Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department.

BACKGROUND: The performance of the GRACE, HEART and TIMI scores were compared in predicting the probability of major adverse cardiac events (MACE) in chest pain patients presenting at the emergency department (ED), in particular their ability to identify patients at low risk. METHODS: Chest pain patients presenting at the ED in nine Dutch hospitals were included. The primary outcome was MACE within 6weeks. The HEART score was determined by the treating physician at the ED. The GRACE and TIMI score were calculated based on prospectively collected data. Performance of the scores was compared by calculating AUC curves. Additionally, the number of low-risk patients identified by each score were compared at a fixed level of safety of at least 95% or 98% sensitivity. RESULTS: In total, 1748 patients were included. The AUC of GRACE, HEART, and TIMI were 0.73 (95% CI: 0.70-0.76%), 0.86 (95% CI: 0.84-0.88%) and 0.80 (95% CI: 0.78-0.83%), respectively (all differences in AUC highly statistically significant). At an absolute level of safety of at least 98% sensitivity, the GRACE score identified 231 patients as "low risk" in which 2.2% a MACE was missed; the HEART score identified 381 patients as "low risk" with 0.8% missed MACE. The TIMI score identified no "low risk" patients at this safety level. CONCLUSIONS: The HEART score outperformed the GRACE and TIMI scores in discriminating between those with and without MACE in chest pain patients, and identified the largest group of low-risk patients at the same level of safety.

Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis.

OBJECTIVE: To investigate which risk score (TIMI score or HEART score) identifies the largest population of low-risk patients at the emergency department (ED). Furthermore, we retrospectively calculated the corresponding expected decrease in medical consumption if these patients would have been discharged from the ED. METHODS: We performed analyses in two hospitals of the multicentre prospective validation study of the HEART score, executed in 2008 and 2009. Patients with chest pain presenting to the ED were included and information was collected on major adverse cardiac events (MACEs) and on hospital admissions and diagnostic procedures within 6 weeks. The TIMI and HEART score were calculated for each patient. RESULTS: We analysed 640 patients (59% male, mean age of 60, cumulative incidence of MACE 17%). An estimated total of €763 468 was spent during follow-up on hospital admission and diagnostic procedures. In total, 256 (40%) patients had a HEART score of 0-3 and were considered low risk (miss rate 1.6%), a total of €64 107 was spent on diagnostic procedures and hospital admission after initial presentation in this group. In comparison, 105 (16%) patients with TIMI score of 0 were considered low risk (miss rate 0%), with a total of €14 670 spent on diagnostic procedures and initial hospital admission costs. With different cut-offs for low risk, HEART 0-2 (miss rate 0.7%), would have resulted in a total of €25 365 in savings, compared with €71 905 when an alternative low risk cut-off for TIMI of TIMI≤1 would be used (miss rate 3.0%). CONCLUSIONS: The HEART score identifies more patients as low risk compared with the TIMI score, which may lead to a larger reduction in diagnostic procedures and costs in this low-risk group. Future studies should prospectively investigate whether adhering to the HEART score in clinical practice and early discharge of low-risk patients is safe and leads to a reduction in medical consumption.

A Binaural CI Research Platform for Oticon Medical SP/XP Implants Enabling ITD/ILD and Variable Rate Processing.

We present the first portable, binaural, real-time research platform compatible with Oticon Medical SP and XP generation cochlear implants. The platform consists of (a) a pair of behind-the-ear devices, each containing front and rear calibrated microphones, (b) a four-channel USB analog-to-digital converter, (c) real-time PC-based sound processing software called the Master Hearing Aid, and (d) USB-connected hardware and output coils capable of driving two implants simultaneously. The platform is capable of processing signals from the four microphones simultaneously and producing synchronized binaural cochlear implant outputs that drive two (bilaterally implanted) SP or XP implants. Both audio signal preprocessing algorithms (such as binaural beamforming) and novel binaural stimulation strategies (within the implant limitations) can be programmed by researchers. When the whole research platform is combined with Oticon Medical SP implants, interaural electrode timing can be controlled on individual electrodes to within ±1 µs and interaural electrode energy differences can be controlled to within ±2%. Hence, this new platform is particularly well suited to performing experiments related to interaural time differences in combination with interaural level differences in real-time. The platform also supports instantaneously variable stimulation rates and thereby enables investigations such as the effect of changing the stimulation rate on pitch perception. Because the processing can be changed on the fly, researchers can use this platform to study perceptual changes resulting from different processing strategies acutely.

Behavior and handling of physically and immunologically castrated market pigs on farm and going to market.

Physical castration is a common management practice on commercial swine farms in the United States to reduce the incidence of boar taint and aggressive behavior. One alternative to physical castration (PC) is to immunologically castrate (IC) male pigs by blocking the gonadotropin-releasing factor (GnRF), thereby reducing levels of LH, FSH, testosterone, and androstenone. The objectives of this study were to evaluate the effects of IC on pig behavior, human-pig interactions, and handling during and after transport. Pigs were given the first immunization at wk 7 of the grower-finisher period, and second immunizations were given at wk 11, 13, or 14 of the grower-finisher period. Behaviors of PC and IC barrows were sampled at 3 time points after entering finishing at 9 wk of age: 7 wk before first injection, 16 wk (after immunization was complete) into finishing, and 1 d before marketing (16 to 19 wk into finishing). Handling during loading and unloading of trailers going to market was also quantified. Before the first injection, intact males showed increased aggression (P=0.014) and mounting (P=0.048), whereas PC barrows spent more (P=0.003) time feeding than intact males. There were treatment×time interactions for lying (P=0.018), aggression (P<0.001), and standing (P=0.009) behaviors. Few differences were observed in pig-human interactions between PC and IC barrows, with IC and PC approaching people in the same amount of time, but IC barrows were more (P<0.001) aggressive in chewing and rubbing on the test person's pant leg and boots. When handling and loading for processing in the home barn, PC barrows were more (P<0.05) vocal than IC barrows. Fewer dead and down pigs were observed among IC (0%) compared with PC barrows (1.17%). Immunological castration may result in similar or improved animal welfare compared to the stress of physical castration without pain relief.

A prospective validation of the HEART score for chest pain patients at the emergency department.

BACKGROUND: The focus of the diagnostic process in chest pain patients at the emergency department is to identify both low and high risk patients for an acute coronary syndrome (ACS). The HEART score was designed to facilitate this process. This study is a prospective validation of the HEART score. METHODS: A total of 2440 unselected patients presented with chest pain at the cardiac emergency department of ten participating hospitals in The Netherlands. The HEART score was assessed as soon as the first lab results and ECG were obtained. Primary endpoint was the occurrence of major adverse cardiac events (MACE) within 6 weeks. Secondary endpoints were (i) the occurrence of AMI and death, (ii) ACS and (iii) the performance of a coronary angiogram. The performance of the HEART score was compared with the TIMI and GRACE scores. RESULTS: Low HEART scores (values 0-3) were calculated in 36.4% of the patients. MACE occurred in 1.7%. In patients with HEART scores 4-6, MACE was diagnosed in 16.6%. In patients with high HEART scores (values 7-10), MACE occurred in 50.1%. The c-statistic of the HEART score (0.83) is significantly higher than the c-statistic of TIMI (0.75)and GRACE (0.70) respectively (p<0.0001). CONCLUSION: The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (0-3), exclude short-term MACE with >98% certainty. In these patients one might consider reserved policies. In patients with high HEART scores (7-10) the high risk of MACE may indicate more aggressive policies.

Consumption of diagnostic procedures and other cardiology care in chest pain patients after presentation at the emergency department.

OBJECTIVE: The HEART score serves risk stratification of chest pain patients at the emergency department (ED). Quicker and more solid decisions may be taken in these patients with application of this score. An analysis of medical consumption of 122 acute chest pain patients admitted before the introduction of this score may be indicative of possible savings. METHODS: Numbers of cardiology investigations and clinical admission days were counted. Charged cost of medicine was divided into three categories: ED, in-hospital, and outpatient clinic. RESULTS: The total cost of care was 469,631, with an average of 3849 per patient. Seventy-five percent of this cost was due to hospitalisation under the initial working diagnosis of acute coronary syndrome (ACS). This diagnosis was confirmed in only 29/122 (24 %) of the patients. The low-risk group (41 patients with HEART scores 0-3) included one patient with a previously scheduled CABG. In the remaining 40 patients, hospitalisation occurred in 12/40 (30 %) patients and 30/40 (75 %) patients visited the outpatient clinic. The total cost of medical care after presentation of these 40 patients was 37,641; there were no cases where a new diagnosis of coronary artery disease was made. When medical care in this subgroup is declared redundant, major savings on national medical care budgets could be made. CONCLUSION: If the HEART score were to be routinely applied, diagnostic pathways could be shortened and costs reduced, in particular in low-risk patients.

Risk scores for patients with chest pain: evaluation in the emergency department.

Chest pain is a common reason for presentation to the emergency department (ED). Absolute criteria for Acute Coronary Syndrome without ST elevation (NSTE-ACS) are lacking. An acute coronary syndrome (ACS) needs to be distinguished from a variety of other cardiac and non-cardiac diseases that may cause chest pain.For patients with confirmed ACS, several scoring methods can be applied in order to distinguish patients in the coronary care unit who may benefit most from therapies. The PURSUIT, TIMI, GRACE and FRISC risk scores are well validated with this respect. However, none of these risk scores has been used in the identification of an ACS in the emergency setting. The vast majority of patients with chest pain due to causes other than ACS were not evaluated in these trials. An evidence-based systematic stratification and policy for these patients does not currently exist.The more recently developed HEART score is specifically designed to stratify all chest pain patients in the ED. The HEART score was validated in a retrospective multicenter study and proved to be a strong predictor of event free survival on one hand and potentially life threatening cardiac events on the other hand. The HEART score facilitates risk stratification of chest pain patients in the ED.

Uninformative visual experience establishes long term perceptual bias.

Visual appearance depends upon the resolution of ambiguities that arise when 2D retinal images are interpreted as 3D scenes. This resolution may be characterized as a form of Bayesian perceptual inference, whereby retinal sense data combine with prior belief to yield an interpretation. Under this framework, the prior reflects environmental statistics, so an efficient system should learn by changing its prior after exposure to new statistics. We conjectured that a prior would only be modified when sense data contain disambiguating information, such that it is clear what bias is appropriate. This conjecture was tested by using a perceptually bistable stimulus, a rotating wire-frame cube, as a sensitive indicator of changes in the prior for 3D rotation direction, and by carefully matching perceptual experience of ambiguous and unambiguous versions of the stimulus across three groups of observers. We show for the first time that changes in the prior-observed as a change in bias that resists reverse learning the next day-is affected more by ambiguous stimuli than by disambiguated stimuli. Thus, contrary to our conjecture, modification of the prior occurred preferentially when the observer actively resolved ambiguity rather than when the observer was exposed to environmental contingencies. We propose that resolving stimuli that are not easily interpreted by existing visual rules must be a valid method for establishing useful perceptual biases in the natural world.

Chest pain in the emergency room: value of the HEART score.

BACKGROUND: Chest pain is one of the most common causes of presentation to the emergency room. The diagnosis of non-ST-elevation acute coronary syndrome typically causes uncertainty. Classical considerations for risk stratification are History, ECG, Age, Risk factors and Troponin (HEART). Each can be scored with zero, one or two points, depending on the extent of the abnormality. The HEART score is the sum of these five considerations. Methods. Clinical data from 122 patients referred to the emergency room for chest pain were analysed. The predictive value of the HEART score for reaching an endpoint was evaluated in 120/122 patients. RESULTS: Twenty-nine patients reached one or more endpoints: an acute myocardial infarction was diagnosed in 16 patients, 20 underwent revascularisation and two died. The HEART score in the patients with and without an endpoint was 6.51+/-1.84 and 3.71+/-1.83 (p<0.0001) respectively. A HEART score of 0-3 points holds a risk of 2.5% for an endpoint and supports an immediate discharge. With a risk of 20.3%, a HEART score of 4-6 points implies admission for clinical observation. A HEART score >/=7points, with a risk of 72.7%, supports early invasive strategies. CONCLUSION: The HEART score facilitates accurate diagnostic and therapeutic choices. The HEART score is an easy, quick and reliable predictor of outcome in chest pain patients. (Neth Heart J 2008;16:191-6.).

Human cortical activity correlates with stereoscopic depth perception.

Stereoscopic depth perception is based on binocular disparities. Although neurons in primary visual cortex (V1) are selective for binocular disparity, their responses do not explicitly code perceived depth. The stereoscopic pathway must therefore include additional processing beyond V1. We used functional magnetic resonance imaging (fMRI) to examine stereo processing in V1 and other areas of visual cortex. We created stereoscopic stimuli that portrayed two planes of dots in depth, placed symmetrically about the plane of fixation, or else asymmetrically with both planes either nearer or farther than fixation. The interplane disparity was varied parametrically to determine the stereoacuity threshold (the smallest detectable disparity) and the upper depth limit (largest detectable disparity). fMRI was then used to quantify cortical activity across the entire range of detectable interplane disparities. Measured cortical activity covaried with psychophysical measures of stereoscopic depth perception. Activity increased as the interplane disparity increased above the stereoacuity threshold and dropped as interplane disparity approached the upper depth limit. From the fMRI data and an assumption that V1 encodes absolute retinal disparity, we predicted that the mean response of V1 neurons should be a bimodal function of disparity. A post hoc analysis of electrophysiological recordings of single neurons in macaques revealed that, although the average firing rate was a bimodal function of disparity (as predicted), the precise shape of the function cannot fully explain the fMRI data. Although there was widespread activity within the extrastriate cortex (consistent with electrophysiological recordings of single neurons), area V3A showed remarkable sensitivity to stereoscopic stimuli, suggesting that neurons in V3A may play a special role in the stereo pathway.

Perceiving slant about a horizontal axis from stereopsis.

Rotating a surface about a horizontal axis alters the retinal horizontal-shear disparities. Opposed torsional eye movements (cyclovergence) also change horizontal shear. If there were no compensation for the horizontal disparities created by cyclovergence, slant estimates would be erroneous. We asked whether compensation for cyclovergence occurs, and, if it does, whether it occurs by use of an extraretinal cyclovergence signal, by use of vertical-shear disparities, or by use of both signals. In four experiments, we found that compensation is nearly veridical when vertical-shear disparities are available and easily measured. When they are not available or easily measured, no compensation occurs. Thus, the visual system does not seem to use an extraretinal cyclovergence signal in stereoscopic slant estimation. We also looked for evidence of an extraretinal cyclovergence signal in a visual direction task and found none. We calculated the statistical reliabilities of slant-from-disparity and slant-from-texture estimates and found that the more reliable of the two means of estimation varies significantly with distance and slant. Finally, we examined how slant about a horizontal axis might be estimated when the eyes look eccentrically.

Stereoscopic vision: what's the first step?

Neurons in primary visual cortex respond to binocular disparity, the raw material of stereoscopic depth perception. Although these neurons are probably essential to depth perception, a recent study has shown that they are unable to compute depth itself.

Visualization and measurement of the cortical surface.

Much of the human cortical surface is obscured from view by the complex pattern of folds, making the spatial relationship between different surface locations hard to interpret. Methods for viewing large portions of the brain's surface in a single flattened representation are described. The flattened representation preserves several key spatial relationships between regions on the cortical surface. The principles used in the implementations and evaluations of these implementations using artificial test surfaces are provided. Results of applying the methods to structural magnetic resonance measurements of the human brain are also shown. The implementation details are available in the source code, which is freely available on the Internet.

Activity in primary visual cortex predicts performance in a visual detection task.

Visual attention can affect both neural activity and behavior in humans. To quantify possible links between the two, we measured activity in early visual cortex (V1, V2 and V3) during a challenging pattern-detection task. Activity was dominated by a large response that was independent of the presence or absence of the stimulus pattern. The measured activity quantitatively predicted the subject's pattern-detection performance: when activity was greater, the subject was more likely to correctly discern the presence or absence of the pattern. This stimulus-independent activity had several characteristics of visual attention, suggesting that attentional mechanisms modulate activity in early visual cortex, and that this attention-related activity strongly influences performance.

Horizontal and vertical disparity, eye position, and stereoscopic slant perception.

The slant of a stereoscopically defined surface cannot be determined solely from horizontal disparities or from derived quantities such as horizontal size ratio (HSR). There are four other signals that, in combination with horizontal disparity, could in principle allow an unambiguous estimate of slant: the vergence and version of the eyes, the vertical size ratio (VSR), and the horizontal gradient of VSR. Another useful signal is provided by perspective slant cues. The determination of perceived slant can be modeled as a weighted combination of three estimates based on those signals: a perspective estimate, a stereoscopic estimate based on HSR and VSR, and a stereoscopic estimate based on HSR and sensed eye position. In a series of experiments, we examined human observers' use of the two stereoscopic means of estimation. Perspective cues were rendered uninformative. We found that VSR and sensed eye position are both used to interpret the measured horizontal disparities. When the two are placed in conflict, the visual system usually gives more weight to VSR. However, when VSR is made difficult to measure by using short stimuli or stimuli composed of vertical lines, the visual system relies on sensed eye position. A model in which the observer's slant estimate is a weighted average of the slant estimate based on HSR and VSR and the one based on HSR and eye position accounted well for the data. The weights varied across viewing conditions because the informativeness of the signals they employ vary from one situation to another.

An analysis of binocular slant contrast.

When a small frontoparallel surface (a test strip) is surrounded by a larger slanted surface (an inducer), the test strip is perceived as slanted in the direction opposite to the inducer. This has been called the depth-contrast effect, but we call it the slant-contrast effect. In nearly all demonstrations of this effect, the inducer's slant is specified by stereoscopic signals; and other signals, such as the texture gradient, specify that it is frontoparallel. We present a theory of slant estimation that determines surface slant via linear combination of various slant estimators; the weight of each estimator is proportional to its reliability. The theory explains slant contrast because the absolute slant of the inducer and the relative slant between test strip and inducer are both estimated with greater reliability than the absolute slant of the test strip. The theory predicts that slant contrast will be eliminated if the signals specifying the inducer's slant are consistent with one another. It also predicts reversed slant contrast if the inducer's slant is specified by nonstereoscopic signals rather than by stereo signals. These predictions were tested and confirmed in three experiments. The first showed that slant contrast is greatly reduced when the stereo-specified and nonstereo-specified slants of the inducer are made consistent with one another. The second showed that slant contrast is eliminated altogether when the stimulus consists of real planes rather than images on a display screen. The third showed that slant contrast is reversed when the nonstereo-specified slant of the inducer varies and the stereo-specified slant is zero. We conclude that slant contrast is a byproduct of the visual system's reconciliation of conflicting information while it attempts to determine surface slant.

Perceived visual direction near an occluder.

When an opaque object occludes a more distant object, the two eyes often see different parts of the distant object. Hering's laws of visual direction make an interesting prediction for this situation: the part seen by both eyes should be seen in a different direction than the part seen by one eye. We examined whether this prediction holds by asking observers to align a vertical monocular line segment with a nearby vertical binocular segment. We found it necessary to correct the alignment data for vergence errors, which were measured in a control experiment, and for monocular spatial distortions, which were also measured in a control experiment. Settings were reasonably consistent with Hering's laws when the monocular and binocular targets were separated by 30 arcmin or more. Observers aligned the targets as if they were viewing them from one eye only when they were separated by 2 arcmin; this behavior is consistent with an observation reported by Erkelens and colleagues. The same behavior was observed when the segments were horizontal and when no visible occluder was present. Perceived visual direction when the two eyes see different parts of a distant target is assigned in a fashion that minimizes, but does not eliminate, distortions of the shape of the occluded object.