A Systematic Review to Compare Chemical Hazard Predictions of the Zebrafish Embryotoxicity Test With Mammalian Prenatal Developmental Toxicity

Originally developed to inform the acute toxicity of chemicals on fish, the zebrafish embryotoxicity test (ZET) has also been proposed for assessing the prenatal developmental toxicity of chemicals, potentially replacing mammalian studies. Although extensively evaluated in primary studies, a comprehensive review summarizing the available evidence for the ZET's capacity is lacking. Therefore, we conducted a systematic review of how well the presence or absence of exposure-related findings in the ZET predicts prenatal development toxicity in studies with rats and rabbits. A two-tiered systematic review of the developmental toxicity literature was performed, a review of the ZET literature was followed by one of the mammalian literature. Data were extracted using DistillerSR, and study validity was assessed with an amended SYRCLE's risk-of-bias tool. Extracted data were analyzed for each species and substance, which provided the basis for comparing the 2 test methods. Although limited by the number of 24 included chemicals, our results suggest that the ZET has potential to identify chemicals that are mammalian prenatal developmental toxicants, with a tendency for overprediction. Furthermore, our analysis confirmed the need for further standardization of the ZET. In addition, we identified contextual and methodological challenges in the application of systematic review approaches to toxicological questions. One key to overcoming these challenges is a transition to more comprehensive and transparent planning, conduct and reporting of toxicological studies. The first step toward bringing about this change is to create broad awareness in the toxicological community of the need for and benefits of more evidence-based approaches.

Developing a Suite of Online Learning Modules on the Components of Next-Generation Sequencing Projects

This column describes a project funded by the Big Data to Knowledge initiative to develop online learning modules for researchers, clinicians, and informationists/librarians on aspects of next-generation sequencing projects. The modules describe a framework for next-generation sequencing projects, with particular emphasis placed on experimental design, ethical considerations, data storage, and data sharing. The author outlines how the modules were developed and summarizes their contents.

Rapid Aspirin Desensitization is Safe and Feasible in Patients With Stable and Unstable Coronary Artery Disease: A Single-Center Experience

AIMS

There are limited data on aspirin (ASA) desensitization for patients with coronary disease. We present our experience with a rapid nurse-led oral desensitization regimen in patients with aspirin sensitivity undergoing coronary angiography.

METHODS

This single-center retrospective observational study includes patients with a history of ASA sensitivity undergoing coronary angiography with intent to perform percutaneous coronary intervention (PCI).

RESULTS

Between January 2012 and January 2017, 24 patients undergoing coronary angiography for stable coronary disease (7 cases) or acute coronary syndromes (non-ST-segment myocardial infarction [NSTEMI; 8 cases], STEMI [9 cases]) underwent aspirin desensitization having reported previous reactions to aspirin. At initial presentation, previous sensitivity reactions were reported as: mucocutaneous reactions in 17 patients (urticaria in 3 [13%], nonurticarial rash in 6 [25%], angio-oedema in 8 [33%]), respiratory sensitivity in 4 (17%), and systemic anaphylactoid reactions in 3 (13%). Seventeen (71%) patients underwent PCI. Desensitization was acutely successful in 22 (92%) patients and unsuccessful in 2 (8%) patients who both had a single short-lived episode of acute bronchospasm treated successfully with nebulized salbutamol. Fifteen successfully desensitized patients completed 12 months of aspirin; no patient had recurrent hypersensitivity reaction. Aspirin was stopped prior to 12 months in 7 patients (replaced by warfarin [1 case], no antiplatelet or single antiplatelet clinically indicated and clopidogrel chosen [4 cases], patient choice without evidence of recurrent hypersensitivity [1 case], and death due to cardiogenic shock following STEMI [1 case]).

CONCLUSION

A rapid aspirin desensitization protocol is safe and effective across a broad spectrum of hypersensitivity reactions and clinical presentations.

An in vivo Model for the Assessment of Acute Fibrinolytic Capacity of the Endothelium

The effects on blood flow and plasma fibrinolytic and coagulation parameters of intraarterial substance P, an endothelium dependent vasodilator, and sodium nitroprusside, a control endothelium independent vasodilator, were studied in the human forearm circulation. At subsystemic locally active doses, both substance P (2-8 pmol/min) and sodium nitroprusside (2-8 μg/min) caused dose-dependent vasodilatation (p <0.001 for both) without affecting plasma concentrations of PAI-1, von Willebrand factor antigen or factor VIII:C activity. Substance P caused local increases in t-PA antigen and activity (p <0.001) in the infused arm while sodium nitroprusside did not. At higher doses, substance P increased blood flow and t-PA concentrations in the noninfused arm. We conclude that brief, locally active and subsystemic infusions of intraarterial substance P cause a rapid and substantial local release of t-PA which appear to act via a flow and nitric oxide independent mechanism. This model should provide a useful and selective method of assessing the in vivo capacity of the forearm endothelium to release t-PA acutely.

Analysis of differential gene expression mediated by clozapine in human postmortem brains

Clozapine is the only medication indicated for treating refractory schizophrenia, due to its superior efficacy among all antipsychotic agents, but its mechanism of action is poorly understood. To date, no studies of human postmortem brain have characterized the gene expression response to clozapine. Therefore, we addressed this question by analyzing expression data extracted from published microarray studies involving brains of patients on antipsychotic therapy. We first performed a systematic review and identified four microarray studies of postmortem brains from antipsychotic-treated patients, then extracted the expression data. We then performed generalized linear model analysis on each study separately, and identified the genes differentially expressed in response to clozapine compared to other atypical antipsychotic medications, as well as their associated canonical pathways. We also found a number of genes common to all four studies that we analyzed: GCLM, ZNF652, and GYPC. In addition, pathway analysis highlighted the following processes in all four studies: clathrin-mediated endocytosis, SAPK/JNK signaling, 3-phosphoinositide synthesis, and paxillin signaling. Our analysis yielded the first comprehensive compendium of genes and pathways differentially expressed upon clozapine treatment in the human brain, which may provide insight into the mechanism and unique efficacy of clozapine, as well as the pathophysiology of schizophrenia.

Guidance on assessing the methodological and reporting quality of toxicologically relevant studies: A scoping review

Assessments of methodological and reporting quality are critical to adequately judging the credibility of a study's conclusions and to gauging its potential reproducibility. To aid those seeking to assess the methodological or reporting quality of studies relevant to toxicology, we conducted a scoping review of the available guidance with respect to four types of studies: in vivo and in vitro, (quantitative) structure-activity relationships ([Q]SARs), physico-chemical, and human observational studies. Our aims were to identify the available guidance in this diverse literature, briefly summarize each document, and distill the common elements of these documents for each study type. In general, we found considerable guidance for in vivo and human studies, but only one paper addressed in vitro studies exclusively. The guidance for (Q)SAR studies and physico-chemical studies was scant but authoritative. There was substantial overlap across guidance documents in the proposed criteria for both methodological and reporting quality. Some guidance documents address toxicology research directly, whereas others address preclinical research generally or clinical research and therefore may not be fully applicable to the toxicology context without some translation. Another challenge is the degree to which assessments of methodological quality in toxicology should focus on risk of bias - as in clinical medicine and healthcare - or be broadened to include other quality measures, such as confirming the identity of test substances prior to exposure. Our review is intended primarily for those in toxicology and risk assessment seeking an entry point into the extensive and diverse literature on methodological and reporting quality applicable to their work.

The dancing heart

A woman with palliative breast cancer presents with dyspnoea and is noted to have an unusual electrocardiogram, with an alternating electrical axis observed. Subsequent echocardiogram demonstrates the classical findings of a large pericardial effusion causing 'electrical alternans' aptly illustrating why this rare phenomenon occurs.

Effects of body mass and water temperature on routine metabolism of American paddlefish Polyodon spathula

This study quantified the effects of temperature and fish mass on routine metabolism of the American paddlefish Polyodon spathula. Thermal sensitivity, as measured by Q(10) value, was low in P. spathula. Mean Q(10) was 1·78 while poikilotherms are generally expected to have Q(10) values in the 2·00-2·50 range. Mass-specific metabolism did not decrease with increased fish size to the extent that this phenomenon is observed in teleosts, as evidenced by a mass exponent (β) value of 0·92 for P. spathula compared with 0·79 in a review of teleost species. Other Acipenseriformes have exhibited relatively high β values for mass-specific respiration. Overall P. spathula metabolism appears to be more dependent on body mass and less dependent on temperature than for many other fishes. An equation utilizing temperature and fish mass to estimate gross respiration for P. spathula was derived and this equation was applied to respiratory data from other Acipenseriformes to assess inter-species variation. Polyodon spathula respiration rates across water temperature and fish mass appear most similar to those of Atlantic sturgeon Acipenser naccarii and white sturgeon Acipenser transmontanus.

Effects of temperature, salinity and body size on routine metabolism of coastal largemouth bass Micropterus salmoides

Routine metabolism (i.e. standard metabolism plus a low level of activity) of coastal largemouth bass Micropterus salmoides from Mobile-Tensaw Delta, AL, U.S.A. was examined as a function of temperature (15, 20, 25 and 30° C), salinity (0, 4, 8 and 12) and body mass (range 24-886 g) using flow-through respirometry. Functionally, a cubic relationship best described the effect of salinity on respiration; the magnitude of these effects increased with temperature and body mass. The best model predicted that specific respiration (mg O(2) g(-1) h(-1)) at temperatures >20° C was lowest at salinities of 0·0 and 9·7, and elevated at 3·2 and 12·0; salinity had little to no effect at temperatures ≤20° C. Respiration increased exponentially with temperature, but when compared with previously published respiration rates for M. salmoides from northern latitudes, predicted respiration was higher at cool temperatures and lower at high temperatures. The reduced energetic cost near the isosmotic level (i.e. c. 9) may be an adaptive mechanism to tolerate periods of moderate salinity levels and may help explain why M. salmoides do not flee an area in response to increased salinity. Further, these results suggest that salinity has high energetic costs for coastal populations of M. salmoides and may contribute to the observed slow growth and small maximum size within coastal systems relative to inland freshwater populations.

Evoked cortical activity and speech recognition as a function of the number of simulated cochlear implant channels

OBJECTIVES

(1) To determine if consonant-vowel-consonant (CVC) syllables [Hillenbrand J, Getty L, Clark M, Wheeler K. Acoustic characteristics of American English vowels. J Acoust Soc Am 1995;97:3099-3111] could be used to evoke cortical far field response patterns in humans, (2) to characterize the effects of cochlear implant-simulated channel number on the perception and physiological detection of these same CVC stimuli, and (3) to define the relationship between perception and the morphology of the physiological responses evoked by these speech stimuli.

METHODS

Ten normal hearing monolingual English speaking adults were tested. Unprocessed CVC naturally spoken syllables, containing medial vowels, as well as processed versions (2, 4, 8, 12, and 16 spectral channels) were used for behavioral and physiological testing.

RESULTS

(1) CVC stimuli evoked a series of overlapping P1-N1-P2 cortical responses. (2) Amplitude of P1-N1-P2 responses increased as neural conduction time (latency) decreased with increases in the number of spectral channels. Perception of the CVC stimuli improved with increasing number of spectral channels. (3) Coinciding changes in P1-N1-P2 morphology did not significantly correlate with changes in perception.

CONCLUSIONS

P1-N1-P2 responses can be recorded using CVC syllables and there is an effect of channel number on the latency and amplitude of these responses, as well as on vowel identification. However, the physiological detection of the acoustic changes does not fully account for the perceptual performance of these same syllables.

SIGNIFICANCE

These results provide evidence that it is possible to use vocoded CVC stimuli to learn more about the physiological detection of acoustic changes contained within speech syllables, as well as to explore brain-behavior relationships.

Three Evidence Based Methods to Compensate for a Lack of Subject Background when Ordering Chemistry Monographs

Objective – The aim of this article is to present evidence based methods for the selection of chemistry monographs, particularly for librarians lacking a background in chemistry. These methods will be described in detail, their practical application illustrated, and their efficacy tested by analyzing circulation data. Methods – Two hundred and ninety-five chemistry monographs were selected between 2005 and 2007 using rigorously-applied evidence based methods involving the Library's integrated library system (ILS), Google, and SciFinder Scholar. The average circulation rate of this group of monographs was compared to the average circulation rate of 254 chemistry monographs selected between 2002 and 2004 when the methods were not used or were in an incomplete state of development. Results – Circulations/month were on average 9% greater in the cohort of monographs selected with the rigorously-applied evidence based methods. Further statistical analysis, however, finds that this result can not be attributed to the different application of these methods. Conclusion – The methods discussed in this article appear to provide an evidence base for the selection of chemistry monographs, but their application does not change circulation rates in a statistically significant way. Further research is needed to determine if this lack of statistical significance is real or a product of the organic development and application of these methods over time, making definitive comparisons difficult.

Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary intervention

OBJECTIVE

To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance.

DESIGN

Analysis of prospectively collected data.

SETTING

Tertiary centre NHS hospital in the north east of England.

PARTICIPANTS

Five cardiologists carrying out percutaneous coronary interventions between January 2003 and December 2006.

MAIN OUTCOME MEASURES

In-hospital major adverse cardiovascular and cerebrovascular events (in-hospital death, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accident) analysed against the logistic north west quality improvement programme predicted risk, for each operator. Results are displayed as funnel plots summarising overall performance for each operator and cumulative funnel plots for an individual operator's performance on a case series basis.

RESULTS

The funnel plots for 5198 patients undergoing percutaneous coronary interventions showed an average observed rate for major adverse cardiovascular and cerebrovascular events of 1.96% overall. This was below the predicted risk of 2.06% by the logistic north west quality improvement programme risk score. Rates of in-hospital major adverse cardiovascular and cerebrovascular events for all operators were within the 3sigma upper control limit of 2.75% and 2sigma upper warning limit of 2.49%.

CONCLUSION

The overall in-hospital major adverse cardiovascular and cerebrovascular events rates were under the predicted event rate. In-hospital rates after percutaneous coronary intervention procedure can be monitored successfully using funnel and cumulative funnel plots with 3sigma control limits to display and publish each operator's outcomes. The upper warning limit (2sigma control limit) could be used for internal monitoring. The main advantage of these charts is their transparency, as they show observed and predicted events separately. By this approach individual operators can monitor their own performance, using the predicted risk for their patients but in a way that is compatible with benchmarking to colleagues, encapsulated by the funnel plot. This methodology is applicable regardless of variations in individual operator case volume and case mix.

Impact of catheter sizes and intracoronary glyceryl trinitrate on the TIMI frame count when digital angiograms are acquired at lower frame rates during elective angiography and PCI

The TIMI frame count (TFC) is a useful measure of coronary flow. To be widely applicable, the effect of different catheter sizes and the use of intracoronary glyceryl trinitrate (ICGTN) must be determined when films are acquired at lower acquisition rates (12.5 frames/s, f/s).

METHODS

We compared 6F versus 5F diagnostic catheters (n = 44), 6F versus 7F diagnostic catheters (n = 45) and 6F diagnostic versus 7F guide catheters (n = 44). In the nitrate angiography group (n = 141), coronary angiography was performed before and after 200 micrograms of ICGTN. In the nitrate percutaneous coronary intervention (PCI) group (n = 48), coronary angiography was performed before and after 200 micrograms of ICGTN after the completion of the elective PCI procedure.

RESULTS

The mean difference in the uncorrected TFC using 6F and 5F was 0.02 (95 % CI -0.5, 0.6; P = 0.9); using 6F and 7F diagnostic catheters it was 0.3 (95% CI -0.49, 1.1; p = 0.4); and using 6F diagnostic and 7F guide catheters it was 0.4 (95% CI -2.6, 3.4; P = 0.7) respectively. In the nitrate angiography group, the uncorrected TFC before and after ICGTN was 13.1+/-6.2 and 15+/-7.5 (equivalent to 31.4+/-14.9 and 36+/-2 at 30 f/s), with a mean difference of 1.9 (95% CI 1.3, 2.5; P = or <0.0001). In the nitrate PCI group, the uncorrected TFC before and after ICGTN administration was 9.2+/-3.7 and 10.3+/-4.2 (equivalent to 22.6+/-9.6 and 25.2+/-11 at 30 f/s) respectively with a mean difference between the two injections of 1.2 (95% CI -0.4, 1.9; P = 0.003).

CONCLUSION

We have demonstrated that the catheter sizes did not significantly affect the TFC when angiography was performed at 12.5f/s. The use of ICGTN significantly increased the TFC in both normal and diseased coronary arteries. This effect was also observed when ICGTN was administered into the culprit vessels after the completion of the elective PCI procedure. This effect must be considered when investigating the impact of specific treatments or drugs on coronary flow.

External validation of established risk adjustment models for procedural complications after percutaneous coronary intervention

BACKGROUND

Workable risk models for patients undergoing percutaneous coronary intervention (PCI) are needed urgently.

OBJECTIVE

To validate two proposed risk adjustment models (Mayo Clinic Risk Score (MC), USA and North West Quality Improvement Programme (NWQIP), UK models) for in-hospital PCI complications on an independent dataset of relatively high risk patients undergoing PCI.

SETTING

Tertiary centre in northern England.

METHODS

Between September 2002 and August 2006, 5034 consecutive PCI procedures (validation set) were performed on a patient group characterised by a high incidence of acute myocardial infarction (MI; 16.1%) and cardiogenic shock (1.7%). Two external models-the NWQIP model and the MC model-were externally validated.

MAIN OUTCOME MEASURE

Major adverse cardiovascular and cerebrovascular events: in-hospital mortality, Q-wave MI, emergency coronary artery bypass grafting and cerebrovascular accidents.

RESULTS

An overall in-hospital complication rate of 2% was observed. Multivariate regression analysis identified risk factors for in-hospital complications that were similar to the risk factors identified by the two external models. When fitted to the dataset, both external models had an area under the receiver operating characteristic curve >or=0.85 (c index (95% CI), NWQIP 0.86 (0.82 to 0.9); MC 0.87(0.84 to 0.9)), indicating overall excellent model discrimination and calibration (Hosmer-Lemeshow test, p>0.05). The NWQIP model was accurate in predicting in-hospital complications in different patient subgroups.

CONCLUSIONS

Both models were externally validated. Both predictive models yield comparable results that provide excellent model discrimination and calibration when applied to patient groups in a different geographic population other than that in which the original model was developed.

Intra-aortic counterpulsation does not improve coronary flow early after PCI in a high-risk group of patients: observations from a randomized trial to explore its mode of action

The intra-aortic balloon pump (IABP) is the most commonly used temporary cardiac assist device. The precise role and the mechanism of any benefit in high-risk patients undergoing percutaneous coronary intervention (PCI) have not been fully determined. We hypothesized that the use of an IABP following PCI in high-risk non-shocked patients would immediately increase coronary blood flow, tissue perfusion and hence preserve left ventricular function.

METHODS

Predefined high-risk, but non-shocked, patients were randomized to either an IABP or no IABP following PCI. Angiography was performed pre-PCI, immediately post-PCI and 10 minutes after the completion of the procedure. TIMI flow grade (TFG), TIMI frame count (TFC) and myocardial blush grade (MBG) were measured. Echocardiographic wall motion index (WMI) was measured on days 1 and 30 following PCI.

RESULTS

Of 33 patients, 17 received IABP and 16 did not. At final angiography, the TFG was 2.8 +/- 0.7 and 2.9 +/- 0.3 (p = 0.6), the TFC was 19.9 +/- 23 and 16.9 +/- 16.9 (p = 0.7), and the MBG was 2.5 +/- 0.9 and 2.5 +/- 0.7 (p = 0.9) in the IABP and the no-IABP arms. The WMI on day 1 was 1.7 +/- 0.4 and 1.7 +/- 0.4 (p = 0.7), and on day 30, it was 1.5 +/- 0.4 and 1.5 +/- 0.4 (p = 0.9). There was no difference in the total sum of ST-segment elevation prior to PCI (12.6 +/- 7.7 vs. 13.5 +/- 7.9; p = 0.8), nor in the summed ST change in subsequent electrocardiograms (ECGs) to 48 hours in both of the groups.

CONCLUSION

Whether an IABP is of any benefit in non-shocked, but high-risk, patients undergoing PCI remains to be established, but any potential benefit does not appear to be associated with early improvement in coronary flow. Whether the insertion of an IABP improves coronary flow beyond 10 minutes is not known. However, the IABP did not significantly affect subsequent left ventricular wall motion index or ECG ST-segment resolution in this study.

Should patients in cardiogenic shock undergo rescue angioplasty after failed fibrinolysis: comparison of primary versus rescue angioplasty in cardiogenic shock patients

BACKGROUND

Trials of rescue angioplasty (rPCI) following failed fibrinolysis have excluded patients with cardiogenic shock and the benefit of rPCI in this setting is unknown. We compared the clinical, angiographic characteristics, 30-day and 1-year outcomes of cardiogenic shock patients undergoing rPCI with those undergoing primary percutaneous coronary intervention (PPCI).

METHODS

Of the 171 patients undergoing PCI for cardiogenic shock between 1994 and 2005 at our institution, the indication was for PPCI in 65 and rPCI in 59 patients. Clinical, procedural, 30- day and 1-year mortality data were compared.

RESULTS

There were no differences between the cohorts with regard to clinical and pre-PCI angiographic variables, except that patients who underwent rPCI were more likely to be interhospital transfers (64% vs. 43%; p = 0.02) and had a longer door-to-balloon time (median 298 [IQR 395 to 180] minutes in the rPCI group vs. 131 [IQR 215 to 90] minutes in the PPCI group; p <0.01). Glycoprotein IIb/IIIa inhibitors were used less often (20% vs. 42%; p = 0.01), but use of stents was similar in both groups. Patients undergoing rPCI had a lower rate of final TIMI 3 flow grade (56% vs. 74%; p = 0.04) and a higher 1-year mortality (71% vs. 49%; p = 0.01). In the patients with final TIMI flow 3, 1-year mortality was higher in the rPCI group (61% vs. 37%; p = 0.04). In patients with successful procedures (survived procedure, no emergency CABG, TIMI 3 flow), 1-year mortality was higher in the rPCI group (59% vs. 33%; p = 0.02). One-year mortality was 85% in both groups if the procedure was unsuccessful. One-year mortality in patients >70 years old with cardiogenic shock undergoing rPCI was 100% (n = 15) and 70% (n = 14) with PPCI. Rescue angioplasty, anterior myocardial infarction, multivessel disease and postprocedure TIMI flow grade <3 were found to be independent predictors of mortality at 30 days.

CONCLUSIONS

In the setting of cardiogenic shock, rPCI patients were treated later than those undergoing PPCI. They had a lower final TIMI 3 flow and higher 1-year mortality. Even patients with a successful rPCI procedure had a higher 1-year mortality than those with a successful PPCI. Rescue angioplasty in the setting of cardiogenic shock was found be an independent predictor of mortality. Rescue angioplasty in elderly patients in cardiogenic shock (>75 years) may be a futile treatment. Efforts should be made to improve reperfusion and survival in these patients, possibly by either adopting PPCI for all patients presenting with ST-elevation acute myocardial infarction or, if this is not logistically possible, adopting PPCI for selected high-risk patients or early referral for rPCI in high-risk groups receiving fibrinolysis.

Early invasive versus conservative treatment in patients with failed fibrinolysis--no late survival benefit: the final analysis of the Middlesbrough Early Revascularisation to Limit Infarction (MERLIN) randomized trial

BACKGROUND

Early (30 days) and midterm (6 months) clinical outcomes in trials comparing rescue angioplasty (rescue percutaneous coronary intervention [rPCI]) with conservative treatment of failed fibrinolysis complicating ST-segment elevation myocardial infarction have shown variable results. Whether early rPCI confers late (up to 3 years) clinical benefits is not known.

METHODS

The MERLIN trial compared rPCI and a conservative strategy in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction. Three hundred seven patients with electrocardiographic evidence of failure to reperfuse at 60 minutes were included. Patients in cardiogenic shock were excluded. Thirty-day and 1-year results have been reported. Results of 3 years of follow-up are presented.

RESULTS

Three-year mortality in the conservative arm and rPCI, respectively, was 16.9% versus 17.6% (P = .9, relative difference [RD] -0.8, 95% CI [-9.3 to 7.8]). Death rates were similar (3.9% vs 3.2%) between 1- and 3-year follow-up, respectively. The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularization, or heart failure was significantly higher in the conservative arm (64.3% vs 49%, P = .01, RD 15.3, 95% CI [4.2-26]). There was no significant difference in the rate of reinfarction (0.7% vs 0.7%) or heart failure (1.3% vs 2.7%) between 1 and 3 years between the conservative and rPCI arms, respectively. The incidence of subsequent unplanned revascularization at 3 years was significantly higher in the conservative arm (33.8% vs 14.4%, P < .01, RD 19.4, 95% CI [10-28.7]), most of which occurred within 1 year; the rates between 1 and 3 years were 3.9% in the conservative arm versus 2% in the rPCI arm. There was a trend toward fewer strokes in the conservative arm at 3 years (conservative arm 2.6% vs rPCI 6.5%, P = .1, RD -3.9%, 95% CI [-9.4 to 0.8]), with similar stroke rates (1.3% vs 1.3%) between 1- and 3-year follow-up.

CONCLUSIONS

Rescue angioplasty did not confer a late survival advantage at 3 years. The composite end point occurred less often in the rPCI arm mainly because of fewer unplanned revascularization procedures in the early phase of follow-up. The highest risk of clinical events in patients with failed reperfusion is in the first year, beyond which the rate of clinical events is low.

A prospective randomised controlled trial to determine the early and late reactions after the use of iopamidol 340 (Niopam™) and iomeprol 350 (Iomeron®) in cardiac catheterisation

A new generation of intravascular contrast agents, the non-ionic monomers have safety profiles that are superior to those of older ionic compounds. There are, however, significant differences between these agents.

AIM

The aim of this study was to determine the incidence of early (<24h) and late (>24h to 7 days) reactions to two non-ionic contrast agents currently used during cardiac catheterisation: iopamidol 340 (Niopam Bracco UK Ltd.) and iomeprol 350 (Iomeron Bracco UK Ltd.).

METHODS

This was a prospective, randomised, double blinded trial. One thousand nine hundred and eighty-five patients undergoing cardiac catheterisation received one of the following contrast agents on a weekly basis: iopamidol 340 (Niopam) and iomeprol 350 (Iomeron). Reactions that were possibly related to the contrast agents were recorded on predefined data collection forms during the first 24h of the procedure (early reaction) and after 24h to 7 days (late reaction) by means of a questionnaire.

RESULTS

The baseline characteristics were matched in both the groups. There was no significant difference in the incidence of heat sensation experienced between the two groups (p=0.1). Early non-heat reactions occurred in 2.7% of patients receiving iopamidol 340 (Niopam) and 4% of those receiving iomeprol 350 (Iomeron) (p=0.1). Significant electrocardiographic changes were recorded in 1.7% of patients who received iopamidol 340 (Niopam), and 1% of those who received iomeprol 350 (Iomeron) (p=0.2). Bradycardia occurred more frequently in the iopamidol 350 group (0.8%) compared to the iomeprol 350 group (0.1%) p=0.02. Late reactions occurred in 16.2% of those receiving iopamidol 340 (Niopam) and 21.7% of those receiving iomeprol 350 (Iomeron) (p=0.02). A total of 23 (3.7%) patients in the iopamidol group and 39 (6.2%) patients in the iomeprol group reported nausea, p=0.01.

CONCLUSIONS

The incidence of early adverse reactions was similar with the two non-ionic contrast agents. Although bradycardia was slightly more frequent using iopamidol 340, nausea was reported more commonly 24h after the procedure in patients receiving Iomeron 350 (Iomeron). We conclude that there were only minor clinical differences between these agents; both are safe and well tolerated.

Successful thrombus extraction with the Rescue thrombus management system during acute percutaneous coronary intervention improves flow but does not necessarily restore optimal myocardial tissue perfusion

We determined the effectiveness of the Rescue device in restoring flow and achieving optimal tissue perfusion during percutaneous coronary intervention (PCI) in thrombus-laden coronary arteries.

METHODS

A total of 30 patients with an acute coronary syndrome underwent PCI using the Rescue device.

RESULTS

The mean age was 65.5 +/- 9.8 years. Although the Rescue device could not be passed across the lesion in 6 (20%) cases, debris was aspirated in 26 (87%). The uncorrected TIMI frame count improved following the use of the Rescue device and improved further at the completion of PCI (92.2 +/- 23.9 pre-PCI vs. 38.7 +/- 31.3 post-Rescue vs. 21.96 +/- 24 post-PCI, P < 0.0001). The thrombus score improved from 4 +/- 0 to 2.2 +/- 1.29 to 0.86 +/- 1.4 (P < 0.0001). TIMI flow grade (TFG) 3 was restored in 60% of cases following the Rescue device and in 87% after PCI. Myocardial blush grade 3 occurred in only 13% of patients following the Rescue device and 37% of patients after PCI.

CONCLUSION

These data suggest that the Rescue device can aspirate considerable amounts of debris in the majority of patients and significantly improves the angiographic epicardial coronary blood flow. How effective such a device is in improving tissue perfusion and, thereby, clinical outcomes for patients remains to be seen.

Superficial siderosis

BACKGROUND

Superficial siderosis (SS) of the CNS is caused by repeated slow hemorrhage into the subarachnoid space with resultant hemosiderin deposition in the subpial layers of the brain and spinal cord. Despite extensive investigations, the cause of bleeding is frequently undetermined.

OBJECTIVES

To review the clinical and imaging features of 30 consecutive patients with SS and provide insights into the underlying causes of subarachnoid bleeding in this disabling disorder.

METHODS

The authors reviewed the medical records of 30 consecutive patients with clinical and MRI evidence of SS.

RESULTS

The commonest neurologic manifestations included gait ataxia and hearing impairment. A clinical history of subarachnoid hemorrhage was relatively rare. Possible predisposing conditions were identified on history in 22 patients, the commonest being a prior trauma (15 patients). In addition to the characteristic MRI findings of SS, 18 patients had abnormalities on MRI possibly related to chronic bleeding. The most common of these was the presence of a fluid-filled collection in the spinal canal seen in 14 patients.

CONCLUSIONS

A history of prior subarachnoid hemorrhage is often absent in patients with superficial siderosis (SS). A past history of trauma is common. Prior intradural surgery may be an additional risk factor. Xanthochromia or the presence of red blood cells in the CSF is a common finding. Only rarely does angiography demonstrate the bleeding source. The presence of a fluid-filled collection in the spinal canal is a common finding on MRI and is likely related to the SS. With longitudinally extensive cavities, a dynamic CT myelogram may help localize the defect and direct the site of laminectomy. Surgical repair of a dural defect, if present, should be considered. Surgical correction of bleeding should be documented by CSF examination months after surgery. Friable vessels in the dural defect are a possible source of the chronic bleeding.

A randomized trial of prophylactic antiarrhythmic agents (amiodarone and sotalol) in patients with atrial fibrillation for whom direct current cardioversion is planned

Antiarrhythmic agents enhance maintenance of sinus rhythm (SR) after direct current cardioversion (DCC) for atrial fibrillation but there are few comparative trials.

BACKGROUND

The aims of the study were (1) to establish whether patients successfully cardioverted to SR are more likely to stay in SR over 6 months if taking amiodarone or sotalol, and if so, to establish whether one agent is better than the other; (2) to establish whether taking amiodarone or sotalol is better at achieving chemical cardioversion within the 6 weeks before DCC; and (3) to establish whether DCC is more likely to be successful on a drug.

METHODS

Randomized, prospective, nonblinded, controlled study of treatment with either amiodarone (n = 27), sotalol (n = 36), or no antiarrhythmic agent (n = 31).

RESULTS

Chemical cardioversion occurred in 7 patients in the amiodarone group (A), 7 patients in the sotalol group (S), but none in the no-antiarrhythmic group (N). A total of 33 (92%) patients in the sotalol group, 22 (81%) patients in the amiodarone group, and 23 (74%) patients in the no-antiarrhythmic group were in SR after cardioversion. Of the original cohort of patients, 17 (63%) patients in the amiodarone group remained in SR at 6-month follow-up, compared with 14 (39%) in the sotalol group and 5 (16%) in the no-antiarrhythmic group (A vs N, P < .0002, P < .0006B [after Bonferroni correction]; A vs S, P = .05, P = .15B; and S vs N, P = .03, P = .09B).

CONCLUSIONS

Amiodarone and sotalol achieved chemical cardioversion before planned electrical cardioversion in 26% and 19% of patients, respectively. After successful cardioversion, amiodarone appears better than sotalol at maintaining SR at 6 months.

Prospective, randomised, controlled trial to study the effect of intracoronary injection of verapamil and adenosine on coronary blood flow during percutaneous coronary intervention in patients with acute coronary syndromes

OBJECTIVES

To study the impact of injection of verapamil and adenosine in the coronary arteries on TIMI (Thrombolysis in Myocardial Infarction) frame count (TFC) after percutaneous coronary intervention (PCI) in patients with an acute coronary syndrome (ACS).

METHODS

Prospective, randomised, controlled study of the intracoronary administration of normal saline versus verapamil versus adenosine in patients undergoing PCI in the setting of an ACS, even when flow is visually established to be normal or near normal. Patients were randomised to receive verapamil (n = 49), adenosine (n = 51) or normal saline (n = 50) after PCI. Quantitative angiography, TIMI flow grade (TFG), TFC and myocardial blush grade were assessed before PCI, after PCI and after drugs were given. Wall motion index (WMI) was measured at days 1 and 30.

RESULTS

9 patients in the verapamil group developed transient heart block, not seen with adenosine (p <or= 0.001). Compared with saline, coronary flow measured by TFC improved significantly and WMI improved slightly but insignificantly in both the verapamil (TFC: p = 0.02; mean difference in improvement in WMI: 0.09, 95% confidence interval (CI) 0.015 to 0.17, p = 0.02) and the adenosine groups (TFC: p = 0.002; mean difference in improvement in WMI: 0.08, 95% CI 0.004 to 0.16, p = 0.04). The improvements in TFC and WMI did not differ significantly between the verapamil and the adenosine groups (TFC: p = 0.2; mean difference in improvement in WMI: 0.01, 95% CI -0.055 to 0.08, p = 0.7, respectively).

CONCLUSION

Administration of verapamil or adenosine significantly improves coronary flow and WMI after PCI in the setting of an ACS. Flow and WMI did not differ significantly between verapamil and adenosine but verapamil was associated with the development of transient heart block.

One year results of the Middlesbrough early revascularisation to limit infarction (MERLIN) trial

OBJECTIVE

To report one year results of the MERLIN (Middlesbrough early revascularisation to limit infarction) trial, a prospective randomised trial comparing the strategy of coronary angiography and urgent revascularisation with conservative treatment in patients with failed fibrinolysis complicating ST segment elevation myocardial infarction (STEMI). The 30 day results have recently been published. At the planning stage of the trial, it was determined that follow up of trial patients would continue annually to three years to determine whether late benefit occurred.

SUBJECTS

307 patients who received a fibrinolytic for STEMI but failed to reperfuse early according to previously described ECG criteria and did not develop cardiogenic shock.

METHODS

Patients were randomly assigned to receive either emergency coronary angiography with a view to proceeding to urgent revascularisation (rescue percutaneous coronary intervention (rPCI) arm) or continued medical treatment (conservative arm). The primary end point was all cause mortality at 30 days. The secondary end points included the composite end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure at 30 days. The same end points were evaluated at one year and these results are presented.

RESULTS

All cause mortality at one year was similar in the conservative arm and the rPCI arm (13.0% v 14.4%, p = 0.7, risk difference (RD) -1.4%, 95% confidence interval (CI) -9.3 to 6.4). The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure was significantly higher in the conservative arm (57.8% v 43.1%, p = 0.01, RD 14.7%, 95% CI 3.5% to 25.5%). This was driven almost exclusively by a significantly higher incidence of subsequent unplanned revascularisation in the conservative arm (29.9% v 12.4%, p < 0.001, RD 17.5%, 95% CI 8.5% to 26.4%). Reinfarction and clinical heart failure were numerically, but not statistically, more common in the conservative arm (14.3% v 10.5%, p = 0.3, RD 3.8%, 95% CI -3.7 to 11.4, and 31.2% v 26.1%, p = 0.3, RD 5.0%, 95% CI -5.1 to 15.1). There was a strong trend towards fewer strokes in the conservative arm (1.3% v 5.2%, p = 0.06, RD -3.9%, 95% CI -8.9 to 0.06).

CONCLUSION

At one year of follow up, there was no survival advantage in the rPCI arm compared with the conservative arm. The incidence of the composite secondary end point was significantly lower in the rPCI arm, but this was driven almost entirely by a highly significant reduction in the incidence of further revascularisation.

Predictors of outcome after percutaneous treatment for cardiogenic shock

OBJECTIVES

To determine predictors of outcome after percutaneous coronary intervention (PCI) in patients with cardiogenic shock complicating acute myocardial infarction.

METHODS

Retrospective analysis of a cohort of 113 patients undergoing emergency coronary angiography and attempted PCI for cardiogenic shock complicating acute myocardial infarction in a regional cardiothoracic unit.

RESULTS

In-hospital mortality was 51% (58 patients). Adverse outcome was associated with previous myocardial infarction, age over 70 years, cardiogenic shock complicating failure to respond to thrombolytic treatment (failed thrombolysis), and multivessel coronary artery disease. Multivariate logistic regression analysis showed that the first three factors were independent predictors of in-hospital death with odds ratios of 5.21 (95% confidence interval (CI) 1.85 to 14.69), 4.02 (95% CI 1.14 to 14.12), and 3.78 (95% CI 1.43 to 9.96), respectively.

CONCLUSION

About 50% of patients with cardiogenic shock undergoing a strategy of urgent coronary angiography and PCI survive to hospital discharge. Survivors do well in the subsequent six months. Emergency PCI for cardiogenic shock reduces mortality from an expected 80% to about 50%. Clinical features can help determine which patients are most likely to gain from urgent coronary angiography and attempted PCI. Alternative strategies are needed to improve the outcome of patients who fare badly.

A prospective, randomized trial to determine the early and late reactions after the use of iopamidol 340 (Niopam) and iobitridol 350 (Xenetix) in cardiac catheterization

BACKGROUND

Intravascular contrast agents presently used in modern digital catheter laboratories during cardiac catheterization are superior to older agents as regards patient tolerance. There are, however, significant differences between these agents.

PURPOSE

The aim of this study was to determine the incidence of early (< 24 hours) and late (> 24 hours to 7 days) reactions to 2 contrast agents currently used during cardiac catheterization: iopamidol 340 (Niopam) and iobitridol 350 (Xenetix).

METHODS

This was a prospective, randomized, double-blinded trial. Two thousand and nineteen patients undergoing cardiac catheterization received one of the following contrast agents: iopamidol 340 (Niopam) and iobitridol 350 (Xenetix). Reactions that were possibly related to the contrast agents were recorded during hospital admission (early reaction) and after discharge (late reaction) by means of a questionnaire.

RESULTS

The baseline characteristics were matched in both the groups. There was no significant difference in the incidence of heat sensation experienced between the 2 groups, (p = 0.1). Early non-heat reactions occurred in 3.2% of patients receiving iopamidol 340 (Niopam) and 3.6% of those receiving iobitridol 350 (Xenetix), (p = 0.65). Electrocardiographic changes were recorded in 0.7% of patients who received iopamidol 340 (Niopam), and 2.6% of those who received iobitridol 350 (Xenetix), (p = < 0.01). Seven patients (0.8%) receiving iobitridol 350 suffered ventricular fibrillation requiring DC cardioversion compared with none in the iopamidol 340 group (p = < 0.01). Late reactions (post discharge symptoms) occurred in 13.9% of those receiving iopamidol 340 (Niopam) and 18.5% of those receiving iobitridol 350 (Xenetix) (p = 0.02).

CONCLUSIONS

Iobitridol 350 (Xenetix) was associated with more ECG changes and, importantly, ventricular fibrillation, than iopamidol (Niopam). There were no features to suggest other benefits from iobitridol 350. These results suggest that iopamidol 340 is a preferable contrast agent in cardiac catheterization.

A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction

OBJECTIVES

We sought to compare emergency coronary angiography with or without rescue percutaneous coronary intervention (PCI) with conservative treatment in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Most patients with STEMI receive fibrinolytic therapy and aspirin. The management of failed fibrinolysis is unclear.

METHODS

A total of 307 patients with STEMI and failed fibrinolysis were randomized to emergency coronary angiography with or without rescue PCI or conservative treatment.

RESULTS

Thirty-day all-cause mortality was similar in the rescue and conservative groups (9.8% vs. 11%, p = 0.7, risk difference [RD] 1.2%, 95% confidence interval [CI] -5.8 to 8.3). The composite secondary end point of death/re-infarction/stroke/subsequent revascularization/heart failure occurred less frequently in the rescue group (37.3% vs. 50%, p = 0.02, RD 12.7%, 95% CI 1.6 to 23.5), driven by less subsequent revascularization (6.5% vs. 20.1%, p < 0.01, RD 13.6%, 95% CI 6.2 to 21.4). Re-infarction and clinical heart failure were less common in the rescue group (7.2% vs. 10.4%, p = 0.3, RD 3.2%, 95% CI -3.3 to 9.9; and 24.2% vs. 29.2%, p = 0.3, RD 5.7%, 95% CI -4.3 to 15.6, respectively). Strokes and transfusions were more common in the rescue group (4.6% vs. 0.6%, p = 0.03, RD 3.9%, 95% CI 0.5 to 8.6; and 11.1% vs. 1.3%, p < 0.001, RD 9.8%, 95% CI 4.9 to 19.9, respectively). Left ventricular function at 30 days was the same in the two groups.

CONCLUSIONS

Rescue angioplasty did not improve survival by 30 days, but improved event-free survival, almost completely due to a reduction in subsequent revascularization. Rescue angioplasty was associated with more strokes and more transfusions and did not result in preservation of left ventricular systolic function at 30 days.

Corrected TIMI frame count: Applicability in modern digital catheter laboratories when different frame acquisition rates are used

The original description of the TIMI frame count (TFC) method was based on angiograms acquired at 30 f/sec. Modern digital angiograms are acquired at lower frame rates (between 12.5 and 25 f/sec). Coronary angiography was acquired at 12.5 and 25 f/sec after 200 mug of intracoronary glyceryl trinitrate. Results of the corrected TIMI frame count (cTFC) at 12.5 and 25 f/sec for each vessel were: right coronary artery, 19.5 +/- 5.2 and 20.4 +/- 6.6 (P = 0.15); circumflex artery, 25.6 +/- 8.2 and 25.9 +/- 8.7 (P = 0.5); and left anterior descending artery, 22.5 +/- 8.1 and 23.8 +/- 10.4 (P = 0.15), respectively. The mean difference in the TFC between two injections by the same operator and by two operators was 0.4 (P = 0.7) and 0.4 (P = 0.2), respectively. The mean difference in the TFC for repeat measurements by the same observer and between two observers was 0.26 (P = 0.3) and 0.06 (P = 0.8), respectively. We confirm that the cTFC is a quantitative method to assess coronary flow that can be applied in a modern digital laboratory.

Adjustments for non-telephone bias in random-digit-dialling surveys

Telephone surveys are widely used in the U.S.A. for the study of health-related topics. They are subject to 'coverage bias' because they cannot sample households that do not have telephones. Although only around 5 per cent of households do not have a telephone, rates of telephone coverage show substantial variation by geography, demographic factors and socio-economic factors. In particular, lack of telephone service is more common among households that contain ethnic and racial minorities or that have lower socio-economic status with fewer opportunities for access to medical care and poorer health outcomes. Thus, failure to adequately account for households without telephones in health surveys may yield estimates of health outcomes that are misleading, particularly in states with at least moderate telephone non-coverage. The dynamic nature of the population of households without telephones offers a way of accounting for such households in telephone surveys. At any given time the population of telephone households includes households that have had a break or interruption in telephone service. Empirical results strongly suggest that these households are very similar to households that have never had telephone service. Thus, sampled households that report having had an interruption in telephone service may be used also to represent the portion of the population that has never had telephone service. This strategy can lead to a reduction in non-coverage bias in random-digit-dialling surveys. This paper presents two methods of adjusting for non-coverage of non-telephone households. The effectiveness of these methods is examined using data from the National Health Interview Survey. The interruption-in-telephone-service methods reduce non-coverage bias and can also result in a lower mean squared error. The application of the interruption-in-telephone-service methods to the National Immunization Survey is also discussed. This survey produces estimates for the 50 states and 28 urban areas. The interruption-in-telephone-service estimates tend be slightly lower than estimates resulting from poststratification and from another non-coverage adjustment method. The results suggest that the reduction in bias is greatest for variables that are highly correlated with the presence or absence of telephone service.

A major role for thalamocortical afferents in serotonergic hallucinogen receptor function in the rat neocortex

Activation of 5-hydroxytryptamine(2A) (5-HT(2A)) receptors by hallucinogenic drugs is thought to mediate many psychotomimetic effects including changes in affect, cognition and perception. Conversely, blockade of 5-HT(2A) receptors may mediate therapeutic effects of many atypical antidepressant and antipsychotic drugs. The purpose of the present study was to determine the source of subcortical glutamatergic afferents, which would project widely throughout the anterior-posterior axis of the rat brain to the apical dendrites of layer V pyramidal cells of the medial prefrontal cortex, from which serotonin induces transmitter release via activation of 5-HT(2A) receptors. Fiber-sparing chemical lesions of the medial thalamus selectively decreased the frequency of serotonin-induced excitatory postsynaptic currents recorded from layer V pyramidal cells in the prelimbic region of the medial prefrontal cortex by 60%. In contrast, large bilateral lesions of the amygdala did not alter the serotonin response. These thalamic lesions significantly decreased the amount of binding to either mu-opioid or metabotropic glutamate 2/3 receptors in the prelimbic region of the medial prefrontal cortex as expected from previous evidence that these agonists for these receptors suppress serotonin-induced excitatory postsynaptic currents by a presynaptic mechanism. Surprisingly, the amount of specific binding to cortical 5-HT(2A) receptors was significantly increased by the medial thalamic lesions. Thus, these experiments demonstrate that activation of cortical 5-HT(2A) receptors modulates transmitter release from thalamocortical terminals. Unexpectedly, lesioning the thalamocortical terminals also alters 5-HT(2A) receptor binding in the prefrontal cortex. These findings are of interest with respect to understanding therapeutic effects of antidepressant/antipsychotic drugs and the known behavioral effects of thalamic lesions in humans.

Hypercholesterolaemia and lipid lowering treatment do not affect the acute endogenous fibrinolytic capacity in vivo

OBJECTIVE

To assess acute tissue plasminogen activator (t-PA) release in vivo in patients with hypercholesterolaemia in the presence and absence of lipid lowering treatment and in matched normocholesterolaemic controls.

DESIGN

Parallel group comparison and double blind randomised crossover.

SETTING

University hospital.

PATIENTS

Eight patients with hypercholesterolaemia (> 7.8 mmol/l) and eight matched normocholesterolaemic controls (< 5.5 mmol/l).

METHODS

Blood flow and plasma fibrinolytic factors were measured in both forearms during unilateral brachial artery infusions of the endothelium dependent vasodilator substance P (2-8 pmol/min) and the endothelium independent vasodilator sodium nitroprusside (1-4 microg/min).

INTERVENTIONS

In patients, measurements were made on three occasions: at baseline and after six weeks of placebo or pravastatin 40 mg daily administered in a double blind randomised crossover design.

MAIN OUTCOME MEASURES

Acute release of t-PA.

RESULTS

Compared with patients, in normocholesterolaemic control subjects substance P caused greater dose dependent increases in forearm blood flow (p < 0.05) but similar increases in plasma t-PA antigen and activity concentrations. During pravastatin treatment in patients, total serum cholesterol fell by 22% from a mean (SEM) of 8.1 (0.3) to 6.4 (0.4) mmol/l (p = 0.002) and substance P induced vasodilatation was no longer significantly impaired in comparison with controls. However, despite reproducible responses, pravastatin treatment was not associated with significant changes in basal or substance P induced t-PA release.

CONCLUSIONS

Hypercholesterolaemia and lipid lowering treatment cause no demonstrable effects on acute substance P induced t-PA release in vivo. This suggests that the preventative benefits of lipid lowering treatment are unlikely to be mediated by improvements in endogenous fibrinolysis.

Alosetron controls bowel urgency and provides global symptom improvement in women with diarrhea-predominant irritable bowel syndrome

OBJECTIVES

Bowel urgency is one of the most bothersome symptoms for nonconstipated IBS patients. The efficacy of alosetron in control of bowel urgency and Global Improvement of IBS symptoms were evaluated in a multicenter double-blind, randomized, placebo-controlled study.

METHODS

Female IBS patients with lack of satisfactory control of bowel urgency were randomized 2:1 to alosetron 1 mg twice daily or placebo treatment groups. The primary endpoint was the proportion of days with satisfactory control of bowel urgency during the 12-wk treatment period and 2-wk follow-up period. Secondary endpoints included IBS Global Improvement (responder defined as patient-reported moderate or substantial improvement in IBS symptoms) and improvements in bowel function (stool frequency, consistency, and sensation of incomplete evacuation).

RESULTS

A total of 801 women were randomized to the alosetron (n = 532) or placebo groups (n = 269). Physicians classified 98% of patients with diarrhea-predominant IBS. Patients treated with alosetron had a significantly greater proportion of days with satisfactory control of urgency compared to placebo for the treatment period (73% vs 57%, p < 0.001). A significantly greater number of patients treated with alosetron were IBS Global Improvement responders compared to placebo at week 12 (76% vs 44%, p < 0.001). IBS Global Improvement responders had more days with satisfactory control of urgency at week 12 (88% vs 48%) as well as firmer stools, fewer stools/day, and fewer days with incomplete evacuation compared with nonresponders. Alosetron-treated patients showed improvements in bowel functions compared to placebo-treated patients. Constipation was the most commonly reported adverse event.

[3H]LY341495 binding to group II metabotropic glutamate receptors in rat brain

[3H]LY341495 is a highly potent and selective antagonist for group II metabotropic glutamate (mGlu) receptors (mGlu2 and mGlu3), which has been used to label these receptors in cells expressing recombinant receptor subtypes. In this study, we characterized the kinetics, pharmacology, and distribution of [3H]LY341495 binding to mGlu receptors in rat brain tissue. Equilibrium experiments in the rat forebrain demonstrated binding to a single site that was saturable, reversible, and of high affinity (Bmax, 3.9 +/- 0.65 pmol/mg of protein, Kd, 0.84 +/- 0.11 nM). The relative order of potencies for displacement of [3H]LY341495 by mGlu receptor ligands was LY341495 >> L-glutamic acid > LY354740 > (2S,1'S,2'S)-2-(carboxycyclopropyl)glycine > 4-(2R,4R)-aminopyrrolidine-2,4-dicarboxylate > (1S,3R)-1-aminocyclopentane-1,3-dicarboxylic acid > (R,S)-alpha-methyl-4-phosphonophenylglycine > (R,S)3,5-dihydroxyphenylglycine > L-(+)-2-amino-4-phosphonobutyric acid. [3H]LY341495 was not displaced by the selective ionotropic glutamate receptor agonists N-methyl-D-aspartic acid, (R,S)-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, or kainate at concentrations up to 1 mM. Comparison of [3H]LY341495 binding in rat brain with recombinant mGlu receptor subtypes demonstrated a very high correlation with mGlu3 receptor binding (r2 = 0.957), a significant, but lower, correlation with mGlu2 receptor binding (r2 = 0.869), but no significant correlation to mGlu8 receptor binding (r2 = 0.284). Regional studies using autoradiography showed a similar distribution of [3H]LY341495 binding to that for group II mGlu receptors previously reported by others using immunocytochemical techniques. These studies indicate that [3H]LY341495 selectively labels group II (mGlu2/3) receptors, but under the conditions used, [3H]LY341495 may bind predominately to mGlu3 receptor populations in the rat forebrain.

Overview of the sampling design and statistical methods used in the National Immunization Survey

Abstract: The National Immunization Survey (NIS) is a large federally funded survey designed to estimate vaccination coverage rates for children residing in the United States aged 19 to 35 months. In 1999, over 8 million telephone call attempts were made to obtain provider-reported vaccination histories on 22,521 children in the age range of interest.

(S)-3,4-DCPG, a potent and selective mGlu8a receptor agonist, activates metabotropic glutamate receptors on primary afferent terminals in the neonatal rat spinal cord

(S)-3,4-Dicarboxyphenylglycine (DCPG) has been tested on cloned human mGlu1-8 receptors individually expressed in AV12-664 cells co-expressing a rat glutamate/aspartate transporter and shown to be a potent and selective mGlu8a receptor agonist (EC(50) value 31+/-2 nM, n=3) with weaker effects on the other cloned mGlu receptors (EC(50) or IC(50) values >3.5 microM on mGlu1-7). Electrophysiological characterisation on the neonatal rat spinal cord preparation revealed that (S)-3,4-DCPG depressed the fast component of the dorsal root-evoked ventral root potential (fDR-VRP) giving a biphasic concentration-response curve showing EC(50) values of 1.3+/-0.2 microM (n=17) and 391+/-81 microM (n=17) for the higher and lower affinity components, respectively. The receptor mediating the high-affinity component was antagonised by 200 microM (S)-alpha-methyl-2-amino-4-phosphonobutyrate (MAP4, K(D) value 5.4+/-1.5 microM (n=3)), a group III metabotropic glutamate (mGlu) receptor antagonist. The alpha-methyl substituted analogue of (S)-3,4-DCPG, (RS)-3,4-MDCPG (100 microM), antagonised the effects of (S)-3,4-DCPG (K(D) value 5.0+/-0.4 microM, n=3) in a similar manner to MAP4. (S)-3,4-DCPG-induced depressions of the fDR-VRP in the low-affinity range of the concentration-response curve were potentiated by 200 microM (S)-alpha-ethylglutamate (EGLU), a group II mGlu receptor antagonist, and were relatively unaffected by MAP4 (200 microM). However, depressions of the fDR-VRP mediated by the AMPA selective antagonist (R)-3,4-DCPG were not potentiated by EGLU, suggesting that the low-affinity component of the concentration-response curve for (S)-3,4-DCPG is not due to antagonism of postsynaptic AMPA receptors. It is suggested that the receptor responsible for mediating the high-affinity component is mGlu8. The receptor responsible for mediating the low-affinity effect of (S)-3,4-DCPG has yet to be identified but it is unlikely to be one of the known mGlu receptors present on primary afferent terminals or an ionotropic glutamate receptor of the AMPA or NMDA subtype.

Binding of [3H](2S,1'S,2'S)-2-(9-xanthylmethyl)-2-(2'-carboxycyclopropyl) glycine ([3H]LY341495) to cell membranes expressing recombinant human group III metabotropic glutamate receptor subtypes

LY341495 is a highly potent and selective antagonist for group II mGlu receptors (mGlu2 and mGlu3). High affinity binding of [3H]LY341495 to recombinant human group II mGlu receptors (mGlu2 and mGlu3), and in rat brain homogenates (Kd approximately 1 nM), has been previously described. Although LY341495 is a very selective nM-potent antagonist for group II mGlu receptors, it is also a relatively potent antagonist for group III mGlu receptors at high nanomolar to low micromolar concentrations. In this study we examined and characterized the binding of [3H]LY341495 to membranes of cells expressing recombinant human group III mGlu receptors. Using up to 100 nM of [3H]LY341495, the level of specific binding in human mGlu4a receptor-expressing cell membranes was not appreciable and binding to this site was not examined further. In contrast, we demonstrated sufficient specific binding of [3H]LY341495 to human mGlu6, mGlu7a and mGlu8a receptor-expressing cell membranes to allow for further characterizations. [3H]LY341495 binding was saturable and rapidly reversible. [3H]LY341495 bound to a single site in each cell line, with Kd and Bmax values of 31.6+/-6.8 nM and 3.3+/-0.7 pmol/mg protein (mGlu6), 72.7+/-22.0 nM and 3.7+/-0.4 pmol/mg protein (mGlu7a), and 14.0+/-1.1 nM and 3.0+/-0.2 pmol/mg protein (mGlu8a). [3H]LY341495 binding to mGlu6, 7a and 8a was displaceable by compounds which interact functionally with group III mGlu receptors. For example, L-AP4 displaced [3H]LY341495 with Ki values of 6.8+/-3.1 microM (mGlu6), 211+/-43 microM (mGlu7a) and 1.6+/-0.3 microM (mGlu8a). With L-glutamate, we obtained Ki values of 12.3+/-3.5, 869+/-154 and 4.5+/-0.83 microM, for mGlu6, mGlu7a and mGlu8a, respectively. Ki values for unlabelled LY341495 were 0.058+/-0.008, 0.22+/-0.05 and 0.029+/-0.008 microM, respectively. These studies demonstrated that [3H]LY341495 is a useful radioligand for studying the pharmacology and expression of recombinant mGlu6, 7a and 8a receptors in cell lines.

Cardioesophageal reflexes: an invasive human study

Neural reflex arcs from the esophagus and heart have been shown in both animals and man. The purpose of this study was to further investigate these pathways in individuals undergoing cardiac catheterization. A total of 298 patients undergoing cardiac catheterization were asked to participate in the protocol. Thirty patients were able to complete the study. Esophageal manometry and pH were monitored throughout the cardiac procedure. Afterwards, esophageal provocation with ice water, hydrochloric acid, and balloon inflation was performed with observation of cardiac rate and rhythm. Twelve patients with normal coronary arteries developed diffuse esophageal spasm on either esophageal or cardiac provocation. In one patient with abnormal coronary arteries, coronary angioplasty precipitated diffuse esophageal spasm. Esophageal acid sensitivity was increased in patients with normal coronaries as compared to those that were abnormal. The esophageal pain threshold was significantly lower in patients undergoing angioplasty versus those undergoing coronary angiography alone. There was no significant change in esophageal pH during invasive cardiac maneuvers and manipulations. In conclusion, cardiac manipulation can induce esophageal motility abnormalities, but not gastroesophageal reflux. Coronary angioplasty is associated with esophageal hyperalgesia.

National, state, and urban area vaccination coverage levels among children aged 19-35 months--United States, 1998

PROBLEM/CONDITION

High vaccination levels in the population are necessary to decrease disease transmission and prevent disease; therefore, an important component of the U.S. vaccination program is the assessment of vaccination coverage. Current goals are for > or = 90% coverage with recommended vaccines during the first 2 years of life.

REPORTING PERIOD

January-December 1998.

DESCRIPTION OF SYSTEMS

The National Immunization Survey (NIS) is an ongoing, random-digit-dialed telephone survey that gathers vaccination coverage data for children aged 19-35 months in all 50 states and 28 urban areas. Vaccination coverage rates derived from NIS data are adjusted statistically for households with multiple telephone lines, household nonresponse, the proportion of households without telephones, and vaccination provider nonresponse. The results were also adjusted to match the known total population of children in each survey area.

RESULTS

On the basis of NIS data, national coverage was > or = 90% for three doses of poliovirus vaccine (Polio), three doses of Haemophilus influenzae type b vaccine (Hib), and one dose of measles-containing vaccine (MCV). Coverage was the highest ever reported for four doses of any diphtheria and tetanus toxoids and pertussis vaccine (DTP) (i.e., diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids [DT], or diphtheria and tetanus toxoids and acellular pertussis vaccine [DTaP]) (83.9%), three doses of hepatitis B vaccine (Hep B, 87.0%), and one dose of varicella vaccine (43.2%). The number of states achieving the > or = 90% goal was 47 for three doses of Hib, 40 for three doses of Polio, 40 for one dose of MCV, nine for three doses of Hep B, and seven for four doses of DTP. Proportionally fewer urban areas achieved the > or = 90% goal: 23 of 28 for three doses of Hib, 13 for three doses of Polio, 16 for one dose of MCV, five for three doses of Hep B, and one for four doses of DTP. No state or urban area has yet achieved the > or = 90% goal for varicella.

INTERPRETATION

Findings from the 1998 NIS indicate that national vaccination coverage levels for routinely recommended childhood vaccines are at the highest levels ever reported. However, substantial variation in coverage remains at the state and urban area levels.

PUBLIC HEALTH ACTIONS

The public health community and vaccination providers in areas with low coverage should intensify their efforts to implement recommended strategies for increasing vaccination coverage to ensure that children are equally well protected throughout the United States.

Focal shoulder-elevation dystonia

We describe 13 cases of isolated focal dystonia of the shoulder with dystonic elevation but without clinically obvious cervical dystonia. All had significant trapezius muscle hypertrophy and limitation of shoulder movement causing substantial morbidity. In nine, this developed in the immediate aftermath of shoulder region trauma, most often a motor vehicle accident; clinically significant head trauma was not a factor. In two other cases this developed in the context of chronic heavy labor (suggesting possible overuse) and in one other it developed concurrent with the symptoms of discogenic cervical (C6-7) radiculopathy. In the one remaining case, no precipitating factors were identified. Preexisting risk factors for dystonia, such as dopamine antagonist drug use, family history of dystonia, or prior brain injury, were not identified in these patients. Administration of medications used to treat dystonia was unsuccessful but botulinum toxin therapy was beneficial in all six treated cases.

Natural history of 46 patients with multifocal motor neuropathy with conduction block

We studied 46 consecutive patients with multifocal motor neuropathy with conduction block (MMN-CB). Typically, asymmetric weakness and atrophy of the hands or arms developed insidiously, but spontaneous improvement (without treatment) or death from this disease did not occur and 94% remained employed. For 18 patients examined on multiple occasions using the weakness subscore of the neuropathy impairment score [NIS(W)] for a median time of 2.3 years, worsening of 1.3 points per year was observed; many patients, however, had received intensive immunomodulating therapy. Median worsening to our first evaluation (generally without treatment) was estimated at 4.2 points per year, perhaps suggesting that treatment had influenced course. Three criteria for conduction block (CB) were compared, but the least stringent was sensitive for the diagnosis. Conduction block accompanied by weakness and atrophy typically affected only motor fibers, especially of midforearm nerves, and these sites of dysfunction persisted for months or years. Neurological signs and electrodiagnostic features were consistent with CB, axonal degeneration, a variable degree of reinnervation, and segmental demyelination. Although this study did not focus on therapy, intravenous gammaglobulin and cyclophosphamide appeared to be associated with neurological improvement, which was seldom complete or sustained. Axonal degeneration and faulty regeneration may in part explain this muted response. Possibly, treatment must be earlier, more intense, or different.

Evaluation of the activity of a novel metabotropic glutamate receptor antagonist (+/-)-2-amino-2-(3-cis and trans-carboxycyclobutyl-3-(9-thioxanthyl)propionic acid) in the in vitro neonatal spinal cord and in an in vivo pain model

The cyclobutylglycine (+/-)-2-amino-2-(3-cis and trans-carboxycyclobutyl-3-(9-thioxanthyl)propionic acid) (LY393053) has been identified as a functionally potent metabotropic glutamate receptor antagonist. It is most potent on the two group I metabotropic glutamate receptors, 1alpha and 5alpha, with IC50 values of 1.0+/-0.4 microM and 1.6+/-1.4 microM, respectively. In this study, LY393053 has also been evaluated electrophysiologically on native group I metabotropic glutamate receptors in an in vitro spinal cord preparation as well as behaviourally, in a mouse model of visceral pain. LY393053 dose-dependently antagonised group I agonist, (RS)-3, 5-dihydroxyphenylglycine, or a broad-spectrum agonist (1S,3R)-amino-1,3-cyclopentanedicarboxylic acid-induced depolarisation of spinal motoneurons. The apparent Kd values were estimated to be 0.3 microM against (RS)-3, 5-dihydroxyphenylglycine-induced depolarisation and 0.5 microM against (1S,3R)-amino-1,3-cyclopentanedicarboxylic acid-induced depolarisation, respectively. On the other hand, the dorsal root-ventral root potential elicited at 8 x threshold was depressed by LY393053 with IC50 values of 9.0+/-0.7 microM and 12.7+/-1.7 microM on monosynaptic and polysynaptic responses, respectively. When investigated using the mouse acetic acid writhing test, LY393053 showed significant analgesic effects at doses of 1-10 mg/kg intraperitoneally. An ED50 value of 6.0 mg/kg was obtained in this test. By revealing a potent effect of LY393053 in antagonising the native group I metabotropic receptor-mediated responses in the spinal cord in rodents, and an antinociceptive efficacy in a mouse visceral pain model, these results, therefore, provide additional evidence in support of the analgesic potential of metabotropic glutamate receptor antagonists.

Physiological antagonism between 5-hydroxytryptamine(2A) and group II metabotropic glutamate receptors in prefrontal cortex

In prefrontal cortex, 5-hydroxytryptamine(2A) (5-HT(2A)) receptors have been linked to the action of hallucinogens and atypical antidepressant/antipsychotic drugs. Previously, we have shown in cortical layer V pyramidal cells that a nonselective metabotropic glutamate (mGlu) receptor agonist suppresses the induction of excitatory postsynaptic potentials/currents (EPSPs/EPSCs) via activation of 5-HT(2A) receptors. In this study, we tested the ability of the selective mGlu2/3 agonist (1S,2S,5R, 6S)-2-aminobicyclo[3.1.0]hexane-2,6-dicarboxylate monohydrate (LY354740) and the selective mGlu2/3 antagonist 2S-2-amino-2-(1S, 2S-2-carboxycycloprop-1-yl)-3(xanthy-9-yl)propanoic acid (LY341495) to modulate serotonin(5-HT)-induced EPSPs and electrically evoked EPSPs by using intracellular recording from layer V pyramidal cells in medial prefrontal cortex. The mGlu2/3 antagonist LY341495 increased the frequency and amplitude of 5-HT-induced EPSCs, suggesting a role for mGlu2/3 receptors in mediating the action of endogenous glutamate on autoreceptors. Conversely, the mGlu2/3 agonist LY354740 was highly effective and potent (EC(50) = 89 nM) in suppressing glutamate release induced by 5-HT(2A) receptor activation in the medial prefrontal cortex, probably via a presynaptic mechanism. The mGlu2/3 antagonist LY341495 potently blocked the suppressant effect of LY354740 on 5-HT-induced EPSCs as well as electrically evoked early EPSPs. Autoradiography with the radioligands [(3)H]LY354740 and [(125)I](+/-)-1-(2, 5-dimethoxy-4-iodophenyl)-2-aminopropane showsa striking overlap of the laminar distribution of mGlu2/3 and 5-HT(2A) receptors in the medial prefrontal cortex that is not apparent in other cortical regions. These findings suggest a close coupling between mGlu2/3 and 5-HT(2A) receptors in the prefrontal cortex that may be relevant for novel therapeutic approaches in the treatment of neuropsychiatric syndromes such as depression and schizophrenia.