Biomedical subjects
Publications and source records attributed to W L Williams.
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OBJECTIVES: We sought to directly compare primary stenting with accelerated tissue plasminogen activator (t-PA) in patients presenting with acute ST-elevation myocardial infarction (AMI). BACKGROUND: Thrombolysis remains the standard therapy for AMI. However, at some institutions primary angioplasty is favored. Randomized trials have shown that primary angioplasty is equal or superior to thrombolysis, while recent studies demonstrate that stent implantation improves the results of primary angioplasty. METHODS: Patients presenting with AMI were randomly assigned to primary stenting (n = 62) or accelerated t-PA (n = 61). The primary end point was the composite of death, reinfarction, stroke or repeat target vessel revascularization (TVR) for ischemia at six months. RESULTS: The primary end point was significantly reduced in the stent group compared with the accelerated t-PA group, 24.2% versus 55.7% (p < 0.001). The event rates for other outcomes in the stent group versus the t-PA group were as follows: mortality: 4.8% versus 3.3% (p = 1.00); reinfarction: 6.5% versus 16.4% (p = 0.096); stroke: 1.6% versus 4.9% (p = 0.36); recurrent unstable ischemia: 9.7% versus 26.2% (p = 0.03) and repeat TVR for ischemia: 14.5% versus 49.2% (p < 0.001). The median length of the initial hospitalization was four days in the stent group and seven days in the t-PA group (p < 0.001). CONCLUSIONS: Compared with accelerated t-PA, primary stenting reduces death, reinfarction, stroke or repeat TVR for ischemia. In centers where facilities and experienced interventionists are available, primary stenting offers an attractive alternative to thrombolysis.
Pulmonary capillary hemangiomatosis (PCH) typically occurs in young patients who have signs and symptoms of pulmonary hypertension. It commonly is misdiagnosed in life as pulmonary veno-occlusive disease, and the correct diagnosis usually is not made until autopsy. Autopsy records, including reports, gross photographs, histologic slides, clinical histories, and radiographic images, were reviewed to identify cases with morphologic changes characteristic of PCH. The previous case reports describe PCH as a diffuse process throughout both lung fields. All patients were symptomatic, and most died of the disease. This article details 8 cases of PCH-like foci that were incidental findings at autopsy in which the patients did not have symptoms of pulmonary hypertension nor did PCH contribute in any way to death. This is the first case series that describes pathologic changes of PCH occurring in this setting, and we hope to provide more interest in PCH and its natural history.
Stenting of saphenous vein graft (SVG) lesions is associated with significant clinical events at late follow-up. We sought to determine predictors of clinical outcome after this procedure. One hundred twenty-eight balloon-expandable stents were implanted in the SVGs of 106 patients. Baseline clinical and angiographic characteristics were analyzed. All grafts, including those not stented, were scored for extent of disease involving the luminal surface of the graft, and for the presence of low profile lesions (< 50% graft stenosis) and/or high profile lesions (> or = 50% graft stenosis). The in-hospital success rate was 98.1%. Before discharge, no patient died, required bypass surgery, or had repeat angioplasty of the same graft. Follow-up was obtained on all the patients. At a median of 18 months, 15% had died, 17% had experienced myocardial infarction, 20% had required repeat bypass surgery, and 37% needed repeat angioplasty to either the same site or a different lesion. Event-free survival was recorded in only 44% of the patients. The cumulative Kaplan-Meier survival at 2.4 years was 78.7%. Using the Cox proportional hazards model, predictors of survival were the absence of a high profile lesion in any nonstented patent graft (p = 0.004), and the use of lipid-lowering agents at follow-up (p = 0.01). Stenting SVG lesions can be performed with a high degree of procedural success, but at long-term follow-up there is a high rate of cardiac events. The absence of a high profile lesion in any nonstented patent graft is the strongest predictor of survival.
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Periorbital edema associated with lupus erythematosus is not frequently reported. To our knowledge, periorbital edema from increased dermal mucin has not been reported with any form of lupus. We present a patient with discoid lupus exhibiting periorbital edema from massive mucinosis.
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Iron uptake by cells may increase the intracellular pool of prooxidant iron prior to storage of iron within ferritin. Because hyperoxia is toxic to alveolar macrophages (AM) via mechanisms involving oxidant stress, we hypothesized that iron uptake by AM might promote hyperoxia-induced injury. To assess this hypothesis, we cultured AM recovered from healthy volunteers under conditions of normoxia or hyperoxia (60% or 95% oxygen) in media of varying iron content, including control media (3 microM iron) and media supplemented with iron (FeCl3; total iron 10, 20, or 40 microM). AM injury was assessed by measuring release of lactate dehydrogenase (LDH), phagocytic activity for yeast, and cytosolic concentrations of calcium ([Ca2+]i) as determined by ratio image analysis of AM loaded with the fluorescent calcium probe indo-1. There was dose-dependent accumulation of iron and ferritin synthesis in AM exposed to iron-supplemented media. Exposure of AM to hyperoxia (60% and 95% oxygen, 18 h) in control media increased LDH release and impaired phagocytic activity for yeast; however, similar hyperoxic exposures in iron-supplemented media significantly increased the cells' LDH release and decreased phagocytosis. Exposure to 95% oxygen increased the [Ca2+]i of AM over 18 h, but similar exposure in iron-supplemented media induced greater increases in [Ca2+]i. As compared with exposure to normoxia, exposure to hyperoxia (60% and 95% oxygen) also decreased iron uptake and, to a greater extent, ferritin synthesis by AM in iron-supplemented media. These data suggest that: (1) iron uptake promotes hyperoxic injury to AM; and (2) hyperoxia impairs the capacity of AM to sequester iron in ferritin.
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OBJECTIVES: This study sought to assess the late clinical and angiographic outcomes of patients who received stents within the first week of acute myocardial infarction (AMI). BACKGROUND: Recent studies have demonstrated that stenting of the infarct-related artery is a useful adjunct to balloon angioplasty in patients with AMI. However, there are limited data on the late clinical and angiographic outcomes of these patients. METHODS: Between January 1994 and September 1995, 32 patients at our institution underwent stenting of the infarct-related artery within 1 week of AMI: 13 within 14 hours (evolving group) and 19 between days 2 and 7 (recent AMI group). Late clinical follow-up was obtained on all survivors. Quantitative angiographic measurements were recorded on the stented segments before stenting, immediately after stenting, and on the follow-up angiograms. RESULTS: At 13.1+/-6.4 months from the time of stenting, three patients died and three required repeat angioplasty, but no patient had reinfarction or required bypass surgery. At follow-up 26 (81%) of 32 patients remained free of major cardiac events; of these, 24 (92%) were free of angina. Repeat angiography performed at 10.8+/-7.5 months in 26 (87%) of 30 discharged patients showed that all infarct-related arteries were patent and the restenosis rate was low: 22% in the 13 patients with evolving AMI (<14 hours) and 12% in the 19 patients with recent AMI (days 2 through 7). CONCLUSION: In this study stenting of the infarct-related artery in patients with evolving and recent AMI was associated with a favorable late clinical outcome. Patency of the infarct-related artery was well maintained, and the restenosis rate was low.
Rumination, or the chewing and re-swallowing of regurgitated stomach contents, can be found in up to 10% of institutionalized individuals with severe or profound mental retardation. Serious physical consequences, including death, can result from the disorder. Unfortunately, rumination can be subtle and difficult to observe and often continues untreated. Additionally, the research literature has provided divergent results without clear treatment guidance for clinicians. We present an overview of the history of rumination, a review of the literature on its etiology and treatment, and recommendations for future research.
PURPOSE: To describe the new definition of mental retardation developed by the American Association of Mental Retardation (AAMR) published in 1992. The previous definition was based on a deficiency model that identified "subaverage intelligence" using an intelligence quotient (IQ) score equal to or less than 70. The new definition places greater emphasis on adaptive skills and environmental support needs. SCOPE: Defining mental retardation according to AAMR criteria reflects a significant paradigm shift from an absolute trait to a functional conception. The new definition is dynamic, attends to context, is inherently holistic--and, therefore--closely aligned with nursing theory. Diagnosis is a three-step process by which functional strengths and weaknesses are identified along 4 dimensions and 10 adaptive-skill areas. Identification of needed supports is incorporated within the three-step process. CONCLUSIONS: Nurses can enhance holistic care by working to have AAMR's new definition adopted by government legislators and administrators of state and county agencies that provide mental-retardation services. Nurses should become active participants as interdisciplinary diagnostic team members as well as case managers. Nurse researchers and educators can contribute toward further developing AAMR's definition by standardizing assessment instruments, working to make diagnostic procedures more user-friendly, and researching the construct validity of adaptive-skill areas. Finally, nurses should help legislators and policy makers understand the sociocultural ramifications of AAMR's new definition.
The thrombotic coronary accident that triggers a myocardial infarction initiates a 'wavefront' of ischaemic cell death that can be aborted by timely restoration of blood flow. Myocardium destined for necrosis can be salvaged by quick lysis of the culprit clot to restore perfusion, reduce infarct size and save lives. While a number of useful thrombolytic regimens have been investigated, the greatest barrier to optimising efficacy is reducing the delay between the onset of symptoms and administration of thrombolytic therapy. Clinical experience has confirmed laboratory evidence that prompt restoration of coronary blood flow can salvage more than 50% of ischaemic myocardium if achieved within 2 hours. However, after 6 hours of sustained ischaemia, the opportunity to achieve meaningful salvage is largely lost. Analysis of pooled data estimates that for each hour of delay 1.6 fewer lives are saved per 1000 patients treated. Other investigators have estimated 60 to 80 lives saved per 1000 patients treated within 1 hour of symptom onset. More realistically, the time from symptom onset to treatment averages 2.5 to 5 hours in various studies. Reluctance to seek medical help results in a delay of more than 4 hours in at least 40% of patients. There may be some benefits of late, time-independent reperfusion from 12 to 24 hours after symptoms. Some hibernating myocardium may be salvaged resulting in less adverse late ventricular remodelling, reduced infarction expansion and improved electrical stability. Barriers to timely thrombolytic treatment may be classified as presentation delay or treatment delay. Strategies to optimise timely treatment have included pre-hospital administration of thrombolytics. This achieves greatest benefit when used in a more rural setting where transportation times tend to be longer. In this setting, as much as 140 minutes has been shaved off the symptom-to-needle time with a 50% reduction in 3-month mortality sustained as a 30% reduction in 5-year mortality. Most hospitals can improve their treatment (door-to-needle) time by focusing on chronic sources of delay. An emergency room culture of quick, coordinated response to chest pain must involve registration clerks, triage nurses, ECG technicians and emergency physicians. The authority to decide thrombolytic therapy must reside with the primary care physicians in any emergency room that encounters an acute infarction. The profound, life-saving benefits of thrombolytic therapy when used in a timely way should evoke a new sense of urgency in medical personnel when encountering the individual with a potential myocardial infarction.
OBJECTIVE: To examine the procedural and long term success of coronary stenting in patients presenting with unstable angina and the effect of warfarin on the clinical outcome of these high risk patients. DESIGN: A nonrandomized, retrospective analysis of patients presenting with unstable angina. SETTING: A tertiary care, Canadian university-affiliated teaching hospital. PATIENTS: Of 1250 patients who underwent percutaneous transluminal coronary angioplasty between January 1994 and June 1995, 365 underwent coronary stenting. The study population consisted of the 156 patients presenting with unstable angina who underwent coronary stenting. Patients with Canadian Cardiovascular Society class IV and postinfarction angina were included. INTERVENTIONS: Stent delivery by standard techniques to the target lesion was successful in all patients. At discharge, 88 patients were prescribed warfarin, ticlopidine and acetylsalicylic acid (ASA); the remaining 68 patients received only ticlopidine and ASA. Late clinical outcomes were assessed by telephone interview. RESULTS: The overall procedural success rate was 96%. One patient died in hospital (0.6%). Other events were abrupt closure (1.9%), myocardial infarction (1.9%) and urgent bypass surgery (1.9%). During follow-up, target vessel reintervention was needed in 19.6% of patients. Early and late clinical outcomes did not differ significantly between anticoagulated patients and those treated with antiplatelet agents alone, but anticoagulated patients had a significantly longer hospital stay. CONCLUSIONS: Coronary stenting in patients with unstable angina was associated with excellent procedural success and favourable late clinical outcomes. Warfarin added no apparent additional clinical benefit to antiplatelet agents in this high risk population.
Acute myocardial infarction (AMI) evolves as a time-dependent wave front of ischemia when the abrupt rupture of an unstable fatty plaque initiates coronary thrombosis. The prospect of salvaging potentially viable myocardial tissue has led to the development of reperfusion strategies using thrombolytic agents. The efficacy of thrombolytic therapy is determined in large measure by the speed with which it is initiated. It is therefore vital to minimize the "door-to-needle" time once a patient with AMI arrives at the emergency department. In this issue (see pages 497 to 505) Dr. Jafna L. Cox and associates report that Canadian centres participating in the GUSTO-I trial were significantly slower to initiate thrombolytic therapy than their US counterparts. In this editorial Cox and associates' report is reviewed against the background of similar trials, and strategies to minimize delays in the initiation of thrombolytic therapy are suggested.
BACKGROUND: Recurrence in breast carcinoma follows a pattern of growth marked by local, regional, or widespread dissemination. Local recurrence may be the harbinger of systemic disease or failure of local control. Delineation of these processes may have implications in treatment. METHODS: A retrospective review found 1,171 patients with stages I and II breast cancer from 1978 to 1990 treated at the City of Hope Medical Center. RESULTS: Twenty-seven percent (n = 313) of patients developed recurrences. These were classified as local, including chest wall and regional nodes (n = 40), local and distant (n = 63), and distant (n = 210). Mean follow-up was 60 months. Multivariate analysis demonstrates tumor size was not different between the three groups, but the presence of positive lymph nodes was: local = 51%, local and distant = 78%, and distant = 64%. The disease-free interval was longest in the local group (42 months) versus the local and distant group (23 months) and distant group (39 months). Median survival was calculated from the time of recurrence: local = 90 months, local and distant = 26 months, and distant = 16 months. CONCLUSIONS: A group of patients with local recurrence have improved survival and do not develop distant disease. This group may benefit from aggressive surgical treatment to control local disease. These data suggest that a subset of breast tumors can act locally aggressive without metastatic potential.
A simplified version of Azrin and Foxx's method of toilet training was evaluated in an adult with profound mental retardation. An ABAB reversal design was used to evaluate intervention effects. Results indicated that the procedure was effective in reducing toileting accidents and in increasing appropriate urinations. Additionally, continence was maintained at a 3 month follow-up evaluation.