ObjectiveTo compare the ability of five established risk scores to identify patients with suspected acute coronary syndromes (ACS) suitable for discharge after a single presentation highsensitivity troponin (hs-cTn) result. MethodsProspective observational study conducted in a U.K. District General Hospital Emergency Department. Consecutive adults recruited with suspected ACS whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to Goldman, TIMI, GRACE, HEART and Vancouver risk scores, incorporating either hs-cTnT or hs-cTnI results. The endpoint was acute myocardial infarction (AMI) within 30 days. A test sensitivity threshold for AMI of 98% was chosen.Clinical utility was defined as a negative predictive value (NPV) ≥99.5% and identification of >30% suitable for discharge. Results959 patients underwent hs-cTnT and 867 hs-cTnI analysis. In the hs-cTnT group, 79/959 (8.2%) had an AMI and 66/867 (7.6%) in the hs-cTnI group. Two risk scores (GRACE<80, HEART≤3) did not have the potential to achieve a sensitivity of 98% with hs-cTnT and three 2 scores (Goldman≤1, TIMI≤1, GRACE<80) with hs-cTnI. TIMI 0 or ≤1 and m-Goldman≤1 with hs-cTnT, and TIMI 0 and HEART≤3, with hs-cTnI have the potential to achieve an NPV ≥99.5% while identifying >30% for discharge. ConclusionUsing established risk scores, it may be possible to identify >30% of patients suitable for discharge with an NPV ≥99.5% for the diagnosis of AMI using a single hs-cTn result taken at presentation. There is variation in hs-cTn assays which may have implications in introducing rapid rule-out protocols.

ObjectiveTo establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We also compared the diagnostic accuracy of this ADP with strategies using initial undetectable hs-cTnT.MethodsThis prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14 ng/L, a non-ischaemic ECG and a modified Goldman risk score. Diagnostic performance of the ADP was compared with the detection limit cut-offs of hs-cTnT (<5 ng/L and <3 ng/L). The primary end point was fatal/non-fatal acute myocardial infarction (AMI) within 30 days.Results960 participants were recruited, mean age 58.0 years, 80 (8.3%) had an AMI. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying AMI of 98.8% (95% CI 92.5% to 99.9%). hs-cTnT detection limits (<5 ng/L and <3 ng/L) had a sensitivity of 100% (94.3 to 100) and 100% (94.4 to 100), respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5 ng/L) and 7.9% (<3 ng/L) (p<0.001) with a lower false-positive rate for AMI detection; specificity 43.3% (95% CI 42.7% to 43.4%) vs 32.0% (95% CI 31.5% to 32.0%) and 8.6% (95% CI 8.1% to 8.6%), respectively.ConclusionsThe TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies.Trial registration numberISRCTN No. 21109279.

Subjective interpretation of "typicality of chest pain" is of limited discriminatory value in the assessment of suspected acute coronary syndromes, in the context of a nondiagnostic electrocardiogram. Greater clinical experience improves accuracy as a rule-in tool but does not improve overall discriminatory ability.

the threshold for detecting external resistive loads during tidal breathing rises in old age. This appears to be a consequence of ageing processes rather than pathology, and might be a manifestation of a fall in proprioceptive acuity in elderly people. This finding has clinical implications for the self-management of asthma in old age. There is a need to conduct a similar study in patients with airways disease.

Background Joint Hypermobility Syndrome (JHS) is a multisystemic connective tissue disorder characterised by pain, tissue fragility and laxity. This study aims to investigate the prevalence of chronic widespread pain (CWP) and the extended neurophysiological features reported by a group of patients with JHS. Methods Ninety patients with JHS (mean age 34.7 ± 9.9 years), which was diagnosed in accordance with the Brighton criteria, and 113 healthy volunteers (mean age 35.7 ± 12.9) with no musculoskeletal pain participated in the study. A self-report questionnaire and pain chart were employed to collect data. Results CWP was reported by 86% of patients with JHS. The mean number of pain sites in this group was 9.8/17 ± 4.2. Fibromyalgia was reported by 19% of this group. Patients with JHS were significantly more likely to report the following than healthy volunteers: autonomic symptoms (70%, 12%); gastrointestinal symptoms (71%, 9%); and chronic fatigue syndrome (31%, 1%). Patients with JHS reported significantly higher mean functional difficulties scores (22.28 ± 4.90) than healthy volunteers (17.96 ± 3.73) (P<0.001), indicative of functional difficulties associated with developmental coordination disorder/dyspraxia. Conclusion Patients with JHS reported a wide range of neurophysiological symptoms of which CWP was a salient feature. There is a need to acknowledge and understand the extended symptoms associated with CWP in order to address the holistic needs of patients with JHS. Further studies and discussion are required to identify the complex inter-related multifactorial neurophysiological mechanisms in those with JHS.