Value of monocyte distribution width for predicting severe cholecystitis: a retrospective cohort study.

OBJECTIVES: Acute cholecystitis is a gallbladder inflammation, and the Tokyo Guidelines 2018 (TG18) can be used to predict its presence and severity with high sensitivity and specificity. However, TG18 grading require the collection of excessive parameters. Monocyte distribution width (MDW) is a parameter used to detect sepsis early. Therefore, we investigated the correlation between MDW and cholecystitis severity. METHODS: We conducted a retrospective study of patients with cholecystitis admitted to our hospital from November 1, 2020, to August 31, 2021. The primary outcome was severe cholecystitis analyzed as a composite of intensive care unit (ICU) admission and mortality. The secondary outcomes were length of hospital stay, ICU stay, and TG18 grade. RESULTS: A total of 331 patients with cholecystitis were enrolled in this study. The average MDWs for TG18 grades 1, 2, and 3 were 20.21 ± 3.99, 20.34 ± 3.68, and 25.77 ± 6.61, respectively. For patients with severe cholecystitis, the average MDW was 25.42 ± 6.83. Using the Youden J statistic, we set a cutoff MDW of 21.6. Multivariate logistic regression revealed that patients with an MDW≥21.6 had a higher risk of severe cholecystitis (odds ratio=4.94; 95 % CI, 1.71-14.21; p=0.003). The Cox model revealed that patients with an MDW≥21.6 were more likely to have a prolonged hospital stay. CONCLUSIONS: MDW is a reliable indicator of severe cholecystitis and prolonged length of stay. Additional MDW testing and a complete blood count may provide simple information for predicting severe cholecystitis early.

Machine learning-based triage to identify low-severity patients with a short discharge length of stay in emergency department.

BACKGROUND: Overcrowding in emergency departments (ED) is a critical problem worldwide, and streaming can alleviate crowding to improve patient flows. Among triage scales, patients labeled as "triage level 3" or "urgent" generally comprise the majority, but there is no uniform criterion for classifying low-severity patients in this diverse population. Our aim is to establish a machine learning model for prediction of low-severity patients with short discharge length of stay (DLOS) in ED. METHODS: This was a retrospective study in the ED of China Medical University Hospital (CMUH) and Asia University Hospital (AUH) in Taiwan. Adult patients (aged over 20 years) with Taiwan Triage Acuity Scale level 3 were enrolled between 2018 and 2019. We used available information during triage to establish a machine learning model that can predict low-severity patients with short DLOS. To achieve this goal, we trained five models-CatBoost, XGBoost, decision tree, random forest, and logistic regression-by using large ED visit data and examined their performance in internal and external validation. RESULTS: For internal validation in CMUH, 33,986 patients (75.9%) had a short DLOS (shorter than 4 h), and for external validation in AUH, there were 13,269 (82.7%) patients with short DLOS. The best prediction model was CatBoost in internal validation, and area under the receiver operating cha racteristic curve (AUC) was 0.755 (95% confidence interval (CI): 0.743-0.767). Under the same threshold, XGBoost yielded the best performance, with an AUC value of 0.761 (95% CI: 0.742- 0.765) in external validation. CONCLUSIONS: This is the first study to establish a machine learning model by applying triage information alone for prediction of short DLOS in ED with both internal and external validation. In future work, the models could be developed as an assisting tool in real-time triage to identify low-severity patients as fast track candidates.

Accessory Climbing Routes Associated With More Rescue Operations Than the Main Climbing Route: A Retrospective 12-Year Report of Yushan National Park.

INTRODUCTION: This study compared the casualties and types of rescues conducted on the main climbing route (MCR) and accessory climbing routes (ACRs) in Yushan National Park (YSNP) between 2008 and 2019. METHODS: We collected the following information for all documented mountain rescue operations conducted on the MCRs and ACRs in YSNP between 2008 and 2019: accident location, casualty type, victim number, and type of rescue. The victims were categorized as to injury, illness, mortality, or no medical problem (NMP) groups according to their condition at the time of rescue. RESULTS: Two-hundred forty-four rescue operations involving 329 victims were conducted during the 12-y study period. Among them, 105 (32%) did not require medical treatment, 102 (31%) were injured, 82 (25%) were ill, and 40 (12%) were deceased. Of the 82 individuals with illness, 69 (84%) had acute altitude sickness. The accident and mortality rates on the ACRs were significantly higher than those on the MCR (P<0.001; χ2). The ACR incidents involved significantly higher percentages of helicopter-based rescues and victims in the NMP group (P<0.001). CONCLUSIONS: Acute altitude sickness accounted for most of the rescues. ACRs had higher injury and mortality rates and required more helicopter-based rescues for patients who did not have medical problems. This study may serve as a reference to reduce casualties and overuse of helicopters by educating tourists on the appropriate use of maps and the evaluation of trails in relation to weather conditions.

Functional recovery in human partial thickness skin wounds after application of multicomponent hydrolipidic film (MAS063DP): A prospective, open-label, comparative clinical trial.

Acute and minor skin wounds are common in daily life. However, in clinical practice, after initial management in the acute phase, the wounds are managed mainly through observation, and the patients are usually lost to follow-up. Considering a multicomponent hydrolipidic dressing (MAS063DP) long-known for its safe application in eczema and recently in laser-induced wounds, we aimed to evaluate its ability in functional recovery of impaired skin integrity during wound healing. Sixteen patients (N = 16) were enrolled and completed (n = 8 vs n = 8) this prospective, open-label, vehicle-controlled clinical trial with 12-week follow-up. Transepidermal water, skin viscoelasticity and bioimpedance analysis were measured initially, at the 1st, 4th, 8th, and 12th weeks. Improvements in these parameters were greater in the MAS063DP group (from 31.4 ± 9.0 to 16.4 ± 4.3 g/m2 h, P < .001; from 77 ± 16% to 88 ± 9%, P < .05; from 4182 ± 3823 to 2644 ± 1772 Ω) than in the white petrolatum group. No significant adverse events occurred, and all participants were more satisfied with the intervention. In this study, MAS063DP can restore skin integrity and reinstitute physiologic function as a feasible and safe intervention more markedly than management through observation during the healing process by providing protective hydrolipidic layer on the skin with simultaneous anti-inflammatory and antioxidant activities from its key ingredients such as glycyrrhetinic acid, Vitis vinifera, telmesteine, and vitamins C and E.

Impact of the COVID-19 pandemic on emergency medical service response to out-of-hospital cardiac arrests in Taiwan: a retrospective observational study.

BACKGROUND: Emergency medical service (EMS) personnel have high COVID-19 risk during resuscitation. The resuscitation protocol for patients with out-of-hospital cardiac arrest (OHCA) was modified in response to the COVID-19 pandemic. However, how the adjustments in the EMS system affected patients with OHCA remains unclear. METHODS: We analysed data from the Taichung OHCA registry system. We compared OHCA outcomes and rescue records for 622 cases during the COVID-19 outbreak period (1 February to 30 April 2020) with those recorded for 570 cases during the same period in 2019. RESULTS: The two periods did not differ significantly with respect to patient age, patient sex, the presence of witnesses or OHCA location. Bystander cardiopulmonary resuscitation and defibrillation with automated external defibrillators were more common in 2020 (52.81% vs 65.76%, p<0.001%, and 23.51% vs 31.67%, p=0.001, respectively). The EMS response time was longer during the COVID-19 pandemic (445.8±210.2 s in 2020 vs 389.7±201.8 s in 2019, p<0.001). The rate of prehospital return of spontaneous circulation was lower in 2020 (6.49% vs 2.57%, p=0.001); 2019 and 2020 had similar rates of survival discharge (5.96% vs 4.98%). However, significantly fewer cases had favourable neurological function in 2020 (4.21% vs 2.09%, p=0.035). CONCLUSION: EMS response time for patients with OHCA was prolonged during the COVID-19 pandemic. Early advanced life support by EMS personnel remains crucial for patients with OHCA.

Derivation and Validation of the SWAP Score for Very Early Prediction of Neurologic Outcome in Patients With Out-of-Hospital Cardiac Arrest.

STUDY OBJECTIVE: For patients with out-of-hospital cardiac arrest who receive cardiopulmonary resuscitation in an emergency department (ED), the early evaluation of their neurologic prognosis is essential for emergency physicians. The aim of this study is to establish a simple and useful assessment tool for rapidly estimating the prognosis of patients with out-of-hospital cardiac arrest after their arrival at an ED. METHODS: A total of 852 patients admitted from January 1, 2015, to June 30, 2017, were prospectively registered and enrolled in the derivation cohort. Multivariate logistic regression on this cohort identified 4 independent factors associated with unfavorable outcomes: initial nonshockable rhythm (odds ratio [OR] 3.40; 95% confidence interval [CI] 1.58 to 7.32), no witness of collapse (OR 3.19; 95% CI 1.51 to 6.75), older than 60 years (OR 3.65; 95% CI 1.64 to 8.09), and pH less than or equal to 7.00 (OR 3.27; 95% CI 1.42 to 7.54). The shockable rhythm-witness-age-pH (SWAP) score was developed and 1 point was assigned to each predictor. RESULTS: For a SWAP score of 4, the specificity was 97.14% (95% CI 91.62% to 100%) for unfavorable outcomes in the derivation cohort. For validation, we retrospectively collected data for 859 patients with out-of-hospital cardiac arrest from January 1, 2012, to December 31, 2014. A SWAP score of 4 was 100% specific (95% CI 99.9% to 100%) for unfavorable outcomes in the validation cohort. CONCLUSION: The SWAP score is a simple and useful predictive model that may provide information for the very early estimation of prognosis for patients with out-of-hospital cardiac arrest. Further research is required to integrate ultrasonographic findings and validate the SWAP score's application in other populations.

E4BP4 inhibits AngII-induced apoptosis in H9c2 cardiomyoblasts by activating the PI3K-Akt pathway and promoting calcium uptake.

The bZIP transcription factor E4BP4 is a survival factor that is known to be elevated in diseased heart and promote cell survival. In this study the role of E4BP4 on angiotensin-II (AngII)-induced apoptosis has been examined in in vitro cell model. H9c2 cardiomyoblast cells that overexpressed E4BP4 were exposed to AngII to observe the cardio-protective effects of E4BP4 on hypertension related apoptosis. The results from TUNEL assays revealed that E4BP4 significantly attenuated AngII-induced apoptosis. Further analysis by Western blot and RT-PCR showed that E4BP4 inhibited AngII-induced IGF-II mRNA expression and cleavage of caspase-3 through the PI3K-Akt pathway. In addition, E4BP4 enhanced calcium reuptake into the sacroplasmic reticulum by down-regulating PP2A and by up-regulating the phosphorylation of PKA and PLB proteins. Our findings indicate that E4BP4 functions as a survival factor in cardiomyoblasts by inhibiting IGF-II transcription and by regulating calcium cycling.

[Complementary Therapy for Patients With Limb Trauma Pain in the Emergency Department].

Acute pain is the main cause for patient visits to the emergency department. An important issue faced in emergency medical care is to resolve patient pain. Moreover, limb traumatic pain is noted in 58-66% of emergency trauma patients. This paper explored the effectiveness of using non-pharmacological complementary interventions, including body operation therapies that used trauma limb care and therapeutic touch and mind-body interventions, in order to strengthen the support system and create a healing environment. The experience described herein is hoped to facilitate the provision of multifaceted emergency care for patients with limb trauma pain in the emergency department in order to improve the comfort and return rate of patients.

NFIL3 suppresses hypoxia-induced apoptotic cell death by targeting the insulin-like growth factor 2 receptor.

The insulin-like growth factor-II/mannose 6-phosphate receptor (IGF2R) over-expression correlates with heart disease progression. The IGF2R is not only an IGF2 clearance receptor, but it also triggers signal transduction, resulting in cardiac hypertrophy, apoptosis and fibrosis. The present study investigated the nuclear factor IL-3 (NFIL3), a transcription factor of the basic leucine zipper superfamily, and its potential pro-survival effects in cardiomyocytes. NFIL3 might play a key role in heart development and act as a survival factor in the heart, but the regulatory mechanisms are still unclear. IGF2 and IGF2R protein expression were highly increased in rat hearts subjected to hemorrhagic shock. IGF2R protein expression was also up-regulated in H9c2 cells exposed to hypoxia. Over-expression of NFIL3 in H9c2 cardiomyoblast cells inhibited the induction of hypoxia-induced apoptosis and down-regulated IGF2R expression levels. Gel shift assay, double-stranded DNA pull-down assay and chromatin immune-precipitation analyses indicated that NFIL3 binds directly to the IGF2R promoter region. Using a luciferase assay, we further observed NFIL3 repress IGF2R gene promoter activity. Our results demonstrate that NFIL3 is an important negative transcription factor, which through binding to the promoter of IGF2R, suppresses the apoptosis induced by IGF2R signaling in H9c2 cardiomyoblast cells under hypoxic conditions.

Tetramethylpyrazine Ameliorated Hypoxia-Induced Myocardial Cell Apoptosis via HIF-1α/JNK/p38 and IGFBP3/BNIP3 Inhibition to Upregulate PI3K/Akt Survival Signaling.

BACKGROUND: Hemorrhagic shock (HS) is the major cause of death from trauma. Hemorrhagic shock may lead to cellular hypoxia and organ damage. Our previous findings showed that HS induced a cardiac apoptosis pathway and synergistically caused myocardial cell damage in diabetic rats under trauma-induced HS. Tetramethylpyrazine (TMP) is a major biologically active ingredient purified from the rhizome of Ligusticum wallichii (called Chuang Xiong in Chinese). Chuan Xiong rescued cells from synergistic cardiomyoblast cell injury under high-glucose (HG) conditions plus hypoxia. TMP is one of the most important active ingredients that elevated the survival rate in ischemic brain injury and prevented inducible NO synthase expression to have anti-inflammatory effects against cell damage in different cell types. METHOD: Here, we further investigate whether TMP can protect against hypoxic (<1% oxygen) conditions in H9c2 cardiomyoblast cells for 24 hrs. RESULTS: Our results showed that hypoxia mediated through HIF-1α/JNK/p38 activation significantly elevated the levels of the hypoxia-related proteins HIF-1α, BNIP3 and IGFBP3, further enhanced the pro-apoptotic protein Bak and upregulated downstream Caspase 9 and 3, resulting in cell death. All of these phenomena were fully recovered under TMP treatment. We observed that TMP exerted this effect by activating the IGF1 receptor survival pathway, dependent primarily on PI3K/Akt. When PI3K (class I) was blocked by specific siRNA, the hypoxia-induced activated caspase 3 and cell apoptosis could not be reversed by TMP treatment. CONCLUSION: Our results strongly suggest that TMP could be used to restore hypoxia-induced myocardial cell apoptosis and cardiac hypoxic damage.

CREB Negatively Regulates IGF2R Gene Expression and Downstream Pathways to Inhibit Hypoxia-Induced H9c2 Cardiomyoblast Cell Death.

During hypoxia, gene expression is altered by various transcription factors. Insulin-like growth factor-II (IGF2) is known to be induced by hypoxia, which binds to IGF2 receptor IGF2R that acts like a G protein-coupled receptor, might cause pathological hypertrophy or activation of the mitochondria-mediated apoptosis pathway. Cyclic adenosine monophosphate (cAMP) responsive element-binding protein (CREB) is central to second messenger-regulated transcription and plays a critical role in the cardiomyocyte survival pathway. In this study, we found that IGF2R level was enhanced in H9c2 cardiomyoblasts exposed to hypoxia in a time-dependent manner but was down-regulated by CREB expression. The over-expression of CREB in H9c2 cardiomyoblasts suppressed the induction of hypoxia-induced IGF2R expression levels and reduced cell apoptosis. Gel shift assay results further indicated that CREB binds to the promoter sequence of IGF2R. With a luciferase assay method, we further observed that CREB represses IGF2R promoter activity. These results suggest that CREB plays an important role in the inhibition of IGF2R expression by binding to the IGF2R promoter and further suppresses H9c2 cardiomyoblast cell apoptosis induced by IGF2R signaling under hypoxic conditions.

Cardiac hypertrophy-related pathways in obesity.

Obesity is often associated with the development of cardiac hypertrophy but the hypertrophy-related pathways in obesity remain unknown. The purpose of this study was to evaluate cardiac hypertrophy-related markers, atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP), tumor necrosis factor-alpha (TNFα) and hypertrophy-related pathways, interleukin (IL)-6-STAT3, IL-6-MEK5-ERK5 and calcineurin-nuclear factor of activated T-cells (NFAT)3 in the excised hearts from obese rats. Twelve obese Zucker rats were studied at 5-6 months of age and twelve age-matched lean Zucker rats served as the control group. The cardiac characteristics, myocardial architecture, ANP, BNP, TNFα levels, IL-6, STAT3, p-STAT3, MEK5, ERK-5, p-ERK-5, calcineurin and NFAT3 in the left ventricle from the rats were measured by heart weight index, echocardiography, vertical cross section, histological analysis, reverse transcription polymerase chain reaction and western blotting. Compared with the lean control, the whole heart weight, the left ventricule weight, the ratio of the whole heart weight to tibia length, echocardiographic interventricular septum, left ventricular posterior wall thickness, myocardial morphological changes and systolic blood pressure were found to increase in the obese rats. The protein levels of ANP, BNP, TNFα, IL-6, STAT3, p-STAT3, MEK-5, ERK-5, p-ERK 5, calcineurin and NFAT3 were also significantly increased in the hearts of the obese rats. The results showed that the hypertrophy-related markers, ANP, BNP and TNFα, the hypertrophy-related pathways IL-6-STAT3 and IL-6-MEK5-ERK5, and the calcineurin-NFAT3 hypertrophy-related pathways were more active in obese Zucker rats, which may provide possible hypertrophic mechanisms for developing cardiac hypertrophy and pathological changes in obesity.

Ruptured celiac artery aneurysm mimicking Boerhaave syndrome.

Ruptured celiac artery aneurysm is a rare cause for epigastric pain and is usually detected incidentally. Atypical presentation with postemetic epigastralgia and pleural effusion usually leads physicians to make the diagnosis of Boerhaave syndrome. Herein, we report a 32-year-old woman who was diagnosed with Boerhaave syndrome initially after presenting with acute postemetic epigastralgia and predominant left side pleural effusion. Diagnostic left thoracentesis yielded bloody fluid with similar amylase level to serum. The chest computed tomographic scan showed no evidence of esophageal rupture. However, a ruptured celiac artery aneurysm with retroperitoneal hematoma extending to the posterior mediastinum and bilateral pleural space was found incidentally. Although ruptured celiac artery aneurysm is an uncommon cause for postemetic epigastralgia, acute vascular events such as the previously stated cause should be the first impression rather than Boerhaave syndrome if the patient also presents with isolated pleural effusion containing unelevated amylase.

Identification of painless aortic dissection before thrombolytic treatment for acute ischemic stroke.

Early detection of acute ischemic stroke secondary to painless aortic dissection is a challenge for emergency physicians, especially when under the stress of the 3-hour golden time window for thrombolytic therapy. We reported a 57-year-old man with acute right hemisphere watershed ischemic stroke caused by painless type A aortic dissection was diagnosed in time with computed tomographic (CT) angiography. The possible detrimental impact which may have been incurred by thrombolytic therapy was avoided. We suggest that cerebral CT angiography, covering from the aortic arch to intracranial arteries, should be performed in acute ischemic stroke patients, particularly in those with watershed CT perfusion deficits, to exclude the possibility of aortic dissection before thrombolytic treatment.

The effectiveness of a health education intervention on self-care of traumatic wounds.

AIMS AND OBJECTIVES: To explore the effectiveness of wound care programme for emergency traumatic patient in Taiwan. BACKGROUND: Wound care is one of the most major issues for trauma patients at home. Wound infection has been alerted mostly on medical treatment. Little is known about how healthcare education impact patient care of traumatic wound after discharged from emergency department. DESIGN: A quasi-experimental design was used by using two groups post-test. METHODS: Random sampling was used to recruited participants, 89 participants in each group in emergency department at a medical centre in Taiwan. A 25-minute wound care programme was given to patients in the intervention group. A questionnaire was used to evaluate the effectiveness of the programme after 72 hours as patient followed up in out-patient department. The data of wound infection were collected from patient's medical record by followed 2 weeks after injured. RESULTS: After wound care programme, the knowledge, skills of wounds care, the satisfaction of health education in experimental group are better than the control group (p < 0·05). Wound infection rate in experimental group (9%) is lower than control group (20·2%), and statistically significant (p < 0·05). CONCLUSION: The wound care programme could increase the knowledge, skills of wound care of emergency patient and reduce the wound infection rate. RELEVANCE TO CLINICAL PRACTICE: Wound care requites technical knowledge; thus, practical demonstration of teaching and self-practice is more effectiveness for patients in learning their wound care. An appropriated health programme can improve the patients' wound care and care quality.

National emergency medical teleconsultation: A novel system applied during the COVID-19 pandemic in Taiwan.

OBJECTIVE: Telemedicine can facilitate social distancing during an infectious disease pandemic and reduce the burden on health-care resources. Moreover, telemedicine can be utilized for medical care in remote island regions, in home health care, and during isolated major disasters such as regional earthquakes. However, the effectiveness of telemedicine for emergency consultation remains unclear. This study introduced and analyzed the national emergency medical teleconsultation (NEMTC) established in Taiwan in 2022 during the COVID-19 pandemic. METHODS: In response to the COVID-19 pandemic, Taiwan's Centers for Disease Control established a temporary 24-h NEMTC contingency system. Patient information was collected from consultations through the NEMTC from April 28 to June 28, 2022. After successful consultation, physicians made recommendations for home observation, emergency department (ED) visit, or outpatient follow-up. ED visits were divided into two categories, namely self-transport and transport, by the emergency medical service system (EMSS). RESULTS: During the aforementioned period, 20,902 consultation requests were made through the NEMTC, and 11,804 consultations (56.5% of 20,902) were successful. Consultation success rates were significantly higher for those who had a consultation between 08:00 and 16:00, had a waiting time of less than 10 min, and were not aged between 18 and 45 years. Moreover, 8.2% of the analyzed patients were advised to visit the ED, and only 0.4% required ambulance transportation. Children and older individuals and patients with cardiovascular symptoms, shortness of breath, or neurological or abdominal symptoms had a significantly higher chance of being referred to the ED than did other individuals. CONCLUSIONS: The NEMTC response system can enhance the efficiency of the EMSS and can reduce the burden of patients with mild conditions overloading the EMSS and EDs. The NEMTC could serve as an effective rapid response system during future pandemics.

Comparison of In-Hospital Major Adverse Cardiovascular Events in Patients with Acute Myocardial Infarction Treated with Ticagrelor or Clopidogrel in the Emergency Department: A Propensity Score Matched Retrospective Cohort Study.

BACKGROUND: Dual antiplatelet therapy (DAPT) is a standard treatment option for acute myocardial infarction (AMI). The difference between the efficacy of ticagrelor and clopidogrel in the emergency department (ED) before percutaneous coronary intervention (PCI) remains unknown. The present study compared the in-hospital major adverse cardiovascular event (MACE) rates between patients with AMI treated with clopidogrel and those treated with ticagrelor in the ED before PCI. METHODS: We retrospectively collected the data of patients diagnosed as having AMI in the ED. Patients were only included if they had successfully received complete DAPT with aspirin and ticagrelor/clopidogrel in the ED and had undergone PCI. The patients were divided into two groups according to their DAPT regimen. The primary outcome was the rate of in-hospital MACEs. The secondary outcomes included an unexpected return to the ED within 72 h, readmission within 14 d, and revascularization. RESULTS: A total of 1836 patients were enrolled. Patients in the ticagrelor group had a lower in-hospital MACE rate (3.01% versus 7.51%, p < 0.001) and in-hospital mortality rate (2.15% versus 5.70%, p < 0.001) than those in the clopidogrel group. Multivariate logistic regression analysis revealed ticagrelor was independently associated with a lower risk of in-hospital MACEs (odds ratio [OR]: 0.53, 95% CI: 0.32-0.88, p = 0.013). After propensity score matching, the risk of in-hospital MACEs remained significantly lower in the ticagrelor group (OR 0.42, 95% CI: 0.21-0.85, p = 0.016). CONCLUSION: DAPT with ticagrelor and aspirin in the ED before PCI is associated with a lower in-hospital MACE rate among patients with AMI.

A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study.

BACKGROUND: Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome. METHODS: This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279. FINDINGS: 3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11.8%) patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of 99.3% (95% CI 97.9-99.8), a negative predictive value of 99.1% (97.3-99.8), and a specificity of 11.0% (10.0-12.2). INTERPRETATION: This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide. FUNDING: Alere Medical (all countries), Queensland Emergency Medicine Research Foundation and National Health and Medical Research Council (Australia), Christchurch Cardio-Endocrine Research Group (New Zealand), Medquest Jaya Global (Indonesia), Science International (Hong Kong), Bio Laboratories Pte (Singapore), National Heart Foundation of New Zealand, and Progressive Group (Taiwan).