Can a modified thrombolysis in myocardial infarction risk score outperform the original for risk stratifying emergency department patients with chest pain?

BACKGROUND

The thrombolysis in myocardial infarction (TIMI) risk score has been shown to risk stratify patients with suspected acute coronary syndromes (ACS) effectively in the emergency department (ED) but cannot be used to guide patient disposition. We aimed to evaluate whether modifying the TIMI risk score to give greater weighting to ischaemic ECG changes and troponin elevations would enhance its risk stratification and thus potentially facilitate safe patient discharge after 12-h troponin testing.

METHODS

A prospective diagnostic cohort study was performed within the ED at Manchester Royal Infirmary, a university-affiliated teaching hospital with an annual ED census of approximately 145,000 patients. 804 patients who had presented to the ED with suspected cardiac chest pain were recruited. All patients underwent 12-h troponin T testing and were followed up by telephone and chart review after 30 days for the composite primary outcome of death, acute myocardial infarction (AMI) or urgent coronary revascularisation.

RESULTS

The modified TIMI risk score outperformed the original (area under the receiver operator characteristic curve 0.87 versus 0.77, p<0.001). Using a cut-off of more than 2 points the score had a sensitivity of 96.4% for the prediction of 30-day events. The specificity of the score was only 51.0%, suggesting that in practice over 40% of patients would be ineligible for discharge even after troponin testing.

CONCLUSIONS

Modifications to the TIMI risk score can improve its performance in the risk stratification of patients presenting to the ED with chest pain. However, a lack of specificity may still limit its use for guiding patient disposition after troponin testing.

Behandlung einer Radiusfehlstellung bei einem Schafbock mittels Keilostektomie

Gegenstand und Ziel: Über die Behandlung, den Heilungsverlauf und mögliche Komplikationen einer hochgradigen Radiusfehlstellung bei einem Schafbock wird berichtet. Material und Methoden: Bei einem zur Zucht selektionierten einjährigen Merino-Schafbock lag im linken distalen Radius eine Achsenknickung von 46° vor. Die Zehenachsen der linken Vorderzehen zeigten in den Fesselgelenken eine geringgradige Varusstellung. Die Gliedmaßenfehlstellung des Radius wurde mittels Keilostektomie korrigiert und mit einer schmalen 4,5-mm-7-Loch-DC-Platte stabilisiert. Die Korrektur der Zehenachsenknickung an den linken Vorderzehen erfolgte konservativ durch ein mit Polymethylmethacrylat fixiertes Holzplättchen an den Klauen. Ergebnisse: Nach stabiler Heilung der Ostektomiewunde wurde 6 Monate nach der Operation die DC-Platte entfernt. Zu diesem Zeitpunkt belastete das Tier die Gliedmaße sehr gut. Die kompensatorische Zehenfehlstellung war durch die Korrektur gebessert. Der Schafbock blieb lahmheitsfrei. Bei der telefonischen Nachfrage 2 Jahre nach dem Eingriff berichtete der Besitzer vom erfolgreichen Einsatz des Bockes in der Zucht. Schlussfolgerung und klinische Relevanz: Die Keilostektomie erwies sich als effektive Behandlungsmethode, deren Aufwand den Nutzen auch bei landwirtschaftlich genutzten Zuchttieren gerechtfertigt erscheinen lässt.

Quantitative risk assessment of sunbeds: impact of new high power lamps

BACKGROUND

A survey of all sunbeds in a local authority area was carried out in 1998. Since then, there have been technological developments leading to new 'fast-tan' sunlamps which have become increasingly popular, along with unmanned sun parlours. In addition, new British and European sunbed standards have been set.

OBJECTIVES

To discover the commercial uptake of new high power sunlamps and to determine the impact on carcinogenic risk from sunbeds.

METHODS

Onsite spectral measurements, traceable to national standards, were conducted at all commercial sunbed premises within two local authorities and a quantitative risk assessment applied to the findings using a skin cancer model. Sunbed users were asked to complete a questionnaire regarding their reasons for using a sunbed and the risk associated with its use.

RESULTS

We found a 30% increase in the number of privately operated sunbeds since our 1998 survey. The median cancer-weighted exposure of all 133 sunbeds was comparable to that of Mediterranean sunlight. This was a significant increase compared to 1998. Moreover, 83% of sunbeds produced ultraviolet (UV) B radiation levels that exceeded the European standard. Fifteen per cent of respondents thought that there were no risks from use of sunbeds.

CONCLUSIONS

Sunbeds in current use carry a cancer risk comparable to Mediterranean sunlight. This is due to the use of new high power lamps. New British and European standards are being largely ignored with more than four out of five sunbeds exceeding the limit specified in the standard. There is a strong case for regulation of sunbed operators coupled to improved public education.

An exploration of human services system contacts prior to suicide in South Carolina: an expansion of the South Carolina Violent Death Reporting System

OBJECTIVE

To link South Carolina Violent Death Reporting System (SCVDRS) data with state government human services databases, enabling expanded analysis of suicide in South Carolina and providing a model for other jurisdictions.

DESIGN

The SCVDRS database compiles data from vital statistics, coroner reports, and law enforcement incident and supplemental reports. The Office of Research and Statistics, South Carolina Budget and Control Board (ORS) created a "Data Warehouse", to which a variety of state agencies and healthcare providers submit data on a regular basis. A unique identifier was used to link SCVDRS data to the Data Warehouse so that data may be analyzed on aggregate and case-specific levels. Year 2004 suicide data from SCVDRS were linked to South Carolina Uniform Billing codes from hospital in-patient and emergency room billing records, State Department of Mental Health service records, and criminal justice databases.

RESULTS

SCVDRS year 2004 suicide data are augmented by hospitalization and emergency room visit data and diagnoses; State Department of Mental Health service provision; and criminal involvement. Of the 491 suicides occurring in 2004, 282 linked with hospitalization and emergency room data, 196 linked with criminal history databases, and 91 had previous contact with the State Department of Mental Health.

CONCLUSIONS

Linking SCVDRS data to additional human services databases enables greater examination of factors surrounding suicide. Results show the positive benefits of partnerships created through SCVDRS, illustrate how SCVDRS and human service databases may augment each other, and suggest practitioners should explore implementation of prevention programs in specific settings.

Melanocortin 1 receptor (MC1R) genotype influences erythemal sensitivity to psoralen-ultraviolet A photochemotherapy

BACKGROUND

The melanocortin 1 receptor (MC1R) is a highly polymorphic G protein-coupled receptor. Inheritance of various MC1R alleles has been associated with a red hair/fair skin phenotype, increased incidence of skin cancer and altered sensitivity to ultraviolet (UV) radiation.

OBJECTIVES

To investigate whether MC1R genotype influences erythemal sensitivity to psoralen-UVA photochemotherapy (PUVA) in patients with psoriasis and other common skin diseases.

METHODS

Patients (n = 111) about to start PUVA were recruited to the study. Erythemal responses were assessed visually at 72 h and 96 h following PUVA by assessment of the minimal phototoxic dose (MPD). MC1R genotype was determined by direct sequencing.

RESULTS

Inheritance of the MC1R Arg(151)Cys allele was associated with a red hair phenotype (odds ratio 25.19, P = 0.0004). In contrast, inheritance of the Val(60)Leu and Arg(163)Gln SNPs was associated with increased PUVA erythemal sensitivity (reduced MPD) 72 h following treatment in all patients (n = 111; Val(60)Leu chi(2) = 5.764, P = 0.016; Arg(163)Gln chi(2) = 5.469, P = 0.019) and in a subset of patients with psoriasis (n = 55; Val(60)Leu chi(2) = 4.534, P = 0.033; Arg(163)Gln chi(2) = 7.298, P = 0.007). Inheritance of two or more MC1R SNPs was also associated with increased PUVA erythemal sensitivity (reduced MPD) in both patient groups (n = 111; chi(2) = 8.166, P = 0.017; n = 55; chi(2) = 10.303, P = 0.016).

CONCLUSIONS

Our data demonstrate that MC1R genotype influences PUVA erythemal sensitivity in patients with psoriasis and other common skin diseases.

Improved COBAS TaqMan hepatitis C virus test (Version 2.0) for use with the High Pure system: enhanced genotype inclusivity and performance characteristics in a multisite study

We have evaluated the COBAS TaqMan hepatitis C virus (HCV) test (version 2.0) for use with the High Pure system (HCVHPS V2), a new, revised real-time reverse transcription-PCR assay developed to improve the genotype quantitation of version 1.0 (HCVHPS V1). Revisions were made in the wash buffer and in the reverse transcription temperature. The genotype inclusivity of HCVHPS V2 was evaluated at three different sites, using HCVHPS V2, HCVHPS V1, and the COBAS AMPLICOR HCV MONITOR test (version 2.0) (CAHCM). The fully automated COBAS Ampliprep/COBAS TaqMan HCV test was also used in one of the participating laboratories. The mean differences in HCV RNA values between HCVHPS V2 and CAHCM and between HCVHPS V2 and HCVHPS V1 ranged from -0.21 to 0.13 log and from 0.24 to 1.27 log, respectively, with >0.5-log differences for genotypes 2, 3, 4, and 5. With a NIBSC panel of HCV genotypes 1 through 6, the measured HCVHPS V2 values were within 0.25 log of the nominal values for all 6 genotypes. When serial dilutions of genotype-specific clinical HCV specimens were tested, the assay showed a limit of detection between 10 and 20 IU/ml and a linear range of 25 IU/ml to 3.91 x 10(8) IU/ml. Clinical and analytical specificities of 100% were demonstrated with 100 HCV-seronegative specimens as well as with 12 non-HCV members of Flaviviridae and 22 additional microorganisms. These data indicate that HCVHPS V2 is a robust and accurate test for the quantitation of all six HCV genotypes and useful in monitoring viral load in all clinical HCV specimens.