Association of troponin status with guideline-based management of acute myocardial infarction in older persons

BACKGROUND: Over the past decade, a large body of evidence has emerged demonstrating the prognostic significance of troponin as well as its use in tailoring therapeutic interventions. Little is known, however, regarding the association of troponin status with guideline-based therapies in older patients with acute myocardial infarction (AMI). METHODS: A nationwide sample of eligible Medicare beneficiaries 65 years or older, who were hospitalized with a primary discharge diagnosis of AMI from April 1998 to March 1999 or from July 2000 to June 2001, was evaluated. The analysis was restricted to patients with clinically confirmed AMI who underwent testing for both creatine kinase-myocardial band (CK-MB) and troponin. Results were assessed in 3 groups of patients based on biomarker status: those whose findings were positive for troponin only (hereinafter, troponin-only patients), those whose findings were positive for CK-MB only (hereinafter, CK-MB-only patients), and those whose findings were positive for both troponin and CK-MB (hereinafter, troponin/CK-MB patients). Then, the use of guideline-recommended care was compared for patients without contraindications to treatment across the 3 groups. RESULTS: The final study sample included 33 096 patients (mean age, 77.6 years [range, 65-105 years]). The crude in-hospital mortality rate was highest for troponin-only patients (14%) and lowest for CK-MB-only patients (10%, P<.001). After adjusting for demographics, physician specialty, and hospital characteristics, CK-MB-only patients were more likely to receive aspirin (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.28-1.65) and beta-blocker (OR, 1.21; 95% CI, 1.08-1.34) within 24 hours of hospital arrival and aspirin on discharge (OR, 1.27; 95% CI, 1.08-1.49) compared with troponin-only patients. In addition, troponin/CK-MB patients were more likely to receive aspirin (OR, 1.55; 95% CI, 1.42-1.69) and beta-blocker (OR, 1.22; 95% CI, 1.12-1.31) within 24 hours of arrival and on discharge compared with troponin-only patients (ORs, 1.31 [95% CI, 1.17-1.46] and 1.33 [95% CI, 1.15-1.52] for aspirin and beta-blocker, respectively) . CONCLUSIONS: Despite the known poor prognosis associated with troponin elevations in AMI, we demonstrate that guideline-based therapies are underused in older patients with AMI. Therefore, national efforts should focus on the unique characteristics of this high-risk patient population to improve the quality of care for older patients with AMI.     

Poststroke restless legs syndrome and lesion location: anatomical considerations

Several case studies have reported on restless legs syndrome (RLS) associated with stroke. In this study, we investigated the prevalence and the lesion topography of poststroke RLS. There were 137 patients with ischemic stroke included in this study. The diagnosis of RLS was made 1 month after the index stroke using the criteria established by the International RLS Study Group. All patients enrolled underwent magnetic resonance imaging within 7 days of the onset of the stroke. The prevalence of stroke-related RLS was calculated, and the topography of the associated ischemic lesions was analyzed. Among 137 patients, 17 patients (12.4%) were diagnosed with RLS after a stroke. Stroke-related RLS was found in 10 out of 33 patients with a basal ganglia/corona radiata infarct (30.3%), 1 out of 8 patients with an internal capsular infarct (12.5%), and 1 out of 7 patients with a thalamic infarct (14.3%). In addition, one out of 54 with a cortical lesion with/without subcortical involvement (1.9%), and 4 out of 18 patients with a pontine lesion (22.2%) had RLS. The analysis of the lesions in the cortical and subcortical group showed only 1 patient in the cortical group had stroke-related RLS, whereas 16 in the subcortical group had stroke-related RLS. The results of this study suggest that lesions of the subcortical brain areas such as the pyramidal tract and the basal ganglia-brainstem axis, which are involved in motor functions and sleep-wake cycles, may lead to RLS symptoms in patients after an ischemic stroke.     

Splenic Injury Following Colonoscopy – An Underdiagnosed,But Soon to Increase,Phenomenon?

INTRODUCTION

We present a case of splenic rupture in a 71-year-old woman admitted 6 days following a diagnostic colonoscopy. She underwent an open splenectomy and made a delayed, but complete, recovery.We proceeded to perform a retrospective review of all relevant literature to assess the frequency of similar post-colonoscopy complications.

MATERIALS AND METHODS

Using relevant keywords, we identified 63 further PubMed reports of splenic injury associated with colonoscopy that were reported in English.

FINDINGS

We have described only the fourth report of splenic injury secondary to colonoscopy from a UK centre. Literature review reveals a mean age of 63 years and a female preponderance for this complication.Most patients present on the day of their colonoscopy with abdominal pain, anaemia, elevated white cell count and Kehr''s sign. CT is the investigation of choice and splenectomy the definitive management of choice. Most patients make a routine recovery, with mortality rates of approximately 8%.There is likely to be an under-reporting of this complication from UK-based centres,with the majority of reports originating from Europe and US.This points to a possible under-diagnosis or under-recognition of this potentially fatal complication. The incidence of such post-colonoscopic complications may increase with the forthcoming introduction of the National Bowel Cancer Screening Programme.     

肝转移病人有手术指征吗

对进展期胰腺神经内颁发肿瘤,即使存在不可切除的肝转移,依然可以存活数年,而非数月.理论上,我们应该姑息性切除这类病人有症状的原发性神经内分泌肿瘤,然而,切除伴肝转移病有的原发胰腺肿瘤的效果和可行性鲜有报道.     

Mohs micrographic surgery for an unusual case of keratoacanthoma arising from a longstanding tattoo

This case report seeks to alert the reader to the possibility that the keratoacanthoma (KA) may develop in tattoo sites, specifically in red tattoo sites. We further wish to describe the senior author's treatment of such a lesion using Mohs micrographic surgery and a rotation flap to preserve the integrity of the original tattoo design in an area of minimal skin laxity. We briefly discuss the etiology of the KA and review potential tattoo reactions as presented in the literature.     

Elevations in serum and urinary calcium with parathyroid hormone (1-84) with and without alendronate for osteoporosis

CONTEXT: The effect of PTH therapy on serum and urinary calcium levels and the risk of hypercalcemia or hypercalciuria has not been formally evaluated. OBJECTIVE: The objective was to examine changes in serum and urinary calcium associated with PTH(1-84) therapy in the PaTH trial and the extent to which a defined algorithm resolved the elevated values. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION: A total of 178 postmenopausal women were randomized to PTH(1-84) either alone or in combination with alendronate during the first year of the PaTH study. MAIN OUTCOME MEASURE(S): The main outcome measures were fasting serum calcium at baseline and 1, 3, and 12 months and 24-h urinary calcium at baseline and 3 months. RESULTS: In 14% of participants, serum calcium more than 10.5 mg/dl (>2.6 mmol/liter) developed. Following the defined algorithm, 58% of elevated measurements were normal on repeat testing; 38% required discontinuation of calcium and vitamin D supplementation, and one necessitated a decrease in PTH injection frequency to normalize serum calcium. One participant developed transient hypercalcemia between study visits and required hospitalization; the episode resolved with iv hydration and PTH discontinuation. Baseline characteristics associated with the development of hypercalcemia were serum calcium [relative hazards = 1.9 per 0.5 mg/dl (0.12 mmol/liter); 95% confidence interval = 1.1-3.2] and serum 1,25-dihydroxyvitamin D [relative hazard = 1.9 per 10 pg/ml (26 pmol/liter); 95% confidence interval = 1.2-3.1]. Fifteen women (8%) developed hypercalciuria [urinary calcium > 400 mg (100 mmol)/24 h or calcium/creatinine ratio > 0.4]; 80% of cases resolved after discontinuing calcium and vitamin D, 13% without intervention, and one after PTH injection frequency was decreased. Higher baseline urinary calcium excretion was associated with development of hypercalciuria [relative hazard = 1.5 per 50 mg/d (12.5 mmol/d); 95% confidence interval = 1.2-4.0]. Proportions of patients with elevated serum and urinary calcium were similar on single and combination therapy. CONCLUSIONS: The frequency of episodic hypercalcemia or hypercalciuria in the PaTH trial was 21%. Episodes were generally mild, and nearly all cases resolved spontaneously or with discontinuation of calcium and vitamin D. The algorithms used to address hypercalcemia and hypercalciuria in the PaTH trial proved effective in safely resolving clinical episodes of increased urinary or serum calcium and might therefore be helpful to clinicians caring for patients on PTH.