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  • 1
    ISSN: 1573-742X
    Keywords: Coronary thrombolysis ; patient selection ; dosing strategies ; body weight
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Background: In epidemiologic studies, excessive body weight, independent of other risk factors, portends a poor prognosis among patients with coronary artery disease experiencing acute myocardial infarction (MI). At least one recent study has suggested that patients of excessive body weight when receiving thrombolytic therapy are often underdosed, potentially reducing early coronary arterial patency and adversely affecting in-hospital clinical outcome. Concern has also been raised that body weight may influence treatment utilization, delays, and complication rates. Despite these concerns, the association between body weight and patient outcome following coronary thrombolysis has received limited attention.Methods/Results: Demographic, procedural, and outcome data from patients with MI were collected at 1073 United States hospitals participating in The National Registry of Myocardial Infarction from 1990 through 1994. Among 350,755 patients with MI enrolled, 87,688 (25.1%) were treated with tissue plasminogen activator (t-PA). Divided into body weight tertiles, 23.5% of patients were less than 70 kg (low weight), 36.8% were 70–85 kg (modrate weight), and 37.5% were greater than 85 kg (high weight). Patients of low weight were older (p 〈 0.001), received treatment later (p 〈 0.001), and were less likely to undergo cardiac catheterization, coronary angioplasty, or bypass surgery (p 〈 0.001) than moderate- or high-weight patients. Low-weight patients also experienced minor bleeding, major bleeding, recurrent MI, and death more often (p 〈 0.001). Adjusted for age, low body weight was independently associated with in-hospital mortality. Despite receiving a lower dose of t-PA per kg body weight, high-weight patients had a low incidence of cardiogenic shock, recurrent MI, death, and hemorrhagic complications. When high-weight women and men were compared, several interesting observations emerged. Mortality was increased twofold in women (6.8% vs. 3.0; p 〈 0.001), even adjusting for their older age. Despite being at increased risk, women were less likely than their male counterparts to undergo cardiac catheterization (p=0.001) or bypass surgery (p=0.008).Conclusions: The National Registry of Myocardial Infarction provides a unique resource for assessing health care trends in the United States. Our findings suggest that low body weight is associated with increased in-hospital morbidity and mortality. They also suggest that current dosing strategies for t-PA administration are probably adequate for high-weight patients. The excessive mortality and limited use of in-hospital interventions among high-weight women deserve further study to address gender-related differences in disease processes, as well as potential bias or discrimination.
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  • 2
    ISSN: 1432-0762
    Source: Springer Online Journal Archives 1860-2000
    Topics: Biology
    Notes: Summary Individual Midas cichlids (Cichlasoma citrinellum) show persistent differences in aggressive behavior toward dummy fish. The starting question was whether the level of such behavior can be used to predict the winner of a fight. In the first (long-term) experiment two fish were matched for size, color, and sex. After 24 h the opaque barrier separating the 2 fish was removed; they immediately behaved aggressively. Scores for aggression toward dummies did not predict the winners, nor did taking the initiative in escalation. But weight did foretell the winners, who averaged only 2% heavier than their opponents. The conventional display phase of such fights was brief (20% of total duration), and escalation was rapid. Both winners and losers sustained damage, but losers accumulated damage faster than winners. In the subsequent (short-term) experiment the fish were separated only 1–2 h. Now aggression scores predicted winners, and winners were the fish who escalated. Weight of fish had no effect. The conventional phase was relatively much longer, about half the length of the fight. Losers accumulated damage at the same rate as the losers in the long-term experiment, but the fights were shorter; winners suffered little damage. The fish had difficulty assessing one another. Fighting prowess was remarkably uniform when weight was factored out. Daring to escalate, in contrast, varied among individuals and correlated with aggression scores. Prowess (=weight) determined the outcome in the long-term experiment, which may find its parallel in nature in intraterritorial disputes. Daring to escalate determined the winner in the short-term experiment; this may be comparable to establishing a territory in nature. Prowess probably results from strong directional selection because it has low costs and high benefits. In contrast, daring is subject to bi-directional selection because both costs and benefits are high. Resource holding potential is conventionally viewed as deriving from prowess of self and opponent and value of resource; to that one must add the individual's inherent aggressiveness.
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  • 3
    ISSN: 1432-0762
    Source: Springer Online Journal Archives 1860-2000
    Topics: Biology
    Notes: Summary The Midas cichlid (Cichlasoma citrinellum) is a large, aggressive monogamous fish from the Great Lakes of Nicaragua. It lives in an ecosystem where breeding sites are at a premium and where breeding success can be low. I tested the strength of the pair bond by manipulating the sex ratios in captive groups, using ratios of 1:1, 2:1, 4:1, 1:2 and 1:4 (♂♂:♀♀). No polygamy was seen at any of the ratios. Departure from a ratio of 1:1 decreased breeding success for those pairs that formed. Both sexes appeared to enforce the pair bond but did so in different ways: females attacked males and females equally but males attacked other males significantly more than they did females. These results, coupled with field observations, indicate the Midas cichlid is obligated to monogamy by the demands of competition for breeding sites, the need for two parents to protect the fry and by energetic constraints.
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  • 4
    ISSN: 1573-3521
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine , Psychology
    Notes: Abstract The association between adherence to medical recommendations and health outcomes (physical, role, and social functioning, energy/fatigue, pain, emotional well-being, general health perceptions, diastolic blood pressure, and glycohemoglobin) was examined in a 4-year longitudinal, observational study of 2125 adult patients with chronic medical conditions (hypertension, diabetes, recent myocardial infarction, congestive heart failure) and/or depression. Change score models were evaluated, controlling for disease and comorbidity. Patient adherence was associated minimally with improvement in health outcomes in this study. Only 11 of 132 comparisons showed statistically significant positive effects of adherence on health outcomes. We conclude that
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  • 5
    ISSN: 1573-742X
    Keywords: hospital policies ; delay ; thrombolysis ; myocardial infarction
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Despite the compelling relationship between early treatment and outcome from reperfusion therapy in patients with acute myocardial infarction, significant delays in early treatment are imposed by the patient, prehospital systems, and hospital processes and protocols used in the identification and treatment of patients with myocardial infarction. A survey instrument designed to determine the prevalence of hospital policies and protocols that might delay or expedite treatment with thrombolytic therapy in patients with acute myocardial infarction was completed by 524 hospitals participating in the National Registry for Myocardial Infarction (NRMI). Participating hospitals had treated 17,646 patients with tissue plasminogen activator. The door to drug time for the entire population of patients treated at each hospital was available. Door to drug times were compared between those hospitals that had a positive response to a policy and those that had a negative response to that policy. Among respondent hospitals, thrombolysis was excluded by protocol in 34.4% for age above 75 and in 55% for presentation after 6 hours of chest pain onset. Furthermore, 29.4% of hospitals required routine laboratory testing other than electrocardiography (ECG), including chest x-ray, prior to determination of eligibility for thrombolysis. Door to drug times were shorter in those hospitals with prehospital 12-lead ECG availability, assessment of the 12-lead ECG by the emergency department nurse and physician as soon as it was available, and initiation of thrombolysis by the emergency physician (in patients with clear-cut ST elevation myocardial infarction) without bedside cardiology consultation. Door to drug times were longer in those hospitals in which predecision laboratory results were required, written informed consent was mandated, and drug was initiated in the cardiac intensive care unit rather than in the emergency department itself. Door to drug times were not significantly different in those hospitals with a designated chest pain center compared with those operating under a focused patient care protocol. We conclude that the earliest possible hospital treatment of acute myocardial infarction patients may be precluded by multiple components of emergency department policies and process, many of them inappropriate for safe, efficient, and effective identification and management of these patients.
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  • 6
    ISSN: 1573-742X
    Keywords: myocardial infarction ; aspirin ; national health care
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objectives: The purpose of our study was to determine the frequency of aspirin administration among patients with acute myocardial infarction (MI) as dictated by physicians practicing in the United States. Background: Aspirin (ASA), a widely available, inexpensive and generally well-tolerated platelet inhibitor, is recommended for patients with acute coronary syndromes, including acute MI. However, there is concern that aspirin is underutilized in daily clinical practice. Methods: Early (〈24 hours) and predischarge ASA administration were determined among 220,171 patients with suspected acute MI enrolled in the Second National Registry of Myocardial Infarction (NRMI 2) between June, 1994 and April 30, 1996. Results: Overall, 165,122 (74.9%) of patients received ASA within 24 hours of hospital admission, whereas 55,049 patients did not. Early ASA recipients were younger, more often male, arrived at the hospital earlier, and were more likely to be classified as Killip Class II or less compared to those who did not receive ASA. Patients who received aspirin were also more likely to have chest pain, electrocardiographic ST segment elevation, and tended to arrive at the hospital earlier than those who did not receive ASA. However, over 20% of patients with ST segment elevation did not receive early ASA therapy. From the total cohort of early ASA recipients, only 69% received ASA at the time of hospital discharge. Trends in early and pre-discharge aspirin administration over a 2 year time period in all patients (72.6 to 75.1% and 71.5 to 74.6%, respectively; p 〈 0.001) and in specific patient subsets were encouraging with a gradual but steady increase; however, utilization remained comparatively low in women and the elderly. By multivariable analysis, in-hospital recurrent MI (OR 0.90, 95% CI; .78–1.0, p = 0.04), stroke (OR 0.65, 95% CI, .52–.80, p 〈 0.001) and death (OR 0.24, 95% CI, .22–.26, p 〈 0.001) occurred less frequently when ASA was administered within 24 hours of hospitalization. Conclusion: Aspirin is currently underutilized in routine clinical practice as both primary and adjunctive forms of therapy in MI, especially among patients known to be at risk for recurrent cardiothrombotic events. The targeted and timely use of aspirin reduces early cardiovascular events and should remain a priority in national health care efforts.
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  • 7
    ISSN: 1573-2649
    Keywords: Key words: Clinical practice ; health status measurement ; MOS SF-36 Health Survey ; epilepsy.
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The objective was to assess the potential benefits of the routine use of the MOS SF-36 Health Survey (SF-36) in the care of ambulatory patients. The design was a longitudinal, prospective, randomized, controlled study set in the outpatient neurology clinic at the New England Medical Center. There were 163 consecutive patients with epilepsy who had 210 follow-up visits with one of two epileptologists. The patients completed the SF-36 before the patient-physician encounter and the forms were optically scanned. The SF-36 results of the intervention group patients were given to the physicians before the encounter and withheld for control group patients. For intervention group patients, the physicians completed a questionnaire assessing the impact of the SF-36 on the process of care. After the visit, all patients completed a satisfaction questionnaire. The main outcome measures were the physicians' responses to standardized questions about the usefulness of the SF-36 for communication with and management of epilepsy patients and the patients' responses to standardized questions about their satisfaction with care. The physicians indicated that the SF-36 provided new information in 63% of the intervention group encounters. A change in therapy was prompted in 13%. The physicians rated the SF-36 as at least moderately useful for communication in 14% of the encounters and to management in 8%. The lower (indicating worse health status) the patients' SF-36 scale scores, the more useful the SF-36 results were rated by the physicians for communication and management. It was concluded that the routine use of health status measures may enhance patients' care.
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  • 8
    ISSN: 1573-5141
    Keywords: genotoxicity ; DNA damage ; community structure ; mutagenicity ; Lepomis auritis
    Source: Springer Online Journal Archives 1860-2000
    Topics: Biology
    Notes: Abstract Genotoxic responses (chromosomal damage, DNA strandbreakage) of redbreast sunfish (Lepomis auritis)populations exposed to industrial effluent andmutagenicity of the associated sediments weredetermined in order to compare them to changes incommunity structure. Data were collected from areference stream and East Fork Poplar Creek (EFPC), afirst-order stream which originates on the grounds ofthe Department of Energy Y-12 Plant at Oak Ridge, TN. This stream is contaminated with mercury, PCBs, andnumerous other compounds. Previous studies have shownthat sediment contaminant concentrations, as well asphysiological biomarker responses of the local fishpopulations, are highest at the headwaters of EFPC anddecrease with increasing distance from the DOEfacility as contaminant loading decreases. Chromosomal damage was measured by flow cytometry – asreflected by variation in cellular DNA content – andstrand breakage was determined by agarose gelelectrophoresis using blood as the source of DNA. Mutagenicity was determined by theSalmonella/microsome assay using organic solventextracts of sediment surface samples. Community levelresponses included community diversity and percentpollution-tolerant species. Biomarker responses andmutagenicity were found to be highest at theheadwaters of EFPC, and tended to decrease withincreasing distance from the effluent. In general,biomarker responses appeared to be correlated withmutagenicity of the sediment, and both of theserelated to fish community disturbance and level ofstream contamination. Because responses at severallevels of biological organization show similarpatterns of downstream effects, this suggests thatthere may be a causal relationship betweencontamination and biological effects.
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  • 9
    ISSN: 1573-2568
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract In order to evaluate the enteropancreatic hormone axis in dogs with pancreatic acinar atrophy, we measured the release of gastric inhibitory polypeptide and pancreatic polypeptide in response to a standard meal and a meal containing pancreatic enzymes in affected dogs and controls. Postprandial release of pancreatic polypeptide was normal in dogs with pancreatic atrophy and was not affected by addition of pancreatic enzymes to the food. Gastric inhibitory polypeptide was not released after a standard meal in affected dogs, but this blunted response was corrected by the addition of pancreatic enzymes to the food. Feeding the enzyme alone did not stimulate a gastric inhibitory polypeptide response. These results, in part, support similar observations previously reported in children with exocrine pancreatic insufficiency associated with cystic fibrosis. We conclude that dogs with idiopathic pancreatic acinar atrophy can be used as an animal model for future study of enteropancreatic hormonal abnormalities that occur in human beings with exocrine pancreatic insufficiency.
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  • 10
    ISSN: 1520-5126
    Source: ACS Legacy Archives
    Topics: Chemistry and Pharmacology
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