One-year Outcomes Following Coronary Computerized Tomographic Angiography for Evaluation of Emergency Department Patients with Potential Acute Coronary Syndrome

Objectives:  Coronary computerized tomographic angiography (CTA) has high correlation with cardiac catheterization and has been shown to be safe and cost-effective when used for rapid evaluation of low-risk chest pain patients from the emergency department (ED). The long-term outcome of patients discharged from the ED with negative coronary CTA has not been well studied.
Methods:  The authors prospectively evaluated consecutive low- to intermediate-risk patients who received coronary CTA in the ED for evaluation of a potential acute coronary syndrome (ACS). Patients with cocaine use, known cancer, and significant comorbidity reducing life expectancy and those found to have significant disease (stenosis ≥ 50% or ejection fraction < 30%) were excluded. Demographics, medical and cardiac history, labs, and electrocardiogram (ECG) results were collected. Patients were followed by telephone contact and record review for 1 year. The main outcome was 1-year cardiovascular death or nonfatal acute myocardial infarction (AMI).
Results:  Of 588 patients who received coronary CTA in the ED, 481 met study criteria. They had a mean (±SD) age of 46.1 (±8.8) years, 63% were black or African American, and 60% were female. There were 53 patients (11%) rehospitalized and 51 patients (11%) who received further diagnostic testing (stress or catheterization) over the subsequent year. There was one death (0.2%; 95% confidence interval [CI] = 0.01% to 1.15%) with unclear etiology, no AMI (0%; 95% CI = 0 to 0.76%), and no revascularization procedures (0%; 95% CI = 0 to 0.76%) during this time period.
Conclusions:  Low- to intermediate-risk patients with a Thrombosis In Myocardial Infarction (TIMI) score of 0 to 2 who present to the ED with potential ACS and have a negative coronary CTA have a very low likelihood of cardiovascular events over the ensuing year.     

Safety and efficacy of a new recombinant FVIII formulated with sucrose (rFVIII–FS) in patients with haemophilia A: a long-term, multicentre clinical study in Japan

The recombinant full-length FVIII product Kogenate has been reformulated using sucrose (rFVIII-FS) instead of human serum albumin as a stabiliser in purification and formulation. The in vivo recovery, haemostatic efficacy, and safety of rFVIII-FS were investigated in 20 previously treated patients with severe or moderate haemophilia A for > or = 24 weeks. In vivo recoveries of 73.5 +/- 16.3%, 78.4 +/- 16.1%, and 82.8 +/- 23.9% after the initial infusion of 50 IU kg(-1) rFVIII-FS and at weeks 12 and 24, respectively, showed no significant changes over time. A total of 1115 infusions (mean dose 24.1 +/- 8.4 IU kg(-1)) were included in the analysis of haemostatic efficacy. One (80.5%) or two (8.2%) infusions achieved adequate haemostasis in 88.7% of all bleeding episodes, and haemostatic efficacy was judged 'excellent' or 'good' in 749 of 764 episodes (98.0%). The haemostatic efficacy was judged as 'excellent' or 'good' in 924 of 1115 (82.9%) infusions. Twenty-one adverse events were observed in 12 patients in the total 1541 infusions included in the safety analysis. Causality with respect to rFVIII-FS could not be ruled out in three events in one HIV-negative patient: elevated CD4(%), decreased CD8(%), and elevated CD4/CD8 ratio. No FVIII inhibitor development was observed in any patient. ELISA assay testing for antibodies to rFVIII, baby hamster kidney cell (BHK) protein, and murine IgG were all negative. These results show that rFVIII-FS is a safe and effective for long-term treatment of patients with haemophilia A.     

沙苑子化学成分的研究Ⅱ

A new flavonoid glucosidc-rhamnocitrin-3,4′-O-β-D-diglucoside named complanatuside was isolated from the seeds Astragalus complanatus R. Brown. The elucidation of its structure was based on chemical and spectroscopic data.     

Visceral larva migrans in French adults: a new disease syndrome?

Visceral larva migrans is apparently an endemic disease among adults in southwest France. Thirty-seven adults living in the Midi-Pyrenees region of France were confirmed as having visceral larva migrans based on an increased specific antibody titer to Toxocara canis as detected by enzyme-linked immunosorbent assay (ELISA) and by the Western blot method. The disease was characterized clinically by weakness, pruritis, rash, difficulty breathing, abdominal pain, and pathologically by allergic manifestations including eosinophilia and increased serum immunoglobulin (Ig) E levels. Conditional logistic regression analysis using a control group of 37 hospital patients with other conditions who were individually matched to patients with visceral larva migrans by age and sex revealed an increased risk for visceral larva migrans associated with hunting or living in a household with a hunter (odds ratio (OR) = 9.0, p = 0.02) and with living in a village of less than 500 persons (OR = 5.7, p = 0.04). Owning two or more dogs compared with owning one or no dogs increased the risk of visceral larva migrans for hunting or living in a household with a hunter (OR = 9.6 vs. OR = 4.5) and for persons living in nonhunting households (OR = 2.1 vs. OR = 1.0). These findings, however, could not be duplicated when 60 age- and sex-matched neighbors were used as a second control group.     

Risk status at discharge and cause of death for postneonatal infant deaths: a total population study

OBJECTIVES: To obtain population-based, clinical information regarding potentially modifiable factors contributing to death during the postneonatal period (28 to 364 days), we examined all postneonatal infant deaths in four areas of the United States to determine: (1) the cause of death from clinical and autopsy data rather than vital statistics, (2) whether death occurred during initial hospitalization or after discharge, and (3) the portion of postneonatal mortality attributable to infants who left the hospital with identified high-risk medical conditions. DESIGN AND SETTING: Retrospective medical record review of all postneonatal infant deaths with birth weights greater than 500 g (total N = 386) born to mothers residing in: (1) the city of Boston (1984 and 1985, N = 55), (2) the city of St Louis and contiguous areas (1985 and 1986, N = 123), (3) San Diego County (1985, N = 112), and (4) the state of Maine (1984 and 1985, N = 96). Deaths were identified using linked birth and death vital statistics, and medical record audits of infants' and mothers' charts were performed. Causes of death were obtained from medical record review in conjunction with autopsy if performed (72%, N = 278), medical record alone (17%, N = 67), or vital statistics if no other source was available (11%, N = 41). The medical conditions at the time of discharge for each infant were reviewed and, if judged to confer an increased risk of morbidity or mortality, were classified as high risk. RESULTS: The causes of death were sudden infant death syndrome (47%, N = 181), congenital conditions (20%, N = 77), prematurity-related conditions (11%, N = 43), infections (9%, N = 34), external causes (including injuries, drownings, ingestions, and burns) (7%, N = 25), and other (6%, N = 23). In 24% of congenital and 25% to 44% of prematurity-related deaths, infection was the acute or associated cause of death. Infants born to black mothers were more likely than those born to white mothers to die during the postneonatal period of all major causes of death (7.3 per 1000 vs 3.0 per 1000). Overall, 18% (N = 68) of deaths occurred to infants who never left the hospital; 79% (N = 305) of the infants were discharged before death; and discharge status was unknown in 3% (N = 13). Eighty-one percent of all infants with prematurity-related postneonatal deaths were never discharged, and of the total infants who were initially discharged, only 1% (N = 4) subsequently died of prematurity-related causes. Of all postneonatal deaths, only 16% (N = 62) left the hospital with identified high-risk medical conditions. CONCLUSIONS: These findings suggest that the etiology of postneonatal mortality is heterogeneous, with significant complexity in attributing specific causes of death and making designations of "preventability." The vast majority of infants who died of prematurity-related postneonatal causes never left the hospital, and only a small percentage of all infants that left the hospital before death were identified as being at high medical risk. Therefore, strategies for further decreasing postneonatal mortality must link high-risk follow-up programs to more comprehensive strategies that address risk throughout pregnancy and early childhood.     

The role of constituency groups in policy formulation

The Veterans Administration medical care system functions within a larger VA services program that has as its direct constituency many organized veterans' groups The VA system is viewed from the larger perspective of consumer representation in its direction through three effective functions of consumer representation: ownership, control, and oversight. In the VA the Congress and the veterans' groups perform these functions with varying levels of impact on the system. While veterans feel a measure of ownership of the medical care system, they have little voice in its actual operation. Research is needed to describe more fully the actual role of the veteran-client in the system and to explore the possibility that aspects of the system may be adopted outside.     

Assessment of laryngeal view: Percentage of glottic opening scorevs Cormack and Lehane grading

PURPOSE: To examine the intra- and inter-rater reliability of two methods that categorize laryngeal view during direct laryngoscopy, the Cormack-Lehane grading system and a new scale, the percentage of glottic opening (POGO) scale. METHODS: Seven anesthesiologists from the University of Pennsylvania Health System viewed 25 identical pairs of slides of laryngeal views during direct laryngoscopy. Each anesthesiologist rated the 50 slides for both Cormack-Lehane grades and POGO scores. The latter CL replaces grades 1 and 2 C-L grades with a percentage of glottic opening: the POGO score. Inter and intra-physician reliability for the Cormack-Lehane grades were determined using the kappa statistic analysis, comparison of POGO scores was performed using the intraclass correlation coefficients (rI). RESULTS: The POGO score had a better inter and intra-physician reliability than the Cormack-Lehane grading system. The intra-physician reliability for the POGO score was very good with an average interclass rI value of 0.88. The inter-physician score was good with a rI of 0.73. The Cormack-Lehane grading system had excellent intra-physician concordance (average kappa = 0.83.) but the inter-physician reliability was poor (kappa = 0.16.) CONCLUSION: The Cormack-Lehane grading system has very poor inter-physician reliability. The lack of inter-physician reliability with Cormack-Lehane grading calls into question the results of previous studies in which different laryngoscopists used this method to assess laryngeal view. The POGO score appears to have good intra and inter-rater reliability. It has several theoretical advantages and may prove to be more useful for research studies in direct laryngoscopy.