Hira Shahzad

B-type natriuretic peptide versus amino terminal pro-B type natriuretic peptide: selecting the optimal heart failure marker in patients with impaired kidney function

BackgroundThe effect of impaired kidney function on B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) is vague. This study was performed to examine the effect of kidney dysfunction on the afore-mentioned markers and determine appropriate cutoffs for systolic heart failure (SHF).MethodsIn this cross sectional study adults with estimated glomerular filtration rate (eGFR) <60u2009ml/min for ≥3u2009months were identified in consulting clinics from June 2009 to March 2010. SHF was defined as documented by a cardiologist with ejection fraction ofu2009<u200940% and assessed by New York Heart Association classification (NYHA). Plasma was assayed for creatinine (Cr), BNP and NT-proBNP.ResultsA total of 190 subjects were enrolled in the study, 95 with and 95 without SHF. The mean age of patients was 58 (±15) years, 67.4% being males. Mean BNP levels showed a 2.5 fold and 1.5 fold increase from chronic kidney disease (CKD) stage 3 to stage 5 in patients with and without SHF respectively. NT-proBNP levels in non-heart failure group were 3 fold higher in CKD stage 5 compared to stage 3. Mean NT-proBNP levels were 4 fold higher in CKD stage 5 compared to stage 3 in patients with SHF. Optimal BNP and NT-proBNP cutoffs of SHF diagnosis for the entire CKD group were 300u2009pg/ml and 4502u2009pg/ml respectively.ConclusionBNP and NT-proBNP were elevated in kidney dysfunction even in the absence of SHF; however the magnitude of increase in NT-proBNP was greater than that of BNP. BNP and NT-proBNP can be useful in diagnosing SHF, nonetheless, by using higher cutoffs stratified according to kidney dysfunction. NT-proBNP appears to predict heart failure better than BNP.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan

BackgroundThe utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation.MethodsThe Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use.ResultsOut of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model.ConclusionUtilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

Pattern of fall injuries in Pakistan: the Pakistan National Emergency Department Surveillance (Pak-NEDS) study.

BackgroundWe aimed to analyse the frequency and patterns of fall-related injuries presenting to the emergency departments (EDs) across Pakistan.MethodsPakistan National Emergency Departments surveillance system collected data from November 2010 to March 2011 on a 24/7 basis using a standardized tool in seven major EDs (five public and two private hospitals) in six major cities of Pakistan. For all patients presenting with fall-related injuries, we analysed data by intent with focus on unintentional falls. Simple frequencies were run for basic patient demographics, mechanism of falls, outcomes of fall injuries, mode of arrival to ED, investigations, and procedures with outcomes.ResultsThere were 3335 fall-related injuries. In cases where intent was available, two-thirds (n = 1186, 65.3%) of fall injuries were unintentional. Among unintentional fall patients presenting to EDs, the majority (76.9%) were males and between 15-44 years of age (69%). The majority of the unintentional falls (n = 671, 56.6%) were due to slipping, followed by fall from height (n = 338, 28.5%). About two-thirds (n = 675, 66.6%) of fall injuries involved extremities, followed by head/neck (n = 257, 25.4%) and face (n = 99, 9.8%). Most of the patients were discharged from the hospital (n = 1059, 89.3%). There were 17 (1.3%) deaths among unintentional fall cases.ConclusionFalls are an important cause of injury-related visits to EDs in Pakistan. Most of the fall injury patients were men and in a productive age group. Fall injuries pose a burden on the healthcare system, especially emergency services, and future studies should therefore focus on safety measures at home and in workplaces to reduce this burden.

Abdominal injury after a fall.

CASE A 20-year-old man was brought to the ED after a fall. He had been leaning against an old railing that broke under his weight; he fell about 20 feet to the ground below, landing on his left side. His only past medical history is a wrist fracture 2 years ago. Physical examination showed stable vital signs and diffuse abdominal tenderness without peritoneal signs. He had no evidence of spinal or skeletal injury. No blood was visualized at the urethral meatus but gross hematuria was seen upon insertion of an indwelling urinary catheter. A FAST examination was positive for free fluid in the Morrison pouch. A CT of the abdomen and pelvis was obtained (Figure 1). The most significant finding is: • free fl uid in the abdomen • free air under the diaphragm • aortic injury • kidney laceration • retroperitoneal hematoma.

Managing traumatic injury in an acute setting.

Waqas Shuaib practices in the Department of Radiology and Imaging Sciences at Emory University in Atlanta, Ga. Hira Shahzad is a research collaborator at the Medical College at Aga Khan University Hospital in Karachi, Pakistan. Richard Alweis is an attending physician at Reading Health System in West Reading, Pa. Edward A. Stettner is an assistant professor in the Department of Emergency Medicine at Emory University. Michelle D. Lall is an assistant professor and assistant residency director in the Department of Emergency Medicine at Emory University. Jason Weiden is an assistant professor in the Department of Radiology and Imaging Sciences at Emory University. The authors have disclosed no potential confl icts of interest, fi nancial or otherwise. Bryan Walker, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000458867.86182.6d Copyright

What caused this patient's chest pain and refractory hypotension?

CASE A 66-year-old man was found unconscious at home by his son, who called 911. The patient was unresponsive without a palpable pulse and was resuscitated and intubated by emergency medical technicians. He was taken to the hospital, where he underwent aggressive fl uid resuscitation and vasopressor therapy. He subsequently regained a palpable pulse. According to his son, the patient had complained of chest and back pain the previous day. The patient is an ex-smoker and has a long-standing history of chronic obstructive pulmonary disease (COPD) and poorly controlled hypertension. He lives alone. His family history is positive for hypertension and heart disease. In the ED, physical examination revealed an intubated, unresponsive patient with a Glasgow Coma Scale score of 3 out of 15, and persistent hypotension (systolic BP of 80 to 90 mm Hg despite vasopressors). He has present but feeble brachial and radial pulses; femoral and pedal pulses cannot be palpated bilaterally. His skin is diffusely mottled and cool to touch. An ECG and chest radiograph were taken emergently (Figure 1). Which imaging study would help to defi ne the exact cause of the fi ndings on the chest radiographs of this patient? • transesophageal echocardiogram • transthoracic echocardiogram • digital subtraction angiography of the lower extremities • contrast-enhanced CT • MRI of the chest