Biomedical subjects
Publications and source records attributed to B Martina.
Evidence and practical approach of Coronary Risk Assessment in noncardiac surgery are reviewed. Growing literature suggests a benefit of perioperative b-blockade. Therefore, risk stratification and management are described in algorithms in order to provide a useful tool for practitioners both in the hospital and ambulatory setting.
UNLABELLED: Many patients with atrial fibrillation do not receive anticoagulation due to accepted contraindications but also due to considerable underuse. We screened 2215 consecutive patients when they entered the Medical Emergency Department for any acute condition. The decision on correct use or underuse of oral anticoagulation was made from the charts by consensus of two experienced physicians. The prevalence of atrial fibrillation was 3.7%. 43 of 83 patients with atrial fibrillation had oral anticoagulation (52%, mean age 76 years). 32 patients were treated with Aspirin only (38%, mean age 79 years). 29 patients (35%) did not receive anticoagulation because of accepted contraindications, i.e., dementia and risk for recurrent falls (n = 16), history of bleeding (n = 6), drug malcompliance due to forgetfulness (n = 4) and psychiatric disease (n = 1). Underuse of anticoagulation occurred only in three patients (4%, unclear reasons in two patients, patient's unwillingness in one patient). CONCLUSION: We did not observe substantial underuse of anticoagulation in patients with atrial fibrillation.
INTRODUCTION: Nodal treatment in papillary (PTC) and in follicular (FTC) thyroid carcinoma is still a subject of debate. METHODS: 1974-95 therapeutic lymphadenectomy (30/95), 1996-1999 frequent prophylactic lymphadenectomy (32/57; P = 0.005) was used for PTC, with therapeutic lymphadenectomy for FTC (15/115). 131I was used selectively for pN1-tumours. RESULTS: PTC: The incidence of pN0-, but not of pN1-status increased significantly (P = 0.03). Nodal recurrence was observed in 5/89 (6%) with therapeutic, vs. 1/54 (2%) with prophylactic lymphadenectomy (P = NS), i.e. in 1/107 (0.9%) patients without evidence of nodal disease, vs. 5/36 (14%) of those with pN1-status (P = 0.0004). Survival at 25 yrs. in stages TNM I and II was 100%, i.e., independent of N-status. FTC: No nodal recurrence was observed. CONCLUSION: Occult untreated nodal disease represented no major clinical problem. Selective nodal treatment may offer optimal results; meticulous nodal dissection is indicated for N1-tumours.
Hypertensive emergencies are acute, life-threatening events, characterised by high blood pressure and concomitant acute hypertensive target organ damage. These patients need immediate lowering of blood pressure mostly with parenteral drugs in the range of the autoregulative capacity of organ circulation and in-hospital monitoring of the vital functions. Hypertensive urgencies are not necessarily life-threatening, but persistence of high blood pressure may lead to acute target organ damage. Blood pressure should be lowered within 24 to 48 hours. Oral therapy is normally sufficient and hospitalisation is rarely necessary, but maintenance of antihypertensive therapy outside the hospital has to be ascertained.
OBJECTIVES: To prospectively compare compliance with treatment in patients with hypertension responsive to treatment versus patients with treatment resistant hypertension. DESIGN: Prospective case-control study. SETTING: Outpatient department in a large city hospital in Switzerland, providing primary, secondary, and tertiary care. PARTICIPANTS: 110 consecutive medical outpatients with hypertension and taking stable treatment with at least two antihypertensive drugs for at least four weeks. MAIN OUTCOME MEASURES: Treatment compliance assessed with MEMS devices; blood pressure determined by 12 hour daytime ambulatory monitoring (pressure <135/85 mm Hg in patients aged </=60 years and <155/90 mm Hg in patients aged >60 indicated hypertension responsive to treatment). RESULTS: Complete data were available for 103 patients, of whom 86 took >/=80% of their prescribed doses ("compliant") and 17 took <80% ("non-compliant"). Of the 49 patients with treatment resistant hypertension, 40 (82%) were compliant, while 46 (85%) of the 54 patients responsive to treatment were compliant. CONCLUSION: Non-compliance with treatment was not more prevalent in patients with treatment resistant hypertension than in treatment responsive patients.
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BACKGROUND AND OBJECTIVE: Patients with community-acquired pneumonia can be allocated into low and high-risk mortality groups by simple clinical criteria. We studied the value of the stratification for outcome as proposed by Fine, et al. to guide the decision for in-hospital versus outpatient treatment in the emergency department. PATIENTS AND METHODS: We studied demographic data, risk group stratification and decision-making for in-hospital versus outpatient treatment in 101 consecutive medical emergency department patients with community-acquired pneumonia. We also analysed predictive factors for hospitalisation of low-risk patients. We obtained complete 30 day follow-up information. RESULTS: Forty-three of 44 high-risk patients were hospitalised after medical emergency department triage. Twenty-seven (47%) of 57 low-risk patients were hospitalised as well. Based on routine clinical assessment, hospitalisation of low-risk patients was required for poor medical condition or severe pneumonia (67%), for lack of social support (15%) and for relevant comorbidity (18%). In an univariate analysis, age (p = 0.003), C-reactive protein (p = 0.0006), presence of comorbidity (p = 0.0001), Charlson index (p = 0.0001) and active oral steroid treatment (p = 0.028) were significantly correlated with hospitalisation of low-risk patients. The 30-day mortality rate was 32% in patients allocated to the high-risk group at the time of diagnosis in the emergency department, compared to 0% in low-risk patients. CONCLUSION: Simple clinical criteria distinguish well between low and high 30-day-mortality risk in patients diagnosed with community-acquired pneumonia. Nevertheless, 47% of low-risk patients require in-hospital treatment. Age, C-reactive protein, presence of comorbidity and steroid treatment are significantly correlated with hospitalisation of low-risk patients with community-acquired pneumonia.
UNLABELLED: The optimum treatment for differentiated thyroid carcinoma (DTC) is still debated. Results obtained using a selective treatment strategy for papillary (PTC) and follicular (FTC) thyroid carcinoma over 25 years in one institution are reported. 149 patients (mean age 46 yrs) had PTC in TNM stages I-IV in 58%, 26%, 15% and 1% respectively. Total thyroidectomy and remnant 131I ablation (43%) were carried out in TNM high-risk patients (stages III and IV) and in low-risk patients (I and II) at risk for a (curable) recurrence (stages pN1 and/or pT4). Hemi- or total thyroidectomy, without radioiodine, was used in 76% of pT1-3 N0 tumours (68%). Central and/or lateral lymphadenectomy was performed in 42% of patients (electively in the last 4 years). The mean follow-up was 7 years. RESULTS: 6 patients died of PTC and 8/143 patients treated for cure had a recurrence (6 nodal, 1 contralateral, 1 local). In low-risk patients--including 68% of patients aged > or = 45 yrs--the cause specific 25-year survival rate was 100%, vs. 62% (at 15 years) (p < 0.0001) in high-risk patients. In stage I and stage II the recurrence-free survival rates at 25 years were 95% and 100% respectively. Risk factors for recurrence were macroscopic (p < 0.0001) but not microscopic local invasion (pT4); stage pN1 (p = 0.0004). Only 1/107 patients initially judged node-negative had a nodal recurrence. FTC (n = 115; mean age 56 yrs; mean follow-up 8 yrs): Cause-related death (n = 8) or serious recurrence (n = 3) occurred in 10/53 grossly invasive FTC, in 1/45 minimally invasive FTC with vascular invasion, and in none of 17 FTC with capsular invasion (CI) alone, under radical treatment (131I) in 75%, 33%, and 12% respectively. 20-year disease-free survival in grossly and in minimally invasive FTC was 78% and 95.5% respectively (p = 0.0007). Patients aged < 45 yrs and patients with minimally invasive FTC with CI alone (all ages) had 100% 20-year disease-free survival vs. 80% (p = 0.013) in the remainder. There was no curable recurrence in FTC. The ratio of grossly invasive FTC decreased (p < 0.0001) during the study period. CONCLUSIONS: Risk-0 groups may be defined and selected for a reduced extent of treatment (PTC pT1-3 N0; FTC < 45 yrs, or CI alone). Older (> or = 45 yrs) patients with PTC in stages I and II have an excellent prognosis (risk 0). With selective (therapeutic) lymphadenectomy the risk of nodal recurrence may be very low in node negative tumours, without use of radioiodine. Meticulous lymphadenectomy is indicated in pN1 tumours with nodal recurrences despite 131I (5/36 patients). The technique of capsular dissection for extracapsular total uni- or bilateral thyroidectomy provides excellent oncological and surgical results. A decrease in the incidence of FTC parallels a decrease in endemic goitre in Switzerland.
BACKGROUND: Case-management programs for secondary prevention of coronary artery disease that utilize extensive resources can reduce cardiovascular risk factors, but less intensive approaches have failed to show benefits. This randomized trial evaluated whether a medium intensity case-management program improves risk factor control in patients with coronary artery disease. METHODS: We assigned 201 consecutive patients hospitalized for acute coronary events in the intensive care unit of University Hospital, Basel, Switzerland, to either a risk factor case-management program (n = 99) or care as usual (n = 102) using the patients' primary care physicians as the unit of randomization (cluster randomization). The case-management program consisted of an hour of counseling by a clinician during hospitalization and two short reminders by phone and mail 3 and 6 months later. Treatment decisions were left to patients and their primary care physicians. RESULTS: After 9 and 18 months of follow-up, there were no significant differences in lipid values, blood pressure control, fasting blood glucose, body-mass index, or number of smokers between the two groups. However, significantly more patients in the intervention group than in the care as usual group achieved target cholesterol values after 18 months (48% versus 27%, P = 0.002 and remained significant after Bonferroni-Holms correction) but not after 9 months of follow-up (31% versus 27%, P >0.2). CONCLUSION: This hospital-based case-management and outreach program, limited to counseling by a clinician, did not substantially improve cardiovascular risk factor control among patients hospitalized for coronary events.
In-hospital emergency medicine in central Europe relies on inter-disciplinary co-operation. To improve team performance in the emergency room (ER), a questionnaire for assessment of attitudes and judgements in resuscitation procedures was developed. A total of 43 items were evaluated according to a five-point Likert scale. With a response rate of 81%, 143 questionnaires were evaluated. Assessment of data was performed with regard to professional speciality and level in the medical hierarchy. Factorial analysis identified four main factors: Assessment of 'quality of performance' (F1), 'importance of structure' (F2), 'quality of team culture' (F3), and 'importance of hierarchy' (F4). Influences from the categories 'speciality' and 'hierarchy' and from the covariate 'gender' on these main factors were evaluated by two-factorial analysis of variance. For all four factors, 'speciality' produced significant differences. Surgeons accorded high values to F1 and low values to F2, whereas anaesthesiologists accorded low values to F1 and high values to F2. F3 showed a low ranking from within the ER nursing staff and the residents in internal medicine, whereas F4 received high scores by medical residents and staff members. For F1 and F3, there was a tendency towards hierarchy dependency, whereas no factor was influenced by gender. In conclusion, team performance in the ER is mainly influenced by different perceptions and attitudes of the different disciplines involved in the resuscitation process.
Background: Patients who have had a coronary heart attack often go completely untreated for hypercholesterolemia. We investigated whether immediate initiation of lipid-lowering drugs during hospitalization for acute coronary events increases the proportion of correctly treated patients compared to referred treatment as recommended by current guidelines. Methods: This prospective, multicenter study randomized 57 hypercholesterolemic patients hospitalized for acute coronary events to immediate in-hospital initiation or to referred initiation of lipid-lowering drugs by primary care physicians 3 months after unsuccessful nutritional intervention. Results: After 6 months, 53 patients were available for follow-up. More patients in the immediate initiation group (26/30 patients, 87%) were treated with lipid-lowering drugs than in the referred initiation-group (13/23 patients, 57%, P=0.03). Twenty-seven patients (87%) in the immediate initiation group versus 17 patients (65%) in the referred initiation group had a 10% or greater decrease in total cholesterol or a 15% or greater decrease in LDL-cholesterol (P=0.18). Although statistically not significant, there was a trend to improved lipid values in the immediate initiation group compared to the referred initiation group (TC, -21.1 vs. -13.8% (P=0.08); LDL-C, -28.2 vs. -18.9% (P=0.13); HDL-C, +10.8 vs. +5% (P=0.44); TC/HDL-C ratio, -24.7 vs. -15.1% (P=0.22)), and the LDL-C/HDL-C ratio was -34.1 vs. -19.1% (P=0.04, P=NS after Bonferroni correction). Conclusion: The immediate initiation of lipid-lowering drugs in hypercholesterolemic patients hospitalized for acute coronary events increases the rate of correctly treated patients and has the potential to improve lipid control.
BACKGROUND: Differentiated thyroid carcinoma is a unique tumour in that a low risk-patient population with a tumour-related death rate of near 0% can be found. Yet in these patients the risk and risk factors of curable recurrences must be considered. The question therefore arises, whether in defined subgroups of low risk-patients a reduced extent of treatment (hemithyroidectomy, total thyroidectomy without 131I ablation) may result in cure without recurrence, including low morbidity of treatment and reduced costs. STUDY DESIGN: In a consecutive series of 257 patients suffering from papillary (146) or follicular (111) carcinomas operated by one surgeon over a period of 25 years, a reduced extent of treatment was carried out essentially in subgroups of minimally invasive follicular carcinoma, namely in pT1,2-tumors of young patients, or in those with capsular invasion alone, and in pT1,2 N0 papillary tumors, representing a subgroup of TNM stage I and II tumors. For N-staging selective lymphadenectomy was carried out at the beginning of the study, but elective lymphadenectomy was used since 1996 for papillary carcinoma. Follow-up was 1-25 (mean = 8) years. All excised tumors were examined by one pathologist. RESULTS: 167 (approximately 2/3) of the patients presented with a single nodule, whereas in 1/3 a concomitant benign nodular goiter or an immunothyropathy was found. The percentage of grossly invasive follicular carcinoma decreased during the 25 year period from 41 to 10% of all patients (p < 0.0005), whereas the percentage of papillary cancer rise from 35% to 66% (p < 0.005). Hemithyroidectomy, total thyroidectomy without, and with 131I ablation respectively, were performed in 32%, 24%, and 44% of patients. In papillary carcinoma N1-status was found in 21 (23%)/ 92 patients with selective, and in 18/54 patients (33%) with elective lymphadenectomy, respectively (n.s.). One (0.4%) patient died postoperatively. Permanent hypoparathyroidism occurred in 1.9% (3% for total thyroidectomy), permanent recurrent nerve lesion in 1.6% of patients (1% of nerves at risk). PAPILLARY CARCINOMA: No tumour-related death and no serious recurrence occurred in the low risk-group (TNM stages I and II) (n = 112 (84%)), including a T4-, N1-, M1-status in 9%, 20% and 3% of patients, respectively. 4/112 patients (3.6%) developed a recurrence (3 nodal, 1 contralateral, following 131I ablation in 2 instances). Only one (1%) instance of a nodal recurrence occurred in N0-tumors (n = 97). In TNM stages III and IV (high risk) patients (with T4-, N1-, M1-status in 79%, 58%, and 8% respectively), residual and recurrent disease occurred in 7 (33%) patients, leading to 6 (29%) tumor-related deaths. Follicular carcinoma: One 74-year old patient (1.6%) died from minimally invasive follicular carcinoma (n = 54 (51%); mean age 48 years). In 44 (81%) patients treatment did not include remnant ablation. 7 (13%) patients died from widely invasive follicular carcinoma (n = 53 (49%); mean age 64 years) and 3 (6%) further patients are alive with a serious recurrence. No curable recurrence was observed in follicular carcinoma. CONCLUSIONS: The decrease in goiter endemicity during the last decades in Switzerland paralleled a decrease in the incidence of grossly invasive follicular carcinoma over the 25 year period of the study. Following selective treatment, low risk TNM stage I and II-patients with papillary carcinoma had a tumor-related death rate of 0% and a low (3.6%) recurrence rate. N1-status represents a risk factor for nodal recurrence (even with remnant ablation). Elective vs. selective lymphadenectomy lead to slight stage migration but it presented no advantage in terms of recurrence and death which were rare events. No death occurred in the subgroups of minimally invasive follicular carcinoma of young (< 45) patients (41%) and in the patients without vascular invasion (28%), even without remnant ablation in most instances. No curable recurrence occurred in foll
AIMS: To evaluate accuracy of patient-reported home blood pressure measurements (HBPM) when compared to real HBPM and their agreement with 12-h daytime ambulatory blood pressure monitoring (ABPM). MAJOR FINDINGS: Self-reported HBPM were compared to stored values of a fully automated, oscillometric blood pressure monitor with integrated memory device and 12-h daytime ambulatory monitoring in 54 patients. In most patients (n = 46, 85%) mean reported systolic or diastolic versus real HBPM differed by no more than 4 mmHg. In eight mostly uneducated patients (15%, 95% confidence interval, CI, 7-27%) means of reported and real HBPM differed by more than 4 mmHg (range 5-28 mmHg for systolic and 0-11 mmHg for diastolic blood pressure). Systolic agreement between self-reported HBPM and 12-h daytime ABPM was better for patients reporting > or = 80% than for patients reporting < 80% of measurements correctly (mean systolic difference 0 +/- 19 versus 5 +/- 14 mmHg, respectively), whereas the opposite was true concerning agreement of diastolic blood pressure values (mean diastolic difference -6 +/- 10 and -1 +/- 9 mmHg, respectively). CONCLUSION: Inadequate conclusions due to poor reporting accuracy of HBPM are possible, especially in less educated patients. Thus, ABPM or automatically stored HBPM may be preferable to self-reported HBPM in these patients.
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Outpatients with essential hypertension were randomized to receive antihypertensive treatment with either mibefradil or enalapril. Ambulatory blood pressure measurement (ABPM) and video capillary microscopy of the finger nailfold were performed at baseline and after 12 weeks of treatment. In the enalapril group (n = 21) baseline ABP was 156 +/- 12/100 +/- 9 mm Hg and decreased to 140 +/- 17/89 +/- 10 mm Hg after 12 weeks. In the mibefradil group (n = 22) mean 24-h ABP decreased from 159 +/- 14/102 +/- 7 to 140 +/- 10/89 +/- 7 mm Hg. Capillary blood cell velocity (CBV) without treatment was 0.90 +/- 0.58 mm/s (mean +/- SD) and 0.83 +/- 0.46 mm/s at rest and 0.30 +/- 0.22 and 0.21 +/- 0.20 mm/s immediately after local finger cooling in the mibefradil and the enalapril group, respectively. In the Enalapril group CBV at week 12 was 0.99 +/- 0. 60 mm/s (n.s.) at rest and 0.40 +/- 0.28 mm/s immediately after local cooling (P = 0.005 compared to 0.21 +/- 0.20 mm/s without treatment). Twelve weeks after initiation of treatment CBV was 0.76 +/- 0.48 mm/s (n.s.) at rest and 0.31 +/- 0.28 mm/s (n.s.) immediately after local cooling in the mibefradil group. Finger nailfold CBV immediately after local finger cooling was increased by enalapril compared to baseline. The T-channel-inhibiting calcium antagonist mibefradil did not change CBV in finger nailfold capillaries.
In this prospective, double-blind, monocenter drug trial, 48 primary care patients with mild to moderate essential hypertension were randomized to mibefradil, 50 mg, titrated to 100 mg, or enalapril, 20 mg, titrated to 2 x 20 mg. Ambulatory 24-h blood pressure measurements (ABPM) and echocardiography were performed at baseline and after 12 weeks' treatment. Complete data from 43 patients were analyzed. Mibefradil (n = 22; titration, 13 patients) reduced mean 24-h ABP from 159+/-14/102+/-7 mm Hg to 140+/-10/89+/-7 mm Hg after 12 weeks. Enalapril (n = 21; titration, six patients) reduced baseline ABP from 156+/-12/100+/-9 mm Hg to 140+/-17/89+/-10 mm Hg (12 weeks). Trough-to-peak ratios in DBP were 86% for mibefradil and 75% with enalapril. Left ventricular mass (LVM) decreased from 199+/-65 to 193+/-62 g [M-mode modified American Society of Echocardiography (ASE)] and from 184+/-65 to 173+/-50 g (truncated ellipsoid method) after 12 weeks in response to mibefradil (p > 0.2), and from 212+/-50 to 196+/-57 g and from 182+/-39 to 170+/-40 g (mean +/- SD, p < 0.02) with enalapril. Mibefradil matched enalapril in 24-h ABP control. Enalapril reduced LVM significantly after 12 weeks (p < 0.02). Mibefradil did not significantly reduce LVM after 12 weeks.
To study the effects of the angiotensin II receptor antagonist Losartan and Amlodipine on left ventricular mass (LVM), we performed blood pressure measurements and transthoracic echocardiographies at baseline. After a 4-week placebo run-in period, 25 patients with mild-to-moderate essential hypertension were randomly allocated to active treatment with Losartan 50 mg titrated to Losartan 50 mg/hydrochlorothiazide (HCT) 12.5 mg (n = 11) or Amlodipine 5 mg titrated to 10 mg (n = 14) for 16 weeks. After treatment, blood pressure decreased significantly in both groups. LVM and LVM index (mean +/- SD/median) in the Losartan group at baseline were 311 +/- 101/288 g and 163 +/- 55/150 g/m(2) and decreased significantly to 252 +/- 25/255 g and 133 +/- 22/128 g/m(2) (p = 0.003 for LVM; p = 0. 01 for LVM index) after 16 weeks of active treatment. In the Amlodipine group LVM and LVM index decreased from 259 +/- 47/243 g and 136 +/- 25/ 131 g/m(2) to 240 +/- 42/234 g and 126 +/- 24/123 g/m(2) (n.s.). In conclusion, LVM decreased significantly as early as 16 weeks after initiation of antihypertensive treatment with the Angiotensin II antagonist Losartan.
L-carnitine is essential to cellular energy production mainly because of its acyl- and acetyl-carrier properties. Athletes commonly take L-carnitine, which is thought to improve exercise performance. There are no reports on carnitine plasma concentrations and carnitine excretion in short-duration maximal exercise in well-trained athletes taking this substance. We measured plasma and urine carnitine concentrations before and 10 min after maximal treadmill ergometry in nine well-trained sportsmen with and without oral supplementation with 1 g L-carnitine. In athletes without L-carnitine intake, plasma free carnitine concentration decreased significantly from 45.2 +/- 5.3 to 41.6 +/- 5.0 mumol/l (mean +/- SD, p < 0.001) 10 min after exercise compared with baseline. In athletes with oral L-carnitine supplementation, plasma free carnitine concentration at baseline was 71.3 +/- 10.2 mumol/l and did not change after maximal exercise (71.8 mumol/l +/- 10.7 mumol/l). The elevated plasma concentration of free carnitine without decrease after maximal exercise in well-trained athletes taking L-carnitine could be important in view of the newly postulated direct vascular effects of L-carnitine in improving skeletal muscle performance.