This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.
A ...comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Cardiovascular Magnetic Resonance is increasingly used to differentiate the aetiology of cardiomyopathies. Late Gadolinium Enhancement (LGE) is the reference standard for non-invasive imaging of ...myocardial scar and focal fibrosis and is valuable in the differential diagnosis of ischaemic versus non-ischaemic cardiomyopathy. Diffuse fibrosis may go undetected on LGE imaging. Tissue characterisation with parametric mapping methods has the potential to detect and quantify both focal and diffuse alterations in myocardial structure not assessable by LGE. Native and post-contrast T1 mapping in particular has shown promise as a novel biomarker to support diagnostic, therapeutic and prognostic decision making in ischaemic and non-ischaemic cardiomyopathies as well as in patients with acute chest pain syndromes. Furthermore, changes in the myocardium over time may be assessed longitudinally with this non-invasive tissue characterisation method.
Cognitive aging reflects not only loss but also adaptation to loss. The adult brain is capable of plastic change, including change in cortical representation. This has been seen in association not ...only with frank lesions but also in healthy individuals as a function of experience and training. This review considers the potential for adult plasticity together with evidence of a relation in old age between regional cortical atrophy/shrinkage and increased activation in neuroimaging. Those cortical regions shown most consistently to shrink in adulthood-prefrontal and parietal cortices-are the same regions showing increased regional activation in aging. Combining several strands of behavioral and neuroimaging evidence, the author argues that functional plasticity alters the course of cognitive aging. The author advances the hypothesis that losses in regional brain integrity drive functional reorganization through changes in processing strategy and makes specific predictions from that hypothesis.
Summary Background In patients with suspected coronary heart disease, single-photon emission computed tomography (SPECT) is the most widely used test for the assessment of myocardial ischaemia, but ...its diagnostic accuracy is reported to be variable and it exposes patients to ionising radiation. The aim of this study was to establish the diagnostic accuracy of a multiparametric cardiovascular magnetic resonance (CMR) protocol with x-ray coronary angiography as the reference standard, and to compare CMR with SPECT, in patients with suspected coronary heart disease. Methods In this prospective trial patients with suspected angina pectoris and at least one cardiovascular risk factor were scheduled for CMR, SPECT, and invasive x-ray coronary angiography. CMR consisted of rest and adenosine stress perfusion, cine imaging, late gadolinium enhancement, and MR coronary angiography. Gated adenosine stress and rest SPECT used99m Tc tetrofosmin. The primary outcome was diagnostic accuracy of CMR. This trial is registered at controlled-trials.com , number ISRCTN77246133. Findings In the 752 recruited patients, 39% had significant CHD as identified by x-ray angiography. For multiparametric CMR the sensitivity was 86·5% (95% CI 81·8–90·1), specificity 83·4% (79·5–86·7), positive predictive value 77·2%, (72·1–81·6) and negative predictive value 90·5% (87·1–93·0). The sensitivity of SPECT was 66·5% (95% CI 60·4–72·1), specificity 82·6% (78·5–86·1), positive predictive value 71·4% (65·3–76·9), and negative predictive value 79·1% (74·8–82·8). The sensitivity and negative predictive value of CMR and SPECT differed significantly (p<0·0001 for both) but specificity and positive predictive value did not (p=0·916 and p=0·061, respectively). Interpretation CE-MARC is the largest, prospective, real world evaluation of CMR and has established CMR's high diagnostic accuracy in coronary heart disease and CMR's superiority over SPECT. It should be adopted more widely than at present for the investigation of coronary heart disease. Funding British Heart Foundation.
Hydrogen and δD measurements of the mineral apatite have been used to measure volatile contents of planets and planetesimals and to infer the sources and evolution of water throughout the solar ...system. All of these studies use Secondary Ion Mass Spectrometry (SIMS) which necessitates the use of apatite mineral standards to correct for matrix effects, which have previously been measured by mass spectrometry for hydrogen isotopes. Here we present a new technique of Elemental Analyzer-Chromium/High Temperature Conversion-Isotope Ratio Mass Spectrometry (EA-Cr/HTC-IRMS) for the measurement of hydrogen and hydrogen isotopes of apatite. This technique presents greater technical advantages over TC/EA due to ability of chromium to bind with phosphorus in the high-temperature reactor, and prevent this elemental P from clogging the instrument components. We also show that removal of adsorbed moisture of nominally hydrous minerals and glasses becomes increasingly important with decreasing grain size of materials and present experiments on moisture removal from nominally anhydrous quartz. We report hydrogen and hydrogen isotope results of five fluorapatite and two hydroxylapatite samples, including Durango apatite. We show that our results of hydrogen content of Durango apatite are similar to published values using the TC/EA technique. Our recommended values for hydrogen using a Cr reactor for H2O and δDVSMOW-SLAP for Durango apatite are 608 ± 102 ppm H2O and δDVSMOW-SLAP = −86 ± 4‰ (2σ).
Cardiac masses are usually first detected at echocardiography. In their further evaluation, cardiac magnetic resonance (MR) imaging has become a highly valuable technique. MR imaging offers ...incremental value owing to its larger field of view, superior tissue contrast, versatility in image planes, and unique ability to enable discrimination of different tissue characteristics, such as water and fat content, which give rise to particular signal patterns with T1- and T2-weighted techniques. With contrast material-enhanced MR imaging, additional tissue properties such as vascularity and fibrosis can be demonstrated. MR imaging can therefore contribute to the diagnosis of a cardiac mass as well as be used to detail its relationship to other cardiac and extracardiac structures. These assessments are important to plan therapy, such as surgical intervention. In addition, serial MR studies can be used to monitor tumor regression after surgery or chemotherapy. Primary cardiac tumors are very rare; metastases and pseudotumors (eg, thrombus) are much more common. This article provides an overview of cardiac masses and reviews the optimal MR imaging techniques for their assessment.
Acute coronary syndromes (ACSs) are driven by inflammation within coronary plaque. Interleukin-1 (IL-1) has an established role in atherogenesis and the vessel-response to injury. ACS patients have ...raised serum markers of inflammation. We hypothesized that if IL-1 is a driving influence of inflammation in non-ST elevation ACS (NSTE-ACS), IL-1 inhibition would reduce the inflammatory response at the time of ACS.
A phase II, double-blinded, randomized, placebo-controlled, study recruited 182 patients with NSTE-ACS, presenting <48 h from onset of chest pain. Treatment was 1:1 allocation to daily, subcutaneous IL-1receptor antagonist (IL-1ra) or placebo for 14 days. Baseline characteristics were well matched. Treatment compliance was 85% at 7 days. The primary endpoint (area-under-the-curve for C-reactive protein over the first 7 days) was: IL-1ra group, 21.98 mg day/L (95%CI 16.31-29.64); placebo group, 43.5 mg day/L (31.15-60.75) (geometric mean ratio = 0.51 mg/L; 95%CI 0.32-0.79; P = 0.0028). In the IL-1ra group, 14-day achieved high-sensitive C-reactive protein (P < 0.0001) and IL-6 levels (P = 0.02) were lower than Day 1. Sixteen days after discontinuation of treatment (Day 30) high-sensitive C-reactive protein levels had risen again in the IL-1ra group IL-1ra; 3.50 mg/L (2.65-4.62): placebo; 2.21 mg/L (1.67-2.92), P = 0.022. MACE at Day 30 and 3 months was similar but at 1 year there was a significant excess of events in the IL-1ra group.
IL-1 drives C-reactive protein elevation at the time of NSTE-ACS. Following 14 days IL-1ra treatment inflammatory markers were reduced. These results show the importance of IL-1 as a target in ACS, but also indicate the need for additional studies with anti-IL-1 therapy in ACS to assess duration and safety.
2006-001767-31-GB: www.clinicaltrialsregister.eu/ctr-search/trial/2006-001767-31/GB.
Receiver operating characteristic analysis was used to determine the diagnostic accuracies (SPSS version 20.00 software; IBM Corp., Armonk, New York). To detect the 50 cases of HCM from the 40 ...athletes, the diagnostic accuracy (area under the curve AUC) of maximal segment thickness, native T1, and ECV were 0.986 (95% confidence interval CI: 0.935 to 0.999), 0.847 (95% CI: 0.756 to 0.914), and 0.936 (95% CI: 0.864 to 0.977), respectively (p < 0.001 for all).
Placebo effects in cognitive training Foroughi, Cyrus K.; Monfort, Samuel S.; Paczynski, Martin ...
Proceedings of the National Academy of Sciences - PNAS,
07/2016, Letnik:
113, Številka:
27
Journal Article
Recenzirano
Odprti dostop
Although a large body of research shows that general cognitive ability is heritable and stable in young adults, there is recent evidence that fluid intelligence can be heightened with cognitive ...training. Many researchers, however, have questioned the methodology of the cognitive-training studies reporting improvements in fluid intelligence: specifically, the role of placebo effects. We designed a procedure to intentionally induce a placebo effect via overt recruitment in an effort to evaluate the role of placebo effects in fluid intelligence gains from cognitive training. Individuals who self-selected into the placebo group by responding to a suggestive flyer showed improvements after a single, 1-h session of cognitive training that equates to a 5- to 10-point increase on a standard IQ test. Controls responding to a nonsuggestive flyer showed no improvement. These findings provide an alternative explanation for effects observed in the cognitive-training literature and the brain-training industry, revealing the need to account for confounds in future research.
Abstract Background The optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial ...infarction is uncertain. Objectives CvLPRIT (Complete versus Lesion-only Primary PCI trial) is a U.K. open-label randomized study comparing complete revascularization at index admission with treatment of the infarct-related artery (IRA) only. Methods After they provided verbal assent and underwent coronary angiography, 296 patients in 7 U.K. centers were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤3 h or >3 h). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months. Results Patient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days). Although there was no significant reduction in death or MI, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups. Conclusions In patients presenting for P-PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival. (Complete Versus Lesion-only Primary PCI Pilot Study CvLPRIT; ISRCTN70913605 )
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