Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences.

AIM: The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may differ between men and women. The aim of this study was to compare sex-associated differences between using a diagnostic strategy including early coronary computed tomography angiography (CCTA) and standard of care (SOC). METHODS: In total, 500 patients who presented with symptoms suggestive of ACS at the emergency department were randomised between a diagnostic strategy supplemented with early CCTA and SOC. RESULTS: Women were generally older than men (mean ± standard deviation 56 ± 10 vs 53 ± 10 years, p < 0.01) and were less often admitted to hospital (33% vs 44%, p = 0.02). Obstructive coronary artery disease on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p = 0.02), and ACS was diagnosed less often in women (5% vs 10%, p = 0.03). Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008). CONCLUSION: Women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. They were subjected to less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS.

Emergency Department visits due to intoxications in a Dutch university hospital: Occurrence, characteristics and health care costs.

BACKGROUND: Intoxications with alcohol and drugs are common in the Emergency Department. This study aimed to describe the occurrence and characteristics of intoxications (alcohol, Drugs of Abuse (DOA), pharmaceutical and chemical) presented to the Emergency Department and the health care costs of these intoxications. METHODS: This was a retrospective medical record study of all patients (≥ 16 years) who presented to the Emergency Department of an inner-city academic hospital in the Netherlands due to single or multiple intoxication(s) as the primary or secondary reason in the year 2016. An intoxication was reported as present if the attending physician described the intoxication in the patient's medical record. RESULTS: A total of 783 patients were included, accounting for 3.2% of the adult Emergency Department population (age ≥ 16 year). In 30% more than one substance was used. Intoxications with alcohol, Drugs of Abuse and pharmaceuticals was reported in respectively 62%, 29% and 21% of the intoxicated patients. The mean costs per patient presenting with an intoxication to the Emergency Department was € 1,490. The mean costs per patient were highest for pharmaceutical intoxications (€ 2,980), followed by Drugs of Abuse (€ 1,140) and alcohol (€ 1,070). CONCLUSIONS: Intoxications among patients aged 16 years and older are frequently seen at the Emergency Department and are frequently caused by multiple substances. Alcohol is the most common intoxication. Substantial healthcare costs are involved. Therefore, this study suggests that further research into hazardous alcohol consumption and DOA abuse is warranted.

Waterpipe smoking: not as innocent as it may seem.

INTRODUCTION: Waterpipe (hookah) smoking is popular; in Dutch surveys, 26% of the respondents have smoked a waterpipe at least once. However, waterpipe smoking is not without risk. We present a series of carbon monoxide (CO) poisonings after waterpipe smoking and discuss the etiology and treatment of CO intoxication after waterpipe smoking. CASE DESCRIPTIONS: We present three patients who presented with syncopial episodes and a variety of other neurological and circulatory symptoms after smoking a waterpipe. All patients had significantly elevated carboxyhaemoglobin levels (26%, 19% and 26%). Patients were treated with oxygen, following Dutch guidelines; one patient was admitted for eight hours of oxygen therapy. The other two patients were observed shortly, diverging from the guidelines because symptoms passed and the carboxyhaemoglobin normalised. DISCUSSION: Reviewing combustion chemistry, the formation of CO is a logical consequence of using burning coals as a heat source. This is due to CO2 reduction with carbon. This chemical process has not previously been related to waterpipe smoking. Dutch guidelines advise eight hours of oxygen therapy. The research this guideline is based on, justifies therapy directed at symptom relief and carboxyhaemoglobin normalisation. This strategy may prevent unnecessary hospital admissions and exposure to high-dose oxygen. CONCLUSION: We described three cases of CO intoxication after waterpipe smoking and argue why this may not be an incidental finding. Greater awareness of this risk is urgently needed. We conclude that the literature does not firmly support a fixed treatment duration.

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.

OBJECTIVES: The 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. METHODS: This 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. RESULTS: A 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). CONCLUSIONS: These 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.

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

OBJECTIVES: Overuse 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. METHODS: This 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 <0.5 µg/L, and starting antibiotic regimens at PCT ≥0.5 µg/L. Exclusion criteria were immunocompromised conditions, pregnancy, moribund patients, patients <72 h 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 2 weeks; 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%. RESULTS: Between August 2014 and January 2017, 551 individuals were included. In the PCT-guided group (n = 275) 200 (73%) patients were prescribed antibiotic regimens, in the control group (n = 276) 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% (n = 526). 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). CONCLUSIONS: PCT-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.

Non-targeted HIV screening in emergency departments in the Netherlands.

BACKGROUND: In the Netherlands a substantial proportion of newly diagnosed human immunodeficiency virus (HIV) patients present late for care and an estimated 12-34% of people living with HIV are undiagnosed. Linkage to care of these patients is important to decrease HIV transmission and to improve individual patient outcomes. We investigated if non-targeted HIV testing in emergency departments is a useful and cost-effective way to identify these patients. METHODS: In a cross-sectional multicentre study, eligible adult patients who underwent phlebotomy were given an active choice to be additionally tested for HIV. In a subset of patients, risk factors for HIV infection were asked for. A cost-effectiveness analysis was conducted. RESULTS: Of 7577 eligible patients, 3223 patients were tested, and two new HIV infections were diagnosed (0.06%). Both patients had risk factors for HIV infection. Non-targeted HIV testing in the emergency department was not considered cost-effective, with a cost per quality adjusted life years gained of € 77,050, more than triple the Dutch cost-effectiveness threshold of € 20,000. CONCLUSION: Non-targeted HIV testing in emergency departments in the Netherlands had a low yield of newly diagnosed HIV infections and was not cost-effective. Our data suggest that targeted HIV testing may offer an alternative approach to decrease the number of undiagnosed people living with HIV.

Knowledge about systemic inflammatory response syndrome and sepsis: a survey among Dutch emergency department nurses.

BACKGROUND: Sepsis has a high mortality. Early recognition and timely treatment are essential for patient survival. The aim of this study is to examine the factors that influence the knowledge and recognition of systemic inflammatory response syndrome (SIRS) criteria and sepsis by emergency department (ED) nurses. METHODS: A prospective, multi-center study including 216 ED nurses from 11 hospitals and academic medical centers in The Netherlands was conducted in 2013. A validated questionnaire was used to evaluate ED nurses' knowledge about SIRS and sepsis. Questions about demographic characteristics were also included, to investigate factors that may contribute to the knowledge about SIRS and sepsis. RESULTS: The mean total score was 15.9 points, with a maximum possible score of 29 points. ED nurses employed at hospitals with a level 3 intensive care unit (ICU) scored significantly higher than their colleagues employed at hospitals with a level 1 or 2 ICU. Recently completed education in sepsis was associated with a higher score. The employees in low ICU level hospitals who reported recent education did not score significantly lower than their ICU level 3 colleagues. ED nurses over the age of 50 scored significantly lower than their younger colleagues. CONCLUSIONS: The knowledge of ED nurses concerning SIRS and sepsis rises proportionally with the level of ICU in hospitals. Recent education in sepsis raises knowledge level as well. We recommend that when there is a low exposure rate to SIRS and sepsis, more emphasis should be placed on regular education.

Pain management in trauma patients in (pre)hospital based emergency care: current practice versus new guideline.

INTRODUCTION: Acute pain in trauma patients in emergency care is still undertreated. Early pain treatment is assumed to effectively reduce pain in patients and improve long-term outcomes. In order to improve pain management in the chain of emergency care, a national evidence-based guideline was developed. The aim of this study was to assess whether current practice is in compliance with the guideline 'Pain management for trauma patients in the chain of emergency care' from the Netherlands Association for Emergency Nurses (in Dutch NVSHV), and to evaluate early and initial pain management for adult trauma patients in emergency care. METHODS: Chart reviews were conducted in three regions of the Netherlands using electronic patient files of trauma patients from the chain of emergency care. We included one after-hours General Practitioner Co-operation (GPC), one ambulance Emergency Medical Services (EMS), two Helicopter Emergency Medical Services (HEMS), and three Emergency Departments (EDs). Organisation of pain management, pain assessment, and pain treatment was examined and compared with national guideline recommendations, including quality indicators. RESULTS: We assessed a random sample of 1066 electronic patient files. The use of standardised tools to assess pain was registered in zero to 52% of the electronic patient files per organisation. Registration of (non-)pharmacological pain treatment was found in less than half of the files. According to the files, pharmacological pain treatment deviated from the guideline in 73-99% of the files. Time of administration of medication was missing in 73-100%. Reassessment of pain following pain medication was recorded in half of the files by the HEMS, but not in files of the other organisations. CONCLUSIONS: The (registration of) current pain management in trauma patients in the chain of emergency care varies widely between healthcare organisation, and deviates from national guideline recommendations. Although guideline compliance differs across groups of healthcare professionals, maximum compliance rate with indicators registered is 52%. In order to improve pain management and evaluate its effectiveness, we recommend to improve pain registration in patient files. Furthermore, we advise to identify barriers and facilitators related to the implementation of the national guideline in all emergency care organisations.

Falsely elevated lactate in severe ethylene glycol intoxication.

A 29-year-old male presented at the emergency department of our hospital in a confused state. He had a history of psychoses and substance abuse. Physical examination revealed hyperventilation and abdominal tenderness. Blood gas analysis in the emergency department using an ABL 725 Radiometer analyser showed a severe metabolic acidosis with massive lactate elevation. Lactate acidosis due to mesenteric ischaemia was suspected. However, toxicology screening demonstrated ethylene glycol intoxication. Treatment with ethanol infusion and acute haemodialysis was started. Repeated laboratory measurements using a clinical chemistry analyser showed minimal plasma lactate elevation. Falsely elevated lactate measurement is a little known phenomenon that can occur in ethylene glycol intoxication and can cause serious delay in diagnosis. Therefore, elevated lactate concentrations measured on intensive care unit and emergency department blood gas analysers should be confirmed by a clinical chemistry analyser in the main laboratory in case of suspected ethylene glycol intoxication.

Islet xenotransplantation: are we really ready for clinical trials?

Four clinical trials of porcine islet transplantation have been reported, and there are verbal reports that clinical trials on much larger scales are continuing in centers in China and Russia. The four reported trials are briefly reviewed and, in the light of the present status of experimental islet xenotransplantation, consideration is given to whether such trials are currently justified. The Ethics Committee of the International Xenotransplantation Association has (1) emphasized the need for encouraging studies in non-human primates before clinical trials should be undertaken, (2) mandatory monitoring for the transfer of porcine microorganisms, and (3) careful regulation and oversight by recognized bodies. Other aspects of the topic, such as the need for informed consent, are briefly discussed. We conclude that, at the present time, more data documenting convincing efficacy, focused on clinically applicable immunosuppressive regimens, are needed to justify the initiation of closely monitored clinical trials. A clinical trial may then be justified even though the potential risk to the patients, and possibly for society, will not be zero.

Pig-to-nonhuman primate islet xenotransplantation: a review of current problems.

Islet allotransplantation has been shown to have potential as a treatment for type 1 diabetic patients. Xenotransplantation, using the pig as a donor, offers the possibility of an unlimited number of islets. This comprehensive review focuses on experience obtained in pig-to-nonhuman primate models, particularly with regard to the different types of islets (fetal, neonatal, adult) and isolation procedures used, and the methods to determine islet viability. The advantages and disadvantages of the methods to induce diabetes (pancreatectomy, streptozotocin) are discussed. Experience in pig-to-nonhuman primate islet transplantation studies is reviewed, including discussion of the possible mechanisms of rejection and the immunosuppressive regimens used. The research carried out to date has led to workable animal models to study islet xenotransplantation, but several questions regarding methodology remain unanswered, and details of these practicalities require to be adequately addressed. The encouraging porcine islet survival reported recently provides an indicator for future immunosuppressive regimens.

Preformed antibodies to alpha1,3-galactosyltransferase gene-knockout (GT-KO) pig cells in humans, baboons, and monkeys: implications for xenotransplantation.

OBJECTIVE: The aim of our study was to determine the prevalence and cytotoxicity of primate antibodies directed to antigens other than Galalpha1,3Gal (Gal), termed nonGal antigens. METHODS: Sera from human, baboon, and cynomolgus monkeys were tested by flow cytometry for IgM and IgG binding to both wild-type (WT) and GT-KO pig peripheral mononuclear cells (PBMC). Also, complement-dependent cytotoxicity assays were performed. RESULTS: All species demonstrated significantly higher antibody binding and cytotoxicity to WT cells compared to GT-KO cells (P < .01). Cynomolgus monkeys had significantly higher IgM binding to WT and GT-KO cells than did baboons or humans (P < .01). Furthermore, approximately 50% of both human and baboon sera proved to be lytic to GT-KO cells, compared to 76% of monkey sera (P < .01). CONCLUSIONS: We confirm the advantage of using GT-KO pig grafts over WT pig grafts. However, our results suggest that, compared to the cynomolgus monkey, the baboon may be a more suitable model to study antibody-mediated rejection of GT-KO pig grafts.

Aspirated foreign bodies in children: why are they more commonly found on the left?

The objective was to present our experience in the brochoscopic removal of foreign bodies in children. This was carried out through a retrospective analysis of the medical records of 96 patients in whom endoscopic removal of an inhaled foreign body was required, at the department of paediatric otorhinolaryngology, Eramus Medical Centre, Rotterdam. The participants were all children who underwent bronchoscopy after suspected foreign body aspiration from 1990 to 2000. The main outcome measures were confirmed diagnosis of foreign body aspiration and localization of aspirated foreign body. It was seen that in children up to 3 years of age, there was no significant difference in foreign body distribution and in children aged 3 and older foreign bodies were more commonly found in the right main bronchus. It was concluded that aspirated foreign bodies are equally distributed between the left and right main bronchus in children younger than 3 years. This could be explained by the handling of choking infants by their parents.