This paper describes the selection of fentanyl as a replacement for morphine as the United Kingdom Ministry of Defence's first-line battlefield analgesic agent. It is a detailed review of the 6 year journey from selection to eventual roll-out in October 2017. It concentrates on the procurement and governance process of the deployment of fentanyl for individual issue and self-use. It highlights the significant differences in military and civilian legislation, the specialist environment we work in and the safety concerns surrounding controlled drugs in the austere environment. The lessons learnt can be applied to other organisations working in specialist environments that are looking to improve patient care through novel or off-license techniques that meet legislative resistance.
We investigated Achilles tendon thickness (ATT) in 43 males with angiographically documented coronary artery disease [CAD group: 5 heterozygous familial hypercholesterolemic (FH) patients and 38 non-FH patients] to assess the relationship between ATT and coronary atherosclerosis. As a control group, 16 males with normal coronary arteries were also examined.The results were following; (1) there was no significant difference in ATT between CAD (non-FH) group and controls, but ATT in CAD (FH) group were significantly thicker than in CAD (non-FH) group and controls (p<0.001), (2) in CAD (non-FH) group, there were no significant correlations between Achilles tendon thickness and various factors (severity of CAD, TC, Apo B, age, modified Broca's index).In conclusion, it seemed that ATT was not so valuable as an index of the degree of coronary atherosclerosis in CAD (non-FH) group, and the thickening of Achilles tendon was closely related to the pathogenesis of FH.
A 58 year old man with an acute, extensive anterior myocardial infarction was found to also have an atrial septal defect secundum. A cardiac catheterization study showed a large left to right shunt (Qp/Qs: 6.0). Since other clinical findings were not consistent with the prolonged existence of a large shunt, we considered it to be secondary to the myocardial infarction. Balloon occlusion of the ASD was carried out to predict the hemodynamics after the surgical correction, which soon resulted in severe left ventricular failure. Therefore, an operation was not feasible in this case.
The stress-redistribution thallium-201 scintigraphy and thallium-201 washout method have limitations in their ability to detect individual coronary lesions in patients with multivessel coronary artery disease. The purpose of this study is to investigate the value of the quantitative planar method using the dynamics of thallium-201 redistribution after exercise. We observed the patterns of thallium clearance in the late stages (at 2 and 4 hrs) which are characteristic of decreased myocardial blood supply by the obstructed coronary arteries. In 20 subjects, quantitative thallium scintigrams (planar image and circumferential count profile) and blood samples for thallium concentration were obtained immediately, and 2 and 4 hrs after maximal treadmill exercise. Coronary angiography was performed in all subjects, and 16 patients had coronary artery disease (CAD) and four were normal. The rate of thallium clearance from the blood (TCB) was compared with the rate of thallium clearance from each segmental lesion of the myocardium (TCM) between the 2- and 4-hr images. The system adopted for assignment of myocardial regions to individual coronary arteries has been used as an approach to localization of anatomic disease. In the four patients with normal coronary arteries, TCM exceeded TCB in all regions of all images (specificity 100%). Fourteen of the 16 CAD patients had at least one region where TCM was less than TCB (sensitivity 88%). Ten of the 14 patients with multivessel CAD had multiple regions where TCM was less than TCB (sensitivity 71%). All of the six patients without multivessel CAD (four with normal coronary arteries and two with one vessel disease) did not have multiple regions where TCM was less than TCB (specificity 100%). Quantitative thallium scintigraphy showed sensitivities of 86%, 56% and 91% in the left anterior descending artery, the circumflex coronary artery and right coronary artery, respectively. These results showed that decreased TCM in the late stage is characteristic of myocardial regions where blood is supplied by the diseased coronary arteries. This finding may improve diagnostic sensitivity under the condition of multivessel coronary artery disease.
We present a case of a 68-year-old male inflicted with a rare anomaly of the coronary artery. He had been suspected to have worsening effort angina and underwent urgent cardiac catheterization. The coronary angiography revealed 75% stenosis in the first diagonal branch. The left anterior descending artery was terminated in the mid portion and did not reach the apex. Instead, an anomalous coronary artery from the portion just proximal to the right coronary artery reached the apex. After cardiac catheterization, nocturnal chest pain at rest started to occur frequently. We suspected that vasospasm may have occurred because ST segment elevations in leads II, III, aVF were recorded on the electrocardiogram. Administration of diltiazem (120 mg per day) suppressed angina. Exercise stress electrocardiogram and thallium-201 myocardial scintigram did not show apparent ischemia. This case suggests that we must consider the presence of coronary vasospasm even in patients with clinically-supposed effort angina, to be possibly due to vasospasm occurring in anomalous coronary arteries.
It has been suggested that isosorbide dinitrate (ISDN)–induced venodilation could be ascribed to preferential accumulation of the agent in venous tissues, resulting in higher concentrations of nitric oxide (NO). Here, the authors investigated whether the venodilating effect of ISDN is associated with a preferential increase in plasma concentrations of NOx (NO2− and NO3−, stable end-products of NO) in venous blood than arterial blood. Plasma NOx was measured by high-performance liquid chromatography–Griess system with a sensitivity of 0.01 μM for NO2− and 0.1 μM for NO3−. Arterial and venous blood samples were obtained after coronary angiography from the aorta and right atrium of patients with or without ischemic heart disease. Nicardipine, a calcium channel blocker, was used as a non–NO-related arteriovasodilator. At 1 mg i.v., it did not cause any changes in NOx concentration in arterial and venous blood irrespective of hemodynamic changes. However, ISDN (3 mg i.v.) increased NO2− and decreased NO3− in both arterial and venous blood, with concomitant venodilation. Further analysis revealed that plasma NO2− increased in the pulmonary circulation and this increase was preserved after nicardipine and ISDN, and that ISDN, but not nicardipine, increased plasma NO3− in the pulmonary circulation. The authors did not detect higher concentrations of NOx in venous blood relative to their level in arterial blood. Further studies are necessary to clarify the kinetics of NO and NO-related compounds in the whole body.
A 46-year-old Japanese woman, who had been diagnosed as having aortitis syndrome 4 years earlier, was admitted to our hospital in May 1989. The diagnosis of aortitis syndrome was confirmed by intravenous digital subtraction angiography which showed stenotic lesions in each subclavian artery, the left common carotid artery, and the descending aorta. Coronary arteriography revealed diffuse and prominent dilatation of entire coronary artery segments. Moreover, a left ventriculogram showed complete obstruction of the mid-ventricle during systole. Thus, we diagnosed this case as aortitis syndrome complicated by coronary artery ectasia and mid-ventricular obstruction. The causal relations of these findings are discussed.
