Variations in the management of acute myocardial infarction. Importance of clinical measures of disease severity

OBJECTIVE

To determine the extent to which resource use for patients hospitalized with acute myocardial infarction varies with clinical status, and to see if an observed difference in resource use between two states can be explained by clinically detailed risk adjustment.

DESIGN

Retrospective review of the clinical characteristics and resource use of 342 patients hospitalised in two states with acute myocardial infarction.

DATA SOURCES

Merged data from three sources: a large, existing research database used in developing the Medicare Mortality Predictor Score, clinical data abstracted from medical charts specifically for this study, and Medicare Parts A and B claims records.

PATIENTS

A probability sample of Medicare patients hospitalized in 1986 with a diagnosis of acute myocardial infarction and residing in either Wisconsin or Washington state; patients dying within 30 days are oversampled.

MEASUREMENTS AND MAIN RESULTS

Although patients were clinically similar in the two states, there were systematic differences in resource use. Patients in Wisconsin spent more than one extra day in the intensive care unit (ICU) (2.8 vs 1.7) as well as more than one extra non-ICU day in the hospital (8.0 vs 6.5) than patients in Washington. Patients in Wisconsin were also more likely to receive an echocardiogram (35.6% vs 15.8%), nuclear ventriculogram (12.8% vs 4.1%), exercise tolerance test (21.5% vs 3.4), and Holter monitoring (5.4% vs 0%). (All p < .01.) Differences in utilization were greater for patients at lower risk of dying. The average cost of care was 20.8% higher in Wisconsin (p = .01); risk adjustment for clinical and other factors reduced this difference to 11.8%, but did not eliminate it (p = .04).

CONCLUSIONS

Patients with acute myocardial infarction vary in resource use as a function of clinical factors present at admission and occurring during the hospital stay; comparisons that do not take account of these factors may not discriminate well between providers who care for sicker patients and those who are inefficient. The greater use of resources for patients in Wisconsin is at least partially explained by differences in clinical characteristics that are not presently captured in administrative data.

RBF, a novel RB-related gene that regulates E2F activity and interacts with cyclin E in Drosophila

Genetic studies have shown that cyclin E and dE2F are critical regulators of S-phase entry during Drosophila embryogenesis. Whereas the ectopic expression of cyclin E activates dE2F-dependent transcription, it has been proposed that cyclin E does not act directly on dE2F but targets a negative regulator of E2F activity. Such a regulator might be analogous to the family of RB-related proteins (pRB, p107, and p130) that associate with E2F in humans; however, extensive efforts have failed to find such homologs in Drosophila. We have developed a two-hybrid approach that allows transcription activators to be used as bait for interacting proteins. From a screen using Drosophila E2F (dE2F and dDP) as bait, we identified a novel gene, RBF. RBF combines several of the structural features of pRB, p107, and p130, suggesting that it may have evolved from a common ancestor to the three human genes. RBF associates with dE2F and dDP in vivo and is a stoichiometric component of E2F DNA-binding complexes. RBF specifically repressed E2F-dependent transcription and suppressed the phenotype generated by ectopic expression of dE2F and dDP in the developing Drosophila eye. RBF was phosphorylated by a cyclin E-associated kinase in vitro, and loss-of-function cyclin E mutations enhanced an RBF overexpression phenotype, consistent with the idea that the biological activity of RBF is negatively regulated by endogenous cyclin E. The properties of RBF suggest that it is the intermediary factor that was proposed to allow cyclin E induction of E2F activity. These findings indicate that RBF plays a critical role in the regulation of cell proliferation in Drosophila and show that analogous pathways regulate S-phase entry in a diverse range of species.

Cyclic strain causes heterogeneous induction of transcription factors, AP-1, CRE binding protein and NF-kB, in endothelial cells: species and vascular bed diversity

Recent studies demonstrate that cyclic strain stimulates protein kinase C in bovine aortic endothelial cells (BAEC) as well as the induction of immediate early genes and the transcription factor activator protein-1 (AP-1) in human umbilical vein endothelial cells (HUVEC). The objective of this study was to determine whether transcriptional factor induction in endothelial cells (EC) exposed to strain is the same with regard to the species and vascular bed they are derived from. Evidence for a heterogeneous response for growth, orientation and prostacyclin secretion has been obtained for a variety of EC exposed to cyclic strain. In this study, we investigated cyclic strain mediated induction of transcription factors, AP-1, cAMP response element binding protein (CRE) and nuclear factor kB (NF-kB) in cultured EC from HUVEC, human aorta (HAEC), and BAEC. EC were exposed to 10% average strain at 60 cpm for up to 24 h. At varying time points, nuclear protein was extracted and analyzed for production of AP-1, CRE and NF-kB by electromobility shift assay. The results demonstrate that EC exposure to cyclic strain leads to a significant induction of AP-1, CRE and NF-kB in HAEC and HUVEC, but not in BAEC. Furthermore, these findings are in marked contrast to the previously described shear stress induced activation of AP-1 and NF-kB in BAEC. There was also a temporal difference in their response such that stretch-induced activation of AP-1 and NF-kB peaked at 4 h, whereas CRE increased in a biphasic manner at 15 min and 24 h. These results may partially explain the divergent effects of cyclic strain on EC gene expression and phenotype in EC from different vascular beds and species and underscore the difference in EC response to cyclic strain and shear stress.

Hypotensive stress retards associative learning in rabbits

This study examined the effects of hypotensive stress on classical conditioning of the rabbit's nictitating membrane response. Hypotension, consisting of an approximately 45% decrease in blood pressure, was maintained for 30 min by the i.v. infusion of sodium nitroprusside. Twenty minutes later animals were exposed to a conditioning session consisting of 60 pairings of a 200 ms tone conditioned stimulus with a 100 ms airpuff unconditioned stimulus directed at the cornea. This procedure was repeated for four consecutive days. Animals exposed to the hypotensive stress demonstrated a significantly retarded acquisition of conditioned responses as measured by their frequency and onset latency as well as by an increase in the number of trials required to reach acquisition criteria of five and 10 consecutive conditioned responses as compared with controls. A separate group of animals received a nitroprusside infusion one day after the acquisition of conditioned responses to the tone conditioned stimulus. These animals demonstrated a normal retention of conditioned responses and a normal response to varying intensities of the conditioned stimulus. Hypotensive stress also had no effect on the frequency and topography of the unconditioned response. It was concluded that a decrease in blood pressure can serve as a physiological stressor. One of the reactions to this stress consists of a retardation in the formation of associations during a learning task, without any decrease in the ability to retrieve previously learned material.

Ultrastructural cytochemistry of human gastric cancer: electron microscopic observations of five organellae marker enzymes

The distribution of ALPase, ACPase, G6Pase TPPase and CCOase of gastric cancer and normal gastric epithelium were studied ultrastructurally. The results showed that normal gastric epithelium had no ALPase reaction. The reactions of ACPase, G6Pase, TPPase and CCOase were found in the corresponding organellae which were consistent with their functions. In tubular adenocarcinoma cells, their reactions were more apparent in the corresponding organellae. Some cells of tubular adenocarcinomas showed ALPase reaction. The mucinous adenocarcinoma cells had higher ACPase and TPPase reactions. In poorly differentiated adenocarcinoma cells, the five marker enzymes showed negative or faint reactions. The biological significance and mechanisms of distribution of the five marker enzymes were discussed.

The high mobility group protein HMG I(Y) can stimulate or inhibit DNA binding of distinct transcription factor ATF-2 isoforms

The high mobility group protein HMG I(Y) stimulates the binding of a specific isoform of the activating transcription factor 2 (ATF-2(195)) to the interferon beta (IFN-beta) gene promoter. HMG I(Y) specifically interacts with the basic-leucine zipper region of ATF-2(195), and HMG I(Y) binds to two sites immediately flanking the ATF-2 binding site of the IFN-beta promoter. Here, we show that HMG I(Y) can stimulate the binding of ATF-2(195), at least in part, by promoting ATF-2 dimerization. In addition, we report the characterization of a naturally occurring isoform of ATF-2 (ATF-2(192)) that binds specifically to the IFN-beta promoter but is unable to interact with HMG I(Y). Remarkably, HMG I(Y) inhibits the binding of ATF-2(192) to the IFN-beta promoter. Thus, the ability of HMG I(Y) to specifically interact with ATF-2 correlates with its ability to stimulate ATF-2 binding to the IFN-beta promoter. Comparisons of the amino acid sequences of the basic-leucine zipper domains of ATF-2(195) and ATF-2(192) suggest that HMG I(Y) interacts with a short stretch of basic amino acids near the amino terminus of the basic-leucine zipper domain of ATF-2(195).

Methylenedioxyamphetamine: a selective effect on cortical content and turnover of 5-HT

This study examined the effects of the hallucinogen, MDA, on brain content of monoamines and their metabolites in the rabbit. A single 1.8 mg/kg dose of MDA produced 30 to 64% increases in the 5-HT content of frontal cortex from 30 to 120 min after injection and a decrease in 5-HT turnover from 30 min to 8 h, but had no effect in hippocampus, caudate nucleus, or hypothalamus. A single 3.6 mg/kg dose of MDA also reduced the turnover of 5-HT in frontal cortex, but this was accompanied by a decrease in 5-HIAA with no increase in 5-HT. The 1.8 and 3.6 mg/kg doses of MDA had no significant or consistent effects on the contents of DA, DOPAC, HVA, and NE in any brain area examined. Chronic administration of MDA (3.6 mg/kg/day for 4 days) failed to produce any evidence of a neurotoxic action on 5-HT neurons. Higher doses could not be employed because the LD50 of MDA was approximately 5 mg/kg. This study has demonstrated that behaviorally effective and nonneurotoxic doses of MDA produce increases in the content and decreases in turnover of 5-HT in frontal cortex that resemble those of other hallucinogens such as LSD and DOM.

Polydioxanone absorbable sutures in vascular anastomoses: experimental and preliminary clinical studies

To assess the safety and efficacy of polydioxanone suture (PDS) for vascular anastomoses, bilateral carotid end-to-end anastomoses using PDSs on the left and Dacron sutures on the right in 18 dogs were performed. The anastomoses were assessed at 4, 6 and 8 weeks after surgery. A breaking-strength test (300 mmHg) did not show a significant difference between PDS and Dacron anastomoses, but partial absorption was grossly evident in the PDS group. Some 35 venous and 21 arterial reconstructive procedures were also carried out using PDS in 53 patients. At follow-up of 3-5 (mean 3.5) years, none of the patients had experienced any suture-related complications. The results indicate that PDS maintains an adequate tensile strength in anastomoses until suture-line healing occurs, suggesting that this material may be safely used in venous or small arterial anastomoses. In addition, because it is absorbable, resulting in decreased foreign-body reactions, PDS may have the potential to improve the long-term patency of venous or small arterial reconstructions.

[Experimental study and clinical application of endothelium seeded vena caval prostheses]

One hundred and eleven mongrel dogs were used for this study. Endothelial cells were harvested from jugular vein or omentum with methods of collagenase digestion and density gradient separation. Animal model of prosthetic interposition into the inferior vena cava with or without distal arteriovenous fistula was established. The complete endothelialization was established 5 to 10 days following a high density seeding. The neointimal hyperplasia was inhibited. A 100-day 100% patency of prosthesis was reached. The seeded endothelium secreted higher level of PGI2 than normal control and lower level of TXB2, hence the positive effect of distal AVF functioning for a week on the patency was demonstrated. This method used in 10 cases with Budd-Chiari syndrome resulting in good outcome after 3 to 5 years follow-up. We conclude that the endothelial seeding technique has a promising future using in the venous circuit.

Mechanisms of transcriptional synergism between distinct virus-inducible enhancer elements

The high mobility group protein HMG I(Y) and the transcription factor NF-kappa B are required for the activity of positive regulatory domain II (PRDII), a virus-inducible regulatory element of the human interferon-beta gene promoter. In this paper we provide evidence that HMG I(Y) is also required for the activity of PRDIV, a regulatory element that synergizes with PRDII. In this case, HMG I(Y) stimulates binding of activating transcription factor 2 (ATF-2) and the assembly of inducible complexes containing ATF-2 and c-Jun. Remarkably, HMG I(Y) also specifically interacts with the leucine zipper/basic region of ATF-2, and ATF-2 in turn interacts with NF-kappa B. We therefore propose that the HMG I(Y) plays a critical structural role in establishing transcriptional synergy between PRDII and PRDIV by promoting the activities and/or binding of NF-kappa B and ATF-2 and by facilitating their interaction.

Enhanced patency of venous Dacron grafts by endothelial cell sodding

The effect of microvessel endothelial cell (EC) sodding on the patency of Dacron grafts interposed in canine inferior vena cava was studied. EC were harvested enzymatically from canine omentum and isolated by density gradient centrifugation. Preclotted, knitted Dacron grafts were sodded with > 10(6) EC/cm2 surface. The results demonstrate significant improvement in patency of sodded grafts placed in the inferior vena cava as compared with control grafts (p < 0.001 in grafts with a distal arteriovenous fistula and p < 0.05 in grafts without a distal fistula). The neointima of the sodded grafts were thinner and scanning electron microscopy confirmed the presence of a confluent layer of EC. In addition, the production of prostacyclin but not thromboxane A2 was significantly enhanced in the sodded grafts as compared with controls. We conclude that microvessel EC sodding of Dacron grafts significantly improves the patency rate and inhibits neointimal thickening of the prosthesis. The mechanism is unknown but may involve a more rapid endothelialization of the graft surface with the potential of producing more prostacyclin and less thromboxane A2.

Weight loss in Alzheimer's disease

In order to determine whether weight loss is a core symptom or secondary manifestation of Alzheimer's disease, we analyzed weight change in 81 outpatients with Alzheimer's disease. During a mean 2.9 years of observation, the mean absolute weight loss was 1.9 +/- 0.8 kg, and the mean weight loss per year was 0.7 +/- 0.3 kg. Although statistically significant (P < .05), the mean absolute weight loss was only 3% of initial body weight. Data analyses revealed that weight change was significantly (P < .0001) correlated with decreased independence in self-feeding. Weight change was not related to duration of dementia, clinical measures of dementia severity, psychiatric symptoms, or medications. These observations support the view that weight loss is a consequence of Alzheimer's disease and does not reflect specific brain lesions.

An ATF/CREB binding site is required for virus induction of the human interferon beta gene [corrected]

We report the characterization of a distinct regulatory element of the human interferon beta (HuIFN-beta) gene promoter, which we designate PRDIV (positive regulatory domain IV). In previous studies, sequences between -104 and -91 base pairs upstream from the start site of transcription were shown to be required for maximal levels of virus induction in mouse L929 cells. We have localized the essential sequence in this region extending from -99 to at least -91, and we show that this sequence is a binding site for a protein of the activating transcription factor/cAMP response element binding protein (ATF/CREB) family of transcription factors. Mutations in PRDIV that decrease the affinity of one member of this family (ATF-2/CRE-BP1) decrease the level of virus induction in vivo. Moreover, multiple copies of PRDIV can confer both virus and cAMP inducibility upon a minimal promoter in L929 cells, while it is constitutively active in HeLa cells. We conclude that PRDIV is a distinct regulatory element of the HuIFN-beta promoter and that the signal transduction pathways involved in virus and cAMP induction may partially overlap.

In vitro microleakage at the gingival margin of porcelain and resin veneers

This in vitro study investigated the effect of dental surface treatments on the seal of porcelain and resin laminate veneers to tooth structure. Nine groups of 20 teeth were prepared for labial veneers--six groups with the apical margin of the veneer in dentin, two groups with the veneer wholly bordered by enamel, and one group with the apical margin coincident with the apical margin of a previously placed glass ionomer restoration. The teeth were treated with a variety of dentin-bonding agents prior to restoration of eight groups with porcelain veneers and one group with Visio-Gem microfilled resin veneers. After placement, the veneers were stored in water for 4 days, then subjected to thermocycling before silver staining and sectioning. Results showed no leakage around the margins of the veneers wholly bordered by enamel. Complete leakage was found around the glass ionomer restorations, and nearly total leakage was found along the resin-dentin interface of the resin veneers. The porcelain veneers that extended onto dentin showed variable but limited leakage for four of five of the dentin-bonding treatments.

Effects of aspirin, dipyridamole, and dibutyryl cyclic adenosine monophosphate on platelet-derived growth factor A chain mRNA levels in human saphenous vein endothelial cells and smooth muscle cells

Aspirin and dipyridamole have frequently failed to control intimal hyperplasia in vascular grafts in animal and clinical trials. These trials were based on the concept that the smooth muscle mitogen, platelet-derived growth factor (PDGF) released from platelets, was a major cause of intimal hyperplasia. Both endothelial and smooth muscle cells (ECs and SMCs), however, can also release PDGF-like SMC mitogens that might cause intimal hyperplasia. We therefore tested whether aspirin and dipyridamole alone or together can affect PDGF-A chain mRNA levels in cultured human saphenous vein ECs and SMCs. Cultures were exposed for 72 hours to 3 x 10(-5) mol/L aspirin and/or 5 x 10(-6) mol/L dipyridamole. Cellular RNA was then extracted, and PDGF-A chain mRNA signal levels were measured by a reverse transcription/polymerase chain reaction method. mRNA for glyceraldehyde-3-phosphate dehydrogenase was used as a constitutively expressed control RNA species. Signal strength on Southern blots of amplified polymerase chain reaction products was measured by densitometry. Neither aspirin nor dipyridamole alone or together reduced the ratio (PDGF-A chain signal/glyceraldehyde-3-phosphate dehydrogenase signal) below that of control cultures. PDGF-A chain expression was not a constitutive artifact of culture because dibutyryl cyclic AMP (5 x 10(-4) mol/L) reduced PDGF-A chain signal from a control index of 1.0 to 0.5 +/- 0.1 (mean +/- SE) (n = 3; p less than 0.05) in EC cultures and to 0.2 (mean) (n = 2) in SMC cultures. These data may explain why aspirin and dipyridamole fail to reduce intimal hyperplasia in some animal and clinical trials despite effective inhibition of platelet aggregation.

Reevaluation of limited side-to-side portacaval shunt

Although the results of limited side-to-side portacaval shunt were better than those of other shunts, postoperative encephalopathy still occurred in 10.2% of the patients. To determine the relationship between the diameter of anastomotic stoma and the development of postoperative encephalopathy, animal experiments and clinical observations were carried out. In 4 of 8 dogs in 3 months after limited side-to-side portacaval shunt and in 6 patients with postoperative encephalopathy, there was significant augmentation of the diameter of anastomotic stoma. To prevent the widening of anastomotic stoma caused by blood flow under high pressure, a limiting ring of 10 mm in diameter was put around the anastomotic site during operation in 21 patients with portal hypertension. Follow-up for 3-15 months (average 6 months) showed that there was no evidence of postoperative encephalopathy and rebleeding. A ring of same kind was put around the dilated anastomotic stoma during exploration in the 6 patients, and all their cerebral symptoms and signs disappeared completely soon after the second operation.

Rapid cellular luminal coverage of Dacron inferior vena cava prostheses in dogs by immediate seeding of autogenous endothelial cells derived from omental tissue: results of a preliminary trial

Endothelial cell seeding methods might reduce the high failure rates of venous vascular prostheses, but low flow rates in venous vascular prostheses impose a need to protect early patency and to attain early endothelial cell coverage without waiting several weeks for relatively small endothelial cell innocula from autologous veins to form confluent linings. To obtain large number of autologous endothelial cells for high-density seeding, canine omental microvascular endothelial cells were harvested by collagenase digestion and density gradient centrifugation, with yields of 1.34 +/- 0.24 (SD) X 10(6) cells/gm of omentum (N = 8 harvests). Primary culture of a subfraction from each harvest showed the cell population to be dominated by factor VIII-related antigen-positive endothelial cells with only a few nonstaining cells (estimated to be 10% or less of total cell number) visible. Freshly harvested omental cells were seeded onto double velour knitted Dacron prostheses at densities of 5 X 10(5) cells/cm2 of graft luminal surface in an autologous plasma suspension by use of prior preclotting with cell-free autologous plasma, followed by endothelial cell seeding in autologous plasma, with plasma recalcification during endothelial cell instillation. Six seeded and two control (sham-seeded) vascular prostheses 5 cm long with 10 mm inner diameter were used as inferior vena cava interposition grafts. A distal arteriovenous fistula and aspirin (300 mg) and dipyridamole (50 mg orally every day) starting 3 days before surgery were used to protect early patency of all grafts. Seeded venous vascular prostheses were explanted for study at intervals of 1,5, and 10 days after surgery (N = 2 prostheses at each time); the two control venous vascular prostheses were explanted at 10 days. All venous vascular prostheses were patent at time of removal. In seeded venous vascular prostheses, light, scanning, and transmission electron microscopy showed emergence of numerous flattened endothelial cell-like cells on the luminal surface 24 hours after surgery, followed by formation of a confluent cellular lining without adherent platelets by 5 to 10 days after surgery. Control venous vascular prostheses, in contrast, remained covered by an irregularly thickened fibrin and red cell thrombus, which sometimes encroached on the lumen. Our results suggest that (1) omental tissue can furnish endothelial cells for high-density immediate seeding of venous vascular prostheses, and (2) that the method we used to combine features of both so-called high density "seeding" and "sodding" techniques offers both more rapid prosthesis coverage than the former and shorter intraoperative times for cell attachment to prostheses than the latter.(ABSTRACT TRUNCATED AT 400 WORDS)