Patient-specific determinants of delay in goal-oriented patient behavior in acute myocardial infarct. Results of the post-infarct late potential study]

369 (63%) of 586 consecutive patients with confirmed myocardial infarction were admitted to hospital within 6 h of symptom onset. Patients' arrival to hospital followed a characteristic circadian distribution with a marked morning increase between 0600 and 1200 hours, and a corresponding decrease in the late night hours. There were no differences in the occurrence of late potentials and in ECG data between early and late arrival group. The early group (less than 5.9 h) was, however, characterized by significantly higher cardiac enzyme levels than the late group (greater than 6.0 h); they also experienced more arrhythmic events in the acute phase (16.0% vs. 9.7%; p less than 0.032). Catecholamines were significantly more often necessary (26.4% vs. 10.3%; p less than 0.0001). Six-month prognosis after AMI was markedly worse. The time between symptom onset and hospital arrival was not affected by age and risk factors. In univariate analysis, pain history and recurrent infarction also had no influence on delay of admission to hospital. The time interval was, however, significantly shorter when the acute event occurred during the night (18.4% vs. 8.3%; p less than 0.0001). Absence of prodromi in the prehospital phase (18.5% vs. 12.0%; p less than 0.04) and a higher socio-economic level (68.3% vs. 61.0%; p less than 0.077) also shortened the admission time, whereas a hyperactive behavioral pattern prolonged the delay time (21.1% vs. 28.9%; p less than 0.05).     

Anesthesia and/or Sedation for Pulsed Dye Laser Therapy

One of the most exciting developments in pediatric dermatology has been the use of the flashlamp-pumped, 585-nm, pulsed dye laser for treatment of vascular birthmarks. In many cases the results are miraculous. The increase in self-esteem and happiness of many children and adolescents has been overwhelming; for some, depression has been lifted, stuttering has ceased, social involvement has increased, and antidepressants have been discontinued. There are many success stories to tell.
Despite the remarkable effects of the pulsed dye laser and the medical and psychosocial indications for its use, the issue of pain control remains significant. We have no perfect outpatient pediatric anesthetic. Most methods carry either some risk or, if not hazardous, often are not very effective for controlling pain. Needless to say, a diversity of opinions exist on how to manage discomfort from this treatment modality. Therefore, we thought it would be useful to share the experiences and opinions of several dermatologists who have extensive experience with the pulsed dye laser.     

Physiological incompatibilities of porcine hepatocytes for clinical liver support.

In fulminant hepatic failure, the use of bioartificial liver support (BAL) with porcine hepatocytes is the subject of a current and controversial debate.1 Specifically, the issue of cross-species physiological incompatibilities has not been addressed so far. We therefore investigated the effects of species-specific cytokines in single and cocultures on hepatocyte function. Hepatocyte cultures were isolated from human resection specimens and from Landrace pigs. Single and cocultures were exposed to porcine and human interleukin (IL)-6 or tumor necrosis factor (TNF)-alpha. Changes in expression of C-reactive protein (CRP), albumin, CCAAT enhancer binding protein (C/EBP)-alpha and C/EBP-beta and metabolic competence of cultured cells was studied by measuring testosterone metabolite production. After human or porcine IL-6 dosing, CRP was induced up to 100-fold in human hepatocyte cultures, while porcine hepatocytes responded marginally (2- to 5-fold). Treatment with human or porcine IL-6 or TNF-alpha resulted in reduced albumin production, albeit at different levels when human and porcine hepatocytes were compared (P = 0.001). Unlike human, porcine hepatocytes produced less of 6alpha-hydroxytestosterone (6alpha-HT) (P < 0.001) and 7alpha-HT (P < 0.001) after human or porcine IL-6 dosing and treatment with species-specific TNF-alpha induced (human hepatocytes) or decreased (porcine hepatocytes) 6beta-HT production (P = 0.021). In coculture with free exchange of metabolites, porcine hepatocytes produced less 6alpha-HT (P = 0.048) and 16alpha-HT (P = 0.033), whereas after treatment with human IL-6 reduced CRP gene and protein expression was observed with human hepatocytes (P = 0.013). In conclusion, species-specific responses of hepatocytes to cytokines and interactions with xenobiotic metabolites may limit the clinical effectiveness of porcine hepatocytes in BAL.     

Reports of Large Immunosuppression Trials in Kidney Transplantation: Room for Improvement

The reporting quality of publications of clinical trials can affect the quality of clinical decision-making. We systematically assessed the quality of publications of large multicenter trials evaluating immunosuppressive regimens in de novo kidney transplantation. Study quality, reporting quality and accessibility of the results of 63 publications were assessed independently by three blinded investigators using an instrument combining the Jadad scale with a list of reporting quality items. Study quality was rated with an average of only 2.3 (range 1-5) on the Jadad scale. Unblinded studies were reported in 68.3% of publications and follow-up longer than 12 months was reported for only 13 out of 50 studies. The reviewed publications fulfilled an average of 69.1% of the reporting quality criteria. Fifty-four percent of publications did not report both treated and biopsy-proven rejections. Whether reported graft survival was censored for death could not be determined for 27% of publications. Only a few publications gave confidence intervals (CIs) or stated whether additional analyses were pre-specified. Even the largest trials of immunosuppression in kidney transplantation show considerable quality deficits in their design and publication. Additional efforts are required of investigators, editors and sponsors to achieve maximum study and reporting quality.     

Characterization of cerebral infarction by multicomponent analysis of transverse magnetization decay curves.

RATIONALE AND OBJECTIVES. Individual components of the transverse magnetization decay curve (TDC) were assessed for their ability to characterize ischemia in photochemically induced cerebral infarcts. METHODS. Fifty rats were randomly divided into equal-sized experimental and control groups, which were subdivided into groups studied at five different time points, ranging from 6 hours to 22 days. All the rats received transcalvarial irradiation with 560-nm light. Five rats in each time group also received a sensitizing dye before irradiation. In these latter animals, lesions of uniform size and location developed. Lesions were compared with tissue of similar volume and location from the contralateral cortex of the experimental animals and with tissue from both hemispheres of the control animals. TDCs of all the samples were measured and fit with mono- and bi-exponential functions. RESULTS. Unlike the control tissue, infarcted tissue displayed definitive two-component TDC behavior. The time course of the bi-exponential parameters yielded information unavailable from mono-exponential analyses. CONCLUSIONS. Bi-exponential analysis of TDCs may have diagnostic use as a more sensitive indicator of cerebral infarction than mono-exponential analyses.     

Plasma Concentrations of Mycophenolic Acid Acyl Glucuronide Are Not Associated with Diarrhea in Renal Transplant Recipients

The aim of this study was to determine whether plasma concentrations of the acyl (AcMPAG) and phenolic (MPAG) glucuronide metabolites of mycophenolic acid (MPA) were related to diarrhoea in renal transplant patients on mycophenolate mofetil (MMF) with cyclosporine (CsA) or tacrolimus (TCL). Blood samples (0, 30, 120 min) were taken at days 3, 10, week 4, months 3, 6 and 12 for determination of MPA, MPAG and AcMPAG. MPA-AUC was estimated using validated algorithms. Two hour AUCs were calculated for MPAG and AcMPAG. Immunosuppressive therapy consisted of CsA/MMF (n= 110) and of TCL/MMF (n= 180). In 70/290 (24%) patients 86 episodes of diarrhoea were recorded during 12 months. Significantly more patients on TCL (31.1%) suffered from diarrhea compared to CsA (12.7%). MMF dose, MPA-AUC and the 2 h AUCs of MPAG and AcMPAG did not differ between patients with and without diarrhoea. Plasma AcMPAG and MPAG concentrations were substantially higher in patients on CsA compared with TCL, while MPA-AUC was lower in the former group. These data support the concept that CsA inhibits the biliary excretion of MPAG and AcMPAG, thereby potentially reducing the risk of intestinal injury through enterohepatic recycling of MPA and its metabolites.     

The relationship between activity and pain in patients 6 months after lumbar disc surgery: Do pain-related coping modes act as moderator variables?

BACKGROUND: In LBP patients, the relationship between pain and physical activity remains unclear. Whereas a negative relationship between pain and self-reported physical activity was found, this relation disappeared in the case of overt behavioral data (e.g., accelerometer). Cognitive-behavioral models of the development of chronic pain suggest subgroups with signs of physical underuse and overuse. AIMS: To examine if patients with pain-related adaptive, endurance and fear-avoidance coping differ in pain, self-reported physical function and overt physical activity 6 months after disc surgery. METHODS: 24 patients completed questionnaires (Von Korff chronic pain grade (CPG), Kiel pain inventory (KPI), Funktionsfragebogen Hannover-Rücken FFbH-R) and underwent an 8-h accelerometer assessment in their daily life (physical activity level (PAL), number of constant postures (CP)). The KPI differed between adaptive coping (AC) (N=9), fear avoidance coping (FAC) (N=1) and endurance coping (EC) (N=14). RESULTS: In the whole group, pain intensity was negative related to self-reported physical activity whereas PAL and CP displayed no correlation with pain. EC patients showed significantly higher pain scores and lower self-reported physical functioning compared to AC but the same level of PAL and furthermore, a significantly higher number of CPs in daily life. The visual inspection of the FAC patient revealed also high pain, low physical functioning and low overt physical activity. CONCLUSIONS: The assessment of pain-related coping modes yielded an important differentiation between subgroups of LBP patients 6 months after surgery. Endurance copers displayed signs of overuse in their daily behavior in spite of pain than adaptive copers. The one fear avoidance coper tends to do less physical activity in the sense of underuse.     

Functional muscular abdominal distension--a case report

The rare clinical picture of the functional muscular distension must be demarcated from organic changes which are connected with an increase of the abdominal volume such as intraabdominal tumours, accumulations of fluid or gatherings of gas or pregnancy. In this symptom a functional disturbance is concerned which appears in patients with vegetative lability or psychic peculiarities and by changes of tension of the musculature surrounding the abdominal space leads to the intermittent or chronic protrusion of the abdomen. By means of an anaesthesia the presence of a functional cause can be made evident: after injection of anaesthetics the protruding abdominal wall is subsiding. The knowledge of the picture of the disease saves long diagnostic ways which contribute to the fact to fix labile patients extremely to the observation of their abdomen and to favour the manifestation of a neurosis. The often unsatisfying therapeutic long-term effect is in contrast to the harmlessness of this symptom.     

Ocular melanoma with retinal detachment: double density sign on CT

A CT examination of a woman with an intraocular melanoma revealed a high density mass lesion with an adjacent retinal detachment of slightly lower density. The "double density" identified in this case can serve as a useful sign in distinguishing melanomatous lesions with accompanying retinal tears.