The influence of team experience on outcomes of endovascular stenting of abdominal aortic aneurysms.

OBJECTIVE: To determine whether the experience of the specialist team was associated with adverse events following endovascular treatment of abdominal aortic aneurysms. METHODS: The EUROSTAR database is a voluntary registry of 2863 patients admitted to 93 hospitals in Europe with an abdominal aortic aneurysm treated with endovascular stenting. Mortality, rupture and the need for secondary interventions were the main outcomes. RESULTS: In patients who underwent endovascular stenting by the most experienced specialist teams the mortality rate was 40% lower than in those treated by the least experienced teams (adjusted hazard ratio 0.60, 95% confidence interval: 0.4-1.0; p = 0.05). Also patients treated by the most experienced specialist teams were 68% less likely to have adverse events necessitating a secondary intervention than those treated by the least experienced teams (adjusted hazard ratio 0.32, 95% confidence interval: 0.2-0.5; p < 0.001). The crude rupture rate was 0.1% among patients treated by the most experienced specialist teams and 0.8% among those treated by the least experienced teams (p = 0.74). CONCLUSIONS: Specialist teams with a high level of experience of endovascular abdominal aortic aneurysm stenting encounter lower mortality rates and fewer adverse events leading to secondary interventions.     

Pseudomembranous tracheobronchitis caused by Aspergillus

Four immunosuppressed patients with a rapidly evolving, febrile, respiratory distress syndrome were found at autopsy to have Aspergillus pseudomembranes of their lower tracheobronchial tree. Steroids, neutropenia, broad spectrum antibiotic use, and alcoholism appear to be predisposing risk factors. Bronchoscopy may reveal the pathology but antemortem diagnosis is difficult because of the low yield of sputum cultures and fulminant nature of the disease.     

Extended therapeutic window and functional recovery after intraarterial administration of neuregulin-1 after focal ischemic stroke.

We have previously shown that neuregulin-1 (NRG-1) protects neurons from ischemic brain injury if administered before focal stroke. Here, we examined the therapeutic window and functional recovery after NRG-1 treatment in rats subjected to 90 mins of middle cerebral artery occlusion (MCAO) and 24 h of reperfusion. Neuregulin-1 (2.5 ng/kg bolus, 1.25 ng/kg/min infusion) reduced infarct volume by 89.2%+/-41.9% (mean+/-s.d.; n=8; P<0.01) if administered immediately after the onset of reperfusion. Neuroprotection was also evident if NRG-1 was administered 4 h (66.4%+/-52.6%; n=7; P<0.01) and 12 h (57.0%+/-20.8%; n=8; P<0.01) after reperfusion. Neuregulin-1 administration also resulted in a significant improvement of functional neurologic outcome compared with vehicle-treated animals (32.1%+/-5.7%; n=9; P<0.01). The neuroprotective effect of the single administration of NRG-1 was seen as long as 2 weeks after treatment. Neurons labeled with the neurodegeneration marker dye Fluoro-JadeB were observed after MCAO in the cortex, but the numbers were significantly reduced after NRG-1 treatment. These results indicate that NRG-1 is a potent neuroprotective compound with an extended therapeutic window that has practical therapeutic potential in treating individuals after ischemic brain injury.     

QALYfying the value of life.

This paper argues that the Quality Adjusted Life Year or QALY is fatally flawed as a way of priority setting in health care and of dealing with the problem of scarce resources. In addition to showing why this is so the paper sets out a view of the moral constraints that govern the allocation of health resources and suggests reasons for a new attitude to the health budget.     

Preneoplastic and neoplastic growth of xenotransplanted lung-derived human cell lines using deepithelialized rat tracheas

The human lung tumor-derived cell lines A549, Calu-1, Calu-3, HuT292, and SW900 and the transformed human bronchial epithelial cell line TBE-1, that was transfected with the v-Harvey-ras oncogene, were inoculated into deepithelialized Fisher 344 rat tracheas (5 X 10(5) cells/trachea). After the ends of the tracheas were sealed, the tracheas were transplanted into s.c. tissues of nude mice. In a parallel experiment, 1 X 10(6) cells from each of these cell lines were injected s.c. Histological examination of the tracheal transplants 2, 4, 8, 12, and 16 weeks after cell inoculation proved to be of greater usefulness than either clinical or histological observation of the s.c. injection sites. A549, Calu-1, and TBE-1 produced intratracheal neoplastic nodules as early as 2 weeks after cell inoculation. Calu-3, HuT292, and SW900 grew relatively slowly in the tracheas, and simple or stratified epithelia with slight or moderate atypia (preneoplastic lesions) were seen at 2 weeks. After the 4th week, they produced tumor nodules in the tracheal transplants, whereas no tumor cells could be seen at the s.c. injection sites. The human derivation of the cells was confirmed by in situ hybridization using human-specific DNA probes. The intratracheal inoculation and xenotransplantation of human-derived cell lines offers a time-saving alternative to the s.c. inoculation assay for tumorigenicity and is at the same time a potentially valuable approach to studying preneoplastic and neoplastic progression with human cell subpopulations.     

NIFEDIPINE BLOCKS ACTH AND CORTISOL RELEASE IN MAN

1. The present study investigated the effect of prior administration of nifedipine on AVP-induced ACTH release in seven normal volunteers. Three protocols were used: 20 mg oral nifedipine; 0.14 pressor units intramuscular (i.m.) per kg bodyweight aqueous AVP; oral nifedipine plus i.m. AVP 90 min later. Plasma ACTH and cortisol were measured at intervals for 2.5 h during each test. 2. The mean peak plasma ACTH and cortisol levels and the mean peak changes from basal in these levels were significantly lower in the nifedipine/AVP test than in the AVP alone test. The integrated area under the cortisol time curve was significantly lower for the nifedipine/AVP test than that for the AVP test alone. Nifedipine alone caused no changes in ACTH or cortisol. 3. Acute administration of oral nifedipine caused an inhibition of AVP-stimulated ACTH and cortisol release in normal humans. This effect may be due to blockade of plasma membrane calcium channels normally activated during AVP stimulation of pituitary corticotrophs.     

A case of lesser curve ulceration after combined highly selective vagotomy and abdominal aortic aneurysm resection

A 71 year old white male is reported in whom ischaemic ulceration of the lesser curve of the stomach, a variant of lesser curve necrosis, occurred after the combined procedures of highly selective vagotomy (HSV) and abdominal aortic aneurysmectomy. Other operations, particularly fundoplication and incidental splenectomy, have been implicated in the aetiology of lesser curve ischaemia, an otherwise rare complication of HSV. This case suggests that concomitant aortic surgery may also increase the risk of lesser curve ischaemia after HSV. Careful endoscopic monitoring of patients undergoing these combined procedures is therefore recommended to better define the risk.     

Tachycardia''s toll: tachycardia induced cardiomyopathy — a case study

Cardiac arrhythmias are a well known cause of mortality for patients with heart disease. However, sinus tachycardia is a more unusual arrhythmia which can lead to serious heart damage or death. Even young patients with structurally normal hearts may become gravely ill.

This case study outlines the condition of sinus tachycardia, and associated changes in heart function, altered cellular structure of the myocardium and compensatory mechanisms in the body. Treatment modalities, including electro-physiological studies and drug therapies to moderate the tachycardia and myocardial oxygen demand of the heart, are discussed. Fourteen year old ‘Ben’ was previously a well, active and outgoing youth who suddenly became critically ill. He endured weeks of hospitalisation, numerous serious complications including Torsade de pointes arrhythmia, Cheyne-Stokes respirations, nausea and dizziness during this acute phase. Despite challenges, Ben's severely compromised heart muscle recovered at a remarkable rate.