The Thrombolysis in Myocardial Infarction (TIMI) risk score is a 7-item tool derived from trials of patients with unstable angina/non–ST segment elevation myocardial infarction for risk ...stratification with respect to outcomes. It has been retrospectively evaluated in emergency department (ED) patients with potential acute coronary syndrome but has not been prospectively validated in this patient population. To validate the use of the TIMI risk score in the ED, we prospectively assess its potential utility in a broad ED chest pain patient population.
This was a prospective observational cohort study of consecutive ED chest pain patients enrolled from July 2003 until October 2004. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily for admitted patients, and 30-day follow-up was performed on hospitalized and discharged patients. The main outcome was death, acute myocardial infarction, or revascularization as stratified by TIMI risk score at 30 days.
There were 1,481 eligible patient visits; 30-day follow-up was completed on 1,458 (98.4%) patients. Patients had mean age of 53.2±14 years and were 40% men, 66% black, and 30% white. Myocardial infarction occurred in 95 patients. The incidence of each TIMI risk factor was age greater than 65 years 21%, known coronary stenosis 18%, 3 or more risk factors 26%, ST-segment deviation 6%, 2 or more anginal events in the previous 24 hours 33%, aspirin use in the previous 7 days 35%, and elevated markers 6%. The incidence of 30-day death, acute myocardial infarction, and revascularization according to TIMI score is as follows: TIMI 0, 1.7% (95% confidence interval CI 0.42 to 2.95); TIMI 1, 8.2% (95% CI 5.27 to 11.04); TIMI 2, 8.6% (95% CI 5.02 to 12.08); TIMI 3, 16.8% (95% CI 10.91 to 22.62); TIMI 4, 24.6% (95% CI 16.38 to 32.77); TIMI 5, 37.5% (95% CI 21.25 to 53.75); and TIMI 6, 33.3% (95% CI 0 to 100). This relationship was highly significant.
Among ED patients with chest pain, the TIMI risk score does correlate with outcome. However, in our study the TIMI risk score failed to stratify these patients into discrete groups according to risk score. Also, patients with the lowest risk as defined by a TIMI score of zero had a 1.7% incidence of adverse events. Therefore, the TIMI risk score should not be used in isolation to determine disposition of ED chest pain patients.
The purpose of this study was to examine the relationships among B-type natriuretic peptide (BNP) levels within the diagnostic range, perceived congestive heart failure (CHF) severity, clinical ...decision making, and outcomes of the CHF patients presenting to emergency department (ED).
Since BNP correlates with the presence of CHF, disease severity, and prognosis, we hypothesized that BNP levels in the diagnostic range offer value independent of physician decision making with regard to critical outcomes in emergency medicine.
The Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) study was a 10-center trial in which patients seen in the ED with shortness of breath were consented to have BNP levels drawn on arrival. Entrance criteria included a BNP level >100 pg/ml. Physicians were blinded to the actual BNP level and subsequent BNP measurements. Patients were followed up for 90 days after discharge.
Of the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be New York Heart Association (NYHA) functional class III or IV. The BNP levels did not differ significantly between patients who were discharged home from the ED and those admitted (976 vs. 766, p = 0.6). Using logistic regression analysis, an ED doctor's intention to admit or discharge a patient had no influence on 90-day outcomes, while the BNP level was a strong predictor of 90-day outcome. Of admitted patients, 11% had BNP levels <200 pg/ml (66% of which were perceived NYHA functional class III or IV). The 90-day combined event rate (CHF visits or admissions and mortality) in the group of patients admitted with BNP <200 pg/ml and >200 pg/ml was 9% and 29%, respectively (p = 0.006).
In patients presenting to the ED with heart failure, there is a disconnect between the perceived severity of CHF by ED physicians and severity as determined by BNP levels. The BNP levels can predict future outcomes and thus may aid physicians in making triage decisions about whether to admit or discharge patients. Emerging clinical data will help further refine biomarker-guided outpatient therapeutic and monitoring strategies involving BNP.
Contrary to common perception, telehealth is not simply a substitute for in-person care. With an array of modalities-live audio-video, asynchronous patient communication, and remote patient ...monitoring, to name a few-telehealth creates entirely new avenues of care delivery (Table 1). Although our current care model is reactive-relying on episodic visits to an office or hospital-telehealth allows us to be proactive, filling in the gaps to provide a continuum of care. Widespread uptake of telehealth has created fertile ground for long-overdue health system reform. In this study, we describe essential next steps: redefine telehealth clinical appropriateness, evolve payment models, provide necessary training, and reimagine the patient-physician interaction.
The authors previously developed a six-item ordinal wound evaluation scale to measure the short-term cosmetic outcome of wounds 1 week after injury. Although it was never intended to measure ...long-term outcomes, it has been used to assess scars 3 to 12 months after injury. The authors developed and validated a scar evaluation scale specifically aimed at measuring the long-term appearance of scars.
Two plastic surgeons and one emergency physician, blinded to each other's assessments, viewed photographs of 50 scars resulting from lacerations or surgical incisions. Scars were assigned 0 or 1 point each for the presence or absence of the following: width greater than 2 mm, elevation or depression, discoloration, suture or staple marks, and overall poor appearance. A total cosmetic score was then calculated by adding the individual scores on each of the five categories ranging from 0 (worst) to 5 (best). Scars were also scored on a validated 100-mm visual analogue scale marked "worst scar" and "best scar" at the low and high ends, respectively. Pairwise interobserver agreement was calculated.
Interobserver agreement for the total scores on the scar evaluation scale was 0.73, 0.75, and 0.85 (p < 0.001 for all). Interobserver correlations on the visual analogue scale were 0.83, 0.86, and 0.87 (p < 0.001 for all). Correlations between the total scar evaluation scale and visual analogue scale scores were 0.75, 0.86, and 0.92. Visual analogue scale scores were significantly higher as scar evaluation scale scores increased (analysis of variance, p < 0.001).
The authors describe a new long-term scar evaluation scale that is highly reliable and correlated with the cosmetic visual analogue scale, suggesting construct validity.
Objectives
The objective was to compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of “triple rule‐out” (TRO) computed tomography (CT) to other diagnostic ...modalities commonly used to evaluate patients with nontraumatic chest pain (dedicated coronary, pulmonary embolism PE, and aortic dissection CT; invasive coronary angiography; and nuclear stress testing).
Methods
Four electronic databases were searched, along with reference lists and contacted content experts, for relevant studies from inception until October 2012. Eligible studies enrolled patients with nontraumatic chest pain, shortness of breath, suspected acute coronary syndrome (ACS), PE, or aortic dissection; used at least 64‐slice CT technology; and compared TRO CT to another diagnostic modality.
Results
Eleven studies enrolling 3,539 patients (791 TRO and 2,748 non‐TRO) were included (one randomized controlled trial and 10 observational). There was no significant difference in image quality between TRO and dedicated CT scans. TRO CT had the following pooled diagnostic accuracy estimates for coronary artery disease: sensitivity of 94.3% (95% confidence interval CI = 89.1% to 97.5%), specificity of 97.4% (95% CI = 96.1% to 98.4%), positive likelihood ratio (LR+) of 17.71 (95% CI = 3.92 to 79.96), and negative likelihood ratio (LR–) of 0.08 (95% CI = 0.02 to 0.27). There were insufficient numbers of patients with PE or aortic dissection to generate diagnostic accuracy estimates for these conditions. Use of TRO CT involved greater radiation exposure (mean difference MD = 4.84 mSv, 95% CI = 1.65 to 8.04 mSv) and contrast exposure (MD = 38.0 mL, 95% CI = 28.1 to 48.0 mL) compared to non‐TRO CT patients.
Conclusions
Triple rule‐out CT is highly accurate for detecting coronary artery disease. Given the low (<1%) prevalence of PE and aortic dissection in the included studies, and the increased radiation and contrast exposure, there are insufficient data to recommend use of TRO CT in the diagnosis of these conditions.
Resumen
Angiotomografía Computarizada de Triple Descarte para el Dolor Torácico: Una Revisión Sistemática Diagnóstica y Metanálisis
Objetivos
Comparar la calidad de imagen, la certeza diagnóstica, la exposición a radiación y el volumen de contraste de la tomografía computarizada (TC) para “triple descarte” (TD) con otras modalidades diagnósticas utilizadas frecuentemente para evaluar a los pacientes con dolor torácico no traumático (TC dirigida a coronarias, embolismo pulmonar (EP) y disección aórtica; angiografía coronaria invasiva; pruebas de estrés isotópicas).
Metodología
Se buscaron los estudios relevantes publicados hasta octubre de 2012 en cuatro bases de datos electrónicas, en las listas de la bibliografía y en los expertos de contenido contactados. Los estudios elegibles incluyeron pacientes con dolor torácico no traumático, disnea, sospecha de síndrome coronario agudo, EP o disección aórtica; utilizaron TC con tecnología de al menos 64 cortes; y compararon la TC TD con otra modalidad diagnóstica.
Resultados
Se incluyeron once estudios (uno aleatorizado y 10 observacionales) con 3.599 pacientes (791 TD y 2.748 no TD). No hubo diferencias significativas en la calidad de la imagen entre TC TD y los dirigidos. La TC TD tuvo las siguientes estimaciones de certeza diagnóstica para la enfermedad de las arterias coronarias: sensibilidad 94,3% (intervalo de confianza IC 95% = 89,1% a 97,5%), especificidad 97,4% (IC 95% = 96,1% a 98,4%), razón de probabilidad positiva 17,71 (IC 95% = 3,92 a 79,96), y razón de probabilidad negativa 0,08 (IC 95% = 0,02 a 0,27). No hay suficiente número de pacientes con EP o disección aórtica para generar estimaciones de certeza diagnóstica para estas enfermedades. La utilización de la TC TD supuso una mayor exposición a la radiación (diferencia de la media DM 4,84 mSv, IC 95% = 1,65 a 8.04 mSv) y al contraste (DM 38,0 mL, IC 95% = 28,1 a 48,0 mL) en comparación con los pacientes con una TC no TD.
Conclusiones
La TC TD es altamente certera para detectar la enfermedad coronaria. Dada la baja prevalencia (<1%) de EP y de disección aórtica en los estudios incluidos, y el incremento de radiación y exposición a contraste, no hay suficientes datos para recomendar el uso de TC TD en el diagnóstico de estas dos enfermedades.
Millions of people seek emergency department (ED) care for injuries each year, the majority for minor injuries. Little is known about the effect of psychiatric co-morbid disorders that emerge after ...minor injury on functional recovery. This study examined the effect of post-injury depression on return to pre-injury levels of function.
This was a longitudinal cohort study with follow-up at 3, 6 and 12 months post-injury: 275 adults were randomly selected from those presenting to the ED with minor injury; 248 were retained over the post-injury year. Function was measured with the Functional Status Questionnaire (FSQ). Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR disorders (SCID).
During the post-injury year, 18.1% 95% confidence interval (CI) 13.3-22.9 were diagnosed with depression. Adjusting for clinical and demographic covariates, the depressed group was less likely to return to pre-injury levels of activities of daily living odds ratio (OR) 8.37, 95% CI 3.78-18.53 and instrumental activities of daily living (OR 3.25, 95% CI 1.44-7.31), less likely to return to pre-injury work status (OR 2.37, 95% CI 1.04-5.38), and more likely to spend days in bed because of health (OR 2.41, 95% CI 1.15-5.07).
Depression was the most frequent psychiatric diagnosis in the year after minor injury requiring emergency care. Individuals with depression did not return to pre-injury levels of function during the post-injury year.
Objectives:
Patients presenting with chest pain or related symptoms suggestive of myocardial ischemia, without ST‐segment elevation (NSTE) on their presenting electrocardiograms, often present a ...diagnostic challenge in the emergency department (ED). Prompt and accurate risk stratification to identify those patients with NSTE chest pain who are at highest risk for adverse events is essential, however, to optimal management. Although validated and used frequently in patients already enrolled in acute coronary syndrome trials, the Thrombolysis in Myocardial Infarction (TIMI) risk score never has been examined for its value in risk stratification in an all‐comers, non–trial‐based ED chest pain population.
Methods:
An analysis of an ED‐based prospective observational cohort study was conducted in 3,929 adult patients presenting with chest pain syndrome and warranting evaluation with an electrocardiogram. These patients had TIMI risk scores determined at ED presentation. The main outcome was the composite of death, acute myocardial infarction (MI), and revascularization within 30 days.
Results:
The TIMI risk score at ED presentation successfully risk‐stratified this unselected cohort of chest pain patients with respect to 30‐day adverse outcome, with a range from 2.1%, with a score of 0, to 100%, with a score of 7. The highest correlation of an individual TIMI risk indicator to adverse outcome was for elevated cardiac biomarker at admission. Overall, the score had similar performance characteristics to that seen when applied to other databases of patients enrolled in clinical trials and registries using a 14‐day end point.
Conclusions:
The TIMI risk score may be a useful tool for risk stratification of ED patients with chest pain syndrome.
Study objective Coronary computed tomographic (CT) angiography has excellent performance characteristics relative to coronary angiography and exercise or pharmacologic stress testing. We hypothesize ...that coronary CT angiography can identify a cohort of emergency department (ED) patients with a potential acute coronary syndrome who can be safely discharged with a less than 1% risk of 30-day cardiovascular death or nonfatal myocardial infarction. Methods We conducted a prospective cohort study at an urban university hospital ED that enrolled consecutive patients with potential acute coronary syndromes and a low TIMI risk score who presented to the ED with symptoms suggestive of a potential acute coronary syndrome and received a coronary CT angiography. Our intervention was either immediate coronary CT angiography in the ED or after a 9- to 12-hour observation period that included cardiac marker determinations, depending on time of day. The main clinical outcome was 30-day cardiovascular death or nonfatal myocardial infarction. Results Five hundred sixty-eight patients with potential acute coronary syndrome were evaluated: 285 of these received coronary CT angiography immediately in the ED and 283 received coronary CT angiography after a brief observation period. Four hundred seventy-six (84%) were discharged home after coronary CT angiography. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% confidence interval CI 0% to 0.8%) or sustained a nonfatal myocardial infarction (0%; 95% CI 0 to 0.8%). Conclusion ED patients with symptoms concerning for a potential acute coronary syndrome with a low TIMI risk score and a nonischemic initial ECG result can be safely discharged home after a negative coronary CT angiography test result.
Abstract
Objectives. The Duration of Untreated Illness (DUI), defined as the time elapsing between the onset of a disorder and the beginning of the first pharmacological treatment, has been ...increasingly investigated as a predictor of outcome and course across different psychiatric disorders. Purpose of this naturalistic study was to evaluate the influence of DUI on treatment response and remission in a sample of patients with obsessive-compulsive disorder (OCD). Methods. Sixty-six outpatients with a DSM-IV diagnosis of OCD were included in the study. Patients received, according to their clinical conditions, an open pharmacological treatment of 12 weeks and were evaluated by the administration of the Yale Brown Obsessive Compulsive Scale (Y-BOCS) at baseline and endpoint. Treatment response was defined as a decrease .25% on Y-BOCS score compared to baseline, while remission was defined as an endpoint Y-BOCS total score #10. A logistic regression was performed considering DUI as the independent continuous variable and treatment response and remission as the dependent variables. Moreover, the sample was divided into two groups according to a categorical cut-off for the DUI of 24 months and odds ratios (OR) were calculated on the basis of the same variables. Results. DUI, considered as a continuous variable, was not predictive of treatment response (OR51.00, P50.15) nor remission (OR51.00, P50.59). When considered as a categorical variable, however, a DUI # 24 months was predictive of treatment response (OR50.27, P50.03). Conclusions. Results from the present naturalistic study suggest a complicated relationship between DUI and treatment outcome in OCD encouraging further investigation with larger samples in order to better define long versus short DUI in this condition.
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