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Ndai AM, Allen BR, Wynn TT, Rajasekhar A, Saqr Z, Sandeli I, Vouri SM, Reise R. Rapid recognition and optimal management of hemophilia in the emergency department: A quality improvement project. J Am Coll Emerg Physicians Open 2024; 5:e13168. [PMID: 38699223 PMCID: PMC11065154 DOI: 10.1002/emp2.13168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/05/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Objectives This study aimed to assess the effectiveness of a continuous quality improvement initiative at the University of Florida Health Physicians practice in reducing the time to administer factor replacement therapy (FRT) for hemophilia patients presenting with bleeding in the emergency department (ED). Methods The study, a quasi-experimental, interventional design, was conducted between January 2020 and January 2023. The intervention, implemented in September 2021, involved training ED physicians, creating a specialized medication order set within the electronic health record (EHR), and a rapid triage system. The effectiveness was measured by comparing the time from ED arrival to factor administration before and after the intervention and benchmarking it against the National Bleeding Disorders Foundation's Medical and Scientific Advisory Council (MASAC)-recommended 1-hour timeline for factor administration. An interrupted time series (ITS) analysis with a generalized least squares model assessed the intervention's impact. Results A total of 43 ED visits (22 pre-intervention and 21 post-intervention) were recorded. Post-intervention, the average time from ED arrival to factor administration decreased from 5.63 to 3.15 hours. There was no significant increase (27% vs. 29%) in the patients receiving factor within 1-hour of ED arrival. The ITS analysis predicted a 20-hour reduction in the average quarterly time to administer factor by the end of the study, an 84% decrease. Conclusions The quality improvement program decreased the time to administer FRT for patients with hemophilia in the ED. However, the majority of patients did not achieve the 1-hour MASAC-recommended timeline for factor administration after ED arrival.
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Affiliation(s)
- Asinamai M. Ndai
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Tung T. Wynn
- Division of Pediatric Hematology/OncologyDepartment of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Anita Rajasekhar
- Division of Hematology/OncologyDepartment of MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Ziad Saqr
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Ina Sandeli
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Scott M. Vouri
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
| | - Rachel Reise
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
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Ashburn NP, Snavely AC, Allen BR, Christenson RH, Madsen T, McCord JK, Mumma BE, Hashemian T, Stopyra JP, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-hour algorithm with high-sensitivity cardiac troponin T at 90 days among patients with known coronary artery disease. Am J Emerg Med 2024; 79:111-115. [PMID: 38417221 DOI: 10.1016/j.ajem.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND The European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥ 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD. METHODS We performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test. RESULTS The STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8-98.8) among patients with known CAD and 98.8% (95%CI 97.6-99.5) in patients without known CAD (p = 0.09). CONCLUSION Patients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD. TRIAL REGISTRATION High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - James K McCord
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Tara Hashemian
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Supples MW, Snavely AC, Ashburn NP, Allen BR, Mahler SA. Response to "troponin thresholds for MI risk stratification" by Dr. Pickering. Acad Emerg Med 2024; 31:306-307. [PMID: 38381470 DOI: 10.1111/acem.14862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 02/22/2024]
Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Supples MW, Snavely AC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Performance of the 0/2-hour high-sensitivity cardiac troponin T diagnostic protocol in a multisite United States cohort. Acad Emerg Med 2024; 31:239-248. [PMID: 37925594 DOI: 10.1111/acem.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 10/13/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain. METHODS A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated. RESULTS Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively. CONCLUSIONS The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy.
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Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Supples MW, Snavely AC, O'Neill JC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Sex and race differences in the performance of the European Society of Cardiology 0/1-h algorithm with high-sensitivity troponin T. Clin Cardiol 2024; 47:e24199. [PMID: 38088463 PMCID: PMC10823440 DOI: 10.1002/clc.24199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 02/01/2024] Open
Abstract
The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-h algorithm in sex and race subgroups of US Emergency Department (ED) patients is unclear. A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-h hs-cTnT measures from eight US EDs (1/2017 to 9/2018) were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. The proportion with the primary outcome in each zone was compared between subgroups with Fisher's exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day CDMI was calculated and compared between subgroups using Fisher's exact tests. Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or myocardial infarction (MI) occurred in 12.9% (183/1422) of participants. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women versus 2.1% (8/436) of men (p = .40) and 1.2% (4/331) of non-white patients versus 1.8% (9/490) of white patients (p = .58). The NPV for 30-day cardiac death or MI was similar among women versus men (98.9% [95% confidence interval, CI: 97.3-99.6] vs. 97.9% [95% CI: 95.9-99.1]; p = .40) and among white versus non-white patients (98.8% [95% CI: 96.9-99.7] vs. 98.2% [95% CI: 96.5-99.2]; p = .39). NPVs <99% in each subgroup suggest the hs-cTnT ESC 0/1-h algorithm may not be safe for use in US EDs. Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
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Affiliation(s)
- Michael W. Supples
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Anna C. Snavely
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - James C. O'Neill
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Nicklaus P. Ashburn
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Section on Cardiovascular Medicine, Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Robert H. Christenson
- Department of PathologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Richard Nowak
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - R. Gentry Wilkerson
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California Davis School of MedicineSacramentoCaliforniaUSA
| | - Troy Madsen
- Division of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Jason P. Stopyra
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Implementation ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Guastello AD, Brunson JC, Sambuco N, Dale LP, Tracy NA, Allen BR, Mathews CA. Predictors of professional burnout and fulfilment in a longitudinal analysis on nurses and healthcare workers in the COVID-19 pandemic. J Clin Nurs 2024; 33:288-303. [PMID: 35949164 PMCID: PMC9538120 DOI: 10.1111/jocn.16463] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 05/14/2022] [Accepted: 06/27/2022] [Indexed: 01/22/2023]
Abstract
AIMS AND OBJECTIVES (1) To investigate the vulnerability of nurses to experiencing professional burnout and low fulfilment across 5 months of the COVID-19 pandemic. (2) To identify modifiable variables in hospital leadership and individual vulnerabilities that may mitigate these effects. BACKGROUND Nurses were at increased risk for burnout and low fulfilment prior to the COVID-19 pandemic. Hospital leadership factors such as organisational structure and open communication and consideration of employee opinions are known to have positive impacts on work attitudes. Personal risk factors for burnout include symptoms of depression and anxiety. METHODS Healthcare workers (n = 406 at baseline, n = 234 longitudinal), including doctors (n = 102), nurses (n = 94), technicians (n = 90) and non-clinical administrative staff (n = 120), completed 5 online questionnaires, once per month, for 5 months. Participants completed self-report questionnaires on professional fulfilment and burnout, perceptions of healthcare leadership, and symptoms of anxiety and depression. Participants were recruited from various healthcare settings in the southeastern United States. The STROBE checklist was used to report the present study. RESULTS Both at baseline and across the 5 months, nurses working during the COVID-19 pandemic reported increased burnout and decreased fulfilment relative to doctors. For all participants, burnout remained largely steady and fulfilment decreased slightly. The strongest predictors of both burnout and fulfilment were organisational structure and depressive symptoms. Leadership consideration and anxiety symptoms had smaller, yet significant, relationships to burnout and fulfilment in longitudinal analyses. CONCLUSIONS Burnout and reduced fulfilment remain a problem for healthcare workers, especially nurses. Leadership styles and employee symptoms of depression and anxiety are appropriate targets for intervention. RELEVANCE TO CLINICAL PRACTICE Leadership wishing to reduce burnout and increase fulfilment among employees should increase levels of organisational support and consideration and expand supports to employees seeking treatment for depression and anxiety.
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Affiliation(s)
- Andrea D. Guastello
- Department of PsychiatryCollege of Medicine, University of FloridaGainesvilleFloridaUSA
- Univeristy of Florida, Evelyn F. and William L. McKnight Brain InstituteGainesvilleFloridaUSA
- UF Center for OCD, Anxiety, and Related DisordersUniversity of FloridaGainesvilleFloridaUSA
| | - Jason Cory Brunson
- Laboratory for Systems MedicineCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Nicola Sambuco
- Univeristy of Florida, Evelyn F. and William L. McKnight Brain InstituteGainesvilleFloridaUSA
- UF Center for OCD, Anxiety, and Related DisordersUniversity of FloridaGainesvilleFloridaUSA
- Department of Clinical and Health PsychologyCollege of Public Health and Health Professions, University of FloridaGainesvilleFloridaUSA
| | - Lourdes P. Dale
- Department of PsychiatryCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFloridaUSA
| | - Natasha A. Tracy
- Department of PsychiatryCollege of Medicine, University of FloridaGainesvilleFloridaUSA
- Univeristy of Florida, Evelyn F. and William L. McKnight Brain InstituteGainesvilleFloridaUSA
- UF Center for OCD, Anxiety, and Related DisordersUniversity of FloridaGainesvilleFloridaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineCollege of Medicine, University of FloridaGainesvilleFloridaUSA
| | - Carol A. Mathews
- Department of PsychiatryCollege of Medicine, University of FloridaGainesvilleFloridaUSA
- Univeristy of Florida, Evelyn F. and William L. McKnight Brain InstituteGainesvilleFloridaUSA
- UF Center for OCD, Anxiety, and Related DisordersUniversity of FloridaGainesvilleFloridaUSA
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Peacock WF, Januzzi JL, de Theije F, Briseno T, Headden G, Birkhahn R, Allen BR, Mahler SA. Methods of the PivotaL triAl of the Atellica VTLi point of care emergencY dePartment high sensitivity troponin evalUationS. Clin Biochem 2023; 121-122:110679. [PMID: 37884085 DOI: 10.1016/j.clinbiochem.2023.110679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The Atellica® VTLi point-of-care (POC) High Sensitivity Cardiac Troponin-I (hs-cTnI) assay is intended for use as an aid in the diagnosis of myocardial infarction (MI). Our primary objective is to assess its diagnostic performance in patients presenting with suspected acute coronary syndrome (ACS). METHODS This prospective observational study will enrol ∼1500 patients at ∼20 U.S. Emergency Departments. After informed consent, adults (>21 years of age) with suspected ACS, and no prior enrollment in this study, will provide a fingerstick and venous blood sample within 2 h of ED presentation, >2 to ≤4 h, and >4 to ≤9 h (max. blood draw = 60 mL). HEART and EDACS scores will be prospectively documented. Patients without the first blood draw may be enrolled if the second draw was obtained. Capillary and venous whole blood will undergo Atellica VTLi assay testing, with remaining venous sample processed to plasma and run. All results will be blinded to the clinical care team. Site operators will undergo a 3-day familiarization period. Quality control testing will be performed daily. At 30 ± 3 days, patient mortality status, major adverse cardiac events, and rehospitalizations will be determined. A clinical endpoint adjudication committee, blinded to hs-cTnI VTLi result, will define the final diagnosis. Sensitivity, specificity, and predictive values will describe the assay performance. RESULTS We expect study completion within 114 weeks of enrollment of the first patient. CONCLUSIONS It is anticipated that the Atellica VTLi hs-cTnI assay validation study will define a performance equivalent to lab-based hs-cTnI, with results within ∼8 min at the point of care.
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Affiliation(s)
| | | | - Femke de Theije
- Siemens Healthineers Headquarters, Siemens Healthcare GmbH, Henkestr. 127, 91052 Erlangen, Germany
| | - Taylor Briseno
- Siemens Healthineers Headquarters, Siemens Healthcare GmbH, Henkestr. 127, 91052 Erlangen, Germany
| | - Gary Headden
- Medical University of South Carolina, United States
| | | | | | - Simon A Mahler
- Wake Forest University School of Medicine, United States
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Popp LM, Ashburn NP, Snavely AC, Allen BR, Christenson RH, Madsen T, Mumma BE, Nowak R, Stopyra JP, Wilkerson RG, Mahler SA. Race differences in cardiac testing rates for patients with chest pain in a multisite cohort. Acad Emerg Med 2023; 30:1020-1028. [PMID: 37306075 DOI: 10.1111/acem.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Identifying and eliminating racial health care disparities is a public health priority. However, data evaluating race differences in emergency department (ED) chest pain care are limited. METHODS We conducted a secondary analysis of the High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP) cohort, which prospectively enrolled adults with symptoms suggestive of acute coronary syndrome without ST-elevation from eight EDs in the United States from 2017 to 2018. Race was self-reported by patients and abstracted from health records. Rates of 30-day noninvasive testing (NIT), cardiac catheterization, revascularization, and adjudicated cardiac death or myocardial infarction (MI) were determined. Logistic regression was used to evaluate the association between race and 30-day outcomes with and without adjustment for potential confounders. RESULTS Among 1454 participants, 42.3% (615/1454) were non-White. At 30 days NIT occurred in 31.4% (457/1454), cardiac catheterization in 13.5% (197/1454), revascularization in 6.0% (87/1454), and cardiac death or MI in 13.1% (190/1454). Among Whites versus non-Whites, NIT occurred in 33.8% (284/839) versus 28.1% (173/615; odds ratio [OR] 0.76, 95% confidence interval [CI] 0.61-0.96) and catheterization in 15.9% (133/839) versus 10.4% (64/615; OR 0.62, 95% CI 0.45-0.84). After covariates were adjusted for, non-White race remained associated with decreased 30-day NIT (adjusted OR [aOR] 0.71, 95% CI 0.56-0.90) and cardiac catheterization (aOR 0.62, 95% CI 0.43-0.88). Revascularization occurred in 6.9% (58/839) of Whites versus 4.7% (29/615) of non-Whites (OR 0.67, 95% CI 0.42-1.04). Cardiac death or MI at 30 days occurred in 14.2% of Whites (119/839) versus 11.5% (71/615) of non-Whites (OR 0.79 95% CI 0.57-1.08). After adjustment there was still no association between race and 30-day revascularization (aOR 0.74, 95% CI 0.45-1.20) or cardiac death or MI (aOR 0.74, 95% CI 0.50-1.09). CONCLUSIONS In this U.S. cohort, non-White patients were less likely to receive NIT and cardiac catheterization compared to Whites but had similar rates of revascularization and cardiac death or MI.
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Affiliation(s)
- Lucas M Popp
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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9
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Mirhosseini T, Guastello AD, Dale LP, Sambuco N, Allen BR, Mathews CA. Effects of COVID-19 stress, proximity, and adverse childhood experiences on healthcare workers' mental health. Front Psychol 2023; 14:1228515. [PMID: 37727750 PMCID: PMC10505740 DOI: 10.3389/fpsyg.2023.1228515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/08/2023] [Indexed: 09/21/2023] Open
Abstract
Past research has shown that healthcare workers (HCWs) experience high levels of psychological distress during epidemics and pandemics, resulting in cascading effects that have led to chronically understaffed hospitals and healthcare centers. Due to the nature of their responsibilities and workplace stress, HCWs are among vulnerable groups especially during global health crises. During COVID-19 many healthcare workers reported greater symptoms of anxiety, depression, and COVID-19 related worries. Furthermore, adverse childhood experiences increase vulnerability for psychological conditions, especially during pandemics. This study sets out to (1) investigate the moderating effects of adverse childhood experiences on healthcare workers' COVID-19 related stressors and depression/anxiety symptoms, and (2) investigate the moderating effects of adverse childhood experiences on proximity to the COVID-19 virus and depression/anxiety symptoms. Participants included 438 employed HCWs recruited from academic medical centers and smaller healthcare agencies in northcentral Florida between October to December 2020. Mean age of participants was 38.23 (SD = 11.5) with most of the HCWs being white (72.1%), non-Hispanic (86.8%) and female (82%). Healthcare workers completed several online questionnaires, including the Adverse Childhood Experiences scale, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, a COVID-19 specific worries scale, and a Social Proximity to COVID-19 scale. Healthcare workers experiencing specific COVID-19 worries reported experiencing anxiety and depressive symptoms. A significant positive interaction was seen between childhood adverse experiences globally and COVID-19 worries on anxiety symptoms. A significant positive interaction was observed between childhood maltreatment specifically and COVID-19 worries on depressive symptoms. Additionally, a positive interaction effect was seen between childhood adverse experiences and COVID-19 social proximity for both depression symptoms and anxiety symptoms. Findings from the present study indicate that adverse childhood experiences strengthen the relationship between COVID-19 worry/proximity and negative psychological symptoms. Vulnerable populations such as individuals who have experienced ACEs could benefit from targeted and specific interventions to cope with the collective trauma experienced globally due to COVID-19. As COVID-19 becomes endemic, hospital leadership and authorities should continue addressing COVID-19 worries and HCWs' psychological symptoms through mental health support and organizational interventions.
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Affiliation(s)
- Tannaz Mirhosseini
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, FL, United States
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, FL, United States
| | - Andrea D. Guastello
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, FL, United States
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, FL, United States
- Evelyn F. and William L. McKnight Brain Institute, University of Florida, Gainesville, FL, United States
| | - Lourdes P. Dale
- Department of Psychiatry, College of Medicine-Jacksonville, University of Florida, Jacksonville, FL, United States
| | - Nicola Sambuco
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, FL, United States
- Evelyn F. and William L. McKnight Brain Institute, University of Florida, Gainesville, FL, United States
| | - Brandon R. Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Carol A. Mathews
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, FL, United States
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, FL, United States
- Evelyn F. and William L. McKnight Brain Institute, University of Florida, Gainesville, FL, United States
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10
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Neumann JT, Twerenbold R, Ojeda F, Aldous SJ, Allen BR, Apple FS, Babel H, Christenson RH, Cullen L, Di Carluccio E, Doudesis D, Ekelund U, Giannitsis E, Greenslade J, Inoue K, Jernberg T, Kavsak P, Keller T, Lee KK, Lindahl B, Lorenz T, Mahler SA, Mills NL, Mokhtari A, Parsonage W, Pickering JW, Pemberton CJ, Reich C, Richards AM, Sandoval Y, Than MP, Toprak B, Troughton RW, Worster A, Zeller T, Ziegler A, Blankenberg S. Personalized diagnosis in suspected myocardial infarction. Clin Res Cardiol 2023; 112:1288-1301. [PMID: 37131096 PMCID: PMC10449973 DOI: 10.1007/s00392-023-02206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. METHODS In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. RESULTS Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. CONCLUSION We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. TRIAL REGISTRATION NUMBERS Data of following cohorts were used for this project: BACC ( www. CLINICALTRIALS gov ; NCT02355457), stenoCardia ( www. CLINICALTRIALS gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www. CLINICALTRIALS gov ; NCT01852123), LUND ( www. CLINICALTRIALS gov ; NCT05484544), RAPID-CPU ( www. CLINICALTRIALS gov ; NCT03111862), ROMI ( www. CLINICALTRIALS gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www. CLINICALTRIALS gov ; NCT04772157), STOP-CP ( www. CLINICALTRIALS gov ; NCT02984436), UTROPIA ( www. CLINICALTRIALS gov ; NCT02060760).
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Affiliation(s)
- Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Hugo Babel
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | | | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Kenji Inoue
- Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thiess Lorenz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Arash Mokhtari
- Department of Internal Medicine and Emergency Medicine and Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - William Parsonage
- Australian Centre for Health Service Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - John W Pickering
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Christoph Reich
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mark Richards
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Martin P Than
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Ziegler
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany.
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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11
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Ashburn NP, Snavely AC, O’Neill JC, Allen BR, Christenson RH, Madsen T, Massoomi MR, McCord JK, Mumma BE, Nowak R, Stopyra JP, in’t Veld MH, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023; 8:347-356. [PMID: 36857071 PMCID: PMC9979014 DOI: 10.1001/jamacardio.2023.0031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/29/2022] [Indexed: 03/02/2023]
Abstract
Importance The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures Cardiac death or MI at 30 days determined by expert adjudicators. Results During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
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Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James C. O’Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael R. Massoomi
- Department of Cardiology, University of Florida College of Medicine, Gainesville
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Maite Huis in’t Veld
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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12
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Snavely AC, Paradee BE, Ashburn NP, Allen BR, Christenson R, O'Neill JC, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Derivation and validation of a high sensitivity troponin-T HEART pathway. Am Heart J 2023; 256:148-157. [PMID: 36400184 DOI: 10.1016/j.ahj.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays. METHODS We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723). RESULTS Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6). CONCLUSIONS A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.
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Affiliation(s)
- Anna C Snavely
- Department of Biostatistics and Data Science, Wake Forest School of Medicine (WFSOM), Winston-Salem, NC; Department of Emergency Medicine, WFSOM, Winston Salem, NC.
| | | | | | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health, Detroit, MI
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Bryn E Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Simon A Mahler
- Department of Emergency Medicine, WFSOM, Winston Salem, NC; Department of Implementation Science, WFSOM, Winston-Salem, NC; Department of Epidemiology and Prevention, WFSOM, Winston-Salem, NC
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13
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Ashburn NP, Snavely AC, Allen BR, Christenson RH, Herrington DM, Hiestand BC, Miller CD, Stopyra JP, Mahler SA. Monocyte chemoattractant protein-1 is not predictive of cardiac events in patients with non-low-risk chest pain. Emerg Med J 2022; 39:853-858. [PMID: 34933919 PMCID: PMC9209560 DOI: 10.1136/emermed-2021-211266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prior studies suggest monocyte chemoattractant protein-1 (MCP-1) may be useful for risk stratifying ED patients with chest pain. We hypothesise that MCP-1 will be predictive of 90-day major adverse cardiovascular events (MACEs) in non-low-risk patients. METHODS A case-control study was nested within a prospective multicentre cohort (STOP-CP), which enrolled adult patients being evaluated for acute coronary syndrome at eight US EDs from 25 January 2017 to 06 September 2018. Patients with a History, ECG, Age, and Risk factor score (HEAR score) ≥4 or coronary artery disease (CAD), a non-ischaemic ECG, and non-elevated contemporary troponins at 0 and 3 hours were included. Cases were patients with 90-day MACE (all-cause death, myocardial infarction or revascularisation). Controls were patients without MACE selected with frequency matching using age, sex, race, and HEAR score or the presence of CAD. Serum MCP-1 was measured. Sensitivity and specificity were determined for cut-off points of 194 pg/mL, 200 pg/mL, 238 pg/mL and 281 pg/mL. Logistic regression adjusting for age, sex, race, and HEAR score/presence of CAD was used to determine the association between MCP-1 and 90-day MACE. A separate logistic model also included high-sensitivity troponin (hs-cTnT). RESULTS Among 40 cases and 179 controls, there was no difference in age (p=0.90), sex (p=1.00), race (p=0.85), or HEAR score/presence of CAD (p=0.89). MCP-1 was similar in cases (median 191.9 pg/mL, IQR: 161.8-260.1) and controls (median 196.6 pg/mL, IQR: 163.0-261.1) (p=0.48). At a cut-off point of 194 pg/mL, MCP-1 was 50.0% (95% CI 33.8% to 66.2%) sensitive and 46.9% (95% CI 39.4% to 54.5%) specific for 90-day MACE. After adjusting for covariates, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.88 (95% CI 0.43 to 1.79)). When including hs-cTnT in the model, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.85 (95% CI 0.42 to 1.73)). CONCLUSION MCP-1 is not predictive of 90-day MACE in patients with non-low-risk chest pain.
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David M Herrington
- Department of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Chadwick D Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Departments of Epidemiology and Prevention and Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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14
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Allen BR, Ashburn NP, Snavely AC, Paradee BE, Christenson RH, Nowak RM, Mumma BE, Madsen T, O'Neill JC, Stopyra JP, Mahler SA. Age and the European Society of Cardiology 0/1-hour high sensitivity troponin T algorithm for the evaluation of patients with possible acute myocardial infarction: results from the STOP-CP study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) 0/1-hour high sensitivity troponin (hs-cTn) algorithm is widely used in the evaluation of patients presenting to the Emergency Department (ED) with symptoms suspicious for non ST-segment elevation myocardial infarction (NSTEMI). The effect of increasing patient age with its use has not been studied in any detail.
Purpose
The objective of this secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) United States (US) multicenter study was to evaluate the efficacy and safety of use of the ESC 0/1-hour hs-cTnT algorithm in younger, middle-aged, and older patients.
Methods
Patients (≥21 years old) presenting to the (ED) with symptoms suggestive of NSTEMI were enrolled (1/25/2017–9/6/2018) at 8 US medical centers. The ESC hs-cTnT 0/1-hour hs-cTnT algorithm was used to place patients into rule-out, observe, and rule-in NSTEMI zones. Algorithm performance for rapid NSTEMI rule-out and 30-day adverse outcomes was studied in 3 patient age (years) intervals: younger (21–45). middle aged (46–64) and older (≥65). Major adverse cardiovascular events (MACE) consisted of cardiac death, myocardial infarction, or coronary revascularization at 30-days. Fisher's exact tests were used to compare NSTEMI ruled out and MACE rates between patient age intervals. Negative likelihood ratios (NLR) with 95% confidence interval (CI) were calculated for 30-day MACE.
Results
Overall 1430 participants were enrolled with 15.7% (224/1430) young, 57.4% (821/1430) middle-aged, and 26.9% (385/1430) being older. The ESC 0/1 hour hs-cTnT algorithm NSTEMI rule-out rates were 79.9% (179/224), 62.1% (510/821) and 35.6% (137/385) respectively for these age groups (p<0.0001). The overall 30-day MACE rate was 14.2% (203/1430) with interval age rates of 7.1% (16/224) in younger, 13.1% (108/821) middle aged and 20.5% (79/385) older patients. Amongst NSTEMI ruled-out patients MACE occurred in 1.1% (2/179) of younger, 3.3% (17/510) middle aged and 2.9% (4/137) older individuals (p=0.320). NLR for 30-day MACE was 0.15 (95% CI 0.04, −0.54) in younger, 0.23 (95% CI 0.15–0.35) middle aged and 0.12 (95% CI 0.04–0.31) for older patients.
Conclusions
With increasing age ED patients were less often rapidly ruled out for NSTEMI during their initial cardiac evaluations. The STOP-CP US study demonstrated that older age interval alone was not an independent variable that increased the risk for 30-day MACE in patients ruled out for NSTEMI using the ESC 0/1 hour hs-cTnT algorithm. Our report suggests that cardiac risk stratification scores using age as an independent variable for predicting 30-day MACE in these patients require reevaluation.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Roche, Basel, Switzerland
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Affiliation(s)
- B R Allen
- University of Florida , Gainesville , United States of America
| | - N P Ashburn
- Wake Forest University , Winston-Salem , United States of America
| | - A C Snavely
- Wake Forest University , Winston-Salem , United States of America
| | - B E Paradee
- Wake Forest University , Winston-Salem , United States of America
| | - R H Christenson
- University of Maryland , Baltimore , United States of America
| | - R M Nowak
- Henry Ford Health System , Detroit , United States of America
| | - B E Mumma
- University of California , Davis , United States of America
| | - T Madsen
- University of Utah , Salt Lake City , United States of America
| | - J C O'Neill
- Wake Forest University , Winston-Salem , United States of America
| | - J P Stopyra
- Wake Forest University , Winston-Salem , United States of America
| | - S A Mahler
- Wake Forest University , Winston-Salem , United States of America
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Nowak RM, O'Neill JC, Ashburn NP, Snavely AC, Paradee BE, Allen BR, Christenson RH, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Patients with known coronary artery disease who are ruled out for acute myocardial infarction using a high sensitivity troponin T 0/1-hour algorithm have increased 30-day major adverse cardiac events. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) 0/1-hour high sensitivity troponin (hs-cTn) algorithm is widely used in the evaluation of patients presenting to the Emergency Department (ED) with symptoms suspicious for non ST-segment elevation myocardial infarction (NSTEMI). There is limited data available for the use of this algorithm comparing NSTEMI rule-out rates and 30-day adverse outcomes in patients with and without known coronary artery disease (CA), defined as prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis.
Purpose
The objective of this secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) United States (US) multicenter study was to compare the ESC 0/1-hour algorithm for rapid NSTEMI rule-out and 30-day adverse outcomes in patients with and without known CAD.
Methods
Patients (≥21 years old) presenting to the (ED) with symptoms suggestive of NSTEMI were enrolled (1/25/2017–9/6/2018) at 8 US medical centers. The ESC hs-cTnT 0/1-hour hs-cTnT algorithm was used to stratify patients into rule-out, observe, and rule-in zones. Algorithm performance for 30-day adverse outcomes was analyzed in patients with or without known CAD. Major adverse cardiovascular events (MACE) consisted of cardiac death, MI, or coronary revascularization. Fisher's exact tests were used to compare NSTEMI rule-out and 30-day MACE rates in patients with and without known CAD. Negative likelihood ratios (NLR) with a 95% confidence interval (CI) were calculated for 30-day MACE.
Results
Overall 1430 patients were enrolled. Of these 31.4% (449/1430) had known CAD while 14.2% (203 /1430) experienced 30-day MACE. Using the ESC 0/1-hour hs-cTnT algorithm 39.6% (178/449) of patients with known CAD were placed in the rule-out zone compared to 66.1% (648/981) without CAD (p<0.0001). Of patients with known CAD 23.2% (104/449) had 30-day MACE compared to 10.1% (99/981) of those without known CAD (p<0.0001). Additionally, amongst those patients placed in the rule-out zone, 30-day MACE occurred in 7.9% (14/178) of individuals with known CAD and 1.4% (9/648) of those without known CAD (p<0.0001). NLR for 30-day MACE was 0.28 (95% CI 0.17–0.47) in patients with known CAD and 0.13 (95% CI 0.07–0.23) in those without CAD.
Conclusions
In the multicenter US STOP-CP study patients with known CAD were less often rapidly ruled out for NSTEMI and had higher 30-day MACE rates than those without known CAD. Patients with known CAD who were rapidly ruled out for NSTEMI had a higher 30-day MACE rate compared to those without known CAD. Our analysis suggests that patients with known CAD require further cardiac reevaluations whether they are ruled out for NSTEMI by the ESC 0/1 hour hs-cTnT algorithm or not.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Roche, Basel, Switzerland
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Affiliation(s)
- R M Nowak
- Henry Ford Health System , Detroit , United States of America
| | - J C O'Neill
- Wake Forest University , Winston-Salem , United States of America
| | - N P Ashburn
- Wake Forest University , Winston-Salem , United States of America
| | - A C Snavely
- Wake Forest University , Winston-Salem , United States of America
| | - B E Paradee
- Wake Forest University , Winston-Salem , United States of America
| | - B R Allen
- University of Florida , Gainesville , United States of America
| | - R H Christenson
- University of Maryland , Baltimore , United States of America
| | - B E Mumma
- University of California , Davis , United States of America
| | - T Madsen
- University of Utah , Salt Lake City , United States of America
| | - J P Stopyra
- Wake Forest University , Winston-Salem , United States of America
| | - S A Mahler
- Wake Forest University , Winston-Salem , United States of America
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Allen BR, Christenson RH, Cohen SA, Weaver MT, Yang K, Mahler SA. Response by Allen et al to Letter Regarding Article, "Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort". Circulation 2021; 144:e285-e286. [PMID: 34748395 DOI: 10.1161/circulationaha.121.056533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Brandon R Allen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C.), University of Florida, Gainesville
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore (R.H.C.)
| | - Scott A Cohen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C.), University of Florida, Gainesville
| | - Michael T Weaver
- Department of Biobehavioral Nursing Science, College of Nursing (M.T.W.), University of Florida, Gainesville
| | - Kai Yang
- Department of Biostatistics, College of Public Health and Health Professions (K.Y.), University of Florida, Gainesville
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (S.A.M.)
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Allen BR, Christenson RH, Cohen SA, Nowak R, Wilkerson RG, Mumma B, Madsen T, McCord J, Huis In't Veld M, Massoomi M, Stopyra JP, Montero C, Weaver MT, Yang K, Mahler SA. Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort. Circulation 2021; 143:1659-1672. [PMID: 33474976 DOI: 10.1161/circulationaha.120.049298] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.
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Affiliation(s)
- Brandon R Allen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Robert H Christenson
- Departments of Pathology (R.H.C.), University of Maryland School of Medicine, Baltimore
| | - Scott A Cohen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Richard Nowak
- Department of Emergency Medicine (R.N.), Henry Ford Hospital, Detroit, MI
| | - R Gentry Wilkerson
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Bryn Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento (B.M.)
| | - Troy Madsen
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City (T.M.)
| | - James McCord
- Heart and Vascular Institute (J.M.), Henry Ford Hospital, Detroit, MI
- Department of Internal Medicine (J.M.), Henry Ford Hospital, Detroit, MI
| | - Maite Huis In't Veld
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Michael Massoomi
- Division of Cardiology, Department of Internal Medicine, College of Medicine (M.M.), University of Florida, Gainesville
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
| | - Cindy Montero
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Michael T Weaver
- Department of Biobehavioral Nursing Science, College of Nursing (M.T.W.), University of Florida, Gainesville
| | - Kai Yang
- Department of Biostatistics, College of Public Health and Health Professions (K.Y.), University of Florida, Gainesville
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
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Carter CC, Allen BR, Bui DV, Daley DA, Goncalves JM, Holinej CM, Lira S, Muniz DE, Santiago AI, Sukran N, Cundari TR, Yousufuddin M. Synthesis, crystal structures, and DFT calculations of tungsten (IV) and tungsten (VI) phosphino polyhydrides. Inorganica Chim Acta 2020. [DOI: 10.1016/j.ica.2020.119638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Background: Studies report the benefit of medical scribes in the emergency department on patient throughput, clinical documentation, patient outcomes, and provider and patient satisfaction. However, studies are silent on the benefits of being a scribe for premedical and medical students. Methods: The senior author interviewed 8 scribes who were applying for medical school and 9 medical students who had been scribes prior to medical school. Discussion was prompted on undergraduate education; scribe recruitment and training; career intentions; experience as a scribe; and the value of being a scribe to themselves, to the doctors with whom they worked, and to the hospital where they were employed. Results: The typical scribe had become a scribe to support his or her chances of entry into medical school. Those already in medical school were not convinced that this experience had actually made a difference in their acceptance. All 17 scribes were emphatic that the role had benefitted them in other ways, specifically, by learning medical terminology, observing communication between doctor and patient, and understanding the practice of medicine in an emergency department. For many scribes, the experience reinforced the desire to become a doctor. The scribes recognized their value in the areas of process and finance. They also recognized that many doctors, particularly those working in academic health centers, derived satisfaction from the training and mentoring that they offered. Conclusion: Scribes perceive the role of a scribe to be highly valuable in terms of their career decision making and future medical education.
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Affiliation(s)
- Robert M. Eley
- Emergency Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL
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Edwards MK, Christenson EN, Corliss BM, Polifka AJ, Allen BR. Corrigendum to "Vertebral Arteriovenous Fistula: An Unwelcome Thrill". Case Rep Emerg Med 2018; 2018:7514784. [PMID: 30174965 PMCID: PMC6106856 DOI: 10.1155/2018/7514784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/18/2018] [Indexed: 11/20/2022] Open
Abstract
[This corrects the article DOI: 10.1155/2017/8386459.].
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Affiliation(s)
- Matthew K. Edwards
- Department of Emergency Medicine, University of Florida Health, Gainesville, FL, USA
| | - Erica N. Christenson
- Department of Emergency Medicine, University of Florida Health, Gainesville, FL, USA
| | - Brian M. Corliss
- Department of Neurosurgery, University of Florida Health, Gainesville, FL, USA
| | - Adam J. Polifka
- Department of Neurosurgery, University of Florida Health, Gainesville, FL, USA
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida Health, Gainesville, FL, USA
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Abstract
Tacrolimus ointment is the first of a new class of non-steroidal topical immunomodulators indicated for the treatment of atopic dermatitis. Topical tacrolimushas been subject to an extensive clinical development program involving more than 16,000 patients. A clinical trial program, including vehicle-controlled studies, short- and long-term comparative studies and long-term safety studies, has investigated tacrolimus 0.1%and 0.03%ointment for the treatment of atopic dermatitis in adults and children aged 24 months and older. Tacrolimusmonotherapy is rapidly effective, resulting in clinical improvements within three days of starting therapy, and produces a progressive increase in efficacy that is sustained during long-term treatment. Tacrolimus treats the signs and symptoms of atopic dermatitis, reduces the incidence of flares, and offers the potential for long-term disease control. No major safety concerns have been reported to date. Tacrolimusointment is generally well tolerated, the primary adverse events being mild to moderate and transient application-site reactions: skin burning, pruritus and erythema. Tacrolimus oint-ment is a significant advance in dermatology and provides physicians with an alternative to conventional topical corticosteroid therapy.
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Affiliation(s)
- A Kapp
- a Dept. of Dermatology and Allergology , Hannover Medical University , Hannover , Germany
| | - B R Allen
- b Dept. of Dermatology , University Hospital, Queen's Medical Centre , Nottingham , UK
| | - S Reitamo
- c Dept. of Dermatology , Hospital for Skin and Allergic Diseases, University of Helsinki , Helsinki , Finland
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Simpson GG, Hahn HR, Powel AA, Leverence RR, Morris LA, Thompson LG, Zumberg MS, Borde DJ, Tyndall JA, Shuster JJ, Yealy DM, Allen BR. A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers. West J Emerg Med 2017; 18:335-339. [PMID: 28435481 PMCID: PMC5391880 DOI: 10.5811/westjem.2016.11.32273] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/04/2016] [Accepted: 11/14/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily. Methods We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a “medical home” for these patients. Results For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [−1.32–34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [−82.9–313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [−1.73–10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [−74.9–146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge. Conclusion This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.
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Affiliation(s)
- Grant G Simpson
- University of Florida, Department of Pharmacology, Gainesville, Florida.,University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Hallie R Hahn
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Alex A Powel
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Robert R Leverence
- University of Florida Health, Department of Medicine, Division of Hospital
| | - Linda A Morris
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Lara G Thompson
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Marc S Zumberg
- University of Florida, Department of Hematology/Oncology, Gainesville, Florida
| | - Deepa J Borde
- University of Florida Health, Department of Medicine, Division of Hospital.,University of Florida Health, Care One Clinic, Division of Hospital Medicine, Gainesville, Florida
| | - Joseph A Tyndall
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
| | - Jonathan J Shuster
- University of Florida Health, Department of Health Outcomes and Policy, Gainesville, Florida
| | - Donald M Yealy
- University of Pittsburgh and UPMC, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Brandon R Allen
- University of Florida, Department of Emergency Medicine, Gainesville, Florida
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Voils SA, Holder MC, Premraj S, Catlin JR, Allen BR. Comparative effectiveness of 3- versus 4-factor prothrombin complex concentrate for emergent warfarin reversal. Thromb Res 2015; 136:595-8. [DOI: 10.1016/j.thromres.2015.07.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/01/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
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Affiliation(s)
- B R Allen
- Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham, UK
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Allen BR. Transition to Practice: From Resident to Faculty at the Same Institution. J Grad Med Educ 2014; 6:799-800. [PMID: 26140141 PMCID: PMC4477588 DOI: 10.4300/jgme-d-14-00266.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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26
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Tsung AH, Allen BR. A 51-year-old woman crushed by an elephant trunk. Wilderness Environ Med 2014; 26:54-8. [PMID: 25443758 DOI: 10.1016/j.wem.2014.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 07/08/2014] [Accepted: 07/12/2014] [Indexed: 10/24/2022]
Abstract
Wild and exotic animal attacks are not common in the United States. Animal-related injuries in the United States are usually caused by dog bites, followed by cattle and horse injuries. Exotic animal attacks can occur when the animals are provoked, depressed, or housed improperly by owners. We report the case of a 51-year-old woman who sustained multiple systemic traumatic injuries after she was pinned to a fence by an elephant's trunk. Upon arrival in the emergency department, she was hypothermic with a temperature of 35.1ºC (95.1ºF), hypotensive to 94/60 mm Hg after 5 L crystalloid, tachycardic at 108 beats/min, and intubated with oxygen saturation of 100%. Tranexamic acid was administered in addition to starting a massive transfusion protocol. Injuries included bilateral multiple rib fractures, left abdominal wall degloving injury, right pneumothorax, right hemothorax, left chest wall puncture wound, grade IV splenic laceration, 3 grade III liver lacerations, retroperitoneal hematoma, and degloving injuries to bilateral posterior thighs requiring more than 30 operations. Why should an emergency physician be aware of this? Several factors need to be considered when evaluating animal-related injuries, including type, age, and sex of the animal. Multisystem traumatic injuries should be assumed when a large animal is involved. Prehospital care and transport time are vital to a patient's survival in both urban and rural settings. During the initial resuscitation, administering antibiotics tailored to the specific animal can greatly decrease risk of infection and morbidity. Additionally, tetanus immunoglobulin, tetanus toxoid, and rabies immunoglobulin and vaccine may be needed, unless the victim has been previously vaccinated.
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Affiliation(s)
- Ann H Tsung
- Department of Emergency Medicine, University of Florida Health, Gainesville, Florida.
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida Health, Gainesville, Florida
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Allen BR, Rodriguez JE. A modest proposal: impressions of a year one medical student. Med Educ 2007; 41:1131-1132. [PMID: 17986192 DOI: 10.1111/j.1365-2923.2007.02918.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Brandon R Allen
- Florida State University College of Medicine, Tallahassee, Florida 32306, USA.
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Lakhanpaul M, Davies T, Allen BR, Schneider D. Low systemic exposure in infants with atopic dermatitis in a 1-year pharmacokinetic study with pimecrolimus cream 1%*. Exp Dermatol 2006; 15:138-41. [PMID: 16433686 DOI: 10.1111/j.1600-0625.2006.00398.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Systemic drug exposure following the application of topical agents is a very important safety consideration, particularly in infants, who have a significantly higher ratio of body surface area to body mass than older children and adults. Here, we report on drug exposure in five infants aged 5.7-11.9 months at baseline, with extensive, moderate-to-severe atopic dermatitis (AD). Patients were treated bid for 1 year, as needed, with pimecrolimus cream 1% in an open-label, non-controlled study. No indication of drug accumulation was found; pimecrolimus blood concentrations were consistently low, ranging from below the limit of quantitation (0.1 ng/ml) to 1.94 ng/ml. Treatment over this prolonged period was well tolerated, with no evidence of any treatment-related adverse events. The results of this 1-year study indicate that long-term management of AD with pimecrolimus cream 1% is associated with consistently very low systemic absorption, even in the youngest patients with extensive disease.
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Affiliation(s)
- M Lakhanpaul
- Division of Child Health, University of Leicester, UK
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Allen BR, Lakhanpaul M, Morris A, Lateo S, Davies T, Scott G, Cardno M, Ebelin ME, Burtin P, Stephenson TJ. Systemic exposure, tolerability, and efficacy of pimecrolimus cream 1% in atopic dermatitis patients. Arch Dis Child 2003; 88:969-73. [PMID: 14612358 PMCID: PMC1719352 DOI: 10.1136/adc.88.11.969] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To measure pimecrolimus blood concentrations and to evaluate tolerability and efficacy in children and infants treated topically for atopic dermatitis with pimecrolimus cream 1% for three weeks. METHODS Three open label, non-controlled, multiple topical dose studies were conducted in children aged 8-14 years (study A, ten patients), and in infants aged 8-30 months (study B, eight patients) and 4-11 months (study C, eight patients). Pimecrolimus blood concentrations were determined on days 4 and 22 of treatment, and at end of study. Efficacy was assessed using the Eczema Area and Severity Index (EASI). RESULTS Pimecrolimus blood concentrations were consistently low, typically (81%) below 1 ng/ml, with more than half of the measurements below the assay limit of quantitation (0.5 ng/ml) in studies A and B. The highest blood concentration measured throughout the three studies was 2.6 ng/ml. The cream was well tolerated, locally and systemically. The most common adverse event suspected to be related to study medication was a transient mild to moderate stinging sensation at the application site in 5/26 patients. There was no indication of any systemic adverse effect. The patients responded well to therapy with a rapid onset of action, usually within four days. Median reductions of EASI from baseline at day 22 were 55% (study A), 63% (study B), and 83% (study C). CONCLUSION Three weeks treatment of children and infants with extensive atopic dermatitis, using pimecrolimus cream 1% twice daily, is well tolerated and results in minimal systemic exposure, at which no systemic effect is expected.
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Affiliation(s)
- B R Allen
- Department of Dermatology, University Hospital, Nottingham, UK
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Kapp A, Allen BR, Reitamo S. Atopic dermatitis management with tacrolimus ointment (Protopic). J DERMATOL TREAT 2003; 14:5-16. [PMID: 14522634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Tacrolimus ointment is the first of a new class of non-steroidal topical immunomodulators indicated for the treatment of atopic dermatitis. Topical tacrolimus has been subject to an extensive clinical development program involving more than 16,000 patients. A clinical trial program, including vehicle-controlled studies, short- and long-term comparative studies and long-term safety studies, has investigated tacrolimus 0.1% and 0.03% ointment for the treatment of atopic dermatitis in adults and children aged 24 months and older. Tacrolimus monotherapy is rapidly effective, resulting in clinical improvements within three days of starting therapy, and produces a progressive increase in efficacy that is sustained during long-term treatment. Tacrolimus treats the signs and symptoms of atopic dermatitis, reduces the incidence of flares, and offers the potential for long-term disease control. No major safety concerns have been reported to date. Tacrolimus ointment is generally well tolerated, the primary adverse events being mild to moderate and transient application-site reactions: skin burning, pruritus and erythema. Tacrolimus ointment is a significant advance in dermatology and provides physicians with an alternative to conventional topical corticosteroid therapy.
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Affiliation(s)
- A Kapp
- Department of Dermatology and Allergology, Hannover Medical University, Hannover, Germany.
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Abstract
BACKGROUND Atopic dermatitis (AD) is the most common inflammatory skin disorder and an important cause of morbidity in young children in the U.K. Such disability produces significant economic burden reflected in direct medical costs associated with health service utilization, direct family care costs such as transport costs, indirect costs associated with loss of productivity of carers, and intangible costs associated with the psychological effects of the disease. OBJECTIVES In order to evaluate this economic burden we conducted a cross-sectional survey of children aged 1-5 years in the Nottingham area in 1995-96. METHODS We sent a postal questionnaire to parents of all children aged 1-5 years with questions to identify those with AD; a second questionnaire was sent to parents of identified children regarding costs and utilization of medical services. Intangible costs were not evaluated. RESULTS The 12-month period prevalence of AD according to a dermatologist's diagnosis in 1761 children was 16.5% (95% confidence interval 14.7-18.2%). Total mean disease costs were estimated to be pound79.59 per child over the 12-month period of the study. The most significant costs were due to costs to the state for National Health Service (NHS) consultations ( pound28.62 mean annual cost) and prescriptions ( pound22.03). Consultations with general practitioners accounted for the significant bulk of consultation costs, with only 6% of children being seen in secondary care (17 of 290). Most prescribing costs (76%) were due to emollients and bath preparations. Family care costs ( pound28.94 mean annual cost) accounted for 36% of total disease costs and were associated with changes to the home environment, purchase of over-the-counter medicines, transport costs, visits to homoeopaths and salary loss. CONCLUSIONS The results signify that AD is an important cause of economic burden both to the NHS and to the families of affected children. Using population census data and the results in this study, we estimated that the annual U.K. cost of AD in children aged 1-5 years in 1995-96 was pound47 million.
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Affiliation(s)
- R M Emerson
- Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, U.K.
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Clark CM, Kirby B, Morris AD, Davison S, Zaki I, Emerson R, Saihan EM, Chalmers RJ, Barker JN, Allen BR, Griffiths CE. Combination treatment with methotrexate and cyclosporin for severe recalcitrant psoriasis. Br J Dermatol 1999; 141:279-82. [PMID: 10468800 DOI: 10.1046/j.1365-2133.1999.02976.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An increasingly important approach to the management of patients with severe psoriasis is the concurrent use of two systemic treatments. Previous guidelines have advised against the use of methotrexate and cyclosporin in combination. We report the successful use of a combination of methotrexate and cyclosporin in the treatment of 19 patients with severe, recalcitrant psoriasis, 15 of whom had psoriatic arthropathy. Most patients had previously received two or more systemic treatments. Before combination treatment was started nine of the patients were taking methotrexate and 10 were taking cyclosporin at the maximum tolerated doses. The duration of combination treatment was bimodally distributed, with seven patients having short-term treatment (mean +/- SD duration 18. 9 +/- 15.7 weeks) and 12 patients having long-term treatment (mean +/- SD duration 193.2 +/- 160.6 weeks). Those patients who received short-term treatment did not develop any evidence of toxicity from either agent. Of those patients on long-term treatment, three developed mild impairment of renal function that returned to normal following a reduction in dose of cyclosporin, and three had impairment of renal function (following long-term cyclosporin monotherapy) that improved, but did not normalize, following a reduction in dose of cyclosporin. In each case, combination treatment for psoriasis resulted in good control of both skin and joint problems using lower doses of each agent than would have been used for monotherapy. We conclude that the combination of methotrexate and cyclosporin is an effective treatment for this group of patients.
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Affiliation(s)
- C M Clark
- Dermatology Centre, University of Manchester, Hope Hospital, Salford M6 8HD, UK
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Abstract
Although atopic dermatitis is the most common inflammatory dermatosis affecting children, no previous studies have evaluated the relationship between disease severity and the referral pattern to secondary health care services. We carried out a cross-sectional survey of 1760 children aged 1-5 years selected from the age-sex registers of four urban and semiurban general practices in Nottingham. Atopic dermatitis was diagnosed by a dermatologist on the basis of symptoms and signs of a flexural itchy rash that had been present in the previous 12 months. The severity of atopic dermatitis was assessed clinically by the same dermatologist on the basis of reported symptoms over the previous 12 months and clinical signs, and was graded on a three-point scale as mild, moderate or severe. Information on the use of primary and secondary health care services was recorded at the time of the interview. The 1-year period prevalence of atopic dermatitis was 16.5% (95% confidence interval 14.7-18.2%). The severity distribution of atopic dermatitis was: mild 84% (n = 242), moderate 14% (n = 41) and severe 2% (n = 7). Of those children with atopic dermatitis, 96% (n = 278) had consulted their general practitioner in the previous 12 months and 6% (n = 17) had been seen in secondary care. Overall, 4% (n = 11) of those children with atopic dermatitis had a consultation with a dermatologist. Other sources of secondary care referral included the paediatric department (n = 2) and accident and emergency department (n = 6). Referral to secondary care was found to be positively related to disease severity, with referral occurring in 3% of mild cases, 15% of moderate cases and 43% of severe cases. Although the relative referral rate of mild and moderately severe disease was low, these cases were found to represent a significant proportion (82%) of the total numbers of children seen in secondary care. This study has shown that: (i) most cases of atopic dermatitis in the community are mild in severity; (ii) referral to secondary health care services by general practitioners is infrequent; (iii) disease severity is an important determinant of referral to secondary care; and (iv) any potential change in the referral pattern of mild/moderate cases of atopic dermatitis to secondary care is likely to produce a significant increase in workload for dermatology departments.
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Affiliation(s)
- R M Emerson
- Dermato-Epidemiology Research Unit, University Hospital, Queen's Medical Centre, Nottingham, U.K
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Parkes IR, Zaki I, Stevens A, Davies JM, Allen BR. Graft-versus-host disease-like eruption in a patient with non-Hodgkin's lymphoma. Br J Dermatol 1997; 137:137-9. [PMID: 9274642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Graft-versus-host disease (GVHD) is most commonly seen as a complication of bone marrow transplantation, although it can occur whenever tissue or blood products are given whereby immunologically competent donor lymphocytes react against host tissues. A 65-year-old man with non-Hodgkin's lymphoma developed a severe widespread erosive eruption of the skin and mucosal surfaces. Clinically and histologically it was identical to cutaneous GVHD even though the patient had never received tissue or blood products. He failed to respond to conventional therapy for GVHD, but his skin improved significantly on treating his underlying lymphoma, which eventually proved fatal. There are two previous reports of GVHD associated with malignancy but we believe this to be the first case secondary to a lymphoma.
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Affiliation(s)
- I R Parkes
- Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham, U.K
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Berth-Jones J, Graham-Brown RA, Marks R, Camp RD, English JS, Freeman K, Holden CA, Rogers SC, Oliwiecki S, Friedmann PS, Lewis-Jones MS, Archer CB, Adriaans B, Douglas WS, Allen BR. Long-term efficacy and safety of cyclosporin in severe adult atopic dermatitis. Br J Dermatol 1997; 136:76-81. [PMID: 9039299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A prospective, open, multicentre study was performed to investigate the efficacy and safety of long-term treatment with cyclosporin in adults with severe atopic dermatitis. Subjects were treated for a maximum of 48 weeks. For the first 8 weeks, cyclosporin was administered at 2.5 mg/kg per day. The dose was then adjusted according to response. Disease activity was monitored using the six-area, six-sign score and the proportion of skin involved. Pruritus and sleep disturbance were assessed using four-point scales. Response was further evaluated on a five-point scale. Adverse events, blood pressure and serum biochemistry were monitored. Tolerability was assessed on a five-point scale. One hundred subjects were enrolled and 65 completed 48 weeks of treatment. Withdrawals occurred due to remission (three), inadequate response (seven), protocol violations (11) and adverse events (14, of which seven were probably treatment related). Cyclosporin produced rapid and highly significant improvements in all indices of disease activity. Sixty-five subjects considered that they had shown a considerable improvement or complete clearance of disease. Most patients relapsed after cessation of treatment, but neither signs nor symptoms had returned to baseline severity 8 weeks later. Blood pressure and serum creatinine levels increased slightly, and in one subject renal impairment was a major factor contributing to withdrawal of the drug. Overall, 85 subjects rated the tolerability of cyclosporin as good or very good. The results indicate that cyclosporin has a place in the long-term treatment of severe atopic dermatitis provided that appropriate patients are selected and careful monitoring is performed.
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Affiliation(s)
- J Berth-Jones
- Department of Dermatology, Walsgrave Hospital, Coventry, UK
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Abstract
Cyclosporin has been shown to be effective in the treatment of adult atopic dermatitis, but there are no clinical trials evaluating its use in childhood. Atopic dermatitis is more common in children and the severe form can be associated with considerable morbidity. We report on 18 children with severe refractory atopic dermatitis who have been treated with cyclosporin on an open basis. The drug was given at an initial daily dose of 5 or 6 mg/kg and in some patients the dose was reduced according to response. Sixteen patients showed a good or excellent response to treatment, one a moderate response and one patient failed to improve. The treatment was well tolerated and there were no significant changes in serum creatinine or blood pressure. Long remission after withdrawal of treatment was seen in some patients, although most relapsed within a few weeks. We suggest that cyclosporin is an effective and safe short-term treatment for severe atopic dermatitis in childhood.
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Affiliation(s)
- I Zaki
- Department of Dermatology, University Hospital, Nottingham, U.K
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Berth-Jones J, Finlay AY, Zaki I, Tan B, Goodyear H, Lewis-Jones S, Cork MJ, Bleehen SS, Salek MS, Allen BR, Smith S, Graham-Brown RA. Cyclosporine in severe childhood atopic dermatitis: a multicenter study. J Am Acad Dermatol 1996; 34:1016-21. [PMID: 8647967 DOI: 10.1016/s0190-9622(96)90281-9] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe atopic dermatitis (AD) remains difficult to treat. Cyclosporine is effective in adults but has not previously been investigated in children with AD. OBJECTIVE The aims were to investigate the efficacy, safety, and tolerability of cyclosporine in severe refractory childhood AD. METHODS Subjects 2 to 16 years of age were treated for 6 weeks with cyclosporine, 5 mg/kg per day, in an open study. Disease activity was monitored every 2 weeks by means of sign scores, visual analogue scales for symptoms, and quality-of-life questionnaires. Adverse events were monitored. Efficacy and tolerability were assessed with five-point scales. RESULTS Twenty-seven children were treated. Significant improvements were seen in all measures of disease activity. Twenty-two showed marked improvement or total clearing. Quality of life improved for both the children and their families. Tolerability was considered good or very good in 25 subjects. CONCLUSION Cyclosporine may offer an effective, safe, and well-tolerated short-term treatment option for children with severe AD.
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Affiliation(s)
- J Berth-Jones
- Department of Dermatology, Walsgrave Hospital, Coventry, U.K
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Scerri L, Williams HC, Allen BR. Dissecting cellulitis of the scalp: response to isotretinoin. Br J Dermatol 1996; 134:1105-8. [PMID: 8763434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We report three patients with dissecting cellulitis of the scalp. Prolonged treatment with oral isotretinoin was highly effective in all three patients. Furthermore, long-term post-treatment follow-up in two of the patients has shown a sustained therapeutic benefit.
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Affiliation(s)
- L Scerri
- Department of Dermatology, University Hospital, Queen's Medical Centre NHS Trust, Nottingham, U.K
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Affiliation(s)
- L Scerri
- Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham, England
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Abstract
Dermatomyositis (DM) is a connective tissue disorder characterized by cutaneous and muscle involvement. It is a well recognized paraneoplastic syndrome and has been linked with malignancy in 15-34% of adult patients. The course of DM in such patients usually correlates closely with the activity of the underlying malignancy. We report a patient who developed DM 4 years after excision of a malignant melanoma (MM) from the back and 1 year before the diagnosis of metastatic disease. A literature review revealed that the association of dermatomyositis with MM is rare and consistent with a dismal prognosis.
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Affiliation(s)
- L Scerri
- Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham, UK
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Salek MS, Finlay AY, Luscombe DK, Allen BR, Berth-Jones J, Camp RD, Graham-Brown RA, Khan GK, Marks R, Motley RJ. Cyclosporin greatly improves the quality of life of adults with severe atopic dermatitis. A randomized, double-blind, placebo-controlled trial. Br J Dermatol 1993; 129:422-30. [PMID: 8217757 DOI: 10.1111/j.1365-2133.1993.tb03170.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A multicentre, randomized, double-blind, controlled crossover clinical trial was conducted on 33 patients with severe refractory atopic dermatitis, to determine the effects of cyclosporin (5 mg/kg/day) on their health-related quality of life. Treatments were administered for 8-week periods. One group (n = 16) received placebo followed by cyclosporin, and the other (n = 17) received cyclosporin and then placebo. Health-related quality of life was assessed at 0, 8 and 16 weeks using a general measure, the United Kingdom Sickness Impact Profile (UKSIP), an eczema-specific measure, the Eczema Disability Index (EDI), and a global 5-point rating scale of overall health (very good to very poor). In addition, clinical assessments (i.e. extent and activity of disease) were made by the investigators. UKSIP and EDI scores indicated significant improvement in quality of life (P < 0.05-P < 0.01) of patients with atopic dermatitis after treatment with cyclosporin. Although no patient required withdrawal from the study, 20 patients receiving cyclosporin reported adverse events, compared with eight taking placebo. There was a close correlation (P < 0.05-P < 0.01) between the UKSIP and EDI scores. In contrast, there was either no correlation, or only a very poor correlation, between the quality of life parameters and clinical measures of extent and activity of eczema. When cyclosporin was stopped, relapse was rapid, but the mean scores for disease activity and extent of disease were less than their baseline values (i.e. an improvement of greater than 25% was maintained in 11 patients at week 4).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M S Salek
- Medicines Research Unit, University of Wales College of Cardiff, U.K
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Abstract
An analysis of peripheral blood lymphocyte subsets and their expression of activation markers was performed using flow cytometry in 12 adult patients with severe atopic dermatitis, and compared with 14 normal individuals. Repeated measurements were made over an 8-week period during which disease activity was also assessed. Increased percentages of activated and unactivated CD4+ lymphocytes, and decreased percentages of CD8+ cells were observed in atopic dermatitis. Increasing disease activity was associated with an increase in the proportion of activated and unactivated CD4+ lymphocytes and a fall in the proportion of CD8+ cells. This study demonstrates that in adults with severe atopic dermatitis, increasing disease activity is associated with selective activation of CD4+ lymphocytes and a relative expansion of the CD4+ cell subset.
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Affiliation(s)
- J M Sowden
- Department of Dermatology, University Hospital, Queen's Medical Centre, Nottingham, U.K
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Affiliation(s)
- J M Sowden
- Dermatology Department, University Hospital, Nottingham, UK
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