Noninvasive assessment of patients undergoing percutaneous intervention in myocardial infarction

FUNDAMENTO: A reestenose pós-intervenção coronariana percutânea primária permanece um problema de relevância clínica, mesmo com o implante de stents. A capacidade das provas não invasivas para detecção de reestenose não foi totalmente demonstrada. OBJETIVO: Avaliar a habilidade do teste ergométrico (TE) e da cintilografia de perfusão miocárdica (CPM) no diagnóstico de reestenose em pacientes com infarto agudo do miocárdio, e supradenivelamento do segmento ST, submetidos à angioplastia coronariana percutânea primária (ACPP), com implante de stent nas primeiras 12 horas de evolução. MÉTODOS: De Ago/2003-Jan/2006, foram selecionados 64 pacientes (ps) (56,2 ± 10,2 anos, 53 homens) submetidos à ACPP. Apenas ps com fração de ejeção do ventrículo esquerdo > 40,0%, definida por ecocardiograma de repouso, foram incluídos. Teste ergométrico, com as 12 derivações do ECG associadas a precordiais direitas, e CPM foram realizados 6 semanas, 6 meses e um ano após o tratamento. Foi realizada cinecoronariografia no 6º mês. RESULTADOS: Doença uniarterial ocorreu em 46,9% dos ps, sendo a artéria descendente anterior tratada em 48,4%. Reestenose angiográfica ocorreu em 28,8%. Sensibilidade, especificidade, valor preditivo positivo (VPP), valor preditivo negativo (VPN) e acurácia do TE para detecção de reestenose não foram significativos. A adição de derivações precordiais direitas não proporcionou informações adicionais. Sensibilidade, especificidade, VPP, VPN e acurácia da CPM apresentaram correlação com reestenose apenas no 6º mês, considerando-se summed difference score > 2 (p = 0,006) e > 4 (p = 0,014). CONCLUSÃO: O TE não discriminou reestenose. A CPM realizada no 6º mês foi relacionada à reestenose e mostrou-se útil durante a evolução.BACKGROUND: Restenosis after primary percutaneous coronary intervention (PPCI) remains an important clinical problem, even with stent implantation. The ability of noninvasive testing to diagnose restenosis has had only inconsistent demonstration. OBJECTIVE: Our objective was to evaluate the ability of exercise treadmill testing (ETT) and myocardial perfusion imaging (MPI) to diagnose restenosis in patients treated by PPCI within 12 hours of ST-elevation myocardial infarction (STEMI). METHODS: From August 2003 to January 2006, 64 patients (mean age of 56.2±10.2 years, 53 males) were enrolled after PPCI. Only patients with left ventricular ejection fraction (LVEF) > 40%, as assessed by resting transthoracic echocardiography (TTE), were included. ETT with 12-lead ECG monitoring and right precordial leads, as also MPI were performed at 6 weeks, 6 months, and one year after intervention. Coronary angiography was performed at six months. RESULTS: Single-vessel disease was observed in 46.9% of the patients. The left anterior descending coronary artery was treated in 48.4% of the patients. Angiographic restenosis occurred in 28.8%. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of ETT in detecting restenosis were not significant. Right precordial leads did not add information. MPI sensitivity, specificity, PPV, NPV, and accuracy correlated with restenosis only in the 6-month follow-up, both when considering summed difference score >2 (p=0.006) and >4 (p=0.014). CONCLUSION: ETT did not discriminate restenosis in this population. MPI performed at 6 months correlated with restenosis and proved useful during follow-up

Apparent diffusion coefficient restriction in the white matter: going beyond acute brain territorial ischemia

BACKGROUND: Reduction of apparent diffusion coefficient (ADC) values in white matter is not always ischaemic in nature. METHODS: We retrospectively analysed our MRI records featuring reduced ADC values in the centrum semiovale without grey matter involvement or significant vasogenic oedema. RESULTS: Several conditions showed the aforementioned MR findings: moose-horn lesions on coronal images in X-linked Charcot-Marie-Tooth disease; small fronto-parietal lesions in Menkes disease; marked signal abnormalities in the myelinised regions in the acute neonatal form of maple syrup urine disease; strip-like involvement of the corpus callosum in glutaric aciduria type 1; persistent periventricular parieto-occipital abnormalities in phenylketonuria; diffuse signal abnormalities with necrotic evolution in global cerebral anoxia or after heroin vapour inhalation; almost completely reversible symmetric fronto-parietal lesions in methotrexate neurotoxicity; chain-like lesions in watershed ischaemia; splenium involvement that normalises in reversible splenial lesions or leads to gliosis in diffuse axonal injury. CONCLUSION: Neuroradiologists must be familiar with these features, thereby preventing misdiagnosis and inappropriate management

Inequalities in Stroke Patients' Management in English Public Hospitals: A Survey on 200,000 Patients

Background: According to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.Aim of the study: To describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.Methods: We collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.Results: In English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P < 0.001), male (P=0.012), and least socio-economically deprived patients (P=0.001), as well as patients with fewer comorbidities (P < 0.001) appear to have more chance of being selected for a brain scan.Conclusion: Some English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities

Transient ischaemic attack (TIA) knowledge in general practice: a cross-sectional study of Western Adelaide general practitioners

Extent: 9p.Background: With evidence to support early assessment and management of TIAs, the role of the general practitioner (GP) needs to be considered in developing a TIA service in Western Adelaide. We thus aimed to determine GP knowledge of TIA assessment and management and identify perceived barriers, in order to tailor subsequent GP education and engage primary care in the co-ordinated care of TIA patients. Findings: A self-administered questionnaire was mailed to all GPs (n = 202) in the Adelaide Western General Practice Network. Response frequencies were calculated for all variables, and associations examined by univariate analysis. 32 GPs responded. All respondents correctly identified early risk of stroke following a TIA. Difficulty accessing neurological expertise was identified as a barrier (40.6 %), as was a lack of GP knowledge (18.8 %). Areas for improvement included access to neurologists (36.7 %), relevant guidelines and education (43.3 %). Conclusions: Diagnosis of TIA is difficult and this study highlights the need for further education and practical guidelines for GPs. With this training, GPs could be better equipped to assess and manage TIAs effectively in the community in consultation with stroke physicians.Elaine Stephanie Leung, Monica Anne Hamilton-Bruce, Cate Price and Simon A. Kobla

Firms reaction to environmental regulation

International agreements arising from the need to deal with the global warming promoted by countries decided to embrace a climate change policy bring on the debate of the impacts on firms in a global competitive market. Facing, therefore, different environmental standards accordingly to firm’s physical location. Once European Union is taking the lead in adopting stringent environmental regulation, this study aims to assess the impact of environmental regulations on firms in Europe. A novel database was constructed providing firm-level air pollution emission information in the European Union. Using difference-in-difference model, the effect of the intervention of EU environmental policy change suggests a negative response in fixed assets among EU firms due to the 2006 EU policy. The evidence to the hypothesis that firms in European Union have been decreasing its firms fixed assets, as a proxy of production capacity, with the change in environmental regulation, provides general support for the PHH, however, it doesn’t remain in robustness checks. The contribution of this work is bringing a revisited view of the actual effect of environmental regulation based on Kyoto Protocol directives on European firms