Additional data from clinical examination on site significantly but marginally improve predictive accuracy of the Revised Trauma Score for major complications during Helicopter Emergency Medical Service missions

Introduction: The Revised Trauma Score (RTS) accurately identifies trauma patients at high risk of adverse events or death. Less is known about its usefulness in the general population and non-trauma recipients of Helicopter Emergency Medical Service (HEMS). The RTS is a simple tool and omits a lot of other data obtained during clinical evaluation. The aim was to assess the role of the RTS to identify patients at risk of major complications (death, cardiopulmonary resuscitation, defibrillation, intubation) in the general population of HEMS patients. Clinical factors beyond the RTS were analyzed to identify additional prognostic factors for predicting major complications. Material and methods: A retrospective analysis of medical records of adult patients routinely collected during HEMS missions in the years 2011-2014 was performed. Results: The analysis included 19 554 HEMS missions. Patients were 55 ±20 years old and 68% were male. The most common indication for HEMS was diseases of the circulatory system - 41%. Major complications occurred in 2072 (10.6%) cases. In the general population of HEMS patients, the RTS accurately identified individuals at risk of major complications at a cut-off value of 10.5 and area under the curve (AUC) of 93.5%. In multivariate analysis, additional clinical data derived from clinical examination (ECG; skin, pupil and breathing examination) significantly but marginally improved the accuracy of RTS assessment: AUC 95.6% (p < 0.001 for the difference). Conclusions: The Revised Trauma Score accurately identifies individuals at risk of major complications during HEMS missions regardless of the indication. Additional clinical data significantly but marginally improved the accuracy of RTS in the general population of HEMS patient

Occurrence and extraction of implantable cardioverter-defibrillator leads with conductor externalization

   Background: The increasing number of patients with implantable cardioverter-defibrillators (ICD) contributes to the rising number of patients qualifying for a transvenous lead extraction (TLE) due to infection, vascular or lead failure related indications. The purpose of this study was to perform a retrospective analysis of the occurrence of conductor externalization in TLE patients and to assess the success rate in the extraction of these leads. Methods: TLE procedure was performed between 2012 and 2014 of 428 electrodes in 259 patients. Out of these, 143 (33.4%) leads in 138 (52.9%) patients were ICD leads. The indications for the TLE in ICD patients were: infection in 37 patients, lead failure in 84 patients, and others in 17 patients. Conductor externalization was observed in 8 ICD leads (5.6%) in 8 (5.8%) patients. The mean dwell­ing time for externalized leads was 87.9 (55 to 132) months compared to 60.1 (3 to 246) months of the remaining 135 ICD leads (p = 0.0329). All externalized leads were successfully and completely extracted using device traction, mechanical telescopic sheaths and/or autorotational cutting sheaths. No complica­tions of lead extraction procedures were observed in 8 patients with externalization. Results: Patients with lead externalization were often in a better New York Heart Association func­tional class (I or II) compared to those in the rest of the study group (p = 0.0212). Conclusions: Conductor externalization is a rare finding in patients undergoing TLE. This occurs with different manufacturers and lead types. In this complication transvenous lead extraction with the mechanical extraction tools can be safely performed.

Nowe schematy diagnostyczne. Protokół badania pilotażowego PET Guidance I: pozytonowa tomografia emisyjna u chorych z podejrzeniem infekcji związanej z wszczepialnym urządzeniem do elektroterapii serca

Background: Cardiovascular implantable electronic device (CIED) infection is a complication of increasing incidence. We present a protocol of an observational case control clinical trial “Positron Emission Tomography Combined With Computed Tomography (PET CT) in Suspected Cardiac Implantable Electronic Device Infection, a Pilot Study — PET Guidance I” (NCT02196753). Aim: The aim of this observational clinical trial is to assess and standardise diagnostic algorithms for CIED infections (lead-dependent infective endocarditis, generator pocket infection, fever of unknown origin) with PET CT in Poland. Methods and results: Study group will consist of 20 patients with initial diagnosis of CIED-related infection paired with a control group of 20 patients with implanted CIEDs, who underwent PET CT due to other non-infectious indications and have no data for infectious process in follow-up. All patients included in the study will undergo standard diagnostic pro­cess. Conventional/standard diagnostic and therapeutic process will consist of: medical interview, physical examination, laboratory tests, blood cultures; imaging studies: echocardiography: transthoracic (TTE), and, if there are no contraindications transoesophageal, computed tomography scan for pulmonary embolism if indicated; if there are abnormalities in other systems, decisions concerning further diagnostics will be made at the physician’s discretion. As well as standard diagnostic procedures, patients will undergo whole body PET CT scan to localise infection or inflammation. Diagnosis and therapeutic decision will be obtained from the Study Committee. Follow-up will be held within six months with control visits at three and six months. During each follow-up visit, all patients will undergo laboratory tests, two blood cultures collected 1 h apart, and TTE. In case of actual clinical suspicion of infective endocarditis or local generator pocket infection, patients will be referred for further diagnostics. Endpoints for the results assessment — primary endpoints are to standardise PET CT in the diagnostic process: sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis made by PET CT; secondary endpoints are: assessment of usefulness of PET CT for detection of remote infective complications (metastatic abscesses, infected pulmonary emboli), incidence of particular localisations of infection, influence of PET CT on therapeutic decision: confirmation or change of decision based on PET CT, safety and complications of diagnostic process of CIED-related infections with PET CT. Conclusions: Evaluation of PET CT use for device-related infections in a case control study may be conclusive and improve diagnostic pathway.Wstęp: Infekcje związane z wszczepialnymi urządzeniami do elektroterapii serca (CIED) są narastającym problemem klinicznym. W artykule przedstawiono, stworzony przez autorów niniejszej pracy, protokół badania obserwacyjnego “Positron Emission Tomography Combined With Computed Tomography (PET CT) in Suspected Cardiac Implantable Electronic Device Infection, a Pilot Study — PET Guidance I” (NCT02196753). Cel: Celem pracy była ocena przydatności i standaryzacja procesu diagnostycznego infekcji związanych z CIED z użyciem pozytonowej tomografii emisyjnej (PET CT). Metody i wyniki: Badana grupa będzie składać się z 20 chorych z CIED, u których ustalono wstępne rozpoznanie infekcji związanej z CIED. Grupę kontrolną będzie stanowić 20 pacjentów z CIED, u których wykonano PET CT z innych, pozainfekcyjnych wskazań i u których w wywiadzie nie stwierdzono rozwoju objawów infekcji. Wszyscy chorzy włączeni do badania będą poddani standardowej diagnostyce z wykorzystaniem rutynowych badań laboratoryjnych (w tym co najmniej 2 posiewy z krwi), echokardiografii przezklatkowej (TTE) i opcjonalnie przezprzełykowej oraz klasycznej tomografii komputerowej. Diag­nostyka może zostać rozszerzona przez zespół leczący w przypadku zaistnienia dodatkowych wskazań. U wszystkich chorych zostanie wykonane badanie PET CT całego ciała. Komitet Badania na podstawie zebranych danych klinicznych postawi diagnozę i ustali sposób postępowania. Wizyty kontrolne odbędą się po 3 i 6 miesiącach; wykonane będą badania laboratoryjne (w tym 2 razy posiewy z krwi) i TTE. W przypadku utrzymującego się/nowego podejrzenia infekcji związanej z CIED podjęta będzie standardowa diagnostyka. Punkty końcowe badania obejmują — pierwszorzędowe punkty końcowe (standaryzacja zastosowania PET CT): czułość, specyficzność, pozytywna i negatywna wartość prognostyczna PET CT; drugorzędowe punkty końcowe: przydatność PET CT w ocenie powikłań infekcyjnych (obecność ropni, zakażonej zatorowości), typowe miejsca lokalizowania się infekcji, wpływ PET CT na decyzje terapeutyczne; potwierdzenie lub modyfikacja decyzji na podstawie PET CT, bezpieczeństwo i powikłania związane z wykorzystaniem PET CT w diagnostyce stanów infekcyjnych związanych z CIED. Wnioski: Oczekuje się, że zastosowanie PET CT w stanach infekcyjnych związanych z CIED może mieć korzystny wpływ na ich diagnostykę