Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. SHOCK Registry Investigators

BACKGROUND

Cardiogenic shock remains the leading cause of death of patients hospitalized with acute myocardial infarction (MI). This study was conducted to examine (1) the current spectrum of cardiogenic shock, (2) the proportion of patients who are potential candidates for a trial of early revascularization, and (3) the apparent impact of early revascularization on mortality.

METHODS AND RESULTS

Nineteen participating centers in the United States and Belgium prospectively registered all patients diagnosed with cardiogenic shock. Two hundred fifty-one patients were registered. The mean age was 67.5 +/- 11.7 years, and 43% were women. Acute mitral regurgitation or ventricular septal rupture was the cause of shock in 8%. Concurrent conditions contributing to the development of shock were noted in 5%, and 2% had isolated right ventricular shock. Among the remaining 214 patients, nonspecific findings on the ECG associated with "nontransmural" MI were seen in 14%. The median time to shock diagnosis after MI was 8 hours. The overall in-hospital mortality was 66%. Patients clinically selected to undergo cardiac catheterization were significantly younger and had a lower mortality than those not selected (51% versus 85%, P < .0001) even if they were not revascularized (58%). Mortality for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) was 60% (n = 55) and 19% (n = 16) for coronary artery bypass graft surgery (CABG). Sixty percent (n = 150) of registered patients were judged eligible for a trial of early revascularization. Trial-eligible patients were significantly younger (65.4 +/- 11.0 versus 70.6 +/- 11.9 years, P < .001), had an earlier median time to shock onset after MI (6.5 versus 17.5 hours, P = .003), and had lower mortality (62% versus 73%, P = .077) than ineligible patients.

CONCLUSIONS

Patients diagnosed with cardiogenic shock complicating acute MI are a heterogeneous group. Those eligible for a trial of early revascularization tended to have lower mortality. Patients selected to undergo cardiac catheterization had lower mortality whether or not they were revascularized. Emergent PTCA and CABG are promising treatment modalities for cardiogenic shock, but biased case selection for treatment may confound the data. Whether PTCA and CABG reduce mortality and which patient subgroups benefit most remain to be determined in a randomized clinical trial.

Immunosuppression in pediatric transplant patients

Nurses in a variety of acute care settings are caring for children receiving transplants. Nurses caring for pediatric transplant patients need to understand the cellular components of the immune system; graft rejection and how it directs immunosuppressive therapy; and specific immunosuppressive agents with their appropriate application in the clinical setting. This knowledge provides a foundation for understanding aspects of nursing interventions as they relate to the pediatric transplant patient receiving immunosuppressive therapy.

Cyclo-oxygenase distribution in human placenta and decidua does not change with labour after term or preterm delivery

Our objective was to determine, in an immunohistochemical study, the distribution of cyclo-oxygenase in placental and decidual tissues before and after labour at varying gestations. Subjects were pregnant women undergoing singleton delivery after idiopathic preterm labour at less than 34 weeks' gestation (n = 13); spontaneous term labour at 37-42 weeks' gestation (n = 11); preterm caesarean section at less than 34 weeks' gestation for pre-eclampsia or intrauterine growth retardation (n = 8); elective term caesarean section at 37-42 weeks' gestation for cephalopelvic disproportion (n = 7). Within the placental basal plate cyclo-oxygenase was localised in decidual stromal cells, extravillous trophoblast, and the apical border of villous syncytiotrophoblast, both before and after labour, regardless of gestational age. Within the placental membranes, decidual stromal cells showed intense cytoplasmic cyclo-oxygenase labelling and the chorion laeve strong membrane-associated cyclo-oxygenase reactivity before and after labour, regardless of gestational age. The amnion showed a heterogeneous staining pattern. After labour at term there was either positive cytoplasmic (5/10) or apical staining (5/10). Cyclo-oxygenase was demonstrated in an apical distribution in only 50% of the other subject groups. Cyclo-oxygenase is present in both decidua and placental tissues prior to the onset of labour at term. Demonstration of decidual and trophoblastic cyclo-oxygenase in both preterm and term subjects suggests that differential availability of cyclo-oxygenase is unlikely to be important in preterm delivery. Research into the withdrawal of inhibition or increased substrate availability is most likely to shed light on the signal pathways involved in the onset of labour, regardless of gestation.

Laryngograph: speech pattern element tools for therapy, training and assessment

The clinically based, real-time analysis of speech into physically definable elements, which are of direct perceptual and productive importance, has become more readily possible in recent years as the result of microprocessor developments. The combination of the acoustic signal of speech derived from a microphone together with the accompanying Laryngograph signal provides the basis for a highly reliable set of facilities. The paper describes methods and results for the analysis of voice, frication and timbre for both quantitative analysis and teaching and therapy using interactive visual displays. A brief discussion is given of links to work in stroboscopy, electropalatography and the associated use of additional sensors. Finally reference is made to a complete clinical work station combining these different facilities together with the quantitative analytical procedures of the speech pattern audiometer.

Inhibition of T lymphocyte activation by a novel p56lck tyrosine kinase inhibitor

A new p56lck tyrosine kinase inhibitor WIN 61651 [1,4-dihydro-7-(4-methyl-1-piperizinyl)-1-(4-(4-methyl-1-piperi zinyl))phenyl- 4-oxo-3-quinolinecarboxamide) is described. WIN 61651, which is competitive with ATP, demonstrates selectivity for the lymphoid restricted tyrosine kinase p56lck over serine/threonine kinases, such as protein kinase C and protein kinase A, and over some other tyrosine kinases, including erbB2, epidermal growth factor receptor, and insulin receptor; however, it is equipotent for inhibition of p56lck and the platelet derived growth factor receptor tyrosine kinases. WIN 61651 inhibits p56lck activity in cell-free assays, tyrosine kinase activity in a T lymphocytic cell line, and T cell activation, as measured by IL-2 production by purified CD4 positive peripheral blood T lymphocytes and the mixed lymphocyte reaction. WIN 61651 constitutes a new tool for studies on the role for tyrosine kinases in lymphocyte function.

Speech pattern audiometry for clinical use

A new PC-based speech perception testing system ('speech pattern audiometer') is described which aims to provide a simple and efficient clinical tool to assess patients' ability to make use of the acoustic speech pattern information which is fundamental to speech perception. The speech pattern audiometer is likely to find its main application in audiology and speech and language therapy clinics with those who are deaf or who have developmental or acquired speech-perceptual disorders. This system constitutes a module of a complete speech and hearing assessment and teaching/therapy workstation.

Dietary intakes of participants in the IditaSport Human Powered Ultra-marathon

Because very little nutritional research has been conducted on participants in ultra marathons and none has been reported on participants in cold weather ultramarathons, this study was undertaken with the purpose of examining the nutritional intakes and urine characteristics of participants in a cold weather ultramarathon. Fourteen participants (13 males and 1 female) in the IditaSport human powered ultramarathon volunteered to be subjects in this study. Pre and post race weights, skinfolds, and urine samples were taken. In addition, a dietary recall was done for the day(s) of the race. Data analysis revealed that a mean of 30,864 (17,143) kJ of energy were consumed with 71% of the energy coming from carbohydrate sources. Despite no significant change in body fat as measured by skinfolds, there was a significant (P < 0.5) decrease in body weight. Ketonuria and proteinuria were present in 83 percent and 92 percent of the subjects. When compared with participants in endurance events taking place in warmer climates, competitors in the IditaSport races consumed more energy with carbohydrates making up a greater percentage of their diets.

Placental heat shock proteins: no immunohistochemical evidence for a differential stress response in preterm labour

The aetiology of idiopathic preterm labour remains obscure. The hypothesis that a stress response induced by low-grade bacterial infection in utero-placental tissues was investigated. Distribution of cognate and inducible isoforms of heat shock proteins (HSP) 70 kD, HSP 60 kD and HSP 90 kD were investigated in an immunohistochemical study of placental and decidual tissues before and after labour at varying gestations. Subjects were pregnant women undergoing singleton delivery after idiopathic preterm labour at less than 34 weeks' gestation (n = 23); spontaneous term labour at 37-42 weeks' gestation (n =24); preterm caesarean sections at less than 34 weeks' gestation for preeclampsia or intrauterine growth retardation (n=14); elective caesarean section at 37-42 weeks' gestation for cephalopelvic disproportion (n = 6). HSP expression was constant throughout the third trimester of pregnancy and did not change following the onset of labour, regardless of gestational age. A stress response in decidual tissues as determined by immunohistochemical analysis is apparently not associated with preterm labour.

Correlational studies of the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms: an overview and update

The interrelationships between the various symptoms of schizophrenia may be explored by examining their intercorrelations. Five different factor analytic studies, which examine these interrelationships, are summarized. Three major factors emerge consistently: psychotic, disorganized, and negative. These three factors appear to represent three dimensions of the psychopathology of schizophrenia.

Cost and utilisation of community services for people with HIV infection in London

This study aimed to describe the use and costs of community services for HIV-infected people by disease stage, sex and transmission category (homosexual, heterosexual, injecting drug use) by use of a prospective cohort study in which people were followed up for six months. There were two major components; gathering quantitative information on service utilisation from people with HIV infection using two interviewer-administered questionnaires and six self-completed monthly diaries; and estimating the costs of the services provided. People were recruited from two London clinics: the Jefferiss Wing Genito-urinary Medicine (GUM) clinic at St. Mary's Hospital, Paddington, and the Patrick Clements GUM clinic at the Central Middlesex Hospital, Harlesden. Costing data was obtained from providers of community services throughout Greater London. The main outcome measures were contacts per person-year, and costs per person-year, for all community services stratified by service sector. The people studied each made, on average, 139 community service contacts per year at a cost of 2,806 pounds; there was little difference in average utilisation between the three transmission categories. There were differences in both the utilisation of services and costs within the formal and informal sectors for subjects from different disease stages. Although the average number of contacts per person-year were similar for women and men, the total cost of community services was higher for women than for men, reflecting the differences in types of services used. The results indicated a high proportion of total care costs for people with HIV and AIDS is incurred through community-based social care.(ABSTRACT TRUNCATED AT 250 WORDS)

CYP19 (aromatase cytochrome P450) gene expression in human malignant endometrial tumors

C19 steroids are converted to estrogens in a number of human tissues by the aromatase enzyme complex, which consists of aromatase cytochrome P450 (P450arom; product of the CYP19 gene) and NADPH-cytochrome P450 reductase. Aromatase activity has been previously demonstrated in endometrial tumors. In the present study, we investigated CYP19 gene expression and its regulation in endometrial tumor samples (n = 9). Using a specific method of competitive polymerase chain reaction after reverse transcription, varying levels of P450arom transcripts were detected in all endometrial adenocarcinomas (n = 8) and one mixed Müllerian tumor studied. No correlations were observed between P450arom transcript levels and histological type of the tumor, grade, myometrial invasion, stage of the disease, or patient age. We have recently demonstrated that the tissue-specific regulation of CYP19 gene transcription is in part the consequence of alternative promoter use. The use of each promoter gives rise to a P450arom transcript with a unique untranslated 5'-end. We analyzed the untranslated first exons in 5'-terminals of P450arom transcripts in endometrial adenocarcinomas using a specific reverse transcription-polymerase chain reaction/Southern hybridization method we recently developed. Our findings indicated the gonadal-type (promoter II) and one of the adipose stromal cell-type (I.3) promoters were primarily used for P450arom expression in adenocarcinomas. On the other hand, distribution of transcripts specific for I.3, I.4 (another adipose-type promoter), and promoter II in one mixed Müllerian tumor was uniform. Placental promoter (I.1)-specific P450arom transcripts were not detected in endometrial tumors. As P450arom transcripts were detected in all endometrial malignancies studied, whereas they were not demonstrable in the disease-free endometrium, activation or failure of inhibition of aromatase expression in these tumors may serve to promote neoplastic proliferation.

The Tec 6 vaporizer: why desflurane needs to be heated

The Ohmeda Tec 6 was designed as an agent-specific vaporizer for desflurane. Its exterior framework offers some unique features. Aside from its unique filling port, broad calibration range, and additional light-emitting diodes (LEDs), its large size literally sets it apart from all other models. As distinctive as the exterior appears, its interior design is even more unconventional; that is, it is not a variable-bypass, flow-over system. There are no mixing chambers, baffles, or temperature-sensing bellows; a differential pressure transducer system takes their place. Many modifications were made primarily to accommodate the remarkably high vapor pressure of desflurane. This is especially true in regard to the sump heating unit. Although there are many options to accommodate a high vapor pressure, a heating unit serves the purpose best. A brief review of vaporization and fundamental thermodynamics will demonstrate why this is so.

Positive and negative symptoms of schizophrenia: past, present, and future

The "group of schizophrenias," normally referred to with a single nominative, is phenomenologically heterogeneous. Its symptoms represent multiple psychological domains, including perception, inferential thinking, language, attention, social interaction, emotion expression, and volition. Studies of psychopathology have simplified this complex array in several ways; one has been a subdivision into positive and negative symptoms. Reports by our group and others suggest that the symptoms of schizophrenia fall into three natural dimensions: positive symptoms subdivided into psychotic and disorganized dimensions, while a third negative dimension also emerges. Since these dimensions have impressive consistency across studies, future work must examine their relationship to clinically relevant concepts such as prognosis or etiology and examine four different aspects: longitudinal course, neural mechanisms, relationship to treatment, and interrelationships in other pathological conditions.

Large scale production and semi-purification of kedarcidin in a 1000-L fermentor

Actinomycete strain ATCC 53650 was grown in a 1000-L fermentor containing 680 L of medium and the production of kedarcidin was monitored by HPLC. The titers of kedarcidin in the fermentor cultures were 0.49-0.53 mg ml-1. A quick and efficient purification method involving the use of anion exchange resin DE23 (batch adsorption-desorption) and an ultrafiltration system yielded high recovery (65% yield) of kedarcidin from the fermentor culture. Over 200 grams of lyophilized kedarcidin of 70% purity was recovered from each of two 1000-L fermentor cultures using this process.

Pseudomonas aeruginosa corneal ulcer isolates distinguished using the arbitrarily primed PCR DNA fingerprinting method

Infection of the eye by Pseudomonas aeruginosa can result in corneal inflammation (keratitis) and ulceration, and permanent decrease in vision if not successfully treated. We tested for diversity among P. aeruginosa strains from corneal ulcers by the sensitive and efficient 'RAPD' (for 'random amplified polymorphic DNA') fingerprinting method. This method uses single oligonucleotides of arbitrarily chosen sequence as primers in low-stringency PCR amplification, and results in strain-specific arrays of DNA fragments. Tests of 20 independent P. aeruginosa corneal ulcer isolates yielded 19 different arrays of products with each of three arbitrary primers, indicating that all but two of the strains differed from one another. Additional isolates from three patients (infected eye, contact lens or eye drops) yielded fragment patterns that were identical to those of the original isolate in each case. Thus, our results demonstrate considerable diversity among P. aeruginosa corneal ulcer isolates, and suggest that just one clone may predominate in typical infections.

Gastroepiploic and inferior epigastric arteries for coronary artery bypass. Early results and evolving applications

BACKGROUND

Internal thoracic artery (ITA) conduits are known to provide long-term patency and increased patient survival with low morbidity after coronary artery bypass grafting (CABG). Excellent clinical results with the ITA have stimulated interest in additional arterial grafts.

METHODS AND RESULTS

To review our experience and evaluate postoperative complications associated with these new conduits, from May 1985 to September 1993, we studied 290 patients who underwent CABG using additional arterial conduits. The right gastroepiploic artery (GEA) was used in 152 patients and the inferior epigastric artery (IEA) was used in 130 patients. Eight patients with both GEA and IEA grafts were excluded. Patient records were analyzed as to preoperative characteristics, angiographic findings, operative data, and postoperative complications. Statistical analysis was done using the Pearson chi 2 statistic and the t test. Ninety-eight percent of patients received one concomitant ITA graft, and the majority of patients in both groups had bilateral ITA grafts. The GEA group had a higher proportion of reoperations (GEA group, 54%; IEA group, 16%; P < .001), previous myocardial infarction (MI) (GEA group, 67%; IEA group, 50%; P = .004) and New York Heart Association class IV (GEA group, 28%; IEA group, 6%; P = .001). The IEA group was generally slightly older (IEA group, 56 years; GEA group, 52 years; P = .001). Hospital mortality (GEA group, 4%; IEA group, 0.8%) and postoperative morbidity (mediastinal bleeding, infection, stroke, MI, and low cardiac output) were not significantly different between the two groups or from our experience with routine CABG using the ITA. Three intraabdominal complications occurred in the GEA group: 2 episodes of bleeding and 1 of pancreatitis. One patient in the IEA group had abdominal wall bleeding. With overall short follow-up, angiographic patency in a small number of patients has been good: 80% for the GEA group and 85.7% for the IEA group.

CONCLUSIONS

We conclude that the morbidity associated with these additional arterial conduits is low and is comparable with that associated with routine CABG using the ITA. Currently we use the ITA for primary targets and alternative arterial conduits for vessels of secondary importance or when the ITA and/or saphenous vein is not available.

Gallbladder surgery for Medicare patients in Mississippi

Mississippi Foundation for Medical Care (MFMC) conducted a review of gallbladder surgery performed on Mississippi Medicare Patients using hospital claims files and limited record review for verification of claims file data. Significant error rates in the surgeon identification number were found in the claims files. It should also be noted that the current ICD-9-CM coding system does not allow for identification of laparoscopic cholecystectomies converted to open procedures. Past studies have attempted to use claims data alone for these types of analyses. These findings demonstrate the importance of using caution by those attempting to use claims data (without verification) to define patterns of hospital utilization, clinical outcomes and/or physician profiling. Claims data must be tested for validity for reliable pattern analysis. In addition, considerable variation was found among providers in elements such as conversion rates, complication and readmission rates. A few surgeons showed patterns for critical variables that were quite different from the universe. There was however, no statistically significant differences associated between volume of cases performed and outcomes. Time frame comparisons over several years show significant (> 80%) increase in gallbladder surgery since the introduction of the laparoscopic procedure.

Functional magnetic resonance imaging (FMRI) of the human brain

Functional magnetic resonance imaging (FMRI) can provide detailed images of human brain that reflect localized changes in cerebral blood flow and oxygenation induced by sensory, motor, or cognitive tasks. This review presents methods for gradient-recalled echo-planar functional magnetic resonance imaging (FMRI). Also included is a discussion of the hypothesized basis of FMRI, imaging hardware, a unique visual stimulation apparatus, image post-processing and statistical analysis. Retinotopic mapping of striate and extrastriate visual cortex is discussed as an example application. The described echo-planar technique permitted acquisition of an image in 40 ms with a repetition rate of up to 2 per second. However, FMRI responses are slow compared to changes in neural activity. Onset of a visual checkerboard test pattern evoked a response that was delayed by 1-2 s and reached 90% of peak in 5 s. Return to baseline following stimulation was slightly slower. Alternating control (blank) and test (checkerboard) patterns every 20 s induced a cyclic response that was detected in the presence of noise using a cross-correlation technique that was verified by parametric statistics. FMRI revealed retinotopically organized patterns of visually evoked activity in response to annular stimuli that increased in visual field eccentricity. Retinotopy was also observed with test patterns rotated around the fixation point (center of gaze). Results from repeated tests 1 week apart were highly similar. Compared to passive viewing, an active visual discrimination task enhanced responses from extrastriate association cortex.

Evaluation of cost minimization strategies of anaesthetic drugs in a tertiary care hospital

A survey was undertaken to compare anaesthetic drug expenditures over a three-year period, to evaluate the impact of strategies offered to curtain continuously rising drug costs. Suggestions to control rising expenditures were based primarily on education of staff and residents regarding drug costs, emphasizing rational use of the more expensive drugs, and minimizing drug wastage. To assess the impact of these measures, a review of annual hospital budgets, global pharmacy expenditures, and anaesthetic drug expenditures was conducted for the period 1991 to 1993. Both absolute and proportional costs of anaesthetic drugs were compared, by year, according to six major classes: opioid analgesics (OA), muscle relaxants (MR), inhalational anaesthetic drugs (INH), intravenous anaesthetic drugs (i.v.), local anaesthetic drugs (LA) and a category labelled other drugs (OTH). In addition, the utilization patterns and unit price changes were compared for each drug for the periods 1991-92, and 1992-93. Total hospital drug costs increased from $7.1 M to $8.5M over the three years. During the same period, the cost of anaesthetic drugs decreased from $379K to $361K, despite an augmentation in annual case load from 12,507 to 13,076 surgical procedures. For the entire survey period, the mean cumulative anaesthetic drug cost was 4.6% of the pharmacy budget, or 0.24% of the hospital budget. Analysis by drug class revealed a $51K decrease in expenditures on OA. due to decreased utilization of fentanyl and alfentanil, and a decrease in the price of fentanyl. The increased expenditure on INH drugs was primarily due to an increase in acquisition costs.(ABSTRACT TRUNCATED AT 250 WORDS)