Plasma vasopressin levels and urinary flow during cardiopulmonary bypass in patients with valvular heart disease: effect of pulsatile flow.

The effect of pulsatile flow on plasma vasopressin levels during cardiopulmonary bypass (CPB) was studied in 20 patients undergoing open valve replacement. Routine bypass was used in 10 patients and the AVCO pulsatile bypass pump was utilized in the other 10. In Group I (nonpulsatile) during CPB, the vasopressin level was markedly elevated (3.1 +/- 2 to 80 +/- 22 pg/ml) as was urine flow (0.6 +/- 0.2 to 5.9 +/- 2 ml/min) and urine Na+ concentration (69 +/- 19 to 116 +/- 7 mEq/L). In Group II (pulsatile) during CPB, the vasopressin level (3.8 +/- 3 to 54 +/- 14 pg/ml), urine flow (0.6 +/- 0.1 to 16.2 +/- 4.8 ml/min), and urine Na+ concentrations (61 +/- 13 to 97 +/- 10 mEq/L) were also elevated. The rise in vasopressin and urine Na+ was less in the pulsatile group (p less than 0.05) whereas the urine flow was higher (p less than 0.05). To maintain comparable blood pressure, the pulsatile flow group required significantly higher flows (4.5 +/- 0.2 compared to 3.8 +/- 0.2; p less than 0.05). These data suggest that CPB produces a marked vasopressin stress response which is beyond the physiological range for an antidiuretic effect on the kidney. At these levels vasopressin can exert a vasopressor effect to maintain resistance and affect renal blood flow, as well as producing an Na+ diuresis. The addition of pulsatile flow creates a more physiological situation attenuating the vasopressin response and producing a decrease in systemic resistance and a less pronounced Na+ diuresis.     

Temperature modulation of α- and β-adrenoceptors in the isolated frog heart

1. The effects of adrenaline on the isolated frog's heart at 27 degrees C are not antagonized by phentolamine (1.5 x 10(-6)M) but are abolished at 7 degrees C.2. At 27 degrees C isoprenaline was more potent than noradrenaline, but at 7 degrees C noradrenaline was more potent than isoprenaline.3. Phenoxybenzamine (1.5 x 10(-5)M) or dibenamine (1.5 x 10(-5)M) at 7 degrees C abolished the work output induced by adrenaline. When the temperature was raised to 24 degrees C, adrenaline caused an increase in work output.4. It is concluded that in the isolated frog heart there are at least two pools of adrenoceptors, the availability of which can be governed by temperature.     

The effect of binocular and monocular distractors on saccades in participants with normal binocular vision

We tested the effect of visual distractors presented monocularly and binocularly on saccade latency and accuracy to determine whether differences occur in saccadic planning with binocular or monocular visual input. For five participants with normal binocular single vision (BSV), saccade latency and accuracy were compared with distractors presented to the dominant eye, non-dominant eye or to both eyes. Eye movements of the dominant eye were recorded using a Skalar infra-red recorder. In the presence of normal BSV, the effect of distractors is significantly larger for saccade latency and accuracy with binocular distractor presentation than for monocular presentations, with no difference between distrators presented to the dominant or non-dominant eye. The implications of these results are discussed with regard to saccade programming.     

Identification of a PAX-FKHR gene expression signature that defines molecular classes and determines the prognosis of alveolar rhabdomyosarcomas

Alveolar rhabdomyosarcomas (ARMS) are aggressive soft-tissue sarcomas affecting children and young adults. Most ARMS tumors express the PAX3-FKHR or PAX7-FKHR (PAX-FKHR) fusion genes resulting from the t(2;13) or t(1;13) chromosomal translocations, respectively. However, up to 25% of ARMS tumors are fusion negative, making it unclear whether ARMS represent a single disease or multiple clinical and biological entities with a common phenotype. To test to what extent PAX-FKHR determine class and behavior of ARMS, we used oligonucleotide microarray expression profiling on 139 primary rhabdomyosarcoma tumors and an in vitro model. We found that ARMS tumors expressing either PAX-FKHR gene share a common expression profile distinct from fusion-negative ARMS and from the other rhabdomyosarcoma variants. We also observed that PAX-FKHR expression above a minimum level is necessary for the detection of this expression profile. Using an ectopic PAX3-FKHR and PAX7-FKHR expression model, we identified an expression signature regulated by PAX-FKHR that is specific to PAX-FKHR-positive ARMS tumors. Data mining for functional annotations of signature genes suggested a role for PAX-FKHR in regulating ARMS proliferation and differentiation. Cox regression modeling identified a subset of genes within the PAX-FKHR expression signature that segregated ARMS patients into three risk groups with 5-year overall survival estimates of 7%, 48%, and 93%. These prognostic classes were independent of conventional clinical risk factors. Our results show that PAX-FKHR dictate a specific expression signature that helps define the molecular phenotype of PAX-FKHR-positive ARMS tumors and, because it is linked with disease outcome in ARMS patients, determine tumor behavior.     

Patterns of hospital transfer for self-poisoned patients in rural Sri Lanka: implications for estimating the incidence of self-poisoning in the developing world

OBJECTIVES: Most data on self-poisoning in rural Asia have come from secondary hospitals. We aimed to: assess how transfers from primary to secondary hospitals affected estimates of case-fatality ratio (CFR); determine whether there was referral bias according to gender or poison; and estimate the annual incidence of all self-poisoning, and of fatal self-poisoning, in a rural developing-world setting. METHODS: Self-poisoning patients admitted to Anuradhapura General Hospital, Sri Lanka, were reviewed on admission from 1 July to 31 December 2002. We audited medical notes of self-poisoning patients admitted to 17 of the 34 surrounding peripheral hospitals for the same period. FINDINGS: A total of 742 patients were admitted with self-poisoning to the secondary hospital; 81 died (CFR 10.9%). 483 patients were admitted to 17 surrounding peripheral hospitals. Six patients (1.2%) died in peripheral hospitals, 249 were discharged home, and 228 were transferred to the secondary hospital. There was no effect of gender or age on likelihood of transfer; however, patients who had ingested oleander or paraquat were more likely to be transferred than were patients who had taken organophosphorus pesticides or other poisons. Estimated annual incidences of self-poisoning and fatal self-poisoning were 363 and 27 per 100,000 population, respectively, with an overall CFR of 7.4% (95% confidence interval 6.0-9.0). CONCLUSION: Fifty per cent of patients admitted to peripheral hospitals were discharged home, showing that CFRs based on secondary hospital data are inflated. However, while incidence of self-poisoning is similar to that in England, fatal self-poisoning is three times more common in Sri Lanka than fatal self-harm by all methods in England. Population based data are essential for making international comparisons of case fatality and incidence, and for assessing public health interventions.     

Challenges to integrating sexual health issues into reproductive health programs in Uzbekistan

This study examines the direction and result of efforts of nongovernmental organizations (NGOs) in the area of reproductive and sexual health in Uzbekistan. It focuses specifically on the institutional, structural, epidemiological, and cultural forces responsible for the exclusion of sexual health issues from reproductive health campaigns in the most populous Central Asian country. In Uzbekistan, as in other countries of the region, significant international support was given to NGOs providing reproductive health services in the mid-to-late-1990s, well into the early period of the HIV/AIDS pandemic and after the 1994 mandate of the International Conference on Population and Development for the inclusion of sexual health as a key reproductive health component. Examining the exclusion of sexual health issues from reproductive health campaigns in Uzbekistan highlights problems relating to time lags in program and evaluative development and the difficulties NGOs experienced in balancing donor-state agendas with recipient-state priorities. Findings question standard assumptions regarding the advantageous structural aspects of NGOs, in terms of flexibility, responsive agenda generation, and state independence.     

An evaluation of digital, split-site and traditional formats in conference poster sessions

The paper reports an evaluation of digital, split-site and traditional poster presentations at the Association for Medical Education in Europe (AMEE) conference in September 2004. The programme included 300 posters in 19 sessions, viewed, potentially, by 1265 conference participants, in parallel with other events. The instrument was a questionnaire of 16 open- and closed-format questions applied opportunistically and gaining 250 complete responses. Qualitative and quantitative analysis suggested that no one format was preferred. Each had different strengths and weaknesses relating to seeing and hearing the presenter and viewing the poster. Opportunities for discussion were highly valued.     

A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging

In this meta-analysis we compared thallium imaging (TI) and stress echocardiography (SE) in patients at risk for myocardial infarction (MI) scheduled for elective noncardiac surgery. Two searches of published articles were used to identify relevant articles. We included all studies that stated the criteria for a positive test and detailed the frequency of postoperative MI and in-hospital death. Data were abstracted by two authors and captured preoperative patient characteristics, study design, blinding, and outcome adjudication. We defined a positive test as a test with a reversible defect and, where possible, quantified the size of the defects in each study. MI and/or death were the only postoperative outcomes of interest. We calculated the sensitivity, specificity, and likelihood ratio (LR) and, where possible, the Receiver Operating Characteristic (ROC) curve of a cardiac event in each study. The LR and ROC were combined by meta-analyses using the random effects model. Heterogeneity was assessed using the I2 test. The search revealed 68 studies of 10,049 patients. There were 25 SE studies and 50 TI studies. There were 7 studies with a direct comparison of the two methodologies. The quality of studies differed; routine screening for MI was used more frequently in SE studies (47.8% versus 21.2%; P = 0.008) and screening dictated treatment more often after TI (72.1%) than after SE (46.3%) (P = 0.027). The LR for SE was more indicative of a postoperative cardiac event than TI (LR, 4.09; 95% CI, 3.21-6.56 versus 1.83; 1.59-2.10; P = 0.001). This difference was attributable to fewer false-negative SEs. There was no difference in the cumulative ROC curves from qualitative studies (SE, 0.80; 95% CI, 0.76-.84 versus TI, 0.75; 95% CI, 0.70-081). Again, the LR for a negative SE was less (0.23; 95% CI, 0.17-0.32 versus 0.44; 95% CI, 0.36-0.54). A moderate-to-large defect, seen in 14% of patients, by either method predicts a postoperative cardiac event (LR, 8.35; 95% CI, 5.6-12.45). This meta-analysis possesses the statistical power to demonstrate that SE has better negative predicative characteristics than TI. A moderate-to-large perfusion defect by either SE or TI predicts postoperative MI and death. We conclude the SE is superior to TI in predicting postoperative cardiac events.     

How I do it: cervical access for carotid artery stenting

Atypical aortic arch anatomy, vessel tortuosity, and extensive atherosclerotic disease in the aortic arch and great vessels represent significant risks for embolization during angioplasty and stenting of carotid occlusive lesions. The technique of cervical access to the proximal common carotid artery is demonstrated as a safer means for dealing with these problems. Combining endovascular and open surgical techniques can simplify and help ensure the safety of carotid stent procedures.