Audit of antenatal clinic for high-risk obstetric patients; activity and outcomes

A specialised clinic for the antenatal care of high-risk patients was established in Cork in January 2004. It is led by 2 specialists in materno-fetal medicine and provides care for patients from a large catchment area. Small clinic numbers, specialised midwives, ready access to medical experts and fetal assessment facilities, facilitate an efficient use of resources. We report on the experience and utcomes of this clinic after the first year in operation. A database was set up to store relevant information on patients who attended the clinic in 2004. 143 patients attended. Risk categories included maternal medical disease (62%); multiple pregnancy (11%); previous poor obstetric history (10%); fetal anomaly (8%). Average gestation; 35.9 weeks, average birth weight; 2598g. Caesarean section rate; 41%/o. Perinatal mortality rate 67 per 1000 (uncorrected); and 20% neonates required NICU care. This approach to high-risk obstetric care resulted in favourable outcomes. The management strategy applied in Cork may be a suitable prototype for comparable areas throughout Ireland.

Total and inorganic arsenic in Mid-Atlantic marine fish and shellfish and implications for fish advisories

Sampling was conducted in 2002 to determine the total concentration and chemical speciation of arsenic in several marine fish and shellfish species collected from the Delaware Inland Bays and the Delaware Estuary, both of which are important estuarine waterbodies in the US Mid-Atlantic region that support recreational and commercial fishing. Edible meats from summer flounder (Paralicthys dentatus), striped bass (Marone saxatilis), Atlantic croaker (Micropogonias undulates), and hard clam (Mercenaria mercenaria) were tested. Total arsenic was highest in summer flounder, followed by hard clam, then striped bass, and finally, Atlantic croaker. Total arsenic was higher in summer flounder collected during the spring, as these fish migrated into the Inland Bays from the continental shelf, compared with levels in summer flounder collected during the fall, after these fish had spent the summer in the Inland Bays. Similarly, striped bass collected in the early spring close to the ocean had higher total arsenic levels compared with levels detected in striped bass collected later during the year in waters with lower salinity. Speciation of arsenic revealed low concentrations (0.00048-0.02 microg/g wet wt) of toxic inorganic arsenic. Dimethylarsinic acid was more than an order of magnitude greater in hard clam meats than in the other species tested, a finding that was attributed to arsenic uptake by phytoplankton and subsequent dietary uptake by the clam. Risk assessment using the inorganic arsenic concentrations was used to conclude that a fish consumption advisory is not warranted.

The radiological spectrum of pulmonary aspergillosis

Imaging findings in the pulmonary aspergilloses can answer important clinical questions. Steroid-responsive chronic asthma due to allergic bronchopulmonary aspergillosis can be differentiated from simple asthma by computed tomography (CT) evidence of extensive and severe central bronchiectasis, mucoid impaction, or small airways lesions. The simple aspergilloma can be differentiated from the complex aspergilloma by the absence of: constitutional symptoms, para-cystic lung opacities, cyst expansion, or progressive pleural thickening. The CT halo sign is a transient finding that can provide a probable diagnosis of early invasive pulmonary aspergillosis in patients who are at extraordinarily high risk of the infection. Patients with a halo sign at baseline are more likely to have a satisfactory treatment response than those without this indicator.

Navigating the waters of pharmacy regulations in hospice care. Facing a common scenario: why can it be so difficult to obtain emergency medications?

Imagine a common scenario that faces many hospice clinicians: It is 1 a.m., and the sister of your newest patient just called the on-call service to alert your hospice that the patient is in excruciating pain. In fact, the patient's pain is so bad that she is asking whether she should take her to the nearest hospital emergency room. You anticipated this pain, of course, but the patient did not have moderate or severe pain to this point, and the physician wouldn't agree to provide a small supply of morphine to have on hand.

A cost-effectiveness analysis of a peak flow-based asthma education and self-management plan in a high-cost population

BACKGROUND

Asthma education and action plans (AP) have been recognized as important components in the optimal management of asthma. Studies have differed on the importance of a peak flow-based self-management plans in reducing health care costs and use due to asthma exacerbation.

OBJECTIVE

To analyze the cost-effectiveness of peak flow-based action plans in reducing costs associated with ER visits and hospitalizations due to acute asthma exacerbation in a population of high-risk and high-cost patients, defined as patients with moderate to severe asthma with a history of recent urgent treatment in the ER or hospitalization due to asthma.

METHODS

A literature review of randomized clinical trials comparing peak flow-based (PFB) action plans, symptom-based (SB) action plans, and usual care/no action plan (NAP) was performed. Probability values regarding the effectiveness of each alternative (as measured by increase/decrease in ER visits and hospitalizations over a 6-month period) were derived. Incremental cost-effectiveness and cost-benefit ratios were calculated for each alternative. Sensitivity analyses were performed.

RESULTS

For high-risk and high-cost asthma patients, our analysis revealed that the most cost-effective alternative for reducing ER visits was a peak flow-based self-management plan. The peak flow-based self-management program had an incremental cost-effectiveness (C/E) ratio of $ 60.57 per ER visit averted compared to usual care/NAP and a C/E ratio of $31.46 compared to the SB-AP. The PFB-AP was also the most cost-effective in reducing asthma hospitalization costs with an incremental C/E ratio of $300 per hospitalization prevented, compared with usual care and a C/E ratio of $311, compared to a SB-AP. Analysis yielded a cost-benefit ratio of 13.79 for the PFB-AP compared to NAP; the SB-AP had a cost-benefit ratio of 11.53 compared to NAP.

CONCLUSION

Cost-effectiveness and cost-benefit analyses reveal that for high-cost patients, a peak flow-based asthma education and self-management plan program is the most cost-effective alternative in reducing costs associated with ER visits and hospitalizations due to asthma exacerbation. Further refinements to this cost-effectiveness analysis including measuring changes in drug use and costs and patients' productivity losses need to be pursued and may demonstrate additional cost-savings due to peak flow-based asthma education plans.

Disinhibition of ventrolateral preoptic area sleep-active neurons by adenosine: a new mechanism for sleep promotion

The ventrolateral preoptic area of the hypothalamus (VLPO) contains a population of sleep-active neurons and is hypothesized to be an important part of the somnogenic process. Adenosine (AD) is an endogenous sleep-promoting factor and may play an important role in promoting natural sleep. We hypothesize that AD may promote sleep, in part, by activating the VLPO sleep-active neurons. Although, in the CNS, AD is generally regarded as an inhibitory neuromodulator, it is possible for AD to be directly excitatory via A2 receptors or indirectly via disinhibition. In order to test the hypotheses that AD can excite VLPO neurons we made intracellular recordings from the VLPO in vitro and examined the effects of AD on VLPO neural activity. Whole cell patch-clamp recordings were obtained from rat brain slices and drugs were bath applied. VLPO neurons were electrophysiologically heterogeneous. Depolarizing current steps elicited rhythmic firing (25 of 57), spike frequency adaptation or accommodation (24 of 57), or an unusual burst firing response (eight of 57). Spontaneous synaptic activity was pronounced in most recorded neurons and consisted of either fast excitatory post-synaptic potentials/currents (EPSP/C's) and/or fast inhibitory post-synaptic potentials/currents (IPSP/C's). The IPSC's were fully blocked by 30 microM bicuculline suggesting they are GABA(A)-mediated events, and the EPSC's were blocked by 40 microM DNQX suggesting they are mediated by the AMPA subtype of glutamate receptor (five of five). AD (20-100 microM) reduced the frequency of spontaneous IPSC's in 11 of 17 VLPO neurons (28-100%; mean reduction=63%) without significant effects on resting membrane potential. IPSC was unaffected in five neurons and one neuron displayed increases in spontaneous IPSC's. In contrast, AD decreased EPSC frequency in seven cells (36-73%; mean=59%), increased frequency in five cells (30-236%; mean 83%) and had no effect in six cells. AD application increased the firing rate in two of four cells tested. These data are consistent with the hypothesis that one mechanism which AD may promote sleep is by blocking inhibitory inputs on VLPO sleep-active neurons.

Circuit analysis of NMDAR hypofunction in the hippocampus, in vitro, and psychosis of schizophrenia

NMDA antagonists provide the best pharmacological model of psychosis-related schizophrenia. Data from circuit analysis of the effects of the antagonism of NMDA receptors in the CA1 region of the hippocampus of rats in vitro suggest a hypothesis concerning cortical circuit dysfunction responsible for NMDA antagonist-dependent psychosis, relevant to the psychosis associated with schizophrenia. The NMDA antagonists may act by causing a selective, partial, disinhibition of cortical projection cells. The effects are partially due to the partial role of NMDA-dependent transmission in the excitatory glutamate drive of interneurons. Characterization of the selectivity is incomplete, but includes disinhibition of the recurrent inhibitory circuit and is concentration-sensitive. It may result from differences in NMDA receptors (NMDARs) on interneurons. At higher concentrations, antagonism of all NMDA-dependent transmission results in anesthesia. At low concentration, selective blockade of NMDA-dependent LTP of the recurrent inhibitory circuit may disrupt particular aspects of information processing involving learning and/or memory, consistent with the generation of abnormal associations. An endogenous peptide, NAAG, is shown to antagonize NMDARs in a manner similar to known psychotogenic agents like ketamine or phencyclidine. Finally, mechanisms that could enhance NMDAR function are discussed as possible therapeutic strategies for psychosis.

Functional comparison of transmyocardial revascularization by mechanical and laser means

BACKGROUND

As a result of the clinical benefit observed in angina patients treated by transmyocardial revascularization (TMR) with a laser, interest in mechanical TMR has been renewed. Although the injury induced by mechanical TMR is similar to laser TMR, the resultant impact on myocardial contractility is unknown. The purpose of this study was to determine whether mechanical TMR improves ventricular function as compared with laser TMR in chronically ischemic myocardium.

METHODS

After establishing an area of chronic myocardial ischemia, 25 domestic pigs were randomized to treatment by: excimer laser (group I), a hot needle (50 degrees C) (group II), a normothermic needle (group III), an ultrasonic needle (40 KHz) (group IV), or no treatment (group V). All devices create a transmural channel of the same diameter; 22 +/- 1 transmural channels were created in each animal. Regional myocardial contractility was assessed by measuring ventricular wall thickening at rest and with dobutamine stress echocardiography. Six weeks after revascularization, the animals were restudied at rest and with stress. Postsacrifice and histologic analysis of angiogenesis and TMR effects was then assessed.

RESULTS

Laser TMR provided significant recovery of ischemic myocardial function. This improvement in contractility after laser TMR was a 75% increase over the baseline function of the ischemic zone (p < 0.01). Mechanical TMR provided no significant improvement in function posttreatment. In fact, TMR achieved with an ultrasonic needle demonstrated a 40% worsening of the contractility versus the pretreatment baseline (p < 0.05). Histologic analysis demonstrated a significant increase in new blood vessels in the ischemic zone after laser TMR, which was not demonstrated for any of the other groups (p < 0.05). Additionally, evaluation of the mechanical TMR channels demonstrated significant scarring, which correlated with the functional results.

CONCLUSIONS

Using devices to create an injury analogous to the laser, mechanical TMR failed to improve the function of chronically ischemic myocardium. Only laser TMR significantly improved myocardial function.

The effects of Phaseolus vulgaris erythro- and leucoagglutinating isolectins (PHA-E and PHA-L) delivered via artificial diet and transgenic plants on the growth and development of tomato moth (Lacanobia oleracea) larvae; lectin binding to gut glycoproteins in vitro and in vivo

Red kidney bean, Phaseolus vulgaris, contains a lectin phytohemagglutinin (PHA) with toxicity towards higher animals. PHA exists in the isoforms PHA-E and PHA-L, which agglutinate erythrocytes and lymphocytes, respectively. Lacanobia oleracea larvae were reared from hatch on artificial diets containing PHA-E or PHA-L at 2% (w/w) dietary protein, and on transgenic Arabidopsis plants expressing either lectin at 0.4-0.6% of total soluble proteins. In artificial diet bioassays neither lectin affected larval survival, development, growth nor consumption. In transgenic plant bioassays both PHA-E and PHA-L promoted larval growth and development. This effect was greatest for PHA-E. Mean larval biomass of insects fed on plants expressing PHA-E was significantly greater (up to two-fold) than controls during the final two instars and the insects developed at a significantly greater rate so that after 26 days 83% of PHA-E exposed insects were in the final instar compared to 44% for control insects. PHA-E and PHA-L were detected by Western blotting in haemolymph, sampled from insects fed diets or plant material containing the lectins. However, despite the demonstrated potential for both isolectins to bind to gut glycopolypeptides in vitro neither was found to accumulate in vivo in the guts of exposed insects. Since lectin binding to gut polypeptides is thought to be necessary for insecticidal activity the failure of PHA-E and PHA-L to bind in vivo may account for their lack of toxicity to L. oleracea.

Validation of transesophageal echocardiography to determine physiologic coronary flow

Human studies have suggested that Doppler transesophageal echocardiography (TEE) can determine normal physiologic coronary blood flow (CBF) and alterations in CBF due to proximal flow-limiting stenoses. However, assessment of CBF by Doppler TEE has not been validated. To determine if true estimation of CBF could be obtained with Doppler TEE, seven mongrel dogs (weight range 28 kg-36 kg) were evaluated. Simultaneous CBF determinations by Doppler TEE and epicardial electromagnetic flow (EMF) and/or epicardial Doppler flow (EDF) probes were compared. Measurements were obtained at baseline and following varying degrees of proximal coronary occlusion, which produced reactive hyperemia.

RESULTS

Consistent Doppler flow waveforms were obtainable by Doppler TEE in 34 different measurements during perturbations: Mean for TEE Flow (ml/min) = 85, EMF or EDF Flow (ml/min) = 53; Standard Deviation for TEE Flow (ml/min) = 45, EMF or EDF Flow (ml/min) = 38; Minimum for TEE Flow (ml/min) = 42, EMF or EDF Flow (ml/min) = 11; and Maximum for TEE Flow (ml/min) = 174, EMF or EDF Flow (ml/min) = 130. TEE Flow (ml/min) = 1.1 EMF/EDF flow + 26.3. There was a general trend towards overestimation of CBF by Doppler TEE. This study demonstrates that Doppler TEE is a promising method for obtaining measurements of CBF over the physiologic range.

The validation of volumetric real-time 3-dimensional echocardiography for the determination of left ventricular function

The objective of this study was to validate a real-time 3-dimensional echocardiography (3DE) technique for the determination of left ventricular (LV) volume and ejection fraction (EF). In 10 mongrel dogs, an electromagnetic flow (EMF) probe was placed on the aorta, and the thorax was closed. Transthoracic imaging was performed during multiple hemodynamic conditions (n = 58) with simultaneous measurement of stroke volume (SV) with the use of EMF. From the volumetric data set, LV volumes were manually traced off-line by 2 independent observers with an apical rotation method (6 planes) and a conventional method (biplane) in a subset of conditions. This tracing technique was also evaluated in 18 human subjects in whom the calculated EF values were compared with values derived by multigated radionuclide angiography (MUGA). Excellent correlation and close limits of agreement were noted between SV measured by 3DE and EMF (r = 0.93) in dogs. In comparison with EMF-derived SV, 3DE provided better correlation than the biplane method (r = 0.93 versus r = 0.61). Interobserver and intraobserver variabilities were comparable (r = 0.94 and r = 0.94, respectively). In a comparison of MUGA-derived EF values and those obtained by 3DE in human subjects, 3DE provided better correlation than the biplane method (r = 0.94 versus r = 0.85). Real-time 3DE accurately measures left ventricular volumes transthoracically over a wide range of hemodynamic conditions in dogs and accurately determines EF in humans.

Pulsatile flow simulation in arterial vascular segments with intravascular ultrasound images

Previous studies have indicated a correlation between local variation in wall shear stress in arterial blood flow and atheroma development. The purpose of this study was to analyze the hemodynamics in vascular segments from morphologically realistic three-dimensional (3D) reconstruction, and to compare the computed wall shear stress in a compliant vascular segment model and the corresponding rigid walled model. Cross-sectional images of the segments of femoral and carotid arteries in five Yucatan miniswine were obtained using intravascular ultrasound (IVUS) imaging and the segment geometry was reconstructed at different times in the cardiac cycle. The actual measured wall motion from the reconstruction was employed to specify the moving boundaries for simulation of physiological distensibility. Velocity profiles and wall shear stress were computed using unsteady computational fluid dynamics analysis. The computed results revealed that the maximum wall shear stress in the compliant model was approximately 4-17 percent less than that in the rigid model if the wall motion is larger than 10 percent. Our analysis demonstrates that inaccuracies due to inflow velocity profile can be minimized by the extension of the model upstream. The phase angle between the diameter change and wall shear is affected by the local changes in geometry of the arteries. These simulations can be potentially used to analyze the effect of regional wall motion changes in the presence of atherosclerotic lesions on the local fluid dynamics and to correlate the same with subsequent growth of the lesions.

Is fetal abdominal subcutaneous fat comparable with established indices of growth restriction?

The purpose of this study was to determine if measurement of the abdominal subcutaneous fat antenatally using ultrasound is comparable to other established indices of fetal growth restriction (FGR). One hundred women with singleton pregnancies had an ultrasound scan within 1 week of delivery at term. Ultrasound measurements included abdominal circumference (AC), liquor assessment by amniotic fluid index (AFI) and abdominal subcutaneous fat thickness (FAB). After delivery,infants were weighed and skinfold thickness at triceps and subscapular sites measured. Ponderal index was also calculated. Infants with an abdominal subcutaneous fat measurement antenatally of 5 mm or less (n = 41) were more likely than those with a fat measurement of more than 5 mm (n = 59) to have an AFI < 8 cm (P < 0.001) and to have an AC < 10th centile (P < 0.001). Decreased antenatal fat thickness was associated postnatally with a lower mean ponderal index (24.2 kg/m3 vs. 25.5 kg/m3, P < 0.02) and a decreased skinfold thickness (4.84 vs. 5.55 mm, P < 0.003 and 3.88 vs. 4.37, P < 0.03 for triceps and subscapular, respectively). This study shows that fetal abdominal subcutaneous fat measurement correlates with established predictors of fetal nutrition such as liquor volume, abdominal circumference, ponderal index, triceps and subscapular skinfold thickness.

Lymphatic drainage of the heart in the laboratory rat

We showed in the Sprague Dawley rat that the principal ascending cardiac lymphatic is similar in location to that of man and dog and can be readily visualized by injection of a small amount of T1824 blue dye (Evans) into the apex of the left ventricle. We also showed that it is possible to ligate and thereby obstruct this principal cardiac lymphatic near its entry beneath the left atrial appendage. This latter technique may be useful for studying in a small relatively inexpensive laboratory animal the effects of blocking cardiac lymph drainage on inflammatory and infectious processes implicated in myocardial and coronary artery disease.

Dermal exposure to strychnine

A non-fatal case of strychnine poisoning through dermal exposure is described. About 24 h after cleaning up a strychnine spill, a 50-year-old woman presented to the emergency department with classical signs of strychnine poisoning, consisting of marked pain in the muscles of her lower limbs, dermal sensitivity, and stiffness in her jaw. Her treatment was intravenous fluid replacement and alkalinization in anticipation of potential renal failure due to rhabdomyolysis. Her plasma creatine kinase was elevated to 677 U/L with no rise in the heart specific MB fraction. Serum myoglobin level obtained retrospectively was 195 microg/L. Biological samples were taken approximately 28 h after her exposure. Strychnine was measured in plasma (196 ng/mL) and urine (6,850 ng/mL) by gas chromatography-mass spectrometry. The small amount of pheniramine in the plasma (35 ng/mL) and urine (1,255 ng/mL) is considered an inconsequential finding.

Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure

The purpose of this study is to perform a cost-effectiveness analysis of long-term moderate exercise training (ET) in patients with stable chronic heart failure. In particular, the study focuses on the survival analysis and cost savings from the reduction in the hospitalization rate in the exercise group. In the past 10 years, ET has been shown to be beneficial for patients with stable class II and III heart failure in many randomized clinical trials. However, the cost-effectiveness of a long-term ET program has not been addressed for outcomes related to morbidity/mortality end points or health care utilization. We examined the cost-effectiveness of a 14-month long-term training in patients with stable chronic heart failure. The estimated increment cost for the training group, $3,227/patient, was calculated by subtracting the averted hospitalization cost, $1,336/patient, from the cost of ET and wage lost due to ET, estimated at $4,563/patient. For patients receiving ET, the estimated increment in life expectancy was 1.82 years/person in a time period of 15.5 years, compared with patients in the control group. The cost-effectiveness ratio for long-term ET in patients with stable heart failure was thus determined at $1,773/life-year saved, at a 3% discount rate. Long-term ET in patients with stable chronic heart failure is cost-effective and prolongs survival by an additional 1.82 years at a low cost of $1,773 per/life-year saved.

Different effects of nocturnal parafunction on the masticatory system: the Weak Link Theory

It is proposed that damage to the masticatory system from intense parafunction can be assessed more accurately by the Weak Link Theory. The theory predicts that the more intense and the more prolonged the forces, the more the tendency of damage to either. 1. the periodontal tissue; 2. the teeth; or 3. the orofacial structures. To test the theory, 22 subjects were selected based on reports of nocturnal bruxism. Each was assessed for masticatory system breakdown on the Russell Periodontal Index, the Helkimo Dysfunction Index, and a Tooth Wear Index. A Bruxcore (Forgione, A. 1974 J Dent Res 53:127) was used to obtain an objective score of bruxism. Five of eleven subjects with mild bruxism scored high on only one index. Significantly more subjects (ten of eleven) with moderate to severe bruxism scored high on one index only.

Predictors of institutionalization of cognitively impaired elders: family help and the timing of placement

Although predictors of nursing home placement have attracted a good deal of attention in gerontological research, the type and amount of family assistance offered to caregivers prior to institutionalization has not been extensively examined. This study analyzed the impact of family help on the timing of placement among cognitively impaired care recipients. Using longitudinal data from the Adult Day Care Collaborative Study, an event-history analysis was performed to determine the effects of family help after sociodemographic characteristics, caregiving stressors, and indicators of caregiver well-being were taken into account. Results showed that caregivers were far less likely to institutionalize their relatives when family members provided overnight help and assisted with activities of daily living care. These findings suggest that specific types of family help play an important role in delaying nursing home placement among older adults suffering from dementia.

Observation of radiative leptonic decay of the tau lepton

Using 4.68 fb(-1) of e(+)e(-) annihilation data collected with the CLEO II detector at the Cornell Electron Storage Ring, we have studied tau radiative decays tau(-)-->nu(tau)&mgr;(-)nu;(&mgr;)gamma and tau(-)-->nu(tau)e(-)nu;(e)gamma. For a 10 MeV minimum photon energy in the tau rest frame, the branching fraction for radiative tau decay to a muon or electron is measured to be (3.61+/-0.16+/-0. 35)x10(-3) or (1.75+/-0.06+/-0.17)x10(-2), respectively. The branching fractions are in agreement with standard model theoretical predictions.

Tamoxifen-induced transient multifocal hepatic fatty infiltration

Tamoxifen is one of the most commonly used anticancer medications. Hepatic damage secondary to tamoxifen treatment is rare. Tamoxifen-induced multifocal hepatic fatty infiltration has not been reported previously. This report describes one case of steatohepatitis caused by tamoxifen in an elderly woman with a history of breast cancer. The patient had multifocal hepatic fatty infiltration secondary to tamoxifen therapy. After tamoxifen was discontinued, the features of multifocal hepatic fatty infiltration on CT improved dramatically, and hepatic transaminases normalized.

What do Irish women know about cervical screening?

In anticipation of the launch of the national cervical screening programme, a questionnaire was distributed amongst 200 women on the maternity wards of the Coombe Women's Hospital. The questionnaires revealed that 24% of the women surveyed never had a smear test and 50% of these did not know how the test was performed. The majority of all women did not know what a smear test showed and 26% did not know the meaning of an abnormal smear. Irish women's knowledge of cervical screening is limited, and the success of the proposed programme will depend on an improvement in public information and education.

Determinants of coronary blood flow after thrombolytic administration. TIMI Study Group. Thrombolysis in Myocardial Infarction

OBJECTIVES

This study evaluated the determinants of coronary blood flow following thrombolytic administration in a large cohort of patients.

BACKGROUND

Tighter residual stenoses following thrombolysis have been associated with slower coronary blood flow, but the independent contribution of other variables to delayed flow has not been fully explored.

METHODS

The univariate and multivariate correlates of coronary blood flow at 90 min after thrombolytic administration were examined in a total of 2,195 patients from the Thrombolysis in Myocardial Infarction (TIMI) 4, 10A, 10B and 14 trials. The cineframes needed for dye to first reach distal landmarks (corrected TIMI frame count, CTFC) were counted as an index of coronary blood flow.

RESULTS

The following were validated as univariate predictors of delayed 90-min flow in two cohorts of patients: a greater percent diameter stenosis (p < 0.0001 for both cohorts), a decreased minimum lumen diameter (p = 0.0003, p = 0.0008), a greater percent of the culprit artery distal to the stenosis (p = 0.03, p = 0.02) and the presence of any of the following: delayed achievement of patency (i.e., between 60 and 90 min) (p < 0.0001 for both cohorts), a culprit location in the left coronary circulation (left anterior descending or circumflex) (p = 0.02, p < 0.0001), pulsatile flow (i.e., reversal of flow in systole, a marker of heightened microvascular resistance, p = 0.0003, p < 0.0001) and thrombus (p = 0.002, p = 0.03). Despite a minimal 16.4% residual stenosis following stent placement, the mean post-stent CTFC (25.8 +/- 17.2, n = 181) remained significantly slower than normal (21.0 +/- 3.1, n = 78, p = 0.02), and likewise 34% of patients did not achieve a CTFC within normal limits (i.e., <28 frames, the upper limit of the 95th percent confidence interval previously reported for normal flow). Those patients who failed to achieve normal CTFCs following stent placement had a higher mortality than did those patients who achieved normal flow (6/62 or 9.7% vs. 1/118 or 0.8%, p = 0.003).

CONCLUSIONS

Lumen geometry is not the sole determinant of coronary blood flow at 90 min following thrombolytic administration. Other variables such as the location of the culprit artery, the duration of patency, a pulsatile flow pattern and thrombus are also related to slower flow. Despite a minimal 16% residual stenosis, one-third of the patients treated with adjunctive stenting still have a persistent flow delay following thrombolysis, which carries a poor prognosis.

Up-regulation of vascular endothelial growth factor mRNA and angiogenesis after transmyocardial laser revascularization

BACKGROUND

Angiogenesis has been proposed as a potential mechanism whereby transmyocardial laser revascularization (TMLR) has provided clinical relief of angina. Experimental work has found histologic evidence supporting this, as well as an improved response when angiogenic growth factors have been added to TMLR. The purpose of this study was to demonstrate that the molecular response to TMLR was an increase in the production of endogenous vascular endothelial growth factor to promote angiogenesis.

METHODS

Ameroid constrictors were placed on the proximal circumflex artery in 12 domestic pigs. After a chronic ischemic zone was established the animals were randomly divided into two groups. In the TMLR group the ischemic zone was treated with carbon dioxide laser. In the control group the ischemic zone was untreated. Six weeks later the animals were sacrificed, and sections from the ischemic zone and the nonischemic zone were submitted for immunohistochemical, histologic, and molecular analysis. Messenger RNA was obtained from northern blot analysis after being probed with vascular endothelial growth factor.

RESULTS

There was a twofold increase in the vascular endothelial growth factor messenger RNA in the ischemic zone of the TMLR group compared with the control group. Additionally, there was a threefold increase in the number of new blood vessels in the ischemic zone of the TMLR group compared with the control group.

CONCLUSIONS

Transmyocardial laser revascularization promotes angiogenesis by upregulation of vascular endothelial growth factor. The resulting angiogenesis could be the principle mechanism for the clinical efficacy of TMLR.

Subcutaneous fat in the fetal abdomen as a predictor of growth restriction

OBJECTIVE

To determine if measuring fetal abdominal fat antenatally using ultrasound can predict fetal growth restriction (FGR).

METHODS

One hundred thirty-seven unselected women with singleton pregnancies had serial ultrasound scans at 20, 26, 31, and 38 weeks' gestation. Subcutaneous fat in the fetal abdomen was measured using the same section as the abdominal circumference (AC). Outcome measures were birth weight, neonatal morbidity, and ponderal index.

RESULTS

Infants with subcutaneous fat less than 5 mm at 38 weeks (n = 51) were almost five times more likely to have a birth weight below the 10th centile than those with subcutaneous fat of 5 mm or more (n = 75). The incidence of neonatal morbidity was significantly higher in infants with subcutaneous fat less than 5 mm, compared with those with subcutaneous fat of 5 mm or more (20% versus 8%, P < .05). Decreased subcutaneous fat was also associated with a high prevalence of low ponderal index, regardless of birth weight category.

CONCLUSION

Measurement of fat in the abdominal wall is a simple technique with a sensitivity for predicting low birth weight similar to that of conventional sonography and might potentially predict FGR irrespective of fetal weight.

Longitudinal patterns of risk for depression in dementia caregivers: objective and subjective primary stress as predictors

The present study examined how patterns of risk for depression over 1 year in 188 dementia caregivers (consistently asymptomatic, n = 88; consistently symptomatic, n = 40; changing risk, n = 60) could be predicted by objective (behavior problems of the relative) and subjective (role captivity and overload) primary stress. Results reveal that all primary stressors differentiated caregivers who remained at low levels of symptomatology over the course of 1 year from those who were at risk for experiencing a depressive disorder. In addition, caregivers' subjective experience of role captivity predicted the chronicity of risk. Findings extend prior caregiving research on patterns of depressive symptomatology by highlighting the relationship between subjective primary stressors and stability and change in caregivers' mental health.

Failure of the canine principal ascending epicardial lymphatic to regenerate after transection

We transected the principal ascending anterior epicardial cardiac lymphatic in 10 dogs, and after varying time intervals reoperated to look for lymphatic regeneration using dye injection. Photographs and sketches were made to record the findings, and in six dogs serial histologic sections were also examined. In none of the 10 dogs was regeneration of the transected principal cardiac lymphatic detected although small lymphatic collaterals from the distal side of the lymphatic developed in 2 dogs. Further studies are merited to assess the role of lymphatic insufficiency in the development of coronary vasculopathy and chronic rejection after cardiac transplantation and other heart operations (e.g., coronary artery bypass) that may injure lymphatic drainage capacity.

Longitudinal patterns of risk for depression in dementia caregivers: objective and subjective primary stress as predictors

The present study examined how patterns of risk for depression over 1 year in 188 dementia caregivers (consistently asymptomatic, n = 88; consistently symptomatic, n = 40; changing risk, n = 60) could be predicted by objective (behavior problems of the relative) and subjective (role captivity and overload) primary stress. Results reveal that all primary stressors differentiated caregivers who remained at low levels of symptomatology over the course of 1 year from those who were at risk for experiencing a depressive disorder. In addition, caregivers' subjective experience of role captivity predicted the chronicity of risk. Findings extend prior caregiving research on patterns of depressive symptomatology by highlighting the relationship between subjective primary stressors and stability and change in caregivers' mental health.

In vivo targeting of acoustically reflective liposomes for intravascular and transvascular ultrasonic enhancement

OBJECTIVES

The purpose of this study was to target acoustically reflective liposomes to atherosclerotic plaques in vivo for ultrasound image enhancement.

BACKGROUND

We have previously demonstrated the development of acoustically reflective liposomes that can be conjugated for site-specific acoustic enhancement. This study evaluates the ability of liposomes coupled to antibodies specific for different components of atherosclerotic plaques and thrombi to target and enhance ultrasonic images in vivo.

METHODS

Liposomes were prepared with phospholipids and cholesterol using a dehydration/ rehydration method. Antibodies were thiolated for liposome conjugation with N-succinimidyl 3-(2-pyridyldithio) propionate resulting in a thioether linkage between the protein and the phospholipid. Liposomes were conjugated to antifibrinogen or anti-intercellular adhesion molecule-1 (anti-ICAM-1). In a Yucatan miniswine model, atherosclerosis was developed by crush injury of one carotid and one femoral artery and ingestion of a hypercholesterolemic diet. After full plaque development the arteries were imaged (20-MHz intravascular ultrasound catheter and 7.5-MHz transvascular linear probe) after injection of saline, unconjugated liposomes and antibody conjugated liposomes.

RESULTS

Conjugated liposomes retained their acoustically reflective properties and provided ultrasonic image enhancement of their targeted structures. Liposomes conjugated to antifibrinogen attached to thrombi and fibrous portions of the atheroma, whereas liposomes conjugated to anti-ICAM-1 attached to early atheroma.

CONCLUSIONS

Our data demonstrate that this novel acoustic agent can provide varying targeting with different antibodies with retention of intravascular and transvascular acoustic properties.

Trends from 1987 to 1991 in alcohol, tobacco, and other drug (ATOD) use among adolescents exposed to a school district-wide prevention intervention

This study involved a school-based prevention program initiated to reduce alcohol, tobacco, and other drug (ATOD) use among adolescents in the Troy School District in the Detroit area. One purpose was to describe the current ATOD situation by investigating changes in reported ATOD use from 1987 to 1991. Another purpose was to explore and identify the most salient risk and protective factors present. In 1987, 1,490 students (comprising grades 8 and 11) and in 1991, 3,171 students (comprising grades 8 to 12) completed questionnaires. Significant decreases were found for use of most drugs with the exception of alcohol. Involvement in problem behaviors was identified as the most salient risk factor, while having a member of a non-using peer group was the most salient protective factor. Implications for the design of subsequent intervention programs are discussed.

Cardiovascular autonomic modulation and activity of carotid baroreceptors at altitude

1. To assess the effects of acute exposure to high altitude on baroreceptor function in man we evaluated the effects of baroreceptor activation on R-R interval and blood pressure control at high altitude. We measured the low-frequency (LF) and high-frequency (HF) components in R-R, non-invasive blood pressure and skin blood flow, and the effect of baroreceptor modulation by 0. 1-Hz sinusoidal neck suction. Ten healthy sea-level natives and three high-altitude native, long-term sea-level residents were evaluated at sea level, upon arrival at 4970 m and 1 week later.2. Compared with sea level, acute high altitude decreased R-R and increased blood pressure in all subjects [sea-level natives: R-R from 1002+/-45 to 775+/-57 ms, systolic blood pressure from 130+/-3 to 150+/-8 mmHg; high-altitude natives: R-R from 809+/-116 to 749+/-47 ms, systolic blood pressure from 110+/-12 to 125+/-11 mmHg (P<0.05 for all)]. One week later systolic blood pressure was similar to values at sea level in all subjects, whereas R-R remained elevated in sea-level natives. The low-frequency power in R-R and systolic blood pressure increased in sea-level natives [R-R-LF from 47+/-8 to 65+/-10% (P<0.05), systolic blood pressure-LF from 1.7+/-0. 3 to 2.6+/-0.4 ln-mmHg2 (P<0.05)], but not in high-altitude natives (R-R-LF from 32+/-13 to 38+/-19%, systolic blood pressure-LF from 1. 9+/-0.5 to 1.7+/-0.8 ln-mmHg2). The R-R-HF decreased in sea-level natives but not in high-altitude natives, and no changes occurred in systolic blood pressure-HF. These changes remained evident 1 week later. Skin blood flow variability and its spectral components decreased markedly at high altitude in sea-level natives but showed no changes in high-altitude natives. Neck suction significantly increased the R-R- and systolic blood pressure-LF in all subjects at both sea level and high altitude.3. High altitude induces sympathetic activation in sea-level natives which is partially counteracted by active baroreflex. Despite long-term acclimatization at sea level, high-altitude natives also maintain active baroreflex at high altitude but with lower sympathetic activation, indicating a persisting high-altitude adaptation which may be genetic or due to baroreflex activity not completely lost by at least 1 year's sea-level residence.