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The occurrence of coronary occlusion in patients without protocol
positive ST segment elevation(1) might be attributable either to early
catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter
also being significantly(p < 0.001) commoner in non ST segment
elevation(NSTEMI) patients catheterised within 6 hours of arrival in
hospital than in STEMI counterparts also catheterised within that time
frame(...
The occurrence of coronary occlusion in patients without protocol
positive ST segment elevation(1) might be attributable either to early
catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter
also being significantly(p < 0.001) commoner in non ST segment
elevation(NSTEMI) patients catheterised within 6 hours of arrival in
hospital than in STEMI counterparts also catheterised within that time
frame(4). According to one study, there is a "higher rate of thrombotic
coronary occlusion in the first NSTEMI patients with early catheterization
than in those catheterized later"(2). That conclusion was based on an
analysis of 878 patients in whom an evaluation was made of the prevalence
of thrombotic occlusion with in time frames of 0-6 hrs, 7-24 hrs, 25-48
hrs, and 49-96 hrs encompassing time elapsed from admission with chest
pain to angiography. A multivariate logistic regression analysis showed
that the time frame of 0-6 hours was the most significant(p < 0.001)
independent marker of coronary occlusion(with reference to the 48-96 hour
interval)(Odds Ratio 3.01, 95% Confidence Interval: 1.94-4.66; p<
0.001), whereas, for anterior ST depression corresponding data for those
parameters amounted to 2.09, 1.36-3.21, p=0.001, respectively, and, for
inferolateral ST depression, corresponding data amounted to 1.83, 1.08-
3.11, and p=0.025, respectively. Total(ie 100%) thrombotic occlusion was
documented in 55% of 141 patients who fell within the 0-6 hr time frame,
and this represented a significant(p < 0.001) trend in comparison with
other time frames. The left circumflex artery was identified as the
culprit artery(in association with the marginal branch and the
intermediate branch) in 50% of patients who fell within that time
frame(2). Conversely, in a study which exclusively enrolled 27,711
patients with myocardial infarction attributable to left circumflex artery
occlusion, the prevalence of NSTEMI was as high as 33%(3). What is more,
in a study where 93% of 125 patients with suspected NSTEMI had coronary
angiography within 6 hours of arrival in hospital the left circumflex
artery was the culprit artery in 26%(as opposed to its involvement in 11%
of 279 STEMI patients), the difference in prevalence being highly
significant(p < 0.001)(4). Accordingly, the greater the delay in
cardiac catheterisation the greater the likelihood that the opportunity
will be missed to identify thrombotic coronary artery occlusion,
especially in patients with left circumflex artery involvement.
References
(1)Apps A., Malhotra A., Tarkin J et al
High incidence of acute coronary occlusion in patients without protocol
positive ST segment elevation referred to an open access primary
angioplasty programme
Postgraduate Medical Journal 2013;89:376-381
(2)Fugueras J., Barrabes JA., Andres M et al
Angiographic findings at different time intervals from hospital admission
in first non-ST elevation myocardial infarction
International Journal of Cardiologydoi.org/10.1016/j.ijcard.2012.09.168
(3)Stribling WK., Kontos MC., Abbate A et al
Left circumflex occlusion in acute myocardial infarction(from the National
Cardiovascular Data Registry)
Am J Cardiol 2011;108:959-963
(4)Koyama Y., Hansen PS., Hanratty CG., Nelson GIC., Rasmussen HH
Prevalence of coronary occlusion and outcome of an immediate invasive
strategy in suspected acut myocardial infarction with and without ST-
segement elevation
Am J Cardiol 2002;90:579-584
Respected Editor,
The case report by Lai et al. [1] was both interesting and informative. We
agree with the usefulness of CT thorax to differentiate pneumothorax from
giant bulla with double wall sign. Though CT offers the most accurate
diagnostic information, it is difficult to transport unstable patient to a
CT suite which is in a remote area from a resuscitative area or to wait
for a specialized technician to perform it...
Respected Editor,
The case report by Lai et al. [1] was both interesting and informative. We
agree with the usefulness of CT thorax to differentiate pneumothorax from
giant bulla with double wall sign. Though CT offers the most accurate
diagnostic information, it is difficult to transport unstable patient to a
CT suite which is in a remote area from a resuscitative area or to wait
for a specialized technician to perform it and a radiologist to interpret
it. Traditionally, the presence of bullae and their advancement are
recognized by chest radiography. At times, even forced expiratory films
are used to demonstrate the existence of bullae [2]. However, limitation
is difficult to differentiate the hairline shadows produced by avascular
bullae from irregular walls of a cavity or cysts in the lung parenchyma in
an emergency setting and may easily be mistaken for a pneumothorax [3]
sometimes.
In this scenario, the bedside transthoracic ultrasonography has emerged as
a reliable technique to detect and exclude pneumothorax which is now well
accepted by the medical community. The effectiveness of ultrasound in
detection of bullae and differentiate it from pneumothorax [4] is well
documented. The lung sliding may be minimal because there may be little
movement of the visceral pleura that covers the bulla. As there is no free
air in the pleural space, the reverberation artifact that produces the
'comet tail artifacts' may be noticed in bullous disease. However, it is
absent when the lung is collapsed as in pneumothorax and thereby helps to
arrive at the diagnosis [5].
Speedy and precise diagnosis of bullous emphysema from pneumothorax will
assist in treatment, as the management of these two entities varies
significantly. Many times patients presenting to the emergency departments
were in extremis and call for an immediate decision making and delaying
can be life threatening. In an emerging culture of protocol and guidelines
regarding effectiveness of treatment, transthoracic ultrasonography may be
considered in the emergency department to assure the high quality of
health care given to patients.
References:
1. Lai CC, Huang SH, Wu TT, Lin SH. Vanishing lung syndrome mimicking
pneumothorax. Postgrad Med J. 2013.
2. Shah N N, Bhargava R, Ahmed Z, Pandey D K, Shameem M, Bachh A A,
Akhtar S, Dar K A, Mohsina M. Unilateral bullous emphysema of lung. Lung
India 2007;24:30-2.
3. Waseem M, Jones J, Brutus S, Munyak J, Kapoor R, Gernsheimer J.
Giant bulla mimicking pneumothorax. J EmergMed 2005;29:155?-8.
4. Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad
Emerg Med 2003;10: 91-4.
5. Simon BC, Paolinetti L. Two cases where bedside ultrasound was
able to distinguish pulmonary bleb fzom pneumothorax. J Emerg Med.
2005.29:201-5
Nwulu and colleagues present a highly relevant analysis of the
financial implications of prescribing by F1 doctors in a UK teaching
hospital1.
It seems that the most important of the recommendations they discuss
are for undergraduate medical education. Whilst they mention that most of
the 79 doctors they investigated graduated from the same medical school,
they do not categorise this further. As their data ind...
Nwulu and colleagues present a highly relevant analysis of the
financial implications of prescribing by F1 doctors in a UK teaching
hospital1.
It seems that the most important of the recommendations they discuss
are for undergraduate medical education. Whilst they mention that most of
the 79 doctors they investigated graduated from the same medical school,
they do not categorise this further. As their data indicate, the large
majority of doctors performed to a very similar level to the reference
doctor, with a minority on either end of the spectrum proving to be the
most cost-effective and lavish prescribers. This raises the possibility
that the doctors at the extremes of this range may have been the minority
that trained at alternative medical schools.
As they highlight, further studies are needed across the country,
although they may prove to be more of a challenge in trusts that do not
have electronic prescribing systems. Future work into this area may
benefit from investigating the medical schools at which doctors trained.
As these doctors are in their first year after graduating, conclusions may
be drawn about the extent to which medical schools are covering the
financial aspects of prescribing in their clinical pharmacology curricula.
With the increasing importance of cost-effectiveness in the NHS, this
important topic should be on the agenda of medical educators across the UK
in order to breed a new generation of financially astute prescribers.
1. Nwulu U, Hodson J, Thomas SK, et al. Variation in cost of newly
qualified doctors' prescriptions: a review of data from a hospital
electronic prescribing system. Postgrad Med J Published Online First: [30
March 2013] doi:10.1136/postgradmedj- 2012-131334
We applaud the timely study by Kennelly et al and agree fully that ED
physicians generally lack proficiency for recognizing and managing
behavioral complications of dementia. As they succinctly state, "Failure
of physicians to identify and highlight cognitive impairment can lead to
disastrous consequences".[1] We venture that ED physicians are even less
aware of the unique and potentially lethal emergenc...
We applaud the timely study by Kennelly et al and agree fully that ED
physicians generally lack proficiency for recognizing and managing
behavioral complications of dementia. As they succinctly state, "Failure
of physicians to identify and highlight cognitive impairment can lead to
disastrous consequences".[1] We venture that ED physicians are even less
aware of the unique and potentially lethal emergency management aspects of
Lewy Body Dementia (LBD). LBD is a degenerative neurological disease
manifested by cognitive impairment, variable Parkinsonism, and marked
psychosis exhibiting both auditory and visual hallucinations. LBD is now
considered the second most common cause of dementia following only
Alzheimer's comprising up to 20-30% of all dementia based on autopsy
studies.[2] Differentiating LBD from other dementias can be difficult but
the key features are daily fluctuation in cognition and the prominent
hallucinations (paradoxically they are not distressful to the patient).
DLB strikes its victims from late middle age up and respects no boundaries
as to gender or race.[3]
ED patients with LBD require careful and distinctive pharmacologic
management of their agitation and psychotic symptoms. Administering
typical neuroleptics will precipitate serious complications ranging from
extrapyramidal symptoms to severe sedation to the often lethal neuroleptic
malignant syndrome (NMS). Up to 50% percent of individuals with LBD are
at an increased risk of these acute reactions to neuroleptics.[2].
The pathophysiology of this phenomenon is based on the finding that
neurons of the basal nucleus of Meynert and substantia nigra are reduced
in LBD thus preferentially depleting acetylcholine and dopamine
neurotransmitters. The typical antipsychotics, such as haloperidol
(Haldol), fluphenazine (Prolixin), and chlorpromazine (Thorazine), block
postsynaptic mesolimbic dopaminergic D1 and D2 receptors which can
typically be helpful for reducing delirium and hallucinations in most
patients with Alzheimer's. The specific neurotransmitter deficits in LBD
however prevent up-regulation of D2 receptors in the affected brain
centers thus uniquely sensitizing these patients to the EPS adverse
effects of antipsychotics.[2] Not only can this exacerbate acute
problems but it may worsen cognitive ability of these patients over the
long term. LBD experts recommend the use of newer and more selective
atypical antipsychotic agents. Importantly, however, case reports show
that even these newer agents are not immune to inducing NMS in LBD, so
small and carefully titrated doses are advised.[4] Employing non-
pharmacologic modalities and the judicious of short acting benzodiazepines
is also advised. Because the Emergency Medicine community is largely
unaware of these unique hazards, the Lewy Body Dementia Association
provides helpful guidelines for ED staff to safely treat these unique
patients at http://www.lbda.org.
1. Kennelly SP, Morley D, Coughlan T, et al. Knowledge, skills and
attitudes of doctors towards assessing cognition in older patients in the
emergency department. Postgraduate medical journal 2012 doi:
10.1136/postgradmedj-2012-131226.
2. Baskys A. Lewy body dementia: the litmus test for neuroleptic
sensitivity and extrapyramidal symptoms. J Clin Psychiatry 2004;65 Suppl
11:16-22
3. Latto J, Jan F. Dementia with Lewy Bodies: Clinical Review.
British Journal of Medical Practitioners 2008;1(1):10 - 14
4. Weintraub D, Hurtig HI. Presentation and management of psychosis
in Parkinson's disease and dementia with Lewy bodies. Am J Psychiatry
2007;164(10):1491-8
The occurrence of coronary occlusion in patients without protocol positive ST segment elevation(1) might be attributable either to early catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter also being significantly(p < 0.001) commoner in non ST segment elevation(NSTEMI) patients catheterised within 6 hours of arrival in hospital than in STEMI counterparts also catheterised within that time frame(...
Respected Editor, The case report by Lai et al. [1] was both interesting and informative. We agree with the usefulness of CT thorax to differentiate pneumothorax from giant bulla with double wall sign. Though CT offers the most accurate diagnostic information, it is difficult to transport unstable patient to a CT suite which is in a remote area from a resuscitative area or to wait for a specialized technician to perform it...
Nwulu and colleagues present a highly relevant analysis of the financial implications of prescribing by F1 doctors in a UK teaching hospital1.
It seems that the most important of the recommendations they discuss are for undergraduate medical education. Whilst they mention that most of the 79 doctors they investigated graduated from the same medical school, they do not categorise this further. As their data ind...
Sir,
We applaud the timely study by Kennelly et al and agree fully that ED physicians generally lack proficiency for recognizing and managing behavioral complications of dementia. As they succinctly state, "Failure of physicians to identify and highlight cognitive impairment can lead to disastrous consequences".[1] We venture that ED physicians are even less aware of the unique and potentially lethal emergenc...
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