Clinical and echocardiographic correlates of health status in patients with acute chest pain

Objective  To assess the ability of echocardiographic data to predict important functional status outcomes in patients with chest pain. Design  Prospective cohort study. Setting  A large, urban teaching hospital. Patients  Three hundred thirty-three patients admitted from the Emergency Department for evaluation of chest pain. Measurements and Main Results  Patients underwent two-dimensional and Doppler echocardiography as well as a face-to-face interview during their initial hospitalization and a telephone interview 1 year thereafter. The interview included the Medical Outcomes Study 36-Item Short Form (SF-36) health inventory, a generic health status instrument with a physical function subscale. The relation between clinical and echocardiographic factors and functional status was explored by univariable and multivariable linear regression and logistic regression analyses. Multiple clinical and echocardiographic factors correlated significantly with functional status measures at 1 year. For the SF-36 score at 1 year, age, male gender, white race, the presence of rales, and a comorbidity score were independently predictors in multivariate analysis; echocardiographic findings of severe left ventricular dysfunction (parameter estimate [PE] −27.6; 95% confidence interval [CI] −43.1, −12.2) and aortic insufficiency (PE −16.7; 95% CI −26.4, −7.0) added independent predictive information. Explanatory power (r ²) for models using clinical and demographic variables was .27 and increased after inclusion of echocardiographic data to an r ² of .35. Results in the subset of patients (n=148) with acute coronary syndromes such as unstable angina or myocardial infarction were qualitatively similar. Selected factors (rales on examination, electrocardiographic changes suggestive of ischemia, and moderate to severe mitral regurgitation) also predicted which patients would die or have a decline in their functional status. In multivariate analysis, only rales remained an independent predictor of poor outcome (odds ratio 2.4; 95% CI 1.2, 4.5). Conclusions  Echocardiographic data are correlated with measures of functional status in patients with chest pain, but the ability to predict future functional status from clinical or echocardiographic information is limited. Because functional status cannot be predicted adequately from either patients’ characteristics or echocardiographic testing, it must be assessed directly. Dr. Fleischmann is the recipient of a Clinical Investigator Development Award (IK08HL02964-01) from the National Heart, Lung and Blood Institute.     

Identification of a cellular polypeptide that distinguishes between acute lymphoblastic leukemia in infants and in older children

We analyzed the polypeptide pattern of leukemic cells of infants and older children with acute lymphoblastic leukemia (ALL), using two- dimensional polyacrylamide gel electrophoresis (PAGE). Patterns were analyzed for the occurrence of a previously detected cytosolic polypeptide, designated L3. Quantitative analysis of L3 in 12 infants and 91 older children with non-T ALL indicated lack of expression of polypeptide L3 in leukemic cells of infants which, in most cases, expressed HLA-DR and CD19 and lacked CD10. Quantitative analysis of L3 in relation to cell surface marker expression revealed that L3 was limited in its occurrence to non-T ALL and was not coordinately expressed with any of the surface markers included in the study. Among patients in the HLA-DR-positive, CD19-positive, and CD10-negative group, different levels of polypeptide L3 were observed between infants and older children. These results indicate differences in leukemic cell constituents between infants and older children with ALL and an otherwise similar cell surface marker phenotype.     

Amifostine (WR-2721) shortens the engraftment period of 4- hydroperoxycyclophosphamide-purged bone marrow in breast cancer patients receiving high-dose chemotherapy with autologous bone marrow support

4-Hydroperoxycyclophosphamide (4-HC), a commonly used marrow-purging agent, is active against many tumors, but is also toxic to normal marrow progenitors. Amifostine (WR-2721) is a sulfhydryl compound with chemoprotectant activity. Preclinical studies using suspensions of bone marrow and breast cancer cells demonstrated that ex vivo treatment with amifostine followed by 4-HC resulted in protection of marrow progenitors, with no compromise in the antitumor effect of 4-HC. This fact stimulated the development of a clinical trial. Bone marrow was harvested from 15 poor-prognosis breast cancer patients and randomly assigned to ex vivo treatment with amifostine followed by 4-HC (amifostine + 4-HC), or treatment with 4-HC alone. High-dose chemotherapy was then administered followed by infusion of the purged autologous bone marrow support (ABMS). Leukocyte engraftment, defined as a white blood cell count > or = 1 x 10(9)/L, was achieved in an average of 26 days for patients whose marrow was purged with amifostine + 4-HC versus 36 days for patients whose marrow was purged with 4-HC alone (P = .032). The average number of platelet transfusions (12 v 29; P = .017) and days of antibiotic therapy (28 v 40; P = .012) were significantly less for patients whose marrow was exposed to amifostine + 4-HC, compared with 4-HC alone. Unpurged backup marrow fractions were infused into three patients whose marrow was purged with 4-HC alone, because of inadequate marrow recovery. None of the patients who received amifostine + 4-HC-purged marrow required a backup marrow fraction. Complete remissions were achieved in 83% of patients with measurable disease, with no difference between the two cohorts. Forty- three percent of patients remained alive and progression-free at a mean of 13 months posttransplant. There was no significant difference in the rate or pattern of relapse for patients whose marrow was purged with amifostine + 4-HC compared with those whose marrow was purged with 4-HC alone. Ex vivo treatment of marrow with amifostine significantly shortens the time to marrow recovery, thereby reducing the risk of myelosuppressive complications in breast cancer patients receiving high- dose chemotherapy and 4-HC-purged ABMS. Since supportive care requirements are also significantly decreased, amifostine may reduce the cost of such therapy.     

Additive effect of alfacalcidol on bone mineral density of the lumbar spine in Taiwanese postmenopausal women treated with hormone replacement therapy and calcium supplementation: a randomized 2-year study

OBJECTIVE: To evaluate the effect of 1alpha-hydroxyvitamin D3 on bone mineral density of the lumbar spine in postmenopausal women receiving hormone replacement therapy and calcium supplement. DESIGN: A randomized, prospective 2-year clinical trial. PATIENTS AND MEASUREMENTS: A total of 240 postmenopausal women were enrolled with randomized assignment of 120 patients to each treatment group (the D + E group of 1alpha-hydroxyvitamin D3 + sequential combined HRT + calcium supplement; the E group: sequential combined HRT + calcium supplement). None of the patients had received HRT for menopausal syndrome or osteoporosis before being enrolled in our study. Serum biochemical assays, electrolytes and calcitonin were performed at baseline and after 6 and 12 months of treatment. Bone mineral density (BMD) of L2-L4 was measured by dual energy X-ray absorptiometry (DXA) at the initial assessment and after 12 and 24 months of treatment. RESULTS: One hundred and five patients (87.5%) in the D + E group and 92 patients (76.7%) in the E group completed the first 1-year study. Ninety-six patients (80%) in the D + E group and 80 patients (66.7%) in the E group completed the 2-year trial. Renal function, liver function, electrolytes and calcitonin showed no significant changes during the first year of follow-up. In the D + E group, the BMD of L2-4 increased 3.24 +/- 0.32% from baseline after 1 year (P < 0.05) and 5.32 +/- 0.23% after 2 years of treatment (P < 0.05). On the other hand, the changes of BMD in the E group were 1.12 +/- 0.34% after 1 year (P < 0.05) and 2.42 +/- 0.26% after 2 years of treatment (P < 0.05). The changes of BMD of L2-L4 of the D + E group were higher than the changes of the E group after both 1 and 2 years of treatment (P < 0.05). CONCLUSIONS: Our study demonstrated that combination of 1alpha-hydroxyvitamin D3 with HRT is superior to HRT alone for the preservation of bone mineral density in postmenopausal women under calcium supplementation.     

Diagnosing delirium by telephone

To determine whether delirium can be diagnosed by telephone, we interviewed 41 subjects aged 65 years or older 1 month after repair of hip fracture, first by telephone and then face-to-face. Interviews included the modified telephone Mini-Mental State Examination and the Delirium Symptom Interview. Delirium was diagnosed using the Confusion Assessment Method diagnostic algorithm, and the telephone results were compared with the face-to-face results (the "gold standard"). Of 41 subjects, 6 were delirious by face-to-face assessment; all 6 were delirious by telephone (sensitivity 1.00). Of 35 patients not delirious by face-to-face assessment, 33 patients were not delirious by telephone (specificity = 0.94). We conclude that telephone interviews can effectively rule out delirium, but the positive diagnosis should be confirmed by a face-to-face assessment, especially in populations with a low prevalence of delirium.     

A brief report on the normal range of forehead temperature as determined by noncontact, handheld, infrared thermometer

BACKGROUND: Noncontact forehead temperature measurement by handheld infrared thermometer was used as a screening tool for fever. However, the accuracy data and normal range of forehead temperature determined by this method were not available. METHODS: The temperature readings from 3 handheld infrared thermometers were validated against an electronic thermometer. Normal range of forehead temperature was determined by measuring the forehead temperature in 1000 apparently healthy subjects. RESULTS: Significant differences were detected in readings obtained by the 3 different handheld infrared thermometers (analysis of covariance, P < .001) The most accurate one was chosen, and the normal range of forehead temperature in 1000 subjects detected by this method was 31.0 degrees C to 35.6 degrees C. CONCLUSIONS: Our study shows that commercially available, handheld infrared thermometers require individual validation. Forehead temperature in excess of 35.6 degrees C is suggestive of fever. Further studies are required to confirm accuracy of this value in detecting fever.     

Lung findings on high-resolution computed tomography in idiopathic ankylosing spondylitis--correlation with clinical findings, pulmonary function testing and plain radiography

Previous studies on the association of ankylosing spondylitis and abnormalities of the lung parenchyma have been based largely on plain radiography and pulmonary function testing. This study, although uncontrolled, is the first to use high-resolution computed tomography to examine the entire lung parenchyma in ankylosing spondylitis patients, and to correlate the findings with clinical assessment, plain radiography and pulmonary function testing. The study population comprised 26 patients meeting the New York criteria for idiopathic ankylosing spondylitis who attended the out-patient department at our institution. High-resolution computed tomography examination revealed abnormalities in 19 patients (70%): these included interstitial lung disease (n = 4), bronchiectasis (n = 6), emphysema (n = 4), apical fibrosis (n = 2), mycetoma (n = 1) and non-specific interstitial lung disease (n = 12). Plain radiography was abnormal in only four patients and failed to identify any patient with interstitial lung disease. All patients with interstitial lung disease on high-resolution computed tomography had respiratory symptoms and three of the four had evidence of a restrictive process on pulmonary function testing. This study raises, for the first time, the possible association between interstitial lung disease and ankylosing spondylitis, and highlights the use of high-resolution computed tomography in detecting such disease in ankylosing spondylitis patients.      

Segregation of human T cell lymphotropic virus type I and II infections by antibody reactivity to unique viral epitopes.

A recombinant protein of the human T cell lymphotropic virus type I (HTLV-I) gp46 outer membrane envelope, MTA-4 (residues 129-203), reacted by Western blot with sera from HTLV-I-infected individuals from the United States and Jamaica but not with 24 (10%) of 242 Japanese sera. A related gp46 recombinant protein, MTA-1 (residues 162-209), reacted with all 58 sera from HTLV-I-infected US and Jamaican individuals and 238 of 242 sera from infected Japanese (combined sensitivity of 99%). Neither recombinant showed reactivity to sera from HTLV-II-infected individuals or uninfected controls. The reactivity of recombinant proteins containing the region of HTLV-II gp46 analogous to MTA-1 was also evaluated by Western blot: GH2-K15 (residues 157-205) and GH2-K55 (residues 162-205) reacted with 88 (98%) and 89 (99%), respectively, of 90 sera from HTLV-II-infected individuals but not with sera from HTLV-I-infected individuals or uninfected controls. These recombinant proteins should permit the development of assays to unambiguously confirm and differentiate HTLV-I and HTLV-II infections.     

Transcatheter closure of patent ductus arteriosus in Chinese adults: immediate and long-term results

BACKGROUND: Transcatheter closure of patent ductus arteriosus (PDA) has been established as a safe and effective treatment for pediatric patients. However, long-term experience in adults remains limited. Therefore, our purpose is to report our experience with this approach in Chinese adults. METHODS: Twenty-five patients (mean age, 34 years) who underwent transcatheter closure of PDA in a tertiary cardiology center in Hong Kong were recruited. RESULTS: The mean PDA diameter measured by angiogram was 3.1 mm (range, 1.3 6.6 mm) and the mean pulmonary-to-systemic shunt was 1.65 (range, 1.3 1.8). All procedures were performed under local anesthesia. The average procedure and fluoroscopy times were 54 14 minutes and 14 4 minutes, respectively. The mean period of hospitalization was 4 days (range, 3 5 days). Immediate, one-month and late success rates were 96%, 92% and 84%, respectively. CONCLUSIONS: Percutaneous closure of PDA in adults is a safe and feasible procedure. It should be a reasonable alternative for adult patients who are either not fit for open-chest surgery or who prefer a less invasive approach.