1538
Correspondence / American Journal of Emergency Medicine 32 (2014) 1534–1552
[9] Behnes M, Bertsch T, Lepiorz D, Lang S, Trinkmann F, Brueckmann M, et al. Diagnostic and prognostic utility of soluble CD 14 subtype (presepsin) for severe sepsis and septic shock during the first week of intensive care treatment. Crit Care 2014;18:507. [10] Balta S, Demirkol S, Hatipoglu M, Ardic S, Aydogan M, Celik T. Other inflammatory indicators should be kept in mind when assessing red cell distribution width in patients with pneumonia. Am J Emerg Med 2013;31:1144–5. [11] Li Z, Wang H, Liu J, Chen B, Li G. Serum soluble triggering receptor expressed on myeloid cells-1 and procalcitonin can reflect sepsis severity and predict prognosis: a prospective cohort study. Mediat Inflamm 2014;2014:641039. [12] Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373–9.
Can red cell distribution width predict mortality rate in patients with necrotizing fasciitis? The Author's Reply☆ To the Editor, We thank Prof Yuefeng Ma for his interest and comments on our article. Although several factors increased red blood cell distribution width (RDW), anemia, chronic kidney disease, and liver cirrhosis were taken into account in our study. When considering about time elapsed between blood sampling and RDW measuring, the complete cell count from emergency department in our hospital was always reported within 1 hour. The receiver operating characteristic curves of RDW levels were used to identify nonsurvivors on a statistically significant level (area under the curve of 0.851, P b .001; 95% confidence interval,
0.772-0.930; Figure). The positive and negative predictive value of high RDW was also evaluated (Table). The predictors of mortality in patients with necrotizing fasciitis had been worked in our hospital [1]. We developed new treatment protocol including early recognize, antibiotics treatment, and surgical fasciotomy by orthopedic surgeons as soon as possible since 2008, the time we started to enroll patients. The number of patients in our study was limited to the low incidence of necrotizing fasciitis and time. Further prospective studies with a larger sample size and including the factors associated with RDW were needed to investigate the mechanism and impact of RDW on necrotizing fasciitis. Hong-Mo Shih, MD Department of Emergency Medicine Chang Gung Memorial Hospital Puzi City, Chiayi County, Taiwan (ROC) Chang Gung University College of Medicine Kwei-Shan Tao-Yuan, Taiwan, ROC Corresponding author. Chang Gung Memorial Hospital, Chiayi No. 6 W. Sec., Jiapu Rd., Puzi City, Chiayi County 613, Taiwan (ROC) Tel.: +886 922877132; fax: +886 5 362 3002 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.10.001 Reference [1] Hsiao Cheng-Ting, Weng Hsu-Huei, Yuan Yao-Dong, Chen Chih-Tsung, Chen I-Chuan. Predictors of mortality in patients with necrotizing fasciitis. Am J Emerg Med 2008; 26:170–5.
Seizure-induced acute coronary syndrome: the value of postictal screening☆
To the Editor,
Figure. Diagonal segments are produced by ties.
Table Sensitivity, specificity, positive likelihood ratio and negative likelihood ratio, positive predictive value, and negative predictive value of RDW RDW
Sensitivity
Specificity
+LR
−LR
PPV
NPV
N14.5
69.5
80.0
3.48
0.044
51.6%
89.6%
Abbreviations: +LR, positive likelihood ratio; −LR, negative likelihood ratio; PPV, positive predictive value; NPV, negative predictive value.
☆ Conflicts of interest statement: None declared.
To the best of our knowledge, there are no reports demonstrating the occurrence of coronary thrombus after complicated seizures without an underlying pathology (eg, atherosclerosis, vasculitis) upon coronary vessels. Acute coronary syndrome (ACS) occurring after seizures is a rare and perhaps unrecognized. It is therefore not surprising that the consensus or practice guidelines on ACS are silent on this clinical entity. Thus, we demonstrated the value of a simple screening tool of serial cardiac enzymes and electrocardiograms (ECGs), which are readily available in the hospital to tease out this rare entity that can prove fatal if not detected early. A 43-year-old white man diagnosed with epilepsy since the age of 12 was brought to the hospital after two episodes of witnessed generalized tonic-clonic (GTC) seizures for 20 minutes, tongue biting, and loss of bladder control. His epilepsy has been controlled, seizure free for 2 years, with carbamazepine and clonazepam. However, he had stopped taking clonazepam 3 days prior to presentation. There was no angina or coronary artery disease. He regained his consciousness fully with stable vital signs and unremarkable computed tomography (CT) of the brain. Complete blood count, chemistry, and lipid panel were normal, and rapid urine drug screen was negative for all drugs, including benzodiazepine. Serum carbamazepine level was therapeutic. The third episode of GTC seizure occurred after a loading dose of levetiracetam was given. He was intubated for airway protection and transferred to
☆ The authors thank Dr Majorie A. Mooney-Jacoby for her pearl of wisdom and dedicated teaching that provided us with the key contents of this manuscript and Dr Mariam A. Khan for her excellent patient care.
Correspondence / American Journal of Emergency Medicine 32 (2014) 1534–1552
[9] Behnes M, Bertsch T, Lepiorz D, Lang S, Trinkmann F, Brueckmann M, et al. Diagnostic and prognostic utility of soluble CD 14 subtype (presepsin) for severe sepsis and septic shock during the first week of intensive care treatment. Crit Care 2014;18:507. [10] Balta S, Demirkol S, Hatipoglu M, Ardic S, Aydogan M, Celik T. Other inflammatory indicators should be kept in mind when assessing red cell distribution width in patients with pneumonia. Am J Emerg Med 2013;31:1144–5. [11] Li Z, Wang H, Liu J, Chen B, Li G. Serum soluble triggering receptor expressed on myeloid cells-1 and procalcitonin can reflect sepsis severity and predict prognosis: a prospective cohort study. Mediat Inflamm 2014;2014:641039. [12] Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373–9.
Can red cell distribution width predict mortality rate in patients with necrotizing fasciitis? The Author's Reply☆ To the Editor, We thank Prof Yuefeng Ma for his interest and comments on our article. Although several factors increased red blood cell distribution width (RDW), anemia, chronic kidney disease, and liver cirrhosis were taken into account in our study. When considering about time elapsed between blood sampling and RDW measuring, the complete cell count from emergency department in our hospital was always reported within 1 hour. The receiver operating characteristic curves of RDW levels were used to identify nonsurvivors on a statistically significant level (area under the curve of 0.851, P b .001; 95% confidence interval,
0.772-0.930; Figure). The positive and negative predictive value of high RDW was also evaluated (Table). The predictors of mortality in patients with necrotizing fasciitis had been worked in our hospital [1]. We developed new treatment protocol including early recognize, antibiotics treatment, and surgical fasciotomy by orthopedic surgeons as soon as possible since 2008, the time we started to enroll patients. The number of patients in our study was limited to the low incidence of necrotizing fasciitis and time. Further prospective studies with a larger sample size and including the factors associated with RDW were needed to investigate the mechanism and impact of RDW on necrotizing fasciitis. Hong-Mo Shih, MD Department of Emergency Medicine Chang Gung Memorial Hospital Puzi City, Chiayi County, Taiwan (ROC) Chang Gung University College of Medicine Kwei-Shan Tao-Yuan, Taiwan, ROC Corresponding author. Chang Gung Memorial Hospital, Chiayi No. 6 W. Sec., Jiapu Rd., Puzi City, Chiayi County 613, Taiwan (ROC) Tel.: +886 922877132; fax: +886 5 362 3002 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.10.001 Reference [1] Hsiao Cheng-Ting, Weng Hsu-Huei, Yuan Yao-Dong, Chen Chih-Tsung, Chen I-Chuan. Predictors of mortality in patients with necrotizing fasciitis. Am J Emerg Med 2008; 26:170–5.
Seizure-induced acute coronary syndrome: the value of postictal screening☆
To the Editor,
Figure. Diagonal segments are produced by ties.
Table Sensitivity, specificity, positive likelihood ratio and negative likelihood ratio, positive predictive value, and negative predictive value of RDW RDW
Sensitivity
Specificity
+LR
−LR
PPV
NPV
N14.5
69.5
80.0
3.48
0.044
51.6%
89.6%
Abbreviations: +LR, positive likelihood ratio; −LR, negative likelihood ratio; PPV, positive predictive value; NPV, negative predictive value.
☆ Conflicts of interest statement: None declared.
To the best of our knowledge, there are no reports demonstrating the occurrence of coronary thrombus after complicated seizures without an underlying pathology (eg, atherosclerosis, vasculitis) upon coronary vessels. Acute coronary syndrome (ACS) occurring after seizures is a rare and perhaps unrecognized. It is therefore not surprising that the consensus or practice guidelines on ACS are silent on this clinical entity. Thus, we demonstrated the value of a simple screening tool of serial cardiac enzymes and electrocardiograms (ECGs), which are readily available in the hospital to tease out this rare entity that can prove fatal if not detected early. A 43-year-old white man diagnosed with epilepsy since the age of 12 was brought to the hospital after two episodes of witnessed generalized tonic-clonic (GTC) seizures for 20 minutes, tongue biting, and loss of bladder control. His epilepsy has been controlled, seizure free for 2 years, with carbamazepine and clonazepam. However, he had stopped taking clonazepam 3 days prior to presentation. There was no angina or coronary artery disease. He regained his consciousness fully with stable vital signs and unremarkable computed tomography (CT) of the brain. Complete blood count, chemistry, and lipid panel were normal, and rapid urine drug screen was negative for all drugs, including benzodiazepine. Serum carbamazepine level was therapeutic. The third episode of GTC seizure occurred after a loading dose of levetiracetam was given. He was intubated for airway protection and transferred to
☆ The authors thank Dr Majorie A. Mooney-Jacoby for her pearl of wisdom and dedicated teaching that provided us with the key contents of this manuscript and Dr Mariam A. Khan for her excellent patient care.
