Prehospital triage to improve diagnostic and therapeutic decisions in patients with suspected myocardial infarction

The organisation of cardiac assistance for the general practitioner in the municipality of Rotterdam is well organised, due to an intensive co-operation between the general practitioners, the cardiologists, the Central Doktors Laboratorium (STA.R.) and the ambulance department of the Municipal Heallh Service. The first initiative towards a more intensive cooperation between cardiologists and general practitioners originated by the inititation of the Imminent Myocardial Infarction Rotterdam (IMIR) study, which started in 1972.'·3 The study was initiated and executed by the departments of Cardiology and General Practice of the Erasmus University of Rotterdam. In that study, the significance of prodromal symptoms, identified by means of history taking and physical examination, were studied prospectively in patients who visited their general practitioner wilh symptoms suggestive of myocardial infarction. Detailed history and physical findings were recorded on a standardized questionnaire by the general practitioner. Subsequently, the patient was referred to a special diagnostic centre (the IMIR centre, which was located at the department of Cardiology of the Thoraxcentre of the University Hospital of Rotte

Optimal use of coronary care units: A review

Patients at a low probability of acute cardiac pathology constitute a considerable proportion in many coronary care units (CCUs), such that physicians should consider more effective alternatives than CCU admission “to rule out myocardial infarction.” In this article, strategies to increase the efficiency of managing patients with acute chest pain are reviewed. Algorithms aiming to improve the diagnostic accuracy of the general practitioner have been developed but require an electrocardiogram recorded at the home of the patient. Another method of triage encompasses the identification in the emergency room of the hospital of patients at a low probability of acute cardiac pathology by using predictive models that include laboratory assessments. A third strategy includes alternatives to CCUs for patients at a low risk of acute cardiac pathology, such as the creation of a simple observation unit. Finally, some investigators have sought to identify patients with good prognosis for early transfer from the CCU to lower levels of care. It is concluded that a combination of these approaches will be most efficient, and that the most appropriate choice will be determined by local circumstances

Comparable low-level mosaicism in affected and non affected tissue of a complex CDH patient

In this paper we present the detailed clinical and cytogenetic analysis of a prenatally detected complex Congenital Diaphragmatic Hernia (CDH) patient with a mosaic unbalanced translocation (5;12). High-resolution whole genome SNP array confirmed a low-level mosaicism (20%) in uncultured cells, underlining the value of array technology for identification studies. Subsequently, targeted Fluorescence In-Situ Hybridization in postmortem collected tissues demonstrated a similar low-level mosaicism, independently of the affected status of the tissue. Thus, a higher incidence of the genetic aberration in affected organs as lung and diaphragm cannot explain the severe phenotype of this complex CDH patient. Comparison with other described chromosome 5p and 12p anomalies indicated that half of the features presented in our patient (including the diaphragm defect) could be attributed to both chromosomal areas. In contrast, a few features such as the palpebral downslant, the broad nasal bridge, the micrognathia, microcephaly, abnormal dermatoglyphics and IUGR better fitted the 5p associated syndromes only. This study underlines the fact that low-level mosaicism can be associated with severe birth defects including CDH. The contribution of mosaicism to human diseases and specifically to congenital anomalies and spontaneous abortions becomes more and more accepted, although its phenotypic consequences are poorly described phenomena leading to counseling issues. Therefore, thorough follow-up of mosaic aberrations such as presented here is indicated in order to provide genetic counselors a more evidence based prediction of fetal prognosis in the future

Richtlijnenprogramma (1997-2002). Deelprogramma iMTA; Eindrapportage maart 2002

Deze rapportage beschrijft de activiteiten die door het iMTA zijn uitgevoerd om samen met (para-) medische beroepsgroepen richtlijnen voor kosten-effectieve patiëntenzorg te ontwikkelen. Dit Richtlijnenproject vormde een onderdeel van het programma "bevordering doelmatig handelen", dat in het najaar van 1997 van start is gegaan. Het iMTA heeft uitgebreid overlegd met de betrokken richtlijnontwikkelaars over de keuze van richtlijnonderwerpen. Daarbij werden naast de gebruikelijke criteria voor de keuze van onderwerpen voor richtlijnontwikkeling mede in beschouwing genomen of een kosten-effectiviteitsanalyse een duidelijk toegevoegde waarde bood en of er voldoende gegevens op dat terrein beschikbaar waren. Uiteindelijk werden 17 onderwerpen geselecteerd. Dit rapport geeft een korte beschrijving van elk van de richtlijnen en beschrijft het doel van de richtlijnontwikkeling, een samenvatting van de uiteindelijke aanbevelingen en de toegevoegde waarde van het kosten-effectiviteitsonderdeel. Aanvullend hierop heeft het iMTA een apart onderzoek geïnitieerd, waarin de evaluatie van zowel het proces als de uitkomsten van het richtlijnenprogramma centraal stonden. Dit onderzoek heeft geleid tot concrete aanbevelingen, welke tevens in dit rapport beschreven zijn. Naast de werkzaamheden aan de richtlijnontwikkeling op zich heeft het iMTA twee producten vervaardigd, die bij de richtlijnontwikkeling in de toekomst van nut kunnen zijn. Er is een handboek voor evaluatie- studies in de gezondheidszorg gepubliceerd, dat met name goed toegankelijk is voor die leden van richtlijncommissies, die nog geen kennis hebben genomen van het terrein van kosten-effectiviteitsanalyses. Daarnaast is een meetinstrument ontwikkeld voor het waarderen van productieverliezen bij betaald en onbetaald werk, hetgeen kan worden ingezet voor het schatten van indirecte kosten

Bevordering van snelle en gerichte verwijzing van patienten met een mogelijk hartinfarct door ECG thuis

Snelle en adequate behandeling van patiënten met een hartinfarct is levensreddend en beperkt de schade aan de hartspier (infarctgrootte). Niet alleen de duur, maar ook de kwaliteit van het leven na een infarct wordt zo verbeterd. Levensbedreigende ritmestoornissen, met name ventrikelfibrilleren, kunnen worden gedetecteerd door middel van elektrocardiografische bewaking, en kunnen doorgaans adequaat worden behandeld met defibrillatie en resusc

Isolated or non-isolated duodenal obstruction: Perinatal outcome following prenatal or postnatal diagnosis

Objectives To determine whether the pre- or postnatal diagnosis of either isolated or non-isolated duodenal obstruction (DO) is associated with different outcomes. Methods A single-center retrospective analysis was carried out of 91 cases diagnosed with a DO between January 1991 and June 2003. Data on the diagnosis, treatment and outcomes of the cases were gathered, and differences between the groups were analyzed. Results Twenty-eight cases of DO were diagnosed before and 63 after birth. Of 15 presumed isolated cases in the prenatally diagnosed group, four revealed associated or chromosomal anomalies after birth. The types of obstruction present were significantly different between the prenatally (n = 11) and postnatally (n = 27) detected subsets of isolated DO. The prenatally detected subset displayed a lower median gestational age at delivery, lower median birth weight and a higher prematurity rate (8/11 vs. 8/27). The diagnosis of DO occurred significantly later in the postnatally detected subset than the postnatal confirmation of the diagnosis in the prenatally detected cases. In the non-isolated cases of DO, no difference was found in the type of chromosomal or associated anomaly or the type of obstruction between the prenatally detected (n = 17) and postnatally detected subsets (n = 36). Trisomy 21 was present in 7/17 (41%) vs. 22/36 (61%) cases, respectively. Two terminations and three intrauterine deaths occurred in the prenatal non-isolated subset. The liveborn infants from the prenatally detected non-isolated subset (n = 12) showed a significantly higher prematurity rate (9/12 vs.14/36), lower median birth weight and earlier confirmation of diagnosis after delivery. After surgery, outcome was similar between both subsets of isolated and non-isolated DO. All the infants with an isolated DO survived. Neonatal death occurred in three prenatally and five postnatally diagnosed cases with non-isolated DO. Conclusions The outcome of prenatally and postnatally diagnosed DO is not essentially different despite more prematurity and a lower birth weight in the former. Of the prenatally detected cases of DO assumed to be isolated, 25% revealed additional chromosomal or associated anomalies after delivery, which influenced outcome. Copyrigh

Phenotypic Variability Associated with a Large Recurrent 1q21.1 Microduplication in a Three-Generation Family

Item does not contain fulltextRecurrent copy number variants of the q21.1 region of chromosome 1 have been associated with variable clinical features, including developmental delay, mild to moderate intellectual disability, psychiatric and behavioral problems, congenital heart malformations, and craniofacial abnormalities. A subset of individuals is clinically unaffected. We describe a unique 3-generation family with a large recurrent 1q21.1 microduplication (BP2-BP4). Our observations underline the incomplete penetrance and phenotypic variability of this rearrangement. We also confirm the association with congenital heart malformations, chronic depression, and anxiety. Furthermore, we report a broader range of dysmorphic features. The extreme phenotypic heterogeneity observed in this family suggests that additional factors modify the clinical phenotype

Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction

OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease. DESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service. METHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not. MAIN OUTCOME MEASUREMENTS: Identification of pati

Pre-hospital thrombolytic therapy with either alteplase or streptokinase.

OBJECTIVE: To assess the practical application, safety and long-term outcome of pre-hospital thrombolytic intervention with either alteplase or streptokinase in patients with extensive myocardial infarction. DESIGN: Prospective study. SUBJECTS: Patients with chest pain of more than 30 min duration, presenting within 6 h of symptom onset and with electrocardiographic evidence of extensive evolving myocardial infarction. METHODS: Eligibility of patients was established by the general practitioner or the ambulance nurse using a standardized questionnaire with (contra-) indications for thrombolytic therapy. Computerized ECG was recorded by ambulance nurses. In the presence of extensive ST segment elevation (sum ST deviation of at least 1.0 mV), eligible patients received either 100 mg alteplase (n = 246) or 50 mg alteplase in the ambulance followed by 0.75 x 10(6) IE streptokinase in hospital (n = 90), or 1.5 x 10(6) IE streptokinase intravenously (n = 193). MAIN OUTCOME MEASUREMENTS: Death and life-threatening complications (ventricular fibrillation, cardiac arrest) and side effects (hypotension, allergic reactions) during transportation to hospital and in the first 24 h following hospitalization, and survival up to 5 years follow-up. RESULTS: From 1988-1993, 529 patients received thrombolytic treatment initiated pre-hospital. The time gained by pre-hospital administration of thrombolysis amounted to 50 min. The rate of complications during transportation and during the first 24 h after hospitalization was low. Hospital mortality was 2% and 1-year mortality 3%. Cumulative survival at 5 years was 92%. This was superior to the 84% 5-year survival observed in a matched group of 239 patients with similar baseline characteristics treated with alteplase in hospital. CONCLUSIONS: Pre-hospital administration of either alteplase or streptokinase is feasible an