by Paul Rega, MD — published on August 1st, 2008
Intro: At least in Montreal, this study helps to calm nervous parents whose kids just got stuck with a needle they found in the street.
Pediatric Injuries From Needles Discarded in the Community: Epidemiology
and Risk of Seroconversion
Jesse Papenburg, Denis Blais, Dorothy Moore, Mohammed Al-Hosni, Celine
Laferriere, Bruce Tapiero, and Caroline Quach
Pediatrics 2008;122 e487-e492
ABSTRACT
OBJECTIVES. Although anxiety exists concerning the perceived risk of transmission of bloodborne viruses after community-acquired needlestick injuries, seroconversion seems to be rare. The objectives of this study were to describe the epidemiology of pediatric community-acquired needlestick injuries and to estimate the risk of seroconversion for HIV, hepatitis B virus, and hepatitis C virus in these events.
METHODS. The study population included all of the children presenting with community-acquired needlestick injuries to the Montreal Children’s Hospital between 1988 and 2006 and to Hôpital Sainte-Justine between 1995 and 2006. Data were collected prospectively at Hôpital Sainte-Justine from 2001 to 2006. All of the other data were reviewed retrospectively by using a standardized case report form.
RESULTS. A total of 274 patients were identified over a period of 19 years. Mean age was 7.9 ± 3.4 years. A total of 176 (64.2%) were boys. Most injuries occurred in streets (29.2%) or parks (24.1%), and 64.6% of children purposely picked up the needle. Only 36 patients (13.1%) noted blood on the device. Among the 230 patients not known to be immune for hepatitis B virus, 189 (82.2%) received hepatitis B immunoglobulin, and 213 (92.6%) received hepatitis B virus vaccine. Prophylactic antiretroviral therapy was offered beginning in 1997. Of the 210 patients who presented thereafter, 82 (39.0%) received chemoprophylaxis, of whom 69 (84.1%) completed a 4-week course of therapy. The use of a protease inhibitor was not associated with a significantly higher risk of adverse effects or early discontinuation of therapy. At 6 months, 189 were tested for HIV, 167 for hepatitis B virus, and 159 for hepatitis C virus. There were no seroconversions.
CONCLUSIONS. We observed no seroconversions in 274 pediatric community-acquired needlestick injuries, thereby confirming that the risk of transmission of bloodborne viruses in these events is very low.
by Paul Rega, MD — published on August 1st, 2008
Intro: We’ve all seen kids in the ER with chronic abdominal pain. You do a workup, despite the fact that the kid looks great and despite the fact that the kid has had negative workups time and time again. Your results, also, come back negative and that further frustrates the parents and if looks could kill, you’d be 6-foot-deep by now. Anyway, at least in the Netherlands, there is an attempt to resolve the problem with alternative medicine.
Use of Complementary and Alternative Medicine by Pediatric Patients With
Functional and Organic Gastrointestinal Diseases: Results From a
Multicenter Survey
Arine M. Vlieger, Marjolein Blink, Ellen Tromp, and Marc A. Benninga
Pediatrics 2008;122 e446-e451
ABSTRACT
OBJECTIVES. Many pediatric patients use complementary and alternative medicine, especially when facing a chronic illness for which treatment options are limited. So far, research on the use of complementary and alternative medicine in patients with functional gastrointestinal disease has been scarce. This study was designed to assess complementary and alternative medicine use in children with different gastrointestinal diseases, including functional disorders, to determine which factors predicted complementary and alternative medicine use and to assess the willingness of parents to participate in future studies on complementary and alternative medicine efficacy and safety.
PATIENTS AND METHODS. The prevalence of complementary and alternative medicine use was assessed by using a questionnaire for 749 children visiting pediatric gastroenterology clinics of 9 hospitals in the Netherlands. The questionnaire consisted of 35 questions on the child’s gastrointestinal disease, medication use, health status, past and future complementary and alternative medicine use, reasons for its use, and the necessity of complementary and alternative medicine research.
RESULTS. In this study population, the frequency of complementary and alternative medicine use was 37.6%. A total of 60.3% of this group had used complementary and alternative medicine specifically for their gastrointestinal disease. This specific complementary and alternative medicine use was higher in patients with functional disorders than organic disorders (25.3% vs 17.2%). Adverse effects of allopathic medication, school absenteeism, age <11 years, and a low effect of conventional treatment were predictors of specific complementary and alternative medicine use. Almost all (93%) of the parents considered it important that pediatricians initiate complementary and alternative medicine research, and 51% of parents were willing to participate in future complementary and alternative medicine trials.
CONCLUSIONS. Almost 40% of parents of pediatric gastroenterology patients are turning to complementary and alternative medicine for their child. Lack of effectiveness of conventional therapy, school absenteeism, and adverse effects of allopathic medication are more important predictors of complementary and alternative medicine use than the type of gastrointestinal disease. Because evidence on most complementary and alternative medicine modalities in children with gastrointestinal disorders is lacking, there is an urgent need for research in this field.
by Paul Rega, MD — published on August 1st, 2008
Intro: Ginseng in respiratory infections. Hmmm… People swear that it works. In fact, there is a province in Canada that includes caches of ginseng for use in the event of a pandemic.
Safety and Tolerability of North American Ginseng Extract in the Treatment
of Pediatric Upper Respiratory Tract Infection: A Phase II Randomized,
Controlled Trial of 2 Dosing Schedules
Sunita Vohra, Bradley C. Johnston, Keri L. Laycock, William K. Midodzi,
Indra Dhunnoo, Evan Harris, and Lola Baydala
Pediatrics 2008;122 e402-e410
ABSTRACT
BACKGROUND. Upper respiratory tract infections are the most common childhood illness. Panax quinquefolius (American ginseng root extract) standardized to contain 80% poly-furanosyl-pyranosyl-saccharides is purported to be effective in adult upper respiratory tract infection but has not been evaluated yet in a pediatric population.
OBJECTIVES. Our primary objective was to document the safety and tolerability of 2 weight-based dosing schedules (standard dose versus low dose versus placebo) in children. We also used the Canadian Acute Respiratory Infection Flu Scale, a quantitative scoring sheet for measuring the severity and duration of upper respiratory symptoms, to establish the SD of the treatment effect to allow sample-size calculations for future clinical trials.
METHODS. We conducted a randomized, double-blind dose-finding 3-arm trial (2 dosing schedules of American ginseng extract with 1 placebo control) during the winter months (November 2005 to March 2006) in children 3 to 12 years of age.
RESULTS. Seventy-five subjects were prerecruited from the general population in Edmonton. Of these, 46 subjects developed an upper respiratory tract infection and were randomly assigned (15 standard dose, 16 low dose, and 15 placebo), with 1 subject withdrawing from the low-dose arm before beginning the intervention. No serious adverse events were reported. The frequency, severity, and degree of association between the intervention and reported adverse events were not significantly different among each of the 3 treatment arms.
CONCLUSIONS. Standard doses of ginseng were well tolerated and merit additional evaluation with regard to treatment of pediatric upper respiratory tract infection.
by Paul Rega, MD — published on August 1st, 2008
Diving-Related Injuries in Children <20 Years Old Treated in Emergency
Departments in the United States: 1990-2006
Coral Day, Uwe Stolz, Tracy J. Mehan, Gary A. Smith, and Lara B. McKenzie
Pediatrics 2008;122 e388-e394
ABSTRACT
OBJECTIVE. The purpose of this work was to comprehensively examine diving-related injuries in the United States among children and adolescents <20 years of age.
METHODS. We conducted a retrospective analysis of diving-related injury data from the National Electronic Injury Surveillance System, including patients aged <20 years old who were seen in an emergency department for a diving-related injury from 1990 through 2006.
RESULTS. An estimated 111,341 patients aged < 19 years were treated in emergency departments for diving-related injuries over the 17-year period of the study. The average annual injury rate was 8.4 injuries per 100000 US residents <20 years old. Patients aged 10 to 14 years composed the largest group (36.3%) of injured divers. Injuries to the head and/or neck (38.2%) and face (21.7%) were the most common, with the most frequent diagnoses being lacerations (33.9%) and soft tissue injuries (24.3%). Collision with a diving board and/or platform was the leading cause of injuries (43.9%). Children <10 years old had increased odds of sustaining a laceration, children <5 years old had increased odds of injury to the face, and 10- to 19-year-olds had increased odds of sustaining a fracture or an injury to the extremities. The odds of injury caused by contact with the diving board dramatically increased if the child was performing a flip and/or handstand or a backward dive.
CONCLUSIONS. To our knowledge, this is the first study to examine recreational and competitive diving-related injuries among children and adolescents using a nationally representative sample. These results can help inform pediatricians, parents, coaches, and trainers regarding injuries seen during recreational and competitive diving and can help guide future prevention efforts.
by Paul Rega, MD — published on August 1st, 2008
Intro: ALTEs are scary events to work through in an ER. This study suggests a tox screen to help with the work-up. Unfortunately, many of the drugs implicated in this study will not be found in a routine tox screen.
Accidental and Nonaccidental Poisonings as a Cause of Apparent
Life-Threatening Events in Infants
Raymond D. Pitetti, Emily Whitman, and Abigail Zaylor
Pediatrics 2008;122 e359-e362
ABSTRACT
BACKGROUND. Apparent life-threatening events are a relatively common event in children for which there may be a number of causes. Previous reports have suggested that poisonings, either accidental or intentional, may be causes of some events. However, this theory has not been systematically studied.
METHODS. We conducted a prospective, descriptive study of infants aged <2 years presenting to a pediatric emergency department of a large, urban tertiary care children’s hospital with signs and symptoms of an apparent life-threatening event. All of the children presenting with an apparent life-threatening event were to undergo a standardized evaluation, which included obtaining a comprehensive urine toxicology screen. A positive toxicology screen result was defined as follows: a clinically insignificant screen result (identification of a medication that would not cause an apparent life-threatening event) or a clinically significant screen result (identification of a medication that could cause apnea or other event consistent with an apparent life-threatening event, even if it was a medication that the child was known to be taking).
RESULTS. During the study period, 596 children presented to the emergency department with an apparent life-threatening event, and 274 (46.0%) had a toxicology screen performed. Of 274 toxicology screen results, 50 were considered truly positive (18.2%), and 23 positive screen results were considered clinically significant (23 of 274 [8.4%]). Thirteen toxicology screen results were positive for an over-the-counter cold preparation (13 of 274 [4.7%]). No parent admitted to having given his or her child an over-the-counter cold preparation.
CONCLUSIONS. A substantial number of children presenting to the emergency department with an apparent life-threatening event had a positive toxicology screen result. In particular, a number of children were found to have been given an over-the-counter cold preparation. We would recommend that toxicology screens be included as part of the routine evaluation of children who present with an apparent life-threatening event.
by Paul Rega, MD — published on August 1st, 2008
Cough and Cold Medication Use by US Children, 1999-2006: Results From the
Slone Survey
Louis Vernacchio, Judith P. Kelly, David W. Kaufman, and Allen A. Mitchell
Pediatrics 2008;122 e323-e329
ABSTRACT
OBJECTIVE. Pediatric cough and cold medications are widely marketed in the United States, but the precise patterns of use among children are not known. Such information is especially important given recent reports suggesting that these medications are responsible for previously underappreciated serious adverse events and deaths among children. We sought to describe the prevalence and patterns of pediatric use of cough and cold medications, with particular attention to use among young children.
METHODS. We analyzed data on the use of cough and cold medications, defined as any oral medication that contains 
1 antitussive, decongestant, expectorant, and/or first-generation antihistamine active ingredients, among 4267 US children who were younger than 18 years and enrolled during 1999–2006 in the Slone Survey, a national random-digit-dial telephone survey of medication use by the US population.
RESULTS. In a given week, a cough and cold medication was used by 10.1% of US children. Exposure was highest to decongestants (6.3%; mostly pseudoephedrine) and first-generation antihistamines (6.3%; most common were chlorpheniramine, diphenhydramine, and brompheniramine), followed by antitussives (4.1%; mostly dextromethorphan) and expectorants (1.5%; almost exclusively guaifenesin). Multiple-ingredient products accounted for 64.2% of all cough and cold medications used. Exposure to antitussives, decongestants, and first-generation antihistamines was highest among 2- to 5-year-olds (7.0%, 9.9%, and 10.1%, respectively) followed by children who were younger than 2 years (5.9%, 9.4%, and 7.6%, respectively); expectorant use was low in all age groups. The use of cough and cold medications declined from 1999 through 2006.
CONCLUSIONS. Approximately 1 in 10 US children uses a cough and cold medication in a given week. The especially high prevalence of use among children of young age is noteworthy, given concerns about potential adverse effects and the lack of data on the efficacy of cough and cold medications in this age group.
by Paul Rega, MD — published on August 1st, 2008
Unexpected Infant Deaths Associated With Use of Cough and Cold Medications
Mary E. Rimsza and Susan Newberry
Pediatrics 2008;122 e318-e322
ABSTRACT
OBJECTIVE. The objective of this study was to determine whether caregivers had given infants who died unexpectedly over-the-counter cough and cold medications before the infant deaths to identify sociodemographic risk factors for their use.
METHODS. The Arizona Child Fatality Review Program reviews the circumstances surrounding every child death that occurs in the state each year. By statute, the multidisciplinary review teams have access to all medical charts, autopsy reports, law enforcement reports, and other records for their review and use these data to determine the cause of death and its preventability. The data on all infants who died unexpectedly in 2006 and had an autopsy and postmortem toxicologic studies were reviewed for this analysis.
RESULTS. Ten unexpected infant deaths that were associated with cold-medication use were identified. The infants ranged in age from 17 days to 10 months. Postmortem toxicology testing found evidence of recent administration of pseudoephedrine, antihistamine, dextromethorphan, and/or other cold-medication ingredients in these infants. The families who used these medications were poor and publicly insured, and 50% of them had limited English proficiency. Only 4 of these infants had received medical care for their current illness before their death. The over-the-counter cough and cold medication had been prescribed by a clinician for only 1 of these infants.
CONCLUSIONS. Review of these infants’ deaths raises concern about the role of the over-the-counter cough and cold medications in these deaths. These findings support the recommendation that such medications not be given to infants. In addition, these findings suggest that warnings on these medications “to consult a clinician” before use are not being followed by parents. Educational campaigns to decrease the use of over-the-counter cough and cold medications in infants need to be increased.
by Paul Rega, MD — published on August 1st, 2008
Randomized Trial of Endotracheal Tube Versus Laryngeal Mask Airway in
Simulated Prehospital Pediatric Arrest
Lei Chen and Allen L. Hsiao
Pediatrics 2008;122 e294-e297
ABSTRACT
OBJECTIVE. Proficiency in airway management in children is difficult to acquire and maintain for prehospital providers. The laryngeal mask airway is a relatively new airway device. Its ease of use makes it an attractive potential alternative to endotracheal tubes in pediatrics. The objective of this study was to investigate whether, in simulated cardiopulmonary arrests in children, the use of laryngeal mask airway, compared with endotracheal tubes, results in shorter time to effective ventilation when performed by prehospital providers.
METHODS. A randomized, crossover study was conducted in a local paramedic training program. Fifty-two emergency medical technicians agreed to participate. After a 2-hour training session, an arrest scenario was presented to each participant by using an infant-sized human patient simulator. The participants were randomly assigned first to use 1 of the 2 devices. Time to successful ventilation was recorded. Number of attempts and results were recorded. After the airway was secured successfully, the scenario was repeated with the alternative device.
RESULTS. The mean ± SD length of time to effective ventilation was 46 seconds when using endotracheal tubes and 23 seconds when using laryngeal mask airway, with a mean difference of 23 seconds. The mean number of attempts to achieve effective ventilation was 1.27 when using endotracheal tubes and 1.1 when using laryngeal mask airway. There were 9 (17%) episodes of esophageal intubations and 14 (27%) episodes of right main-stem intubations in the endotracheal tube group, and there were 5 (9.5%) episodes of malposition in the laryngeal mask airway group.
CONCLUSIONS. In simulated pediatric arrests, the use of laryngeal mask airway, compared with endotracheal tubes, led to more rapid establishment of effective ventilation and fewer complications when performed by prehospital providers.
by Paul Rega, MD — published on August 1st, 2008
Title: Girls Who Disclose Sexual Abuse: Urogenital Symptoms and Signs After
Genital Contact
Authors: Cynthia DeLago, Esther Deblinger, Christine Schroeder, and Martin A. Finkel
Journal: Pediatrics 2008;122 e281-e286
ABSTRACT
BACKGROUND. Little information is available about idiosyncratic historical details provided by sexually abused girls, yet this information can help medical professionals diagnose sexual abuse.
OBJECTIVES. Our goals were to describe types and frequencies of urogenital symptoms/signs reported by girls who disclosed direct genital contact and to explore factors associated with this reporting.
METHODS. We reviewed 161 medical charts of 3- to 18-year-old girls who disclosed sexual abuse by direct genital contact for urogenital symptoms/signs, type of genital contact (oral, object, digital, or genital), time interval between last perpetrator contact and physical examination, age and sexual maturity at the time of last perpetrator contact, genital findings, and other medical diagnoses. Regression analyses were performed to determine factors that were most predictive of symptom/sign reporting.
RESULTS. Many of the girls reported multiple types of genital contact; 33% reported oral/object-genital contact, 72% reported digital-genital contact, and 55% reported genital-genital contact. Sixty percent of the girls reported experiencing 1 symptom/sign; 53% of the total sample had genital pain, 37% had dysuria, and 11% had genital bleeding. Symptoms/signs were highly associated with genital-genital contact: 48% of the girls reporting genital-genital contact had dysuria compared with 25% of girls not reporting genital-genital contact, 72% had genital pain/soreness compared with 32% not reporting genital-genital contact, and 16% had bleeding compared with 4% of those not reporting genital-genital contact. Using regression analysis, the strongest factor predictive of symptom reporting by the girls was genital-genital contact.
CONCLUSIONS. Sexually abused girls who experienced direct genital contact frequently reported symptoms related to the abusive episode. These symptoms were reported most frequently with genital-to-genital contact. This information sheds some light on the mechanism of injury leading to symptom reporting and can be used to further study symptoms/signs reported by sexually abused girls compared with the general population.
by Paul Rega, MD — published on August 1st, 2008
Intro: This is a Health Advisory from the HURON COUNTY GENERAL HEALTH DISTRICT. A cluster of GI cases have been linked to La Campasina restaurant in Willard, Ohio (Huron County). To date, there are 19 cases. Twelve cases are linked to La Campasina; epidemiologists are waiting on return calls to interview the other 7 cases. For more information, please contact Angie Smith at 419-668-1652 ext: 231.
SUBJECT: Gastrointestinal Illness Outbreak Investigation
DATE/TIME SENT: 7/31/2008
URGENCY LEVEL: [ ] Health Alert [ P ] Health Advisory [ ] Health Update
FOR MORE INFORMATION CONTACT:
Beverly Morgan, Communicable Disease Nurse
Huron County General Health District
180 Milan Avenue
Norwalk, Ohio 44857
Phone: 419-668-1652, ext: 232
immunization@huroncohealth.com
SENT TO: Huron County physicians, Northwest Ohio health departments, Ashland County Health Department, Crawford County Health Department, Lorain County Health Department, Richland County Health Department
DETAILS: The Huron County General Health District is investigating a cluster of reports of gastrointestinal illness. We have interviewed 12 cases to date. The chief symptoms reported were nausea (100% reported this symptom), cramps (92%), fatigue (92%) and diarrhea (83%). Eight of the 12 respondents reported vomiting, body aches and chills. The onset of symptoms for all cases was 7/25, 7/26 or 7/27.
The investigation is ongoing. No agent has been identified nor is there a confirmed outbreak or outbreak source. However, the cases do appear to be linked. Eleven of the 12 cases interviewed to date had eaten at La Campasina in Willard on 7/23, 7/24 or 7/25. The twelfth case had taken care of her mother who had become ill after eating at La Campasina; the twelfth case reported exposure to fecal material in the course of providing that care.
If you are treating patients who experienced similar symptoms within that timeframe, please consider ordering a stool sample.
If you have questions, please call Bev Morgan, Communicable Disease Nurse at 419/668-1652 ext: 232.
by Paul Rega, MD — published on August 1st, 2008
MedScape has a discussion site and this one is dedicated to the Super User or the Frequent Flyer. Click on the link below for a look-see:
http://boards.medscape.com/forums/.29e34bbd.29e34bbb?@191.dezWaNYedOq@
by Paul Rega, MD — published on August 1st, 2008
FDA Recall, 8/1/08: Levitronix and FDA notified healthcare professionals of a Class 1 recall of the Levitronix CentriMag Extracorporeal Blood Pumping System and Primary & Backup Consoles manufactured by Levitronix, GmbH, Zurich, Switzerland and distributed from January, 2001 through March, 2008. The Blood Pumping System is used to provide short-term extracorporeal circulatory support during cardiac and other types of surgeries. This device temporarily replaces the function of the heart and lungs in order to maintain the appropriate circulation of blood and oxygen levels in the body during the surgical procedure. A July 24, 2008 Levitronix device correction letter informed physicians not to use Valleylab Force FX-C or SSE2L electrosurgery devices with the CentriMag Blood Pumping System because use may result in stoppage of the pump and may cause serious injury or death. This recall action is an interim fix while the firm further investigates the source of the problem.Read the complete MedWatch 2008 Safety summary, including links to the FDA recall notice and the Levitronix Dear Doctor letter, at:
http://www.fda.gov/medwatch/safety/2008/safety08.htm#CentriMag
by Paul Rega, MD — published on August 1st, 2008
Intro: This study concludes that chronic kidney disease is an independent predictor of MI, stroke, and death among men and women younger than age 55 and 65 years, respectively. Are we surprised by that?
TITLE: Chronic kidney disease, prevalence of premature cardiovascular disease, and relationship to short-term mortality
ABSTRACT
Background
Chronic kidney disease (CKD) is recognized as an independent cardiovascular disease (CVD) risk state, particularly in the elderly, and has been defined by levels of estimated glomerular filtration rate (eGFR) and markers of kidney damage. The relationship between CKD and CVD in younger and middle-aged adults has not been fully explored.
Methods
Community volunteers completed surveys regarding past medical events and underwent blood pressure and laboratory testing. Chronic kidney disease was defined as an eGFR <60 mL·min−1·1.73 m−2 or urine albumin-creatinine ratio (ACR) ≥30 mg/g. Premature CVD was defined as self-reported myocardial infarction or stroke at <55 years of age in men and <65 years of age in women. Mortality was ascertained by linkage to national data systems.
Results
Of 31 417 participants, the mean age was 45.1 ± 11.2 years, 75.5% were female, 36.8% African American, and 21.6% had diabetes. A total of 20.6% were found to have CKD, with the ACR and eGFR being the dominant positive screening tests in the younger and older age deciles, respectively. The prevalences of premature myocardial infarction (MI), stroke, or death, and the composite were 5.3%, 4.7%, 0.8%, 9.2%, and 2.5%, 2.2%, 0.2%, 4.2% for those with and without CKD, respectively (P < .0001 for composite). Multivariable analysis found CKD (OR 1.44, 95% CI 1.27-1.63), age (OR 1.05 [per year], 95% CI 1.04-1.06), hypertension (OR 1.61, 95% CI 1.40-1.84), diabetes (OR 2.03, 95% CI 1.79-2.29), smoking (OR 1.91, 95% CI 1.66–2.21), and less than high school education (OR 1.59, 95% CI 1.37-1.85) as the most significantly associated factors for premature CVD or death (all P < .0001). Survival analysis found those with premature MI or stroke and CKD had the poorest short-term survival over the next 3 years after screening.
Conclusions
Chronic kidney disease is an independent predictor of MI, stroke, and death among men and women younger than age 55 and 65 years, respectively. These data suggest the biologic changes that occur with kidney failure promote CVD at an accelerated rate that cannot be fully explained by conventional risk factors or older age. Screening for CKD by using both the ACR and eGFR can identify younger and middle-aged individuals at high risk for premature CVD and near-term death.
by Paul Rega, MD — published on August 1st, 2008
Intro: Does it have an impact when a NSTEMI patient presents late to the ER? This study says, “No, but that shouldn’t stop us.”
TITLE: Impact of delayed presentation on management and outcome of non–ST-elevation acute coronary syndromes
in Amer Heart J
Volume 156, Issue 2, Pages 262-268 (August 2008)
AUTHORS: Basem Elbarouni, Shaun G. Goodman, Raymond T. Yan, Amparo Casanova, Abdul Al-Hesayen, Stephen Pearce, David H. Fitchett, Anatoly Langer, Andrew T. Yan, for the Canadian ACS Registries Investigators
ABSTRACT
Background
The impact of delayed presentation on the management and outcomes of patients with non–ST-elevation acute coronary syndromes (NSTE-ACS) has not been well studied. Furthermore, the prognostic value of initial biomarker level in relation to the time of presentation has not been determined.
Methods
The Canadian ACS II registry was a national, multicenter, prospective observational study of 1,956 patients with NSTE-ACS (October 2002-December 2003). We compared the baseline characteristics, treatment, and outcomes in early (within 6 hours of symptom onset) versus late presenters (>6 hours). A logistic regression model was developed to examine the independent association of late presentation with 1-year mortality. We also evaluated the prognostic value of initial biomarker level in relation to early versus late presentation.
Results
A total of 1,219 (62.3%) patients presented early, whereas 727 (37.7%) presented late; their rates of in-hospital revascularization were similar (40.5% vs 42.5%, respectively, P = .39). There was also no significant difference in hospital mortality (1.6% vs 2.2%, P = .30) or 1-year mortality (7.6% vs 5.7%, P = .13) between early and late presenters. After adjusting for other prognosticators, late presentation was not an independent predictor of 1-year mortality (adjusted odds ratio 0.78, 95% confidence interval 0.48-1.26, P = .3). Elevated initial biomarker was independently associated with higher 1-year mortality (adjusted odds ratio 2.17, 95% CI 1.31-3.58, P = .002) regardless of whether hospital presentation was early or late (P for interaction = .74).
Conclusions
There is still considerable delay between symptom onset of NSTE-ACS and hospital presentation in the contemporary era. In contrast to studies of ST-elevation myocardial infarction, we found no significant differences in the management and outcome of early presenters as compared with late presenters with NSTE-ACS. Nevertheless, measures to reduce patient delay time should continue to be implemented. Initial biomarker status is a useful prognosticator irrespective of the delay time.
by Paul Rega, MD — published on August 1st, 2008
MedWire, 8/1/08 (http://www.medwire-news.md/38/76756/Cardiology_News/Right_bundle_branch_block_does_not_predict_mortality_in_NSTEMI.html):
“Right bundle branch block (RBBB) does not independently predict mortality in non-ST-elevation myocardial infarction (NSTEMI) patients, as it does in those with STEMI, say researchers…”
Title: Incidence and clinical impact of right bundle branch block in patients with acute myocardial infarction: ST elevation myocardial infarction versus non-ST elevation myocardial infarction
Authors: Thomas Kleemann, Claus Juenger, Anselm Kai Gitt, Rudolf Schiele, Steffen Schneider, Jochen Senges, Harald Darius, Karlheinz Seidl, for the MITRA PLUS Study Group
pages 256-261
ABSTRACT (http://www.ahjonline.com/article/S0002-8703(08)00163-4/abstract)
Background
Both left bundle branch block and right bundle branch block (RBBB) have been associated with increased inhospital and long-term mortality in patients with acute ST elevation myocardial infarction (STEMI). However, the prognostic role of RBBB in acute non-ST elevation myocardial infarction (NSTEMI) is not well known. Therefore, the aim of the study was to evaluate the incidence and clinical impact of RBBB in patients with NSTEMI compared to patients with STEMI.
Methods
From the German prospective multicenter registry “Maximal Individual Therapy of Acute Myocardial Infarction” (MITRA PLUS), 6,403 consecutive patients with NSTEMI and 20,233 patients with STEMI were analyzed. Patients with left bundle branch block were excluded. The median follow-up time for NSTEMI was 378 days and for STEMI 479 days.
Results
A total of 455 (7.1%) patients with NSTEMI and 894 (4.4%) patients with STEMI presented with RBBB on admission. In general, RBBB patients were older, more often had comorbidities, and less often received short-term inhospital treatment according to guidelines. In STEMI, RBBB patients had higher peak enzyme levels and lower left ventricular ejection fraction (LV-EF) than patients without BBB. Right bundle branch block in STEMI was associated with an increased inhospital and long-term mortality. In NSTEMI, however, peak enzyme levels and LV-EF were similar in both groups with and without RBBB. Right bundle branch block in NSTEMI was not independently associated with a worse outcome.
Conclusions
Unlike RBBB in STEMI, RBBB in NSTEMI is not an independent predictor of inhospital and long-term mortality.
