| 1. |
- Eggers, Kai M., 1962-, et al.
(author)
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High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients : A Review of Validation and Clinical Implementation Studies
- 2018
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In: Clinical Chemistry. - : American Association for Clinical Chemistry. - 0009-9147 .- 1530-8561. ; 64:11, s. 1572-1585
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Research review (peer-reviewed)abstract
- BACKGROUND: The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies. CONTENT: We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms [level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms. CONCLUSIONS: There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients. (C) 2018 American Association for Clinical Chemistry
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| 2. |
- Eriksson Lindstrand, Anna, et al.
(author)
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Playful learning about light and shadow : a learning study project in early childhood education
- 2016
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In: Creative Education. - : Scientific Research Publishing, Inc.. - 2151-4755 .- 2151-4771. ; 7:2, s. 333-348
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Journal article (peer-reviewed)abstract
- The purpose of the project was to explore how a learning study (LS) based on variation theory could support the development of playful physics learning in early childhood education. The study explored what patterns of variation used during a three-cycle LS challenged and developed children’s ways of discerning why a shadow occurred. The empirical material comprised a screening (n = 7), three video-documented interventions, and 78 individual pre- and post-test interviews (n = 39) at 4 - 5 years old. Three somewhat different patterns of variation were implemented within a playful frame in the three groups. The results indicate low and non/significant improvements in cycle A, somewhat higher and significant improvements in cycle B, and substantially higher and significant improvements in cycle C. The study indicates a promising ability to combine a playful approach with the variation theory perspective to stimulate children’s understanding of a quite advanced scientific phenomenon. The careful process of identifying potential critical aspects, the awareness of the relationship between the whole and its parts, and the concretization of simultaneity are discussed as key aspects of these findings.
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| 3. |
- Jernberg, Tomas, et al.
(author)
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Long-Term Effects of Oxygen Therapy on Death or Hospitalization for Heart Failure in Patients With Suspected Acute Myocardial Infarction
- 2018
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In: Circulation. - : LIPPINCOTT WILLIAMS & WILKINS. - 0009-7322 .- 1524-4539. ; 138:24, s. 2754-2762
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Journal article (peer-reviewed)abstract
- Background: In the DETO2X-AMI trial (Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction), we compared supplemental oxygen with ambient air in normoxemic patients presenting with suspected myocardial infarction and found no significant survival benefit at 1 year. However, important secondary end points were not yet available. We now report the prespecified secondary end points cardiovascular death and the composite of all-cause death and hospitalization for heart failure.Methods: In this pragmatic, registry-based randomized clinical trial, we used a nationwide quality registry for coronary care for trial procedures and evaluated end points through the Swedish population registry (mortality), the Swedish inpatient registry (heart failure), and cause of death registry (cardiovascular death). Patients with suspected acute myocardial infarction and oxygen saturation of ≥90% were randomly assigned to receive either supplemental oxygen at 6 L/min for 6 to 12 hours delivered by open face mask or ambient air.Results: A total of 6629 patients were enrolled. Acute heart failure treatment, left ventricular systolic function assessed by echocardiography, and infarct size measured by high-sensitive cardiac troponin T were similar in the 2 groups during the hospitalization period. All-cause death or hospitalization for heart failure within 1 year after randomization occurred in 8.0% of patients assigned to oxygen and in 7.9% of patients assigned to ambient air (hazard ratio, 0.99; 95% CI, 0.84–1.18; P=0.92). During long-term follow-up (median [range], 2.1 [1.0–3.7] years), the composite end point occurred in 11.2% of patients assigned to oxygen and in 10.8% of patients assigned to ambient air (hazard ratio, 1.02; 95% CI, 0.88–1.17; P=0.84), and cardiovascular death occurred in 5.2% of patients assigned to oxygen and in 4.8% assigned to ambient air (hazard ratio, 1.07; 95% CI, 0.87–1.33; P=0.52). The results were consistent across all predefined subgroups.Conclusions: Routine use of supplemental oxygen in normoxemic patients with suspected myocardial infarction was not found to reduce the composite of all-cause mortality and hospitalization for heart failure, or cardiovascular death within 1 year or during long-term follow-up.Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01787110.
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| 4. |
- Khorram-Manesh, Amir, 1958, et al.
(author)
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Emergency Management and Preparedness Training for Youth (EMPTY) : The Results of the First Swedish Pilot Study
- 2018
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In: Disaster Medicine and Public Health Preparedness. - : Cambridge University Press (CUP). - 1935-7893 .- 1938-744X. ; 12:6, s. 685-688
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To examine the impact of a simulation training in raising a group of young students' personal and situational awareness in disasters and emergencies.METHODS: In total, 25 young students participated in two simulation scenarios representing two actual events, fire, and shooting, using a combination of two validated simulation training (Emergency Management and Preparedness Training for Youth [EMPTY]). The changes in their knowledge and awareness were evaluated by using questionnaires and the whole simulation was evaluated by three independent observers and a reference group.RESULTS: New concepts of emergency management, for example, evacuation, and barricading, could be trained in a safe environment. There was a significant increase in students' personal and situational awareness and their active engagement in the management of emergencies.CONCLUSION: EMPTY could raise the youth basic knowledge and ability to understand the concept of preparedness by being mentally prepared, available for collaboration, gaining a higher confidence, understanding the physical and psychological consequences of a major incident and the importance of their own safety. (Disaster Med Public Health Preparedness. 2018; page 1 of 4).
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| 5. |
- Lindahl, Bertil, et al.
(author)
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An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin I assay
- 2017
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In: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 103:2, s. 125-131
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Journal article (peer-reviewed)abstract
- Objective To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay. Methods The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers. Results In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts. Conclusions This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.
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| 8. |
- Ljung Faxén, Ulrika, et al.
(author)
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HFpEF and HFrEF Display Different Phenotypes as Assessed by IGF-1 and IGFBP-1
- 2017
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In: Journal of Cardiac Failure. - : Elsevier BV. - 1071-9164 .- 1532-8414. ; 23:4, s. 293-303
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Journal article (peer-reviewed)abstract
- BackgroundAnabolic drive is impaired in heart failure with reduced ejection fraction (HFrEF) but insufficiently studied in heart failure with preserved ejection fraction (HFpEF). Insulin-like growth factor 1 (IGF-1) mediates growth hormone effects and IGF binding protein 1 (IGFBP-1) regulates IGF-1 activity. We tested the hypothesis that HFpEF and HFrEF are similar with regard to IGF-1 and IGFBP-1.Methods and ResultsIn patients with HFpEF (n = 79), HFrEF (n = 85), and controls (n = 136), we analyzed serum IGF-1 and IGFBP-1 concentrations, correlations, and associations with outcome. Age-standardized scores of IGF-1 were higher in HFpEF, median arbitrary units (interquartile range); 1.21 (0.57–1.96) vs HFrEF, 0.09 (-1.40–1.62), and controls, 0.22 (-0.47-0.96), P overall <.001. IGFBP-1 was increased in HFpEF, 48 (28–79), and HFrEF, 65 (29–101), vs controls, 27(14–35) µg/L, P overall <.001. These patterns persisted after adjusting for metabolic and HF severity confounders. IGF-1 was associated with outcomes in HFrEF, hazard ratio per natural logarithmic increase in IGF-1 SD score 0.51 (95% confidence interval 0.32–0.82, P = .005), but not significantly in HFpEF. IGFBP-1 was not associated with outcomes in either HFpEF nor HFrEF.ConclusionHFpEF and HFrEF phenotypes were similar with regard to increased IGFBP-1 concentrations but differed regarding IGF-1 levels and prognostic role. HFrEF and HFpEF may display different impairment in anabolic drive.
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| 9. |
- Ljung, Lina, et al.
(author)
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A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions
- 2019
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In: Annals of Emergency Medicine. - : MOSBY-ELSEVIER. - 0196-0644 .- 1097-6760. ; 73:5, s. 491-499
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Journal article (peer-reviewed)abstract
- Study objective: We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care-related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.Methods: This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.Results: A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference -20.4 to -11.4); median health care-related costs, from $1,748 to $1,079 (95% CI of difference -$953 to -$391). The number of clinical events was very low.Conclusion: In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.
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| 10. |
- Ljung, Lina
(author)
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Early diagnosis and risk stratification in patients with symptoms suggestive of acute coronary syndrome
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Background: Chest pain is one of the most common symptoms in patients presenting to the emergency department (ED). Identifying the minority of patients with an acute coronary syndrome (ACS) is a challenge. The introduction of high-sensitivity cardiac troponin (hs-cTn T and I) assays has radically improved the assessment. The aim of this thesis was to evaluate four methods of assessing patients presenting with suspected ACS in the era of hs-cTn. Methods and results: In Study I, we retrospectively evaluated the value of predischarge exercise ECG testing in 951 chest pain patients in whom myocardial infarction (MI) had been ruled out by means of hs-cTnT. We found no significant differences regarding death or MI between patients with a positive or a negative test, neither at 90 (n=1 [1.1%] vs. n=1 [0.2%]), nor at 365 days (n=2 [2.1%] vs. n=4 [0.7%]) of follow-up. In total, there were 9 (0.9%) deaths and 10 (1.1%) MIs within 365 days. The one-year rates of death (1.3%) and MI (0.5%) in a matched Swedish population were comparable. Study II was a retrospective evaluation of the diagnostic sensitivity of an undetectable level of hs-cTnT at presentation, with and without information from the electrocardiogram (ECG), to rule out MI in a non-ST-segment elevation MI (NSTEMI) population presenting early. Twenty-four (2.6%) of the 911 early presenting NSTEMI patients initially had an undetectable level of hs-cTnT. In patients presenting >1–≤2 hours from symptom onset, the sensitivity for MI when combining hs-cTnT and ECG was 99.4% (95% confidence interval [CI] 98.4%–99.8%). In patients presenting ≤1 hour from symptom onset and in patients aged ≤65 years without prior MI, the sensitivity was insufficient. NSTEMI patients presenting with an undetectable level of hs-cTnT were younger but had a similar 30-day outcome to NSTEMI patients presenting with a detectable level of hs-cTnT. In Study III, we retrospectively evaluated a one-hour hs-cTnT algorithm in 1,091 chest pain patients with a non-elevated hs-cTnT when presenting to the ED and examined early dynamic changes in hs-cTnT. Dynamic one-hour changes (Δ ≥3 ng/L) occurred in 23 patients (2.1%). Fifteen patients (65.2%) in the dynamic group were admitted, compared to 148 patients (13.9%) in the non-dynamic group (p<0.001). Four of the patients admitted (26.7%) in the dynamic and one (0.7%) in the non-dynamic group were diagnosed with an MI (p<0.001). No death or MI occurred within 30 days among those discharged from the ED. In Study IV, we evaluated the clinical effects of implementing a one-hour hs-cTnT or I algorithm combined with the HEART score in a prospective observational before-after study including 1,233 patients at six centres. The new strategy was associated with a reduction in admission rate (59% to 33%, p<0.001, adjusted odds ratio [95% CI]: 0.33 [0.25–0.42]), median time to discharge (23.2 to 4.7 hours, p<0.001) and median health care-related costs (€1,651 to €1,019, p<0.001). The rates of death and MI were very low. Conclusions: Rapid hs-cTn algorithms improve the prognostic assessment in patients with suspected ACS, making routine admission and predischarge exercise ECG testing redundant.
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