Hepatocyte growth factor is a better indicator of therapeutic response than C-reactive protein within the first day of treatment in pneumonia

Acute bacterial infectious diseases are mostly treated empirically at admission before the culture results are available. According to the risk for serious complications in the case of therapeutic failure, it is important to evaluate the therapy results and change to a more appropriate antibiotic regime as soon as possible. In the present study, 40 patients with X-ray-verified community-acquired pneumonia were examined and blood specimens were collected before and within 24 h of treatment. Body temperature, C-reactive protein (CRP) and hepatocyte growth factor (HGF) were investigated. Thirty-two patients received an appropriate initial antibiotic therapy regarding clinical outcome, but in 8 patients the treatment was changed because of therapy failure. Changes of HGF levels after 18-24 h of treatment could predict the therapeutic results accurately in 38 of 40 cases (sensitivity 100%, specificity 94%, positive likelihood ratio 16.0). HGF was significantly better to predict therapy outcome than CRP (p < 0.0001).     

Prognostic value of cardiovascular magnetic resonance in patients with suspected arrhythmogenic right ventricular cardiomyopathy

Background

Early recognition and accurate risk stratification are important in the management of arrhythmogenic right ventricular cardiomyopathy (ARVC). Identification of predictors of outcome by cardiovascular magnetic resonance (CMR) in patients undergoing evaluation for ARVC is limited. We investigated the predictive value of morphological abnormalities detected by CMR for major clinical events in patients with suspected ARVC.

Methods

We performed a longitudinal study on 369 consecutive patients with at least one criterion for ARVC. Abnormal CMR was defined by the presence of one of the following: increased right ventricular (RV) volumes, reduced RV ejection fraction, RV regional wall motion abnormalities, myocardial fatty infiltration, and myocardial fibrosis. The end-point was a composite of cardiac death, sustained ventricular tachycardia, ventricular fibrillation, and appropriate ICD discharge.

Results

Twenty patients met the composite end-point over a mean follow-up of 4.3 ± 1.5 years. An abnormal CMR was an independent predictor of outcomes (p < 0.001). The presence of multiple abnormalities heralded a particular high risk of events (HR 23.0, 95% CI 5.7–93.2, p < 0.001 for 2 abnormalities; HR 35.8, 95% CI 9.7–132.6, p < 0.001 for 3 or more abnormalities). The positive predictive value of an abnormal CMR study was 21.0% for an adverse event, whilst the negative predictive value of a normal CMR study was 98.8% over the follow-up period.

Conclusions

CMR provides important prognostic information in patients under evaluation for ARVC. A normal study portends a good prognosis. Conversely, the presence of multiple abnormalities identifies a high risk group of patients who may benefit from ICD implantation.     

Physical and Chemical Characterization of Mn Phosphate/Sulfate Mixture Used in an Inhalation Toxicology Study

The use of methylcyclopentadienyl manganese tricarbonyl (MMT) in unleaded gasoline has given rise to numerous debates on the potential public health risk associated with manganese emissions. In fact, combustion products are mainly Mn phosphate, Mn sulfate, and Mn phosphate/sulfate mixture. Our research group did several inhalation studies in order to assess the toxicity of each Mn species. The objective of this study is to determine the physical and the chemical characteristics of a mixture of Mn phosphate/sulfate used in one of these inhalation toxicology studies. First, the mixture was analyzed by X-ray diffraction in order to obtain the specific peak of Mn phosphate and Mn sulfate. These peaks were used as reference. Second, samples of the mixture were collected on filters in the inhalation chamber at a concentration level of 3000 μg/m³. They were analyzed by scanning electron microscopy (SEM), analytical transmission electron microscopy (ATEM), and x-ray energy-dispersive spectrometry (EDS) to show their size, morphology, and chemical composition. Results indicate that 33% of the particles were found to be agglomerated, while free particles accounted for 44% for Mn phosphate and 23% for Mn sulfate.     

Withholding or continuing beta-blocker treatment before dipyridamole myocardial perfusion imaging for the diagnosis of coronary artery disease? A randomized clinical trial

Background

Although it has been shown that acute beta-blocker administration may reduce the presence or severity of myocardial perfusion defects with dipyridamole stress, little information is available about the potential effect of chronic beta-blocker treatment on the sensitivity of dipyridamole myocardial perfusion imaging (DMPI).

Methods

As a randomized clinical trial, one hundred twenty patients (103 male and 17 female) with angiographically confirmed CAD who were on long-term beta blocker therapy (≥3 months) enrolled in a randomized clinical trial study. The patients were allocated into two groups: Group A (n=60) in whom the beta-blocker agent was discontinued for 72h before DMPI and Group B (n=60) without discontinuation of beta-blockers prior to DMPI.

Results

No significant difference was noted between the groups concerning age, sex, type of the injected radiotracer and number of involved coronary vessels. The mean rank of total perfusion scores for whole myocardium (irrespective of reversibility or irreversibility) in group B was not significantly different from that of group A, (65.75 vs. 55.25, P=0.096). Regarding the only irreversible perfusion defects, the mean rank of perfusion score in group B was higher than that of group A for whole myocardium (72 vs. 49, P=0.0001); however, no difference was noted between two groups for only reversible perfusion defects (61.0 vs. 60.0, P=0.898). The overall sensitivity of DMPI for the diagnosis of CAD in group A (91.7%) was not statistically different from group B (90%).

Conclusion

Beta-blocker withholding before DMPI did not generally affect the sensitivity of the test for the diagnostic purposes in our study. Thus, beta-blocker withdrawal for just the purpose of diagnostic imaging is not mandatory particularly when medication discontinuation may cause the patients to face increased risk of heart events.     

Conservative management of placenta increta: case report and literature review

Placenta increta, a rare complication of pregnancy, is associated with significant postpartum hemorrhage often requiring emergency hysterectomy. We report a case of conservative management, with a combination of parenteral methotrexate, serial ultrasound and β-hCG assessment. Serum β-hCG levels were undetectable after 8 weeks of therapy. A scan at 6 months showed complete involution of the uterus. Review of the literature discussing the diagnostic tools, clinical features, management and outcome of pregnancies with placenta increta.     

As death approaches: a retrospective survey of the care of adults dying in Alice Springs Hospital

Objective: Australians are more likely to die in a hospital than anywhere else, and most of these deaths are ‘expected’. The aims of this survey were to identify if specific end‐of‐life issues were documented in clinical records of a regional hospital serving remote Australia. Design: A retrospective consecutive case‐note audit covering 18 months from 1 January 2006. Setting: Alice Springs Hospital. Participants: Adult deaths in Alice Springs Hospital. During this period there were 128 deaths. Outcome measures: Demographic, process (diagnosis of dying documented, ‘not for resuscitation’ documentation, intensive care unit (ICU) admission, social worker referral and specialised palliative care service referral) and outcome data (‘comfort at end of life’) were surveyed. Results: Of the 128 admissions, 55 cases were excluded: 10 were children under 18, 33 died in <48 hours, nine were coroner's cases and three files could no't be found. Of the 73 deaths surveyed (33 men), 47 (64%) were Aboriginal. A diagnosis of dying was made in 84%, 88% had an ‘not for resuscitation’ order, 48% were admitted to ICU during their last admission, 66% were referred to social workers, 68% were referred to palliative care and 85% of people were documented to be ‘comfortable’ during the dying process with no differential outcomes for Aboriginal and non‐Aboriginal decedents except age (P < 0.0001). Conclusion: This survey highlights the continuing need to diagnose dying, understand optimal use of intensive care and improve comfort care at the end of life.