What is a safe waiting time for coronary artery bypass surgery?

To determine the factors that influenced doctors' prioritization and decisions on safe waiting time for coronary artery bypass surgery, 50 'paper patients', based on a random sample of cases who actually had surgery, were assessed by 33 clinicians. We used linear regression models to reflect the impact of clinical and non-clinical 'cues' on safe waiting time and priority decisions. The benefits of surgery tended to be over-estimated. For example, the average perceived gain in life expectancy for patients with left main-stem disease was 6.74 years. However, models incorporating only the perceptions of benefit as independent variables (i.e. the anticipated symptom reduction, MI risk reduction and life expectancy extension), had only modest explanatory power (mean R2 was 0.55 for safe waiting time, and 0.56 for priority decisions). Models which incorporated perceptions of benefit and the cases' clinical and non-clinical characteristics had generally much higher explanatory power (mean R2, 0.83 and 0.86, respectively). Lifestyle and demographic variables had much less impact on the doctors' judgements than the major clinical cues of angina severity and left main-stem stenosis. Demographic and lifestyle cues had different impacts on safe waiting time and priority for about 25% of doctors.      

Thrombosis in inflammatory bowel disease: clinical setting, procoagulant profile and factor V Leiden

Patients with inflammatory bowel disease have an increased frequency of thromboembolism, and microvascular thrombosis has been proposed as a contributory pathogenic factor. The mechanism of enhanced procoagulant activity is not understood. We examined the clinical setting of thromboembolic events in 52 patients with Crohn's disease or ulcerative colitis, and assessed the procoagulant laboratory profile, including Factor V Leiden, in a subset of 20 patients to identify procoagulant risk factors. Patients who developed thrombosis tended to be young; 60% of thrombotic events occurred in patients under 50 years. Multiple thromboembolic episodes occurred in 13% and unusual sites of thrombosis (e.g. intracardiac, cerebral, inominate veins) in 11%. No risk factor was identifiable in 52% of cases and two-thirds of thromboses occurred in an out-patient setting. The mortality rate was 8%. Evidence for inflammatory disease activity was found in only 45% of patients with ulcerative colitis at the time of the thromboembolic event, in contrast to 89% of those with Crohn's disease. Assays for specific coagulation defects were negative in all cases tested (protein S, C were normal in 17/17; anti-thrombin III, anti-phospholipid antibodies and activated protein C resistance were negative in 20/20, and only 1/20 patients was found to be heterozygous for Factor V leiden. Thrombosis in inflammatory bowel disease is important because it occurs in a young population, often in unusual sites, and has a high mortality. The development of thrombosis is related to active inflammatory disease in most patients with Crohn's disease but apparently not in those with ulcerative colitis. Since approximately half of the patients had no other identifiable risk factor, there remains a substantial group of patients with IBD who develop thrombosis for unknown reasons.      

Effect of freezing on the in vivo recovery of irradiated red cells

BACKGROUND: Transfusion-associated graft-versus-host disease can be prevented by gamma radiation of blood components. The increased use of blood components donated for patients by their family members has resulted in an increased demand for the storage and handling of irradiated units, and the ability to freeze the cells would allow storage beyond their current expiration date. STUDY DESIGN AND METHODS: To assess the effect of freezing and deglycerolization on irradiated red cells, studies of autologous radiolabeled red cell recovery were performed using normal volunteers. Each unit of CPDA-1 red cells was immediately divided into two equal volumes. Further handling of each half was identical except that one was irradiated (3500 cGy). The units were grouped under three protocols: I, irradiated on Day 0 and frozen on Day 5 (n = 4); II, irradiated on Day 7, rejuvenated, and frozen on Day 14 (n = 5); and III, irradiated on Day 14, rejuvenated, and frozen on Day 18 (n = 3). All cells were frozen for 3 to 10 months at -80 degrees C. RESULTS: Irradiated and control units showed no significant differences in supernatant potassium or hemoglobin. Autologous 24-hour posttransfusion recoveries (mean +/− SD) for the three groups were: I, 89.7 +/− 5.6 percent (control, 90.6 +/− 3.2%); II, 85.3 +/− 5.7 percent (control, 83.7 +/− 3.0%); and III, 79.5 +/− 1.4 percent (control, 82.6 +/− 5.2%). CONCLUSION: Irradiated red cells can be frozen after being stored under various conditions and can still meet established guidelines requiring 75-percent recovery 24 hours after transfusion.     

The stated and tacit impact of demographic and lifestyle factors on prioritization decisions for cardiac surgery

In a clinical judgement analysis, we used linear regression models to reflect the impact of clinical and non-clinical cues on priority decisions, by comparing the stated prioritization policies of 30 clinicians with their actual policies as revealed by an appraisal of 50 'paper patients'. Correspondence was modest for some cues, e.g. 25 doctors said they accounted for age, but age only had a significant bearing in the derived decision models of two doctors. Correspondence between the derived and expressed weights was greatest for clinical angina grade and the presence of left main stem stenosis. Correlation between the rank order of importance between the two models was poor for most of the cues, and statistically significant only for smoking. However, stated policies made it appear that lifestyle factors such as smoking habit would influence prioritization decisions for most clinicians but policies derived from actual prioritization decisions seldom related to lifestyle or demographic variables. There were significant differences in the degree of correlation between the two models according to the experience of the clinician. However, correspondence was not significantly better for doctors with cardiological training than those without. The overall contribution of demographic and lifestyle factors to decision making appears to be small, suggesting that they should be omitted from prioritization guidelines.      

Alu-primed polymerase chain reaction for regional assignment of 110 yeast artificial chromosome clones from the human X chromosome: identification of clones associated with a disease locus.

Over 400 yeast artificial chromosome (YAC) clones were isolated from the human X chromosome, and 110 of these were assigned to regions defined by chromosome translocation and deletion breakpoints. Polymerase chain reaction using Alu primers was applied to YAC clones in order to generate probes, to identify overlapping clones, and to derive "fingerprints" and sequence data directly from total yeast DNA. Several clones were identified in regions of medical interest. One set of three overlapping clones was found to cross a chromosomal translocation implicated in Lowe syndrome. The regional assignment of groups of YAC clones provides initiation points for further attempts to develop large cloned contiguous sequences, as well as material for investigation of regions involved in genetic diseases.     

Determination of the solute removal index for urea by using a partial spent dialysate collection method

In 22 hemodialysis patients, during a dialysis session, the solute removal index (SRI) for urea obtained from the use of a partial spent dialysate collection method was compared with that derived from the use of a total spent dialysate collection technique. The partial spent dialysate collection method was used to harvest a small representative sample of the total spent dialysate. The volumes of spent dialysate collected by the partial and the total spent dialysate collection methods were 1.7 +/- 0.4 L and 129.6 +/- 15.3 L, respectively. The total amount of urea nitrogen removed by dialysis as estimated by the partial spent dialysate collection method was similar to that determined by the total spent dialysate collection approach. As a result, the SRI value for urea obtained by the partial spent dialysate collection method (namely, 63% +/- 8%) correlated very well (r = 0.95, P < 0.001) with that derived by the total spent dialysate collection technique (namely, 62% +/- 8%). Our data suggest that it is feasible to use a simple partial spent dialysate collection method to obtain SRI results in patients treated with hemodialysis.     

Absence of mutations in the transforming growth factor-beta type II receptor in sporadic lung cancers with microsatellite instability and rare H-ras1 alleles

The transforming growth factor-beta type II receptor (RII) is commonly mutated in colon and gastric cancers with microsatellite instability (MI). We utilized our series of lung cancers with MI and rare alleles of the H-ras1 gene to determine the association between MI and RII mutations and searched the entire RII coding region in 33 lung cancers with MI by polymerase chain reaction-single-strand conformation polymorphism analysis. We found no mutations, and these data support other recent evidence that RII mutations rarely occur except in colon and gastric tumors with MI.      

Population sub-structuring among <Emphasis Type="Italic">Trypanosoma evansi</Emphasis> stocks

To investigate the population genetic structure of Trypanosoma evansi from domesticated animals, we have analysed 112 stocks from camels, buffaloes, cattle and horses using the tandemly repeated coding sequence (MORF2) and minisatellite markers 292 and cysteine-rich acidic integral membrane protein (CRAM). We recorded a total of six alleles at the MORF2 locus, seven at 292 and 12 at the CRAM loci. Nei’s genetic distance showed reduced allelic diversity between buffaloes and cattle stocks (1.2) as compared to the diversity between camels and buffaloes (3.75) and camels and cattle stock (1.69). The mean index of association (I _A = 0.92) significantly deviated from zero, and the average number of multilocus genotypes (G/N ratio) was 0.21. Twenty-four multilocus genotypes were defined from the combination of alleles at the three loci. The Kenyan sub-populations showed F _st = 0.28 and analysis of molecular variance showed significant divergence (22.7%) between the Laikipia, Kulal and Galana regions. The regional and host distribution of multi-locus genotypes significant population differentiation and high Nei’s genetic distances suggest existence of genetic sub-structuring within T. evansi stocks while the few multi-locus genotypes and deviation of association index from zero indicate the lack of recombination. In conclusion, this study reveals that some genetic sub-structuring does occur within T. evansi, which has a clonal population structure.