Comparison of the National Early Warning Score in non-elective medical and surgical patients.

BACKGROUND: The National Early Warning Score (NEWS) is used to identify deteriorating patients in hospital. NEWS is a better discriminator of outcomes than other early warning scores in acute medical admissions, but it has not been evaluated in a surgical population. The study aims were to evaluate the ability of NEWS to discriminate cardiac arrest, death and unanticipated ICU admission in patients admitted to surgical specialties, and to compare the performance of NEWS in admissions to medical and surgical specialties. METHODS: Hospitalwide data over 31 months, from adult inpatients who stayed at least one night or died on the day of admission, were analysed. The data were categorized as elective or non-elective surgical or medical admissions. The ability of NEWS to discriminate the outcomes above in these different groups was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: There were too few outcomes to permit meaningful comparison of elective admissions, so the analysis was constrained to comparison of non-elective admissions. NEWS performed equally well, or better, for surgical as for medical patients. For death within 24 h the AUROC for surgical admissions was 0·914 (95 per cent c.i. 0·907 to 0·922), compared with 0·902 (0·898 to 0·905) for medical admissions. For the combined outcome of any of death, cardiac arrest or unanticipated ICU admission, the AUROC was 0·874 (0·868 to 0·880) for surgical admissions and 0·874 (0·871 to 0·877) for medical admissions. CONCLUSION: NEWS discriminated deterioration in non-elective surgical patients at least as well as in non-elective medical patients.

Pacemaker-induced endocardial friction rub.

Two patients had a typical sounding cardiac friction rub after placement of a temporary transvenous pacemaker. Absence of myocardial perforation was documented in one patient during thoracotomy for placement of an epicardial electrode and in the other with an electrogram recorded from the pacemaker as it was being withdrawn. The rubs disappeared during pacemaker removal. These cases are believed to represent endocardial friction rubs resulting from contact of the pacing wire with the endocardium.

Effect of thrombolysis (streptokinase) on left ventricular function during acute myocardial infarction.

One hundred ninety-two consecutive patients with acute myocardial infarction were enrolled in a prospective trial of coronary thrombolysis in which either intracoronary or intravenous streptokinase was administered. First-pass radionuclide ejection fraction (EF) was measured early (within 24 hours of admission) and late (10 to 14 days after admission) to assess changes in left ventricular (LV) function. In 68 patients in whom reperfusion was successful, mean EF increased from 39 +/- 11% early to 47 +/- 13% late. In 36 patients in whom reperfusion was not successful, the mean EF increase was significantly smaller (from 38 +/- 10% to 42 +/- 11%, p less than 0.025). Patients in whom reperfusion was successful were then grouped according to extent of LV functional change. The extent of EF change (delta EF) was not significantly influenced by time to lysis at intervals up to 7 hours (delta EF = 9.1 +/- 10% at 2 to 3 hours, 8.7 +/- 12% at 3 to 4 hours, 10 +/- 10% at 4 to 5 hours, and 7.0 +/- 10% at 5 to 7 hours; difference not significant [NS]), location of the infarct (delta EF = 8.9 +/- 11% for inferior and 5.7 +/- 8.0% for anterior, NS), or presence of Q waves on the initial electrocardiogram (delta EF = 8.8 +/- 11% in patients with and 7.8 +/- 9.9% in patients without Q waves). Only the initial EF was predictive of subsequent EF change.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous versus intracoronary streptokinase in acute myocardial infarction.

One hundred sixty-four consecutive patients with acute myocardial infarction were enrolled in a prospective trial of coronary thrombolysis with streptokinase (STK). The first 98 patients received intracoronary (i.c.) STK after coronary angiography and the next 66 received a high-dose rapid infusion of STK (900,000 IU) intravenously (i.v.) before angiography. First-pass radionuclide ejection fraction (EF) was performed early (within 24 hours of admission) and late (10 to 14 days after admission) to evaluate left ventricular function. In the i.v. group, 42 of 66 (64%) of infarct-related arteries were patent at the initial angiogram and 6 (9%) opened with subsequent i.c. STK. In the i.c. group, 13 of 98 (13%) of infarct-related arteries were patent at the initial angiogram and 50 of 85 (59%) opened with the i.c. STK. The i.v. and i.c. groups did not differ in time from onset of chest pain to presentation, type of infarct or underlying severity of coronary artery disease. In the i.v. group, STK was begun 67 minutes earlier than in the i.c. group. In 62 patients in whom reperfusion was successful, mean EF increased from 39 +/- 11% early to 48 +/- 13% late. In 30 in whom it was not, the mean EF increased from 36 +/- 10% to 40 +/- 12%. The increase in EF was significantly greater in patients in the reperfused group (p less than 0.03). In 18 patients who underwent reperfusion by i.v. STK, the mean EF increased 11 +/- 12%, whereas in 44 patients who had reperfusion by i.c. STK, the mean EF increased 9 +/- 10% (difference not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Left atrial myxoma: pulmonary infarction caused by pulmonary venous occlusion.

Atrial myxomas are the most common primary cardiac tumors. Typical complications include congestive heart failure, systemic emboli, or vasculitic type syndromes. Presented is a case of postpartum congestive heart failure in a 17-year-old girl. Echocardiography revealed a left atrial mass. Intraoperatively this mass was found to be extending into and occluding the left pulmonary veins. Left pulmonary infarction had occurred, and left pneumonectomy was required to completely remove the lesion. This case thus represents an unusual complication of left atrial myxoma.