Multislice computed tomography to detect coronary stenosis among asymptomatic patients with cardiovascular risk factors and equivocal prior stress test: preliminary study

Multislice computed tomography (MSCT) is a non-invasive and validated technique to detect coronary stenoses. Some questions remain about its accuracy to detect coronary stenoses (CS), especially for asymptomatic patients (P) when a prior stress test isn't conclusive. METHODS: MSCT was performed among 45 asymptomatic men (mean age: 58,3 +/- 16), with a high ten year risk of fatal cardiovascular disease (SCORE 2003 data for low-risk regions of Europe), without any previous coronary history and with previous non conclusive exercise testing. When significant (> 50%) CS was suspected at MSCT, an angiocoronarography (AC) was done. RESULTS: Eighteen MSCT were normal, unsignificant CS (< 50%) were detected on 14 MSCT and significant coronary stenoses (SCS) for 13 P. Among this 13 P, 19 SCS were identified: 2 SCS of left main coronary artery (CA), 9 of the left descending CA, 6 of the right CA and 2 of the left circumflex CA. 13 CS were confirmed at AC. Finally, because of critical angiographic lesions +/- ischemia at nuclear tomoscintigraphy (NT), 9 P had coronary revascularization (7 catheter based, 2 surgical bypass), 4 P had medical treatment. DISCUSSION: Benefits of this preliminary study are obvious: 9 coronary revascularization/45 P. However, the place of MSCT for the screening of CS is uncertain, but may be usefull as a complement for the screening of coronary arterial disease.     

Retinal oximetry and fractal analysis of capillary maps in sickle cell disease patients and matched healthy volunteers

Graefe's Archive for Clinical and Experimental Ophthalmology - Fractal analysis can be used to quantitatively analyze the retinal microvasculature and might be a suitable method to quantify...     

The Effect of Sex-Mismatched Red Blood Cell Transfusion on Endothelial Cell Activation in Critically Ill Patients

BackgroundObservational studies suggest that sex-mismatched transfusion is associated with increased mortality. Mechanisms driving mortality are not known but may include endothelial activation. The aim of this study is to investigate the effects of sex-mismatched red blood cell (RBC) transfusions on endothelial cell activation markers in critically ill patients.Study Design and MethodsIn patients admitted to the intensive care unit who received a single RBC unit, blood samples were drawn before (T₀), 1 h after (T₁), and 24 h after transfusion (T₂₄) for analysis of soluble syndecan-1, soluble intercellular adhesion molecule-1, soluble thrombomodulin (sTM), von Willebrand factor antigen, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFα). Changes in the levels of these factors were compared between sex-matched and sex-mismatched groups.ResultsOf 69 included patients, 32 patients were in the sex-matched and 37 patients were in the sex-mismatched group. Compared to baseline, sex-matched transfusion was associated with significant reduction in sTM level (p value = 0.03). Between-group comparison showed that levels of syndecan-1 and sTM were significantly higher in the sex-mismatched group compared to the sex-matched group at T₂₄ (p value = 0.04 and 0.01, respectively). Also, TNFα and IL-6 levels showed a statistically marginal significant increase compared to baseline in the sex-mismatched group at T₂₄ (p value = 0.06 and 0.05, respectively), but not in the sex-matched group.DiscussionTransfusion of a single sex-mismatched RBC unit was associated with higher syndecan-1 and sTM levels compared to transfusion of sex-matched RBC unit. These findings may suggest that sex-mismatched RBC transfusion is associated with endothelial activation.     

Care-as-Worry, or "don't worry, be happy"

Care, or caring, is one of the central concepts in North American health science and nursing theories. Yet, experiential accounts of caring show dimensions of meaning that have received little attention in the literature. The author compares the meanings of the terms care and caring with their counterparts in other languages. He explores the significance of care-as-worry embedded in lived relations of caring and relates these concepts to ethical considerations surrounding health care. It is because of this felt "care-as-worry" that the life of care may be experienced as a complex moral-emotional relation of responsibility.     

Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2

A high delivered Kt/V(urea) (dKt/V(urea)) is advocated in the U.S. National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines on hemodialysis (HD) adequacy, irrespective of the presence of residual renal function. The contribution of treatment adequacy and residual renal function to patient survival was investigated. The Netherlands Cooperative Study on the Adequacy of Dialysis is a prospective multicenter study that includes incident ESRD patients older than 18 yr. The longitudinal data on residual renal function and dialysis adequacy of patients who were treated with HD 3 mo after the initiation of dialysis (n = 740) were analyzed. The mean renal Kt/V(urea) (rKt/V(urea)) at 3 mo was 0.7/wk (SD 0.6) and the dKt/V(urea) at 3 mo was 2.7/wk (SD 0.8). Both components of urea clearance were associated with a better survival (for each increase of 1/wk in rKt/V(urea), relative risk of death = 0.44 [P < 0.0001]; dKt/V(urea), relative risk of death = 0.76 [P < 0.01]). However, the effect of dKt/V(urea) on mortality was strongly dependent on the presence of rKt/V(urea), low values for dKt/V(urea) of <2.9/wk being associated with a significantly higher mortality in anuric patients only. Furthermore, an excess of ultrafiltration in relation to interdialytic weight gain was associated with an increase in mortality independent of dKt/V(urea). In conclusion, residual renal clearance seems to be an important predictor of survival in HD patients, and the dKt/V(urea) should be tuned appropriately to the presence of renal function. Further studies are required to substantiate the important role of fluid balance in HD adequacy.     

alpha-Galactosidase A deficiency in Dutch patients on dialysis: a critical appraisal of screening for Fabry disease.

INTRODUCTION: Fabry disease or alpha-galactosidase A (alpha-Gal A) deficiency is an X-linked lysosomal storage disorder that often leads to renal insufficiency in males and occasionally in females. The disease is rare, but its prevalence may be underestimated due to its variable clinical picture. Enzyme supplementation therapy with rHu-alphaGal A is currently available. Limited experience has so far shown that therapy may at best stabilize renal function. Despite these preliminary findings, much effort is being put into screening high-risk groups for undiagnosed alpha-Gal A deficiency. We studied the prevalence of alpha-Gal A deficiency in a Dutch dialysis cohort to establish possible underdiagnosis. We discuss the benefits of screening for Fabry disease. METHODS: Activity of alpha-Gal A in whole blood was measured in a group of 508 male Dutch dialysis patients. RESULTS: Of the 508 patients studied only one patient, already known with Fabry disease, had a alpha-Gal A deficiency, a prevalence of 0.22% (95 CI 0-1.1%). CONCLUSIONS: No undiagnosed Fabry patients were found, indicating that in our studied cohort there is no large-scale underestimation of its prevalence. Even though screening of dialysis patients for Fabry disease might identify patients who remain otherwise unrecognized, screening of high-risk populations for alpha-Gal A deficiency should be carried out with caution since long-term efficacy of treatment is currently unknown.     

A decision aid for men with early stage prostate cancer: theoretical basis and a test by surrogate patients

Background We developed a decision aid for patients with curable prostate cancer based on Svenson’s DiffCon Theory of Decision Making. This study was designed to determine if surrogate patients using the aid could understand the information presented, complete all tasks, show evidence of differentiation, and arrive at a preferred treatment choice. Methods Men, at least 50 years old and never diagnosed with prostate cancer, were recruited through local advertisements. Participants were asked to imagine that they were a case‐scenario patient. Then they completed the decision aid interview, which included three components: (i) information presentation, with comprehension questions, (ii) exercises to help identify attributes important to the decision, and (iii) value‐clarification exercises. Results Sixty‐nine men volunteered. They had a mean age of 61.2 (range 50–83) years, 37% had no formal education beyond high school, and 87% were living with a partner. All participants completed all aspects of the interview. They answered an average of 10 comprehension questions each, with a mean of 94.7% correct without a prompt. Each attribute in the information presented was identified by at least one participant as important to his decision. Participants identified a median of five attributes as important (ranges 1–14) at each of three points during the interview; 75% changed at least one important attribute during the interview. Forty‐nine per cent of participants also identified attributes as important that were not included in the presented information. Participants showed a wide range of values in each of seven trade‐off exercises. Eighty‐eight per cent of participants showed evidence of differentiation; 75% had a clear treatment preference by the end of the interview. Conclusions Our decision aid appears to meet its goals for surrogate patients and illustrates the strengths of the DiffCon theory. The ability of the aid to accommodate wide variability, both in information needs and in important attributes, is a particular strength of the decision aid. It now requires testing in patients with prostate cancer.     

Cefsulodin treatment for serious Pseudomonas aeruginosa infections

Cefsulodin, a narrow-spectrum cephalosporin with excellent antipseudomonal activity was used to treat 48 patients with 51 Pseudomonas aeruginosa infections. These included osteomyelitis, infected prostheses, post-operative and post-traumatic superficial wounds, decubitus and stasis ulcers, lower respiratory tract infections and infections of the urinary tract. Many of the patients were compromised by underlying debilitating conditions such as severe trauma, diabetes mellitus, vascular impairment, and abuse of alcohol and drugs. In cases of polymicrobial infections, a concomitant non-antipseudomonal antibiotic was sometimes administered. Cefsulodin was administered intravenously to 47 patients and by intramuscular injections to one individual. The dosage ranged from 0.5 to 2.0 g every six hr and duration of therapy was from 4 to 70 days. A satisfactory clinical response was observed in 88% of the patients. P. aeruginosa was eradicated from 76% of the infection sites. Failures, which included relapse within one year, were generally associated with prior severe trauma or vascular impairment in cases of osteomyelitis. Reinfections and superinfections developed in 12 individuals. Adverse reactions reported for two patients were nausea and vomiting. A third patient had transient increases in alkaline phosphatase and SGOT. These data indicate that cefsulodin is an effective and safe antibiotic in various types of P. aeruginosa infections.     

Treatment specifics for spontaneous pneumothorax in flight personnel

Spontaneous pneumothorax is one cause of aeronautical unfitness in flight personnel, because of the risk of recurrence in flight, making it an issue of flight safety. Specific treatment is required for fighter pilots, pilots flying single-pilot and pilots in professional training: surgical synthesis via video-thoracoscopy is obligatory from the first episode. Considering the exposure to an accumulation of aeronautical factors that are likely to encourage pneumothorax recurrence in flight, it is apical pleurectomy together with abrasion of the remaining pleura and resection of bullae/blebs that is required for fighter pilots to allow them to recover aeronautical fitness unrestrictedly. For all other categories of flight personnel, treatment is no different from that of the common patient. Knowledge of these treatment specifics is essential, to avoid unnecessary systematic surgical indication for all flight personnel, or jeopardise professional fitness in some of them due to inappropriate treatment.