Predicting the need for hospital admission in patients with intentional drug overdose.

BACKGROUND: Self-poisoned patients are often admitted to a medical unit. However, often no treatment is given. We have developed a model to predict those patients who will not be treated and how long patients should be observed before this prediction can be safely made. METHODS: In this retrospective study a model to predict treatment was developed based on cases of self-poisoning in 1996 and validated on cases between 1997 and 1999. In a teaching hospital in The Netherlands 299 adults performing 353 episodes of self-poisoning were studied. The main outcome measures were predicted versus initiated medical treatment, time to prediction and time to initiation of treatment. RESULTS: The model predicted that in 51% (156/307) of all autointoxications no treatment would be given. In 2% (6/307) of all cases, treatment was incorrectly not predicted. All but one of these were preventive treatments based on the ingested compound. 4.5 hours after admission no additional patients fulfilled the criteria for prediction of treatment and all treatments were started within 4.5 hours. CONCLUSIONS: In 51% of patients that present with an autointoxication the model accurately predicts that no treatment will be initiated. This decision can be made in the first 4.5 hours after presentation. This model can be used for a first screening of patients. It can also be used as a basis for a further prospective study to establish rational guidelines in the management of these patients.

Clinical correlates of depression following myocardial infarction.

OBJECTIVE: Post-MI depression increases mortality, especially in the first 18 months after MI. Identifying patients at risk for post-MI depression is therefore important. In the present study we investigated possible correlates for post-MI depression on an a priori basis. METHOD: Based on the literature, four clinically easily attainable variables were selected as possible correlates for post-MI depression. These were prescription of benzodiazepines during acute hospitalization, cardiac complications during acute hospitalization, history of depression, and not being able to stop smoking within six months after MI. A consecutive cohort of 173 first-MI patients was screened with the SCL-90 depression scale and DSM-III-R criteria for major depression. Of this cohort 35 depressed patients were compared with 35 non-depressed post-MI patients, matched for gender, age, and severity of MI. RESULTS: In univariate analyses, complications during hospitalisation (OR = 2.14; CI = 0.89-5.14), prescription of benzodiazepines (OR = 3.67; CI = 1.11-12.1), history of depression (OR = 3.0; CI = 0.87-10.4), and not being able to stop smoking (OR = 4.5; CI = 1.11-18.2) were clinical correlates for post-MI depression. Multivariate analyses showed that none of these variables were independent of the others in predicting depression. CONCLUSIONS: A number of easily measurable patient characteristics identify those MI-patients at risk of post-MI depression. Further investigations should focus on the predictive value of these factors in relation to post-MI depression.

[Lavage almost never indicated after an autointoxication]. / Na een auto-intoxicatie spoelen vaak niet geïndiceerd.

In many Dutch hospitals gastric lavage leaving charcoal and a laxative is the treatment of choice after autointoxication. Gastric lavage is not without risks. No difference has been demonstrated in efficacy and safety of gastric lavage combined with administration of activated charcoal on the one hand and just administration of activated charcoal on the other. In theory, gastric lavage might be useful in patients presenting shortly after the selfpoisoning (up to 2 hours) and in the case of delayed gastric emptying up to 4 hours. Gastric lavage is indicated without doubt in patients presenting shortly after ingestion of toxic substances which are poorly adsorbed by charcoal (for instance lithium). In case of a mild intoxication (for example with benzodiazepines), the risks of drug toxicity do not outweigh those of lavage, regardless of the time elapsed after ingestion. If gastric lavage is applied, it should be performed properly, i.e. with warm water (38 degrees C), with a 36-40 Fr. tube, using aliquots of 200-300 ml. In a minority of the intoxications whole bowel lavage should be employed.

Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting. Long-term results.

In 83 patients with previous coronary artery bypass grafting, 92 percutaneous transluminal coronary angioplasty attempts were done, 33 in a venous bypass graft (success rate 97%) and 59 in a native coronary artery (success rate 86.4%). There were no procedural-related deaths and two myocardial infarctions. Forty-six percent of the patients with successful angioplasty after previous bypass grafting remain symptom free after 5 years versus 79% of the patients without previous bypass grafting (p less than 0.001). Long-term success rates for native vessel angioplasty as compared with bypass graft angioplasty are similar. Patients with a short interval between the recurrence of angina after bypass grafting and the angioplasty attempt have a better chance of long-term success. Repeat angiography indicates that a restenosis occurs after angioplasty of a venous graft in 31% and in the native system in 28.6% and that signs of progression of coronary artery disease elsewhere are present in 30%. Of the 83 patients, 11 had reoperation eventually. We conclude that percutaneous transluminal coronary angioplasty after coronary bypass grafting gives less satisfactory results than a primary procedure, that angioplasty provides symptomatic relief in a smaller number of patients than in those with primary angioplasty, but that symptomatic relief is often sufficient to further postpone or prevent bypass grafting and can be achieved with low mortality and low complication rates.

New triple-lumen balloon catheter for percutaneous (pulmonary) valvuloplasty.

Percutaneous transluminal balloon pulmonary valvuloplasty has been performed since 1982. In publications, the most critical problems mentioned are severe systemic hypotension and bradycardia due to stasis of blood flow. A triple-lumen balloon was developed to allow more rapid inflation and deflation and to preserve the preexistent forward blood flow during maximal inflation. Only a slight systemic hypotension and no bradycardia were seen in the first two patients with pulmonary valve stenosis treated with this type of balloon. Thus, the maximal inflation time is not a critical parameter, whereas with the former types of balloon, maximal inflation times were critical, and, if longer than 5 to 10 sec, severe systemic hypotension was registered. We conclude that the triple-lumen pulmonary valve-dilatation balloon catheter is superior to the single-lumen balloon catheter used up to now.