The clinical spectrum of HbSC sickle cell disease-not a benign condition.

Sickle cell disease (SCD) includes a group of heterogenous disorders that result in significant morbidities. HbSS is the most common type of SCD and HbSC is the second most common type of SCD. The prevalence of HbSC disease in the United States and United Kingdom is ~1 in 7174 births and 1 in 6174 births respectively. Despite its frequency, however, HbSC disease has been insufficiently studied and was historically categorized as a more 'mild' form of SCD. We conducted this study of HbSC disease as part of the NHLBI funded Sickle Cell Disease Implementation Consortium (SCDIC). The SCDIC registry included 2282 individuals with SCD, ages 15-45 years of whom 502 (22%) had HbSC disease. Compared with people with sickle cell anaemia (SCA), the study found that people with HbSC disease had a higher frequency of splenomegaly (n (%) = 169 (33.7) vs. 392 (22.1)) and retinopathy (n (%) = 116 (23.1) vs. 189 (10.6)). A Many people with HbSC also had avascular necrosis (n (%) = 112 (22.3)), pulmonary embolism (n (%) = 43 (8.6)) and acute chest syndrome (n (%) = 228 (45.4)) demonstrating significant disease severity. HbSC disease is more clinically severe than was previously recognized and deserves additional evaluation and targeted treatments.

Evaluating the implementation of a multi-level mHealth study to improve hydroxyurea utilization in sickle cell disease.

Background: Sickle Cell Disease (SCD) is a progressive genetic disease that causes organ damage and reduces longevity. Hydroxyurea is an underutilized evidence-based medication that reduces complications and improves survival in SCD. In a multi-site clinical trial, part of the NIH-funded Sickle Cell Disease Implementation Consortium (SCDIC), we evaluate the implementation of a multi-level and multi-component mobile health (mHealth) patient and provider intervention to target the determinants and context of low hydroxyurea use. Given the complexity of the intervention and contextual variability in its implementation, we combined different behavioral and implementation theories, models, and frameworks to facilitate the evaluation of the intervention implementation. In this report, we describe engagement with stakeholders, planning of the implementation process, and final analytical plan to evaluate the implementation outcomes. Methods: During 19 meetings, a 16-member multidisciplinary SCDIC implementation team created, conceived, and implemented a project that utilized Intervention Mapping to guide designing an intervention and its evaluation plan. The process included five steps: (1) needs assessment of low hydroxyurea utilization, (2) conceptual framework development, (3) intervention design process, (4) selection of models and frameworks, and (5) designing evaluation of the intervention implementation. Results: Behavioral theories guided the needs assessment and the design of the multi-level mHealth intervention. In designing the evaluation approach, we combined two implementation frameworks to best account for the contextual complexity at the organizational, provider, and patient levels: (1) the Consolidated Framework for Implementation Research (CFIR) that details barriers and facilitators to implementing the mHealth intervention at multiple levels (users, organization, intervention characteristics, broader community), and (2) the Technology Acceptance Model (TAM), a conceptual model specific for explaining the intent to use new information technology (including mHealth). The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework was used to measure the outcomes. Discussion: Our research project can serve as a case study of a potential approach to combining different models/frameworks to help organize and plan the evaluation of interventions to increase medication adherence. The description of our process may serve as a blueprint for future studies developing and testing new strategies to foster evidence-based treatments for individuals living with SCD.

The Sickle Cell Pro-Inflammatory Response to Interval Testing Study (SPRINTS) in children and young adults with sickle cell anemia - Study design and methodological strategies.

The impact of sickle cell anemia (SCA) and its complications on physical functioning and cardiopulmonary/aerobic fitness in affected individuals is significant. Although limited data support the safety of maximal cardiopulmonary exercise testing (CPET) for children and adults with SCA, the safety of submaximal moderate and high intensity, and longer duration, exercise in this population is not clear. The Sickle Cell Pro-Inflammatory Response to Interval Testing Study (SPRINTS) is a multicenter, randomized, prospective trial. SPRINTS leverages unique collaborations between investigators in pediatric hematology and exercise science to evaluate the impact of exercise intensity on the acute phase inflammatory response to exercise and changes in airway dynamics in children and young adults with SCA. Here we describe the study design and methodological strategies employed in SPRINTS, including an exercise challenge that mimics real-life patterns of childhood physical activity, characterized by multiple moderate and high intensity brief bouts of exercise interspersed with rest periods. Primary outcomes comprise pre- and post-exercise biomarkers of inflammation and endothelial dysfunction and spirometry. Secondary outcomes include assessment of physical activity and functioning, genomic studies and near-infrared spectroscopy measurements to assess tissue oxygenation status during exercise. SPRINTS aims to enroll 70 subjects with SCA and 70 matched, healthy controls. We anticipate that data from SPRINTS will address gaps in our understanding of exercise responses and safety in SCA and support the future development of evidence-based, exercise prescription guidelines in this population.

Evaluation of SWI in children with sickle cell disease.

BACKGROUND AND PURPOSE: SWI is a powerful tool for imaging of the cerebral venous system. The SWI venous contrast is affected by blood flow, which may be altered in sickle cell disease. In this study, we characterized SWI venous contrast in patients with sickle cell disease and healthy control participants and examined the relationships among SWI venous contrast, and hematologic variables in the group with sickle cell disease. MATERIALS AND METHODS: A retrospective review of MR imaging and hematologic variables from 21 patients with sickle cell disease and age- and sex-matched healthy control participants was performed. A Frangi vesselness filter was used to quantify the attenuation of visible veins from the SWI. The normalized visible venous volume was calculated for quantitative analysis of venous vessel conspicuity. RESULTS: The normalized visible venous volume was significantly lower in the group with sickle cell disease vs the control group (P < .001). Normalized visible venous volume was not associated with hemoglobin, percent hemoglobin F, percent hemoglobin S, absolute reticulocyte count, or white blood cell count. A hypointense arterial signal on SWI was observed in 18 of the 21 patients with sickle cell disease and none of the 21 healthy control participants. CONCLUSIONS: This study demonstrates the variable and significantly lower normalized visible venous volume in patients with sickle cell disease compared with healthy control participants. Decreased venous contrast in sickle cell disease may reflect abnormal cerebral blood flow, volume, velocity, or oxygenation. Quantitative analysis of SWI contrast may be useful for investigation of cerebrovascular pathology in patients with sickle cell disease, and as a tool to monitor therapies. However, future studies are needed to elucidate physiologic mechanisms of decreased venous conspicuity in sickle cell disease.

Effect of dietary vitamin E supplementation and refrigerated storage on quality of rainbow trout fillets.

Rainbow trout were fed a low vitamin E (200 mg/kg; LVE) or a high vitamin E (5000 mg/kg; HVE) diet for 9 wk to characterize the effect of vitamin E supplementation at 5000 mg/kg on fillet quality. Fish were sampled at 2, 3, 4, 5, 7, and 9 wk of the trial. Fillets were stored at 2 °C for 0, 7, and 14 d, and analyzed for pH, psychrotrophic counts, color, cook yield, shear force, crude fat and moisture content, α-tocopherol, fatty acid composition, and lipid oxidation. There was a significant feeding duration by fillet storage time interaction for psychrotrophic counts, crude fat content, cook yield, and shear force. Fillet L* value was not affected by diet, feeding duration or storage time. Fillet a* was lowest at 14-d storage, and b* values increased with fillet storage time. High vitamin E diet increased fillet α-tocopherol from 33 to 155 mg/kg. High vitamin E decreased palmitic acid and increased linoleic acid and omega-6 fatty acids. Feeding through 9 wk increased the relative proportions of unsaturated, polyunsaturated, and omega-3 fatty acids, and decreased saturated and omega-6 fatty acids. At 0-d storage, HVE diet did not affect thiobarbituric acid-reactive substances (TBARS) at any sampling week, and fasted fish generated fewer TBARS compared to non-fasted fish.

Interactions of the RNA-binding protein Hfq with cspA mRNA, encoding the major cold shock protein.

CspA, a small protein that is highly induced by cold shock, is encoded by a monocistronic mRNA of 428 nucleotides (nt) whose half-life and abundance are greatly increased following cold shock. We show here that in vitro cspA mRNA can bind multiple copies of Hfq, a hexameric Sm-like protein which promotes a variety of RNA-RNA interactions. Binding of the first Hfq hexamer occurs with an apparent K(d) (dissociation constant) of <40 nM; up to seven additional hexamers can bind sequentially at higher concentrations. Known ligands of Hfq, including the small regulatory RNA, RyhB, compete with cspA mRNA. Several experiments suggest that the first binding site to be occupied by Hfq is located at or near the 3' end of cspA mRNA. The consequences of limited Hfq binding in vitro include nearly total inhibition of RNase E cleavage at a site approximately 35 nt from the 3' end of the mRNA, stimulation of polyadenylation by poly(A) polymerase 1, and subsequent exonucleolytic degradation by polynucleotide phosphorylase. We propose that Hfq may play a facilitating role in the metabolism of cspA mRNA.

F-18-fluoro-deoxy-glucose positron emission tomography in the assessment of peripheral T-cell lymphomas.

F-18-fluoro-deoxy-glucose positron emission tomography (PET) is highly sensitive and specific in the imaging of B-cell lymphomas. In contrast, its utility in the diagnostic evaluation of T-cell lymphomas is less defined. In this article, we present our finding utilizing PET in peripheral T-cell lymphomas (PTCL). A retrospective review of patients who underwent PET examinations at our institution produced 24 PET examinations among patients with PTCL. A lesion-based analysis was undertaken to evaluate the diagnostic accuracy of PET in PTCL. PET findings were compared with a standard of reference and sensitivity, specificity, positive and negative predictive values were calculated. PET had an overall sensitivity of 86% and specificity of 100%. PET had high sensitivity (95%) at nodal and non-cutaneous extra-nodal sites and poor sensitivity (13%) at cutaneous sites. The mean SUV of abnormal foci in anaplastic large cell lymphoma was 11 mg/ml (range: 3 - 40), and PTCL-unclassified was 8 mg/ml (range: 1 - 23).

A case of cholecystohepatic duct with atrophic common hepatic duct.

BACKGROUND: Cholecystohepatic ducts are rare congenital variants of the biliary tree. CASE OUTLINE: An 81-year-old woman presented with biliary colic and elevated liver function tests. An ERCP demonstrated a common bile duct stone and stricture of the common hepatic duct. An operative cholangiogram demonstrated an atrophic common hepatic duct and retrograde filling of the gallbladder through a large cholecystoheptic duct. The patient had a cholecystectomy and reconstructive cholecystohepatic duct jejunostomy. DISCUSSION: This case demonstrates a rare congenital anomaly where the gallbladder fills retrograde during an intraoperative cholangiogram despite clipping of the cystic duct. The major path of biliary drainage was through a large cholecystoheptic duct similar to a gallbladder interposition; however, the common hepatic duct was still present but atrophic. This anomaly has not been described previously.

Influence of body condition score on carcass characteristics and subprimal yield from cull beef cows.

Mature beef cows (n = 83) were slaughtered to measure the influence of body condition score (BCS) on carcass characteristics and subprimal yields. All cows were weighed and assigned BCS, based on a 9-point scale, 24 h before slaughter. Cows were slaughtered, and, after a 48-h chilling period, quality and yield grade data were collected on the left side of each carcass. The right side was quartered, fabricated into primal cuts, and weighed. Each primal cut was further processed into boneless subprimal cuts, minor cuts, lean trim, fat, and bone. Cuts were progressively trimmed to 6.4 and 0 mm of external and visible seam fat. Weights were recorded at all stages of fabrication, and subprimal yields were calculated as a percentage of the chilled carcass weight. Live weight, carcass weight, dressing percentage, fat thickness, longissimus muscle area, muscle:bone ratio, and numerical yield grade increased linearly (P = .0001) and predicted cutability and actual muscle-to-fat ratio decreased linearly (P = .0001) as BCS increased from 2 to 8. Carcasses from BCS-8 cows had the most (P<.05) marbling. The percentage of carcasses grading U.S. Utility, or higher, was 16.7, 20.0, 63.6, 43.3, 73.3, 100.0, and 100.0% for cows assigned a BCS of 2, 3, 4, 5, 6, 7, and 8, respectively. At 6.4 mm of fat trim, carcasses from BCS-5 cows had higher (P<.05) shoulder clod yields than carcasses from cows having a BCS of 6, 7, and 8. Carcasses of BCS-2 cows had lower (P<.05) strip loin yields than carcasses from BCS-3, 4, 5, 6, and 7 cows. Top sirloin butt yields were higher (P<.05) for carcasses of BCS-2, 3, 4, and 5 cows than those of BCS-6, 7, or 8 cows. Carcasses from BCS-7 and 8 cows had lower (P<.05) tenderloin and inside round yields than carcasses of BCS-5, or less, cows. At both fat-trim levels, carcasses from BCS-5 cows had higher (P<.05) eye of round yields than cows assigned BCS of 2, 7, or 8. When subprimal cuts were trimmed to 6.4 mm of visible fat, carcasses from BCS-5 cows had higher (P<.05) total lean product yields than cows assigned a BCS of 2, 4, 7, and 8. Regardless of fat trim, total fat yields increased (P = .0001) and total bone yields decreased (P = .0001) linearly as BCS increased from 2 to 8. Although carcasses from BCS-5 and 6 cows had the highest yields of lean product, cattle producers and packers may benefit most by marketing and(or) purchasing BCS-6 cows because a higher percentage of their carcasses had quality characteristics deemed desirable for fabrication into boneless subprimal cuts.

Application of oligo-(14-amino-3,6,9,12-tetraoxatetradecanoic acid) lipid conjugates as steric barrier molecules in liposomal formulations.

Lipid conjugates of oligo-(14-amino-3,6,9,12-tetraoxatetradecanoic acid) (ATTAn) were synthesized as monodisperse analogues of poly(ethylene glycol) (PEG) derivatives used in liposomal drug delivery systems. The new lipids were shown to be at least equivalent to MePEGA-2000-DSPE in assays designed to evaluate the effectiveness of polymers as steric barrier molecules in liposomes. Liposomes containing 1-5% of ATTA8-DSPE (octamer) showed comparable long circulation behavior relative to PEG-2000-DSPE analogues. Surprisingly, the shorter ATTA4-DSPE (tetramer) appeared to be quite effective in reducing clearance. Liver enzyme levels and systemic single dose tolerability of ATTA8-DSPE liposomes were comparable to controls, suggesting that the new materials are nontoxic. Prolonged exposure of ATTA8-DSPE liposomes to splenocytes in vitro showed no evidence of mitogenicity relative to controls or MePEGA-2000-DSPE liposomes. ATTA8-DSPE was as effective as MePEGC-2000-DSPE in preventing complement activation by cationic liposome systems. Repeat dosage in vivo regimes in ICR mice using DSPC/cholesterol liposomes, with and without 5% ATTA8-DSPE and MePEGC-2000-DSPE, showed no evidence of enhanced clearance on successive doses. Splenocytes recovered after repeat doses showed no significant evidence of mitogenicity on restimulation with liposomes. Cellular differentiation and activation marker levels in splenocytes recovered after the fourth in vivo administration were at normal levels. These results suggest that ATTAn oligomers do not induce an immune response in isolation. It was demonstrated that ATTA8-DSPE could be used to replace PEG-lipids in the formulation of doxorubicin, plasmid DNA and oligonucleotides using a variety of formulation techniques. The study demonstrates that ATTAn oligomers can be safely and effectively used in place of poly(ethylene glycol) as well-defined biomaterials in liposomal applications where reproducible behavior is critical.

Laser-based capillary polarimeter.

A laser-based capillary polarimeter has been configured to allow for the detection of optically active molecules in capillary tubes with a characteristic inner diameter of 250 microm and a 39-nL (10(-9)) sample volume. The simple optical configuration consists of a HeNe laser, polarizing optic, fused-silica capillary, and charge-coupled device (CCD) camera in communication with a laser beam analyzer. The capillary scale polarimeter is based on the interaction between a polarized laser beam and a capillary tube, which results in a 360 degree fan of scattered light. This array of scattered light contains a set of interference fringe, which respond in a reproducible manner to changes in solute optical activity. The polarimetric utility of the instrument will be demonstrated by the analysis of two optically active solutes, R-mandelic acid and D-glucose, in addition to the nonoptically active control, glycerol. The polarimetric response of the system is quantifiable with detection limits facilitating 1.7 x 10(-3) M or 68 x 10(-12) nmol (7 psi 10(-9) g) sensitivity.

Superior sulcus (Pancoast) tumor: experience with 105 patients.

BACKGROUND: The evolution of therapy in 105 patients with superior sulcus (Pancoast) tumor over the past 42 years was reviewed. METHODS: There were 82 men and 23 women aged 30 to 75 years. Tumor cell types were: squamous, 41 (39%); adenocarcinoma, 23 (21.9%); anaplastic, 14 (13.3%); undetermined, 12 (11.4%); mixed, 9 (8.7%); and large cell 6 (5.7%). Therapy was based on extent of disease and lymph node involvement. There were 5 treatment groups: I, preoperative radiation and operation (n = 28); II, operation and postoperative radiation (n = 16); III, radiation (n = 37); IV, preoperative chemotherapy, radiation, and operation (n = 11); and V, operation (n = 12). RESULTS: The median survival for group I was 21.6 months; group II, 6.9 months; group III, 6 months; and group V, 36.7 months. Median survival for group IV has not yet been reached (estimated at 72% at 5 years). On univariate analysis, mediastinal lymph node involvement, Horner syndrome, TNM classification, and method of therapy affected survival. On multivariate regression analysis, only N2 and N3 disease and method of therapy were significant (p < 0.05). CONCLUSIONS: The optimal treatment for superior sulcus tumor was preoperative radiation and operation. However, triple modality therapy, although promising, requires longer follow-up.

Plasma vitamins E and C concentrations of adult patients during cardiopulmonary bypass.

OBJECTIVE: This study was designed with two aims: 1) to determine if the coronary artery bypass graft (CABG) procedure alters plasma vitamin E and C concentrations of adult patients through repeated determinations of vitamin levels at time points before, during and following CABG, and 2) to assess whether plasma vitamin E concentrations reflect myocardial tissue content. METHODS: A consecutive sample of 38 patients undergoing CABG surgery at a Midwest tertiary care hospital was enrolled. Patients receiving blood transfusions before or during surgery were excluded. RESULTS: Plasma vitamin E/total lipid ratios rose with reperfusion, remained elevated immediately following bypass, and fell to preoperative concentrations by 24 hours. Plasma vitamin E/total cholesterol levels varied little throughout this time course. Both plasma uric acid and ascorbate concentrations (corrected for hemodilution) also rose by the preischemic interval, and remained elevated until a return to preoperative levels by 24 hours. Corrected malondialdehyde (MDA) concentrations rose by pre-ischemia but returned more quickly to preoperative levels. Atrial appendage tissue vitamin E concentrations bore a significant relationship to those of plasma prior to surgery (r=+0.49, p=0.004). Reported supplement use, plasma concentrations and body mass index contributed to the variability in atrial tissue concentrations of vitamin E. CONCLUSIONS: In short, when not confounded by transfusions or hemodilution, several peripheral indices of antioxidants increase with the reperfusion segment of CABG procedure and return to baseline levels within 24 hours of surgery. Parallel changes in MDA were observed. The observed changes are consistent with the hypothesis that oxidative stress accompanies the ischemia-reperfusion components of the CABG procedure.

Paraplegia after thoracotomy: report of five cases and review of the literature.

Paraplegia complicating thoracotomy is rare but catastrophic. This report comprises 40 cases: 5 of our cases and 35 reported cases. Our cases comprised a stab wound of the left chest (1), decortication (1), lobectomy for bronchogenic carcinoma (2), and segmental resection for tuberculosis (1). The reported cases included 25 cases following thoracotomy for thoracic pathology (bronchogenic carcinoma, 12; pulmonary tuberculosis, 7; thoracic trauma, 2; bronchiectasis, 1; peptic esophagitis, 1; neurogenic tumors, 2; and benign lung lesion, 1 and 10 cases following operation for malignant hypertension. The surgical procedures performed on the 25 patients with thoracic pathology were lobectomy (8), bilobectomy (1), pneumonectomy (7), decortication (1), thoracoplasty (1), excision of neurogenic tumors (2), drainage of tuberculous cavity (1), and Nissen procedure (1). The intraoperative factors contributing to the neurologic deficit were bleeding at the costovertebral angle (9), migration of oxidized cellulose into spinal canal (9), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic (2), metastatic carcinoma (1), and hypotension (1). This serious complication can be prevented by meticulous operation and careful hemostasis. The immediate use of tomographic scanning or magnetic resonance imaging followed by surgical decompression might avert this serious complication.

Effect of exercise level on the diagnostic accuracy of thallium-201 SPECT scintigraphy.

The sensitivity of electrocardiographic ST analysis for detecting coronary artery disease is markedly decreased in patients unable to exercise vigorously. To determine the diagnostic accuracy of Thallium-201 SPECT scintigraphy at various exercise levels, we evaluated 179 patients without evidence of prior myocardial infarction or other confounding factors who performed symptom-limited exercise with Thallium-201 SPECT scintigraphy. Sensitivity decreased from 89% in those patients achieving greater than or equal to 85% of maximal heart rate to 63% in those achieving less than 65%. Like ST segment analysis, Thallium 201 SPECT scintigraphy has decreased diagnostic yield at low levels of exertion.

Penetrating cardiac injuries.

One hundred nine penetrating cardiac injuries were reviewed: 49 gunshot wounds and 60 stab wounds. They were classified into four groups: group 1 (lifeless), 38; group 2 (agonal), 16; group 3 (shock), 33; and group 4 (stable), 22. Thirty-six patients in group 1 (94%) and 8 of 16 patients in group 2 (50%) underwent emergency room thoracotomy; 24 of 33 in group 3 (73%) and 20 of 22 (90%) underwent thoracotomy in the operating room. Twenty-one (38%) of 55 patients undergoing emergency room thoracotomy survived, whereas 47 (87%) of 54 patients undergoing operating room thoracotomy survived. Survival was 12 of 38 (31%) in group 1, 11 of 16 (69%) in group 2, 26 of 33 (79%) in group 3, and 18 of 22 (82%) in group 4 with an overall survival of 67 of 109 (61%). Gunshot wounds of the heart portend a worse prognosis than stab wounds. Survival of gunshot wounds was 20 of 49 (40%) compared with 47 survivors of 60 stab wounds (78%). Aggressive treatment, including emergency room thoracotomy, is justified for lifeless and deteriorating cardiac injury victims.

Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience.

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.

Esophageal perforation: a therapeutic challenge.

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

The effect of baseline electrocardiographic abnormalities on the diagnostic accuracy of exercise-induced ST segment changes.

Although exercise-induced ST segment depression is thought to be unreliable marker of myocardial ischemia in the presence of resting electrocardiographic changes, this conclusion is based on limited and disparate data from studies often lacking acceptable measures of ischemia. To determine the diagnostic accuracy of the ST segment response in a blinded prospective protocol, we compared ST deviation to thallium201 SPECT scintigraphy in 95 patients during exercise. Diagnostic accuracy was poor in the 95 patients with resting abnormalities: left bundle branch block (LBBB) = 70%, complete right bundle branch block (cRBBB) = 75%, incomplete right bundle branch block (incRBBB) = 79%, intraventricular conduction delay (IVCD) = 44%, left ventricular hypertrophy (LVH) = 59%, digitalis = 53%, compared with a diagnostic accuracy of 90% in 29 patients without resting changes. There were 20 false negative and 17 false positive ST segment responses. The extent and direction of resting ST deviation varied substantially and had no influence on diagnostic accuracy. The extent of change in ST deviation with exercise required for a positive response did not alter diagnostic accuracy: -1.0 mm = 61%, -1.5 mm = 63%, and -2.0 = 61%. While the location of regional ischemia did not influence the accuracy of ST segment analysis, a QRS duration less than 120 msec did improve diagnostic accuracy. Our data confirm that ST segment analysis with exercise testing is not reliable in patients with resting electrocardiographic abnormalities and demonstrates that accuracy is not improved by adjusting for either resting or exercise-induced ST segment changes or for location of the ischemic region.