Prehospital risk stratification in patients with chest pain

OBJECTIVES: The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital. METHODS: In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018. RESULTS: Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4-99.3), a positive predictive value (PPV) of 35.5% (31.8-39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78-0.85). The preHEART Score had an NPV of 99.3% (98.1-99.8), a PPV of 49.4% (42.0-56.9) and an AUC of 0.85 (0.82-0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort. CONCLUSIONS: The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Chemical and physical characteristics of grain related to variability in energy and amino acid availability in pigs: a review

To optimise pig production, there is a need to define the variation in the available energy and amino acid content of feed grains and to understand those factors that influence nutritive value. Differences of up to 3.7 MJ/kg dry matter (DM) in digestible energy (DE) content were observed following a review of data for more than 70 cultivars of wheat. Similarly, analysis of data for more than 125 cultivars of barley revealed a range in DE estimates from 11.7 to 16.0 MJ/kg DM. Differences of this magnitude are economically significant to pig producers. Cultivar has a minimal effect on the availability of energy and amino acids in cereals, although this variation is larger in legumes, particularly lupins. The cultural conditions and agronomic practices (e.g. fertiliser rate) have a greater influence on amino acid and energy availability than the growing region or the growing year. Many factors are shown to influence the availability of energy and amino acids in feed grains, including protein source and type, starch characteristics, fat source and type, non-starch polysaccharide components, and anti-nutritional factors. Although all of these factors can influence the nutritive value of a feed grain for pigs in some way, the availability of energy and amino acids will ultimately depend on the particular combination of these components in a grain and how they behave in the presence of nutrients from other feed ingredients. For this reason, an understanding of the factors that influence the nutritive value of feed grains is more likely to eventuate when multiple regressions of grain components are made against the availability of energy and amino acids

Physical and chemical contaminants in grains used in livestock feeds

This review focuses on 3 main sources of contamination of Australian grains used in livestock feeds, namely chemical residues, moulds and mycotoxins, and weed seeds, including natural toxins such as pyrrolizidine alkaloids. By evaluating the risk to livestock from chemical contaminants (pre-emergent herbicides, selective herbicides, fungicides, insecticides used during growth phases and at pre-harvest, and post harvest insecticides) and the influence of chemical contaminants on livestock production efficiency and grain nutritional quality, the relative priorities for residue management strategies can be established. The chemicals with the highest priority for inclusion in a residue management strategy include bifenthrin (synthetic pyrethroid), chlorpyrifos-methyl (organophosphate), deltamethrin (synthetic pyrethroid), endosulfan (organochlorine), and fenitrothion (organophosphate). It also appears that the Australian maximum residue limit standards do not meet the needs of the livestock industries for effective management of residues in animal feeds, and consequently, a revised approach is required. The amount of research and literature available on the effects of mould and mycotoxin contamination of grain on livestock production, and techniques available for the measurement of moulds and mycotoxins, far exceeds the potential risk these contaminants pose to the livestock industries in Australia. In addition, the effects of moulds and mycotoxins are rarely widespread, with many accounts in the literature referring to a small number of animals on individual enterprises. The actual economic impact of moulds and mycotoxin contamination is also difficult to assess due to a lack of systematic surveys and varying livestock production responses to the presence of these compounds. Finally, weed seeds and the toxic components of weed seeds are still prevalent contaminants of Australian grains used in livestock feeds, and are responsible for significant livestock losses, but there is a lack of screening methods for qualitative or quantitative identification of these contaminants and a lack of uniform standards for use of contaminated grain

The nutritive value of citrus pulp ensiled with wheat straw and poultry litter for sheep

In experiment 1, 4 treatments were prepared consisting of a mixture of chopped wheat straw in different proportions, a fixed proportion of poultry litter and 0, 15, 30 and 45% citrus pulp on a dry matter basis. The mixtures were ensiled for 60 days at room temperature in polythene bags. Ensiling (time effect) resulted in an increase (P0.05) in dry matter intake between diets containing 0, 76 and 167 g/kg citrus pulp when the intake was expressed on the basis of metabolic body weight. However, there was a decrease (P<0.001) in intake of silage and diet dry matter, organic matter and digestible organic matter when the level of citrus pulp in the basal silage diet increased from 167 to 272 g/kg. Only animals on the basal silage diet containing 167 g/kg citrus pulp had a higher (P<0.05) and positive nitrogen balance of 1.0 g/day. It is concluded that wheat straw and poultry litter can be ensiled successfully with citrus pulp to produce silage that is safe and of high fermentation quality. This silage has a medium to high feeding value in sheep, provided that the level of citrus pulp in the diet is in the range of 150–200 g/kg.P. K. Migwi, J. R. Gallagher and R. J. Van Barnevel

Quantifying the dynamics of microtopography during a snowmelt event

Knowledge of soil microtopography and its changes in space and over time is important to the understanding of how tillage influences infiltration, runoff generation and erosion. In this study, the use of a terrestrial laser scanner (TLS) is assessed for its ability to quantify small changes in the soil surface at high spatial resolutions for a relatively large surface area (100 m2). Changes in soil surface morphology during snow cover and melt are driven by frost heave, slaking, pressure exertion by the snowpack and overland flow (erosion and deposition). An attempt is undertaken to link these processes to observed changes at the soil surface. A new algorithm for soil surface roughness is introduced to make optimal use of the raw point cloud. This algorithm is less scale dependent than several commonly used roughness calculations. The results of this study show that TLSs can be used for multitemporal scanning of large surfaces and that small changes in surface elevation and roughness can be detected. Statistical analysis of the observed changes against terrain indices did not yield significant evidence for process differentiation.</p

Quantifying the dynamics of microtopography during a snowmelt event

<p>Knowledge of soil microtopography and its changes in space and over time is important to the understanding of how tillage influences infiltration, runoff generation and erosion. In this study, the use of a terrestrial laser scanner (TLS) is assessed for its ability to quantify small changes in the soil surface at high spatial resolutions for a relatively large surface area (100 m²). Changes in soil surface morphology during snow cover and melt are driven by frost heave, slaking, pressure exertion by the snowpack and overland flow (erosion and deposition). An attempt is undertaken to link these processes to observed changes at the soil surface. A new algorithm for soil surface roughness is introduced to make optimal use of the raw point cloud. This algorithm is less scale dependent than several commonly used roughness calculations. The results of this study show that TLSs can be used for multitemporal scanning of large surfaces and that small changes in surface elevation and roughness can be detected. Statistical analysis of the observed changes against terrain indices did not yield significant evidence for process differentiation.</p