FGF-23 and PTH levels in patients with acute kidney injury: A cross-sectional case series study.

BACKGROUND: Fibroblast growth factor-23 (FGF-23), a novel regulator of mineral metabolism, is markedly elevated in chronic kidney disease and has been associated with poor long-term outcomes. However, whether FGF-23 has an analogous role in acute kidney injury is unknown. The goal of this study was to measure FGF-23 levels in critically ill patients with acute kidney injury to determine whether FGF-23 levels were elevated, as in chronic kidney disease. METHODS: Plasma FGF-23 and intact parathyroid hormone (PTH) levels were measured in 12 patients with acute kidney injury and 8 control subjects. RESULTS: FGF-23 levels were significantly higher in acute kidney injury cases than in critically ill subjects without acute kidney injury, with a median FGF-23 level of 1948 RU/mL (interquartile range (IQR), 437-4369) in cases compared with 252 RU/mL (IQR, 65-533) in controls (p = 0.01). No correlations were observed between FGF-23 and severity of acute kidney injury (defined by the Acute Kidney Injury Network criteria); among patients with acute kidney injury, FGF-23 levels were higher in nonsurvivors than survivors (median levels of 4446 RU/mL (IQR, 3455-5443) versus 544 RU/mL (IQR, 390-1948; p = 0.02). Severe hyperparathyroidism (defined as intact PTH >250 mg/dL) was present in 3 of 12 (25%) of the acute kidney injury subjects versus none of the subjects without acute kidney injury, although this result did not meet statistical significance. CONCLUSIONS: We provide novel data that demonstrate that FGF-23 levels are elevated in acute kidney injury, suggesting that FGF-23 dysregulation occurs in acute kidney injury as well as chronic kidney disease. Further studies are needed to define the short- and long-term clinical effects of dysregulated mineral metabolism in acute kidney injury patients.

Differential use of diagnostic ultrasound in u.s. Emergency departments by time of day.

BACKGROUND: Survey data over the last several decades suggests that emergency department (ED) access to diagnostic ultrasound performed by the radiology department is unreliable, particularly outside of regular business hours. OBJECTIVE: To evaluate the association between the time of day of patient presentation and the use of diagnostic ultrasound services in United States (U.S.) EDs. METHODS: This was a cross-sectional study of ED patient visits using the National Hospital Ambulatory Medical Care Survey for the years 2003 to 2005. Our main outcome measure was the use of diagnostic ultrasound during the ED patient visit as abstracted from the medical record. We performed multivariate analyses to identify any association between ultrasound use and time of presentation for all patients, as well as for two subgroups who are more likely to need ultrasound as part of their routine workup: patients at risk of deep venous thrombosis, and patients at risk for ectopic pregnancy. RESULTS: During the three-year period, we analyzed 110,447 patient encounters, representing 39 million national visits. Of all ED visits, 2.6% received diagnostic ultrasound. Presenting to the ED "off hours" (defined as Monday through Friday 7pm to 7am and weekends) was associated with a lower rate of ultrasound use independent of potential confounders (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.65 - 0.82). Patients at increased risk of deep venous thrombosis who presented to the ED during "off hours" were also less likely to undergo diagnostic ultrasound (OR 0.34, 95% CI: 0.15 - 0.79). Similarly, patients at increased risk of ectopic pregnancy received fewer diagnostic ultrasounds during "off hours" (OR 0.56, 95% CI 0.35 - 0.91). CONCLUSION: In U.S. EDs, ultrasound use was lower during "off hours," even among patient populations where its use would be strongly indicated.

Mandatory triage does not identify high-acuity patients within recommended time frames.

STUDY OBJECTIVE: We determine whether mandatory formal triage of walk-in emergency department (ED) patients provides timely recognition of the most acutely ill. METHODS: This retrospective cross-sectional study was conducted at a US urban academic ED, annual census 39,000, which uses Emergency Severity Index-5 triage (ESI-5) for all arriving patients. ESI-5 recommends that level 1 and 2 patients be treated by a physician immediately or within 10 minutes, respectively. For all high-acuity (ESI 1 or 2) patients presenting between January 1 and December 31, 2008, data from electronic medical records and registration and tracking systems were used to determine elapsed time from arrival to completion of triage (median, range, 95th percentile), proportion of these intervals that met ESI-5 recommendations, and whether triage throughput differed during peak arrival hours. RESULTS: For 3,932 high-acuity walk-in visits (ESI 1=63; ESI 2=3,869), median time from arrival to triage completion was 12.3 minutes, range 0 to 128 minutes. Twenty-seven percent (95% confidence interval [CI] 26% to 29%) of high-acuity patients were taken to rooms on arrival; 41% (95% CI 40%, 43%), including those roomed immediately, completed triage within 10 minutes. Twenty-five percent (95% CI 24% to 26%) completed triage in greater than 20 minutes and 10% (95% CI 9% to 11%) greater than 30 minutes after arrival. Between 10 am and 10 pm (peak arrival hours), triage took longer for level 2 patients, and fewer met ESI recommendations. CONCLUSION: Less than half of high-acuity patients in this urban ED completed triage within time frames recommended by the ESI-5, resulting in potentially unsafe delays. Although mandatory formal triage theoretically identifies patients who should be treated most quickly, the value and safety of this process should be reassessed.

Use of a ß-hCG discriminatory zone with bedside pelvic ultrasonography.

STUDY OBJECTIVE: We seek to assess the performance of the ß human chorionic gonadotropin (ß-hCG) "discriminatory zone" when using bedside pelvic ultrasonography in the evaluation of symptomatic pregnant emergency department (ED) patients. METHODS: This was a cross-sectional study of bedside pelvic ultrasonography performed on consecutive pregnant patients in the first trimester who presented to the ED with abdominal pain or vaginal bleeding. Patients received pelvic ultrasonography, serum ß-hCG testing, and blinded formal radiologic ultrasonography. All patients were followed for 8 weeks to determine outcomes. The sensitivity and specificity of a discriminatory ß-hCG level of 3,000 mIU/mL for the diagnosis of ectopic pregnancy were calculated for patients without an intrauterine pregnancy visualized by bedside ultrasonography. RESULTS: Thirty-six faculty physicians performed bedside pelvic ultrasonography on 256 patients. There were 161 cases with a confirmed visualizable intrauterine pregnancy and 29 ectopic pregnancies. Bedside ultrasonography identified 115 intrauterine pregnancies. The range of ß-hCG for cases of confirmed visualizable intrauterine pregnancy with a nondiagnostic bedside ultrasonography was 15 mIU/mL to 123,368 mIU/mL (median 6,633; interquartile range 1,551 to 32,699). For patients with nondiagnostic bedside ultrasonography, using a discriminatory ß-hCG level of 3,000 mIU/mL to further assess for ectopic pregnancy showed sensitivity of 35% (95% confidence interval [CI] 18% to 54%) and specificity of 58% (95% CI 48% to 67%). Finally, the overall sensitivity of bedside pelvic ultrasonography for the detection of intrauterine pregnancy was 71% (95% CI 63% to 78%), and the specificity was 99% (95% CI 94% to 100%). CONCLUSION: When bedside pelvic ultrasonography does not demonstrate an intrauterine pregnancy, serum ß-hCG level is not helpful in differentiating intrauterine from ectopic pregnancy in symptomatic ED patients.