Quality and safety issues of direct oral anticoagulants in the emergency department.

The direct oral anticoagulants (DOACs) are increasingly used in patients with atrial fibrillation and venous thromboembolism. The decision making of clinicians and especially emergency physicians for the appropriate management of patients taking DOACs entails a thorough understanding of pharmacologic profile, practical guidance on their usage, and management of bleeding and/or thrombotic events. The available evidence suggests that the bleeding complications observed in patients taking DOACs are less frequent and potentially less severe than those in patients taking vitamin K antagonists or heparins. This should be regarded as an advantage for emergency physicians, since it would decrease the admission rate of anticoagulated patients and probably require a less aggressive treatment in the emergency department (ED). The greatest challenge of DOACs is so far represented by the lack of clinically usable antidotes, since these (i.e., idarucizumab, andexanet alfa, and aripazine) are in different phases of development. A second major concern is the current lack of consensus about laboratory monitoring for these drugs. Although there is widespread perception that patients on DOACs do not require dose adjustment based on laboratory testing, in some selected clinical situations, laboratory testing may be taken into consideration in the ED. The type of laboratory diagnostics needed for emergency management should hence include tests that are promptly available, affordable to all stat laboratories, and cost effective. The aim of this article is to provide a personal overview on quality and safety issues of DOACs with an ED perspective.

Diagnostic significance of combining D-dimer with high-sensitivity cardiac troponin I for improving the diagnosis of venous thromboembolism in the emergency department.

BACKGROUND: Although cardiac troponins are valuable tools for risk stratification in patients with venous thromboembolism (VTE), their significance remains elusive in diagnosing venous thrombosis. METHODS: D-dimer (age-adjusted cut-off) and high-sensitivity cardiac troponin I (HS-cTnI; reference limit, <10.5 ng/L in women and <17.8 ng/L in men) were measured in 2199 consecutive patients (1106 women and 1093 men; mean age, 63±20 years), admitted to the Emergency Department of the University Hospital of Parma during a 3-month period. Overall, 53 patients were finally diagnosed with VTE (12 with deep vein thrombosis and 41 with pulmonary embolism). RESULTS: The diagnostic performance (area under the curve; AUC) of D-dimer and HS-cTnI was 0.70 and 0.71 for all VTE episodes, 0.70 and 0.63 for deep vein thrombosis (DVT), 0.70 and 0.74 for pulmonary embolism (PE), respectively. The combination of positive values of both biomarkers yielded better diagnostic performance than D-dimer values alone for diagnosing PE (AUC, 0.80; p<0.001 vs. D-dimer alone), but not for diagnosing DVT (AUC, 0.73; p=0.458 vs. D-dimer alone). In patients with PE, positive HS-cTnI values in patients with concomitantly positive D-dimer values yielded identical diagnostic sensitivity compared to D-dimer positivity alone (i.e., 1.00), but nearly double diagnostic specificity (i.e., 0.71 vs. 0.40). Positive HS-cTnI values (AUC, 0.68), but not D-dimer positivity (AUC, 0.51), were associated with 30-day hospital readmission of VTE patients. CONCLUSIONS: The results of this study open intriguing opportunities for combining HS-cTnI and D-dimer in the diagnostic approach of patients with PE.

Spinal cord infarction. A case report and narrative review.

Spinal cord infarction is a rare but severe disorder, consistently less frequent than ischemic brain injury. It constitutes only 1-2% of all neurological vascular emergencies. Here we describe a case of spinal cord infarction in a 68-year-old Caucasian man without any neurological problem in his clinical history. The patient presented to the Emergency Department complaining for sudden onset of lower limbs weakness, as well as pain and mild loss of sensitivity in both legs. These symptoms suddenly arose after a 10 minutes bicycle race. He underwent a CT angiography, which confirmed the presence of a fusiform aneurysm of infra-renal abdominal aorta with thrombotic apposition on right lateral side and some ulcerated thrombi. As such, the patient underwent a spinal cord Magnetic Resonance Imaging, that showed images compatible with an acute ischemic injury (infarction) from D11 to medullary cone. He was then treated with low molecular weight heparin, aspirin, and methylprednisolone, and was then admitted to the Stroke Unit. He gradually regained lower limbs sensitivity totally, but the strength was only partially restored. Although a rare entity, Emergency Physicians should always keep in mind this possibility when evaluating patients with sudden loss of sensitivity and/or strength in their lower limbs.

Hypertensive crisis and pulmonary edema following rituximab-induced anaphylaxis.

Rituximab is a monoclonal antibody against the protein CD20. Various lymphomas as well as non-malignant immune disorders are treated with this antibody. Hypersensitivity reactions associated with the use of rituximab include urticaria, hypotension, chest tightness, vomiting, oxygen desaturation and bronchospasm. A very uncommon case of hypertensive crisis and pulmonary edema following rituximab-induced hypersensitivity reaction in an 80-year-old man receiving rituximab for non-Hodgkin lymphoma is reported. Anaphylaxis manifesting as coronary vasospasm following drug treatment, including rituximab, could be proved a serious condition in patients who need specific treatment. In these patients desensitization protocols seem to be mandatory.

Anaphylactic cardiovascular collapse manifesting as myocardial infarction following salad consumption. A case of Kounis variant type I syndrome.

Anaphylactic cardiovascular events constitute an underrated cause of medical emergencies in hospitalized patients. Coronary arteries and myocardium are targeted by anaphylactic mediators leading to acute coronary syndrome and imminent cardiovascular collapse. Early diagnosis and high clinical suspicion are required to secure prompt life-saving treatment in these cases. However, physicians of both Cardiology and Internal Medicine Departments are not familiar with this condition. Recently, we diagnosed and treated a case of anaphylactic cardiovascular collapse manifesting as acute myocardial infarction following salad consumption. Notably, Kounis anaphylaxis-associated acute coronary syndrome is a rare cause of ST segment elevation myocardial infarction with normal or diseased coronary arteries. We recommend that Kounis syndrome and its variants should be taken into consideration in the differential diagnosis of ischemic heart disease in patients with signs of allergic reaction and/or medical history of previous allergic reactions, who experience acute coronary syndrome after exposure to certain environmental stimuli.

An Italian registry of chest pain patients in the emergency department: clinical predictors of acute coronary syndrome.

BACKGROUND: The aim of this study was to describe the population of patients arriving in several Italian Emergency Departments (EDs) complaining of chest pain suggestive of acute coronary syndrome (ACS) in order to evaluate the incidence of ACS in this cohort and the association between ACS and different clinical parameters and risk factors. METHODS: This is an observational prospective study, conducted from the 1st January to the 31st December 2014 in 11 EDs in Italy. Patients presenting to ED with chest pain, suggestive of ACS, were consecutively enrolled. RESULTS: Patients with a diagnosis of ACS (N.=1800) resulted to be statistically significant older than those without ACS (NO ACS; N.=4630) (median age: 70 vs. 59, P<0.001), and with a higher prevalence of males (66.1% in ACS vs. 57.5% in NO ACS, P<0.001). ECG evaluation, obtained at ED admission, showed new onset alterations in 6.2% of NO ACS and 67.4% of ACS patients. Multiple logistic regression analysis showed that the following parameters were predictive for ACS: age, gender, to be on therapy for cardio-vascular disease (CVD), current smoke, hypertension, hypercholesterolemia, heart rate, ECG alterations, increased BMI, reduced SaO2. CONCLUSIONS: Results from this observational study strengthen the importance of the role of the EDs in ruling in and out chest pain patients for the diagnosis of ACS. The analysis put in light important clinical and risk factors that, if promptly recognized, can help Emergency Physicians to identify patients who are more likely to be suffering from ACS.

Is anticoagulant therapy always indicated in "medium-risk" patients with first diagnosed atrial fibrillation? Insights from a real world, 10-year observational study.

BACKGROUND: The choice of antithrombotic prophylaxis in the so-called "medium-risk" patients (i.e., CHA2DS2-VASc score = 1 in males or 2 in females) is one of the major enigmatic issues in clinical management of atrial fibrillation (AF). METHODS: We retrospectively evaluated 30-day and 1-year thromboembolic events in all consecutive medium-risk patients visited for first diagnosed AF in the local Emergency Department during a 10-year period. The main aim was to establish whether anticoagulant or antiplatelet therapy was effective to lower the thromboembolic risk in patients receiving these drugs. Bleeding events, related to anticoagulant or antiplatelet therapy, was defined as secondary end point. RESULTS: The final study population consisted of 6389 (3640 males and 2749 females) patients for whom a complete dataset regarding targeted follow-up was available. Patients were then subdivided into two subgroups, according to performance of cardioversion and spontaneous sinus rhythm restoring. In both genders, no significant difference in thromboembolic or bleeding events was noted between patients who underwent cardioversion and were discharged with oral anticoagulant therapy or antiplatelet treatment versus those who were not treated with antithrombotic drugs. Moreover, no difference was also observed in thromboembolic or hemorrhagic event rate between low risk and "medium-risk" patients. CONCLUSIONS: The results of this study suggest that anticoagulant or antiplatelet therapy would not produce clinical benefits in "medium-risk" AF patients.

Adult Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Two case reports and a narrative review.

The term SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) indicates a clinically appreciable post-traumatic myelopathy in the absence of spinal column findings on radiographs and/or computed tomography (CT), but with pathologic findings at magnetic resonance imaging (MRI) in approximately two-thirds of cases. Affecting mainly children younger than 8 years, SCIWORA has been, however, also described in adult patients, but, due to the uncertainty of classification and frequent co-morbidity, the term "adult SCIWORA" has generated controversy, and some debate is still active. In this article, we report two different cases of adult SCIWORA involving cervical spinal cord, characterized by distinct and peculiar clinical features. A literature review and some clinical suggestions are also reported, mainly focused on the importance of a high level of suspicion in order to achieve a timely diagnosis and optimize the management and, consequently, the outcome of these trauma patients.

Improved efficiency and cost reduction in the emergency department by replacing contemporary sensitive with high-sensitivity cardiac troponin immunoassay.

BACKGROUND: Although unquestionable evidence has been provided that high-sensitive (HS) cardiac troponin (cTn) immunoassay outperform the former contemporary-sensitive techniques, some clinicians are still hesitant to implement HS methods in routine clinical practice. This study was hence planned to evaluate the impact of replacing a contemporary-sensitive with HS cTnI immunoassay on hospital and laboratory workload. METHODS: Information on the total number of cTnI tests ordered, total number of blood samples collected, total number of CK-MB tests ordered, number of patients with the first HS-cTnI value below the limit of detection (LoD) and cumulative HS-cTnI values was extracted from the local hospital information system for the semesters before and after the HS method was introduced. RESULTS: Although the total emergency department (ED) visits modestly increased after introducing HS-cTnI, the number of total cTnI tests declined by over 10%. A substantial reduction of single-sample test requests was noted, accompanied by a considerable decline of 3- and 4-sample collections (i.e., -61% and -73%, respectively). A high percentage of patients (27.5%) displayed HS-cTnI values

Effectiveness and safety of electrical cardioversion for acute-onset atrial fibrillation in the emergency department: a real-world 10-year single center experience.

OBJECTIVE: Despite limited evidence, electrical cardioversion of acute-onset atrial fibrillation (AAF) is widely performed in the emergency department (ED). The aim of this study was to describe the effectiveness and safety of electrical cardioversion of AAF performed by emergency physicians in the ED. METHODS: All episodes of AAF electrically cardioverted in the ED were retrieved from the database for a 10-year period. Most patients not already receiving anticoagulants were given enoxaparin before the procedure (259/419). Procedural complications were recorded, and the patients were followed-up for 30 days for cardiovascular and hemorrhagic complications. RESULTS: Four hundred nineteen eligible cases were identified; men represented 69%, and mean age was 61±13 years. The procedure was effective in 403 cases (96.2%; 95.4% in women, 96.5% in men), with considerable differences with respect to the age of the patients, the procedure being effective in 100% of patients aged 18 to 39 and only 68.8% in those >80 years. New ED visits (33/419) were identified within 30 days (31 due to atrial fibrillation/atrial flutter recurrence, 1 due to iatrogenic hypokalemia, 1 due to hypertensive emergency). No strokes, major bleeding, life-threatening arrhythmias or peripheral thromboembolism were recorded. Nine small and mild skin burns were observed. CONCLUSION: Electrical cardioversion is an effective and safe procedure in the vast majority of patients, albeit less effective in patients aged >80 years. It appears reasonable to avoid anticoagulation in low-risk patients with AAF and administer peri-procedural heparin to all remaining patients. Long-term anticoagulation should be planned on an individual basis, after assessment of thromboembolic and hemorrhagic risk.

Multicenter observational study on the reliability of the HEART score.

OBJECTIVE: To rapidly and safely identify the risk of developing acute coronary syndrome in patients with chest pain who present to the emergency department, the clinical use of the History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) scoring has recently been proposed. This study aimed to assess the inter-rater reliability of the HEART score calculated by a large number of Italian emergency physicians. METHODS: The study was conducted in three academic emergency departments using clinical scenarios obtained from medical records of patients with chest pain. Twenty physicians, who took the HEART score course, independently assigned a score to different clinical scenarios, which were randomly administered to the participants, and data were collected and recorded in a spreadsheet by an independent investigator who was blinded to the study's aim. RESULTS: After applying the exclusion criteria, 53 scenarios were finally included in the analysis. The general inter-rater reliability was good (kappa statistics [κ], 0.63; 95% confidence interval, 0.57 to 0.70), and a good inter-rater agreement for the high- and low-risk classes (HEART score, 7 to 10 and 0 to 3, respectively; κ, 0.60 to 0.73) was observed, whereas a moderate agreement was found for the intermediate-risk class (HEART score, 4 to 6; κ, 0.51). Among the different items of the HEART score, history and electrocardiogram had the worse agreement (κ, 0.37 and 0.42, respectively). CONCLUSION: The HEART score had good inter-rater reliability, particularly among the high- and low-risk classes. The modest agreement for history suggests that major improvements are needed for objectively assessing this component.

Takotsubo cardiomyopathy in an ultra-centenarian woman.

A 101 years-old woman was admitted to our Emergency Department (ED) for acute dyspnea which onset nearly two hours before presentation. She had been on hydrochlorothyazyde-amiloride therapy due to mild hypertension. No other relevant features were present in the clinical history. The old lady had never been admitted to the hospital, and she was still living alone. A few days before hospital admission, one of the daughters became ill, so that a caregiver was paid for assisting her 12/24. This new circumstance was reluctantly accepted by the old lady. At ED presentation the patient was dyspnoic but alert. The electrocardiogram showed a marked elevation of the ST segment in V2-V6 leads. The echocardiogram showed the typical apical ballooning, characteristic of takotsubo cardiomyopathy. Blood test only showed a significant increase of cardiac troponin I. Considering the very good conditions of the patient, a coronary angiography was performed, that demonstrated a coronary tree totally free of lesions, thus confirming the clinical suspicion of takotsubo syndrome. The patient was admitted to the Coronary Care Unit, where she had a very good clinical course, and was discharged on day 6th after presentation. After one month of follow-up the clinical course was uneventful and the lady remained in good clinical and lifestyle conditions as before presenting to the ED. This unique case attests that takotsubo cardiomyopathy can be also observed at extreme ages, and should hence be considered in the differential diagnosis of acute dyspnea and chest pain in extremely elderly patients.

Anaphylactic cardiovascular collapse and Kounis syndrome: systemic vasodilation or coronary vasoconstriction?

The first reported human anaphylactic death is considered to be the Pharaoh Menes death, caused by a wasp sting. Currently, anaphylactic cardiovascular events represent one of most frequent medical emergencies. Rapid diagnosis, prompt and appropriate treatment can be life saving. The main concept beyond anaphylaxis lies to myocardial damage and ventricular dysfunction, thus resulting in cardiovascular collapse. Cardiac output depression due to coronary hypoperfusion from systemic vasodilation, leakage of plasma and volume loss due to increased vascular permeability, as well as reduced venous return, are regarded as the main causes of cardiovascular collapse. Clinical reports and experiments indicate that the human heart, in general, and the coronary arteries, in particular, could be the primary target of the released anaphylactic mediators. Coronary vasoconstriction and thrombosis induced by the released mediators namely histamine, chymase, tryptase, cathepsin D, leukotrienes, thromboxane and platelet activating factor (PAF) can result to further myocardial damage and anaphylaxis associated acute coronary syndrome, the so-called Kounis syndrome. Kounis syndrome with increase of cardiac troponin and other cardiac biomarkers, can progress to heart failure and cardiovascular collapse. In experimental anaphylaxis, cardiac reactions caused by the intracardiac histamine and release of other anaphylactic mediators are followed by secondary cardiovascular reactions, such as cardiac arrhythmias, atrioventricular block, acute myocardial ischemia, decrease in coronary blood flow and cardiac output, cerebral blood flow, left ventricular developed pressure (LVdp/dtmax) as well as increase in portal venous and coronary vascular resistance denoting vascular spasm. Clinically, some patients with anaphylactic myocardial infarction respond satisfactorily to appropriate interventional and medical therapy, while anti-allergic treatment with antihistamines, corticosteroids and fluid replacement might be ineffective. Therefore, differentiating the decrease of cardiac output due to myocardial tissue hypoperfusion from systemic vasodilation and leakage of plasma, from myocardial tissue due to coronary vasoconstriction and thrombosis might be challenging during anaphylactic cardiac collapse. Combined antiallergic, anti-ischemic and antithrombotic treatment seems currently beneficial. Simultaneous measurements of peripheral arterial resistance and coronary blood flow with newer diagnostic techniques including cardiac magnetic resonance imaging (MRI) and myocardial scintigraphy may help elucidating the pathophysiology of anaphylactic cardiovascular collapse, thus rendering treatment more rapid and effective.

Clinical management of paroxysmal nocturnal hemoglobinuria in pregnancy: a case report and updated review.

UNLABELLED: Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%). TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period.

In the kingdom of "tortelli" (ravioli-like pasta) plant poisoning is still a threat. A case report of near-fatal poisoning from Digitalis Purpurea accidentally confused with Borago Officinalis.

A 58 years healthy old woman was admitted to the Emergency Department (ED) with cardiac arrest due to ventricular fibrillation (VF). Appropriate cardiopulmonary resuscitation (CPR), multiple DC shocks and oro-tracheal intubation (OTI) were effective to induce recovery of spontaneous circulation (ROSC). After ROSC was achieved, the electrocardiogram (ECG) showed an idio-ventricular rhythm with atrioventricular dissociation. A transcutaneous pacing was hence applied and the patient was administered with isoproterenol. Simultaneously, her husband was evaluated in the ED for gastrointestinal symptoms occurred after assumption of home-made "tortelli" (ravioli-like pasta) stuffed with cheese and leaves of a plant which they supposed to be borage two days before admission. Borage, during the non-flowering seasons, can be easily confused with foxglove (Digitalis spp.), and this was the main clue to suspect poisoning. Both patients were given DigiFab®, a sheep antibody fragment with high affinity for digoxin. The woman was then admitted in intensive care unit (ICU), where a rapid clinical  improvement occurred, thus allowing discharge in a few days. The husband was instead discharged from the ED after clinical observation and ECG monitoring. In both cases, a significant plasma concentration of digoxin could be measured.

Predictive significance of detectable cardiac troponin I measured with a contemporary-sensitive assay in a real life experience.

BACKGROUND: Cardiac troponin (cTn) testing has reduced the likelihood of erroneous discharge of patients with acute coronary syndrome (ACS) from the emergency department (ED), but doubts remain about optimal clinical use. This study was planned for evaluating the predictive significance of cTn values between the limit of detection of the method and the 99th percentile in ED patients evaluated for suspected ACS. METHODS: In this retrospective study all hospital records of patients admitted over a 6-month period to the ED and with at least one cTnI value comprised between the limit of detection (0.01 ng/mL) and the 99th percentile of the assay (0.05 ng/mL) were analyzed. RESULTS: A total of 4,749 patients with cTnI value between 0.01-0.05 ng/mL were identified among 57,879 ED visits throughout the study period. Overall, 2,189 patients (46.1%) were discharged from the ED, 2,529 (53.25%) were admitted to the hospital and 31 (0.65%) died during ED stay. A total number of 289 patients out of 2,189 who were discharged (i.e., 13.2%) had additional ED visits within 30 days. Among these, 6 were diagnosed with ACS, representing 0.27% of patients discharged [negative predictive value (NPV) 0.997; 95% CI, 0.994-0.999] and 2.1% of those with second admission (NPV 0.979; 95% CI, 0.955-0.992). Only one of the 2,529 patients admitted to the hospital (i.e., 0.04%) developed an ACS during hospital stay. CONCLUSIONS: The results of our retrospective study suggest that the suitability of using a contemporary-sensitive cTnI immunoassay assay in the context of an appropriate protocol represents a safe and effective strategy for ruling in and ruling out ACS in patients presenting to the ED.

Serum potassium levels inversely correlate with D-dimer in patients with acute-onset atrial fibrillation.

BACKGROUND: D-dimer values are frequently increased in patients with atrial fibrillation (AF) compared to subjects in sinus rhythm. Hypokalemia plays a role in several cardiovascular diseases, but little is known about the association with AF. OBJECTIVE: D-dimer values are frequently increased in patients with atrial fibrillation (AF) compared with subjects in sinus rhythm. Hypokalemia plays a role in several cardiovascular diseases, but little is known about the association with AF. The aim of this study was to investigate correlations between D-dimer and serum potassium in acute-onset AF (AAF). METHODS: To investigate the potential correlation between the values of serum potassium and D-dimer in patients with AAF, we retrospectively reviewed clinical and laboratory data of all emergency department visits for AAF in 2013. RESULTS: Among 271 consecutive AAF patients with D-dimer assessments, those with hypokalemia (n = 98) had significantly higher D-dimer values than normokalemic patients (139 versus 114 ng/mL, p = 0.004). The rate of patients with D-dimer values exceeding the diagnostic cut-off was higher in the group of patients with hypokalemia than in those with normal serum potassium (26.5% versus 16.2%; p = 0.029). An inverse and highly significant correlation was found between serum potassium and D-dimer (r = -0.21; p < 0.001), even after adjustments for age and sex (beta coefficient -94.8; p = 0.001). The relative risk for a positive D-dimer value attributed to hypokalemia was 1.64 (95% CI, 1.02 to 2.63; p = 0.040). The correlation remained statistically significant in patients free from antihypertensive drugs (r = -0.25; p = 0.018), but not in those taking angiotensin-receptor blockers, angiotensin-converting enzyme inhibitors, or diuretics. CONCLUSIONS: The inverse correlation between values of potassium and D-dimer in patients with AAF provides important and complementary information about the thromboembolic risk of these patients.

The use of S-Monovette is effective to reduce the burden of hemolysis in a large urban emergency department.

BACKGROUND: Due to the high prevalence of hemolysis in specimens received from the emergency department (ED), several strategies have been proposed to improve sample quality, but none of these seem effective to overcome the problem. In a preliminary study we showed that the use of S-Monovette blood collection system was effective to lower the risk of hemolysis in venous blood samples collected from intravenous catheters. This study was hence aimed to verify whether the replacement of a conventional vacuum system with S-Monovette may be effective to reduce the burden of hemolysis in the daily practice of a large urban ED. MATERIALS AND METHODS: The study was divided in two observational periods of 4 months each. In the former period, blood was collected from intravenous catheters using BD Vacutainer SST II Plus plastic serum tubes, whereas in the latter period the blood was drawn from intravenous catheters using S-Monovette blood tubes in aspiration mode. Sample hemolysis was automatically assessed in all serum samples by photometrical measurement. RESULTS: The total number of hemolysed serum specimens was 624/14155 (4.41%) in the first phase of the study, and 342/13319 (2.57%) in the second phase of the study (P<0.001). CONCLUSION: Results of our study confirm that the introduction of the Sarstedt S-Monovette blood tubes has reduced the hemolysis rate in the emergency department compared to the previously used BD Vacutainer® SST II Plus plastic serum tubes.

Association of Hyponatremia and Hypovitaminosis D in Ambulatory Adults.

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.