In October 2016, a severe infection with swine influenza A(H1N1) virus of the Eurasian avian lineage occurred in a child with a previous history of eczema in the Netherlands, following contact to ...pigs. The patient's condition deteriorated rapidly and required life support through extracorporeal membrane oxygenation. After start of oseltamivir treatment and removal of mucus plugs, the patient fully recovered. Monitoring of more than 80 close unprotected contacts revealed no secondary cases.
Background
Fast and accurate platelet inhibition is an important therapeutic goal in the acute treatment of patients with ST-elevation myocardial infarction (STEMI). Platelet inhibitory effects ...induced by oral P2Y12-receptor antagonists are delayed in STEMI patients undergoing primary percutaneous coronary intervention (PCI) due to haemodynamic changes and delayed gastro-intestinal absorption. Concomitant use of opioids, although recommended in the American College of Cardiology/American Heart Association and European Society of Cardiology STEMI guidelines, further delays gastro-intestinal absorption. To date, trials investigating alternative analgesics in STEMI patients have been scarce. This trial aims to assess the feasibility of a novel drug strategy for treatment of STEMI patients with crushed ticagrelor in combination with paracetamol (acetaminophen) instead of opioids.
Hypothesis
STEMI patients who are pre-treated with crushed ticagrelor and paracetamol have a higher level of platelet inhibition after primary PCI than patients pre-treated with crushed ticagrelor and fentanyl.
Study design
The Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial is a randomised controlled trial designed to examine whether administration of paracetamol instead of fentanyl can optimise platelet inhibition in STEMI patients who are pre-treated with crushed ticagrelor in the ambulance. One hundred and ninety patients with STEMI will be randomised (1:1 fashion) to intravenous (IV) fentanyl or IV paracetamol. The primary endpoint is the level of platelet reactivity units measured immediately after primary PCI.
Summary
The ON-TIME 3 trial (NCT03400267) aims to achieve optimal platelet inhibition and pain relief in STEMI patients receiving crushed ticagrelor in the ambulance by investigating IV fentanyl and IV paracetamol as analgesics.
Abstract
Background
Recent studies show that pre-hospital risk stratification of patients with suspected non-ST-elevation Acute Coronary Syndrome (NSTE-ACS) by ambulance paramedics is feasible. ...However, it is not investigated whether making referral decisions based on this risk stratification is safe and not associated with an increased risk of Major Adverse Cardiac Events (MACE). The hypothesis of the Famous Triage study is that implementation of referral decisions by ambulance paramedics based on a pre-hospital HEART score (History, ECG, Age, Risk factors and Troponin), is non-inferior to routine management on the occurrence of MACE within 45 days.
Methods
Famous Triage phase III is the first study where referral decisions by paramedics are based on a pre-hospital acquired HEART score. In the second phase (before implementation) a pre-hospital HEART score was assessed without consequences for referral decisions. In the third phase low-risk patients (HEART score ≤3) were not transferred to the hospital. Primary endpoint was the comparison of MACE (acute coronary syndrome, revascularization or death by all causes) within 45 days between phase II and III.
Results
A total of 1,236 patients were included, mean age was 63 years, 43% was female, 700 patients were included in the second phase (all referred to the hospital) and 536 in the third phase in which 149 low-risk patients (28%, HEART score ≤3) were not transferred to the hospital. Occurrence of 45 days MACE was 16.6% in phase II and 15.7% in phase III (p=0.67). Percentage MACE in low-risk patients was 2.9% in phase II and 1.3% in phase III. After adjustments for differences in baseline variables, the odds ratio of 45 days MACE in phase III was 0.88 (95% CI 0.63 – 1.25) as compared to phase II.
Conclusion
Pre-hospital risk stratification of patients with suspected NSTE-ACS, avoiding hospitalization of a substantial number of low-risk patients, is feasible and non-inferior to transferring all patients to the hospital. This pre-hospital triage strategy might improve value based healthcare (equal outcomes at less costs).
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Roche Diagnostics, The Netherlands
The gram-negative intracellular bacteria
C. caviae
was identified as the likely cause of severe community-acquired pneumonia in three patients. Guinea pigs were the likely source.
In van der Waals bonded or rotationally disordered multilayer stacks of two-dimensional (2D) materials, the electronic states remain tightly confined within individual 2D layers. As a result, ...electron-phonon interactions occur primarily within layers and interlayer electrical conductivities are low. In addition, strong covalent in-plane intralayer bonding combined with weak van der Waals interlayer bonding results in weak phonon-mediated thermal coupling between the layers. We demonstrate here, however, that Coulomb interactions between electrons in different layers of multilayer epitaxial graphene provide an important mechanism for interlayer thermal transport, even though all electronic states are strongly confined within individual 2D layers. This effect is manifested in the relaxation dynamics of hot carriers in ultrafast time-resolved terahertz spectroscopy. We develop a theory of interlayer Coulomb coupling containing no free parameters that accounts for the experimentally observed trends in hot-carrier dynamics as temperature and the number of layers is varied.
This study examines the extent to which parental reading socialization and early school involvement account for performance differences between low-status and high-status children in successive ...primary school grades. It investigates not only the direct effects of these parental practices on children's academic performance, but also the indirect effects, that is, controlling for the children's prior performance. It furthermore examines the influence of parental reading socialization and early school involvement on the longer term development of scholastic performance. Panel data are employed from four waves of the Dutch primary education cohort study, starting in 1996-1997. Using multilevel (repeated measurement) models, we find that parental reading socialization and parental school involvement both explain part of the association between social background and academic performance in successive primary school years. The positive, mainly indirect, impact of these factors, however, is stronger for children's language performance than for arithmetic achievement. Finally, children socialized in reading retain or even expand their advantage in language performance over children who lack early reading socialization. The positive impact of parental school involvement fades as primary school progresses.
Alternatives to lithium for prophylactic treatment of patients with bipolar affective disorders are increasingly being advocated. However, trials comparing lithium with alternatives are scarce and ...often biased.
We studied 94 patients with at least 2 episodes of bipolar disorder (DSM-III-R) during the previous 3 years who were in remission at entry into the study. Treatment with lithium or carbamazepine had not exceeded a total of 6 months during their lifetime. Patients were randomly assigned to carbamazepine or lithium at entry into the 2-year double-blind study or during the acute index episode previous to entry into the study. No concurrent antipsychotics or antidepressants were allowed.
On lithium treatment, 12/44 patients developed an episode, compared with 21/50 on carbamazepine treatment. Episodes on lithium treatment occurred almost exclusively during the first 3 months of the trial. Carbamazepine carried a constant risk of an episode of about 40% per year. Efficacy of lithium was superior to that of carbamazepine in patients with a (hypo)manic index episode that had not been treated with study drug during the index episode (p <.01) and also in patients with prior hypomanic but no manic episodes (p <.05). The proportion of patients who dropped out was slightly higher among those taking lithium (16/44) compared with those taking carbamazepine (13/50), resulting in 16/44 patients (36%) on lithium treatment completing the 2 years with no episode, compared with 16/50 (32%) on carbamazepine treatment.
Lithium appears to be superior in prophylactic efficacy to carbamazepine in bipolar patients not previously treated with mood stabilizers. Our results should reinforce efforts to put and maintain such patients on treatment with lithium.
The management of patients with suspected acute coronary syndrome, especially in prehospital settings, is challenging. This Special Report focuses on studies in emergency medical services concerning ...chest pain patients' triage and risk stratification. In addition, it emphasizes advancements in point-of-care cardiac troponin testing. These developments are compared with in-hospital guidelines, proposing an initial framework for a new acute care pathway. This pathway integrates a risk stratification tool with high-sensitivity cardiac troponin testing, aiming to deliver optimal care and collaboration within the acute care chain. It has the potential to contribute to a significant reduction in hospital referrals, reduce observation time and overcrowding at emergency departments and hospital admissions.
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