We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and ...affects time to discharge, health care–related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.
This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.
A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 95% confidence interval {CI} 0.48 to 0.63; odds ratio 0.33 95% CI 0.26 to 0.42; adjusted odds ratio 0.33 95% CI 0.25 to 0.42). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference –20.4 to –11.4); median health care–related costs, from $1,748 to $1,079 (95% CI of difference –$953 to –$391). The number of clinical events was very low.
In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.
Little attention has been paid to tailings from skarn ore deposits and their environmental impact, even though they can contain elevated concentrations of elements of potential concern together with ...sulfides and fluorite. Historical skarn tailings at Yxsjöberg, Sweden, containing e.g. Be, Bi, Cu, F, Sn, S, W, and Zn were geochemically characterized as a first step to evaluate the environmental impact and the potential to re-mine the tailings. The tailings were deposited between 1897 and 1963 in the Smaltjärnen Repository without dams or a complete cover, and have been in contact with the atmosphere for >30 years. Four vertical cores throughout the tailings were taken and divided into 134 subsamples, which were analyzed for total concentrations and paste pH. Selected samples from different depths were mineralogically characterized using optical microscopy, scanning electron microscopy (SEM) with energy dispersive X-ray spectroscopy (EDS), Raman vibrational spectroscopy, and X-ray diffraction (XRD). Minerals, hand-picked from drilled rock cores, were analyzed for the element content, and a modified Element to Mineral Conversion (EMC) that pinpoints the quantitative distribution of elements between the minerals in the tailings was carried out. The average concentrations of Be, Bi, Cu, Sn, Zn, W, F and S in the tailings were 284, 495, 946, 559, 301, and 960 ppm, and 1.9 and 1.2 wt%, respectively. The tailings has reached a late stage development due to pyrrhotite oxidation resulting in low pH (<4) in the uppermost tailings, and formations of secondary minerals such as gypsum, hydrous ferric oxides (HFO) and orthogonal calcite. Secondary pyrite and magnetite, formed from monoclinic pyrrhotite was detected, and different weathering rates of secondary pyrite, hexagonal and monoclinic pyrrhotite was indicated, with secondary pyrite as the most stable and monoclinic pyrrhotite as the least. The rare and easily-weathered mineral danalite (Fe4Be3(SiO4)3S) was found in the drilled rock cores and by XRD in the tailings. However, the mineral could not be found by optical microscopy or SEM-EDS. This suggests that the mineral has been weathered to a great extent, which poses a high risk of releasing elements of potential concern to the groundwater since danalite contains approximately 40% of the total Be and Zn concentrations in the tailings. Fluorine was mainly found in fluorite, Cu in chalcopyrite, and Bi in bismuthinite; which all showed signs of weathering in acidic condition in the uppermost part, subsequent with decreased concentrations, followed by accumulation peaks deeper down in the tailings correlated with Al. Tungsten was mainly found in scheelite; most grains were unweathered, but a few grains had altered rims or HFO on the mineral surfaces. Tin was mainly found in ferrohornblende, hedenbergite and grossular. Beryllium, Cu, F, and Zn has high potential to be released to the surrounding environment from the Smaltjärnen Repository, while W, Bi and Sn are relatively stable in the tailings. Most of the scheelite is intact and re-mining could, therefore, be a suitable remediation method that would both reduce the environmental impact and simultaneously support the supply of critical raw materials in the EU.
•Be, Bi, Cu, F, W and Zn were all affected by pyrrhotite oxidation, calcite depletion, and reduced pH in the skarn tailings.•Different weathering rates of secondary pyrite, hexagonal and monoclinic pyrrhotite were indicated.•The rare and easily-weathered danalite (Fe4Be3(SiO4)3S) poses a high risk of releasing Be and Zn to the groundwater.•Scheelite (CaWO4) grains were found as unaltered grains, grains with yellow rims, and grains with rims of HFO.•Re-mining could reduce the environmental impact and simultaneously support the supply of critical raw materials.
Even though serotonin (5-HT) has been ascribed immunomodulatory features, very little is known about its role in chronic inflammatory diseases. Serotonin is implicated in inflammation and increased ...levels have been associated with progression of bone erosions in RA.
To investigate serum serotonin levels in patients with increased risk of rheumatoid arthritis (RA) and patients with recent-onset disease. Moreover, we aimed to determine the prognostic value of serotonin for arthritis development and the disease course.
Two prospective observational patient cohorts were studied; anti-citrullinated protein antibody (ACPA) -positive patients with musculoskeletal pain without clinical arthritis (
= 82) and patients with early RA (
= 412). Serotonin levels were measured by enzyme-linked immunosorbent assay (ELISA) in baseline serum samples from both cohorts, and longitudinally in at-risk individuals.
Compared to healthy controls (median 65 ng/ml), serotonin levels were significantly higher in both at-risk individuals (median 111 ng/ml,
< 0.0001) and patients with early RA (median 135 ng/ml,
< 0.0001). No significant differences were found between at-risk individuals and patients with early RA. At-risk individuals progressing to arthritis had similar levels as those not progressing, and no significant differences were seen over time. Baseline levels in early RA did not associate with mean 28-joint disease activity scores during 3 years follow-up.
Serum serotonin levels are elevated both at, and prior to, onset of RA. However, increased serotonin is not prognostic for arthritis development or disease course.
The speciation, mobility, transport, and fate of beryllium (Be) in the terrestrial environment is poorly studied even though it is considered to be one of the most hazardous elements in the periodic ...table. Historical tailings containing the unusual mineral danalite Be3(Fe4.4Mn0.95Zn0.4)(SiO4)3.2S1.4 together with Fe-sulfides and fluorite has been stored open to the atmosphere for more than 50y. Environmental mineralogy, which combines geochemical and mineralogical techniques, was used to elucidate the weathering of danalite and fluorite. Danalite is unstable in oxic conditions due to the occurrence of Fe (II) and S-(II) in the crystal lattice and has oxidized at the same pace as pyrrhotite in the tailings. The acidic conditions generated from sulfide oxidation and the release of F from fluorite weathering have most likely enhanced Be mobility in the tailings. Secondary gypsum, hydrous ferric oxides and Al-oxyhydroxides are hypothesized to have played an important role regarding the mobility of Be in the tailings. The results indicate that Be released from danalite was first scavenged by these secondary minerals through co-precipitation. However, the dissolution of secondary gypsum due to changing geochemical conditions has also released Be to the groundwater. The groundwater at the shore of the tailings revealed the highest Be concentrations measured anywhere in the world (average: 4.5 mg/L) even though the water has a circumneutral pH. This extraordinary finding can be explained by high concentrations of F (73 mg/L), as F and Be have been shown to form strong complexes. The weathering of danalite and fluorite will continue for hundreds of years if remediation measures are not taken. Re-mining the tailings could be an appropriate remediation method.
•The unusual mineral danalite releases Be due to oxidation and acidic tailings.•Be has been temporarily scavenged by co-precipitation with secondary gypsum.•The NMD contains one of the highest Be groundwater levels (4.5 mg/L) in the world.•High fluorine levels may explain why Be levels were so high under a circumneutral pH.•Re-mining the Yxsjöberg tailings may be a viable remediation strategy.
To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay.
...The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers.
In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts.
This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.
The History, Electrocardiogram (ECG), Age, Risk factors and Troponin, (HEART) score is useful for early risk stratification in chest pain patients. The aim was to validate previous findings that a ...simplified score using history, ECG and troponin (HET-score) has similar ability to stratify risk.
Patients presenting with chest pain with duration of ≥10 min and an onset of last episode ≤12 h but without ST-segment elevation on ECG at 6 emergency departments were eligible for inclusion. The HEART-score and the simplified HET-score were calculated. The endpoint was a composite of myocardial infarction (MI) as index diagnosis, readmission due to new MI or death within 30 days.
HEART-score identified 32% as low risk (0-2p), 47% as intermediate risk (3-5p), and 20% as high risk (6-10p) patients. The endpoint occurred in 0.5%, 7.3% and 35.7%, respectively. HET-score identified 39%, 42% and 19% as low- (0p), intermediate- (1-2p) and high-risk (3-6p) patients, with the endpoint occurring in 0.6%, 6.2% and 43.2%, respectively.
When all variables included in the HEART-score were included in a multivariable logistic regression analysis, only History (OR, CI 95%): 2.97(2.16–4.09), ECG (1.611.14–2.28) and troponin level (5.213.91–6.95) were significantly associated with cardiovascular events. When HEART- and HET-score were compared in a ROC-analysis, HET-score had a significantly larger AUC (0.887 vs 0.853, p < 0.001).
Compared with HEART-score, HET-score is simpler and appears to have similar ability to discriminate between chest pain patients with and without cardiovascular event.
•HET-score had a similar ability as HEART score in predicting prognosis in the ED•Both among those without and with elevated troponin at presentation, HET-score had a similar ability as HEART-score to stratify individuals risk•The score variable reflecting the troponin level had the strongest association with the risk of cardiovascular event•Age and risk factors were significantly associated with a lower risk of events
Interpretation of geochemical data based primarily on elemental concentrations often lead to ambiguous results due to multiple potential sources including mineral weathering, atmospheric input, ...biological cycling, mineral precipitation and exchange processes. The 87Sr/86Sr ratio is however not fractionated by these processes. In this study, Sr isotope (87Sr/86Sr) ratios have been coupled with chemical data of Sr and Rb-bearing minerals, tailings and leachates (water-soluble) to gain insight into the geochemical processes occurring within the Yxsjöberg Cu-W mine tailings, Sweden. The tailings have been exposed to oxidizing conditions resulting in three geochemical zones namely (i) oxidized, (ii) transition and (iii) unoxidized zones. Leachates from the oxidized zone are acidic (pH = 3.6–4.5) and contain elevated concentrations of metals (e.g. Fe, Cu and Zn) and SO4. The low pH has also led to subsequent weathering of most silicates, releasing Al, Ca, Mg and Na into solution. The 87Sr/86Sr ratio in the tailings ranges from 0.84787 to 1.26640 in the oxidized zone, 0.92660–1.06788 in the transition zone, whilst the unoxidized zone has values between 0.76452 and 1.05169. For the leachates, the 87Sr/86Sr ratio ranges from 2.44479 to 5.87552 in the oxidized zone, 1.37404–1.68844 in the transition zone and 1.03697–2.16340 in the unoxidized zone. Mixing (between mineral weathering and atmospheric sources) was identified as the major process regulating the Sr composition of the tailings and leachates. The highly radiogenic signatures of the leachates in the oxidized zone suggests weathering of biotite, K-feldspar and muscovite. Despite the very radiogenic signatures in the oxidized zone, increments in Ca/K ratios, Be, Ce, Tl, Al, Fe and SO4 concentrations in the water-soluble phase were recorded in its lower parts which suggests the dissolution of amphibole, pyroxene, plagioclase, fluorite, gypsum, Al and Fe –(oxy) hydroxides as well as cation exchange by clay minerals. Presence of clay minerals has led to the partial retainment of radiogenic 87Sr/86Sr resulting in increased 87Sr/86Sr in the solid tailings material at these depths. The 87Sr/86Sr ratios of the water-soluble phase in the transition zone is similar to that of helvine and could indicate its dissolution. In the upper part of the unoxidized zone, the 87Sr/86Sr ratios and trends of Be, Ca, SO4, Tl and Zn in the water-soluble phase suggest the dissolution of gypsum which precipitated from a leachate with the isotopic signature of helvine. In the lower part of the unoxidized zone, elevated concentrations of W were recorded suggesting scheelite weathering. But the 87Sr/86Sr ratios are higher than that expected from dissolution of scheelite and indicates additional processes. Possible sources include biotite weathering and groundwater. This study reveals that when interpreting geochemical processes in mine waste environments, 87Sr/86Sr should be considered in addition to chemical constituents, as this isotopic tracer offers better insights into discriminating between different solute sources.
We aimed to evaluate the diagnostic sensitivity for myocardial infarction (MI) when using an undetectable level of high-sensitivity cardiac troponin T (hs-cTnT < 5 ng/L) at presentation combined with ...a non-ischemic electrocardiogram (ECG), to rule out MI in a non-ST-segment elevation MI (NSTEMI) cohort presenting ≤2 h from symptom onset. We also aimed to compare baseline characteristics and 30-day outcome in NSTEMI patients presenting with and without hs-cTnT < 5 ng/L.
All patients admitted to five centers in Sweden 2011–2015, after the introduction of hs-cTnT, who presented ≤2 h from symptom onset and received a final diagnosis of NSTEMI, were identified through the SWEDEHEART registry. These data and data of hs-cTnT levels were verified in the hospitals' medical records. The registry provided baseline and outcome data.
Twenty-four (2.6%) of 911 NSTEMI patients presented with hs-cTnT < 5 ng/L. In patients presenting >1–≤2 h from symptom onset the sensitivity for MI when combining hs-cTnT and ECG was 99.4% (95% CI 98.4%–99.8%). In patients presenting ≤1 h, and in patients aged ≤65 years without prior MI, the sensitivity was insufficient. NSTEMI patients presenting with hs-cTnT < 5 ng/L were younger and had less often a prior MI. A total of 62.5 vs. 63.5% of the NSTEMI patients presenting with and without hs-cTnT < 5 ng/L underwent revascularization within 30 days and 4.5 and 3.2% died respectively.
Hs-cTnT < 5 ng/L at presentation combined with a non-ischemic ECG may be used to rule out MI in patients presenting as early as >1 h from symptom onset with a sufficient sensitivity.
•High-sensitivity troponin T < 5 ng/L combined with a non-ischemic ECG can rule out NSTEMI.•The rule-out algorithm may be used in the second hour from symptom onset.•Younger patients with no prior myocardial infarction should be assessed with caution.•NSTEMI patients with and without T < 5 ng/L have a similar 30-day outcome.
We aimed to evaluate the use of a 1-hour measurement of high-sensitivity cardiac troponin T (hs-cTnT) in an emergency department (ED) population of chest pain patients with a nonelevated baseline ...hs-cTnT and to examine the prevalence of early dynamic changes in hs-cTnT and the association with admission rate, diagnosis, and outcome.
All patients with a chief complaint of chest pain presenting to the ED of Karolinska University Hospital, Solna, Sweden, from December 2014 to September 2015 who had a baseline hs-cTnT of ≤14 ng/L and a second value obtained within >30 to ≤90 minutes were followed for 30 days regarding admission, readmission, myocardial infarction (MI), and death.
A total of 1091 patients were included. Dynamic 1-hour changes in hs-cTnT defined as an increase or decrease of ≥3 ng/L occurred in 23 patients (2.1%). Fifteen patients (65.2%) in the dynamic group were admitted, compared with 148 patients (13.9%) in the nondynamic group (P < 0.001). Four of the admitted patients (26.7%) in the dynamic and 1 (0.7%) in the nondynamic group were diagnosed with an MI (P < 0.001). No death or MI occurred within 30 days among those discharged from the ED.
Dynamic 1-hour changes in hs-cTnT were uncommon but associated with a higher rate of admission and of MI in an unselected population of chest pain patients with a nonelevated hs-cTnT at presentation. Lack of dynamic changes makes MI highly unlikely, and a 1-hour measurement may facilitate an early rule out of MI but should be used together with clinical assessment.
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