FIBRILLATION OF THE AURICLES: ITS EFFECTS UPON THE CIRCULATION

When the auricles fibrillate, the following effects are observed. 1. The arterial blood pressure may rise, fall, or remain stationary. Usually it falls. If it falls, it generally rises again towards or to the initial pressure. 2. The venous pressure changes are the reverse of the arterial. 3. The intestinal volume and the cardiac output changes are in the same direction as those of arterial blood pressure. 4. From these observations it may be concluded that the peripheral circulatory effects are purely passive. 5. The volume of the heart decreases except in instances where there is reason to believe that the circulation is failing. All the changes described in the foregoing paragraphs, and also the variations in blood pressure reactions which occur from time to time, are attributable to alterations in the rate of ventricular contraction. Similar, though perhaps less profound changes, are seen when the heart rate accelerates in like degree in response to regular induction shocks.

High-throughput whole-genome sequencing to dissect the epidemiology of Acinetobacter baumannii isolates from a hospital outbreak

Shared care of military and civilian patients has resulted in transmission of multidrug-resistant Acinetobacter baumannii (MDR-Aci) from military casualties to civilians. Current typing technologies have been useful in revealing relationships between isolates of A. baumannii but they are unable to resolve differences between closely related isolates from small-scale outbreaks, where chains of transmission are often unclear. In a recent hospital outbreak in Birmingham, six patients were colonised with MDR-Aci isolates indistinguishable using standard techniques. We used whole-genome sequencing to identify single nucleotide polymorphisms in these isolates, allowing us to discriminate between alternative epidemiological hypotheses in this setting.

Management of obstetric anal sphincter injuries at the University Hospital of the West Indies

Up to 6% of women sustain severe perineal lacerations that involve the anal sphincters during vaginal delivery. When they occur obstetric anal sphincter injuries (OASI) may be accompanied by significant morbidity. Therefore, it is important to detect these injuries promptly and for experienced staff to perform sound repair. This report retrospectively assesses a series of seven women with OASI who were managed at a tertiary level hospital in Jamaica over a period of 28 months. Unfavourable details of management that may have adversely affected outcomes were sought from the various cases treated The incidence of OASI was low (0.2%). There were five third degree and two fourth degree lacerations. After these injuries were repaired, three patients (43%) experienced morbidity such as chronic pelvic pain (43%), anal incontinence (29%), dyspareunia (23%) and recto-vaginal fistulae (14%). In order to improve the outcomes at this institution, several aspects of current care can be improved. Operative repair of these injuries should be delayed until senior staff is available to supervise OASI repair. Both methods of sphincter repair are reasonable options but the use of rapidly absorbable sutures is not appropriate. Finally, prophylaxis against wound infections can be achieved by administering a single dose of intravenous second or third generation cephalosporin at the time of induction of anaesthesia.

A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces

Hospital cleaning continues to attract patient, media and political attention. In the UK it is still primarily assessed via visual inspection, which can be misleading. Calls have therefore been made for a more objective approach to assessing surface cleanliness. To improve the management of hospital cleaning the use of adenosine triphosphate (ATP) in combination with microbiological analysis has been proposed, with a general ATP benchmark value of 500 relative light units (RLU) for one combination of test and equipment. In this study, the same test combination was used to assess cleaning effectiveness in a 1300-bed teaching hospital after routine and modified cleaning protocols. Based upon the ATP results a revised stricter pass/fail benchmark of 250 RLU is proposed for the range of surfaces used in this study. This was routinely achieved using modified best practice cleaning procedures which also gave reduced surface counts with, for example, aerobic colony counts reduced from >100 to <2.5 cfu/cm(2), and counts of Staphylococcus aureus reduced from up to 2.5 to <1 cfu/cm(2) (95% of the time). Benchmarking is linked to incremental quality improvements and both the original suggestion of 500 RLU and the revised figure of 250 RLU can be used by hospitals as part of this process. They can also be used in the assessment of novel cleaning methods, such as steam cleaning and microfibre cloths, which have potential use in the National Health Service.

The elder patient with suspected acute coronary syndromes in the emergency department

OBJECTIVES

To describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED).

METHODS

This was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients.

RESULTS

A total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients.

CONCLUSIONS

Elder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age.

Discovery of new C3aR ligands. Part 1: Arginine derivatives

The synthesis and in vitro binding of several new arginine-containing C3aR ligands are reported. DMPK properties and functional activities of selected compounds have been evaluated. One compound is shown to be active in an in vivo model of airway inflammation after aerosol administration.