A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients.

STUDY OBJECTIVE: The HEART score is a risk stratification aid that may safely reduce chest pain admissions for emergency department patients. However, differences in interpretation of subjective components potentially alters the performance of the score. We compared agreement between HEART scores determined during clinical practice with research-generated scores and estimated their accuracy in predicting 30-day major adverse cardiac events. METHODS: We prospectively enrolled adult ED patients with symptoms concerning for acute coronary syndrome at a single tertiary center. ED clinicians submitted their clinical HEART scores during the patient encounter. Researchers then independently interviewed patients to generate a research HEART score. Patients were followed by phone and chart review for major adverse cardiac events. Weighted kappa; unweighted Cohen's kappa; prevalence-adjusted, bias-adjusted kappa (PABAK); and test probabilities were calculated. RESULTS: From November 2016 to June 2019, 336 patients were enrolled, 261 (77.7%) were admitted, and 30 (8.9%) had major adverse cardiac events. Dichotomized HEART score agreement was 78% (kappa 0.48, 95% confidence interval [CI] 0.37 to 0.58; PABAK 0.57, 95% CI 0.48 to 0.65) with the lowest agreement in the history (72%; WK 0.14, 95% CI 0.06 to 0.22) and electrocardiogram (85%; WK 0.4, 95% CI 0.3 to 0.49) components. Compared with researchers, clinicians had 100% sensitivity (95% CI 88.4% to 100%) (versus 86.7%, 95% CI 69.3% to 96.2%) and 27.8% specificity (95% CI 22.8% to 33.2%) (versus 34.6%, 95% CI 29.3% to 40.3%) for major adverse cardiac events. Four participants with low research HEART scores had major adverse cardiac events. CONCLUSION: ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

Prenatal Depression and Risk of Short Interpregnancy Interval in a Predominantly Puerto Rican Population.

Background: Short interpregnancy interval (IPI) is associated with risk of adverse pregnancy outcomes; however, few studies have evaluated the role of depression as a risk factor for short IPI. Puerto Rican women in the United States experience disparities in adverse birth outcomes and have the highest birth rates. Methods: We analyzed the association between prenatal depressive symptoms and IPI in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women in Western Massachusetts (2006-2011). Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in early, mid, and late pregnancy. We calculated follow-up time as the difference between the date of delivery of the index pregnancy and the last menstrual period of the subsequent pregnancy using medical records and billing data. We defined short IPI as ≤18 months. Results: Of 1262 eligible women, 35% (n = 440) had at least probable minor depression (EPDS scores ≥13) and 25% (n = 315) had probable major depression (EPDS scores ≥15). Participants were followed for a median of 3.7 years (interquartile range = 1.4-6.0 years) and 240 (20.6%) participants experienced a short IPI. After adjusting for risk factors, women with probable minor depression (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 1.02-1.88) and probable major depression (aOR = 1.42, 95% CI = 1.02-1.97) during pregnancy had increased odds of short IPI. Conclusions: Prenatal depressive symptoms were common in this Puerto Rican population and were associated with a modest increase in odds of short IPI. Further examination of the pathways through which mental health may affect IPI in vulnerable populations is warranted.

A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain.

BACKGROUND: Color and power Doppler ultrasound are commonly used in the evaluation of ovarian torsion but are unreliable. Because normal-sized ovaries are unlikely to cause torsion, maximum ovarian diameter (MOD) could theoretically be used as a screening test in the ED. Identification of MOD values below which torsion is unlikely would be of benefit to providers interpreting radiology department or point-of-care pelvic ultrasound. OBJECTIVES: The objective was to determine if sonographic MOD can be used as a screening tool to rule out torsion in selected patients. METHODS: Via a retrospective case-control study spanning a 14-year period, we examined the ultrasound characteristics of patients with torsion and age-matched controls, all presenting to the emergency department with lower abdominal pain and receiving a radiology department pelvic ultrasound for "rule-out torsion." Standardized data collection forms were utilized. Distributions of MOD were compared and sensitivity, specificity, and likelihood ratios were calculated for multiple cutoffs. RESULTS: We identified 92 cases of surgically confirmed ovarian torsion and selected 92 age-matched controls. In postmenarchal patients the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 3- and 5-cm MODs were 100% (96%-100%), 30% (20%-41%), 1.4 (1.3-1.7), and 0 and 91% (83%-97%), 92% (83%-97%), 11.2 (5.5-22.9), and 0.09 (0.04-0.19), respectively. The 5-cm MOD, however, excluded an additional 52 of 84 (62%) postmenarchal patients. CONCLUSIONS: A threshold MOD of 5 cm on pelvic ultrasound may be useful to rule out ovarian torsion in postmenarchal females presenting with lower abdominal and pelvic pain.

Improving Management of Hospitalized Adults With Uncomplicated Cellulitis or Cutaneous Abscess.

Implementation of a guideline for the management of hospitalized adults with uncomplicated skin and soft-tissue infections may decrease unnecessary antibiotic use. For cellulitis, treatment with vancomycin and broad-spectrum antibiotics decreased significantly. For cutaneous abscess, treatment with broad-spectrum antibiotics decreased significantly. There were no differences in rates of treatment failure, recurrence, or adverse events.