Combination of Copeptin and Troponin Assays to Rapidly Rule Out Non-ST Elevation Myocardial Infarction in the Emergency Department.

Acad Emerg Med. 2012 May;19(5):517-24

Authors: Charpentier S, Maupas-Schwalm F, Cournot M, Elbaz M, Botella JM, Lauque D

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19: 517-524 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The aim of this study was to analyze the diagnostic accuracy and the clinical usefulness of the combination of troponin I (cTnI) and copeptin measured at presentation with an automated assay to rapidly rule out non-ST elevation myocardial infarction (NSTEMI) in patients with suspected cardiac chest pain presenting to an emergency department (ED). Methods:? This study was an ancillary analysis of a prospective observational study. Copeptin and cTnI levels were sampled at presentation in 641 consecutive patients admitted to the ED for chest pain with onset within the last 12?hours and without ST elevation on a 12-lead electrocardiogram (ECG). Copeptin was measured with an automated assay and troponin with conventional assay. The performance of a combination of cTnI and copeptin for NSTEMI diagnosis was studied, the clinical utility was assessed by multivariate analysis, and an area under the curve (AUC) calculation was used to determine accuracy. Results:? NSTEMI was diagnosed in 95 patients (15%). The sensitivity and negative predictive value (NPV) of the combination of copeptin and cTnI measures were 90.4% (95% confidence interval [CI]?=?88.2% to 92.7%) and 97.6% (95% CI?=?96.4% to 98.7%) versus 55.3% (95% CI?=?51.5% to 59.2%) and 92.8% (95% CI?=?90.8% to 94.8%) with cTnI alone. The AUC of the combination of copeptin and cTnI was 0.89 (95% CI?=?0.85% to 0.92%) and was significantly higher than the AUC of cTnI alone (0.77, 95% CI?=?0.72% to 0.82%, p?<?0.05). The patient classification was slightly improved when copeptin was added to the usual diagnostic tools used for NSTEMI management. Conclusions:? In this study, determination of copeptin, in addition to cTnI, improves early diagnostic accuracy of NSTEMI. However, the sensitivity of this combination even using a conventional troponin assay remains insufficient to safely rule out NSTEMI at the time of presentation.

PMID: 22594355 [PubMed - in process]

Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope.

Acad Emerg Med. 2012 May;19(5):488-96

Authors: Derose SF, Gabayan GZ, Chiu VY, Sun BC

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:488-496 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The risk of short-term mortality after an emergency department (ED) visit for syncope is poorly understood, resulting in prognostic uncertainty and frequent hospital admission. The authors determined patterns and risk factors for short-term mortality after a diagnosis of syncope or near syncope to aid in medical decision-making. Methods:? A retrospective cohort study was performed of adult members of Kaiser Permanente Southern California seen at 11 EDs from 2002 to 2006 with a primary discharge diagnosis of syncope or near syncope (International Classification of Diseases, Ninth Revision [ICD-9] 780.2). The outcome was 30-day mortality. Proportional hazards time-to-event regression models were used to identify risk factors. Results:? There were 22,189 participants with 23,951 ED visits, resulting in 307 deaths by 30?days. A relatively lower risk of death was reached within 2?weeks for ages 18 to 59?years, but not until 3?months or more for ages 60 and older. Preexisting comorbidities associated with increased mortality included heart failure (hazard ratio [HR]?=?14.3 in ages 18 to 59?years, HR?=?3.09 in ages 60 to 79?years, HR?=?2.34 in ages 80?years plus; all p?<?0.001), diabetes (HR?=?1.49, p?=?0.002), seizure (HR?=?1.65, p?=?0.016), and dementia (HR?=?1.41, p?=?0.034). If the index visit followed one or more visits for syncope in the previous 30?days, it was associated with increased mortality (HR?=?1.86, p?=?0.024). Absolute risk of death at 30?days was under 0.2% in those under 60?years without heart failure and more than 2.5% across all ages in those with heart failure. Conclusions:? The low risk of death after an ED visit for syncope or near syncope in patients younger than 60?years old without heart failure may be helpful when deciding who to admit for inpatient evaluation. The presence of one or more comorbidities that predict death and a prior visit for syncope should be considered in clinical decisions and risk stratification tools for patients with syncope. Close clinical follow-up seems advisable in patients 60?years and older due to a prolonged risk of death.

PMID: 22594351 [PubMed - in process]

Building a better mousetrap for chest pain.

Acad Emerg Med. 2012 May;19(5):594-7

Authors: Baumann BM, Miller CD, Cone DC

Abstract
This commentary discusses two articles in the current issue of Academic Emergency Medicine that report on investigations of copeptin, a novel biomarker used in conjunction with troponin and an accelerated diagnostic protocol (ADP) in the evaluation of chest pain patients. The authors discuss the challenges and future directions of the evaluation and identification of low-risk chest pain patients who are safe for discharge without additional diagnostic testing.

PMID: 22594365 [PubMed - in process]

Effect of testing and treatment on emergency department length of stay using a national database.

Acad Emerg Med. 2012 May;19(5):525-34

Authors: Kocher KE, Meurer WJ, Desmond JS, Nallamothu BK

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19: 525-534 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? Testing and treatment are essential aspects of the delivery of emergency care. Recognition of the effects of these activities on emergency department (ED) length of stay (LOS) has implications for administrators planning efficient operations, providers, and patients regarding expectations for length of visit; researchers in creating better models to predict LOS; and policy-makers concerned about ED crowding. Methods:? A secondary analysis was performed using?years 2006 through 2008 of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide study of ED services. In univariate and bivariate analyses, the authors assessed ED LOS and frequency of testing (blood test, urinalysis, electrocardiogram [ECG], radiograph, ultrasound, computed tomography [CT], or magnetic resonance imaging [MRI]) and treatment (providing a medication or performance of a procedure) according to disposition (discharged or admitted status). Two sets of multivariable models were developed to assess the contribution of testing and treatment to LOS, also stratified by disposition. The first was a series of logistic regression models to provide an overview of how testing and treatment activity affects three dichotomized LOS cutoffs at 2, 4, and 6?hours. The second was a generalized linear model (GLM) with a log-link function and gamma distribution to fit skewed LOS data, which provided time costs associated with tests and treatment. Results:? Among 360 million weighted ED visits included in this analysis, 227 million (63%) involved testing, 304 million (85%) involved treatment, and 201 million (56%) involved both. Overall, visits with any testing were associated with longer LOS (median?=?196?minutes; interquartile range [IQR]?=?125 to 305?minutes) than those with any treatment (median?=?159?minutes; IQR?=?91 to 262?minutes). This difference was more pronounced among discharged patients than admitted patients. Obtaining a test was associated with an adjusted odds ratio (OR) of 2.29 (95% confidence interval [CI]?=?1.86 to 2.83) for experiencing a more than 4-hour LOS, while performing a treatment had no effect (adjusted OR?=?0.84; 95% CI?=?0.68 to 1.03). The most time-costly testing modalities included blood test (adjusted marginal effects on LOS?=?+72?minutes; 95% CI?=?66 to 78?minutes), MRI (+64?minutes; 95% CI?=?36 to 93?minutes), CT (+59?minutes; 95% CI?=?54 to 65?minutes), and ultrasound (US; +56?minutes; 95% CI?=?45 to 67?minutes). Treatment time costs were less substantial: performing a procedure (+24?minutes; 95% CI?=?20 to 28?minutes) and providing a medication (+15?minutes; 95% CI?=?8 to 21?minutes). Conclusions:? Testing and less substantially treatment were associated with prolonged LOS in the ED, particularly for blood testing and advanced imaging. This knowledge may better direct efforts at streamlining delivery of care for the most time-costly diagnostic modalities or suggest areas for future research into improving processes of care. Developing systems to improve efficient utilization of these services in the ED may improve patient and provider satisfaction. Such practice improvements could then be examined to determine their effects on ED crowding.

PMID: 22594356 [PubMed - in process]

Electrocardiographic Diagnosis of Acute ST-elevation Myocardial Infarction in the Presence of Left Bundle Branch Block.

Acad Emerg Med. 2012 May;19(5):593

Authors: Smith SW

Abstract
This lecture can be viewed in its entirety online by visiting http://vimeo.com/34634434. ACADEMIC EMERGENCY MEDICINE 2012; 19:593 © 2012 by the Society for Academic Emergency Medicine.

PMID: 22594364 [PubMed - in process]

A New Improved Accelerated Diagnostic Protocol Safely Identifies Low-risk Patients With Chest Pain in the Emergency Department.

Acad Emerg Med. 2012 May;19(5):510-6

Authors: Aldous SJ, Richards MA, Cullen L, Troughton R, Than M

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19: 510-516 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? To assess whether the accelerated diagnostic protocol (ADP) studied in the Asia Pacific Evaluation of Chest Pain Trial (ASPECT) could be optimized to effectively risk stratify patients with symptoms suggestive of acute coronary syndrome (ACS) and allow early discharge of very-low-risk patients. Methods:? Patients presenting to the emergency department (ED) with chest pain were prospectively enrolled between November 2007 and April 2010. Blood samples were analyzed at 0 and 2?hours postpresentation with a point-of-care multimarker panel (POC-MMP; troponin I [TnI], creatine kinase myocardial band [CKMB] isoenzyme fraction, and myoglobin) and a high-sensitivity cardiac troponin T assay (hsTnT). Patients received standard care. The original ADP (Thrombolysis in Myocardial Infarction [TIMI] risk score?=?0, no ischemic electrocardiogram [ECG] changes, and the multimarker panel negative) was compared with an ADP using the point of care TnI only, hsTnT only, or TIMI risk score?=?0 to 1. Primary outcome was ACS within 30?days. Results:? Of the 1,000 patients recruited, 362 (36.2%) had ACS. There were 12.3% identified as low risk by the original ADP with a sensitivity for ACS of 99.2% (95% confidence interval [CI]?=?97.5% to 99.8%). The ADP with the point of care TnI only or hsTnT had the same sensitivity, but identified more patients for discharge (15.0% vs. 12.3%). Including patients with a TIMI risk score of 1 identified more patients as low risk (19.7%), but with a lower sensitivity (97.0% vs. 99.2%). Conclusions:? An ADP consisting of a TIMI risk score of 0, no new ECG changes, and negative troponin at 0 and 2?hours postpresentation safely identifies patients at low risk of ACS, in whom discharge without further evaluation can be considered.

PMID: 22594354 [PubMed - in process]

National study of antibiotic use in emergency department visits for pneumonia, 1993 through 2008.

Acad Emerg Med. 2012 May;19(5):562-8

Authors: Neuman MI, Ting SA, Meydani A, Mansbach JM, Camargo CA

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19: 562-568 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) developed guidelines for the management of community-acquired pneumonia (CAP); however, there are sparse data on actual rates of antibiotic use in the emergency department (ED) setting. Methods:? Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits during 1993 through 2008 for adults with a diagnosis of pneumonia. Results:? During the study period there were an estimated 23,252,000 pneumonia visits, representing 1.8% of all ED visits. The visit rate for pneumonia during this 16-year period may have increased (p trend?=?0.055). Overall, 66% of adult patients with a primary diagnosis of pneumonia had documentation of an antibiotic administered while in the ED. There was an increase in antibiotic administration for adults with pneumonia from 1993 through 2008 (49% to 80%; p trend?<?0.001). Specifically, there was an increase in use of macrolides from 1993 to 2006 (20% to 30%, p trend?<?0.001) and a marked increase in use of quinolones from 0% to 39% from 1993 through 2008 (p trend?<?0.001). Penicillin and cephalosporin use remained stable. Use of an antibiotic consistent with 2007 IDSA/ATS guidelines increased from 22% (95% confidence interval [CI]?=?16% to 27%) of cases in 1993-1994 to 68% (95% CI?=?63% to 73%) of cases in 2007-2008 (p trend?<?0.001). Conclusions:? ED visit rates for pneumonia increased slightly from 1993 through 2008. Although antibiotic administration in the ED has increased for adults with CAP, guideline-concordant antibiotics may not be consistently administered.

PMID: 22594360 [PubMed - in process]

Being a mentor: what's in it for me?

Acad Emerg Med. 2012 Jan;19(1):92-7

Authors: Coates WC

Abstract
The benefits of mentorship for the protégé are well established and include increased career satisfaction, advancement, and income. Mentors can derive satisfaction from personal and professional networks within their institutions and specialties. However, the advantages of being a mentor are underreported in the medical literature. The purpose of this review is to investigate the effect of the mentoring relationship on the mentors and institutions in disciplines that have studied it widely and to draw parallels to academic medicine. Literature in the fields of business, organizational psychology, and kindergarten through high school (K-12) education describe benefits of serving as a mentor to the individual, organization, and discipline. Potential mentors are intensely self-motivated and derive satisfaction from developing junior colleagues and improving their institutions. Business mentors take pride in junior colleagues' achievements and enjoy improved recognition by superiors, favorable perception within the organization, increased job satisfaction, accelerated promotion rates, higher salaries, development of managerial skills, and improved technical expertise. Organizations enjoy worker longevity from both members of the partnership and benefit from the formation of networks. In the K-12 education model, master teachers who train novices are more likely to remain in the classroom or advance to an administrative role. Application of the principles from these disciplines to academic medicine is likely to produce similarly positive outcomes of personal satisfaction, collaboration, and academic and institutional advancement.

PMID: 22221391 [PubMed - indexed for MEDLINE]

Lung sound patterns help to distinguish congestive heart failure, chronic obstructive pulmonary disease, and asthma exacerbations.

Acad Emerg Med. 2012 Jan;19(1):79-84

Authors: Wang Z, Xiong YX

Abstract
OBJECTIVES: Although congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and asthma patients typically present with abnormal auscultatory findings on lung examination, respiratory sounds are not normally subjected to rigorous analysis. The aim of this study was to evaluate in detail the distribution of respiratory sound intensity in CHF, COPD, and asthma patients during acute exacerbation.
METHODS: Respiratory sounds throughout the respiratory cycle were captured and displayed using an acoustic-based imaging technique. Breath sound distribution was mapped to create a gray-scale sequence of two-dimensional images based on intensity of sound (vibration). Consecutive CHF (n = 22), COPD (n = 19), and asthma (n = 18) patients were imaged at the time of presentation to the emergency department (ED). Twenty healthy subjects were also enrolled as a comparison group. Geographical area of the images and respiratory sound patterns were quantitatively analyzed.
RESULTS: In healthy volunteers and COPD patients, the median (interquartile range [IQR]) geographical areas of the vibration energy images were similar, at 75.6 (IQR = 6.0) and 75.8 (IQR = 10.8) kilopixels, respectively (p > 0.05). Compared to healthy volunteers and COPD patients, areas for CHF and asthma patients were smaller, at 66.9 (IQR = 9.9) and 53.9 (IQR = 15.6) kilopixels, respectively (p < 0.05). The geographic area ratios between the left and right lungs for healthy volunteers and CHF and COPD patients were 1.0 (IQR = 0.2), 1.0 (IQR = 0.2), and 1.0 (IQR = 0.1), respectively. Compared to healthy volunteers, the geographic area ratio between the left and right lungs for asthma patients was 0.5 (IQR = 0.4; p < 0.05). In healthy volunteers and CHF patients, the ratios of vibration energy values at peak inspiration and expiration (peak I/E ratio) were 4.6 (IQR = 4.4) and 4.7 (IQR = 3.5). In marked contrast, the peak I/E ratios of COPD and asthma patients were 3.4 (= 2.1) and 0.1 (IQR = 0.3; p < 0.05), respectively.
CONCLUSIONS: The pilot data generated in this study support the concept that relative differences in respiratory sound intensity may be useful in distinguishing acute dyspnea caused by CHF, COPD, or asthma.

PMID: 22251194 [PubMed - indexed for MEDLINE]

Patients Who Leave Without Being Seen in Emergency Departments: An Analysis of Predictive Factors and Outcomes.

Acad Emerg Med. 2012 Apr;19(4):439-447

Authors: Tropea J, Sundararajan V, Gorelik A, Kennedy M, Cameron P, Brand CA

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19: 439-447 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia. Methods:? This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital-level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48?hour re-presentations to ED; 48-hour hospital admissions; and 2-,7-, and 30-day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented. Results:? There were 239,305 LWBS episodes, for 205,500 patients over the 5-year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24?years, OR?=?2.46, 99% CI?=?2.37 to 2.56), male (OR?=?1.07, 99% CI?=?1.05 to 1.08), of Australian indigenous background (OR?=?1.63, 99% CI?=?1.53 to 1.73), of non-English-speaking background (OR?=?1.08, 99% CI?=?1.06 to 1.10), noncompensable status (OR?=?1.73, 99% CI?=?1.68 to 1.79), self-referring (OR?=?1.46, 99% CI?=?1.43 to 1.49), nonassisted arrival mode (OR?=?1.35, 99% CI?=?1.30 to 1.40), and those with a hospital admission in the 12?months before the ED presentation (OR?=?1.53, 99% CI?=?1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR?=?8.21, 99% CI?=?8.00 to 8.43), attended during the evening (OR?=?1.10, 99% CI?=?1.08 to 1.12), on either Sunday (OR?=?1.20, 99% CI?=?1.18 to 1.23) or Monday (OR?=?1.20, 99% CI?=?1.17 to 1.23), in winter (OR?=?1.14, 99% CI?=?1.12 to 1.16), with higher rates occurring in higher volume EDs (OR?=?2.20, 99% CI?=?2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48?hours of discharge was lower for LWBS patients (OR?=?0.60, 99% CI?=?0.58 to 0.62); however, ED re-presentation risk was higher (OR?=?1.63, 99% CI?=?1.60 to 1.67). Conclusions:? Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re-presenting to an ED compared to patients who complete treatment and are discharged home.

PMID: 22506948 [PubMed - as supplied by publisher]

Efficacy of Patient-controlled Analgesia for Patients With Acute Abdominal Pain in the Emergency Department: A Randomized Trial.

Acad Emerg Med. 2012 Apr;19(4):370-7

Authors: Birnbaum A, Schechter C, Tufaro V, Touger R, Gallagher EJ, Bijur P

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19: 370-377 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The objective was to assess the efficacy of patient-controlled analgesia (PCA) in the emergency department (ED) and to compare two PCA dosing regimens. Methods:? A randomized controlled trial with three treatment arms was performed in an urban ED. A convenience sample of ED patients ages 18 to 65?years with abdominal pain of 7?days or less duration requiring intravenous (IV) opioid analgesia was enrolled between April 2009 and June 2010. All patients received an initial dose of 0.1?mg/kg IV morphine followed by physician-managed analgesia as needed. Patients in the PCA arms also received IV morphine with on-demand doses of 1?or 1.5?mg, with a 6-minute lockout between doses. Pain intensity was rated by patients on an 11-point numeric rating scale (NRS). Satisfaction with pain treatment, desire for the same treatment in the future, and need for additional analgesia were assessed at study end. Adverse events (O(2) sat <?92%, respiratory rate [RR] <?10/min, systolic blood pressure [sBP] <?90?mm?Hg, and naloxone use) were counted. One-way analysis of variance was used to test the difference among groups in short-term pain relief, as assessed by mean change in NRS pain intensity from baseline to 30?minutes and pain over the entire 2-hour study period measured by area under the curve (AUC) of NRS pain ratings. A post hoc hierarchical linear model was used to test the observed difference in NRS between the groups between 30 and 120?minutes. Results:? A total of 211 patients were enrolled. A sharp, nearly identical decline in mean NRS scores occurred from baseline to 30?minutes in the three groups (p?=?0.82). Between 30 and 120?minutes, there was little further decline in the non-PCA NRS scores, while both PCA groups continued to decline (p?=?0.004). The net treatment effect over the entire 2?hours was smallest in the non-PCA group and largest in the group receiving 1.5?mg of morphine (p?=?0.06). The mean decline in pain from baseline to 120?minutes postbaseline in both PCA groups was 1.4 NRS units (95% confidence interval [CI]?=?0.3 to 2.4) greater than the decline in patients treated without PCA. More patients in the PCA arms reported satisfaction, wanting the same pain management in the future, and not wanting further analgesics at 120?minutes than patients who did not receive PCA. There were no clinically or statistically significant differences in any outcomes between the two PCA groups. One PCA patient had a transient oxygen saturation of 88% after the initial bolus only, and one non-PCA patient had a brief drop in sBP to 87?mm Hg. Conclusions:? This study provides support for efficacy of PCA when applied to the ED setting. Future studies designed to assess implementation of this modality in the context of conditions of actual ED staffing and competing patient demands are warranted.

PMID: 22506940 [PubMed - in process]

Outcomes of Early, Late, and No Admission to the Intensive Care Unit for Patients Hospitalized with Community-acquired Pneumonia.

Acad Emerg Med. 2012 Mar;19(3):294-303

Authors: Renaud B, Brun-Buisson C, Santin A, Coma E, Noyez C, Fine MJ, Yealy DM, Labarère J

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:294-303 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP). Methods:? This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission. Results:? Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p?<?0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR]?=?2.63; 95% confidence interval [CI]?=?1.42 to 4.90), and no ICU admissions (OR?=?3.40; 95% CI?=?2.11 to 5.48), but did not differ between early and no ICU admissions (OR?=?1.29; 95% CI?=?0.79 to 2.09). The median hospital LOS was 10?days for early (interquartile range [IQR]?=?7 to 18), 15?days for late (IQR 9 to 23), and 6?days (IQR 4 to 9) for no ICU admissions (p?<?0.001). Conclusions:? This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU. ACADEMIC EMERGENCY MEDICINE 2012; 19:#-# © 2012 by the Society for Academic Emergency Medicine.

PMID: 22435862 [PubMed - as supplied by publisher]

Point-of-care Urine Albumin:Creatinine Ratio Is Associated With Outcome in Emergency Department Patients With Sepsis: A Pilot Study.

Acad Emerg Med. 2012 Mar;19(3):259-64

Authors: Drumheller BC, McGrath M, Matsuura AC, Gaieski DF

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:259-264 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? Sepsis is characterized by an initial systemic proinflammatory response leading to endothelial damage and increased capillary permeability. The authors conducted a pilot study to determine if microalbuminuria, measured by the urine albumin:creatinine ratio (ACR), was associated with outcome in emergency department (ED) sepsis patients. Methods:? This was an observational cohort study of a convenience sample of adult patients presenting to two EDs over 10?months with sepsis (two or more systemic inflammatory response syndrome [SIRS] criteria and suspected infection). Those who received a urinalysis were prospectively enrolled. Patients with anuria, grossly contaminated specimens, or concurrent noninfectious diagnoses were excluded. Urine ACR was measured on a point-of-care (POC) device. The primary study outcome was ED disposition (three groups): treated and discharged, admitted to the floor, or admitted to the intensive care unit (ICU). Kruskal-Wallis testing was used to compare ACR based on disposition. Variables associated with ACR were identified by Spearman rank correlation or Mann-Whitney rank-sum testing. A post hoc subgroup analysis of patients with and without a genitourinary (GU) source of infection was also performed. Results:? A total of 121 patients were screened, and 29 (24%) were excluded; 92 patients met criteria (mean?±?SD age, 51.2?±?17.0?years; 51 [55%] had severe sepsis, three [3%] had septic shock). There were three in-hospital deaths. Median ACR for patients treated and discharged (n?=?22), admitted to floor (n?=?50), and admitted to ICU (n?=?20) was 2.54 (interquartile range [IQR]?=?0.89 to 6.16) versus 2.8 (IQR?=?1.69 to 8.8) versus 12.15 (IQR?=?4.76 to 20.95), respectively (p?=?0.0049). Age, serum creatinine, and GU source of infection were associated with ACR. ACR was significantly associated with disposition among patients without a GU source of infection (p?=?0.003), but not among patients with a GU source (p?=?0.3744). Conclusions:? In this pilot study, microalbuminuria measured by POC ACR was associated with disposition in ED patients with sepsis or severe sepsis. Larger studies using more robust outcomes comparing ACR with validated sepsis biomarkers are needed to elaborate on these results.

PMID: 22435857 [PubMed - in process]

Normalization of vital signs does not reduce the probability of acute pulmonary embolism in symptomatic emergency department patients.

Acad Emerg Med. 2012 Jan;19(1):11-7

Authors: Kline JA, Corredor DM, Hogg MM, Hernandez J, Jones AE

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:11-17 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? In a patient with symptoms of pulmonary embolism (PE), the presence of an elevated pulse, respiratory rate, shock index, or decreased pulse oximetry increases pretest probability of PE. The objective of this study was to evaluate if normalization of an initially abnormal vital sign can be used as evidence to lower the suspicion for PE. Methods:? This was a prospective, noninterventional, single-center study of diagnostic accuracy conducted on adults presenting to an academic emergency department (ED), with at least one predefined symptom or sign of PE and one risk factor for PE. Clinical data, including the first four sets of vital signs, were recorded while the patient was in the ED. All patients underwent computed tomography pulmonary angiography (CTPA) and had 45-day follow-up as criterion standards. Diagnostic accuracy of each vital sign (pulse rate, respiratory rate, shock index, pulse oximetry) at each time was examined by the area under the receiver operating characteristic curve (AUC). Results:? A total of 192 were enrolled, including 35 (18%) with PE. All patients had vital signs at triage, and 174 (91%), 135 (70%), and 106 (55%) had second to fourth sets of vital signs obtained, respectively. The initial pulse oximetry reading had the highest AUC (0.63, 95% confidence interval [CI]?=?0.50 to 0.76) for predicting PE, and no other vital sign at any point had an AUC over 0.60. Among patients with an abnormal pulse rate, respiratory rate, shock index, or pulse oximetry at triage that subsequently normalized, the prevalences of PE were 18, 14, 19, and 33%, respectively. Conclusions:? Clinicians should not use the observation of normalized vital signs as a reason to forego objective testing for symptomatic patients with a risk factor for PE.

PMID: 22251189 [PubMed - in process]

Urinary Metabolomic Analysis for the Identification of Renal Injury in Patients With Acute Heart Failure.

Acad Emerg Med. 2012 Jan 5;

Authors: Diercks DB, Owen K, Tolstikov V, Sutter M

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:1-6 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? Worsening renal function in patients admitted with heart failure is associated with increased morbidity. These changes are not usually apparent initially and often take up to 48?hours to be detected. Using the novel technique of metabolomic analysis, this study aims to determine if markers of renal injury are identifiable at presentation that are associated with the development of worsening renal function in high-risk patients with heart failure. Methods:? A prospective exploratory study enrolled a convenience sample of patients with suspected heart failure. Eligible patients had to be older than 18?years, have a B-type natriuretic peptide (BNP) level over 100?pg/mL, have a history of diabetes or hypertension, meet Boston criteria for heart failure (>8), and require hospital admission as judged by the treating physician. Patients receiving no more than one dose of diuretic prior to enrollment were excluded. Urine was collected during the emergency department (ED) stay. Initial creatinine and the peak value between 24 to 48?hours were used to determine worsening renal function as defined by a change?of >0.3?mg/dL or absolute 25% increase. Urine samples underwent gas chromatography/mass spectrometry (GC/MS) profiling. Peak metabolite values were measured and data were log-transformed. Partial least squares-discriminant analysis (PLS-DA) was used to identify metabolites associated with worsening renal function. Specific urinary metabolites were ranked based on their regression coefficients. Results:? The 24 enrolled subjects had a median age of 58?years (interquartile range [IQR]?=?49.5 to 67.5?years) with 58% being male. Worsening renal function occurred in 10 subjects (41.7%). A total of 156 metabolites were identified. The optimal number of metabolites for class discrimination as determined by PLS-DA was three, with a classification accuracy of 78%. These metabolites were taurine, sulfuric acid, and talose. Conclusions:? Urinary metabolites found at the time of presentation may be markers of early renal injury. It is therefore possible that the process of renal injury is initiated prior to ED arrival in patients with suspected heart failure, and these may be used to identify a high-risk patient population.

PMID: 22222043 [PubMed - as supplied by publisher]