False-positive troponin elevation due to an immunoglobulin-G-cardiac troponin T complex: a case report.

Background: Troponin is a crucial biomarker for the diagnosis of an acute coronary syndrome (ACS). It rises in response to myocardial injury from significant acute myocardial ischaemia caused by obstructive coronary artery disease ['classical' myocardial infarction (MI)]. However, raised levels have also been noted in conditions not recognized as classical ACS. This may include MI with non-obstructed coronary arteries such as takotsubo cardiomyopathy and other acute or chronic conditions such as pulmonary embolus or chronic kidney disease. This is commonly labelled as a 'falsely elevated' troponin although there is some myocardial strain to explain the rise, such as an increase in cardiac oxygen demand. True 'falsely elevated' troponin, characterized by a persistent elevation in the absence of cardiac injury does occur and thought to be secondary to an immunoglobulin-troponin complex (macrotroponin). Case summary: A 53-year-old gentleman with a background of diabetes, hypertension, hypercholesterolaemia, and hepatitis B was admitted with chest pain and persistently elevated cardiac troponin T (cTnT) levels. Investigations revealed unobstructed coronary arteries and a structurally normal, well-functioning heart. Subsequent biochemical analysis found the persistently elevated cTnT secondary to macrotroponin T. Discussion: Macrotroponin, an immunoglobulin-troponin bound complex should be considered as a differential diagnosis when the biochemistry is not reflective of the clinical picture. Early recognition requires effective collaboration with the biochemistry laboratory for accurate diagnosis

Etiologic predictive value of a rapid immunoassay for detection of group A streptococcus antigen from throat swabs in patients presenting with a sore throat

Context: A sore throat is a common symptom mainly caused by virus but also by a variety of bacteria such as group A betahaemolytic streptococci (GAS) often resulting in unnecessary antibiotic prescribing. Combinations of symptoms and scores are not specific enough to accurately sort out aetiology. Rapid diagnostic antigen tests (RADT) have demonstrated high sensitivity and specificity in detecting presence of GAS. Objective: Establish the probability that finding of GAS in a RADT shows a true link between symptoms and GAS while considering carriers of GAS ill from a virus. Design: Cross-sectional study comparing two groups. Setting: Emergency department (ED) also managing primary health care cases in a remote rural town with 22,000 residents. Patients/Participants: 101 consecutive children aged 3-15 years attending for a sore throat as the main complaint and 147 consecutive children of the same age attending the same ED for other reasons than an infection. Main And Secondary Outcome Measures: Positive and negative Etiologic Predictive Value (EPV). Results: Positive EPV was 98% (88-100%). Negative EPV was 98% (97-99%). The positive EPV depends on setting and findings in this study and may not be transferable to other settings. It was mathematically shown that negative EPV found in this study is valid in all other reasonable settings and hence can be transferred to any other setting. Conclusions: The evaluated RADT (Alere Test Pack+Plus With OBC Strep A) is always useful to rule out GAS infection in patients with an uncomplicated sore throat. It is often, depending on setting, useful to rule in a GAS infection in these patients

Etiologic predictive value of a rapid immunoassay for detection of group A streptococcus antigen from throat swabs in patients presenting with a sore throat

Context: A sore throat is a common symptom mainly caused by virus but also by a variety of bacteria such as group A betahaemolytic streptococci (GAS) often resulting in unnecessary antibiotic prescribing. Combinations of symptoms and scores are not specific enough to accurately sort out aetiology. Rapid diagnostic antigen tests (RADT) have demonstrated high sensitivity and specificity in detecting presence of GAS. Objective: Establish the probability that finding of GAS in a RADT shows a true link between symptoms and GAS while considering carriers of GAS ill from a virus. Design: Cross-sectional study comparing two groups. Setting: Emergency department (ED) also managing primary health care cases in a remote rural town with 22,000 residents. Patients/Participants: 101 consecutive children aged 3-15 years attending for a sore throat as the main complaint and 147 consecutive children of the same age attending the same ED for other reasons than an infection. Main And Secondary Outcome Measures: Positive and negative Etiologic Predictive Value (EPV). Results: Positive EPV was 98% (88-100%). Negative EPV was 98% (97-99%). The positive EPV depends on setting and findings in this study and may not be transferable to other settings. It was mathematically shown that negative EPV found in this study is valid in all other reasonable settings and hence can be transferred to any other setting. Conclusions: The evaluated RADT (Alere Test Pack+Plus With OBC Strep A) is always useful to rule out GAS infection in patients with an uncomplicated sore throat. It is often, depending on setting, useful to rule in a GAS infection in these patients

Fungicidal effect of volatile oils from Eucalyptus citriodora and its major constituent citronellal

A study was undertaken to explore the effect of volatile oils fromEucalyptus citriodora and its major constituent citronellal against two well-known rice pathogens, Rhizoctonia solani and Helminthosporium oryzae. The radial growth and dry weight of both the test fungi were drastically reduced in response to the volatile oils. A complete inhibition of R. solani and H. oryzae was observed at 10 and 20 ppm, respectively. Citronellal alone was found to be more effective than eucalypt oils. Based on the study, it was concluded that eucalypt volatile oils have potential for the suppression of phytopathogenic fungi

Using routine clinical and administrative data to produce a dataset of attendances at Emergency Departments following self-harm

Background: Self-harm is a significant public health concern in the UK. This is reflected in the recent addition to the English Public Health Outcomes Framework of rates of attendance at Emergency Departments (EDs) following self-harm. However there is currently no source of data to measure this outcome. Routinely available data for inpatient admissions following self-harm miss the majority of cases presenting to services. Methods: Using the Clinical Record Interactive Search system, the electronic health records (EHRs) used in four EDs were linked to Hospital Episode Statistics to create a dataset of attendances following self-harm. This dataset was compared with an audit dataset of ED attendances created by manual searching of ED records. The proportion of total cases detected by each dataset was compared. Results: There were 1932 attendances detected by the EHR dataset and 1906 by the audit. The EHR and audit datasets detected 77 and 76 of all attendances respectively and both detected 82 of individual patients. There were no differences in terms of age, sex, ethnicity or marital status between those detected and those missed using the EHR method. Both datasets revealed more than double the number of self-harm incidents than could be identified from inpatient admission records. Conclusions: It was possible to use routinely collected EHR data to create a dataset of attendances at EDs following self-harm. The dataset detected the same proportion of attendances and individuals as the audit dataset, proved more comprehensive than the use of inpatient admission records, and did not show a systematic bias in those cases it missed. © 2015 Polling et al

Mind the gap: avoiding paravalvular leak using computer simulation in bicuspid transcatheter aortic valve replacement-a case report.

Background: Transcatheter aortic valve replacement (TAVR) is becoming increasingly prevalent worldwide and is now more common than surgical aortic valve replacement. It is expanding into all patient subsets including younger and lower risk patients. Bicuspid aortic valve (BAV) accounts for a significant proportion of TAVR, but due to heterogenous anatomy, it is of increased complexity. One of the greatest challenges in BAV is the selection of the correct TAVR size. Transcatheter aortic valve replacement sizing is based upon computed tomography-derived annular measurements. There are a number of sizing algorithms for BAV based upon anatomical characteristics, often yielding different results. This is noted especially when a patient falls near the borderline between two valve sizes, an anatomical grey zone. Complementary to the algorithm approach is the use of pre-procedural patient-specific computer simulation using finite-element modelling. Case summary: An 86-year-old female was treated for heart failure secondary to severe and calcific BAV aortic stenosis with TAVR. Due to anatomical difficulty and grey-zone valve sizing, we demonstrate the use of pre-procedural patient-specific computer simulation with the novel Medtronic Evolut PRO+ platform to achieve a good result. Discussion: Using patient-specific computer simulation, we were able to safely select the valve and the deployment height and then accurately predict the result in a difficult, severely calcified BAV. In addition to improving outcome, this allows for patient-specific, tailored discussion to occur at heart team meetings

I Am Getting Healthier". Perceptions of Urban Aboriginal and Torres Strait Islander People in a Chronic Disease Self-Management and Rehabilitation Program

Abstract Chronic disease is a main contributor to the disproportionately high burden of illness experienced by Aboriginal and Torres Strait Islander Australians. However, there are very few programs addressing chronic disease self-management and rehabilitation which are designed specifically for urban Aboriginal and Torres Strait Islander people. This paper aims to explore client and staff perceptions of the Work It out Program, a chronic disease rehabilitation and self-management program designed for urban Aboriginal and Torres Strait Islander people. The study used a mixed methods approach to explore the success, barriers and self-reported outcomes of the program. Quantitative data were collected through a structured survey, comprising social and demographic data. Qualitative data were collected through interviews using Most Significant Change theory. Twenty-eight participants were recruited, 6 staff and 22 clients (M = 7, F = 21) with an age range between 21 and 79 years of age (Mean = 59.00, SD = 17.63). Interviews were completed in 2013 across four Work It out locations in Southeast Queensland. Semi-structured interviews were conducted either individually or in groups of two or three, depending on the participants' preference. Thematic analysis of the data revealed six main themes; physical changes, lifestyle improvements, social and emotional well-being, perceptions about the successful features of the program, perceived barriers to the program and changes for the future. This exploratory study found that clients and staff involved in the Work It out Program perceived it as an effective self-management and rehabilitation program for urban Aboriginal and Torres Strait Islander Australians. Further evaluation with a larger sample size is warranted in order to establish further outcomes of the program. A. Nelson et al. 53

Improving GHB withdrawal with baclofen: study protocol for a feasibility study for a randomised controlled trial

Background: GHB (gamma-hydroxybutyrate) and its pro-drugs GBL (gamma-butyrolactone) and 1,4-butanediol (1,4-BD) are central nervous system depressants whose street names include ‘G’ and ‘liquid ecstasy’. They are used recreationally predominately for their stimulant and pro-sexual effects or for sedation to help with sleep and/or to ‘come down’ after using stimulant recreational drugs. Although overall population prevalence is low (0.1 %), in some groups such as men who have sex with men, GHB/GBL use may reach 20 %. GHB/GBL dependence may be associated with severe withdrawal with individuals presenting either acutely to emergency departments or to addiction services for support. Benzodiazepines are currently prescribed for GHB/GBL detoxification but do not prevent all complications, such as behavioural disinhibition, that may require hospitalisation or admission to a high dependency /intensive care unit. The GABAB receptor mediates most effects of GHB/GBL and the GABAB agonist, baclofen, has shown promise as an adjunct to benzodiazepines in reducing withdrawal severity when prescribed both during withdrawal and as a 2-day ‘preload’ prior to detoxification. The key aim of this feasibility study is provide information about recruitment and characteristics of the proposed outcome measure (symptom severity, complications including delirium and treatment escalation) to inform an application for a definitive randomised placebo controlled trial to determine the role of baclofen in the management of GHB/GBL withdrawal and whether starting baclofen 2 days earlier improves outcomes further. Methods/design: This is a prospective, randomised, double-blind, placebo-controlled feasibility study that will recruit participants (aged over 18 years) who are GHB/GBL- dependent and wish to undergo planned GHB/GBL detoxification or are at risk of acute withdrawal and are inpatients requiring unplanned withdrawal. We aim to recruit 88 participants: 28 unplanned inpatients and 60 planned outpatients. During detoxification we will compare baclofen 10 mg three times a day with placebo as an adjunct to the usual benzodiazepine regimen. In the planned outpatient arm, we will also compare a 2-day preload of baclofen 10 mg three times a day with placebo. Ratings of GHB/GBL withdrawal, sleep, depression, anxiety as well as GHB/GBL use will be collected. The main data analyses will be descriptive about recruitment and characterising the impact of adding baclofen to the usual benzodiazepine regimen on measures and outcomes of GHB/GBL withdrawal to provide estimates of variability and effect size. A qualitative approach will evaluate research participant and clinician acceptability and data collected to inform cost-effectiveness. Discussion: This feasibility study will inform a randomised controlled trial to establish whether adding baclofen to a benzodiazepine regimen reduces the severity and complications of GHB/GBL withdrawal