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

The effects of biofeedback on rectal sensation and distal colonic motility in patients with disorders of rectal evacuation: evidence of an inhibitory rectocolonic reflex in humans?

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Impact of delay to surgery on survival in stage I-III colon cancer.

To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer. National Cancer database (NCDB) analysis (2004-2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS. Time to treatment was &lt;16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p &lt; 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05-1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days. This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis