Correspondence / American Journal of Emergency Medicine 33 (2015) 1515–1535

so they may prefer to be managed with Specialized care in the ED. In a

1519

Ozcan Basaran, Med Dr

study by Yildirim and Tanriverdi, it was found that 60% of 107 decedents with cancer followed up at the department of medical oncology made at least 1 visit to ED within 1 month before death [4].

There are efforts to improve End-of-life care and to define good death, and goals have been outlined by medical associations [5,6]. End-of-life care can be improved when health care providers support patients’ and their families’ needs, collaborate on decision making, and coordinate be- tween health care settings [6]. Poor quality care for patients with cancer can be described when patients visit EDs frequently and when deaths occur in hospital settings [7]. End-of-life care training such as managing palliative care has been added to the core curriculum of emergency med- icine by some medical institutions and a new curriculum has been devel- oped for emergency medicine professionals for palliative care principles in the ED [8]. The World Health Organization’s definition for palliative care is as follows: “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” [9]. Improving palliative care in the ED will undoubtedly involve communica- tion skills training, Symptom management training (eg, pain manage- ment), and palliative care consultations in the ED [8,10].

For home-based inpatient palliative care, family-centered palliative care is recommended that these advices involve determining the key fam- ily members, assessing the individual family caregiver’s needs regularly, assisting the family members with skills to optimize patient comfort, and preparing the family members to support a dying relative [11].

Patient-centered care has been defined as “providing care that is respectful of and responsive to individual patient preferences, need, and values, and ensuring that patient values guide all Clinical decisions,” in the report of Institute of Medicine in 2001 [12].

Continuity of cancer patients’ care is an important aspect for providing optimized patient outcomes, and it is consistently found to be a significant domain contributing to patient satisfaction [13].

Our opinion is that ED visits would be more informed and

appropriate with greater PCP involvement in cancer care, and when the patients visit the ED, a communication network with oncologists would be available 24 hours a day to facilitate appropriate palliation.

Symptom management of cancer patients, treatment of oncologic emergencies, and palliative care will increase life quality. To avoid unnecessary and costly ED visits by cancer patients for symptom control and palliative care, both patients and PCPS need to be better ed- ucated better regarding palliative care. Reevaluation of emergency triage about cancer patients is an important issue.

Birdal Yildirim, Ass Prof Dr

Department of Emergency Medicine, Education and Research Hospital

Mugla Sitki Kocman University, Mugla, Turkey Corresponding author at: Mugla Sitki Kocman Universitesi Tip Fakultesi Orhaniye Mah, Haluk Ozsoy Cad, 48000 Mugla, Turkey

Tel.: +90 252 214 13 26

E-mail address: birdalgul@gul.com

Emine Nese Yeniceri, Ass Prof Dr

Department of Family Medicine Faculty of Medicine, Mugla Sitki Kocman

University Mugla, Turkey

Ozgur Tanriverdi, Ass Prof Dr

Department of Medical Oncology, Faculty of Medicine Mugla Sitki Kocman

University, Mugla, Turkey

Mehmet Unaldi, Med Dr

Department of Cardiology, Faculty of Medicine Mugla Sitki Kocman University, Mugla, Turkey

Omer Dogan Alatas, Med Dr Ethem Acar, Ass Prof Dr

Department of Emergency Medicine, Education and Research Hospital

Mugla Sitki Kocman University, Mugla, Turkey

http://dx.doi.org/10.1016/j.ajem.2015.07.046

References

1. Tanriverdi O, Beydilli H, Yildirim B, Karagoz U. Single center experience on causes of cancer patients visiting the emergency department in southwest Turkey. Asian Pac J Cancer Prev 2014;15:687-90.
2. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010;182:563-8.
3. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D. The effect of emergency de- partment crowding on clinically oriented outcomes. Acad Emerg Med 2009;16:1-10.
4. Yildirim B, Tanriverdi O. Evaluation of cancer patients admitted to the emergency de- partment within one month before death in Turkey: what are the problems needing attention? Asian Pac J Cancer Prev 2014;15:349-53.
5. Teno MJ, Clerridge R, Casy V, Welch LC, Wetle T. Family perspectives on end-of-life care at the last place of care. JAMA 2004;291:88-93.
6. Steinhauser K, Christakis N, Clipp E, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family physicians and other health care providers. JAMA 2000;284:2476-82.
7. Earle C, Park E, Lai B, Weeks J, Ayanian J, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003;15:1133-8.
8. Smith A, Fisher J, Schonberg MA, Pallin D, Block SD, Forrow L, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency de- partment. Ann Emerg Med 2009;54:86-93.
9. World Health Organization [WHO]. Cancer: WHO definition of palliative care. Available at http://www.who.int/cancer/palliative/definition/en/. [Accessed June 08, 2014].
10. Ventura AD, Burney S, Brooker J, Fletcher J, Ricciardelli. Home-based palliative care: a systematic literature review of the self-reported unmet needs of patients and carers. Palliat Med 2014;28:391-402.
11. Hudson P. Home-based support for palliative care families: challenges and recom- mendations. Med J Aust 2003;179:35-7.
12. Balogh EP, Ganz PA, Murphy SB, Nass SJ, Ferrell BR, Stovall E. Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop. Oncologist 2011;16:1800-5.
13. Husain A, Barbera L, Howell D, Moineddin R, Bezjak A, Sussman J. Advanced lung cancer patients’ experience with continuity of care and supportive care needs. Sup- port Care Cancer 2013;21:1351-8.

Prevalence of diabetes mellitus in patients with sepsis-triggered Takotsubo syndrome?

To the Editor,

The article by Fabbian et al [1] published on line ahead of print on June 18, 2015 in the journal about the concurrence of infections/sepsis and Takotsubo syndrome (TTS) is of interest from the pathogenetic point of view, that a physical stress like sepsis can trigger TTS, and that male pa- tients afflicted with this combinations have worse in-hospital mortality than do their female counterpart. It is conceivable that we are in error when we think that we can separate physical and emotional stresses, and it is possible to consider an emotional overlay over the physical stress of sepsis, as a trigger of TTS. The authors refer to a multitude of mecha- nisms predisposing patients with infections/sepsis to develop TTS. Also in their concluding statement, the authors state that “male patients suspected for TTC should be carefully protected against infectious compli- cations, since the onset of sepsis could be more harmful and life- threatening” appearing to imply that not only sepsis could trigger TTS, but patients presenting with TTS may be prone to sepsis and high in- hospital mortality. It is conceivable that this is a possibility considering the many morbid mechanisms being at play in both sepsis and TTS, and the difficulty in making either of these 2 diagnoses very early in their

Emergency Department, Goztepe Training and Research Hospital

Medeniyet University, Istanbul, Turkey

? Conflicts of interest: None.

1520 Correspondence / American Journal of Emergency Medicine 33 (2015) 1515–1535

inception (ie, which started first TTS or infection leading to sepsis?). Final- ly, because the authors had assembled 38 articles comprising single- patient cases and case series, I wonder whether they have any informa- tion about the prevalence of diabetes mellitus among the reported patients with sepsis-triggered TTS; although DM has been recently re- ported having a low prevalence in patients suffering from TTS [2], the overwhelmingly morbid nature of sepsis might have mitigated the “pro- tective” effect of DM, and thus patients with sepsis-triggered TTS have the expected or even enhanced (for other reasons) prevalence of DM.

John E. Madias, MD Icahn School of Medicine at Mount Sinai, New York, NY Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY

Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway Elmhurst, NY 11373. Tel.: +1 718 334 5005; fax: +1 718 334 5990

E-mail address: madiasj@nychhc.org http://dx.doi.org/10.1016/j.ajem.2015.07.041

References

1. Fabbian F, De Giorgi A, Tiseo R, Boari B, Salmi R, Signani F, et al. Takotsubo cardiomyop- athy, sepsis and clinical outcome: does gender matter? Am J Emerg Med 2015. http://dx. doi.org/10.1016/j.ajem.2015.06.030 [pii: S0735-6757(15)00507-0. Epub ahead of print].
2. Madias JE. Low prevalence of diabetes mellitus in patients with Takotsubo syndrome: a plausible ‘protective’ effect with pathophysiologic connotations. Eur Heart J Acute Cardiovasc Care 2015 [pii: 2048872615570761. Epub ahead of print].

Possible association between Takotsubo cardiomyopathy, sepsis, and diabetes mellitus:

a still open question

To the Editor,

We appreciated the comments by Dr Madias [1], raising some inte- resting key points. On one hand, we quite agree that emotional and phy- sical stressors are not strictly separated entities and, in most cases, may overlap as triggering factors of Takotsubo cardiomyopathy . Howev- er, this definition is widely used [2,3]. The association between diabetes mellitus (DM) and TTC has been matter of several investigations. Pelliccia et al [3], evaluating a series of 19 studies (1109 patients), after a contact with corresponding authors, asked to provide additional quantitative de- tails, concluded that patients with TTC have a relevant prevalence of car- diovascular risk factors and associated comorbidities. Obesity was present in 17% of patients; hypertension, in 54%; smoking, in 22%; dyslipidemia, in 32%; and DM, in 17%. Madias [4], who recently reviewed articles accessed in PubMed to evaluate the prevalence of DM in TTC patients (959 studies and 33894 patients), confirmed an overall prevalence of 16.8%.

A gender difference for mortality has been confirmed also very recently. Krishnamooorthy et al [5], in an analysis of all patients 18 years or older di- agnosed with TTC identified in the Nationwide Inpatient Sample 2009- 2010 database, found that the total Inhospital mortality rate was 2.4%, with a higher mortality in men (4.8%) than in women (2.1%). Sepsis (9% vs 4.2%) was more prevalent in men with an increased prevalence of other critical illness. As for the possible association between TTC, sepsis, and DM, apparently negligible in our series of case reports [6] (clearly doc- umented in 1 case [7]), the available evidence is limited. In their study on patients diagnosed with TTC in the National Inpatient Sample 2008-2009 database (n = 24701), Brinjikji et al [8] reported a total inhospital mortality rate of 4.2%, but significantly higher in males than in females (8.4% vs 3.6%, respectively). Male patients with TTC had higher incidence of underlying Critical illnesses than female (36.6% vs 26.8%). Diabetes mellitus was present in 18.9% of cases; sepsis, in 21.6%; but no data are given on this combined association and relative analysis of mortality rates. Finally, in their sample of 3719 Japanese patients with TTC (419 with inhospital TTC and 3300 with out-of-hospital TTC), Isogai et al [9] found that inhospital TTC was

significantly associated with higher inhospital mortality in males (odds ratio, 1.24) and in the presence of sepsis (odds ratio, 2.02). However, among all the several chronic comorbidities and acute medical illnesses considered, DM was not present at all (or, at least, not reaching the mini- mum reported proportion of >=0.5%). Further studies are needed on this rel- atively infrequent, but potentially harmful relationship.

Fabio Fabbian, MD Alfredo De Giorgi, MD Ruana Tiseo, MD Benedetta Boari, MD

University of Ferrara, School of Medicine

Ferrara, Italy E-mail addresses: f.fabbian@ospfe.it (F. Fabbian) degiorgialfredo@libero.it (A. De Giorgi) ruana.tiseo@unife.it (R. Tiseo) brobdt@unife.it (B. Boari)

Raffaella Salmi, MD Ferrara General Hospital, Ferrara, Italy E-mail address: raffaella.salmi@ospfe.it

Fulvia Signani, PsyD

University of Ferrara, Ferrara, Italy E-mail address: fulvia.signani@unife.it

Beatrice Zucchi, PedD Roberto Manfredini, MD?

University of Ferrara, School of Medicine, Ferrara, Italy

?Corresponding author at: Clinica Medica Unit, University of Ferrara School

of Medicine, via Aldo Moro 8, 44124 Cona (Ferrara), Italy Tel.: +39 0532 237166; fax: +39 0532 236816

E-mail addresses: beatrice.zucchi@unife.it (B. Zucchi) roberto.manfredini@unife.it (R. Manfredini)

http://dx.doi.org/10.1016/j.ajem.2015.07.042

References

1. Madias JE. Prevalence of diabetes mellitus in patients with sepsis-triggered Takotsubo syndrome. Am J Emerg Med 2015;33:1519-20.
2. Summers MR, Prasad A. Takotsubo cardiomyopathy. Definition and clinical profile. Heart Fail Clin 2013;9:111-22.
3. Pelliccia F, Parodi G, Greco C, Antoniucci D, Brenner R, Bossone E, et al. Comorbidities frequency in takotsubo syndrome: an international collaborative systematic review including 1109 patients. Am J Med 2015;128:654.e11-9.
4. Madias JE. Low prevalence of diabetes mellitus in patients with Takotsubo syndrome: a plausible “protective” effect with pathophysiologic connotations. Eur Heart J Acute Cardiovasc Care 2015 [pii 2048872615570761. Epub ahead of print].
5. Krishnamoorthy P, Garg J, Sharma A, Palaniswamy C, Shah N, Lanier G, et al. Gender differences and predictors of mortality in Takotsubo cardiomyopathy: analysis from the National Inpatient Sample 2009-2010 database. Cardiology 2015;132:131-6.
6. Fabbian F, De Giorgi A, Tiseo R, Boari B, Salmi R, Signani F, et al. Takotsubo cardiomyopathy, sepsis and clinical outcome: does gender matter? Am J Emerg Med 2015. http://dx.doi.org/ 10.1016/j.ajem.2015.06.030 [pii: S0735-6757(15)00507-0. Epub ahead of print].
7. Ohigashi-Suzuki S, Saito Y, Tatsuno I. Takotsubo cardiomyopathy associated with sepsis in type 2 diabetes mellitus. Am J Emerg Med 2007;25:230-2.
8. Brinjikji W, El-Sayed AM, Salka S. In-hospital mortality among patients with takotsubo cardiomyopathy: a study of the National Inpatient Sample 2008 to 2009. Am Heart J 2012;164:215-21.
9. Isogai T, Yasunaga H, Matsui H, Tanaka H, Ueda T, Horiguchi H, et al. Out-of-hospital versus in-hospital Takotsubo cardiomyopathy: analysis of 3719 patients in the Diagnosis Procedure Nomination database in Japan. Int J Cardiol 2014;176:413-7.

Hemodynamic monitoring and mortality

To the Editor,

transpulmonary thermodilution associated to pulse contour analysis is a monitoring technique used in states of shock and is presently a subject of debate. We therefore read with interest the article “Improved Sepsis Bundles in the treatment of septic shock: a prospective clinical study” by Lu et al and would like to stress the importance of the objectives of their study. In a similar recent study [1], pulse-indicated continuous