Political issues in emergency medicine: The United States.

The format of the paper is to allow three authors to discuss what they believe are the most significant political issues facing emergency medicine (EM) in their country or region. Each author writes independently and does not see any other contributing author's work, therefore potential overlap of subject matter is inevitable. However, we were soliciting their individual opinions about the serious issues confronting us today, rather than a consensus.

Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention.

Background: Although prior studies have shown a relationship between anemia and in-hospital mortality after coronary artery bypass grafting and acute myocardial infarction (MI), the prognostic implication of anemia in patients undergoing percutaneous coronary intervention (PCI) is unknown. Therefore, we evaluated the relationship between anemia and outcomes of PCI.

Methods And Results: Clinical and outcome data on 48,851 consecutive PCIs were prospectively collected.

Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography.

Purpose: This review summarizes the available evidence regarding the efficacy of medications used for ventricular rate control, stroke prevention, acute conversion, and maintenance of sinus rhythm, as well as the efficacy of electrical cardioversion and the use of echocardiography in patients with atrial fibrillation.

Data Sources: The Cochrane Collaboration's database of controlled clinical trials and MEDLINE.

Study Selection: Primarily randomized, controlled trials of medications.

Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians.

The Joint Panel of the American Academy of Family Physicians and the American College of Physicians, in collaboration with the Johns Hopkins Evidence-based Practice Center, systematically reviewed the available evidence on the management of newly detected atrial fibrillation and developed recommendations for adult patients with first-detected atrial fibrillation. The recommendations do not apply to patients with postoperative or post-myocardial infarction atrial fibrillation, patients with class IV heart failure, patients already taking antiarrhythmic drugs, or patients with valvular disease. The target physician audience is internists and family physicians dedicated to primary care.

Predictors of cause-specific hospital readmission in patients with heart failure.

Background: Repeated hospital readmissions are frequent and increasing over time in patients with heart failure (HF). The predictors for readmission in patients with HF are not completely understood.

Hypothesis: The study was undertaken to investigate the time course of readmission by specific cause in patients with HF, and to examine the independent effects of HF etiology and left ventricular (LV) function on cause-specific readmissions.

Racial disparity in long-term mortality rate after hospitalization for myocardial infarction: the Atherosclerosis Risk in Communities study.

Background: The underlying reasons why African American patients have a significantly higher mortality rate than European American patients after a myocardial infarction (MI) remain unclear. This study examined the racial disparity in mortality rates after MI and possible explanatory factors.

Methods: A prospective analysis was conducted within the Atherosclerosis Risk in Communities (ARIC) study, a community-based study of 15,792 middle-aged adults.

Treatment of limb-threatening ischemia with percutaneous intentional extraluminal recanalization: a preliminary evaluation.

Objective: We assessed the technical success, safety, and short-term effectiveness of percutaneous intentional extraluminal recanalization (PIER) in patients with limb-threatening ischemia and no autologous vein or with a major contraindication to surgery.

Methods: From 1999 through 2002, 25 patients with femoropopliteal occlusion and rest pain or tissue loss underwent PIER. Thirteen patients had undergone one or more failed bypass surgeries in the treated lower extremity, and no patient had suitable vein for bypass grafting.

Postnatal maternal separation elevates the expression of the postsynaptic protein kinase C substrate RC3, but not presynaptic GAP-43, in the developing rat hippocampus.

We have shown that exposure of rats to neonatal handling/maternal separation results in mossy fiber axon hypoplasia in field CA3 of the hippocampus. To better understand the molecular basis of this neuroanatomical alteration, the present study examined three developmentally regulated protein kinase C substrate mRNAs that are highly expressed in hippocampal granule cells during mossy fiber outgrowth: GAP-43, a presynaptic substrate implicated in axonal outgrowth, RC3 (neurogranin), a postsynaptic substrate implicated in calmodulin signaling, and MARCKS-like protein (MLP), which binds calmodulin and filamentous actin in neurons and glial cells. mRNA expression was examined by quantitative in situ hybridization in the developing [postnatal day 7 (P7), P13, P21, and P90] hippocampus (CA1, CA3, granule cells) in Long-Evans hooded rats: (1) reared under normal animal facility (AFR) conditions, (2) subjected to brief (15 min/day, HMS15), or (3) subjected to moderate (180 min/day) handling/maternal separation (HMS180) on P2-14.

Differential expression and regulation of myristoylated alanine-rich C kinase substrate (MARCKS) in the hippocampus of C57/BL6J and DBA/2J mice.

The myristoylated alanine-rich C kinase substrate (MARCKS) is a major protein kinase C (PKC) substrate in brain that binds the inner surface of the plasma membrane, calmodulin, and cross-links filamentous actin, all in a PKC phosphorylation-reversible manner. MARCKS has been implicated in hippocampal-dependent learning and long-term potentiation (LTP). Previous studies have shown DBA/2 mice to exhibit poor spatial/contextual learning, impaired hippocampal LTP, and hippocampal mossy fiber hypoplasia, as well as reduced hippocampal PKC activity and expression relative to C57BL/6 mice.

New approaches to developing antidepressants by enhancing monoaminergic neurotransmission.

Major depressive disorder (MDD) is a serious illness with far reaching societal and economic ramifications. The monoamine-deficiency hypothesis that depressive symptoms are associated with reductions in monoamine neurotransmission, particularly serotonin and noradrenaline, is supported by both neurochemical findings and the successful treatment of MDD with compounds that enhance monoaminergic neurotransmission. This review focuses on novel compounds in different stages of development for the treatment of MDD that enhance monoaminergic neurotransmission via a number of different mechanisms, including re-uptake inhibition of one or more monoamines, monoamine oxidase inhibitors, the combination of monoamine antagonists with re-uptake inhibitors and monoamine receptor subtype agonists.

Anaphylaxis after low dose intravenous vitamin K.

Over-anticoagulation from warfarin is a common occurrence, and these patients are often referred to the Emergency Department for further treatment. Unfortunately, there is little guidance in the Emergency Medicine literature for the management of such patients. The American College of Chest Physicians (ACCP) issued guidelines in 1998 that address the use of vitamin K for patients with over-anticoagulation.

The 6-min walk test: a quick measure of functional status in elderly adults.

Objectives: To determine the correlates of the total 6-min walk distance (6MWD) in a population sample of adults > or = 68 years old.

Methods: The standardized 6-min walk test (6MWT) was administered to the Cardiovascular Health Study cohort during their seventh annual examination.

Results: Of the 3,333 participants with a clinic visit, 2,281 subjects (68%) performed the 6MWT.

Dual monoamine modulation for improved treatment of major depressive disorder.

The worldwide scope of depressive illness and lack of fully effective pharmacotherapy mandates significant improvements in treatment paradigms. Current antidepressant medications remain limited by poor efficacy, slow onset of action, and untoward side effects. While the introduction of serotoninspecific reuptake inhibitors (SSRIs) offered significant improvements in tolerability, no improvements in efficacy or speed of onset have been made relative to the traditional and poorly tolerated tricyclic antidepressants (TCA).

Duloxetine 60 mg once daily dosing versus placebo in the acute treatment of major depression.

Existing therapies for major depressive disorder (MDD) have either limited efficacy and/or poor tolerability. The present study examined the effects of duloxetine, a potent and balanced dual reuptake inhibitor of serotonin (5-HT) and norepinephrine (NE), in patients with MDD. Adult patients (N = 267) with MDD were randomly assigned to receive duloxetine (60 mg/day) or placebo in this 9-week, multi-center, double-blind, parallel-group clinical trial.

Neonatal maternal separation reduces hippocampal mossy fiber density in adult Long Evans rats.

Neonatal maternal separation of rat pups leads to a stable stress hyper-responsive phenotype characterized by increased basal levels of corticotropin releasing factor (CRF) mRNA in the hypothalamic and extra-hypothalamic nuclei, increased hypothalamic CRF release, and enhanced adrenocorticotrophin hormone (ACTH) and corticosterone (CORT) responses to psychological stressors. Stress and exposure to glucocorticoids either early in life or in adulthood have been associated with hippocampal atrophy and impairments in learning and memory. In this study, male Long Evans rat pups were exposed to daily 3-h (HMS180) or 15-min (HMS15) periods of maternal separation on postnatal days (PND) 2-14 or normal animal facility rearing.

Remediation of refractive amblyopia by optical correction alone.

Amblyopia--the commonest vision abnormality of childhood--is characterized by a loss of visual acuity usually of one eye only. Treatment aims to promote function of the amblyopic eye and does this by restricting, usually through occlusion, the competitive advantage of the fellow eye. Recent experimental evidence demonstrates that the recovery of vision following early deprivation is facilitated by increasing visually evoked activity.

Targeted disruption of RC3 reveals a calmodulin-based mechanism for regulating metaplasticity in the hippocampus.

We used homologous recombination in the mouse to knock-out RC3, a postsynaptic, calmodulin-binding PKC substrate. Mutant brains exhibited lower immunoreactivity to phospho-Ca(2+)/calmodulin-dependent protein kinase II (CaMKII) but had the same synaptic density as wild type and did not exhibit a gross neuroanatomical phenotype. Basal excitatory synaptic transmission in CA1 was depressed, long-term potentiation (LTP) was enhanced, and the depressant effects of the metabotropic glutamate receptor (mGluR) agonist (RS)-3,5-dihydroxyphenylglycine was occluded compared with littermate controls.

Evidence-based practice centers: production of evidence report on management of atrial fibrillation.

Healthcare practitioners are increasingly expected to understand and practice evidence-based healthcare. However, to apply evidence-based healthcare methods on an individual basis in a specific clinic or with a specific patient is rarely possible because it is time consuming and requires specialized skills. One way of facilitating evidence-based care is to use evidence-based products produced by others.

Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter.

Background: Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves comparing the patient's risk of stroke to the risk of hemorrhage from medication use.

Objectives: To quantify risk of stroke, major hemorrhage and death from using medications that have been rigorously evaluated for prevention of thromboembolism in AF.