Editor’s note: Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals, and are not peer reviewed or edited by Hong Kong Journal of Emergency Medicine.
Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts
Richard Body, Edward Carlton, Matthew Sperrin, Philip S Lewis, Gillian Burrows, Simon Carley, Garry McDowell, Iain Buchan, Kim Greaves and Kevin Mackway-Jones
Body R, et al. Emerg Med J 2016;0:1-8. doi:10.1136/emermed-2016-205983
Background: The original Manchester Acute Coronary Syndromes model (MACS) ‘rules in’ and ‘rules out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT.
Methods: We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30 days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set).
Results: At the ‘rule out’ threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%–99.8%) sensitivity for ACS, ‘ruling out’ 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%–99.8%) NPV and 98.1% (95.2%–99.5%) sensitivity, ‘ruling out’ 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation).
Conclusions: T-MACS could ‘rule out’ ACS in 40% of patients, while ‘ruling in’ 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources.
Nontherapeutic international normalized ratio results in hospital emergency patients on vitamin K antagonists: prevalence and associated factors
Xavier López Altimiras, Emili Gené Tous, Antonio De Giorgi, Andrés Gadea Polo, Raquel Martín Horcajo and Sònia Jiménez Hernández.
Emergencias 2017;29:93-98 Available at: http://emergencias.portalsemes.org/descargar/prevalencia-y-factores-asociados-a-un-international-normalized-ratio-inr-fuera-de-rango-en-pacientes-en-tratamiento-con-antivitamina-k-atendidos-en-servicios-de-urgencias-hospitalarios/
Cited: López Altimiras X, Gené Tous E, De Giorgi A, Gadea Polo A, Martín Horcajo R, Jiménez Hernández S. Nontherapeutic international normalized ratio results in hospital emergency patients on vitamin K antagonists: prevalence and associated factors. Emergencias 2017; 29: 93–98.
Objectives: To determine the prevalence of international normalized ratio (INR) findings outside the normal range in hospital emergency department patients on vitamin K antagonists (VKAs). To identify factors associated with abnormal anticoagulant levels in these patients.
Methods: Observational, cross-sectional, multicentric study in 4 hospital emergency departments. We included a convenience sample of patients on VKA treatment for whom INR levels were on record and who had sought emergency care for complications unrelated to anticoagulant treatment.
Results: We included 376 patients with a mean (SD) age of 76.8 (10.1) years; 50.3% were women and 86.7% had atrial fibrillation. We found that 60.4% (95% CI, 55.3%–65.2%) had INRs outside the reference range. Multivariate analysis showed that changes in the patients’ other long-term medications were independently associated with nontherapeutic INR results (odds ratio, 1.6; 95% CI, 1.02–2.79; P=.035).
Conclusions: Over 60% of patients on VKA treatment who come to hospital emergency departments with complaints unrelated to anticoagulant therapy have INR values outside the normal range. Changes in a patient’s usual medications are significantly associated with nontherapeutic INR findings.
African journal of emergency medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria and the Rwanda Emergency Care Association
African emergency care providers’ attitudes and practices towards research
Van Hoving DJ, Brysiewicz P. African emergency care providers’ attitudes and practices towards research. Afr J Emerg Med 2017; 7(1): 9–14
doi: http://dx.doi.org/10.1016/j.afjem.2017.01.003
Introduction: Emergency care research in Africa is not on par with other world regions. The study aimed to assess the perceptions and practices towards research among current emergency care providers in Africa.
Methods: A survey was sent to all individual members of the African Federation of Emergency Medicine. The survey was available in English and French.
Results: One hundred and sixty-eight responses were analysed (invited n = 540, responded n = 188, 34.8%, excluded n = 20). Responders’ mean age was 36.3 years (SD = 9.1); 122 (72.6%) were male, 104 (61.9%) were doctors, and 127 (75.6%) were African trained. Thirty-seven (22%) have never been involved in research; 33 (19.6%) have been involved in ≥5 research projects. African related projects were mostly relevant to African audiences (n = 106, 63.1%). Ninety-four (56%) participants have never published. Forty-one (24.4%) were not willing to publish in open access journals requesting a publication fee; 65 (38.7%) will consider open access journals if fees are sponsored. Eighty responders (47.6%) frequently experienced access block to original articles due to subscription charges. Lack of research funding (n = 108, 64.3%), lack of research training (n = 86, 51.2%), and lack of allocated research time (n = 76, 45.2%) were the main barriers to research involvement. Improvement of research skills (n = 118, 70.2%) and having research published (n = 117, 69.6%) were the top motivational factors selected. Responders agreed that research promotes critical thinking (n = 137, 81.5%) and serve as an important educational tool (n = 134, 80.4%). However, 134 (79.8%) feel that emergency care workers need to be shown how to use research to improve clinical practice. Most agreed that insufficient emergency care research is being conducted in Africa (n = 113, 67.3%).
Discussion: There is scope to increase research involvement in emergency care in Africa, but solutions need to be find to address lack of research-related funding, training and time.
Reproduced with permission
Annals of Emergency Medicine
How to Measure the Glasgow Coma Scale
Steven M Green, Jason S Haukoos, David L Schriger
Green, SM, Haukoos, JS, Schriger, DL. How to measure the Glasgow Coma Scale.
AnnEmergMed, 2017. doi.org/10.1016/j.annemergmed.2016.12.016
It is now beyond reasonable dispute that the standard 13-point Glasgow Coma Scale (GCS) (score range 3 to 15) is unnecessarily complicated for out-of-hospital field assessment, and that it can be just as effectively replaced with any one of several simpler subset versions of itself. Such functional equivalence has been reported repeatedly and is now further confirmed by a rigorous meta-analysis by Chou et al in this issue of Annals. Indeed, last year Annals published the single largest study on this topic, which concluded that the GCS could be effectively replaced with the single binary decision point GCS motor score less than 6, ie, “Patient does not follow commands.” The full GCS was never intended for trauma prognostication and has been established as unreliable, unnecessarily complex, difficult to apply in practice, statistically inappropriate, and with accuracy similar to that of more simple approaches.
Currently, out-of-hospital personnel are required to calculate a full GCS score on every injured patient, an unnecessary burden that requires more than minimal time and a reference card to enhance accuracy. Why has this complicated task persisted in modern out-of-hospital care? Supporting reasons include inertia, tradition, and the illusory sense of psychological order provided by a seemingly precise tool. A final justification is the notion that the GCS is statistically superior to replacement measures. This latter assertion is flawed, and we will rebut it in this editorial.
