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      Focused sonographic examination of the heart, lungs and deep veins in an unselected population of acute admitted patients with respiratory symptoms: a protocol for a prospective, blinded, randomised controlled trial

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          Article summary

          Article focus
          • Focused sonography of the heart, lungs and deep veins.

          • Initial diagnostics of acute admitted patients with respiratory symptoms.

          Key messages
          • The results of the study may help to determine whether sonography should be included as a fully integrated part of the primary evaluation in these patients.

          Strengths and limitations of this study
          • First randomised trial to compare the overall diagnostic performance between the conventional approach and an approach including focused sonography to evaluate and diagnose acute admitted patients with respiratory symptoms, admitted to an emergency department.

          • Pragmatic design with inclusion of most patients with respiratory symptoms.

          • Single-centre study that could affect external validity.

          • Study not powered to investigate morbidity or mortality.

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          Most cited references21

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          Transthoracic echocardiography for cardiopulmonary monitoring in intensive care.

          To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring. The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed. Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive. By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients.
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            Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis

            Introduction Our objectives were to determine the causes of acute respiratory failure (ARF) in elderly patients and to assess the accuracy of the initial diagnosis by the emergency physician, and that of the prognosis. Method In this prospective observational study, patients were included if they were admitted to our emergency department, aged 65 years or more with dyspnea, and fulfilled at least one of the following criteria of ARF: respiratory rate at least 25 minute-1; arterial partial pressure of oxygen (PaO2) 70 mmHg or less, or peripheral oxygen saturation 92% or less in breathing room air; arterial partial pressure of CO2 (PaCO2) ≥ 45 mmHg, with pH ≤ 7.35. The final diagnoses were determined by an expert panel from the completed medical chart. Results A total of 514 patients (aged (mean ± standard deviation) 80 ± 9 years) were included. The main causes of ARF were cardiogenic pulmonary edema (43%), community-acquired pneumonia (35%), acute exacerbation of chronic respiratory disease (32%), pulmonary embolism (18%), and acute asthma (3%); 47% had more than two diagnoses. In-hospital mortality was 16%. A missed diagnosis in the emergency department was noted in 101 (20%) patients. The accuracy of the diagnosis of the emergency physician ranged from 0.76 for cardiogenic pulmonary edema to 0.96 for asthma. An inappropriate treatment occurred in 162 (32%) patients, and lead to a higher mortality (25% versus 11%; p 45 mmHg (odds ratio 2.79, p < 0.004), clearance of creatinine < 50 ml minute-1 (odds ratio 2.37, p < 0.013), elevated NT-pro-B-type natriuretic peptide or B-type natriuretic peptide (odds ratio 2.06, p < 0.046), and clinical signs of acute ventilatory failure (odds ratio 1.98, p < 0.047) were predictive of death. Conclusion Inappropriate initial treatment in the emergency room was associated with increased mortality in elderly patients with ARF.
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              High-resolution computed tomography for the diagnosis of community-acquired pneumonia.

              We compared high-resolution computed tomography (HRCT) with chest radiography (CR) to determine if there is any advantage to using HRCT in the diagnosis of community-acquired pneumonia (CAP). Simultaneously obtained chest radiographs were compared with HRCT scans for 47 patients with clinical symptoms and signs suspicious for CAP, HRCT identified all 18 CAP cases (38.3%) apparent on radiographs as well as eight additional cases (i.e., 55.3%); P = .004. The corresponding figures for bilateral involvement were six by CR (33.3%) and 16 by HRCT (61.5%), P = .001. CR did not show changes particularly affecting the upper and lower lung lobes and the lingula. Bronchopneumonia was visualized by CR in 11 cases (61.1%) and by HRCT in 22 cases (84.6%). The corresponding figures for airspace pneumonia were four (22.2%) and one (3.8%), respectively. The use of HRCT seems to increase the number of CAP cases confirmed by imaging and to improve the accuracy of diagnosing and typing of CAP.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2012
                30 May 2012
                30 May 2012
                : 2
                : 3
                : e001369
                Affiliations
                [1 ]Research Unit at the Department of Respiratory Medicine, Odense University Hospital, Odense C, Denmark
                [2 ]Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Skejby, Aarhus, Denmark
                [3 ]Medical Emergency Ward, Odense University Hospital, Odense, Denmark
                [4 ]Research Unit of General Practice, Institute of Public Health, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
                [5 ]Department of Cardiology, Odense University Hospital, Svendborg, Denmark
                [6 ]Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
                [7 ]Department of Allergy and Respiratory medicine, Near East University Hospital, Lefcosa, Turkey
                Author notes
                Correspondence to Dr Christian Borbjerg Laursen; christian.b.laursen@ 123456ouh.regionsyddanmark.dk
                Article
                bmjopen-2012-001369
                10.1136/bmjopen-2012-001369
                3367153
                22649177
                e088f68f-4806-4fbb-af50-80596d7d53e8
                © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 24 April 2012
                : 8 May 2012
                Categories
                Emergency Medicine
                Protocol
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                Medicine
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