A pre-endoscopy patient education program apparently increase patient compliance, thereby decreasing both the need for repeated examinations and their attendant costs.

BACKGROUND Long-term trends of the incidence and outcome of cardiogenic shock (CS) patients are scarce. We analyze for the first time trends in the incidence and outcome of CS during a 20-year period in Switzerland. METHODS AND RESULTS The AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry enrolls patients with acute myocardial infarction from 83 hospitals in Switzerland. We analyzed trends in the incidence, treatment, and in-hospital mortality of patients with CS enrolled between 1997 and 2017. The impact of revascularization strategy on outcome was assessed for the time period 2005 to 2017. Among 52 808 patients enrolled, 963 patients were excluded because of missing data and 51 842 (98%) patients remained for the purpose of the present analysis. Overall, 4090 patients (7.9%) with a mean age of 69.6±12.5 years experienced acute myocardial infarction complicated by CS. Overall, rates of CS declined from 8.

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SUMMARY The -effect of verapamil on the pharmacokinetics of digoxin was studied in 49 patients with chronic atrial fibrillation. A dose of 240 mg/day of verapamil was given to the patients who were receiving a stable dose of digoxin.Serum digoxin levels rose from 0.76 i 0.54 ng/ml (mean ± SD) to 1.31 ± 0.54 ng/ml during verapamil treatment (p < 0.0005). This effect was dose-dependent, as shown in seven subjects who received 160 mg and then, 240 mg of verapamil: There was a stepwise rise in serum digoxin concentration from a control value of 0.60 ± 0.11 ng/ml to 0.84 ± 0.18 ng/ml and 1.24 ± 0.40 ng/ml, respectively (p < 0.01 for both steps). The effect of verapamil developed gradually within the first few days in seven subjects in whom serum digoxin concentration reached, within 7 days, 90% of the increase observed 14 days after onset of verapamil. Renal digoxin clearance decreased significantly (26.1 i 9.7 vs 55.1 ± 12.3 ml/min,p < 0.005) in six patients in whom serum digoxin concentration increased. It did not change in one patient in whom serum digoxin concentration was not influenced by verapamil. Creatinine clearance did not change in any of these seven. The same effects on digoxin clearance were observed in three normal subjects. Among the 49 patients, verapamil resulted in the development of signs and symptoms that suggested digitalis toxicity in seven.Verapamil significantly increases serum digoxin concentration. The process is dose-dependent and gradual, and it is at least partially explained by reduced renal excretion without reduction in glomerular filtration. The dose of digoxin may need readjustment in patients who are concomitantly receiving verapamil.VERAPAMIL, a calcium antagonist, is an effective antiarrhythmic agent.' It also appears to be useful in other clinical settings.", 8I" Many of the patients who receive verapamil are also treated with digitalis. Since various drugs affect the serum digoxin concentration and clearance, 6121 we tested the effect of verapamil on the pharmacokinetics of digoxin in a consecutive series of 49 patients who were taking digoxin as treatment of chronic atrial fibrillation.22 Methods SubjectsThe study included 49 patients (20 men and 29 women), ages 30-78 years (mean ± SD 61 ± 9.6 years), who were taking a daily maintenance dose of 0.25 mg of digoxin (manufactured by Teva Group, Inc.; bioavailability of this brand equals that of Lanoxin23) for chronic atrial fibrillation. The dose of digoxin had remained unchanged for at least 2 months before the study. The diagnosis of the patients and their functional capacity are listed in tables 1 and 2. Main ProtocolThe main protocol of the study is illustrated in figure 1. The patient took the daily digoxin dose between 8 p.m. and 9 p.m. The blood samples for serum digoxin concentration were always drawn during the next morning, 12-14 hours after ingestion of digoxin. When the patients were receiving verapamil, the morning dose of verapamil was taken between 6 a.m. and 7 a.m. All other medications, such as diuretics, vasodil...

2 ) that were referred to a general endocrine outpatient clinic for evaluation of simple obesity, diabetes mellitus, hypertension, polycystic ovary disease, or pituitary tumor. One milligram dexamethasone was administered orally at 11:00 PM, and serum cortisol levels were measured the following morning between 8:00 AM and 9:00 AM. Suppression of serum cortisol to Ͻ80 nM (3 g/dL) was chosen as the cut-off point for normal suppression. Patients with serum cortisol levels Ն80 nM were evaluated for Cushing's syndrome. Results: Suppression of morning cortisol levels to Ͻ80 nM occurred in 79 of the 86 obese patients. Seven patients had serum cortisol levels higher than 80 nM; five were eventually diagnosed with Cushing's syndrome and two were considered false positive results in view of normal 24-hour free urinary cortisol and normal suppression on a low dose dexamethasone suppression test (0.5 mg of dexamethasone every 6 hours for 2 days). We found a false positive rate of 2.3% for the ODST using a cut-off serum cortisol of 80 nM. Discussion: The ODST is a valid screening test for Cushing's syndrome in the obese population. The false positive rate was 2.3%, even when using a strict cut-off serum cortisol of 80 nM. Abnormal cortisol suppression in obese patients should be investigated and not be considered false positive results.