The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on acute-on-chronic liver failure (ACLF) in 2004, with a mandate to develop consensus guidelines on various aspects of ACLF relevant to disease patterns and clinical practice in the Asia-Pacific region. Experts predominantly from the Asia–Pacific region constituted this working party and were requested to identify different issues of ACLF and develop the consensus guidelines. A 2-day meeting of the working party was held on January 22–23, 2008, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and subsequently presented at the Annual Conference of the APASL at Seoul, Korea, in March 2008. The consensus statements along with relevant background information are presented in this review.

/pdf/acute-on-chronic-liver-failure-consensus-recommendations-of-41vjck9vv5.pdf

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL)

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

In this article, we review some of the key methodologic points that should be considered with regard to clinical evaluation of artificial intelligence tools for use in medical diagnosis and prediction.

Methodologic Guide for Evaluating Clinical Performance and Effect of Artificial Intelligence Technology for Medical Diagnosis and Prediction

Previous evidence suggests different cortical areas naturally oscillate at distinct frequencies, reflecting tuning properties of each region. The concurrent use of transcranial magnetic stimulation (TMS) and electroencephalography (EEG) has been used to perturb cortical regions, resulting in an observed post-stimulation response that is maximal at the natural frequency of that region. However, little is known about the spatial extent of TMS-induced activation differences in cortical regions when comparing resting state (passive) versus active task performance. Here, we employed TMS-EEG to directly perturb three cortical areas in the right hemisphere while measuring the resultant changes in maximal evoked frequency in healthy human subjects during a resting state (N=12) and during an active sensorimotor task (N=12). Our results revealed that the brain engages a higher dominant frequency mode when actively engaged in a task, such that the frequency evoked during a task is consistently higher across cortical regions, regardless of the region stimulated. These findings suggest that a distinct characteristic of active performance versus resting state is a higher state of natural cortical frequencies.

https://emj.bmj.com/content/emermed/20/5/453.full.pdf

An introduction to power and sample size estimation

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00391-8.pdf

High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study

Background: Numerous studies have evaluated the accuracy of D-dimer in diagnosing suspected deep vein thrombosis (DVT), but results are conflicting.

Aim: To overview estimates of the diagnostic accuracy of D-dimer and identify causes of variation.

Design: Systematic review, meta-analysis and meta-regression.

Methods: We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, citation lists, and contacted manufacturers. We selected studies that compared D-dimer to a reference standard in patients with suspected DVT. Data were analysed by random effects meta-analysis and meta-regression.

Results: We included 97 studies reporting 198 assays in 99 different patient groups. Overall estimated sensitivity and specificity of D-dimer were 90.5% and 54.7%, but both estimates were subject to significant heterogeneity ( p < 0.001). Meta-regression identified that some heterogeneity was explained by study setting, exclusion criteria, whether recruitment was consecutive or the study prospective, whether D-dimer and the reference standard were measured blind, and whether the D-dimer threshold was determined a priori . Sensitivity and specificity also varied between ELISA (94% and 45% respectively), latex (89% and 55%) and whole blood agglutination assays (87% and 68%). Sensitivity was higher for proximal than distal DVT. Specificity was dependent upon whether clinical probability of DVT was high (specificity 51%), intermediate (67%) or low (78%).

Discussion: D-dimer has good sensitivity, but poor specificity, for DVT. Estimates are subject to substantial heterogeneity from various sources. D-dimer specificity appears to be strongly dependent upon the pre-test clinical probability of DVT.

/pdf/variation-in-the-diagnostic-performance-of-d-dimer-for-4mmrgc8dyp.pdf

Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis

Pelvic girdle pain (PGP) is a term used specifically to pregnancy-related pain in the lumbosacral, sacroiliac and symphysis pubis joints. Pregnancy-induced hormonal and physical changes increase the risk of musculoskeletal problems in pregnancy. The severity of these conditions varies from mild self-limiting pain to a severe disabling condition. PGP is common in pregnancy and while most can be managed as outpatients, a few patients require inpatient admission for further investigations and management. Prompt identification of these conditions is essential to avoid serious disability. Lack of awareness and failure of recognition not only results in women feeling isolated, but may also result in long-term morbidity. In this review, we explore the aetiology, presentation, risk factors, risk of recurrence, differential diagnosis and multidisciplinary management of these conditions. We also enclose obstetric guidelines to increase the awareness of the health professionals.

Pelvic girdle pain during pregnancy and puerperium

Objectives: To apply a previously validated clinical model for predicting pre-test probability of deep vein thrombosis (DVT) to patients attending an emergency department with symptoms suggestive of DVT and assess its reproducibility in the patient population. To measure the diagnostic value of the SimpliRED D-dimer assay in effectively excluding DVT. 

Method: Prospective study between March 1999 and October 2000 of adult patients attending with suspected DVT. Patients were assessed using Wells' clinical prediction tool and risk stratified. SimpliRED D-dimer estimations were then performed and compression ultrasonography arranged. The pre-test probabilities of DVT in the low, moderate, and high risk groups of Wells' original cohort were compared with the authors' figures and the sensitivity, specificity, and predictive values of the SimpliRED assay calculated for the patient population. 

Results: Application of Wells' criteria to patients in the department permitted stratification into high, moderate, and low risk groups (prevalence of DVT 58.3%, 8.9%, and 1.5% respectively). SimpliRED D-dimer assay sensitivity was 63.4% with specificity of 74.8%, with a likelihood ratio of 2.52 for a positive test and 0.49 for a negative test. 

Conclusions: Clinical risk stratification allowed patients to be categorised into high, moderate, and low risk groups, albeit with less discriminatory power than originally described by Wells. The low sensitivity of the SimpliRED D-dimer assay when used routinely in a busy emergency department raises substantial doubt over the use of this test to rule out DVT, even in low risk patients.

https://emj.bmj.com/content/emermed/20/1/29.full.pdf

Emergency department investigation of deep vein thrombosis.

Background: Increases in emergency medical admissions are placing a strain upon hospitals throughout the world. The aim of the study was to evaluate the effect of a new post, the "A&E physician", upon emergency medical admissions to a hospital. 

Methods: For six months the A&E physician workload was audited and a randomised controlled comparison undertaken. Days were randomised to "A&E physician present" or "A&E physician absent". The A&E physician recorded details of all patients referred for medical admission, any intervention made, and their disposal from A&E. Routine hospital data compared the mean daily number of medical admissions, non-medical admissions, and referrals to other hospitals. 

Results: 124 days were randomised: 59 to A&E physician present, 65 to A&E physician absent. The A&E physician received 581 referrals and intervened in the management of 142 (24%). Of these, 80 were discharged home, apparently saving 1.4 admissions per day. However, randomised comparison showed that presence of the A&E physician was associated with a reduction of only 0.7 medical admissions per day (95% CI -1.7 to 3.2, p = 0.561), and an increase of 1.1 non-medical admissions (95% CI -0.2 to 2.3, p = 0.09) and 0.3 transfers to other hospitals per day (95% CI zero to 0.6, p = 0.09). Overall, hospital admissions were increased by 0.9 per day when the A&E physician was present (95% CI -1.8 to 3.6, p = 0.5). 

Conclusion: Despite receiving many referrals and discharging a substantial proportion of these patients home, the A&E physician did not significantly change emergency medical admissions and may have increased admissions to other specialties.

https://emj.bmj.com/content/emermed/21/1/51.full.pdf

Can additional experienced staff reduce emergency medical admissions

Objectives—Developments in triage have led to patients being directed to triage rather than reception upon arrival in A&E. This study aimed to discover if attending triage or reception first, was preferable in terms of timeliness, clarity and safety. 

Methods—The study compared two consecutive four week periods during which patients were directed to attend triage first and then reception first. Observers recorded their actions on arrival. Questionnaires recorded the patients' perceptions of each strategy. High priority triage categories were audited during the reception first phase. 

Results—1850 patients were observed in the triage first phase with a mean door to triage time of 10.6 minutes, triage to reception 5.3 minutes and door to reception 15.8 minutes. A total of 1522 patients were observed in the reception first phase with a mean door to reception time of 0.5 minutes, reception to triage 12.4 minutes and door to triage of 12.9 minutes. Patients were more likely to present to the appropriate place during the reception first phase (88% versus 34%) and reported better understanding of instructions. No case given triage category one or two suffered an adverse outcome resulting from delay associated with attending reception first. 

Conclusion—Directing patients to attend reception first is timely and less confusing. It is safe provided booking in does not delay assessment by more than 15 minutes.

https://emj.bmj.com/content/emermed/18/6/441.full.pdf

Should ambulant patients be directed to reception or triage first

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