An evaluation of the relationship between specialist training in cardiology and implementation of evidence-based care of patients following acute myocardial infarction.

AIMS: Large clinical trials have provided evidence of prognostically beneficial treatment strategies for patients with acute myocardial infarction. However, the implementation of this evidence into routine clinical practice is suboptimal. We hypothesised that the speciality of the attending physician (cardiologist or not) would affect the use of evidence-based strategies. METHODS: Over a 3-month period (1st September to 30th November 1995), 3684 consecutive potential cases of acute myocardial infarction (AMI) in 20 adjacent hospitals in the Yorkshire Region were identified from coronary care registers, clinical coding and biochemistry records of cardiac enzyme assay requests. There were 2153 consecutive cases of AMI identified, of which 1643 patients were alive at discharge. We compared the admission use of aspirin and thrombolysis, and the use of aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and statins at discharge between cardiologists and other physicians. RESULTS: AMI patients under the care of cardiologists are more likely to receive aspirin and thrombolysis on the day of their event and to be prescribed aspirin, beta-blockers and statins on discharge. After correction for contraindications to their use, the above findings were broadly confirmed. DISCUSSION: Cardiologists are more likely than general physicians to use evidence-based treatment strategies recognised to improve AMI patient outcome. It is likely that this will translate into a reduction of mortality or other hard endpoints in patient outcomes.

Induction of metamorphosis in the marine gastropod Ilyanassa obsoleta: 5HT, NO and programmed cell death.

The central nervous system (CNS) of a metamorphically competent larva of the caenogastropod Ilyanassa obsoleta contains a medial, unpaired apical ganglion (AG) of approximately 25 neurons that lies above the commissure connecting the paired cerebral ganglia. The AG, also known as the cephalic or apical sensory organ (ASO), contains numerous sensory neurons and innervates the ciliated velar lobes, the larval swimming and feeding structures. Before metamorphosis, the AG contains 5 serotonergic neurons and exogenous serotonin can induce metamorphosis in competent larvae. The AG appears to be a purely larval structure as it disappears within 3 days of metamorphic induction. In competent larvae, most neurons of the AG display nitric oxide synthase (NOS)-like immunoreactivity and inhibition of NOS activity can induce larval metamorphose. Because nitric oxide (NO) can prevent cells from undergoing apoptosis, a form of programmed cell death (PCD), we hypothesize that inhibition of NOS activity triggers the loss of the AG at the beginning of the metamorphic process. Within 24 hours of metamorphic induction, cellular changes that are typical of the early stages of PCD are visible in histological sections and results of a terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay in metamorphosing larvae show AG nuclei containing fragmented DNA, supporting our hypothesis.

Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain.

OBJECTIVE: To describe the clinical features, prognosis, and treatment of patients presenting with atypical forms of acute myocardial infarction. DESIGN: Consecutive cases of possible acute myocardial infarction were sought from coronary care registers, biochemistry records, and hospital management systems. Case notes were reviewed and predefined epidemiological and clinical variables were abstracted. SETTING: 20 adjacent hospitals in the former Yorkshire region. PATIENTS: 3684 consecutive cases of possible acute myocardial infarction admitted in a three month period were identified, of whom 2096 had a first episode of confirmed acute myocardial infarction. RESULTS: 20.2% of all patients admitted with an eventual diagnosis of acute myocardial infarction presented with symptoms other than chest pain. Compared with the group presenting with chest pain, these patients were older (76.6 v 69.1 years, p < 0.001), were more often women (54.6% v 35.3%, p < 0.001), and were more likely to have a history of heart failure (18.6% v 6.9%, p < 0.001). They had a higher 30 and 365 day mortality (49.2% and 61.0%, respectively) compared with patients presenting with chest pain (17.9% and 26.2%). In a Cox regression analysis the hazard ratio for presentation without chest pain was 1.60 (95% confidence interval 1.30 to 1.97) (p < 0.001) adjusted for age, heart rate, blood pressure, left ventricular impairment, and infarction with ST segment elevation as covariates. Importantly, they were also less likely to receive treatments with a proven ability to improve prognosis. CONCLUSIONS: Atypical presentation of myocardial infarction without chest pain is common and associated with increased mortality. This may result in part from a failure to use beneficial treatment strategies.

Autonomic assessment of cardiovascular disease.

Autonomic dysfunction plays a major role in the pathophysiology of many medical conditions, particularly cardiovascular disorders and diabetes mellitus. This article describes some of the methods used to assess cardiovascular autonomic function, and concentrates on the techniques that have a current or potential clinical application.

An anatomical study of inguinal lymph node topography and clinical implications for the surgical management of vulval cancer.

There is significant morbidity associated with inguinofemoral lymphadenectomy in the surgical treatment of vulval cancer, but surgical removal of all involved lymph nodes is integral to the treatment of the disease. In order to examine the feasibility of limiting the surgical dissection of the groin without compromising the removal of all lymph nodes, a study was undertaken to determine the exact location of the inguinal lymph nodes. Bilateral lower limb lymphangiograms from 73 patients were analyzed to determine the location of the most laterally occurring lymph node relative to the anterior superior iliac spine (ASIS) and the most medial node relative to the pubic tubercle (PT). By conserving the lateral 15% of fibro-fatty tissue overlying the right inguinal ligament and the lateral 20% over the left inguinal ligament, there is statistically a greater than 99.8% chance of complete nodal clearance. The anatomical basis for a more conservative inguinofemoral dissection is provided that may decrease surgical morbidity without compromising survival.

Dermatoglyphic indicators of congenital heart defects in Down's syndrome patients: a preliminary study.

In a preliminary study fingerprint patterns of Down's syndrome children were examined to determine correlations with congenital heart defects (CHD). The results demonstrate that the left hand digit ridge count minus the right hand digit ridge count, and number of ridges on the fifth digit of the left hand separate patients with CHD from those without heart defects (W/OHD). The method correctly classified 92% of the CHD group and 73% of the W/OHD group.

Behavior of mouse placental and uterine estrogen sulfotransferase during chromatography and other procedures.

The estrogen sulfotransferase activity of high-speed supernatants of mouse placenta and uterus behaves on conventional and high-performance liquid chromatographic gel filtration as an enzyme species with a molecular weight of the order of 30 000. This is so whether the cytosols are freshly prepared or have been stored at -20 degrees C before chromatography. The presence of thiol groups or EDTA has no effect on the elution pattern. The partially purified enzyme is extremely unstable and is poorly recovered by (NH4)2SO4 fractionation. Some stabilization can be achieved in the presence of 0.1 microM estradiol. Chromatofocusing of cytosols results in the elution of one or two sulfotransferase peaks, depending upon experimental conditions such as the presence or absence of thiol groups. These peaks act upon both estrone and estradiol as substrates. Chromatofocusing by fast protein liquid chromatography (FPLC) in the absence of thiol groups results in the elution of one sulfotransferase peak whose activity can be detected only when thiol groups are present during enzyme assay.

Simple agar block slide culture suitable for varying the environment of bacteria during time-lapse cinephotomicrography.

A simple paper wick agar block slide culture is described for use in experiments which vary the chemical environment of bacteria during time-lapse cinephotomicrography.

Synthesis and biological activity of some derivatives of thiochroman-4-one and tetrahydrothiapyran-4-one.

A small series of pyrazoles and isoxazoles derived from thiochroman-4-one has been synthesized and characterized. The compounds were examined for their in vitro inhibitory activity against Bacillus subtilis and Pseudomonas fluorescens. Among the tested compounds the pyrazole derivative from thiochroman-4-one was found to be the most effective inhibitor of growth of B. subtilis. Extensive H NMR analysis was recorded for all compounds.

Synthesis and antimicrobial activity of azasteroid-type compounds and related systems. Effect of hydrophilic and lipophilic groups on activity.

Pyrazole-, pyrazolone- and isoxazole-containing systems were prepared from 3,4-dihydro-6-(hexyloxy)-1(2H)-naphthalenone, 3,4-dihydro-6-(hexadecyloxy)-1(2H)-naphthalenone,3,4-dihydro-6(2-dimethylaminoethyloxy)-1-(2H)-naphthalenone, 3,4-dihydro-7-hexyloxy-1(2H)-phenanthrone, and 3,4-dihydro-7-(2-dimethylaminoethyloxy)-1(2H)-phenanthrone. A number of compounds derived from 7, 8-dihydro-5(6H)-quinolinone were also synthesized and characterized. Both hydrophilic and lipophilic groups were incorporated into certain systems as well as cidal groups. The compounds were screened for their in vitro inhibitory activity against Bacillus subtilis and Pseudomonas fluorescens. Structure-acitivity relationships among the molecular systems are discussed.

15-Azasteroid blockage of cell permeability and mitochondrial respiration.

The 15-azasteroid, 1,10,11,11a-tetrahydro-11a-methyl-2H naphth (1,2-g)indol-7-o1, inhibits the growth of the cell culture lines KB and L-M as well as several strains of bacteria. The inhibition of growth is reversed following removal of the steroid from the growth medium. Using in vitro grown L-M cells, the compound inhibited the transport of amino acids and uracil. The action was non-detergent like and at least 100 times more effective in terminating metabolite transport than sodium azide. The azasteroid inhibited the oxidation of glutamate in isolated rat liver mitochondria. The oxidation of succinate was not effected by the azasteroid alone but in the presence of glutamate, the azasteroid uncoupled the oxidation of succinate from the ADP-ATP control. It is suggested that the azasteroid may be acting directly on the electron transport system and/or acting indirectly through membrane perturbations which disrupts the electron transport process.

Antibacterial activity of 15-azasteroids alone and in combination with antibiotics.

A new class of 15-azasteroid analogues has been synthesized and tested for antimicrobial activity. The compounds 1, 10, 11, 11a-tetrahydro-7-methoxy-11a-methyl-2H-naphth (1,2-g) indol (methoxyimine) and 1,10,11,11a-tetrahydro-11a-methyl-2H-naphth (1,2-g) indol-7-ol (hydroxyimine) inhibit the growth of Bacillus subtillis and Escherichia coli at concentrations as low as 10-5 M. Addition of either compound to the growth medium casued a rapid inhibition in the transport of radioactive glucose, uracil and several amino acids. The inhibition of growth and substrate transport was reversed following removl of the steroid from the medium. The evidence is consistent with a site of steroid action at the cell periphery. Combining the methoxyimine with polyor circulin at subinhibitory concentrations produced greatly enhanced antimicrobial activity against Pseudomonas fluorescens. Similar action was observed against B. subtilis when the azasteroid was combined with vancomycin or chloramphenicol. The inhibitory action of other antibiotics such as penicillin or erythromycin was not affected by addition of the test compound. The results suggest formation of a molecular complex between the azasteroid and antibiotic which is responsible for the enhanced biological activity.

Molecular changes in cell surface membranes resulting from trypsinization of sarcoma 180 tumor cells.

Sarcoma-180 tumor cells in culture or grown as an ascites form in the CD-1 mouse have been subjected to mild trypsinization procedures in order to study morphological and molecular changes resulting from proteolysis. The cells attached to a substratum become rounded within 20 min. and most undergo cell division, but they do not detach from the substratum. Removal of trypsin permits the cells to go back to their original spindle shape over an 8-20 h period. Surface membranes were isolated from trypsinized ascites and cultured cells and subjected to dodecyl sulfate-acrylamide gel electrophoresis. Both cell types showed the same two kinds of changes in electrophoretic patterns. First, there was a loss of glycoproteins from both cell types even though they show different complements of cell surface glycoproteins. Second, there is a loss of high molecular weight polypeptides, which have previously been suggested to play a role in membrane stabilization and cell shape. These results further implicate these polypeptides in the control of cell morphology and offer circumstanital evidence for transmembrane interactions of surface glycoproteins with the high molecular weight polypeptides as a factor in controlling cell morphology.

Novel pyrazolo, isoxazolo, and thiazolo steroidal systems and model analogs containing dimethyoxylaryl (or dihydroxylaryl) groups and derivatives. Synthesis, spectral properties, and biological activity.

The total syntheses of a series of vicinal-substituted dimethoxy and dihydroxy heterosteroids of the equilenin type and model analogs are described. A novel class of pyrazolo steroidal N-glucosides has also been synthesized. Compounds prepared were screened in vitro for growth inhibition of different microorganisms. Of these, 1-alpha-d-glucopyranosyl-4,5-dihydro-7-methyoxy-1H-benz[g]indazole tetraacetate (3) was quite active. For example, N-glucoside 13 inhibited the growth of Bacillus subtilis, Pseudomonas fluorescens, Staphylococcus aureus, and KB cells at moderate concentrations.

Synthesis and structure-activity relationships of heterocyclic compounds containing a trimethoxyarene function.

Pyrazole-, isoxazole-, and pyrazolone-containing systems were prepared from 3,4-dihydro-5,6,7-trimethoxy-1(2H)-naphthalenone, 3,4-dihydro-6,7,8-trimethoxy-1(2H)-naphthalenone, and 3,4-dihydro-6,7,8-trimethoxy-1(2H)-phenanthrone. Primarily, the pyrazoles displayed inhibition of growth in the microbial screens and in tissue culture. Correlation of the heteroatom distances between the oxygen atoms of two methoxy groups and a nitrogen atom in the pyrazole function with the percent plating efficiency on KB cell growth suggests increased inhibition as the (OA-N)/(OB-N) ratio deviates from one. No trend was observed in relating the OA-N-OB angle and activity for the examples studied.

Construction of the perineal body in the female.

A simple, one-stage operation is presented for the construction of a perineal body in a female who has a common rectovaginal opening, or cloaca. The operation has been performed on 3 teenaged girls, with an excellent result in each. In only one instance has been necessary to perform a secondary operation for correction of the rectal incontinence.