Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis.

Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI). Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (<0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain. Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016). Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization. Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements <0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies. Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died. Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies. Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome. Primary Funding Source: Emergency Care Foundation

Motivation and satisfaction of volunteers for community-based urban agriculture programmes

Urban agriculture means cultivating plants and raising livestock within cities for food and other uses. A Community‐based Urban Agriculture Programme is where people from residential areas get together as volunteers to practise urban agriculture in an empty space within residential areas. However, the programme encounters problems when it is incapable of attracting enough volunteers and retaining them in order to establish a sustainable programme. This study aims to determine the relationship between the dimensions of motivation and satisfaction of volunteers on the Community‐based Urban Agriculture Programme. Data collected from 375 volunteers on the Community‐based Urban Agriculture Programme in Klang Valley, Malaysia were analysed using descriptive analysis, reliability analysis, correlation analysis, and hierarchical multiple regression analysis. It was found that the most significant predictor of Community‐based Urban Agriculture Programme volunteers’ satisfaction was favoured by external factors such as campaigns, support groups, Department of Extension, and community as well as government policy, followed by love of farming, social referents, and values. Therefore, there should be a focus on the above‐mentioned dimensions of motivation in order to enhance the satisfaction of volunteers towards the Community‐based Urban Agriculture Programme

Sustained reductions in emergency department laboratory test orders: impact of a simple intervention

Objectives To determine whether a pathology request form allowing interns and residents to order only a limited range of laboratory blood tests prior to consultation with a registrar or consultant can reduce test ordering in an emergency department (ED). Methods A prospective before-and-after study in an adult tertiary-referral teaching hospital ED was conducted. A pathology request form with a limited list of permissible tests was implemented for use by junior medical officers. Tests for patients 16 years and older presenting in a 20-week pre-intervention period from 19 January 2009 were compared with those in a corresponding 20-week post-intervention period from 18 January 2010. Main outcome measures were the number and cost of blood tests ordered. Results 24 652 and 25 576 presentations were analysed in the pre- and post-intervention periods, respectively. The mean number of blood tests ordered per 100 ED presentations fell by 19% from 172 in the pre- to 140 in the post-intervention period (p=0.001). The mean cost of blood tests ordered per 100 ED presentations fell by 17% from $A3177 in the pre- to$A2633 in the post-intervention period (p=0.001). There were falls in the number of coagulation profiles (11.1 vs 4.8/100 patients), C-reactive protein (5.6 vs 2.7/100 patients), erythrocyte sedimentation rate (2.5 vs 1.3/100 patients) and thyroid function tests (2.2 vs 1.6/ 100 patients). Conclusions Pathology request forms limiting tests that an intern and resident may order prior to consultation with a registrar or consultant are an effective low maintenance method for reducing laboratory test ordering in the ED that is sustainable over 12 months

The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study

Objectives: To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays. Methods: Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results. Results: Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay. Conclusions: The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk

Heart Fatty Acid Binding Protein and cardiac troponin: Development of an optimal rule-out strategy for acute myocardial infarction

10.1186/s12873-016-0089-yBMC Emergency Medicine1613

Tolerance of genetically characterized Folsomia candida strains to phenmedipham exposure

Abstract Background, Aims, and Scope The springtail Folsomia candida is a commonly used model species in ecotoxicological soil testing. The species reproduces parthenogenetically and, thus, laboratories use different clonal lineages. In this study, we investigated if genetic divergence between F. candida strains impacts the reaction to chemical stress and may thus affect the outcome of toxicity tests. Methods In two exposure assays (life-cycle reproduction test and avoidance behaviour test), three laboratory strains of F. candida from Portugal (PTG), Spain (SPN) and Denmark (DNK) were exposed to different concentrations of the reference chemical phenmedipham. Genetic divergence among strains was estimated based on mitochondrial COI sequence data. Results No significant differences between tolerance towards phenmedipham exposure were observed in a reproduction test. In contrast, one strain (SPN) showed a decreased susceptibility to phenmedipham compared to the other strains (PTG and DNK) in the avoidance assay. Discussion A phylogenetic tree based on mitochondrial COI sequences revealed clear genetic differentiation between both ‘reaction types’. Thus, we found a potential lineage dependent stress reaction in avoidance behaviour towards the pesticide. Conclusions Our findings have implications for the comparability of test results among laboratories. Reproduction tests seem to be more robust towards interclonal genetic differentiation than avoidance tests. Recommendations and Perspectives We recommend the use of molecular tools for simple and cost effective genetic characterization of F. candida strains used in chemical avoidance tests. Closer investigations concerning the relation between genetic relatedness and chemical response will provide a more detailed and comprehensive picture on the role of intraspecific genetic differentiation in stress tolerance