Early standardized clinical judgement for syncope diagnosis in the emergency department

BACKGROUND

The diagnosis of cardiac syncope remains a challenge in the emergency department (ED).

OBJECTIVE

Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score.

METHODS

In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ.

RESULTS

Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy.

CONCLUSION

ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

Incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope

Background

Cardiac syncope has been shown to carry the highest hazard for all-cause death compared to other causes of syncope including vasovagal and orthostatic syncope. However, little is known about the incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope.

Purpose

To evaluate the incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope.

Methods

We enrolled patients presenting to the emergency department (ED) with syncope in a large prospective international multicentre study. The cause of syncope (cardiac vs non-cardiac) including the detailed cardiac aetiology (if cardiac) was centrally adjudicated by two independent cardiologists based on detailed in-hospital as well as outpatient cardiac work-up during 360 days following presentation. Cardiac syncope was classified into four groups: bradyarrhythmia, tachyarrhythmia, structural disease and other (cardiopulmonary and great vessels), as recommended in the ESC Syncope Guidelines. All-cause death during 2-years follow-up was the primary outcome.

Results

Among 2025 patients presenting with syncope to the ED, cardiac syncope was the final adjudicated diagnoses in 318 (15.7%) patients. The incidence rate of all-cause death among cardiac syncope patients was 103 cases per 1000 person-years. Bradyarrhythmia was the most frequent primary cause of cardiac syncope (n=146, 45.9%) followed by tachyarrhythmia (n=75, 23.6%), structural disease (n=64, 20.1%) and other cardiac (n=26, 8.2%). Patients were 37% female with a median age of 77 years (IQR 67–83) showing no statistically significant difference between subgroups. Clinical characteristics differed significantly among the four subgroups. E.g. syncope occurred during exercise in 12 patients (8.2%) with bradyarrhythmia, 10 patients (13.3%) with tachyarrhythmia, 16 patients (25%) with structural disease, and 5 patients (19%) with other cardiac (p&lt;0.01). Likely of most importance, long-term mortality differed significantly among the four different cardiac subgroups. The multivariable-adjusted hazard ratios (HR) among patients with bradyarrhythmia, tachyarrhythmia, structural disease and other cardiac as compared to patients with vasovagal syncope, the HR were 1.3 (95% CI 0.7–2.5), 4.6 (95% CI 2.3–9.1), 3.1 (95% CI 1.5–6.4) and 5.9 (95% CI 2.3–15.2), respectively (Figure 1).

Conclusions

Bradyarrhythmia, tachyarrhythmia, and structural cardiac disease are the dominant causes of cardiac syncope. Interestingly, with the appropriate therapy initiated long-term mortality of bradyarrhythmia is comparable to that of vasovagal syncope, while long-term mortality of tachyarrhythmia and structural cardiac disease were substantially increased 3 to 5 fold.

Figure 1. Kaplan-Meier curve

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel and the University Hospital Basel.

Validation of a machine learned model to predict the diagnosis of myocardial infarction

Introduction

The myocardial-ischemic-injury-index (MI3) is a promising machine learned algorithm that predicts the likelihood of myocardial infarction in patients with suspected acute coronary syndrome. Whether this algorithm performs well in unselected patients or predicts recurrent events is unknown.

Methods

In an observational analysis from a multi-centre randomised trial, we included all patients with suspected acute coronary syndrome and serial high-sensitivity cardiac troponin I measurements without ST-segment elevation myocardial infarction. Using gradient boosting, MI3 incorporates age, sex, and two troponin measurements to compute a value (0–100) reflecting an individual's likelihood of myocardial infarction, and estimates the negative predictive value (NPV) and positive predictive value (PPV). Model performance for an index diagnosis of myocardial infarction, and for subsequent myocardial infarction or cardiovascular death at one year was determined using previously defined low- and high-probability thresholds (1.6 and 49.7, respectively).

Results

In total 20,761 of 48,282 (43%) patients (64±16 years, 46% women) were eligible of whom 3,278 (15.8%) had myocardial infarction. MI3 was well discriminated with an area under the receiver-operating-characteristic curve of 0.949 (95% confidence interval 0.946–0.952) identifying 12,983 (62.5%) patients as low-probability (sensitivity 99.3% [99.0–99.6%], NPV 99.8% [99.8–99.9%]), and 2,961 (14.3%) as high-probability (specificity 95.0% [94.7–95.3%], PPV 70.4% [69–71.9%]). At one year, subsequent myocardial infarction or cardiovascular death occurred more often in high-probability compared to low-probability patients (17.6% [520/2,961] versus 1.5% [197/12,983], P&lt;0.001).

Conclusions

In unselected consecutive patients with suspected acute coronary syndrome, the MI3 algorithm accurately estimates the likelihood of myocardial infarction and predicts probability of subsequent adverse cardiovascular events.

Performance of MI3 at example thresholds

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Medical Research Council

Utility of echocardiography in patients with suspected acute myocardial infarction in the presence of left bundle-branch block

Background

Rapid identification of acute myocardial infarction (AMI) as life-threatening disorder by clinical assessment, cardiac troponin and the electrocardiogram (ECG) is important for the early initiation of highly effective, evidence-based therapy. Patients presenting with suspected AMI and left bundle branch block (LBBB) to the emergency department (ED) represent a unique diagnostic and therapeutic challenge, as altered ventricular depolarization masks changes in ventricular repolarization associated with myocardial ischemia. Current guidelines suggest, based on expert opinion, early echocardiography as a helpful tool in patients with suspected AMI and LBBB to identify new wall motion abnormalities, which guides further diagnostics strategies in these patients.

Purpose

To evaluate the diagnostic accuracy of echocardiography among patients with suspected AMI and LBBB in the recorded ECG at ED presentation.

Methods

We prospectively evaluated the diagnostic accuracy of echocardiography in patients with LBBB presenting with chest discomfort to 26 ED's in three international, prospective, diagnostic studies. Two independent cardiologists centrally adjudicated the final diagnosis in each study according to the universal definition of myocardial infarction. All patients underwent a clinical assessment that included standardized and detailed medical history including assessment of chest pain characteristics, vital signs, physical examination, 12-lead ECG, continuous ECG rhythm monitoring, pulse oximetry, standard blood test, and chest radiography and echocardiography if indicated. We compared echocardiographic findings in patients with LBBB who were diagnosed with an AMI to those without an AMI.

Results

Among 283 patients presenting with chest pain and LBBB to the ED, AMI was the final diagnosis in 36% (102 of 283 patients) of patients. An echocardiography had been performed in 100/283 patients (35%) in the emergency department. AMI was the final diagnosis in 41/100 (41%) of patients. A wall motion abnormality in any region was seen in 77 (77%) of patients with no difference between patients diagnosed with AMI (33 patients, 81%) versus without AMI (44 patients, 75%, p=0.49). Additionally, we found no differences for each wall region (Table 1). Most patients with LBBB had moderately reduced left ventricular ejection fraction (LVEF, median 40%), a dilated left atrium (67%) or left ventricular hypertrophy (55%) without any differences between the two groups (Table 1).

Conclusions

Early echocardiography in patients with suspected AMI and LBBB provided only limited utility to identify patients, which may benefit from immediate coronary angiography. Our findings scrutinize current guidelines and downgrades the utility of echocardiography in this setting.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Queensland Emergency Medicine Research Foundation, Christchurch Heart Institute and Health Research Council and Heart Foundation of New Zealand, Christchurch Emergency Care Foundation

P2723Diagnosis of acute myocardial infarction in the presence of left bundle-branch block

Objective

Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician.

Methods

We prospectively evaluated incidence of AMI, and diagnostic performance of specific electrocardiographic (ECG) and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. Presence of LBBB, ECG criteria, and final diagnoses were centrally adjudicated by two independent cardiologists using the fourth universal definition of myocardial infarction.

Results

Among 8830 patients, LBBB was present in 247 patients (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1–12%), but high specificity (95–100%). The diagnostic accuracy as quantified by the receiver-operating-characteristics curve of hs-cTnT and hs-cTnI concentrations at presentation (AUC 0.91; 95% CI 0.85–0.96 and 0.89; 95% CI 0.83–0.95) as well as that of their 0/1h and 0/2h changes was very high. A diagnostic algorithm (Figure 1) combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1h or 2h derived in cohort 1 (45 of 45 (100%) of patients with AMI correctly identified), showed high efficacy and accuracy when externally validated in cohort 2 & 3 (28 of 29 patients, 97%).

Figure 1

Conclusion

Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with Hs-cTn testing at 0/1h or 0/2h allows early and accurate diagnosis of AMI in LBBB.

Acknowledgement/Funding

European Union, Swiss National Foundation, University Hospital Basel, University Basel

P1756The protein APRIL predicts adverse outcomes in DAPT patients better than NT-proBNP and troponin

Aim

Dual antiplatelet therapy (DAPT) is a mainstay of post-ACS treatment. However, prediction of adverse events in these patients needs improving. We show here that the TNFα-related protein APRIL (which is produced in platelets and atherosclerotic plaque) is a superior predictor of MACE and new MI in DAPT recipients post-ACS.

Methods

We prospectively recruited 518 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated to have ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for APRIL measurements using a two site ELISA. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP were also measured. Statistical assessments were made using SPSS v23 (IBM). Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative diagnostic abilities of APRIL, hsTnT, NT-proBNP and hsTnI were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis. The comparative power of each biomarker (log values) to predict new MACE, MI, bleeding and mortality in 1) the whole group and in 2) DAPT recipients alone, within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT, with APRIL and NT-proBNP each included in additional multivariate analyses.

Results

Of the 518 recruited patients (median age 63 (IQR: 54–73, 35% female), 152 were adjudicated to have ACS (29%, 115 MI, 37 UAP). Presentation APRIL levels were higher in those with a cardiac versus non-cardiac cause for presentation (3.0, (2.0–4.7) vs. 2.4, (1.6–3.8) ng/mL, P=0.001) and positively correlated with hsTnT and NT-proBNP (all P<0.001), but it did not add to the hsTnI (ROC = 0.96) or hsTnT (ROC =0.92) assisted diagnosis of ACS. In all 518 patients, in the multivariate regression model, APRIL was a significant independent predictor of mortality (n=54, P=0.032), new MI (n=43, P=0.006), new ADHF (n=24, P=0.016) and MACE (n=71, P=0.005) that was additive to NT-proBNP and troponin. In DAPT recipients alone (n=156), APRIL was the only biomarker to independently predict new MI (n=27, 95% CI: 1.125–3.982, P=0.020) and MACE (n=37, 95% CI: 1.058–3.389, P=0.031). None of the markers, only age, predicted bleeding episodes.

Conclusion

APRIL is an platelet/plaque derived marker that provides independent risk assessment in ACS patients. In DAPT recipients, the ability of APRIL to predict new MI and MACE is superior to that of cardiac troponins and NT-proBNP and could be used to identify high risk individuals.

Acknowledgement/Funding

Health Research Council of New Zealand; Heart Foundation of New Zealand

P2674Rapid rule-out of myocardial infarction with a novel high precision point-of-care troponin assay appears safe and effective

Background

High sensitivity troponin assays were developed to improve analytical sensitivity and precision at the decision cut-points for the diagnosis and rule out of acute myocardial infarction (AMI). Central laboratory assays have achieved this but point of care assays, which have the ability to accelerate decision making due to much shorter turnaround times, have remained lacking.

Purpose

To ascertain the threshold for decision making and subsequent clinical utility for ruling out AMI on presentation in patients attending the emergency department acutely with chest pain, using a high precision point of care troponin assay (TnI Nx), (i-STAT, Abbott).

Methods

We measured arrival TnI-Nx concentrations in stored plasma samples in adults presenting acutely to the emergency department with chest pain. The primary outcome was an AMI or cardiac death on index admission or within 30 days. We used 2000 bootstrapped data sets to derive and validate a suitable threshold for TnI-Nx before calculating diagnostic test performance. We pre-specified this threshold must have a <1% false negative rate for the primary outcome. We compared this with a core laboratory high sensitivity troponin I (hs-TnI) (Abbott Architect) using the early rule-out cut-point (European Society of Cardiology) at the limit of detection (2 ng/L).

Results

We recruited 1320 patients of whom 192 (14.1%) had the primary outcome. The TnI-Nx threshold was determined to be 8 ng/L with subsequent sensitivity of 99.0% (95% confidence interval: 97.3% to 100%), negative predictive value of 99.7% (99.2% to 100%) and specificity of 59.0% (56.0% to 62.0%). The hs-TnI had a sensitivity of 99.5% (98.2% to 100%), negative predictive value of 99.7% (99.0% to 100%), and specificity of 28.4% (25.8% to 31.2%) at 2ng/L.

Conclusion

A high precision point of care assay, TnI-Nx, with a decision threshold of 8ng/L, has comparable rule out performance compared with a core laboratory high sensitivity assay and therefore could potentially be used for early decision making in the assessment of acute chest pain.

Acknowledgement/Funding

Research grant from Abbott Point of Care. Senior Research Fellowship from ECF, CMRF and CDHB. Clinical Research Fellowship from NZ HRC

P3408The signal peptide of CNP is a novel predictor of MI, MACE and bleeding risk in chest pain patients

Aim

CNP is an important vascular and cardiac derived member of the natriuretic peptide family. We have previously provided the first reports that the signal peptide of CNP (CNPsp) is present in the human circulation and is elevated in those with chest pain suspicious of ACS. Here, show that CNPsp levels are highly predictive of new MI, MACE and post-index bleeding in patients presenting with potential ACS.

Methods

We prospectively recruited 493 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated as ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for CNPsp measurements using our validated, specific assay. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP (both Roche Cobas e411) were also measured. Statistical assessments were made using SPSS v23. Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative abilities of CNPsp, hsTnT, NT-proBNP and hsTnI (log values) to predict new MACE, MI, bleeding and mortality within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT and NT-proBNP, with CNPsp added to into the multivariate analyses.

Results

Of the 493 recruited patients (median age 63 (IQR: 54–73, 35% female), 148 were adjudicated to have ACS (30%, 109 MI, 39 UAP). Presentation CNPsp levels were not higher in those with adjudicated ACS versus non-ACS (51, (45–65) vs. 50, (42–63) pmol/L, P=0.412), did not correlate with hsTnI, hsTnT or NT-proBNP, but were significantly lower in those with a history of MI (49, (42–59) vs. 51, (43–64) pmol/L, P=0.044). In contrast, they were significantly higher in those with ECG ST-depression (56, (47–85) vs. 50 (42–62) pmol/L, P=0.038). In the multivariate regression model of all 493 patients, lower values of CNPsp were a significant multivariate predictor of new MI (n=37, 95% CI: 0.06–0.89, P=0.038), MACE (n=64, 95% CI: 0.08–0.81, P=0.020) and new bleeding (n=40, 95% CI: 0.05–0.63, P=0.005) within 2 years of presentation. This predictive ability was additive and independent from NT-proBNP and troponin.

Conclusion

This is the first report that CNPsp measurement provides meaningful and independent risk assessment of important outcomes in ACS patients. In particular, the fact that lower levels of CNPsp are predictive of negative MI, MACE and bleeding outcomes suggests that CNPsp may have an unappreciated protective role in the cardiovascular system.

Acknowledgement/Funding

Health Research Council of New Zealand; Heart Foundation of New Zealand

Preinjury characteristics of children with mild traumatic brain injury: Is "other injury" an appropriate comparison group"?

BACKGROUND

Mild traumatic brain injury (mTBI) has been associated with ongoing problems in children and young people. However, there remains to be considerable debate regarding whether outcomes are a result of brain impairment, or simply reflect preinjury characteristics of the child or family. To reliably assess outcomes, an appropriate control group is required.

AIMS

This study aimed to identify the preinjury characteristics of children with mTBI, and to examine whether an "other injury to the head" group is an appropriate comparison to control for preinjury characteristics of children with mTBI.

METHOD

Parents of 290 children admitted to the emergency department with either a diagnosis of mTBI (n = 186, M = 6.44 years) or a superficial injury to the head (SIH) (n = 104, M = 5.40 years) were assessed. Parents completed three questionnaires examining behavioral problems (Clinical Assessment of Behavior), parental stress (Parenting Stress Index), and background variables (e.g., medical issues, socioeconomic factors).

RESULTS

A series of chi-square analyses and multivariate analysis of variance tests revealed no differences for behavior, parental stress, and other preexisting problems between children with mTBI and those with SIH.

CONCLUSIONS

Children who experience a mTBI event present similarly to individuals with a SIH, and SIH is an appropriate comparison group to examine the outcomes of childhood mTBI, as it may help minimize any confounding effects of preexisting issues associated with mTBI.

Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests

OBJECTIVE

To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain.

METHODS

International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days.

RESULTS

15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as 'ruled out' with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were 'ruled out' with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients 'ruled out' defined by the hsTnI and hsTnT algorithms, respectively.

CONCLUSIONS

The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification.

TRIAL REGISTRATION NUMBER

ACTRN12611001069943, NCT00470587; post-results.

Treatment of ulcerated necrobiosis lipoidica with ovine forestomach matrix

Necrobiosis lipoidica (NL) results from degradation of the collagen extracellular matrix; these recurring ulcerated lesions are an especially challenging condition to treat. Ovine forestomach matrix (OFM) is a decellularised extracellular matrix and was used to successfully close a pretibial ulcer resulting from NL. Complete closure of the wound was achieved in 22 weeks, after four applications of OFM. This suggests OFM may be considered for the treatment of these challenging wounds.

Functional analysis of the miRNA-mRNA interaction network in C. elegans

MicroRNAs (miRNAs) are conserved small non-coding RNAs that typically regulate gene expression by binding to the 3' untranslated region (UTR) of mRNAs. Developmental functions of miRNAs have been extensively studied, but additional roles in various cellular processes remain to be understood. The investigation of the biological importance of individual miRNA-target interactions and the miRNA-target interaction network as a whole has been an exciting and challenging field of study. Here we briefly discuss the contributions our lab has made to our understanding of the physiological impact of this miRNA-network in C. elegans, in the context of recent studies in this advancing field. These studies have advanced our knowledge of the role of miRNAs in ensuring a robust cellular response to different physiological conditions. We briefly outline the genetic, biochemical, and computational strategies utilized to understand miRNA functions and discuss our recent study of the miRNA-interaction network in neurons and potential directions for future studies.

Variations of the origin and branches of the external carotid artery in a human cadaver

We report a unique variation in the origin and branches of both the left and right external carotid artery (ECA) found during the dissection of a human cadaver. Knowledge of the possible anatomical variations of the ECA is especially important in facio-maxillary and neck surgeries. Surgeons need to be aware of the possibility of encountering such variations, as they may lead to difficulties in differentiating between the external and internal carotid arteries, and in identifying the branches and origins. This knowledge is also important for radiologists in the image interpretation of the face and neck regions.

Cigarette, alcohol use and physical activity among Myanmar youth workers, Samut Sakhon Province, Thailand

Over 1.2 million migrants from Myanmar are currently residing in Thailand. Little information is known about Myanmar youth risk behaviors. This cross-sectional study aimed to determine the prevalence and the factors associated with cigarette and alcohol use, and physical inactivity, among Myanmar youth working in a harbor town in Samut Sakhon Province, Thailand. One hundred and seventy-seven young workers aged 15-24 years, living in the study area, were interviewed by structured questionnaire. About 21.5% were current smokers, 25.4% were alcohol drinkers, and 36.7% were physically inactive. Univariate analysis indicated one variable was significantly associated with cigarette smoking: education level higher than primary school (OR=2.3, 95% CI 1.02-5.0), Three variables were significantly associated with alcohol drinking: married status (OR=2.2, 95%CI 1.02-4.5); non-seafood-processing workers, i e, street vendors, construction laborers, etc. (OR=3.4, 95% CI 1.7-7.1), and high job stress due to supervisor/boss (OR=2.1 95% CI 1.1-4.2). Two variables were significantly associated with physical inactivity: female youth (OR=3.9 95% CI 2.1-7.5), and education level higher than primary school (OR=0.4, 95% CI 0.2-0.8). The prevalence of smoking, alcohol drinking and physical inactivity among Myanmar migrant youths was quite high. Government and non-government organizations should co-operate to provide interventions to reduce youths' risk behaviors.

Dermatoglyphic analysis in Malay subjects with bipolar mood disorder

Dermatoglyphic is the study of the epidermal ridges and the pattern formed by them. It may be pointed out that genetic factors have a large share in determining the variations in dermatoglyphics. It is however, suggested by evidence that bipolar mood disorder factors are determined more by genetic factors than by the environmental factors. The experiment has been undertaken to look for the effects of the bipolar mood disorder on dermatoglyphics. The dermatoglyphic characteristics of subjects with bipolar mood disorder when compared with control group revealed significant differences. The radial loop were increased in bipolar mood disorder, but there were little changes in 'atd' angles between normal and bipolar mood disorder.

Ear lobe crease: incidence in a healthy Malay population

The incidence of ear lobe crease (ELC) was studied in 1576 healthy Malay subjects (566 males and 1010 females), randomly selected from the residents of Kota Bharu, Malaysia. ELC was present in 31.1% of males and in 3.6% of females; this difference in incidence between the two sexes is statistically significant (p > 0.05). In males the incidence of Type I crease was highest (10.1%) while that of Type III crease was lowest (2.3%). In females Type II crease showed the highest incidence (1.9%) and Type III the lowest. The incidence of bilateral presence of all three types of ELC showed an age-related increase in males. The ELC often starts unilaterally and later develops bilaterally and earlier in males than in females.

Can the distance fallen predict serious injury after a fall from a height?

BACKGROUND

After a fall, the distance fallen is sometimes used to predict the injury severity. We aimed to examine how distance fallen performs as a predictor of major injury.

METHOD

A cohort of trauma victims attending our emergency department after having fallen from a height was identified retrospectively, and data were collected regarding the fall and injuries sustained. Performance of threshold heights, ranging from 2 meters (6.6 feet) to 10 meters (32.8 feet), as a diagnostic test for major injury was assessed.

RESULTS

Height fallen performed poorly over the range of thresholds used. At low thresholds, sensitivity was inadequate to rule out major trauma, whereas the low prevalence meant that, despite impressive specificity at higher thresholds, positive predictive value was poor. At the optimal threshold of 5 meters (16.4 feet), the positive predictive value was 0.17 and sensitivity was 0.33.

CONCLUSION

Height of fall is a poor predictor of major injury.

Pre-operative blood tests in children undergoing plastic surgery

In a retrospective review of 1177 children presenting for plastic surgical procedures, investigations were performed in 487 and abnormal results were found in 138 as defined by variation from the local laboratory reference range. Most of the abnormalities were of no clinical significance. Twenty one children had abnormal haemoglobin results (the lowest was 9 g/dl) and 101 children had clinically insignificant platelet or white cell abnormalities. One child, with a family history of sickle cell trait, was confirmed as sickle-cell trait. No case was postponed as a result of these investigations. The non-selective ordering of pre-operative blood tests leads to unnecessary patient discomfort, the potential for additional superfluous investigations and higher costs.

Decreased sensory neuropeptide release from trachea of rats with streptozotocin-induced diabetes

We studied the release of somatostatin, calcitonin gene-related peptide (CGRP) and substance P in response to electrical field stimulation from isolated tracheas of rats following 4 weeks of streptozotocin (50 mg/kg i.v.)-induced diabetes. Field stimulation (40 V, 0.1 ms, 10 Hz for 120 s) increased the release of somatostatin, CGRP and substance P from the baseline 0.18+/-0.029, 0.17+/-0.027, and 1.77+/-0.086 to 0.51+/-0.022, 0.69+/-0.115, and 5.96+/-0.377 in control preparations and 0.31+/-0.081, 0.41+/-0.142, and 3.14+/-0.443 fmol/mg wet tissue weight in preparations from diabetic rats as measured by radioimmunoassay (control vs. diabetic P<0.01 for each). The results show a simultaneous decrease in release of the three sensory neuropeptides and an enhanced plasma somatostatin level in rats with streptozotocin-induced diabetes.

Normal values for total hand length, palm length and middle finger length in Malaysian newborns from 34-42 weeks of gestation

Early identification of a syndrome at birth is of paramount importance for genetic counselling and possible prevention. Often malformation of the hands and fingers are cardinal manifestations of recognizable syndromes. As there are no published standards for hand and finger size for Malay newborn infants, this study was undertaken to establish normal values for hand, middle finger and palmar lengths, and their indices. A cross-sectional study was done on 509 consecutive newborn Malay babies between 34 and 42 weeks of gestation. Measurements were made on the right hand according to the recommended guidelines of Bergsma & Feingold (1975). The mean values for the measurements did not differ significantly between boys and girls, or change with gestation. For the whole group the mean value for total hand length was 64.4 +/- 3.42 mm, middle finger length 37.1 +/- 2.91 mm, palmar length 27.4 +/- 2.15 mm, finger index 0.425 +/- 0.03 and palmar index 0.58 +/- 0.03. A comparison with published measurements for newborns of different racial origin shows significant differences for the total hand length, middle finger length and palm length from Indian and Jewish infants, but not from Japanese infants. The indices were similar in Malay, Indian, Jewish and Japanese newborn infants.

Dermatoglyphics of Down's syndrome patients in Malays--a comparative study

There has been no recent report on the dermatoglyphics of the Malays (normal population as well as patients with Down's syndrome). A study on the frequencies of the dermal patterns (dermatoglyphics) of the digits, palms and hallucal areas was done therefore in 40 Malay patients with Down's syndrome and 200 unrelated normal controls. Only the patients with the standard 21 trisomy karyotype were included in the study. Comparison was made with the published data on studies done in various racial groups. Significant differences of the dermal patterns were found not only between the controls but also among patients of different races.

Variations in the formation of the cardiac plexus--a study in human foetuses

The origin and distribution of nerves forming the cardiac plexus and the subdivision of this plexus were studied in six human foetuses (2 male, 4 female) of gestational ages 30 to 40 weeks. The cardiac plexus was not divided into superficial and deep parts in any foetus. True plexiform arrangement of nerves forming the cardiac plexus was seen only after the nerves reached the walls of the heart. The sympathetic trunks, vagi, recurrent laryngeal nerves and phrenic nerves of both sides contributed to the cardiac plexus. The cervical sympathetic trunk showed only two ganglia bilaterally in one foetus; this has not been reported before. In one foetus on the right side, the middle cervical sympathetic cardiac branch joined the recurrent laryngeal and the phrenic nerves which has not been reported earlier. The sympathetic pathways to the heart were found to be very variable; no two foetuses showed the same arrangement. Awareness of these variations in the nerves forming the cardiac plexus would enhance the success of sympathectomy to augment cardiac blood flow or to relieve the severity of cardiac pain.

Five anthroposcopic traits of the ear in a Malaysian population

Five anthroposcopic traits concerning the ear, namely ear lobe attachment, position of ears, shape of the helix, presence of Darwin's tubercle and hairy ears have been studied in a Malay population from Malaysia. The results of the present study are compared with similar reports in other ethnic groups.

Assessment of patients' knowledge about their illness and treatment

One hundred and twenty two patients over the age of 65 were questioned about their knowledge of their illness and treatment. They were unaware of a quarter of both their illnesses and medications. There was a considerable lack of knowledge about certain groups of diseases and medications, while patients were much better informed about others. The possible reasons for this discrepancy are briefly discussed and some practical suggestions are put forward.