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Background: Values of a QRS score have been positively related to the number of narrowed coronary arteries and to the extent of myocardial ischemia in radionuclide imaging techniques. Hypothesis: This study was conducted to evaluate the potential prognostic information of abnormal values of this QRS score during treadmill exercise testing in patients with established coronary artery disease (CAD). Methods: In all, 309 patients (258 men, 51 women, mean age 56.1 ± 10.0 years) with documented CAD, underwent a treadmill exercise test and coronary arteriography at baseline. Subsequently, they were prospectively followed to a maximum of 36 months (mean follow‐up 23 ± 13 months, median 25 months). Results: During the follow‐up period, 20 patients (6.5%) died from acute myocardial infarction. Abnormal QRS score values were found to be significantly and independently associated with cardiac mortality (QRS ≤ −4: relative risk 11.7; 95% confidence interval = 2.5‐55.4; p = 0.002). Conclusions: Taking into consideration the importance of exercise testing in the management of ischemic heart disease, the use of this QRS score could be of clinical value in predicting the outcome of patients with documented CAD.

Objective: The aim of this study was to investigate the ability of Athens QRS score values to detect stenoses in other coronary arteries than the obstructed ones (which caused the myocardial infarction [MI]) in patients with a history of MI. Methods: We studied 125 patients (93 males and 32 females, mean age 54 ± 7 years [range 45–68 years]) with a history of MI (46 patients with anterior MI, 54 patients with inferior MI, 25 patients with lateral MI). All patients underwent treadmill exercise testing and coronary arteriography. Results: Athens QRS score values were inversely related to the extent of CAD: −0.5 ± 0.3 mm for patients with 1-VD (obstructed vessel), −3.4 ± 2.2 mm for patients with 2-VD (obstructed vessel and stenosis in another vessel), and −5 ± 1.8 mm for patients with 3-VD (obstructed vessel and stenoses in two more vessels). The ROC curves for the detection of multivessel disease showed that the area under the curve for QRS score values < −3 mm is significantly higher than the curve for ST-segment depression ≥1 mm (0.948 vs 0.792, P < 0.001). Conclusions: Values of the Athens QRS score less than −3 may distinguish single- from multivessel coronary artery disease in patients with a history of MI.

It is known that exercise-induced ischemia in patients with coronary artery disease (CAD) may produce QRS prolongation in the surface electrocardiogram (ECG). To investigate the presence of exercise-induced Q-wave prolongation in patients with single-vessel CAD and Q-wave myocardial infarction (MI), in association with the presence of reversible perfusion defects during thallium scintigraphy in the infarcted area.107 consecutive patients (89 males, mean age 56+/-8 years) were evaluated. All patients underwent coronary arteriography, maximal treadmill exercise testing and thallium-201 scintigraphy. Q-wave duration was measured both before exercise testing and during maximal heart rate from 12-lead ECGs recorded with a paper speed of 50 mm/s.Only 57 out of the 107 studied patients showed reversible perfusion defects in the infarcted area during thallium scintigraphy. Q-wave duration was significantly increased from the resting to the stress ECG (DeltaQ-wave duration) in patients with reversible perfusion defects in the infarcted areas (10+/-13 ms), but not in patients with fixed defects in the infarcted zone (-2.0+/-5 ms, p0.01). The sensitivities and the specificities of Q-wave prolongation, ST segment elevation, and the combination of ST segment elevation with ST segment depression in the reciprocal leads for the detection of myocardial viability in the infarcted area were 82%, 48%, 29% and 88%, 50%, and 90%, respectively.Exercise-induced Q-wave prolongation is demonstrated in those patients with single-vessel CAD and a recent MI who show reversible perfusion defects in thallium scintigraphy. Exercise-induced Q-wave prolongation was found to be a sensitive and specific ECG marker for the detection of myocardial viability in the infarcted area.

BACKGROUND The diagnostic ability of exercise testing based on ST-segment changes is low for the detection of restenosis after percutaneous transluminal coronary angioplasty (PTCA) or ischaemia after bypass surgery (CABG). The aim of this study was to improve the diagnostic accuracy of exercise testing in patients with a history of PTCA or CABG, with the implementation of a QRS score. METHODS We studied 128 post-PTCA patients (aged 49 +/- 8 years) and 104 post-CABG patients (aged 54 +/- 8 years), who had either positive exercise tests with or without angina, or negative exercise tests with continuing angina-like symptoms, and underwent cardiac catheterisation. RESULTS The univariate risk ratio of exercise-induced ST-segment deviation to detect restenosis was 3.05 (p = 0.005) and 0.83 (p = 0.690) in group A and group B patients, respectively. The univariate risk ratios of abnormal QRS score values to detect restenosis were 32.1 (p < 0.001) and 18.8 (p < 0.001) for group A and group B patients, respectively. The univariate risk ratios of the combination of exercise-induced ST-segment changes and of abnormal QRS score values to detect restenosis was 9.43 (p < 0.001) and 3.77 (p < 0.044) for group A and group B patients, respectively. The value of the area under the ROC curves is higher for the QRS score in group A patients, group B patients and for the whole study population. CONCLUSIONS QRS score values significantly improve the diagnostic ability of ST-segment change-based exercise testing, for the assessment of restenosis after PTCA or ischaemia after CABG.

OBJECTIVE: Our purpose was to compare the accuracy of maternal perception of preterm uterine activity by self-palpation versus home uterine activity monitoring. STUDY DESIGN: A total of 72,962 uterine activity records of 778 women receiving home uterine activity monitoring services were analyzed. Simultaneously with home uterine activity monitoring, the women indicated by an electronic marker when they felt a "contraction" through self-palpation. The perceptions of the women were compared to the tocodynamometrically measured uterine activity. RESULTS: Using self-palpation, women correctly identified 17.2% of contractions recorded by tocodynamometry. Overall mean percent correct correlation per patient was only 14.1%. Patients missed an average of 85.7% of their contractions. Patients incorrectly perceived contractions that were not present an average of 40.3% of the time. Singleton gestations had significantly better correct correlations than twin gestations. Multiparous women had improved correlations compared with primiparous women. No significant correlation was found between maternal perceptive ability and gestational age. CONCLUSION: Women were unable to perceive accurately the presence or absence of preterm uterine activity through self-palpation compared with simultaneous measurement by home uterine tocodynamometry. (AM J OBSTET GYNECOL 1996;174:672-5.)

We have successfully determined the internuclear distance of I2 molecules in an alignment laser field by applying our molecular structure determination methodology to an I 2p X-ray photoelectron diffraction profile observed with femtosecond X-ray free electron laser pulses. Using this methodology, we have found that the internuclear distance of the sample I2 molecules in an alignment Nd:YAG laser field of 6 × 10^11 W/cm2 is elongated by from 0.18 to 0.30 Å “in average” relatively to the equilibrium internuclear distance of 2.666 Å. Thus, the present experiment constitutes a critical step towards the goal of femtosecond imaging of chemical reactions and opens a new direction for the study of ultrafast chemical reaction in the gas phase.

Local distrust for Marine Protected Area (MPA) managers is emerging as an important factor obstructing the fulfillment of MPA objectives, and, thus, there is a need to develop a means of enhancing relationship building between MPA managers and local people. We used the National Marine Park of Alonissos, Northern Sporades (NMPANS), Greece, as a relevant case-study to investigate whether the local print media’s framing of the marine park and its management affected locals’ attitudes. We conducted a longitudinal review of local newspaper articles pertaining to the NMPANS during 1980–2008, and we conducted telephone interviews with local people. We found that salience of the NMPANS in the local print media remained limited and sporadic, the main stakeholder remained the centralized public sector, and the regional print media was rather detached, moderate, and largely supportive of the NMPANS throughout 1980–2008. The progression of the management periods of the NMPANS, however, was accompanied by increased importance of the NMPANS, increased deviance from conservation as the chief objective of the NMPANS’s establishment, a shift from presenting facts to presenting reactions, and a shift from a positive to a mixed image of the NMPANS. Locals who relied on newspapers for local news were better informed about the NMPANS, more likely to accept the NMPANS, and more likely to participate in meetings regarding the NMPANS regardless of gender, age, and occupation than those who did not rely on newspapers. The local print media may be utilized as a free-choice learning vehicle to enhance the value of an MPA among local people and to enhance the development of trust between park managers and locals through a proactive, empowering, and cognitive media strategy.

Background: It is known that exercise-induced ST-segment elevation in lead V1 (V1-E) detects left anterior descending (LAD) stenosis. It was also postulated that ST elevation in aVR and simultaneous ST depression in V5 (aVR-E + V5-D) is a marker of ischemia due to significant stenosis of the LAD in patients with single-vessel disease. Hypothesis: This study was undertaken to investigate the significance of the concomitant appearance of both electrocar-diographic (ECG) ischemic markers, and of each of them alone during exercise, to detect either LAD stenosis as single-vessel coronary artery disease (CAD), or multivessel CAD involving LAD stenosis. Methods: A total of 196 consecutive patients (152 men and 44 women, mean age 54 ± 7 years) with at least one of these ECG markers, who underwent treadmill exercise testing with the Bruce protocol and coronary arteriography, were studied. Results: Patients were divided into three groups. In Group A (83 patients with V1-E + aVR-E & V5-D), 93% of patients with single-vessel disease had significant LAD stenosis (p < 0.001), whereas 75% of patients with double-vessel disease had significant stenoses of the LAD and the left circumflex (LCx) coronary arteries (p < 0.01). In Group B (97 patients with aVR-E & V5-D but without V1-E), 43% of patients with single-vessel disease had significant LAD stenosis (p < 0.08), whereas 85% of patients with double-vessel disease had significant stenoses of the LAD and the right coronary artery (RCA) (p < 0.01). In Group C (16 patients with only V1-E), 60% of patients with single-vessel disease had significant LAD stenosis (p < 0.05), whereas 75% of patients with double-vessel disease had significant LAD and LCx stenoses (p < 0.05). Conclusions: The concomitant appearance of exercise-induced ST elevation in lead V1, ST elevation in lead aVR, and ST depression in lead V5, as well as the isolated appearance of ST elevation in lead V1 detect significant LAD stenosis as single-vessel disease, or significant stenoses of LAD and LCx arteries in patients with double-vessel disease, whereas the appearance of ST elevation in aVR & ST depression in V5 but without ST elevation in V1 correlates strongly with significant LAD and RCA stenoses and usually indicates double-vessel disease.

BACKGROUND Cerebral ischemia is recognized as one of the most important mechanisms responsible for secondary brain damage following severe traumatic brain injury (TBI), contributing to an increased mortality and a worse neurologic outcome. METHOD A simple 5-item scoring system, taking into account the occurrence of specific potentially brain-damaging events (hypoxemia, hypotension, low cerebral blood flow, herniation, and low cerebral perfusion pressure) has been tested in a large population of severe TBI patients. Aims of this retrospective study were to validate the ability of the proposed ischemic score to predict neurologic outcome and to correlate the ischemic score with the results of microdialysis-based neurochemical monitoring and brain tissue oxygen monitoring. FINDINGS In a population of 172 severe TBI patients, a significant correlation was found between ischemic score and neurologic outcome, both at 3 months (r = -0.32; P < 0.01) and at 6 months (r = -0.31; P < 0.01). Significant correlations were also found with the most important neurochemical analytes. CONCLUSIONS The ischemic score proposed here, may be determined during the acute intensive care unit period, and correlates closely with outcome, which can only be determined 3 to 6 months, after injury. It also shows a correlation with neurochemical analytes.

Objective To evaluate the improvement of diagnostic ability of exercise testing to detect multivessel coronary artery disease in patients with extended Q-wave anterior myocardial infarction, using additional right-sided chest leads. Methods Fifty-two consecutive patients with Q-wave anterior myocardial infarction underwent exercise testing, using the standard 12 and the additional right-sided (V3R, V4R, V5R) chest leads, thallium-201 scintigraphy and coronary arteriography. Results Twenty-one (40%) patients had one-vessel disease, 18 (35%) had two-vessel disease and 13 (25%) had three-vessel disease. The sensitivities of the standard 12-lead exercise testing and its combination with the additional right-sided chest leads were 24% (5/21) versus 28% (6/21) for the detection of one-vessel disease (P: NS), 33% (6/18) versus 83% (15/18) for the detection of two-vessel disease (P

To evaluate the improvement of diagnostic ability of exercise testing to detect multivessel coronary artery disease in patients with extended Q-wave anterior myocardial infarction, using additional right-sided chest leads. Fifty-two consecutive patients with Q-wave anterior myocardial infarction underwent exercise testing, using the standard 12 and the additional right-sided (V3R, V4R, V5R) chest leads, thallium-201 scintigraphy and coronary arteriography. Twenty-one (40%) patients had one-vessel disease, 18 (35%) had two-vessel disease and 13 (25%) had three-vessel disease. The sensitivities of the standard 12-lead exercise testing and its combination with the additional right-sided chest leads were 24% (5/21) versus 28% (6/21) for the detection of one-vessel disease (P:NS), 33% (6/18) versus 83% (15/18) for the detection of two-vessel disease (P < 0.05) and 38% (5/13) versus 92% (12/13) for the detection of three-vessel disease (P < 0.05), respectively. In thallium-201 scintigraphy, 29 of the 31 (94%) patients with multivessel coronary artery disease reversible ischemia. The usual 12-lead exercise testing could detect ischemia in 11 (35%) of these 31 patients, while the addition of the right-sided chest leads could detect ischemia in 27 (87%) of them (P < 0.05). The additional right-sided chest leads significantly improve the low sensitivity of the usual exercise testing to detect multivessel coronary artery disease in patients with previous extended Q-wave anterior myocardial infarction.

Severe traumatic brain injury (TBI) leads to an immunocompromised state responsible for an increased morbidity and mortality. Our understanding of the mechanisms responsible for this brain damage is incomplete. Damage maybe mediated by a complex cascade of neuroinflammation, and cytokine activation. In addition, translocation and accumulation of T cells in the brain parenchyma could take place and be related to detrimental effects. Our aims in this prospective randomized pilot study, were to detect the early effect of severe TBI upon cell-mediated immunity, to verify if early immunologic impairment correlates with neurologic outcome, and finally, to test the effect of early administration of iv infusion of cyclosporin A upon cell-mediated immunologic function. Forty-nine patients with severe TBI were studied. Thirty-six of these patients received a 24-h intravenous infusion of Cyclosporin A, or two 24-h infusions of the drug. 10 patients were in the placebo group. Three patients, not enrolled in the cyclosporin trial, were studied only for the relationship between cellular immunity, neurological outcome, and infection rate. T cell counts and microbiological cultures were performed in all patients. Sixty-five percent of patients demonstrated reduced T lymphocyte counts on admission. Furthermore, reduction of T cell numbers was related with significantly worse neurologic outcome and an increase in pulmonary infection. There was no significant difference between the placebo and CsA treated patients for the studied immunological parameters, or for incidence of infection. We also observed sequestration/diapedesis of T cells into the brain parenchyma, around contusions, after human TBI and we speculate that this could be responsible for further brain damage.

A case of a 25-year-old woman with familiar hypercholesterolemia, who was admitted complaining for chest pain on exertion, is presented. She underwent a treadmill stress test and during the exercise left bundle branch block with concomitant chest pain in low heart rate (105/min) was demonstrated. After these findings TL-201 scintigraphy with dipyridamole infusion was performed: Chest pain and left bundle branch block appeared again during the test, and the stress TL-201 tomographic images showed reversible defect in the anterior wall. Finally, the young woman underwent coronary arteriography, which showed normal coronary vessels. The ergonovine test for coronary spasm was negative.

To determine the influence of a lean prepregnancy body mass index (BMI) on pregnancy outcome in women with mild preeclampsia.A matched cohort design was used. A total of 99 pregnant women with mild preeclampsia and a nonobese prepregnancy BMI (22-28 kg/m2) were matched 1 : 1 for gestational age at diagnosis, race, and parity to 99 women with mild preeclampsia, but a lean prepregnancy BMI (or = 20 kg/m2). All patients were enrolled in an outpatient management program between 24 and 36 weeks' gestation for a minimum of 2 days, had singleton pregnancies, and exhibited proteinuria ofor = 1+ at the start of the program. Outpatient monitoring included automated blood pressure measurements and daily assessment of weight, proteinuria, and fetal movement.The mean gestational age at enrollment was 33.4 +/- 2.8 weeks for both groups. By matching, 65% of patients in each group were nulliparous and 79% of patients in each group were of the white race. There were no patients in either group with a history of preterm delivery. The mean gestational age at delivery (36.8 +/- 2.3 versus 36.3 +/- 2.3 weeks, p = 0.047) was greater in the lean prepregnancy BMI group with a lower cesarean section rate (32% versus 52%, p = 0.006) but similar mean birth weights (2728 +/- 698 versus 2679 +/- 802 g, p = 0.635). There were two perinatal deaths in the lean prepregnancy BMI group and one in the nonobese prepregnancy BMI group (p = 1.0).In patients with mild preeclampsia remote from term, a lean prepregnancy BMI was associated with a later gestational age at delivery and a reduced incidence of cesarean delivery. Neonatal outcomes, however, did not differ significantly between the groups.

To report on pregnancy outcome in six twin pregnancies with delayed-interval delivery in a single maternal-fetal medicine practice.All cases of attempted delayed-interval delivery from January 1988 to August 2000 in a single maternal-fetal medicine practice were retrospectively reviewed. Patients were managed with a treatment protocol that included rescue cerclage after delivery of the first born twin, antibiotics, corticosteroids and tocolysis.Five of the six twin gestations resulted in viable birth of the second-born twin. One pregnancy had loss of both fetuses before viability. All first-born twins were nonviable. The median pregnancy prolongation achieved following delivery of the first-born, nonviable twin was 93 days, with a range of 23-153. Three of the five viable, second-born twins had a neonatal intensive care nursery stay of 3, 4 and 35 days (mean, 8.4). No infant required a ventilator.Based on our analysis of these six cases, the pregnancy prolongation gained resulted in a clinically significant benefit to the second-born twin, without significant morbidity in the mother.

Objective: Limited information is available regarding the progression of disease in women with mild gestational hypertension. Our purpose was to describe the prognostic signs in the natural course of mild gestational hypertension and pregnancy outcomes in women who were remote from term with mild gestational hypertension that was expectantly managed. Study Design: Women with mild gestational hypertension participating in an outpatient hypertension monitoring program were studied. Inclusion criteria were patients with a singleton pregnancy between 24 and 35 weeks' gestation who had no proteinuria by dipstick (0 or trace) on the first 2 days of program participation. Progression to preeclampsia was the primary outcome. The rate of progression to severe preeclampsia, obstetric complications, and neonatal outcomes were secondary measures. Data were compared by independent Student t and Fisher exact tests where applicable. Results: A total of 748 patients were studied during the observation period; preeclampsia (persistent proteinuria ≥1+) developed in 343 (46%), and 72 (9.6%) had antepartum progression to severe preeclampsia. No significant differences in maternal age, race, marital status, or tobacco use were observed between those women in whom persistent proteinuria developed and those in whom it did not develop. Gestational age of the infants at delivery (36.5 ± 2.4 vs 37.4 ± 2.0 weeks), birth weight (2752 ± 767 vs 3038 ± 715 g), incidence of small-for-gestational-age newborns (24.8% vs 13.8%), and duration of neonatal hospital stay (7.1 ± 10 vs 5.0 ± 9.3 days) differed significantly in the patients with versus those without proteinuria ( P Conclusions: In patients with mild gestational hypertension remote from term, 46% ultimately had preeclampsia, with progression to severe disease in 9.6%. The development of proteinuria is associated with an earlier gestational age at delivery, lower birth weight, and an increased incidence of small-for-gestational age newborns. (Am J Obstet Gynecol 2001;184:979-83.)

Testimony in support of House Bill 2618. "CURB is one of the few state agencies that practices almost exclusively before another state agency-the KCC-and that regularly appeals another agency's decisions to the courts. We know firsthand how deferential the courts are to agency decisions, and we support the proposed amendment to K.S.A. 77-621(d) ... because it will restore the appropriate standard of judicial review of agency action that was intended by the federal act and the Kansas act, which was modeled after the federal act. The standard of review of agency action that has developed in Kansas courts since the adoption of the judicial review act has become so deferential to agency decisions that judicial review often amounts to no real review at all. ... So long as there is some evidence in the record that supports [an agency decision], even if there is overwhelming evidence that contradicts it, the court must affirm. The court will not review the record as a whole. ... This bill will restore the court's obligation to review the entire record when an appellant challenges a decision as arbitrary and capricious."

OBJECTIVES: Our purpose was to compare maternal and perinatal outcomes of mature women with those in younger women with pregnancies complicated by mild hypertension remote from term. STUDY DESIGN: A matched cohort design was used. A total of 379 mature pregnant women (≥35 years old) with mild hypertension remote from term were matched for race, gestational age, and proteinuria status at enrollment with 379 adult controls aged 20 to 30 years also with mild hypertension remote from term. All were enrolled in an outpatient management program that included automated blood pressure measurements and daily assessment of weight, proteinuria, and fetal movement. RESULTS: The mean gestational age at enrollment was 32.7 ± 3.0 weeks for both groups (range 24 to 36 weeks). By matching 20.6% of patients in each group had ≥1+ proteinuria on urinary dipstick at enrollment, and 77.3% of patients in each group were white. Chronic hypertension was more common in the mature group (22.4% vs 14.5%, p = 0.007). The mean gestational age at delivery (37.2 ± 2.3 vs 37.2 ± 2.2 weeks), the mean pregnancy prolongation (28.1 ± 21.0 vs 28.4 ± 22.0 days), and the mean birth weights (2864 ± 770 vs 2906 ± 788 gm) were similar between the mature and younger groups (all p > 0.05). There were no differences regarding abruptio placentae (2 vs 3 cases) or thrombocytopenia or HELLP ( h emolysis, e levated l iver enzymes, l ow p latelets) syndrome (7 vs 9 cases), and there were no cases of eclampsia. There were five stillbirths in the mature group and none in the younger group ( p = 0.063). CONCLUSION: Outpatient management of mild hypertension remote from term in the mature pregnant woman was associated with similar maternal outcomes but with a nonstatistically higher stillbirth rate compared with the younger pregnant woman. (Am J Obstet Gynecol 1997;176:1236-43.)