Outcome at 30 days for low-risk chest pain patients assessed using an accelerated diagnostic pathway in the emergency department

OBJECTIVES

Primary: to determine incidence of 30 day major adverse cardiac events (MACE) in patients discharged from the ED following assessment using an accelerated diagnostic pathway (ADP). Secondary: to determine incidence of 30 day MACE for all ADP patients.

METHODS

Monash Health ED patients thought at low risk for acute myocardial infarction (AMI) or hospital admission are assessed using an ADP, based on arrival and 90 min point-of-care (POC) cardiac troponin I and myoglobin concentration. Other patients are assessed using a traditional pathway of arrival and 6 h central lab cardiac troponin I. Choice of pathway is based on the clinical judgement of the attending ED doctor. To investigate the safety of the ADP component, an observational study of all ADP patients presenting from 6 June 2013 to 30 September 2013 was conducted. After 30 days, occurrence of MACE was determined by examination of hospital records or telephone contact with patients who had not returned.

RESULTS

Of 1547 eligible patients, 1384 (89.5%) were followed up. Of the 1143 discharged patients with follow-up information, 30 day MACE occurred in one (0.09%, 95% CI 0.002-0.5). Of all 1547 patients, 60 patients had a MACE detected: 56 AMI during the initial attendance, four AMI post-discharge (one from ED, three after hospital admission). In total, of the 1328 patients who did not have AMI during the target admission and were followed up, 30 day post-discharge MACE occurred in four patients (0.3%, 95% CI 0.08-0.8).

CONCLUSION

The ADP supports safe, early discharge of low-risk chest pain patients from the ED.

Reimbursement for new health technologies. Breakthrough pharmaceuticals as a 20th century challenge

The regulation of pricing and trade for in-patent medicines within the European pharmaceutical sector presents a major challenge. In conditions of large sunk costs and consumers with differential willingness to pay--between different Member States--an efficient way of pricing in-patent medicines is through price discrimination, by which more is charged in markets that can bear it and re-exports are prevented from undercutting this strategy. Parallel trade and the use of international price comparisons by government regulators can result in pressure for price convergence with consequent delays in launching products in certain markets. Imposing free movement of pharmaceuticals may particularly harm patients in lower income Member States, who may find pharmaceuticals more expensive or unavailable. Data on first consumption of important new pharmaceuticals show long delays for patients in certain Member States.

A prospective study of neurophysiologic, neurologic and immunologic abnormalities in systemic lupus erythematosus

OBJECTIVE

To describe neurologic and neurophysiologic (NP) outcome in patients with systemic lupus erythematosus (SLE) followed prospectively and to determine predictors of change in NP status.

METHODS

Clinical examination, laboratory and NP tests (brain stem auditory and visual evoked responses, peripheral nerve conduction studies) were performed in 18 unselected patients with SLE attending a general rheumatology clinic at enrollment into the study (baseline) and after a 2-year (mean) period of followup.

RESULTS

Fifty percent (9/18) and 83% (15/18) of patients had neurological abnormalities at baseline and followup, respectively, the most common of which were headache and peripheral neuropathy. NP abnormalities were found in 56% (10/18) and 61% (11/18) of patients at baseline and followup. The most frequent abnormalities at both visits were of peripheral nerve conduction [33% (6/18) and 56% (10/18), respectively] and abnormalities of brainstem and/or visual evoked responses were found in 28% (5/18) and 22% (4/18) of patients at both visits. At baseline, vasculitis was significantly increased in patients with NP abnormalities (p = 0.04). NP status deteriorated between visits in 8 patients (44%), 6 of whom acquired peripheral abnormalities. Improvement in NP status was only noted in patients (2/18, 11%) who had NP abnormalities restricted to the central nervous system. Associations were seen between elevated dsDNA antibodies, vasculitis, and lymphopenia, and the risk of acquiring new NP abnormalities.

CONCLUSION

Patients with SLE had many neurological and NP abnormalities. NP deficits acquired were most often of peripheral nerve conduction. The ability to identify and classify clinical and subclinical neurological abnormalities in patients with SLE using NP tests may enhance our understanding and management of their neurological disease.

Histologic comparison of regeneration in human intrabony defects when osteogenin is combined with demineralized freeze-dried bone allograft and with purified bovine collagen

A bone-inductive protein, osteogenin, has been isolated from long bones of humans and offers promise as a grafting material. Studies, however, suggest that osteogenin must be combined with a bone-derived matrix in order to initiate bone differentiation. The purpose of this study was to determine if osteogenin combined with demineralized freeze dried bone allograft (DFDBA), a bone-derived matrix, and with a bovine tendon-derived matrix will enhanced regeneration of intrabony defects in humans. The tendon-derived matrix and DFDBA used alone served as controls. The ability of each material to form a new attachment apparatus was evaluated independently in submerged and nonsubmerged environments in 2 patient populations. Lymphocyte testing was performed to assess development of an immune reaction to osteogenin. The most apical level of calculus on the root served as the histologic reference point to measure regeneration. Biopsies were obtained at 6 months and regeneration was measured histomorphometrically by 2 blinded evaluators. Serial sections from 36 submerged defects in 8 patients and 50 nonsubmerged defects in 6 patients were submitted for statistical analysis. Mean results indicate that osteogenin combined with DFDBA significantly enhanced regeneration of a new attachment apparatus and component tissues in a submerged environment. DFDBA plus osteogenin and DFDBA alone formed significantly more new attachment apparatus and component tissues than either the tendon-derived matrix plus osteogenin or the tendon-derived matrix alone in both submerged and nonsubmerged environments. There were no significant differences between the tendon-derived matrix plus osteogenin and the tendon-derived matrix alone in either the submerged or nonsubmerged environment. Osteogenin does not impair normal lymphocyte blastogenesis at 6 months postsurgical challenge.

Contrast sensitivity in multiple sclerosis measured by Cambridge Low Contrast Gratings: a useful clinical test?

The Cambridge Low Contrast Gratings (CLCG) were used to assess contrast sensitivity (CS) in 39 patients with clinically definite multiple sclerosis and 60 control subjects. CS was determined in both horizontal and vertical orientations and compared with visual evoked responses (VERs) in the same populations. Only 33% of patients had abnormal CS whereas 82% had abnormal VERs. There was no correlation between the degree of abnormalities in CS and VERs. There was no significant difference between CS determined in the vertical and horizontal orientation; however, examination in the vertical orientation increased the number of abnormalities detected by 2 (5%). We conclude that although CS, using the CLCG, is abnormal in a proportion of multiple sclerosis patients its detection is not clinically useful and is insensitive as a measure of subclinical optic neuropathy in multiple sclerosis.

Clinical neurophysiology in the assessment of neurological symptoms in systemic lupus erythematosus

Neurophysiological studies were performed on 22 randomly selected patients with systemic lupus erythematosus in order to determine whether this form of assessment might be of value in the diagnosis and management of neurological lupus. Sixteen patients described neurological lupus. In eight, neurological symptoms were present at the time of neurophysiological testing. All eight had neurophysiological abnormalities. In six the abnormality was of central origin manifesting as a disorder of either visual evoked response (VER) or brain-stem auditory evoked response (BAER). In the remaining two, an isolated disorder of peripheral nerve conduction (PNC) was present. In the eight patients with previous neurological symptoms five (63%) had neurophysiological abnormalities, but a central disorder was observed in only one and abnormal PNC was present in all. Of the six patients with no neurological symptoms, three (50%) had central neurophysiological disorders. No correlation between individual neurophysiological disorders and specific neurological symptoms was observed. However, all four patients with active vasculitis and all seven with lymphopenia had a neurophysiological disorder. If these observations are extended and confirmed, neurophysiological studies may provide a useful test to the clinician in the evaluation and management of neurological lupus.

Clinical correlates of abnormal brain-stem auditory evoked responses in multiple sclerosis

Brain-stem auditory evoked responses (BAERs) were examined in 178 patients with multiple sclerosis (MS) and compared to the frequency of abnormalities in visually evoked responses (VERs) and in CSF electrophoresis. In clinically definite MS, BAERs were abnormal in 61% and a significant relationship was noted between disability due to MS and the frequency and severity of BAER abnormalities. In suspected MS, BAERs showed evidence of a second lesion in 14% whereas VERs indicated a second lesion in 24%. Abnormal BAERs in patients with suspected MS with brain-stem signs were significantly associated with the presence of truncal and limb ataxia. In progressive possible MS, abnormal BAERs were found in 49% but indicated a second lesion in 35% of patients and were significantly related to the duration of illness. In progressive possible MS, abnormal VERs but not abnormal BAERs, were significantly associated with the presence of CSF oligoclonal IgG banding. Normal BAERs in association with clinical brain-stem abnormalities were found in 24% of patients with clinically definite MS, 50% with suspected MS and 33% with progressive possible MS.

Visual evoked responses and immunoglobulin abnormalities in the diagnosis of multiple sclerosis

Visually evoked responses (VERs), CSF IgG/albumin ratio and CSF oligoclonal IgG were examined in 136 patients with multiple sclerosis (MS) admitted to hospital for investigation, and compared to the CSF findings in 87 patients with other neurological diseases (OND). 33% of patients with OND had abnormal CSF IgG/albumin ratios but only 9% had CSF oligoclonal IgG banding. In clinically definite MS, VERs were abnormal in 87% and CSF oligoclonal banding was found in 80% of patients, but CSF oligoclonal banding was found significantly more frequently than abnormal VERs in patients with suspected MS. We were unable to show any relationship between benign MS and the absence or presence of CSF oligoclonal IgG. The significance of CSF oligoclonal IgG in the less clinically definite forms of MS will only emerge with prolonged follow-up.

Reduction of streptozotocin toxicity by 3-O-methyl-D-glucose with enhancement of antitumor activity in murine L1210 leukemia

3-O-Methyl-D-glucose (3-OMG), a nontoxic nonmetabolizable derivative of glucose, is effective in reducing the toxicity of streptozotocin (SZ). In mice the administration of 3-OMG prior to SZ increased the dose that killed 50% of the animals from 240 to 340 mg/kg. Furthermore, the combination of 3-OMG plus nicotinamide (also effective in reducing SZ toxicity) increased the dose that killed 50% of the animals to 540 mg/kg. In L1210 leukemic mice treated with SZ, there was a 2-fold increase in the median survival of animals pretreated with 3-OMG and a 3-fold increase in that of animals pretreated with the combination of 3-OMG and nicotinamide. Neither 3-OMG nor nicotinamide alone enhanced the survival of the leukemic mice. Pretreatment of normal mice with 3-OMG partially prevented the expected fall in hepatic nicotinamide adenine dinucleotide content. This study suggests that 3-OMG, by protecting normal tissue, will permit the administration of larger therapeutic doses of SZ in leukemic L1210 mice. The protective effect of 3-OMG against SZ toxicity appears to be partially mediated through conservation of the nicotinamide adenine dinucleotide content in the tissue.