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Smith S.W.,Hennepin County Medical Center | Smith S.W.,University of Minnesota | Dodd K.W.,Hennepin County Medical Center | Henry T.D.,Abbott Laboratories | And 2 more authors.
Annals of Emergency Medicine | Year: 2012

Study objective: Sgarbossa's rule, proposed for the diagnosis of acute myocardial infarction in the presence of left bundle branch block, has had suboptimal diagnostic utility. We hypothesize that a revised rule, in which the third Sgarbossa component (excessively discordant ST-segment elevation as defined by <5 mm of ST-segment elevation in the setting of a negative QRS) is replaced by one defined proportionally by ST-segment elevation to S-wave depth (ST/S ratio), will have better diagnostic utility for ST-segment elevation myocardial infarction (STEMI) equivalent, using documented coronary occlusion on angiography as reference standard. Methods: We collected admission ECGs for all patients with an acutely occluded coronary artery and left bundle branch block at 3 institutions. The ECGs of emergency department patients with chest pain or dyspnea and left bundle branch block, but without coronary occlusion, were used as controls. The R or S wave, whichever was most prominent, and ST segments, relative to the PR segment, were measured to the nearest 0.5 mm. The ST/S ratio was calculated for each lead that has both discordant ST deviation of greater than or equal to 1 mm and an R or S wave of opposite polarity; others were set to 0. The cut point for the most negative ST/S ratio with at least 90% specificity was determined. The revised rule is unweighted, requiring just 1 of 3 criteria. Diagnostic utilities of the original and revised Sgarbossa rules were computed and compared. McNemar's test was used to compare sensitivities and specificities. Results: The study and control groups included 33 and 129 ECGs, respectively. The cut point selected for relative discordant ST-segment elevation was -0.25. Excessive absolute discordant ST-segment elevation of 5 mm was present in at least one lead in 30% of ECGs in patients with confirmed coronary occlusion versus 9% of the control group, whereas excessive relative discordant ST-segment elevation less than -0.25 was present in 58% versus 8%. Sensitivity of the revised rule in which ST-segment elevation with an ST/S ratio less than or equal to -0.25 replaces ST-segment elevation greater than or equal to 5 mm was significantly greater than either the weighted (P<.001) or unweighted (P=.008) Sgarbossa rule: 91% (95% confidence interval [CI] 76% to 98%) versus 52% (95% CI 34% to 69%) versus 67% (95% CI 48% to 82%). Specificity of the revised rule was lower than that of the weighted rule (P=.002) and similar to that of the unweighted rule (P=1.0): 90% (95% CI 83% to 95%) versus 98% (95% CI 93% to 100%) versus 90% (95% CI 83% to 95%). Positive and negative likelihood ratios for the revised rule were 9.0 (95% CI 8.0 to 10) and 0.1 (95% CI 0.03 to 0.3). The revised rule was significantly more accurate than both the weighted (16% difference; 95% CI 5% to 27%) and unweighted (12% difference; 95% CI 2% to 22%) Sgarbossa rules. Conclusion: Replacement of the absolute ST-elevation measurement of greater than or equal to 5 mm in the third component of the Sgarbossa rule with an ST/S ratio less than -0.25 greatly improves diagnostic utility of the rule for STEMI. An unweighted rule using this criterion resulted in excellent prediction for acute coronary occlusion. Copyright © 2012 by the American College of Emergency Physicians. Source


Levkovitz Y.,Tel Aviv University | Isserles M.,Hebrew University of Jerusalem | Padberg F.,Ludwig Maximilians University of Munich | Lisanby S.H.,Duke University | And 21 more authors.
World Psychiatry | Year: 2015

Major depressive disorder (MDD) is a prevalent and disabling condition, and many patients do not respond to available treatments. Deep transcranial magnetic stimulation (dTMS) is a new technology allowing non-surgical stimulation of relatively deep brain areas. This is the first double-blind randomized controlled multicenter study evaluating the efficacy and safety of dTMS in MDD. We recruited 212 MDD outpatients, aged 22-68 years, who had either failed one to four antidepressant trials or not tolerated at least two antidepressant treatments during the current episode. They were randomly assigned to monotherapy with active or sham dTMS. Twenty sessions of dTMS (18 Hz over the prefrontal cortex) were applied during 4 weeks acutely, and then biweekly for 12 weeks. Primary and secondary efficacy endpoints were the change in the Hamilton Depression Rating Scale (HDRS-21) score and response/remission rates at week 5, respectively. dTMS induced a 6.39 point improvement in HDRS-21 scores, while a 3.28 point improvement was observed in the sham group (p=0.008), resulting in a 0.76 effect size. Response and remission rates were higher in the dTMS than in the sham group (response: 38.4 vs. 21.4%, p=0.013; remission: 32.6 vs. 14.6%, p=0.005). These differences between active and sham treatment were stable during the 12-week maintenance phase. dTMS was associated with few and minor side effects apart from one seizure in a patient where a protocol violation occurred. These results suggest that dTMS constitutes a novel intervention in MDD, which is efficacious and safe in patients not responding to antidepressant medications, and whose effect remains stable over 3 months of maintenance treatment. © 2015 World Psychiatric Association. Source


Kapusta L.,Radboud University Nijmegen | Kapusta L.,Pediatric Cardiology Unit | Mainzer G.,Rambam Medical Center | Weiner Z.,Rambam Medical Center | And 4 more authors.
Journal of the American Society of Echocardiography | Year: 2013

Background The aim of this study was to detect normal changes in fetal two-dimensional speckle-tracking echocardiography-derived values for global and regional longitudinal left and right ventricular strain, strain rate, and time to peak (T2P) global strain during pregnancy. Methods Forty-four healthy fetuses were examined prospectively during the second-trimester and third-trimester ultrasound examinations (20-24 and 30-34 weeks, respectively). Clips with high frame rates (mean, 120 frames/sec) of two-dimensional (B-mode) grayscale images of apical or basal four-chamber views of both ventricles were used for offline analyses of global and regional walls and segments (basal, mid, and apical) of myocardial strain and strain rate as well as T2P global strain in the longitudinal direction. Results There were statistically significant decreases in global and regional strain of the right ventricle between the second and third trimesters. No statistically significant changes were observed in global and regional strain of the left ventricle. Global and regional strain rates of both ventricles decreased in a similar way during pregnancy. The mean T2P longitudinal left ventricular global strain (adjusted for heart rate) increased mildly during fetal life. Whereas T2P longitudinal strain of the left ventricle at 20 to 24 weeks was statistically significantly shorter than that of the right ventricle, no difference in T2P longitudinal strain was found at 30 to 34 weeks of gestation between both ventricles. Conclusions The establishment of these changes between the second-trimester and third-trimester two-dimensional speckle-tracking echocardiography-derived reference values is a mandatory prerequisite for its use in evaluating (pathologic) changes in both ventricular functions during pregnancy. © 2013 by the American Society of Echocardiography. Source


Segel R.,Medical Genetics Institute | Ben-Pazi H.,Neuropediatric Unit | Zeligson S.,Medical Genetics Institute | Fatal-Valevski A.,Pediatric Neurology Unit | And 9 more authors.
Neurology | Year: 2015

Objective: To determine the prevalence and characteristics of copy number variations (CNVs) in children with cerebral palsy (CP) of unknown etiology, comprising approximately 20% of the CP population. Methods: Fifty-two participants (age 10.5 ± 7.8 years; Gross Motor Function Classification System scale 2.8 ± 1.3) with nonprogressive pyramidal and/or extrapyramidal signs since infancy and no identified etiology were enrolled. Individuals with evidence of acquired causes were excluded. Participants underwent neurologic and clinical genetic examinations before the genomic testing. Chromosomal microarray analysis to detect CNVs was performed using the Affymetrix platform. CNVs identified were classified as pathogenic, likely pathogenic, likely benign, or benign. Only pathogenic and likely pathogenic CNVs were defined as clinically significant. Results: Thirty-nine CNVs were found in 25 of 52 participants (48%). Sixteen participants (31%) had clinically significant CNVs: 10 pathogenic and 6 likely pathogenic, of which 7 were not previously associated with motor disability. Nine participants had likely benign CNVs. Clinically significant CNVs were more frequently de novo (12/16; p < 0.001) including in 5 of 8 individuals who had a first- or second-degree relative with a major neurologic disorder. Dysmorphic features and nonmotor comorbidities were more prevalent in individuals with clinically significant CNVs (p < 0.05 for both). Conclusion: CNVs, most frequently de novo, are common in individuals with cryptogenic CP. We recommend CNV testing in individuals with CP of unknown etiology. © 2015 American Academy of Neurology. Source


Kapusta L.,Radboud University Nijmegen | Kapusta L.,Pediatric Cardiology Unit | Mainzer G.,Rambam Medical Center | Weiner Z.,Rambam Medical Center | And 4 more authors.
Journal of the American Society of Echocardiography | Year: 2012

Background: Data on myocardial deformation during the internationally widely used second-trimester screening are scarce and confusing. Reference values of time to peak strain are missing. The aims of this study were to assess reference values derived from two-dimensional speckle-tracking echocardiography for global and regional longitudinal right ventricular (RV) and left ventricular (LV) strain, strain rate, and time to peak global strain and to determine the influence of heart rate and gender on these strain parameters. Methods: Seventy-five healthy fetuses were enrolled during second-trimester ultrasound (20-24 weeks). Clips with high frame rates (mean, 132 frames/sec) and two-dimensional (B-mode) grayscale images of apical or basal four-chamber views of both ventricles were used for offline analyses. Results: There were no statistically significant differences in global strain and strain rate between both ventricles (P =.679 and P =.734, respectively) or among the RV, septal, and LV free walls. Regional measurements, modeled also as an interaction of wall and segment (basal mid and apical), showed only a small, statistically significant difference between the basal RV and LV free walls. Strain and strain rate values were independent of heart rate. The mean time to peak LV global strain adjusted for heart rate was statistically significantly shorter than the RV value (P <.0001]). Strain, strain rate, and time to peak global strain were not found to be associated with gender. Conclusions: The establishment of second-trimester two-dimensional speckle-tracking echocardiographic reference values for global and regional strain, strain rate, and time to peak global strain in a healthy fetal cohort is a mandatory prerequisite for its use in evaluating (pathologic) changes in both ventricular functions during pregnancy. Copyright 2012 by the American Society of Echocardiography. Source

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