Failure of a chest pain clinical policy to modify physician evaluation and management.

STUDY OBJECTIVE: To assess the effectiveness of a specific, targeted clinical policy regarding the evaluation of nontraumatic chest pain in the emergency department (ED) to modify physician evaluation and management. DESIGN: Retrospective, blinded chart review. SETTING: Twelve metropolitan EDs. PARTICIPANTS: All males older than 35 years and females older than 45 years who presented with nontraumatic chest pain during one of the two study periods--1 year before (1989) or 1 year after (1991) dissemination of the American College of Emergency Physicians' (ACEP) chest pain clinical policy. MEASUREMENTS: Physician's compliance with various documentation rules regarding history and physical examination were compared between the two periods with chi 2 analysis. Fisher's exact test was used when any one cell value was less than five. The physician's compliance with the rules and guidelines of management (Actions) were compared between the two periods with chi 2 analysis. RESULTS: Rates of compliance for 1989 and 1991 were as follows: history documentation, 368 (82%) vs. 255 (78%) (P = .22); physical examination documentation, 397 (88%) vs. 287 (88%) (P = .94); Action rules, 292 (65%) vs. 208 (64%) (P = .76); and Action guidelines, 247 (55%) vs. 172 (53%) (P = .55). CONCLUSION: We conclude that the dissemination of the ACEP chest pain clinical policy has not significantly modified the behavior of our metropolitan area emergency physicians regarding the evaluation and management of patients who present to the ED with a chief complaint of nontraumatic chest pain.

The 26S proteasome of the yeast Saccharomyces cerevisiae.

Proteasomes are large multicatalytic proteinase complexes found in all eukaryotic organisms investigated so far. They have been shown to play a central role in cytosolic and nuclear proteolysis. According to their sedimentation coefficients two types of these particles can be distinguished: 20S proteasomes and 26S proteasomes. In contrast to 20S proteasomes, which were mainly characterized on the basis of their ability to cleave small chromogenic peptide substrates and certain proteins in an ATP-independent manner, 26S proteasomes degrade ubiquitinylated proteins in an ATP-dependent reaction. 20S proteasomes have been found in all eukaryotes from yeast to man. So far 26S proteasomes have only been discovered in higher eukaryotes. We now report the existence of the 26S proteasome in a lower eukaryote, the yeast Saccharomyces cerevisiae. Formation of the 26S proteasome could most effectively be induced in crude extracts of heat stressed yeast cells by incubation with ATP and Mg2+ ions. This treatment yielded a protein complex, which eluted from gel filtration columns at molecular masses higher than 1500 kDa. Besides chromogenic peptide substrates, this complex cleaves ubiquitinylated proteins in an ATP-dependent fashion. In non-denaturing-PAGE, the purified 26S proteasome disintegrated and migrated as four protein bands. One of these bands could be identified as the 20S proteasome. On SDS-PAGE, the 26S proteasome showed a complex pattern of subunit bands with molecular masses between 15 and 100 kDa. Further evidence for the 20S proteasome being the proteolytically active core of the 26S proteasome was obtained by following peptide cleaving activities in extracts of yeast strains carrying mutations in various subunits of the 20S proteasome.

Degradation of the yeast MAT alpha 2 transcriptional regulator is mediated by the proteasome.

Rapid degradation of specific regulatory proteins plays a role in a wide range of cellular phenomena, including cell cycle progression and the regulation of cell growth and differentiation. A major mechanism of selective protein turnover in vivo involves a large multi-subunit protease known as the proteasome or multi-catalytic proteinase. At the same time, the degradation of many cellular proteins requires their covalent ligation to the polypeptide ubiquitin. Here we show that the yeast S. cerevisiae MAT alpha 2 repressor, which is known to be ubiquitinylated in vivo, requires the proteasome for its rapid intracellular proteolysis.

A noninvasive method for monitoring cerebral perfusion during cardiopulmonary resuscitation.

PURPOSE: This study evaluates the use of transcranial Doppler (TCD) ultrasound in assessing the changes experienced by the cerebral circulation during cardiopulmonary resuscitation (CPR) and compares it with measurements of internal carotid artery (ICA) flow rates (ultrasonic flow-meter measurements) and cerebral blood flow (CBF) (radioactive-microsphere measurements) in a porcine cardiac arrest model undergoing closed chest CPR. METHODS: Sixteen piglets were anesthetized and subjected to TCD monitoring, ICA flow-rate measurements, and CBF measurements during CPR following induction of ventricular fibrillation. A total of 14 comparisons between TCD and CBF measurements, and 36 comparisons between TCD and ICA flow measurements were performed. Correlations were determined using Pearson's method, and the validity of the correlation was determined using Bonferoni's adjusted probabilities. RESULTS: The correlation between mean cerebral blood flow velocity and mean total ICA flow rate was 0.67 (P < .01). The correlation between peak systolic blood flow velocity and CBF was 0.76 (P = .02). CONCLUSIONS: TCD can provide on-line information about cerebral perfusion during CPR.

Proteasome and cell cycle. Evidence for a regulatory role of the protease on mitotic cyclins in yeast.

The cell cycle of eukaryotic cells is strictly regulated. This regulation is performed by a serine/threonine kinase. The different functions of this kinase in the cell cycle are modulated by different cyclins, which fluctuate in concentration ('cycle') during the different stages of the cell cycle. Using yeast as a model organism we show here that the activity of the multifunctional proteinase, the proteasome, is directly connected to the function of the mitotic cyclin Clb2. Our studies indicate that the proteasome is the proteolytic regulator of this cyclin and thus a central regulator of the cell cycle.

Tissue and organ procurement in the emergency department setting.

A retrospective chart review of all emergency department (ED) deaths in patients younger than 65 years in seven area hospitals was performed for the calendar year of 1990. The number and percentage of families approached and consenting to tissue donation among the various EDs was compared and reasons for not approaching families were evaluated for their validity. Procurement rates between the years 1990 and 1991 were compared for two area hospitals, which made a specified (nonmedical) service responsible for tissue requests in 1991. There were 368 deaths, 255 of which were potential donors by acceptable criteria. Only 109 (43%) families were approached regarding tissue donation. The overall procurement rate was 12%. Suburban EDs had a higher approach and procurement rate than did urban EDs (49% vs 36%; P < .05 and 19% vs 5%; P < .01, respectively). Procurement rates for two hospitals that designated a specific procurement service in 1991 more than doubled (5% vs 11%; P = NS). Tissue procurement rates in EDs with procurement systems in place are low despite consent rates of those approached of 36%. The major contributing factor is the failure to request tissue from the families of eligible candidates even when there are no exclusion criteria met. Suburban EDs had a higher success rate than urban EDs.

Characterization of the self-splicing products of a mobile intron from the nuclear rDNA of Physarum polycephalum.

We have characterized the splicing products formed in vitro from RNA derived from the mobile group I intron in the nuclear rDNA of Physarum polycephalum, Pp LSU 3. This intron is a close relative of the well known Tetrahymena intron Tt LSU 1, being inserted at exactly the same position in the rDNA and sharing about 90% sequence identity with Tt LSU 1 in the conserved elements characteristic of the catalytic core of all group I introns. However, Pp LSU 3 differs from Tt LSU 1 in that it encodes a site-specific endonuclease, which mediates the homing of the intron to unoccupied target sites. The endonuclease, I-Ppo, would appear to be a unique example of a protein encoded by an RNA polymerase I transcript. To gain clues to the splicing products formed in vivo, and to the nature of the messenger RNA for I-Ppo, we subjected Pp LSU 3 RNA to standard self-splicing conditions in vitro, and then analyzed the products by size, by northern blotting, and by primer extension. The results show two novel features. First, in addition to the expected 5' splice site, there is an alternative 5' splice site in the upstream exon, just preceding the first codon of the I-Ppo open reading frame. Second, at the position corresponding to the major circularization site in Tt LSU 1 there is an internal processing site, leading to the efficient separation of two halves of the excised intron, the 5' half encoding I-Ppo and 3' half containing the ribozyme. Surprisingly, this cleavage appears not to be due to circularization followed by hydrolytic opening of the circle, but rather to G addition. The formation of these products in vitro suggests how the messenger RNA for the I-Ppo endonuclease may be generated in vivo.

The proteasome/multicatalytic-multifunctional proteinase. In vivo function in the ubiquitin-dependent N-end rule pathway of protein degradation in eukaryotes.

Proteinase yscE, the proteasome/multicatalytic-multifunctional proteinase of yeast had been shown to function in stress response and in the degradation of ubiquitinated proteins [(1991) EMBO J. 10, 555-562]. A well-defined set of proteins degraded via ubiquitin-mediated proteolysis are the substrates of the N-end rule pathway [(1986) Science 234, 179-186; (1989) Science 243, 1576-1583]. We show that mutants defective in the chymotryptic activity of proteinase yscE fail to degrade substrates of the N-end rule pathway. This gives further proof of the proteasome being a central catalyst in ubiquitin-mediated proteolysis.

Flexion-extension views in the evaluation of cervical-spine injuries.

STUDY OBJECTIVE: To determine the efficacy of flexion-extension (F/E) cervical-spine radiographs in detecting acute cervical-spine instability in emergency patients. DESIGN: We retrospectively reviewed the charts of 141 consecutive trauma patients who had F/E views performed after a routine cervical-spine series (three views) was obtained in the emergency department. Interpretations of the routine series were compared with those of the F/E views to determine if additional useful information was provided by the latter. The charts also were reviewed to determine if any variables were associated with an increased use of F/E views, an increased likelihood of these views demonstrating instability, or any neurologic sequelae resulted from these studies. SETTING: An urban Level I adult trauma center. MEASUREMENTS: The interpretations of the routine series were noted to be either normal, abnormal but without demonstrable fracture/dislocation, or demonstrating a fracture/dislocation. The F/E views were categorized as stable, unstable, or uninterpretable. RESULTS: Cervical-spine instability was demonstrated by F/E views in 11 of the 141 patients (8%), four of whom had normal routine cervical-spine films. Three of these four patients required surgical stabilization. Prolonged neck pain (more than 24 hours), an initially abnormal spine series, and a neurosurgical consult were all associated with an increased use of F/E views. Ten of 11 patients with radiographic instability had significant neck pain by history; the remaining patient was intoxicated. No neurologic sequelae resulted from performing F/E studies. There was one false-negative F/E study, which raises concern about the reliability of this procedure in the ED. CONCLUSION: We believe that a large prospective study is required to determine which patients warrant F/E views.

Comparative biochemistry of mammalian arylsulfatase C and steroid sulfatase.

1. Hepatic arylsulfatase C (ASC) and steroid sulfatase (SS) from six of eleven mammals (rat, dog, baboon, cow, goat, and sheep) coeluted from DEAE-Sephacel as a single anionic species. A minor cationic peak of ASC and SS activity was also recovered from solubilized microsomes derived from the domestic cat. Characterization of the cationic activities indicated they were most likely contributed by a protein structurally related to the anionic isozyme. Properties of ASC and SS activities occurring in these seven species were most consistent with the presence of both activities in the same enzyme. 2. Guinea-pig liver SS activity was partitioned between an alkylsulfatase (hydrolyzing dehydroepiandrosterone sulfate (DHEAS)) and an arylsulfatase (hydrolyzing both estrone sulfate (E1S) and 4-methylumbelliferyl sulfate (4MUS) at a common active site). These enzymes were physically separable by ion-exchange chromatography and possessed distinct immunological and chemical properties. 3. Porcine, squirrel, and human livers possessed a major isozyme of ASC that lacked both E1S- and DHEAS-sulfatase activities. The human hepatic ASC was separable from SS by electrophoresis and was partially resolved from SS by DEAE-Sephacel chromatography. The ASC isozyme lacking SS activity was heat-labile in all three species.

Transcranial Doppler determination of cerebral perfusion in patients undergoing CPR: methodology and preliminary findings.

STUDY OBJECTIVES: To correlate cerebral arterial blood velocity measurements as determined by transcranial Doppler ultrasound with various resuscitation maneuvers performed in an uncontrolled manner in a series of cardiac arrest patients undergoing standard resuscitation. TYPE OF PARTICIPANTS: Any patient undergoing resuscitation for a nontraumatic cardiac arrest was eligible for the study. INTERVENTIONS: Resuscitation was carried out while flow velocities were monitored in various intracranial arteries by transcranial Doppler ultrasound. Vessel identification was based on the angle and depth of insonation. MEASUREMENTS AND MAIN RESULTS: The internal carotid artery was located more consistently than either middle cerebral or ophthalmic arteries and provided superior waveforms for analysis. Alterations in flow velocity were noted and correlated to various therapeutic interventions. Flow velocities were 70% of normal during the early phase of resuscitation but deteriorated over time until there was no evidence of net forward flow. Even early in CPR, flow was demonstrated only during systole. CONCLUSION: Transcranial Doppler ultrasound appears to be a potentially promising means of determining cerebral flow in patients undergoing CPR.

Characterization of I-Ppo, an intron-encoded endonuclease that mediates homing of a group I intron in the ribosomal DNA of Physarum polycephalum.

A novel and only recently recognized class of enzymes is composed of the site-specific endonucleases encoded by some group I introns. We have characterized several aspects of I-Ppo, the endonuclease that mediates the mobility of intron 3 in the ribosomal DNA of Physarum polycephalum. This intron is unique among mobile group I introns in that it is located in nuclear DNA. We found that I-Ppo is encoded by an open reading frame in the 5' half of intron 3, upstream of the sequences required for self-splicing of group I introns. Either of two AUG initiation codons could start this reading frame, one near the beginning of the intron and the other in the upstream exon, leading to predicted polypeptides of 138 and 160 amino acid residues. The longer polypeptide was the major form translated in vitro in a reticulocyte extract. From nuclease assays of proteins synthesized in vitro with partially deleted DNAs, we conclude that both polypeptides possess endonuclease activity. We also have expressed I-Ppo in Escherichia coli, using a bacteriophage T7 RNA polymerase expression system. The longer polypeptide also was the predominant form made in this system. It showed enzymatic activity in bacteria in vivo, as demonstrated by the cleavage of a plasmid carrying the target site. Like several other intron-encoded endonucleases, I-Ppo makes a four-base staggered cut in its ribosomal DNA target sequence, very near the site where intron 3 becomes integrated in crosses of intron 3-containing and intron 3-lacking Physarum strains.

Is emergency department resuscitation of out-of-hospital cardiac arrest victims who arrive pulseless worthwhile?

It is still a common practice to continue unsuccessful field resuscitations in the emergency department (ED) even after prolonged estimated down times. The authors studied patients who arrested in the field and did not regain a pulse before their arrival in the ED to determine if any ever leave the hospital neurologically intact. All cardiac arrests in the urban St Louis area that were brought to our facility over a 2 1/2-year period by advanced life support units (excluding all patients with hypothermia, drug overdose, near drowning, and traumatic cardiac arrest) were reviewed. Of 243 such patients 32 (13%) arrived with a pulse. Twenty-three of these patients were admitted and 10 discharged alive, 7 were neurologically intact. Out of 211 patients who arrived without a pulse, 24 (11%) developed a pulse with further resuscitative efforts in the ED. Eighteen of these patients were admitted but only one was discharged neurologically intact. The only survivor in the group without a pulse arrested while en route to the ED. It is concluded that cardiac arrest victims who arrive in the ED without a pulse on arrival or en route have almost no chance of functional recovery.

Real-time duplex ultrasound mapping of the greater saphenous vein before in situ infrainguinal revascularization.

From November 1983 through September 1985, 102 greater saphenous veins (GSVs) were assessed and mapped by means of real-time duplex ultrasonic scanning before in situ infrainguinal revascularization. Each GSV was also visually assessed at operation. Eighty-five GSVs were successfully used for infrainguinal revascularization; duplex scanning correctly identified 82 of these GSVs as being acceptable for use in in situ bypass. Seventeen GSVs were unacceptable for in situ bypass; duplex scanning correctly identified 11 of these as being unacceptable. Duplex scanning provides anatomic information about the GSV, including size, patency, course, varicosities, double segments, and tributaries. This information permits the surgeon to perform infrainguinal revascularization expeditiously.

Extended study of aneurysm formation in umbilical vein grafts.

The rate of aneurysm formation in umbilical vein grafts has been reported to lie between 1% and 8%. However, in these reported series the number of grafts with aneurysms was related to the number of grafts inserted. When the denominator is changed to patent grafts at a given time period, the incidence changes drastically. In this study, duplex scanning was used to detect aneurysms in patent grafts. Four types of aneurysms--localized fusiform, localized eccentric, diffuse, and anastomotic--were recognized. Excluding anastomotic aneurysms, 33% of the grafts patent at 3 years were aneurysmal; in those patent at 4 years, 45% were aneurysmal; and in those patent at 5 or more years, 65% were aneurysmal. On grounds of theoretical considerations, it is believed that duplex scanning is more reliable than either clinical examination or arteriographic study for detecting these aneurysms. There is now evidence that the supporting Dacron mesh is too weak and must be strengthened. Despite aneurysm formation, the patency rate in our series has remained second only to saphenous vein grafts, as previously reported.

Systemic lupus erythematosis presenting as isolated congestive heart failure.

We describe a patient with systemic lupus erythematosus, who presented with congestive heart failure. The diagnosis and favorable response to corticosteroid therapy was confirmed by myocardial biopsy and cardiac catheterization.

Purification and properties of arylsulfatase B from high- and low-activity mouse strains.

Arylsulfatase B (arylsulfate sulfohydrolase; EC 3.1.6.1) activities in C57BL/6J, SWR/J, and A/J mouse liver approximate a 5:3:1 ratio. Each enzyme was purified to apparent homogeneity, and the properties of the three purified enzymes were compared. The purified enzyme behaved as a monomer with an apparent molecular weight of 50,000. The purified enzyme catalyzed the hydrolysis of p-nitrocatechol sulfate (pNCS), 4-methylumbelliferyl sulfate (4MUS), and chondroitin-4-sulfate (C4S) heptasaccharide. Purified SWR/J arylsulfatase B possessed a higher relative electrophoretic mobility at pH 4.0 than the A/J and C57BL/6J isozymes, and the SWR/J enzyme was more thermostable than either the C57BL/6J or the A/J enzyme. No differences were observed among the three enzymes with respect to their Michaelis constants for 4MUS and pNCS, isoelectric points, responses to inhibitors, pH optima, or electrophoretic mobilities at pH 8.3. The relative in vivo rates of synthesis of C57BL/6J, A/J, and SWR/J arylsulfatase B were comparable.