Bedside tests for predicting difficult airways: an abridged Cochrane diagnostic test accuracy systematic review.

Although bedside screening tests are routinely used to identify people at high risk of having a difficult airway, their clinical utility is unclear. We estimated the diagnostic accuracy of commonly used bedside examination tests for assessing the airway in adult patients without apparent anatomical abnormalities scheduled to undergo general anaesthesia. We searched for studies that reported our pre-specified bedside index screening tests against a reference standard, published in any language, from date of inception to 16 December 2016, in seven bibliographic databases. We included 133 studies (127 cohort type and 6 case-control) involving 844,206 participants. Overall, their methodological quality (according to QUADAS-2, a standard tool for assessing quality of diagnostic accuracy studies) was moderate to high. Our pre-specified tests were: the Mallampati test (6 studies); modified Mallampati test (105 studies); Wilson risk score (6 studies); thyromental distance (52 studies); sternomental distance (18 studies); mouth opening test (34 studies); and the upper lip bite test (30 studies). Difficult facemask ventilation, difficult laryngoscopy, difficult intubation and failed intubation were the reference standards in seven, 92, 50 and two studies, respectively. Across all reference standards, we found all index tests had relatively low sensitivities, with high variability, but specificities were consistently and markedly higher than sensitivities. For difficult laryngoscopy, the sensitivity and specificity (95%CI) of the upper lip bite test were 0.67 (0.45-0.83) and 0.92 (0.86-0.95), respectively; upper lip bite test sensitivity (95%CI) was significantly higher than that for the mouth opening test (0.22, 0.13-0.33; p < 0.001). For difficult tracheal intubation, the modified Mallampati test had a significantly higher sensitivity (95%CI) at 0.51 (0.40-0.61) compared with mouth opening (0.27, 0.16-0.41; p < 0.001) and thyromental distance (0.24, 0.12-0.43; p < 0.001). Although the upper lip bite test showed the most favourable diagnostic test accuracy properties, none of the common bedside screening tests is well suited for detecting unanticipated difficult airways, as many of them are missed.

High-sensitivity cardiac troponin T in young, healthy adults undergoing non-cardiac surgery.

BACKGROUND: It is unclear if isolated postoperative cardiac-troponin elevation, often referred to as myocardial injury, represents a pathological event, as control studies in otherwise healthy adults are lacking. METHODS: In this single-centre prospective observational cohort study, serial high-sensitivity cardiac troponin T (hscTnT) plasma concentrations were obtained from young, healthy adults undergoing elective orthopaedic surgery at three time points: before operation, 2-6 h, and 18-30 h after surgery. End points were hscTnT increases after surgery: ≥20% (exceeding analytical variability), ≥50% (exceeding short-term biological variability), and ≥85% (exceeding long-term biological variability). The secondary end point was myocardial injury, defined as new postoperative hscTnT elevation >99th % upper reference limit (URL) (women >10 ng litre-1; men >15 ng litre-1). RESULTS: Amongst the study population (n=95), no hscTnT increase ≥20% was detected in 68 patients (73%). A hscTnT increase between 20% and 49% was observed in 17 patients (18%), 50-84% in seven patients (7%), and ≥85% in three patients (3%). Twenty patients (21%) had an absolute ΔhscTnT between 0 and 2 ng litre-1, 12 patients (13%) between 2 and 4 ng litre-1, three patients between 4 and 6 ng litre-1, and one patient (1%) between 6 and 8 ng litre-1. Myocardial injury (new hscTnT elevation >99th%) was diagnosed in one patient (1%). The median hscTnT concentrations did not increase after operation, and were 4 (3.9-5, inter-quartile range) ng litre-1 at baseline, 4 (3.9-5) ng litre-1 at 2-6 h after surgery, and 4 (3.9-5) ng litre-1 on postoperative day 1. CONCLUSIONS: One in four young adult patients without known cardiovascular disease developed a postoperative hscTnT increase, but without exceeding the 99th% URL and without evidence of myocardial ischaemia. These results may have important ramifications for the concept of postoperative myocardial injury, as they suggest that, in some patients, postoperative cardiac-troponin increases may be the result of a normal physiological process in the surgical setting. CLINICAL TRIAL REGISTRATION: NCT 02394288.

Predictors for and coverage of influenza vaccination among HIV-positive patients: a cross-sectional survey.

OBJECTIVES: Influenza vaccination is recommended for HIV-infected patients, but limited data about vaccination rates are available. The aim of this study was to evaluate the coverage of and predictors for influenza vaccination among HIV-positive patients. METHODS: All HIV-positive patients who visited the HIV out-patient department of the University Hospital of Vienna, Austria, between June and August 2015 were asked to participate in this survey by completing a questionnaire. RESULTS: A total of 455 HIV-positive patients completed a questionnaire, with 359 male and 96 female participants with a mean age of 46 years. The influenza vaccination rate for the previous season (2014/2015) was 11.9% [n = 54/455; 95% confidence interval (CI) 9.2-15.2%]. Older age was significantly associated with a positive influenza vaccination status. Obtaining information through a medical consultation or receiving a direct recommendation for vaccination by a physician had a significant impact on vaccination behaviour. The probability of being vaccinated against influenza was about 13 times higher among patients who received a recommendation for vaccination by their family physician or by their HIV specialist (P < 0.001). Important reasons for declining vaccination were fear of side effects (39%), not considering influenza as a severe disease (36%) and reasons related to HIV: 17% were worried that the vaccine could worsen the course of HIV infection and 16% believed vaccination would fail because of their compromised immune system. CONCLUSIONS: A low influenza vaccination rate of 11.9% was detected in this HIV-positive cohort. The most effective impact for a positive vaccination status was direct recommendation of the influenza vaccine by the attending physician.

Emergency extracorporeal life support and ongoing resuscitation: a retrospective comparison for refractory out-of-hospital cardiac arrest.

BACKGROUND: In refractory cardiac arrest, with cardiopulmonary resuscitation (CPR) for more than 30 min, chances of survival are small. Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for certain patients with cardiac arrest. The aim of this study was to evaluate characteristics of patients selected for ECPR. METHODS: Anonymised data of adult patients suffering refractory cardiac arrest, transported with ongoing CPR to an ED of a tertiary care centre between 2002 and 2012 were analysed. Outcome measure was the selection for ECPR. Secondary outcome was 180 days survival in good neurological condition. RESULTS: Overall, 239 patients fulfilled the inclusion criteria. ECPR was initiated in seven patients. Patients treated with ECPR were younger (46 vs 60 years; p=0.04), had shorter intervals before CPR was started (0 vs 1 min; p=0.013), faster admissions at the ED (38 vs 56 min; p=0.31) and lower blood glucose levels on admission (14 vs 21 mmol/L; p=0.018). Survival to discharge in good neurological condition was achieved in 14 (6%) of all patients. One patient in the ECPR group survived in excellent neurological condition. Age was independently associated with the selection for ECPR (OR 0.07; 95% CI 0.01 to 0.85; p=0.037). CONCLUSIONS: Emergency extracorporeal life support was used for a highly selected group of patients in refractory cardiac arrest. Several parameters were associated with the decision, but only age was independently associated with the selection for ECPR. The patient selection resulting in a survival of one patient out of seven treated seems reasonable. Randomised controlled trials evaluating the age limit as selection criteria are urgently needed to confirm these findings.

Admission blood pressure and 1-year mortality in acute myocardial infarction.

AIMS: Arterial hypertension is a well-established factor for increased risk of cardiovascular diseases, but low admission blood pressure has also been suggested as predictor for increased mortality. We hypothesised that in patients with acute myocardial infarction admission blood pressure at the Emergency Department predicts long-term mortality. METHODS: We included consecutive patients treated for acute myocardial infarction (AMI) at our 2,200-bed tertiary care hospital from 1991 to 2009 into our cohort. Systolic, diastolic and pulse pressure on admission were analysed as main predictors for 1-year mortality. We adjusted for several baseline factors and tested for interactions using multivariable regression models. RESULTS: We included 3943 patients among whom 3604 were alive after 1 year. With increasing admission blood pressure 1-year mortality risk decreased incrementally to a 70% reduced relative risk in the highest blood pressure categories vs. the lowest categories. This effect was independent of blood pressure modifying interventions. CONCLUSIONS: In acute myocardial infarction, admission blood pressure predicts long-term mortality in an inverse relation. With increasing admission blood pressure long-term mortality decreases. Low admission blood pressure should serve as a warning sign in patients with AMI. Admission blood pressure should therefore be interpreted in opposite to the regular, preventive, point of view.

Prevalence of carbon monoxide poisoning in patients presenting to a large emergency department.

AIMS: Carbon monoxide (CO) can cause lethal intoxication, but the burden of occult CO poisoning is still unclear. We aimed at prospectively assessing the number of patients with occult CO poisoning presenting to an emergency department within one year. METHODS: Prospective, observational study according to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement for cross sectional studies at a European high volume tertiary-care emergency department. RESULTS: Thirty-two thousand three-hundred and ninety-six consecutive patients whose vital signs were assessed at triage, regardless of their complaints. Active screening for CO-poisoning by non-invasive CO-oximetry was performed at triage. A pragmatic diagnosis of CO poisoning was made by attending physicians in 32 cases, representing 99/100,000 emergency department (ED)-patients. Three different definitions of poisoning were developed based on physicians' decision criteria, resulting in 9, 12, and 48 cases, respectively. CONCLUSIONS: In our study population, the prevalence of CO poisoning was twice as high as previously reported. The number of cases highly depends on the definition used, with more strict definitions excluding mainly cases during the summer months, where the source of CO often remains unknown. A clear consensus on which patients have to be regarded as 'poisoned' is urgently needed in order to allow comparison across studies.

High prevalence of antibodies against Leptospira spp. in male Austrian adults: a cross-sectional survey, April to June 2009.

To assess the distribution of specific antibodies against Leptospira spp. in Austrian adults, we conducted an explorative nationwide cross-sectional serological study in 400 healthy individuals. Antibody titres against Leptospira spp. were determined in a microscopic agglutination test using a panel of 14 serovar cultures. Sera of 18 participants were excluded because the samples were unsuitable for testing; the remaining 382 participants comprised 166 professional soldiers and 216 civilians. Overall, 88 (23%) individuals tested positive in serological screening. The subjects' sera reacted most frequently with serovars Canicola (16.5%) and Hardjo (11.8%). Epidemiological information was obtained from a questionnaire: no correlation was found for area of residence, travel abroad, regular outdoor activities, occupational animal contact, or ownership of companion animals. The proportion of seropositive samples was significantly lower among professional soldiers (15.7%) than among civilians (28.7%) (p=0.003). Our data demonstrate serological evidence of a high rate of exposure to Leptospira spp. among the Austrian population. No increased risk of exposure to Leptospira spp. was detected in military personnel.

Clinical aspects of 2009 pandemic influenza A (H1N1) virus infection in Austria.

PURPOSE: To describe the clinical features, risk factors for severe disease and effectiveness of oseltamivir in patients with 2009 pandemic influenza A (H1N1) virus infection. METHODS: In a prospective, cross-sectional, multicentre study, data on 540 patients with confirmed 2009 H1N1 infection from seven Austrian hospitals were collected using a standardised online case-history form. RESULTS: The median age of the patients was 19.3 years (range 26 days-90.8 years); point-of-care testing yielded false-negative results in 60.2% of the 176 cases tested. The most common symptoms were fever, cough, fatigue and headache. Overall, 343 patients (63.5%) were hospitalised, 49 (9.1%) were admitted to an intensive care unit (ICU) and 14 (4.1%) died. Case fatality rates were highest (9.1%) in those aged 65 years or older. Factors significantly associated with a higher risk for ICU admission included age, neurological disease, adipositas, and both interstitial pathology and lobular pathology on chest X-ray. No association with pregnancy, malignancy or immunosuppressive therapy was detected. Antiviral treatment significantly reduced the duration of fever by 0.66 days and lowered the risk of ICU admission, but had no significant benefit on survival. CONCLUSIONS: During the 2009 H1N1 influenza pandemic, elderly or obese patients and those with neurological disease had an increased risk for severe H1N1 infection in Austria. Pregnancy was not associated with a higher risk for severe disease in the later phase of the 2009 H1N1 pandemic. Antiviral treatment provided a minimal effect on the symptoms of influenza but reduced the risk of admission to an ICU.

Immunogenicity of a combined schedule of 7-valent pneumococcal conjugate vaccine followed by a 23-valent polysaccharide vaccine in adult recipients of heart or lung transplants.

A combined schedule of 7-valent pneumococcal conjugate vaccine (PCV7) followed by 23-valent pneumococcal polysaccharide vaccine (PPV23) was evaluated retrospectively in 26 adult recipients of heart or lung transplants. PCV7 was immunogenic in these patients but there appeared to be no benefit from the additional PPV23 dose.

Restricting evidence syntheses of interventions to English-language publications is a viable methodological shortcut for most medical topics: a systematic review.

OBJECTIVES: To assess the impact of restricting systematic reviews of conventional or alternative medical treatments or diagnostic tests to English-language publications. STUDY DESIGN AND SETTING: We systematically searched MEDLINE (Ovid), the Science Citation Index Expanded (Web of Science), and Current Contents Connect (Web of Science) up to April 24, 2020. Eligible methods studies assessed the impact of restricting systematic reviews to English-language publications on effect estimates and conclusions. Two reviewers independently screened the literature; one investigator performed the data extraction, a second investigator checked for completeness and accuracy. We synthesized the findings narratively. RESULTS: Eight methods studies (10 publications) met the inclusion criteria; none addressed language restrictions in diagnostic test accuracy reviews. The included studies analyzed nine to 147 meta-analyses and/or systematic reviews. The proportions of non-English-language publications ranged from 2% to 100%. Based on five methods studies, restricting literature searches or inclusion criteria to English-language publications led to a change in statistical significance in 23/259 meta-analyses (9%). Most commonly, the statistical significance was lost, but had no impact on the conclusions of systematic reviews. CONCLUSION: Restricting systematic reviews to English-language publications appears to have little impact on the effect estimates and conclusions of systematic reviews.

An inosine 5'-monophosphate dehydrogenase 2 single-nucleotide polymorphism impairs the effect of mycophenolic acid.

Mycophenolic acid (MPA) is a selective inhibitor of inosine 5'-monophosphate dehydrogenase (IMPDH), the rate-limiting enzyme of de novo synthesis of guanine nucleotides. The isoenzyme IMPDH2 predominates in activated lymphocytes, and its inhibition by MPA is part of standard immunosuppressive regimens. Yet, there are significant unexplained differences in efficacy and tolerability among patients. The objective of this study was to analyze whether frequent variants in the IMPDH2 gene lead to changes in IMPDH activity and to differences in responsiveness to MPA therapy. All 14 exons and intron-exon boundary regions of IMPDH2 were sequenced from genomic DNA probes from 100 healthy individuals. Two novel exonic single-nucleotide polymorphisms were identified in 1% and one intronic polymorphism (rs11706052) in 19% of the study population. Lymphocyte IMPDH activity and proliferation under three MPA concentrations (2.5, 10 and 25 micromol l(-1)) were compared in rs11706052 carriers and wild-type individuals. The presence of rs11706052 polymorphism reduced the antiproliferative effect of MPA on lymphocytes by approximately 50% compared with the IMPDH2 wild-type form at therapeutic relevant concentrations of 10 micromol l(-1) and 25 micromol l(-1). We conclude that a poorer response to MPA therapy can be explained in some individuals by the presence of the rs11706052 polymorphism.

Time of out-of-hospital cardiac arrest is not associated with outcome in a metropolitan area: A multicenter cohort study.

AIM: Whether time of day influences survival after out-of-hospital cardiac arrest (OHCA) remains controversial. We compared outcomes after OHCA between day and night and explored whether characteristics of pre-hospital advanced life support (ALS)-quality varied by time of day. METHODS: We conducted a prospective cohort study of individuals that suffered a non-traumatic OHCA in the city of Vienna between August 2013 and August 2015 and who received resuscitative efforts by EMS. We compared clinical outcomes between day and night, defined as 7:00 pm-7:00 am based on EMS shift time including rates of sustained return of spontaneous circulation (ROSC), 30-day survival and favourable neurologic outcome (cerebral performance category 1 or 2). ALS quality measures included time to first medical contact, time to first shock, total dose of epinephrine, and multiple ALS performance measures. RESULTS: We included 1811 patients (37% female) with a mean age of 67 ± 16 years in our analyses. Rates of ROSC and 30-day survival with favourable neurological outcome did not differ between day or night (30% vs 28%, p =  0.33; 12% vs. 11%, p =  0.51, respectively). These results remained unchanged after multivariate adjustment for ROSC (RR, 1.1; 95% CI, 1.0-1.3, p = 0.19) and 30-day survival with favourable neurological outcome (RR, 1.2; 95% CI, 1.0-1.5, p =  0.10). The quality of ALS did not differ between day and night. CONCLUSIONS: In contrast to previous studies, there was no significant difference in sustained ROSC rates and 30-day survival with favourable neurological outcome after OHCA between day and night in the city of Vienna. This is likely due to nearly identical high bystander CPR rates and identical ALS performance provided by EMS personnel irrespective of time of the day.

Transport with ongoing cardiopulmonary resuscitation may not be futile.

BACKGROUND: Despite it being generally regarded as futile, patients are regularly brought to the emergency department with ongoing cardiopulmonary resuscitation (CPR). METHODS: Long-term outcome and its predictors in patients who were transported during ongoing CPR were evaluated in an observational study. Adult patients with non-traumatic cardiac arrest admitted to the Department of Emergency Medicine of a tertiary-care facility after transport with ongoing chest compression were retrospectively analysed. Multivariate analysis of epidemiological variables, treatment, blood gas values on admission, cause of arrest, and location of arrest was performed to find factors that were predictive for favourable long-term outcome (6-month survival, best cerebral performance category 1 or 2). RESULTS: Over 15 yr (1991-2006), a total of 2643 patients were treated after cardiac arrest. Of these, 327 patients received chest compressions during transport and were analysed (out-of-hospital cardiac arrest: n=244, in-hospital: n=83; the remaining 2316 patients were either stabilized before transport or suffered their arrest in our department). Return of spontaneous circulation was achieved in 31% of patients (n=102). Of these, 19 (19%) had favourable long-term outcome (6% of total). Independent predictors of good outcome were age, witnessed arrest, amount of epinephrine, and initial shockable rhythm. Among the patients with cardiac origin of arrest, 11 out of 197 patients (6%) survived; pulmonary origin, 4 out of 46 patients (9%); hypothermic arrest, 1 of 10 patients (10%); and intoxications, one out of nine patients (11%). CONCLUSIONS: Post-resuscitation care in patients who receive CPR during transport is not futile. Once restoration of spontaneous circulation is established, one out of five patients will have good long-term outcome.

Leishmania infections in Austrian soldiers returning from military missions abroad: a cross-sectional study.

OBJECTIVES: The incidence of leishmaniasis is known to increase in conflict areas. The aims of this study were to determine the exposure to Leishmania species in Austrian soldiers returning from missions abroad and to assess possible risk factors. METHODS: A retrospective explorative cross-sectional serologic study was conducted in 225 healthy Austrian soldiers returning from UN or EU peacekeeping missions in Syria, Lebanon and Bosnia and Herzegovina (BIH). Sera were tested for anti-Leishmania antibodies using a commercial enzyme-linked immunosorbent assay. All positive individuals were screened for Leishmania DNA by PCR targeting the ITS1 region using EDTA blood samples. RESULTS: In total, 13.3% (30/225) of the individuals tested were either positive (8%, 18/225) or borderline (5.3%, 12/225) in the enzyme-linked immunosorbent assay, with the highest seroprevalence in soldiers returning from Syria (17.8%, 18/101; 12 positive, six borderline), second from Lebanon (11.1%, 7/63; four positive, three borderline) and lowest from BIH (8.2%, 5/61; two positive, three borderline). Ten soldiers returning from Syria and one from BIH were also positive for Leishmania DNA. Six of these were identified as Leishmania donovani/infantum complex, two as L. tropica and another three as mixed infections by DNA sequencing. Epidemiologic data were collected via a questionnaire, and seropositivity was correlated with a history of insect bites that took a long time to heal (odds ratio, 5.33; 95% confidence interval, 1.23-23.04; p 0.025). CONCLUSIONS: Although pretravel serologic data were not available in this study, the exposure of soldiers to Leishmania spp. during their missions can be assumed to be considerable. Because even asymptomatic infections may resurge in case of emerging immunodeficiencies, adequate prevention measures seem important.

Human heart-type fatty-acid-binding protein as a point-of-care test in the early diagnosis of acute myocardial infarction.

BACKGROUND: At very early stages of acute myocardial infarction (AMI), highly sensitive biomarkers are still lacking. AIM: To evaluate the utility of human heart-type fatty acid-binding protein (h-FABP) for early diagnosis of AMI. DESIGN: Prospective diagnostic study. METHODS: Consecutive patients presenting to the emergency department with chest pain or dyspnoea within 24 h of symptom onset were included. At presentation, the h-FABP test result was compared to the standard diagnostic work-up, including repeated ECG and troponin T measurements. Sensitivity analysis was performed for inconclusive tests. RESULTS: We enrolled 280 patients presenting to hospital with a median symptom onset of 3 h (IQR 2-6 h): 109 (39%) had AMI. At presentation, h-FABP had a sensitivity of 69% (95%CI 59-77) and specificity of 74% (95%CI 66-80); 45 tests were false-positive and 34 were false-negative. Omitting inconclusive tests increased sensitivity and specificity only slightly. AMI was identified significantly earlier by h-FABP than by troponin T (24 vs. 8 patients, p=0.005). DISCUSSION: Although h-FABP can help to detect myocardial damage at an early stage in patients with chest pain or dyspnoea, it appears unsuitable as a stand-alone test for ruling out AMI.

Bed rest for acute uncomplicated myocardial infarction.

BACKGROUND: Bed rest is prescribed to all patients with acute myocardial infarction (AMI), but to a variable extent. Current guidelines (American College of Cardiology/ American Heart Association) recommend at least 12 hours bed rest in patients with uncomplicated ST-elevation myocardial infarction, however the basis for this recommendation is unclear. OBJECTIVES: To compare the effects of short versus longer bed rest in patients with uncomplicated AMI. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2005), MEDLINE (January 1966 - August 2005), EMBASE (January 1988 - August 2005), PASCAL BioMed (January 1996 - August 2005); PsycINFO (January 1966 - August 2005) and BIOSIS Previews (January 1990 - August 2005). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of short versus longer bed rest in patients with uncomplicated AMI were sought. DATA COLLECTION AND ANALYSIS: Study selection was performed independently by at least two investigators according to the predefined inclusion criteria. Data were extracted by two investigators independently and in duplicate. Authors were contacted to obtain missing information. MAIN RESULTS: We found 15 trials with 1487 patients assigned to a short period of bed rest (median 6 days) and 1471 patients assigned to longer bed rest (median 13 days). Generally the studies were outdated and appeared to be of moderate to poor methodological reporting quality. There was no evidence that shorter bed rest was more harmful than longer bed rest in terms of all cause mortality (RR=0.85 (95%CI 0.68 to 1.07), cardiac mortality (RR=0.81 (95%CI 0.54 to 1.19), or reinfarction (RR=1.07 (95%CI 0.79 to 1.44)). AUTHORS' CONCLUSIONS: Bed rest ranging from 2 to 12 days appears to be as safe as longer periods of bed rest. The quality of most trials is unsatisfactory. Current bed rest recommendations are not supported by the existing evidence as the optimal duration of bed rest is unknown. The lack of adequate trials is surprising, considering the large size of several studies to compare effectiveness of drugs on people with AMI.

Creatine kinase-mb fraction and cardiac troponin T to diagnose acute myocardial infarction after cardiopulmonary resuscitation.

OBJECTIVES: This study sought to evaluate the diagnostic value of the biochemical markers creatine kinase (CK), creatine kinase-MB fraction (CK-MB) and cardiac troponin T (cTNT) to diagnose acute myocardial infarction (AMI) after cardiopulmonary resuscitation (CPR). BACKGROUND: Elevations of CK and CK-MB after CPR are a frequent finding and might be associated with ischemic myocardial injury, as well as physical trauma to the chest. METHODS: Patients who had cardiac arrest and primary successful resuscitation were included in the study. The diagnosis of AMI was confirmed or ruled out by means of typical electrocardiographic findings, thallium-201 myocardial scintigraphy or autopsy, if death occurred during the hospital period, in 39 primary survivors of sudden cardiac death. In 24 patients (62%) the diagnosis of AMI was established. Serum cTNT, CK and CK-MB were measured, and the CK-MB/CK ratio was calculated on admission and after 12 h. RESULTS: On admission all markers of myocardial injury proved to be weak methods for the diagnosis of AMI. After 12 h cTNT as well as CK-MB exhibited a similar diagnostic performance; CK and the CK-MB/CK ratio proved to be worthless. Sensitivity and specificity for a cTNT cutoff value of 0.6 ng/ml, 12 h after cardiac arrest, were 96% and 80%, respectively. For a CK-MB cutoff value of 26 U/liter, sensitivity was 96% and specificity was 73%. CONCLUSIONS: Cardiac TNT and CK-MB are valuable tools in detecting AMI as the cause of sudden cardiac death. However, there is a considerable lack of sensitivity and specificity. Cardiac injury is probably caused not only by AMI, but also by myocardial damage related to CPR efforts.

Clinical evaluation of different doses of intravenous enalaprilat in patients with hypertensive crises.

BACKGROUND: The appropriate dose of intravenous enalaprilat to be used in the treatment of hypertensive crisis is controversial. There has been no comparative study of the efficacy and safety of different dosages of enalaprilat in hypertensive patients. METHODS: Sixty-five consecutive patients with hypertensive urgencies (systolic blood pressure > 210 mm Hg and/or diastolic blood pressure > 110 mm Hg) or emergencies (diastolic blood pressure > 100 mm Hg and evidence of end-organ damage, ie, angina pectoris, hypertensive encephalopathy, or congestive heart failure) admitted to an emergency department from January 1, 1994, to September 30, 1994, were identified. The patients were randomized to receive different doses of enalaprilat (0.625, 1.25, 2.5, and 5 mg). Response to treatment was defined as a stable reduction of systolic blood pressure to below 180 mm Hg and diastolic blood pressure to below 95 mm Hg within 45 minutes after the start of treatment and relief of symptoms in patients with hypertensive emergencies. RESULTS: In 41 (63%) of 65 patients, the treatment goal was reached. Twenty-four patients (37%) failed to achieve the goal of treatment within 45 minutes after administration of enalaprilat. The response rates in the 0.625-mg, 1.25-mg, 2.5-mg, and 5-mg groups were 67%, 65%, 59%, and 62%, respectively. The proportion of patients initially randomized who responded to treatment was not different between any of the four groups of enalaprilat doses. There were no significant differences according to enalaprilat dose with respect to changes in systolic, diastolic, and mean arterial blood pressure. No severe side effects were observed. CONCLUSION: Enalaprilat is a safe antihypertensive drug with moderate efficacy in the treatment of hypertensive crisis. As doses above 0.625 mg alter neither response rates nor the magnitude of blood pressure reduction, we recommend 0.625 mg as the initial dose in the treatment of hypertensive crisis.

Low tetanus, diphtheria and acellular pertussis (Tdap) vaccination coverage among HIV infected individuals in Austria.

Current management guidelines of HIV infected adults include recommendation to immunization against common vaccine preventable diseases. This effort is hindered by the scarce knowledge regarding the immunization status of this especially vulnerable patient group. This study analyzed the serostatus for pertussis, diphtheria and tetanus of more than 700 HIV infected individuals residing in Austria. These individuals were representative for the Austrian HIV cohort regarding sex, age, transmission risk and HIV progression markers. Overall, 73.6% were on suppressive HAART, mean CD4 cell count was 603c/µl. Seropositivity was 84% for diphtheria, 51% for tetanus and 1% for pertussis. Migrants had a lower chance of tetanus seropositivity (OR 0.30 (CI 0.21 to 0.43)). Increase in CDC classification were associated with increased diphtheria seropositivity (OR 1.42 (CI 1.02 to 1.98)) and a CD4 nadir<200c/µl was associated with increased pertussis seropositivity (OR 12.2, 95% CI 1.2 to 121). Importantly due to the well preserved immune status of nearly all participants vaccination would be feasible in the majority of the seronegative patients. In patients with a CD4 count>200c/µl, 95% lacked seroprotection to at least one of the antigens included in the triple vaccine Tdap and could be vaccinated. Thus, a proactive approach would largely reduce the number of patients at risk for these vaccine-preventable diseases.