坦洛辛缓释片治疗混合痔切除术后尿潴留的疗效观察

目的探讨坦洛辛缓释片对混合痔切除术后尿潴留的预防效果。方法将102例混合痔患者随机分为观察组和对照组,两组患者均接受硬膜外麻醉下混合痔外剥内扎术。观察组于术后30min口服坦洛辛缓释片0.2mg,对照组术前、术后均未使用坦洛辛缓释片和其他预防尿潴留的药物,比较两组麻醉时间、术后第1次排尿时间、第1次排尿伴随症状和尿潴留发生情况。结果观察组第1次排尿时间短于对照组,第1次排尿伴随症状、尿潴留发生率低于对照组,差异均具有统计学意义(P0.05)。结论坦洛辛缓释片在缩短第1次排尿时间和减少第1次排尿伴随症状、尿潴留发生率有一定疗效。     

A new side effect of BCG immunotherapy — BCG-induced arthritis in man

Summary Ten of 159 patients showed arthritic symptoms during the course of BCG immunotherapy for advanced cancer. The arthritic symptoms occurring after BCG injections had the following characteristics: (1) The incidence of arthritis was closely correlated with the host immunologic responsiveness to BCG; (2) These symptoms usually occurred 1–5 months after the first BCG injection (7/10); (3) The arthritic symptoms usually started with morning stiffness (9/10), which was followed by acute inflammatory signs in the affected joints. They gradually subsided in response to treatment with nonsteroid antiinflammatory drugs, but were not completely cured while the effectiveness of BCG continued; (4) The symptoms were aggravated by additional BCG injections (8/10). (5) This form of arthritis could be differentiated from rheumatoid arthritis, tuberculous, or purulent arthritis by its clinical course and by roentgenograms of the affected joints. It is thought to be induced by the adjuvant effect of BCG, and is a new side effect of BCG immunotherapy.     

The efficacy and safety of solifenacin in patients with overactive bladder syndrome

The aim of the randomised, double blind, placebo controlled study was to evaluate the efficacy, tolerability and safety of solifenacin, a once-daily M3 selective receptor antagonist, in patients with overactive bladder syndrome. Following a single blind 2-week placebo run in period, patients who complained from symptoms of OAB for at least 6 months, were randomized to 4 weeks of solifenacin in 5 mg once daily doses or placebo. 171 patients were enrolled in the study and 157 patients completed the study. Patients with solifenacin had significantly improved micturitions per 24 hours after first week of treatment (1.75 +/- 0.63 vs. 2.64 +/- 0.48, p < 0.001), and after four weeks (1.56 +/- 0.58 vs. 2.71 +/- 0.45, p < 0.001) compared to placebo group. The mean number of urgency episodes per 24 hours had significantly decreased in patients with solifenacin compared to placebo after first week (5.75 +/- 1.43 vs. 6.65 +/- 0.65, p < 0.001), and after four weeks of treatment (5.77 +/- 1.33 vs. 6.54 +/- 0.50, p < 0.001). Solifenacin was also significantly more effective than placebo in reducing the mean number of episodes of severe urgency from baseline to end point (5.83 +/- 1.16 vs. 6.48 +/- 0.50, p < 0.001). Compared with changes obtained with placebo, episodes of urinary frequency were significanlty reduced after first week (0.3 vs. -0.5, p < 0.001) and four weeks check up periods in patients treated with solifenacin (0.19 vs. -0.15, p < 0.001). Episodes of nocturia was significantly reduced in patients treated with solifenacin after first week (0.3 vs. -0.5, p < 0.001), and after four weeks treatment period (0.45 vs. -0.50, p < 0.001). The number of incontinence episodes was also significantly decreased in solifenacin group compared to placebo group after first week (1.06 +/- 0.57 vs. 2.74 +/- 0.47, p < 0.001) and four weeks check up (0.96 +/- 0.57 vs. 2.75 +/- 0.43, p < 0.001). The most common adverse effects with solifenacin were dry mouth and constipation. Adverse effects were mild or moderate severity. The discontinuation rate owing to adverse effects was 4.5%-6.7% with solifenacin and 3.8%-6.1% with placebo, respectively. According to subjective estimation, significant improvement was achieved in 71 (92.21%) of patients treated with solifenacin and in 68 (85%) patients treated with placebo there was no change in OAB symptoms compared to baseline values. UDI score was significantly improved after solifenacin (22.26 +/- 5.91 vs. 29.61 +/- 8.45, p < 0.001) compared to placebo. IIQ score was significantly decreased in patients with solifenacin (36.25 +/- 10.34 vs. 46.86 +/- 6.81, p < 0.001) compared to placebo. In conclusion, solifenacin is a safe and effective treatment alternative for patients with overactive bladder symptoms.     

肝癌致创伤后应激障碍的心理咨询探讨

目的:初步探索心理咨询对肝癌所致创伤后应激障碍患者的干预效果。方法:一例肝癌患者接受六次心理咨询服务。采用PTSD症状评估和生活事件症状测评量表,在咨询第一次和第六次对患者实施测评,并收集患者及家属的主观描述。结果:患者经过认知行为、放松和眼动脱敏干预后,其警觉性下降、创伤再体验次数明显减少、睡眠状况改善以及对癌症治疗的管理观念提高,三个月后对患者及家属回访显示,患者症状改善在回访期维持。结论:认知和眼动脱敏疗法对肝癌所致的创伤后应激障碍患者具有潜在的正性干预效果,未来尚需广泛的实证研究。     

Esomeprazole versus pantoprazole for healing erosive oesophagitis

The aim of this study was to compare the efficacy of esomeprazole and pantoprazole with regard to healing and relief from gastroesophageal reflux disease-related symptoms. I this multicentre, randomized, single-blind study 180 patients (ITT population) diagnosed with endoscopically proven GERD grade A,B,C received esomeprazole (40 mg once daily (o.d.), n = 90) orpantoprazole (40 mg o.d., n = 90). Healing and relief from GERD-related symptoms were assessed at first and final visit (after 4 or 8 weeks of treatment). Esomeprazole 40 mg provided significantly greater healing than pantoprazole 40 mg after 4 weeks of treatment in patients with EE (77.8% vs. 72.2%). Esomeprazole-treated patients were healed after up to 8 weeks of treatment similar those treated with pantoprazole (92.2% vs. 91.1%). The proportion of heartburn-free days was similar in patients treated with esomeprazole and to those treated with pantoprazole.     

北京怀柔“4.23”急性可乐定中毒事件临床救治体会

本研究旨在观察群体性急性可乐定中毒的流行病学特点、临床表现及救治方法,尤其是评价血液灌流（hemoperfusion,HP）治疗急性可乐定中毒的有效性和安全性.通过对北京怀柔4.23急性可乐定中毒事件行流行病学调查,分析所有80例患者的所有流行病学资料,研究病情较重的34例患者的临床表现、治疗方案、预后情况.采用HA230树脂血液灌流器数次HP治疗前后血可乐定、尿可乐定浓度的变化,计算血可乐定浓度下降率,及与常规内科治疗相比HP的排毒效率.观察治疗前患者血压、心率及其他实验室指标如血小板、心肌酶谱、肝酶谱的变化并评价疗效及副作用.研究发现急性可乐定中毒具有隐蔽性强,发病潜伏期短,症状重等特点,HP治疗可显著降低血可乐定水平,短暂升高尿可乐定水平.患者临床症状亦显著改善,血可乐定的下降率为（81±12）%,所有患者经间断HP治疗1～3次后血、尿可乐定水平接近正常.随着患者血可乐定浓度渐趋正常,其临床症状及实验室指标亦能明显改善,短期HP治疗无明显副作用,随访观察半月余,未观察到后遗症.群体性可乐定中毒常常具有危害人群广,症状重风险大,诊治难度大的特点,重者致人死亡,或者造成社会极大恐慌.研究群体性可乐定中毒有浓厚的军事医学意义,HP是治疗可乐定中毒安全有效的治疗手段.     

A herbal remedy, Hyben Vital (stand. powder of a subspecies of Rosa canina fruits), reduces pain and improves general wellbeing in patients with osteoarthritis--a double-blind, placebo-controlled, randomised trial.

The treatment of osteoarthritis, a disease that eventually affects the majority of the older population, involves the alleviation of symptoms such as pain and stiffness, and the reduction of inflammation. The double-blind, placebo-controlled, crossover study reported here examined the effect of Hyben Vital, a herbal remedy made from a subtype of Rosa canina and recently reported to have anti-inflammatory properties, on the symptoms of osteoarthritis. One hundred and twelve patients with osteoarthritis were randomly allocated to treatment with either Hyben Vital 5 g daily or an identical placebo for 3 months, followed immediately by the alternative treatment. The patients assessed changes in joint pain and stiffness after each treatment period on a 5-point categorical scale. General wellbeing, including mood, sleep quality and energy were also assessed and recorded in a personal diary. The results in the two arms of the crossover differed markedly. Group A (placebo first) showed significantly more improvement from Hyben Vital than from placebo, p < 0.0078 for pain and < 0.0025 for stiffness. But Group B (Hyben Vital first) revealed a positive effect of the same order as for Hyben Vital in group A, not only from the active drug, but also from placebo (difference not significant). An identical pattern was observed when we evaluated general wellbeing from the diary records. When patients, on the basis of reduction in joint pain, were divided into responders and non-responders, the first 3 months of active treatment (group A) showed a response rate of 31/47 (66%) compared to that of placebo (group B) 18/50 (36%), p < 0.0185. No major side effects occurred in either group. The data indicate that Hyben Vital reduces the symptoms of osteoarthritis. We interpret the marked differences in the responses of the two groups as indicating a strong "carryover" effect of Hyben Vital.     

Comparison of infrared coagulation and rubber band ligation for first and second degree haemorrhoids: a randomised prospective clinical trial.

One hundred and thirty seven previously untreated out-patients with first and second degree haemorrhoids were allocated at random to treatment by infrared coagulation (n=66) or rubber band ligation (n=71). Complete follow up was obtained in 122 patients (60 who had undergone infrared coagulation (group 1), and 62 rubber band ligation (group 2)) at periods from three months to one year after completion of treatment. Infrared coagulation produced a satisfactory outcome in 51 patients (85%): 34 were rendered asymptomatic and 17 improved. Rubber band ligation produced a satisfactory outcome in 57 patients (92%): 33 were rendered asymptomatic and 24 improved. Both methods were equally effective in first and second degree haemorrhoids. The incidence of side effects, particularly discomfort, during and after treatment was significantly higher in those treated by rubber band ligation (p less than 0.001). This appeared to be an appreciable deterrent to future patient compliance. The number of patients losing more than 24 hours from work was higher after rubber band ligation than after infrared coagulation. The number of treatments necessary to cure symptoms did not differ significantly between the two methods. Infrared coagulation was significantly faster than rubber band ligation (p less than 0.001). Infrared coagulation is a simple, fast, and effective outpatient method for the treatment of first and second degree haemorrhoids with fewer troublesome side effects and higher patient acceptability than rubber band ligation.     

ALTERATIONS IN THE TURNOVER OF BRAIN NOREPINEPHRINE AND DOPAMINE IN ALCOHOL-DEPENDENT RATS

Abstract— The turnover of brain norepinephrine (NE) and dopamine (DA) was studied in five groups of male Sprague-Dawley rats under different conditions of alcohol treatment: no treatment, acute treatment while intoxicated, acute treatment subsequent to elimination of alcohol from the blood, alcohol-dependence while still intoxicated and alcohol-dependence during a withdrawal syndrome. Turnover was determined from the rate of depletion of brain catecholamine levels after inhibition of tyrosine hydroxylase. In rats given a single dose of alcohol, NE turnover was increased, while DA turnover was unaffected during the few first hours after treatment. After that time the turnover of both NE and DA was reduced. In alcohol-dependent rats, whether intoxicated or undergoing a withdrawal syndrome, the turnover of NE was increased, while that of DA was decreased. These data suggest that catecholamines may mediate some of the symptoms of the alcohol withdrawal syndrome in the rat.     

Congenital tuberculosis associated with maternal disseminated miliary tuberculosis

Untreated tuberculosis during pregnancy presents a serious risk for transmission of disease to the newborn and can result in adverse perinatal and obstetrical outcomes. Tuberculosis during pregnancy and congenital tuberculosis are infrequent conditions and are difficult to diagnose due the non-specificity of the symptoms. A case report is presented of a woman who had no children previously with disseminated miliary tuberculosis. Tuberculosis symptoms appeared immediately after birth of the first child, with a clinical diagnosis on the second month after childbirth, whereupon the patient died. The son, a premature infant, showed disease symptoms from the first day, with primary pulmonary complex and persistent atelectasis due to bronchial obstruction. The obstruction was due to thoracic lymphadenitis and coinfection with cytomegalovirus. The infant received standard treatment and his condition improved.     

Effects of "natural oestrogen" replacement therapy on menopausal symptoms and blood clotting.

In a double-blind study on the value of equine ("natural") oestrogens 30 patients presenting with menopausal symptoms in a group practice were monitored for possible adverse effects on blood clotting, weight, and blood pressure. The women were randomly allocated to two groups and given either three months'' hormone treatment followed by three months'' placebo or vice versa. An appreciable amelioration of all symptoms on placebo made it difficult to asses the genuine value of oestrogen treatment during the period of study. Both groups made a dramatic clinical improvement during the first three months. Nevertheless, the symptoms of the 15 women who received oestrogen first returned after the cross-over to placebo without any suggestion of a placebo response. In contrast, the other group who took placebo first did not deteriorate after changing to oestrogen. The menopausal index and the karyopyknotic index were not reliable guides to the need for oestrogen treatment. Hot flushes, however, were proportionately reduced on oestrogen and they seemed to be more readily eliminated in individual cases by oestrogen. The results of blood clotting studies indicated that natural oestrogen administration raised the levels of the extrinsic clotting factors VII and X and accelerated the prothrombin time. The findings were similar to those observed after three months synthetic oestrogen administration with oral contraception. Long-term studies and epidemiological surveys of the clinical incidence of thrombotic and other sequelae are needed before large-scale oestrogen replacement treatment can be recommended.     

四联疗法和序贯疗法治疗服用非甾体类消炎药人群幽门螺杆菌感染的临 床对照研究

目的:对比四联疗法和序贯疗法对根除服用非甾体类消炎药(NSAID)人群幽门螺杆菌(Hp),改善其消化道不良症状及促进消化性溃疡愈合的临床效果。方法:对有消化不良症状的服用非甾体类消炎药物患者行胃镜检查、快速尿激酶及13C呼气试验检查,将155例幽门螺杆菌阳性合并有慢性胃炎或消化性溃疡患者作为研究对象,随机分为两组,A组采用四联疗法,B组采用序贯疗法。A组予雷贝拉唑+克拉霉素+阿莫西林+枸橼酸铋钾治疗10天;B组前5天予雷贝拉唑+阿莫西林,后5天予雷贝拉唑+克拉霉素+甲硝唑。治疗结束后,予雷贝拉唑和胃黏膜保护剂治疗8周。停药4周后,复查胃镜、13C呼气试验,观察和比较两组Hp根除率、消化不良症状缓解率及溃疡愈合率。结果:A、B两组Hp根除率分别为(ITT分析:86.7%和81.9%;PP分析:87.8%和84.3%);症状缓解率为(81.9%对79.2%);胃溃疡愈合率为(68.8%对66.7%),十二指肠球部溃疡的愈合率为(68.2%对70.0%),两组患者间Hp根除率、症状缓解率及溃疡愈合率比较均未见明显统计学差异(P>0.05)。四联疗法组和序贯疗法组不良反应的发生率分别为4.9%和4.3%。两组比较无明显差异(P>0.05)。结论:四联疗法和序贯疗法对长期服用非甾体类消炎药物人群的Hp根除疗效、消化不良症状的缓解及促进溃疡愈合的治疗作用均无明显差异。     

Can prefrontal theta cordance differentiate between depression recovery and dissimulation?

We present a case report of a 37-year old woman diagnosed with depressive disorder, first episode, who was admitted into a psychiatric hospital after a failed suicidal attempt. She responded to antidepressant therapy, as evidenced by a >50% reduction in MADRS total score. She was discharged after 4 weeks of treatment, denying any suicidal ideations. The following day the patient committed suicide; she burned herself to death. It is very likely that the patient dissimulated her symptoms and ideations. Subsequently, her quantitative EEG records were retrospectively analyzed. An increase of prefrontal theta cordance value after the first week of mirtazapine therapy was found. Recently three small studies have revealed that decrease of prefrontal theta cordance after 1 week of antidepressant administration can predict clinical response in patients with unipolar depression. In our previous study the absence of a decreased theta prefrontal cordance was associated with lack of treatment response with NPV 1.0 (Bares et al., 2007). Thus, we hypothesize that prefrontal theta cordance could become an objective marker of change of depressive symptoms, independent of patients' compliance and symptom dissimulation, more precise than objective and self-rated depression rating scales.     

Adrenocortical carcinoma responded to treatment with o,p'-DDD--a case report

A case of a huge inoperable adrenocortical carcinoma which secreted testosterone without characteristic symptoms was treated with o,p'-DDD (2,2-bis(2-chlorophenyl-4 cholorophenyl) 1,1-dichloroethane). With this therapy, the tumor decreased in size which was confirmed by the computed tomography (CT). Eighteen months later, however, lethargy and logopathy appeared and the tumor grew again rapidly with the withdrawal of o,p'-DDD performed for the evaluation of these mental disturbances. The tumor then diminished gradually in size soon after the treatment was resumed and the above unfavorable symptoms were not developed again with the combined administration of a central nervous stimulant. During o,p'-DDD treatment, plasma testosterone and estrogen decreased, and plasma aldosterone also decreased but within the normal range. Plasma cortisol also tended to decrease despite hydrocortisone was administered. Plasma adrenocorticotropic hormone (ACTH) was maintained within the normal range for the first six months but then increased gradually. It decreased and became normal with the additional administration of hydrocortisone. The patient's normal menstruation at the preadministrative stage changed to oligomenorrhea, then amenorrhea after the treatment, but no endocrinological sign except for the menses was observed during the treatment.     

Successful use of olanzapine in adolescent monozygotic twins with catatonic schizophrenia resistant to electroconvulsive therapy: case report

We describe a case of monozygotic (MZ) male twins (14.6 years old) who suffered from a severe form of catatonic schizophrenia. On admission, the principal symptoms of the brothers were stupor, mutism, catatonic posturing, rigidity, negativism, and refusal of food and liquids. They were treated with electroconvulsive therapy (ECT) with no effect (twin A) and almost no effect (twin B). Both twins improved with initiation of olanzapine therapy. Twin B showed a marked improvement by week 2 on a dose of 10 mg daily (qd). Improvement in twin A was seen by week 4 on a dose of 15 mg qd. Twin B was discharged after 8 weeks and twin A after 11 weeks of olanzapine treatment. This appears to be the first report on concordant positive responses to olanzapine in MZ twins with catatonic schizophrenia, as well as, the first report on concordant resistance to ECT.     

Gametocytaemia in Senegalese children with uncomplicated falciparum malaria treated with chloroquine, amodiaquine or sulfadoxine + pyrimethamine

Plasmodium falciparum gametocytaemia was studied in 266 Senegalese children (median 4 years, range 0.5-16) with uncomplicated malaria treated with chloroquine (CQ), amodiaquine (AQ) or sulfadoxine + pyrimethamine (SP). The proportion of resistant infections in vivo to these drugs was 44%, 16% and 7%, respectively. Gametocytes were counted by microscopy in thick smears on days 0, 4, 7 and 14 after treatment. There was a peak of gametocytaemia one week after treatment; on days 0, 7 and 14 the gametocyte prevalences were 35%, 73% and 63%, and the geometric means of gametocyte densities were 1.3, 12.5 and 5.6/microliter of blood. Three factors were found to influence gametocytaemia: treatment, efficacy of treatment, and duration of symptoms before treatment. Gametocyte prevalence and density significantly appeared higher in children treated with SP than with CQ, and higher with CQ than with AQ. Gametocyte prevalence and density were higher in resistant than in sensitive infections. The period between the appearance of the first clinical symptoms and treatment was positively and significantly linked to gametocyte prevalence and density on days 0 and 4. Early treatment with AQ, against sensitive infection, was followed by the lowest gametocytaemia. By contrast, treatment with SP against resistant infection was followed by the highest gametocytaemia. No clear relationship was observed between the density of asexual stages on day 0 and the gametocytaemia at any day between days 0 and 14. The epidemiological significance of post-therapeutic gametocytaemia and its possible role in the spread of resistant parasites are underlined. Solutions are proposed in order to avoid or reduce this gametocytaemia.     

Changes in the structure of ovary tissues and in the ultrastructure of mesocarp cells during ovary senescence or fruit development induced by plant growth substances in Pisum sativum

Structural changes of tissues in unpollinated ovaries of Pisum sativum L. cv. Alaska after treatment with different plant growth substances (gibberellic acid, 2,4-dichlorophenoxyacetic acid, and 6-benzyladenine) or decapitation of the plant were studied. All the treatments resulted in the prevention of cellular disorganization associated with ovary senescence. They effected the enlargement of mesocarp cells and the differentiation of endocarp cells in very similar patterns, suggesting a similar induction of the structural processes involved in fruit development. Ultrastructural changes in mesocarp cells after treatment with gibberellic acid showed that rapid enlargement of mesocarp cells was sustained mainly by a reorganization of the membrane systems directed to the sysnthesis of primary cell wall. Early changes in the subcellular components in mesocarp cells were observed as the first symptoms in ovary senescence.     

Prediction and course of symptoms and lung function around an exacerbation in chronic obstructive pulmonary disease

Background

Frequent exacerbations induce a high burden to Chronic Obstructive Pulmonary Disease (COPD). We investigated the course of exacerbations in the published COSMIC study that investigated the effects of 1-year withdrawal of fluticasone after a 3-month run-in treatment period with salmeterol/fluticasone in patients with COPD.

Methods

In 373 patients, we evaluated diary cards for symptoms, Peak Expiratory Flow (PEF), and salbutamol use and assessed their course during exacerbations.

Results

There were 492 exacerbations in 224 patients. The level of symptoms of cough, sputum, dyspnea and nocturnal awakening steadily increased from 2 weeks prior to exacerbation, with a sharp rise during the last week. Symptoms of cough, sputum, and dyspnea reverted to baseline values at different rates (after 4, 4, and 7 weeks respectively), whereas symptoms of nocturnal awakening were still increased after eight weeks. The course of symptoms was similar around a first and second exacerbation. Increases in symptoms and salbutamol use and decreases in PEF were associated with a higher risk to develop an exacerbation, but with moderate predictive values, the areas under the receiver operating curves ranging from 0.63 to 0.70.

Conclusions

Exacerbations of COPD are associated with increased symptoms that persist for weeks and the course is very similar between a first and second exacerbation. COPD exacerbations are preceded by increased symptoms and salbutamol use and lower PEF, yet predictive values are too low to warrant daily use in clinical practice.     

Evaluation of the results of combined treatment of patients with testicular seminoma in the II stage of clinical advancement]

An attempt to introduce combined therapy for patients with testicular seminoma in the II degree of clinical advancement was undertaken at the Centre of Oncology. Combined therapy consisted of 3 courses of PVB in the following daily doses: DDP 100 mg/m2 i.v. on the first day; VLB 10 mg i.v. on the first and second day; bleomycin 30 mg i.v. on the second, ninth and sixteenth day every 21 days, and 60Co on lymphatic glands area in which metastases were diagnosed prior to chemotherapy. Twenty three patients were treated that way between January 1985 and June 1989. Mean follow-up period after the treatment was 14 months. One patient died for the tumor, metastases to the lungs were diagnosed in one patient 9 months after completion of the treatment which ameliorated after "second" chemotherapy, and 22 patients (96%) are still free from the symptoms of active disease.     

Course of angina pectoris after an acute coronary event.

The course of postcoronary angina pectoris was examined in 555 men who had survived a first attack of myocardial infarction or unstable angina. Patients were aged less than 60 and were followed up yearly for up to 17 years. Only 25 (4.5%) had coronary artery bypass surgery. Most patients with angina were treated by nitrates alone. One year after infarction 24.1% of survivors (124/515) reported the presence of angina pectoris, and the proportions at five, 10, and 15 years were 29.9%, 30.4%, and 43.5% respectively. Seventeen years after the initial event 35.3% of the survivors had never reported postcoronary anginal symptoms. The patients who experienced anginal symptoms in the year after their coronary attack had a poorer long term survival than the group who were symptom free over the first year. These patients also had longer subsequent periods with angina, though in 41.7% angina resolved before death after a median of 2.9 years. Throughout follow up mortality during periods in which patients experienced angina was higher than in the symptom free periods. This long term follow up study of patients after a coronary event confirms that the presence or absence of angina may vary considerably over time in patients treated medically and that the presence of angina is associated with a poorer prognosis. These findings have important implications when assessing the effects of various treatment modalities on postcoronary angina, including coronary artery bypass surgery.