Pleunie P.M. Rood

Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study.

BACKGROUNDnIt is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).nnnOBJECTIVESnThis study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.nnnMETHODSnIn a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.nnnRESULTSnThe study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.nnnCONCLUSIONSnCCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).

Self-referred patients at the Emergency Department: patient characteristics, motivations, and willingness to make a copayment

BackgroundIn many countries, including the Netherlands, a substantial number of patients visit the Emergency Department (ED) without a referral by a general practitioner. The goal of this study was to determine the characteristics and motivations of self-referred patients (SRPs) at the ED. The secondary objective was to explore SRPs’ opinion about copayments.MethodsA survey, in seven different languages was performed among SRPs from October 2011 until January 2012 at an academic ED in the Netherlands. Patients were included on 21xa0day-, 21 evening-, and 21 nightshifts during week and weekend days equally. Patient characteristics, motivations, complaints, diagnosis, and the opinion regarding copayments were examined.ResultsA total of 436 SRPs were included (response rate 82%). Forty-seven percent of the ED population was self-referred. SRPs were mainly male (58%), between 18 and 35xa0years (54%), Dutch (67%), single without children (42%), and low-educated (73%). The most commonly presented complaints were of musculoskeletal origin (35%). Expected need for additional medical care (e.g., X-rays, blood tests) was the reason to visit the ED for 28% of the SRPs. Around 30% of the SRPs were not prepared to pay for an ED visit. Fifty percent of SRPs were prepared to pay up to 25 or 50 EUR. Highly educated patients were willing to pay more than patients with a low level of education (pu2009<u20090.05).ConclusionsSRPs (47% of the total ED population) are often young men with musculoskeletal complaints. They are convinced that additional medical tests are necessary. About 70% of the SRPs are willing to make a copayment, half of the SRPs with a maximum between 25 EUR and 50 EUR. As highly educated SRPs are prepared to pay more, introducing copayments might influence equity in health care accessibility.

Procalcitonin-guided therapy for the initiation of antibiotics in the ED: a systematic review

BACKGROUNDnProcalcitonin (PCT) is a new biomarker with a higher accuracy in the diagnosis of bacterial infections. Utilization of PCT may reduce the number of unnecessary antibiotics prescribed to patients and consequently may decrease the rise in antibiotic resistance. The aim of this systematic review is to determine if a PCT-guided algorithm can safely reduce the number of antibiotics prescribed to all patients with a suspected of infection in the emergency department (ED).nnnMETHODSnMEDLINE, EMBASE, Web of Science, COCHRANE central, PubMed publisher, and Google scholar were searched. Two reviewers performed the screening independently. The QUADAS 2 tool was used to assess quality.nnnRESULTSnIn total, 1621 articles were screened. Nine articles were included in the analysis. In the 6 studies on adult patients, only patients with respiratory tract infections were investigated. In these studies, a cutoff value of 0.25 μg/L was used, and PCT-guided therapy reduced the number of prescribed antibiotics significantly. Three studies were on pediatric patients, 2 on fever without source and 1 on respiratory complaints. Procalcitonin-guided therapy did not reduce antibiotic prescription in children. Procalcitonin-guided therapy did not result in an increase in adverse events in any of the studies.nnnDISCUSSIONnProcalcitonin-guided therapy in the ED is only studied in subpopulations, where it was effective and safe in adult patients with respiratory tract infections and not effective but safe nonetheless in specific pediatric populations. Nonadherence is a significant problem in prospective PCT-guided therapy studies. There is not enough evidence to use PCT-guided therapy in a general ED population.

Non-invasive blood pressure and cardiac index measurements using the Finapres Portapres in an emergency department triage setting

UNLABELLEDnEmergency department (ED) patients are triaged to determine the urgency of care. The Finapres Portapres (FP) measures blood pressure (BP) and cardiac output (CO) non-invasively, and may be of added value in early detection of patients at risk for hemodynamic compromise.nnnOBJECTIVESnCompare non-invasive BP measurements using FP and standard automated sphygmomanometry. Compare FP cardiac index (CI), CO corrected for body surface area, of normotensive patients, to chart-based physician estimate of shock, to discover if there is additional value in CI measurements in triage.nnnMETHODSnED Patients requiring BP measurement in triage were included. Systolic (SBP) and diastolic (DBP) BP were measured using both devices during a two minutes measurement. Two physicians independently judged probability of shock, defined as estimated CI ≤2.5 L min(-1) m(-2), based on chart review, three weeks after ED visit.nnnRESULTSnOf a total of 112 patients 97 patients were included. Pearsons correlation coefficient was 0.50 for SBP, 0.53 for DBP, with a Blant-Altman mean bias of 11.3 (upper limit 65.3, lower limit -42.8) and 7.7 (39.2, -23.7) for SBP and DBP respectively. In normotensive patients, the group with low FP CI measurements had significantly more cases with physician-estimated shock, compared to the normal to high measurements (P = .036).nnnCONCLUSIONSnWhen used as a triage device in the emergency department setting, non-invasive BP measurements using FP do not correlate well with automated sphygmomanometry. However, this study does indicate that use of the FP device in triage may aid physicians to recognize patients in early phases of shock.

Higher diagnostic accuracy and cost-effectiveness using procalcitonin in the treatment of emergency medicine patients with fever (The HiTEMP study): a multicenter randomized study

AbstractBackgroundFever is a common symptom in the emergency department(ED). Fever can be caused by bacterial infections, which are treated with antibiotics. Often, bacterial infections cannot be ruled out in the ED using standard diagnostics, and empiric antibiotic treatment is started. Procalcitonin(PCT) is a biomarker for bacterial infections, but its role in an undifferentiated ED population remains unclear. We hypothesize that PCT-guided therapy may reduce antibiotics prescription in undifferentiated febrile ED patients. The primary objectives of this study are to determine a) the efficacy, b) the safety of PCT-guided therapy, and c) the accuracy of the biomarker PCT for bacterial infections. The secondary objective is to study the cost-effectiveness of PCT-guided therapy.Methods/designThis is a multicenter noninferiority randomized controlled trial. All adult ED patients with fever(≥38.2xa0°C) are randomized between standard care with and without the addition of a PCT level, after written informed consent.a)For efficacy, the reduction of patients receiving antibiotics is calculated, using a superiority analysis: differences between the PCT-guided group and control group are assessed using a Fisher’s exact test, and a multivariable logistic regression analysis to account for the effects of demographic and medical variables on the percentage of febrile patients receiving antibiotics.b)Safety consists of a composite endpoint, defined as mortality, intensive care admission and ED return visit within 14xa0days. Noninferiority of PCT will be tested using a one-sided 95xa0% confidence interval for the difference in the composite safety endpoint between the PCT-guided and control groups using a noninferiority margin of 7.5xa0%.c)Accuracy of PCT and CRP for the diagnosis of bacterial infections will be reported, using the sensitivity, specificity, and the area under the receiver-operating-characteristic curve in the definitive diagnosis of bacterial infections.n The sample size is 550 patients, which was calculated using a power analysis for all primary objectives. Enrollment of patients started in August 2014 and will last 2 years.DiscussionPCT may offer a more tailor-made treatment to the individual ED patient with fever. Prospective costs analyses will reveal the economic consequences of implementing PCT-guided therapy in the ED.This trial is registered in the Dutch trial registerNTR4949

Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study)

OBJECTIVESnOveruse of broad-spectrum antibiotics in emergency departments (EDs) results in antibiotic resistance. We determined whether procalcitonin (PCT) -guided therapy can be used to reduce antibiotic regimens in EDs by investigating efficacy, safety and accuracy.nnnMETHODSnThis was a non-inferiority multicentre randomized clinical trial, performed in two Dutch hospitals. Adult patients with fever ≥38.2°C (100.8°F) in triage were randomized between standard diagnostic workup (control group) and PCT-guided therapy, defined as standard workup with the addition of one single PCT measurement. The treatment algorithm encouraged withholding antibiotic regimens with PCT <0.5xa0μg/L, and starting antibiotic regimens at PCT ≥0.5xa0μg/L. Exclusion criteria were immunocompromised conditions, pregnancy, moribund patients, patients <72xa0h after surgery or requiring primary surgical intervention. Primary outcomes were efficacy, defined as number of prescribed antibiotic regimens; safety, defined as combined safety end point consisting of 30 days mortality, intensive-care unit admission, ED return visit within 2xa0weeks; accuracy, defined as sensitivity, specificity and area-under-the-curve (AUC) of PCT for bacterial infections. Non-inferiority margin for safety outcome was 7.5%.nnnRESULTSnBetween August 2014 and January 2017, 551 individuals were included. In the PCT-guided group (nxa0=xa0275) 200 (73%) patients were prescribed antibiotic regimens, in the control group (nxa0=xa0276) 212 (77%) patients were prescribed antibiotics (p 0.28). There was no significant difference in combined safety end point between the PCT-guided group, 29 (11%), and control group, 46 (16%) (p 0.16), with a non-inferiority margin of 0.46% (nxa0=xa0526). AUC for confirmed bacterial infections for PCT was 0.681 (95% CI 0.633-0.730), and for CRP was 0.619 (95% CI 0.569-0.669).nnnCONCLUSIONSnPCT-guided therapy was non-inferior in terms of safety, but did not reduce prescription of antibiotic regimens in an ED population with fever. In this heterogeneous population, the accuracy of PCT in diagnosing bacterial infections was poor. TRIAL REGISTRATION IN NETHERLANDS TRIAL REGISTER: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4949.

Procalcitonin guided antibiotic therapy in patients presenting with fever in the emergency department

In this journal, Tromp et al. reported on the biomarker procalcitonin (PCT), a precursor protein of calcitonin, in the diagnosis of bacterial infections. The study compared the accuracy of PCT, interleukin-6 (IL-6), lipopolysaccharidebinding protein (LBP), C-reactive protein (CRP) in diagnosing bacterial infections. PCT was tested the best single biomarker for the prediction of bacteraemia in septic patients in the emergency department (ED). We describe our findings of a study using PCT guided antibiotic therapy to reduce antibiotics prescription in the ED. We show a trend toward significance in reducing antibiotic prescription using a single PCT measurement, in undifferentiated febrile patients visiting the ED. The surviving sepsis campaign states that broadspectrum antibiotics have to be administered within one hour, when patients have a suspected infection with systemic inflammatory response syndrome (SIRS). This increases the rate of antibiotic prescriptions in the emergency department (ED), and may contribute to further resistance for antibiotics. Antimicrobial stewardship stands for targeted and effective antibacterial therapy, with special attention for the initiation and timely ending of antibiotics use. The goal of antimicrobial stewardship is to contain the increasing resistance of microorganisms. The aim of this study was to reduce the unnecessary antibiotics prescription by introducing a PCT guided therapy algorithm. Undifferentiated febrile ED patients were randomized to either PCT guided therapy or standard-ofcare. In both groups routine blood testing was performed, including CRP. Only in the PCT guided therapy group, a PCT value was reported to the physicians. The PCT results were appraised using cut-off points as found by other research groups, in which a PCT level of PCT > 0.5 mg/L was associated with bacterial infection. Samples for bacterial and viral cultures and polymerase chain reaction (PCR) were taken from the suspected focus of infection, to confirm a definitive diagnosis. Although PCT guided antibiotic prescription advice was given, the treating physician

Workflow and factors associated with delay in the delivery of intra-arterial treatment for acute ischemic stroke in the MR CLEAN trial

Objective The effect of intra-arterial treatment (IAT) for acute ischemic stroke is highly time-dependent. We investigated the delay of IAT and factors associated with such delay. Methods MR CLEAN was a randomized trial of IAT plus usual care versus usual care alone (n=500). With multivariable linear regression, we analyzed the effect of intravenous treatment, general anesthesia, off-hours and inter-hospital transfer on time to admission to the emergency department (ED) of the intervention center and time to treatment. Furthermore, we assessed compliance with a target of 75u2009min for time from ED to treatment, and calculated the potential absolute increase in the number of patients with a good outcome (modified Rankin Scale score ≤2) if this target had been achieved in all treated patients. Results Inter-hospital transfer prolonged time to ED by 140u2009min (95% CI 129 to 150) but reduced time from ED to treatment by 77u2009min (95%u2009CI 64 to 91). Time from ED to treatment was increased by 19u2009min by general anesthesia (95%u2009CI 5 to 33) and total time was increased by 23u2009min during off-hours (95%u2009CI 6 to 40). The in-hospital target was achieved in 11.5% (22/192) of patients. Full compliance with the target time of 75u2009min from ED to treatment would have increased the proportion of patients with a good outcome by 7.6% (95% CI 6.7% to 8.5%). Conclusion Inter-hospital transfer is an important cause of delay in the delivery of IAT and every effort should be made to avoid transfers and reduce transfer-related delay. Furthermore, in-hospital workflow should be optimized to improve functional outcome after IAT.

Round-the-clock performance of coronary CT angiography for suspected acute coronary syndrome: Results from the BEACON trial

AbstractObjectiveTo assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours.MethodsPatients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3.ResultsThere were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0–33.5] for patients presenting during office hours in comparison to 27.5 [19.75–32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0–1.0] vs. 1.0 [0–4.0], p=0.009).ConclusionImage quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished.Key Points• Quality scores were higher for coronary-CTA during office hours.n • There were no differences in acquisition parameters.n • There was a non-significant trend towards higher heart rates outside office hours.n • Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff.n • Coronary-CTA on the ED needs preparation time and optimisation of the procedure.

Identifying patients with bacterial infections using a combination of C-reactive protein, procalcitonin, TRAIL, and IP-10 in the emergency department: a prospective observational cohort study

OBJECTIVESnThe aim was to effectively reduce the unnecessary use of broad spectrum antibiotics in the emergency department (ED), patients with bacterial infections need to be identified accurately. We investigated the diagnostic value of a combination of biomarkers for bacterial infections, C-reactive protein (CRP), and procalcitonin (PCT), together with biomarkers for viral infections, tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), and interferon-gamma-induced protein-10 (IP-10), in identifying suspected and confirmed bacterial infections in a general ED population with fever.nnnMETHODSnThis is a sub-study in the HiTEMP cohort. Patients with fever were included during ED triage, and blood samples were obtained. Using both diagnostics and expert panel analysis, all patients were classified as having either suspected or confirmed bacterial infections, or non-bacterial disease. Using multivariable logistic regression analysis, three biomarker models were analysed: model 1, CRP, TRAIL, IP-10; model 2, PCT, TRAIL, IP-10; and model 3, CRP, PCT, TRAIL, IP-10.nnnRESULTSnA total of 315 patients were included, of whom 228 patients had a suspected or confirmed bacterial infection. The areas under the curve for the combined models were the following: model 1, 0.730 (95% CI 0.665-0.795); model 2, 0.748 (95% CI 0.685-0.811); and model 3, 0.767(95% CI 0.704-0.829).nnnCONCLUSIONSnThese findings show that a combination of CRP, PCT, TRAIL and IP-10 can identify bacterial infections with higher accuracy than single biomarkers and combinations of a single bacterial biomarkers combined with TRAIL and IP-10.