Trends in Childhood Anaphylaxis in Singapore: 2015-2022.

BACKGROUND: There has been limited data regarding the incidence of anaphylaxis in Asia. We aim to describe patterns in patient characteristics, triggers and clinical presentation of childhood anaphylaxis in Singapore. METHODS: This was a retrospective review of emergency electronic medical records of children with anaphylaxis. Patients with the allergy-related diagnoses of anaphylaxis, angioedema, allergy and urticaria based on ICD-9 codes were screened. Cases fulfilling the World Allergy Organization criteria for anaphylaxis were included. RESULTS: A total of 1188 cases of anaphylaxis were identified with a median age of 6.3 years. Extrapolating data from the study sites, from 2015 to 2022, the incidence rate of childhood anaphylaxis emergency visits in Singapore doubled from 18.9 to 38.8 per 100,000 person-years, with an incidence rate ratio (IRR) of 2.06 (95% confidence interval [CI] 1.70-2.49). In 2022, the incidence rate of food anaphylaxis was 30.1 per 100,000 person-years, IRR 2.39 (95% CI 1.90-3.01) and drug anaphylaxis was 4.6 per 100,000 person-years, IRR 1.89 (95% CI 1.11-3.25). The incidence rate in children aged 0-4 years quadrupled during the study period. Common triggers were egg (10.4%), peanut (9.3%), tree nut (8.8%), milk (8%), shellfish (7.8%) and non-steroidal anti-inflammatory drug (4.4%). The majority (88.6%) of patients were treated with intramuscular adrenaline. Total number of allergy-related visits did not increase over time between 2015 and 2019. Rates of severe anaphylaxis, namely anaphylactic shock and admission to high-dependency and intensive care, did not increase over time, with a mean incidence of 1.6, IRR 0.85 (95% CI 0.40-1.83) and 0.7, IRR 1.77 (95% CI 0.54-5.76) per 100,000 person-years, respectively. CONCLUSION: While the number of emergency visits due to childhood anaphylaxis has increased, the number of cases of allergy-related visits, anaphylactic shock and anaphylaxis requiring high-dependency and intensive care did not rise.

Cause and Clinical Presentation of Anaphylaxis in Singapore: From Infancy to Old Age.

BACKGROUND: The study objective was to compare age-related differences in the cause and clinical presentation of anaphylaxis. METHODS: We conducted a prospective study of patients visiting the emergency department for anaphylaxis. Data were collected from 3 emergency departments from 1 April 2014 to 31 December 2015. Patient electronic records with the diagnoses of allergy, angioedema, urticaria, and anaphylaxis (ICD-9 codes 9953, 9951, 7080, 9950, 7089) were screened and cases fulfilling World Allergy Organisation criteria for anaphylaxis were included. RESULTS: A total of 426 cases of anaphylaxis were identified with a median age of 23 years (range 3 months to 88 years and 9 months). The causes of anaphylaxis were food (n = 236, 55%), drugs (n = 85, 20%), idiopathic (n = 64, 15%), and insect bites or stings (n = 28, 7%). The most common food was shellfish (n = 58, 14%) and the most common drugs were non-steroidal anti-inflammatory drugs (n = 26, 6%). There were more cases of food anaphylaxis in children than in adults (72 vs. 42%, p < 0.001) and more cases of drug anaphylaxis in adults than in children (28 vs. 10%, p < 0.001). Compared to patients of other ages, infants and young children had more gastrointestinal symptoms (adjusted odds ratio [aOR] 2.1, 95% CI 1.1-3.9), while schoolchildren and adolescents had more respiratory symptoms (aOR 2.7, 95% CI 1.4-5.2). Adults had more cardiovascular symptoms (aOR 2.9, 95% CI 1.8-4.6) and hypotension (aOR 3.7, 95% CI 2.1-6.8) compared to children. However, 42% of the infants lacked blood pressure measurements. CONCLUSIONS: Knowledge of age-related variation in the cause and clinical presentation of anaphylaxis aids in diagnosis and acute management.

Emergency Department Management of Sepsis Patients: A Randomized, Goal-Oriented, Noninvasive Sepsis Trial.

STUDY OBJECTIVE: The noninvasive cardiac output monitor and passive leg-raising maneuver has been shown to be reasonably accurate in predicting fluid responsiveness in critically ill patients. We examine whether using a noninvasive protocol would result in more rapid lactate clearance after 3 hours in patients with severe sepsis and septic shock in the emergency department. METHODS: In this open-label randomized controlled trial, 122 adult patients with sepsis and serum lactate concentration of greater than or equal to 3.0 mmol/L were randomized to receive usual care or intravenous fluid bolus administration guided by measurements of change of stroke volume index, using the noninvasive cardiac output monitor after passive leg-raising maneuver. The primary outcome was lactate clearance of more than 20% at 3 hours. Secondary outcomes included mortality, length of hospital and ICU stay, and total hospital cost. Analysis was intention to treat. RESULTS: Similar proportions of patients in the randomized intervention group (70.5%; N=61) versus control group (73.8%; N=61) achieved the primary outcome, with a relative risk of 0.96 (95% confidence interval [CI] 0.77 to 1.19). Secondary outcomes were similar in both groups (P>.05 for all comparisons). Hospital mortality occurred in 6 patients (9.8%) each in the intervention and control groups on or before 28 days (relative risk=1.00; 95% CI 0.34 to 2.93). Among a subgroup of patients with underlying fluid overload states, those in the intervention group tended to receive clinically significantly more intravenous fluids at 3 hours (difference=975 mL; 95% CI -450 to 1,725 mL) and attained better lactate clearance (difference=19.7%; 95% CI -34.6% to 60.2%) compared with the control group, with shorter hospital lengths of stay (difference=-4.5 days; 95% CI -9.5 to 2.5 days). CONCLUSION: Protocol-based fluid resuscitation of patients with severe sepsis and septic shock with the noninvasive cardiac output monitor and passive leg-raising maneuver did not result in better outcomes compared with usual care. Future studies to demonstrate the use of the noninvasive protocol-based care in patients with preexisting fluid overload states may be warranted.

Prognostic performance of soluble urokinase plasminogen activator receptor for heart failure or mortality in Western and Asian patients with acute breathlessness.

AIMS: The performance of circulating soluble urokinase plasminogen activator receptor (suPAR) for predicting the composite endpoint of subsequent heart failure (HF) hospitalisation and/or death at 1 year was assessed in (i) patients with undifferentiated breathlessness, and generalisability was compared in (ii) disparate Western versus Asian sub-cohorts, and in (iii) the sub-cohort adjudicated with HF. METHODS AND RESULTS: Patients with acute breathlessness were recruited from the emergency departments in New Zealand (NZ, n = 612) and Singapore (n = 483). suPAR measured in the presentation samples was higher in patients incurring the endpoint (n = 281) compared with survivors (5.2 ng/mL vs 3.1 ng/mL, P < 0.0001). The discriminative power of suPAR for endpoint prediction was c-statistic of 0.77 in the combined population, but was superior in Singapore than NZ (c-statistic: 0.83 vs 0.71, P < 0.0001). Although the highest suPAR tertile (>4.37 ng/mL) was associated with risks of >4-fold in NZ, >20-fold in Singapore, and ≥3-fold in HF for incurring the outcome, there was no interaction between country and suPAR levels after adjustment. Multivariable analysis indicated suPAR to be robust in predicting HF/death at 1-year [hazard ratio: 1.9 (95% CI:1.7 to 2.0) per SD increase] and improved risk discrimination for outcome prediction in HF (∆0.06) and for those with NT-proBNP >1000 pg/mL (∆0.02). CONCLUSION: suPAR is a strong independent predictor of HF and/or death at 1 year in acutely breathless patients, in both Asian and Western cohorts, and in HF. suPAR may improve stratification of acutely breathless patients, and in acute HF, for risk of later onset of heart failure or mortality.

Predictors of major adverse cardiac events among patients with chest pain and low HEART score in the emergency department.

AIM: For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks. METHODS: We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models. RESULTS: Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score. CONCLUSION: Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge.

Circulating erythroferrone has diagnostic utility for acute decompensated heart failure in patients presenting with acute or worsening dyspnea.

Objectives: In dyspneic patients with atrial fibrillation (AF) or obesity, the diagnostic performance of NT-proBNP for acute heart failure is reduced. We evaluated the erythroblast derived protein erythroferrone (ERFE) as an ancillary biomarker for the diagnosis of acute decompensated heart failure (ADHF) in these comorbid subgroups in both Western and Asian populations. Methods: The diagnostic performance of ERFE (Intrinsic Lifesciences) and NT-proBNP (Roche Cobas e411) for ADHF was assessed in 479 New Zealand (NZ) and 475 Singapore (SG) patients presenting with breathlessness. Results: Plasma ERFE was higher in ADHF, compared with breathlessness from other causes, in both countries (NZ; 4.9 vs. 1.4 ng/ml, p < 0.001) and (SG; 4.2 vs. 0.4 ng/ml, p = 0.021). The receiver operating characteristic (ROC) areas under the curve (AUCs) for discrimination of ADHF were reduced in the NZ cohort compared to SG for ERFE (0.75 and 0.84, p = 0.007) and NT-proBNP (0.86 and 0.92, p = 0.004). Optimal cut-off points for ERFE yielded comparable sensitivity and positive predictive values in both cohorts, but slightly better specificity, negative predictive values and accuracy in SG compared with NZ. In patients with AF, the AUC decreased for ERFE in each cohort (NZ: 0.71, n = 105, SG: 0.61, n = 44) but increased in patients with obesity (NZ: 0.79, n = 150, SG: 0.87, n = 164). Conclusions: Circulating ERFE is higher in patients with ADHF than in other causes of new onset breathlessness with fair diagnostic utility, performing better in Asian than in Western patients. The diagnostic performance of ERFE is impaired in patients with AF but not patients with obesity.

Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis.

OBJECTIVE: This study aims to explore the risk factors and predictors involved in the missed diagnosis of acute aortic dissection (AAD) among patients in the emergency medicine department (EMD). METHODS: This is a single-center retrospective chart review conducted over a 10-year period (January 1998 to December 2008). Records with a diagnosis of "dissection of aorta" (International Classification of Diseases, Ninth Revision code 441.0) from the hospital discharge database and hospital death register were selected. Acute aortic dissection was defined as missed if diagnostic imaging to diagnose AAD or cardiothoracic surgeon consult was not elicited while in the EMD. We compared the history, clinical findings, and investigations between patients who had the diagnosis of AAD missed in the EMD and those who did not. RESULTS: A total of 68 patients were included in the analysis during the study period, of which 38.2% had a missed diagnosis. There was 63.2% of type A AAD by Stanford classification. Neither age, sex, nor a history of hypertension were significant risk factors for missed diagnosis of AAD. The likelihood of missed diagnosis was significantly higher in the absence of a pulse deficit (odds ratio, 35.76; 95% confidence interval, 3.70-345.34) and absence of widened mediastinum on chest radiography (odds ratio, 33.16; 95% confidence interval, 5.74-191.49). CONCLUSION: Well-known risk factors for AAD such as age, male sex, and hypertension were not risk factors for missed diagnosis for AAD presenting in the EMD. The absence of pulse deficit or widened mediastinum does not exclude the diagnosis of AAD.

Hospital admission risk stratification of patients with gout presenting to the emergency department.

To characterise gout patients at high risk of hospitalisation and to develop a web-based prognostic model to predict the likelihood of gout-related hospital admissions. This was a retrospective single-centre study of 1417 patients presenting to the emergency department (ED) with a gout flare between 2015 and 2017 with a 1-year look-back period. The dataset was randomly divided, with 80% forming the derivation and the remaining forming the validation cohort. A multivariable logistic regression model was used to determine the likelihood of hospitalisation from a gout flare in the derivation cohort. The coefficients for the variables with statistically significant adjusted odds ratios were used for the development of a web-based hospitalisation risk estimator. The performance of this risk estimator model was assessed via the area under the receiver operating characteristic curve (AUROC), calibration plot, and brier score. Patients who were hospitalised with gout tended to be older, less likely male, more likely to have had a previous hospital stay with an inpatient primary diagnosis of gout, or a previous ED visit for gout, less likely to have been prescribed standby acute gout therapy, and had a significant burden of comorbidities. In the multivariable-adjusted analyses, previous hospitalisation for gout was associated with the highest odds of gout-related admission. Early identification of patients with a high likelihood of gout-related hospitalisation using our web-based validated risk estimator model may assist to target resources to the highest risk individuals, reducing the frequency of gout-related admissions and improving the overall health-related quality of life in the long term. KEY POINTS : • We reported the characteristics of gout patients visiting a tertiary hospital in Singapore. • We developed a web-based prognostic model with non-invasive variables to predict the likelihood of gout-relatedhospital admissions.

Development and validation of a decision support tool for the diagnosis of acute heart failure: systematic review, meta-analysis, and modelling study.

OBJECTIVES: To evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics. DESIGN: Individual patient level data meta-analysis and modelling study. SETTING: Fourteen studies from 13 countries, including randomised controlled trials and prospective observational studies. PARTICIPANTS: Individual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated. MAIN OUTCOME MEASURE: Adjudicated diagnosis of acute heart failure. RESULTS: Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure. CONCLUSIONS: In an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach. STUDY REGISTRATION: PROSPERO CRD42019159407.

Point-of-care bedside gas analyzer: limited use of venous pCO2 in emergency patients.

BACKGROUND: Because arterial punctures are more painful, venous blood gas analysis has been proposed as an alternative. OBJECTIVES: To determine if venous pCO(2) can replace arterial pCO(2) in emergency patients using a bedside blood gas analyzer. METHODS: This is a cross-sectional study. We recruited patients who were deemed by the attending Emergency Physicians to require arterial blood gas analysis to determine their ventilation or acid-base status. A venous and an arterial blood gas sample were drawn from the patient, temporally as close to each other as possible. Both samples were then analyzed using the same bedside blood gas analyzer immediately after collection. RESULTS: There were 122 paired samples obtained. The strength of the association between arterial and venous pCO(2) is r = 0.838 (p = 0.001). The Bland-Altman bias plot methods for agreement show a mean difference of 3.3 mm Hg with two standard deviation limits of agreement being -17.4 to 23.9; 93.4% of the pCO(2) values fell within two standard deviation limits. Venous pCO(2) below 30 mm Hg had a 100% (95% confidence interval [CI] 90.5-100) sensitivity and 100% (95% CI 80.7-100) Negative predictive value to rule out hypercarbia, defined as arterial pCO(2) > 45 mm Hg. CONCLUSIONS: There is significant variability in the arteriovenous difference of pCO(2) readings, hence, arterial punctures are still needed to specifically determine the arterial pCO(2).

Agreement between arterial and venous blood gases in trauma resuscitation in emergency department (AGREE).

INTRODUCTION: Arterial blood gas (ABG) sampling is routinely performed in major trauma patients to assess the severity of hemorrhagic shock. Compared to venous blood gas (VBG), ABG is an additional procedure with risks of hematoma and pain. We aim to determine if pH, base deficit (BD), and lactate from VBG and ABG in trauma patients are clinically equivalent. If proven, the need for ABG and its associated risks can be eliminated. METHODS: This prospective observational study was conducted in the Emergency Department of National University Hospital, Singapore, between February and October 2016. We correlated paired ABG and VBG results in adult trauma patients. VBG and ABG were obtained within 10 min and processed within 5 min using a point-of-care blood gas analyzer. Bland-Altman plot analysis was used to evaluate the agreement between peripheral VBG and ABG in terms of pH, base deficit and lactate. RESULTS: There were 102 patients included, with a median age of 34 (interquartile range 28-46) years and male predominance (90.2%). Majority of patients sustained blunt trauma (96.1%), and had injuries of Tier 1 and Tier 2 severity (60/102, 58.8%). Bland-Altman plot analyses demonstrated that only 72.6% of venous pH and 76.5% of venous BD lie within the pre-defined clinically acceptable limits of agreement, whereas 96.0% of venous lactate was within these limits. CONCLUSION: Venous and arterial pH and BD are not within clinically acceptable limits of agreement, and ABG should be obtained for accurate acid-base status. However, venous lactate may be an acceptable substitute for arterial lactate.

Validation of "Care of the Dying Evaluation" in Emergency Medicine (CODE-EM): pilot phase of end-of-life management protocol offered within emergency room (EMPOWER) study.

BACKGROUND: An increasing number of patients who present to emergency departments are at their end-of-life phase and have significant palliative care needs such as in symptom control for pain and dyspnoea. Evaluating quality of care provided is imperative, yet there is no suitable tool validated in the emergency and Asian settings. We aim to examine the face and construct validity, and reliability of a newly developed questionnaire, Care of the Dying Evaluation - Emergency Medicine, for measuring the quality of end-of-life care in an Asian emergency context. METHODS: A mixed methods pilot study was conducted. Participants composed of the next-of-kin to thirty dying patients who presented to the emergency departments of three public hospitals in Singapore. Qualitative evaluation, using cognitive "think-aloud" interviews, and quantitative analysis were employed. Percentage agreement and κ statistic were measured to evaluate temporal stability of the questionnaire. Cronbach's α and item-total correlations were used to assess internal consistency within the constructs. Confirmatory factor analysis was performed for construct validity. RESULTS: All participants reported clear understanding of the questionnaire with no ambiguity; a minority felt the questions caused emotional distress (7/30, 23.3%). The questions showed moderate to good test-retest reliability. Internal consistencies within the constructs were good for "ENVIRONMENT" and "CARE", and moderate for "COMMUNICATION". Factor loadings range from 0.40 to 0.99. CONCLUSIONS: The Care of the Dying Evaluation - Emergency Medicine questionnaire may be valid and reliable for use in an Asian emergency setting. Our prospective multicentre study using this evaluation tool may provide more insight on the quality of care rendered to dying patients and identify areas for improvement. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03906747).

Impact of 24-hour specialist coverage and an on-site CT scanner on the timely diagnosis of acute aortic dissection.

INTRODUCTION: Acute aortic dissection (AAD) is a rare and potentially fatal condition that has been known to be missed in diagnoses. Our primary objective was to determine if the availability of 24-hour emergency department (ED) specialist coverage and an on-site computed tomography (CT) scanner reduced the rate of missed diagnoses of AAD. METHODS: We selected records of patients diagnosed with dissection of the aorta from a hospital's discharge database and death register in the period of January 1998 to December 2014. AAD was defined as missed if imaging to diagnose AAD or a cardiology/cardiothoracic surgical consultation was not obtained in the ED. We compared the rates of missed diagnosis before and after the availability of 24-hour ED specialist coverage and an on-site CT scanner in the ED. RESULTS: Among 145 patients, 42 (29.0%) had a missed diagnosis. The proportion of missed AAD was lower in the post-implementation period compared to the pre-implementation period (20.0% vs. 37.3%, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.20‒0.89; p = 0.023). After adjusting for confounders, the difference remained significant (OR 0.31, 95% CI 0.14‒0.70; p = 0.005). In the post-implementation period, concurrent signs of congestive cardiac failure (OR 33.51, 95% CI 1.42‒789.20; p = 0.024) and absence of a widened mediastinum on chest radiography (OR 11.52, 95% CI 1.37‒96.80; p = 0.029) were independent predictors of missed diagnoses. CONCLUSION: The availability of 24-hour ED specialist coverage and an on-site CT scanner improved the diagnosis of AAD in our study.

Extracellular vesicle Cystatin C and CD14 are associated with both renal dysfunction and heart failure.

AIMS: Extracellular vesicles (EVs) are small double-membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients. METHODS AND RESULTS: Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2 . The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub-fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co-morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub-fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub-fractions, and with presence of heart failure in the high density lipoprotein sub-fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub-fractions and in plasma, but not with renal dysfunction. CONCLUSIONS: We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment.

End-of-life management protocol offered within emergency room (EMPOWER): study protocol for a multicentre study.

BACKGROUND: Patients at their end-of-life (EOL) phase frequently visit the emergency department (ED) due to their symptoms, yet the environment and physicians in ED are not traditionally equipped or trained to provide palliative care. This multicentre study aims to measure the current quality of EOL care in ED to identify gaps, formulate improvements and implement the improved EOL care protocol. We shall also evaluate healthcare resource utilisation and its associated costs. METHODS AND ANALYSIS: This study employs a quasiexperimental interrupted time series design using both qualitative and quantitative methods, involving the EDs of three tertiary hospitals in Singapore, over a period of 3 years. There are five phases in this study: (1) retrospective chart reviews of patients who died within 5 days of ED attendance; (2) pilot phase to validate the CODE questionnaire in the local context; (3) preimplementation phase; (4) focus group discussions (FGDs); and (5) postimplementation phase. In the prospective cohort, patients who are actively dying or have high likelihood of mortality this admission, and whose goal of care is palliation, will be eligible for inclusion. At least 140 patients will be recruited for each preimplementation and postimplementation phase. There will be face-to-face interviews with patients' family members, review of medical records and self-administered staff survey to evaluate existing knowledge and confidence. The FGDs will involve hospital and community healthcare providers. Data obtained from the retrospective cohort, preimplementation phase and FGDs will be used to guide prospective improvement and protocol changes. Patient, family and staff relevant outcomes from these changes will be measured using time series regression. ETHICS AND DISSEMINATION: The study protocol has been reviewed and ethics approval obtained from the National Healthcare Group Domain Specific Review Board, Singapore. The results from this study will be actively disseminated through manuscript publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03906747.

Mid-regional pro-adrenomedullin outperforms N-terminal pro-B-type natriuretic peptide for the diagnosis of acute heart failure in the presence of atrial fibrillation.

AIMS: The performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in diagnosing acute decompensated heart failure (ADHF) among patients presenting with breathlessness is markedly impaired in the presence of atrial fibrillation (AF). We evaluated the diagnostic performance of mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin T as possible alternative markers for discrimination of ADHF in this setting. METHODS AND RESULTS: Breathless patients (n = 1107) were prospectively and contemporaneously recruited in emergency departments in Singapore and New Zealand. The diagnoses of ADHF and presence of AF were adjudicated by two clinician specialists, blinded to MR-proADM, NT-proBNP and high-sensitivity cardiac troponin T (hs-cTnT) results. MR-proADM exhibited strong discrimination of ADHF with little change in performance irrespective of the presence of AF (area under the curve 0.83 in non-AF vs. 0.76 in AF) compared to NT-proBNP (0.91 vs. 0.71) and hs-cTnT (0.83 vs. 0.62), respectively. The accuracy of MR-proADM (73.3%) for diagnosing ADHF among patients with AF was superior to both NT-proBNP (61.6%) and hs-cTnT (64.6%). The superior performance of MR-proADM remained apparent when data from Singapore and New Zealand were analysed separately. CONCLUSION: In the presence of AF, MR-proADM showed greater discrimination and accuracy, and less impairment in performance compared to that in non-AF cases, for the diagnosis of ADHF, compared to the guideline-endorsed NT-proBNP.

Appropriateness of blood culture: A comparison of practices between the emergency department and general wards.

BACKGROUND: The decision to perform a blood culture is influenced by factors, such as the pretest probability of bacteremia, resource availability and individual clinician's preference. The lack of formal guidelines results in inconsistencies in practices and an inappropriate or overuse of blood cultures. The primary aim of this study is to compare the rate of positive blood cultures in the emergency department (ED) and general ward. The secondary aim of this study is to analyze factors associated with a positive blood culture. METHODS: We compared 200 consecutive patients in the ED with 200 consecutive patients with first blood cultures done within 24 h of admission from ED to the general ward. We analyzed the clinical characteristics, proportion of positive blood cultures, and variables associated with a positive blood culture. RESULTS: The percentage of positive blood cultures was 13.5% (n = 27) in the ED group, compared with 6.0% (n = 12) in the general ward group. Contamination rates were higher in the ED compared to general ward (4% vs 0.5%). Heart rate and rigors were independently associated with a positive blood culture in a multivariate logistic regression model. CONCLUSION: There was a lower rate of positive blood cultures in the general ward group. Reasons may include a lower threshold for performing blood cultures in the general ward, and prior antibiotics in the ED reducing the sensitivity of blood cultures taken in the general ward. Adherence to clinical decision rules and education of junior staff are needed to improve the efficiency of blood culture taking practices.