Using a multihospital systems framework to evaluate and establish drug use policy.

PURPOSE: In order to develop rational drug purchasing and use policy for a class of pharmaceuticals used in a consortium system of 14 university based hospitals, the antiemetic use patterns of inpatients receiving cancer chemotherapy were evaluated to assess the comparative effectiveness of granisetron, ondansetron, and conventional antiemetics. PATIENTS AND METHODS: A prospective, observational study was conducted in 14 academic health centers linked under research and purchasing consortium arrangements from October to December 1994. The use of antiemetics was evaluated in hospitalized patients receiving cancer chemotherapy agents with a known propensity for causing, alone or in combination, varying degrees of nausea or vomiting. Clinical outcomes measured were the impact of chemotherapy administration on the functional status of patients, and the occurrence of post-treatment vomiting. RESULTS: The most often prescribed cancer chemotherapy regimens consisted of cisplatin, paclitaxel, etoposide and cyclophosphamide, and the most often prescribed antiemetics were the 5-hydroxytryptamine subtype-3 antagonists (5-HT3 antagonists, granisetron and ondansetron), dexamethasone and lorazepam. Of the 439 patients studied, 329 (75%) reported no episodes of emesis. Of the patients receiving highly emetogenic chemotherapy, those receiving 5-HT3 antagonists experienced better overall outcomes (as measured by functional health status and the absence of vomiting) than patients receiving conventional (non-5-HT3 antagonist) antiemetics. In contrast, patients receiving chemotherapy associated with moderate or low emetogenicity experienced similar outcomes, regardless of the antiemetic regimen selected. No statistical difference was seen between granisetron and ondansetron in achieving positive patient outcomes. CONCLUSION: The study results suggest that 5-HT3 antagonists are associated with better clinical outcomes than other antiemetics in patients receiving highly emetogenic chemotherapy. Less costly conventional antiemetic therapy (or, in some cases, no antiemetic therapy) provide comparable outcomes in patients receiving chemotherapy associated with moderate or low emetogenic potential. Granisetron and ondansetron were found to be clinically comparable.

National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia.

The National Heart Attack Alert Program (NHAAP), which is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), promotes the early detection and optimal treatment of patients with acute myocardial infarction and other acute coronary ischemic syndromes. The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations pertaining to the management of patients with acute cardiac ischemia. This position paper offers recommendations to assist emergency physicians in EDs, including those with chest pain centers, in providing comprehensive care for patients with acute cardiac ischemia.

Evaluating the outcome of two teaching methods of breath actuated inhaler in an inner city asthma clinic.

OBJECTIVES: Our objective was to compare two different teaching methods used to educate patients in the use of a breath actuated inhaler (BAI) and to assess the impact of its continued use on their metered-dose inhaler (MDI) technique. DESIGN: Prospective, randomized, controlled trial. SETTING: Adult Pulmonary/Asthma clinic of Cook County Hospital, Chicago, IL. PATIENTS: Diagnosed, stable asthmatics. INTERVENTION: The patients were randomized into two groups. The experimental group received verbal instructions and demonstration on breath actuated inhaler technique while the control group received written instructions only on BAI use. The metered dose inhaler technique of both groups of patients was also evaluated. MEASURES: A checklist evaluating the key aspects of proper BAI and MDI inhalation techniques was used to assess the use of both types of inhalers at entry into the study and upon postintervention follow-up at 8 to 20 weeks. RESULTS: At baseline, 97% of patients in the experimental group and 83% of patients in the control group were initially able to demonstrate BAI inhalation technique correctly. Upon follow-up, 82% of the control group and 68% of the experimental group were able to use the BAI correctly, which was a statistically significant deterioration in the experimental group. In both of these groups, there was a statistically significant improvement in MDI technique. CONCLUSIONS: Written instructions alone may be an adequate teaching tool for proper inhalation technique of BAI. Continued BAI use appears not to impact adversely on proper MDI technique.

Comparison of two regimens of beta-adrenergics in acute asthma.

BACKGROUND AND METHODS: Inhaled adrenergics and steroids are the main agents used in acute asthma. Dosing recommendations for adrenergics, while generally becoming more aggressive, lack prospective validation. A double blind, randomized trial of two regimens of nebulized metaproterenol was conducted in patients presenting to an Emergency Department with an acute asthma exacerbation. Asthmatics age 16-55, with no other cardio-pulmonary disease, presenting with peak expiratory flow rate (PEFR) < 30% of predicted and greater than 80 L/m were enrolled. All patients received 125 mg of methylprednisolone and theophylline, if needed, to reach therapeutic levels. The experimental group received 0.3 cc metaproterenol in 2.5 cc of saline at times 0, 20", 40", 1', 2', 3', 4', 5', 6', and 7'. The control group received metaproterenol at times 0, 1 hr, and hours 3, 5, and 7. Placebo was given to control group patients at 20", 40", 2', 4', and 6'. PEFR and vital signs were measured 10 min after each treatment. Study end points included discharge upon reaching set criteria or admission if patients were not discharged following the hour 7 treatment. RESULTS: Seventy one patients were enrolled, 40 in experimental group and 31 in the control group. The group characteristics did not differ at entry in any significant way, and the groups began with mean expected PEFR of 23.4% and 24.5%, respectively. There were no significant differences at any point in PEFR outcomes, time to discharge, or admission rate. The experimental group showed a greater increase in pulse rate and a reduced diastolic blood pressure at 20, 40 and 60 min. The experimental group had a 12- and 8-fold increase in the risk of a pulse rate > 140 at 40 and 60 min, respectively. This group also had two moderate complications, both near the 60-minute mark. These were an induction of atrial fibrillation in one patient and ischemic electrocardiographic changes in another. CONCLUSION: Three treatments in the first hour, and hourly thereafter showed no benefit over treatments initially, at one hour, and every other hour in acute, moderate, or severe exacerbation of asthma. Side effects were markedly increased in the control group. Such dosing should not be recommended as routine therapy.

Outcome of case management and comprehensive support services following policy changes in mental health care delivery.

UNLABELLED: An assessment of policy toward the care of seriously mentally ill (SMI) persons residing in a suburban Chicago community was undertaken. Results indicated the SMI population was classically "underserved." Few alternatives to a state inpatient hospital were being utilized. A policy change in SMI care was instituted by the local community mental health board which included implementation of the Unified Services Program (USP). The features of the USP were: centralized case management and outreach; and an expansion of service philosophy into a comprehensive, multidisciplinary service model of mental health delivery. METHODS: This study examined SMI service utilization, quality of life, and satisfaction with care outcomes following 12 months of USP exposure. Fifty percent of USP caseloads were randomly sampled for study participation. USP study results were compared to a large SMI population with similar exposures in another state. RESULTS: 100% of USP SMI reported to be satisfied or very satisfied with their place of residence compared to the state hospital; and 100% were satisfied or very satisfied with the USP overall. Eighty two to 100% of the study participants rated their status as better than before enrolling in USP. SMI utilized USP services, and service combinations which they find useful (88 to 100%); and felt they could not access their services without USP case managers or outreach. Compared to New York State SMI, study SMI reported similar scores, but superior ratings on "services/facilities." CONCLUSION: The study supports use of the USP for SMI living in the community, and also identified areas for programmatic improvement.

CD8+ lymphocytes in pregnancy and HIV infection: characterization of CD8+ subpopulations and CD8+ noncytotoxic antiviral activity.

The distribution and function of lymphocytes vary in different clinical states. The object of this study was to characterize the CD8+ lymphocyte subpopulations and CD8+ anti-HIV suppressor activity in HIV-infected and uninfected pregnant and nonpregnant women. The total percentage of CD8+ lymphocytes was not altered by pregnancy but the percentage of activated CD8+ T cells increased during pregnancy and decreased postpartum. HIV infection in pregnant women resulted in both an increased percentage of CD8+ lymphocytes and a marked increase in activated and memory CD8+ lymphocyte subsets, which did not change in the postpartum period. Most HIV-infected women had CD8+-mediated noncytotoxic antiviral activity. However, the activity was not correlated with alterations in CD8+ lymphocyte subsets. This study provides baseline information on changes in CD8 immunologic parameters during pregnancy and HIV infection for further studies that employ antiretroviral therapeutic regimens capable of impacting the immune response.

The rate and risk of heat-related illness in hospital emergency departments during the 1995 Chicago heat disaster.

OBJECTIVES: To conduct an Emergency Department (ED)-based treated prevalence study of heat morbidity and to estimate the rate and risk of heat morbid events for all Chicago MSA EDs (N = 95; 2.7 million visits per year). METHODS: ED patient log data were compiled from 13 randomly selected hospitals located throughout the Chicago MSA during the 2 weeks of the 1995 heat disaster and from the same 2-week period in 1994 (controls). Measurements included: age, sex, date, and time of ED service, up to three ICD-9 diagnoses, and disposition. RESULTS: Heat morbidity for Chicago MSA hospital EDs was calculated at 4,224 (95% CI = 2964-5488) cases. ED heat morbidity increased significantly 5 days prior to the first heat-related death. In 1995, there was an increase in the estimated relative risk for the city = 3.85 and suburbs = 1.89 over the control year of 1994. CONCLUSIONS: Real time ED-based computer automated databanks should be constructed to improve public health response to infectious or noninfectious outbreaks. Rapid area-wide M&M tabulations can be used for advancing the effectiveness of community-based prevention programs, and anticipating hospital ED resource allocation.

Patient satisfaction with an emergency department asthma observation unit.

OBJECTIVE: To compare levels of patient satisfaction between the diagnostic and treatment protocols in an ED-based asthma observation unit (AOU) and those with standard inpatient hospitalization. METHODS: This was a prospective, randomized, controlled trial with a sample of 163 patients presenting to the ED with acute asthma exacerbations over a 30-month period. Eligible patients were those who could not resolve their symptoms after three hours of standard ED therapy. Patients were then randomly assigned to an ED-based AOU (experimental group) or to customary inpatient care (control group). Patient satisfaction and problems with care processes were assessed by standardized instrumentation at discharge in both groups. RESULTS: The AOU patients scored higher than those randomized to the inpatient hospitalization protocol on four summary ratings of patient satisfaction measures: received service wanted, recommendation of the service to others, satisfaction with the service, and overall satisfaction. The AOU patients reported fewer total number of problems with care received, and fewer specific problems with communication, emotional support, physical comfort, and special needs, than did the inpatient group. However, the AOU patients reported more problems regarding their knowledge of financial costs and liabilities for their service than did the inpatients. CONCLUSION: Patients were more satisfied and had fewer problems with rapid diagnosis and treatment in the AOU than they did with routine inpatient hospitalization. Since AOUs represent a new ambulatory service modality, patients would benefit from greater awareness of the costs and coverage for AOUs as compared with hospital inpatient care. These findings have important implications for the future short- and long-term success and feasibility of ED-based AOUs.

Distribution of variable vs fixed costs of hospital care.

CONTEXT: Most strategies proposed to control the rising cost of health care are aimed at reducing medical resource consumption rates. These approaches may be limited in effectiveness because of the relatively low variable cost of medical care. Variable costs (for medication and supplies) are saved if a facility does not provide a service while fixed costs (for salaried labor, buildings, and equipment) are not saved over the short term when a health care facility reduces service. OBJECTIVE: To determine the relative variable and fixed costs of inpatient and outpatient care for a large urban public teaching hospital. DESIGN: Cost analysis. SETTING: A large urban public teaching hospital. MAIN OUTCOME MEASURES: All expenditures for the institution during 1993 and for each service were categorized as either variable or fixed. Fixed costs included capital expenditures, employee salaries and benefits, building maintenance, and utilities. Variable costs included health care worker supplies, patient care supplies, diagnostic and therapeutic supplies, and medications. RESULTS: In 1993, the hospital had nearly 114000 emergency department visits, 40000 hospital admissions, 240000 inpatient days, and more than 500000 outpatient clinic visits. The total budget for 1993 was $429.2 million, of which $360.3 million (84%) was fixed and $68.8 million (16%) was variable. Overall, 31.5% of total costs were for support expenses such as utilities, employee benefits, and housekeeping salaries, and 52.4% included direct costs of salary for service center personnel who provide services to individual patients. CONCLUSIONS: The majority of cost in providing hospital service is related to buildings, equipment, salaried labor, and overhead, which are fixed over the short term. The high fixed costs emphasize the importance of adjusting fixed costs to patient consumption to maintain efficiency.

A national survey of emergency department chest pain centers in the United States.

Although chest pain centers are promoted as improving emergency cardiac care, no data exist on their structure and processes. This national study determines the 1995 prevalence rate for emergency department (ED)-based chest pain centers in the United States and compares organizational differences of EDs with and without such centers. A mail survey was directed to 476 EDs randomly selected from the American Hospital Association's database of metropolitan hospitals (n = 2,309); the response rate was 63%. The prevalence of chest pain centers was 22.5% (95% confidence interval 18% to 27%), which yielded a projection of 520 centers in the United States in 1995. EDs with centers had higher overall patient volumes, greater use of high-technology testing, lower treatment times for thrombolytic therapy, and more advertising (all p <0.05). Hospitals with centers had greater market competition and more beds per annual admissions, cardiac catheterization, and open heart surgery capability (all p <0.05). Logistic regression identified open heart surgery, high-admission volumes, and nonprofit status as independent predictors of hospitals having chest pain centers. Thus, chest pain centers have a moderate prevalence, offer more services and marketing efforts than standard EDs, and tend to be hosted by large nonprofit hospitals.

Emergency Department Observation Unit versus hospital inpatient care for a chronic asthmatic population: a randomized trial of health status outcome and cost.

OBJECTIVES: This study was designed to determine if an accelerated treatment protocol administered to acute asthmatics presenting to a Hospital Emergency Department Observation Unit (EDOU) can offset the need for inpatient admissions and reduce total cost per episode of care without sacrificing patient quality of life. METHODS: The authors used a prospective randomized controlled trial comparing postintervention patient quality of life for EDOU care versus standard inpatient care as measured by the standardized Medical Outcomes Study (MOS) SF-36 instrument. Other measures reported include: clinical status as measured by peak flow rates, total cost per treatment arm using microcosting techniques, and relapse-free survival 8 weeks after treatment. Eligible patients (n = 113) were assigned randomly to an EDOU or inpatient care from a consecutive sample of 250 acute asthmatic patients presenting to an urban hospital emergency department who could not resolve their acute asthma exacerbation after 3 hours of emergency department therapy. RESULTS: Patients assigned to the EDOU had lower mean costs of treatment (EDOU = $1,202 versus Hospital Inpatient = $2,247) and higher quality of life outcomes after intervention in five of eight domains measured by the MOS SF-36: Physical Functioning, Role Functioning-Emotional, Social Functioning, Mental Health, and Vitality. No differences were found in clinical outcomes as measured by peak flow rates or postintervention relapse-free survival. Univariate comparative findings were re-examined and confirmed through multivariable analysis when baseline SF-36 scores and postintervention peak expiratory flow rates clinical status were used as covariates. CONCLUSIONS: The study showed that the EDOU was a lower cost and more effective treatment alternative for a refractory asthmatic population presenting to the Emergency Department. Several baseline MOS SF-36 domains proved useful in predicting or validating posttreatment clinical status, relapse, and total costs of care. Outcome SF-36 domain scores were also useful in identifying patients with the most favorable clinical, cost, and relapse rate outcomes at the study endpoint.

Prediction of relapse within eight weeks after an acute asthma exacerbation in adults.

Associations between historical, presenting, and treatment-related characteristics and relapse within 8 weeks after a moderate to severe asthma exacerbation were studied in a cohort of 284 adult asthmatics. Data were collected prospectively, and a multivariate model was developed and internally validated. Within 10 days, only 8% had relapsed, increasing to 45% by 8 weeks. Three variables that could be identified at the time of discharge were independently associated with relapse. These included: having made three or more visits to an emergency department in the prior 6 months (hazard ratio (HR) = 2.3, 95% CI = 1.6-3.4); difficulty performing work or activities as a result of physical health in the 4 weeks prior (HR = 2.7, 95% CI = 1.6-4.3); discontinuing hospital-based treatment for the exacerbation within 24 hours without having achieved a peak expiratory flow rate of at least 50% of predicted (HR = 2.6, 95% CI = 1.6-4.1). These risk factors may help to identify patients with poorly controlled asthma in need of more intensive and comprehensive management.

ST segment elevation and the prediction of hospital life-threatening complications: the role of right ventricular and posterior leads.

UNLABELLED: Accurate prognosis in suspected acute myocardial infarction (AMI) is essential for appropriate use of thrombolytic therapy and primary angioplasty. However, previous models may be limited because the 12-lead electrocardiogram (ECG) does not examine the right ventricular (RV) and posterior myocardium. We evaluated ST segment elevation (STSE) in posterior (V7-V9) and RV (V4R-V6R) leads to determine their predictive value for hospital life-threatening complications (HLTCs). METHOD AND RESULTS: This prospective trial of seven Midwestern hospital emergency departments (EDs) had inclusion criteria of age 35 years, chest pain suggestive of ischemia, and coronary care unit (CCU) admission. ECG leads were test positive if STSE was > 0.1 mV. Patients were positive for HLTCs if ED or inpatient hospital course included: ventricular fibrillation or tachycardia, second- or third-degree block, shock, arrest, or death. Univariate and multivariate analyses were performed to test each lead's association with HLTCs. Of 533 patients, 64.7% (345/533) had AMI and 15.8% (85/533) had HLTCs. The sensitivity of 18 leads for HLTCS was increased by 5.8%, but specificity decreased by 8.2%. ECG subgroups by STSE were associated with the following HLTC rates: inferior/+RV (32.4%); anterior (29.5%), lateral (23.1%), inferior RV (17.9%), and posterior (16.2%). V1 (odds = 3.2) and V6R (odds = 3.1) were statistically significant independent predictors. CONCLUSION: Posterior and RV leads did not increase the ECG's overall prognostic value, but in the presence of inferior STSE, were associated with low and high complication rates, respectively. Right and left precordial leads were the best predictors of HTLCs.

Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in patients with chest pain: a randomized controlled trial.

CONTEXT: More than 3 million patients are hospitalized yearly in the United States for chest pain. The cost is over $3 billion just for those found to be free of acute disease. New rapid diagnostic tests for acute myocardial infarction (AMI) have resulted in the proliferation of accelerated diagnostic protocols (ADPs) and chest pain observation units. OBJECTIVE: To determine whether use of an emergency department (ED)-based ADP can reduce hospital admission rate, total cost, and length of stay (LOS) for patients needing admission for evaluation of chest pain. DESIGN: Prospective randomized controlled trial comparing admission rate, total cost, and LOS for patients treated using ADP vs inpatient controls. Total costs were determined using empirically measured resource utilization and microcosting techniques. SETTING: A large urban public teaching hospital serving a predominantly African American and Hispanic population. PATIENTS: A sample of 165 patients was randomly selected from a larger consecutive sample of 429 patients with chest pain concurrently enrolled in an ADP diagnostic cohort trial. Eligible patients presented to the ED with clinical findings suggestive of AMI or acute cardiac ischemia (ACI) but at low risk using a validated predictive algorithm. MAIN OUTCOME MEASURES: Primary outcomes measured for each subject were LOS and total cost of treatment. RESULTS: The hospital admission rate for ADP vs control patients was 45.2% vs 100% (P<.001). The mean total cost per patient for ADP vs control patients was $1528 vs $2095 (P<.001). The mean LOS measured in hours for ADP vs control patients was 33.1 hours vs 44.8 hours (P<.01). CONCLUSIONS: In this trial, ADP saved $567 in total hospital costs per patient treated. Use of ED-based ADPs can reduce hospitalization rates, LOS, and total cost for low-risk patients with chest pain needing evaluation for possible AMI or ACI.

Evaluation of immunologic markers in cervicovaginal fluid of HIV-infected and uninfected women: implications for the immunologic response to HIV in the female genital tract.

We analyzed 21 cervicovaginal lavage (CVL) specimens from 19 women participating in the Women's Interagency HIV Study to characterize levels of antibody, cytokine, and complement and to determine associations between these levels and stage of the menstrual cycle, HIV status, and the presence of concurrent genital infection and genital dysplasia. Sixteen samples were collected from HIV-infected women and five from high-risk HIV-seronegative women. CVL fluid was assayed for levels of IgG, secretory IgA (s-IgA), interleukin 2 (IL-2), IL-10, IL-6, tumor necrosis factor alpha (TNF-alpha), IL-1beta, interferon gamma (IFN-gamma), C3, C1q, and C4. Women with HIV were more likely to have cervicovaginal dysplasia (9/16 vs. 0/5; p = 0.027) but were not more likely to have concurrent vaginal infection (10/16 vs. 2/5; p = 0.38). Antibody, cytokine, and complement were detectable in all samples, although not all samples had measurable IL-10, C3, or C4. HIV-infected women demonstrated a trend toward higher levels of IFN-gamma than did uninfected women (p = 0.098); no differences were noted in other parameters. HIV-infected women with vaginal infections had significantly higher CVL levels of IgG (p = 0.023) and IFN-gamma (p = 0.02) than did HIV-infected women without genital infections. HIV-infected women with cervicovaginal dysplasia were found to have higher levels of IL-1beta (p = 0.045) and IFN-gamma (p = 0.039) than those without. Analysis of the HIV-infected cohort by CD4 cell count revealed higher levels of IgG and IFN-gamma in CVL from women with lower CD4 cell counts, although these differences were not statistically significant. Higher levels of proinflammatory cytokines in CVL fluid of women with genital infection or cervicovaginal dysplasia may affect local HIV replication and may influence the risk of acquisition or transmission of HIV for women with these underlying conditions.

A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma.

BACKGROUND: Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy. OBJECTIVE: To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care. METHODS: A prospective, randomized clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomization or with routine therapy in a hospital ward. Patients were followed up for 8 weeks. MAIN OUTCOME MEASURES: Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patients satisfaction, and patient quality of life. RESULTS: The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P = .74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favoring EDTU care. The mean (+/-SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P < .001). CONCLUSIONS: Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.

Predictive value of letters of recommendation vs questionnaires for emergency medicine resident performance.

OBJECTIVE: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program. METHODS: A retrospective association of LORs and PPQs with in-training residents performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the specialty of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings. RESULTS: Statistically, no differences were found between the LORs and PPQs in predicting resident performance. CONCLUSIONS: PPQs may substitute for LORs in the evaluation of resident applicants.

Value of posterior and right ventricular leads in comparison to the standard 12-lead electrocardiogram in evaluation of ST-segment elevation in suspected acute myocardial infarction.

In this multicenter prospective trial, we studied posterior (V7 to V9) and right ventricular (V4R to V6R) leads to assess their accuracy compared with standard 12-lead electrocardiograms (ECGs) for the diagnosis of acute myocardial infarction (AMI). Patients aged >34 years with suspected AMI received posterior and right ventricular leads immediately after the initial 12-lead ECG. ST elevation of 0.1 mV in 2 leads was blindly determined and inter-rater reliability estimated. AMI was diagnosed by World Health Organization criteria. The diagnostic value of nonstandard leads was determined when 12-lead ST elevation was absent and present and multivariate stepwise regression analysis was also performed. Of 533 study patients, 64.7% (345 of 533) had AMI and 24.8% received thrombolytic therapy. Posterior and right ventricular leads increased sensitivity for AMI by 8.4% (p = 0.03) but decreased specificity by 7.0% (p = 0.06). The likelihood ratios of a positive test for 12, 12 + posterior, and 12 + right ventricular ECGs were 6.4, 5.6, and 4.5, respectively. Increased AMI rates (positive predictive values) were found when ST elevation was present on 6 nonstandard leads (69.1%), on 12 leads only (88.4%), and on both 6 and 12 leads (96.8%; p <0.001). Treatment rates with thrombolytic therapy increased in parallel with this electrocardiographic gradient. Logistic regression analysis showed that 4 leads were independently predictive of AMI (p <0.001): leads I, II, V3, V5R; V9 approached statistical significance (p = 0.055). The standard ECG is not optimal for detecting ST-segment elevation in AMI, but its accuracy is only modestly improved by the addition of posterior and right ventricular leads.

An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department.

BACKGROUND: Although accelerated diagnostic protocols are being increasingly used in emergency departments to diagnose acute cardiac ischemia, there have been no prospective evaluations of a chest pain diagnostic protocol with serial determinations of creatine kinase MB isoenzyme and mandatory exercise electrocardiography (ExECG). METHODS: Prospective cross-sectional study in which chest pain protocol results were compared with final (reference) diagnoses of acute cardiac ischemia (including acute myocardial infarction and unstable angina). Patients in need of hospital admission but at low probability (by a validated algorithm) for acute myocardial infarction were examined for exclusions: known coronary artery disease, cardiac complications, severe comorbidities, or inability to perform exercise testing. A 12-hour diagnostic protocol included serial measurements of creatine kinase MB, ECG, and clinical assessments followed by ExECG for those with negative initial serial testing. Reference diagnoses were established during hospitalization and diagnostic accuracy was assessed. RESULTS: The study group of 317 patients was 54% male and 65% black, and had a mean age of 46.6 years; 9.5% had a final diagnosis of acute cardiac ischemia. For this diagnosis, the protocol had a sensitivity of 90.0% (95% confidence interval, 72.3%-97.4%); specificity, 50.5% (95% confidence interval, 44.6%-56.4%); positive predictive value, 16.0%; and negative predictive value, 98.0%. Creatine kinase MB, serial ECGs, and ExECG each made a contribution to improved sensitivity and accuracy, whereas clinical reassessments were less discriminating, as indicated by protocol's receiver operating characteristic curve. CONCLUSIONS: A chest pain diagnostic protocol achieved high sensitivity and improved specificity over the standard emergency department workup. There were no adverse advents associated with early ExECG.

Function and phenotype of immature CD4+ lymphocytes in healthy infants and early lymphocyte activation in uninfected infants of human immunodeficiency virus-infected mothers.

The function and phenotypes of CD4+ lymphocytes in infants are different than in adults and are modulated by maturational changes and exposure to environmental antigens. Infants of non-human immunodeficiency virus (HIV)-infected mothers and uninfected infants of HIV-infected mothers, 0 to 6 months of age, were examined for CD4+ lymphocyte function by in vitro interleukin-2 (IL-2) production and for CD4+ phenotypes by three-color flow cytometry. A minority of these uninfected infants (28%) had functional responses similar to those of healthy adult women (IL-2 production in response to anti-CD3, alloantigen, and mitogen), while the remainder were capable of responding to alloantigen and mitogen but not to anti-CD3. We did demonstrate reduced phytohemagglutinin-stimulated IL-2 production in uninfected infants born to HIV-seropositive mothers compared to that in infants from seronegative mothers. The proportions of CD3+ CD4+, CD4+ HLA-DR- CD38+, and CD4+ CD45RA+ RO- (naive) lymphocytes were much higher in infants than in adults, and the proportions of CD4+ CD45RA- RO+ (memory) and CD4+ CD25+ (IL-2 receptor-bearing) lymphocytes were lower in infants than in adults. The proportions of activated (CD4+ HLA-DR+ CD38+) and memory (CD4+ CD45RA- RO+) lymphocytes were increased in uninfected infants of HIV-infected mothers compared to infants of uninfected mothers. Therefore, T-helper-cell function is immature in many infants, but the CD4+ lymphocytes of some HIV-exposed, uninfected infants have been stimulated by antigen at an early age.