Which diagnostic tests are most useful in a chest pain unit protocol?

Background The chest pain unit (CPU) provides rapid diagnostic assessment for patients with acute, undifferentiated chest pain, using a combination of electrocardiographic (ECG) recording, biochemical markers and provocative cardiac testing. We aimed to identify which elements of a CPU protocol were most diagnostically and prognostically useful. Methods The Northern General Hospital CPU uses 2–6 hours of serial ECG / ST segment monitoring, CK-MB(mass) on arrival and at least two hours later, troponin T at least six hours after worst pain and exercise treadmill testing. Data were prospectively collected over an eighteen-month period from patients managed on the CPU. Patients discharged after CPU assessment were invited to attend a follow-up appointment 72 hours later for ECG and troponin T measurement. Hospital records of all patients were reviewed to identify adverse cardiac events over the subsequent six months. Diagnostic accuracy of each test was estimated by calculating sensitivity and specificity for: 1) acute coronary syndrome (ACS) with clinical myocardial infarction and 2) ACS with myocyte necrosis. Prognostic value was estimated by calculating the relative risk of an adverse cardiac event following a positive result. Results Of the 706 patients, 30 (4.2%) were diagnosed as ACS with myocardial infarction, 30 (4.2%) as ACS with myocyte necrosis, and 32 (4.5%) suffered an adverse cardiac event. Sensitivities for ACS with myocardial infarction and myocyte necrosis respectively were: serial ECG / ST segment monitoring 33% and 23%; CK-MB(mass) 96% and 63%; troponin T (using 0.03 ng/ml threshold) 96% and 90%. The only test that added useful prognostic information was exercise treadmill testing (relative risk 6 for cardiac death, non-fatal myocardial infarction or arrhythmia over six months). Conclusion Serial ECG / ST monitoring, as used in our protocol, adds little diagnostic or prognostic value in patients with a normal or non-diagnostic initial ECG. CK-MB(mass) can rule out ACS with clinical myocardial infarction but not myocyte necrosis(defined as a troponin elevation without myocardial infarction). Using a low threshold for positivity for troponin T improves sensitivity of this test for myocardial infarction and myocardial necrosis. Exercise treadmill testing predicts subsequent adverse cardiac events

Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective. Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom. Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance. Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service. Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, –7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (–£56 to £210, P = 0.252). Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care

Microtubule-dependent Organization of Vaccinia Virus Core-derivd Early mRNAs into Distinct Cytoplasmic Structures.

Vaccinia virus (vv) early transcription can be reconstituted in vitro from purified virions; in this assay mRNAs are made inside the viral core and subsequently extruded. Although the in vitro process has been extensively characterized, relatively little is known about vv early transcription in vivo. In the present study the fate of vv early mRNAs in infected HeLa cells was followed by BrUTP transfection and confocal and electron microscopy. The extruded vv early mRNAs were found to be organized into unique granular cytoplasmic structures that reached a size up to 1 μm. By EM these structures appeared as amorphous electron-dense cytoplasmic aggregates that were surrounded by ribosomes. Confocal images showed that the RNA structures were located some distance away from intracellular cores and that both structures appeared to be aligned on microtubules (MTs), implying that MT tracks connected mRNAs and cores. Accordingly, intact MTs were found to be required for the typical punctate organization of viral mRNAs. Biochemical evidence supported the notion that vv mRNAs were MT associated and that MT depletion severely affected viral (but not cellular) mRNA synthesis and stability. By confocal microscopy the viral mRNA structures appeared to be surrounded by molecules of the translation machinery, showing that they were active in protein synthesis. Finally, our data suggest a role for a MT and RNA-binding viral protein of 25 kDa (gene L4R), in mRNA targeting away from intracellular cores to their sites of cytoplasmic accumulation

Working capital management in the Swiss chemical industry

The investigation of Swiss chemical and pharmaceutical companies regarding their working capital management has revealed the huge potential which is lying in the management of short term assets and liabilities. Furthermore, the considerable differences between the single firms show that an optimized working capital management may play an important role for a firm’s competitiveness. A successful working apital strategy relies on the commitment and awareness of the management and on efficient working capital practices on the operative level. In addition, internal and external collaboration leads to more competitiveness, both for the firm as well as for the whole supply chain. A consistent and ongoing monitoring ensures sustainable improvements, and can be supported and enhanced by a benchmarking analysis and the adaption of best practices

Psychometric properties and the prevalence, intensity and causes of oral impacts on daily performance (OIDP) in a population of older Tanzanians

BACKGROUND: The objective was to study whether a Kiswahili version of the OIDP (Oral Impacts on Daily Performance) inventory was valid and reliable for use in a population of older adults in urban and rural areas of Tanzania; and to assess the area specific prevalence, intensity and perceived causes of OIDP. METHOD: A cross-sectional survey was conducted in Pwani region and in Dar es Salaam in 2004/2005. A two-stage stratified cluster sample design was utilized. Information became available for 511 urban and 520 rural subjects (mean age 62.9 years) who were interviewed and participated in a full mouth clinical examination in their own homes. RESULTS: The Kiswahili version of the weighted OIDP inventory preserved the overall concept of the original English version. Cronbach's alpha was 0.83 and 0.90 in urban and rural areas, respectively, and the OIDP inventory varied systematically in the expected direction with self-reported oral health measures. The respective prevalence of oral impacts was 51.2% and 62.1% in urban and rural areas. Problems with eating was the performance reported most frequently (42.5% in urban, 55.1% in rural) followed by cleaning teeth (18.2% in urban, 30.6% in rural). More than half of the urban and rural residents with impacts had very little, little and moderate impact intensity. The most frequently reported causes of impacts were toothache and loose teeth. CONCLUSION: The Kiswahili OIDP inventory had acceptable psychometric properties among non-institutionalized adults 50 years and above in Tanzania. The impacts affecting their performances were relatively common but not very severe

Validity and reliability of the Oral Impacts on Daily Performance (OIDP) frequency scale: a cross-sectional study of adolescents in Uganda

BACKGROUND: Assessing oral health related quality of life impact of mouth in adolescents is a relatively ignored area in dental research. This study aimed to examine reliability and validity of an abbreviated version of the oral impact of daily performance (OIDP) questionnaire and to analyse the interrelationship among OIDP scores, socio-demographic characteristics and oral health status in Uganda. METHOD: 1146 adolescents (mean age 15.8, response rate 87%) attending secondary schools in Kampala (urban) and Lira (rural) completed a survey instrument designed to measure subjective oral health indicators including the eight-item OIDP frequency scores. A clinical examination was conducted among 372 students (mean age 16.3, response rate 72%) and caries was assessed following the World Health Organisation criteria (1997). RESULTS: 62% of the students experienced at least one oral impact during the 6 months preceding the survey. Cronbach's alpha for the OIDP frequency items was 0.91 and the corrected item-total correlation ranged from 0.62 to 0.75. Discriminant and construct validity were demonstrated in that the OIDP scores varied systematically in the expected direction with missing teeth and self-report indicators of oral health status, respectively. Socio-demographics and dental attendance did not predict OIDP through interaction with clinical indicators but varied systematically and independently with OIDP frequency scores in the multivariate analysis. CONCLUSION: the OIDP frequency score have acceptable psychometric properties in the context of an oral health survey among Ugandan adolescents. Some evidence of the importance of social and personal characteristics in shaping adolescents' responses to oral disorders was provided

Success in periodontology: An evolutive concept

AimThe purpose of this editorial was to discuss a definition of success after periodontal therapy based on the retention of natural dentition.Materials and MethodsBased on topic and relevance, references were collected and then divided into four categories: (a) the influence of available therapeutic techniques on the definition of hopeless teeth, (b) the longâ term rate of tooth loss during supportive periodontal therapy, (c) the duration of time that the treatment outcomes may be considered stable and (d) patientsâ perception and satisfaction of periodontal therapy.ResultsPeriodontal therapy can change the prognosis of hopeless teeth, making them maintainable in the long term. The rate of tooth loss can be minimized in a way that a period of 10 years or more is needed to evaluate further periodontal breakdown. In addition, patientsâ perception and satisfaction of the treatment should be considered as the main therapeutic endpoints of the provided periodontal therapy.ConclusionsDefinition of success is linked to the available therapeutic tools. Due to the recent advancement of treatment modalities, periodontally hopeless teeth can now be treated and maintained for a long period of time with health, function and patient satisfaction.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150541/1/jcpe13150.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150541/2/jcpe13150_am.pd

African swine fever virus assembles a single membrane derived from rupture of the endoplasmic reticulum

Collective evidence argues that two members of the nucleocytoplasmic large DNA viruses (NCLDVs) acquire their membrane from open membrane intermediates, postulated to be derived from membrane rupture. We now study membrane acquisition of the NCLDV African swine fever virus. By electron tomography (ET), the virion assembles a single bilayer, derived from open membrane precursors that collect as ribbons in the cytoplasm. Biochemically, lumenal endoplasmic reticulum (ER) proteins are released into the cytosol, arguing that the open intermediates are ruptured ER membranes. ET shows that viral capsid assembles on the convex side of the open viral membrane to shape it into an icosahedron. The viral capsid is composed of tiny spikes with a diameter of ∼5nm, connected to the membrane by a 6nm wide structure displaying thin striations, as observed by several complementary electron microscopy imaging methods. Immature particles display an opening that closes after uptake of the viral genome and core proteins, followed by the formation of the mature virion. Together with our previous data, this study shows a common principle of NCLDVs to build a single internal envelope from open membrane intermediates. Our data now provide biochemical evidence that these open intermediates result from rupture of a cellular membrane, the ER. © 2015 John WileyDeutsche Forschungsgemeinschaft personal grant KR2173 to Jacomine Krijnse Locker. German Andres is supported by the ‘Amarouto Program for senior scientists from the Comunidad Autónoma de Madrid’ and by grants BFU2009-08085 and AGL2013-48998-C2- 2-R from the Spanish Ministerio de Economía y CompetitividadPeer Reviewe

Expression of Epstein–Barr Virus–Encoded Small RNA (by the EBER-1 Gene) in Liver Specimens from Transplant Recipients with Post-Transplantation Lymphoproliferative Disease

Epstein-Barr virus (EBV)—associated post-transplantation lymphoproliferative disease (PTLD) develops in 1 to 10 percent of transplant recipients, in whom it can be treated by a reduction in the level of immunosuppression. We postulated that the tissue expression of the small RNA transcribed by the EBER-1 gene during latent EBV infection would identify patients at risk for PTLD. We studied EBER-1 gene expression in liver specimens obtained from 24 patients 2 days to 22 months before the development of PTLD, using in situ hybridization with an oligonucleotide probe. Control specimens were obtained from 20 recipients of allografts with signs of injury due to organ retrieval, acute graft rejection, or viral hepatitis in whom PTLD had not developed 9 to 71 months after the biopsy. Of the 24 patients with PTLD, 17 (71 percent) had specimens in which 1 to 40 percent of mononuclear cells were positive for the EBER-1 gene. In addition, 10 of these 17 patients (59 percent) had specimens with histopathological changes suggestive of EBV hepatitis. In every case, EBER-1—positive cells were found within the lymphoproliferative lesions identified at autopsy. Only 2 of the 20 controls (10 percent) had specimens with EBER-1—positive cells (P<0.001), and such cells were rare. EBER-1 gene expression in liver tissue precedes the occurrence of clinical and histologic PTLD. The possibility of identifying patients at risk by the method we describe here and preventing the occurrence of PTLD by a timely reduction of immunosuppression needs to be addressed by future prospective studies. (N Engl J Med 1992;327:1710–4.), POST-TRANSPLANTATION lymphoproliferative disease (PTLD), either polyclonal or monoclonal, complicates the clinical course of 1 to 10 percent of organ-transplant recipients.123 Immunohistochemical studies have demonstrated that the lymphoid cells within the lesions of PTLD almost invariably contain Epstein–Barr virus (EBV), primarily in a state of latent infection.4,5 The EBER-1 gene is expressed early during latent EBV infection and codes for a small messenger RNA (mRNA) expressed at up to 107 copies per cell.6 We and others have previously demonstrated the value of the detection of EBER-1 RNA for identifying EBV-infected cells in formalin-fixed paraffin-embedded tissues.7,8 In the current investigation, we used… © 1992, Massachusetts Medical Society. All rights reserved