Giuseppe Lippi, Ruggero Buonocore, Michele Mitaritonno and Gianfranco Cervellin
Background: We performed a retrospective case-control study to assess the values of cardiac troponin I (cTnI) in a large number of patients admitted to the emergency department (ED) with different types of trauma.
Methods: The study population consisted of all patients aged 18 years or older admitted to the local ED with all types of traumas over a 1-year period. Results of cTnI were compared with those of 125 consecutive blood donors and 25 non-cardiac chest pain ED patients.
Results: The final study population consisted of 380 trauma patients, 10 with isolated abdominal trauma, 99 with isolated trauma of the limbs, 49 with isolated chest trauma, 145 with isolated head trauma and 77 with polytrauma. The concentration of cTnI did not differ among the three study populations, but the frequency of measurable values was substantially higher in patients with trauma (63%) than in blood donors and non-cardiac chest pain ED patients (both 20%). The frequency of cTnI values above the 99th percentile of the reference range was significantly higher in trauma patients (20%) than in blood donors (0%) and noncardiac chest pain ED patients (8%). Increased cTnI values were more frequent after head trauma (21%), chest trauma (27%) and polytrauma (29%) compared to patients with abdominal (0%) or limbs trauma (8%).
Conclusions: These results suggest that the measurement of cardiac troponin may be advisable to identify potential cardiac involvement in trauma patients, especially in those with polytrauma and head or chest trauma.
Giuseppe Lippi, Silvia Pipitone, Valentina Campana and Gianfranco Cervellin
Background: Anemia is a public healthcare problem, which is associated with increased morbidity and mortality. Some studies assessed the frequency of anemia in pediatric emergency departments (EDs), but no such information is available in adult patients admitted to the ED.
Methods: The study population consisted of adult patients admitted to the ED of the Academic Hospital of Parma during the year 2010 with the five most frequent acute pathologies (i.e., acute myocardial infarction, AMI), renal colics, pneumonia, pancreatitis and major trauma). Hospital re - cords were extracted from informatics database according to ICD-9 code and related terms. Routine hematological testing was performed on the entire population with identical instrumentation.
Results: The study population consisted of 462 ED patients (cases; 262 renal colics, 62 pneumonia, 51 acute pancreatitis, 46 AMI and 41 major trauma) and 429 healthy blood donors (controls). The median hemoglobin value was significantly lower in all patients than in controls (137 versus 151 g/L; p<0.01), whereas the median RDW value was significantly higher (13.7 versus 13.4%; p<0.01). The frequency of anemia and anysocytosis was higher in patients than in controls (anemia: 23 versus 4%, p<0.01; anysocytosis: 25 versus 16%; p=0.03). Hemoglobin values of all subclasses of patients were significantly lower than those of the controls, while those of RDW were significantly increased in patients with AMI, pancreatitis and pneumonia.
Conclusions: We found a high prevalence of anemia and anysocytosis in a population of ED patients, whose identification may be vital for appropriate therapy and subsequent management.
Gianni Turcato, Gianfranco Cervellin, Antonio Bonora, Danieli Prati, Elisabetta Zorzi, Giorgio Ricci, Gian Luca Salvagno, Antonio Maccagnani and Giuseppe Lippi
The usual history of chronic heart failure (HF) is characterized by frequent episodes of acute decompensation (ADHF), needing urgent management in the emergency department (ED). Since the diagnostic accuracy of routine laboratory tests remains quite limited for predicting short-term mortality in ADHF, this retrospective study investigated the potential significance of combining red blood cell distribution width (RDW) with other conventional tests for prognosticating ADHF upon ED admission. We conducted a retrospective study including visits for episodes of ADHF recorded in the ED of the Uni versity Hospital of Verona throughout a 4-year period. Demo - graphic and clinical features were recorded upon patient presentation. All patients were subjected to standard Chest X-ray, electrocardiogram (ECG) and laboratory testing in - cluding creatinine, blood urea nitrogen, B-type natriuretic peptide (BNP), complete blood cell count (CBC), sodium, chloride, potassium and RDW. The 30-day overall mortality after ED presentation was defined as primary endpoint. Results: The values of sodium, creatinine, BNP and RDW were higher in patients who died than in those who survived, whilst hypochloremia was more frequent in patients who died than in those who survived. The multivariate model, incorporating these parameters, displayed a modest efficiency for predicting 30-day mortality after ED admission (AUC, 0.701; 95% CI, 0.662-0.738; p=0.001). Notably, the inclusion of RDW in the model significantly enhanced prediction efficiency, with an AUC of 0.723 (95% CI, 0.693-0.763; p<0.001). These results were confirmed with net reclassification improvement (NRI) analysis, showing that combination of RDW with conventional laboratory tests resulted in a much better prediction performance (net reclassification index, 0.222; p=0.001). The results of our study show that prognostic assessment of ADHF patients in the ED can be significantly improved by combining RDW with other conventional laboratory tests.
Gianfranco Cervellin, Fiorenza Robuschi, Francesco Scioscioli, Livia Ruffini, Mariella Dipalo, Gian Luca Salvagno and Giuseppe Lippi
Background: The patients with episodes of chest pain and no electrocardiographic or biomarker abnormalities are currently monitored and subjected to non-invasive testing. Stress echocardiography is one of the most often used provocative tests, being the most cost- and risk-effective imaging technique. Some concerns about this technique have been raised regarding potential drug-induced myocardial injury. Our study hence aimed to establish whether or not dipyridamole stress echocardiography elicits release of troponin I (TnI) and T (TnT), as reliable bio-markers of myocardiocyte injury.
Methods: Thirty-two patients, after exclusion of ongoing acute coronary syndrome (ACS) during evaluation in the emergency department (ED), were studied with echocar-diography both at the baseline and after pharmacological stress with dipyridamole.
Results: All subjects had biomarkers assessment immediately before the stress-test (T1), 1 h from conclusion of the test (T2), and 6 h afterwards (T3). Cardio specific troponins were assessed with one contemporary-sensitive (TnI) and two highly-sensitive (HS) methods (HS-TnI and HS-TnT). The concentration of TnI, HS-TnI and HS-TnT did not differ throughout the three time points. At no time point the concentration of either HS-TnI or HS-TnT was significantly different among patients with negative or positive stress test.
Conclusions: The data shows that dipyridamole stress testing does not trigger release of troponin in patients with and without inducible reversible ischemia.
Gianfranco Cervellin, Gianluca Salvagno, Laura Bonfanti, Patrizia Bonelli, Gian Cesare Guidi and Giuseppe Lippi
Background: Hyponatremia and vitamin D deficiency are frequent disorders, and both have been associated with gait disturbances, falls and fractures. The aim of this study was to evaluate the existence of an association between serum sodium and vitamin D serum levels.
Methods: We performed a retrospective investigation to establish whether hyponatremia and vitamin D deficiency may be associated in a general population of unselected outpatients. An electronic search was performed in the laboratory information systems of the Hospital of Verona and the Hospital of Parma (Italy), to retrieve combined results for total vitamin D and sodium obtained in all outpatients referred for health check-up in the year 2013.
Results: Combined results of vitamin D and sodium could be retrieved for 5097 outpatients (3859 females and 1238 males; mean age 64±17 years). Vitamin D deficient subjects displayed significantly lower levels of serum sodium (140 versus 141 mmol/L; p<0.001), along with a significantly higher rate of hyponatremia (6.3% versus 5.1%; p=0.037). Accordingly, hyponatremic subjects had significantly lower levels of serum vitamin D (55 versus 60 nmol/L; p=0.015), along with a significantly higher rate of vitamin D deficiency (41.8% versus 36.1%; p=0.030). A highly significant correlation was found between sodium and total vitamin D after adjustment for age and gender (p<0.001).
Conclusions: The results of this study demonstrate for the first time the existence of a significant correlation between the serum levels of sodium and total vitamin D in a general population of unselected outpatients.
Gianni Turcato, Gianfranco Cervellin, Gian Luca Salvagno, Eleonora Zaccaria, Giuseppe Bartucci, Marco David, Antonio Bonora, Massimo Zannoni, Giorgio Ricci and Giuseppe Lippi
Background: Universally accepted and validated instruments for predicting the outcome of patients presenting to the emergency department (ED) with severe dyspnoea do not exist so far, nor are they regularly used by the emergency physicians. This study hence aimed to establish whether red blood cell distribution width (RDW) may be a predictive parameter of 1-year mortality in a population of patients admitted to the ED with severe dyspnoea attributable to different underlying disorders.
Methods: We retrospectively evaluated all the patients undergoing arterial blood gas analysis for severe dyspnoea (irrespective of the cause) during admission to ED of University Hospital of Verona from September 1, 2014 to November 31, 2014.
Results: The final study population consisted of 287 patients for whom complete clinical and laboratory information was available. Overall, 36 patients (12.5%) died after a 1-year follow-up. The RDW value was found to be considerably increased in patients who deceased during the follow-up compared to those who survived (17.2% versus 14.8%; p<0.001). In both univariate and multivariate analyses, the RDW value was found to be a significant predictor of 1-year mortality. In particular, patients with RDW ≥ 15.0% displayed a 72% increased risk of 1-year mortality after multiple adjustments.
Conclusions: The measurement of RDW, a very simple and inexpensive laboratory parameter, may represent an important factor for predicting medium-term mortality in patients presenting to the ED with severe dyspnoea.
Gianni Turcato, Fabian Sanchis-Gomar, Gianfranco Cervellin, Elisabetta Zorzi, Valentina Sivero, Gian Luca Salvagno, Andrea Tenci and Giuseppe Lippi
To investigate the association between both neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and 30-day mortality in patients hospitalized for an episode of acute decompensated heart failure (ADHF).
439 patients admitted to emergency department (ED) for an episode of ADHF. Clinical history, demographic, clinical and laboratory data recorded at ED admission and then correlated with 30-day mortality.
45/439 (10.3%) patients died within 30 days from ED admission. The median values of NLR (4.1 vs 11.7) and PLR (159.1 vs 285.9) were significantly lower in survivors than in patients who died. The area under the ROC curve of NLR was significantly higher than that of the neutrophil count (0.76 vs 0.59; p<0.001), whilst the AUC of PLR was significantly better than that of the platelet count (0.71 vs 0.51; p<0.001). In univariate analysis, both NLR and PLR were significantly associated with 30-day. In the fully-adjusted multivariate model, NLR (odds ratio, 3.63) and PLR (odds ratio, 3.22) remained independently associated with 30-day mortality after ED admission.
Routine assessment of NLR and PLR at ED admission may be a valuable aid to complement other conventional measures for assessing the medium-short risk of ADHF patients.