诊断呼吸困难的老年急诊患者：一项试点研究。
Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study.
机构信息
From the, Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA.
and the, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA.
出版信息
Acad Emerg Med. 2021 Jun;28(6):675-678. doi: 10.1111/acem.14183. Epub 2020 Dec 16.
STUDY OBJECTIVES
: Pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure (HF) exacerbations can present similarly in the older adult in the Emergency Department (ED), leading to sub-optimal treatment from over- and under-diagnosis. There may be a role for antimicrobial peptides (AMPs) in improving the accurate diagnosis of pneumonia in these patients.
METHODS
: This pilot was a prospective, observational cohort study of older adults (aged ≥65 years of age) who presented to the ED with dyspnea or elevated respiratory rate. To identify biomarkers of pneumonia, serum levels of white blood cell count, procalcitonin (PCT), and antimicrobial peptides (human beta defensin 1 and 2 [HBD-1, -2], human neutrophil peptides 1–3 [HNP1–3] and cathelididin [LL-37]) were compared between those with and without pneumonia. Criterion standard reviewers retrospectively determined the diagnoses present in the ED.
RESULTS
: Three hundred ninety-one patients were screened, 140 were eligible, and 79 were enrolled. Based on criterion standard review, pneumonia was present in 10 (12.7%), COPD in 9 (11.4%) and HF in 31 (39.2%) with a co-diagnosis rate of 10.1% by criterion standard review. Comparatively, emergency medicine attending physicians diagnosed pneumonia in 16 (20.3%), COPD in 12 (15.2%), and HF in 30 (38.0%) with co-diagnosis rate of 15.2%. Emergency physicians agreed with criterion standard diagnoses in 90% of pneumonia, 75% of COPD and 65% of HF diagnoses. Differences in leukocyte count (p<0.01) and two novel AMPs (DEFA5 (p=0.08) and DEFB2 (p=0.09)) showed promise for diagnosing pneumonia.
CONCLUSIONS
: Emergency physicians continue to have poor diagnostic accuracy in dyspneic older adult patients. Serum AMP levels are one potential tool to improve diagnostic accuracy and outcomes for this important population and require further study.
研究目的
在急诊科（ED），老年人的肺炎、慢性阻塞性肺疾病（COPD）和心力衰竭（HF）恶化可能表现相似，导致过度诊断和漏诊导致治疗效果不佳。抗菌肽（AMPs）可能在改善这些患者肺炎的准确诊断方面发挥作用。
方法
这是一项针对老年患者（年龄≥65 岁）的前瞻性观察队列研究，这些患者因呼吸困难或呼吸频率升高而到急诊科就诊。为了确定肺炎的生物标志物，比较了肺炎患者和非肺炎患者的血清白细胞计数、降钙素原（PCT）和抗菌肽（人β防御素 1 和 2 [HBD-1、-2]、人中性粒细胞肽 1-3 [HNP1-3]和 cathelididin [LL-37]）水平。标准审查员回顾性确定 ED 中的诊断。
结果
共筛查 391 例患者，符合条件的 140 例，入组 79 例。根据标准审查，10 例（12.7%）存在肺炎，9 例（11.4%）存在 COPD，31 例（39.2%）存在 HF，标准审查的共病诊断率为 10.1%。相比之下，急诊医学主治医生诊断肺炎 16 例（20.3%）、COPD 12 例（15.2%）和 HF 30 例（38.0%），共病诊断率为 15.2%。急诊医师对肺炎、COPD 和 HF 的诊断与标准诊断的一致性分别为 90%、75%和 65%。白细胞计数差异有统计学意义（p<0.01），两种新型 AMPs（DEFA5（p=0.08）和 DEFB2（p=0.09））在诊断肺炎方面有一定前景。
结论
急诊医师在诊断呼吸困难的老年患者时，诊断准确性仍然较差。血清 AMP 水平是一种提高该重要人群诊断准确性和预后的潜在工具，需要进一步研究。
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