Validation in a community hospital setting of a clinical rule to predict preserved left ventricular ejection fraction in patients after myocardial infarction

BACKGROUND: A previous study showed that patients with previous myocardial infarction (MI) who meet 4 simple clinical and/or electrocardiographic criteria have a left ventricular ejection fraction (LVEF) of 40% or greater, with a positive predictive value of 98%. The objective of this study was to validate this clinical rule in the community hospital setting. METHODS: Retrospective chart review in a 330-bed community hospital. Two hundred thirteen consecutive patients with MI were identified between June 1, 1993, and March 31, 1995. Left ventricular ejection fraction was predicted in a blinded fashion by means of the clinical rule before the actual LVEF test was reviewed. RESULTS: We identified 213 patients admitted with the primary discharge diagnosis of acute MI. All patients met standard clinical and enzymatic definitions for acute MI and had at least 1 measure of LVEF, such as echocardiography, ventricular angiography, or gated blood pool scan. The clinical rule predicted that 83 patients (39.0%) would have an LVEF of 40% or greater. Of these 83 patients, 71 had an ejection fraction of 40% or greater, for a positive predictive value of 86%. Of the 12 patients who were incorrectly predicted to have a preserved LVEF, 6 (50%) had an index non-Q-wave anterior MI (P<.001). Reanalyzing the patient population with a fifth variable (anterior non-Q-wave MI) added to the original 4 variables increased the positive predictive value to 91%. CONCLUSION: This simple clinical prediction rule has a positive predictive value of 86% when applied in the community hospital setting. Patients with anterior non-Q-wave MI may be 1 group in whom the rule is inaccurate, and expanding the clinical rule to 5 variables may increase the positive predictive value. When a technology-based assessment of left ventricular function is considered in patients after an MI, this prediction rule may allow for a more cost-effective patient selection, and as many as 40% of patients who have had acute MIs may require no testing at all.     

Malignant fibrous histiocytoma manifesting as a cavitary lung metastasis

Exploration prompted by acute abdominal symptoms in a 29-year-old woman discovered to have an asymptomatic right upper lobe cavitary lesion disclosed a malignant fibrous histiocytoma, the primary lesion of which was in the duodenum. At autopsy, the lung lesion was found to be metastatic. We believe this is the first recorded instance of cavitary lung metastasis from this type of tumor.     

Lungenembolie mit Lungeninfarkt als Folge einer Thrombophlebitis der V.cephalica

Die Enstehung der Lungenembolie in Folge tiefer Beinvenen- und Armvenenthrombosen sowie oberfl?chlicher Beinvenenthrombophlebitiden und -thrombosen ist gut bekannt und in vielen Studien publiziert. In der vorliegenden Arbeit wird der seltene Fall eines Lungeninfarktes in Folge einer Lungenembolie bei Thrombophlebitis einer epifascialen Unterarmvene (V. cephalica) bei einem 45-j?hrigem Patienten, der sich einer Sigmaresektion bei Divertikulose unterziehen musste, vorgestellt. Ein ?tiologischer Zusammenhang der zu Grunde liegenden Lungenembolie mit dem durchgeführten operativen Eingriff konnte ebenso wie andere Thromboemboliequellen ausgeschlossen werden. ?11 Tage postoperativ trat an der Einstichstelle einer Infusionsnadel eine Verh?rtung, Schwellung und R?tung im Sinne einer Thrombophlebitis auf, die im weiteren Verlauf vom distalen Unterarm bis zur Ellenbeuge aszendierte und durch die durchgeführten konservativen Ma?nahmen (Wickeln, kühlende Umschl?ge, antiphlogistische Therapie) nicht hinreichend behandelt werden konnte. 14 Tage sp?ter stellte sich der Patient mit pl?tzlich aufgetretener Luftnot im Rahmen einer Lungenembolie in unserer Klinik vor. Der zuvor verh?rtet tastbare?proximale Anteil der Thrombophlebitis war nicht mehr vorhanden.?   Der vorliegende Fallbericht soll auf die Bedeutung der Thromboembolieprophylaxe bei oberfl?chlichen, aszendierenden Thrombophlebitiden auch der oberen Extremit?t und die gro?zügige Indikationsstellung zur Thrombektomie bei aszendierenden Thrombosen hinweisen.     

Crevicular fluid myeloperoxidase--an indicator of acute gingival inflammation

Paper strips inserted into 100 gingival sulci or periodontal pockets in 9 patients for 3 minutes in each case were assayed for polymorphonuclear (PMN) leukocyte-derived myeloperoxidase (MP) activity. This activity was then analysed in relation to the simultaneously recorded gingival index, probing depth and bleeding on probing. MP activity was always very low if the gingiva was clinically healthy, with no bleeding or signs of loss of attachment. However, sites at which the marginal gingiva was inflamed and bleeding and/or the pocket depth was greater than or equal to 6 mm exhibited MP activities ranging from very low to very high. The wide variation most likely reflects differing numbers of PMN cells in these crevices and is, therefore, probably indicative of acute or chronic periodontal disease at any particular site. The assays of the paper strips resulted in values linear with respect to the actual concentrations of purified, PMN cell-derived MP in the strips. Our method is a relatively simple way to quantitate the products of PMN cells at a single periodontal site and, in this way, to possibly identify the acute phases of the disease.     

Magnetic resonance imaging of myocardial infarction using albumin-(Gd-DTPA), a macromolecular blood-volume contrast agent in a rat model

Magnetic resonance (MR) contrast enhancement of acute myocardial infarction was studied in rats using albumin-(Gd-DTPA), a paramagnetic macromolecule with prolonged intravascular retention after intravenous injection. Histologic examination and distribution measurements of radiolabeled microspheres confirmed induction of regional myocardial infarction after ligation of the left coronary artery. ECG-gated spin-echo images at 2.0 Tesla, employing short, T1-weighted pulse sequence settings, demonstrated time-persistent and significant (P less than .05) enhancement of normal myocardium (66%) and an even greater enhancement of the infarcted area (100%), for as long as 60 minutes after injection of 160 mg/kg albumin-(Gd-DTPA). The contrast difference between normal and infarcted myocardium was increased significantly (P less than .05) after administration of albumin-(Gd-DTPA). The prolonged enhancing effects of albumin-(Gd-DTPA) on MR images are useful for evaluating regional differences in blood volume and capillary integrity between normal and infarcted myocardium.