BackgroundLowering the diagnostic threshold for troponin is controversial because it may disproportionately increase the diagnosis of myocardial infarction in patients without acute coronary syndrome. We assessed the impact of lowering the diagnostic threshold of troponin on the incidence, management, and outcome of patients with type 2 myocardial infarction or myocardial injury.MethodsConsecutive patients with elevated plasma troponin I concentrations (≥50 ng/L; n = 2929) were classified with type 1 (50%) myocardial infarction, type 2 myocardial infarction or myocardial injury (48%), and type 3 to 5 myocardial infarction (2%) before and after lowering the diagnostic threshold from 200 to 50 ng/L with a sensitive assay. Event-free survival from death and recurrent myocardial infarction was recorded at 1 year.ResultsLowering the threshold increased the diagnosis of type 2 myocardial infarction or myocardial injury more than type 1 myocardial infarction (672 vs 257 additional patients, P < .001). Patients with myocardial injury or type 2 myocardial infarction were at higher risk of death compared with those with type 1 myocardial infarction (37% vs 16%; relative risk [RR], 2.31; 95% confidence interval [CI], 1.98-2.69) but had fewer recurrent myocardial infarctions (4% vs 12%; RR, 0.35; 95% CI, 0.26-0.49). In patients with troponin concentrations 50 to 199 ng/L, lowering the diagnostic threshold was associated with increased healthcare resource use (P < .05) that reduced recurrent myocardial infarction and death for patients with type 1 myocardial infarction (31% vs 20%; RR, 0.64; 95% CI, 0.41-0.99), but not type 2 myocardial infarction or myocardial injury (36% vs 33%; RR, 0.93; 95% CI, 0.75-1.15).ConclusionsAfter implementation of a sensitive troponin assay, the incidence of type 2 myocardial infarction or myocardial injury disproportionately increased and is now as frequent as type 1 myocardial infarction. Outcomes of patients with type 2 myocardial infarction or myocardial injury are poor and do not seem to be modifiable after reclassification despite substantial increases in healthcare resource use.

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Purpose: This scoping review aims to map the breadth of the literature examining how trust is defined in health care teams, describe what measurements of trust are used, and investigate the precursors and outcomes of trust. Method: Five electronic databases (Ovid MEDLINE, CINAHL, PsycInfo, Embase, and ASSIA [Applied Social Sciences Index and Abstracts]) were searched alongside sources of grey literature in February 2021. To be included studies needed to discuss a health care team directly involved in managing patient care and one aspect of trust as a relational concept. A content count of the definitions of trust and tools used to measure trust and a deductive thematic analysis of the precursors and outcomes of trust in health care teams were conducted. Results: Ultimately, 157 studies were included after full-text review. Trust was the main focus of 18 (11%) studies and was not routinely defined (38, 24%). Ability appeared to be key to the definition. Trust was measured in 34 (22%) studies, often using a bespoke measure (8/34, 24%). The precursors of trust within health care teams occur at the individual, team, and organizational levels. The outcomes of trust occur at the individual, team, and patient levels. Communication was a broad overarching theme that was present at all levels, both as a precursor and outcome of trust. Respect, as a precursor, influenced trust at the individual, team, and organizational levels, while trust influenced learning, an outcome, across the patient, individual, and team levels. Conclusions: Trust is a complex, multilevel construct. This scoping review has highlighted gaps in the literature, including exploration of the swift trust model, which may be applicable to health care teams. Furthermore, knowledge from this review may be integrated into future training and health care practices to optimize team processes and teamworking.

We read with interest the article by Dzara et al. reflecting upon professional identity formation through using social media to create virtual communities of practice (CoP). 1 As early career academics, we

Despite the majority of laparoscopic visceral injuries occurring with primary entry, high-fidelity training models are lacking. Three healthy volunteers underwent non-contrast 3T MRI at Edinburgh Imaging. A direct entry 12mm trocar was filled with water to improve MR visibility, placed on the skin at entry points, then images were acquired in the supine position. Composite images were created, and distances from the trocar tip to the viscera were measured, demonstrating anatomical relationships during laparoscopic entry. With a BMI of 21 kg/m2, gentle downward pressure during skin incision or trocar entry reduced the distance to the aorta to less than the length of a No. 11 Scalpel blade (22mm). The need for counter-traction and stabilisation of the abdominal wall during incision and entry is demonstrated. With a BMI of 38 kg/m2, deviating from the vertical angle for trocar insertion can result in the entire trocar shaft being placed within the abdominal wall without entering the peritoneum, creating a ‘failed entry.’ At Palmer’s point distance between the skin and bowel is only 20mm. Ensuring the stomach is not distended will minimise gastric injury risk. The use of MRI to provide visualisation of the critical anatomy during primary port entry allows the surgeon to gain better understanding of textually described best practice techniques.