ORCID Profile
0000-0002-1448-0899
Current Organisations
University of Queensland
,
Royal Brisbane and Women's Hospital
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Publisher: Wiley
Date: 03-2001
DOI: 10.1046/J.1442-2026.2001.00180.X
Abstract: To report on: 1. Prevalence of seat-belt sign in motor vehicle accident victims with abdominal injuries 2. Prevalence of intestinal injuries in patients with seat-belt sign and 3. Spectrum of abdominal injuries in a population with high usage of three-point restraints. A retrospective chart review was conducted in an adult tertiary-referral hospital from January 1992 to August 1998. Patients were identified from International Classification of Disease-9 codes for abdominal wall and intra-abdominal injuries. The seat-belt sign was present in 60/99. The proportion of intestinal injuries in patients with and without seat-belt sign were 9/60 and 0/39, respectively (P = 0.01). In the 25 patients with intra-abdominal injuries, there were 10 hepatic, 8 splenic, 9 intestinal and 4 retroperitoneal injuries. The seat-belt sign is indicative of an increased risk of intestinal injury, which is difficult to detect with no single test providing reliable diagnosis. Other intra-abdominal and retroperitoneal injuries may also occur, which are more readily diagnosed on computed tomography scan or focused abdominal utlrasound when available, but are no more frequent in patients with the seat-belt sign than those without.
Publisher: Wiley
Date: 28-07-2015
DOI: 10.1111/IMJ.12799
Abstract: Angioedema occurs in up to 2% of those taking angiotensin-converting enzyme (ACE) inhibitors. Upper airway angioedema may potentially require endotracheal intubation or cricothyrotomy, and is usually unresponsive to adrenaline. The bradykinin receptor antagonist icatibant is proven to be effective in the treatment of acute attacks of hereditary angioedema, and has also been reported effective in the treatment of angioedema associated with ACE inhibitors. To describe the use of icatibant for ACE inhibitor-associated airway angioedema. We treated 13 consecutive emergency department (ED) patients, who had not improved with adrenaline and/or corticosteroids, with icatibant 30 mg subcutaneously for ACE inhibitor-associated upper respiratory tract angioedema according to an agreed protocol. Four patients were intubated in the ED either before or after receiving icatibant three of these were extubated within 24 h of treatment. Eight patients received early icatibant and did not require intubation. The time from onset of airway angioedema to ED presentation ranged from 1 h to 3 days (median 4 h) from ED presentation to receiving icatibant, from 30 minutes to 3 days (median 3 h) and to onset of symptom improvement after icatibant, 15 minutes to 7 h (median 2 h). One patient received a second dose of icatibant. All patients improved after receiving icatibant, consistent with its bradykinin receptor blocking mechanism. Icatibant rapidly reversed symptoms, and appeared to avert the need for intubation or expedite extubation. Timely use of icatibant in ACE inhibitor-associated angioedema may avert the need for invasive airway procedures and intensive care unit admission.
Publisher: Elsevier BV
Date: 07-2013
DOI: 10.1016/J.AJEM.2013.04.016
Abstract: The objective of this study is to evaluate the accuracy of the Vancouver Chest Pain Rule using troponin as the only biomarker in an emergency department (ED) setting. This is an analysis of prospectively collected data from 2 EDs in Australia and New Zealand. Trained research nurses collected clinical data using a customised case report form. Based on a modified Vancouver Chest Pain Rule using troponin as the only biomarker, low-risk patients were identified using clinical history, age, pain characteristics, electrocardiography, and troponin results at 0 and 2 hours after presentation. The primary outcome was diagnosis of acute coronary syndrome (ACS) within 30 days of presentation as adjudicated by 2 independent cardiologists. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated to assess the accuracy of the rule. There were 1635 patients, and 20.4% had ACS. One hundred twenty-one patients (7.4%) were assigned to the low-risk group on presentation, and a further 418 (25.6%) were assigned low risk after 2-hour electrocardiography and troponin testing. Of the 539 patients (33%) who were eligible for early discharge, 30 (5.6%) had ACS. Sensitivity was 91.0% (95% confidence interval [CI], 85.7%-93.6%), negative predictive value was 94.4% (95% CI, 92.2-96.1), specificity was 39.1% (95% CI, 36.5-41.8), and positive predictive value was 27.7% (95% CI, 25.2-30.5). The Vancouver Chest Pain Rule with troponin as the only biomarker identified a sizable low-risk cohort. However, sensitivity was lower than that identified in the original derivation study and was considered insufficient to enable safe early discharge. Modifications to the tool would be required if troponin was incorporated as the only biomarker.
Publisher: Wiley
Date: 03-1993
Publisher: Wiley
Date: 2017
DOI: 10.1111/ACEM.13062
Abstract: The objective of this study was to describe demographic and clinical characteristics including features that were consistent with subarachnoid hemorrhage (SAH), use of diagnostic tests, emergency department (ED) discharge diagnoses, and disposition of adult patients presenting with an acute headache to EDs statewide across Queensland, Australia. In addition, potential variations in the presentation and diagnostic workup between principal-referral and city-regional hospitals were examined. A prospective cross-sectional study was conducted over 4 weeks in September 2014. All patients ≥ 18 years presenting to one of 29 public and five private hospital EDs across the state with an acute headache were included. The headache had to be the principal presenting complaint and nontraumatic. The 34 study sites attend to about 90% of all ED presentations statewide. The treating doctor collected clinical information at the time of the ED visit including the characteristics of the headache and investigations performed. A study coordinator retrieved results of investigations, ED discharge diagnoses, and disposition from state databases. Variations in presentation, investigations, and diagnosis between city-regional and principal-referral hospitals were examined. There were 847 headache presentations. Median (range) age was 39 (18-92) years, 62% were female, and 31% arrived by ambulance. Headache peaked instantly in 18% and ≤ 1 hour in 44%. It was "worst ever" in 37%, 10/10 in severity in 23%, and associated with physical activity in 7.4%. Glasgow Coma Scale score was < 15 in 4.1%. Neck stiffness was noted on examination in 4.8%. Neurologic deficit persisting in the ED was found in 6.5%. A computed tomography (CT) head scan was performed in 38% (318/841, 95% CI = 35% to 41%) and an lumbar puncture in 4.7% (39/832, 95% CI = 3.4% to 6.3%). There were 18 SAH, six intraparenchymal hemorrhages, one subdural hematoma, one newly diagnosed brain metastasis, and two bacterial meningitis. Migraine was diagnosed in 23% and "primary headache not further specified" in 45%. CT head scans were more likely to be performed in principal-referral hospitals (41%) compared to city-regional hospitals (33%). The headache in patients presenting to the latter was less likely to be instantly peaking or associated with activity, but was no less severe in intensity and was more frequently accompanied by nausea and vomiting. Their diagnosis was more likely to be a benign primary headache. Variations in CT scanning could thus be due to differences in the case mix. The median (interquartile range) ED length of stay was 3.1 (2.2 to 4.5) hours. Patients was discharged from the ED or admitted to the ED short-stay unit prior to discharge in 57 and 23% of cases, respectively. The majority of patients had a benign diagnosis, with intracranial hemorrhage and bacterial meningitis accounting for only 3% of the diagnoses. There are variations in the proportion of patients receiving CT head scans between city-regional and principal-referral hospitals. As 38% of headache presentations overall underwent CT scanning, there is scope to rationalize diagnostic testing to rule out life-threatening conditions.
Publisher: Wiley
Date: 05-02-2018
Publisher: Elsevier BV
Date: 10-2013
DOI: 10.1016/J.HLC.2013.03.074
Abstract: To compare the predictive ability of three risk stratification tools used to assess patients presenting to the ED with potential acute coronary syndrome. Pre-planned analysis of an observational study. A single tertiary referral hospital. 1495 patients presented with chest pain. 948 patients were screened and enrolled. Patients with at least 5 min of chest pain suggestive of ACS were eligible. Subjects were risk categorised using the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines (HFA/CSANZ), the TIMI score and the GRACE score. Three strata of the TIMI and GRACE score were used to compare to the HFA/CSANZ risk categories. 30-Day cardiac event rates including cardiac death, acute myocardial infarction and unstable angina. There were 152 events in 91 patients (9.6%). The discriminatory ability of the scores determined by the AUC was 0.83 (95% CI 0.79-0.87) for the GRACE score, 0.79 (95% CI 0.74-0.83) for TIMI score and 0.75 (95% CI 0.70-0.80) for HFA/CSANZ. The AUCs with three strata of the GRACE and TIMI scores were 0.76 (95% CI 0.72-0.81) and 0.68 (95% CI 0.62-0.73) respectively. All three scores were similar in performance in quantifying risk in ED patients with possible ACS. The GRACE score identified a sizable low risk cohort with high sensitivity and NPV but complexity of this tool may limit its utility. Improved scores are needed to allow early identification of low- and high-risk patients to support improvements in patient flow and ED overcrowding.
Publisher: Wiley
Date: 12-2001
Publisher: Elsevier BV
Date: 10-2013
DOI: 10.1016/J.JACC.2013.02.078
Abstract: The study objective was to validate a new high-sensitivity troponin I (hs-TnI) assay in a clinical protocol for assessing patients who present to the emergency department with chest pain. Protocols using sensitive troponin assays can accelerate the rule out of acute myocardial infarction in patients with low-risk (suspected) acute coronary syndrome (ACS). This study evaluated 2 prospective cohorts of patients in the emergency department with ACS in an accelerated diagnostic pathway integrating 0- and 2-h hs-TnI results, Thrombolysis In Myocardial Infarction (TIMI) risk scores, and electrocardiography. Strategies to identify low-risk patients incorporated TIMI risk scores= 0 or ≤ 1. The primary endpoint was a major adverse cardiac event (MACE) within 30 days. In the primary cohort, 1,635 patients were recruited and had 30-day follow-up. A total of 247 patients (15.1%) had a MACE. The finding of no ischemic electrocardiogram and hs-TnI ≤ 26.2 ng/l with the TIMI = 0 and TIMI ≤ 1 pathways, respectively, classified 19.6% (n = 320) and 41.5% (n = 678) of these patients as low risk 0% (n = 0) and 0.8% (n = 2) had a MACE, respectively. In the secondary cohort, 909 patients were recruited. A total of 156 patients (17.2%) had a MACE. The TIMI = 0 and TIMI ≤ 1 pathways classified 25.3% (n = 230) and 38.6% (n = 351), respectively, of these patients as low risk 0% (n = 0) and 0.8% (n = 1) had a MACE, respectively. Sensitivity, specificity, and negative predictive value for TIMI = 0 in the primary cohort were 100% (95% confidence interval [CI]: 98.5% to 100%), 23.1% (95% CI: 20.9% to 25.3%), and 100% (95% CI: 98.8% to 100%), respectively. Sensitivity, specificity, and negative predictive value for TIMI ≤ 1 in the primary cohort were 99.2 (95% CI: 97.1 to 99.8), 48.7 (95% CI: 46.1 to 51.3), and 99.7 (95% CI: 98.9 to 99.9), respectively. Sensitivity, specificity, and negative value for TIMI ≤ 1 in the secondary cohort were 99.4% (95% CI: 96.5 to 100), 46.5% (95% CI: 42.9 to 50.1), and 99.7% (95% CI: 98.4 to 100), respectively. An early-discharge strategy using an hs-TnI assay and TIMI score ≤ 1 had similar safety as previously reported, with the potential to decrease the observation periods and admissions for approximately 40% of patients with suspected ACS. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study, NCT00470587 A 2 hr Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker [ADAPT]: a prospective observational validation study, ACTRN12611001069943).
Publisher: Wiley
Date: 03-1994
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2014
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1016/J.JACC.2012.02.035
Abstract: The purpose of this study was to determine whether a new accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge (with follow-up shortly after discharge). Patients presenting with possible acute coronary syndrome (ACS), who have a low short-term risk of adverse cardiac events may be suitable for early discharge and shorter hospital stays. This prospective observational study tested an ADP that included pre-test probability scoring by the Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiography, and 0 + 2 h values of laboratory troponin I as the sole biomarker. Patients presenting with chest pain due to suspected ACS were included. The primary endpoint was major adverse cardiac event (MACE) within 30 days. Of 1,975 patients, 302 (15.3%) had a MACE. The ADP classified 392 patients (20%) as low risk. One (0.25%) of these patients had a MACE, giving the ADP a sensitivity of 99.7% (95% confidence interval [CI]: 98.1% to 99.9%), negative predictive value of 99.7% (95% CI: 98.6% to 100.0%), specificity of 23.4% (95% CI: 21.4% to 25.4%), and positive predictive value of 19.0% (95% CI: 17.2% to 21.0%). Many ADP negative patients had further investigations (74.1%), and therapeutic (18.3%) or procedural (2.0%) interventions during the initial hospital attendance and/or 30-day follow-up. Using the ADP, a large group of patients was successfully identified as at low short-term risk of a MACE and therefore suitable for rapid discharge from the emergency department with early follow-up. This approach could decrease the observation period required for some patients with chest pain. (An observational study of the diagnostic utility of an accelerated diagnostic protocol using contemporary central laboratory cardiac troponin in the assessment of patients presenting to two Australasian hospitals with chest pain of possible cardiac origin ACTRN12611001069943).
Publisher: Wiley
Date: 10-2006
Publisher: Wiley
Date: 12-2011
Publisher: Wiley
Date: 06-2001
Publisher: Wiley
Date: 02-2011
Publisher: Wiley
Date: 25-07-2003
Publisher: Wiley
Date: 26-02-2018
Abstract: Gender equality and workforce ersity has recently been in the forefront of College discussions. Reasons for the difference between various groups may not be as they initially appeared. The results of comparing the outcome between two groups can sometimes be confounded and even reversed by an unrecognised third variable. This concept is known as Simpson's Paradox, and is illustrated here using a renowned case study on potential gender bias for acceptance to Graduate School at the University of California, Berkeley. The investigation showed that males were 1.8 times more likely to be admitted to Graduate School than females in 1973. Initially it appeared that women were discriminated against in the selection process. However, when admissions were re-examined at in idual Departments of the School, admission tended to be better for women than men in four of six Departments. This contradiction or paradox tells us that the association between admission and gender was dependent upon on Department. The confounding effect of Department was defined by two characteristics. Firstly, a strong association between Department and admission: some Departments admitted much smaller percentages of applicants than others. Secondly, a strong association between Department and gender: females tended to apply to Departments with lower admission rates. The explanation of differences between groups can be multifactorial. A search for possible confounders will assist in this understanding. This could apply whenever two groups initially appear to differ, but on closer analysis this difference is either unfounded, or even reversed by reference to a third, confounding variable.
Publisher: Wiley
Date: 04-2012
Publisher: Wiley
Date: 06-2000
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.JOCN.2014.07.025
Abstract: This study aimed to determine if performing cerebrospinal fluid spectrophotometry in addition to visual inspection detects more ruptured cerebral aneurysms than performing cerebrospinal fluid visual inspection alone in patients with a normal head CT scan but suspected of suffering an aneurysmal subarachnoid haemorrhage (SAH). We performed a single-centre retrospective study of patients presenting to the emergency department of a tertiary hospital who underwent both head CT scan and lumbar puncture to exclude SAH. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of an approach utilising both spectrophotometry and visual inspection (combined approach) was compared to visual inspection alone. A total of 409 patients (mean age 37.8 years, 56.2% female) were recruited and six (1.5%) had a cerebral aneurysm on angiography. The sensitivity of visual inspection was 50% (95% confidence interval [CI]: 12.4-82.6%), specificity was 99% (95% CI: 97.5-99.7%), PPV was 42.9% (95% CI: 10.4-81.3%) and NPV was 99.2% (95% CI: 97.8-99.8%). The combined approach had a sensitivity of 100% (95% CI: 54.1-100%), specificity of 79.7% (95% CI: 75.4-83.5%), PPV of 6.8% (95% CI: 2.6-14.3%) and a NPV of 100% (95% CI: 98.8-100%). The sensitivity of the combined approach was not significantly different to that of visual inspection alone (p=0.25). Visual inspection had a significantly higher specificity than the combined approach (p<0.01). The combined approach detected more cases of aneurysmal SAH than visual inspection alone, however the difference in sensitivity was not statistically significant. Visual xanthochromia should prompt angiography because of a superior specificity and PPV. Due to its reduced sensitivity, caution should be applied when using only visual inspection of the supernatant.
Publisher: Wiley
Date: 30-10-2016
Publisher: BMJ
Date: 03-2004
Publisher: BMJ
Date: 24-10-2014
DOI: 10.1136/EMERMED-2014-204046
Abstract: This study aims to evaluate admission blood glucose level (BGL) in patients presenting to the emergency department (ED) as a risk factor for a major adverse cardiac event (MACE) on presentation and up to 30 days post discharge. Admission BGL is a prognostic indicator in patients with confirmed acute coronary syndrome (ACS). It is unclear if admission BGL improves the diagnosis and stratification of patients presenting to the ED with suspected ACS. This study is an analysis of data collected from a prospective observational study. The study population consisted of ED patients from Brisbane, Australia and Christchurch, New Zealand. Patients were enrolled between November 2007 and February 2011. Admission BGL was taken as part of routine admission blood with fasting status unknown. The primary end point for this study was a MACE at presentation and up to 30 days post discharge. Logistic regression analyses examined the relationship between admission hyperglycaemia and MACE. A hyperglycaemic threshold of 7 mmol/L was chosen based on WHO standards. A total of 1708 patients were eligible. A MACE was identified in 336 patients (19.7%) within 30 days. Of these 98 had confirmed unstable angina and 232 had non-ST elevation myocardial infarction. Hyperglycaemia was identified in 476 (27.9%) patients with 147 (30.9%) having a MACE. Admission BGL >7 mmol/L was demonstrated as an independent predictor of a MACE (OR1.51 CI 1.06 to 2.14). Gender, age, hypertension, dyslipidaemia, family history, ischaemic ECG and positive troponin remained important factors. Admission BGL is an independent risk factor for a MACE in patients with suspected ACS. Hyperglycaemia should be considered a risk factor for MACEs and consideration be given to its inclusion in existing diagnostic tools.
Publisher: Wiley
Date: 18-05-2006
Publisher: Wiley
Date: 02-2009
DOI: 10.1111/J.1742-6723.2008.01146.X
Abstract: To seek an association between access block and time to parenteral opioid analgesia (POA) in ED patients presenting with renal colic. Renal colic patients given POA were retrospectively identified over 3 months. Time of administration of POA was abstracted from patients' charts. Access block data, time of arrival and demographics were retrieved electronically. A logistic regression was used to seek an association between time to POA (dichotomized into 1 h of arrival) with daily access block (proportion of patients requiring hospital admission in a 24 h period who have a total ED time >8 h, dichotomized at its median), time of administration of POA (00.00-07.59 hours [T1], 08.00-15.59 hours [T2], 16.00-23.59 hours [T3] ), age and sex. Of 69 patients, 42 (60.1%, 95% CI 51-70%) received POA within 1 h. Access block occurred daily (median 28.8%, range 6.8-53.1%). Mean hourly ED attendance rates for all patients during T1, T2 and T3 were 4.0, 11.7 and 7.8 patients/h respectively. As predictors of time to POA (>1 h vs or=29% vs or=47 years vs <47 years) was 0.8 (95% CI 0.3-2.3) and for sex (female vs male) was 0.4 (95% CI 0.1-1.6). Time to POA was related to time of administration, but not to access block. Access block might be too crude a measure to quantify ED overcrowding, and so its influence on time to POA may not be exhibited.
Publisher: Wiley
Date: 10-2011
Publisher: Elsevier BV
Date: 04-1994
Publisher: AMPCo
Date: 05-2015
DOI: 10.5694/MJA14.00472
Abstract: We sought to characterise the demographics, length of admission, final diagnoses, long-term outcome and costs associated with the population who presented to an Australian emergency department (ED) with symptoms of possible acute coronary syndrome (ACS). Prospectively collected data on ED patients presenting with suspected ACS between November 2008 and February 2011 was used, including data on presentation and at 30 days after presentation. Information on patient disposition, length of stay and costs incurred was extracted from hospital administration records. Primary outcomes were mean and median cost and length of hospital stay. Secondary outcomes were diagnosis of ACS, other cardiovascular conditions or non-cardiovascular conditions within 30 days of presentation. An ACS was diagnosed in 103 (11.1%) of the 926 patients recruited. 193 patients (20.8%) were diagnosed with other cardiovascular-related conditions and 622 patients (67.2%) had non-cardiac-related chest pain. ACS events occurred in 0 and 11 (1.9%) of the low-risk and intermediate-risk groups, respectively. Ninety-two (28.0%) of the 329 high-risk patients had an ACS event. Patients with a proven ACS, high-grade atrioventricular block, pulmonary embolism and other respiratory conditions had the longest length of stay. The mean cost was highest in the ACS group ($13 509 95% CI, $11 794-$15 223) followed by other cardiovascular conditions ($7283 95% CI, $6152-$8415) and non-cardiovascular conditions ($3331 95% CI, $2976-$3685). Most ED patients with symptoms of possible ACS do not have a cardiac cause for their presentation. The current guideline-based process of assessment is lengthy, costly and consumes significant resources. Investigation of strategies to shorten this process or reduce the need for objective cardiac testing in patients at intermediate risk according to the National Heart Foundation and Cardiac Society of Australia and New Zealand guideline is required.
Publisher: Wiley
Date: 02-2011
DOI: 10.1111/J.1553-2712.2010.00976.X
Abstract: The objective was to determine whether prior statin use is associated with lower mortality in emergency patients admitted with infection. A prospective observational study was conducted at the emergency department (ED) of a tertiary adult hospital with an annual census of over 73,000 patients. Patients presenting to the ED who were subsequently hospitalized with a primary diagnosis of infection were identified within 24 hours of presentation. Data were abstracted from patients' charts and from hospital electronic databases. Patients were stratified according to reported regular statin use on presentation. The outcome measure was in-hospital mortality truncated at 30 days. An association between statin use and mortality was sought using logistic regression analysis. Data were collected over a 60-week period from 2,642 admissions. Patients taking a statin on admission had a higher unadjusted mortality risk (odds ratio [OR] = 2.14, 95% confidence interval [CI] = 1.32 to 3.46) compared to those not on a statin. However, this result became nonsignificant (OR = 0.96, 95% CI = 0.55 to 1.69) after adjusting for age, severity of disease, comorbid status, and propensity score. These data do not support an independent association between current preadmission statin use and lower 30-day in-hospital mortality in emergency patients admitted with infection. This result is contrary to most previously published studies.
Publisher: Wiley
Date: 12-2008
Publisher: Wiley
Date: 12-1994
Publisher: Wiley
Date: 04-2014
Abstract: National guidelines for management of intermediate risk patients with suspected acute coronary syndrome, in whom AMI has been excluded, advocate provocative testing to final risk stratify these patients into low risk (negative testing) or high risk (positive testing suggestive of unstable angina). Adults less than 40 years have a low pretest probability of acute coronary syndrome. The utility of exercise stress testing in young adults with chest pain suspected of acute coronary syndrome who have National Heart Foundation intermediate risk features was evaluated. A retrospective analysis of exercise stress testing performed on patients less than 40 years was evaluated. Patients were enrolled on a chest pain pathway and had negative serial ECGs and cardiac biomarkers before exercise stress testing to rule-out acute coronary syndrome. Chart review was completed on patients with positive stress tests. The 3987 patients with suspected intermediate risk acute coronary syndrome underwent exercise stress testing. One thousand and twenty-seven (25.8%) were aged less than 40 years (age 33.3 ± 4.8 years). Four of these 1027 patients had a positive exercise stress test (0.4% incidence of positive exercise stress testing). Of those, three patients had subsequent non-invasive functional testing that yielded a negative result. One patient declined further investigations. Assuming this was a true positive exercise stress test, the incidence of true positive exercise stress testing would have been 0.097% (95% confidence interval: 0.079-0.115%) (one of 1027 patients). Routine exercise stress testing has limited value in the risk stratification of adults less than 40 years with suspected intermediate risk of acute coronary syndrome.
Publisher: BMJ
Date: 26-08-2016
DOI: 10.1136/EMERMED-2016-205893
Abstract: To explore bibliometric markers in a worldwide s le of emergency physician investigators to define global, continental and in idual patterns over time. We evaluated the number of papers published, citations received, cumulative impact factor and h-index of editorial board members of six international emergency medicine journals. We calculated the in idual values for every year of each author's career to evaluate their dynamic evolution. We analysed the results by researcher world area and growth rate. We included 107 researchers (76 American, 21 European and 10 Australasian 46 slow-rate -group C-, 43 medium-rate -group B- and 18 fast-rate growth -group A-). The median experience was 18 (IQR: 12) years, without subgroups differences. Dynamic analysis over time showed good fit with quadratic function in all in idual researchers and for all bibliometric markers (R Dynamic analysis of every in idual author indicator over time has a very good fit with a quadratic model, with the h-index achieving the best R
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2016
Publisher: Cambridge University Press
Date: 10-04-2012
Publisher: Wiley
Date: 02-2014
Publisher: Elsevier BV
Date: 02-2014
DOI: 10.1016/J.AJEM.2013.10.021
Abstract: To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays. Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results. Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay. The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk.
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.AUCC.2015.05.001
Abstract: The objective of this study was to explore factors associated with the triage category assigned by the triage nurse for patients ultimately diagnosed with acute myocardial infarction. This was a retrospective analysis of 12 months of data, on adult emergency department patients ultimately diagnosed with acute myocardial infarction. Data were obtained from hospital databases and included patient demographics, patient clinical characteristics and nurses' experience. Of the 153 patients, 20% (95% CI: 14-27%) were given a lower urgency triage category than recommended by international guidelines. Compared to patients who were triaged Australasian Triage Category 1 or 2, patients with an Australasian Triage Category 3-5 were older (mean age 76 versus 68 years), more likely to be female (63% versus 32%), more likely to present without chest pain (93% versus 35%) and less likely to have a cardiac history (3.3% versus 17.9%). A slightly higher proportion of patients Australasian Triage Category 3-5 were triaged by an experienced nurse (50%) compared to patients categorised Australasian Triage Category 1-2 (35.2%) but this finding did not reach statistical significance. One in five presentations was given a lower urgency triage category than recommended by international guidelines, potentially leading to delays in medical treatment. The absence of chest pain was the defining characteristic in this group of patients, along with other factors identified by previous research such as being of female sex and elderly.
Publisher: Wiley
Date: 16-03-2016
Abstract: The objective of this present study is to compare pain associated with the double-dorsal versus a single-volar subcutaneous injection in the provision of digital anaesthesia for finger injuries presenting to the ED. A randomised controlled trial from November 2012 to January 2014 at a single adult tertiary-referral hospital. ED patients with finger injuries requiring digital anaesthesia was randomised to either the double-dorsal or a single-volar subcutaneous injection technique. The primary outcome was patient reported injection pain measured on a 100 mm visual analogue scale with the assessor blinded to the injection technique. The secondary outcome was success of anaesthesia defined as ability to perform the assessment and treatment without further anaesthetic supplementation after 5 min. Eighty-six patients were enrolled. Median (IQR) age was 34 (24-47) years and 79% were men. The majority (66.3%) had distal phalanx injuries. Forty patients were randomised to the double-dorsal and 46 to a single-volar subcutaneous injection technique. The mean (standard deviation) pain score of the double-dorsal injection was 39.1 (24.2) and a single-volar injection was 37.3 (24.5) with a difference of 1.8 (95% CI -8.8 to 12.3). Digital anaesthesia was successful in 64.9% of the double-dorsal and 71.7% of the single-volar subcutaneous injections, a difference of 6.8% (95% CI -12.7 to 26.3). In ED patients with finger injuries requiring digital anaesthesia, both the double-dorsal or single-volar subcutaneous injection techniques have similar pain of injection and success rates of anaesthesia. Single-volar injection appears suitable alternative to the commonly performed double-dorsal injection in the ED.
Publisher: Wiley
Date: 21-06-2015
Publisher: Elsevier BV
Date: 09-1994
DOI: 10.1016/0020-1383(94)90284-4
Abstract: miR-1284 has been reported to inhibit tumor growth in some human cancers, including lung cancer, ovarian cancer, and gastric cancer. Whether it regulates breast cancer progression remains elusive. In this study, we found that miR-1284 was downregulated in breast cancer tissues and cell lines compared to normal control cells. Moreover, we showed that overexpression of miR-1284 significantly inhibited the proliferation, migration, and invasion of breast cancer cells while promoting apoptosis. In terms of mechanism, we found that transcription factor ZIC2 was a target of miR-1284 in breast cancer cells. Through the luciferase reporter assay, we demonstrated their direct interaction. RT-qPCR and Western blot also indicated that miR-1284 overexpression inhibited the protein levels of ZIC2 in breast cancer cells. Moreover, we found that ZIC2 knockdown inhibited the proliferation, migration, and invasion of breast cancer cells, whereas restoration of ZIC2 reversed the effects of miR-1284 on breast cancer cells. Taken together, our findings demonstrated that miR-1284 suppressed the proliferation, migration, and invasion of breast cancer cells via targeting ZIC2, which provided a new insight on the development of therapeutic targets for breast cancer treatment.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Publisher: Wiley
Date: 12-2001
DOI: 10.1046/J.1035-6851.2001.00259.X
Abstract: To describe and analyse the study design and manuscript deficiencies in original research articles submitted to Emergency Medicine. This was a retrospective, analytical study. Articles were enrolled if the reports of the Section Editor and two reviewers were available. Data were extracted from these reports only. Outcome measures were the mean number and nature of the deficiencies and the mean reviewers' assessment score. Fifty-seven articles were evaluated (28 accepted for publication, 19 rejected, 10 pending revision). The mean (+/- SD) number of deficiencies was 18.1 +/- 6.9, 16.4 +/- 6.5 and 18.4 +/- 6.7 for all articles, articles accepted for publication and articles rejected, respectively (P = 0.31 between accepted and rejected articles). The mean assessment scores (0-10) were 5.5 +/- 1.5, 5.9 +/- 1.5 and 4.7 +/- 1.4 for all articles, articles accepted for publication and articles rejected, respectively. Accepted articles had a significantly higher assessment score than rejected articles (P = 0.006). For each group, there was a negative correlation between the number of deficiencies and the mean assessment score (P > 0.05). Significantly more rejected articles ' em leader did not further our knowledge' (P = 0.0014) and ' em leader did not describe background information adequately' (P = 0.049). Many rejected articles had ' em leader findings that were not clinically or socially significant' (P = 0.07). Common deficiencies among all articles included ambiguity of the methods (77%) and results (68%), conclusions not warranted by the data (72%), poor referencing (56%), inadequate study design description (51%), unclear tables (49%), an overly long discussion (49%), limitations of the study not described (51%), inadequate definition of terms (49%) and subject selection bias (40%). Researchers should undertake studies that are likely to further our knowledge and be clinically or socially significant. Deficiencies in manuscript preparation are more frequent than mistakes in study design and execution. Specific training or assistance in manuscript preparation is indicated.
Publisher: Wiley
Date: 10-2017
Abstract: Your department has had a good track record over many years for preparing trainees to successfully sit for the ACEM Fellowship exam. On average the pass rate for your trainees is over 80%. Then, to your dismay, suddenly only two of five of your trainees pass the latest Fellowship exam. Does this anomaly necessitate an urgent review of your department's training programme, or is it just a statistical quirk? Let us suppose you can prepare candidates so that they all have at least an 80% chance of passing. The probability that all five candidates would have passed is 32.8% (or 0.8
Publisher: BMJ
Date: 11-2004
Publisher: Oxford University Press (OUP)
Date: 08-1993
Publisher: Springer Science and Business Media LLC
Date: 26-01-2011
Publisher: SAGE Publications
Date: 25-07-2015
Abstract: CARING is a screening tool developed to identify patients who have a high likelihood of death in 1 year. This study sought to validate a modified CARING tool (termed PREDICT) using a population of patients presenting to the Emergency Department. In total, 1000 patients aged over 55 years who were admitted to hospital via the Emergency Department between January and June 2009 were eligible for inclusion in this study. Data on the six prognostic indicators comprising PREDICT were obtained retrospectively from patient records. One-year mortality data were obtained from the State Death Registry. Weights were applied to each PREDICT criterion, and its final score ranged from 0 to 44. Receiver operator characteristic analyses and diagnostic accuracy statistics were used to assess the accuracy of PREDICT in identifying 1-year mortality. The s le comprised 976 patients with a median (interquartile range) age of 71 years (62–81 years) and a 1-year mortality of 23.4%. In total, 50% had ≥1 PREDICT criteria with a 1-year mortality of 40.4%. Receiver operator characteristic analysis gave an area under the curve of 0.86 (95% confidence interval: 0.83–0.89). Using a cut-off of 13 points, PREDICT had a 95.3% (95% confidence interval: 93.6–96.6) specificity and 53.9% (95% confidence interval: 47.5–60.3) sensitivity for predicting 1-year mortality. PREDICT was simpler than the CARING criteria and identified 158 patients per 1000 admitted who could benefit from advance care planning. PREDICT was successfully applied to the Australian healthcare system with findings similar to the original CARING study conducted in the United States. This tool could improve end-of-life care by identifying who should have advance care planning or an advance healthcare directive.
Publisher: Wiley
Date: 02-2010
DOI: 10.1111/J.1742-6723.2010.01256.X
Abstract: Patients with chest discomfort or other symptoms suggestive of acute coronary syndrome are one of the most common categories seen in many Emergency Departments (EDs). Although the recognition of patients at high risk of acute coronary syndrome has improved steadily, identifying the majority of chest pain presentations who fall into the low-risk group remains a challenge. Research in this area needs to be transparent, robust, applicable to all hospitals from large tertiary centres to rural and remote sites, and to allow direct comparison between different studies with minimum patient spectrum bias. A standardized approach to the research framework using a common language for data definitions must be adopted to achieve this. The aim was to create a common framework for a standardized data definitions set that would allow maximum value when extrapolating research findings both within Australasian ED practice, and across similar populations worldwide. Therefore a comprehensive data definitions set for the investigation of non-traumatic chest pain patients with possible acute coronary syndrome was developed, specifically for use in the ED setting. This standardized data definitions set will facilitate 'knowledge translation' by allowing extrapolation of useful findings into the real-life practice of emergency medicine.
Publisher: Wiley
Date: 14-11-2007
Publisher: CSIRO Publishing
Date: 2008
DOI: 10.1071/RJ07048
Abstract: There is a continuing policy debate about whether it is possible to have sustainable small settlements in outback regions of Australia, where there is low and variable primary production and a sparse and mobile population. This debate is focused largely on Aboriginal settlements, but applies equally to all desert dwellers. In this contribution, we review the sources of economic flows through settlements occupied by different communities with common livelihood sources, whether based on mining, grazing, tourism, cultural resources, welfare or services, concluding that most desert livelihoods depend directly or indirectly on temporally variable inputs. In idual remote settlements tend to be dominated by one such ‘community of livelihood’, and differ in nature according to the source of that livelihood. These create types of settlement and service aspirations which are alien to more densely settled regions. Settlement ‘viability’ is a measure of the short-term balance between aspirations for services (technical, social, but also for livelihoods and well being) and the costs of fulfilling these aspirations, and consequently is not a simple on/off switch – the community can adjust both its aspirations and the cost factors involved in meeting them. We define a resilient settlement as one that is viable in the long term in the face of its variable inputs. Thus, we determine that the concepts of settlement viability and resilience must be analysed differently according to the strategy adopted by different resident communities. In particular, Aboriginal (and pastoral) communities are particularly dependent on social and natural capital, yet these are not monitored. The whole analysis emphasises the importance of taking a demand- rather than supply-driven approach to services in desert settlements. Our conclusion is that, if top-down solutions continue to be imposed without appreciating the fundamental drivers of settlement in desert regions, then those solutions will continue to be partial, and ineffective in the long term.
Publisher: Wiley
Date: 09-2002
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2015
Publisher: Elsevier BV
Date: 11-2001
Abstract: There are few data on the incidence, clinical features, and management of patients with acute anaphylaxis presenting to the emergency department. We investigated all presentations to one department during the course of a year to improve current awareness of this medical emergency. The purpose of the study was to describe the clinical features, management, and outcome of anaphylaxis presentations to a single Australian adult emergency department in a single year, 1998-1999. This was a retrospective, case-based study of adult patients (>or=13 years of age) attending a single emergency department in Brisbane, Australia, during the year 1998-1999. The medical records of 304 patients satisfying the relevant discharge diagnostic codes were studied. We determined incidence, sex ratio, age, clinical features, management, disposal, asthma prevalence, and causes in patients presenting with acute allergic reactions and anaphylaxis. In all, 162 emergency department patients with acute allergic reactions and 142 emergency department patients with anaphylaxis, including 60 whose anaphylaxis was severe, were seen during the year, for an anaphylaxis presentation incidence of 1 in 439. One patient died this gave a case fatality rate of 0.70%. Cutaneous features were present in 94% of the patients with anaphylaxis. Of those with severe anaphylaxis, 35% had dizziness/syncope before hospital presentation, 25% laryngeal edema, and 21.7% systolic hypotension on hospital presentation. A cause was recognized in 73% of the anaphylaxis cases most commonly, the causative agent was a drug, insect venom, or food. Adrenaline was used in 57% of the severe cases before hospital presentation or in the hospital. The emergency department alone definitively cared for 94% of all patients, though only 43% severe anaphylaxis cases were referred for follow-up. The emergency department anaphylaxis presentation incidence of 1 in 439 cases is greater than previously recognized, though death remains rare. In three fourths of cases, a precipitant was identified, a fact that emphasizes the need for a detailed initial history. Definitive management in the emergency department alone is possible in most cases, provided that the appropriate use of adrenaline and the need for allergy clinic follow-up are appreciated.
Publisher: Wiley
Date: 10-2010
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.ANNEMERGMED.2014.01.023
Abstract: We assess the sensitivity and specificity of xanthochromia as adjudicated by visual inspection and spectrophotometry at predicting the presence of cerebral aneurysm in patients with suspected subarachnoid hemorrhage who have a normal computed tomography (CT) head scan result. A systematic review was performed. MEDLINE and EMBASE databases were searched. Relevant studies with clinical data on the diagnostic accuracy of visual inspection or spectrophotometry were considered. Patients who had a normal CT head scan result followed by a lumbar puncture were included in this review. Sensitivities, specificities, and heterogeneity (I(2)) were calculated. Subgroup analyses were performed to explore reasons for the heterogeneity. There were major methodological limitations in the studies found. Twenty-two relevant articles were heterogeneous in regard to time to lumbar puncture, spectrophotometry methods, and follow-up of patients not undergoing cerebral angiography. Twelve of the 22 studies selected patients on the basis of a cerebral aneurysm or subarachnoid hemorrhage on imaging, or a positive lumbar puncture result. These studies were excluded from our initial analysis, which included only patients with clinically suspected subarachnoid hemorrhage. In this initial analysis, pooled estimates of sensitivity and specificity for spectrophotometry were 87% (95% confidence interval [CI] 71% to 96% I(2)=26%) and 86% (95% CI 84% to 88% I(2)=96%), respectively. For visual inspection, pooled sensitivity and specificity were 83% (95% CI 59% to 96% I(2)=52%) and 96% (95% CI 93% to 97% I(2)=76%), respectively. Sensitivity estimates are difficult to interpret without knowing time to lumbar puncture. The heterogeneity in the underlying studies, combined with significant overlap in pooled confidence limits, makes it impossible to provide a definite conclusion about the diagnostic accuracy of spectrophotometry versus visual inspection.
Publisher: Wiley
Date: 28-04-2015
Publisher: Wiley
Date: 04-2009
DOI: 10.1111/J.1553-2712.2009.00360.X
Abstract: The objective was to investigate the efficacy of magnesium sulfate (MgSO4) in decreasing the ventricular rate in emergency department (ED) patients presenting with new-onset, rapid atrial fibrillation (AF). A double-blinded, placebo-controlled randomized clinical trial was conducted in an adult university hospital. Patients aged > or =18 years with AF onset of less than 48 hours and a sustained ventricular rate of >100 beats/min were randomized to either intravenous (IV) MgSO4 10 mmol or normal saline (NSal). Rhythm and instantaneous heart rate as measured by the monitor were recorded at baseline and every 15 minutes for 2 hours after starting the trial drug. Heart rate and rhythm were compared at 2 hours. A multilevel modeling analysis was performed to adjust for differences in baseline heart rate and any additional treatment and to examine changes in heart rate over time. Twenty-four patients were randomized to MgSO4 and 24 to NSal. Baseline heart rate was lower in the MgSO4 group (mean +/- standard deviation [+/-SD] = 125 +/- 24 vs. 140 +/- 21 beats/min]. One and 3 patients in the MgSO4 and NSal groups, respectively, were given another antiarrhythmic or were electrically cardioverted within 2 hours after starting the trial drug. Heart rate (mean +/- SD) at 2 hours in both MgSO4 (116 +/- 30 beats/min) and NSal groups (114 +/- 31 beats/min) decreased below their respective baseline levels. However, the rate of heart rate decrease across time did not differ between groups (p = 0.124). The proportion of patients who converted to sinus rhythm 2 hours post-trial drug did not differ (MgSO4 8.7% vs. NSal 25.0%, p = 0.25). This study was unable to demonstrate a difference between IV MgSO4 10 mmol and saline placebo for reducing heart rate or conversion to sinus rhythm at 2 hours posttreatment in ED patients with AF of less than 48 hours duration.
Publisher: Wiley
Date: 12-2012
Abstract: To compare cardiac risk stratification using a 0 and 2 h point-of-care (POC) cardiac troponin (cTn), 0 and 2 h POC multi-biomarkers against the 0 and 6 h laboratory cTn reference standard. A prospective observational study of ED patients presenting with chest pain was performed. Patients were risk stratified and treated as per the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (HF-A/CS-ANZ) guidelines using the 0 and 6 h laboratory cTn (T6). Patients were further stratified using a 0 and 2 h POC cTn (T2) plus 0 and 2 h POC multi-biomarkers (cTn, creatine kinase-MB, myoglobin) (M2). The T6, T2 and M2 strategies were compared using the 30-day major adverse cardiac events as the primary outcome. Seven hundred and four patients (median age 54 years, male 62.1%) were enrolled. Using the T6 reference standard, 2%, 61% and 37% were stratified as low, intermediate and high risk, respectively. The 30-day event rates were 0%, 3.5% and 28.6%, respectively. The T2 strategy stratified 1.5%, 57% and 41% as low, intermediate and high risk, respectively, with 30-day event rates of 0%, 4.2% and 24.8%, respectively. The M2 strategy resulted in significantly different risk distribution with 1%, 40% and 59% stratified as low, intermediate and high risk, respectively, with 30-day event rates of 0%, 3.9% and 18.8%, respectively. Using a 2 h POC cTn-only biomarker strategy with the HF-A/CS-ANZ guidelines accurately identified a population at intermediate risk of 30-day events in whom further objective testing might be accelerated, allowing subsequent early discharge of the majority of this cohort. Within 2 h of presentation a high risk population could be identified in whom early management, including admission, was required.
Publisher: Walter de Gruyter GmbH
Date: 2014
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.CHEST.2016.10.057
Abstract: A proposed revision of sepsis definitions has abandoned the systemic inflammatory response syndrome (SIRS), defined organ dysfunction as an increase in total Sequential Organ Function Assessment (SOFA) score of ≥ 2, and conceived "qSOFA" (quick SOFA) as a bedside indicator of organ dysfunction. We aimed to (1) determine the prognostic impact of SIRS, (2) compare the diagnostic accuracy of SIRS and qSOFA for organ dysfunction, and (3) compare standard (Sepsis-2) and revised (Sepsis-3) definitions for organ dysfunction in ED patients with infection. Consecutive ED patients admitted with presumed infection were prospectively enrolled over 3 years. Sufficient observational data were collected to calculate SIRS, qSOFA, SOFA, comorbidity, and mortality. We enrolled 8,871 patients, with SIRS present in 4,176 (47.1%). SIRS was associated with increased risk of organ dysfunction (relative risk [RR] 3.5) and mortality in patients without organ dysfunction (OR 3.2). SIRS and qSOFA showed similar discrimination for organ dysfunction (area under the receiver operating characteristic curve, 0.72 vs 0.73). qSOFA was specific but poorly sensitive for organ dysfunction (96.1% and 29.7%, respectively). Mortality for patients with organ dysfunction was similar for Sepsis-2 and Sepsis-3 (12.5% and 11.4%, respectively), although 29% of patients with Sepsis-3 organ dysfunction did not meet Sepsis-2 criteria. Increasing numbers of Sepsis-2 organ system dysfunctions were associated with greater mortality. SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. A qSOFA score ≥ 2 showed high specificity, but poor sensitivity may limit utility as a bedside screening method. Although mortality for organ dysfunction was comparable between Sepsis-2 and Sepsis-3, more prognostic and clinical information is conveyed using Sepsis-2 regarding number and type of organ dysfunctions. The SOFA score may require recalibration.
Publisher: Wiley
Date: 08-2011
Publisher: BMJ
Date: 24-05-2005
Publisher: BMJ
Date: 28-01-2015
DOI: 10.1136/EMERMED-2013-203191
Abstract: The objective of this study was to compare the triage category assigned to older trauma patients with younger trauma patients upon arrival to the emergency department. The focus was to examine whether older major trauma patients were less likely to be assigned an emergency triage category on arrival to the emergency department after controlling for relevant demographics, injury characteristics and injury severity. This was an observational study using data from the Queensland Trauma Registry. All trauma patients aged 15 years and older who presented to contributing hospitals between 1 January 2005 and 31 December 2009 with an Injury Severity Score (ISS)>15 were included. Logistic regression analysis examined the odds of assignment to emergency (Australasian Triage Scale (ATS) 1 or 2) versus urgent (ATS 3-5) treatment for patients across various age categories after adjustment for relevant demographics, injury characteristics and injury severity. The study used data on 6923 patients with a median (IQR) age of 43 (26-62) years and a mortality of 11.4% (95% CI 10.7% to 12.2%). Compared with in iduals aged 15-34, the adjusted odds of being assigned an ATS category 1 or 2 were 30% lower (OR=0.68, 95% CI 0.57 to 0.81) for in iduals aged 55-75 years and were 50% lower (OR=0.46, 95% CI 0.37 to 0.56) for in iduals aged 75 years or older. Among patients with an ISS>15, older major trauma patients were less likely to be assigned an emergency triage category compared with younger patients. This suggests that the elderly may be undertriaged and provides a potential area of study for reducing mortality and morbidity in older trauma patients.
Publisher: Elsevier BV
Date: 03-2010
DOI: 10.1016/J.MCNA.2010.01.010
Abstract: Much of the focus of research on patients with chest pain is directed at technological advances in the diagnosis and management of acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic dissection (AAD), despite there being no significant difference at 4 years as regards mortality, ongoing chest pain, and quality of life between patients presenting to the emergency department with noncardiac chest pain and those with cardiac chest pain. This article examines future developments in the diagnosis and management of patients with suspected ACS, PE, AAD, gastrointestinal disease, and musculoskeletal chest pain.
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.HLC.2013.11.003
Abstract: Risk stratification processes for patients with possible acute coronary syndrome (ACS) recommend the use of serial sensitive troponin testing over at least 6h. Troponin assays vary in their analytical performance. Utility in accurate risk stratification at 2h post-presentation is unknown. A diagnostic accuracy study of patients presenting to the emergency department (ED) with symptoms of ACS was performed. Troponin was measured at 0, 2 and 6h post-presentation. Acute myocardial infarction (AMI) was adjudicated by cardiologists and incorporated the 0 and 6h troponin values measured by a sensitive troponin assay. Results were described using standard measures of test accuracy. Of the 685 patients, 51 (7.4%) had 30-day AMI or cardiac death, and 76 (11.1%) had secondary outcomes (all cause death, ACS and revascularisation procedures). There was no significant difference in the diagnostic accuracy of early versus late biomarker strategies when used with the current risk stratification processes. Incorporation of a significant delta did not improve the stratification at 2h post-presentation. Accelerated risk stratification of patients with ACS symptoms may occur at 2h post-presentation using troponin results measured by a sensitive assay. Incorporation of such a strategy could support improvements in patient flow within EDs.
Publisher: Institute of Electrical and Electronics Engineers (IEEE)
Date: 10-2018
Publisher: Elsevier BV
Date: 09-2015
DOI: 10.1016/J.HLC.2015.03.025
Abstract: To assess the utility of routine exercise stress testing (EST) in patients at intermediate risk of acute coronary syndrome (ACS) according to the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (HFA/CSANZ) guidelines. Prospective observational study of patients presenting to the Emergency Department (ED) with chest pain suggestive of ACS between November 2008 and July 2014. Participants included 1205 patients who presented to the ED with chest pain suggestive of ACS and who met the HFA/CSANZ intermediate risk criteria. The outcome was diagnosis of ACS occurring on presentation or within 30 days of presentation to the ED. ACS included acute myocardial infarction and unstable angina pectoris. Twenty (1.66%) of the intermediate risk patients were diagnosed with ACS. Of the 777 patients who underwent EST, eight had ACS. EST identified all ACS cases except for one patient with a negative test, who was ultimately diagnosed with ACS following angiography. 164 patients deemed inappropriate to undergo EST underwent an alternative form of objective testing, of which 12 were positive for ACS. 264 patients underwent no objective testing. EST stratifies intermediate risk patients to a near zero short-term risk of ACS. However, the overall yield of EST within this group of patients is extremely low. Intermediate risk patients with normal zero and six hour biomarkers have a very low probability of ACS, and over half of these patients ultimately diagnosed with ACS in this group were deemed unsuitable for EST anyway. Future research should focus on the identification of patients who do not require EST and the inclusion of routine EST within the HFA/CSANZ guidelines should be reconsidered.
Publisher: AMPCo
Date: 02-2014
DOI: 10.5694/MJA13.10466
Abstract: To validate an accelerated biomarker strategy using a high-sensitivity cardiac troponin T (hs-cTnT) assay for diagnosing acute myocardial infarction (AMI) in patients presenting to the emergency department with chest pain and to validate this strategy in combination with the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand risk stratification model. Single-centre, prospective, observational cohort study of 764 adults presenting to a tertiary hospital with symptoms of possible acute coronary syndrome between November 2008 and February 2011. AMI or cardiac death within 24 hours of presentation (primary), and major adverse cardiac events within 30 days (secondary). An elevated hs-cTnT assay result above the 99th percentile at either the 0 h or 2 h time points had sensitivity of 96.4% (95% CI, 87.9%-99.0%), specificity of 82.6% (95% CI, 79.7%-85.2%), negative predictive value of 99.7% (95% CI, 98.8%-99.9%) and positive predictive value of 30.5% (95% CI, 24.2%-37.6%) for diagnosing AMI. Compared with a traditional 6 h cardiac troponin testing strategy, the accelerated strategy led to reclassification of risk in only two patients with adverse cardiac outcomes, with no net effect on appropriate management. In patients presenting with chest pain, an accelerated biomarker strategy using the hs-cTnT assay performed well in the initial diagnosis of AMI. The accelerated strategy was also effective when incorporated into a comprehensive strategy of risk stratification that included clinical and demographic factors. The time saved by this approach could have a major impact on health service delivery. Australian New Zealand Clinical Trials Registry ACTRN12610000053022.
Publisher: Elsevier BV
Date: 10-2013
DOI: 10.1016/J.IJCARD.2013.03.044
Abstract: In patients presenting to the Emergency Department (ED) with potential acute myocardial infarction (AMI), elevated cardiac troponin (cTn) levels are indicative of myocardial necrosis. We assessed the accuracy of 'delta cTn' at 2h or 6h compared to the cTn concentration above the 99th percentile reference value for AMI in a prospective study of adult patients presenting to ED with symptoms suggestive of possible acute coronary syndrome. Blood was s led for cardiac troponin I (cTnI) on presentation, and at 2h and 6h following presentation using a sensitive assay (Beckman AccuTnI). All clinical endpoints were adjudicated by a cardiologist who was blinded to the 2h cTn assay result. Of the 874 patients, 70 (8%) were diagnosed with an AMI during their index presentation. The area under the ROC curve for diagnosing AMI at 2h was 0.89 [95%CI, 0.84-0.95] for absolute delta cTn versus 0.79 [95%CI 0.73-0.85] for the relative change. Specificity and PPV at 2h were optimized using a delta cTnI ≥ 0.03 μg/L (95.8% [95%CI 94.1-97.0] and 61.4% [95%CI 50.9-70.9] respectively). Sensitivity and NPV for AMI were optimized using the 99th percentile with the addition of a delta of<0.03 μg/L (97.1% [95%CI 90.2-99.2] and 99.7% [95%CI 99-99.9] respectively). An algorithm incorporating cTnI concentration and delta cTn values with a sensitive troponin assay allows accurate diagnosis of AMI within 2h from presentation and earlier rule-out of AMI in the majority of patients.
Publisher: Elsevier BV
Date: 04-2014
DOI: 10.1016/J.CLINBIOCHEM.2013.11.019
Abstract: Concentrations of troponin measured with high sensitivity troponin assays are raised in a number of emergency department (ED) patients however many are not diagnosed with acute myocardial infarction (AMI). Clinical comparisons between the early use (2h after presentation) of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) assays for the diagnosis of AMI have not been reported. Early (0 h and 2 h) hs-cTnT and hs-cTnI assay results in 1571 ED patients with potential acute coronary syndrome (ACS) without ST elevation on electrocardiograph (ECG) were evaluated. The primary outcome was diagnosis of index AMI adjudicated by cardiologists using the local cTnI assay results taken ≥6 h after presentation, ECGs and clinical information. Stored s les were later analysed with hs-cTnT and hs-cTnI assays. The ROC analysis for AMI (204 patients 13.0%) for hs-cTnT and hs-cTnI after 2h was 0.95 (95% CI: 0.94-0.97) and 0.98 (95% CI: 0.97-0.99) respectively. The sensitivity, specificity, PLR, and NLR of hs-cTnT and hs-cTnI for AMI after 2h were 94.1% (95% CI: 90.0-96.6) and 95.6% (95% CI: 91.8-97.7), 79.0% (95% CI: 76.8-81.1) and 92.5% (95% CI: 90.9-93.7), 4.48 (95% CI: 4.02-5.00) and 12.86 (95% CI: 10.51-15.31), and 0.07 (95% CI: 0.04-0.13) and 0.05 (95% CI:0.03-0.09) respectively. Exclusion of AMI 2h after presentation in emergency patients with possible ACS can be achieved using hs-cTnT or hs-cTnI assays. Significant differences in specificity of these assays are relevant and if using the hs-cTnT assay, further clinical assessment in a larger proportion of patients would be required.
Publisher: Elsevier BV
Date: 07-2013
DOI: 10.1016/J.ANNEMERGMED.2013.01.011
Abstract: This study seeks to examine whether the finding of an abnormal estimated glomerular filtration rate (eGFR) in the emergency department (ED) was associated with acute coronary syndrome in the population of patients presenting for investigation of chest pain. We used prospectively collected data on adult patients presenting with suspected acute coronary syndrome to 2 EDs in Australia and New Zealand. Trained research nurses collected clinical data with a customized case report form. Creatinine measurements were taken on presentation, and the glomerular filtration rate ([GFR] milliliters per minute per 1.73 m(2)) was estimated with the chronic kidney disease epidemiologic collaboration equation. The primary endpoint was acute coronary syndrome within 30 days of presentation, as adjudicated by cardiologists using standardized guidelines. Logistic regression analyses examined the relationship between eGFR and acute coronary syndrome. Acute coronary syndrome was diagnosed in 421 (21%) of the 1,968 patients recruited. Compared with patients with an eGFR greater than 90 mL/minute per 1.73 m(2), patients with an eGFR between 60 and 90 mL/minute per 1.73 m(2) and patients with an eGFR less than 60 mL/minute per 1.73 m(2) were 1.64 (95% confidence interval 1.10 to 2.44) and 1.70 (95% confidence interval 1.01 to 2.77) times more likely to receive a diagnosis of acute coronary syndrome after controlling for age, sex, hypertension, dyslipidemia, family history of cardiac disease, diabetes, patient history of cardiac disease, cardiac troponin level, and ECG findings. There is an independent association between eGFR and acute coronary syndrome risk in patients presenting to the ED with chest pain this association is independent of age, traditional cardiac risk factors, medical history, troponin level, and ECG findings. Reduced eGFR should be considered an acute coronary syndrome risk factor, and clinicians should maintain high clinical suspicion for acute coronary syndrome in patients with abnormal renal function results regardless of whether they have known kidney disease, traditional acute coronary syndrome risk factors, or abnormal diagnostic test results. Risk stratification tools should include reduced eGFR as a high-risk feature.
Publisher: Wiley
Date: 06-2007
Publisher: Oxford University Press (OUP)
Date: 04-06-2013
DOI: 10.1136/POSTGRADMEDJ-2012-130833
Abstract: To determine whether a pathology request form allowing interns and residents to order only a limited range of laboratory blood tests prior to consultation with a registrar or consultant can reduce test ordering in an emergency department (ED). A prospective before-and-after study in an adult tertiary-referral teaching hospital ED was conducted. A pathology request form with a limited list of permissible tests was implemented for use by junior medical officers. Tests for patients 16 years and older presenting in a 20-week pre-intervention period from 19 January 2009 were compared with those in a corresponding 20-week post-intervention period from 18 January 2010. Main outcome measures were the number and cost of blood tests ordered. 24 652 and 25 576 presentations were analysed in the pre- and post-intervention periods, respectively. The mean number of blood tests ordered per 100 ED presentations fell by 19% from 172 in the pre- to 140 in the post-intervention period (p=0.001). The mean cost of blood tests ordered per 100 ED presentations fell by 17% from $A3177 in the pre- to $A2633 in the post-intervention period (p=0.001). There were falls in the number of coagulation profiles (11.1 vs 4.8/100 patients), C-reactive protein (5.6 vs 2.7/100 patients), erythrocyte sedimentation rate (2.5 vs 1.3/100 patients) and thyroid function tests (2.2 vs 1.6/100 patients). Pathology request forms limiting tests that an intern and resident may order prior to consultation with a registrar or consultant are an effective low maintenance method for reducing laboratory test ordering in the ED that is sustainable over 12 months.
Publisher: Wiley
Date: 12-2012
Publisher: Springer Science and Business Media LLC
Date: 25-07-2014
Publisher: Wiley
Date: 24-11-2009
No related grants have been discovered for Anthony Brown.