Prognostic Value of Electrocardiography in Elderly Patients with Acute Pulmonary Embolism

BackgroundElectrocardiographic (ECG) signs of right ventricular strain could be used as a simple tool to risk-stratify patients with acute pulmonary embolism.MethodsWe studied consecutive patients aged ≥ 65 years with acute pulmonary embolism in a prospective multicenter cohort study. Two readers independently analyzed 12 predefined ECG signs of right ventricular strain in all patients. The outcome was the occurrence of an adverse clinical event, defined as death from any cause within 90 days or a complicated in-hospital course. We determined the interrater reliability for each ECG sign and examined the association between right ventricular strain signs and adverse events using logistic regression, adjusting for the Pulmonary Embolism Severity Index and cardiac troponin.ResultsOverall, 320/390 patients (82%) showed at least one ECG sign of right ventricular strain. The interrater reliability for individual ECG signs was highly variable (? 0.40-0.95). Patients with ≥ 1 of the 3 classic signs of right ventricular strain (S1Q3T3, right bundle branch block, or T wave inversions in V1-V4) had a higher incidence of adverse events than those without (13% vs 6%; P = .026). After adjustment, the presence of ≥ 1 of the 3 classic signs of right ventricular strain (odds ratio 2.11; 95% confidence interval, 1.00-4.46) and the number of right ventricular strain signs present were significantly associated with adverse events (odds ratio 1.35 per sign; 95% confidence interval, 1.08-1.69).ConclusionsECG signs of right ventricular strain are common in elderly patients with acute pulmonary embolism. Although such signs may have prognostic value, their variable reliability and the rather modest prognostic effect size may limit their usefulness in the risk stratification of pulmonary embolism.     

Prevalence of pfcrt mutations in Congolese and Malawian Plasmodium falciparum isolates as determined by a new Taqman assay

A real-time PCR assay was developed to detect the K76T point mutation in the Plasmodium falciparum putative chloroquine resistance transporter gene. The assay was used with malaria positive clinical isolates from Rutshuru in the eastern part of the Democratic Republic of the Congo (DRC) and from Malawi. The K76T mutation was found in 52/56 (93%) clinical isolates from the DRC, where chloroquine resistance is high, but in none of the 12 isolates tested from Malawi where chloroquine is now rarely used. Sixteen percent of specimens from the DRC had detectable levels of both wild-type and mutant alleles. The real-time PCR results were compared to results from a nested allele-specific PCR assay and from direct DNA sequencing. Using allele-specific PCR as the reference method, the new assay is 100% sensitive and specific towards the mutant allele. In addition to its low per-test cost, the new assay is fast, easily automated, sensitive and well-suited to large-scale epidemiological studies.     

Cardiovascular and endocrine profile of adrenergic neurone blockade in normal and hypertensive man.

Some cardiovascular and endocrine effects of adrenergic blockade were assessed in six normal subjects, six patients with mild hypertension (diastolic pressure < 100 mm Hg) and six patients with moderate to severe essential hypertension. Administration of the inhibitory agent, debrisoquine, for six weeks markedly decreased supine and upright plasma norepinephrine levels, and norepinephrine excretion in all three groups. Supine and upright blood pressure was decreased more (p < 0.001) in those with moderate to severe hypertension (15 and 27 per cent) than in those with mild hypertension (6 and 8 per cent) and remained unchanged in normal subjects. Pulse rate and plasma renin levels were lowered (p <0.01) in patients with moderate to severe hypertension, but not in normal or mildly hypertensive subjects. The different influence of blood pressure, pulse rate and renin in the three groups could not be explained by variations in drug dosage, norepinephrine inhibition, age, basal sodium balance or secondary blood volume expansion, the latter being marked in all groups. Diuretic therapy in addition to sympathetic inhibition reversed blood volume expansion, and further augmented the reduction in supine and upright blood pressure in patients with moderate to severe (?21 and ?47 per cent) or mild hypertension (?8 and ?12 per cent). Plasma aldosterone, cortisol and epinephrine values remained unchanged, and no severe or intolerable side effects occurred during treatment. These data suggest that adrenergic neuron blockade with modest doses of debrisoquine, combined with a diuretic, may be an effective and acceptable mode of therapy in patients with either mild or more severe hypertension. The hypotensive, cardiac-slowing and renin-inhibitory potential of adrenergic neuron blockade may be initiated by decreased norepinephrine outflow and modulated by variations in end-organ responsiveness, normal subjects being relatively insensitive and patients with essential hypertension being more sensitive as the severity of their hypertension increases.     

Clinical assessment of fractured implant abutment screws: The Bernese silicone replica technique

Fractured implant abutment screws can be retrieved with repair or rescue devices. However, whether the screw was completely retrieved or the inner implant body was damaged may be uncertain. A silicone replica technique was recently implemented in Bern and may be the most predictable method available at the moment for clinically assessing the internal implant body. This technique is straightforward and precise and may help dentists determine the internal implant condition when managing a fractured screw.     

Routine opioid outcome monitoring in community pharmacy: Pilot implementation study protocol

BackgroundIncreases in opioid use and related harms such as mortality are occurring in many high income countries. Community pharmacists are often in contact with patients at risk of opioid-related harm and represent an ideal point for intervention. Best practice in monitoring opioid-related outcomes involves assessing analgesia, pain functioning, mood, risks and harms associated with opioid use. Community pharmacists are well-placed to undertake these tasks.ObjectivesOur pilot study will test the implementation of a computer-facilitated screening and brief intervention (SBI). The SBI will support pharmacist identification of opioid-related problems and provide capacity for brief intervention including verbal reinforcement of tailored information sheets, supply of naloxone and referral back to the opioid prescriber. The SBI utilises software that embeds study procedures into dispensing workflow and assesses opioid outcomes with domains aligned with a widely accepted clinical framework.MethodsWe will recruit and train 75 pharmacists from 25 pharmacies to deliver the Routine Opioid Outcome Monitoring (ROOM) SBI. Pharmacists will complete the SBI with up to 500 patients in total (20 per pharmacy). Data will be collected on pharmacists’ knowledge and confidence through pre- and post-intervention online surveys. Data on feasibility, acceptability and implementation outcomes, including naloxone supply, will also be collected.Project impactOur study will examine changes in pharmacists’ knowledge and confidence to deliver the SBI. Through the implementation pilot, we will establish the feasibility and acceptability of a pharmacist SBI that aims to improve monitoring and clinical management of patients who are prescribed opioids.     

Changes in renal function in essential hypertension

Studies of renal hemodynamics, plasma renin activity (PRA), plasma aldosterone, and water and sodium excretion were performed in 171 patients with essential hypertension and 61 normotensive subjects. The para-amino hippurate clearance (C_PAH) was usually normal or moderately reduced in those with benign hypertension and markedly depressed in those with malignant hypertension. The PAH extraction ratio was normal or slightly reduced in the patients with benign hypertension and moderately impaired in those with low C_PAH indicating that a disproportionate decrease in cortical flow occurred only in the latter. The c_pah did not correlate Inversely with the mean blood pressure in the patients with benign hypotension. Reexamination of untreated patients after an average of 28 $\text{1}\text{2}$ months revealed a decrease in renal plasma flow but no further increase in blood pressure. These findings suggest that in uncomplicated hypertension the increase in blood pressure is not caused by renal circulatory disturbances.PRA was unrelated to renal hemodynamics in benign hypertension. In malignant hypertension, it was inversely correlated with the renal plasma flow. Under mild loading with isotonic saline solution, the fractional water excretion correlated with the blood pressure. Sodium excretion was neither related to the blood pressure nor to the estimated peritubular oncotic pressure, but correlated inversely with plasma aldosterone. These observations provide no support for the causative role of a primary disturbance in sodium excretion in essential hypertension.     

The Slavcleft: A three-center study of the outcome of treatment of cleft lip and palate. Part 2: Dental arch relationships

PurposeOur aim was to evaluate the dental arch relationship in a preadolescent Slavic population with unilateral cleft lip and palate (UCLP) by using the Goslon Yardstick.Materials and methodsPatients treated in Warsaw, Poland (n = 32), Prague, Czech Republic (n = 33) and Bratislava, Slovakia (n = 30) were included in this retrospective study. Each cleft center used a unique surgical protocol. Three raters scored blindly the dental arch relationship on plaster models. Intra- and inter-rater agreement were assessed with kappa statistics, and differences between the groups were evaluated with one-way analysis of variance. Intra-rater agreement was very good (k > 0.825), while inter-rater agreement was either good or very good (kappa >0.703).ResultsWe found that patients treated in Warsaw showed a more favorable dental arch relationship (Goslon score = 2.58, SD = 0.77) than patients treated in Prague (Goslon score = 3.21, SD = 1.04). Patients treated in Bratislava showed an intermediate Goslon score (3.07; SD = 0.99).ConclusionThis study showed that the dental arch relationships in patients treated in Warsaw with a one-stage repair were more favorable than in patients treated in Prague and Bratislava with a two-stage protocol and comparable to the best results obtained in the Eurocleft and Americleft studies.     

PPAR-β/δ agonists for Type 2 diabetes and dyslipidemia: an adopted orphan still looking for a home

Background: The identification of small molecule agonists for the nuclear receptor peroxisome proliferator-activated receptor beta/delta (PPAR-β/δ, NR1C2) has enabled the characterization of this receptor's functions in preclinical models. Subsequently, a number of small molecule agonists of PPAR-β/δ have been progressed into clinical trials. Objective: This review will examine the major preclinical findings that underpin the hypothesis that PPAR-β/δ agonists may be beneficial in treating dyslipidemia and Type 2 diabetes, as well as emerging clinical data with a variety of PPAR-β/δ agonists. Methods: The literature concerning preclinical experiments that combine in vivo and in vitro mechanistic studies are reviewed and compared with the results of the early clinical trials. Conclusions: Thus far, the activities of the agonists seen in the clinic are broadly similar to those seen in preclinical models. However, it is still not known if PPAR-β/δ agonists will truly be differentiated enough from current treatments to justify their use in treating dyslipidemia or Type 2 diabetes. Major challenges for the development of PPAR-β/δ agonists exist and the path forward is as yet undefined.