Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study.

BACKGROUND: Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED. METHODS: We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared. RESULTS: The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%. CONCLUSIONS: The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED. TRIAL REGISTRY: Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.

Development and validation of a simultaneous extraction procedure for HPLC-MS quantification of daptomycin, amikacin, gentamicin, and rifampicin in human plasma.

A simultaneous extraction method to measure daptomycin, amikacin, gentamicin, and rifampicin in human plasma, by high-performance liquid chromatography, was developed and validated. The method involved a rapid sample preparation by protein precipitation with acetonitrile followed by direct injection into a high-performance liquid chromatography system coupled with mass detection. Drug retention times were 10.00 +/- 0.25, 2.00 +/- 0.25, 3.50 +/- 0.25, 11.50 +/- 0.25, and 12.50 +/- 0.25 min for daptomycin, amikacin, gentamicin, rifampicin, and quinoxaline, respectively. Good linearity (mean r(2) = 0.998) was obtained for all drugs quantified over the range of clinically relevant concentrations in human plasma and the use of the internal standard quinoxaline improves accuracy (RSD% <14.9%) and intra-day (RSD% <11.56) and inter-day (RSD% <12.10) precision for the analytical procedure. The limits of quantification for daptomycin, amikacin, gentamicin, and rifampicin were 1.56, 2.34, 0.63, 0.63 microg/ml, respectively. Moreover, the addition of ion pair trifluoroacetic acid in the sample allowed the majority of gentamicin and amikacin separation. A rapid, specific, sensitive, accurate, and reproducible HPLC method was developed and validated to measure daptomycin, amikacin, gentamicin, and rifampicin in human plasma. This method is suitable for clinical pharmacokinetic studies.

[Invasive aspergillosis in an immunocompromised patient: clinical and therapeutic considerations]. / Aspergillosi invasiva in paziente immunocompromesso: considerazioni cliniche e terapeutiche.

The paper describes a case report of a young female with invasive aspergillosis diagnosed after brief treatment with high-dose steroids for autoimmune thrombocytopenia. Early diagnosis of invasive aspergillosis was made with cultures of tracheoaspirates and bronchoalveolar lavage and was confirmed with a transbronchial biopsy. After initial ineffective treatment with liposomal amphotericin B and dissemination from pulmonary to central nervous system involvement, treatment was switched to a combination of voriconazole and caspofungin. After marked clinical and radiological improvement, treatment was switched to the orally administered formulation of voriconazole until the complete disappearance of central nervous system lesion was observed. In the discussion section we underscore the most significant data of the host susceptibility, diagnosis of invasive aspergillosis, complications and treatment. This case ably demonstrates the efficacy of new antifungal agents, even when administered orally, and underscores the variability of host susceptibility to atypical and often unexpected invasive fungal infections.