Anna Maria Rusconi

Interobserver agreement in the interpretation of computed tomography in acute pulmonary embolism

Multidetector computed tomography (MDCT) is one of the best diagnostic tools for the diagnosis of pulmonary embolism (PE). However, differences in MDCT interpretation, depending on the operator personal expertise, is an important factor that could interfere with the right diagnosis and, consequently, with the more adequate and well-timed therapy. The aim of the present study was to evaluate the interobserver agreement in the interpretation of MDCT for the diagnosis of acute PE. On a blind basis, 4 radiologists with different expertise in CT interpretation evaluated 46 different MDCT executed for acute PE. They had to verify the presence or absence of PE and, in the positive case, localize (right-left) and quantify (massive, segmentarian or subsegmentarian) it. The interobserver concordance was expressed using the Cohen K statistic. The mean concordance between the 4 operators was high (0.82; range, 0.68-0.95). Ruling out the massive PE cases, the mean concordance over the other cases was only moderate (0.47; range, 0.16-0.84). We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.

Bleeding Risk during Treatment of Acute Thrombotic Events with Subcutaneous LMWH Compared to Intravenous Unfractionated Heparin; A Systematic Review

Background Low Molecular Weight Heparins (LMWH) are at least as effective antithrombotic drugs as Unfractionated Heparin (UFH). However, it is still unclear whether the safety profiles of LMWH and UFH differ. We performed a systematic review to compare the bleeding risk of fixed dose subcutaneous LMWH and adjusted dose UFH for treatment of venous thromboembolism (VTE) or acute coronary syndromes (ACS). Major bleeding was the primary end point. Methods Electronic databases (MEDLINE, EMBASE, and the Cochrane Library) were searched up to May 2010 with no language restrictions. Randomized controlled trials in which subcutaneous LMWH were compared to intravenous UFH for the treatment of acute thrombotic events were selected. Two reviewers independently screened studies and extracted data on study design, study quality, incidence of major bleeding, patients’ characteristics, type, dose and number of daily administrations of LMWH, co-treatments, study end points and efficacy outcome. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using the random effects model. Results Twenty-seven studies were included. A total of 14,002 patients received UFH and 14,635 patients LMWH. Overall, no difference in major bleeding was observed between LMWH patients and UFH (OR = 0.79, 95% CI 0.60–1.04). In patients with VTE LMWH appeared safer than UFH, (OR = 0.68, 95% CI 0.47–1.00). Conclusion The results of our systematic review suggest that the use of LMWH in the treatment of VTE might be associated with a reduction in major bleeding compared with UFH. The choice of which heparin to use to minimize bleeding risk must be based on the single patient, taking into account the bleeding profile of different heparins in different settings.

Is there a benefit for a care protocol in the treatment of septic shock

Severe sepsis and septic shock have a short-term mortality in excess of 20 % [1]. In 2001, a single-center ED-based study of a 6-hour early goal-directed therapy (EGDT) protocol reported a significant reduction in in-hospital mortality (30.5 vs 46.5 %) [2]. This EGDT protocol mandated early central venous catheterization to monitor central venous pressure, central venous oxygen saturation, and to guide use of intravenous fluids, vasopressors and packed red cell transfusions. Many trials have been published in the subsequent decade raising the question of whether all elements of the protocol are necessary.

Timing of the initiation of parenteral nutrition in critically ill adults

BackgroundCritical illness in hospitalized patients induces anorexia: aninability to eat suitably, predisposing to nutritional deficit,weakness, infections, increased duration of mechanicalventilation, delayed recovery and death [1]. To date,whether artificial nutritional support improves outcomesfor critically ill patients is unclear. Enteral nutrition isassociated with fewer complications than parenteral nutri-tion, and is less expensive [2], but enteral nutrition alonedoes not often achieve caloric targets. Combining paren-teral and enteral nutrition could prevent nutritional deficit.However, this strategy may carry the risk of overfeeding,which has been associated with complications such as liverdysfunction [3]. Current clinical practice guidelines fornutritional support in critically ill patients are largely basedon expert opinion, and differ substantially across conti-nents, in particular about the timing to start parenteralnutrition. The European Society of Parenteral and EnteralNutrition (ESPEN) recommends the commencement ofparenteral nutrition within 2 days after admission to theintensive care unit (ICU) for patients who cannot be ade-quately fed enterally [4], while the American and Canadianguidelines recommend early initiation of enteral nutrition,but suggest starting parenteral nutrition after a week inpatients who are not malnourished at baseline [5].SummaryCasaer and coworkers [6] in a randomized, multicenter trial,comparedanearlytoalateinitiationofparenteralnutritioninadults admitted to the ICU who were not malnourished atbaseline [body-mass index (BMI) of C17] in order to sup-plement insufficient enteral nutrition. The primary endpoints were the number of days spent in ICU (for survivorsand non-survivors), and the time to discharge from the ICU.In 2,312 patients, parenteral nutrition was initiated within48 h after ICU admission, whereas in 2,328 patients, it wasnot initiated before the eighth day from admission. ThemedianstayintheICUwas1 dayshorterinthelate-initiationgroup than in the early-initiation group (3 vs. 4 days,respectively, P = 0.02), which was reflected in a relativeincrease of 6.3% of the likelihood of earlier discharge alivefrom the ICU [hazard ratio 1.06, 95% confidence interval(CI), 1.00–1.13, P = 0.04]. Considering the secondary out-comes, patients in the late-initiation group had fewer healthassistance related infections (22.8 vs. 26.2%, P = 0.008), alowerincidenceofcholestasis(32.6vs.38.4%,P\0.001),areduction in the proportion of patients requiring more than2 days of mechanical ventilation (36.3 vs. 40.2%,P = 0.006), a median reduction of 3 days in the duration ofrenal replacement therapy (7 vs. 10 days, P = 0.008) and areduction in mean health care costs of €1,110 as comparedwith the early-initiation group (€16863 vs. €17973,P = 0.04). The safety outcomes (in-hospital mortality rates,survival at 90 days, rates of nutrition-related complications)weresimilarinthetwogroups,buthypoglycaemiawasmorecommon in the late-initiation group patients (3.5 vs. 1.9%,P = 0.001). Although enteral nutrition was initiated if pos-sible in the majority of patients, the post hoc subgroupanalyses including patients for whom early enteral nutritionwas contraindicated showed the same results.

Five steps for use and interpretation of troponin in the Emergency Department

Troponin (Tn) is a protein complex formed by three isoforms, TnI, TnT and TnC, involved in muscle contraction that is present at high concentration in heart muscle. Cardiac troponins are, together with EKG signs and clinical evaluation, the fundamental tools used to diagnose or exclude an acute coronary syndrome (ACS) in patients presenting to the Emergency Department (ED) with chest pain. Modern assays for troponin serum measurement are now able to detect even minimal myocardial insults, increasing significantly our capability to rapidly identify acute myocardial infarction (AMI). This great sensitivity, nevertheless, comes inevitably at the cost of a reduced specificity. The serum troponin concentration can increase following any type of myocardial damage, not only of ischemic aetiology (Table 1). Moreover, troponin serum levels depend also on renal clearance, which might be impaired in renal failure (acute or chronic) or in advanced age. Finally, values of normality, i.e. values in the 99th percentile of a healthy population, and level of detection are characteristics that are specific for each assay. Correct interpretation of troponin levels is thus often challenging, especially when complex patients with multiple diseases are involved. To overcome the relative low specificity of a single troponin measurement and to increase sensitivity in patients presenting shortly after pain onset, most protocols for the management of suspected ACS proposed throughout the literature consider both troponin baseline values and variation over-time. The purpose of this article is to review the most common ED scenarios where troponin measurement can be helpful, providing a few practical steps that we think should be followed by the physician to correctly test and interpret troponin levels when evaluating patients with suspected ACS (Fig. 1).

Highly sensitive troponin and diagnostic accuracy in acute myocardial infarction

Chest pain is one of the most common reasons for which patients seek care in the emergency department. When evaluating these patients, much effort is made to recognize cardiac causes of chest pain, in particular acute coronary syndrome (ACS), and to identify high-risk patients who may benefit from more aggressive treatments. Cardiac troponins play a pivotal role for this purpose. The diagnosis of acute myocardial infarction (AMI) is based mainly on an elevated cardiac troponin level exceeding the 99th percentile; this since 2000, when the joint committee of the European Society of Cardiology and the American College of Cardiology (ESC/ACC) published a new definition of AMI that for the first time officially included these biomarkers [1]. Recently introduced high-sensitivity troponin assays have improved the early diagnosis of acute myocardial infarction, and have a pivotal role in diagnosis, risk stratification, and management of patients with acute coronary syndromes [2–4], but their ideal cut-off and critical changes are yet to be established. Moreover, in clinical practice, the use of troponin high sensitivity is likely to increase the number of false-positive results. Summary

Cardioversion in atrial fibrillation. Focus on recent-onset atrial fibrillation.

Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice. Its prevalence is rising due to an increasing elderly population and the improvement in management of life-threatening diseases such as myocardial infarction and heart failure. Over the past few years effective non-pharmacological treatments, new antiarrhythmics drugs, and anticoagulants have been introduced. Regardless of rate-control or rhythm control strategy, adequate stroke prevention still remains a cornerstone in the treatment of this arrhythmia. This review aims to illustrate the main practical issues in the management of atrial fibrillation, focusing on patients with recent-onset and hemodynamically stable atrial fibrillation.

Ivabradine added to guidelines-based therapy in systolic heart failure patients

Raised resting heart rate is a risk factor for morbidity and mortality in a patient with heart disease [1]. Several patients with heart failure show increased heart rate even if treated with beta-blockers. Furthermore, most patients are intolerant to these drugs. Ivabradine is a selective inhibitor of the If current in the sinoatrial node, resulting in heart rate reduction without affecting myocardial contractility and intracardiac conduction. This pure negative chronotropic effect was previously evaluated in patients with stable angina pectoris. Previously randomised clinical studies demonstrate that ivabradine reduces the heart rate and the risk of angina attacks, and improves exercise capacity, without affecting cardiovascular death and hospital admission for heart failure [2–4].