Search

Background The 1-hour rule-out high-sensitive cardiac troponin T protocol (hs-cTnT), in which a serial troponin measurement is performed 1 hour after the first to assess the possibility of acute coronary syndrome (ACS), has been implemented in the European guidelines in 2015. Our aim was to assess the safety of this protocol in low-risk patients in the Emergency Department (ED) when implemented in daily practice. Methods Patients with acute chest pain presenting to the ED of our hospital and younger than 75 years were included (May 2013 to October 2014, The Netherlands). Hs-cTnT was measured at presentation (T0) and 1-1.5 hours after T0 (T1). Patients with a first troponin (T0) ≥ 0.012 ug/l were excluded. Primary endpoint was the 6-week occurrence of major adverse cardiac events (MACEs), defined as unstable angina, acute myocardial infarction (AMI), percutaneous coronary intervention, significant stenosis managed conservatively, coronary artery bypass grafting, and death. Results Of the 374 analyzed patients, 16 patients (4.3%) developed 35 MACE. Of these 16 patients with endpoints, 3 were primarily discharged with noncardiac chest pain but returned within 6 weeks with unstable angina. Importantly, no patients experienced an AMI or died during follow-up. Conclusion No AMIs or deaths occurred after introducing the 1-hour hs-cTnT protocol to rule-out ACS in chest pain patients, but other MACE such as unstable angina occurred. Our results suggest the protocol is safe to implement in the ED in The Netherlands.

Objective: To evaluate the occurrence and prognostic relevance of seizures in adults with community-acquired bacterial meningitis. Methods: An observational cross-sectional study, in which patients with seizures are selected from a prospective nationwide cohort of 696 episodes of community-acquired bacterial meningitis, confirmed by culture of CSF in patients aged > 16 years. We retrospectively collected data on EEGs. Results: Seizures occurred in 121 of 696 episodes (17%). Death occurred in 41% of patients with seizures compared to 16% of patients without seizures (p

Objective. The decision whether and when to perform a relaparotomy in secondary peritonitis is largely subjective and based on professional experience. No existing scoring system aids in this decisional process. Our aim was to search for variables that could predict positive findings at relaparotomy. Design. Retrospective, clinical study. Setting. Tertiary university hospital. Patients: Two hundred and nineteen patients of a consecutive series who underwent an emergency laparotomy for secondary peritonitis. Interventions. None. Sequential prediction models were constructed by accumulation of clinical information in chronological order using logistic regression to determine the strength of association between predictive variables and positive findings at relaparotomy outcome. Positive findings were defined as persistent peritonitis or a new infectious focus at relaparotomy. Measurements and Main Results. Relaparotomy (planned or on demand) for secondary peritonitis was performed in 117 of 219 patients (53%), yielding either positive (n = 62) or negative (n = 55) findings. Discriminatory power for positive findings at relaparotomy improved in the successive (multivariate) models: general patient characteristics (area under the curve, 0.60; 95% confidence interval, 0.52-0.68), adding peritonitis-related variables (area under the curve, 0.73; 95% confidence interval, 0.66-0.80), adding operation-related variables (area under the curve, 0.74; 95% confidence interval, 0.67-0.81), and adding postoperative variables (area under the curve, 0.87; 95% confidence interval, 0.82-0.92). Bootstrap resampling reduced the areas under the curve of the subsequent models only slightly. Sensitivity and specificity of the final model were 82% and 76%, respectively, at a total error rate of 16%. One preoperative predictor and five postoperative predictors significantly increased the need for relaparotomy: younger age, decreased hemoglobin levels, temperature >39 degrees C, lower Pao(2)/FIO2 ratio, increased heart rate, and increased sodium levels. Conclusions: These data suggest that the causes of secondary peritonitis and findings at emergency laparotomy for peritonitis are poor indicators for whether patients will need a relaparotomy. Factors indicative of progressive or persistent organ failure during early postoperative follow-up are the best indicators for ongoing infection and associated positive findings at relaparotomy

BACKGROUND AND AIMS: Colonoscopy is the best available method to detect and remove colonic polyps and therefore serves as the gold standard for less invasive tests such as virtual colonoscopy. Although gastroenterologists agree that colonoscopy is not infallible, there is no clarity on the numbers and rates of missed polyps. The purpose of this systematic review was to obtain summary estimates of the polyp miss rate as determined by tandem colonoscopy. METHODS: An extensive search was performed within PUBMED, EMBASE, and the Cochrane Library databases to identify studies in which patients had undergone two same-day colonoscopies with polypectomy. Random effects models based on the binomial distribution were used to calculate pooled estimates of miss rates. RESULTS: Six studies with a total of 465 patients could be included. The pooled miss rate for polyps of any size was 22% (95% CI: 19-26%; 370/1,650 polyps). Adenoma miss rate by size was, respectively, 2.1% (95% CI: 0.3-7.3%; 2/96 adenomas > or =10 mm), 13% (95% CI: 8.0-18%; 16/124 adenomas 5-10 mm), and 26% (95% CI: 27-35%; 151/587 adenomas 1-5 mm). Three studies reported data on nonadenomatous polyps: zero of eight nonadenomatous polyps > or =10 mm were missed (0%; 95% CI: 0-36.9%) and 83 of 384 nonadenomatous polyps or =10 mm, but the miss rate increases significantly in smaller sized polyps. The available evidence is based on a small number of studies with heterogeneous study designs and inclusion criteria

Introduction: Familial hypercholesterolemia (FH) is a hereditary disease that warrants early diagnosis to prevent premature cardiovascular disease (CVD) by initiating therapy. A definitive diagnosis is made by demonstrating a causal mutation. This might not only increase therapy adherence, but is also an important requirement for cascade screening. However, DNA analysis is costly and careful selection of subjects is important. Unfortunately, the accuracy of current selection criteria is poor. Hypothesis: We set out to develop a model to predict the presence of an FH causing mutation in persons referred by general practitioners. Methods: All participants in the Dutch FH screening program from January 1994 till January 2014 were included. Cross-sectional data was available on medical history, lipid profile and DNA analysis. The primary outcome was the presence of a deleterious FH mutation. We developed a prediction model using multivariable logistic regression analysis. Results: Our study population consisted of 25,809 FH patients and 38,297 unaffected relatives. Our final model included age, gender, levels of LDL-cholesterol, HDL-cholesterol and triglycerides, history of CVD, use of statins and other lipid lowering therapy, smoking and alcohol. The performance was good: the area under the receiver operating characteristic curve (AUC) was 85.2% (95% CI: 84.9 - 85.5). The model was well calibrated with a slope of 1.02 (1 is optimal). Internal validation was excellent: the AUC was unaltered in 100 bootstrap samples. The performance of the model can be illustrated by selecting subjects with a predicted probability of 30% or lower. This would identify 87.0% of all unaffected subjects, and avoid testing in 46.1% of the population. Conclusions: We developed a model to predict the presence of a deleterious FH mutation in subjects referred by general practitioners. Our model showed good discrimination and calibration, with no signs of overfitting during internal validation. After external validation, we will develop an interactive web-based calculator or smart phone application that can be used to calculate the probability of the presence of an FH mutation in individual subjects and will facilitate the use of our prediction model in daily clinical practice.