Objective. Oxygen (O2) have been a cornerstone in the treatment of acute myocardial infarction. Studies have been inconclusive regarding the cardiovascular and analgesic effects of oxygen in these patients. In the SOCCER trial, we compared the effects of oxygen treatment versus room air in patients with ST-elevation myocardial infarction (STEMI). There was no difference in myocardial salvage index or infarct size assessed with cardiac magnetic resonance imaging. In the present subanalysis, we wanted to evaluate the effect of O2 on chest pain in patients with STEMI. Design. Normoxic patients with first time STEMI were randomized in the ambulance to standard care with 10 l/min O2 or room air until the end of the percutaneous coronary intervention (PCI). The ambulance personnel noted the patients chest pain on a visual analog scale (VAS; 1-10) before randomization and after the transport but before the start of the PCI, and also registered the amount of morphine given. Results. 160 patients were randomized to O2 (n = 85) or room air (n = 75). The O2 group had a higher median VAS at randomization than the air group (7.0 ± 2.3 vs 6.0 ± 2.9; p = .02) and also received a higher median total dose of morphine (5.0 mg ± 4.4 vs 4.0 mg ± 3.7; p = .02). There was no difference between the O2 and air groups in VAS at the start of the PCI (4.0 ± 2.4 vs 3.0 ± 2.5; p = .05) or in the median VAS decrease from randomization to the start of the PCI (2.0 ± 2.2 vs 1.0 ± 2.9; p = .18). Conclusion. Taken together with previously published data, these results do not support a significant analgesic effect of oxygen in patients with STEMI.
Förmaksflimmer är den vanligaste ihållande arytmin och ökar markant patienternas risk för stroke, hjärtsvikt och död. Tidig antikoagulantiabehandling är av vikt då det minskar morbiditet och mortalitet. En snabb, effektiv och bra behandling på akuten vid förmaksflimmer bidrar till en bättre livskvalitet för patienten.
In STEMI patients undergoing acute PCI, we found no effect of high-flow oxygen compared with room air on the size of ischemia before PCI, myocardial salvage, or the resulting infarct size. These results support the safety of withholding supplemental oxygen in normoxic STEMI patients.
Paper I: An Artificial Neural Network (ANN) was constructed to identify ST Elevation Myocardial Infarction (STEMI) and predict the need for Percutaneous Coronary Intervention (PCI).
Paper II, III and IV: Studies suggest that O2 therapy may be harmful in STEMI patients. We therefore conducted the SOCCER study to evaluate the effects of O2 therapy in STEMI patients.
Paper I: 560 ambulance ECGs sent to the Cardiac Care Unit (CCU), was together with the CCU physicians interpretation and decision of conducting an acute PCI or not collected, and compared with the interpretation and PCI decision of the ANN.
Paper II, III, IV: Normoxic (≥94%) STEMI patients accepted for acute PCI were in the ambulance randomized to standard care with 10 L/min O2 or room air. A subset of the patients underwent echocardiography for determination of the Left Ventricular Ejection Fraction (LVEF) and the Wall Motion Score Index (WMSI). All patients had a Cardiac Magnetic Resonance Imaging (CMRI) to evaluate Myocardial area at Risk (MaR), Infarct Size (IS) and Myocardial Salvage Index (MSI).
Paper I: The area under the ANN’s receiver operating characteristics curve for STEMI detection as well as predicting the need of acute PCI were very good.
Paper II, III, IV: No significant differences could be shown in discussing MaR, MSI or IS between the O2 group (n=46) and the air group (n=49). Neither could any differences be shown for LVEF and WMSI at the index visit as well after six months between the O2 group (n=46) and the air group (n=41)
Paper I: The results indicate that the number of ECGs sent to the CCU could be reduced with 2/3 as the ANN would safely identify ECGs not being STEMI.
Paper II, III, IV: The results suggest that it is safe to withhold O2 therapy in normoxic, stable STEMI patients.
Twenty-three offenders convicted of homicide or attempted murder/manslaughter, and their respective crimes, were examined to identify any common characteristics. Court documents were assessed, and the most prominent information of the offenders was that they were often single, most of them had no psychiatric diagnoses, the most frequent modus operandi was a knife or sharp weapon (although firearms resulted in more homicides), and the most common homicide typology was domestic disputes, and disputes between friends or acquaintances. Based on a cluster analysis, two profiles emerged: one with so-called traditional criminals and another profile over-represented with offenders who commit domestic crimes.
The present findings indicate no harm or benefit of supplemental O2 on myocardial function in STEMI patients. Our results support that it is safe to withhold supplemental O2 in normoxic STEMI patients.
An ADP using the guideline recommended 0h/1h hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.
A single hs-cTnT result of less than 5 ng/L at ED presentation when combined with a nonischemic ECG result and a nonhigh risk history identified 29% of chest pain patients at a very low risk of 30-day major adverse cardiac events. A similar strategy with hs-cTnT less than or equal to 14 ng/L was associated with a higher miss rate.
A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.
Mohammad Reza Pahlavi, the Shah of Iran, was toppled in the Islamic Revolution of 1979. A year later he passed away from lymphoma, a disease he had secretly battled for several years, but still it remains unknown exactly when he was diagnosed with cancer, if he was aware of his condition and who close to him knew about his illness. Following his 1979 exile from Iran, physicians from numerous countries became involved in his treatment, which was typified by political and medical intrigues, contributing to a suboptimal and dangerous medical care which may ultimately have contributed to his death. After acute surgery of his spleen in June 1980, the Shah’s condition worsened and he eventually passed away on July 27. This study shows that the international intelligence organizations were probably aware of the Shah’s disease, and that the Shah was not cared for in accordance with good medical practice.
It is possible to estimate the level of crowding based on workload in Swedish EDs using data from the patient log system. Our model may be applicable to EDs with different sizes and characteristics, and may be used for continuous monitoring of ED workload. Before widespread use, additional validation of the model is needed.
Even though oxygen therapy is a part of standard care, oxygen may not be beneficial for patients with AMI and is possibly even harmful. The results of the present and concurrent oxygen trials may change international treatment guidelines for patients with AMI or ischemia.
The majority of patients who present to the Emergency Department with vertigo suffer from benign conditions. However, a few percent of these patients have life-threatening conditions, such as a cerebellar stroke. The HINTS clinical decision rule (Head-Impulse test, Nystagmus, Test-of-Skew) allows the physician to identify patients with an acute vestibular syndrome of central origin. HINTS is more sensitive than early magnetic resonance imaging. There is no role for computed tomography in the evaluation of patients with isolated acute vestibular syndrome in the Emergency Department. For patients with benign paroxysmal positional vertigo, simple reposition maneuvers are effective for symptom relief.
A digital rectal examination (DRE) is standard practice in cases of acute abdomen in adult patients. We analyzed the evidence for this by a systematic literature search, and identified 16 relevant original studies. These studies showed that there is no evidence for a diagnostic value of DRE in adult patients with acute abdomen. We should stop doing routine DRE in adult cases of acute abdomen.
Our results indicate that there is a circadian variation in the likelihood of ACS among ED chest pain patients, and suggest that physicians should consider the time of presentation to the ED when determining the likelihood of ACS.
Our ANN had an excellent ability to predict STEMI and the need of acute PCI in ambulance ECGs, and has a potential to safely reduce the number of ECG transmitted to the CCU by almost two thirds.