Beyond Triage: The Diagnostic Accuracy of Emergency Department Nursing Staff Risk Assessment in Patients with Suspected Acute Coronary Syndromes.

Objectives To establish the accuracy of emergency department (ED) nursing staff risk assessment using an established chest pain risk score alone and when incorporated with presentation high-sensitivity troponin testing as part of an accelerated diagnostic protocol (ADP). Design Prospective observational study comparing nursing and physician risk assessment using the modified Goldman (m-Goldman) score and a predefined ADP, incorporating presentation high-sensitivity troponin. Setting A UK District ED. Patients Consecutive patients, aged 7ge;18, with suspected cardiac chest pain and non-ischaemic ECG, for whom the treating physician determined serial troponin testing was required. Outcome measures 30-day major adverse cardiac events (MACE). Results 960 participants were recruited. 912/960 (95.0%) had m-Goldman scores recorded by physicians and 745/960 (77.6%) by nursing staff. The area under the curve of the m-Goldman score in predicting 30-day MACE was 0.647 (95% CI 0.594 to 0.700) for physicians and 0.572 (95% CI 0.510 to 0.634) for nursing staff ( p=0.09). When incorporated into an ADP, sensitivity for the rule-out of MACE was 99.2% (95% CI 94.8% to 100%) and 96.7% (90.3% to 99.2%) for physicians and nurses, respectively. One patient in the physician group (0.3%) and three patients (1.1%) in the nursing group were classified as low risk yet had MACE. There was fair agreement in the identification of low-risk patients (kappa 0.31, 95% CI 0.24 to 0.38). Conclusions The diagnostic accuracy of ED nursing staff risk assessment is similar to that of ED physicians and interobserver reliability between assessor groups is fair. When incorporating high-sensitivity troponin testing, a nurse-led ADP has a miss rate of 1.1% for MACE at 30 days. Trial registration number Controlled Trials Database (ISRCTN no. 21109279)

Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays.

STUDY OBJECTIVE: We compare the ability of 5 established risk scores to identify patients with suspected acute coronary syndromes who are suitable for discharge after a modified single-presentation high-sensitivity troponin result. METHODS: This was a prospective observational study conducted in a UK district general hospital emergency department. Consecutive adults recruited with suspected acute coronary syndrome for whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to modified Goldman, Thrombolysis in Myocardial Infarction (TIMI), Global Registry of Acute Cardiac Events (GRACE), History, ECG, Age, Risk Factors, Troponin (HEART), and Vancouver Chest Pain Rule risk scores, incorporating either high-sensitivity troponin T or I results. The endpoint was acute myocardial infarction within 30 days. A test sensitivity threshold for acute myocardial infarction of 98% was chosen. Clinical utility was defined as a negative predictive value greater than or equal to 99.5% and identification of greater than 30% suitable for discharge. RESULTS: Nine hundred fifty-nine patients underwent high-sensitivity troponin T analysis and 867 underwent high-sensitivity troponin I analysis. In the high-sensitivity troponin T group, 79 of 959 (8.2%) had an acute myocardial infarction and 66 of 867 (7.6%) in the high-sensitivity troponin I group. Two risk scores (GRACE <80 and HEART ≤3) did not have the potential to achieve a sensitivity of 98% with high-sensitivity troponin T, and 3 scores (Goldman ≤1, TIMI ≤1, and GRACE <80) with high-sensitivity troponin I. A TIMI score of 0 or less than or equal to 1 and modified Goldman score less than or equal to 1 with high-sensitivity troponin T, and TIMI score of 0 and HEART score of less than or equal to 3 with high-sensitivity troponin I had the potential to achieve a negative predictive value greater than or equal to 99.5% while identifying greater than 30% of patients as suitable for immediate discharge. CONCLUSION: With established risk scores, it may be possible to identify greater than 30% of patients suitable for discharge, with a negative predictive value greater than or equal to 99.5% for the diagnosis of acute myocardial infarction, using a single high-sensitivity troponin test result at presentation. There is variation in high-sensitivity troponin assays, which may have implications in introducing rapid rule-out protocols

Phase I Archaeological Survey of a 10-acre Habitat for Humanity Tract in Laredo, Webb County, Texas

On December 7, 2004, the Center for Archaeological Research (CAR) conducted a Phase I intensive pedestrian archaeological survey of a 10-acre portion of Tract 4 in the Las Blancas Subdivision located near Laredo in Webb County, Texas, for Habitat for Humanity of Laredo. The proposed development consists of the construction of low-income housing within this parcel. Twenty shovel tests were excavated along 20-meter transects and in areas considered to have high or moderate probability of buried cultural materials. In addition, two backhoe trenches were excavated in alluvial deposits along the eastern margin of the project area overlooking Blancas Creek. The survey resulted in the identification of one archaeological site, 41WB633, an apparent lithic procurement locality. Site 41WB633 covers approximately 6.4 acres and extends beyond the survey area. The core area with the highest density of surface materials measures approximately 65 x 45 meters and contains early reduction stage bifaces, cores, and lithic debitage scattered across the surface. Only one of the 20 shovel tests (ST 10) placed within the site recovered subsurface materials buried in Levels 1–3, at 0–30 cm below surface. Neither of the two backhoe trenches excavated within the boundaries of the site yielded subsurface materials. The geoarchaeological investigations indicate that the prehistoric lithic artifacts show no evidence of alluvial or colluvial abrasion and only minimal patination was observed on a few pieces. This suggests that they are not the product of significant high-energy redeposition. Although the surface gravels may have been formed by colluvial or eolian processes, the fresh, undamaged edges of the lithics indicate that events concentrating the gravels probably occurred prior to deposition of the archaeological materials. Given the lack of isolable archaeological deposits at 41WB633, the overall low density of cultural materials, and the absence of a comprehensive research context within which such lithic procurement sites can be interpreted, CAR recommends that the site does not merit designation as a State Archeological Landmark and does not warrant nomination to the National Register of Historic Places. Therefore, it is CAR’s recommendation that the construction work associated with the development of this 10-acre portion of the Las Blancas Subdivision proceed as planned. Because the property was privately owned at the time of the fieldwork, and no state funds will be employed in the construction effort, no Texas Antiquities Committee permit was necessary for this undertaking. The artifacts collected during the survey will be curated at CAR unless otherwise requested by the landowner. All project-associated documents are curated at the Center for Archaeological Research at The University of Texas at San Antonio

Boron Studies in Interdisciplinary Fields Employing Nuclear Track Detectors (NTDs)

Pollution & threats to the environmen

Archaeological Survey for the Proposed Salado Creek Hike and Bike Trail, City of San Antonio, Bexar County, Texas

In November of 2002 and March of 2003, a crew from the Center for Archaeological Research at The University of Texas at San Antonio conducted archeological and geoarcheological investigations along Salado Creek in San Antonio, Bexar County, Texas. The purpose of this fieldwork was to investigate, using shovel testing and backhoe trenching, the impact of the proposed construction of an approximately three-mile-long hike and bike trail along the creek. The work included testing for the presence of the historic Alsbury Family Cemetery and Homestead that may be in close proximity to the trail’s right-of-way. Work was performed under contract with HNTB Corporation of San Antonio. This work was conducted under Texas Antiquities Permit No. 2917, with Steve A. Tomka serving as Principal Investigator. Shovel testing and backhoe trenching yielded no significant archeological deposits. No cultural material was collected during the survey. A backhoe trench and shovel tests placed along the trail’s path in the vicinity of the cemetery encountered no signs of graves and archival research suggests the cemetery is well outside the trail right-of-way. It is believed that locating the Alsbury Family Cemetery may require pedestrian survey and subsurface investigations that are outside the scope of this project. Finally, it is recommended that the construction of the proposed hike and bike trail proceed as planned since it will not impact intact cultural deposits of significant research potential

Underperforming policy networks : the biopesticides network in the United Kingdom

Loosely integrated and incomplete policy networks have been neglected in the literature. They are important to consider in terms of understanding network underperformance. The effective delivery and formulation of policy requires networks that are not incomplete or underperforming. The biopesticides policy network in the United Kingdom is considered and its components identified with an emphasis on the lack of integration of retailers and environmental groups. The nature of the network constrains the actions of its agents and frustrates the achievement of policy goals. A study of this relatively immature policy network also allows for a focus on network formation. The state, via an external central government department, has been a key factor in the development of the network. Therefore, it is important to incorporate such factors more systematically into understandings of network formation. Feedback efforts from policy have increased interactions between productionist actors but the sphere of consumption remains insufficiently articulated