Comparative performances of soluble urokinase plasminogen activator receptor and Mid-regional proADM to predict composite death and new heart failure rehospitalisation in acutely breathless patients

Background

Soluble urokinase plasminogen activator receptor (suPAR) is a pleotropic receptor, capable of orchestrating plaque vulnerability and vascular immune dysfunction. Mid-regional pro-adrenomedullin (MR-proADM) is the stable peptide precursor of adrenomedullin, with concentrations reflective of vasodilation and cardiac remodelling. We compared the prognostic performances of suPAR and MR-proADM for the composite clinical endpoint of death and new heart failure (HF) in patients with undifferentiated breathlessness.

Methods

Patients presenting to hospital with the primary complaint of acute dyspnoea were recruited in New Zealand (n=612) and in Singapore (n=483)]. Baseline plasma measurements were undertaken for suPAR (ViroGates) and MR-proADM (Thermo Scientific). Cardiac biomarker levels of NT-proBNP (Roche) was available on all patients. Statistical assessment was made using SPSS v28 (IBM), with all biomarkers treated as continuous variables and presented as median [interquartile range (IQR)]. Prognostic performance of suPAR, MR-proADM and NT-proBNP to predict the composite clinical endpoint of death/new HF at 90-days and 1-yr were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis (Z-scores) and Cox hazard regression analysis (per doubling of biomarker concentrations) after adjustment for traditional risk factors. P-value <0.05 was considered statistically significant.

Results

In the entire acutely breathless cohort [median age: 65 years (IQR: 52.9–76.0), 63.1% males], 343/1095 of patients had the final adjudication of ADHF. suPAR and MR-proADM concentrations were higher with increasing age (Spearmans rho, r>0.46, P<0.0001), lower eGFR (r>0.58, P<0.0001) and in those with ADHF (r>0.40, P<0.0001). During the follow-up period, 122 patients were categorised with death/new HF by 90-days, rising to 281 at 1-year. suPAR and MR-proADM were able to predict death/new HF at 90-days (both ROC-AUC >0.77) and at 1-year (both ROC-AUC ≥0.78) (Table 1). All markers were however less accurate in predicting this endpoint in the presence of ADHF (ROC-AUC <0.71). After adjustment in Cox-regression modelling, suPAR obtained HR >1.35 per doubling of suPAR concentrations (P=0.001) for outcomes at 90-days and at 1-year (Table 2), achieving the highest prognostic performance for this clinical endpoint, followed by NT-proBNP (HR >1.29) (Table 2), whilst MR-proADM was not an independent predictor of death/HF in this cohort. suPAR was also an independent predictor of death/HF for patients with ADHF, obtaining HR >1.35 per doubling of concentrations. Above a cut-off concentration of 3.6 ng/mL, suPAR was associated with a HR of 2.1 (95% CI: 1.55–2.91) for death/HF at 1-year for acutely dyspnoeic patients.

Conclusion

suPAR concentrations is superior than MR-proADM in predicting the clinical end-point of death/HF at 1-year in this cohort. It may aid in risk-stratification strategies for the management of acutely breathless patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of New ZealandHealth Research Council of New Zealand

A Fatal Case of Acute Appendicitis

Appendicitis continues to be the most common acute surgical emergency. We report a fatal case of acute appendicitis, illustrating that the early presentation of appendicitis is non-specific and that serial examination is the key to the diagnosis to avoid a fatal outcome. We also present an evidence-based approach to the diagnosis of acute appendicitis in the emergency department and highlight the pearls and pitfalls of diagnosing acute appendicitis.

Utilisation of emergency medical service among Singapore patients presenting with ST-segment elevation myocardial infarction: prevalence and impact on ischaemic time

BACKGROUND

Previous studies in Western countries found that the emergency medical service (EMS) was under-used in patients with myocardial infarction.

AIM

We sought to determine the prevalence of immediate EMS utilisation among Singapore patients presenting with ST-segment elevation myocardial infarction (STEMI), and correlated the use of the EMS with the symptom-to-balloon and door-to-balloon times.

METHODS

We studied 252 patients admitted with STEMI to our institution from August 2008 to September 2009. Information regarding demographic characteristics, whether EMS was used, reperfusion procedural details and mortality rates were collected prospectively.

RESULTS

Among the recruited patients, 89 (35.3%) used the EMS (EMS group) and 163 (64.7%) did not use the EMS (non-EMS group). In the latter group, 98 (60.1%) arrived at our institution through their own transport, 56 (34.4%) first consulted general practitioners, and 9 (5.5%) initially consulted another hospital without acute medical services. Among the 245 (out of 252, 97.2%) patients who received percutaneous coronary intervention (PCI), the EMS group was more likely to undergo primary PCI (P= 0.003) while the non-EMS group was more likely to undergo non-urgent PCI (P= 0.002). In patients who underwent primary PCI, the EMS group had a shorter symptom-to-balloon time (average difference 81.6 min, P= 0.002). The door-to-balloon time was similar for both groups.

CONCLUSION

Despite the availability of a centralised EMS, 64.7% of patients with STEMI did not contact EMS at presentation. These patients were less likely to receive primary PCI and had a significantly longer symptom-to-balloon time.

A review of elderly injuries seen in a Singapore emergency department

INTRODUCTION

The elderly population in Singapore is steadily increasing, thus increasing the stress on healthcare provision and financing. Elderly injuries result in significant mortality and morbidity. This study aimed to identify the injury patterns, specific risk factors involved and needs of the elderly so that the current emergency model of care for the injured elderly can be improved and injury prevention strategies devised.

METHODS

We conducted a retrospective study of all elderly aged 65 years and older seen for trauma in an emergency department over six months. Data captured in the real-time computer system was studied with regard to patient profile, mechanism of injury and patient disposition.

RESULTS

720 patients aged 65 years and older were seen for trauma in the first six months of 2005, accounting for 10.4 percent of the total attendance for that age group. Home injuries (67.9 percent) were the most common, followed by road-related injuries (21.2 percent). 85.3 percent of the injuries were due to falls. 49.9 percent of the patients were admitted to hospital. We also examined the underlying causes of the injuries and the common injuries sustained.

CONCLUSION

Injuries in the elderly is a significant problem. Most of the injuries occur at home and falling is the commonest cause. Many of the injuries are potentially preventable. Several possible injury prevention strategies and improvements to the current emergency model of care of the injured elderly are discussed. The establishment of a national elderly injury surveillance database is advocated.

A review of 2,517 childhood injuries seen in a Singapore emergency department in 1999--mechanisms and injury prevention suggestions

BACKGROUND

Childhood injuries cause significant mortality and morbidity in Singapore. With injury surveillance, patterns of repeated injury can be identified and injury prevention strategies devised.

METHODS

We conducted a retrospective study of all children aged 12 and below seen for trauma in an Emergency Department over one year. Data captured in the real-time computer system was studied with regards to patient profile, mechanism of injury and patient disposition. Clinical summaries were extracted with follow-up telephone interviews done.

RESULTS

Two thousand five hundred and seventeen children aged 12 and below were seen for accidental trauma in 1999, accounting for 37.1% of the total attendance for that age. Mean age was 7.7 years with males making up 62.7%. Home injuries (56.4%) were the most common, followed by road-related (14.4%), sports (8.2%) and playground injuries (7.4%). 48.5% sustained head and face injuries. Pre-school children (age <5) were more likely to sustain home injuries (p<0.0001), a higher proportion of head injuries (p<0.0001), foreign bodies, burns and poisoning compared to school-going children (age 6-12), who were more likely to sustain injuries in road accidents, sports, at playgrounds or schools, with more limb, trunk and multi-trauma. We highlight drownings, falls from height, rollover falls from beds, slamming door injuries, the low use of child car restraints, bicycle injuries and playground falls as areas of concern.

CONCLUSION

Several injury prevention strategies have been suggested and it is hoped these may contribute to addressing preventable childhood injuries in Singapore. We also advocate the establishment of a national childhood injury surveillance database.

A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study)

STUDY OBJECTIVE

We evaluate a new technique of treating scalp lacerations, the hair apposition technique (HAT). After standard cleaning procedures, hair on both sides of a laceration is apposed with a single twist. This is then held with tissue adhesives. HAT was compared with standard suturing in a multicenter, randomized, prospective trial.

METHODS

All linear lacerations of the scalp less than 10 cm long were included. Severely contaminated wounds, actively bleeding wounds, patients with hair strand length less than 3 cm, and hemodynamically unstable patients were excluded. Patients were randomized to receive either HAT or standard suturing, and the time to complete the wound repair was measured. All wounds were evaluated 7 days later in a nonblinded manner for satisfactory wound healing, scarring, and complications.

RESULTS

There were 96 and 93 patients in the study and control groups, respectively. Wound healing trended toward being judged more satisfactory in the HAT group than standard suturing (100% versus 95.7%; P =.057; effect size 4.3%; 95% confidence interval 0.1% to 8.5%). Patients who underwent HAT had less scarring (6.3% versus 20.4%; P =.005), fewer overall complications (7.3% versus 21.5%; P =.005), significantly lower pain scores (median 2 versus 4; P <.001), and shorter procedure times (median 5 versus 15 minutes; P <.001). There was a trend toward less wound breakdown in the HAT group (0% versus 4.3%; P =.057). When patients were asked whether they were willing to have HAT performed in the future, 84% responded yes, 1% responded no, and 15% were unsure.

CONCLUSION

HAT is equally acceptable and perhaps superior to standard suturing for closing suitable scalp lacerations. Advantages include fewer complications, a shorter procedure time, less pain, no need for shaving or removal of stitches, similar or superior wound healing, and high patient acceptance. HAT has become our technique of choice for suitable scalp lacerations.[Ong Eng Hock M, Ooi SBS, Saw SM, Lim SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).

Acute coronary syndrome--factors causing delayed presentation at the Emergency Department

INTRODUCTION

The aim of the study was to identify factors that contributed to delays in presentation of patients with acute coronary syndrome (ACS) at the Emergency Department (ED).

MATERIALS AND METHODS

The study population comprised patients presenting with the signs and symptoms of ACS at the ED of 5 government and restructured hospitals in Singapore from 1 April to 31 May 1999. These patients were interviewed with a structured questionnaire which explored patient demographic data, risk factors, prehospital symptomatology, timing of chest pain, patient response to chest pain and mode of transport to the hospital.

RESULTS

Three hundred and two patients who made 307 visits were recruited. More than three-quarters of the patients presented with central or left-sided chest pain. Forty-seven per cent had breathlessness and 42% had sweating. The commonest day of presentation was Monday. It took patients a median time of 2.1 hours from their worst chest pain to arrive at the ED. Past history of diabetes mellitus was associated with a longer delay in presentation. Most of the delay was due to patients awaiting symptom resolution. Forty per cent came by emergency ambulances to hospital.

CONCLUSION

Our findings identified various patient characteristics that contributed to delay in presentation to hospital which should be addressed in future education campaigns.