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Behavioural symptoms eased in Alzheimer's
SCIENCE AND MEDICINE
Blood-pressure control preserves renal function with type 2 diabetes—75% of whom reservation of renal function in were African American—out of 1100 patients with hypertension and hypertensive patients enrolled in the the problems of blood-pressure Community Hypertension Intercontrol in African Americans were vention Project. Half of the substudy related themes at the American patients had some evidence of Society of Hypertension meeting diabetic nephropathy. (New York, USA; May 13–16). 140 patients took angiotensin-conIn type 1 diabetes, the renoprotecverting-enzyme inhibitors; 61 took tive effect of controlling blood prescalcium-channel sure is generally blockers or a combiaccepted, but the nation of these with benefit of such conan ␣-blocker and/or trol in type 2 diadiuretic therapy. betes is less clear. Mean arterial blood Clarification may pressure in the two eventually come groups during the from ALLHAT, a study was around trial comparing the 102 mm Hg. At 2effect of several antiyears follow-up, six hypertensive regi- Good blood pressure for everyone patients had endmens on coronary stage renal failure. Mean creatinine events—more than one-third of the values and progression to end-stage 42 516 trial patients have diabetes. renal failure were the same in the two William Cushman (University of treatment groups. The type of Tennessee, Memphis, TN, USA) calcium-channel blockers taken also presented early ALLHAT data. 53% had no effect on renal deterioration. of patients have met the goal of blood “This observational study suggests pressure below 140/90 mm Hg. But that level of blood-pressure control is African American participants are not a more critical factor in delaying the doing as well. This, along with the progression of nephropathy in type 2 higher prevalence of type 2 diabetes diabetics than the drug class used”, among African Americans compared says Ward. “The controlled clinical with the general population, was trials now underway will answer the addressed by Harry Ward (University question more definitively.” of California, Los Angeles, CA, USA). Ward presented an observational substudy of 201 hypertensives David H Frankel
P
caregivers showed “concurrent cognitive, global, and behavioural benefit” for treated patients compared with those on placebo, extending the findings seen in an earlier 12-week study (Neurology 1998; 50: 1222–30). Metrifonate, concludes Morris, “appears to allow patients to maintain better control of their problem behaviours [eg, hallucinations, agitation] than if they didn’t take it”. “The weight of the evidence”, he adds, “is that tacrine, donepezil, and now metrifonate, all work to a modest degree. Alzheimer’s disease should now be considered a treatable disorder”. Next steps, says Morris, include comparative studies of the effects of individual AChE inhibitors, and investigation of their use in combination with other agents thought to influence the onset or rate of decline in Alzheimer’s disease. Marilynn Larkin
Bruno Simini
Photofusion
he acetylcholinesterase (AChE) inhibitor metrifonate improves psychiatric and behavioural symptoms, as well as cognitive performance, in patients with mild-tomoderate Alzheimer’s disease, according to John Morris (Washington University, St Louis, MO, USA). “My sense is that all the drugs in this class show very similar effects in these domains—that patients seem brighter, demonstrate more initiative, and are easier to get along with in general”, says Morris, lead author of the first controlled study to document behavioural benefits for an AChE inhibitor in Alzheimer’s disease. 215 patients took a loading dose of metrifonate 100–180 mg (2·0 mg/kg) for 2 weeks, followed by a once-daily dose of 30–60 mg (0·65 mg/kg) for 24 weeks; 119 patients took placebo. Objective tests and interviews with study participants, clinicians, and
1562
A
n unprecedented surgical procedure on a 17-month-old normally developed girl with a previously undescribed congenital cardiovascular malformation was done last month by consultant paediatric cardiac surgeon Paolo Arciprete and colleagues at the Giovanni XXIII Hospital in Bari, Italy. The child presented at birth with a double-outlet right ventricle—ie, both aorta and pulmonary artery originated in the right ventricle— and pulmonary artery atresia. This condition is usually associated with a ventricular septal defect. Rarely, the interventricular septum is not patent, in which case the mitral valve is atretic and the left ventricle is hypoplastic; a dozen such cases have been reported since 1965. The peculiarity of this girl’s malformation was that she did not have a ventricular septal defect and her mitral valve was patent which caused dilatation of the left ventricle and mitral regurgitation. Arciprete told The Lancet that he is unaware of any similar cases. At 1 week old, the girl underwent palliative anastomosis of the subclavian to the pulmonary artery (Blalock procedure); when 1 month old, the child’s interatrial septum was excised under cardiopulmonary bypass to create a single atrium . In the latest operation, necessary to avert an otherwise inevitable heart transplantation, Arciprete closed the mitral valve, thereby excluding the left ventricular cavity from the circulation, but leaving its wall in place. He also anastomosed the superior vena cava to the pulmonary artery (bidirectional Glenn procedure). This procedure created a single atrium, single right ventricle heart. The Blalock shunt was left patent as an additional source of pulmonary blood. Postoperative recovery was uneventful, and the collapsed left ventricle no longer interfered with right ventricular function. The girl was discharged 3 weeks after the operation with no symptoms or limitation to her physical activities, and with 90% arterial oxygen saturation in air. The child is still doing well 6 weeks after surgery.
Behavioural symptoms eased in Alzheimer’s
T
Unique operation done in Italy for congenital heart defect
THE LANCET • Vol 351 • May 23, 1998
Blood-pressure control preserves renal function with type 2 diabetes—75% of whom reservation of renal function in were African American—out of 1100 patients with hypertension and hypertensive patients enrolled in the the problems of blood-pressure Community Hypertension Intercontrol in African Americans were vention Project. Half of the substudy related themes at the American patients had some evidence of Society of Hypertension meeting diabetic nephropathy. (New York, USA; May 13–16). 140 patients took angiotensin-conIn type 1 diabetes, the renoprotecverting-enzyme inhibitors; 61 took tive effect of controlling blood prescalcium-channel sure is generally blockers or a combiaccepted, but the nation of these with benefit of such conan ␣-blocker and/or trol in type 2 diadiuretic therapy. betes is less clear. Mean arterial blood Clarification may pressure in the two eventually come groups during the from ALLHAT, a study was around trial comparing the 102 mm Hg. At 2effect of several antiyears follow-up, six hypertensive regi- Good blood pressure for everyone patients had endmens on coronary stage renal failure. Mean creatinine events—more than one-third of the values and progression to end-stage 42 516 trial patients have diabetes. renal failure were the same in the two William Cushman (University of treatment groups. The type of Tennessee, Memphis, TN, USA) calcium-channel blockers taken also presented early ALLHAT data. 53% had no effect on renal deterioration. of patients have met the goal of blood “This observational study suggests pressure below 140/90 mm Hg. But that level of blood-pressure control is African American participants are not a more critical factor in delaying the doing as well. This, along with the progression of nephropathy in type 2 higher prevalence of type 2 diabetes diabetics than the drug class used”, among African Americans compared says Ward. “The controlled clinical with the general population, was trials now underway will answer the addressed by Harry Ward (University question more definitively.” of California, Los Angeles, CA, USA). Ward presented an observational substudy of 201 hypertensives David H Frankel
P
caregivers showed “concurrent cognitive, global, and behavioural benefit” for treated patients compared with those on placebo, extending the findings seen in an earlier 12-week study (Neurology 1998; 50: 1222–30). Metrifonate, concludes Morris, “appears to allow patients to maintain better control of their problem behaviours [eg, hallucinations, agitation] than if they didn’t take it”. “The weight of the evidence”, he adds, “is that tacrine, donepezil, and now metrifonate, all work to a modest degree. Alzheimer’s disease should now be considered a treatable disorder”. Next steps, says Morris, include comparative studies of the effects of individual AChE inhibitors, and investigation of their use in combination with other agents thought to influence the onset or rate of decline in Alzheimer’s disease. Marilynn Larkin
Bruno Simini
Photofusion
he acetylcholinesterase (AChE) inhibitor metrifonate improves psychiatric and behavioural symptoms, as well as cognitive performance, in patients with mild-tomoderate Alzheimer’s disease, according to John Morris (Washington University, St Louis, MO, USA). “My sense is that all the drugs in this class show very similar effects in these domains—that patients seem brighter, demonstrate more initiative, and are easier to get along with in general”, says Morris, lead author of the first controlled study to document behavioural benefits for an AChE inhibitor in Alzheimer’s disease. 215 patients took a loading dose of metrifonate 100–180 mg (2·0 mg/kg) for 2 weeks, followed by a once-daily dose of 30–60 mg (0·65 mg/kg) for 24 weeks; 119 patients took placebo. Objective tests and interviews with study participants, clinicians, and
1562
A
n unprecedented surgical procedure on a 17-month-old normally developed girl with a previously undescribed congenital cardiovascular malformation was done last month by consultant paediatric cardiac surgeon Paolo Arciprete and colleagues at the Giovanni XXIII Hospital in Bari, Italy. The child presented at birth with a double-outlet right ventricle—ie, both aorta and pulmonary artery originated in the right ventricle— and pulmonary artery atresia. This condition is usually associated with a ventricular septal defect. Rarely, the interventricular septum is not patent, in which case the mitral valve is atretic and the left ventricle is hypoplastic; a dozen such cases have been reported since 1965. The peculiarity of this girl’s malformation was that she did not have a ventricular septal defect and her mitral valve was patent which caused dilatation of the left ventricle and mitral regurgitation. Arciprete told The Lancet that he is unaware of any similar cases. At 1 week old, the girl underwent palliative anastomosis of the subclavian to the pulmonary artery (Blalock procedure); when 1 month old, the child’s interatrial septum was excised under cardiopulmonary bypass to create a single atrium . In the latest operation, necessary to avert an otherwise inevitable heart transplantation, Arciprete closed the mitral valve, thereby excluding the left ventricular cavity from the circulation, but leaving its wall in place. He also anastomosed the superior vena cava to the pulmonary artery (bidirectional Glenn procedure). This procedure created a single atrium, single right ventricle heart. The Blalock shunt was left patent as an additional source of pulmonary blood. Postoperative recovery was uneventful, and the collapsed left ventricle no longer interfered with right ventricular function. The girl was discharged 3 weeks after the operation with no symptoms or limitation to her physical activities, and with 90% arterial oxygen saturation in air. The child is still doing well 6 weeks after surgery.
Behavioural symptoms eased in Alzheimer’s
T
Unique operation done in Italy for congenital heart defect
THE LANCET • Vol 351 • May 23, 1998