Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest pain.

OBJECTIVE: The objective of the study is to evaluate cardiac risk factors and risk scores for prediction of coronary artery disease (CAD) and adverse outcomes in an emergency department (ED) population judged to be at low to intermediate risk for acute coronary syndrome. METHODS: Informed consent was obtained from consecutive ED patients who presented with chest pain and were evaluated with coronary computed tomography angiography (cCTA). Cardiac risk factors, clinical presentation, electrocardiogram, and laboratory studies were recorded; the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores were tabulated. Coronary computed tomography angiography findings were rated on a 6-level plaque burden scale and classified for significant CAD (stenosis ≥50%). Adverse cardiovascular outcomes were recorded at 30 days. RESULTS: Among 250 patients evaluated by cCTA, 143 (57%) had no CAD, 64 (26%) demonstrated minimal plaque (70% stenosis). Six patients developed adverse cardiovascular outcomes. Among traditional cardiac risk factors, only age (older) and sex (male) were significant independent predictors of CAD. Correlation with CAD was poor for the TIMI (r = 0.12) and GRACE (r = 0.09-0.23) scores. The TIMI and GRACE scores were not useful to predict adverse outcomes. Coronary computed tomography angiography identified severe CAD in all subjects with adverse outcomes. CONCLUSION: Among ED patients who present with chest pain judged to be at low to intermediate risk for acute coronary syndrome, traditional risk factors are not useful to stratify risk for CAD and adverse outcomes. Coronary computed tomography angiography is an excellent predictor of CAD and outcome

Adolpho Lutz and controversies over the transmission of leprosy by mosquitoes Adolpho Lutz e as controvérsias sobre a transmissão da lepra por mosquitos

During his years of study in Switzerland and Germany, Adolpho Lutz published his first articles on zoology, clinical practice, and therapeutics. In Limeira, São Paulo, he began studies on animal and human diseases caused by germs and parasites. In 1885-86, Lutz traveled to Hamburg to study the morphology of germs related to skin diseases, in conjunction with Paul Gerson Unna, one of Germany's foremost dermatologists. He proposed the inclusion of Hansen's and Koch's bacilli in a new genus. In 1889, Unna nominated his student as physician-in-chief of the Leper Settlement on Molokai Island, Hawaii. From then on, Lutz sustained the theory that the disease was transmitted by mosquitoes. He conducted research to prove this theory when he was head of the Instituto Bacteriológico de São Paulo (1893-1908) and, later, after he moved to the Instituto Oswaldo Cruz (1908-1940). Although this research was not successful, on commissions and at congresses in which he participated until his death in October 1940, he still held to his conviction that leprosy was transmitted by mosquitoes.<br>Quando estudava na Suíça e Alemanha, Adolpho Lutz publicou os primeiros trabalhos sobre zoologia, clínica e terapêutica. Em Limeira, São Paulo, iniciou estudos sobre doenças humanas e animais causadas por germes e parasitas. Em 1885-86, viajou para Hamburgo para estudar microrganismos relacionados a doenças de pele sob a orientação de Paul Gerson Unna, um dos mais renomados dermatologistas alemães. Propôs a inclusão dos bacilos de Hansen e Koch num novo gênero. Em 1889, Unna indicou seu discípulo como chefe dos serviços médicos do Leprosário de Molokai, no Havaí. Lutz passou a defender a transmissão da doença por mosquitos. Realizou pesquisas para provar esta teoria depois que assumiu a chefia do Instituto Bacteriológico de São Paulo (1893-1908) e, sobretudo, após a transferência para o Instituto Oswaldo Cruz (1908-1940). Apesar de não terem sido bem-sucedidas estas pesquisas, sustentou a transmissão da lepra por mosquitos nas comissões e congressos de que participou, até sua morte em outubro de 1940

Postoperative continuous positive airway pressure to prevent pneumonia, re-intubation, and death after major abdominal surgery (PRISM): a multicentre, open-label, randomised, phase 3 trial

Background: Respiratory complications are an important cause of postoperative morbidity. We aimed to investigate whether continuous positive airway pressure (CPAP) administered immediately after major abdominal surgery could prevent postoperative morbidity. Methods: PRISM was an open-label, randomised, phase 3 trial done at 70 hospitals across six countries. Patients aged 50 years or older who were undergoing elective major open abdominal surgery were randomly assigned (1:1) to receive CPAP within 4 h of the end of surgery or usual postoperative care. Patients were randomly assigned using a computer-generated minimisation algorithm with inbuilt concealment. The primary outcome was a composite of pneumonia, endotracheal re-intubation, or death within 30 days after randomisation, assessed in the intention-to-treat population. Safety was assessed in all patients who received CPAP. The trial is registered with the ISRCTN registry, ISRCTN56012545. Findings: Between Feb 8, 2016, and Nov 11, 2019, 4806 patients were randomly assigned (2405 to the CPAP group and 2401 to the usual care group), of whom 4793 were included in the primary analysis (2396 in the CPAP group and 2397 in the usual care group). 195 (8\ub71%) of 2396 patients in the CPAP group and 197 (8\ub72%) of 2397 patients in the usual care group met the composite primary outcome (adjusted odds ratio 1\ub701 [95% CI 0\ub781-1\ub724]; p=0\ub795). 200 (8\ub79%) of 2241 patients in the CPAP group had adverse events. The most common adverse events were claustrophobia (78 [3\ub75%] of 2241 patients), oronasal dryness (43 [1\ub79%]), excessive air leak (36 [1\ub76%]), vomiting (26 [1\ub72%]), and pain (24 [1\ub71%]). There were two serious adverse events: one patient had significant hearing loss and one patient had obstruction of their venous catheter caused by a CPAP hood, which resulted in transient haemodynamic instability. Interpretation: In this large clinical effectiveness trial, CPAP did not reduce the incidence of pneumonia, endotracheal re-intubation, or death after major abdominal surgery. Although CPAP has an important role in the treatment of respiratory failure after surgery, routine use of prophylactic post-operative CPAP is not recommended