Magnetic resonance imaging and pathological findings in a case of canine idiopathic eosinophilic meningoencephalitis

A case of idiopathic eosinophilic meningoencephalitis in a six-month-old male Maremma shepherd dog is reported. The dog was referred with a four month history of progressive weakness and depression with loss of trained habits. Tendency to recumbency, disorientation, visual impairment, bilaterally decreased menace response and hindlimb conscious proprioception deficits were detected. Magnetic resonance imaging showed a diffuse hypointense signal involving the cerebral grey matter with enlargement of the cerebral sulci on T1-weighted and fast fluid-attenuated inversion recovery (FLAIR) sequences consistent with a diffuse necrosis or atrophy of the cortical grey matter. Histological examination revealed severe inflammatory infiltration mainly composed of eosinophils and macrophages in the subarachnoid space and in the superficial layer of the cerebral cortex where parenchymal rarefaction and necrosis of neurones were also evident. No parasites, cysts or fungi were detected, and an immunologically mediated disorder was suspected. Magnetic resonance imaging may represent a useful diagnostic tool to differentiate idiopathic eosinophilic meningoencephalitis from other inflammatory brain diseases of young dogs.

Endogenous stem and precursor cells for demyelinating diseases: an alternative for transplantation?

Remyelination can be very effective in human. However, this process ultimately fails in multiple sclerosis (MS). In this paper, we discuss the possibility of stimulating endogenous oligodendrocyte precursors to participate in remyelination in experimental models (rat and primate Callithrix jacchus) of MS through thyroid hormone (TH) administration. TH is in fact known to be a key signal in brain development, oligodendrocyte development and myelin protein gene expression regulation.

Molecular bases of type II protein S deficiency: the I203-D204 deletion in the EGF4 domain alters GLA domain function

OBJECTIVE

To characterize the first type II protein S (PS) deficiency affecting the epidermal growth factor (EGF)4 domain, a calcium-binding module with a poorly defined functional role.

PATIENTS

The proband suffered from recurrent deep vein thrombosis and showed reduced PS anticoagulant activity (31%), and total, free PS antigen and C4bBP levels in the normal range.

RESULTS

Reverse transcription-polymerase chain reaction analysis showed the presence of the IVSg-2A/T splicing mutation that, by activating a cryptic splice site, causes the deletion of codons Ile203 and Asp204. Free PS, immunopurified from proband's plasma, showed an altered electrophoretic pattern in native condition or in the presence of Ca2+. The recombinant PS (rPS) mutant showed reduced anticoagulant (<10%) and activated protein C-independent activities (24-38%) when compared with wild-type rPS (rPSwt). Binding of the rPS variant to phospholipid vesicles (Kd 235.7 +/- 30.8 nM, rPSwt; Kd 15.2 +/- 0.9 nM) as well as to Ca2+-dependent conformation-specific monoclonal antibodies for GLA domain was significantly reduced.

CONCLUSIONS

These data aid in the characterization of the functional role of the EGF4 domain in the anticoagulant activities of PS and in defining the thrombophilic nature of type II PS deficiency.

Thoracolumbar disc extrusion associated with extensive epidural haemorrhage: a retrospective study of 23 dogs

OBJECTIVES

To describe the clinical features and outcome in dogs suffering from thoracolumbar disc extrusion associated with extensive epidural haemorrhage (DEEH) and treated with extensive hemilaminectomy (from three to seven vertebrae).

METHODS

The records of 23 dogs with surgically confirmed DEEH were reviewed retrospectively.

RESULTS

All cases were characterised by rapid progression to severe neurological dysfunction (grade III, V and VI). Myelography was performed in 21 cases and showed an absence (16 cases) or attenuation (five cases) of contrast medium column along three to seven vertebrae. In two dogs, magnetic resonance imaging was accurate in confirming extradural compression due to disc material and haemorrhage, determining the extent of compression and side of the lesion. All cases were treated surgically with extensive hemilaminectomy involving all the compressed spinal segments. Twenty-one dogs (91 per cent) recovered and regained ambulatory function. Two dogs, without deep pain perception before surgery, did not improve. A two-year follow-up history was available for 15 dogs. Disc extrusion recurred in two dogs (9 per cent), two and 20 months after surgery.

CLINICAL SIGNIFICANCE

Extensive hemilaminectomy can adequately decompress the spinal cord after DEEH and may produce a recovery and recurrence rate similar to thoracolumbar disc extrusion not complicated by extensive epidural haemorrhage.

Principal component analysis of some oxidative stress parameters and their relationships in hemodialytic and transplanted patients

BACKGROUND

Oxidative stress profoundly influences the biochemistry of proteins and many other molecules in tissues of uremic patients. In three different groups of uremic patients, the concentrations of the free and bound pentosidine and low-molecular-weight-advanced glycoxydation end products (LMW-AGEs), carbonyls (LMW-C), advanced oxidation protein products (AOPP) and the total antioxidant power of serum were studied in order to determine the relationships between these factors in hemodialytic and transplanted patients.

PATIENTS AND METHODS

The above-mentioned parameters were determined in 10 subjects who were currently in hemodialysis (HD) treatment, 10 kidney transplanted patients with chronic renal failure (Tx-CRF), 10 kidney transplanted patients with normal renal function (Tx-N) and 10 healthy subjects (Ctr). The data matrix (40x7) was analyzed using the principal component analysis (PCA).

RESULTS

AGEs, carbonyls and AOPP were strongly correlated, while the total antioxidative serum capacity was not related to the other oxidative stress parameters. All the oxidative stress-related parameter values (AGEs, AOPP and LMW-C) in the Tx patients were similar to those of the control group, but were higher in the patients with chronic renal failure.

CONCLUSIONS

The correlation between early and advanced oxidative stress markers indicates that reactive oxygen species are involved in a common step in the mechanism of protein modification in all the patient examined. The relationships between carbonyls and AGEs (free, bound pentosidine and LMW-AGEs) support the hypothesis of "carbonyl stress". The common mechanism of the formation of oxidation products in healthy and diseased subject suggests their role of detoxification within kidney function. The total antioxidant power of the serum is not related to the other parameters, which indicates a possible role of molecule interfering.

The Gly972-->Arg IRS-1 variant is associated with type 1 diabetes in continental Italy

The Arg(972) insulin receptor substrate-1 (IRS-1) variant has been hypothesized to play a role in pancreatic beta-cell stimulus-coupled insulin secretion and survival. We analyzed the relations between type 1 diabetes and the Arg(972) IRS-1 variant. The frequency of the IRS-1 Arg(972) variant was investigated in two independent sets of unrelated patients: a case-control study and a collection of type 1 diabetes simplex families. In the former group, frequency of the IRS-1 Arg(972) variant was significantly increased in the patients (P = 0.0008), conferring an OR of 2.5. Transmission disequilibrium analysis of data obtained from the family set revealed that the Arg(972) IRS-1 variant was transmitted from heterozygous parents to affected probands at a frequency of 70.2% (P < 0.02). Arg(972) IRS-1 frequency showed no significant correlation with HLA genotypic risk for type 1 diabetes. Arg(972) IRS-1 type 1 diabetic patients also had lower fasting plasma concentrations of C-peptide at the time of diagnosis with respect to patients carrying the wild-type IRS-1 (0.49 +/- 0.058, n = 34, and 0.76 +/- 0.066, n = 134, respectively [means +/- SE]; P = 0.051). Our findings suggest a role for Arg(972) IRS-1 in conferring risk for the development of type 1 diabetes.

Intramedullary hemangioblastoma in a dog

A 6-year-old male Pointer dog was presented with a 4-week history of progressive hind-limb stiffness. Magnetic resonance imaging demonstrated a focal intramedullary lesion at T1 level with a pattern of ring contrast enhancement. At necropsy, a circumscribed intramedullary reddish-gray tumor was observed. Microscopically, the tumor was composed of thin-walled capillaries lined by endothelial cells and separated by pleomorphic cells (stromal cells) with a moderate degree of anisokaryosis. Immunohistochemically, the endothelial cells were positive for factor VIII-related antigen and the stromal cells were positive for neuron-specific enolase and vimentin. GFAP-positive astrocytes were occasionally observed within the tumor. Both endothelial and stromal cells were negative for synaptophysin, S-100 protein, pankeratin, smooth muscle actin, CD34, CD68, alpha1-antichymotrypsin, and lysozyme. The tumor showed considerable morphologic and immunohistochemical similarities with human hemangioblastoma, and hence the inclusion of this tumor type within the primary neoplasms of the canine central nervous system is suggested.

Diagnosing shoulder dislocations: time for a change of view

Posterior shoulder dislocations are uncommon, with frequent delays in the diagnosis. Three missed posterior dislocations within our hospital caused us to review the standard radiographs taken and the knowledge of this condition. A total of 40 radiographers and 40 casualty officers were surveyed. Of the radiographers, 63% felt it unnecessary to perform two views, they complained that laterals were difficult to obtain because of patient distress. All the radiographers surveyed knew of alternative views, but would not perform them unless specifically requested. Casualty officers claimed always to request two views, but did not in 75% of cases. Only 20% were aware of alternative views, all would accept one view for exclusion of a dislocation and none were aware of the radiographic signs associated with a posterior dislocation. Increased education and a change of view would assist in decreasing the rate of missed diagnoses.

Reduced activation of the Gla19Ala FX variant via the extrinsic coagulation pathway results in symptomatic CRMred FX deficiency

We characterized a symptomatic CRMred factor X (FX) deficiency produced by the Glu19Ala mutation in the gamma-carboxyglutamic-rich domain. FX activity levels in plasma were markedly reduced in prothrombin time assays (< 1-5%), whereas in activated partial thromboplastin assays (16%) and in RVV assays (17%) the reduction in activity mirrored that in antigen levels (17%). Activation of recombinant 19Ala-FX by factor IXa/factor VIIIa or RVV, and the activity in thrombin generation assays, were comparable to those of wild-type FX. Differently, complete activation of recombinant 19Ala-FX required a factor VIIa/TF concentration 30-fold higher than that of wild-type FX. The recombinant FVIIa significantly reduced PT values in 19Ala-FX reconstituted plasma, thus suggesting an alternative approach for treatment of FX deficiencies characterized by defective FX activation. The study of this FX deficiency provides an "in vivo" and "in vitro" model for the investigation of Gla domain interactions.

Pre-operative plasma levels of soluble fibrin polymers correlate with the development of deep vein thrombosis after elective neurosurgery

The role of blood tests in identifying patients at high risk for post-operative venous thromboembolism is undefined. The aim of this study was to evaluate the correlation between pre-operative plasma levels of soluble fibrin polymers (SFP), as determined by a recently developed enzyme-linked immunosorbent assay (ELISA) assay (TpP), and the incidence of deep vein thrombosis (DVT) after elective neurosurgery. Blood samples for SFP assay were withdrawn on the day before surgery from 157 consecutive patients undergoing elective neurosurgery for brain or spinal tumour. Patients were randomized to subcutaneous enoxaparin (40 mg once daily) or placebo given for at least 7 days. All patients wore compression stockings. DVT was assessed by bilateral venography, performed on day 8 +/- 1. Thirty-four patients (21.7%) were found to have a DVT, proximal in 11 (7%) and isolated distal in 23. Patients with and without DVT had a plasma pre-operative SFP levels of 6.2 +/- 4.6 and 1.9 +/- 1.5 mg/ml respectively (mean +/- SD) (P < 0.001). SFP levels in patients with proximal and isolated distal DVT were 7.6 +/- 5.1 and 5.5 +/- 4.4 microg/ml, respectively (P = 0.22). SFP cut-off levels categorized patients into three classes of DVT incidence. The incidence of DVT was 7.4% (6 of 81) for SFP levels < 2 microg/ml, 20.4% (11 of 54) for levels between 2 and 4.5 microg/ml, and 77.3% (17 of 22) for levels > 4.5 microg/ml (P= 0.001, Cochran-Mantel-Haenszel test). We conclude that pre-operative SFP levels correlate with post-operative DVT in elective neurosurgery patients. Further studies are required to define whether pre-operative SFP measurement could be useful in patient management.

The flow-function relationship in patients with chronic coronary artery disease and reduced regional function: a Doppler transesophageal and bidimensional transthoracic echocardiography study

BACKGROUND

Infra-low dose dipyridamole allows one to selectively explore myocardial viability. Transesophageal echocardiography Doppler measurement of left anterior descending coronary artery flow at baseline and following dipyridamole is an efficient tool to assess coronary flow response. Aim of this study was to determine the flow-function relationship during coronary vasodilatory stress in patients with coronary artery disease and baseline dysfunction.

METHODS AND RESULTS

Twelve patients with resting dyssynergies and 6 controls underwent assessment of regional function and of left anterior descending blood flow velocity. Flow and function were evaluated at rest and following infra-low dose dipyridamole (0.28 mg/Kg over 4 min). Controls showed a normal function at rest and after dipyridamole. Six patients ('Responders') with resting dyssynergies showed an improvement in segments of left anterior descending artery territory, whereas the other six ones ('Non-responders') showed no functional change. Controls and 'Responders' had similar values of resting peak diastolic left anterior descending artery flow velocity both at rest and after dipyridamole, whereas 'Non-responders' showed a blunted flow response to dipyridamole.

CONCLUSION

Myocardial segments with a resting dysfunction and a contractile reserve more often exhibit a residual flow response, whereas segments with fixed pattern show a flat flow response during coronary vasodilator stress.

A case of narcolepsy-cataplexy associated with distemper encephalitis

Narcolepsy associated with localized brain lesions is described in a 10-month-old Argentine Dogo. Neurological examination and MRI study suggested an inflammatory lesion of the left frontal lobe. Postmortem examination revealed diffuse encephalitis in the forebrain and marked necrotic lesions in the ventral pontine area. Immunohistochemistry for distemper virus antigen showed positive staining of the cytoplasm of many neurones of the pons and cerebral cortex. The pathological pattern was suggestive of post-vaccinal distemper encephalitis and the localization of the lesions was consistent with the neurological syndrome shown by the animal. At any event, the possibility of coincidental findings of distemper encephalitis and idiopathic narcolepsy must be accounted for.

Computer evaluation of left ventricular wall motion by means of shape-based tracking and symbolic description

Relevant cardiac pathologies manifest themselves as abnormal movements of left ventricular (LV) myocardial wall. An objective quantification is usually accomplished by computer analysis of temporal sequences of LV contours, as obtained by angiography or echography. However the choice of the reference system for measuring motion is still open to discussion. Simple geometric models cannot deal with the non-uniform myocardial fibre structure, which gives rise to non-rigid movements, asynchronous even in normal subjects. Therefore, a new method, Curvature-Motion (CM), was developed for improving motion assessment. Since LV contour shape and position change smoothly throughout the cardiac cycle, the points of curvature extremes are tracked frame-to-frame and selected by exploiting physiologically-based assumptions; then, the points lying among these landmarks are mapped onto sequential contours, according to local displacements and curvature changes. In this way point-trajectories are allowed to be curvilinear and different in systole and diastole. CM gave no significant differences in estimating the known motion of computer-generated contours (R=0.88), unlike other methods commonly adopted (R<0.80). Moreover, for the evaluation of regional wall motion of a preclassified set of angiographic contours, CM showed a greater specificity (88%) and accuracy (90%) with respect to the centre-line method (respectively 83% and 87%). Finally, a fuzzy logic inference system is proposed for translating significant motion patterns from the quantitative form, as provided by the analysis method, into the linguistic terms used by cardiologists in their clinical examinations. This makes the interpretation of quantitative analysis easier and allows medical users to interact with the system for searching particular properties in a single clinical report as well as in a large database.

Effects of reconstructive surgery for left ventricular anterior aneurysm on ventriculoarterial coupling

OBJECTIVE

To investigate left ventricular elastance (Emax) and effective arterial elastance (Ea) in postinfarction left ventricular aneurysm and evaluate their role in left ventricular function improvement after endoventricular circular patch plasty (EVCPP). Ventriculoarterial coupling has never been studied in these patients.

PATIENTS

22 consecutive patients (49 to 73 years) with left ventricular anterior aneurysm.

METHODS

Haemodynamic studies were done before and two weeks after EVCPP. Ventriculography was performed during atrial pacing (100 beats/min). Pressure/volume loops were analysed and derived parameters measured. Emax was estimated by applying the "single beat" method. Ea was calculated as end systolic pressure/stroke volume.

RESULTS

Left ventricular volumes and Ea decreased after surgery: end diastolic volume index from mean (SD) 155 (53) to 106 (29); end systolic volume index from 112 (51) to 62 (30) ml/m2 (both p < 0.0001); Ea from 1.65 (0.70) to 1.39 (0.41) mm Hg/ml (p = 0.04). Ejection fraction and Emax increased, without significant changes in stroke volume and work. The decrease in Ea was directly correlated with its preoperative value. The time interval between left ventricular pressure upstroke and peak systolic pressure decreased, from 237 (39) to 191 (41) ms (p < 0.0001), paralleling morphological changes in pressure tracings.

CONCLUSIONS

After EVCPP, ventriculoarterial coupling improves because of the fall in Ea caused by end systolic pressure reduction. The improvement is related to aortic pressure waveform changes and improved relaxation.

Symbolic representation and visual querying of left ventricular image sequences

In the evaluation of regional left ventricular function, relevant cardiac disorders manifest themselves not only in static features, such as shape descriptors and motion excursion in end-diastolic and end-systolic frames, but also in their temporal evolution. In common diagnostic practice, such dynamic patterns are analysed by direct inspection of frame sequences through the use of a moviola. This permits only a subjective and poorly defined evaluation of functional parameters, and definitely prevents a systematic and reproducible analysis of large sets of reports. Retrieval by contents techniques may overcome this limitation by permitting the automatic comparison of the reports in a database against queries expressing descriptive properties related to significant pathological conditions. A system is presented which is aimed at investigating the potential of this approach by supporting retrieval by contents from a database of cineangiographic or echocardiographic images. The system relies on a symbolic description of both geometrical and temporal properties of left ventricular contours. This is derived automatically by an image processing and interpretation module and associated with the report at its storage time. In the retrieval stage, queries are expressed by means of an iconic visual language which describes searched content properties over a computer screen. The system automatically interprets iconic statements and compares them against concrete descriptions in the database. This enables medical users to interact with the system to search for motion and shape abnormalities on a regional basis, in single or homogeneous groups of reports, so as to enable both prospective and retrospective diagnosis.

Regional and temporal nonuniformity of shape and wall movement in the normal left ventricle

Asymmetry of left ventricular (LV) shape and asynchrony of regional LV movement have been described in the normal human heart, but never correlated to each other. In 16 normal subjects, right anterior oblique ventriculography was used to obtain volumes, regional wall motion (centerline method) and curvature (windowed Fourier series approximation of contours) over the entire cardiac cycle. The apex had the greatest curvature, while the posterior wall had a negative end-diastolic curvature that decreased further at early-systole and became positive at end-systole. The anterior region had the greatest and the anteroapical region the least fractional shortening. Asynchrony was evident as a delayed contraction of the infero- and anteroapical regions, and as a greater rate of late-systolic shortening of the anterior wall than that of the apex. Shape changes and shortening were dyssynchronous in the apical regions where the greatest changes occurred at early diastole. Temporal and regional nonuniformity of shape and movement exists in normal subjects. Dyssynchrony between shape and regional contraction of the apical regions deserves further studies.

Acute hemodynamic effects of endogenous adenosine in patients with chronic heart failure

OBJECTIVE

The objective of this study was to assess the acute hemodynamic effects of endogenous adenosine accumulation in patients with chronic heart failure. Exogenously administered adenosine has been shown to reduce pulmonary vascular resistance and to increase cardiac index in normal subjects and in patients with pulmonary hypertension or end-stage biventricular heart failure. Endogenous adenosine accumulation can be provoked by dipyridamole.

METHODS AND RESULTS

Ultra-low-dose dipyridamole (0.07 mg/kg/min for 4 minutes) was administered in 20 patients with either symptomatic idiopathic (n = 12) or ischemic (n = 8) dilated cardiomyopathy and reduced left ventricular ejection fraction (mean 25%+/-5%). Hemodynamic variables were measured before and within 1 minute from the end of dipyridamole infusion. After dipyridamole administration, a mild but significant increase in heart rate (4.5%; p = 0.03) and reduction in mean blood pressure (6.8%; p < 0.001) without changes in right atrial pressure (p = NS) were detected. Dipyridamole increased cardiac output by 26.6% (p < 0.001), cardiac index by 24% (p < 0.001), and stroke volume by 19.8% (p < 0.001), with concomitant 24.6% reduction of systemic vascular resistance (p < 0.001). Moreover, dipyridamole reduced mean pulmonary artery pressure by 8.3% (p < 0.01) and pulmonary vascular resistance by 33.3% (p = 0.001), without changes in pulmonary wedge pressure (p = NS). A significant correlation between percent decrease from baseline in pulmonary and systemic vascular resistance (r = 0.66; p = 0.002) was found after administration of dipyridamole.

CONCLUSIONS

Endogenous adenosine accumulation induced by ultra-low-dose dipyridamole infusion acutely improves the hemodynamic profile, decreasing pulmonary and, to a lower extent, systemic vascular resistance and increasing cardiac index in patients with severe chronic heart failure.

Glucose transporters (GLUT 1, GLUT 3) mRNA in human placenta of diabetic and non-diabetic pregnancies

Glucose transporters (GLUT) catalyse the transport of glucose in many human tissues, including the placenta. On the other hand glucose concentrations can affect both glucose transport activity and level of GLUT mRNA and protein. Up to now very few studies, concerning GLUT in the placenta appeared and studies in vivo in human diabetic pregnancy are lacking. Therefore we investigated placental GLUT 1 and GLUT 3 mRNA in 10 diabetic (5 IDDM, 2 NIDDM, 3 GDM) and 9 non-diabetic women. GLUT 1 mRNA was found significantly correlated with maternal age (> 30 vs < 30 years: p < 0.025), with placental weight (> 575 vs < 575 g: p < 0.05), while GLUT 3 mRNA decreased significantly in late gestation of diabetic women (38-40 vs < 38 weeks: p < 0.025). In addition GLUT 3 was significantly lower in the diabetic than in non-diabetic women in late gestation. These preliminary results deserve to better elucidate feto-maternal carbohydrate metabolism at the placental level in normal as well as diabetic pregnancy.

Preoperative assessment of coronary artery disease in aortic stenosis: a dipyridamole echocardiographic study

BACKGROUND

The aim of this study was to establish the feasibility, safety, and diagnostic accuracy of the dipyridamole echocardiography test in patients with severe aortic valve stenosis for noninvasive detection of coexisting coronary artery disease.

METHODS

The high-dose dipyridamole echocardiography test was performed in 52 patients with severe aortic stenosis; all patients also underwent coronary angiography, independent of test results, before cardiac operation.

RESULTS

The dipyridamole echocardiography test was completed without major complications. One patient had transient atrial fibrillation that was reversed by aminophylline. Thirty-one patients (60%) had a negative test result; all had normal coronary arteries. Ten of the 21 patients (48%) with a positive test result had coexisting coronary artery disease. The positive predictive value of the dipyridamole echocardiography test for detection of coronary disease in patients with severe aortic stenosis was 48%. The negative predictive value was 100%. The sensitivity was 100% and the specificity was 74%.

CONCLUSIONS

Dipyridamole echocardiography is a safe and feasible tool in patients with severe aortic stenosis eligible for a cardiac operation. A negative test result reliably rules out a significant stenosis, whereas a positive one is much less accurate in predicting coronary artery disease.

Highly Efficient Palladium-Catalyzed Boronic Acid Coupling Reactions in Water: Scope and Limitations

The "ligandless" palladium acetate-catalyzed Suzuki cross-coupling reaction of ArX with aryl- and vinylboronic acids in water without organic cosolvent in the presence of tetrabutylammonium bromide is reported. Aryl bromides give high yields and considerably accelerate the coupling. A wide variety of functional groups can be tolerated. Aryl iodides, however, give incomplete conversion and aryl triflate coupling shows no improvement over reported conditions.

Dipyridamole stress echocardiography: state of the art 1996. EPIC (Echo Persantin International Cooperative) Study Group

Dipyridamole stress is the forerunner and prototype of pharmacological stress echo tests in the diagnosis of coronary artery disease. Among the various stress echo tests, it is probably the least technically demanding to perform and the easiest to interpret. Its accuracy is similar to dobutamine stress echocardiography but its feasibility is higher. The prognostic impact of dipyridamole stress echo has also been proven for presentation of hard end-points such as cardiac death. The safety and prognostic value of this test has been conclusively demonstrated as a result of extensive experience in large scale multicentre projects. Dipyridamole stress is many different tests in one: dipyridamole atropine is best for diagnosis; dipyridamole dobutamine or dipyridamole-exercise is highly sensitive for the detection of minor forms of coronary artery disease; low and high dose dipyridamole is best suited for prognostic stratification; infra-low dipyridamole with low dose dobutamine administration is probably best suited for selective myocardial viability identification. Each patient should have their own test, tailored on the basis of the clinical picture and the diagnostic issue.

The relative value of exercise-electrocardiography and dipyridamole stress echocardiography for risk stratification early after uncomplicated myocardial infarction. The EPIC (Echo Persantine International Cooperative) Study Group

BACKGROUND

Rational prognostic algorithm should be developed considering the logical progression of the information as it becomes available to the physician, with clinical data first, ECG data second and stress imaging data last. The aim of the present study was to assess in a clinically realistic fashion the relative prognostic value of exercise electrocardiography test (EET) and dipyridamole-echocardiography test (DET) early after first acute uncomplicated myocardial infarction.

METHODS AND RESULTS

Five hundred and forty-seven in-hospital patients (age = 56 +/- 9 years) with recent clinically uncomplicated first myocardial infarction, baseline echocardiographic findings of satisfactory quality, interpretable ECG and capability to exercise underwent a resting 2D echocardiogram, a DET and an EET at a mean of 10 days from the infarction and were followed up for 16.2 +/- 11 months. During the follow-up, there were 17 cardiac deaths, 19 non-fatal myocardial infarctions and 49 unstable angina. When cardiac death was considered as the only significant event, with multivariate analysis, peak dipyridamole Wall Motion Score Index was the only significant predictor (chi 2 = 5.66; p = 0.013; relative risk estimate = 4.7; confidence intervals = 1.35-16.08). In presence of a negative exercise electrocardiography test for both chest pain and electrocardiographic criteria, the death rate was 2%.

CONCLUSION

DET provides stronger information in comparison with historical and EET variables. However, a negative maximal EET is sufficient to identify a very low risk subset in whom additional testing may not be warranted.

Education for the nursing of children and their families: standards and guidelines for prelicensure and early professional education

To strengthen the preparation of nurses for care of children and families, standards and guidelines for prelicensure and early professional education were developed by a working group with broad-based input. Assumptions, theory, practice, and research underlying the standards and guidelines concerned the nature of health care, knowledge, teaching, learning, and evaluation. The 11 standards are presented and guidelines are illustrated. How they are implemented will depend on local resources and philosophies. Continued dialogue among nurse educators is needed to refine and develop the standards and guidelines.