The effect of mesalazine therapy on quality of life in patients with mildly and moderately active ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) has a major impact on the quality of life (QoL) of affected patients. Patient-reported outcomes have not been thoroughly evaluated in patients with UC receiving oral mesalazine (mesalamine).

AIM

To examine the effect of mesalazine on QoL of patients with mildly and moderately active UC and assess the time course of change, baseline disease severity, mesalazine dose and responder status on QoL parameters.

METHODS

Inflammatory Bowel Disease Questionnaire (IBDQ) data were combined from two double-blind, randomized, multicentre, active-controlled trials assessing 2.4 and 4.8 g/day oral delayed-release mesalazine in 687 patients. Mean score changes from baseline were compared at 3 and 6 weeks and effects of baseline severity, mesalazine dose and response to therapy were examined.

RESULTS

Mesalazine significantly improved IBDQ scores at 3 and 6 weeks (mean increase, 29.6 and 39.7 points, respectively; P < 0.0001 for both). Improvement was greater for patients with moderate disease. Greater week 6 changes occurred in clinical responders than nonresponders (50.1 vs. 23.6 points, respectively; P < 0.0001).

CONCLUSIONS

Delayed-release oral mesalazine produces significant clinical and statistical improvements in QoL of patients with UC by 3 weeks, with further improvement at 6 weeks.

'Perimeteritis' and rural health in Manitoba, Canada: perspectives from rural healthcare managers

INTRODUCTION

Rural areas in many parts of the world are facing issues such as economic restructuring, environmental degradation, aging, and depopulation. These issues impact the health and wellbeing of the people living in rural communities. The purpose of this study was to assess rural healthcare managers' understanding of rural community wellbeing. Specifically, definitions were sought for rural, community, health, wellbeing, and healthy rural community.

METHODS

The research reported in this article is based on a set of interviews with each of the 20 healthcare professionals who either managed healthcare centres or administered specialized programs in the rural health care centres in the Assiniboine Regional Health Authority in southwestern Manitoba, Canada.

RESULTS

Capitalizing on the open-ended structure of the interviews, respondents were thoughtful and philosophical in their responses. This produced a rich array of definitions of rural, community, health, wellbeing, and healthy rural community. In doing so, the struggles for rural communities in southwestern Manitoba were highlighted. The findings also illustrated that definitions of health and wellbeing do not fit standard biomedical or health determinant models alone.

CONCLUSIONS

This study was a follow up to another study that employed focus groups to obtain rural resident perceptions of rural, community, wellbeing, and health in southwestern Manitoba. The study reported on here argued that the specific views of healthcare managers were necessary to further illustrate the complexities in understanding definitions of community and condition. The results are consistent with previous research on this topic in southern Manitoba and the recent literature in that there are no universally accepted definitions of rural, community, wellbeing, or health. Further, the study illustrated that professionals charged with managing healthcare services in rural Manitoba maintain very broad definitions of health and wellbeing. Most significantly, the determinants of health and wellbeing were central to defining individual and community condition and quality of life.

Prospects for the future: is there a role for virally vectored immunocontraception in vertebrate pest management?

Virally vectored immunocontraception (VVIC) has been studied and promoted as an alternative to lethal methods for vertebrate pest control in Australia and New Zealand. Virally vectored immunocontraception offers a potentially humane and species-specific control method with potential for a good benefit–cost outcome, but its applicability for broad-scale management remains unknown. We present case studies for the house mouse, European rabbit, red fox and common brushtail possum and describe the current status of research into the use of VVIC as a broad-scale pest-management tool. All case studies indicated that there are significant problems with delivery and efficacy. The current state of development suggests that VVIC is not presently a viable alternative for the management of these vertebrate pests, and it is highly unlikely that this will change in the foreseeable future. An absence of benefit–cost data also hinders decision-making, and until benefit–cost data become available it will not be clear if there are short- or long-term benefits resulting from the use of VVIC for broad-scale pest management.

Prognostic role of c-met tyrosine kinase receptor expression in breast carcinoma

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Background: Hepatocyte growth factor is a pleotropic growth factor that regulates cell proliferation, survival, tumor angiogenesis and metastasis. Its biological effects are mediated through interaction with its receptor: c-met protein.In this study, we evaluated c-met expression in the homogenous group of 99 patients diagnosed with stage II ductal breast carcinomas (G2, G3). We analyzed 5 and 10-years overall (OS) and disease free survival (DFS). Methods: Microscopic studies were performed on formalin-fixed, paraffin-embedded tumor tissue, obtained during surgery and stained routinely with haematoxylin and eosin. Expression of c-met was evaluated using a standard immunoperoxidase technique and percentage of cells with protein expression was counted. Survival was estimated using Kaplan-Meier method. Results: The expression of c-met was found in 37 (37.37%) tumors, with the strong expression of c-met observed only in 7 (7.07%) specimens. The 5-year DFS in patients with overexpression of c-met was statistically significantly worse (p =0.00493) compared with the group with low or no expression (recurrent rates: 57.14% vs 20.65%). Also with a time horizon of 10 years, high values of c-met expression were associated with the higher rate of recurrences (71.43% vs 30.77%, p = 0.01351). The 5-years OS rate in patients with c-met overexpression was 71.43% compared with 84.78% in the group with low or no expression, but this result did not reach statistical significance (p = 0.30345). Comparable tendency was seen in 10-years OS, which was 42.86% in patients with overexpression and 73.63% with low or no expression (p = 0.06154). Conclusions: The results of the study suggest that c-met overexpression is associated with shorter disease-free survival and it may be a useful prognostic indicator of more aggressive disease in patients with breast carcinoma.

No significant financial relationships to disclose.

Correlation between vascular endothelial growth factor and c-met expressions in breast carcinoma

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Background: Vascular endothelial growth factor (VEGF) is a specific mitogen and survival factor for endothelial cells and a key promoter of angiogenesis. This cytokine selectively induces cells proliferation and migration, increases permeability of microvessels and activates proteolitic enzymes involved in tumor invasiveness. C-met is tyrosine kinase receptor; its activation can increase tumorigenicity, induce cell motility and enhance invasiveness and metastasis. This protein can increase production of protease and urokinase which are associated with membrane degradation crucial for metastasis. The relationships between both cytokines are not clearly identified. In this study, we evaluated VEGF and c-met expression in homogenous group of 99 patients with stage II ductal breast carcinomas and analyzed correlations between both markers. Methods: Microscopic studies were performed on formalin-fixed, paraffin-embedded cancer tissues, obtained during surgery and stained routinely with haematoxylin and eosin. Expression of VEGF and c-met was evaluated using a standard immunoperoxidase technique and area with molecule expression, intensity of color reaction and product of both findings were counted. Association between markers expressions was tested by Spearman Correlation Coefficient. Results: Expression of c-met was found in 37 (37.37%) breast tumors, while expression of VEGF was observed in 67 (67.67%) cases. There were strong correlations between expressions of both cytokines. The relationships were found between area with molecules’ expression (p = 0.0438) and intensity of reaction (p = 0.0461), also in the product of both findings (p = 0.0229). Conclusions: The results of our study confirms hypothesis that c-met may act as an indirect angiogenic factor by inducing expression of VEGF.

No significant financial relationships to disclose.

Prevention of percutaneous endoscopic gastrostomy site infections caused by methicillin-resistant Staphylococcus aureus

Percutaneous endoscopic gastrostomy (PEG) is widely used to maintain enteral nutrition in patients who are unable to swallow. Peristomal wound infection is the most common complication of this procedure. In a hospital endemic for methicillin-resistant Staphylococcus aureus (MRSA), MRSA can be the most common organism associated with these infections. We have evaluated a strategy consisting of screening, skin decontamination and glycopeptide prophylaxis for preventing PEG-site infections. None of the 34 patients who received the decontamination protocol and glycopeptide prophylaxis (Group A) developed PEG-site infections within one month of surveillance. Two patients were infected with MRSA after that period. One of seven patients who received the decontamination protocol alone (Group B) was infected within the period of surveillance, while another patient was infected after that period. Both were infected with MRSA. None of nine patients who received glycopeptide prophylaxis alone (Group C) were infected. The results suggest that the strategy of screening, decontamination and glycopeptide prophylaxis is effective in the prevention of PEG-site infections with MRSA. Further trials are necessary to confirm these findings.

Impairment of MLH1 and CDKN2A in oncogenesis of laryngeal cancer

Our study aimed at elucidating which genetic alterations tend to form a network and could be applied as molecular markers of larynx squamous cell carcinoma (LSCC). A panel of genes involved in tumorigenesis was investigated. To search for the possible mechanisms of gene silencing, loss of heterozygosity (LOH) was analysed followed by testing DNA methylation and protein expression for those genes found with the highest frequency of LOH (CDKN2A (55.4%), MLH1 (46.0%), RB1 (35.7%)). A correlation of both LOH and hypermethylation with the loss of expression for CDKN2A and MLH1 was found. Disrupted Rb pathway (loss of expression of RB1 and/or of CDKN2A) in 55.9% of analysed cases confirmed the hypothesis that RB1 pathway is altered in head and neck squamous cell carcinomas, with CDKN2A (45%), rather than RB1 (11.8%) being more frequently inactivated. In LSCC, LOH tends to occur together in gene pairs or triplets. The pair MLH1/CDKN2A and triplets MLH1/TSG on 8p22/CDKN2A and MLH1/CDKN2A/RB1 are related to staging and grading. LOH in MLH1 correlates with lower and LOH in CDKN2A with higher grades of LSCC. It can be concluded that MLH1 and CDKN2A play an important role in LSCC development and progression.

Impact of bovine tuberculosis on a population of brushtail possums (Trichosurus vulpecula Kerr) in the Orongorongo Valley, New Zealand

Brushtail possums are the main wildlife vectors of bovine tuberculosis (Tb) in New Zealand. Possum–Tb models form the basis of possum control aimed at eradicating the disease, and yet competing models show different behaviour, and are highly sensitive to parameters about which there is considerable uncertainty. One area of great uncertainty is the impact of the disease on possum populations. We investigated the impact of Tb on a local population of brushtail possums in the Orongorongo Valley, Wellington. Bovine Tb was first detected in 1997 at one site within an intensively studied population, but has not been detected in another intensively studied population 3 km away since the early 1980s. Using a Before-After-Control-Impact (BACI) analysis, detection of Tb coincided with a 42% (95% CI = 23–56%) reduction in the odds of apparent yearly survival of a possum >17 months of age, i.e. a decrease in yearly survival from 0.85 to 0.77 in 'good' years, and a decrease from 0.71 to 0.60 in 'bad' years. This suggests that Tb had a significant impact on overall survival. However, there was no impact on local population density in September each year due to compensatory recruitment.

Mortality rate and movements of brushtail possums with clinical tuberculosis (Mycobacterium bovisinfection)

AIM

To describe the mortality rate and movements of brushtail possums (Trichosurus vulpecula) with clinical tuberculosis (Mycobacterium bovis) from a site in native podocarp/hardwood forest, in the Orongorongo Valley, Wellington.

METHODS

Possums with clinical tuberculosis (Tb) were identified through routine trapping on live capture grids and were fitted with radio-collars, and located at approximately monthly intervals for 2.5 years. The survival times of radio-collared tuberculous and non-diseased possums were used to estimate the instantaneous additional mortality rate due to clinical Tb. The spatial behaviour of clinically tuberculous possums was compared with that of non-diseased possums, using both den and trap locations. The frequency of long-distance movements of both tuberculous and non-diseased possums was also determined. A possum was defined as having undertaken along-distance movement when it moved at least 200 m from the centre of its activity range and then returned to its established activity range or died.

RESULTS

The mean survival time of clinically tuberculous possums was 4.7 (SE 0.79) months. The instantaneous additional mortality rate due to clinical Tb was estimated to be between 1.08 year-1 and 2.38 year-1, with the lower figure including an unknown portion of the incubation period in the estimate. Estimates of denning and activity ranges of tuberculous possums were approximately 22-30% larger, on average, than the ranges of non-diseased possums, but the differences were not significant. Both tuberculous and non-diseased possums undertook long-distance movements up to 700 m from the centre of their activity range. However, the majority of tuberculous possums died within or near their established activity range.

CONCLUSIONS

This study estimated the mortality rate during the clinical stages of Tb and, as such, did not represent a true estimate of the disease-induced mortality rate (alpha) used in most epidemiological models of possums and Tb. However, the lower estimate of the additional mortality rate due to clinical disease could be considered an approximation to alpha. The movement patterns of clinically tuberculous possums were, overall, not substantially different from non-diseased possums. The occurrence of long-distance movements by tuberculous possums sometimes coincided with the advanced stage of clinical disease. However, the majority of tuberculous possums died within their established activity area. Long-distance movements by resident possums during the terminal stages of disease represent a direct risk for transmission of Tb to livestock on farms within approximately 1 km of infected possum populations.

Time course of pulmonary response of rats to inhalation of crystalline silica: histological results and biochemical indices of damage, lipidosis, and fibrosis

Previous studies have determined that alpha-quartz (crystalline silica) can cause pulmonary inflammation, damage, and fibrosis. However, the temporal relationship between silica inhalation and pulmonary inflammation, damage, and fibrosis has not been fully examined. To address this gap in our knowledge of silica-induced pulmonary fibrosis, a chronic inhalation study using rats was designed. Specifically, rats were exposed to a silica aerosol (15 mg/m3 silica, 6 h/d, 5 d/wk, 116 d), and measurements of pulmonary inflammation, damage, and fibrosis were monitored throughout the study. We report (1) data demonstrating that the silica aerosol generation and exposure system produced a consistent silica aerosol of respirable size particles; (2) the time course of silica deposition in the lung; (3) calculations that demonstrate that the rats were not in pulmonary overload; (4) histopathological data demonstrating time-dependent enhancement of silica-induced alveolitis, epithelial hypertrophy and hyperplasia, alveolar lipoproteinosis, and pulmonary fibrosis in the absence of overload; and (5) biochemical data documenting the development of lipidosis, lung damage, and fibrosis.

Eplerenone suppresses constrictive remodeling and collagen accumulation after angioplasty in porcine coronary arteries

BACKGROUND

Coronary artery angioplasty triggers healing that causes constrictive remodeling. Because collagen accumulation correlates with constrictive remodeling and aldosterone has been implicated in collagen accumulation, we examined how aldosterone and the mineralocorticoid receptor antagonists spironolactone and eplerenone affect remodeling and collagen in porcine coronary and iliac arteries after angioplasty.

METHODS AND RESULTS

Twenty-four pigs were allocated into 4 treatment groups: oral eplerenone (100 mg/d), oral spironolactone (200 mg/d), subcutaneous aldosterone (400 microgram/d), or no treatment. Twenty-eight days after angioplasty of the coronary arteries, eplerenone increased total vessel area by 30% (P<0.05) and luminal area by nearly 60% (P<0.05) compared with the no-treatment group, without affecting neointima size. These effects were accompanied by a 65% reduction in neointimal and medial collagen density (both P<0.05). Spironolactone was less effective, and aldosterone tended to exert opposite effects on coronary artery structure after angioplasty. These effects were not observed in angioplastied iliac arteries.

CONCLUSIONS

Eplerenone attenuates constrictive remodeling after coronary artery angioplasty by mechanisms involving reduction in collagen accumulation, which thus appears to be an important contributor to constrictive remodeling of angioplastied coronary arteries.

Do "conditions contributing to the death" clarify the predictors of infant mortality in Texas?

Predictors of infant mortality are usually based on the underlying causes reported on infant death certificates. Death certificates also contain space for "Other significant conditions contributing to the death but not resulting in the underlying cause." We investigated whether these "contributing conditions" might clarify the predictors of infant death in Texas or interventions that might reduce deaths from the underlying causes. A "multiple cause of death" file converted the underlying causes and contributing conditions associated with each infant death in 1996 into International Classification of Diseases codes. We ranked the major underlying causes, the conditions contributing to those causes, the conditions contributing to all infant deaths, and the effect of combining the underlying causes with contributing conditions to determine the main predictors of infant mortality. We found that extreme immaturity was the most common condition, causing or contributing to 604 of the 2081 deaths in 1996. We conclude that the underlying causes provide a misleading perception of the major predictors of infant death in Texas; combining them with the conditions contributing to those deaths provides a clearer picture. Given the powerful predictive value of preterm birth for infant mortality, the limited current ability to prevent preterm birth, and the cost of its complications, expanded efforts to improve understanding of its causal processes and develop preventive strategies should be top national and state priorities.

Effect of silica inhalation on the pulmonary clearance of a bacterial pathogen in Fischer 344 rats

Silica inhalation predisposes workers to bacterial infection and impairments in pulmonary defense function. In this study, we evaluated the effect of pre-exposure to silica on lung defense mechanisms by use of a rat pulmonary Listeria monocytogenes infection model. Male Fischer 344 rats were exposed by inhalation to filtered air or silica (15 mg/m3 x 6 h/day x 5 days/wk). After 21 or 59 days of silica exposure, the rats were inoculated intratracheally with 5 x 10(3) L. monocytogenes. At 0 (noninfected controls), 3, and 7 days after infection, the left lungs were removed, homogenized, and the number of viable L. monocytogenes was counted after an overnight culture at 37 degrees C. Bronchoalveolar lavage (BAL) was performed on the right lungs. Alveolar macrophages (AM) were collected, and the AM production of chemiluminescence (CL), an index of reactive oxygen species generation, was measured. The number of lavagable neutrophils (PMNs) and acellular BAL lactate dehydrogenase (LDH) activity were determined as indices of inflammation and injury, respectively. Pre-exposure to silica for 59 days caused substantial increases in PMN number and LDH activity compared with the air controls, whereas silica inhalation for both 21 and 59 days significantly enhanced the pulmonary clearance of L. monocytogenes compared with air controls. Dramatic elevations were also observed in zymosan- and phorbol myristate acetate (PMA)-stimulated CL production by lung phagocytes recovered from rats pre-exposed to silica for 59 days. These results demonstrate that short-term exposure to inhaled silica particles activates lung phagocytes, as evidenced by increases in reactive oxygen species. This up-regulation in the production of antimicrobial oxidants is likely responsible for the enhancement in pulmonary clearance of L. monocytogenes observed with short-term silica inhalation.

Response to balloon injury is vascular bed specific: a consequence of de novo vessel structure?

Relative contributions of remodelling and neointimal hyperplasia to restenosis after coronary angioplasty have been inferred from studies using iliofemoral arteries, despite differences in structure/function and smooth muscle cell lineage. We compared the response to balloon overstretch injury of coronary arteries (C, n = 16) and similar sized branches of the iliac arteries (I, n = 18) using preinjury vessel diameter (P). inflated balloon size in vivo (B) and the manufacturer predicted inflated size (M) to examine arterial compliance, as well as resulting injury and morphology in perfusion fixed vessels. Despite similar degrees of oversizing (M/P) in the coronary and iliac arteries (C, 1.44 +/- 0.04; I, 1.51 +/- 0.02), the compliance to overstretch (B-P/M-P) was significantly greater in the coronary than the iliac arteries (C, 0.71 +/- 0.05; I, 0.51 +/- 0.03) (P <0.05) and was associated with a higher injury score (C, 1.64 +/- 0.31; I, 0.39 +/- 0.18 P < 0.05)--only 5/18 iliac vessels had rupture of the IEL compared with 13/16 in the coronary bed. In a subgroup of animals whose vessels (C:n = 7; I:n = 8) were perfusion fixed 28 days after injury, coronary arteries had greater intimal area (C:1.03 +/- 0.42; I:0.10 +/- 0.03 mm2, P < 0.05) but larger luminal area (C:1.61 +/- 0.71; 1:0.76 +/- 0.51, P < 0.05) due to greater area within EEL (C:3.38 +/- 0.49;1:] .49 +/- 0.54, P < 0.05) or less inward remodelling. The injuries resulting from similar strategies of balloon overstretch in the coronary and the iliac arteries are different and affect healing responses--iliac arteries remodel more while coronary arteries develop more intimal hyperplasia. These results indicate that caution is warranted when extrapolating results from the iliac to the coronary artery when investigating restenosis after angioplasty.

Greater stroke rate during hospitalization for acute heart disease among Mexican Americans than non-Hispanic whites

BACKGROUND AND PURPOSE

This study compared the risk for stroke during acute myocardial infarction (AMI), percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) between Mexican Americans (MAs) and non-Hispanic whites.

METHODS

We examined the age-specific rate ratios (RR) of acute stroke during hospitalization for AMI, CABG and PTCA in a population-based study in Corpus Christi, Tex. by searching the cardiac surveillance data for ICD-9 codes for stroke (430-437). ICD-9 stroke codes were validated by comparing medical chart abstraction with ICD-9 discharge diagnoses.

RESULTS

Stroke codes were found in 220 of the 5,697 admissions for AMI, CABG and PTCA. In the 45- to 59-year age-group MAs had a RR of 2.66 (95% CI 1.36-5.23) relative to non-Hispanic whites. In the 60- to 74-year age-group the RR was 1.52 (95% CI 1.11-2.08). There were no significant differences in the 25- to 44-year age-group. These ethnic relationships were found in nondiabetics but not in diabetics. Women in the 45- to 59-year age-group had a RR of 1.88 (95% CI 1.09-3.25) compared with men, but there were no significant sex differences in the 25- to 44- or 59- to 74-year age-groups. Stroke ICD-9 codes have a poor positive predictive value for acute stroke ranging from 10 to 76%. The stroke misclassifications were nondifferential with respect to ethnicity or sex.

CONCLUSIONS

MAs have a higher stroke rate complicating acute heart disease in Corpus Christi. A rigorous stroke surveillance project is needed to study the burden of stroke in MAs, the United States' largest Hispanic population.

Comparison of reported symptoms of acute myocardial infarction in Mexican Americans versus non-Hispanic whites (the Corpus Christi Heart Project)

This study examines whether there are differences between Mexican Americans and non-Hispanic whites in reported symptoms of acute myocardial infarction (AMI). The symptoms experienced by patients identified in a community-based surveillance program were examined to determine whether between-group differences existed by ethnicity, gender, and diabetic status. Data were available regarding the symptoms of 589 patients, between the ages of 25 and 74 years, who were hospitalized and diagnosed as either having definite or possible AMI in special care units at 1 of 7 hospitals in Corpus Christi, Texas. The most frequently reported symptoms were chest pain (83.2%), chest pressure or discomfort (67.6%), sweating (64.2%), fatigue (62.6%), dyspnea (60.3%), and arm or jaw pain (58.2%). After adjusting for age, diabetes mellitus, and gender, and relative to non-Hispanic whites, Mexican Americans were more likely to report chest pain, upper back pain, and palpitations, and less likely to report arm or jaw pain. Likewise, relative to men, women were more likely to report fatigue, dyspnea, dizziness, upper back pain, palpitations, and cough, and were less likely to report chest pain. Significant differences were also observed when older patients' symptoms were compared with younger patients' symptoms.

Association between the severity of chronic lung disease and first-year outcomes of very low birth weight infants

OBJECTIVE

The objective of this study was to determine if there is an association between the severity of chronic lung disease in very low birth weight infants (as assessed by the duration of supplemental oxygen requirements in the neonatal period) and first-year neurodevelopmental, sensory, and growth outcomes as well as duration of neonatal hospitalization and first-year hospital readmissions.

STUDY DESIGN

Retrospective chart review with matched subject groups.

METHODS

The subjects of this study were very low birth weight infants born between 1987 and 1991 in a 17-county perinatal region of North Carolina. Infants were categorized into one of three groups on the basis of duration of supplemental oxygen requirements. Infants who were breathing room air by 28 days were classified as having no chronic lung disease; infants who required supplemental oxygen at 28 days but not at 36 weeks postmenstrual age were classified as having mild chronic lung disease; and infants who required supplemental oxygen at 36 weeks postmenstrual age were classified as having severe chronic lung disease. Infants were matched for birth weight, sex, and race. The matched groups (n = 174) were compared with respect to the incidence of first year adverse neurodevelopmental and sensory outcomes, growth patterns, and hospital readmissions during the first year. Results were analyzed with general linear models and logistic regression analyses.

RESULTS

The incidence of any adverse neurodevelopmental or sensory outcome increased as severity of chronic lung disease increased from none (3.6%) to mild (21.4%) to severe (31.6%, p < 0.001). Growth patterns were similar in infants with no and mild chronic lung disease, but infants with severe chronic lung disease were significantly lighter (p < 0.01) and shorter (p < 0.005) at 40 weeks postmenstrual age and significantly lighter at 1 year adjusted age (p < 0.05). The duration of the initial hospitalization increased with chronic lung disease severity (p < 0.001). Infants with severe chronic lung disease were readmitted to the hospital significantly more often (p < 0.005) than infants with no chronic lung disease or mild chronic lung disease.

CONCLUSIONS

Very low birth weight infants who required supplemental oxygen at or beyond 28 days were at increased risk for adverse neurodevelopmental and sensory outcomes, but only those infants who continued to require supplemental oxygen at 36 weeks were at increased risk for poor growth and readmission to the hospital.

Local anesthesia for infrainguinal arterial reconstruction

PURPOSE

Perioperative cardiac complications occur in 4% to 6% of patients undergoing infrainguinal revascularization under general, spinal, or epidural anesthesia. The risk may be even greater in patients whose cardiac disease cannot be fully evaluated or treated before urgent limb salvage operations. Prompted by these considerations, we investigated the feasibility and results of using local anesthesia in these high-risk patients.

METHODS

From January 1, 1994, through August 30, 1996, 86 infrainguinal reconstructions were performed under local infiltration anesthesia (0.5% or 1.0% lidocaine). Supplementary intravenous sedation with propofol or other agents was given as needed for patients comfort. Most patients had arterial lines but Swan Ganz catheters were used infrequently. Postoperatively, continuous electrocardiographic monitoring was continued in the intermediate or intensive care units. Patients ranged in age from 37 to 86 years (mean 68 +/- 12); 47% were diabetic, 69% had severe coronary artery disease, and 14% had end-stage renal disease.

RESULTS

Operations included 7 femoral-femoral, 21 femoral-popliteal, 16 femoral-tibial and 13 popliteal-tibial bypass grafts, 9 pseudoaneurysms, and 20 distal graft revisions (+/- thrombectomy). Autogenous vein was used in eight of the femoral-popliteal and all of the femoral-tibial and popliteal-tibial bypass grafts. There were two postoperative deaths. One patient died of a stroke (1.2%) on postoperative day (POD) 2 and one died on POD 27 of unknown cause. Two other (2%) patients had nonfatal subendocardial myocardial infarctions. Conversion to general anesthesia was required in four (5%) operations, three because patients became agitated and one because a long segment of vein had to be harvested from the opposite leg. Otherwise, patients tolerated the procedures well and postanesthetic recovery problems were minimized.

CONCLUSIONS

Limb salvage operations can be done under local anesthesia with acceptable complication rates. In selected patients with high-risk coronary artery disease, local anesthesia has theoretic and practical advantages and should be considered an alternative to general or regional anesthesia.

Malignant rhabdoid tumor of brain: an aggressive clinical entity

OBJECTIVE

We report three patients with malignant rhabdoid tumor (MRT) of the brain, two children and an adult. There were three purposes to this report: to describe the clinical course in an adult with MRT; to describe the interesting histopathological metamorphosis of one of the tumors; and to report the outcome of the treatment regimens we used in order to help guide future treatment. Since these tumors are quite rare it is important to continue to try new regimens in the search for effective therapy rather than to repeat ineffective ones.

METHOD

Report of three patients.

RESULTS

The clinical course in all three patients was typical of these aggressive neoplasms in that chemotherapy and radiotherapy were ineffective in modifying the rapid deterioration leading to death.

CONCLUSIONS

MRT can occur in adults. Autopsy in one patient showed that the tumor seemed to undergo an evolution in appearance when compared with the original pathology specimen from craniotomy. Administration of systemic therapy should be prompt and include intrathecal chemotherapy.

An assessment of the validity of ICD Code 410 to identify hospital admissions for myocardial infarction: The Corpus Christi Heart Project

BACKGROUND

The identification of myocardial infarction (MI) is typically based on finding events designated by a nosologist with the appropriate International Classification of Diseases (ICD) code, currently code 410. These codes are applied based on review of medical records or death certificates. However, other factors, including reimbursement considerations, may influence the coding process, especially for hospitalizations. Thus, the validity of using ICD code 410 to identify MI must be assessed.

METHODS

The Corpus Christi Heart Project (CCHP) is a population-based surveillance programme for hospitalized MI. Patients were identified using concurrent ascertainment in coronary care units and retrospective review of medical records. Events were validated as definite or possible MI using data regarding chest pain, electrocardiographic changes and cardiac enzymes. The validity of using ICD code 410 to identify cases of MI was assessed by calculating the sensitivity, specificity, predictive values and efficiency of ICD code 410 versus the CCHP 'gold standard'.

RESULTS

Use of ICD code 410 identified 80.9% (401/496) of definite MI, but only 19.0% (243/1280) of possible MI. Only 12.3% (90/734) of discharges with an ICD 410 code received a 'no MI' designation based on the 'gold standard'. The efficiency of ICD code 410 for identifying MI was 92.0% for definite MI and 77.1% for definite and possible MI.

CONCLUSIONS

The use of ICD code 410 to identify hospitalized cases of MI results in a modestly biased overestimate of the number of definite MI hospitalizations; however, this approach warrants consideration due to the expense of validation procedures.