Rochester, New York: a decade of emergency department overcrowding

Overcrowding is common in emergency departments (EDs) throughout the United States. The history of ED overcrowding in Rochester, New York, is notable due to its unique health care system that introduced the concepts of managed care as early as the 1950s. An effect of this system was to intentionally restrict resources and allow the issue of access to limit utilization. Overcrowding in EDs was severe in the late 1990s-2000, and became an accepted local standard of care.

OBJECTIVE

To study the strategies to reduce ED overcrowding in Rochester in the last decade.

METHODS

A descriptive analysis of individual hospital and community efforts to decrease ED overcrowding.

RESULTS

Of the strategies tried, those that had little effect on ED overcrowding were based from the ED, such as ambulance diversion. Those that were successful were those that addressed factors external to the ED such as increased flexibility of inpatient resources; float nurses who responded to acute care needs; a transition team (mid-level provider along with registered nurse (RN)/licensed practical nurse) who cared for inpatients boarded in the ED; integrated services across affiliated hospitals/systems; an early alert system that notified key personnel before "code red" criteria were met; and a multidisciplinary team to round in the ED and analyze resource needs. Current community-wide initiatives include precise tracking of code red hours; monitoring patient length of stay (LOS) in the ED and inpatient units; education of physicians and nursing homes regarding ED alternatives; exploration of additional resources for subacute and long-term care; establishing a regional forum to address the nursing shortage; development of an ED triage system to coordinate diversion activities during code red; and consideration of a county-wide state of emergency when needed.

CONCLUSIONS

Emergency department overcrowding is the end result of a variety of factors that must be addressed system-wide.

Pharmacokinetics of two oral prednisolone tablet formulations in healthy volunteers

Two prednisolone (CAS 50-24-8) formulations (Prednisolone 50 mg Ferring tablets as the test preparation and tablets of a reference preparation) were investigated in 13 healthy volunteers in order to prove bioequivalence between these preparations. A single oral dose of 50 mg was given using a randomized, two-way cross-over design with a wash-out period of one week. Blood samples for determination of prednisolone plasma concentrations were collected up to 15 h following drug administration. Additionally, in vitro tests were performed with tablets from the same lots to determine dissolution characteristics. Prednisolone concentrations were measured by means of validated HPLC with UV-detection. Maximum concentrations (Cmax) of 1020.9 +/- 57.8 and 1053.3 +/- 55.7 ng/ml were achieved for the test and the reference preparation, respectively. The AUC0-infinity was 212.2 +/- 13.2 micrograms.min/ml (test preparation) and 222.2 +/- 14.3 micrograms.min/ml (reference preparation). The 90% confidence intervals of the test to reference ratios were within the range of 80-125% with 97.8-101.3% for Cmax and 98.1-100.4% for AUC0-infinity. The time to reach maximum plasma concentration (tmax) tended to be lower (-25%) in the test (39.6 +/- 6.4 min) as compared to the reference preparation (52.8 +/- 9.0 min). Interestingly, this difference correlated well with the observation of a more rapid dissolution rate of the test preparation by some 10 min. Both prednisolone formulations were well tolerated. Based on the results obtained in this study, (1) bioequivalence between the test and the reference preparation was clearly demonstrated and (2) a positive correlation between dissolution rate observed in vitro and tmax as measured in vivo was found.

Case report. Mycotic arteritis due to Aspergillus fumigatus in a diabetic with retrobulbar aspergillosis and mycotic meningitis

A 74-year-old man with diabetes mellitus type II, retinopathy and polyneuropathy suffered from exophthalmus, ptosis and diplopia. Magnetic resonance imaging and computer tomography showed a space-occupying process in the right orbital apex. An extranasal ethmoidectomy accompanied by an orbitotomia revealed the presence of septated hyphae. Aspergillus fumigatus was grown from the tissue. After surgical removal of the fungal masses, therapy with amphotericin B (1 mg kg(-1) body weight) plus itraconazole (Sempera, 200 mg per day) over 6 weeks was initiated. Five months later the patient's condition deteriorated again, with vomiting, nausea and pain behind the right eye plus increasing exophthalmus. Antifungal therapy was started again with amphotericin B and 5-fluorocytosine. Neutropenia did not occur. The patient became somnolent and deteriorated, a meningitis was suggested. Aspergillus antigen (titre 1:2, Pastorex) was detected in liquor. Anti-Aspergillus antibodies were not detectable. Both the right eye and retrobulbar fungal masses were eradicated by means of an exenteratio bulbi et orbitae. However, renal insufficiency and an apallic syndrome developed and the patient died. At autopsy, a mycotic aneurysm of the arteria carotis interna dextra was detected. The mycotic vasculitis of this aneurysm had caused a rupture of the blood vessel followed by a massive subarachnoidal haemorrhage. In addition, severe mycotic sphenoidal sinusitis and aspergillosis of the right orbit were seen, which had led to a bifrontal meningitis.

Bioequivalence of different prednisolone tablet formulations

The relative bioavailability of different prednisolone (CAS 50-24-8) tablet formulations (Prednisolon Ferring 2, 5, and 20 mg) was investigated in comparison to a reference formulation. The study was performed in a GCP/ICH-conform manner using a randomized cross-over design in 13 healthy volunteers. With respect to the pharmacokinetic parameters Cmax (maximal prednisolone concentration), AUC0-12 h (area under the concentration-time curve until 12 h after drug intake), AUC0-infinity (area under the concentration-time curve until infinity), and t1/2 (elimination half-life time), 10 x 2 mg prednisolone tablets did not show any relevant differences as compared to the reference (1 x 20 mg) meaning that the 90% confidence intervals were within the given 0.80-1.25 limits for the decision of bioequivalence. Although not statistically significant, tmax (time to reach the maximal prednisolone plasma concentration) was 11 min shorter regarding the test preparation as compared to the reference. The pharmacokinetic parameters of 4 x 5 prednisolone tablets were also well in accordance with the reference. The most important parameters Cmax, AUC and t1/2 were within the defined limits for the acceptance of bioequivalence and, in addition, tmax did not show any significant differences. The 20 mg prednisolone tablet formulation showed almost identical parameters of Cmax, AUC, t1/2 und tmax in comparison to the reference substance. Taken together, the results of the bioavailability parameters indicate the bioequivalence of the three prednisolone test preparations as compared to the reference.

Ultralong dephasing time in InGaAs quantum dots

We measure a dephasing time of several hundred picoseconds at low temperature in the ground-state transition of strongly confined InGaAs quantum dots, using a highly sensitive four-wave mixing technique. Between 7 and 100 K the polarization decay has two distinct components resulting in a non-Lorentzian line shape with a lifetime-limited zero-phonon line and a broadband from elastic exciton-acoustic phonon interactions.

Differences in treatment and outcome of patients with acute myocardial infarction admitted to hospitals with compared to without departments of cardiology; results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA 1+2) Registries and the Myocardial Infarction Registry (MIR)

AIMS

The specialty of the admitting physician may influence treatment and outcome in patients with acute myocardial infarction.

METHODS AND RESULTS

The pooled data of three German acute myocardial infarction registries: the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) 1+2 studies and the Myocardial Infarction Registry (MIR) were analysed. Patients admitted to hospitals with departments of cardiology were compared to hospitals without such departments. A total of 24 814 acute myocardial infarction patients were included, 9020 (36%) patients at 91 (29.8%) hospitals with departments of cardiology and 15 794 (64%) at 214 (70.2%) hospitals without cardiology departments. There were only minor differences in patient characteristics and prevalence of concomitant diseases between the two types of hospital. The first electrocardiogram was more often diagnostic at hospitals with cardiology departments (71.8% vs 66.5%, P<0.001). Reperfusion therapy and adjunctive medical therapy, such as aspirin, beta-blockers and ACE-inhibitors were used more often at cardiology departments (all P -values <0.001), even after adjustment for confounding parameters. Treatment improved at both types of hospital over time. Admission to a hospital with a department of cardiology was independently associated with a lower hospital mortality (14.2% vs 15.4%, adjusted OR=0.91; 95%CI: 0.83-0.99). Additional logistic regression models showed that the higher use of reperfusion therapy and recommended concomitant medical therapy was responsible for most of the survival benefit at such hospitals.

CONCLUSION

Treatment of acute myocardial infarction patients at hospitals with departments of cardiology was independently associated with a higher use of recommended therapy and a lower hospital mortality compared to hospitals without such departments.

[Standards, options and recommendations: nutritional support in palliative or terminal care of adult patients with progressive cancer]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the National Federation of Comprehensive Cancer Centres (FNCLCC), the 20 French Cancer Centers and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVES

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for nutritional support in adult patients with advanced or terminal cancer.

METHODS

Data were identified by searching Medline, web sites and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 95 independent reviewers.

RESULTS

The main recommendations for nutritional support in adult patients with advanced or terminal cancer are: 1) Palliative care has been defined in a consensual way and is governed by the law (standard). Nutritional support is a palliative care which aim is to maintain and restore the "well-being" of the patient (standard). 2) Digestive symptoms and nutritional troubles are frequently noted in patients with advanced or terminal cancer (standard, level of evidence B2). Karnofsky index (KPS) and performance status (PS) are functional scores with a prognostic value and have to be used (standard, level of evidence B2). 3) Anorexia has a bad predictive value in patients with advanced or terminal cancer (standard, level of evidence B2). 4) In France, patients with advanced or terminal cancer are referred to medical institutions, palliative care units or remained at home (standard). Patients need a multidisciplinary follow-up (standard). An active participation of patients and/or their family circle is very important and physicians have to pay attention for their opinions (standard). 5) Dietetic counseling can help patients to improve their alimentation and its drawbacks (standard). 6) Palliative nutritional care often includes medicinal treatments (standard). 7) Artificial nutrition can slow down nutritional degradation, avoid dehydration and improve quality of life in patients with advanced stage cancer (especially head and neck cancer for enteral nutrition and digestive occlusions for parenteral nutrition) and unable to eat adapted meals (standard, level of evidence C). 8) When life expectancy is below 3 months with a KPS 3/4 50% (or PS > 2), artificial nutrition is not recommended (recommendation, expert agreement). 9) The assessment of nutritional care in patients with advanced or terminal cancer has to include functional scores measurement, quality of life and satisfaction degree of the patient and/or their family (standard, expert agreement).

Compliance with cotrimoxazole prophylaxis for the prevention of opportunistic infections in HIV-positive tuberculosis patients in Thyolo district, Malawi

OBJECTIVE

To verify compliance with cotrimoxazole prophylaxis in human immunodeficiency virus (HIV) infected tuberculosis (TB) patients during the continuation phase of anti-tuberculosis treatment, and to assess the sensitivity, specificity and positive predictive values of verbal verification and pill counts as methods of checking compliance.

DESIGN

Cross-sectional study.

METHODS

Cotrimoxazole compliance was assessed in a cohort of TB patients who were attending four TB follow-up centres during the continuation phase of anti-TB treatment between months 4 and 6. Verbal verification of drug intake, physical verification of pill count balance, and urine trimethoprim detection by gas chromatography and mass spectrometry were used for assessing compliance.

RESULTS

Using urine trimethoprim detection as the gold standard for compliance, trimethoprim was detected in 82 (94%) of 87 patients in the cohort. Verbal verification of cotrimoxazole intake and objective pill count balances showed high sensitivity and positive predictive values compared with the gold standard of urine trimethoprim detection.

CONCLUSIONS

In a rural district in Malawi, compliance with cotrimoxazole as an adjunct to anti-tuberculosis treatment in HIV-infected TB patients was good, and can be assessed simply and practically by verbal verification and pill counts.

Triamidoamine complexes of chromium(III) and chromium(IV)

Treatment of [CrCl3(THF)3] with slightly more than 1 equiv of Li3(N3N) [(N3N)(3-) = ((Me3SiNCH2CH2)3N)(3-)] affords the triamidoamine complex [Cr(N3N)] (1) in 75% yield. 1 is oxidized by PhICl2, CuCl2, or AgCl to give the chromium(IV) complex [Cr(N3N)Cl] (2) in moderate yields. Alternatively, complex 2 is obtained directly from [CrCl3(THF)3] in 50% yield after treatment with 0.5 equiv of Li3(N3N). Both compounds are high-spin complexes bearing three and two unpaired electrons, respectively. Their molecular structures are described revealing a trigonal monopyramidal and trigonal bipyramidal coordination geometry of the chromium center, respectively.

Impact of prehospital delay on mortality in patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis

BACKGROUND

In patients with acute myocardial infarction treated with thrombolysis, longer times to treatment are associated with increasingly worse clinical outcome. This relation may be different for treatment with primary angioplasty.

METHODS

We analyzed the pooled data of the German acute myocardial infarction registries Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) and Myocardial Infarction Registry (MIR) to determine the influence of prehospital delays on hospital mortality rates. Primary angioplasty was performed in 1063 patients and thrombolysis in 7552 patients.

RESULTS

In patients treated with thrombolysis, in-hospital time to treatment was constantly 30 minutes median. In patients treated with primary angioplasty, in-hospital time to treatment increased from 60 minutes median up to 87 minutes median with increasing prehospital delay. Hospital mortality rates slightly decreased with increasing prehospital delays in patients treated with primary angioplasty (P for trend =.02). However, in patients treated with thrombolysis, mortality rate was nonsignificantly increased (P for trend =.11). Logistic regression analysis showed no significant difference in mortality rates between primary angioplasty and thrombolysis for prehospital delays of <3 hours. However, when prehospital delay was >3 hours, thrombolysis was independently associated with a higher mortality rate compared with primary angioplasty.

CONCLUSIONS

Compared with thrombolysis, primary angioplasty is independently associated with a lower mortality rate in prehospital delays of >3 hours. The reason for this may be a time-dependent loss of efficacy to achieve reperfusion for thrombolysis but not for primary angioplasty.

Multilayer capsules: a promising microencapsulation system for transplantation of pancreatic islets

In 1980, Lim and Sun introduced a microcapsule coated with an alginate/polylysine complex for encapsulation of pancreatic islets. Characteristic to this type of capsule is, that it consists of a plain membrane which is formed during a single procedural step. With such a simple process it is difficult to obtain instantly a membrane optimized with respect to all the properties requested for islet transplantation. To overcome these difficulties, it is recommended to build up the membrane in several consecutive steps, each optimized for a certain property. In this study, we have analysed such a multilayer microcapsule for the encapsulation of pancreatic islets. Therefore, empty and islet containing alginate beads were coated with alternating layers of polyethyleneimine, polyacrylacid or carboxymethylcellulose and alginate. By scanning electron microscopy the thickness of the covering multilayer-membrane was estimated to be less than 800 nm by comparison with an apparatus scale. Ellipsometric measurements showed that the membrane thickness is in the range of 145 nm. Neither the encapsulation procedure, nor the membrane-forming step did impede the stimulatory response of the islets. The encapsulation even lead to a significantly better stimulatory response of the encapsulated islets during week three and five of cell culture. Furthermore, the multilayer-membrane did not deteriorate the biocompatibility of the transplanted microcapsules, allowing an easy tuning of the molecular cut-off and the mechanical stability depending on the polycation-polyanion combination used. The multilayer membrane capsule has obvious advantages compared to a one-step encapsulation procedure. These beads guarantee a high biocompatibility, a precisely adjusted cut-off, an optimal insulin-response and high mechanical stability although the membrane is only 145 nm thick.

Functional domains of the yeast splicing factor Prp22p

The essential Saccharomyces cerevisiae PRP22 gene encodes a 1145-amino acid DEXH box RNA helicase. Prp22p plays two roles during pre-mRNA splicing as follows: it is required for the second transesterification step and for the release of mature mRNA from the spliceosome. Whereas the step 2 function of Prp22p does not require ATP hydrolysis, spliceosome disassembly is dependent on the ATPase and helicase activities. Here we delineate a minimal functional domain, Prp22(262-1145), that suffices for the activity of Prp22p in vivo when expressed under the natural PRP22 promoter and for pre-mRNA splicing activity in vitro. The biologically active domain lacks an S1 motif (residues 177-256) that had been proposed to play a role in RNA binding by Prp22p. The deletion mutant Prp22(351-1145) can function in vivo when provided at a high gene dosage. We suggest that the segment from residues 262 to 350 enhances Prp22p function in vivo, presumably by targeting Prp22p to the spliceosome. We characterize an even smaller catalytic domain, Prp22(466-1145) that suffices for ATP hydrolysis, RNA binding, and RNA unwinding in vitro and for nuclear localization in vivo but cannot by itself support cell growth. However, the ATPase/helicase domain can function in vivo if the N-terminal region Prp22(1-480) is co-expressed in trans.

Use of structured self-monitoring in transplant education

A self-assessment instrument for use at home by transplant recipients was developed to help foster partnership between patients and their healthcare provider. Self-monitoring at home has not replaced the need for close follow-up but does allow patients to provide concrete data to their healthcare provider in order to promote earlier detection of and response to adverse events. Patients are taught the essentials of self-monitoring while they are in the hospital for their transplant. Patients who perform routine self-assessment would be able to detect and provide information about problems early in the course of events. Thus, early intervention could potentially decrease the severity of the problem and prevent repeated hospitalizations. The concern that patients would not be able to perform a reliable self-assessment was unfounded; patients exceeded expectations and embraced the opportunity to communicate physical signs and symptoms effectively.

[Current prescription practice of CSE inhibitors at clinic discharge after acute myocardial infarct]

We investigated the use of statins in clinical practice in patients with acute myocardial infarction in Germany in 17,732 consecutively included patients of the registries MIR-1 and MITRA-1. A clinical follow-up has been performed in the MITRA-1 study after a mean period of 18 months. In total 30% of all patients with acute myocardial infarction received statins at discharge. From 1994 to 1998 the use of statins increased from 6% to 44%; however in 1998 still less than half of the patients with acute myocardial infarction received statins at discharge. In a logistic regression model, concomittant diseases as renal failure (OR 0.7), heart failure (OR 0.7) and diabetes mellitus (OR 0.9) were associated with a lower use of statins. Age > 70 years (OR 0.5) was also associated with a lower use of statins at hospital discharge. Patients with statins at discharge had a lower long-term mortality of 5.8% versus 12.9% in patients without statins. After adjustment to age and comorbidity, use of statins at discharge was associated with a borderline significant reduction of long-term mortality (multivariate OR 0.7, 95% CI 0.4-1.0). In a subgroup analysis of therapeutic benefit, measured by the "number needed to treat" (NNT), the number of patients to treat with statins to save one life, patients with cardiovascular risk factors, as heart failure (NNT 7.5), diabetes mellitus (NNT 7.8) and age > 70 years (NNT 13.8) had a larger therapeutic benefit as patients without these risk factors (NNT 345). However, these high-risk patients received less often statins than patients without risk factors (use of statins 11.8% versus 19.8%).

Conditions for interference versus facilitation during sequential sensorimotor adaptation

We investigated how sensorimotor adaptation acquired during one experimental session influenced the adaptation in a subsequent session. The subjects' task was to track a visual target using a joystick-controlled cursor, while the relationship between joystick and cursor position was manipulated to introduce a sensorimotor discordance. Each subject participated in two sessions, separated by a pause of 2 min to 1 month duration. We found that adaptation was achieved within minutes, and persisted in the memory for at least a month, with only a small decay (experiment A). When the discordances administered in the two sessions were in mutual conflict, we found evidence for task interference (experiment B). However, when the discordances were independent, we found facilitation rather than interference (experiment C); the latter finding could not be explained by the use of an "easier" discordance in the second session (experiment D). We conclude that interference is due to an incompatibility between task requirements, and not to a competition of tasks for short-term memory. We further conclude that the ability to adapt to a sensorimotor discordance can be improved by practicing with an unrelated discordance.

Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry

OBJECTIVES

We sought to determine the effectiveness of primary angioplasty compared with thrombolysis in clinical practice.

BACKGROUND

In clinical practice, primary angioplasty for the treatment of acute myocardial infarction (AMI) has not yet been proven more effective than intravenous thrombolysis, nor have subgroups of patients been identified who would perhaps benefit from primary angioplasty.

METHODS

The pooled data of two AMI registries--the Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and the Myocardial Infarction Registry (MIR)--were analyzed. A total of 9,906 lytic-eligible patients with AMI, with a pre-hospital delay of < or =12 h, were treated with either primary angioplasty (n = 1,327) or thrombolysis (n = 8,579).

RESULTS

Despite differences in the patients' characteristics and concomitant diseases between the two groups, the prevalence of adverse risk factors was balanced. Univariate analysis of hospital mortality showed a more favorable course for patients treated with primary angioplasty: 6.4% versus 11.3% (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43 to 0.67). This was confirmed by logistic regression analysis (multivariate OR 0.58, 95% CI 0.44 to 0.77). Primary angioplasty was associated with a lower mortality in all subgroups analyzed. We observed a significant correlation between mortality and absolute risk reduction (r = 0.82, p < 0.0001) in the different subgroups: as mortality increased, there was an increase in absolute benefit of primary angioplasty compared with thrombolysis.

CONCLUSIONS

These large registry data showed the effect of primary angioplasty to be more favorable than thrombolysis for the treatment of patients with AMI in clinical practice. This effect was not restricted to special subgroups of patients. As mortality increased, the absolute benefit of primary angioplasty also increased.

[Standards, Options and Recommendations for home parenteral or enteral nutrition in adult cancer patients]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVES

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for home parenteral or enteral nutrition in adult cancer patients.

METHODS

Data were identified by searching Medline, Cancerlit, web sites and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 72 independent reviewers.

RESULTS

The main recommendations for home parenteral or enteral nutrition in adult cancer patients are: 1) Home parenteral or enteral nutrition concerns cancer patients with malnutrition or with inadequate/impossible oral intake, during therapy of because of therapeutic after-effects (standard). Same indications apply for home and hospital artificial nutrition (standard). 2) Patients need a multidisciplinary follow-up (oncologists, nutritionists, and pain specialists), and this follow-up will make treatment adaptations according to the nutritional status possible (recommendation, expert agreement). An active participation of patients and/or their family circle is very important (standard). 3) The benefit of home parenteral or enteral nutrition on the quality of life of terminally ill patients (vs. hydration) has not been demonstrated. When life expectancy is below 3 months, and the Karnofsky index below 50, the drawbacks of home artificial nutrition are more important than its advantages. In this case, home parenteral or enteral nutrition is not recommended (recommendation, expert agreement). 4) Prospective clinical trials are recommended to evaluate the impact of home nutrition on quality of life in cancer patients (expert agreement). 5) The use of educational booklets that mention the telephone number of a referent health care and what to do when a problem happens (e.g. fever on home parenteral nutrition) is recommended (expert agreement). In France, patients should be referred to authorized home parenteral nutrition centres (recommendation, expert agreement).

Improvement of breast cancer prognostication using cell kinetic-based silver-stainable nucleolar organizer region quantification of the MIB-1 positive tumor cell compartment

Recently, it was stated that the proliferative activity (P) of a cell population could be indirectly calculated by multiplying the MIB-1 immunopositivity and silver-stainable nucleolar organizer region (AgNOR) features extracted exclusively in MIB-1 positive (pos.) nuclei: P=MIB-1 x AgNOR(MIB-1pos.). To study the prognostic significance of this hypothesis, MIB- immunohistochemistry and AgNOR staining were applied on a series of 89 cases of breast cancer with an 8-year follow-up period. The mean MIB-1 immunopositivity (MIB-1mean) was evaluated immunohistometrically on paraffin sections using a TV image analysis system CM-2 (Hund, Wetzlar, Germany). Later, a combined MIB-1/AgNOR staining was applied and evaluated using a TV image analysis system AMBA (IBSB, Berlin, Germany). The AgNOR features of 150 randomly chosen tumor nuclei were investigated, irrespective of their MIB-1 status (AgNOR count, AgNOR area). Later, a second measurement was performed on 100 MIB-1 positive tumor nuclei exclusively (AgNOR countMIB-1pos., AgNOR areaMIB-1pos.). AgNOR count and AgNOR countMIB-1pos. showed a different data distribution [2.7+/-0.7 (mean+/-SD) vs 3.9+/-1.1; r=0.315, P=0.014]. Similar results were obtained for AgNOR area and AgNOR areaMIB-1pos. (5.1+/-2.1 microm2 vs 7.5+/-2.4 microm2; r=0.501, P<0.001). Kaplan-Meier survival curves revealed significant differences for MIB-1mean (P=0.0018) and AgNOR areaMIB-1pos. (P=0.0340). In Cox models, both parameters provided independent prognostic information. Using their combination, the P, three groups of patients with statistically different survival could be separated (P=0.0014). Thus, the combination of MIB-1-immunopositivity and AgNOR measurements in MIB-1 positive nuclei appears to be more useful in breast cancer prognosis than the exclusive application of one of the two methods. By this combined application, probably effects of tumor biology are represented more precisely.

Primary angioplasty versus no reperfusion therapy in patients with acute myocardial infarction and a pre-hospital delay of > 12-24 hours: results from the pooled data of the maximal individual therapy in acute myocardial infarction (MITRA) registry and the myocardial infarction registry (MIR)

OBJECTIVE

In patients with acute myocardial infarction (AMI), treatment with thrombolysis is superior to no reperfusion therapy only up to 12 hours after the onset of symptoms. There are no data addressing whether this time limit is also justified for treatment with primary angioplasty.

DESIGN

The pooled data of two German ST-segment elevation AMI registries, the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) study and the Myocardial Infarction Registry (MIR), were analyzed.

PATIENTS

Out of 22,749 patients, eight hundred and forty-eight with a pre-hospital delay of > 12 hours and < or = 24 hours were treated with either primary angioplasty (94/848; 11.1%) or no reperfusion therapy (754/848; 88.9%).

RESULTS

Patients treated with primary angioplasty were 10 years younger (59 years versus 69 years; p = 0.001), more often male [72.3% versus 59.9%; odds ratio (OR) = 0.57; 95% confidence interval (CI) = 0.36-0.92] and less likely to be diabetics (17% versus 27.2%; OR = 0.55; 95% CI = 0.31-0.97). Hospital mortality was 8.5% in patients treated with primary angioplasty compared to 17.1% in patients with no reperfusion therapy (OR = 0.45; 95% CI = 0.21-0.95; p = 0.033) and the combined endpoint (death, reinfarction or stroke) occurred significantly less often (11.7% versus 20.3%; OR = 0.52; 95% CI =0.27-1; p = 0.045). However, multiple logistic regression showed only a non-significant trend for lower mortality (OR = 0.54; 95% CI =0.20-1.23) and the combined endpoint (OR = 0.65; 95% CI = 0.29-1.31) in patients treated with primary angioplasty.

CONCLUSIONS

These data show the possibility of a benefit of primary angioplasty over conservative treatment in patients with pre-hospital delays of > 12 up to 24 hours, although multiple logistic regression analysis failed to find significant differences between treatments. This might be due to inadequate study power or a selection bias. These findings encourage further investigation of this subject.

Dopamine D2-like receptors and amino acid-induced glomerular hyperfiltration in humans

AIMS

In rodents, blockade of dopamine D2-like receptors abolishes both the physiological increase in glomerular filtration rate (GFR) induced by amino acids and the pathological hyperfiltration in experimental diabetes mellitus. This study addressed the contribution of dopamine D2-like receptors to changes in renal haemodynamics after amino acid infusion in humans.

METHODS

Twelve healthy volunteers participated in this double-blind, randomized, cross-over study. GFR and renal blood flow (RPF) were assessed by renal clearance of inulin and p-aminohippuric acid (PAH), respectively. Following infusion of 0.45% saline at baseline, an electrolyte-balanced solution of mixed amino acids (10%) was infused. Prior to the experiments, the subjects received orally either placebo, or sulpiride (10 mg kg-1), a centrally and peripherally acting D2-like receptor antagonist, or domperidone (1 mg kg-1) which affects only peripheral D2-like receptors.

RESULTS

In the placebo series, amino acid infusion significantly increased GFR and RPF by up to 15.8 +/- 5.3% and 14.4 +/- 6.1%, respectively, while mean blood pressure and heart rate remained unchanged. Pretreatment with domperidone only marginally altered the renal response to amino acids (maximal increase by 13.2 +/- 5.6 and 11.9 +/- 4.0% in GFR and RPF, respectively), while sulpiride completely abolished the renal haemodynamic changes induced by amino acids. Total and fractional urinary sodium excretion as well as urinary osmolality were similar at baseline and increased in response to amino acids, to the same extent, in all series. No changes in renal dopamine excretion occurred.

CONCLUSION

The results indicate that in man dopamine D2-like receptors are involved in the renal haemodynamic response to amino acid infusion. Whether dopamine D2-like receptor blockade diminishes glomerular hyperfiltration in pathological states requires clinical investigations.

Amplitude of distortion product otoacoustic emissions in the guinea pig in f(1)- and f(2)-sweep paradigms

The amplitude versus frequency relations of distortion product otoacoustic emissions (DPOAEs) were studied in the guinea pig, using both the f(1)- and the f(2)-sweep paradigms to vary the primary frequency separation. The amplitude of the DPOAEs 2f(1)-f(2), 3f(1)-2f(2), 4f(1)-3f(2), and 2f(2)-f(1), plotted as a function of DP frequency, exhibited a bandpass structure. The separation of the primaries for which the DPOAE level is maximum is referred to as the optimum ratio f(2)/f(1). For the lower sideband DPOAEs (f(dp)<f(1), f(2)), the optimum ratio varies non-monotonically with the primary frequency region. At an f(2) around 4.4 kHz, the optimum ratio for 2f(1)-f(2) reaches a maximum of about 1.46 while elsewhere it is in the more commonly found 1.2-1.3 range. The width of the amplitude profiles was studied by determining their Q(10 dB). The f(2)-sweep yielded significantly larger Q(10 dB) than f(1)-sweep, for the lower sideband DPOAEs. The amplitude versus frequency functions of the lower sideband DPOAEs approximately line up. Upon closer inspection, however, with f(1)-sweep the 2f(1)-f(2) DPOAE has its maximum at a slightly smaller DP frequency than the higher order DPOAEs. With f(2)-sweep, on the contrary, the 2f(1)-f(2) tends to peak at a higher DP frequency than the other lower sideband distortion products. When the amplitude is considered as a function of the ratio between f(dp) and f(2), the difference between f(1)- and f(2)-sweep with respect to the width and the alignment of the amplitude functions disappears. The amplitude profiles of the lower sideband DPOAEs are a function of the DPOAE frequency f(dp) relative to f(2).