Effects of Intensive Statin Therapy on Left Ventricular Function in Patients with Myocardial Infarction and Abnormal Glucose Tolerance

Objectives: Abnormal glucose tolerance in patients with acute myocardial infarction (AMI) is associated with greater mortality and adverse cardiovascular effects. As statins possess a range of beneficial pleiotropic effects on the cardiovascular system, we sought to assess the cardioprotective effects of statins on left ventricular function in patients with AMI in relation to glycometabolic state. Methods: In a prospective, randomized trial, 140 patients with AMI were randomized to intensive statin therapy receiving statin loading with 80 mg of rosuvastatin followed by 40 mg daily or standard statin therapy. Patients were assessed with an oral glucose tolerance test and their left ventricular (LV) function was assessed with speckle-tracking echocardiography measuring regional longitudinal systolic strain (RLSS) in the infarct area. Results: Overall RLSS in the infarct area improved by a mean (±SD) of -4.22% (±5.19) in the intensive-care group and -2.48% (±4.01) in the usual-care group after 1 month (p = 0.047). In patients with abnormal glucose tolerance, RLSS improved by -5.01% (±5.28) in the intensive-care group and -2.15% (±4.22) in the usual-care group (p = 0.01). Conclusions: Early high-dose statin treatment improved RLSS in the infarct area in patients with AMI, and a trend of greater improvement was seen in patients with abnormal glucose tolerance.

Influence of adaptive statistical iterative reconstruction algorithm on image quality in coronary computed tomography angiography

Background

Coronary computed tomography angiography (CCTA) requires high spatial and temporal resolution, increased low contrast resolution for the assessment of coronary artery stenosis, plaque detection, and/or non-coronary pathology. Therefore, new reconstruction algorithms, particularly iterative reconstruction (IR) techniques, have been developed in an attempt to improve image quality with no cost in radiation exposure.

Purpose

To evaluate whether adaptive statistical iterative reconstruction (ASIR) enhances perceived image quality in CCTA compared to filtered back projection (FBP).

Material and Methods

Thirty patients underwent CCTA due to suspected coronary artery disease. Images were reconstructed using FBP, 30% ASIR, and 60% ASIR. Ninety image sets were evaluated by five observers using the subjective visual grading analysis (VGA) and assessed by proportional odds modeling. Objective quality assessment (contrast, noise, and the contrast-to-noise ratio [CNR]) was analyzed with linear mixed effects modeling on log-transformed data. The need for ethical approval was waived by the local ethics committee as the study only involved anonymously collected clinical data.

Results

VGA showed significant improvements in sharpness by comparing FBP with ASIR, resulting in odds ratios of 1.54 for 30% ASIR and 1.89 for 60% ASIR (P = 0.004). The objective measures showed significant differences between FBP and 60% ASIR (P < 0.0001) for noise, with an estimated ratio of 0.82, and for CNR, with an estimated ratio of 1.26.

Conclusion

ASIR improved the subjective image quality of parameter sharpness and, objectively, reduced noise and increased CNR.

The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65-74 Years

OBJECTIVE/BACKGROUND

This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD.

METHODS

In total, 2060 randomly selected Danish men and women aged 65-74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden.

RESULTS

Attendance rates were 64.9% (n = 678) and 63.0% (n = 640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9-14.9) in men and 1.1% (95% CI 0.3-1.9) in women, respectively (p < .001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p < .001), along with a significant increase in median CAC score with age (p = .03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8-21.8) than in women (11.2%, 95% CI 8.7-13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%).

CONCLUSION

Owing to the higher prevalence of severe conditions, such as aneurysms and CAC ≥ 400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.

Impact of a motion correction algorithm on image quality in patients undergoing CT angiography: A randomized controlled trial

AIMS

To investigate the motion correction algorithm Snapshot-Freeze (SSF) compared to standard reconstruction (STD) in patients randomized to receive beta-blockers (BB) or no beta-blockers (non-BB) before coronary CT, and to investigate if SSF can replace BB.

METHODS

One hundred and forty patients scheduled for coronary CT were randomized. All images were reconstructed by the SSF and STD algorithms. Image quality was evaluated according to Likert score (1: excellent, 2: good, 3: adequate, 4: non-diagnostic) and presence of artifacts was noted.

RESULTS

Images from 64 patients in the BB group (mean HR 56±4bpm) and 51 patients in the non-BB group (mean HR 67±7bpm) were analyzed. Twenty five patients were excluded because of tachycardia, bradycardia or reconstruction errors in SSF. SSF increased the number of excellent images in both groups compared to the STD algorithm (BB: 59% vs.44%; non-BB: 25% vs. 8%), but the number of non-diagnostic images was not significantly reduced. SSF reduced motion artifacts (BB: 11% vs. 31%; non-BB: 49% vs. 75%), but despite this reduction, motion artifacts in non-BB were still more frequent compared to the BB group analyzed by STD (49% vs. 31%).

CONCLUSION

SSF improves image quality and reduces motion artifacts, but does not compensate for the absence of BB.

First experiences with model based iterative reconstructions influence on quantitative plaque volume and intensity measurements in coronary computed tomography angiography

PURPOSE

Investigate the influence of adaptive statistical iterative reconstruction (ASIR) and the model-based IR (Veo) reconstruction algorithm in coronary computed tomography angiography (CCTA) images on quantitative measurements in coronary arteries for plaque volumes and intensities.

METHODS

Three patients had three independent dose reduced CCTA performed and reconstructed with 30% ASIR (CTDI_vol at 6.7 mGy), 60% ASIR (CTDI_vol 4.3 mGy) and Veo (CTDI_vol at 1.9 mGy). Coronary plaque analysis was performed for each measured CCTA volumes, plaque burden and intensities.

RESULTS

Plaque volume and plaque burden show a decreasing tendency from ASIR to Veo as median volume for ASIR is 314 mm³ and 337 mm³-252 mm³ for Veo and plaque burden is 42% and 44% for ASIR to 39% for Veo. The lumen and vessel volume decrease slightly from 30% ASIR to 60% ASIR with 498 mm³-391 mm³ for lumen volume and vessel volume from 939 mm³ to 830 mm³. The intensities did not change overall between the different reconstructions for either lumen or plaque.

CONCLUSION

We found a tendency of decreasing plaque volumes and plaque burden but no change in intensities with the use of low dose Veo CCTA (1.9 mGy) compared to dose reduced ASIR CCTA (6.7 mGy & 4.3 mGy), although more studies are warranted.

The Danish Cardiovascular Screening Trial (DANCAVAS): study protocol for a randomized controlled trial

Background

The significant increase in the average life expectancy has increased the societal challenge of managing serious age-related diseases, especially cancer and cardiovascular diseases. A routine check by a general practitioner is not sufficient to detect incipient cardiovascular disease.

Design

Population-based randomized clinically controlled screening trial.

Methods

Participants: 45,000 Danish men aged 65–74 years living on the Island of Funen, or in the surrounding communities of Vejle and Silkeborg. No exclusion criteria are used.

Interventions: One-third will be invited to cardiovascular seven-faceted screening examinations at one of four locations. The screening will include: (1) low-dose non-contrast CT scan to detect coronary artery calcification and aortic/iliac aneurysms, (2) brachial and ankle blood pressure index to detect peripheral arterial disease and hypertension, (3) a telemetric assessment of the heart rhythm, and (4) a measurement of the cholesterol and plasma glucose levels. Up-to-date cardiovascular preventive treatment is recommended in case of positive findings.

Objective: To investigate whether advanced cardiovascular screening will prevent death and cardiovascular events, and whether the possible health benefits are cost effective.

Outcome: Registry-based follow-up on all cause death (primary outcome), and costs after 3, 5 and 10 years (secondary outcome).

Randomization: Each of the 45,000 individuals is, by EPIDATA, given a random number from 1–100. Those numbered 67+ will be offered screening; the others will act as a control group.

Blinding: Only those randomized to the screening will be invited to the examination;the remaining participants will not.

Numbers randomized: A total of 45,000 men will be randomized 1:2.

Recruitment: Enrollment started October 2014.

Outcome: A 5 % reduction in overall mortality (HR = 0.95), with the risk for a type 1 error = 5 % and the risk for a type II error = 80 %, is expected. We expect a 2-year enrollment, a 10-year follow-up, and a median survival of 15 years among the controls. The attendance to screening is assumed to be 70 %.

Discussion

The primary aim of this so far stand-alone population-based, randomized trial will be to evaluate the health benefits and costeffectiveness of using non-contrast full truncus computer tomography (CT) scans (to measure coronary artery calcification (CAC) and identify aortic/iliac aneurysms) and measurements of the ankle brachial blood pressure index (ABI) as part of a multifocal screening and intervention program for CVD in men aged 65–74.

Attendance rate and compliance to initiated preventive actions must be expected to become of major importance.

Trial registration

Current Controlled Trials: ISRCTN12157806 (21 March 2015).

Improving Medication Adherence in Patients with Hypertension: A Randomized Trial

BACKGROUND AND PURPOSE

In patients with hypertension, medication adherence is often suboptimal, thereby increasing the risk of ischemic heart disease and stroke. In a randomized trial, we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients. Motivational interviewing was a key element of the intervention.

METHODS

Patients (n = 532) were recruited from 3 hospital outpatient clinics and randomized to usual care or a 6-month pharmacist intervention comprising collaborative care, medication review, and tailored adherence counseling including motivational interviewing and telephone follow-ups. The primary outcome was composite medication possession ratio (MPR) to antihypertensive and lipid-lowering agents, at 1-year follow-up, assessed by analyzing pharmacy records. Secondary outcomes at 12 months included persistence to medications, blood pressure, hospital admission, and a combined clinical endpoint of cardiovascular death, stroke, or acute myocardial infarction.

RESULTS

At 12 months, 20.3% of the patients in the intervention group (n = 231) were nonadherent (MPR <0.80), compared with 30.2% in the control group (n = 285) (risk difference -9.8; 95% confidence interval [CI], -17.3, -2.4) and median MPR (interquartile range) was 0.93 (0.82-0.99) and 0.91 (0.76-0.98), respectively, P = .02. The combined clinical endpoint was reached by 1.3% in the intervention group and 3.1% in the control group (relative risk 0.41; 95% CI, 0.11-1.50). No significant differences were found for persistence, blood pressure, or hospital admission.

CONCLUSIONS

A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension. The intervention had no significant impact on blood pressure and secondary clinical outcomes.

Does point-of-care ultrasonography cause discomfort in patients admitted with respiratory symptoms?

BACKGROUND

This study aimed to assess the patient-rated level of discomfort during point-of-care ultrasonography (POCUS) of the heart, lungs and deep veins in a population of patients admitted to an ED with respiratory symptoms and to what extent the patients would accept being assessed by the use of POCUS if they had to be examined for possible disease.

METHODS

A questionnaire-based observational study was conducted in an ED. Inclusion criteria were one or more of the following: respiratory rate > 20/min, oxygen saturation < 95 %, oxygen therapy initiated, dyspnoea, cough or chest pain. Patients were examined by the use of POCUS of the heart, lungs and deep veins. Patient-rated level of discomfort and acceptance were assessed using a standardised questionnaire.

RESULTS

The median duration of the sonographic examinations was 12 min (IQR 11-13, range 9-23). The median patient-rated level of discomfort for all three types of POCUS was 1 (IQR 1-1, range 1-8) on a scale from 1 to 10. All but one patient (99.6 % (95 % CI: 98.9-100 %)), would accept being examined by the use of POCUS as a part of routine ED diagnostics.

CONCLUSIONS

The patient-rated level of discomfort during POCUS of the heart, lungs and deep veins is very low and the vast majority of patients would accept being assessed by the use of POCUS if the patients once again had to be examined for possible disease.

Effects of intensive lipid-lowering therapy on coronary plaques composition in patients with acute myocardial infarction: Assessment with serial coronary CT angiography

BACKGROUND

Statins have been shown to possess favourable effects on the cardiovascular system with stabilization of the vulnerable plaque. We sought to assess the effects of early aggressive statin treatment on plaque composition in patients with acute myocardial infarction (AMI), using serial assessment with coronary CT-angiography (CTA).

METHODS

In a prospective randomized blinded endpoint trial patients with AMI were randomized to an intensive lipid lowering treatment receiving statin loading with 80 mg rosuvastatin followed by 40 mg daily or standard statin therapy according to current guidelines. Patients were assessed with CTA at baseline and after 12 months with evaluation of plaque volume and composition.

RESULTS

In total, 140 patients with AMI were randomized and plaque composition was assessed in 96 patients. In the intensive care group LDL-level was median 1.3 [0.9; 1.5] mmol/l at 12 months follow-up and 2.0 [1.7; 2.4] mmol/l in the usual care group, p < 0.001. Plaque volume increased over 12 months with 43.5 (±225.8) mm(3) in the intensive care group and 19.1 (±190.2) mm(3) in the usual care group, p = 0.57. Plaque composition changed over 12 months with an increase in total dense calcium volume by 11.1 (±39.6) mm(3), corresponding to a 23% increase, in the intensive care group and a decreased by -0.4 (±26.6) mm(3) in the usual care group, p < 0.001. Necrotic core volume increased 26.8 (±122.1) mm(3) in the intensive care group and 25.2 (±80.1) mm(3) in the usual care group, p = 0.94.

CONCLUSIONS

Early aggressive lipid lowering therapy significantly increases dense calcium volume in patients with AMI.

The Western Denmark Cardiac Computed Tomography Registry: a review and validation study

BACKGROUND

As a subregistry to the Western Denmark Heart Registry (WDHR), the Western Denmark Cardiac Computed Tomography Registry (WDHR-CCTR) is a clinical database established in 2008 to monitor and improve the quality of cardiac computed tomography (CT) in Western Denmark.

OBJECTIVE

We examined the content, data quality, and research potential of the WDHR-CCTR.

METHODS

We retrieved 2008-2012 data to examine the 1) content; 2) completeness of procedure registration using the Danish National Patient Registry as reference; 3) completeness of variable registration comparing observed vs expected numbers; and 4) positive predictive values as well as negative predictive values of 19 main patient and procedure variables.

RESULTS

By December 31, 2012, almost 22,000 cardiac CTs with up to 40 variables for each procedure have been registered. Of these, 87% were coronary CT angiography performed in patients with symptoms indicative of coronary artery disease. Compared with the Danish National Patient Registry, the overall procedure completeness was 72%. However, an additional medical record review of 282 patients registered in the Danish National Patient Registry, but not in the WDHR-CCTR, showed that coronary CT angiographies accounted for only 23% of all nonregistered cardiac CTs, indicating >90% completeness of coronary CT angiographies in the WDHR-CCTR. The completeness of individual variables varied substantially (range: 0%-100%), but was >85% for more than 70% of all variables. Using medical record review of 250 randomly selected patients as reference standard, the positive predictive value for the 19 variables ranged from 89% to 100% (overall 97%), whereas the negative predictive value ranged from 97% to 100% (overall 99%). Stratification by center status showed consistently high positive and negative predictive values for both university (96%/99%) and nonuniversity centers (97%/99%).

CONCLUSION

WDHR-CCTR provides ongoing prospective registration of all cardiac CTs performed in Western Denmark since 2008. Overall, the registry data have a high degree of completeness and validity, making it a valuable tool for clinical epidemiological research.

Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial

BACKGROUND

When used with standard diagnostic testing, point-of-care ultrasonography might improve the proportion of patients admitted with respiratory symptoms who are correctly diagnosed 4 h after admission to the emergency department. We therefore assessed point-of-care ultrasonography of the heart, lungs, and deep veins in addition to the usual initial diagnostic testing in this patient population.

METHODS

In a prospective, parallel-group trial in the emergency department at Odense University Hospital, Odense, Denmark, patients (≥18 years) with a respiratory rate of more than 20 per min, oxygen saturation of less than 95%, oxygen therapy, dyspnoea, cough, or chest pain were randomly assigned in a 1:1 ratio with a computer-generated list to a standard diagnostic strategy (control group) or to standard diagnostic tests supplemented with point-of-care ultrasonography of the heart, lungs, and deep veins (point-of-care ultrasonography group). The primary endpoint was the percentage of patients with a correct presumptive diagnosis 4 h after admission to the emergency department. Only the physicians doing the primary clinical assessment and the auditors were masked. Analyses were by intention to treat. The study is registered with ClinicalTrials.gov, number NCT01486394.

FINDINGS

Between Dec 7, 2011, and March 15, 2013, 320 patients were randomly assigned to the control group (n=160) and point-of-care ultrasonography group (n=160). 158 patients in the point-of-care ultrasonography group and 157 in the control group were analysed. 4 h after admission to the emergency department, 139 patients (88·0%; 95% CI 82·8-93·1) in the point-of-care ultrasonography group versus 100 (63·7%; 56·1-71·3) in the control group had correct presumptive diagnoses (p<0·0001). The absolute and relative effects were 24·3% (95% CI 15·0-33·1) and 1·38 (1·01-1·31), respectively. No adverse events were reported.

INTERPRETATION

Point-of-care ultrasonography is a feasible, radiation free, diagnostic test, which alongside standard diagnostic tests is superior to standard diagnostic tests alone for establishing a correct diagnosis within 4 h. It should therefore be considered for routine use as part of the standard diagnostic tests in the emergency department for patients admitted with respiratory symptoms.

FUNDING

University of Southern Denmark, Odense University Hospital, and Højbjerg Fund.

Focused sonography of the heart, lungs, and deep veins identifies missed life-threatening conditions in admitted patients with acute respiratory symptoms

BACKGROUND

Patients with acute respiratory symptoms still remain a diagnostic challenge. The aim of the study was to evaluate whether focused sonography could potentially diagnose life-threatening conditions missed at the primary assessment in a patient population consisting of admitted patients with acute respiratory symptoms.

METHODS

A prospective blinded observational study was conducted in a medical ED. Inclusion criteria were the presence of one or more of the following: respiratory rate &gt; 20/min, oxygen saturation &lt; 95%, oxygen therapy initiated, dyspnea, cough, or chest pain. After the initial assessment, focused sonography of the heart, lungs, and deep veins was performed by a physician blinded to patient history and the results of the primary assessment.

RESULTS

One hundred thirty-nine patients were included. The focused sonographic examinations could be performed in 134 patients (96%). Focused sonography identified 19 patients (14%) with an acute life-threatening condition missed at the primary assessment. Diagnostic performance of focused sonography for the diagnosis of an acute life-threatening condition, when using audit as gold standard, was as follows: sensitivity, 100% (95% CI, 85.2%-100%); specificity, 93.3% (95% CI, 86.7%-97.3%); positive predictive value, 76.7% (95% CI, 57.7%-90.1%); and negative predictive value, 100% (95% CI, 96.3%-100%).

CONCLUSIONS

Focused sonography of the heart, lungs, and deep veins is fast, highly feasible, and able to diagnose life-threatening conditions missed at the primary assessment in admitted patients with acute respiratory symptoms. In an ED setting sonography can be used both for ruling in and ruling out acute life-threatening conditions in these patients.

Acute Myocardial Infarction and Pulmonary Diseases Result in Two Different Degradation Profiles of Elastin as Quantified by Two Novel ELISAs

BACKGROUND

Elastin is a signature protein of the arteries and lungs, thus it was hypothesized that elastin is subject to enzymatic degradation during cardiovascular and pulmonary diseases. The aim was to investigate if different fragments of the same protein entail different information associated to two different diseases and if these fragments have the potential of being diagnostic biomarkers.

METHODS

Monoclonal antibodies were raised against an identified fragment (the ELM-2 neoepitope) generated at the amino acid position '552 in elastin by matrix metalloproteinase (MMP) -9/-12. A newly identified ELM neoepitope was generated by the same proteases but at amino acid position '441. The distribution of ELM-2 and ELM, in human arterial plaques and fibrotic lung tissues were investigated by immunohistochemistry. A competitive ELISA for ELM-2 was developed. The clinical relevance of the ELM and ELM-2 ELISAs was evaluated in patients with acute myocardial infarction (AMI), no AMI, high coronary calcium, or low coronary calcium. The serological release of ELM-2 in patients with chronic obstructive pulmonary disease (COPD) or idiopathic pulmonary fibrosis (IPF) was compared to controls.

RESULTS

ELM and ELM-2 neoepitopes were both localized in diseased carotid arteries and fibrotic lungs. In the cardiovascular cohort, ELM-2 levels were 66% higher in serum from AMI patients compared to patients with no AMI (p<0.01). Levels of ELM were not significantly increased in these patients and no correlation was observed between ELM-2 and ELM. ELM-2 was not elevated in the COPD and IPF patients and was not correlated to ELM. ELM was shown to be correlated with smoking habits (p<0.01).

CONCLUSIONS

The ELM-2 neoepitope was related to AMI whereas the ELM neoepitope was related to pulmonary diseases. These results indicate that elastin neoepitopes generated by the same proteases but at different amino acid sites provide different tissue-related information depending on the disease in question.

The relation between coronary artery calcification in asymptomatic subjects and both traditional risk factors and living in the city centre: a DanRisk substudy

OBJECTIVE

To evaluate the association between the risk factor for living in the city centre as a surrogate for air pollution and the presence of coronary artery calcification (CAC) in a population of asymptomatic Danish subjects.

DESIGN AND SUBJECTS

A random sample of 1825 men and women of either 50 or 60 years of age were invited to take part in a screening project designed to assess risk factors for cardiovascular disease (CVD). Noncontrast cardiac computed tomography was performed on all subjects, and their Agatston scores were calculated to evaluate the presence of subclinical coronary atherosclerosis. The relationship between CAC and several demographic and clinical parameters was evaluated using multivariate logistic regression.

RESULTS

A total of 1225 individuals participated in the study, of whom 250 (20%) were living in the centres of major Danish cities. Gender and age showed the greatest association with the presence of CAC: the odds ratio (OR) for men compared with women was 3.2 [95% confidence interval (CI) 2.5-4.2; P < 0.0001], and the OR for subjects aged 60 versus those aged 50 years was 2.2 (95% CI 1.7-2.8; P < 0.0001). Other variables independently associated with the presence of CAC were diabetes and smoking with ORs of 2.0 (95% CI 1.1-3.5; P = 0.03) and 1.9 (95% CI 1.4-2.5, P < 0.0001), respectively. The adjusted OR for subjects living in city centres compared to those living outside was 1.8 (95% CI 1.3-2.4; P = 0.0003).

CONCLUSION

Both conventional risk factors for CVD and living in a city centre are independently associated with the presence of CAC in asymptomatic middle-aged subjects.

Focused sonographic examination of the heart, lungs and deep veins in an unselected population of acute admitted patients with respiratory symptoms: a protocol for a prospective, blinded, randomised controlled trial

INTRODUCTION

Patients admitted to hospital with acute respiratory symptoms remain a diagnostic challenge for the emergency physician. The use of focused sonography may improve the initial diagnostics, as most of the diseases, commonly seen and misdiagnosed in patients with acute respiratory symptoms, can be diagnosed with sonography. The protocol describes a prospective, blinded, randomised controlled trial that aims to assess the diagnostic impact of a pragmatic implementation of focused sonography of the heart, lungs and deep veins as a diagnostic modality in acute admitted patients with respiratory symptoms.

METHODS AND ANALYSIS

The primary outcome of the study is the number of patients with a correct presumptive diagnosis within 4 h of admission to the emergency department. The patient is randomised to either an intervention or a control group. In the intervention group, the usual initial diagnostic work up is supplemented by focused sonographic examination of the heart, lungs and deep veins of the legs. In the control group, usual diagnostic work up is performed. The χ(2) test, alternatively the Fischer exact test will be used, to establish whether there is a difference in the distribution of the total number of patients with a correct/incorrect '4 h' presumptive diagnosis in the control group and in the intervention group.

ETHICS AND DISSEMINATION

This clinical trial is performed according to the Declaration of Helsinki and has been approved by the Regional Scientific Ethical Committee for Southern Denmark and the Danish Data Protection Agency. The results of the trial will be published according to the CONSORT statement with the extension for pragmatic trials. The results of the trial will be published in a peer-reviewed scientific journal regardless of the outcome.

TRIAL REGISTRATION NUMBER

This study is registered at http://clinicaltrials.gov, registration number NCT01486394.

Discrepancy between coronary artery calcium score and HeartScore in middle-aged Danes: the DanRisk study

Background: Coronary artery calcification (CAC) is an independent and incremental risk marker. This marker has previously not been compared to the HeartScore risk model. Design: A random sample of 1825 citizens (men and women, 50 or 60 years of age) was invited for screening. Methods: Using the HeartScore model, the 10-year risk of fatal cardiovascular events based on gender, age, smoking, systolic blood pressure, and total cholesterol was estimated. A low risk was defined as <5%. The CAC score was calculated from a non-contrast enhanced cardiac-CT scan and given in Agatston U. Results: A total of 1257 (69%) of the invited subjects were interested in the screening. Due to previous cardiovascular disease or diabetes mellitus, 101 were excluded. Of the remaining 1156, 47% were men and 53% women; one half were 50 years old and the other half 60 years old. A low HeartScore was found in 901 of which 334 (37%) had CAC. A high HeartScore was recorded in 251 of which 80 (32%) did not have any CAC. High HeartScores and CAC were significantly more common in males than females. Conclusions: CAC is common in healthy middle-aged Danes with a low HeartScore, and, on the contrary, high-risk subjects very frequently do not have CAC. The therapeutic and prognostic implications of these observations remain to be clarified.

[Dilated cardiomyopathy in an amphetamine user]

The patient presented himself at the primary practitioner with dyspnoea and chest pain, and was initially misdiagnosed as having pneumonia. Two weeks later the patient developed universal oedema and was hospitalized. Echocardiography showed dilated cardiomyopathy. The initial diagnosis was delayed because the patient was not asked about his possible drug abuse. Remember to ask about drug abuse in younger patients with dyspnoea and uncharacteristic chest pains.

[Hypertension in children and adolescents]

In children and adolescents, the normal range of blood pressure (BP) is determined by body size and age. Hypertension is defined as average systolic BP or diastolic BP at or above the 95th percentile for the gender, age and height in question. The possibility that some underlying disorder may be the cause of the hypertension should be considered in every child or adolescent who has elevated BP. Primary hypertension in children or adolescents is only an elimination diagnosis. All classes of antihypertensive drugs have been shown to lower BP in children and adolescents. The choice of drug for initial antihypertensive therapy resides in the preference of the treating physician.

High-sensitive C-reactive protein is associated with reduced lung function in young adults

Systemic inflammation has been associated with reduced lung function. However, data on the interrelationships between lung function and inflammation are sparse, and it is not clear if low-grade inflammation leads to reduced lung function. Associations between high-sensitive C-reactive protein (CRP) and spirometric lung function were assessed in a population-based cohort of approximately 1,000 Danes aged 20 yrs. In males, the average decline in forced expiratory volume in one second (FEV(1)) in the highest CRP quintile was 23 mL.yr(-1) versus 1.6 mL.yr(-1) in the lowest quintile. In females, the average decline was 6.2 mL.yr(-1) in the highest CRP quintile versus an increase of 1.8 mL.yr(-1) in the lowest CRP quintile. In a multiple regression analysis adjusted for sex, body mass index, cardiorespiratory fitness, smoking, asthma, airway hyperresponsiveness and serum eosinophil cationic protein, higher levels of CRP at age 20 yrs were associated with a greater reduction in both FEV(1) and forced vital capacity between ages 20 and 29 yrs. The findings show that higher levels of C-reactive protein in young adults are associated with subsequent decline in lung function, suggesting that low-grade systemic inflammation in young adulthood may lead to impaired lung function independently of the effects of smoking, obesity, cardiorespiratory fitness, asthma and eosinophilic inflammation.

[Telemedical pre-hospital diagnosis of a patient with thoracic aortic dissection]

Thoracic aortic dissection is a life-threatening emergency that must be met and surmounted immediately to increase survival. In this case, telemedicine involving ECG and GSM-based communication between the patient in the ambulance and the centre doctor was used to obtain remote pre-hospital suspicion of aorta dissection. Thus, the ambulance was re-routed directly to a specialized unit where the diagnosis was confirmed and immediate and successful surgical treatment was performed. Telemedicine allowing direct communication between the patient and the doctor is recommended.

[ST elevation myocardial infarction after therapeutic injection of adrenaline]

A case of acute myocardial infarction (AMI) following accidental iatrogenic overdose by adrenaline injection is described in a male aged 55 years. This patient was given 1 mg of adrenaline due to anaphylactic symptoms. Afterwards he presented with angina pectoris, dyspnoea and ST-segment elevation in the ECG. Plasma TnT and CK-MB were raised. A coronary angiography revealed a 66% stenosis of RCA. This patient had an asymptomatic RCA stenosis that probably became symptomatic due to coronary artery spasm related to adrenaline injection and thereby presented symptoms and signs of AMI.

Low physical fitness in childhood is associated with the development of asthma in young adulthood: the Odense schoolchild study

Intense physical activity in children may either improve fitness and protect against asthma, or may trigger symptoms. The aim of this study was to determine whether physical fitness in childhood has an impact on the development of asthma. In this prospective, community-based study, 757 (84%) asymptomatic children with an average age at inclusion of 9.7 yrs were followed for 10.5 yrs. In both surveys a maximal progressive exercise test on a bicycle ergometer was used to measure physical fitness (maximal workload) and to induce airway narrowing. A methacholine provocation test was performed in the subjects at follow-up. During the 10-yr study period, 51 (6.7%) of the previously asymptomatic children developed asthma. These subjects had a lower mean physical fitness in 1985 than their peers: (3.63 versus 3.89 W x kg(-1); p=0.02) in boys and (3.17 versus 3.33 W x kg(-1); p=0.02) in girls. A weak correlation was found between physical fitness in childhood and airway responsiveness to methacholine at follow-up when adjusted for body mass index, age and sex (r=0.11; p<0.01). In a multiple regression analysis, physical fitness was inversely related to the development of physician diagnosed asthma, odds ratio=0.93 (0.87-0.99). Thus, the risk for the development of asthma during adolescence is reduced 7% by increasing the maximal workload 1 W x kg(-1). In conclusion, this study showed that physical fitness in childhood is weakly correlated with the development of asthma during adolescence and that high physical fitness seems to be associated with a reduced risk for the development of asthma.

Impact of airway lability, atopy, and tobacco smoking on the development of asthma-like symptoms in asymptomatic teenagers

AIM

To investigate the impact of airway lability, atopy, and tobacco smoking on the development of asthma-like symptoms in asymptomatic subjects.

METHODS

In this prospective, community-based study, 271 asymptomatic adolescents with an average age at inclusion of 13.9 years were followed for 6.4 years. Airway lability was assessed at baseline by three tests, including exercise challenge, airway provocation with methacholine, and monitoring of peak expiratory flow. Atopy was defined by one or more positive reactions (> or = 3-mm weal) to 10 common aeroallergens by skin prick testing. The influence of airway lability, atopy, and smoking on the development of asthma-like symptoms was assessed by logistic regression.

RESULTS

During the 6-year study period, 68 of the previously asymptomatic teenagers (25%) developed asthma-like symptoms. Among those, 50% reported cough only, 29% reported wheezing only, and 21% reported both wheezing and coughing. Hyperresponsiveness to methacholine (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1 to 11.6), smoking (OR, 2.1; 95% CI, 1. 2 to 3.8), and atopy (OR, 3.5; 95% CI, 1.8 to 6.8) each contributed independently to explain symptom development (wheezing and cough together). Girls, but not boys, with airway lability were less likely to take up smoking, compared with subjects of that set with no airway lability (32% vs 51%; p < 0.05). No effect of airway lability on the likelihood of giving up smoking could be demonstrated, nor did the presence of atopy have any significant impact on smoking behavior.

CONCLUSION

Hyperresponsiveness to methacholine, atopy, and smoking were independent risk factors for the development of asthma-like symptoms during adolescence. The presence of airway lability may prevent girls from taking up smoking.

Increased eosinophil cation protein level in sensitized nonasthmatics is linked to subsequent hyperresponsiveness to methacholine. The Odense Schoolchild Study

BACKGROUND

Increased levels of eosinophil cation protein (ECP) in sensitized subjects may reflect early stages of an ongoing inflammatory process and therefore precede asthma and bronchial hyperreactivity.

AIM

To study whether nonasthmatic subjects with sensitization to allergens and increased ECP levels are at a higher risk for subsequent increased bronchial reactivity compared with sensitized nonasthmatics with normal ECP levels.

METHODS

A prospective study of 240 schoolchildren with a mean age of 13.9 years (range: 12.6-15.9) who were followed up after 6.3 years. Bronchial reactivity was assessed by methacholine provocation testing. Sensitization was defined by one or more positive reactions (>3 mm wheal) to 10 common aeroallergens by skin prick testing. Increased ECP was defined as values above 20 microg/l. This separated the subjects into four categories: group 1: healthy controls without sensitization (n = 147); group 2: sensitized subjects with a serum ECP below 20 microg/l (n = 55); group 3: sensitized subjects with an ECP level at or above 20 microg/l (n = 16), and group 4: all asthmatics (n = 22).

RESULTS

Bronchial reactivity was similar in subjects of groups 2 and 3 at baseline (p = 0.8). Six years later, subjects from group 3 were more responsive to methacholine compared with subjects from group 2 (median: 12.7 versus 20.5 micromol; p < 0.05). In a logistic regression with hyperresponsiveness to methacholine at follow-up as dependent variable, the odds ratios (OR) for the groups were, with group 1 as reference: group 2: OR = 2.2 (0.8-6.6: p = 0.2), group 3: 5.9 (1. 6-21.7: p < 0.01).

CONCLUSION

Subjects with sensitization and increased ECP levels are subsequently more airway-responsive to methacholine compared with sensitized subjects with normal ECP levels. This supports the hypothesis that sensitization is linked to increased bronchial reactivity through a process in which markers of inflammation are involved.

Asymptomatic bronchial hyperresponsiveness to exercise in childhood and the development of asthma related symptoms in young adulthood: the Odense Schoolchild Study

BACKGROUND

Exercise testing may be of value in identifying a group of children at high risk of subsequently developing respiratory symptoms. As few longitudinal studies have investigated this issue, the bronchial hyperresponsiveness to exercise in asymptomatic children was evaluated as a risk factor for developing asthma related symptoms in young adulthood.

METHODS

A community based sample of 1369 schoolchildren, first investigated in 1985 at a mean age of 9.7 years, was followed up after a mean of 10.5 years. Nine hundred and twenty children (67%) were asymptomatic in childhood and 777 (84.9%) of these were re-investigated at follow up. At the first examination a maximum progressive exercise test on a bicycle ergometer was used to induce airway narrowing. The forced expiratory volume in one second (FEV1) after exercise was considered abnormal if the percentage fall in FEV1 was more than 5% of the highest fall in the reference subjects characterised by having no previous history of asthma or asthma related symptoms. The threshold for a positive test was 8.6% of pre-exercise FEV1.

RESULTS

One hundred and three subjects (13%) had wheeze within the last year at follow up and, of these, nine (9%) had been hyperresponsive to exercise in 1985. One hundred and seventy subjects (22%) had non-infectious cough within the previous year, 11 of whom (6%) had been hyperresponsive to exercise in 1985. Multiple regression analysis showed that subjects with hyperresponsiveness to exercise had an increased risk of developing wheeze compared with subjects with a normal response to exercise when the fall in FEV1 after exercise was included as a variable (threshold odds ratio (OR) 2.3 (95% CI 1.1 to 5.5)). The trend was not significant when exercise induced bronchospasm was included as a continuous variable (OR 1.02 (95% CI 0.97 to 1.06)).

CONCLUSIONS

Asymptomatic children who are hyperresponsive to exercise are at increased risk of developing new symptoms related to wheezing but the predictive value of exercise testing for individuals is low.

Tracking and factors predicting rising in 'tracking quartile' in blood pressure from childhood to adulthood: Odense Schoolchild Study

This prospective study determines the degree of tracking and investigates factors predicting a rise in blood pressure (BP) quartile in a cohort of 1369 subjects who were followed for 11 years from childhood into young adulthood. In 900 of these subjects BP, height, weight, physical fitness and BP responses to a maximal exercise testing were measured both at baseline and at follow-up. BP, weight, height and body mass index (BMI) were divided into sex-specific quartiles at both examinations. Tracking was evaluated by examining the tendency of remaining in the same quartile from baseline to follow-up and by measuring product-moment correlation coefficients. Tracking in the upper and lower quartile for BP, weight, height and BMI were significant. Odds ratios for staying in the upper or lower quartile through the follow-up period ranged from 1.6 to 2.4 for diastolic BP and from 2.1 to 3.1 for systolic BP. The range of correlation coefficients for the anthropometric measurements were 0.57-0.75, for diastolic BP 0.12-0.22 and for systolic BP 0.34-0.36 respectively. Changes in weight or relative weight as well as BP response to an exercise test were the factors which predicted a rise in quartile through the 11 years of follow-up. The existence of the inevitable regression to the mean problem in large longitudinal studies of BP was demonstrated by the finding of baseline BP being a significant factor in the prediction of rising in systolic, diastolic or both systolic and diastolic BP quartiles.

Ambulatory blood pressure in 570 Danes aged 19-21 years: the Odense Schoolchild Study

Ambulatory blood pressure (ABP) measurements were performed in a Danish population of 295 males and 275 females aged 19-21 years. Individualised day and night periods were defined from the subjects own recording of bedtime and rising on the day of their ABP measurements. During these individualised periods the ABP values for daytime, night-time and for the whole 24-h period were measured. The mean +/- s.d. values for systolic/diastolic ABP for the whole population were (124+/-11)/(70+/-7) mm Hg in the daytime, (106+/-12)/(60+/-9) mm Hg in the night-time, and (120+/-11)/(68+/-7) mm Hg in the whole 24-h period. Males had a mean systolic ABP of 9 mm Hg and mean diastolic ABP of 5 mm Hg higher than females. In males mean +/- s.d. systolic/diastolic ABP values in the daytime were (129+/-10)/(73+/-7) mm Hg, in the night-time (111+/-12)/(63+/-8) mm Hg, and in the whole 24-h period (125+/-10)/(71+/-7) mm Hg. The corresponding values in females were (119+/-10)/(68+/-6) mm Hg, (103+/-11)/(57+/-8) mmHg, and (115+/-10)/(66+/-6) mm Hg, respectively. In conclusion this study provides sex-specific normal values for ABP in a 19 to 21-year-old age group based on individualised daytime and night-time periods.

[Use of thermotherapy, ultrasound and laser by practising physiotherapists. Physiotherapists' choice of treatment]

The purpose of this examination was to examine the practising physiotherapist's way of treating patients with nine selected diagnoses (fibrosites, osteoarthritis, rheumatoid arthritis, cervical slipped disc, lumbar slipped disc, generalized lumbar/back pain, generalized bursitis, generalized tendinitis, and sprains). In addition, nine different forms of therapy were examined (hot packs, infra-red light, ice packs, short waves, microwaves, diadynamic current, ultrasound, transcutaneous electric nerve stimulation and laser). All in all, 41 clinics with 2,018 treatment confrontations in the examination period, the last week of March 1990, took part in the survey. The majority of therapists were in possession of short wave, hot packs, ultrasound and laser which are also the four forms of therapy most frequently used for treatment. Compared to a Swedish examination from 1979, there is a doubling in ultrasound treatments from 24% to 48%, while the amount of short wave and microwave treatment remained unchanged. There was a remarkable variation in the physiotherapist's choice of therapy in each different diagnosed case. This can be due to the lack of specification of the diagnosis, so that different symptoms, course and stage of illness changed the treatment pattern elected.

Efficiency of the countercurrent transfer of heat and 133Xenon between the pampiniform plexus and testicular artery of the bull under in-vitro conditions

The efficiency of countercurrent transfer of heat and 133Xenon (133Xn) in spermatic cords of the bull was measured under in-vitro conditions. Plasma was pumped through the artery and veins via two separate systems under controlled temperature conditions. Cold plasma or 133Xn-saline was introduced into the afferent veins and the transfer of heat or gas from the venous to the arterial side was measured. The mean efficiency of heat transfer was found to be 91% in five experiments. In four experiments a mean of 12% of the radioactive gas introduced into the venous system was recovered from the arterial side. It is concluded that the countercurrent transfer system in the spermatic cord is very effective with respect to the transfer of heat and probably moderately effective in the transfer of inert gases. The transfer is probably due to diffusion as eventual transfer through arterio-venous shunts was minimal.