Frequency, compliance, and yield of cardiac testing after high-sensitivity troponin accelerated diagnostic protocol implementation.

BACKGROUND: Among persons presenting to the emergency department with suspected acute myocardial infarction (MI), cardiac troponin (cTn) testing is commonly used to detect acute myocardial injury. Accelerated diagnostic protocols (ADPs) guide clinicians to integrate cTn results with other clinical information to decide whether to order further diagnostic testing. OBJECTIVE: To determine the change in the rate and yield of stress test or coronary CT angiogram following cTn measurement in patients with chest pain presenting to the emergency department pre- and post-transition to a high-sensitivity (hs-cTn) assay in an updated ADP. METHODS: Using electronic health records, we examined visits for chest pain at five emergency departments affiliated with an integrated academic health system 1-year pre- and post-hs-cTn assay transition. Outcomes included stress test or coronary imaging frequency, ADP compliance among those with additional testing, and diagnostic yield (ratio of positive tests to total tests). RESULTS: There were 7564 patient-visits for chest pain, including 3665 in the pre- and 3899 in the post-period. Following the updated ADP using hs-cTn, 862 (23.5 per 100 patient visits) visits led to subsequent testing versus 1085 (27.8 per 100 patient visits) in the pre-hs-cTn period, (P < 0.001). Among those who were tested, the protocol-compliant rate fell from 80.9% to 46.5% (P < 0.001), but the yield of those tests rose from 24.5% to 29.2% (P = 0.07). Among tests that were noncompliant with ADP guidance, yield was similar pre- and post-updated hs-cTn ADP implementation (pre 13.0%, post 15.4% (P = 0.43). CONCLUSION: Implementation of hs-cTn supported by an updated ADP was associated with a lower rate of stress testing and coronary CT angiogram.

The high prevalence of inappropriate feeding among infants presenting with an apparent life-threatening event.

Kojima K, Mckinley K, Donohue P, Sigal Y. The high prevalence of inappropriate feeding among infants presenting with an apparent life-threatening event. Turk J Pediatr 2017; 59: 304-310. Although there are anecdotal reports of a link between inappropriate feeding and an apparent life-threatening event (ALTE), previous studies have not examined this association in a cohort of affected infants. This study compared the feeding behaviors of infants who have had an ALTE with age- and sex-matched controls. This is a single-center case control study. Forty-six term infants aged 6 months or less, who were hospitalized over a 34-month period following an ALTE, comprised the study sample; 92 age- and sex-matched controls were recruited from a wellness clinic. Feeding practices reported by parents were evaluated for their appropriateness with respect to the volume of each feeding, and the frequency and total volume of feedings per 24-hour period, based on the American Academy of Pediatrics guidelines. Comparisons were made between the ALTE cases and controls. Inappropriately fed infants were compared with the rest of the sample. The ALTE and control groups were similar with respect to the prevalence of breastfeeding, insurance, birth weight, and weight percentile at presentation. The ALTE group had a lower prevalence of appropriate feeding compared to the control group (43.5% versus 63.0%, p = 0.029). Overfed infants were at a higher weight percentile at the time of presentation (46.5th percentile versus 31.4 < sup > th < /sup > percentile, p = 0.037). These results represent the association between ALTE and inappropriate feeding practice, which emphasizes the need for assessment and education regarding feeding practices in patient presenting with an ALTE.