Adjunct thrombus aspiration reduces mortality in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction with high-risk angiographic characteristics

Routine aspiration thrombectomy (AT) in percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) has not proved effective in randomized trials. However, in patients undergoing primary percutaneous coronary intervention with severely reduced flow or visible thrombus, AT remains an intuitively attractive option. The use of adjunctive AT in a high-risk cohort of 158 consecutive patients with STEMI and Thrombolysis In Myocardial Infarction (TIMI) 0 to 1 flow or visible thrombus on baseline angiography was examined. Of these, 80 patients underwent AT as an adjunct to primary percutaneous coronary intervention, and 78 underwent percutaneous coronary intervention without AT (non-AT). TIMI 3 flow rates, residual thrombus after percutaneous coronary intervention, and major adverse cardiac events (mortality and nonfatal Q-wave myocardial infarction) at 30 days, 6 months, and 1 year were compared. Baseline characteristics were similar between groups. The AT group more frequently achieved TIMI 3 flow after the intervention (91.3% AT vs 67.9% non-AT; p <0.001) and had less residual thrombus (7.5% AT vs 19.2% non-AT; p = 0.03). AT was associated with reduced major adverse cardiac events at 6 months (6.8% AT vs 24.0% non-AT; p = 0.004) and 1 year (16.6% AT vs 29.2% non-AT; p = 0.009), and decreased mortality rates in the AT group at 6 months (5.4% AT vs 21.3% non-AT; p = 0.004) and 1 year (7.7% AT vs 26.2% non-AT; p = 0.005). In conclusion, for patients with STEMI and TIMI 0 or 1 flow or visible thrombus on baseline angiography, AT was associated with increased TIMI 3 flow rates, decreased residual thrombus, and decreased clinical events, including mortality.     

Construct and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST)

This paper reports on the construct validity (scale design and convergent validity) and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST). The performance of 208 participants following stroke on the OT-APST and a reference tool (either the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) or the LOTCA-Geriatric version (LOTCA-G)) was compared. The OT-APST performance of the stroke sample was compared with a healthy normative sample (n = 356). The relationship between the OT-APST performance and the Functional Independence Measure (FIM) score of the participants following stroke was also examined. Factor analysis and internal consistency results supported the scale design of the OT-APST. Significant correlations between the performance of the participants following stroke on the OT-APST and the reference tool supported the convergent validity of the OT-APST. The ability of the OT-APST to separate the two participant groups provided further evidence of its construct validity. Significant correlations between OT-APST and FIM scores supported the ecological validity of this tool. This study shows that the OT-APST is an ecologically valid tool with demonstrated construct validity in the assessment of visual perception.     

Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery

OBJECTIVE: The aim of this study was to investigate the maternal and neonatal morbidity related to use of episiotomy for vacuum and forceps deliveries. DESIGN: Retrospective population-based cohort study. SETTING: Dundee, Scotland. POPULATION: Two thousand one hundred and fifty three women who experienced an instrumental vaginal delivery between January 1998 and December 2002. METHODS: Univariate and multivariate logistic regression analyses were performed comparing deliveries with and without the use of episiotomy. MAIN OUTCOME MEASURES: Extensive perineal tears (third and fourth degree) and shoulder dystocia. RESULTS: Two hundred and forty-one (11%) of the 2153 women who underwent instrumental vaginal deliveries did not receive an episiotomy. Vacuum delivery was associated with less use of episiotomy compared with forceps (odds ratio 0.10, 95% CI 0.07-0.14). Extensive perineal tears were more likely with use of episiotomy (7.5%vs 2.5%, adjusted OR 2.92, 95% CI 1.27-6.72) as was neonatal trauma (6.0%vs 1.7%, adjusted OR 2.62, 95% CI 1.05-6.54). Use of episiotomy did not reduce the risk of shoulder dystocia (6.9%vs 4.6%, adjusted OR 1.43, 95% CI 0.74-2.76). The findings were similar for delivery by vacuum and forceps. CONCLUSION: The use of episiotomy increased the risk of extensive perineal tears without a reduction in the risk of shoulder dystocia.     

Obstetric management of a woman's first delivery and the implications for pelvic floor surgery in later life

OBJECTIVE: To determine the influence of intrapartum care during a first delivery on the risk of pelvic floor surgery in later life. DESIGN: Nested case-control study with record linkage of a historical cohort and a current morbidity database. SETTING: Hospital births in Dundee 1952-1966. POPULATION: The 7556 primiparous women from the Walker cohort. METHODS: The cases (n= 352) were women who delivered a first singleton baby at term (> or =37 weeks) and subsequently had pelvic floor surgery. Controls (n= 1403) were women who delivered their first baby during the same time period and did not undergo surgery. Univariate and multivariate logistic regression analyses were performed taking account of demographic, anthropometric and obstetric factors. MAIN OUTCOME MEASURE: Pelvic floor surgery. RESULTS: Caesarean section was associated with a reduced risk of pelvic floor surgery compared with spontaneous vaginal delivery (odds ratio 0.16, 95% CI 0.05-0.55). Forceps delivery and infant birthweight >4.0 kg were not identified as significant risk factors (OR 0.94, 95% CI 0.71, 1.25, and OR 0.94, 95% CI 0.50, 1.75, respectively). Episiotomy and prolonged labour (>12 hours) may be associated risk factors but were of borderline significance (OR 1.46, 95% CI 0.99, 2.10, and OR 1.51, 95% CI 1.00, 2.27). CONCLUSION: Caesarean section in a first pregnancy appears to protect against pelvic floor surgery in later life.     

Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects

OBJECTIVE: The purpose of this study was to describe the distribution of pelvic organ support in a gynecologic clinic population to define the clinical disease state of pelvic organ prolapse and to analyze its epidemiologic condition. STUDY DESIGN: This was a multicenter observational study. Subjects who were seen at outpatient gynecology clinics who required an annual gynecologic examination underwent a pelvic organ prolapse quantification examination and completed a prolapse symptom questionnaire. Receiver operator characteristic curves were used to define pelvic organ prolapse with the use of symptoms and pelvic organ prolapse quantification examination measures. Standard age-adjusted univariate and multivariate logistic regression analysis were used to evaluate various relationships. RESULTS: The population consisted of 1004 women who were aged 18 to 83 years. The prevalence of pelvic organ prolapse quantification stages was 24% (stage 0), 38% (stage 1), 35% (stage 2), and 2% (stage 3). The definition of pelvic organ prolapse that was determined by the receiver operator characteristic curve was the leading edge of their vaginal wall that was -0.5 cm above the hymenal remnants. Multivariate analysis revealed age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus as risk factors for pelvic organ prolapse, as defined in this population. CONCLUSION: The results from this population suggest that there is a bell-shaped distribution of pelvic organ support in a gynecologic clinic population. Advancing age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus have the strongest correlations with prolapse.     

Fracture hematoma is a potent proinflammatory mediator of neutrophil function

BACKGROUND: Patients with multiple skeletal injuries are susceptible to acute respiratory distress syndrome and multiple organ failure, which result from hyperactivation of the immune system. This study was designed to evaluate in vitro the proinflammatory properties of fracture hematoma (FH). METHODS: FH was isolated from patients undergoing emergent open reduction and internal fixation for isolated closed fractures. Neutrophils (PMNs), isolated from healthy volunteers, were exposed to the FH supernatant and activation was examined (CD11b and CD18 adhesion receptor expression and respiratory burst). PMN phagocytosis, apoptosis, and transmigration across an endothelial barrier were also assessed. RESULTS: FH increased PMN respiratory burst (control, 100; FH-treated, 186) and phagocytosis (control, 100; FH-treated, 172) but had no effect on adhesion receptor expression. Transendothelial migration of PMNs was unaffected, although FH was toxic to endothelial cells. In contrast, apoptosis of FH-treated PMNs was delayed (control, 46; FH-treated, 8). CONCLUSION: These effects, although beneficial at the site of injury in the context of antibactericidal function, may cause PMN-mediated tissue injury systemically.     

In-line milk filter analysis: Escherichia coli O157 surveillance of milk production holdings

Escherichia coli O157 is a major etiological agent of food-borne illness. Bovine animals are recognized reservoirs for this organism and represent a significant source from where these pathogens can enter the food chain. Food products derived from these animals are convenient vehicles, and are often the focal point(s) of infection. As a useful strategy to provide herd-level surveillance and to investigate for the presence of this pathogen in a population of Irish dairy cattle, milk filters from 97 farms were analysed by conventional culture and other methods. Five hundred and thirty-six milk filters were evaluated over a 2-year period. Filters from 12 of the 97 farms (12%) were found to contain E. coli O157, based on culture methods. Sixteen verocytotoxigenic E. coli O157 organisms were recovered and characterized in detail. The farm families in each case were consuming raw milk from their respective herds. The potential risk to public health associated with the detection of E. coli O157 and the local consumption of raw milk are discussed.