Stéphanie André

Midregional Pro–Atrial Natriuretic Peptide for the Diagnosis of Cardiac-Related Dyspnea according to Renal Function in the Emergency Department: A Comparison with B-Type Natriuretic Peptide (BNP) and N-Terminal ProBNP

BACKGROUND Although renal dysfunction influences the threshold values of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in diagnosis of cardiac-related dyspnea (CRD), its effects on midregional pro-atrial natriuretic peptide (MR-proANP) threshold values are unknown. We evaluated the impact of renal function on MR-proANP concentrations and compared our results to those of BNP and NT-proBNP. METHODS MR-proANP, BNP, and NT-proBNP concentrations were measured in blood samples collected routinely from dyspneic patients admitted to the emergency department. Patients were subdivided into tertiles based on their estimated glomerular filtration rate [eGFR, in mL · min(-1) · (1.73 m(2))(-1)]: tertiles 1 (<44.3), 2 (44.3-58.5), and 3 (≥58.6). RESULTS Of 378 patients studied, 69% (n = 260) had impaired renal function [<60 mL · min(-1) · (1.73 m(2))(-1)] and 30% (n = 114) had CRD. MR-proANP, BNP, and NT-proBNP concentrations were significantly increased in patients with impaired renal function. In each tertile, all peptides remained significantly increased in CRD patients by comparison with non-CRD patients. By ROC analysis, MR-proANP, BNP, and NT-proBNP threshold values for the diagnosis of CRD increased as eGFR decreased from tertile 3 to tertile 1. Areas under the ROC curve for all peptides were significantly lower in tertile 1. Using adapted thresholds, MR-proANP, BNP, and NT-proBNP remained independently predictive of CRD, even in tertile 1 patients. CONCLUSIONS Renal function influences optimum cutoff points of MR-proANP for the diagnosis of CRD. With use of an optimum threshold value adapted to the eGFR category, MR-proANP remains as effective as BNP and NT-proBNP in independently predicting a diagnosis of CRD in the emergency department.

Febrile neutropenia in French emergency departments: results of a prospective multicentre survey.

IntroductionFebrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED).MethodsThis prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk.Results198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001).ConclusionsIn this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.

Extra-Hematopoietic Effects of Erythropoietin

Erythropoietin (Epo) has a long-lasting history as the hormon that allows production of red blood cells. It is now well established that, besides erythropoiesis, Epo has the ability to sustain proliferation of myeloid lineages. More recently, extra-haematological roles have been described for Epo. Its receptor, EpoR, has been detected at the membrane of several neoplastic and normal cell types from the central nervous system and other non haematological cell lines. Whereas Epo-EpoR have been detected several years ago in some extra-haematological normal lineages, their role has long been underestimated whereas they may be crucial for proliferation and survival. Consequently, efforts have recently increased to identify the precise role of Epo-EpoR in a variety of cell types. This allowed identification of physiologically relevant targets that led to original therapeutic strategies.

Accuracy of oxygen tissue saturation values in assessing severity in patients with sepsis admitted to emergency departments.

Introduction Near-infrared spectrometry assesses hemoglobin saturation of oxygen in tissues (StO2). Although it may provide additional information on local microcirculation function, the usefulness of near-infrared spectrometry in septic patients is debated. This study evaluated whether baseline StO2 value is useful in septic patients admitted to the emergency department with a diagnosis of severe sepsis. Materials and methods We carried out a prospective multicenter study in three emergency departments in Paris, France. Triage nurses were to record StO2, the results were blinding to the emergency physicians. Patients were eligible when presenting with at least two of the following parameters: temperature higher than 38°C or less than 36°C, respiratory rate greater than 30/min, heart rate greater than 120/min, and systolic arterial blood pressure less than 110 mmHg. Patients with a final diagnosis of sepsis and severe sepsis were analyzed. Results We analyzed 98 patients (70 with sepsis and 28 with severe sepsis). Thirty-day mortality was 2.9 versus 14.3% (P=0.048) in the sepsis and the severe sepsis group, respectively. No significant difference in the median StO2 was observed in patients with sepsis and severe sepsis [79% (74–85%) vs. 77% (72–83%), respectively; P=0.66]. The area under the curve of the receiver operating characteristic curve for StO2 to predict severe sepsis was 0.53 (0.39–0.66; P=0.5) and the cutoff value was 77%. Median StO2 did not differ in patients admitted to the ICU [80% (60–88%) vs. 79% (74–84%); P=0.78] and in nonsurvivors compared with that of survivors [79% (74–85%) vs. 76% (73–83%); P=0.64]. Conclusion This study fails to show any value of StO2 baseline at triage for early detection of severe sepsis in emergency patients.

Anemia e Pronto Soccorso

Pochi studi si sono interessati all’anemia in Pronto Soccorso, mentre questo problema e pluriquotidiano al letto del paziente per ogni urgentista. L’anemia puo essere la causa del sintomo che conduce il paziente a visita e l’oggetto stesso della visita o essere scoperta al momento della presa in carico del paziente. La presenza di un’anemia pone numerose domande nel contesto dell’urgenza: quali eziologie ricercare e con quali tempi, qual e la ripercussione dell’anemia, il paziente deve essere sottoposto a una trasfusione? Lo scopo di questo capitolo e di fornire degli elementi di risposta a ciascuna di queste domande che si pone legittimamente l’urgentista di fronte all’anemia nella sua pratica clinica.

Neutropenia febbrile e Pronto Soccorso

La comparsa di una neutropenia febbrile in un paziente trattato con chemioterapia antineoplastica e un evento importante gravato da una forte morbilita e da una mortalita che dipende dal terreno. La gestione in urgenza si basa su una valutazione scrupolosa che determina l’orientamento e la terapia antibiotica. Questa valutazione e tanto piu difficile in quanto la clinica e, il piu delle volte, povera e la sensibilita dei germi in causa non e prevedibile. In effetti, la terapia antibiotica iniziale deve essere somministrata precocemente e coprire un ampio spettro. Si fa una riflessione sulle procedure di gestione delle neutropenie febbrili nel contesto dell’urgenza.