Voiding dysfunction in women with systemic lupus erythematosus

OBJECTIVE

We sought to explore bladder dysfunction in a cohort of women with systemic lupus erythematosus (SLE).

METHODS

We conducted a prospective study of 152 female patients with SLE during a 15-month period. The clinical status of SLE was determined according to the SLE Disease Activity Index (SLEDAI), and bladder function was evaluated by lower urinary tract symptoms and urodynamic studies. We adapted the American Urological Association (AUA) index questionnaire to assess lower urinary tract symptoms in patients, which were compared with those in 227 age-matched healthy women.

RESULTS

The proportion of individuals reporting urinary frequency, urgency, weak urinary stream, and incomplete emptying, as well as severe lower urinary tract symptoms (AUA index score >/=20), was significantly higher in the SLE group when compared with the control group. The AUA index score showed a modest correlation with the SLEDAI score (r = 0.35, P < 0.001) but not with patient age or disease duration. There was a significant relationship between central nervous system involvement and the AUA index score. The most common urodynamic finding was a small cystometric bladder capacity (<150 ml; n = 7 patients), followed by a subnormal urinary flow rate (<12 ml/second; n = 6 patients). In 3 of 7 patients with small cystometric bladder capacities, imaging studies documented a contracted bladder with marked hydroureteronephrosis.

CONCLUSION

Patients with SLE experience an increased prevalence of voiding dysfunction compared with healthy individuals. Voiding dysfunction can be attributable to either direct bladder involvement or other disease-related factors.

Effect of Eurycoma longifolia Jack on orientation activities in middle-aged male rats

The effects of various fractions of Eurycoma longifolia Jack were studied on the orientation activities of the inbred, adult middle-aged Sprague-Dawley rats, 9 months old and retired breeders towards the receptive females (anogenital sniffing, licking, mounting), the environment (climbing, raring, exploration), themselves (nongenital grooming, genital grooming) and mobility (restricted, unrestricted) after treating these subjects twice daily for 10 days. Results showed that subjects treated with 800 mg/kg of E. longifolia Jack increased orientation activities towards the receptive females (anogenital sniffing, licking and mounting), increased genital grooming towards themselves and restricted movements to a particular area of the cage but decreased interest in the external environment (climbing, raring, exploration) as compared with the controls during the investigation period. In conclusion, this study gives further evidences that different fractions of E. longifolia Jack modified the orientation activities of the middle-aged male rats.

[The medical system and its characteristics during the Koryo Dynasty period]

This article explores the medical system of the Koryo Dynasty period and its social characteristics. First, the structure of medical system and roles of medical institutions during the Koryo Dynasty period will be summarized. Then, the characteristics of the medical system will be identified through exploring the principles of its formation in a view of social recognition of medical care and a view of public policy. During the Koryo Dynasty period, medical experts were trained in national education institutions from the early days of Dynasty. After trained, they were appointed to the posts at government service with their medical profession. In the meantime, they sought ways to ascend their social position. Physicians of Oriental medicine were appointed to the posts at each local government and troops to take charge of medical treatments of the common people. Also, the state tried to assume the reins of medical system by actively taking part in circulation (collection and distribution) of herb. Taeuigam and Sangyakguk represent central medical institutions of the Koryo, taking charge of medical service for the aristocracy and the bureaucracy. The Common people were treated at DongSeoDaeBiWOn, JeWuiBo, HyeMinGuk, and YakJum in SeoKyung. However, activities of these institutions became less active around the days of military officials regime, as officers became negligent and financial base went broken. The roles of medical institutions of the Koryo government were not restricted to the treatment of diseases. Policies for the common people were constituted by two main policies, the policy for encouraging agriculture and the policy for giving relief to people. Medical institutions, with other social systems, had a social responsibility to support the governing system of the Koryo and maintain the stability of the society. In this aspect, medical institutions such as DongSeoDaeBiWon and JeWuiBo, and relief institutions such as UiChang, were all related and connected organically, and they were results of, and bases of the relief policy. However, medical system for the common people was made up first for practical needs and then improved successively. Allocation of medical experts and execution of relief work were carried out by each local government, except the case of serious disaster, which central government took part in. As the Koryo Dynasty went into its latter period, temporary institutions and one - time benefits replaced permanent institutions. These four characteristics described above were systemic characteristics of medical system during the Koryo Dynasty period.

[The Gurhigae Jejoongwon: its size and activities]

This article explores the location, size of the site, and medical activities of the Gurhigae Jejoongwon. Relevant documents such as reminiscences, diplomatic notes, newspaper accounts, maps, and photographs were referred for this study. The Gurhigae Jejoongwon located on a hill that, at present, covers the area from Ulchi-ro to MyungDong Cathedral. Its main entrance was towards Ulchi-ro. Real estate including the buildings of the Gurhigae Jejoongwon was returned to the Chosun government in 1905, and the estimated size of its site varied from 1,810 pyung to 5,036 pyung. The site of the Gurhigae Jejoongwon was 2 - 5 times larger than the 862.16-pyung-site of the Jejoongwon in its Jaedong days. With such larger size, the Jejoongwon could take care of more patients. Dr. Avison started medical education again. The Gurhigae Jejoongwon took the central part in medical treatment activities for public in Seoul, as it carried out the prevention activities against Cholera in 1895. The Chosun government highly recognized its medical treatment activities for the common people.

Should all implantable cardioverter defibrillators for ventricular arrhythmias be dual-chamber devices?

The advantages of a dual-chamber implantable cardioverter defibrillator (ICD) over a single-chamber ICD include physiologic pacing capability, atrial electrogram storage, enhanced arrhythmia discrimination algorithms, and a potential to treat atrial arrhythmia by pacing or defibrillation. Current evidence supports the supposition that dual-chamber ICDs are definitely indicated in patients who have a concomitant indication for physiologic pacing, such as bradycardia or bradycardia-dependent ventricular tachyarrhythmias. Refined dual-chamber arrhythmia discrimination algorithms and enhanced atrial therapies are probably required for patients with frequent supraventricular arrhythmias. Furthermore, in patients with systolic heart failure, low ejection fraction, and intraventricular conduction delay, triple-chamber ICDs with biventricular pacing may improve their functional status and prevent sudden arrhythmic death. Careful patient selection is required to optimize the cost-effectiveness of these sophisticated technologies.

Differences in inducibility and prognosis of in-hospital versus out-of-hospital identified nonsustained ventricular tachycardia in patients with coronary artery disease: clinical and trial design implications

OBJECTIVES

The goal of this study was to describe the influence of the clinical setting (in-hospital vs. out-of-hospital) in which nonsustained ventricular tachycardia (NSVT) is discovered on the rate of inducibility of sustained ventricular tachycardia (VT), arrhythmic events and survival in patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction.

BACKGROUND

In-hospital presentation of sustained VT is independently associated with lower long-term overall survival. The impact of the clinical setting in which NSVT is documented is unknown.

METHODS

In the Multicenter Unsustained Tachycardia Trial (MUSTT), designed to assess the benefit of randomized antiarrhythmic therapy guided by electrophysiologic testing in patients with asymptomatic NSVT, CAD and LV dysfunction, eligible patients were enrolled irrespective of the setting in which the index arrhythmia was discovered. In this retrospective analysis, we compared the rate of VT inducibility and outcome of MUSTT-enrolled patients with in-hospital versus out-of-hospital presentation of NSVT.

RESULTS

Monomorphic sustained VT was induced in 35% and 28% of the patients whose index NSVT occurred in-hospital and out-of-hospital, respectively (adjusted p = 0.006). Cardiac arrest or death due to arrhythmia at two- and five-year follow-ups were 14% and 28% for untreated patients with in-hospital-identified NSVT and 11% and 21% for the out-of-hospital group (adjusted p = 0.10). Overall mortality rates at two- and five-year follow-ups were 24% and 48% for inpatients and 18% and 38% for outpatients (adjusted p = 0.018). In patients randomized to antiarrhythmic therapy, there was no significant interaction between patient status (in-hospital vs. out-of-hospital) and treatment impact on the rates of total mortality (p = 0.98) and arrhythmic events (p = 0.08).

CONCLUSIONS

In patients with CAD and impaired LV function, asymptomatic NSVT identified in-hospital, compared with that identified out-of-hospital, is associated with a higher rate of induction of sustained VT and overall mortality. Therefore, in similar patients, the clinical setting in which NSVT is discovered should be taken into account when formulating patient risk, treatment and clinical trial design.

Using observational data to estimate prognosis: an example using a coronary artery disease registry

With the proliferation of clinical data registries and the rising expense of clinical trials, observational data sources are increasingly providing evidence for clinical decision making. These data are viewed as complementary to randomized clinical trials (RCT). While not as rigorous a methodological design, observational studies yield important information about effectiveness of treatment, as compared with the efficacy results of RCTs. In addition, these studies often have the advantage of providing longer-term follow-up, beyond that of clinical trials. Hence, they are useful for assessing and comparing patients' long-term prognosis under different treatment strategies. For patients with coronary artery disease, many observational comparisons have focused on medical therapy versus interventional procedures. In addition to the well-studied problem of treatment selection bias (which is not the focus of the present study), three significant methodological problems must be addressed in the analysis of these data: (i) designation of the therapeutic arms in the presence of early deaths, withdrawals, and treatment cross-overs; (ii) identification of an equitable starting point for attributing survival time; (iii) site to site variability in short-term mortality. This paper discusses these issues and suggests strategies to deal with them. A proposed methodology is developed, applied and evaluated on a large observational database that has long-term follow-up on nearly 10 000 patients.

Increase in B19 viral load prior to relapse of anaemia in an AIDS patient with persistent B19 infection

Anaemia caused by persistent parvovirus B19 infection can be remitted by intravenous immunoglobulin (IVIG) treatment. However, maintenance IVIG therapy is required in some AIDS patients as well as patients with combined immuno-deficiency because of relapse of anaemia. We used a simple semi-quantitative polymerase chain reaction (PCR) method to trace plasma B19 viral load after administration of IVIG. We noted that the rebound of B19 viral load occurred 6 weeks prior to detection of anaemia. This method may be helpful in determining the interval of maintenance IVIG therapy.

The human HMGB1 promoter is modulated by a silencer and an enhancer-containing intron

The highly conserved, ubiquitous high mobility group protein HMGB1 (formerly named as HMG1) is an architectural transcription factor encoded by a single functional gene in human. HMGB1 is expressed in almost all cell or tissue types studied. In general, it is expressed at a basal level in most cells but at a slightly elevated level of 2--3-fold in actively proliferating tissues or estrogen stimulated breast cancer cells. To understand the regulatory mechanism controlling expression of the human HMGB1 gene, we cloned and analyzed the upstream region as well as the first intron of this gene. We found that transcription of the human HMGB1 gene in the breast cancer MCF-7 cells starts at one major site 57 nucleotides upstream from the first exon-intron boundary. Expression of the human HMGB1 gene is under the control of a very strong TATA-less promoter, which has an activity more than 18-fold that of the SV40 promoter. Immediately upstream, a silencer element is present. This silencer can repress the activity of the HMGB1 promoter down to just one-sixth. The first intron of the human HMGB1 gene contains enhancer elements, which can increase the human HMGB1 promoter activity by 2--3-fold. We postulate that the human HMGB1 gene is capable of being expressed at a very high level. The basal level of expression observed in most cells is probably a result of the strong promoter being held in check by the silencer. The 2--3-fold increase in HMGB1 expression observed in proliferating cells or breast cancer cells stimulated by estrogen may probably result from the action of the enhancer elements in intron 1.

Prediction of long-term outcomes by signal-averaged electrocardiography in patients with unsustained ventricular tachycardia, coronary artery disease, and left ventricular dysfunction

BACKGROUND

An abnormal signal-averaged ECG (SAECG) is a noninvasive marker of the substrate of sustained ventricular tachycardia after myocardial infarction. We assessed its prognostic ability in patients with asymptomatic unsustained ventricular tachycardia, coronary artery disease, and left ventricular dysfunction.

METHODS AND RESULTS

A blinded core laboratory analyzed SAECG tracings from 1925 patients in a multicenter trial. Cox proportional hazards modeling was used to examine individual and joint relations between SAECG variables and arrhythmic death or cardiac arrest (primary end point), cardiac death, and total mortality. We also assessed the prognostic utility of SAECG at different levels of ejection fraction (EF). A filtered QRS duration >114 ms (abnormal SAECG) independently predicted the primary end point and cardiac death, independent of clinical variables, cardioverter-defibrillator implantation, and antiarrhythmic drug therapy. With an abnormal SAECG, the 5-year rates of the primary end point (28% versus 17%, P=0.0001), cardiac death (37% versus 25%, P=0.0001), and total mortality (43% versus 35%, P=0.0001) were significantly higher. The combination of EF <30% and abnormal SAECG identified a particularly high-risk subset that constituted 21% of the total population. Thirty-six percent and 44% of patients with this combination succumbed to arrhythmic and cardiac death, respectively.

CONCLUSIONS

SAECG is a powerful predictor of poor outcomes in this population. The noninvasive combination of an abnormal SAECG and reduced EF may have utility in selecting high-risk patients for intervention.

P wave polarity during pacing in pulmonary veins

INTRODUCTION

Recent studies have demonstrated that premature depolarizations that trigger atrial fibrillation often arise in pulmonary veins. The purpose of this study was to evaluate whether P wave polarity is helpful in distinguishing which of the 4 pulmonary veins is the site of origin of a premature depolarization.

METHODS AND RESULTS

In 28 patients without structural heart disease who underwent focal ablation of paroxysmal atrial fibrillation, P wave polarity on a 12-lead electrocardiogram (ECG) was analyzed during sinus rhythm, and during pacing at a cycle length of 500--600 ms in the high right atrium and within each of the 4 pulmonary veins. P waves were categorized as positive, negative, biphasic or isoelectric. A negative or biphasic P wave in lead I (sensitivity 85 %, specificity 71 %) or a positive P wave in V1 (sensitivity 85 %, specificity 89 %) were helpful in predicting a pulmonary venous site of origin as opposed to a right atrial site of origin. A positive P wave in lead II and III distinguished superior from inferior pulmonary veins (sensitivity 90 %, specificity 84 %). The sensitivity and specificity of negative or biphasic P waves in lead aVL in distinguishing a left from right pulmonary vein site of origin were 94 % and 42 %, respectively.

CONCLUSIONS

Analysis of P waves polarity may be helpful in localizing the pulmonary vein that is the site of origin of a premature depolarization. Among the 12 ECG leads, I, II, III, aVL, and V1 are the most helpful in regionalizing premature depolarizations arising in the pulmonary veins.

Hepatopulmonary syndrome in poorly compensated postnecrotic liver cirrhosis by hepatitis B virus in Korea

BACKGROUND

Hepatopulmonary syndrome (HPS) refers to the association of hypoxemia, intrapulmonary shunting and chronic liver disease. But there is no clear data about the prevalence of HPS in postnecrotic liver cirrhosis by hepatitis B virus (HBV), the most common cause of liver disease in Korea. The aim of this study was to investigate the prevalence of HPS in poorly compensated postnecrotic liver cirrhosis by HBV, and the correlation of the hepatopulmonary syndrome with clinical aspects of postnecrotic liver cirrhosis by HBV.

METHODS

Thirty-five patients underwent pulmonary function test, arterial blood gas analysis and contrast-enhanced echocardiography. All patients were diagnosed as HBV-induced Child class C liver cirrhosis and had no evidence of intrinsic cardiopulmonary disease.

RESULTS

Intrapulmonary shunt was detected in 6/35 (17.1%) by contrast-enhanced echocardiography. Two of six patients with intrahepatic shunts had significant hypoxemia (PaO2 < 70 mmHg) and four showed increased alveolar-arterial oxygen gradient over 20 mmHg. Only cyanosis could reliably distinguish between shunt positive and negative patients.

CONCLUSIONS

The prevalence of intrapulmonary shunt in poorly compensated postnecrotic liver cirrhosis by HBV was 17.1% and the frequency of hepatopulmonary syndrome was relatively low (5.7%). 'Subclinical' hepatopulmonary syndrome (echocardiographically positive intrapulmonary shunt but without profound hypoxemia) exists in 11.4% of cases with poorly compensated postnecrotic liver cirrhosis by HBV. Cyanosis is the only reliable clinical indicator of HPS of HBV-induced poorly compensated liver cirrhosis. Further studies are required to determine if the prevalence and clinical manifestations of HPS varies with etiology or with geographical and racial differences.

Reversible impairment of left and right ventricular systolic and diastolic function during short-lasting atrial fibrillation in patients with an implantable atrial defibrillator: a tissue Doppler imaging study

AF with a fast ventricular response may cause ventricular mechanical impairment, though whether short-lasting AF with satisfactory rate control may affect ventricular function is unknown. This study investigated if prompt cardioversion by an implantable atrial defibrillator (IAD) may prevent left (LV) and right ventricular (RV) systolic and diastolic dysfunction. Ten patients (mean age 61 +/- 9 years, 8 men) with paroxysmal AF without structural heart disease who received an IAD were studied by echocardiography and tissue Doppler imaging (TDI) for both ventricles. Measurements were made during baseline sinus rhythm and at 1-minute, 20-minute, 4-hour, and 1-week postcardioversion of an episode of spontaneous AF. The occurrence of AF and the ventricular rate were monitored at 2-hour intervals by the device. There were 50 episodes of AF with a mean duration of 8.8 +/- 8.9 days (2 hours to 37 days). There was no difference in M-mode measured LV fractional shortening and ejection fraction between baseline sinus rhythm and after cardioversion. However, the TDI derived myocardial systolic velocity (TDI-S) was significantly lower at 1-minute postcardioversion and was normalized at 1 week in both LVs (baseline: 5.7 +/- 1.8, 1 minute: 4.2 +/- 1.0, 20 minutes: 4.3 +/- 0.9, 4 hours: 4.8 +/- 1.0, 1 week: 5.5 +/- 1.8 cm/s; P < 0.005 when comparing 1 minute and 20 minutes to baseline; P < 0.05 when comparing 4 hour to baseline) and RV (baseline: 10.4 +/- 2.1, 1 minute: 7.8 +/- 1.4, 20 minutes: 8.1 +/- 1.2, 4 hours: 9.2 +/- 1.5, 1 week: 10.0 +/- 2.0 cm/s; P < 0.005 when comparing 1 minute, 20 minutes, and 4 hours to baseline). For diastolic function, transmitral Doppler study showed a decrease in early filling velocity at 1 minute (P < 0.05) and 20 minutes (P < 0.005), which was normalized at 4 hours. There was no change in transtricuspid Doppler flow. However, TDI derived myocardial early filling velocity was decreased in the LV (baseline: 6.0 +/- 2.8, 1 minute: 5.4 +/- 2.3, 20 minutes: 5.4 +/- 2.1, 4 hours: 6.1 +/- 2.2, 1 week: 5.8 +/- 1.7 cm/s; P < 0.05 when comparing 1 minute and 20 minutes to baseline) and RV (baseline: 8.9 +/- 3.5, 1 minute: 7.9 +/- 3.3, 20 minutes: 8.1 +/- 3.3, 4 hours: 8.5 +/- 2.9, 1 week: 8.4 +/- 3.5 cm/s; P < 0.05 when comparing 1 minute to baseline). AF of a longer duration (> 48 hours) resulted in a more depressed TDI-S in LV (> 48 hours: 4.2 +/- 1.0, < or = 48 hours: 5.3 +/- 1.3 cm/s; P < 0.01). Shocks in sinus rhythm did not affect any of the above echocardiographic parameters. Therefore, despite adequate rate control, short-lasting AF impairs systolic and diastolic function in both ventricles, which improves gradually after cardioversion. Early restoration of sinus rhythm by an IAD minimizes ventricular dysfunction. TDI is a sensitive tool to assess early systolic and diastolic dysfunction.

Dietary trial in prostate cancer: Early experience and implications for clinical trial design

Much epidemiologic and case-controlled evidence suggests that diet may be a modifier of prostate cancer risk. However, the role of dietary modification in men known to have prostate cancer is a matter of some debate. To elucidate the effect of diet and comprehensive lifestyle changes on cancer risk, we are conducting a randomized, prospective clinical trial on men with clinically localized prostate cancer who have selected "watchful waiting" as primary therapy. Since its inception in April 1997, 93 men have been randomized to control (n = 47) or dietary and lifestyle intervention (n = 46). Patients in the intervention group are asked to eat a low-fat, soy-supplemented vegan diet and take part in stress management, psychosocial group support, and exercise programs. After 1 year, adherence to all four interventions was greater than 80%, and no deaths or adverse outcomes have occurred. To date, we have collected prostate-specific antigen and endorectal magnetic resonance imaging and spectroscopy data on 63 patients (34 control and 29 intervention). This study demonstrates that a randomized, prospective dietary trial for men with localized prostate cancer is safe and feasible. The methodologies used provide insights into practical aspects of diet design and compliance assessment that may be useful templates for future dietary trials.

Electrophysiologic and clinical effects of angiotensin-converting enzyme inhibitors in patients with prior myocardial infarction, nonsustained ventricular tachycardia, and depressed left ventricular function. MUSTT Investigators. Multicenter UnSustained Tachycardia Trial

Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce sudden cardiac death and all-cause mortality. They also may have direct antiarrhythmic properties. We retrospectively analyzed the data from the Multicenter UnSustained Tachycardia Trial (MUSTT), to determine the effects of ACE inhibitors on inducibility of sustained ventricular tachycardia and on sudden cardiac death and overall mortality in 2,087 patients with prior myocardial infarction, nonsustained ventricular tachycardia, and depressed left ventricular function. Results of electrophysiologic testing were compared by use of ACE inhibitors at baseline, and outcomes were compared between the 564 patients prescribed ACE inhibitors at discharge and the 1,523 patients who did not receive treatment. The inducibility of sustained ventricular tachycardia during electrophysiologic testing did not differ by baseline ACE inhibitor use (unadjusted p = 0.75). Patients discharged from hospital on ACE inhibitors had a lower ejection fraction, more extensive coronary artery disease, and fewer previous revascularizations at baseline. After adjustments for differences in baseline factors and initial hospitalization variables, there were no significant differences in total mortality (p = 0.47) or arrhythmic death or cardiac arrest (p = 0.51) with ACE inhibitor use at discharge over a median 43 months of follow-up.

Initial clinical experience with a new self-retaining left ventricular lead for permanent left ventricular pacing

This study evaluated the performance of a new lead for permanent left ventricular (LV) pacing via the coronary sinus (CS) in four men and nine women (mean age = 71 +/- 13 years) with sick sinus syndrome. It consists of a 75-cm-long, 4.8-Fr, unipolar ventricular lead with a distal portion preshaped in an S curve to provide steerability and stability within the CS. Its efficacy and stability for permanent LV pacing were tested at implant, predischarge, and at 1, 3 and 6 months of follow-up. The lead was successfully implanted in 11/13 patients (85%) within a mean fluoroscopy time of 35 +/- 22 minutes. The final positions of the electrodes at the tip of the lead within venous tributaries of the CS were: (1) anterior (n = 2, 18%); (2) posterolateral (n = 5, 45%); and (3) the lateral (n = 4, 36%). Unsuccessful implants were due to unstable lead position (n = 1), or high pacing threshold (n = 1). There was no postprocedural lead dislodgment or significant changes in the R wave amplitude, LV pacing threshold and lead impedance up to 6 months of follow-up. In summary, this initial experience suggests that this new lead offers safe and reliable permanent LV pacing via the CS in the majority of patients and may be used in isolation or in conjunction with right ventricular pacing for biventricular synchronization.

Efficacy and tolerability of continuous overdrive atrial pacing in atrial fibrillation

Overdrive right atrial pacing has been used to prevent atrial fibrillation, but its efficacy in atrial fibrillation prevention and the patient tolerability and quality of life during high rate pacing remain uncertain. The objective of this study was to test the effects of a consistent atrial pacing algorithm that automatically paced the atrium at 30 ms shorter than the sinus P-P interval for atrial fibrillation prevention. Fifteen patients with sick sinus syndrome implanted with a Thera DR (model 7940 or 7960, Medtronic Inc.) were randomly programmed to rate adaptive dual chamber pacing (DDDR) or DDDR + consistent atrial pacing mode, each for an 8-week study period. The efficacy of consistent atrial pacing was assessed by the number of automatic mode switching and the number of premature atrial complexes. Symptoms and quality of life were assessed by the SF-36 quality of life questionnaire and an atrial fibrillation symptom checklist. The percentage of atrial pacing increased from 57 +/- 32% to 86 +/- 28%. Overall, there was no significant difference in the number of automatic mode switching episodes between DDDR and DDDR + consistent atrial pacing (47 +/- 90 vs 42 +/- 87, P > 0.05), but a significant reduction in premature atrial complexes by 74.7% (P < 0.001). There was no undue increase in atrial rate by the DDDR + consistent atrial pacing mode versus DDDR (63 +/- 13 vs 70 +/- 7 bpm). There was no significant difference in quality of life scores and symptom severity on frequency between the two modes of pacing, but a trend towards a lower frequency of symptoms in the DDDR + consistent atrial pacing mode compared with baseline (29.5 +/- 10.2 vs 25.1 +/- 9.7, P = 0.07). An algorithm that provides consistent atrial overdrive pacing can suppress atrial fibrillation triggering premature atrial complexes without the need to increase the overall atrial rate compared with conventional pacing. The algorithm appears to be well-tolerated, but further studies are needed to address the clinical impact of this atrial fibrillation prevention algorithm.

A convenient method for the synthesis of DNA-recognizing polyamides in solution

A convenient method for the synthesis of polyamides containing N-methylpyrrole (Py) and N-methylimidazole (Im) in solution has been developed. Most of the building blocks have been prepared by a haloform reaction in a simple way that column chromatography can be avoided. By use of the DCC/HOBT coupling reaction, the building blocks prepared have been effectively connected to construct a variety of subchains and polyamides without employing amino protection and deprotection. By use of the present method, an eight-ring polyamide, PyPyPyPygammaPyImImPybetaDp (gamma is gamma-aminobutyric acid, beta is beta-alanine, Dp is N, N-dimethylpropyldiamine), has been synthesized by the coupling of two four-ring subchains in one step.

Effects of biatrial pacing in prevention of postoperative atrial fibrillation after coronary artery bypass surgery

BACKGROUND

Atrial fibrillation (AF) is common after coronary artery bypass surgery (CABG) and results in prolonged hospitalization. The purpose of this study was to evaluate the efficacy of biatrial pacing in preventing post-CABG AF compared with single-site atrial pacing.

METHODS AND RESULTS

A total of 132 patients who had no history of AF and who underwent CABG were randomized to 1 of the following 4 groups: biatrial pacing (BiA), left atrial pacing (LA), right atrial pacing (RA), or no pacing (control) in postoperative period. Overdrive atrial pacing was performed for 5 days. The incidence of AF was significantly reduced in the BiA group (12.5%) compared with the other 3 groups (LA, 36.4%; RA, 33.3%; control, 41. 9%; P<0.05). The mean length of hospital stay was significantly reduced in the BiA group. At baseline, the mean P-wave duration (P(dur)) and dispersion (P(dis)) were not prolonged. BiA pacing resulted in the most significant percentage of reduction in P(dis) when compared with the LA or RA groups (BiA, 42+/-8%; LA, 13+/-6%; RA, 10+/-9%; P<0.05 for BiA versus LA or RA). No significant differences existed in mean P(dur) and P(dis) between patients who developed AF and those who remained in sinus rhythm at baseline. However, only those patients who remained in sinus rhythm had a significant reduction in mean P(dur) and P(dis) after pacing therapy.

CONCLUSIONS

Biatrial overdrive pacing is more effective in preventing post-CABG AF than single-site atrial pacing; this therapy also results in a shortened hospital stay. The overall reduction in atrial activation time with BiA pacing was reflected in the reduction in P(dis).

Prevention of ventricular fibrillation by pacing in a man with Brugada syndrome

The unique ECG appearance of Brugada syndrome is caused by failure of the dome of the action potential to develop. It occurs when the outward currents (mainly Ito) overwhelm the inward currents (mainly Ica) at the end of phase 1 of the action potential. Because Ito becomes less prominent at a faster rate, increased heart rate is associated with decreased ST segment elevation on ECG and probably decreased incidence of ventricular arrhythmia. We present the first report on prevention of ventricular fibrillation in a man with Brugada syndrome by overdrive pacing from his dual chamber implantable cardioverter defibrillator.

Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators

BACKGROUND

The mortality rate among patients with coronary artery disease, abnormal ventricular function, and unsustained ventricular tachycardia is high. The usefulness of electrophysiologic testing for risk stratification in these patients is unclear.

METHODS

We performed electrophysiologic testing in patients who had coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias could be induced were randomly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy. The primary end point was cardiac arrest or death from arrhythmia. Patients without inducible tachyarrhythmias were followed in a registry. We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were randomly assigned to receive no antiarrhythmic therapy in order to assess the prognostic value of electrophysiologic testing.

RESULTS

Patients were followed for a median of 39 months. In a Kaplan-Meier analysis, two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent, respectively, among the patients in the registry, as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy (adjusted P<0.001). Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias, as compared with 44 percent among the patients in the registry (adjusted P=0.005). Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias (45 and 54 percent, respectively; P=0.06).

CONCLUSIONS

Patients with coronary artery disease, left ventricular dysfunction, and asymptomatic, unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias cannot be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias.

Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators

BACKGROUND

Appropriate treatment policies should include an accurate estimate of a patient's baseline risk. Risk modeling to date has been underutilized in patients with acute coronary syndromes without persistent ST-segment elevation.

METHODS AND RESULTS

We analyzed the relation between baseline characteristics and the 30-day incidence of death and the composite of death or myocardial (re)infarction in 9461 patients with acute coronary syndromes without persistent ST-segment elevation enrolled in the PURSUIT trial [Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy]. Variables examined included demographics, history, hemodynamic condition, and symptom duration. Risk models were created with multivariable logistic regression and validated by bootstrapping techniques. There was a 3.6% mortality rate and 11.4% infarction rate by 30 days. More than 20 significant predictors for mortality and for the composite end point were identified. The most important baseline determinants of death were age (adjusted chi(2)=95), heart rate (chi(2)=32), systolic blood pressure (chi(2)=20), ST-segment depression (chi(2)=20), signs of heart failure (chi(2)=18), and cardiac enzymes (chi(2)=15). Determinants of mortality were generally also predictive of death or myocardial (re)infarction. Differences were observed, however, in the relative prognostic importance of predictive variables for mortality alone or the composite end point; for example, sex was a more important determinant of the composite end point (chi(2)=21) than of death alone (chi(2)=10). The accuracy of the prediction of the composite end point was less than that of mortality (C-index 0.67 versus 0.81).

CONCLUSIONS

The occurrence of adverse events after presentation with acute coronary syndromes is affected by multiple factors. These factors should be considered in the clinical decision-making process.

[A study on the size, location and medical function of the Jaedong Jejoongwon]

This is the study of Jaedong Jejoongwon, the first westernized hospital in Korea founded in 1885. To build the groundwork for study of Jejoongwon, its size, location, building structure, and medical functions were studied. At the same time, the history of Jejoongwon, particularly that of the time when there arose a need for its moving and expansion, was studied. Jaedong Jejoongwon was founded in a renovated building. The building was formerly owned by Hong Young-sik, who was killed while leading the Gapsinjungbyun. According to the existing block plan of Jaedong Jejoongwon, when it was opened in 1885, it was located in the place which later became a park. Nowadays this park is to northwest of the Constitutional Court. At that time, its size was about 600 p'yung. As the medical school was built, from end of 1885 to early 1886, Jejoongwon was expanded to north, and its size was enlarged to 862.16 p'yung. Jaedong Jejoongwon reflected the characteristics of western medical system. When it was opened in 1885, Jejoongwon consisted of a servants' room, an assistants' room, the outpatient clinic, the operation room (which was also used as the pharmacy), surgical wards, women's wards, and general wards. In 1886, as the number of patients was increased and medical school was opened, the function and the structure of hospital changed. The most significant change was that a new medical school building was built, as the nearby buildings were brought. The medical school consisted of the students' dormitory, a chemistry laboratory, and classrooms. Moreover, new functions were added to already-existed hospital building : a contagious ward, a waiting room for outpatients, an eye ward, a darkroom, a room for special diagnosis and treatment, and a vaccination room. Also, from the time when it was first opened, Jejoongwon needed the expansion, as too many patients came in and the medical education was started. Therefore, in the summer of 1886, Allen positively explored ways toward the hospital's moving. At last, in early 1887, Jaedong Jejoongwon moved to Kurigae on along with the development of medical education and medical treatment, shows how the modern medical system was formed and developed in Korea.

Detection of microcalcifications using spatial filtering

This paper studied the feasibility of applying a spatial filter, called the iris filter, in microcalcification detection. While a majority of techniques manipulate data in the transform space, this spatial filter was chosen in an attempt to reduce computation. The iris filter has the ability to differentiate between circular and line-like objects. It computes the convergence of nearby gradient vectors relative to the centre of the filter. However, as the results of this paper show, the decrease in the constraint factor, which is an inner limit of the support region of the filter, also leads to a decrease in the detection ability of the filter. Hence, this filter is not ideal for detection of microcalcifications.

A new bacterial white spot syndrome (BWSS) in cultured tiger shrimp Penaeus monodon and its comparison with white spot syndrome (WSS) caused by virus

This paper describes a new bacterial white spot syndrome (BWSS) in cultured tiger shrimp Penaeus monodon. The affected shrimp showed white spots similar to those caused by white spot syndrome virus (WSSV), but the shrimp remained active and grew normally without significant mortalities. The study revealed no evidence of WSSV infection using electron microscopy, histopathology and nested polymerase chain reaction. Electron microscopy indicated bacteria associated with white spot formation, and with degeneration and discoloration of the cuticle as a result of erosion of the epicuticle and underlying cuticular layers. Grossly the white spots in BWSS and WSS look similar but showed different profiles under wet mount microscopy. The bacterial white spots were lichen-like, having perforated centers unlike the melanized dots in WSSV-induced white spots. Bacteriological examination showed that the dominant isolate in the lesions was Bacillus subtilis. The occurrence of BWSS may be associated with the regular use of probiotics containing B. subtilis in shrimp ponds. The externally induced white spot lesions were localized at the integumental tissues, i.e., cuticle and epidermis, and connective tissues. Damage to the deeper tissues was limited. The BWS lesions are non-fatal in the absence of other complications and are usually shed through molting.

Prediction of 1-year survival after thrombolysis for acute myocardial infarction in the global utilization of streptokinase and TPA for occluded coronary arteries trial

BACKGROUND

When a patient survives thrombolysis for acute myocardial infarction, little information from large studies exists from which to estimate prognosis during follow-up visits.

METHODS AND RESULTS

Baseline, in-hospital, and later survival data were collected from 41 021 patients enrolled in Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries, a randomized trial of 4 thrombolytic-heparin regimens with standard aspirin and beta-blockade. Cox proportional hazards models were developed to predict 1-year survival in 30-day survivors (n=37 869) from baseline clinical and ECG factors and in-hospital factors; a combined model then was developed (C-index 0.800). The model was simplified into a nomogram to predict individual outcomes (C-index 0.754). Factors reflecting demographics (advanced age, lighter weight), larger infarctions (higher Killip class, lower blood pressure, faster heart rate, longer QRS duration), cardiac risk (smoking, hypertension, prior cerebrovascular disease), and arrhythmia were important predictors of death between 30 days and 1 year. Black race was associated with a substantial increase in risk after considering other factors. Revascularization was associated with reduced risk between 30 days and 1 year.

CONCLUSIONS

When evaluating a patient who has survived acute infarction treated with thrombolysis, clinicians can estimate the likelihood of survival from factors easily measured during admission. Although many risk factors clearly relate to age, left ventricular dysfunction, or clinical instability, black race is an unexplained risk factor requiring further examination.

Clinical trials in acute myocardial infarction: should we adjust for baseline characteristics?

BACKGROUND

Clinical trials concerning acute myocardial infarction often evaluate short-term death. Several baseline characteristics are predictors of death, most notably age. Adjustment for one or more predictors in a multivariable analysis may be considered to correct the estimate of the treatment effect for any imbalance that by chance may have occurred between the randomized groups. Moreover, adjustment results in a stratified estimate of the effect of treatment.

METHODS AND RESULTS

The effects of adjustment (correction for imbalance and stratification) were studied with logistic regression analysis in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO)-I trial. The primary end point was 30-day death, which occurred in 6.3% of 10,348 patients randomly assigned to tissue plasminogen activator and 7.3% of 20,162 patients randomly assigned to streptokinase thrombolytic therapy. This is equivalent to an unadjusted odds ratio of 0.853. No significant imbalance had occurred for any of 17 baseline characteristics considered, including well-known demographic, presenting, and history characteristics. Adjusted for age, the odds ratio was 0.829, which is an 18% increase in estimated effect on the logistic scale. When adjusted for 17 characteristics, the odds ratio was 0.820, an increase of 25%. The increase in effect estimate was largely explained by the stratification effect and only partly by imbalance of predictors.

CONCLUSIONS

Adjustment for predictive baseline characteristics, even when largely balanced, may lead to clearly different estimates of the treatment effect on mortality rates. Adjustment for important predictors such as age is recommended in clinical trials studying patients with acute myocardial infarction.

Stability of methylene chloride spiked passive samplers: an international shipping and transportation study

A stability study was carried out by dynamically spiking Assay Technology Model 541 passive samplers with known amounts of methylene chloride (MeCl2) and shipping them to facilities around the world. Once arrived, these samples remained on site briefly and then were returned to the laboratory in North Chicago, III. A total of 22 sets of samples was prepared. Each sample set contained four passive samplers: blank, low (2.5 ppm), medium (25 ppm), and high (125 ppm) concentrations. Twelve of the 22 sets were separated into 4 groups of 3 sets, with each group defined as a cluster. One cluster was shipped to a pharmaceutical production facility in each country--South Africa, Pakistan, and Indonesia--and then shipped back to the lab, under normal shipping conditions. The fourth cluster was carried by one of the authors, who traveled through all three countries. The remaining 10 sets of samples were kept in the lab as controls. Each returning cluster was analyzed with two lab sets on arrival in the lab. Results obtained were evaluated using a t-test at a 95% confidence level. No significant differences were found in MeCl2 spiked passive samplers between traveled and lab controls, samples stored at room temperature and in the freezer, or analyzed right after being spiked and stored up to 7 weeks. It was concluded that MeCl2 spiked passive samplers were stable for at least 4 weeks at room temperature. There was no impact observed from international shipping and transportation on MeCl2 spiked passive samplers without temperature control.

Pharmacotherapy for erectile dysfunction

OBJECTIVE

To review current pharmacologic treatment options for erectile dysfunction.

METHODS

Relevant literatures from the past two decades regarding the following treatments were reviewed: intracavemous injection, topical therapy, transurethral therapy and oral drugs.

STUDY SELECTION

More than 125 originally identified articles were reviewed, and 45 were selected that especially addressed the stated purpose.

RESULTS

Among the pharmacologic treatment options available, intracavemous injection therapy remains the most effective although the drop-out rate is high. Topical creams and gels have not been very successful. Transurethral alprostadil can be more effective if a constriction device is applied at the base of the penis. Oral sildenafil has the highest patient acceptance rate although systemic side effects can be a major drawback.

CONCLUSIONS

Effective pharmacotherapies for ED of various etiologies are now available. However, proper evaluation of every patient should be performed before giving treatment so that a number of potentially life-threatening causes of erectile dysfunction would not be missed.

Prenyltransferase inhibitors block superoxide production by pulmonary vascular smooth muscle

We recently showed that the farnesyltransferase inhibitor FTI-277 blocks interleukin 1beta (IL-1beta)-induced nitric oxide production in pulmonary vascular smooth muscle cells (SMC), whereas the geranylgeranyltransferase inhibitor GGTI-298 enhances this effect. Here we show that IL-1beta and platelet-derived growth factor (PDGF) stimulate superoxide production by pulmonary vascular SMC and that this effect is blocked by both FTI-277 and GGTI-298, suggesting that farnesylated and geranylgeranylated proteins are required for superoxide production. We also show that FTI-277 and GGTI-298 block superoxide production stimulated by constitutively active mutant H-Ras. Furthermore, superoxide production by IL-1beta, PDGF factor, and constitutively activated Ras is blocked by diphenyleneiodonium, implicating NAD(P)H oxidase as the generating enzyme. Given the role of oxidant radicals in vascular reactivity and injury, the action of both FTI-277 and GGTI-298 in suppressing superoxide generation by an inflammatory cytokine as well as by a potent smooth muscle mitogen may be therapeutically useful.

Prognostic models based on literature and individual patient data in logistic regression analysis

Prognostic models can be developed with multiple regression analysis of a data set containing individual patient data. Often this data set is relatively small, while previously published studies present results for larger numbers of patients. We describe a method to combine univariable regression results from the medical literature with univariable and multivariable results from the data set containing individual patient data. This 'adaptation method' exploits the generally strong correlation between univariable and multivariable regression coefficients. The method is illustrated with several logistic regression models to predict 30-day mortality in patients with acute myocardial infarction. The regression coefficients showed considerably less variability when estimated with the adaptation method, compared to standard maximum likelihood estimates. Also, model performance, as distinguished in calibration and discrimination, improved clearly when compared to models including shrunk or penalized estimates. We conclude that prognostic models may benefit substantially from explicit incorporation of literature data.

Immunoglobulin M and G immunoblots in the diagnosis of parvovirus B19 infection

BACKGROUND AND PURPOSE

To identify parvovirus B19 infection by means of immunoglobulin (Ig) G and IgM immunoblots among immunocompetent patients who tested negative or had low-titer B19 IgM antibodies in enzyme-linked immunosorbent assays (ELISA).

METHODS

Serum samples were obtained from 20 patients with parvovirus B19 infection. Another 130 study subjects presumed to be without B19 infection (40 medical personnel and 90 prisoners) were also included. All sera from the patient and study groups tested positive for IgG or IgM with ELISA and were further evaluated using the immunoblot method. Detection of B19 DNA by nested polymerase chain reaction (PCR) was also performed on IgG and IgM positive sera.

RESULTS

IgM immunoblots disclosed one false positive IgM ELISA result in the patient group and three false positive results in the study group. In the patient group, four patients were in the latter stage of antibody response to B19 infection as suggested by the low titer of anti-B19 IgM, incomplete IgM immunoblots, with only a weak viral capsid protein VP-N reaction band, and fading but still strong reaction bands on IgG immunoblots. Strong reaction bands on IgG immunoblots comparable to these four patients were found in three of the 130 study group sera. Furthermore, B19 DNA was detected in three of the four patients and one of the three study subjects by means of nested-PCR. A serum sample from one study subject showed strong IgG but no IgM reactivity to viral capsid protein VP2; nested PCR identified B19 DNA in this serum sample.

CONCLUSIONS

Immunoblots and nested PCR should be applied in the diagnosis of B19 infection for patients with low-titer anti-B19 IgM tested by means of ELISA. For diagnosis of B19 infections in certain clinical entities such as chronic arthritis of recent onset and hydrops fetalis, B19 IgM antibodies may have disappeared but B19 infection can still be recognized by the intensity of the reaction bands on IgG immunoblots. The correlation between chronic B19 infection and persistence of antilinear VP2 epitopes requires further study.

A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators

BACKGROUND

Empirical antiarrhythmic therapy has not reduced mortality among patients with coronary artery disease and asymptomatic ventricular arrhythmias. Previous studies have suggested that antiarrhythmic therapy guided by electrophysiologic testing might reduce the risk of sudden death.

METHODS

We conducted a randomized, controlled trial to test the hypothesis that electrophysiologically guided antiarrhythmic therapy would reduce the risk of sudden death among patients with coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias were induced by programmed stimulation were randomly assigned to receive either antiarrhythmic therapy, including drugs and implantable defibrillators, as indicated by the results of electrophysiologic testing, or no antiarrhythmic therapy. Angiotensin-converting-enzyme inhibitors and beta-adrenergic-blocking agents were administered if the patients could tolerate them.

RESULTS

A total of 704 patients with inducible, sustained ventricular tachyarrhythmias were randomly assigned to treatment groups. Five-year Kaplan-Meier estimates of the incidence of the primary end point of cardiac arrest or death from arrhythmia were 25 percent among those receiving electrophysiologically guided therapy and 32 percent among the patients assigned to no antiarrhythmic therapy (relative risk, 0.73; 95 percent confidence interval, 0.53 to 0.99), representing a reduction in risk of 27 percent). The five-year estimates of overall mortality were 42 percent and 48 percent, respectively (relative risk, 0.80; 95 percent confidence interval, 0.64 to 1.01). The risk of cardiac arrest or death from arrhythmia among the patients who received treatment with defibrillators was significantly lower than that among the patients discharged without receiving defibrillator treatment (relative risk, 0.24; 95 percent confidence interval, 0.13 to 0.45; P<0.001). Neither the rate of cardiac arrest or death from arrhythmia nor the overall mortality rate was lower among the patients assigned to electrophysiologically guided therapy and treated with antiarrhythmic drugs than among the patients assigned to no antiarrhythmic therapy.

CONCLUSIONS

Electrophysiologically guided antiarrhythmic therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease.

Effect of the implantable atrial defibrillator on the natural history of atrial fibrillation

INTRODUCTION

The purpose of our study was to evaluate the effect of repeated cardioversion with an implantable atrial defibrillator on the clinical outcome of patients with atrial fibrillation.

METHODS AND RESULTS

The effects of the implantable atrial defibrillator on the total duration of atrial fibrillation, number of atrial fibrillation recurrences, and left atrial size were evaluated prospectively in 16 patients with atrial fibrillation (13 men and 3 women; mean age 58 +/- 11 years). Seven patients had no cardiovascular disease, 5 patients had hypertension, 3 patients had coronary heart disease, and 1 patient had congenital heart disease. Eight patients had paroxysmal atrial fibrillation for a mean duration of 80 +/- 61 months, and eight patients had persistent atrial fibrillation for a mean duration of 68 +/- 119 months. Except for one patient who received digoxin throughout the study, all patients received the same Class I or III antiarrhythmic agent throughout the study. The implantable atrial defibrillator successfully converted 50 (93%) of 54 spontaneous episodes of atrial fibrillation in 12 patients. During the initial 3 months of clinical follow-up, the atrial defibrillator documented 261 +/- 270 hours of atrial fibrillation compared with 126 +/- 172 hours (P = 0.01) during the subsequent 3 months. The left atrial size decreased from 4.4 +/- 0.7 cm at the time of atrial defibrillator implantation to 4.1 +/- 0.6 cm (P = 0.02) 6 months later. The number of atrial fibrillation recurrences did not change. These findings were observed in the absence of changes in drug therapy. No complications were observed.

CONCLUSION

Restoration and maintenance of sinus rhythm in patients with atrial fibrillation by repeated cardioversion with an implantable atrial defibrillator was associated with a reduction in the total arrhythmia duration and a reduction in left atrial size. These results suggest that maintenance of sinus rhythm with the atrial defibrillator may reverse the remodeling process associated with atrial fibrillation.

Autologous blood use in percutaneous nephrolithotomy

OBJECTIVES

Preoperative autologous blood (AUB) donation has decreased patient exposure to allogenic blood (ALB) products and associated infectious risk. The risk of contracting hepatitis C and human immunodeficiency virus is 1 in 103,000 and 1 in 678,000, respectively, after receiving 1 U ALB. Elective surgical procedures require surgeons to offer preoperative AUB donation in California. Unused AUB is discarded. We report our use of AUB obtained for percutaneous nephrolithotomy.

METHODS

A retrospective study of 144 consecutive patients who underwent 193 percutaneous nephrolithotomies between January 1994 and April 1998 at one of four teaching hospitals at the University of California, San Francisco was performed. Preoperative AUB donation, transfusion rates, hemoglobin levels, blood use, and costs were analyzed.

RESULTS

Ninety-six units of blood were collected from 63 patients (44%) and were available for 70 procedures (36%). The overall transfusion rate per procedure was 7%, with 13 patients receiving a total of 24 U, 7 AUB and 17 ALB. Eighty-nine units (92.7%) of AUB were discarded, and the transfusion rate in donors and nondonors was similar. There was no significant difference in preoperative hemoglobin or operative blood loss between donors and nondonors. The 13 transfused patients had a lower preoperative hemoglobin ( 11.5 versus 12.8 g/dL; P = 0.029) and higher operative blood loss as measured by hemoglobin level (3.2 versus 1.6 g/dL; P <0.001). Blood bank charges for ALB and AUB were $ 119/U and $244 to $498/U, respectively, depending on transportation and thawing charges.

CONCLUSIONS

Routine preoperative blood donation adds substantial cost for minimal benefit, given the low infectious risk of ALB and the two- to fourfold higher cost of AUB. In our series, women had an increased incidence of blood transfusion compared with men. AUB donation may provide peace of mind but is rarely used and is discarded 93% of the time.

Effect of adenosine and verapamil in catecholamine-induced accelerated atrioventricular junctional rhythm: insights into the underlying mechanism

Accelerated AV junctional rhythm is postulated to be due to enhanced automaticity of a high AV junctional focus. The adenosine response of this rhythm was tested in 17 patients (7 males, 12-83 years). The indications of electrophysiology study were nonspecific palpitation (n = 5), unexplained syncope (n = 6), postablation of accessory pathways (n = 4), and postmodification of AV nodal reentry tachycardia (n = 2). The sinus node and AV nodal functions were normal. Pacing and programmed electrical stimulation failed to induce any arrhythmia at baseline. The accelerated junctional rhythm (cycle length = 553 +/- 134 ms) was initiated spontaneously in all patients after isoproterenol infusion (1-2 micrograms/min). It was not suppressible by overdrive pacing. Cessation of isoproterenol infusion terminated the rhythm in all patients. Adenosine (6 mg) reproducibly terminated the accelerated junctional rhythm in all patients. In six patients, adenosine suppressed the junctional rhythm without producing AV nodal block. In the other 11 patients, the junctional rhythm was terminated prior to the occurrence of AV nodal block. Verapamil was tested in ten patients and 5 mg of intravenous verapamil terminated the junctional rhythm in all patients. In conclusion, the mechanism of catecholamine-induced accelerated AV junctional rhythm is most likely enhanced automaticity, and catecholamine-induced accelerated AV junctional automaticity is sensitive to adenosine and verapamil. Adenosine appears to have differential effects on catecholamine-enhanced AV junctional automaticity and AV nodal conduction. This suggests that, under catecholamine stimulation, adenosine may have different mechanisms of action on AV nodal conduction and automaticity.

Prediction of sustained ventricular tachycardia inducible by programmed stimulation in patients with coronary artery disease. Utility of clinical variables

BACKGROUND

Cardiologists often use clinical variables to determine the need for electrophysiological studies to stratify patients for risk of sudden death. It is not clear whether this is rational in patients with coronary artery disease, left ventricular dysfunction, and nonsustained ventricular tachycardia.

METHODS AND RESULTS

We analyzed the first 1721 patients enrolled in the Multicenter UnSustained Tachycardia Trial to determine whether clinical variables could predict which patients would have inducible sustained monomorphic ventricular tachycardia. The rate of inducibility of sustained ventricular tachycardia was significantly higher in patients with a history of myocardial infarction and in men compared with women. There was a progressively increased rate of inducibility with increasing numbers of diseased coronary arteries. There was a significantly lower rate of inducibility in patients with prior coronary artery bypass surgery and in patients who also had noncoronary cardiac disease. The rate of inducibility was higher in patients of white race, patients with recent (</=6 weeks) angina, left ventricular dyskinesis, and in patients with greater numbers of fixed thallium defects. Inducibility was more likely in patients who had a prior myocardial infarction complicated by congestive heart failure, ventricular tachycardia, or fibrillation </=48 hours after the onset of infarction. Although these associations are statistically significant, the accuracy of the clinical variables in discriminating between patients with and those without inducible ventricular tachycardia is only modest (receiver operator characteristic area <0.70).

CONCLUSIONS

Multiple clinical variables are independently associated with inducible sustained ventricular tachycardia. However, they have limited utility to guide clinical decisions regarding the use of electrophysiological testing for risk stratification in this patient population.

Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators

BACKGROUND

Recurrent ischemia after an acute coronary syndrome portends an unfavorable outcome and has major resource-use implications. This issue has not been studied systematically among the spectrum of patients with acute coronary presentations, encompassing those with and without ST-segment elevation.

METHODS AND RESULTS

We assessed the 1-year prognosis of the 12 142 patients enrolled in the GUSTO-IIb trial by the presence (n=4125) or absence (n=8001) of ST-segment elevation. This latter group was further categorized into those with baseline myocardial infarction (n=3513) or unstable angina (n=4488). We also assessed the incidence of recurrent ischemia and its impact on outcomes. Recurrent ischemia was significantly rarer in those with ST-segment elevation (23%) than in those without (35%; P<0.001). Mortality at 30 days was greater among patients with ST-segment elevation (6.1% versus 3.8%; P<0.001) but less so at 6 months; by 1 year, mortality did not differ significantly (9.6% versus 8.8%). Patients with non-ST-segment-elevation infarction had higher rates of reinfarction at 6 months (9.8% versus 6.2%) and higher 6-month (8.8% versus 5.0%) and 1-year mortality rates (11.1% versus 7.0%) than such patients who had unstable angina.

CONCLUSIONS

Refractory ischemia was associated with an approximate doubling of mortality among patients with ST-segment elevation and a near tripling of risk among those without ST elevation. This study highlights not only the substantial increase in late mortality and reinfarction with non-ST-segment-elevation infarction but also the opportunities for better triage and application of therapeutic strategies for patients with recurrent ischemia.

Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. The GUSTO-IIa Investigators

BACKGROUND

The baseline cardiac troponin T (cTnT) level strongly predicts short-term mortality in acute coronary syndromes, but the added value of later measures to predict short- and long-term outcome and in the context of baseline clinical characteristics is unclear.

METHODS AND RESULTS

Relations between baseline, peak, and 8- and 16-hour (late) cTnT results and outcomes were assessed in 734 patients in a GUSTO-IIa substudy. Proportional-hazards models assessed the prognostic information gained from late cTnT when added to a mortality model containing the baseline cTnT result and clinical factors. At baseline, 260 patients were cTnT-positive (>0.1 ng/mL), 323 became positive later, and 151 remained negative (</=0.1 ng/mL). Mortality at 30 days was 10% in the baseline-positive group, 5% in late-positive patients, and 0% in negative patients. After adjustment for baseline characteristics, any positive cTnT result predicted 30-day mortality (baseline, chi2=8.96, P=0.0113; 8-hour, chi2=6.51, P=0.0107; 16-hour, chi2=8.40, P=0.0038). Both the 8- and the 16-hour results added to the strength of the baseline result (baseline+8-hour, chi2=12.04, P=0.0072; baseline+16-hour, chi2=13.52, P=0.0036). Only age and ST-segment elevation were stronger predictors of 30-day mortality than baseline cTnT; results were similar for prediction of 1-year mortality. Most of the mortality difference between cTnT-positive and -negative patients occurred within the first 30 days.

CONCLUSIONS

The cTnT level is a strong, independent predictor of short-term outcome in acute coronary syndromes. The addition of later samples to a baseline level is useful to evaluate the risk of serious cardiac events.

In vitro bovine ciliary body/epithelium in a small continuously perfused Ussing type chamber

Our goal is to assess the viability of an in vitro preparation of bovine ciliary body/epithelium (CBE) in a small volume Ussing-type chamber. A new small volume Ussing-type chamber with continuous perfusion was developed for bovine CBE. The trans-CBE electrical parameters were monitored and the electrical responses of the CBE to ouabain (1 and 0.01 mM) were recorded. The trans-CBE fluxes of [14C]-L-ascorbate and [3H]-L-glucose were also studied. The bovine CBE preparation was stable inside the chamber in terms of its potential difference (PD), short circuit current (SCC) and trans-CBE resistance. They were -0.51+/-0.05 mV (aqueous side negative), -5.43+/-0.04 microAcm-2 and 94+/-2 Q.cm2 (mean s.e.m., n=35), respectively. The preparation hyperpolarised when 0.01 mM ouabain was administered to the aqueous side, depolarised when ouabain was applied to the stromal side. [3H]-L-glucose diffusion was about 74 nEq h(-1)cm(-2) in either direction (n=12). Taking the area magnification factor of the CBE into consideration, the diffusional L-glucose flux across the bovine CBE was comparable to other tight epithelia. A significant net ascorbate flux (0.26+/-0.05 nEq h(-1)cm(-2), n=4, p<0.01) was found in the stroma to aqueous direction. We have developed a viable in vitro bovine CBE preparation which was (1) electrically stable, (2) responsive to ouabain, (3) tight to L-glucose diffusion, and (4) capable of actively secreting ascorbate. A net trans-CBE chloride transport (0.81+/-0.30 microEq h(-1)cm(-2), n=12, p=0.01) from stromal to aqueous side was found in the present in vitro model under short-circuited conditions.

Chloride and sodium transport across bovine ciliary body/epithelium (CBE)

PURPOSE

To study the chloride and sodium ion transports across the bovine ciliary body/epithelium (CBE) by a modified Ussing-Zerahn type chamber.

METHODS

Isolated bovine CBE preparations were mounted in a modified Ussing-type chamber and the transepithelial electrical parameters were monitored. The inward (stroma to aqueous) and outward (aqueous to stroma) fluxes of 36[Cl] chloride and 22[Na] sodium ions across the CBE were measured under short-circuited conditions. The effect of 0.1 mM of furosemide and bumetanide on the chloride transport were studied.

RESULTS

The potential difference (PD), the resistance and the short-circuit current (SCC) across the isolated bovine ciliary body were found to be -0.20+/-0.01 mV (aqueous negative), 75+/-1 omegacm2 and -2.70+/-0.17 microAcm(-2) (mean+/-SEM, n=50) respectively. A statistically significant net inward chloride ion flux of 1.12+/-0.41 microEq h(-1)cm(-2) (p < 0.01) was found (n=15). The net chloride transport was abolished when 0.1 mM furosemide (82% inhibition) and 0.1 mM bumetanide (100% inhibition) were applied bilateral. No significant net sodium ion flux was detected.

CONCLUSIONS

Electrolyte and fluid transport across the bovine CBE may be via a bumetanide and furosemide-sensitive chloride transport mechanism. The Na-K-2Cl cotransporter plays a significant role in the trans-CBE chloride transport. The net chloride flux/current was about 12 times higher than the measured SCC, suggesting that the chloride ion transport may be coupled to other ion species.