S. S. W. Chan

Disease severity prediction for nursing home-acquired pneumonia in the emergency department

Background Prediction rules exist for the assessment of community-acquired pneumonia but their use in nursing home-acquired pneumonia (NHAP) remains undefined. The objectives of this study were to compare the prognostic ability for severe NHAP of five prediction rules (PSI, CURB-65, M-ATS, R-ATS, España rule), and to evaluate their usefulness to identify patients with less severe disease in the emergency department for outpatient care. Methods A prospective observational study of consecutive NHAP patients was conducted at a university teaching hospital emergency department in Hong Kong between January 2004 and June 2005. The primary outcome was severe pneumonia (defined as combined 30-day mortality and/or intensive care unit (ICU) admission). Results 767 consecutive NHAP patients were included. Mean (SD) age was 83.4 (9.0) years; 350 (45.6%) were male and 644 (84.0%) had coexisting illness. 95 patients died within 30 days (12.4%), five patients were admitted to the ICU (0.7%) and 98 patients had severe pneumonia (12.8%). Sensitivity and specificity of each decision rule ranged from 37.8% to 95.9% and 15.1% to 87.6% respectively. The overall predictive performance of each rule was between 0.627 and 0.712. The negative likelihood ratios of PSI (0.27) and CURB-65 (0.23) were lower than M-ATS (0.71), R-ATS (0.45) and España (0.39). After excluding 204 patients with either poor functional status or those >90 years of age, sensitivities of M-ATS (96.0%) and R-ATS (100%) improved greatly with negative likelihood ratios of <0.1. Conclusion PSI and CURB-65 are useful for identification of patients with less severe NHAP.

Haemodynamic changes in emergency department patients with poorly controlled hypertension

OBJECTIVES This study aimed to measure cardiac output, systemic vascular resistance, cardiac index, and systemic vascular resistance index in emergency department patients with poorly controlled hypertension; and to determine the frequency in which antihypertensive drugs prescribed do not address the predominant haemodynamic abnormality. METHODS This cross-sectional observational study was conducted in an emergency department of a 1400-bed tertiary hospital in Hong Kong. Patients aged 18 years or above, with systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥100 mm Hg based on two or more measurements and on two separate occasions within 2 to 14 days, were included. Haemodynamic measurements were obtained using a non-invasive Doppler ultrasound monitor. Doctors were blinded to the haemodynamic data. Any antihypertensive medication adjustment was evaluated for correlation with haemodynamic changes. RESULTS Overall, 164 patients were included. Their mean age was 69.0 years and 97 (59.1%) were females. Systemic vascular resistance and cardiac output were elevated in 65.8% (95% confidence interval, 57.9-72.9%) and 15.8% (10.8-22.5%) of patients, respectively. Systemic vascular resistance index and cardiac index were elevated in 43.9% (95% confidence interval, 36.2-51.8%) and 19.5% (13.9-26.5%) of patients, respectively. Of 71 patients in whom antihypertensive medications were adjusted, 25 (35.2%; 95% confidence interval, 24.5-47.5%) were prescribed agents that did not correlate with the primary haemodynamic abnormality. CONCLUSIONS The profile of haemodynamic changes in emergency department patients with poorly controlled hypertension is characterised. The antihypertensive drugs prescribed did not correspond to the patients primary haemodynamic derangement in 35% of cases.

Children's discomfort during noninvasive cardiac output monitoring by suprasternal ultrasonographic transducer

Objectives To investigate the level of discomfort/pain in children receiving Ultrasonic Cardiac Output Monitoring (USCOM), as compared to blood pressure measurement. Methods Healthy children, aged 3-12 years old, were recruited from kindergartens and schools as a part of the “Healthy childrens vital signs and USCOM values” project. Oscillometric blood pressure was measured, followed by USCOM measurement. The discomfort experienced by the child during each intervention was assessed using the Wong-Baker FACES pain rating scale. The pain scores (scale from 0-5) were compared using Wilcoxon signed rank test. A difference in score of one point was considered to be clinically relevant. Gender differences in pain score were analysed using Mann-Whitney-U test. Results A total of 254 subjects (131 boys, 123 girls) were included. Mean age was 7.9 years with standard deviation (SD) of 2.4 years. The median pain score for USCOM measurement was 1.0 (95% CI=1.0 to 2.0) with interquartile range 1.0 to 2.0. The median pain score for BP measurement was 1.0 (95% CI,=1.0 to 1.0) with interquartile range 0.0 to 2.0. Overall, the pain score associated with USCOM was significantly higher than that associated with BP measurement. However, the difference fails to reach the minimum clinically significant difference of one-point. No significant difference was shown between boys and girls. Conclusion USCOM appears to be tolerated well by healthy children. The discomfort reported during USCOM measurement is comparable to that associated with blood pressure measurements.

Initial combination therapy for treatment of hypertension

The article by Morris Brown and colleagues (Jan 22, p 312) assesses the initial combination therapy of aliskiren and amlodipine against initial monotherapy of the individual drugs and their sequential add-on regimen. As noted, a doubling of dose for both aliskiren and amlodipine as well as add-on monotherapy resulted in a more eff ective reduction of systolic or diastolic blood pressure. However, the plausible increase in the risk of cancer, associated with long-term use of aliskiren in combination with am lodipine, is not addressed by the present trial and warrants further investigation. Chronic use of antihypertensive drugs, specifi cally those that act on the renin-angiotensin-aldosterone sys tem, such as angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), have been implicated in increasing the risk of cancer. These drugs that act via the angiotensinII-type 2 receptor kinin cGMP vasodilator-stimulated phosphoprotein pathway (VASP) might augment cancer risk. Aliskiren presents an additional advantage over ACE inhibitors and ARBs, since it inhibits renin directly. It also protects against diabetic retinopathy and obesity that could lead to type 2 diabetes. However, aliskiren, similarly to ACE inhibitors and ARBs, induces a reactive increase in renin secretion, which might con comitantly trigger VASP. Additionally, amlodipine has also been associated with increasing the incidence of cancer. Therefore, a multicentre trial with cancer as a prespecifi ed outcome needs to be done for aliskiren versus aliskirenamlodipine combination, before it can be endorsed for treating chronic hypertension. 2 Butler D. Radioactivity spreads in Japan. Nature 2011; 471: 555–56. 3 Tabuchi H. Japanese workers braved radiation for a temp job. New York Times April 10, 2011. http://www.nytimes. com/2011/04/10/world/asia/10workers. html?src=me&ref=homepage (accessed April 10, 2011). 4 Mettler FA, Voelz GL. Major radiation exposure—what to expect and how to respond. N Engl J Med 2002; 346: 1554–61. 5 Martin A. No. 3 cool pump test-run readied. Japan Times Online. March 24, 2011. http:// search.japantimes.co.jp/member/member. html?mode=getarticle&fi le=nn20110324x2. html (accessed April 10, 2011). 6 Klymenko SV, Belyi DA, Ross JR, et al. Hematopoietic cell infusion for the treatment of nuclear disaster victims: new data from the Chernobyl accident. Int J Radiat Biol 2011; published online March 16. DOI:10.3109/ 09553002.2011.560995. 7 Hirama T, Tanosaki S, Kandatsu S, et al. Initial medical management of patients severely irradiated in the Tokai-mura criticality accident. Br J Radiol 2003; 76: 246–53. 8 Chiba S, Saito A, Ogawa S, et al. Transplantation for accidental acute high-dose total body neutronand gamma-radiation exposure. Bone Marrow Transplant 2002; 29: 935–39. 9 Gooley TA, Chien JW, Pergam SA, et al. Reduced mortality after allogeneic hematopoietic-cell transplantation. N Engl J Med 2010; 363: 2091–101. 10 Taniguchi S. Health care planning for nuclear workers. MRIC Mail Magazine March 25, 2011. http://medg.jp/mt/2011/03/vol85. html#more (accessed April 10, 2011). 11 Siddiq S, Pamphilon D, Brunskill S, et al. Bone marrow harvest versus peripheral stem cell collection for hemopoietic stem cell donation in healthy donors. Cochrane Database Syst Rev 2009; 1: CD006406. 12 Japan Society for Hematopoietic Cell Transplantation. The statement from Japan Society for Hematopoietic Cell Transplantation (JSHCT) on recent earthquake disaster and subsequent nuclear power plant accident in Japan. http://www. jshct.com/english (accessed April 10, 2011). 13 Pulsipher MA, Chitphakdithai P, Miller JP, et al. Adverse events among 2408 unrelated donors of peripheral blood stem cells: results of a prospective trial from the National Marrow Donor Program. Blood 2009; 15: 3604–11. 14 Fujita A. Interview with Dr. Robert Gale. Asahi-shimbun March 29, 2011. https:// aspara.asahi.com/blog/kochiraapital/entry/ H09GQUXUMx (accessed April 10, 2011) 15 Sample I. Japanese offi cials consider cell transplants for nuclear workers. The Guardian March 29, 2011. http://www.guardian.co.uk/ world/2011/mar/29/japan-cell-transplantsnuclear-workers?INTCMP=SRCH#history-linkbox (accessed April 10, 2011). 16 Anon. “No need for hematopoietic stem cell harvesting” by Nuclear Safety Commission of Japan. Sankei-shimbun April 3, 2011. http:// sankei.jp.msn.com/politics/news/110403/ plc11040301310001-n1.htm (accessed April 10, 2011). the Japanese people but also people all over the world have a sense of distrust towards the industry, which is seen as insuffi ciently transparent in terms of information disclosure. Furthermore, the offi cials and authorities related to the industry seem to be reluctant to admit the seriousness of the problem to protect the industry’s reputation as much as possible. However, the most important mission is to save the nuclear workers’ lives and to protect the local communities. Such an approach would be the industry’s best defence: if a fatal accident happened to the nuclear workers, the nuclear power industry of Japan would collapse. It would also cause serious damage to the industry and the nuclear power policy all over the world. Therefore, we should prioritise support for the nuclear workers’ health. The process to completely shut down the reactors in Fukushima is expected to take years. The risk of accidental radiation exposure will thus accumulate for the nuclear workers and banking of their autologous PBSCs will become increasingly important. A judgment of right or wrong on this scheme must be determined from the standpoint of the nuclear workers and their families, not from a point of view of cost–benefi t balance in ordinary times. Toranomon Hospital in Tokyo is ready to harvest and bank autologous PBSCs for the nuclear workers upon request.

Open-access colonoscopy: outcomes of referrals from the emergency department

Aim  The study investigated the diagnostic outcome of colonoscopy referrals from the emergency department (ED) via an open‐access system.