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Background and aims Circulating endothelial microparticles (EMPs) are increased in arterial hypertension. The role of physicomechanical factors that may induce EMP release in vivo is still unknown. We studied the relationship of EMPs and physicomechanical factors in stable arterial hypertension and hypertensive emergencies, and investigated the pattern of EMP release after mechanical endothelial injury. Methods In a pilot study, 41 subjects (50% hypertensives) were recruited. EMPs were discriminated by flow-cytometry (CD31 + /41 - , CD62e + , CD144 + ). Besides blood pressure measurements, pulse-wave-analysis was performed. Flow-mediated dilation (FMD), nitroglycerin-mediated dilation (NMD), and wall-shear-stress (WSS) were measured ultrasonographically in the brachial artery; microvascular perfusion by laser-Doppler (Clinicaltrials.gov: NCT02795377). We studied patients with hypertensive emergencies before and 4 h after BP lowering by urapidil (n = 12) and studied the release of EMPs due to mechanical endothelial injury after coronary angiography (n = 10). Results Hypertensives exhibited increased EMPs (CD31 + /41 - , CD144 + , CD62e + ) as compared to normotensives and EMPs univariately correlated with systolic BP (SBP), augmentation index, and pulse wave velocity and inversely with FMD. CD31 + /41 - -EMPs correlated with diameter and inversely with WSS and NMD. CD62e + and CD144 + -EMPs inversely correlated with microvascular function. During hypertensive emergency, only CD62e + and CD144 + -EMPs were further elevated and FMD was decreased compared to stable hypertensives. Blood pressure lowering decreased CD62e + and CD144 + -EMPs and increased FMD. CD31 + /41 — EMPs, diameter, and WSS remained unaffected. Similar to hypertensive emergency, catheter-related endothelial injury increased only CD144 + and CD62e + -EMPs. Conclusions EMP release in hypertension is complex and may involve both physicomechanical endothelial injury and activation (CD144 + , CD62e + ) and decreased wall shear stress (CD31 + /41 - ). [ABSTRACT FROM AUTHOR]

Background Black carbon (BC) is a ubiquitous component of particulate matter (PM) emitted from combustion-related sources and is associated with a number of health outcomes. Objectives We conducted a systematic review to evaluate the potential for cardiovascular morbidity and mortality following exposure to ambient BC, or the related component elemental carbon (EC), in the context of what is already known about the associations between exposure to fine particulate matter (PM 2.5 ) and cardiovascular health outcomes. Data sources We conducted a stepwise systematic literature search of the PubMed database and employed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting our results. Study eligibility criteria Studies meeting inclusion criteria (i.e., include a quantitative measurement of BC or EC used to characterize exposure and an effect estimate of the association of the exposure metric with ED visits, hospital admissions, or mortality due to cardiovascular disease) were evaluated for risk of bias in study design and results. Study appraisal and synthesis methods Risk of bias evaluations assess some aspects of internal validity of study findings based on study design, conduct, and reporting and identify potential issues related to confounding or other biases. Results The results of our systematic review demonstrate similar results for BC or EC and PM 2.5 ; that is, a generally modest, positive association of each pollutant measurement with cardiovascular emergency department visits, hospital admissions, and mortality. There is no clear evidence that health risks are greater for either BC or EC when compared to one another, or when either is compared to PM 2.5 . Limitations We were unable to adequately evaluate the role of copollutant confounding or differential spatial heterogeneity for BC or EC compared to PM 2.5 . Conclusions and Implications of Key Findings Overall, the evidence at present indicates that BC or EC is consistently associated with cardiovascular morbidity and mortality but is not sufficient to conclude that BC or EC is independently associated with these effects rather than being an indicator for PM 2.5 mass. Systematic review registration number Not available. [ABSTRACT FROM AUTHOR]

Objective To test the hypothesis that more cardiovascular emergencies occur at low rather than at high temperatures under moderate climatic conditions. Methods This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and from the local weather station were evaluated over a 5-year period. Temperature data were matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the temperature and the frequency of individual cardiovascular emergencies. In addition, three threshold-temperatures (0 °C, 10 °C, 20 °C) were defined in order to determine the frequency of cardiovascular emergencies above and below each cut-off value. The severity of emergencies was assessed using the National Advisory Committee for Aeronautics (NACA) scoring system. Results A total of 35,390 cardiovascular emergencies were treated by Emergency Physicians. Transient Loss of Consciousness increased at high temperatures (above 20 °C): + 43% (95%-CI: [27%; 59%]). In contrast, Coronary Artery Disease + 26% (95%-CI: [17%; 34%]), Cardiac Pulmonary Edema + 21% (95%-CI: [14%; 27%]), Hypertensive Urgency + 18% (95%-CI: [10%; 25%]) and Cerebrovascular Accident + 17% (95%-CI: [8%; 24%]) increased at low temperatures, particularly below 10 °C (significance level for all: p < 0.001). No temperature-related effect was seen in Cardiac Arrhythmia and Pulmonary Embolism and no significant correlation was found between the severity of emergencies and temperature. Conclusions Our findings suggest that some cardiovascular emergencies such as Coronary Artery Disease, Cardiac Pulmonary Edema, Hypertensive Urgency and Cerebrovascular Accident are more frequent in low temperatures even under mild climatic conditions. [ABSTRACT FROM AUTHOR]

Background Limited data exists about management of syncope in Asia. The American College of Emergency Physicians (ACEP) and European Society of Cardiology (ESC) guidelines have defined the high-risk syncope patient. This study aims to determine the effectiveness of managing syncope in an Asian healthcare system and whether strict adherence of international guidelines would reduce hospitalizations. Methods Patients attending the Emergency Department of a Singaporean tertiary hospital with syncope were identified. Clinical journeys of all patients were meticulously mapped by interrogation of a comprehensive electronic medical record system and linkages with national datasets. Primary endpoint was hospitalization. Secondary endpoints were recurrent syncope within 1 year and all-cause mortality. Expected admission rates based on application of ACEP/ESC guidelines were calculated. Results 638 patients (43.8 ± 22.4 years, 49.0% male) presented with syncope. 48.9% were hospitalized for 2.9 ± 3.2 days. Yields of common investigations ranged from 0 to 11.5% and no diagnosis was reached in 51.5% of patients. Diuretics use (HR 5.1, p = 0.01) and prior hospitalization for syncope (HR 6.9, p < 0.01) predicted recurrent syncope. Over 2.8 SD 0.3 years of follow-up, 40 deaths occurred. 24 patients who died within 12 months of presentation were admitted or had a firm diagnosis upon discharge. Application of guidelines did not significantly reduce hospitalisations, with limited agreement which patients warrant admission. (Actual 376, ACEP 354, ESC 391 admissions, p = NS). Conclusions Unstructured management of syncope results in nearly half of patients being admitted and substantial healthcare expenditures, yet with limited diagnostic yield. Strict adoption of ACEP or ESC guidelines does not reduce admissions. [ABSTRACT FROM AUTHOR]

Background We performed a systematic review and meta-analysis of the risk of cardiovascular adverse events associated with ramucirumab. Patients and methods Eligible studies included randomized phase II and III trials of patients with solid tumors on ramucirumab; describing events of hypertension, bleeding, arterial/venous thrombosis and congestive heart failure. Results Our search strategy yielded 160 potentially relevant citations from Pubmed/Medline, CENTRAL Cochrane registry and ASCO meeting library. After exclusion of ineligible studies, a total of 11 clinical trials were considered eligible for the meta-analysis. The RR of all-grade hypertension, bleeding, ATE, VTE and congestive heart failure were 2.83 (95% CI 2.43–3.29; p < 0.0001), 1.98 (95% CI 1.77–2.21; p < 0.0001); 0.97 (95% CI 0.62–1.52; p = 0.91), 0.83 (95% CI 0.52–1.35; p = 0.46), 1.36 (95% CI 0.77-2.4; p = 0.28), respectively. Conclusions Our meta-analysis has demonstrated that ramucirumab is associated with an increased risk of hypertension and bleeding. Clinicians should be aware of this risk and perform regular clinical monitoring. [ABSTRACT FROM AUTHOR]

Learning to handle cardiovascular emergencies is complex and can cause psychological stress for nursing students. Gamification using question cards as a learning aid is one of the creative educational strategies that can help students learn in a fun way. The design of cards with valid and reliable questions is essential in gamification; however, such cards are still lacking in cardiovascular emergency learning. To develop and validate cardiovascular emergency question cards for the future use of gamification for education regarding cardiovascular emergencies among undergraduate nursing students. The development process included two phases: designing the question cards and testing validity evidence. A table of specifications was used to select and assign questions based on three levels with six learning outcome categories. Five nurse experts assessed the evidence based on test content, including the relevance, clarity, and essentiality of the questions. Seven final-year nursing students evaluated the evidence based on the response process. After revision, 61 nursing students evaluated the internal consistency reliability of each level. In the design phase, ninety English question cards were categorized into three levels based on the learning outcomes expected in an undergraduate emergency nursing course. Most of the questions were multiple-choice questions, and some were short answer questions. The final item-content validity index = 1.00, the scale-content validity index/universal agreement = 1.00, and the content validity ratio = 1.00. Cronbach's α for internal structure was 0.81 for level I (n = 61), 0.92 for level II (n = 54), and 0.81 for level III (n = 46). The cardiovascular emergency question cards showed acceptable evidence based on the test content, response process, and internal structure. In the future, testing the feasibility of applying the question cards to gamification and assessing their learning effect on cardiovascular emergency knowledge retention will be necessary. • A Table of Specifications helps frame the questions in a cardiovascular emergency. • Ninety question cards are created based on three levels of learning outcomes. • The question cards show acceptable validity and reliability evidence. [ABSTRACT FROM AUTHOR]

Objective We describe a methodological framework to estimate potential cost savings in Belgium for a decrease in cardiovascular emergency admissions (ischemic heart disease (IHD), heart rhythm disturbances (HRD), and heart failure) due to a reduction in air pollution. Methods Hospital discharge data on emergency admissions from an academic hospital were used to identify cases, derive risk functions, and estimate hospital costs. Risk functions were derived with case-crossover analyses with weekly average PM 10 , PM 2.5 , and NO 2 exposures. The risk functions were subsequently used in a micro-costing analysis approach. Annual hospital cost savings for Belgium were estimated for two scenarios on the decrease of air pollution: 1) 10% reduction in each of the pollutants and 2) reduction towards annual WHO guidelines. Results Emergency admissions for IHD and HRD were significantly associated with PM 10 , PM 2.5 , and NO 2 exposures the week before admission. The estimated risk reduction for IHD admissions was 2.44% [95% confidence interval (CI): 0.33%–4.50%], 2.34% [95% CI: 0.62%–4.03%], and 3.93% [95% CI: 1.14%–6.65%] for a 10% reduction in PM 10 , PM 2.5 , and NO 2 respectively. For Belgium, the associated annual cost savings were estimated at €5.2 million, €5.0 million, and €8.4 million respectively. For HRD, admission risk could be reduced by 2.16% [95% CI: 0.14%–4.15%], 2.08% [95% CI: 0.42%–3.70%], and 3.46% [95% CI: 0.84%–6.01%] for a 10% reduction in PM 10 , PM 2.5 , and NO 2 respectively. This corresponds with a potential annual hospital cost saving in Belgium of €3.7 million, €3.6 million, and €5.9 million respectively. If WHO annual guidelines for PM 10 and PM 2.5 are met, more than triple these amounts would be saved. Discussion This study demonstrates that a model chain of case-crossover and micro-costing analyses can be applied in order to obtain estimates on the impact of air pollution on hospital costs. [ABSTRACT FROM AUTHOR]

Brown snake ( Pseudonaja spp.)-induced early cardiovascular collapse is a life-threatening medical emergency in Australia. We have previously shown that this effect can be mimicked in animals and is mediated via the release of endogenous mediators. In the present study, we aimed to purify and characterize the component in Pseudonaja textilis venom which induces cardiovascular collapse following envenoming. The component (fraction 3) was isolated using a combination of techniques including hydroxyapatite and reverse phase chromatography. Fraction 3 (10 or 20 μg/kg, i.v.) produced a rapid decrease in mean arterial pressure (MAP) followed by cardiovascular collapse. Fraction 3-induced early collapse was abolished by prior administration of smaller priming doses of fraction 3 (i.e. 2 and 5 μg/kg, i.v.) or heparin (300 units/kg, i.v.). P. textilis whole venom (1 and 3 μg/ml), but not fraction 3 (1 or 3 μg/ml), induced endothelium-dependent relaxation in isolated rat mesenteric arteries. SDS-PAGE gel indicated the presence of 9–10 protein bands of fraction 3. Using proteomic based analysis some protein bands of fraction 3 were identified as subunits of venom prothrombin activator, pseutarin C of P. textilis venom. Our results conclude that prothrombin activator-like toxin is likely to be a contributor to the rapid collapse induced by P. textilis venom. [ABSTRACT FROM AUTHOR]

A 17-year-old African-American male adolescent had recurrent emergency department visits for hypertension resistant to initial treatment, which resulted in multiple hospital admissions. Hypertension was associated with significant weight loss, peripheral neuropathy, and night sweats. An extensive laboratory and imaging workup ruled out renal, cardiac, rheumatologic, and endocrine causes for his symptoms. Ultimately, a more detailed history and toxicology consultation led to the cause of his persistent symptoms: mercury poisoning. [ABSTRACT FROM AUTHOR]

Background The entirely subcutaneous implantable cardioverter-defibrillator (S-ICD) is the first implantable defibrillator that avoids placing electrodes in or around the heart. Two large prospective studies (IDE [S-ICD System IDE Clinical Investigation] and EFFORTLESS [Boston Scientific Post Market S-ICD Registry]) have reported 6-month to 1-year data on the S-ICD. Objectives The objective of this study was to evaluate the safety and efficacy of the S-ICD in a large diverse population. Methods Data from the IDE and EFFORTLESS studies were pooled. Shocks were independently adjudicated, and complications were measured with a standardized classification scheme. Enrollment date quartiles were used to assess event rates over time. Results Eight hundred eighty-two patients who underwent implantation were followed for 651 ± 345 days. Spontaneous ventricular tachyarrhythmia (VT)/ventricular fibrillation (VF) events (n = 111) were treated in 59 patients; 100 (90.1%) events were terminated with 1 shock, and 109 events (98.2%) were terminated within the 5 available shocks. The estimated 3-year inappropriate shock rate was 13.1%. Estimated 3-year, all-cause mortality was 4.7% (95% confidence interval: 0.9% to 8.5%), with 26 deaths (2.9%). Device-related complications occurred in 11.1% of patients at 3 years. There were no electrode failures, and no S-ICD–related endocarditis or bacteremia occurred. Three devices (0.3%) were replaced for right ventricular pacing. The 6-month complication rate decreased by quartile of enrollment (Q1: 8.9%; Q4: 5.5%), and there was a trend toward a reduction in inappropriate shocks (Q1: 6.9% Q4: 4.5%). Conclusions The S-ICD demonstrated high efficacy for VT/VF. Complications and inappropriate shock rates were reduced consistently with strategic programming and as operator experience increased. These data provide further evidence for the safety and efficacy of the S-ICD. (Boston Scientific Post Market S-ICD Registry [EFFORTLESS]; NCT01085435 ; S-ICD® System IDE Clinical Study; NCT01064076 ) [ABSTRACT FROM AUTHOR]

This case describes the management of a patient admitted to an emergency department with general malaise, who deteriorated into cardiac arrest and refractory to advanced life support measures. After extracorporeal cardiopulmonary resuscitation (eCPR) with veno-arterial extracorporeal membrane oxygenation in association with an Impella 2.5 device, the patient underwent cardiac surgery (tissue aortic valve replacement, coronary artery bypass grafting and implantation of short-term paracorporeal left ventricular assist device). Subsequently a long-term LVAD was implanted and the patient was successfully discharged shortly afterwards. This report illustrates the challenges of 'clinical decision making' in a complex patient utilising a wide range of left ventricular support mechanical devices with varying degrees of invasiveness, whilst also reflecting on the current financial and economic considerations in utilizing this type of care pathway. [ABSTRACT FROM AUTHOR]

Objectives We sought to investigate the potential impact of preoperative short-term mechanical circulatory support (MCS) with extracorporeal devices on postoperative outcomes after emergency heart transplantation (HT). Methods We conducted an observational study of 669 patients who underwent emergency HT in 15 Spanish hospitals between 2000 and 2009. Postoperative outcomes of patients bridged to HT on short-term MCS (n = 101) were compared with those of the rest of the cohort (n = 568). Short-term MCS included veno-arterial extracorporeal membrane oxygenators (VA-ECMOs, n = 23), and both pulsatile-flow (n = 53) and continuous-flow (n = 25) extracorporeal ventricular assist devices (VADs). No patient underwent HT on intracorporeal VADs. Results Preoperative short-term MCS was independently associated with increased in-hospital postoperative mortality (adjusted odds-ratio 1.75, 95% CI 1.05-2.91) and overall post-transplant mortality (adjusted hazard-ratio 1.60, 95% CI 1.15-2.23). Rates of major surgical bleeding, cardiac reoperation, postoperative infection and primary graft failure were also significantly higher among MCS patients. Causes of death and survival after hospital discharge were similar in MCS and non-MCS candidates. Increased risk of post-transplant mortality affected patients bridged on pulsatile-flow extracorporeal VADs (adjusted hazard-ratio 2.21, 95% CI 1.48-3.30) and continuous-flow extracorporeal VADs (adjusted hazard-ratio 2.24, 95% CI 1.20-4.19), but not those bridged on VA-ECMO (adjusted hazard-ratio 0.51, 95% CI 0.21-1.25). Conclusions Patients bridged to emergency HT on short-term MCS are exposed to an increased risk of postoperative complications and mortality. In our series, preoperative bridging with VA-ECMO resulted in comparable post-transplant outcomes to those of patients transplanted on conventional support. [ABSTRACT FROM AUTHOR]

Abstract: Background: Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. Study Objective: We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. Methods: We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics—hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. Results: We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001). Conclusion: Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times. [Copyright &y& Elsevier]

Background: Patients awaiting heart transplantation in Eurotransplant are prioritized by waiting time and medical urgency. To reduce mortality, the introduction of post-transplant survival in an allocation model based on the concept of survival benefit might be more appropriate. The aim of this study was to assess the prognostic accuracy of the Heart Failure Survival Score (HFSS), the Seattle Heart Failure Model (SHFM), the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) model, and the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score for predicting mortality. Methods: The HFSS, SHFM, the adapted SHFM, and the INTERMACS model were evaluated for predicting waiting list mortality among heart transplant candidates, and the IMPACT score was tested for predicting post-transplant mortality in separate Cox regression models. Included were the 448 adult heart transplant candidates listed for an urgent status between October 2010 and June 2011 in Eurotransplant. A Cardiac Allocation Score (CAS) was calculated based on the estimated survival times as predicted by the scores. All analyses were performed for the total cohort and separately for ventricular assist device (VAD) and non-VAD patients. Results: Mortality on the waiting list could significantly be predicted in the non-VAD cohort by HFSS (p = 0.005) and SHFM (p < 0.0001) and after transplant by IMPACT (p < 0.0001). None of the tested scores could predict mortality among VAD-supported patients. Conclusions: In non-VAD patients, the HFSS, SHFM, and IMPACT provide accurate risk stratification. Further studies will reveal whether these models should be considered as the basis for a new heart allocation policy in Eurotransplant. [Copyright &y& Elsevier]

Abstract: Aim: Emergency cardiopulmonary bypass (E-CPB) is an advanced and rarely used procedure for patients in cardiac arrest that do not regain restoration of spontaneous circulation with standard resuscitation methods. The feasibility, safety and outcome of the intervention with E-CPB in cardiac arrest situations at our department have been evaluated. Methods: Clinical presentation, time intervals, diagnosis and outcome of all patients who received E-CPB at an emergency department of a tertiary care university hospital were evaluated. Patient charts were reviewed regarding cardiac arrest variables and treatment data of all patients from 1993 to 2010. Results: E-CPB was performed in 55 patients. Of all patients, 33 (60%) were male and the median age was 32 years (IQR 24–44). In all cases cardiac arrest was witnessed. The first recorded ECG rhythm showed pulseless electric activity in 23 (42%), ventricular fibrillation in 21 (38%) and asystole in 11 (20%) patients. Cardiac arrest occurred out-of-hospital in 33 (60%) patients. The median duration of CPR before performing E-CPB was 86min (IQR 69–121). The median ‘cannulation’-time was 33min (IQR 21–45) and the duration on bypass was 311min (IQR 161–953). Cardiac causes of arrest were found in 19 (35%) patients. Eight patients (15%) survived to 6 months with good neurological outcome. Conclusion: E-CPB for cardiac arrest is feasible and safe. In this seemingly desperate patient population after prolonged cardiac arrest, we observed a high survival rate of 15%. E-CPB is a meaningful treatment option, which should be considered more often and earlier. [Copyright &y& Elsevier]

Abstract: Background: Cardiovascular disease (CVD) is a leading cause of hospitalizations, death, and health care costs. Although studies have shown that modifying CVD risk factors at the patient level improves patient prognosis, the effect of community-wide interventions at the population level has been uncertain. Objective: To evaluate the resource use and cost consequences of a community-wide Cardiovascular Health Awareness Program (CHAP). Methods: Thirty-nine medium-sized communities in Ontario, Canada, participated in a community cluster randomized controlled trial stratified by population size and geographic location. All community-dwelling elderly residents (>65 years) in each community were included. Family physicians, pharmacists, community nurses, local organizations, and volunteers in the intervention communities implemented the program. Rates and costs of CVD hospitalizations, all hospitalizations, emergency department visits, physician visits, and prescription medication use in the year before and after the intervention were compared for the 19 control and 20 CHAP communities by using province-wide linked administrative databases. The cost of implementing and administrating CHAP in each community was combined with total community health care cost to determine the net cost effect. Results: CHAP was associated with a reduction in CVD hospitalization costs. There were no differences in utilization rates or costs for overall hospitalizations, in visits to emergency rooms, physicians, or specialists, or in the use of prescription medications. Results were robust over a range of cost assumptions. Conclusions: A community-wide CVD awareness program can be implemented and can reduce CVD-related hospitalization costs at the level of the community without a corresponding increase in overall health care costs. [Copyright &y& Elsevier]

Objectives: The study aim was to determine the prognostic value of a multimarker strategy for risk-assessment in patients presenting to the emergency department (ED) with dyspnea. Background: Combining biomarkers with different pathophysiological backgrounds may improve risk stratification in dyspneic patients in the ED. Methods: The study prospectively investigated the prognostic value of the biomarkers N-terminal pro–B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), Cystatin-C (Cys-C), high-sensitivity C-reactive protein (hs-CRP), and Galectin-3 (Gal-3) for 90-day mortality in 603 patients presenting to the ED with dyspnea as primary complaint. Results: hs-CRP, hs-cTnT, Cyst-C, and NT-proBNP were independent predictors of 90-day mortality. The number of elevated biomarkers was highly associated with outcome (odds ratio: 2.94 per biomarker, 95% confidence interval [CI]: 2.29 to 3.78, p < 0.001). A multimarker approach had incremental value beyond a single-marker approach. Our multimarker emergency dyspnea-risk score (MARKED-risk score) incorporating age ≥75 years, systolic blood pressure <110 mm Hg, history of heart failure, dyspnea New York Heart Association functional class IV, hs-cTnT ≥0.04 μg/l, hs-CRP ≥25 mg/l, and Cys-C ≥1.125 mg/l had excellent prognostic performance (area under the curve: 0.85, 95% CI: 0.81 to 0.89), was robust in internal validation analyses and could identify patients with very low (<3 points), intermediate (≥3, <5 points), and high risk (≥5 points) of 90-day mortality (2%, 14%, and 44% respectively; p < 0.001). Conclusions: A multimarker strategy provided superior risk stratification beyond any single-marker approach. The MARKED-risk score that incorporates hs-cTnT, hs-CRP, and Cys-C along with clinical risk factors accurately identifies patients with very low, intermediate, and high risk. [ABSTRACT FROM AUTHOR]

Abstract: Pre-cordial thump (PT) relies on cardiac mechano-electric transduction to transform mechanically-delivered energy into an electrophysiologically relevant stimulus. Its use for emergency resuscitation has declined recent years, amidst concerns about effectiveness and side-effects. In addition, there is insufficient knowledge about bio-mechanical properties and mechanisms of PT. Using a PT-mechanics recorder, we measured PT off-patient among healthcare professionals (n = 58) in North-East Italy, and related this to retrospective information on self-reported PT outcomes. Impact-speed and peak-force were 4.7 ± 1.3 m s−1 (2.2–7.8 m s−1) and 394 ± 110 N (202–648 N), respectively. Average self-reported cardioversion rate by PT was 35%. No adverse events were stated. All but 3 of PT providers with self-reported cardioversion rates ≥50% had pre-impact fist-speeds of ≥3.7 m s−1. In comparison with previously-reported data from UK and US (n = 22 each), self-reported success-rates and pre-impact fist-speeds were more similar to US (PT-induced cardioversion rate 27.7%; fist-speed 4.17 ± 1.68 m s−1) than to UK participants (PT-induced cardioversion rate 13.3%; fist-speed 1.55 ± 0.68 m s−1). Small cohort-size, retrospective nature of data-gathering, and ‘self-selection bias’ (participants who have used PT on patients) limits the extent to which firm conclusions can be drawn. Observations are compatible, though, with the possibility that pre-impact fist-speed may affect success-rate of PT. Thus, where PT is used for acute resuscitation, it is delivered because it is immediately ‘at hand’. Negative side effects are rare or absent in witnessed cardiac arrest cases. Pre-impact fist-speed may be a determinant of outcome, and this could be trained using devices suitable for self-assessment. [Copyright &y& Elsevier]

End-stage renal disease is the result of complete or near-complete renal failure. Once renal function is lost, patients have difficulty eliminating excess fluids and waste from the body. Most pediatric patients rely on peritoneal dialysis for renal replacement, although a small population will undergo hemodialysis. A common complication of renal failure is electrolyte abnormalities, especially hyperkalemia. These patients are also at risk for catheter site infections as well as intraperitoneal infections. This article will review common disease complications and emergency care needs for children with end-stage renal disease. [Copyright &y& Elsevier]

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Abstract: Background and aim: In the area of acute emergency care, the needs of adult congenital heart disease patients (ACHD) are unique and burden on hospital resources are likely substantial. We aim to understand the reasons for emergency admissions and associations of increased hospital length of stay (LOS). Methods: We evaluated 600 ACHD patients in our adult congenital database. Patients who required emergency admissions between January 2007 and December 2007 were studied from hospital records. Results: Sixty-eight ACHD patients (11%) required emergency admissions, culminating in a total of 108 admissions. Mean age was 37.6years (SD 18.0), with a female preponderance (56%). Most were either schooling or working (62%) and were single (62%). Atrial septal defect (24%), ventricular septal defect (19%) and tetralogy of fallot (13%) formed the majority of diagnoses, mirroring proportions in our cohort. A third of the admissions were for cardiac reasons including arrhythmia, heart failure, endocarditis, and thromboembolism; the remaining two-thirds were for non-cardiac reasons. Median hospital LOS was 5.0days. Those who were older (p =0.02) and neither employed nor schooling (p =0.021) had longer LOS. Thromboembolism accounted for longer LOS (p =0.047). One-third of the admissions that required interdisciplinary referrals had increased LOS (p <0.001), with utilization of non-cardiac investigations (p =0.002). Increased LOS was not associated with adverse clinical outcome (p =0.68). Conclusions: ACHD patients require emergency admissions for both cardiac and non-cardiac reasons. Older age groups, unemployment and thromboembolic complications were associated with increased LOS. Non-cardiac conditions required interdisciplinary resources and were associated with increased LOS. Understanding their diverse acute needs may potentially improve care and outcome for these patients. [Copyright &y& Elsevier]

Satisfactory results are achieved by elective coronary artery bypass grafting (CABG), but the results of emergency CABG are less than satisfactory and readmission for cardiac events is common. We examined long-term results of emergency CABG for unstable angina pectoris from the viewpoints of preoperative, intraoperative, and postoperative factors. Subjects were 154 patients who underwent emergency CABG for unstable angina pectoris. Operative mortality rate was 1.9%. Univariate analysis showed female gender, chronic renal failure, hemodialysis, nonuse of human atrial natriuretic peptide (hANP), nonuse of angiotensin II receptor blockers and aldosterone blockers, 3-month postoperative brain natriuretic peptide level ≥200 pg/ml, and 3-month postoperative aldosterone level ≥100 pg/ml as risk factors for late cardiac events. Multivariate analysis confirmed nonuse of hANP, nonuse of aldosterone blockers, 3-month brain natriuretic peptide level ≥200 pg/ml, and 3-month aldosterone level ≥100 pg/ml as risk factors. Intraoperative hANP infusion and postoperative treatment with aldosterone blockers and angiotensin II receptor blockers can control the renin-angiotensin-aldosterone system, inhibit left ventricular remodeling, decrease extent of infarction, and improve cardiac function, yielding a favorable long-term prognosis. The best results are obtained by combining good surgical technique and perioperative management with the long-term outcome in mind. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Transport of patients with ongoing cardiopulmonary resuscitation (CPR) occurs frequently. It may not be possible to obtain rapid hospital access while maintaining CPR quality, because the ambulance''s high speed can cause increased vibration and vehicle movement. We aimed to assess how the speed of ambulance affects chest compressions. Materials and methods: Five cycles of CPR were performed to the Resusci Anne manikin with the PC skill reporting system by experienced emergency medical technicians in ambulance traveling at one of four different speeds: stationary, 30, 60, or 90km/h. Performance and acceleration data of chest compressions at different speeds were compared using repeated measures analysis of variance (ANOVA). Results: Fractions of chest compressions with adequate depth, duty cycles, average rates of chest compressions, and no flow fractions showed significant differences among different speeds (p =0.026, <0.001, <0.001, 0.005, respectively), while average depth of chest compressions did not. Accelerations of 2Hz component and ratios of 3–12Hz to 0–2Hz components showed significant differences among different speeds (p =0.001 for all). None of the outcome variables showed a significant difference between the two types of ambulance. Conclusions: The speed of ambulance affects some aspects in the quality of chest compression during transport. Chest compressions with excessive depth, the average rate of chest compressions, and no-flow fraction increase as the speed of ambulance increase. Increase in the speed of ambulance also causes relative increase of high frequency acceleration in the chest compression, which represents unnecessary movement and force applied. [Copyright &y& Elsevier]

Objectives: The aim of this study was to develop and validate a clinical decision rule (CDR) to predict 1-month serious outcome and all-cause death in patients presenting with syncope to the emergency department. Background: Syncope is a common, potentially serious condition accounting for many hospital admissions. Methods: This was a single center, prospective, observational study of adults presenting to the emergency department with syncope. A CDR was devised from 550 patients in a derivation cohort and tested in a validation cohort of a further 550 patients. Results: One-month serious outcome or all-cause death occurred in 40 (7.3%) patients in the derivation cohort. Independent predictors were brain natriuretic peptide concentration ≥300 pg/ml (odds ratio [OR]: 7.3), positive fecal occult blood (OR: 13.2), hemoglobin ≤90 g/l (OR: 6.7), oxygen saturation ≤94% (OR: 3.0), and Q-wave on the presenting electrocardiogram (OR: 2.8). One-month serious outcome or all-cause death occurred in 39 (7.1%) patients in the validation cohort. The ROSE (Risk stratification Of Syncope in the Emergency department) rule had a sensitivity and specificity of 87.2% and 65.5%, respectively, and a negative predictive value of 98.5%. An elevated B-type natriuretic peptide (BNP) concentration alone was a major predictor of serious cardiovascular outcomes (8 of 22 events, 36%) and all-cause deaths (8 of 9 deaths, 89%). Conclusions: The ROSE rule has excellent sensitivity and negative predictive value in the identification of high-risk patients with syncope. As a component, BNP seems to be a major predictor of serious cardiovascular outcomes and all-cause death. The ROSE rule and BNP measurement might be valuable risk stratification tools in patients with emergency presentations of syncope and should now be subjected to external validation. [Copyright &y& Elsevier]

More than 10 million people, many elderly and likely to harbor cardiovascular (CV) disease, embark on cruise ship travel worldwide every year. The clinical presentation and outcome of CV emergencies presenting during cruise ship travel remain largely unknown. Our department provides contracted cardiology consultations to several large cruise lines. We prospectively maintained a registry of all such consultations during a 2-year period. One hundred consecutive patients were identified (age 66 ± 14 years, range 18 to 90, 76% men). The most common symptom was chest pain (50%). The most common diagnosis was acute coronary syndrome (58%; ST elevation in 21% and non-ST elevation in 37%). On-board mortality was 3%. Overall, 73% of patients required hospital triage. Of the 25 patients triaged to our institution, 17 underwent a revascularization procedure. One patient died. Ten percent of patients had cardiac symptoms in the days or weeks before boarding; all required hospital triage. Access to a baseline electrocardiogram would have been clinically useful in 23% of cases. In conclusion, CV emergencies, such as acute coronary syndrome and heart failure, are not uncommon on cruise ships. They are often serious, requiring hospital triage and coronary revascularization. A pretravel medical evaluation is recommended for passengers with a cardiac history or a high-risk profile. Passengers should be encouraged to bring a copy of their electrocardiogram on board if abnormal. Cruise lines should establish mechanisms for prompt consultation and triage. [Copyright &y& Elsevier]

Abstract: Study objective: This study compares adhesive tape, non-adhesive tape and a commercial endotracheal tube holder in terms of the force required to extubate endotracheal tubes from a cadaver. Methods: A newly deceased, unembalmed cadaver was orotracheally intubated. Senior paramedic students secured the endotracheal tube using adhesive tape applied using the Lillehei method, non-adhesive tape and the Thomas Tube Holder™ in a random order. The time taken to secure the endotracheal tube and the force required to remove the distal tip of the endotracheal tube from the glottis were recorded. Results: Use of adhesive tape using the Lillehei method resulted in greatest resistance to tube dislodgement, although it took significantly longer to apply than the other two methods. Conclusion: Although the Lillehei method provided the greatest resistance to tube dislodgement, it may not be ideal for the prehospital or emergency department context. The Thomas Tube Holder™ was quick and effective and may provide a good compromise in these environments, although once time is no longer important, clinicians may elect to revert to the Lillehei method which provides greater security. [Copyright &y& Elsevier]

Abstract: Background: Search and rescue helicopters from the French navy conduct ambulance and search and rescue missions near the western coast of the French Britain. The team on board includes military doctor and paramedic. Operations in this area are challenging due to long distances and severe weather conditions. Methods: We studied retrospectively 205 search and rescue missions from 2000 to 2007 with special emphasis on acute heart disease and operative conditions. Results: 12.2% of the missions (25/205) concern acute heart disease dominated by myocardial infarction elevation myocardial infarction. All of the patients are male. Most of them are seafarers and the others come from ferries with a median age of 53.4 years. Sixty-two percent of the missions were carried in darkness. The median range is about 80 nautical miles. Two patients died during search and rescue missions. All patient are hospitalized. Conclusion: Ambulance and search and rescue mission near the western coasting of the French Britain are a challenge. Using a heavy helicopter from French Navy was the best way to carry medical treatment to seafarers and passengers of ferries suffering from acute heart disease. [Copyright &y& Elsevier]

Background: Patient safety and emergency department (ED) functionality are compromised when inefficient coordination between hospital departments impedes ED patients'' access to inpatient cardiac care. The objective of this study was to determine how bed demand from competing cardiology admission sources affects ED patients'' access to inpatient cardiac care. Methods: A stochastic discrete event simulation of hospital patient flow predicted ED patient boarding time, defined as the time interval between cardiology admission request to inpatient bed placement, as the primary outcome measure. The simulation was built and tested from 1 year of patient flow data and was used to examine prospective strategies to reduce cardiology patient boarding time. Results: Boarding time for the 1,591 ED patients who were admitted to the cardiac telemetry unit averaged 5.3 hours (median 3.1, interquartile range 1.5-6.9). Demographic and clinical patient characteristics were not significant predictors of boarding time. Measurements of bed demand from competing admission sources significantly predicted boarding time, with catheterization laboratory demand levels being the most influential. Hospital policy required that a telemetry bed be held for each electively scheduled catheterization patient, yet the analysis revealed that 70.4% (95% CI 51.2-92.5) of these patients did not transfer to a telemetry bed and were discharged home each day. Results of simulation-based analyses showed that moving one afternoon scheduled elective catheterization case to before noon resulted in a 20-minute reduction in average boarding time compared to a 9-minute reduction achieved by increasing capacity by one additional telemetry bed. Conclusions: Scheduling and bed management practices based on measured patient transfer patterns can reduce inpatient bed blocking, optimize hospital capacity, and improve ED patient access. [Copyright &y& Elsevier]

Background: Circulating markers that indicate atherosclerotic plaque instability may have diagnostic and prognostic value in patients with acute coronary syndromes. We evaluated activated protein C (APC), which has antithrombotic, anti-inflammatory, and profibrinolytic properties, as a possible clinical predictor in ST-elevation myocardial infarction (STEMI), including return of spontaneous circulation after sudden cardiac arrest. Methods: Patients with STEMI whose APC level was measured upon arrival at the emergency room were enrolled in this study (n = 335). The primary end point was inhospital death from any cause. Results: The APC level ranged from 29% to 142% with a median of 80%. The unadjusted death rate increased in a stepwise fashion with decreasing APC levels (33.7% in quartile 1, 12.7% in 2, 6.0% in 3, and 3.6% in 4, P < .001). This association remained significant in subgroups of patients with STEMI only (P = .04) or with return of spontaneous circulation (P = .01). After adjusting for independent predictors of inhospital death, the odds ratio for death among those in the first quartile of APC levels was 9.4 (95% CI 1.1-81.6, P = .04). A cutoff APC level of 65% had the highest combined sensitivity and specificity in predicting death. Conclusions: Measuring APC levels provides predictive information for use in risk stratification across the STEMI spectrum. Decreased APC levels may be a unifying feature among patients at high risk for death after STEMI. [Copyright &y& Elsevier]

Summary: Emergency preservation and resuscitation (EPR) is a new approach for resuscitation of exsanguination cardiac arrest (CA) victims to buy time for surgical hemostasis. EPR uses a cold aortic flush to induce deep hypothermic preservation, followed by resuscitation with cardiopulmonary bypass (CPB). We previously reported that 20min of EPR was feasible with intact outcome. In this report, we tested the limits for EPR in rats. Adult male isoflurane-anesthetized rats were subjected to rapid hemorrhage (12.5ml over 5min), followed by esmolol/KCl-induced CA and 1min of no-flow. EPR was then induced by perfusion with 270ml of ice-cold Plasma-Lyte to decrease body temperature to 15°C. After 60min (n =7) or 75min (n =7) of EPR, resuscitation was attempted with CPB over 60min, blood transfusion, correction of acid–base balance and electrolyte disturbances, and mechanical ventilation for 2h. Survival, overall performance category (OPC: 1=normal, 5=death), neurological deficit score (NDS), and histological damage score (HDS) were assessed in survivors on day 3. While all rats after 60min EPR survived, only two out of seven rats after 75min EPR survived (p <0.05). All rats after 60min EPR achieved OPC 1 and normal NDS by day 3. Survivors after 75min EPR achieved best OPC 3 (p <0.05 vs. 60min EPR). HDS of either brain or individual viscera was not statistically different after 60 versus 75min EPR, except for kidneys (0±0 vs. 1.9±1.3, respectively; p <0.05), with a strong trend toward greater injury in all extracerebral organs in the 75-min EPR group (p <0.06). Histological findings were dominated by cardiac lesions observed in both groups and acute renal tubular and liver necrosis in the 75-min EPR group. In conclusion, we have shown that 60min of EPR after exsanguination CA is associated with survival and favorable neurological outcome, while 75min of EPR results in significant mortality and neurological damage in survivors. Surprisingly, extracerebral lesions predominated at 75-min EPR group. This model should serve as a screening model both for testing new pharmacological adjuncts to improve survival after exsanguination CA, and for elucidating the underlying mechanisms of ischemia/reperfusion injury. [Copyright &y& Elsevier]

Abstract: Objectives. – This prospective study had for aim to determine the frequency and characteristics of cardiovascular events in the course of tetanus. Patients and methods. – From September to December 2002, we studied all patients over 4 years of age presenting with tetanus without any documented underlying disease. Results. – Thirty cases were included (mean age 36±20 years; sex-ratio 2.3). Seventy-three per cent had a mild-gravity tetanus (stage II of Mollaret) upon admission. One hundred and seventeen ECG were recorded and 93.3% of the patients had more than one abnormality: arrhythmia (24 cases), prolonged QT interval (23 cases), ventricular hypertrophia (17 cases), and atrial hypertrophia (4 cases) especially left (3 cases), failure of AV conduction (3 cases), ST segment depression (3 cases), left and right axis deviation (3 cases), baseline undulation (3 cases) and repolarization disturbances (1 case). All patients had a normal Doppler echocardiographic examination. The mean hospitalization stay was 11.6±1.4 days and complications were noted in 60%; sinus tachycardia in apyrexia (5 cases), instable BP (5 cases), excessive sweatiness in apyrexia (1 case), and access of bradycardia with sudden cardiac arrest (2 cases). 8 patients died (26.7%). Six patients with cardiac autonomic dysfunction died, the case fatality rate being statistically higher in this group (P =0.007). A prolonged QT interval, sinus tachycardia and left ventricular hypertrophia were statistically more frequent at the acute phase of the illness. Conclusion. – The case fatality rate of tetanus is still high, due among others to autonomic dysfunctions. [Copyright &y& Elsevier]

La plupart des événements cardiovasculaires sont une conséquence thrombotique de l’évolution d’une lésion d’athérosclérose. L’inflammation joue un rôle central tant dans le développement que dans la survenue des complications évolutives des lésions d’athérosclérose (en particulier de rupture de plaques). Les données épidémiologiques montrent de manière concordante que l’augmentation du fibrinogène (par rapport aux valeurs de contrôles appariés) est prédictive du risque d’accident cardiovasculaire aussi bien dans la population générale pour prédire le premier événement cardiovasculaire que chez les patients pour prédire le risque de récidive. La concentration plasmatique du fibrinogène est déterminée à la fois par une prédisposition génétique et par des facteurs acquis et environnementaux. C’est un exemple des interrelations gène-environnement. Il faut prendre conscience que l’augmentation du fibrinogène (responsable de l’augmentation significative du risque) est une augmentation très modérée (comprise dans les valeurs de référence du taux plasmatique). Cela permet de comprendre que ce facteur si prédictif lorsqu’il est considéré d’un point de vue épidémiologique, n’a aucune valeur pour établir le risque cardiovasculaire à un niveau individuel en pratique clinique quotidienne (sauf pour les très fortes augmentations qui ne sont rencontrées que très rarement). Mots clés : fibrinogène, risque cardiovasculaire, athérome, thrombose Abstract Most cardiovascular events result from a thrombotic complication of an atherosclerotic lesion. Inflammation plays a central role in both the pathogenesis of atherosclerosis and the progression of its complications (especially plaque rupture). Fibrinogen, on the one hand a marker of inflammation and on the other a major determinant in thrombosis and haemorrheology, plays a central role in atherosclerosis and its thrombotic complications. The clinical data are in agreement with epidemiological data, and show that increased plasma fibrinogen levels (compared with values in paired controls) are predictive of the risk of cardiovascular events - both primary cardiovascular events in the general population and recurrence in patients. Determining the plasma fibrinogen level in terms of genetic predisposition and environmental factors provides a good example of the interrelationship between genes and the environment. It must be recognised that a minimal increase in the fibrinogen level (within the plasma reference values) is an indicator of a significantly increased risk. This shows why epidemiological data are not useful for determining cardiovascular risk in individual patients in daily clinical practice (with the exception of the very high levels that are infrequently observed). Keywords: fibrinogen, cardiovascular risk, atheroma, thrombosis [ABSTRACT FROM AUTHOR]

Dans leur grande majorité, les événements cardiovasculaires sont une complication thrombotique de lésions d’athérosclérose. En condition de flux sanguin artériel, comme dans les artères coronaires, les facteurs d’hémostase favorisent le risque thrombotique (surtout aux phases initiales), mais les facteurs de coagulation et de fibrinolyse interagissent également. S’il est admis que le fibrinogène est un marqueur/facteur de risque cardiovasculaire, la place, le rôle et l’intérêt des autres paramètres sont toujours controversés. Etant donnée la place des plaquettes (démontrée par l’efficacité préventive des antiplaquettaires dans cette pathologie), on s’attendrait à ce que les marqueurs plaquettaires présentent un intérêt. En fait, en dehors des augmentations du chiffre plaquettaire, il n’y a pas d’autre paramètre plaquettaire évident. Cette absence est due au moins en partie à la difficulté d’étudier les fonctions plaquettaires ex vivo. Plusieurs polymorphismes de glycoprotéines membranaires plaquettaires confèrent un excès modéré de risque, risque qui n’est retrouvé que chez les patients les plus jeunes. Pour la coagulation, il apparaît que la structure du caillot de fibrine est un paramètre important. Ce paramètre implique, outre le fibrinogène, la cinétique de génération de la thrombine, la fonctionnalité du facteur XIII et l’association aux cellules de la coagulation. Les facteurs de coagulation sont à l’évidence impliqués dans la vitesse de génération de la thrombine. L’activité du système fibrinolytique (et en particulier son déficit) est corrélée avec le risque cardiovasculaire. Les marqueurs globaux comme les D-dimères sont potentiellement utiles bien que faiblement corrélés avec la survenue d’événements cliniques. Tous les systèmes d’hémostase, de coagulation et de fibrinolyse sont impliqués dans la réactivité thrombotique (et certains dans l’athérogenèse elle-même). Il s’agit d’un système multifactoriel. Une meilleure prédictibilité des tests d’hémostase peut venir de la mise au point de tests plus représentatifs et de l’évaluation simultanée d’un grand nombre de paramètres (phénotypiques et génotypiques) qui permettraient d’aboutir à des scores de risque. Mots clés : hémostase, coagulation, facteur VII, facteur de von Willebrand Abstract Most cardiovascular events result from a thrombotic complication of atherosclerotic lesions. In arterial vessels such as the coronary bed, an interrelationship of haemostatic, coagulation and fibrinolytic factors is implicated. While it can be demonstrated that fibrinogen is a risk factor/marker, the role of other factors is not well established. Under arterial flow conditions, platelets are predominantly involved in the thrombotic reaction. Yet, apart from a large increase in the platelet count, the involvement of platelet parameters in cardiovascular risk is not clearly evident. The lack of definitive platelet markers is at least partly due to the difficulty of studying platelet function ex vivo. Several polymorphisms of platelet glycoproteins carrying a moderate increase in risk have been reported, but only in younger patients. One potentially important factor for coagulation is the fibrin structure, which is dependent on fibrinogen, the rate of thrombin generation, the activity of factor XIII and the interrelationship of the cells concerned, all of which act on its sensitivity to thrombosis. Coagulation factors largely affect the rate of thrombin generation. The activity of the fibrinolytic system (and principally any deficiency) has a role in the cardiovascular risk. General markers of cardiovascular risk such as D-dimers are potentially useful, but they increase with thrombin generation and are decreased by a deficiency in fibrinolysis. Furthermore, possibly because they are not indicative of the fibrin structure, they are poorly correlated with clinical events. The poor significance of the available haemostatic, coagulation and/or fibrinolytic parameters is probably due to their lack of representativeness, since haemostatic, coagulation and fibrinolytic systems are all involved in the thrombotic response (and some in atherogenesis itself). Atherogenesis is a multifactorial process and numerous moderate risk factors act in association. Better predictability of the haemostatic tests would probably result from both the design of more representative tests and the evaluation of multiple parameters, and would lead to the definition of a risk score. Technological advances will make this possible. Keywords: haemostasis, coagulation, factor VII, von Willebrand factor [ABSTRACT FROM AUTHOR]

Cardiovascular complications of cocaine abuse include myocardial ischemia and infarction, dysrhythmias, cardiomyopathies and aortic dissection.The case in point pertains to a 26-year-old, Caucasian male, substance abuser who suffered a thoracic aortic dissection following the use of crack cocaine.The autopsy and histological findings showed a connective tissue abnormality including a focal microcystic medial necrosis and a fragmentation of the elastic fibbers in the arterial walls.Blood concentrations of cocaine and benzoylecgonine, taken individually, were considered to be within a potentially toxic range.Blood concentrations of methadone also indicated use of this drug at the same time.The small amounts of morphine found in the blood and urine were compatible with heroine or morphine use more than 24 h before death. [Copyright &y& Elsevier]

It is widely believed that the incidence of specific emergency cases shows clustering during long observation periods. Though there is no scientific proof, many physicians and other emergency staff believe in influences of the moon or the signs of the zodiac. The aim of our retrospective study over 6 years was to evaluate (a) if there are any statistically documented peaks of frequency of emergency cases at all, and (b) if they can be linked to lunar phenomena. We evaluated all three aspects of the moon: The ‘synodic’ moon (=lunar phases), the ‘sideric’ moon (=distance between moon and the earth) and the moon in her relation to the signs of the zodiac (=influence of the zodiac). A total of 11 134 patients entered the study. We found highly significant clusters of emergency calls, mainly for lung disorders. However, neither aspect of the moon showed the slightest correlation with the frequency of emergency calls (sideric month (P=0.99), synodic month (P=0.85) and zodiac (P=0.85)). Trigonometric regression with the period of the anomalistic month (P=0.173) and with the synodic month (P=0.28) did not show any influence of the moon on emergency in either cases. Though our retrospective data analysis documented clustering of emergency cases, any influence of the moon and the signs of the zodiac can be definitely ruled out. [Copyright &y& Elsevier]

Abstract: Introduction: Chest compressions performed correctly have the potential to increase survival post cardiac arrest. The 2005 European Resuscitation Council (ERC) guidelines altered and simplified instructions for hand position placement to increase the number of chest compressions performed. This randomised controlled trial compares chest compression efficacy (hand position and number of effective chest compressions) after training using the 2005 guidelines or the 2005 guidelines with a hand position modification based on 2000 ERC guidelines. Methods: First year healthcare students at the University of Birmingham, United Kingdom, were randomly allocated to either ‘2005’ or ‘intervention’ group immediately after passing a Basic Life Support (BLS) assessment to ERC standards. The 2005 group performed 2min of BLS on a SkillReporter™ manikin (Laerdal Medical, Stavanger, Norway). The intervention group received training on hand placement using landmark techniques from the 2000 ERC guidelines; emphasising rapid hand positioning. This group also performed 2min of BLS on a SkillReporter™ manikin. Results: 82 students were assessed; 41 in the 2005 group and 41 in the intervention group. Average compression rate was 102 in the 2005 group and 104 in the intervention group (p =0.29). Average number of incorrect hand placements was 24 in the 2005 group and 9 in the intervention group (p =0.03). Conclusions: The use of landmark measurement techniques in hand placement for external chest compressions does not have a detrimental effect on the number of chest compressions performed during BLS and increases correct hand positioning. [Copyright &y& Elsevier]

Paradoxical embolism accounts for 2% of patients who present with acute arterial embolism of extremities. We report a case of a 41 year-old male with hereditary spherocytosis who presented to the emergency department with acute limb ischaemia and pulmonary embolism. On further evaluation, he was found to have patent foramen ovale (PFO) and deep vein thrombosis (DVT), leading to paradoxical embolism. The purpose of this report is to emphasise that in a patient presenting with acute limb ischaemia without an obvious systemic arterial embolic source, an evaluation for a right-to-left shunting lesion, especially PFO, should be performed. [ABSTRACT FROM AUTHOR]

Abstract: Cannabis smoking is on the increase both in the United Kingdom and in the United States. For over three decades it has been known that cannabis has pathophysiological effects on the cardiovascular system, and previously an association with an increased risk of myocardial infarction has been reported. However, it is not yet known whether cannabis contributes directly to coronary artery disease. We describe two distinct cases; in the first cannabis use precipitated a malignant arrhythmia in a patient with critical ischaemia from longstanding coronary artery disease. In the second, a young patient presented with an acute myocardial infarction that had started whilst smoking marijuana; subsequently diffuse coronary artery disease was found at angiography despite the patient''s low risk factor status. Patients who are known cannabis smokers and who have cardiovascular disease should be warned that it is likely to aggravate coronary ischaemia, and may even trigger myocardial infarction. [Copyright &y& Elsevier]

: BackgroundRenal transplants (RTs) from elderly donors show a high incidence of delayed graft function, which may be increased by the initial use of calcineurin inhibitors.: ObjectivesThe purpose of this study was to assess the safety and efficacy of an immunosuppressive regimen using anti–IL-2R antibodies and mycophenolate mofetil (MMF) with delayed introduction of low-dose tacrolimus in RT from elderly donors to elderly recipients.: MethodsThis observational study in 13 centers included 78 patients, aged 61 ± 7 years (range, 50–77), who received a kidney from a donor with a mean age of 64 ± 5 years (range, 55–76), 94% of whom had died from a cardiovascular accident (CVA). Immunosuppression consisted of 1 mg/kg daclizumab in two doses (pre-RT and on day 14) combined with steroids, mycophenolate mofetil (initial dose of 2 g/d), and tacrolimus (0.1 mg/kg per day). Tacrolimus was introduced before day 7 (mean, 5.5 days) and adjusted to a target level of 5 to 8 ng/ml. The mean follow up was 27 weeks.: ResultsOne graft was lost due to primary renal failure and 28 patients (36.4%) required dialysis due to delayed graft function, although it was generally of short duration (median, 4 days; only 2 cases >2 weeks). Acute rejection was seen in 11 patients (14%), with 9 of these confirmed by biopsy (11%, Banff 1997 grade I or II). Three patients withdrew from the study and two patients died (sepsis and accident). The remaining 72 patients continued follow up with a median 6-month creatinine value of 1.6 mg/dL. Sixty-seven percent of patients had at least one episode of infection, half of which were of urinary tract infections. There were nine cases of CMV infection.: ConclusionsThese initial results suggest that this immunosuppressive regimen offers good efficacy with regard to short-term renal function, while maintaining both an acceptable low rejection rate and incidence of serious infections. [Copyright &y& Elsevier]

Background: Thyroid storm (also known as thyroid or thyrotoxic crisis) is part of the spectrum of thyrotoxicosis and represents the extreme end of that spectrum. The condition is quite rare, yet mortality rates are high and may approach 10-30%.Case Report: A 34-year-old-man who had a history of Graves disease presented in atrial fibrillation with rapid ventricular response and mild congestive heart failure. During the course of his Emergency Department (ED) stay he deteriorated into cardiogenic shock. Roughly 10 h transpired between his presentation and the development of cardiogenic shock. He had received an intravenous contrast load of iohexol shortly after initial presentation, and the associated iodine bolus, we suspect, contributed to his abrupt deterioration into cardiogenic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Thyroid storm is infrequently seen in the ED, and there is potential for management errors that can lead to a detrimental patient outcome. [ABSTRACT FROM AUTHOR]

Abstract: For Emergency Department (ED) patients presenting with acute chest pain, troponin-I (TnI) is reported not just as negative or positive, but also within an “indeterminate range”. We reviewed 150 patients with a first-drawn ED TnI level in the indeterminate range (0.08–0.79 ng/dL) and compared outcomes to 150 control patients with a negative TnI. An initial ED indeterminate TnI yielded a statistically significant association with a composite adverse outcome (44% vs. 24%; OR=2.49; CI=1.52–4.08). Indeterminate TnI also showed a significantly increased risk of both an acute myocardial infarction and of the need for an invasive cardiac procedure during the admission. Our study further supports the hypothesis that any detectable level of TnI increases risk of cardiovascular events during acute hospitalization. [Copyright &y& Elsevier]

Syncope is a common presentation to emergency departments. Arrhythmias account for 14% of those presentations [1] , which requires careful assessment due to the potential for sudden cardiac death (SCD). QTc prolongation either due to congenital channelopathy or acquired aetiology can lead to polymorphic ventricular tachycardia and SCD, and should be excluded on electrocardiography. On the other hand, detailed history and thorough clinical examination are the most important tools in reaching the diagnosis, even in the presence of QTC prolongation. [ABSTRACT FROM AUTHOR]