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Selected AbstractsPredictive Value of Admission Electrocardiography in Patients With Heart FailureCONGESTIVE HEART FAILURE, Issue 4 2008Karolina M. Zareba MD Admission electrocardiography (ECG) in heart failure (HF) patients provides important diagnostic information; however, there are limited data regarding the prognostic significance of ECG parameters for predicting cardiac events (CEs). The ECGs of 246 patients admitted with acute HF were evaluated for heart rate, rhythm, QRS and ST-T wave abnormalities, QTc duration, QT peak corrected (QTpc), T amplitude, and axis. The end points included rehospitalization for a CE or death during 30-day follow-up. There were 71 (29%) patients with CEs. In patients with CEs, atrial fibrillation (AF) was observed more frequently (27% vs 13%, respectively; P=.009) and QTpc was shorter (370±43 vs 386±44 ms, respectively; P=.020). Multivariate logistic regression analysis revealed that QTpc ,360 ms and AF were predictive of CE after adjustment for clinical covariates. In conclusion, apart from AF, the presence of short QTpc ,360 ms is independently associated with increased risk of rehospitalization or death in HF patients. [source] Biofeedback for foot offloading in diabetic patients with peripheral neuropathyDIABETIC MEDICINE, Issue 1 2010Z. Pataky Diabet. Med. 27, 61,64 (2010) Abstract Aims, The reduction of high plantar pressure in diabetic patients with peripheral neuropathy is mandatory for prevention of foot ulcers and amputations. We used a new biofeedback-based method to reduce the plantar pressure at an at-risk area of foot in diabetic patients with peripheral neuropathy. Methods, Thirteen diabetic patients (age 60.8 ± 12.3 years, body mass index 29.0 ± 5.0 kg/m2) with peripheral neuropathy of the lower limbs were studied. Patients with memory impairment were excluded. The portable in-shoe foot pressure measurement system (PEDAR®) was used for foot offloading training by biofeedback. The learning procedure consisted in sequences of walking (10 steps), each followed by a subjective estimation of performance and objective feedback. The goal was to achieve three consecutive walking cycles of 10 steps, with a minimum of seven steps inside the range of 40,80% of the baseline peak plantar pressure. The peak plantar pressure was assessed during the learning period and at retention tests. Results, A significant difference in peak plantar pressure was recorded between the beginning and the end of the learning period (when the target for plantar pressure was achieved) (262 ± 70 vs. 191 ± 53 kPa; P = 0.002). The statistically significant difference between the beginning of learning and all retention tests persisted, even at the 10-day follow-up. Conclusions, Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term. [source] Changes of gallbladder and gastric dynamics in patients with acute hepatitis AEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 7 2001P. Portincasa Transient alterations of gallbladder morphology and dynamics have been reported in patients with during acute hepatitis A. The presence of dyspepsia also suggests involvement of gastric motility. During a 60-day follow-up, we investigated gallbladder and gastric motility in relation to dyspepsia in acute viral hepatitis A patients. Twenty patients were assessed at referral (day 0) and at days 7, 21, 42 and 60 and compared with 20 healthy volunteers. Gallbladder morphology and motility and gastric motility were assessed in the fasting and postprandial period by functional ultrasonography using a liquid test meal. Dyspeptic symptoms were scored. At day 0, fasting gallbladder volume was 5·9 ± 1·3 mL, 32·6 ± 4·6 mL, and 21·5 ± 1·9 mL (mean ±,SE) in patients with gallbladder sludge (n = 7), without sludge (n = 13) and controls, respectively (P < 0·05 in sludge vs. no sludge and controls; P < 0·05 in no sludge vs. controls, anova). Small fasting gallbladder volume in patients with sludge increased and sludge disappeared within 7 days. At day 0, patients with sludge also had increased thickness of fasting gallbladder wall and increased serum transaminase levels compared with patients without sludge and controls. Gallbladder contraction was similar in patients and controls. However, patients had delayed gastric emptying, which positively correlated with dyspepsia score. Gallbladder morphological changes observed in the acute phase of hepatitis A are transient and are associated with hepatocellular damage. Gastric emptying is delayed during the first week of disease and is associated with dyspeptic symptoms. [source] Early-onset and persisting thrombocytopenia in post-cardiac surgery patients is rarely due to heparin-induced thrombocytopenia, even when antibody tests are positiveJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 1 2010S. SELLENG See also Gruel Y, Pouplard C. Post-operative platelet count profile: the most reliable tool for identifying patients with true heparin-induced thrombocypenia after cardiac surgery. This issue, pp 27,29. Summary.,Background:,The high frequency of thrombocytopenia in post-cardiac surgery patients makes it challenging to diagnose heparin-induced thrombocytopenia (HIT). Two platelet count profiles are reported as indicating possible HIT in these patients: profile 1 describes a platelet count fall that begins between postoperative days 5 and 10, whereas profile 2 denotes early-onset thrombocytopenia that persists beyond day 5. Objectives: To examine how these platelet count profiles correlate with antibody status and HIT post-cardiac surgery. Methods: We prospectively screened 581 cardiac surgery patients for heparin-dependent antibodies by platelet factor 4 (PF4),heparin immunoassay and platelet-activation test, and performed daily platelet counts (until day 10) with 30-day follow-up. Results: All three patients with platelet count profile 1 tested positive for platelet-activating anti-PF4,heparin IgG antibodies [odds ratio (OR) 521.7, 95% confidence interval (CI) 3.9,34 000, P = 0.002], and were judged to have HIT. In contrast, none of 25 patients with early-onset and persisting thrombocytopenia (profile 2) was judged to have HIT, including five patients testing positive for platelet-activating anti-PF4,heparin IgG antibodies. In these patients, the frequency of heparin-dependent antibodies did not differ from that in non-thrombocytopenic controls, either for anti-PF4,heparin IgG (OR 1.7, 95% CI 0.7,4.1, P = 0.31) or for platelet-activating antibodies (OR 1.9, 95% CI 0.6,5.7, P = 0.20). Multivariate analysis revealed that type of cardiac surgery, but not HIT antibody status, predicted early-onset and persisting thrombocytopenia. Together, these findings show that HIT was uncommon in this study population [overall frequency, 3/581 (0.5%), 95% CI 0.1,1.5%]. Conclusions: Thrombocytopenia that begins between 5 and 10 days post-cardiac surgery is highly predictive for HIT. In contrast, early-onset and persisting thrombocytopenia is usually caused by non-HIT factors with coinciding heparin-dependent antibody seroconversion. [source] Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular OutcomesACADEMIC EMERGENCY MEDICINE, Issue 8 2009Abhinav Chandra MD Abstract Objectives:, The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event. Methods:, This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina. Results:, Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2). Conclusions:, In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes. [source] Predictive Value of T-wave Abnormalities at the Time of Emergency Department Presentation in Patients with Potential Acute Coronary SyndromesACADEMIC EMERGENCY MEDICINE, Issue 6 2008Kathy B. Lin BA Abstract Objectives:, T-wave abnormalities on electrocardiograms (ECGs) are common, but their ability to predict 30-day cardiovascular outcomes at the time of emergency department (ED) presentation is unknown. The authors determined the association between T-wave abnormalities on the presenting ECG and cardiovascular outcomes within 30 days of presentation in patients with potential acute coronary syndromes (ACSs). Methods:, This was a secondary analysis of a prospective cohort study of ED patients that presented with a potential ACS. Patients were excluded if they had a prior myocardial infarction, ST-segment elevation or depressions, right or left bundle branch block, or Q-waves on the initial ECG. Data included demographics, medical and cardiac history, and ECG findings including the presence or absence of T-wave flattening, inversions of 1,5 mm, and inversions >5 mm. Investigators followed the hospital course for admitted patients, and 30-day follow-up was performed on all patients. The main outcome was a composite of death, acute myocardial infarction, revascularization, coronary stenosis greater than 50%, or a stress test with reversible ischemia. Results:, Of 8,298 patient visits, 5,582 met criteria for inclusion: 4,166 (74.6%) had no T-wave abnormalities, 721 (12.9%) had T-wave flattening in two or more leads, 659 (11.8%) had T-wave inversions of 1,5 mm, and 36 (0.64%) had T-wave inversions >5 mm. The composite endpoint was more common in patients with T-wave flattening (8.2% vs. 5.7%; p = 0.0001; relative risk [RR] = 1.4; 95% confidence interval [CI] = 1.1 to 1.9), T-wave inversions 1,5 mm (13.2% vs. 5.7%; p = 0.0001; RR = 2.4; 95% CI = 1.8 to 3.1), and T-wave inversions >5 mm (19.4% vs. 5.7%; p = 0.0001; RR = 3.4; 95% CI = 1.7 to 6.1), or any T-wave abnormality (10.8% vs. 5.7%; p = 0.0001; RR = 1.9; 95% CI = 1.6 to 2.3), even after adjustment for initial troponin. This association also existed in the subset of patients without known coronary artery disease. Conclusions:, In patients with potential ACS presenting to the ED, T-wave abnormalities are associated with higher rates of 30-day cardiovascular events. [source] Carotid artery stenting in high surgical risk patients using the FiberNet® embolic protection system: The EPIC trial results,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 6 2010FACC, Subbarao Myla MD Abstract Objective: The multicenter EPIC (FiberNet Embolic Protection System in Carotid Artery Stenting Trial) single-arm trial evaluated the 30-day outcomes of a new design concept for embolic protection during carotid artery stenting (CAS). Background: Embolic protection filters available for use during CAS include fixed and over-the-wire systems that rely on embolic material capture within a "basket" structure. The FiberNet® Embolic Protection System (EPS), which features a very low crossing profile, consists of a three-dimensional fiber-based filter distally mounted on a 0.014 inch guidewire with integrated aspiration during filter retrieval. Methods: The trial enrolled 237 patients from 26 centers. Demographics, clinical and lesion characteristics, as well as adverse events through a 30-day follow-up were recorded. The mean age of the patients was 74 years, 64% were male and 20% had symptomatic carotid artery disease. Results: The combined major adverse event (MAE) rate at 30 days for all death, stroke, and myocardial infarction was 3.0%. There were three major strokes (two ischemic and one hemorrhagic) and two minor strokes (both ischemic) for a 2.1% 30-day stroke rate. The procedural technical success rate was 97.5% and macroscopic evidence of debris was reported in 90.9% of the procedures. Conclusions: The FiberNet EPS, used with commercially available stents, produced low stroke rates following CAS in high surgical risk patients presenting with carotid artery disease. The unique filter design including aspiration during retrieval may have contributed to the low 30-day stroke rate reported during CAS in patients considered at high risk for complications following carotid endarterectomy (CEA). © 2009 Wiley-Liss, Inc. [source] Can C-reactive protein, procalcitonin and mid-regional pro-atrial natriuretic peptide measurements guide choice of in-patient or out-patient care in acute pyelonephritis?CLINICAL MICROBIOLOGY AND INFECTION, Issue 6 2010Biomarkers In Sepsis (BIS) multicentre study Clin Microbiol Infect 2010; 16: 753,760 Abstract Whereas C-reactive protein (CRP), procalcitonin (PCT) and mid-regional pro-atrial natriuretic peptide (ANP) may be of use at the bedside in the management of adult patients with infectious disorders, their usefulness has not been established in the setting of acute pyelonephritis. To assess the effectiveness of CRP, PCT and ANP measurements in guiding emergency physicians' decisions whether to admit to hospital patients with acute pyelonephritis, we conducted a multicentre, prospective, observational study in 12 emergency departments in France; 582 consecutive patients were included. The reference standard for admission was defined by experts' advice combined with necessity of admission or death during the 28-day follow-up. Baseline CRP, PCT and ANP were measured and their accuracy in identifying the necessity of admission was analysed using area under curves (AUC) of receiver,operating characteristic (ROC) plots. According to the reference standard, 126 (22%) patients required admission. ANP (AUC 0.75, 95% CI 0.69,0.80) and PCT (AUC 0.75, 95% CI 0.71,0.80) more accurately predicted this than did CRP (AUC 0.69, 95% CI 0.64,0.74). The positive and negative likelihood ratios for each biomarker remained clinically irrelevant whatever the threshold. Our results did not support the use of these markers to help physicians in deciding about admission of patients experiencing acute pyelonephritis in daily practice. [source] | ||||||||||