Chest pain in the emergency department and the chest pain unit

The diagnosis and assessment of acute chest pain remain challenging. Inappropriate discharge of patients with unrecognised life-threatening acute cardiovascular disease such as acute myocardial infarction or acute aortic syndromes from the hospital can result in potentially avoidable death. By contrast, routine hospital admission of patients with non-significant chest pain can lead to unnecessary investigations and interventions, with associated potential harm and increased healthcare costs. As only a small minority of the patients presenting with acute chest pain will ultimately be diagnosed with an acute coronary syndrome or another life-threatening acute cardiovascular syndrome it is essential to use rapid and straightforward diagnostic methods that allow accurate identification of high-risk chest pain patients and safe and early discharge of low risk patients in order to avoid congestion in the emergency department. Triage and diagnosis of patients presenting with acute chest pain should rely on careful history taking, judicious interpretation of the 12 lead ECG on presentation and the use of rapid rule-in/rule out diagnostic algorithms of acute myocardial infarction using high sensitivity cardiac troponin assays for the detection of myocardial cell necrosis. Chest pain units (CPU) are organizational short-stay units with specific management protocols designed to facilitate and optimize the diagnosis of patients presenting with chest pain. Implementation of CPU has results in increased adherence to guidelines and an improved clinical outcome.

Conclusion: Breaking the Spell of Scarcity

The conclusion begins with a personal story from the author, whose life was saved after his heart stopped as a child. Later, as a young man, he saw a young girl in Rwanda die of tuberculosis. Her avoidable death spurred him to study the global public health literature; he found that many in the field seemed focused less on remedying inequities than on the proper means of dividing up “inherently limited” resources. The assumption was that health-care spending in poor countries would remain, for the foreseeable future, at its current level. This work demonstrates both that this assumption is the product of history and that it continues to have mortal consequences.

An Appraisal of Antidotes’ Effectiveness: Evidence of the Use of Phyto-Antidotes and Biotechnological Advancements

Poisoning is the greatest source of avoidable death in the world and can result from industrial exhausts, incessant bush burning, drug overdose, accidental toxication or snake envenomation. Since the advent of Albert Calmette’s cobra venom antidote, efforts have been geared towards antidotes development for various poisons to date. While there are resources and facilities to tackle poisoning in urban areas, rural areas and developing countries are challenged with poisoning management due to either the absence of or inadequate facilities and this has paved the way for phyto-antidotes, some of which have been scientifically validated. This review presents the scope of antidotes’ effectiveness in different experimental models and biotechnological advancements in antidote research for future applications. While pockets of evidence of the effectiveness of antidotes exist in vitro and in vivo with ample biotechnological developments, the utilization of analytic assays on existing and newly developed antidotes that have surpassed the proof of concept stage, as well as the inclusion of antidote’s short and long-term risk assessment report, will help in providing the required scientific evidence(s) prior to regulatory authorities’ approval.

Perinatal mortality: epidemiological profile, causes and avoidable factors at a reference public maternity hospital in the State of Santa Catarina, Brazil, 2011–2015

BackgroundThis study aimed to identify the perinatal mortality coefficient, the epidemiological profile, causes and avoidable factors at a reference public maternity hospital in southern Brazil.MethodsIn this cross-sectional study, 334 medical records of postpartum women and newborns were evaluated between January 1st, 2011 and December 31st, 2015. The Expanded Wigglesworth Classification was used to assess the causes of perinatal mortality and the International Statistical Classification of Diseases and Related Health Problems (ICD-10/SEADE Foundation) was used for the preventable perinatal mortality analysis. Absolute numbers and percentages were used for data analysis. The perinatal mortality formula was used to calculate the perinatal mortality rate.ResultsThe perinatal mortality rate was 13.2/1000 total births, with a predominance of white race/color; mothers were 21–30 years of age, had experienced their first pregnancy and had completed their high school education.ConclusionThe main factors associated with perinatal death were antepartum fetal death in 182 (54.49%) cases, and avoidable death through appropriate prenatal care in 234 (70.05%) cases.

External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study

ObjectiveInjury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.SettingAgincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.ParticipantsAgincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.MethodsA literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the ‘three delays framework’ (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs—a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.ResultsUsing VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.ConclusionsA substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

Primary prevention and smoking habit among BRCA1/2 mutation carriers.

e13061 Background: Smoking is the leading cause of avoidable death in the world. Although controversial for years, current prospective studies suggest that smoking increases the risk of cancer in women with a deleterious BRCA1/2 mutation. Actually, we have very limited information about tobacco habit among BRCA1/2 carriers. Methods: We report an observational retrospective study of a consecutive sample of 198 BRCA1/2 carriers studied between April 2014 and March 2018 at the Family Cancer Clinic of the University Hospital of Coruña (NW-Spain). The main objective of the study is to know the prevalence of smoking in BRCA1/2 women, and to determine if carriers undergoing risk-reducing surgeries (RRS) abandon their tobacco habit as part of the primary prevention strategy. Results: The sample includes 136 patients affected by cancer (84% breast, 19% ovary) and 62 healthy women. During their follow-up [Median = 22, (1-43) months], 85 carriers underwent RRS (29% mammary, 54% prophylactic salpingo-oophorectomy, 16% both). At first visit, 46 were active smokers, 47 ex-smokers, 77 non-smokers and 28 did not specify their habit. The percentage of smokers and never smokers is similar between sick and healthy BRCA1/2 carriers, presenting a greater proportion of former smokers among those affected of cancer (30% vs. 23%), and of active smokers among healthy women (35% vs. 23%) [p > 0.5)]. Moreover, 23% of BRCA1/2 carriers are active smokers despite a previous diagnosis of cancer. RRS are not associated to a greater tobacco cessation, persisting in the habit 18% of the women that underwent any preventive surgery (p > 0.5). Conclusions: Smoking habit is high (55%) among BRCA1/2 carriers followed at our family cancer clinic. At least 23% of our BRCA1/2 positive women are active smokers despite a previous diagnosis of cancer.The performance of aggressive RRS is not associated with greater abandonment of tobacco in carriers, persisting in the smoking habit 18% of operated women.It is essential to improve anti-tobacco strategies in family cancer consultations if we want to be efficient in the management of high-risk cancer individuals.

Regulation of Surgical Procedures and Health Care Facilities Rankings in Nepal

Globally, millions of surgeries are performed each year to compliment and manage a diverse set of medical conditions. Adverse surgical outcomes constitute a major proportion of avoidable death and disabilities in the hospital, especially in low-income countries like Nepal. A comprehensive study on the standards of surgical procedures and its institutional regulations is missing. We discuss here the importance of surgical regulation based on it’s financial as well as healthcare implications in the Nepalese healthcare system. Keywords: surgical procedures; health care facilities; safety; surgery; WHO.

Oxygen delivery system in pre-hospital emergency care in india GVK EMRI 108: a review article

The goal of an effective emergency medical system should be to provide universal emergency care along with assured quality. Oxygen is often used drug in the pre hospital. Oxygen delivery can be monitored by pulse oximetry, typically with a goal of reversing hypoxemia. This paper describes the importance of oxygen in emergency care and its contribution to reducing avoidable death and disability. It also highlights the oxygen delivery systems and training processes /protocols in ambulance based pre-hospital care. In addition, it also shares the usage rates of oxygen and delivery methods in thermal and electrical burns in 108 GVK EMRI, India ambulances. A descriptive study methodology was adopted for explaining the training and pre-hospital care processes of oxygen delivery. Retrospective study method was adopted to measure the oxygen utilization rates in management of burns cases in 108 ambulances in the year 2015. EMTs consistently assessed vitals and provided oxygen to patients’. When EMTs found that patients’ had oxygen saturation less than 95%, they provided supplemental oxygen 95% of the times. EMTs though adhering to the routine use of oxygen in 9 out of 10 cases “where indicated, refresher training should focus on use of oxygen in special circumstances and the benefit to be closely monitored for favourable clinical outcomes”. There is a need to study such common and important essential pre-hospital interventions in all types of emergencies being served.

Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review

BackgroundThe proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods.MethodsA retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care.ResultsWe found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital’s report system.ConclusionsAvoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.