Article

Chloride validity in Emergency Department settings

Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520 1501

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    Chloride validity in Emergency Department settings?

    Optimal laboratory utilization is a growing concern due to increas- ing pressures on reducing Healthcare costs while continuously improv- ing patients’ management [1-3]. Efficient laboratory tests ordering is essential for the effectiveness of the Emergency Department (ED) [2, 4]. However, inappropriate tests ordering is common in EDs [4-8]. It seems that the most probable underlying causes are: defensive medi- cine, scarce knowledge of tests’ diagnostic accuracy, unawareness of costs and possibility of ordering via settled protocols with numerous tests [2,4,6,8,9]. The main purpose of laboratory-testing in the ED should primarily be to confirm or confute the working diagnosis deter- mined by clinical examination rather than to be a triage-tool of widely varied population [6]. Inappropriate laboratory-testing can consequent- ly lower the provided care quality by delaying diagnosis and misleading with false-positive results [5-10]. Chloride is one of the essential human electrolytes responsible for maintaining acid-base balance and fluid dis- tribution [11]. It is one of the most common laboratory test performed, often combined with sodium and potassium [1,2,6,10]. However, the validity and significance of chloride level remains controversial in ev- eryday patients’ management in the ED.

    We conducted a retrospective study including all patients examined in

    the ED in 12-month period (January 1st-December 31st 2016). All data were taken from the hospital information system. We compared frequen- cy of pathological Chloride levels with frequency of pathological sodium, potassium, aspartate-aminotransferase (AST) and haemoglobin levels, and whether the pathological chloride levels influenced patients’ acute therapy or the decision on hospital admittance. Additionally, we calculat- ed costs generated by chloride assessing in USA dollars ($).

    Baseline characteristics were presented as absolute values and per- centages. The correlation between the variables was investigated by Cohen’s kappa-coefficient using SPSS-Version 20 (IBM, New York, USA). 21,533 patients were examined in the Internal medicine ED in 2016.

    96.7% of examined patients had biochemistry and haematology labora- tory findings done. During the study period, the reference value for chloride in ED laboratory was 97-111 mmol/L. 18,020 patients (83.7%) had chloride levels assessed. 1148 patients had pathological chloride (6.37%), out of which 872 had lower levels than reference values (4.84%) and 276 had higher levels (1.53%). Only 11 patients had ex- tremely low value of chloride defined as b 70 mmol/L (0.06%) and 34 ex- tremely high values N 120 mmol/L (0.19%). Pathological chloride levels

    ? The study was conducted without grant support. The authors report no conflict of interest.

    Table 1

    Pathological chloride levels frequency in comparison with that of sodium, potassium as- partate-aminotranspherase and haemoglobin levels in the Emergency Department settings

    Chloride

    P value

    Sodium

    13.3% (2409/18102)

    6.37% (1148/18020)

    b 0.0001

    Potassium

    9.16% (1528/16671)

    6.37% (1148/18020)

    b 0.0001

    AST

    23.22% (4130/17790)

    6.37% (1148/18020)

    b 0.0001

    Hb

    32.09% (5780/18012)

    6.37% (1148/18020)

    b 0.0001

    AST – aspartate-aminotranspherase, Hb – haemoglobin.

    frequency was significantly lower in comparison with frequencies of pathological sodium, potassium, AST and haemoglobin levels (p b 0.001) (Table 1). Out of 276 patients with high chloride, 108 had elevat- ed sodium (39.13%). 51.4% of patients with elevated chloride (142/276) were admitted to hospital, mostly due to infection (pneumonia, pyelo- nephritis/urinary tract infection) and consequent dehydration. Out of 872 patients with low chloride, 691 had low sodium (79.24%). 587 pa- tients with low chloride (67.3%) were admitted to hospital, mostly due to acute heart failure, myocardial infarction, gastrointestinal pathol- ogy (hepatic cirrhosis, ileus, pancreatitis) or hyponatraemia. All patients with pathological chloride and normal Sodium levels (375/1148, 32.7%) were released from hospital and none of them got any therapy for chlo- ride level. We conducted a survey among physicians working in the ED (54 fellows and internal medicine specialists), and 92.6% did not take chloride into clinical consideration. Only acidosis and respiratory failure were settings in which physicians (15/54, 28%) considered chloride as partially important finding. None of the physicians were influenced by it to change the patient’s therapy or decision on hospital admittance. Re- agent costs for chloride in the ED settings for 2016 amounted to

    $45,700. If we had provided chloride only to those who had pathological sodium (2408 patients), we would have saved approximately $39,600. Also, if we had additionally excluded those who were admitted to hos- pital where chloride levels could be controlled, the savings would in- clude an additional $2100, meaning 91% of Total costs.

    To our knowledge, this was the first chloride validity and cost- benefit analysis in the ED settings. There is a very small percentage of ED patients who have pathological chloride levels, especially with normal sodium levels, whose clinical value is much higher [1,9,12]. None of the patients with pathological chloride levels who had normal sodium levels were admitted to hospital. The at- tending physicians did not consider chloride levels as an impor- tant test among standard laboratory findings in the ED. Pathological chloride levels were not corrected in the ED settings. According to this, chloride does not contribute significantly to pa- tients’ management in the ED. Lippi et al. proposed that there is a need to create universal laboratory tests protocol [9]. However, ac- cording to our results it should be examined whether chloride could be excluded from these protocols. The patient-oriented lab- oratory testing according to differential diagnosis in ED settings is extremely challenging, but very important for correct decision- making [1,6,12,13]. If chloride levels could be assessed in the ED only as patient-oriented testing (pathological sodium, acidosis and Respiratory insufficiency), this could result in reduced costs and time delays without lowering the provided care-quality [2, 4-6,9,10,12-14].

    Matea Kolacevic, MD Dina Vukicevic Baudoin, MD

    Unit of Clinical Pharmacology and Toxicology, Department of Internal Medicine, Sestre milosrdnice University Hospital Centre

    Alen Babacanli, MD

    Department of Emergency Medicine, Sestre milosrdnice University Hospital

    Centre

    1502 Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520

    Marina Repusic Babacanli, MD

    Croatian Institute of Transfusion Medicine, Zagreb, Croatia

    Ivan Brdar, MD

    Department of Internal Emergency Medicine, Split University Hospital

    Centre

    Ivan Zeljkovic, MD* Nikola Bulj, MD, PhD

    *Corresponding author at: Department of Cardiology, Sestre milosrdnice University Hospital Centre, Vinogradska cesta 29, 10 000 Zagreb,

    Croatia.

    E-mail address: [email protected] (I. Zeljkovic).

    Marina Repusic Babacanli

    Department of Cardiology, Sestre milosrdnice University Hospital Centre

    20 November 2017

    https://doi.org/10.1016/j.ajem.2017.12.002

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      Is there an association between trichomoniasis and other sexually transmitted infections in adolescent ED patients?

      Trichomoniasis is a common sexually transmitted infection (STI) caused by the protozoan, Trichomonas vaginalis (TV), which causes vag- initis and cervicitis. TV coinfection with chlamydia, gonorrhea or both may account for over 2% of STI cases per year [1]. While TV infection is clearly a public health issue, few published studies have assessed TV prevalence in the adolescent emergency department (ED) population or its association with an increased risk of coinfection with other STIs.

      The goals of this study were: 1) to compare the prevalence of TV in the adolescent versus adult female population; and 2) to determine if findings on wet mount microscopy were associated with two other sex- ually transmitted infections: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG).

      We conducted a retrospective, cohort analysis of consecutive fe- males seen at seven EDs in West Michigan from August 2010 to July 2013. Affiliated institutions included three rural medical centers, three university-affiliated hospitals and a children’s tertiary care facility. All patients underwent a pelvic exam with endocervical specimens submit- ted for wet mount microscopy for TV, and Polymerase chain reaction assays for chlamydia and gonorrhea. Demographics, clinical find- ings, and Laboratory test results were obtained from ED records using standardized abstraction forms. Inter-rater reliability was determined using kappa statistics. The primary outcome measure was a positive likelihood ratio of patients with positive TV that are co-infected with CT and/or NG. Adult and adolescent (ages 13-19) groups were com- pared using 2-tailed unpaired t-tests and Wilcoxon rank sum tests for continuous and ordinal data, while nominal data was analyzed by chi- square tests.

      During the 36-month study period, 8413 consecutive females were evaluated for STIs; 1432 were adolescents (17.0%). A total of 275 adoles- cents had at least one documented STI (19.2%; 95% CI = 17.1 to 21.2%); 101 patients tested positive for TV (7.1%, 95% CI = 5.8 to 8.4%). In the adult population, 1537 had at least one documented STI (22.0%; 95% CI = 21.0 to 23.0%) and 569 patients tested positive for TV (8.1%, 95% CI = 7.5 to 8.7%). TV was the most common STI in adult women, while CT was the most prevalent in the adolescent age group (8.7%). Coinfection rates were significantly lower in the adolescent age group (9.8% vs. 16.1%, P b 0.001). Statistical analysis revealed a weakly positive association with other STIs in adults with TV (+LR = 1.75, 95% CI = 1.4 to 2.1), but not in Adolescent patients (+LR = 0.79, 95%

      CI = 0.5 to 1.3).

      In our ED study population, TV was the most common STI in adult women and was associated with a slightly increased risk of coinfection with other STIs. In the adolescent age group, CT was the most prevalent STI. There was no association between the presence of TV and coinfec- tion with other STIs in young patients. This supports previous studies which also found that TV is not a reliable marker for concurrent infec- tion with CT or NG [2]. Lo et al. have found however, that having elevat- ed numbers of white cells present on wet preps increases the probability of a likely NG or CT infection [2]. Lacking rapid point-of- care testing in the ED, this may be a suitable substitute to indicate that further investigation for possible coinfection is necessary.

      It is difficult to estimate the true burden of TV infection in the USA simply because it is not a reportable disease and there is no surveillance system in place to track infections. In addition, the diagnosis of tricho- moniasis involves visualization of motile trichomonads on a saline wet mount of vaginal fluid. Although this diagnostic test has been used for many years, it has a poor sensitivity and is highly user-dependent [3, 4]. More sensitive diagnostic tests for TV are now available, but must be weighed against their added costs, including waiting time and need for follow-up. No test has been shown to be more cost-effective than the wet mount in an emergency setting [4].

      Mild or asymptomatic infections with CT and NG are common, and untreated infection can lead to severe health consequences. Centers for Disease Control and Prevention urges physicians to have a low threshold for diagnosing Pelvic inflammatory disease and initiating empiric antibi- otic therapy for CT and NG [5]. In the ED setting, the difficulties evaluat- ing patients for STIs are compounded by the transient physician-patient encounter, delayed return of GC and NG study results, and problems en- suring follow-up [6]. Due to these difficulties, and the logical belief that High-risk sexual behavior tends to produce infection with multiple or- ganisms, emergency physicians may choose to treat for GC and CT when they have a positive Trichomonas result [6,7]. The findings from our study do not support this strategy. Until real-time testing for STIs

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