Identifying low-risk chest pain in the emergency department without troponin testing: a validation study of the HE-MACS and HEAR risk scores.

INTRODUCTION: Patients presenting to EDs with chest pain of possible cardiac origin represent a substantial and challenging cohort to risk stratify. Scores such as HE-MACS (History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid) and HEAR (History, ECG, Age, Risk factors) have been developed to stratify risk without the need for troponin testing. Validation of these scores remains limited. METHODS: We performed a post hoc analysis of the Limit of Detection and ECG discharge strategy randomised-controlled trial dataset (n=629; June 2018 to March 2019; 8 UK hospitals) to calculate HEAR and HE-MACS scores. A <4% risk of major adverse cardiac events (MACE) at 30 days using HE-MACS and a score of <2 calculated using HEAR defined 'very low risk' patients suitable for discharge. The primary outcome of MACE at 30 days was used to assess diagnostic accuracy. RESULTS: MACE within 30 days occurred in 42/629 (7%) of the cohort. HE-MACS and HEAR scores identified 85/629 and 181/629 patients as 'very low risk', with MACE occurring in 0/85 and 1/181 patients, respectively. The sensitivities of each score for ruling out MACE were 100% (95% CI: 91.6% to 100%) for HE-MACS and 97.6% (95% CI: 87.7% to 99.9%) for HEAR. Presenting symptoms within these scores were poorly predictive, with only diaphoresis reaching statistical significance (OR: 4.99 (2.33 to 10.67)). Conventional cardiovascular risk factors and clinician suspicion were related to the presence of MACE at 30 days. CONCLUSION: HEAR and HE-MACS show potential as rule out tools for acute myocardial infarction without the need for troponin testing. However, prospective studies are required to further validate these scores.

Rates of Bile Acid Diarrhoea After Cholecystectomy: A Multicentre Audit.

INTRODUCTION: Bile acid diarrhoea (BAD) can occur due to disruption to the enterohepatic circulation, e.g. following cholecystectomy. Post-cholecystectomy diarrhoea has been reported in 2.1-57.2% of patients; however, this is not necessarily due to BAD. The aim of this study was to determine the rates of bile acid diarrhoea diagnosis after cholecystectomy and to consider investigation practices. METHODS: A retrospective analysis of electronic databases from five large centres detailing patients who underwent laparoscopic cholecystectomy between 2013 and 2017 was cross-referenced with a list of patients who underwent 75SeHCAT testing. A 7-day retention time of <15% was deemed to be positive. Patient demographics and time from surgery to investigation were collected and compared for significance (p < 0.05). RESULTS: A total of 9439 patients underwent a laparoscopic cholecystectomy between 1 January 2013 and 31 December 2017 in the five centres. In total, 202 patients (2.1%) underwent investigation for diarrhoea via 75SeHCAT, of which 64 patients (31.6%) had a 75SeHCAT test result of >15%, while 62.8% of those investigated were diagnosed with bile acid diarrhoea (BAD). In total, 133 (65.8%) patients also underwent endoscopy and 74 (36.6%) patients had a CT scan. Median time from surgery to 75SeHCAT test was 672 days (SD ± 482 days). DISCUSSION/CONCLUSION: Only a small proportion of patients, post-cholecystectomy, were investigated for diarrhoea with significant time delay to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher, and clinicians need to have an increased awareness of this condition due to its amenability to treatment. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.

Impact of COVID-19 on inpatient referral of acute heart failure: a single-centre experience from the south-west of the UK.

AIMS: Healthcare services worldwide have been significantly impacted by the COVID-19 pandemic. Recent reports have shown a decline in hospitalization for emergency cardiac conditions. The impact of the COVID-19 pandemic on hospitalization and particularly mortality due to acute heart failure has not been thoroughly described. METHODS AND RESULTS: In this single-centre observational study, we examined referrals to the acute heart failure team over a period of 16 weeks (7 January to 27 April 2020) spanning the ongoing COVID-19 pandemic; 283 patients referred to our acute heart failure services over the study period were included on the basis of typical symptoms, raised BNP, and echocardiogram. There was a substantial but statistically non-significant drop in referrals with 164 referred in the 8 weeks before the first UK death due to COVID-19 on 2 March 2020 (BC), compared with 119 referred after (AC) in the subsequent 8 weeks, representing a 27% reduction overall (P = 0.06). The 30 day case fatality rate was increased from 11% in the BC group compared with 21% in the AC group (risk ratio = 1.9, 95% confidence interval 1.09-3.3). Age, gender, length of stay, left ventricular ejection fraction, and N-terminal pro-brain natriuretic peptide were similar between the groups. Admission creatinine, age, and AC cohort status were found to be univariable predictors of mortality. On multivariate Cox regression analysis, only age (hazard ratio 1.04, P = 0.03) and AC cohort status (hazard ratio 2.1, P = 0.017) remained significant predictors of mortality. On sensitivity analysis, this increased mortality was driven by COVID-19 positive status. CONCLUSIONS: There was a reduction in referral of patients with acute heart failure with significant increase in mortality in the 8 weeks following the first reported UK death due to COVID-19. The observation of increased mortality does not appear related to a change in population in terms of demographics, left ventricular ejection fraction, or N-terminal pro-brain natriuretic peptide. The observed increased mortality appears to be related to the coexistence of COVID19 infection with acute heart failure. The study highlights the need for widespread preventative and shielding measures particularly in this group of patients especially in the light of the second wave. Longer follow-up with inclusion of data from other centres and community heart failure services will be needed.

Can We Use Routinely Collected Healthcare Data for a Nationwide Trial on Venous Thromboembolism Prophylaxis Following Primary Joint Replacement? A Feasibility Study.

BACKGROUND: UK hospitals nationally report venous thromboembolism (VTE) within 90 days of hospital admission, with hospital-acquired thrombosis (HAT) registers at each center used for this. We assessed the accuracy of our HAT register in identifying VTE following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We assessed 982 elective admissions for primary THA and TKA at a large tertiary center during 2018. The primary outcome was any VTE (deep vein thrombosis and/or pulmonary embolism) within 90 days postsurgery. VTEs were identified by systematically searching hospital databases (including discharge and outpatient letters, readmissions, emergency department visits, and imaging) for every patient. VTEs were also collected using the HAT database at our center, which is maintained regularly by a specialist nursing team and used to report VTEs nationally. Diagnostic test characteristics were assessed for HAT in identifying VTEs compared to the gold standard (ie, VTEs from the hospital databases). RESULTS: The prevalence of VTE was 2.7% (n = 27), with 20 VTEs identified by HAT. The accuracy of HAT in identifying VTEs were as follows: sensitivity = 74.1% (95% confidence interval [CI] = 53.7-88.9), specificity = 100% (CI = 99.6-100), positive predictive value = 100% (CI = 83.2-100), and negative predictive value = 99.3% (CI = 98.5-99.7). CONCLUSION: One-quarter of VTEs occurring after THA and TKA were not identified by the HAT register. These cases would be missing when our hospital's data are sent for national VTE reporting, and therefore would have substantial implications if HAT was primarily used to identify VTEs in a trial. Further work is needed to improve the accuracy of HAT VTE reporting before this could be relied upon in this setting.

Postgraduate Alcohol and Other Drug Practitioner Training in New Zealand: Significant Influences.

OBJECTIVE: The purpose of this article is to present a case study of the evolution of postgraduate-level training programs for alcohol and other drug (AOD) practitioners provided by two universities in New Zealand. METHOD: The case study compiles details on relevant treatment contexts and systems in New Zealand and key milestones and significant developments in postgraduate AOD practitioner programs in two locations over a 30-year period. The details were compiled by the authors, all of whom were closely involved with the development of the training programs. RESULTS: The key ingredients for success that were identified included a focus on specialized learning overlaying generic undergraduate professional training; a core commitment to practice oriented teaching; investment in the training by government bodies; and the parallel emergence of professional bodies, registration systems, and collaborative relationships across agencies. In a small country, the two programs have enabled 345 students to obtain specialist postgraduate qualifications in AOD practice over a 10-year period. CONCLUSIONS: Little could have been achieved without ongoing cooperation between education providers, government agencies, and AOD services. This history may be of interest to those in other locations attempting to establish nation- or statewide approaches to AOD practitioner training.

Drug use and addiction: evolutionary perspective.

Drug use creates a significant amount of harm in modern societies. From an evolutionary perspective, the pervasive use of drugs and the ongoing risk of drug addiction can be explained in terms of the action of drugs on evolved motivational-emotional systems. Addiction arises through interaction of these evolutionarily ancient systems, designed to promote the pursuit of natural rewards, and contemporary environments where purified and potent forms of drugs are readily available. This evolutionary analysis is extended to account for developmental patterns in problem drug use, and to explain the existence of behavioural addictions, such as problem gambling. The paper concludes by considering some of the clinical and public policy implications of the evolutionary perspective presented.

Coexisting psychiatric disorders in a New Zealand outpatient alcohol and other drug clinical population.

OBJECTIVE: To describe the extent of psychiatric disorder and mental health service utilization in a representative outpatient alcohol and other drug (AOD) treatment sample in New Zealand. METHOD: A total of 105 patients were randomly recruited from two outpatient AOD treatment services in New Zealand and completed a diagnostic interview within the first 2 months of treatment. Axis I psychiatric diagnoses were made using the computerized Composite International Diagnostic Interview (CIDI-Auto), and were supplemented by the South Oaks Gambling Scale (SOGS) and the conduct disorder and antisocial personality disorder section of the Diagnostic Interview for Genetic Studies (DIGS). RESULTS: Seventy-four per cent of the sample had a current non-substance or gambling axis I disorder, with a lifetime rate of 90%. The most commonly diagnosed of these coexisting psychiatric disorders were major depressive episode (34%), social phobia (31%) and posttraumatic stress disorder (31%). Past contact with mental health services was common, while contact at the time of baseline assessment was uncommon. CONCLUSIONS: Coexisting psychiatric disorder was the rule and not the exception in this sample. AOD patients are clearly part of the larger population of mental health patients. AOD services need to be capable of comprehensive assessment and treatment planning, which includes coexisting psychiatric disorders, and should work toward better integration with other mental health services.

Barriers to optimal care for patients with coexisting substance use and mental health disorders.

OBJECTIVE: This paper describes qualitative research that was carried out as part of a project aimed at drawing up a series of guidelines for the assessment and management for people with coexisting substance use and mental health disorders, or dual diagnosis. METHOD: A core consultation team of 14 experts with experience in the areas of both substance use and mental health in New Zealand was established to advise on the development of eight clinical scenarios. The clinical scenarios were selected to highlight a range of real life issues in the treatment of people with coexisting substance use and mental health disorders and were presented at 12 focus groups around New Zealand. The 261 participants of the focus groups were asked to comment on what was optimal management for each of the scenarios and to identify barriers to optimal care in their region. Written notes were analysed for recurring and strongly stated themes and these comprise the results of the study. RESULTS: While there was marked regional variation in treatment approaches and service structures, many of the barriers to optimal care that were identified were common to all regions. The results are considered under the headings of systems issues, clinical issues and attitudes. CONCLUSIONS: A wide variety of barriers that impede the delivery of optimal care have been identified. These range from the attitudes of individual clinicians to the structure of the systems within which they work. A system of key principles and processes for organizing treatment in a way which helps overcome these barriers is proposed.