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Overdose of modified-release paracetamol calls for changed treatment routines. New guidelines from the Swedish Poisons Information Centre  The sales of modified-release paracetamol tablets are steadily increasing in Sweden as are the number of overdose cases with this formulation. The Swedish Poisons Information Centre has noted that the standard treatment protocol with N-acetylcysteine (NAC), which is based on overdoses with immediate-release paracetamol formulations, is often inadequate in this setting. In this paper, an adult who overdosed on 66.5 grams of modified-release paracetamol tablets and developed severe liver impairment (max ALT 6,660 U/l) despite timely and rigorous NAC treatment is presented. The patient's peak S-paracetamol of 2,800 µmol/l was delayed to 19 hours post-ingestion. Moreover, a pharmacokinetic and clinical study of similar cases showed that seven (21%) of the 34 patients who received NAC treatment within 8 hours after ingestion developed liver impairment. Finally, new Swedish guidelines for management of these cases are presented. The guidelines are also available on www.giftinfo.se.

Cardiomyopathy is a disorder of the cardiac muscle and can be either primary or secondary. The primary disorders have been classified by WHO into 4 groups based on structure and function; hypertrophic, dilated and restricted cardiomyopathies and arrythmogenic right ventricle dysplasia. During the last decade the familial nature of many of these cardiomyopathies has been elucidated and different genes have been found to be mutated and causative of disease. Certain patterns can be distinguished in the mutated genes, e.g. in general the genes causing hypertrophic cardiomyopathies code for proteins involved in the contractile apparatus, the sarcomere, and the genes causing dilated cardiomyopathy code for proteins that anchor the sarcomere to the cell membrane and extracellular matrix. This article reviews these recent genetic findings and discusses their potential clinical applicability.

Regional programs for secondary prevention of coronary artery disease have been under development for nearly a decade in Sweden. To achieve maximum adherence these programs were created in close collaboration between hospital and primary care physicians. The programs are local applications of national guidelines and aim to support compliance among both patients and physicians. In January 1998 the Swedish Society of Cardiology and the Swedish Association of General Practice launched a program for quality control and quality assurance of these initiatives. So far, 51 of 79 districts have joined the program. Patients' diaries used for risk factor registration contain 7 report cards on the management of risk factors and medication. These cards are sent to a central registry upon release from the hospital, after 3-6 months, and annually for 5 years. Results from the first year point to differences between the various districts with respect to compliance with both local programs and European guidelines. Overall, results are promising and indicate that this program is successful and leads to improved management of patients with coronary artery disease.