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.     

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.     

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.     

The validity of 9 physical tests for full-thickness rotator cuff tears after primary anterior shoulder dislocation in ED patients

Purpose

This study was undertaken to validate the diagnostic values of 9 different physical tests in emergency department patients with primary anterior shoulder dislocation (PASD) to select the best screening test for full-thickness rotator cuff tear (FTRCT) after PASD.

Methods

A prospective analysis of 49 consecutive patients with x-ray-confirmed PASD was performed. All patients were followed at an average of 6.9 days (ranged from 4 to 10 days) in the emergency department. On the day of follow-up, 9 physical tests (namely, Jobe test, external rotation lag sign test, infraspinatus muscle strength test, dropping test, drop test, liftoff test, internal rotation lag sign test, belly-press test, and belly-off test) followed by shoulder ultrasound scan were performed to detect FTRCT.

Results

The prevalence of FTRCT after PASD is 37% (95% confidence interval [CI], 24%-52%). Fourteen percent of the patients with PASD were complicated with isolated supraspinatus tendon tear, whereas 22% were complicated with supraspinatus tendon tear combined with subscapularis and/or infraspinatus tendon tear. Jobe test has the highest sensitivity among the 9 physical tests being evaluated. The sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio for positive test, and likelihood ratio for negative test of Jobe test as a screening test for FTRCT after PASD are 89% (95% CI, 64%-98%), 55% (95% CI, 36%-72%), 53% (95% CI, 35%-71%), 89% (95% CI, 65%-98%), 1.97 (95% CI, 1.29-2.99), and 0.20 (95% CI, 0.05-0.79), respectively.

Conclusions

The prevalence of FTRCT after PASD is 37% (95% CI, 24%-52%). Jobe test has the highest sensitivity (89% CI, 64%-98%) among the tests.     

The accuracy of adult limb radiograph interpretation by emergency nurse practitioners: A prospective comparative study

Background

One of the extensions to practice for the emergency nurse practitioner role is to appropriately order and interpret radiographs in the emergency department.

Objective

The aim of the study was to compare the accuracy in interpreting isolated adult limb radiographs between emergency nurse practitioners and emergency physicians.

Design

A prospective comparative study was undertaken.

Setting

Emergency department in a large metropolitan hospital.

Participants

200 adult patients with isolated limb injuries were consented.

Methods

Six emergency nurse practitioners and ten emergency physicians participated. One emergency physician and emergency nurse practitioner independently clinically assessed each patient, determined the need for radiograph and separately recorded their interpretation of the radiograph as either definite fracture, no fracture or possible fracture. A single consultant radiologist reviewed each radiograph and their interpretation was seen as the gold standard. The sensitivity and specificity of emergency physicians and emergency nurse practitioners were calculated. To measure the level of agreement between the two-clinician groups, the weighted Kappa statistic was used.

Results

The sensitivity for the emergency nurse practitioners was 91% and 88% for the emergency physicians. The specificity for the emergency nurse practitioners was 85% and for the emergency physicians 91%. The weighted Kappa on the presence of a fracture between the emergency nurse practitioners and emergency physicians was 0.83.

Conclusions

This study validates the clinical and diagnostic skills of emergency nurse practitioners assessed in the interpretation of isolated adult limb injury radiographs.     

Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department

Background

Overuse of resources when evaluating pulmonary embolism (PE) is a concern if the D-dimer assay is improperly used in the evaluation of emergency department patients with suspected PE. The pulmonary embolism rule-out criteria (PERC) rule was derived to prevent unnecessary diagnostic testing in this patient population. The objective of this study was to assess the PERC rule's performance in an external population.

Methods

This was a secondary analysis of a prospectively collected database comparing PERC rule variables to diagnosis of PE in consecutive patients with suspicion for PE. Bivariate analysis on individual variables and the overall accuracy of the PERC rule were performed.

Results

Patients on 120 randomly assigned shifts were enrolled with a PE prevalence of 12%. The sensitivity, specificity, positive predictive, and negative predictive values of the PERC rule were 100% (95% confidence interval [CI], 79%-100%), 16% (95% CI, 10%-24%), 14% (95% CI, 8%-14%), and 100% (95% CI, 80%-100%), respectively, for the total patient population, and 100% (95% CI, 25%-100%), 33% (95% CI, 12%-35%), 2% (95% CI, 0%-11%), and 100% (95% CI, 75%-100%), respectively, for the low pretest probability population. Bivariate analysis showed unilateral leg swelling, recent surgery, and a history of venous thromboembolic event to be predictive of the diagnosis of PE.

Conclusions

The PERC rule may identify a cohort of patients with suspected PE for whom diagnostic testing beyond history and physical examination is not indicated.     

A pilot study of emergency medical technicians' field assessment of intoxicated patients' need for ED care

Objective

Alcohol–intoxicated individuals account for a significant proportion of emergency department care and may be eligible for care at alternative sobering facilities. This pilot study sought to examine intermediate-level emergency medical technician (EMT) ability to identify intoxicated individuals who may be eligible for diversion to an alternative sobering facility.

Methods

Intermediate-level EMTs in an urban fire department completed patient assessment surveys for individual intoxicated patients between May and August 2010. Corresponding patient medical records were retrospectively reviewed for diagnosis, disposition, and blood alcohol content. Statistical analysis was conducted to determine correlates of survey response, diagnosis, and disposition; and survey sensitivity and specificity were calculated.

Results

One hundred ninety-seven patient transports and medical records were analyzed. Emergency medical technicians indicated 139 patients (71%) needed hospital-based care, and 155 patients (79%) had a primary ethanol diagnosis. Fourteen patients (7%) were admitted to the hospital, and EMTs identified 93% of admitted patients as requiring hospital-based care. Overall sensitivity and specificity of the survey were 93% (95% confidence interval, 66.1-99.8) and 40% (95% confidence interval, 33.3-47.9), respectively.

Conclusion

Intermediate-level EMTs may be able to play an important role in facilitating triage of intoxicated patients to alternate sobering facilities.     

Urinalysis is not reliable to detect a urinary tract infection in febrile infants presenting to the ED

Objective

Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants.

Methods

A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38°C or if they were between 3 and 24 months of age and had a temperature of at least 39°C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives.

Results

Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%).

Conclusion

Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.     

Liver trauma diagnosis with contrast-enhanced ultrasound: interobserver variability between radiologist and emergency physician in an animal study

Objective

The purpose of our study was to evaluate interobserver variability between the radiologist and emergency physician in detecting blunt liver trauma by conventional and contrast-enhanced ultrasound (US) (CEUS).

Methods

We created 20 sites of blunt liver trauma in rabbits and performed conventional US and CEUS on the animals. A radiologist and an emergency physician independently evaluated the degree of liver trauma. Using contrast-enhanced computed tomography as a reference standard, the diagnostic performance of US and CEUS was calculated. Interobserver variability between radiologist and emergency physician was compared before and after contrast enhancement of US.

Results

Overall sensitivity and specificity for detecting liver trauma on conventional US, regardless of the degree of trauma, were 61.1% and 100% for the radiologist and 50% and 100% for the emergency physician. On CEUS, the sensitivity and specificity were 94.4% and 100% for both the radiologist and emergency physician. The interobserver agreement between emergency physician and radiologist increased from 0.867 to 0.955 after contrast enhancement on US.

Conclusions

Contrast-enhanced US may permit a more accurate diagnosis for liver trauma than conventional US by both the radiologist and emergency physician. Contrast-enhanced US may also reduce interobserver variability for this diagnosis.     

Diagnosing heart failure among acutely dyspneic patients with cardiac,inferior vena cava,and lung ultrasonography

Background

Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED.

Methods

This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results.

Results

One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92).

Conclusion

In this study, US was 100% specific for the dx of ADHF.     

The prognostic value of continuous amplitude-integrated electroencephalogram applied immediately after return of spontaneous circulation in therapeutic hypothermia-treated cardiac arrest patients

Introduction

The purpose of this study was to examine the prognostic value of continuous amplitude-integrated electroencephalogram (aEEG) applied immediately after return of spontaneous circulation (ROSC) in therapeutic hypothermia (TH)-treated cardiac arrest patients.

Methods

From September 2010 to August 2011, we prospectively studied comatose patients treated with TH after cardiac arrest who were monitored with aEEG. Monitoring at the forehead was applied as soon as possible after ROSC in the emergency department and continued until recovery of consciousness, death, or 72 h after ROSC. Neurological outcome was assessed with the Cerebral Performance Category (CPC) scale at hospital discharge, and good neurological outcome was defined as a CPC score of 1 or 2.

Results

A total of 55 TH-treated patients were included. Monitoring started at a median of 96 min after ROSC (interquartile range, 49–174). At discharge, 28 patients had a CPC of 1–2, and 27 patients had a CPC of 3–5. Seventeen patients had a continuous normal voltage (CNV) trace at the start of monitoring, and this voltage was strongly associated with a good outcome (16/17 [94.1%]; sensitivity and specificity of 57.1 and 96.3%, respectively). No development of a CNV trace within the recorded period accurately predicted a poor outcome (21/21 [100%]; sensitivity and specificity of 77.8 and 100%, respectively).

Conclusions

An initial CNV trace in aEEG applied to forehead immediately after ROSC is a good early predictor of a good outcome in TH-treated cardiac arrest patients. Conversely, no development of a CNV trace within 72 h is an accurate and reliable predictor of a poor outcome with a false-positive rate of 0%.     

Risk of venous thromboembolism in patients with borderline quantitative D-dimer levels

Objective

The lower threshold for D-dimer in evaluating patients with low clinical risk of venous thromboembolism (VTE) ranges from 200 to 500 ng/mL. We compared the rates of VTE in patients based on D-dimer values. We hypothesized that the rate of VTE in low-risk patients with D-dimer levels less than 500 would be less than 1%.

Methods

Study Design: This was a retrospective chart review: Setting: The study was performed in a academic, suburban emergency department (ED). Subjects: Emergency department patients with suspected VTE and D-dimer obtained were included in the study. D-dimer assay: The D-dimer assay is a quantitative instrumentation latex suspension of plasma specimens. Outcomes: Presence of VTE within 30 days of ED visit. Data Analysis: Assuming a 0% event rate in patients with D-dimer levels between 200 and 500 ng/mL, a sample of 450 patients would result in a 95% confidence interval upper limit of 0.6%.

Results

There were 1270 ED patients with suspected VTE in which D-dimer levels were performed between October 2005 and October 2006. Patient mean age was 47.8 ± 19.3 years; 63.2% were female, 78.2% were white. Of all D-dimer levels, 497 (39.1%) were less than 200 ng/mL, 479 (37.7%) were between 200 and 500 μg/mL, and 294 (23.1%) were greater than 500 ng/mL. There were no VTE events diagnosed in any of the patients with D-dimer levels less than 200 ng/mL. Four patients with D-dimer levels between 200 and 500 μg/mL had a pulmonary embolism on computed tomography angiography. Of these 4 patients, 3 had moderate clinical risk based on Well's criteria and one had a false-positive computed tomography. There were no cases of VTE in the remaining 475 patients (0%; 95% confidence interval 0%-0.6%).

Conclusion

The rate of confirmed VTE in low-risk patients with D-dimer levels between 200 and 500 ng/mL is very low. Low-risk patients with suspected VTE with D-dimer levels less than 500 ng/mL might not require additional testing.     

Urinalysis is an inadequate screen for rhabdomyolysis

Study Objectives

Hematuria by urine dipstick with absent red blood cells (RBCs) on microscopy is indicative of rhabdomyolysis. We determined the sensitivity of this classic urinalysis (UA) finding in the diagnosis of rhabdomyolysis.

Methods

We conducted a retrospective electronic medical record review of patients with a primary or secondary diagnosis of rhabdomyolysis with a creatine phosphokinase (CPK) greater than 1000 IU/L and a UA within the first 24 hours. Data were collected using a standardized data form, and a blinded panel of 3 emergency medicine physicians reviewed selected cases. Sensitivity and 95% confidence intervals (CIs) were calculated for detection of rhabdomyolysis by UA.

Results

During the study period, 1796 patients were diagnosed with rhabdomyolysis, of whom 228 met inclusion criteria. The mean peak CPK was 27 509 IU/L. One hundred ninety-five (86%) had a urine dip-positive for blood. However, only 94 patients (41%) had a positive urine dip and negative microscopic hematuria, resulting in a sensitivity of 41% (95% CI, 35%-47%). In a subset of 66 patients (29%) with more severe rhabdomyolysis (initial CPK, ≥ 10 000 IU/L; mean CPK, 53 365 IU/L), UA had a sensitivity of 55% (95% CI, 43%-67%). Broadening the definition of negative microscopy from 0 to 3 RBCs to less than 10 RBCs only increased the sensitivity to 79% (95% CI, 73%-83%).

Conclusions

The combination of a positive urine dip for blood and negative microscopy is an insensitive test for rhabdomyolysis, and the absence of this finding should not be used to exclude the diagnosis.     

Evaluation of a modified early goal-directed therapy protocol

Objectives

The study aimed to determine mortality in septic patients 2 years after introduction of a modified early goal-directed therapy (EGDT) protocol and to measure compliance with the protocol.

Design

This was an observational study of prospectively identified patients treated with EGDT in our emergency department (ED) from May 2007 through May 2008 and compared with retrospectively obtained data on patients treated before protocol implementation, from May 2004 to May 2005.

Setting

This study was conducted at a large tertiary-care suburban community hospital with more than 85?000 ED visits annually and 700 inpatient beds.

Patients

Patients with severe sepsis or septic shock were included in the study.

Interventions

A modified EGDT protocol was implemented.

Measurements and Main Results

A total of 216 patients were treated with our EGDT protocol, with 32.9% mortality (95% confidence interval [CI], 26.6%-39.2%); 183 patients (84.7%) had septic shock, with a mortality of 34.4% (95% CI, 28%-41%). Our control group of 205 patients had a 27.3% mortality (95% CI, 21.2%-33.5%), of which 123 had septic shock with a mortality of 43.1% (95% CI, 34%-52%). Early goal-directed therapy protocol compliance was as follows: 99% received adequate intravenous fluids, 99% had a central line, 98% had antibiotics in the first 6 hours, 28% had central oxygen saturation measured, 3.7% received dobutamine, and 19% were transfused blood.

Conclusions

Although we found a trend toward decreased mortality in patients with septic shock treated with EGDT, with an absolute difference of 8.7%, this difference was not statistically significant. Compliance with individual elements of the protocol was variable.     

New oral anticoagulants in the ED setting: a review

Background

Emergency department (ED) clinicians are not typically involved in the long-term management of patients' anticoagulation therapy, but they are responsible for decision making for emergency conditions requiring anticoagulation, such as acute venous thromboembolism (VTE). In addition, emergency physicians are often faced with patients who present first to the ED with conditions that may prompt long-term anticoagulation upon hospital discharge, such as atrial fibrillation (AF), or who have acute or potential bleeding complications from anticoagulation.

Objective

In this review, clinical trials of new oral anticoagulants evaluated for treatment of VTE and stroke prophylaxis in AF, as well as practical management aspects, will be discussed. In addition, clinical trials evaluating the adjunctive use of the new oral anticoagulants with antiplatelet therapy in patients who have experienced acute coronary syndrome will be explored.

Discussion

Both dabigatran etexilate and rivaroxaban have successfully completed phase III trials for acute VTE treatment and are currently approved for the reduction of risk of stroke and systemic embolism in patients with nonvalvular AF. In a recently completed phase III trial, apixaban also demonstrated promising efficacy and safety in that indication. Rivaroxaban represents the only new anticoagulant to date to have shown promising phase III results as an adjunct to antiplatelet therapy after acute coronary syndrome.

Conclusion

Knowledge of the appropriate clinical use and safety concerns of the new anticoagulants is imperative as they become more frequently prescribed, and their potential uses in the ED setting represent an important aspect of continuing education for emergency physicians.     

Application of San Francisco Syncope Rule in elderly ED patients

Objectives

The San Francisco Syncope Rule (SFSR) is a decision rule with the potential to identify patients at risk for serious outcomes within 7 days of the emergency department (ED) visit for syncope. The initial studies of the SFSR reported a high sensitivity and specificity for identifying patients, of all ages, with serious outcomes. Our objective was to determine if the SFSR can be safely and accurately applied to ED patients aged 65 and older with syncope or near-syncope.

Methods

A retrospective review of ED patients aged 65 years and older with syncope or near-syncope between January 2000 and August 2001 was performed. Charts were reviewed for evidence of SFSR risks for the ED visit and serious outcomes within 7 days of the ED visit.

Results

Of 773 subjects identified as having syncope or near-syncope, 517 subjects were included. There were 98 patients with serious outcomes. Twenty-three patients who were negative on SFSR had serious outcomes. The sensitivity and specificity of the SFSR were 76.5% (95% confidence interval [CI], 66.7%-84.3%) and 36.8% (95% CI, 32.2%-41.6%), respectively. The negative and positive predictive values were 87.0% (95% CI, 80.9%-91.4%) and 22.1% (95% CI, 17.8%-26.9%), respectively.

Conclusions

In our cohort of elderly ED patients, the SFSR had a lower sensitivity and specificity. The SFSR may not be applicable to the elderly ED population. Future prospective validation is necessary before application to the ED elderly population.     

Clinically manifest thromboembolic complications of femoral vein catheterization for continuous renal replacement therapy

Purpose

The safety of femoral vein (FV) catheterization for continuous renal replacement therapy is uncertain. We sought to determine the incidence of clinically manifest venous thromboembolism (VTE) in such patients.

Methods

We retrospectively studied patients with femoral high flow catheters (≥ 13F) (December 2005 to February 2011). Discharge diagnostic codes were independently screened for VTE. The incidence of VTE was also independently similarly assessed in a control cohort of patients ventilated for more than 2 days (January 2011 to December 2011) in the same intensive care unit (ICU).

Results

We studied 380 patients. Their mean age was 61 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation III score was 84; average duration of continuous renal replacement therapy was 74 hours, and 232 patients (61%) survived to hospital discharge with an average length of hospital stay of 22 days. Only 5 patients (1.3%) had clinically manifest VTE after FV catheterization. In the control cohort of 514 ICU patients, the incidence of VTE was 4.4% (P < .05 compared with FV group).

Conclusion

The incidence of clinically manifest VTE after FV catheterization with high flow catheters is low and lower to that seen in general ICU patients.     

Indications and performance of pelvic radiography in patients with blunt trauma

Objectives

The objectives of this study are to validate a set of clinical variables to identify patients with pelvic fractures and to determine the sensitivity of anteroposterior (AP) pelvic radiographs in patients with pelvic fractures.

Methods

We conducted a prospective observational cohort study of adults (>18 years) with blunt torso trauma evaluated with abdominal/pelvic computed tomography. Physicians providing care in the emergency department documented history and physical examination findings after initial evaluation. High-risk variables included any of the following: hypotension (systolic blood pressure <90 mm Hg), Glasgow Coma Scale score less than 14, pelvic bone tenderness, or instability. Pelvic fractures were present if the orthopedic faculty documented a fracture to the pubis, ilium, ischium, or sacrum.

Results

We enrolled 4737 patients, including 289 (6.1%; 95% confidence interval [CI], 5.4%-6.8%) with pelvic fractures. Of the 289 patients, 256 (88.6%; 95% CI, 84.3%-92.0%) had at least one of the high-risk variables identified. Initial plain AP radiographs identified 234 (81.0%; 95% CI, 76.0%-85.3%) of 289 patients with pelvic fractures. The high-risk variables identified all 87 patients (100%; 95% CI, 96.6%-100%) undergoing surgery, whereas plain AP pelvic radiography identified a fracture in 83 patients (95.4%; 95% CI, 88.6%-98.7%) undergoing surgery.

Conclusion

Previously identified high-risk variables for pelvic fracture identify most but not all patients with pelvic fractures. However, these high-risk variables identify all patients undergoing surgery and may be implemented as screening criteria for pelvic radiography. Anteroposterior pelvic radiographs fail to demonstrate a fracture in a substantial number of patients with pelvic fracture including patients who undergo surgery.     

Role of procalcitonin in the diagnosis of infective endocarditis: a meta-analysis

Background

Infective endocarditis (IE) is a diagnostic challenge. We aimed to systemically summarize the current evidence on the diagnostic value of procalcitonin (PCT) in identifying IE.

Methods

We searched EMBASE, MEDLINE, Cochrane database, and reference lists of relevant articles with no language restrictions through September 2012 and selected studies that reported the diagnostic performance of PCT alone or compare with other biomarkers to diagnose IE. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models.

Results

We found 6 qualifying studies that included 1006 episodes of suspected infection with 216 (21.5%) confirmed IE episodes from 5 countries. Bivariate pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios were 64% (95% confidence interval [CI], 52%-74%), 73% (95% CI 58%-84%), 2.35 (95% CI 1.40-3.95), and 0.50 (95% CI 0.35-0.70), respectively. Of the 5 studies examining C-reactive protein (CRP), the pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios were 75% (95% CI 62%-85%), 73% (95% CI 61%-82%), 2.81 (95% CI 1.70-4.65), and 0.34 (95% CI 0.19-0.60), respectively. The global measures of accuracy, area under the receiver operating characteristic curve (AUC) and diagnostic odds ratio (dOR), showed CRP (AUC 0.80, dOR 8.55) may have higher accuracy than PCT (AUC 0.71, dOR 4.67) in diagnosing IE.

Conclusions

Current evidence does not support the routine use of serum PCT or CRP to rule in or rule out IE in patients suspected to have IE.     

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED

Purposes

Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR).

Methods

Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS.

Results

In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis.

Conclusions

Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.