Inflammatory reaction to fabric collars from percutaneous antennas attached to intracoelomic radio transmitters implanted in harlequin ducks (Histrionicus histrionicus).

In wild birds implanted intracoelomically with radio transmitters, a synthetic fabric collar placed around the base of a percutaneous antenna is believed to function as a barrier to contamination of the coelom. We examined 13 fabric collars recovered from percutaneous antennas of radio transmitters implanted intracoelomically in harlequin ducks (Histrionicus histrionicus) 12 months earlier. Both the transmitters and antenna collars were encapsulated in fibrous connective tissue, with adhesions to internal organs. Histologically, bacteria were evident at the fabric-plastic interface in 8 of 10 collars examined in cross section and along the length of the collar in 3 collars examined longitudinally. Bacteria were confined within the fibrotic sheath surrounding the transmitter and the antenna collar in all birds. No evidence of chronic systemic effects secondary to implantation was present on hematologic or serum biochemical testing. These findings indicate that antenna collars do not prevent the entry of bacteria along the percutaneous antenna but may help stabilize the antenna and minimize coelomic contamination. We conclude that radio transmitters implanted into the coelom of harlequin ducks do not appear to cause significant health problems for at least 1 year after implantation.

Prognostic importance of lower extremity arterial disease in patients undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI).

OBJECTIVES: The purpose of this study was to evaluate the prevalence and prognostic importance of lower extremity arterial disease (LEAD) in patients with multivessel coronary artery disease. BACKGROUND: The presence of clinically evident LEAD increases the risk of death in patients with known coronary artery disease. Because studies have lacked noninvasive measures of subclinical LEAD, the true prognostic importance of lower extremity atherosclerosis in this population has probably been underestimated. METHODS: Ankle blood pressures were measured in 405 consecutive patients with angiographically documented multivessel coronary disease from seven Bypass Angioplasty Revascularization Investigation (BARI) sites and a parallel study site within 3 years of enrollment. Lower extremity arterial disease was defined as an ankle/arm systolic blood pressure ratio of 0.90 or less. RESULTS: Among patients studied, 69 (17%) had LEAD. These patients were more likely to be current smokers, treated for diabetes, older and present with unstable angina compared with patients without LEAD. Among patients who underwent coronary arterial bypass grafting, major complications occurred in 2.8% of those without LEAD compared with 20.7% of those with LEAD (p = 0.002). Five-year mortality rates were similar for symptomatic LEAD (14%) and asymptomatic LEAD (14%). Patients without LEAD had a 3% mortality. After adjusting for baseline differences, the relative risk of death was 4.9 times greater for patients with LEAD compared with those without (95% confidence interval [CI]: 1.8, 13.4, p < 0.01). CONCLUSIONS: Patients with LEAD have a significantly higher risk of death than patients without LEAD, regardless of the presence of symptoms. An abnormal ankle/arm index is a strong predictor of mortality and can be used to further stratify risk among patients with multivessel coronary artery disease.

In-hospital costs associated with new percutaneous coronary devices.

To determine the relative economic impact of alternative methods of coronary revascularization, in-hospital patient accounts were reviewed in 149 patients undergoing elective coronary angioplasty (n = 50), coronary atherectomy (n = 72) or intracoronary stent placement (n = 27) over an 18-month period. Clinical and angiographic features were similar in the 3 groups, except that prior restenosis was seen more often in patients undergoing intracoronary stent placement. Procedural success, obtained in greater than 90% of patients, was independent of the treatment strategy. Total in-hospital stay was significantly longer in patients undergoing intracoronary stent placement than in patients undergoing coronary angioplasty and directional atherectomy (4.9 +/- 2.4 days vs 1.5 +/- 1.3 and 2.2 +/- 3.9 days, respectively; p less than 0.0001). Furthermore, the total in-hospital charges were significantly higher in patients undergoing intracoronary stent placement ($12,574 +/- $4,564 vs $6,220 +/- $5,716; p less than 0.001) and directional atherectomy ($8,329 +/- $8,588 vs $6,220 +/- $5,716; p less than 0.01) than in patients undergoing coronary angioplasty, reflecting overall differences in room costs, laboratory fees and pharmacy fees. The longer in-hospital stay in the intracoronary stent group was primarily attributed to the time required for anticoagulation with coumadin. It is concluded that a 102 and 34% increase in early hospital charges resulted with stenting or directional atherectomy, respectively, compared with coronary angioplasty. These increased in-hospital charges were chiefly due to the prolonged hospitalization time, device cost, laboratory fees and, in patients with intracoronary stents, the prolonged time needed to achieve systemic anticoagulation.

Exercise testing three days after onset of acute myocardial infarction.

To determine the feasibility and predictive value of early exercise testing 72 hours after acute myocardial infarction, 109 consecutive patients who received reperfusion therapy were prospectively evaluated. In the group studied, in 87 (80%) the course was uncomplicated 3 days after admission, as defined by a lack of congestive heart failure, arrhythmias and angina, and 53 patients (49%) performed heart rate-limited (140 beats/min) treadmill exercise. These patients exercised for 7.9 +/- 3.4 minutes, achieving a heart rate of 129 +/- 11 beats/min and a systolic blood pressure of 151 +/- 27 mm Hg. The exercise test was not accompanied by any protracted ischemia, infarction or significant arrhythmias. Accompanying tomographic thallium-201 scintigraphy demonstrated a reversible perfusion defect in 14 patients (26%), no evidence for ischemia in 36 patients (69%) and an equivocal result in 3 patients (6%). Of the 14 patients with a positive exercise-thallium test result, 4 had an adverse clinical outcome of either reinfarction, postinfarction angina or ventricular tachycardia during hospital days 4 to 10; an adverse in-hospital outcome was not seen in the 40 patients with a negative exercise-thallium test result (p = 0.009). Thus, early exercise testing after acute myocardial infarction is safe in selected patients with an uncomplicated course and the test is predictive of in-hospital clinical outcomes.

Long-term prognostic value of clinically evident noncoronary vascular disease in patients undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI).

In the general population, peripheral atherosclerosis is a strong predictor of cardiovascular disease and death. In patients with known coronary artery disease, it is unclear whether the presence of additional noncoronary atherosclerosis is of further prognostic value. In the Bypass Angioplasty Revascularization Investigation, 5-year outcome was compared between patients with and without clinically evident noncoronary atherosclerosis. Within the subgroup with noncoronary atherosclerosis, surgery, and angioplasty treatment strategies were compared. Noncoronary atherosclerosis was defined as claudication, peripheral vascular surgery, abdominal aortic aneurysm, history of cerebral ischemia, or carotid disease. Among 1,816 patients, 303 (17%) had noncoronary atherosclerosis. These patients were more likely to have a history of congestive heart failure, diabetes, and hypertension, and were more likely to smoke. Coronary angiographic variables were similar between the 2 groups. Five-year survival was 75.8% for patients with noncoronary atherosclerosis and 90.2% for those without (p < 0.001). The adjusted relative risk of death was 1.7 for any noncoronary atherosclerosis, 1.5 for lower extremity disease alone, 1.7 for cerebral disease alone, and 2.3 for both conditions. Among the 303 patients with noncoronary atherosclerosis, the adjusted relative risk of death for surgery versus angioplasty was 0.87 (p = 0.40). However, the study has limited power to detect a treatment effect in this small subgroup. Thus, patients with combined coronary and clinically evident noncoronary atherosclerosis are a high-risk group with significantly worse long-term outcome compared patients with isolated coronary disease.

Serologic and virologic evidence of a Prospect Hill-like hantavirus in Wisconsin and Minnesota.

The purposes of this study were to determine if hantaviruses were present in the Great Lakes port areas of Wisconsin and Minnesota and if so, to identify which virus and which rodent host species were involved. Rodents were trapped in Duluth, Minnesota, Superior, Green Bay, and Milwaukee, Wisconsin, all ports of call for international maritime shipping. A total of 675 wild rodents were captured and tested, including 310 meadow voles (Microtus pennsylvanicus), 173 Norway rats (Rattus norvegicus), 179 Peromyscus spp., (including white footed mice [P. leucopus] and deer mice [P. maniculatus gracilis and P. maniculatus bairdii]), and 13 house mice (Mus musculus). Twenty percent of the rats, 17% of the meadow voles, 8% of the house mice, and 3% of the Peromyscus spp. had antibody to a hantavirus by immunofluorescent antibody assay (IFA). By the plaque-reduction neutralization test (PRNT), nine of 36 meadow voles, one of 4 P. leucopus, and one of 34 rats had hantavirus antibody, with the highest titers to Prospect Hill (PH) virus. All of the PRNT-seropositive individuals were from the twin cities of Superior and Duluth. Hantavirus antigen was detected in lung tissue by IFA in M. pennsylvanicus and Peromyscus spp., but not in rats. Two hantaviruses, designated SD-1 and SD-2, were isolated from M. pennsylvanicus captured in Duluth and found to be very similar to prototype PH virus by cross-IFA and cross-PRNT. Virus isolation attempts were unsuccessful from tissues of the Peromyscus spp. and the rats.

Exercise capacity in patients 3 days after acute, uncomplicated myocardial infarction.

In a randomized, controlled trial of early hospital discharge after acute myocardial infarction (MI), a heart rate, symptom-limited exercise thallium test was performed after the onset of MI. Patients' exercise capacity was evaluated by the exercise treadmill with accompanying thallium scintigraphy. Of 507 consecutive patients screened, the condition of 179 was classified as uncomplicated, which is defined as the absence of angina, heart failure, or serious arrhythmias at 72 hours from admission. Of the patients with uncomplicated conditions, 126 had an exercise test on day 3 and 53 did not exercise on day 3. Of the 126 patients who exercised on day 3, 36 had a positive test and 90 had a negative test for ischemia. The 36 patients with a positive test result exercised a mean time of 6.71 +/- 2.8 minutes, achieved a mean peak heart rate of 120.9 +/- 21.4 beats/min, reached a peak systolic blood pressure of 144.7 +/- 33.3 mm Hg, and achieved a double product (rate-pressure product) of 183.4 +/- 67.6. The 90 patients with a negative test result for ischemia exercised 9.45 +/- 12.7 minutes, achieved a peak heart rate of 130.2 +/- 14.4 beats/min, reached a mean systolic blood pressure of 155.5 +/- 29.4 mm Hg, and achieved a rate-pressure product of 210.5 +/- 44.0. Of the 90 patients with uncomplicated conditions who had a negative exercise test for ischemia, 85 patients received reperfusion therapy, which included thrombolysis or coronary angioplasty or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of bilateral nasal polyposis and chronic refractory inhalant allergic rhinitis in a chimpanzee (Pan troglodytes).

Over a 15-yr time span, a 30-yr-old female chimpanzee (Pan troglodytes) exhibited recurrent upper respiratory disease that was suspected to be allergen induced. Until 1993, symptomatic therapy with several different antibiotics and antihistamines yielded variable results. In early 1993, the chimpanzee was consistently observed to be open-mouth breathing despite medication. Nasal polyposis was diagnosed using rigid endoscopy in September 1993, and the polyps were removed by loop excision. A fluorescent allergosorbent test was performed to differentiate hypersensitivity to specific regional allergens causing chronic inhalant allergic rhinitis. Oral immunotherapy was then instituted using standard human treatment for Sacramento Valley pollens. This combination of polyp removal and immunotherapy resulted in a marked reduction of clinical signs, and continuous oral immunotherapy has controlled these signs. Hyposensitization therapy will continue for at least 2-3 yr. The chimpanzee continues to breath normally following occasional antihistamine treatment.

Genetic identification of novel poxviruses of cetaceans and pinnipeds.

Novel poxviruses were identified in skin lesions of several species of cetaceans and pinnipeds using polymerase chain reaction targeting DNA polymerase and DNA topoisomerase I genes of members of the subfamily Chordopoxvirinae. With the exception of parapoxviruses, no molecular data of marine mammal poxviruses were available to infer genetic and evolutionary relatedness to terrestrial vertebrate poxviruses. Viruses were assigned to a cetacean poxvirus 1 (CPV-1) group based on nucleotide and amino acid identities of gene fragments amplified from skin lesions of Asian bottlenose (Tursiops aduncus), Atlantic bottlenose (Tursiops truncatus), rough-toothed (Steno bredanensis), and striped (Stenella coeruleoalba) dolphins. A different poxvirus was detected in skin lesions of a bowhead whale (Balaena mysticetus) and provisionally assigned to a CPV-2 group. These viruses showed highest identity to terrestrial poxviruses of the genera Orthopoxvirus and Suipoxvirus. A novel species-specific poxvirus was also identified in skin lesions of Steller sea lions (Eumetopias jubatus). None of these poxviruses were found to have amplifiable hemagglutinin gene sequences. Novel parapoxviruses were also identified in skin lesions of Steller sea lions and spotted seals (Phoca largha). A significant degree of divergence was observed in sequences of Steller sea lion parapoxviruses, while those of spotted seals and harbor seals (Phoca vitulina) were highly conserved.

Metastatic adenocarcinoma of a minor salivary gland in a cat.

Neoplasms derived from salivary glands are uncommon in domestic animals and descriptions of neoplasms derived from minor salivary glands are quite rare. A primary neoplasm derived from a minor salivary gland is described in a 13-year-old domestic shorthair cat. The oral neoplasm was locally invasive, and had metastasized to the regional lymph nodes and hilus of the lungs.

The cost:benefit ratio of acute intervention for myocardial infarction: results of a prospective, matched pair analysis.

Parallel to the increased acceptance of intervention for acute myocardial infarction, there has been a decrease in financial resources and reimbursement. To ascertain the relative cost to benefit of intervention, we evaluated 78 matched pairs of acute myocardial infarction patients from a prospective data base of 507 consecutive patients presenting with infarction from May 1986 to July 1987. The pairs were matched for age (mean 61 years), sex (68% male), and infarct location (43% anterior). Intervention (thrombolytics and/or percutaneous transluminal coronary angioplasty [PTCA]) was only applied to patients at less than 6 hours from symptom onset. Nonintervention patients were subsequently considered for angiography and revascularization (PTCA, coronary artery bypass grafting [CABG]) based on clinical criteria. Clinical outcome was evaluated by in-hospital mortality and uncomplicated status (free of angina, heart failure, or arrhythmias) at 72 hours. Intervention was associated with decreased mortality (5.3% versus 13%, p = 0.16) and increased uncomplicated course (43% versus 19%, p less than 0.001) as compared with patients not receiving intervention. Hospital procedures for the intervention and nonintervention group were as follows: diagnostic cardiac catheterization (99% versus 51%); PTCA (60% versus 0%); and CABG (14% versus 19%), respectively. The mean cumulative hospital and professional charges were $31,684 for the intervention group and $29,022 for the nonintervention group (p = 0.50). In conclusion, despite the potential marked incremental expense of technology associated with intervention for acute myocardial infarction, this analysis demonstrates that benefit in clinical outcome can be derived without substantially increased costs.

Organizational structure and communication strategies of the bypass angioplasty revascularization investigation: a multicenter clinical trial.

Efficient communication is a challenge for the many operating components of a multicenter randomized clinical trial. Traditional management theory states that communications generally flow along a path established by a hierarchical organizational structure. A multicenter clinical trial does not fit traditional organizational models well and requires modification of traditional communication techniques. While the scientific community typically views a clinical trial as one large and cohesive enterprise, at each site the trial may actually be conducted as a small project related to the medical specialty of the investigator. Therefore overall trial management must be accomplished through collaboration rather than through direct management. In the Bypass Angioplasty Revascularization Investigation (BARI), the BARI clinical coordinating center has designed and utilized several mechanisms that facilitate effective communication and administrative control of a multicenter clinical trial. These mechanisms provide a framework of communication techniques that accommodate the specific needs of a complex organization.

A randomized controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion.

To evaluate the feasibility and cost savings of hospital discharge three days after acute myocardial infarction, we screened 507 consecutive patients prospectively for clinical complications and exercise-test performance. Of 179 patients whose condition was classified as uncomplicated (no angina, heart failure, or arrhythmia 72 hours after admission), 126 underwent early exercise testing and 90 had no provocable myocardial ischemia. Eighty of these patients were randomly assigned to early (day 3) or conventional (days 7 to 10) hospital discharge. Seventy-six of them had received coronary reperfusion therapy (thrombolysis, angioplasty, or both). At six months of follow-up, there were no deaths or new ventricular aneurysms, and the early-discharge and conventional-discharge groups had similar numbers of hospital readmissions (6 and 10), reinfarctions (none and 5), and patients with angina (3 and 8). In the early-discharge group, 25 of 29 previously employed patients returned to work 40.7 +/- 21.9 days (mean +/- SD) after admission, as compared with 25 of 27 patients in the conventional-discharge group, who returned to work after a mean of 56.9 +/- 30.3 days (P = 0.054). The mean cumulative hospital and professional charges were $12,546 +/- 3,034 in the early-discharge group, as compared with $17,868 +/- 3,688 in the conventional-discharge group (P less than 0.0001). In carefully selected patients with uncomplicated myocardial infarction, hospital discharge after three days is feasible and leads to a substantial reduction in hospital charges. Before this strategy can be widely recommended, however, its safety must be confirmed in larger prospective clinical trials.