Correlation between salivary and serum oxidized LDL levels: a pilot study on overweight/obese subjects.

BACKGROUND: Saliva contains a variety of substances and could be functionally equivalent to serum in reflecting the physiological state of the body, including metabolic variations. Salivary samples are non-invasive, safe, and easier to handle than serum. Oxidized LDL cholesterol (oxLDL) is an additional cardiovascular risk factor playing an important role in atheromatous plaque formation; overweight/obese subjects present an increase in oxLDL concentrations. The aims of the study were to assess oxLDL salivary levels, if detectable, and to verify their possible correlation with serum in overweight/obese subjects. METHODS: Thirty-five consecutive overweight/obese subjects and 10 normal weight controls were enrolled. Serum and salivary oxLDL levels were measured by a commercial enzyme-linked-immunosorbent assay (ELISA method). RESULTS: oxLDL levels were detectable in salivary samples and correlated (P = 0.001) with serum levels. Overweight/obese subjects showed serum and salivary oxLDL levels higher than controls (P = 0.000 and P = 0.022, respectively). CONCLUSIONS: Our study showed the presence of oxLDL in salivary samples and highlighted a correlation between salivary oxLDL levels and their counterpart in serum. Moreover, salivary oxLDL levels were higher in overweight/obese subjects than in controls. Therefore, a salivary sample could be functionally equivalent to serum in monitoring cardiovascular risk in overweight/obese subjects.

GISSI trial: early results and late follow-up. Gruppo Italiano per la Sperimentazione della Streptochinasi nell'Infarto Miocardico.

In the GISSI trial, 11,712 patients with acute myocardial infarction were randomized to receive either standard care or standard care with 1.5 million units streptokinase intravenously. A highly significant reduction in mortality during hospitalization in streptokinase-treated patients was observed. The mortality at 1 year was determined in 98.3% of the patients who had been originally randomized; the 1 year mortality of patients discharged alive was similar in those patients treated with streptokinase and those who were not; that is, the beneficial effects of streptokinase treatment on survival that were observed in the hospital phase of the study persisted unchanged and with comparable statistical significance for 1 year. However, a higher incidence of reinfarction occurred in the treated versus the control groups both during the hospital phase and at the 6 month follow-up. Streptokinase treatment had no detectable effect in patients with a history of previous infarction.

A simple electrocardiographic predictor of the outcome of patients with acute myocardial infarction treated with a thrombolytic agent. A Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)-Derived Analysis.

OBJECTIVES: This analysis aimed to evaluate in a large patient cohort the relation between ST segment alterations after fibrinolytic therapy for acute myocardial infarction and 1) the combined end point of in-hospital mortality plus clinical congestive heart failure or extensive left ventricular damage, and 2) mortality 30 and 180 days after randomization. BACKGROUND: Angina relief, enzyme release acceleration and ST segment normalization are related to coronary artery reperfusion and prognosis. Electrocardiographic (ECG) evaluation before and after fibrinolytic drug administration has been used to predict short- and long-term clinical outcome in acute myocardial infarction. METHODS: Patients enrolled in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial underwent a standard ECG on admission and after 4 h of alteplase or streptokinase therapy; 7,426 recordings were suitable for ST segment analysis. A decrease > or = 50% in the sum of ST segment elevation in all ECG leads was adopted as the cutoff for predicting coronary artery patency. Recanalization was deemed to have occurred in 4,951 patients (group A) versus 2,475 patients without reperfusion (group B). RESULTS: Group A patients experienced a lower incidence of the combined end point than did group B patients (16.2% vs. 22.9%, respectively), as well as of all its components (death, clinical heart failure, ejection fraction < 35%, injured myocardial segment > 45%, QRS score > 10). Thirty- and 180-day mortality rates were lower in group A than group B (3.5% and 5.7% vs. 7.4% and 9.9%, respectively); relative risk (Cox) was 0.46 (95% confidence interval [CI] 0.37 to 0.57) for 30-day and 0.58 (95% CI 0.48 to 0.70) for 180-day mortality. Patients in group A had significantly less ventricular fibrillation and sustained ventricular tachycardia but more ischemic episodes (early recurrent angina plus myocardial infarction recurrence). CONCLUSIONS: A simple, inexpensive instrumental evaluation, unaffected by different epidemiologic and clinical characteristics of the population analyzed, can allow early assessment of the effectiveness of fibrinolytic treatment with respect to the main clinical outcomes.

Predictors of nonfatal reinfarction in survivors of myocardial infarction after thrombolysis. Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) Data Base.

OBJECTIVES: This study was designed to reassess the prediction of recurrent nonfatal myocardial infarction in patients recovering from acute myocardial infarction after thrombolysis. BACKGROUND: Recurrent nonfatal myocardial infarction is a strong and independent predictor of subsequent mortality. Current knowledge of risk factors for nonfatal reinfarction is still largely based on data gathered before the advent of thrombolysis. Thus, this prospective study was planned to identify harbinger of nonfatal reinfarction in the postinfarction patients of the multicenter Grouppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial. METHODS: Predictors of nonfatal reinfarction at 6 months were analyzed by multivariate technique (Cox model) in 8,907 GISSI-2 survivors of myocardial infarction with clinical follow-up, relying on a set of prespecified variables reflecting residual ischemia, left ventricular failure or dysfunction, complex ventricular arrhythmias, comorbidity as well as demographic and historical factors. RESULTS: The postdischarge to 6-month incidence rate of nonfatal reinfarction was 2.5%. Independent predictors of nonfatal reinfarction were cardiac ineligibility for exercise test (relative risk 2.97, 95% confidence interval [CI] 1.98 to 4.45), previous myocardial infarction (relative risk 1.70, 95% CI 1.22 to 2.36) and angina at follow-up (relative risk 1.50, 95% CI 1.10 to 2.04). On further multivariate analysis, performed in 6,580 patients with both echocardiographic and electrocardiographic monitoring data available, a history of angina emerged as an additional risk predictor (relative risk 1.58, 95% CI 1.10 to 2.25). CONCLUSIONS: The 6-month incidence of nonfatal reinfarction is rather low in survivors of myocardial infarction after thrombolysis. Cardiac ineligibility for exercise testing and a history of coronary artery disease are risk predictors. Recurrent nonfatal infarction is not predictable by qualitative variables reflecting residual ischemia, except by postdischarge angina. Prediction of nonfatal reinfarction appears less accurate than prediction of mortality, as almost 50% of reinfarctions occur in patients without any of the identified risk factors.

Acute rejection after heart transplantation: noninvasive echocardiographic evaluation.

OBJECTIVES: The purpose of this study was to assess the reliability of echocardiography in the noninvasive diagnosis of acute rejection in heart transplant recipients. BACKGROUND: Although echocardiographic results seem to correlate well with allograft rejection, published data are limited and contradictory. METHODS: In 130 transplant recipients, 1,400 serial echocardiograms were recorded within 24 h of endomyocardial biopsy. Increased wall thickness, myocardial echogenicity, pericardial effusion, shorter pressure half-time, isovolumetric relaxation time and a decrease in left ventricular ejection fraction were considered markers of rejection. RESULTS: The distribution of echocardiographic markers revealed highly significant differences between bioptically graded moderate, mild and no rejection and between untreated and treated rejection episodes (both chi-square test, p < 0.0001). Specificity was 98.6% for two markers, but sensitivity was good (80%) for only moderate rejection because of the large number of false negatives in untreated patients with mild rejection. In untreated patients, there was a highly significant difference in the number of echocardiographic criteria between a benign and nonbenign outcome (chi-square test, p < 0.0001). In treated patients, the significant difference in the variation in echocardiographic criteria between favorable and unfavorable responses after 1 week was more pronounced after 2 weeks (t test, p < 0.01 vs. < 0.001). Diastolic indexes and pericardial effusion at 2 weeks seemed to be predictive of therapeutic response. CONCLUSIONS: Poor sensitivity to mild rejection indicates that serial echocardiography cannot supplant endomyocardial biopsy in the early diagnosis of acute rejection, but it seems to be a reliable noninvasive means of identifying acute rejection requiring intensified immunosuppressive therapy and of evaluating outcome.

Reflex vasopressin and renin modulation by cardiac receptors in humans.

Animal studies have shown that vasopressin secretion is modulated by arterial baroreceptors and cardiopulmonary volume receptors. Whether this is the case also in humans is controversial, however. To determine whether vasopressin is reflexly modulated by cardiac volume receptors, we studied the effect on plasma vasopressin (venous blood, radioimmunoassay) of reducing venous return and left ventricular end-diastolic diameter (echocardiography) by producing a 20-minute lower body negative pressure in 14 healthy subjects (aged 49.3 +/- 3.8 years, mean +/- SEM). The data were compared with those of 14 age-matched heart-transplant recipients, i.e., subjects with cardiac denervation. In healthy subjects, lower body negative pressure at -15 mm Hg caused a modest reduction in left ventricular end-diastolic diameter (-5 +/- 3.4%) and no change in vasopressin, whereas lower body negative pressure at -37.5 mm Hg caused a more marked reduction in left ventricular end-diastolic diameter (-12 +/- 2.5%) and a small, variable, but overall statistically significant (p < 0.05) increase in vasopressin (+145 +/- 46%, p < 0.01). The left ventricular end-diastolic diameter changes induced by the two lower body negative pressure stimuli were similar in heart-transplant recipients, but the vasopressin increase seen with the lower body negative pressure at -37.5 mm Hg was abolished. The marked increase in plasma renin activity and forearm vascular resistance induced by lower body negative pressure in healthy subjects was also abolished or drastically attenuated in heart-transplant recipients.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of clinical findings in idiopathic dilated cardiomyopathy in women versus men. The Italian Multicenter Cardiomyopathy Study Group (SPIC)

Clinical and laboratory findings were compared in 65 women and 238 men with invasively documented idiopathic dilated cardiomyopathy. Women had more severe symptoms (New York Heart Association class > or = III in 48 vs 39%; p < 0.05), presented more frequently with heart failure signs (63 vs 41%; p < 0.01), and had a higher cardiothoracic ratio (0.56 +/- 0.06 vs 0.53 +/- 0.06; p < 0.05) and higher frequency of left bundle branch block (41 vs 29%; p < 0.05). Echocardiographic measurements in women showed significantly greater left ventricular (LV) end-diastolic (42 +/- 7 vs 39 +/- 6 mm/m2; p < 0.0001) and end-systolic (36 +/- 7 vs 33 +/- 6 mm/m2; p < 0.001) diameters, and mean myocardial thickness (11 +/- 2 vs 10 +/- 2 mm; p < 0.05). Exercise duration was shorter in women than in men (7 +/- 3 vs 10 +/- 4 minutes; p < 0.001). After 18 +/- 16 months, 9 women and 27 men died, and 7 and 17, respectively, received transplants. Transplant-free survival was not significantly different according to gender. By Cox multivariate analysis, LV ejection fraction was a significant independent predictor of cardiac death or heart transplantation in both sexes (p < 0.05 in men, and p < 0.005 in women), together with left atrial diameter index (p < 0.01) in women, and mean pulmonary artery pressure (p < 0.001) in men. In conclusion, women with idiopathic dilated cardiomyopathy present a more advanced phase of the disease with greater LV dilation, but do not have a different prognosis.

Value of negative predischarge exercise testing in identifying patients at low risk after acute myocardial infarction treated by systemic thrombolysis.

Although thrombolytic therapy reduces mortality in patients with acute myocardial infarction (AMI), it is associated with a greater incidence of successive coronary events, and there is still no ideal diagnostic and therapeutic strategy for such patients. The present study verifies the value of negative predischarge exercise testing in identifying low-risk patients treated with thrombolysis after AMI. One hundred fifty-seven consecutive patients with an uncomplicated clinical course underwent maximal or symptom-limited exercise testing (Bruce treadmill protocol) within 15 days of AMI in the absence of therapy. The location of the AMI was anterior in 51 patients, inferior in 85 and non-Q-wave in 21. All of the patients were followed for 6 months. Death and nonfatal reinfarction were considered as major coronary events, and the recurrence of angina as a minor event. Exercise test results were negative in 105 patients (group 1) and positive for angina or ST depression greater than or equal to 0.1 mV in 52 (group 2). No deaths occurred during follow-up; there were 3 reinfarctions (3%) and 7 cases (7%) of postinfarction angina in group 1, and 2 reinfarctions (4%) and 21 cases (40%) of postinfarction angina in group 2. By the end of follow-up, 90% of the patients with negative exercise test results were event-free (97% in the case of major events). These results show that thrombolytic therapy does not affect the value of negative postinfarction exercise testing in identifying low-risk patients.

Exercise thallium scintigraphy versus high-dose dipyridamole echocardiography testing for detection of asymptomatic restenosis in patients with positive exercise tests after coronary angioplasty.

The usefulness of high-dose (< or = 0.84 mg/kg over 10 minutes) dipyridamole echocardiography testing was compared with that of exercise thallium-201 scintigraphy in detecting restenosis (> 70% lumen reduction) in 50 asymptomatic patients with ST-segment depression during maximal exercise testing 3 months after successful coronary angioplasty. Dipyridamole echocardiography testing and exercise thallium scintigraphy showed a similar sensitivity (75 vs 83%; p = NS) and specificity (90 vs 84%; p = NS) for the detection of restenoses, which occurred in 12 patients. It is concluded that dipyridamole echocardiography testing is as accurate as exercise thallium testing for the noninvasive detection of severe restenosis in patients with exercise-induced asymptomatic ST-segment depression after successful angioplasty. Furthermore, the site, extent and severity of the thallium perfusion defects during exercise are correlated to those of the dyssynergy during dipyridamole echocardiography.

Comparison of usefulness of high-dose dipyridamole echocardiography and exercise electrocardiography for detection of asymptomatic restenosis after coronary angioplasty.

The present study compares the relative usefulness of the maximal treadmill exercise electrocardiography test with the high-dose dipyridamole echocardiography test (echocardiographic monitoring during dipyridamole infusion up to 0.84 mg/kg in 10 minutes) in detecting severe restenosis or coronary artery disease progression (greater than 70% stenosis) in asymptomatic patients 12 months after a primary successful coronary angioplasty. Criteria of positivity were: for the exercise electrocardiography test, an ST-segment shift greater than or equal to 0.1 mV from baseline, 0.08 second from the J point; for the dipyridamole echocardiography test, a transient dyssynergy of contraction, absent or of a lesser degree than that in the baseline examination. The exercise electrocardiography and dipyridamole echocardiography tests revealed a similar feasibility (91 vs 87%, difference not significant). Both tests could be performed in 75 patients. For detection of restenosis or disease progression, or both, the exercise electrocardiography test revealed a sensitivity similar to the dipyridamole echocardiography test (71 vs 71%, difference not significant), but a lower specificity (61 vs 90%). It is concluded that the high-dose dipyridamole echocardiography test is equally feasible but more accurate than the exercise electrocardiography test for noninvasive detection of severe asymptomatic restenosis or disease progression at 1 year after successful coronary angioplasty.

Significance of pericardial effusion after heart transplantation.

The aim of this study was to evaluate the clinical significance of pericardial effusion after heart transplantation and to assess its correlation with acute rejection. One hundred fifty transplanted patients were followed up for the first year: serial echocardiographic studies were performed on the same day as were the endomyocardial biopsies; hemodynamic studies and coronary angiographies were performed 1 year after transplant. Ten days after surgery, pericardial effusion was absent in 77 patients, small in 52, moderate in 14, and large in 7, and was significantly related to severe postoperative bleeding (p < 0.001). Patients were classified according to the presence and the course of pericardial effusion in group A (absence or disappearance of previous pericardial effusion within 1 month, 107 patients) and in group B (onset, persistence, or increase in pericardial effusion, 43 patients). One hundred nineteen patients experienced > or = 1 acute rejection episode. The evolution of pericardial effusion was different (p < 0.0001) according to the number of acute rejection episodes and biopsy specimens showing acute rejection, histologic grading and time of the first episode, and histologic grading of the most severe acute rejection episode. Furthermore, there was a significant correlation with the cumulative duration of acute rejection episodes (p < 0.005) and the presence of previous cardiac surgical history (p < 0.007), but no correlation with cardiac transplant vasculopathy or with a positive weight mismatch. This study suggests that pericardial effusion in transplant recipients is associated with a higher incidence and more severe histologic grading of acute rejection episodes; its presence indicates the need for stricter monitoring of acute rejection.

Restrictive criteria for heart transplantation candidacy maximize survival of patients with advanced heart failure.

BACKGROUND: The shortage of organ donors and the amelioration of medical management of advanced heart failure mandate strict selection of heart transplant candidates on the basis of the need and probability of success of transplantation, with the aim of maximizing survival of patients with advanced heart failure, both with and without transplantation. This study analyzes the impact of restricting the criteria for heart transplantation candidacy on the outcome of patients with advanced heart failure referred for transplantation. METHODS: Survival and freedom from major cardiac events (death, resuscitated cardiac arrest, transplantation while supported with inotropes or mechanical devices) were compared between patients listed during 1990 to 1991, when standard criteria were applied (group 1, n = 118), and patients listed during 1993 to 1994, when only patients requiring continuous/recurrent intravenous inotrope therapy in spite of optimized oral medications and outpatients showing actual progression of the disease were admitted to the waiting list (group 2, n = 88). Survival and freedom from cardiac events (defined as above plus listing in urgent status) were also calculated in stable outpatients evaluated in 1993 to 1994, who were potential heart transplant candidates according to standard criteria but were not listed because of restrictive criteria (group 3, n = 52, New York Heart Association functional class > or = III, mean echocardiographic ejection fraction 0.22 +/- 0.05, mean peak oxygen consumption 12.3 +/- 1.5 ml/kg/min, mean follow-up 19 +/- 10 months). RESULTS: Thirty-one percent, 40%, and 50% of group 1 patients versus 58%, 65%, and 77% of group 2 patients underwent transplantation within 3, 6, and 12 months after listing (p < 0.0007). The 1- and 2-year survival rates after listing were 80% and 71% in group 1 versus 85% and 84% in group 2 (p < 0.0001). Freedom from death/urgent transplantation was lower in group 2 than in group 1 (55% and 48% versus 72% and 59% at 6 and 12 months, respectively; p < 0.0001). In patients undergoing transplantation, the postoperative survival rate was similar (87% and 91% at 2 years in group 1 and group 2, respectively). Two years after heart transplantation candidacy was denied, 86% of group 3 patients were alive, and 74% were event-free. CONCLUSIONS: Restricting the admissions to the waiting list to patients with refractory/progressive heart failure improved survival rates after listing by increasing the probability to undergo transplantation in a short time. Selection of most severely ill candidates did not affect postoperative survival. Survival and freedom from cardiac events were good in patients with advanced but stable heart failure, in spite of their severe functional limitation. Thus restrictive criteria for heart transplantation candidacy allows maximal survival benefit from both medical therapy and transplantation.

A semiquantitative approach to the evaluation of acute cardiac allograft rejection at endomyocardial biopsy.

BACKGROUND: Histopathologic criteria for grading of acute cardiac allograft rejection are focused on the most severe lesion that is recognized among the myocardial fragments provided by each endomyocardial biopsy specimen. Considering the distribution of rejection lesions among all the fragments improved the accuracy in characterizing the severity of rejection in pathologic studies. This study was undertaken to verify the usefulness of a semiquantitative evaluation of endomyocardial biopsy specimens, consisting of the calculation of the proportion of fragments showing rejection in the clinical setting. METHODS: Of the 2386 biopsy specimens obtained during the first posttransplantation year in 168 consecutive cardiac allograft recipients, 290 biopsy specimens constituted by > or = 3 adequate fragments and showing rejection not followed by treatment (n = 159) or being the first biopsy specimen prompting treatment with augmented immunosuppression for that rejection episode (n = 131) were selected. These biopsy specimens (index biopsy specimens) were grouped according to whether rejection was present in < or = 33%, > 33% to < or = 67%, and > 67% of the fragments. The rejection grade (according to the standardized grading system) and the proportion of fragments positive for rejection were correlated with the occurrence of clinical symptoms and signs of rejection at index biopsy and with the results of the next biopsy. RESULTS: Rejections graded > or = 3A were more frequently symptomatic (36% vs 9% for those graded < 3, p < 0.0001), as were those involving increasing proportions of fragments (< or = 33%: 5 of 124, 4%; > 33 to < or = 67%: 13 of 99, 13%; > 67%: 19 of 67, 28% [p < 0.0001]). Spontaneous resolution after untreated biopsies was more frequent in focal (grade 1A and 2) than in diffuse mild (1B) rejections (68% vs 38% [p < 0.04]), whereas progression to grade 3A or greater was less frequent (4% vs 27% [p < 0.01]). Increasing proportions of positive fragments were associated with lower frequencies of spontaneous resolution (p < 0.05) and higher frequencies of worsening (9%, 22%, 43% [p < 0.009]) or progression to grade 3A or greater (2%, 6%, 28% [p < 0.005]). Complete resolution after treatment was less frequent for increasing proportions of positive fragments at index biopsy (80%, 66%, 49% [p < 0.05]). CONCLUSIONS: Diffuse versus focal rejection pattern and the proportion of positive fragments seem to be clinically relevant in terms of occurrence of symptoms, spontaneous evolution, and response to treatment.

Prognostic indices in heart transplant candidates after the first hospitalization triggered by the need for intravenous pharmacologic circulatory support.

BACKGROUND: Patients with heart failure refractory to optimal oral pharmacologic therapy have a dismal short term prognosis. Heart transplantation is the only therapy shown to improve survival in these patients. Unfortunately, due to the critical shortage of donor organs, approximately 30% of listed patients with end-stage heart failure die before a suitable donor heart becomes available. The principal aim of this study was to determine whether intravenous pharmacologic circulatory support favorably influences the clinical course of heart transplant candidates or whether mechanical circulatory support should be instituted in this high risk patient population. METHODS: Data from 154 consecutive hospitalizations in 125 patients 49+/-12 years were retrospectively reviewed. The product limit method was used to estimate survival. Multiple logistic regression analysis was used to identify the clinical and hemodynamic variables that independently predict outcome after each admission in which heart transplantation did not occur. RESULTS: One year survival for the study population was 65%. This survival is significantly lower than the 91% 1 year survival in similarly ill patients undergoing heart transplantation. The Cox proportional hazard method identified serum bilirubin, blood urea nitrogen (BUN), serum sodium levels and right atrial pressure as independent prognostic indices. Serum bilirubin, BUN levels and duration of intravenous pharmacologic circulatory support were associated with a poor outcome. A composite index including serum bilirubin and BUN levels predicted outcome with a sensitivity and specificity of 79% and 77%, respectively. The addition of pharmacologic support duration increased the model's sensitivity to 95%, but did not significantly alter specificity that was 74%. Of the 125 patients hospitalized due to the need to initiate intravenous pharmacologic support for the first time (index hospitalization), 69 (55%) were discharged after optimization of medical therapy. Of 21 patients who did not undergo transplantation during the follow-up period, 18 (86%) died within 2 years of the index hospitalization. The duration of intravenous pharmacologic support beyond which prognosis dramatically worsens without heart transplantation is 21 days. CONCLUSION: Heart transplant candidates who require intravenous pharmacologic circulatory support for more than 21 days and do not receive a suitable donor heart within this period of time have a high mortality. Alternative therapies, such as implantation of a mechanical circulatory assist device should be considered in this high risk population.

The United States at mid-decade.

PIP: This report examines the demographic forces at work in the US that will influence the country's future. A profile of the US population in the mid-1990s reveals that the US is the third most populated countries in the world and one of the fastest growing of the industrialized countries. 70% of this growth is due to natural increase and 30% to immigration. The first topic covered in this report, geographic patterns of growth and change, includes a consideration of regional patterns, population growth by state, residential patterns, and the increase in the number of minorities living in suburban areas. The second topic is the changing age structure, which is characterized by an aging of the population and an increase in the number of children. Racial and ethnic diversity is discussed in terms of fastest growing groups, where minorities live, the Native American population, and the impact of this diversity on political participation. Immigration is analyzed to reveal sources and destinations, linguistic diversity, effects on schools and the labor market, and socioeconomic effects. The section on American families focuses on trends in marriage and divorce, types of households and families, and household patterns by race/ethnicity. The last topic looks at the distribution of income and poverty as well as at regional and state differences, race/ethnicity differences, the effects of marital status on income, who constitutes the poor, and how income is distributed. In conclusion, it is noted that America's social and economic future depends upon whether current demographic trends will lead to a fragmented and divisive society or to a stronger nation built upon diversity.^ieng

New realities of the American family.

PIP: The demographic, social, and economic characteristics of American families have changed dramatically over the past few decades. While the male breadwinner/female homemaker model was long traditionally typical,l contemporary families may be openly made up of single-parents, remarried couples, unmarried couples, stepfamilies, foster families, extended or multigenerational families, or 2 families within 1 household. Families are now most likely to have 3 or fewer children, a mother employed outside of the home, and a 50% chance of parental divorce before the children are grown. These trends are common not only in America, but in most industrialized nations around the world. In fact, family trends are so fluid that the US Census Bureau and workplace policy find it difficult to keep pace. This report presents and discusses social and demographic trends behind the ever-changing face of the American family. Households and types of families are further defined, as are the living arrangements of children, young adults, and the elderly. Marriage, divorce, and remarriage trends, age at marriage rates, and interracial marriage are then discussed. Next examined are declining family size, teenage parents, contraception and abortion, unwed mothers, and technological routes to parenthood. The changing roles of family members and family economic well-being are discussed in sections preceding closing comments on the outlook for the American family.^ieng

[Non-Q infarct. Clinical and prognostic aspects]. / L'infarto non Q. Aspetti clinici e prognostici.

Prognosis of on-Q wave myocardial infarction (nQMI) has been the subject of considerable controversy over the last few years and a systematically aggressive approach with PTCA or coronary by-pass surgery (CBS) has been advocated as a means to reduce subsequent coronary events rate. To investigate clinical outcome and possibly identify high-risk subgroups 131 consecutive patients (pts) meeting diagnostic criteria for nQMI, admitted to our CCU for their first myocardial infarction between January 1980 and June 1985, were followed-up for a mean period of 34 months (range 6-72). Mean age of pts was 59 +/- 7 yrs; 101 (76%) were males, 30 (24%) females. No pt was lost to follow-up. During the same period 684 pts were admitted for Q wave myocardial infarction. Major coronary events such as angina, reinfarction, CBS, cardiac death as well as overall early and late mortality were considered for statistical evaluation with uni-multivariate analysis taking into account multiple data from pts history and acute clinical presentation. Angina appeared or recurred in 71 pts (54%), reinfarction occurred in 14 (10.7%); 25 pts underwent CBC (19%). Early cardiac deaths were 7 (5.3%), late cardiac deaths 12 (9.2%); overall mortality rate 18.1%. Uni- and multivariate statistical analysis did not disclose significant criteria predicting major coronary events and no high-risk subgroup could be identified, confirming uncertainties and doubts from literature.

[Acute epiglottitis in children: current criteria for the diagnosis and treatment]. / Epiglottite acuta in età infantile: attuali criteri di diagnosi e trattamento.

Acute epiglottitis is still a potentially lethal pathology, particularly in early childhood. The present study involves seven cases of acute epiglottitis in children under 4 years of age. The authors describe the diagnostic and therapeutic protocols used in these pediatric patients placing particular emphasis on the use of endoscopy and the need for prompt hospitalization in an intensive care unit to best integrate the diagnostic approach with therapeutic treatment.

["Silent" gastroesophageal reflux and upper airway pathologies in childhood]. / Reflusso gastroesofageo "silente" e patologia delle alte vie respiratorie in età pediatrica.

In children, gastroesophageal reflux (GER) plays an important role in both acute and chronic upper airway disorders including stridor, chronic cough, recurrent upper respiratory infections, obstructive apnea, laryngospasm, and wheezing. Diagnosis may prove difficult unless there is reason to suspect GER and one is aware of the concept of "silent" GER. This paper presents our experience with chronic and/or recurrent respiratory disorders of uncertain origin and without gastrointestinal symptoms in children. Thirty-two pediatric patients with upper respiratory symptoms were evaluated. Out-patient 24-hour intraesophageal pH was monitored and 56% of the patients underwent pharyngo-laryngeal fibroscopy. The patients were divided into two subgroups: Group A (18 patients < 6 months of age) and Group B (14 patients > 6 months). All the patients tested positive for GER with a mean Reflux Index of 21.5. The most common symptoms in Group A were apnea-cianosis and stridor while they were chronic cough for group B. The present study confirms the association between GER and respiratory disease and between GER respiratory-related symptoms and patient age. Emphasis is placed on the importance of otolaryngological diagnostic procedures and 24-hour pH-gastroesophageal monitoring in evaluating patients with respiratory disorders related to silent GER.