Rapid and safe discharge from the emergency department: A single troponin to exclude acute myocardial infarction.

OBJECTIVE: To determine variables that could facilitate safe discharge from the ED following a single high-sensitivity troponin I (HsTnI) result to exclude acute myocardial infarction (AMI). METHODS: A retrospective cohort study was performed at a tertiary hospital of all patients that had serial HsTnI performed within 12 h of arrival to the ED over a 3 year period. The primary exposure variable of interest was a very low troponin initial result (HsTnI <5 ng/L). Medical record review and risk stratification score calculations were undertaken for all patients with the exposure variable of interest and an abnormal second troponin measurement (HsTnI ≥16 ng/L in women and HsTnI ≥26 ng/L in men). RESULTS: There were 11 970 patients who presented between 1 July 2013 and 30 June 2016 that had serial HsTnI measurements performed. Of these, 4172 (34.9%) patients had an initial HsTnI measurement <5 ng/L. Of the patients with an initial HsTnI <5 ng/L that met inclusion criteria, 56 (1.3%) had a second troponin result above the 99th percentile and 32 (0.8%) cases of non-ST elevation myocardial infarction were diagnosed as well as 15 (0.4%) cases of ST elevation myocardial infarction. There were 44 (93.6%) of all AMI cases that met criteria for high-risk presentations under the National Heart Foundation of Australia guidelines. The negative predictive value of an initial HsTnI <5 ng/L to exclude AMI was 98.9% (95% confidence interval 98.5-99.1). CONCLUSIONS: This supports the utilisation of a rapid rule out strategy to exclude AMI for patients that have an initial HsTnI measurement <5 ng/L in conjunction with a robust risk assessment.

Delaying urinary catheter insertion in the reception and resuscitation of blunt multitrauma and using a full bladder to tamponade pelvic bleeding.

This article proposes a counter-argument to standard Advanced Trauma Life Support (ATLS) training--which advocates bladder catheterisation to be performed as an adjunct to the primary survey and resuscitation for early decompression of the bladder and urine output monitoring. We argue the case for delaying bladder catheterisation until after definitive truncal Computed Tomography (CT) imaging. To reduce pelvic volume and associated bleeding, our trauma team delay catheter insertion until after the initial CT scan. The benefits of a full bladder also include improved views on initial Focussed Assessment with Sonography in Trauma (FAST) scan and improved interpretation of injuries on CT. Our urinary catheter related infection rates anecdotally decreased when insertion was delayed and consequently performed in a more controlled, non-resuscitation setting following CT. Adult blunt multitrauma patients with pelvic ring fractures are at risk of significant haemorrhage. Venous, arterial and medullary injuries with associated bleeding may be potentiated by an increased pelvic volume with ring disruption, as well as a reduced pressure effect from retroperitoneal and intra-pelvic organs on bleeding sites. Various techniques are used to reduce intra-pelvic bleeding. For shocked patients who have sustained major pelvic injuries with no other signs of urinary tract trauma and minimal urine in the bladder on initial FAST scan, we advocate careful, aseptic Foley catheter insertion followed by bladder insufflation with 500-600 mL of Normal Saline (NS) and subsequent catheter clamping to tamponade pelvic bleeding.

Distribution and size of mucous glands in the ferret tracheobronchial tree.

A transgenic ferret model of cystic fibrosis has recently been generated. It is probable that malfunction of airway mucous glands contributes significantly to the airway pathology of this disease. The usefulness of the ferret model may therefore depend in part on how closely the airway glands of ferrets resemble those of humans. Here, we show that in the ferret trachea glands are commonest in its most ventral aspect and disappear about half way up the lateral walls; they are virtually absent from the dorsal membranous portion. Further, the aggregate volume of glands per unit mucosal surface declines progressively by about 60% between the larynx and the carina. The average frequency of glands openings for the ferret trachea as a whole is only about one-fifth that in humans (where gland openings are found at approximately the same frequency throughout the trachea). Glands in the ferret trachea are on average about one-third the size of those in the human. Therefore, the aggregate volume of tracheal glands (per unit mucosal surface area) in the ferret is only about 6% that in humans. As in other mammalian species, airway glands in the ferret disappear at an airway internal diameter of ∼1 mm, corresponding approximately in this species to airway generation 6.

Chloride secretion by cultures of pig tracheal gland cells.

Malfunction of airway submucosal glands contributes to the pathology of cystic fibrosis (CF), and cell cultures of CF human airway glands show defects in Cl(-) and water transport. Recently, a transgenic pig model of CF (the CF pig) has been developed. Accordingly, we have developed cell cultures of pig airway gland epithelium for use in investigating alterations in gland function in CF. Our cultures form tight junctions (as evidenced by high transepithelial electrical resistance) and show high levels of active anion secretion (measured as amiloride-insensitive short-circuit current). In agreement with recent results on human airway glands, neurohumoral agents that elevate intracellular Ca(2+) potently stimulated anion secretion, while elevation of cAMP was comparatively ineffective. Our cultures express lactoferrin and lysozyme (serous gland cell markers) and MUC5B (the main mucin of airway glands). They are, therefore, potentially useful in determining if CF-related alterations in anion transport result in altered secretion of serous cell antimicrobial agents or mucus.

Trauma reception and resuscitation in Sri Lanka: the Health for the South Capacity-Building project.

In response to the Indian Ocean tsunami of 2004, the Health for the South project, Capacity-Building programme was implemented in Galle, Sri Lanka. The objectives of the Capacity-Building programme were to develop the emergency and trauma service capability at Teaching Hospital Karapitiya in Galle. Over 15 months, ED clinicians, from the Alfred Hospital and Royal Children's Hospital in Melbourne, provided training in the Emergency Treatment Unit of the main referral hospital for the south of Sri Lanka. This programme, completed in June 2008, significantly improved the hospital's ability to conduct trauma resuscitation, and to attain an increased level of disaster preparedness. In addition, valuable lessons were noted that will guide future initiatives in trauma care training in similar contexts.