Paired risk scores to predict ischaemic and bleeding risk twenty-eight days to one year after an acute coronary syndrome

OBJECTIVE

The recommended duration of dual anti-platelet therapy (DAPT) following acute coronary syndrome (ACS) varies from 1 month to 1 year depending on the balance of risks of ischaemia and major bleeding. We designed paired ischaemic and major bleeding risk scores to inform this decision.

METHODS

New Zealand (NZ) patients with ACS investigated with coronary angiography are recorded in the All NZ ACS Quality Improvement registry and linked to national health datasets. Patients were aged 18-84 years (2012-2020), event free at 28 days postdischarge and without atrial fibrillation. Two 28-day to 1-year postdischarge multivariable risk prediction scores were developed: (1) cardiovascular mortality/rehospitalisation with myocardial infarction or ischaemic stroke (ischaemic score) and (2) bleeding mortality/rehospitalisation with bleeding (bleeding score).

FINDINGS

In 27 755 patients, there were 1200 (4.3%) ischaemic and 548 (2.0%) major bleeding events. Both scores were well calibrated with moderate discrimination performance (Harrell's c-statistic 0.75 (95% CI, 0.74 to 0.77) and 0.69 (95% CI, 0.67 to 0 .71), respectively). Applying these scores to the 2020 European Society of Cardiology ACS antithrombotic treatment algorithm, the 31% of the cohort at elevated (>2%) bleeding and ischaemic risk would be considered for an abbreviated DAPT duration. For those at low bleeding risk, but elevated ischaemic risk (37% of the cohort), prolonged DAPT may be appropriate, and for those with low bleeding and ischaemic risk (29% of the cohort) short duration DAPT may be justified.

CONCLUSION

We present a pair of ischaemic and bleeding risk scores specifically to assist clinicians and their patients in deciding on DAPT duration beyond the first month post-ACS.

The impact of a national COVID-19 lockdown on acute coronary syndrome hospitalisations in New Zealand (ANZACS-QI 55)

Background

Countries with a high incidence of coronavirus 2019 (COVID-19) reported reduced hospitalisations for acute coronary syndromes (ACS) during the pandemic. This study describes the impact of a nationwide lockdown on ACS hospitalisations in New Zealand (NZ), a country with a low incidence of COVID-19.

Methods

All patients admitted to a NZ Hospital with ACS who underwent coronary angiography in the All NZ ACS Quality Improvement registry during the lockdown (23 March – 26 April 2020) were compared with equivalent weeks in 2015–2019. Ambulance attendances and regional community troponin-I testing were compared for lockdown and non-lockdown (1 July 2019 to 16 February 2020) periods.

Findings

Hospitalisation for ACS was lower during the 5-week lockdown (105 vs. 146 per-week, rate ratio 0•72 [95% CI 0•61–0•83], p = 0.003). This was explained by fewer admissions for non-ST-segment elevation ACS (NSTE-ACS; p = 0•002) but not ST-segment elevation myocardial infarction (STEMI; p = 0•31). Patient characteristics and in-hospital mortality were similar. For STEMI, door-to-balloon times were similar (70 vs. 72 min, p = 0•52). For NSTE-ACS, there was an increase in percutaneous revascularisation (59% vs. 49%, p<0•001) and reduction in surgical revascularisation (9% vs. 15%, p = 0•005). There were fewer ambulance attendances for cardiac arrests (98 vs. 110 per-week, p = 0•04) but no difference for suspected ACS (408 vs. 420 per-week, p = 0•44). Community troponin testing was lower throughout the lockdown (182 vs. 394 per-week, p<0•001).

Interpretation

Despite the low incidence of COVID-19, there was a nationwide decrease in ACS hospitalisations during the lockdown. These findings have important implications for future pandemic planning.

Funding

The ANZACS-QI registry receives funding from the New Zealand Ministry of Health.

Studying the peripheral sympathetic nervous system and neuroblastoma in zebrafish

The zebrafish serves as an excellent model to study vertebrate development and disease. Optically clear embryos, combined with tissue-specific fluorescent reporters, permit direct visualization and measurement of peripheral nervous system formation in real time. Additionally, the model is amenable to rapid cellular, molecular, and genetic approaches to determine how developmental mechanisms contribute to disease states, such as cancer. In this chapter, we describe the development of the peripheral sympathetic nervous system (PSNS) in general, and our current understanding of genetic pathways important in zebrafish PSNS development specifically. We also illustrate how zebrafish genetics is used to identify new mechanisms controlling PSNS development and methods for interrogating the potential role of PSNS developmental pathways in neuroblastoma pathogenesis in vivo using the zebrafish MYCN-driven neuroblastoma model.

Diagnosis of MI after CABG with high-sensitivity troponin T and new ECG or echocardiogram changes: relationship with mortality and validation of the universal definition of MI

AIMS

Criteria for diagnosing myocardial infarction (MI) after coronary artery bypass grafting (CABG) are controversial. Uncertainties remain around the optimal threshold for biomarker elevation and the need for associated criteria. There are no studies of high-sensitivity troponin (hs-TnT) after CABG. We assessed whether using hs-TnT to define MI after CABG was associated with 30-day and medium-term mortality and evaluated the utility of adding to the troponin criteria new Q-waves or imaging evidence of new wall motion abnormality as suggested in the Universal Definition of MI.

METHODS

Isolated CABG was performed in 818 patients from July 2010 to June 2012 and hs-TnT was measured 12-24 hours after CABG. Patients with rising baseline or missing troponins (n=258) were excluded. Thresholds of 140 ng/l (10-times 99th percentile upper reference limit) and 500 ng/l (10-times coefficient of variation of 10% for fourth-generation troponin T applied to hs-TnT) were prespecified.

RESULTS

Mean follow up was 1.8±0.6 years. On multivariate analyses, isolated hs-TnT rise >140 ng/l (n=360) or >500 ng/l (n=162) were not associated with mortality. Additional ECG and/or echocardiographic criteria plus hs-TnT >140 ng/l was associated with 30-day mortality (hazard ratio, HR, 4.92, 95% CI 1.34-18.1; p=0.017) and medium-term mortality (HR 3.44, 95% CI 1.13-10.5; p=0.030), whereas ECG and/or echocardiographic abnormalities with hs-TnT >500 ng/l was not (p=0.281 and p=0.123 for 30-day and medium-term mortality, respectively).

CONCLUSIONS

A definition for MI following CABG using hs-TnT with a cut point of 10-times 99th percentile upper reference limit and ECG and/or echocardiographic criteria predicts 30-day and medium-term mortality. These findings validate the Third Universal Definition of type 5 MI.

Maternal contact differentially modulates central and peripheral oxytocin in rat pups during a brief regime of mother-pup interaction that induces a filial huddling preference

Central oxytocin mediates the acquisition of a filial preference for maternal odour in rat pups, manifested by their huddling preferences. The present study was designed to examine whether maternal care modulates oxytocin concentrations in rat pups and, if so, how different types of maternal contact are associated with the pups' oxytocin concentrations. Pairs of 14-day-old littermates were removed from their home cage for 1 h and then placed with a lactating foster mother for 2 h, or they remained isolated at room temperature. Enzyme immunoassays revealed that maternal care and maternal separation can differentially modulate pups' oxytocin concentrations. Both hypothalamic and serum oxytocin increased during the 1-h separation. Pups placed with a foster mother after the separation maintained the same concentrations in the hypothalamus and serum through the fostering period. By contrast, pups placed with no mother showed a further increase in hypothalamic oxytocin but serum oxytocin decreased. Behavioural analyses revealed that skin-to-skin contact with the mother, but not simple physical contact or maternal licking/grooming, was positively correlated with the pups' hypothalamic oxytocin concentrations. These neuroendocrine data match previous findings showing that skin-to-skin contact with mother facilitates the acquisition of the pups' huddling preference for a maternally-associated odour. Taken together, the present study suggests that maternal skin-to-skin contact stimulates pups' central oxytocin, at the same time as creating the conditions for inducing a preference for maternal odour and establishing a social affiliation in rat pups; the natural schedule of maternal separation and reunion may modulate pups' oxytocin concentrations, providing scaffolding for the acquisition of their filial huddling preference.

Novel methods to assess heart valve disease

Optimal timing of surgery for heart valve disease relies on the accurate assessment of symptoms, lesion severity, cardiac function and the risks of disease progression. Recent studies suggest potential roles for new echocardiographic techniques, including tissue Doppler and strain imaging at rest or after exercise stress, cardiac magnetic resonance imaging and biomarkers such as B-type natriuretic peptide. These techniques may identify patients at higher risk of symptomatic deterioration or adverse clinical events, and improve the cost-effectiveness and reliability of follow-up.

Detection of Coccidioides species in clinical specimens by real-time PCR

Coccidioides spp. are dimorphic fungal pathogens endemic to the semiarid regions of North, Central, and South America. Currently, direct smear and culture are the most common means of identifying Coccidioides spp. While these methods offer relatively sensitive and specific means of detecting Coccidioides spp., growth in culture may take up to 3 weeks, potentially delaying the diagnosis and initiation of appropriate antifungal therapy. In addition, growth of the organism represents a significant safety risk to laboratory personnel. The need for a rapid and safe means of diagnosing coccidioidomycosis prompted us to develop a real-time PCR assay to detect Coccidioides spp. directly from clinical specimens. Primers and fluorescent resonance energy transfer (FRET) probes were designed to target the internal transcribed spacer 2 region of Coccidioides. The assay's limit of detection is below 50 targets per reaction. An analysis of 40 Coccidioides sp. clinical isolates grown in culture demonstrated 100% sensitivity of the assay. A cross-reactivity panel containing fungi, bacteria, mycobacteria, and viruses was tested and demonstrated 100% specificity for Coccidioides spp. An analysis of 266 respiratory specimens by LightCycler PCR demonstrated 100% sensitivity and 98.4% specificity for Coccidioides spp. compared with culture. Analysis of 66 fresh tissue specimens yielded 92.9% sensitivity and 98.1% specificity versus those of the culture method. The sensitivity of the assay testing 148 paraffin-embedded tissue samples is 73.4%. A rapid method for the detection of Coccidioides spp. directly from clinical material will greatly assist in the timely diagnosis and treatment of patients, while at the same time decreasing the risk of accidental exposure to laboratory personnel.

Effects of variety, the 1B/1R translocation and xylanase supplementation on nutritive value of wheat for broilers

1. Three consecutive studies were done with 12 wheat samples (4 per study), each of different variety (6 containing the 1B/1R rye translocation) to examine the effects of wheat variety, presence of 1B/1R and interactions with xylanase addition (Avizyme 1310). The wheat varieties covered a wide range of in vitro viscosity (6.3 to 19.8 cps). In each study 64 male, Ross broilers were individually caged and given the diets ad libitum from d 7 to 28. Bird performance, viscosity of ileal contents and diet metabolisability (AME) were measured. 2. The diets contained (g/kg): wheat 790, casein 134, dicalcium phosphate 21.4, potassium bicarbonate 10.8, sodium bicarbonate 7.5, soya oil 10, arginine 5, minerals etc. 21.3. 3. Within each study there were large differences in dry matter (DM) intake between varieties but the variety effect was significant (P<0.01) only in study 2. Liveweight gain (LWG) differences mirrored DM intake, being significant (P<0.01) in study 2. Mean gain:food was unaffected by variety in any study. 4. Calculated wheat AME (MJ/kg DM) ranged from 13.4 to 14.4 in study 2 (P<0.05), the values for studies 1 and 3 lying within this range. 5. Across all 3 studies, in vivo viscosity (proximal ileum) ranged from 5.0 to 37.6 in the absence of enzyme and from 3.9 to 12.1 with enzyme addition; in studies 1 and 2 variety differences were significant (P<0.05). 6. Enzyme addition had no effect on DM intake or LWG but gain:food tended to be improved (NS), metabolisability of energy (ME:GE) was increased (P<0.01) by 2.2% and calculated wheat AME by 4% while in vivo viscosity was reduced (P<0.001). 7. There were no significant differences in DM intake, LWG, gain:food, ME:GE or calculated wheat AME concentration associated with the presence of the 1B/1R translocation and no interactions between enzyme and 1B/1R. 8. There were poor relationships between either gain:food or wheat AME concentration and in vitro or in vivo viscosity. There was no significant relationship between AME concentration and either specific weight or thousand grain weight. 9. It was concluded that (a) variety differences tended to be small (b) there was no negative impact of the 1B/1R rye translocation with the diet formulation used (c) in vitro viscosity failed to predict satisfactorily any aspect of performance with the high wheat/low fat diet formulation used.

Importance of amino-acid and electrolyte balance in experimental diets used to determine the apparent metabolisable energy (AME) value of wheat

1. An experiment was done with male, Ross broiler chicks to study the effect of diet composition and electrolyte balance on the measurement of diet AME and performance parameters in diets containing high levels of wheat inclusion. 2. The control diet (G) was based on wheat (667 g/kg) with full-fat soya, soyabean meal, Extrupro and herring meal providing the protein supplements. The experimental treatments were based on 2 diets, one based on wheat (790 g/kg) with casein as the protein supplement and the other containing 667 g/kg wheat plus casein, cellulose and starch. Each of these was formulated to contain one of three concentrations of sodium and potassium bicarbonate giving final values for dietary electrolyte balance of approximately 90, 180 and 280 meq/kg diet. 3. DM intake was numerically lower with the lower level of wheat inclusion and LWG (P < 0.05) and gain:food (P < 0.001) were reduced. ME:GE was similar for the two levels of wheat/casein but higher (P < 0.001) than for the control diet. 4. The two higher electrolyte balances improved DM intake (P < 0.01), LWG and gain:food (P < 0.01) compared with the diets containing no added bicarbonate. ME:GE was unaffected by electrolyte inclusion. 5. Viscosity of ileal digesta supernatant fell (P < 0.01) with increasing bicarbonate inclusion but the value for the highest electrolyte level was still higher than for the control diet. 6. It is concluded that addition of both arginine and electrolyte is needed with a wheat/casein diet to improve performance to levels seen with a more commercial diet but that the determination of diet AME, with the type of fat addition used in this study, is unaffected by electrolyte balance. The interaction between electrolyte balance and in vivo viscosity requires further study.

Long-term assessment of psychological well-being in a randomized placebo-controlled trial of cholesterol reduction with pravastatin. The LIPID Study Investigators

BACKGROUND

There is controversial evidence that a low serum cholesterol level is associated with an increased risk of depression, suicide, and violence. The aim of this study was to identify or exclude any small or infrequent adverse effect of long-term reduction of serum cholesterol with pravastatin sodium on psychological well-being.

METHODS

The study population consisted of 1130 respondents from a representative sample of 1222 patients with stable coronary artery disease participating in the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) study. Subjects were randomized in a double-blind manner to treatment with pravastatin sodium, 40 mg/d (n = 559), or placebo (n = 571) for at least 4 years. Psychological well-being was assessed with a standard self-administered questionnaire at baseline and after 6 months, 1 year, 2 years, and 4 years. The questionnaire assessed anxiety and depression, anger, impulsiveness, alcohol consumption, and adverse life events.

RESULTS

Serum cholesterol levels decreased by an average of 1.3 mmol/L (50 mg/dL) with pravastatin therapy and did not change with placebo. During follow-up there was no significant difference by treatment group in measures of anxiety and depression, anger expression, or impulsiveness (95% confidence interval excluded differences of >0.2 SD) and no difference in the proportion of subjects with excessive alcohol consumption or adverse life events (odds ratio, 1.0; 95% confidence interval, 0.8-1.2). There was no evidence of a treatment effect for persons whose baseline serum cholesterol level was in the lowest 10% (<4.6 mmol/L [178 mg/dL]) or whose scores for anxiety and depression, anger, or impulsiveness were in the highest 10% at baseline. There was no association between change in the serum cholesterol level and measures of anxiety and depression, anger, or impulsiveness during follow-up.

CONCLUSION

Long-term reduction of serum cholesterol with pravastatin has no adverse effect on psychological well-being.

Randomised comparison of the effects of nicardipine and esmolol on coronary artery wall stress: implications for the risk of plaque rupture

OBJECTIVE

To determine whether the beta blocker esmolol reduces coronary artery wall stress more than the short acting dihydropyridine calcium antagonist nicardipine.

DESIGN

Randomised double blind placebo controlled trial.

SETTING

Tertiary cardiology centre.

PATIENTS

Patients with coronary artery disease.

INTERVENTIONS

20 patients were randomised double blind to an infusion of nicardipine (n = 10) or esmolol (n = 10) titrated to reduce systolic blood pressure by 20 mm Hg.

MAIN OUTCOME MEASURES

Peak systolic wall circumferential stress.

RESULTS

Esmolol reduced peak coronary stress by a mean of 0.17 x 10(6) dyn/cm(2) (95% confidence interval (CI) 0.14 to 0.21 x 10(6) dyn/cm(2)) compared with a reduction of 0.07 x 10(6) dyn/cm(2) (95% CI 0.05 to 0.10 x 10(6) dyn/cm(2)) after nicardipine. Peak systolic radius was reduced by 0.04 mm (95% CI 0.03 to 0.06 mm) after esmolol compared with an increase of 0.08 mm (95% CI 0.05 to 0.10 mm) after nicardipine. Heart rate increased by 11.5 beats/min (95% CI 6.9 to 16.2 beats/min) after nicardipine and decreased by 5.3 beats/min (95% CI 1.9 to 8.6 beats/min) after esmolol.

CONCLUSIONS

Intravenous esmolol is more effective than nicardipine at reducing circumferential coronary artery wall stress.

Statistical methods to improve the precision of the treadmill exercise test

OBJECTIVES

The study systematically compared different measures of ST segment depression from the treadmill exercise test.

BACKGROUND

The value of the treadmill exercise test for objectively measuring treatment effects is limited by random error in the measurement of ST depression and may be biased by regression to the mean or by the decision to terminate the test.

METHODS

Treadmill exercise was performed in 21 subjects with ischemic heart disease 1 h after isosorbide dinitrate 10 mg or placebo in a double-blind randomized crossover study. A 12-lead electrocardiogram (ECG) was recorded every 30 s during and at peak exercise. The relative sample size needed to detect the nitrate effect was compared for different summary measures of ST depression.

RESULTS

The ST depression measured from a single unmatched lead at longest equivalent sub-maximal exercise needed the lowest sample size to detect the nitrate effect in paired comparisons (p = 0.000006). Averaging over multiple leads or times did not improve detection of the nitrate effect. The rate of increase in ST depression (in mm/min) calculated by linear regression needed a similar sample size (x1.32, 95% CI 0.62 to 2.58). A larger sample size was needed for ST depression at peak exercise (x2.9, CI 1.3, 11.1) and exercise duration (x4.5, CI 1.5, 38). Time to 1-mm ST depression was the least efficient measurement (relative sample size x15.5, CI 1.6, >1,000). Comparison of matched leads resulted in >2-fold differences in estimates of the nitrate effect because of bias from regression to the mean.

CONCLUSIONS

Maximal ST depression at longest equivalent sub-maximal exercise and the maximal rate of increase in ST depression had less bias and random variation than did other commonly used measures. The rate of increase in ST depression is preferred because it can be calculated in either paired or unpaired studies.

Collateral recruitment and "warm-up" after first exercise in ischemic heart disease

BACKGROUND

Proposed mechanisms for "warm-up" after angina on first exercise include ischemic preconditioning and collateral recruitment. The aim of this study was to determine whether patients with ischemic heart disease and well-developed coronary collateral vessels have a greater warm-up response than those with no visible collateral vessels.

METHODS AND RESULTS

Fifteen patients with a total coronary occlusion and collateral vessels and 18 patients with a single coronary artery stenosis and no angiographically visible collateral vessels were studied. Warm-up was measured as the difference in ST depression on the second compared with the first of 2 sequential treadmill exercise tests separated by 10 minutes of rest. There was a trend for the duration of second exercise to increase more in patients with occlusion than in those with stenosis (+1.3 vs +0.54 minutes, respectively, P =.087). In both groups, ST depression was less on second exercise than on first exercise. The size of this decrease was greater in the occlusion group than in the stenosis group. ST depression at equivalent submaximal exercise decreased by 0.52 vs 0.19 mm, respectively (P =.049). The rate of increase in ST depression during exercise decreased by 1.08 versus 0. 55 mm/min, respectively (P =.034). These differences were less after adjustment for ST depression on first exercise (P =.11 and P =.063, respectively).

CONCLUSIONS

The trend for a greater decrease in ST depression on second compared with first exercise in the patients with total coronary occlusion suggests that an increase in collateral flow is a mechanism for warm-up after first exercise in ischemic heart disease.

B7.1 costimulation increases T-cell proliferation and cytotoxicity via selective expansion of specific variable alpha and beta genes of the T-cell receptor

BACKGROUND

Optimal T-cell activation requires not only ligation of the T-cell receptor (TcR) but also delivery of costimulatory signals by various accessory molecules. The interaction of the costimulatory molecule B7.1 (CD80) with its receptor CD28 provides a strong positive signal to T cells.

METHODS

The B7.1 gene was transduced into cultured human ovarian, breast, and pancreatic tumor cells by using a retroviral vector. Autologous as well as allogeneic naive T-cells were stimulated with either wild-type or B7.1-transduced tumor cells in a mixed lymphocyte tumor cell culture (MLTC). In addition to cytolytic activity, T-cell proliferation, T-cell subset composition, and the frequencies of TcR variable (V) alpha and beta genes were compared in T cells from both types of MLTC.

RESULTS

Introduction of the B7.1 gene into tumor cells was successful in all tumors to a varying degree. Those tumors expressing high levels of B7.1 induced significantly higher levels of T-cell proliferation than wild-type tumor cells. T-cell subset composition did not markedly differ between T cells stimulated with wild-type tumor cells or B7.1-expressing tumor cells. However, T cells stimulated with B7.1-expressing tumor cells showed a significantly increased cytolytic potential. The increased cytotoxic T lymphocyte activity was associated with a higher frequency of specific TcR V alpha and V beta genes. In addition, B7.1 costimulation promoted oligoclonality among the responding T cells.

CONCLUSIONS

These data suggest that costimulation through B7.1 promotes T-cell proliferation and cytotoxic activity through clonal expansions of T cells bearing antigen-specific TcR V alpha and V beta genes and through promotion of oligoclonality. The data also suggest that promoting B7.1-mediated costimulation is an important aspect of immune therapies.

Relation between duration and intensity of first exercise and "warm up" in ischaemic heart disease

OBJECTIVE

To determine the importance of the duration and intensity of "warm up" exercise for reducing ischaemia during second exercise in patients with exertional angina.

DESIGN

Randomised crossover comparison of three warm up exercise protocols.

PATIENTS

18 subjects with stable ischaemic heart disease and > 0.1 mV ST segment depression on treadmill exercise testing.

INTERVENTIONS

The warm up protocols were 20 minutes of slow exercise at 2.7 km/h, symptom limited graded exercise for a mean of 7.4 (range 5.0 to 10.5) minutes, and three minutes of symptom limited fast exercise of similar maximum intensity.

MAIN OUTCOME MEASURES

ST segment depression during graded treadmill exercise undertaken 10 minutes after each warm up protocol or no warm up exercise.

RESULTS

Compared with exercise with no warm up, the duration of graded exercise after earlier slow warm up increased by 4.9% (95% confidence interval (CI), -3.3% to 13.7%), after graded warm up by 10.3% (95% CI, 5.6% to 15.2%), and after fast warm up by 16% (95% CI, 6.2% to 26.7%). ST segment depression at equivalent submaximal exercise decreased after slow warm up by 27% (95% CI, 5% to 44%), after graded warm up by 31% (95% CI, 17% to 44%), and after fast warm up by 47% (95% CI, 27% to 61%). Compared with slow warm up exercise, the more intense graded and fast warm up protocols significantly increased the duration of second exercise (p = 0.0072) and reduced both peak ST depression (p = 0.0026) and the rate of increase of ST depression (p = 0.0069).

CONCLUSIONS

In patients with exertional angina the size of the warm up response is related to the maximum intensity rather than the duration of first exercise.

Assessment of the mechanical properties of coronary arteries using intravascular ultrasound: an in vivo study

The pressure-area relation of coronary arteries provides important information about the mechanical properties of these vessels. In human subjects methodological limitations have precluded measurement of instantaneous compliance and coronary stress in vivo. The purpose of this study was to assess a new method for measuring instantaneous values of coronary artery compliance and wall stress utilizing simultaneously acquired pressure and intravascular ultrasound measurements of vessel area. Ten subjects with coronary artery disease had intravascular ultrasound studies of the proximal left anterior descending or circumflex coronary arteries. Coronary luminal area was measured with a 30-MHz (3F or 3.5F) intravascular ultrasound catheter and simultaneous coronary pressure measured with a 2F micromanometer-tipped catheter. Using this technique the nonlinear pressure-area relation and mean circumferential wall stress were determined over the physiological pressure range. Coronary artery compliance at 100 mmHg ranged from 0.010 to 0.052 mm2/mmHg (mean +/- SD, 0.020+/-0.012 mm2/mmHg). Peak systolic circumferential stress ranged from 0.52 to 2.03 x 10(6) dyn/cm2 (1.09+/-0.42 x 10(6) dyn/cm2). This study describes a new method of determining coronary artery mechanical properties over the physiological pressure range. This technique may be useful in further studies of coronary artery mechanics.

Coronary artery flow ten weeks after myocardial infarction or unstable angina: effects of combined warfarin and aspirin therapy

Forty-three patients presenting with unstable angina or myocardial infarction were randomised double blind to warfarin [target international normalised ratio (INR), 2.0 to 2.5] and aspirin (150 mg) daily or placebo plus aspirin (150 mg) daily. Coronary flow was assessed with the thrombolysis in myocardial infarction (TIMI) flow grade and corrected TIMI frame count (CTFC). Coronary artery flow was reduced (higher CTFC) at baseline in culprit arteries (mean +/-SD, 37.1+/-15.4 frames) compared to nonculprit arteries (22.5+/-6.7 frames, P<0.0001). In patients with a patent artery at follow-up, coronary flow was unchanged after ten weeks of warfarin and aspirin (-2.0+/-19.9 frames) or aspirin alone (3.8+/-10.4 frames, P = 0.20). Patients randomised to aspirin alone were more likely to progress to total occlusion [aspirin, 7 of 19 (37%) vs. warfarin and aspirin, 1 of 24 (4%); P = 0.01). Higher baseline culprit artery CTFC was also associated with an increased risk of late occlusion [+10 frames; odds ratio (OR), 1.65; 95% CI, 1.01 to 2.33]. Coronary flow remained impaired ten weeks after presentation with myocardial infarction or unstable angina. Combination warfarin and aspirin therapy did not improve flow in vessels that remained patent but did reduce the risk of progression to occlusion.

Human homologue of the Drosophila melanogaster lats tumour suppressor modulates CDC2 activity

We have previously used mosaic flies to screen for tumour suppressors or negative regulators of cell proliferation. The cellular composition of these flies resembles that of cancer patients who are chimaeric individuals carrying a small number of mutated somatic cells. One of the genes we identified is the large tumour suppressor gene, lats (also known as wts), which encodes a putative serine/threonine kinase. Somatic cells mutant for lats undergo extensive proliferation and form large tumours in many tissues in mosaic adults. Homozygous mutants for various lats alleles display a range of developmental defects including embryonic lethality. Although many tumour suppressors have been identified in Drosophila melanogaster, it is not clear whether these fly genes are directly relevant to tumorigenesis in mammals. Here, we have isolated mammalian homologues of Drosophila lats. Human LATS1 suppresses tumour growth and rescues all developmental defects, including embryonic lethality in flies. In mammalian cells, LATS1 is phosphorylated in a cell-cycle-dependent manner and complexes with CDC2 in early mitosis. LATS1-associated CDC2 has no mitotic cyclin partner and no kinase activity for histone H1. Furthermore, lats mutant cells in Drosophila abnormally accumulate cyclin A. These biochemical observations indicate that LATS is a novel negative regulator of CDC2/cyclin A, a finding supported by genetic data in Drosophila demonstrating that lats specifically interacts with cdc2 and cyclin A.

Influence of heart rate on stroke volume variability in atrial fibrillation in patients with normal and impaired left ventricular function

Both resting tachycardia and irregular ventricular rhythm may contribute to impaired cardiac performance in atrial fibrillation (AF). This study assesses the relation between resting heart rate and beat-to-beat changes in left ventricular (LV) ejection and filling in patients with normal and impaired LV systolic function. Beat-to-beat variation in LV outflow and inflow velocity-time integral was measured using pulsed Doppler ultrasound in 39 patients with chronic AF and normal (n=22) or impaired (n=17) LV systolic function. Aortic velocity-time integral variability increased with mean heart rate (p=0.003) even though RR interval variability decreased (p <0.001). Aortic velocity-time integral was more sensitive to the duration of both the preceding (p <0.001) and prepreceding (p <0.001) RR intervals at higher heart rates. These relations were similar for patients with normal and impaired LV systolic function. The sensitivity of the filling velocity-time integral to RR interval variability also increased with heart rate (p <0.001). However, at higher heart rates the filling velocity-time integral (p=0.009) and filling time (p=0.005) were less sensitive to change in RR intervals in patients with impaired LV function. We conclude that beat-to-beat stroke volume variability in AF increases with heart rate. Stroke volume variability was not influenced by LV systolic function.

Long stenting in native coronary arteries: relation between vessel size and outcome

Procedural and 6-mo clinical outcomes were evaluated in 34 consecutive patients who had stenting (<40 mm) of a long segment of coronary artery. Procedural success was achieved in 32 (96%) patients. Before stenting, 32 (96%) patients had Canadian Cardiovascular Society Class 3 or 4 angina compared to 7 (21%) at 6-mo follow-up (P<0.001). Eleven patients (32%) suffered either acute/subacute stent thrombosis (n=4) or restenosis (n=7). On logistic regression distal reference diameter <2.5 mm (odds ratio 26, P<0.01) and previous cardiac intervention (odds ratio 9.0, P<0.01) were independent predictors of a major adverse event during follow-up. There was no significant association between outcome and indication for stenting, type of stent, or use of ticlopidine and aspirin. These results indicate that distal vessel diameter <2.5 mm is a powerful predictor of subacute thrombosis or restenosis after long coronary artery stenting.

Imaging and pathological features of primary malignant rhabdoid tumours of the brain and spine

In this article two cases of primary malignant extrarenal rhabdoid tumour are described. In the affected children the brain and the spinal cord were the primary sites of origin of the tumour. The imaging findings are presented and the pathology discussed. Although the imaging features are non-specific, rhabdoid tumour should be included in the differential diagnosis of childhood intracranial and spinal neoplasms.

Pictorial review: the imaging features of male breast disease

Although breast carcinoma in men is rare, the presentation of a male patient with evidence of breast enlargement or of a palpable lump, is not uncommon. In such patients, radiological assessment may be requested to exclude malignant change. Mammography has been traditionally the dominant modality of investigation, although ultrasound, using high-frequency linear transducers, is playing an increasingly important role for both imaging and biopsy and the two techniques should be regarded as complementary. In this article the pathological conditions which may affect the male breast are reviewed and the imaging findings presented.

Progression of the culprit lesion in unstable coronary artery disease with warfarin and aspirin versus aspirin alone: preliminary study

OBJECTIVES

This study assessed whether combination therapy with aspirin and warfarin for 10 weeks reduces the risk of progression or reocclusion of the unstable coronary artery lesion.

BACKGROUND

Reocclusion of the culprit coronary artery occurs in up to one third of patients during the 3 months after myocardial infarction (MI) or unstable angina and is associated with increased morbidity and mortality.

METHODS

Fifty-seven patients presenting with unstable angina or MI who had an identifiable culprit lesion at coronary angiography were randomized in double-blind manner to receive warfarin (target international normalized ratio [INR] 2.0 to 2.5) or placebo in addition to aspirin (150 mg daily). Changes in the culprit lesion were assessed by quantitative angiography in 50 patients after 10 weeks of therapy or after a clinical event. Progression of the culprit lesion was defined as a decrease in minimal lumen diameter > 0.4 mm or a new total occlusion. Regression was defined as an increase in minimal lumen diameter > 0.4 mm.

RESULTS

In subjects randomized to receive warfarin, the culprit lesion was less likely to progress (1 [4%] vs. 8 [33%]) and more likely to regress (5[19%] vs. 2[9%]) than in subjects receiving placebo (p = 0.02). Recurrent MI or a new occlusion at angiography occurred in 2 (7%) of 29 patients receiving warfarin versus 11 (39%) of 28 patients receiving placebo (p = 0.005).

CONCLUSIONS

In patients with an acute coronary syndrome, combined therapy with aspirin and warfarin with a target INR of 2.0 to 2.5 for 10 weeks reduces the risk of progression or reocclusion of the culprit coronary lesion.

Serial angiography in cocaine-induced myocardial infarction

A young man suffered an acute inferior myocardial infarction following clinical use of cocaine as topical anesthesia. Coronary angiography showed occlusion of both the posterior descending and posterolateral arteries which was resistant to intracoronary administration of nitroglycerin and verapamil, a finding consistent with thrombotic occlusion. A subsequent angiogram 3 months later showed no residual lesions.

Association between activity at onset of symptoms and outcome of acute myocardial infarction

OBJECTIVES

This study sought to compare the clinical features and outcome of a first myocardial infarction with onset of symptoms during or within 30 min of exercise, at rest and in bed.

BACKGROUND

It is not known whether activity at onset influences outcome of acute myocardial infarction.

METHODS

Information collected using a standard questionnaire was used to relate activity at the onset of symptoms to in-hospital outcome in 2,468 consecutive patients admitted to a coronary care unit with a first myocardial infarction between 1975 and 1993.

RESULTS

Patients with exercise-related onset were more likely to be younger and male. Those with onset in bed were more likely to be older and have a history of stable or unstable angina. Compared with patients whose symptoms began at rest, those with exercise-related onset had a lower in-hospital mortality rate after adjusting for age, gender and year of admission (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.89), and patients with onset in bed had a higher mortality rate (OR 1.38, 95% CI 1.03 to 1.85). The incidence of cardiac failure requiring diuretic therapy was also lower for exercise-related onset (OR 0.83, 95% CI 0.67 to 1.04) and higher when onset was in bed (OR 1.36, 95% CI 1.11 to 1.66).

CONCLUSIONS

There is an association between activity at onset and outcome of acute myocardial infarction. Differences in pathophysiology or in the population at risk could explain this observation.

The effect of exercise on gait patterns in older women: a randomized controlled trial

BACKGROUND

This study was undertaken to determine (a) whether a program of regular exercise can improve gait patterns in older women, and (b) whether any such improvement in gait is mediated by increased lower limb muscle strength.

METHOD

A 22-week randomized controlled trial of exercise was conducted as part of the Randwick Falls and Fractures Study in Sydney, Australia. Subjects were 160 women aged 60-83 years (Mean age 71.1, SD = 5.2) who were randomly recruited from the community. Exercise and control subjects were tested prior to and at the end of the trial. At initial testing, exercisers and controls performed similarly in the strength and gait parameters. They were well matched in terms of age and a number of health and life-style characteristics.

RESULTS

At the end of the trial, the exercise subjects showed improved strength in five lower limb muscle groups, increased walking speed, cadence, stride length, and shorter stride times as indicated by both reduced swing and stance duration. There were no significant improvements in any of the strength or gait parameters in the controls. Within the exercise group, increased cadence was associated with improved ankle dorsiflexion strength, and increased stride length was associated with improved hip extension strength. Exercise subjects with initial slow walking speed showed greater changes in velocity, stride length, cadence, and stance duration than those with initial fast walking speed.

CONCLUSION

These findings show that exercise can increase gait velocity and related parameters in older persons, and that part of this increase may be mediated by improved lower limb muscle strength.

Time course of "warm-up" in stable angina

Warm-up exercise can significantly reduce the severity of myocardial ischemia on exercise after a 10-minute rest, but this benefit is significantly less after a 30-minute rest. Further study is needed to clarify the mechanisms responsible for warm-up. The results of this study are consistent with a change in myocardial metabolism similar to ischemic preconditioning or a delayed increase in myocardial perfusion to the ischemic territory, which has returned toward baseline after 30 minutes.

Primitive neuroectodermal kidney tumour

Images

Identifying tumor suppressors in genetic mosaics: the Drosophila lats gene encodes a putative protein kinase

We have identified recessive overproliferation mutations by screening and examining clones of mutant cells in genetic mosaics of the fruitfly Drosophila melanogaster. This type of screen provides a powerful approach for identifying and studying potential tumor suppressors. One of the identified genes, lats, has been cloned and encodes a putative protein kinase that shares high levels of sequence similarity with three proteins in budding yeast and Neurospora that are involved in regulation of the cell cycle and growth. Mutations in lats cause dramatic overproliferation phenotypes and various developmental defects in both mosaic animals and homozygous mutants.

Coronary artery ectasia: local pathology or diffuse disease?

It is not known whether general or local factors influence the pathogenesis of coronary ectasia. We analyzed prospectively coronary angiograms from 2,186 consecutive patients with 32 patients (1.5%), identified as having coronary artery ectasia. Sixteen subjects had coronary ectasia in more than one segment of the same or a different artery. In 20 of 72 (28%) ectatic segments there was a proximal, related stenosis. In these cases ectasia was more often saccular than fusiform (16 vs. 4) compared to ectasia without a proximal, related stenosis (21 vs. 31, P = 0.003), and the mean length of the ectatic segment was shorter (8.0 vs. 15.1 mm, P = 0.013). Subjects with ectasia after a stenosis often had other ectatic segments unrelated to stenoses. The high incidence of multisegment involvement suggests that coronary ectasia results from a diffuse abnormality of the vessel wall. In predisposed individuals localized ectasia may follow a stenosis, suggesting poststenotic dilatation.

Adjustment for the influence of age and heart rate on Doppler measurements of left ventricular filling

OBJECTIVE

To determine the normal range of pulsed Doppler measurements of left ventricular filling adjusted for age and heart rate.

DESIGN

Multiple regression was used to measure the effects of age and heart rate on pulsed Doppler indices of left ventricular filling in normal subjects. These regression equations were used to calculate a predicted normal value and 95% confidence interval (95% CI) for any subject from his age and heart rate.

PARTICIPANTS

61 subjects with no evidence of cardiovascular disease, aged 20 to 90 years, with a resting heart rate of 47-89 beats/min.

RESULTS

The effect of a 10 year increase in age was peak atrial filling velocity +15% (95% CI 12.0% to 18.5%); peak early filling velocity -3.2% (-6.0% to 0%); isovolumic relaxation time +6.2% (3.9% to 8.4%); acceleration time -3.8% (-6.0% to -1.5%); deceleration time +7.9% (5.1% to 10.8%). The effect of a 10 beat/min increase in heart rate was: peak atrial filling velocity +5.5% (1.2% to 10.1%); peak early filling velocity -4.0% (-8.1% to 2.0%); isovolumic relaxation time -2.5% (-4.6% to 0.6%); acceleration time -3.1% (-6.4% to 0.4%); deceleration time -1.8% (-4.0% to 3.8%).

CONCLUSION

For any individual, comparison of the predicted normal measurement and 95% CI with the observed measurement allows an assessment of the effects of disease on left ventricular filling that is independent of age and heart rate.

Prospective, double-blind, placebo-controlled trial of low-dose amiodarone in patients with severe heart failure and asymptomatic frequent ventricular ectopy

Sudden cardiac death is a common cause of mortality in patients with congestive heart failure. To determine if low-dose amiodarone could reduce sudden death among these patients, a prospective, placebo-controlled, double-blind pilot trial was conducted. One hundred one patients with ejection fractions less than 30%, New York Heart Association class III or IV symptoms, and frequent but asymptomatic spontaneous ventricular ectopy (Lown class II to V) were randomly assigned to treatment with low-dose amiodarone (400 mg/day for 4 weeks and then 200 mg/day) or placebo. Mean follow-up was 357 days (range 4 to 1009 days). Side effects were infrequent and there was no difference in the incidence of side effects between the treatment groups. The frequency of spontaneous ventricular ectopy in the group receiving amiodarone fell from 4992 +/- 1240 beats/24 hours at baseline to 1135 +/- 494 beats/24 hours after 1 month of treatment (p = 0.02) and remained low after 6 months, while there was no change in ventricular ectopy among the patients receiving placebo. Despite the reduction in ectopy, there was no improvement in mortality or decrease in the incidence of sudden death. One-year mortality by Kaplan-Meier analysis was 28% in the group receiving amiodarone and 19% in the group receiving placebo (p = NS). One-year mortality in patients with greater than 75% reduction in ventricular ectopy after 1 month of treatment was 31% versus 17% in patients with less than or equal to 75% ectopic suppression (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Good prognosis for dilated cardiomyopathy without severe heart failure or arrhythmia

In 124 patients with dilated cardiomyopathy, symptoms of heart failure and ventricular arrhythmia at initial assessment were related to outcome a mean of 43 months later. Using life table analysis, the two-year mortality from progressive heart failure was 59 per cent (90 per cent symptoms, six per cent (1-11 per cent) for patients with class 2 symptoms and zero for patients with class 1 symptoms. The two-year mortality from sudden death was 18 per cent (5-32 per cent) for patients with class 3 symptoms, eight per cent (3-14 per cent) for patients with class 2 symptoms and seven per cent (0-17 per cent) for patients with class 1 symptoms. Sudden death was more frequent in patients with ventricular tachycardia or frequent ventricular ectopics, irrespective of the severity of heart failure (15 per cent (7-23 per cent) vs. three per cent (0-8 per cent) at two years). These findings suggest that patients with dilated cardiomyopathy and mild symptoms often have a benign clinical course. However, occult ventricular arrhythmia is associated with an increased risk of sudden death.

Assessment of diastolic filling indexes obtained by radionuclide ventriculography

This study assesses how differences in residual volume and heart rate influence the measurement and interpretation of commonly used indexes of left ventricular filling obtained by radionuclide ventriculography. Thirty patients with hypertrophic cardiomyopathy (HC) and 26 normal subjects were studied. The time to peak filling rate (168 +/- 42 vs 139 +/- 35 ms; p = 0.006) and time to 30% filling (154 +/- 32 vs 131 +/- 29 ms; p = 0.009 were prolonged in patients with HC compared to normal subjects, suggesting impaired early diastolic filling. However the peak filling rate, measured in end-diastolic counts/s, was greater in patients with HC (3.31 +/- 0.89 vs 3.06 +/- 0.51, p = 0.19). This measurement was influenced by the relative residual volume (HC r = 0.41, p less than 0.001; normal r = 0.29, difference not significant), which was smaller in patients with HC (22.4 +/- 8.0 vs 35.5 +/- 5.6%; p less than 0.0001). The peak filling rate measured in stroke volume counts did not vary with the relative residual volume (HC r = 0.10, difference not significant; normal r = 0.21, difference not significant) and was less than normal in patients with HC (4.27 +/- 0.69 vs 4.72 +/- 1.0; p = 0.58). There was a strong association between the first third filling fraction and the heart rate (HC r = 0.66, p less than 0.001; normal r = 0.71, p less than 0.001), reflecting its dependence on the duration of the first third of diastole.(ABSTRACT TRUNCATED AT 250 WORDS)

Enalapril for severe heart failure in infancy

Eight infants aged between 4 days and 12 weeks with severe heart failure that was refractory to optimal conventional treatment with diuretics were treated with enalapril. The starting dose was 0.1 mg/kg/day, increasing according to response to 0.12-0.43 mg/kg/day. One infant with severe myocarditis did not tolerate enalapril because of hypotension and later died of intractable heart failure. Six of the remaining patients had congenital systemic to pulmonary shunts and one had a simple aortic coarctation. Two weeks after starting enalapril the clinical features of heart failure had improved in all the infants, the mean (SEM) plasma sodium concentration had increased from 129 (2.4) to 136 (1.1) mmol/l and plasma urea concentration had fallen from 7.0 (0.85) to 2.9 (0.85) mmol/l. These data suggest that enalapril is a potentially useful treatment for severe heart failure in infancy.

An assessment of the usage of the plasma theophylline assay service in a teaching hospital

A four-week assessment of all inpatients who had been prescribed theophylline therapy was carried out at a major Australian teaching hospital. A total of 49 theophylline assays was requested for 36 of 116 patients who were prescribed theophylline. Only 38 (78%) assays were ordered for appropriate indications and at appropriate times. In 26 of the 34 appropriately requested assays that could be followed-up, appropriate action was judged to have been taken on receipt of the assay result. Of the 80 patients who were prescribed theophylline for whom theophylline assays were not ordered, 19 might have benefited from the performance of an assay. It is concluded that the theophylline assay service is not being used optimally.

Factor analysis and rotation of responses to the Junior Eysenck Personality Inventory

To investigate further the basic item-factor structure of the Junior Eysenck Personality Inventory, a principal components analysis and varimax rotation were conducted on responses of 866 children (aged 7 to 16 yr.) from schools in the Rotorua area of New Zealand. Ten factors were extracted of which 7 were interpretable. These were named: Factor 1. Neuroticism I (Neurotic affect), Factor 2. Extraversion I (Impulsivity), Factor 3. Lie Scale, Factor 4. Extraversion II (Introversion), Factor 5. Extraversion III (Jocularity), Factor 6. Extraversion IV (Sociability), Factor 8. Neuroticism II (Neurotic ideation).

Effects of self-esteem and status on size of signature

142 second year university students from both Memorial University of Newfoundland (n = 81) and Laurentian University (n = 61) wrote their own signatures as they imagined the following people would do: (a) faculty member (high status) with high self-esteem, (b) faculty member (high status) with low self-esteem, (c) student (low status) with high self-esteem, and (d) student (low status) with low self-esteem. The areas of the signatures were calculated in square centimeters, and there was a significant positive relationship between size of signature and the conditions of high and low self-esteem for both "faculty" and "student" role-playing conditions. There was however no significant relationship between size of signature and status. The results held for both groups of subjects.