Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago.

BACKGROUND: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. METHODS: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. RESULTS: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. CONCLUSIONS: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Autonomic modulation, spontaneous baroreflex sensitivity and fatigue in young men after COVID-19.

Impaired autonomic modulation and baroreflex sensitivity (BRS) have been reported during and after COVID-19. Both impairments are associated with negative cardiovascular outcomes. If these impairments were to exist undetected in young men after COVID-19, they could lead to negative cardiovascular outcomes. Fatigue is associated with autonomic dysfunction during and after COVID-19. It is unclear if fatigue can be used as an indicator of impaired autonomic modulation and BRS after COVID-19. This study aims to compare parasympathetic modulation, sympathetic modulation, and BRS between young men who had COVID-19 versus controls and to determine if fatigue is associated with impaired autonomic modulation and BRS. Parasympathetic modulation as the high-frequency power of R-R intervals (lnHFR-R), sympathetic modulation as the low-frequency power of systolic blood pressure variability (LFSBP), and BRS as the -index were measured by power spectral density analysis. These variables were compared between 20 young men who had COVID-19 and 24 controls. Independent t-tests and Mann-Whitney U tests indicated no significant difference between the COVID-19 and the control group in: lnHFR-R, P=0.20; LFSBP, P=0.11, and -index, P=0.20. Fatigue was not associated with impaired autonomic modulation or BRS. There is no difference in autonomic modulations or BRS between young men who had COVID-19 compared to controls. Fatigue did not seem to be associated with impaired autonomic modulation or impaired BRS in young men after COVID-19. Findings suggest that young men might not be at increased cardiovascular risk from COVID-19-related dysautonomia and impaired BRS.

Gene's hubs in retinal diseases: A retinal disease network.

BACKGROUND: Retinal diseases associated with the dysfunction or death of photoreceptors are a major cause of blindness around the world, improvements in genetics tools, like next generation sequencing (NGS) allows the discovery of genes and genetic changes that lead to many of those retinal diseases. Though, there very few databases that explores a wide spectrum of retinal diseases, phenotypes, genes, and proteins, thus creating the need for a more comprehensive database, that groups all these parameters. METHODS: Multiple open access databases were compiled into a new comprehensive database. A biological network was then crated, and organized using Cytoscape. The network was scrutinized for presence of hubs, measuring the concentration of grouped nodes. Finally, a trace back analysis was performed in areas were the power law reports a high r-squared value near one, that indicates high nodes density. RESULTS: This work leads to creation of a retinal database that includes 324 diseases, 803 genes, 463 phenotypes, and 2461 proteins. Four biological networks (1) a disease and gene network connected by common phenotypes, (2) a disease and phenotype network connected by common genes, (3) a disease and gene network with shared disease or gene as the cause of an edge, and (4) a protein and disease network. The resulting networks will allow users to have easier searching for retinal diseases, phenotypes, genes, and proteins and their interrelationships. CONCLUSIONS: These networks have a broader range of information than previously available ones, helping clinicians in the comprehension of this complex group of diseases.

Surviving at high elevations: an inter- and intra-specific analysis in a mountain bird community.

Elevation represents an important selection agent on self-maintenance traits and correlated life histories in birds, but no study has analysed whether life-history variation along this environmental cline is consistent among and within species. In a sympatric community of passerines, we analysed how the average adult survival of 25 open-habitat species varied with their elevational distribution and how adult survival varied with elevation at the intra-specific level. For such purpose, we estimated intra-specific variation in adult survival in two mountainous species, the Water pipit (Anthus spinoletta) and the Northern wheatear (Oenanthe oenanthe) in NW Spain, by means of capture-recapture analyses. At the inter-specific level, high-elevation species showed higher survival values than low elevation ones, likely because a greater allocation to self-maintenance permits species to persist in alpine environments. At the intra-specific level, the magnitude of survival variation was lower by far. Nevertheless, Water pipit survival slightly decreased at high elevations, while the proportion of transient birds increased. In contrast, no such relationships were found in the Northern wheatear. Intra-specific analyses suggest that living at high elevation may be costly, such as for the Water pipit in our case study. Therefore, it seems that a species can persist with viable populations in uplands, where extrinsic mortality is high, by increasing the investment in self-maintenance and prospecting behaviours.

Cystatin B and HIV regulate the STAT-1 signaling circuit in HIV-infected and INF-ß-treated human macrophages.

Cystatin B is a cysteine protease inhibitor that induces HIV replication in monocyte-derived macrophages (MDM). This protein interacts with signal transducer and activator of transcription (STAT-1) factor and inhibits the interferon (IFN-ß) response in Vero cells by preventing STAT-1 translocation to the nucleus. Cystatin B also decreases the levels of tyrosine-phosphorylated STAT-1 (STAT-1PY). However, the mechanisms of cystatin B regulation on STAT-1 phosphorylation in MDM are unknown. We hypothesized that cystatin B inhibits IFN-ß antiviral responses and induces HIV replication in macrophage reservoirs through the inhibition of STAT-1 phosphorylation. Macrophages were transfected with cystatin B siRNA prior to interferon-ß treatment or infected with HIV-ADA to determine the effect of cystatin B modulation in STAT-1 localization and activation using immunofluorescence and proximity ligation assays. Cystatin B decreased STAT-1PY and its transportation to the nucleus, while HIV infection retained unphosphorylated STAT (USTAT-1) in the nucleus avoiding its exit to the cytoplasm for eventual phosphorylation. In IFN-ß-treated MDM, cystatin B inhibited the nuclear translocation of both, USTAT-1 and STAT-1PY. These results demonstrate that cystatin B interferes with the STAT-1 signaling and IFN-ß-antiviral responses perpetuating HIV in macrophage reservoirs.

Inhibition of interferon response by cystatin B: implication in HIV replication of macrophage reservoirs.

Cystatin B and signal transducer and activator of transcription-1 (STAT-1) phosphorylation have recently been shown to increase human immunodeficiency virus-1 (HIV-1) replication in monocyte-derived macrophages (MDM), but the molecular pathways by which they do are unknown. We hypothesized that cystatin B inhibits the interferon (IFN) response and regulates STAT-1 phosphorylation by interacting with additional proteins. To test if cystatin B inhibits the IFN-ß response, we performed luciferase reporter gene assays in Vero cells, which are IFN deficient. Interferon-stimulated response element (ISRE)-driven expression of firefly luciferase was significantly inhibited in Vero cells transfected with a cystatin B expression vector compared to cells transfected with an empty vector. To determine whether cystatin B interacts with other key players regulating STAT-1 phosphorylation and HIV-1 replication, cystatin B was immunoprecipitated from HIV-1-infected MDM. The protein complex was analyzed by liquid chromatography tandem mass spectrometry. Protein interactions with cystatin B were verified by Western blots and immunofluorescence with confocal imaging. Our findings confirmed that cystatin B interacts with pyruvate kinase M2 isoform, a protein previously associated cocaine enhancement of HIV-1 replication, and major vault protein (MVP), an IFN-responsive protein that interferes with JAK/STAT signals. Western blot studies confirmed the interaction with pyruvate kinase M2 isoform and MVP. Immunofluorescence studies of HIV-1-infected MDM showed that upregulated MVP colocalized with STAT-1. To our knowledge, the current study is the first to demonstrate the coexpression of cystatin B, STAT-1, MVP, and pyruvate kinase M2 isoform with HIV-1 replication in MDM and thus suggests novel targets for HIV-1 restriction in macrophages, the principal reservoirs for HIV-1 in the central nervous system.

Gas exchange in Paulownia species growing under different soil moisture conditions in the field.

In order to evaluate their responses to drought, we determined the photosynthetic activity water potential, stomatal conductance, transpiration, water use efficiency photosynthetic photon flux density and leaf temperature of Paulownia imperialis, P. fortunei and P. elongata in three different soil moisture conditions in the field. Our results showed that P. imperialis had greater photosynthesis (8.86 micromol CO2 m(-2) s(-1)) and instantaneous water use efficiency (0.79 micromol CO2 mmol H2O(-1)) than either P. elongata (8.20 micromol CO2 m(-2) s(-1) and 0.71 micromol CO2 mmol H2O(-1)) or P. fortunei (3.26 micromol CO2 m(-2) s(-1) and 0.07 micromol CO2 mmol H2O(-1)). The rapid growth of Paulownia did not appear to be correlated with photosynthetic rates. Paulownia fortunei showed more transpiration (48.78 mmol H2O m(-2) s(-1)) and stomatal conductance (840 mmol m(-2) s(-1)) than P. imperialis (20 mmol H2O m(-2) s(-1) and 540 mmol m(-2) s(-1)) and P. elongata (20 mmol H2O m(-2) s(-1) and 410 mmol m(-2) s(-1)), which allowed these two Paulownia species to increase their tolerance to low soil moisture, and maintain higher water use efficiency under these conditions. According to our physiological gas exchange field tests, Paulownia imperialis does appear to be capable of successful growth in semiarid zones.

Restricted HIV-1 replication in placental macrophages is caused by inefficient viral transcription.

HIV-infected PM show restricted replication as compared with MDM. We aimed to determine at what point in the viral replication cycle this restriction occurs in PM as compared with MDM. We performed Alu-LTR PCR for proviral DNA to detect differences in HIV integration, real-time RT-PCR to measure env and gag mRNA levels, and Western blot analysis to detect differences in viral protein expression. PM and MDM were infected with HIV-1 BaL, and DNA was extracted after 24 h and at 6 days p.i. for real-time PCR studies. At 6 and 12 days p.i., cells were lysed for Western blot analyses. We found no difference in viral integration between PM and MDM but significantly lower levels of viral protein gp120 in PM than in MDM. Real-time RT-PCR analyses revealed 24-fold less env mRNA and tenfold less gag mRNA in PM. These results suggest that HIV-1 restriction in PM occurs at the level of transcription. This study is significant, as it advances our understanding of HIV-1 infection in PM and its contribution to decreased in utero vertical transmission.

Restauraciones cerámicas en molares jóvenes con endodoncia / Ceramics restorations in young molars with endodontic

Objetivo: Efectuar restauraciones cerámicas Cerec (feldespática y de dióxido de circonio) en molares jóvenes con endodoncia, para prevenir complicaciones en el aparato estomatognático por la pérdida de estos dientes. Material y métodos: Se describe la confección de restauraciones cerámicas a nivel de la zona molar mandibular derecha de un paciente del género femenino de 18 años de edad, a quien se le realizó radiografía periapical, por presentar dolor espontáneo en el lado derecho mandibular. Se diagnosticó una pulpitis irreversible en el primer y segundo molar que fue tratada en odónticamente. Las restauraciones cerámicas de ambos molares fueron confeccionadas con los sistemas CAD/CAM Cerec y evaluadas clínicamente a los 6 y 12 meses, de acuerdo a los criterios establecidos por el Servicio de Salud Pública de los Estados Unidos (USPHS).Resultados: La evaluación clínica evidenció que las estructuras de cerámica feldespática y de dióxido de circonio ofrecen en el lapso evaluado, adecuada forma anatómica, adaptación marginal, estabilidad en el color, ausencia de caries recidiva a nivel de dientes del sector posterior con tratamiento endodóntico y aceptación del paciente (AU)

Material and methods: It describes the making of ceramic restorations in the right mandibular molar area to a female patient of 18 years old, to whom it was made a periapical radiography, for presenting spontaneous pain on the mandibular right side. It was diagnosed as an irreversible pulpitis at the first and second molar, that were treated endodontically. The ceramic restorations of both molars were made with the Cerec CAD/CA Msystem and were examined after 6 and 12 months in accordance with the US Public Health Service (USPHS)criteria at baseline. Results: The clinical evaluation showed that the structures of feldspathic ceramic and zirconium dioxide in the offer period evaluated presented, proper anatomical shape, marginal adaptation, color stability, absence of recurrence cavities in the posterior teeth with endodontic treatment and acceptance of the patient (AU)

Cystatin B associates with signal transducer and activator of transcription 1 in monocyte-derived and placental macrophages.

Cystatin (CSTB, also known as stefin B), a cysteine protease inhibitor, recently was found to be down-regulated in the proteome of uninfected and HIV-1-infected placental macrophages (PMs) and associated with restricted HIV-1 replication in PM but not in monocyte-derived macrophages (MDMs). We investigated CSTB interactions with signal transducer and activator of transcription 1 (STAT-1) by immunoprecipitation studies because this molecule is known to activate HIV-1 replication. Since both CSTB and STAT-1 are related to HIV-1 replication, we hypothesized that these proteins could be interacting. We applied immunoprecipitation assays to determine STAT-1-CSTB interaction in uninfected and HIV-1-infected PM as compared with MDM. We found that CSTB associates with STAT-1 in PM and MDM. Further analyses indicated that the levels of STAT-1 tyrosine phosphorylation were higher in PM than MDM. High levels of tyrosine phosphorylation previously have been associated with HIV-1 inhibitory activity. This is the first report to demonstrate that cystatin B interacts with STAT-1 and that the levels of STAT-1 tyrosine phosphorylation (but not serine phosphorylation) between uninfected and HIV-infected PM and MDM are differentially regulated.

Characterization of the placental macrophage secretome: implications for antiviral activity.

It is well documented that placental macrophages show lower levels of HIV-1 infection than monocyte-derived macrophages (MDM). We used proteomic methods to test the hypothesis that placental macrophages secrete different proteins as compared to MDM that may contribute to decreased HIV-1 replication. Placental macrophages and MDM were cultured for 12 days and supernatant was collected. To characterize supernatants, the protein profiles of placental macrophages and MDM were compared using the protein chip assay. Subsequently, proteins were separated by one-dimensional gel electrophoresis and identified by tandem mass spectrometry at the corresponding mass to charge (m/z) range of 5000-20,000. Significant differences were found between placental macrophages and MDM in seven protein peaks with m/z values of 6075, 6227, 11,662, 14,547, 6158, 7740, and 11,934 on the CM10 and IMAC chips. After sequencing and identification, five proteins were validated for differential expression in placental macrophages and MDM by Western blot analyses. Peroxiredoxin 5, found to be more abundant in placental macrophage supernatants, is important in the cellular antioxidant mechanisms, and other members of its family have shown antiviral activity. Cystatin B was less abundant in PM supernatant, and decreased intracellular levels have recently been shown to be associated with lower HIV-1 replication in placental macrophages than in MDM. This study elucidates for the first time the placental macrophage secretome corresponding to 5000-20,000 Da and advances our understanding of the proteins secreted in the placenta that can protect the fetus against HIV-1 and other viral infections.

Proteomic analyses of monocyte-derived macrophages infected with human immunodeficiency virus type 1 primary isolates from Hispanic women with and without cognitive impairment.

The signature for human immunodeficiency virus type 1 (HIV-1) neurovirulence remains a subject of intense debate. Macrophage viral tropism is one prerequisite but others, including virus-induced alterations in innate and adaptive immunity, remain under investigation. HIV-1-infected mononuclear phagocytes (MPs; perivascular macrophages and microglia) secrete toxins that affect neurons. The authors hypothesize that neurovirulent HIV-1 variants affect the MP proteome by inducing a signature of neurotoxic proteins and thus affect cognitive function. To test this hypothesis, HIV-1 isolates obtained from peripheral blood of women with normal cognition (NC) were compared to isolates obtained from women with cognitive impairment (CI) and to the laboratory adapted SF162, a spinal fluid R5 isolate from a patient with HIV-1-associated dementia. HIV-1 isolates were used to infect monocyte-derived macrophages (MDMs) and infection monitored by secreted HIV-1 p24 by enzyme-linked immunosorbent assay (ELISA). Cell lysates of uninfected and HIV-1-infected MDMs at 14 days post infection were fractionated by cationic exchange chromatography and analyzed by surface enhanced laser desorption ionization time of flight (SELDI-TOF) using generalized estimating equations statistics. Proteins were separated by one-dimensional sodium dodecyl sulfate-polyacrylamide gel electrophoresis (1D SDS-PAGE) and identified by tandem mass spectrometry. Levels of viral replication were similar amongst the HIV-1 isolates, although higher levels were obtained from one viral strain obtained from a patient with CI. Significant differences were found in protein profiles between virus-infected MDMs with NC, CI, and SF162 isolates (adjusted P value after multiple testing corrections, or q value <.10). The authors identified 6 unique proteins in NC, 7 in SF162, and 20 in CI. Three proteins were common to SF162 and CI strains. The MDM proteins linked to infection with CI strains were related to apoptosis, chemotaxis, inflammation, and redox metabolism. These findings support the hypothesis that the macrophage proteome differ when infected with viral isolates of women with and without CI.

Proteomic analyses associate cystatin B with restricted HIV-1 replication in placental macrophages.

Mononuclear phagocytes (MP; monocytes, tissue macrophages, and dendritic cells) are reservoirs, vehicles of dissemination, and targets for persistent HIV infection. However, not all MP population equally support viral growth. Such differential replication is typified by the greater ability of placental macrophages (PM), as compared to blood borne monocyte-derived macrophages (MDM), to restrict viral replication. Since cytosolic protein patterns can differentiate macrophage subtypes, we used a proteomics approach consisting of surface-enhanced laser desorption ionization time-of-flight (SELDI-TOF), tandem mass spectrometry, and Western blots to identify differences between the uninfected and HIV-infected PM and MDM protein profiles linked to viral growth. We performed proteome analysis of PM in the molecular range of 5-20kDa. We found that a SELDI-TOF protein peak with an m/z of 11,100, which was significantly lower in uninfected and HIV-infected PM than in MDM, was identified as cystatin B (CSTB). Studies of siRNA against CSTB treatment in MDM associated its expression with HIV replication. These data demonstrate that the low molecular weight placental macrophage cytosolic proteins are differentially expressed in HIV-infected PM and MDM and identify a potential role for CSTB in HIV replication. This work also serves to elucidate a mechanism by which the placenta protects the fetus from HIV transmission.

Ejection fraction velocity ratio as an indicator of aortic stenosis severity.

BACKGROUND: Despite the widespread use of the continuity equation in the estimation of aortic valve area (AVA) in patients with aortic stenosis, it is subject to errors, time consuming, and can be technically demanding. As such, simpler methods of assessing aortic stenosis severity have been pursued. METHODS: The ejection fraction velocity ratio [EFVR = ejection fraction (%) / maximal aortic velocity (m/sec)] was compared to AVA determined with the continuity equation in 857 patients with aortic stenosis and varying degrees of LV systolic dysfunction. Severe aortic stenosis was defined as an AVA < 1.0 cm2. RESULTS: There was good to excellent correlation between our index and aortic valve area (P < 0.001 for each ejection fraction subgroup). Receiver operating characteristic analysis showed that the EFVR functioned well with areas under the curve between 0.893 and 0.938. CONCLUSION: The EFVR is a simple noninvasive method for screening patients for an AVA of 1.0 cm2. It could be used as a screening test or in lieu of the continuity equation particularly when there is problematic measurement of either the LVOT diameter or velocity.

Recomendaciones para mejorar la atención en enfermería / Recommendations to improve attention in nursing

El personal de enfermería desempeña una actividad fundamental en los servicios de salud, con fuerte apego a principios científicos y éticos; sus intervenciones permiten fortalecer la calidad en los servicios de salud, através de acciones interdisciplinarias. Se analizaron las inconformidades relacionadas con atención de enfermería que recibió la Comisión Nacional de Arbitraje Médico (CONAMED) de junio de 1996 a diciembre de 2001. Con base en el análisis se elaboraron recomendaciones dirigidas a prevenir el conflicto, mejorar la práctica de enfermería y propiciar la adecuada comunicación con el paciente, familiares y equipo interprofesional de salud. Se integró un grupo representativo de las instituciones educativas y gremiales de enfermería más prestigiadas y reconocidas, para su validación externa. De esta manera, la CONAMED y el grupo de validación externa, proponen al personal de enfermería atender las siguientes recomendaciones: 1) Mantener una comunicación efectiva con las personas a las que proporciona atención; 2) Reconocer en la persona su concepción holística; 3) Proporcionar cuidados que garanticen la atención libre de riesgos y daños innecesarios; 4) Establecer una coordinación efectiva con el equipo interprofesional de salud; 5) Actuar con base en los principios éticos que rigen la práctica profesional de enfermería.

Nurse personnel performs a fundamental activity in t health services, with strong attach at scientific and ethical principles, whose interventions can fortify the services of health quality, through interdisciplinary actions. We analyzed the compliants related to nursing attention that were received in CONAMED since June 1996 to December 2001. Wedevised recommendations directed to prevent patient-health care professionals conflicts, improve the practice of nursing and favor adequate communication with the patient, family and interprofessional health care team. Those recommendations were presented to the more prestigious and recognized educational and professional groups of nursing, for their external validation. In this manner, CONAMED and the external group of validation, propose to nurses to attend the following recommendations: 1) Maintain an effective communication with the patients that provides attention; 2) Recognize the holistic concept in the person; 3) Provide cares that guarantee tree-risk attention and prevent unnecessary damages; 4) Establish an effective coordination with the health care interprofessional team and 5) Act based on ethical principles that govern the professional practice of nursing.

Macrophage proteomic fingerprinting predicts HIV-1-associated cognitive impairment.

BACKGROUND: Specific proteins produced from monocytes may be linked to the pathogenesis and aid in the diagnosis of HIV-1-associated dementia (HAD). OBJECTIVE: The authors assessed whether a diagnostic phenomic protein profile could be obtained from monocyte-derived macrophages (MDM) from HIV-1-infected patients with cognitive impairment. METHODS: Twenty-one HIV-1-infected Hispanic women and 10 seronegative controls matched by age and sex were followed at the University of Puerto Rico Medical Sciences Campus, where neuropsychological, immune, and viral parameters were tested. Monocytes were recovered by Percoll gradient centrifugation from peripheral blood mononuclear cells. MDM lysates were prepared after 7 days of cultivation and protein profiles analyzed by surface enhanced laser desorption/ionization (SELDI)-time of flight (TOF) ProteinChip tests. Classification trees were prepared for statistical analyses. RESULTS: A total of 177 protein peaks from 2 to 80 kDa were evaluated in 31 patient MDM lysates by SELDI-TOF ProteinChip assays. Select protein peaks, at 5028 and 4320 Da, separated HIV-1-infected from HIV-1-seronegative subjects with a sensitivity of 100% and a specificity of 80%. Thirty-eight peaks were used to differentiate HIV-1-infected subjects with and without cognitive impairment. A 4348 Da protein separated the two groups with a sensitivity of 100% and a specificity of 75%. CONCLUSIONS: The identification of unique phenomic MDM profiles from cognitively impaired HIV-1-infected patients supports the hypothesis that changes in monocyte function parallel the development of HAD.

Care and cleaning of the endoscope.

The purchase of veterinary endoscopy equipment requires a large investment on the part of the hospital. To ensure good return on the investment as well as to provide adequate service to clients, the equipment should be properly maintained. Close attention to this detail enables the practitioner to extend the life of the endoscope and its accessory instruments.

Strict reliance on a computer algorithm or measurable ST segment criteria may lead to errors in thrombolytic therapy eligibility.

BACKGROUND: There is accumulating evidence that thrombolytic therapy is underused among eligible patients with acute myocardial infarction. We sought to determine whether potential errors in electrocardiographic diagnosis might be a contributing factor. METHODS: Seventy-five electrocardiograms were interpreted on 2 separate occasions by 3 cardiologists. Two criteria were compared for thrombolysis eligibility: (1) measurement of > or =1 mm ST-segment elevation in 2 contiguous leads (measured) and (2) criterion 1 plus the subjective opinion that the changes represented acute transmural injury (interpretive). The results were compared with computerized interpretations by the Marquette 12SL system. RESULTS: Raw agreement and agreement corrected for chance between raters for both criteria were excellent and tended to be better for interpretive compared with measured criteria (kappa = 0.89 vs 0.78, respectively). Strict reliance on measured electrocardiographic criteria alone would have resulted in overuse of thrombolysis among all 3 raters. Based on the consensus opinion, the absolute overuse of thrombolysis would have been approximately 15% (P <.0034). The computer algorithm had a specificity of 100% and a sensitivity of 61.5%. Reliance on the computerized interpretation alone would have lead to underuse of thrombolytic therapy compared with consensus opinion (21.3% vs 34. 6%; P <.005). CONCLUSION: Agreement for suspected acute myocardial infarction tended to be better when the appearance of the ST segments was added to measurable ST elevation criteria. Strict reliance on measurable criteria may lead to the inappropriate overuse of thrombolysis. Although the Marquette 12SL system has excellent specificity, it has poor sensitivity for the diagnosis of thrombolysis-eligible AMI. Reliance on computerized electrocardiographic interpretation would lead to the inappropriate underuse of thrombolytic therapy in situations in which qualifying electrocardiographic criteria are actually met.

Inhaled nitric oxide delivery by anesthesia machines.

UNLABELLED: Inhaled nitric oxide (NO) is a selective pulmonary vasodilator used to treat intraoperative pulmonary hypertension and hypoxemia. In contrast to NO delivered by critical care ventilators, NO delivered by anesthesia machines can be complicated by rebreathing. We evaluated two methods of administering NO intraoperatively: via the nitrous oxide (N(2)O) flowmeter and via the INOvent (Datex-Ohmeda, Madison, WI). We hypothesized that both systems would deliver NO accurately when the fresh gas flow (FGF) rate was higher than the minute ventilation (VE). Each system was set to deliver NO to a lung model. Rebreathing of NO was obtained by decreasing FGF and by simulating partial NO uptake by the lung. At FGF > or = VE (6 L/min), both systems delivered an inspired NO concentration ([NO]) within approximately 10% of the [NO] set. At FGF < VE and complete NO uptake, the N(2)O flowmeter delivered a lower [NO] (70 and 40% of the [NO] set at 4 and 2 L/min, respectively) and the INOvent delivered a higher [NO] (10 and 23% higher than the [NO] set at 4 and 2 L/min, respectively). Decreasing the NO uptake increased the inspired [NO] similarly with both systems. At 4 L/min FGF, [NO] increased by 10%-20% with 60% uptake and by 18%-23% with 30% uptake. At 2 L/min, [NO] increased by 30%-33% with 60% uptake and by 60%-69% with 30% uptake. We conclude that intraoperative NO inhalation is accurate when administered either by the N(2)O flowmeter of an anesthesia machine or by the INOvent when FGF > or = VE. IMPLICATIONS: Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In a lung model, we demonstrated that NO can be delivered accurately by a N(2)O flowmeter or by a commercial device. We provide guidelines for intraoperative NO delivery.