Growth differentiation factor-15 significantly improves prognostication of short-term mortality in acute settings

Introduction

Acute dyspnoea is one of the most common complaints in the emergency department with a diverse range of diagnoses and a vastly different prognosis. There is still a need for a reliable biomarker for prognostication in acute settings.

Purpose

To evaluate and compare the role of three biomarkers, which represent different pathophysiological pathways, in stratifying short-term mortality risk in patients admitted to the emergency department with acute dyspnoea.

Methods

Prospective observational cohort enrolled 1455 acute dyspnoea patients admitted to emergency departments of two university centres from 2015 to 2017. The present study included 867 (71 [62–79] years, 40% female) patients who had N-terminal pro–B-type natriuretic peptide (NT-proBNP), high-sensitive troponin T (hsTnT) and growth differentiation factor 15 (GDF-15) measured at admission. Clinical variables known to affect prognosis (age, gender, use of beta blockers, angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers at admission, history of chronic heart failure, diabetes and coronary artery disease, systolic blood pressure, heart rate, creatinine, sodium, haemoglobin and C-reactive protein levels) were used to build a baseline model for all-cause 3-month mortality risk prediction in acute dyspnoea [“Clinical score”]. The ability of each biomarker to improve risk prediction on top of the Clinical score was evaluated by area under the curve (AUC), comparing AUC of the model with the biomarker to the AUC of the clinical model alone using the DeLong test. The clinical benefit in risk prediction of adding a biomarker was further assessed by reclassification analysis, including the net reclassification improvement (NRI) and the integrated discrimination index (IDI). The statistical analyses were performed using R statistical software. P value of <0.05 was considered statistically significant.

Results

Mortality at 3 months was 16% (143 patients). The AUC of the Clinical score was 0.787 [95% confidence interval (CI) 0.735 - 0.836]. GDF-15 was the only biomarker that significantly improved risk prediction on top of the Clinical score. The results of the individual biomarkers are displayed in Figure 1A. GDF-15 significantly reclassified 3-month mortality risk with an NRI of 32% [13%-51%] and an IDI of 0.026 [0.011–0.042]; other biomarkers had lower reclassification rates (Figure 1B).

Conclusions

This study demonstrates that the cellular stress biomarker GDF-15 taken at admission provides a substantial additive value to conventional clinical parameters for risk stratification in patients with acute dyspnoea.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The work was supported by the Research Council of Lithuania (Lietuvos mokslo taryba), grant Nr. MIP-049/2015 and approved by Lithuanian Bioethics Committee, no. L-15-01. Roche Diagnostics supported the research with measurement of NT-proBNP, high-sensitivity troponin T and growth differentiation factor-15

Early Experience with the StopLoss Jones Tube

PURPOSE

Extrusion is the most common reason for failure after Jones tube placement. The StopLoss Jones tube (SLJT) is a new innovation in Jones tubes that incorporates a flexible silicone internal flange to resist extrusion. We present our early experience of using this new tube and associated introducer system.

METHODS

We retrospectively analysed the case notes of a single surgeon consecutive series of patients having SLJT placement from November 2011 to November 2013.

RESULTS

29 SLJTs were placed in 25 eyes of 19 patients. Tube follow-up ranged from 1-25 months (mean 10 months) with a total of 291 tube-months. The indications for SLJT placement were: previous LJT complications (52%), failed canalicular-DCR surgery (31%), primary placement for inoperable canalicular occlusion (14%) and patent non-functioning DCR (3%). Tube length ranged from 10-16 mm. The tube introducer system was simple and effective and there were no intra-operative complications. The tube extrusion rate was 0%. Complications occurred in 5 tubes: 1 was too long, and 4 others (14%) developed conjunctival overgrowth/medial tube migration. Patient satisfaction with the tube was: 86% fully satisfied, 10% was moderately satisfied, 3% not satisfied. The overall final surgical success rate at last follow-up was 92%.

CONCLUSIONS

In this short follow-up initial study the SLJT is simple to use and has a high rate of success and patient satisfaction. The addition of the internal silicone flange appears to prevent the previously common problem of extrusion.

Adult alveolar rhabdomyosarcoma of the lacrimal sac

Lacrimal sac tumours are rare, but must be considered in the diagnosis of patients presenting with masses in the medial canthal region. We report a single case of lacrimal sac rhabdomyosarcoma in a 31-year-old man. The patient self-presented to the eye department with a 4-week history of discomfort, epiphora and a medial canthal mass. After no response to 1 week of oral antibiotics for a presumed diagnosis of dacryocystitis and the presence of firm mass extending above the medial canthal tendon, surgical exploration was carried out which revealed a lacrimal sac mass. Histologically this showed an alveolar rhabdomyosarcoma, which was confirmed on immunohistochemistry. After 4 rounds of chemotherapy and 50.4Gy of radical radiotherapy, the patient is well with no signs of further local or distant disease at 11-months follow-up and 20 months following initial diagnosis. To our knowledge, there are no previously reported adult cases of lacrimal sac alveolar rhabdomyosarcoma in the peer-reviewed literature. We want to highlight the unique diagnosis in this case as well as drawing attention to the possibility of malignancy in patients responding poorly to management when an initial diagnosis of dacryocystitis is made in the presence of a medial canthal mass.

Multidisciplinary management of adult orbital rhabdomyosarcoma*

We report the case of a 52-year-old man who presented with a 10-day history of right eye and eyelid inflammation and intermittent diplopia following blunt trauma to the right eyebrow. The CT and MRI scans revealed an extraconal soft tissue mass on the orbital floor with maxillary and ethmoid sinus wall destruction, which on orbital biopsy was proven to be an Alveolar Rhabdomyosarcoma. The patient had a central retinal vein occlusion due to mass effect that resulted in total visual loss at 2 months. He was referred to oncologists who treated him according to the paediatric RMS protocol and is still in remission at 2-year follow-up. Rhabdomyosarcoma is a rare tumour in adults which requires multi-disciplinary management. This highlights the necessity of considering rhabdomyosarcoma in the differential diagnosis of orbital tumours in any age group.