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
ACADEMIC EMERGENCY MEDICINE 2012; 19:79-84 © 2012 by the Society for Academic Emergency Medicine 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 - 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]

Being a Mentor: What's in It for Me?

Acad Emerg Med. 2012 Jan 5;

Authors: Coates WC

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:1-6 © 2012 by the Society for Academic Emergency Medicine 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 - as supplied by publisher]

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]

Ethics Seminar: The Hospice Patient in the ED: An Ethical Approach to Understanding Barriers and Improving Care.

Acad Emerg Med. 2011 Nov;18(11):1201-7

Authors: Zieske M, Abbott J

Abstract
ACADEMIC EMERGENCY MEDICINE 2011; 18:1201-1207 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: Emergency physicians (EPs) are asked to evaluate and treat a growing population of hospice patients who present to the emergency department (ED) for a number of important reasons. Hospice patients pose unique ethical challenges, and "best practices" for these patients can differ from the life-preserving interventions of usual ED care. Having a solid understanding of professional responsibilities and ethical principles is useful for guiding EP management of these patients. In end-of-life care, EPs need to recognize that there are barriers and complexities to the best management of hospice patients, but they need to commit to strategies that optimize their care. This article describes the case of a hospice patient who presented with sepsis and end-stage cancer to the ED. Patient, system, and physician factors made management decisions in the ED difficult. The goal in the ED should be to determine the best way to address terminally ill patient needs while respecting wishes to limit interventions that will only increase suffering near the end of life.

PMID: 22092905 [PubMed - in process]

Can Junior Emergency Physicians Use E-Point Septal Separation to Accurately Estimate Left Ventricular Function in Acutely Dyspneic Patients?

Acad Emerg Med. 2011 Nov 1;

Authors: Secko MA, Lazar JM, Salciccioli LA, Stone MB

Abstract
ACADEMIC EMERGENCY MEDICINE 2011; 18:1-4 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The authors determined if E-point septal separation (EPSS) as measured by junior emergency physicians (EPs) correlated with visual estimation of left ventricle ejection fraction (LVEF) by senior EPs and cardiologists in acutely dyspneic patients presenting to an adult emergency department (ED). Methods:? Acutely dyspneic patients were enrolled in a prospective, observational study. EPSS was measured using bedside ultrasonography by junior EPs (PGY 3 and PGY 4 residents) with variable ultrasound experience. M-mode measurements of EPSS were recorded in the parasternal long-axis orientation and were calculated during diastole by measuring distance from the tip of the anterior mitral valve leaflet to the septal wall. LVEF was visually estimated at the bedside by emergency medicine (EM) ultrasound fellows and an EM ultrasound fellowship-trained attending physician and was subsequently visually estimated by two cardiologists reviewing video clips obtained by the junior EPs. The correlation between EPSS and visually estimated LVEF was calculated. Results:? Of the 58 patients, the median age was 63?years (range?=?28 to 90?years) and 66% were women. Interobserver reliability between EPs and cardiologists for the visual estimation of LVEF was excellent (??=?0.75). The correlation between measurements of EPSS by junior EPs and visual estimations of LVEF by the senior EPs was ??=?-0.844 (p?<?0.001). Conclusions:? In this study, junior EPs were able to obtain measurements of EPSS that correlated closely with visual estimates of LVEF by clinicians with extensive point-of-care and comprehensive echocardiography experience.

PMID: 22044429 [PubMed - as supplied by publisher]

Palliative care needs of seriously ill, older adults presenting to the emergency department.

Acad Emerg Med. 2010 Nov;17(11):1253-7

Authors: Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS

Abstract
OBJECTIVES: The objective was to identify the palliative care needs of seriously ill, older adults in the emergency department (ED).
METHODS: The authors conducted a cross-sectional structured survey. A convenience sample of 50 functionally impaired adults 65 years or older with coexisting cancer, congestive heart failure, end-stage liver or renal disease, stroke, oxygen-dependent pulmonary disease, or dementia was recruited from an urban academic tertiary care ED. Face-to-face interviews were conducted using the Needs Near the End-of-Life Screening Tool (NEST), McGill Quality of Life Index (MQOL), and Edmonton Symptom Assessment Survey (ESAS) to assess 1) range and severity of symptoms, 2) goals of care, 3) psychological well-being, 4) health care utilization, 5) spirituality, 6) social connectedness, 7) financial burden, 8) the patient-clinician relationship, and 9) overall quality of life (QOL).
RESULTS: Mean (±SD) age was 74.3 (±6.5) years and cancer was the most common diagnosis. Mean (±SD) QOL on the MQOL was 3.6 (±2.9). Over half of the patients exceeded intratest severity-of-needs cutoffs in four categories of the NEST: physical symptoms (47/50, 94%), finances (36/50, 72%), mental health (31/50, 62%), and access to care (29/50, 58%). The majority of patients reported moderate to severe fatigue, pain, dyspnea, and depression on the ESAS.
CONCLUSIONS: Seriously ill, older adults in an urban ED have substantial palliative care needs. Future work should focus on the role of emergency medicine and the new specialty of palliative care in addressing these needs.

PMID: 21175525 [PubMed - indexed for MEDLINE]

Diagnostic Accuracy of Venous Blood Gas Electrolytes for Identifying Diabetic Ketoacidosis in the Emergency Department.

Acad Emerg Med. 2011 Sep 26;

Authors: Menchine M, Probst MA, Agy C, Bach D, Arora S

Abstract
Objectives:? Diagnosing diabetic ketoacidosis (DKA) has traditionally required a venous blood gas (VBG) to obtain serum pH and a serum chemistry panel to obtain electrolyte values. Because newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, this diagnostic process could theoretically be condensed. However, neither the diagnostic accuracy of the VBG for DKA nor the agreement between the VBG electrolytes and the serum chemistry electrolytes, including sodium, chloride, and bicarbonate, has been evaluated in the context of acute hyperglycemia. The purpose of this study was to assess the accuracy of VBG electrolytes for diagnosing DKA using serum chemistry electrolytes measures as the criterion standard and to describe the correlation between VBG and serum chemistry electrolytes in a sample of hyperglycemic patients seen in the emergency department (ED). Methods:? The authors prospectively identified a convenience sample of ED patients with serum blood glucose ? 250?mg/dL and examined their paired VBG and serum chemistry electrolytes. The diagnosis of DKA was made by using American Diabetes Association (ADA) criteria including serum glucose ? 250?mg/dL, serum anion gap?>?10?mEq/L, bicarbonate ? 18?mEq/L, serum pH ? 7.30, and presence of ketosis. Serum chemistry electrolyte values were considered to be the criterion standard. Diagnostic test characteristics of VBG electrolytes including sensitivity and specificity were compared against this standard. In addition, correlation coefficients for individual electrolytes and anion gap between VBG and chemistry electrolytes were calculated. Results:? Paired VBG and serum chemistry panels were available for 342 patients, of whom 46 (13.5%) had DKA. The sensitivity and specificity of the VBG electrolytes for diagnosing DKA was 97.8% (95% confidence interval [CI]?=?88.5% to 99.9%) and 100% (95% CI?=?98.8% to 100%), respectively. One case of DKA was missed by the VBG. Correlation coefficients between VBG and serum chemistry were 0.90, 0.73, 0.94, and 0.81 for sodium, chloride, bicarbonate, and anion gap, respectively. Conclusions:? The VBG electrolytes were 97.8% sensitive and 100% specific for the diagnosis of DKA in hyperglycemic patients. These preliminary findings support the use of VBG electrolytes in lieu of VBG along with serum chemistry analysis to rule in or rule out DKA. ACADEMIC EMERGENCY MEDICINE 2011; 18:1-4 © 2011 by the Society for Academic Emergency Medicine.

PMID: 21951652 [PubMed - as supplied by publisher]

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]

Hospital-reported data on the pneumonia quality measure "Time to First Antibiotic Dose" are not associated with inpatient mortality: results of a nationwide cross-sectional analysis.

Acad Emerg Med. 2011 May;18(5):496-503

Authors: Quattromani E, Powell ES, Khare RK, Cheema N, Sauser K, Periyanayagam U, Pirotte MJ, Feinglass J, Mark Courtney D

Abstract
OBJECTIVES: Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality.
METHODS: This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance.
RESULTS: Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05).
CONCLUSIONS: In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.

PMID: 21545670 [PubMed - indexed for MEDLINE]

National Study of Emergency Department Observation Services.

Acad Emerg Med. 2011 Aug 30;

Authors: Wiler JL, Ross MA, Ginde AA

Abstract
Objectives:? The objective was to describe patient and facility characteristics of emergency department (ED) observation services in the United States. Methods:? The authors analyzed the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Characteristics of EDs with observation units (OUs) were compared to those without, and patients with a disposition of ED observation were compared to those with a "short-stay" (<48?hour) hospital admission. Results are descriptive and without formal statistical comparisons for this observational analysis. Results:? An estimated 1,746 U.S. EDs (36%) reported having OUs, of which 56% are administratively managed by ED staff. Fifty-two percent of hospitals with ED-managed OUs are in an urban location, and 89% report ED boarding, compared to 29 and 65% of those that do not have an OU. The admission rate is 38% at those with ED-managed OUs and 15% at those without OUs. Of the 15.1% of all ED patients who are kept in the hospital following an ED visit, one-quarter are kept for either a short-stay admission (1.8%) or an ED observation admission (2.1%). Most (82%) ED observation patients were discharged from the ED. ED observation patients were similar to short-stay admission patients in terms of age (median?=?52?years for both, interquartile range?=?36 to 70?years), self-pay (12% vs. 10%), ambulance arrival (37% vs. 36%), urgent/emergent triage acuity (77% vs. 74%), use of ?1 ED medication (64% vs.76%), and the most common primary chief complaints and primary diagnoses. Conclusions:? Over one-third of U.S. EDs have an OU. Short-stay admission patients have similar characteristics as ED observation patients and may represent an opportunity for the growth of OUs. ACADEMIC EMERGENCY MEDICINE 2011; 18:1-7 © 2011 by the Society for Academic Emergency Medicine.

PMID: 21883638 [PubMed - as supplied by publisher]

Evidence-based Diagnostics: Adult Septic Arthritis.

Acad Emerg Med. 2011 Aug;18(8):781-96

Authors: Carpenter CR, Schuur JD, Everett WW, Pines JM

ACADEMIC EMERGENCY MEDICINE 2011; 18:782-796 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: Background:? Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality. Objectives:? The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy. Methods:? Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2?×?2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits. Results:? The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI]?=?17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR]?=?6.9) or skin infection overlying a prosthetic joint (+LR?=?15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0?×?10(9) -25?×?10(9) /L was 0.33; for 25?×?10(9) -50?×?10(9) /L, 1.06; for 50?×?10(9) -100?×?10(9) /L, 3.59; and exceeding 100?×?10(9) /L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (-LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3?hours. Based on 56% sensitivity and 90% specificity for sWBC counts of?>50?×?10(9) /L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%. Conclusions:? Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50?×?10(9) /L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate.

PMID: 21843213 [PubMed - in process]

Getting the evidence straight in emergency diagnostics.

Acad Emerg Med. 2011 Aug;18(8):797-9

Authors: Lang ES, Worster A

ACADEMIC EMERGENCY MEDICINE 2011; 18:797-799 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: The interpretation and optimal application of the myriad of diagnostic modalities at the emergency physician's (EP's) disposal is a core challenge of clinical practice. Connecting the wealth of scientific literature that informs our understanding of test performance, including elements of the history and the physical examination, is a daunting task. Translating this knowledge into improved patient outcomes requires two fundamentals; the first involves getting the evidence "straight" through systematic approaches that highlight quality work and methods for getting evidence to the point of need. This commentary discusses the potential impact of the first installment in the "evidence-based diagnostics" series of the journal, highlighting how this work complements existing resources of evidence-based medicine. In addition, a vision is presented for how the insight from this series can achieve integration into the clinical and academic mission of emergency medicine.

PMID: 21843214 [PubMed - in process]

High Plasma Lactate Levels Are Associated With Increased Risk of In-hospital Mortality in Patients With Pulmonary Embolism.

Acad Emerg Med. 2011 Aug;18(8):830-5

Authors: Vanni S, Socci F, Pepe G, Nazerian P, Viviani G, Baioni M, Conti A, Grifoni S

ACADEMIC EMERGENCY MEDICINE 2011; 18:830-835 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? The objective was to investigate the prognostic value of plasma lactate in patients with acute pulmonary embolism (PE). Methods:? This was a retrospective study at the emergency department (ED) of a third-level teaching hospital. The authors considered consecutive patients with a diagnosis of PE established by lung scan or spiral computed tomography (CT) and confirmed by pulmonary angiography if necessary. Only patients for whom plasma lactate levels had been tested within 6?hours from presentation to the ED were included. Primary outcome was in-hospital death due to any cause; secondary outcome was mortality related to PE. Results:? From September 1997 to June 2006, a total of 384 patients were diagnosed with PE in the ED. Of these patients, 287 had registered plasma lactate levels and were included in this analysis. Included patients had a mean age of 70 (SD?±?15?years, range?=?18 to 100?years), 163 (57%) were female, 26 (9%) showed systolic blood pressure lower than 100?mm?Hg at presentation, and 160 (56%) had echocardiographic evidence of right ventricular dysfunction (RVD). Twenty patients died during their hospital stay (7%). Plasma lactate levels ? 2?mmol/L were associated with in-hospital mortality from all causes (odds ratio [OR]?=?4.60, 95% confidence interval [CI]?=?1.57 to 13.53) and with PE-related mortality (OR?=?4.94, 95% CI?=?1.38 to 17.63), independent of hypotension or RVD at presentation. Conclusions:? High plasma lactate was associated with increased in-hospital mortality in this sample of patients with acute PE.

PMID: 21843218 [PubMed - in process]

Predicting hospital admissions at emergency department triage using routine administrative data.

Acad Emerg Med. 2011 Aug;18(8):844-50

Authors: Sun Y, Heng BH, Tay SY, Seow E

ACADEMIC EMERGENCY MEDICINE 2011; 18:844-850 © 2011 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:? To be able to predict, at the time of triage, whether a need for hospital admission exists for emergency department (ED) patients may constitute useful information that could contribute to systemwide hospital changes designed to improve ED throughput. The objective of this study was to develop and validate a predictive model to assess whether a patient is likely to require inpatient admission at the time of ED triage, using routine hospital administrative data. Methods:? Data collected at the time of triage by nurses from patients who visited the ED in 2007 and 2008 were extracted from hospital administrative databases. Variables included were demographics (age, sex, and ethnic group), ED visit or hospital admission in the preceding 3?months, arrival mode, patient acuity category (PAC) of the ED visit, and coexisting chronic diseases (diabetes, hypertension, and dyslipidemia). Chi-square tests were used to study the association between the selected possible risk factors and the need for hospital admission. Logistic regression was applied to develop the prediction model. Data were split for derivation (60%) and validation (40%). Receiver operating characteristic curves and goodness-of-fit tests were applied to the validation data set to evaluate the model. Results:? Of 317,581 ED patient visits, 30.2% resulted in immediate hospital admission. In the developed predictive model, age, PAC status, and arrival mode were most predictive of the need for immediate hospital inpatient admission. The c-statistic of the receiver operating characteristic (ROC) curve was 0.849 (95% confidence interval [CI]?=?0.847 to 0.851). The goodness-of-fit test showed that the predicted patients' admission risks fit the patients' actual admission status well. Conclusions:? A model for predicting the risk of immediate hospital admission at triage for all-cause ED patients was developed and validated using routinely collected hospital data. Early prediction of the need for hospital admission at the time of triage may help identify patients deserving of early admission planning and resource allocation and thus potentially reduce ED overcrowding.

PMID: 21843220 [PubMed - in process]