Outcomes in patients with non-ST-elevation acute coronary syndrome randomly assigned to invasive versus conservative treatment strategies: A meta-analysis

OBJECTIVE:

The goal of the present study was to compare the prognoses of patients with non-ST-elevation acute coronary syndromes who were treated with invasive or conservative treatment strategies.

METHODS:

We performed a meta-analysis of studies of patients with non-ST-elevation acute coronary syndromes to assess the benefits of an invasive strategy vs. a conservative strategy for short- and long-term survival. We searched PubMed for studies published from 1990 to November 2012 that investigated the effects of an invasive vs. conservative strategy in patients with non-ST-elevation acute coronary syndromes. The following search terms were used: “non-ST-elevation myocardial infarction”, “unstable angina”, “acute coronary syndromes”, “invasive strategy”, and “conservative strategy”. The primary endpoints were all-cause mortality at 30 days and 1 year.

RESULTS:

Seven published studies were included in the present meta-analysis. The pooled analyses show that an invasive strategy decreased the risk of death (risk ratio [0.839] [95% confidence interval {0.648-1.086}; I², 86.46%] compared to a conservative strategy over a 30-day-period. Furthermore, invasive treatment also decreased patient mortality (risk ratio [0.276] [95% confidence interval {0.259-0.294}; I², 94.58%]) compared to a conservative strategy for one year.

CONCLUSION:

In non-ST-elevation acute coronary syndromes, an invasive strategy is comparable to a conservative strategy for decreasing short- and long-term mortality rates.     

Critical care 24 × 7: But,why is critical nutrition interrupted?

Background and Aims:

Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN.

Materials and Methods:

Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others.

Results:

Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to “procedures inside CCU”.

Conclusion:

Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.     

Ependymoblastoma: Dear,Damned, Distracting Diagnosis,Farewell!

Ependymoblastoma is a diagnostic label that has been applied to a variety of rare central nervous system (CNS) tumors over the last eight decades. Consequently, there is uncertainty about whether such an entity exists and what its characteristic features might be. The current study, based on 14 cases from our institutional archives and identified by the search terms “ependymoblastoma,”“ependymoblastomatous,”“ependymoblastic” or “PNET with ependymal differentiation,” aimed to test the hypothesis that the ependymoblastoma is a distinct and recognizable entity. Ependymoblastic rosettes are a key diagnostic feature and were present in 11/14 (79%) tumors, eight (73%) of which were embryonal tumors with abundant areas of neuropil‐like differentiation. Three other cases showed rare ependymoblastic rosettes in the histopathological setting of a typical primitive neuroectodermal tumor (PNET), medulloblastoma (MB) or atypical teratoid/rhabdoid tumor (AT/RT). The remaining cases were all embryonal tumors with structures that mimicked ependymoblastic rosettes. Our results indicate that ependymoblastic rosettes are most frequently encountered in embryonal tumors with abundant neuropil and less frequently in other CNS embryonal neoplasms, including PNET, MB and AT/RT. We believe that ependymoblastoma as a diagnosis is neither precise nor specific and that it is time once and for all to retire this diagnosis from the lexicon of neuropathology.     

The Lung in Sickle Cell Disease: A Clinical Overview of Common Vascular, Infectious, and Other Problems

Acute pulmonary complications of sickle cell anemia are sickle cell lung disease and bacterial pneumonias. Chronic abnormalities in lung function include a restrictive ventilatory defect and perhaps increased venous admixture to the pulmonary circulation. Coexisting sarcoidosis may complicate sickle cell anemia and interact to potentiate sickling. Sickle cell lung disease, or acute “chest syndrome,” occurs with greatest frequency in adults, is due primarily to pulmonary infarction, and may lead to cor pulmonale. On the other hand, bacterial pneumonia due to Streptococcus pneumoniae occurs with greater frequency in infancy and childhood. Mycoplasma and other organisms may also cause pneumonia with protracted illness and slow resolution. Bacteremia and meningitis may be further complications, particularly in children. Precise diagnosis of the acute febrile pulmonary episode is often difficult. In adults the illness is commonly self-limited. However, a vigorous diagnostic approach is warranted in all severely ill patients.     

Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit

Background:

The etiology of patients presenting with pulmonary-renal syndrome (PRS) to Intensive Care Units (ICUs) in India is not previously reported.

Aims:

The aim was to describe the prevalence, etiology, clinical manifestations, and outcomes of PRS in an Indian ICU and identify variables that differentiate immunologic causes of PRS from tropical syndromes presenting with PRS.

Materials and Methods:

We conducted a prospective observational study of all patients presenting with PRS over 1-year. Clinical characteristics of patients with “definite PRS” were compared with those with “PRS mimics”.

Results:

We saw 27 patients with “provisional PRS” over the said duration; this included 13 patients with “definite PRS” and 14 with “PRS mimics”. The clinical symptoms were similar, but patients with PRS were younger and presented with longer symptom duration. Ninety-two percent of the PRS cohort required mechanical ventilation, 77% required vasopressors and 61.5% required dialysis within 48 h of ICU admission. The etiologic diagnosis of PRS was made after ICU admission in 61.5%. Systemic lupus erythrematosus (54%) was the most common diagnosis. A combination of biopsy and serology was needed in the majority (69%, 9/13). Pulse methylprednisolone (92%) and cyclophosphamide (61.5%) was the most common protocol employed. Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to “PRS mimics”.

Conclusion:

The spectrum of PRS is different in the tropics and tropical syndromes presenting with PRS are not uncommon. Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.     

The Era of Molecular and Other Non-Culture-Based Methods in Diagnosis of Sepsis

Summary: Sepsis, a leading cause of morbidity and mortality throughout the world, is a clinical syndrome with signs and symptoms relating to an infectious event and the consequent important inflammatory response. From a clinical point of view, sepsis is a continuous process ranging from systemic inflammatory response syndrome (SIRS) to multiple-organ-dysfunction syndrome (MODS). Blood cultures are the current “gold standard” for diagnosis, and they are based on the detection of viable microorganisms present in blood. However, on some occasions, blood cultures have intrinsic limitations in terms of sensitivity and rapidity, and it is not expected that these drawbacks will be overcome by significant improvements in the near future. For these principal reasons, other approaches are therefore needed in association with blood culture to improve the overall diagnostic yield for septic patients. These considerations have represented the rationale for the development of highly sensitive and fast laboratory methods. This review addresses non-culture-based techniques for the diagnosis of sepsis, including molecular and other non-culture-based methods. In particular, the potential clinical role for the sensitive and rapid detection of bacterial and fungal DNA in the development of new diagnostic algorithms is discussed.     

Comparing the association of cardiovascular nursing care with blood pressure and length of stay of in-patients with coronary artery disease in Wuhan,China

BackgroundCoronary artery disease is a leading cause of morbidity and mortality worldwide. Comorbidity-like hypertension has been among the major risks of coronary artery disease. Recent evidence identified multiple benefits of cardiovascular nursing care to coronary patients. However, little has been appraised on benefits regarding patients'' blood pressure control and length of hospitalisation.ObjectiveTo compare the association of cardiovascular nursing care delivered to coronary artery patients with patients'' blood pressure and length of stay.MethodsRecords based retrospective design was applied at a large teaching hospital in Wuhan, China. SPSS 21 version was used for data entry and analysis with univariate and multivariate logistic regression models for comparing study variables.ResultsOf 300 patients, 224 (74.7%) were known to be hypertensive and admitted with subnormal blood pressure. Cardiovascular nursing care like “assess to grade pain severity on 1–10 scale” and “counsel patient to cope with stress” were six and three times more likely to contribute improved patients'' blood pressure (AOR=5.8; 95%CI: 2.8–12.2, p=0.001) and (AOR=3.1; 95%CI: 1.2–7.8, p=0.015) respectively. No significant difference with length of stay (p>0.05).ConclusionThere is a possibility of coronary artery patients to recover with normal blood pressure following reception of evidence-based cardiovascular nursing care.     

多层螺旋CT在急诊胸痛患者中的诊断价值

目的：探讨多层螺旋CT(multi-slice computer tomography,MSCT)在急诊胸痛患者诊断中的临床价值。方法：对本院急诊收治的162例胸痛患者进行MSCT平扫、增强扫描和血管造影成像,并对数据进行容积再现、曲面重组、多平面重组、最大密度投影等方法观察冠状动脉、主动脉、肺动脉。结果：急诊收治的162例胸痛患者中,所有患者可以清晰显示冠状动脉左右主干及主要分支、胸主动脉以及肺动脉段以上分支。发现冠状动脉狭窄者129例(79.6%),主动脉夹层18例(11.1%),肺动脉栓塞15例(9.3%)。结论：多层螺旋CT能够一次性完成对常见胸痛病因的鉴别诊断,迅速提供清晰、高质图像,是急诊胸痛患者的理想影像学检查方法。     

规范化双腔支气管导管插管及其就位判定方法的临床应用

目的：评价规范化双腔支气管插管法的临床应用，以及吸痰管通畅试验联合听诊法在插管位置判定中的作用。方法：60例择期行胸外科手术的病人，在麻醉诱导完全后，行规范化双腔支气管插管，并采用吸痰管通畅试验复合听诊法判断双腔管的就位情况。在双腔管就位满意后，再以纤支镜下的准确定位为判定双腔支气管的位置。结果：纤支镜定位双腔支气管导管满意就位率96．6％，无一例发生与双腔管就位不良有关的并发症。结论：吸痰管通试验复合听诊法判断双腔管满意就位的方法简单、可靠，可反复用于术中患者体位变动后对双腔管满意就位状态的判断，且不增加损伤机会，是临床上一个很好的方法。     

Surgical checklist application and its impact on patient safety in pediatric surgery

Background:

Surgical care is an essential component of health care of children worldwide. Incidences of congenital anomalies, trauma, cancers and acquired diseases continue to rise and along with that the impact of surgical intervention on public health system also increases. It then becomes essential that the surgical teams make the procedures safe and error proof. The World Health Organization (WHO) has instituted the surgical checklist as a global initiative to improve surgical safety.

Aims:

To assess the acceptance, application and adherence to the WHO Safe Surgery Checklist in Pediatric Surgery Practice at a university teaching hospital.

Materials and Methods:

In a prospective study, spanning 2 years, the checklist was implemented for all patients who underwent operative procedures under general anesthesia. The checklist identified three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anesthesia (“sign in”), before the skin incision (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, an anesthesiologist,-“checklist coordinator”, confirmed that the anesthesia, surgery and nursing teams have completed the listed tasks before proceeding with the operation and exit. The checklist was used for 3000 consecutive patients.

Results:

No major perioperative errors were noted. In 54 (1.8%) patients, children had the same names and identical surgical procedure posted on the same operation list. The patient identification tag was missing in four (0.1%) patients. Mention of the side of procedures was missing in 108 (3.6%) cases. In 0.1% (3) of patients there was mix up of the mention of side of operation in the case papers and consent forms. In 78 (2.6%) patients, the consent form was not signed by parents/guardians or the side of the procedure was not quoted. Antibiotic orders were missing in five (0.2%) patients. In 12 (0.4%) cases, immobilization of the patients was suboptimal, which led to displacement of diathermy grounding pad. In 54 (1.8%) patients, the checklist was not used at all. In 76 (2.5%) patients the checklist was found to be incompletely filled.

Conclusions:

Our study supports the use of the checklist as an essential safety tool and reinforcement of the same. The checklist may act as a valuable prompt to focus the team, to ensure that even the simple things have been cared for.KEY WORDS: Adverse events, checklist, communication, patient safety     

Population Dynamics of Tuberculous Bacilli in Cameroon as Assessed by Spoligotyping

Genetic assessment by spoligotyping of 565 Mycobacterium tuberculosis complex strains collected from the Western Region of Cameroon between 2004 and 2005 has confirmed the establishment of the “Cameroon family” as the leading cause of tuberculosis in 45.9% of cases and evidenced the rapid quasi extinction of Mycobacterium africanum, isolated in 3.3% of tuberculosis cases.     

Analysis of time intervals involved in admission to a coronary care unit

Time intervals between the onset of the presenting symptom (chest pain) and arrival in a coronary care unit were studied for 221 admissions arranged by conventional means. The median figure for “patient delay” was 60 minutes, for “general-practitioner delay” 20 minutes, for “ambulance delay” 30 minutes, and for “transit delay” 30 minutes. The median “total delay” was three hours 30 minutes.

Only 4·5 per cent of the patients were under intensive coronary care within one hour, the time of the highest mortality risk. A mobile coronary service should be capable of increasing the proportion of patients brought under special care within the first hour, but the time taken by the patient to realise the nature of the emergency and summon aid is likely to remain the most critical factor.

     

Intermediate hypocretin-1 cerebrospinal fluid levels and typical cataplexy: their significance in the diagnosis of narcolepsy type 1

Study ObjectivesThe diagnosis of narcolepsy type 1 (NT1) is based upon the presence of cataplexy and/or a cerebrospinal fluid (CSF) hypocretin-1/orexin-A level ≤ 110 pg/mL. We determined the clinical and diagnostic characteristics of patients with intermediate hypocretin-1 levels (111–200 pg/mL) and the diagnostic value of cataplexy characteristics in individuals with central disorders of hypersomnolence.MethodsRetrospective cross-sectional study of 355 people with known CSF hypocretin-1 levels who visited specialized Sleep-Wake Centers in the Netherlands. For n = 271, we had full data on cataplexy type (“typical” or “atypical” cataplexy).ResultsCompared to those with normal hypocretin-1 levels (>200 pg/mL), a higher percentage of individuals with intermediate hypocretin-1 levels had typical cataplexy (75% or 12/16 vs 9% or 8/88, p < .05), and/or met the diagnostic polysomnographic (PSG) and Multiple Sleep Latency Test (MSLT) criteria for narcolepsy (50 vs 6%, p < .001). Of those with typical cataplexy, 88% had low, 7% intermediate, and 5% normal hypocretin-1 levels (p < .001). Atypical cataplexy was also associated with hypocretin deficiency but to a lesser extent. A hypocretin-1 cutoff of 150 pg/mL best predicted the presence of typical cataplexy and/or positive PSG and MSLT findings.ConclusionIndividuals with intermediate hypocretin-1 levels or typical cataplexy more often have outcomes fitting the PSG and MSLT criteria for narcolepsy than those with normal levels or atypical cataplexy. In addition, typical cataplexy has a much stronger association with hypocretin-1 deficiency than atypical cataplexy. We suggest increasing the NT1 diagnostic hypocretin-1 cutoff and adding the presence of clearly defined typical cataplexy to the diagnostic criteria of NT1. Clinical trial information: This study is not registered in a clinical trial register, as it has a retrospective database design.     

Neuropathology associated with ventricular assist devices: an autopsy series of 33 patients

The ventricular assist device (VAD) is a mechanical pump that has been shown to be an effective modality of cardiac support in patients with heart failure refractory to pharmacologic intervention and who are awaiting cardiac allograft transplantation. Neuropathologic findings in these patients have not been well described. We retrospectively reviewed 2,632 autopsy reports (between 1990 and 2000) and found 64 patients who received VADs. Of these 64 patients, brain and spinal cord tissue was available for review in 33 patients (25 males and eight females; age range, 4 to 69 years; mean age, 52 years). The study group was composed of these 33 patients. Ventricular assist devices were in place from one to 603 days (mean 49 days). Twenty-five patients had left VAD, three had right VAD, and five had biventricular VADs. Brain weights ranged from 928 g to 1,740 g (mean 1,325 g). The most common central nervous system pathologic findings included infarct (N = 23; 70%), acute neuronal necrosis (N = 22; 67% focal and N = 1; diffuse anoxic encephalopathy), hemorrhage (N = 14; 42%), and herniations (N = 7; 21%). Two patients had no neuropathologic findings at autopsy. Cause of death was central nervous system-related in eight patients (24%) including six with massive parenchymal hemorrhage and herniations, one with brainstem infarction, and one with air embolism (radiographically diagnosed). The most common causes of death in the remaining 25 patients included sepsis (n = 10; 30%), pneumonia (n = 4; 12%), and embolic events with widespread infarcts (n = 4; 12%). The most common neuropathologic findings in patients with VAD were related to ischemia and infarction. In a significant subset of patients, central nervous system pathology, particularly hemorrhage with herniation, was the primary cause of death. Ann Diagn Pathol 5:67-73, 2001.     

Novel Chest Radiographic Biomarkers for COVID-19 Using Radiomic Features Associated with Diagnostics and Outcomes

COVID-19 is a highly contagious disease that can cause severe pneumonia. Patients with pneumonia undergo chest X-rays (XR) to assess infiltrates that identify the infection. However, the radiographic characteristics of COVID-19 are similar to the other acute respiratory syndromes, hindering the imaging diagnosis. In this work, we proposed identifying quantitative/radiomic biomarkers for COVID-19 to support XR assessment of acute respiratory diseases. This retrospective study used different cohorts of 227 patients diagnosed with pneumonia; 49 of them had COVID-19. Automatically segmented images were characterized by 558 quantitative features, including gray-level histogram and matrices of co-occurrence, run-length, size zone, dependence, and neighboring gray-tone difference. Higher-order features were also calculated after applying square and wavelet transforms. Mann–Whitney U test assessed the diagnostic performance of the features, and the log-rank test assessed the prognostic value to predict Kaplan–Meier curves of overall and deterioration-free survival. Statistical analysis identified 51 independently validated radiomic features associated with COVID-19. Most of them were wavelet-transformed features; the highest performance was the small dependence matrix feature of “low gray-level emphasis” (area under the curve of 0.87, sensitivity of 0.85, p<0.001). Six features presented short-term prognostic value to predict overall and deterioration-free survival. The features of histogram “mean absolute deviation” and size zone matrix “non-uniformity” yielded the highest differences on Kaplan–Meier curves with a hazard ratio of 3.20 (p<0.05). The radiomic markers showed potential as quantitative measures correlated with the etiologic agent of acute infectious diseases and to stratify short-term risk of COVID-19 patients.     

Acquired somatic MMR deficiency is a major cause of MSI tumor in patients suspected for “Lynch-like syndrome” including young patients

Patients with tumors displaying high microsatellite instability (MSI-H) but no germline MMR inactivation are suspected for Lynch-like syndrome (LLS). To explore the involvement of acquired somatic MMR alteration as a cause, we screened 113 patient tumor samples for MMR gene variations and loss of heterozygosity. Somatic MMR alterations were found in 85.8% of patients including “double hits” in 63.7% of patients, mainly diagnosed with colon and endometrial cancers. Interestingly, 37.5% of them were under the age of 50, and seven patients were under 30. Somatic alterations were mainly attributed to the MLH1, MSH2 genes, likely reflecting the functional importance of these key MMR genes. Pathogenic variants co-existed in other cancer genes in particular the APC gene displaying a characteristic MMR deficiency-related “mutational signature”, indicating that it may be inactivated owing to MMR deficiency. We speculated that APC inactivation could trigger an accelerated malignant transformation underlying early-onset cancers. Our findings provide further insight into the mechanisms underlying LLS, somatic MMR inactivation being a major cause for early-onset LLS through pathways differing from those involved in late-onset sporadic cases.Subject terms: Cancer genetics, High-throughput screening     

Empirical Evidence for “Syndrome Z”: A Hierarchical 5-Factor Model of the Metabolic Syndrome Incorporating Sleep Disturbance Measures

Study Objective:

Sleep disturbances have been associated with individual components of the metabolic syndrome (“syndrome X”), and, although the concept has been proposed, it is not known whether sleep disturbances actually cluster with features of the metabolic syndrome to produce a unifying trait, “syndrome Z”. Therefore, we evaluated a second-order factor model, whereby syndrome Z was described by 5 first-order factors – insulin resistance, obesity, hypertension, dyslipidemia, and sleep disturbance – with the sleep disturbance factor defined using the apnea-hypopnea index, arousal index, percentage of sleep time with oxygen saturation less than 90%, and percentage of slow wave sleep.

Design:

Observational, cross-sectional study.

Setting:

Clinical research center.

Participants:

Five hundred thirty-three adults from the Cleveland Family Sleep Study who underwent polysomnography and were not treated by continuous positive airway pressure.

Measurements and Results:

When modeling syndrome Z as a second-order factor unifying 5 first-order factors, we observed good overall model fit (χ²/df = 3.20; CFI = 0.96; RMSEA = 0.06; SRMR = 0.05) and found that obesity was the most important determining factor (standardized loading = 0.85 ± standard error = 0.02; P < 0.01) followed by sleep disturbance (0.82 ± 0.03; P < 0.01), insulin resistance (0.67 ± 0.03; P < 0.01), hypertension (0.64 ± 0.04; P < 0.01), and dyslipidemia (0.60 ± 0.05; P < 0.01). Simultaneous multiple group analyses revealed that this model was essentially generalizable across age, race, and sex subgroups.

Conclusions:

Our results demonstrate that sleep disturbance co-aggregates with other metabolic features to represent a single unifying trait, syndrome Z. Although our model awaits validation in other populations, it provides a tool for better understanding the synergistic risk of syndrome Z, compared with syndrome X, on type 2 diabetes and cardiovascular disease in future studies.

Citation:

Nock NL; Larkin EK; Patel SR; Redline S. Empirical evidence for “Syndrome Z”: a hierarchical 5-factor model of the metabolic syndrome incorporating sleep disturbance measures. SLEEP 2009;32(5):615-622.     

Health-Related Quality of Life and Blood Pressure Control in Hypertensive Patients with and without Complications

INTRODUCTION:

The goal of antihypertensive treatment is to reduce blood pressure without interfering in health-related quality of life (HRQL)

OBJECTIVE:

This study aimed to assess the influence of hypertension control upon HRQL in hypertensive patients with and without complications.

MATERIALS AND METHODS:

Seventy-seven hypertensive outpatients (71% women, 58% white, 60% with elementary school level education, average age 54 ± 8 years) were observed during a 12-month special care program (phase 1: clinical visits every two months, donation of all antihypertensive medications, meetings with a multidisciplinary team, and active telephone calls) and three years of standard care (phase 2: clinical visits every four months, medication provided by the drugstore of the hospital with a two-hour wait and a possible lack of medication, no meetings with a multidisciplinary team or active telephone calls). The patient HRQL was assessed using Bulpitt and Fletcher’s Specific Questionnaire, as well as the SF-36 scores. Hypertensive patients were divided into “with complications” (n=37, diastolic blood pressure great than 110 mm Hg for patients with or without treatment, with clinically evident target-organ or other associated illness) and “without complications” (n=40). The variables studied were quality of life, blood pressure control, hypertension gravity, and demographic characteristics.

RESULTS:

In hypertensive patients with and without complications, both the systolic and diastolic blood pressure were significantly higher (p<0.05) in phase 2 of observation (143±18/84±11 and 144±21/93±11 mm Hg for patients with and without complications, respectively) relative to phase 1 (128±17/75±13 and 128±15/83±11mmHg). The proportion of patients with controlled blood pressure (defined as a blood pressure less than 140/90 mm Hg) decreased from 70% to 49% in the “with complications” group and from 78% to 50% in the “without complications” group during phase 2 of observation. The patients with complications showed a decrease in bodily pain, vitality, and mental health component summary scores in both phases. In phase 2, the patients without complications had significantly better HRQL scores compared to complicated patients using both the Bulpitt and Fletcher’s Questionnaire and the SF-36 assessment of physical capacity, bodily pain, and vitality domain summary scores. With regards to hypertension control, there was a significant decrease from phase 1 to phase 2 in the vitality component summary scores and an increase in the emotional aspect component summary scores assessed by the SF-36, whereas Bulpitt and Fletcher’s Questionnaire showed no differences in these scores.

CONCLUSION:

Special care programs with multidisciplinary activities, individualized and personalized assistance, easy access to pharmacological treatment, frequent meetings, and active telephone calls for hypertensive patients significantly increase blood pressure control but do not interfere with the HRQL.     

Multi-centre retrospective analysis of anaphylaxis during general anaesthesia in the United Kingdom: aetiology and diagnostic performance of acute serum tryptase

This is the first multi-centre retrospective survey from the United Kingdom to evaluate the aetiology and diagnostic performance of tryptase in anaphylaxis during general anaesthesia (GA). Data were collected retrospectively (2005–12) from 161 patients [mean ± standard deviation (s.d.), 50 ± 15 years] referred to four regional UK centres. Receiver operating characteristic curves (ROC) were constructed to assess the utility of tryptase measurements in the diagnosis of immunoglobulin (Ig)E-mediated anaphylaxis and the performance of percentage change from baseline [percentage change (PC)] and absolute tryptase (AT) quantitation. An IgE-mediated cause was identified in 103 patients (64%); neuromuscular blocking agents (NMBA) constituted the leading cause (38%) followed by antibiotics (8%), patent blue dye (6%), chlorhexidine (5%) and other agents (7%). In contrast to previous reports, latex-induced anaphylaxis was rare (0·6%). A non-IgE-mediated cause was attributed in 10 patients (6%) and no cause could be established in 48 cases (30%). Three serial tryptase measurements were available in 34% of patients and a ROC analysis of area under the curve (AUC) showed comparable performance for PC and AT. A ≥ 80% PPV for identifying an IgE-mediated anaphylaxis was achieved with a PC of >141% or an AT of >15·7 mg/l. NMBAs were the leading cause of anaphylaxis, followed by antibiotics, with latex allergy being uncommon. Chlorhexidine and patent blue dye are emerging important health-care-associated allergens that may lead to anaphylaxis. An elevated acute serum tryptase (PC >141%, AT >15·7 mg/l) is highly predictive of IgE-mediated anaphylaxis, and both methods of interpretation are comparable.