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Objectives To evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics. Design Individual patient level data meta-analysis and modelling study. Setting Fourteen studies from 13 countries, including randomised controlled trials and prospective observational studies. Participants Individual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated. Main outcome measure Adjudicated diagnosis of acute heart failure. Results Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure. Conclusions In an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach. Study registration PROSPERO CRD42019159407.

Over last fifty years, intravenous (iv) phenytoin (PHT) loading dose has been the treatment of choice for patients with benzodiazepine-resistant convulsive status epilepticus and several guidelines recommended this treatment regimen with simultaneous iv diazepam. Clinical studies have never shown a better efficacy of PHT over other antiepileptic drugs. In addition, iv PHT loading dose is a complex and time-consuming procedure which may expose patients to several risks, such as local cutaneous reactions (purple glove syndrome), severe hypotension and cardiac arrhythmias up to ventricular fibrillation and death, and increased risk of severe allergic reactions. A further disadvantage of PHT is that it is a strong enzymatic inducer and it may make ineffective several drugs that need to be used simultaneously with antiepileptic treatment. In patients with a benzodiazepine-resistant status epilepticus, we suggest iv administration of levetiracetam as soon as possible. If levetiracetam would be ineffective, a further antiepileptic drug among those currently available for iv use (valproate, lacosamide, or phenytoin) can be added before starting third line treatment.

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performing a bedside US will decrease the use of CT imaging in the ED by 15% in patients with abdominal pain.Methods: This is a preliminary prospective observational study of ED patients at two urban academic medical centers beginning December 2014. Inclusion criteria include all patients between the ages of 18 and 65 who present with abdominal pain and have a CT of the abdomen and pelvis performed. Patients with an extensive abdominal surgical history or those who end up not having a CT are excluded. Emergency physician co-investigators trained in US, blinded to CT results, performed the following studies: a Focused Assessment with Sonography in Trauma (FAST) exam, right upper quadrant US, bilateral renal US, an abdominal aorta US, and a right lower quadrant US. All US results were discussed with the treating physician and any changes in management were documented. Medical records were reviewed for the final results of all CTs.Results: We calculated a sample size of 200 patients in order to reduce CT scan usage from 25% to 10%. Our preliminary data identified 31 eligible patients of which 28 were enrolled in the study. Three patients have been dropped due to the CT being canceled. Twenty-five patients received both the US and CT in the ED and were included in the analysis. Eleven patients (44%) had a normal US and no significant findings on a subsequent CT. Four patients (16%) had a normal US, but a positive CT. Two of these four had mild hydronephrosis on CT that was missed on US and two had more complicated diagnoses of fistulizing Crohn's and diverticulitis. Ten patients (40%) had a positive US, of which eight had the same diagnosis confirmed on CT and two patients (8%) had CT findings that differed from the US: one had acute appendicitis on US, but renal colic on CT and one had a possible SBO on US but a rectus muscle hematoma on CT. Ultrasound could have theoretically reduced CT utilization in 32% of patients. Although three patients were dropped, two of these had the CT scan canceled and a change in management based on US findings. The two diagnoses were appendicitis and cholelithiasis and both had subsequent radiology US confirming the findings. Therefore, our preliminary total theoretical and actual CT usage reduction is 40%.Conclusions: These preliminary findings suggest that ED performed bedside US in patients with uncomplicated abdominal pain may significantly reduce CT utilization. Bedside US will not replace CT in all patients and subsequent imaging may still be required. However, incorporating US into an abdominal pain algorithm may reduce radiation exposure, length of stay and costs associated with unnecessary CT usage in the ED. An Evidence-Based Lung Ultrasound Scanning Protocol for Diagnosing Pediatric PneumoniaMilliner BHA, Tsung JW/Icahn School of Medicine at Mount Sinai, New York City, NY Study Objective: Respiratory complaints are the most frequent reason for visits to emergency departments (ED) in children. Lung ultrasound has been shown to be highly accurate in diagnosing pneumonia in chi...

In the Emergency Department (ED), the decision to hospitalize or discharge COVID-19 patients is challenging. We assessed the utility of lung ultrasound (LUS), alone or in association with a clinical rule/score. This was a multicenter observational prospective study involving six EDs (NCT046291831). From October 2020 to January 2021, COVID-19 outpatients discharged from the ED based on clinical judgment were subjected to LUS and followed-up at 30 days. The primary clinical outcome was a composite of hospitalization or death. Within 393 COVID-19 patients, 35 (8.9%) reached the primary outcome. For outcome prognostication, LUS had a C-index of 0.76 (95%CI 0.68–0.84) and showed good performance and calibration. LUS-based classification provided significant differences in Kaplan–Meier curves, with a positive LUS leading to a hazard ratio of 4.33 (95%CI 1.95–9.61) for the primary outcome. The sensitivity and specificity of LUS for primary outcome occurrence were 74.3% (95%CI 59.8–88.8) and 74% (95%CI 69.5–78.6), respectively. The integration of LUS with a clinical score further increased sensitivity. In patients with a negative LUS, the primary outcome occurred in nine (3.3%) patients (p < 0.001 vs. unselected). The efficiency for rule-out was 69.7%. In unvaccinated ED patients with COVID-19, LUS improves prognostic stratification over clinical judgment alone and may support standardized disposition decisions.