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Yates GP, Barrett A, Ogedengbe O. Ionised hypocalcaemia in emergency and acute medicine. BMJ Case Rep 2022; 15:e251611. [PMID: 36375853 PMCID: PMC9664304 DOI: 10.1136/bcr-2022-251611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute hypocalcaemia can be life-threatening and must be diagnosed promptly. The gold-standard investigation is ionised calcium, which is measured on most blood gas analysers. Total calcium measurements are inaccurate in severe depletion even if 'corrected' or 'adjusted' for albumin. We present an illustrative case of a woman in her 30s with symptomatic hypocalcaemia and a very low ionised calcium on VBG analysis. Emergency calcium replacement was delayed due to a falsely reassuring corrected calcium result. Our discussion includes a systematic literature review on the use of ionised calcium in emergency and acute medical settings. We suggest cognitive biases that may explain clinical over-reliance on corrected calcium, and call for the inclusion of ionised calcium values in major treatment guidelines for acute hypocalcaemia.
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Affiliation(s)
| | - Alice Barrett
- Barts and The London School of Medicine and Dentistry, London, UK
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Admission Serum Ionized and Total Calcium as New Predictors of Mortality in Patients with Cardiogenic Shock. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6612276. [PMID: 33928149 PMCID: PMC8049792 DOI: 10.1155/2021/6612276] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/05/2021] [Accepted: 03/20/2021] [Indexed: 12/22/2022]
Abstract
Background Although serum calcium has been proven to be a predictor of mortality in a wide range of diseases, its prognostic value in critically ill patients with cardiogenic shock (CS) remains unknown. This retrospective observational study is aimed at investigating the association of admission calcium with mortality among CS patients. Methods Critically ill patients diagnosed with CS in the Medical Information Mart for Intensive Care-III (MIMIC-III) database were included in our study. The study endpoints included 30-day, 90-day, and 365-day all-cause mortalities. First, admission serum ionized calcium (iCa) and total calcium (tCa) levels were analyzed as continuous variables using restricted cubic spline Cox regression models to evaluate the possible nonlinear relationship between serum calcium and mortality. Second, patients with CS were assigned to four groups according to the quartiles (Q1-Q4) of serum iCa and tCa levels, respectively. In addition, multivariable Cox regression analyses were used to assess the independent association of the quartiles of iCa and tCa with clinical outcomes. Results A total of 921 patients hospitalized with CS were enrolled in this study. A nonlinear relationship between serum calcium levels and 30-day mortality was observed (all P values for nonlinear trend < 0.001). Furthermore, multivariable Cox analysis showed that compared with the reference quartile (Q3: 1.11 ≤ iCa < 1.17 mmol/L), the lowest serum iCa level quartile (Q1: iCa < 1.04 mmol/L) was independently associated with an increased risk of 30-day mortality (Q1 vs. Q3: HR 1.35, 95% CI 1.00-1.83, P = 0.049), 90-day mortality (Q1 vs. Q3: HR 1.36, 95% CI 1.03-1.80, P = 0.030), and 365-day mortality (Q1 vs. Q3: HR 1.28, 95% CI 1.01-1.67, P = 0.046) in patients with CS. Conclusions Lower serum iCa levels on admission were potential predictors of an increased risk of mortality in critically ill patients with CS.
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Lind L, Zanetti D, Högman M, Sundman L, Ingelsson E. Commonly used clinical chemistry tests as mortality predictors: Results from two large cohort studies. PLoS One 2020; 15:e0241558. [PMID: 33152050 PMCID: PMC7644047 DOI: 10.1371/journal.pone.0241558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/18/2020] [Indexed: 12/01/2022] Open
Abstract
Background The normal ranges for clinical chemistry tests are usually defined by cut-offs given by the distribution in healthy individuals. This approach does however not indicate if individuals outside the normal range are more prone to disease. Methods We studied the associations and risk prediction of 11 plasma and serum biomarkers with all-cause mortality in two population-based cohorts: a Swedish cohort (X69) initiated in 1969, and the UK Biobank (UKB) initiated in 2006–2010, with up to 48- and 9-years follow-up, respectively. Results In X69 and in UKB, 18,529 and 425,264 individuals were investigated, respectively. During the follow-up time, 14,475 deaths occurred in X69 and 17,116 in UKB. All evaluated tests were associated with mortality in X69 (P<0.0001, except bilirubin P<0.005). For calcium, blood urea nitrogen, bilirubin, hematocrit, uric acid, and iron, U-shaped associations were seen (P<0.0001). For leukocyte count, gamma-glutamyl transferase, alkaline phosphatases and lactate dehydrogenase, linear positive associations were seen, while for albumin the association was negative. Similar associations were seen in UKB. Addition of all biomarkers to a model with classical risk factors improved mortality prediction (delta C-statistics: +0.009 in X69 and +0.023 in UKB, P<0.00001 in both cohorts). Conclusions Commonly used clinical chemistry tests were associated with all-cause mortality both in the medium- and long-term perspective, and improved mortality prediction beyond classical risk factors. Since both linear and U-shaped relationships were found, we propose to define the normal range of a clinical chemistry test based on its association with mortality, rather than from the distribution.
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Affiliation(s)
- Lars Lind
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Daniela Zanetti
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
- Stanford Cardiovascular Institute, Stanford, CA, United States of America
- Stanford Diabetes Research Center, Stanford, CA, United States of America
| | - Marieann Högman
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Sundman
- Department of Public Health Medicine, County Council of Gävleborg, Gävle, Sweden
| | - Erik Ingelsson
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
- Stanford Cardiovascular Institute, Stanford, CA, United States of America
- Stanford Diabetes Research Center, Stanford, CA, United States of America
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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Wilson W, Selvaraj DR, Ramya Kumar MV, Jain V, Umra S, Murty S. Arterial lactate as a prognostic tool to predict mortality and disposition in the emergency department: A prospective observational single-centre study. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920964177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Point-of-care tools are invaluable in the emergency department. Arterial lactate has been used for prognostication in subsets of population in the emergency department but not often for a heterogeneous population. Objectives: We aimed to study the use of arterial lactate as a prognostication and disposition tool in an undifferentiated population presenting to the emergency department. Methods: We conducted a prospective study among all consenting emergency department patients with age >18 years, who had an arterial blood gas performed as a part of routine care and had a lactate value ⩾2 mmol/L. We collected data on demographics, comorbidities and patient disposition from the emergency department and 28-day mortality as a follow-up telephonically. Results: We included 469 patients with a median age of 37 years. Sixteen provisional diagnoses were made in the emergency department, and pneumonia/lower respiratory tract infection was relatively higher (13.6%). The median lactate was 4.6 (interquartile range = 3.2–7) with 155 patients (33%) being transferred to intensive care unit and 62 deaths (13.2%) recorded at 28 days. Furthermore, we observed optimum values for lactates at 5 mmol/L predicted intensive care unit admissions and 6 mmol/L predicted mortality. A unit increase in arterial lactate in the emergency department significantly increased mortality by 66% (95% confidence interval = 1.45–1.88; p < 0.001) and had a 2.15 times (95% confidence interval = 1.63–2.83; p < 0.001) significantly higher chance of being transferred to the intensive care unit. Conclusion: Arterial lactate can be used as a prognostication tool for a heterogeneous population presenting to the emergency department. Clinical significance: Point-of-care investigations such as arterial lactate can help the emergency physician make quick decisions on the floor and guide prognostication and disposition.
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Affiliation(s)
- William Wilson
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dhiraj Ravindran Selvaraj
- Division of Clinical Research and Training, St. John’s Research Institute, Bengaluru, Karnataka, India
| | - MV Ramya Kumar
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vinayak Jain
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Simran Umra
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shakuntala Murty
- Department of Emergency Medicine, St. John’s Medical College, Bengaluru, Karnataka, India
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Abensur Vuillaume L, Ferreira JP, Asseray N, Trombert-Paviot B, Montassier E, Legrand M, Girerd N, Boivin JM, Chouihed T, Rossignol P. Hypokalemia is frequent and has prognostic implications in stable patients attending the emergency department. PLoS One 2020; 15:e0236934. [PMID: 32750075 PMCID: PMC7402484 DOI: 10.1371/journal.pone.0236934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 07/16/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Potassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is poorly described. AIMS This study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness. METHODS Post-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed. RESULTS A total of 1242 patients were included. The mean age was 57.2±22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia<4mmol/L(n = 620, 49.9%), normokalemia 4-5mmol/L(n = 549, 44.2%) and hyperkalemia >5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia<3.5mmol/L was 8% (n = 101). Renal insufficiency (OR [95% CI] = 3.56[1.94-6.52], p-value <0.001) and hemoglobin <12g/dl (OR [95% CI] = 2.62[1.50-4.60], p-value = 0.001) were associated with hyperkalemia. Female sex (OR [95% CI] = 1.31[1.03-1.66], p-value = 0.029), age <45years (OR [95% CI] = 1.69 [1.20-2.37], p-value = 0.002) and the use of thiazide diuretics (OR [95% CI] = 2.04 [1.28-3.32], p-value = 0.003), were associated with hypokalemia<4mmol/l. Two patients died in the ED and 629 (52.7%) were hospitalized. Hypokalemia <3.5mmol/L was independently associated with increased odds of hospitalization or death (OR [95% CI] = 1.47 [1.00-2.15], p-value = 0.048). CONCLUSIONS Hypokalemia is frequently found in the ED and was associated with worse outcomes in a low-risk ED population.
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Affiliation(s)
- Laure Abensur Vuillaume
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France
- Emergency Departement, Regional Hospital Metz-Thionville, Metz, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
| | - Nathalie Asseray
- Infectious Diseases Department, Nantes University Hospital and CIC 1413, INSERM, Nantes, France
| | - Béatrice Trombert-Paviot
- Department of Public Health and Medical Informatics, University Hospital of Saint Etienne and Host Research Team SNA-EPIS, PRES Lyon, Jean Monnet University, Lyon, France
| | - Emmanuel Montassier
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
- Department of Emergency Medicine, Nantes University Hospital; MiHAR lab, Université de Nantes, Nantes, France
| | - Matthieu Legrand
- APHP, Department of Anaesthesiology, Critical Care Medicine and Burn Unit, Saint Louis University Hospital, INSERM UMR-S942, INI-CRCT network and Univ Paris Diderot, Paris, France
| | - Nicolas Girerd
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
| | - Jean-Marc Boivin
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
| | - Tahar Chouihed
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
- Emergency Departement, University Regional Hospital, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), France
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Lee S, Hong S, Cha WC, Kim K. Predicting Adverse Outcomes for Febrile Patients in the Emergency Department Using Sparse Laboratory Data: Development of a Time Adaptive Model. JMIR Med Inform 2020; 8:e16117. [PMID: 32213477 PMCID: PMC7146241 DOI: 10.2196/16117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/23/2019] [Accepted: 12/27/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND A timely decision in the initial stages for patients with an acute illness is important. However, only a few studies have determined the prognosis of patients based on insufficient laboratory data during the initial stages of treatment. OBJECTIVE This study aimed to develop and validate time adaptive prediction models to predict the severity of illness in the emergency department (ED) using highly sparse laboratory test data (test order status and test results) and a machine learning approach. METHODS This retrospective study used ED data from a tertiary academic hospital in Seoul, Korea. Two different models were developed based on laboratory test data: order status only (OSO) and order status and results (OSR) models. A binary composite adverse outcome was used, including mortality or hospitalization in the intensive care unit. Both models were evaluated using various performance criteria, including the area under the receiver operating characteristic curve (AUC) and balanced accuracy (BA). Clinical usefulness was examined by determining the positive likelihood ratio (PLR) and negative likelihood ratio (NLR). RESULTS Of 9491 eligible patients in the ED (mean age, 55.2 years, SD 17.7 years; 4839/9491, 51.0% women), the model development cohort and validation cohort included 6645 and 2846 patients, respectively. The OSR model generally exhibited better performance (AUC=0.88, BA=0.81) than the OSO model (AUC=0.80, BA=0.74). The OSR model was more informative than the OSO model to predict patients at low or high risk of adverse outcomes (P<.001 for differences in both PLR and NLR). CONCLUSIONS Early-stage adverse outcomes for febrile patients could be predicted using machine learning models of highly sparse data including test order status and laboratory test results. This prediction tool could help medical professionals who are simultaneously treating the same patient share information, lead dynamic communication, and consequently prevent medical errors.
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Affiliation(s)
- Sungjoo Lee
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Sungjun Hong
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Health Information and Strategy Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Kyunga Kim
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Tazmini K, Ranhoff AH. Electrolyte outpatient clinic at a local hospital - experience from diagnostics, treatment and follow-up. BMC Health Serv Res 2020; 20:154. [PMID: 32111205 PMCID: PMC7048094 DOI: 10.1186/s12913-020-5022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background Electrolyte imbalances (EI) are common among patients. Many patients have repeated hospitalizations with the same EI without being investigated and treated. We established an electrolyte outpatient clinic (EOC) to diagnose and treat patients with EI to improve symptoms and increase their quality of life (QoL). In addition, we also wanted to reduce the number of admissions with the same EI. Methods Uncontrolled before-after study reporting experiences from this outpatient clinic as a quality assurance project. From October 2010 to October 2015, doctors at our local hospital and general practitioners could refer adult patients with EI to the EOC. Ninety patients with EI were referred, of whom 60 were included. Medical history, clinical examination and laboratory tests were performed, and results registered. Admissions with the same EI were recorded 1 year before and 1 year after consultation at the EOC. Patients responded to a questionnaire, composed by the authors, about symptoms before the first consultation, as well as symptom and QoL improvement after the last consultation. Results Hyponatremia was the reason for referral in 45/60 patients. The total number of admissions with the same EI 1 year before the first consultation was 71, compared with 20 admissions 1 year after the last consultation. Improvement of symptoms was reported by 60% of patients, and 62% reported improvement in QoL. Conclusions An EOC may be an appropriate way to organize the assessment and treatment of patients with EI.
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Affiliation(s)
- Kiarash Tazmini
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Faculty of Medicine, Oslo University Hospital, Postbox 4950 Nydalen, 0424, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway. .,Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway.
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Tazmini K, Nymo SH, Louch WE, Ranhoff AH, Øie E. Electrolyte imbalances in an unselected population in an emergency department: A retrospective cohort study. PLoS One 2019; 14:e0215673. [PMID: 31022222 PMCID: PMC6483356 DOI: 10.1371/journal.pone.0215673] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/05/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although electrolyte imbalances (EIs) are common in the emergency department (ED), few studies have examined the occurrence of such conditions in an unselected population. OBJECTIVES To investigate the frequency of EI among adult patients who present to the ED, with regards to type and severity, and the association with age and sex of the patient, hospital length of stay (LOS), readmission, and mortality. METHODS A retrospective cohort study. All patients ≥18 years referred for any reason to the ED between January 1, 2010, and December 31, 2015, who had measured blood electrolytes were included. In total, 62 991 visits involving 31 966 patients were registered. RESULTS EIs were mostly mild, and the most common EI was hyponatremia (glucose-corrected) (24.6%). Patients with increasing severity of EI had longer LOS compared with patients with normal electrolyte measurements. Among all admitted patients, there were 12928 (20.5%) readmissions within 30 days from discharge during the study period. Hyponatremia (glucose-corrected) was associated with readmission, with an adjusted odds ratio (OR) of 1.25 (95% CI, 1.18-1.32). Hypomagnesemia and hypocalcemia (albumin-corrected) were also associated with readmission, with ORs of 1.25 (95% CI, 1.07-1.45) and 1.22 (95% CI, 1.02-1.46), respectively. Dysnatremia, dyskalemia, hypercalcemia, hypermagnesemia, and hyperphosphatemia were associated with increased in-hospital mortality, whereas all EIs except hypophosphatemia were associated with increased 30-day and 1-year mortality. CONCLUSIONS EIs were common and increasing severity of EIs was associated with longer LOS and increased in-hospital, 30-days and 1-year mortality. EI monitoring is crucial for newly admitted patients, and up-to-date training in EI diagnosis and treatment is essential for ED physicians.
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Affiliation(s)
- Kiarash Tazmini
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- * E-mail:
| | - Ståle H. Nymo
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - William E. Louch
- Institute of Experimental Medical Research, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Anette H. Ranhoff
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
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Faisal M, Scally AJ, Jackson N, Richardson D, Beatson K, Howes R, Speed K, Menon M, Daws J, Dyson J, Marsh C, Mohammed MA. Development and validation of a novel computer-aided score to predict the risk of in-hospital mortality for acutely ill medical admissions in two acute hospitals using their first electronically recorded blood test results and vital signs: a cross-sectional study. BMJ Open 2018; 8:e022939. [PMID: 30530474 PMCID: PMC6286481 DOI: 10.1136/bmjopen-2018-022939] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES There are no established mortality risk equations specifically for emergency medical patients who are admitted to a general hospital ward. Such risk equations may be useful in supporting the clinical decision-making process. We aim to develop and externally validate a computer-aided risk of mortality (CARM) score by combining the first electronically recorded vital signs and blood test results for emergency medical admissions. DESIGN Logistic regression model development and external validation study. SETTING Two acute hospitals (Northern Lincolnshire and Goole NHS Foundation Trust Hospital (NH)-model development data; York Hospital (YH)-external validation data). PARTICIPANTS Adult (aged ≥16 years) medical admissions discharged over a 24-month period with electronic National Early Warning Score(s) and blood test results recorded on admission. RESULTS The risk of in-hospital mortality following emergency medical admission was 5.7% (NH: 1766/30 996) and 6.5% (YH: 1703/26 247). The C-statistic for the CARM score in NH was 0.87 (95% CI 0.86 to 0.88) and was similar in an external hospital setting YH (0.86, 95% CI 0.85 to 0.87) and the calibration slope included 1 (0.97, 95% CI 0.94 to 1.00). CONCLUSIONS We have developed a novel, externally validated CARM score with good performance characteristics for estimating the risk of in-hospital mortality following an emergency medical admission using the patient's first, electronically recorded, vital signs and blood test results. Since the CARM score places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.
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Affiliation(s)
- Muhammad Faisal
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford, UK
| | - Andrew J Scally
- School of Clinical Therapies, University College Cork, Cork, Ireland
| | | | - Donald Richardson
- Department of Renal Medicine, York Teaching Hospital NHS Foundation Trust Hospital, York, UK
| | - Kevin Beatson
- Department of Renal Medicine, York Teaching Hospital NHS Foundation Trust Hospital, York, UK
- York Teaching Hospital NHS Foundation Trust Hospital, York, UK
| | - Robin Howes
- Department of Strategy and Planning, Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, UK
| | - Kevin Speed
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, UK
| | - Madhav Menon
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, UK
| | - Jeremey Daws
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, UK
| | - Judith Dyson
- School of Health and Social Work, University Of Hull, Hull, UK
| | - Claire Marsh
- Bradford Institute for Health Research, Bradford, UK
| | - Mohammed A Mohammed
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford, UK
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Cheungpasitporn W, Thongprayoon C, Mao MA, Kittanamongkolchai W, Sakhuja A, Erickson SB. Impact of admission serum calcium levels on mortality in hospitalized patients. Endocr Res 2018; 43:116-123. [PMID: 29381079 DOI: 10.1080/07435800.2018.1433200] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To assess the relationship between admission serum calcium levels and in-hospital mortality in all hospitalized patients. METHODS All adult hospitalized patients who had admission serum calcium levels available between years 2009 and 2013 were enrolled. Admission serum calcium was categorized based on its distribution into six groups (<7.9, 7.9 to <8.4, 8.4 to <9.0, 9.0 to <9.6, 9.6 to <10.1, and ≥10.1 mg/dL). The odds ratio (OR) of in-hospital mortality by admission serum calcium, using the calcium category of 9.6-10.1 mg/dL as the reference group, was obtained by logistic regression analysis. RESULTS 18,437 patients were studied. The lowest incidence of in-hospital mortality was associated with admission serum calcium within 9.6 to <10.1 mg/dL. A higher in-hospital mortality rate was observed in patients with serum calcium <9.6 and ≥10.1 mg/dL. Also, 38% and 33% of patients with admission serum calcium <7.9 and ≥10.1 mg/dL were on calcium supplements before admission, respectively. After adjusting for potential confounders, both serum calcium <8.4 and ≥10.1 mg/dL were associated with an increased risk of in-hospital mortality with ORs of 2.86 [95% confidence interval (CI) 1.98-4.17], 1.74 (95% CI 1.21-2.53), and 1.69 (95% CI 1.10-2.59) when serum calcium were within <7.9, 7.9 to <8.4, and ≥10.1 mg/dL, respectively. CONCLUSION Hypocalcemia and hypercalcemia on admission were associated with in-hospital mortality. Highest mortality risk is observed in patients with admission hypocalcemia (<7.9 mg/dL). One-third of patients with hypercalcemia on admission were on calcium supplements.
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Affiliation(s)
- Wisit Cheungpasitporn
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA
- b Division of Nephrology, Department of Internal Medicine , University of Mississippi Medical Center , Jackson , Mississippi , USA
| | - Charat Thongprayoon
- c Department of Internal Medicine , Bassett Medical Center , Cooperstown , NY , USA
| | - Michael A Mao
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | | | - Ankit Sakhuja
- d Division of Pulmonary and Critical Care Medicine, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Stephen B Erickson
- d Division of Pulmonary and Critical Care Medicine, Department of Medicine , Mayo Clinic , Rochester , MN , USA
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Kohen CJ, Hopper K, Kass PH, Epstein SE. Retrospective evaluation of the prognostic utility of plasma lactate concentration, base deficit, pH, and anion gap in canine and feline emergency patients. J Vet Emerg Crit Care (San Antonio) 2017; 28:54-61. [DOI: 10.1111/vec.12676] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 04/07/2016] [Accepted: 04/27/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Casey J. Kohen
- William R. Pritchard Veterinary Medical Teaching Hospital; School of Veterinary Medicine; University of California at Davis; Davis CA 95616
| | - Kate Hopper
- Departments of Veterinary Surgical and Radiological Sciences; School of Veterinary Medicine; University of California at Davis; Davis CA 95616
| | - Philip H. Kass
- Population Health and Reproduction; School of Veterinary Medicine; University of California at Davis; Davis CA 95616
| | - Steven E. Epstein
- Departments of Veterinary Surgical and Radiological Sciences; School of Veterinary Medicine; University of California at Davis; Davis CA 95616
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Serum lactate as a marker of mortality in patients with hip fracture: A prospective study. Injury 2015; 46:2201-5. [PMID: 26337798 DOI: 10.1016/j.injury.2015.06.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 06/21/2015] [Accepted: 06/29/2015] [Indexed: 02/02/2023]
Abstract
Outcomes from patients suffering hip fracture remain poor, with 9% mortality at 30 days and 35% at 1 year. Despite robust guidelines these mortality rates have undergone little change. Admission serum lactate in patients with sepsis or suffering general trauma has been shown to be an indicator of adverse clinical outcomes. We investigated whether venous lactate can predict mortality for hip fracture patients. Over a 12-month period the admission venous lactate of all patients presenting to our institution with hip fractures was prospectively collated. Demographic and patient survivorship data were also prospectively recorded. Multivariate binary logistic regression and Cox proportional hazards ratio analysis was used to evaluate the relationship between admission venous lactate and 30-day mortality and early survivorship, whilst adjusting for age and gender. 770 patients were included in the study. The mean age was 80 years. The overall 30-day mortality for this cohort was 9.5%. Admission venous lactate was associated with early death. A 1mmol/L increase in venous lactate resulted in a 1.9 (95% CI 1.5-2.3 p<0.0001) fold increase in the odds of 30-day mortality and a 1.4 (95% CI: 1.2-1.6 p<0.0001) factor increase in the risk of death at any time after hip fracture. Admission venous lactate remained a predictor of mortality despite adjustment for patients American Society of Anesthesiologists (ASA) grade. Those with an admission serum lactate of 3mmol/L or greater were particularly at risk. This cohort had a 30-day mortality odds that was 5-fold higher than those whose level was less than 3mmol/L (p<0.0001) and at any-time risk of death that was 1.9 times higher (p<0.0001). Those with a level of less than 3mmol/L had a 30-day mortality of 6.8%. For those with an admission venous lactate of 3mmol/L or greater this was four times higher at 28%. The difference was statistically significant (p<0.0001). Elevated admission venous lactate following hip fracture is a predictor of early death. Venous lactate may be useful as a prognostic indicator or risk stratifier in patients with proximal femoral fractures.
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Sauter TC, Lindner G, Ahmad SS, Leichtle AB, Fiedler GM, Exadaktylos AK, Haider DG. Calcium Disorders in the Emergency Department: Independent Risk Factors for Mortality. PLoS One 2015; 10:e0132788. [PMID: 26172117 PMCID: PMC4501826 DOI: 10.1371/journal.pone.0132788] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 06/19/2015] [Indexed: 12/15/2022] Open
Abstract
Background Calcium disorders are common in both intensive care units and in patients with chronic kidney disease and are associated with increased morbidity and mortality. It is unknown whether calcium abnormalities in unselected emergency department admissions have an impact on in-hospital mortality. Methods This cross-sectional analysis included all admissions to the Emergency Department at the Inselspital Bern, Switzerland from 2010 to 2011. For hyper- and hypocalcaemic patients with a Mann-Whitney U-test, the differences between subgroups divided by age, length of hospital stay, creatinine, sodium, chloride, phosphate, potassium and magnesium were compared. Associations between calcium disorders and 28-day in-hospital mortality were assessed using the Cox proportional hazard regression model. Results 8,270 patients with calcium measurements were included in our study. Overall 264 (3.2%) patients died. 150 patients (6.13%) with hypocalcaemia and 7 patients with hypercalcaemia (6.19%) died, in contrast to 104 normocalcaemic patients (1.82%). In univariate analysis, calcium serum levels were associated with sex, mortality and pre-existing diuretic therapy (all p<0.05). In multivariate Cox regression analysis, hypocalcaemia and hypercalcaemia were independent risk factors for mortality (HR 2.00 and HR 1.88, respectively; both p<0.01). Conclusion Both hypocalcaemia and hypercalcaemia are associated with increased 28-day in-hospital mortality in unselected emergency department admissions.
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Affiliation(s)
- Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, Bern, Switzerland
- * E-mail:
| | - Gregor Lindner
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, Bern, Switzerland
| | - Sufian S. Ahmad
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, Bern, Switzerland
| | | | - Georg-Martin Fiedler
- Centre of Laboratory Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, Bern, Switzerland
| | - Dominik G. Haider
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, Bern, Switzerland
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Kaufman M, Bebee B, Bailey J, Robbins R, Hart GK, Bellomo R. Laboratory tests to identify patients at risk of early major adverse events: a prospective pilot study. Intern Med J 2015; 44:1005-12. [PMID: 24942389 DOI: 10.1111/imj.12509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/10/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND/AIMS To test whether commonly measured laboratory variables can identify surgical patients at risk of major adverse events (death, unplanned intensive care unit (ICU) admission or rapid response team (RRT) activation). METHODS We conducted a prospective observational study in a surgical ward of a university-affiliated hospital in a cohort of 834 surgical patients admitted for >24 h. We applied a previously validated multivariable model-derived risk assessment to each combined set of common laboratory tests to identify patients at risk. We compared the clinical course of such patients with that of control patients from the same ward who had blood tests but were identified as low risk. RESULTS We studied 7955 batches and 73,428 individual tests in 834 patients (males 55%; average age 65.8 ± 17.6 years). Among these patients, 66 (7.9%) were identified as 'high risk'. High-risk patients were older (75.9 vs 61.8 years of age; P < 0.0001), had much greater early (48 h) mortality (6/66 (9%) vs 4/768 (0.5%); P < 0.0001) and greater overall hospital mortality (11/66 (16.7%) vs 9/768 (1.2%); P < 0.0001). They also had more early (8/66 (12.1%) vs 14/768 (1.8%); P = 0.0001) and overall in-hospital unplanned ICU admissions (12/66 (18.2%) vs 18/768 (2.3%); P < 0.0001) and more early (26/66 (39.3%) vs 50/768 (6.5%); P < 0.0001) and overall in-hospital RRT calls (26/66 (39.4%) vs 55/768 (7.2%); P < 0.0001). CONCLUSIONS Commonly performed laboratory tests identify surgical ward patients at risk of early major adverse events. Further studies are needed to assess whether such identification system can be used to trigger interventions that help improve patient outcomes.
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Affiliation(s)
- M Kaufman
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
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Pedersen M, Brandt VS, Holler JG, Lassen AT. Lactate level, aetiology and mortality of adult patients in an emergency department: a cohort study. Emerg Med J 2015; 32:678-84. [DOI: 10.1136/emermed-2014-204305] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/15/2015] [Indexed: 11/04/2022]
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Sierink JC, Joosse P, de Castro SM, Schep NW, Goslings JC. Does repeat Hb measurement within 2 hours after a normal initial Hb in stable trauma patients add value to trauma evaluation? Int J Emerg Med 2015; 7:26. [PMID: 25635189 PMCID: PMC4306047 DOI: 10.1186/s12245-014-0026-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 06/13/2014] [Indexed: 11/10/2022] Open
Abstract
Background In our level I trauma center, it is considered common practice to repeat blood haemoglobin measurements in patients within 2 h after admission. However, the rationale behind this procedure is elusive and can be considered labour-intensive, especially in patients in whom haemorrhaging is not to be expected. The aim of this study was to assess the value of the repeated Hb measurement (r-Hb) within 2 h in adult trauma patients without evidence of haemodynamic instability. Methods The local trauma registry was used to identify all trauma patients without evidence of haemodynamic instability from January 2009 to December 2010. Patients in whom no initial blood Hb measurement (i-Hb) was done on admission, referrals, and patients without risk for traumatic injuries or haemorrhage based upon mechanism of injury (e.g. inhalation or drowning injury) were excluded. Results A total of 1,537 patients were included in the study, 1,246 of which did not present with signs of haemodynamic instability. Median Injury Severity Score (ISS) was 5 (interquartile range (IQR) 1 to 13), 22% of the patients were multitrauma patients (ISS > 15). A normal i-Hb was found in 914 patients (73%). Of the 914 patients with a normal i-Hb, 639 (70%) had a normal r-Hb, while in 127 patients (14%), an abnormal r-Hb was found. In none of these patients, the abnormal r-Hb led to new diagnoses. In 148 patients (16%), no repeated Hb measurement was done without clinical consequences. Conclusion We conclude that repeated blood Hb measurement within 2 h after admission in stable, adult trauma patients with a normal initial Hb concentration does not add value to a trauma patient's evaluation.
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Affiliation(s)
- Joanne C Sierink
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam AZ 1105, The Netherlands
| | - Pieter Joosse
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam AZ 1105, The Netherlands
| | - Steve Mm de Castro
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam AZ 1105, The Netherlands
| | - Niels Wl Schep
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam AZ 1105, The Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam AZ 1105, The Netherlands
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Mohammed MA, Rudge G, Watson D, Wood G, Smith GB, Prytherch DR, Girling A, Stevens A. Index blood tests and national early warning scores within 24 hours of emergency admission can predict the risk of in-hospital mortality: a model development and validation study. PLoS One 2013; 8:e64340. [PMID: 23734195 PMCID: PMC3667137 DOI: 10.1371/journal.pone.0064340] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/11/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We explored the use of routine blood tests and national early warning scores (NEWS) reported within ±24 hours of admission to predict in-hospital mortality in emergency admissions, using empirical decision Tree models because they are intuitive and may ultimately be used to support clinical decision making. METHODOLOGY A retrospective analysis of adult emergency admissions to a large acute hospital during April 2009 to March 2010 in the West Midlands, England, with a full set of index blood tests results (albumin, creatinine, haemoglobin, potassium, sodium, urea, white cell count and an index NEWS undertaken within ±24 hours of admission). We developed a Tree model by randomly splitting the admissions into a training (50%) and validation dataset (50%) and assessed its accuracy using the concordance (c-) statistic. Emergency admissions (about 30%) did not have a full set of index blood tests and/or NEWS and so were not included in our analysis. RESULTS There were 23248 emergency admissions with a full set of blood tests and NEWS with an in-hospital mortality of 5.69%. The Tree model identified age, NEWS, albumin, sodium, white cell count and urea as significant (p<0.001) predictors of death, which described 17 homogeneous subgroups of admissions with mortality ranging from 0.2% to 60%. The c-statistic for the training model was 0.864 (95%CI 0.852 to 0.87) and when applied to the testing data set this was 0.853 (95%CI 0.840 to 0.866). CONCLUSIONS An easy to interpret validated risk adjustment Tree model using blood test and NEWS taken within ±24 hours of admission provides good discrimination and offers a novel approach to risk adjustment which may potentially support clinical decision making. Given the nature of the clinical data, the results are likely to be generalisable but further research is required to investigate this promising approach.
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Affiliation(s)
- Mohammed A Mohammed
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom.
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Abstract
BACKGROUND AND PURPOSE Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures. METHOD AND RESULTS Over a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02-1.41) increased risk of in-hospital mortality. Patients with a venous lactate of 3 mmol/L or higher had twice the odds of death in hospital compared to matched individuals. There was no statistically significant difference in ASA distribution between those with a lactate of less than or greater than 3 mmol/L. CONCLUSIONS Patients with an elevated venous lactate following hip trauma should be identified as being at increased risk of death and may benefit from targeted medical therapy.
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AlZahrani A, Sinnert R, Gernsheimer J. Acute kidney injury, sodium disorders, and hypercalcemia in the aging kidney: diagnostic and therapeutic management strategies in emergency medicine. Clin Geriatr Med 2013. [PMID: 23177611 DOI: 10.1016/j.cger.2012.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article summarizes the current literature regarding the structural and functional changes of the aging kidney and describes how these changes make the older patient more susceptible to acute kidney injury and fluid and electrolyte disorders. It discusses the clinical manifestations, evaluation, and management of hyponatremia and shows how the management of hypernatremia in geriatric patients involves addressing the underlying cause and safely correcting the hypernatremia. The current literature regarding evaluation and management of hypercalcemia in older patients is summarized. The management of severe hypercalcemia is discussed in detail. The evaluation and management of acute kidney injury is described.
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Affiliation(s)
- Abdullah AlZahrani
- Department of Emergency Medicine, SUNY Downstate College of Medicine, Brooklyn, NY 11203, USA
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Loekito E, Bailey J, Bellomo R, Hart GK, Hegarty C, Davey P, Bain C, Pilcher D, Schneider H. Common laboratory tests predict imminent medical emergency team calls, intensive care unit admission or death in emergency department patients. Emerg Med Australas 2013; 25:132-9. [DOI: 10.1111/1742-6723.12040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Elsa Loekito
- Department of Computing and Information Systems; The University of Melbourne; Melbourne; Victoria; Australia
| | - James Bailey
- Department of Computing and Information Systems; The University of Melbourne; Melbourne; Victoria; Australia
| | | | - Graeme K Hart
- Department of Intensive Care; Austin Hospital; Melbourne; Victoria; Australia
| | - Colin Hegarty
- Department of Intensive Care; Austin Hospital; Melbourne; Victoria; Australia
| | - Peter Davey
- Department of Administrative Informatics; Austin Hospital; Melbourne; Victoria; Australia
| | - Christopher Bain
- Department of Health Informatics; Alfred Hospital and Australian Centre for Health Innovation; Melbourne; Victoria; Australia
| | - David Pilcher
- Department of Intensive Care Medicine; Alfred Hospital; Melbourne; Victoria; Australia
| | - Hans Schneider
- Department of Pathology Services; Alfred Hospital; Melbourne; Victoria; Australia
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Which is more useful in predicting hospital mortality--dichotomised blood test results or actual test values? A retrospective study in two hospitals. PLoS One 2012; 7:e46860. [PMID: 23077528 PMCID: PMC3471950 DOI: 10.1371/journal.pone.0046860] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 09/10/2012] [Indexed: 11/24/2022] Open
Abstract
Background Routine blood tests are an integral part of clinical medicine and in interpreting blood test results clinicians have two broad options. (1) Dichotomise the blood tests into normal/abnormal or (2) use the actual values and overlook the reference values. We refer to these as the “binary” and the “non-binary” strategy respectively. We investigate which strategy is better at predicting the risk of death in hospital based on seven routinely undertaken blood tests (albumin, creatinine, haemoglobin, potassium, sodium, urea, and white blood cell count) using tree models to implement the two strategies. Methodology A retrospective database study of emergency admissions to an acute hospital during April 2009 to March 2010, involving 10,050 emergency admissions with routine blood tests undertaken within 24 hours of admission. We compared the area under the Receiver Operating Characteristics (ROC) curve for predicting in-hospital mortality using the binary and non-binary strategy. Results The mortality rate was 6.98% (701/10050). The mean predicted risk of death in those who died was significantly (p-value <0.0001) lower using the binary strategy (risk = 0.181 95%CI: 0.193 to 0.210) versus the non-binary strategy (risk = 0.222 95%CI: 0.194 to 0.251), representing a risk difference of 28.74 deaths in the deceased patients (n = 701). The binary strategy had a significantly (p-value <0.0001) lower area under the ROC curve of 0.832 (95% CI: 0.819 to 0.845) versus the non-binary strategy (0.853 95% CI: 0.840 to 0.867). Similar results were obtained using data from another hospital. Conclusions Dichotomising routine blood test results is less accurate in predicting in-hospital mortality than using actual test values because it underestimates the risk of death in patients who died. Further research into the use of actual blood test values in clinical decision making is required especially as the infrastructure to implement this potentially promising strategy already exists in most hospitals.
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Loekito E, Bailey J, Bellomo R, Hart GK, Hegarty C, Davey P, Bain C, Pilcher D, Schneider H. Common laboratory tests predict imminent death in ward patients. Resuscitation 2012; 84:280-5. [PMID: 22863543 DOI: 10.1016/j.resuscitation.2012.07.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 07/18/2012] [Accepted: 07/25/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate the ability of commonly measured laboratory variables to predict an imminent (within the same or next calendar day) death in ward patients. DESIGN Retrospective observational study. SETTING Two university affiliated hospitals. PATIENTS Cohort of 42,701 patients admitted for more than 24 hours and external validation cohort of 13,137 patients admitted for more than 24 hours. INTERVENTION We linked commonly measured laboratory tests with event databases and assessed the ability of each laboratory variable or combination of variables together with patient age to predict imminent death. MEASUREMENTS AND MAIN RESULTS In the inception teaching hospital, we studied 418,897 batches of tests in 42,701 patients (males 55%; average age 65.8 ± 17.6 years), for a total of >2.5 million individual measurements. Among these patients, there were 1596 deaths. Multivariable logistic modelling achieved an AUC-ROC of 0.87 (95% CI: 0.85-0.89) for the prediction of imminent death. Using an additional 105,074 batches from a cohort of 13,137 patients from a second teaching hospital, the multivariate model achieved an AUC-ROC of 0.88 (95% CI: 0.85-0.90). CONCLUSIONS Commonly performed laboratory tests can help predict imminent death in ward patients. Prospective investigations of the clinical utility of such predictions appear justified.
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Affiliation(s)
- Elsa Loekito
- Department of Computing and Information Systems, The University of Melbourne, Australia
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Lam SW, Leenen LP, van Solinge WW, Hietbrink F, Huisman A. Evaluation of hematological parameters on admission for the prediction of 7-day in-hospital mortality in a large trauma cohort. Clin Chem Lab Med 2011; 49:493-9. [DOI: 10.1515/cclm.2011.069] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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The Impact of Serum Potassium Concentration on Mortality After Liver Transplantation: A Cohort Multicenter Study. Transplantation 2009; 88:402-10. [DOI: 10.1097/tp.0b013e3181aed8e4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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ten Boekel E, Vroonhof K, Huisman A, van Kampen C, de Kieviet W. Clinical laboratory findings associated with in-hospital mortality. Clin Chim Acta 2006; 372:1-13. [PMID: 16697361 DOI: 10.1016/j.cca.2006.03.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 03/17/2006] [Accepted: 03/21/2006] [Indexed: 01/08/2023]
Abstract
The diagnostic approach and the clinical management of critically ill patients is challenging. The recognition of biomarkers related to in-hospital mortality is of importance for identification of patients at increased risk of death. Many prediction models assessing the severity of illness and likelihood of hospital survival were developed using logistic regression analyses. These models include several laboratory parameters, such as white blood cell counts, serum bilirubin, serum albumin, blood glucose, serum electrolytes and markers which reflect acid-base disturbances. Recently, several other biomarkers, including troponin, B-type natriuretic peptide (BNP), N-terminal proBNP, C-reactive protein, procalcitonin, cholesterol and coagulation related markers have emerged as clinically useful tools for risk stratification and mortality prediction of heterogeneous and more specific subgroups of critically ill patients. More investigations are required to verify whether risk stratification based on mortality-related biomarkers may translate into targeted treatment strategies to improve clinical outcome of the critical illness. Biomarkers which are related to in-hospital mortality are highlighted in the current review.
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Affiliation(s)
- Edwin ten Boekel
- Clinical Laboratory, Sint Lucas Andreas Hospital, P.O. Box 9243, 1006 AE Amsterdam, The Netherlands.
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