Incidence and one year outcome of periprocedural myocardial infarction following cardiac surgery: are the universal definition and SCAI criteria fit for purpose?

Introduction

The diagnosis and clinical implication of periprocedural myocardial infarction (PPMI) following coronary artery bypass grafting (CABG) is contentious, especially given its importance in the interpretation of trial data. Two accepted definitions of PPMI yield discrepant results. Little is known about the association between the diagnosis of PPMI, using high sensitivity troponin (hs-cTn), and medium term mortality in patients who undergo CABG, either alone or in conjunction with another procedure. In addition, there are currently no criteria for the diagnosis of PPMI following non-CABG surgery.

Method

Consecutive patients admitted to a cardiothoracic critical care unit (CCCU) over a six month period following open cardiac surgery had hs-cTnI assay performed on admission and every day for forty-eight hours, regardless of whether there was a clinical indication. Patients were categorised as PPMI using both the Universal Definition of MI (UDMI) and Society of Cardiovascular Angiography and Interventions (SCAI) criteria. Comorbidity data, surgical details and clinical progress in CCCU were recorded. One year mortality data were obtained from NHS Digital.

Results

There were 245 CABG patients, of whom 20.4% met criteria for UDMI PPMI and 87.6% for SCAI UDMI (figure 1). The diagnosis of UDMI PPMI was independently associated with one year mortality (hazard ratio 4.175 (95% confidence interval 1.281 – 13.608)), whereas there was no association between SCAI PPMI and one year mortality (figure 2). Of the 243 patients who had non CABG cardiac surgery, 11.4% met criteria for UDMI PPMI and 85.2% for SCAI PPMI (figure1) but neither was associated with one year mortality.

Conclusions

The incidence of SCAI PPMI in a real world cohort of cardiac surgery patients is so high as to be of limited clinical value. By contrast, a diagnosis of UDMI PPMI post CABG is independently associated with one year mortality, so may have clinical utility.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Beckman Coulter - supplied the assays used in the study but had no role in the study Figure 1. Frequency of PPMIFigure 2. Kaplan Meier curves

The relationship between high-sensitivity troponin taken on admission to critical care, regardless of whether there was a clinical indication for testing, and one year mortality

Introduction

High-sensitivity troponin (hs-cTn) assays now form a key component of the diagnostic pathways for patients presenting to emergency medical services with chest pain. However, hs-cTn concentrations above the manufacturer-provided upper limit of normal (ULN) are now frequently reported in patients presenting with conditions not traditionally associated with type 1 myocardial infarction (T1MI). This is particularly true of severe illness states. We investigated the possible association between hs-cTn and 1 year mortality in critical care patients.

Method

Consecutive patients admitted to two adult critical care units (general critical care unit (GCCU) and neuroscience critical care unit (NCCU)) over a six month period had hs-cTnI assay performed on admission, regardless of whether there was a clinical indication, and the results nested unless a clinical request had been made. Comorbidity data, illness severity and critical care outcome were recorded and have been previously reported. One year mortality data were obtained from NHS Digital.

Results

After excluding patients diagnosed with T1MI by the clinical team, there were 1,033 patients remaining. At one year a total of 253 (24.5%) patients had died. The Kaplan-Meier curves in figure 1 demonstrate a positive association between mortality and increasing hs-cTnI concentrations relative to the ULN. Specifically, using the log-rank test, the mortality at one year was significantly higher (p<0.001) in patients with hs-cTnI concentrations above the ULN. Furthermore, on multivariable Cox regression analysis, the log(10) hs-cTnI concentration was independently associated with the hazard of one year mortality (hazard ratio 1.587 (95% confidence interval 1.358–1.856).

Conclusions

These data suggest that admission hs-cTnI is a biomarker for one year mortality in critical care patients. Further work is now required to assess whether any medical intervention can alter this risk.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Beckman Coulter provided the assays for the tests used in this study. They had no other involvement in the study

Distribution of high sensitivity troponin taken without conventional clinical indications in critical care patients and its association with mortality

Background

High sensitivity troponin (hs-cTn) concentrations above the manufacturer's upper limit of normal (ULN) are frequently seen outside the context of MI, particularly in critical care units. The current evidence regarding the prognostic value of hs-cTn in critical care settings is discrepant.

Purpose

To describe the distribution of hs-cTn in a consecutive cohort of patients in critical care units, regardless of whether there is a conventional clinical indication, and the association of this distribution with clinical outcomes.

Methods

Consecutive patients admitted to three adult critical care units (cardiothoracic (CCU), general (GCU), neuroscience (NCU)) over a six month period had hs-cTnI tests performed serially throughout the admission, regardless of whether the supervising team felt there was a clinical indication. The results were nested and not revealed to patients or clinicians unless they were requested as part of routine care. The hs-cTnI results were correlated with parameters of clinical outcome.

Results

After excluding those diagnosed with a type 1 MI, there were 1,563 patients remaining in the study cohort (CCU 530, GCU 750, NCU 283). The median hs-cTnI was 77ng/L (IQR 11–1932ng/L, with 1081 (69.2%) patients above the manufacturer-provided ULN. Overall there was a bimodal distribution; GCU and NCU were positively skewed and CCU negatively skewed. Hs-cTnI concentrations above the ULN were associated with age, comorbidity, illness severity and need for organ support (table 1). The degree by which the hs-cTnI concentration was above the ULN remained an independent predictor of critical care mortality (figure 1) in NCU and GCU.

Conclusion

Hs-cTnI elevation taken outside the context of conventional clinical indications is common in the critically ill and is associated with age, comorbidity and illness severity. Admission hs-cTnI is an independent predictor of mortality and provides additional discriminative ability to the APACHE II score alone. This assay may represent a novel prognostic biomarker on admission in non-CCU critical care settings.

Mortality relative to ULN

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Beckman Coulter

NICU lactation consultant increases percentage of outborn versus inborn babies receiving human milk

OBJECTIVE

To determine the effect of a dedicated lactation consultant (LC) on the percentage of neonates receiving any human milk in the neonatal intensive care unit (NICU) and at discharge over time.

STUDY DESIGN

Retrospective chart review of three time periods of 3 months each; Time period 1 (before LC hire), Time period 2 (T2; after LC arrival) and Time period 3 (subsequent period after T2).

RESULT

Percentage of infants receiving any HM during hospital stay and at discharge increased significantly over time after LC hire and with LC experience. Outborn (OB) infants receiving any HM in the NICU and at discharge increased over time, but there was no significant change for inborn infants, as the proportion receiving any HM remained consistently high over time.

CONCLUSION

Addition of a dedicated LC to the NICU increased the percentage of neonates receiving any HM, specifically in the OB population.

Norms of the Rorschach Test for Indian Subjects

BACKGROUND

The clinical utility of the Rorschach test in Indians is hampered by the absence of reliable normative data. Method : The Rorschach by Dlopfer's method was administrated to 1256 subjects consisting of 300 normal army personnel, 300 normal civilians, 250 schizophrenics, 300 neurotics and 106 patients with organic disorders.

RESULTS

The Rorschach protocols of normal Indian army personnel and normal civilians showed significant differences from one another and also from the western norms. These differences are culturally determined and are not indicative of low intelligence or psychopathology. Patients with schizophrenia, neurosis, head injury and epilepsy show significant differences from the records of normal subjects. The protocols of army schizophrenics show significant deviations from those of normal army personnel and these changes revert to normal with clinical recovery.

CONCLUSION

The Rorschach test is not a culture fee test as claimed earlier. In view of the differences from Western norms, Rorschach protocols of Indians should be interpreted using the norms for Indians. In the case of army personnel the norms for army personnel should be used. While the use of the Rorschach to study the personality patterns of normal individuals and as an aid to clinical diagnosis was strongly supported, the findings of the study indicate that the test can also be employed to assess therapeutic response of patients with schizophrenia.

Functional analysis of aberrant behavior through measurement of separate response topographies

Functional analysis results for multiple topographies of aberrant behavior were graphed in an aggregate fashion and then separately for 48 clients. The results indicated that multiple topographies of behavior may be maintained by different contingencies. These results indicate that graphing functional analysis data in an aggregate fashion and then separately may improve the accuracy of their interpretation.

Prevalence of Australia antigen (HBsAg) in institutionalised patients with psychosis

In a study of 100 institutionalised patients with psychosis and an equal number of age- and sex-matched healthy controls from the same regional background, the prevalence of Australia antigen (HBsAg) was 11 and 2, respectively. Institutionalised psychotic patients are a high-risk group for hepatitis B virus infection.

Urinary incontinence in acute psychosis

A prospective two year study of consecutive admissions (n=984) to a psychiatry ward revealed that the incidence of temporary urinary incontinence in psychiatric patients without delirium or dementia was 1.63% (n=l6). When compared with controls (n=64) the incontinent patients were more often psychotic, gave a history of childhood enuresis and a past history of temporary incontinence during psychosis. Compared with psychotic controls (n=26), incontinent patients (n=16) had been exposed to a greater variety of treatments and were hospitalized for longer periods.

AUSTRALIA ANTIGEN (HBsAG) IN INSTITUTIONALISED SCHIZOPHRENICS

In a study of sixty institutionalist Schizophrenic patients, sixty chronic schizophrenic outpatients and an equal number of age and sex matched normal controls from the same regional background, the prevalence of HBsAG was six, one and zero respectively. Institutionalized schizophrenic patients are a high risk group for hepatitis B virus infection.

Post - cataractomy delirium : a two year prospective study

A two year prospective study of 221 consecutive inpatients undergoing cataractomy revealed the incidence of post-cataractomy delirium to be 1.8%. While in one case the delirium was due to anticholinergic toxicity, in the remaining three cases no organic cause was evident. Sensory deprivation was present in two patients. Preventive measures for the condition are discussed.

Cardiogenic shock with imipramine

A 35 years old physically healthy individual, being treated far depression with imipramine and electroplexy, developed cardiogenic shock which was managed successfully with inotropic support. The case is presented to highlight a rare and potentially fatal side effect of tricyclic anti-depressants.

Monosymptomatic hypochondriacal psychosis-2 case reports

Two patients with monosymptoniatic hypochondriacal psychosis are reported and the condition is briefly discussed.

The dexamethasone supperssion test in endogenous depression

In 34 patients of endogenous depression and 30 normal controls, the dexamethasone suppression test (DST) had a sensitivity of 67.6%, a specificity of 93.3% and a positive predictive power of 92%, which compares favourably with other diagnostic tests in clinical medicine. DST non-suppressors were significantly more depressed as compared to DST suppressors, had a higher incidence of suicidal attempts and past and family history of depression, needed electroconvulsive therapy more often, but showed a better response to therapy. Though the claim of the DST being a specific biological marker for endogenous depression remains controversial, it is an useful investigative tool for the diagnosis and treatment of endogenous depression.