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It should be noted that the current first-line therapies are not effective against Pseudomonas aeruginosa cost of levitra super active pump for erectile dysfunction. Medication Different drugs are possible for ambulatory treatment buy levitra super active amex erectile dysfunction when drunk. Even an attempt with peni- cillin may be justified in some circumstances – depending on local rates of Pneumococcus and Hemophilus influenzae resistance generic levitra super active 20 mg without prescription erectile dysfunction beta blockers. It should be noted that HIV+ patients frequently develop allergies. Empiric treatment/prophylaxis of community-acquired bacterial pneumonia (daily doses) – there may be significant differences in prices! Outpatient Duration: 7–10 days Mild Amoxicillin + 1 tab. However, when combined with clavulanic acid, active against beta-lactamase- producing bacteria, they are associated with more gastrointestinal complaints. Newer oral cephalosporins have a broader spectrum against gram-negatives, while at the same time have good efficacy against Pneumococcus and Hemophilus. Opportunistic Infections (OIs) 383 Macrolides are advantageous for atypical bacteria such as Mycoplasma, Chlamydia and Legionella – but the proportion of macrolide-resistant Pneumococcus is increas- ing (14% in Germany). Efficacy is also limited in some Hemophilus strains. For quinolones, it should be noted that ciprofloxacin has no or only weak efficacy against many important pathogens. However, in 2009, a ‘Dear Doctor’ letter was sent to European health care pro- fessionals, describing the rare occurrence of fulminant hepatitis and the Stevens- Johnson syndrome or toxic epidermal necrolysis in patients using moxifloxacin. These side effects must be placed in the overall balance of pros and cons of moxi- floxacin as compared to the alternatives. If patients are hospitalized, then intravenous administration is possible initially. In this case, at least two antibiotics should be combined. Targeted treatment after isolation of the pathogen, and, in particular, treatment of nosocomial pneumonia, should depend on local resistance patterns and the recom- mendations of the in-house microbiologist. Prophylaxis The Pneumovax vaccine provides effective protection. It should be utilized in all HIV+ patients with >200 CD4 T cells/µl. However, newer data suggest that Pneumovax has a significant, independent protective effect against pneumococcal disease, regardless of CD4 lymphocyte count (Peñaranda 2007). Although it does not avert pneumonia in all cases it seems to have a positive effect on the further course of the treatment (Imaz 2009). Bacterial Pneumonia among HIV-infected patients: decreased risk after tobacco smoking cessation. Usefulness of sputum culture for diagnosis of bacterial pneumonia in HIV- infected patients. Systematic review and meta-analysis: influence of smoking cessation on incidence of pneumonia in HIV. Nosocomial bacterial pneumonia in HIV-infected patients: risk factors for adverse outcome and implications for rational empiric antibiotic therapy. Pneumonia in HIV-infected persons: increased risk with cigarette smoking and treatment interruption. Epidemiologic changes in bacteremic pneumococcal disease in patients with human immunodeficiency virus in the era of highly active antiretroviral therapy. Impact of prior pneumococcal vaccination on clinical outcomes in HIV- infected adult patients hospitalized with invasive pneumococcal disease. A Clinical Predictor Score for 30-Day Mortality among HIV-Infected Adults Hospitalized with Pneumonia in Uganda. Does enfuvirtide increase the risk of bacterial pneumonia in patients receiving combination antiretroviral therapy? Bacterial community-acquired pneumonia in HIV-infected patients. Risk factors and clinical characteristics associated with hospitalization for community-acquired bacterial pneumonia in HIV-positive patients according to the presence of liver cirrhosis. Effectiveness of polysaccharide pneumococcal vaccine in HIV-infected patients: a case-control study. Prospective study of etiologic agents of community-acquired pneumonia in patients with HIV infection. Ambulant erworbene untere Atemwegsinfektionen/ambulant erworbene Pneumonien bei erwachse- nen Patienten. Empfehlungen einer Expertengruppe der Paul-Ehrlich-Gesellschaft für Chemotherapie e. Chemotherapie Journal 2000, 1:3-23 384 AIDS Cryptosporidiosis Cryptosporidiosis is a parasitic intestinal disease with fecal-oral transmission. It is mainly caused by the protozoon Cryptosporidium parvum (two genotypes exist, geno- type 1 is now also known as C. First described in 1976, cryp- tosporidia are among the most important and most frequent causes of diarrhea world- wide. Important sources of infection for this intracellular parasite include animals, contaminated water and food. While diarrhea almost always resolves within a few days in otherwise healthy hosts or in HIV+ patients with CD4 counts greater than 200 cells/µl, cryptosporidiosis is often chronic in AIDS patients. Particularly in severely immunocompromised patients (<50 CD4 T cells/µl), diarrhea may become life-threatening due to water and electrolyte loss (Colford 1996). Only chronic, and not acute, cryptosporidiosis is AIDS-defining. Signs and symptoms The typical watery diarrhea can be so severe that it leads to death as a result of elec- trolyte loss and dehydration. Up to twenty bowel movements a day are not uncom- mon. Tenesmus is frequent, along with nausea and vomiting. Additionally, the biliary ducts may occasionally be affected with the elevation of biliary enzymes. Diagnosis When submitting stool samples, the laboratory should be informed of the clinical suspicion. If the lab is experienced and receives the correct information, usually just one stool sample is sufficient for detection. In contrast, antibodies or other diagnostic tests are not helpful. The dif- ferential diagnosis should include all diarrhea-causing pathogens. Treatment No specific treatment has been established to date. Diarrhea is self-limiting with a good immune status; therefore, poor immune status should always be improved with ART – and this often leads to resolution (Carr 1998, Miao 2000).

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American Journal of Cardiovascular Disease 2011 buy levitra super active without a prescription impotence test, 1: 176–184 order cheapest levitra super active and levitra super active how is erectile dysfunction causes. Ren X discount levitra super active online amex erectile dysfunction wife, Trilesskaya M, Kwan DM, Nguyen K, Shaw RE, Hui PY. Comparison of outcomes using bare metal versus drug-eluting stents in coronary artery disease patients with and without human immunodeficiency virus infec- tion. Epidemiology of pericardial effusions at a large academic hospital in South Africa. Immune reconstitution inflammatory syndrome and human immunodefi- ciency virus-associated myocarditis. Treatment of primary pulmonary hypertension with continuous intravenous prostacyclin (epoprostenol). Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study. Premature Atherosclerosis in HIV Positive Patients and Cumulated Time of Exposure to Antiretroviral Therapy (SHIVA Study). Myocardial disease in human immunodeficiency virus (HIV) infection: a review. Acute myocardial infarction and rescue percutaneous transluminal coronary angioplasty in a young HIV – infected patient. Subclinical Cardiac Abnormalities in Human Immunodeficiency Virus- Infected Men Receiving Antiretroviral Therapy. The American Journal of Cardiology 2008; 101: 1213–1217. Pulmonary Hypertension in HIV Infection: A Prospective Echocardiographic Study. Pericardial involvement in human immunodeficiency virus infection. Updated clinical classification of pulmonary hypertension. HIV infection and left ventricular assist devices: a case series. Bosentan for the treatment of human immunodeficiency virus-associated pulmonary arterial hypertension. Prevalence of HIV-related pulmonary arterial hypertension in the current antiretroviral therapy era. Contribution of the human immunodeficiency virus/acquired immun- odeficiency syndrome epidemic to de novo presentations of heart disease in the Heart of Soweto Study cohort. HIV and Cardiac Diseases 599 Stotka JL, Good CB, Downer WR, et al. Pericardial effusion and tamponade due to Kaposi`s sarcoma in AIDS. Asymptomatic HIV patient with cardiomyopathy and nephropathy: case report and literature review. Association of C-reactive protein and HIV infection with acute myocardial infarction. Increased acute myocardial infarction rates and cardiovascular risk factors among patients with HIV disease. Twagirumukiza M, Nkeramihigo E, Seminega B, Gasakure E, Boccara F, Barbaro G. Prevalence of dilated car- diomyopathy in HIV-infected African patients not receiving HAART: a multicenter, observational, prospective, cohort study in Rwanda. Wever-Pinzon O, Bangalore S, Romero J, Silva EJ, Chaudhry FA. Inotropic contractile reserve can risk-stratify patients with HIV cardiomyopathy: a dobutamine stress echocardiography study. Comparison of Rates of Death Having Any Death-Certificate Mention of Heart, Kidney, or Liver Disease Among Persons Diagnosed with HIV Infection with Those in the General US Population, 2009-2011. Diabetes mellitus, preexisting coronary heart disease, and the risk of subse- quent coronary heart disease events in patients infected with HIV: the data collection on adverse events of anti- hiv drugs (D:A:D Study). Circulation 2009, 17;119:805-811 Worm SW, Sabin C, Weber R et al. Risk of myocardial infarction in patients with HIV infection exposed to spe- cific individual antiretroviral drugs from the 3 major drug classes: the data collection on adverse events of anti- HIV drugs (D:A:D) study. In situ detection of human cytomegalovirus immediate-early gene tran- scripts within cardiac myocytes of patients with HIV-associated cardiomyopathy. Pulmonary arterial hypertension related to HIV infection: improved hemo- dynamics and survival associated with antiretroviral therapy. HIV and Respiratory Diseases MARKUS UNNEW EHR, MARTIN HOW ER, BERNHARD SCHAAF The spectrum of lung diseases in encompasses typical HIV-related complications such as TB and PCP, bacterial pneumonia, lymphomas and HIV-associated pulmonary hypertension, but also includes usual respiratory problems like acute bronchitis and asthma (see Table 1). Due to the better management of HIV+ people, comorbidities of the older patient become more important, such as COPD, bronchial carcinomas and lung fibrosis (Staitieh 2014, Feldman 2014). With ART, PCP and TB have become less frequent and pulmonary mortality has decreased (Grubb 2006, Morris 2011). HIV influences toll-like receptors and other factors of immune function that increase the risk of pneumonia (Morris 2011). Particularly in patients with respiratory pro- blems and advanced immune deficiency, it is essential to take all differential diag- noses into consideration, of which this chapter presents an outline. PCP, myco- bacterial infections and pulmonary hypertension are covered in detail in other chapters. Table 1: Pulmonary complications in HIV+ patients Infections Neoplasia Other Pneumocystis jiroveci Kaposi sarcoma (KS) Lymphocytic interstitial pneumonia (LIP) Non-Hodgkin lymphoma Non-specific interstitial pneumonia (NSIP) Bacterial pneumonia Hodgkin lymphoma Cryptogenic organizing pneumonia (COP) S. Cryptococcus neoformans Histoplasma capsulatum Toxoplasma gondii Talking with the patient The most important question: What is the immune status? The number of CD4 T cells is an excellent marker of the patient’s individual risk of opportunistic infec- tions. More important than the trough level (nadir) is the current CD4 T cell count. Above 200 cells/µl, typical opportunistic infections are unlikely. In these patients, generally “usual” problems such as acute bronchitis and bacterial pneumonia can be expected. Although the risk increases with immunodeficiency, more than half of HIV+ TB patients have more than 200 cells/µl (Wood 2000, Lange 2004). HIV and Respiratory Diseases 601 In patients with less than 200 CD4 T cells/µl the most common pulmonary disease is bacterial pneumonia, and PCP is also typical. Pulmonary Kaposi sarcoma and pulmonary Toxoplasma gondii infection tend to appear at less than 100 cells/µl but are rarely seen. Below 50 cells/µl, pulmonary infections with CMV (mostly in combination with PCP), invasive pulmonary aspergillosis (IPA), endemic fungi (Histoplasma capsulatum, Coccidioides immitis) and infections with atypical mycobac- teria occur. Especially in patients with advanced immunodeficiency, pulmonary disease might be an indicator of a systemic infection (e.

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You can 2 suture medial do this by using your index fingers or a non- 3 suture superior toothed curved forceps cheap 40mg levitra super active erectile dysfunction my age is 24. The axillary vein is your Figure 10 The former location of the specimen is clearly superior border of excision order levitra super active now erectile dysfunction medicines. The medial and inferior marked at medial discount levitra super active 20 mg with visa erectile dysfunction protocol review scam, lateral and superior margins for the border is the chest wall, the lateral and posterior pathologist border is the latissimus dorsi muscle. Note that Breast-conserving surgery the intercostobrachial nerves are crossing the Breast-conserving surgery together with whole- triangle rather superficially and take care not to cut breast irradiation yields the same rates of mortality them if ever possible as this will cause loss of sensa- as modified radical mastectomy, but in settings tion to the inner upper arm. Both surgical techniques are com- nerve at the floor of the axilla and the long thoracic bined with axillary lymph node dissection. Breast- nerve along the chest wall and preserve them. After removing your specimen from the Control for hemostasis with either cauterization breast mark the posterior, lateral, medial and supe- or 3–0 Vicryl or cat gut ligatures. Irrigate the axilla rior surface with different numbers of sutures and with normal saline to identify small bleeding vessels. If available put drainages in the axilla and mastec- This is extremely important to establish whether tomy wound. Close the axilla with several single you left microscopic malignant tissue behind and if subcutaneous stiches using 2–0 catgut or Vicryl. Ask your assistant to approximate the skin flaps of the mastectomy site and put single subcutaneous CHEMOTHERAPY stiches with 2–0 Vicryl or catgut. These sutures are important as there will be quite some tension on Chemotherapy for breast cancer patients who are them, so make sure you do this well. Start with a in good general condition may generally be done as suture in the middle of the incision dividing the an out-patient procedure. Add a stitch in the middle anthracycline-based regimens as first choice. The of each part and so forth until you have approxi- patient will have an additional 5–10% survival- mated the skin flaps well without too much tension benefit when chemotherapy is added to the opera- on one spot. The same holds true for endocrine treatment my incision with 3–0 absorbable sutures either with if indicated. Giving chemotherapy with a bandage around the chest wall for 24h. The requires laboratory facilities including full blood patient should receive postoperative antibiotic count and serum chemistry. Many healthcare insti- prophylaxis according to local standards. She can tutions even in BHGI level 1 facilities have been move, eat and drink as soon as she is fully awake. See Chapter 31 on more information about how to give chemotherapy and ENDOCRINE THERAPY how to monitor and treat side-effects. Chemotherapy is given on one day; then after a Breast cancer cells may express receptors for estro- 3-week interval the next dose is given. The most gen and progesterone on their surface which, when important side-effect of chemotherapy used in reacting with those hormones, will induce cell and breast cancer is neutropenia. Endocrine therapy aims at either re- immunodeficiency during nadir (time-point of ducing the level of natural hormones or blocking lowest blood counts) during one cycle, e. The total number of cycles (estrogen or progesterone) doesn’t fit anymore given is usually six. Make sure to see the patient because another key (endocrine therapy) has been weekly during each cycle to check full blood count inserted. In case of signs of infection Estrogen and progesterone production is re- AND low blood counts broad-spectrum antibiotics duced by interfering with the production of pituit- have to be given immediately – specific antibiotic ary hormones which regulate the production of therapy should be added according to the results of estrogens and progestins. This is either achieved a blood culture where this is available. Always through drugs or by performing a bilateral oophor- document the toxicities experienced according to ectomy (see Chapter 11 on how to perform a bi- common toxicity criteria (CTC, see Chapter 31). The patient will then be There should not be more toxicities than CTC postmenopausal either temporarily (expensive! The general idea in the adjuvant resources – knowledge of the hormone-receptor situation is to cure the patient. Therefore giving status through pathology results is needed to assure the total dose in the appropriate time-schedule a benefit. Patients with unknown receptor status should be aimed at. Preferably a single-agent regi- standard for patients with hormone receptor- men should be chosen to have less toxicities. Patients Polychemotherapy (basic level 1) may include with metastasis may receive tamoxifen as long as a the following agents (see Chapter 31 for detailed response to the therapy is observed (stable disease regimen): or remission). Tamoxifen may cause thrombosis – take a careful history to find out about previous • CMF (cyclophosphamide, methotrexate, 5-flu- thrombosis, this is a contraindication. Temporary castration may be • EC (epirubicin and cyclophosphamide) achieved by luteinizing hormone-releasing hor- • CAF (5-fluorouracil, doxorubicin and cyclo- mone (LHRH) inhibitors as described above, but phosphamide) they are expensive, if available at all and have to be Single-agent therapy (enhanced level 3) includes given intramuscularly monthly for 2 years. When the following: epirubicin/doxorubicin, capecita- considering surgical castration through bilateral bine, vinorelbine, gemcitabine, carboplatin. These oophorectomy be aware that very young patients drugs are usually not available in a low-resource set- will suffer from osteoporosis. Especially in hormone receptor-positive occur but there is no therapeutic benefit. Non-hormonal RADIOTHERAPY family planning must be used (e. Counseling should be done The usefulness of radiation is proven for breast- to the family as inherited breast cancer is likely and conserving therapy, chest-wall radiation after mas- close female relatives such as daughters, sisters or tectomy (in case of positive lymph nodes or large mothers should have regular examination of the tumor) and palliation of metastasis or locally breast. Any Diagnosis of breast cancer in pregnancy is often de- patient who opts for breast-conservative surgery in layed (even in high-resource countries). The early-stage disease must know that she will have to operation is done just as in non-pregnant women. There is a large demand in low- information on metastasis will greatly affect the resource settings but only a few centers provide recommended therapy, exposure to radiation is radiotherapy either by cobalt machine or linear justified and dosage is most likely unharmful to a accelerator. There are studies PALLIATIVE CARE showing good results with anthracyclines. Do not Radiotherapy is an excellent option for pain relief give methotrexate (as in CMF)! Endocrine treat- of metastasis (especially bone metastasis). Addition- ment is also contraindicated – start after delivery. This is usually mainly an administrative son to terminate the pregnancy (it will NOT im- problem! Please refer to the WHO guidelines for prove the maternal outcome!

Carvedilol reduced reinfarction rates in the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) trial 40 mg levitra super active with visa impotence zantac, which recruited stable inpatients with recent myocardial infarction and a left ventricular ejection fraction of 40% or less order levitra super active 20mg with visa erectile dysfunction doctors. Carvedilol is the only beta blocker shown to reduce mortality in post-myocardial infarction patients who are already taking an ACE inhibitor buy generic levitra super active 20 mg online next generation erectile dysfunction drugs. An extended-release form of carvedilol (carvedilol phosphate) was approved by the US Food and Drug Administration in October 2006. No studies of carvedilol phosphate in patients following myocardial infarction were identified through literature searches. Approval of the left ventricular dysfunction following myocardial infarction indication for carvedilol phosphate was based on pharmacokinetic and pharmacodynamic data that demonstrated bioequivalence with carvedilol. Indirect comparisons of beta blockers across these trials must be done with caution because the study populations differed in duration, the presence or absence of left ventricular dysfunction, the dose and timing of therapy, and the use of other medications. Beta blockers Page 25 of 122 Final Report Update 4 Drug Effectiveness Review Project Table 6. Comparison of outcomes of mortality-reducing beta blockers in patients following myocardial infarction Mortality reduction in Mortality general reduction in population of post-myocardial post- infarction myocardial patients with infarction left ventricular Reinfarction Beta blocker patients dysfunction Sudden death reduction reduction Acebutolol Effective Uncertain Insignificant effect Insignificant effect Not Carvedilol Effective Uncertain (trend) Effective established Carvedilol phosphate No evidence No evidence No evidence No evidence Metoprolol tartrate Effective Probable Effective Effective Insignificant effect Propranolol Effective Probable Effective (BHAT, Hansteen 1982) Timolol Effective Uncertain Effective Effective Head-to-Head Trials No consistent differences between beta blockers were found in 3 head-to-head trials in post- 53-55 myocardial infarction patients. A 6-week trial comparing atenolol 100 mg to propranolol 120 53 mg had inconclusive results. The second trial, an open-label study with a median follow-up of 1. Patients in this study had mean left ventricular ejection fraction 53. The primary outcome of the study was the change in left ventricular ejection fraction at 1 year; time to first serious cardiovascular event was a secondary endpoint. No significant difference was found between the 2 interventions in either change in left ventricular ejection fraction (P=NR) or time to occurrence of a serious cardiovascular event 56 (P=0. However, these results are not conclusive, as the study’s authors acknowledge that the study was underpowered to detect such a difference for this secondary outcome. A study of 313 patients comparing metoprolol tartrate 100 mg twice daily to carvedilol 25 mg twice daily for a mean of 13. There were statistically significant differences in 5 of 8 health-related quality-of-life domains measured using the Short Form-36 55 questionnaire (adjusted for age and baseline differences) favoring the carvedilol group. Placebo-controlled Trials Because there are so few comparative trials, inferences about the comparative effectiveness of beta blockers in post-myocardial infarction patients must be made on other grounds. The criteria for making these comparisons might include: 1. Demonstration of reduced mortality in large, multicenter placebo-controlled trials 2. Degree of mortality reduction compared with other beta blockers 3. Improvements in other outcomes Beta blockers Page 26 of 122 Final Report Update 4 Drug Effectiveness Review Project 4. Effectiveness studies and applicability of efficacy studies to current practice. Mortality Three systematic reviews have analyzed over 60 trials of beta blockers after myocardial 57-59 infarction. The first (Yusuf, 1985) analyzed 22 long-term trials of beta blockers in acute myocardial infarction. Overall beta blockers reduced mortality by 23%, from an average of 10% to 8%. The second (Hjalmarson, 1997) found an average 20% mortality reduction in 24 trials of a total of 25000 patients. A more recent review (Freemantle, 1999) used meta-regression to examine the 59 relationship of characteristics of different beta blockers with the outcome of treatment. In their analysis of 24 long-term trials, cardioselectivity had no effect, but there was a near significant trend towards decreased benefit in drugs with intrinsic sympathomimetic activity. The analysis included just 1 trial of carvedilol, a pilot study in 151 post- 60 myocardial infarction patients. Table 7 summarizes placebo-controlled trials that enrolled over 100 patients, had long- term follow-up (greater than 6 weeks), and met our other inclusion criteria. All of these trials were analyzed in the 1999 systematic review except for CAPRICORN, which was conducted 61 from 1997 to 2000 at 163 sites in 17 countries and published in 2001. Unlike the other trials, CAPRICORN included only patients who had reduced left ventricular function (≤ 40%) after acute myocardial infarction as determined by echocardiography or cardiac catheterization. Patients with uncontrolled heart failure, such as those requiring intravenous diuretics, were excluded. Of 1959 subjects randomized to either carvedilol or placebo at an average of 10 days following a confirmed myocardial infarction, 1289 had no clinical signs of heart failure (Killip Class I), 593 had Killip Class II heart failure, and 65 had Killip Class III failure. The original primary endpoint was all-cause mortality. Subsequently, following a masked interim analysis in which the data and safety monitoring board found that overall mortality rates were lower than predicted, the CAPRICORN steering committee decided to adopt the co- primary endpoints of all-cause mortality together with all-cause mortality plus cardiovascular hospital admissions. There was no difference between carvedilol and placebo for the primary endpoint of mortality plus cardiovascular admissions (35% compared with 37% for placebo over 1. However, carvedilol reduced the original primary endpoint of total mortality in the first 30 days (19% compared with 33%; hazard ratio, 0. CAPRICORN was the only trial to demonstrate the added benefit of a beta blocker in post-myocardial infarction patients taking ACE inhibitors or having undergone thrombolytic therapy or angioplasty. It was also the only trial specifically designed to evaluate a beta blocker in post-myocardial infarction patients who have asymptomatic left ventricular dysfunction. Based on CAPRICORN, the United States Food and Drug Administration gave carvedilol an indication to reduce mortality in “left ventricular failure after a myocardial infarction. However, the case for relevance could be strengthened if data were available to compare other practices and the quality of care between sites that recruited successfully and those that did not. Additional information about the recruitment of patients and the centers at which the CAPRICORN was conducted might provide additional insight into its relevance to current practice in the United States and Canada. Of the 1949 subjects in the trial, 83 were enrolled in the United States and 5 were from Canada. Five of the 6 top recruiting sites were in Russia, which enrolled the most subjects of any country (600). In their Lancet paper, the authors of CAPRICORN noted that “recruitment was slow in some countries where it was widely perceived that the case for beta blockers in all patients with myocardial infarction was proven. Is the mortality reduction in CAPRICORN different from what would be expected from older trials of beta blockers in post-myocardial infarction patients or in patients with heart failure? The authors of the Lancet paper raised this question, noting that the 23% mortality reduction in CAPRICORN is identical to that found in meta-analyses of the older beta blocker trials. Mortality was higher in CAPRICORN than in previous trials of beta blockers in post- myocardial infarction patients. The likeliest explanation is that many earlier trials included a broader mix of patients, including many who had normal left ventricular function and a better prognosis. Unlike many major trials, the CAPRICORN publication did not say how many patients with myocardial infarction were seen at the participating centers during the period of recruitment. It was also not clear what proportion of potentially eligible patients were excluded because they had an ejection fraction greater than 40%.

J. Dudley. Georgia College and State University.