Retrospective application of the HEAR score on patients evacuated for chest pain: Assessing the utility of point-of-care troponin.

INTRODUCTION: The HEART scoring system codifies the clinical gestalt used by physicians with 0-2 points assigned to 5 criteria (history, electrocardiography, age, risk factors and troponin). This scoring provides a prognostic tool that assists in disposition planning. The use of a truncated HEART score, minus the troponin data (HEAR score), was used for patients presenting with chest pain at one of four outpost nursing stations served by La Ronge Health Centre in northern Saskatchewan. These nursing stations have no onsite physician and no ability to obtain any troponin data. This study set out to determine if there was any utility in conducting point-of-care (PoC) troponins in these nursing outposts. MATERIALS AND METHODS: A retrospective analysis was conducted using the La Ronge regional electronic medical record by searching for all patients for whom an outpost nurse had called a physician regarding chest pain symptoms between 01 January 2011 and 31 December 2016. The HEAR and HEART score were then calculated for each individual presentation of patients with chest pain that met inclusion and exclusion criteria. RESULTS: By calculating both the patient's HEART score before evacuation from the outposts and after (i.e. with the troponin data), we were able to determine that, in 89.4% of cases (110/123 events), patients would require evacuation regardless of the troponin values due to a HEART score ≥4. In 10.6% (13/124 events) of cases, the patients who were evacuated had a HEART score ≤3, and in only one case did the troponin data increase this score. CONCLUSIONS: The majority of patients would continue to be evacuated regardless of the result of their PoC troponin due to an already elevated HEAR score. PoC troponin is unlikely to reduce the rate of evacuation of patients with chest pain from the nursing stations served by the La Ronge Health Centre.

Résumé Introduction: Le système de pointage HEART codifie la gestalt clinique utilisée par les médecins avec 0­2 points attribués à 5 critères (anamnèse, ECG, âge, facteurs de risque, troponine). Ce pointage est un outil pronostique qui aide à planifier les soins aux patients. Un score HEART tronqué, c'est-à-dire moins les données de troponine (score HEAR), a été utilisé chez les patients qui se présentaient pour douleur thoracique à 1 des 4 avant-postes de soins infirmiers servis par le centre La Ronge Health Centre au nord de la Saskatchewan. Il n'y a pas de médecin sur place à ces postes de soins infirmiers, et il est impossible d'obtenir des données sur la troponine. Cette étude voulait déterminer si le dosage ciblé de troponine est utile dans ces avant-postes de soins infirmiers. Méthodes: Une analyse rétrospective a été réalisée à l'aide du dossier médical électronique de la région de La Ronge après une recherche de tous les patients pour lesquels un avant-poste de soins infirmiers avait appelé un médecin pour des symptômes de douleur thoracique entre le 1er Janvier 2011 et le 31 Décembre 2016. Les scores HEAR et HEART ont alors été calculés pour chaque cas de douleur thoracique qui répondait aux critères d'inclusion et d'exclusion. Résultats: En calculant le score HEART (c.-à-d. avec les données sur la troponine) avant et après l'évacuation du patient de l'avant-poste, nous avons pu déterminer que dans 89,4% des cas (110/123 événements), les patients devraient être évacués sans égard aux valeurs de troponine en raison d'un score HEART ≤3 et la troponine a augmenté ce score dans un seul cas. Conclusions: La majorité des patients continueraient d'être évacués, peu importe les résultats de troponine ciblée en raison d'un score HEAR déjà élevé. La troponine ciblée ne réduirait probablement pas le taux d'évacuation des patients pour douleur thoracique des postes de soins infirmiers servis par le centre La Ronge Health Centre. Mots-clés: Maladie cardiaque, médecine rurale, score HEART, troponine.

Clinical features of perineuritis.

We report 13 patients with pathologically confirmed perineuritis. Seven patients had diabetes mellitus, 5 had nutritional abnormalities, 2 had associated rheumatological illnesses, 2 had sepsis with multiorgan failure, and 1 had a history of malignancy. Electrophysiologic testing demonstrated mononeuritis multiplex in 7, demyelinating neuropathy in 4, distal sensory and motor neuropathy in 1, and polyradiculoneuropathy in 1. Twelve patients received immunomodulating therapy with variable responses. We conclude that perineuritis is associated with a number of different systemic conditions and several clinical patterns of peripheral neuropathy. Response to immunomodulation is variable. The most frequent association is with diabetes mellitus, a previously unrecognized association.

The application of the Screening Cerebral Assessment of Neppe (BROCAS SCAN) to a neuropsychiatric population.

Assessments of higher cortical functioning are often neglected in patients with possible coarse neurobehavioral psychiatric disease, such as dementia, stroke, or focal cerebral lesions. When performed, the short Folstein Mini-Mental State Exam (MMSE) is typically used. The authors' research on 45 neuropsychiatric patients compared the MMSE with a new 20-30-minute bedside examination, the Screening Cerebral Assessment of Neppe (BROCAS SCAN). This screens 10 areas: recall, recognition, orientation, organization of thought, concentration, calculation, agnosia, apraxia, speech, and sensory-motor-reflex phenomena. The BROCAS SCAN (total) correlated extremely well with neuropsychiatric prediction, MRI changes, and neuropsychological testing, and distinguished diagnoses, demonstrating construct and face validity. It also accounted for a larger proportion of variance than the MMSE in correlating with these parameters and was more sensitive in mildly cognitive impaired patients. The briefer first section of the BROCAS SCAN, the core SCAN, also showed statistically relevant relationships to age, diagnosis, MRI, and neuropsychiatric prediction.