Black breast milk due to minocycline therapy

Summary We report the unusual case of a 29-year-old female who developed black discoloration of breast milk 3 weeks after commencing oral minocycline therapy for acne vulgaris. Histochemical analysis of the breast milk revealed the presence of pigment particles within macrophages with iron staining characteristics. We propose that the pigment may represent an iron chelate of minocycline or one of its derivatives.     

A KELLOGG FOUNDATION INITIATIVE: COMMUNITY PARTNERSHIPS — SOUTH AFRICA

Health personnel education in South Africa is currently directed towards preparation for work in tertiary care settings, is highly specialized, and segmented racially. The majority of South Africans are in desperate need of primary health care services. In preparing for transition to a future South Africa, a community-partnership effort is in its initial stages to redress this imbalance.     

Management and outcomes of lower risk patients presenting with acute coronary syndromes in a multinational observational registry

OBJECTIVE: To document patterns of risk stratification, management practices, and outcomes among patients with acute coronary syndromes (ACS) presenting without high risk features. PATIENTS: The study was based on 11,885 consecutive patients presenting with non-ST segment elevation ACS enrolled in GRACE (global registry of acute coronary events). Patients without dynamic ST segment changes, positive troponin (or other cardiac markers), or haemodynamic or arrhythmic instability were defined as being at lower risk. MAIN OUTCOME MEASURES: Management and outcomes were compared with high risk presentations. RESULTS: Of 11,885 patients presenting with unstable angina or non-ST segment elevation myocardial infarction, 4252 (36%) were regarded as being at lower risk. Functional testing for risk stratification was performed in 1163 of 4207 (28%) lower risk and 1531 of 7521 (20%) high risk patients (p < 0.0001). Coronary angiography was performed in 1930 of 4190 (46%) and 3860 of 7544 (51%), and echocardiography in 1692 of 4190 (40%) and 4348 of 7533 (58%) of lower risk and high risk patients, respectively (p < 0.0001 for both). Over one third of patients did not undergo further risk assessment with angiography or functional testing (2746 of 7437 (37%) high risk, 1499 of 4148 (36%) lower risk, not significant). Death occurring in hospital was more likely in the high risk cohort (41 of 4227 (1.0%) lower risk v 215 of 7586 (2.8%) high risk, p < 0.0001), whereas rates of recurrent angina during admission and readmission were similar in both groups (1354 of 4231 (32%) high risk, 2313 of 7587 (31%) lower risk, not significant). In the six months after discharge, death or myocardial infarction occurred in 79 of 3223 (2.5%) lower risk patients and 302 of 5451 (5.5%) high risk patients (p < 0.0001). CONCLUSIONS: Globally, further risk stratification after ACS presentation is suboptimal, regardless of presenting characteristics. Although in-hospital death and myocardial infarction are uncommon, recurrent ischaemia is encountered often in both groups. It remains to be seen whether better outcomes may be achieved with wider application of risk stratification and appropriately directed management strategies.     

Grade variation in the rheology of white soft paraffin B.P.

The rheology of six grades of white soft paraffin B.P. at 25° has been investigated using continuous shear viscometry and a creep viscometer. Temperature effects between 25° and 50° have been measured in continuous shear, and activation energies from 14·0 to 25·3 k cal mol^?1 (58·6 to 105·9 k J mol^?1) have been determined. Working the samples on a triple roller mill at 25° was found to decrease the apparent viscosity and, initially, to increase the yield stress. Five of the grades were linear viscoelastic, one was non-linear viscoelastic. The nature of ductility and its relation to measured rheological parameters have been discussed. Creep viscometry data gave a better correlation with the manufacturer's data than did continuous shear measurements.     

A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry

Context  Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy. Objective  To develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS. Design, Setting, and Patients  A multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge. From 17 142 patients presenting with an ACS from April 1, 1999, to March 31, 2002, and discharged alive, 15 007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients admitted from April 1, 2002, to December 31, 2003. Main Outcome Measure  All-cause mortality during 6 months postdischarge after admission for an ACS. Results  The 6-month mortality rates were similar in the development (n = 717; 4.8%) and validation cohorts (n = 331; 4.7%). The risk-prediction tool for all forms of ACS identified 9 variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram, and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively. Conclusions  The GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS. Clinicians may find it simple to use and applicable to clinical practice.      

CORRESPONDENCE

Letters to the Editor are weIconied for Publication (subject to editing). Letters must be signed by all authors, typewritten double spaced, and mast not exceed two pages of text including references. Two copies of all Ietters sbonld be submitted. Letters should not duplicate material submitted to or published in other journals. Re-publication proofs will not be provkled.     

Acute Success of Cryoablation of Left-Sided Accessory Pathways: A Single Institution Study

Objective: To compare the acute success and recurrence rate of cryoablation for left-sided accessory pathways (AP) with controls who underwent radiofrequency ablation (RFA) at the same institution.
Background: Catheter cryoablation of supraventricular tachycardia (SVT) is considered to be a safer alternative a compared with RFA. At our institution, cryoablation has become the primary interventional modality for all APs. The reported success rates of cryoablation for AP-mediated tachycardia have generally been less favorable than for RFA. However, the location of AP may influence cryoablation outcome. Furthermore, there are little data available on cryoablation of left-sided pathways.
Methods: A chart review was performed for all patients undergoing cryoablation between August 2005 and August 2007. Twenty-nine patients (mean age 13 years, range 6–18 years) were identified with SVT secondary to left-sided AP. The data collected included patient age, height, weight, date of procedure, mapping, ablation and procedure time, pathway location, success, and recurrence. Cryoablation was performed via a transseptal approach. Procedural success and recurrence rate were compared with our most recent 28 patients undergoing RFA ablation.
Results: Procedural success was achieved in 97% of patients in the cryoablation group, compared with 100% in the RFA control group. Recurrence rate in the cryoablation group was 1 of 24 (4.2%) patients compared with 4 of 28 (14%) patients in the RFA group over 12 months.
Conclusion: Cryoablation can be safely and effectively used in the treatment of left-sided AP. Long-term outcomes remain to be seen.