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This study sought to identify pharmacy services offered to patients with diabetes and demonstrate patients receiving pharmaceutical care services had better glucose control as measured by laboratory values and medication compliance. Two hundred randomly selected patients with diabetes were identified from a pharmacy benefits manager's database. Their pharmacists were mailed a survey requesting information concerning morbidity risk factors, concomitant disease states, concomitant medications, diabetes pharmacotherapy, blood glucose concentrations, and percent hemoglobin A1c values. Information concerning diabetes cognitive services offered was also requested. A statistically significant correlation between diabetes cognitive services and improved disease control was not demonstrated secondarily to the small number of responses returned with glucose control information. Our results indicate pharmacists must improve documentation of their services and the impact these interventions have on disease control in order to prepare for reimbursement for cognitive services.

Transesophageal echocardiography is the method of choice for investigating suspected intracardiac masses. It also plays a valuable role in the detection of central pulmonary artery embolism. We present a case that highlights the use of transesophageal echocardiography for imaging of a mass in the right atrium and the right pulmonary artery.

Background: Although only 7-8% of US healthcare expenditures are spent on prescription drug products, the pharmaceutical industry's profitability and high cost of prescriptions to consumers make prescription drugs a visible target for reform. When compared with other products, it appears as if unfair pricing tactics are used. The pharmaceutical industry cites costs of research and development and a short patent life as justifiable grounds for high prices, but the reason why US drug prices appear to be so high has yet to be answered., Objective: To examine identified components of the pharmaceutical industry that allow US prescription drugs to appear to be highly priced and to review the apparent factors that affect pricing policies for pharmaceuticals., Data Sources: The literature was reviewed to identify current research regarding the pharmaceutical market. Sources included MEDLINE, Econolit, Business Periodical Index, International Pharmaceutical Abstracts, the Wall Street Journal, New York Times, and the F-D-C Pink Sheet., Summary: Key factors account for the fact that US prescription drug prices are higher and that price discrimination occurs in the pharmaceutical industry within the US and among other countries. These factors include the unique market structure of the pharmaceutical industry, asymmetry of information, research and development costs, numerous channels of distribution and the differences among them, and government laws and regulations of prescription drugs. Pricing policies of pharmaceutical companies are based on manufacturing, promotion, and distribution costs; drug characteristics; and economic goals of the parent company.

Systolic and diastolic left ventricular function was assessed using an echocardiographic automatic boundary detection system (ABD) in 50 unselected patients undergoing left cardiac catheterisation. Automatic boundary detection system derived parameters (fractional area change [FAC], peak positive rate of area change [+dA/dt] and peak negative rate of area change [-dA/dt]) were compared with invasively (left ventricular angiography and pressures) and non invasively (Doppler mitral filling velocities and isovolumic relaxation time) acquired conventional indices of ventricular function. Adequate detection of endocardial boundaries and subsequent measurements using the ABD system were achieved in 40/50 (80%) patients in the short axis parasternal view, in 41/50 (82%) in the apical four chamber view and in 34/50 (68%) in both views. For the whole group of patients the FAC (maximal left ventricular diastolic area--minimal left ventricular systolic area/maximal left ventricular diastolic area) estimated in the short axis view correlated with the angiographic ejection fraction (EF) measured in the right oblique projection (r = 0.51, p < 0.001). There was only a weak correlation of the FAC estimated in the apical four chamber view with the EF (r = 0.36, p < 0.01). The mean FAC (mean value of the FAC in the short axis and apical four chamber views) correlated reasonably with the EF (r = 0.62, p < 0.0001). There was no correlation between ABD derived parameters and left ventricular end diastolic pressure (LVEDP) in these patients. In a subgroup of patients with normal coronary arteries and left ventricular function (n = 17), although there was no correlation between EF and FAC, there was a strong positive correlation between FAC (apical four chamber and mean) and LVEDP (r = 0.77, p < 0.01 and r = 0.87, p < 0.01 respectively). No correlation was found in these patients between EF and LVEDP. In a further subgroup of patients with angiographically abnormal left ventricular function (EF < 45%), there was a positive correlation between FAC (short axis, apical four chamber and mean) and EF (r = 0.52, p < 0.05, r = 0.83, p < 0.0001 and r = 0.80, p < 0.001 respectively) and a negative correlation between FAC (short axis and mean) and LVEDP (r = -0.52, p < 0.05 and r = -0.60, p < 0.01 respectively). There was also a negative correlation between LVEDP and EF in the same subgroup of patients (r = -0.65, p < 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Percutaneous balloon mitral valvuloplasty is a standard alternative to surgery in a selected group of patients with symptomatic dominant rheumatic mitral stenosis. With careful transthoracic and transesophageal echocardiographic selection of patients, there is a low complication and high success rate. Echocardiography has also been established as extremely useful in the long-term follow-up of patients. We present four cases that highlight our view that transthoracic echocardiography should be performed during the procedure, after each balloon inflation, and before and after the intervention. In our experience transthoracic echocardiography during balloon mitral valvuloplasty is invaluable in assessing commissural separation, increasing mitral valve area, new mitral regurgitation, and occasional unexpected anatomic sequelae of balloon inflation.

Conventional contrast echo techniques have proved inadequate for the detection of myocardial perfusion using intravenously injected echo contrast agents because of the limitations and relative insensitivity of standard echocardiographic equipment. In order to avoid these problems, we have obtained pure digital radiofrequency ultrasound data from the left ventricle and myocardium during i.v. contrast myocardial perfusion echo studies. In 30 patients, following coronary arteriography, i.v. injections of the echo contrast agent Albunex (sonicated human serum albumin) in two doses of 0.08 and 0.22 ml.kg-1 were administered during digital radiofrequency echocardiography sampling of data from the myocardium and left ventricular cavity. Analysis of mean integrated backscatter (MIB, a measure of the total ultrasound energy) was performed before, during and after Albunex injection. The data were also analysed for a shift in frequency spectrum which could be caused by resonance of the Albunex contrast microspheres in the heart, a phenomenon which has been previously demonstrated in vitro. Digital radiofrequency ultrasound data were successfully obtained and analysed in 23 patients. In 31 segments where reasonable resting perfusion was expected, there was a significant increase in MIB from 0.644 to 1.245, P < 0.001 and time intensity curves could be constructed showing wash-in and wash-out of contrast from the myocardium. In 10 segments supplied by significantly diseased vessels, MIB intensity increased from 1.044 to 1.874, P = 0.054. In myocardial segments supplied by non-diseased vessels, microsphere resonance also caused a drop in mean frequency of 140 KHz, P < 0.001, and permitted similar temporal analysis of myocardial perfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives: (a) To assess the echocardiographic incidence of restenosis after successful balloon dilatation of the mitral valve at a mid-term follow up of one year among a population of predominantly United Kingdom patients. (b) To identify any factors, assessed before or during dilatation, which may predict the development of restenosis., Design: Successful dilatation of the mitral valve was defined as an increase in mitral valve area of > 25% and a final valve area of at least 1.5 cm2. Echocardiographic restenosis was defined at follow up as a loss of 50% of initial gain and a valve area of less than 1.5 cm2. Mitral valve area was assessed by transthoracic echocardiography before, during, 48 hours after, and one year after successful balloon dilatation of the mitral valve. Echo score before dilatation (an assessment of valvar and subvalvar calcification, thickening, and mobility), age, rhythm, echocardiographic mitral valve area before and after dilatation, left atrial pressure before and after dilatation, and end diastolic mitral valve gradient before and after dilatation were compared in those patients with and without echocardiographic restenosis at one year., Setting: A regional cardiothoracic centre in the United Kingdom that performs 20-30 balloon dilatations of mitral valves each year., Patients: 39 patients, with symptomatic dominant mitral stenosis, who had undergone successful balloon dilatation of the mitral valve, and in whom echocardiographic assessment of mitral valve area was available at one year. 92% of patients were citizens of the United Kingdom., Interventions: Balloon dilatation of the mitral valve by the Inoue technique., Main Outcome Measures: Mitral valve area and patient symptom class (New York Heart Association) one year after successful dilatation of the mitral valve., Results: The incidence of echocardiographic restenosis was eight of 39 patients (21%). Of the eight patients with restenosis four underwent mitral valve replacement, two had repeat dilatation of the mitral valve, and two remained on medical treatment. With univariant analysis, factors associated with restenosis were increased age, higher echo score before dilatation, and a lower mitral valve area immediately after the operation. The only independent risk factor for restenosis, shown by multivariant analysis, was a high echo score before dilatation. There was no significant fall in mitral valve area at one year in those patients without restenosis. Most (28/31) of these patients had echocardiographic evidence of splitting of at least one commissure after dilatation compared with only two of eight patients who developed restenosis. Of 10 patients with an echo score before dilatation > or = 10 only two had an initially successful operation and no restenosis at one year., Conclusions: The echocardiographic incidence of restenosis after dilatation of the mitral valve by the Inoue technique in patients of the United Kingdom is 21%. The principal factor associated with restenosis is a high echo score before dilatation. Increases in mitral valve area are maintained in those patients without restenosis and it is likely that the mechanism of initial increase in valve area is different in the two groups, being commissural splitting in those patients who do not get restenosis and valve stretching in those that do. In patients with an echo score > or = 10 dilatation of the mitral valve should be considered only as a palliative procedure.

The incidence of spontaneous echo contrast in the left atrium, the factors with which it is associated, and its clinical significance were studied in 128 patients with native mitral valve disease or mitral valve replacement. All patients underwent both transesophageal and transthoracic echocardiography. Spontaneous echo contrast was visualized in 42 patients (33%) during transesophageal and in none during transthoracic echocardiography. Patients with spontaneous echo contrast had a significantly larger left atrial diameter (6.1 [1.1] cm vs 4.9 [0.9] cm, p < 0.001) and a greater incidence of both atrial fibrillation (54% vs 4%, p < 0.001) and left atrial thrombi (60% vs 28%, p < 0.01) compared with patients without spontaneous echo contrast. Multivariant analysis confirmed that these factors were independently associated with spontaneous echo contrast (left atrial size, p < 0.001; atrial fibrillation, p < 0.001; left atrial thrombus, p < 0.01). Patients with pure mitral regurgitation did not have any spontaneous echo contrast and anticoagulation did not influence its incidence. Spontaneous echo contrast was the only factor that was associated with a previous history of systemic embolization (history of systemic emboli in 28.6% of patients with spontaneous echo contrast vs 13.9% without spontaneous echo contrast, p < 0.05). In conclusion, spontaneous echo contrast is a common finding in the left atrium of patients with mitral valve disease or mitral valve replacement and represents a marker of increased thromboembolic risk in these patients.

Primary mitral valve tumors are rare. We describe the transesophageal appearances of a papillary fibroelastoma (Lambl's giant excrescence) of the anterior mitral valve leaflet causing partial mitral valve obstruction. Transesophageal echocardiography proved particularly useful in identifying the limited attachment of the tumor to the anterior mitral valve leaflet and excluding its attachment to the interatrial septum. These features helped to exclude the possibility of the tumor being a left atrial myxoma, the primary differential diagnosis of the lesion. Transesophageal echocardiography enabled the planned surgical option to be mitral valve repair and also allowed intraoperative monitoring to assess the results of the surgical repair.

Aortoatrial fistulae are uncommon, providing a difficult diagnostic challenge both in the clinical diagnosis and in the choice of an imaging modality that fully delineates the abnormal anatomy and flow patterns. This report describes four cases of aortoatrial fistula resulting from three different underlying causes. The fistula communicated with the right atrium in three cases and the left atrium in one. We also describe the diagnostic information obtained during both transthoracic and transesophageal echocardiography and stress that full detail of the abnormal anatomy and shunting could be obtained only with the transesophageal approach, with its improved image quality of the aortic root. No extra information, other than the coronary anatomy, was obtained during aortography in the two patients who underwent cardiac catheterization. Transesophageal echocardiography should, therefore, be the investigation of choice in patients in whom there is a suspicion of aortoatrial shunting after clinical examination and routine transthoracic studies, and it may avoid the need for invasive investigation in these potentially hemodynamically unstable patients.

Objective: To assess the relative merits of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve., Design: Transthoracic and transoesophageal echocardiograms were prospectively performed in 35 patients being considered for balloon dilatation of the mitral valve. Echocardiograms were analysed for image quality, the assessment of valve morphology, the detection of left atrial thrombus, and the assessment of mitral regurgitation and other valvar pathology., Patients: 35 consecutive patients with symptomatic dominant mitral stenosis., Interventions: 30 eventually underwent balloon dilatation of the mitral valve by the Inoue technique. Five patients had mitral valve replacement., Main Outcome Measures: Echocardiographic and surgical detection of left atrial thrombus and successful, uncomplicated balloon dilatation of the mitral valve., Results: Left atrial thrombus was detected in 1/35 patients by transthoracic studies compared with 6/35 from transoesophageal studies. Otherwise both techniques gave comparable results. Thrombus was confirmed at mitral valve replacement in five patients. Successful dilatation of the mitral valve was performed in 30 patients., Conclusions: Transthoracic echocardiography is a useful screening procedure but transoesophageal echocardiography is mandatory before balloon dilatation of the mitral valve for the detection of left atrial thrombus.

The incidence and severity of atrial septal defects following balloon mitral valvuloplasty have been assessed using transthoracic and transoesophageal echocardiography in 20 patients 3-36 months following the procedure. In eight patients (group A) the atrial septum was dilated with an 8 mm Olbert balloon and either a double or bifoil balloon used to dilate the mitral valve. In 12 patients (group B) the Inoue balloon, with a slimmer deflated profile, was used following dilatation of the interatrial septum with a 14 French vessel dilator. In group A, using transthoracic echocardiography, one atrial septal defect was imaged and transatrial flow detected by colour flow Doppler in five patients. In seven of the eight patients transoesophageal echocardiography clearly imaged an atrial septal defect and left-to-right shunting was demonstrated by colour flow Doppler. Valsalva contrast studies revealed residual transatrial flow in all eight patients. The mean width of the colour flow jet was 5.8 mm. In group B patients, using transthoracic echocardiography, only one patient had evidence of residual transatrial flow (demonstrated by Valsalva contrast). Using transoesophageal echocardiography Valsalva contrast studies, transatrial flow was seen in 11 of the 12 patients. However, no defects were imaged and colour flow Doppler indicated left-to-right shunting in only two patients. The mean width of the colour flow jet was 1.5 mm. Transoesophageal echocardiography with colour flow Doppler and Valsalva contrast studies therefore provides a sensitive method for the detection of residual atrial septal defects following balloon mitral valvuloplasty. Transatrial flow persists in the majority of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Colour flow Doppler mapping can show abnormalities of flow even when the echocardiographic image is equivocal. Routine echocardiography in two patients who were thought to have pulmonary valve stenosis and a ventricular septal defect initially appeared to be normal. Colour flow Doppler mapping, however, showed multiple flow aliasing within the pulmonary artery, approximately 1.5 cm downstream from the pulmonary valve. More detailed examination by cross sectional echocardiography showed a membrane at this level in both patients. It is possible that more cases of this uncommon anomaly will come to light with increasing use of Doppler techniques.

Characteristic Doppler echocardiographic abnormalities were noted in five patients with a failing tissue prosthesis shown to have severe regurgitation and no evidence of obstruction. The audio signal was musical in quality and the regurgitant flow pattern was bidirectional and striated. There were 4 to 6 striations in the mitral and 18 in the aortic regurgitant jets per 100 cm/s length of signal. Pulsed Doppler ultrasound localized the jet to the valve in all cases although angiography failed to localize it in one of four cases. At surgery each valve had a tear in or partial disintegration of one cusp whereas the other two cusps were intact, mobile and of normal thickness. The Doppler appearance is thought to be caused by fluttering of the disrupted cusp leading to the shedding of families of vortices in both a retrograde and an orthograde direction. It is suggested that this is likely to be a useful sign for the diagnosis of cusp tears.

Although Doppler colour flow mapping may considerably reduce the need for conventional pulsed Doppler examination, quantitative flow measurements (particularly by continuous wave Doppler) are still essential in the evaluation of many conditions such as aortic stenosis. Doppler colour flow mapping is an important addition to the accurate non-invasive evaluation of several haemodynamic disorders of the heart and, as the technology improves, the range of applications will undoubtedly increase. Any technique that provides additional diagnostic information, makes an examination easier and quicker to perform, and at the same time provides data in a more comprehensible format has surely found a niche.

During a five-year period, 26 cases of acute thoracic aortic dissection were studied by M-mode and cross-sectional echocardiography prior to cardiac catheterization and aortography. The diagnosis could be made non-invasively in 20 patients. Important information concerning the extent of the dissection, and the presence or absence of aortic regurgitation or a pericardial effusion could be obtained. Negative examinations were largely confined to cases where the distal thoracic aorta alone was involved. In a further 30 cases admitted to the coronary care unit during this period in which echocardiography was performed to rule out aortic dissection, two false-positive examinations led to aortography which demonstrated aortic dilatation and aortic regurgitation only. In the remaining 28 cases, echocardiographic examination was negative and none of these patients subsequently evidenced aortic dissection. Echocardiography using both M-mode and cross-sectional techniques is a rapid and highly effective method of making an early diagnosis of thoracic aortic dissection. Cross-sectional echocardiography is complementary to the M-mode technique, enhancing diagnostic accuracy by improving structural recognition in a condition where the normal anatomy is often severely distorted.

Imaging echocardiography is an important extension of the clinical examination and will answer most questions in an emergency-for example, whether an enlarged cardiac shadow on the chest radiograph represents ventricular dilatation or an effusion. Doppler ultrasonography is essential for hospitals with an interest in cardiology because it provides direct haemodynamic data that are complementary to imaging. It requires more skill than imaging and may also be time consuming. Colour flow Doppler mapping is speedy and simple to use and aids the interpretation of continuous wave Doppler. It is therefore a natural companion to conventional Doppler, but there would have to be a high clinical load to justify its purchase.

The potential of contrast enhanced digital subtraction echocardiography to demonstrate and quantitate myocardial perfusion was evaluated in 36 patients undergoing routine coronary arteriography or angioplasty. In 24 technically successful studies, multiple cross sectional echocardiographic images, obtained before and after intracoronary (sonicated contrast) injection, were stored by high speed, real time data transfer to an on line minicomputer. Subsequent digital subtraction processing of the stored image data provided composite images in which the distribution of myocardial perfusion was easily seen. Quantitative analysis of peak enhanced myocardial grey level and washout half time successfully differentiated between myocardial segments in which angiography had suggested normal, reduced, and grossly impaired or absent perfusion. The results suggest that this new method of digital image capture and quantitative processing has substantial advantages over previous off line qualitative techniques. It is likely to be of considerable value for routine coronary arteriography, angioplasty, and coronary thrombolysis.

The place of balloon dilatation of the aortic valve in the treatment of calcific aortic stenosis is controversial. Thirty two patients (mean age 76) in whom valve replacement was contraindicated were followed up for three to 24 months (mean 8); 25 were in functional class III or IV according to the New York Heart Association's classification. Major complications of the procedure occurred in four patients. Echocardiography and Doppler studies were performed before operation and before discharge in 28 patients, and the area of the valve was measured again six to 50 (mean 23) weeks after operation in 11 patients. The peak to peak aortic pressure gradient fell from a mean of 65 (SD 24) to 46 (20) mm Hg, but the area of the aortic valve, measured by Doppler echocardiography, in 18 patients showed a modest but significant increase, from 0.61 (0.16) to 0.74 (0.23) cm2. One month after dilatation, 29 patients were alive, of whom 17 had improved symptoms. Only two had lasting clinical benefit. Sixteen patients died, 12 of a cardiac cause. The estimated one year survival rate was 49%. Six patients underwent or required valve replacement because of persisting symptoms. In view of its limited long term efficacy balloon dilatation of the aortic valve should be used only for patients with severe symptoms whose life expectancy is limited by other disease or who are considered to be unsuitable for valve replacement. It may have a role in improving the condition of patients who present with cardiogenic shock or pulmonary oedema before valve replacement is undertaken.

Felodipine is a new calcium antagonist with a high degree of vascular selectivity. To examine its potential value as an afterload reducing agent in congestive heart failure 11 patients were studied. Substantial increments in cardiac index were associated with a fall in systemic vascular resistance. Left ventricular end diastolic pressure was also significantly reduced. Although left ventricular maximum dP/dt remained unchanged, maximum dP/dt/P increased. Left ventricular unloading was reflected by a reduction in cavity dimensions and a shift in the relation between end systolic pressure and dimension downwards and to the left. The myocardial oxygen supply to demand ratio was also improved: coronary sinus flow increased significantly despite a decline in myocardial oxygen consumption. These beneficial haemodynamic and metabolic effects suggest that felodipine may extend the clinical application of calcium antagonists to include the treatment of congestive heart failure.

This study was designed to investigate and compare the haemodynamic and metabolic responses to pirbuterol and salbutamol in patients with congestive heart failure and coronary artery disease. Attention was directed towards the effects these beta 2-adrenoceptor agonists have on left ventricular systolic function, systemic and coronary haemodynamics and myocardial substrate metabolism. Sixteen patients were randomly allocated to treatment with either pirbuterol 20 mg or salbutamol 6 mg. Since no statistically significant differences between the responses to these drugs were observed, combined data for both agents are presented. Ninety minutes after the drug intervention cardiac index increased from 2.2 +/- 0.1 to 2.9 +/- 0.2 1/min per m2 (P less than 0.001) in association with marked reductions in systemic vascular resistance (from 22 +/- 1 to 15 +/- 1 units, P less than 0.001) and increments in left ventricular dp/dtmax (from 1074 +/- 85 to 1422 +/- 133 mm Hg/sec, P less than 0.05). Modest reductions in left ventricular end-diastolic pressure (from 21 +/- 1 to 15 +/- 1 mm Hg, P less than 0.01) were observed. Heart rate increased from 82 +/- 5 to 91 +/- 4 beats/min (P less than 0.01) but the small fall in mean arterial pressure (from 86 +/- 3 to 78 +/- 3 mm Hg) was not significant. Drug-induced coronary vasodilatation reduced coronary coronary vascular resistance from 0.65 +/- 0.06 to 0.47 +/- 0.04 units (P less than 0.01) and led to a marked increase in coronary sinus blood flow (from 124 +/- 9 to 155 +/- 9 ml/min, P less than 0.05). Arterial levels of free fatty acids increased from 0.78 +/- 0.13 to 1.05 +/- 0.18 mmol/l (P less than 0.05) resulting in the preferential utilization of this substrate as a myocardial energy source. Despite the substantial haemodynamic improvement, however, no significant increase in myocardial oxygen uptake or lactate production was observed. Thus, in patients with coronary artery disease and congestive heart failure pirbuterol and salbutamol improve left ventricular function by a combination of afterload reduction and positive inotropism such that no appreciable deterioration in myocardial energetics occurs.

Two patients showed evidence of chronic cardiac toxicity after repeated exposure to 1,1,1-trichloroethane. In both cases there was circumstantial evidence of a deterioration after routine anaesthetic use of the related compound halothane. An adolescent boy who sniffed trichloroethane presented with multiple ventricular arrhythmias during tonsillectomy. Follow up showed mild chronic left ventricular impairment. A 54 year old man had repeated industrial exposure to trichloroethane and deteriorated from mild stable cardiac failure to end stage cardiac failure after halothane anaesthesia for herniorrhaphy. Chronic cardiac toxicity is a previously unreported feature of this type of solvent exposure. Related compounds such as halothane may have a toxic interaction after exposure to trichloroethane.