Ability of troponins to predict adverse outcomes in patients with renal insufficiency and suspected acute coronary syndromes: a case-matched study.

OBJECTIVES: The purpose of this study was to investigate the utility of cardiac troponin T and troponin I for predicting outcomes in patients presenting with suspected acute coronary syndromes and renal insufficiency relative to that observed in similar patients without renal disease. BACKGROUND: Cardiac troponin T and troponin I have shown promise as tools for risk stratification of patients with acute coronary syndromes. However, there is uncertainty regarding their cardiac specificity and utility in patients with renal disease. METHODS: We measured troponin T, troponin I and creatine kinase MB in 51 patients presenting with suspected acute coronary syndromes and renal insufficiency and in 102 patients without evidence of renal disease matched for the same peak troponin T or I value, selected from a larger patient cohort. Blood samples were obtained at presentation to an emergency room 4 hours, 8 hours and 16 hours later. The ability of biochemical markers to predict adverse outcomes in both groups including infarction, recurrent ischemia, bypass surgery, heart failure, stroke, death or positive angiography/angioplasty during hospitalization and at six months was assessed by receiver-operator curve analysis. The performance of both troponins was compared between groups. RESULTS: Thirty-five percent of patients in the renal group and 45% of patients in the nonrenal group experienced an adverse initial outcome; over 50% of patients in all groups had experienced an adverse outcome by 6 months, but these differences were not significant. The area under the curve (AUC) for the ROC curve for troponin T as predictor of initial outcomes was significantly lower in the renal group than in the nonrenal group: 0.56+/-0.07 and 0.75+/-0.07, respectively. The area under the curve was also significantly lower in the renal group compared with the nonrenal group for troponin T as predictor of six month outcomes: 0.59+/-0.07 and 0.74+/-0.07, respectively. The area under the curve was also significantly lower in the renal group compared to the nonrenal group for troponin I as predictor of both initial and six month outcomes: 0.54+/-0.06 vs. 0.71+/-0.07 and 0.53+/- 0.06 vs. 0.65+/-0.07, respectively. The sensitivity of troponin T for both initial and six month adverse outcomes was significantly lower in the renal group than in the nonrenal group at a similar level of specificity (0.87): 0.29 vs. 0.60 and 0.45 vs. 0.56, respectively. Troponin I also exhibited similar differences in sensitivity in the renal group (0.29 vs. 0.50 and 0.33 vs. 0.40, respectively). CONCLUSIONS: The ability of cardiac troponin T and troponin I to predict risk for subsequent adverse outcomes in patients presenting with suspected acute coronary syndromes is reduced in the presence of renal insufficiency.

The spleen-lung interface as diagnostic information.

Left anterior, lateral, and posterior views on 50 consecutive RES-lung scams were examined. Normal patients had continuity of activity between the left lung and the spleen on all three views. Patients with subphrenic abscess or large left pleural effusions showed no continuity between lung and spleen activity on any view, while other abnormalities, most commonly cardiomegaly, accounted for lack of lung-spleen continuity on the anterior view only. It is suggested that in all combined RES-lung studies, the left side be examined as well as the right for abnormalities adjacent to the left diaphragm.

Comparison of troponin T versus creatine kinase-MB in suspected acute coronary syndromes.

Limitations of creatine kinase-MB (CK-MB) have led to alternative biochemical markers, including troponin T (TnT), to detect myocardial necrosis. Limited data are available regarding the predictive value of this new marker in patients with chest pain of uncertain etiology. Therefore, we prospectively compared CK-MB and TnT in a broad population with suspected acute coronary syndromes, including those admitted to a short-stay chest pain unit. CK-MB, quantitative TnT levels, and a rapid bedside assay were performed at 0, 4, 8, and 16 hours. Adverse events, including infarction, recurrent ischemia, coronary surgery, need for catheterization and/or intervention, stroke, congestive heart failure, or death, were identified by chart review and by follow-up phone call at 6 months. Of 707 patients, 104 were excluded for creatinine >2 mg/dl or incomplete data, leaving a total cohort of 603 patients. Coronary Care Unit admissions were 18%, intermediate care admissions were 14%, telemetry admissions is 21%, and admissions to 24-hour short-stay area were 47%. TnT (at 0.1 ng/ml) and CK-MB were positive in a similar proportion of patients (20.4% and 19.7%, respectively); however, the patients identified by TnT and CK-MB were not identical. In-hospital adverse events occurred in 37.1% with no differences in positive predictive value for the markers (p = NS). If CK-MB and TnT were negative, the early adverse event rate was 27%. No cardiac marker was positive by 16 hours in 54.9% of patients with an adverse event. Six-month follow-up was obtained in 576 of the 603 patients (95.5%). One hundred fifty-five late adverse events occurred in 134 patients (23.3%) at an average of 3.3+/-2.5 months after discharge. If both markers were negative, the late event rate was 20.2% and did not increase in patients with positive CK-MB or TnT >0.2 ng/ml. However, the late event rate was substantially higher (52.9%) in those with intermediate TnT levels of 0.1 to 0.2 ng/ml (p = 0.002). Thus, TnT is a suitable alternative to CK-MB in patients with suspected acute coronary syndromes. The rapid bedside assay is comparable to quantitative TnT and may enable early diagnosis and triage. A negative cardiac marker value (TnT or CK-MB) does not necessarily confer a low risk of complication in patients presenting with acute chest pain to an emergency department.

Low-dose transaxial tomography. An alternative to computed tomography for the evaluation of anteversion of the femur during childhood.

Low-dose transaxial tomography is a technique that can produce cross-sectional images of the hips and femurs in children to permit calculation of the angle of femoral anteversion. Transaxial tomography was compared with computed tomography in terms of measured radiation dose and image quality. Transaxial tomography was found to require at least 90% less radiation dose, and the images were judged to be acceptable for the determination of anteversion.

Survey of current practice patterns for percutaneous transluminal coronary angioplasty. SANDBAG Nursing Coordinators.

BACKGROUND: The increasing complexity of coronary intervention has led to variations in current patterns of nursing practice for patients undergoing routine percutaneous transluminal coronary angioplasty. In preparation for a large study examining the effects of specific nursing practices on complications at the site of vascular access, we surveyed institutions participating in a randomized phase III trial involving 4010 patients to determine current patterns of practice. OBJECTIVE: The purpose of this study was to determine the current patterns of nursing practice for patients undergoing percutaneous transluminal coronary angioplasty. METHODS: An eight-page questionnaire was completed by 70 hospitals participating in the study titled Integrelin to Manage Platelet Aggregation to Prevent Coronary Thrombosis (IMPACT II). RESULTS: The hospitals participating in this study have an average of 500 beds; 34% of the institutions do 500 to 1000 angioplasty procedures annually. At many sites (39%), heparin is infused for 12 to 18 hours after the intervention, but heparin is not infused at all in 31% of the hospitals studied. At 27% of the hospitals, arterial sheaths are removed 12 to 18 hours after angioplasty, and at 15% of the hospitals, sheaths are removed more than 18 hours after the procedure. Typically after angioplasty (36%), patients are transferred to an ICU, with a nurse-patient ratio of 1:2. Eighty-three percent of the hospitals use CareMAPs or care plans for standardization of care. Most hospitals (83%) require complete bed rest for patients who have had angioplasty, with the affected leg restrained to prevent mobility. Ninety-one percent of the hospitals reported continuing to treat the patient with bed rest for an additional 6 hours after the sheath is removed. CONCLUSION: Comprehensive nursing standards of care based on well-designed clinical trials for patients after angioplasty are not available. In the second phase of our study, we hope to correlate nursing practices with clinical outcome data to improve further the care of patients who have had angioplasty.

Nursing interventions to decrease bleeding at the femoral access site after percutaneous coronary intervention. SANDBAG Nursing Coordinators. Standards of Angioplasty Nursing Techniques to Diminish Bleeding Around the Groin.

BACKGROUND: This trial is the first prospective, multicenter clinical nursing trial conducted to measure the effect of nursing interventions on bleeding at the femoral access site after percutaneous coronary intervention with or without a potent antiplatelet agent given along with heparin and aspirin. OBJECTIVE: To measure the relationship between nursing interventions and complications at the arterial access site in patients undergoing percutaneous coronary interventions and to recommend a standard of care to minimize bleeding complications. METHODS: In a descriptive, correlational 4010-patient study, nursing care interventions after coronary procedures were measured. Observed standards of care were assessed, and regression techniques were used to evaluate nursing interventions and the effect of the interventions on bleeding at the access site after percutaneous coronary procedures. RESULTS: Several significant correlations between nursing interventions and the occurrences of moderate to severe bleeding at the access site were found; however, most interventions had little effect. The most significant factors in decreasing complications at the access site were early removal of the arterial sheath, the type of pressure mechanism used to achieve arterial hemostasis, staffing allocation, and the person and method used to remove the sheath. CONCLUSION: Many nursing interventions after percutaneous coronary intervention have become routine in the absence of clinical outcome data. Most nursing interventions aimed at decreasing bleeding at the vascular access site increase nursing workload but do not significantly affect bleeding in the groin. These results underscore the importance of continued clinical research studies to validate nursing practice on the basis of patients' outcomes.

Normal CK, elevated MB predicts complications in acute coronary syndromes.

The implications of an elevated Creatine kinase (CK)-MB isoenzyme (MB) in suspected acute coronary syndromes, with a normal total CK, is not well established. Despite many guidelines on managing patients with acute coronary ischemia, none indicates strategies for patients with elevated MB and with a normal CK. The outcome consequence of this result is not firmly established. Our objective was to prospectively evaluate outcomes in patients with suspected acute coronary syndromes, normal initial total CK, and increased MB. All Emergency Department patients with suspected acute coronary syndromes and creatinine < 2.0 mg/dL were eligible for study entry. Serial CK and MB fractions were measured on arrival in the Emergency Department, then 8 and 16 h postpresentation. A composite outcome of death, Q-wave myocardial infarction, or revascularization was defined at the index visit and 6 months later. Outcomes were determined by blinded record review and by telephone contact. In the 698 patients entered, the acute composite outcome rate was 25% (175) and 6.3% (44) at 6 months. Acute and 6 month adverse outcome rates were statistically the same for all patients with an elevated MB fraction, regardless of the total CK level. An elevated MB conferred a higher event rate than did a normal MB. We conclude that the adverse event rate for patients with suspected acute coronary syndromes and an elevated MB is the same whether or not the total CK is elevated. These patients should be considered as having had an acute coronary syndrome.

The effects of chemotherapy on bony metastases as measured by quantitative skeletal imaging.

The effect of chemotherapy on bony metastases from adenocarcinoma of the colon was investigated by quantitative skeletal imaging over a two-month interval. The quantitative skeletal imaging results correlated with conventional blood chemistry results over this time period. While chemical assay techniques furnish an average value of lesion response, the quantitative bone scan represents a method for individual lesion analysis. This methodology has the potential to provide a better understanding of metastatic bone disease therapy.

Hypertrophic pyloric stenosis.

Hypertrophic pyloric stenosis is a gastrointestinal tract disorder common in infancy. The disorder causes projectile vomiting, weight loss, and fluid and electrolyte abnormalities. The problem can usually be diagnosed by clinical symptoms and manual detection of an enlarged pylorus. When the diagnosis cannot be confirmed by these methods, however, imaging studies are relevant. Until recently, plain radiographs and upper gastrointestinal contrast studies have been used to make the diagnosis, but ultrasonography is becoming the method of choice because it is highly accurate and lacks the ionizing radiation inherent in a radiologic procedure. Surgery provides a safe and effective treatment.

Coarctation of the aorta.

Coarctation of the aorta is a common cardiovascular disorder with an unknown etiology. In the preductal type, blood flows from a patent ductus into the distal aorta. When the coarctation is juxtaductal or postductal, blood flows to the lower extremities by way of the subclavian arteries and collaterals. Plain films may show the reverse sign in postductal coarctation. Arteriography is the gold standard for making the diagnosis. However, magnetic resonance imaging will probably become an increasingly important diagnostic tool. The treatment of choice is surgery, with complete resection of the stenosed segment.

Thoracic spine fractures.

Diagnosis of thoracic spine fractures in patients with multiple trauma requires careful evaluation of the chest radiograph. Primary findings, consisting of a fracture line through the vertebral bodies, decreased height of the vertebral body, an increase in the interpediculate distance and misalignment of the vertebral bodies, may all be noted on the anteroposterior supine chest radiograph. Early diagnosis and intervention may prevent a catastrophic neurologic event, such as spinal cord or nerve root damage.

Transvaginal ultrasonography.

Transvaginal ultrasonography is an adjunct to abdominal ultrasonography. It is indicated for investigation of suspected abnormalities of the ovaries, fallopian tubes and uterus, and can provide better resolution than traditional views of this anatomic region. Transvaginal ultrasonography is particularly useful in diagnosing ectopic pregnancy.

Desmoplastic fibroma.

This benign bone tumor is locally invasive and has a high rate of recurrence. Three-quarters of cases present before age 30. The characteristic plain film finding is a centrally located lytic lesion, usually in the metaphysis or metadiaphyseal region of a long bone. Treatment is surgical.

Castleman's disease.

Castleman's disease is characterized by lymph node enlargement. There are two distinct histologic subtypes. Most patients are asymptomatic and under age 30, and a mediastinal or hilar mass is found incidentally on chest radiograph. The pathogenesis is unknown, but a chronic inflammatory process has been suggested by some investigators. Complete surgical excision is the treatment of choice and is generally curative.

Pulmonary hypertension.

Conventional radiography reflects the underlying cause of pulmonary hypertension and may help to distinguish between precapillary and postcapillary etiologies. Adjunctive nuclear medicine studies may aid in identifying chronic pulmonary emboli as a cause of precapillary hypertension.

Esophageal varices.

Barium swallow is generally used to demonstrate esophageal varices, which appear as serpiginous filling defects in the distal esophagus and cardia of the stomach. Angiography is used for pre- and postoperative shunt evaluation.

Traumatic pancreatic transection.

Pancreatic contusion or transection may result from blunt or penetrating trauma. Considerable morbidity and mortality may occur if the injury is not diagnosed and treated promptly. Clinical diagnosis of pancreatic injury due to blunt trauma is difficult, because the symptoms are often delayed and nonspecific. Computed tomographic scanning is the method of choice for the diagnosis of pancreatic injury, although abdominal ultrasound may be particularly useful in children. Endoscopic retrograde cholangiopancreatography is used to assess ductal integrity.

Posterior mediastinal masses in children: ganglioneuroblastoma.

Ganglioneuroblastoma, although a rare neoplasm, is one of the most common causes of posterior mediastinal masses in children. This tumor occurs in children from one to 10 years of age. With intrathoracic involvement, the tumor may remain asymptomatic until it is large. The case reported illustrates a typical presentation of intrathoracic ganglioneuroblastoma.