Should we reconsider lung transplantation through uncontrolled donation after circulatory death?

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 h of ex vivo lung perfusion. The postoperative course was uneventful, and the recipient was discharged home on day 9. While this case represents a "best-case scenario," it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

A study of sequential high dose cyclophosphamide and high dose carboplatin with peripheral stem-cell rescue in resistant or recurrent pediatric brain tumors

PURPOSE

To determine the maximum tolerated dose (MTD) of carboplatin with autologous hematopoietic stem-cell rescue, in children with poor-prognosis brain tumors.

PATIENTS AND METHODS

A previously determined dose of cyclophosphamide with stem-cell rescue was used as a first course. In a second course, carboplatin was given for 3 days with stem-cell rescue to 20 children. The starting dose of carboplatin was 400 mg/m2/day with increments of 75 mg/m2/day in subsequent cohorts. Toxicity and tumor response were recorded.

RESULTS

There were two grade IV toxicities at the dose level of 775 mg/m2/day. There were no toxic deaths. Thus, the MTD of carboplatin was 700 mg/m2/day for 3 days. There were six complete responses (33%, 95% confidence interval [CI], 13-59%), two partial responses (11%; 95% CI, 1-35%), four with stable diseases (22%; 95% CI, 6-48%) and six progressed (33%; 95% CI, 13-59%) out of 18 assessable. Seven of the eight responses were in primitive neuroectodermal tumors (PNETs) or Germinomas. One child with a metastatic anaplastic astrocytoma had a CR. The median duration of tumor response was 10 months (range: 1.5-87 months) with two children disease free at 66 and 87 months. Actuarial survival is 21%. Median follow-up of survivors is 35 months (range: 15-87 months).

CONCLUSION

The MTD of carboplatin with stem-cell rescue is 700 mg/m2/day for 3 days. Sequential stem-cell supported cyclophosphamide and carboplatin was tolerable in children with brain tumors and produced responses in PNETs and Germinomas.

Muscarinic receptor subtype determines vulnerability to oxidative stress in COS-7 cells

Research has suggested that there may be increased brain-region selective vulnerability to oxidative stress in aging and that Vulnerability to oxidative stress may be important in determining regional differences in neuronal aging. We assessed whether one factor determining vulnerability to oxidative stress might involve qualitative/quantitative differences in receptor subtypes in various neuronal populations. COS-7 cells were transfected with one of five muscarinic receptor subtypes (M1-M5 AChR) to DA (1 mM for 4 h) and intracellular Ca2+ levels were examined via fluorescent imaging analysis prior to and following 750 microM oxotremorine (oxo). Results indicated that the ability of the cells to clear excess Ca2+ (i.e., Ca2+ Recovery) following oxo stimulation varied as a function of transfected mAChR subtype, with DA-treated M1, M2, or M4 cells showing greater decrements in Recovery than those transfected with M3 or M5 AChR. A similar pattern of results in M1- or M3-transfected DA-exposed cells was seen with respect to Viability. Viability of the untransfected cells was unaffected by DA. Pretreatment with Trolox (a Vitamin E analog) or PBN (a nitrone trapping agent) did not alter the DA effects on cell Recovery in the M1-transfected cells, but were effective in preventing the decrements in Viability. The calcium channel antagonists (L and N, respectively), Nifedipine and Conotoxin prevented both the DA-induced deficits in Recovery and Viability. Results are discussed in terms of receptor involvement in the regional differences in Vulnerability to oxidative stress with age, and that loss of neuronal function may not inevitably lead to cell death.

Clustering of biological risk factors for cardiovascular disease and the longitudinal relationship with lifestyle of an adolescent population: the Northern Ireland Young Hearts Project

OBJECTIVE

To determine whether clustering of biological cardiovascular disease (CVD) risk factors exists and to investigate the longitudinal relationship between lifestyle parameters (dietary intake, physical activity and smoking behaviour) and clustering of biological CVD risk factors, which was defined as belonging to one or more sex-specific 'high-risk' quartiles for the ratio between levels of total serum cholesterol and high-density lipoprotein cholesterol, diastolic blood pressure, body fatness (sum of four skinfolds) and cardiopulmonary fitness (number of laps accomplished on a 20 m shuttle-run test).

METHODS

The study was part of the Northern Ireland Young Hearts Project, a 3-year observational longitudinal study concerning adolescent boys (n=229) and girls (n=230) who were initially aged 12 years. The longitudinal relationships were analysed with generalized estimating equations.

RESULTS

Significant clustering of biological CVD risk factors was observed both for boys and for girls, but the stability over time was rather low. Smoking was the only lifestyle parameter related to this clustering and was observed only among girls (rate ratio 1.5, P < 0.01); furthermore, none of the lifestyle parameters was significantly related to this clustering.

CONCLUSIONS

Because biological CVD risk factors tend to cluster, it is important to investigate these risk factors together. However, for subjects in this age group, according to our analysis, lifestyle parameters were hardly related to this clustering.

Multiple protein domains contribute to the action of the copper chaperone for superoxide dismutase

The copper chaperone for superoxide dismutase (SOD1) inserts the catalytic metal cofactor into SOD1 by an unknown mechanism. We demonstrate here that this process involves the cooperation of three distinct regions of the copper chaperone for SOD1 (CCS): an amino-terminal Domain I homologous to the Atx1p metallochaperone, a central portion (Domain II) homologous to SOD1, and a short carboxyl-terminal peptide unique to CCS molecules (Domain III). These regions fold into distinct polypeptide domains as revealed through proteolysis protection studies. The biological roles of the yeast CCS domains were examined in yeast cells. Surprisingly, Domain I was found to be necessary only under conditions of strict copper limitation. Domain I and Atx1p were not interchangeable in vivo, underscoring the specificity of the corresponding metallochaperones. A putative copper site in Domain II was found to be irrelevant to yeast CCS activity, but SOD1 activation invariably required a CXC in Domain III that binds copper. Copper binding to purified yeast CCS induced allosteric conformational changes in Domain III and also enhanced homodimer formation of the polypeptide. Our results are consistent with a model whereby Domain I recruits cellular copper, Domain II facilitates target recognition, and Domain III, perhaps in concert with Domain I, mediates copper insertion into apo-SOD1.

Variation in the biochemical/biophysical properties of mutant superoxide dismutase 1 enzymes and the rate of disease progression in familial amyotrophic lateral sclerosis kindreds

Mutations in superoxide dismutase 1 (SOD1) polypeptides cause a form of familial amyotrophic lateral sclerosis (FALS). In different kindreds, harboring different mutations, the duration of illness tends to be similar for a given mutation. For example, patients inheriting a substitution of valine for alanine at position four (A4V) average a 1.5 year life expectancy after the onset of symptoms, whereas patients harboring a substitution of arginine for histidine at position 46 (H46R) average an 18 year life expectancy after disease onset. Here, we examine a number of biochemical and biophysical properties of nine different FALS variants of SOD1 polypeptides, including enzymatic activity (which relates indirectly to the affinity of the enzyme for copper), polypeptide half-life, resistance to proteolytic degradation and solubility, in an effort to determine whether a specific property of these enzymes correlates with clinical progression. We find that although all the mutants tested appear to be soluble, the different mutants show a remarkable degree of variation with respect to activity, polypeptide half-life and resistance to proteolysis. However, these variables do not stratify in a manner that correlates with clinical progression. We conclude that the basis for the different life expectancies of patients in different kindreds of sod1-linked FALS may result from an as yet unidentified property of these mutant enzymes.

Relationships between the development of biological risk factors for coronary heart disease and lifestyle parameters during adolescence: The Northern Ireland Young Hearts Project

The purpose of this study was to examine relationships between the longitudinal development of biological risk factors for coronary heart disease (CHD) (namely, serum lipids, body fatness, blood pressure and cardiorespiratory fitness) and the development of lifestyles considered to be atherogenic. The study was conducted in a representative sample of adolescents from Northern Ireland, a region of high coronary mortality, and atherogenic aspects of lifestyle such as cigarette smoking, physical inactivity and selected aspects of diet were examined. Repeated measurements were made at 12 and 15 y of age on 229 boys and 230 girls. Longitudinal relations were analysed with generalised estimating equations, and the following longitudinal relations were found: for boys diastolic blood pressure was positively associated with vitamin C intake (P = 0.014), and inversely with energy intake (P = 0.006), and smoking (P = 0.048). Systolic blood pressure was inversely related to physical activity (P = 0.012), and smoking (P = 0.000). Body fatness was also inversely related to smoking (P = 0.006). Total cholesterol (TC) was positively related to physical activity (P = 0.044) and the TC:HDL cholesterol ratio positively to vitamin C intake (P = 0.008). Cardiorespiratory fitness was positively related to physical activity (P = 0.000) and inversely to smoking (P = 0.031). For girls, systolic blood pressure was positively related to vitamin C intake (P = 0.042); HDL cholesterol inversely to carbohydrate intake (P = 0.014), fat intake (P = 0.031), cholesterol intake (P = 0.042) and smoking (P = 0.035) and positively to energy intake (P = 0.035). The TC:HDL cholesterol ratio was inversely related to energy intake (P = 0.038) and finally, cardiorespiratory fitness positively to physical activity (P = 0.001). These results offer additional evidence that changes in lifestyle are associated with changes in biological risk factors in adolescents. Education and intervention at this stage, particularly in relation to cigarette smoking, physical activity and certain aspects of diet appear justified as part of a preventative strategy for CHD.

Suppressors of superoxide dismutase (SOD1) deficiency in Saccharomyces cerevisiae. Identification of proteins predicted to mediate iron-sulfur cluster assembly

Yeast deficient in the cytosolic copper/zinc superoxide dismutase (SOD1) exhibit metabolic defects indicative of oxidative damage even under non-stress conditions. To help identify the endogenous sources of this oxidative damage, we isolated mutant strains of S. cerevisiae that suppressed metabolic defects associated with loss of SOD1. Six complementation groups were isolated and three of the corresponding genes have been identified. One sod1Delta suppressor represents SSQ1 which encodes a hsp70-type molecular chaperone found in the mitochondria. A second sod1Delta suppressor gene, designated JAC1, represents a new member of the 20-kDa J-protein family of co-chaperones. Jac1p contains a mitochondrial targeting consensus sequence and may serve as the partner for Ssq1p. Homologues of Ssq1p and Jac1p are found in bacteria in close association with genes proposed to be involved in iron-sulfur protein biosynthesis. The third suppressor gene identified was NFS1. Nfs1p is homologous to cysteine desulfurase enzymes that function in iron-sulfur cluster assembly and is also predicted to be mitochondrial. Each of the suppressor mutants identified exhibited diminished rates of respiratory oxygen consumption and was found to have reduced mitochondrial aconitase and succinate dehydrogenase activities. Taken together these results suggest a role for Ssq1p, Jac1p, and Nfs1p in assembly/maturation of mitochondrial iron-sulfur proteins and that one or more of the target Fe/S proteins contribute to oxidative damage in cells lacking copper/zinc SOD.

The copper chaperone for superoxide dismutase

Copper is distributed to distinct localizations in the cell through diverse pathways. We demonstrate here that the delivery of copper to copper/zinc superoxide dismutase (SOD1) is mediated through a soluble factor identified as Saccharomyces cerevisiae LYS7 and human CCS (copper chaperone for SOD). This factor is specific for SOD1 and does not deliver copper to proteins in the mitochondria, nucleus, or secretory pathway. Yeast cells containing a lys7Delta null mutation have normal levels of SOD1 protein, but fail to incorporate copper into SOD1, which is therefore devoid of superoxide scavenging activity. LYS7 and CCS specifically restore the biosynthesis of holoSOD1 in vivo. Elucidation of the CCS copper delivery pathway may permit development of novel therapeutic approaches to human diseases that involve SOD1, including amyotrophic lateral sclerosis.

Cholesterol: a two-edged sword in brain aging

Previous research from several laboratories has indicated that cholesterol (CHO) accumulates in neuronal membranes and alters their structural and signal transduction (ST) properties during aging. The possible reasons for these increases in membrane CHO have not been specified. However, present findings suggest that such accumulation may actually serve to protect neuronal tissue from oxidative damage. Striatal slices (6, 24 month rats) were preincubated in 1 mM CHO (30 min) followed by incubation with H2O2 (10 microM, 30 min). The slices were then either superfused with 30 mM KCl in the presence or absence of 500 microM oxotremorine (Ox), and K(+)-evoked dopamine release (K(+)-ERDA) examined or assessed for carbachol-stimulated low K(m) GTPase activity. The results indicated that CHO incubation prior to H2O2 in either age group was effective in preventing H2O2 reductions in both non-Ox-enhanced K(+)-ERDA and Ox conditions, as well as sodium nitroprusside (SNP 150 microM)-induced decreases in K(+)-ERDA. In addition, H2O2-induced deficits in carbachol-stimulated low K(m) GTPase activity were reduced in the striatal tissue from the old animals pretreated with CHO. However, if the slices were incubated in H2O2 prior to CHO exposure, CHO enhanced the H2O2 effects in the tissue from the old animals. Thus, depending upon the order of exposure, CHO functioned to enhance or retard the effects of oxidative stress, in an age-dependent manner.

Physicians' reactions to patients: what has happened during the past 10 years

New stresses have been added to the medical life of physicians in training during the past decade. These include the newly diverse and complex sociocultural environment of the patient, new and renascent lethal diseases, widespread substance abuse, and the effects of the breakdown of the fabric of our society. These factors complicate the practice of medicine as never before. Educators must keep pace and prepare young physicians to understand and then cope with these major new forces.

Increased sensitivity to oxidative stress and the loss of muscarinic receptor responsiveness in senescence

Although there are numerous findings which suggest that the pathogenesis of age-related neurodegenerative disorders (e.g., AD and PD) may involve oxidative stress (OS), relationships between functional age-related neuronal deficits, especially those with behavioral correlates, and OS have been difficult to establish. We have attempted to establish such relationships by determining the role of OS in the loss of muscarinic receptor (mAChR) sensitivity in aging. These decrements are expressed as age-related reductions in oxotremorine enhancement of K(+)-evoked dopamine release (K(+)-ERDA) from superfused striatal slices. Using this model we have found that: a) The reductions can be restored with in vivo administration of the free-radical trapping agent, N-tert-butyl-alpha-phenylnitrone (PBN); b) Striatal slices from old animals showed increased sensitivity (e.g., reduced DA release or oxo-enhancement of K(+)-ERDA) to the in vitro application of sodium nitroprusside, a potent NO generator or to H2O2 which treatment of striatal slices from young animals with these agents or exposure of young animals to low doses of whole-body 56Fe irradiation decreased mAChR sensitivity and signal transduction (ST). Protection from the NO- or H2O2-induced deficits could be prevented with Trolox, PBN or cholesterol pretreatment. Evidence derived from PC-12 cells suggests that OS may directly affect ST by decreasing Ca2+ flux and increasing the length of the recovery period (i.e., return to baseline Ca2+ levels) after KCI (30 mM) depolarization.

Copper ions and the regulation of Saccharomyces cerevisiae metallothionein genes under aerobic and anaerobic conditions

We have previously reported that the Saccharomyces cerevisiae CRS5 metallothionein gene is negatively regulated by oxygen. The mechanism of this repression was the focus of the current study. We observed that the aerobic repression of CRS5 is rapid and occurs within minutes of exposing anaerobic cultures to air. Furthermore, the CUP1 metallothionein gene of S. cerevisiae was found to be subject to a similar downregulation of gene expression. We provide evidence that the aerobic repression of yeast metallothioneins involves copper ions and Ace1, the copper trans-activator of CUP1 and CRS5 gene expression. A functional Ace1 binding site was found to be necessary for the aerobic repression of CRS5. Moreover, the aerobic down-regulation of the metallothioneins was abolished when cells were treated with elevated levels of copper. Our studies show that anaerobic cultures accumulate higher levels of copper than do aerobic cells and that this copper is rapidly lost when cells are exposed to air. In fact, the kinetics of this copper loss closely parallels the kinetics of CUP1 and CRS5 gene repression. The yeast metallothionein genes, therefore, serve as excellent markers for variations in copper accumulation and homeostasis that occur in response to changes in the oxidative status of the cell.

Oxidative stress and age-related neuronal deficits

Research from our laboratory has indicated that the loss of sensitivity that occurs in several receptor systems as a function of age may be an index of an increasing inability to respond to oxidative stress (OS). This loss occurs partially as a result of altered signal transduction (ST). Assessments have involved determining the nature of age-related reductions in oxotremorine enhancement of K(+)-evoked dopamine release (K(+)-ERDA) from superfused striatal slices. Using this model, we have found that 1. Reductions can be restored with in vivo administration of the free-radical trapping agent, N-tert-butyl-alpha-phenylnitrone (PBN); 2. Decrements in DA release induced by NO or H2O2 from striatal slices from both young and old animals could be restored with alpha-tocopherol or PBN; 3. ST decrements, such as those seen in aging, could be induced with radiation exposure; and 4. Pre-incubation of the striatal slices with cholesterol decreased subsequent deleterious effects of NO or OH. on DA release. Thus, cholesterol, which increases in neuronal membranes as a function of age, may function as a potent antioxidant and protectant against neuronal damage. These results suggest that therapeutic efforts to restore cognitive deficits in aging and age-related disease might begin with antioxidant reversal of ST decrements.

Age differences in sensitivity to H2O2- or NO-induced reductions in K(+)-evoked dopamine release from superfused striatal slices: reversals by PBN or Trolox

Previous research has indicated that many age-related functional alterations may be the result of a decreased ability of the organism to respond to oxidative stress (OS). However, this hypothesis is based on indirect indices of function (e.g., increased vulnerability of hepatocytes from senescent animals to H2O2-induced DNA damage, increases in lipofuscin accumulation). More direct tests of this hypothesis, especially as it relates to brain aging, have not been extensively undertaken. Present experiments were carried out to make such tests by examining age differences in the sensitivity to OS on reductions in striatal dopamine (DA) release. Thus, K(+)-evoked DA (K(+)-ERDA) release from superfused striatal slices from young (6-8 month) and old (24-25 month) animals was examined following either: (a) application of the NO-generator sodium nitroprusside or (b) preincubation with H2O2. In order to assess the specific effects of OS on muscarinic (mAChR) sensitivity, oxotremorine-enhancement of K(+) -ERDA was examined following incubation with H2O2. Results showed that the striatal tissue from the old animals showed greater sensitivity to both H2O2 and NO than young animals, and stimulated DA decreased at lower concentrations of these agents (e.g., NO--100 microM young, 30 microM old). In addition, H2O2 was also effective in reducing oxo-enhanced K(+)-ERDA and was more effective as a function of age. If the striatal tissue was incubated in either Trolox (alpha-tocopherol) or alpha-phenyl-n-tert-butyl nitrone (PBN) prior to OS, the negative effects of NO. and H2O2 were reversed in both age groups. Results are discussed in terms of age-related membrane and endogenous antioxidant alterations that could induce increases in sensitivity to OS and the specificity of antioxidants in reducing this sensitivity in key functional systems.

A physiological role for Saccharomyces cerevisiae copper/zinc superoxide dismutase in copper buffering

The copper toxicity of yeast lacking the CUP1 metallothionein is suppressed by overexpression of the CRS4 gene. We now demonstrate that CRS4 is equivalent to SOD1, encoding copper/zinc superoxide dismutase (SOD). While overexpression of SOD1 enhanced copper resistance, a deletion of SOD1, but not SOD2 (encoding manganese SOD), conferred an increased sensitivity toward copper. This role of SOD1 in copper buffering appears unrelated to its superoxide scavenging activity, since the enzyme protected against copper toxicity in anaerobic as well as aerobic conditions. The distinct roles of SOD1 in copper and oxygen radical homeostasis could also be separated genetically: the pmr1, bsd2, and ATX1 genes that suppress oxygen toxicity in sod1 mutants failed to suppress the copper sensitivity of these cells. The Saccharomyces cerevisiae SOD1 gene is transcriptionally induced by copper and the ACE1 transactivator, and we demonstrate here that this induction of SOD1 promotes protection against copper toxicity but is not needed for the SOD1-protection against oxygen free radicals. Collectively, these findings indicate that copper/zinc SOD functions in the homeostasis of copper via mechanisms distinct from superoxide scavenging.

Combination antithrombotic therapy in unstable rest angina and non-Q-wave infarction in nonprior aspirin users. Primary end points analysis from the ATACS trial. Antithrombotic Therapy in Acute Coronary Syndromes Research Group

BACKGROUND

The purpose of this study was to compare combination antithrombotic therapy with aspirin plus anticoagulation versus aspirin alone, when added to conventional antianginal therapy in patients with unstable rest angina or non-Q-wave myocardial infarction who were nonprior aspirin users.

METHODS AND RESULTS

Two hundred fourteen patients were randomized; 109 were randomized to receive aspirin alone (162.5 mg daily) and 105 to receive a combination of aspirin plus anticoagulation, ie, aspirin 162.5 mg daily plus heparin (activated partial thromboplastin time, two times control) followed by aspirin 162.5 mg daily plus warfarin (international normalized ratio, 2 to 3). Trial therapy was begun by 9.5 +/- 8.8 hours of qualifying pain and was continued for 12 weeks. Primary end points were recurrent angina with ECG changes, myocardial infarction, and/or death. Analysis by intention to treat of primary events at 12 weeks was performed. At 14 days, there was a significant reduction in total ischemic events in the combination group versus aspirin alone (10.5% versus 27%, P = .004). An efficacy analysis of primary events at 12 weeks also revealed a large reduction in total ischemic events in the combination group versus aspirin alone (13% versus 25%, P = .06). Bleeding complications were slightly more common with combination therapy.

CONCLUSIONS

In nonprior aspirin users, combination antithrombotic therapy with aspirin plus anticoagulation significantly reduces recurrent ischemic events in the early phase of unstable angina.

Coronary risk factors in schoolchildren

Death rates from coronary heart disease (CHD) in Northern Ireland are among the highest in the world. However, no data have been available to test the hypothesis that the high prevalence of CHD is reflected by the risk status of the childhood population. A randomly selected 2% population sample of 1015 children aged 12 and 15 years was studied to obtain baseline information on blood pressure, lipid profile, cigarette smoking, family history, physical activity, cardiorespiratory fitness, and dietary fat intake. Using available criteria thresholds, 15-23% displayed increased blood pressure, 12-25% had unfavourable lipid profiles, and 18-34% were overfat. In 15 year old children, 16-21% admitted being regular smokers, 26-34% displayed poor cardiorespiratory fitness, and 24-29% reported little physical activity in the previous week. Dietary analysis revealed relatively low polyunsaturated to saturated fatty acid ratios and high mean fat intakes, accounting for approximately 40% total daily energy. Despite the exclusion of family history from the analysis, 16% of the older children exhibited three or more risk factors. These results justify major concern about the level of potential coronary risk in Northern Ireland schoolchildren. Broadly based primary prevention strategies aimed at children are essential if future adult CHD mortality is to be reduced.

The problem of coping as a reason for psychiatric consultation

To examine those patients referred to psychiatry for the "problem of coping," a structured clinical databased management system--MICRO-CARES--was employed to identify the frequency, demographic characteristics, psychiatric diagnoses, psychosocial interventions, use of psychopharmacology, number of follow-up visits, and discharge placement of these referrals. Consultations totaling 1,157 from July 1, 1988 through January 1, 1990 were divided into two groups and compared: "Not coping" (N = 456, 28.5%) and "others" (N = 701, 61%). Those with a "problem in coping" more often had no Axis I diagnosis (p = 0.001), or were described as adjustment disorders (p = 0.0001). Fewer recommendations were made for those with a coping problem, although lag time (admission date to request for consultation), number of follow-ups, and discharge placement were not significantly different between the two groups. Stepwise logistic regression analyses revealed that the aged had lesser risk for being referred with a coping problem; those who were white, had their own income, experienced greater stress prior to hospitalization (Axis IV), and had higher functioning during the last year (Axis V) were at greater risk.

Using patient reports to assess hospital treatment of persons with AIDS: a pilot study

Providing efficacious, compassionate, and efficient medical care to persons with HIV infection is one of the greatest challenges that will face US hospitals this decade. Unfortunately, there have been almost no studies of how organizational arrangements are related to the quality of care. We developed an interview protocol and conducted a pilot study to evaluate the instrument's ability to detect differences in selected interpersonal aspects of care provided to persons with AIDS. We evaluated the care received in two different treatment models in a major teaching hospital: a designated AIDS unit and general medical beds. We assessed several areas of patient care that are clinically important and that patients can evaluate: communication between patients and providers, patient education, respect for patient preferences, emotional support, involvement of family and friends, trust and confidence, physical care, pain management, AIDS knowledge, perceived segregation, confidentiality, and financial information. Patients generally were very satisfied with their hospital care, but many reported problems with certain aspects of their care. The instrument used detected differences between the care reported by patients treated in general hospital beds and in a designated AIDS unit in several specific aspects of care.

The inpatient AIDS unit: a preliminary empirical investigation of access, economic, and outcome issues

An AIDS unit model ("cluster beds") and a general inpatient placement model ("scatter beds") in a major teaching hospital were compared to determine whether they differed on several dimensions of care. After controlling for severity of illness, (the major predictor of admission to the AIDS unit), length of stay, charges, and inpatient mortality rates did not differ between the two settings. Equal proportions of White, Hispanic, male, and privately insured patients were found in both settings. Nursing staff turnover rates were comparable to those of other sites. However, the data raise new issues regarding access to AIDS units for older, Black, and female patients.

Adjustment disorder in children and adolescents

The literature on adjustment disorder in children and adolescents is reviewed to evaluate the empirical and conceptual basis of this disorder as defined in DSM-III-R, and to determine whether revisions, are indicated in DSM-IV. Existing studies suggest that adjustment disorder is a disorder of high prevalence in all settings, which carries significant morbidity and poor outcome in children and adolescents. Problems identified with the DSM-III-R definition include low reliability, the predominance of mixed rather than discrete symptom presentations in children and adolescents, and the persistence of symptoms in excess of 6 months in a significant number of cases.

Usefulness of the Neurobehavioral Cognitive Status Examination in the hospitalized elderly

A prospective pilot study compared the Neurobehavioral Cognitive Status Examination (NCSE) to the Folstein Mini-Mental State Examination (MMSE) to determine the usefulness of the NCSE as a cognitive screen in a geriatric inpatient population. All patients directly admitted to the geriatric evaluation and treatment unit (GETU) of a university teaching hospital over a two-and-a-half-month period were eligible for the study, in which 42% participated. Within 72 hours of admission, patients were given the MMSE and the NCSE in a nonrandom order by a trained psychologist and a structured interview by a psychiatrist. The ability of the NCSE to detect global cognitive impairment was compared to the MMSE and psychiatrist's assessment. Differences in sensitivity were examined by discordant pair analysis. The psychiatrist's determination of the presence of cognitive impairment was used as the criterion standard. Comparisons of the MMSE and NCSE, respectively, revealed the following: sensitivity 83% versus 100%; specificity 78% versus 11%; positive predictive value 83% versus 43%; and negative predictive value 78% versus 100%. Seven patients who were cognitively impaired by the NCSE were not impaired by the MMSE (p less than 0.05 by discordant pair analysis). The time of administration for the two tests was significantly shorter for the MMSE (14.75 +/- 5.7 minutes) than for the NCSE (38.9 +/- 12.9 minutes). The NCSE was found to be more sensitive than the MMSE in detecting cognitive impairment among geriatric inpatients, but its specificity and positive predictive values were lower. Beyond this pilot study, additional work examining the utility of the NCSE in other geriatric settings and for different purposes (e.g., as part of comprehensive assessment) needs to be performed.

Adipose dysplasia of the right ventricle: is endomyocardial biopsy useful?

Right ventricular dysplasia (RVD) is a cardiac anomaly characterized by replacement of right ventricular myocardium by adipose and fibrous tissue that was first described at autopsy, and is now being recognized pre-mortem. Sudden death and ventricular arrhythmias are the most common clinical manifestation of the condition. This paper reviews the literature on myocardial biopsies performed in patients with idiopathic arrhythmias who had pathologic findings consistent with RVD, and the results of biopsies from patients suspected of having RVD. The significance of sampling error in myocardial biopsies, possible familial associations, and other conditions associated with myocardial adipose infiltration are also discussed. Based on the review, the possibility is raised that RVD may represent the end result of an unusual healing process, whereby genetically susceptible individuals recover from a variety of RV insults by deposition of adipose tissue. These fatty scars may then be the focus for arrhythmias which remain the major clinical manifestation of the syndrome.

Angiographic and hemodynamic correlations in hypertrophic cardiomyopathy with intracavitary systolic pressure gradients

To correlate angiographic and hemodynamic events in hypertrophic cardiomyopathy (HC), 14 patients with HC were investigated using pressure recordings and caudocranial left anterior oblique contrast angiography. Patients were separated into 2 groups on the basis of the presence (group I) or absence (group II) of systolic anterior motion of the anterior mitral leaflet on caudocranial angiography. In group I (10 patients), the pressure gradient could be recorded with the left ventricular (LV) catheter in the nonobliterated inflow region of the left ventricle. Simultaneous micromanometer tracings and caudocranial angiography revealed that contact between the anterior mitral leaflet and the ventricular septum was an early systolic event (occurring 136 +/- 33 ms after the R wave of the electrocardiogram) and was coincident with the onset of the pressure gradient. Cavitary obliteration was present in only 7 of 10 patients in group I, and occurred late in systole well after the peak gradient (292 +/- 28 ms after the R wave). In group II (4 patients), the pressure gradients could be recorded only from the obliterated portion of the ventricle distal to the level of the papillary muscles. Total LV cavitary obliteration was present in all group II patients. In 1 patient, simultaneous micromanometer pressure recording and caudocranial angiography revealed that cavitary obliteration preceded the peak gradient by 40 ms. Thus, in group I patients the onset of the pressure gradient is coincident with mitral leaflet-septal contact, while cavitary obliteration is an inconsistent late systolic event.(ABSTRACT TRUNCATED AT 250 WORDS)

Systemic and coronary effects of intravenous milrinone and dobutamine in congestive heart failure

The effects of dobutamine and intravenous milrinone on systemic hemodynamics, coronary blood flow and myocardial metabolism were studied in 11 patients with severe congestive heart failure. Although milrinone and dobutamine similarly increased cardiac index from 1.9 +/- 0.4 to 2.5 +/- 0.4 liters/min per m2 (p less than 0.001) and from 1.9 +/- 0.4 to 2.8 +/- 0.8 liters/min per m2 (p less than 0.001), respectively, milrinone decreased left ventricular end-diastolic pressure to a greater extent than dobutamine, that is, from 26 +/- 6 to 12 +/- 8 mm Hg (p less than 0.001) versus 26 +/- 8 to 20 +/- 8 mm Hg (p less than 0.001). In contrast to dobutamine, milrinone significantly reduced mean systemic arterial and right atrial pressures. Dobutamine increased the first derivative of left ventricular pressure (dP/dt) from 1,013 +/- 309 to 1,360 +/- 538 mm Hg/s (p less than 0.01) but milrinone did not. Similarly, blood flow and myocardial oxygen consumption were increased by dobutamine from 152 +/- 87 to 187 +/- 118 ml/min (p less than 0.05) and from 17.7 +/- 10.9 to 21.5 +/- 14.9 ml O2/min (p less than 0.05), respectively, but were unchanged by milrinone. Both drugs significantly decreased coronary vascular resistance and myocardial oxygen extraction but did not change myocardial lactate extraction. Thus, dobutamine and milrinone produce similar improvement in cardiac index. However, dobutamine increases myocardial oxygen consumption, whereas milrinone does not. This difference can probably be explained by the substantial vasodilating properties of milrinone.

Effects of milrinone on left ventricular performance and myocardial contractility in patients with severe heart failure

The potent vasodilating properties of the bipyridine derivatives confounds the assessment of changes in contractility as measured by peak positive left ventricular dP/dt and explains why the positive inotropic action of these agents has not been consistently demonstrated in patients with ventricular dysfunction. Therefore we studied the individual dose-response effects of intravenous milrinone on myocardial contractility as measured by peak positive left ventricular dP/dt in the context of concurrent changes in ventricular filling pressure. Incremental doses of milrinone caused a dose-related increase in peak positive left ventricular dP/dt in six of 11 patients. Peak positive left ventricular dP/dt was unchanged in four patients and reduced in one patient, all of whom experienced a substantial fall in left ventricular filling pressure. Thus milrinone has a definite inotropic effect in addition to its potent vasodilating properties.

Effects of a new cardiotonic agent, MDL-17,043, on myocardial contractility and left ventricular performance in congestive heart failure

MDL-17,043, a newly synthesized imidazole derivative, has been shown to manifest both inotropic and peripheral vasodilating properties in experimental animals and to be effective when administered orally. Although MDL-17,043 has been demonstrated to inhibit cyclic adenosine monophosphate (AMP) phosphodiesterase activity in vitro, whether its inotropic activity derives from increased myocellular levels of cyclic AMP is not yet known. After intravenous administration of MDL-17,043 to seven patients with severe congestive heart failure (CHF) at the time of cardiac catheterization, the rate of left ventricular (LV) pressure rise increased almost immediately from a control of 878 +/- 161 to a peak of 1010 +/- 217 mm Hg/sec (p less than 0.01), while cardiac index tended to increase but not significantly. Subsequently, as mean aortic pressure decreased from 86.4 +/- 15.9 at control to 75.6 +/- 16.4 mm Hg (p less than 0.01), cardiac index rose from 1.87 +/- 0.35 at control to 2.30 +/- 0.27 L/min/m2 at peak effect (p less than 0.01), while pulmonary capillary wedge pressure fell from 23.7 +/- 5.1 to 13.1 +/- 4.6 mm Hg (p less than 0.01). Concomitantly, the rate of LV pressure rise returned to control value. Thus, intravenous administration of MDL-17,043 improves myocardial contractility and LV performance in patients with severe CHF. This manifest improvement in LV performance most probably results from both the positive inotropic and direct vasodilating effects of MDL-17,043.

Pulmonary arterial V waves in mitral regurgitation: clinical and experimental observations

Pulmonary arterial early diastolic waves (V waves) were investigated in patients and experimental animals with mitral regurgitation. V waves exceeding systolic pressure in the pulmonary artery were recorded in the main pulmonary artery with micromanometer catheters both in patients and animals, eliminating the possibility of catheter artifact. In experimental animals, aortic closure preceded pulmonic closure by 33 +/- 12 msec at baseline. With the creation of acute mitral insufficiency, a pulmonary arterial V wave occurred in six of eight animals. Early pulmonic valve closure occurred only in the six animals with a pulmonary arterial V wave. In these animals, pulmonic closure preceded aortic closure by 28 +/- 7 msec during mitral insufficiency (p less than .05). Of 70 patients with severe mitral regurgitation at cardiac catheterization, 14 had a pulmonary arterial V wave. In five patients recordings with micromanometer catheters were made and early pulmonic closure was also observed in four of these patients who had pulmonary arterial V waves at rest or upon provocation. Patients with pulmonary arterial V waves had a more acute onset of symptoms, shorter duration of mitral regurgitation, higher pulmonary capillary wedge V waves, and lower pulmonary arterial resistances than patients without them and were more likely to have nonrheumatic mitral regurgitation.

Right ventricular function in valvular heart disease: relation to pulmonary artery pressure

Right ventricular angiography was performed in 46 patients with acquired valvular heart disease and 8 normal subjects. Right ventricular ejection fraction (RVEF) correlated highly only with right ventricular peak systolic pressure (RVPSP) and mean pulmonary artery pressure, both in patients with and without tricuspid insufficiency. For the group, RVEF = -0.33 RVPSP + 63 (correlation coefficient [r] = -0.76, probability [p] less than 0.001). Of 20 patients with moderate or severe elevation of pulmonary artery pressure, 17 (85%) had an abnormally low ejection fraction (less than 47%), while 19 (73%) of 26 patients with normal or mildly elevated pulmonary artery pressure had a normal right ventricular ejection fraction. In seven patients with elevated pulmonary artery pressure, a second ventriculogram was performed during intravenous nitroglycerin administration. Nitroglycerin produced a significant decrease in right ventricular peak systolic pressure (59 +/- 22 to 49 +/- 18 mm Hg, mean +/- standard deviation) (p less than 0.05) and in end-systolic volume (71 +/- 16 to 59 +/- 11 m1/m2) (p less than 0.05), and an increase in ejection fraction (43 +/- 9 to 48 +/- 7%) (p less than 0.05). Thus, at least part of the depression of ejection fraction in patients with elevated pulmonary pressure is reversible with a decrease in pulmonary artery pressure.