Use of an accelerated chest pain assessment protocol in patients at intermediate risk of adverse cardiac events

Objective: To determine the feasibility, safety and effectiveness of a structured clinical pathway for stratification and management of patients presenting with chest pain and classified as having intermediate risk of adverse cardiac outcomes in the subsequent six months. Design: Prospective clinical audit. Participants and setting: 630 consecutive patients who presented to the emergency department of a metropolitan tertiary care hospital between January 2000 and June 2001 with chest pain and intermediate-risk features. Intervention: Use of the Accelerated Chest Pain Assessment Protocol (ACPAP), as advocated by the Management of unstable angina guidelines - 2000 from the National Heart Foundation and the Cardiac Society of Australia and New Zealand. Main outcome measure: Adverse cardiac events during six-month follow-up. Results: 409 patients (65%) were reclassified as low risk and discharged at a mean of 14 hours after assessment in the chest pain unit. None had missed myocardial infarctions, while three (1%) had cardiac events at six months (all elective revascularisation procedures, with no readmissions with acute coronary syndromes). Another 110 patients (17%) were reclassified as high risk, and 21 (19%) of these had cardiac events (mainly revascularisations) by six months. Patients who were unable to exercise or had non-diagnostic exercise stress test results (equivocal risk) had an intermediate cardiac event rate (8%). Conclusions: This study validates use of ACPAP. The protocol eliminated missed myocardial infarction; allowed early, safe discharge of low-risk patients; and led to early identification and management of high-risk patients.

CPR training in households of patients with chest pain

The objectives of this study are to (1) quantify prior cardiopulmonary resuscitation (CPR) training in households of patients presenting to the Emergency Department (ED) with or without chest pain or ischaemic heart disease (IHD); (2) evaluate the willingness of household members to undertake CPR training; and (3) identify potential barriers to the learning and provision of bystander CPR. A cross-sectional study was conducted by surveying patients presenting to the ED of a metropolitan teaching hospital over a 6-month period. Two in five households of patients presenting with chest pain or IHD had prior training in CPR. This was no higher than for households of patients presenting without chest pain or IHD. Just under two in three households of patients presenting with chest pain or IHD were willing to participate in future CPR classes. Potential barriers to learning CPR included lack of information on CPR classes, perceived lack of intellectual and/or physical capability to learn CPR and concern about causing anxiety in the person at risk of cardiac arrest. Potential barriers to CPR provision included an unknown cardiac arrest victim and fear of infection. The ED provides an opportunity for increasing family and community capacity for bystander intervention through referral to appropriate training. (C) 2003 Published by Elsevier Science Ireland Ltd.

Effect of storage time and conditions on the cotyledon cell wall of the adzuki bean (Vigna angularis)

Two varieties of adzuki grown in Australia, Bloodwood and Erimo, were stored for up to 6 months at three temperatures (10, 20 and 30 degreesC), and two relative humidities (RH; 40 and 65%). The amount of cell wall material increased with time under all storage conditions. This increase was greatest at 30 degreesC and 40% RH. Storage time and conditions did not affect the total pectin levels in the cell wall. Erimo constantly exhibited a higher total pectin level than Bloodwood. The Bloodwood soluble pectin, Ca++ and Mg++ and Erimo Ca++ in the cell wall remained stable during storage, while the Erimo soluble pectin and Mg++ exhibited a slight decrease at 20 and 30 degreesC after 3 months of storage. (C) 2002 Elsevier Science Ltd. All rights reserved.

Wall mediated transport in confined spaces: Exact theory for low density

We present a theory for the transport of molecules adsorbed in slit and cylindrical nanopores at low density, considering the axial momentum gain of molecules oscillating between diffuse wall reflections. Good agreement with molecular dynamics simulations is obtained over a wide range of pore sizes, including the regime of single-file diffusion where fluid-fluid interactions are shown to have a negligible effect on the collective transport coefficient. We show that dispersive fluid-wall interactions considerably attenuate transport compared to classical hard sphere theory.

Optimizing electrode positioning in 3-lead ECG chest devices

Although the 12-lead electrocardiogram has become an essential medical and research tool, many current and envisaged applications would benefit from simpler devices, using 3-lead ECG configuration. This is particularly true for Ambient Assisted Living (in a broad perspective). However, the chest anatomy of female patients, namely during pregnancy, can hamper the adequate placement of a 3-lead ECG device and, very often, electrodes are placed below the chest rather than at the precise thoracic landmarks. Thus, the aim of this study was to compare the effect of electrode positioning on the ECG signal of pregnant women and provide guidelines for device development. The effect of breast tissue on the ECG signal was investigated by relating breast size with the signal-to-noise ratio, root mean square and R-wave amplitude. Results show that the 3-lead ECG should be placed on the breast rather than under the breast and indicate positive correlation between breast size and signal-to-noise ratio.

Thoracic wall reconstruction using ultrasound images to model/bend the thoracic prosthesis for correction of pectus excavatum

Pectus excavatum is the most common congenital deformity of the anterior thoracic wall. The surgical correction of such deformity, using Nuss procedure, consists in the placement of a personalized convex prosthesis into sub-sternal position to correct the deformity. The aim of this work is the CT-scan substitution by ultrasound imaging for the pre-operative diagnosis and pre-modeling of the prosthesis, in order to avoid patient radiation exposure. To accomplish this, ultrasound images are acquired along an axial plane, followed by a rigid registration method to obtain the spatial transformation between subsequent images. These images are overlapped to reconstruct an axial plane equivalent to a CT-slice. A phantom was used to conduct preliminary experiments and the achieved results were compared with the corresponding CT-data, showing that the proposed methodology can be capable to create a valid approximation of the anterior thoracic wall, which can be used to model/bend the prosthesis

The use of wide-mesh gauze impregnated with lambda-cyhalothrin covering wall openings in huts as a vector control method in Suriname

An alternative vector control method, using lambda-cyhalothrin impregnated wide-mesh gauze covering openings in the walls of the houses was developed in an area in the Eastern part of the interior of Suriname. Experimental hut observations showed that Anopheles darlingi greatly reduced their biting activity (99-100%) during the first 5 months after impregnation. A model assay showed high mortality both of mosquitoes repelled by the gauze as well as of those that succeeded in getting through it. A field application test in 270 huts showed good acceptance by the population and good durability of the applied gauze. After introducing the method in the entire working area, replacing DDT residual housespraying, the malaria prevalence, of 25-37% before application dropped and stabilized at between 5 and 10% within one year. The operational costs were less than those of the previously used DDT housespraying program, due to a 50% reduction in the cost of materials used. The method using widemesh gauze impregnated with lambdacyhalothrin strongly affects the behavior of An. darlingi. It is important to examine the effect of the method on malaria transmission further, since data indirectly obtained suggest substantial positive results.

A new cloning system based on the OprI lipoprotein for the production of recombinant bacterial cell wall-derived immunogenic formulations

The conjugation of antigens with ligands of pattern recognition receptors (PRR) is emerging as a promising strategy for the modulation of specific immunity. Here, we describe a new Escherichia coli system for the cloning and expression of heterologous antigens in fusion with the OprI lipoprotein, a TLR ligand from the Pseudomonas aeruginosa outer membrane (OM). Analysis of the OprI expressed by this system reveals a triacylated lipid moiety mainly composed by palmitic acid residues. By offering a tight regulation of expression and allowing for antigen purification by metal affinity chromatography, the new system circumvents the major drawbacks of former versions. In addition, the anchoring of OprI to the OM of the host cell is further explored for the production of novel recombinant bacterial cell wall-derived formulations (OM fragments and OM vesicles) with distinct potential for PRR activation. As an example, the African swine fever virus ORF A104R was cloned and the recombinant antigen was obtained in the three formulations. Overall, our results validate a new system suitable for the production of immunogenic formulations that can be used for the development of experimental vaccines and for studies on the modulation of acquired immunity.

Determination of chitin content in fungal cell wall: an alternative flow cytometric method

The conventional methods used to evaluate chitin content in fungi, such as biochemical assessment of glucosamine release after acid hydrolysis or epifluorescence microscopy, are low throughput, laborious, time-consuming, and cannot evaluate a large number of cells. We developed a flow cytometric assay, efficient, and fast, based on Calcofluor White staining to measure chitin content in yeast cells. A staining index was defined, its value was directly related to chitin amount and taking into consideration the different levels of autofluorecence. Twenty-two Candida spp. and four Cryptococcus neoformans clinical isolates with distinct susceptibility profiles to caspofungin were evaluated. Candida albicans clinical isolate SC5314, and isogenic strains with deletions in chitin synthase 3 (chs3Δ/chs3Δ) and genes encoding predicted Glycosyl Phosphatidyl Inositol (GPI)-anchored proteins (pga31Δ/Δ and pga62Δ/Δ), were used as controls. As expected, the wild-type strain displayed a significant higher chitin content (P < 0.001) than chs3Δ/chs3Δ and pga31Δ/Δ especially in the presence of caspofungin. Ca. parapsilosis, Ca. tropicalis, and Ca. albicans showed higher cell wall chitin content. Although no relationship between chitin content and antifungal drug susceptibility phenotype was found, an association was established between the paradoxical growth effect in the presence of high caspofungin concentrations and the chitin content. This novel flow cytometry protocol revealed to be a simple and reliable assay to estimate cell wall chitin content of fungi.

Lean thinking: Glass Wall Management

Sendo os desperdícios “Waste” associados à atividade industrial em Portugal e nos mercados globais e os seus custos inerentes, uma das maiores preocupações a todos os níveis de gestão empresarial, a filosofia “Lean” nasce como ajuda e encaminhamento na solução desta problemática. O conceito “Lean”, no que se refere à indústria, desde sempre e até aos dias de hoje, tem uma enorme ênfase, com a adoção deste conceito.Verificam-se bons resultados ao nível da redução de custos, melhoria da qualidade geral dos artigos produzidos, no controlo da produção em geral e é uma poderosa ferramenta no estreitamento da relação entre os diferentes intervenientes da cadeia de valor de determinado produto, sobretudo com fornecedores e com clientes. Com “Lean Management” e “Glass Wall Management”, em ambientes onde as empresas mais avançadas estão a procurar melhorar a sua competitividade através de uma gestão transparente (“Glass Wall Management”), a partir da qual, “toda informação relevante é compartilhada de maneira a que todos entendam a situação”(Suzaki, K, 1993), ganha cada vez mais importância a existência de uma estrutura organizacional que permita esta transparência e a consequente maturidade das empresas. Neste trabalho foram descritos alguns processos de gestão transparente desenvolvidos nos últimos dois anos numa PME portuguesa, aprofundando o processo de gestão transparente vigente e as ferramentas que ajudam a empresa e que na sua globalidade poderão ser extrapoladas a outras PME Portuguesas de modo que a informação importante e relevante seja partilhada por todos os intervenientes na estrutura empresarial, sendo entendida e desenvolvida por todos através de Edições e Revisões aos documentos mais importantes da empresa. Neste estudo foram contactadas vinte e uma PME’S portuguesas de tipologia de produção MTO (Make to Order) do sector dos estofos/mobiliário, e solicitado o preenchimento de um Questionário, tendo como fim em vista, a verificação do uso desta metodologia “Glass Wall Management” à escala empresarial portuguesa e a interpretação do Conceito Geral “Lean” como filosofia de redução de materiais, tempos e custos.

Development and validation of a psychometric scale for assessing PA chest image quality: a pilot study

Purpose - To develop and validate a psychometric scale for assessing image quality perception for chest X-ray images. Methods - Bandura's theory was used to guide scale development. A review of the literature was undertaken to identify items/factors which could be used to evaluate image quality using a perceptual approach. A draft scale was then created (22 items) and presented to a focus group (student and qualified radiographers). Within the focus group the draft scale was discussed and modified. A series of seven postero-anterior chest images were generated using a phantom with a range of image qualities. Image quality perception was confirmed for the seven images using signal-to-noise ratio (SNR 17.2–36.5). Participants (student and qualified radiographers and radiology trainees) were then invited to independently score each of the seven images using the draft image quality perception scale. Cronbach alpha was used to test interval reliability. Results - Fifty three participants used the scale to grade image quality perception on each of the seven images. Aggregated mean scale score increased with increasing SNR from 42.1 to 87.7 (r = 0.98, P < 0.001). For each of the 22 individual scale items there was clear differentiation of low, mid and high quality images. A Cronbach alpha coefficient of >0.7 was obtained across each of the seven images. Conclusion - This study represents the first development of a chest image quality perception scale based on Bandura's theory. There was excellent correlation between the image quality perception scores derived using the scale and the SNR. Further research will involve a more detailed item and factor analysis.

Image quality and dose analysis for a PA chest X-ray: comparison between AEC mode acquisition and manual mode using the 10 kVp ‘rule’

Purpose - To compare the image quality and effective dose applying the 10 kVp rule with manual mode acquisition and AEC mode in PA chest X-ray. Method - 68 images (with and without lesions) were acquired using an anthropomorphic chest phantom using a Wolverson Arcoma X-ray unit. These images were compared against a reference image using the 2 alternative forced choice (2AFC) method. The effective dose (E) was calculated using PCXMC software using the exposure parameters and the DAP. The exposure index (lgM provided by Agfa systems) was recorded. Results - Exposure time decreases more when applying the 10 kVp rule with manual mode (50%–28%) when compared with automatic mode (36%–23%). Statistical differences for E between several ionization chambers' combinations for AEC mode were found (p = 0.002). E is lower when using only the right AEC ionization chamber. Considering the image quality there are no statistical differences (p = 0.348) between the different ionization chambers' combinations for AEC mode for images with no lesions. Considering lgM values, it was demonstrated that they were higher when the AEC mode was used compared to the manual mode. It was also observed that lgM values obtained with AEC mode increased as kVp value went up. The image quality scores did not demonstrate statistical significant differences (p = 0.343) for the images with lesions comparing manual with AEC mode. Conclusion - In general the E is lower when manual mode is used. By using the right AEC ionising chamber under the lung the E will be the lowest in comparison to other ionising chambers. The use of the 10 kVp rule did not affect the visibility of the lesions or image quality.

Image quality and dose analysis in PA chest x-ray: comparison between AEC and manual mode acquisition using the 10 kVp rule

Purpose: To compare image quality and effective dose when the 10 kVp rule is applied with manual and AEC mode in PA chest X-ray. Methods and Materials: A total of 68 images (with and without lesions) were acquired of an anthropomorphic chest phantom in a Wolverson Arcoma X-ray unit. The images were evaluated against a reference image using image quality criteria and the 2 alternative forced choice (2 AFC) method by five radiographers. The effective dose was calculated using PCXMC software using the exposure parameters and DAP. The exposure index (lgM) was recorded. Results: Exposure time decreases considerably when applying the 10 kVp rule in manual mode (50%-28%) compared to AEC mode (36%-23%). Statistical differences for effective dose between several AEC modes were found (p=0.002). The effective dose is lower when using only the right AEC ionization chamber. Considering image quality, there are no statistical differences (p=0.348) between the different AEC modes for images with no lesions. Using a higher kVp value the lgM values will also increase. The lgM values showed significant statistical differences (p=0.000). The image quality scores did not present statistically significant differences (p=0.043) for the images with lesions when comparing manual with AEC modes. Conclusion: In general, the dose is lower in the manual mode. By using the right AEC ionising chamber the effective dose will be the lowest in comparison to other ionising chambers. The use of the 10 kVp rule did not affect the detectability of the lesions.

Lesion detection performance in an anthropomorphic chest phantom: comparative analysis of low-dose CT data on two hybrid imaging systems

Introduction: multimodality environment; requirement for greater understanding of the imaging technologies used, the limitations of these technologies, and how to best interpret the results; dose optimization; introduction of new techniques; current practice and best practice; incidental findings, in low-dose CT images obtained as part of the hybrid imaging process, are an increasing phenomenon with advancing CT technology; resultant ethical and medico-legal dilemmas; understanding limitations of these procedures important when reporting images and recommending follow-up; free-response observer performance study was used to evaluate lesion detection in low-dose CT images obtained during attenuation correction acquisitions for myocardial perfusion imaging, on two hybrid imaging systems.

Maintaining image quality for paediatric chest CTs while lowering dose: FBP versus SAFIRE

Objectives: Children have a greater risk from radiation, per unit dose, due to increased radiosensitivity and longer life expectancies. It is of paramount importance to reduce the radiation dose received by children. This research concerns chest CT examinations on paediatric patients. The purpose of this study was to compare the image quality and the dose received from imaging with images reconstructed with filtered back projection (FBP) and five strengths of Sinogram-Affirmed Iterative Reconstruction (SAFIRE). Methods: Using a multi-slice CT scanner, six series of images were taken of a paediatric phantom. Two kVp values (80 and 110), 3 mAs values (25, 50 and 100) and 2 slice thicknesses (1 mm and 3 mm) were used. All images were reconstructed with FBP and five strengths of SAFIRE. Ten observers evaluated visual image quality. Dose was measured using CT-Expo. Results: FBP required a higher dose than all SAFIRE strengths to obtain the same image quality for sharpness and noise. For sharpness and contrast image quality ratings of 4, FBP required doses of 6.4 and 6.8 mSv respectively. SAFIRE 5 required doses of 3.4 and 4.3 mSv respectively. Clinical acceptance rate was improved by the higher voltage (110 kV) for all images in comparison to 80 kV, which required a higher dose for acceptable image quality. 3 mm images were typically better quality than 1 mm images. Conclusion: SAFIRE 5 was optimal for dose reduction and image quality.