Can Electrocardiographic Criteria Predict Adverse Cardiac Events and Positive Cardiac Markers?

OBJECTIVES: To determine electrocardiogram (ECG) predictors of positive cardiac markers and short-term adverse cardiac events in an undifferentiated chest pain population presenting to emergency departments (EDs). The authors hypothesized that specific ECG findings, other than those previously identified in higher-risk populations, would be predictive of cardiac outcomes and positive cardiac markers. METHODS: This study used data from a prospectively collected, retrospectively analyzed Internet-based data registry of undifferentiated chest pain patients (i*trACS). Logistic regression modeling was performed to determine the ECG findings that were predictive of 1) positive cardiac markers and 2) short-term adverse cardiac events. RESULTS: ST-segment elevation (STE), ST-segment depression (STD), pathological Q-waves (PQW), and T-wave inversion were associated with increased odds of percutaneous coronary intervention or catheterization, myocardial infarction, or coronary artery bypass grafting. The odds of creatine kinase-MB (CK-MB) measuring positive were increased if STE, STD, or PQW were present [odds ratio (OR) 2.495, 2.582, and 1.295, respectively]. A right bundle branch block tended to decrease the odds of CK-MB measuring positive (OR 0.658). A similar pattern of results was observed for troponin I (OR 3.608 for STE, 3.72 for STD, 1.538 for PQW). Troponin T showed an increased odds of measuring positive if any of STE, STD, left bundle branch block, or T-wave inversion were evident (OR 2.313, 2.816, 1.80, and 1.449, respectively). CONCLUSIONS: Initial ECG criteria can be used to predict short-term cardiac outcomes and positive cardiac markers. These findings can be important aids in the risk-stratification and aggressive treatment regimens of chest pain patients presenting to EDs.     

奥利司他对肥胖青少年体重和机体组分的影响——随机对照试验

背景：儿童和青少年超重和肥胖正迅速增加。在该人群，单纯行为疗法减肥及维持体重下降的效果有限，但是对药物治疗尚未进行广泛的研究。 目的：确定奥利州他（Orlistat）在青少年体重治疗方面的效果及其安个性。 设计、地点和病例：于美国和加拿大32个中心、539例肥胖青少年（12—16岁；体重指数[body mass index，BMI]在第95百分化之上≥2单位）进行的多ln0、54剧（2000年8月至2002年10月）随机双盲研究。 干预：给予奥利司他（n=357）或安慰剂（n=182）120mg，每口3次，持续1年；加适度低热卡饮食（脂肪占30％）、运动和行为治疗。 主要观察指标：BMI变化；二级指标包括腰围和髋用、体重下降、脂质测量以及机体对口服葡萄糖的血糖和胰岛素反心。 结果：至12周时，两组BMI均有下降；此后，奥利司他组体重维持稳定而安慰剂组则超过基线。研究结束时，奥利司他组BMI下降0．55。而安慰剂组则增加0．31（P=0．001）。与安慰剂组的15．7％相比，奥利司他组26．5％的病例BMI下降≥5％（P=0．005）；BMI下降≥10％者分别为4．5％和13．3％（P=0．002）。在研究结束时，奥利司他组体重增加0．53kg，安慰剂组增加3．14kg（P〈0．001）。双能X线吸收测量娃示，这种差异可用脂肪体再的变化解释。奥利司他组腰围下降，安慰剂组腰围上升（-1．33cm比＋0．12cm；P〈0．05）。奥利司他组发生轻至中度胃肠道不良事件者为9％-50％，安慰剂组为1％～13％。 结论：与安慰剂比较，奥利司他与饮食、运动和行为改善联合可显著改善肥胖青少年体重的治疗。在这个青少年人群，连续使用奥利司他1年并无重要安全问题，尽管奥利司他组胃肠道不良事件较为常见。     

Boerhaave’s syndrome: Primary repair vs. esophageal resection—Case reports and meta-analysis of the literature

Boerhaave’s syndrome is a life-threatening disease with a high mortality. With regard to the heterogeneity of treatment strategies, no comparative studies exist and recommendations remain controversial. Seventeen cases of Boerhaave’s syndrome operated on between 1989 and 2000 at our hospital were reviewed retrospectively to compare the time period between perforation and diagnosis, and the morbidity and mortality among the different treatment options. In addition, we conducted a meta-analysis of the literature including all series containing five or more patients and compared the findings with our own data. Our patients with a perforation history of less than 12 hours showed significantly fewer signs of sepsis compared to patients with a history of more than 12 hours. In a comparison of patients with primary repair vs. patients treated with esophageal resection or an exclusion operation, no differences were found. In the literature, patients with a long period of perforation (more than 24 hours) were treated more often with an esophageal resection than patients with primary repair. In cases of Boerhaave’s syndrome, primary suturing of the esophageal perforation should be reserved only for those patients presenting within 12 hours after perforation. In all other cases, depending on the extent of the tissue damage, a two-stage esophageal resection with cervical esophagostomy and gastrostomy is recommended as the safest treatment.     

Parallel image reconstruction using B-spline approximation (PROBER).

A new reconstruction method for parallel MRI called PROBER is proposed. The method PROBER works in an image domain similar to methods based on Sensitivity Encoding (SENSE). However, unlike SENSE, which first estimates the spatial sensitivity maps, PROBER approximates the reconstruction coefficients directly by B-splines. Also, B-spline coefficients are estimated at once in order to minimize the reconstruction error instead of estimating the reconstruction in each pixel independently (as in SENSE). This makes the method robust to noise in reference images. No presmoothing of reference images is necessary. The number of estimated parameters is reduced, which speeds up the estimation process. PROBER was tested on simulated, phantom, and in vivo data. The results are compared with commercial implementations of the algorithms SENSE and GRAPPA (Generalized Autocalibrating Partially Parallel Acquisitions) in terms of elapsed time and reconstruction quality. The experiments showed that PROBER is faster than GRAPPA and SENSE for images wider than 150x150 pixels for comparable reconstruction quality. With more basis functions, PROBER outperforms both SENSE and GRAPPA in reconstruction quality at the cost of slightly increased computational time.     

Outpatient Initiation of Insulin: A Nurse Practitioner Protocol

Noninsulin dependent diabetes (type II diabetes) is a chronic disease characterized by hyperglycemia. Clients can generally be controlled by diet and exercise or a combination of diet, exercise, and oral hypoglycemic agents. When this therapy is not effective in controlling the hyperglycemia, the health care provider must choose to initiate insulin therapy. Outpatient initiation of insulin is an alternative to hospitalization in the type II diabetic client. Clinical guidelines for the initiation of insulin on an outpatient basis and management of the diabetic client are presented.     

The natural course of DSM-IV somatoform disorders and syndromes among adolescents and young adults: a prospective-longitudinal community study.

OBJECTIVE: Although somatoform disorders are assumed to be chronic clinical conditions, epidemiological knowledge on their natural course based on representative samples is not available. METHOD: Data come from a prospective epidemiologic study of adolescents and young adults in Munich, Germany. Respondents' diagnoses (N = 2548) at baseline and follow-up on average 42 months later are considered. The follow-up incidence, stability as well as selected baseline risk factors (sociodemographics, psychopathology, trauma exposure) for the incidence and stability of somatoform disorders and syndromes are prospectively examined. Diagnostic information was assessed by using the standardized Munich-Composite International Diagnostic Interview (M-CIDI). RESULTS: Over the follow-up period, incidence rate for any of the covered somatoform diagnoses was 25.7%. Stability for the overall group of any somatoform disorder/syndrome was 48%. Female gender, lower social class, the experience of any substance use, anxiety and affective disorder as well as the experience of traumatic sexual and physical threat events predicted new onsets of somatoform conditions, while stability was predicted by being female, prior existing substance use, affective and eating disorders as well as the experience of a serious accident. CONCLUSIONS: At least for a substantial proportion of individuals, the overall picture of somatization seems to be relatively stable, but with fluctuation in the symptom picture over time. Being female, the experience of substance use as well as anxiety disorder seem to constitute risk factors for the onset of new somatoform conditions as well as for a stable course over time.     

Imaging of activated microglia with PET and [11C]PK 11195 in corticobasal degeneration.

Positron emission tomography (PET) using [(11)C]PK 11195, a ligand for peripheral benzodiazepine receptor binding sites, offers the opportunity to image activated microglia in vivo. This tool may therefore be used to display the occurrence of microglial activation in the course of neurodegeneration. A patient with the clinical diagnosis of corticobasal degeneration (CBD) and left-sided symptoms was studied using fluorodeoxyglucose (FDG) and [(11)C]PK 11195 PET. We found a marked right hemispheric hypometabolism and asymmetric microglial activation in corresponding areas of the basal ganglia and right temporal and parietal cortex. [(11)C]PK 11195 PET suggests involvement of microglial activation in the pathogenesis of CBD.