Reducing costs and improving processes for the interventional cardiology patient

The cardiology unit at the University of Chicago Hospitals developed a cost-saving mechanism in the care of postinterventional cardiology patients, reducing time spent in the coronary care unit. Increased nursing education and training and better identification of patient outcomes made this collaborative effort a cost-saving and effective pilot.

Osteoprotegerin ligand is a cytokine that regulates osteoclast differentiation and activation

The ligand for osteoprotegerin has been identified, and it is a TNF-related cytokine that replaces the requirement for stromal cells, vitamin D3, and glucocorticoids in the coculture model of in vitro osteoclastogenesis. OPG ligand (OPGL) binds to a unique hematopoeitic progenitor cell that is committed to the osteoclast lineage and stimulates the rapid induction of genes that typify osteoclast development. OPGL directly activates isolated mature osteoclasts in vitro, and short-term administration into normal adult mice results in osteoclast activation associated with systemic hypercalcemia. These data suggest that OPGL is an osteoclast differentiation and activation factor. The effects of OPGL are blocked in vitro and in vivo by OPG, suggesting that OPGL and OPG are key extracellular regulators of osteoclast development.

Cardiac tamponade during laparoscopic Nissen fundoplication

Laparoscopic Nissen fundoplication is becoming a popular technique in the surgical management of reflux disease. The advantages of laparoscopic surgery include shorter hospital stays, greater patient acceptance and decreased overall morbidity. Laparoscopic surgery eliminates the necessity for an upper abdominal incision and the consequent post-operative impairment of pulmonary mechanics. Laparoscopic Nissen fundoplication has been associated with a low incidence of severe peri-operative complications although of a different nature to those following the open procedure. We are reporting a rare case of acute cardiovascular collapse secondary to cardiac tamponade during laparoscopic Nissen fundoplication.

Light versus heavy sedation after cardiac surgery: myocardial ischemia and the stress response. Maritime Heart Centre and Dalhousie University

The influence of light versus heavy sedation after coronary artery bypass graft (CABG) surgery on the development of postoperative myocardial ischemia has not been described. After uncomplicated CABG surgery, 50 patients were randomly assigned to receive LOW (n = 24; target Ramsay Sedation Score [RSS] = 2) or HIGH (n = 26; target RSS = 4) sedation with propofol. Analgesia was provided to maintain a visual analog scale (VAS) pain score <7. Myocardial ischemia was identified perioperatively using continuous 3-lead Holter monitoring. By measuring creatine kinase (CK) MB levels preoperatively, at entry to the intensive care unit (ICU), and every 12 h for 48 h; and by obtaining serial 12-lead electrocardiograms (ECG) (preoperatively; 2, 4, 12, 24, and 48 h after ICU admission, 8:00 AM the morning after surgery; and 5 min pre- and postextubation), myocardial infarction was identified. Endocrine stress response was assessed by measuring serum cortisol levels preoperatively, on admission to the ICU, and 24 h postoperatively. In a subset of patients (LOW n = 10, HIGH n = 11), plasma and urinary catecholamine levels were also measured. There were no between-group differences in demographics, operative course, hemodynamic variables, or cortisol levels while in the ICU. The VAS pain score and target RSS were achieved and sustained, and they differed between groups. There were three myocardial infarctions in each group by CKMB criteria alone. No ECG-identifiable myocardial infarction occurred. The ST segment versus time curve (LOW 187 +/- 295 versus HIGH 1071 +/- 2137 mm/min) differed between groups. Urinary and plasma catecholamine levels were similar between groups over the observation period. We conclude that the use of a reduced sedation regimen in combination with adequate analgesia did not result in an increased endocrine stress response or risk of myocardial ischemia.

IMPLICATIONS

This randomized study of patients after coronary artery bypass surgery examined whether light (versus heavy) sedation with propofol in the intensive care unit was associated with an increased degree of myocardial ischemia. Using techniques to detect myocardial ischemia, including Holter monitoring, electrocardiogram, and myocardial enzyme measurements, no differences were found. We conclude that light sedation does not increase the endocrine stress response or the risk of myocardial infarction.

Midterm results with the Sorin Monostrut heart valve prosthesis

OBJECTIVE

To monitor the hematological and clinical sequelae of a single tilting disc cardiac valve prosthesis.

DESIGN

Prospective nonrandomized trial.

SETTING

University teaching hospital.

PARTICIPANTS

All patients receiving a single mechanical cardiac valve prosthesis were offered the Sorin Monostrut valve if they met the criteria for valve use. Seventy-five per cent of the patients entered were in New York Heart Association (NYHA) functional class III or IV. One hundred and forty-seven patients were subsequently followed at three months and then yearly after valve implantation for seven years.

MAIN OUTCOME MEASURES

At one year, preoperative indexes of hemolysis were compared with three-month and one-year postoperative values. Actuarial curves for survival, freedom from cerebrovascular events and explantation were constructed for the seven-year follow-up period.

RESULTS

Hemolysis, as measured by lactate dehydrogenase values, commonly occurs preoperatively, remaining significantly elevated three months and one year following valve implantation. Serum haptoglobin was normal preoperatively but was significantly low at one year. Anemia was uncommon and most patients had normal reticulocyte counts at one year. At three years, 81% of patients were in NYHA functional class I.

CONCLUSIONS

Midterm results show that this valve is structurally reliable and meets all current requirements for a safe mechanical valve.

Phylogeography and molecular systematics of the Peromyscus aztecus species group (Rodentia: Muridae) inferred using parsimony and likelihood

Mice of the Peromyscus aztecus species group occur at mid to high elevations in several mountain ranges in the highlands of Middle America (Mexico and Central America), a region of high endemicity. We examined the biogeography of this group by conducting phylogenetic analyses of 668 bp of the mitochondrial cytochrome b (cyt b) gene. Phylogenetic analyses under both parsimony and likelihood frameworks produced the same topologies, but estimates of nodal support were artificially high in weighted parsimony analyses. This difference is attributed to the inability of parsimony to optimize branch lengths when evaluating topologies. These data indicate that the P. aztecus-like populations from south and east of the Isthmus of Tehuantepec currently assigned to P. a. oaxacensis represent a distinct species, with genetic distances as high as 0.091. In addition, P. hylocetes is strongly divergent from Mexican populations of P. aztecus (genetic distances of 0.044-0.069), supporting the recognition of this taxon as a distinct species. The history of divergence in this group can be explained by a series of apparently early to middle Pleistocene vicariance events associated with glacial cycles. The Sierra Madre Occidental and Cordillera Transvolcanica each appear to be faunistically isolated, the Isthmus of Tehuantepec appears to have been a strong Pleistocene barrier, and the Sierra Madre Oriental has affinities with the Sierra Madre del Sur and the highlands of central Oaxaca.

Pediatric phase II cancer chemotherapy trials: a Pediatric Oncology Group study

PURPOSE

This study reviewed the Pediatric Oncology Group experience with phase II clinical trials in children (< 21 years of age) with refractory tumors.

PATIENTS AND METHODS

Patients registered in Pediatric Oncology Group phase II studies were evaluated. Patients had to be < 21 years of age with recurrent and refractory measurable disease. Tumor types and response rates were determined. Death on therapy from either drug toxicity, progressive disease, infection, or hemorrhage was measured. Tumor-specific, disease-free survival curves were calculated by Kaplan-Meier analysis.

RESULTS

Between 1984 and 1994, 2,465 patient entries were made on 45 phase II trials. Malignancies registered included acute lymphocytic leukemia (ALL) (16.7%), acute myeloid leukemia (AML) (12.0%), osteogenic sarcoma (7.8%), neuroblastoma (7.2%), astrocytoma (7.2%), medulloblastoma (7.1%), glioma (6.7%), ependymoma (6.1%), and others (29.2%). The overall response rate was 19.6% (CR + PR) for children entered on phase II trials. Tumor-specific response rates ranged from 62.1% (23/37) for children with Hodgkin's disease to no responses (0/23) in patients with hepatoblastoma. When comparing single versus multiagent trials, a significantly better initial response rate was seen in the latter studies. However, 5-year survival was comparable. Progression-free survival for all tumor histologies were 12.9% and 9.2% at 2 and 5 years, respectively. Death on study was seen in 11.6% of the patients; however, only three deaths were directly related to drug toxicity. There were no significant gender differences in regards to response, progressive disease, or death on study.

CONCLUSION

Phase II studies conducted in children offer a considerable likelihood of therapeutic benefit without exposing these patients to untoward toxicity.

Osteoprotegerin: a novel secreted protein involved in the regulation of bone density

A novel secreted glycoprotein that regulates bone resorption has been identified. The protein, termed Osteoprotegerin (OPG), is a novel member of the TNF receptor superfamily. In vivo, hepatic expression of OPG in transgenic mice results in a profound yet nonlethal osteopetrosis, coincident with a decrease in later stages of osteoclast differentiation. These same effects are observed upon administration of recombinant OPG into normal mice. In vitro, osteoclast differentiation from precursor cells is blocked in a dose-dependent manner by recombinant OPG. Furthermore, OPG blocks ovariectomy-associated bone loss in rats. These data show that OPG can act as a soluble factor in the regulation of bone mass and imply a utility for OPG in the treatment of osteoporosis associated with increased osteoclast activity.

Evolution of the mitochondrial cytochrome oxidase II gene in collembola

The sequence of the mitochondrial COII gene has been widely used to estimate phylogenetic relationships at different taxomonic levels across insects. We investigated the molecular evolution of the COII gene and its usefulness for reconstructing phylogenetic relationships within and among four collembolan families. The collembolan COII gene showed the lowest A + T content of all insects so far examined, confirming that the well-known A + T bias in insect mitochondrial genes tends to increase from the basal to apical orders. Fifty-seven percent of all nucleotide positions were variable and most of the third codon positions appeared free to vary. Values of genetic distance between congeneric species and between families were remarkably high; in some cases the latter were higher than divergence values between other orders of insects. The remarkably high divergence levels observed here provide evidence that collembolan taxa are quite old; divergence levels among collembolan families equaled or exceeded divergences among pterygote insect orders. Once the saturated third-codon positions (which violated stationarity of base frequencies) were removed, the COII sequences contained phylogenetic information, but the extent of that information was overestimated by parsimony methods relative to likelihood methods. In the phylogenetic analysis, consistent statistical support was obtained for the monophyly of all four genera examined, but relationships among genera/families were not well supported. Within the genus Orchesella, relationships were well resolved and agreed with allozyme data. Within the genus Isotomurus, although three pairs of populations were consistently identified, these appeared to have arisen in a burst of evolution from an earlier ancestor. Isotomurus italicus always appeared as basal and I. palustris appeared to harbor a cryptic species, corroborating allozyme data.

Identification of the major positive regulators of c-myb expression in hematopoietic cells of different lineages

The c-myb gene is primarily expressed in hematopoietic cells, and it is overexpressed in many leukemias. The regulation of its expression is of critical importance in hematopoietic cells. We identified the major positive regulatory sites in the 5'-flanking sequence of the human c-myb gene, and we found that the positive regulators differed in cells of different lineages. In the Molt-4 T-cell line, two Ets-like binding sites were required for the expression of c-myb. The 5' site played a minor role in the regulation of c-myb expression, and we demonstrated that a protein of 67 kDa bound to this site. Antibodies against Ets proteins showed no cross-reactivity with this protein. We showed that Ets-1 bound to the 3'-regulatory site in the c-myb promoter by electrophoretic mobility shift assay and antibody studies. Both of these Ets-like binding sites were nonfunctional in the DHL-9 B-cell line and the K562 myeloid cell line. We identified a novel transcription factor of 50.5 kDa that was required for expression of c-myb in these cell lines.

Cognitive behavioural nursing therapy in paranoid psychosis

This paper provides an account of cognitive behavioural interventions applied by nurses to a patient experiencing paranoia. The paper provides a brief review of the process of such interventions and incorporates a case study.

Reducing costs and improving processes for the interventional cardiology patient

The cardiology unit at the University of Chicago Hospitals developed a cost-saving mechanism in the care of postinterventional cardiology patients, reducing time spent in the coronary care unit. Increased nursing education and training and better identification of patient outcomes made this collaborative effort a cost-saving and effective pilot.

Valsartan, a new angiotensin II antagonist for the treatment of essential hypertension: efficacy and safety compared to hydrochlorothiazide

OBJECTIVE

To compare the antihypertensive efficacy of a new angiotensin II antagonist, valsartan, with a reference therapy, hydrochlorothiazide (HCTZ).

METHODS

In this double-blind study, 167 adult out-patients with mild-to-moderate essential hypertension were randomly allocated in equal number to receive valsartan 80 mg or HCTZ 25 mg for 12 weeks. In patients whose blood pressure (BP) remained uncontrolled after 8 weeks of monotherapy, atenolol 50 mg was added to the initial treatment. Patients were assessed at 4, 8 and 12 weeks. The primary efficacy variable was change from baseline in mean sitting diastolic BP (SDBP) at 8 weeks. Secondary variables included change in sitting systolic BP (SSBP) and responder rates (percentage of patients with SDBP < 90 mmHg or drop > or = 10 mmHg compared to baseline) at 8 weeks.

RESULTS

Valsartan and HCTZ were both effective at lowering diastolic and systolic blood pressure at all time points. Similar falls were seen in both groups with no significant differences between treatments. For the primary variable (decrease in SDBP) there was no significant difference between treatments. For SSBP there was also no significant difference observed. Responder rates at 8 weeks were 74% for valsartan and 62% for HCTZ (P = 0.10). Both treatments were well tolerated, both as monotherapy, and when combined with atenolol 50 mg per day.

CONCLUSION

The data show valsartan 80 mg to be as effective as HCTZ in the treatment of mild-to-moderate hypertension. The results also show valsartan to be well tolerated when taken alone or in combination with atenolol.

Valsartan, a new angiotensin II antagonist for the treatment of essential hypertension: a comparative study of the efficacy and safety against amlodipine

OBJECTIVE

To compare the antihypertensive efficacy of a new angiotensin II antagonist, valsartan, with a reference therapy, amlodipine.

METHODS

One hundred sixty-eight adult outpatients with mild to moderate hypertension were randomly allocated in double-blind fashion and equal number to receive 80 mg valsartan or 5 mg amlodipine for 12 weeks. After 8 weeks of therapy, in patients whose blood pressure remained uncontrolled, 5 mg amlodipine was added to the initial therapy. Patients were assessed at 4, 8, and 12 weeks. The primary efficacy variable was change from baseline in mean sitting diastolic blood pressure at 8 weeks. Secondary variables included change in sitting systolic blood pressure and responder rates.

RESULTS

Both valsartan and amlodipine were effective at lowering blood pressure at 4, 8, and 12 weeks. Similar decreases were observed in both groups, with no statistically significant differences between the groups for any variable analyzed. For the primary variable the difference was 0.5 mm Hg in favor of valsartan (p = 0.68; 95% confidence interval, -2.7 to 1.7). Responder rates at 8 weeks were 66.7% for valsartan and 60.2% for amlodipine (p = 0.39). Both treatments were well tolerated. The incidence of drug-related dependent edema was somewhat higher in the amlodipine group, particularly at a dose of 10 mg per day (2.4% for 80 mg valsartan; 3.6% for 5 mg amlodipine; 0% for valsartan plus 5 mg amlodipine; 14.3% for 10 mg amlodipine).

CONCLUSIONS

The data show that valsartan is at least as effective as amlodipine in the treatment of mild to moderate hypertension. The results also show valsartan to be well tolerated and suggest that it is not associated with side effects characteristic of this comparator class, dihydropyridine calcium antagonists.

Characterization and determination of the biological activities of noncleavable high molecular weight forms of inhibin A and activin A

Recombinant expression of human alpha- and beta A-inhibin subunit cDNAs in mammalian 293 cells results in the secretion of 20-53K free alpha-subunit-derived products, 30-105K alpha beta A-inhibin dimers, and 24-110K beta A-activin dimers. The present study verifies that the wide variation in the size of these products is due to incomplete cleavage of the proteolytic processing sites and the differential glycosylation of the N-linked glycosylation site at amino acid number 302 in the alpha C-subunit. The identity of each of these products was established by mutagenesis of proteolytic processing sites and N-linked glycosylation sites, combined with the analysis of transfection products by immunoprecipitation and one- and two-dimensional SDS-PAGE (SDS/SDS-beta-ME). Transient expression of processing site mutants of the alpha- and beta A-subunits in 293 cells was used to generate microgram quantities of noncleavable 55K and 65K inhibin dimers, and noncleavable 110K activin A dimers. The 55K and 65K inhibin A forms were purified and found to be fully biologically active in a rat pituitary cell bioassay. The 110K high molecular weight (HMW) form of human activin A failed to show any FSH-releasing activity in the pituitary assay. Since radioactively labeled 55K and 65K inhibin A and 110K activin A remained intact after incubation with rat pituitary cells for 72 h, there appears to be no conversion of these dimers to lower molecular weight forms by proteolytic cleavage at additional sites. These results show for the first time that 55K and 65K inhibit A are intrinsically biologically active and do not require cleavage to the 32K form for activation. In contrast, cleavage of the 110K activin A precursor to the 24K form would appear to be necessary for activity.

Ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection: a case-control and molecular epidemiologic investigation

In a molecular, microbiologic, and case-control study to describe the epidemiology of ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection, 32 unique isolates were recovered over 31 months from the blood of patients hospitalized in a 900-bed hospital in Chicago. Multivariate analysis revealed cases occurred more frequently in debilitated nursing home patients with central venous catheters than in younger, healthier patients. Mortality rates were similar for cases and controls. Case-patients were less likely to die if they received appropriate antibiotic treatment within 3 days of bacteremia onset (P = .02). Pulsed-field gel electrophoresis analysis indicated a polyclonal outbreak, with strain-specific temporal and geographic clustering. Isoelectric focusing results suggested that a predominant enzyme, TEM-10, was responsible for the ceftazidime resistance. The resistance gene was usually carried on a large conjugative plasmid. The polyclonality of the resistant strains suggests that ceftazidime resistance due to TEM-10 is now endemic in Chicago.

Large differences in substitutional pattern and evolutionary rate of 12S ribosomal RNA genes

We demonstrate using Drosophila, periodical cicadas, and hominid primates, that the molecular clock based on animal mitochondrial small-subunit (12S) rRNA genes ticks at significantly different relative rates depending on which taxa and which region of the gene are examined. Drosophila, which are commonly used as model taxa, are evolving in a highly peculiar manner with the majority of sites in the 3' half of the 12S gene apparently invariant. The analogous 3' half of the mitochondrial large-subunit rRNA gene (16S) appears to be similarly constrained. It is surprising that these regions that are already highly constrained in all animals should be even more constrained in Drosophila, especially when the Drosophila mitochondrial genome as a whole does not display a similar rate slowdown. This extreme 12S rate slowdown is not apparent in periodical cicadas or hominid primates and appears to be related to strong structural and functional constraints rather than a depressed mutation rate. Finally, the slow average rate of evolution in the third domain of Drosophila does not imply that the few variable sites lack multiple hits.