[The value of low-molecular-weight heparins in the treatment of acute coronary syndrome].
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Angina, Unstable↗
Biomedical subjects
J Carlsson
Publications and source records attributed to J Carlsson.
A descriptive analysis of disorders in patients 17 years following motor vehicle accidents.
Whiplash-associated disorders (WAD) are described and analysed 17 years after involvement in a motor vehicle accident. A self-report questionnaire was mailed to 121 patients registered at emergency departments in Gothenburg in 1983 because of neck complaints following a car collision. The questionnaire contained items on symptoms referred to WAD, treatment, work disability, involvement in settlement of claims, medical disability and the Neck Disability Index (NDI). Of the 121 patients, 108 (89%) chose to participate in the present study. Fifty-nine (55%) had residual disorders referable to the original accident. Neck pain, radiating pain and headache were the most common symptoms. One-third of the patients with residual symptoms suffered from work disability, compared to 6% in the group of patients without residual disorders. All 25 patients who had reached a final claim settlement (42%) had a poor outcome, and 15 of the claiming patients had been assigned a medical disability ranging from 5 to 30%. Patients with WAD reported a significantly higher score on the NDI than those without residual disorders. There was no significant correlation between the patients' degree of medical disability and the scores on the NDI. The results of the study show that approximately half of the patients with neck complaints following motor vehicle accidents in Gothenburg in 1983 suffered frequent residual symptoms 17 years after the accident, mostly comprising neck pain, radiating pain, and headache. The residual disorders contributed to the patients' overall disability.
Accidents, Traffic↗
[37-year-old patient with eye muscle paralysis and rapidly progressing respiratory insufficiency].
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Adult↗
DNA fragmentation by charged particle tracks.
High-LET (linear energy transfer) charged particles induce DNA double-strand breaks (DSB) in a non-random fashion in mammalian cells. The clustering of DSB, probably determined by track structure as well as chromatin conformation, results in an excess of small- and intermediate-sized DNA fragments. DNA fragmentation in normal human fibroblasts (GM5758) was analyzed by pulsed-field gel electrophoresis after irradiation with photons (60Co) or 125 keV/micrometers nitrogen ions. Compared to conventional DSB analysis, i.e. assays only measuring the fraction of DNA smaller than a single threshold, the relative biological effectiveness (RBE) for DSB induction increased with 100%. Further, the size distribution of DNA fragments showed a significant dependence on radiation quality, with an excess of fragments up to 1 Mbp. Irradiation of naked genomic DNA without histone proteins increased the DSB yields 25 and 13 times for photons and nitrogen ions, respectively. The results suggest possible roles of both track structure and chromatin organization in the distribution of DNA double-strand breaks along the chromosome.
Cells, Cultured↗
Clinical and angiographic outcome after conventional angioplasty with optional stent implantation compared with direct stenting without predilatation.
OBJECTIVE: To compare in a randomised trial the procedural and clinical outcome and long term patency of conventional angioplasty with optional stent implantation versus direct stenting without predilatation. METHODS: Patients undergoing coronary intervention for symptomatic coronary artery disease were randomly assigned to conventional angioplasty with optional stenting or to direct stent implantation without predilatation. The post-stent treatment consisted of antiplatelets. Follow up angiography was performed six months after the initial procedure. RESULTS: Between December 1998 and August 1999, 181 of 190 eligible patients were randomly assigned to either optional stenting (n = 92) or direct stenting (n = 89). The procedural success was similar in both groups (87 (97.8%) in the optional v 87 (94.6%) in direct stenting group, p = 0.88). There were five cases of crossover from the direct stenting to the optional stenting group. Six patients experienced a Q wave myocardial infarction without further complications (4 in the optional v 2 in the direct stenting group, p = 0.36). One patient in whom coronary angioplasty failed underwent elective bypass surgery. No patients required urgent bypass surgery and no patients died. The reduction in late luminal loss (mean (SD) 1.19 (0.87) mm in the optional v 0.62 (0.69) mm in the direct stenting group, p = 0.004) led to a significant improvement in minimal luminal diameter at follow up (1.87 (0.93) mm in the optional v 2.56 (0.86) mm in the direct stenting group, p = 0.002), resulting in a significant reduction in restenosis rate, defined as > 50% diameter stenosis at follow up 6.5 (2.1) months after the initial procedure (28 (30.4%) in the optional v 14 (15.7%) in the direct stenting group, p = 0.019). Direct stenting significantly reduced the overall procedure and fluoroscopy times, the amount of contrast medium used, and the number of angioplasty catheters needed. The incidence of clinical events during the six month follow up did not differ significantly between the groups. No patient died during follow up. CONCLUSIONS: Direct stent implantation without predilatation significantly reduced late luminal loss, giving a better improvement in minimal luminal diameter and restenosis rate than with optional stenting. There were five patients in whom direct stenting failed who needed predilatation followed by stent implantation. However, in most patients direct stent implantation without predilatation is a feasible treatment option with a favourable long term outcome and a low incidence of complication. The procedure may help to reduce the cost of coronary interventions by reducing overall procedure and fluoroscopy times, the amount of contrast medium used, and the number of angiography catheters needed.
Angioplasty, Balloon, Coronary↗
[Clinical characteristics of patients with AV-nodal reentrant tachycardia (AVNRT): modification by high frequency catheter ablation. Study of 748 patients after high frequency catheter ablation].
AIM: The aim of the study was to analyze the medical history of patients with AV-nodal reentry tachycardia (AVNRT). PATIENTS AND METHODS: Between 1990 and 1999 radiofrequency catheter ablation was performed in 1,024 patients suffering from AVNRT. Data of the previous history were comprehended by questionnaire. RESULTS: 748 (73%) patients replied to the questionnaire. The interval between the first appearance of the symptoms and the catheter ablation was 4.1 +/- 1.5 years. The mean age of the patients was 55.4 years (female) and 58.7 years (male). Merely 6% of all patients had a structural heart disease. The mean duration of case history was 16.8 years. In comparison to the male patients, the assignment for female patients to catheter ablation was after a significant 7 years longer lasting anamnesis. The distribution of age showed that the first tachycardia appeared in 16% of the female patients older than 50 years of age and only in 17% younger than 20 years of age; the corresponding percentages for men were 31% and 18%. With reference to the duration of the longest tachycardia episodes and arrhythmia-related presyncopes and syncopes, women showed a more defined symptomatic. On 20% of the patients a radiofrequency catheter ablation ensued without previous antiarrhythmic treatment; 80% of the patients were treated with 2.8 different antiarrhythmic medications. Medical consultations regarding AVNRT were named as follows (mean/range): family doctor 6.1/1-250, emergency physicians 1.1/0-15, hospital 1.0/0-20. The indication for catheter ablation was set by the family doctor in 13% and by the cardiologist in 77%. Patients got their information about catheter ablation in 2.9% from acquainted persons or news services. CONCLUSION: There is no "typical" anamnesis of AVNRT patients. There is an amazingly high rate of patients with an AVNRT begin in elder stage of age and the fact of therapy delay of 7 years in behalf of women.
Adult↗
Chromatographic performance of a thin microporous bed of nitrocellulose.
Chromatography along thin (125 microm) porous beds of nitrocellulose, layered on top of an polyester backing, shows good separation efficiency with plate heights of 10-20 microm. Flow is controlled by capillary forces and shows low rate variations between the individual disposable devices. Positively charged groups were introduced into the nitrocellulose and efficient separation of transferrin isoforms, differing by only 0.1 pI units, was found after a short migration distance (1 cm). The upper surface is not covered, which allows sample and reagents to be added, and the clear backing permits detection. The chromatography can easily be combined on-line with sensitive immunoassay detection down to the microM (10(-12) M) range. This microscaled combination device should have a wide range of applications in analytical biochemistry.
Anion Exchange Resins↗
[Leading symptoms of chest pain in the emergency room. Using cardiac markers for risk stratification].
BACKGROUND AND OBJECTIVE: The acute coronary syndrome (ACS)--acute infarction or unstable angina pectoris--requires special monitoring and differentiated treatment. A prospective trial was undertaken to determine (1) clinical characteristics of patients with chest pain; (2) value of cardiac markers troponin T, myoglobin and CK-MB mass in differentiating cardiac and noncardiac chest pain; (3) the proportion of patients with ACS in whom these markers provided helpful additional information on admission and afterwards. PATIENTS AND METHODS: 233 consecutive patients (134 men, 99 women; aged 18-98 years), presenting in 1998 with nontraumatic chest pain at the emergency unit of the Lippe-Detmold Hospital were prospectively enrolled in the study. Levels of troponin T, myoglobin, CK-MB mass and activity and creatine kinase were measured on admission and after 2, 4 and 12-24 hours. RESULTS: ACS was ultimately diagnosed in 73 patients (31%). These were significantly older (p = 0.0015) and more often male (p = 0.046). 91% of patients with ACS but only 68% of those without described the chest pain as a sense of pressure or stabbing (p = 0.0002). Measurement of troponin T and myoglobin on admission was helpful in 39% of those with ACS, compared with 15% of those without. When the admission ECG was normal or nonspecific in patients with ACS, troponin T was elevated in 16%, CK-MB mass in 24%. In patients with unstable angina no single marker was associated with an increased risk (high rate of special supervision and intervention). CONCLUSION: In the assessment of patients with acute chest pain clinical judgement plays the predominant role. In the mostly elderly and male patients with ACS (31% of the cohort) feeling of pressure or stabbing chest pain were most prominent (91%). Cardiac markers troponin T, CK-MB mass and myoglobin were helpful in the differential diagnosis of chest pain, even when the ECG was unremarkable or nonspecific. At the time of admission myoglobin was the most significant marker for acute myocardial infarction or unstable angina.
Adolescent↗
Quantitative detection in the attomole range for immunochromatographic tests by means of a flatbed scanner.
This work describes the use of the combination of carbon black as an antibody label, a membrane-based immunochromatographic device, and a flatbed scanner as a quantitative test system. The scanner detected 0.4-345 ng carbon black/mm(2) on a nitrocellulose membrane (0.2-170 amol carbon black/mm(2)) with an imprecision (coefficient of variation, CV) lower than 2% for the carbon black determination and a detection limit of 0.04 ng carbon black/mm(2) (0.02 amol/mm(2)). The detection ability was compared to that obtained with alkaline phosphatase (ALP) using a substrate yielding a chemiluminescent signal (0.02 amol ALP/well), beta-galactosidase using a substrate yielding a fluorescent signal (0.3 amol beta-galactosidase/well), and horseradish peroxidase (HRP) using a substrate yielding a colored signal (5 amol HRP/microtiter well). The carbon black immunochromatographic test for immunoglobulin E (IgE) showed a detection limit of 0.13 pM IgE (0.01 kU/L) after a testing time of 10 min. The scanner detection imprecision for the IgE determination was 0.6% CV in the range 1-10 kU IgE/L when 2.3 mm(2) was used for detection and 1% CV when 0.19 mm(2) was used. A flatbed scanner is an inexpensive instrument with multiple uses, which now also includes the sensitive evaluation of immunoassays.
Adsorption↗
Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease.
BACKGROUND: The efficacy of antireflux surgery (ARS) and proton pump inhibitor therapy in the control of gastroesophageal reflux disease is well established. A direct comparison between these therapies is warranted to assess the benefits of respective therapies. STUDY DESIGN: There were 310 patients with erosive esophagitis enrolled in the trial. There were 155 patients randomized to continuous omeprazole therapy and 155 to open antireflux surgery, of whom 144 later had an operation. Because of various withdrawals during the study course, 122 patients originally having an antireflux operation completed the 5-year followup; the corresponding figure in the omeprazole group was 133. Symptoms, endoscopy, and quality-of-life questionnaires were used to document clinical outcomes. Treatment failure was defined to occur if at least one of the following criteria were fulfilled: Moderate or severe heartburn or acid regurgitation during the last 7 days before the respective visit; Esophagitis of at least grade 2; Moderate or severe dysphagia or odynophagia symptoms reported in combination with mild heartburn or regurgitation; If randomized to surgery and subsequently required omeprazole for more than 8 weeks to control symptoms, or having a reoperation; If randomized to omeprazole and considered by the responsible physician to require antireflux surgery to control symptoms; If randomized to omeprazole and the patient, for any reason, preferred antireflux surgery during the course of the study. Treatment failure was the primary outcomes variable. RESULTS: When the time to treatment failure was analyzed by use of the intention to treat approach, applying the life table analysis technique, a highly significant difference between the two strategies was revealed (p < 0.001), with more treatment failures in patients who originally were randomized to omeprazole treatment. The protocol also allowed dose adjustment in patients allocated to omeprazole therapy to either 40 or 60 mg daily in case of symptom recurrence. The curves subsequently describing the failure rates still remained separated in favor of surgery, although the difference did not reach statistical significance (p = 0.088). Quality of life assessment revealed values within normal ranges in both therapy arms during the 5 years. CONCLUSIONS: In this randomized multicenter trial with a 5-year followup, we found antireflux surgery to be more effective than omeprazole in controlling gastroesophageal reflux disease as measured by the treatment failure rates. But if the dose of omeprazole was adjusted in case of relapse, the two therapeutic strategies reached levels of efficacy that were not statistically different.
Aged↗
Inappropriate arrhythmia detection in implantable defibrillator therapy due to oversensing of diaphragmatic myopotentials.
Nonadequate arrhythmia detection and delivery of electrical therapy is still a main problem in current implantable cardioverter defibrillator therapy. Besides supraventricular arrhythmias extra-cardiac biosignals also can cause inadequate shock delivery. The present study focuses on nonadequate arrhythmia detection due to oversensing of diaphragmatic myopotentials. Their clinical characteristics, incidence and management are presented. Three-hundred-eighty-four recipients of a transvenous cardioverter-defibrillator who were implanted and followed-up at our institution between October 1991 and June 1999 were enrolled. During a mean follow-up of 32+/-25 months a total number of 139 nonadequate episodes of arrhythmia detection due to oversensing of diaphragmatic myopotentials were observed in 33 patients (8.6%). In 11 patients a total of 32 high energy shock deliveries occurred. Oversensing of diaphragmatic myopotentials was primarily observed in patients implanted with defibrillator leads providing "integrated bipolar" sensing. The vast majority of nonadequate arrhythmia detection were observed during intrinsic bradycardia heart rate and/or antibradycardia pacing. Electrical lead failure was ruled out in every patient. In 90% of the patients with a cardioverter-defibrillator providing programmable maximal sensitivity (n=16), the reduction of maximum sensitivity was effective in preventing further episodes of nonadequate arrhythmia detection. In 48% of the patients with devices without programmable maximal sensitivity (n=17), surgery revision was necessary to solve the problem.
Adult↗
Possible role of epicardial left ventricular programmed stimulation in Brugada syndrome.
A patient with recurrent syncope due to polymorphic ventricular tachycardia was diagnosed with Brugada syndrome. Programmed right ventricular stimulation could not induce arrhythmia. Epicardial stimulation from a left ventricular site through the coronary sinus led to polymorphic VT. The stimulation protocol for risk stratification in Brugada syndrome is discussed.
Adult↗
Myocardial injury during radiofrequency catheter ablation: comparison of focal and linear lesions.
The aim of study was to investigate the extent of myocardial injury incurred by creation of continuous RF current induced linear ablation lesions (LL; ablation of atrial fibrillation, right atrial procedure) in comparison to focal RF lesions (FL; AV node reentry tachycardia, WPW tachycardia). In 23 patients with LL (age 51.3 +/- 11.2 years, 18 men, 5 women) and in 16 patients with FL (age 53.9 +/- 5.1 years, 8 men and 8 women), levels of creatine kinase (CK), myoglobin (MG), CKMB mass (CKMB M), CKMB activity (CKMB A), and cardiac troponin T (cTnT) were determined before and 2, 4, 8, 24, and 48 hours after ablation. CKMB A was normal in 87% in LL and 100% in FL (< 6% of CK) with median maximum CK values of 214 (45-1583) U/L in LL and 36 (29-212) U/L in FL. Peak values of all parameters were significantly higher in LL than in FL. The sensitivity of cTnT was 50% in FL and 100% in LL. In FL MG, total CK, and CKMB M were abnormal in only 12.5% of cases while in LL MG and CKMB M were pathological in 100% and total CK was abnormal in 91.3% of patients. The amount of energy and number of RF applications correlated with cTnT, MG, and CKMB M (P = 0.01). In conclusion, (1) long linear RF current lesions for ablation of atrial fibrillation are associated with significantly greater myocardial injury than focal ablations. (2) In focal lesions only cTnT provided a sensitivity of 50% in the detection of myocardial injury while in linear lesions cTnT, CKMBM, and CKMB M seemed suitable for detection of RF current induced myocardial damage with 100% sensitivity. All biochemical parameters do not differentiate patients with coronary ischemia up to 48 hours after an ablation. (3) Further investigations are necessary to determine if RF current linear lesions lead to impaired atrial contractility in cases of extensive tissue damage.
Adult↗
Dual-coil vs single-coil active pectoral implantable defibrillator lead systems: defibrillation energy requirements and probability of defibrillation success at multiples of the defibrillation energy requirements.
AIMS: The aim of the study was to compare the defibrillation energy requirements and the probability of successful defibrillation at multiples of the minimum defibrillation energy requirements in active pectoral implantable defibrillators with single- and dual-coil lead systems. METHODS AND RESULTS: Eighty-three consecutive patients undergoing implantation of an active pectoral cardioverter-defibrillator were randomized to receive a dual- or single-coil lead system. Defibrillators of two manufacturers with a fixed tilt biphasic defibrillation waveform were used. Defibrillation energy requirements were determined using a step-down defibrillation testing protocol. According to the randomization protocol, the patients were assigned to three additional consecutive defibrillation attempts during device implantation and during pre-discharge testing of either 1.0, 1.5 or 2.0 times the determined defibrillation energy requirement. Patients presenting defibrillation energy requirements > 15 J were excluded from analysis. Eighty of 83 patients (96%) completed the study protocol. Three patients were excluded due to elevated defibrillation energy requirements. The defibrillation energy requirements in the dual- and single-coil patient groups were 8.0 +/- 3.6 J and 8.4 +/- 3.7 J (ns), respectively. A comparable percentage of study patients showed defibrillation energy requirements <10 J (dual-coil: 88% vs single-coil: 83%). Defibrillation impedance was significantly different (dual-coil: 50 +/- 5.8 Ohm; single-coil: 39.8 +/- 4.2 Ohm). Regarding the probabilities of successful defibrillation, there were no significant differences between the two patient groups. The probabilities of defibrillation at the three multiples of the defibrillation energy requirement using a dual- and single-coil lead system were 82, 89.7 and 93.6 and 77.8, 94.1 and 95.8%, respectively (P=0.88, P=0.42, P=0.62, respectively). CONCLUSIONS: Dual- and single-coil active pectoral defibrillator systems show no difference in defibrillation energy requirements and no difference in the probability of successful defibrillation at multiples of the minimum defibrillation energy requirement. The use of more simplified defibrillator lead systems may contribute to a future lead design focusing on improvement in lead durability.
Aged↗
Electrochemical potentials during radiofrequency energy delivery: a new method to control catheter ablation of arrhythmias.
AIMS: Thermal injury of subendocardial tissue leads to a release of electrolytes and free radicals from the intracellular site creating a change in electrochemical potential (eP) between the distal and the proximal catheter tip electrodes. The aim of the study was to verify the detection of ablation-induced release of electrolytes and free radicals and to assess the suitability of control-line energy delivery at ablation by measuring eP. METHODS AND RESULTS: In vitro tests under constant flow conditions were performed in a 101 bath of physiological saline solution or bovine blood. Endomyocardial preparations of fresh bovine hearts were used. Closed-loop temperature-controlled, irrigated and closed-loop eP-controlled ablations were performed. In vivo animal investigations were performed in six anaesthetized and ventilated pigs. The existence of the eP was established in the tank model and was confirmed in animal investigations. High correlations were found between eP and catheter tip temperature (r=0.87) and between maximum eP and induced lesion size (r=0.85). Also a high correlation (r=0.85, P<0.001) was found between eP and lesion volume. CONCLUSIONS: Control of energy delivery during RF ablation by the measurement of eP is feasible. In comparison with temperature controlled RF ablation, ablation guided by eP-measurement revealed a superior correlation with induced lesion size. Especially during cooled radiofrequency catheter ablation eP is the only parameter for control of energy delivery.
Action Potentials↗
Randomized comparison of J&J Crown stent versus NIR stent after routine coronary angioplasty.
BACKGROUND: Coronary artery stents are used for the treatment of acute or threatening vessel occlusion complicating coronary angioplasty or for prevention of restenosis after angioplasty. The current randomized trial compared the procedural outcome and long-term patency of 2 different flexible stents in unselected lesion morphology. METHODS: The study population consisted of consecutive patients undergoing coronary angioplasty for symptomatic coronary artery disease followed by high-pressure stent implantation. The poststent treatment consisted of antiplatelet therapy. The primary hypothesis was an assumed restenosis rate of 30% in the group receiving NIR stents (Boston Scientific Europe SPRL, Parc Industriel de Petit-Rechain, Belgium) and a reduction of the restenosis rate (defined as >50% vessel diameter at follow-up) by 50% in the group undergoing J&J Crown stent (Cordis, Johnson & Johnson Interventional Systems, Warren, NJ) implantation: the restenosis rate and minimal luminal diameter at follow-up. Follow-up angiography was performed 6 months after the initial procedure. RESULTS: A total of 203 patients were randomized to receive either the J&J Crown stent (n = 103) or the NIR stent (n = 100). The procedural success was similar in both groups (96.1% vs 99% in the NIR stent group, respectively; P =.19). There were 4 cases of crossover from the J&J Crown to the NIR stent group. In one patient, stent implantation of either stent model did not succeed. One patient died from fulminant pulmonary embolism. Restenosis, defined as >50% diameter stenosis at follow-up 5.8 +/- 1.3 months after the initial procedure occurred in 19 patients (18.4%) in the J&J Crown stent group compared with 22 patients (22.0%) in the NIR stent group (P =.42). There was a significantly higher rate of crossover from the J&J Crown stent to the NIR stent (3.9% vs 0%, respectively, P =.047), whereas reverse crossover did not occur. The one lesion in which NIR stent implantation was not successful had an extremely tortuous proximal part. This patient underwent only balloon angioplasty. Clinical events were rare during 6 months of follow-up and the incidence did not differ between both groups (nonfatal myocardial infarction: J&J Crown stent 1.0% vs 0% in the NIR stent group, P =.32; all-cause mortality: J&J Crown stent 1.0% vs 0% in the NIR stent group, P =.32). CONCLUSIONS: There were no significant angiographic and clinical differences between the J&J Crown and NIR stents. Both stents had a similar procedural success rate, although the implantation of NIR stents was successful even in vessels in which previous attempts at J&J Crown stent placement had failed.
Angioplasty, Balloon, Coronary↗
The cost of long term therapy for gastro-oesophageal reflux disease: a randomised trial comparing omeprazole and open antireflux surgery.
BACKGROUND AND AIM: To comprehensively assess the relative merits of medical and surgical therapy for gastro-oesophageal reflux disease (GORD), health economic aspects have to be incorporated. We have studied the direct and indirect costs of medical and surgical therapy within the framework of a prospective randomised multicentre trial. METHODS: After initial treatment of reflux oesophagitis with omeprazole to control symptoms and to heal oesophagitis, 154 patients were randomised to continue treatment with omeprazole (20 or 40 mg daily) and 144 patients to have an open antireflux operation (ARS). In case of GORD relapse, patients allocated to omeprazole were offered ARS and those initially operated on had either a reoperation or were treated with omeprazole. The costs were assessed over five years from randomisation. RESULTS: Differences in cumulative direct medical costs per patient between the two therapeutic strategies diminished with time. However, five year direct medical costs per patient when given omeprazole were still significantly lower than for those having ARS in Denmark, Norway, and Sweden (differences were DKK 8703 (US$1475), NOK 32 992 (US$ 5155), and SEK 13 036 (US$ 1946), respectively). However, in Finland the reverse was true (the difference in favour of ARS amounted to FMK 7354 (US$ 1599)). When indirect costs (loss of production due to GORD related sick leave) were also included, the cost of surgical treatment increased substantially and exceeded the cost of medical treatment in all countries. CONCLUSIONS: The total costs of medical therapy for chronic GORD were lower than those of open ARS when prospectively assessed over a five year period, although significant differences in cost estimates were revealed between countries.
Aged↗
Electrical interference between two transvenous implantable defibrillator leads.
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Defibrillators, Implantable↗