Low-molecular-weight heparin venous thromboprophylaxis in critically ill patients with renal dysfunction: A subgroup analysis of the PROTECT trial.

Introduction: There is concern about excessive bleeding when low-molecular-weight heparins (LMWHs) are used for venous thromboembolism (VTE) prophylaxis in renal dysfunction. Our objective was to evaluate whether LMWH VTE prophylaxis was safe and effective in critically ill patients with renal dysfunction by conducting a subgroup analysis of PROTECT, a randomized blinded trial.

Methods: We studied intensive care unit (ICU) patients with pre-ICU dialysis-dependent end-stage renal disease (ESRD; pre-specified subgroup; n = 118), or severe renal dysfunction at ICU admission (defined as ESRD or non-dialysis dependent with creatinine clearance [CrCl] <30 ml/min; post hoc subgroup; n = 590).

Stem-cell therapy in ST-segment elevation myocardial infarction with reduced ejection fraction: A multicenter, double-blind randomized trial.

Background: Left ventricular ejection fraction (LVEF) is a major determinant of long-term prognosis after ST-segment elevation myocardial infarction (STEMI). STEMI patients with reduced LVEF have a poor prognosis, despite successful reperfusion and the use of renin-angiotensin-aldosterone inhibitors.

Hypothesis: Intracoronary infusion of bone marrow-derived mononuclear cells (BMMC) may improve LVEF in STEMI patients successfully reperfused.

Myocardial perfusion imaging study of CO(2)-induced panic attack.

Chest pain is often seen alongside with panic attacks. Moreover, panic disorder has been suggested as a risk factor for cardiovascular disease and even a trigger for acute coronary syndrome. Patients with coronary artery disease may have myocardial ischemia in response to mental stress, in which panic attack is a strong component, by an increase in coronary vasomotor tone or sympathetic hyperactivity setting off an increase in myocardial oxygen consumption.

Accuracy of a neural diagnostic tree for the identification of acute coronary syndrome in patients with chest pain and no ST-segment elevation.

Identifying acute coronary syndrome is a difficult task in the emergency department because symptoms may be atypical and the electrocardiogram has low sensitivity. In this prospective cohort study done in a tertiary community emergency hospital, we developed and tested a neural diagnostic tree in 566 consecutive patients with chest pain and no ST-segment elevation for the diagnosis of acute coronary syndrome. Multivariate regression and recursive partitioning analysis allowed the construction of decision rules and of a neural tree for the diagnosis of acute myocardial infarction and acute coronary syndrome.

Probability stratification and systematic diagnostic approach for chest pain patients in the emergency department.

Management of chest pain patients in the emergency department has been a dilemma because of difficulty in identifying those who can be immediately discharged and those who need to be hospitalized. We assessed the efficacy of a probability stratification model and a systematic diagnostic strategy in 1003 consecutive chest pain patients prospectively evaluated and stratified for acute coronary syndromes according to chest pain characteristics and admission electrocardiogram. Patients with no suspicion of acute coronary syndromes (n = 224) were immediately discharged, whereas those with very-high probability (n =119) were admitted to the coronary care unit.

A latitudinal gradient study of common anti-infectious agent antibody prevalence in Italy and Colombia.

Background: Infectious agents are important in the pathogenesis of autoimmune disease since they are a major part of the environmental trigger of autoimmunity. A negative relationship between latitude and infectious disease species richness has been suggested.

Objectives: To examine whether their prevalence differs in two latitudinally different populations.

Infections and autoimmunity: a panorama.

For more than 2,000 years, it was thought that malignant spirits caused diseases. By the end of nineteenth century, these beliefs were displaced by more modern concepts of disease, namely, the formulation of the "germ theory," which asserted that bacteria or other microorganisms caused disease. With the emergence of chronic degenerative and of autoimmune diseases in the last century, the causative role of microorganisms has been intensely debated; however, no clear explanatory models have been achieved.

Bone-marrow mononuclear cell therapy of severe ischemic heart failure.

We describe cell therapy for severe ischemic heart failure using transendocardial injection of autologous bone-marrow-derived mononuclear cells. The treated patients had significantly less heart failure and angina, sustained significant improvement of pumping power, exercise capacity, cardiac muscle irrigation, and blood supply to the body. Electrical and mechanical mappings of the myocardium before and after the therapy, and anatomopathological examination of the myocardium of one of the patients that had deceased of a stroke eleven months after the treatment indicated sustained neoangiogenesis and improvement of activity and quantity of cardiomyocytes in the injected regions.

Medium term prognostic value of stress myocardial perfusion scintigraphy in a chest pain unit.

Objective: To evaluate the prognostic value of stress myocardial perfusion scintigraphy (MPS) applied to patients with suspected acute coronary syndrome (ACS).

Methods: Retrospective study. Patients with suspected acute coronary syndrome (ACS) admitted into the chest pain unit (CPU) from December 2002 to April 2004, after exclusion of acute myocardial infarction (AMI) and high risk unstable angina they underwent stress MPS.

C-reactive protein diagnostic and prognostic value in patients presenting at the emergency room with chest pain.

Objective: To test immediate diagnostic and prognostic values of C-reactive protein (CRP) in patients admitted to the emergency room (ER) with chest pain (CP) without ST-segment elevation on the electrocardiogram (ECG).

Methods: From January 2002 to December 2003, 980 patients were consecutively seen in the ER with CP suggestive of acute coronary syndrome (ACS) (age = 64.9 +/- 14.

Elderly patients with unexplained syncope: what should be considered a positive tilt test response?

Introduction: Syncope is a common problem and can lead to serious consequences in the elderly. Tilt test is useful to investigate recurrent syncope, but few studies have investigated the hemodynamic responses of this population to tilt test.

Objective: To describe the tilt test responses of elderly patients with recurrent syncope of unknown origin and to determine the occurrence of altered cardiovascular autonomic function in a subset of those with the diagnosis of dysautonomic pattern to the tilt test.

Parasympathetic-mediated atrial fibrillation during tilt test associated with increased baroreflex sensitivity.

The autonomic mechanism that triggered atrial fibrillation in a patient during tilt test was investigated. Neurocardiogenic syncope is often characterized by diminished baroreflex sensitivity during the hypotension period. Increased barorereflex sensitivity preceding the onset of atrial fibrillation in tilt testing may indicate the involvement of a vagally mediated mechanism, as shown in the present case.

Gastrointestinal bleeding diagnosed by red blood cell scintigraphy in a patient with aortic stenosis: a case of Heyde syndrome.

The authors report a case of small bowel bleeding diagnosed by Tc-99m-labeled red blood cell (RBC) scintigraphy during the postoperative period after aortic valve replacement. There is a relationship between aortic valve stenosis and gastrointestinal bleeding in elderly patients, called Heyde syndrome. The described patient had chronic anemia that worsened after surgery.

Chest pain units: a modern way of managing patients with chest pain in the emergency department.

It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED) in the United States 1,2, which corresponds to 5 to 10% of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS). This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6.

[Chest pain units: state of the art of the management of patients with chest pain in the emergency department].

Chest pain is one of the most common reasons for patients coming to emergency departments. Most of these individuals end up being hospitalized due to uncertainty of the cause of their complaint. This aggressive and defensive attitude is taken by emergency physicians because some 10 to 30% of these patients actually have acute coronary syndrome.

Chest pain in the emergency room. Importance of a systematic approach.

Objective: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units.

Methods: One thousand and three consecutive patients with chest pain were screened according to a preestablished process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes.

Results: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]).

Chest pain in the emergency room. Importance of a systematic approach.

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]).

[Hospital mortality in acute myocardial infarction: is it possible to predict using admission data?].

Purpose: To identify clinical variables on admission that are related to hospital mortality in acute myocardial infarction (AMI) and to generate a mathematic model to predict accurately this mortality.

Methods: Prospective study with 347 consecutive patients with AMI in which clinical variables related to mortality were identified by univariate and multivariate analysis. The mathematic model generated by multivariate logistic regression analysis was applied in each patient to determine his/her probability (P) of hospital death.