Implementation of a pre-hospital decision rule in general practice: Triage of patients with suspected myocardial infarction

OBJECTIVE: To improve pre-hospital triage of patients with suspected acutecardiac disease DESIGN: Prospective study SUBJECTS: Patients with symptoms suggestive of acute cardiac pathology,who were seen by a general practitioner, for whom acute admissioninto hospital was requested, and in whom a pre-hospital electrocardiogramwas recorded by the ambulance service METHODS: The study consisted of two phases. In the first phase, a decisionrule was developed based on clinical characteristics and electrocardiographicfindings in 1005 patients with suspected acute cardiac pathology.In the second phase, the decision rule was prospectively validated.Symptoms were recorded by a standardized questionnaire by thegeneral practitioner and a computerized electrocardiogram wasmade by the ambulance nurses at the patient's home. Three electrocardiographicoutcomes were available: ‘normal electrocardiogram’,‘possible myocardial infarction’ or ‘extensivemyocardial infarction’. By use of the predictive model,the general practitioner could decide if hospitalization wasnecessary or not. MAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chestpain, other pathology) and high (myocardial infarction, unstableangina) probability of acute cardiac pathology. RESULTS: Among 977 patients with a complete pre-hospital evaluation inthe validation phase of the study, the decision rule recommended‘no hospitalization’ in 227 patients (23%). Thegeneral practitioner followed this advice in 44% of these patients.Although seven of them developed a non-Q wave myocardial infarction,no complications occurred in patients not admitted. In addition,the general practitioner did not hospitalize 19 (2%) of 750patients for whom the decision rule recommended admission. Prehospitaltriage by the general practitioner resulted in a 12% (118 of977 patients) reduction of the number of patients admitted tothe Coronary Care Units. CONCLUSIONS: Pre-hospital triage by the general practitioner was facilitatedusing a standardized questionnaire and pre-hospital electrocardiography,and resulted in a reduction in the number of patients admittedto the Coronary Care Unit, and proved to be safe.     

Does nonsteroidal anti-inflammatory drug use modify the effect of a low-fat, high-fiber diet on recurrence of colorectal adenomas?

The Polyp Prevention Trial was designed to evaluate the effects of a high-fiber (18 g/1,000 kcal), high-fruit and -vegetable (3.5 servings/1,000 kcal), low-fat (20% energy) diet on recurrence of adenomatous polyps. Participants > or =35 years of age, with histologically confirmed colorectal adenoma(s) removed in the prior 6 months, were randomized to the intervention or control group. Demographic, dietary, and clinical information, including use of nonsteroidal anti-inflammatory drugs (NSAID), was collected at baseline and four annual visits. Adenoma recurrence was found in 754 of 1,905 participants and was not significantly different between groups. NSAID use was associated with a significant reduction in recurrence [odds ratio (OR), 0.77; 95% confidence interval (95% CI), 0.63-0.95]. In this analysis, NSAIDs modified the association between the intervention and recurrence at baseline (P = 0.02) and throughout the trial (P = 0.008). Among participants who did not use NSAIDs, the intervention was in the protective direction but did not achieve statistical significance (OR, 0.87; 95% CI, 0.69-1.09). The intervention was protective among males who did not use NSAIDs at baseline (OR, 0.71; 95% CI, 0.54-0.94), but not among NSAIDs users (OR, 1.09; 95% CI, 0.74-1.62). For females, corresponding OR estimates were 1.28 (95% CI, 0.86-1.90) and 2.30 (95% CI, 1.24-4.27), respectively. The protective association observed for NSAID use was stronger among control (OR, 0.63; 95% CI, 0.47-0.84) than for intervention group participants (OR, 0.97; 95% CI, 0.74-1.28). These results should be interpreted cautiously given that they may have arisen by chance in the course of examining multiple associations and Polyp Prevention Trial study participants were not randomly assigned to both dietary intervention and NSAID use. Nevertheless, our results suggest that adopting a low-fat, high-fiber diet rich in fruits and vegetables may lower the risk of colorectal adenoma recurrence among individuals who do not regularly use NSAIDs.     

Systematic Evidence Map for Over One Hundred and Fifty Per- and Polyfluoroalkyl Substances (PFAS)

Background: Per- and polyfluoroalkyl substances (PFAS) are a large class of synthetic (man-made) chemicals widely used in consumer products and industrial processes. Thousands of distinct PFAS exist in commerce. The 2019 U.S. Environmental Protection Agency (U.S. EPA) Per- and Polyfluoroalkyl Substances (PFAS) Action Plan outlines a multiprogram national research plan to address the challenge of PFAS. One component of this strategy involves the use of systematic evidence map (SEM) approaches to characterize the evidence base for hundreds of PFAS.Objective: SEM methods were used to summarize available epidemiological and animal bioassay evidence for a set of ∼150 PFAS that were prioritized in 2019 by the U.S. EPA’s Center for Computational Toxicology and Exposure (CCTE) for in vitro toxicity and toxicokinetic assay testing.Methods: Systematic review methods were used to identify and screen literature using manual review and machine-learning software. The Populations, Exposures, Comparators, and Outcomes (PECO) criteria were kept broad to identify mammalian animal bioassay and epidemiological studies that could inform human hazard identification. A variety of supplemental content was also tracked, including information on in vitro model systems; exposure measurement–only studies in humans; and absorption, distribution, metabolism, and excretion (ADME). Animal bioassay and epidemiology studies meeting PECO criteria were summarized with respect to study design, and health system(s) were assessed. Because animal bioassay studies with ≥21-d exposure duration (or reproductive/developmental study design) were most useful to CCTE analyses, these studies underwent study evaluation and detailed data extraction. All data extraction is publicly available online as interactive visuals with downloadable metadata.Results: More than 40,000 studies were identified from scientific databases. Screening processes identified 44 animal and 148 epidemiology studies from the peer-reviewed literature and 95 animal and 50 epidemiology studies from gray literature that met PECO criteria. Epidemiological evidence (available for 15 PFAS) mostly assessed the reproductive, endocrine, developmental, metabolic, cardiovascular, and immune systems. Animal evidence (available for 40 PFAS) commonly assessed effects in the reproductive, developmental, urinary, immunological, and hepatic systems. Overall, 45 PFAS had evidence across animal and epidemiology data streams.Discussion: Many of the ∼150 PFAS were data poor. Epidemiological and animal evidence were lacking for most of the PFAS included in our search. By disseminating this information, we hope to facilitate additional assessment work by providing the initial scoping literature survey and identifying key research needs. Future research on data-poor PFAS will help support a more complete understanding of the potential health effects from PFAS exposures. https://doi.org/10.1289/EHP10343     

Oxidative Balance Score during Pregnancy Is Associated with Oxidative Stress in the CANDLE Study

The objective of this study was to calculate an oxidative balance score (OBS) utilizing diet and lifestyle information collected from 1322 women during the second trimester of pregnancy in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study. An energy-adjusted OBS was calculated using nutrient information from a Food Frequency Questionnaire (FFQ), lifestyle measures, and plasma folate and vitamin D levels. Using the least absolute shrinkage and selection operator method, 91 food items from the FFQ were selected and they accounted for 82% of the variance in the OBS, with cruciferous vegetables, citrus fruits, fruit juice, and coffee being among the highest anti-oxidant predictors, and red meats and alcohol among the highest pro-oxidant contributors. Urinary F₂-isoprostane, an objective indicator of oxidative stress, was lower with increasing OBS quintiles in a stairstep manner (p for trend = 0.0003), suggesting the possible utility of the OBS as an indicator of oxidative stress. The OBS was moderately correlated with the Healthy Eating Index (correlation coefficient = 0.6076), suggesting it provides a distinct measure of a healthy diet. In conclusion, the OBS may serve as a valid reflective indicator of urinary F₂-isoprostanes and an epidemiological tool to inform intervention studies, in order to minimize oxidative stress during pregnancy.     

Assessment of functioning in Dutch primary care: Development study of a consultation tool for patients with chronic conditions and multimorbidity

BackgroundIn primary care, a shift from a disease‐oriented approach for patients with multimorbidity towards a more person‐centred approach is needed.AimTo transform a self‐report questionnaire for patients with chronic conditions in primary care, the Primary Care Functioning Scale (PCFS), into an understandable, visually attractive and feasible consultation tool for patients and health care providers. The consultation tool consists of a web‐based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person‐centred conversation for patients with chronic conditions and multimorbidity in general practice.Design and SettingIn this qualitative study, we developed the consultation tool by using design thinking in a participatory developmental process.MethodsIn the first phase, we constructed five different feedback report templates to summarize and display the results of a completed PCFS questionnaire in a series of two expert meetings with patients and general practitioners (GPs). In the second phase, we performed an exploratory qualitative interview study involving dyads of patients with chronic conditions and their practice nurses. In an iterative process, we explored their experiences with the consultation tool.ResultsPatients, as well as GPs, preferred a clear manner of presenting the results of the questionnaire in a feedback report. In 18 interviews with patients and practice nurses during three different interview rounds, we adjusted the feedback report and consultation tool based on the input from patients and practice nurses. After the final interview round, patients and practice nurses consented that the consultation tool was useful for having a more in‐depth consultation about functioning and patients'' preferences when integrated into the regularly scheduled consultations.ConclusionWe were able to develop an understandable and feasible consultation tool that is applicable in already existing chronic disease management programmes in general practice in the Netherlands.Patient or Public ContributionTo increase the understandability and feasibility of the consultation tool, we collaborated with end‐users and actively involved patients, GPs and practice nurses in a participatory development process.     

Assessment of Functional Ability of People with Alzheimer's Disease

The aim of this study was to examine the sensitivity of the Assessment of Motor and Process Skills (AMPS) in discriminating between independent people, those with dementia of the Alzheimer's type (DAT) requiring minimal assistance to live in the community (DAT-min) and those with DAT requiring moderate to maximal assistance (DAT-mod). The subjects comprised 329 non-disabled older adults, 167 people with DAT-min and 292 with DAT-mod. The AMPS was used to measure the subjects' ADL motor and ADL process abilities. Significant main effects were seen for ADL motor and ADL process abilities. All three groups differed significantly in both motor and process mean ability measures and the proportion of people with DAT with ability measures below AMPS cut-off measures increased significantly as the functional level decreased. The ADL process scale was a more discriminative measure of ability to function in the community than was the ADL motor scale.     

Effect of underlying disease and age on pneumococcal serotype distribution

The hospital records of 264 patients with 277 episodes of pneumococcal bacteremia occurring at New York Hospital-Cornell Medical Center over the period 1970 to 1980 were examined to determine whether serotype distribution varied with the underlying disease or age of the patient. The patients were placed into three groups according to their underlying disease. Group A consisted of all patients with significant impairment of their immune system. Group B included those patients with underlying conditions that were not associated with immune deficiency. Group C comprised those patients considered to be normal hosts. Overall, 84 percent of blood isolates were serotypes included in the vaccine. In Group A, only 73 percent of these isolates were vaccine types, compared with 85 percent in Group B and 97 percent in Group C (differences significant at p < 0.001). Vaccine serotypes were more common in children than adults (92 versus 81 percent), but in analysis that controlled for underlying disease, the elderly did not differ from younger adults in serotype distribution. The apparent predilection of nonvaccine serotypes to cause bacteremia in immunocompromised patients may be one factor limiting vaccine efficacy in this high-risk population.