Echocardiography has minimal yield and may not be warranted in Staphylococcus aureus bacteremia without clinical risk factors for endocarditis.

Current guidelines recommend performing echocardiography in all patients with Staphylococcus aureus bacteremia (SAB), but patients at very low risk of endocarditis may not benefit from this investigation. This study seeks to identify patients at very low risk of endocarditis. A retrospective single-center consecutive case series of patients with SAB was examined. Microbiological and echocardiographic data were used to identify patients with community onset, prolonged bacteremia, and intracardiac prosthetic devices. The diagnostic performance of these criteria for endocarditis as measured against transesophageal echocardiography (TEE) was calculated. 593 episodes of SAB were examined over a period of 6 years. 10 % were excluded from analysis due to death or discharge less than 48 h after the first positive blood culture or no admission to hospital, leaving 532 episodes for analysis. 64 % of the included episodes were investigated with echocardiography: 39 % with TEE and 26 % with transthoracic echocardiography (TTE) only. 16 % of the episodes investigated with echocardiography were demonstrated to have endocarditis. The rate of endocarditis was higher for episodes undergoing TEE (24 %) than TTE only (5 %). There were no instances of endocarditis amongst the 23 episodes investigated with TEE where none of the three risk factors were present. This group represented 57 % of the nosocomial (non-community-onset) episodes investigated with TEE. Patients with none of the three criteria examined in this study have a very low rate of endocarditis and may fall below the test threshold for echocardiography.

Overview of shorthand medical glossary (OMG) study.

BACKGROUND: Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable. AIM: We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries. METHODS: Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff. RESULTS: The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary. CONCLUSION: Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.

Mobilized peripheral blood stem cells provide rapid reconstitution but impaired long-term engraftment in a mouse model.

In this study, we use competitive repopulation to compare the quality and frequency of stem cells isolated from mobilized blood with stem cells isolated from bone marrow (BM) in a mouse model. Lin(-)Sca-1(+)c-Kit(+) (LSK) cells were harvested from control BM and peripheral blood of mice following granulocyte colony-stimulating factor (G-CSF) administration. LSK cells were used because of their resemblance to human CD34(+) cells. We confirmed that transplantation of phenotypically defined mobilized peripheral blood (MPB) stem cells results in rapid recovery of blood counts. However, in vitro results indicated that LSK cells purified from MPB had lower cobblestone area-forming cell day 35 activity compared to BM. Additionally, evaluation of chimerism after co-transplantation of LSK cells purified from blood and BM revealed that MPB stem cells contained 25-fold less repopulation potential compared to BM stem cells. Competitive repopulating unit frequency analysis showed that freshly isolated MPB LSK cells have 8.8-fold fewer cells with long-term repopulating ability compared to BM LSK cells. Secondary transplantation showed no further decline in contribution of hematopoiesis relative to BM. We conclude that the reduced frequency of stem cells within the LSK population of MPB, rather than poorer quality, causes the reduced repopulation potential.Bone Marrow Transplantation (2007) 39, 401-409. doi:10.1038/sj.bmt.1705601; published online 12 February 2007.

Late neurological complications after prophylactic cranial irradiation in patients with small-cell lung cancer: the Toronto experience.

We retrospectively analyzed the charts of 58 long-term survivors of small-cell lung cancer (SCLC) (greater than 2 years) for neurological complications and their impact on the well-being of these patients. We also attempted to have patients complete a questionnaire regarding any possible neurological problems. This was done in 14 patients. Metastasis to the CNS occurred significantly less often in patients who received prophylactic cranial irradiation (PCI) in a dose of 20 Gy in five equal fractions (two of 48), compared with patients who did not receive it (four of 10) (P less than .006). Delayed neurological complications occurred in nine of 48 (19%) patients who received PCI. However, in only two patients did PCI appear to be responsible for progressive dementia. In the other seven patients (one with weakness in the arms and legs, one with transient left hemiparesis, two with hearing loss, and three with various visual disturbances), chemotherapeutic agents (mainly cisplatin and vincristine) and underlying diseases probably contributed significantly to the occurrence of these complications. In addition, these neurological disturbances were transient or ran a stable course and did not adversely affect the daily life of these patients. In comparison, amongst the 10 patients who did not receive PCI one had progressive dementia and another had hemiparesis secondary to probable brain embolism. We conclude that the use of PCI in these doses was effective in reducing the frequency of CNS metastases and had an adverse effect on the daily life and well-being only in a minority of the patients. Until results of controlled randomized studies show otherwise, PCI should continue to be used as a part of the combined modality treatment of completely responding patients with limited SCLC.

Small-cell carcinoma of the lung: derivation of a prognostic staging system.

Retrospective data on 22 pretreatment attributes were evaluated in 614 patients with small-cell carcinoma of the lung (SCCL). The series included 284 patients with limited disease (LD) and 328 patients with extensive disease (ED) managed between 1974 and 1986. Prognostic factors were evaluated by univariate analysis and by the Cox multivariate regression model. Recursive partition and amalgamation algorithm (RECPAM), two clustering methods well suited for obtaining strata and adapted for censoring survival data, were developed and used in the formulation of a new prognostic staging system. In univariate analysis, prognosis was significantly influenced by extent of disease (DE), the number of metastatic sites, and the detection of mediastinal spread in LD. Poor performance status (PS), male sex, and advanced age were negatively correlated with survival, as were increased serum levels of alkaline phosphates (AP), lactate dehydrogenase (LDH), carcinoembryonic antigen (CEA), total WBC count (WBCC), and low platelet count and low serum sodium. The Cox model identified plasma LDH and mediastinal spread as the only significant factors in LD; the influence of PS, number of metastatic sites, bone metastasis, brain metastasis, and platelet count were identified as significant in ED. The RECPAM model identified four distinct risk groups defined in a classification tree by the following eight attributes: DE, PS, serum AP, serum LDH, mediastinal spread, sex, WBCC, and liver metastasis. The four groups were distinguished by median survival times of 59, 49, 35, and 24 weeks, respectively (P = .0001). Interactions among prognostic factors are emphasized in the RECPAM classification model as evidenced by reassignment of patients across conventional staging barriers into alternate prognostic groups. The advantages of using RECPAM over the more conventional Cox regression techniques for a new staging system are discussed.

The prognostic significance of pretreatment serum lactate dehydrogenase in patients with small-cell lung cancer.

Pretreatment serum lactate dehydrogenase (LDH) levels were assayed in 288 patients presenting with small-cell lung cancer (SCLC) between 1976 and 1985. Patients were routinely staged by physical examination, chest x-ray, bone, brain, and liver scans, and bone marrow evaluation. Clinical response and survival were assessed following treatment with combination chemotherapy as part of four clinical trials. Patients with extensive disease (ED) presented with a higher incidence (108 of 147, 73%) of abnormally elevated LDH (greater than 193 IU/L) than those (65 of 141, 46%) with limited disease (LD) (P = 2 x 10(-6)). Forty percent of patients had an initial normal LDH level and a higher response rate (89 of 108, 82%; complete response [CR], 47%) than those with elevated values of LDH (119 of 156, 76%; CR, 29%). The CR rate varied inversely with the level of LDH in patients with LD (P = .026) but not in those with ED (P = .300). The median survival time and 1-year and 2-year survival rates for patients with elevated LDH were 39 weeks and 33% and 6%, respectively, whereas for those with a normal LDH level these were 53 weeks and 54% and 16%, respectively. Patients with LD and elevated levels of LDH manifested a higher relative death rate (1.63:1) when compared with patients with LD and LDH in the normal range (P = .0083). The survival of patients with ED did not differ between those with normal and elevated levels of LDH (P = .273). A significant survival advantage persisted for patients with LDH in the normal range following adjustments for extent of disease, performance status (PS), and treatment protocol (P = .044, log-rank analysis). In conclusion, serum LDH appears to be a significant independent pretreatment prognostic factor in patients with SCLC that correlates with stage of disease, response to treatment, and survival.

Combined modality induction therapy without maintenance chemotherapy for small cell carcinoma of the lung.

One hundred fifty-three patients with limited and 167 with extensive small cell carcinoma of the lung (SCCL) were evaluable for response to treatment with six courses of chemotherapy (cyclophosphamide, doxorubicin, and vincristine), irradiation to intrathoracic disease, and prophylactic cranial irradiation (PCI). No maintenance chemotherapy was given. Fifty-two percent of patients with limited disease (LD) and 10% of extensive disease patients (ED) achieved a complete response. The median survival times for LD and ED patients were 49 and 34 weeks, respectively. These results were compared to a previous experience with 147 patients who were treated with three courses of similar induction chemotherapy and thoracic irradiation, as well as one year of maintenance chemotherapy (CCNU, procarbazine, and methotrexate) but without PCI. Although the use of PCI was found to reduce the frequency of brain metastases as the site of first relapse, detailed comparisons of response rates and survival showed no significant differences between the two study populations. Prolonged maintenance chemotherapy of the type used in the first study does not favorably influence outcome after intensive induction therapy for SCCL.

Second primary malignancies following diagnosis of small-cell lung cancer.

PURPOSE AND METHODS: The records of 800 patients with small-cell carcinoma of the lung (SCLC) treated between 1971 and 1985 at University of Toronto-affiliated hospitals were reviewed for the occurrence and relative risk of second primary malignancies (SPMs). Almost all patients who developed a SPM were treated previously with chemotherapy and radiation therapy. RESULTS: Nineteen metachronous SPMs (MSPMs) and 11 synchronous SPMs (SSPMs) were identified. SSPMs were detected between 1 and 12 months after the diagnosis of SCLC. The MSPMs were identified between 1 and 10 years after the diagnosis of SCLC. MSPMs included non-small-cell lung cancer (NSCLC) (four patients), hematologic malignancies (HM) (three patients), and 12 with other solid tumors (OST). The median survival times after the diagnosis of MSPM was 33 months, 10 months, and 1 month, respectively, for those with NSCLC, OST, and HM. Expected cancer incidence rates were used to compute a relative risk rate for developing a MSPM in a subset of 392 patients on whom accurate follow-up information was available. The calculated relative risk for all tumors was 3.73. The relative risk for the development of secondary NSCLC was 6.83. CONCLUSION: We suggest that increased predisposition to SPM may relate to secondary effects of multimodality treatment and biologic considerations.

Clinical significance and origin of artifacts in transesophageal echocardiography of the thoracic aorta.

OBJECTIVES: The aim of this study was to identify the mechanism and features of artifacts encountered during transesophageal echocardiography of the aorta. BACKGROUND: Artifacts are an important potential limitation of transesophageal echocardiography of the aorta. METHODS: The mechanism of the artifacts was examined by in vitro modeling. The frequency and clinical correlates of artifacts were examined by retrospective review of transesophageal echocardiograms in 36 patients with aortic pathologic lesions. RESULTS: Two classes of artifact were seen: linear artifacts in the ascending aorta, which may mimic intimal flaps, and mirror image artifacts in the transverse and descending thoracic aorta. Linear artifacts in the ascending aorta, seen in 44% of patients, were shown in vitro to be multiple path artifacts caused by reflection of ultrasound within the left atrium. Linear artifacts in the ascending aorta were associated with dilatation of the ascending aorta and were more frequent when the aortic diameter exceeded the left atrial diameter (p < 0.001). The mirror image artifacts of the transverse and descending thoracic aorta give the appearance of a double-barrel aorta and were shown in vitro to be caused by the aorta-lung interface, which acts as a total reflector of ultrasound. Mirror image artifacts were seen in > 80% of patients. Artifacts were equally frequent with the sagittal and transverse imaging planes when biplane transesophageal echocardiography was used. CONCLUSIONS: Artifacts occur frequently during transesophageal echocardiography of the aorta. An understanding of why they occur and the features that distinguish them from true abnormalities should enhance the diagnostic accuracy of transesophageal echocardiography for aortic disease.

Ectopic corticotropin syndrome and small-cell carcinoma of the lung. Clinical features, outcome, and complications.

BACKGROUND: Ectopic corticotropin syndrome is a rare complication of small-cell lung cancer (SCLC). There is little information concerning this syndrome available in the literature. We therefore reviewed all cases of ectopic corticotropin syndrome seen at our institution during a 20-year period. METHODS: Cases were identified by searching a computerized database and reviewing the charts of all 840 patients with SCLC seen between 1971 and 1991. Patients were included if they met at least two of the following criteria: spontaneous hypokalemia (potassium level, < 3.2 mmol/L); plasma cortisol level greater than 600 nmol/L; 24-hour urinary free cortisol level greater than 400 nmol/d; and plasma corticotropin level greater than 22 pmol/L. Data were abstracted from the patients' medical records. RESULTS: Of 840 patients with SCLC, 14 (1.6%) had ectopic corticotropin production. This was diagnosed at the time of presentation with SCLC in seven patients and from 3 to 19 months later in the remainder. Five patients had limited disease and nine had extensive disease. One or more features of Cushing's syndrome were observed in 57% of patients, but the entire syndrome occurred rarely. Spontaneous hypokalemia was present in all patients, and 10 patients (71%) had hyperglycemia. There were two complete responses and one partial response to chemotherapy, giving an overall response rate of 21%, and the median survival was 5.5 months. Ten patients died of progressive growth of tumor, while three patients died of infections. In one other patient, infection probably contributed to death. A high rate of nonfatal infections was also seen. CONCLUSIONS: The occurrence of SCLC with ectopic corticotropin syndrome is associated with poor survival, and a high incidence of infective complications, in patients treated with chemotherapy.

Combined modality treatment of small cell carcinoma of the lung.

Ninety patients with extensive and 61 with limited small cell carcinoma of the lung were treated with three courses of intravenous chemotherapy (cyclophosphamide, doxorubicin hydrochloride, and vincristine sulfate) followed by radiotherapy to intrathoracic disease, and a second three-drug oral combination consisting of lomustine, procarbazine, and methotrexate for one year. Among the 147 patients who were evaluated, 55 of 66 (83%) with limited disease and 53 of 81 (65%) with extensive disease showed response after three courses of chemotherapy. The complete response rate in patients with limited disease prior to radiotherapy was 24%, but increased to 58% when evaluated following radiotherapy. The median survival was 47 weeks for patients with limited disease and 36 weeks for those with extensive disease. A 24% two-year survival is projected for complete responders. Important prognostic factors for survival are performance status, extent of disease, and sex, with female subjects doing somewhat better than male subjects. Among patients with limited disease, 45% failed within the CNS despite the use of chemotherapeutic agents that cross the blood-brain barrier. The initial induction regimen and radiotherapy were well tolerated; the oral three-drug combination was more toxic and did not prevent CNS metastases.

Circadian rhythms of heart rate and blood pressure after heart transplantation.

Blood pressure and heart rate were recorded over 24-hour periods on 39 occasions in 20 subjects 5 to 72 weeks after heart transplantation. All patients were receiving cyclosporine, azathioprine, and prednisolone. In 38 of the 39 records the mean nighttime heart rate was lower than the mean daytime rate, with a peak difference of 20.1 +/- 1.8 beats/min. Blood pressure responses were, however, of two patterns. In 15 of the 39 recordings (approximately 50% of patients) the mean nighttime systolic pressure was higher than the mean daytime systolic pressure; in the remainder the converse was observed. The pattern was generally consistent on repeated recordings from the same patient and was not related to time since transplantation, renal function, or other therapy. Echocardiographic/Doppler studies were available at the time of 31 of these recordings. No differences in left ventricular diameters, systolic function, or transmitral filling patterns were present between patients whose blood pressure was higher or lower at night. Left ventricular posterior wall thickness and the ratio between wall thickness and ventricular diameter at end diastole were greater in the group showing nighttime pressure falls. Blood pressure responses after heart transplantation show the presence of nighttime "dippers" and "nondippers." At least early after transplantation, however, nondipper status is not preferentially associated with the development of left ventricular hypertrophy. The mechanisms accounting for the different circadian blood pressure responses in heart transplant recipients are not known.

Doppler-echocardiographic assessment of Carbomedics prosthetic values in the mitral position.

We prospectively studied 37 consecutive patients implanted with the Carbomedics prosthetic heart value in the mitral position (without clinical evidence of prosthetic valve dysfunction) with two-dimensional and Doppler echocardiography. The peak mitral prosthetic gradient ranged from 4.60 to 14.63 (mean 8.97 +/- 2.29) mm Hg; mean mitral prosthetic gradient ranged from 1.67 to 6.18 (mean 3.24 +/- 0.95) mm Hg; pressure half-time derived mitral valve area ranged from 1.67 to 5.30 (mean 2.70 +/- 0.80) cm2. These values compare favorably with that of another bileaflet valve (i.e., the St. Jude Medical valve). There was a wide overlap in peak and mean transmitral gradients, even with the valves of the same size, with a significant but weak inverse relationship between peak mitral gradients and valve size (p = 0.03, r = -0.36). The performance index showed a smaller range of values, again with a significant but weak inverse relationship with valve size (p = 0.001, r = -0.54). The inverse relationship between valve size and peak mitral gradient and performance index should be borne in mind when analyzing Doppler hemodynamic data.

Total occlusion of left main coronary artery in Orientals: profile of 4 cases.

The authors report 4 Oriental cases of total occlusion of the left main coronary artery (LMCA) with differing presentations. The first patient had a twelve-year history of stable angina pectoris. The second patient had angina for a year, which became unstable two months prior to diagnosis. The third patient had myocardial infarction seven years ago and presented with a one-month history of rest angina. The fourth patient had stable effort angina for six years but presented with accelerated angina three months prior to diagnosis. The incidence of total occlusion of the LMCA is rare and survival depends on the existence of collateral circulation. In LMCA disease, there is usually disease in other parts of the coronary arterial tree, and hence, the need for urgent coronary bypass surgery.

A review of patients with a 'normal' coronary angiogram over a 3-year period.

Over a period of 36 months, we detected 54 patients with normal coronary arteries or non-critical coronary artery stenosis within our study series of coronary angiography. We studied these patients to determine their clinical, electrocardiographic, stress testing and angiocardiographic characteristics. We detected among them a preponderance of female sex and a higher incidence of ethnic Indians. The majority of the patients studied had one or more coronary risk factors. 52% had a normal resting ECG. In those with a positive stress test and reports available for review, there is a near equal distribution of horizontal and J-type ST depression. Those patients with a positive treadmill tend to have a higher left ventricular end diastolic pressure (LVEDP) at cardiac catheterization. We also noted in this group of patients a higher proportion with a small distal left anterior descending artery. These patients also tend to have higher LVEDP even in the presence of normal left ventriculogram. Our current series suggests the possibility of raised left ventricular end-diastolic pressure and the presence of a "small distal left anterior descending artery" syndrome in association with patients with a 'false positive' treadmill test.

Diagnosis of left atrial myxoma following systemic embolism.

Cardiac myxomas are rare and noted for their varied clinical manifestations. Consequently, the diagnosis is often unsuspected until the symptoms and signs become advanced and obvious, or when the diagnosis is made fortuitously during echocardiography. This report illustrates a case in point in which the diagnosis was made on transthoracic echocardiography and amplified using transesophageal echocardiography.

Dobutamine stress echocardiography in the elderly Asian patients.

Dobutamine stress echocardiography (DSE) is an established non-invasive technique for the evaluation of coronary artery disease (CAD). It has been shown to be both safe and accurate. However, its utility and safety in the elderly, in particular, elderly Asian patients has not been studied. Between September 1992 and December 1994, we performed a total of 75 consecutive DSE studies in patients over the age of 65. Of these, 50 (67%) were females. Forty-nine patients had hypertension, 26 had diabetes mellitus, 10 were smokers, 5 had a recent or previous myocardial infarction and another 4 had a history of heart failure. Indications for DSE were, inability to perform the standard treadmill exercise test (40 patients), an abnormal resting electrocardiogram (ECG) (14 patients), a prior false positive or inconclusive treadmill test, risk stratification post myocardial infarction (4 patients) or preoperative cardiac evaluation (23 patients). The test was terminated in the majority of patients following attainment of the target heart rate. Atropine stimulation was required in 61 (81%) patients. Chest pain was provoked in 11 patients. No death or myocardial infarction occurred. Minor non-cardiac symptoms occurred in another 6 patients but this did not necessitate termination of the procedure. Three patients had transient hypotension, none of which was symptomatic. Arrhythmia occurred in 23 patients but the majority were isolated atrial or ventricular premature beats (20); 1 patient had atrial fibrillation and another developed transient junctional rhythm. Only one patient developed ventricular tachycardia but this was not haemodynamically significant and terminated easily with an intravenous dose of lignocaine. A conclusive result could be obtained in 72 (96%) patients. We concluded that DSE could be performed and interpreted in the majority of elderly Asian patients studied. Despite supplemental atropine, an aggressive dosing protocol and the inclusion of patients with a myocardial scar or history of heart failure, adverse effects were rare and often did not require any specific therapy.

Dobutamine stress echocardiography: angiographic correlates.

We started a dobutamine stress echocardiography (DSE) programme in September 1992. Until January 1994, we had performed 300 such procedures. Of these patients, 81 underwent cardiac catheterisation within 6 months of DSE without a cardiac event in the interim. Eleven DSEs were performed to assess myocardial viability and another 6 were inconclusive for myocardial ischaemia. The remaining 64 were correlated with the angiographic data to determine the utility of this technique in our institution. The mean age of the cohort was 57 years. Thirty-six patients were referred for DSE in the workup for chest pain, either anginiform (22) or atypical (14). Fourteen patients had a recent (6) or remote (8) myocardial infarction. Thirteen patients were asymptomatic. Significant obstructive coronary artery disease (CAD) was identified in 36 patients of whom 17 and 19 had single and multivessel disease respectively. The sensitivity of DSE in the entire cohort was 89% and the specificity 82%. Positive and negative predictive values of DSE were 86% and 85% respectively. Although the numbers involved were small, sensitivity figures for single and multivessel disease were 94% and 84% respectively. Of the patients with single vessel CAD, prediction of the artery involved by presumed territorial supply was accurate in 81%. DSE is a highly accurate tool for evaluating CAD, identifying both the patient with CAD and the location of disease.

Librarian or educator: into the classroom.

There is a traditional view of librarians as keepers of information. This paper reports on the development of a post of Tutor Librarian who is actively involved in nurse education and inservice training. Project 2000 and its accompanying curriculum changes provide an opportunity to develop the Tutor Librarian's role.