Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era

This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate “observation zone” even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.     

Calgary-Cambridge会谈指南用于护生治疗性沟通教学实践

目的探讨Calgary-Cambridge会谈指南在护生实习期间治疗性沟通实践教学中的应用效果。方法采用随机数字表将167名实习护生分为实验组(84人)和对照组(83人),实验组按照Calgary-Cambridge会谈指南对护生进行治疗性沟通临床实践指导,包括开始会谈、收集信息、提供访谈结构、建立关系、解释和计划、结束会谈共6个步骤,对照组采用常规沟通指导,实习前后分别采用护生临床沟通能力测评量表进行测评。结果实习结束后,实验组护生沟通能力总分及5个维度(除建立和谐关系维度外)评分显著高于对照组(P0.05,P0.01)。结论在临床实践活动中,采用Calgary-Cambridge会谈指南对护生进行护患沟通技能训练,效果优于常规方法。     

Defunding preoperative histories and physical exams: putting the cart before the evidence?

Objective

Several Canadian health authorities have defunded preoperative cataract history and physical examinations performed by general practitioners. While these authorities suggest that such decisions are evidence-based, we are unaware of reviews addressing this topic, nor have health authorities been forthcoming with evidence used in their decision-making processes. The objective of this study is to perform a comprehensive review of the literature regarding the value of preoperative histories and physical examinations in cataract surgery.

Completion pancreatectomy in the acute management of pancreatic fistula after pancreaticoduodenectomy: a systematic review and qualitative synthesis of the literature

Background

Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula.

Effect of pericardiocentesis on right and left ventricular function and volumes in pericardial effusion

To assess the effects of pericardial effusion on ventricular performance and volumes, electrocardiographically gated blood pool cardiac scintigraphy was performed immediately before and after 14 pericardiocenteses in 10 patients, 7 men and 3 women, aged 28 to 73 years (mean 50). Cardiac tamponade was present in 5 patients. After removal of 140 to 1,100 ml of pericardial fluid (527 ± 305 ml [mean ± standard deviation]), left ventricular (LV) ejection fraction increased from 63 ± 5 to 64 ± 4% (p > 0.05) and right ventricular (RV) ejection fraction decreased from 47 ± 4 to 46 ± 2% (p > 0.05). LV end-diastolic and end-systolic volumes increased (p < 0.01) by 28 and 33%, and RV volumes by 40 and 43%, respectively. There were 8 patients with normal LV function (ejection fraction > 60 %) and 6 patients with subnormal LV function. Changes in ejection fraction were nonsignificant in the 4 subgroups. LV end-diastolic volume changes were more marked (p < 0.01) in patients with cardiac tamponade (+ 56%) than in those without tamponade (+ 17%), and in those with normal LV function (+ 36%) than in those with subnormal LV function (+ 21%). RV end-diastolic volume increased more markedly (p < 0.05) in patients with tamponade (+ 72%) than in those without tamponade (+ 23%), but were similar in patients with normal (+ 38% ) and abnormal (+ 43% ) LV function. After pericardiocentesis, RV volume increased more markedly than did LV volume. Thus, hemodynamic and clinical improvement after pericardiocentesis may be related only to an increase in stroke volume. RV and LV ejection fraction, a measure of myocardial contractility, was not affected significantly by the presence of pericardial effusion, even in those patients who had cardiac tamponade.     

Prediction of Early Adverse Events in Emergency Department Patients With Acute Heart Failure: A Systematic Review

Background

Acute heart failure (AHF) accounts for a substantial proportion of Emergency Department (ED) visits and hospitalizations. Previous studies have shown that emergency physicians' clinical gestalt is not sufficient to stratify patients with AHF into severe and requiring hospitalization vs nonsevere and safe to be discharged. Various prognostic algorithms have been developed to risk-stratify patients with AHF, however there is no consensus as to the best-performing risk assessment tool in the ED.

Reliability and validity of the Danish version of the Calgary Depression Scale for Schizophrenia

Depressive symptoms within the range of schizophrenic syndromes constitute a major diagnostic and therapeutic problem. Earlier research has indicated that available depression scales are not adequate when examining mood disturbances in patients with schizophrenia. We have made an attempt to estimate the reliability and validity of the Danish version of the Calgary Depression Scale for Schizophrenia. The external validity has been analysed in relation to the Major Depression Inventory (MDI). The internal validity has been analysed by using Loevinger's coefficient of homogeneity as the primary statistic. For the inter-observer reliability the intra-class coefficients have been calculated. It was shown that a subscale of the Calgary scale has sufficient reliability and validity.     

The effect of a progestin on gallbladder function in young women

Female sex hormones have been considered to be a risk factor for the development of cholesterol gallstone disease, because of increased cholesterol saturation of bile. Impaired gallbladder function is an additional factor which is suspect but unproved. We investigated gallbladder function in 10 young women on two occasions: first during the follicular phase of the menstrual cycle, when endogenous progesterone is low, and again after the ingestion of medroxyprogesterone acetate, 10 mg/day for 10 days, just prior to the next menstrual period. Another group, 15 young women, was studied during their luteal phase, when endogenous progesterone is high. Gallbladder filling and emptying in response to cholecystokinin (0.02 U/kg-min) was quantitated by ^99mTc-HIDA cholescintigraphy. Gallbladder filling and emptying were no different in women in the follicular phase than in women in the luteal phase of the menstrual cycle. In both menstrual phases, the administration of the exogenous progestin significantly (p < 0.05) reduced the fraction of hepatic bile entering the gallbladder. Gallbladder emptying was also depressed: the total amount ejected was less, the time to empty half the contents was prolonged, and the rate was slower (p < 0.05). Thus, different phases of the normal menstrual cycle do not appear to have any effect on gallbladder function. Administration of an exogenous progestin, however, significantly impairs both gallbladder filling and emptying, factors which could predispose to the formation of cholesterol gallstones.     

Outcome and effect of medical intervention in women experiencing infertility following removal of an ectopic pregnancy

The outcome of pregnancy and the effect of medical intervention were reviewed in patients who had had a previous ectopic pregnancy and a subsequent history of infertility. The case records of 3.650 patients were reviewed. Seventy met the study criteria. Twenty patients either voluntarily withdrew or were discouraged on medical grounds; one conceived. Five of the remainder of the patients conceived prior to laparoscopy. In the other 45 patients, the remaining tube was normal in 13, irreparable in 16, and suitable for surgical repair in 16. To date, among the original patients, there have been 13 live births (18.5%) and two ectopic pregnancies (2.8%). One patient was delivered of a live-born infant subsequent to surgical intervention. The pregnancy outcome in this group of patients is poor. Medical intervention was useful primarily in ruling out other causes of infertility and to provide advice to the couple on future fertility. Medical intervention altered outcome in a very few cases.     

Obsessive-compulsive symptoms in schizophrenia: prevalance and clinical correlates

Obsessive-compulsive symptoms (OCS) have been observed in a substantial proportion of schizophrenic patients. In this study, the rate of occurrence of OCS and obsessive-compulsive disorder (OCD) in schizophrenic patients, and also the interrelationship between OCS and schizophrenic symptoms and depressive symptoms were assessed. A total of 100 subjects with a diagnosis of schizophrenia from the 4th edition of the Diagnostic and Statistical Manual (DSM-IV) were evaluated by the structured and clinical interview for axis-1 DSM-IV disorders-patient edition (SCID-P), the Positive and Negative Syndrome Scale (PANSS), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and the Calgary Depression Rating Scale for Schizophrenia. The prevalance of OCS in individuals meeting criteria for schizophrenia was 64%. A total of 30 of these patients (Y-BOCS total score > or =7) also met the DSM-IV criteria for OCD. The total score on Y-BOCS was significantly correlated with total score on PANSS, Positive-PANSS score, General-PANSS score and total score on Calgary Depression Rating Scale for Schizophrenia. OCS and OCD relatively frequent in schizophrenic patients and OCS are significantly correlated with the severity of psychosis, positive symptoms, and depressive symptoms in schizophrenic patients. These findings provide further evidence for the importance of OCS in schizophrenia.