2011 September 15

Validation of an abbreviated Vitalpac™ Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital.

Sep 152011

Validation of an abbreviated Vitalpac™ Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital.

Resuscitation. 2011 Sep 8;

Authors: Kellett J, Kim A

Abstract
BACKGROUND: : the early warning score derived from 198,755 vital sign sets in the Vitalpac™ database (ViEWS) has an area under the receiver operator characteristic curve (AUROC) for death of acute unselected medical patients within 24hours of 88%. METHODS: : this study validated an abbreviated version of ViEWS, which did not include mental status, in 75,419 consecutive patients admitted to the Thunder Bay Regional Health Sciences Center between 2005 and 2010. RESULTS: : the abbreviated score had an AUROC for death within 48hours of admission of 93% for all patients and 89% for medical patients-there were no significant differences in the discrimination of the score between surgical and medical patients or patients admitted to different medical sub-specialty services. The AUROC for intensive care patients, however, was significantly lower at 72%. Although medical patients appeared to have a higher mortality than surgical patients with the same score, these only reached statistical significance for surgical patients with a score between 3 and 10 points, stroke patients between 3 and 6 points, oncology patients between 7 and 10 points, and ICU patients with 3 or more points. CONCLUSION: : the abbreviated ViEWS score has comparable discrimination to the original score and has reasonable "goodness of fit" for most patients except for those requiring intensive care.

PMID: 21907689 [PubMed - as supplied by publisher]

Link to Article at PubMed

A systematic review of nicardipine vs labetalol for the management of hypertensive crises.

Am J Emerg Med Start a Discussion »

Sep 152011

A systematic review of nicardipine vs labetalol for the management of hypertensive crises.

Am J Emerg Med. 2011 Sep 9;

Authors: Peacock WF, Hilleman DE, Levy PD, Rhoney DH, Varon J

Abstract
Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage. Hypertensive urgencies, defined as elevated BP without acute end-organ damage, can often be treated with oral agents, whereas hypertensive emergencies are best treated with intravenous titratable agents. However, a lack of head-to-head studies has made it difficult to establish which intravenous drug is most effective in treating hypertensive crises. This systematic review presents a synthesis of published studies that compare the antihypertensive agents nicardipine and labetalol in patients experiencing acute hypertensive crises. A MEDLINE search was conducted using the term "labetalol AND nicardipine AND hypertension." Conference abstracts were searched manually. Ultimately, 10 studies were included, encompassing patients with hypertensive crises across an array of indications and practice environments (stroke, the emergency department, critical care, surgery, pediatrics, and pregnancy). The results of this systematic review show comparable efficacy and safety for nicardipine and labetalol, although nicardipine appears to provide more predictable and consistent BP control than labetalol.

PMID: 21908132 [PubMed - as supplied by publisher]

Link to Article at PubMed

Gender and stress test use in an ED chest pain unit.

Am J Emerg Med Start a Discussion »

Sep 152011

Gender and stress test use in an ED chest pain unit.

Am J Emerg Med. 2011 Sep 9;

Authors: Napoli A, Choo EK

Abstract
BACKGROUND: Women with acute coronary syndrome appear to be treated less aggressively than men. However, little is known about potential sex biases in the evaluation of patients with low-risk chest pain admitted to emergency department (ED) chest pain units. METHODS: This was a secondary analysis of prospectively collected data on consecutively admitted chest pain unit patients in a large-volume academic urban ED. Thrombolysis in myocardial infarction (TIMI) risk prediction and Diamond and Forrestor (D&F) scores were calculated for each patient. ?(2) And t tests were used for univariate comparisons of demographics, cardiac comorbidities, risk scores, and stress testing between sexes. Multivariable logistic regression was used to estimate odds ratios (ORs) for testing based on sex, controlling for race, insurance status, and either TIMI or D&F score. RESULTS: Eight hundred eleven patients were enrolled (48% male, 52% female) in the study. The mean age for men was 52 ± 12 and 54 ± 12 years for women (P < .01). Men had a higher mean D&F score (42.0 vs 24.4; P < .01), but TIMI risk scores did not differ between sexes. Women received testing more often than men, a difference that was not statistically significant (50% [95% confidence interval {CI}, 45%-55%] vs 43% [95% CI, 39%-48%]; probability ratio of 1.16; P = .19). Women had a higher OR for receiving stress testing (1.61, 95% CI 1.14-2.29 controlling for TIMI score; OR, 1.69, 95% CI 1.12-2.51 controlling for D&F score). CONCLUSIONS: This study demonstrates no association between physician discretionary uses of stress testing based on sex. There is a need for further research on patient- or provider-specific factors that determine stress use and on how differences may affect clinical outcomes.

PMID: 21908137 [PubMed - as supplied by publisher]

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Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease.

Am J Emerg Med Start a Discussion »

Sep 152011

Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease.

Am J Emerg Med. 2011 Sep 9;

Authors: McCanny P, Bennett K, Staunton P, McMahon G

Abstract
OBJECTIVE: The purpose of this study was to investigate the clinical correlation between arterial and venous blood gas (VBG) values in patients presenting to the emergency department (ED) with acute exacerbation of chronic obstructive pulmonary disease. METHODS: A prospective study of patients with chronic obstructive pulmonary disease presenting to the ED with acute ventilatory compromise was done. Patients were included if their attending physician considered arterial blood gas sampling important in their initial assessment. Data from arterial and venous samples were compared using Spearman correlation and bias plot (Bland-Altman) methods. RESULTS: Ninety-four patients were enrolled in the study. Eighty-nine patients had complete data sets for analysis. Arterial hypercarbia was present in 30 patients (33.7%; range, 51-140.19 mm Hg). All cases of arterial hypercarbia were detected using VBG sampling when a screening cutoff of 45 mm Hg was applied (sensitivity, 100%; 95% confidence interval, 88.7%-100% and specificity, 34%; 95% confidence interval, 23.1%-46.6%). Bias plot revealed moderate agreement between arterial and venous Pco(2) with an average difference of 8.6 mm Hg and 95% limits of agreement of -7.84 to 25.05 mm Hg. For pH, mean difference between each group was 0.07 (range, -0.9 to 0.06). Linear regression analysis for pH demonstrated very close equivalence with a regression coefficient of 0.955, and Spearman correlation showed significant correlation of 0.826 (P = .001). CONCLUSION: Venous pH and HCO(3) values show excellent correlation with arterial values. Using a previously validated screening cutoff of 45 mm Hg, venous CO(2) has 100% sensitivity in detecting arterial hypercarbia. There is insufficient agreement between venous and arterial CO(2) for VBG to replace arterial blood gas in determining the degree of hypercarbia.

PMID: 21908141 [PubMed - as supplied by publisher]

Link to Article at PubMed

Short-term Mortality Risk in Emergency Department Acute Heart Failure.

Acad Emerg Med Start a Discussion »

Sep 152011

Short-term Mortality Risk in Emergency Department Acute Heart Failure.

Acad Emerg Med. 2011 Sep;18(9):947-958

Authors: Frank Peacock W, Nowak R, Christenson R, Disomma S, Neath SX, Hartmann O, Mueller C, Ponikowski P, Möckel M, Hogan C, Wu AH, Richards M, Filippatos GS, Anand I, Ng LL, Daniels LB, Morgenthaler N, Anker SD, Maisel AS

Abstract
ACADEMIC EMERGENCY MEDICINE 2011; 18:947-958 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? Few tools?exist that provide objective accurate prediction of short-term mortality risk?in patients presenting with acute heart failure (AHF). The purpose was to describe the accuracy of several biomarkers for predicting short-term death rates in patients diagnosed with AHF in the emergency department (ED). Methods:? The Biomarkers in ACute Heart failure (BACH) trial was a prospective, 15-center, international study of patients presenting to the ED with nontraumatic dyspnea. Clinicians were blinded to all investigational markers, except troponin and natriuretic peptides, which used the local hospital reference range. For this secondary analysis, a core lab was used for all markers except troponin. This study evaluated patients diagnosed with AHF by the on-site emergency physician (EP). Results:? In the 1,641 BACH patients, 466 (28.4%) had an ED diagnosis of AHF, of whom 411 (88.2%) had a final diagnosis of AHF. In the ED-diagnosed HF patients, 59% were male, 69% had a HF history, and 19 (4.1%) died within 14?days of their ED visit. The area under the curve (AUC) for the 14-day mortality receiver operating characteristic (ROC) curve was 0.484 for brain natriuretic peptide (BNP), 0.586 for N-terminal pro-B-type natriuretic peptide (NT-proBNP), 0.755 for troponin (I or T), 0.742 for adrenomedullin (MR-proADM), and 0.803 for copeptin. In combination, MR-proADM and copeptin had the best 14-day mortality prediction (AUC?= 0.818), versus all other markers. Conclusions:? MR-proADM and copeptin, alone or in combination, may provide superior short-term mortality prediction compared to natriuretic peptides and troponin. Presented results are explorative due to the limited number of events, but validation in larger trials seems promising.

PMID: 21906204 [PubMed - as supplied by publisher]

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Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Variability Among Physicians in an Emergency Department.

Ann Emerg Med Start a Discussion »

Sep 152011

Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Variability Among Physicians in an Emergency Department.

Ann Emerg Med. 2011 Sep 8;

Authors: Dean NC, Jones JP, Aronsky D, Brown S, Vines CG, Jones BE, Allen T

Abstract
STUDY OBJECTIVE: We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. METHODS: We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. RESULTS: Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. CONCLUSION: We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.

PMID: 21907451 [PubMed - as supplied by publisher]

Link to Article at PubMed

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