Measurement of Procalcitonin as an Indicator of Severity in Patients With Chronic Obstructive Pulmonary Disease Admitted With Respiratory Illness.

Introduction Exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for hospital admission and a major cause of morbidity and mortality. A useful biomarker or indicator of disease severity at the time of presentation could help guide treatment and identify those with poor prognosis who need early aggressive intervention. We hypothesized that patients who present to the hospital with COPD exacerbations who are found to have elevated procalcitonin (PCT) levels will have worse outcomes such as longer admissions, increased intensive care unit (ICU) utilization, and more frequent readmissions than those with normal levels, regardless of presence or absence of infiltrate on initial chest X-ray (CXR). Methods We conducted a retrospective chart review of patients admitted to our facility with a respiratory complaint and a diagnosis of COPD to examine the relation between PCT and disease severity. A total of 156 unique encounters were reviewed, with 87 included in the final data set. Data was collected on baseline medical conditions as well as clinical status at the time of presentation. Primary endpoints included the need for overnight ICU admission, hospital length of stay greater than seven days, and repeat visit within 30 days of discharge. Secondary endpoints included the need for intubation at the time of admission, in-hospital mortality or discharge to hospice, and ICU length of stay. Results Patients with elevated PCT levels (>0.25ng/mL) had a significantly increased likelihood of a need for ICU admission (odds ratio 3.18) and hospital length of stay greater than seven days (odds ratio 3.38). There was no statistically significant difference in the Emergency Department readmission rate or any of the secondary outcomes. Conclusions Our data suggests that PCT may be a useful early biomarker for patients with COPD presenting with an acute respiratory illness.

Severe hyponatremia associated with thiazide diuretic use.

BACKGROUND: Thiazide diuretics are commonly used as first-line antihypertensive agents. Hyponatremia is a reported, though uncommon, complication of thiazide use. Although the exact mechanism of thiazide-induced hyponatremia (TIH) is unclear, it can be a significant cause of morbidity and mortality. CASE REPORT: We report a 69-year-old man with generalized weakness beginning 2 weeks after starting hydrochlorothiazide (HCTZ). Evaluation revealed a serum sodium level of 120 mmol/L. The patient was admitted and successfully treated with free water restriction and discontinuation of the HCTZ. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hyponatremia is an uncommon complication of thiazide diuretic use, which frequently presents with nonspecific symptoms. Identification of TIH is crucial to prevent its potentially life-threatening complications.

Atrial tachycardia mimicking atrioventricular nodal reentry tachycardia.

BACKGROUND: The term supraventricular tachycardia (SVT) is used to describe tachydysrhythmias that require atrial or atrioventricular nodal tissue for their initiation and maintenance. SVT can be used to describe atrioventricular nodal reentry tachycardia, atrioventricular reentry tachycardia, and atrial tachycardia (AT). AT is the least common of these SVT subtypes, accounting for only 10% of cases. Although the suggested initial management of each SVT subtype is different, they all can present with similar symptoms and electrocardiographic findings. OBJECTIVE: Discuss the pathophysiology, diagnosis, and treatment of AT as compared with other types of SVT. CASE REPORT: We report a 56-year-old woman with symptoms and electrocardiographic findings consistent with SVT. Although standard treatment with intravenous adenosine failed to convert the SVT, it revealed AT as the cause of the tachydysrhythmia. The AT was successfully terminated with beta-blockade and the patient eventually underwent successful radioablation of three separate AT foci. CONCLUSIONS: AT frequently mimics other more common forms of SVT. AT might be recognized only when standard treatment of SVT has failed. Identification of AT in this setting is crucial to allow for more definitive therapy.

Elevation of troponin I in athletes: a case report in a marathon runner.

The case of a 24-year-old athlete who presented with a syncopal episode after having run 25 miles in a marathon is reported. The patient was subsequently found to have significant elevations of troponin I, which remained detectable for 3 days. The patient remained asymptomatic during his 8-day hospitalization without other evidence of cardiac ischemia: studies included echocardiography and multiple gated acquisition (MUGA) scan. The current knowledge about elevation of troponin I unrelated to cardiac injury in endurance athletes is discussed.

Locked anterior-inferior shoulder subluxation presenting as luxatio erecta.

Shoulder subluxation may present as a complication of either traumatic injury to a joint, repetitive mictrotrauma, or atraumatic joint laxity. The case of a middle-aged man who presented with a confusing clinical picture similar to inferior shoulder dislocation, luxatio erecta, with a radiographic diagnosis of anterior-inferior shoulder subluxation is discussed. An understanding of the differential diagnosis of shoulder dislocation and subluxation and the management of atypical presentations is critical to the emergency physician.