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1.
Clin Chem ; 65(11): 1426-1436, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31570633

RESUMO

BACKGROUND: We aimed to validate the clinical performance of the high-sensitivity cardiac troponin I [VITROS® Immunodiagnostic Products hs Troponin I (hs-cTnI-VITROS)] assay. METHODS: We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by 2 independent cardiologists considering all clinical information, including cardiac imaging: first, using serial hs-cTnT-Elecsys (primary analysis) and, second, using hs-cTnI-Architect (secondary analysis) measurements in addition to the clinically used (hs)-cTn. hs-cTnI-VITROS was measured at presentation and at 1 h in a blinded fashion. The primary objective was direct comparison of diagnostic accuracy as quantified by the area under the ROC curve (AUC) of hs-cTnI-VITROS vs hs-cTnT-Elecsys and hs-cTnI-Architect, and in a subgroup also hs-cTnI-Centaur and hs-cTnI-Access. Secondary objectives included the derivation and validation of an hs-cTnI-VITROS-0/1-h algorithm. RESULTS: AMI was the adjudicated final diagnosis in 158 of 1231 (13%) patients. At presentation, the AUC for hs-cTnI-VITROS was 0.95 (95% CI, 0.93-0.96); for hs-cTnT-Elecsys, 0.94 (95% CI, 0.92-0.95); and for hs-cTnI-Architect, 0.92 (95% CI, 0.90-0.94). AUCs for hs-cTnI-Centaur and hs-cTnI-Access were 0.95 (95% CI, 0.94-0.97). Applying the derived hs-cTnI-VITROS-0/1-h algorithm (derivation cohort n = 519) to the validation cohort (n = 520), 53% of patients were ruled out [sensitivity, 100% (95% CI, 94.1-100)] and 14% of patients were ruled in [specificity, 95.6% (95% CI, 93.4-97.2)]. Patients ruled out by the 0/1-h algorithm had a survival rate of 99.8% at 30 days. Findings were confirmed in the secondary analyses using the adjudication including serial measurements of hs-cTnI-Architect. CONCLUSIONS: The hs-cTnI-VITROS assay has at least comparable diagnostic accuracy with the currently best validated hs-cTnT and hs-cTnI assays. CLINICALTRIALSGOV IDENTIFIER: NCT00470587.

2.
Clin Chem ; 65(11): 1437-1447, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31570634

RESUMO

BACKGROUND: We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay. METHODS: We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion. RESULTS: AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration ≥50 ng/L (direct rule-in) or an absolute change within 2 h ≥20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3-100) and sensitivity of 99.4% (95% CI, 96.5-99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1-79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3-100) and sensitivity of 97.7% (95% CI, 92.0-99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8-86) in the validation cohort. CONCLUSIONS: Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high. TRIAL REGISTRATION: APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.

3.
J Am Coll Cardiol ; 74(6): 744-754, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31395124

RESUMO

BACKGROUND: The prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. OBJECTIVES: This study sought to determine the prevalence of PE in patients with syncope. METHODS: Unselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. RESULTS: Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). CONCLUSIONS: PE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352).

4.
J Am Coll Cardiol ; 74(7): 842-854, 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31416527

RESUMO

BACKGROUND: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS: Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization. RESULTS: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).

6.
Int J Cardiol ; 292: 1-12, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31056411

RESUMO

BACKGROUND: Rapid and reliable diagnosis of ST-elevation myocardial infarction (STEMI) as a surrogate for acute coronary occlusion is critical for early reperfusion therapy. OBJECTIVES: We aimed to examine the diagnostic performance of current guideline-recommended Electrocardiogram (ECG) STEMI criteria. METHODS: In a prospective diagnostic multicenter study, we objectively quantified the extent of ST-segment elevation in all ECG leads using an automated software-based analysis of the digital 12-lead-ECG in adult patients presenting to the emergency department (ED) with suspected myocardial infarction (MI). Classification according to current guideline-recommended ECG criteria for STEMI at ED presentation was compared against a final diagnosis adjudicated by two independent cardiologists after reviewing all available medical records including serial ECGs, cardiac imaging and coronary angiograms. RESULTS: Among 2486 patients, 52 (2%) were found to have significant ST-segment elevation on ECG at ED presentation according to current guideline-recommended ECG criteria for STEMI. Eighty-one (3%) patients received a final adjudicated diagnosis of STEMI. Only 35% (28 of 81) of all patients with a final diagnosis of STEMI were correctly identified (PPV 54% (95% CI 41-66%), sensitivity 35% (95% Cl 24-46%), NPV 97.8% (95% CI 97.5-98.1%). Four reasons for missing STEMIs emerged: timing (significant STE at an earlier/later time point) in 25%, incorrect measurement points in 30%, non or borderline-significant STE in 36% and inferoposterior MI localisation in 9%. CONCLUSIONS: A computerized analysis of current guideline-recommended ECG criteria for STEMI showed suboptimal diagnostic performance when applied to a single 12­lead ECG performed at ED presentation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.

7.
Eur J Radiol ; 113: 245-250, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30927955

RESUMO

OBJECTIVES: To compare texture analysis (TA) with subjective visual diagnosis of myocardial infarction (MI) in cardiac computed tomography (CT) and to evaluate the impact of iterative reconstruction (IR). METHODS: Ten patients (4 women, mean age 68 ± 11 years) with confirmed chronic MI and 20 controls (8 women, mean age 52 ± 11 years) with no cardiac abnormality underwent contrast-enhanced cardiac CT with the same protocol. Images were reconstructed with filtered back projection (FBP) and with advanced modeled IR at strength levels 3-5. Subjective diagnosis of MI was made by three independent, blinded readers with different experience levels. Classification of MI was performed using machine learning-based decision tree models for the entire data set and after splitting into training and test data to avoid overfitting. RESULTS: Subjective visual analysis for diagnosis of MI showed excellent intrareader (kappa: 0.93) but poor interreader agreement (kappa: 0.3), with variable performance at different image reconstructions. TA showed high performance for all image reconstructions (correct classifications: 94%-97%, areas under the curve: 0.94-0.99). After splitting into training and test data, overall lower performances were observed, with best results for IR at level 5 (correct classifications: 73%, area under the curve: 0.65). CONCLUSIONS: As compared with subjective, nonreliable visual analysis of inexperienced readers, TA enables objective and reproducible diagnosis of chronic MI in cardiac CT with higher accuracy. IR has a considerable impact on both subjective and objective image analysis.


Assuntos
Infarto do Miocárdio/diagnóstico por imagem , Idoso , Algoritmos , Estudos de Casos e Controles , Feminino , Coração/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Doses de Radiação , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Cintilografia , Tomografia Computadorizada por Raios X/métodos
9.
Clin Chem ; 65(7): 893-904, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30988172

RESUMO

BACKGROUND: The aim of this study was to validate the clinical performance of the Beckman Access high-sensitivity cardiac troponin I (hs-cTnI) assay. METHODS: We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by 2 independent cardiologists with all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis), and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used hs-cTn. hs-cTnI Access was measured at presentation and at 1 h. The primary objective was a direct comparison of diagnostic accuracy as quantified by the area under the ROC curve (AUC) of hs-cTnI Access vs the hs-cTnT Elecsys and hs-cTnI Architect assays. Secondary objectives included the derivation and validation of an hs-cTnI Access-specific 0/1-h algorithm. RESULTS: AMI was the adjudicated final diagnosis in 243 of 1579 (15.4%) patients. The AUC at presentation for hs-cTnI Access was 0.95 (95% CI, 0.94-0.96), higher than hs-cTnI Architect [0.92 (95% CI, 0.91-0.94; P < 0.001)] and comparable to hs-cTnT Elecsys [0.94 (95% CI, 0.93-0.95; P = 0.12)]. Applying the derived hs-cTnI Access 0/1-h algorithm (derivation cohort n = 686) to the validation cohort (n = 680), 60% of patients were ruled out [sensitivity, 98.9% (95% CI, 94.3-99.8)], and 15% of patients were ruled in [specificity, 95.9% (95% CI, 94.0-97.2)]. Patients ruled out by the 0/1-h algorithm had a survival rate of 100% at 30 days. Findings were confirmed in the secondary analyses by the adjudication including serial measurements of Architect hs-cTnI. CONCLUSIONS: Diagnostic accuracy and clinical utility of the Beckman hs-cTnI Access assay are very high and at least comparable to Roche hs-cTnT and Abbott hs-cTnI assays. ClinicalTrials.gov Identifier: NCT00470587.

10.
Circulation ; 2019 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-30798615

RESUMO

BACKGROUND: The utility of B-type Natriuretic Peptide (BNP), N-terminal proBNP (NT-proBNP), and high-sensitivity cardiac troponin (hs-cTn) concentrations for diagnosis and risk-stratification of syncope is incompletely understood. METHODS: We evaluated the diagnostic and prognostic accuracy of BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations, alone and against the ones of clinical assessments, in patients >45years presenting with syncope to the emergency department (ED) in a prospective diagnostic multicenter study. BNP, NT-proBNP, hs-cTnT and hs-cTnI concentrations were measured in a blinded fashion. Cardiac syncope, as adjudicated by two physicians based on all information available including cardiac work-up and 1-year follow-up, was the diagnostic endpoint. The EGSYS, a syncope-specific diagnostic score, served as the diagnostic comparator. Death and MACE at 30 and 720 days were the prognostic endpoints. MACE were defined as death, cardiopulmonary resuscitation, life-threatening arrhythmia, implantation of pacemaker/implantable cardioverter defibrillator, acute myocardial infarction, pulmonary embolism, stroke/transient ischemic attack, intracranial bleeding or valvular surgery. The ROSE, OESIL, San Fransisco Syncope Rule (SFSR) and Canadian Syncope Risk Score (CSRS) served as the prognostic comparators. RESULTS: Among 1538 patients eligible for diagnostic assessment, cardiac syncope was the adjudicated diagnosis in 234 patients (15.2%). BNP, NT-proBNP, hs-cTnT, and hs-cTnI were significantly higher in cardiac syncope vs. other causes (p<0.01). The diagnostic accuracy for cardiac syncope, as quantified by the area under the curve (AUC), was 0.77-0.78 (95% confidence interval (CI) 0.74-0.81) for all four biomarkers, and superior to the one of EGSYS (AUC 0.68 [95%-CI 0.65-0.71], p<0.001). Combining BNP/NT-proBNP with hs-cTnT/hs-cTnI further improved diagnostic accuracy to an AUC of 0.81 (p<0.01). BNP, NT-proBNP, hs-cTnT, and hs-cTnI cut-offs, achieving pre-defined thresholds for sensitivity and specificity (95%), allowed for rule-in or rule-out of ~30% of all patients. A total of 450 MACE occurred during follow-up. The prognostic accuracy of BNP, NT-proBNP, hs-cTnI, and hs-cTnT for MACE was moderate-to-good (AUC 0.75-0.79), superior to ROSE, OESIL and SFSR, and inferior to the CSRS. CONCLUSIONS: BNP, NT-proBNP, hs-cTnT, and hs-cTnI concentrations provide useful diagnostic and prognostic information in ED patients with syncope. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov Unique Identifier: NCT01548352.

11.
Eur J Heart Fail ; 21(6): 792-800, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30790397

RESUMO

BACKGROUND: Previous studies suggested that genetic status affects the clinical course of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) patients. The aim of this study was to compare the outcome of desmoglein-2 (DSG2) mutation carriers to those who carry the plakophilin-2 (PKP2) mutation, the most common ARVC/D-associated gene. METHODS AND RESULTS: Consecutive ARVC/D patients carrying a pathogenic mutation in PKP2 or DSG2 were selected from a national ARVC/D registry. The cumulative freedom from sustained ventricular arrhythmia and cardiac transplantation/death from heart failure (HF) during follow-up was assessed, compared between PKP2 and DSG2, and predictors for ventricular arrhythmia and HF events determined. Overall, 118 patients from 78 families were included: 27 (23%) carried a DSG2 mutation and 91 (77%) a PKP2 mutation. There were no significant differences between DSG2 and PKP2 mutation carriers concerning gender, proband status, age at diagnosis, T-wave inversion, or right ventricular dysfunction at baseline. DSG2 patients displayed more frequent epsilon wave (37% vs. 17%, P = 0.048) and left ventricular dysfunction at diagnosis (54% vs. 10%, P < 0.001). During a median follow-up of 5.6 years (2.5-16), DSG2 and PKP2 mutation carriers displayed a similar risk of sustained ventricular arrhythmia (log-rank P = 0.20), but DSG2 mutation carriers were at higher risk of transplantation/HF-related death (log-rank P < 0.001). The presence of a DSG2 mutation vs. PKP2 mutation was a predictor of transplantation/HF-related death in univariate Cox analysis (P = 0.0005). CONCLUSIONS: In this multicentre cohort, DSG2 mutation carriers were found to be at high risk of end-stage HF compared to PKP2 mutation carriers, supporting careful haemodynamic monitoring of these patients. The benefit of early HF treatment needs to be assessed in DSG2 carriers.

12.
Clin Chem ; 65(3): 437-450, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30626633

RESUMO

BACKGROUND: We desired to determine cardiac troponin (cTn) concentrations necessary to achieve a positive predictive value (PPV) of ≥75% for acute myocardial infarction (AMI) to justify immediate admission of patients to a monitored unit and, in general, early coronary angiography. METHODS: In a prospective multicenter diagnostic study enrolling patients presenting to the emergency department with symptoms suggestive of AMI, final diagnoses were adjudicated by 2 independent cardiologists based on clinical information including cardiac imaging. cTn concentrations were measured using 5 different sensitive and high-sensitivity cTn (hs-cTn) assays in a blinded fashion at presentation and serially thereafter. The diagnostic end point was PPV for rule-in of AMI of initial cTn concentrations alone and in combination with early changes. RESULTS: Among 3828 patients, 616 (16%) had an AMI. At presentation, 7% to 14% of patients had cTnT/I concentrations associated with a PPV of ≥75%. Adding absolute or relative changes did not significantly further increase the PPV. PPVs increased from 46.5% (95% CI, 43.6-49.4) for hs-cTnT at presentation >14 ng/L to 78.9% (95% CI, 74.7-82.5) for >52 ng/L (P < 0.001), whereas PPVs in higher hs-cTnT strata remained largely unchanged [e.g., 82.4% (95% CI, 77.5-86.7) for >80 ng/L vs 83.9% (95% CI, 76.0-90.1) for >200 ng/L (P = 0.72)]. The addition of early changes in hs-cTnT further increased the PPV up to 60 ng/L, but not for higher concentrations. CONCLUSIONS: Serial sampling does not seem necessary for predicting AMI and concurrent decision-making in about 10% of patients, as it only marginally increases the PPV for AMI and not in a statistically or clinically significant way. CLINICALTRIALSGOV IDENTIFIER: NCT00470587.

13.
Int J Cardiol ; 283: 41-47, 2019 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-30545622

RESUMO

BACKGROUND: The clinical availability of high-sensitivity cardiac troponin (hs-cTn) has enabled the development of several innovative strategies for the rapid rule-out of acute myocardial infarction (AMI). Due to the lack of direct comparisons, selection of the best strategy for clinical practice is challenging. METHODS: In a prospective international multicenter diagnostic study enrolling 3696 patients presenting with suspected AMI to the emergency department, we compared the safety and efficacy of 14 different hs-cTn-based strategies: hs-cTn concentrations below the limit of detection (LoD), dual-marker combining hs-cTn with copeptin, ESC 0 h/1 h-algorithm, 0 h/2 h-algorithm, 2 h-ADP-algorithm, NICE-algorithm, and ESC 0 h/3 h-algorithm, each using either hs-cTnT or hs-cTnI. The final diagnosis of AMI was adjudicated by two independent cardiologists using all available clinical information including cardiac imaging and serial hs-cTn concentrations. RESULTS: AMI was the final diagnosis in 16% of patients. Using hs-cTnT, safety quantified by the negative predictive value (NPV) and sensitivity was very high (99.8-100% and 99.5-100%) and comparable for all strategies, except the dual-marker approach (NPV 98.7%, sensitivity 96.7%). Similarly, using hs-cTnI, safety quantified by the NPV and sensitivity was very high (99.7-100% and 98.9-100%) and comparable for all strategies, except the dual-marker approach (NPV 96.9%, sensitivity 90.4%) and the NICE-algorithm (NPV 99.1%, sensitivity 94.7%). Efficacy, quantified by the percentage of patients eligible for rule-out, differed markedly, and was lowest for LoD-algorithm (15.7-26.8%). CONCLUSION: All rapid rule-out algorithms, except the dual-marker strategy and the NICE-algorithm using hs-cTnI, favorably combine safety and efficacy, and can be considered for routine clinical practice. CLINICAL TRIAL REGISTRATION: NCT00470587, http://clinicaltrials.gov/show/NCT00470587.

14.
Artigo em Inglês | MEDLINE | ID: mdl-30534364

RESUMO

Background: Hand Hygiene (HH) compliance was shown to be poor in several studies. Improving the availability of alcohol-based hand rub (ABHR) is a cornerstone for increasing HH compliance. Methods: In this study, we introduced wearable dispensers for ABHR in an Emergency Department (ED) well equipped with mounted ABHR dispensers and accompanied this single-modal intervention by a quasi-experimental mixed-method study. The study was performed in the ED of the University Hospital Zurich, Switzerland, a 950-bed tertiary teaching hospital. During a five-week baseline period and a seven-week intervention period, we observed HH compliance according to the WHO 'Five Moments' concept, measured ABHR consumption, and investigated perceived ABHR availability, self-reported HH compliance and knowledge of HH indications by questionnaire. Multivariable logistic regression was used to identify independent determinants for HH compliance. In addition, semi-structured interviews were conducted and thematically analyzed to assess barriers and facilitators for the use of the newly introduced dispensers. Results: Across 811 observed HH opportunities, the HH compliance for all moments was 56% (95% confidence interval (CI), 51-62%) during baseline and 64% (CI, 59-68%) during intervention period, respectively. In the multivariable analysis adjusted for sex, profession, and WHO HH moment, there was no difference in HH compliance between baseline and intervention (adjusted Odds ratio: 1.22 (0.89-1.66), p = 0.22), No significant changes were observed in consumption and perceived availability of ABHR. During intervention, 7.5% ABHR was consumed using wearable dispensers. HCP perceived wearable dispensers as unnecessary since mounted dispensers were readily accessible. Poor ergonomic design of the wearable dispenser emerged as a main barrier, especially its lid and fastening mechanism. Interviewees identified two ideal situations for wearable dispensers, HCP who accompany patients from ED to other wards, and HCP approaching a patient from a non-patient areas in the ED such as the central working station or the meeting room. Conclusion: The introduction of wearable dispensers did not increase observed hand hygiene compliance or ABHR consumption in an ED already well equipped with mounted dispensers. For broader acceptance and use, wearable dispensers might benefit from an optimized ergonomic design.


Assuntos
Etanol/administração & dosagem , Desinfecção das Mãos/métodos , Higiene das Mãos/métodos , Controle de Infecções/métodos , Anti-Infecciosos Locais/farmacologia , Infecção Hospitalar/prevenção & controle , Serviço Hospitalar de Emergência , Feminino , Hospitais de Ensino , Hospitais Universitários , Humanos , Modelos Logísticos , Masculino , Quartos de Pacientes , Recursos Humanos em Hospital/educação , Fatores de Risco , Suíça , Centros de Atenção Terciária
15.
Eur J Radiol Open ; 5: 202-208, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30456219

RESUMO

Rationale and Objectives: To evaluate the frequency and relevance of hypodense myocardium (HM) encountered in patients undergoing chest-pain CT in the emergency department (ED). Material and Methods: In this IRB-approved retrospective study, ECG-gated chest-pain CT examinations of 300 consecutive patients (mean age 60 ± 17 years) presenting with acute chest-pain to our ED were evaluated. Once ST-segment elevation infarction was excluded, chest-pain CT including the coronary arteries (rule-out acute coronary syndrome (ACS), pulmonary embolism (PE) and acute aortic syndrome (AAS): chest-pain CTcoronary, n = 121) or not including the coronary arteries was performed (rule-out PE and AAS: chest-pain CTw/o coronary, n = 179). Each myocardial segment was assessed for the presence of HM; attenuation was measured and compared to normal myocardium. Results: HM was identified in 27/300 patients (9%): 12/179 in chest-pain CTw/o coronary (7%) and 15/121 in chest-pain CTcoronary (12%). Mean attenuation of HM (40 ± 17 HU) was significantly lower than that of healthy myocardium (103 ± 18 HU, p < 0.001), with a mean difference of 61 ± 19 HU. In 15/27 patients (55.6%) with HM, the final diagnosis was acute MI, and in the remaining 12/27 patients (44.4%) previous MI was found in the patients' history. Chest-pain CTw/o coronary identified HM in 10/15 patients (66.6%) with a final diagnosis of acute MI. Conclusion: HM indicating acute MI are often encountered in chest pain CT in the ED, also in chest-pain CTw/o coronary when MI is not suspected. This indicates that the myocardium should always be analyzed for hypodense regions even when MI not suspected.

16.
Int J Cardiol ; 2018 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-30274750

RESUMO

BACKGROUND: The value of the 12-lead ECG in the diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is limited due to insufficient sensitivity and specificity of standard ECG criteria. The QRS-T angle reflects depolarization-repolarization heterogeneity and might assist in detecting patients with a NSTEMI (diagnosis) as well as predicting patients with an increased mortality risk (prognosis). METHODS: We prospectively enrolled 2705 consecutive patients with symptoms suggestive of NSTEMI. The QRS-T angle was automatically derived from the standard 10 s 12-lead ECG recorded at presentation to the ED. Patients were followed up for all-cause mortality for 2 years. RESULTS: NSTEMI was the final diagnosis in 15% (n = 412) of patients. QRS-T angles were significantly greater in patients with NSTEMI compared to those without (p < 0.001). The use of the QRS-T angle in addition to standard ECG criteria indicative of ischemia improved the diagnostic accuracy for NSTEMI as quantified by the area under the ROC curve from 0.68 to 0.72 (p < 0.001). An algorithm for the combined use of standard ECG criteria and the QRS-T angle improved the sensitivity of the ECG for NSTEMI from 45% to 78% and the specificity from 86% to 91% (p < 0.001 for both comparisons). The 2-year survival rates were 98%, 97% and 87% according to QRS-T angle tertiles (p < 0.001). CONCLUSION: In patients with suspected NSTEMI, the QRS-T angle derived from the standard 12-lead ECG provides incremental diagnostic accuracy on top of standard ECG criteria indicative of ischemia, and independently predicts all-cause mortality during 2 years of follow-up.

17.
Eur Heart J ; 39(42): 3780-3794, 2018 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-30169752

RESUMO

Aims: We aimed to evaluate the impact of age on the performance of the European Society of Cardiology (ESC) 0/1h-algorithms and to derive and externally validate alternative cut-offs specific to older patients. Methods and results: We prospectively enrolled patients presenting to the emergency department (ED) with symptoms suggestive of acute myocardial infarction in three large diagnostic studies. Final diagnoses were adjudicated by two independent cardiologists. High-sensitivity cardiac troponin (hs-cTn) T and I concentrations were measured at presentation and after 1 h. Patients were stratified according to age [<55 years (young), ≥55 to <70 years (middle-age), ≥70 years (old)]. Rule-out safety of the ESC hs-cTnT 0/1h-algorithm was very high in all age-strata: sensitivity 100% [95% confidence interval (95% CI) 94.9-100] in young, 99.3% (95% CI 96.0-99.9) in middle-age, and 99.3% (95% CI 97.5-99.8) in old patients. Accuracy of rule-in decreased with age: specificity 97.0% (95% CI 95.8-97.9) in young, 96.1% (95% CI 94.5-97.2) in middle-age, and 92.7% (95% CI 90.7-94.3) in older patients. Triage efficacy decreased with increasing age (young 93%, middle-age 80%, old 55%, P < 0.001). Similar results were found for the ESC hs-cTnT 0/1h-algorithm. Alternative, slightly higher cut-off concentrations optimized for older patients maintained very high safety of rule-out, increased specificity of rule-in (P < 0.01), reduced overall efficacy for hs-cTnT (P < 0.01), while maintaining efficacy for hs-cTnI. Findings were confirmed in two validation cohorts (n = 2767). Conclusion: While safety of the ESC 0/1h-algorithms remained very high, increasing age significantly reduced overall efficacy and the accuracy of rule-in. Alternative slightly higher cut-off concentrations may be considered for older patients, particularly if using hs-cTnI. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT00470587, number NCT00470587 and NCT02355457 (BACC).

18.
BMC Emerg Med ; 18(1): 29, 2018 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-30180803

RESUMO

BACKGROUND: Smuggling of illegal drugs by hiding them inside one's own body, also called body packing, is a worldwide phenomenon. Cocaine is the most frequently transported drug. Body packing is a potentially lethal practice. The most serious complications of body packing are gastrointestinal obstruction or perforation and drug toxicity due to packet leakage or rupture. CASE PRESENTATION: A 30-year-old confirmed body packer was brought to our emergency department from jail because of agitation and mydriasis. He presented with a high respiratory rate of 40/min but normal oxygen saturation on ambient air, a heart rate of 116 bpm, a blood pressure of 116/68 mmHg and a temperature of 38.0° Celsius. Blood tests were suggestive of infection, urine analysis was positive for cocaine. Abdominal and thoracic computed tomography scans showed pulmonary infiltrates as a possible focus of infection; signs of bowel obstruction or perforation were absent. Given his clinical presentation, we suspected severe infection rather than massive cocaine intoxication to be the main problem. We therefore withheld immediate surgical decontamination. Instead, we started broad-spectrum antibiotic treatment with piperacillin/tazobactam plus clarithromycin for suspected severe community-acquired pneumonia or abdominal sepsis and treated the patient with intravenous midazolam for symptomatic cocaine intoxication. After detection of urinary pneumococcal antigen, the antibacterial regimen was changed to ceftriaxone and vancomycin for pneumococcal pneumonia. In addition, we found human immunodeficiency virus (HIV) type 1 infection as underlying disease. The patient recovered from his acute illness and was discharged after 7 days of treatment with ceftriaxone plus vancomycin. Antiretroviral therapy was started in an outpatient setting. CONCLUSIONS: With this case report, we emphasize the need to look for alternative diagnoses to intoxication and gastrointestinal obstruction in acutely ill body packers with atypical presentation. Special risks, such as underlying HIV infection and potential antimicrobial resistance according to the individual's geographical origin, should be taken into account while treating these patients.

19.
Int J Cardiol ; 269: 114-121, 2018 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-30224031

RESUMO

BACKGROUND: Various scores have been derived for the assessment of syncope patients in the emergency department (ED) but stay inconsistently validated. We aim to compare their performance to the one of a common, easy-to-use CHADS2 score. METHODS: We prospectively enrolled patients ≥ 40 years old presenting with syncope to the ED in a multicenter study. Early clinical judgment (ECJ) of the treating ED-physician regarding the probability of cardiac syncope was quantified. Two independent physicians adjudicated the final diagnosis after 1-year follow-up. Major cardiovascular events (MACE) and death were recorded during 2 years of follow-up. Nine scores were compared by their area under the receiver-operator characteristics curve (AUC) for death, MACE or the diagnosis of cardiac syncope. RESULTS: 1490 patients were available for score validation. The CHADS2-score presented a higher or equally high accuracy for death in the long- and short-term follow-up than other syncope-specific risk scores. This score also performed well for the prediction of MACE in the long- and short-term evaluation and stratified patients with accuracy comparative to OESIL, one of the best performing syncope-specific risk score. All scores performed poorly for diagnosing cardiac syncope when compared to the ECJ. CONCLUSIONS: The CHADS2-score performed comparably to more complicated syncope-specific risk scores in the prediction of death and MACE in ED syncope patients. While better tools incorporating biochemical and electrocardiographic markers are needed, this study suggests that the CHADS2-score is currently a good option to stratify risk in syncope patients in the ED. TRIAL REGISTRATION: NCT01548352.

20.
Sci Rep ; 8(1): 13804, 2018 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-30218094

RESUMO

Dilated cardiomyopathy (DCM) is a structural heart disease that causes dilatation of cardiac chambers and impairs cardiac contractility. The SCN5A gene encodes Nav1.5, the predominant cardiac sodium channel alpha subunit. SCN5A mutations have been identified in patients with arrhythmic disorders associated with DCM. The characterization of Nav1.5 mutations located in the voltage sensor domain (VSD) and associated with DCM revealed divergent biophysical defects that do not fully explain the pathologies observed in these patients. The purpose of this study was to characterize the pathological consequences of a gating pore in the heart arising from the Nav1.5/R219H mutation in a patient with complex cardiac arrhythmias and DCM. We report its properties using cardiomyocytes derived from patient-specific human induced pluripotent stem cells. We showed that this mutation generates a proton leak (called gating pore current). We also described disrupted ionic homeostasis, altered cellular morphology, electrical properties, and contractile function, most probably linked to the proton leak. We thus propose a novel link between SCN5A mutation and the complex pathogenesis of cardiac arrhythmias and DCM. Furthermore, we suggest that leaky channels would constitute a common pathological mechanism underlying several neuronal, neuromuscular, and cardiac pathologies.

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