Feasibility study of a candidate reference material for ions in PM2.5: does commutability matter also for inorganic matrices?

The existing Air Quality Directive 2008/50/EC establishes within the European Union (EU) member states limit values for fine air particulate matter (PM2.5) including the possibility to discount natural sources of pollution when assessing compliance with the legislation. In proving this, EU member states shall determine, amongst others, the rural background concentration of some anions (Cl-, NO3- and SO42-) and cations (Na+, NH4+, K+, Ca2+ and Mg2+). To deliver reliable data and to comply with the data quality objectives of the legislation, environmental control laboratories should use certified reference materials (CRMs) to validate or verify the performance of their analytical methods. Since no CRMs for anions and cations in PM2.5 are presently available, we present the commutability issues encountered during the first attempt to develop such a material. We demonstrate that a dust, collected in a road tunnel and previously used for the production of two CRMs of a PM10-like material, does not behave as an authentic fine particulate matter collected according to EN12341:2014 when measured by an established method proposed by the European Committee for Standardization (CEN/TR 16269:2011). The water-soluble fractions of SO42-, NH4+, K+, Ca2+ and Mg2+ in a PM2.5-like candidate CRM produced from that road tunnel dust are only fully extracted after 3 h of sonication and not after 30 min, as stated in the method. Moreover, we found that the particle size of the test material influenced the extraction yield of K+, Ca2+ and Mg2+, suggesting that these ionic species were incorporated in the core of the particles and inaccessible to the extraction procedure. These particular features make the material unsuitable for the measurements of ions with the CEN method. The difference in the extraction time can be seen as a commutability issue and the candidate CRM should be considered as not commutable with routine samples. This demonstrates that commutability studies should not only be considered for clinical CRMs, but also for inorganic CRMs when they are intended to be used to quantify operationally defined analytes.

Targeting ß-catenin dependent Wnt signaling via peptidomimetic inhibitors in murine chondrocytes and OA cartilage.

OBJECTIVE: The canonical Wnt signaling pathway has been shown to be involved in regulating chondrocyte hypertrophic differentiation during Osteoarthritis (OA). The aim of this study was to test the therapeutic potential of two stapled peptide canonical Wnt inhibitors - SAH-Bcl9 and StAx-35R - in preventing Wnt induced cartilage changes in OA. METHODS: Primary neonatal murine chondrocytes and cartilage explants from OA patients undergoing total joint replacement for knee OA, were used for microscopy to determine matrix and cell penetrating capacity of fluorescein isothiocyanate FITC-tagged SAH-Bcl9 and StAx-35R peptides. T cell factor/lymphoid enhancer-binding factor (TCF/LEF) reporter assays were used to monitor the inhibition of Wnt3a induced ß-catenin signaling by each peptide. Changes in chondrocyte phenotypic marker gene expression were analyzed by qRT PCR. RESULTS: Both peptides localized intercellular in primary murine chondrocytes and cartilage explants. They inhibited Wnt3a induced TCF/LEF promoter activity in primary murine chondrocytes. Both inhibitors did not rescue Wnt3a altered expression of chondrocyte phenotypic genes (Sox9, Col2a1, Acan) and hypertrophy marker gene (Col10a1) at high doses (100 ng/ml). Upon application of 10 ng/ml Wnt3a, StAx-35R partially reversed the Wnt effect on Sox9 and Col2a1 gene expression. Both peptides, however, reversed the downregulation of SOX9 and aggrecan (ACAN), and decrease of COL10A1 gene expression in preserved human OA cartilage explants. CONCLUSION: These data indicate that blockade of canonical Wnt signaling might be a therapeutic strategy to treat early OA cases and protect further cartilage degradation by preventing chondrocyte hypertrophic differentiation.

Urban eddy covariance measurements reveal significant missing NOx emissions in Central Europe.

Nitrogen oxide (NOx) pollution is emerging as a primary environmental concern across Europe. While some large European metropolitan areas are already in breach of EU safety limits for NO2, this phenomenon does not seem to be only restricted to large industrialized areas anymore. Many smaller scale populated agglomerations including their surrounding rural areas are seeing frequent NO2 concentration violations. The question of a quantitative understanding of different NOx emission sources is therefore of immanent relevance for climate and air chemistry models as well as air pollution management and health. Here we report simultaneous eddy covariance flux measurements of NOx, CO2, CO and non methane volatile organic compound tracers in a city that might be considered representative for Central Europe and the greater Alpine region. Our data show that NOx fluxes are largely at variance with modelled emission projections, suggesting an appreciable underestimation of the traffic related atmospheric NOx input in Europe, comparable to the weekend-weekday effect, which locally changes ozone production rates by 40%.

[A New Diagnostic Tool for Apraxia in Patients with Right-Hemisphere Stroke: The Revised Cologne Apraxia Screening (KAS-R)]. / Das revidierte Kölner Apraxie-Screening (KAS-R) als diagnostisches Verfahren für Patienten mit rechtshemisphärischem Schlaganfall.

The Cologne Apraxia Screening (KAS) was developed to diagnose apraxia following left-hemisphere (LH) stroke. The present study aims at developing a diagnostic tool for patients with right-hemisphere (RH) stroke (KAS-R) by modifying the test material of the KAS and reducing the test items based on psychometric analyses.A total of 100 patients with RH stroke and 77 healthy control participants were tested. Psychometric analyses led to the exclusion of 8 KAS items. The final KAS-R, consisting of 12 items, shows good internal consistency (α = 0.795) as well as high sensitivity (79.4 %) and specificity (84.4 %). Applying a cut-off value of ≤ 46 (out of 48) points, 39 RH stroke patients were diagnosed with apraxia. Significant correlations were found between the KAS-R and an imitation test as well as expert ratings, indicating high construct validity. The results suggest that the KAS-R is a reliable and valid diagnostic tool for apraxic deficits after RH stroke.

How salt lakes affect atmospheric new particle formation: A case study in Western Australia.

New particle formation was studied above salt lakes in-situ using a mobile aerosol chamber set up above the salt crust and organic-enriched layers of seven different salt lakes in Western Australia. This unique setup made it possible to explore the influence of salt lake emissions on atmospheric new particle formation, and to identify interactions of aqueous-phase and gas-phase chemistry. New particle formation was typically observed at enhanced air temperatures and enhanced solar irradiance. Volatile organic compounds were released from the salt lake surfaces, probably from a soil layer enriched in organic compounds from decomposed leaf litter, and accumulated in the chamber air. After oxidation of these organic precursor gases, the reaction products contributed to new particle formation with observed growth rates from 2.7 to 25.4nmh-1. The presence of ferrous and ferric iron and a drop of pH values in the salt lake water just before new particle formation events indicated that organic compounds were also oxidized in the aqueous phase, affecting the new particle formation process in the atmosphere. The contribution of aqueous-phase chemistry to new particle formation is assumed, as a mixture of hundreds of oxidized organic compounds was characterized with several analytical techniques. This chemically diverse composition of the organic aerosol fraction contained sulfur- and nitrogen-containing organic compounds, and halogenated organic compounds. Coarse mode particles were analyzed using electron microscopy, energy dispersive X-ray spectroscopy and Raman spectroscopy. Ultra-high resolution mass spectrometry was applied to analyze filter samples. A targeted mass spectral analysis revealed the formation of organosulfates from monoterpene precursors and two known tracers for secondary organic aerosol formation from atmospheric oxidation of 1,8-cineole, which indicates that a complex interplay of aqueous-phase and gas-phase oxidation of monoterpenes contributes to new particle formation in the investigated salt lake environment.

Effect of meaning on apraxic finger imitation deficits.

Apraxia typically results from left-hemispheric (LH), but also from right-hemispheric (RH) stroke, and often impairs gesture imitation. Especially in LH stroke, it is important to differentiate apraxia-induced gesture imitation deficits from those due to co-morbid aphasia and associated semantic deficits, possibly influencing the imitation of meaningful (MF) gestures. To explore this issue, we first investigated if the 10 supposedly meaningless (ML) gestures of a widely used finger imitation test really carry no meaning, or if the test also contains MF gestures, by asking healthy subjects (n=45) to classify these gestures as MF or ML. Most healthy subjects (98%) classified three of the 10 gestures as clearly MF. Only two gestures were considered predominantly ML. We next assessed how imitation in stroke patients (255 LH, 113 RH stroke) is influenced by gesture meaning and how aphasia influences imitation of LH stroke patients (n=208). All patients and especially patients with imitation deficits (17% of LH, 27% of RH stroke patients) imitated MF gestures significantly better than ML gestures. Importantly, meaningfulness-scores of all 10 gestures significantly predicted imitation scores of patients with imitation deficits. Furthermore, especially in LH stroke patients with imitation deficits, the severity of aphasia significantly influenced the imitation of MF, but not ML gestures. Our findings in a large patient cohort support current cognitive models of imitation and strongly suggest that ML gestures are particularly sensitive to detect imitation deficits while minimising confounding effects of aphasia which affect the imitation of MF gestures in LH stroke patients.

[Cervical spine osteoblastoma in children: Selective diagnostics as the basis for effective surgical management]. / Osteoblastom der Halswirbelsäule im Kindesalter: Gezielte Diagnostik als Grundlage einer erfolgreichen operativen Therapie.

Expansively growing cervical spine osteoblastomas are rare but can cause severe neurological damage as a result of their anatomical relationship to nerve structures. Also, cerebral vessels, especially the vertebral artery in its transvertebral position, are often covered by tumor tissue. In complete resection of the tumor, it is sometimes possible to retain the affected vessel. In addition to conventional radiographic diagnostics, computed tomography, and magnetic resonance imaging, angiography and Doppler sonography of the intracranial arteries executed in parallel can provide evidence of the dimension of the neurological deficit to be expected during resection. This case report describes the staged diagnostic procedure and successful complete resection, retaining the affected vertebral artery, of an osteoblastoma of the 5th cervical body with massive intraspinal expansion in an 11-year-old child.

[Comparison of anterior lumbar fusion rates after circumferential fusion using beta-tricalcium phosphate (Cerasorb) versus autologous iliac crest spongiosa]. / Vergleich der anterioren lumbalen Fusionsrate nach dorsoventraler Fusion unter Einsatz von beta-Trikalziumphosphat (Cerasorb) versus autologer Beckenkammspongiosa.

AIM: The aim of this prospective clinical trial was to analyse the ventral fusion rate following circumferential fusion for degenerative spine disease using a radiolucent carbon fibre cage (Brantigan, Fa. DePuy-Acromed) loaded with either autogeneous bone graft (iliac crest) or with the tricalcium phosphate Cerasorb with PRP (Curasan AG, Kleinostheim, Deutschland). METHODS: In 26 patients (15 female, 11 male, average age: 57.7 years) a circumferential fusion of the lumbar spine was performed (titanium posterior instrumentation and Brantigan, Fa. DePuy-Acromed). Autogeneous bone graft (iliac crest) and Cerasorb-PRP as cage filling substance were randomly assigned to each level in all patients. Anterior fusion was evaluated in a total number of 69 Brantigan cages by radiographs after 3, 6, 9 and 12 months and by CT 1 year after surgery. RESULTS: The evaluation of radiographs resulted in a fusion rate 49 %. This was significantly different from the fusion rate accessed by CT scanning (28 %). None of the Brantigan cages (n = 33) filled with Cerasorb with PRP showed an anterior fusion in the CT while fusion was proven in 19 of 36 (49 %) Brantigan cages loaded with cancellous bone from the iliac crest. CONCLUSION: The use a of cancellous bone from the iliac crest as filling substance for Brantigan cages in circumferential fusion of the lumbar spine leads to a significantly higher anterior fusion rate than Cerasorb with PRP.

[Cage failure following replacement of the third lumbar vertebral body in Hodgkin's disease]. / Cageversagen nach LWK3-Ersatz bei M. Hodgkin.

AIM: We present a case report and the histological analysis of cage failure following vertebral body replacement in Hodgkin's disease. METHOD: In a 35-year-old patient with a single metastasis of Hodgkin's disease replacement of the third lumbar vertebral body (Harms-titanium-mesh-cage, DePuy Acromed, completely filled with autogenous spongiosa from the iliac crest) was performed. 51 months postoperatively, the patient presented with acute back pain without trauma. The X-ray showed a collapse of the Harms-titanium-mesh-cage. The cage fragments had caused ventral dislocation of the main blood vessels and dura compression without neurological deficits. After the replacement of the failed Harms-cage (Synex, Synthes) histological analysis (light microscope, non-decalcified horizontal cuts, thickness of 150-200 microm, Giemsa und van Gieson staining) was done. RESULT: The histology showed a remodelling of new bone in the area of the endplates without contact to the cage wall. In the region of the cage corpus, bony necrosis and connective tissue rich in cells was found. CONCLUSION: Bridging fusion in vertebral body replacement cages is not proven. As a result cage failure may occur. Therefore, in tumour patients with high live expectancy, Palacos filling of the cages should be discussed.

Homogeneity and stability study of the candidate reference material Adamussium colbecki for trace elements.

The preparation of a new candidate certified reference material (CRM) for trace elements based on the antarctic bivalve Adamussium colbecki(IRMM 813) was carried out by the Istituto Superiore di Sanità(ISS, Rome, Italy) in cooperation with the Institute for Reference Materials and Measurements, Joint Research Centre of the European Commission (EC-JRC-IRMM), in the frame of the Italian National Programme of Research in Antarctica (Programma Nazionale di Ricerca in Antartide, PNRA). Samples were collected at Terra Nova Bay (Ross Sea) during the 2000-2001 expedition in Antarctica. The preparation of a material suitable for certification was performed by the EC-JRC-IRMM. Measurements for homogeneity and short-term stability tests were carried out by ISS. The elements selected for the certification project were As, Cd, Cu, Cr, Fe, Mn, Ni and Zn. For the above-mentioned tests, the determination of the elements of interest was performed on samples mineralised by microwave-assisted acid digestion. The analytical techniques employed to this end were inductively coupled plasma atomic emission spectrometry (ICP-AES) and inductively coupled plasma dynamic reaction cell quadrupole mass spectrometry (ICP-DRC-Q-MS). The candidate material was shown to be fit for purpose with regard to homogeneity and short-term stability, thus allowing the following phases of the certification project to be undertaken, in the first place the selection of expert laboratories for the accomplishment of the certification campaign.

Differential effects of surgical sympathetic block on sudomotor and vasoconstrictor function.

OBJECTIVE: To assess the effects of a surgical block of the sympathetic chain at the T2 level on vasoconstriction and palmar sweating in patients with palmar hyperhidrosis. METHODS: In a prospective study, sympathetic vasoconstriction was measured by laser-Doppler imaging and by computer-assisted infrared thermography (rewarming kinetics following immersion of both hands in ice water [4 degrees C, 30 seconds]) in 61 patients with hyperhidrosis preoperatively and 2 days and 3 months postoperatively. In addition, palmar sweating preoperatively and 3 months postoperatively was assessed by quantitative sudometry. RESULTS: Before surgery, rewarming kinetics was significantly slower in the patients (n = 61) than in the healthy control subjects (n = 28). Two days after the block, baseline skin temperature increased by about 5 degrees C, and rewarming was massively accelerated in each of the patients. Three months postoperatively, rewarming kinetics was still accelerated in 36 hands, was unchanged from the preoperative condition in 42, and had worsened in 12. These changes were accompanied by parallel alterations of laser-Doppler flux. However, palmar sweating was massively reduced in all but one patient, irrespective of the different rewarming kinetics. CONCLUSIONS: T2 sympathectomy leads to long-lasting inhibition of palmar sweating, which does not correlate to loss of vasoconstriction. Recurrent and enhanced vasoconstrictor function 3 months following endoscopic sympathetic block has major implications for its use to treat enhanced vasoconstriction.

Observations and model simulations of carbon monoxide emission factors from a California highway.

A series of twelve intensively monitored 1-hr CO dispersion studies were conducted near Davis, CA, in winter 1996. The experimental equipment included twelve CO sampling ports at elevations up to 50 m, three sonic anemometers, a tethersonde station, aircraft measurements of wind and temperature profile aloft, and a variety of conventional meteorological equipment. The study was designed to explore the role of vehicular exhaust buoyancy during worst-case meteorological conditions, such as low winds oriented in near-parallel alignment with the road during a surface-based nocturnal inversion. From the study, field estimates of the CO emission factor (EF) from a California vehicle fleet were computed using two different methods. The analysis suggests that the CT-EMFAC/EMFAC (EMission FACtor) models currently used to conduct federal conformity modeling significantly overpredict CO emissions for high-speed, free-flowing traffic on California highways.

Mechanism of Ca(2+) overload in endothelial cells exposed to simulated ischemia.

OBJECTIVE: Several studies have shown that myocardial ischemia leads to functional failure of endothelial cells (EC) whereby disturbance of Ca(2+) homeostasis may play an important role. The mechanisms leading to Ca(2+) disbalance in ischemic EC are not fully understood. The aim of this study was to test effects of different components of simulated ischemia (glucose deprivation, anoxia, low extracellular pH (pH(o)) and lactate) on Ca(2+) homeostasis in EC. METHODS: Cytosolic Ca(2+) (Ca(i)), cytosolic pH (pH(i)) and ATP content were measured in cultured rat coronary EC. RESULTS: In normoxic cells 60 min glucose deprivation at pH(o) 7.4 had no effect on pH(i). It only slightly increased Ca(i) and decreased ATP content. Reduction of pH(o) to 6.5 under these conditions led to marked cytosolic acidosis and Ca(i) overload, but had no effect on ATP content. Anoxia at pH(o) 6.5 had no additional effect on Ca(i) overload, but significantly reduced cellular ATP. Addition of 20 mmol/l lactate to anoxia at pH(o) 6.5 accelerated Ca(i) overload due to faster cytosolic acidification. Acidosis-induced Ca(i) overload was prevented by inhibition of Ca(2+) release channels of endoplasmic reticulum (ER) with 3 micromol/l ryanodine or by pre-emptying the ER with thapsigargin. Re-normalisation of pH(o) for 30 min led to recovery of pH(i), but not of Ca(i). CONCLUSION: The ischemic factors leading to cytosolic acidosis (low pH(o) and lactate) cause Ca(i) overload in endothelial cells, while anoxia and glucose deprivation play only a minor role. The ER is the main source for this Ca(i) rise. Ca(i) overload is not readily reversible.

Evaluation of guidelines for the use of telemetry in the non-intensive-care setting.

To determine if the American College of Cardiology (ACC) cardiac monitoring guidelines accurately stratify patients according to their risks for developing clinically significant arrhythmias in non-intensive-care settings, we conducted a prospective cohort study of 2,240 consecutive patients admitted to a non-intensive-care telemetry unit over 7 months. Sixty-one percent of patients were assigned to ACC class I (telemetry indicated in most patients), 38% to class II (telemetry indicated in some), and 1% to class III (telemetry not indicated). Arrhythmias were detected in 13.5% of the class I patients, 40.7% of the class II patients, and 12% of the class III patients (p <.001). Telemetry detected an arrhythmia resulting in transfer to an intensive care unit in 0.4% of the class I patients, 1.6% of the class II patients, and none of the class III patients (p =.006). Telemetry led to a change in management for 3.4% of the class I patients, 12.7% of the class II patients, and 4% of the class III patients (p <.001). When patients with chest pain as the reason for admission were moved from class I to class II and patients with arrhythmias as the reason for admission were moved from class II to class I, more arrhythmias and more clinically significant arrhythmias occurred in class I patients and the trends from class I to class III were more consistent with the purpose of the guidelines. These findings indicate that when the ACC guidelines are reexamined, consideration should be given to changing them so they are more useful in non-intensive-care settings.

Coordination polymerization in water affording amorphous polyethylenes.

The coordination polymerization of ethylene in water as a reaction medium was studied. Rubbery amorphous branched polyethylene was obtained when a known cationic diimine-substituted methyl complex was employed as a catalyst precursor. High rates of up to 900 TOh(-1) (turnover frequency) were observed. In contrast to solution polymerization in an organic solvent, the rate of suspension polymerization in water increases greatly with ethylene pressure in the range up to 20 bar; this indicates control of the polymerization rate by the concentration of the olefin monomer at the catalytically active site. The effect and mode of mass transfer phenomena were studied. A high catalyst stability in the aqueous coordination polymerization was observed. It was found to be due to an "encapsulation" of the water-insoluble catalyst precursor in the hydrophobic amorphous polymer during the polymerization reaction, and this resulted in strongly restricted accessibility for the aqueous phase. Surprisingly, exposure of the water-stable catalyst precursor to ethylene monomer in solution in the presence of water resulted in immediate decomposition. Polymer microstructure, and thermal and mechanical properties were investigated. The different degree of branching, molecular weight, and corresponding macroscopic properties of the polymers obtained in water as a reaction medium versus solution polymerization in methylene chloride under the same conditions are due to the different phase behavior during polymerization (suspension vs. solution), as opposed to an effect of water on the catalytically active centers.

A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease. Antithrombotic Therapy Consortium Investigators.

BACKGROUND: Therapy with intravenous unfractionated heparin improves clinical outcome in patients with active thromboembolic disease, but achieving and maintaining a therapeutic level of anticoagulation remains a major challenge for clinicians. METHODS: A total of 113 patients requiring heparin for at least 48 hours were randomly assigned at 7 medical centers to either weight-adjusted or non-weight-adjusted dose titration. They were separately assigned to either laboratory-based or point-of-care (bedside) coagulation monitoring. RESULTS: Weight-adjusted heparin dosing yielded a higher mean activated partial thromboplastin time (aPTT) value 6 hours after treatment initiation than non-weight-adjusted dosing (99.9 vs 78.8 seconds; P =.002) and reduced the time required to exceed a minimum threshold (aPTT >45 seconds) of anticoagulation (10.5 vs 8.6 hours; P =.002). Point-of-care coagulation monitoring significantly reduced the time from blood sample acquisition to a heparin infusion adjustment (0.4 vs 1.6 hours; P <.0001) and to reach the therapeutic aPTT range (51 to 80 seconds) (16.1 vs 19.4 hours; P =.24) compared with laboratory monitoring. Although a majority of patients participating in the study surpassed the minimum threshold of anticoagulation within the first 12 hours and reached the target aPTT within 24 hours, maintaining the aPTT within the therapeutic range was relatively uncommon (on average 30% of the overall study period) and did not differ between treatment or monitoring strategies. CONCLUSIONS: Weight-adjusted heparin dosing according to a standardized titration nomogram combined with point-of-care coagulation monitoring using the BMC Coaguchek Plus System represents an effective and widely generalizable strategy for managing patients with thromboembolic disease that fosters the rapid achievement of a desired range of anticoagulation. Additional work is needed, however, to improve on existing patient-specific strategies that can more effectively sustain a therapeutic state of anticoagulation.

[Cerebellar hemorrhage as an early complication of spinal operations. 2. Case reports and review of the literature]. / Kleinhirnblutung als Frühkomplikation von Wirbelsäulenoperationen. 2 Fallberichte und Literaturübersicht.

GOAL: The present paper investigates the etiology and pathogenesis of cerebellar hemorrhage after spine surgery. METHOD: This paper reports two patients in those this complication was seen. In respect to the current literature we discuss the etiology and pathogenesis of cerebellar hemorrhage due to spine surgery. RESULTS: Cerebellar hemorrhages represent a life-threatening situation. There are no reports in the literature about cerebellar hemorrhage as an early complication of intraoperative dura injuries in spine surgery. It seems that a bigger cerebrospinal fluid loss is responsible for the developing of cerebellar hemorrhages. The loss creates a pressure gradient from infratentoriell to site of lesion and also leads to mechanical stress on cerebellar blood vessels such as traction, tearing and kinking. CONCLUSIONS: Every condition after spine surgery with dura injuries and neurological deficits should be carefully evaluated and intracranial hypotension as well as hemorrhage should be ruled out.

Role of telemetry monitoring in the non-intensive care unit.

To determine the outcomes of patients admitted to a non-intensive care telemetry unit and to assess the role of telemetry for guiding patient management decisions, data from 2,240 patients admitted to a telemetry unit were collected prospectively during 7 months. Physicians recorded the outcomes (intensive care unit transfer and mortality) and assessed whether telemetry assisted in guiding patient management. Indications for admission to the telemetry unit included chest pain syndromes (55%), arrhythmias (14%), heart failure (12%), and syncope (10%). Telemetry led to direct modifications in management in 156 patients (7%; 95% confidence interval [CI] 5.9% to 8%). Telemetry was perceived as useful but did not alter management for 127 patients (5.7%; 95% CI 4.7% to 6.6%). Two hundred forty-one patients were transferred to an intensive care unit from the telemetry unit (10.8%; 95% CI 9.5% to 12%). Nineteen patients (0.8% of all admissions; 95% CI 0.5% to 1.2%) were transferred because of an arrhythmia identified by telemetry. Routine transfer after cardiac revascularization or surgery accounted for 134 transfers; clinical deterioration accounted for 88 transfers. There were 20 deaths in the unit (0.9%; 95% CI 0.5% to 1.3%): 4 of the 20 deaths occurred while patients were being monitored. The role of telemetry in guiding patient management may be overestimated by physicians, since it detected significant arrhythmias that led to change in medications or urgent interventions in a small fraction of patients.