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Background: We report a case of prosthetic hip joint infection in a heart transplant recipient due to Anaerobiospirillum succiniciproducens, a genus of spiral-shaped curved anaerobic gram-negative rod which colonizes the gastrointestinal tract of cats and dogs. Invasive infections in humans are rare and typically occur in immunocompromised hosts.Case Presentation: A 65-year-old male dog breeder with a history of rheumatoid arthritis, bilateral hip arthroplasties, and non-ischemic cardiomyopathy with a heart transplant 10 years ago presented with a three month history of progressive left hip pain and frank purulence on hip aspiration. He underwent irrigation and debridement of the left hip and one-stage revision with hardware exchange. Although gram stain and culture from synovial fluid and intraoperative cultures were initially negative, anaerobic cultures from tissue specimens later grew a spiral-shaped gram-negative rod, identified as Anaerobiospirillum spp. by 16S rRNA gene sequencing. The patient was treated with ceftriaxone 2 g daily for 6 weeks with a good response to treatment. A similar organism was unable to be isolated from culture of 2 of the patient's dogs, however, they were thought to be the most likely source of his infection.Conclusion: Anaerobiospirillum spp. should be considered in immunocompromised patients with exposure to dogs or cats who present with bacteremia, gastrointestinal infection, pyomyositis, or prosthetic joint infections, especially in cases of culture-negative or with anaerobic culture growth. [ABSTRACT FROM AUTHOR]

Background: Thymidine analogs, namely AZT (Zidovudine or Retrovir™) and d4T (Stavudine or Zerit™) are antiretroviral drugs still employed in over 75% of first line combination antiretroviral therapy (cART) in Kampala, Uganda despite aversion to prescribing these drugs for cART in high income countries due in part to adverse events. For this study, we explored how the continued use of these thymidine analogs in cART could impact emergence of drug resistance and impact on future treatment success in Uganda, a low-income country. Methods: We examined the drug resistance genotypes by Sanger sequencing of 262 HIV-infected patients failing a first line combined antiretroviral treatment containing either AZT or d4T, which represents approximately 5% of the patients at the Joint Clinical Research Center receiving a AZT or d4T containing treatment. Next generation sequencing (DEEPGEN™HIV) and multiplex oligonucleotide ligation assays (AfriPOLA) were then performed on a subset of patient samples to detect low frequency drug resistant mutations. CD4 cell counts, viral RNA loads, and treatment changes were analyzed in a cohort of treatment success and failures. Results: Over 80% of patients failing first line AZT/d4T-containing cART had predicted drug resistance to 3TC (Lamivudine) and non-nucleoside RT inhibitors (NNRTIs) in the treatment regimen but only 45% had resistance AZT/d4T associated resistance mutations (TAMs). TAMs were however detected at low frequency within the patients HIV quasispecies (1-20%) in 21 of 34 individuals who were failing first-line AZT-containing cART and lacked TAMs by Sanger. Due to lack of TAMs by Sanger, AZT was typically maintained in second-line therapies and these patients had a low frequency of subsequent virologic success. Conclusions: Our findings suggest that continued use of AZT and d4T in first-line treatment in low-to-middle income countries may lead to misdiagnosis of HIV-1 drug resistance and possibly enhance a succession of second- and third-line treatment failures. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to provide evidence regarding the real-life efficacy of pregabalin in the treatment of peripheral neuropathic pain (NeP) in Denmark. Methods: In this prospective, observational, noninterventional study, pregabalin (Lyrica®) was prescribed following usual clinical practice. Compared with baseline, the primary study end points after 3 months of observation were changes in 1) the average level of pain during the past week, 2) the worst level of pain during the past week, and 3) the least level of pain during the past week. The Wilcoxon signed-rank test was used to perform paired analyses, and a multivariate regression analysis investigated factors driving change in pain. Results: A total of 86 of the 128 patients included were regarded as efficacy evaluable (those completing 3 months of pregabalin treatment). Patients (59 years) were long-time sufferers of peripheral NeP, and 38% of them had comorbidities. The majority had previously been treated with tricyclic antidepressants or gabapentin. The average dose of pregabalin was 81.5 mg/d at baseline and 240 mg/d after 3 months. A clinically and statistically significant improvement of 2.2 points in the average level of pain intensity was found after 3 months. The higher the pain intensity at baseline, the higher was the reduction of the pain score. Positive results were also found for pain-related sleep interference, patients' global impression of change, quality of life, and work and productivity impairment. Twenty-one patients reported 28 adverse events. Conclusion: This real-life study indicates that for some patients (two-thirds), addition of pregabalin for peripheral NeP helps to reduce their pain intensity significantly. [ABSTRACT FROM AUTHOR]

Introduction Portal biliopathy ( PB) is a rare condition in which portal hypertension because of extrahepatic portal vein obstruction can lead to biliary abnormalities, with some patients developing obstructive jaundice. At present, there is no international consensus on the management of PB. We present the experience of an Australian tertiary referral hospital with the diagnosis and management of PB, and compare this with reported international experience. Methods The records of nine patients presenting with PB between June 2003 and March 2012 were reviewed and analysed. Results All patients had portal hypertension because of portal vein thrombosis, with seven patients showing cavernous transformation of the portal vein. Biliary abnormality presented with jaundice (3/9), abdominal pain (2/9) or without symptoms (3/9). All patients developed a cholestatic pattern of liver function tests ( LFTs). First-line endoscopic management was employed in 7 of 8 symptomatic patients. Four patients required endoscopic management alone (sphincterotomy alone (1/9), single stent (2/9), repeated stent changes (1/9) ), while four required second-line surgical intervention (portosystemic shunt (1/9), bilioenteric anastomosis (3/9) ). All patients were well, with stable LFTs, at median 18-month follow-up, with two patients undergoing regular stent changes, and the remainder requiring no further intervention. Conclusion PB can be managed successfully with endoscopic therapy as the first-line option, but a multidisciplinary approach is necessary, with second-line surgical intervention often required. We recommend a management algorithm similar to that presented in the UK PB literature, and confirm that bilioenteric anastomosis can be performed successfully without prior portal decompression. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Treating Idiopathic Pulmonary Fibrosis With the Addition of Co-Trimoxazole: A Randomized Controlled Trial." by L. Shulgina and colleagues in the 2013 issue.

Background Idiopathic pulmonary fibrosis (IPF) is a fatal condition with limited treatment options. However, in a previous small study, co-trimoxazole was found to be beneficial. Methods In a double-blind multicentre study, 181 patients with fibrotic idiopathic interstitial pneumonia (89% diagnosed as definite/probable IPF) were randomised to receive co-trimoxazole 960 mg twice daily or placebo for 12 months in addition to usual care. Measurements were made of forced vital capacity (FVC) ( primary endpoint), diffusing capacity of carbon monoxide (DLCO) and EuroQol (EQ5D)-based utility, 6-minute walk test (6MWT) and Medical Research Council (MRC) dyspnoea score (secondary endpoints). All-cause mortality and adverse events were recorded (tertiary endpoints). Results Co-trimoxazole had no effect on FVC (mean difference 15.5 ml (95% CI -93.6 to 124.6)), DLCO (mean difference -0.12 mmol/min/kPa (95% CI 0.41 to 0.17)), 6MWT or MRC dyspnoea score (intention-to-treat analysis). The findings of the per-protocol analysis were the same except that co-trimoxazole treatment resulted in a significant improvement in EQ5D-based utility (mean difference 0.12 (95% CI 0.01 to 0.22)), a reduction in the percentage of patients requiring an increase in oxygen therapy (OR 0.05 (95% CI 0.00 to 0.61)) and a significant reduction in all-cause mortality (co-trimoxazole 3/53, placebo 14/65, HR 0.21 (95% CI 0.06 to 0.78), p=0.02)) compared with placebo. The use of cotrimoxazole reduced respiratory tract infections but increased the incidence of nausea and rash. Conclusions The addition of co-trimoxazole therapy to standard treatment for fibrotic idiopathic interstitial pneumonia had no effect on lung function but resulted in improved quality of life and a reduction in mortality in those adhering to treatment. ISRCTN22201583 [ABSTRACT FROM AUTHOR]

Systemic hypertension is a long-term risk factor for the development of atherosclerotic vascular disease and when uncontrolled is a short-term trigger of acute vascular events such as acute coronary syndromes and stroke. Thus, rapid reduction in BP is desirable. Patients at high risk for vascular disease, such as those with diabetes mellitus, have aggressive goal BP targets because studies have shown that achieving these targets reduces events. Given the dual goals in high-risk patients of reducing BP quickly and to aggressively low targets, the classic 'step therapy' of one drug titrated at a time to reduce BP is inadequate. Combination therapy with at least two potent medications makes more sense, and manufacturers are now increasing their offerings of single-pill combinations for hypertension. Combination pills are popular with patients and increase compliance with therapy. Many believe that renin-angiotensin aldosterone system (RAAS) blockers are the cornerstone of hypertension treatment in patients at high risk for vascular disease. The newer combination pills include a RAAS blocker and diuretics or a long-acting calcium channel antagonist (CCA). Recent studies have shown that a RAAS blocker plus a dihydropyridine CCA is superior to older diuretic-based combinations for preventing cardiovascular events. These considerations support a new approach to the higher risk hypertensive patient: effective doses of RAAS blocker/CCA combination pills to rapidly lower BP to <130/80 mmHg. [ABSTRACT FROM AUTHOR]

Hepatocellular carcinoma (HCC) is a primary cancer of the liver with an established causal link to viral hepatitis and other forms of chronic liver disease. Aims: The aim of this study was to analyse the determinants of outcome in patients with HCC referred to a tertiary centre for management. Method: Two hundred and thirty-five prospective patients with HCC and minimum 12-month follow-up were studied. Results: The cohort was heterogeneous, with 52% Caucasian, 40% Asian and 5% of Middle-Eastern origin. Independent predictors of outcome included tumour size and number, the presence of ascites or portal vein thrombosis, α-foetoprotein >50 U/L and an impaired performance status. Treatment was determined on an individual case basis by a multidisciplinary tumour team. Surgical resection was primary treatment in 43 patients, liver transplantation in 40 patients, local ablation (percutaneous radiofrequency ablation or alcohol injection) in 33 patients, transarterial chemoembolisation in 33 patients, chemotherapy or other systemic therapy in 30 patients and no treatment in 56 patients. After adjustment for significant covariates, both liver transplantation ( P<0.001) and surgical resection ( P=0.029) had a significant effect on patient survival compared with no treatment, but local ablation ( P=0.410) and chemoembolisation ( P=0.831) did not. Liver transplantation resulted in superior overall and, in particular, disease-free survival compared with surgical resection (disease-free survival 84 vs 15% at 5 years). Conclusion: In conclusion, both surgical resection and liver transplantation significantly improve the survival of patients with HCC, but improvements need to be made to the delivery of loco-regional therapy to enhance its effectiveness. [ABSTRACT FROM AUTHOR]

Glatiramer acetate (GA; Copaxone) is a random copolymer of glutamic acid, lysine, alanine, and tyrosine that is used therapeutically in patients with multiple sclerosis (MS). To investigate the mechanism of the drug's immunomodulatory effect, we used immunophenotypic approaches to characterize the precise nature of GA-induced T cell responses. We demonstrate here that healthy individuals and untreated MS patients exhibit prominent T cell proliferative responses to GA. However, these responses are different in distinct subsets of T cells. Whereas GA-induced CD4(+) T cell responses are comparable in healthy individuals and MS patients, CD8(+) T cell responses are significantly lower in untreated MS patients. Treatment with GA results in upregulation of these CD8(+) responses with restoration to levels observed in healthy individuals. Both CD4(+) and CD8(+) GA-specific responses are HLA-restricted. GA therapy also induces a change in the cytokine profile of GA-specific CD4(+) and CD8(+) T cells. This study provides the first direct immunophenotypic evidence, to our knowledge, of GA-specific CD8(+) T cell responses and their upregulation during the course of therapy, which may suggest a role for these responses in the immunomodulatory effects of the drug. [ABSTRACT FROM AUTHOR]

Clinical trials have been extensively used in order to explore the effectiveness of drug treatments for psychiatric disorders. Double-blind, randomized controlled trials provide the potential to explore the effectiveness of treatments free from the effects of bias and confounding factors. More recently clinical trials have been used in order to evaluate the effects of more complex interventions such as psychological treatments and alternatives to inpatient treatment. Clinical trials of complex interventions present several methodological challenges including the need to identify their mechanisms of action, problems ensuring the fidelity of the experimental intervention and variations in the effects that interventions have in sub-groups of people. We argue that some of these challenges can be met by incorporating qualitative research methods into the experimental evaluation of complex interventions. The benefits and some of the problems of combining methods are illustrated by examples of recent and ongoing research. [ABSTRACT FROM AUTHOR]

Assesses the effects of oral propranolol and digoxin alone and in combination on angina frequency, heart size, systolic time intervals and treadmill exercise tolerance in 20 patients with coronary heart disease. Treatment for patients with angina pectoris; Statistical data on heart rate recorded during the treatment periods.

In this article the author questions the use of eplerenone as an alternative to spironolactone in systolic heart failure (HF) patients with mild symptoms, by referencing a study by F. Zannad and colleagues. He presents details related to the study, and opines that its unique features have probably augmented the benefits of eplerenone. He recommends the use of eplerenone, particularly for men, if affordable by the patient.

A propensity score-matching analysis of all patients undergoing coronary angiography in Alberta, Canada identified a subgroup with diabetes, multivessel coronary artery disease, and left ventricular ejection fraction < 50% who were undergoing revascularization and could be separated into a group undergoing percutaneous coronary intervention (PCI) and another coronary artery bypass grafting (CABG). At five years follow-up, the CABG group experienced significantly fewer major cardiac or cerebral vascular events compared to PCI and a low risk of stroke that was similar to that observed with PCI. [ABSTRACT FROM AUTHOR]

A randomized, prospective, noninferiority study of the safety of two automated CPR devices (LUCAS and AutoPulse) against the standard manual chest compressions in cardiac arrest victims showed that in cases of severe or life-threatening complications, the LUCAS device was noninferior to standard CPR, but more organ damage with the AutoPulse cannot be excluded. [ABSTRACT FROM AUTHOR]

A large German experience with the wearable cardioverter-defibrillator confirms the finding of U.S. registry studies and suggests that the device is useful for patients with reduced left ventricular function at high risk of sudden cardiac death who are not currently good candidates for an implantable cardioverter-defibrillator. [ABSTRACT FROM AUTHOR]

Asymptomatic patients suffering from moderate aortic stenosis and regurgitation with preserved left ventricular function have the same prognosis as asymptomatic patients with severe aortic stenosis and normal left ventricular function and should be followed closely for the development of symptoms. [ABSTRACT FROM AUTHOR]

The article presents an abstract of the article "Value of the Physical Examination in Heart Failure" by Michael H. Crawford and a comment about the article. The therapeutic decision factors in treating heart failure including the serial use of brain natriuretic peptide levels, echocardiography and assessment of renal function are also outlined.

The article presents an abstract of the article "Mechanical Chest Compressions in CPR" by Michael H. Crawford and presents a commentary about the article. It mentions the doubts on the effectiveness of the mechanical chest compression devices compared to manual compression. The need to further capitalize the advantages of using the mechanical chest compressions is also emphasized.

The author discusses the improvement of predicting risk in atrial fibrillation (AF) patients administered with anticoagulants. Topics discussed by the author include the observations on pixaban vs warfarin trial-derived research in non-valvular AF patients, the risk posed to AF patients on anticoagulants, and the restriction of using anticoagulation therapy nased on research results.

The article presents a study regarding the risk of embolic events in patients with infective endocarditis (IE). Topics discussed include the diagnosis and the initiation of antibiotic therapy in IE, the importance of the early deployment of blood cultures and echocardiography in IE and the use of magnetic resonance imaging (MRI) to detect the lesions in the diagnosis of emboli.

The article discusses a study by W. B. Borden and colleagues to assess the use of optimal medical therapy (OMT) in patients with stable coronary artery disease (CAD) before and after Percutaneous Intervention (PCI) and before and after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study. Also offered is a review of the study which indicated that a large opportunity is being missed to improve patient outcomes after performing PCI.

In this article, the author discusses a study by I. M. Kronish and colleagues, which revealed that renin-angiotensin system blockers have the highest rate of adherence to antihypertensive therapy, while beta-blockers and diuretics have the lowest. He emphasizes on the compliance with antihypertensive drugs in the treatment of hypertension. It is his opinion that the study was limited as angiotensin receptor blockers (ARBs) were the lease prescribed drugs, and not all drug classes were examined.

The author examines a study by F. Dumas and colleagues who evaluated the outcomes of hypothermia in patients who are comatose survivors of out-of-hospital cardiac arrest. It is inferred that patients whose initial rhythm was ventricular tachycardia (VT)/ventricular fibrillation (VF) versus pulseless electrical activity (PEA) or asystole showed better outcomes with hypothermia. It is recommended that current guidelines for initiating hypothermia should be followed for all cardiac arrest patients.

DESPITE IMPRESSIVE REDUCTIONS IN CARDIOVASCULAR RISK in primary and secondary prevention trails with statin therapy, risk does not reach zero. A low HDL could explain at least some of this residual risk, but current data are inconsistent. Thus, the JUPITER trial database was analyzed to answer this question. JUPITER was a randomized trial of 20 mg of rosuvastatin vs. placebo in more than 17,000 apparently healthy individuals with LDL cholesterol levels < 130 mg/dL, but who had an elevated high sensitivity (hs) CRP (> 2 mg/L). JUPITER showed a 20% reduction in mortality after less than two years follow-up and a 44% reduction in cardiovascular events. Average LDL was 55 mg/dL in the statin group. For this analysis, the subjects were divided into quartiles of HDL, and an association with the primary endpoint of first non-fatal myocardial infarction, stroke, hospitalization for unstable angina, arterial revascularization, or cardiovascular death was sought. As compared to placebo, for all quartiles of HDL, rosuvastatin significantly reduced the primary endpoint to a similar extent as the main trial. Rosuvastatin also increased HDL by 4% on average. In the placebo group, cardiovascular events increased inversely with the HDL level. The highest HDL quartile patients (> 55 mg/dL) had a 46% lower event rate. In the rosuvastatin group, this difference in events across the HDL quartiles was abolished. Factors shown to be associated with residual cardiovascular risk in the statin-treated patients were age, male sex, and smoking status. The authors concluded that HDL is a useful component of initial cardiovascular risk assessment, but HDL does not predict residual risk in those treated with a potent statin who achieve low LDL levels. [ABSTRACT FROM AUTHOR]

THERE IS CONSIDERABLE CONCERN REGARDING IN-STENT THROMbosis of drug-eluting stents (DES) when aspirin and clopidogrel are stopped for non-cardiac surgery (NCS), but a paucity of data. Thus, this group from Australia surveyed more than five million patients in two large private insurance company databases and sent questionnaires to all who had DES followed by surgery. Questionnaires were returned by 1,086 of the 4,126 patients who received them. Cardiac surgery excluded 376, leaving 710 who were suitable for analysis. None of the non-responders died within 30 days of NCS. Mean time from DES to NCS was 348 days. NCS occurred within 30 days in 3%, six months in 27%, and 12 months in 56%. Before surgery, 66% were on dual antiplatelet therapy, 21% aspirin alone, 9% on clopidogrel alone, and 4% were on no antiplatelet therapy. Surgery was performed on dual therapy in 18%, on single therapy in 23%, and no antiplatelet therapy in 59%. The average time of medication cessation prior to surgery was about one week. Results: Perioperative myocardial infarction (MI) (confirmed by medical records) occurred in 11 (1.5%), and angiography showed that only two patients had stent thromboses while seven had new culprit lesions. Two patients did not have angiography, but one probably had in-stent thrombosis clinically, for a total of three. None of these three patients were on antiplatelet therapy, and only one of the other eight patients was on therapy with aspirin alone. Among the 11 MIs, one occurred < 30 days post-DES, none from one to six months, six from six to 12 months, and four >12 months. The authors concluded that NCS after DES has a low morbidity despite a majority being off antiplatelet therapy and more post-operative MIs occurred because of new culprit lesions in non-stented vessels, rather than stent thrombosis. [ABSTRACT FROM AUTHOR]

ALTHOUGH ISCHEMIC LEFT VENTRICULAR (LV) DYSFUNCTION is an indication for revascularization, little is known about the long-term benefits of revascularization and the value of viability studies. Thus, these investigators from Indiana University performed a retrospective, observational study of their database of 14 years of dobutamine stress echocardiography (DSE) for viability. In 274 patients with reduced left ventricular ejection fraction (LVEF), those who had revascularization therapy were compared to those who had medical therapy. Viable myocardium by DSE was present in 32% of the 274 patients. Other baseline characteristics of the two groups were similar, except that revascularized patients had more non-viable myocardium. Revascularization was performed in 47% (93% had bypass surgery). Over the mean 4.5-year follow-up, 35% of the revascularized patients died vs. 48% of the medically treated patients. After adjustment for propensity score showed that revascularized patients had a better survival (5.9 years) vs. medically treated patients (3.3 years, HR 0.42, 95% CI 0.27-0.65, p <.0001). This difference was apparent early in the first year and increased with time. Cardiac mortality showed the same results. The authors concluded that revascularization increases long-term survival in patients with ischemic cardiomyopathy and variable viability. [ABSTRACT FROM AUTHOR]

HEART FAILURE DUE TO DIASTOLIC DYSFUNCTION IS COMMON in hypertensive patients, yet little is known about the effect of antihypertensive agents on diastolic dysfunction. A substudy of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) evaluated diastolic function by echo-Doppler techniques and addressed the effect of beta blocker plus diuretic vs. a calcium blocker plus an ACE inhibitor. In the main trial, death or myocardial infarction was less on amlodipine plus perindopril as compared to atenolol plus thiazide diuretic. Enrolled patients had hypertension and at least three other cardiovascular disease risk factors. A subgroup of 1,006 patients from two centers in the British Isles underwent more detailed evaluation, including echo-Doppler studies and BNP at one year after randomization. Baseline characteristics in the two treatment groups in this substudy population were similar. Systolic blood pressure was reduced equally in the two groups, but heart rate was lower on the beta blocker-based therapy. Early diastolic mitral annular tissue Doppler velocity (E') was lower on the atenolol regimen (7.9 vs. 8.8 cm/s; p < 0.001). Mitral valve velocity (E) over E' and BNP were higher on the atenolol regimen (8.1 vs. 7.8; p = 0.013) and (37 vs. 19 pg/mL; p < 0.001). These differences remained significant after adjusting for age and sex. Adjustment for systolic blood pressure, left ventricular mass, and heart rate attenuated the difference in E/E', but not E', on BNP. The authors concluded that in an ASCOT study subgroup, echo-Doppler diastolic function was better on the amlodipine-based treatment vs. the atenolol-based treatment, and these differences were independent of blood pressure lowering and other loading factors known to affect diastolic function measures. [ABSTRACT FROM AUTHOR]

The article discusses research being done on the impact of nicotinic acid on vascular function and atherosclerosis. It references studies including one by J. M. S. Lee and colleagues in a 2009 issue of the "Journal of the American College of Cardiology," and another by A. J. Taylor and colleagues in a 2009 issue of "The New England Journal of Medicine." It has been found out that niacin is effective for reducing carotid intima-media thickness in patients with coronary artery disease.

Nebivolol is a new beta 1 selective blocker with vasodilatation properties via activation of the L-arginine/ nitric oxide pathway. Short-term studies, and a long-term, open-label study, have shown excellent efficacy and safety in stages 1-11 hypertension. Papademetriou presents the results of a nine-month extension of three trials of nebivolol monotherapy vs placebo, where patients were titrated with nebivolol monotherapy or other agents. The protocol involved dose titration of nebivolol monotherapy (5, 10, or 20 mg/day in a single dose) or the addition of other drugs (thiazide diuretic, amlodipine, others) until diastolic blood pressure was < 90 mmHg and trough heart rate was > 55 beats/min. The primary endpoint was trough diastolic blood pressure at the end of nine months. Of the 1,738 patients who completed the three-feeder studies, 845 entered the nine-month extension study. During the feeder study, 90% were on nebivolol and 10% were on placebo. Men and women were about evenly divided, and about a quarter were African-American. The patients were distributed into four groups: nebivolol alone (607); nebivolol plus diuretic (206); nebivolol plus calcium channel blocker (21); and nebivolol plus other meds (11). Compliance was high-ranging, from 92%- 100% across the four groups. Results: Patients on nebivolol monotherapy exhibited the greatest decrease in blood pressure (15 mmHg for systolic and diastolic pressure); 78% of the patients achieved goal blood pressure. The pressures remained decreased throughout the study period. Among those on nebivolol plus diuretic, 65% reached goal blood pressure. More than half the patients reported some adverse event, but none exceeded 5% incidence. Whether all were related to the drug is difficult to say since there was no placebo arm in the long-term study. Adverse events usually attributed to beta blockers were low; one patien developed sexual dysfunction, five bradycardia, 39 fatigue (4.6%), and 25 dizziness (3%). Serious adverse events were rare (2%). Papademetriou concluded that nebivolol alone, or in combination with other antihypertensive drugs, is a safe and effective long-term antihypertensive therapy. [ABSTRACT FROM AUTHOR]

The appropriate treatment of infective endocarditis (IE), to avoid embolic stroke, is unclear. Thus, Dickerman and colleagues explored the International Collaboration on Endocarditis Prospective Cohort Study (ICE-CPS) database to define the temporal occurrence of stroke in relation to antibiotic therapy. The study population included 1437 patients with left-sided IE who met modified Duke criteria for the diagnosis of IE. The case report forms from 61 centers in 28 countries included 275 variables, including indications for surgery. However, information on vegetation size and mobility was not collected. Most of the patients were male (67%), elderly (mean age 62), and had native valve IE (74%). The numbers with IV drug use or AIDS were small (6 and 2%). In this cohort, 219 (15%) had a stroke, but incomplete data about the stroke reduced the analyzed population to 185 stroke patients. One half had a stroke prior to antibiotic administration. The daily rate of stroke fell dramatically the second day of antimicrobial therapy. This observation is influenced by the fact that stroke was often the reason for seeking medical attention. If day one is eliminated, the rate of stroke still fell 65% in the second week of therapy (4.82/1000 patient days to 1.7, P < .001). Correction for patients going to surgery did not change the results significantly. After one week of therapy, only 3% of the entire cohort (44/1437) experienced a stroke. Multivariate analysis showed mitral vegetation (P < .0001), S. aureus (P = .01), and intracardiac abscess (P = .02) were significantly associated with stroke. Viridans strep was associated with a lower risk of stroke (P = .04). Overall, 40% of the patients had valvular surgery on the index admission, but only 3.5% had the indication of large mobile vegetations alone. All the rest met standard criteria for surgery. Patients who had surgery had a lower incidence of stroke. There was no subgroup in which antibiotic therapy did not reduce the risk of stroke. Dickerman et al concluded that the risk of stroke falls dramatically after initiation of effective antibiotic therapy and precludes stroke prevention as a sole indicator for valve surgery after one week of therapy. [ABSTRACT FROM AUTHOR]

The article reports on the results of a study comparing the combination of the direct renin inhibitor aliskiren and angiotensin receptor-blocker valsartan with either agent alone in patients with hypertension. It found that treatment with valsartan and aliskiren monotherapy augmented by combination therapy resulted into a significant decrease in blood pressure. The study concluded that aliskiren is effective as monotherapy.

THE ROLE OF STATINS IN HEART FAILURE PATIENTS IS poorly studied and controversial. Thus, Khush and colleagues analyzed the secondary endpoint in the Treating to New Targets (TNT) study of hospitalization for heart failure. TNT was a study of over 10,000 patients with stable coronary heart disease (CHD) treated with either 10 or 80 mg/day of atorvastatin and followed for about 5 years. The primary endpoint of cardiac death, myocardial infarction (MI) and stroke was reduced 22% by high-dose atorvastatin. A history of heart failure was obtained in 8% of the patients, however, advanced heart failure or an ejection fraction (EF) of < 30% were exclusion criteria. Patients with heart failure had more hypertension, diabetes, peripheral arterial disease, prior MI and stroke, and were on higher doses of renin-angiotensin-blocking drugs and diuretics. Baseline lipid panels were similar between those with and without a history of heart failure. Lipid/lipoprotein levels were lower in the atorvastatin 80-mg group except for high-density lipoprotein cholesterol which was not. Hospitalization for heart failure occurred in about 3% of the study population; 14% of those with a history of heart failure and 2% of those without. Heart failure portended a poor prognosis. In the atorvastatin 80-mg group, 2.4% were hospitalized for heart failure vs 3.3% in the atorvastatin 10-mg group (P < 0.02). This protective effect was strongest in those with a history of heart failure, but was not different in a variety of other subgroups. One-third of the patients who developed heart failure had angina or MI prior to the event as compared to 15% overall of patients who did not have heart failure. Hospitalization for heart failure decreased as low-density cholesterol decreased. There was no relation between heart failure and blood pressure. The authors concluded that intensive treatment with atorvastatin in stable CHD patients reduces the incidence of heart failure hospitalization as compared to less intensive treatment, but only in those with a history of heart failure. A reduction in coronary events did not seem to explain the results. [ABSTRACT FROM AUTHOR]

The article presents an abstract of the article "Spironolactone for Heart Failure" by Michael H. Crawford and a comment about the article. The study is deemed as part of observational literature on the lack of effectiveness of spironolactone for such disease in real world. The study's strengths are mentioned, including the inclusion of patients with new heart failure diagnosis, elimination of those with prior spironolactone use, and the researchers' knowledge on the drugs used by the patients.

The article discusses two research on natriuretic peptide levels (BNP, NT-proBNP), published in the 2010 issue of the "Journal of the American College of Cardiology." The first study concluded that NT-proBNP levels independently predict new-onset heart failure and cardiovascular (CV) death. The other study noted that heart-failure management, using NT-proBNP levels to guide therapy, is superior to multi-disciplinary care and standard management in terms of reducing heart-failure recurrence and death.

The article presents a study about the effect of n-3 polyunsaturated fatty acids (PUFA) in patient with heart failure. It notes that a lower mortality rate in post myocardial infarction patients who were treated with n-3 PUFA is demonstrated in this study. It states that in this study, the beneficial effects of PUFA were modest as these effects only emerge after two years. It also notes that PUFA is one of the most practiced medical therapy for heart failure.

The article presents a study about bridging therapy for patients with mechanical heart valves. It states that the standard bridging therapy for mechanical valve patient who are required to stop oral anticoagulants for a while is unfractionated heparin (UFH). It notes that for the reason that valve thrombosis may occur after 48 hours of subtherapeutic international normalized ration (INR) values, patients with mechanical prosthetic valves are high-risk for anticoagulation cessation.

Background: An abnormality in long chain-polyunsaturated fatty acid (LC-PUFA) levels has been implicated in attention-deficit/hyperactivity disorder (ADHD). Studies evaluating LC-PUFA supplementation for therapeutic efficacy in ADHD have shown mixed and, therefore, inconclusive results.Methods: Seventy-six male adolescents (age 12-16 years, mean = 13.7) with ADHD were assessed for the effects of 12 weeks omega-3 and omega-6 supplements on biochemical and psychological outcomes in a randomized, placebo-controlled, clinical trial. The primary outcome measure was change in the Conners' Teacher Rating Scales (CTRS) following 12 weeks of supplementation of LC-PUFA or placebo. At baseline, the placebo and treatment groups had comparable levels of LC-PUFA as measured by red blood cell phosphatidylcholine. In the treatment group, supplementation enhanced eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and total omega-3 fatty acid levels.Results: No superiority of LC-PUFAs to placebo was observed on the primary outcome. Further, there were no reliable treatment effects on aggression, impulsivity, depression, and anxiety.Conclusions: Future studies should use larger sample sizes and longer supplementation period to detect small-modest effects for clinical recommendations in ADHD. [ABSTRACT FROM AUTHOR]

Background: Health anxiety is common in medical settings and can be treated successfully by cognitive behaviour therapy. However it is not clear who might be best placed to deliver this therapy. Objectives: In a planned secondary analysis of data from a randomised trial of adapted cognitive behaviour therapy for health anxiety we compared outcomes of therapy delivered by nurses and other professional groups. Design: A randomised controlled trial with two treatment arms, 5–10 sessions of cognitive behaviour therapy adapted health anxiety or standard care. Setting: Cardiology, endocrine, gastroenterology, neurological and respiratory clinics in six general hospitals in the UK covering urban, suburban and rural areas. Participants: Medical patients attending the clinics who had pathological health anxiety and also scored for a diagnosis of hypochondriasis. Methods: Patients were randomised to one of two treatment arms, 5–10 sessions of cognitive behaviour therapy adapted health anxiety or standard care delivered by naive therapists (not randomised) who were trained in advance before delivering the treatment. Independent assessment of outcomes by researchers masked to allocation status at 3 m, 6 m, 12 m and 24 m. Results: 444 patients were randomised in the trial, 219 to cognitive behaviour therapy adapted health anxiety and 225 to standard care. 373 (84%) completed assessments after two years. Those treated by nurses (n = 66) had improvement in health anxiety, generalised anxiety and depression outcomes that were significantly better and twice as great as those of the professional groups of assistant psychologists (n = 87) and graduate workers (n = 66) (P < 0.01 over all time points). The number needed to treat to show superiority of nurse-delivered treatment over other treatment delivery was 4 at 6 months and 6 at one year. Conclusion: General nurses, after suitable training, are very effective therapists for patients with health anxiety in medical clinics and should be the therapists of choice for patients in these settings. [ABSTRACT FROM AUTHOR]