Gender differences in presentation and diagnosis of chest pain in primary care

<p>Abstract</p> <p>Background</p> <p>Chest pain is a common complaint and reason for consultation in primary care. Research related to gender differences in regard to Coronary Heart Disease (CHD) has been mainly conducted in hospital but not in primary care settings. We aimed to analyse gender differences in aetiology and clinical characteristics of chest pain and to provide gender related symptoms and signs associated with CHD.</p> <p>Methods</p> <p>We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 general practitioners (GPs). GPs recorded symptoms and findings of each patient and provided follow up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the aetiology of chest pain at the time of patient recruitment. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out CHD in women and men.</p> <p>Results</p> <p>Women showed more psychogenic disorders (women 11,2%, men 7.3%, p = 0.02), men suffered more from CHD (women 13.0%, men 17.2%, p = 0.04), trauma (women 1.8%, men 5.1%, p < 0.001) and pneumonia/pleurisy (women 1.3%, men 3.0%, p = 0.04) Men showed significantly more often chest pain localised on the right side of the chest (women 9.1%, men 25.0%, p = 0.01). For both genders known clinical vascular disease, pain worse with exercise and age were associated positively with CHD. In women pain duration above one hour was associated positively with CHD, while shorter pain durations showed an association with CHD in men. In women negative associations were found for stinging pain and in men for pain depending on inspiration and localised muscle tension.</p> <p>Conclusions</p> <p>We found gender differences in regard to aetiology, selected clinical characteristics and association of symptoms and signs with CHD in patients presenting with chest pain in a primary care setting. Further research is necessary to elucidate whether these differences would support recommendations for different diagnostic approaches for CHD according to a patient's gender.</p

A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology

<p>Abstract</p> <p>Background</p> <p>Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge.</p> <p>Methods/design</p> <p>The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions.</p> <p>Discussion</p> <p>The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.</p

Nitrogen and Carbon Isotopic Dynamics of Subarctic Soils and Plants in Southern Yukon Territory and its Implications for Paleoecological and Paleodietary Studies

We examine here the carbon and nitrogen isotopic compositions of bulk soils (8 topsoil and 7 subsoils, including two soil profiles) and five different plant parts of 79 C3 plants from two main functional groups: herbs and shrubs/subshrubs, from 18 different locations in grasslands of southern Yukon Territory, Canada (eastern shoreline of Kluane Lake and Whitehorse area). The Kluane Lake region in particular has been identified previously as an analogue for Late Pleistocene eastern Beringia. All topsoils have higher average total nitrogen δ15N and organic carbon δ13C than plants from the same sites with a positive shift occurring with depth in two soil profiles analyzed. All plants analyzed have an average whole plant δ13C of −27.5 ± 1.2 ‰ and foliar δ13C of ±28.0 ± 1.3 ‰, and average whole plant δ15N of −0.3 ± 2.2 ‰ and foliar δ15N of ±0.6 ± 2.7 ‰. Plants analyzed here showed relatively smaller variability in δ13C than δ15N. Their average δ13C after suitable corrections for the Suess effect should be suitable as baseline for interpreting diets of Late Pleistocene herbivores that lived in eastern Beringia. Water availability, nitrogen availability, spacial differences and intra-plant variability are important controls on δ15N of herbaceous plants in the study area. The wider range of δ15N, the more numerous factors that affect nitrogen isotopic composition and their likely differences in the past, however, limit use of the modern N isotopic baseline for vegetation in paleodietary models for such ecosystems. That said, the positive correlation between foliar δ15N and N content shown for the modern plants could support use of plant δ15N as an index for plant N content and therefore forage quality. The modern N isotopic baseline cannot be applied directly to the past, but it is prerequisite to future efforts to detect shifts in N cycling and forage quality since the Late Pleistocene through comparison with fossil plants from the same region

The Southern African Regional Science Initiative (SAFARI 2000) : overview of the dry season field campaign.

The Southern African Regional Science Initiative (SAFARI 2000) is an international science project investigating the earth-atmosphere-human system in southern Africa. The programme was conducted over a two-year period from March 1999 to March 2001. The dry season field campaign (August-September 2000) was the most intensive activity and involved over 200 scientists from eighteen countries. The main objectives were to characterize and quantify biogenic, pyrogenic and anthropogenic aerosol and trace gas emissions and their transport and transformations in the atmosphere, and to validate NASA\u27s Earth Observing System\u27s satellite Terra within a scientific context. Five aircraft - two South African Weather Service Aerocommanders, the University of Washington\u27s CV-580, the U.K. Meteorological Office\u27s C-130, and NASA\u27s ER-2-with different altitude capabilities, participated in the campaign. Additional airborne sampling of southern African air masses, that had moved downwind of the subcontinent, was conducted by the CSIRO over Australia. Multiple observations were made in various geographical sectors under different synoptic conditions. Airborne missions were designed to optimize the value of synchronous over-flights of the Terra satellite platform, above regional ground validation and science targets. Numerous smaller-scale ground validation activities took place throughout the subcontinent during the campaign period

Trophic ecology of two savanna grazers, blue wildebeest Connochaetes taurinus and black wildebeest Connochaetes gnou

The feeding niches and trophic ecology of two South African grazers, blue wildebeest Connochaetes taurinus and black wildebeest Connochaetes gnou, are compared using stable carbon and nitrogen isotope data from feces and tooth dentine collagen. As sympatric, closely related taxa predicted to occupy similar trophic positions, the blue and black wildebeest provide a good model for studying the mechanisms of coexistence and macroevolution in mammals. Data from feces collected from a single reserve in the Free State Province reveal different trophic behaviors between two herds of blue wildebeest and between both compared with a single herd of black wildebeest. These data suggest that sympatric coexistence of blue and black wildebeest is facilitated by differential niche occupation at family group or herd levels, rather than between species. However, such separation does not occur over longer time scales: results from dentine collagen support the hypothesis that the two species are indistinct in terms of trophic behavior, although blue wildebeest show more feeding flexibility, probably because of their wider habitat tolerance range. Similarities in premaxillary width of males and females of both species also suggest that both species are adapted to similar feeding styles. Thus, it is unlikely that changes in trophic behavior provided the trigger for divergence of the black from the blue wildebeest lineage in the Middle Pleistocene. We argue that the case of these two species represents an example of speciation that was not driven by resource competition, as is often assumed for many turnover events in mammalian evolution. We briefly discuss a previous suggestion that links black wildebeest evolution to their more territorial breeding behavior associated with Middleto-Late Pleistocene landscape changes in southern Africa