Impact of a Negative Evaluation for Underlying Coronary Artery Disease on One-year Resource Utilization for Patients Admitted with Potential Acute Coronary Syndromes

Reduction in emergency department (ED) overcrowding is a major Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiative. One major source of ED overcrowding is patients waiting for telemetry beds. OBJECTIVE: To determine whether, in patients admitted with a potential acute coronary syndrome, a negative evaluation for underlying coronary artery disease would reduce ED and hospital revisits over the subsequent year compared with patients who did not receive an evaluation for underlying coronary artery disease. METHODS: Nine hundred ninety-nine consecutive patients admitted for potential acute coronary syndromes through the ED during a one-year period were screened for inclusion. Patients who had a negative evaluation for underlying coronary disease were compared with patients who were not evaluated for underlying coronary artery disease for subsequent ED visits, hospital admissions, and cardiac resource utilization over the year following the index visit via a health system-wide computerized record review. Patients with positive tests or biomarkers at the index visit were excluded. Each repeat visit was rated as "potentially cardiac" or "noncardiac." Results of echocardiograms, stress tests, and catheterizations and information about in-hospital deaths were obtained. RESULTS: Six hundred ninety-two patients met the inclusion criteria: 556 patients received no evaluation for underlying coronary artery disease, 116 had a negative stress test, and 20 had a negative cardiac catheterization during the index visit. Patients with no evaluation for underlying coronary artery disease and patients with a negative evaluation had similar likelihoods of a repeat ED visit (negative test 39.0% vs. no test 40.3%; p = 0.85) and repeat hospital admission (28.7% vs. 31.5%; p = 0.61). The rates of a potentially cardiac-related ED visit (21.3 vs. 23.4%; p = 0.65) and hospital admission (17.7% vs. 20.7%; p = 0.48) were not significantly different. The two populations had similar utilization rates of echocardiograms, stress tests, and catheterizations (p > 0.70 for all). CONCLUSIONS: For patients admitted to the authors' institution with a potential acute coronary syndrome, there was no association between a negative evaluation for underlying coronary artery disease and overall or potentially cardiac ED visits, admissions, or cardiac resource test utilization over the year following the index visit.     

Meeting Highlights on Psychosis and Schizophrenia: The 3 Annual Chair Summit

The Institute of Medicine report Redesigning Continuing Education in the Health Professions (2010) calls for CME to align learning with health professionals’ needs. To meet that goal, The 3rd Annual Chair Summit, The Master Class for Neuroscience Professional Development, held in Chicago, Illinois (August 2010), brought together chairpersons in psychiatry and neurology to act as expert peer teachers for frontline clinician learners. Faculty and learners collaboratively evaluated evidence, shared ideas and clinical practice challenges, developed individualized clinical strategies, explored the role of the multidisciplinary team, discussed health-system issues, and translated the neuroscience discoveries into patient-centered practice improvements. This third article in the CME-certified companion series, “Meeting Highlights of the 3^rd Annual Chair Summit, The Master Class for Neuroscience Professional Development, 2010,” will analyze plenary and breakout educational sessions on psychosis and schizophrenia genetic research, clinical research, and patient care. Highlights of the important issues related to management of psychosis and extreme or violent situations are discussed. Two clinical case challenges help cement previous learning and encourage readers to consider management options and sketch out patient-centered, tailored treatment plans. Summary points connecting research to clinical practice for each topic are also presented.     

Family physicians' knowledge of malignant melanoma

Background: The incidence and mortality of melanoma have been increasing during the past two decades. Melanoma is relatively easy to detect and, when diagnosed early, is curable.Objective: Our purpose was to assess the baseline knowledge of malignant melanoma among family practitioners and to identify their preferred method of learning new information about the skin.Methods: The design was a randomized survey by mailed questionnaire.Results: More than 50% of physicians stated they lacked confidence in being able to recognize melanoma. Family physicians were well informed on factors affecting prognosis, but knowledge deficits were identified on history, physical examination, and risk factors. The most effective method of learning new information about the skin was hands-on teaching demonstration.Conclusion: Many family physicians are not confident in their ability to recognize melanoma, and knowledge deficits were identified. In addition, some important risk factors were not well recognized. Thus, those at highest risk may not be receiving education on early detection that may help decrease the incidence and mortality of melanoma. (J Am Acad Dermatol 1997;37:953-7.)     

Lack of association of delta-aminolevulinate dehydratase polymorphisms with blood lead levels and hemoglobin in Romanian women from a lead-contaminated region

As part of a project on environmental pollution, this study aimed to evaluate associations between blood lead (BPb) levels, hemoglobin (Hb) content, and single-nucleotide polymorphisms (SNPs) of delta-aminolevulinic acid dehydratase (ALAD) gene in 129 unrelated women from Romania. Five SNPs (rs1805313, rs2228083, rs1805312, rs1800435, rs1139488) were analyzed with respect to haplotype structure and impact on BPb levels and Hb content with proportional odds and analysis of covariance models. Combinations of SNPs were rare (16%). Low haplotype diversity was found with seven haplotypes. One rare haplotype implied the C allele of rs1800435, often referred to as the ALAD2 allele (frequency 8.6%). The putative risk genotype (CC) occurred in only one woman with BPb below 0.5 microg/dl. Median BPb was 4.8 microg/dl and differed markedly by community with a level of 12.5 microg/dl near a mining-spill region. Hb was regular (interquartile range 12.3-13.7 g/dl) and not correlated with BPb, although quantitatively lower in women living near the spill region. No significant associations were found for BPb or Hb with SNPs, haplotypes, or diplotypes. BPb levels were higher in this region than in populations from industrialized countries but without hematotoxic effects. An impact of ALAD2 on BPb or Hb was not seen in these women.     

Variation of the N-acetyltransferase 2 gene in a Romanian and a Kyrgyz population.

As part of a project on environmental disasters in minority populations, this study aimed to evaluate differences in the sequence of N-acetyltransferase 2 (NAT2) as a metabolic susceptibility gene in yet unexplored ethnicities. Eight single nucleotide polymorphisms (SNP) in the NAT2 coding region and a variant in the 3' flanking region were analyzed in 290 unrelated Kyrgyz and 140 unrelated Romanians by SNP-specific PCR analysis. The variants 341C, 481T, and 803G were less and 857A more prevalent in Kyrgyz (P < 0.0001). The variant at site 857 indicates Asian descent. 282C>T and 590G>A showed no significant variation by ethnicity. 364G>A and 411A>T turned out to be monomorphic. Database comparisons of the NAT2 minor allele frequencies support that Romanians belong to Caucasians and Kyrgyz are in between Caucasians and East Asians. The distributions of predicted haplotypes differed significantly between the two ethnicities where the Kyrgyz showed a higher genetic diversity. The haplotype without mutations was more common in Kyrgyz (40.1% in Kyrgyz, 29.3% in Romanians). Accordingly, the imputed slow acetylator phenotype was less prevalent in Kyrgyz (35.2% versus 51.4% in Romanians). We found pronounced ethnic differences in NAT2 genotypes with yet unknown effect on the health risks for environmental or occupational exposures in minority populations.