Diagnostic and Prognostic Utility of Procalcitonin in Patients Presenting to the Emergency Department with Dyspnea

Background Among patients in the emergency department, dyspnea is a common complaint and can pose a diagnostic challenge. Biomarkers are used increasingly to improve diagnostic accuracy and aid with prognostication in dyspneic patients. The purpose of this study was to examine the clinical utility of serum procalcitonin (PCT) for the diagnosis of pneumonia in patients presenting to the emergency department with dyspnea. A secondary objective was to evaluate the prognostic value of PCT for death to 1 year. Methods This study pooled the patient populations of 2 prospective cohorts that previously enrolled patients presenting to 2 urban emergency departments with dyspnea. A total of 453 patients had serum samples available for biomarker analysis. Clinician certainty for the diagnosis of acutely decompensated heart failure was reviewed. Discrimination, calibration, and net reclassification improvement for the diagnosis of pneumonia as well as fatal outcomes were considered. The main outcome was accuracy of PCT for diagnostic categorization of pneumonia. The prognostic value of PCT for survival to 1 year was a secondary outcome. Results Pneumonia alone was diagnosed in 30 patients (6.6%), heart failure without pneumonia in 212 patients (47%), and both diagnoses in 30 patients (6.6%). Procalcitonin concentrations were higher in subjects with pneumonia (0.38 vs 0.06 ng/mL; P < .001). Area under the receiver operating characteristic curve for the diagnosis of pneumonia based on PCT was 0.84 (95% confidence interval [CI], 0.77-0.91; P < .001). Across all levels of clinician-based estimates of heart failure, PCT was sensitive and specific; notably, in patients judged with diagnostic uncertainty (n = 70), a PCT value of 0.10 ng/mL had the optimal balance of sensitivity and specificity (80% and 77%, respectively) for pneumonia. Adding PCT results to variables predictive of pneumonia resulted in a net reclassification improvement of 0.54 (95% CI, 0.24-0.83; P < .001) for both up- and down-reclassifying events. In adjusted analyses, elevated PCT was a predictor of 1-year mortality (hazard ratio 1.8; 95% CI, 1.4-2.3; P < .001) and was additive when elevated in conjunction with natriuretic peptides for this application. Conclusion In emergency department patients with acute dyspnea, PCT is an accurate diagnostic marker for pneumonia and adds independent prognostic information for 1-year mortality

Evidence of Uncoupling between Renal Dysfunction and Injury in Cardiorenal Syndrome: Insights from the BIONICS Study

Objective: The objective of the study was to assess urinary biomarkers of renal injury for their individual or collective ability to predict Worsening renal function (WRF) in patients with acutely decompensated heart failure (ADHF). Methods: In a prospective, blinded international study, 87 emergency department (ED) patients with ADHF were evaluated with biomarkers of cardiac stretch (B type natriuretic peptide [BNP] and its amino terminal equivalent [NT-proBNP], ST2), biomarkers of renal function (creatinine, estimated glomerular filtration rate [eGFR]) and biomarkers of renal injury (plasma neutrophil gelatinase associated lipocalin [pNGAL], urine kidney injury molecule-1 [KIM-1], urine N-acetyl-beta-D-glucosaminidase [NAG], urine Cystatin C, urine fibrinogen). The primary endpoint was WRF. Results: 26% developed WRF; baseline characteristics of subjects who developed WRF were generally comparable to those who did not. Biomarkers of renal function and urine biomarkers of renal injury were not correlated, while urine biomarkers of renal injury correlated between each other. Biomarker concentrations were similar between patients with and without WRF except for baseline BNP. Although plasma NGAL was associated with the combined endpoint, none of the biomarker showed predictive accuracy for WRF. Conclusions: In ED patients with ADHF, urine biomarkers of renal injury did not predict WRF. Our data suggest that a weak association exists between renal dysfunction and renal injury in this setting (Clinicaltrials.gov NCT#0150153)

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0-18 years

After a previous survey on the incidence of diabetic ketoacidosis (DKA) at onset of type 1 diabetes in children in 2013-2014 in Italy, we aimed to verify a possible decline in the incidence of DKA at onset during a national prevention campaign

Utility of a Bedside Pocket-Sized Ultrasound Device to Promptly Manage Abdominal Pain in the Emergency Department

Introduction: Abdominal pain is a frequent reason for Emergency Department (ED) admission; it amounts for around 5–10% of all ED visits. Early assessment should focus on immediately distinguishing cases of acute abdomen that require urgent surgical intervention. The clinical localization of pain is crucial, suggesting an initial evaluation of the origin of the abdominal pain; however, imaging is often required for final diagnosis. Ultrasound (US) represents a rapid imaging modality that is readily available in the ED and does not involve radiation or contrast agent administration. A new generation of portable, battery-powered, low-cost, hand-carried ultrasound devices have become available recently; these devices can provide immediate diagnostic information in patients presenting with abdominal pain in ED.The aim of the study was to demonstrate the diagnostic usefulness of a bedside pocket-sized ultrasound (BPU) device (Vscan from General Electrics) in non-traumatic patients complaining of acute abdominal pain in a tertiary care university hospital in Italy.Methods: Patients with acute non-traumatic abdominal pain presenting in ED were prospectively enrolled and underwent physical examination, traditional imaging and BPU.Results: A total number of 230 patients with acute non-traumatic abdominal pain were enrolled. Overall agreement between routine standard imaging and BPU turned out to be equal for computed tomography (K=0.3) and traditional ultrasound (K=0.29). Receiver operating characteristics curve (ROC) analysis for diagnostic power of the BPU in comparison with traditional US showed an area under the curve of 0.65, sensitivity and specificity of 87.2% and 42.31% respectively.Conclusions: Emergency use of BPU in patients with non-traumatic abdominal pain demonstrated good diagnostic performance when compared to traditional imaging, with the potential advantage of reducing costs and delay in patient final disposition

Emergency Care of Acute Hypertension. An Italian Experience

Objective: Scant data are available on the subset of patients who present to emergency departments with acute severe elevations in blood pressure (BP). Recently the STAT registry has highlighted this topic. No recent Italian data are available. We characterized the population afferent to our emergency room (ER) and the medical behavior in treating hypertensive emergency/urgencies. Design: Our study is a retrospective analysis of patients presented to our ER whit acute elevated blood pressure (BP) from January 2008 to Dicember 2008. Methods: Data were collected by querying computerized hospital registry (Gestione Informazioni Pronto Soccorso ed Emergenza – GIPSE). Patients enrolled had BP values over 180/120mmHg for emergencies and upper levels of stage 2 hypertension for urgencies. Patients with known secondary hypertension were excluded. Results: Three hundred eight patients (308) were enrolled for analysis. Mean age was 66 years, 60.4% were women. Five percent had chronic kidney disease, 21.4% had diabetes, 15% had coronary artery disease. Mean BP values were 198.2 mmHg for systolic BP and 104 mmHg for diastolic BP. Therapeutic approach varied enormously both in used drugs and in the way of administration, independently of it was an hypertensive emergency or urgency. The most used drug was furosemide independently of the presence of pulmonary edema. Hypertensive emergencies (with organ damage) were 26.3%; about urgencies, the most common presenting symptom was headache (16.2%). Many patients took at home a multidrug therapy, clearly ineffective; others were untreated (32%) maybe on the persistent belief that elderly need quite high BP levels to keep cerebral perfusion. Conclusions: This study highlights heterogeneity in emergency care of this kind of patients, still lack of information on hypertension and the importance to keep it under control, and the need of guidelines for emergency treatment of acute hypertension

The use of a new automatic device for patients' assessment at Triage in Emergency Department.

Obiettivo: Valutare in Pronto Soccorso il risparmio di tempo ottenuto grazie all’impiego di un dispositivo automatico (Carescape™ V100) per misurare i parametri vitali rispetto agli attuali dispositivi manuali. Metodi: Abbiamo condotto uno studio prospettico osservazionale su pazienti eleggibili afferenti al Pronto Soccorso dell’Ospedale Sant’Andrea durante tutto il mese di ottobre 2009, suddivisi in modo casuale in due gruppi. Nel primo gruppo, di 476 pazienti, la rilevazione dei parametri vitali è stata effettuata con dispositivi manuali, mentre nel secondo gruppo, di 477 pazienti, con dispositivo automatico Carescape™ V100. Risultati: I dati hanno evidenziato che la differenza dei tempi totali tra i due gruppi è risultata statisticamente significativa (1993 vs 1518 min, p < 0,001). I due gruppi di studio erano omogenei per età, sesso e numerosità del campione nell’ambito dello stesso codice-colore. Differenze significative sono state invece riscontrate confrontando i tempi nei sottogruppi divisi per codice di priorità: codici bianchi 4,33 vs 2,27 (min), p < 0,05; codici verdi 4,28 vs 3,37 (min), p < 0,001; codici gialli 3,92 vs 2,72 (min), p < 0,001. Conclusioni: I risultati di questo studio hanno dimostrato tra i due gruppi una differenza statisticamente significativa di 475 minuti totali impiegati nelle procedure di triage, compresa la misurazione dei parametri vitali. In conclusione, il tempo risparmiato nella rilevazione di tali parametri mediante un dispositivo automatico potrebbe consentire ai medici d’emergenza-urgenza di avere un approccio qualificato con una diagnosi precoce e una terapia più rapida ed efficace, migliorando possibilmente l’outcome dei pazienti

Procalcitonin variations after Emergency Department admission are highly predictive of hospital mortality in patients with acute infectious diseases.

BACKGROUND AND AIM: To evaluate the diagnostic and prognostic usefulness of procalcitonin (PCT) in patients admitted to the Emergency Department (ED) with signs of infections and to assess the prognostic value of repeated measurements in predicting hospital mortality. MATERIALS AND METHODS: A prospective, observational study was conducted in our 400bed General Teaching Hospital. 261 patients arriving in ED with signs/symptoms of infection were enrolled. PCT was performed upon arrival in the ED (T0), and 5 days after antibiotic therapy (T5). Blood cultures were performed in all patients upon arrival in the ED. RESULTS: Mean T0 PCT value was 7.1 +/- 17.9 ng/ml, and at T5 3 +/- 9.1 ng/ml (p 28% showed a lower number of deaths, with a statistical significant difference if compared to those patients with a < 28% decrease (p < 0.004). ROC curve of delta % PCT for prediction of death has an AUC = 0.82 (p < 0.03). CONCLUSIONS: PCT is a useful marker for diagnosis of systemic and local infections, and for prognostic stratification in patients with acute infectious diseases at their arrival in ED. PCT variations after antibiotic therapy are highly predictive for in-hospital mortality. PCT normalization during antibiotic therapy suggests a good response to infection possibly leading to less infection-related deaths

Management of Hypertensive Crisis in the Emergency Department, An Italian Epidemiological Study. Preliminary Data

Introduction: Aim of our experimental epidemiological study was to improve the understanding of the clinical condition of acute, severe hypertension managed in the Emergency Department (ED). We evaluated epidemiological data of the in-hospital mortality, end-organ damage, time to achieve controlled blood pressure. We show preliminary data collected in the period October-December 2009. Patients and Methods: 48 patients were studied until now (28F,20 M,mean age 68.6yrs) arriving in ED with elevated blood pressure (BP). We recorded anamnestic data, physical examination, blood tests, levels of BP leading to initiation of treatment, antihypertensive medications used, time required to achieve blood pressure control, in-hospital outcomes. Results: mean Sistolic BP/Diastolic BP(SBP/DBP) at admission was 212.3/105.8 mmHg(mean BP 141.3mmHg), and at pressure control (after mean 5.5 hours) was 143.7/76.5 mmHg(mean BP 98.9mmHg). Medications used for BP control were in 93.7% of cases intravenous drugs (iv), and in a short percentage of cases oral drugs (6.3%). Patients presented history of hypertension 70.8%, diabetes 20.8%, cardiac ischemic disease 25%, chronic cerebro-vascular disease 6.2%, chronic kidney failure 2%. The in-hospital outcomes consist mainly in hospitalization (66.7%) for complications, or for those cases of poor pressure control after more than 24 hours of stay in ED (8 patients). No patients died in ED. 29/48 patients completed a 30-days follow-up, and no events have been recorded until now. Conclusions: Preliminary data, show that hypertensive crisis is 1% of the total visits in our ED in a period of 3 months. In ED it is treated mainly with iv drugs, but also oral drugs are used. This indicates that ED physician's decision making for hypertension therapy is not standardized yet. The time required in pressure control is 5.5 hours, and this mirrors the different behaviours of ED physicians based on individual skill and experience. We are continuing the study to achieve a larger number of data useful to build a sort of “standardized protocol” for the diagnosis and treatment of hypertensive crisis in ED

Emergency Department Pain Management and Its Impact On Patients’ Short Term Outcome

Abstract: Background: Although pain is the most common complaint in the Emergency Department (ED), there is still a lack of adequate pain treatment by Emergency Physicians. Aim of this study was to describe pain management in ED from triage to discharge and to verify the effect of pain treatment in ED on a short term follow-up after discharge in order to evaluate patient’s outcome. Methods: A prospective multicentric study was conducted over two consecutive one week period in 4 ED teaching hospitals in Italy. All patients presenting with an acute, painful condition were eligible to participate in the study. The complete ED pain treatment was recorded, we enrolled 582 consecutive patients. One week after ED discharge a follow up evaluation through a phone call on patient’s pain clinical condition was also obtained. Results: There was a statistical significant difference between nurse and Emergency Physicians pain judgement (p<0.001). During ED visit: 54.2% received non steroid anti inflammatory drug (NSAID), 12.2% received paracetamol and 9.9% tramadol while morphine was used only in 5.6%of patients. Overall patient’s satisfaction at one-week follow-up was as follows: in 63% of patients pain was completely absent, but on the other hand, 37% of patients had no pain relief, despite analgesic therapy prescription. Conclusion: In our study we found differences between nurses and physicians judgments, they disagreed on the severity of pain. It was observed a low use of pain intensity scale with a formal measurement scales to assess pain. Our study demonstrates the importance of adequate ED and analgesic drug prescription for patients referring for pain in ED, and follow up assessment, many patients in follow up reported continued pain because of poor prescription of analgesic drug at discharge from ED. Improving analgesia in ED seems to be crucial for patients’ quality of life and for preventing ED readmission for relapse of pain