Decision support tool aims to lower referrals of low-risk patients with chest pain

When primary care pediatricians go digital when investigating a patient's electronic health record to help them make assessments, they are more likely to refer only those patients whose chest pain is rooted in a cardiac problem to a specialist. To that end, this evidence-based change to standard practice could reduce needless referrals of low-risk patients to cardiac specialists, according to a quality-improvement project presented during the American Academy of Pediatrics National Conference and Exhibition. Momentum has grown for creating an evidence-based approach for determining which children with chest pain to refer to cardiac specialists. To that end, this abstract built on a multi-institutional study published in Clinical Pediatrics in 2017. More than 620,000 office-based visits (1.3%) to pediatricians in 2012 were for chest pain, Ashraf Harahsheh, pediatric and preventive cardiologist and director of Resident Education in Cardiology at Children's National Hospital, and co-authors wrote at the time. While children often complain of having chest pain, typically, it is not due to a heart problem. "Our decision support tool incorporates the know-how of providers and helps them to accurately capture the type of red flags that point to a cardiac origin for chest pain," explained Harahsheh. Those red flags include abnormal personal medical history, chest pain with exertion and chest pain that increases with supine position. Now, the team's quality-improvement tool, first introduced at two local primary pediatric offices, has been expanded to the entire Children's Pediatricians & Associates network of providers who offer pediatric primary care in Washington and Maryland. "If the chest pain decision support tool/medical red-flags criteria were adopted nationwide, we expect to save a minimum of $3.8 million in health care charges each year," Harahsheh said. "That figure is very likely an underestimate of the true potential savings, because we did not calculate the value of lost productivity and other direct costs to families who shuttle from one appointment to the next."

Zebrafish could hold key to heart repair

Zebrafish can regenerate their hearts after injury. Now, a team has shown that certain heart muscle cells play a central role in this process, potentially leading to a similar benefit in humans. After an acute heart attack in mammals, millions of cardiomyocytes die and are replaced by a scar. However, other vertebrates can recover much better from a cardiac damage. For example, after heart injury, zebrafish cardiomyocytes can divide, and the scar is replaced by new cardiac muscle. Researchers from the Institute of Anatomy at the University of Bern have probed the cellular mechanisms of heart regeneration. They have determined that not all cardiomyocytes in the zebrafish heart contribute equally in the regeneration of lost muscle. Instead, there is a specific subset of cardiomyocytes with enhanced regenerative capacity. Marcos Sande-Melón, lead author of the study, and colleagues identified a small subset of cardiomyocytes in the zebrafish heart – marked by sox10 gene expression – that expanded more than the rest of myocardial cells in response to injury. "We were able to identify a specific cell population that is more efficient than all other heart muscle cells during regeneration, and showed that its contribution to repair is essential," said Nadia Mercader, professor at the University of Bern. Looking ahead, the authors would like to determine the role of sox10 in this cell population: "We want to find out whether the absence of such a sox10 cell population in mammals could explain why their heart does not regenerate well," explained Mercader. If so, the researchers believe that this finding could be of great importance in stimulating the repair process in the human heart. The study, which is titled "Adult sox10+ Cardiomyocytes Contribute to Myocardial Regeneration in the Zebrafish," appeared Oct. 22, 2019, in Cell Reports.

Concerns expressed about emergency CPR device use in face of lack of evidence

There is significant cost and minimal evidence related to the use of mechanical resuscitation devices in terms of benefiting those experiencing cardiac arrest vs. resuscitation performed by people. That has not stopped increased use of these devices, a new study has highlighted. The research, published under the title "Use of Mechanical Cardiopulmonary Resuscitation Devices for Out-of-Hospital Cardiac Arrest, 2010-2016" in the Journal of the American Medical Association Oct. 16, 2019, found a fourfold increase of the cardiopulmonary resuscitation (CPR) devices among emergency medical technicians in the U.S. over a six-year period. "It was particularly surprising because the mechanical CPR has not been tested for effectiveness by the FDA, even though it was approved by the FDA," explained T. Greg Rhee of UConn Health, and a study author. "We don't really know if it is effective in terms of keeping people alive and whether it is cost effective." Rhee, along with collaborators at Yale University and the University of California, San Francisco, looked at data from 892,022 patients who were identified by emergency medical professionals as experiencing cardiac arrest outside a health care facility. Even though manual CPR is far more common, emergency medical technicians, mechanical use is on the rise – from about 2% in 2010 to 8% in 2016. Not only are mechanical CPR devices expensive, clinical trials have not provided evidence of benefit for patients when compared with manual CPR, the authors say. "Given the high costs of mechanical CPR devices, better evidence is needed to determine whether these devices improve clinically meaningful outcomes for patients treated for out-of-hospital cardiac arrest by emergency services professionals to justify the significant increase in their use," the researchers wrote.

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