C-reactive protein velocity to distinguish febrile bacterial infections from non-bacterial febrile illnesses in the emergency department.

INTRODUCTION: C-reactive protein (CRP) is a real-time and low-cost biomarker to distinguish febrile bacterial infections from non-bacterial febrile illnesses. We hypothesised that measuring the velocity of the biomarker instead of its absolute serum concentration could enhance its ability to differentiate between these two conditions. METHODS: We prospectively recruited adult patients (age >or= 18 years) who presented to the emergency department with fever. We recorded their data regarding the onset of fever and accompanying symptoms. CRP measurements were obtained upon admission. CRP velocity (CRPv) was defined as the ratio between CRP on admission and the number of hours since the onset of fever. Patients were diagnosed by clinical symptoms, blood cultures and imaging studies, and the diagnoses were confirmed by an infectious disease specialist. The efficacy of CRPv as a diagnostic marker was evaluated by using receiver operator curves (ROC). Excluded were patients who did not know the time fever started with certainty, patients with malignancy, patients with HIV infection and patients who had been using antibiotics upon presentation. RESULTS: Of 178 eligible patients, 108 (60.7%) had febrile bacterial infections (mean CRP: 63.77 mg/L, mean CRPv: 3.61 mg/L/hour) and 70 (39.3%) had non-bacterial febrile illnesses (mean CRP: 23.2 mg/L, mean CRPv: 0.41 mg/L/hour). The area under the curve for CRP and CRPv were 0.783 (95% confidence interval (CI) = 0.717 to 0.850) and 0.871 (95% CI = 0.817 to 0.924), respectively. In a 122-patient subgroup with a CRP level of less than 100 mg/L, the area under the curve increased from 0.689 (95% CI = 0.0595 to 0.782) to 0.842 (95% CI = 0.77 to 0.914) by using the CRPv measurements. CONCLUSIONS: CRPv improved differentiation between febrile bacterial infections and non-bacterial febrile illnesses compared with CRP alone, and could identify individuals who need prompt therapeutic intervention.

Non-hip fracture-associated trauma in the elderly population.

BACKGROUND: The rate of trauma in the elderly is growing. OBJECTIVES: To evaluate the characteristics of non-hip fracture-associated trauma in elderly patients at a level I trauma center. METHODS: The study database of this retrospective cohort study was the trauma registry of a level I trauma center. Trauma patients admitted from January 2001 to December 2003 were stratified into different age groups. Patients with the diagnosis of hip fracture were excluded. RESULTS: The study group comprised 7629 patients. The non-hip fracture elderly group consisted of 1067 patients, 63.3% women and 36.7% men. The predominant mechanism of injury was falls (70.5%) and most of the injuries were blunt (94.1%). Injury Severity Score was found to increase significantly with age. The average mortality rate among the elderly was 6.1%. Age, ISS, Glasgow Coma Score on admission, and systolic blood pressure on admission were found to be independent predictors of mortality. CONCLUSIONS: Falls remain the predominant cause of injury in the elderly. Since risk factors for mortality can be identified, an effective community prevention program can help combat the future expected increase in morbidity and mortality associated with trauma in the elderly.

Alcohol use among trauma victims admitted to a level I trauma center in Israel.

BACKGROUND: The contribution of drugs and alcohol to current trauma-related morbidity and mortality in Israel is not known. Identification of these factors in the fast-changing demographics of the Israeli population might lead to better care and, no less importantly, to targeted prevention measures. OBJECTIVES: To determine the incidence of alcohol-related trauma, and to specify the time of day, the cause of trauma, and the morbidity and mortality rates as compared to non-alcohol-associated trauma in the tertiary trauma unit of a large medical center in Tel Aviv. METHODS: Data were obtained from the Israel National Trauma Registry, based on patient records in our institution (Tel Aviv Sourasky Medical Center) from January 2001 to December 2003. RESULTS: Of the 5529 patients in the study, 170 had high alcohol blood levels (> 50 mg/dl). Patients intoxicated with alcohol had higher rates of road accident injuries (35% versus 24% non-intoxicated) and stab wounds (29% vs. 7%). The Injury Severity Score of the alcohol-intoxicated patients was higher (32% > or = 16 vs. 12% > 16). The alcohol-intoxicated patients were more likely to be non-Jewish (34% vs. 9%), young (82% aged 15-44 years) and males (91%). Most of the alcohol-related injuries occurred during the weekend (47%) and during evening-late night hours (from 11 p.m. to 7 a.m., 55%). CONCLUSIONS: Alcohol-associated trauma differs from non-alcohol-associated trauma in many ways. Since the population at risk can be identified, it is important that legislative, social, enforcement and educational measures be adopted to reduce the extent of alcohol abuse and thereby improve the level of public safety.

Acute phase response detection and quantitation at the point of care in older adults with acute bacterial infections.

BACKGROUND: We investigated the reliability of a slide test in determining the presence of acute bacterial infections in a group of older adults to determine the usefulness of this test at the point of care. METHODS: The study group included older adults with an acute bacterial infection and matched controls. We examined the white blood cell count (WBCC), the erythrocyte sedimentation, fibrinogen concentration, and high sensitivity C-reactive protein (hs-CRP), in addition to the slide test that reveals the number of leukocytes and degree of erythrocyte aggregation. RESULTS: There were 144 patients and 144 controls at a respective mean +/- standard deviation age of 71.3 +/- 20.7 and 70.6 +/- 20.2 years. A highly significant difference was noted between patients and controls in all laboratory markers, both conventional and those obtained by the slide test. By using hs-CRP, we correctly predicted the individual group as control or bacterial infection. When analyzed by means of a receiver-operated characteristic (ROC) curve, hs-CRP was again most reliable, with the slide leukocyte test being superior to the WBCC. CONCLUSION: The slide leukocyte count provided a similar diagnostic yield to that of the WBCC. The availability of this slide test at the point of care will provide the clinician with a useful biomarker when faced with clinical decisions in the care of older adults.

Inflammation-related erythrocyte aggregation in patients with inflammatory bowel disease.

Chronic inflammation is associated with increased erythrocyte adhesiveness/aggregation. This might have deleterious effects on the microcirculatory flow and tissue oxygenation. We aimed to determine the degree of erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with inflammatory bowel disease (IBD). Fifty-two patients (24 women and 28 men) with ulcerative colitis (UC) at a mean age of 44.0+/-16.8 years and 96 patients (44 women and 52 men) with Crohn's disease (CD) at a mean age of 38.0+/-15.5 years, with various degrees of disease activity, were matched to normal controls. A simple slide test and image analysis were used to determine the degree of erythrocyte adhesiveness/aggregation. CD activity index (CDAI) was determined in patients with CD, while clinical colitis activity index was applied for patients with UC. A significant (P < 0.0005) increment in the degree of erythrocyte adhesiveness/aggregation was noted in both groups of IBD patients compared with matched control groups. This increment was evident even in individuals with a low index of disease activity and during remission. The highly significant correlation with the concentrations of fibrinogen suggests that the degree of erythrocyte adhesiveness/aggregation is an inflammation-related phenomenon. An enhanced state of erythrocyte adhesiveness/aggregation was noted in the peripheral blood of patients with IBD. This might have a deleterious effect on intestinal microcirculatory flow and tissue oxygenation.