Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy

BACKGROUND

Use of abciximab in combination with administration of thrombolytics has been shown to improve epicardial and microvascular coronary blood flow in acute myocardial infarction (AMI). As a potential mechanism, we hypothesized that combination therapy would reduce angiographically evident thrombus (AET) and would increase lumen diameter compared with thrombolytic monotherapy.

METHODS AND RESULTS

Patients who received combination therapy in TIMI 14 (low-dose thrombolytic plus abciximab, n=732) were compared with patients who received thrombolytic monotherapy without abciximab in the TIMI 4, 10A, 10B, and 14 trials (n=1662). Thrombus burden was assessed 90 minutes after treatment, and quantitative angiography was performed in an angiographic core laboratory by investigators blinded to treatment assignment. The frequency of AET was reduced in patients who received abciximab combination therapy compared with thrombolytic monotherapy (26.6% versus 35.4%, P<0.001). Similar findings were observed when the analysis was restricted to patients with patent arteries (14.7% versus 20.8%, P=0.001). Residual percent diameter stenosis at 90 minutes was also improved in the abciximab therapy group both in patent arteries (64.6+/-16.6 versus 68.3+/-14.8, P<0.001) and between patent and occluded arteries (69.3+/-19.5 versus 73.8+/-17.9, P<0.001). The absence of AET was associated with an increased frequency of >70% ST-segment resolution by 90 minutes (37.2%, 110/296 versus 18.9%, 54/286, P<0.001).

CONCLUSIONS

Compared with thrombolytic monotherapy, combination therapy with abciximab reduces AET, which in turn is associated with reduced residual stenosis and improved ST-segment resolution in AMI. These data provide a pathophysiological link between platelet inhibition, reduced thrombus, and improvements in both epicardial and microvascular perfusion in AMI.

Impact of contrast agent type (ionic versus nonionic) used for coronary angiography on angiographic, electrocardiographic, and clinical outcomes following thrombolytic administration in acute myocardial infarction

The goal of this study was to examine the relationship between contrast agent type (ionic vs. nonionic) and angiographic, electrocardiographic, and clinical outcomes after thrombolytic administration. Ionic or nonionic contrast agents were selected in a nonrandomized fashion for 90-min angiography and percutaneous coronary intervention (PCI) following thrombolytic administration in the TIMI 14 trial [tissue plasminogen activator (tPA) or reteplase (rPA) vs. low-dose lytic + abciximab]. There was no relationship between contrast agent type and overall patency, rate of TIMI grade 3 flow, or corrected TIMI frame counts (CTFCs) in open culprit arteries and in post-PCI patency rates or post-PCI CTFCs. In patients treated with ionic contrast, ejection fractions at 90 min were slightly but significantly lower (56.2 +/- 16.5, n = 122, vs. 59.8 +/- 14.4, n = 322; P = 0.02), chest pain duration was longer (2.8 +/- 4.1 hr, n = 255, vs. 1.7 +/- 3.6, n = 550; P = 0.0003), and complete ST segment resolution was less frequent (41.5% vs. 50.8%; P = 0.04). While there was no difference in epicardial blood flow, ionic contrast agent use was associated with poorer ST segment resolution, longer chest pain duration, and poorer ejection fractions, perhaps as a result of microvascular dysfunction.

Abciximab and early adjunctive percutaneous coronary intervention are associated with improved ST-segment resolution after thrombolysis: Observations from the TIMI 14 Trial

BACKGROUND

Percutaneous coronary intervention (PCI) improves clinical outcomes in selected patients with failed thrombolysis but has not been proven to benefit patients who achieve a patent infarct-related artery. Even after successful epicardial reperfusion, myocardial perfusion may be inadequate. We sought to evaluate whether a strategy that uses a reperfusion regimen containing abciximab and a reduced-dose thrombolytic agent (combination therapy), followed by early adjunctive PCI, would result in improved myocardial perfusion, as assessed by ST-segment resolution.

METHODS

ST resolution from 90 to 180 minutes after therapy was calculated for all 410 patients from the TIMI 14 trial who had evaluable electrocardiograms at both time points and who were treated with alteplase or reteplase. Patients were grouped according to whether they were treated with combination therapy or full-dose thrombolytic agent alone and whether they underwent PCI between the 90- and 180-minute electrocardiographic measurements.

RESULTS

Among 105 patients who underwent adjunctive PCI between 90 and 180 minutes, mean ST resolution from 90 to 180 minutes was significantly greater in those who had received combination therapy versus those who had received full-dose thrombolytic alone (54% vs 8%; P =.002). Among 241 patients with TIMI grade 3 flow in the infarct-related artery at 90 minutes, adjunctive PCI significantly improved mean ST resolution in patients who had been treated with combination therapy (57% [PCI] vs 24% [no PCI]; P =.006), but PCI did not have this effect in patients who had received thrombolytic therapy alone (1% [PCI] vs 10% [no PCI]; P =.70). In a multivariate model controlling for factors that would be expected to independently influence 90- to 180-minute ST resolution, abciximab treatment remained significantly associated with greater ST resolution (P =.008).

CONCLUSIONS

A strategy that uses a combination reperfusion regimen that includes abciximab, followed by early adjunctive PCI, is associated with greater ST-segment resolution, which may reflect enhanced tissue level and microvascular perfusion. Future studies should evaluate prospectively the clinical efficacy of this strategy.

Can we replace the 90-minute thrombolysis in myocardial infarction (TIMI) flow grades with those at 60 minutes as a primary end point in thrombolytic trials? TIMI Study Group

The establishment of patency (Thrombolysis In Myocardial Infarction [TIMI] grade 2 or 3 flow) and/or TIMI grade 3 flow at 60 minutes after thrombolytic administration is both a univariate and multivariate predictor of in-hospital and 30-day mortality, and the odds ratios for mortality are nearly identical for TIMI grade 3 flow at 60 and 90 minutes. Thus, the 60-minute angiographic end point appears to be a valid alternative to that at 90 minutes and may permit earlier decisions regarding post-thrombolytic intervention.

Global impairment of coronary blood flow in the setting of acute coronary syndromes (a RESTORE substudy). Randomized Efficacy Study of Tirofiban for Outcomes and Restenosis

Acute coronary syndromes result in a global impairment of coronary blood flow with nonculprit artery blood flow being associated with culprit artery flow and vice versa. Improvements in nonculprit artery flow are related to improvements in culprit artery flow after percutaneous intervention; nonculprit arteries with abnormal flow sustain greater improvements in their flow after culprit artery intervention.

Roles, lifestyles, and well-being as predictors of alcohol consumption among young and midlife women

Much remains to be learned about drinking patterns and their contexts among population-based women, that is, nontreatment seeking. This report involved secondary analysis of data obtained from 405 young women aged 18 to 35 years and 508 midlife women aged 36 to 55 years who were recruited for participation in two separate studies of women's health. Data were obtained from measures of women's roles: gender role attitudes; role strain; lifestyle behaviors, including alcohol use; well-being and distress; and demographic data; and were measured by descriptive and inferential statistics. Three important findings emerged. First, levels of weekly drinking patterns in both samples studied were consistent with national data. Second, when women were classified by the number of drinks of alcoholic beverages consumed per week, that is, fewer than 12 drinks per year, up to 10 drinks per week, or more than 10 drinks per week, significant differences emerged in both samples. However, patterns of risk and protective factors were inconsistent, which made it impossible to develop specific profiles across both study samples. Finally, the desire to cut down on weekly alcohol consumption was the most significant predictor of drinks per week in both samples.

Association between white blood cell count, epicardial blood flow, myocardial perfusion, and clinical outcomes in the setting of acute myocardial infarction: a thrombolysis in myocardial infarction 10 substudy

BACKGROUND

Elevation of the white blood cell (WBC) count during acute myocardial infarction (AMI) is associated with adverse outcomes. We examined the relationship between the WBC count and angiographic findings to gain insight into this relationship. Results and Methods-We evaluated data from 975 patients in the Thrombolysis In Myocardial Infarction (TIMI) 10A and 10B trials. Patients with a closed artery at 60 and 90 minutes had higher a WBC count than patients with an open artery (P:=0.02). Likewise, the presence of angiographically apparent thrombus was associated with a higher WBC count (11.5+/-5.2x10(9)/L, n=290, versus 10.7+/-3. 5x10(9)/L, n=648; P=0.008). In addition, a higher WBC count was associated with poorer TIMI myocardial perfusion grades (4-way P=0.04). Mortality rates were higher in patients with a higher WBC count (0% for WBC count 0 to 5x10(9)/L, 4.9% for WBC count 5 to 10x10(9)/L, 3.8% for WBC count 10 to 15x10(9)/L, 10.4% for WBC count >15x10(9)/L; P=0.03). The development of new congestive heart failure or shock was also associated with a higher WBC count (0% for WBC count 0 to 5x10(9)/L, 5.2% for WBC count 5 to 10x10(9)/L, 6.1% for WBC count 10 to 15x10(9)/L, 17.1% for WBC count >15x10(9)/L; P<0.001), an observation that remained significant in a multivariable model that adjusted for potential confounding variables (odds ratio 1.21, P=0.002).

CONCLUSIONS

Elevation in WBC count was associated with reduced epicardial blood flow and myocardial perfusion, thromboresistance (arteries open later and have a greater thrombus burden), and a higher incidence of new congestive heart failure and death. These observations provide a potential explanation for the higher mortality rate observed among AMI patients with elevated WBC counts and helps explain the growing body of literature that links inflammation and cardiovascular disease.

TIMI risk score for ST-elevation myocardial infarction: A convenient, bedside, clinical score for risk assessment at presentation: An intravenous nPA for treatment of infarcting myocardium early II trial substudy

BACKGROUND

Considerable variability in mortality risk exists among patients with ST-elevation myocardial infarction (STEMI). Complex multivariable models identify independent predictors and quantify their relative contribution to mortality risk but are too cumbersome to be readily applied in clinical practice.

METHODS AND RESULTS

We developed and evaluated a convenient bedside clinical risk score for predicting 30-day mortality at presentation of fibrinolytic-eligible patients with STEMI. The Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI was created as the simple arithmetic sum of independent predictors of mortality weighted according to the adjusted odds ratios from logistic regression analysis in the Intravenous nPA for Treatment of Infarcting Myocardium Early II trial (n=14 114). Mean 30-day mortality was 6.7%. Ten baseline variables, accounting for 97% of the predictive capacity of the multivariate model, constituted the TIMI risk score. The risk score showed a >40-fold graded increase in mortality, with scores ranging from 0 to >8 (P:<0.0001); mortality was <1% among patients with a score of 0. The prognostic discriminatory capacity of the TIMI risk score was comparable to the full multivariable model (c statistic 0. 779 versus 0.784). The prognostic performance of the risk score was stable over multiple time points (1 to 365 days). External validation in the TIMI 9 trial showed similar prognostic capacity (c statistic 0.746).

CONCLUSIONS

The TIMI risk score for STEMI captures the majority of prognostic information offered by a full logistic regression model but is more readily used at the bedside. This risk assessment tool is likely to be clinically useful in the triage and management of fibrinolytic-eligible patients with STEMI.

The use of research findings in bereavement programs: a case study

Violent death is a major public health problem in the United States, yet there is no consensus among bereavement researchers and clinicians regarding a "gold standard" of bereavement services to be offered to family survivors. This article has three purposes: (a) to describe the planning, implementation, and results of a theory-based intervention study involving parents bereaved by the violent deaths of their children; (b) to suggest programmatic elements of bereavement services based on some findings from both the bereavement program and the follow-up data obtained from parents up to 5 years postdeath; and (c) to identify future research and theory development needs. The results of the intervention study involving 261 bereaved parents provide helpful insights regarding parent bereavement program preferences as well as changes in parent outcomes. Some of the most relevant findings pertain to variability in distress levels, gender, and causes of deceased children's deaths. Findings suggest that many different types of services are needed to meet parents' needs. The follow-up data collected from the parents 1, 2, and 5 years postdeath demonstrate that loss accommodation following violent death bereavement is both lengthy and difficult. Recommendations follow for both bereavement services and research studies.

Non-tuberculous mycobacterial lung infection complicated by chronic necrotising pulmonary aspergillosis

We report four cases of pulmonary mycobacterial disease (three due to Mycobacterium malmoense and one to Myco- bacterium avium intracellulare) complicated by the development of chronic necrotising pulmonary aspergillosis. Difficulties with treatment and the potential benefits of steroids are discussed.

A comparative study of the isolation of type II epithelial cells from rat, hamster, pig and human lung tissue

Data is reported on the reproducibility and purity of alveolar type II cell isolations from 4 species. Human and pig type II cells were isolated using a tissue slice method to remove blood and contaminating cells, whilst rat and hamster cells were isolated using the method of protease instillation. All cells were purified on Percoll gradients and by differential attachment. Cell type purity was assessed by phase contrast microscopy, electron microscopy (EM), percentage of cells alkaline phosphatase (AP) positive and percentage of cells staining strongly for NADPH dependent nitro blue tetrazolium reductase (NBT). These enzymes are considered as markers for type II and Clara cells respectively. The purity of all cell preparations was enhanced following 24 h culture on a biomatrix and whilst plating efficiency was similar for all species, the human tissue consistently yielded the highest purity of type II cells. All cells with lamellar bodies did not contain AP, and activity was variable between species. Further studies are needed to determine if NBT is equally nonspecific as a cell marker enzyme. In summary, sufficient type II cells of high purity can be isolated thus permitting interspecies comparative studies to investigate the effects of selective and non-specific pulmonary toxins, but more specific marker enzymes are required to identify Type II and Clara cells.

ST-segment resolution and infarct-related artery patency and flow after thrombolytic therapy. Thrombolysis in Myocardial Infarction (TIMI) 14 investigators

Because patients who fail to achieve reperfusion after thrombolytic therapy remain at high risk for morbidity and mortality, noninvasive measures of infarct-related artery (IRA) patency are needed to identify candidates for rescue interventions. We prospectively studied 444 patients from the Thrombolysis In Myocardial Infarction (TIMI) 14 trial with interpretable baseline and 90 minute 12-lead electrocardiograms. The percent resolution of ST-segment deviation from baseline to 90 minutes was compared with 90-minute IRA TIMI flow grade, as determined in an angiographic core laboratory. Patients with complete (> or = 70%) ST resolution (n = 208; 47%) had a patency (TIMI 2 or 3 flow) rate of 94%, a TIMI 3 flow rate of 79%, and a 30-day mortality rate of 1.0%. Patients with partial (30% to 70%) or no (< or = 30%) ST resolution had significantly lower rates of patency (72% and 68%; p < 0.0001 vs complete ST resolution) and TIMI 3 flow (50% and 44%; p < 0.0001 vs complete ST resolution), and higher 30-day mortality (4.2% and 5.9%; p = 0.01 vs complete ST resolution). With use of electrocardiographic criteria alone, approximately 50% of patients can be classified as having a high (94%) probability of IRA patency and a very low risk for mortality. Angiography to determine patency of the IRA may be unnecessary in these patients. In patients without complete (> or = 70%) ST resolution, the IRA is still likely to be patent, and additional information from clinical variables or serum markers may help to identify candidates for coronary angiography. Patients with persistent ST elevation despite a patent IRA are at increased risk for mortality, likely due to extensive microvascular and tissue injury.

Abciximab improves both epicardial flow and myocardial reperfusion in ST-elevation myocardial infarction. Observations from the TIMI 14 trial

BACKGROUND

In the presence of ST-elevation myocardial infarction, patients with successful epicardial reperfusion (TIMI 3 flow) but persistent ST elevation on a 12-lead ECG are at high risk for subsequent death and left ventricular dysfunction. In the TIMI 14 trial, a dose-ranging angiographic study, combined therapy with abciximab plus reduced-dose tPA enhanced the speed and efficacy of epicardial reperfusion. We determined whether the combination of abciximab plus reduced-dose tPA provided additional benefit in terms of myocardial reperfusion, as evidenced by greater resolution of ST elevation.

METHODS AND RESULTS

All 346 patients with interpretable baseline and 90-minute ECGs, treated with either tPA alone or abciximab plus reduced-dose tPA (combination therapy), were included. Patients receiving combination therapy (n=221) had a 59% rate of complete (>/=70%) ST resolution at 90 minutes versus 37% in those treated with tPA alone (n=125) (P<0.0001). When the analysis was limited to patients with TIMI 3 flow, patients treated with combination therapy (n=151) remained significantly more likely to achieve complete ST resolution than those receiving tPA alone (n=80) (69% versus 44%; P=0.0002).

CONCLUSIONS

Combination therapy with abciximab and reduced-dose tPA improves myocardial (microvascular) reperfusion, as reflected in greater ST-segment resolution, in addition to epicardial flow. This finding may translate into improved clinical outcomes by enhancing myocardial salvage.

Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs

BACKGROUND

Although improved epicardial blood flow (as assessed with either TIMI flow grades or TIMI frame count) has been related to reduced mortality after administration of thrombolytic drugs, the relationship of myocardial perfusion (as assessed on the coronary arteriogram) to mortality has not been examined.

METHODS AND RESULTS

A new, simple angiographic method, the TIMI myocardial perfusion (TMP) grade, was used to assess the filling and clearance of contrast in the myocardium in 762 patients in the TIMI (Thrombolysis In Myocardial Infarction) 10B trial, and its relationship to mortality was examined. TMP grade 0 was defined as no apparent tissue-level perfusion (no ground-glass appearance of blush or opacification of the myocardium) in the distribution of the culprit artery; TMP grade 1 indicates presence of myocardial blush but no clearance from the microvasculature (blush or a stain was present on the next injection); TMP grade 2 blush clears slowly (blush is strongly persistent and diminishes minimally or not at all during 3 cardiac cycles of the washout phase); and TMP grade 3 indicates that blush begins to clear during washout (blush is minimally persistent after 3 cardiac cycles of washout). There was a mortality gradient across the TMP grades, with mortality lowest in those patients with TMP grade 3 (2.0%), intermediate in TMP grade 2 (4.4%), and highest in TMP grades 0 and 1 (6.0%; 3-way P=0.05). Even among patients with TIMI grade 3 flow in the epicardial artery, the TMP grades allowed further risk stratification of 30-day mortality: 0.73% for TMP grade 3; 2.9% for TMP grade 2; 5.0% for TMP grade 0 or 1 (P=0.03 for TMP grade 3 versus grades 0, 1, and 2; 3-way P=0.066). TMP grade 3 flow was a multivariate correlate of 30-day mortality (OR 0.35, 95% CI 0.12 to 1.02, P=0.054) in a multivariate model that adjusted for the presence of TIMI 3 flow (P=NS), the corrected TIMI frame count (OR 1.02, P=0.06), the presence of an anterior myocardial infarction (OR 2.3, P=0.03), pulse rate on admission (P=NS), female sex (P=NS), and age (OR 1.1, P<0.001).

CONCLUSIONS

Impaired perfusion of the myocardium on coronary arteriography by use of the TMP grade is related to a higher risk of mortality after administration of thrombolytic drugs that is independent of flow in the epicardial artery. Patients with both normal epicardial flow (TIMI grade 3 flow) and normal tissue level perfusion (TMP grade 3) have an extremely low risk of mortality.

Bioreactivity of carbon black and diesel exhaust particles to primary Clara and type II epithelial cell cultures

OBJECTIVES

To begin to elucidate the mechanisms of particle toxicity to the lung, the bioreactivity of four carbon black (CB) and diesel exhaust particles ((DEPs), a surrogate for particulate matter of aerodynamic diameter < 10 microns (PM10), were examined with primary cultures of Clara and type II epithelial cells.

METHODS

The particles were extensively characterised by surface chemistry, size, and aggregation properties. Toxicity of the particles was assessed by determining cell attachment to an extracellular matrix substratum.

RESULTS

The spherulite size range for the particles ranged from 50, 40, 20, 20, and 30 nm for CB1-4 and DEPs. All particle samples had different surface chemical compositions. CB1 was the least toxic to Clara (170 micrograms) and type II cells (150 micrograms) and CB4 was the most toxic (55 micrograms and 23 micrograms respectively). DEPs stored for 2 weeks were equally toxic to both epithelial cell types (27-28 micrograms). DEPs became progressively less toxic to type II cells with time of storage. Both primary epithelial cell types internalised the particles in culture.

CONCLUSIONS

Bioreactivity was found to be related to CB particle spherulite size and hence surface area: the smaller the particle and larger the surface area, the more toxic the particles. Also, CB particles with the most complicated surface chemistry were the most bioreactive. Freshly prepared DEPs were equally toxic to type II and Clara cells and they became progressively less toxic to the type II cells with time. With all CB and DEPs, the primary epithelial cells internalised the particles, although this was noted most in cells of low functional competence.

Weight-adjusted dosing of TNK-tissue plasminogen activator and its relation to angiographic outcomes in the thrombolysis in myocardial infarction 10B trial. TIMI 10B Investigators

Fixed doses of thrombolytic agents are generally administered to patients of varying body weights, and the dose-response relation may be confounded by the variability in patient weight. We hypothesized that higher doses of TNK-tissue plasminogen activator (tPA) per unit body weight would be related to improved flow at 90 minutes after thrombolytic administration. A total of 886 patients with acute myocardial infarction were randomized to receive either a single bolus of 30, 40, or 50 mg of TNK-tPA or front-loaded tPA in the Thrombolysis In Myocardial Infarction (TIMI) 10B trial. The dose of TNK-tPA administered was divided by the patient's weight to arrive at the TNK-tPA dose (mg) per unit body weight (kg), and patients were stratified into tertiles based on mg/kg of TNK-tPA: low dose, 0.2 to 0.39 mg/kg; mid-dose, 0.40 to 0.51 mg/kg; high dose, 0.52 to 1.24 mg/kg. Flow in the culprit and nonculprit arteries was analyzed using the TIMI flow grades and the corrected TIMI frame count (CTFC). The median CTFC in culprit arteries differed between the tertiles (3-way p = 0.007), with the CTFC being 7.2 frames faster in high-dose than in low-dose patients (43.1 +/- 30.1, median 31.2, n = 171 vs 54.6 +/- 34.8, median 38.4, n = 166, 2-way p = 0.002). Patients in the mid- and high-dose tertiles achieved patency more frequently (TIMI grade 2 or 3 flow) by 60 minutes (p = 0.02), and the 90-minute percent diameter stenosis was less severe in patients in the high- versus low-dose tertile (p = 0.03). In nonculprit arteries, the CTFC was faster in high- than in low-dose tertiles (29.6 +/- 13.4, median 26.9, n = 130 vs 34.7 +/- 16.3, median 32.8, n = 108, 3-way p = 0.03, 2-way p = 0.008). In patients who underwent percutaneous transluminal coronary angioplasty (PTCA), the CTFC in culprit arteries after PTCA was fastest in the high- and mid-dose tertiles than in those receiving low doses (2-way p = 0.05). Thus, higher doses per unit body weight of TNK-tPA result in not only faster culprit artery flow, but also faster nonculprit, global, and post-PTCA flow, which may reflect earlier opening, reduced stunning, or improved microvascular function. The greater effectiveness of thrombolysis must be weighed against any increase in risk.

Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction

OBJECTIVES AND BACKGROUND

While attention has focused on coronary blood flow in the culprit artery in acute myocardia infarction (MI), flow in the nonculprit artery has not been studied widely, in part because it has been assumed to be normal. We hypothesized that slower flow in culprit arteries, larger territories infarcted and hemodynamic perturbations may be associated with slow flow in nonculprit arteries.

METHODS

The number of frames for dye to first reach distal landmarks (corrected TIMI [Thrombolysis in Acute Myocardial Infarction] frame count [CTFC]) were counted in 1,817 nonculprit arteries from the TIMI 4, 10A, 10B and 14 thrombolytic trials.

RESULTS

Nonculprit artery flow was slowed to 30.9 +/- 15.0 frames at 90 min after thrombolytic administration, which is 45% slower than normal flow in the absence of acute MI (21 +/- 3.1, p < 0.0001). Patients with TIMI grade 3 flow in the culprit artery had faster nonculprit artery CTFCs than those patients with TIMI grades 0, 1 or 2 flow (29.1 +/- 13.7, n = 1,050 vs. 33.3 +/- 16.1, n = 752, p < 0.0001). The nonculprit artery CTFC improved between 60 and 90 min (3.3 +/- 17.9 frames, n = 432, p = 0.0001), and improvements were related to improved culprit artery flow (p = 0.0005). Correlates of slower nonculprit artery flow included a pulsatile flow pattern (i.e., systolic flow reversal) in the nonculprit artery (p < 0.0001) and in the culprit artery (p = 0.01), a left anterior descending artery culprit artery location (p < 0.0001), a decreased systolic blood pressure (p = 0.01), a decreased ventriculographic cardiac output (p = 0.02), a decreased double product (p = 0.0002), a greater percent diameter stenosis of the nonculprit artery (p = 0.01) and a greater percent of the culprit artery bed lying distal to the stenosis (p = 0.04). Adjunctive percutaneous transluminal coronary angioplasty (PTCA) of the culprit artery restored a culprit artery CTFC (30.4 +/- 22.2) that was similar to that in the nonculprit artery at 90 min (30.2 +/- 13.5), but both were slower than normal CTFCs (21 +/- 3.1, p < 0.0005 for both). If flow in the nonculprit artery was abnormal (CTFC > or = 28 frames) then the CTFC after PTCA in the culprit artery was 17% slower (p = 0.01). Patients who died had slower global CTFCs (mean CTFC for the three arteries) than patients who survived (46.8 +/- 21.3, n = 47 vs. 39.4 +/- 16.7, n = 1,055, p = 0.02).

CONCLUSIONS

Acute MI slows flow globally, and slower global flow is associated with adverse outcomes. Relief of the culprit artery stenosis by PTCA restored culprit artery flow to that in the nonculprit artery, but both were 45% slower than normal flow.

Parents' health, health care utilization, and health behaviors following the violent deaths of their 12- to 28-year-old children: a prospective longitudinal analysis

Health status, health care utilization, and health behaviors of parents bereaved by the violent deaths of their adolescent and young adult children were examined 4, 12, and 24 months later. Participants were 261 bereaved parents (171 mothers, 90 fathers). About 20% of the parents reported "poor" physical health during the early bereavement period compared with 16% of Americans the same age. Over time, mothers' health improved whereas fathers' health deteriorated. Fathers in poor health compared with fathers in good health are 15 times more likely to report emotional distress and 4.6 times more likely to report trauma symptoms. Mothers in poor health compared with mothers in good health are 11 times more likely to report emotional distress and 3 times more likely to report trauma symptoms. Mothers' reports of physician visits and medication use were higher than fathers', however, mothers' rates for both decreased significantly over time whereas fathers' rates remained constant. Over 70% of the mothers and nearly 60% of the fathers practiced 2 or more health protective behaviors over time--a finding significantly associated with fewer stress-related illnesses, days absent from work, and non-productivity at work. Implications for the findings are discussed.

Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Thrombolysis In Myocardial Infarction (TIMI) Study Group

BACKGROUND

The corrected TIMI frame count (CTFC) is the number of cine frames required for dye to first reach standardized distal coronary landmarks, and it is an objective and quantitative index of coronary blood flow.

METHODS AND RESULTS

The CTFC was measured in 1248 patients in the TIMI 4, 10A, and 10B trials, and its relationship to clinical outcomes was examined. Patients who died in the hospital had a higher CTFC (ie, slower flow) than survivors (69. 6+/-35.4 [n=53] versus 49.5+/-32.3 [n=1195]; P=0.0003). Likewise, patients who died by 30 to 42 days had higher CTFCs than survivors (66.2+/-36.4 [n=57] versus 49.9+/-32.1 [n=1059]; P=0.006). In a multivariate model that excluded TIMI flow grades, the 90-minute CTFC was an independent predictor of in-hospital mortality (OR=1.21 per 10-frame rise [95% CI, 1.1 to 1.3], an approximately 0.7% increase in absolute mortality for every 10-frame rise; P<0.001) even when other significant correlates of mortality (age, heart rate, anterior myocardial infarction, and female sex) were adjusted for in the model. The CTFC identified a subgroup of patients with TIMI grade 3 flow who were at a particularly low risk of adverse outcomes. The risk of in-hospital mortality increased in a stepwise fashion from 0.0% (n=41) in patients with a 90-minute CTFC that was faster than the 95% CI for normal flow (0 to 13 frames, hyperemia, TIMI grade 4 flow), to 2.7% (n=18 of 658 patients) in patients with a CTFC of 14 to 40 (a CTFC of 40 has previously been identified as the cutpoint for distinguishing TIMI grade 3 flow), to 6.4% (35/549) in patients with a CTFC >40 (P=0.003). Although the risk of death, recurrent myocardial infarction, shock, congestive heart failure, or left ventricular ejection fraction </=40% was 13.0% among patients with TIMI grade 3 flow (CTFC </=40), the CTFC tended to segregate patients into lower-risk (CTFC </=20, risk of adverse outcome of 7. 9%) and higher-risk subgroups (CTFC >20 to </=40, risk of adverse outcome of 15.5%; P=0.17).

CONCLUSIONS

Faster (lower) 90-minute CTFCs are related to improved in-hospital and 1-month clinical outcomes after thrombolytic administration in both univariate and multivariate models. Even among those patients classified as having normal flow (TIMI grade 3 flow, CTFC </=40), there may be lower- and higher-risk subgroups.

Identification of the factors affecting the rate of deactivation of hypochlorous acid by melatonin

It has been found that melatonin reacts rapidly with hypochlorous acid in phosphate-buffered, ethanol-water solutions to produce 2-hydroxymelatonin. The rate law, d[2 - HOMel]/dt - kHOCl[Mel][HOCl] - kOCl-[Mel][OCl-], was obtained. At 37 degrees C and at a water concentration of 23.5 M, kOCl- = 6.0 x 10(2) L. mol-1. s-1, and kHOCl was found to be a function of the water concentration, kHOCl = 11 +/- 3 L3. mol-3. s-1. [H2O]2, indicating that the availability of water at the site of the reaction plays a significant role. The part that the structural components of melatonin play in determining the reaction pathway was examined by comparing the rate of deactivation of HOCl by melatonin to that of the model compounds indole, 5-methoxyindole, and 3-methylindole. The relative reactivity is explained in terms of steric and electronic effects, and it was found that the presence of the substituent at the 3-position influences the nature of the oxidation product. Melatonin and 3-methylindole yielded hydroxylated products, whereas indole and 5-methoxyindole produce chlorinated products.

PTSD among bereaved parents following the violent deaths of their 12- to 28-year-old children: a longitudinal prospective analysis

This study examined the prevalence of posttraumatic stress disorder (PTSD) among parents bereaved by the violent deaths of their 12- to 28-year-old children. A community-based sample of 171 bereaved mothers and 90 fathers was recruited by a review of Medical Examiner records and followed for 2 years. Four important findings emerged: Both parents' gender and children's causes of death significantly affected the prevalence of PTSD symptoms. Twice as many mothers and fathers whose children were murdered met PTSD caseness (full diagnostic) criteria compared with accident and suicide bereavement. Symptoms in the reexperiencing domain were the most commonly reported. PTSD symptoms persisted over time, with 21% of the mothers and 14% of the fathers who provided longitudinal data still meeting caseness criteria 2 years after the deaths. Parents who met caseness criteria for PTSD, compared with those who did not, were significantly different on multiple study variables. Both theoretical and clinical implications for the findings are discussed.

Changes in parents' mental distress after the violent death of an adolescent or young adult child: a longitudinal prospective analysis

This study examined changes in bereaved parents' mental distress following the violent deaths of their 12- to 28-year-old children. A community-based sample of 171 bereaved mothers and 90 fathers was recruited by a review of medical examiner records. Data were collected 4, 12, and 24 months post-death. Repeated measures analysis of variance showed significant reductions in 8 of 10 measures of mental distress among mothers and 4 of 10 for fathers, with the most change for both genders occurring between 4 and 12 months post-death. During the 2nd year of bereavement, mothers' symptoms continued to decline, whereas fathers, who started out with less distress than mothers, reported slight increases in 5 of 10 symptom domains. Nonetheless, 2 years after the deaths, mothers' mental distress scores were up to 5 times higher than those of "typical" U.S. women and fathers' scores were up to 4 times higher than "typical" U.S. men. Of the 7 intervening variables examined, higher scores on self-esteem and self-efficacy predicted lower distress for both mothers and fathers 4, 12, and 24 months post-death. Repressive coping was predictive of distress among fathers. It was concluded that violent death bereavement has sustained, distressing consequences on parents of children who die as a result of accidents, homicides, and suicide.

Drug Use Prevention Data, Missed Assessments and Survival Analysis

In prevention studies, researchers often investigate the incidence of initial drug experimentation or other drug use milestones and its relationship to individual attributes such as the level of parental monitoring or rebelliousness. In this case, survival analysis is the methodology of choice. Survival analysis methods deal efficiently with data from individuals who leave the study prematurely and do not return. However often individuals do return to the study. The application of survival analysis to a situation in which individuals miss assessments and later return is nonstandard. This article examines the use of multiple imputation as a methodology for utilizing information from all assessments.

A bereavement intervention for parents following the sudden, violent deaths of their 12-28-year-old children: description and applications to clinical practice

This report describes a randomized clinical trial with a longitudinal design involving parents bereaved by the violent deaths of their 12-28-year-old children, with a view to applying selected components of the study to clinical practice. Parents of children who died in the previous two to seven months by accident, homicide, or suicide were identified through the death certificates of the children. Of the 261 parents recruited and randomized to intervention and control conditions, 171 were mothers and 90 were fathers. Among the most important findings were: gender differences in both baseline distress and treatment response; and a very slow rate of reduction in distress over time, irrespective of participation in the intervention. Regardless of study group assignment and measurement period, mothers reported higher mental distress, more evidence of trauma, poorer loss accommodation, poorer physical health, and less marital satisfaction than did fathers. Among mothers, 85% met mental distress caseness criteria at baseline (2 to 7 months post-death), 81% met the criteria immediately following the treatment (5 to 10 months post-death), and 67% met the criteria six months later (11 to 16 months post-death). For fathers, 63% met mental distress caseness criteria at baseline, 71% met the criteria immediately post-treatment, and 69% met criteria six months later. Recommendations concern program planning, recruiting and retaining participants, screening and orientation of participants, program format, and evaluation.

Bacterial vaginosis: a review

Bacterial vaginosis (BV) is a clinically definable condition that is frequently diagnosed in the primary care setting. Changes in the nomenclature, causative microorganisms, as well as treatment have caused confusion over the last century. BV is currently viewed as a shift in the normal vaginal ecosystem from a predominance of aerobic bacteria to anaerobic bacteria (Soper, 1993), resulting in a malodorous discharge. However, more than one half of clinically diagnosed patients are asymptomatic. Recent evidence indicates that the anaerobes identified as components of BV have been implicated in obstetric complications, postoperative pelvic infections, and pelvic inflammatory disease. Practice issues resulting from this research include the appropriate treatment of asymptomatic women, especially in pregnancy. This article reviews BV from a historical perspective, provides a summary of recent research findings identifying BV as a possible risk factor in various serious medical conditions and their sequelae, and discusses related practice concerns resulting from the implications of these findings.

The response of lung epithelium to well characterised fine particles

Diesel particles form a large component of the fine particle fraction (PM10) in urban air in the UK. During pollution episodes small increases in PM10 have been linked to detrimental health effects. The comparative toxicological effects of diesel exhaust and other well-characterised particles (carbon black, amorphous and crystalline silica) on rat respiratory epithelium were investigated in the present study. The effects of small masses of particles (1 mg) delivered by intratracheal instillation were monitored by changes in components of lavage fluid. Respirable, crystalline quartz, produced significant increases in lung permeability, persistent surface inflammation, progressive increases in pulmonary surfactant and activities of epithelial marker enzymes up to 12 weeks after primary exposure. Ultrafine amorphous silica did not induce progressive effects but it promoted initial epithelial damage with permeability changes and these regressed with time after exposure. By contrast, ultrafine/fine carbon black had little, if any, effect on lung permeability, epithelial markers or inflammation, despite being given at a dose which readily translocated the epithelium and which has been reported to induce inflammation. Similarly, diesel exhaust particles produced only minimal changes in lavage components, although they were smaller individual particles and differed in surface chemistry from carbon black. It is concluded that diesel exhaust particles are less damaging to respiratory epithelium than silicon dioxide and that the surface chemistry of a particle is more important than ultrafine size in explaining its biological reactivity.

Broad-spectrum group treatment for parents bereaved by the violent deaths of their 12- to 28-year-old children: a randomized controlled trial

This study assessed the efficacy of a 10-week broad-spectrum intervention offered to bereaved parents about 4 months after the deaths of their 12--28-year-old children due to accidents, homicide, or suicide. For three outcomes of distress there was a significant interaction between treatment and baseline values for each outcome for mothers both immediately posttreatment and 6 months later. The intervention appeared to be the most beneficial for mothers most distressed at baseline. Fathers showed no immediate benefits of treatment. Further research is needed to investigate these unexpected results for fathers and to further characterize those who benefit from similar programs.

Social support and network conflict in firefighters and paramedics

The relationship(s) between self-rated social support network conflict (both at work and off-work) and self-report measures of occupational stressors, job satisfaction, and health outcomes were examined in samples of currently employed professional firefighters (n = 1,730) and paramedics (n = 253). In both samples, perceived social support and network conflict at work were more strongly correlated with job satisfaction and work morale, as well as a measure of their appraised occupational stressors, than with their comparable home (off-work) satisfaction/conflict ratings. The path analysis generated suggested that, with only one exception, social support and relational conflict in the combined respondent sample could be conceptualized as direct sources of stress influencing the respondents' appraisal of their occupational stressors. The path model further suggested that firefighter/paramedics' appraisal of their occupational stressors mediated the network variables' influences on self-reported job dissatisfaction and stress symptom health outcome measures.

The disposition of intramuscular artemether in children with cerebral malaria; a preliminary study

The disposition of intramuscular artemether (AM) was studied in 26 Kenyan children with cerebral malaria. Antimalarial activity determined by bioassay was compared with total plasma AM plus dihydroartemisinin (DHA) determined by high power liquid chromatography (HPLC). Therapeutic levels were achieved in most subjects (21/26) within 1 h of receiving intramuscular AM (3.2 mg/kg), with close correlation between bioassay and HPLC measurements (r = 0.706). However, there was marked inter-individual variation, antimalarial activity was undetectable in 5 subjects ('non-absorbers'), and plasma concentrations were lower in subject with respiratory distress. The 50% parasite clearance time was significantly longer in non-absorbers (mean = 13.1 h, SD = 10.8 vs. mean = 7.8 h, SD = 5.5; P = 0.013). We conclude that the bioavailability of intramuscular AM in children with severe malaria may be highly variable, particularly in the presence of respiratory distress, and may be associated with an inadequate therapeutic response.

Clinical Knowledge and Skill Priorities in Substance Abuse Education: A Nursing Faculty Longitudinal Survey

The aims of this study were to: 1) determine which of 16 substance abuse content areas nursing faculty fellows considered important for their professional growth; 2) determine content areas in which faculty fellows planned to obtain knowledge and skill development during the coming year; and 3) to identify content areas faculty fellows thought undergraduate and/or graduate students should be taught. Questionnaires were mailed to the 43 nursing faculty fellows who were recipients of substance abuse federal training during the 1989-1994 academic years. The response rate was 81%. One and a half years later, 66% responded to the same items on a follow-up survey. The results showed that faculty ratings of knowledge and skill development needs for themselves and their students in nursing were stable over time. Findings can be used to guide faculty and curriculum development in alcohol and other substance abuse.

Parents' evaluation of a preventive intervention following the sudden, violent deaths of their children

A preventive intervention for 156 bereaved parents whose 12- to 28-year-old children died by accident, homicide, or suicide was tested using a multisite longitudinal cohort pretest/posttest experimental design. Reported here are bereaved parents' evaluations of the two-dimensional support program. Problem-focused support was rated by parents' perceptions of readiness, relevance, timing, and understanding of the information and skills presented. Emotion-focused support was rated by the identification of I. Yalom's (1985) therapeutic group factors and group leader/clinician support. Over 70% of all the person/session responses showed that both support dimensions were rated at 6 or 7 on a 7-point scale (e.g., 0 = not at all relevant, 7 = very relevant.) Additional exploratory analyses examined the extent to which 5 participant and treatment characteristics influenced parents' evaluations. Clinical implications and future research directions are suggested.

Parent bereavement stress and preventive intervention following the violent deaths of adolescent or young adult children

It is currently believed that effective intervention programs can reduce the negative consequences of stressful life events. The purpose of this paper is to describe a three-step process used to develop a theory-based preventive intervention for parents whose 12- to 28-year-old children had died 2 to 7 months previously by accident, homicide, or suicide. Assumptive world, family life cycle, victimization, and social support theories form the basis for "matching" parent bereavement stress with selected intervention strategies.

Hyponatraemia and dehydration in severe malaria

The prevalence and likely cause of hyponatraemia in severe childhood malaria were investigated. One hundred and thirty two children, 47 of whom had cerebral malaria, were prospectively recruited and serial simple indices of fluid and electrolyte balance and renal function monitored during admission. In 55%, hyponatraemia (sodium < 135 mmol/l) was present on admission. Hyponatraemia was pronounced (sodium < or = 130 mmol/l) in 21%, and these children gained less weight during admission (mean weight gain 2.4% v 4.3%) than children with a normal sodium (135-145 mmol/l). Overall, 31% of survivors were at least moderately dehydrated on admission (5% weight gain by discharge). These children had higher plasma urea concentrations on admission (6.1 v 4.5 mmol/l) and were more acidotic (mean base excess -12.1 v -8.0) than children who were not dehydrated. There were changes in simple indices of renal function between admission and discharge in children who survived (creatinine 65.7 v 37.9 mumol/l and urea 5.5 v 1.9 mmol/l). The results suggest that dehydration is common in severe childhood malaria, that it may contribute to mild impairment in renal function, and that hyponatraemic children are less water depleted, showing appropriate rather than inappropriate secretion of antidiuretic hormone.

Reliability, construct validity, and subscale norms of the Brief Symptom Inventory when administered to bereaved parents

The Brief Symptom Inventory (BSI) was administered to parents (N = 260; 171 mothers and 89 fathers) whose adolescent and young adult children died unexpectedly and violently by accident, homicide, or suicide. Summary statistics and reliability coefficients (Cronbach's alpha) for the nine subscales and the Global Severity Index were calculated. A comparison of means and standard deviations confirmed the expectation that this sample is dramatically different from the normative American community standard. Raw scores for the subscales were transformed into standardized T scores and critical values for a screening heuristic presented. An attempt to obtain construct validity using factor analysis suggested that a five-factor solution provided a description of this population of bereaved parents that is more insightful than the nine standard subscales of the BSI. Implications for both clinicians and future research are discussed.

An analysis for menstrual data with time-varying covariates

This paper concerns the analysis of menstrual data; in particular, methodology to identify variables that contribute to the variability of menstrual cycles both within and between women. The basis for the proposed methodology is a parameterization of the mean length of a menstrual cycle conditional upon the past cycles and covariates. This approach accommodates the length-bias and censoring commonly found in menstrual data. Data from a longitudinal study of menstrual patterns and other variables among Lese women of the Ituri Forest, Zaire, illustrate the methodology. A small simulation illustrates the bias caused by incorrectly deleting the censored cycles.

Psychological assessment of postdisaster class action and personal injury litigants: a case study

The case study method is used to describe psychological assessments undertaken with victims of a combined natural/technological disaster for litigation purposes. A class action suit was filed in which the authors determined levels of traumatic stress in 27 plaintiffs as a group and relative to each other. The process was effective--the case was settled out of court in favor of the litigants. Individual litigants were satisfied with monetary awards received.

Halofantrine pharmacokinetics in Kenyan children with non-severe and severe malaria

1. Kenyan children with uncomplicated malaria given oral halofantrine (HF; non-micronised suspension; 8 mg base kg-1 body weight 6 hourly for three doses) showed wide variation in the disposition of HF and desbutylhalofantrine (HFm). 2. Eight Kenyan children with severe (prostrate) falciparum malaria who were receiving intravenous quinine, were given the same HF regimen by nasogastric tube. One patient had undetectable HF and two had undetectable HFm at all times after drug administration. 3. The mean AUC(0,24 h) of HF in prostrate children was half (7.54 compared with 13.10 micrograms ml-1 h) (P = 0.06), and that for HFm one-third (0.84 compared with 2.51 micrograms ml-1 h) (P < 0.05) of the value in children with uncomplicated malaria. 4. Oral HF may be appropriate for some cases of uncomplicated falciparum malaria in Africa, but in patients with severe malaria, the bioavailability of HF and HFm may be inadequate.

Gender differences in fire fighter job stressors and symptoms of stress

This study described gender differences in fire fighter appraisal of job stressors and symptoms of stress. A sample of 670 male and 41 female fire fighters responded to an anonymous mail survey consisting of three standardized and investigator-developed questionnaires. Male and female fire fighter respondents were more similar than different on both job stressor and symptoms of stress measures. Five job stressors were ranked the most "bothersome" by both males and females during the last 10 shifts worked. These were: sleep disturbance, wage/benefit concerns, job skill concerns, substandard equipment, and safety concerns. Of these five job stress factors, only one gender difference was noted. Female fire fighters reported significantly higher scores than males on job skill concerns. Job discrimination reported by female respondents was significantly higher than for males (t = 3.51, p < .0001) even though it was not ranked among the five most stressful factors. Partial correlations computed between job stressors and symptoms of stress, while controlling for the number of years as a fire fighter, were of moderately high magnitude for both genders and similar to simple correlations computed. These results suggest that the number of years of service did not account for gender differences reported.

Evaluating students' substance abuse assessment skills

Graduating nursing students' abilities to assess clients for substance use were evaluated using two standardized patient (SP) cases. In the comprehensive health history case (unprompted), 55% of the study participants assessed alcohol use and 20% assessed drug use. When prompted to conduct a substance use history, at least 90% of the subjects asked about the quantity and frequency of alcohol use and 80% asked about drug use. However, in the prompted case, fewer than 10% of the subjects linked current alcohol and drug (AOD) use with risks and consequences, nor did they ask the SP if he had considered decreasing substance use. The mean score for communication skills used in the two assessment interviews were 3.65 and 3.56 on a 1 to 6 Likert scale. These data point out the need for additional emphasis on instructing students to include AOD questions as part of routine assessments, what questions to ask in a substance use assessment, and how to act on the information received. The use of SPs is one way to obtain valid information about students' assessment competencies.

Firefighters and paramedics: years of service, job aspirations, and burnout

1. Data were collected from an anonymous mail survey of over 2,000 paramedics and firefighters to determine the relationships among years of service and four occupational outcomes, including burnout. 2. Paramedics had poorer outcomes than firefighters. Job title, not percent of emergency service runs per se, significantly differentiated the groups with respect to burnout and job aspiration variables. 3. After adjusting for age, years of service correlated negatively with three measures of job aspirations: job satisfaction, work related morale, and career goal attainment in both groups. 4. If signs and symptoms of burnout occur throughout the worker's life cycle rather than with increasing years of experience, the findings have implications for both prevention and intervention strategies.

Towards optimal regimens of parenteral quinine for young African children with cerebral malaria: unbound quinine concentrations following a simple loading dose regimen

Nine children with severe falciparum malaria were treated with an intravenous quinine regimen which did not require burettes or infusion pumps, to determine its practicability and to ensure that therapeutic drug concentrations were achieved and maintained throughout the dose interval. The regimen comprised quinine dihydrochloride (15 mg/kg; 12.5 mg/kg of the free base), which was added to a bag of intravenous fluid (after wastage of all but 100 mL), and given via standard giving sets over 2 h. Blood was drawn sequentially during the infusion, and for 12 h thereafter; plasma water was obtained by ultrafiltration of samples at the bedside, and quinine concentration was measured, in plasma and plasma water, by high performance liquid chromatography. Drug administration was practicable without burettes or infusion pumps; unbound drug concentrations exceeded the 99% inhibitory concentration for local parasites within 0.5 h, and remained within the therapeutic range for the entire dose interval. This loading dose regimen can now be recommended for young children in African hospitals; maintenance doses of 10 mg/kg should be given at 12 h intervals until oral antimalarial drugs are possible. These recommendations will need to be modified if susceptibility to quinine declines.

A study of the comparative bioavailability of pyrimethamine-sulfadoxine obtained from two oral preparations

The bioavailability of two oral preparations of pyrimethamine-sulfadoxine are compared in a randomised cross-over study. Pyrimethamine(PM)-sulfadoxine(SD) was given orally in a single dose to healthy male adults (SD 12 mgkg-1; PM 0.64 mgkg-1). For Fansidar(Hoffman-LaRoche) the mean AUC for PM and SD were; 0.47 mghl-1 and 45.4 mghl-1, and for Falcidin(Cosmos), the mean AUC for PM and SD were; 0.49 mg hl-1 and 42.9 mghl-1 respectively. There was no significant difference in bioavailability of PM or SD between the two preparations.

An outbreak of intravenous cannulae associated nosocomial septicaemia due to multidrug-resistant Klebsiella pneumoniae

We present the clinical course of four children involved in an outbreak of intravenous cannulae associated nosocomial septicaemia due to multidrug-resistant Klebsiella pneumoniae. The patients involved, two of whom died became bacteraemic within a three week period, and evidence for an environmental source of the organism was obtained.

Brain swelling and ischaemia in Kenyans with cerebral malaria

Computed tomography was performed on 14 unconscious Kenyan children recovering from cerebral malaria (seven of whom had another scan 12-120 days later) to elucidate the cause of intracranial hypertension and neurological sequelae. Brain swelling, defined as a loss of cerebrospinal fluid spaces, was documented in six children, while a further two had conspicuously small ventricles only. There was severe intracranial hypertension in the two children with definite brain swelling in whom intracranial pressure was monitored. There was no evidence of acute hydrocephalus or vasogenic oedema. Four children with brain swelling also had widespread low density areas suggestive of ischaemic damage. The patterns of damage were not uniform but were consistent with a critical reduction in cerebral perfusion pressure (which was documented in the two in whom this was monitored), hypoglycaemia, or status epilepticus. All four had serious neurological sequelae. These data suggest that brain injury in cerebral malaria may be due in part to secondary systemic and intracranial factors as well as to the direct effect of intravascular sequestration.

Sources of occupational stress among firefighter/EMTs and firefighter/paramedics and correlations with job-related outcomes

INTRODUCTION/OBJECTIVE

This paper reports the results of an initial effort to develop and test a measure of the various sources of job-related stress in firefighter and paramedic emergency service workers.

METHODS

A 57-item paper and pencil measure of occupational stressors in firefighter/Emergency Medical Technicians (EMTs) and firefighter/paramedics was developed and administered by anonymous mail survey.

RESULTS

More than 2,000 (50% rate of return) emergency service workers completed and returned the surveys. The responses of 1,730 firefighter/EMTs and 253 firefighter/paramedics were very similar in terms of the degree to which job stressors were bothersome. A factor analysis of replies yielded 14 statistically independent "Occupational Stressor" factors which together accounted for 66.3% of the instrument's variance. These Sources of Occupational Stress (SOOS) factor scale scores essentially did not correlate with a measure of the social desirability test-taking bias. Finally, SOOS factors were identified that correlated with job satisfaction and work-related morale of the respondents. Conflict with administration was the job stressor factor that most strongly correlated with reports of low job satisfaction and poor work morale in both study groups.

CONCLUSION

The findings suggest that firefighter and paramedic job stress is very complicated and multi-faceted. Based on this preliminary investigation, the SOOS instrument appears to have adequate reliability and concurrent validity.

Coping strategies of abstainers from alcohol up to three years post-treatment

This study characterizes the experiences and coping strategies of 23 alcohol-dependent persons who maintained abstinence from alcohol use up to three years post-treatment. Interview, journal, and mail questionnaire data were collected at 12, 18 and 36 months post-treatment. The results support and extend the theoretical model of change proposed by Prochaska and DiClemente (1984). Hallmarks of successful change included factors that can be learned, practiced, perfected and are transferable to other alcohol-dependent persons who decide to break the addictive cycle.

An empirical description of phases of maintenance following treatment for alcohol dependence

This article reports two longitudinal prospective studies conducted sequentially to describe participants' maintenance of abstinence experiences up to 36 months posttreatment. Study 1 reports responses of 102 subjects who maintained alcohol abstinence following treatment and who were assessed for duration and intensity of symptoms associated with postacute withdrawal at baseline, 3, 6, and 12 months. A decreasing linear trend of symptoms was found as time of alcohol abstinence increased. Study 2 obtained interview and survey data from 23 successful abstainers from Study 1 at 12, 18, and 36 months posttreatment to describe coping strategies, perceptions of relapse risk, extent and duration of "aftercare," and substitute addictions as these phenomena developed and changed over time. Multiple occasions of data collection supported the description of three phases of maintenance: symptom stabilization/management accompanied by a cognitive paradigm shift, distancing self from alcohol-dependent behavior, and normalization of life processes.