Increased plasma levels of N-terminal pro-B-type natriuretic peptide as biomarker for the diagnosis of cardioembolic ischaemic stroke.

BACKGROUND: Despite comprehensive study, the aetiology of stroke is not identified in 35% of cases. AIMS: We conducted a study to assess the diagnostic capacity of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the identification of ischaemic stroke of cardioembolic origin. The secondary purpose of the study was to evaluate the prognostic value of NT-proBNP for predicting 90-day all-cause mortality. METHODS: We designed a prospective observational study including patients hospitalised due to stroke between March 2019 and March 2020. Blood samples were collected on admission to the emergency department and serum NT-proBNP levels were determined. Statistical analysis was performed using a bivariate logistic regression model and receiver operating characteristic (ROC) and Kaplan-Meier curves. Statistical significance was established at p<.05. RESULTS: The study included 207 patients with first ischaemic stroke. Plasma NT-proBNP levels were significantly higher (p<.001) in the cardioembolic stroke group (2069pg/mL±488.5). ROC curves showed that NT-proBNP>499pg/mL was the optimum value for diagnosing cardioembolic ischaemic stroke (sensitivity, 82%; specificity, 80%). Moreover, plasma NT-proBNP levels>499pg/mL were independently associated with cardioembolic stroke (OR: 9.881; p=.001). Finally, NT-proBNP>1500pg/mL was useful for predicting 90-day mortality (sensitivity, 70%; specificity, 93%). CONCLUSIONS: NT-proBNP was independently associated with cardioembolic stroke and should be quantified in blood tests within 24h of stroke onset. High plasma levels (>499pg/mL) may indicate an underlying cardioembolic cause, which should be further studied, while NT-proBNP >1500pg/mL was associated with increased 90-day mortality.

Diagnostic accuracy of procalcitonin for bacterial infection in the Emergency Department: a systematic review.

INTRODUCTION AND OBJECTIVE: The care of patients with a suspected infectious process in hospital emergency departments (ED) accounts for 15%-35% of all daily care in these healthcare areas in Spain and Latin America. The early and adequate administration of antibiotic treatment (AB) and the immediate making of other diagnostic-therapeutic decisions have a direct impact on the survival of patients with severe bacterial infection. The main objective of this systematic review is to investigate the diagnostic accuracy of PCT to predict bacterial infection in adult patients treated with clinical suspicion of infection in the ED, as well as to analyze whether the different studies manage to identify a specific value of PCT as the most relevant from the diagnostic point of view of clinical decision that can be recommended for decision making in ED. METHOD: A systematic review is carried out following the PRISMA regulations in the database of PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase and ClinicalTrials.gov from January 2005 to May 31, 2023 without language restriction and using a combination of MESH terms: "Procalcitonin", "Infection/Bacterial Infection/Sepsis", "Emergencies/Emergency/Emergency Department", "Adults" and "Diagnostic". Observational cohort studies (diagnostic performance analyses) were included. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the method used and the risk of bias of the included articles. Observational cohort studies were included. No meta-analysis techniques were performed, but results were compared narratively. RESULTS: A total of 1,323 articles were identified, of which 21 that met the inclusion criteria were finally analyzed. The studies include 10,333 patients with 4,856 bacterial infections (47%). Eight studies were rated as high, 9 as moderate, and 4 as low. The AUC-ROC of all studies ranges from 0.68 (95% CI: 0.61-0.72) to 0.99 (95% CI: 0.98-1). The value of PCT 0.2-0.3 ng/ml is the most used and proposed in up to twelve of the works included in this review whose average estimated performance is an AUC-ROC of 0.79. If only the results of the 5 high-quality studies using a cut-off point of 0.2-0.3 ng/ml PCT are taken into account, the estimated mean AUC-COR result is 0.78 with Se:69 % and Es:76%. CONCLUSIONS: PCT has considerable diagnostic accuracy for bacterial infection in patients treated in ED for different infectious processes. The cut-off point of 0.25 (0.2-0.3) ng/ml has been positioned as the most appropriate to predict the existence of bacterial infection and can be used to help reasonably rule it out.

Hormona paratiroidea, calcidiol, calcitriol y riesgo de eventos adversos en pacientes con síndrome coronario agudo / Parathyroid hormone, calcidiol, calcitriol and adverse events in the acute coronary syndrome

Objetivo: Conocer el perfil clínico, así como el significado pronóstico, de la presencia de niveles elevados de hormona paratiroidea (PTH) en pacientes ingresados por síndrome coronario agudo (SCA). Diseño y ámbito: Estudio observacional y prospectivo de pacientes ingresados por SCA en un único centro español durante un periodo de 6meses. Intervención y variables de interés: Se determinaron las concentraciones de PTH, calcidiol, calcitriol, NT-proBNP, proteína Creactiva, cistatinaC y fibrinógeno circulantes en las primeras 48h del ingreso y se realizaron modelos ajustados para predecir muerte o reingreso por SCA tras el alta. Resultados: Se reclutaron 161 pacientes (edad 67±14años; 75,2% varones) de los cuales 41 (25,5%) presentaron valores elevados de PTH. Se registraron 50 eventos adversos durante un seguimiento de 275 personas-año. Los pacientes con niveles elevados de PTH fueron en mayor proporción mujeres (21,2 vs. 39,0%) y de mayor edad (63,3 vs. 77,8años, ambos p<0,05). Asimismo, presentaron mayor riesgo cardiovascular y una peor evolución en el seguimiento (razón de tasas de incidencia: 2,64; IC 95%: 1,5-4,6). Sin embargo, en un modelo ajustado por la escala GRACE, los niveles de PTH no se mostraron como un factor de riesgo independiente (hazard ratio=1,1; IC 95%: 0,6-2,2); tampoco el resto de componentes del panel. Conclusiones: La proporción de pacientes con niveles elevados de PTH ingresados por SCA es elevada. Su presencia se asoció con un perfil clínico más adverso y peor evolución durante el seguimiento, aunque no resultó ser un predictor independiente de mal pronóstico (AU)

Objective: To know the clinical profile as well as the prognostic significance of elevated levels of parathyroid hormone (PTH) in patients admitted for acute coronary syndrome (ACS). Design and setting: Observational and prospective study of patients admitted for ACS in a single Spanish center during a period of six months. Intervention and variables of interest: The circulating concentrations of PTH, calcidiol, calcitriol, NT-proBNP, C-reactive protein, cystatinC and fibrinogen were determined within the first 48h at admission. We performed adjusted models to predict death or re-entry for ACS after hospital discharge. Results: A total of 161 patients were recruited (age 67±14 years, 75.2% were men). Forty-one (25.5%) patients had elevated PTH values. During follow-up for a period of 275 person-years, 50 adverse events were recorded. Patients with elevated PTH levels were proportionally more women (21.2 vs. 39.0%) and older (63.3 vs. 77.8 years, both P<.05). Likewise, they presented significantly more cardiovascular risk and a worse prognosis during follow-up (incidence rate ratio 2.64 CI 95%: 1.5-4.6). However, in an adjusted model by the GRACE score, PTH levels were not shown to be an independent risk factor (hazard ratio=1.1; 95% CI: 0.6-2.2), neither other components of the panel. Conclusions: The proportion of patients with elevated levels of PTH admitted for ACS was high. The presence of high PTH levels was associated with an unfavorable clinical profile and a worse outcome during the follow-up, although it was not an independent predictor of poor prognosis (AU)

Respuesta de la carta al director «La metodología utilizada puede influir en el valor de copeptina para la exclusión del infarto agudo de miocardio sin elevación del segmento ST» / Methods can influence the value of copeptin to rule-out acute myocardial infarction without ST segment elevation

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Valor de la copeptina para la exclusión del infarto agudo de miocardio sin elevación del segmento ST en pacientes con dolor torácico y primera troponina negativa / Usefulness of copeptin in discarding non-ST elevation acute myocardial infarction in patients with acute chest pain and negative first troponin I

OBJETIVO: Evaluar la utilidad de la copeptina para descartar de forma rápida y segura el infarto agudo de miocardio sin elevación del segmento ST (IAMNST) en pacientes atendidos en un Servicio de Urgencias por dolor torácico agudo con electrocardiograma normal o no diagnóstico y primera determinación de troponina I (cTnI) negativa. DISEÑO: Estudio prospectivo y observacional. ÁMBITO: Servicio de Urgencias de un hospital universitario. PACIENTES: Un total de 97 pacientes atendidos en el Servicio de Urgencias por dolor torácico sugestivo de síndrome coronario agudo de menos de 12 h de evolución, con electrocardiograma no diagnóstico y primera cTnI negativa. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS: Datos demográficos y características basales, copeptina en admisión, cTnI en admisión y a las 6 h, diagnóstico final. RESULTADOS: El diagnóstico final fue de IAMNST en 14 pacientes (14,4%), no observándose diferencias significativas en las concentraciones de copeptina entre ambos grupos, aunque se observó una tendencia a valores superiores en aquellos con IAMNST (mediana: 24,6 pmol/L [amplitud intercuartil: 42,0] vs. 12,0 pmol/L [16,1]; p = 0,06). El AUC ROC para la medida al ingreso de copeptina fue de 0,657 (IC 95%: 0,504-0,810), con un valor predictivo negativo del 92% para un punto de corte de 14 pmol/L. CONCLUSIONES: La determinación de copeptina al ingreso en el Servicio de Urgencias en pacientes con dolor torácico ≤ 12 h sugestivo de síndrome coronario agudo, electrocardiograma no diagnóstico y primera TnI negativa no permite descartar de forma rápida y segura la presencia de IAMNST, siendo necesaria la realización de medidas seriadas de cTn

AIM: To evaluate the usefulness of copeptin as a rapid and reliable marker for discarding non- ST elevation acute myocardial infarction (NSTEMI) in patients attended in an Emergency Care Department due to acute chest pain with a normal or non-diagnostic electrocardiogram and a negative first troponin I result. Design: A prospective observational study was carried out. Setting: The Emergency Care Department of a university hospital. The study comprised a total of 97 patients attended in the Emergency Care Department due to chest pain suggestive of acute coronary syndrome with an evolution of under 12 h, a non-diagnostic electrocardiogram and a negative first troponin I result. Interventions: None. Variables of interest: Patient demographic data and baseline characteristics, copeptin upon admission, troponin I upon admission and after 6 h, and final diagnosis. Results: The final diagnosis was NSTEMI in 14 patients (14.4%) ---no significant differences in copeptin concentration being observed between the 2 groups, though a tendency towards higher values was recorded in the NSTEMI group (median: 24.6 pmol/l [interquartile range: 42.0] vs. 12.0 pmol/l [16.1]; P=.06). The AUC ROC for copeptin upon admission was 0.657 (95%CI: 0.504- 0.810), with a negative predictive value of 92% for a cutoff point of 14 pmol/l. Conclusions: Copeptin determination upon admission to the Emergency Care Department in patients with chest pain for ≤12 h, suggestive of acute coronary syndrome, with a non-diagnostic electrocardiogram and a negative first troponin I determination does not allow rapid and reliable exclusion of the presence of NSTEMI. Serial troponin I measurements are needed in this respect

Valor pronóstico de la proteína fijadora de lipopolisácaridos y la procalcitonina en pacientes consepsis grave y shock séptico ingresados en una unidad de cuidados intensivos / Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care

OBJETIVOS: 1) Valorar la utilidad pronóstica de la determinación inicial y seriada de la proteína fijadora de lipopolisacáridos (LBP) y de la procalcitonina (PCT) y 2) evaluar si su adicción a los scores de gravedad mejoraría su valor pronóstico. DISEÑO: Estudio prospectivo observacional. ÁMBITO: Unidad de Cuidados Intensivos de un hospital general universitario. PACIENTES: Se incluyó a 100 pacientes ingresados por sepsis grave/shock séptico. Variables de interés Datos demográficos, APACHE II y SOFA, concentración de PCT y LBP inicial y a las 48 h y mortalidad hospitalaria. RESULTADOS: Los scores APACHE II al ingreso y SOFA a las 48 h presentaron el mayor rendimiento como predictores de mortalidad hospitalaria (AUC ROC: 0,75 para ambos). La concentración inicial de PCT y LBP y el aclaramiento de LBP fueron similares en pacientes supervivientes y fallecidos. Solo el aclaramiento de PCT fue superior en supervivientes respecto a los fallecidos (AUC ROC: 0,66). La combinación de los scores de gravedad con el aclaramiento de PCT no mejoró su valor pronóstico. CONCLUSIONES: La concentración inicial de LBP y de PCT y el aclaramiento de LBP no presentaron valor pronóstico en pacientes con sepsis grave/shock séptico. Solo el aclaramiento de PCT se comportó como predictor de mortalidad hospitalaria. El rendimiento de los scores APACHE II al ingreso y SOFA a las 48 h fue superior al de los biomarcadores analizados y la adición del aclaramiento de PCT no aumentó su valor pronóstico

AIMS: 1) To assess the prognostic value of levels on admission and serial measurements of lipopolysaccharide binding protein (LBP) and procalcitonin (PCT) in relation to in-hospital mortality; and 2) to determine whether the addition of these parameters to severity scores (APACHE II and SOFA) is able to improve prognostic accuracy. DESIGN: A single-center, prospective observational study was carried out. Setting Intensive Care unit of a university hospital. PATIENTS: One hundred severe sepsis and septic shock patients were included. Data collected Demographic data, APACHE II and SOFA scores, PCT and LBP levels on admission and after 48hours, and in-hospital mortality. RESULTS: The best area under the curve for predicting in-hospital mortality corresponded to APACHE II on admission and SOFA after 48h (AUC ROC: 0.75 for both). PCT and LBP levels on admission and LBP clearance were not statistically different between in-hospital survivors and non-survivors. Only PCT clearance was higher among in-hospital survivors than in non-survivors (AUC ROC: 0.66). The combination of severity scores and PCT clearance did not result in superior areas under the curve. CONCLUSIONS: LBP and PCT levels on admission and LBP clearance showed no prognostic value in severe sepsis and septic shock patients. Only PCT clearance was predictive of in-hospital mortality. The prognostic accuracy was significantly better for APACHE on admission and SOFA after 48h than for any of the analyzed biomarkers, and the addition of PCT clearance did not improve their prognostic value

Bacteriemia por Escherichia coli resistente a ciprofloxacino: factores de riesgo para resistencia a ciprofloxacino e impacto de recibir tratamiento empírico con este antibiótico / Bacteremia due to ciprofloxacin-resistant E. coli: risk factors for ciprofloxacin resistance and impact of receiving empirical treatment with this antibiotic

Antecedentes y objetivos: La incidencia de Escherichia coli resistente a ciprofloxacino (CIP-R) ha aumentado en el Hospital General Universitario Gregorio Marañón (Madrid) durante la última década. CIP continua siendo utilizado como tratamiento empírico de elección en muchas complicaciones sépticas. Nuestro objetivo es analizar los factores que favorecen la adquisición de resistencia a CIP, y en segundo lugar estudiar las consecuencias de administrar empíricamente este antibiótico en casos de bacteriemia por una cepa CIP-R. Material y Métodos: El estudio se ha realizado en el Hospital General Universitario Gregorio Marañón (Madrid). Se revisaron las historias de 224 pacientes con bacteriemia por E. Coli, diagnosticadas en 2001 y 2002. De ellas, 112 eran CIP-R y 112 CIP-S (sensible a ciprofloxacino). Se han estudiado los factores de riesgo posibles para adquirir resistencia a CIP mediante un estudio de “casos y controles”. En una segunda parte hemos estudiado el impacto de recibir empíricamente esta quinolona en aquellos pacientes que tenían una bacteriemia por una cepa resistente. Resultados: De las 224 bacteriemias por E. coli, 161 (23%) fueron cepas CIP-R; de éstas 161 cepas, el 62,5% habían recibido quinolonas en los seis meses previos. Para el segundo objetivo se dividieron los pacientes en aquellos tratados inadecuadamente con quinolonas al menos 48 horas durante los primeros cuatro días de tratamiento: 28 pacientes (25%), y aquellos tratados adecuadamente: 84 pacientes (75%). Los datos obtenidos fueron los siguientes respectivamente: media de días de tratamiento antibiótico global: 15,6 vs 13,2; media de días de estancia hospitalaria: 21,1 vs 18,9; porcentaje de mortalidad: 28,6 vs 6,0; y porcentaje de mala evolución: 50,0 vs 7,1. Conclusiones: El uso previo de quinolonas constituye un factor de riesgo para desarrollar resistencia. Ciprofloxacino podría dejar de ser una elección idónea como tratamiento empírico de episodios de bacteriemia potencialmente atribuible a E.coli, al menos en aquellos pacientes con riesgo de tener una infección por una cepa resistente. La elección equivocada de antimicrobiano no influye en el alargamiento de estancia hospitalaria, pero sí aumenta la morbimortalidad (AU)

Antecedents and objectives: The incidence of ciprofloxacin-resistant E. coli (CIP-R) has increased in the Hospital General Universitario Gregorio Marañón (Madrid) during the last decade. CIP is still in use as the empirical treatment of choice in many septic complications. Our objective is to analyze the factors that favour the acquisition of CIP resistance, and secondly study the consequences of the empiric administration of this antibiotic in bacteremic cases due to a CIP-R strain. Material and Methods: the study has been carried out in the Hospital General Universitario Gregorio Marañón (Madrid).The clinical histories of 224 patients with E.coli bacteremia diagnosed in 2001 and 2002 were revised. Of these histories 112 were CIP-R and 112 CIP-S (ciprofloxacin-sensitive).The possible risk factors for acquisition of CIP resistance were analyzed through a “case-control” study. In a second part we have studied the impact of empirical treatment with this quinolone in those patients who suffered a bacteremia due to a resistant strain. Results: of the 224 E. coli bacteremias 161 (72 %) were CIP-R strains; of these 161 strains 62.5 % had received quinolones in the previous six months. For the second objective the patients were divided in two groups: those who were treated inadequately with quinolones for at least 48 hours during the first four days of treatment, i.e. 28 patients (25 %) and those adequately treated, i.e. 84 patients (75 %). The data obtained were respectively the following: average duration of antibiotic treatment: 15.5 days vs 13.2 days; average duration of hospital stay: 21.1 days vs 18.9 days; percent mortality rate: 28.6 vs 6.0; and percentage of unsatisfactory evolution: 50.0 vs 7.1. Conclusions: the previous use of quinolones is a risk factor for the appearance of resistance. Ciprofloxacin could stop being the best choice for empirical treatment for bacteremic episodes possibly due to E. coli, at least in those patients who risk having an infection with a resistant strain. The wrong choice of antimicrobial agent does not have an impact on the lengthening of the hospital stay but does increase the morbidity and mortality (AU)