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Application of High-Sensitivity Troponin in Suspected Myocardial Infarction
Data from 15 international cohorts of patients with suspected acute MI were used to create and validate a risk-assessment tool integrating high-sensitivity troponin I or T at presentation, the change during serial sampling, and the time between samples to estimate the probability of MI on ED presentation and 30-day outcomes.
Journal Article
Evaluation of the diagnostic accuracy of two point-of-care tests for COVID-19 when used in symptomatic patients in community settings in the UK primary care COVID diagnostic accuracy platform trial (RAPTOR-C19)
Point-of-care lateral flow device antigen testing has been used extensively to identify individuals with active SARS-CoV-2 infection in the community. This study aimed to evaluate the diagnostic accuracy of two point-of-care tests (POCTs) for SARS-CoV-2 in routine community care.
Adults and children with symptoms consistent with suspected current COVID-19 infection were prospectively recruited from 19 UK general practices and two COVID-19 testing centres between October 2020 and October 2021. Participants were tested by trained healthcare workers using at least one of two index POCTs (Roche-branded SD Biosensor Standard™ Q SARS-CoV-2 Rapid Antigen Test and/or BD Veritor™ System for Rapid Detection of SARS-CoV-2). The reference standard was laboratory triplex reverse transcription quantitative PCR (RT-PCR) using a combined nasal/oropharyngeal swab. Diagnostic accuracy parameters were estimated, with 95% confidence intervals (CIs), overall, in relation to RT-PCR cycle threshold and in pre-specified subgroups.
Of 663 participants included in the primary analysis, 39.2% (260/663, 95% CI 35.5% to 43.0%) had a positive RT-PCR result. The SD Biosensor POCT had sensitivity 84.0% (178/212, 78.3% to 88.6%) and specificity 98.5% (328/333, 96.5% to 99.5%), and the BD Veritor POCT had sensitivity 76.5% (127/166, 69.3% to 82.7%) and specificity 98.8% (249/252, 96.6% to 99.8%) compared with RT-PCR. Sensitivity of both devices dropped substantially at cycle thresholds ≥30 and in participants more than 7 days after onset of symptoms.
Both POCTs assessed exceed the Medicines and Healthcare products Regulatory Agency target product profile's minimum acceptable specificity of 95%. Confidence intervals for both tests include the minimum acceptable sensitivity of 80%. In symptomatic patients, negative results on these two POCTs do not preclude the possibility of infection. Tests should not be expected to reliably detect disease more than a week after symptom onset, when viral load may be reduced.
ISRCTN142269.
Journal Article
The derivation and validation of the Manchester Acute Coronary Syndrome Electrocardiograph model for the identification of non-ST-elevation myocardial ischaemia in the Emergency Department
AbstractObjectiveAcute coronary syndromes (ACS) are a diagnostic challenge for Emergency Medicine (EM) clinicians. To help clinicians assess patients with non-ST-elevation ACS (NSTEACS), clinical decision aids have been developed, combining clinical history, cardiac troponin and the electrocardiograph (ECG). These models ask the clinician to subjectively assess the ECG variable, introducing reliability issues. We set out to derive an ECG model that would provide an objective measure for ischaemia using non-ST-elevation myocardial infarction (NSTEMI) as the primary outcome. MethodsWe derived an ECG model in a retrospective Emergency Department cohort using logistic regression with a primary outcome of NSTEMI. All patients presented with signs or symptoms suggestive of an ACS. The model was validated in a multi-centre prospective Emergency Department cohort. ResultsDerivation included 1246 patients, 156 (12.5%) had the primary outcome; validation included 1139 patients, 170 (14.9%) had the primary outcome. Derivation demonstrated Sn 25.6% (95% CI 19.0–33.2), Sp 96.3% (95% CI 95.0–97.4), PPV 50.0% (95% CI 40.0–60.0) and NPV 90.1% (95% CI 89.2–90.9). Validation demonstrated Sn 23.5% (95% CI 17.4% to 30.6%), Sp 95.2% (95% CI 93.6% to 96.4%), PPV 46.0% (95% CI 36.6% to 55.7%) and NPV 87.6% (95% CI 86.7% to 88.5%). ConclusionWe have derived and validated an ECG model that is highly specific for NSTEMI and may be suitable for integration into existing clinical decision aids.
Journal Article
Retaining doctors in emergency medicine: an ethnographic study of emergency departments in England
ObjectivesTo gain a deep understanding of factors driving retention in emergency medicine. To understand in detail the day-to-day lived experience of emergency medicine doctors, to identify and explore factors influencing retention, to situate these descriptions within the current educational and health policy contexts and to advance the debate and make policy and practice recommendations.DesignEthnography and semistructured interviews.SettingTwo purposively sampled emergency departments in England, with additional interview participants recruited via social media and relevant stakeholder organisations.Participants41 interview participants comprising 21 emergency physicians across 2 sites, 10 former emergency physicians and 10 stakeholders, with 132 hours of observation over 11 weeks in one emergency department in England.ResultsThree key themes were developed as relevant to the day-to-day lived experience of work in the emergency department, presenting challenges to retention and opportunities for change. First, emergency physicians needed to develop workarounds to mitigate the sensory and material challenges of working in a difficult environment.Second, education influences retention through valuing, fostering competence and entrustment and supporting interdependence. These were primarily observable in the workplace through senior staff prioritising the education of more junior staff.Third, community was important for retention. Linked to education through communities of practice, it was built by brief interpersonal interactions between emergency department workers.Situating these descriptions in current policy contexts identified less than full-time working, portfolio careers and mentorship as retention strategies. Self-rostering and annualisation facilitated these retention strategies.ConclusionsThe emergency department represents a difficult environment with many challenges, yet by focusing on how doctors navigate these difficulties, we can see the way in which retention occurs in everyday practices, and that valuing staff is critical for retention.
Journal Article
The rough guide to Kenya
The Rough Guide to Kenya is the essential travel guide to East Africa's biggest travel destination.
Book
Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for patients with chest pain: a systematic literature review
ObjectiveTo systematically appraise the available evidence to determine the accuracy of decision aids for emergency medical services (EMS) telephone triage of patients with chest pain suspected to be caused by acute coronary syndrome (ACS) or life-threatening conditions.DesignSystematic review.Data sourcesElectronic searches were performed in Embase 1974, Medline 1946 and CINAHL 1937 databases from 3 March 2020 to 4 March 2020.Eligibility criteriaThe review included all types of original studies that included adult patients (>18 years) who called EMS with a primary complaint of chest pain and evaluated dispatch triage priority by telephone. Outcomes of interest were a final diagnosis of ACS, acute myocardial infarction or other life-threatening conditions.Data extraction and synthesisTwo authors independently extracted data on study design, population, study period, outcome and all data for assessment of accuracy, including cross-tabulation of triage priority against the outcomes of interest. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 assessment tool.ResultsSearches identified 553 papers, of which 3 were eligible for inclusion. Those reports described the evaluation of three different prediction models with variation in the variables used to detect ACS. The overall results showed that dispatch triage tools have good sensitivity to detect ACS and life-threatening conditions, even though they are used to triage signs and symptoms rather than diagnosing the patients. On the other hand, prediction models were built to detect ACS and life-threatening conditions, and therefore, prediction models showed better sensitivity and negative predictive value than dispatch triage tools.ConclusionWe have identified three prediction models for telephone triage of patients with chest pain. While they have been found to have greater accuracy than standard EMS dispatch systems, prospective external validation is essential before clinical use is considered.PROSPERO registration numberThis systematic review was pre-registered on the International prospective register of systematic reviews (PROSPERO) database (reference CRD42020171184).
Journal Article