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The yeast mitogen-activated protein kinase pathways serve as a model system for understanding how network interactions affect the way in which cells coordinate the response to multiple signals. We have quantitatively compared two yeast strain backgrounds YPH499 and ∑1278b (both of which have previously been used to study these pathways) and found several important differences in how they coordinate the interaction between the high osmolarity glycerol (HOG) and mating pathways. In the ∑1278b background, in response to simultaneous stimulus, mating pathway activation is dampened and delayed in a dose-dependent manner. In the YPH499 background, only dampening is dose-dependent. Furthermore, leakage from the HOG pathway into the mating pathway (crosstalk) occurs during osmostress alone in the ∑1278b background only. The mitogen-activated protein kinase Hog1p suppresses crosstalk late in an induction time course in both strains but does not affect the early crosstalk seen in the ∑1278b background. Finally, the kinase Rck2p plays a greater role suppressing late crosstalk in the ∑1278b background than in the YPH499 background. Our results demonstrate that comparisons between laboratory yeast strains provide an important resource for understanding how signalling network interactions are tuned by genetic variation without significant alteration to network structure., (© 2022 The Authors. The FEBS Journal published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies.)

Objectives: The study aim is to determine whether invasive cardiac procedures following a 3-day (holiday) weekend have worse outcomes compared with procedures following a 2-day (normal) weekend., Background: Catheterization laboratory schedules after 3-day holiday weekends tend to be overloaded with urgent procedures for patients who have waited up to 3 days. We hypothesized that this would be reflected by more procedural complications in patients undergoing procedures after a 3-day weekend., Methods: Invasive cardiac procedures that occurred after a weekend at Geisinger Medical Center from July 2012 to December 2019 were included. Baseline characteristics, presentation, periprocedural variables, adverse events, and clinical outcomes were compared between catheterizations on the day following a 2-day weekend and catheterizations following a 3-day weekend. Independent correlates of adverse events were identified by logistic regression analysis., Results: We identified 13,704 invasive cardiac procedures performed after a weekend, of which 722 occurred after a 3-day (holiday) weekend. Baseline demographics, presentation, and case volumes were similar between the 2 groups. Procedures after a 3-day weekend were not associated with any differences in in-hospital mortality, myocardial infarction, or stroke compared with those after a standard 2-day weekend. By univariate analysis, procedural complications were more frequent after a 3-day weekend (15.1% vs 12.3%; P=.03), but this difference was not significant on multivariate analysis (odds ratio, 1.22; P=.30)., Conclusions: Cardiac catheterization procedures performed after a 3-day weekend were not associated with differences in in-patient mortality, myocardial infarction, stroke, or procedural complications.

Background: Patients with iodinated contrast material (ICM) adverse reactions are at increased risk for breakthrough reactions. Previous studies suggest that the severity of a prior ICM adverse reaction corresponds to the severity of a repeat reaction., Objective: We investigated whether the severity of prior ICM adverse reactions in patients receiving emergency premedication therapy prior to PCI predicts outcomes., Methods: A retrospective observational study of percutaneous coronary intervention (PCI) encounters between January 1, 2005, and May 30, 2018, was conducted at Geisinger Medical Center. Patients with ICM adverse reactions premedicated with an emergency premedication regimen prior to PCI were included in the study. PCIs were stratified based on the severity of the index ICM adverse reactions; PCIs with a prior severe reaction were compared to PCIs with a prior mild-moderate reaction., Results: We evaluated 604 PCI, of these, 144 (23.8%) had prior severe reactions and 460 (76.2%) had mild-to-moderate reactions. Nine patients had breakthrough reactions, of which seven were of the same or decreased severity in comparison to the index reactions. The overall breakthrough reactions occurred in 1 of 144 patients (0.7%) with an initial severe reaction and in 8 of 460 (1.7%) with an initial mild/moderate reaction (p = 0.69). Outcomes including length of hospital stay and 30-day mortality were similar for PCI with or without severe index ICM reactions., Conclusion: Frequency and severity of breakthrough reaction and clinical outcomes in patients treated with emergency premedication regimen prior to PCI were independent of the severity of index ICM reactions., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To study radiation exposure to the primary operator during diagnostic cardiac catheterizations using a radio-dense RAD BOARD® radial access arm board., Background: The use of radial access for catheterization in the United States has increased from 1% in 2007 to 41% in 2018. Compared to femoral access, operator radiation exposure from radial access is similar or higher. The RAD BOARD radio-dense radial access arm board has been marketed as reducing radiation to operators by 44%., Materials and Methods: We randomized 265 patients undergoing catheterization via right radial access to standard pelvic lead drape shielding (nonboard group) versus RAD BOARD in addition to pelvic drape (board group). Operator radiation exposure was measured using Landauer Microstar nanoDot™ badges worn by the operator., Results: Board and nonboard groups were similar with respect to demographic and procedural variables. Mean operator dose per case was higher in the board group (.65mSieverts) than in the nonboard group (.56mSieverts, P < 0.0001). In sub-group analyses, radiation doses were higher in the board group compared to the nonboard group in patients across all body mass index groups (P < 0.03). In multivariate analysis, operator dose correlated with use of the RAD BOARD more closely than any other variable (P < 0.001). Post hoc analysis of the table setup with RAD BOARD revealed that use of RAD BOARD prevented placement of a shield normally inserted into the top of the standard below-table shield., Conclusion: RAD BOARD with the pelvic shield was associated with higher radiation exposure to the operator compared with pelvic shield alone, likely due to inability to use standard radiation shielding along with the RAD BOARD., (© 2019 Wiley Periodicals, Inc.)

The nonsense-mediated mRNA decay (NMD) pathway regulates mRNAs that aberrantly terminate translation. This includes aberrant mRNAs and functional natural mRNAs. Natural mRNA degradation by NMD is triggered by mRNA features and environmental cues. Saccharomyces cerevisiae encodes multiple proteins with ferric and cupric reductase activity. Here, we examined the regulation by NMD of two mRNAs, FRE1 and FRE2, encoding ferric and cupric reductases in S. cerevisiae. We found that FRE2 mRNAs are regulated by NMD under noninducing conditions and that the FRE2 3'-UTR contributes to the degradation of the mRNAs by NMD. Conversely, FRE1 mRNAs are not regulated by NMD under comparable conditions. These findings suggest that regulation of functionally related mRNAs by NMD can be differential and conditional., (© 2019 Federation of European Biochemical Societies.)

Biological networks sense extracellular stimuli and generate appropriate outputs within the cell that determine cellular response. Biological signal generators are becoming an important tool for understanding how information is transmitted in these networks and controlling network behavior. Signal generators produce well-defined, dynamic, intracellular signals of important network components, such as kinase activity or the concentration of a specific transcription factor. Synthetic biology tools coupled with in silico control have enabled the construction of these sophisticated biological signal generators. Here we review recent advances in biological signal generator construction and their use in systems biology studies. Challenges for constructing signal generators for a wider range of biological networks and generalizing their use are discussed.

The differential regulation of COX17, COX19 and COX23 mRNAs by the nonsense-mediated mRNA decay (NMD) pathway was investigated. The NMD pathway regulates mRNAs that aberrantly terminate translation. This includes mRNAs harboring premature translation termination codons and natural mRNAs. Most natural mRNAs regulated by NMD encode fully functional proteins involved in various cellular processes. However, the cause and targeting of most of these mRNAs by the pathway is not understood. Analysis of a set of mRNAs involved in copper homeostasis showed that a subset of these mRNAs function in mitochondrial copper homeostasis. Here, we examined the regulation of COX17, COX19 and COX23 mRNAs by NMD. These mRNAs encode homologous mitochondrial proteins involved in metallation of cytochrome c oxidase. We found that COX17, COX19 and COX23 mRNAs are differentially regulated by NMD depending on environmental copper levels. A long 3'-UTR contributes to the direct regulation of COX19 mRNA by the pathway. Alternatively, COX23 mRNA contains a long 3'-UTR, but is indirectly regulated by the pathway under two conditions tested here. Analysis of the functionality of the NMD targeting features in COX23 mRNA showed that the COX23 3'-UTR is sufficient to trigger NMD. The regulation of mRNAs involved in mitochondrial copper metabolism by NMD is physiologically significant because excess copper enhances growth of NMD mutants on a non-fermentable carbon source. These findings suggest that regulation of mRNAs encoding homologous proteins by NMD can be differential depending on environmental copper levels. Furthermore, these findings suggest copper ion homeostatic mechanisms in the mitochondria occur at the mRNA level via the NMD pathway.

We report on a study of the effect of peers' interest in high school biology, chemistry, and physics classes on students' STEM (science, technology, engineering, and mathematics)-related career intentions and course achievement. We define an interest quorum as a science class where students perceive a high level of interest for the subject matter from their classmates. We hypothesized that students who experience such an interest quorum are more likely to choose STEM careers. Using data from a national survey study of students' experiences in high school science, we compared the effect of five levels of peer interest reported in biology, chemistry, and physics courses on students' STEM career intentions. The results support our hypothesis, showing a strong, positive effect of an interest quorum even after controlling for differences between students that pose competing hypotheses such as previous STEM career interest, academic achievement, family support for mathematics and science, and gender. Smaller positive effects of interest quorums were observed for course performance in some cases, with no detrimental effects observed across the study. Last, significant effects persisted even after controlling for differences in teaching quality. This work emphasizes the likely importance of interest quorums for creating classroom environments that increase students' intentions toward STEM careers while enhancing or maintaining course performance.

Background: Pre-hospital electrocardiograms (ECGs) are believed to reduce time to reperfusion in ST Segment Elevation Myocardial Infarction (STEMI) patients. Little is known of their impact on clinical outcomes in a rural setting. Geisinger regional STEMI network provides percutaneous coronary intervention (PCI) care to over a 100-mile radius in rural central Pennsylvania., Methods: A retrospective analysis identified 280 consecutive STEMI patients treated with PCI between 1/1/09 and 8/31/11. Comparison between two STEMI groups was performed: 205 patients who were taken by the emergency medical system (EMS) to the nearest hospital (a non-PCI center), underwent an ECG revealing a STEMI, and were transported immediately to Geisinger Medical Center (GMC) for PCI (transfer group) versus 75 patients in whom a pre-hospital ECG was obtained and who were transported by EMS directly to Geisinger for PCI, bypassing the nearest hospital that did not perform PCI (the pre-hospital ECG group)., Results: Analysis of baseline characteristics revealed that the pre-hospital ECG cohort was older (65 vs. 60 years); had a higher percentage of previous myocardial infarctions (MI) (28% vs. 15%), heart failure (11% vs. 4%), and prior PCI (23% vs. 13%; p < 0.05 all comparisons). Median time from EMS contact to pre-hospital ECG in the pre-hospital ECG group was 5 minutes; from pre-hospital ECG to the GMC ED was 34 minutes. Median time from first medical contact (EMS contact) to reperfusion (device activation) was 79 versus 157 minutes (P < 0.001), respectively in pre-hospital ECG vs. transfer groups. Mortality in the two groups at 1 year was 4.1% in the pre-hospital ECG group versus 8.3% in the transfer group (P-value = 0.34). After adjusting for the difference in age between the two groups, the 62% reduction in 1 year mortality associated with having obtained a pre-hospital ECG was still not statistically significant (P-value = 0.19)., Conclusion: In a rural regional STEMI network, pre-hospital ECGs decreased time from first medical contact to reperfusion by 50% and were associated with an excellent clinical outcome at 1 year. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

The nonsense-mediated mRNA decay pathway (NMD) is an mRNA degradation pathway that degrades mRNAs that prematurely terminate translation. These mRNAs include mRNAs with premature termination codons as well as many natural mRNAs. In Saccharomyces cerevisiae a number of features have been shown to target natural mRNAs to NMD. However, the extent to which natural mRNAs from the same functional group are regulated by NMD and how environmental conditions influence this regulation is not known. Here, we examined mRNAs involved in copper homeostasis and are predicted to be sensitive to NMD. We found that the majority of these mRNAs have long 3'-UTRs that could target them for degradation by NMD. Analysis of one of these mRNAs, COX19, found that the long 3'-UTR contributes to regulation of this mRNA by NMD. Furthermore, we examined an additional mRNA, MAC1 under low copper conditions. We found that low copper growth conditions affect NMD sensitivity of the MAC1 mRNA demonstrating that sensitivity to NMD can be altered by environmental conditions. MAC1 is a copper sensitive transcription factor that regulates genes involved with high affinity copper transport. Our results expand our understanding of how NMD regulates mRNAs from the same functional group and how the environment influences this regulation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: We sought to examine the relationship between preoperative platelet function and perioperative bleeding in patients undergoing CABG., Background: There are many ways to measure platelet aggregability. Little is known about their correlations with one another, or with bleeding., Methods: We prospectively studied 50 patients undergoing a first isolated off-pump CABG. Thirty-four were exposed to a thienopyridine prior to surgery; 16 were not. Preoperative platelet function was measured by VerifyNow®, TEG®, AggreGuide™, Plateletworks®, vasodilator-stimulated phosphoprotein (VASP) phosphorylation, and light transmission aggregometry. Bleeding was assessed 2 ways: drop from pre- to nadir postoperative hematocrit, and chest tube drainage. Correlation coefficients were calculated using Spearman's rank-order correlation., Results: Mean age was 62 years. Patient characteristics and surgical details were similar between the thienopyridine-exposed and non-exposed patients. The correlation coefficients between the 4 point-of-care platelet function measurements and hematocrit change ranged from -0.2274 to 0.2882. Only Plateletworks® correlated with drop in hematocrit (r = 0.2882, P = 0.0470). The correlation coefficients between each of the 4 point-of-care platelet function tests and the chest tube drainage were also poor, ranging from -0.3073 to 0.2272. Both AggreGuide™ (r = -0.3073, P = 0.0317) and VASP (r = -0.3187, P = 0.0272) were weakly but significantly correlated with chest tube drainage. The correlation among the 4 point-of-care platelet function measurements was poor, with coefficients ranging from -0.2504 to 0.1968., Conclusions: We observed little correlation among 4 platelet function tests, and between those assays and perioperative bleeding defined 2 different ways. Whether any of these assays should be used to guide decision making in individual patients is unclear., (© 2015, Wiley Periodicals, Inc.)

The nonsense-mediated mRNA decay (NMD) pathway was originally identified as a pathway that degrades mRNAs with premature termination codons; however, NMD is now known to regulate natural mRNAs as well. Natural mRNAs are degraded by NMD due to the presence of specific NMD targeting features. An atypically long 3'-UTR is one of the features that has been shown to induce the rapid degradation of mRNAs by NMD in Saccharomyces cerevisiae and other organisms. S. cerevisiae CTR2 mRNAs have long 3'-UTRs and are sensitive to NMD, although the extent by which these long 3'-UTRs target the CTR2 mRNAs to the pathway is unknown. Here, we investigated the sequence elements that induce NMD of the CTR2 mRNAs and determined that the long CTR2 3'-UTR is sufficient to target an NMD-insensitive mRNA to the pathway. We also found that, although the CTR2 3'-UTR contributes to NMD-induced degradation, CTR2 mRNAs contain additional NMD-inducing features that function cooperatively with the atypically long 3'-UTR to trigger mRNA degradation. Lengthening the CTR2 ORF abrogates NMD and renders the mRNAs immune to the NMD pathway. Moreover, we found that transcription of CTR2 driven by the GPD promoter, which is not identical to the CTR2 promoter, affects degradation of the transcripts by NMD., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: To evaluate access site and other bleeding complications associated with radial versus femoral access in patients receiving oral anticoagulation (OAC) with warfarin., Background: Patients receiving OAC with warfarin undergoing coronary angiography and percutaneous coronary intervention (PCI) may have OAC continued despite the risk of bleeding. To what extent arterial access site impacts bleeding in such patients is not well studied., Methods: Over 6 years, we identified 255 consecutive patients in whom warfarin was continued who underwent coronary angiography with an international normalized ratio >1.8. A total of 97 patients also underwent PCI at the same setting (27% femoral vs 73% radial). The primary outcome was Bleeding Academic Research Consortium bleeds; a secondary end point was frequency of access site complications in the 72 hours post-PCI. Complications were evaluated based on the initial access site attempted., Results: Minimal baseline clinical characteristics differences existed between the groups. International normalized ratio was significantly higher in the radial group (2.42 ± 0.67 vs 2.24 ± 0.49, P = .02). Bivalirudin use was greater during radial PCI than femoral (76% vs 42%, P < .05), whereas unfractionated heparin alone was greater during femoral PCI than radial (46% vs 18%, P < .05). No significant difference was seen in the primary end point between femoral (2.8%) and radial (1.6%, P = .54) during coronary angiography alone. However, PCI via the femoral artery had significantly more Bleeding Academic Research Consortium bleeding (19.2% vs 1.4%, P = .005) and transfusions (15% vs 0%, P = .004) than via the radial artery. Patients who underwent PCI using radial access were less likely to have any vascular or bleeding complications (1% vs 23%, P = .001)., Conclusions: Patients who underwent coronary angiography during uninterrupted OAC had similar bleeding rates regardless of access site. However, when PCI was performed, radial access was associated with fewer bleeding and vascular complications than the femoral approach., Condensed Abstract: We retrospectively identified 255 consecutive patients on warfarin who underwent coronary angiography, 97 of whom underwent a percutaneous coronary intervention. The data reveal a reduction in Bleeding Academic Research Consortium bleeds (1.6% vs 8.1%, P = .02) with radial versus femoral access. The radial approach was associated with an overall lower rate of any vascular or bleeding complication than the femoral approach during percutaneous coronary intervention (1% vs 23%, P = .001)., (Copyright © 2014. Published by Elsevier Inc.)

Objectives: This study sought to identify the frequency and etiology of readmission within 30 days of percutaneous coronary intervention (PCI) in a large integrated healthcare system., Background: One-fifth of Medicare patients are readmitted within 30 days of hospitalization. Identifying the causes of readmission may help identify strategies to prevent readmission., Methods: All patients undergoing PCI (elective, urgent, and emergent) at our center between January 1, 2007, and April 12, 2010, were prospectively entered into the American College of Cardiology National Cardiovascular Data Registry. Patients readmitted to any hospital within 30 days of the index procedure were identified using an administrative database and telephone follow-up. Individual charts were reviewed independently by 2 investigators; disagreements regarding the cause for readmission were resolved by a third investigator., Results: During the study period, 3,255 PCI were performed, and 262 patients (8.0%) were readmitted within 30 days. Of these, 261 (99.6%) had medical records available for review. Reasons for readmission included: complications related to the PCI (n = 31, 11.9%); non-PCI cardiac causes related to index admission (n = 93, 35.6%); noncardiac causes related to index admission (n = 34, 13%); causes unrelated to the index admission (n = 103, 39.5%). Multivariable logistic regression modeling revealed that female sex, advanced age, peripheral arterial disease, prior valvular surgery, and PCI complications during the index procedure were associated with 30-day readmission., Conclusions: Readmissions within 30 days due to complications related to PCI performed on index admission are rare (0.9% of all PCI) and are an infrequent cause of readmission (<12% of readmissions). Thirty-day readmission after PCI should not be used as a quality metric of PCI performance., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine sex bias in the selection of strategies to evaluate patients with acute myocardial infarction (AMI), and determine if the choice of strategy influences survival., Background: Controversy exists regarding the role of female sex in the use of invasive evaluation for AMI and its possible effect on adverse outcomes., Methods: Electronic health record data from the Geisinger Acute Myocardial Infarction Cohort (GAMIC) was analyzed which included 1,968 men and 1,047 women admitted to the Geisinger Medical Center between January 2001 and December 2006 with acute myocardial infarction (AMI).Multivariate logistic regression analyses were used to determine independent correlates of an invasive evaluation. Multivariate logistic regression modeling stratified on sex was used to determine when invasive evaluation was done and whether there was a correlation with mortality., Results: In unadjusted analyses, male sex was a significant predictor for the use of invasive evaluation (odds ratio = 1.71, 95% CI = [1.46, 2.00]). Adjusted for baseline differences (like age, renal function, co-morbid conditions) multivariate analyses found no significant relationship between male sex and invasive evaluation (OR = 1.02, 95% CI = [0.82, 1.23]). Females in the STEMI group were found to be less revascularized. No difference was observed in the one-year mortality between women and men regardless of invasive evaluation or revascularization., Conclusions: Sex was not independently associated with the occurrence of an invasive evaluation of a MI. Females in the STEMI group were less revascularized. There was no strong gender effect on survival irrespective of the performance on an invasive evaluation or revascularization., (© 2012, Wiley Periodicals, Inc.)

Objectives: The purpose of this study was to demonstrate the feasibility of routine transfer of ST-segment elevation myocardial infarction (STEMI) patients to achieve percutaneous coronary intervention (PCI) in less than 90 min from presentation., Background: Many PCI hospitals have achieved routine door-to-balloon times under 90 min for patients with STEMI presenting directly to the hospital. However, few patients transferred from a non-PCI center undergo PCI within 90 min of presentation., Methods: Our rural PCI hospital implemented a program in 2005 for rapid triage, transfer, and treatment of STEMI patients and made additional improvements in 2006 and 2007. Intervals between milestones in the STEMI triage/transfer/treatment process were assessed before and after implementation of the program., Results: During the 5-year study period, 676 patients with 687 STEMIs were transferred from 19 community hospitals and underwent PCI. Median door-to-balloon time decreased from 189 min to 88 min (p < 0.001). The time intervals reflecting efficiency of the referring hospitals, transfer services, and PCI hospital all significantly improved. In 2008, median door-to-balloon times were <90 min for 6 of the 7 most frequently referring hospitals. Delays during off-hours presentation in 2004 were abolished after the program was implemented in 2005. In-hospital mortality decreased from 6% before to 3% after implementation of the program. In multivariate modeling, presentation before initiation of the STEMI program predicted increased risk of in-hospital mortality (odds ratio: 3.74, 95% confidence interval: 1.22 to 11.51, p = 0.021)., Conclusions: A program of rapid triage, transfer, and treatment of STEMI patients presenting to non-PCI hospitals can reduce in-hospital mortality and produce progressive improvements in door-to-balloon time such that median door-to-balloon times under 90 min are feasible., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Primary percutaneous coronary intervention (PCI) is the optimal method of reperfusion when performed expeditiously. Factors contributing to delays in PCI for ST-segment elevation myocardial infarction (STEMI) have not been thoroughly characterized or quantified. We sought to identify the factors associated with the delays to reperfusion in patients with STEMI undergoing primary PCI. Primary PCI was performed in 3,340 patients with STEMI in the international, multicenter Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Multivariate analysis was used to identify independent predictors of delay in achieving reperfusion from 38 baseline and procedural variables. A total of 905 patients (27.1%) presented to non-PCI hospitals and were subsequently transferred; the remainder presented to PCI hospitals. The most powerful independent predictor of the interval from symptom onset to arrival at the PCI hospital and the first door-to-balloon time was an initial presentation at a non-PCI hospital (median incremental 58- and 54-minute delay, respectively, both p < 0.001). Other independent predictors of prolonged door-to-balloon times included presentation with respiratory failure (42-minute incremental delay, p = 0.003), presentation during off-work hours (11-minute incremental delay, p < 0.001), and co-morbid conditions such as diabetes and heart failure. In conclusion, among patients undergoing primary PCI, presentation to a non-PCI hospital was the variable associated with the greatest delay to reperfusion. Systems of care that encourage ambulance diagnosis and direct delivery of patients with STEMI to a PCI hospital might shorten the overall door-to-balloon times and improve the clinical outcomes., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Embolization during diagnostic catheterization is rare. When it occurs, angiographers need to recognize and treat it immediately. Mechanical removal of the embolized material may help restore flow promptly and salvage myocardium. We describe two cases of iatrogenic embolization into the internal mammary artery grafts resulting in left anterior descending artery occlusion, and describe how prompt intervention by catheter aspiration prevented anterior myocardial infarction.

Background: Multicenter trials are necessary to compare the effectiveness of new drugs and devices for patients with ST-elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI). However, enrollment of STEMI patients in clinical trials could be detrimental to patients if it significantly delayed reperfusion therapy. We sought to determine whether STEMI patients treated with PCI could be enrolled in clinical trials without prolonging door-to-balloon times., Methods: At a single PCI center between October 17, 2004, and December 31, 2007, patients were enrolled in 1 of 4 trials requiring central enrollment and informed consent if (1) a study was actively enrolling, (2) the patient met inclusion/exclusion criteria, (3) and a study nurse was available. Median door-to-balloon times were compared for patients enrolled in clinical trials compared to those not enrolled., Results: Of 581 STEMI patients treated with PCI, 123 were enrolled in clinical trials and 458 were not. For patients transferred for PCI, community hospital door-to-balloon times were similar for research and nonresearch patients (104 vs 108 minutes, P = .4). For patients presenting directly to the PCI center, median door-to-balloon times were similar for research (55 minutes) and nonresearch patients (44 minutes, P = .5) after adjustment for age, culprit artery, and operator., Conclusions: Patients with STEMI may be enrolled in clinical trials with no significant delay in achieving reperfusion. For patients presenting directly to the PCI center, median door-to-balloon times well under 90 minutes can be achieved even with enrollment into clinical trials.

Background: The frequency of ad hoc percutaneous coronary intervention (PCI) varies among institutions and regions of the country. It is unclear what factors limit use of the ad hoc strategy., Objective: To define factors which limit the use of the ad hoc strategy., Methods: All patients who underwent PCI at our center in 2004 were reviewed. Patients who had emergent PCI for ST-elevation myocardial infarction (n = 188), those who had undergone diagnostic coronary angiography at a referring facility (n = 54), and those who had a repeat PCI after a previous ad hoc PCI (n = 19) were excluded. PCIs performed the same day as diagnostic angiography were considered "ad hoc"; all others were designated "staged". Demographic and procedural factors through hospital discharge were prospectively recorded. Logistic regression analysis was performed to identify correlates of ad hoc PCI, PCI success, and PCI complications., Results: Of the 580 PCI procedures eligible for analysis, 557 (96%) were ad hoc and 23 (4%) were staged. Patients undergoing staged PCI had more lesions treated, a higher rate of no-reflow and periprocedural myocardial infarction, and higher contrast volumes and fluoroscopic times. Logistic regression analysis revealed that patients with history of heart failure, renal insufficiency and a recent myocardial infarction were more likely to undergo a staged PCI. Patients undergoing a staged PCI and those who had previous bypass surgery were more likely to have an unsuccessful PCI procedure., Conclusion: Most PCI procedures can be performed safely and effectively on the same day as diagnostic coronary angiography.

Patients with previous adverse contrast reactions occasionally present with ST-segment elevation myocardial infarction. Whether they can undergo catheterization safely using current contrast and medications is unknown. We reviewed catheterization laboratory records of all 501 patients (January 2005 to December 2006) presenting with ST-segment elevation myocardial infarction who underwent emergency coronary angiography. Six patients (1.2%) reported a previous contrast reaction including rash, acute bronchospasm, or anaphylaxis. All received a combination of intravenous steroids and H1 and H2 blockers in the emergency department or catheterization laboratory before catheterization. None of these had complications or evidence of allergy in any patient. In conclusion, some patients with previous contrast reaction may undergo emergency catheterization without adverse consequences, although the safety of this approach has not been proved.

A study was carried out to compare the effectiveness of upper limb exsanguination using the Esmarch bandage, a crepe bandage and the Rhys-Davies exsanguinator. Upper limb volume changes were measured in ten volunteers using a water displacement method. The crepe bandage produced a mean volume reduction of 59 ml (range, 39-94), which was very similar to the Esmarch bandage, which achieved 63 ml (range, 42-101). This difference is negligible in practical terms. Both bandages were more effective than the Rhys-Davies exsanguinator, which reduced the volume by a mean of 28 ml (range, 11-54). It is our opinion that the use of the Esmarch bandage in hand surgery is unnecessary and recommend the crepe bandage as a safer alternative.

The object of this study was to develop a simple method for accurately calculating the volume of bovine claws under field conditions. The digits of 30 slaughterhouse beef cattle were examined and the following four linear measurements taken from each pair of claws: (1) the length of the dorsal surface of the claw (Toe); (2) the length of the coronary band (CorBand); (3) the length of the bearing surface (Base); and (4) the height of the claw at the abaxial groove (AbaxGr). Measurements of claw volume using a simple hydrometer were highly repeatable (r(2)= 0.999) and could be calculated from linear measurements using the formula:Claw Volume (cm(3)) = (17.192 x Base) + (7.467 x AbaxGr) + 45.270 x (CorBand) - 798.5This formula was found to be accurate (r(2)= 0.88) when compared to volume data derived from a hydrometer displacement procedure. The front claws occupied 54% of the total volume compared to 46% for the hind claws., (Copyright 1999 Harcourt Publishers Ltd.)

Objective: In an attempt to reduce the cesarean delivery rate nationally, many obstetricians are offering a trial of labor to their patients who have had a prior low transverse cesarean delivery. Many studies have demonstrated the success and safety of a vaginal birth after cesarean. However, few studies have actually compared elective repeat cesareans with a trial of labor. Recent articles suggest that the morbidities associated with a failed trial of labor (TOL) may be more serious than that associated with an elective repeat cesarean delivery (RC/D). Our objective was to review and compare the morbidities and complications of repeat elective cesarean delivery versus patients attempting a trial of labor in our institution.Methods and Materials: A retrospective or nonconcurrent cohort study was conducted. Inclusion criteria included all women at our institution who had delivered from July 1993 through March 1997 and had a prior cesarean delivery. Patients were eligible for a trial of labor according to the recommendations of ACOG Practice Patterns. Exclusion criteria were nonvertex presentation, prior classical or T-incision, placenta previa, previous myomectomy, or multiple gestation. The patients were divided into those who underwent an elective repeat delivery and those who consented to a trial of labor. Outcomes studied included major complications (uterine rupture or operative injury) and minor complications (puerperal fever, postpartum hemorrhage requiring transfusion or operative intervention, or abdominal wound infection). Data were ascertained from medical records, the delivery log book, and the Quality Improvement data base. Prior to performing this study, a power analysis was conducted using an alpha of 0.05 and beta of 0.20. The required number in each arm was 2,280 to determine a 50% difference in outcome.Results: There were 1,148 women who had a repeat cesarean delivery during the study time period. Of that, 174 were excluded by the criteria, leaving 973 eligible. There were 1,030 women who underwent a trial of labor. Seven hundred seventy-three women successfully delivered vaginally (75%). The overall maternal morbidity was 2.4%; 0.8% had a major complication and 1.5% had a minor complication. The total complication rate was similar for both the trial of labor group (TOL) and the elective repeat cesarean delivery group (RC/D): 2.33% and 2.57%, respectively. However, major complications were more frequent among those that attempted a trial of labor than those who underwent an elective repeat cesarean delivery; 1.65% versus 0.1% (relative risk 16.08 with a 95% CI of 2.14-120.57; P =.00024). The relative risk for minor complications in the TOL group compared to the RC/D group was 0.28 with a 95% CI 0.12-0.64 (P =.001). Stratified analysis of the TOL group was performed. Compared to the RC/D group, those who failed VBAC had a relative risk for major complications of 56.85 using a 95% CI of 7.45-428.37. The successful VBAC group did not have statistically higher major complication rate (RR = 2.52, CI 0.23-27.74, P =.4).Conclusions: At our institution, there is a trend that major maternal complications are more frequent among those who have a trial of labor compared to those who have an elective repeat cesarean delivery. This trend was even more evident in those who failed a VBAC trial. When VBAC was successful, complications did not seem to be higher than repeat cesarean delivery. Our study did not have the power because of insufficient numbers in each arm. However, data collection is continuing to achieve the power to this study. This prompted us to reconsider the safety for a trial of labor. Perhaps more stringent criteria for selection of VBAC candidates and determination of when a trial of labor should be abandoned need to be defined. Ongoing study is warranted in this area.

Forty-three patients with chronic wrist pain have been investigated prospectively with magnetic resonance imaging and arthroscopy. Pathology within the wrist joint was detected in 30 cases with magnetic resonance imaging and 32 cases with arthroscopy. The sensitivity and specificity of magnetic resonance imaging compared with arthroscopy were 0.8 and 0.7 for triangular fibrocartilage complex pathology, 0.37 and 1.0 for scapholunate ligament and 0 and 0.97 for lunotriquetral ligament. It is concluded that magnetic resonance imaging is unhelpful in the investigation of suspected carpal instability. In analysis of the triangular fibrocartilage complex, the results of magnetic resonance imaging should be interpreted with caution.

To monitor the effect of open carpal tunnel decompression on grip strength in the hand, a prospective study was made of 25 patients undergoing a total of 31 operations. Hand grip, key pinch and pulp-to-pulp pinch strengths were measured pre-operatively and at regular intervals until 1 year following operation. At that time there was no significant difference in the hand grip and pulp-to-pulp pinch strengths compared to their pre-operative values, but the key pinch in females showed a marginally significant reduction (P = 0.04) compared to the pre-operative value.

Contrary to standard practice in the United Kingdom, primary surgery for Dupuytren's contracture can be performed safely on a day care basis provided that strict criteria are followed. Although demanding on Consultant surgical time, this policy offers a considerable saving in hospital resources.

Tumours arising from large blood vessels are very rare and usually malignant, commonly arising from large veins such as the inferior vena cava. We present two cases of malignant tumours of peripheral vessels.