In this issue:

Resurrected Interest in an Old and Controversial Treatment for AMI

Legislative news

ARB on the WWW

A Diagnosis 199 Years Later?

Some of the Ig Nobel Prize Winners

Quotable Quotes

Financial sponsorship statement & How to contact us

Resurrected Interest in an Old and Controversial Treatment for AMI

An infusion of glucose, insulin and potassium (GIK), a simple and inexpensive adjunctive treatment for heart attacks, originally surfaced in the early 1960s and then later abandoned amid controversy-is getting another look.

An earlier study, in 1996, looked at the results of a GIK administration to diabetic patients experiencing heart attacks. Researchers found a 29-58% decrease in relative mortality within the subgroups studied that received the GIK. 

Then a second study, this time a pilot study that was published in 1998, looked at six Latin American countries, utilizing 29 hospitals and 407 people. Participants were given either high does GIK, low dose GIK or no GIK within 24 hours of onset of symptoms. Two-thirds of the group included patients who were also treated with angioplasty or thrombolytics. Results were also stratified to also look at those that suffered significant arrhythmias and/or heart failure. Those that received GIK infusions had a death rate of 6.7 percent compared to a rate of 11.5 percent for those that did not receive the infusion. The difference was even greater in those that received thrombolytics and/or cardiac catheterization----5.2 percent death rate for those receiving GIK and 15.2 percent for those that did not (a 66% relative reduction). Researchers stated that in almost every stratification, those that received GIK "showed significant benefit or a trend towards a benefit…" Results did not reveal a difference in benefit between low dose and high dose GIK. Side effects reported were few and relatively minor, with IV site-specific phlebitis being the most common (2 percent).

"The sample size is very small and perhaps the findings are influenced by chance," said the study's lead author, Rafael Diaz, MD. "So instead of looking for the magnitude of the benefit, we should look for the direction of the benefit. And the direction of the benefit is consistently positive. " 

Diaz is co-director of the cardiovascular medicine division of the Instituto Cardiovascular de Rosario in Argentina and the co-director of the ECLA Collaborative Group, which carried out the study. The trial was not intended to be pilot study but rather to indicate whether a larger investigation was warranted. 

In an editorial in Circulation following the pilot study's published results in 1998, Carl S. Apstein, MD., professor of medicine and director of the Cardiac Muscle Research Laboratory at Boston University's School of Medicine, stated, "The decrease in the death rate is dramatic; the largest
reduction of just about any intervention that's been tried… The mechanism of efficacy is also completely different, in that it alters heart muscle metabolism and biochemistry to protect the region of the heart deprived of oxygen by a heart attack." 

GIK's benefit appears to come from several actions. Animal research suggests the combination reduces the high concentrations of free fatty acids during the hyperacute phase of a heart attack. The combination provides additional glucose, which heart muscles can metabolize even without oxygen to produce enough energy to help them maintain their membranes and the integrity of the cellular sodium and potassium pumps. It also replaces lost potassium as a result of cell damage. It also may overcome the insulin resistance that occurs during heart attacks.

In a more recent study, Pol-GIK, however, there was no reduction in mortality noted. Researchers speculate that the patient acuity was greater in the ECLA study and advocate larger scale studies to clarify the results. 

The recently released "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiac Care---International Consensus on Science" in the August 22, 2000 supplement to Circulation, states "GIK therapy for patients with AMI may be helpful; it is easily administered and associated with few adverse effects…Before GIK can be widely recommended, larger clinical trials are needed to further evaluate its efficacy in a broad patient group with AMI and to identify patient subgroups for which it may be particularly beneficial (Class Indeterminate).

The GIK combination was first reported as a treatment for heart attack in 1962 and examined during clinical trial in 1969. Human study results have been conflicting, historically, despite consistent benefit being noted in animal studies. 

Legislative News:

Senate Approves Rural Heart Attack Support 

The U.S. Senate passed Senate Bill 2528 on Oct. 10 providing $25 million over three years to help heart attack victims in rural, public places. The money from the Rural Access to Emergency Devices Act will go to community hospitals, police and fire departments, and other emergency care providers to purchase automated external defibrillators (AED) and train personnel in their proper use as well as in cardio-pulmonary resuscitation.

Needlestick Legislation Pending

H.R. 5178 is a measure to require employers to consider and use safer medical devices, such as needle-less systems and retractable needles, passed the House Education Subcommittee and the Workforce Protection Subcommittee on September 19. A companion bill (S. 3067) was recently introduced in the Senate. The Centers for Disease Control has estimated that as many as 800,000 health care workers are accidentally stuck with needles each year, which, as we all know, can expose us to many nasty bloodborne pathogens. The bill approved by the House subcommittee would instruct OSHA to amend its 1991 bloodborne pathogen standard to require health care employers to identify, evaluate, and (when appropriate) use safer medical devices. 

ARB on the WWW

A new class of drugs, ARBs (Angiotensin II Receptor Blockers), for the treatment of high blood pressure, may offer hope for patients with heart failure. Richard W. Smalling, MD., Ph.D., the Jay Brent Sterling Professor of Cardiovascular Medicine and Co-Director, Division of Cardiology, University of Texas Medical School at Houston and Frank A. Laws, MD., Fellow in the Department of Internal Medicine, Division of Cardiology, author a look at this emerging treatment at http://www.tdwsyn.com/articles/emerging_treatments/congest_8/

A Diagnosis 199 Years Later?

The just concluded four-year analysis of strands of Ludwig van Beethoven's hair suggests lead poisoning could explain at least some of the ailments, strange behavior, deafness and the eventual death of the composer. These findings are based on chemical analysis done by the McCrone Research Institute in Chicago and images taken at Argonne National Laboratory using an electron accelerator that creates the most detailed X-rays available.

The testing, headed by the Health Research Institute in suburban Chicago, revealed lead levels 100 times higher than commonly found in people today. Many researchers were surprised since their initial hypothesis centered on mercury poisoning (since mercury was a common treatment for syphilis at the time and Beethoven was rumored to be suffering from it).

The hair sample (some 582 strands of gray and brown hair 3-6 inches long) was acquired by Ira Brilliant, founder of the Center of Beethoven Studies, and Alfredo Guevara, a surgeon from Nogales, Ariz., in a 1994 London Sotheby's auction for $7,300. at Sotheby's auction house in  London. 

Apparently when Beethoven died at age 56 in 1827, many mourners took hair from his head as his body was on view in the Vienna apartment where he had lived at the time. Brilliant reports that Beethoven was consequently "…practically bald when he was buried." He died of pneumonia and "abdominal problems"-a common symptom of lead poisoning

Since his 20s, Beethoven suffered abdominal pain, writing to his brothers some 25 years before his death, asking them to insist that doctors find the cause after his death.

Lead poisoning may also explain erratic behavior and mood swings reported--researchers note that the composer was given to "towering rages" with an unkempt appearance often wearing an oversized tophat and coat, strolling down streets humming off-key and scribbling in his 
notebook. Deafness is relatively rare but plausible side effect from lead poisoning.

The Health Research Institute scientists revealed that Beethoven's lead exposure came as an adult but that the source of the lead is unclear. Some now suggest the mineral water he swam in and drank during his stays at spas could have been the source.

The analysis did not find drug metabolites, which indicate Beethoven avoided painkillers during his long and painful death.

Additional testing is proposed using hair strands collected from the Beethoven house in Bonn, Germany five or more years prior to his death.

Some of the 2000 Ig® Nobel Prize Winners 

These awards are given each year to accomplishments that "cannot or should not be reproduced" by the Journal of improbable Research. Amongst recent winners:

The 2000 Prize winner for PEACE:
The British Royal Navy. It seems that recruits at a gunnery school near Plymouth are required to shout "bang" rather than fire real shells as a move by the Ministry of Defence to save money. By checking their coordinates, lining up a target, preparing to fire, then shouting rather than actually launching a round saves 642 British pounds per shout. Apparently recruits are embarassed and disgusted while the Ministry figures to save one million pounds this year doing this.

1999 awards included:
MEDICINE 
Dr. Arvid Vatle of Stord, Norway, for carefully collecting, classifying, and contemplating which kinds of containers his patients chose when submitting urine samples. (REFERENCE: "Unyttig om urinprøver," Arvid Vatle, Tidsskift for Den norske laegeforening [The Journal of the Norwegian Medical Association], no. 8, March 20, 1999, p. 1178.) 

MANAGED HEALTH CARE 
The late George and Charlotte Blonsky of New York City and San Jose, California, for inventing a device (US Patent 3,216,423) to aid women in giving birth -- the woman is strapped onto a circular table, and the table is then rotated at high speed. 

Quotable Quotes

Dorothy Parker US author, poet, journalist, humorist. (1893-1967)

"I might repeat to myself . . . a list of quotations from minds profound - if I can remember any of the damn things."

"They sicken of the calm, who knew the storm."

"You can't teach an old dogma new tricks."

"Brevity is the soul of lingerie."

"This is not a novel to be tossed aside lightly. It should be thrown with great force."