The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

Objectives: International guidance recommends that early serial sampling of high sensitivity troponin be used to accurately identify acute myocardial infarction (AMI) in chest pain patients. The background evidence for this approach is limited. We evaluated whether on presentation and 4-hour high-sensitivity troponin I (hs-cTnI) could be used to accurately rule-out AMI. Design and methods: hs-cTnI was measured on presentation and at 4-hours in adult patients attending an emergency department with possible acute coronary syndrome. We determined the sensitivity for AMI for at least one hs-cTnI above the 99th percentile for a healthy population or alone or in combination with new ischemic ECG changes. Both overall and sex-specific 99th percentiles were assessed. Patients with negative tests were designated low-risk. Results: 63 (17.1%) of 368 patients had AMI. The median (interquartile range) time from symptom onset to first blood sampling was 4.8. h (2.8-8.6). The sensitivity of the presentation and 4. h hs-cTnI using the overall 99th percentile was 92.1% (95% CI 82.4% to 97.4%) and negative predictive value 95.4% (92.3% to 97.4%) with 78.3% low-risk. Applying the sex-specific 99th percentile did not change the sensitivity. The addition of ECG did not change the sensitivity. Conclusion: Hs-cTnI >. 99th percentile thresholds measured on presentation and at 4-hours was not a safe strategy to rule-out AMI in this clinical setting irrespective of whether sex-specific 99th percentiles were used, or whether hs-cTnI was combined with ECG results

2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker

Objectives The purpose of this study was to determine whether a new accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge (with follow-up shortly after discharge). Background Patients presenting with possible acute coronary syndrome (ACS), who have a low short-term risk of adverse cardiac events may be suitable for early discharge and shorter hospital stays. Methods This prospective observational study tested an ADP that included pre-test probability scoring by the Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiography, and 0 + 2 h values of laboratory troponin I as the sole biomarker. Patients presenting with chest pain due to suspected ACS were included. The primary endpoint was major adverse cardiac event (MACE) within 30 days. Results Of 1,975 patients, 302 (15.3%) had a MACE. The ADP classified 392 patients (20%) as low risk. One (0.25%) of these patients had a MACE, giving the ADP a sensitivity of 99.7% (95% confidence interval [CI]: 98.1% to 99.9%), negative predictive value of 99.7% (95% CI: 98.6% to 100.0%), specificity of 23.4% (95% CI: 21.4% to 25.4%), and positive predictive value of 19.0% (95% CI: 17.2% to 21.0%). Many ADP negative patients had further investigations (74.1%), and therapeutic (18.3%) or procedural (2.0%) interventions during the initial hospital attendance and/or 30-day follow-up. Conclusions Using the ADP, a large group of patients was successfully identified as at low short-term risk of a MACE and therefore suitable for rapid discharge from the emergency department with early follow-up. This approach could decrease the observation period required for some patients with chest pain. (An observational study of the diagnostic utility of an accelerated diagnostic protocol using contemporary central laboratory cardiac troponin in the assessment of patients presenting to two Australasian hospitals with chest pain of possible cardiac origin; ACTRN12611001069943

‘An almost continuous picture of sordid vice’: The Keeler Affair, the Profumo Scandal and ‘Political’ Film Censorship in the 1960s

In 1963, the Profumo affair brought Christine Keeler to public attention and transformed her, briefly, into one of the most talked about women in the world. Seeking to exploit her notoriety, Topaz Films entered into an agreement with Keeler to make a cinematic version of her life story, The Keeler Affair. This article explores some of the controversies surrounding The Keeler Affair, especially in terms of the way in which the British Board of Film Censors dealt with the film. The Keeler Affair was submitted to the BBFC on two occasions – once when it was completed and then again in 1969 when Keeler's memoirs were serialised in the News of the World – and was rejected both times. On the second occasion, The Keeler Affair was also submitted to, and rejected by, the Greater London Council. The article seeks to establish some of the political factors that shaped the BBFC's and the GLC's attitudes towards politically contentious films, and demonstrates that the decisions made by the censors were guided not simply by the content of The Keeler Affair, but also by personal relationships, shared Establishment attitudes, concerns about public perceptions of the film industry and a desire not to be drawn into political controversies. Consequently, the article serves to reinforce the idea that censorship is best understood as a dynamic process shaped by a host of determining factors, many of which might best be described as extra- or para-cinematic

A research update on the demography and injury burden of victims of New Zealand earthquakes between 2010 and 2014

(c) 2020 The Author/sThis study compared the populations exposed to different shaking intensities of recent New Zealand earthquakes with injury burden, demography, and scene of injury. The population exposed to each earthquake was approximated by overlaying estimates of ground shaking with a model of population distribution for day and night populations. Injury data from all earthquakes and their aftershock periods were analysed for patient age and sex, location, scene of injury, and date of injury. An association was found between population exposed to shaking intensity and injury burden. The total injury burdens for each earthquake were: 2,815 (Darfield, 2010); 9,048 (Christchurch, February 2011); 2,057 (Christchurch, June 2011); 1,385 (Christchurch, December 2011),;106 (Cook Strait, 2013); 166 (Grassmere, 2013); and 49 (Eketahuna, 2014). All earthquakes injured approximately twice as many females as males. Most people who were injured were in the age range of 40-59 years. Two-thirds of injuries occurred at home, followed by 14% in commercial locations and 6.5% on roads and streets. This pattern was repeated within the data for each sex. The results suggest that the total injury burden was positively associated with both the intensity of shaking and size and density of the exposed population. The localities where most injuries occurred suggest that where people were at the time of shaking influenced their risk of injury. Potential explanations for the sex disparity in number of injuries are discussed

The potential impact of the next influenza pandemic on a national primary care medical workforce

BACKGROUND: Another influenza pandemic is all but inevitable. We estimated its potential impact on the primary care medical workforce in New Zealand, so that planning could mitigate the disruption from the pandemic and similar challenges. METHODS: The model in the "FluAid" software (Centers for Disease Control and Prevention, CDC, Atlanta) was applied to the New Zealand primary care medical workforce (i.e., general practitioners). RESULTS: At its peak (week 4) the pandemic would lead to 1.2% to 2.7% loss of medical work time, using conservative baseline assumptions. Most workdays (88%) would be lost due to illness, followed by hospitalisation (8%), and then premature death (4%). Inputs for a "more severe" scenario included greater health effects and time spent caring for sick relatives. For this scenario, 9% of medical workdays would be lost in the peak week, and 3% over a more compressed six-week period of the first pandemic wave. As with the base case, most (64%) of lost workdays would be due to illness, followed by caring for others (31%), hospitalisation (4%), and then premature death (1%). CONCLUSION: Preparedness planning for future influenza pandemics must consider the impact on this medical workforce and incorporate strategies to minimise this impact, including infection control measures, well-designed protocols, and improved health sector surge capacity

Surveillance, anticipation and firefighting in hospital: Perspectives of patient safety from a New Zealand case study

Aim This study explored how doctors, nurses and managers working in a New Zealand tertiary hospital understand patient safety. Background Despite health care systems implementing proven safety strategies from high reliability organisations, such as aviation and nuclear power, these have not been uniformly adopted by health care professionals with concerns raised about clinician engagement. Design Instrumental, embedded case study design using qualitative methods. Methods The study used purposeful sampling, and data was collected using focus groups and semi-structured interviews with doctors (n = 31); registered nurses (n = 19); and senior organisational managers (n = 3) in a New Zealand tertiary hospital. Results Safety was described as a core organisational value. Clinicians appreciated proactive safety approaches characterized by anticipation and vigilance, where they expertly recognized and adapted to safety risks. Managers trusted evidence-based safety rules and approaches that recorded, categorized and measured safety. Conclusion and Implications for Nursing Management It is important that nurse managers hold a more refined understanding about safety. Organisations are more likely to support safe patient care if cultural complexity is accounted for. Recognizing how different occupational groups perceive and respond to safety, rather than attempting to reinforce a uniform set of safety actions and responsibilities, is likely to bring together a shared understanding of safety, build trust and nurture safety culture