A randomised controlled trial to measure the effect of chest pain unit care upon anxiety, depression, and health-related quality of life [ISRCTN85078221]

The Establishment and Management of an Observation Unit

The current health care landscape and evidence support the establishment of observation units (OUs) for safe and efficient care for observation patients. Careful attention is required in the design of OU process, location, and layout to enable optimal care and finances. Developing and maintaining protocols to guide patient selection and clinical care are critical. OU management requires a strong, collaborative leadership model, appropriate staffing, and a robust monitoring system for quality, safety, and finances. With a better understanding of these principles of OU establishment and management, hospital leaders can generate and sustain service excellence.

Patient-reported health state utilities in metastatic gastroenteropancreatic neuroendocrine tumours - an analysis based on the CLARINET study

Background

Gastroenteropancreatic neuroendocrine tumours (GEP-NETs) are rare cancers most often found in the gastrointestinal system or the pancreas. However, patient-reported health state utilities based on clinical trials have not been previously reported in this disease area.

Methods

The CLARINET study collected EORTC QLQ-C30 data from patients in both stable and progressive disease states, although data for the latter were only available during the early stage of progression due to trial design. Using published algorithms, data were mapped to EQ-5D utility values. Random-effects generalised least squares models were used to investigate the impacts of progression status, tumour site and other patient characteristics on mapped utility values.

Results

In total, 1053 observations from 204 patients were mapped to EQ-5D utilities using the McKenzie mapping algorithm. The final random-effects model included age, gender, baseline utility and progression status as covariates; it was not feasible to investigate time-to-death utility due to a limit number of deaths in the CLARINET study. Tumour location (midgut vs pancreas) does not seem to affect utility. However, the difference in utilities based on progression status is statistically significant (p < 0.05) in the base case analysis, and the estimated utilities for stable and progressive disease are 0.776 and 0.726, respectively. Furthermore, scenario analyses showed that utility for progressive disease is numerically lower than for stable disease, but this may not be statistically significant in scenarios where alternative Longworth mapping algorithm was used.

Conclusions

Patients with GEP-NETs experience worse utility values in the progressive disease state compared to the stable disease state, based on patient-reported health-related quality of life (HRQL) data from the CLARINET study. The decline of utility in the progressive disease state may be underestimated because progressive HRQL data were only collected shortly after the progression event in the trial. The estimated trial-based utilities can be used in future economic evaluations for GEP-NET treatments and to provide more insights to physicians on patient-reported quality of life outcomes in GEP-NETs.

Trial registration

CLARINET EU Clinical Trials Register Number, 2005–004904-35.

Coping, uncertainty and health-related quality of life as determinants of anxiety and depression on a sample of hospitalized cardiac patients in Southern Italy

OBJECTIVES

Being hospitalized often causes psychological distress and compromises patients' psychological well-being, thereby augmenting the burden of illness. The aim of this paper is to investigate two possible determinants of anxiety and depression among hospitalized cardiac patients, namely uncertainty in illness, and coping strategies, controlling for the perceived health-related quality of life, and distinguishing between borderline and pathological levels of anxiety and depression.

METHODS

Data on anxiety, depression, coping style, uncertainty in illness and self-assessed quality of life concerning 200 cardiac inpatients from a university hospital were collected through validated questionnaires. A biprobit analysis, whose dependent variables are hospital anxiety and depression, was carried out.

RESULTS

Uncertainty in illness has a significant impact on the possibility of crossing the borderline level of both anxiety and depression. The coping strategy of Positive Reappraisal and Growth is inversely and significantly correlated to anxiety and depression, be it borderline or pathological; the Restraint Coping strategy is positively and significantly related to borderline anxiety.

CONCLUSIONS

The reduction of uncertainty in illness and the development of adequate coping strategies should be promoted in order to decrease the patients' risk of crossing the borderline threshold of anxiety and depression.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Impact of clinical predictors and routine coronary artery disease testing on outcome of patients admitted to chest pain decision unit

BACKGROUND

Chest pain decision unit (CDU) evaluation of patients with acute chest pain (ACP) and nondiagnostic electrocardiogram (ECG) usually includes noninvasive testing for coronary artery disease (CAD).

HYPOTHESIS

CAD evaluation will not improve clinical outcome in low-risk ACP patients.

METHODS

We studied 459 adults admitted to CDU with ACP and no troponin release who underwent noninvasive CAD testing (stress testing in 396 and coronary computed tomographic angiography in 63). Multivariate logistic regression was used to determine predictors of adverse outcome over a 3-year follow-up period.

RESULTS

Initial noninvasive test was normal in 367 (80%) and abnormal (positive or indeterminate) in 92 (20%). A total of 42 (9%) patients underwent invasive coronary angiography, and 16 (3.5%) underwent revascularization. During follow-up, 33 patients had a total of 36 major clinical events: 12 revascularizations, 9 myocardial infarctions, and 15 deaths. Multivariate logistic regression analysis identified abnormal ECG (odds ratio [OR]: 2.7, P = 0.03), typical chest pain (OR: 3.8, P = 0.002), diabetes (OR: 4.1, P = 0.001), and known CAD (OR: 2.3, P = 0.03) as independent predictors for adverse outcome, but not noninvasive test result. Thus, in 187 patients with no high-risk features (41% of the cohort), the annualized event rate was 0.5%. In 272 patients with at least 1 high-risk feature, annualized event rates were 2.8% and 5.7% when noninvasive test was normal or abnormal, respectively (P = 0.04).

CONCLUSIONS

Clinical risk stratification allows identification of patients at low risk of adverse outcome over an intermediate period of follow-up. Noninvasive testing is not warranted in such patients.

State of the art: emergency department observation units

Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 4), MEDLINE (1966 to December 2008), CINAHL (1982 to December 2008) EMBASE (1980 to December 2008), PsycINFO (1887 to December 2008), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to December 2008). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Ten RCTs (484 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (mean difference = -1.73 (95% CI -2.21 to -1.26)) and severity (mean difference = -6.86 (95% CI -10.74 to -2.97)). However, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

[Acute thoracic pain: Chest Pain Unit - the certification campaign of the German Society of Cardiology]

The Chest Pain Unit (CPU) Task Force of the German Society of Cardiology inaugurated elaborated prerequisites for a CPU certification program to evaluate CPUs across the country. For this reason, a consensus document including criteria for CPUs was developed and published in October 2008. Aim of this effort is to ensure a network of elaborated centers which meet or exceed quality-of-care measures in order to improve the standard of care of patients with acute thoracic pain. After application and a formal checkup of the institution, the minimum requirements are assessed by an expert committee of the German Society of Cardiology according to presubmitted documentation of the care processes for patients with acute thoracic pain. Components of certification include characteristic locations, equipment, diagnostic and therapeutic strategies, cooperations, staff education, and organization. Certification specifically implies algorithms for ST segment elevation myocardial infarction, non-ST segment elevation myocardial infarction, unstable angina, stable angina, hypertensive crisis, acute pulmonary embolism, acute aortic syndrome, cardiogenic shock, and resuscitation. Availability of a catheter laboratory ready within the facility is mandatory. The CPU and the cath lab are obliged to be available 24 h per day over 365 days per year. After successful documentation review, a certification audit team reviews the facility's application, infrastructure, patient care, and each of the requirements according to the consensus document on site and makes recommendations to the expert committee. Certification is finally awarded by the expert committee of the German Society of Cardiology to those CPUs which fulfill the dedicated requirements and successfully run through the complete certification process. Within this process, CPUs can plan and organize the delivery of care in a systematic manner, and the differentiation between minimum requirements and best practice allows further developments and innovations.

Effect on quality of life of different accelerated diagnostic protocols for management of patients presenting to the emergency department with acute chest pain

This study assessed the effects on quality of life (QoL) of dobutamine-atropine stress echocardiography (DASE) and electrocardiogram exercise testing (EET) accelerated diagnostic protocols for early stratification of low-risk patients with acute chest pain (ACP). A total of 290 patients with ACP, a nondiagnostic electrocardiogram, and negative biomarkers were randomly assigned to an accelerated diagnostic protocol (DASE, n = 110, or EET, n = 89) or usual care (n = 91) and followed up for 2 months. QoL was assessed at discharge and 2-month follow-up using the Nottingham Health Profile questionnaire. Baseline and 2-month follow-up answers to the Nottingham Health Profile questionnaire were available for 207 patients (71%; 55 in the usual-care, 77 in the DASE, and 75 in the ETT arm). At predischarge, patients in the usual-care arm reported higher impairment in the physical mobility and pain dimensions compared with the DASE and EET arms (p = 0.019 and p = 0.023, respectively). At 2-month follow-up, QoL improved in all groups; however, patients in the usual-care arm had significantly worse scores than patients managed using accelerated diagnostic protocols in the physical mobility, pain, social isolation, emotional reactions, and energy level dimensions (p = 0.014, p = 0.002, p = 0.04, p = 0.01, and p = 0.003, respectively). In conclusion, low-risk patients with ACP had non-negligible impairment of QoL in the acute phase. Emergency department ADPs with early DASE and EET reduced QoL impairment at both baseline and 2-month follow-up.

Use of the hospital anxiety and depression scale (HADS) in a cardiac emergency room: chest pain unit

OBJECTIVE

To determine the prevalence of anxiety and depression in patients complaining of chest pain who seek a chest pain unit attendance.

INTRODUCTION

Patients arriving at a Chest Pain Unit may present psychiatric disorders not identified, isolated or co-morbid to the main illness, which may interfere in the patient prognosis.

METHODOLOGY

Patients were assessed by the 'Hospital Anxiety and Depression Scale' as a screening instrument wile following a systematized protocol to rule out the diagnosis of acute coronary syndrome and other potentially fatal diseases. Patients with 8 or more points in the scale were considered 'probable case' of anxiety or depression.

RESULTS

According to the protocol, 59 (45.4%) of 130 patients studied presented Chest Pain of Determined Cause, and 71 (54.6%) presented Chest Pain of Indefinite Cause. In the former group, in which 43 (33.1%) had acute coronary syndrome, 33.9% were probable anxiety cases and 30.5% depression cases. In the second group, formed by patients without acute coronary syndrome or any clinical conditions involving greater morbidity and mortality risk, 53.5% were probable anxiety cases and 25.4% depression.

CONCLUSION

The high anxiety and depression prevalence observed may indicate the need for early and specialized approach to these disorders. When coronary arterial disease is present, this may decrease complications and shorten hospital stay. When psychiatric disorder appears isolated, is possible to reduce unnecessary repeated visits to emergency room and increase patient's quality of life.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: Sleepiness, Sleeplessness, and Pain in End-Stage Renal Disease: Distressing Symptoms for Patients

Symptoms are increasingly recognized as problematic for patients with end-stage renal disease (ESRD) treated with dialysis. Sleep disorders are common in ESRD patients treated with dialysis and are associated with patients' perceptions of quality of life, assessed by diverse measures, as well as depressive affect. Sleep disorders appear to be equally prevalent in peritoneal dialysis (PD) and hemodialysis (HD) patients. Treatment for sleep disorders in dialysis patients depends on establishing the diagnosis, often in a sleep laboratory, using polysomnography. Reversing coexistent medical and psychological disorders is important. The sleep apnea syndrome (SAS) can be treated with continuous positive airway pressure in dialysis patients, but conventional hemodialytic techniques have little effect on its severity. In contrast, nocturnal HD and transplantation appear to have important beneficial effects on sleep disordered breathing in ESRD patients. Although pain has been appreciated as a problem for ESRD patients for more than 20 years, few studies exist on this subject. Pain appears to be an underappreciated problem for ESRD patients. More research must be performed on the problem of pain in patients with chronic kidney disease (CKD).

Medically unexplained physical symptoms in emergency medicine

Medically unexplained physical symptoms (MUPS) are physical symptoms for which no relevant organic pathology can be found. Patients with MUPS commonly present to the emergency department (ED) but are rarely considered in emergency medicine teaching or literature. Management of these patients is frequently more challenging than where there is an obvious organic pathology. This review provides the emergency physician with background knowledge regarding the classification and aetiology of MUPS. It then provides strategies for more effective management, such as exploring the contribution of psychosocial factors with patients, explaining negative test results, and providing reassurance and avoiding creating iatrogenic anxiety. Early recognition of the fact that symptoms may not result from organic disease and an appreciation of the role of psychosocial factors may improve outcomes by reducing unnecessary investigation and admission, and avoiding reinforcement that encourages further similar presentations and unhelpful coping mechanisms.

Pain characteristics in patients with unexplained chest pain and patients with ischemic heart disease

BACKGROUND

Little scientific attention has been paid to providing a comprehensive multidimensional description of chest pain in patients with unexplained chest pain.

AIMS

The aims of the present study were: (1) to describe the symptom chest pain, including the dimensions of intensity, quality, duration and location in patients with unexplained chest pain (UCP); and (2) to identify similarities and differences in how patients with UCP and patients with ischemic heart disease (IHD) describe chest pain.

METHOD

A descriptive, correlational and comparative design. Totally 208 consecutive UCP patients and 40 IHD patients below 70 years of age participated. Pain was assessed using the instrument Pain-O-Meter.

RESULTS

The occurrence of chest pain was 79% (n=165) in UCP patients versus 60% (n=22) in the IHD patients (p=0.001). Patients with UCP reported greater pain intensity and used more sensory and affective words than IHD patients (p<0.01). Relationships between pain location and amount of body surface involved in the pain and pain intensity in both groups were found (p<0.001).

CONCLUSIONS

Our results showed some defining characteristics of the UCP group, but the many similarities between the two groups in their experience of chest pain made it impossible to clearly differentiate the groups' pain profiles.

Prospective multicenter study of quantitative pretest probability assessment to exclude acute coronary syndrome for patients evaluated in emergency department chest pain units

STUDY OBJECTIVE

We compare the diagnostic accuracy of 3 methods--attribute matching, physician's written unstructured estimate, and a logistic regression formula (Acute Coronary Insufficiency-Time Insensitive Predictive Instrument, ACI-TIPI)--of estimating a very low pretest probability (< or = 2%) for acute coronary syndromes in emergency department (ED) patients evaluated in chest pain units.

METHODS

We prospectively studied 1,114 consecutive patients from 3 academic EDs, evaluated for acute coronary syndrome. Physicians collected data required for pretest probability assessment before protocol-driven chest pain unit testing. A pretest probability greater than 2% was considered "test positive." The criterion standard was the outcome of acute coronary syndrome (death, myocardial infarction, revascularization, or > 60% stenosis prompting new treatment) within 45 days, adjudicated by 3 independent reviewers.

RESULTS

Fifty-one of 1,114 enrolled patients (4.5%; 95% confidence interval [CI] 3.4% to 6.0%) developed acute coronary syndrome within 45 days, including 4 of 991 (0.4%; 95% CI 0.1% to 1.0%) patients, discharged after a negative chest pain unit evaluation result, who developed acute coronary syndrome. Unstructured estimate identified 293 patients with pretest probability less than or equal to 2%, 2 had acute coronary syndrome, yielding sensitivity of 96.1% (95% CI 86.5% to 99.5%) and specificity of 27.4% (95% CI 24.7% to 30.2%). Attribute matching identified 304 patients with pretest probability less than or equal to 2%; 1 had acute coronary syndrome, yielding a sensitivity of 98.0% (95% CI 89.6% to 99.9%) and a specificity of 26.1% (95% CI 23.6% to 28.7%). ACI-TIPI identified 56 patients; none had acute coronary syndrome, yielding sensitivity of 100% (95% CI 93.0% to 100%) and specificity of 6.1% (95% CI 4.7% to 7.9%).

CONCLUSION

In a low-risk ED population with symptoms suggestive of acute coronary syndrome, patients with a quantitative pretest probability less than or equal to 2%, determined by attribute matching, unstructured estimate, or logistic regression, may not require additional diagnostic testing.