Prospective study of early discharge after acute myocardial infarction (SHORT)

AIMS: To identify, without additional investigation, a large group of myocardial infarction patients at low risk who would qualify for early discharge. METHODS: The decision rule was developed in 647 unselected patients with consecutively admitted myocardial infarction, and validated in 825 others. Daily event-rates were calculated for major (death, ventricular fibrillation, recurrent infarction, heart failure, advanced AV-block) and minor (unstable angina and rhythm-abnormalities) cardiac complications. RESULTS: Patients free from major complications until day 7 (44% of all patients) were found to constitute a very low risk group and thus would qualify for discharge at day 7. Of the 39% of patients with an uncomplicated infarction (low risk) in the validation group, 31% were discharged at day 7, while 8% stayed longer because of non-cardiac co-morbidity, for social reasons or logistic problems. No major adverse event occurred within 7 days after hospital discharge and only 1.8% developed complications within 1 month. The median duration of hospital stay for all in-hospital survivors was 7 days compared to 10 days in the control group. CONCLUSION: Prospective application of the early discharge decision rule, based upon simple clinical variables and without the need for additional non-invasive and/or invasive tests, resulted in a significant reduction of hospital stay. The decision rule correctly classified patients into high and low risk groups and appeared feasible and safe. Its efficacy was demonstrated by its ability to identify a large group of post infarction survivors at low risk for complications during follow-up.

Peripheral natural killer cytotoxicity and CD56(pos)CD16(pos) cells increase during early pregnancy in women with a history of recurrent spontaneous abortion.

For diagnostic purposes we assessed peripheral natural killer (NK) cell cytotoxicity and NK and T cell numbers to assess their putative predictive value in recurrent spontaneous abortion (RSA). A total of 43 women with subsequent pregnancy, 37 healthy controls and 39 women successfully partaking in an in-vitro fertilization (IVF) procedure, were included in the study. We show that before pregnancy, levels of NK cytotoxicity and numbers of both single CD56(pos) and double CD56(pos)CD16(pos) cells were similar between RSA women and controls. But notably, within the RSA group, NK cell numbers of <12% were strongly associated with a subsequent pregnancy carried to term. Supplementation of folic acid led to an increase of single CD56(pos) cells, but cytotoxic function appeared unaffected. The expression pattern of killer inhibitory receptors on CD56(pos) cells was not different between patients and controls. A longitudinal study revealed that, compared with controls, in RSA women higher numbers of double CD56(pos)CD16(pos) cells were present during early pregnancy, paralleled by an increase in cytotoxic NK cell reactivity. The single CD56(pos) population decreased in number. In conclusion, the analysis of peripheral NK cell characteristics appears a suitable diagnostic tool in RSA. Immunomodulation aimed at NK cell function appears a promising therapeutic measure.

[Pleural amyloidosis as a cause of excessive pleural effusions]. / Amyloïdose van de pleura als oorzaak van overmatig veel pleuravocht.

A 83-year-old woman known with a stable disease multiple myeloma was hospitalized frequently with dyspnoea caused by copious bilateral pleural effusions. Thoracentesis was performed repeatedly but pleural effusions returned. Extensive laboratory and radiological examinations failed to reveal the cause of the pleural effusions. Finally, after pleural biopsy the diagnosis of amyloidosis of the pleura could be made. The patient died in hospital from a stroke. Pleural amyloidosis is rarely reported and is accompanied by large uni- or bilateral pleural effusions even without amyloidosis of the heart.

Variation in the use of coronary angiography in patients with unstable angina is related to differences in patient population and availability of angiography facilities, without affecting prognosis.

OBJECTIVES: Examination of the difference in management strategies with respect to coronary angiography in patients with unstable angina pectoris, and the consequences of this difference on prognosis. DESIGN: Prospective registration of consecutive patients admitted to two different hospitals. SETTING: University and a large community hospital in Rotterdam, the Netherlands. SUBJECTS: Patients under 80 years, without recent (< 4 weeks) infarction or recent (< 6 months) coronary revascularization procedure, admitted for chest pain suspected to indicate unstable angina pectoris. MAIN OUTCOME MEASURES: Decision to initiate coronary angiography or to continue on medical treatment. At 6 months the occurrence of death and myocardial infarction was measured. RESULTS: Clinical variables associated with the decision to initiate angiography were young age, male gender, progression of angina, multiple pain episodes and use of beta-blocker or calcium antagonists before admission, abnormal ST-T segment on baseline ECG, recurrent pain in hospital, and ECG changes during pain. These associations did not differ between hospitals. Nevertheless, angiography was performed more often in the presence of angiography facilities (university hospital), independent of the variable case-mix. Survival and infarct-free survival were similar in both hospitals, 96% and 90% respectively. CONCLUSION: The difference in angiography rate for unstable angina can be explained in part by differences in patient population and hospital facilities, but no difference was observed in physicians' assessment of patient characteristics. The observed practice variation did not affect prognosis.