A Risk Assessment Score and Initial High‐sensitivity Troponin Combine to Identify Low Risk of Acute Myocardial Infarction in the Emergency Department

Objectives

Early discharge of patients with presentations triggering assessment for possible acute coronary syndrome (ACS) is safe when clinical assessment indicates low risk, biomarkers are negative, and electrocardiograms (ECGs) are nonischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score (EDACS) combined with a single measurement of high‐sensitivity cardiac troponin (hs‐cTn) could allow early discharge of a clinically meaningful proportion of patients.

Methods

We pooled data from four patient cohorts from New Zealand and Australia presenting to an emergency department with symptoms suggestive of ACS. The primary outcome was major adverse cardiac events (MACE) within 30 days of presentation. In patients with a nonischemic ECG we evaluated the sensitivity for MACE and percentage low risk of every combination of high‐sensitivity cardiac troponin T (hs‐cTnT) concentration and high‐sensitivity cardiac troponin I (hs‐cTnI) concentration with EDACS. We used a standard smoothing technique on the probability density function for hs‐cTn and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely, the combination that maximized the percentage low risk with ≥98.5% sensitivity for MACE.

Results

From 2,536 patients, 2,258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs‐cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low risk). The optimal thresholds for hs‐cTnT were 8 ng/L combined with an EDACS threshold of 15 (30.2% patients low risk).

Conclusion

Single measurements of both hs‐cTnI and hs‐cTnT at presentation combined with EDACS to identify over 30% of patients as low risk and therefore eligible for safe early discharge after only one blood draw.

     

Associations of Diet and Lifestyle With Headache in High‐School Students: Results From a Cross‐Sectional Study

(Headache 2010;50:1104‐1114) Background.— Diet and lifestyle are seen as factors which influence headache in adults. However, population‐based studies on this issue in adolescents are rare. Objective.— Aim of the present study was to investigate associations between diet and lifestyle factors and different types of headache, ie, migraine and tension‐type headache (TTH) in adolescents. Methods.— A total of 1260 adolescents from the 10th and 11th grades of high schools filled in questionnaires on intake of meals, coffee, nonalcoholic and alcoholic drinks, smoking, and physical activity. Type of headache was classified according to the International Classification of Headache Disorders – 2nd edition. Multiple logistic regression models, adjusted for sex and grade, were calculated. Results.— High consumption of cocktails (odds ratio = 3.4; 95% confidence interval 1.9‐6.0) and coffee (2.4; 1.3‐4.7), smoking (2.7; 1.4‐5.1), and lack of physical activity (2.2; 1.3‐3.7) were significantly associated with migraine plus TTH episodes, consumption of coffee and physical inactivity particularly with migraine (3.4; 1.6‐7.0 and 4.2; 2.2‐7.9, respectively) and physical inactivity with TTH (1.7; 1.1‐2.7). Skipping of meals or insufficient fluid intake were not associated with any type of headache. Conclusions.— Adolescents with any type of headache might benefit from regular physical activity and low consumption of alcoholic drinks, while for migraine patients a low consumption of coffee should additionally be recommended. Intervention studies are warranted to assess whether psycho‐educational programs conferring knowledge of these associations will influence headache‐triggering behavior and headache in adolescents.     

Clinical Application of a Modern High‐Definition Head‐Mounted Display in Sonography

Because of the remarkably improved image quality and wearability of modern head‐mounted displays, a monitoring system using a head‐mounted display rather than a fixed‐site monitor for sonographic scanning has the potential to improve the diagnostic performance and lessen the examiner's physical burden during a sonographic examination. In a preclinical setting, 2 head‐mounted displays, the HMZ‐T2 (Sony Corporation, Tokyo, Japan) and the Wrap1200 (Vuzix Corporation, Rochester, NY), were found to be applicable to sonography. In a clinical setting, the feasibility of the HMZ‐T2 was shown by its good image quality and acceptable wearability. This modern device is appropriate for clinical use in sonography.     

Small Liver Nodule Detection With a High‐Frequency Transducer in Patients With Chronic Liver Disease

We report 3 cases in which small liver lesions were revealed on sonography with the supplemental use of a high‐frequency transducer. In all 3 cases, the patients had cirrhosis or chronic liver disease. The lesions were not seen on computed tomography or magnetic resonance imaging. Sonography plays a pivotal role in surveillance for hepatocellular carcinoma and, with modern transducer technology, may be the first imaging modality to show an early small tumor. A more thorough search for focal liver lesions with adjunctive use of high‐frequency transducers may prolong the examination time but can improve surveillance for hepatocellular carcinoma.     

Clinical diagnosis and outcomes for Troponin T ‘positive’ patients assessed by a high sensitivity compared with a 4th generation assay

Background: High sensitivity troponin T (hsTnT) detects lower levels of troponin T with greater precision than the 4th generation (cTnT) assay. However, the clinical implications of this are uncertain. Objectives: Primary: Describe the proportion of patients who test ‘positive’ with hsTnT but negative with cTnT. Secondary: Determine proportion in each group with an adverse event (representation, AMI or died) within 90 days of the index test. Method: 161 patients samples were tested with cTnT and hsTNT assays. McNemar's test was used to compare paired samples. Electronic medical records were reviewed, with discharge diagnosis and 90 day outcomes determined blind to hsTnT results. Patients were then classified as ‘TnT negative’ (hsTnT was <0.014 mcg/mL), ‘new positive’ (hsTnT was ≥0.014 mcg/mL and cTnT <0.03 mcg/mL) and ‘TnT positive’ (cTNT was ≥0.03 mcg/mL). Results: Positive results more than doubled with the hsTnT assay (50% vs 22%, P < 0.001). 81 patients were ‘TnT negative’, 44 were ‘new positive’ and 36 ‘cTnT positive’. The discharge diagnosis for ‘new positives’ was AMI in 4 (9%), other cardiac in 13 (30%) and non‐cardiac in 27 (61%). At 90 days adverse events occurred in 30%, 54% and 50% of the groups respectively. There were no late cases of AMI or cardiovascular death in ‘new positive’ patients. Conclusion: Many patients with diagnoses other than AMI will have hsTNT above the reference level. Indiscriminate testing with hsTnT might lead to more patients requiring serial troponin testing and/or invasive further tests, which will have process and resource implications for EDs and health services.     

Chronic Migraine With Medication Overuse Pre–Post Withdrawal of Symptomatic Medication: Clinical Results and fMRI Correlations

(Headache 2010;50:998‐1004) Background.— Chronic migraine with symptomatic medication overuse (CMwMO) is a common and often debilitating clinical condition. Withdrawal of the offending drug(s) is considered the first step in management. Functional magnetic resonance imaging (fMRI) may be a useful technique for obtaining information on particular neuronal changes in the pain network involved in this condition. Objective.— To identify specific fMRI patterns in patients suffering from CMwMO before and after withdrawal intervention. Methods.— We collected fMRI data from a group of patients suffering from CMwMO, evaluating those patients prior to and 6 months following withdrawal. We applied stimuli at sites far removed from where the headaches were experienced. Moreover, pre‐intervention fMRI data from the headache patients were compared with those obtained from headache‐free and otherwise healthy controls. Results.— Before withdrawal, the right supramarginal gyrus, the right inferior and superior parietal cortex were hypoactive. Activity recovered to almost normal 6 months after withdrawal of the offending medications. Conclusions.— The hypoactivation we detected in the lateral pain system indicate that there exists a modification of the pain network in CMwMO and that these changes are reversible with therapy.     

Externalizing Metaphors: Anxiety and High‐Functioning Autism

TOPIC: The intent of this article is to explore the efficacy of both the literal and concrete externalization aspects within narrative therapy, and the implementation of interactive metaphors as a combined psychotherapeutic approach for decreasing anxiety with people who present with high‐functioning autism. PURPOSE: The purpose of this exploratory article is to propose the use of externalizing metaphors as a treatment modality as a potentially useful way to engage clients. Specifically, a three‐step process of change is described, which allows for concretizing affective states and experiences, and makes use of visual strengths of people presenting with an autism spectrum disorder. SOURCE: A selective review was conducted of significant works regarding the process of change in narrative therapy, with particular emphasis on metaphors. Works were selected based on their relevance to the current paper and included both published works (searched via Psyc‐INFO) and materials from narrative training sessions. CONCLUSIONS: Further research is needed to address the testable hypotheses resulting from the current model. This line of research would not only establish best practices in a population for which there is no broadly accepted treatment paradigm, but would also contribute to the larger fields of abnormal psychology, emotion regulation, and cognitive psychology by further elucidating the complex ways these systems interact.