Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes.

STUDY OBJECTIVE: Although lay people often assume that severe pain is more commonly associated with worse outcomes, the relationship between pain severity and outcome for patients presenting with potential acute coronary syndrome has not been well described. We hypothesize that pain severity will not be associated with acute myocardial infarction or 30-day cardiovascular complications. METHODS: We conducted a secondary analysis of a prospective cohort study of patients presenting to the emergency department (ED) with potential acute coronary syndrome. Trained research assistants collected data, including demographics, medical history, symptoms, hospital course, and 30-day outcomes (record review and telephone). Pain score on arrival (0 to 10) was abstracted from nurses' triage documentation in the electronic record. Severe pain was defined as 9 or 10. The main outcomes were the prevalence of acute myocardial infarction during index visit and composite of death, acute myocardial infarction, revascularization including percutaneous coronary intervention, or coronary bypass artery grafting at 30 days. Multivariable modeling was prespecified to adjust for age, race, sex, pain duration, thrombolysis in myocardial infarction (TIMI) score, and mode of arrival. Data are presented as relative risk (RR) with 95% confidence intervals (CI). RESULTS: Patients (3,306) had pain documented (mean age 51.0 years; SD 12.6 years; 57% women; 66% black). Follow-up was 93%. By 30 days, 34 patients had died, 105 patients underwent revascularization (94 percutaneous coronary intervention, 14 coronary bypass artery grafting), and 111 patients experienced acute myocardial infarction. There was not a relationship between severe pain and acute myocardial infarction (RR 1.28; 95% CI 0.93 to 1.76) or 30-day composite outcome (1.19; 95% CI 0.91 to 1.56). After adjusting for potential confounding variables, we found that the prevalence of inhospital acute myocardial infarction was related to TIMI score (adjusted relative risk [aRR] 2.00; 95% CI 1.05 to 3.80), male sex (aRR 1.48; 95% CI 1.00 to 2.18), and arrival by emergency medical services (EMS) (aRR 1.73; 95% CI 1.13 to 2.63) but not age (aRR 1.42; 95% CI 0.68 to 2.95), white race (aRR 1.25; 95% CI 0.85 to 1.86), pain duration greater than 1 hour (aRR 1.36; 95% CI 0.89 to 2.07), or severe pain (aRR 1.43; 95% CI 0.91 to 2.22). Thirty-day composite outcome was related to male sex (aRR 1.53; 95% CI 1.16 to 2.01), white race (aRR 1.43; 95% CI 1.09 to 1.87), and higher TIMI score (aRR 2.24; 95% CI 1.39 to 3.60) but was not related to age (aRR 1.26; 95% CI 0.75 to 2.11), pain duration greater than 1 hour (aRR 0.8; 95% CI 0.60 to 1.06), EMS arrival (aRR 1.23; 95% CI 0.96 to 1.60), or severe pain (aRR 1.39; 95% CI 0.95 to 1.97). CONCLUSION: For patients who present to the ED with potential acute coronary syndrome, severe pain is not related to likelihood of acute myocardial infarction at presentation or death, acute myocardial infarction or revascularization within 30 days.

Derivation of a clinical prediction rule for evaluating patients with abdominal pain and diarrhea.

OBJECTIVE: The objective of the study was to develop a simple prediction rule to reliably identify abdominal pain patients with diarrhea who may require surgical intervention. METHODS: We performed a secondary analysis of a prospective cohort study of adults with acute nontraumatic abdominal pain and diarrhea in an urban emergency department (ED). Structured data collection included 109 historical and 28 physical examination items, laboratory and radiographic results, and final diagnosis. The main outcome was operative intervention. RESULTS: One thousand patients were enrolled; 174 patients with diarrhea were included in this analysis. Patients had a mean age of 39 +/- 16 years and were likely to be female (64%) and black (60%). Fifteen (9%) patients received a surgical intervention from the ED. Clinical variables associated with the need for surgical intervention using univariate analysis were age older than 40 years, constant pain, and peritonitis on examination. Using recursive partitioning multivariate analysis, the derived prediction rule included 2 variables: age older than 40 years and constant pain. This rule had a sensitivity of 1.0 (95% confidence interval, 0.78-1.0) and specificity of 0.23 (95% confidence interval, 0.16-0.30). CONCLUSION: Patients older than 40 years with constant abdominal pain and diarrhea are likely to have a surgical cause of their symptoms.

Gender disparity in analgesic treatment of emergency department patients with acute abdominal pain.

OBJECTIVES: Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain. METHODS: This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used. RESULTS: Of the 981 patients enrolled (mean age +/- standard deviation [SD] 41 +/- 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes). CONCLUSIONS: Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.

Application of the TIMI risk score in ED patients with cocaine-associated chest pain.

OBJECTIVE: The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain. METHODS: This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation. RESULTS: There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100). CONCLUSIONS: The TIMI risk score has no clinically useful predictive value in patients with cocaine-associated chest pain.

Does sex matter? Effect of screener sex in intimate partner violence screening.

STUDY HYPOTHESIS: The sex of the individual performing screening affects the willingness of adult male and female ED patients to disclose incidents of intimate partner violence (IPV). METHODS: We performed a prospective cross-sectional survey at an urban academic medical center. A consecutive sample of adults who presented to the ED from 7:00 am to 00:00 am, 7 days/wk, over an 8-week period, were screened for IPV by 26 trained research assistants (42.3% female; mean age 23 years; 3.8% African American, 53.8% white). Intimate partner violence was detected using a 4-item tool to measure both physical and psychological abuse within the past 6 months. Comparison of medical history and disposition was performed using chi2 tests and t tests. Regression analysis was performed to determine the association of sex and screening outcomes, controlling for patient and screener age and race. RESULTS: A total of 2853 patients participated (63.0% female; mean age, 36 years; 67.5% African American, 22.9% white). During the study 48 female patients (2.7%) and 21 male patients (2.0%) reported incidents of IPV within the past 6 months. The sex of the screener was not associated with the screening outcomes for male (odds ratio, 0.98; CI, 0.35-2.72) or female patients (odds ratio, 0.90; CI, 0.45-1.82). CONCLUSIONS: Sex of the screener does not appear to affect disclosure of IPV. These results support the continuation of existing screening practices and call for IPV detection at multiple stages throughout patient care.

Emergency physicians do not use more resources to evaluate obese patients with acute abdominal pain.

OBJECTIVE: We hypothesized that emergency physicians would use more resources to evaluate acute abdominal pain in obese patients as compared with that in nonobese patients. METHODS: We conducted a secondary analysis of a prospective cohort of adults with acute abdominal pain. Collected data included self-reported height and weight, demographics, medical history, laboratory and x-ray results, and final diagnosis. We followed the patients until they obtained their final diagnosis or for up to 21 days. Patients were grouped according to their body mass index (BMI): nonobese (BMI < 30 kg/m2), obese (BMI = 30-40 kg/m2), and morbidly obese (BMI > 40 mg/m2). The main outcome measure was laboratory and radiographic testing. chi2 Tests and analysis of variance were used as appropriate. RESULTS: Of the 971 patients (mean age, 41 years; 62% black; 65% female), 665 (68%) were nonobese, 246 (25%) were obese, and 60 (6%) were morbidly obese. In comparing nonobese patients with obese patients, we found no difference in laboratory or radiographic testing (3.20 vs 3.21 tests; mean difference, 0.004; 95% confidence interval [CI], -0.26 to 0.27), physicians' pre-computed tomographic scan confidence level in their diagnosis (6.17 vs 6.04, mean difference, -0.13; 95% CI, -0.76 to 0.49), and emergency department (ED) length of stay (LOS; 7.40 vs 7.57 hours; mean difference, -0.17; 95% CI, -0.49 to 0.83). In comparing all 3 groups, we found no difference in diagnostic testing, ED LOS, surgical intervention (10% vs 5% vs 9%, P = .2), disposition, and final diagnosis (P > .05). CONCLUSIONS: Physicians do not use more resources to identify the etiology of acute abdominal pain in obese patients as compared with that in nonobese patients. Furthermore, ED LOS, likelihood of surgical intervention, physicians' confidence level in their preimaging diagnosis, and final diagnosis do not appear to be influenced by BMI.

Gender bias in cardiovascular testing persists after adjustment for presenting characteristics and cardiac risk.

OBJECTIVES: Previous studies have found that female patients receive fewer invasive tests for cardiovascular disease than male patients. The authors assessed whether different clinical characteristics at emergency department presentation account for this gender bias. METHODS: Patients with potential acute coronary syndrome (ACS) who presented to a university hospital were prospectively identified. A structured data instrument that included demographic information, chest pain description, history, physical examination, chest radiography, and electrocardiogram (ECG) data was completed. Hospital course was tracked daily. Patients received 30-day telephone follow-up. The main outcome was whether the patients received objective evaluation for coronary artery disease after adjustment for cardiac risk, including race, age, total number of risk factors, Thrombolysis in Myocardial Infarction (TIMI) score, ECG, and whether the patient sustained an acute myocardial infarction on index hospitalization. RESULTS: There were 3,514 women (58%) and 2,547 men (42%) studied. They had similar presenting characteristics: chest pain quality (pressure/tightness: female 60% vs. male 59%, p = 0.6), location (substernal: female 82% vs. male 80%; p = 0.2), radiation (female 27% vs. male 26%; p = 0.3), and most associated symptoms. Men had more cardiac risk factors (mean 1.5 vs 1.4; p < 0.001), more abnormal ECGs (59% vs. 48%; p < 0.001), and a higher TIMI risk score (p < 0.001). With respect to the main outcome, men received more cardiac catheterizations (12.6% vs. 6.0%; odds ratio [OR], 2.25; 95% confidence interval [CI] = 1.88 to 2.70) and more stress tests (14.7% vs. 12.3%; OR, 1.22; 95% CI = 1.05 to 1.42). After adjustment for age, race, cardiac risk factors, ECG, and TIMI risk score, men still received more cardiac catheterizations (adjusted OR, 1.72; 95% CI = 1.40 to 2.11) and stress tests (adjusted OR, 1.16; 95% CI = 1.01 to 1.33). Models adjusting for acute myocardial infarction or death, high-risk initial clinical impression, or emergency department disposition found similar results for increased likelihood of cardiac catheterization in men but no difference in stress testing between men and women. CONCLUSIONS: Female patients with potential ACS receive fewer cardiac catheterizations than male patients, even when presenting complaint, history, ECG, and diagnosis are taken into account. The gender bias cannot be explained by differences in presentation or clinical course.

TIMI risk score: does it work equally well in both males and females?

OBJECTIVE: The TIMI (Thrombolysis In Myocardial Infarction) risk score is a seven item risk stratification tool derived from trials of patients with non-ST segment elevation acute coronary syndromes (ACS) that has been validated in emergency department (ED) patients with potential ACS. We hypothesised that it might have different prognostic abilities in male and female patients. METHODS: This was a prospective cohort study of ED patients with potential ACS. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily. The main outcome was death, acute myocardial infarction (AMI), or revascularisation within 30 days as stratified by TIMI risk score and compared between genders using chi2 tests. RESULTS: There were 2022 patients enrolled: 1204 (60%) females and 818 (40%) males. The incidence of 30 day death, AMI, revascularisation (n = 168) according to TIMI score is as follows (female vs male): TIMI 0 (n = 670), 1.6% vs 2.0%, p = 0.2; TIMI 1 (n = 525), 4.6% vs 8.5%, p = 0.02; TIMI 2 (n = 378), 6.3% vs 10.4%, p = 0.05; TIMI 3 (n = 234), 6.5% vs 24.6%, p<0.001; TIMI 4 (n = 157), 22.7% vs 24.4%, p = 0.15; TIMI 5 (n = 52), 35.5% vs 39.1%, p = 0. 2; TIMI 6 or 7 (n = 6), 33.3% vs 66.7%, p = 1.0. The relationship between TIMI score and outcome was highly significant (p<0.001) for each gender; however, males tended to have worse outcomes at lower TIMI risk scores. CONCLUSIONS: The TIMI risk score successfully risk stratifies both males and females with potential ACS at the time of ED presentation; however, males have worse outcomes at lower TIMI scores than females.

The risk for acute coronary syndrome associated with atrial fibrillation among ED patients with chest pain syndromes.

OBJECTIVE: We sought to determine if atrial fibrillation is associated with an increased risk for an acute coronary syndrome (ACS) among emergency department (ED) patients with chest pain syndromes. METHODS: We performed a retrospective analysis of a prospectively collected database on ED patients with chest pain by selecting patients with atrial fibrillation and frequency-matched control subjects without atrial fibrillation. Measured outcomes were acute myocardial infarction (AMI), ACS, and unstable angina (UA). The relative risks of AMI, ACS, and UA associated with atrial fibrillation were calculated. RESULTS: One hundred forty patients with atrial fibrillation and 683 matched control subjects were identified. The rates of AMI for the atrial fibrillation and control groups were 11.4% and 10.8%, respectively; those of ACS were 27.9% and 26.7%, respectively; and those of UA were 16.4% and 15.8%, respectively. The relative risks of AMI and ACS did not increase in patients with atrial fibrillation: AMI, 1.05 (95% confidence interval [CI] = 0.63-1.75); ACS, 1.05 (95% CI = 0.78-1.40); and UA, 1.05 (95% CI = 0.6-1.7). CONCLUSION: Among patients presenting to the ED with chest pain syndromes, atrial fibrillation is not associated with an increased risk for AMI, ACS, and UA.

ST2 in emergency department chest pain patients with potential acute coronary syndromes.

STUDY OBJECTIVE: The emergency department (ED) evaluation of potential acute coronary syndrome patients is limited by the initial sensitivity of cell injury biochemical markers. Increased ST2, a protein thought to participate in the response to cardiovascular injury, has been noted to be prognostic in patients with acute myocardial infarction. We hypothesize that ST2 would be increased at presentation in ED chest pain patients with myocardial ischemia, thus allowing for the early identification of acute myocardial infarction, acute coronary syndrome, and 30-day adverse cardiovascular events, with an area under the receiver operator characteristic curve (AUC) for each outcome of greater than 0.7. METHODS: Patients aged 25 years or older and presenting to the ED with chest pain prompting an ECG were prospectively enrolled. ST2 was measured at presentation. Main outcomes were acute myocardial infarction, acute coronary syndrome, and 30-day events (death, acute myocardial infarction, or revascularization). Median ST2 values were calculated for patients with and without each outcome. The AUCs were calculated for each outcome. In a post hoc analysis, patients with outlying increased ST2 values were examined to determine possible alternative causes for ST2 expression. RESULTS: There were 348 patients enrolled. The outcomes were acute myocardial infarction 17 patients (4.9%), acute coronary syndrome 39 (11.2%), and 30-day events 23 (6.6%). The AUCs for acute myocardial infarction, acute coronary syndrome, and 30-day events were 0.636, 0.630, and 0.579, respectively. ST2 did not predict acute myocardial infarction, acute coronary syndrome, or 30-day events. It was increased in a small number of patients with pulmonary disease, notably, pulmonary emboli, systemic infection or inflammation, and alcohol abuse. CONCLUSION: ST2 was not of value in the evaluation of ED patients with potential acute coronary syndrome.

Discordance between serum creatinine and creatinine clearance for identification of ED patients with abdominal pain at risk for contrast-induced nephropathy.

STUDY OBJECTIVE: Despite creatinine clearance (CrCl) being a better estimate of renal function, serum creatinine (Cr) is more commonly used to screen for renal insufficiency in patients scheduled for an enhanced abdominal computed tomography (CT) in an attempt to reduce the likelihood of contrast-induced nephropathy (CIN). Our objective was to determine the incidence of renal insufficiency (a CrCl <60 mL/min) among patients who have serum Cr below 1.5 mg/dL (the most commonly accepted Cr cutoff for the administration of intravenous contrast). This study was conducted in a population of emergency department patients with acute abdominal pain being considered for CT scan. METHODS: We performed post hoc analysis of a prospective cross-sectional study that enrolled nongravid adults with acute nontraumatic abdominal pain. Patients on dialysis were excluded. The data that we collected included demographics, history, duration/description of pain, patient reported weight, laboratory data, imaging studies, and final diagnosis. Creatinine clearance values (< or >60 mL/min) were compared to Cr values of 1.0, 1.2, 1.5, and 1.8 mg/dL to determine the percentage of patients at risk for nephropathy after contrast injection at each Cr cutoff. Descriptive statistics were used with 95% confidence intervals (CIs). RESULTS: Seven hundred sixty-five patients were enrolled; 59% (451/765) had an abdominal CT scan. Of 108 patients with CrCl less than 60 mL/min, 59 patients had a Cr less than 1.8 mg/dL (55%; 95% CI, 45%-64%); 43 had a Cr less than 1.5 mg/dL, the most commonly accepted Cr cutoff for contrast administration (40%; 95% CI, 31%-50%); 21 patients had a Cr less than 1.2 mg/dL (19%; 95% CI, 12%-28%); and 10 had a Cr less than 1.0 mg/dL (9%; 95% CI, 5%-16%). CONCLUSION: The most commonly used Cr cutoff (1.5 mg/dL) for contrast administration fails to identify 40% of the patients at risk for CIN. Future studies should address whether using CrCl rather than serum Cr decreases the incidence of contrast-induced nephropathy.

Relationship between a clear-cut alternative noncardiac diagnosis and 30-day outcome in emergency department patients with chest pain.

BACKGROUND: Accurate identification of patients with acute coronary syndromes (ACSs) in the emergency department (ED) remains problematic. Studies have not been able to identify a cohort of patients that are safe for immediate ED discharge; however, prior studies have not examined the utility of a clear-cut alternative noncardiac diagnosis. OBJECTIVES: To compare the 30-day event rate in ED chest pain patients who were diagnosed with a clear-cut alternative noncardiac diagnosis with the 30-day event rate in the cohort of patients in whom a definitive diagnosis could not be made in the ED. METHODS: This was a prospective cohort study of consecutive ED patients with potential ACS. Data included demographics, medical and cardiac history, laboratory and electrocardiogram results, and whether or not the treating physician ascribed the condition to a clear-cut alternative noncardiac diagnosis. The main outcome was death, acute myocardial infarction (AMI), or revascularization within 30 days, as determined by phone follow-up or medical record review. RESULTS: The investigators enrolled 1,995 patients in the ED who had potential ACSs. Overall, 77 had a final hospital diagnosis of AMI (4%). Within 30 days, 73 patients received revascularization (4%), and 26 died (1%). There were 599 (30%) patients given a clear-cut alternative noncardiac diagnosis. Comparing the patients with a clear-cut alternative noncardiac diagnosis with those without an obvious noncardiac diagnosis, the presence of a clear-cut alternative noncardiac diagnosis was associated with a reduced risk of an in-hospital triple-composite endpoint (death, MI, and revascularization), with a risk ratio of 0.32 (95% confidence interval [CI] = 0.19 to 0.55) and 30-day triple-composite endpoint with a risk ratio of 0.45 (95% CI = 0.29 to 0.69); however, patients with a clear-cut alternative noncardiac diagnosis still had a 4% event rate at 30 days (95% CI = 2.4% to 5.6%). CONCLUSIONS: In the ED chest pain patient, the presence of a clear-cut alternative noncardiac diagnosis reduces the likelihood of a composite outcome of death and cardiovascular events within 30 days. However, it does not reduce the event rate to an acceptable level to allow ED discharge of these patients.

Impact of a negative prior stress test on emergency physician disposition decision in ED patients with chest pain syndromes.

OBJECTIVE: Many emergency department (ED) patients with potential acute coronary syndromes (ACS) have prior visits and prior cardiac testing; however, the effect of knowledge of prior testing on the emergency physician disposition decision making is not known. We studied the impact of prior noninvasive testing (ie, stress testing) for myocardial ischemia on disposition decision making in ED patients with potential ACS. METHODS: We performed a prospective cohort study of ED patients with chest pain who received an electrocardiogram for potential ACS. Data included demographics, medical history, stress test history, and TIMI risk score. Patients were followed in-house; 30-day telephone interviews were performed for follow-up. Main outcomes were ED disposition (admit/discharge) and a composite of 30-day death, acute myocardial infarction, and revascularization stratified on the basis of prior stress testing known at the time of presentation. Standard statistical techniques were used with 95% confidence intervals (CI). RESULTS: There were 1853 patients enrolled and 97% had follow-up. Patients had a mean age of 53 +/- 14 years; 60% were women, 67% were black. There were 1491 (79%) patients without a prior stress test, 291 (16%) had a normal prior stress test result, and 89 (5%) had an abnormal prior stress test result. Admission rates were 92% (95% CI, 87%-98%) for patients with a prior abnormal stress test, 73% (95% CI, 67%-78%) for patients with a normal prior stress test, and 70% (95% CI, 67%-72%) for patients without a prior stress test. Adverse outcomes were the highest among patients with prior abnormal stress test but did not differ significantly between patients with no prior stress test and patients with prior normal stress test (10.1% [95% CI, 3.6-16.7%] vs 5.2% [95% CI, 4.1-6.4%] vs 4.8% [95% CI, 2.4-7.3%]). CONCLUSION: Patients without prior stress tests and patients with prior normal stress tests were admitted for potential ACS at the same rate and had the same 30-day cardiovascular event rates. This suggests that prior stress testing does not affect subsequent disposition decisions. Perhaps cardiac catheterization or computed tomography coronary angiograms would have more of an impact on subsequent visits, making them potentially more cost-effective in the low-risk patient.

The impact of B-type natriuretic peptide in addition to troponin I, creatine kinase-MB, and myoglobin on the risk stratification of emergency department chest pain patients with potential acute coronary syndrome.

STUDY OBJECTIVE: The emergency department (ED) evaluation of chest pain patients with potential acute coronary syndrome is limited by the initial sensitivity of cell injury markers. BNP is increased during myocardial ischemia and is associated with adverse outcomes. We determine whether the addition of B-type natriuretic peptide (BNP) to troponin I, creatine kinase-MB (CK-MB), and myoglobin increases the sensitivity and negative predictive value (NPV) for acute myocardial infarction, acute coronary syndrome, and 30-day adverse events among chest pain patients with potential acute coronary syndrome. METHODS: A convenience sample of patients aged 30 years or older and presenting to an urban academic ED with nontraumatic chest pain, thus prompting an ECG, was enrolled, and consent was obtained. Blood samples were drawn at 0 and 90 minutes. Thirty-day follow-up was performed for all enrolled patients. Main outcomes were acute myocardial infarction, acute coronary syndrome, and 30-day events (death, acute myocardial infarction, or revascularization). BNP cutoffs were derived from receiver operator characteristics curves. The sensitivity, specificity, positive predictive value (PPV), and NPV with 95% confidence intervals (CIs) were calculated with and without BNP. Differences in sensitivity and specificity with the addition of BNP were calculated with 95% CIs, and McNemar's test was performed to compare sensitivities and specificities. RESULTS: Four hundred twenty-six patients were enrolled and analyzed. The cohort was 54.7+/-13.9 years old, 47.7% men, and 63.5% black. The outcomes were acute myocardial infarction, 39 (9.2%), acute coronary syndrome, 101 (23.7%), and 30-day adverse cardiovascular events 52 (12.2%). BNP cutoffs derived were 51, 31, and 31 pg/mL for acute myocardial infarction, acute coronary syndrome, and 30-day events, respectively. The addition of BNP showed increased sensitivity at the cost of decreased specificity for all 3 outcomes, as follows: (1) acute myocardial infarction: sensitivity: 87.2% (95% CI 72.6% to 95.7%) to 97.4% (95% CI 86.5% to 100%), difference 10.3% (95% CI-0.2% to 24.6%), P=.125; specificity: 62.3% (95% CI 57.2% to 67.1%) to 47.8% (95% CI 42.7% to 52.9%), difference 14.5% (95% CI 11.1% to %18.4), P<.0001; (2) acute coronary syndrome: sensitivity: 75.2% (95% CI 65.7% to 83.3%) to 88.1% (95% CI 80.2% to 93.7%), difference 12.9% (95% CI 7.0% to 21.0%), P=.0002; specificity: 68.0% (95% CI 62.6% to 73.0%) to 48.6% (95% CI 43.1% to 54.2%), difference 19.4% (95% CI 15.2% to 24.1%), P<.0001; (3) 30-day events: sensitivity: 71.2% (95% CI 56.9% to 82.9%) to 88.5% (95% CI 76.6% to 95.7%), difference 17.3% (95% CI 7.7% to 30.3%), P=.004; specificity: 61.8% (95% CI 56.6% to 66.7%) to 43.9% (95% CI 38.8% to 49.0%), difference 17.9% (95% CI 14.2% to 22.2%), P<.0001. There were trends toward increased NPV and decreased PPV for all outcomes, and the addition of BNP achieved a NPV of 99.5% (95% CI 97.0% to 100%) compared with 98.0% (95% CI 95.3% to 99.3%) for acute myocardial infarction. CONCLUSION: The addition of BNP as a dichotomous test to troponin I, CK-MB, and myoglobin produces increased sensitivity at a cost of decreased specificity for acute myocardial infarction, acute coronary syndrome, and 30-day adverse events. Because of this tradeoff, BNP cannot be recommended for use among all ED chest pain patients. However, the improved sensitivity may make this test useful in selected cohorts when the decreased specificity is less important.

The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes.

STUDY OBJECTIVE: Trauma systems improve the care of trauma patients; however, it is possible that prioritizing the emergency care of trauma patients might adversely affect other potentially ill patients requiring the same resources. We seek to determine whether the presence of a concurrent trauma activation negatively affects processes of care and outcomes for patients with potential acute coronary syndromes. METHODS: Patients who presented to the emergency department (ED) with a potential acute coronary syndrome from July 2003 to June 2004 were stratified according to whether they presented concurrently with a trauma activation. Structured data collection included demographics, medical history, and daily tracking of inhospital course. Thirty-day follow-up was performed. The main outcome was a composite of inhospital cardiovascular complications and 30-day death and myocardial infarction. Secondary outcomes were time from triage to ECG acquisition, transfer to an evaluation room, return of laboratory results, disposition decision, and actual disposition. RESULTS: Patients who presented concurrently with (n=357) or not concurrently with (n=1,235) a trauma activation were similar with respect to demographic characteristics, cardiac risk factors, and TIMI risk score. The unadjusted incidence of 30-day adverse cardiovascular events between potential acute coronary syndrome patients who presented with and without a concurrent trauma activation was 6.2% versus 3.6% (unadjusted odds ratio 1.74 [95% confidence interval (CI) 1.03 to 2.93]). After adjustment for measures of patient acuity (triage classification, TIMI risk score) and ED volume (total patient care hours and ED activity), concurrent trauma activation was independently associated with increased rate of 30-day cardiovascular complications (odds ratio 1.72; 95% CI 1.01 to 2.92). CONCLUSION: The presence of a concurrent trauma activation at the time of presentation of a patient with potential acute coronary syndrome was associated with an increased incidence of 30-day adverse cardiovascular events. Although trauma activations improve the care of trauma patients, they may be associated with a negative impact on the care of other patients requiring contemporaneous resources.

Prognostic value of symptoms during a normal or nonspecific electrocardiogram in emergency department patients with potential acute coronary syndrome.

OBJECTIVES: Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do those who are asymptomatic. METHODS: This was a prospective cohort study of ED patients with potential ACS. Outcomes were acute myocardial infarction (AMI), ACS, and 30-day cardiovascular events (death, AMI, revascularization). Fisher's exact test, t-tests, and logistic regression were used for data analysis. RESULTS: Of 2,593 patient visits, 2,007 patients had normal or nonspecific ECG findings. There were 1,196 who had symptoms during ECG, whereas 811 did not. Patients with symptoms at ECG acquisition were younger (49.9 vs. 55.2 years; p < 0.001) and were more likely to be black (70% vs. 64%; p = 0.002), female (63% vs. 58%; p = 0.03), and to have used cocaine (5% vs. 2%; p = 0.004). They were less likely to have hypertension (49% vs. 58%; p < 0.001), and diabetes (22% vs. 17%; p = 0.002). Patients with and without symptoms were equally likely to have AMI (both 2.8%; p > 0.99), ACS (10.1% vs. 11.5%; p = 0.34), and 30-day adverse outcomes (both 5.3%; p > 0.99). After adjustment for baseline cardiovascular-risk factors, odds ratios for patients with symptoms at the time of ECG acquisition were not significantly different for any of the outcomes: AMI (1.1; 95% confidence interval [CI] = 0.6 to 1.9); ACS (1.1; 95% CI = 0.8 to 1.4); or 30-day events (1.2; 95% CI = 0.8 to 1.9). CONCLUSIONS: Patients who are symptomatic during acquisition of a normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms. Clinicians should not rely on the absence of ECG abnormalities during symptoms to help exclude ACS.

Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population.

STUDY OBJECTIVE: The Thrombolysis in Myocardial Infarction (TIMI) risk score is a 7-item tool derived from trials of patients with unstable angina/non-ST segment elevation myocardial infarction for risk stratification with respect to outcomes. It has been retrospectively evaluated in emergency department (ED) patients with potential acute coronary syndrome but has not been prospectively validated in this patient population. To validate the use of the TIMI risk score in the ED, we prospectively assess its potential utility in a broad ED chest pain patient population. METHODS: This was a prospective observational cohort study of consecutive ED chest pain patients enrolled from July 2003 until October 2004. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily for admitted patients, and 30-day follow-up was performed on hospitalized and discharged patients. The main outcome was death, acute myocardial infarction, or revascularization as stratified by TIMI risk score at 30 days. RESULTS: There were 1,481 eligible patient visits; 30-day follow-up was completed on 1,458 (98.4%) patients. Patients had mean age of 53.2+/-14 years and were 40% men, 66% black, and 30% white. Myocardial infarction occurred in 95 patients. The incidence of each TIMI risk factor was age greater than 65 years 21%, known coronary stenosis 18%, 3 or more risk factors 26%, ST-segment deviation 6%, 2 or more anginal events in the previous 24 hours 33%, aspirin use in the previous 7 days 35%, and elevated markers 6%. The incidence of 30-day death, acute myocardial infarction, and revascularization according to TIMI score is as follows: TIMI 0, 1.7% (95% confidence interval [CI] 0.42 to 2.95); TIMI 1, 8.2% (95% CI 5.27 to 11.04); TIMI 2, 8.6% (95% CI 5.02 to 12.08); TIMI 3, 16.8% (95% CI 10.91 to 22.62); TIMI 4, 24.6% (95% CI 16.38 to 32.77); TIMI 5, 37.5% (95% CI 21.25 to 53.75); and TIMI 6, 33.3% (95% CI 0 to 100). This relationship was highly significant. CONCLUSION: Among ED patients with chest pain, the TIMI risk score does correlate with outcome. However, in our study the TIMI risk score failed to stratify these patients into discrete groups according to risk score. Also, patients with the lowest risk as defined by a TIMI score of zero had a 1.7% incidence of adverse events. Therefore, the TIMI risk score should not be used in isolation to determine disposition of ED chest pain patients.

The impact of a concurrent trauma alert evaluation on time to head computed tomography in patients with suspected stroke.

BACKGROUND: Emergency department (ED) overcrowding threatens quality of care by delaying the time to diagnosis and treatment of patients with time-sensitive diseases, such as acute stroke. OBJECTIVE: The authors hypothesized that the presence of a trauma alert evaluation would impede the time to head computed tomography (hCT) in patients with stroke-like symptoms. METHODS: This was a secondary analysis of prospectively collected data on patients with potential stroke who received an hCT in an urban trauma center ED from January 1, 2004, to November 30, 2004. Structured data collection included historical and examination items, National Institutes of Health (NIH) stroke scale score, laboratory and radiographic results, and final diagnosis. Admitted patients were followed in hospital. Patients who presented within one hour following a trauma evaluation were compared with patients who presented without concurrent trauma for triage time until completion of hCT. Chi-square, t-tests, and 95% confidence intervals (95% CIs) were used for comparisons. RESULTS: The 171 patients enrolled had a mean (+/- standard deviation) age of 60.7 (+/- 7) years; 60% were female; and 58% were African American. Of these, 72 patients had a significant cerebrovascular event (38 [22%] ischemic stroke, 25 [15%] transient ischemic attack, seven [4%] intracranial hemorrhage, one [0.6%] subarachnoid hemorrhage, and one [0.6%] subdural hematoma). The remaining diagnoses included 4.6% migraine, 2.3% seizure, 2.9% syncope, 2.3% Bell's palsy, and 2.9% vertigo. There was no significant difference in time to hCT in patients who presented during a trauma activation and those who did not (99 minutes [interquartile range (IQR) = 24-156] vs. 101 minutes [IQR = 43-151.5]; p = 0.537). In subgroup analysis of patients with a significant cerebrovascular event, times to hCT were also similar (24 minutes [IQR = 12-99] vs. 61 minutes [IQR = 15-126]; p = 0.26). CONCLUSIONS: In the authors' institution, the presence of concurrent trauma evaluation does not delay CT imaging of patients with potential stroke.

Psychometric analysis of the Minnesota Test of Critical Thinking.

With the increase over the past two decades in interest in critical thinking instruction, reliable and valid means for measuring critical thinking are necessary. The Minnesota Test of Critical Thinking was developed to measure critical thinking as defined by the American Philosophical Association in 1990. The present purpose was to explore the structure and reliability of the intervention and its instantiation of the critical thinking framework. Analyses of responses from 151 adult participants gave estimates of reliability varying from .29 to .78. A factor analysis of the test scores supported critical thinking conceptualized as a single, latent trait. With further refinement, the invention should become a valuable measure of general critical thinking skills of upper-division secondary and postsecondary students.

PICKLE acts throughout the plant to repress expression of embryonic traits and may play a role in gibberellin-dependent responses.

A seed marks the transition between two developmental states; a plant is an embryo during seed formation, whereas it is a seedling after emergence from the seed. Two factors have been identified in Arabidopsis that play a role in establishment of repression of the embryonic state: PKL (PICKLE), which codes for a putative CHD3 chromatin remodeling factor, and gibberellin (GA), a plant growth regulator. Previous observations have also suggested that PKL mediates some aspects of GA responsiveness in the adult plant. To investigate possible mechanisms by which PKL and GA might act to repress the embryonic state, we further characterized the ability of PKL and GA to repress embryonic traits and reexamined the role of PKL in mediating GA-dependent responses. We found that PKL acts throughout the seedling to repress expression of embryonic traits. Although the ability of pkl seedlings to express embryonic traits is strongly induced by inhibiting GA biosynthesis, it is only marginally responsive to abscisic acid and SPY (SPINDLY), factors that have previously been demonstrated to inhibit GA-dependent responses during germination. We also observed that pkl plants exhibit the phenotypic hallmarks of a mutation in a positive regulator of a GA response pathway including reduced GA responsiveness and increased synthesis of bioactive GAs. These observations indicate that PKL may mediate a subset of GA-dependent responses during shoot development.