Which diagnostic tests are most useful in a chest pain unit protocol?

Background The chest pain unit (CPU) provides rapid diagnostic assessment for patients with acute, undifferentiated chest pain, using a combination of electrocardiographic (ECG) recording, biochemical markers and provocative cardiac testing. We aimed to identify which elements of a CPU protocol were most diagnostically and prognostically useful. Methods The Northern General Hospital CPU uses 2–6 hours of serial ECG / ST segment monitoring, CK-MB(mass) on arrival and at least two hours later, troponin T at least six hours after worst pain and exercise treadmill testing. Data were prospectively collected over an eighteen-month period from patients managed on the CPU. Patients discharged after CPU assessment were invited to attend a follow-up appointment 72 hours later for ECG and troponin T measurement. Hospital records of all patients were reviewed to identify adverse cardiac events over the subsequent six months. Diagnostic accuracy of each test was estimated by calculating sensitivity and specificity for: 1) acute coronary syndrome (ACS) with clinical myocardial infarction and 2) ACS with myocyte necrosis. Prognostic value was estimated by calculating the relative risk of an adverse cardiac event following a positive result. Results Of the 706 patients, 30 (4.2%) were diagnosed as ACS with myocardial infarction, 30 (4.2%) as ACS with myocyte necrosis, and 32 (4.5%) suffered an adverse cardiac event. Sensitivities for ACS with myocardial infarction and myocyte necrosis respectively were: serial ECG / ST segment monitoring 33% and 23%; CK-MB(mass) 96% and 63%; troponin T (using 0.03 ng/ml threshold) 96% and 90%. The only test that added useful prognostic information was exercise treadmill testing (relative risk 6 for cardiac death, non-fatal myocardial infarction or arrhythmia over six months). Conclusion Serial ECG / ST monitoring, as used in our protocol, adds little diagnostic or prognostic value in patients with a normal or non-diagnostic initial ECG. CK-MB(mass) can rule out ACS with clinical myocardial infarction but not myocyte necrosis(defined as a troponin elevation without myocardial infarction). Using a low threshold for positivity for troponin T improves sensitivity of this test for myocardial infarction and myocardial necrosis. Exercise treadmill testing predicts subsequent adverse cardiac events

Partnership research with older people: moving towards making the rhetoric a reality

As nursing develops closer partnerships with older people in delivering care, it also needs to develop partnerships in order to create the knowledge base for practice in a way that challenges professional hegemony and empowers older people. However, the process of developing partnerships in research takes place against a background of academic research traditions and norms, which can present obstacles to collaboration. This paper is a reflection on the issues that have arisen in three projects where older people were involved in research at different levels, from sources of data to independent researchers. It points to some of the areas that need further exploration and development

Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective. Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom. Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance. Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service. Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, –7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (–£56 to £210, P = 0.252). Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care

Effect of herbage density, height and age on nutrient and invertebrate generalist predator abundance in permanent and temporary pastures

© 2020 by the authors. The aim of this research was to assess differences in the quantity and quality of herbage and invertebrate generalist predator abundance among permanent and temporary pastures. Two permanent pastures and four temporary ley pastures (either one year or two years since being sown) were monitored weekly for 10 weeks in the spring. Permanent pastures included a diverse range of native UK grass species, and temporary ley pastures were predominantly perennial ryegrass (Lolium perenne) with or without white clover (Trifolium repens). Weekly measurements of herbage height (in centimeters), herbage cover (fresh and dry matter in kg per hectare) and herbage density (fresh and dry matter in kg per hectare per centimeter) were obtained for each field, along with lycosid spider and carabid beetle abundance. Weekly pasture samples were used to obtain nutrient concentrations of dry matter, crude protein, neutral detergent fibre (NDF), acid detergent fibre (ADF), ash, oil, sugars, digestible organic matter in the dry matter (DOMD) and metabolisable energy (ME) in the herbage as a measure of forage quality for grazing or harvesting. A linear mixed model was used to assess the effect of sward age, herbage density and height on herbage production, nutrient concentrations and invertebrate abundance. Although this study showed that permanent pastures were associated with lower nutrient concentrations of crude protein, ash, oil and ME compared to younger and predominantly perennial ryegrass pastures, the older pastures were associated with higher carabid numbers. Furthermore, permanent pastures had a higher density of dry matter herbage compared to younger pastures, and more dense and taller swards were associated with higher lycosid numbers. The study suggests that within pastures of 3 to 20 cm height, increasing the height and density of swards increases both ME and oil concentrations in herbage, therefore enhancing forage nutrient quality. Older and more permanent pastures can be beneficial for plant and invertebrate generalist predator populations, and still provide a useful source of nutrients for forage production

Loma Linda University Dentistry - Volume 23, Number 2

Contents: 9 | Gathering of Alumni 201214 | Joni Stephens Retires16 | CAD/CAM Technology26 | Student Research Awards30 | Commencement Number 5648 | Donor Appreciation58 | Recently Departedhttps://scholarsrepository.llu.edu/articulator/1003/thumbnail.jp

A flavour of omics approaches for the detection of food fraud

Food fraud has been identified as an increasing problem on a global scale with wide-ranging economic, social, health and environmental impacts. Omics and their related techniques, approaches, and bioanalytical platforms incorporate a significant number of scientific areas which have the potential to be applied to and significantly reduce food fraud and its negative impacts. In this overview we consider a selected number of very recent studies where omics techniques were applied to detect food authenticity and could be implemented to ensure food integrity. We postulate that significant reductions in food fraud, with the assistance of omics technologies and other approaches, will result in less food waste, decreases in energy use as well as greenhouse gas emissions, and as a direct consequence of this, increases in quality, productivity, yields, and the ability of food systems to be more resilient and able to withstand future food shocks

Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury : systematic review and network meta‐analysis

Background Thromboprophylaxis has the potential to reduce venous thromboembolism (VTE) following lower limb immobilization due to injury. Objectives We aimed to estimate the effectiveness of thromboprophylaxis, compare different agents and identify any factors associated with effectiveness. Methods We undertook a systematic review and network meta‐analysis (NMA) of randomised trials reporting VTE or bleeding outcomes that compared thromboprophylactic agents to each other or to no pharmacological prophylaxis, for this indication. An NMA was undertaken for each outcome or agent used, and a series of study level network meta‐regressions examined whether population characteristics, type of injury, treatment of injury or duration of thromboprophylaxis were associated with treatment effect. Results Data from 6857 participants across 13 randomised trials showed that, compared to no treatment, low molecular weight heparin (LMWH) reduced the risk of any VTE (OR 0.52; 95% CrI 0.37, 0.71), clinically detected deep vein thrombosis (DVT) (OR 0.39; 95% CrI 0.12, 0.94) and pulmonary embolism (PE) (OR 0.16; 95% CrI 0.01, 0.74), while fondaparinux reduced the risk of any VTE (OR 0.13; 95% CrI 0.05, 0.30) and clinically detected DVT (OR 0.10; 95% CrI 0.01, 0.86), with inconclusive results for PE (OR 0.40; 95% CrI 0.01, 7.53). Conclusions Thromboprophylaxis with either fondaparinux or LMWH appears to reduce the odds of both asymptomatic and clinically detected VTE in people with temporary lower limb immobilization following an injury. Treatment effects vary by outcome and are not always conclusive. We were unable to identify any treatment effect modifiers other than thromboprophylactic agent used

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study

Background Some emergency admissions can be avoided if acute exacerbations of health problems are managed by the range of health services providing emergency and urgent care. Aim To identify system-wide factors explaining variation in age sex adjusted admission rates for conditions rich in avoidable admissions. Design National ecological study. Setting 152 emergency and urgent care systems in England. Methods Hospital Episode Statistics data on emergency admissions were used to calculate an age sex adjusted admission rate for conditions rich in avoidable admissions for each emergency and urgent care system in England for 2008–2011. Results There were 3 273 395 relevant admissions in 2008–2011, accounting for 22% of all emergency admissions. The mean age sex adjusted admission rate was 2258 per year per 100 000 population, with a 3.4-fold variation between systems (1268 and 4359). Factors beyond the control of health services explained the majority of variation: unemployment rates explained 72%, with urban/rural status explaining further variation (R2=75%). Factors related to emergency departments, hospitals, emergency ambulance services and general practice explained further variation (R2=85%): the attendance rate at emergency departments, percentage of emergency department attendances converted to admissions, percentage of emergency admissions staying less than a day, percentage of emergency ambulance calls not transported to hospital and perceived access to general practice within 48 h. Conclusions Interventions to reduce avoidable admissions should be targeted at deprived communities. Better use of emergency departments, ambulance services and primary care could further reduce avoidable emergency admissions

Diagnostic accuracy of the magnetocardiograph for patients with suspected acute coronary syndrome

Background We aimed to estimate the diagnostic accuracy of the VitalScan magnetocardiograph (MCG) for suspected acute coronary syndrome (ACS). Methods We undertook a prospective cohort study evaluating the diagnostic accuracy of the MCG in adults with suspected ACS. The reference standard of ACS was determined by an independent adjudication committee based on 30-day investigations and events. The cohort was split into a training sample, to derive the MCG algorithm and an algorithm combining MCG with a modified Manchester Acute Coronary Syndrome (MACS) clinical probability score, and a validation sample, to estimate diagnostic accuracy. Results We recruited 756 participants and analysed data from 680 (293 training, 387 validation), of whom 96 (14%) had ACS. In the training sample, the respective area under the receiver operating characteristic (AUROC) curves were the following: MCG 0.66 (95% CI 0.58 to 0.74), MACS 0.64 (95% CI 0.54 to 0.73) and MCG+MACS 0.70 (95% CI 0.63 to 0.77). MCG specificity was 0.16 (95% CI 0.12 to 0.21) at the threshold achieving acceptable sensitivity for rule-out (>0.98). In the validation sample (n=387), the respective AUROCs were the following: MCG 0.56 (95% CI 0.48 to 0.64), MACS 0.69 (95% CI 0.61 to 0.77) and MCG+MACS 0.64 (95% CI 0.56 to 0.72). MCG sensitivity was 0.89 (95% CI 0.77 to 0.95) and specificity 0.15 (95% CI 0.12 to 0.20) at the rule-out threshold. MCG+MACS sensitivity was 0.85 (95% CI 0.73 to 0.92) and specificity 0.30 (95% CI 0.25 to 0.35). Conclusion The VitalScan MCG is currently unable to accurately rule out ACS and is not yet ready for use in clinical practice. Further developmental research is required