The best way to assess oedema using T1, T2 mapping or three-dimensional T2-weighted fast-spin-echo triple inversion recovery sequences via cardiovascular MRI in outpatients with suspected myocarditis

AIM

To evaluated T1-, T2 mapping, and a three-dimensional (3D) T2-weighted fast-spin-echo triple inversion recovery sequences (3D STIR) for diagnosing myocardial oedema in patients with suspected early myocarditis and at follow-up.

MATERIALS AND METHODS

Sixteen patients with suspected myocarditis and 15 controls matched for gender and age were examined prospectively. To evaluate oedema, an electrocardiogram-triggered T1 and T2 mapping with a gradient spin echo technique and 3D STIR sequences were used to cover the entire left ventricle. The signal intensity ratio (heart muscle in relation to skeletal muscle) was calculated (3D STIR ratio). All patients underwent repeat examinations at follow-up.

RESULTS

The mean 3D-STIR ratio was 2.14±0.45 at the patients' initial examination as compared to the control patients' 1.54±0.18 in (p=0.0001) and 1.75±0.16 in patients at follow-up (p=0.002 versus first visit). The 3D STIR ratio of the septum, anterior, lateral, and inferior wall also differed significantly between patients and controls. No significant difference was observed in T1 and T2 mapping between patients and controls at baseline and patients at follow-up.

CONCLUSIONS

A significantly higher global signal intensity ratio with 3D-STIR was identified in patients with suspected myocarditis compared to controls, and a significant change during follow-up. No significant difference was detected in T1-, T2 mapping between patients and controls, or between the initial examination and follow-up of patients. The global 3D-STIR ratio may therefore be useful for the diagnosis of myocarditis and should be explored further.

Recovering Quantum Gates from Few Average Gate Fidelities

Characterizing quantum processes is a key task in the development of quantum technologies, especially at the noisy intermediate scale of today's devices. One method for characterizing processes is randomized benchmarking, which is robust against state preparation and measurement errors and can be used to benchmark Clifford gates. Compressed sensing techniques achieve full tomography of quantum channels essentially at optimal resource efficiency. In this Letter, we show that the favorable features of both approaches can be combined. For characterizing multiqubit unitary gates, we provide a rigorously guaranteed and practical reconstruction method that works with an essentially optimal number of average gate fidelities measured with respect to random Clifford unitaries. Moreover, for general unital quantum channels, we provide an explicit expansion into a unitary 2-design, allowing for a practical and guaranteed reconstruction also in that case. As a side result, we obtain a new statistical interpretation of the unitarity-a figure of merit characterizing the coherence of a process.

Early diastolic septal movement in patients with myocarditis

AIM

To evaluate early diastolic septal relaxation as a parameter in the diagnostic workup via cardiovascular magnetic resonance imaging (CMRI) in patients with myocarditis.

MATERIALS AND METHODS

Early diastolic septal movement was evaluated (EDS) prospectively via frame-by-frame analysis in 255 consecutive patients with presenting signs of myocarditis and in 64 controls matched 4:1 for gender and age. ECG-triggered, T2-weighted, fast spin echo triple inversion recovery sequences and late gadolinium enhancement were obtained, as well as left ventricular (LV) function and dimensions in patients and controls.

RESULTS

EDS was detected in 66.7% of the patients and 18.7% of the controls (p<0.001). Sensitivity was 69.4% and specificity 79.7%. Patients with EDS had a significant lower LV ejection fraction (LV-EF) of 61.1±0.6% and significant higher end-diastolic volume (EDV) of 158.5±2.7 ml than in patients without EDS (LV-EF 65.3±0.9%, p=0.0001; EDV 148.4±3.9 ml, p=0.04). A significant negative correlation was observed between LV-EF and EDS in patients, and a lower LV-EF correlated with a more frequent occurrence of EDS (r=-0.24, p=0.0001). Scar tissue was also more frequent in patients than controls (63.1% and 7.8%, p=0.007).

CONCLUSIONS

EDS is a parameter obtained non-invasively by CMRI and is present in a high percentage of patients with myocarditis. Cardiac functional parameters are significantly altered in patients with EDS. EDS is a feasible parameter that can play an important role in the diagnosis of myocarditis.

A nonrandomized observational trial of short-term preoperative endocrine therapy in ER-positive breast cancer to investigate change in genomic expression using the 21-gene breast cancer assay

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Background: Preoperative systemic treatment is commonly employed for women with locally advanced breast cancer. Women with early-stage breast cancer, whose resections may be delayed for 30 to 60 days while they undergo preoperative evaluation, may benefit from receiving preoperative endocrine therapy while awaiting surgery. One rationale for not initiating such treatment is that the cancer may be rendered less chemosensitive. The 21-gene assay is a proven predictor of chemotherapy responsiveness. The objective of this study is to examine the association between recurrence score (RS) and ER, PR, and HER2 RT-PCR values in core biopsy and surgical specimens from patients treated with short term pre-operative endocrine therapy.

Methods: Pre- and postmenopausal women with clinical T1-N0-M0, sonographically visible, ER-positive, HER2-negative breast cancer were eligible. Patients were treated with 4-8 weeks of preoperative endocrine therapy; letrozole if postmenopausal or tamoxifen if premenopausal. Clinical breast examination and ultrasound were conducted every two weeks, with the final ultrasound immediately prior to surgery. Tumor blocks from the core biopsy and surgical excision were submitted to Genomic Health, Inc., where RS, ER, PR, and HER2 results were obtained from each of the paired specimens.

Results: Nineteen matching core biopsy and surgical specimens were available for analysis. Pearson correlation coefficients between core biopsy and excisional sample results were 0.89 for RS, 0.87 for ER, 0.72 for PR, and 0.77 for HER2. On average, small but statistically significant increases in RS and decreases in ER and PR were observed (all p < 0.005 from paired t-test). No obvious associations between these markers and clinical response were observed.

Conclusions: In this small, hypothesis-generating study, paired RS and RT-PCR for ER/PR/HER2 remained correlated after short-term preoperative endocrine therapy. This study provides no suggestion of decreasing chemosensitivity during preoperative endocrine therapy, but additional research is warranted to explore these findings further.

Integration of genetic, clinical, and INR data to refine warfarin dosing

Well-characterized genes that affect warfarin metabolism (cytochrome P450 (CYP) 2C9) and sensitivity (vitamin K epoxide reductase complex 1 (VKORC1)) explain one-third of the variability in therapeutic dose before the international normalized ratio (INR) is measured. To determine genotypic relevance after INR becomes available, we derived clinical and pharmacogenetic refinement algorithms on the basis of INR values (on day 4 or 5 of therapy), clinical factors, and genotype. After adjusting for INR, CYP2C9 and VKORC1 genotypes remained significant predictors (P < 0.001) of warfarin dose. The clinical algorithm had an R(2) of 48% (median absolute error (MAE): 7.0 mg/week) and the pharmacogenetic algorithm had an R(2) of 63% (MAE: 5.5 mg/week) in the derivation set (N = 969). In independent validation sets, the R(2) was 26-43% with the clinical algorithm and 42-58% when genotype was added (P = 0.002). After several days of therapy, a pharmacogenetic algorithm estimates the therapeutic warfarin dose more accurately than one using clinical factors and INR response alone.

Factors associated with regression of cervical dysplasia in adolescents: A retrospective study

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Background: Sexually active adolescents have high rates of infection with human papilloma virus (HPV) and abnormal pap smears. They are considered a special population as they are likely to regress to normal cytology. The aim of our study was to identify factors associated with regression of cervical dysplasia in adolescents. Methods: We identified adolescent patients (aged 12–21 years) who had abnormal pap smears at the Center for Women's Medicine at Lehigh Valley Hospital in Allentown, PA, by CPT code from a database between Jan 2004 and Dec 2006. A chart review was performed to capture demographic data, cytology, smoking history, number of sexual partners, parity, race, contraceptive choice, use of barrier contraception. Chi-square analysis with logistic regression and multivariate analysis were used to identify factors associated with regression of cervical dysplasia. Results: Two-hundred two patients were identified. Mean age was 18.84 years (14–22 years). One hundred twenty-two (57.8%) were Hispanic, 71 (33.6%) Caucasian, and 16 (7.6%) Black. Fifty-two (24.6%) were pregnant at the time of diagnosis. Seventy-six (36%) were smokers. There were 125 (61.9%) cases of ASCUS, 33.7% (68 cases) LGSIL and 4.5% (9 cases) HGSIL on initial pap smear. One hundred eighteen (55.9%) patients had colposcopy, and of these, 32 (15.2%) had surgical intervention. Follow-up demonstrated that 72 (57.6%) patients had disease regression, 24 (19.2%) persistence and 29 (23.2%) progression. On multivariate analysis, patients who did not smoke were significantly more likely to show regression of cervical dysplasia on pap smear than women who smoked (OR 2.17, 95% CI 1.03–4.55, p = 0.039). Other factors were not statistically significant in predicting regression of cervical dysplasia. Conclusions: Adolescents who smoke were more likely to have persistent cervical dysplasia than non-smoking adolescents, putting smokers at an increased risk of advanced disease. We suggest that this subset have follow-up at shorter intervals and be enrolled in a smoking cessation program.

No significant financial relationships to disclose.

[Sporadic lymphangioleiomyomatosis. Clinical and lung functional characteristics of 32 female patients]

BACKGROUND AND OBJECTIVE

Lymphangioleiomyomatosis (LAM) is a rare and progressive multi-systemic disorder almost exclusively of women. Clinical and lung functional data of a substantial number of German patients have not so far been published.

PATIENTS AND METHODS

In 32 women with sporadic LAM we performed the following investigations: medical history, clinical examination, lung function (spirometry, bodyplethysmography, diffusion capacity for carbon monoxide), ECG, echocardiography, and abdominal ultrasound.

RESULTS

The mean age at the time of investigation was 48 (25 - 66) years, while the mean age at time of diagnosis had been 45 (21 - 61) years. The median time between onset of first symptoms and diagnosis was 8 years (1 months - 30 years). Most frequently stated first symptom was dyspnea on exertion (12/32 patients) and the most frequently stated first clinical sign was pneumothorax (12/32). Changes of hormonal status (contraception, treatment for fertility, pregnancy) occurred in 31 of the 32 patients before onset of first symptoms or clinical signs. Hormonal (16/32) and antiobstructive therapy (16/32) were the most frequently applied forms of treatment. Airway obstruction (26/32 patients), hyperinflation (20/32) and reduced diffusion capacity for carbon monoxide (24/32) were found on lung function test. Abnormal auscultation (6 patients), ECG signs of chronic cor pulmonale (4/32) and an elevated systolic pulmonary artery pressure (2 patients) were rare findings. Abdominal lesions (angiomyolipoma, 11/32 patients; lymphangioleiomyoma, 4 patients) were common.

CONCLUSION

Lymphangioleiomyomatosis should be considered in women with spontaneous pneumothorax, unexplainable dyspnoea or angiomyolipoma.

Dual neurokinin NK(1)/NK(2) antagonists: N-[(R,R)-(E)-1-arylmethyl-3-(2-oxo-azepan-3-yl)carbamoyl]allyl-N-methyl-3,5-bis(trifluoromethyl)benzamides and 3-[N'-3,5-bis(trifluoromethyl)benzoyl-N-arylmethyl-N'-methylhydrazino]-N-[(R)-2-oxo-azepan-3-yl]propionamides

Based on the structure of N-[(R,R)-(E)-1-(4-chlorobenzyl)-3-(2-oxoazepan-3-yl)carbamoyl]allyl-N-methyl-3,5-bis(trifluoromethyl)benzamide (1), attempts to improve the NK(2) affinity have resulted in the discovery of N-[(R,R)-(E)-1-(3,4-dichlorobenzyl)-3-(2-oxoazepan-3-yl)carbamoyl]allyl-N-methyl-3,5-bis(trifluoromethyl)benzamide (9, DNK333) exhibiting a 5-fold improved affinity to the NK(2) receptor in comparison to 1. Simplification of the structure via elimination of a chiral centre led to 3-[N'-3,5-bis(trifluoromethyl)benzoyl-N-(3,4-dichlorobenzyl)-N'-methylhydrazino]-N-[(R)-2-oxo-azepan-3-yl]propionamide (22), a potent and fairly balanced NK(1)/NK(2) antagonist.

Predicting post-coronary bypass surgery atrial arrhythmias from the preoperative electrocardiogram

BACKGROUND

Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is a common occurrence and adds to the morbidity and cost associated with the procedure. Various therapies have been demonstrated to reduce the risk of post-CABG AF, but their use should be targeted to high-risk patients. The purpose of this study was to develop a prediction rule for post-CABG AF on the basis of patient age and the preoperative electrocardiogram (ECG).

METHODS

The charts of 152 consecutive patients undergoing isolated CABG at one institution were reviewed and the preoperative ECG was analyzed with use of commercially available software. Logistic regression was performed and age-adjusted predictors of the primary end point, any post-CABG AF, were derived. The discriminatory values of the various models were compared by receiver-operating characteristic curves.

RESULTS

Sixty-four patients (42.1%) had AF. Multivariable predictors were dichotomized on the basis of variable distribution, and a high-risk patient population was identified by age >65 years, PR interval >/=180 milliseconds (age-adjusted odds ratio [OR] 2.12, P =.05), and a P-wave duration in lead V1 >/=110 milliseconds (age-adjusted OR 2.30, P =.02).

CONCLUSIONS

This study demonstrates that post-CABG AF can be predicted preoperatively from patient age and evidence of intra-atrial conduction delay on ECG. Such information can be used to guide prophylactic therapy.

Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.

Factors associated with emergency department utilization for nonurgent pediatric problems

OBJECTIVE

To identify specific caretaker and utilization characteristics predictive of the use of the emergency departments (EDs) for nonurgent reasons. Each year more than 20 million children in the United States seek medical care in EDs. Between one third and one half of these visits are for nonurgent reasons.

DESIGN

A descriptive study conducted during a 6-month period.

SETTING

Two urban hospital EDs.

MEASURE

A questionnaire was designed to elicit information about specific caretaker characteristics and their reasons for using the ED for their child's nonurgent medical care.

SUBJECTS

Two hundred caretakers and children brought to the ED for nonacute medical care. Caretakers in this study included mothers (82%) with a mean age of 30 years, single caretakers (70%), and unemployed caretakers (60%). The average age of the children was 6.2 years.

RESULTS

Most caretakers (92%) reported having a continuity physician for their children. Caretakers who reported being taken to the ED when they were children (P<.002) and those with Medicaid insurance (P<.001) were more likely to view the ED as the usual site of care. Being a single parent was a predictor for nonurgent visits (P<.05).

CONCLUSIONS

Predicting which caretakers are at risk for using the ED for nonurgent care when their children are sick provides the primary care physician a means of identifying specific patients who may benefit from interventions designed to promote a more cost-effective approach to using medical resources. Arch Fam Med. 2000;9:1086-1092

Contemporary trends in coronary intervention: a report from the Registry of the Society for Cardiac Angiography and Interventions

This report of the Registry for the Society for Cardiac Angiography and Interventions provides data on the trends in coronary interventional procedures from the time period June 1966 through December 1998. A total of 19,510 consecutive coronary interventional procedures were recorded. Over this time period, significant trends in coronary stent implantation were recorded along with a decreasing reliance on balloon angioplasty as sole therapy. Patients with acute myocardial infarction comprised an increased fraction of all procedures. Almost half of all interventions were performed in patients with multivessel disease. Finally, decreasing rates of in-hospital death and emergent bypass surgery compared to prior reports from the registry characterize the current practice of interventional cardiology. Cathet. Cardiovasc. Intervent. 49:19-22, 2000.

T cells are necessary and critical for xenograft rejection in new concordant cardiac xenotransplant model

BACKGROUND

A new vascularized concordant xenotransplant model using the Chinese hamster as donor and mouse as recipient species is reported. This model takes advantage of the wealth of informative immune reagents and knockout and transgenic backgrounds available for the mouse.

METHODS

Heterotopic auxillary cardiac transplantation was performed. The mean survival time was assessed by daily palpation. Xenoreactive antibody production was measured by flow cytometry, and cardiac xenografts were examined by light microscopy.

RESULTS

The tempo of xenograft rejection in this model is consistent with concordant species combination. IgM and IgG3 responses were not critical for the concordant xenograft rejection. Long-term survival (>100 days) of the concordant cardiac xenografts was observed without any immunosuppression in nude mice. Reconstitution of nude mice with CD3+ T cells induced the xenograft rejection in 5.7 days (P<0.01).

CONCLUSION

This new concordant cardiac xenotransplant model demonstrates that T-dependent xenogeneic immune response is necessary and critical for the xenograft rejection.

Prognostic significance of atrial fibrillation in patients at a tertiary medical center referred for heart transplantation because of severe heart failure

Atrial fibrillation (AF) occurs frequently in advanced heart failure. The prognostic significance of AF remains controversial. To determine the relation of AF to survival in patients with advanced heart failure, 234 consecutive patients referred for heart transplantation evaluation from January 1993 to June 1996 were studied to determine the effect of AF on event-free survival (freedom from death, heart transplantation, or placement of a left ventricular assist device). Clinical characteristics of the study population included: age, 51 +/- 17 years; maximum exercise oxygen consumption, 14.2 +/- 5.3 ml/kg/min; left ventricular ejection fraction, 24 +/- 11%; pulmonary capillary wedge pressure, 23 +/- 9 mm Hg; and ischemic etiology, 52%. Medical therapy included: diuretics (86%), angiotensin-converting enzyme inhibitors (80%), digoxin (80%), and anticoagulation therapy (72%). Mean duration of follow-up was 1.1 +/- 1.0 years. Sixty-two patients (27.4%) had AF. One-year event-free survival of the study population was 48%. No difference in event-free survival between patients with and without AF was observed. Univariate predictors of decreased event-free survival included: (1) advanced New York Heart Association class; (2) higher pulmonary capillary wedge pressure; (3) lower cardiac index; (4) lower maximum exercise oxygen consumption; (5) use of inotropic therapy; and (6) greater pulmonary artery systolic pressure. By multivariate analysis, independent predictors of decreased event-free survival included advanced New York Heart Association class (p <0.002) and higher pulmonary capillary wedge pressure (p = 0.02). Thus, AF in patients with advanced heart failure is not associated with decreased event-free survival.

Synthesis and SAR of a novel, potent and structurally simple LTD4 antagonist of the quinoline class

The two geminal ethyl groups in the succinic acid moiety of CGP57698 (4-[3-(7-fluoro-2-quinolinyl-methoxy)phenyl-amino]-2,2-diethyl-4-oxo- butanoic acid) are responsible for the high in vitro and in vivo potency of this peptidoleukotriene antagonist of the quinoline type. The synthesis and structure activity relationships of CGP57698 and its analogs are described.

Growth in children following liver transplantation

Although liver transplantation (OLT) has become standard therapy for end-stage liver disease in children, growth after OLT remains an area of concern. We reviewed our experience with growth after OLT at the Hospital for Sick Children in 83 patients who survived at least 1 yr post-transplant. Our aims were to describe the success rate in steroid cessation in patients after transplantation, to examine the effect of transplantation on subsequent growth, to see if steroid reduction had a beneficial effect on growth, and to quantify the risk of stopping steroids on rejection. Patients below age 5 yr were weaned off steroids more easily than those over age 5: 19.2% vs. 0% (p<0.05), 65.9% vs. 50%, and 79.5% vs. 37.5% (p<0.05) at post-transplant years 1, 2, and 3, respectively. Pre-transplant, 30% of patients were below the third percentiles for height and weight. Post-transplant, there was a steady improvement in the distribution of patients above the 3rd percentile, so that by post-transplant year 6, only 5% were below the 3rd percentile. Height and height velocity percentiles were found to correlate inversely with total yearly steroid dose (mg/kg) at post-transplant years 2, 3 and 6 (p<0.05). In 60% of patients, steroids were successfully discontinued. In these patients, height and height velocity percentiles have achieved a near normal distribution with 40% and 46% of patients above the 50th percentile for height and height velocity percentiles, respectively. No grafts were lost to rejection in those off steroids, and all rejection episodes were easily reversed. We conclude that the majority of children can be weaned off steroids successfully after OLT and that growth in those children in the presence of good graft function is near normal.

Head-upright tilt table testing. A safe and easy way to assess neurocardiogenic syncope

Head-upright tilt table testing has emerged as an exciting technique for evaluating episodes of autonomically mediated syncope. It may be performed using gravity alone as the provocative stimulus or with the addition of isoproterenol. The classic neurocardiogenic response to the test is a sudden drop in blood pressure followed by a decrease in heart rate, but other abnormal response patterns have also been reported. Continuing investigations will improve understanding of autonomic disturbances that cause orthostatic intolerance and will help elaborate the role of tilt table testing in their evaluation and management.

Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A postmarketing surveillance study

OBJECTIVE

To evaluate the risk of gastrointestinal and operative site bleeding associated with the use of parenteral ketorolac tromethamine.

DESIGN

Postmarketing surveillance inception cohort study.

SETTING

A total of 35 hospitals throughout the Philadelphia, Pa, region, 1991 to 1993.

PATIENTS

Patients administered 10,272 courses of parenteral ketorolac therapy were compared with patients administered 10,247 courses of a parenteral opiate who were matched to the ketorolac patients by hospital, admitting service, and date of initiation of study drug.

MAIN OUTCOME MEASURES

Medical records were reviewed for demographics, medical history, doses and duration of study drug, various aspects of the hospital course including surgery and concomitant medications, and adverse events.

RESULTS

The multivariate adjusted odds ratio (OR) comparing ketorolac with opiates for gastrointestinal bleeding was 1.30 (95% confidence interval [CI], 1.11 to 1.52); for operative site bleeding, the OR was 1.02 (95% CI, 0.95 to 1.10). The OR was elevated further in subjects 75 years of age or older for both gastrointestinal bleeding (OR = 1.66; 95% CI, 1.23 to 2.25) and operative site bleeding (OR = 1.12; 95% CI, 0.94 to 1.35). A dose-response relationship was evident between average daily ketorolac dose and both gastrointestinal bleeding and operative site bleeding (trend test P < .001 for both). When analgesic therapy lasted 5 or fewer days, ketorolac was associated with only a small increased risk of gastrointestinal bleeding (OR = 1.17; 95% CI, 0.99 to 1.30); when therapy was prolonged beyond 5 days, the OR was 2.20 (95% CI, 1.36 to 3.57). The association of ketorolac with operative site bleeding was not affected by duration of therapy.

CONCLUSIONS

The overall associations between ketorolac use and both gastrointestinal bleeding and operative site bleeding are small. However, the risk associated with the drug is larger and clinically important when ketorolac is used in higher doses, in older subjects, and for more than 5 days. Improving physicians' prescribing practices by limiting the dose and duration of ketorolac use, especially in the elderly, should enhance its overall risk-benefit balance.

Inaccuracies in certification of nonmelanoma skin cancer deaths

Nonmelanoma skin cancer is the most common cancer site in the United States, yet mortality from this cause is poorly understood. We sought medical records of the 16 reported deaths during 1979 through 1987 from this cause (International Classification of Diseases, 9th version [ICD-9], code 173) among Rhode Island residents to evaluate the accuracy of the reported cause of death. Of the 110 cases for which the cause of death could be classified as correct or incorrect, 59 (54%) were misclassified, 49 (83%) of which were mucous-membrane, squamous-cell carcinomas of the head and neck. For most of these, the written death certificate diagnosis was squamous-cell carcinoma of the head and neck, which was coded 173.4. Other problematic diagnoses were cancer of the head and neck and malignant fibrous histiocytoma. In response to a mailed survey, most health departments replied that squamous-cell carcinoma of the head and neck was coded under rubric 173 and malignant fibrous histiocytoma was coded under rubric 171, but there was no unanimity. The misclassification of other causes of death to ICD-9 rubric 173 is substantial. The vast majority were coded to rubric 173.4 and were due to a small number of diagnoses that are recognizable on examination of the death certificate.

Nonmelanoma skin cancer mortality. A population-based study

To estimate the magnitude of nonmelanoma skin cancer mortality and describe its parameters, we reviewed the medical records of all deaths certified as due to this cause among Rhode Island residents from 1979 through 1987. After excluding acquired immunodeficiency syndrome-associated Kaposi's sarcoma, we confirmed that nonmelanoma skin cancer was the cause of death for 51 individuals, a quarter of the number of melanoma deaths reported. The age-adjusted nonmelanoma skin cancer mortality rate was 0.44/10(5) per year. Fifty-nine percent were due to squamous cell carcinoma, and 20% were due to basal cell carcinoma. Most appeared actinically induced. Among deaths from squamous cell carcinoma, the mean age was 73 years. At least 80% of the squamous cell carcinomas metastasized, and 47% arose on the ear. None appeared due to refusal of treatment. Among deaths from basal cell carcinoma, the mean age was 85 years, and refusal of surgical intervention was documented in 40%. Study of nonmelanoma skin cancer mortality provides for estimation of the magnitude of this problem, complements other studies of prognosis, and helps guide prevention, early detection, and treatment.

Modes of action of aspirin-like drugs

Current dogma holds that nonsteroidal anti-inflammatory drugs (NSAIDs) act by inhibition of the synthesis and release of prostaglandins. However, NSAIDs also inhibit the activation of neutrophils, which provoke inflammation by releasing products other than prostaglandins. We now report that NSAIDs (e.g., indomethacin, piroxicam) inhibit activation of neutrophils by inflammatory stimuli, such as C5-derived peptides and leukotriene B4, even when cyclooxygenase products generated in suspensions of stimulated neutrophils (prostaglandin E and thromboxanes) are present. Sodium salicylate (3 mM) greatly inhibited aggregation of neutrophils but had no effect on aggregation of platelets or production of thromboxane induced by arachidonate. Sodium salicylate and other NSAIDs also inhibit calcium movements (45Ca uptake, changes in fluorescence of chlortetracycline and quin-2). Aspirin, sodium salicylate, indomethacin, and piroxicam also enhanced the poststimulation increase in intracellular cyclic AMP. NSAIDs therefore inhibit early steps in neutrophil activation as reflected by their capacity to inhibit movements of Ca and to enhance intracellular levels of cyclic AMP.