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ABSTRACT Introduction: A 28-year-old man presented with acute flaccid paralysis and respiratory failure that persisted for 2 weeks after suicidal ingestion of unknown substances. Methods: Extensive clinical, nerve, laboratory, and neuroimaging testing excluded alternative causes of this neuromuscular syndrome. Prompted by clues provided by family members, liquid chromatography time-of-flight mass spectrometry was used to investigate for the presence of poison hemlock. Results: Testing of the residue in a jar used for the ingestion of a poisonous concoction confirmed the presence of the nicotinic alkaloid coniine. Analysis of patient serum suggested the presence of conhydrine. Concentrations of amitriptyline and diazepam were also found to be supratherapeutic, but only through the first few days of hospitalization. Conclusions: Herein we describe a case of reversible coma, flaccid quadriparesis, and neuromuscular respiratory failure caused by intentional ingestion of poison hemlock. Muscle Nerve 48:823-827, 2013 [ABSTRACT FROM AUTHOR]

Aims Biomarkers have proven their ability in the evaluation of cardiopulmonary diseases. We investigated the utility of concentrations of the biomarker procalcitonin (PCT) alone and with clinical variables for the diagnosis of pneumonia in patients presenting to emergency departments (EDs) with a chief complaint of shortness of breath. Methods and results The BACH trial was a prospective, international, study of 1641 patients presenting to EDs with dyspnoea. Blood samples were analysed for PCT and other biomarkers. Relevant clinical data were also captured. Patient outcomes were assessed at 90 days. The diagnosis of pneumonia was made using strictly validated guidelines. A model using PCT was more accurate [area under the curve (AUC) 72.3%] than any other individual clinical variable for the diagnosis of pneumonia in all patients, in those with obstructive lung disease, and in those with acute heart failure (AHF). Combining physician estimates of the probability of pneumonia with PCT values increased the accuracy to >86% for the diagnosis of pneumonia in all patients. Patients with a diagnosis of AHF and an elevated PCT concentration (>0.21 ng/mL) had a worse outcome if not treated with antibiotics (P = 0.046), while patients with low PCT values (<0.05 ng/mL) had a better outcome if they did not receive antibiotic therapy (P = 0.049). Conclusion Procalcitonin may aid in the diagnosis of pneumonia, particularly in cases with high diagnostic uncertainty. Importantly, PCT may aid in the decision to administer antibiotic therapy to patients presenting with AHF in which clinical uncertainty exists regarding a superimposed bacterial infection. [ABSTRACT FROM PUBLISHER]

Aims Midregional pro atrial natriuretic peptide (MR-proANP) is useful for diagnosing acute heart failure (HF) in patients presenting to the Emergency Department with dyspnoea. Optimal interpretation of MR-proANP requires understanding of how various demographic variables influence its levels and performance as a diagnostic marker. We sought to determine how age, race, sex, and body mass index (BMI) affect the levels and interpretation of MR-proANP for the diagnosis of acute HF. Methods and results The Biomarkers in Acute Heart Failure (BACH) study was an international 15-centre study of 1641 patients presenting to the Emergency Department with acute dyspnoea. Of these, 1352 had complete information on age, race, sex, and BMI. MR-proANP levels increased with age and were higher in men and in patients with lower BMI. MR-proANP performed better as a diagnostic marker in younger individuals and in blacks compared with whites. Despite this, MR-proANP at the recommended cut-off point of 120 pmol/L was >90 % sensitive in ruling out the diagnosis of acute HF in all subgroups of patients except white subjects <50 years old. Conclusion Age, race, sex, and BMI affect MR-proANP levels to various degrees. However, the diagnostic performance of the recommended cut-off point of 120 pmol/L to rule out acute HF was robust across most subgroups. Although both sex and BMI affected MR-proANP levels, they did not alter its overall diagnostic performance. Lower cut-off points for MR-proANP could be considered in younger patients and in patients with a higher BMI, to optimize diagnostic sensitivity. [ABSTRACT FROM AUTHOR]

Background: Anaemia is associated with elevated levels of natriuretic peptides. Whether the association of anaemia with natriuretic peptides is independent of other cardiovascular risk factors is unclear.Methods: This was a cross-sectional study of 809 ambulatory patients with coronary heart disease (CHD) and no history of heart failure (HF). We evaluated the extent to which the relationship between haemoglobin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) was explained by differences in cardiovascular risk factors, inflammation, and kidney dysfunction.Results: Of the 809 participants, 189 (23%) had anaemia (haemoglobin <13 g/dL). Haemoglobin (as a continuous variable) was inversely associated with log NT-proBNP (beta coefficient -.28, p<.0001). This association was considerably attenuated after accounting for cardiovascular risk factors, C-reactive protein, and kidney dysfunction. However, haemoglobin remained independently associated with log NT-proBNP even after adjustment for these variables (beta coefficient -.11, p=0.0003). Each 1 g/dL decrease in haemoglobin was associated with a 20% greater odds of having NT-proBNP in the highest quartile.Conclusions: The relationship between anaemia and NT-proBNP is largely explained by differences in cardiovascular risk factors, ventricular function, myocardial ischaemia, inflammation, and kidney function. Nonetheless, haemoglobin appears to be inversely associated with NT-proBNP even after adjustment for these risk factors. [ABSTRACT FROM AUTHOR]

Background: B-type natriuretic peptide (BNP) and the inactive metabolite NT-proBNP are proven tests for diagnosis and staging of severity for patients with heart failure. However, the utility of these biomarkers for monitoring the success of drug therapy remains to be determined. Results of longitudinal studies on serial blood testing must be linked to overall patient morbidity and mortality outcomes. We previously determined the 8-week biological variability (BV) of BNP and NT-proBNP assays in healthy subjects and the 1-day BV for BNP alone in patients with compensated and stable heart failure. From these studies, the percent statistical change in serial samples of approximately 100% difference was estimated (95% confidence). Methods: We applied the biological variability concepts to the serial results of BNP and NT-proBNP collected from patients with heart failure and compared the performance of these two markers. Results: While there are minor differences in the results between the assays from one time period to another, the overall interpretation of results are essentially identical. Moreover, the majority of individual serial time points are not significantly different from the previous value. Conclusion: Frequent testing (e.g. daily) for BNP and NT-proBNP to monitor therapy for patients with CHF is not indicated, as overall changes require several days to become evident. [Copyright &y& Elsevier]

Background: Patients with heart failure (HF) or pulmonary diseases (PD) present with similar symptoms. Effective disease management requires an accurate diagnosis. B-type natriuretic peptide (BNP) is increased in patients with HF and is normal in PD patients without cardiac involvement. Objective: To determine if the readmission rate for patients with either HF or PD who later present with the alternate diagnosis (PD or HF) is decreased with the implementation of BNP testing at one hospital. Methods: We retrospectively determined the impact of BNP testing on reducing diagnostic ambiguities for patients admitted to an emergency department (ED) with these diseases. We compared a HF DRG (Diagnostic Related Group) (#428) and PD DRGs (#480–496) before vs. 1 and 2 y after implementation of BNP testing. Results: In a 12-month period before BNP, there were 42 total visits (15 cases) where a patient presented with a HF DRG and returned within 6 months with a PD DRG, and 41 visits (14 cases) where there was a PD→HF readmission. One year after BNP implementation, the corresponding number of visits decreased 52% to 20 visits (15 cases) for HF→PD, and 73% to 11 visits (8 cases) for PD→HF readmissions. A similar reduction in readmissions was observed in the second year after BNP testing. The total number of HF and PD cases in 1999 (1029 patients) was similar to 2001 (985), and was higher in 2002 (1350) during these time intervals. The ED length-of-stay (LOS) was slightly higher for the HF→PD cases with BNP testing, whereas there was no change in LOS for the PD→HF cases. Conclusion: We hypothesize that prior to BNP implementation, there may have been diagnostic ambiguities in the initial diagnosis of HF or PD, which contributed to a repeat visit for the alternate diagnosis (PD or HF). With BNP testing, the apparent number of inappropriate visits decreased. Reducing unnecessary ED admissions helps justify the costs for implementing BNP testing in the hospital. [Copyright &y& Elsevier]