Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients

PurposeThe objective of our study was to assess the reliability of the distensibility index of the inferior vena cava (dIVC) as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and compare its accuracy with that of the pulse pressure variation (PPV) measurement.Materials and methodsWe included postoperative mechanically ventilated and sedated patients who underwent volume expansion with 500 mL of crystalloids over 15 minutes. A response to fluid infusion was defined as a 15% increase in the left ventricular outflow tract velocity time integral according to transthoracic echocardiography. The inferior vena cava diameters were recorded by a subcostal view using the M-mode and the PPV by automatic calculation. The receiver operating characteristic (ROC) curves were generated for the baseline dIVC and PPV.ResultsTwenty patients were included. The area under the ROC curve for dIVC was 0.84 (95% confidence interval, 0.63-1.0), and the best cutoff value was 16% (sensitivity, 67%; specificity, 100%). The area under the ROC curve for PPV was 0.92 (95% confidence interval, 0.76-1.0), and the best cutoff was 12.4% (sensitivity, 89%; specificity, 100%). A noninferiority test showed that dIVC cannot replace PPV to predict fluid responsiveness (P = .28).ConclusionThe individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.     

Automation of the Hepascore and validation as a biochemical index of liver fibrosis in patients with chronic hepatitis C from the ANRS HC EP 23 Fibrostar cohort

BackgroundHepascore combining serum bilirubin, gamma glutamyl transpeptidase, hyaluronic acid (HA) and α2-macroglobulin with age and sex, was reported as relevant in predicting liver fibrosis in patients with chronic HCV infection and was proposed as an alternative to liver biopsy.MethodsSince an automated HA assay (Latex method, Wako, Japan) became available, we investigated to automate Hepascore by simultaneous measurements of components using an OLYMPUS AU640 analyzer (Tokyo, Japan). For its clinical evaluation, we considered a cohort of chronic HCV patients included in a multicenter prospective study (ANRS HC EP 23 Fibrostar).ResultsAutomated Hepascore was not significantly different than assayed as previously described. An improvement in HA variability was evidenced. In 512 chronic HCV patients, automated Hepascore, using ROC curves analysis, showed good predictive performances for significant fibrosis (AUROC = 0.81), severe fibrosis (AUROC = 0.82), and cirrhosis (AUROC = 0.88). For significant fibrosis, Hepascore (cut-off = 0.5) had a sensitivity of 0.77, a specificity of 0.70, a positive predictive value of 0.71 and a negative predictive value (NPV) of 0.77. Hepascore < 0.25 could exclude significant fibrosis with a sensitivity of 0.95 and a NPV of 0.90 and Hepascore < 0.75 could exclude cirrhosis with a sensitivity of 0.86 and a NPV of 0.97.ConclusionsThis study shows that Hepascore, a non-invasive index of liver fibrosis, necessitating only one serum sample, can be totally automated using a single analyzer and confirms that Hepascore accurately predicts liver fibrosis in chronic HCV. Hepascore might be largely used in assessing liver fibrosis as surrogate to the liver biopsy.     

The association of inflammatory markers with cerebral vasoreactivity and carotid atherosclerosis in transient ischaemic attack

ObjectivesInflammatory mediators have an important role in the pathogenesis of stroke. Increased activity of inflammatory mediators initiates the development of atherosclerosis independently of other risk factors, thus compromising brain microcirculation and causing transient ischaemic attack (TIA). The aim of our study was to evaluate the relationship between serum level of cellular adhesion molecules (ICAM-1), interleukin-6 (IL-6) and C-reactive protein (CRP) with carotid intima–media thickness (IMT) and breath-holding index (BHI) in subjects with transient ischaemic attack. We also aimed to assess the difference of those markers between TIA patients and disease-free control individuals.Design and methodsThe study included 45 TIA patients and 36 disease-free controls matched for age, gender and vascular risk profile. The degree of carotid atherosclerosis was assessed by colour Doppler with measurements of carotid IMT. Transcranial Doppler (TCD) ultrasound was performed in order to assess BHI. IMT, TCD, BHI and serum concentrations of ICAM-1, IL-6, and CRP were measured for all study subjects.ResultsInflammatory markers IL-6, ICAM-1 and CRP were significantly higher in TIA patients than in disease-free controls (P < 0.001, P = 0.026, P < 0.001, respectively). TIA patients had significantly lower values of BHI and higher IMT relative to disease-free control individuals (P < 0.001).ConclusionsTIA is associated with higher ICAM-1, IL-6 and CRP, pointing to the marked inflammatory response to cerebral ischaemia. Inflammatory markers are associated with higher IMT and lower BHI, indicating the insufficient cerebral perfusion due to the underlying atherosclerotic disease. Our findings highlight the key significance of inflammation in the early response to ischaemia during the transitory ischaemic episode.     

The involvement of nitric oxide in the physiopathology of hepatoportal sclerosis

Background and aimHepatoportal sclerosis (HPS) is a clinical syndrome of unspecified etiology depicted by enlarged spleen and portal hypertension in the lack of other chronic liver disease findings, hematological disorders or any infectious disease in the liver. Nitric oxide (NO) molecule has many important functions in human body including phagocytosis in macrophages, neural transmission and endothelial relaxation. Although there is no data in literature that depicts the role of NO in HPS pathogenesis, this study was conducted in order to evaluate the potential role of NO in patients with HPS.Patients and methodsThe study participants included 24 HPS patients and 20 healthy controls. The median age of HPS and control patients was 41.2 ± 13.9 and 46.5 ± 12.4 years, respectively. NO was predicted as nitric oxide metabolites (NOx) by Griess reaction after transformation of nitrate to nitrite by nitrate reductase using the commercially obtainable Nitric Oxide Assay Kit.ResultsSerum NOx levels were 2.69 ± 2.98 μmol/L and 0.85 ± 1.05 μmol/L for the HPS patients and controls, respectively. Serum NO levels were significantly higher in patients with HPS compared to the control group (p < 0.001). ROC curve analysis suggested that the optimum NOx cut-off point for HPS was 1.305 with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 83.3%, 90 %, 90.9 %, and 81.8% respectively.ConclusionCirculating NO concentration was notably higher in patients with HPS in comparison to the control group. Our study verified that an elevated level of NO might have a role in the pathogenesis of HPS.     

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children

ObjectiveWe evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth.MethodsWe performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth.ResultsForty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI = 90–100%), a specificity of 96.4% (95% CI = 87–100%), a PPV of 96.5% (95% CI = 87–100%), a NPV of 98.8% (95% CI = 89–100%), a positive likelihood ratio of 32 (95% CI = 6–185), and a negative likelihood ratio of 0.015 (95% CI = 0.004–0.2). Agreement between reviewers was high (kappa co-efficient = 0.93; 95% CI = 0.86 to 1). The mean duration of the ultrasound exam was 4.0 s (range 1.0–15.0 s).ConclusionsSonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.     

Diagnostic performance of IgG anti-deamidated gliadin peptide antibody assays is comparable to IgA anti-tTG in celiac disease

BackgroundDetection of IgG antibodies against deamidated gliadin peptides (DGP) is more sensitive and more specific for celiac disease than detection of IgG antibodies against native gliadin. Our aim was to evaluate the technical performance and diagnostic accuracy of four commercial IgG anti-DGP assays.MethodsCommercial IgG anti-DGP assays from Euroimmun, Inova, Phadia and The Binding Site were evaluated and their diagnostic accuracy (sensitivity and specificity) compared to other serologic assays for celiac disease (3 IgA and 2 IgG anti-tTG assays, 1 IgA and 1 IgG anti-gliadin assay, 1 IgA anti-DGP assay). The study population consisted of 86 consecutive CD patients and 741 disease controls.ResultsThe technical performance (linearity, interference and imprecision) of the IgG anti-DGP assays was acceptable. The sensitivity of the IgG anti-DGP assays varied between 76.7% and 86.0% at the cut-off recommended by the manufacturer and between 74.4% and 86.0% at the cut-off that corresponded to a specificity of 98%. The specificity varied between 97.3% and 99.3%. The diagnostic accuracy of the IgG anti-DGP assays was comparable to the diagnostic accuracy of the IgA anti-tTG assays. The sensitivity of the IgG anti-DGP assays was significantly better than sensitivity of the IgG anti-tTG assays (p < 0.05) and the specificity was significantly better than the IgA and IgG anti-gliadin assays (p < 0.05).ConclusionsThe overall performance of the four IgG anti-DGP assays was acceptable and the diagnostic accuracy comparable to the three IgA anti-tTG assays.     

Comparison of 1,3-β-d-glucan with galactomannan in serum and bronchoalveolar fluid for the detection of Aspergillus species in immunosuppressed mechanical ventilated critically ill patients

PurposeInvasive pulmonary aspergillosis (IPA) is an important cause of morbidity/mortality in immunocompromised critically ill patients. New diagnostic strategies for early detection of IPA include the noninvasive biomarkers 1,3-β-d-glucan (BDG), serum, and bronchoalveolar (BAL) fluid galactomannan (GM). The aim of this study was to compare these markers for early detection of IPA in immunosuppressed critically ill patients.MethodsBetween December 2014 and December 2015, 49 immunosuppressed patients with respiratory failure were treated at our intensive care unit (ICU). We compared the BDG Fungitell assay with GM Platelia assay in serum and BAL for early detection of IPA. All tests were performed initially after admission at the ICU.ResultsIn our study with 49 patients, 13 (26%) had probable IPA. These patients had a higher Acute Physiology And Chronic Health Evaluation II score (28 vs 23, P < .001), Sequential Organ Failure Assessment score (16 vs 14, P < .001), more neutropenia (77% vs 30%, P < .001), worse Horowitz Index (99 vs 73 P < .020), a longer ICU stay (26 vs 17 days, P < .044), and a higher mortality rate (77% vs 58%, P < .001) as compared with patients without probable IPA.The used biomarker BDG presented in patients with probable IPA showed significantly higher levels as compared with patients without probable IPA (375 [103-1000 pg/mL; P < .001] vs 64 [30-105 pg/mL; P < .001]).Comparison of BDG with GM showed that positive serum GM could be detected in only 4 (30%), whereas positive BAL GM could be detected in 12 (92%; mean optical density index, 3.7) of 13 probable IPA cases.These results can be expressed as an overall sensitivity of 88% and a specificity of 82% for probable IPA using the BDG Fungitell assay, a sensitivity of 35% and a specificity of 70% using the serum GM Platelia assay, and a sensitivity of 70% and a specificity of 94% using the BAL GM Platelia assay. The negative predictive values of the used tests were 94% for the BDG Fungitell assay, 94% for the serum GM Platelia assay, and 90% for the BAL GM Platelia assay.Conclusion1,3-β-d-Glucan may be a useful marker for patients under surveillance at risk for IPA. In critically ill patients with immunosuppression, early diagnosis of IPA may be improved by BDG as compared with serum GM. However, diagnostic performance and accuracy increase when BDG is run in parallel with GM from BAL; moreover, the association of the 2 parameters has also the advantage of detecting early and reliable IPA.     

Diagnostic performance of four point of care cardiac troponin I assays to rule in and rule out acute myocardial infarction

ObjectiveThis study evaluated the diagnostic performance of four point-of-care (POC) cardiac troponin I (cTnI) assays compared to a central laboratory cTnI assay for detecting myocardial injury and diagnosing acute myocardial infarction (AMI).Design and methodsPlasma obtained at admission, 3 h, and 6 h post-admission in 169 patients presenting with symptoms suggestive of acute coronary syndrome (ACS) was studied. cTnI concentrations were measured on the Instrumentation Laboratory prototype GEM Immuno, Radiometer AQT90, Mitsubishi PATHFAST, Abbott i-STAT and the Ortho-Clinical Diagnostic Vitros assays. MI was determined based on 99th percentiles according to Universal MI guidelines.ResultsFor ruling in MI at presentation (0 h), the GEM Immuno (sensitivity 63%, specificity 85%) and PATHFAST (sensitivity 53%, specificity 86%) were comparable to the OCD (sensitivity 68%, specificity 81%), and significantly better (p < 0.05) than the AQT90 (sensitivity 26%, specificity 93%) and i-STAT (sensitivity 32%, specificity 92%). cTnI concentrations and serial rising patterns after MI differed by each assay. Negative predictive values were > 90% and ROC AUCs were > 0.90 after 6 h for all assays. Detection of myocardial injury in non-ischemic pathologies accounted for lower than 100% specificity for MI.ConclusioncTnI is a sensitive biomarker for detection of myocardial injury. The analytical variability that exists between POC cTnI assays demonstrates substantial diagnostic differences for ruling in and ruling out MI in patients presenting with symptoms suggestive of ACS.     

Predictive value of osteocalcin in bone metastatic differentiated thyroid carcinoma

ObjectivesTo evaluate the diagnostic value of serum osteocalcin in the detection of bone metastases from differentiated thyroid carcinoma (DTC).Design and methodsSerum samples from DTC patients with (DTC BM+, n = 19) or without bone metastases (DTC BM?, n = 19), and matched healthy volunteers (n = 30) were tested for serum osteocalcin with electrochemiluminescent immunoassay.ResultsOsteocalcin was higher in DTC BM+ than in DTC BM? patients (+ 35.8%, p = 0.002), acting as an independent risk factor for bone metastases (R² = 0.142, p = 0.039). The sensitivity was 78.9% and the specificity was 63.2% at a cut-off value of 11.2 μg/L.ConclusionsSerial measurements of osteocalcin could be useful in the detection of bone metastases from DTC.     

Diagnostic and prognostic value of serum procalcitonin concentrations in primary lung cancers

ObjectivesProcalcitonin (PCT) is widely used for the diagnosis of bacterial infections. The aim of this study was to evaluate PCT as a tumor and as a prognostic marker in patients with primary lung cancer.Design and methodsWe retrospectively performed a PCT dosage in the frozen serum samples of 147 patients with pulmonary neoplasia for whom a test of neuron-specific enolase (NSE) had been conducted at the time of diagnosis.ResultsWe show that a PCT serum level above 0.15 ng/mL was independently linked to the presence of a neuroendocrine component in the tumor (HR = 5.809 95% CI [1.695–19.908] p: 0005). Thus, median PCT serum levels were significantly more elevated in small-cell lung cancers than in pulmonary adenocarcinomas: 0.33 ng/mL versus 0.07 ng/mL (p < 0.001). However, the diagnostic value of serum PCT levels for diagnosing carcinoma with a neuroendocrine component remains low (sensitivity 63.8%; specificity 71.9%). In this series, serum PCT levels were significantly more elevated in the presence of liver metastases: 0.37 ng/mL versus 0.09 ng/mL in the absence of liver metastasis (p < 0.001). In uni- and multivariate analyses, a serum PCT level above 0.15 ng/mL and the presence of metastases and of sepsis at the time of diagnosis were independent factors of unfavorable prognosis.ConclusionsSerum PCT is elevated in patients with lung cancer with neuroendocrine component or with liver metastases. As a consequence, in this population, PCT has a poor specificity for bacterial infection. At diagnosis, an elevated serum PCT is an independent predictive factor of bad prognosis.     

Diagnostic value of alpha-1-fetoprotein (AFP) as a biomarker for hepatocellular carcinoma recurrence after liver transplantation

BackgroundAlpha-1-fetoprotein (AFP) is used to monitor progression, evaluate response to therapy and predict recurrence of hepatocellular carcinoma (HCC) in liver transplantation (LTx) patients. To date, the diagnostic value of serum AFP determinations for detecting tumor recurrence in HCC patients after LTx is unclear.ObjectiveA retrospective, single-center, cross-sectional, non-interventional study was performed with the objective of determining post-transplant cut-off AFP values for detecting HCC recurrence post LTx.MethodsUsing receiver operating characteristic (ROC) analyses, post-transplant serum AFP values were evaluated against HCC recurrences in 63 HCC patients who had LTx between November 1995 and December 2011 at the University Medical Center Göttingen (UMG). Optimal and application-independent cut points for predicting tumor recurrence at 1, 3, and 5 years after LTx were determined.ResultsPost-LTx serum AFP was found to represent an independent risk factor (predictor) for HCC relapse. Post-operative AFP cut-off values of 7 μg/l, 6 μg/l, and 6 μg/l, respectively, were determined to be optimal at 1, 3, and 5 years after LTx respectively for predicting a HCC relapse. Using these cut-off values, patients were correctly classified as relapse-positive with a diagnostic sensitivity of 79%, 81%, and 77%, and as relapse-free with a specificity of 82%, 79%, and 69%. The diagnostic accuracy measured by area under the curve (AUC) values ranged from 0.813 to 0.886. However, a limitation is that at a clinically relevant specificity of ≥ 95%, the analyses showed sensitivity values of only 50%, 52%, and 50%, respectively.ConclusionPost-transplant serum AFP may have diagnostic value to detect HCC recurrence after LTx.     

Imaging detection of new HCCs in cirrhotic patients treated with different techniques: Comparison of conventional US,spiral CT,and 3-dimensional contrast-enhanced US with the Navigator technique (Nav 3D CEUS)

IntroductionThe commercially available Navigator system^© (Esaote, Italy) allows easy 3D reconstruction of a single 2D acquisition of contrast-enhanced US (CEUS) imaging of the whole liver (with volumetric correction provided by the electromagnetic device of the Navigator^©). The aim of our study was to compare the efficacy of this panoramic technique (Nav 3D CEUS) with that of conventional US and spiral CT in the detection of new hepatic lesions in patients treated for hepatocellular carcinoma (HCC).Materials and methodsFrom November 2006 to May 2007, we performed conventional US, Nav 3D CEUS, and spiral CT on 72 cirrhotic patients previously treated for 1 or more HCCs (M/F: 38/34; all HCV-positive; Child: A/B 58/14) (1 examination: 48 patients; 2 examinations: 20 patients; 3 examinations: 4 patients). Nav 3D CEUS was performed with SonoVue^© (Bracco, Milan, Italy) as a contrast agent and Technos MPX^© scanner (Esaote, Genoa, Italy). Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values (PPV and NPV, respectively) were evaluated. Differences between the techniques were assessed with the chi-square test (SPSS release-15).ResultsDefinitive diagnoses (based on spiral CT and additional follow-up) were: 6 cases of local recurrence (LocRecs) in 4 patients, 49 new nodules >2 cm from a treated nodule (NewNods) in 34 patients, and 10 cases of multinodular recurrence consisting of 4 or more nodules (NewMulti). The remaining 24 patients (22 treated for 1–3 nodules, 2 treated for >3 nodules) remained recurrence-free. Conventional US correctly detected 29/49 NewNods, 9/10 NewMultis, and 3/6 LocRecs (sensitivity: 59.2%; specificity: 100%; diagnostic accuracy: 73.6%; PPV: 100%; NPV: 70.1%). Spiral CT detected 42/49 NewNods plus 1 that was a false positive, 9/10 NewMultis, and all 6 LocRecs (sensitivity: 85.7%; specificity: 95.7%; diagnostic accuracy: 90.9%; PPV: 97.7%; NPV: 75.9%). 3D NAV results were: 46N (+9 multinodularN and 6 LR), 3 false-negatives, and one false-positive (sensitivity: 93.9; specificity: 97.9%; diagnostic accuracy: 95.6; PPV: 97.9; NPV: 93.9).Conclusions3D Nav CEUS is significantly better than US and very similar to spiral CT for detection of new HCCs. This technique revealed the presence of lesions that could not be visualized with spiral CT.     

Serum amyloid A is independently related to apolipoprotein A-I but not to HDL-cholesterol in patients with angina pectoris

BackgroundInflammation processes are considered important links between classical lipid risk factors and the progression of atherosclerosis. The interrelationship of high density lipoproteins (HDL) and apolipoprotein apoA-1 with acute phase proteins and cytokines was examined in a clinical setting of patients with angina pectoris.MethodsOn exclusion criteria (myocardial infarction, heart failure, CHD > 2 years, anticoagulant therapy), 198 patients were recruited and were subdivided according to angiographically documented stenosis, no stenosis vs. = 50% stenosis, in accordance with CASS guidelines. Lipids, apoA-1 and apoB, C-reactive protein (hs-CRP), fibrinogen, serum amyloid A (SAA) and cytokines (IL-6, IL-8, IL-10, IL2R, TNFα) were measured.ResultsLow HDL-C (and apoA-I) is associated with advanced coronary stenosis (= 50%) and with the number of diseased vessels, independent of age, gender, diabetes, smoking and lipid-lowering therapy. In contrast to hs-CRP and fibrinogen, SAA as well as cytokine levels were not significantly associated with stenosis. SAA (P = 0.0003) and diabetes (P = 0.0002) were strong predictors of apoA-I concentration independent of age, gender, BMI, smoking, CRP, as well as IL-6 in a multiple regression model. High SAA (P = 0.0067) and TG (P = 0.0123) were significant predictors of apoA-I/HDL-C ratio. However, SAA was not independently related to HDL-C.ConclusionsSAA is independently and inversely related to apoA-I but not to HDL-C in patients with angina pectoris, reflecting the effect of SAA on the quality of HDL particles. However, HDL-c but not SAA is inversely related to the degree of coronary artery stenosis.     

Could trisialotransferrin be used as an additional biomarker to CDT in order to improve detection of chronic excessive alcohol intake?

ObjectivesCarbohydrate-deficient transferrin is a well-known biomarker widely used for detection of chronic excessive alcohol intake. However, under certain clinical conditions particularly frequently met amongst heavy drinkers (steatosis, fibrosis, cirrhosis…), it isn't a reliable biomarker. In this study, we tried to find additional biomarkers to CDT in order to improve detection of chronic excessive alcohol intake.Design and methodsWe conducted a retrospective cohort study from December 2007 to December 2009. We focused mainly on three different groups: heavy drinking patients with active alcohol consumption (n = 243), cirrhotic patients (abstinent patients and non alcoholic cirrhosis, n = 44) and control group (n = 85).ResultsIn our study, CDT showed a poor sensitivity for diagnosis of heavy drinking patients (around 63%, and even lower) for cirrhotic patients and patients at advanced stage of fibrosis. Combination of CDT with trisialotransferrin enabled to improve significantly sensitivity and specificity (p-value AUC ROC < 0.001). When adding mean corpuscular volume and gamma-glutamyltransferase to this first combination, performances were even better (p-value < 0.001). This second cluster enabled to make a statistically significant difference between cirrhotic patients with active alcohol consumption compared to abstinent cirrhotic patients and to non alcoholic cirrhotic patients (p-value < 0.001).ConclusionFrom our study, trisialotransferrin seems to be a useful additional biomarker to CDT in order to improve detection of chronic excessive alcohol intake.     

T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: An RCT

ObjectiveTo compare the duration of positive pressure ventilation (PPV) during delivery room resuscitation in neonates resuscitated with self-inflating bag (SIB) and T-piece resuscitator (TPR).DesignRandomized control trial.SettingDelivery room and neonatal intensive care unit of a tertiary care center in northern India.PatientsConsecutively born neonates more than 26 weeks of gestation requiring PPV at birth.InterventionEligible neonates were randomized to two groups, SIB and TPR.Outcome measuresDuration of PPV, intubation rates in delivery room, incidence of respiratory distress, need for mechanical ventilation during first 48 h and its duration, need for surfactant replacement therapy and mortality during NICU stay.ResultsFifty neonates received PPV with a SIB and 40 received PPV with a TPR. The mean (SD) birth weight and gestational age of neonates in SIB and TPR groups were 2264 (872) and 2065 (814) g; 35.1 (3.6) and 34.3 (3.7) weeks, respectively. The median (IQR) duration of PPV in delivery room was significantly less in TPR group as compared to SIB; 30 (30–60) s vs. 60 (30–90) s, respectively; (p < 0.001). A higher proportion of neonates required delivery room intubation in SIB group as compared to TPR group (34% vs. 15%, p = 0.04). In the TPR group, a higher proportion of neonates could be resuscitated with room air only (72.5% vs. 38%, p = 0.001). Other outcomes were comparable in the two groups. Similar findings were observed in neonates <34 weeks, except that fewer neonates resuscitated with TPR required invasive ventilation (31.6% vs. 77.8%, p = 0.008).ConclusionUse of TPR during delivery room resuscitation resulted in shorter duration of PPV and lesser rates of intubation as compared to SIB. More infants in this group could be resuscitated with room air only (CTRI/2010/091/002946).     

Single point biochemical measurement algorithm for early diagnosis of ectopic pregnancy

ObjectivesTubal rupture as a result of an ectopic pregnancy is the leading cause of first trimester maternal mortality. Currently, the diagnosis of ectopic pregnancy depends on transvaginal ultrasound and serial serum measurements of human chorionic gonadotrophin (hCG), which requires follow up. The objective of this study was to examine whether single point measurements at presentation could distinguish between women with ectopic pregnancy, viable pregnancy, and spontaneous miscarriage.Design and methodsSerum total hCG (hCGt), hyperglycosylated hCG (hCGh), free beta subunit of hCG (hCGβ), progesterone (P), and CA-125 were measured by chemiluminescence immunoassay over a 3 month period in 441 women presenting at the emergency room with abdominal pain and a positive pregnancy test. Patient outcomes were followed and confirmed by histology. 65 samples were excluded due to poor sample storage, or lost to follow up.ResultsThe pregnancy outcomes were 175 viable pregnancies, 175 spontaneous miscarriages, and 26 ectopic pregnancies. A serum hCGt < 3736 mIU/mL cut off was 100% sensitive, with 76% specificity, for distinguishing ectopic pregnancy from viable pregnancy; but did not differentiate spontaneous miscarriage. Serum CA125 < 41.98 U/mL produced 100% sensitivity and 43% specificity in distinguishing ectopic pregnancy from spontaneous miscarriage. Sequential application of hCGt and CA-125 cut off followed by ultrasound could detect 100% of ectopic pregnancies with 87% specificity for all intrauterine pregnancies.ConclusionThe combination of serum hCGt < 3736 mIU/mL, followed by CA125 < 41.98 U/mL is a promising algorithm for detecting all ectopic pregnancy at initial presentation.     

Short-term (90 min) diagnostic performance for acute non-ST segment elevation myocardial infarction and 30-day prognostic evaluation of a novel third-generation high sensitivity troponin I assay

ObjectivesWe evaluated a third-generation high sensitivity “guidelines acceptable” troponin I assay (hs-cTnI) against a contemporary “clinically usable” troponin assay (cTnI).Design and methodsRemnant samples of undifferentiated emergency department (ED) patients with suspected acute coronary syndrome were enrolled. Baseline and 90-minute samples were analyzed for cTnI and hs-cTnI. Sensitivity, specificity, positive and negative predictive values for AMI and 30-day adverse cardiac events (ACE) were compared.ResultsOf 486 ED patients, there were 465 patients who had blood remaining at the presentation for the hs-cTnI assays, with 12 AMIs. At presentation, the clinical sensitivity and specificity for AMI was 75% and 97% for cTnI and 83.3 and 82.1% for hs-cTnI. There were 407 patients who had paired baseline and 90-minute blood samples for cTnI and hs-cTnI including 9 of the 12 AMI patients. The sensitivity and specificity was 77.7% and 96.5% for cTnI and 100% and 81.9% for hs-cTnI at 90 min. A Δ change of 30% increase from baseline to 90 min improved the specificity to 94.5% (95% CI 92%–96%) without lowering the sensitivity. When AMI was defined as a Δ30% change of hs-cTnI at t = 0 and 90 min and one hs-cTnI result > 99th percentile cutoff, more than 3 times as many patients met the diagnostic criteria for AMI compared to results from the normal sensitive troponin assay; 28 (6.9%) for hs-cTnI vs. 9 (2.2%) with cTnI. There were 37 in-hospital or 30-day events, producing an OR of 3.03, 95% CI: 0.86–9.59 for cTnI, and 2.54, 95% CI: 1.27–5.10 for hs-cTnI, which detected 11 more cases.ConclusionsThe hs-cTnI assay achieved a 90-minute rule out for AMI and detected more 3 times as many AMI cases. The specificity increased with the Δ30% criteria. The hs-cTnI assay also detected more cases of patient at risk for adverse cardiac events at 30 days.     

Interleukin-1β genotype and circulating levels in cancer patients: Metastatic status and pain perception

ObjectivesProinflammatory cytokines released during inflammation can cause hyperexcitability in pain transmission neurons, leading to hyperalgesia and allodynia. Polymorphisms in interleukin 1 (IL-1) family of genes (IL1A, IL1B) and in IL-1 receptor antagonist (IL-1Ra, coded by IL1RN) may therefore induce alterations in cytokine levels/effects and pain related response. Our purpose was to investigate the influence of polymorphisms in IL1A/B/RN on cytokine serum levels and its correlation with pain intensity, performance status, adverse effects, metastases and breakthrough pain in Caucasian cancer patients.Design and methodsSerum IL-1α/β levels of 74 cancer patients were measured by competitive enzyme immunosorbent assay. All patients were also genotyped for the polymorphisms in IL1A (rs17561), IL1B (rs1143634) and IL1RN (rs419598) with Real-Time PCR. Results were then correlated to the appearance of bone or CNS metastases and several pain-related parameters.ResultsIL-1β rs1143634 homozygous for T allele were associated with lower levels of IL1-β (p = 0.032, Mann–Whitney test) and presented a trend for lower levels of pain (p = 0.06, Fisher's Exact Test). Also, IL1-β levels were related with cancer onset status, since a four-fold increase probability of metastatic disease was observed in high IL-1β individuals (OR = 4.074, p = 0.010, Pearson χ² test). Among the female patients presenting metastatic disease and carriers of the TT genotype we observed a trend to lower levels of IL1-β (p = 0.053, Pearson χ² test).ConclusionsOur results indicate that genetic variation at IL1-β gene may influence serum levels of IL1-β, with proportional consequences in cancer-related pain.     

Performance of cardiac troponins within the HEART score in predicting major adverse cardiac events at the emergency department

BackgroundThis study compared the performance of a single blood draw of high-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI) and conventional troponin I (cTnI) within a modified HEART score for predicting 30-day MACE at Emergency Department (ED) presentation, and established local reference norms for all three assays by determining the cut-off point which yielded the highest sensitivity and negative predictive value for acute myocardial infarction and 30-day MACE.MethodsThis single-center prospective cohort study recruited chest pain patients at the ED, whose hsTnT, hsTnI and cTnI were taken on admission. Subjects were classified into low and non-low risk group according to their modified HEART score, with MACE as the primary endpoint. Receiver-operating characteristic (ROC) curves were generated, area under the curves (AUCs) were calculated; the performance characteristics were determined.ResultsThe performance of modified HEART scores was comparable among the three assays for 30-day MACE (84.9–87.0% sensitivity, 95.6–96.0% NPV, 95%CI) and none of these had very high AUC and specificity (AUC 0.70–0.71, 53.7–56.7% specificity, 95% CI). The modified HEART score using a single blood draw of either hsTnT (3.9 ng/L), hsTnI (0.9 ng/L) or cTnI (0.0 ng/L) at presentation yielded a sensitivity of 100% for 30-day MACE.ConclusionThe modified HEART score using a single blood draw of either hsTnT, hsTnI or cTnI was equally effective in risk-stratifying chest pain patients for safe discharge. The theoretical cut-off points yielding 100% sensitivity are potentially useful (when achieved) for safely discharging low risk patients with undifferentiated chest pain in the ED.     

Detection of survivin protein in aqueous humor and serum of retinoblastoma patients and its clinical significance

ObjectivesThere is growing biomedical interest in survivin as a diagnostic and prognostic factor in human neoplasms. The present work assessed survivin expression in retinoblastoma.Design and methodsSurvivin was quantitatively measured in 82 aqueous humor and serum samples from 41 children with retinoblastoma and nonmalignant ophthalmic diseases. After treatment, 12 serum samples from retinoblastoma patients were included.ResultsSurvivin levels were higher in aqueous humor and serum of retinoblastoma patients than the controls ( P < 0.05). In aqueous, it was significantly correlated with the tumor stage and optic nerve affection. The best cutoff values for survivin in aqueous and serum that differentiate between retinoblastoma and nonmalignant ophthalmic diseases were 25.2 pg/mg protein and 12.9 pg/mL, respectively. The sensitivity and specificity were 100% and 90% in serum and 94% and 48% in aqueous, respectively. Serum survivin has decreased significantly after treatment.ConclusionMeasurement of survivin protein might have a great diagnostic and prognostic potential in retinoblastoma.