Radiologic diagnoses of patients who received imaging for venous thromboembolism despite negative D-dimer tests

Objective

The literature supports a negative D-dimer (−DD) excluding venous thromboembolic disease (VTE) in low-risk patients. We determined the radiologic diagnoses in patients where imaging was ordered despite a −DD.

Methods

This is a retrospective chart review of patients with a −DD (Tinaquant; Roche Diagnostics, Mannheim, Germany) and a radiologic study within 48 hours, sought to determine radiologic diagnosis (primary outcome), treatment of VTE, and consensus diagnosis of acute VTE.

Results

Among 3462 DD tests, 1678 met the inclusion criteria. Of 1362 patients with DD values of 350 ng/mL or less, 166 (12.2%) had radiologic studies: 93.4% of the final radiologic diagnoses were negative for VTE, 3.6% were indeterminate, and 3.0% (1.0%-6.9%) were positive; 1.8% ultimately had a consensus diagnosis of acute VTE. In 316 patients with DD values between 351 and 500 ng/mL, 88 (27.8%) had radiologic studies: 95.5% were negative, 1.1% were indeterminate, and 3.4% (0.7%-9.6%) were positive.

Conclusions

Of patients who receive radiologic studies despite −DD tests, 3.0% have positive radiologic diagnoses for acute VTE; only 1.8% had acute VTE after the review of their hospital course.     

Utilization and Yield of Chest Computed Tomographic Angiography Associated with Low Positive D-dimer Levels

Background

It is unclear to what degree broadly applied D-dimer testing combined with a low threshold for imaging with even minimally positive results may be contributing to the utilization of chest computed tomographic angiography (CTA).

Study Objectives

To determine what proportion of chest CTAs for suspected pulmonary embolism (PE) were performed in the setting of minimally elevated D-dimer levels, and to determine the prevalence of PE in those patients when stratified by clinical risk.

Methods

Retrospective chart review of all patients who had chest CTA for the evaluation of suspected PE during the years 2002–2006 in a suburban community teaching hospital emergency department.

Results

There were 1136 eligible patient visits, of which 353 (31.1%) were found to have D-dimer levels in the low positive range (0.5–0.99 μg/mL). Of these 353 patients, 9 (2.6%; 95% confidence interval [CI] 0.9–4.2%) were diagnosed with PE. There were also 109 patients (9.6%) who had normal D-dimer levels (<0.5 μg/mL). Two of these 109 (1.8%; 95% CI 0–4.2%) were diagnosed with PE. When stratified by the Pulmonary Embolism Rule-out Criteria, 99 of 353 patients with low positive D-dimer levels (28.0%; 95% CI 23.4–32.7%), and 14 of 109 with normal D-dimer levels (12.8%; 95% CI 6.6–19.1%) were classified as low risk, none of whom had PE.

Conclusions

Nearly one-third of all chest CTAs were done for patients with minimally elevated D-dimer levels, and another 9.6% for patients with normal D-dimer levels with very low yield. Further research to define clinical criteria identifying patients with minimal risk of PE despite low positive D-dimer levels represents an opportunity to improve both patient safety and utilization efficiency of chest CTA.     

Diagnostic Accuracy and Financial Implications of Age-Adjusted D-Dimer Strategies for the Diagnosis of Deep Venous Thrombosis in the Emergency Department

Background

Multiple D-dimer cutoffs have been suggested for older patients to improve diagnostic specificity for venous thromboembolism. These approaches are better established for pulmonary embolism.

D-dimer levels in VTE patients with distal and proximal clots

Objectives

There is growing evidence that venous thromboembolism (VTE) patients with distal clots (distal calf deep vein thrombosis [DVT] and sub-segmental pulmonary embolism [PE]) may not routinely benefit from anticoagulation. We compared the D-dimer levels in VTE patients with distal and proximal clots.

Cardiac ultrasound helps for differentiating the causes of acute dyspnea with available B-type natriuretic peptide tests

Introduction

The aim of this study was to evaluate the role of cardiac ultrasound in diagnosing acute heart failure (AHF) in patients with acute dyspnea with available plasma B-type natriuretic peptide (BNP) level.

Methods

Patients with acute dyspnea presenting to the emergency department (ED) of a tertiary medical center were prospectively enrolled. The enrolled 84 patients received both BNP tests and cardiac ultrasound studies and were classified into AHF and non–heart failure groups.

Results

Plasma BNP levels were higher in the AHF group (1236 ± 1123 vs 354 ± 410 pg/mL; P < .001). The AHF group had larger left ventricular end-diastolic dimension (LVEDD; 32 ± 7 vs 27 ± 4 mm/m²; P < .001) and worse left ventricular ejection fraction (52% ± 18% vs 64% ± 15%; P = .003). Multiple logistic regression analysis showed that both BNP levels more than 100 pg/mL and LVEDD were independent predictors for AHF. In patients with plasma BNP levels within gray zone of 100 to 500 pg/mL, LVEDD was larger in the AHF group than that in the non–heart failure group (29 ± 4 vs 26 ± 4 mm/m²; P = .044).

Conclusion

Both LVEDD by cardiac ultrasound and BNP levels can help emergency physicians independently diagnose AHF in the ED. In patients with plasma BNP levels within 100 to 500 pg/mL, cardiac ultrasound can help differentiate heart failure or not.     

Platelet aspirin resistance in ED patients with suspected acute coronary syndrome

Background

Platelet aspirin resistance is reported to be as high as 45%. The prevalence of emergency department (ED) platelet aspirin resistance in suspected acute coronary syndrome (ACS) is not described. Our purpose was to determine the prevalence of platelet aspirin resistance.

Methods

We determined platelet aspirin resistance in a convenience sample of ED suspected ACS patients. Eligible patients had longer than 10 minutes of chest pain or an ischemic equivalent. Two hours after receiving 325 mg of aspirin, blood was assessed for platelet function (Accumetrics, San Diego, CA). Definitions are as follows: aspirin resistance, at least 550 aspirin reaction units; positive troponin T, greater than 0.1 ng/mL; significant coronary lesion, at least 70% stenosis. The composite end point was prospectively defined as a 30-day revisit, positive cardiac catheterization, or hospital length of stay (LOS) longer than 3 days.

Results

Of 200 patients, 50.5% were male, 50.0% were black, troponin T was positive in 7.5%, cardiac catheterization was done in 10.5%, and 33.3% had a significant stenosis. Final diagnoses were noncardiac in 83.4%, stable angina in 8.0%, and unstable angina in 8.5%. Overall, 6.5% were resistant to aspirin; and high-risk patients trended to more aspirin resistance than non–high-risk patients (23.1% [3] vs 9.1% [17]; P value 95% confidence interval [CI], −0.0929 to 0.373). One-month follow-up found ED revisits in 12.5% of aspirin-resistant vs 4.9% of non–aspirin-resistant patients (95% CI, −0.114 to 0.182) and rehospitalization in 12.5% of resistant patients vs 4.3% of nonresistant patients (P value 95% CI, −0.108 to 0.187). Although LOS was similar at index admission, if rehospitalized, LOS was 6.5 for aspirin-resistant patients vs 3.2 days in nonresistant patients (P < .0001).

Conclusion

This first report of platelet aspirin resistance in patients presenting to the ED with suggested ACS finds that it is present in 6.5% of patients.     

Pulmonary Embolism Rule-out Criteria vs D-dimer testing in low-risk patients for pulmonary embolism: a retrospective study

Study objectives

The Pulmonary Embolism Rule-out Criteria (PERC) score has shown excellent negative predictive value; however, its use in the European population with high prevalence of PE is controversial. In Europe, PERC is not part of routine practice. For low-risk patients, guidelines recommend D-dimer testing, followed if positive by imaging study. We aimed to study the rate of diagnosis of PE after D-dimer testing in PERC-negative patients that could have been discharged if PERC was applied.

Method

This was a multicenter retrospective study in Paris, France. We included all patients with a suspicion of PE who had D-dimer testing in the emergency department, low pre-test probability, and a negative PERC score (that was retrospectively calculated). Patients with insufficient record to calculate PERC score were excluded. The primary end point was the rate of PE diagnosis before discharge in this population. Secondary end points included rate of invasive imaging studies and subsequent adverse events.

Results

We screened 4301 patients who had D-dimer testing, 1070 of whom were PERC negative and could be analyzed. The mean age was 35 years and 46% were men. D-dimer was positive (> 500 ng/L) in 167 (16%) of them; CTPA or V/Q scan was performed in 153 (14%) cases. PE was confirmed in 5 cases (total rate 0.5%, 95% confidence interval 0.1%-1.1%). Fifteen patients (1%) experienced non-severe adverse events.

Conclusion

D-dimer testing in PERC-negative patients led to a diagnosis of PE in 0.5% of them, with 15% of patients undergoing unnecessary irradiative imaging studies.     

Confirmed glyburide poisoning from ingestion of "street Valium"

Background

Pharmaceuticals with little to no abuse potential are often sold surreptitiously as drugs of abuse on the street. Anecdotally, sulfonylureas are suspected to be commonly sold as “street Valium.”

Case Reports

Two patients presented with altered mental status and persistent hypoglycemia requiring continuous intravenous dextrose, in the context of suspected attempted benzodiazepine abuse. Supratherapeutic glyburide levels of 1198 and 647 ng/mL were measured in these patients.

Conclusions

These are two cases of glyburide poisonings from ingestion of “street Valium” that have been confirmed by laboratory testing.     

d-dimer is a significant prognostic factor in patients with suspected infection and sepsis

Purpose

The aim of the study was to determine whether C-reactive protein (CRP), procalcitonin (PCT), and d-dimer (DD) are markers of mortality in patients admitted to the emergency department (ED) with suspected infection and sepsis.

Basic Procedures

We conducted a prospective cohort in a university hospital in Medellín, Colombia. Patients were admitted between August 1, 2007, and January 30, 2009. Clinical and demographic data and Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores as well as blood samples for CRP, PCT, and DD were collected within the first 24 hours of admission. Survival was determined on day 28 to establish its association with the proposed biomarkers using logistic regression and receiver operating characteristic curves.

Main Findings

We analyzed 684 patients. The median Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores were 10 (interquartile range [IQR], 6-15) and 2 (IQR, 1-4), respectively. The median CRP was 9.6 mg/dL (IQR, 3.5-20.4 mg/dL); PCT, 0.36 ng/mL (IQR, 0.1-3.7 ng/mL); and DD, 1612 ng/mL (IQR, 986-2801 ng/mL). The median DD in survivors was 1475 ng/mL (IQR, 955-2627 ng/mL) vs 2489 ng/mL (IQR, 1698-4573 ng/mL) in nonsurvivors (P = .0001). The discriminatory ability showed area under the curve–receiver operating characteristic for DD, 0.68; CRP, 0.55; and PCT, 0.59. After multivariate analysis, the only biomarker with a linear relation with mortality was DD, with an odds ratio of 2.07 (95% confidence interval, 0.93-4.62) for values more than 1180 and less than 2409 ng/mL and an odds ratio of 3.03 (95% confidence interval, 1.38-6.62) for values more than 2409 ng/mL.

Principal Conclusions

Our results suggest that high levels of DD are associated with 28-day mortality in patients with infection or sepsis identified in the emergency department.     

ED patient estimation of blood loss

Purpose

Emergency department (ED) patients frequently estimate blood loss. How such information should guide evaluation and management, however, is unclear. The objective of this study was to examine ED patient accuracy in estimating blood loss on different surfaces.

Methods

A convenience sample of 100 ED patients were asked to estimate the amount of moulage blood present in 4 scenarios: 178 mL spilled in a baking sheet on the floor; 5 mL in 2.5 mL of mucous in a tissue; 119 mL on a t-shirt; and 119 mL in a commode filled with water.

Results

The mean percent error for all estimates was 412% with a range of 0% to 1080%. Estimates were within 100% of the actual amount 44% of the time. Eleven percent of assessments were correct and 70% were overestimates.

Conclusion

Emergency department patients do not estimate blood loss well in a variety of scenarios, erring on the side of overestimation.     

The predictive characteristics of D-dimer testing in outpatients with suspected venous thromboembolism: a Bayesian approach

BACKGROUND: Despite the widespread use of quantitative methods to measure D-dimer, clinical decisions commonly are based only on binary test information (positive/negative). This study aimed to determine the significance of quantitative D-dimer results in the evaluation of venous thromboembolism (VTE) by means of a differentiated Bayesian approach. METHODS: Prospective study in 118 outpatients referred for workup of suspected pulmonary embolism (n = 75) or deep vein thrombosis (n = 43). The sensitivity and specificity of D-dimer results obtained by DD VIDAS (Biomerieux, France), STA Liatest (Diagnostica Stago, France), and D-dimer plus (Dade, US) were assessed for five different cut-offs. Further, predictive values and multilevel likelihood ratios were calculated in order to assess the operative test characteristics in excluding or confirming VTE. RESULTS: At a cut-off of 500 ng/ml and pretest probabilities < 47%, the VIDAS provides a negative predictive value (NPV) > 95%, whereas a positive predictive value (PPV) > 95% is obtained in patients with a D-dimer > 10,000 ng/ml and pretest probabilities > 50%. At a cut-off of 500 ng/ml and pretest probabilities < 33%, the Liatest exhibits a NPV > 95%, whereas a PPV > 95% is obtained in patients with a D-dimer >10,000 ng/ml and pretest probabilities > 37%. Finally, with the D-dimer plus, a NPV > 95% is seen at a cut-off of 150 ng/ml and pretest probabilities < 30%, whereas a PPV > 95% is obtained at a cut-off > 1000 ng/ml and pretest probabilities > 67%. CONCLUSIONS: D-dimer measurements in outpatients cannot only allow for exclusion but, in some situations, also for confirmation of venous thromboembolism. It is therefore advisable to conduct a quantitative interpretation of D-dimer results.     

The usefulness of the semiquantitative procalcitonin test kit as a guideline for starting antibiotic administration

Objectives

The Surviving Sepsis Campaign has recommended that antibiotic therapy should be started within the first hour of recognizing severe sepsis. Procalcitonin has recently been proposed as a biomarker of bacterial infection, although the quantitative procalcitonin assay is often time consuming, and it is not always available in many emergency departments (EDs). Our aim is to evaluate usefulness of the semiquantitative procalcitonin fast kit as a guideline for starting antibiotic administration for patients with severe sepsis or septic shock that requires prompt antibiotic therapy in the ED.

Methods

We include those patients who were admitted to the ED and who were suspected of having infection. The procalcitonin concentration was determined by semiquantitative PCT-Q strips, and the points of the severity scoring system were calculated. The receiver operating characteristic curve was used to assess the diagnostic value of the PCT-Q strips to predict severe sepsis or septic shock.

Results

Of the 80 recruited patients, 33 patients were categorized as having severe sepsis or septic shock according to the definition. At a procalcitonin cutoff level of 2 ng/mL or greater, the sensitivity of the PCT-Q for detecting severe sepsis or septic shock was 93.94% and the specificity was 87.23. The receiver operating characteristic curve for PCT-Q to predict severe sepsis or septic shock had an area under the curve of 0.916.

Conclusion

PCT-Q is probably a fast, useful method for detecting severe sepsis in the ED, and it can be used as a guideline for antibiotic treatment.     

Acute kidney injury risk in patients with ST-segment elevation myocardial infarction at presentation to the ED

Introduction

Acute kidney injury (AKI) is common in acute myocardial infarction (AMI) patients and has serious prognostic implications. The early identification of patients at risk of developing AKI at the emergency department (ED) can reduce its incidence.

Methods

Patients with ST-segment elevation myocardial infarction (STEMI) at the ED were included. Associated factors playing a role at ED presentation and during hospitalization were collected, and independent risk factors of developing AKI were assessed.

Results

Mean age among patients (n = 406, 69.7% male) was 62.5 ± 12.5 years. At ED admission, the mean glomerular filtration rate (GFR) was 70.5 ± 28.1 mL/min per 1.73 m², and 140 (34.5%) patients had a GFR < 60 mL/min per 1.73 m². Eighty-three patients (20.4%) developed AKI: 47 (11.6%) with stage 1, 26 (6.4%) with stage 2 and 10 (2.5%) with stage 3. Mortality was 11.8% and was higher in patients with AKI (34.9% vs 5.9%, P < .0001). Univariate analysis disclosed age, reduced GFR at presentation, severe Killip class, heart rate and longer door-to-needle time as risk factors to develop AKI. Moreover, these patients received less β-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in the ED. Multivariate analysis revealed that age, Killip class, heart rate, door-to-needle time, and β-blocker non-use were independent factors associated with AKI. These factors provided the ED physician with good accuracy in identifying patients at high risk of developing AKI.

Conclusion

Factors associated with AKI in STEMI patients allowed physicians to identify patients at high risk in the ED. Moreover, reduced door-to-needle time and β-blocker use were associated with renal protection in AMI patients.     

Diagnostic performance of initial salivary alpha-amylase activity for acute myocardial infarction in patients with acute chest pain

Background

To rule out acute myocardial infarction (AMI) in chest pain patients constitutes a diagnostic challenge to emergency department (ED) physicians.

Study Objectives

To evaluate the diagnostic value of measuring salivary alpha-amylase (sAA) activity for detecting AMI in patients presenting to the ED with acute chest pain.

Methods

sAA activity was measured in a prospective cohort of 473 consecutive adult patients within 4 h of onset of chest pain. Comparisons were made between patients with a final diagnosis of AMI and those with non-AMI. Univariate analysis and multiple logistic regression model were used to identify independent clinical predictors of AMI.

Results

Initial sAA activity in the AMI group (n = 85; 266 ± 127.6 U/mL) was significantly higher than in the non-AMI group (n = 388; 130 ± 92.8 U/mL, p < 0.001). sAA activity levels were also significantly higher in patients with ST elevation AMI (n = 53) compared to in those with non-ST elevation AMI (n = 32) (300 ± 141.1 vs. 210 ± 74.1 U/mL, p < 0.001). The area under the receiver operating characteristic curve of sAA activity for predicting AMI in patients with acute chest pain was 0.826 (95% confidence interval [CI] 0.782–0.869), with diagnostic odds ratio 10.87 (95% CI 6.16–19.18). With a best cutoff value of 197.7 U/mL, the sAA activity revealed moderate sensitivity and specificity as an independent predictor of AMI (78.8% and 74.5%).

Conclusions

High initial sAA activity is an independent predictor of AMI in patients presenting to the ED with chest pain.     

Hyperglycemia in ED patients with no history of diabetes

Introduction

The purpose of this study was to determine the prevalence of incidentally discovered hyperglycemia in patients with non–glucose-related complaints and to consider the potential care implications.

Methods

A retrospective chart review identified patients older than 18 years with obtained serum glucose levels. Patients with diabetic ketoacidosis were excluded. Three levels of hyperglycemia (≥126, ≥140, and ≥200 mg/dL) were considered.

Results

Of 2473 adult patients, 290 patients (11.7%) had serum glucose values greater than or equal to 126 mg/dL. There were 154 patients with hyperglycemia and no prior history of diabetes (6.2% of the emergency department [ED] population, 53.1% of those with hyperglycemia).

Conclusion

More than half of the patients found to be hyperglycemic had no known history of diabetes and were being seen for a non–glucose-related complaint. The reason for this prevalence and its impact on the health of these patients is unclear. Whether ED intervention would be helpful remains unanswered.     

The VIDAS D-dimer test for venous thromboembolism: a prospective surveillance study shows maintenance of sensitivity and specificity when used in normal clinical practice

Background

As a result of a number of clinical management studies, D-dimer (DD) tests such as VIDAS (BioMérieux Australia P/L-Sydney, NSW) have been recommended to reduce venous thromboembolism (VTE) investigations. Surveillance studies for new tests are recommended. We prospectively assessed VIDAS DD in normal practice.

Methods

Consecutive emergency patients and inpatients (IPs) with DD or VTE investigations were prospectively identified. Investigation results and early chart review including predefined factors reducing specificity were documented. A latex DD was also performed. Patients were followed for at least 3 months for recurrent VTE.

Results

Four hundred three patients (emergency, 64%; VTE-positive, 12%; 95% followed up) were analyzed. VIDAS sensitivity was 96% (95% confidence interval 86%-99%), specificity 38% (confidence interval, 34%-44%; negative likelihood ratio, 0.11), and emergency specificity 51%. Latex sensitivity was 76%. Cancer, trauma, recent operations, IP status, and advanced age were associated with markedly reduced specificity. Specificity in older emergency patients (>70 years old) and younger IPs (<70) without comorbidities was 20% to 30%, but sensitivity was maintained at 100%.

Conclusions

VIDAS DD probably maintains adequate sensitivity in normal clinical practice for low- or even intermediate-risk patients. Latex agglutination had poor sensitivity. Specificity is best in younger low-morbidity emergency patients. These findings need validation in larger multicenter surveillance studies.     

Resistance of Escherichia coli urinary isolates in ED-treated patients from a community hospital

Purpose

The purpose of this study is to provide resistance data for Escherichia coli isolates causing urinary tract infections in emergency department (ED) patients not requiring admission and explore if differences between this subpopulation and the hospital antibiogram exist. Differences between community-acquired urinary tract infection (CA-UTI) and health care–associated (HA-UTI) subgroups were also investigated.

Methods

Patients with a positive urine culture treated and discharged from the ED of a 200-bed community hospital were reviewed. Patients with urinary isolates of more than 100 000 colony-forming unit/mL and documented intention to treat were included. Patients who required admission, were pregnant, less than the age of 18 years, or who had a positive culture but without any evidence of intention to treat were excluded. Only the initial visit was included for patients who returned to the ED within 7 days.

Results

Overall, 308 visits were screened, and 217 were included. Of these, 78.3% were CA-UTI, and 21.7% were HA-UTI. Females comprised 88.5% of all patients. E coli was the most common pathogen overall and in both subgroups. E coli resistance to levofloxacin was 13.5% overall, 9.2% for CA-UTI, and 38.5% for HA-UTI compared with 27% on the hospital antibiogram. E coli resistance to sulfamethoxazole/trimethoprim was 26.9% overall, 25.2% for CA-UTI, and 34.6% for HA-UTI vs 26% on the antibiogram.

Conclusions

E coli susceptibility for ED patients not requiring admission may not be accurately represented by hospital antibiograms that contain culture data from various patient types, sites of infection, or patients with varying illness severity. Separation of the ED population into CA-UTI and HA-UTI subgroups may be helpful when selecting empiric antibiotic therapy.     

Incidence and risk factors for venous thromboembolism in patients with nonsurgical isolated lower limb injuries

Purpose

The aim of our study was to determine the incidence of venous thromboembolism (VTE) in patients with nonsurgical isolated lower limb injury and to determine the risk factors associated with the development of the condition.

Methods

This observational study was conducted in French hospital emergency departments (EDs). Patients older than 18 years presenting with nonsurgical isolated lower limb injury below the knee in the ED were included. Deep VTE was diagnosed with compression ultrasound. The final diagnosis of VTE was confirmed by an expert panel.

Results

Three thousand six hundred ninety-eight patients were included, and compression ultrasound examination was obtained in 2761 (75%) of them who were retained in the analysis. Deep venous thrombosis occurred in 177 patients and nonfatal pulmonary embolism in 1 patient. The incidence of VTE, mainly distal and asymptomatic, was 6.4% (95% confidence interval, 5.5%-7.4%). In a multivariate analysis, predictive variables of VTE were age of at least 50 years (odds ratio, 3.14; P < .0001), rigid immobilization (odds ratio, 2.70; P < .0001), no weight bearing (odds ratio, 4.11; P = .0015), and severe injury (odds ratio, 1.88; P = .0002). The discriminant analysis showed that age was the only variable independent of an antithrombotic prophylaxis associated with VTE.

Conclusion

The incidence of VTE was 6.4% in patients with nonsurgical lower limb injury. Rigid immobilization, recommendation not to bear weight, severe injury, and age of at least 50 years should be considered as risk factors for VTE. Emergency physicians should also take age into account when prescribing antithrombotic prophylaxis.     

Evaluation of mid-regional pro-atrial natriuretic peptide,procalcitonin, and mid-regional pro-adrenomedullin for the diagnosis and risk stratification of dyspneic ED patients

Objective

The aim of this study was to evaluate the diagnostic and the prognostic value of a laboratory panel consisting of mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) for patients presenting to the emergency department (ED) with acute dyspnea.

Methods

We prospectively enrolled ED patients who presented with a chief complaint of dyspnea and who had an uncertain diagnosis after physician evaluation. Final primary diagnosis of the cause of shortness of breath was confirmed through additional testing per physician discretion. We recorded inpatient admission and 30-day mortality rates.

Results

One hundred fifty-four patients were enrolled in the study. Congestive heart failure exacerbation was the final primary diagnosis in 42.2% of patients, while infectious etiology was diagnosed in 33.1% of patients. For the diagnosis of congestive heart failure exacerbation, MR-proANP had a sensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR−) of 0.16 and a positive likelihood ratio (LR+) of 1.44 (cut-off value: 120 pmol/L). For the diagnosis of an infectious etiology, PCT had a 96.5% specificity and 48.8% sensitivity (LR−: 0.58, LR+: 13.8, cutoff value: 0.25 ng/mL). As a prognostic indicator, MR-proADM demonstrated similar values: odds ratio for 30-day mortality was 8.5 (95% CI, 2.5-28.5, cutoff value: 1.5 nmol/L) and the area under the receiver operating characteristic curve in predicting mortality was 0.81 (95% CI, 0.71-0.91).

Conclusion

The good negative LR− of MR-proANP and the good positive LR+ of PCT may suggest a role for these markers in the early diagnosis of ED patients with dyspnea. Furthermore, MR-proADM may assist in risk stratification and prognosis in these patients..     

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.