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Biomedical subjects

D L Clement

Publications and source records attributed to D L Clement.

At least 37 records · Page 2Linked to original sources
PubMed2000

Management of venous edema: insights from an international task force.

An International Task Force made up of a panel of 16 experts has reviewed and objectively evaluated all aspects of chronic venous disease of the leg (CVDL). All available publications on CVDL from 1983 to 1997 were identified through computerized search in Medline and by a manual search. Next, three different screenings were performed in order to select only relevant papers providing a level of scientific evidence that was considered moderate to strong. Final conclusions and further therapeutic recommendations were made based on these publications. Medication, compression, local therapy, sclerotherapy, and surgery are the accepted available therapeutic options for CVDL. For edema, the following recommendations can be made: edema is an early sign of CVDL, but before starting any treatment, nonvenous causes of edema should be excluded. Medication and compression are the therapeutic options for edema that are accepted by the Task Force. Evaluation of their efficacy is based on objective measures of edema. Several well-conducted, placebo-controlled trials have shown efficacy of drugs such as micronized purified flavonoid fraction, rutosides, calcium dobesilate, and coumarin rutin. Graduated compression stockings have been shown to be effective; compression needs to be exerted at least at 35 mm Hg. Bandages, if properly applied, both fixed and stretched, can produce favorable results. Sclerotherapy or surgery is not indicated unless there is saphenofemoral or saphenopopliteal reflux. In the absence of such reflux or following deep venous thrombosis, there is no evidence to support sclerotherapy or surgery.

Anticoagulants↗
PubMed2000

Long-term effects of clinical outcome with low and high dose in the Captopril in Heart Insufficient Patients Study (CHIPS).

BACKGROUND: Although angiotensin-converting enzyme inhibitors are recommended as first line therapy in patients with chronic heart failure, the target doses proven to be effective in major morbidity and mortality trials (e.g. captopril 50 mg b.i.d), are generally not used in daily practice in Belgium. AIM: The objective of this study (CHIPS, Captopril in Heart Insufficient Patients Study) was to compare the long-term effects of a low dose (25 mg b.i.d.) and a high dose (50 mg b.i.d.) of captopril in mild to moderate heart failure. After a titration period of at least 10 days, patients who tolerated 50 mg b.i.d., were randomly assigned to receive either the low dose or the high dose of captopril and followed up to 2 years. RESULTS: 298 patients were included and were followed up for a mean of 12 months. Progression in heart failure seems to be favourably influenced by therapy with high dose in comparison to low dose; a relative difference of 29% in the rates of heart failure worsening was observed between the two doses, 31.5% and 22.4% for low and high dose (p = 0.088), respectively. Treatment with high dose showed also a trend to benefit as compared to low dose in reducing the number of hospitalizations for all causes from 22.4 to 14.5% (p = 0.1) and for congestive heart failure from 14.7 to 7.2% (p = 0.06); moreover, the incidence of fatal and nonfatal cardiac events showed a trend in favour of the high dose of 22% (p = 0.142). The total number of adverse events was comparable for both doses, but dizziness and hypotension were a little more frequently reported in the high-dose group. Serum creatinine values showed no significant changes either in the low-dose or in the high-dose group. CONCLUSION: In the CHIPS-study, in comparison to a low dose, therapy with a high dose of captopril tends to improve the long-term clinical outcome of patients with mild to moderate heart failure without significantly more toxicity.

Adolescent↗
PubMed2000

A non-invasive cardiovascular index for the quantification of arterial load.

OBJECTIVE: Our aim is to quantify steady and pulsatile components of arterial load in a concise and sensitive way by means of a new non-invasive cardiovascular index (NICI). METHODS AND RESULTS: NICI is based on non-invasively measured pressure (sphygmomanometer), stroke volume index and cardiac index (Doppler echocardiography and ECG) and yields a numerical value (in mm Hg). It expresses the difference between the actual arterial load and reference loading conditions as determined in a control group (29 M/35 F, age 34 +/- 13 yr.) of healthy subjects, with blood pressure 116/61 mm Hg (systolic/diastolic), stroke volume index (SVI) 34 +/- 18 ml.m-2 and cardiac index (CI) 2.1 +/- 0.5 l.min-1.m-2. NICI was calculated in the control group and in 23 borderline hypertensive subjects (10 M/13 F, age 65 +/- 12 yr.) with blood pressure 156/79 mm Hg, SVI 36 +/- 10 ml.m-2 and CI 2.4 +/- 0.6 l.min-1.m-2. NICI was higher in borderline hypertensives (33 +/- 51 vs. 0 +/- 34 mm Hg; P < 0.001) and was strongly correlated with total peripheral resistance index (r = 0.89; P < 0.001) and with the ratio of SVI and pulse pressure (r = -0.89; P < 0.001), expressing the combined effect of both known determinants of cardiac load. NICI was also correlated with effective arterial elastance index (r = 0.89; P < 0.001). CONCLUSIONS: NICI quantifies, within a logical biomechanical framework, the arterial load as seen by the ejecting ventricle. It combines steady and pulsatile components of arterial load and has a single control value of zero mm Hg.

Adult↗
PubMed2000

A clinical approach to the management of the patient with coronary (Co) and/or carotid (Ca) artery disease who presents with leg ischaemia (Lis).

The purpose of this document is to provide the clinician with easy-to-use guidelines when faced with a patient with severe ischaemia in the limbs requiring interventional treatment; the CoCaLis document does not focus on the management of the lower limb ischaemia, but rather on the best possible approach to the associated coronary and/or carotid artery disease. The first part of the text deals with the epidemiological aspects of this condition followed by a description of, and proposals for, the management of risk factors. The next part deals with the approach to the coronary circulation and the carotid territory. In each part attention is mainly given to the practical aspects in terms of both diagnosis and treatment; for each of these steps the costs involved are considered and attention given to balancing the clinical decisions against the costs. The recommendations given are 'evidence based' when such evidence exists and, if not, the proposals are based on the consensus of the members of the group. In many instances it was apparent that the necessary information is not available in the literature. The authors hope that the CoCaLis document may not only improve the management of the vascular patient but also stimulate further research in this difficult clinical condition which carries a significantly increased risk for the patient.

Angioplasty, Balloon, Coronary↗
PubMed1999

Relationship between left ventricular mass index and 24-h urinary free cortisol and cortisone in essential arterial hypertension.

OBJECTIVE: Besides arterial blood pressure, nonhemodynamic factors are known to induce cardiac hypertrophy. In Cushing's syndrome, severe ventricular hypertrophy has been linked not only to increased aortic pressure, but also to elevated plasma cortisol. The aim of this study was to examine the relationship between the cortisol/cortisone levels and left ventricular mass index (LVMI) in essential arterial hypertension with and without echocardiographic left ventricular hypertrophy (LVH). DESIGN: Eighteen untreated Caucasian patients (nine men, nine women, mean age 48+/-6 years) with essential hypertension (163+/-26/100+/-14 mm Hg) were enrolled. An age-matched control group of 13 subjects (seven men, six women) with normotension (121+/-9/79+/-7 mm Hg) were enrolled also. Left ventricular dimensions were echocardiographically assessed and cortisol production evaluated by 24-h urinary free cortisol and cortisone concentrations. RESULTS: LVMI averaged 115+/-31 g/m2 and 24-h urinary free cortisol and cortisone were 23+/-14 microg per 24 h and 31+/-18 microg per 24 h. Prevalence of echocardiographic LVH was 56%. LVMI correlated significantly with 24-h urinary free cortisol (r = 0.61, P = 0.007) and cortisone (r = 0.60, P = 0.009). Patients with echocardiographic LVH were characterized by higher daytime ambulatory blood pressure, LVMI (particularly the posterior wall), and 24-h urinary cortisol, while office blood pressure, septal: posterior wall ratio and 24-h urinary cortisone were comparable in all patients. In control individuals, LVMI averaged 91+/-18 g/m2 and 24-h urinary free cortisol and cortisone, respectively, were 34.7+/-6.6 microg per 24 h and 64.3+/-10.8 microg per 24 h (P<0.05 versus patients). Neither LVMI nor the contributing ventricular dimensions showed significant correlation with 24-h urinary free cortisol or cortisone in the control group. CONCLUSIONS: Our data provide evidence for a significant relationship between LVMI and cortisol production independently of arterial blood pressure in untreated mild to moderate hypertension.

Adult↗
PubMed1999

Venous ulcer reappraisal: insights from an international task force. Veines International Task Force.

UNLABELLED: An international task force made up of a panel of 16 experts was mandated to review and objectively evaluate all aspects of chronic venous disease of the leg. All available publications on chronic venous disease of the leg from 1983 to 1997 were identified through computerized search. Three different screenings were then performed in order to select only relevant papers providing moderate to strong scientific evidence. Final conclusions and further therapeutic recommendations were made based on these publications. Compression, medications, local therapies, sclerotherapy and surgery are the existing therapeutic options for which the following recommendations can be made. Compression: Properly applied bandages both fixed and stretched have been shown to be effective. Compression stockings may be used. Compression needs to be in excess of 35 mm Hg. Medications: Although preliminary results have shown a beneficial effect of several vasodilators and oral micronized purified flavonoid fraction, the evidence for the efficacy of medications on venous ulcer healing is still limited and further studies are required before recommendations can be made. There is no evidence to routinely administer antibiotics. Local therapies have an as yet unproven adjunctive role. Sclerotherapy is unlikely to be effective unless there is superficial venous insufficiency, in which it may have an as yet unproven role. SURGERY: Patients with active venous ulcer and sapheno-femoral or sapheno-popliteal junction incompetence benefit from surgical treatment. In the absence of reflux or following deep vein thrombosis, there is no evidence to support surgical treatment.

Algorithms↗
PubMed1999

Primary pulmonary hypertension with fatal outcome in a young woman and review of the literature.

A 32-year-old female is described, who was admitted with symptoms of severe right heart failure. The most likely diagnosis of pulmonary embolism was excluded. Echocardiography and left-right catheterisation confirmed the diagnosis of primary pulmonary hypertension. A possible mediator in the process of PPH could be the appetite suppressants she had taken for some months after her second pregnancy. Before further pharmacologic tests could be performed the patient died in circulatory collapse. Postmortem pathological examination confirmed the diagnosis of PPH by the presence of narrowed pulmonary arterioles, media hypertrophy, thrombotic lesions and normal surrounding pulmonary parenchyma. The literature on primary pulmonary hypertension is revised with special emphasis on diagnosis and treatment algorithms.

Adult↗
PubMed1999

Why is training effective in the treatment of patients with intermittent claudication?

Patients with peripheral arterial obstructive disease (PAOD) often have complaints of intermittent claudication. This causes a great limitation in the quality of life because of reduction in walking ability. PAOD is associated with increased morbidity and mortality. Beside other therapies, training has been shown to be an effective treatment option for patients with intermittent claudication. Exercise training significantly increases walking distance and consequently the functional behaviour of the patient. Several authors have identified different mechanisms involved in this beneficial effect. The most important are discussed in this review, namely adaptation or redistribution of the peripheral blood flow, inhibition of the progression of the atherosclerotic disease, changes in blood rheology, metabolic changes, changes in skeletal muscle morphology, economisation of walking, a change in pain perception and an effect on the cardiovascular system. It is concluded that training works through a combination of mechanisms. Further research is needed to clarify the precise mechanisms.

Exercise Therapy↗
PubMed1998

Variations of autonomic tone preceding onset of atrial fibrillation after coronary artery bypass grafting.

Assessment of autonomic tone preceding the onset of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) with heart rate variability was examined in 64 patients scheduled for elective CABG (days 2 to 5). Ninety-six-hour Holter tapes were analyzed in each patient and all events labeled by an experienced technician. The hour preceding AF was divided into 4 quarters (heart rate variability calculated per quarter) and compared with similar time episodes from the group without AF. Twenty-six of 64 patients (40%) had a total of 35 episodes. Only increased age (68+/-5 vs 62+/-9 years) and lower ejection fraction (66+/-16% vs 73+/-8%) were associated with an increased risk for AF. Before onset, a greater number of atrial premature complexes was observed. The standard deviation of all RR intervals (SDNN) showed an increase in the group with AF in the last 15 minutes (significant vs controls and within the AF group). The low-frequency/high-frequency ratio was significantly lower in patients in the first 30 minutes, followed by an increase mainly because the high-frequency spectrum became less important. Thus, initiation of postoperative AF is influenced by autonomic tone variations. A shift in the autonomic balance with a loss of vagal tone and a moderate increase in sympathetic tone are observed before the onset of AF compared with those in controls.

Aged↗
PubMed1998

Long- and short-term blood pressure and RR-interval variability and psychosomatic distress in chronic fatigue syndrome.

1. Chronic low blood pressure has been associated with fatigue and low mood. However, in the chronic fatigue syndrome (CFS) the blood pressure (BP) and heart rate profile and their variabilities have not been characterized as yet. 2. We performed office and 24 h ambulatory BP recordings in 38 subjects (age, 34.8 +/- 8.0 years) who fulfilled the Holmes criteria for CFS and in 38 healthy control subjects (age 35.6 +/- 10.5 years), as well as short-term beat-to-beat BP and RR-interval recordings for 10 min in supine and standing position, and calculated spectral indices. 3. In CFS office (123 +/- 19/70 +/- 12 mmHg) as well as 24-h, day- and night-time blood pressure values (116 +/- 11.1/71 +/- 11.1, 121 +/- 9.2/77 +/- 8.0 and 110 +/- 10.5/65 +/- 9.2 mmHg respectively) were within reference limits. 4. Heart rate was consistently higher (P < 0.01) in CFS patients, based on both office (77 +/- 12 compared with 68 +/- 12 beats min-1) and 24 h ambulatory recordings (77 +/- 12 compared with 67 +/- 15 beats min-1). 5. In supine position, spectral indices of BP variability (total, low-frequency and high-frequency variances) were all significantly (P < 0.01) lower in CFS. In standing position the differences disappeared. Analysis of RR-interval variability could not detect major alterations in autonomic function in CFS.

Adult↗
PubMed1998

Inverse relationship between aldosterone and large artery compliance in chronically treated heart failure patients.

AIMS: The purpose of this study was to examine, in chronically treated heart failure patients vs control subjects, the influence of neurohumoral activation and aldosterone escape on arterial elastic behaviour, assessed by non-invasive mathematical lumped-parameter modelling of the compliance of the arterial system. METHODS AND RESULTS: Radial arterial pulse waves were recorded non-invasively for 30 s with an arterial tonometer sensor array in 13 chronic heart failure patients (mean age, 59 +/- 2.5 years) in New York Heart Association class II. The patients had been taking digoxin, furosemide, captopril and aspirin for more than 3 months. Thirteen healthy subjects (mean age, 50 +/- 4.0 years) acted as controls. Compliance of the proximal (aorta and major branches, C1) and distal parts (C2) of the circulation were derived from a third order four-element modified Windkessel model which can reproduce arterial pressure waveforms, including both exponential and oscillatory sections. Active renin, angiotensin II and aldosterone levels were determined on venous blood samples in the supine position and after 30 min active standing. There was decreased proximal (C1, 1.51 +/- 0.11 ml x mmHg(-1), P<0.01) and distal (C2, 0.050 +/- 0.011 ml x mmHg(-1)) arterial compliance in the chronic heart failure patients vs controls (C1, 1.71 +/- 0.16 ml x mmHg(-1); C2, 0.054 +/- 0.006 ml x mmHg(-1)). The chronic heart failure patients were characterized by an aldosterone escape phenomenon which was inversely correlated with the proximal arterial compliance in both supine (r= - 0.795, P=0.002) and standing (r= - 0.628, P=0.029) positions. CONCLUSIONS: In chronically treated heart failure patients with full angiotensin-converting enzyme-inhibition and diuretics, there is decreased compliance of the aorta and its major branches, which is inversely correlated with the aldosterone escape phenomenon.

Aldosterone↗
PubMed1998

Calcium antagonists, is there a real concern about safety?

Calcium antagonists are widely used in the treatment of arterial hypertension and, or in ischemic heart disease. During the last 3 years, controversial articles and editorials have been published concerning the potential risk of calcium antagonists in regard to mortality, cancer and haemorrhage. The information has been mainly derived from case-control studies. The major concern about such observational studies of treatment outcome is the large potential for systematic error to affect the results. However, overviews of controlled trials with calcium antagonists do not provide clear evidence of an effect of calcium antagonists on mortality, risk of cancer and risk of bleeding.

Bias↗
PubMed1998

Analysis of the P wave with signal averaging to assess the risk of atrial fibrillation after coronary artery bypass surgery.

P wave signal averaging was performed in 91 consecutive patients undergoing coronary artery bypass grafting to detect patients at risk of postoperative atrial fibrillation (AF). Sixteen patients (17.5%) developed AF after surgery. The P wave duration on the signal-averaged electrocardiogram (ECG) and on surface ECG was prolonged in AF patients compared to others (respectively 141 +/- 12 vs. 132 +/- 12 ms and 124 +/- 9 vs. 113 +/- 9 ms). The root mean square voltages (RMS) of the total P wave were not different between the two groups; the RMS of the late portion of the P wave (late RMS) was significantly higher (0.25 +/- 0.15 vs. 0.17 +/- 0.10 microV) and the RMS of the first 110 ms of the P wave (early RMS) significantly lower (0.88 +/- 0.28 vs. 1.09 +/- 0.33 microV) in AF. The late/ early RMS ratio was different (0.29 +/- 0.16 vs. 0.17 +/- 0.11). In a multivariate analysis only age and the late/early RMS ratio were predictive for AF.

Adult↗
PubMed1998

Signal-averaged P wave: predictor of atrial fibrillation.

Abnormalities of the P wave seen during sinus rhythm are associated with atrial fibrillation and other supraventricular arrhythmias. Intra-atrial conduction delays can be seen on the surface ECG as P wave prolongation, which is more visible with averaging techniques used in advanced recording devices. Averaging followed by amplification after proper filtering of the electrical signal should allow more precise measurements of duration and amplitude of the P wave. Data on reproducibility, filter settings, required number of beats, and precise definitions of onset and offset are dependent largely on the system used, which can be QRS or, preferably, P wave triggered. This explains conflicting data in the literature. It is clear that P wave duration is one of the best predictors of perioperative atrial fibrillation. For paroxysmal forms, the data are less convincing. Root mean square voltages of the P wave can be useful. Combining the P wave duration with other data often improves the diagnostic value of signal averaging. Standardization of the techniques appears to be necessary.

Atrial Fibrillation↗