Primary graft failure after heart transplantation: the importance of donor pharmacological management.

BACKGROUND: Primary graft failure (PGF) remains the strongest determinant of perioperative mortality after heart transplantation (HT). Donor management may play an important role in the incidence of PGF. MATERIALS AND METHODS: Multivariate analysis was used to identify PGF determinants after HT. Donor and recipient data were analyzed together with preharvest management information and perioperative results. PGF was defined as the need for mechanical circulatory support immediately post-HT. RESULTS: Isolated HT was performed in 54 consecutive patients from January 2006 to June 2009. PGF occurred in 11 (20%) patients. Upon univariate analysis, preoperative mean pulmonary arterial pressure was significantly higher among patients developing PGF (P=.02). The donors for PGF patients had more often been managed with high inotropic support (dopamine>10 microg/kg/min and/or alpha agonists>0.06 microg/kg/min; P=.008). In contrast, death for head trauma was more common among donors for patients who did not develop PGF (P=.02). In-hospital mortality was 13% (7/54); 71% of these deceased patients displayed PGF (5/7). Upon multivariate analysis, preharvest high donor inotropic support was the strongest determinant of PGF (P=.01, odds ratio [OR]=7.5). Donor death due to head trauma showed a protective effect against PGF (P=.03, OR=0.1). CONCLUSION: PGF remains a lethal perioperative complication despite modern tools for prompt cardiac mechanical assistance. As a result of the organ shortage, many centers accept marginal hearts assuming that donor hemodynamic management shows a reduced impact on PGF. We suggest a timely evaluation of the hazards for PGF whenever high inotropic support is used, especially among donors dying for causes other than head trauma.

Awareness, treatment, and control of hypertension in the elderly in a general practice experience. Study Group on Hypertension in the Elderly.

In 3858 ambulatory elderly people (age greater than or equal to 65 years) prevalence of hypertension was 67.8%. The hypertensive status was unknown to both the doctor and the patient in 21.4% of cases. More than 90% of known hypertensives were treated, but hypertension could be considered as controlled in less than 30% of them.

Feasibility of a large prospective study in general practice: an Italian experience. Gruppo di Studio sulla Pressione Arteriosa nell'Anziano.

A study of blood pressure control in elderly outpatients was carried out with the participation of 444 Italian general practitioners. Of 4096 patients aged 65 years or over who were considered for recruitment, 3959 (96.7%) fulfilled all the criteria of admission and were followed up for 12 months. The findings regarding one of the aims of the study--that is, to assess the feasibility of a large scale trial in general practice--are reported. Most (87%) of the doctors completed the study. Their adherence to the protocol was highly satisfactory, leading to an acceptable quality of work. Patients' compliance was also good; 98.6% (3898) of the patients who had fulfilled the admission criteria agreed to participate in the study, and only 4% (158) dropped out. Both of these observations support the feasibility of carrying out prospective studies in general practice. The creation of networks of general practitioners who are prepared to carry out research in their practices would allow treatment and preventive measures to be studied simply and at low cost in the appropriate setting.

Reduction of beta-adrenergic receptors by tertatolol: an additional mechanism for beta-adrenergic blockade.

Tertatolol is a potent new beta-blocker with no intrinsic sympathomimetic activity or beta 1/beta 2-receptor subtype selectivity. When given at therapeutic doses (5 mg/day) to human subjects it induced a reduction in the beta-adrenergic receptor number measured by 3H-CGP 12177 specific binding, without any change in the affinity on intact lymphocytes. This reduction was seen 7 hours (54%), 24 hours (35%), and 48 hours (30%) after a single drug dose. A similar receptor reduction was observed 7 hours (42%), 24 hours (37%), and 48 hours (15%) after 14 doses of the drug. In parallel, the pharmacologic efficacy of the drug was evident from the reduction in supine and upright heart rates and after submaximal exercise; heart rate was reduced to the same extent after single or repeated drug doses. The reduction of receptor number correlated well with the reduction in heart rate in the supine (P less than 0.001) and upright (P less than 0.01) positions and after exercise (P less than 0.02). In in vitro competitive binding experiments tertatolol was found to be a competitive inhibitor of beta-adrenergic receptors. However, on intact human lymphocytes preincubated with this drug, tertatolol reduced the density of beta-adrenergic receptors. We conclude that tertatolol, besides competitively inhibiting beta-adrenergic receptors, induced a marked and lasting decrease in the beta-adrenergic receptor number. This effect may be important for its beta-blocking effects.

Homes for the elderly in Liguria.

A survey of 55 old people's homes in Liguria, a region in northern Italy, was carried out to investigate some social and demographic characteristics of the residents, their level of dependence and management. A total of 1666 residents was randomly selected and information was obtained from the records and from an interview with the care staff. Homes admitting only independent people were smaller than those admitting both dependent and independent people. Private homes tended to admit only independent people. The resident population showed relatively high geographical stability and a fair amount of outside support. Nearly half the residents were fully independent and 75% were prescribed at least one drug. 'Cerebroactive' drugs, psychotropic drugs, diuretics, and cardiac glycosides were extensively prescribed. Drug treatment was almost the only therapeutic intervention.