Early stratification of patients with chest pain and suspected acute coronary syndrome in the Emergency Department.

AIM: The aim of this study was to investigate the accuracy of a critical pathway in the early stratification and management of patients with chest pain and suspected acute coronary syndrome (ACS) in the Emergency Department (ED). METHODS: An observational study was performed enrolling all patients with non-traumatic chest pain and suspected ACS who presented during a one-year period in the ED, where a critical pathway with five-level risk stratification, based on risk factors, characteristics of pain and ECG, was implemented. Patients were prospectively evaluated for rates of death, unstable angina, myocardial infarction or revascularization procedure occurring during admission or in the 30 days following discharge from the ED. Receiver-Operating Characteristics (ROC) curve was used to measure the accuracy of the stratification method. RESULTS: Overall, 1813 patients were enrolled: 475 patients (26.1%, 95% CI: 24.0-28.1 ) were admitted and 1338 (73.8%, 95% CI: 71.7-75.8) were discharged. Main outcomes occurred in 233 (49.9%, 95% CI: 47.5-52.2) of patients admitted and in 6 (0.4%, 95% CI: 0.06-0.7) of those discharged. The risk stratification system showed a good accuracy with an AUC-ROC curve of 0.90 (95% CI: 0.88-0.93). A total of 1541 (85%) patients were managed according to critical pathway. Adverse events were significantly fewer in patients discharged according to pathway criteria than in those who were not (0.27% vs. 1.37%, difference: 1.1% CI 95%: 0.06-2.1), without significant increase of inappropriate admissions. CONCLUSION: A critical pathway, based on clinical and ECG features, is a safe and accurate tool to stratify and manage the patients with non-traumatic chest pain and suspected ACS in the ED.

Vertebroplasty in the treatment of osteoporosis vertebral fractures: report on 52 cases.

BACKGROUND: Percutaneous vertebroplasty (PV) is largely employed in vertebral body compression fractures (VCF). PURPOSE: To evaluate the efficacy of PV on pain relief and functional status, and its complications rate. MATERIALS AND METHODS: A prospective observational study was conducted by the Division of Internal Medicine of St. Croce and Carle Hospital. INCLUSION CRITERIA: Diagnosis of osteoporosis, intense back pain, unresponsive to conservative treatment, associated with radiological evidence of recent VCF. Pain control and functional improvement were respectively assessed using Visual Analogue Scale (VAS) and Activity of Daily Living scale (ADL) on admission, 24 h after PV and at follow-up. PV complications were detected by an immediate computed tomography (CT) scan on the vertebra treated as well as the vertebrae above and below the treated level(s) and by CT chest scan to exclude pulmonary emboli. A magnetic resonance imaging (MRI) follow-up at 6 or 12 months was performed. RESULTS: Fifty-two (46 with primary osteoporosis) patients were enrolled (mean age 73.18 yr, range 44-92). Median follow-up was 20.4 months (range 6-24). Treated vertebrae were 124. VAS, mean value was 9.05 (range 6-10) before treatment, 5.95 (range 2-8) at 24 h after PV and 4.94 (range 2-9) at follow-up (p<0.001). Before PV, 18 patients (34.6%) were functionally impaired vs 8 patients (15.3%) at follow-up (p<0.003). Control MRI evidenced 9 (17.3%) new VCF adjacent and 13 (25%) non-adjacent to treated vertebras. There was one case of discitis. Seven cases (13%) of cement leakage in para-vertebral space were observed. CONCLUSION: PV is safe and effective in immediate pain reduction and functional improvement and at a median term follow-up.

Tenderisation of lamb meat: Effect of rapid postmortem temperature drop on muscle conditioning and aging.

Lamb Longissimus dorsi muscles were excised from carcasses of 9-12 kg and 16-20 kg weight and brought to internal temperatures of either 0°C, 4°C, 10°C, 15°C, 20°C or 36°C within 3-4h post mortem. After rigor completion they were allowed to age at 4°C for 7 days. Sensory panel scores obtained on the first day of post-rigor aging showed that meat from heavier animals was tougher than that of lighter ones at any temperature. In all cases aging for 7 days had a marked tenderising effect which was similar at all studied temperatures, and greater in heavier animals. Tenderness was also dependent on the temperature at conditioning, as shortening caused by either high or low temperature resulted in meat toughening. The sole and surprising exception to this fact was, however, the high sensory scores obtained in 0°C experiments, even though shortening occurred as expected. In fact, a more intense proteolysis was evident in this case, which was already apparent on the first day of aging. The effect of a rapid drop of muscle temperature to 0°C on the fast and intense proteolysis, capable of even overcoming toughness due to cold shortening, was explained by the higher pH and the dramatic increase of the sarcoplasmic Ca(++) level induced early post mortem by chilling and which might result in the activation of calpain.

Proteolytic activity of isolated lamb calpains on myofibrils under the conditions of pH, Ca2+ concentration and temperature existing in postmortem muscle.

The two calcium-activated neutral proteinases (calpains I and II) and their specific inhibitor were isolated by ion exchange chromatography in DEAE-Sephacel from lamb skeletal muscle (longissimus dorsi). Their proteolytic activities were then determined using myofibrils as substrate. The Ca2+ requirements were different for each form of the enzyme: calpain I needed only 50 mumol Ca2+ for half-maximal activity, while the other isoenzyme, calpain II, needed 1,000 mumol Ca2+ for reaching 50% of its maximum activity. Both calpains showed a relevant activity in the pH range 5.5-6.5 (over 40% of maximum activity found at pH 7.5). With regard to the effect of temperature, both isoenzymes retained about 25% of their activity at 25 degrees C with a temperature reduction down to 4 degrees C. It is concluded that calpain I is an active protease under conditions similar to that prevalent in lamb meat during postmortem storage.

Ultrasonication of lamb skeletal muscle fibres enhances postmortem proteolysis.

The effect of ultrasound upon the postmortem proteolytic activity of muscle fibres was investigated. As a preliminary result it was demonstrated that ultrasonication released lysosomal enzymes from liver cells while cell membranes suffered little damage. Proteolysis brought about by endogenous proteinases after 2 days of fibre storage at 4 degrees C was assessed by means of sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE). Ultrasonic treatment of fibres enhanced proteolytic activity, as shown by the increased intensity of 30-kDa region degradation bands. A distinct change featuring sonicated fibres was the degradation of an 87-kDa protein and the appearance of an 83-kDa peptide. Cell damage was not very extensive, although it depended upon ultrasonication and fibre conditions.