Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care.

BACKGROUND: This prospective observational study was aimed at evaluating the appropriateness of use of upper gastrointestinal endoscopy (UGE) in primary care in a country with open access to and high availability of the procedure. METHODS: Outpatients were consecutively included in two clinical settings: Setting A (20 primary care physicians during 4 weeks) and B (university-based outpatient clinic during 3 weeks). In patients undergoing UGE, appropriateness of referral was judged by explicit Swiss criteria developed by the RAND/UCLA panel method. RESULTS: Patient visits (8135) were assessed. Six hundred eleven patients complained of upper gastrointestinal symptoms. Physicians decided to perform UGE in 63 of these patients. Twenty-five (40%) of the endoscopies were rated appropriate, 7 (11%) equivocal, and 31 (49%) inappropriate. Overuse of UGE occurred in 5.1% (setting A: 4.7%; setting B:6.5%; p = 0.39) of the patients who presented with upper gastrointestinal symptoms. The decision to perform UGE in previously untreated dyspeptic patients was the most common clinical situation resulting in overuse. CONCLUSIONS: Inappropriate use of UGE is high in Switzerland. However, to better reflect primary care decision making, overuse should be related not only to patients referred for a medical test, but also to the number of patients who complain of the symptoms that would be investigated by the procedure.

Obese and fit adolescents have lower blood pressure levels than obese and unfit counterparts.

The aim of the study was to assess the effects of physical fitness on the relationships between body mass index (BMI) and body fat (BF) on blood pressure (BP) levels. Cross-sectional study conducted in 25 schools of Lisbon (Portugal), including 2041 boys and 1995 girls aged 10-18. BF was assessed by bioimpedance. Cardiovascular fitness was assessed by the 20-meter shuttle run and classified as fit/unfit. Obesity (BMI or BF defined) was defined according to international criteria. In both sexes, BMI was positively related with systolic and diastolic BP, while BF was only positively related with diastolic BP z-scores. No interaction was found between fitness and BMI categories regarding BP levels, while for BF a significant interaction was found. Being fit reduced the BF-induced increase in the Odds ratio (OR) of presenting with high BP: OR (95% confidence interval) 1.01 (0.73-1.40) and 0.99 (0.70-1.38) for overweight and obese fit boys, respectively, the corresponding values for unfit overweight and obese boys being 1.33 (0.94-1.90) and 1.75 (1.34-2.28), respectively. The values were 0.88 (0.57-1.35) and 1.66 (0.98-2.80) for overweight and obese fit girls, respectively, the corresponding values for unfit overweight and obese being 1.63 (1.12-2.37) and 1.90 (1.32-2.73) respectively. No interaction was found between fitness and BMI-defined overweight and obesity. Being fit reduces the negative impact of BF on BP levels and high BP status in adolescents. This protective effect was not found with BMI.

Produção de grãos e absorção de Cu, Fe, Mn e Zn pelo milho em solo adubado com lodo de esgoto, com e sem calcário

O lodo de esgoto (LE), apesar do seu reconhecido valor como fertilizante, ainda é motivo de preocupação quando usado na agricultura, em virtude do potencial de absorção excessiva de metais pesados pelas plantas e entrada na cadeia alimentar. Para avaliar o efeito da adição de 0, 20, 40, 60 e 80 Mg ha-1 (com base no material seco) de LE, aplicado de forma única ou parcelada em 2, 3 e 4 anos nas doses de 40, 60 e 80 Mg ha-1, respectivamente, com e sem calcário, na produção de grãos e massa seca da parte aérea e na absorção de Cu, Fe, Mn e Zn pelo milho, foi realizado, em Cordeirópolis (SP), um experimento em condições de campo, utilizando um Latossolo Vermelho distrófico típico, no período de 1983 a 1987. Foi utilizado o experimento em faixas ("split block") com quatro repetições. A maior dose de LE adicionou ao solo, em kg ha-1, 63, 3040, 25 e 152 de Cu, Fe, Mn e Zn, respectivamente. A produção de grãos e de massa seca da parte aérea aumentou linearmente com a adição de LE nos anos estudados. O LE aumentou significativamente as concentrações de Zn nas folhas e na parte aérea e provocou a redução nas concentrações de Fe e Mn, mas não alterou as de Cu. As concentrações dos metais nos grãos não foram influenciadas de forma significativa pela adição de LE, estando mesmo nas maiores doses, dentro dos níveis aceitáveis, sem causar restrição ao consumo humano. A absorção de Zn, Fe e Mn pelo milho foi significativamente reduzida pela adição de calcário. O Zn foi o metal que mais teve reduzida sua concentração na parte aérea pela adição de calcário. O parcelamento das doses de lodo de 40 a 80 Mg ha-1 provocou, de modo geral, aumento das quantidades absorvidas de metais pelo milho, sendo o Fe e o Zn os elementos que mais se acumularam na planta em resposta a esse parcelamento.

Effets bénéfiques du ranélate de strontium compare à l'alendronate sur le TBS chez les femmes ostéoporotiques ménopausées: une étude de 2 ans.

Introduction. - Le TBS ou Score Trabéculaire Osseux (TBS, Med- Imaps, France) est un index d'architecture osseuse apportant des informations indépendantes de la densité minérale osseuse (DMO), et calculé par la quantification des variations locales des niveaux de gris à partir d'examen de densitométrie (DXA) lombaire. Dans des études antérieures prospectives et cas-témoins, cet index a été considéré comme associé aux fractures. Nous avons comparé les effets du ranélate de strontium (RanSr) et de l'alendronate (ALN) sur l'architecture vertébrale à l'aide du TBS, chez des femmes ostéoporotiques ménopausées. Patients et méthodes. - Une analyse post hoc a été réalisée sur des DXA (Hologic and GE Lunar Devices) de 79 des 189 femmes incluses dans une étude en double aveugle et double placebo et réparties de façon randomisée entre un groupe à 2 g/jour de RanSr et un groupe à 70 mg/semaine d'ALN pendant 2 ans. Les paramètres de TBS ont été évalués en aveugle par TBS iNsight (v1,9) au niveau vertébral après 12 et 24 mois de traitement. Nous avons appliqué les règles de l'ISCD (International Society for Clinical Densitometry) pour chaque exclusion de vertèbre, de façon indépendante respectivement pour la DMO et le TBS. Des doubles mesures ayant été réalisées initialement, la reproductibilité est exprimée en % CV. Résultats. - Les caractéristiques initiales (moyenne ± DS) étaient identiques entre les groupes en termes d'âge, 69,2 ± 4,4 ans ; d'IMC, 23,8 ± 4,4 kg/m2 ; de T-score L1-L4, - 2,9 ± 0,9 et de TBS, 1,230 ± 0,09. Comme prévu, le coefficient de détermination entre la DMO et le TBS au niveau du rachis était très basse r2 = 0,12. Les reproductibilités brutes étaient respectivement de 1,1 et 1,6 % pour la DMO et le TBS au niveau vertébral. Après 1 et 2 ans, la DMO en L1-L4 a augmenté de façon significative de respectivement 5,6 % et 9 % dans le groupe RanSr et de respectivement 5,2 % et 7,6 % dans le groupe ALN. De même, le TBS au niveau vertébral a augmenté respectivement de 2,3 % (p < 0,001) et de 3,1 % (p < 0,001) dans le groupe RanSr et de 0,5 % (NS) et de 1 % (NS) dans le groupe ALN avec une différence entre groupe significative en faveur du RanSr (p = 0,04 et p = 0,03). Il n'y avait aucune corrélation entre la différence de DMO et de TBS à 1 ou 2 ans. Les deux traitements étaient bien tolérés. Discussion. - Ces résultats sur le TBS confortent des études précédentes qui sont en faveur de l'effet bénéfique du RanSr sur l'architecture osseuse. Conclusion. - Le ranélate de strontium a des effets plus importants que l'alendronate sur le score trabéculaire osseux, indice d'architecture osseuse au niveau vertébral, chez les femmes ayant une ostéoporose post-ménopausique, après 2 ans de traitement.

Interação de chumbo, da saturação por bases do solo e de micorriza arbuscular no crescimento e nutrição mineral da soja

Existem divergências sobre o efeito do fungo micorrízico arbuscular (FMA) na absorção de metais pesados pelas plantas. Isso pode ser atribuído não só às diferenças na disponibilidade do metal no solo, espécie de FMA e de planta, mas também às possíveis interações que ocorrem entre estes e os demais fatores ambientais. Realizou-se um experimento em casa de vegetação, com a finalidade de avaliar o efeito da inoculação de FMAe da saturação por bases do solo sobre o crescimento, nutrição e absorção de Pb em soja crescida em um Latossolo Vermelho-Amarelo. Os tratamentos consistiram de inoculação, ou não, de Glomus macrocarpum, duas doses de calcário, elevando a saturação por bases do solo a 63 e 82 %, e cinco doses de Pb (0; 7,5; 37,5; 150 e 300 mg dm-3), utilizando-se como fonte Pb(NO3)2. A inoculação do FMA aumentou a produção de matéria seca da parte aérea das plantas, as quais também apresentaram maiores teores de P e maiores quantidades acumuladas de P, Ca, Mg, Mn, Fe e Zn. A produção de matéria seca da soja micorrizada reduziu linearmente com o aumento da dose de Pb adicionada, em ambas as saturações por bases. No solo com menor V %, a colonização radicular pelo FMA diminuiu 40 % na maior dose de Pb adicionada, o teor de Pb na parte aérea da soja foi cinco vezes maior e as plantas micorrizadas apresentaram um teor de Pb 30 % menor do que as não micorrizadas. A adição de Pb afetou tanto o estabelecimento quanto o desempenho da simbiose. O FMA teve papel relevante na diminuição da concentração do Pb na parte aérea da soja, no solo com menor saturação por bases, conferindo tolerância à planta em uma condição de excesso de metal pesado no solo.

Aporte de nutrientes pela serapilheira em uma área degradada e revegetada com leguminosas arbóreas

O objetivo deste trabalho foi avaliar o aporte de nutrientes pela deposição de serapilheira em uma área degradada, que sofreu empréstimo de solo, após dez anos da sua revegetação com as leguminosas arbóreas: Mimosa caesalpiniifolia (sabiá), Acacia auriculiformis (acácia) e Gliricidia sepium (gliricídia); e outra área vizinha, um fragmento da mata Atlântica em crescimento secundário (capoeira). O trabalho foi realizado no campo experimental da Embrapa-Agrobiologia, Km 47, Seropédica, Rio de Janeiro. Na amostragem, utilizaram-se coletores circulares do material formador da serapilheira com área de 0,25 m², determinando-se os teores de nutrientes (N, P, K, Ca e Mg) e polifenóis. A quantidade de serapilheira depositada foi influenciada pelas espécies de leguminosas utilizadas na revegetação, variando de 5,7 Mg ha -1 ano-1 de matéria seca (MS), onde predominava gliricídia, até 11,2 Mg ha-1 ano-1 , na faixa formada pela sabiá com contribuição do material de acácia. A deposição na capoeira foi de 9,2 Mg ha-1 ano-1 de MS. O material de gliricídia foi o mais rico em nutrientes (N, P, Ca e Mg) e o que apresentou os menores teores de polifenóis; qualitativamente formou a serapilheira mais favorável ao processo de decomposição. O aporte de nutrientes correlacionou-se com a quantidade de serapilheira depositada. Na revegetação, o aporte anual de nutrientes, em kg ha-1 ano-1 , variou: para o N, de 130 a 170; para o P, de 4,9 a 7,9; para K, de 24 a 31; para o Ca, de 150 a 190, e para o Mg, de 28,6 a 40,0. Estes valores foram similares ou superiores aos observados para a capoeira, que foram para o N, 140, para o P, 4,9, para o Ca, 110, e para o Mg, 31,7, exceto para o K, 63. A revegetação com leguminosas, em áreas degradadas, adiciona, relativamente, em pouco tempo, grande quantidade de matéria orgânica e N por meio da produção de serapilheira, favorecendo a ciclagem de nutrientes e o processo de recuperação.

Is Less Chemotherapy Detrimental in Adults with Philadelphia Chromosome (Ph)-Positive Acute Lymphoblastic Leukemia (ALL) Treated with High-Dose Imatinib? Results of the Prospective Randomized Graaph-2005 Study

Aim: To compare a less intensive regimen based on high-dose imatinib (IM) to an intensive IM/HyperCVAD regimen in adults with Ph+ ALL, in terms of early response and outcome after stem cell transplantation (SCT). Methods: Patients aged 18-60 years with previously untreated Ph+ ALL not evolving from chronic myeloid leukemia were eligible if no contra-indication to chemotherapy and SCT (ClinicalTrials.gov ID, NCT00327678). After a steroid prephase allowing Ph and/or BCR-ABL diagnosis, cycle 1 differed between randomization arms. In arm A (IM-based), IM was given at 800 mg on day 1-28, combined with vincristine (2 mg, day 1, 8, 15, 22) and dexamethasone (40 mg, day 1-2, 8-9, 15-16, and 22-23) only. In arm B (IM/HyperCVAD), IM was given at 800 mg on day 1-14, combined with adriamycin (50 mg/m2, day 4), cyclophosphamide (300 mg/m2/12h, day 1, 2, 3), vincristine (2 mg, day 4 and 11), and dexamethasone (40 mg, day 1-4 and 11-14). All patients received a cycle 2 combining high-dose methotrexate (1 g/m2, day 1) and AraC (3 g/m2/12h, day 2 and 3) with IM at 800 mg on day 1-14, whatever their response. Four intrathecal infusions were given during this induction/consolidation period. Minimal residual disease (MRD) was centrally evaluated by quantitative RQ-PCR after cycle 1 (MRD1) and cycle 2 (MRD2). Major MRD response was defined as BCR-ABL/ABL ratio <0.1%. Then, all patients were to receive allogeneic SCT using related or unrelated matched donor stem cells or autologous SCT if no donor and a major MRD2 response. IM/chemotherapy maintenance was planned after autologous SCT. In the absence of SCT, patients received alternating cycles 1 (as in arm B) and cycles 2 followed by maintenance, like in the published IM/HyperCVAD regimen. The primary objective was non-inferiority of arm A in term of major MRD2 response. Secondary objectives were CR rate, SCT rate, treatment- and transplant-related mortality, relapse-free (RFS), event-free (EFS) and overall (OS) survival. Results: Among the 270 patients randomized between May 2006 and August 2011, 265 patients were evaluable for this analysis (133 arm A, 132 arm B; median age, 47 years; median follow-up, 40 months). Main patient characteristics were well-balanced between both arms. Due to higher induction mortality in arm B (9 versus 1 deaths; P=0.01), CR rate was higher in the less intensive arm A (98% versus 89% after cycle 1 and 98% versus 91% after cycle 2; P= 0.003 and 0.006, respectively). A total of 213 and 205 patients were evaluated for bone marrow MRD1 and MRD2. The rates of patients reaching major MRD response and undetectable MRD were 45% (44% arm A, 46% arm B; P=0.79) and 10% (in both arms) at MRD1 and 66% (68% arm A, 63.5% arm B; P=0.56) and 25% (28% arm A, 22% arm B; P=0.33) at MRD2, respectively. The non-inferiority primary endpoint was thus demonstrated (P= 0.002). Overall, EFS was estimated at 42% (95% CI, 35-49) and OS at 51% (95% CI, 44-57) at 3 years, with no difference between arm A and B (46% versus 38% and 53% versus 49%; P=0.25 and 0.61, respectively). Of the 251 CR patients, 157 (80 arm A, 77 arm B) and 34 (17 in both arms) received allogeneic and autologous SCT in first CR, respectively. Allogeneic transplant-related mortality was similar in both arms (31.5% versus 22% at 3 years; P=0.51). Of the 157 allografted patients, 133 had MRD2 evaluation and 89 had MRD2 <0.1%. In these patients, MRD2 did not significantly influence post-transplant RFS and OS, either when tested with the 0.1% cutoff or as a continuous log covariate. Of the 34 autografted patients, 31 had MRD2 evaluation and, according to the protocol, 28 had MRD2 <0.1%. When restricting the comparison to patients achieving major MRD2 response and with the current follow-up, a trend for better results was observed after autologous as compared to allogeneic SCT (RFS, 63% versus 49.5% and OS, 69% versus 58% at 3 years; P=0.35 and P=0.08, respectively). Conclusions: In adults, the use of TK inhibitors (TKI) has markedly improved the results of Ph+ ALL therapy, now close to those observed in Ph-negative ALL. We demonstrated here that chemotherapy intensity may be safely reduced when associated with high-dose IM. We will further explore this TKI-based strategy using nilotinib prior to SCT in our next GRAAPH-2013 trial. The trend towards a better outcome after autologous compared to allogeneic SCT observed in MRD responders validates MRD as an important early surrogate endpoint for treatment stratification and new drug investigation in this disease.

Qualidade da matéria orgânica e estoques de carbono e nitrogênio em Latossolo tratado com biossólido e cultivado com eucalipto

O objetivo deste estudo foi determinar o efeito da aplicação de doses de um biossólido alcalino nos estoques de C e N, bem como na qualidade da matéria orgânica (MO) de um Latossolo Vermelho-Amarelo distrófico cultivado com eucalipto, após cinco anos da aplicação do resíduo. O trabalho foi desenvolvido em área pertencente à Estação Experimental da ESALQ/USP, no município de Itatinga, Estado de São Paulo. Em março de 1998, após corte de uma plantação de Eucalyptus grandis com sete anos de idade e novo plantio, com a mesma espécie, no sistema de cultivo mínimo, foi iniciado o experimento. Quatro meses depois, foi aplicado o biossólido digerido anaeróbio, com umidade original, sobre a superfície do solo, nas entrelinhas da cultura e sem posterior incorporação. Cinco tratamentos foram avaliados: (a) controle; (b) fertilização mineral com N, P, K, B e Zn (Fert. Mineral); (c) 10 t ha-1 de biossólido + K (10 t ha-1 + K); (d) 20 t ha-1 de biossólido + K (20 t ha-1 + K); e (e) 40 t ha-1 de biossólido + K (40 t ha-1 + K). Amostras de solo das camadas de 0-5, 5-10, 10-20, 20-30 e 30-60 cm foram coletadas em setembro de 2003, cerca de cinco anos após a aplicação do resíduo. Para todas as profundidades foram determinados os teores totais de C e N e a densidade do solo. Nas amostras coletadas até 20 cm de profundidade, foram feitas também determinações de pH, frações de carbono orgânico (CO) por graus de oxidação, teores de açúcares solúveis, proteína bruta, lipídeos, hemicelulose, celulose e lignina, CTC potencial (a pH 7,0) e CTC efetiva (ao pH natural). Após cinco anos da aplicação do biossólido, não foram observadas diferenças entre os tratamentos, para os teores totais e estoques de C e N, densidade e frações do CO. Os estoques médios de C foram iguais a 26,52; 7,96; 10,31; 12,88; e 31,19 t ha-1; e de N iguais a 0,97; 0,39; 0,99; 0,63; e 0,34 t ha-1, respectivamente, para as camadas de 0-5, 5-10, 10-20, 20-30 e 30-60 cm. Cerca de 50 % do total de CO esteve presente no compartimento denominado lábil, comportamento típico de áreas com espécies e, ou, manejo que favorecem o retorno de resíduos vegetais ao solo. Dos compostos orgânicos determinados, somente a lignina mostrou alteração de acordo com os tratamentos. Os tratamentos 40 t ha-1 + K e Fert. Mineral apresentaram a MO do solo na camada de 0-5 cm mais enriquecida com lignina, em comparação aos demais, sendo esse efeito atribuído à maior deposição de folhas nesses dois tratamentos e à natureza recalcitrante da lignina. Os resultados de CTC não evidenciaram efeitos dos tratamentos na qualidade da MO, pelo menos no que se refere a esta propriedade. A CTC (pH natural) mostrou-se mais dependente dos valores de pH do solo do que dos teores de C.

Prédiction de la fracture vertébrale: pouvoir discriminant de l'IMC, de la DMO, du TBS, du FRAX, seuls ou combinés. L'étude OsteoLaus.

Introduction. - L'ostéoporose est caractérisée par une diminution de la DMO et une altération de la microarchitecture (MA). La MA est évaluable en routine clinique par la mesure du Trabecular Bone Score (TBS), par simple ré-analyse de l'image lombaire de la DMO. Le TBS a démontré sa valeur diagnostique et pronostique, partiellement indépendante des FRC et le la DMO. Le but de la cohorte OsteoLaus est de combiner en routine clinique les FRC et les informations données par la DXA (DMO, TBS, VFA) et FRAX pour mieux identifier les femmes à risque de fracture. Matériels et Méthodes. - Dans la cohorte OsteoLaus (1 500 femmes, 50 à 80 ans, Lausanne, Suisse) les FRC, la DMO lombaire et de la hanche, l'IVA, le TBS et le FRAX sont relevés. La sensibilité et la spécificité des différents outils pour prédire les fractures vertébrales (FxV) de grade 2/3 ont été calculées. Résultats. - Nous avons inclus 451 femmes : âge 67,4 ± 6,7 ans, IMC 26,1 ± 4,6, DMO lombaire 0,943 ± 0,168 (T-score -1,4 SD), TBS 1,271 ± 0,103. La corrélation entre DMO et TBS est faible (r2 = 0,16). La prévalence des FxV 2/3 est de 9,3 %. Conclusion. - L'IMC a un mauvais pouvoir discriminant dans notre cohorte. Ces résultats préliminaires confirment l'indépendance partielle entre le TBS et la DMO. Une approche combinant TBS et FRAX semble être le meilleur compromis en termes de sensibilité/spécificité pour identifier les femmes avec une FxV 2/3 prévalente qui aurait pu être mal classifiée par la DMO ou le TBS ou le FRAX seuls.

Biomass and nutrient cycling in pure and mixed stands of native tree species in southeastern Bahia, Brazil

The objective of this paper is to study selected components of the nutrient cycle of pure and mixed stands of native forest species of Atlantic Forest in southeastern Brazil. Tree diameter, height, above-ground biomass, and nutrient content were determined in 22-year-old stands. Litterfall, litter decomposition, and nutrient concentration were evaluated from August 1994 to July 1995. The following species were studied: Peltogyne angustiflora, Centrolobium robustum, Arapatiella psilophylla, Sclerolobium chrysophyllum, Cordia trichotoma, Macrolobium latifolium. The litter of a natural forest and a 40-year-old naturally regenerated second-growth forest was sampled as well. The mixed-species outmatched pure stands in height, stem volume and total biomass (29.4 % more). The greatest amount of forest litter was observed in the natural forest (9.3 Mg ha-1), followed by the mixed-species stand (7.6 Mg ha-1) and secondary forest (7.3 Mg ha-1), and least litterfall was measured in the pure C. robustum stand (5.5 Mg ha-1). Litterfall seasonality varied among species in pure stands (CV from 44.7 to 91.4 %), unlike litterfall in the mixed-tree stand, where the variation was lower (CV 31.2 %). In the natural and second-growth forest, litterfall varied by 57.8 and 34.0 %, respectively. The annual rate of nutrient return via litterfall varied widely among forest ecosystems. Differences were detected between forest ecosystems in both the litter accumulation and quantity of litterlayer nutrients. The highest mean nutrient accumulation in above-ground biomass was observed in mixed-species stands. The total nutrient accumulation (N + P + K+ Ca + Mg) ranged from 0.97 to 1.93 kg tree-1 in pure stands, and from 1.21 to 2.63 kg tree-1 in mixed-species stands. Soil fertility under mixed-species stands (0-10 cm) was intermediate between the primary forest and pure-stand systems. The litterfall rate of native forest species in a mixed-species system is more constant, resulting in a more continuous decomposition rate. Consequently, both nutrient availability and quantity of organic matter in the soil are higher and the production system ecologically more sustainable.

Comparison of clinical and angiographic prognostic risk scores in elderly patients presenting with acute coronary syndrome and referred for percutaneous coronary intervention.

BACKGROUND: Multiple risk prediction models have been validated in all-age patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI); however, they have not been validated specifically in the elderly. METHODS: We calculated the GRACE (Global Registry of Acute Coronary Events) score, the logistic EuroSCORE, the AMIS (Acute Myocardial Infarction Swiss registry) score, and the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in a consecutive series of 114 patients ≥75 years presenting with ACS and treated with PCI within 24 hours of hospital admission. Patients were stratified according to score tertiles and analysed retrospectively by comparing the lower/mid tertiles as an aggregate group with the higher tertile group. The primary endpoint was 30-day mortality. Secondary endpoints were the composite of death and major adverse cardiovascular events (MACE) at 30 days, and 1-year MACE-free survival. Model discrimination ability was assessed using the area under receiver operating characteristic curve (AUC). RESULTS: Thirty-day mortality was higher in the upper tertile compared with the aggregate lower/mid tertiles according to the logistic EuroSCORE (42% vs 5%; odds ratio [OR] = 14, 95% confidence interval [CI] = 4-48; p <0.001; AUC = 0.79), the GRACE score (40% vs 4%; OR = 17, 95% CI = 4-64; p <0.001; AUC = 0.80), the AMIS score (40% vs 4%; OR = 16, 95% CI = 4-63; p <0.001; AUC = 0.80), and the SYNTAX score (37% vs 5%; OR = 11, 95% CI = 3-37; p <0.001; AUC = 0.77). CONCLUSIONS: In elderly patients presenting with ACS and referred to PCI within 24 hours of admission, the GRACE score, the EuroSCORE, the AMIS score, and the SYNTAX score predicted 30 day mortality. The predictive value of clinical scores was improved by using them in combination.

Analysis of patient physical restraints usage in a Swiss emergency service

Introduction: Emergency services (ES) are often faced with agitated,confused or aggressive patients. Such situations may require physicalrestraint. The prevalence of these measures is poorly documented,concerning 1 to 10% of patients admitted in the ES. The indications forrestraint, the context and the related complications are poorly studied.The emergency service and the security service of our hospital havedocumented physical restraint for several years, using specific protocolsintegrated into the medical records. The study evaluated the magnitudeof the problem, the patient characteristics, and degree of adherence tothe restraint protocol.Methods: Retrospective study of physical restraint used on adultpatients in the ES in 2009. The study included analysis of medical anddemographic characteristics, indications justifying restraint and qualityof restraint documentation. Patients were identified from computerizedES and security service records. The data were supplemented byexamination of patients' medical records.Results: In 2009, according to the security service, 390 patients (1%)were physically restrained in the ES. The ES computerized systemidentified only 196 patients. Most patients were male (62%). The medianage was 40 years (15-98 years; P90 = 80 years). 63 % of the situationsoccurred between 18h00 and 6h00, and most frequently on Saturday(19%). Substance or alcohol abuse was present in 48.7% of cases andacute psychiatric crisis was mentioned in 16.7%. In most cases,restraint was motivated by extreme agitation or auto / hetero-aggressiveviolence. Most patients (68 %) were restrained with upper limb andabdominal restraints. More than three anatomic restraints werenecessary in 52 % of the patients. Intervention of security guards wasrequired in 77% of the cases. 61 restraint protocols (31 %) were missingand 57% of the records were incomplete. In many cases, the protocolsdid not include the signature of the physician (22%) or of the nurse(43.8%). Medical records analysis did not allow reliable estimation ofthe number of restraint-induced complications.Conclusions: Physical restraint is most often motivated by majoragitation and/or secondary to substance abuse. Caregivers regularlycall security guards for help. Restraint documentation is often missing orincomplete, requiring major improvement in education and prescription.