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25: Additional Diagnostic Utility of Upright T-Wave in V1 and T-Wave V1 Vs. T-Wave in V6 in Differentiating Acute Anterior ST-Elevation Myocardial Infarction From Benign Early Repolarization
Research Forum Abstracts DBT decreased to 66.84 minutes (⫹/⫺SD ⫽ 19.76). By implementing this protocol change DBT was decreased an average of 25 minutes (p⬍0.0001). Furthermore, the mean CCL transfer time was 38.17 minutes (⫹/⫺ SD 12.49). After the protocol was revised, the mean CCL transfer time was 26.73 minutes (⫹/⫺ SD 9.04); with an absolute reduction of 11.44 minutes (p⬍0.0001). Conclusions: Immediate transport of the patient to the CCL prior to initiation of all medical therapies in the ED significantly decreases DBTs for acute STEMI.
25
Additional Diagnostic Utility of Upright T-Wave in V1 and T-Wave V1 Vs. T-Wave in V6 in Differentiating Acute Anterior ST-Elevation Myocardial Infarction From Benign Early Repolarization
Smith SW/Hennepin County Medical Center, Minneapolis, MN
Background: Using logistic regression, we previously derived, then later validated, a predictive rule to differentiate benign early repolarization (BER) from subtle acute anterior ST elevation myocardial infarction (STEMI) due to acute left anterior descending (LAD) coronary artery occlusion. The logistic regression rule (LRR) uses the mean R wave (RA) amplitude in V2-V4, mean ST elevation at the J-point (STEJ) in V2-V4, and Bazett corrected QT interval (QTc-B) in milliseconds (ms) such that if (1.553 x mean STEJ) ⫹ (.0546 x mean QTc-B in ms) – (0.3813 x mean RA) ⬎ 21, vs. ⬍/⫽ 21, then anterior STEMI was predicted. It has been suggested that an upright T-wave (TW) in lead V1 (TV1) is predictive of acute myocardial infarction, especially when the amplitude of TV1 ⬎ TV6. Study Objective: We sought to determine how the addition of this latter TW rule to the LRR would improve the utility of the LRR alone in the diagnosis of anterior STEMI. Methods: Retrospective study combining the derivation and validation sets for the previous study. The study group comprised consecutive anterior STEMI sent for primary percutaneous coronary intervention who had proven LAD occlusion. The control group comprised consecutive ED chest pain patients whose ECGs were coded as BER and who had 3 negative serial troponins. ECGs were excluded if MI was obvious: this was defined if there was inferior ST depression, STE ⬎ 5mm, anterior TW inversion, terminal QRS distortion, or a single straight or convex ST segment in any of leads V2-V6. Computerized QTc-B, and hand measured RA and STEJ in leads V2-V4 were measured to the nearest 0.5mm relative to the PR interval. In addition, TV1 was scrutinized and deemed inverted if either the entire T, or just the terminal portion of it, was inverted. It was coded as upright if there was no inversion. An upright TV1 was ⬎ TV6 if it was at least 1.0 mm greater in amplitude. Statistics were by two-tailed Chi square and Fisher exact test. Results: There were 292 ECGs; 125 with anterior STEMI and 167 with BER. 78/167 BER (47%) and 88/125 anterior STEMI (70%) had an upright TW in V1 (p⬍ .0001). 24/167 (14%) BER and 51/125 (41%) anterior STEMI had TV1⬎TV6 (p⬍.0001). Sensitivity (Sens), specificity (Spec), and accuracy (Acc) of upright TV1, and TV1 ⬎ TV6 for MI were, respectively, 70%, 47%, and 61%, and 41%, 86%, and 66%. Sens, Spec, and Acc of the LRR value ⬎ 21 was 91%, 83%, and 87%. Sens, Spec, and Acc of the LRR value ⬎ 21 or upright TW in V1, vs. neither, was 97% (p⫽0.11 vs. LRR alone), 42% (p⬍.0001), and 65% (p⬍.0001). Sens, Spec, and Acc of the LRR value ⬎ 21 or TV1 ⬎ TV6, vs. neither, was 96% (p⫽0.20 vs. LRR alone), 72% (p⫽.01), and 82% (p⫽0.17). Conclusion: An upright TW in V1, and TV1⬎TV6, are both significantly more common in anterior STEMI than BER. Neither rule performed as well as the LRR which uses RA, STEJ, and QTc-B. The addition of upright TW in V1, or TV1⬎TV6, minimally and nonsignificantly improved sensitivity of the LRR for LAD occlusion at the expense of significant decrement in specificity and accuracy.
26
When “Good” Is Below Average
Kiefer CS, Colletti JE, Bellolio M, Thomas KB, Woolridge DP/Mayo Clinic, Rochester, MN; University of Arizona, Tucson, AZ
Study Objectives: The Medical Student Performance Evaluation (MSPE) is a summarative evaluation composed by a student’s medical school dean that takes into account the student’s performance during pre clinical and clinical years. The aim of this study was to determine if there was a relationship between usage of the term “good” in the descriptive paragraph of the MSPE and academic performance in medical school as described by the ranking within the class. Methods: The final paragraph of the MSPE contains a summary statement in which the writer of the evaluation often uses a descriptive term such as “good,”
Volume , . : September
“outstanding,” or “excellent” in order to summarize a student’s overall performance. All MSPEs submitted to 3 different residency programs were reviewed. Each MSPE was examined to determine the presence or absence of the descriptive term “good” in either the summary statement or the appendices accompanying the MSPE. For institutions using the term “good,” the percentile ranking of students in the class receiving “good” as a descriptive term was noted. Following tabulation, the data was dichotomized in “bad” for institutions describing students in the bottom 25% and “intermediate” for the rest of the institutions, and analyzed with Wilcoxon test according to its non-normal distribution. Results: MSPEs were collected from122/125 accredited medical schools. Overall, 34 (27.9%) of institutions sampled used the term “good,” 86 (70.5%) of schools had no mention or category of students that was classified as “good,” and the use of the term “good” was unclear in 2 institutions. Of the 34 institutions utilizing “good” to describe students, all used the term to classify students in either the bottom 50%. Specifically, 25 schools used the term to classify students in the bottom quartile (0 –25%), 4 schools to students in the bottom 33%, 4 schools to students ranked between the 20 and 40th percentile, and in 1 institution “good” was applied to students in the bottom half of the class (0 –50%). There was a significant difference in the use of the term “good” among different medical schools when comparing those in the bottom 25% versus those with intermediate scores (p⬍0.0001). Students described by “good” could be anywhere between the 1st and 50th percentile. Conclusion: In the MSPE, the term “good” was utilized to describe students in the bottom 50% of the class. This makes a “good” medical student, a code for a below average medical school performance.
27
An Assessment of Resident Training in Emergency Department Administration
Farley HL, Buehler G/Christiana Care Health Systems, Newark, DE; Christiana Care Health Systems, Newark, DE
Background: Emergency department (ED) administration encompasses a wide range of topics which residents spend a variable amount of time learning during training. Study Objective: To examine the curricula of emergency medicine (EM) residency programs with regards to ED administration. Methods: An electronic survey was sent to all U.S. EM residency coordinators to evaluate resident training in ED administration. Data included which post-graduate year (PGY) residents completed the rotation, the amount of time dedicated to ED administration, and administrative topics covered. Possible administrative topics covered included ED operations, billing/coding, quality assurance/performance improvement, risk management/medical-legal, EMTALA, contracts, budget planning/financing, scheduling, marketing, public policy/political advocacy, and an option to specify other topics. Results: 55/140(39.3%) of coordinators completed the survey. Of programs that completed the survey, 73.6% reported having ED administration as part of the curriculum, and 57.7% had a dedicated rotation block for ED administration. Of those with dedicated administration rotations, 77.4% occurred during the PGY-3 year. The most common length of an administration rotation was 4 weeks (41.9%). However, about half (51.6%) reported having ED administration combined with another rotation, such as EMS, research, or toxicology. The most common topics covered included ED operations (93.8%), quality assurance/performance improvement (84.4%), and risk management(87.5%). Other topics covered included billing/coding (62.5%), EMTALA (56.3%), contracts (34.4%), budget planning/ financing (46.9%), scheduling (28.1%), marketing (9.4%), and public policy/political advocacy (43.8%). Conclusions: The amount of time dedicated to ED administration and the administrative topics covered vary widely among training programs.
28
The Use of Video Laryngoscopy in Massachusetts Emergency Departments
Raja AS, Sullivan AF, Pallin DJ, Bohan J, Camargo Jr CA/Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: Video laryngoscopy decreases time to intubation, diminishes cervical spine motion, and increases the chance of first pass success during difficult intubations when compared to direct laryngoscopy. We sought to determine how many emergency departments (EDs) in Massachusetts were using video laryngoscopy, the characteristics of user and non-user EDs, and the reasons why non-users do not use video laryngoscopy.
Annals of Emergency Medicine S9
25
Additional Diagnostic Utility of Upright T-Wave in V1 and T-Wave V1 Vs. T-Wave in V6 in Differentiating Acute Anterior ST-Elevation Myocardial Infarction From Benign Early Repolarization
Smith SW/Hennepin County Medical Center, Minneapolis, MN
Background: Using logistic regression, we previously derived, then later validated, a predictive rule to differentiate benign early repolarization (BER) from subtle acute anterior ST elevation myocardial infarction (STEMI) due to acute left anterior descending (LAD) coronary artery occlusion. The logistic regression rule (LRR) uses the mean R wave (RA) amplitude in V2-V4, mean ST elevation at the J-point (STEJ) in V2-V4, and Bazett corrected QT interval (QTc-B) in milliseconds (ms) such that if (1.553 x mean STEJ) ⫹ (.0546 x mean QTc-B in ms) – (0.3813 x mean RA) ⬎ 21, vs. ⬍/⫽ 21, then anterior STEMI was predicted. It has been suggested that an upright T-wave (TW) in lead V1 (TV1) is predictive of acute myocardial infarction, especially when the amplitude of TV1 ⬎ TV6. Study Objective: We sought to determine how the addition of this latter TW rule to the LRR would improve the utility of the LRR alone in the diagnosis of anterior STEMI. Methods: Retrospective study combining the derivation and validation sets for the previous study. The study group comprised consecutive anterior STEMI sent for primary percutaneous coronary intervention who had proven LAD occlusion. The control group comprised consecutive ED chest pain patients whose ECGs were coded as BER and who had 3 negative serial troponins. ECGs were excluded if MI was obvious: this was defined if there was inferior ST depression, STE ⬎ 5mm, anterior TW inversion, terminal QRS distortion, or a single straight or convex ST segment in any of leads V2-V6. Computerized QTc-B, and hand measured RA and STEJ in leads V2-V4 were measured to the nearest 0.5mm relative to the PR interval. In addition, TV1 was scrutinized and deemed inverted if either the entire T, or just the terminal portion of it, was inverted. It was coded as upright if there was no inversion. An upright TV1 was ⬎ TV6 if it was at least 1.0 mm greater in amplitude. Statistics were by two-tailed Chi square and Fisher exact test. Results: There were 292 ECGs; 125 with anterior STEMI and 167 with BER. 78/167 BER (47%) and 88/125 anterior STEMI (70%) had an upright TW in V1 (p⬍ .0001). 24/167 (14%) BER and 51/125 (41%) anterior STEMI had TV1⬎TV6 (p⬍.0001). Sensitivity (Sens), specificity (Spec), and accuracy (Acc) of upright TV1, and TV1 ⬎ TV6 for MI were, respectively, 70%, 47%, and 61%, and 41%, 86%, and 66%. Sens, Spec, and Acc of the LRR value ⬎ 21 was 91%, 83%, and 87%. Sens, Spec, and Acc of the LRR value ⬎ 21 or upright TW in V1, vs. neither, was 97% (p⫽0.11 vs. LRR alone), 42% (p⬍.0001), and 65% (p⬍.0001). Sens, Spec, and Acc of the LRR value ⬎ 21 or TV1 ⬎ TV6, vs. neither, was 96% (p⫽0.20 vs. LRR alone), 72% (p⫽.01), and 82% (p⫽0.17). Conclusion: An upright TW in V1, and TV1⬎TV6, are both significantly more common in anterior STEMI than BER. Neither rule performed as well as the LRR which uses RA, STEJ, and QTc-B. The addition of upright TW in V1, or TV1⬎TV6, minimally and nonsignificantly improved sensitivity of the LRR for LAD occlusion at the expense of significant decrement in specificity and accuracy.
26
When “Good” Is Below Average
Kiefer CS, Colletti JE, Bellolio M, Thomas KB, Woolridge DP/Mayo Clinic, Rochester, MN; University of Arizona, Tucson, AZ
Study Objectives: The Medical Student Performance Evaluation (MSPE) is a summarative evaluation composed by a student’s medical school dean that takes into account the student’s performance during pre clinical and clinical years. The aim of this study was to determine if there was a relationship between usage of the term “good” in the descriptive paragraph of the MSPE and academic performance in medical school as described by the ranking within the class. Methods: The final paragraph of the MSPE contains a summary statement in which the writer of the evaluation often uses a descriptive term such as “good,”
Volume , . : September
“outstanding,” or “excellent” in order to summarize a student’s overall performance. All MSPEs submitted to 3 different residency programs were reviewed. Each MSPE was examined to determine the presence or absence of the descriptive term “good” in either the summary statement or the appendices accompanying the MSPE. For institutions using the term “good,” the percentile ranking of students in the class receiving “good” as a descriptive term was noted. Following tabulation, the data was dichotomized in “bad” for institutions describing students in the bottom 25% and “intermediate” for the rest of the institutions, and analyzed with Wilcoxon test according to its non-normal distribution. Results: MSPEs were collected from122/125 accredited medical schools. Overall, 34 (27.9%) of institutions sampled used the term “good,” 86 (70.5%) of schools had no mention or category of students that was classified as “good,” and the use of the term “good” was unclear in 2 institutions. Of the 34 institutions utilizing “good” to describe students, all used the term to classify students in either the bottom 50%. Specifically, 25 schools used the term to classify students in the bottom quartile (0 –25%), 4 schools to students in the bottom 33%, 4 schools to students ranked between the 20 and 40th percentile, and in 1 institution “good” was applied to students in the bottom half of the class (0 –50%). There was a significant difference in the use of the term “good” among different medical schools when comparing those in the bottom 25% versus those with intermediate scores (p⬍0.0001). Students described by “good” could be anywhere between the 1st and 50th percentile. Conclusion: In the MSPE, the term “good” was utilized to describe students in the bottom 50% of the class. This makes a “good” medical student, a code for a below average medical school performance.
27
An Assessment of Resident Training in Emergency Department Administration
Farley HL, Buehler G/Christiana Care Health Systems, Newark, DE; Christiana Care Health Systems, Newark, DE
Background: Emergency department (ED) administration encompasses a wide range of topics which residents spend a variable amount of time learning during training. Study Objective: To examine the curricula of emergency medicine (EM) residency programs with regards to ED administration. Methods: An electronic survey was sent to all U.S. EM residency coordinators to evaluate resident training in ED administration. Data included which post-graduate year (PGY) residents completed the rotation, the amount of time dedicated to ED administration, and administrative topics covered. Possible administrative topics covered included ED operations, billing/coding, quality assurance/performance improvement, risk management/medical-legal, EMTALA, contracts, budget planning/financing, scheduling, marketing, public policy/political advocacy, and an option to specify other topics. Results: 55/140(39.3%) of coordinators completed the survey. Of programs that completed the survey, 73.6% reported having ED administration as part of the curriculum, and 57.7% had a dedicated rotation block for ED administration. Of those with dedicated administration rotations, 77.4% occurred during the PGY-3 year. The most common length of an administration rotation was 4 weeks (41.9%). However, about half (51.6%) reported having ED administration combined with another rotation, such as EMS, research, or toxicology. The most common topics covered included ED operations (93.8%), quality assurance/performance improvement (84.4%), and risk management(87.5%). Other topics covered included billing/coding (62.5%), EMTALA (56.3%), contracts (34.4%), budget planning/ financing (46.9%), scheduling (28.1%), marketing (9.4%), and public policy/political advocacy (43.8%). Conclusions: The amount of time dedicated to ED administration and the administrative topics covered vary widely among training programs.
28
The Use of Video Laryngoscopy in Massachusetts Emergency Departments
Raja AS, Sullivan AF, Pallin DJ, Bohan J, Camargo Jr CA/Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: Video laryngoscopy decreases time to intubation, diminishes cervical spine motion, and increases the chance of first pass success during difficult intubations when compared to direct laryngoscopy. We sought to determine how many emergency departments (EDs) in Massachusetts were using video laryngoscopy, the characteristics of user and non-user EDs, and the reasons why non-users do not use video laryngoscopy.
Annals of Emergency Medicine S9