Usefulness of midregional proadrenomedullin to predict poor outcome in patients with community acquired pneumonia.

BACKGROUND: midregional proadrenomedullin (MR-proADM) is a prognostic biomarker in patients with community-acquired pneumonia (CAP). We sought to confirm whether MR-proADM added to Pneumonia Severity Index (PSI) improves the potential prognostic value of PSI alone, and tested to what extent this combination could be useful in predicting poor outcome of patients with CAP in an Emergency Department (ED). METHODS: Consecutive patients diagnosed with CAP were enrolled in this prospective, single-centre, observational study. We analyzed the ability of MR-proADM added to PSI to predict poor outcome using receiver operating characteristic (ROC) curves, logistic regression and risk reclassification and comparing it with the ability of PSI alone. The primary outcome was "poor outcome", defined as the incidence of an adverse event (ICU admission, hospital readmission, or mortality at 30 days after CAP diagnosis). RESULTS: 226 patients were included; 33 patients (14.6%) reached primary outcome. To predict primary outcome the highest area under curve (AUC) was found for PSI (0.74 [0.64-0.85]), which was not significantly higher than for MR-proADM (AUC 0.72 [0.63-0.81, p > 0.05]). The combination of PSI and MR-proADM failed to improve the predictive potential of PSI alone (AUC 0.75 [0.65-0.85, p=0.56]). Ten patients were appropriately reclassified when the combined PSI and MR-proADM model was used as compared with the model of PSI alone. Net reclassification improvement (NRI) index was statistically significant (7.69%, p = 0.03) with an improvement percentage of 3.03% (p = 0.32) for adverse event, and 4.66% (P = 0.02) for no adverse event. CONCLUSION: MR-proADM in combination with PSI may be helpful in individual risk stratification for short-term poor outcome of CAP patients, allowing a better reclassification of patients compared with PSI alone.

Alpha-Fetoprotein-Producing Extrahepatic Tumor: Clinical and Histopathological Significance of a Case.

INTRODUCTION: The serum rise of alpha-fetoprotein (AFP) has been relationed to hepatic tumors. Other than these, such as gastric adenocarcinoma, can present with high levels of this glycoprotein. One rare kind of gastric adenocarcinoma, called hepatoid subtype, has two essential features: hepatoid differentiation in histology and high levels of AFP in serum. DISCUSSIONS: We report a Spanish female who consulted because of fatigue, anorexia, and weight loss. In laboratory data, she presented anemia and markedly elevation of AFP. On CT scan, a gastric mass resulted without hepatic dissemination, and subsequently, gastroduodenoscopy was performed for histological diagnosis. Then, an ulcerated mass was detected and sample was taken, resulting in poorly-differentiated adenocarcinoma of stomach with hepatoid tissue foci, with intense positivity for AFP-immunohistochemical staining. This rare cancer has poor prognosis even with early gastrectomy and chemotherapy.

Patient outcomes after noninvasive mechanical ventilation at a high dependency unit of an emergency department.

OBJECTIVE: To describe the outcome of patients after noninvasive ventilation in a high dependency unit (HDU) of an emergency department (ED). Secondary aims were to define the role of intensive care consultation and to identify variables associated with mortality. METHODS: Observational, prospective 6-month study. RESULTS: Two hundred and nine cases were analysed. Thirty-four patients were initially rejected by the intensive care unit (ICU). Physicians in the ED did not request ICU consultation in the remaining 175 (83%) because of 'belief of improvable medical condition in the ED in patients without therapeutic limits' in 93 (group 1) and to 'preset therapeutic limits' or 'comfort measures only' in 82 (groups 2 and 3). Ten out of these 175 were subsequently admitted to the ICU. The global in-hospital mortality rate was 22% (3.3% in the high dependency unit), but only 10% in group 1. Place of referral for ventilation (P<0.001), absence of subsequent ventilation on the general ward (P<0.001), group of assignation (P=0.004), intensive care initial rejection (P=0.022), no previous home ventilation (P=0.028), older age (P=0.03) and longer duration on ventilation (P=0.047) were significantly associated with mortality. In the multivariate regression model, ventilating patients from general wards (odds ratio=7.1; 2.3-25, 95% confidence interval) and ventilation under preset limits (odds ratio=3.57; 1.42-8.98, 95% confidence interval) remained significantly associated with mortality. CONCLUSION: Noninvasive ventilation is a relatively safe and effective treatment in the ED when performed in carefully controlled settings. ICU consultation may be securely deferred in this setting.