Predictors of attendance at cardiac rehabilitation after myocardial infarction

OBJECTIVE

The purpose of this study was to determine predictors of attendance at cardiac rehabilitation after myocardial infarction (MI).

METHODS

Various demographic, behavioural, and clinical variables were measured during hospitalisation in 288 MI patients. Of these, 263 were available to attend outpatient-based cardiac rehabilitation: 108 actually attended.

RESULTS

Multiple logistic regression analyses indicated that nonattenders lived in more deprived areas and were less likely to have paid employment. Nonattenders also registered more symptoms of depression and anxiety and exercised less frequently prior to their MI, although only the last of these variables were predicted in a multivariate model. In terms of clinical status, whether patients had been thrombolysed or not was the strongest predictor of attendance.

CONCLUSIONS

Attendance at cardiac rehabilitation is not an arbitrary matter. Strategies should be developed for encouraging greater attendance among those not in paid employment, those from deprived areas, and those who exercise infrequently.

Delya's story: from expert to novice, a critique of Benner's concept of context in the development of expert nursing practice

The concepts identified within Benner's Nineteen Eighty Four research 'From Novice to Expert' have been widely adopted within UK nursing education and development. This paper combines a narrative from a post-registration student with analysis of the literature as a case study for gaining greater understanding of Benner's work in practice. Delya's story both validates aspects of the concept of skill acquisition and challenges some of the interpretations of the model within professional education. The focus of the critique of Benner's work within the literature to date has been on a deconstruction of the concepts and semantics of her work. In presenting verbatim extracts from a case study this paper seeks to move the focus to nursing practice.

Economic analysis of amifostine as adjunctive support for patients with advanced head and neck cancer: preliminary results from a randomized phase II clinical trial from Germany

In a randomized phase II trial in Germany, we investigated the clinical and economic impact of amifostine protection against the hematological and oral toxicities of carboplatin administered concurrently with standard fractions of radiotherapy. 28 patients with squamous cell carcinomas of the head and neck received adjunctive or primary radiotherapy (5 days per week with daily fractions of 2 Gy, up to a total dose of 60 Gy) in conjunction with carboplatin (70 mg/m2) on days 1-5 and days 21-26. All patients received radiation encompassing at least 75% of the major salivary glands. Patients were randomized to receive radiation and carboplatin (RCT) alone or RCT preceded by rapid infusion of amifostine (500 mg) on days carboplatin was administered. The 14 patients who received amifostine, in comparison to 14 patients in the control arm, had significantly fewer episodes of grade 3 or 4 thrombocytopenia (p = 0.001), mucositis (p = 0.001), and xerostomia (p = 0.001). The patients receiving amifostine accrued significantly lower supportive care costs for resources related to infection ($241 vs. $1,275, p < 0.01), red blood cell and platelet support ($286 vs. $1,276 p = 0.06) alimentation ($343 vs. $894, p = .01), and hospitalization ($286 vs. $2,429, p < 0.01). Overall, including the costs of amifostine, mean per patient supportive care costs were $4,401 for the amifostine group and $5,873 (p = .02) for the control group. Our results from a randomized phase II trial indicate that selective cytoprotection with amifostine potentially offers clinical and economic benefits in patients with advanced head and neck cancer receiving radiochemotherapy. Additional economic studies alongside randomized phase III trials and from other countries are needed.

Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety

OBJECTIVE

The purpose of this study was to determine the impact of symptoms of depression and anxiety on mortality and quality of life in patients hospitalized for acute myocardial infarction (MI).

METHODS

The Beck Depression Inventory and the State-Trait Anxiety Inventory were completed by 288 patients hospitalized for MI. Twelve-month survival status was ascertained, and quality of life among survivors was assessed at 12 months using the Dartmouth COOP charts.

RESULTS

Thirty-one (10.8%) patients died, 27 of cardiac causes, during the 12-month follow-up. Symptoms of depression and anxiety predicted neither cardiac nor all-cause mortality. Severity of infarction and evidence of heart failure predicted both cardiac and all-cause mortality. The same findings emerged from supplementary analyses of data from patients who died after discharge from the hospital. Symptoms of depression and anxiety, measured at entry, predicted 12-month quality of life among survivors, as did gender, partner status, employment status, living alone, previous frequency of exercise, and indices of disease severity (Killip class and Peel Index). In a multiple regression model in which all of these variables were entered, initial depression scores provided the best independent prediction of quality of life, although living alone, severity of infarction, and state anxiety also entered the model.

CONCLUSIONS

Symptoms of depression and anxiety did not predict either cardiac or all-cause mortality after MI, but they did predict quality of life among those who lived to 12 months.

Coherent probability from incoherent judgment

People often have knowledge about the chances of events but are unable to express their knowledge in the form of coherent probabilities. This study proposed to correct incoherent judgment via an optimization procedure that seeks the (coherent) probability distribution nearest to a judge's estimates of chance. This method was applied to the chances of simple and complex meteorological events, as estimated by college undergraduates. No judge responded coherently, but the optimization method found close (coherent) approximations to their estimates. Moreover, the approximations were reliably more accurate than the original estimates, as measured by the quadratic scoring rule. Methods for correcting incoherence facilitate the analysis of expected utility and allow human judgment to be more easily exploited in the construction of expert systems.

The role of fluorescence in situ hybridization technologies in molecular diagnostics and disease management

Large genomic changes, such as aneuploidy, deletions, and other chromosomal rearrangements, have long been associated with pregnancy loss, congenital abnormalities, and malignancy. These genomic changes are quantitative, unambiguous, and fundamental in the transition of normal cells to abnormal ones. Detection of these large genetic changes has an increasingly important role in determining patient diagnosis and care, including therapeutic selection. We have developed two major product platforms that assess genomic changes at various levels of resolution. Fluorescence in situ hybridization (FISH) techniques and the related technology of array-based comparative genomic hybridization (CGH) allow detection of genesized or larger alterations in the genome. FISH is a robust DNA probe technology that can measure both balanced and unbalanced genomic changes on a cell-by-cell basis. In most instances, it is not dependent on metaphase chromosomes, and it is widely used in clinical diagnostics. Array-based CGH has much greater multiplexing capabilities than FISH. This technology has the potential to examine many regions of the genome simultaneously for changes in DNA copy number and identify complex patterns of gains and losses within the genome. In this article, we review several of the current medical applications of FISH and discuss such advanced techniques as CGH and array-based CGH.

Interleukin-2 involvement in early acute respiratory distress syndrome: relationship with polymorphonuclear neutrophil apoptosis and patient survival

OBJECTIVE

To determine blood and lung alveolar concentrations of interleukin (IL)-2 in acute respiratory distress syndrome (ARDS) and their relationship with polymorphonuclear neutrophil (PMN) apoptosis and patient survival.

DESIGN

Prospective cohort study.

SETTING

Medical and surgical intensive care units (ICUs; Canada) and the intensive care department (Belgium).

PATIENTS

Nineteen consecutive patients with ARDS, 14 non-ARDS ICU patients, and 20 healthy volunteers.

INTERVENTIONS

Blood samples and bronchoalveolar lavages (BAL) obtained via venous puncture and by fiberoptic bronchoscopy in the first 72 hrs after the onset of ARDS.

MEASUREMENTS AND MAIN RESULTS

One early point concentration of IL-2 was measured in both blood and BAL fluids of the three groups. In vivo alveolar PMN apoptotic index in BAL fluids and the influence of BAL fluid exposure on normal blood PMN spontaneous apoptosis in vitro were evaluated. Blood IL-2 was significantly lower in patients with ARDS compared with non-ARDS ICU patients and controls. In contrast, IL-2 in BAL fluids of patients with ARDS was dramatically elevated compared with non-ARDS ICU patients and controls. ARDS survivors exhibited lower early IL-2 blood levels than nonsurvivors and generally had a higher IL-2 lung content Lung alveolar PMN apoptosis in vivo was lower in patients with ARDS in comparison with controls. This apoptotic index was correlated with corresponding IL-2 alveolar levels in patients with ARDS. Exposure of normal blood PMN to BAL fluids from patients with ARDS delayed apoptosis in vitro. Immunodepletions of IL-2, granulocyte-macrophage colony stimulating factor, and a combination of both cytokines from BAL fluids of ARDS patients significantly restored PMN apoptosis. The recovery of PMN apoptosis was more effective when IL-2 was depleted in BAL fluids from ARDS survivors compared with nonsurvivors.

CONCLUSIONS

Opposite and disproportional concentrations of IL-2 are observed in blood and lung fluids of patients with early ARDS. IL-2 significantly contributes (with granulocyte-macrophage colony stimulating factor) to the inhibition of PMN apoptosis in BAL fluids of patients with ARDS. Early low blood IL-2 and high IL-2-driven inhibition of PMN apoptosis are beneficial to survivors. Thus, IL-2 is a new candidate for monitoring in early ARDS and an interesting indicator of prognosis.

Disruption of the F plasmid partition complex in vivo by partition protein SopA

The SopA protein plays an essential, though so far undefined, role in partition of the mini-F plasmid but, when overproduced, it causes loss of mini-F from growing cells. Our investigation of this phenomenon has revealed that excess SopA protein reduces the linking number of mini-F. It appears to do so by disturbing the partition complex, in which SopB normally introduces local positive supercoiling upon binding to the sopC centromere, as it occurs only in plasmids carrying sopC and in the presence of SopB protein. SopA-induced reduction in linking number is not associated with altered sop promoter activity or levels of SopB protein and occurs in the absence of changes in overall supercoil density. SopA protein mutated in the ATPase nucleotide-binding site (K120Q) or lacking the presumed SopB interaction domain does not induce the reduction in linking number, suggesting that excess SopA disrupts the partition complex by interacting with SopB to remove positive supercoils in an ATP-dependent manner. Destabilization of mini-F also depends on sopC and SopB, but the K120Q mutant retains some capacity for destabilizing mini-F. SopA-induced destabilization thus appears to be complex and may involve more than one SopA activity. The results are interpreted in terms of a regulatory role for SopA in the oligomerization of SopB dimers bound to the centromere.

Do depression and anxiety predict recurrent coronary events 12 months after myocardial infarction?

We examined the association between depression and anxiety and recurrent coronary heart disease events during the first 12 months subsequent to myocardial infarction. The Beck Depression Inventory and the State-Trait Anxiety Inventory were completed during hospitalization by 288 myocardial infarction patients. Peel Index score and Killip class were used as indices of disease severity. The 12-month incidence of recurrent coronary heart disease events (fatal and non-fatal) was determined. Eighty-two patients experienced recurrent coronary heart disease events, including 27 cardiac fatalities, during follow-up. Whereas the Peel Index differentiated patients who experienced recurrent events from those who did not (OR 3.00, 95% CI 1.46-6.20), symptoms of depression (OR 0.97, 95% CI 0. 55-1.70) and anxiety (OR 1.00, 95% CI 0.98-1.02) were unrelated to outcome. Depression and anxiety did not predict subsequent coronary heart disease events and were not associated with either Peel Index scores or Killip class.

Effects of depression and anxiety on mortality and quality-of-life 4 months after myocardial infarction

OBJECTIVE

The purpose of this study was to determine the impact of depression and anxiety on mortality and quality-of-life in patients hospitalized for an acute myocardial infarction (MI).

METHODS

Questionnaire measures of depression and anxiety were completed during hospitalization by 288 MI patients. The main outcomes were mortality and quality-of-life, assessed by the Dartmouth COOP charts, at 4 months.

RESULTS

A total of 25 patients died, 22 from cardiac causes, during the 4-month follow-up. Symptoms of depression and anxiety did not predict either cardiac or all-cause mortality. Severity of infarction, extent of heart failure, and a longer stay in hospital predicted mortality. Symptoms of depression and anxiety predicted 4-month quality-of-life among survivors, as did gender, partner status, occupational status, living alone, previous exercise behaviour, length of hospital admission, and Peel Index scores. In a multiple regression model, depression emerged as the strongest predictor of quality-of-life. State anxiety, severity of infarction, and partner status also entered the model.

CONCLUSION

Neither depression nor anxiety predicted mortality 4 months after MI. Both depression and anxiety predicted quality-of-life at 4 months among survivors.

Cultural differences in music chosen for pain relief

Nurses use music therapeutically but often assume that all patients will equally appreciate the same type of music. Cultural differences in music preferences are compared across five pain studies. Music preferences for pain relief are described as the most frequently chosen type of music for each culture. Findings indicate that in four studies, musical choices were related to cultural background (p = .002 to .049). Although the majority in each group chose among the other types of music, Caucasians most frequently chose orchestra music, African Americans chose jazz, and Taiwanese chose harp music. For culturally congruent care, nurses should become aware of cultural differences in music preference and provide culturally specific selections among other music expected to have a therapeutic effect.

Cost analysis of filgrastim for the prevention of neutropenia in pediatric T-cell leukemia and advanced lymphoblastic lymphoma: a case for prospective economic analysis in cooperative group trials

BACKGROUND

Growth factor use has been shown to ameliorate chemotherapy-induced neutropenia, leading to shorter hospital stays and lower use of parenteral antibiotics, two costly areas of cancer treatment. Prior reports on pediatric patients have shown evidence of cost savings in some studies, but no such evidence in others. In this study a retrospective analysis compared the costs of inpatient supportive care for pediatric patients with T-cell leukemia and advanced lymphoblastic lymphoma enrolled in a Pediatric Oncology Group trial.

PROCEDURE

Patients 1-22 years of age were randomized to receive either granulocyte colony-stimulating factor (G-CSF; n = 45) or no G-CSF (n = 43) following induction and two cycles of maintenance therapy. There were no significant differences in neutropenia-related outcomes during the induction phase. During maintenance therapy, G-CSF patients had significantly fewer days to an ANC >500 cells/microl and a trend towards fewer days of hospitalization. Data on resource utilization were tabulated from case report forms. Costs were imputed from national data on hospitalization costs, average wholesale prices of pharmaceuticals, and patient billing information from a single institution.

RESULTS

Total median costs of supportive care were $34,190 for patients receiving G-CSF and $28,653 for patients not receiving G-CSF (P > 0. 05 for the cost difference). Sensitivity analyses demonstrated that the total cost difference was not statistically significant, even in scenarios that included reasonable variations in estimates of the range of the length of stay, antibiotic regimen, and dosage and cost of G-CSF.

CONCLUSIONS

In the setting of pediatric leukemia, the cost of growth factor may offset potential savings from shorter hospital stays or lower antibiotic use, a finding consistent with that from the Children's Cancer Study Group.

Effect of Healon and Viscoat on outflow facility in human cadaver eyes

PURPOSE

To compare the acute effects of Healon (sodium hyaluronate) and Viscoat (sodium chondroitin sulfate-sodium hyaluronate) on outflow facility in human cadaver eyes and determine which viscoelastic agent is least likely to cause an intraocular pressure (IOP) spike after cataract surgery.

SETTING

The Glaucoma Research Lab, University of Toronto, Ontario, Canada.

METHODS

In this prospective paired study, 15 pairs of human cadaver eyes were used. Following the construction of a 3.0 mm scleral tunnel, 0.25 cc of Healon was injected into the anterior chamber of 1 eye and 0.25 cc of Viscoat was injected into the contralateral eye. The viscoelastic agents were removed from both eyes in a standardized fashion and the scleral tunnels closed. The eyes were then perfused at a constant IOP of 8.0 mm Hg, corresponding to 16.0 mm Hg in vivo. Outflow facility (microL/minute [min]/mm Hg) was recorded every 15 minutes for 24 hours using standard methods.

RESULTS

Outflow facility in the Viscoat-treated eyes decreased appreciably for the first 3 hours, then recovered somewhat after 12 hours; facility in the Healon-treated eyes showed less of an overall decrease. Over the 24 hour perfusion period, mean outflow facility was 0.037 microL/min/mm Hg +/- 0.015 (SD) in the Viscoat-treated eyes and 0.060 +/- 0.012 microL/min/mm Hg in the Healon-treated eyes. Healon reduced outflow facility significantly less than Viscoat between 3.25 and 10.50 hours postoperatively (P < .05, 2-tailed t test).

CONCLUSIONS

Healon reduced outflow facility less than Viscoat between 3.25 and 10.50 hours postoperatively.

Partition of the linear plasmid N15: interactions of N15 partition functions with the sop locus of the F plasmid

A locus close to one end of the linear N15 prophage closely resembles the sop operon which governs partition of the F plasmid; the promoter region contains similar operator sites, and the two putative gene products have extensive amino acid identity with the SopA and -B proteins of F. Our aim was to ascertain whether the N15 sop homologue functions in partition, to identify the centromere site, and to examine possible interchangeability of function with the F Sop system. When expressed at a moderate level, N15 SopA and -B proteins partly stabilize mini-F which lacks its own sop operon but retains the sopC centromere. The stabilization does not depend on increased copy number. Likewise, an N15 mutant with most of its sop operon deleted is partly stabilized by F Sop proteins and fully stabilized by its own. Four inverted repeat sequences similar to those of sopC were located in N15. They are distant from the sop operon and from each other. Two of these were shown to stabilize a mini-F sop deletion mutant when N15 Sop proteins were provided. Provision of the SopA homologue to plasmids with a sopA deletion resulted in further destabilization of the plasmid. The N15 Sop proteins exert effective, but incomplete, repression at the F sop promoter. We conclude that the N15 sop locus determines stable inheritance of the prophage by using dispersed centromere sites. The SopB-centromere and SopA-operator interactions show partial functional overlap between N15 and F. SopA of each plasmid appears to interact with SopB of the other, but in a way that is detrimental to plasmid maintenance.

Psychology in coronary care

Psychological stress has been implicated in the onset and progression of coronary heart disease (CHD). Recent research has highlighted the importance of depression and anxiety as independent risk factors for mortality in cardiac patients. Accordingly, it is critical that clinically significant levels of distress are identified, both in-hospital and after discharge, to target patients who require specific psychological intervention, in addition to conventional cardiac rehabilitation. Ameliorating distress has been shown to improve adherence to treatment advice, such as modifying cardiac risk factors, compliance with medication regimens, and attendance at exercise programmes, which in turn should reduce cardiac morbidity and mortality. The emphasis within cardiac rehabilitation should be on tailoring provision to meet individual patients' needs.

The F plasmid centromere, sopC, is required for full repression of the sopAB operon

The SopB protein of the F plasmid has a dual role in the partition of F plasmid copies to daughter cells prior to division. It binds to the sopC centromere site to form the partition complex needed for stabilizing the plasmid, and it interacts with SopA to repress transcription of the sopAB operon, thus preventing the destabilization that results from excess SopB. We have isolated sop mutants by screening for unstable inheritance of mutagenized mini-F DNA. Four of the mutants resulted from different missense mutations in sopB. All four were deficient, to varying degrees, in autoregulation of Sop protein synthesis. The mutant proteins showed diminished capacity for reducing the linking number of mini-F and for destabilizing a plasmid carrying sopC, indicating that reduced ability to form a normal complex with sopC might underlie the autoregulation defect. Repression of the transcription of a sop promoter- lacZ fusion by SopA and SopB was strongly enhanced in the presence of sopC, in cis or in trans, and the enhancement was reduced or nullified when wild-type sopB was replaced by the mutant sopB alleles. A single 43 bp unit of sopC was almost as effective as sopC itself in enhancing repression. The results show that sopC is necessary for full repression of the sop promoter. They thus indicate a previously unsuspected role for this centromere site, and suggest that autoregulation and partition might normally be coordinated processes.

Transcription factor E2F-1 is upregulated in response to DNA damage in a manner analogous to that of p53

The transcription factor E2F-1 directs the expression of genes that induce or regulate cell division, and a role for E2F-1 in driving cells into apoptosis is the subject of intense discussion. Recently it has been shown that E2F-1 binds and coprecipitates with the mouse double-minute chromosome 2 protein (Mdm2). A domain of E2F-1 (amino acids 390 to 406) shows striking similarity to the Mdm2 binding domain of the tumor suppressor protein p53. It is known that interaction of Mdm2 with p53 through this domain is required for Mdm2-dependent degradation of p53. We show here that E2F-1 protein is upregulated in response to DNA damage. The kinetics of induction are dependent upon the source of DNA damage, i.e., fast and transient after irradiation with X rays and delayed and stable after irradiation with UVC, and thus match the kinetics of p53 induction in response to DNA damage. We show further that E2F-1 is also upregulated by treatment with the transcription inhibitor actinomycin D and with the kinase inhibitor DRB, as well as by high concentrations of the kinase inhibitor H7, all conditions which also upregulate p53. In our experiments we were not able to see an increase in E2F-1 RNA production but did find an increase in protein stability in UVC-irradiated cells. Upregulation of E2F-1 in response to DNA damage seems to require the presence of wild-type p53, since we did not observe an increase in the level of E2F-1 protein in several cell lines which possess mutated p53. Previous experiments showed that p53 is upregulated after microinjection of an antibody which binds to a domain of Mdm2 that is required for the interaction of Mdm2 with p53. Microinjection of the same antibody also increases the expression of E2F-1 protein, while microinjection of a control antibody does not. Furthermore, microinjection of Mdm2 antisense oligonucleotides upregulates E2F-1 protein, while microinjection of an unrelated oligonucleotide does not. These data suggest that E2F-1 is upregulated in a similar way to p53 in response to DNA damage and that Mdm2 appears to play a major role in this pathway.