The infected heart: ventriculoseptal abscess and intracardiac fistulization.

Infective endocarditis is a rare but potentially deadly infection of the endocardial layer, which can involve the valves of the heart among other structures. The extraordinarily rare complication seen in this case involves extensive damage manifesting in an aortic root abscess resulting in an abnormal communication between the aorta and the atrium known as an aortocavitary fistula (Eur Heart J 2005;26:288-297; Pediatr Cardiol 2011;32:1057-1059; J Am Coll Cardiol 1991;18:663-667). As the disease progresses, wading through the complex symptoms, which may seem unrelated, represents a key challenge in diagnosis. This case describes both early and late findings of endocarditis and highlights a rare complication in which rapid diagnosis and early surgical intervention before the development of hemodynamic sequelae are paramount. In this case, infective endocarditis, a great masquerader in this case, provided a challenging diagnostic situation, a very rare complication, and commonalities of disease characteristics that health care provider should appreciate.

Retrospective analysis of clinical data associated with patients enrolled in a molecular diagnostic feasibility study highlights the potential utility for rapid detection of bloodstream infection.

BACKGROUND: Measurement of pathogen DNA polymerase activity by enzymatic template generation and amplification (ETGA) has shown promise in detecting pathogens in bloodstream infection (BSI). We perform an in-depth analysis of patients with clinical BSI enrolled in ETGA feasibility experiments. METHODS: In addition to hospital blood cultures, 1 study aerobic culture bottle was drawn from patients with suspected BSI. The study bottle was split into 2 bottles and was additionally subjected to ETGA analysis. Enzymatic template generation and amplification sensitivity/specificity for BSI detection was determined against the Centers for Disease Control BSI definition. When split cultures were both positive, time course analysis was performed to determine time to detection. The records of patients with BSI were reviewed for presence of systemic inflammatory response syndrome, antibiotic timing and appropriateness, and organism identification. RESULTS: Of 307 enrollees, 38 met the Centers for Disease Control BSI definition. Seventy-four percent met systemic inflammatory response syndrome criteria on admission. Antibiotic coverage was adequate in 76% of patients. Antibiotics were more often delayed in afebrile patients (odds ratio, 5). Twenty-seven of the split study culture bottles were positive in at least 1 sample, and ETGA detected microbes within all samples (sensitivity/specificity, 70.3%/99.3%). Of these, 22 were culture positive in both split study bottles and underwent ETGA time course analysis. Enzymatic template generation and amplification detected microbes within these 3-fold faster than culture. CONCLUSIONS: Patients with BSI often have diagnostic and treatment delays. Enzymatic template generation and amplification provides clinically meaningful data more rapidly than cultures. Future development should focus on real-time application of assays that detect microbes at the molecular level.

Spontaneous Coronary Artery Dissection Presenting As ST-Segment Elevation Myocardial Infarction.

Spontaneous coronary artery dissection (SCAD) is a non-traumatic spontaneous separation of a coronary wall that can present as acute myocardial infarction. Pregnant females are already at a considerably higher risk of acute myocardial infarction when compared to non-pregnant women of child-bearing age, and dissection explains the majority of these cases. Here, we present a 36-year-old female at 36-weeks gestation who experienced ventricular fibrillation arrest after ST-segment elevation myocardial infarction (STEMI) secondary to spontaneous dissection of the left anterior descending (LAD) coronary artery.

Accuracy of Height Estimation Among Bystanders.

INTRODUCTION: High-risk mechanisms in trauma usually dictate certain treatment and evaluation in protocolized care. A 10-15 feet (ft) fall is traditionally cited as an example of a high-risk mechanism, triggering trauma team activations and costly work-ups. The height and other details of mechanism are usually reported by lay bystanders or prehospital personnel. This small observational study was designed to evaluate how accurate or inaccurate height estimation may be among typical bystanders. METHODS: This was a blinded, prospective study conducted on the grounds of a community hospital. Four panels with lines corresponding to varying heights from 1-25 ft were hung within a building structure that did not have stories or other possibly confounding factors by which to judge height. The participants were asked to estimate the height of each line using a multiple-choice survey-style ballot. Participants were adult volunteers composed of various hospital and non-hospital affiliated persons, of varying ages and genders. In total, there were 96 respondents. RESULTS: For heights equal to or greater than 15 ft, less than 50% of participants of each job description were able to correctly identify the height. When arranged into a scatter plot, as height increased, the likelihood to underestimate the correct height was evident, having a strong correlation coefficient (R=+0.926) with a statistically significant p value = <0.001. CONCLUSION: The use of vertical height as a predictor of injury severity is part of current practice in trauma triage. This data is often an estimation provided by prehospital personnel or bystanders. Our small study showed bystanders may not estimate heights accurately in the field. The greater the reported height, the less likely it is to be accurate. Additionally, there is a higher likelihood that falls from greater than 15 ft may be underestimated.

Measurement of a Novel Biomarker, Secretory Phospholipase A2 Group IIA as a Marker of Sepsis: A Pilot Study.

INTRODUCTION: Early identification of sepsis is critical as early treatment improves outcomes. We sought to identify threshold values of secretory phospholipase A2 (sPLA2)-IIA that predict sepsis and bacterial infection compared to nonseptic controls in an emergency department (ED) population. MATERIALS AND METHODS: This is a prospective cohort of consenting adult patients who met two or more systemic inflammatory response syndrome (SIRS) criteria with clinical diagnosis of infectious source likely (septic patients). Controls were nonseptic consenting adults undergoing blood draw for other ED indications. Both groups had blood drawn, blind-coded, and sent to an outside laboratory for quantitative analysis of sPLA2-IIA levels. The study investigators reviewed patients' inpatient medical record for laboratory, imaging, and microbiology results, as well as clinical course. RESULTS: sPLA2-IIA levels were significantly lower in control patients as compared to septic patients (median = 0 ng/ml [interquartile range (IQR): 0-6.5] versus median = 123 ng/ml [IQR 44-507.75]; P < 0.0001). SPLA2-IIA levels were higher in patients with confirmed source (n = 28 patients, median = 186 ng/ml, 95% confidence interval = 115.1-516.8) as compared to those with no source identified or a viral source (n = 17, median = 68 ng/ml, 95% confidence interval = 38.1-122.7; P = 0.04). Using a cutoff value of 25 ng/ml, sPLA2-IIA had a sensitivity of 86.7% (confidence interval 72.5-94.5) and a specificity of 91.1% (confidence interval 77.9-97.1) in detecting sepsis. CONCLUSIONS: sPLA2-IIA shows potential as a biomarker distinguishing sepsis from other disease entities. Further study is warranted to identify predictive value of trends in sPLA-IIA during disease course in septic patients.

Are all-terrain vehicle injuries becoming more severe?

BACKGROUND: There are several reasons to suspect that injuries from all-terrain vehicles (ATV) have become both more serious and frequent in recent years. These reasons include increasing engine power, younger age of operators and inconsistent enforcement of helmet laws. The purpose of this study was to determine if the increase in ATV injuries was out of proportion to the increase in ATV usage and whether ATV injuries have increased in severity. METHODS: A retrospective analysis of the Consumer Product Safety Commission (CPSC) ATV injury data and the Pennsylvania Trauma System Foundation (PTSF) database from 1989 to 2002 was performed. ATV use, sales, deaths, trauma center admissions, Injury Severity Score (ISS), hospital length of stay (LOS) and Glascow Coma Score (GCS) were reviewed. RESULTS: ATV sales increased to 316%. In the decade prior to 2003, reported deaths nationally increased from 183 to 357 (95%) nationally and from 5 to 10 (100%) in Pennsylvania (PA). Admissions to trauma centers in PA increased 240%, yet the percentage of deaths to trauma center admissions remained constant at 2.6% during this period (p>.50). ISS and LOS from 1989 to 2002 did not significantly change (all p>.05) and GCS improved significantly. CONCLUSION: Despite concerns regarding the increasing dangers associated with ATVs, it appears that the severity of injuries from ATV use has not increased.

Can emergency medicine residents detect acute deep venous thrombosis with a limited, two-site ultrasound examination?

The purpose of this prospective clinical study was to determine the ability of Emergency Medicine (EM) residents to accurately detect acute deep venous thrombosis (aDVT) after training in a limited, two-site examination. Six residents received a 90-min session consisting of a lecture and a hands-on component. Each resident then performed the examination on symptomatic extremities referred to the vascular laboratory of a community teaching hospital. The examination was limited to the femoral and popliteal sites and was considered normal when the vein completely compressed. A formal examination was completed by the vascular technician (who was blinded to the resident's results) within 30 min of the resident examination. Of the 121 symptomatic extremities, vascular technicians detected nine cases of aDVT in the target area (7% prevalence); resident examinations revealed eight of these (sensitivity 89%). EM residents can perform a limited duplex examination with considerable but not perfect accuracy after receiving very limited instruction.

Keys to successful organ procurement: An experience-based review of clinical practices at a high-performing health-care organization.

Organ procurement (OP) from donors after brain death and circulatory death represents the primary source of transplanted organs. Despite favorable laws and regulations, OP continues to face challenges for a number of reasons, including institutional, personal, and societal barriers. This focused review presents some of the key components of a successful OP program at a large, high-performing regional health network. This review focuses on effective team approaches, aggressive resuscitative strategies, optimal communication, family support, and community outreach efforts.

Cardiac cath lab activation by the emergency physician without prior consultation decreases door-to-balloon time.

OBJECTIVE: The purpose of this before-and-after study is to determine whether an ED strategy which calls for cardiac catheterization lab (cath lab) activation directly by the emergency physician (EP) is effective in decreasing door-to-balloon time (DTBT). METHODS: In our active community teaching hospital ED, with an annual census of 55,000, the traditional practice for STEMI required cardiology consultation prior to cath lab notification. In November 2003 we instituted an ED protocol which mandated direct cath lab activation by the EP for eligible STEMI patients without prior notification of the cardiologist. We measured clinically relevant time intervals, including DTBT, prior to and after institution of the protocol. RESULTS: Twenty-four patients were enrolled after institution of the protocol; these were compared to twenty STEMI patients enrolled prior to the new protocol. DTBT decreased significantly, from 118 to 89 minutes, p=.039. Other ED parameters, including door to exam (17 vs. 15 minutes) and total ED time (80 vs. 56 minutes, p = .056) decreased post-protocol but were not significantly different for the two periods. Those arriving by ambulance continued to have a significantly lower DTBT than non-ambulance patients (pre: change of 47 minutes, p = .03, post: change of 33 minutes; p = .012). Both groups were affected similarly by the change in protocol, decreasing DTBT by approximately 25%. CONCLUSION: We conclude that a strategy which mandates cath lab activation by the emergency physician for STEMI without prior cardiology consultation, reduces door to balloon time.

Thiopental vs. etomidate for rapid sequence intubation in aeromedicine.

INTRODUCTION: Although there is a general agreement that rapid sequence intubation (RSI) is the preferred technique for intubation in aeromedical care, several pharamacological regimens have been employed without clear evidence of which is superior. HYPOTHESIS: This study was designed to compare the use of etomidate (ETOM) with that of thiopental (THIO) as an adjunctive agent used with succinylcholine (SCh) for RSI in an urban, aeromedical system. METHODS: This was a retrospective, before-and-after study utilizing computer-assisted chart review. Adult patients who received THIO for RSI over a two-year period were compared to adult patients who received ETOM for RSI over a similar period, after a change in protocol, which mandated ETOM rather than THIO for all intubations. RESULTS: No difference was found in any of the primary endpoints. Stabilization time (13.1 vs. 12.9 minutes), number of intubation attempts (1.1 vs. 1.2), successful first intubation attempts (90% vs. 82%), overall successful intubations (100% vs. 96%), and intubation time (18.4 vs. 21.7 seconds) were similar for all comparisons of THIO vs. ETOM (all p > 0.05). CONCLUSION: This study found no clinically relevant differences between the use of ETOM or THIO as adjuncts with SCh for RSI in the aeromedical setting.

Measurement of microbial DNA polymerase activity enables detection and growth monitoring of microbes from clinical blood cultures.

Surveillance of bloodstream infections (BSI) is a high priority within the hospital setting. Broth-based blood cultures are the current gold standard for detecting BSI, however they can require lengthy incubation periods prior to detection of positive samples. We set out to demonstrate the feasibility of using enzymatic template generation and amplification (ETGA)-mediated measurement of DNA polymerase activity to detect microbes from clinical blood cultures. In addition to routine-collected hospital blood cultures, one parallel aerobic blood culture was collected and immediately refrigerated until being transported for ETGA analysis. After refrigeration holding and transport, parallel-collected cultures were placed into a BACTEC incubator and ETGA time-course analysis was performed. Of the 308 clinical blood cultures received, 22 were BACTEC positive, and thus were initially selected for ETGA time course analysis. The ETGA assay detected microbial growth in all 22 parallel-positive blood cultures in less time than a BACTEC incubator and also yielded genomic DNA for qPCR-based organism identification. In summary, feasibility of detecting microbes from clinical blood culture samples using the ETGA blood culture assay was demonstrated. Additional studies are being considered towards development of clinically beneficial versions of this methodology.