P341 DANTE (DIAGNOSTIC ACUTE PATIENT TOOL IN EMERGENCY) & BEATRICE (BEDSIDE ECHOCARDIOGRAPHIC ASSESMENT FOR IMPROVE CLINICAL EVALUATION) FOR GERIATRIC PATIENTS

Objectives

To determine whether comprehensive quantitative bed side echocardiogram could be used as a usual assessment tool in acute geriatric patients and to assess its effect on patient care.

Design

Retrospective. Setting: DEA di II livello IRCSS Policlinico san Matteo.

Patients

Acute ill medical, trauma and surgical patients. A doctor enrolled in the discipline of emergency medicine was assigned to perform bedside echocardiograms of acute inpatients. This work took only geriatric patients into consideration. (> 65aa). Interventions: The Bedside Echocardiographic AssesmenT foR Improve Clinical Evaluetion (BEATRICE), a comprehensive transthoracic echocardiogram was performed.

Measurements and Main Results

6–month period, 369 BEATRICEs were performed. The mean patient age was 76.2 (±14.3) years. 95% were hospitalized in medical departments and 5% in surgical ward. In 97.4% of cases BEATRICE was performed in a timely manner. The ejection fraction, cardiac index and the volumetric indices of the left ventricle is reported in 97% of the reports. Estimated stroke volume, longitudinal systolic function with tissue Doppler and atrium study is reported in 99.7%, 98.6% and 98.9% of BEATRICE studies. The study of diastolic and atrium function is reported in 99.3% and 98.9% of the reports respectively. Estimated left ventricular filling pressures are reported in 98.3% of the measurements. Information on the vena cava reported for 98%. Right heart function was assessed for 91.8%. Mean or systolic right ventricular pressures, or both, were also estimated in 91.9% of the reports. The BEATRICE was judged to be useful by the consulting primary care team in over 96% of cases, BEATRICEs allow the modification of therapy or the diagnostic process in over 40% of cases (in 27% of cases they allow to significantly modify the therapy and in 16% of cases they allow to significantly modify the diagnostic therapeutic procedure) and speeding up the diagnostic process in over 30% of cases.

Conclusions

The BEATRICE is feasible and alters care in the intensive care unit by providing clinical data not otherwise available at the bedside. Further studies are warranted to assess the impact of comprehensive echocardiogram–directed resuscitation on patient outcomes.

Utility of biochemical markers in the follow-up of heart transplant recipients

Endomyocardial biopsy (EMB) is currently the standard method to diagnose acute graft rejection. However, considering the potential complications of this procedure, a noninvasive marker of rejection would be an ideal alternative or at least a helpful adjunct to posttransplant management. We measured myoglobin (Myo), creatine kinase MB mass (CK-MBm), troponin T (cTnT), serum amyloid A (SAA), and C-reactive protein (CRP) in 57 patients (mean age 37.5 years) who underwent orthotopic heart transplantation for end-stage cardiac failure between January and December 2001.Endomyocardial biopsies were performed routinely after surgery and histologically diagnosed rejection was graded according to the criteria of the International Society of Heart and Lung Transplantation. Concomittant with the biopsies, blood samples were drawn from the coronary sinus (central blood samples) and from a peripheral vein (peripheral blood samples) to assay biochemical markers. Among 149 EMB evaluated, 87 were negative (grade 0); 28 showed grade 1a rejection; 26 showed grade 1b; and 8 showed grade > 1b (2 were grade 2, 6 were grade 3a). Grades 0 and 1a were considered to be negative, while grades 1b and >1b were considered positive indicating potential acute graft rejection. cTnT, Myo, CK-MBm, SAA, and CRP levels were measured in 149 central blood samples and 149 peripheral blood samples. Myo and CK-MBm did not show significant changes. cTnT seems to be a potentially useful addition to the EMB results, while SAA and CRP showed variations with respect to EMB grade both in central and peripheral samples.

Urinary proteins in multiple myeloma: correlation with clinical parameters and diagnostic implications

Renal failure is one of the worst complications occurring in multiple myeloma (MM) patients. It does not affect survival if reverted by a prompt chemotherapy before the damage becomes irreversible; therefore, the early diagnosis of renal dysfunction is crucial. High and low molecular weight urinary proteins have proved to be helpful in diagnosing initial renal damage since they are more sensitive than urea and creatinine serum levels or creatinine clearance. We studied the renal function of 111 MM patients through serum creatinine, urea, urinary IgG, alpha(1)-microglobulin (alpha(1)-M), and albumin (Alb). Two successive controls were made in a subset of 30 patients, categorized in three groups (improved, stable, worsened) according to the behavior of tumor burden markers (bone marrow plasmacytosis, monoclonal component, and beta(2)-microglobulin). In every group, we evaluated the behavior of urinary proteins. Renal dysfunction evaluated with serum parameters was present in 19 patients (17%), while if studied with urinary proteins was revealed in 71 patients (64.5%). Urinary proteins statistically correlated with each other. They correlated with creatinine, IgG, and alpha(1)-M also with urea. By contrast, they showed a variable correlation with clinical parameters: alpha(1)-M correlated with bone marrow plasmacytosis (BMPC) ( p=0.02) and beta(2)-M ( p=0.000001), IgG with all three disease parameters (MC p=0.0005, BMPC p=0.009, beta(2)-M p=0.007), and Alb only with beta(2)-M ( p=0.0004). In the subset of 30 patients followed with two successive controls, urinary proteins showed a parallel behavior with the indices of tumor burden. In conclusion, IgG, alpha(1)-microglobulin, and albumin are reliable and sensitive to precociously reveal renal damage, and we recommend their routine use for the definition and monitoring of renal function in multiple myeloma patients, mainly those in early stage, to better identify initial signs of progression.

The Pavia approach to clinical protein analysis

The protein chemistry laboratory of the Pavia University Hospital is specialized in the study of monoclonal components in body fluids. It is closely connected with the research laboratory devoted to the structural and functional study of pathogenic proteins and with the Clinical Chemistry Central Laboratory. The analyses are performed on specific medical request. The analytical approach is mainly based on analysis of patient's serum and urine by high-resolution agarose gel electrophoresis and immunofixation with the possible addition of the quantification of specific proteins. The interpretation of the protein pattern and the final reporting result from the integration of the laboratory data with the clinical information. This labor-intensive approach requires skills in the performance of protein analysis and in the interpretation/referral phase, as well as close communication with the attending physician.

Serum amyloid A, procalcitonin, and C-reactive protein in early assessment of severity of acute pancreatitis

Amyloid A (SAA) and procalcitonin (PCT) have been reported as useful indicators of inflammation. Our aim was to assess the utility of SAA and PCT in establishing the severity of acute pancreatitis in comparison to C-reactive protein (CRP): Thirty-one patients with acute pancreatitis enrolled within 24 hr from the onset of pain and 31 healthy subjects were studied. Nineteen patients had mild acute pancreatitis, and 12 had severe pancreatitis. Serum SAA, PCT, and CRP were measured in all subjects at admission and, in acute pancreatitis patients, during the following five days. Patients with acute pancreatitis had serum concentrations of SAA, PCT, and CRP significantly higher (P < 0.001) than those of healthy subjects during the entire study period. Using cutoff values ranging from 240 to 250 mg/liter for SAA, from 0.252 to 0.255 ng/ml for PCT, and from 12.8 to 12.9 mg/dl for CRP, the sensitivity (calculated on patients with severe pancreatitis), the specificity (calculated on patients with mild pancreatitis), and the efficiency (calculated as the percentage of correct classifications) were 76.8%, 69.3%, and 72.4% for SAA; 21.7%, 83.2%, and 58.2% for PCT; and 60.9%, 89.1%, and 77.6% for CRP. In conclusion, the sensitivity of SAA is significantly higher than that of PCT and CRP in assessing the severity of pancreatitis, whereas PCT and CRP had a specificity significantly higher than SAA. The accuracy and efficiency were similar for SAA and CRP, and both these markers had an accuracy and efficiency significantly higher than those of PCT.

Assessment of renal function in patients with multiple myeloma: the role of urinary proteins

Renal failure (RF) in multiple myeloma (MM) is considered an ominous complication even though, when timely therapy is started in patients with minimal damage, a high percentage of cases can achieve a regression. The evaluation of renal involvement usually relies on serum creatinine or its clearance, but these parameters have proved to be inadequate to identify initial damage. The aim of this study was to assess the role of the following urinary proteins in diagnosing renal impairment at an early stage: high-molecular-mass proteins (transferrin, IgG, albumin) as markers of glomerular damage, and low-molecular-weight proteins and parenchymal enzymes [alpha(1)-acid glycoprotein (AGP), alpha(1)-microglobulin (alpha(1)M), retinol-binding protein (RBP), beta(2)-microglobulin (beta(2)M), lysozyme (LZ), and N-acetyl-beta-d-glucosaminidase (NAG)] as indicators of tubular disorder. Thirty MM patients (nine at disease onset and 21 previously treated) were included in the study. No correlation was found between the urinary proteins and the phase or the stage of the disease. By the Spearman test, Bence Jones proteinuria correlated significantly with the 24 h proteinuria (p=0. 01) and beta(2)M (p=0.02), and weakly with the alpha(1)M. Serum creatinine concentrations and urea correlated with most of the analytes evaluated: RBP correlated well with urea (p=0.004) and creatinine (p=0.004); IgG (p=0.006) albumin (p=0.009), AGP (p=0.04), and NAG (p=0.02) correlated with serum creatinine. Significant statistical correlation was found between all the analytes except LZ and the creatinine clearance. Twelve of the 30 MM patients (40%) showed abnormal values of urinary proteins. Four of these patients showed overt renal failure with significant modification of the serum parameters and of creatinine clearance, three showed an isolated decrease of creatinine clearance, and five did not present any alteration of serum or urinary parameters. This testifies to the utility of urinary proteins in highlighting renal damage even in cases where the customary serum indicators of renal disorder are normal. In conclusion, our results demonstrate that AGP, RBP, NAG, transferrin, and IgG are good indicators of renal damage. They do not correlate with the severity of the disease, but they seem to be helpful in identifying a subset of patients with initial renal dysfunction.

Study of factors affecting the determination of total plasma 7-fluorobenzo-2-oxa-1,3-diazole-4-sulfonate (SBD)-thiol derivatives by liquid chromatography

A detailed investigation of the factors affecting the determination of total plasma 7-fluorobenzo-2-oxa-1,3-diazole-4-sulfonate (SBD)-thiol derivatives (i.e. cysteine, homocysteine and cysteinylglycine) is described. Essentially, this assay entails extracting specific thiols by plasma disulphide bond reduction, protein precipitation, sulphydryl compound derivatization with the thiol-specific fluorogenic reagent ammonium 7-fluorobenzo-2-oxa-1,3-diazole-4-sulphonate (SBD-F), and subsequent separation with isocratic reversed-phase high-performance liquid chromatography. By improving the reliability of several analytical parameters (composition of the mobile phase, pretreatment of the sample using different reducing and protein precipitation agents, and optimization of the derivatization of thiols with SBD-F), a number of critical issues can be identified and solved.

[Relations between plasma-erythrocyte viscosity factors and ESR]

The ESR is usually put in relationship: to the real density of the RBCs (erythrocytes) (difference between the RBC specific gravity and the plasma one), and to the resistance that the RBCs meet moving in a medium, which is due to the plasma viscosity and to the total external RBC surface. When the RBCs take shape of aggregates, their external surface is decreased and ESR increases. The most important plasma factor causing changes in ESR is the fibrinogen level followed by the plasma globulins and by the products arising from the tissue damage. The resistance that the RBCs meet moving in the plasma is well expressed by the measurement of the plasma-RBC viscosity considering that is inclusive of both factors that are the plasma viscosity and the external RBC surface. The plasma-RBC viscosity is the resultant of several factors: Fa = Fb - Fe - Fs - Fm, were: Fa is the resultant, Fb the attracting forces due to the proteic macromolecules, Fe the repulsing forces due the negative charges. Fs the repulsing forces due to the shear-stress, Fm the force which opposes itself against the surface tension of the aggregation; it depends on the RBC morphology and on the RBC rigidity. The ESR has been recently used like an index of the RBC aggregation. The Authors study the relationship between several hemorheological parameters and the ESR in infective and inflammatory processes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Plasma-erythrocyte viscosity and evaluation of several pro- and anti-aggregating factors in NIDDM patients in metabolic decompensation state]

In NIDDM diabetic subjects, the microcirculatory damage shows a double aspect: an alteration of the vascular wall, particularly of the arteriolar capillary, and a hemorheological alteration at the level of the capillary district. In the microcirculation, because of the low velocity of the flow and the inverse relationship between capillary size and RBC diameter, the viscosity has an important role with its components: RBC viscosity and deformability. Even the erythrocyte aggregation has a key role as resultant of the attracting and repulsing forces, among which the plasma-RBC viscosity and the deformability play opposite role. Our method allows to evaluate the erythrocyte, the whole blood, the plasma and the plasma-RBC viscosity, and the deformability. Studies from this laboratory in NIDDM subjects show an increase in the blood viscosity, a decrease in the erythrocyte deformability and plasma-RBC viscosity. It is suggested that in microcirculatory district the flow reductions are particularly of hemorheological type and that the sludged blood is an "optical" phenomenon with poor meaning. We consider some hematological parameters, namely the Hgb A1c %, Hgb concentration, RBC count, MCV, etcetera.