Acute myocardial infarction caused by coronary embolization of a papillary fibroelastoma of the thoracic ascending aorta.

Papillary fibroelastomas (PFE) are benign endocardial masses and generally originate from the cardiac valves, while PFE arising from the ascending thoracic aorta are an uncommon clinical finding. We report the case of a 78-year-old female who presented to the emergency department with an acute ST segment elevation myocardial infarction. Urgent coronary angiography showed no significant coronary artery obstructive disease but left ventriculography revealed the presence of a highly mobile mass located in the proximal portion of the ascending thoracic aorta. We postulated that the clinical symptoms were caused by embolization from the aortic mass and surgical excision of the peduncle was performed. Histopathological examination revealed a PFE with thrombotic material. Nowadays, surgical excision of PFE remains, the treatment of choice for symptomatic patients with excellent short- and long-term results but recurrence of PFE following surgical excision has not been reported.

Evaluación económica de la determinación del propéptido natriurético cerebral N-terminal (NT-proBNP) en pacientes con disnea en los servicios de urgencias españoles

Introducción: Analizar la eficiencia de añadir la determinación NT-proBNP al examen clínico convencional (ECC) para el diagnóstico de insuficiencia cardíaca (IC) en pacientes con disnea que acuden a servicios de urgencias (SU) españoles. Material y métodos: Se desarrolló un árbol de decisión para evaluar los resultados clínicos y económicos de ambas alternativas durante 60 días de seguimiento desde la visita al SU en pacientes hospitalizados y no hospitalizados. Los parámetros clínicos fueron principalmente obtenidos del estudio PRIDE y validados por médicos de SU y cardiólogos. El punto de corte de la determinación NT-proBNP fue de 900 pg/mL (sensibilidad del 90% y especificidad del 85%). En base a datos espa noles publicados, se asumió que el 65% de pacientes con disnea sufrían IC. El uso de recursos fue identificado mediante opinión de expertos y evaluado desde la perspectiva del Sistema Nacional de Salud (SNS). El análisis comparó el diagnóstico final del paciente con el diagnóstico realizado en el SU. Se realizaron diversos análisis de sensibilidad para evaluar la incertidumbre del modelo. Resultados: El diagnóstico incorporando la determinación NT-proBNP fue correcto en el 91,96% de los pacientes (59,09% verdaderos positivos y 32,87% verdaderos negativos) frente al 85,53% mediante ECC (50,79% verdaderos positivos y 34,74% verdaderos negativos). La incorporación de la determinación NT-proBNP resultó tener un coste menor (3.720 versus 5.188 ). Los análisis de sensibilidad realizados confirmaron los resultados.

Acute alcohol consumption and injury: risk associations and attributable fractions for different injury mechanisms.

OBJECTIVE: Most studies on alcohol as a risk factor for injuries have been mechanism specific, and few have considered several mechanisms simultaneously or reported alcohol-attributable fractions (AAFs)-which was the aim of the current study. METHOD: Data from 3,592 injured and 3,489 noninjured patients collected between January 2003 and June 2004 in the surgical ward of the emergency department of the Lausanne University Hospital (Switzerland) were analyzed. Four injury mechanisms derived from the International Classification of Diseases, 10th Revision, were considered: transportation-related injuries, falls, exposure to forces and other events, and interpersonal violence. Multinomial logistic regression models were calculated to estimate the risk relationships of different levels of alcohol consumption, using noninjured patients as quasi-controls. The AAFs were then calculated. RESULTS: Risk relationships between injury and acute consumption were found across all mechanisms, commonly resulting in dose-response relationships. Marked differences between mechanisms were observed for relative risks and AAFs, which varied between 15.2% and 33.1% and between 10.1% and 35.9%, depending on the time window of consumption (either 6 hours or 24 hours before injury, respectively). Low and medium levels of alcohol consumption generally were associated with the most AAFs. CONCLUSIONS: This study underscores the implications of even low levels of alcohol consumption on the risk of sustaining injuries through any of the mechanisms considered. Substantial AAFs are reported for each mechanism, particularly for injuries resulting from interpersonal violence. Observation of a so-called preventive paradox phenomenon is discussed, and prevention or intervention measures are described.

Persistent hyperglycemia at 24-48 h in acute hyperglycemic stroke patients is not associated with a worse functional outcome.

BACKGROUND: Recently, it was shown that the relation between admission glucose and functional outcome after ischemic stroke is described by a J-shaped curve, with a glucose range of 3.7-7.3 mmol/l associated with a favorable outcome. We tested the hypothesis that persistence of hyperglycemia above this threshold at 24-48 h after stroke onset impairs 3-month functional outcome. METHODS: We analyzed all patients with glucose >7.3 mmol/l on admission from the Acute STroke Registry and Analysis of Lausanne (ASTRAL). Patients were divided into two groups according to their subacute glucose level at 24-48 h after last well-being time (group 1: ≤7.3 mmol/l, group 2: >7.3 mmol/l). A favorable functional outcome was defined as a modified Rankin Score (mRS) ≤2 at 3 months. A multiple logistic regression analysis of multiple demographic, clinical, laboratory and neuroimaging covariates was performed to assess predictors of an unfavorable outcome. RESULTS: A total of 1,984 patients with ischemic stroke were admitted between January 1, 2003 and October 20, 2009, within 24 h after last well-being time. In the 421 patients (21.2%) with admission glucose >7.3 mmol/l, the proportion of patients with a favorable outcome was not statistically significantly different between the two groups (59.2 vs. 48.7%, respectively). In multiple logistic regression analysis, unfavorable outcome was significantly associated with age (odds ratio, OR: 1.06, 95% confidence interval, 95% CI: 1.03-1.08 for every 10-year increase), National Institute of Health Stroke Score, NIHSS score, on admission (OR: 1.16, 95% CI: 1.11-1.21), prehospital mRS (OR: 12.63, 95% CI: 2.61-61.10 for patients with score >0), antidiabetic drug usage (OR: 0.36, 95% CI: 0.15-0.86) and glucose on admission (OR: 1.16, 95% CI: 1.02-1.31 for every 1 mmol/l increase). No association was found between persistent hyperglycemia at 24-28 h and outcome in either diabetics or nondiabetics. CONCLUSIONS: In ischemic stroke patients with acute hyperglycemia, persistent hyperglycemia (>7.3 mmol/l) at 24-48 h after stroke onset is not associated with a worse functional outcome at 3 months whether the patient was previously diabetic or not.

Prospective study on procalcitonin and other systemic infection markers in patients with leukocytosis.

OBJECTIVE: To better assess the diagnosis of an infection in patients presenting at an emergency department with peripheral blood leukocytosis (>10 x 10(9) cells/l) on laboratory testing. METHODS: We prospectively evaluated serum procalcitonin concentration (PCT), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Patients were divided into two groups according to their final diagnosis: patients with infection and those without infection. PCT, CRP, and ESR were compared between these groups. Sensitivity, specificity, positive predictive values, negative predictive values, receiver operating characteristic curves, and areas under the curves were calculated for each biological measurement. RESULTS: Out of 173 patients, 99 (57%) had a final diagnosis of systemic infection. If a cutoff point of 0.5 ng/ml is considered, procalcitonin concentration had a sensitivity of 0.57, a specificity of 0.85, a negative predictive value of 0.59, and a positive predictive value of 0.84 for the diagnosis of a systemic infection. Adding CRP or ESR to PCT gave no more information (p=0.84). CONCLUSIONS: Only about half of the patients attending the emergency department with leukocytosis were suffering from an infection. Determination of the procalcitonin level may be useful for these patients, particularly in the case of a value higher than 0.5 ng/ml.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

BACKGROUND: We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). METHODS: We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. RESULTS: In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. CONCLUSIONS: Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Clinical characteristics and outcome of inpatients versus outpatients with venous thromboembolism: findings from the RIETE Registry.

BACKGROUND: Patients with venous thromboembolism (VTE) treated with anticoagulants are at risk of death from pulmonary embolism (PE) and/or bleeding. However, whether patients who develop VTE in hospital have a higher complication rate than those who develop VTE in an outpatient setting is unclear. PATIENTS AND METHODS: RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. We compared the 3-month incidence of fatal PE and fatal bleeding in patients in whom the VTE had developed while in hospital for another medical condition (inpatients) with those who presented to the emergency ward because of VTE (outpatients). RESULTS: Up to April 2008, 22,133 patients with acute VTE were enrolled: 10,461 (47%) presented with PE, 11,672 with deep vein thrombosis. Overall, 6445 (29%) were inpatients. During the study period, those who developed VTE as inpatients had a significantly higher incidence of fatal PE (2.1% vs. 1.5%; odds ratio: 1.4; 95% CI: 1.1-1.7), overall death (7.0% vs. 5.4%; odds ratio: 1.3; 95% CI: 1.2-1.5), and major bleeding (2.9% vs. 2.1%; odds ratio: 1.4; 95% CI: 1.1-1.6) than outpatients. The incidence of fatal bleeding was not significantly increased (0.7% vs. 0.5%; odds ratio: 1.2; 95% CI: 0.9-1.8). In multivariable analysis, inpatient status was significantly associated with a higher risk for fatal PE (odds ratio: 1.3; 95% CI: 1.1-1.7). CONCLUSIONS: VTE occurring in hospitalized patients carries a significantly higher risk for death of PE than in outpatients, underscoring the importance of VTE prevention strategies in the hospital setting.

Current state of knowledge on neuroendocrine small bowel tumours: non-systematic review of the literature based on one case.

More than 60% of neuroendocrine tumours, also called carcinoids, are localised within the gastrointestinal tract. Small bowel neuroendocrine tumours have been diagnosed with increasing frequency over the past 35 years, being the second most frequent tumours of the small intestine. Ileal neuroendocrine tumours diagnosis is late because patients have non-specific symptoms. We have proposed to illustrate as an example the case of a patient, and on its basis, to make a brief review of the literature on small bowel neuroendocrine tumours, resuming several recent changes in the field, concerning classification criteria of these tumours and new recommendations and current advances in diagnosis and treatment. This patient came to our emergency department with a complete bowel obstruction, along with a 2-year history of peristaltic abdominal pain, vomits and diarrhoea episodes. During emergency laparotomy, an ileal stricture was observed, that showed to be a neuroendocrine tumour of the small bowel.

Expérience de dix ans de réanimation chirurgicale d'un centre hospitalier universitaire. Détermination d'un critère d'identification des patients à risque de décéder de coagulopathie irréversible [10 years experience in surgical resuscitation at a university hospital center. Determination of a criterion for identifying patients at risk for fatal irreversible coagulopathy]

The authors evaluated ten years of surgical reanimation in the University Centre of Lausanne (CHUV). Irreversible coagulopathy (IC) is the predominant cause of death for the polytraumatized patient. Acidosis, hypothermy, and coagulation troubles are crucial elements of this coagulopathy. The authors looked for a criterion allowing the identification of dying of IC. In a retrospective study, laboratory results of pH, TP, PTT, thrombocyte count and the need for blood transfusion units were checked for each major step of the primary evaluation and treatment of the polytraumatized patients. These results were considered as critical according to criteria of the literature (30). The authors conclude that the apparation of a third critical value may be useful to identify the polytraumatized patient at risk of dying of IC status. This criterion may also guide the trauma team in selecting a damage control surgical approach (DCS). This criterion was then introduced into an algorithm involving the Emergency Department, the operating room and the Intensive Care Unit. This criterion is a new tool to address the patient at the crucial moment to the appropriate hospital structure.

L'arrêt cardiaque: quelle réalité et quelle formation pour le praticien [Heart arrest: which reality and which training for the practitioner?]

Sudden death related to out-of hospital cardiac arrest is an important cause of mortality, which is mainly caused by ventricular fibrillation, a potentially reversible condition. The prognosis of out-of-hospital cardiac arrest remains dismal despite well developed emergency medical services. Witnessed arrest, ventricular fibrillation as the initial arrhythmia, cardiopulmonary resuscitation and early defibrillation are systematically associated with better survival. Key interventions must therefore be enforced to improve survival from out-of-hospital cardiac, introducing the concept of a "chain of survivals". The aim of the present article, which is illustrated by local results, is to review this important public health issue, to emphasize the role of the general practitioner in the chain of survival, and to promote education and training of basic and advanced life support.

Acute opiate overdose: characteristics of 190 consecutive cases.

AIMS: To characterize the population of drug users consulting the Emergency Room (ER) of a university hospital with acute opiate overdose (AOO) and to assess rate of referral to specialized treatment programme. DESIGN: Survey of a 12-month sample of AOO patients. MEASUREMENTS: Medical and psychosocial features of the drug users, details of emergency treatment and referral by a mobile resuscitation team (SMUR) and the ER of our hospital (CHUV-Lausanne, Switzerland). In addition fatal AOO cases were collected by the Institute of Forensic Medicine (IFM) during the same period. FINDINGS: One hundred and eighty-four cases of AOO (134 patients) were treated. The files of the IFM detailed six additional deceased cases. This population of drug users was characterized by an over-representation of men (73%), by young age (27.4 years), by a high rate of multi-drugs use (90%) and by a high rate of multiple previous overdoses (2.6). Average length of stay was 20.1 hours but 41% of cases stayed less than 8 hours. Only one patient was readmitted within an 8-hour period. When discharged, 78% returned home. Unexpectedly, 67% of patients were not referred to any therapeutic programme for drug addiction. CONCLUSION: This study shows the low mortality of AOO when treated but also demonstrates the need to improve psychosocial evaluation and referral of drug addicts admitted with AOO.

Is the 23-valent pneumococcal polysaccharide vaccine useful in preventing community-acquired pneumonia?

Although bacteremic pneumococcal pneumonia is the most severe form of pneumonia, non-bacteremic forms are much more frequent. Laboratory methods for the diagnosis of nonbacteremic pneumococcal pneumonia have a low sensitivity and specificity, and therefore all-cause pneumonia has been proposed as a suitable outcome to evaluate vaccination effectiveness. This work reviews the epidemiology of community-acquired pneumonia (CAP) and evaluates the effectiveness of the 3-valent pneumococcal polysaccharide vaccine (PPV-23) in preventing CAP requiring hospitalization in people aged ≥65 years. We performed a case-control study in patients aged ≥65 years admitted through the emergency department who presented with clinical signs and symptoms compatible with pneumonia. Weincluded 489 cases and 1,467 controls and it was obtained a vaccine efectiveness of 23.6 (0.9-41.0). Our results suggest that PPV-23 vaccination is effective and reduces hospital admissions due to pneumonia in the elderly, strengthening the rationale for vaccination programmes in this age group.

Practice guidelines for evaluation of Fever in returning travelers and migrants.

BACKGROUND: Fever upon return from tropical or subtropical regions can be caused by diseases that are rapidly fatal if left untreated. The differential diagnosis is wide. Physicians often lack the necessary knowledge to appropriately take care of such patients. OBJECTIVE: To develop practice guidelines for the initial evaluation of patients presenting with fever upon return from a tropical or subtropical country in order to reduce delays and potential fatal outcomes and to improve knowledge of physicians. TARGET AUDIENCE: Medical personnel, usually physicians, who see the returning patients, primarily in an ambulatory setting or in an emergency department of a hospital and specialists in internal medicine, infectious diseases, and travel medicine. METHOD: A systematic review of the literature--mainly extracted from the National Library of Medicine database--was performed between May 2000 and April 2001, using the keywords fever and/or travel and/or migrant and/or guidelines. Eventually, 250 articles were reviewed. The relevant elements of evidence were used in combination with expert knowledge to construct an algorithm with arborescence flagging the level of specialization required to deal with each situation. The proposed diagnoses and treatment plans are restricted to tropical or subtropical diseases (nonautochthonous diseases). The decision chart is accompanied with a detailed document that provides for each level of the tree the degree of evidence and the grade of recommendation as well as the key points of debate. PARTICIPANTS AND CONSENSUS PROCESS: Besides the 4 authors (2 specialists in travel/tropical medicine, 1 clinical epidemiologist, and 1 resident physician), a panel of 11 European physicians with different levels of expertise on travel medicine reviewed the guidelines. Thereafter, each point of the proposed recommendations was discussed with 15 experts in travel/tropical medicine from various continents. A final version was produced and submitted for evaluation to all participants. CONCLUSION: Although the quality of evidence was limited by the paucity of clinical studies, these guidelines established with the support of a large and highly experienced panel should help physicians to deal with patients coming back from the Tropics with fever.

Exclusion of pulmonary embolism using C-reactive protein and D-dimer. A prospective comparison.

Our goal was to evaluate the diagnostic utility of C-reactive protein (CRP) alone or combined with clinical probability assessment in patients with suspected pulmonary embolism (PE), and to compare its performance to a D-dimer assay. We conducted a prospective study in which we performed a common immuno-turbidimetric CRP test and a rapid enzyme-linked immunosorbent assay (ELISA) D-dimer test in 259 consecutive outpatients with suspected PE at the emergency department of a teaching hospital. We assessed clinical probability of PE by a validated prediction rule overridden by clinical judgment. Patients with D-dimer levels > or = 500 microg/l underwent a work-up consisting of lower-limb venous ultrasound, spiral computerized tomography, ventilation-perfusion scan, or pulmonary angiography. Patients were followed up for three months. Seventy-seven (30%) of the patients had PE. The CRP alone had a sensitivity of 84% (95% confidence interval [CI).: 74 to 92%) and a negative predictive value (NPV) of 87% (95% CI: 78 to 93%) at a cutpoint of 5 mg/l. Overall, 61 (24%) patients with a low clinical probability of PE had a CRP < 5 mg/l. Due to the low prevalence of PE (9%) in this subgroup, the NPV increased to 97% (95% CI: 89 to 100%). The D-dimer (cutpoint 500 micro g/l) showed a sensitivity of 100% (95% CI: 95 to 100%) and a NPV of 100% (95% CI: 94 to 100%) irrespective of clinical probability and accurately rule out PE in 56 (22%) patients. Standard CRP tests alone or combined with clinical probability assessment cannot safely exclude PE.

TraumaHawk: Improving Treatment for Crash Victims Using Photos and a Smartphone App

Photographic documentation of crashed vehicles at the scene can be used to improve triage of crash victims. A U.S. expert panel developed field triage rules to determine the likelihood of occupants sustaining serious injuries based on vehicle damage that would require transport to a trauma center (Sasser et al., 2011). The use of photographs for assessing vehicle damage and occupant compartment intrusion as it correlates to increased injury severity has been validated (Davidson et al., 2014). Providing trauma staff with crash scene photos remotely could assist them in predicting injuries. This would allow trauma care providers to assess the appropriate transport, as well as develop mental models of treatment options prior to patient arrival at the emergency department (ED). Crash-scene medical response has improved tremendously in the past 20-30 years. This is in part due to the increasing number of paramedics who now have advanced life support (ALS) training that allows independence in the field. However, while this advanced training provides a more streamlined field treatment protocol, it also means that paramedics focused on treating crash victims may not have time to communicate with trauma centers regarding crash injury mechanisms. As a result, trauma centers may not learn about severe trauma patients until just a few minutes before they arrive. The information transmitted by the TraumaHawk app allows interpretation of injury mechanisms from crash scene photos at the trauma center, providing clues about the type and severity of injury. With strategic crash scene photo documentation, trained trauma professionals can assess the severity and patterns of injury based on exterior crush and occupant intrusion. Intrusion increases the force experienced by vehicle occupants, which translates into a higher level of injury severity (Tencer et al., 2005; Assal et al., 2002; Mandell et al., 2010). First responders have the unique opportunity to assess the damaged vehicle at the crash scene, but often the mechanism of injury is limited or not even relayed to ED trauma staff. To integrate photographic and scene information, an app called TraumaHawk was created to capture images of crash vehicles and send them electronically to the trauma center. If efficiently implemented, it provides the potential advantage of increasing lead-time for preparation at the trauma center through the crash scene photos. Ideally, the result is better treatment outcomes for crash victims. The objective of this analysis was to examine if the extra lead-time granted by the TraumaHawk app could improve trauma team activation time over the current conventional communication method.