Emergency medical service providers' role in the early heart attack care program: prevention and stratification strategies.

Emergency Medical Services-Early Heart Attack Care (EMS-EHAC) is a community-based program where paramedics increase the consumer's awareness about early chest pain symptom recognition. EMS-EHAC prevention, along with seamless chest pain care (between the paramedic and chest pain emergency department) can be the basis for an outcome-based study to examine the impact of advanced life support EMS. Studies that show the impact of care given by paramedics on the outcome of patient care must be designed to demonstrate the value and the cost benefit of providing advanced life support (ALS). Third party payers are going to examine if there are significant quality differences between ALS and basic life support (BLS) services. If significant benefits of ALS care cannot be demonstrated, the cost differences could potentially place the future of advanced life support paramedic programs in jeopardy. A positive outcome resulting in a lower acute cardiac event, and the realization of the cost benefits from the EMS-EHAC program could be utilized by EMS management to justify or expand advanced life support programs.

Non-surgical approaches to stones in the biliary tree.

Medical treatment of cholesterol gall stones aims to dissolve the stones leaving the biliary tract stone-free and the gall bladder in situ. The introduction of extracorporeal shock wave lithotripsy and contact solvent therapy with methyl tert butyl ether have revolutionised the medical management of both gall bladder stones and bile duct stones which are too large to be treated by sphincterotomy. Both approaches represent a major advance over cheno- and ursodeoxycholic acid which are effective in less than 30% of cases and require prolonged therapy. All medical treatments require a functioning gall bladder and suffer from relapse rates in the order of 10% per annum. Secondary prophylaxis is expensive and the rate of compliance and long term safety have yet to be established.

Enhanced secretion of prostaglandin E2 by tissue-fixed macrophages in colonic carcinoma.

Prostaglandin E2 (PGE2) secretion by peripheral blood and tissue-fixed macrophages from patients with colorectal carcinoma was assessed. There was no significant difference between PGE2 production by peripheral blood mononuclear cells between patients with colorectal carcinoma and normal controls. However, secretion of PGE2 by tissue-fixed macrophages from within the colorectal carcinomata in response to opsonised zymosan was significantly higher than in the uninvolved colonic tissue. PGE2 production by tissue-fixed macrophages from within colonic polyps was found to be normal. These results could not be explained on the basis of increased availability of substrate arachidonic acid since addition of excess arachidonic acid resulted in similar findings. The enhanced production of PGE2 correlated with Dukes staging but not the level of differentiation. The production of PGE2 from epithelial cells in response to ionophore A23187 was not significantly enhanced. Leukotriene B4 secretion by intestinal macrophages in response to opsonised zymosan was not significantly elevated in the colonic tumour tissue. Modulation of levels of prostaglandin production within colonic tumours may play a role in the rate of growth and vascularity of these tumours and in the regulation of the local immune response to malignancy.