Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction : An International Collaborative Meta-analysis.

BACKGROUND: The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)-based strategies for triage of patients with suspected acute myocardial infarction (AMI). PURPOSE: To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479). STUDY SELECTION: Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. DATA EXTRACTION: The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. DATA SYNTHESIS: A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays. LIMITATION: Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies. CONCLUSION: The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI. PRIMARY FUNDING SOURCE: National Taiwan University Hospital.

Evaluation of the Deterioration of Untreated Commercial Polystyrene by Psychrotrophic Antarctic Bacterium.

Polystyrene (PS) and microplastic production pose persistent threats to the ecosystem. Even the pristine Antarctic, which is widely believed to be pollution-free, was also affected by the presence of microplastics. Therefore, it is important to comprehend the extent to which biological agents such as bacteria utilise PS microplastics as a carbon source. In this study, four soil bacteria from Greenwich Island, Antarctica, were isolated. A preliminary screening of the isolates for PS microplastics utilisation in the Bushnell Haas broth was conducted with the shake-flask method. The isolate AYDL1 identified as Brevundimonas sp. was found to be the most efficient in utilising PS microplastics. An assay on PS microplastics utilisation showed that the strain AYDL1 tolerated PS microplastics well under prolonged exposure with a weight loss percentage of 19.3% after the first interval (10 days of incubation). Infrared spectroscopy showed that the bacteria altered the chemical structure of PS while a deformation of the surface morphology of PS microplastics was observed via scanning electron microscopy after being incubated for 40 days. The obtained results may essentially indicate the utilisation of liable polymer additives or "leachates" and thus, validate the mechanistic approach for a typical initiation process of PS microplastics biodeterioration by the bacteria (AYDL1)-the biotic process.

Big Data Reality Check (BDRC) for public health: to what extent the environmental health and health services research did meet the 'V' criteria for big data? A study protocol.

INTRODUCTION: Big data technologies have been talked up in the fields of science and medicine. The V-criteria (volume, variety, velocity and veracity, etc) for defining big data have been well-known and even quoted in most research articles; however, big data research into public health is often misrepresented due to certain common misconceptions. Such misrepresentations and misconceptions would mislead study designs, research findings and healthcare decision-making. This study aims to identify the V-eligibility of big data studies and their technologies applied to environmental health and health services research that explicitly claim to be big data studies. METHODS AND ANALYSIS: Our protocol follows Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Scoping review and/or systematic review will be conducted. The results will be reported using PRISMA for Scoping Reviews (PRISMA-ScR), or PRISMA 2020 and Synthesis Without Meta-analysis guideline. Web of Science, PubMed, Medline and ProQuest Central will be searched for the articles from the database inception to 2021. Two reviewers will independently select eligible studies and extract specified data. The numeric data will be analysed with R statistical software. The text data will be analysed with NVivo wherever applicable. ETHICS AND DISSEMINATION: This study will review the literature of big data research related to both environmental health and health services. Ethics approval is not required as all data are publicly available and involves confidential personal data. We will disseminate our findings in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42021202306.

Effectiveness of pelvic floor muscle training alone or combined with either a novel biofeedback device or conventional biofeedback for improving stress urinary incontinence: A randomized controlled pilot trial.

PURPOSE: To (i) compare the acceptance of a newly developed, novel biofeedback device (PelviSense) with that of conventional biofeedback (CB) using an intravaginal probe for the treatment of stress urinary incontinence (SUI) in women, (ii) examine the feasibility and safety of using the PelviSense device as a pelvic floor muscle (PFM) training (PFMT) adjunct, and (iii) compare the PFMT adherence and effectiveness of CB, the PelviSense device, with PFMT alone for women with SUI. METHODS: An assessor-blinded, three-arm, randomized controlled pilot trial was conducted among 51 women with SUI. Women were randomly allocated to one of three study groups (PelviSense-assisted PFMT, CB-assisted PFMT, or PFMT alone [control]). Outcome measures included the International Consultation on Incontinence Questionnaire-Short Form, the 1-h pad test, and the Modified Oxford Scale. RESULTS: Participants in the PelviSense-assisted PFMT group expressed good device acceptance. PFMT adherence was greater in the PelviSense-assisted PFMT group than in the unassisted or CB-assisted PFMT groups. Between-groups analysis revealed significant effects on improved SUI symptoms, urine loss severity, and PFM strength for the PelviSense-assisted PFMT group compared with the CB-assisted and PFMT alone groups. CONCLUSIONS: The pilot trial results demonstrated moderate to high PFMT adherence in the PelviSense-assisted PFMT group and supported the safety of using the PelviSense device. The preliminary results of the pilot trial showed that PelviSense-assisted PFMT was more effective for reducing SUI symptoms among women than unassisted or CB-assisted PFMT. TRIAL REGISTRATION: This trial was registered in http://ClinicalTrials.gov (reference number: NCT04638348) before the recruitment of the first participant.

Use of Teleconsultations in a Regional Stereotactic Radiosurgery Service: Pilot Study.

BACKGROUND: The National Health Service Long Term Plan details plans to make digital interactions available to all patients in 5 years. Teleconsultations can improve access to specialist services; however, there is a lack of evidence for the use of teleconsultations in an oncology setting in the United Kingdom. OBJECTIVE: We aim to describe a service evaluation of teleconsultations for patients attending a regional brain metastases clinic. These patients have unique travel restrictions that prevent them from driving. METHODS: From April to October 2018, all patients attending the brain metastases clinic were offered the choice of teleconsultation in place of a face-to-face appointment. Feedback was assessed using a satisfaction questionnaire, and data of all clinic attendances were collected. RESULTS: A total of 69 individual patients had 119 appointments over the duration of the pilot, of which 36 (30.2%) were new patient appointments and 73 (61.3%) were follow-ups. Of the 69 patients, 24 (35%) took part in teleconsultations (41/119, 34.5%). User satisfaction was high, and no patients who took part in a teleconsultation reverted to face-to-face appointments. These patients avoided 2521 miles (61.6 miles per appointment) of hospital-associated travel and travel costs of £441.48 (US $599.83) to £10.78 (US $14.65) per appointment. CONCLUSIONS: Teleconsultations appear to be acceptable in this cohort of patients with brain metastases attending a regional stereotactic radiosurgery service with the potential for significant savings in travel and expenses.

Impact of Locally Adopted Simulation-Based Crew Resource Management Training on Patient Safety Culture: Comparison Between Operating Room Personnel and General Health Care Populations Pre and Post Course.

Crew resource management (CRM) was introduced to enhance patient safety and reduce medical errors through multidisciplinary learning experience. This study investigates the impact of locally adopted simulation-based CRM training on participants' perceptions and knowledge. A 32-item web-based questionnaire was administered pre course, 1 month, and 1 year post course to assess changes in perceptions and knowledge. Another 12-item paper-based questionnaire was administered immediately post course to assess reactions. Among 712 participants analyzed, 165 were operating room staff. The majority agreed that the training is useful and relevant in daily practice. All participants showed significant improvements in perception and knowledge 1 month post course; however, these improvements declined 1 year post course. The CRM course is associated with satisfactory reaction (Kirkpatrick level 1) and improvement in attitude and knowledge (level 2) toward patient safety. However, the effect may be short-lived and regular refresher courses should be mandatory to sustain momentum of ongoing change.

Prevalence of Nontuberculous Mycobacterium Infections versus Tuberculosis among Autopsied HIV Patients in Sub-Saharan Africa: A Systematic Review and Meta-Analysis.

In industrialized countries, Mycobacterium avium complex and other nontuberculous mycobacteria (NTM) are major causes of opportunistic infection-related deaths in HIV patients. However, in resource-limited regions, data on NTM are scarce, and tuberculosis (TB) was often assumed to be the cause of death in HIV patients with a positive acid-fast smear. We searched MEDLINE and Embase databases for studies on autopsied HIV patients in sub-Saharan Africa published between January 1997 and April 2020. We included studies that reported histopathological or microbiological evidences for diagnosis of TB and NTM infection. We excluded articles without mycobacterial evidence from culture or molecular testing, such as those that used verbal autopsy, death certificates, or national registry data (systematic review registration number: CRD42019129836 at PROSPERO). We included six eligible studies that reported 391 autopsies in sub-Saharan African HIV patients. The prevalence of NTM and TB at autopsy ranged from 1.3% to 27.3% and 11.8% to 48.7%, respectively. The weighted prevalence ratio of NTM versus TB was 0.16 indicating that for every seven HIV patients died with mycobacterial infections, there was one died with NTM infection. Of the 13 NTM infections, six were caused by M. avium complex. Mycobacterium avium complex and other NTM infections are important differential diagnoses of TB at the time of death among HIV patients in sub-Saharan Africa. Our findings highlight the need to systematically survey the prevalence of NTM infections among HIV patients seeking medical care in resource-limited regions.

Short and Long term predictions of Hospital emergency department attendances.

OBJECTIVE: Emergency departments in the United Kingdom (UK) experience significant difficulties in achieving the 95% NHS access standard due to unforeseen variations in patient flow. In order to maximize efficiency and minimize clinical risk, better forecasting of patient demand is necessary. The objective is therefore to create a tool that accurately predicts attendance at emergency departments to support optimal planning of human and physical resources. METHODS: Historical attendance data between Jan-2011 - December-2015 from four hospitals were used as a training set to develop and validate a forecasting model. To handle weekday variations, the data was first segmented into each weekday time series and a separate model for each weekday was performed. Seasonality testing was performed, followed by Box-Cox transformations. A modified heuristics based on a fuzzy time series model was then developed and compared with autoregressive integrated moving average and neural networks models using Harvey, Leybourne and Newbold (HLN) test. The time series models were tested in four emergency department sites to assess forecasting accuracy using the root mean square error and mean absolute percentage error. The models were tested for (i) short term prediction (four weeks ahead), using weekday time series; and (ii) long term predictions (four months ahead) using monthly time series. RESULTS: Data analysis revealed that presentations to emergency department and subsequent admissions to hospital were not a purely random process and therefore could be predicted with acceptable accuracy. Prediction accuracy improved as the forecast time intervals became wider (from daily to monthly). For each weekday time series modelling using fuzzy time series, for forecasting daily admissions, the mean absolute percentage error ranged from 2.63% to 4.72% while for monthly time series mean absolute percentage error varied from 2.01%-2.81%. For weekday time series, the mean absolute percentage error for autoregressive integrated moving average and neural network forecasting models ranged from 6.25% to 7.47% and 6.04%-7.42% respectively. The proposed fuzzy time series model proved to have statistically significant performance using Harvey, Leybourne and Newbold (HLN) test. This was explained by variations in attendances in different sites and weekdays. CONCLUSIONS: This paper described a heuristic-based fuzzy logic model for predicting emergency department attendances which could help resource allocation and reduce pressure on busy hospitals. Valid and reproducible prediction tools could be generated from these hospital data. The methodology had an acceptable accuracy over a relatively short time period, and could be used to assist better bed management, staffing and elective surgery scheduling. When compared to other prediction models usually applied for emergency department attendances prediction, the proposed heuristic model had better accuracy.

The oral mTOR inhibitor RAD001 (everolimus) in combination with letrozole in patients with advanced breast cancer: results of a phase I study with pharmacokinetics.

PURPOSE: To investigate the safety and pharmacokinetics (PK) of combined treatment with letrozole and the oral mTOR inhibitor RAD001 in patients with metastatic breast cancer stable or progressing after > or = 4 months on letrozole alone. METHODS: Eighteen patients received letrozole (2.5 mg/day) and RAD001 at 5 mg/day (cohort 1) or 10 mg/day (cohort 2). In the absence of DLT in cohort 1, cohort 2 was expanded to 12 patients to obtain additional safety and PK data. RESULTS: Most common adverse events were stomatitis (50.0% of patients), fatigue (44.4%), anorexia and/or decreased appetite (44.4%), diarrhoea (38.9%), headache (33.3%) and rash (33.3%). There was 1 DLT, a grade 3 thrombocytopaenia in cohort 2. No clinically relevant PK interaction was detected. Seven patients received the combination therapy for >6 months. One patient had a complete response, and one had a 28% reduction in liver metastases, both in cohort 2. CONCLUSION: Daily therapy with RAD001 plus letrozole is promising: the results suggest anti-tumour activity with no PK interactions. The overall safety profile of the combination is consistent with that expected for RAD001 monotherapy. A daily dose of RAD001 10mg is recommended for further trials.

Changes in medical students' attitudes towards end-of-life decisions across different years of medical training.

BACKGROUND: Decisions to forgo life-sustaining medical treatments in terminally ill patients are challenging, but ones that all doctors must face. Few studies have evaluated the impact of medical training on medical students' attitudes towards end-of-life decisions and none have compared them with an age-matched group of non-medical students. OBJECTIVE: To assess the effect of medical education on medical students' attitudes towards end-of-life decisions in acutely ill patients. DESIGN: Cross-sectional study. PARTICIPANTS: Four hundred and two students at The Chinese University of Hong Kong. MEASUREMENTS: Completion of a questionnaire focused on end-of-life decisions. MAIN RESULTS: The number of students who felt that cardiopulmonary resuscitation must always be provided was higher in non-medical students (76/90 (84%)) and medical students with less training (67/84 (80%) in year 1 vs. 18/67 (27%) in year 5) (p < 0.001). Discontinuing life-support therapy was more accepted among senior medical students compared to junior medical and non-medical students (27/66 (41%) in year 5 vs. 18/83 (22%) in year 1 and 20/90 (22%) in non-medical students) (p = 0.003). An unexpectedly large proportion of non-medical students (57/89 (64%)) and year 1 medical students (42/84 (50%)) found it acceptable to administer fatal doses of drugs to patients with limited prognosis. Euthanasia was less accepted with more years of training (p < 0.001). When making decisions regarding limitation of life-support therapy, students chose to involve patients (98%), doctors (92%) and families (73%) but few chose to involve nurses (38%). CONCLUSIONS: Medical students' attitudes towards end-of-life decisions changed during medical training and differed significantly from those of non-medical students.

Issues associated with dog bite injuries in children and adolescents assessed at the emergency department.

OBJECTIVES: The aim of this study was to determine the pattern of dog bites seen at the emergency department of a university hospital. The information will be used to plan prevention and enhance management strategies. METHODS: All patients (younger than 22 years) assessed at the emergency department between January 2003 and December 2004 with a discharge diagnosis of animal bites were identified through the computerized discharge network. RESULTS: One hundred forty-four incidents of animal bites (82 males and 62 females) occurred over the 2-year period. Eighty-nine percent was due to dog bites. Among the dog bite victims, the mean age was 11.82 years (SD, 6.39 years; range, 0.06-21.83 years). Family dogs were only involved in 15% of cases. The species of dogs were not recognized in three fifths, and attacks provoked in two fifths of victims. Most bites (90%) of bites involved only single anatomical sites. The extremities were commonly involved (right upper limb [23%], left upper limb [16%], right lower limb [35%], left lower limb [20%]). Torso (4%) and genitalia (0.8%) were uncommonly involved. Pain, erythema, bleeding, and bruising were common symptoms, but 60 patients were asymptomatic at presentation. Compared with older patients, children younger than 10 years had a much higher risk of facial injuries (25% vs. 2%, P = 0.0002; odds ratio, 21.8, 95% confidence interval, 2.9-455.9) and were more likely to be triaged as being urgent (P = 0.01). Most attacks were trivial and did not require hospitalization. Antirabies treatment was given in approximately half, analgesics in two fifths, and antibiotics in one fourth. CONCLUSIONS: In mammalian attacks, canines are most commonly involved. Most injuries are trivial, and the limbs are usually involved. However, younger children are at higher risk of facial injuries. Extent of pain and adverse psychological impacts are typically not documented in the emergency assessment.

Fulfilling the psychological and information need of the family members of critically ill patients using interactive mobile technology: A randomised controlled trial.

BACKGROUND: Intensive care nurses may have an important role in empowering families by providing psychological support and fulfilling the family's pivotal need for information. AIM: To determine whether 'education of families by tab' about the patient's condition was more associated with improved anxiety, stress, and depression levels than the 'education of families by routine'. RESEARCH DESIGN: A randomized control trial of 74 main family caregivers (intervention: 39; control: 35). SETTING: An adult intensive care unit. MAIN OUTCOME MEASURES: Depression Anxiety Stress Scale, and Communication and Physical Comfort Scale. RESULTS: Although information need satisfaction was not significantly different between intervention and control groups, the former reported significantly better depression score on Depression Anxiety Stress Scale comparing to the control group (p<0.01; η2=0.09) with a medium effect size. Reduction of anxiety in the intervention group were clinically significant. CONCLUSION: The results suggest that use of 'education of family by tab' is promising for intensive care nurses to provide psychological support for family members. More studies are needed to investigate this aspect of family care for better psychological support and information need satisfaction that contributes to the evidence-based practice of intensive care nursing.

Dose- and schedule-dependent inhibition of the mammalian target of rapamycin pathway with everolimus: a phase I tumor pharmacodynamic study in patients with advanced solid tumors.

PURPOSE: Everolimus is a selective mammalian target of rapamycin (mTOR) inhibitor with promising anticancer activity. In order to identify a rationally based dose and schedule for cancer treatment, we have conducted a tumor pharmacodynamic phase I study in patients with advanced solid tumors. PATIENTS AND METHODS: Fifty-five patients were treated with everolimus in cohorts of 20, 50, and 70 mg weekly or 5 and 10 mg daily. Dose escalation depended on dose limiting toxicity (DLT) rate during the first 4-week period. Pre- and on-treatment steady-state tumor and skin biopsies were evaluated for total and phosphorylated (p) protein S6 kinase 1, eukaryotic initiation factor 4E (elF-4E) binding protein 1 (4E-BP1), eukaryotic initiation factor 4G (eIF-4G), AKT, and Ki-67 expression. Plasma trough levels of everolimus were determined on a weekly basis before dosing during the first 4 weeks. RESULTS: We observed a dose- and schedule-dependent inhibition of the mTOR pathway with a near complete inhibition of pS6 and peIF-4G at 10 mg/d and >or= 50 mg/wk. In addition, pAKT was upregulated in 50% of the treated tumors. In the daily schedule, there was a correlation between everolimus plasma trough concentrations and inhibition of peIF4G and p4E-BP1. There was good concordance of mTOR pathway inhibition between skin and tumor. Clinical benefit was observed in four patients including one patient with advanced colorectal cancer achieving a partial response. DLTs occurred in five patients: one patient at 10 mg/d (grade 3 stomatitis) and four patients at 70 mg/wk (two with grade 3 stomatitis, one with grade 3 neutropenia, and one with grade 3 hyperglycemia). CONCLUSION: Everolimus achieved mTOR signaling inhibition at doses below the DLT. A dosage of 10 mg/d or 50 mg/wk is recommended for further development.