Risk Scores for Clinical Risk Stratification of Emergency Department Patients With Chest Pain but No Acute Myocardial Infarction: A Systematic Review.

BACKGROUND: Chest pain is a common cause for emergency department (ED) presentations. After myocardial infarction (MI) has been ruled out by means of electrocardiography and troponin testing, decisions around anatomic or functional testing may be informed by clinical risk scores. We conducted a systematic review to synthesize evidence of the prognostic performance of chest pain risk scores among ED patients who have had MI ruled out by means of a high-sensitivity troponin assay. METHODS: We queried multiple databases from inception to May 17, 2022. We included studies that quantified risk of 30-day major adverse cardiac events (MACE), at different cutoffs of clinical risk scores, among adult patients who had MI ruled out by means of a high-sensitivity troponin assay. Prognostic performance of each score was synthesized and described, but meta-analysis was not possible. RESULTS: Six studies met inclusion criteria. Short-term MACE risk among patients who had MI ruled out by means of high-sensitivity cardiac troponin assays was very low. The HEART score, with a cutoff of 3 or less, predicted a very low risk of MACE among the greatest proportion of patients. Other scores had lower sensitivity or classified fewer patients as low risk. CONCLUSIONS: The HEART score with a cutoff value of 3 or less accurately identified the greatest number of patients at low risk of 30-day MACE. However, MACE risk among patients who have MI ruled out by means of high-sensitivity troponin testing is sufficiently low that clinical risk stratification or noninvasive testing may be of little additional value in identifying patients with coronary disease.

Perioperative management for people with kidney failure receiving dialysis: A scoping review.

BACKGROUND: People with kidney failure receiving dialysis (CKD-G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD-G5D. METHODS: We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD-G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design. RESULTS: We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant-related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non-randomized study designs. CONCLUSIONS: Despite many current gaps in perioperative research for patients with CKD-G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non-randomized studies. Our review may inform organization of evidence-based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address.

The emergency department incidence of incidental intracranial aneurysm on computed tomography angiography (EPIC-ACT) study.

BACKGROUND: Subarachnoid hemorrhage has been traditionally ruled-out in the emergency department (ED) through computed tomography (CT) followed by lumbar puncture if indicated. Mounting evidence suggests that non-contrast CT with CT angiography (CTA) can safely rule-out subarachnoid hemorrhage and obviate the need for lumbar puncture, but adoption of this approach is hindered by concerns of identifying incidental aneurysms. This study aims to estimate the incidence of incidental aneurysms identified on CTA head and neck in an ED population. METHODS: This was a health records review of all patients ≥ 18 years who underwent CTA head and neck for any indication at four large urban tertiary care EDs over a 3 month period. Patients were excluded if they underwent CT venogram only, had previously documented intracranial aneurysms, or had intracranial hemorrhage with or without aneurysm. Imaging reports were reviewed by two independent physicians before extracting relevant demographic (age, sex), clinical (CTAS level, CEDIS primary complaint) and radiographic (number, size, and location of aneurysms) information. The incidence rate of incidental aneurysms was calculated. RESULTS: A total of 1089 CTA studies were reviewed with a 3.3% (95% CI 2.3-4.6) incidence of incidental intracranial aneurysms. The median size of incidental aneurysms was 4 mm (0.7-11) and 10 (27.7%) patients had multiple aneurysms. Patients with incidental aneurysms did not differ based on mean age, sex, and CTAS levels. CONCLUSIONS: The "risk" of discovering an incidental aneurysm is 3.3%. Clinicians should not be deterred from using CTA in the appropriate clinical settings. These estimates can inform shared decision-making conversations with patients when comparing subarachnoid hemorrhage rule-out options.

RéSUMé: CONTEXTE: L'hémorragie sous-arachnoïdienne (HSA) a été traditionnellement exclue au service des urgences (SU) par tomodensitométrie cérébrale (TDM) suivie d'une ponction lombaire si indiquée. Des preuves de plus en plus nombreuses suggèrent que la tomographie sans contraste avec l'angiographie par tomodensitométrie (l'angio-TDM) permet d'exclure en toute sécurité les HSA et d'éviter la ponction lombaire, mais l'adoption de cette approche est entravée par les craintes d'identifier des anévrismes accidentels. Cette étude vise à estimer l'incidence des anévrismes accidentels identifiés par l'angiographie de la tête et du cou dans une population d'urgences. MéTHODES: Il s'agissait d'une étude des dossiers médicaux de tous les patients âgés de ≥ 18 ans qui ont subi une angioplastie de la tête et du cou, quelle qu'en soit l'indication, dans quatre grands services d'urgence urbains de soins tertiaires sur une période de trois mois. Les patients étaient exclus s'ils n'avaient subi qu'une phlébographie par tomodensitométrie, s'ils avaient déjà eu des anévrismes intracrâniens documentés ou s'ils avaient eu une hémorragie intracrânienne avec ou sans anévrisme. Les rapports d'imagerie ont été examinés par deux médecins indépendants avant d'extraire les informations démographiques pertinentes (âge, sexe), cliniques (niveau CTAS, plainte primaire CEDIS) et radiographiques (nombre, taille et emplacement des anévrismes). Le taux d'incidence des anévrismes accidentels a été calculé. RéSULTATS: Un total de 1089 études angio-TDM ont été examinées avec une incidence de 3,3 % (IC à 95 % : 2,3-4,6) d'anévrismes intracrâniens accidentels. La taille médiane des anévrismes fortuits était de 4 mm (plage : 0,7-11) et 10 (27,7 %) patients présentaient des anévrismes multiples. Les patients présentant des anévrismes accidentels ne différaient pas en fonction de l'âge moyen, du sexe et des niveaux CTAS. CONCLUSIONS: Le « risque ¼ de découvrir un anévrisme fortuit est de 3,3 %. Les cliniciens ne doivent pas être dissuadés d'utiliser l'angio-TDM dans les contextes cliniques appropriés. Ces estimations peuvent éclairer les conversations de prise de décision partagée avec les patients lors de la comparaison des options d'exclusion de l'HSA.

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing.

BACKGROUND: The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). METHODS: This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. RESULTS: Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. CONCLUSIONS: A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.

RéSUMé: CONTEXTE: Le score HEAR (History, ECG, Age, Risk Factor) a été proposé pour identifier les patients présentant un risque suffisamment faible de syndrome coronarien aigu pour ne pas nécessiter de test à la troponine. L'objectif de cette étude était de valider à l'externe un faible score HEAR afin d'identifier les patients du service d'urgence (DE) souffrant de douleurs thoraciques à très faible risque d'événements cardiaques indésirables majeurs (MACE) de 30 jours. MéTHODES: Il s'agissait d'une analyse secondaire d'une cohorte prospective de patients nécessitant un test à la troponine pour exclure un infarctus du myocarde (IM) dans un grand service d'urgence urbain. Les scores HEAR ont été calculés dans deux cohortes : (1) les patients sans antécédents connus de maladie coronarienne (MC) ; et (2) tous les patients éligibles. La proportion de patients classés à très faible risque, la sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance à chaque seuil ont été quantifiés pour l'infarctus aigu du myocarde (IAM) de l'index et la MACE à 30 jours aux seuils HEAR = 0 et HEAR ≤ 1. RéSULTATS: Sur les 1 150 patients inclus dans cette étude, 820 (71.3%) n'avaient pas d'antécédents de coronaropathie, 97 (8.4%) avaient un IAM index et 123 (10.7%) avaient une MACE à 30 jours. Chez les patients sans antécédents de coronaropathie, HEAR ≤ 1 a identifié 202 (24,6%) des patients comme présentant un très faible risque de MACE à 30 jours avec une sensibilité de 98.4% (IC 95% 91.6­99.9%). Parmi tous les patients, HEAR ≤ 1 a identifié 202 (17.6%) patients comme présentant un très faible risque de MACE à 30 jours avec une sensibilité de 99.2% (IC 95% 95.6­99.9%). CONCLUSIONS: Un score HEAR ≤ 1 peut identifier plus de 17% de tous les patients comme étant à très faible risque d'IAM d'index et de MACE à 30 jours et peu susceptibles de bénéficier d'un test à la troponine. La mise en œuvre à grande envergure de cette stratégie pourrait permettre de réaliser d'importantes économies de ressources.

Surgery and COVID-19: a rapid scoping review of the impact of the first wave of COVID-19 on surgical services.

OBJECTIVES: To understand how surgical services have been reorganised during and following public health emergencies, particularly the first wave of the COVID-19 pandemic, and the consequences for patients, healthcare providers and healthcare systems. DESIGN: A rapid scoping review. SETTING: We searched the MEDLINE, Embase and grey literature sources for documents and press releases from governments and surgical organisations or associations. PARTICIPANTS: Studies examining surgical service delivery during public health emergencies including COVID-19, and the impact on patients, providers and healthcare systems were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were strategies implemented for the reorganisation of surgical services. Secondary were the impacts of reorganisation and resuming surgical services, such as: adverse events (including morbidity and mortality), primary care and emergency department visits, length of hospital and ICU stay, and changes to surgical waitlists. RESULTS: One hundred and thirty-two studies were included in this review; 111 described reorganisation of surgical services, 55 described the consequences of reorganising surgical services; and 6 reported actions taken to rebuild surgical capacity in public health emergencies. Reorganisations of surgical services were grouped under six domains: case selection/triage, personal protective equipment (PPE) regulations and practice, workforce composition and deployment, outpatient and inpatient patient care, resident and fellow education, and the hospital or clinical environment. Service reorganisations led to large reductions in non-urgent surgical volumes, increases in surgical wait times and impacted medical training (ie, reduced case involvement) and patient outcomes (eg, increases in pain). Strategies for rebuilding surgical capacity were scarce but focused on the availability of staff, PPE and patient readiness for surgery as key factors to consider before resuming services. CONCLUSIONS: Reorganisation of surgical services in response to public health emergencies appears to be context dependent and has far-reaching consequences that must be better understood in order to optimise future health system responses to public health emergencies.

Perioperative management for people with chronic kidney disease receiving dialysis undergoing major surgery: a protocol for a scoping review.

INTRODUCTION: People with chronic kidney disease receiving dialysis (CKD G5D) have an increased risk of poor postoperative outcomes and a high incidence of major surgery. Despite the high burden of these combined risks, there is a paucity of evidence to support tailored perioperative strategies to manage this population. A comprehensive evidence synthesis would inform the management of these patients in the perioperative period and identify knowledge gaps. We describe a protocol for a scoping review of the literature to identify existing perioperative strategies, protocols, pathways and interventions for people with CKD G5D undergoing major surgery. METHODS AND ANALYSIS: We will conduct a scoping review in accordance with the Joanna Briggs Institute methodology and report per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. In February 2020, we will complete our search of MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials Registry for published literature from inception to present. All study types are eligible for inclusion, without language restriction. Studies reporting a perioperative intervention in adult patients with CKD G5D are eligible for inclusion. Studies in prevalent kidney transplant patients or patients with acute kidney injury, and studies that report on surgical approaches without consideration of perioperative management strategies, will be excluded. Reviewers will independently assess abstracts for all identified studies in duplicate, and again at the full-text stage. Following published literature searches, a search of the grey literature will be developed. We will extract and narratively report study, participant and intervention details. This will include a summary table outlining the strategies employed, organised into post hoc developed perioperative domains. ETHICS AND DISSEMINATION: Ethical considerations do not apply to this scoping review. Findings will be disseminated through relevant conference presentations and publications.

The Characteristics and Effectiveness of Interventions for Frequent Emergency Department Utilizing Patients With Chronic Noncancer Pain: A Systematic Review.

BACKGROUND: Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group. METHODS: We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, and Web of Science from database inception to June 2018 for eligible interventional studies aimed at reducing frequent ED utilization among adult patients with CNCP. Articles were assessed in duplicate in accordance with methodologic recommendations from the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes of interest were the frequency of subsequent ED visits, type and amount of opioids administered in the ED and prescribed at discharge, and costs. Methodologic quality was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias tools for nonrandomized and randomized studies, respectively. RESULTS: Thirteen studies including 1,679 patients met the inclusion criteria. Identified interventions implemented pain policies (n = 4), individualized care plans (n = 5), ED care coordination (n = 2), chronic pain management pathways (n = 1), and behavioral health interventions (n = 1). All of the studies reported a decrease in ED visit frequency following their respective interventions. These reductions were especially pronounced in studies whose interventions were focused around individualized care plans and primary care involvement. Interventions implementing opioid restriction and pain management policies were largely successful in reducing the amounts of opioid medications administered and prescribed in the ED. CONCLUSIONS: Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.

Longitudinal qualitative study describing family physicians' experiences with attempting to integrate physical activity prescriptions in their practice: 'It's not easy to change habits'.

OBJECTIVE: Physical activity (PA) prescriptions provided by family physicians can promote PA participation among patients, but few physicians regularly write PA prescriptions. The objective of this study was to describe family physicians' experiences of trying to implement written PA prescriptions into their practice. DESIGN: Longitudinal qualitative study where participants were interviewed four times during a 12-month period. After the first interview, they were provided with PA prescription pads. Data were analysed using thematic analysis. SETTING: Family medicine clinics in New Brunswick, Canada. PARTICIPANTS: Family physicians (n=11) with no prior experience writing PA prescriptions, but who expressed interest in changing their practice to implement written PA prescriptions. RESULTS: Initially, participants exhibited confidence in their ability to write PA prescriptions in the future and intended to write prescriptions. However, data from the follow-up interviews indicated that the rate of implementation was lower than anticipated by participants and prescriptions were not part of their regular practice. Two themes emerged as factors explaining the gap between their intentions and behaviours: (1) uncertainty about the effectiveness of written PA prescription, and (2) practical concerns (eg, changing well-established habits, time constraints, systemic institutional barriers). CONCLUSION: It may be effective to increase awareness among family physicians about the effectiveness of writing PA prescriptions and address barriers related to how their practice is organised in order to promote written PA prescription rates.

The effectiveness of health care provider physical activity recommendations in cancer survivors: a systematic review and meta-analysis protocol.

BACKGROUND: Cancer survivors face a range of negative physical and psychological effects that can be mitigated by participating in physical activity. Despite this, most do not meet recommended levels. Health care providers may be in a unique position to promote participation in physical activity among cancer survivors. The aim of this systematic review and meta-analysis is to synthesize the findings from randomized controlled trials and controlled clinical trials investigating the effectiveness of health care provider-administered physical activity recommendations on participation in physical activity among cancer survivors. METHODS/DESIGN: Ten electronic databases (CINAHL, CENTRAL, Education Source, EMBASE, LILACS, MEDLINE, OTSeeker, PEDro, PsycINFO, SPORTDiscus) will be searched to identify relevant studies. The electronic searches will be supplemented by scanning the reference lists of relevant articles retrieved during these searches to ensure all potentially relevant studies are identified. Two reviewers will independently screen all titles and abstracts resulting from the searches to identify potentially eligible studies. They will then screen the full-text articles passing the first screen to identify studies for inclusion using predetermined inclusion/exclusion criteria, extract data from studies meeting all criteria, and assess the risk of bias of these studies. Results will be summarized narratively and statistically. DISCUSSION: By summarizing the best available evidence for the effectiveness of health care provider physical activity recommendations for increasing participation in physical activity among cancer survivors, the results of this systematic review and meta-analysis will help determine if making physical activity recommendations effectively changes cancer survivors behaviour. It will also help to identify knowledge gaps and highlight areas in need of additional research.