Total endoscopic off-pump coronary artery bypass grafting

Two cases of totally endoscopic off-pump coronary artery bypass grafting (TECAB) of the left internal thoracic artery to the left anterior descending artery using the da Vincitrade mark telemanipulation system (Intuitive Surgical, Mountain View, CA) are described. A new articulating endoscopic stabilizer with cleats was developed to enable endoscopic anchoring of silastic vessel loops for vascular occlusion. Newly created attachments for irrigation and suction, along with active robotic enhanced assistance by a second surgical console, permitted our group to perform for the first time a truly endoscopic bypass grafting without any thoracotomy.

Pegylated interferon-alpha2b: pharmacokinetics, pharmacodynamics, safety, and preliminary efficacy data. Hepatitis C Intervention Therapy Group

AIMS

The objectives of this study were to assess the safety, pharmacokinetic and pharmacodynamic profiles, and antiviral efficacy of pegylated interferon-alpha2b monotherapy in patients with chronic hepatitis C.

METHODS

Fifty-eight patients (38 men, 20 women; age range, 25 to 65 years) with compensated chronic hepatitis C were enrolled in this open-label, randomized, active controlled study. Patients received 0.035 to 2.0 microg/kg pegylated interferon-alpha2b subcutaneously weekly or the active control, interferon-alpha2b 3 million IU subcutaneously three times/week, for 24 weeks. Safety and antiviral efficacy assessments were performed during treatment and in a subsequent 4-week follow-up period. Detailed pharmacokinetic assessments were performed at weeks 1 and 4.

RESULTS

Pegylated interferon-alpha2b produced dose-related reductions in white blood cells, neutrophils, and platelets, and dose-related increases in oral temperature, serum neopterin, and serum 2'5'-oligoadenylate synthetase activity, which were qualitatively similar to those produced by nonpegylated interferon-alpha2b. Reported adverse events (flu-like symptoms, asthenia) were qualitatively similar in pegylated interferon-alpha2b- and nonpegylated interferon-alpha2b-treated groups. Dose-related antiviral activity, as measured by loss of detectable serum hepatitis C virus RNA (<100 copies/mL), was noted at the end of treatment and after 4 weeks of follow-up. Both pegylated and nonpegylated interferon-alpha2b were rapidly absorbed, with maximal concentrations occurring approximately 8 to 12 hours after dose administration. Pegylated interferon-alpha2b had sustained maximal serum concentrations for 48 to 72 hours after dose administration, whereas nonpegylated interferon-alpha2b concentrations declined rapidly. Volume of distribution for both compounds was similar (approximately 1 L/kg). Pegylated interferon-alpha2b elimination half-life was approximately 10-fold greater, and mean apparent clearance was one tenth that of nonpegylated interferon-alpha2b.

CONCLUSIONS

Pegylated and nonpegylated interferon-alpha2b safety and pharmacodynamic profiles were comparable. Pegylated interferon-alpha2b demonstrated delayed clearance compared with nonpegylated interferon-alpha2b, consistent with once-weekly administration.

Simultaneous cadaver pancreas living-donor kidney transplantation: a new approach for the type 1 diabetic uremic patient

OBJECTIVE

To review the authors' experience with a new approach for type I diabetic uremic patients: simultaneous cadaver-donor pancreas and living-donor kidney transplant (SPLK).

SUMMARY BACKGROUND DATA

Simultaneous cadaver kidney and pancreas transplantation (SPK) and living-donor kidney transplantation alone followed by a solitary cadaver-donor pancreas transplant (PAK) have been the transplant options for type I diabetic uremic patients. SPK pancreas graft survival has historically exceeded that of solitary pancreas transplantation. Recent improvement in solitary pancreas transplant survival rates has narrowed the advantage seen with SPK. PAK, however, requires sequential transplant operations. In contrast to PAK and SPK, SPLK is a single operation that offers the potential benefits of living kidney donation: shorter waiting time, expansion of the organ donor pool, and improved short-term and long-term renal graft function.

METHODS

Between May 1998 and September 1999, the authors performed 30 SPLK procedures, coordinating the cadaver pancreas transplant with simultaneous transplantation of a laparoscopically removed living-donor kidney. Of the 30 SPLKs, 28 (93%) were portally and enterically drained. During the same period, the authors also performed 19 primary SPK and 17 primary PAK transplants.

RESULTS

One-year pancreas, kidney, and patient survival rates were 88%, 95%, and 95% for SPLK recipients. One-year pancreas graft survival rates in SPK and PAK recipients were 84% and 71%. Of 30 SPLK transplants, 29 (97%) had immediate renal graft function, whereas 79% of SPK kidneys had immediate function. Reoperative rates, early readmission to the hospital, and initial length of stay were similar between SPLK and SPK recipients. SPLK recipients had a shorter wait time for transplantation.

CONCLUSIONS

Early pancreas, kidney, and patient survival rates after SPLK are similar to those for SPK. Waiting time was significantly shortened. SPLK recipients had lower rates of delayed renal graft function than SPK recipients. Combining cadaver pancreas transplantation with living-donor kidney transplantation does not harm renal graft outcome. Given the advantages of living-donor kidney transplant, SPLK should be considered for all uremic type I diabetic patients with living donors.

A dose-ranging study of pegylated interferon alfa-2b and ribavirin in chronic hepatitis C. The Hepatitis C Intervention Therapy Group

The objectives of this study were to assess the safety, pharmacokinetics, and efficacy of pegylated interferon alfa-2b (PEG-Intron) plus ribavirin in patients with chronic hepatitis C. A total of 72 patients (35 men/37 women, age range 20-68 years) with clinically compensated chronic hepatitis C virus (HCV) were enrolled into this open-label, randomized, active controlled study. Patients received either PEG-Intron 0.35, 0.7, or 1.4 microg/kg subcutaneously weekly for 24 weeks alone, or in combination with ribavirin 600, 800, or 1,000 to 1,200 mg orally daily. Patients were evaluated during treatment and after a 24-week follow-up period for safety and efficacy. Detailed pharmacokinetic assessments were performed at weeks 1 and 4. PEG-Intron alone produced expected dose-related reductions in white cells, neutrophils and platelets. Addition of ribavirin reduced hemoglobin levels in a dose-related manner, did not further reduce PEG-Intron-induced decreases in neutrophil or white cell count, and increased platelet counts. Neutrophil function tests (C5a and FMLP migration, killing curves) were unaltered. Reported adverse events (flu-like symptoms, asthenia) were qualitatively similar in all dose groups. Anti-HCV activity, as measured by loss of detectable serum HCV RNA (i.e. <100 copies/mL) at the end of treatment (week 24) and after 24 weeks of follow-up (week 48) showed dose-response trends for PEG-Intron. At each PEG-Intron dose level, anti-HCV activity was higher in patients coadministered ribavirin than in patients treated with PEG-Intron monotherapy. There was no evidence of pharmacokinetic interactions with either drug. We conclude that the safety and tolerability of combined PEG-Intron/ribavirin and PEG-Intron alone were comparable. Combined PEG-Intron/ribavirin showed dose-related synergistic anti-HCV effects, which were numerically superior to those obtained with PEG-Intron monotherapy.

Psychotherapy of traumatic grief: a review of evidence for psychotherapeutic treatments

The authors present the concept of Traumatic Grief and then review controlled studies that pertain to its psychotherapeutic treatment. They conclude that it will most likely be a specific therapy for Traumatic Grief that will be proven most effective in systematic studies completed in the future.

Increased rates of donation with laparoscopic donor nephrectomy

OBJECTIVE

To examine the impact of laparoscopic nephrectomy and recipient education on the proportion of kidney recipients who could identify a potential live donor, and on the live donor (LD) transplantation rate.

SUMMARY BACKGROUND DATA

Laparoscopic donor nephrectomy (LDN) results in less postoperative surgical pain, a shorter hospital stay, and quicker recovery than the standard open donor nephrectomy (ODN). The authors hypothesized that the availability of this less invasive surgical technique would enhance the willingness of family and friends to donate.

METHODS

The study population consisted of 3,298 end-stage renal disease patients referred for kidney transplant evaluation between November 1991 and February 2000, divided into three groups. The first group received no formal LD education and had only ODN available. The second group received formal education about the LD process and had only ODN available. The third group had both formal LD education and LDN available. Records were examined to determine what proportion of each group had any potential donors tissue-typed, and the rate at which they received an LD transplant.

RESULTS

Before LDN availability and formal LD education, only 35.1% of referrals found a potential donor, and only 12.2% received an LD transplant within 3 years. Institution of a formal education program increased the volunteer rate to 39.0%, and 16.5% received an LD transplant. When LDN became available, 50% of patients were able to find at least one potential donor, and within 3 years 24.7% received an LD transplant. Regression analysis indicated that availability of LDN was independently associated with a 1.9 relative risk of receiving an LD transplant. Kaplan-Meier death-censored 1- and 3-year graft survival rates for ODN transplants were 95.8% and 90.6%, versus 97.5% and 94. 8% for LDN.

CONCLUSIONS

The availability of LDN and an LD family education program has doubled the live donor transplantation rate, and outcomes remain excellent.

Understanding managed behavioral health care

Managed care can be understood from an historical perspective as a reaction to perceived abuses by providers or an extension of earlier efforts to manage care in the public sector. It can be viewed as a young and emerging force--a fourth party to the health care transaction--that is rapidly progressing through a series of generations that redefine the approach to organizing and delivering services. And finally, because managed care emerges with so many faces, consumers and providers can perhaps best understand its implementation in a specific state or community by examining the multiple dimensions, such as those outlined herein, on which these initiatives vary. Until the forms and functions are more uniform, no simple definition of managed care will exist.

Diagnostic criteria for traumatic grief

This article reviews the rationale for the development of diagnostic criteria for Traumatic Grief. Traumatic Grief is a new nosologic entity that a panel of experts recently proposed. It is a direct descendent of the concept of pathologic grief, and it has roots in attachment behavior, separation distress, and traumatic distress. We present consensus, diagnostic criteria for Traumatic Grief and discuss them in relation to another recently proposed set of criteria. In conclusion, we recommend the development of empirically tested, consensus, diagnostic criteria for Traumatic Grief. Diagnostic criteria would facilitate early detection and intervention for those bereaved persons afflicted by this disorder and lead to additional studies of the prevalence, the nature, and the treatment of the disorder.

Effect of pentaglobin and piperacillin on survival in a rat model of faecal peritonitis: importance of intervention timings

BACKGROUND

Faecal peritonitis is a progressive pathophysiological condition which may lead to multiple organ failure and death. The reason for the associated morbidity and mortality could be attributed to the fact that some of the subtle alterations in cellular function that occur during the early stage of peritonitis are unidentified and consequently missed, leading to inadequate or delayed intervention. Recent studies have shown that early treatment with antibiotic and antisera containing antibodies to lipopolysaccharide (immunoglobulin) improve the survival rate in these patients. The present investigation was undertaken to study the effect of pentaglobin and piperacillin with particular attention to time lag of drug intervention on animal survival following experimental peritonitis.

METHODS

Experimental peritonitis was produced by inoculating 1 ml/kg of faecal suspension (2:1 w/v in saline) into the peritoneal cavity. Two groups of animals were treated with pentaglobin (4 ml/kg) or piperacillin (1000 mg/kg) respectively, whereas rats in another group received both drugs simultaneously. The first dose of each drug was given at 4 h, 6 h, 8 h and 12 h after faecal inoculation followed by 3 additional doses at 8-h intervals. For biochemical studies, separate groups of animals were used in which the treatment was started 4 h after faecal inoculation and the animals were killed at 12 h after the treatment.

RESULTS

Both piperacillin and pentaglobin prolonged survival time of animals which received the treatment within 6 h of faecal insult. The combination of pentaglobin plus piperacillin produced better results as compared to the individual effect. There was a significant decrease in serum superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) and increase in catalase following faeces-induced septicaemia, suggesting a significant increase in oxidative stress. The changes in enzyme levels were significantly attenuated by both the drugs.

CONCLUSION

The findings suggest that intervention with a combination of pentaglobin and antibiotics within 6 h of peritonitis might significantly improve survival rate in rat.

Methicillin-resistant Staphylococcus aureus in the community: a hospital-based study

To determine the proportion of methicillin-resistant Staphylococcus aureus (MRSA) among patients presenting for hospitalization and to assess risk factors for MRSA carriage, we conducted a study for 13 months at five Pittsburgh-area hospitals. Of 504 S aureus identified, 125 (25%) were MRSA. Independent risk factors for MRSA included organ transplantation, employment in a healthcare facility, pressure sores, tube feeding, and hospitalization within the preceding year.

Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique

BACKGROUND

Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN.

METHODS

The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups.

RESULTS

Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03).

CONCLUSIONS

The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.

ADP-ribosylation factor (ARF)-like 4, 6, and 7 represent a subgroup of the ARF family characterization by rapid nucleotide exchange and a nuclear localization signal

The novel ARF-like GTPase ARL7 is a close relative of ARL4 and ARL6 (71% and 59%) identical amino acids). A striking characteristic of these GTPases is their basic C-terminus which, when fused to the C-terminus of green fluorescent protein (GFP), targets the constructs to the nucleus of transfected COS-7 cells. Full length ARL4 was detected in both nuclear and extranuclear compartments, whereas a construct of ARL4 lacking its C-terminus was excluded from the nucleus. Nucleotide exchange rates of recombinant ARL4, ARL6 and ARL7 were similar and appeared considerably higher than those of other members of the ARF family (ARF1, ARP). It is concluded that ARL4, ARL6 and ARL7 form a subgroup within the ARF family with similar, possibly nuclear, function.

The Multiple Organ Dysfunction Score as a descriptor of patient outcome in septic shock compared with two other scoring systems

OBJECTIVE

To demonstrate if daily Multiple Organ Dysfunction scoring could describe outcome groups in septic shock better than daily Acute Physiology and Chronic Health Evaluation (APACHE) II and Organ Failure scores.

DESIGN

A prospective cohort study.

SETTING

A medical and surgical adult intensive care unit (ICU) at a tertiary referral center.

MEASUREMENTS AND MAIN RESULTS

Daily data collection over a 14-month period was performed on 368 ICU patients, 39 of whom developed septic shock while in the ICU. These data were entered into a computer programmed to calculate APACHE II, Organ Failure, and Multiple Organ Dysfunction scores. The admission Multiple Organ Dysfunction scores for nonsurvivors and survivors of septic shock in the ICU was 6.5 +/- 2.7 and 6.6 +/- 2.8 (SD), respectively. These patients deteriorated due to the development of septic shock during their ICU stay resulting in a maximum Multiple Organ Dysfunction score of 12.2 +/- 3.7 in nonsurvivors and 9.4 +/- 2.7 in survivors (p < .05). The difference between the maximum and initial Multiple Organ Dysfunction scores (delta score) was also significantly greater in nonsurvivors than in survivors (5.6 +/- 4.7 vs. 2.8 +/- 3.0) (p < .05). There were no significant differences between the maximum and delta scores in the outcome groups using the APACHE II and Organ Failure scoring systems. These results were mirrored by 2.3 +/- 0.7 and 1.7 +/- 0.5 organ failures in nonsurvivors and survivors, respectively (p < .01). For all 368 patients, the initial and maximum Multiple Organ Dysfunction scores were 3.5 +/- 2.5 and 10.5 +/- 3.6, respectively.

CONCLUSION

Maximum and delta Multiple Organ Dysfunction scores mirrored organ dysfunction and could accurately describe the outcome groups, whereas daily APACHE II and Organ Failure scores could not.

A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy (laparoNx) has the potential to increase living kidney donation rates by reducing the pain and suffering of the donor. However, renal function outcomes of a large series of recipients of laparoNx have not been studied.

METHODS

We retrospectively reviewed the records of 132 recipients of laparoNx done at our center between 3/96 and 11/97 and compared them to 99 recipients of kidneys procured by the open technique (openNx) done between 10/93 and 3/96.

RESULTS

Significantly more patients in the laparoNx group (25.2%) were taking tacrolimus within the first month than those in the openNx group (2.1%). Mean serum creatinine was higher in laparoNx compared with openNx at 1 week (2.8+/-0.3 and 1.8+/-0.2 mg/dl, respectively; P=0.005) and at 1 month (2.0+/-0.1 and 1.6+/-0.1 mg/dl, P=0.05) after transplant. However, by 3 and 6 months, the mean serum creatinine was similar in the two groups (1.7+/-0.1 versus 1.5+/-0.05 mg/dl, and 1.7+/-0.1 versus 1.7+/-0.1, respectively). By 1 year posttransplant, the mean serum creatinine for laparoNx was actually less than that for openNx (1.4+/-0.1 and 1.7+/-0.1 mg/dl, P=0.03). Although patients in the laparoNx compared to the openNx group were more likely to have delayed graft function (7.6 versus 2.0%) and ureteral complications (4.5 versus 1.0%), the rate of other complications, as well as hospital length of stay, patient and graft survival rates were similar in the two groups.

CONCLUSION

Although laparoNx allografts have slower initial function compared with openNx, there was no significant difference in longer term renal function.

Gender differences in the effects of bereavement-related psychological distress in health outcomes

BACKGROUND

This study examined whether traumatic grief, depressive and anxiety symptoms formed three distinct factors for widows and widowers. In addition, we examined whether high symptom levels of traumatic grief, depression and anxiety predicted different mental and physical health outcomes for widows and widowers.

METHOD

Ninety-two future widows and 58 future widowers were interviewed at the time of their spouse's hospital admission and then at 6 weeks, 6, 13 and 25 month follow-ups. Principal axis factor analyses tested the distinctiveness of traumatic grief, depressive and anxiety symptoms, by gender. Repeated measures ANOVA tested for gender differences and changes over time in mean symptom levels of traumatic grief, depression and anxiety. Linear and logistic regression models estimated the effects of high symptom levels of traumatic grief, depression and anxiety at 6 months on health outcomes at 13 and 25 months post-intake by gender.

RESULTS

Three distinct symptom clusters (i.e. traumatic grief, depressive and anxiety symptoms) were found to emerge for both widows and widowers. Widows had higher mean levels of traumatic grief, depressive and anxiety symptoms. High symptom levels of traumatic grief measured at 6 months predicted a physical health event (e.g. cancer, heart attack) at 25 months post-intake for widows. High symptom levels of anxiety measured at 6 months predicted suicidal ideation at 25 months for widowers.

CONCLUSIONS

The results suggest that there are gender differences in the levels of psychological symptoms resulting from bereavement and in their effects on subsequent mental and physical health for widows and widowers.

Ten dimensions of public-sector managed care

Managed care in the public sector remains a poorly defined concept. It is currently understood largely through case examples, an approach of limited usefulness because each managed care initiative is shaped by local forces and is constantly changing. The authors describe ten key dimensions on which such initiatives vary and suggest that they can be used to examine essential characteristics of the initiatives and core differences between them. The dimensions are objectives, scope, organizational structures and authority, enrollment, benefit package, strategies for managing utilization, best practices, financing, quality management and outcomes measurement, and the impact of the initiative on the public mental health system. Using these dimensions to assess existing initiatives, the authors conclude that most focus on one principal dimension to the exclusion of other critical dimensions. The authors argue for a comprehensive approach to planning and implementing managed care projects that should ultimately lead to better care for public-sector populations.

Correction of diabetic nod mice with insulinomas implanted within Baxter immunoisolation devices

Insulin replacement by injection is clearly not a cure for Insulin Dependent Diabetes Mellitus (IDDM). Replacement of the destroyed islets by pancreas or islet allograft transplantation can achieve the good metabolic control required to prevent diabetic complications, but tissue supply is limited. The problem of islet supply to treat the 1 million IDDM patients in the USA could be overcome by using immortalized islet beta-cells as a donor source. However, before either allogeneic or xenogeneic immortalized beta-cells are used, some major problems have to be overcome: control of immortalized cell growth, allograft or xenograft rejection and recurrence of autoimmunity. To tackle these problems we have used a cell impermeable immunoisolation device containing mouse insulinoma cells. Transplantation of devices with insulinomas from NOD mice carrying the Rat-insulin promoter regulated SV40 T-Antigen transgene (RIP-TAg), normalized the blood glucose levels of diabetic NOD mice. Insulinomas from allogeneic CBA/NOD-RIP-TAg mice were also capable of normalizing diabetic NOD mice. Not only were non-fasting blood glucoses normalized but when given an intraperitoneal injection of glucose, the corrected mice had a near normal clearance of glucose from the blood. When the devices were removed from normalized mice they became diabetic again, demonstrating that the immunoisolation device was capable of protecting against both alloimmune and autoimmune destruction. The results with allogeneic mouse beta-cells suggest the possibility that immortalized human beta-cells could be an effective source of tissue to correct diabetes in IDDM patients without the use of immunosuppression.

Laparoscopic living donor nephrectomy and multiple renal arteries

BACKGROUND

Laparoscopic donor nephrectomy (LDN) is a new technique. While the short-term recipient renal function is equivalent to that of the traditional open nephrectomy (ODN), long-term function and potential exclusion criteria, such as the presence of multiple renal arteries, are as yet unknown.

METHODS

Retrospective review of 124 consecutive LDN performed from March 1996 to September 1997 with 117 ODN as historical controls.

RESULTS

The 1-year actuarial graft and patient survival for LDN kidneys were 94% and 95%, respectively. These were not statistically different from that of the ODN controls. The presence of multiple renal arteries did not alter graft and patient survival or prevalence of immunologic events. The number of recipient ureteral complications in the LDN group was 11.2% compared with 3.4% in ODN (P < 0.01). Following correction for a learning curve with accompanying technical modifications, the prevalence of recipient ureteral complications has decreased to 7% in the last 94 patients (P = nonsignificant versus ODN).

CONCLUSIONS

LDN represents a viable alternative to ODN for living renal transplants. Advantages for the donor are matched by equivalent functional results for the recipients.

Effects of therapy with nifedipine GITS or atenolol on mental stress-induced ischemic left ventricular dysfunction

OBJECTIVES

We sought to determine the effect of nifedipine gastrointestinal therapeutic system (GITS) or atenolol on ischemic left ventricular dysfunction induced by mental stress.

BACKGROUND

The efficacy of conventional antianginal therapy in preventing myocardial ischemia induced by mental stress is unknown.

METHODS

Nifedipine GITS, atenolol and placebo were administered to 15 subjects with stable angina in a double-blind crossover trial. Subjects underwent a series of mental stressors at the end of each treatment. Radionuclide ventriculography was performed at baseline and at peak mental stress. Other measured variables included time to ischemia on exercise treadmill testing, ischemia on 48-h ambulatory electrocardiogram (ECG) monitoring, and resting and mental stress-induced levels of plasma catecholamines, tissue plasminogen activator antigen, plasminogen activator inhibitor-1 and platelet aggregability.

RESULTS

Mental stress resulted in a significant increase in plasma epinephrine and norepinephrine levels during each treatment phase. Atenolol therapy was associated with lower baseline and postmental stress rate-pressure product compared with nifedipine or placebo. Therapy with either nifedipine GITS or atenolol prevented the development of wall-motion abnormalities and the decline in regional ejection fraction (EF) in the segment with the largest deterioration in wall motion during placebo therapy. Both medications prevented the decrease in global EF in subjects who demonstrated at least a 5% fall in global EF on placebo therapy. No therapy exerted a statistically significant benefit on exercise performance or frequency of ischemia during ambulatory ECG monitoring.

CONCLUSIONS

Both nifedipine GITS and atenolol are effective at preventing mental stress-induced wall-motion abnormalities, although the mechanisms may be different.

Advanced nursing practice in New Zealand: 1998

In the last decade, change in the health sector has often seemed to deny and thwart the professionalism and expertise of nurses. However, in the first half of 1998, a number of positive initiatives have come to fruition, which support the development of clinical and educational structures for advanced practice nursing in New Zealand. Within one month of each other the Nursing Council published its framework for post-registration nursing education, and the Nurse Executives of New Zealand published a proposal for the development of advanced practice roles: clinical nurse specialist and nurse practitioner. This article will explore these initiatives, and will examine the proposed clinical nurse specialist and nurse practitioner roles in light of experience in the United States in developing advanced or expanded nursing practice.

The mouse ADP-ribosylation factor-like 4 gene: two separate promoters direct specific transcription in tissues and testicular germ cell

ADP-ribosylation factor-like protein 4 (ARL4) is a Ras-related GTPase that has been cloned from the 3T3-L1 preadipocyte cell line as an adipocyte-specific cDNA [Schürmann, Breiner, Becker, Huppertz, Kainulainen, Kentrup and Joost (1994) J. Biol. Chem. 269, 15683-15688]. The Arl4 gene maps to the proximal region of mouse chromosome 12 linked to Lamb1-1, Hfhbf1 and Sos2. Compared with all other known genes of Ras-related GTPases, the genomic organization of Arl4 is unusual in that its entire coding region, the 3' untranslated region (UTR) and most of the 5' UTR are located on a single exon. This structure suggests that Arl4 has evolved by retroposition of an Arf (ADP-ribosylation factor) or Arf-like gene. Isolation of the 5' UTR by rapid amplification of cDNA ends (RACE)-PCR revealed heterogeneous transcription initiation sites in alternative exons 1. Both 5'-flanking regions exhibited promoter activity when expressed in COS-7 cells, indicating that the expression of Arl4 is directed by two separate promoters. mRNA transcribed under the control of the downstream promoter was isolated by RACE-PCR from all investigated tissues. In contrast, the upstream promoter seems to drive specifically the expression of Arl4 in adult testis. Hybridization of rat testis in situ indicated that Arl4 is expressed in germ cells of puberal and adult testis, but not in prepuberal testis, suggesting that Arl4 is involved in sperm production.