***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background — Among intermediate- to high-risk patients with chest pain , we have shown that a cardiac magnetic resonance ( CMR ) stress test strategy implemented in an observation unit ( OU ) reduces 1-year health care costs compared with inpatient care . In this study , we compare 2 OU strategies to determine among lower-risk patients if a m and atory CMR stress test strategy was more effective than a physicians ' ability to select a stress test modality . Methods and Results — On emergency department arrival and referral to the OU for management of low- to intermediate-risk chest pain , 120 individuals were r and omly assigned to receive ( 1 ) a CMR stress imaging test ( n=60 ) or ( 2 ) a provider-selected stress test ( n=60 : stress echo [ 62 % ] , CMR [ 32 % ] , cardiac catheterization [ 3 % ] , nuclear [ 2 % ] , and coronary CT [ 2 % ] ) . No differences were detected in length of stay ( median CMR=24.2 hours versus 23.8 hours , P=0.75 ) , catheterization without revascularization ( CMR=0 % versus 3 % ) , appropriateness of admission decisions ( CMR 87 % versus 93 % , P=0.36 ) , or 30-day acute coronary syndrome ( both 3 % ) . Median cost was higher among those r and omly assigned to the CMR-m and ated group ( $ 2005 versus $ 1686 , P<0.001 ) . Conclusions — In patients with lower-risk chest pain receiving emergency department – directed OU care , the ability of a physician to select a cardiac stress imaging modality ( including echocardiography , CMR , or radionuclide testing ) was more cost-effective than a pathway that m and ates a CMR stress test . Contrary to prior observations in individuals with intermediate- to high-risk chest pain , in those with lower-risk chest pain , these results highlight the importance of physician-related choices during acute coronary syndrome diagnostic protocol s. Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00869245 STUDY OBJECTIVE Older adults are frequently hospitalized from the emergency department ( ED ) after an episode of unexplained syncope . Current admission patterns are costly , with little evidence of benefit . We hypothesize that an ED observation syncope protocol will reduce re source use without adversely affecting patient-oriented outcomes . METHODS This r and omized trial at 5 EDs compared an  ED observation syncope protocol to inpatient admission for intermediate-risk adults ( ≥50 years ) presenting with syncope or near syncope . Primary outcomes included inpatient admission rate and length of stay . Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge , index and 30-day hospital costs , 30-day quality -of-life scores , and 30-day patient satisfaction . RESULTS Study staff r and omized 124 patients . Observation result ed in a lower inpatient admission rate ( 15 % versus 92 % ; 95 % confidence interval [ CI ] difference -88 % to -66 % ) and shorter hospital length of stay ( 29 versus 47 hours ; 95 % CI difference -28 to -8 ) . Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days ( 3 % versus 0 % ; 95 % CI difference -1 % to 8 % ) and 6 months ( 8 % versus 10 % ; 95 % CI difference -13 % to 9 % ) . Index hospital costs in the observation group were $ 629 ( 95 % CI difference -$1,376 to -$56 ) lower than in the admission group . There were no differences in 30-day quality -of-life scores or in patient satisfaction . CONCLUSION An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay . Analyses of secondary outcomes suggest reduction in index hospital costs , with no difference in safety events , quality of life , or patient satisfaction . Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce re source use OBJECTIVES Prior studies demonstrating shorter length of stay ( LOS ) from coronary computed tomography angiography ( CCTA ) relative to stress testing in emergency department ( ED ) patients have not considered time of patient presentation . The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA  have differences in ED plus observation unit ( OU ) LOS and if there are disparities in testing modality use , based on the time of patient presentation to the ED . METHODS The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospect i ve and retrospective OU registry data . During the study period , stress testing and CCTA were both available from 08:00 to 17:00 hours . CCTA was not available on weekends , and therefore only subjects presenting on weekdays were included . Cox regression analysis was used to model the effect of testing modality ( stress testing vs. CCTA ) on OU LOS . Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight . The primary independent variable was testing modality : stress testing or CCTA . Age , sex , and race were included as covariates . Logistic regression was used to model testing modality choice by time period adjusted for age , sex , and race . RESULTS Over the study period , 841 subjects presented Monday through Friday . Median LOS was 18.0 hours ( interquartile range [ IQR ] = 11.7 to 22.9 hours ) . Objective cardiac testing was completed in 788 of 841 ( 94 % ) patients , with 496 ( 63 % ) receiving stress testing and 292 ( 37 % ) receiving CCTA . After age , race , and sex were adjusted for , patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA ( p < 0.0001 ) , but also had a greater likelihood of being tested by CCTA ( p = 0.001 ) . None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing . CONCLUSIONS In an OU setting with weekday and st and ard business hours CCTA availability , CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours . That time period was also associated with a greater likelihood of being tested by CCTA , suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times Background —The HEART Pathway is a decision aid design ed to identify emergency department patients with acute chest pain for early discharge . No r and omized trials have compared the HEART Pathway with usual care . Methods and Results —Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG ( n=282 ) were r and omized to the HEART Pathway or usual care . In the HEART Pathway arm , emergency department providers used the HEART score , a vali date d decision aid , and troponin measures at 0 and 3 hours to identify patients for early discharge . Usual care was based on American College of Cardiology/American Heart Association guidelines . The primary outcome , objective cardiac testing ( stress testing or angiography ) , and secondary outcomes , index length of stay , early discharge , and major adverse cardiac events ( death , myocardial infa rct ion , or coronary revascularization ) , were assessed at 30 days by phone interview and record review . Participants had a mean age of 53 years , 16 % had previous myocardial infa rct ion , and 6 % ( 95 % confidence interval , 3.6%–9.5 % ) had major adverse cardiac events within 30 days of r and omization . Compared with usual care , use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1 % ( 68.8 % versus 56.7 % ; P=0.048 ) and length of stay by 12 hours ( 9.9 versus 21.9 hours ; P=0.013 ) and increased early discharges by 21.3 % ( 39.7 % versus 18.4 % ; P<0.001 ) . No patients identified for early discharge had major adverse cardiac events within 30 days . Conclusions —The HEART Pathway reduces objective cardiac testing during 30 days , shortens length of stay , and increases early discharges . These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique Identifier : NCT01665521 OBJECTIVE To develop and vali date a new st and ardized confusion assessment method ( CAM ) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk setting s. DESIGN Prospect i ve validation study . SETTING Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University ( site 1 ) and in general medicine wards at the University of Chicago ( site 2 ) . PATIENTS The study included 56 subjects , ranging in age from 65 to 98 years . At site 1 , 10 patients with and 20 without delirium participated ; at site 2 , 16 patients with and 10 without delirium participated . MEASUREMENTS AND MAIN RESULTS An expert panel developed the CAM through a consensus building process . The CAM instrument , which can be completed in less than 5 minutes , consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders ( DSM-III-R ) . An a priori hypothesis was established for the diagnostic value of four criteria : acute onset and fluctuating course , inattention , disorganized thinking , and altered level of consciousness . The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion . At both sites , the diagnoses made by the CAM were concurrently vali date d against the diagnoses made by psychiatrists . At sites 1 and 2 values for sensitivity were 100 % and 94 % , respectively ; values for specificity were 95 % and 90 % ; values for positive predictive accuracy were 91 % and 94 % ; and values for negative predictive accuracy were 100 % and 90 % . The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium . The CAM was shown to have convergent agreement with four other mental status tests , including the Mini-Mental State Examination . The interobserver reliability of the CAM was high ( kappa = 0.81 - 1.0 ) . CONCLUSIONS The CAM is sensitive , specific , reliable , and easy to use for identification of delirium STUDY OBJECTIVE Patient satisfaction is an essential outcome measure in the diagnosis and treatment of acute chest pain in the emergency department . We compared patient satisfaction with the diagnostic protocol of a chest pain observation unit ( CPOU ) and st and ard inpatient hospitalization . METHODS We prospect ively studied patients who presented to the ED with chest pain and were found to have a low risk of acute myocardial infa rct ion ( AMI ) but who still might have benefited from a diagnostic protocol to rule out AMI . Consenting patients ( N = 104 ) were r and omized to the  CPOU ( experimental ) arm or the hospital inpatient ( control ) arm  and assessed for satisfaction by means of an interview before hospital discharge . RESULTS The CPOU protocol scored higher on four summary ratings of overall patient satisfaction . Correlations between overall satisfaction , number , and type of problems with care , and patient characteristics demonstrated content validity and revealed strengths and improvements that might be made in CPOUs . CONCLUSION Patients were more satisfied with rapid diagnosis in the CPOU than with inpatient stays for acute chest pain . Our findings add important information to the st and ard practice of weighing clinical and cost outcomes between two medical care alternatives Background and Purpose — Very early rehabilitation , with an emphasis on mobilization , may contribute to improved outcomes after stroke . We hypothesized that a very early rehabilitation protocol would be safe and feasible . Methods — We performed a r and omized , controlled trial with blinded outcome assessment . Patients at < 24 hours after stroke were recruited from 2 Melbourne metropolitan stroke units . Patients were r and omly assigned to receive st and ard care ( SC ) or SC plus very early mobilization ( VEM ) until discharge or 14 days ( whichever was sooner ) . The primary safety outcome was the number of deaths at 3 months . The primary feasibility outcome was a higher “ dose ” of mobilization achieved in VEM . Secondary safety outcomes included adverse events ( including falls and early neurologic deterioration ) , compliance with physiologic monitoring criteria , and patient fatigue after interventions . Secondary feasibility outcomes included “ contamination ” of st and ard care . Results — Overall , 18 % of patients screened were suitable for recruitment . Seventy-one patients were recruited and r and omized , with 2 dropouts by 12 months . The majority experienced ischemic strokes ( 87 % ) . The group mean±SD age was 74.7±12.5 years , and 58 % ( n=41 ) had a National Institutes of Health Stroke Scale score > 7 . There was no significant difference in the number of deaths between groups ( SC , 3 of 33 ; VEM , 8 of 38 ; P=0.20 ) . Almost all deaths occurred in patients with severe stroke . Secondary safety outcomes were similar between groups . The intervention protocol was successfully delivered , achieving VEM dose targets ( double SC , P=0.003 ) and faster time to first mobilization ( P 
    Output:
    
There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life , activities of daily living , non-serious adverse events , and costs .