Effectiveness and Safety of the European Society of Cardiology 0-/1-h Troponin Rule-Out Protocol: The Design of the ESC-TROP Multicenter Implementation Study.

Chest pain is one of the most common complaints at the emergency department (ED), and it is commonly the perceived likelihood of acute coronary syndrome (ACS) that drives management. Guidelines from the European Society of Cardiology (ESC) recommend the use of a 0-/1-h high-sensitivity cardiac troponin T (hs-cTnT) protocol to rule out or in ACS, but this is mostly based on observational studies. The aim of the ESC-TROP trial is to determine the safety and effectiveness of the ESC 0-/1-h hs-cTnT protocol when implemented in routine care. Adult chest pain patients at 5 EDs in the Skåne Region, Sweden, are included in the trial. The 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and electrocardiography (ECG) is implemented at 3 EDs, and the other 2 EDs act as concurrent controls. Outcomes will be evaluated during the 10 months after the implementation and the corresponding 10 months of the previous year. The 2 co-primary outcomes are (a) acute myocardial infarction (AMI) and all-cause death within 30 days in patients discharged from the ED, and (b) ED length of stay of the same patients. Secondary outcomes include the proportion of chest pain patients discharged from the ED and the number of ruled-out patients undergoing objective testing within 30 days. The ESC-TROP trial will determine the performance and applicability of the 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and ECG when implemented in routine ED care. It will provide evidence whether 0-/1-h hs-cTnT testing is safe, effective, and feasible, and whether widespread implementation as recommended by ESC guidelines should be supported.

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

BACKGROUND: Studies carried out in simulated environments suggest that checklists improve the management of surgical and intensive care crises. Whether checklists improve the management of medical crises simulated in actual emergency departments (EDs) is unknown. METHODS: Eight crises (anaphylactic shock, life-threatening asthma exacerbation, haemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure) were simulated twice (once with and once without checklist access) in each of four EDs-of which two belong to an academic centre-and managed by resuscitation teams during their clinical shifts. A checklist for each crisis listing emergency interventions was derived from current authoritative sources. Checklists were displayed on a screen visible to all team members. Crisis and checklist access were allocated according to permuted block randomisation. No team member managed the same crisis more than once. The primary outcome measure was the percentage of indicated emergency interventions performed. RESULTS: A total of 138 participants composing 41 resuscitation teams performed 76 simulations (38 with and 38 without checklist access) including 631 interventions. Median percentage of interventions performed was 38.8% (95% CI 35% to 46%) without checklist access and 85.7% (95% CI 80% to 88%) with checklist access (p=7.5×10-8). The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. On a Likert scale of 1-6, most participants agreed (gave a score of 5 or 6) with the statement 'I would use the checklist if I got a similar case in reality'. CONCLUSION: In this multi-institution study, checklists markedly improved local resuscitation teams' management of medical crises simulated in situ, and most personnel reported that they would use the checklists if they had a similar case in reality.

[The Swedish specialist examination in emergency medicine: reflections on the first decade]. / Svensk specialisttentamen i akutsjukvård: 10 års perspektiv - Med slutgiltigt mål att förbättra vården för patienterna på Sveriges akutmottagningar.

Emergency Medicine became a supraspeciality in Sweden in 2008. The Swedish Specialist Examination in Emergency Medicine is a formative examination that seeks to guide local training in Emergency Medicine, provide feedback to physicians during their residency, and establish national standards for various processes in Emergency Medicine. It consists of six partial examinations and 118 cases. Documents and checklists accessible on the internet specify the degree of competence expected during the examination. Program directors are tasked with offering the examination locally to their residents. During the past 10 years, the examination has been offered during 53 days to 180 residents belonging to 27 training programs. The total number of passed partial examinations is 201. Six physicians have so far passed all six partial examinations.

Goda resultat när akutläkare diagnostiserade djup ventrombos - DVT-diagnostik kan utföras med ultraljud på akuten, enligt pilotstudie vid Lasarettet i Ystad.

Good outcomes when emergency physicians diagnosed deep vein thrombosis Deep vein thrombosis of the lower limb is best diagnosed with ultrasound. Internationally, several studies have shown promising and often equal results when emergency physicians have been compared with radiologists in diagnosing thrombosis. Our results confirm these findings in a non-academic hospital and for the first time in a Swedish setting. Our findings form the basis for a multi-centre study on new diagnostic routines in patients with suspected proximal deep vein thrombosis in the emergency department, potentially resulting in faster and more resource-effective management.

Activation of silenced transgene expression in neural precursor cell lines by inhibitors of histone deacetylation.

BACKGROUND: Ex vivo gene therapy in the central nervous system (CNS) holds great promise for diseases such as the neurodegenerative disorders. However, achieving stable, long-term transgene expression in grafted cells has proven problematic. This study reports the establishment of an in vitro model of transgene down-regulation in cells grafted to the CNS using the immortalized neural progenitor cell lines HiB5 and RN33B. METHODS: Neural cell lines were transduced at 33 degrees C with different GFP constructs, both viral and non-viral, containing either viral or non-viral promoters. Cell differentiation in vitro was obtained by culturing the cells at 37 degrees C in serum-free defined media, which halts cell division, and GFP-expression was analysed by FACS. As early as day 3 of culture at 37 degrees C, the transgene expression decreased markedly in most cell lines. To validate the assay, the same clones were grafted to the adult rat striatum and the down-regulation of GFP-expression was evaluated. RESULTS: The temporal pattern of down-regulation was found to be similar in vitro and in vivo. Using this assay, it was shown that addition of inhibitors of histone deacetylation, but not an inhibitor of DNA methylation, reversed the silencing of GFP in quiescent neural progenitors by up to 308% of control values. CONCLUSION: These results suggest that the same mechanisms controlling gene transcription of the host cell's genome are active in controlling transgene expression and that this should be taken into account when constructing vectors for gene therapy. The assay reported in this study could be used as a screening method to evaluate new vectors.