Impact of the history of congestive heart failure on the utility of B-type natriuretic peptide in the emergency diagnosis of heart failure: results from the Breathing Not Properly Multinational Study.

Purpose: B-type natriuretic peptide is known to correlate with hemodynamic state, presence and severity of congestive heart failure, and prognosis. Although low-range B-type natriuretic peptide less than 100 pg/mL has a high negative predictive value (90%), and high-range B-type natriuretic peptide greater than 500 pg/mL has a high positive predictive value (87%), there remains some ambiguity in the interpretation of results in the medium range (100-500 pg/mL). We hypothesized that taking into account the history of congestive heart failure along with other clinical variables would be helpful in this range of B-type natriuretic peptide levels.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference).

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed.

Emergency department considerations regarding erectile dysfunction.

The emergency department functions from a unique perspective. Often complex decisions must be made about patient management with incomplete information because of poor patient recall, lack of medical records, and no prior interactions with the patient being treated. Treatment decisions are often made before definitive diagnostic tests are performed and before complete historical information can be obtained.

The Environmental Protection Agency's brownfields pilot program.

Objective: We studied the diffusion of the US Environmental Protection Agency's national brownfields pilot innovation to more than 300 local governments between 1993 through 2002 to determine why some local governments received grants very early in the process while other awardees received funding later.

Methods: We did an ordinal regression analysis of the characteristics of all local government award recipients, and we conducted interviews with early-award recipients.

Results: The first set of local government awardees had lost much of their manufacturing base, had large concentrations of economically disadvantaged minority residents, and had local capacity to compete for funding.

Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.

Objectives: Patients presenting with chest pain or related symptoms suggestive of myocardial ischemia, without ST-segment elevation (NSTE) on their presenting electrocardiograms, often present a diagnostic challenge in the emergency department (ED). Prompt and accurate risk stratification to identify those patients with NSTE chest pain who are at highest risk for adverse events is essential, however, to optimal management. Although validated and used frequently in patients already enrolled in acute coronary syndrome trials, the Thrombolysis in Myocardial Infarction (TIMI) risk score never has been examined for its value in risk stratification in an all-comers, non-trial-based ED chest pain population.

Door-to-ECG time in patients with chest pain presenting to the ED.

Objective: To describe time to electrocardiogram (ECG) acquisition, identify factors associated with timely acquisition, and evaluate the influence of time to ECG on adverse clinical outcomes.

Methods: We measured the door-to-ECG time for emergency department patients enrolled in prospective chest pain registry. Clinical outcomes were defined as occurrence of myocardial infarction or death within 30 days of the visit.

Evaluation and management of the patient who has cocaine-associated chest pain.

Patients who have chest pain following the use of cocaine have become more common in emergency departments throughout the United States,with approximately 6% of these patients sustaining an acute MI. The authors have described the rationale for recommending aspirin, benzodiaze-pines, and nitroglycerin as first-line treatments and calcium-channel blockade or phentolamine as possible second-line therapies and have summarized the controversies surrounding the use of fibrinolytic agents. Admission for observation is one reasonable approach to the management of the low-risk cohort.

[Optimizing the antibiotics policy in The Netherlands. VIII. Revised SWAB guidelines for antimicrobial therapy in adults with community-acquired pneumonia].

The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-acquired pneumonia (CAP) in light of changing resistance patterns for common pathogens and new developments in epidemiology, diagnostic testing and treatment strategies. The current guideline is applicable to both primary and inpatient care, and has been developed by delegates of all professional organisations involved in the treatment of CAP, following recommendations for evidence-based guideline development. Assessment of a patient's 'severity of illness' at presentation is considered important when choosing an optimal empirical antibiotic regimen for CAP.

Defining the outcomes of risk stratification studies of ED patients with chest pain: the marginal value of adding revascularization to the composite end point.

Objectives: Cardiovascular risk stratification studies use various end points, sometimes including revascularization. We assessed whether adding revascularization to a strictly defined composite end point of death, acute myocardial infarction (AMI), and unstable angina (UA) impacts the likelihood of patients attaining the composite end point.

Methods: We conducted a secondary analysis of a prospectively collected data set of emergency department patients who received an electrocardiogram for chest pain.

B-type natriuretic peptide levels in patients in the emergency department with possible heart failure and previous stable angina pectoris and/or healed myocardial infarction.

We examined the relation between B-type natriuretic peptide (BNP) levels and a history of stable angina pectoris and/or healed myocardial infarction in 1,240 patients who were evaluated in the emergency department for possible heart failure. In patients who had heart failure, there was no relation between BNP levels and previous stable angina pectoris and/or healed myocardial infarction. However, in patients who did not have heart failure, there was a relation between BNP levels and previous stable angina pectoris and/or healed myocardial infarction but no significant independent relation in multiple regression analysis.

Outcome of travelers who refuse transport after emergency medical services evaluation at an international airport.

Objective: To determine the short-term outcome of patients refusing transport after emergency medical services (EMS) evaluation at an international airport.

Methods: This was a prospective, descriptive, observational study of patients who refused transport after evaluation by Philadelphia Fire Department paramedics at Philadelphia International Airport from July 2003 through March 2004. Paramedics contacted a medical command physician (MCP), who recorded the patient's contact information.

Relationship of B-type natriuretic peptide and anemia in patients with and without heart failure: a substudy from the Breathing Not Properly (BNP) Multinational Study.

While anemia is a significant risk factor for poor outcomes in patients with heart failure (HF), it is not in defined guidelines for HF assessment. B-type natriuretic peptide (BNP) is a marker for diagnosis and management of patients with HF. We determined the incidence of anemia in patients with HF and the relationship between BNP and hemoglobin (Hgb) levels in patients with and without HF.

Revised SWAB guidelines for antimicrobial therapy of community-acquired pneumonia.

The Dutch Working Party on Antibiotic Policy (SWAB) develops evidence-based guidelines, aimed at optimalisation of antibiotic use and limitation of the spread of antimicrobial resistance. A revision of the SWAB guideline for the treatment of community-acquired pneumonia (CAP), published in 1998, was considered necessary because of changes in resistance patterns and new insights into the epidemiology, diagnostics and treatment of CAP. In contrast to the former version, this guideline is transmural and has been drawn up according to the recommendations for evidence-based guideline development by a multidisciplinary committee consisting of experts from all relevant professional societies.

Impact of atrial fibrillation on the diagnostic performance of B-type natriuretic peptide concentration in dyspneic patients: an analysis from the breathing not properly multinational study.

Objectives: This study was designed to assess the diagnostic performance of B-type natriuretic peptide (BNP) in the diagnosis of acute congestive heart failure (CHF) in patients with permanent/paroxysmal atrial fibrillation (AF) presenting with acute dyspnea.

Background: It is unknown to what extent AF affects the diagnostic performance of BNP in patients presenting with acute dyspnea.

Methods: We studied 1,431 patients drawn from a cohort of patients (n = 1,586) with acute dyspnea who had BNP levels measured on arrival.

Pretest probability assessment derived from attribute matching.

Background: Pretest probability (PTP) assessment plays a central role in diagnosis. This report compares a novel attribute-matching method to generate a PTP for acute coronary syndrome (ACS). We compare the new method with a validated logistic regression equation (LRE).

Practical implementation of the Guidelines for Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction in the emergency department.

In the United States each year, >5.3 million patients present to emergency departments with chest discomfort and related symptoms. Ultimately, >1.

Challenging despair: teaching about women's resistance to violence.

In this article, the author describes an approach to teaching about violence against women that balances discussion of violence with information about women's individual and collective resistance. This strategy addresses two concerns about traditional approaches to this topic: that focusing only on victimization disempowers students and that it provides only a partial view of the reality of violence in women's lives. To address these problems, the author integrates discussion of resistance into the class's working definition of violence, assigned readings, guest speakers, and course assignments.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference).

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed.

B-type natriuretic peptide and echocardiographic determination of ejection fraction in the diagnosis of congestive heart failure in patients with acute dyspnea.

Background: Echocardiography and B-type natriuretic peptide (BNP) are diagnostic tests for congestive heart failure (CHF), but an emergency diagnosis can be difficult.

Objective: To assess the diagnostic performance of BNP testing and echocardiographic assessment of left ventricular systolic function, separately and combined, for the identification of CHF in patients with acute dyspnea.

Design: Prospective, multinational, multicenter study.

Predictors of elevated B-type natriuretic peptide concentrations in dyspneic patients without heart failure: an analysis from the breathing not properly multinational study.

Study Objective: B-type natriuretic peptide (BNP) is an established tool for the diagnosis of acute congestive heart failure in patients presenting with dyspnea. Some patients have moderately elevated BNP levels (ie, 100 to 500 pg/mL) in the absence of acute congestive heart failure. The objective of the current study was to identify independent predictors of elevated BNP concentrations in the absence of congestive heart failure.

Residual backbone and side-chain 13C and 15N resonance assignments of the intrinsic transmembrane light-harvesting 2 protein complex by solid-state Magic Angle Spinning NMR spectroscopy.

This study reports the sequence specific chemical shifts assignments for 76 residues of the 94 residues containing monomeric unit of the photosynthetic light-harvesting 2 transmembrane protein complex from Rhodopseudomonas acidophila strain 10050, using Magic Angle Spinning (MAS) NMR in combination with extensive and selective biosynthetic isotope labeling methods. The sequence specific chemical shifts assignment is an essential step for structure determination by MAS NMR. Assignments have been performed on the basis of 2-dimensional proton-driven spin diffusion (13)C-(13)C correlation experiments with mixing times of 20 and 500 ms and band selective (13)C-(15)N correlation spectroscopy on a series of site-specific biosynthetically labeled samples.

Gene transfer of a phospholamban-targeted antibody improves calcium handling and cardiac function in heart failure.

Background: Abnormalities of intracellular calcium handling are widely recognized as a common hallmark of heart failure in animal models and humans. Modifying the interaction of phospholamban (PLB) with the sarcoplasmic reticulum ATPase (SERCA) by PLB mutants improves cardiac function but may also lead to heart failure. In this study we describe the in vivo effects of a new approach to modify the PLB-SERCA interaction using a recombinant, intracellularly expressed chicken-antibody derived protein (PLADP) targeting the cytoplasmic domain of PLB in the cardiomyopathic BIO 14.

Practical implementation of the guidelines for unstable angina/non-ST-segment elevation myocardial infarction in the emergency department: a scientific statement from the American Heart Association Council on Clinical Cardiology (Subcommittee on Acute Cardiac Care), Council on Cardiovascular Nursing, and Quality of Care and Outcomes Research Interdisciplinary Working Group, in Collaboration With the Society of Chest Pain Centers.

In the United States each year, >5.3 million patients present to emergency departments with chest discomfort and related symptoms. Ultimately, >1.