Comprehensive validation of early diagnostic algorithms for myocardial infarction in the emergency department.

OBJECTIVE: To comprehensively evaluate diagnostic algorithms for myocardial infarction using a high-sensitivity cardiac troponin I (hs-cTnI) assay. PATIENTS AND METHODS: We prospectively enrolled patients with suspected myocardial infarction without ST-segment elevation from nine emergency departments in Japan. The diagnostic algorithms evaluated: (i) based on hs-cTnI alone, such as the European Society of Cardiology (ESC) 0/1-h or 0/2-h and High-STEACS pathways; or (ii) used medical history and physical findings, such as the ADAPT, EDACS, HEART, and GRACE pathways. We evaluated the negative predictive value (NPV), sensitivity as safety measures, and proportion of patients classified as low or high-risk as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days. RESULTS: We included 437 patients, and the hs-cTnI was collected at 0 and 1 hours in 407 patients and at 0 and 2 hours in 394. The primary outcome occurred in 8.1% (33/407) and 6.9% (27/394) of patients, respectively. All the algorithms classified low-risk patients without missing those with the primary outcome, except for the GRACE pathway. The hs-cTnI-based algorithms classified more patients as low-risk: the ESC 0/1-h 45.7%; the ESC 0/2-h 50.5%; the High-STEACS pathway 68.5%, than those using history and physical findings (15-30%). The High-STEACS pathway ruled out more patients (20.5%) by hs-cTnI measurement at 0 hours than the ESC 0/1-h and 0/2-h algorithms (7.4%). CONCLUSIONS: The hs-cTnI algorithms, especially the High-STEACS pathway, had excellent safety performance for the early diagnosis of myocardial infarction and offered the greatest improvement in efficiency.

Management and outcome trends in type 2 myocardial infarction: an investigation from the SWEDEHEART registry.

Despite poor prognosis, patients with type 2 myocardial infarction (MI) tend to be underdiagnosed and undertreated compared to those with type 1 MI. Whether this discrepancy has improved over time is uncertain. We conducted a registry-based cohort study investigating type 2 MI patients managed at Swedish coronary care units (n = 14,833) during 2010-2022. Multivariable-adjusted changes (first three vs last three calendar years of the observation period) were assessed regarding diagnostic examinations (echocardiography, coronary assessment), provision of cardioprotective medications (betablockers, renin-angiotensin-aldosterone-system inhibitors, statins) and 1-year all-cause mortality. Compared to type 1 MI patients (n = 184,329), those with type 2 MI less often had diagnostic examinations and cardioprotective medications. Increases in the use of echocardiography (OR 1.08 [95% confidence interval 1.06-1.09]) and coronary assessment (OR 1.06 [95% confidence interval 1.04-1.08]) were smaller compared to type 1 MI (pinteraction < 0.001). The provision of medications did not increase in type 2 MI. All-cause mortality rate in type 2 MI was 25.4% without temporal change (OR 1.03 [95% confidence interval 0.98-1.07]). Taken together, the provision of medications and all-cause mortality did ot improve in type 2 MI despite modest increases in diagnostic procedures. This emphasizes the need of defining optimal care pathways in these patients.

Primary prevention in the intensive care unit: a prospective single-centre study of the risk factors for invasive pneumococcal disease.

Invasive pneumococcal disease is a significant health burden in Australia, with immunisation recommended for children and at-risk adults. Health benefits of immunisation are clear, but less effective when immunisation rates are low, as in Western Australia. We hypothesised that patients admitted unplanned to the intensive care unit (ICU) would have high eligibility for pneumococcal immunisation, but low rates of recorded vaccine administration. We performed a prospective observational study of 119 emergency admissions to Royal Perth ICU, a 20-bed mixed ICU at a tertiary teaching hospital in Western Australia. Each admission was screened for vaccine eligibility (age and risk factors as per Australian Technical Advisory Group of Immunisation guidelines), with patients' health records examined and primary care providers contacted after ICU discharge. Risk factors for invasive pneumococcal disease were common, with 52% of the study population having one or more. Fifty-four of 119 admitted patients (45%) were assessed as eligible for immunisation after ICU discharge. ICU survivors represent a high-risk population for which intervention against modifiable targets, such as invasive pneumococcal disease, may reduce both their chronic health burden and future health expenditure. Future efforts should concentrate on assessing the feasibility of a screening program for modifiable factors in ICU survivors, and the logistics of delivering these interventions in a timely manner during their hospital stay.

Fulminant hepatic failure in autoimmune polyendocrine syndrome type-1.

Fulminant hepatic failure is liver disease that causes encephalopathy within 8 weeks of onset of symptoms or within 2 weeks of onset of jaundice in a patient without prior evidence of liver disease. Autoimmune polyendocrine syndrome type-1 is an autoimmune autosomal-recessive condition causing parathyroid and adrenal insufficiency, alopecia, chronic mucocutaneous candidiasis, ectodermal dystrophy and, rarely, hepatitis. Although the liver can be affected as a consequence of the autoimmune process, the spectrum of disease activity is varied. Autoimmune hepatitis develops in 10-20% of patients and successful liver transplantation has been reported in pediatric patients who failed immunosuppressive treatment. We report fulminant hepatic failure in an adult patient with autoimmune polyendocrine syndrome type-1 who responded to medical treatment and did not require liver transplantation. We highlight the diagnostic scoring system for autoimmune hepatitis and the referral criteria for liver transplantation in fulminant hepatic failure.

Potential costs of B-type natriuretic peptide for the identification of people with heart failure in primary care in Scotland - a pilot study.

BACKGROUND AND AIMS: The utility of B-type natriuretic peptide as a screening test for heart failure has been proven in a number of clinical trials. The aims of this study were to assess the utility of the measurement of B-type natriuretic peptide in a 'real life' setting and to estimate the potential costs of implementing its use in primary care in Scotland. METHODS AND RESULTS: Eight general practitioner practices with a combined population of approximately 62,000 were invited to participate. During the 9-month study period, 82 samples for B-type natriuretic peptide measurement were requested. The negative predictive value for B-type natriuretic peptide was 96.9%. Compared with electrocardiography, B-type natriuretic peptide reduced the need for echocardiography by 308 tests per million population per year. The estimated cost of implementation in Scotland is approximately £220,000 per annum, equating to £64.93 per patient correctly diagnosed with heart failure, with a potential saving in echocardiography of £110,800. CONCLUSION: In this pilot study, measurement of plasma B-type natriuretic peptide in a 'real life' setting in primary care had a similar sensitivity, specificity and negative predictive value to that observed in trial populations. B-type natriuretic peptide aids early diagnosis of heart failure in primary care and may help to facilitate prompt introduction of evidence based therapies to modify patient outcomes. The costs of measuring plasma B-type natriuretic peptide in suspected cases of heart failure are modest, and its use would increase the diagnostic capacity of primary care if supported by local cardiology services.

Cranial rhythmic impulse related to the Traube-Hering-Mayer oscillation: comparing laser-Doppler flowmetry and palpation.

The primary respiratory mechanism (PRM) as manifested by the cranial rhythmic impulse (CRI), a fundamental concept to cranial osteopathy, and the Traube-Hering-Mayer (THM) oscillation bear a striking resemblance to one another. Because of this, the authors developed a protocol to simultaneously measure both phenomena. Statistical comparisons demonstrated that the CRI is palpably concomitant with the low-frequency fluctuations of the THM oscillation as measured with the Transonic Systems BLF 21 Perfusion Monitor laser-Doppler flowmeter. This opens new potential explanations for the basic theoretical concepts of the physiologic mechanism of the PRM/CRI and cranial therapy. Comparison of the PRM/CRI with current understanding of the physiology of the THM oscillation is therefore warranted. Additionally, the recognition that these phenomena can be simultaneously monitored and recorded creates a new opportunity for further research into what is distinctive about the science and practice of osteopathic medicine.