Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences.

AIM: The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may differ between men and women. The aim of this study was to compare sex-associated differences between using a diagnostic strategy including early coronary computed tomography angiography (CCTA) and standard of care (SOC). METHODS: In total, 500 patients who presented with symptoms suggestive of ACS at the emergency department were randomised between a diagnostic strategy supplemented with early CCTA and SOC. RESULTS: Women were generally older than men (mean ± standard deviation 56 ± 10 vs 53 ± 10 years, p < 0.01) and were less often admitted to hospital (33% vs 44%, p = 0.02). Obstructive coronary artery disease on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p = 0.02), and ACS was diagnosed less often in women (5% vs 10%, p = 0.03). Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008). CONCLUSION: Women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. They were subjected to less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS.

Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: A systematic review and meta-analysis.

AIMS: The purpose of this study was to determine (a) the ability of serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and (b) the ability of a single high baseline high-sensitivity cardiac troponin T measurement to rule in acute myocardial infarction in patients presenting to the emergency department with acute chest pain. METHODS AND RESULTS: Embase, Medline, Cochrane, Web of Science and Google scholar were searched for prospective cohort studies that evaluated parameters of diagnostic accuracy of serial high-sensitivity cardiac troponin T to rule out acute myocardial infarction and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction. The search yielded 21 studies for the systematic review, of which 14 were included in the meta-analysis, with a total of 11,929 patients and an overall prevalence of acute myocardial infarction of 13.0%. For rule-out, six studies presented the sensitivity of serial measurements <14 ng/l. This cut-off classified 60.1% of patients as rule-out and the summary sensitivity was 96.7% (95% confidence interval: 92.3-99.3). Three studies presented the sensitivity of a one-hour algorithm with a baseline high-sensitivity cardiac troponin T value<12 ng/l and delta 1 hour <3 ng/l. This algorithm classified 60.2% of patients as rule-out and the summary sensitivity was 98.9% (96.4-100). For rule-in, six studies reported the specificity of baseline high-sensitivity cardiac troponin T value>50 ng/l. The summary specificity was 94.6% (91.5-97.1). CONCLUSION: Serial high-sensitivity cardiac troponin T measurement strategies to rule out acute myocardial infarction perform well, and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction has a high specificity.

Transcatheter closure of a traumatic ventricular septum defect resulting from a stab wound.

A 25-year-old man with a ventricular septal defect resulting from a stab wound to his chest was admitted to our hospital. Because of extensive comorbidity and favourable location, transcatheter closure with an Amplatzer device was preferred over surgical repair. Ventricular septal defects are an uncommon complication of cardiac trauma, but when they do occur from this cause, they often have more dramatic consequences. Transcatheter closure is an attractive, less-invasive alternative in patients with increased surgical risk, multiple previous surgical interventions, or poorly accessible defects.

Standardized evaluation framework for evaluating coronary artery stenosis detection, stenosis quantification and lumen segmentation algorithms in computed tomography angiography.

Though conventional coronary angiography (CCA) has been the standard of reference for diagnosing coronary artery disease in the past decades, computed tomography angiography (CTA) has rapidly emerged, and is nowadays widely used in clinical practice. Here, we introduce a standardized evaluation framework to reliably evaluate and compare the performance of the algorithms devised to detect and quantify the coronary artery stenoses, and to segment the coronary artery lumen in CTA data. The objective of this evaluation framework is to demonstrate the feasibility of dedicated algorithms to: (1) (semi-)automatically detect and quantify stenosis on CTA, in comparison with quantitative coronary angiography (QCA) and CTA consensus reading, and (2) (semi-)automatically segment the coronary lumen on CTA, in comparison with expert's manual annotation. A database consisting of 48 multicenter multivendor cardiac CTA datasets with corresponding reference standards are described and made available. The algorithms from 11 research groups were quantitatively evaluated and compared. The results show that (1) some of the current stenosis detection/quantification algorithms may be used for triage or as a second-reader in clinical practice, and that (2) automatic lumen segmentation is possible with a precision similar to that obtained by experts. The framework is open for new submissions through the website, at http://coronary.bigr.nl/stenoses/.

Propofol injection pain: is it still an issue? The effect of premedication.

BACKGROUND: The use of propofol often results in pain upon injection. Various strategies can be used to reduce this pain, ranging from the administration of analgesics to modification of the propofol emulsion. However, basic premedication protocol aimed at peri- and postoperative pain reduction could also sufficiently reduce propofol injection pain, rendering other special interventions redundant. METHODS: With the approval of the Local Ethics Committee of the Erasmus Medical Centre Rotterdam, and after obtaining written informed consent from each patient included, 209 surgical patients (ASA physical status I-III) were randomized in a double-blind manner to receive premedication consisting of 7.5 mg midazolam, 50 mg diclofenac and 1000 mg acetaminophen (all orally administered) and fentanyl (intravenously administered) or placebo medication the hour before surgery. In both groups a mixture of 40 mL propofol 1% with 2 mL lidocaine 1% was used to induce anesthesia. Pain scores were assessed using a verbal analog scale (VAS) ranging from 0-10. RESULTS: The premedication group was found to have significantly less pain upon injection of propofol (median VAS 0+/-0-2) (median+/-interquartile range) when compared to the control group (median VAS 1.5+/-0-4; P=0.001). In addition, more patients in the premedication group experienced no pain at all. This effect was still present one hour after extubation. CONCLUSION: Even when injection pain is reduced, the use of a premedication regimen clearly has additional value with respect to the patients' experience. Considering the low VAS scores observed overall, it might be worthwhile to reserve additional injection pain-reducing interventions for individual patients rather than adding them as a component of standard practice.

Prevalence of IgE-binding to Art v 1, Art v 4 and Amb a 1 in mugwort-allergic patients.

BACKGROUND: Mugwort (Artemisia vulgaris) represents an important source of weed pollen allergens. The objectives of the present study were (i) to analyze the IgE binding profiles in a group of mugwort-allergic patients, (ii) to identify individual marker allergens crucial for the diagnosis of mugwort allergy and (iii) to identify potential crossreactive allergens present in ragweed (Ambrosia artemisiifolia) pollen extract. METHODS: Sera from 100 pediatric mugwort-allergic patients were analyzed for their IgE binding pattern to natural mugwort and ragweed pollen proteins, purified natural and recombinant Art v 1, recombinant Art v 4 and recombinant Amb a 1 using immunoblots and ELISA. RESULTS: 91% of the patients' sera tested displayed IgE binding to one or more mugwort pollen allergens in ELISA and 88% were positive in immunoblot. Purified natural Art v 1 was recognized by 79%, the recombinant protein by 39% of the patients tested and purified recombinant Art v 4 by 34% of the patients' sera. 67% of the sera displayed crossreactive IgE to one or more ragweed pollen allergens. Recombinant Amb a 1 was noted in only 14% of the mugwort-allergic sera. CONCLUSIONS: Allergen-specific in vitro diagnosis was performed in 100 pediatric mugwort-allergic serum samples. Using two allergens (Art v 1 and Art v 4), 91% of the patients could be identified as mugwort pollen-sensitized patients by IgE in vitro tests. Crossreactivity to ragweed pollen allergens was demonstrated by in vitro experiments, suggesting a new important and potent allergen source expanding across Europe.

[Pathology and genetic hereditary kidney cysts]. / Pathologie und Genetik hereditärer Zystennieren.

The classification of cystic kidney diseases according to the pathologic-anatomic potter classification may be difficult. New molecular genetic findings are important to understand the underlying pathogenesis, but less useful to classify the hereditary diseases. An exact classification of polycystic kidney disease in fetus and children is very important for the human genetic consultation. Therefore, the investigation of pathological anatomy of kidney and liver, as well as the evaluation of additional malformations and family history is necessary. For clinical use the mode of inheritance (autosomal dominant and autosomal recessive) is used to differentiate hereditary polycystic kidney diseases.

Optimization of codon usage is required for effective genetic immunization against Art v 1, the major allergen of mugwort pollen.

BACKGROUND: As the major allergen of mugwort pollen, Art v 1 is an important target for specific immunotherapy. However, both recombinant protein as well as a gene vaccine for Art v 1 failed to be immunogenic in mice. In order to improve immunogenicity we focused on genetic immunization because interspecific differences of codon usage have been shown as an obstacle for effective induction of immune responses with gene vaccines encoding infectious pathogens. OBJECTIVE: In order to find out, whether codon usage might also be used to improve genetic immunization with allergen genes, the response against a gene vaccine expressing the wild-type gene of Art v 1 (pCMV-wtArt) was compared with a synthetic codon-optimized vector with human codon usage (pCMV-humArt). METHODS: Balb/c mice were injected intradermally with pCMV-wtArt or pCMV-humArt. In vitro expression levels of both constructs were compared in transfection experiments. Total immunoglobulin G (IgG), IgG1, IgG2a and IgE antibodies were analyzed by enzyme-linked immunosorbent assay and the anaphylactic activity of the sera was determined by allergen-specific degranulation of rat basophil leukemia-2H3 cells. RESULTS: No immune response was detectable with the gene vaccine expressing the wildtype Art v 1, but immunization with pCMV-humArt revealed a strong and allergen-specific induction of antibody responses. The antibodies recognized both the recombinant as well as the purified natural (glycosylated) Art v 1 molecule. The response type was Th1-biased, as indicated by high levels of IgG2a antibodies. Expression analysis with B16 mouse melanoma cells transfected with pCMV-humArt or pCMV-wtArt revealed an impaired expression of the wild-type vector but normal translation after recoding. CONCLUSION: The results demonstrate that optimization of codon usage offers a simple way to improve immunogenicity and therefore should be routinely considered in the development of gene vaccines for the treatment of allergy.

[Therapy of the Melkersson-Rosenthal syndrome with kenalog]. / Terapija Melkersson-Rosenthal sindroma sa preparatom kenalog.

IA case of Melkersson-Rosenthal syndrome with major and minor symptoms is presented. Clinical diagnosis was established on the basis of the triad: macrocheilia, lingua plicata and facial paralysis and a number of minor symptoms. The upper lip macrocheilia with palpation evident infiltrates corresponded to the diagnosis of granulomatous cheilitis of the upper lip. The upper lip was of intense red color, with the vermilion border effaced causing a marked cosmetic defect. The predominant subjective symptoms were burning and itching sensations with a reduction of movement of the lip. Clinical examination and palpation revealed three granulations enclosed by fissures. A slight exfoliation of the epithelia with serous exudate was dominant feature. The patient was admitted to the Oral Medicine Department of Dental School in Sarajevo on October 8th 1999 for macrocheilia relapses. The therapy using subcutaneous application of kenalog-40 suspension once a week in duration of five weeks showed substantial improvement. According to the prognostic criteria and the control examinations there were no relapses.

[Diabetes mellitus and Candida albicans]. / Diabetes mellitus i Candida albicans.

According to Salomon, diabetes mellitus is a chronic disease caused by inadequate insulin action. As a syndrome, it could come in practice in many different forms. This disease, from genetic aspect presents a very heterogeneous phenomenon. For that reason a research of oral cavity tissue in diabetic patients presents a very complex problem from the scientific point of view. Truly, in the research today there are controversial cognition about relationship between diabetes mellitus and oral cavity diseases: diabetic stomatopathy, oral candidiasis, alterations of oral mucosa and periodontia. In this paper a special aspect is given to the research of incidence of candidiasis which is the result of contamination of all other pathological alterations in oral cavity.

[Diabetes mellitus and periodontal diseases]. / Diabetes mellitus i parodontalne bolesti.

Opinions on the interdependence between diabetes mellitus and oral periodontal disease are controversial. Experimental and clinical investigations carried out so far have not brought unique results. General objective of our research is to investigate on the strictly defined group of subjects aged 35-44 with diabetes mellitus type I the influence of metabolic control HbA1C on changes of periodontium and other organs. According to duration of diabetes mellitus the patients are divided into subdecade and postdecade groups. This group consists of 56 patients out of which 33 patients are with subdecade and 23 with postdecade insulin-dependent diabetes mellitus. In this group periodontal pocket depths, gingival index, number of extracted teeth and the volume of nonstimulated saliva are measured in comparison with a control group. The incidence of oral diseases and complications in other organs of insulin-dependent patients in subdecade and postdecade period are also examined and recorded. Periodontal diabetic disease is verified by pathohistological findings. Values of HbA1C in either subdecade or postdecade group with diabetes mellitus are above normal values. Values of periodontal pocket depths as well as the values of gingival index are substantially greater at insulin-dependent diabetes mellitus patients compared to the control group.