A comprehensive strategy for the evaluation and triage of the chest pain patient: A cost comparison study

BACKGROUND: Our objective was to determine the cost-effectiveness of a comprehensive, risk-based triage system, composed of multiple critical pathways, with the use of early myocardial perfusion imaging (MPI) in low-risk patients. We found previously that a chest pain evaluation system that uses MPI in low-risk patients was safe and effective, but the cost-effectiveness of this approach was not studied. METHODS AND RESULTS: We compared two groups. The Acute Cardiac Team (ACT) group (n = 874) was assigned prospectively to 1 of 4 risk levels by emergency department (ED) physicians. Level 1, 2, and 3 patients were admitted; level 4 patients were evaluated in the ED. Level 3 and 4 patients underwent ED MPI. The control group (n = 713) represented consecutive patients evaluated in the prior year according to standard care and assigned retrospectively to an ACT level based on the presenting electrocardiographic and clinical data. Record and hospital administrative data were assessed for clinical variables, outcomes, lengths of stay, and all expenses incurred within 30 days of the index visit. The baseline characteristics of the two groups were similar, including age, sex, myocardial infarction prevalence, and 30-day revascularization rates within each level or between the two groups. Mean costs per encounter were reduced for the ACT patients for each level, which was significant when all patients were compared ($5,030 +/- $7,081 vs $6,044 +/- $10,432, P =.02). Use of MPI in the low-risk patients was associated with reduced costs (level 3, $4,958 +/- $4,948 vs $5,051 +/- $7,036; level 4, $1,529 +/- $2,664 vs $1,794 +/- $6,854) and was associated with a significantly lower angiography rate and shorter length of stay. CONCLUSIONS: Implementation of a comprehensive strategy for chest pain evaluation and triage reduced overall costs for patients with chest pain on presentation. Acute MPI in the ED setting did not increase net cost.     

Animal experiments for the evaluation of laserspectroscopy in the fetus during labor.

Laserspectroscopy with near-infrared light is newly available for clinical application. The equipment consists of a near-infrared data collection unit (NIRDCU) and a personal computer. Emission of laser light at wavelengths of 775, 805, 845 and 904 nm is provided by the four laser diodes of the NIRDCU. By analyzing changes of optical density during laser radiation, information is obtained regarding the intracellular redox state and relative changes of blood volume. During measurement with the system on the fetal scalp during delivery we were able to get a first impression of the method's potential. While the application of the laser sensors is still cumbersome, signals providing information of the relative changes of hemoglobin concentration, relative changes of blood volume and cytochrome aa3 seems achievable. Laserspectrophotometric monitors may become safe, low cost and portable instruments for the non-invasive assessment of the biochemical and biophysical status in the fetus.     

Neurokinin A-like immunoreactivity in articular afferents of the cat.

Dorsal root ganglion cells with axons innervating the cat's knee joint via the medial articular nerve were retrogradely labelled with Fast blue. Neurokinin A-like immunoreactivity was found in 4.5 +/- 1.1% (mean +/- S.D. of 5 nerves and 695 cells) of the articular afferents. Colchicine treatment of the ganglia increased the percentage of immunopositive cells to 8.5 +/- 0.7% (mean +/- S.D. of 6 nerves and 554 cells) after 3-22 h. The diameter distribution of the immunopositive somata ranged from 20 to 50 microns with a maximum at 26-30 microns. Comparing the proportions of neurokinin A-immunopositive cells with those of substance P, it can be calculated on the basis of mRNA encoding that neurokinin A is synthetized in about half of the substance P-containing primary articular afferents.     

Toxicity of 2,3,7,8-tetrabromodibenzo-p-dioxin in rats after single oral administration.

Five male and female rats per dose-group received 2,3,7,8-tetrabromodibenzo-p-dioxin (2,3,7,8-TBDD) once on the first day of the study. Doses of 10, 33, 100, or 300 micrograms 2,3,7,8-TBDD/kg body wt. and the vehicle control were administered by gavage. About 20% of 2,3,7,8-TBDD was excreted via feces. Severe body weight retardation was observed in the 100 and 300 micrograms/kg dose-groups. Most animals in the 300 micrograms/kg dose-group and the females receiving 100 micrograms/kg showed emaciation, rough coat and a poor health (wasting syndrome). Of the animals dosed with 300 micrograms/kg, 3 males and all females died. After 100 micrograms 2,3,7,8-TBDD/kg 3 females died. Measured 4 weeks after dosing, triiodothyronine (T3) was increased and thyroxin (T4) was reduced dose dependently in serum. A dose-dependent decrease in thymus weights was observed at necropsy and histological examinations showed that thymus and spleen were depleted of mature lymphocytes. An increase in liver-to-body weight ratio was observed in all dose-groups. The histological examination revealed hypertrophy of centrilobular hepatocytes in the liver of animals treated with 100 micrograms/kg, which was less severe at the 33 micrograms/kg dose. Hypertrophic hepatocytes were also detected in some animals at the lowest dose. Induction of enzyme activities of the mixed function oxidases ethoxycoumarin O-deethylase (ECOD), ethoxyresorufin O-deethylase (EROD) and aryl hydrocarbon hydroxylase (AHH) in liver tissue differed for each of the three enzymes. Two days after administration, enzyme activities were increased but did not differ substantially between dose-groups. Twenty-eight days after dosing the increase in activity after 10 micrograms/kg was largest and the EROD of the 100 micrograms/kg dose-group in females was close to that of the control. This inverse dose-response relationship may be due to impaired liver cell function at higher doses.     

Magnetic resonance imaging (MRI) of the breast

Zusammenfassung Grundlagen: Der Zweck war es, die Anzahl der im Mammogramm entdeckten duktalen Carcinoma in situ (DCIS) und multizentrische Karzinome aufzudecken. Die verschiedenen Methoden der Biopsie werden diskutiert. Methodik: Rastermammographie (Fokus 0,3 mm) und hochaufl?sende Sonographie (7,5 bis 10 MHz) wurden bei Brustkrebspatientinnen eingesetzt. Ergebnisse: Der Zeitraum der aufgelisteten Patientinnen erstreckt sich über 20 Jahre. Die Zahl der DCIS hat in den letzten Jahren zugenommen und betr?gt nun 18%. Die Mammographie ist hoch sensitiv für Entdeckung von Mikrokalzifikationen. Die Spezifit?t ist gering. Schlu?folgerungen: Die Anzahl der entdeckten DCIS ist in den letzten Jahren besonders angestiegen und wird auch noch weiter bei Verbesserung der mammographischen Techniken ansteigen. Diese Studie wurde vom Ludwig-Boltzmann-Institut für radiologisch-physikalische Tumordiagnostik unterstützt.     

Effects of castration, exogenous testosterone and estrogen on endotoxin response in male rats

Using an experimental model of continuous endotoxin infusion, the effects of castration, testosterone and estrogen substitution on disseminated intravascular coagulation in male rats were investigated. Male rats which are not pretreated react in the same way to an endotoxin infusion as female animals, with an increase in free plasma hemoglobin, decrease of fibrinogen level, decrease of hematocrit and platelets and glomerular fibrin depositions. Different experimental groups of testectomized rats were pretreated with (i) 0.3 micrograms (pregnancy-conserving dose) or (ii) 30 micrograms ethinylestradiol (ovulation-suppression dose) or (iii) 250 mg testosterone. They were then compared to groups of animals treated with sesame oil as well as untreated group of rats. The pretreatment with testosterone and estrogens in the small-dose group had only an insignificant effect on the shock sequence. Only those animals which were treated with a high dose of estrogens showed a dramatic enhancement of their endotoxin sensitivity. It was also shown that in male animals an increased estrogen level might mediate a state of 'preparation', but testosterone does not 'prepare' castrated rats for the generalized Schwartzman reaction. The possible significance of enhancement of endotoxin toxicity by estrogens in explaining some pathophysiological characteristics of disseminated intravascular coagulation in pregnancy is discussed.