Rapid Response Events in Hospitalized Patients: Patient Symptoms and Clinician Communication

Context

Patients triggering rapid response team (RRT) intervention are at high risk for adverse outcomes. Data on symptom burden of these patients do not currently exist, and current symptom management and communication practices of RRT clinicians are unknown.

Prognostic implications of the rapid recruitment of coronary collaterals during ST elevation myocardial infarction (STEMI): a meta-analysis of over 14,000 patients

Journal of Thrombosis and Thrombolysis - Acute coronary collateralisation of an infarct-related arterial (IRA) territory may be identified during angiography for ST elevation myocardial infarction...     

Automatic external defibrillators: importance of field testing to evaluate performance

A new automatic external defibrillator was tested first against a tape-recorded data base of rhythms and then during use by first-responding fire fighters in a tiered emergency system. The sensitivity for correctly classifying ventricular fibrillation and ventricular tachycardia was substantially less during clinical testing in 298 patients than would have been predicted from preclinical results: 52% of ventricular fibrillation analyses in patients were correctly classified versus 88% of episodes in the data base, and 22 versus 86%, respectively, for ventricular tachycardia (p less than 0.001). The detection algorithm was modified and evaluated further in another 322 patients. The modified detector performed substantially better than did the one that had been designed from prerecorded rhythms: with its use, 118 (94%) of 125 patients in ventricular fibrillation were counter-shocked compared with 91 (77%) of 118 similar patients with use of the initial algorithm (p less than 0.001). No inappropriate shocks were delivered. This improvement resulted in a shorter time to first shock (p less than 0.01) and more shocks being delivered for persistent or recurrent episodes of ventricular fibrillation (p less than 0.05). Of 620 patients treated with the automatic defibrillator, 243 (39%) had ventricular fibrillation; 57 (23%) of the 243 regained pulse and blood pressure before paramedics arrived, 141 (58%) were admitted to hospital and 71 (29%) were discharged.(ABSTRACT TRUNCATED AT 250 WORDS)     

Risk of Second Cancers in Patients with Colorectal Carcinoids

INTRODUCTION: It is often stated that patients with colorectal carcinoid tumors have an increased risk of developing other malignancies. However, this risk has not been conclusively documented. A comprehensive evaluation is needed to more thoroughly assess the risk of second cancers in patients with colorectal carcinoids. METHODS: A search of the National Cancer Institute Surveillance, Epidemiology, and End Result database from 1973 to 1996 revealed 2,086 patients with colorectal carcinoids. This subset of patients was examined for occurrence of second cancers. The observed incidence of cancer for each site was compared with the expected incidence based on the gender-adjusted and age-adjusted cancer rates in the remaining Surveillance, Epidemiology, and End Result file. A Poisson distribution probability was used to determine the significance of these comparisons. RESULTS: Patients with colorectal carcinoids had an increased rate of cancer in the colon and rectum (P < 0.001), small bowel (P < 0.001), esophagus/stomach (P = 0.02), lung/bronchus (P < 0.001), urinary tract (P = 0.005), and prostate (P < 0.001), when compared with a control population. Most of the gastrointestinal tract cancers were synchronous cancers, whereas lesions outside the gastrointestinal tract were most commonly metachronous tumors. CONCLUSIONS: A significantly increased risk of synchronous colorectal, small-bowel, gastric, and esophageal cancers and metachronous lung, prostate, and urinary tract neoplasms is clearly demonstrated. After the diagnosis of colorectal carcinoid tumors, patients should undergo appropriate screening and surveillance for cancer at these sites.     

Acquired granular pool defect in stored platelets

Platelets stored as concentrates (PC) for 72 h at 22 degrees C develop a functional defect. Alterations in adenine nucleotides of platelets have been shown to affect platelet function. Adenine nucleotide content of platelets was measured before and after storage and a decrease of 27.1 /+- 1.7% (mean /+- SE) in ATP and 39.1 /+- 2.6% in ADP were found in 34 PC stored with final volume of 50 ml. In 11 PC with 30 ml volume. ATP and ADP decreased by 39.4 /+- 3.2% and 49.4 /+- 2.1%, respectively. The mean ATP to ADP ratio of stored platelets was significantly higher than of fresh platelets in both groups, suggesting a relatively greater decrease in granular than metabolic pool nucleotides. Levels of low affinity platelet factor 4 measured by radioimmunoassay in plasma from 0.86 /+- 0.08 microgram/ml in the fresh PC to 8.59 /+- 0.39 microgram/ml in stored PC, indicating a concomitant alpha-granular secretion. Labeling of metabolic pool with 14C-adenine revealed a mean decrease in the adenylate energy charge of 2.0 /+- 0.4% in 12 of 16 stored PC, with a lower ATP and higher hypoxanthine labeling in stored as compared to fresh platelets. These observations suggest that stored platelets develop an acquired defect in both dense and alpha granules and in their ability to maintain ATP homeostasis.     

Ligation of erythrocyte CR1 induces its clustering in complex with scaffolding protein FAP-1

The primary identified function of complement receptor 1 (CR1/CD35) on primate erythrocytes is to bind complement-tagged inflammatory particles including microbes and immune complexes. When erythrocytes circulate through liver and spleen, sinusoidal phagocytes remove CR1-adherent particles and erythrocytes return to the circulation. This process of immune adherence clearance is important for host defense and prevention of autoimmunity. CR1 was previously described as clustered in the human erythrocyte membrane, which was thought to be necessary for binding complement-opsonized particles. In contrast, we demonstrate that on erythrocytes CR1 is not clustered, but dispersed, and able to bind complement-tagged particles. When fresh erythrocytes are solubilized by nonionic detergent, CR1 partitions to the cytoskeleton fraction. Using a PDZ-peptide array, CR1's cytoplasmic tail, which contains 2 PDZ-motifs, binds PDZ domains 2, 3, and 5 of Fas-associated phosphatase 1 (FAP-1), a scaffolding protein. We show that FAP-1, not previously recognized as an erythroid protein, is expressed on circulating erythrocytes. CR1 and FAP-1 coimmunoprecipitate, which confirms their molecular association. Disperse CR1 on erythrocytes may be advantageous for capturing immune-complexes, while ligation-induced CR1 clustering may prevent ingestion of the erythrocyte during the immune-complex transfer to the macrophages by keeping the opsonic stimulus localized thus preventing phagocyosis.     

Accuracy of computer-interpreted electrocardiography in selecting patients for thrombolytic therapy. MITI Project Investigators

A prehospital computer-interpreted electrocardiogram (ECG) was obtained in 1,189 patients with chest pain of suspected cardiac origin during an ongoing trial of prehospital thrombolytic therapy in acute myocardial infarction. Electrocardiograms were performed by paramedics 1.5 +/- 1.2 h after the onset of symptoms. Of 391 patients with evidence of acute myocardial infarction, 202 (52%) were identified as having ST segment elevation (acute injury) by the computer-interpreted ECG compared with 259 (66%) by an electrocardiographer (p less than 0.001). Of 798 patients with chest pain but no infarction, 785 (98%) were appropriately excluded by computer compared with 757 (95%) by an electrocardiographer (p less than 0.001). The positive predictive value of the computer- and physician-interpreted ECG was, respectively, 94% and 86% and the negative predictive value was 81% and 85%. Prehospital screening of possible candidates for thrombolytic therapy with the aid of a computerized ECG is feasible, highly specific and with further enhancement can speed the care of all patients with acute myocardial infarction.     

Nontypable Haemophilus influenzae (biotype 4) as a neonatal, maternal, and genital pathogen

Between 1976 and 1981 Haemophilus influenzae was identified in 16 women with postpartum bacteremia and 36 neonates with bacteremia or meningitis. H. influenzae was also recovered from neonatal or genital cultures of 50 additional patients. By counter-immunoelectrophoresis 17% of neonatal isolates from blood or cerebrospinal fluid (CSF) were type b. All remaining strains (94% overall) were nontypable (NT). Of the NT blood or CSF isolates, 38% belonged to biotype 4. Of all the NT biotype 4 isolates referred to the Centers for Disease Control during the study, 82% were of genital, neonatal, or maternal origin, a finding that suggests that this isolate is a genital biotype. Clinical disease was similar to that observed in patients infected with group B Streptococcus except for the infrequent (11%) occurrence of meningitis. Maternal bacteremia resulted in mild febrile illness, while neonatal bacteremia was associated with a high incidence of shock, respiratory distress (50%), and death (30%). H. influenzae bacteremia in these two patient groups was rare in Houston before 1976, but since then it has been responsible for 2.5% of cases of significant bacteremia. NT H. influenzae should be recognized as a definite neonatal, maternal, and genital pathogen.     

Ventricular fibrillation causes sudden death in Southeast Asian immigrants

Young, male, Southeast Asian immigrants living in the United States have a high incidence of unexplained, sudden, nocturnal death. We report the cases of three patients, two Laotians and one Filipino, who were resuscitated and subsequently studied extensively. Each patient was having ventricular fibrillation when first examined by paramedics outside the hospital, and episodes of fibrillation recurred in the early hospital course. Clinical evaluation found no significant coronary atherosclerosis or structural cardiac disease. One patient is asymptomatic after 2 years; the second patient died suddenly at 4 months; and the third is asymptomatic but had inducible ventricular tachycardia on electrophysiologic testing 6 months after resuscitation. The mechanism of sudden death in young Southeast Asian men appears to be ventricular fibrillation. The cause of the arrhythmia is unclear, although in our patients the arrhythmia was not an isolated event; underlying predispositions to further cardiac arrest persisted.