Aims:
Coronary computed tomography angiography is increasingly employed in the emergency department for suspected acute coronary syndrome patients. The HEART score has been proposed for initial risk ...stratification in these patients. The aim of this study was to investigate the diagnostic value and efficiency of the HEART score before coronary computed tomography angiography.
Methods and results:
We included patients suspected of acute coronary syndrome who underwent coronary computed tomography angiography in the emergency department. Based on the HEART score, patients were stratified as low-risk (HEART≤3), intermediate-risk (HEART4–6) and high-risk (HEART≥7). We assessed coronary computed tomography angiography for the presence of significant coronary artery disease (>50% stenosis). The primary outcome, the level of major adverse cardiac events, was a composite endpoint of all-cause mortality, acute coronary syndrome or coronary revascularisation within 30 days. The study population consisted of 340 patients (mean age: 55.6±10.1 years, 44.7% women), major adverse cardiac events occurred in 45 (13.2%) patients. The incidence of major adverse cardiac events in patients stratified as low-risk (35.0%), intermediate-risk (56.8%) and high-risk (8.2%) was 3.4%, 12.4% and 60.7%, respectively. All four low-risk patients with major adverse cardiac events had a HEART score of three. An algorithm where coronary computed tomography angiography is reserved for patients with HEART 3–6 resulted in a sensitivity of 97.8%, specificity of 84.1%, negative predictive value of 99.6% and positive predictive value of 48.4%, while reducing the need for coronary computed tomography angiography by 22% (n=75).
Conclusion:
The predictive value of coronary computed tomography angiography for 30-day major adverse cardiac events in suspected acute coronary syndrome patients is good, and reserving coronary computed tomography angiography for HEART score 3–6 patients reduces the number of needed coronary computed tomography angiograms without affecting diagnostic accuracy.
Background
The objective of this study was to determine the attitude of patients, healthcare professionals, and noninjured lay persons towards adding a video with discharge instructions to patient ...care for patients with mild traumatic brain injury (MTBI). A survey was conducted at the emergency department (ED). Participants consisted of MTBI patients (
n
= 50), healthcare professionals (
n
= 50), and noninjured lay persons (
n
= 50). The participants viewed a video with discharge instructions on MTBI and filled out a questionnaire that measured their attitude towards the use of a video as part of discharge instructions.
Findings
Nearly all healthcare professionals (94%) and 70% of the noninjured lay persons considered the video to be a valuable addition to oral discharge instructions. For 84% of patients, verbal information from the doctor is of importance. And, 50% of patients would like to receive additional video discharge instructions.
Conclusions
The majority of noninjured lay persons and healthcare professionals and half of the MTBI patients consider a video with discharge instructions to be a valuable addition to patient care. Video discharge instructions are a relative low-cost measure that could enhance patient care at the ED, provided that this does not compromise the personal contact between patient and healthcare professional.
Four clinical trials of porcine islet transplantation have been reported, and there are verbal reports that clinical trials on much larger scales are continuing in centers in China and Russia. The ...four reported trials are briefly reviewed and, in the light of the present status of experimental islet xenotransplantation, consideration is given to whether such trials are currently justified. The Ethics Committee of the International Xenotransplantation Association has (1) emphasized the need for encouraging studies in non‐human primates before clinical trials should be undertaken, (2) mandatory monitoring for the transfer of porcine microorganisms, and (3) careful regulation and oversight by recognized bodies. Other aspects of the topic, such as the need for informed consent, are briefly discussed. We conclude that, at the present time, more data documenting convincing efficacy, focused on clinically applicable immunosuppressive regimens, are needed to justify the initiation of closely monitored clinical trials. A clinical trial may then be justified even though the potential risk to the patients, and possibly for society, will not be zero.
Islet allotransplantation has been shown to have potential as a treatment for type 1 diabetic patients. Xenotransplantation, using the pig as a donor, offers the possibility of an unlimited number of ...islets. This comprehensive review focuses on experience obtained in pig-to-nonhuman primate models, particularly with regard to the different types of islets (fetal, neonatal, adult) and isolation procedures used, and the methods to determine islet viability. The advantages and disadvantages of the methods to induce diabetes (pancreatectomy, streptozotocin) are discussed. Experience in pig-to-nonhuman primate islet transplantation studies is reviewed, including discussion of the possible mechanisms of rejection and the immunosuppressive regimens used. The research carried out to date has led to workable animal models to study islet xenotransplantation, but several questions regarding methodology remain unanswered, and details of these practicalities require to be adequately addressed. The encouraging porcine islet survival reported recently provides an indicator for future immunosuppressive regimens.
Abstract Background Head injury is the leading cause of death and long term disability from bicycle injuries and may be prevented by helmet wearing. We compared the pattern of injury in major trauma ...victims resulting from bicyclist injury admitted to hospitals in the State of Victoria, Australia and South-West Netherlands, with respective high and low prevalence of helmet use among bicyclists. Methods A cohort of bicycle injured patients with serious injury (defined as Injury Severity Score > 15) in South-West Netherlands, was compared to a cohort of serious injured bicyclists in the State of Victoria, Australia. Additionally, the cohorts of patients with serious injury admitted to a Dutch level 1 trauma centre in Rotterdam, the Netherlands and an Australian level 1 trauma centre in Melbourne, Australia were compared. Both cohorts included patients admitted between July 2001 and June 2009. Primary outcome was in-hospital mortality and secondary outcome was prevalence of severe injury per body region. Outcome was compared using univariate analysis and mortality outcomes were also calculated using multivariable logistic regression models. Results A total of 219 cases in South-West Netherlands and 500 cases in Victoria were analyzed. Further analyses comparing the major trauma centres in each region, showed the percentage of bicycle-related death was higher in the Dutch population than in the Australian ( n = 45 (24%) vs n = 13(7%); P < 0.001). After adjusting for age, mechanism of injury, GCS and head injury severity in both hospitals, there was no significant difference in mortality (adjusted odds ratio 1.4; 95% confidence interval = 0.6, 3.5). Patients in Netherlands trauma centre suffered from more serious head injuries (Abbreviated Injury Scale ≥ 3) than patients in the Australian trauma centre ( n = 165 (88.2%) vs n = 121 (62.4%); P < 0.001). The other body regions demonstrated significant differences in the AIS scores with significantly more serious injuries (AIS ≥ 3) of the chest, abdominal and extremities regions in the Australian group. Conclusion Bicycle related major trauma admissions in the Netherlands trauma centre, and in South-West Netherlands had a higher mortality rate associated with a higher percentage of serious head injuries compared with that in the Australian trauma centre and the State of Victoria.
: Background: As pigs homozygous for α1,3‐galactosyltransferase gene‐knockout (GT‐KO) are available, primate antibodies to pig non‐Gal antigens can be studied.
Methods: Sera from 56 baboons were ...tested for binding of IgM and IgG to peripheral blood mononuclear cells (PBMC) from both wild‐type (WT) and GT‐KO pigs by flow cytometry. Complement‐dependent cytotoxicity was measured in 39 sera. Antibody and cytotoxicity responses were measured in two baboons exposed to a GT‐KO pig heart, one not immunosuppressed and one that received only cobra venom factor.
Results: IgM and IgG bound to 95% and 79% of WT PBMC, and 32% and 9% GT‐KO PBMC, respectively (WT vs. GT‐KO, P < 0.01). Whereas 97% of sera were cytotoxic to WT PBMC, only 64% were cytotoxic to GT‐KO PBMC, and the level of cytotoxicity was less (mean 60% vs. 25% lysis, P < 0.05). In the two baboons exposed to GT‐KO hearts, anti‐non‐Gal antibodies increased markedly, peaking after 2 (IgM) and 3 (IgG) weeks, associated with an increase in lysis of GT‐KO PBMC.
Conclusions: Two‐thirds of baboon sera demonstrated cytotoxicity to GT‐KO PBMC. After GT‐KO organ transplantation, if an elicited antibody response develops, it is likely to cause rapid graft rejection.
: Introduction: Pig islets have been proposed as an alternative to human islets for clinical use, but their use is limited by rejection. The availability of genetically modified pigs devoid of ...α1,3‐galactosyltransferase might provide islets more suitable for xenotransplantation. To limit the costs involved in the logistics and health care of pigs for clinical xenotransplantation, we have studied whether younger, rather than older, pigs that are typically preferred can be used as islet donors.
Methods: We utilized pancreases from Yorkshire and White Landrace wild‐type pigs and α1,3‐galactosyltransferase gene‐knockout pigs of three main different age and size groups: (i) <6 months, (ii) 6 to 12 months, and (iii) >2 yr of age, inclusive of retired breeders. We compared isolation yield and in vitro and in vivo function of islet cells obtained from these groups.
Results: Islets from adult pigs (>2 yr) offered not only higher islet yields, but retained the ability to preserve intact morphology during the isolation process and culture, in association with high functional properties after transplantation. Following isolation, islet cells from young (<6 m) and young‐adult (6 to 12 m) pigs dissociated into small aggregates and single cells, and exhibited inferior functional properties than adult islets both in vitro and in vivo.
Conclusions: These data support the conclusion that, in view of the large number of islets needed to maintain normoglycemia after xenotransplantation, organ‐source pigs need to reach adult age (>2 yr) before being considered optimal islet donors, in spite of the higher costs involved.
A real-time PCR assay based on the 16S rRNA gene was optimized for the detection of a broad range of bacteria in plasma and platelet concentrates (PC). A lambda phage internal control was constructed ...and implemented in the assay, which made it suitable for diagnostic use. Spiking studies in plasma and PCs were performed to determine the analytical sensitivity of the assay. Thirty three colony forming units (CFU)/ml of
E. coli and 72 CFU/ml of
Staphylococcus epidermidis could be detected in plasma, and 97 CFU/ml of
S. epidermidis in PCs. The assay detected all bacteria relevant for bacterial contamination of PCs. The short turn around time of the assay made it suitable for testing PCs for bacterial contamination prior to transfusion.
OBJECTIVEThe aim of this study was to determine the prevalence and risk factors of alcohol, medication and illicit drug use before accidents in Emergency Department (ED)-treated trauma victims with ...internationally recommended methods to minimize registration bias.
PATIENTS AND METHODSThe study design was cross-sectional and was carried out at Erasmus Medical Centre in Rotterdam. Alcohol, psychoactive medication and illicit drug use were assessed in an interview by an independent researcher on the basis of the standardized WHO questionnaire. During 84 shifts, covering 4 weeks 24/7, data on a comprehensive population of ED-treated injury patients were collected prospectively.
RESULTSA total of 475 patients were included (response rate 87%). The prevalence of alcohol intoxication (defined as ≥3 U alcohol) before trauma was 19%. Alcohol-intoxicated trauma patients were significantly more often men odds ratio (OR) 2.88, 95% confidence interval (CI) 1.54–5.40, of Dutch descent (native) (OR 2.26, 95% CI 1.24–4.13), unemployed or students (OR 1.77, 95% CI 1.03–3.04), and alcohol intoxication decreased with age (OR 0.98, 95% CI 0.96–0.99). Psychoactive medication was used by 7% of ED trauma patients; increasing age (OR 1.05, 95% CI 1.03–1.07) and living alone (OR 2.4, 95% CI 1.04–5.52) were risk factors. Illicit drugs were used by 4% of trauma patients. Overall, 27% of patients were under the influence of at least one psychoactive substance.
CONCLUSIONOver a quarter of trauma patients visiting the ED had used alcohol, psychoactive medication and/or illicit drugs before their accident. By far, the majority of intoxications before trauma were because of alcohol (19%). We found higher prevalence rates of alcohol intoxication and lower prevalence rates for illicit drug use than others. Because of our comprehensive approach and high response rates, registration bias was minimized.
Summary
The recent availability of pigs homozygous for α1,3‐galactosyltransferase gene‐knockout (GT‐KO) has enabled the study of incidence and cytotoxicity of antibodies of cynomolgus monkeys ...directed to antigens other than Galα1,3Gal (Gal), termed nonGal antigens. To this aim, sera from 21 cynomolgus monkeys were tested by flow cytometry for binding of IgM and IgG to peripheral blood mononuclear cells (PBMC) from wild‐type (WT) and GT‐KO pigs. The sera were also tested for complement‐dependent cytotoxicity to WT and GT‐KO PBMC. Anti‐WT IgM and IgG were found in 100% and 95%, respectively, and anti‐GT‐KO IgM and IgG in 76% and 66%, respectively, in the sera of the monkeys tested (P < 0.01). Whereas 100% of sera were cytotoxic to WT PBMC, only 76% were cytotoxic to GT‐KO PBMC, and the level of cytotoxicity was significantly less (P < 0.01). Although the incidence and cytotoxicity of antibodies in monkey sera to GT‐KO pig PBMC are significantly less than to WT PBMC, approximately three‐quarters of the monkeys tested had cytotoxic antibodies to GT‐KO PBMC. This incidence of cytotoxicity is significantly higher than that found in baboons and humans, suggesting the baboon may be an easier and possibly more suitable model to study antibody‐mediated rejection of transplanted GT‐KO pig organs and cells.
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