Acute coronary syndrome and myocardial infarct--new definitions

Until recently a general consensus existed for the clinical entity diagnosed as myocardial infarction using the world health organisation (WHO) definition. According to the WHO definition myocardial infarction was defined by a combination of two of three typical characteristics: typical symptoms, rise of cardiac enzymes (CK, CK-MB), and a typical ECG pattern involving the development of Q waves. New insights into the development of acute myocardial infarction, the superiority of the biochemical characteristics of cardiac troponin assays over CK and CK-MB measurements in blood, and new therapeutic concepts made a new definition of myocardial infarction, e.g. of the acute myocardial infarction, necessary. Timing of the diagnosis of myocardial necrosis is of outmost importance relative to the time of observation (acute, evolving, healing, healed MI), as is the classification of the extent of myocardial damage (microscopic, small, medium or large). The term "acute coronary syndrome" (ACS) has been established as a working diagnosis for choosing the appropriate therapeutic strategy. In patients with ACS and ST elevation ischemia (STEMI ACS, true posterior ischemia inclusive) as well as in patients with presumably new LBBB, immediate reperfusion therapy should be performed (primary PTCA or thrombolytic therapy), whereas in patients with ECG changes other than ST elevation or new LBBB (NSTEMIACS) additional antiplatlet therapy on top of aspirin and heparin is indicated. In contrast to the acute phase of infarction when troponin in blood often is not detectable yet, the diagnosis of definitive myocardial infarction is based primarily on troponin elevation. Hard criteria for established infarction are the development of pathologic Q waves or healing or healed myocardial necrosis in pathology; troponin may be normal then, depending of time relapsed.     

Fluctuations in uncorrected visual acuity after refractive surgery using intra-stromal corneal rings]

PURPOSE: Refractive surgery is meant to provide early stable and good uncorrected visual acuity. Our main concern in this study was to take special interest in fluctuation in uncorrected acuity within the first three months after implantation of Schanzlin intracorneal ring segments (ICRS) produced by Keravision. PATIENTS AND METHODS: Ten eyes in 6 patients underwent implantation of 2 intrastromal corneal segments for myopias ranging from -1.00 to -3.50 Dipoters. Visual acuity was measured with cytoplegy on day one, on day 8, two weeks, 1 month, and 2 months after surgery. The fluctuations of visual acuity were noted between observations. RESULTS: Uncorrected visual acuity varied up to 4 lines without an obvious pattern of progression over time. Fifty percent of the eyes had a variation of 2 lines. The best spectacle corrected visual acuity was preserved in all patients. DISCUSSION: Corneal topography with measurement of keratometry, intraocular pressure, and examination of the anterior chamber must be studied to identify the parameter that could condition these fluctuations of visual acuity. No parameter was found to predict these variations that may result from individual corneal healing factors peculiar to each patient. The fluctuations of uncorrected visual acuity were relatively important during the 3 first postoperative months. In all patients, final uncorrected visual acuity was always at least 10/10.     

Das absolute Sphygmogramm der Arteria subclavia beim Menschen

Zusammenfassung Mit der vonH. J. Wolf undB. v. Bonsdorff angegebenen Methode werden beim Menschen absolute Sphygmogramme der Arteria subclavia registriert. Die Sphygmogramme zeigen die charakteristischen Eigenheiten des zentralen Pulses. An Hand eines Kurvenbildes werden die h?modynamischen Auswirkungen eines Hustensto?es er?rtert. Die Ergebnisse der blutigen und der unblutigen Seitenwanddruckbestimmungen in der Arteria subclavia werden besprochen. Bei einer Versuchsperson wird gleichzeitig mit der Aufnahme absoluter Sphygmogramme am gleichen Arm der Blutdruck auskultatorisch und oszillographisch registriert. Die Punktion der Arteria subclavia ist schwierig. Wir halten sie bei sorgsamer Durchführung und vorsichtiger Handhabung für gefahrlos.     

Multiorgan dysfunction caused by travel-associated African trypanosomiasis

We describe a case of multiorgan dysfunction secondary to Trypanosoma brucei rhodesiense infection acquired on safari in Zambia. This case was one of several recently reported to ProMED-mail in persons who had traveled to this region. Trypanosomiasis remains rare in travelers but should be considered in febrile patients who have returned from trypanosomiasis-endemic areas of Africa.     

Risk for tuberculosis among children

Contacts of adults with tuberculosis (TB) are at risk for infection. Tests based on interferon-gamma (IFN-gamma) expression in response to Mycobacterium tuberculosis antigens may be more sensitive than the tuberculin skin test (TST). Risk for infection was assessed by using TST and an IFN-y-based assay (QuantiFERON Gold in Tube [QFT-IT] test) for 207 children in Nigeria in 1 of 3 groups: contact with adults with smear-positive TB, contact with adults with smear-negative TB, and controls. For these 3 groups, respectively, TST results were >10 mm for 38 (49%) of 78, 13 (16%) of 83, and 6 (13%) of 46 and QFT-IT positive for 53 (74%) of 72, 8 (10%) of 81, and 4 (10.3%) of 39 (p < 0.01). Most test discrepancies were TST negative; QFT-IT positive if in contact with TB-positive persons; and TST positive, QFT-IT negative if in contact with TB-negative persons or controls. TST may underestimate risk for infection with TB in children.     

Correlation between tear IgE levels and HLA-DR expression by conjunctival cells in allergic and nonallergic chronic conjunctivitis

Background: Chronic conjunctival inflammatory diseases may depend upon various mechanisms. Discriminating allergy from nonspecific inflammation has become of striking importance for diagnosis and treatment. We investigated conjunctival inflammatory response by comparing two objective biological tools, tear IgE and HLA-DR expression by conjunctival epithelium, as indirect indicators of activation of the Th2 and Th1 subsets, respectiv-ely. Methods: Eighty-two patients with chronic conjunctivitis underwent tear IgE measurement by an ELISA technique and quantitation of HLA-DR expression in impression cytology specimens. Forty-two had direct or indirect clinical indications of allergic mechanisms, 26 had chronic conjunctivitis without any sign of allergy, and 14 suffered from isolated nonallergic dry eyes. Results: Patients clinically considered as allergic only showed positive IgE in 47 of 84 eyes (56%), whereas 21% and 25% of eyes with nonspecific conjunctivitis and dry eyes respectively were also positive. IgE levels were significantly higher in the allergic group than in the other two groups. HLA-DR positivity in epithelial cells was found in 28.5%, 48% and 50% of eyes, respectively. HLA-DR expression by epithelial cells was negatively correlated with tear IgE, as most specimens positive to one criterion were negative to the other one (49 eyes DR+, IgE–; 47 eyes DR–, IgE+; only 9 eyes positive to both criteria; chi-square: P=0.0001). Conclusion: As IgE synthesis and HLA-DR induction may represent indirect indicators of the activation of the Th2 and Th1 subsets, association of these two simple tests could be interesting for the routine assessment of the mechanisms of inflammatory ocular surface diseases. Received: 22 February 2000 Revised: 4 May 2000 Accepted: 16 May 2000     

Early deaths during tuberculosis treatment are associated with depressed innate responses, bacterial infection, and tuberculosis progression

Up to 14% of Malawian adults die during the intensive phase of tuberculosis treatment. In a prospective cohort of 199 Malawian adults with microbiologically confirmed pulmonary tuberculosis, clinical and laboratory parameters were compared between those who died or deteriorated with those who had an uneventful recovery. Baseline tumor necrosis factor alpha responses to stimulation with heat-killed Mycobacterium tuberculosis and lipopolysaccharide were reduced among the 22 patients with poor outcome (P = .017). Low body mass index (P = .002) and elevated respiratory rate (P = .01) at tuberculosis diagnosis independently predicted poor outcome. Validation of a clinical score identifying high-risk individuals is warranted, together with further investigation of immunological derangements.     

Lactate,N-acetylaspartate,choline and creatine concentrations,and spin-spin relaxation in thalamic and occipito-parietal regions of developing human brain

Previous studies of the brains of normal infants demonstrated lower lactate (Lac)/choline (Cho), Lac/creatine (Cr), and Lac/N-acetylaspartate (Naa) peak-area ratios in the thalamic region (predominantly gray matter) compared with occipitoparietal (mainly unmyelinated white matter) values. In the present study, thalamic Cho, Cr, and Naa concentrations between 32–42 weeks' gestational plus postnatal age were greater than occipito-parietal: 4.6 ± 0.8 (mean ± SE), 10.5 ± 2.0, and 9.0 ± 0.7 versus 1.8 ± 0.6, 5.8 ± 1.5, and 3.4 ± 1.1 mmol/kg wet weight, respectively: Lac concentrations were similar, 2.7 ± 0.6 and 3.3 ± 1.3 mmol/kg wet weight, respectively. In the thalamic region, Cho and Naa T₂s increased, and Cho and Lac concentrations decreased, during development. Lower thalamic Lac peak-area ratios are principally due to higher thalamic concentrations of Cho, Cr, and Naa rather than less Lac. The high thalamic Cho concentration may relate to active myelination; the high thalamic Naa concentration may be due to advanced gray-matter development including active myelination. Lac concentration is higher in neonatal than in adult brain.     

Drug-resistant tuberculosis--current dilemmas, unanswered questions, challenges, and priority needs

Tuberculosis was declared a global emergency by the World Health Organization (WHO) in 1993. Following the declaration and the promotion in 1995 of directly observed treatment short course (DOTS), a cost-effective strategy to contain the tuberculosis epidemic, nearly 7 million lives have been saved compared with the pre-DOTS era, high cure rates have been achieved in most countries worldwide, and the global incidence of tuberculosis has been in a slow decline since the early 2000s. However, the emergence and spread of multidrug-resistant (MDR) tuberculosis, extensively drug-resistant (XDR) tuberculosis, and more recently, totally drug-resistant tuberculosis pose a threat to global tuberculosis control. Multidrug-resistant tuberculosis is a man-made problem. Laboratory facilities for drug susceptibility testing are inadequate in most tuberculosis-endemic countries, especially in Africa; thus diagnosis is missed, routine surveillance is not implemented, and the actual numbers of global drug-resistant tuberculosis cases have yet to be estimated. This exposes an ominous situation and reveals an urgent need for commitment by national programs to health system improvement because the response to MDR tuberculosis requires strong health services in general. Multidrug-resistant tuberculosis and XDR tuberculosis greatly complicate patient management within resource-poor national tuberculosis programs, reducing treatment efficacy and increasing the cost of treatment to the extent that it could bankrupt healthcare financing in tuberculosis-endemic areas. Why, despite nearly 20 years of WHO-promoted activity and >12 years of MDR tuberculosis-specific activity, has the country response to the drug-resistant tuberculosis epidemic been so ineffectual? The current dilemmas, unanswered questions, operational issues, challenges, and priority needs for global drug resistance screening and surveillance, improved treatment regimens, and management of outcomes and prevention of DR tuberculosis are discussed.