A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: A randomized clinical trial

IMPORTANCE Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge. OBJECTIVE To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting. DESIGN, SETTING, AND PARTICIPANTS A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up. INTERVENTIONS An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control. MAIN OUTCOMES AND MEASURES Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days. RESULTS Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation. CONCLUSIONS AND RELEVANCE Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required.

Development and validation of the Emergency Department Assessment of Chest pain Score and 2h accelerated diagnostic protocol

Objective Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge. Methods Logistic regression identified statistical predictors for major adverse cardiac events in a derivation cohort. Statistical coefficients were converted to whole numbers to create a score. Clinician feedback was used to improve the clinical plausibility and the usability of the final score (Emergency Department Assessment of Chest pain Score [EDACS]). EDACS was combined with electrocardiogram results and troponin results at 0 and 2 h to develop an ADP (EDACS-ADP). The score and EDACS-ADP were validated and tested for reproducibility in separate cohorts of patients. Results In the derivation (n = 1974) and validation (n = 608) cohorts, the EDACS-ADP classified 42.2% (sensitivity 99.0%, specificity 49.9%) and 51.3% (sensitivity 100.0%, specificity 59.0%) as low risk of major adverse cardiac events, respectively. The intra-class correlation coefficient for categorisation of patients as low risk was 0.87. Conclusion The EDACS-ADP identified approximately half of the patients presenting to the ED with possible cardiac chest pain as having low risk of short-term major adverse cardiac events, with high sensitivity. This is a significant improvement on similar, previously reported protocols. The EDACS-ADP is reproducible and has the potential to make considerable cost reductions to health systems.

Semiotic, rhetoric and democracy

This paper unites Deely’s call for a better understanding of semiotics with Jaeger’s insight into the sophists and the cultural history of the Ancient Greeks. The two bodies of knowledge are brought together to try to better understand the importance of rhetorical processes to political forms such as democracy. Jaeger explains how cultural expression, particularly poetry, changed through the archaic and classical eras to deliver, or at least to be commensurate with contemporary politics and ideologies. He explains how Plato (429-347 BCE) struggled against certain poetry and prose manifestations in his ambition to create a ‘perfect man’ – a humanity which would think in a way which would enable the ideal Republic to flourish. Deely’s approach based on Poinsot and Peirce presents a theoretical framework by means of which we can think of the struggle to influence individual and communal conceptualisation as a struggle within semiotics. This is a struggle over the ways reality is signified by signs. Signs are physical and mental indications which, in the semiotic tradition, are taken to produce human subjectivity – human ‘being’. Deely’s extensive body of work is about how these signs are the building blocks of realist constructions of understanding. This paper is concerned with the deliberate use of oral and written signs in rhetorical activity which has been deliberately crafted to change subjectivity. We discuss: (1) what thought and culture is in terms of semiotics and (2) Jaeger’s depiction of Ancient Greece as an illustration of the conjunction between culture and subjectivity. These two fields are brought together in order to make the argument that rhetoric can be theorised as the deliberate harnessing of semiotic affects. The implication is that the same semiotic, subjectivity-changing potency holds for 21st century rhetoric. However fourth century BCE Athens is the best setting for a preliminary discussion of rhetoric as deliberate semiotic practice because this was when rhetoric was most clearly understood for what it is. By contrast a discussion concentrating on modern rhetoric: public relations; advertising; lobbying; and public affairs would open wider controversies requiring considerably more complex explanation.

Recession-oscopy : can universities be the light at the end?

This paper paints the philosophical and ethical backdrop to some of the issues raised in Australian Universities’ Review vol. 53, no. 2. It links academic performance pay; the measurement of research output; and the astonishing pay levels of vice chancellors to the present global financial crisis. These are explained as part of a general malaise of institutions, which has its roots in the early Enlightenment. Drawing from semioticians Charles Sanders Peirce and John Deely it uses the terms ideoscopy and cenoscopy to characterise the hijacking of unwarranted scientific status for much of the way our world is managed. But crisis can lead to opportunity. Consequently, the paper points to the glaring opportunity for thinkers who can articulate the present situation in a way which could avert disaster.