Thirty and ninety days mortality predictive value of admission and in-hospital procalcitonin and mid-regional pro-adrenomedullin testing in patients with dyspnea. Results from the VERyfing DYspnea trial

Introduction

Mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) demonstrated usefulness for management of emergency department patients with dyspnea.

Methods

To evaluate in patients with dyspnea, the prognostic value for 30 and 90 days mortality and readmission of PCT, MR-proADM, and MR-proANP, a multicenter prospective study was performed evaluating biomarkers at admission, 24 and 72 hours after admission. Based on final diagnosis, patients were divided into acute heart failure (AHF), primary lung diseases, or both (AHF + NO AHF).

Results

Five hundred one patients were enrolled. Procalcitonin and MR-proADM values at admission and at 72 hours were significantly (P < .001) predictive for 30-day mortality: baseline PCT with an area under the curve (AUC) of 0.70 and PCT at 72 hours with an AUC of 0.61; baseline MR-proADM with an AUC of 0.62 and MR-proADM at 72 hours with an AUC of 0.68. As for 90-day mortality, both PCT and MR-proADM baseline and 72 hours values showed a significant (P < .0001) predictive ability: baseline PCT with an AUC of 0.73 and 72 hours PCT with an AUC of 0.64; baseline MR-proADM with an AUC of 0.66 and 72 hours MR-proADM with an AUC of 0.71. In AHF, group biomarkers predicted rehospitalization and mortality at 90 days, whereas in AHF + NO AHF group, they predict mortality at 30 and 90 days.

Conclusions

In patients admitted for dyspnea, assessment of PCT plus MR-proADM improves risk stratification and management. Combined use of biomarkers is able to predict in the total cohort both rehospitalization and death at 30 and 90 days.     

Diagnostic power of the mid-regional pro-atrial natriuretic peptide for heart failure patients with dyspnea: A meta-analysis

Objective

To evaluate the diagnostic performance of the mid-regional portion of the pro-atrial natriuretic peptide (MR-proANP) for heart failure (HF) in dyspnea patients.

Design and methods

We performed a systematic review of English-language studies published during the past three decades. The performance characteristics (diagnostic sensitivity, specificity, and other measures of accuracy) were pooled and examined by random-effects models.

Results

Five studies met the inclusion criteria, which included 1153 patients with HF and 1904 non-HF patients. The summary estimates for MR-proANP in HF diagnosis had a diagnostic sensitivity of 0.90 (95% confidence interval (CI), 0.88–0.92), a specificity of 0.68 (95% CI, 0.66–0.70), and a diagnostic odds ratio (DOR) of 22.89 (95% CI, 12.54–41.77). The area under the curve (AUC) and Q value for the summary receiver operating characteristic (sROC) curves were 0.88 and 0.81, respectively.

Conclusion

MR-proANP showed a high diagnostic accuracy for HF in dyspnea patients.     

The Value of Procalcitonin, a Novel Inflammatory Marker, in the Diagnosis of Myocardial Infarction and Evaluation of Acute Coronary Syndrome Patients

Background

Procalcitonin is a calcitonin precursor that is used as an inflammatory biomarker in the plasma of patients with sepsis.

Objective

The aim of this study was to determine the diagnostic accuracy of emergency department (ED) point-of-care blood procalcitonin testing in identifying myocardial infarction (MI) in patients with chest pain of presumed ischemic origin.

Methods

Patients over 18 years of age who presented to the ED with MI-typical chest pain of presumed ischemic origin were included in the study. An initial point-of-care blood sample was drawn from each study patient for testing procalcitonin, troponin T, myoglobin, and creatine kinase-MB levels. A second sample was taken 4 h after admission for a procalcitonin test. Finally, a 6-h post-admission blood sample was taken to measure troponin T, myoglobin, and creatine kinase-MB levels in each study patient who had an initial negative cardiac marker test.

Results

A total of 1008 patients with chest pain were admitted to the ED during the study period, and a total of 141 patients met study criteria and were entered into the study. ED point-of-care blood procalcitonin testing to identify myocardial infarction in patients with chest pain of presumed ischemic origin had a sensitivity of 38.3% (95% confidence interval [CI] 28.8-47.3%) and a specificity of 77.8% (95% CI 70.0-84.4%), a positive likelihood ratio (LR+) of 1.725 and a negative likelihood ratio (LR−) of 0.792. The 4th hour diagnostic values (sensitivity, specificity, LR+ and LR−) of procalcitonin semi-quantitative (PCT-Q) testing were 90% (95% CI 80.9−95.7%), 59.3% (95% CI 52.5−63.5%), 2.2, and 0.16, respectively.

Conclusion

ED point-of-care testing for procalcitonin had poor diagnostic accuracy for predicting myocardial infarction.     

Impact of procalcitonin on the management of children aged 1 to 36 months presenting with fever without source: A randomized controlled trial

Objective

The aim of the study was to evaluate the impact of procalcitonin (PCT) measurement on antibiotic use in children with fever without source.

Method

Children aged 1 to 36 months presenting to a pediatric emergency department (ED) with fever and no identified source of infection were eligible to be included in a randomized controlled trial. Patients were randomly assigned to 1 of 2 groups as follows: PCT+ (result revealed to the attending physician) and PCT− (result not revealed). Patients from both groups also had complete blood count, blood culture, urine analysis, and culture performed. Chest radiography or lumbar puncture could be performed if required.

Results

Of the 384 children enrolled and equally randomized into the PCT+ and PCT− groups, 62 (16%) were diagnosed with a serious bacterial infection (urinary tract infection, pneumonia, occult bacteremia, or bacterial meningitis) by primary ED investigation. Ten were also found to be neutropenic (<500 × 10⁶/L). Of the remaining undiagnosed patients, 14 (9%) of 158 received antibiotics in the PCT+ group vs 16 (10%) of 154 in the PCT− group (Δ −2%; 95% confidence interval [CI], −8 to 5). A strategy to treat all patients with PCT of 0.5 ng/mL or greater with prophylactic antibiotic in this group of patients would have resulted in an increase in antibiotic use by 24% (95% CI, 15-33).

Conclusion

Semiquantitative PCT measurement had no impact on antibiotic use in children aged 1 to 36 months who presented with fever without source. However, a strategy to use prophylactic antibiotics in all patients with abnormal PCT results would have resulted in an increase use of antibiotics.     

Cord blood plasma reference intervals for potential sepsis markers: pro-adrenomedullin, pro-endothelin, and pro-atrial natriuretic peptide

Objectives

To establish reference values in cord blood of the following new sepsis markers: pro-adrenomedullin (MR-proADM), pro-endothelin (CT-proET-1), and pro-atrial natriuretic peptide (MR-proANP).

Methods

MR-proADM, CT-proET-1, MR-proANP, and procalcitonin (PCT) were measured in cord blood of newborn infants by Time Resolved Amplified Cryptate Emission (TRACE) technology. The inclusion criteria in the control group (n = 194) was the absence of any clinical sign or risk factor of sepsis. A group of 73 newborn infants presenting with risk factors of sepsis at delivery was also studied.

Results

The median values (reference interval) of CT-proET-1, MR-pro-ADM, and MR-proANP measured in cord blood plasma were 72 pmol/L (39–115), 0.84 nmol/L (0.5–1.38), and 163 pmol/L (76–389), respectively. The PCT reference interval was not significantly different from that previously described in cord blood serum.

Conclusions

The reference intervals established will serve as a starting point for further clinical investigations aimed to elucidate the potential prognostic/diagnostic value of these markers in neonatal sepsis management.     

The prognostic value of mid-regional pro-adrenomedullin in the evaluation of acute dyspnea

Introduction: Acute dyspnea is a common chief complaint among patients who visit an emergency room and presents diagnostic challenges for clinicians in both identifying the etiology and determining the clinical severity. The study of biomarkers in the prognostication and risk stratification of these patients has been increasing, including the investigation of the prognostic value for mid-regional pro-adrenomedullin (MR-proADM).

Areas covered: In this review, the authors cover what is known about MR-proADM testing in patients presenting with acute dyspnea and the supporting evidence of its prognostic value in common conditions in medical patients with acute dyspnea, including acute heart failure, community acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease, and acute pulmonary embolism.

Expert commentary: Numerous studies have proposed MR-proADM as a more accurate, prognostic tool in the evaluation of acute dyspnea than other biomarkers and consensus risk scores such as Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA). The authors review recent prospective studies, systematic reviews, and meta-analyses that demonstrate its prognostic value and role in risk stratification, including its use in biomarker-based triage algorithms as part of the diagnostic evaluation of the acutely dyspneic patient.     

The value of procalcitonin level in community-acquired pneumonia in the ED

Objectives

The aim of this study was to investigate the value of procalcitonin (PCT) level in patients with community-acquired pneumonia (CAP) in the emergency department (ED).

Methods

We conducted a prospective study of patients with CAP in the ED. Patients presenting with a clinical and radiographic diagnosis of CAP were enrolled. The authors measured inflammatory biomarkers. The severity of CAP was assessed by 3 prediction rules. We performed an analysis to assess the value of each biomarker for the prediction of mortality and CAP severity.

Results

A total of 126 patients with CAP are included. Sixteen patients who were older and belonged to high-risk group died within 28 days. Nonsurvivors had significantly increased median PCT level (1.96 vs 0.18 ng/mL) and high-sensitivity C-reactive protein (158.57 vs 91.28 mg/dL) compared with survivors. The median PCT levels were significantly higher in more severe disease, on 3 prediction rules. In regression logistic analyses, the area under the receiver operating characteristic curve of PCT level were 0.828 (95% confidence interval, 0.750-0.889). The addition of PCT level to three prediction rules significantly increased the area under the receiver operating characteristic curve. These results suggest that PCT measurement is more versatile tool for predicting mortality and the severity of disease among patients with CAP in the ED.

Conclusions

Procalcitonin level is valuable for predicting mortality and the severity of disease among patients with CAP at ED admission. Procalcitonin level as an adjunct to CAP prediction rules may be valuable for prognosis and severity assessment.     

Pro-adrenomedullin,pro-endothelin-1, procalcitonin,C-reactive protein and mortality risk in critically ill children: a prospective study

Introduction

We tested the hypothesis that higher mid-regional pro-adrenomedullin (MR-proADM), carboxy-terminal pro-endothelin-1 (CT-proET-1), procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations would be associated with increased prediction of mortality risk scores.

Methods

Prospective observational study set in two pediatric intensive care units (PICUs). Two-hundred-thirty-eight patients were included. MR-proADM, CT-proET-1, PCT and CRP levels were compared between children with PRISM III and PIM 2 > p75 (Group A; n = 33) and the rest (Group B; n = 205).

Results

Median (range) MR-proADM levels were 1.39 nmol/L (0.52–12.67) in group A versus 0.54 (0.15–3.85) in group B (P < 0.001). CT-proET-1 levels were 172 pmol/L (27–500) versus 58 (4–447) (P < 0.001). PCT levels were 7.77 ng/mL (0.34–552.00) versus 0.28 (0.02–107.00) (P < 0.001). CRP levels were 6.23 mg/dL (0.08-28.25) versus 1.30 mg/dL (0.00-42.09) (P = 0.210). The area under the ROC curve (AUC) for the differentiation of group A and B was 0.87 (95% CI:0.81–0.821) for MR-proADM, 0.86 (95% CI:0.79–0.92) for CT-proET-1 and 0.84 (95% CI:0.74–0.94) for PCT. A MR-proADM > 0.79 nmol/L had 93% sensitivity and 76% specificity to differentiate groups, whereas a CT-proET-1 > 123 pmol/L had 77% sensitivity and 84% specificity, and a PCT concentration > 2.05 ng/mL had 80% sensitivity and specificity.

Conclusions

In critically ill children, high levels of MR-proADM, CT-proET-1 and PCT were associated with increased prediction of mortality risk scores. MR-proADM, CT-proET-1 and PCT concentrations higher than 0.80 nmol/L, 123 pmol/L and 2 ng/mL, respectively, could be used by clinicians to identify critically ill children at higher prediction of risk death scores.     

Pneumonia Quality Measures not Associated with Antibiotics for Congestive Heart Failure Patients

Background

Pneumonia antibiotic timing performance measures can result in unnecessary antibiotic administration to patients in whom a diagnosis of pneumonia remains possible but has not been confirmed.

Objective

Our objective was to determine if unnecessary antibiotic administration to admissions with Emergency Department (ED) congestive heart failure (CHF) diagnoses increased as institutional attention to pneumonia antibiotic timing intensified.

Methods

We performed a cross-sectional study in an academic ED with 39,000 annual visits. Our subjects included adult admissions with ED CHF diagnoses between October and March of 2004−2005, 2005−2006, and 2006−2007. We excluded patients with any concomitant infectious diagnosis from primary analysis. We obtained patient age, sex, triage acuity, vital signs, ED diagnoses, and admitting service from electronic databases. Trained abstractors confirmed infectious diagnosis presence and noted if antibiotics were administered. Inter-observer agreement was assessed. Multivariate logistic regression determined association of time period with antibiotic administration. We assessed trends in concomitant infectious diagnoses.

Results

Of 778 CHF admissions, 125 had infectious diagnoses, leaving 653 for primary analysis. Inter-observer agreement was good to excellent (κ = 0.71−0.83). Demographic and presenting characteristics did not vary by period. Antibiotics were administered to 18.4% (95% confidence interval [CI] 12.7−23.3), 15.0% (95% CI 9.6−18.5), and 15.1% (95% CI 10.2−19.8), per period, respectively. Time period was not associated with antibiotics, odds ratios were 0.8 (95% CI 0.5−1.4) and 0.9 (95% CI 0.5−1.6) for periods 2 and 3, respectively. Concomitant infectious diagnoses did not increase significantly (from 15.5% to 19.4%). Pneumonia antibiotic timing compliance remained low (50−70%).

Conclusions

Unnecessary antibiotic administration to ED CHF admissions did not increase as institutional scrutiny of pneumonia antibiotic timing intensified, although neither did compliance with pneumonia antibiotic timing.     

Serum procalcitonin level for the prediction of severity in women with acute pyelonephritis in the ED: value of procalcitonin in acute pyelonephritis

Purpose

Predicting medical outcomes for acute pyelonephritis (APN) in women is difficult. Delay in diagnosis and treatment often results in rapid progression to circulatory collapse, multiple-organ failure, and death. The aim of this study was to investigate the value of procalcitonin (PCT) level in women with APN at ED.

Methods

We conducted a prospective study of women with APN presenting to the ED. The authors measured inflammatory biomarkers, and the severity of pyelonephritis was assessed by 4 severity of disease classification system and stage of sepsis. We performed an analysis to assess the value of PCT for the prediction of 28-day mortality and disease severity.

Results

A total of 240 female patients with APN are included. Patients were divided into 4 groups on the basis of systemic inflammatory response syndrome criteria, organ dysfunction, and persistent hypotension. The median PCT level was higher in the septic shock group compared with other groups. Of the other inflammatory markers, only white blood cell count was significantly different among the groups, whereas high-sensitivity C-reactive protein level and erythrocyte sedimentation rate revealed no differences. The area under the curve for PCT in predicting 28-day mortality was 0.68. For predicting mortality, a cutoff value of 0.42 ng/mL had a sensitivity of 80% and a specificity of 50%. However, the disease classification systems were demonstrated to be superior to PCT in predicting 28-day mortality.

Conclusions

Relative to other classic markers of inflammation, by distinguishing the severity of sepsis related to APN, PCT levels can provide additional aid to clinicians in disease severity classification and their decision of treatment at ED.     

Evaluation of the Mortality in Emergency Department Sepsis score combined with procalcitonin in septic patients

Objective

To determine an effective method for predicting severity of sepsis and 28-day mortality of emergency department (ED) patients, we compared the Mortality in Emergency Department Sepsis (MEDS) score with procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) and evaluated the MEDS score combined with relevant biomarkers.

Methods

A total of 501 adult ED patients with sepsis were selected for this prospective clinical study. The optimal combination was assessed by logistic regression. All cases were divided into the sepsis group (319 cases) and the severe sepsis and septic shock group (182 cases) according to the severity of sepsis, as well as the survivor group (367 cases) and nonsurvivor group (134 cases) according to the 28-day outcomes.

Results

The area under the curve of the MEDS score, PCT, IL-6, and CRP was 0.793, 0.712, 0.695, and 0.681 for severity of sepsis and 0.776, 0.681, 0.692, and 0.661 for 28-day mortality, respectively. Only PCT was an independent predictor when combined with the MEDS score. The new combination of the MEDS score with PCT improved the area under the curve for severity (0.852) and mortality (0.813). This new combination for evaluation of severity had better sensitivity (63.2%), specificity (92.2%), and positive predictive (82.1%) and negative predictive (81.4%) values.

Conclusions

The predictive ability of the MEDS score for severity and 28-day mortality of septic ED patients is better than PCT, IL-6, and CRP levels. The MEDS score combined with PCT enhances the ability of risk stratification and prognostic evaluation.     

Patient Factors Associated with Failure to Diagnose Tuberculosis in the Emergency Department

Background

Emergency department (ED) presentation of pulmonary tuberculosis (TB) can be highly atypical and an ED visit might be the only health care interaction for high-risk patients.

Objective

Our objective was to identify patient factors associated with discharge without a diagnosis of TB during an infectious ED visit.

Methods

The study population consisted of 150 patients from 2000 to 2009 with 190 infectious ED visits. Patients were initially identified from the state registry of confirmed TB cases and epidemiological characteristics were identified prospectively during case investigation. A retrospective review was performed for clinical characteristics of visits dichotomized according to whether the diagnosis of TB was made during the ED visit.

Results

Analysis revealed that 77% of all infectious-patient visits ended with a diagnosis of TB. A TB diagnosis was more likely when patients presented with pulmonary or infectious chief complaints, endorsed cough, subjective fever, chills, dyspnea, previous TB infection, or had an abnormal lung examination or chest x-ray study. Patients were significantly less likely to be diagnosed with TB when they were unresponsive during clinical evaluation or when they reported a history of both homelessness and any substance abuse during the last year. In addition, these characteristics were independent predictors of nondiagnosis when traditional TB risk factors or abnormal vital signs were considered.

Conclusions

Patients with atypical presentations, as well as those who were unresponsive or reported a history of homelessness and substance abuse, were at greater risk for nondiagnosis of TB during an infectious ED visit.     

Inferior vena cava assessment in the bedside diagnosis of acute heart failure

Objectives

The objective of this study was to determine the test characteristics of the caval index and caval-aortic ratio in predicting the diagnosis of acute heart failure in patients with undifferentiated dyspnea in the emergency department (ED).

Methods

This prospective observational study was performed at an urban ED that enrolled patients, 50 years or older, with acute dyspnea. A sonographic caval index was calculated as the percentage decrease in the inferior vena cava (IVC) diameter during respiration. A caval-aortic ratio was defined by the maximum IVC diameter divided by the aortic diameter. The sensitivity, specificity, and likelihood ratios of these measurements associated with heart failure were estimated.

Results

Eighty-nine patients were enrolled in the study with a mean age of 68 years. A caval index of less than 33% had 80% sensitivity (95% confidence interval [CI], 63%-91%) and 81% specificity (95% CI, 68%-90%) in diagnosing acute heart failure, whereas an index of less than 15% had a 37% sensitivity (95% CI, 22%-55%) and 96% specificity (95% CI, 86%-99%). The sensitivity of a caval-aortic ratio of more than 1.2 was 33% (95% CI, 18%-52%) and the specificity was 96% (95% CI, 86%-99%). Positive likelihood ratios were 10 for a caval index of less than 15%, 4.3 for an index of less than 33%, and 8.3 for a caval-aortic ratio of more than 1.2.

Conclusion

Bedside assessments of the caval index or caval-aortic ratio may be useful clinical adjuncts in establishing the diagnosis of acute heart failure in patients with undifferentiated dyspnea.     

Is Pelvic Ultrasound Associated with an Increased Time to Appendectomy in Pediatric Appendicitis?

Background

Appendicitis is a common pediatric condition requiring urgent surgical intervention to prevent complications. Pelvic ultrasound (US) as a diagnostic aid has become increasingly common. Despite its advantages, evidence suggests US can lead to delayed definitive management.

Objective

The objective was to test the hypothesis that US is associated with an increased time to appendectomy in children with acute appendicitis.

Methods

A chart review was conducted of all children aged 0−17 years who presented to the pediatric emergency department (ED) with a discharge diagnosis of appendicitis. The primary outcome variable was the interval between initial evaluation to appendectomy between patients who received an US and those who did not.

Results

Of 662 cases included, 424 patients (64%) underwent a pelvic US and 238 patients underwent an appendectomy without US. Median time interval from initial evaluation in the ED by a physician to appendectomy among patients who received an US was 9.7 h (interquartile range [IQR]: 6.8−15.0 h) compared with 5.5 h (IQR: 3.8−8.6 h) among patients who did not receive an US (Mann-Whitney, p < 0.001). The increased time to appendectomy in patients who received an US was dependent on the patient being female and presenting to the ED after hours (univariate analysis of variance test for interaction, p < 0.05).

Conclusions

Female pediatric patients and those presenting after hours that undergo an US have a significantly increased time to appendectomy compared with those who do not undergo diagnostic imaging.     

Prediction of myocardial infarction risk in older patients with acute coronary syndrome

Purposes

To identify bedside variables that aid in diagnosis of acute coronary syndrome (ACS) and might facilitate rapid triage of patients aged ≥65 years.

Basic Procedures

Prospective, observational study of consecutive patients aged ≥65 years with suspicion of ACS presenting to our emergency department (ED). Patients' medical characteristics were collected at baseline and during a 1-month follow-up period. We identified variables independently associated with ACS by multivariate analyses and bootstrapping techniques.

Main Findings

Among 399 patients, 124 (31.1%) received a diagnosis of ACS (61 acute myocardial infarction, 63 unstable angina). We surveyed multiple clinical and ECG variables to develop a predictive model which included the following variables: male sex, history of coronary artery disease, typical chest pain, dyspnea, epigastric pain, pathological Q-wave, ST-segment elevation (area under the receiver operating characteristic curve (AUC) 0.79, 95% confidence interval 0.71 to 0.82). With the addition of cardiac troponin I to the model the AUC increased to 0.83 (0.79 to 0.88). We used these findings to create the Heart Attack Risk for aged Patient (HARP) scale. Our data suggest that patients with a low HARP score might be safely managed without further testing.

Principal Conclusions

A model based on variables easily available at ED presentation from history, physical examination, and electrocardiography, can help ED physicians to identify seniors at very low risk of ACS.     

Incidence,clinical presentation,and management of constipation in a pediatric ED

Objectives

The study aimed to assess, in pediatric patients presenting to the emergency department (ED), the incidence of visit to the ED for functional constipation (FC), symptoms, signs of presentation, and management from ED physicians.

Design

This is a retrospective study of hospital records for a period of 1 year at the ED of “Bambino Gesù” Children's Hospital, Rome, Italy. Children younger than 15 years discharged from ED with a diagnosis of FC in the 1-year period were included.

Interventions

We analyzed medical records of 202 patients (<15 years) with FC diagnosis at discharge. Main outcome measures included incidence, demographic characteristics, clinical presentations of FC patients, and ED physicians' interventions.

Results

Two hundred two FC cases were studied in a 12-month study period. Compared with the total number of ED consultations, the incidence of FC was 0.4%. The number of patients 4 years or younger was much higher than patients older than 4 years (P < .0001). Bowel frequency of 3 bowel movements or less per day, acute abdominal pain, and stool retention were found to be significantly more frequent than the other presenting symptoms (P < .0001). The number of patients beginning a therapy after ED discharge was significantly higher compared with that already treated before ED visit (P < .0001). Discharged patients were referred to community pediatricians significantly more frequently than to pediatric gastroenterologists (P = .003).

Conclusions

Emergency department physicians have an important role in the diagnosis and management of FC despite its relatively low incidence. Indeed, ED intervention in many cases leads not only to recognition this disease but also to an approach for therapeutic strategy, avoiding complications of chronic constipation.     

Procalcitonin,as an early biomarker of colorectal anastomotic leak,facilitates enhanced recovery after surgery

Purpose

Procalcitonin (PCT) is a biomarker used to help sepsis diagnosing and monitoring and guide antibiotic therapy. Anastomotic leak (AL) after colorectal surgery is a severe complication associated with relevant short- and long-term sequelae. The aim of our study is to assess the predictive value of PCT levels to early diagnose AL after colorectal surgery.

Methods

Between September 2011 and September 2012, a series of 99 patients underwent colorectal surgery in our institution. In all cases, white blood cell (WBC) count, C-reactive protein (CRP), and PCT levels were measured in first, third, and fifth postoperative day (POD). Anastomotic leaks and all other postoperative complications were recorded.

Results

We registered 7 ALs (7.1%). Decreased PCT levels had a significant negative predictive value (NPV) for AL in third and fifth POD (96.7% and 96.7%, respectively), compared with CRP and WBC. The best diagnostic performance was obtained with the combination of PCT and CRP measurements in third and fifth POD (area under the curve, 0.87 and 0.94, respectively). In 5th POD, PCT improves diagnosis, but not in a statistically significant way (area under the curve, 0.86).

Conclusions

Compared with more established biochemical values such as CRP and WBC, PCT is an earlier, more sensitive, and reliable marker of AL. Increased PCT levels in early PODs after colorectal surgery may provide a more effective way to detect AL, before clinical symptoms appear. Moreover, normal PCT values might be also a useful marker to facilitate a safe and early discharge of selected patients after colorectal surgery.     

Effect of Certificate of Need Law on Emergency Department Length of Stay

Background

The impact of the Certificate of Need (CON) law on Emergency Department (ED) care remains elusive in the academic literature.

Objectives

We study the impact of CON law on ED Length of Stay (LOS).

Methods

We examine ED LOS to detect any statistically significant difference between CON and non-CON states. We then estimate the effects of CON law on ED LOS by treating CON as an exogenous (endogenous) variable.

Results

We find that the CON legislation positively impacts ED care by reducing ED LOS (95% confidence interval [CI] −61.3 to −10.3), and we can't reject the hypothesis that the CON legislation can be treated as an exogenous variable in our model. An increase in the stringency of the CON law (measured by the threshold on equipment expenditure that is subject to a CON review) tends to diminish this positive impact on ED LOS (95% CI 9.9–68.0). The party affiliation of the Governor (95% CI 10.3–37.5), the political environment as a function of the agreement on voting between state senators (95% CI−64.8 to −12.9), proportion of young population (0–17 years) when compared with the elderly (>65 years) (95% CI−2299.7 to −184.1), proportion of population covered by privately purchased insurance (95% CI−819.3 to −59.9), etc., are found to significantly impact ED LOS in a state.

Conclusion

This study provides a better understanding of the impact of CON law on ED care, which extends the previous literature that has mainly focused on CON effects on inpatient care.     

Acute Vision Loss: A Fuzzy Presentation of Sarcoidosis

Background

Acute vision loss is a devastating problem for patients and a challenging diagnostic dilemma for Emergency Physicians. This chief complaint is one in which we must be adept at quickly evaluating and initiating either care or referral.

Objectives

This case reviews the approach to acute vision loss and shows the importance of expanding the differential in atypical and complex presentations.

Case Report

A 31-year-old, previously healthy, white woman presented to the Emergency Department (ED) with 1 day of painless right eye vision loss. Ocular ultrasound and slit-lamp examination were unremarkable. Fundoscopic examination revealed retinal hemorrhages and papillitis. Her chest X-ray study was significant for bilateral hilar adenopathy, and subsequent lymph node biopsy confirmed the diagnosis of sarcoidosis.

Conclusions

Although sarcoidosis is more common in African Americans, it must be considered in all patients in the appropriate clinical context. Sarcoidosis is an important diagnosis to include on the differential of many chief complaints that present to the ED, including acute vision loss and dyspnea.     

Acquired Hemophilia Presenting as Profound Hematuria: Evaluation,Diagnosis, and Management of Elusive Cause of Bleeding in the Emergency Department Setting

Background

There are numerous causes of bleeding that may present to the Emergency Department (ED). Although rare, acquired hemophilia is a potentially life-threatening bleeding disorder, with reported mortality rates ranging from 6% to 8% among patients who received proper diagnosis and treatment. Approximately two thirds of patients with this condition will present with major bleeding, the magnitude of which may necessitate urgent evaluation and care.

Objectives

The aim of this article is to provide an overview of the evaluation, differential diagnosis, and management of acquired hemophilia for the emergency physician.

Case Report

A case report of a patient who presented to the ED with gross hematuria secondary to undiagnosed acquired hemophilia is described to facilitate a review of the laboratory evaluation, differential diagnosis, and treatment of acquired hemophilia.

Conclusion

Patients with acquired hemophilia–related bleeding may present to the ED for care, given the often serious nature of their bleeding. Delayed diagnosis may postpone the initiation of targeted, effective treatments for achieving hemostasis, with potentially catastrophic consequences, particularly in patients who require emergent invasive procedures. Recognition of the potential for an underlying bleeding disorder and subsequent consultation with a hematologist are critical first steps in effectively identifying and managing a patient with acquired hemophilia who presents with bleeding.