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Catheter-associated urinary tract infections in 592 hospitals immediately declined after federal value-based incentive program implementation, but this was fully attributable to a concurrent surveillance case definition revision. Post revision, more hospitals had favorable standardized infection ratios, likely leading to artificial inflation of their performance scores unrelated to changes in patient safety.
We have observed the G23 field of the Galaxy AndMass Assembly (GAMA) survey using the Australian Square Kilometre Array Pathfinder (ASKAP) in its commissioning phase to validate the performance of the telescope and to characterise the detected galaxy populations. This observation covers ~48 deg2 with synthesised beam of 32.7 arcsec by 17.8 arcsec at 936MHz, and ~39 deg2 with synthesised beam of 15.8 arcsec by 12.0 arcsec at 1320MHz. At both frequencies, the root-mean-square (r.m.s.) noise is ~0.1 mJy/beam. We combine these radio observations with the GAMA galaxy data, which includes spectroscopy of galaxies that are i-band selected with a magnitude limit of 19.2. Wide-field Infrared Survey Explorer (WISE) infrared (IR) photometry is used to determine which galaxies host an active galactic nucleus (AGN). In properties including source counts, mass distributions, and IR versus radio luminosity relation, the ASKAP-detected radio sources behave as expected. Radio galaxies have higher stellar mass and luminosity in IR, optical, and UV than other galaxies. We apply optical and IR AGN diagnostics and find that they disagree for ~30% of the galaxies in our sample. We suggest possible causes for the disagreement. Some cases can be explained by optical extinction of the AGN, but for more than half of the cases we do not find a clear explanation. Radio sources aremore likely (~6%) to have an AGN than radio quiet galaxies (~1%), but the majority of AGN are not detected in radio at this sensitivity.
Global inequity in access to and availability of essential mental health services is well recognized. The mental health treatment gap is approximately 50% in all countries, with up to 90% of people in the lowest-income countries lacking access to required mental health services. Increased investment in global mental health (GMH) has increased innovation in mental health service delivery in LMICs. Situational analyses in areas where mental health services and systems are poorly developed and resourced are essential when planning for research and implementation, however, little guidance is available to inform methodological approaches to conducting these types of studies. This scoping review provides an analysis of methodological approaches to situational analysis in GMH, including an assessment of the extent to which situational analyses include equity in study designs. It is intended as a resource that identifies current gaps and areas for future development in GMH. Formative research, including situational analysis, is an essential first step in conducting robust implementation research, an essential area of study in GMH that will help to promote improved availability of, access to and reach of mental health services for people living with mental illness in low- and middle-income countries (LMICs). While strong leadership in this field exists, there remain significant opportunities for enhanced research representing different LMICs and regions.
Despite many interventions aiming to reduce excessive gestational weight gain (GWG), it is currently unclear the impact on infant anthropometric outcomes. The aim of this review was to evaluate offspring anthropometric outcomes in studies designed to reduce GWG. A systematic search of seven international databases, one clinical trial registry and three Chinese databases was conducted without date limits. Studies were categorised by intervention type: diet, physical activity (PA), lifestyle (diet + PA), other, gestational diabetes mellitus (GDM) (diet, PA, lifestyle, metformin and other). Meta-analyses were reported as weighted mean difference (WMD) for birthweight and birth length, and risk ratio (RR) for small for gestational age (SGA), large for gestational age (LGA), macrosomia and low birth weight (LBW). Collectively, interventions reduced birthweight, risk of macrosomia and LGA by 71 g (WMD: −70.67, 95% CI −101.90 to −39.43, P<0.001), 16% (RR: 0.84, 95% CI 0.73–0.98, P=0.026) and 19% (RR: 0.81, 95% CI 0.69–0.96, P=0.015), respectively. Diet interventions decreased birthweight and LGA by 99 g (WMD −98.80, 95% CI −178.85 to −18.76, P=0.016) and 65% (RR: 0.35, 95% CI 0.17–0.72, P=0.004). PA interventions reduced the risk of macrosomia by 51% (RR: 0.49, 95% CI 0.26–0.92, P=0.036). In women with GDM, diet and lifestyle interventions reduced birthweight by 211 and 296 g, respectively (WMD: −210.93, 95% CI −374.77 to −46.71, P=0.012 and WMD:−295.93, 95% CI −501.76 to −90.10, P=0.005, respectively). Interventions designed to reduce excessive GWG lead to a small reduction in infant birthweight and risk of macrosomia and LGA, without influencing the risk of adverse outcomes including LBW and SGA.
Sepsis – syndrome of infection complicated by organ dysfunction – is responsible for over 750 000 hospitalisations and 200 000 deaths in the USA annually. Despite potential nutritional benefits, the association of diet and sepsis is unknown. Therefore, we sought to determine the association between adherence to a Mediterranean-style diet (Med-style diet) and long-term risk of sepsis in the REasons for Geographic Differences in Stroke (REGARDS) cohort. We analysed data from REGARDS, a population-based cohort of 30 239 community-dwelling adults age ≥45 years. We determined dietary patterns from a baseline FFQ. We defined Med-style diet as a high consumption of fruit, vegetables, legumes, fish, cereal and low consumption of meat, dairy products, fat and alcohol categorising participants into Med-style diet tertiles (low: 0–3, moderate: 4–5, high: 6–9). We defined sepsis events as hospital admission for serious infection and at least two systematic inflammatory response syndrome criteria. We used Cox proportional hazard models to determine the association between Med-style diet tertiles and first sepsis events, adjusting for socio-demographics, lifestyle factors, and co-morbidities. We included 21 256 participants with complete dietary data. Dietary patterns were: low Med-style diet 32·0 %, moderate Med-style diet 42·1 % and high Med-style diet 26·0 %. There were 1109 (5·2 %) first sepsis events. High Med-style diet was independently associated with sepsis risk; low Med-style diet referent, moderate Med-style diet adjusted hazard ratio (HR) 0·93 (95 % CI 0·81, 1·08), high Med-style diet adjusted HR=0·74 (95 % CI 0·61, 0·88). High Med-style diet adherence is associated with lower risk of sepsis. Dietary modification may potentially provide an option for reducing sepsis risk.
The role that vitamin D plays in pulmonary function remains uncertain. Epidemiological studies reported mixed findings for serum 25-hydroxyvitamin D (25(OH)D)–pulmonary function association. We conducted the largest cross-sectional meta-analysis of the 25(OH)D–pulmonary function association to date, based on nine European ancestry (EA) cohorts (n 22 838) and five African ancestry (AA) cohorts (n 4290) in the Cohorts for Heart and Aging Research in Genomic Epidemiology Consortium. Data were analysed using linear models by cohort and ancestry. Effect modification by smoking status (current/former/never) was tested. Results were combined using fixed-effects meta-analysis. Mean serum 25(OH)D was 68 (sd 29) nmol/l for EA and 49 (sd 21) nmol/l for AA. For each 1 nmol/l higher 25(OH)D, forced expiratory volume in the 1st second (FEV1) was higher by 1·1 ml in EA (95 % CI 0·9, 1·3; P<0·0001) and 1·8 ml (95 % CI 1·1, 2·5; P<0·0001) in AA (Prace difference=0·06), and forced vital capacity (FVC) was higher by 1·3 ml in EA (95 % CI 1·0, 1·6; P<0·0001) and 1·5 ml (95 % CI 0·8, 2·3; P=0·0001) in AA (Prace difference=0·56). Among EA, the 25(OH)D–FVC association was stronger in smokers: per 1 nmol/l higher 25(OH)D, FVC was higher by 1·7 ml (95 % CI 1·1, 2·3) for current smokers and 1·7 ml (95 % CI 1·2, 2·1) for former smokers, compared with 0·8 ml (95 % CI 0·4, 1·2) for never smokers. In summary, the 25(OH)D associations with FEV1 and FVC were positive in both ancestries. In EA, a stronger association was observed for smokers compared with never smokers, which supports the importance of vitamin D in vulnerable populations.
D-dimer testing is an important component of the workup for pulmonary embolism (PE). However, age-related increases in D-dimer concentrations result in false positives in older adults, leading to potentially unnecessary imaging utilization. The objective of this study was to quantify the test characteristics of an age-adjusted D-dimer cut-off for ruling out PE in older patients investigated in actual clinical practice.
This observational study used administrative data from four emergency departments from July 2013 to January 2015. Eligible patients were ages 50 and older with symptoms of PE who underwent D-dimer testing. The primary outcome was 30-day diagnosis of PE, confirmed by imaging reports. Test characteristics of the D-dimer assay were calculated using the standard reference value (500 ng/ml), the local reference value (470 ng/ml), and an age-adjusted threshold (10 ng/ml × patient’s age).
This cohort includes 6,655 patients ages 50 and older undergoing D-dimer testing for a possible PE. Of these, 246 (3.7%) were diagnosed with PE. Age-adjusted D-dimer cut-offs were more specific than standard cut-offs (75.4% v. 63.8%) but less sensitive (90.3% v. 97.2%). The false-negative risk in this population was 0.49% using age-adjusted D-dimer cut-offs compared with 0.15% with traditional cut-offs.
Age-adjusted D-dimer cut-offs are substantially more specific than traditional cut-offs and may reduce CT utilization among older patients with suspected PE. We observed a loss of sensitivity, with an increased risk of false-negatives, using age-adjusted cut-offs. We encourage further evaluation of the safety and accuracy of age-adjusted D-dimer cut-offs in actual clinical practice.
OBJECTIVES/SPECIFIC AIMS: Background: Delirium is a well described form of acute brain organ dysfunction characterized by decreased or increased movement, changes in attention and concentration as well as perceptual disturbances (i.e., hallucinations) and delusions. Catatonia, a neuropsychiatric syndrome traditionally described in patients with severe psychiatric illness, can present as phenotypically similar to delirium and is characterized by increased, decreased and/or abnormal movements, staring, rigidity, and mutism. Delirium and catatonia can co-occur in the setting of medical illness, but no studies have explored this relationship by age. Our objective was to assess whether advancing age and the presence of catatonia are associated with delirium. METHODS/STUDY POPULATION: Methods: We prospectively enrolled critically ill patients at a single institution who were on a ventilator or in shock and evaluated them daily for delirium using the Confusion Assessment for the ICU and for catatonia using the Bush Francis Catatonia Rating Scale. Measures of association (OR) were assessed with a simple logistic regression model with catatonia as the independent variable and delirium as the dependent variable. Effect measure modification by age was assessed using a Likelihood ratio test. RESULTS/ANTICIPATED RESULTS: Results: We enrolled 136 medical and surgical critically ill patients with 452 matched (concomitant) delirium and catatonia assessments. Median age was 59 years (IQR: 52–68). In our cohort of 136 patients, 58 patients (43%) had delirium only, 4 (3%) had catatonia only, 42 (31%) had both delirium and catatonia, and 32 (24%) had neither. Age was significantly associated with prevalent delirium (i.e., increasing age associated with decreased risk for delirium) (p=0.04) after adjusting for catatonia severity. Catatonia was significantly associated with prevalent delirium (p<0.0001) after adjusting for age. Peak delirium risk was for patients aged 55 years with 3 or more catatonic signs, who had 53.4 times the odds of delirium (95% CI: 16.06, 176.75) than those with no catatonic signs. Patients 70 years and older with 3 or more catatonia features had half this risk. DISCUSSION/SIGNIFICANCE OF IMPACT: Conclusions: Catatonia is significantly associated with prevalent delirium even after controlling for age. These data support an inverted U-shape risk of delirium after adjusting for catatonia. This relationship and its clinical ramifications need to be examined in a larger sample, including patients with dementia. Additionally, we need to assess which acute brain syndrome (delirium or catatonia) develops first.
Background: High volumes, ill patients, and steep learning curves can make neurosurgical rotations challenging for medical students. Furthermore, existing rotations often lack neurosurgery-specific orientation materials and level-appropriate pre-reading resources reducing the educational yield of short rotations. This is compounded by the lack of mandatory neurosurgical rotations across medical schools. We hypothesized that a “Neurosurgery Clerkship Manual” covering key orientation, knowledge, and practical topics would enhance educational experiences and generate sustained knowledge retention. Methods: Students rotating through neurosurgery at three hospitals were randomized to receive(intervention) or not receive(control) free access to the manual before their rotation. Participants completed surveys before, immediately after, and 4-weeks after the rotation assessing expectations, experiences, and clinically-relevant knowledge. Results: 61 participants were randomized between 2014 and 2017 with 43(70.5%) completing all three questionnaires. Baseline demographics, characteristics, and experiences were not significantly different. Those receiving the manual reported increased rotation enjoyment(p=0.02), decreased stress levels (p=0.05), and a greater feeling of being “part of the team”(p=0.01). There were also reductions in feeling like they were “not learning” (p=0.01). Finally, those receiving the manual demonstrated significantly better knowledge after the rotation (91.6%vs80.9%;p=0.04) which was sustained at 4-weeks post-rotation (89.2%vs79.0%;p=0.05). Conclusions: A simple and inexpensive clerkship manual can improve the neurosurgery rotation experience and knowledge retention for medical students.
Background: Heterozygous loss-of-function mutations in the synaptic scaffolding gene SHANK2 are strongly associated with autism spectrum disorder (ASD). However, their impact on the function of human neurons is unknown. Derivation of induced pluripotent stem cells (iPSC) from affected individuals permits generation of live neurons to answer this question. Methods: We generated iPSCs by reprogramming dermal fibroblasts of neurotypic and ASD-affected donors. To isolate the effect of SHANK2, we used CRISPR/Cas9 to knock out SHANK2 in control iPSCs and correct a heterozygous nonsense mutation in ASD-affected donor iPSCs. We then derived cortical neurons from SOX1+ neural precursor cells differentiated from these iPSCs. Using a novel assay that overcomes line-to-line variability, we compared neuronal morphology, total synapse number, and electrophysiological properties between SHANK2 mutants and controls. Results: Relative to controls, SHANK2 mutant neurons have increased dendrite complexity, dendrite length, total synapse number (1.5-2-fold), and spontaneous excitatory postsynaptic current (sEPSC) frequency (3-7.6-fold). Conclusions: ASD-associated heterozygous loss-of-function mutations in SHANK2 increase synaptic connectivity among human neurons by increasing synapse number and sEPSC frequency. This is partially supported by increased dendrite length and complexity, providing evidence that SHANK2 functions as a suppressor of dendrite branching during neurodevelopment.
Hunger relief agencies have a limited capacity to monitor the nutritional quality of their food. Validated measures of food environments, such as the Healthy Eating Index-2010 (HEI-2010), are challenging to use due to their time intensity and requirement for precise nutrient information. A previous study used out-of-sample predictions to demonstrate that an alternative measure correlated well with the HEI-2010. The present study revised the Food Assortment Scoring Tool (FAST) to facilitate implementation and tested the tool’s performance in a real-world food pantry setting.
We developed a FAST measure with thirteen scored categories and thirty-one sub-categories. FAST scores were generated by sorting and weighing foods in categories, multiplying each category’s weight share by a healthfulness parameter and summing the categories (range 0–100). FAST was implemented by recording all food products moved over five days. Researchers collected FAST and HEI-2010 scores for food availability and foods selected by clients, to calculate correlations.
Five food pantries in greater Minneapolis/St. Paul, Minnesota, USA.
Food carts of sixty food pantry clients.
The thirteen-category FAST correlated well with the HEI-2010 in prediction models (r = 0·68). FAST scores averaged 61·5 for food products moved, 63·8 for availability and 62·5 for client carts. As implemented in the real world, FAST demonstrated good correlation with the HEI-2010 (r = 0·66).
The FAST is a flexible, valid tool to monitor the nutritional quality of food in pantries. Future studies are needed to test its use in monitoring improvements in food pantry nutritional quality over time.
Introduction: Ruling out acute myocardial infarction (AMI) using serial troponin testing is central to the care of many emergency department (ED) patients with chest pain. While diagnostic strategies using conventional troponin assays require repeat sampling over many hours to avoid missed diagnoses, serial high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in most patients within 1 or 2 hours. However, many of the initial studies deriving and validating these rapid diagnostic algorithms had all hs-cTn samples analyzed in a central core lab likely representing optimal assay performance. This objective of this study is to validate a 1-hour rapid diagnostic algorithm to exclude AMI in ED chest pain patients using an hs-cTn assay in real world practice. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at ED presentation and 1-hour later. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and 30-day major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. The study was REB approved. Results: A total of 350 patients were enrolled from August 2014 September 2016 with 1-hour serial hs-cTnT results, of which 219 (62.6%) met the 1-hour rapid diagnostic algorithm low risk criteria (time 0h hs-cTnT <12ng/L and delta 1h <3ng/L). The sensitivity of the 1-hour low risk criteria for index AMI was 97.2% (95% CI 85.5%-99.9%) and for 30-day AMI was 97.3% (95% CI 85.8-99.9%). The sensitivity of the low risk criteria for 30-day MACE was lower 80.9% (95% CI 66.7-90.9%) but maintained a high negative predictive value, 95.9% (95% CI 92.3-98.1%). Conclusion: A 1-hour rapid diagnostic algorithm using an hs-cTnT assay was highly sensitive for AMI on the index visit and successfully identified patients at low risk of 30-day AMI; however, sensitivity for 30-day MACE was much lower. Of note, the 1-hour algorithm appears to be less sensitive for both AMI and 30-day MACE than a 2-hour algorithm validated in the same population.
Introduction: Ruling out acute myocardial infarction (AMI) using serial troponin testing is central to the care of many emergency department (ED) patients with chest pain. While diagnostic strategies using conventional troponin assays require repeat sampling over many hours to avoid missed diagnoses, serial high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in most patients within 1 or 2 hours. However, many of the initial studies deriving and validating these rapid diagnostic algorithms had all hs-cTn samples analyzed in a central core lab likely representing optimal assay performance. This objective of this study is to validate a 2-hour rapid diagnostic algorithm to exclude AMI in ED chest pain patients using an hs-cTn assay in real world practice. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at ED presentation and 2-hours later. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and 30-day major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. This study was REB approved. Results: A total of 549 patients were enrolled from August 2014 September 2016 with 2-hour serial hs-cTnT results, of which 349 (63.6%) met the 2-hour rapid diagnostic algorithm low risk criteria (time 0 h/2 h hs-cTnT <14 ng/L and delta 2 h <4 ng/L). The sensitivity of the 2-hour low risk criteria for index AMI was 98.4% (95% CI 91.3%-100%) and for 30-day AMI was 98.4% (95% CI 91.6-100%). The sensitivity for 30day MACE was lower 84.4% (95% CI 74.4-91.7%) but maintained a high negative predictive value, 96.6% (95% CI 94.1-98.2%). Conclusion: A 2-hour rapid diagnostic algorithm using an hs-cTnT assay was highly sensitive for AMI on the index visit and successfully identified patients at low risk of 30-day AMI. Sensitivity for MACE was lower, reminding us that while biomarker-only rapid diagnostic algorithms excel at ruling out AMI, careful clinical risk stratification is needed to avoid missed MACE events.
Introduction: On March 16 2017, emergency departments and urgent care centres (collectively, EDs) in Calgary saw 3 times the number of fall-related ED visits, and 8 times the number of ED orthopedic consultations and admissions than the daily average for March 2014-2016. Fall-related injuries have significant associated morbidity and burden of disease, as well as cost to the health care system, caregivers and society. The purpose of this study was to use regression analysis to generate best fit models and identify weather and temporal variables which predict the frequency of fall-related ED visits, orthopedic consultations and admissions in winter (November-March). Methods: Daily number of ED visits, orthopedic consults, and orthopedic admissions for presenting complaint of Lower Extremity Injury, Upper Extremity Injury, or with an ED diagnosis of Fracture or Fall, were obtained for winter months from November 1 2013 to March 31 2017 from the Alberta Health Services ED database. Weather data was obtained from Environment Canada. Linear and multiple regression were performed to evaluate the predictive value of individual weather and temporal parameters, and derive the best-fitting model to predict the number of ED visits, orthopedic consultations, and orthopedic admissions. Results: Individual predictive factors (p<0.05) were month, temperature, overnight temperature drop from >0C to <0C, day of the week, amount of snow on the ground at 05:00, post-chinook day (chinooks are a warm winter wind in Calgary that can cause large temperature swings), maximum wind gust speed, and presence of precipitation. The best-fit multivariable models predicting fall-related ED visits (F-stat=15.36, R2=0.171), orthopedic consults (F-stat=6.369, R2=0.048), and orthopedic admissions (F-stat=8.658, R2=0.126) were statistically significant (probability of F-statistics all <0.0001). Conclusion: This study is, to the best of our knowledge, the first to use multiple regression to compute models using weather and temporal variables that can predict fall-related ED visits, orthopedic consults and admissions. This information could be used to alert the population regarding an increased fall and fracture risk ahead of the weather occurrence, as well as municipal snow and ice clearing services, who may be able to mitigate that risk. The ability to predict the frequency of fall-related injuries could enable EDs, EMS, orthopedic services, and hospitals to adjust resource and staffing allocation in anticipation of increases in fall-related injuries.
Introduction: Administrative data are attractive for research, policy and quality improvement initiatives as large amounts of data can often be obtained quickly and at low cost. Unfortunately, administrative data often have significant limitations owing to how they were collected and coded. In many cases, free text, often hand written, diagnoses provided by physicians are converted into ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) codes by trained nosologists for administrative purposes. However, because of the large data sets often obtained from administrative sources, it is difficult to verify the accuracy of the data, which may lead researchers to misleading or false conclusions. The objective of this study was to evaluate the accuracy of ICD-10 codes for the diagnosis of pulmonary embolism (PE) in emergency department (ED) patients. Methods: As part of a larger study examining the effectiveness of a clinical decision support intervention on CT utilization and diagnostic yield for ED patients with suspected PE, all patients with an ICD-10 code corresponding to PE (126.0 and 126.9) on ED discharge were obtained from four adult urban EDs and one urgent care center from August 2016 to March 2017. PE diagnosis was confirmed by reviewing electronic medical records and imaging reports for all patients. Discrepancies between coded ICD-10 diagnoses and actual imaging findings were quantified. This study was REB approved. Results: Of 584 ED patients with ICD-10 codes identifying PE as a discharge diagnosis, 535 had imaging that could be reviewed. Of these, 225 (42.1%) did not have clinical diagnoses of PE, and thus were incorrectly coded, resulting in false positive ICD-10 codes. Common coding errors included physician free text diagnoses of rule out PE or query PE being coded as positive for PE. Conclusion: Administrative data are subject to errors in coding. In this study ICD-10 codes were not reliable for the diagnosis of PE, with 42.1% of PE diagnoses being false positives. Similar coding errors are likely for other diagnoses that require waits for confirmatory imaging (e.g. appendicitis). Nosologist coding of physician free text diagnoses is challenging and prone to errors. Consequently, validation of ICD-10 coding prior to analysis of administrative datasets is crucial for meaningful results.
Introduction: Hospital admission within 72 hours of emergency discharge is a widely accepted measure of emergency department quality of care. Patients returning for unplanned admission may reveal opportunities for improved emergency or followup care. Calgary emergency physicians, however, are rarely notified of these readmissions. Aggregate site measures provide a high level view of readmissions for managers, but dont allow for timely, individual reflection on practice and learning opportunities. These aggregations may also not correctly account for variation in planned readmissions and other workflow nuances. There was a process in place at one facility to compile and communicate readmission details to each physician, but it was manual, provided limited visit detail, and was done weeks or months following discharge. Methods: A new, realtime 72 hour readmission notification recently implemented within the Calgary Zone provides direct and automated email alerts to all emergency physicians and residents involved in the care of a patient that has been readmitted. This alert is sent within hours of a readmission occurring and contains meaningful visit detail (discharge diagnosis, readmit diagnosis, patient name, etc) to help support practice reflection. An average of 15 alerts per day are generated and have been sent since implementation in April, 2017. Although an old technology, the use of email is a central component of the solution because it allows physicians to receive notifications at home and outside the hospital network where they routinely perform administrative tasks. A secondary notification is sent to personal email accounts (Gmail, Hotmail, etc) to indicate an unplanned admission has occurred, but without visit detail or identifiable information. It also allowed implementation with no new hardware or software cost. Results: A simple thumbs up/down rating system is used to adjust the sensitivity of the alert over time. More than 66% of those providing feedback have indicated the alert is helpful for practice reflection (i.e., thumbs up). And of those that indicated it was not helpful, comments were often entered indicating satisfaction with the alert generally, or suggestions for improvement. For example, consulted admitting physicians are often responsible for discharge decisions and should be added as recipients of the alert. Conclusion: Many physicians have indicated appreciation in knowing about return patients, and that they will reflect on their care, further review the chart, or contact the admitting physician for further discussion. Most are accepting of some ‘expected’ or ‘false positive’ alerts that aren’t helpful for practice reflection. Further tuning and expansion of the alert to specialist and consult services is needed to ensure all physicians involved in a discharge decision are adequately notified.
Introduction: ex-specific diagnostic cutoffs may improve the test characteristics of high-sensitivity troponin assays for the diagnosis of myocardial infarction. Sex-specific cutoffs for ruling in MI improve the sensitivity of the assay for MI among women, and improve the specificity of diagnosis among men. We hypothesized that the use of sex-specific high-sensitivity Troponin T (hsTnT) cutoffs for ruling out MI at the time of ED arrival would improve the classification efficiency of the assay by enabling more patients to have MI ruled out at the time of ED arrival while maintaining diagnostic sensitivity. The objective of this study was to quantify the test characteristics of sex-specific cutoffs of an hsTnT assay for acute myocardial infarction (AMI) when performed at ED arrival in patients with chest pain. Methods: This retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs were, excluding those with ST-elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes was AMI at 7 days. Secondary outcomes included major adverse cardiac events (MACE: all-cause mortality, AMI and revascularization) and the individual MACE components. We quantified test characteristics (sensitivity, negative predictive value, likelihood ratios and proportion of patients ruled out) for multiple combinations of sex-specific rule-out cutoffs. We calculated net reclassification improvement compared to universal rule-out cutoffs of 5ng/L (the assays limit of detection) and 6ng/L (the FDA-approved limit of quantitation for US laboratories). Results: 7130 patients, including 3931 men and 3199 women, were included. The 7-day incidence of AMI was 7.38% among men and 3.78% among women. Universal cutoffs of 5 and 6 ng/L ruled out AMI with 99.7% sensitivity in 33.6 and 42.2% of patients. The best-performing combination of sex-specific cutoffs (8g/L for men and 6ng/L for men) ruled out AMI with 98.7% sensitivity in 51.9% of patients. Conclusion: Sex-specific hsTnT cutoffs for ruling out AMI at ED arrival may achieve substantial improvement in classification performance, enabling more patients to be ruled out at ED arrival, while maintaining acceptable diagnostic sensitivity for AMI. Universal and sex-specific rule-out cutoffs differ by only small changes in hsTnT concentration. Therefore, these findings should be confirmed in other datasets.