Grace Kissling

Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction

OBJECTIVES The purpose of this study was to evaluate the importance of time to reperfusion for outcomes after primary angioplasty for acute myocardial infarction. BACKGROUND Survival benefit of thrombolytic therapy for acute myocardial infarction is strongly dependent on time to treatment. Recent observations suggest that time to treatment may be less important for survival with primary angioplasty. METHODS Consecutive patients (n=1,352) with acute myocardial infarction treated with primary angioplasty were followed for up to 13 years. Paired acute and follow-up ejection fraction data were obtained at cardiac catheterization in 606 patients. RESULTS Reperfusion was achieved within 2 h in 164 patients (12%). Thirty-day mortality was lowest with early reperfusion (4.3% at <2 h vs. 9.2% at > or = 2 h, p=0.04) and was relatively independent of time to reperfusion after 2 h (9.0% at 2 to 4 h, 9.3% at 4 to 6 h, 9.5% at >6 h). Thirty-day-plus late cardiac mortality was also lowest with early reperfusion (9.1% at <2 h vs. 16.3% at > or = 2 h, p=0.02) and relatively independent at time to reperfusion after 2 h (16.4% at 2 to 4 h, 16.9% at 4 to 6 h, 15.6% at >6 h). Improvement in left ventricular ejection fraction was greatest in the early reperfusion group and relatively modest after 2 h (6.9% at <2 h vs. 3.1% at > or =2 h, p=0.007). CONCLUSIONS Time to reperfusion, up to 2 h, is important for survival and recovery of left ventricular function. After 2 h, recovery of left ventricular function is modest and survival is relatively independent of time to reperfusion. These data suggest that factors other than myocardial salvage may be responsible for survival benefit in patients treated with primary angioplasty after 2 h.

Importance of infarct-related artery patency for recovery of left ventricular function and late survival after primary angioplasty for acute myocardial infarction

OBJECTIVES The purpose of this study was to evaluate the importance of late infarct-related artery patency for recovery of left ventricular function and late survival after primary angio-plasty for acute myocardial infarction. BACKGROUND Infarct-related artery patency is thought to improve late survival by its effect on preservation of left ventricular function. Patency may also enhance late survival by preventing left ventricular dilation and reducing arrhythmias, independent of myocardial salvage. However, most studies have not shown patency to be an independent predictor of survival when late left ventricular function is taken into account. METHODS We followed up 576 hospital survivors of acute myocardial infarction treated with primary angioplasty for 5.3 years. Ejection fraction and infarct-related artery patency were determined at follow-up catheterization at 6 months. Predictors of late cardiac survival were determined using Cox regression models. RESULTS Patients with patent arteries had more improvement and a better late ejection fraction than patients with occluded arteries (56.3% vs. 47.9%, p = 0.001). In patients with acute ejection fraction < 45%, late survival was better in those with patent versus occluded arteries (89% vs. 44%, p = 0.003), but patency was not a significant predictor after improvement in ejection fraction was taken into account. In patients with a large anterior infarction, patency was a significant independent predictor of late survival. CONCLUSIONS Infarct-related artery patency is important for recovery of left ventricular function, and in patients with acute ejection fraction < 45%, patency is important for late survival. Our data are consistent with the hypothesis that the survival benefit is due primarily to the effect of patency on recovery of left ventricular function. In patients with a large anterior infarction, patency appears to provide an additional late survival benefit independent of myocardial salvage. These observations support the need for additional clinical trials of late reperfusion in patients with a large anterior infarction.

Characteristics of the plaque under a coronary thrombus

Young men dying suddenly and autopsied by the coroner sometimes have coronary thrombosis at a relatively early stage of arteriosclerosis. The plaques under such thrombi often have a complex of features, a) rupture, b) hemorrhage, c) medial destruction, d) nodular collections of foam cells, e) calcification, f) cellular infiltrates of the fibrous cap, fibrous base and adventitia, and g) a newly described kind of phagocytic activity at the boundary between the necrotic core and the fibrous base of the plaque. Commonplace innocuous plaques in most middle and old aged subjects without heart disease also often have some of these features. What structural characteristics might distinguish rare thrombogenic from commonplace innocuous plaques? Twenty-one thrombotic plaques from 18 cases of sudden coronary heart disease (CHD) death were histologically compared with 129 nonthrombotic plaques from these same 18 cases, 85 plaques from 23 cases of CHD death due to arteriosclerotic occlusion, and 94 plaques from 22 cases having no CHD. Plaques with thrombosis all had necrotic cores; plaques for comparison with these were therefore chosen all to have necrotic cores. Rupture and hemorrhage were found in 90% of thrombotic plaques, with mixing of plaque gruel and blood in the thrombus. Medial destruction, foam cells and calcification (features c, d, and e) were commonplace in all types of plaques. Small-cell infiltrates and atherophagocytosis (features f or g) were found in 72–94% of the 21 thrombotic plaques, but only in 18–24% of the 94 not CHD plaques. The necrotic core, characterized by crystalline cholesterol, appears to incite cellular responses in some plaques but not others; those responses distinguish thrombogenesis. The findings imply that thrombogenicity and its accompanying plaque cellularity are incited not by cholesterol, but by some trace or minor component of the plaque gruel of the necrotic core. The possibility of testing these hypotheses by practical methods has been shown to be feasible.

Racial Differences in Patients’ Perceptions of Debilitated Health States †

OBJECTIVE: To determine health utility scores for specific debilitated health states and to identify whether race or other demographic differences predict significant variation in these utility scores.DESIGN: Utility analysis.SETTING: A community hospital general internal medicine clinic, a private internal medicine practice, and a private pulmonary medicine practice.PARTICIPANTS: Sixty-four consecutive patients aged 50 to 75 years awaiting appointments. In order to participate, patients at the pulmonary clinic had to meet prespecified criteria of breathing impairment.MEASUREMENTS: Individuals’ strength of preference concerning specific states of limited physical function as measured by the standard gamble technique.MAIN RESULTS: Mean utility scores used to quantitate limitations in physical function were extremely low. Using a scale for which 0 represented death and 1.0 represented normal health, limitation in activities of daily living was rated 0.19 (95% confidence interval [CI] 0.13, 0.25), tolerance of only bed-to-chair ambulation 0.17 (95% CI 0.11, 0.23), and permanent nursing home placement 0.16 (95% CI 0.10, 0.22). Bivariate analysis identified female gender and African-American race as predictors of higher utility scores (p ≦ .05). In multiple regression analysis, only race remained statistically significant (p ≦ .02 for all three outcome variables).CONCLUSION: Comparisons of African-American values with those of whites concerning defined states of debility demonstrate greater than threefold increases in utility scores. This finding suggests that racial differences need to be taken into account when studying the effects of medical interventions on quality of life.

Changes in Life-Style Characteristics, Health, and Mood of Freshman Medical Students.

A comprehensive questionnaire on life-style was completed by 104 of 184 freshman medical students at orientation and again seven months later. Life-style changes during this period were related to physical-psychological health and affect-mood changes. There was a decrease in the following characteristics: physical activity, salt and bread consumption, sleep and interrupted sleep, general health, leisure, and recreational activities. During the studied time period, few students maintained a balanced diet. There was an increase in perceived stress as the school year progressed and a tendency to improve coping effectiveness. This increase in coping effectiveness was associated with improved health and mood. Enjoying medical school more, feeling more competent as a medical student, and questioning the desire to enter medical school less were also related to improved health and mood.

Relationship of hassles, uplifts, and life events to psychological well-being of freshman medical students

Hassles, uplifts, and life events were related to psychological well-being with a representative sample of 55 (of 179) freshman medical students. Students were sent measures of hassles, uplifts, and affect-moods measures for 9 consecutive months and a measure of life stress at the beginning and middle of the school year. The hassles measure was found to be a better predictor of concurrent and subsequent negative mood than was the life stress measure, whereas life stress was found to be a better predictor of subsequent positive mood than hassles. On the whole, uplifts were unrelated to mood. The relationship between life stress and hassles was also investigated. The implications of the findings for future stress and health outcome research are discussed.

Price Spreads and Residential Housing Market Liquidity

Most studies of housing market liquidity have measured liquidity in terms of time on the market (TOM), and have sought to explain TOM in terms of property characteristics and measures of market conditions. This paper departs from past studies of housing market liquidity by examining the spread between the listing and contract prices.We develop theory to explain the price spreads in the residential housing market. The model includes the list price of the home, the cost of the search, the standard deviation of offer prices, and TOM. Empirical tests using 3,597 sales for 25 months show a robust relationship of housing market spreads and these variables. Listing price and cost of search have the predicted positive coefficients, and the standard deviation of price offers is found to be negatively related to the price spread.

Health insurance does not guarantee access to primary care: a national study of physicians' acceptance of publicly insured patients.

The roles of reimbursement and other predictors that affect physicians’ willingness to accept publicly insured continuing care patients were examined in a national survey. The response rate was 47%. Eighty-eight percent of the respondents were accepting new patients. Forty-two percent of these physicians were willing to accept new continuing care patients insured by Medicaid, 70% reported accepting those paying by Medicare assignment, and 85% said they accept patients covered by Medicare plus balance-billing payments. Low reimbursement was the strongest predictor for lack of acceptance. The results suggest that systems of multitiered reimbursement are associated with diminished access for patients insured in the lower tiers.

Institutional Conflict of Interest Policies at U.S. Academic Research Institutions.

Purpose Institutional conflicts of interest (ICOIs) occur when the institution or leaders with authority to act on behalf of the institution have conflicts of interest (COIs) that may threaten the objectivity, integrity, or trustworthiness of research because they could impact institutional decision making. The purpose of this study was to gather and analyze information about the ICOI policies of the top 100 U.S. academic research institutions, ranked according to total research funding. Method From May–June 2014, the authors attempted to obtain ICOI policy information for the top 100 U.S. academic research institutions from publicly available Web sites or via e-mail inquiry. If an ICOI policy was not found, the institutions’ online COI policies were examined. Data on each institution’s total research funding, national funding rank, public versus private status, and involvement in clinical research were collected. The authors developed a coding system for categorizing the ICOI policies and used it to code the policies for nine items. Interrater agreement and P values were assessed. Results Only 28/100 (28.0%) institutions had an ICOI policy. ICOI policies varied among the 28 institutions. Having an ICOI policy was positively associated with total research funding and national funding ranking but not with public versus private status or involvement in clinical research. Conclusions Although most U.S. medical schools have policies that address ICOIs, most of the top academic research institutions do not. Federal regulation and guidance may be necessary to encourage institutions to adopt ICOI policies and establish a standard form of ICOI review.

Smooth muscle cell - reticulin lamellar units of 13.2 µm thickness composing the aortic intima

Smooth muscle cells of the aortic intima are generally of two forms, spindle and stellate. Spindle cells are typically axial in their orientation, while stellate cells lie parallel to the luminal surface; cell processes do not characteristically extend in the radial direction through the intimal thickness. Evidence is given here to suggest that these cells are clustered in layers of about 13.2 µm thickness which are separated by condensations of reticulin fibers. These layered clusters may extend as much as 1 cm to 2 cm in the axial direction. The numbers of layers appear to increase during growth and maturation to a stable value of about 12 by age 30–40. With further aging and growth. of fibrous plaques, the layers seem to become thicker and to merge, obliterating their boundaries, to become 15 to 35 µm or more in average thickness. This expansion and merging of lamellar units precedes atheronecrosis and appears to represent an important precursor of the necrotic core. The greatest growth of fibrous plaques, at ages 40 to 60, takes place after the stabilization of cell numbers at ages 30 to 40, and is almost as likely to happen in the least cellular as in the most cellular places. Hence, these data suggest that smooth muscle cell numbers are not important determinants of the locations nor of the growth rates of fibrous plaques in the lateral thoracic aorta.