Biomarkers in Shock Patients and Their Value as A Prognostic Tool; A Prospective Multi-Center Cohort Study.

OBJECTIVE: To investigate the prognostic value of clinical and laboratory tests in prediction of outcome in patients at day 30 post presentation to hospital with shock and to determine the prognostic value of mid regional pro-adrenomedullin (MR-proADM) on mortality prediction at 30 days in the same patient cohort. METHOD: This prospective multicenter cohort study analyzed data from patients who had presenting with shock to the emergency departments of eleven urban, tertiary-care University hospitals in Spain between March, 2011 and May, 2011. Recruitment of patients was via convenience sampling. Inclusion criteria included age between 14 and 100 years with clinical diagnostic criteria of shock on admission. Various patient parameters were analysed, such as age, sex, past medical history. Other clinical variables were measured on arrival to hospital, including sequential organ failure assessment score (score SOFA), blood pressure, oxygen saturations, capillary refill time and shock index (SI). Laboratory variables investigated included base excess, MR-proADM, lactate, C-Reactive Protein (CRP) and procalcitonin (PCT). RESULTS: There were 212 patients included in the study from the eleven hospitals involved. The mean age was 72.2 years old and 60.4% of the patients were men. In the discriminant analysis only age, MR-proADM and PCT remained in the final discriminant equation. The separate analysis of MR-proADM showed that, in the non-survivors group, MR-proADM levels are significantly higher than those found in the group of survivors (p<0.001). CONCLUSION: Age, PCT and MR-proADM were useful to predict short-term mortality in patients presenting to the emergency department shock. This suggests that PCT and MR-proADM in combination with the most common prediction models will improve prognostic value.

Dover sole.

Negative pressure pulmonary edema (NPPE) is a clinical syndrome well described in the literature and easy to recognize in cases of suspicion, but probably underdiagnosed. It can be a cause of morbidity and admission to the intensive care unit of healthy young individuals. It is present in approximately one in every thousand anesthetics and in 10% of the episodes of upper airway obstruction that are observed in routine clinical practice. It is a non-cardiogenic form of pulmonary oedema thought to be caused by the highly negative intra-thoracic pressure generated when trying to breathe against an acute obstruction. We report a case of NPPE after an airway obstruction in a young male patient.

Catastrophic antiphospholipid antibody syndrome presenting as acute vascular occlusion in a young female patient.

Acquired thrombotic and thromboembolic disorders may be presented initially with symptoms and signs of acute ischaemia or organ dysfunction that will lead many of these patients to seek care in the emergency department. We report a case of a 19-year-old female patient who developed catastrophic antiphospholipid syndrome (CAPS syndrome or Asherson syndrome) 6 weeks post stillbirth with an initial presentation of acute vascular occlusion. The patient was immediately operated and anticoagulated with significant improvement.

Physical fitness as an indicator of health status and its relationship to academic performance during the prepubertal period.

Background: Physical activity (PA) is considered one of the most important determinants of the health status in children, and predictor of morbidity/mortality in adults. The aim is to examine the relationship between physical fitness (PF), PA, obesity and academic performance (AP) in primary school children. Methods: Cross-sectional studies including 91 primary school students, aged 9 to 12 years, from the province of Córdoba. Data was collected from April to June 2014. We measured PF using part of the EUROFIT fitness testing battery. The level of PA was measured as low or high PF and the level of obesity was measured using body mass index, waist circumference, percentage of fat mass, lean body mass, percentage of lean mass and basal metabolism. AP by scores on the second quarter was based on the total average of scores of basic subjects and other subjects, including physical education. Cognitive performance was assessed by the Spanish overall and factorial intelligence test. Results: The results of AP were positively related to levels of PF. Students who achieve better PF score better in Maths, (P=0.019), Natural Sciences (P=0.024), Religion (P=0.018) and Physical Education (P<0.001). A direct association between maximal aerobic capacity with Mathematics (r=0.325, P=0.02), AP (r=0.349, P=0.001) and cognitive performance (CP)(r=0.312, P=0.003) was observed. There was also a direct association of better jump tests with higher AP (r=0.328, P=0.002). Conclusion: The AP is associated with higher levels of fitness. Therefore, the education system should consider implementing curriculum strategies favouring the improvement of the PF, and therefore the health and AP of students.

Swimming-induced pulmonary oedema an uncommon condition diagnosed with POCUS ultrasound.

Swimming Induced Pulmonary Edema, or SIPE, is an emerging condition occurring in otherwise healthy individuals during surface swimming or diving that is characterized by cough, dyspnea, hemoptysis, and hypoxemia. It is typically found in those who spend time in cold water exercise with heavy swimming and surface swimming, such as civilian training for iron Man, triathalon, and military training. We report the case of a highly trained young female swimmer in excellent cardiopulmonary health, who developed acute alveolar pulmonary oedema in an open water swimming training diagnosed in the emergency department using POCUS ultrasound.

Acute ischemic stroke what is hidden behind?

Acute aortic dissection (AAD) is a rare and potentially fatal disease. The classic presentation is sudden and severe pain in the chest, back, or abdomen, described as tearing or ripping pain radiating to the interscapular region. Cerebral ischemic complications occur in 18-30% of aortic dissections and patients may present to the emergency department (ED) with isolated focal neurology and no chest pain. In AAD patients, presenting with stroke and subsequently thrombolized, a 71% mortality rate has been reported in patients receiving recombinant tissue plasminogen activator (r-TPA). We present a case of a 58-year-old male patient that presented to ED with sudden onset of headache and left-sided hemiparesis, computed tomography (CT) demonstrated an ischemic stroke of the right middle cerebral artery. When the question of whether to start r-TPA or mechanical thrombectomy was discussed, a cardiac point-of-care ultrasound was performed in ED and showed a type A aortic dissection; immediately a CT aortic angiogram was performed and confirmed the diagnosis. The patient was taken to theater and had a favorable outcome. .

Characteristics and mortality of elderly patients admitted to the Intensive Care Unit of a district hospital.

AIM: To study all the elderly patients (≥75 years) who were admitted in an Intensive Care Unit (ICU) of a Spanish hospital and identify factors associated with mortality. PATIENTS AND METHODS: A retrospective, observational data collected prospectively in patients ≥75 years recruited from the ICU in the period of January 2004 to December 2010. RESULTS: During the study period, 1661 patients were admitted to our unit, of whom 553 (33.3%) were older than 75 years. The mean age was 79.9 years, 317 (57.3%) were male, and the overall in-hospital mortality was 94 patients (17% confidence interval 14-20.3%). When comparing patients who survived to those who died, we found significant differences in mean age (P = 0.001), Acute Physiologic Assessment and Chronic Health Evaluation II and Simplified Acute Physiology Scoring II (SAPS II) on admission (P < 0.0001, postoperative patients (P = 0.001), and need for mechanical ventilation (P < 0.0001). Comparing age groups, we found statistically significant differences in SAPS II (P = 0.007), diagnosis of non-ST-segment elevation myocardial infarction (P = 0.014), complicated postoperative period (P = 0.001), and pacemaker (P = 0.034). Mortality between the groups was statistically significant (P = 0.004). The survival between the group of 65 and 74 years and patients >75 years was not significant (P = 0.1390). CONCLUSIONS: The percentage of elderly patients in our unit is high, with low mortality rates. The age itself is not the sole determinant for admission to the ICU and other factors should be taken into account.

Community Acquired Spondylodiscitis caused by Escherichia Coli; Case Report and Literature Review.

Vertebral osteomyelitis, or spondylodiscitis, is a rare disease with increasing prevalence in recent years due to a greater number of spinal surgical procedures, nosocomial bacteraemia, an aging population and intravenous drug addiction. Haematogenous infection is the most common cause of spondylodiscitis. We report a 47-year-old man diagnosed with Escherichia coli spondylodiscitis. The patient initially presented with a 4-day history of inflammatory, mechanical pain in the lower back suggesting sciatica. Treatment included NSAIDs and opioids. Two days after discharge from hospital following an admission due to an upper GI bleeding, the back pain intensified, precipitating a new attendance to the emergency department; during which lumbosacral radiography showed marked reduction of L2/L3 intervertebral space. After a new admission to the rheumatology unit due to worsening of symptoms and raised inflammatory markers, an expedited MRI showed loss of intervertebral disc space at L2/L3, with an irregular high intensity area at L2; suggesting a fluid collection extending to adjacent soft tissues. Fluoroscopy-guided core needle bone biopsies were reported positive for Escherichia coli sensitive to ceftriaxone. The patient was treated (received treatment) with a three week course of ceftriaxone following a formal diagnosis of E. coli spondylodiscitis. Follow-up MRI demonstrated complete recovery with the patient able to return (has returned) to normal activity. In this case we highlight the importance of correct and timely diagnosis of spondylodiscitis. Diagnosis of spondylodiscitis is often difficult, delayed or even missed due to the rarity of the disease but can lead to devastating consequences. Therefore a high index of suspicion is needed for prompt diagnosis to ensure improved long-term outcomes.

Limb-Shaking TIA Presenting as Hemichorea-Hemiballismus: TIA Chameleons Diagnostic Challenge in the Emergency Department.

BACKGROUND: demonstrate the importance of considering limb-shaking syndrome in the differential diagnosis of patients who present to the emergency department (ED) with hyperkinetic movements. METHODS: In this article, we describe a diagnostic challenge in the ED in which a patient presents with hyperkinetic movements that are initially diagnosed as hemichorea-hemiballismus (HCHB) but are subsequently found to be limb-shaking syndrome with important therapeutic opportunities. RESULTS: Following a diagnosis of left carotid obstruction, the patient underwent left carotid endarterectomy 5 days after admission. Six months after surgery, the patient had no further symptoms, and an ultrasound scan and magnetic resonance angiography have confirmed no restenosis. CONCLUSION: Limb shaking is an uncommon form of transient ischemic attack that should be recognized and differentiated from conditions such as focal motor seizures. Recognition will almost invariably indicate carotid artery occlusion, and timely treatment may not only abolish the attacks in patients but also reduce their risk of stroke. HCHB represents a spectrum of hyperkinetic movement disorders varying in the severity of choreic and/or ballistic movements. The presented case includes limb-shaking syndrome in the differential diagnosis and prompts for further investigations to complete the assessment.

Varicella zoster encephalitis mimicking stroke.

Physicians need to consider a broad differential diagnosis when evaluating a patient presenting with a suspected stroke. The rates of overdiagnosis of stroke in studies of consecutive patients vary from 19% to 31%. The two most common stroke mimics are hypoglycemia and seizure, but several etiologies have been reported.We reported the case of a 41-year-old patient presenting to the emergency department with aphasia and right-side hemiparesis, initially suspected to have stroke and finally diagnosed of varicella-zoster encephalitis.

Gastric wall abscess presenting as thoracic pain: rare presentation of an old disease.

Acute phlegmonous gastritis, a suppurative infection of the gastric wall, has a high mortality rate. This disease remains a mystery to most clinicians. The rarity of this disease and its nonspecific presentation make early diagnosis difficult, especially in the emergency department. We describe a case of acute phlegmonous gastritis presenting as gastric wall abscess in a 55-year-old woman who visited the emergency department, illustrating the severity of this disease, the difficulty in its diagnosis and its unusual presentation.