ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.366692000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

High‐technology medicine, which is often expensive, and most often very useful for old people, whose numbers are rapidly increasing, is presenting huge moral problems for physicians. There are now pressures to make physicians salaried employees rather than professionals, and this will decrease or obliterate their efficiency as advocates for patients. Advocacy is a previously non‐described duty, which is an important ethical principle for physicians, in addition to the four universally recognized principles: beneficence, non‐maleficence, respect for autonomy, and justice.Not‐so‐subtle economic pressure by managed care, government, administrators, and politicians, is already in force. If physicians, by advocating expensive treatment for many, irritate those with economic power, they may violently retaliate.Chronic dialysis illustrates well the dilemma of high‐technology medicine because acceptance numbers are accurate and widely known, most patients are old, the treatment is rationed everywhere by age, and, as patients die if excluded, it can be used to analyse reactions to an ongoing age rationing.Post‐modern bioethics and moral philosophy appears helpless and, in some regards, irrelevant in elucidating and solving the concrete moral conflict posed by high‐technology medicine and the old. Administrators and politicians wish physicians to be society's economic gatekeepers; however, this is incompatible with classical ethical concepts of the profession of physicians. Physicians and their professional organizations had better realize this in order to map out defensive strategies so that physicians, as a profession, d

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.452799000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

The factors that normally regulate the proliferation of the insulin‐producing pancreatic β‐cell largely remain elusive although several factors have been identified that influence β‐cell growthin vitro.The adult β‐cell is normally virtually quiescent, but its replicatory activity can be enhancedin vitroby certain nutrients and growth factors, and long‐term alterations in β‐cell mass constitute an important means to accommodate an increased demand for insulin. Likewise, expansion of the β‐cell mass by recruitment of β‐cells to proliferate may constitute a means by which the organism can compensate for the loss or dysfunction of β‐cells occurring in diabetes. However, neither in human or animal models for type‐1 diabetes, nor in type‐2 diabetes, is β‐cell regeneration a noteworthy feature. Thus, if β‐cells could be induced to replicate at a higher rate, this may prove beneficial in maintaining normoglycaemia, since the β‐cell mass is a major determinant of the total amount of insulin that can be secreted by the pancreas. The present review will focus on the normal regulation of β‐cell mitogenesis and hormones productionin vitroandin vivo,and furthermore, will present evidence for an insufficient extent of β‐cell regeneration in different forms of diabetes mellitus. Additionally, the possibility of manipulating β‐cell proliferation by peptides and genetic engineering, and the significance of β‐cell mitogenesis in islet transplantation will be discuss

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.377740000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objective.Haemostatic imbalance may be an aetiological factor in the development of acute coronary syndromes. Inherited resistance to activated protein C (APC) is a common disorder associated with hypercoagulability and lifelong risk of venous thrombosis. APC resistance is due to a single mutation in the gene coding for coagulation factor V (FV:Q506). To test the importance of the FV:Q506mutation in premature myocardial infarction (MI), its prevalence was investigated in Swedish patients with MI before the age of 50 years.Design, setting and subjects.In a retrospective case‐control study, the FV:Q506mutation was investigated in 101 survivors of MI (79 men, 22 women) and in 101 healthy sex‐ and age‐matched controls.Main outcome measure.The prevalence of FV:Q506mutation.Results.The FV:Q506mutation was found in 18% of patients versus 11% of controls (P=0.16). The mutation was significantly more frequent amongst male patients than amongst controls (23 vs. 10%;P=0.03), the calculated odds ratio being 2.6 (95% CI, 1.1–6.4).Conclusion.The high prevalence of the FV:Q506mutation found amongst Swedish MI patients, especially amongst men, is noteworthy, and calls for further studies on the outcome of MI in APC‐resistant patients. The prevalence of the FV:Q506mutation in controls is higher than figures reported from other countries, suggesting that at least 10% of the Swedish population are carriers of a congenital prothrombotic

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.470808000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objectives.To study whether the addition of metformin further improves the blood lipid pattern in non‐diabetic patients with coronary heart disease already treated with lovastatin, diet and lifestyle advice.Design.An open, prospective, randomized study in a university hospital setting.Subjects.Sixty non‐diabetic male patients previously treated with coronary artery bypass surgery or angioplasty and with serum cholesterol6.0  mmol L‐1and/or HDL‐cholesterol1.2 mmol L‐1.Interventions.After a 4‐week run‐in period with lovastatin (40 mg day‐1), and diet and lifestyle advice, patients were randomized into two groups, both continuing the run in treatment. One group received metformin up to 2000 mg day‐1; the control group got no additional treatment.Main outcome measures.Fasting serum lipids, glucose and weight were registered at entrance (=week‐4), and at weeks 0, 4 and 12. Changes from week 0 to week 4 and from week 0 to week 12 were compared. Side‐effects of the treatment were also registered.Results.Metformin lowered the LDL/HDL‐cholesterol ratio by 12 and 6% at weeks 4 and 12, respectively, and reduced body weight by 1.8 kg at week 12. There was also a transient lowering effect on LDL‐cholesterol and apolipoprotein B. In the normal weight subgroup of patients (body mass index27 kg m‐2), metformin had no significant effects on blood lipids, but induced a weight loss of ‐3.0 kg and a transient reduction of fasting glucose. No side‐effects were registered apart from those expected from each individual drug.Conclusions.Metformin given for 12 weeks as a supplement to lovastatin, diet and lifestyle advice to non‐diabetic male patients with coronary heart disease further improves the lipid pattern in normal weight patients, and reduces weight in the overweight patients. Because metformin is cheap and other lipid lowering drugs are expensive, the potential of metformin as a lip

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.444790000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objectives.To study the relationship between insulin sensitivity and sodium‐lithium countertransport (Na+‐Li+CT) in mild, essential hypertension, and to investigate the effect of metformin and metoprolol, respectively.Design.A double‐blind, triple cross‐over, placebo‐controlled study over a total period of 18 weeks.Setting.A hypertension out‐patient clinic and research laboratory at Sahlgrenska University Hospital.Subjects.Seventeen non‐obese men with mild essential hypertension and 17 weight‐matched, healthy controls.Interventions.Metformin 850 mg b.i.d., metoprolol CR 100 mg once daily and placebo were given during 18 weeks. Each treatment period was 6 weeks. A euglycaemic clamp was performed and erythrocyte Na+‐Li+CT measured after each 6‐week treatment period.Main outcome measures.Insulin sensitivity, erythrocyte Na+‐Li+CT, their interrelation, and the effect of metformin and metoprolol CR on both variables, respectively.Results.The hypertensive men tended to have an elevated Na+‐Li+CT compared with the control subjects (0.34±0.03 versus 0.26±0.02 mmol L‐1  h‐1,P<0.1). Glucose disposal rate was similar, but plasma insulin levels higher (P<0.05) among the hypertensives than the controls. Na+‐Li+CT exhibited a positive relationship to BMI (r=0.53,P=0.03) and a negative correlation to glucose disposal rate (r=‐0.66,P=0.008) in the hypertensive subjects. In multiple regression analysis, Na+‐Li+CT showed a significant correlation to glucose disposal rate only. In the control subjects, there was no relation between glucose metabolism and Na+‐Li+CT. Neither metformin nor metoprolol influenced Na+‐Li+CT, glucose disposal rate or plasma insulin.Conclusion.Erythrocyte Na+‐Li+CT seemed to be closely related to insulin‐glucose metabolism in mild hypertension, but w

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.445791000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objectives.To test whether cardiological syndrome X is an insulin‐resistant state.Setting, design and subjects.The coronary care unit of a referral centre for angina pectoris in Pisa, Italy. A case‐control study, involving 10 patients with unequivocal (angiographycally proven) cardiological syndrome X, but normal glucose tolerance, blood pressure and lipid levels, and 13 matched healthy subjects.Main outcome measures.Insulin sensitivity and pattern of substrate oxidation (assessed by the euglycaemic insulin clamp technique in combination with indirect calorimetry).Results.Fasting plasma glucose and insulin levels were 5.05±0.11 versus 4.88±0.11 mmol l‐1and 68±10 versus 56±6 pmol l‐1, respectively (controls versus patients, ns). During the insulin clamp, glucose disposal rate was nearly identical in patients and controls (25.9±1.8 and 27.2±1.8 μmol kg‐1min‐1, respectively,P=0.88). Non‐oxidative glucose disposal accounted for similar proportions of total glucose uptake (59 versus 53%, patients versus controls, ns). Resting energy expenditure (13.7±0.6 versus 13.8±0.8 cal kg‐1min‐1, ns) and insulin‐induced thermogenesis were similar in the two groups. Fasting plasma NEFA concentrations (0.64±0.09 and 0.64±0.06 mmol l‐1, patients and controls, ns) fell in a similar time‐course and to virtually identical nadirs (0.13±0.02 and 0.14±0.02 mmol l‐1) after insulin infusion. Fasting plasma potassium was similar in patients and controls (3.99±0.10 and 4.16±0.04 mmol l‐1, ns), and insulin induced equivalent hypokalaemia (‐14 versus ‐19%).Conclusions.None of thein vivoactions of insulin were impaired in patients with when compared to matched controls. Therefore, we conclude that cardiological syndrome X is not an insulin resistant stateper se,and that any decrease in insulin sensitivity fou

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.448802000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objective.To study the clinical presentation, treatment and outcome of tetanus in a European population.Design.A retrospective study.Setting.A large university hospital with a regional as well as a referral service.Subjects.All patients with tetanus from 1983 till 1993.Results.Twenty‐seven patients (13 men, 14 women; mean age 68.5 years) were studied. Seventeen out of 24 wounds (three patients had no history of a recent wound) were described as tetanus‐prone. Ten patients had medical wound care, but none received tetanus immunoglobulins despite the absence of tetanus immunity. All patients had the generalized type of the disease. The classical symptoms of trismus, dysphagia and muscular rigidity were present in all patients. Treatment consisted of wound management, neutralization of tetanus toxin by immunoglobulins, antibiotics, treatment of muscle spasm and instability of the autonomic nervous system, and supportive care. Twenty‐five patients were admitted to the intensive care unit for a mean duration of 25.7 days. Sixteen patients were artificially ventilated for a mean duration of 27.5 days. Three patients died, 11 patients had a complicated course caused by haemodynamic instability and 15 patients had pulmonary complications.Conclusions.Tetanus has not vanished. It remains a difficult‐to‐treat disease with a substantial morbidity and mortality rate. Prevention during wound management of tetanus‐prone wounds was inappropriate in many patients. The elderly population may have the highest risk for tetanus since they may not have had tetanus toxoid immunization or regular booster

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.450804000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objective.The main aim of the study was to evaluate the safety and efficacy of propafenone versus quinidine as an initial choice in treatment of symptomatic paroxysmal atrial fibrillation.Design.The study consisted of a 3‐month treatment with oral propafenone hydrochloride or quinidine sulphate in patients with paroxysmal symptomatic atrial fibrillation, according to a double‐blind randomized system.Setting.The study was performed in the out‐patient clinic of university hospital.Main outcome measures.The effects of the two drugs on attack frequency, ventricular rate and symptoms of symptomatic paroxysmal atrial fibrillation.Results.In the oral propafenone group (n=48), two patients (4%) discontinued the treatment because of dizziness. In the 46 patients who continued the treatment, the attack frequency decreased from 11±3 times per week at baseline to 1±1 times per week after treatment (P<0.01). Forty (87%) out of the 46 patients had effective response to oral propafenone (more than 75% reduction of symptomatic arrhythmic attacks) on a mean dose of 615±10 mg day‐1; the decrease in attack frequency was from 10±3 to 1±1 times per week. Twenty‐three (50%) patients were free from recurrence of symptomatic paroxysmal atrial fibrillation. Comparisons of symptom scores for patients (n=23) with attacks of paroxysmal atrial fibrillation after oral propafenone treatment showed that there was a significantly lower symptom score of palpitation, asthenia, effort dyspnea, dizziness, rest dyspnea and chest oppression in attacks of paroxysmal atrial fibrillation after propafenone treatment (11.05±3.78 versus 7.60±3.46,P<0.01). From the oral quinidine group (n=48), two patients (4%) discontinued treatment because of gastrointestinal discomfort. In the 46 patients who continued the treatment, the attack frequency decreased from 11±4 times per week at baseline to 3±2 times per week after treatment (P<0.01). Twenty‐one (46%) out of the 46 patients had effective response to oral quinidine on a mean dose of 1067±462 mg day‐1, with a decrease in attack frequency from 12±3 to 1±1 times per week. Only 10 (22%) patients were free from recurrence of paroxysmal atrial fibrillation. Comparisons of symptom scores for patients (n=36) with attacks of paroxysmal atrial fibrillation after quinidine treatment showed that there was no significant decrease of symptom score in attacks of atrial fibrillation (10.65±3.92 versus 10.20±3.80,P=0.57). Furthermore, the percentage decrease of ventricular rate during atrial fibrillation was significantly greater in patients with propafenone (‐25±4% versus ‐8±3%,P<0.01).Conclusions.Oral propafenone appeared to be more effective than quinidine in suppressing attacks and alleviating symptoms

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.451805000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY

摘要:

Objectives.To investigate daytime sleepiness and napping in relation to age, health and nocturnal sleep.Design.An epidemiological survey by means of a questionnaire.Setting.The counties of Västerbotten and Norrbotten in northern Sweden.Subjects.All 10216 members of the pensioners' association SPF.Main outcome measures.Daytime sleep, daytime sleepiness, health, night sleep, somatic diseases and medication.Results.Daytime sleepiness was 4.9 (3.7–6.4) and 5.1 (4.2–6.1) times more common in men and women, respectively, in poor health than in those in good health. It was also more common in subjects suffering from cardiac diseases, diabetes and musculo‐skeletal diseases, urological symptoms, and diseases with sensory and neurological impairments, compared with symptomless subjects. Stepwise regression analysis showed an increase in daytime sleepiness in men in association with impaired general health (r2=0.067), frequent awakenings (r2=0.098), higher age (r2=0.109) and difficulty in falling asleep again after nocturnal awakening (r2= 0.115), and in the women, in association with impaired health (r2=0.118), difficulty in falling asleep again (r2=0.149), frequent awakenings(r2=0.160) and higher age (r2=0.171). There was no further increase inr2=either for men or women in relation to use of hypnotics.Conclusion.Age, poor health and different somatic diseases, but not hypnotics, are associated with daytime sleepiness in elderly p

ISSN:0954-6820    

DOI:10.1046/j.1365-2796.1996.453806000.x

出版商:Blackwell Science Ltd    

年代:1996

数据来源: WILEY