, will be needed if such health risks to the community are to be discovered and counteracted.

Long-term ECG recordings in hyperthyroid patients before and after antithyroid treatment.

Heart rate and heart rhythm were studied in 19 hyperthyroid patients before and after antithyroid treatment inducing a euthyroid state. The mean 24-hour heart rate in patients with sinus rhythm and without drugs influencing heart rate was 100 beats/min before and 80 after antithyroid treatment. The difference was greatest in the sleeping hours. The heart rate, especially in the sleeping hours, correlated significantly with serum triiodothyronine but not with serum thyroxine concentrations.