Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance.

PURPOSE: Acute heart failure (AHF) causes high burden of mortality, morbidity, and repeated hospitalizations worldwide. This guidance paper describes the tailored treatment approaches of different clinical scenarios of AHF and CS, focusing on the needs of professionals working in intensive care settings. RESULTS: Tissue congestion and hypoperfusion are the two leading mechanisms of end-organ injury and dysfunction, which are associated with worse outcome in AHF. Diagnosis of AHF is based on clinical assessment, measurement of natriuretic peptides, and imaging modalities. Simultaneously, emphasis should be given in rapidly identifying the underlying trigger of AHF and assessing severity of AHF, as well as in recognizing end-organ injuries. Early initiation of effective treatment is associated with superior outcomes. Oxygen, diuretics, and vasodilators are the key therapies for the initial treatment of AHF. In case of respiratory distress, non-invasive ventilation with pressure support should be promptly started. In patients with severe forms of AHF with cardiogenic shock (CS), inotropes are recommended to achieve hemodynamic stability and restore tissue perfusion. In refractory CS, when hemodynamic stabilization is not achieved, the use of mechanical support with assist devices should be considered early, before the development of irreversible end-organ injuries. CONCLUSION: A multidisciplinary approach along the entire patient journey from pre-hospital care to hospital discharge is needed to ensure early recognition, risk stratification, and the benefit of available therapies. Medical management should be planned according to the underlying mechanisms of various clinical scenarios of AHF.

Trends in death attributed to myocardial infarction, heart failure and pulmonary embolism in Europe and Canada over the last decade.

BACKGROUND: Worldwide, cardiovascular diseases and cancer account for ∼40% of deaths. Certain reports have shown a progressive decrease in mortality. Our main objective was to assess mortality trends related to myocardial infarction (MI), heart failure (HF) and pulmonary embolism (PE). METHODS: MI, HF and PE were studied as cause of death based on the analysis of death certificates in Canada (C), England and Wales (E), France (F) and Sweden (S). We also used a multiple cause approach. Age-standardized death rates (SDR) were calculated. RESULTS: The SDR for MI, HF or PE as the underlying cause of death, all decreased during the last decade. The decrease in SDR secondary to MI exceeded that for HF or PE. Concerning multiple cause of death, a greater decrease was also found for MI, compared with HF or PE. CONCLUSIONS: We confirm the beneficial trends in SDR with MI, HF or PE both as underlying or multiple causes in the studied countries. For HF and PE, multiple cause approach seems more accurate to describe the burden of these two pathologies. Our study also suggests that more efforts should be dedicated to HF and PE in order to achieve similar trends than in MI.

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.

Emergency medical evaluation of psychiatric patients.

STUDY OBJECTIVES: To determine the completeness of documentation and accuracy of medical evaluation for a sample of emergency psychiatric patients. DESIGN: Descriptive, retrospective chart review. SETTING: Nine hundred-bed community teaching hospital with a voluntary psychiatric inpatient unit. TYPE OF PARTICIPANTS: Two hundred ninety-eight emergency department patients with psychiatric chief complaints, all of whom were admitted to the voluntary psychiatric unit of the same community teaching hospital. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: There was failure to document mental status at triage in 56% of patients. The most frequent process deficiencies in the medical evaluation were in the neurological examination. Twelve patients (4%) required acute medical treatment within 24 hours of psychiatric admission, and the ED history and physical examination should have identified an acute condition in 83%. The chart was documented "medically clear" in 80% of patients in whom medical disease should have been identified. Patients less than 55 years old had a four times greater chance of a missed medical diagnosis. CONCLUSION: Process deficiencies in the medical history and physical examination accounted for the vast majority of missed acute medical conditions. The statement "medically clear" is inaccurate and should be replaced by a thorough discharge note.

Reproductive and maternal performance of rotational three-breed, and inter se crossbred cows in Florida.

Reproductive, calf growth, and cow weight data were collected during a 16-yr period in southern Florida. Data included 1,767 calves at weaning from purebred, F1, backcross, F2, and three-breed crossbred cows of the Angus (A), Brahman (B), and Charolais (C) breeds. The purebred cows primarily produced purebred calves, the F1 and F2 Cows produced inter se crossbred calves, and the backcross cows produced 3/8:5/8 calves. The 1/2 C:1/4 A:1/4 B three-breed crossbred cows were mated to A series, whereas three-breed crossbred dams with breed compositions of 1/2 B:1/4 A:1/4 C, and 1/2 A:1/4 B:1/4 C were mated to C and B sires, respectively. For analysis of additive breed and heterosis effects, pregnancy rate and cow weight were considered to be traits of the dam alone. The A additive breed effect increased (P < .05) pregnancy rate but reduced (P < .001) cow weight. The effects of AB, AC, and BC heterozygosity all increased pregnancy rate, but the advantage was greater for the crosses that involved B. Both AB and BC heterozygosity increased (P < .001) cow weight, whereas AC did not. The additive direct effect of B and C increased birth weight (BWT) and weaning weight (WWT). The additive maternal effect of B reduced BWT. The direct effect of AB heterozygosity increased BWT and WWT, and that of BC increased only WWT (P < .001). A comparable pattern was observed for maternal heterosis on weight traits. A much smaller effect of AC maternal heterosis on WWT was found. Pregnancy rates of F1, backcross, and three-breed dams were similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Rural poverty and development in West Malaysia.

PIP: Rural poverty in West Malaysia during the 1957-1970 period is examined. The period covered was 1 of a high rate of growth combined with an increasing inequality of income and worsening poverty. During the 1955-1970 period, a large amount of development funds, manpower, and expertise was directed towards a reduction of West Malaysia's rural poverty. Despite these efforts, rural poverty increased. Over the period under review, the share of income going to the richest 20% of the population increased from 50% to 56%; the share going to the middle 20% of the population remained constant at 20%; the poorest 60% of the population saw their share of income decline from 30% to 24%. The poorest 40% of the population received only 11.6% of income in 1970. They were predominantly rural, with this sector accounting for 87% of all poverty. The 3 development plans of this period set high aggregate growth rates as the primary targets and emphasized productivity and income in the rural sector. Rural development has not been sold short; the total funding figure of $2,209.46 million represents 40% of all development spending between 1956 and 1970. The money funded 3 broad areas of rural development: replanting of smallholder rubber with high-yielding clones; increasing rice production; and opening new land. The strategy has been to concentrate upon raising the yields from existing farmland and expanding into new areas of settlement. The problem of dealing with poverty in West Malaysia was made worse by the rapid rate of population increase. The population increase of 1,657,000 was absorbed into the traditional smallholder sector, very largely in exisitng areas of settlement. Over the same period, the modern sector of agriculture, the rubber estates, reduced their labor force by 30,000 as they moved into the cultivation of oil palm, a crop requiring less labor. Some of the additional agricultural workers were placed on new land under government land-development and resettlement schemes, but by 1970 these schemes had only absorbed about 100,000 people. The failure to reduce poverty during the 1955-1970 period resulted from the use of strategies that tried to resolve the poverty problem by using more modern methods of agriculture to increase the output of rice and rubber while leaving traditional patterns of peasant agriculture undisturbed. There was a failure to recognize that poverty was the result of these traditional patterns, with its tiny landholdings, high rents, and low-value crops. The strategies, which perpetuated peasant smallholding, worked to reinforce and bind the farmer into a structure that he needed to get away from if he were to escape poverty. Radical initiatives are needed. These would include a faster alienation of land, a shift away from the smallholder cultivation of rice and rubber, and a plan to facilitate a large number of the rural poor moving out of peasant farming.^ieng

Additive genetic and heterosis effects in crosses among cattle breeds of British, European and Zebu origin.

Breed and heterosis effects for maternal and calf components for weaning traits were measured in the progeny of Angus (A), Brahman (B) and Charolais (C) sires mated to A, B, C and reciprocal AB, AC and BC dams. Additive breed effects for the calf component for weaning weight were -3.0 +/- 3.2, -26.6 +/- 3.1 and 29.6 +/- 3.3 kg for A, B and C, respectively. Corresponding maternal breed effects were -1.7 +/- 2.4, 7.8 +/- 2.3 and -6.1 +/- 2.6 kilograms. Heterosis effects on weaning weight for the calf component were 21.2 +/- 3.6 for AB, 1.4 +/- 3.7 for AC and 16.5 +/- 3.4 for BC crosses, while heterosis levels for the maternal component were 28.9 +/- 2.7 for AB, 16.5 +/- 3.2 for AC and 18.7 +/- 2.9 kg for BC dams. The corresponding estimates for condition scores tended to parallel those for weaning weight. Approximate relative production efficiency rates were computed for the different mating groups as (calf weight divided by cow weight) x weaning rate. These values were .34 for purebred matings, .36 for purebred dams raising F1 calves, .40 for F1 cows raising backcross calves and .43 for F1 dams raising three breed crossbred calves.