Background

Erythropoietin (EPO), a renal type I cytokine, plays key role in the regulation of erythropoiesis. EPO is also increased at the area of inflammation in addition to erythropoiesis and hypoxia showing an anti-inflammatory mechanism. EPO decreases releasing of proinflammatory factors such as TNFα, IL-6, IL-12/IL-23, reduce production of NO by inhibiting inducible NO synthase (iNOS), shows anti-inflammatory effect by reducing NF-κB dependent immunocytokines production, inhibits reactive oxygen species at neutrophils and changes activity of T cells indirectly by disruption of antigen presentation or affecting signal transmission of antigen presenting cells. EPO shows non-erythropoietic functions such as immunoregulatory effect in autoimmune diseases and tissue protective effect in trauma and ischemia.

Aim

We aimed that whether there is a significant difference between erythropoietin (EPO) levels in patients who were administrated to emergency department with urticaria, angioedema and anaphylaxis or not.

Method

Our study was conducted prospectively in ED during two years. Exclusion criteria: Patients who refused to participate, with previously known anemia, renal failure, liver disease, chronic obstructive pulmonary disease, asthma, any disease affecting bone marrow, and malignancies. Patients were classified as urticaria (just skin lesions), angioedema (skin and/or mucosa signs) and anaphylaxis (according to international anaphylaxis criteria). Blood levels of white blood cell (WBC), neutrophil (NEU), lymphocyte (LEN), eosynophil (EO), basophil (BAS), red blood cell (RBC), haemoglobine, haematocrit (HTC), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MHC), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), platelet, platelet distribution width (PDW), creatinine, blood urea nitrogen (BUN) were evaluated. Parameters related to erythropoietin as HTC/EPO, RDW/EPO, WBC/EPO, NEU/EPO, LEN/EPO, RBC/EPO, PLT/EPO, EO/EPO, BAS/EPO were calculated and compared.

Results

156 patients grouped as urticaria (n=62, 41.7%), angioedema (n=56, 35.9%), anaphylaxis (n=38, 24.4%) were included. Of 38 anaphylaxis patients, 65.8% had rash, 50% had itching, 13.2% had facial edema, 21.1% had periorbital edema, 34.2% had perioral edema, 18.4% had tongue edema, 84.2% had shortness of breath. There was no significant difference, in terms of erythropoietin and related parameters among urticaria (6.2±1.7 mlU/ml), angioedema (6.2±1.7 mlU/ml) and anaphylaxis (6.4±1.7 mlU/ml) patients (p=0.799). Erythropoietin levels were significantly higher in patients with uvula edema compared to patients without (6.0±1.7 vs. 6.5±1.6; p=0.027). HTC/EPO and RDW/EPO ratios were lower in patients who had rash than patients who had not (8.0±1.9 vs. 7.1±2.3; p=0.033 and 2.7±0.9 vs. 2.2±0.6, respectively; p=0.013). 

Discussion

EpoR expression in non-hematopoietic tissues is shown in previous studies. A study conducted on cutaneous mast cells of subjects with or without dermatologic diseases showed the presence of soluble EpoR in secretory granules. Other immune cells such as macrophages also can release EPO which activate mast cells in paracrine way to express EpoR. Considering the paracrine effect on mast cells, the tissue level of EPO may be high before blood levels elevated. The relationship of mast cells in different tissues and difference between tissue and blood levels of EPO need further studies.

Conclusion

Urticaria, angioedema, anaphylaxis cannot be differentiated via using levels of erythropoietin. However, uvula edema is correlated with higher erythropoietin levels.  

Background

The critical decision of whether to discharge or admit a patient to the hospital is often made at the hospital’s acute care department. More than half of the patients that present at our acute care department are discharged within 24 h and not admitted to the specialized wards of the hospital. Still, some of these patients are subsequently readmitted or may die. Therefore, improvement of the current methods to prognosticate and assess patient risk must be improved, in order to avoid discharge of high-risk patients.

In this study, we aimed to determine whether the prognostic biomarker: soluble urokinase plasminogen activator receptor (suPAR) was able to predict readmission and mortality in patients who are discharged from the acute care department within 24 h.

Methods

Between 18 November 2013 and 30 September 2015 20,193 patients were admitted to the acute medical department, Copenhagen University Hospital Hvidovre. Follow-up was carried out for 30 days via Danish national registries. suPAR measurements and registry data on diagnoses, vital status etc. were available for 17,262 patients. The Charlson score was calculated and used as a measure of comorbidity burden. Statistical analysis was carried out using Kruskal-Wallis test and multiple Cox regression analysis.

Results

A total of 9623 patients (4459 men and 5164 women) were discharged within 24 h. Median suPAR was 2.3 ng/ml (Interquartile range (IQR) 1.7-3.2) for patients discharged within 24 h, compared with 3.7 ng/ml (IQR 2.5-5.5, P<0.0001) for patients with in-hospital stays longer than 24 h. Median age for patients discharged within 24 h was 52.1 years (IQR 36.0-68.4) and 71.2 years (IQR 57.0-82.0, P<0.0001) for patients with longer admissions.

Among patients who were discharged within 24 h, 174 patients (1.8%) died and 1262 patients (13.1%) were readmitted during 30-day follow-up. In comparison, 685 patients (9.0%) died and 1639 (21.5%) were readmitted among patients with in-hospital stays longer than 24 h.

For patients discharged within 24 h, the median suPAR level among those who survived and were not readmitted during follow-up (n=8230) was 2.2 ng/ml (IQR 1.7-3.1). Patients who were readmitted had a slightly elevated suPAR level of 2.8 ng/ml (IQR 2.0-4.0, P<0.0001), and those who died had a median suPAR of 6.9 ng/ml (IQR 4.3-9.7, P<0.0001).

In multiple Cox regression analyses of log2-transformed suPAR values adjusted for age, sex, Charlson score, and C-reactive protein, the HRs for 30-day mortality and readmission were 2.90 (95% confidence interval (CI) 2.25-3.75) and 1.43 (95% CI 1.33-1.53), respectively, for patients discharged within 24 h. For patients with in-hospital stays longer than 24 h, the HRs were 2.06 (95% CI 1.86-2.28, P 0.0002) for 30-day mortality and 1.21 (95% CI 1.14-1.29, P 0.01) for 30-day readmission.

Conclusion

Patients with short admissions (<24 h) had lower suPAR levels as well as 30-day readmission and mortality rates, however, among these patients, a high suPAR level was associated with an increased risk of readmission and mortality compared with patients with in-hospital stays longer than 24 h.

Background: Risk stratification with systematic triage plays a pivotal role in the emergency setting, ensuring that acutely sick patients are cared for first and observed closest. Current triage algorithms serve as risk stratification tools in many emergency departments (ED) and are all based on a combination of the patients’ vital parameters and primary symptoms. Several retrospective studies have identified biomarkers that contain prognostic information, which goes beyond the current triage utilized, and these studies suggests biomarkers as supplement to triage to improve risk stratification. Identifying patients at high and low risk shortly after admission can guide clinical decision-making towards the patients in need, regarding treatment, observation, and allocation of resources. 

Whether the implementation of a prognostic biomarker in initial risk stratification of acutely admitted patients translates into better management and treatment and actually decreases mortality, morbidity, admissions or readmissions has yet to be shown.

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker with potential use in the EDs, as several studies have found it to be an independent predictor of 30-day mortality and adverse outcomes such as readmission, admission to ICU, and longer length of stay. The suPAR blood level reflects immune activation, and it is strongly associated with presence, prognosis, and severity of a broad variety of acute and chronic diseases, as well as being a predictor of disease development in the general population. Although unspecific, suPAR might be an ideal biomarker for risk stratification of unselected patients. 

Study hypothesis: The main hypothesis is that the introduction, fast measurement, and immediate reporting of the suPAR level to the attending physicians in the EDs will enhance risk stratification and be associated with an absolute risk reduction in all-cause mortality at 10 months after inclusion by 1.5%.  The suPAR level can draw attention towards patients with an unrecognized high risk, leading to improved diagnosis and treatment.

Method: The study is designed as an open cross-over cluster-randomized interventional multicenter trial. suPAR is included in the routine blood work of all eligible patients admitted acutely during the interventional period, measured within 2 hours after admission, and immediately reported to the treating physicians in the ED. Prior to the inclusion period, these physicians are educated in the prognostic capabilities of suPAR.

Results: The inclusion period began January 11^th 2016 and ends June 6^th 2016.  The study aims to include 10.000 patients in both the interventional and control arm. Results regarding the primary outcome are expected to be presented in 2017. 

Conclusion: The present abstract describes the design and rationale of the TRIAGE III trial. If our hypothesis is confirmed, strong considerations should be given towards standardizing prognostic biomarkers as routine blood work in relation to early risk stratification in the ED. The TRIAGE III trial has the potential to investigate the concept: Having prognostic information can change the patients prognosis. This concept is central in triage and several other clinical situations, and the study might therefore have a central impact on future clinical organizing and decision-making.

Background: The demand for emergency department (ED) care and non-elective hospital admissions exhibit “natural” variability and do not vary significantly by day of the week. In contrast, the elective surgical schedule is subject to “artificial” variability and is created, in large part, for the convenience of physicians. Consequently, the majority of patients requiring elective surgical procedures are admitted on Mondays and the procedures are subsequently performed on Tuesdays, Wednesdays and Thursdays. Many of these patients occupy a hospital bed post-operatively. We examined the effect of “smoothing” or balancing the elective surgical schedule over the five weekdays on ED length of stay as a surrogate marker of ED crowding. Previous literature has demonstrated that each additional elective surgical case can prolong the mean length of stay per ED patient because of competition for in-patient beds.

Methods: The Division of Vascular Surgery was asked to each limit the number of elective surgical cases to no more than two per day. Based on previous experience, two cases per day for five days exceeded the number that the vascular surgeons typically performed in a week. Agreement with this new paradigm was accomplished by assuring surgeons that they would be able to perform all elective cases in timely fashion and that no case would be turned away. A similar plan was developed for the Department of Thoracic Surgery. After implementation, the need for in-patient beds for elective surgical cases was measured for both services. The number of direct nursing hours on the floors that received these post-operative patients was measured since the demand for nursing staffing was expected to become more predictable. Finally, the time from ED decision to admit to actual departure to the floor, and, total length of stay for admitted ED patients were measured.

Results: The interventions were successful in limiting the number of elective vascular and thoracic surgical cases requiring in-patient beds to the maximum of two cases per day per service. The number of direct nursing hours decreased by over 6% from 8.66 hours per patient day to 8.16 after “smoothing” of the surgical schedule. This resulting in a savings of several hundreds of thousands of dollars because of more predictable nursing scheduling and fewer overtime payments. The time from ED presentation to decision to admit did not change; but, the time from decision to admit to departure for the floor for admitted patients decreased by a mean of 30 minutes (19%) per patient from 162 to 132 minutes. As a result, the total ED length of stay for admitted patients decreased by a mean of 30 minutes.

Conclusion: “Smoothing” the elective surgical schedule can result in lowering costs for overtime pay on the nursing floors that receive these patient postoperatively. Moreover, by reducing “artificial” variability in surgical scheduling we were able to reduce the total length of stay for patients admitted from the ED by a mean of 30 minutes.

Background: The percentage of patients who leave without being seen (LWBS) by a physician is commonly used as a surrogate marker of ED crowding. In December 2012, a new ED opened at Baystate Medical Center in Springfield, Massachusetts. The new ED had 94 licensed beds, four separate Pods and three times the area (72,000 sq. ft.) of the old facility. The demand for ED care grew quickly from a baseline of 265 patients “seen” per day (96,725 per year). The percentage of patients who LWBS quickly became a priority because of a very high daily rate of 8.2% the first month. Nursing leadership on duty was responsible for managing patient flow, but was loosely organized and determined on an ad hoc daily basis.

 Methods: With the goals of improving efficiency, reducing the percentage of patients who LWBS and increasing the number of patients “seen” per day, nursing leadership roles were assigned to selected individuals with demonstrated management skills. Physician staffing was not added. The Charge Nurse was responsible for coordinating care throughout the ED and was responsible for all four Pods. This individual managed current resources and requested additional personnel and equipment when necessary. The Charge Nurse also coordinated the transfer of admitted patients to appropriate in-patient settings and initiated a call for assistance from in-patient services when the boarding of these patients exceeded certain benchmarks. The Flow Coordinator accepted transfers from other facilities and notification of patient arrivals from primary care and specialist physicians. Reports from Emergency Medical Services regarding in-coming traffic were also accepted by the Flow Coordinator. The Pod Lead Nurse assumed the coordination of care within each Pod for every shift. “Direct bedding” of new patients into open ED bays was the became the standard while bypassing the Waiting Room altogether after triage. Measures were calculated over a 3-year period as the mean per week of daily outcomes. The number of patients actually “seen” was approximately normally distributed; therefore, simple linear regression was used for analysis. Total walkouts as a percentage of total volume was analyzed using fractional logistic regression, since the dependent variable was a proportion ranging between 0 and 1.  All analyses were conducted in Stata (version 14.0, StataCorp, Colleg Station, TX).  A critical test level of 5% was considered statistically significant.

 Results: The percentage of patients who LWBS declined steadily over time with a negative trend line reaching 4.5% in December 2015. This was a 45% decrease in three years. The number of patients “seen” rose steadily with a positive trend line to a mean of 316 per day (115,340 per year) in the same timeframe. This represented a 19% increase despite no increase in physicians staffing. The regression lines for both measures were significant at P< 0.001.

 Conclusion: Measures of ED efficiency include the percentage of patients who LWBS and the number of patients “seen” on a daily basis. These outcomes can be improved significantly with a dedicated nursing management structure that is clearly focused on efficiency without adding physician staffing.

Background:

The management in acute coronary syndrome (ACS) is influenced by risk assessment. The Global Registry of Acute Coronary Events (GRACE) and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines (CRUSADE) scores are among the most frequently used risk assessment tools. A recently published study on 1,587 patients suggested a clear superiority of the GRACE vs. the CRUSADE score to predict in-hospital mortality and major bleeding. These results were noted controversially in the scientific community.  

Objectives:

We aimed to assess the performance of the GRACE and CRUSADE risk scores to predict in-hospital mortality and major bleeding in a contemporary ACS population at a high-volume centre.

Methods:

All patients treated for ACS from January 1, 2006 to December 31, 2015 at our tertiary care centre were prospectively included in our registry. Demographic and clinical characteristics as well as details on diagnostic findings and therapy were collected according to the Cardiology Audit and Registration Data Standards (CARDS) of the European Society of Cardiology. GRACE and CRUSADE risk scores were calculated. The discrimination capacity of both scores for in-hospital mortality and major bleeding were compared using receiver operating characteristic curves and the method suggested by DeLong et al.

Results:

In total 4,087 patients (874 (21.4%) female; age 62±14 years) were included, 2218 (54.3%) were diagnosed with ST-elevation myocardial infarction (STEMI), 2973 (72.7%) underwent acute percoutaneous coronary intervention (PCI), 92 (2.3%) received thrombolytic therapy, 113 (2.8%) died, and major bleeding occurred in 65 (1.6%).  Based on GRACE risk categories 1,031 patients (25.2%) had low risk, 1,401 patients (34.3%) had intermediate risk, and 1,655 patients (40.5%) had high risk. Risk based on CRUSADE categories was very low/low in 1,505 patients (36.8%), moderate in 924 patients (22.6%), and high/very high risk in 1,658 patients (40.6%). Discrimination capacity for in-hospital mortality of the GRACE score was superior to the CRUSADE score (area under the curve (AUC) 0.91 (95% CI 0.89 - 0.93) vs. 0.83 (95% CI 0.80-0.86); p<0.05). Performance for major bleeding was poor for both scores (AUC 0.71 (0.65-0.76) for GRACE vs. 0.61 (0.55-0.68) for CRUSADE; ns).

Conclusion:

Our findings support a superiority of the GRACE over the CRUSADE score to predict in-hospital mortality. Major bleeding is rare in the era of primary PCI and performance of both scores to predict it was poor, however there was a trend towards superiority of the GRACE score for this outcome, too.

Introduction

Chest pain is a frequent complaint at the emergency department (ED). It is often difficult to differentiate between an acute coronary syndrome (ACS) and other causes of chest pain. The HEART score is a validated risk score for all patients with chest pain at the ED.

Troponin is one of the key elements of the HEART score. Currently other biomarkers are known to rise early in case of an ACS, such as copeptin and fatty acid binding protein (FABP). We investigated if the accuracy of the HEART score increases by adding copeptin and FABP to the HEART score.

Study design

In 586 patients with chest pain we collected all elements of the HEART score plus copeptin and FABP on arrival at the ED.

We compared the discriminative performances (c-statistic) of the original HEART score vs the HEART score plus copeptin or FABP for the occurrence of Major Adverse Cardiac Events (MACE).

Results

In total 164 patients (28.96 %) reached at least one MACE within six weeks (140 AMI, 88 PCI, 15 CABG, one death). The event rate in patients with a HEART score of zero to three was 0.6%. The c-statistics for MACE were: HEART 0.877, HEART+copeptin 0.877 (p=0.868), HEART+FABP 0.886 (p=0.032).

Conclusions

In this study the addition of copeptin does not improve the HEART score. The addition of FABP slightly improves the discriminating performance of the HEART score in chest pain patients. Adding FABP to the HEART score could improve the rule out of ACS at the ED.

Introduction:

Hemorrhagic complications were associated with short-term mortality in patients with acute coronary syndrome without ST elevation (NSTEMI). The CRUSADE score (Circulation 2009) was used to assess the short-term mortality. But its predictive value for the midterm mortality has been poorly studied.

Objective: We propose to determine the predictive value of the 6 month mortality CRUSADE score for NSTEMI patients seen in the emergency department (ED).

Materials and methods:

A prospective observational study was conducted over two years. Patients with NSTEMI diagnosis was made. Anamnestic, clinical, electrocardiographic, biological and therapeutic criteria were collected. The CRUSADE score was calculated. The prognosis was based on the 6-month mortality. Multivariate analysis by multiple logistic regression was performed.

Results:

Three hundred and ninety patients were included. Mean age 61 + -11 years. Sex ratio to 1.34. Comorbidities N (%): HTA 235 (60), Diabetes 208 (53), dyslipidemia 112 (29), tobacco 101 (26), Coronary Artery Disease 112 (31). Overall mortality at 6 months was 5%. The mean CRUSADE score was higher in the non survivors patients comparing to the survivors: 45± 11 vs 27 ±11 respectively, P <0.001.  The CRUSADE score was predictive of 6 months mortality with a cut-off at 45 with an area under the curve at 0.82, 95% CI [0.74 to 0.90]. Sensitivity = 53%, specificity = 86%, Liklehood ratio (LR) += 3.78, LR- = 0.54.

Conclusion:

Hemorrhagic complications have a major impact on the short and midterm mortality prognosis of NSTEMI patients. Including the CRUSADE score in the management and risk stratification of NSTEMI patients could reduce the midterm mortality.

Introduction:

Dyspnea is a common pattern to seek care in the emergency department (ED). Distinguish cardiac or respiratory origin is a diagnostic challenge for the emergency physicians especially with patients with several comorbidities and intricate clinical presentation.

NT-proBNP is a specific marker of acute heart failure, however, its usefulness in the diagnostic approach of acute dyspnea remains controversial which may  lead us to resort to a echocardigraphy.

Material and methods

Descriptive prospective observational study. Were included all patients who presented to the ED with acute dyspnea and whose etiology remains unclear. Patients with renal impairment have not been included (false positives of NT-pro BNP).

The diagnosis of heart failure was excluded if the NT-proBNP rate was inferior than 300 pg per ml, made if the NT-proBNP was superior than 1800 pg per ml and doubtful if the NT-proBNP rate was between 300 and 1800pg per ml. the rate of NT-pro BNP was adjusted to the patient's age by the standards of the laboratory.

Results:

During one year, 126 patients were included. The mean age was 62 ± 20 years. The sex ratio was 2.33.

The dosage of NT proBNP has laid the diagnosis of acute heart failure in 70% of cases, revealed the respiratory origin of dyspnea in 18% of cases (negative NT-proBNP). In 12% of the remaining cases, we used the transthoracic echocardiography to seek the etiological diagnosis of acute dyspnea.

Conclusion:

The dosage of NT-proBNP has laid the etiological diagnosis of dyspnea in 88% of cases. Through this study we find that the determination of NT-proBNP for any acute dyspnea of uncertain etiology may be useful. The recourse to echocardiography occurred only in 12% of cases

Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) require frequent hospitalization, may necessitate mechanical ventilation (MV) and are associated with a remarkable in-hospital mortality. The BAP-65 score is based on information easily available (elevated blood urea nitrogen [BUN], altered mental status, pulse > 109 beats/min, age > 65 years), and may serve clinicians as a simple risk-stratification tool. We aimed to describe the characteristics of patients attending EDs for an AECOPD, the management of events and the final outcome. We further validated the BAP-65 ability to predict in-hospital death or the need for mechanical ventilation (MV) in a large cohort of AECOPD patients admitted to the ED.

Methods We report the preliminary results of a retrospective analysis of data from 13 Italian EDs in a 12-month period (January-December 2014). Patients aged ≥ 40 years presenting to the ED with either a principal diagnosis of AECOPD or acute respiratory failure with a secondary diagnosis of AECOPD were included in the study. Information on patient demographics, clinical characteristics, including chronic COPD-related treatment, comorbidity burden according to the Charlson Comorbidity Index (CCI), presenting symptoms, BUN level, and ED management was collected. Disposition following ED admission was retrieved. In-hospital mortality or the need for MV served as composite primary outcome. Association between a BAP-65 and the occurrence of composite outcome was investigated through univariate and multivariate logistic regression. We assessed the discrimination of BAP-65 via the area under the receiver operating characteristic curve (AUROC) and the prognostic performance of a BAP-65 score ≥ 4 for the primary outcome.

Results A total of 2098 patients were included in the study; 789 (37.6%) were female, mean age was 74±15 years. Comorbidity burden was low (CCI 0) in 623 (29.7%) cases, moderate (CCI 1-2) in 909 (43.3%), and severe (CCI ≥3) in 566 (26.9%) patients. Almost half cases (n = 1100, 52.7%) required the intervention of the emergency ambulance services. Following the ED visit, 621 cases (29.6%) were sent home; 153 cases (7.3%) received a short-term observation; 1172 (55.9%) were admitted to hospital wards. In-hospital death occurred in 74 patients (3.5%), MV was deemed necessary in 27 (1.3%) cases. Five centres (680 patients) were not able to provide data on BUN and were excluded from the validation analysis. A total of 273 (19.2%) patients had a BAP-65 score ≥ 4. The multivariable analysis showed a significant association between the BAP-65 score and the primary outcome (OR 1.65, 95% CI 1.08-2.53). The AUROC for BAP-65 was 0.67 (95 % CI 0.60-0.75). The sensitivity of BAP-65 score ≥ 4 to predict the composite outcome was 92.5% (95% CI 91.1-93.8), the specificity was 21.6% (95% CI 19.5-23.8)., the positive predictive value was 4.4% (95% CI 3.3-5.4), and the negative predictive value was 98.7 (95% CI 98.1-99.3).

Conclusion: We confirmed BAP-65 score to have high sensitivity and negative predictive value for short-term mortality or use of MV in patients with AECOPD. Our findings suggest that it can be safely used as triage instrument at ED to identify low risk patients.

Background

The original Manchester Acute Coronary Syndromes decision aid (MACS) is a computer-based model that ‘rules in’ and ‘out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as T-MACS, cutting down the biomarkers to just hs-cTnT. Our primary objective was therefore to return to the derivation of the original MACS model but using hs-cTnT as the only biomarker (T-MACS), and then to evaluate the model in three separate external cohort studies. A secondary objective was to compare the predictive characteristics of TMACS to MACS and to the alternative ‘LoD strategy’, by which ACS is excluded in patients with a hs-cTnT concentration below the limit of detection (LoD) of the assay and no ECG ischaemia.

Methods

We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the Emergency Department (ED) with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularization within 30 days. AMI was adjudicated based on reference standard troponin testing (12h after symptom onset or 6h after arrival) with reference to the third universal definition of myocardial infarction. T-MACS was built by logistic regression in one cohort (derivation set) and validated in three external cohorts (validation set).

Results

In the derivation set (n=703), T-MACS could ‘rule out’ 37.7% patients with 99.3% (95% CI 97.3– 99.9%) negative predictive value (NPV) and 98.7% (95.3–99.8%) sensitivity for ACS. In the validation set (n=1,459), T-MACS could ‘rule out’ 40.4% (n=590) patients with 99.3% (98.3–99.8%) NPV and 98.1% (95.2–99.5%) sensitivity. T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs. MACS 0.90 on validation).

In the validation set, original MACS had 100.0% sensitivity, which was not significantly different to T-MACS (absolute difference 1.6%, 95% CI -0.7 to 1.6%, p=0.25) but T-MACS had greater specificity (absolute difference 25.9%, 95% CI 35.3 - 25.9%, p<0.0001) meaning that T-MACS would avoid more hospital admissions. T-MACS had identical sensitivity to the 'LoD strategy' (absolute difference 0.0%, 95% CI -2.2 to 2.2%, p=1.00) but T-MACS had greater specificity (absolute difference 9.8%, 95% CI 6.7 to 12.7%, p<0.0001). Thus, T-MACS would have 'ruled out' ACS in 40.4% patients (n=590) compared to 32.1% (n=468) for the LoD strategy. 

Conclusions

T-MACS could ‘rule out’ ACS in 40% of patients while ‘ruling in’ 5% at highest risk using a single hscTnT measurement on arrival. It has similar sensitivity to the original MACS decision aid and the LoD strategy but greater specificity than both. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources. 

Background

Observational research, including two external validation studies, shows that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes following a single blood test in the Emergency Department (ED). MACS is a computer model that uses a combination of clinical features and two biomarkers (high sensitivity cardiac troponin T and heart-type fatty acid binding protein) to estimate the probability that a patient has an acute coronary syndrome (ACS) and stratify patients into four groups. Patients in the 'very low risk' group could be immediately discharged from hospital in the appropriate clinical circumstances. 

We aimed to evaluate the impact of using the MACS rule in practice. Anticipating a modest effect size that would require a large trial, our objectives were two-fold: (a) to evaluate the feasibility of running a multi-centre randomised controlled trial (RCT) to compare use of the MACS rule to standard practice; and (b) to assess, in patients presenting to the ED with possible acute coronary syndromes, whether use of the MACS rule can increase the proportion of patients safely discharged within 4 hours, compared with contemporary clinical pathways.

Methods

In a pragmatic pilot RCT, consenting patients presenting to two EDs with suspected cardiac chest pain were randomised, stratified by trial centre and MACS risk group in a 1:1 ratio, to receive care guided by the MACS decision rule (intervention group) or standard care according to contemporary guidelines (controls). The primary efficacy outcome was successful discharge from the ED, defined as a decision to discharge within 4h of arrival providing that the patient did not have a missed AMI or develop a major adverse cardiac event (MACE: death, acute myocardial infarction or coronary revascularization) within 30 days. Feasibility outcomes included recruitment and attrition rates, patient satisfaction and acceptability of the MACS decision rule to clinicians.

Results

In total 138 patients were included across 22 weeks, of whom 131 (95%) were randomised (66 in the intervention group and 65 controls). All 131 patients completed 30-day follow up and were included in the final analysis. Seventeen (26%) patients in the intervention group were successfully discharged within 4h compared to 5 (8%) controls (odds ratio 5.5, 95% CI 1.7-17.1, p=0.004). No patients in either group who were discharged within 4h developed MACE. There were no significant differences in patient satisfaction between groups. Clinicians gave a median acceptability score of 5.1/6 indicating high overall acceptability.

Conclusions

In this pilot trial, the MACS rule led to a significant reduction in safe discharges from the ED when used in practice. We have demonstrated the feasibility of a larger trial, which would provide greater statistical power for safety outcomes.

Background: The presence of ST- segment depression (STD) on the admission electrocardiogram (ECG) has been well recognized to be a powerful adverse prognosticator [1].Several clinical trial investigations have further suggested that more extensive STD on admission predicts a greater risk of adverse cardiovascular events [2].

Purpose:The aim of this study was to examine the relationship between the magnitude of STD and adverse events: angina recurrence, myocardial infarction (MI) and death at 30 days.

Methods: A prospective observational study conducted in the emergency department (ED). We enrolled patients aged more than 18 years, presenting to the hospital alive with presumptive diagnosis of ACS and STD on the admission ECG.STD was considered to be present if ≥ 1leads exhibited STD ≥ 0, 05 mV. Three groups were defined according to quantitative ST depression : GP1 < 1 mm, GP2 = 1 - 2 mm , GP3 ≥ 2 mm. Patients with incomplete ECG, left bundle branch block, right bundle branch block, ventricular pacemakers were excluded from the analysis.

Results: Eighty one patients were included, mean age= 61± 11 years, 60%were male. Patients history (%): Smoker (47), hypertension (49), diabetes mellitus (59), hyperlipidemia(10), previous MI(35), heart failure (8%), Previous coronary intervention (18), previous coronary bypass surgery (6). The troponin I was positive in 52 patients. Among patients exhibiting STD on admission we individualized: GP1 (N=37), GP2 (N=33), GP3 (N=11).The magnitude of STD has a significant interaction for all outcomes (P-values for interaction): angina recurrence (0,012), MI (0,002), 30 days mortality (0,003).

Conclusion: Although the presence of STD has been incorporated as an independent dichotomous prognosticator into several trials, the magnitude of STD confers adverse prognosis in patients with NSTEMI-ACS and should be employed to assist medical decision making.

References:

[1] Kaul et al. J Am Coll Cardiol 2001; 38:64-71.

[2] Raymond Tet al. Eur Heart J 2010; 31:958-966

Introduction :

Thrombolytic therapy of acute coronary syndromes with ST segment elevation (STEMI) helped ahieve better outcome especially in hospitals without cath-lab department .

Objetive :

 The purpose of this study was to identify patient characteristics that are a priori predictors of early infarct related artery patency following thrombolytic therapy in patients presenting to the emergency department (ED) with STEMI.

Materiel and method:

Prospective study over a period of 5 years. Were included all the patients admitted to the emergency department with STEMI within less than 12 hours, which were thrombolysed and for whom the results of coronary angiography was collected. Anamnestic, clinical features, treatment and outcome characteristic were collected. The success of lysis was defined by a TIMI III coronary flow.

Results:

During a period of 5 years, 193 patients were included, mean age  58 +/- 11 years, the sex ratio was 6.4. Comorbidities: N (%) : history of smoking 153 (79), Diabetes 63 (32), hypertension 60 (31), dyslipidemia 23 (12%), coronaropathy  8 (4%). The mean time of ED visit was 179 +/- 158 min, with a mean first-time medical thrombolysis contact 32 min +/- 22, and a mean hospital stay of 231 minutes (+/- 325).

In univariate analysis, time of visit to the ED, SBP, history of smoking, diabetes and inferior infraction were identified as predictive factors of success.

In multivariate analysis, only the inferior infraction was identified as predictor of thrombolysis success with OR 1.4, 95% CI [1.04 to 1.89], p = 0.02.

Conclusion :

STEMI in the lower territory have better outcomes after thrombolysis in the ED.

Introduction: The prognosis for patients with an acute coronary syndrome with ST segment elevation (STEMI) is determined by the reperfusion time period. The presence of an intermediary, such as a general practitioner (GP) or cardiologist before the call to the prehospital Emergency Medical Services could help extend these time periods.

Goal: To evaluate patient handling times and the rate of reperfusion decisions by origin of the call to theprehospital Emergency Medical Services.

Methods: Data was retrieved from a regional register of 8 prehospital Emergency Medical Services and 39 medical intensive care units (MICU). Inclusion criteria: patients with a STEMI of less than 24 hours. Exclusion criteria: secondary transfer. Judgement criteria: period between pain and patient handling by MICU and the rate of reperfusion decisions.

Results: 9,858 patients with STEMI were included from 2009 to 2014. The prehospital Emergency Medical Services were called in 6,457 (65%) of the cases by the patient, relative or friend, in 1,209 (12%) of the cases by a GP/cardiologist, in 1,810 (18%) of the cases by firefighters and in 382 (4%) of the cases by other callers. Consistent breakdown over the period was studied. The average period between pain and patient handling was significantly prolonged if the call was from a GP/cardiologist (versus a call by the patient or firefighters) (181 [79-437] minutes versus 50 [20-130] minutes; p <0.0001). By comparison, people using a medical intermediary before calling the prehospital Emergency Medical Services were significantly older (64.2 [53.8 to 76.5] against 60.2 [51.8 to 72.2]), more likely to be women (29.2% against 20.4%), were less typical syndrome (83.7% against 88.5%), had less medical history (90.3% against 92.3%) and had fewer unblocking decisions (89.2% against 95.9%). The main prognosis was not significantly different (3.9% against 4.5%; p = 0.4).

Conclusion: The delay before patient handling was significantly extended if there was an intermediary, GP or cardiologist. These patients, who were older and more often women, with less medical history and more unusual pain, encountered lower rates of reperfusion decisions.

Background

In most cases in which venous thromboembolism (VTE) is developed in the outpatient setting, the Emergency Departments (EDs) is where the disease is actually diagnosed. Surprisingly, however, few studies have analyzed the characteristics of patients with VTE and the disease itself from the perspective of the ED.  This is relevant for several reasons. Firstly, little is known about the epidemiology of VTE in the ED and the risk factors most frequently presented by patients diagnosed with an episode of VTE in the ED. Secondly, few studies have evaluated the most adequate management of patients with VTE by emergency physicians or whether this managment is carried out according to the recommendations of the clinical practice guidelines (CPG), and if this has any repercussion on the final outcome of the patient. Lastly, little is known about the treatment performed in the ED and how this may influence the outcome of the patient.

Aim. The aim of this study was to determine the clinical presentation of VTE and the main risk factors involved in patients diagnosed in Spanish EDs as well as evaluate the management of these patients and adherence to clinical practice guidelines by emergency physicians.

Methods. We performed a prospective cohort study in 53 Spanish EDs, consecutively including patients diagnosed with VTE in the ED. The following data were evaluated: demographic, comorbidities, risk factors for the development of VTE, index event, hemorrhagic risk factors, prognostic factors [pulmonary embolism (PE)] and in-hospital mortality. To evaluate health care quality we determined the percentage of patients registered with clinical probability of PE, requests for D-dimer concentrations according to clinical probability, administration of treatment prior to confirmation of diagnosis based on clinical probability and records of risk of bleeding and prognosis of the patients with VTE. 

Results. Of 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (impact 1.6/1000 visits). Of these, 801 patients were included in the analysis, 49.8% of whom had PE with or without deep venous trhrombosis (DVT).  The most frequent risk factors for VTE were: age (≥70 years), obesity, new immobility, previous VTE and active cancer. In the ED medical reports a scale of clinical probability, the prognosis or the risk of bleeding were only described in 7.6%, 7.5% and 1%, respectively of the cases. Of the patients with PE and high clinical probability, D-dimer was determined in 87.2%, and treatment was initiated prior to confirmation in 35.9%. Regarding risk, 31.3% of the patients with PE presented low risk, 59.1% intermediate-low risk, 6% intermediate-high risk and 3.5% high risk. Of the patients with PE, 98.7% were hospitalized while 50.2% of the VTE (without PE) were admitted. The in-hospital mortality of the patients with PE was 3.8%. 

Conclusion. VTE has an appreciable impact on Spanish EDs. Risk profile for the VTE development  in patients diagnosed in ED being similar to previous studies. Adherence to CPG recommendations needs to significantly improve.

INTRODUCTION

Low molecular weight heparin (LMWH) are commonly prescribed in the emergency department (ED). Not prescribing LMWH for patients with lower limb immobilization (LLI) and at risk for venous thromboembolic events (VTE) can be life-threatening. The incidence of VTE in patients with LLI is estimated between 5 - 39%. The known risk factors for VTE are easily misinterpreted we noticed in our departement. 

METHODS

Participants were asked about their prescribing behavior: the influence of risk factors for VTE, the level of evidence and the need for dose reduction in patients with renal failure.

Ethical committee was obtained and a online questionnaire was created.

RESULTS

75 questionnaires were filled out by physicians, both attendings (65,3%) and residents (32%), working at EDs.

89% of the respondents does not differentiate immobilization of grade III distortions from fractures when prescribing LMWH and 14,9% indicates being influenced by the type of immobilization (splint versus circular cast).

Withholding treatment in patients with known risk factors, other than the immobilization itself, was seen for known risk factors: hormonal therapy (28%), history (24%) and pregnancy (22.6%). Of the respondents 88% recognized that BMI is a risk factor.

56% wrongly indicated being influenced by the patient’s gender in their decision and 4% indicated using the age of 60 or higher as the cut-off for prescribing LMWH.

Renal insufficiency was not taken into account in 39.1% of the responders.

CONCLUSION

It is important to only initiate VTE-prophylaxis in patients where benefits outweigh the possible risks.

Based on the results of our multi-center survey, we can conclude that a lot of physicians aren’t familiar with the correct use of LMWH in the ED. It seems that the role of gender and age is not well known. More surprisingly, more than half of the respondents does not consider LLI itself as risk factor. In contrast, about one fourth of the physicians would not prescribe LMWH even though the patient has a proven risk factor for VTE.

Dose reduction is an important issue in patients with severe renal insufficiency and is apparently easily forgotten.

Even though there is extensive research available about the risk factors for development of VTE, a lot of physicians seem to be having difficulties identifying patients at increased risk. In addition, most research available about the subject is not applicable on the population encountered in the ED. 

The decision pathway is not difficult so flowcharts could easily be created to limit the possibility of errors in interpretation of the risk factors.

Further research is planned based on the results of this research, an international multi-center study is planned to follow this national enquiry.

Background: Half of cardiac arrests (CA) complicating acute coronary syndromes with ST segment elevation (STEMI) occurred during the first two hours. During this initial phase, STEMI were supported in emergency department in the absence of direct orientation to the interventional cardiology structures. Prevalence, risk factors and prognosis of CA complicating STEMI admitted to the emergency department were not well assessed.   

Aim of study:  To study the risk factors and prognosis of cardiac arrest occurring during the initial management of STEMI in the emergency department.

Methods: Prospective observational study extended over a period of 81 months (January 2009-September 2015) in the emergency department of regional hospital in Ben Arous. Inclusion of patients admitted for STEMI lasting for less than 24 hours. The demographic, clinical, electrocardiographic and therapeutic data were collected. Analysis of patients group complicated of CA in emergency department. Identification of factors related to the occurrence of CA using a logistic regression model.

Results: Inclusion of 694 STEMI with a mean age of 60 ± 12 years and a sex ratio of 5. The cardiovascular risk factors were dominated by active smoking (71%) followed by hypertension (35%) and diabetes (32%). The median time of consultation was 150 min (5 min to 24 h). Fibrinolysis was administered in 72% of patients with a success rate of 59%.the most dreaded complications related to the SCA were the cardiogenic shock (10%) and  the cardiac arrest (9%). Patients who experienced CA (n=62) had a mean age of 60 ± 12 years and a male predominance with a sex ratio of 6. Active smoking was the most common cardiovascular risk factor (73%). The median time of consultation was 120 min (30 min and 16 h). Analysis of the initial rhythm of CA objectified ventricular fibrillation (72%), asystole (18%) and ventricular tachycardia (10%). The STEMI was in the anterior territory in 70% of patients and in the lower area in 32% of patients. The treatment in emergency includes (n): External Defibrillation (55), intubation (28), catecholamines (22), anti-arrhythmic (16). Multivariate analysis identified three independent factors related to the occurrence of CA: cardiogenic shock (OR = 2.44 95% CI 1,31- 44,54), reaching the anterior territory (OR = 1 97 95% CI 1.12 to 3.43) and pulsed oxygen saturation less than 90% (OR = 1.05 95% CI 1.02 to 1.09). The mortality of CA in the emergency department was 29%.

Conclusion: Identifying and improving care of risk factors can prevent the occurrence of CA, reduce mortality and improve the short-term prognosis of STEMI.

Aims: This study aimed to evaluate the effects of esmolol treatment for patients with refractory ventricular fibrillation (RVF) and out-of-hospital cardiac arrest (OHCA).

Methods: This single-centre retrospective pre-post study evaluated patients who were treated between January 2012 and December 2015. Some patients had received esmolol (loading dose: 500 µg/kg, infusion: 0–100 µg/kg/min) for RVF (≥3 defibrillation attempts), after obtaining consent from the patient’s guardian.

Results: Twenty-five patients did not receive esmolol (the control group), and 16 patients received esmolol. Sustained return of spontaneous circulation (ROSC) was significantly more common in the esmolol group, compared to the control group (56% vs. 16%, p = 0.007). Survival and good neurological outcomes at 30 days and at 3 months were >2-fold better in the esmolol group, compared to the control group, although these increases were not statistically significant. A multiple logistic regression model revealed that esmolol treatment provided an odds ratio of 9.24 for sustained ROSC (95% confidence interval: 1.64–52.11, p = 0.012).

Conclusions: Among patients with RVF and OHCA, treatment with esmolol was associated with higher rates of sustained ROSC and survival, and patients who received esmolol exhibited an odds ratio of 9.24 for sustained ROSC. Therefore, we suggest considering esmolol for patients with RVF and OHCA after administering standard therapy.

Introduction: Out-of-hospital cardiac arrest (OHCA) in children is a situation that faced by the whole pre-hospital emergency team. The aim of this study was to describe pediatric OHCA heart rhythms recorded by semi-automated external defibrillators (AED) used by on-scene First Aid professionals.

Material and methods: This was a prospective observational study of an urban area with high population density. It included children from 0 to 18 years in OHCA who received an AED.  When used, pediatric electrodes delivered 30 joules of energy.  The collected variables showed a relation to the epidemiological data in accordance with Utstein's recommendations, as well as the electrocardiographic data from the AEDs.

Vincent Thomas, Sabine Lemoine, Daniel Jost, Vincent Lanoë, Marilyn Franchin, Benoit Frattini, Michel Bignand, Jean-Pierre Tourtier 

Results: Over a period of 4 years, 229 children were included and 191 AED plots were analyzed.  The median [Inter Quartile Range] age was 6 [5-16] years, with 129 boys (56%). Twenty-eight children (12%) had a shockable rhythm on the First Aid workers' arrival and were multi-shocked in 39% of cases. The fraction of time devoted to external chest compressions over the total time of care was 60%. The AED reported shock in 3 children and administered an excessive shock in 1 case. The rate of successful defibrillation was 95.4%.

Conclusion: Shockable rhythms in children were rare. Reducing chest compression interruptions by First Aid workers and better consideration of pediatric specifics in the analysis algorithm of AEDs can improve care. The study continues with the collection of survival and neurological outcome data at 1 year.

Background:

Venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE) remains one of the main direct causes of maternal death according to the Centre for Maternal and Child Enquiries. The risk of antenatal VTE is four to five folds higher in pregnant versus non-pregnant women. Acute VTE should be suspected in pregnant women with signs and symptoms of DVT and PE.

The subjective clinical assessment is unreliable in pregnancy and only a minority of women with suspected VTE have the diagnosis confirmed with objective testing. Failure to obtain objective diagnosis and subsequent treatment has been attributed to mortality in these patients according to the sequential reports on Confidential Enquiries into Maternal Deaths. Early recognition of VTE and widespread use of low-molecular-weight-heparin (LMWH) thromboprophylaxis until the diagnosis is reached by objective testing can prevent mortality.

Method:

A retrospective study of 46 pregnant patients referred to acute ambulatory care unit with suspected VTE (suspected PE  n=24, suspected DVT n=22) was conducted over a 1 year period.

Patient demographics (age, gestation), signs and symptoms consistent with VTE, predisposing risk factors (Wells score), thromboprophylaxis with LMWH, objective testing with investigations including bloods (d-dimer<250), Chest X-rays, ECGs, Duplex Ultrasound, Ventilation perfusion (V/Q) or CT pulmonary Angiogram (CTPA) scans were analysed.

Results:

The mean age of our pregnant patients was 31 years (18-43). The mean presentation with suspected VTE was at 27 weeks.

21(46%) out of 46 patients were given LMWH thromboprophylaxis prior to objective testing. 25(64%) patients did not receive thromboprophylaxis due to prompt access to radiological imaging, low suspicion index of VTE(negative d-dimer, low Wells score) or maternal refusal until imaging was conducted. 1(2.5%) out of these 25 patients had a positive DVT scan and was commenced on LMWH immediately.

D-dimer was raised in 21(46%) patients, negative in 7(15%) patients but proven positive in 1 patient for a DVT and not conducted in 18(39%) patients given a high index of suspicion for a VTE.

9(37%) patients suspected of having a PE had a CXR and 1(4.2%) CXR was suggestive of consolidation. ECGs were performed in all patients (100%).

Of the 46 pregnant patients with suspected VTE, 5(11%) patients had a confirmed VTE on objective testing. 25(54%) patients underwent a Duplex Ultrasound, 6(13%) underwent a CTPA, V/Q scan was not conducted in any patient. 3(14%) out of 22 patients with suspected DVT had a positive duplex ultrasound. 2(8%) out of 24 patients with suspected PE had a confirmed VTE 1(4%) positive CTPA and 1(4%) positive duplex ultrasound.

Conclusion:

Pregnancy is associated with a hypercoagulable state, increasing the risk of VTE. The subjective clinical assessment of VTE is unreliable in pregnancy and if clinically suspected, treatment with LMWH should be commenced immediately until a definitive diagnosis is reached by objective testing. D-dimer is affected due to physiological changes in pregnancy and should not be relied upon. Radiological objective testing with patient counselling should be considered in all suspected cases to confirm or exclude VTE, leading to appropriate management in these high risk patients. 

Background: It is important to know the factors affecting survival, good neurological outcome and prognosis in patients underwent cardiopulmonary resuscitation (CPR). NR2 (N-methyl-D-aspartate receptor 2) peptide is a plasma biomarkers for acute cerebral ischemia.  In literature, it has not been demonstrated any study assessing NR2 levels in patients undergoing CPR. In this study, we investigated the relationship between the NR2 peptide levels and prognosis in patients underwent CPR in our hospital emergency room.

Method: In the study, the patients with cardiopulmonary arrest (CPA) consecutively admitted to the emergency room and the patients suffer from CPA while being followed in the emergency department, were evaluated prospectively between October 2014 and June 2015. Traumatic, non-traumatic, pre-hospital and in-hospital cardiac arrest patients were included the study. Blood samples for NR2 and other biochemical analysis were  taken during resuscitation. NR2 levels in patients who can provided return of spontaneous circulation (ROSC) and not provided ROSC, and the benefits of NR2 in predicting 28-day mortality were investigated. SPSS ™ ver.16.0 was used for statistical analysis.

Results: A  hundred patients were included in the study but nine patients were excluded from the study due to errors in the blood sampling. Mean age of the patients was 63.6±17.6/year and 64.8% were male. Pre-hospital and in-hospital cardiac arrest percents were 56.0% and 44.0% respectively, and 13.2% of them were traumatic cardiac arrest patients. ROSC was achieved in 60.4% of patients. Between the patients who were achieved ROSC and those who died were detected significant differences in terms of NR2 levels (p=0.004). Although NR2 values of survivors at twenty-eight days were higher than those being exitus, there was no statistical difference (p=0,075). Also in the study,  lactate levels in patients who provided ROSC  and the patients who living 28 days were found significantly lower than those who died  (p=0.02 and p=0.01 respectively).

Conclusion: NR2 levels are increased as an indicator of the ROSC in patients who underwent CPR. This condition is thought to be associated with reperfusion. However, NR2 levels has not been shown to be superior to lactate levels in 28-day mortality prediction.

Background: In-hospital cardiac arrest (IHCA) are often preceded by abnormal vital signs. Preceding abnormal vital signs might lower the physiological reserve capacity and therefore decrease survival after an IHCA.

Aim: To assess preceding national early warning score (NEWS) and its impact on survival after IHCA.

Material and methods: All patients ≥18 years suffering IHCA at Karolinska University Hospital between 1^st January 2014 and 31^st December 2015 were included. Data regarding the IHCA, patient characteristics, NEWS and 30days survival were drawn from the electronic patient records. Parameters included in NEWS were assessed up to 12hrs before the IHCA.  Differences in survival were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI) between patients with NEWS of 0-4 points (low) versus those with at least 5points (moderate) and high (7 points). Adjustments included hospital site, gender, co-morbidities, first rhythm and place of IHCA.

Results: In all, 358 patients suffered IHCA, of whom 109 (30%) survived at least 30 days. The 87 patients with medium NEWS had a minor chance and those 78 with high NEWS (22%) had a minimal chance of surviving IHCA compared to those with low NEWS (Adjusted OR 0.24, 95% CI 0.12-0.50 and OR 0.08, 95% C.I. 0.03-0.22, respectively).

Conclusion: The NEWS can be a probable proxy for estimating physiological reserve capacity when discussing prognosis with patients and relatives. But even more important, it stresses the need for better preventive strategies in IHCA.

Objectives: 


The outcome of patients after OHCA is poor. Return to spontaneous circulation (ROSC) dramatically decreases with the duration of CPR. Extracorporeal membrane oxygenation has been proposed to assist CPR (ECPR) in OHCA. This study was to investigate the effects and characteristics of ECPR for adult non-­traumatic OHCA versus Non­ECPR on a community­wide basis.

Methods:


A prospective four­-year observational database collected from a community­wide OHCA web registry in an urban EMS (emergency medical services) was studied. The EMS ambulance teams were capable with advanced airway, intravenous (iv) fluid skills, basic and advanced life support and automated external defibrillator techniques. Outcomes included survival and cerebral performance category scale (CPC) at discharge. Adult non-traumatic OHCAs with and without ECPR were compared by regression analysis including factors of patient, pre­hospital and hospital characteristics and outcomes.


Results: 


Comparing OHCA receiving ECPR (n=79) to those without (n=959), ECPR group were younger (median age 56 vs 78, p<0.001) and had higher portion for men (89 vs 64%, p<0;001), witnessed arrest (Wit) (60.8 vs 32.5%, p<0.001), bystander CPR (BCPR) (53.2 vs 36.8%, p=0.005), initial shockable rhythms (SR) (74.6 vs 12.2%, p<0.001) and therapeutic hypothermia (TH) (22.8 vs 1.1%, p<0.001). They (EPCR vs non­ECPR) had no difference for prehospital time intervals (22.5 vs 23 min.), laryngeal mask airway treatment (55.7 vs 52.8%), EMS iv epinephrine (20.3 vs 15.5%), endotracheal intubation (6.3 vs 8.0%), prehospital ROSC (11.4 vs 6%, p=0.09), and ROSC upon hospital arrival (10.1 vs 8.5%). Outcomes were better in ECPR for discharged survival (41 vs 7%, p<0.001) and CPC 1or2 (20.8 vs 3.8%, p<0.001). After adjusting for Wit, BCPR, SR, TH, age and sex, both survival (adjusted odds ratio: 3.6 [95% CI: 2.0­-6.6]) and good CPC 1or2 (adjusted OR: 2.9 [95% CI: 1.2­-6.9]) were still significantly higher in ECPR.

Conclusions:

In current clinical practice for adult non­traumatic OHCA, ECPR tended to apply to patients of younger age, men, witnessed arrest, BCPR, and initially shockable rhythms regardless of positive ROSC upon hospital arrival, that can independently lead to higher survival and good neurological outcome compared to non­ECPR.

Purpose:

Recognition of cardiac arrest with checking carotid pulse is less than a half correct by the public. Poor recognition of cardiac arrest or patient of agonizing situation delays early bystander cardiopulmonary resuscitation (BCPR) that should be critically provided in the first five minutes before emergency ambulance arrival. Globally we still lack of effective technology to assist better recognition of cardiac arrest to facilitate early BCPR and public access defibrillation (PAD). In this study, we aim to innovate a video signals analysis tool to assist recognition of cardiac arrest.

Method:

We designed an innovative skill algorithm for transforming and analyzing the signals of the video recordings filmed with mobile smartphone for part of human body. Fast Fourier Transform (FFT) signals were evaluated in our skill algorithm. The time length for each video recording was fifteen seconds, which was filmed within the first five minutes after cardiac arrest witnessed in the intensive care unit. This signal analysis skill algorithm was applied on the video recordings of cardiac arrest patients and compared with that of normal volunteers.

Results:

We applied our skill algorithm analysis on video segments from twenty cardiac arrest patients (asystole for 18 cases, ventricular fibrillation for 2 cases) and twenty non-arrest volunteers (median heart rate 74/min, IQR: 65-88/min), matched in age and sex. We innovated a mathematic formula to calculate a value (we called it Slope Alfa) mainly from the cluster of FFT signals evaluated by the skill algorithm. The Slope Alfa value (Mean, [SD]) of cardiac arrest patients was significantly different from the value of non-arrest volunteers (0.14, [0.09] vs 1.96, [0.37], p<0.01). The results also indicated a tendency that for cardiac arrest patient the Slope Alfa would be less than 1.0.

Conclusions:

The skill algorithm we innovated for smartphone video signals analysis may successfully recognize patient after cardiac arrest. Further integration of this technology with mobile devices would provide the general public an easily accessible tool for cardiac arrest recognition and early chest compressions.

The Emergency deparments (ED) are very important, among other things,  because are the places where the diagnosis of venous thromboembolic disease  (VTE) that develops on an outpatient basis in most cases is established. It is also where doctors often start specific treatment for VTE and management is decided.

AIM

The principle aim of this study was to evaluate the therapeutic management by emergency physicians of patients diagnosed with VTE in Spanish ED. On the other hand, which is the process of change that has experienced this treatment during follow-up of the patients for six months.

METHODS

The EDITH study is a multicenter retrospective cohort study involving 50 Spanish emergency services belonging to fifteen regions .

We included consecutive patients who were diagnosed with VTE (-PE- pulmonary embolism or deep vein thrombosis -DVT-) and were treated in emergency services between October 13 and December 14, 2014 were included in the study.

We were collected demographic variables, morbidity, risk factors for VTE in the moment of diagnosis , besides the diagnostic and therapeutic management in the emergency department and 6 months later.

RESULTS

A total of 775 patients with VTE were included in the study. 386 patients (49.8%) have PE, with or without DVT. The mean age of patients was 66 years. A 96.9% received anticoagulant therapy in the emergency department, of which 90.6% was LMWH. Only 30 patients in the emergency began acenocumarol and 7 patients received rivaroxaban. At hospital discharge, 65% of DVT and 33.6% of PE remained with LMWH monotherapy. At 1, 3 and 6 months after the stay in the emergency these percentages were maintained for DVT in 42.7, 30.6% and 17.8%, and for PE in 29.2%, 23.1% and 18.9%, respectively. These results are not exclusive to cancer patients but it also observed in all study population. A 73.1% of patients maintained anticoagulant therapy for at least 6 months (83.9% of PE and 61.2% of DVT).

CONCLUSION

A hospital management centered in the use  of  heparins and low transition to antivitamins K in patients with VTE was observed. Similarly, in the outpatient management  the introduction of oral anticoagulants was less than would be expected according to the guidelines of recommendation and a more prolonged duration of treatment it was observed.

Background

Due to the undifferentiated presentation of EVD during the recent outbreak in West Africa, some suspect patients were isolated who subsequently tested negative for the virus. In Sierra Leone, a country in which 69% of healthcare is funded (1) through out of pocket payments, these patients were effectively made destitute as a result of stigmatization and destruction of personal possessions. A number of factors highlighted a need to provide emergency care pathways for these patients. This paper describes the design and implementation of a novel initiative to provide a level of free healthcare to EVD negative patients at Connaught Hospital, the main government hospital in Sierra Leone.

Methods and Findings

Following review of existing global schemes and a consultation period, data was collected from a random sample of 50 patients requiring admission to Connaught Hospital, after presentation to the A&E, in order to estimate routine aggregate costs for investigations and medical treatment. This data was used to set a funding cap of 260,000 Leones (approx GBP £35), which was calculated to provide free investigations and treatment for 98% of cases. In total, free care was provided to ~300 eligible patients over a 6 month period. The major boundaries to implementation were absence of strong patient advocacy, and lack of hospital resources: both preventing patients receiving the full complement of prescribed services.

Conclusions

In resource-poor settings such as Sierra Leone, where free healthcare is provided in incremental packages alongside the existing out-of-pocket payment system, it is essential for successful implementation that new initiatives are embedded within existing systems. This paper presents a number of lessons learned in the design and implementation process of a novel capped free healthcare system and proposes an extended approach to provide on-going tertiary care to EVD survivors and other vulnerable groups in Sierra Leone. This work also proposes a generalizable mechanism to support patients and strengthen healthcare systems in the transitional phase that follows other such humanitarian crises.