Optimal measuring point for ST deviation in chest pain patients with possible acute coronary syndrome.

INTRODUCTION: In the ECG, significant ST elevation or depression according to specific amplitude criteria can be indicative of acute coronary syndrome (ACS). Guidelines state that the ST amplitude should be measured at the J point, but data to support that this is the optimal measuring point for ACS detection is lacking. We evaluated the impact of different measuring points for ST deviation on the diagnostic accuracy for ACS in unselected emergency department (ED) chest pain patients. MATERIAL AND METHODS: We included 14,148 adult patients with acute chest pain and an ECG recorded at a Swedish ED between 2010 and 2014. ST deviation was measured at the J point (STJ) and at 20, 40, 60 and 80 ms after the J point. A discharge diagnosis of ACS or not at the index visit was noted in all patients. RESULTS: In total, 1489 (10.5%) patients had ACS. ST amplitude criteria at STJ had a sensitivity of 28% and a specificity of 92% for ACS. With these criteria, the highest positive and negative predictive values for ACS were obtained near the J point, but the optimal point varied with ST deviation, age group and sex. The overall best measuring points were STJ and ST20. CONCLUSIONS: This study indicates that the diagnostic accuracy of the ECG criteria for ACS is very low in ED chest pain patients, and that the optimal measuring point for the ST amplitude in the detection of ACS differs between ST elevation and depression, and between patient subgroups.

Peripheral venous lactate at admission is associated with in-hospital mortality, a prospective cohort study.

BACKGROUND: The prognostic value of blood lactate as a predictor of adverse outcome in the acutely ill patient is unclear. The aim of this study was to investigate if a peripheral venous lactate measurement, taken at admission, is associated with in-hospital mortality in acutely ill patients with all diagnosis. Furthermore, we wanted to investigate if the test improves a triage model in terms of predicting in-hospital mortality. METHODS: We retrieved a cohort of 2272 adult patients from a prospectively gathered acute admission database. We performed regression analysis to evaluate the association between the relevant covariates and the outcome measure: in-hospital mortality. RESULTS: Lactate as a continuous variable was a risk for in-hospital mortality with an odds ratio (OR) of 1.40 [95% confidence interval (CI) 1.25-1.57, P<0.0001]. OR for in-hospital mortality increased with increasing lactate levels from 2.97 (95% CI 1.55-5.72, P<0.001) for lactate between 2 mmol/l and 4 mmol/l, to 7.77 (95% CI 3.23-18.66, P<0.0001) for lactate>4 mmol/l. If the condition was non-compensated (i.e. pH<7.35), OR for in-hospital mortality increased to 19.99 (7.26-55.06, P<0.0001). Patient with a blood lactate at 4 mmol/l or more had a risk of in-hospital mortality equivalent to the patients in the most urgent triage category. CONCLUSION: We found elevated admission peripheral venous lactate to be independently associated with in-hospital mortality in the acutely ill patient admitted to the emergency department. Patients with a lactate>4 mmol/l at hospital admission should be considered triaged to the most urgent triage category.

New methods for improved evaluation of patients with suspected acute coronary syndrome in the emergency department.

This paper aims to identify and review new and unproven emergency department (ED) methods for improved evaluation in cases of suspected acute coronary syndrome (ACS). Systematic news coverage through PubMed from 2000 to 2006 identified papers on new methods for ED assessment of patients with suspected ACS. Articles found described decision support models, new ECG methods, new biomarkers and point-of-care testing, cardiac imaging, immediate exercise tests and the chest pain unit concept. None of these new methods is likely to be the perfect solution, and the best strategy today is therefore a combination of modern methods, where the optimal protocol depends on local resources and expertise. With a suitable combination of new methods, it is likely that more patients can be managed as outpatients, that length of stay can be shortened for those admitted, and that some patients with ACS can get earlier treatment.

New methods for improved evaluation of patients with suspected acute coronary syndrome in the emergency department.

This paper aims to identify and review new and unproven emergency department (ED) methods for improved evaluation in cases of suspected acute coronary syndrome (ACS). Systematic news coverage through PubMed from 2000 to 2006 identified papers on new methods for ED assessment of patients with suspected ACS. Articles found described decision support models, new ECG methods, new biomarkers and point-of-care testing, cardiac imaging, immediate exercise tests and the chest pain unit concept. None of these new methods is likely to be the perfect solution, and the best strategy today is therefore a combination of modern methods, where the optimal protocol depends on local resources and expertise. With a suitable combination of new methods, it is likely that more patients can be managed as outpatients, that length of stay can be shortened for those admitted, and that some patients with ACS can get earlier treatment.

Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community.

Despite reports of high prevalence of human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) among the transgender community, very little prevention education has targeted this population. To fill this gap, we developed and evaluated a transgender-specific intervention, All Gender Health, which incorporates prevention strategies into comprehensive sexuality education. Transgender participants (N=181) attended the two-day seminar in community-based venues. The curriculum was delivered via lectures, panel discussions, videos, music, exercises and small group discussions. Attitudes toward condom use, safer sex self-efficacy and sexual risk behaviour were evaluated before participation in the intervention (pre-test), immediately after participation (post-test) and at three-month follow-up. Compared to pre-test values, significant improvements were seen in attitudes toward condom use and in safer sex self-efficacy at post-test, and in attitudes toward condom use, increased monogamy and decreased sexual risk behaviour at three-month follow-up. Pre-test data identified unprotected anal, vaginal and oral sex as the most commonly reported risk behaviours. Many respondents also indicated problems with social discrimination, depression, suicidal ideation and sexual functioning. Future interventions should address these risk co-factors. Alternative interventions need to be developed to target those who, as a result of social marginalization, are less likely to be reached with an intensive seminar-based intervention.

Human alpha2-macroglobulin: genotype-phenotype relation.

A pentanucleotide deletion polymorphism in the gene of alpha2-macrolgobulin (alpha2-M) is suggested to be associated with late-onset Alzheimer's disease (AD), though controversial results have been reported. The underlying assumption is that the intronic pentanucleotide deletion may affect the biological function and quantity of the inhibitor and thus contribute to the AD pathology. In the present study we have analyzed the distribution of the deletion polymorphism within a group of 227 healthy Caucasians. In parallel studies, we determined the plasma concentrations of total and transformed alpha2-M. A strong correlation of the total concentration of alpha2-M with age was ascertained (r(s) = -0.54, P < 0.001). However, no significant correlation between age and the genotypes (P = 0.68) was detected, and no statistically significant effect of the genotype on the concentrations of total and transformed alpha2-M was found (P = 0.49 and 0.96, respectively). A significant correlation was observed between total and transformed alpha2-M in the genotype groups Ins/Ins (r(s) = 0.56, P < 0.001) and Ins/Del (r(s) = 0.35, P < 0.004). Furthermore, in the entire data set, a significantly elevated concentration of total alpha2-M was found in females as compared to males (P = 0.003). There was a slight but nonsignificant difference in the genotype distributions between males and females (P = 0.14). To test the proposed existence of genotype-specific alterations of functional properties of alpha2-M, we isolated alpha2-M from the plasma of carriers with different genetic background and analyzed the alpha2-M subunit structure as well as the binding of the inhibitor to growth factors/cytokines, to amyloid-beta and to the receptor. The experiments failed to reveal any genotype-specific functional alterations of the alpha2-M. The absence of abnormalities in alpha2-M mRNA and protein suggests that the alpha2-M deletion polymorphism is probably not associated with functional deficiencies important in AD pathology. However, it can be speculated that the observed general age-related alpha2-M deficiency may lead to accelerated accumulation of amyloid-beta, which might be relevant to AD pathology.

Prevalence of Chlamydia specific antibodies among obstetric and gynecological outpatients in Gondar, north-west Ethiopia.

A total of 533 obstetric and gynecological outpatients who visited the dedicated clinics in Gondar, Ethiopia, between April and August 1995 were investigated for Chlamydia-specific antibodies. Relevant epidemiological and clinical data were collected using a pretested questionnaire, clinical examinations and laboratory tests. Earlier, using an antigen specific ELISA technique, we had reported that only 33 (6%) of these women were positive for C. trachomatis in cervical swabs. In this study, we evaluated the prevalence of C. trachomatis-specific antibodies in serum samples of the same patients collected at the time the cervical swabs were taken. Employing a genus-specific ELISA for the detection of chlamydial LPS antibodies, 90% of the sera were found to be positive for IgG, while 49% of the sera contained IgA and 28% IgM antibodies. For 436 of the positive sera, species specificity of the antibodies was determined by means of a micro-immunofluorescence assay. Antibodies against C. trachomatics were present in 75% and antibodies against C. pneumoniae in 69% of these sera. Forty-nine percent of the patients carried antibodies against both species. The antibody based assay estimated that 13.9% of the patients had acute genital chlamydial infection (antigen specific IgM and the simultaneous presence of C. trachomatis specific IgG, IgM and IgA). C. trachomatis antigen detection in cervical swabs apparently underestimated the real frequency of acute infections. Seroprevalence of C. pneumoniae antibodies in the Ethiopian patients was similar to that in industrialized countries.

[Effect of pregnancy and perinatal parameters--including mode of delivery--on survival rate of "low birth weight premature infants" (less than 1,500 g)]. / Der Einfluss von Schwangerschafts- und perinatologischen Parametern--einschliesslich Entbindungsmodus--auf die Uberlebensrate "kleiner Frühgeborener" (less than 1500 g).

A retrospective analysis of 225 very low birth weight infants (less than 1500 g) was made, to assess the influence of the mode of delivery on the survival rate. In 186 preterm deliveries which could not be prevented by therapeutic measures, we included additionally certain gestational and perinatological parameters. Generally, an average survival rate of 72% was found in this study. In addition to the well-known negative influence of birth weight less than 1000 g and gestational age of less than 28 weeks, such parameters as antenatal pre-pathological CTG findings, haemorrhages at the time of hospitalisation, and ineffectuousness of tocolytic drugs, were associated with a reduced survival rate. In contrast, the presence of anamnestic risk factors of preterm delivery and prolongation of gestation by one day and more improved the survival rate. Additional consideration of foetal presentation showed, that abdominal delivery was fundamentally safer in cases with breech and transverse presentation. Whether a higher survival rate can be achieved by vaginal delivery in cases of breech presentation with premature rupture of membranes or a gestational age greater or equal to 28 weeks, remains to be proved. A gestational age of less than 28 weeks or antenatal prepathological cardiotocographic findings will facilitate in future the decision to perform Cesarean section in cases of inevitable premature deliveries with cephalic presentation.

[Fetal systolic time intervals in threatened premature labor and their relation to therapeutic efforts]. / Fetale systolische Zeitintervalle bei drohender Frühgeburt und deren Abhängigkeit von therapeutischen Bemühungen.

In a total of 113 single pregnancies we determined foetal systolic time intervals (pre-ejection period, left ventricular ejection time, a quotient of both) in order to investigate the impact of threatened premature labour and the different therapeutic regimen (betamimetics, maternal O2-inhalation, maternal transcutaneous dorsal nerve stimulation) on the myocardial performance capacity. Prolonged systolic time intervals (significant for pre-ejection period) in threatened premature labour (compared with control) supplement the concept of a chronic respiratory impairment of the foe-to-materno-placental relationships. Therapeutic prolongation of the pregnancy by betamimetics led to further impairment of the myocardial contractility while additional oxygen inhalation brought about a positive effect. As indicated by "no changes" after transcutaneous dorsal nerve stimulation, the decisive effect apparently seems not to be in the improvement of the uteroplacental perfusion but more on the direct influence of the raised O2-provision on the foetal myocardium. Non-demonstrable obvious relations to the cardiotocographic findings, such as to the postnatal evaluation criteria, speak against a serious threat to the foetus as the advantages of a reasonable prolongation of the gestational period by betamimetics preponderate. More than that the foetal myocardial impairments are to be favourably influenced by additional O2-therapy.

[Relation of uteroplacental hemodynamics and fetal respiratory behavior in pregnancy with threatened premature labor or intrauterine retardation]. / Beziehungen zwischen uteroplazentarer Hämodynamik und fetalem respiratorischem Verhalten bei Schwangerschaft mit drohender Frühgeburt oder intrauteriner Retardierung.

The results of uteroplacental hemodynamics obtained by nuclear medicine were correlated with the corresponding antepartal and intrapartal cardiotocographic findings in 52 patients with preterm labor and in 53 patients with intrauterine-growth-retarded fetuses. With the existence of continued disturbance in pregnancy the relationship between primary maternal hemodynamic disorders and decreased fetal respiratory performance is already evident antepartum and unambiguously intrapartum. The dependence of the antepartal cardiotocographic findings on therapeutical improvements in perfusion is of clinical relevance.

[Results of treatment of 718 endometrial cancers with reference to clinical and morphologic prognostic factors]. / Therapieergebnisse bei 718 Endometriumkarzinomen unter Berücksichtigung klinischer und morphologischer Prognosefaktoren.

This article deals with a retrospective analysis of therapeutic achievements in 718 endometrial carcinoma patients in relation to important prognostic factors (clinical stage, age, tumour type/degree of differentiation). The unfavourable age structure (64.9 years) and frequent multimorbidity of endometrial cancer patients require a close interdisciplinary cooperation for optimal management planning. With the priority of a graduated operative procedure with differential additional radiation therapy on the basis of essential clinical and morphological factors in contrast to the primary radiation therapy, the unsettled cumulative 5-year-survival rate accounted for in stage Ia 69%, Ib 64%, II 41%, III 33% and also for the whole material 59%. The obvious deterioration of the prognosis already with the involvement of the cervix (stage II) as well as in the presence of unfavourable prognostic factors in stage I (tumour type, undifferentiated, myometrial invasion, suspicion of lymph node involvement) justify a radical operative intervention (lymphadenectomy, Wertheim-Meigs) in these cases despite possible anaesthesiological risk on the basis of an extended pretherapeutic diagnostic procedures (sonography, lymphography, computer tomography). Under these conditions mentioned above we had only 6 per cent late therapeutic consequences requiring treatment.

[Therapeutic results in uterine sarcoma (1955-1985)]. / Therapieergebnisse bei uterinen Sarkomen (1955-1985).

This is a retrospective analysis of prognostic factors and treatment outcomes in 126 uterine sarcoma cases from the period of 1955 to 1985 inclusively. Up to now there lacks unanimity and extensive scientific based therapeutic concept; and treatment results could not be improved despite better operative and radiation therapy possibilities. From the examined charts and materials, the five year survival rate achieved for all stages is 31%. The mean age of the patients is 57.9 years and significant prognostic differences will be appreciated only in relation to the clinical stages at the commencement of therapy and also after local total operative intervention (stages I and II) in conjunction with postoperative radiation therapy. The difference in course in relation to the histologic tumour type can not be statistically verified.

[Premature labor in gestosis]. / Frühgeburtlichkeit bei Gestose.

796 pregnancies complicated by preeclampsia and 1,299 pregnancies without toxemia of the years 1981 to 1985 have been compared with regard to prematurity. Prematurity rates were 12.4 respectively 13.8 per cent, hypotrophy rates were 20 resp. 13 per cent, acidosis morbidity was 75 resp. 20 per cent and Apgar values below 8 were 63 resp. 24 per cent. Morbidity rate of respiratory distress syndrome was 8 resp. 12 per cent, of sepsis 2 resp. 7 per cent, intrauterine death rate 5 resp. 2 per cent, but survival rate overall was 93 resp. 90 per cent. Prematurity was influenced by severity of preeclampsia, time of onset and prenatal care. Prolongation of pregnancy by tocolysis is possible principally, but influenced in its effect by maternal and fetal symptoms and the necessity of termination of pregnancy by these factors.

[Therapy of suspected intrauterine fetal retardation]. / Zur Therapie bei Verdacht auf intrauterine fetale Retardierung.

In a randomized prospective study, performed on 45 pregnancies with clinical and sonographic suspicion for intrauterine fetal growth retardation, examinations were done to evaluate the therapeutic effect of bed rest and of additional daily administered glucose infusions or oral galactose applications respectively on the fetal growth, the hemodynamic, respiratory and endocrine insufficiency of the materno-feto-placental unit as well as selected biochemical parameters of the umbilical blood. There is no positive therapeutic effect, either on the impaired endocrine partial function nor on the reduced respiratory function of the feto-placental unit. It is obvious, that despite the improvement of the nutritional supply of the fetus and the revival of the regular fetal growth, the previous lack of fetal growth can not be altered. This can be demonstrated in all three therapeutic groups due to the fact of a resulting high hypotrophy-rate of the newborns. The results prove that the additional supply of the fetus with glucose or galactose does not remarkably improve the therapeutic effectivity as opposed by strict bed rest alone.

[Antepartal cardiotocographic studies in threatened premature labor and intravenous tocolysis]. / Antepartale kardiotokographische Untersuchungen bei drohender Frühgeburt und intravenöser Tokolyse.

In view of the connection which exists between premature birth and placental insufficiency and the means which are available for determining the respiratory performance of the fetoplacental unit by way of cardiotocography, the authors investigated the incidence of prepathological findings in the fetal heart frequency parameters for 81 cases of imminent premature delivery before, during and after intravenous tocolysis, and for 10 normal pregnancies between the 28th and 36th week. The greater number of prepathological cardiotocograms (oscillation amplitude and frequency, periodic acceleration and deceleration) found at the beginning of a trend toward premature delivery beginning with the 30th week of pregnancy, confirms the assumption of a restricted respiratory function of the fetoplacental unit. This restriction is, however, slight. The increase which is observed in these changes, particularly during up to 7 days of intravenous tocolysis in the 28th/29th week of pregnancy, and which continues after the end of intravenous therapy in the further course of pregnancy, is not seen as a result of the effect of betamimetics. The latter obviously do not succeed in positively influencing respiratory insufficiency in the event of imminent premature delivery. Neither the cardiotocographic findings from the beginning of the therapy nor later results permit conclusions to be drawn with regard to its possible success. On the other hand, a prepathological finding, especially where this occurs immediately before delivery, suggests possible larger disturbances of respiratory performance intrapartum, and problems with neonatal adaptation.

[Hemodynamic placental insufficiency and its therapeutic modification in threatened premature labor]. / Hämodynamische Plazentainsuffizienz und ihre therapeutische Beeinflussung bei drohender Frühgeburt.

The authors are involved in a study in the field of nuclear medicine aimed at further clarifying the connection between premature delivery and placental insufficiency. They are particularly concerned with uteroplacental perfusion at the time when a trend is emerging toward premature birth, and with ways of treating this by exclusive therapy using betamimetics and/or additional maternal oxygen inhalation/additional maternal transcutaneous dorsal nerve stimulation (TNS). The significantly longer half-life periods of activity increase found at the time of hospitalization similar to pregnancies with intra-uterine fetal retardation, as compared with a normal control group, are interpreted as expressing a hemodynamic placental insufficiency and a risk of premature delivery. In contrast to exclusive betamimetic therapy, additional O2 inhalation/additional TNS significantly shorten the half-life period both in short-time and long-time tests. The better therapeutic effect on uteroplacental perfusion in cases of imminent premature delivery which is thus demonstrated can be seen also in an improved respiratory condition of the fetus as shown in a cardiotocogram. From a clinical point of view, the authors call attention to the clearly prolonged pregnancy periods regardless of the duration of gestation, at the time when a trend is emerging toward premature birth, as compared with exclusive betamimetic therapy, the duration of tocolysis/amount of betamimetic applied being the same.

[Value of cardiotocographic studies in threatened premature labor and intrauterine retardation. A contribution to respiratory placental insufficiency]. / Wertigkeit kardiotokografischer Untersuchungen bei drohender Frühgeburt und intrauteriner Retardierung. Ein Beitrag zur respiratorischen Plazenta-Insuffizienz.

The authors evaluated a total of 1,237 cardiotocograms obtained from 138 pregnancies where premature delivery was imminent, 49 pregnancies with intrauterine retardation and 10 pregnancies without pathological findings from a clinical and anamnestic point of view. The cardiotocograms resulted from antepartal screening, and the Fischer score was used for evaluation. Restricted fetal respiration was assumed in all cases where prepathological CTGs were significantly more frequent in the course of pregnancy (24%) and where there was a significant increase in such findings immediately before delivery (41%) in the event of imminent premature birth, compared with normal controls (10%) and pregnancies with intrauterine retardation in the absence of premature uterine contractions (13%). Similar findings were also obtained for individual parameters of the fetal heart frequency such as the oscillation frequency, oscillation amplitude, acceleration and deceleration. By way of comparison with normal controls of the same age it is insured in each case that the disturbance observed expresses a respiratory insufficiency in the feto-placento-maternal unit rather than an immature fetal heart and circulatory system. In this connection, particular hazards exist during early gestation where a premature delivery is imminent, whereas IUR carries only a limited risk. This assumption is reinforced by the greater number of prepathological findings encountered in pregnancies which have successfully been prolonged (beyond the 37th week), compared with normal controls of the same age. The connections shown between a prepathological CTG (particularly in the last week before delivery) and a greater frequency of intra- and postnatal disturbances (hypoxia, acidosis morbidity, impaired adaptation) confirm the value which must be attached to a prepathological cardiotocographic finding. In this connection it is important to include results gained in the course of monitoring and to see if the antepartal CTG is normal at all times, prepathological at all times or, in the case of variations, normal or prepathological in the end.