Urine-Based Biomarker Test Uromonitor® in the Detection and Disease Monitoring of Non-Muscle-Invasive Bladder Cancer-A Systematic Review and Meta-Analysis of Diagnostic Test Performance.

Optimal urine-based diagnostic tests (UBDT) minimize unnecessary follow-up cystoscopies in patients with non-muscle-invasive bladder-cancer (NMIBC), while accurately detecting high-grade bladder-cancer without false-negative results. Such UBDTs have not been comprehensively described upon a broad, validated dataset, resulting in cautious guideline recommendations. Uromonitor®, a urine-based DNA-assay detecting hotspot alterations in TERT, FGFR3, and KRAS, shows promising initial results. However, a systematic review merging all available data is lacking. Studies investigating the diagnostic performance of Uromonitor® in NMIBC until November 2023 were identified in PubMed, Embase, Web-of-Science, Cochrane, Scopus, and medRxiv databases. Within aggregated analyses, test performance and area under the curve/AUC were calculated. This project fully implemented the PRISMA statement. Four qualifying studies comprised a total of 1190 urinary tests (bladder-cancer prevalence: 14.9%). Based on comprehensive analyses, sensitivity, specificity, positive-predictive value/PPV, negative-predictive value/NPV, and test accuracy of Uromonitor® were 80.2%, 96.9%, 82.1%, 96.6%, and 94.5%, respectively, with an AUC of 0.886 (95%-CI: 0.851-0.921). In a meta-analysis of two studies comparing test performance with urinary cytology, Uromonitor® significantly outperformed urinary cytology in sensitivity, PPV, and test accuracy, while no significant differences were observed for specificity and NPV. This systematic review supports the use of Uromonitor® considering its favorable diagnostic performance. In a cohort of 1000 patients with a bladder-cancer prevalence of ~15%, this UBDT would avert 825 unnecessary cystoscopies (true-negatives) while missing 30 bladder-cancer cases (false-negatives). Due to currently limited aggregated data from only four studies with heterogeneous quality, confirmatory studies are needed.

Burnout and job satisfaction among physicians working in urologic departments who immigrated to Germany, taking into account the income structure of their country of origin.

BACKGROUND: Studies are available on physician burnout and job satisfaction (JS) in relation to the specific income structure of the country of residence. However, no studies exist that investigate burnout of immigrated physicians taking into account the income structure of their country of origin (IS-COO) as well as duration of immigration. OBJECTIVE: To determine the influence of IS-COO on JS, income satisfaction, and critical burnout thresholds in the domains of emotional exhaustion (EE), depersonalization (DP) and reduction in personal accomplishment (RPA) among urologists with a migrant background working at German hospitals. METHODS: A questionnaire (Survey-Monkey®/101-items) was conducted among urologists of German hospitals with a migrant background. The online questionnaire was open for study participation from 1 August to 31 October 2020. The study included all physicians with a migration background who were born in a country other than Germany and were currently employed in a German department of urology. Physician burnout (Maslach-Burnout-Inventory) and JS were assessed using validated instruments. The influence of IS-COO and different covariates on the designated endpoints was tested using multivariate-models. RESULTS: 96 urologists with a median stay in Germany of 7 years participated and were stratified according to low (LIC/41.7%), middle (MIC/36.5%) and high (HIC/21.9%) income based on IS-COO. No significant influence of IS-COO on critical thresholds in each burnout domain could be found. Of urologists from LIC, MIC and HIC, 42%, 59% and 57%, respectively, showed rather or extreme JS (p = .446). There was also no significant difference between groups in income satisfaction (p = .838). However, in multivariate-models, duration of stay in Germany (≥7 vs. <7 years) had significant effects on DP (OR: 0.28, p = .038) and RPA (OR: 0.09, p = .014), but not on EE and JS. CONCLUSION: IS-COO has no impact on burnout and JS among urologists who immigrated to Germany. Similarly, income satisfaction in the country of residence is not influenced by IS-COO.

Job Satisfaction and Intentions to Leave of Foreign-National Urologists Working at German Hospitals: Results of the Cross-Sectional EUTAKD Study.

BACKGROUND: Studies exist that identify factors associated with higher professional satisfaction among clinicians. However, there are no reliable findings for clinicians with a migration background as to whether there is a correlation between particular dimensions of professional satisfaction and the desire to leave their current specialty or country of employment. For the first time, these data were collected within a questionnaire-based study from urological clinicians with a migration background (UCMBs) working in Germany. MATERIAL AND METHODS: A SurveyMonkey® with 101 items relating to characterizing features of the study participants and questions about job satisfaction (n = 39) was opened for UCMBs between August and October 2020. The influence of different dimensions of job satisfaction on the desire to quit the urological specialty/leave Germany was analyzed (group A: neither want to leave urology nor Germany; group B: can at least imagine leaving the urological profession and/or Germany). RESULTS: Eighty-one UCMBs were distributed almost equally in groups A (50.6%) and B (49.4%). Occupational satisfaction was higher in several respects in group A. Three dimensions that differed significantly with regard to occupational satisfaction were used to create an aggregate score ranging from 3 to 15 points as follows: (1) relationship to superiors (p = 0.014), (2) career opportunities in the clinic (p < 0.001), and (3) opportunities for the further development of surgical skills (p = 0.006). For each point value of this aggregate score, the UCMB's desire to quit urology or leave Germany (or at least uncertainty about this question) decreased by a relative value of 34.6% (odds ratio: 0.654, 95% confidence interval: 0.496-0.861, p = 0.002). CONCLUSIONS: Various dimensions of job satisfaction have been identified, the improvement of which could contribute to the long-term retention of UCMBs at German urological clinics.

Ruptured giant left anterior descending coronary artery pseudoaneurysm.

We report a rare case of a ruptured giant left anterior descending coronary artery pseudoaneurysm that necessitated salvage operative repair. This case affirms the life-threatening nature of this clinically significant pathology, as well as the need for emergent repair before pseudoaneurysm rupture to maximize the likelihood of patient survival.

[Relationship between non-medical reading and burnout as well as professional satisfaction among urologists with migrant background: results of the EUTAKD survey study conducted at German hospitals]. / Zusammenhang zwischen dem Lesen nicht-medizinischer Bücher mit Burnout und beruflicher Zufriedenheit bei Urologen mit Migrationshintergrund ­ Ergebnisse einer Fragebogenstudie an deutschen Kliniken.

BACKGROUND: There are no study results on the private and professional satisfaction and the burnout risk of urologists with a migrant background at German hospitals to date. Non-medical reading has been described to have an influence on lower burnout rates among physicians of different specialties. MATERIAL AND METHODS: A SurveyMonkey questionnaire with 101 items on criteria characterising the study participant, questions on private and professional satisfaction and the complete Maslach Burnout Inventory was opened to urologists with a migrant background at German clinics between August and October 2020. The impact of non-medical reading on professional satisfaction and burnout was comparatively assessed (group A: ≤1 book/12 months versus group B: ≥2 books/12 months). RESULTS: Eighty-one study participants were included. They were almost equally distributed into groups A (49.4%) and B (50.6%). In several items on personal and professional satisfaction, there was a significantly higher satisfaction in group B. In the burnout dimensions of emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA), a high risk of burnout was present in 27.9%, 35.3% and 73.5% of the study participants. A group comparison revealed significant advantages for Group B in the PA dimension in both the sum score (p=0.001) and the categorical comparison (p=0.002). Study participants in Group B also had a significantly lower DP dimension sum score compared with Group A (p=0.047). The group variable was independently associated with a combined score of EE and DP on the one hand (OR 0.316; p=0.031) and the PA dimension on the other (OR 0.170; p=0.024). CONCLUSIONS: Reading non-medical books was associated with higher professional satisfaction and a lower burnout risk among urologists with a migrant background at German hospitals.

A review of a regional primary percutaneous coronary intervention service, with a focus on door to reperfusion times: the 2012 Auckland/Northland experience.

AIMS: Primary percutaneous coronary intervention (PCI) is the optimal management for ST segment elevation myocardial infarction (STEMI) patients. We reviewed the largest primary PCI regional service in New Zealand: the Auckland/Northland service based at Auckland City Hospital, to assess patient management, in particular the door to reperfusion times (DTRTs), and predictors of death in hospital. METHODS: We obtained patient details from a comprehensive prospective database of all primary PCI patients admitted with STEMI from 1/1/12 to 31/12/12 to the Auckland City Hospital cardiac catheterisation laboratory. Of four District Health Boards (DHBs) within the region, two accessed this regional service at all times, and two accessed the Auckland City Hospital cardiac catheterisation laboratory 'after hours': all times except for 08:00 to 16:00 hours on Monday to Friday. RESULTS: A total of 401 adult patients underwent a primary PCI at the Auckland City Hospital Regional centre for a STEMI presentation, over the 12 months period. The median patient age was 61 years, 77% were male. Overall 183 (46%) (95% CI 41, 51) patients achieved a DTRT of < 90 mins, and 266 (66%) (95% CI 61, 71) a DTRT of < 120 mins, with a clear geographical influence to these times. Of 27 patients with direct transfer to the catheter laboratory from the community, the DTRT was < 120 mins in 24 (92%) (95% CI 72, 96) patients. In-hospital mortality was 24 (6%) patients (95% CI 4, 9). CONCLUSIONS: The 2012 Auckland/Northland primary PCI service delivers good outcomes consistent with current Australasian standards. Although geographical isolation complicates door to reperfusion times, these may potentially be improved by more focus on direct transfer to the cardiac catheterisation laboratory, especially directly from the community.

Evaluating the use of prostate-specific antigen as an instrument for early detection of prostate cancer beyond urologists: results of a representative cross-sectional questionnaire study of general practitioners and internal specialists.

OBJECTIVES: The aim of this cross-sectional study was to evaluate the value of prostate-specific antigen (PSA) testing as a tool for early detection of prostate cancer (PCa) applied by general practitioners (GPs) and internal specialists (ISs) as well as to assess criteria leading to the application of PSA-based early PCa detection. METHODS: Between May and December 2012, a questionnaire containing 16 items was sent to 600 GPs and ISs in the federal state Brandenburg and in Berlin (Germany). The independent influence of several criteria on the decision of GPs and ISs to apply PSA-based early PCa detection was assessed by multivariate logistic regression analysis (MLRA). RESULTS: 392 evaluable questionnaires were collected (return rate 65%). 81% of the physicians declared that they apply PSA testing for early PCa detection; of these, 58 and 15% would screen patients until the age of 80 and 90 years, respectively. In case of a pathological PSA level, 77% would immediately refer the patient to a urologist, while 13% would re-assess elevated PSA levels after 3-12 months. Based on MLRA, the following criteria were independently associated with a positive attitude towards PSA-based early PCa detection: specialisation (application of early detection more frequent for GPs and hospital-based ISs) (OR 3.12; p < 0.001), physicians who use exclusively GP or IS education (OR 3.95; p = 0.002), and physicians who recommend yearly PSA assessment after the age of 50 (OR 6.85; p < 0.001). CONCLUSIONS: GPs and ISs frequently apply PSA-based early PCa detection. In doing so, 13% would initiate specific referral to a urologist in case of pathological PSA values too late. Improvement of this situation could possibly result from specific educational activities for non-urological physicians active in fields of urological core capabilities, which should be guided by joint boards of the national associations of urology and general medicine.

Two causes of ventricular tachycardia in a 26 year-old male.

We present the case of a 26 year-old man who presented to hospital with monomorphic ventricular tachycardia (VT) at a rate of 170bpm after exercising on a treadmill. Multimodality imaging with transthoracic echocardiogram (TTE), cardiac magnetic resonance imaging (CMRI) and computed tomography coronary angiogram (CTCA) demonstrated two causes for ventricular tachycardia; hypertrophic cardiomyopathy (HCM) and an anomalous right coronary artery (RCA) arising from the left coronary sinus, with a potentially malignant interarterial course. Both conditions can be associated with sudden cardiac death (SCD). We discuss the management dilemmas in this unique patient.

Coronary artery anatomy and apical sparing in apical ballooning syndrome: implications for diagnosis and aetiology.

BACKGROUND: Apical ballooning syndrome (ABS) is characterised by transient regional systolic dysfunction involving the left ventricular apex and mid-myocardial segments. The absence of obstructive coronary disease is required in some diagnostic criteria. Some investigators have suggested that a long "wrap-around" left anterior descending (LAD) artery may explain the pattern of regional wall motion abnormalities. METHODS AND RESULTS: We reviewed the coronary angiograms and ventriculograms findings in a prospective ABS cohort of 46 patients (mean age 63+/-13, female 96%). Normal smooth coronary arteries were observed in 54%, with 30% having minor irregularities. Moderate or severe coronary artery lesions were identified in 7 (15%) patients, including 4 with moderate LAD disease. The extent of the LAD artery around the left ventricular apex to the diaphragmatic surface of the heart was scored. This score was compared to 60 consecutive gender-matched control patients without ABS and no observed difference between the two groups (p=0.62). 42% had sparing of LV apical akinesis which was independent of the LAD extent. CONCLUSION: Moderate or severe coronary artery stenosis may co-exist in a small proportion of patients with ABS. Exclusion of these patients will underestimate the true incidence of ABS. The prevalence of "wrap-around" LAD is similar in ABS and non-ABS patients. Apical sparing in ABS is more consistent with aetiological hypotheses implicating LV stunning due to acutely elevated LV wall stress, rather than single or multi-vessel coronary spasm.

Post-void residual urine as a predictor of urinary tract infection--is there a cutoff value in asymptomatic men?

PURPOSE: Post-void residual urine can lead to various complications, including urinary tract infection. Recently investigators calculated that a cutoff value of 180 ml has considerably high sensitivity and specificity for significant bacteriuria in asymptomatic men. We determined the association between post-void residual urine volume and urinary tract infection, and validated the suggested 180 ml cutoff in asymptomatic men. MATERIALS AND METHODS: In a prospective study we analyzed certain criteria in 225 asymptomatic male patients, including prostate specific antigen, prostate volume, International Prostate Symptom Score, peak urine flow rate, urine culture results and post-void residual urine volume using transabdominal ultrasound. Using ROC analysis a cutoff predicting bacteriuria was calculated. Different cutoff values were validated. RESULTS: Of the study group 60% were able to completely empty the bladder and had a post-void residual urine volume of 10 ml or less. However, in 31% of the study group urine culture was positive. Patients presenting with urinary tract infection had significantly higher mean post-void residual urine volume than patients without urinary tract infection (113 vs 41 ml, p <0.001). In 29 men (13%) post-void residual volume was 180 ml or greater. Confirming urinary tract infection, this cutoff showed only 28% sensitivity and 94% specificity (AUC 0.606, p = 0.01). CONCLUSIONS: No cutoff value could be determined to predict positive urine culture with sufficient sensitivity and specificity. Based on the results of the current study it seems premature to recommend a cutoff value leading to therapeutic consequences.

The antiplatelet effect of higher loading and maintenance dose regimens of clopidogrel: the PRINC (Plavix Response in Coronary Intervention) trial.

OBJECTIVES: This study evaluated the antiplatelet effect of a higher loading and maintenance dose regimen of clopidogrel and a possible drug interaction with verapamil. BACKGROUND: Clopidogrel loading doses above 600 mg have not resulted in more rapid or complete platelet inhibition. Higher maintenance dosages may be more effective than 75 mg/day. METHODS: A double-blind, randomized, placebo-controlled trial was undertaken in 60 patients undergoing percutaneous coronary intervention. All patients received clopidogrel 600 mg at the start of the procedure. Using a 2 x 2 design, patients were allocated to clopidogrel 600 mg given 2 h later or matching placebo, and to verapamil 5 mg intra-arterial or placebo. Platelet function was measured using the VerifyNow P2Y12 analyzer (Accumetrics Ltd., San Diego, California) at 2, 4, and 7 h. Patients were further randomized to receive a clopidogrel 75 or 150 mg once daily, with platelet function assessed after 1 week. RESULTS: Two hours after the second dose of clopidogrel or placebo, platelet inhibition was 42 +/- 27% with clopidogrel, compared with 24 +/- 22% with placebo (p = 0.0006). By 5 h after the second dose, platelet inhibition was 49 +/- 30% with clopidogrel, compared with 29 +/- 22% with placebo (p = 0.01). No drug interaction was seen with verapamil. A clopidogrel maintenance dosage of 150 mg daily for 1 week resulted in greater platelet inhibition than 75 mg daily (50 +/- 28% vs. 29 +/- 19%, p = 0.01). CONCLUSIONS: In an unselected population undergoing percutaneous coronary intervention a clopidogrel 1,200-mg loading dose, given as two 600-mg doses 2 h apart, results in more rapid and complete platelet inhibition than a single 600-mg dose. A maintenance dosage of 150 mg daily produces greater platelet inhibition than 75 mg daily. (The PRINC trial; ACTRN12606000129583).

The pharmacogenetics and pharmacodynamics of clopidogrel response: an analysis from the PRINC (Plavix Response in Coronary Intervention) trial.

OBJECTIVES: This study assessed the effect of pharmacogenetics on the antiplatelet effect of clopidogrel. BACKGROUND: Variability in clopidogrel response might be influenced by polymorphisms in genes coding for drug metabolism enzymes (cytochrome P450 [CYP] family), transport proteins (P-glycoprotein) and/or target proteins for the drug (adenosine diphosphate-receptor P2Y12). METHODS: Sixty patients undergoing elective percutaneous coronary intervention in the randomized PRINC (Plavix Response in Coronary Intervention) trial had platelet function measured using the VerifyNow P2Y12 analyzer after a 600-mg or split 1,200-mg loading dose and after a 75- or 150-mg daily maintenance dosage. Polymerase chain reaction-based genotyping evaluated polymorphisms in the CYP2C19, CYP2C9, CYP3A4, CYP3A5, ABCB1, P2Y12, and CES genes. RESULTS: CYP2C19*1*1 carriers had greater platelet inhibition 2 h after a 600-mg dose (median: 23%, range: 0% to 66%), compared with platelet inhibition in CYP2C19*2 or *4 carriers (10%, 0% to 56%, p = 0.029) and CYP2C19*17 carriers (9%, 0% to 98%, p = 0.026). CYP2C19*2 or *4 carriers had greater platelet inhibition with the higher loading dose than with the lower dose at 4 h (37%, 8% to 87% vs. 14%, 0% to 22%, p = 0.002) and responded better with the higher maintenance dose regimen (51%, 15% to 86% vs. 14%, 0% to 67%, p = 0.042). CONCLUSIONS: Carriers of the CYP2C19*2 and *4 alleles showed reduced platelet inhibition after a clopidogrel 600-mg loading dose but responded to higher loading and maintenance dose regimens. Genotyping for the relevant gene polymorphisms may help to individualize and optimize clopidogrel treatment. (Australia New Zealand Clinical Trials Registry; ACTRN12606000129583).

Timing of thrombotic events in patients receiving 2 weeks of clopidogrel therapy post bare metal coronary artery stenting: a New Zealand retrospective study.

OBJECTIVE: To investigate if increased thrombotic events occurred after cessation of a 2-week course of clopidogrel treatment in patients who had implantation of bare metal stent. SETTING: Dunedin Public Hospital, a tertiary referral centre in New Zealand. PATIENTS: 1000 consecutive patients undergoing percutaneous coronary intervention (PCI) with stent implantation from January 2000 to October 2003 were analysed. Those who had successful implantation of bare metal stent without clinical events in the first 24 hours and who received 2 weeks of clopidogrel treatment were included in the study (n=983). MAIN OUTCOME MEASURES: Stent thromboses between 24 hours and 6 weeks post PCI. RESULTS: There were 13 (1.3%) stent thromboses between 24 hours and 6 weeks post PCI, resulting in 3 deaths (23%), 2 ST-elevation acute coronary syndrome [ACS] (15%), and 8 non-ST elevation ACS (62%). The median time for stent thrombosis was 18 +/-s 14 days. Five of the 13 cases (38%) of stent thrombosis occurred after the first 2-weeks (1 in week 3, 1 in week 5, 3 in week 6), and all had predisposing factors for stent thrombosis (2 with stent length > or = to 30 mm, 3 with stent diameter < or = to 2.5mm and 2 with bifurcation stenting). CONCLUSION: Five of 13 (38%) stent thromboses occurred in week 3 to week 6 after cessation of a 2-week course of clopidogrel post bare metal stenting.

Lunar phases and zodiac signs do not influence quality of radical cystectomy--a statistical analysis of 452 patients with invasive bladder cancer.

OBJECTIVE: To determine the influence of the lunar phases and the position of the moon in the zodiac on the frequency of complications and the survival of bladder cancer patients after radical cystectomy. It has been postulated that radical cystectomy performed during the waxing moon, or particularly at full moon, or at the zodiac sign Libra is associated with a poorer outcome. MATERIAL AND METHODS: We tested this hypothesis by evaluating the progression-free survival, the complication rate and the re-operation rate for 452 consecutive patients after radical cystectomy. In this retrospective review, the dates of surgery were allocated to the lunar phases and the zodiac signs. Based on these classifications, the patients were placed in groups which combined the lunar phase laws and differentiated between evidently unfavorable (full moon or waxing moon and/or the zodiac sign Libra; assigned to group 1) and favorable periods for surgery (new moon or waning moon and other signs of the zodiac apart from Libra; assigned to group 2). The mean follow-up was 49 months (range 0-158 months). RESULTS: A total of 244 patients (54%) were operated during an unfavorable period (group 1) and 208 (46%) patients during the auspicious period (group 2). The mean age, gender and kind of urinary derivation did not differ significantly in the two groups. Pathological tumor stages were evenly distributed according to the lunar phase groups (P = 0.713). We found no significant differences in the perioperative mortality rates, early re-operation rates, early complications, and late complications across the two groups. No significant differences in progression-free survival were observed when timing of cystectomy during the lunar cycle was considered (P = 0.231). CONCLUSIONS: Our analysis demonstrated no predictable influence of the lunar phase on survival or complications. Although this was not a prospective randomized trial, the statistical magnitude of the results do not support any recommendations for scheduling patients for radical cystectomy at any particular day of the lunar phase.

Clinical outcome of older patients with acute coronary syndrome over the last three decades.

OBJECTIVE: To Evaluate the clinical outcome of patients with acute coronary syndrome (ACS) in the Coronary Care Unit (CCU) over three decades in Dunedin, New Zealand. DESIGN: Registry study. SETTING AND PATIENTS: all consecutive patients (n = 3,013) with ACS admitted to the CCU from 1979 to 1981 (n = 966) and from 1989 to 1991 (n = 1470) were included prospectively. Data on ACS patients managed in the CCU in 2001-2002 (n = 577) were obtained via medical chart review. RESULTS: There was a rising proportion of older (> or = 75 years of age) patients with ACS (3.8% in 1979-1981, 15.2% in 1989-1991 and 25.6% in 2001-2002, P < 0.0005). However, we observed a progressive reduction of in-hospital mortality for ACS (10.7, 7.3 and 5.0%, P < 0.005) and for ST-elevation myocardial infarction (STEMI) (18.4, 16.1 and 6.6%, P < 0.005). The progressive fall in mortality rate was also observed amongst older patients, both for ACS (27, 19.2 and 11.5%, P = 0.011) and for STEMI (34.8, 30.9 and 15.4%, P < 0.005). Of concern, only 10% of patients presented within 1 h of symptom onset and 50% within 5 h, and this has not changed over three decades. The variables associated with < 5 h from symptom onset to presentation were men [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.42, P = 0.001], a history of ischaemic heart disease (OR 1.25, 95% CI 1.09-1.43, P = 0.002) and STEMI (OR 1.41, 95% CI 1.18-1.67, P < 0.0001). Advanced age was not a predictor for late presentation. CONCLUSIONS: Over the past three decades, more old patients were treated in the CCU. However, there was a decline in hospital mortality, particularly for STEMI. Further efforts are required to decrease the time to presentation.

Use of evidence-based management for acute coronary syndrome.

AIMS: This study compared the management of acute coronary syndrome (ACS) for patients admitted to Dunedin Coronary Care with evidence-based recommendations from the American College of Cardiology / American Heart Association in 1999 and 2002 and with management reported in international and local registries. METHODS: All patients with ACS from 2001-2002 were included. RESULTS: Guidelines stated that aspirin, beta-blockers, statins, and ACE-inhibitors/angiotensin-II-blockers are appropriate treatment for acute coronary syndrome. These medications were prescribed respectively in 98%, 80%, 70% and 55% of patients on discharge. In patients with documented dyslipidaemia, Statins was prescribed in 80% on discharge. The use of ACE inhibitors was 73% in patients with impaired left ventricular function, 79% in patients with clinical heart failure and 84% in patients with anterior ST-elevation myocardial infarction (STEMI). For patients with STEMI, 67% received coronary angiography, 50% had PCI and 7% underwent inpatient coronary artery bypass grafting. For Non-ST-elevation myocardial infarction (NSTEMI), the respective numbers were 73%, 38% and 21%. Our use of evidence-based medications was consistent with published guidelines and comparable to results of international registries (CRUSADE, EUROESPIRE II, GRACE) in 2001-2002. CONCLUSION: There is good adherence to the use of evidence-based management for acute coronary syndrome in Dunedin Coronary Care Unit.

Pre-transplant inosine monophosphate dehydrogenase activity is associated with clinical outcome after renal transplantation.

UNLABELLED: Mycophenolate mofetil (MMF), an inhibitor of inosine monophosphate dehydrogenase (IMPDH) activity, is usually administered as a standard dose of 1 g b.i.d. after renal transplantation. Because MMF dose reductions are associated with inferior outcome, we investigated pre-transplant IMPDH activity, MMF dose reductions and outcome. IMPDH activity was determined in isolated peripheral mononuclear cells immediately prior to renal transplantation. We observed considerable inter-individual variability in pre-transplant IMPDH activity (9.35 +/- 4.22 nmol/mg/h). Thirty of 48 patients (62.5%) with standard MMF dose (1 g b.i.d.) had dose reductions within 3 years post-transplant; these patients also had significantly lower IMPDH activity. The area under the receiver-operating characteristics curve (AUC-ROC) for prediction of dose reduction within 6 months post-transplant was 0.75 (95% CI, 0.61-0.89; p < 0.004). IMPDH activity above the cut-off value, MMF dose reduction and age of recipient were significant contributors for the occurrence of acute rejection in the multivariate logistic regression. Patients with high IMPDH activity and MMF dose reduction had the highest rejection rate (81.8% vs. 36.4%; p < 0.01). CONCLUSION: Patients with low IMPDH activity experienced more complications of MMF therapy. High pre-transplant IMPDH activity and MMF dose reductions were associated with rejection. Determination of IMPDH activity prior to transplantation may help to improve MMF therapy after renal transplantation.

Drug-eluting stents for coronary bifurcations: insights into the crush technique.

Sirolimus-eluting stents appear to reduce substantially restenosis following percutaneous coronary bifurcation intervention. The crush technique was devised to reduce restenosis further by improving stent and drug application to the side-branch ostium. We aimed to investigate the performance of drug-eluting stent (DES) platforms with the crush technique, to identify deployment pitfalls, and to clarify the best deployment strategies. Each stage of the crush technique was photographed in a bifurcation phantom. Simultaneous side- and main-branch dilatation (kissing balloons) fully expanded the stent in the side-branch ostium, widened the gaps between stent struts covering the side branch, and eliminated main-branch distortion. With side branches angled at > 70 degrees , sequential (side- then main-branch) inflations may be needed to achieve best results. Postdilatation of the main branch with a balloon of narrower diameter than the deploying balloon caused main-branch stent distortion. These principles applied to all the bifurcation strategies and stent designs tested.