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Burkett E, Macdonald SPJ, Carpenter CR, Arendts G, Hullick C, Nagaraj G, Osborn TM. Sepsis in the older person: The ravages of time and bacteria. Emerg Med Australas 2018; 30:249-258. [DOI: 10.1111/1742-6723.12949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Stephen PJ Macdonald
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- Emergency Department, Royal Perth Hospital; Perth Western Australia Australia
- Discipline of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
| | - Christopher R Carpenter
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- Discipline of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
| | - Carolyn Hullick
- Emergency Department; John Hunter Hospital; Newcastle New South Wales Australia
- Faculty of Health and Medicine; The University of Newcastle; Newcastle New South Wales Australia
| | - Guruprasad Nagaraj
- Emergency Department; Liverpool Hospital; Sydney New South Wales Australia
- School of Medicine, The University of Sydney; Sydney New South Wales Australia
| | - Tiffany M Osborn
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
- Department of Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
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Goulden R, Hoyle MC, Monis J, Railton D, Riley V, Martin P, Martina R, Nsutebu E. qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J 2018; 35:345-349. [PMID: 29467173 DOI: 10.1136/emermed-2017-207120] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 01/11/2018] [Accepted: 01/26/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The third international consensus definition for sepsis recommended use of a new prognostic tool, the quick Sequential Organ Failure Assessment (qSOFA), based on its ability to predict inhospital mortality and prolonged intensive care unit (ICU) stay in patients with suspected infection. While several studies have compared the prognostic accuracy of qSOFA to the Systemic Inflammatory Response Syndrome (SIRS) criteria in suspected sepsis, few have compared qSOFA and SIRS to the widely used National Early Warning Score (NEWS). METHODS This was a retrospective cohort study carried out in a UK tertiary centre. The study population comprised emergency admissions in whom sepsis was suspected and treated. The accuracy for predicting inhospital mortality and ICU admission was calculated and compared for qSOFA, SIRS and NEWS. RESULTS Among 1818 patients, 53 were admitted to ICU (3%) and 265 died in hospital (15%). For predicting inhospital mortality, the area under the receiver operating characteristics curve for NEWS (0.65, 95% CI 0.61 to 0.68) was similar to qSOFA (0.62, 95% CI 0.59 to 0.66) (test for difference, P=0.18) and superior to SIRS (P<0.001), which was not predictive. The sensitivity of NEWS≥5 (74%, 95% CI 68% to 79%) was similar to SIRS≥2 (80%, 95% CI 74% to 84%) and higher than qSOFA≥2 (37%, 95% CI 31% to 43%). The specificity of NEWS≥5 (43%, 95% CI 41% to 46%) was higher than SIRS≥2 (21%, 95% CI 19% to 23%) and lower than qSOFA≥2 (79%, 95% CI 77% to 81%). The negative predictive value was 88% (86%-90%) for qSOFA, 86% (82%-89%) for SIRS and 91% (88%-93%) for NEWS. Results were similar for the secondary outcome of ICU admission. CONCLUSION NEWS has equivalent or superior value for most test characteristics relative to SIRS and qSOFA, calling into question the rationale of adopting qSOFA in institutions where NEWS is already in use.
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Affiliation(s)
- Robert Goulden
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Marie-Claire Hoyle
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Jessie Monis
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Darran Railton
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Victoria Riley
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Paul Martin
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Reynaldo Martina
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Emmanuel Nsutebu
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
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Shetty A, Macdonald SP, Keijzers G, Williams JM, Tang B, de Groot B, Thompson K, Fraser JF, Finfer S, Bellomo R, Iredell J. Review article: Sepsis in the emergency department - Part 2: Investigations and monitoring. Emerg Med Australas 2018; 30:4-12. [PMID: 29341498 DOI: 10.1111/1742-6723.12924] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 12/14/2022]
Abstract
Sepsis is characterised by organ dysfunction resulting from infection, with no reliable single objective test and current diagnosis based on clinical features and results of investigations. In the ED, investigations may be conducted to diagnose infection as the cause of the presenting illness, identify the source, distinguish sepsis from uncomplicated infection (i.e. without organ dysfunction) and/ or risk stratification. Appropriate sample collection for microbiological testing remains key for subsequent confirmation of diagnosis and rationalisation of antimicrobials. Routine laboratory investigations such as creatinine, bilirubin, platelet count and lactate are now critical elements in the diagnosis of sepsis and septic shock. With no biomarker sufficiently validated to rule out bacterial infection in the ED, there remains substantial interest in biomarkers representing various pathogenic pathways. New technologies for screening multiple genes and proteins are identifying unique network 'signatures' of clinical interest. Other future directions include rapid detection of bacterial DNA in blood, genes for antibiotic resistance and EMR-based computational biomarkers that collate multiple information sources. Reliable, cost-effective tests, validated in the ED to promptly and accurately identify sepsis, and to guide initial antibiotic choices, are important goals of current research efforts.
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Affiliation(s)
- Amith Shetty
- Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Pj Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Gerben Keijzers
- School of Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Julian M Williams
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Benjamin Tang
- Immunology Department, Westmead Millennium Institute for Medical Research, Sydney, New South Wales, Australia.,Nepean Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Kelly Thompson
- Critical Care and Trauma Division, George Institute for Global Health, Sydney, New South Wales, Australia
| | - John F Fraser
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
| | - Simon Finfer
- Division of Critical Care, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Iredell
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Infectious Diseases, Westmead Hospital, Western Sydney Local Health District, Sydney, New South Wales, Australia.,Institute of Clinical Pathology and Medical Research, Pathology West, Sydney, New South Wales, Australia
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Macdonald SP, Williams JM, Shetty A, Bellomo R, Finfer S, Shapiro N, Keijzers G. Review article: Sepsis in the emergency department - Part 1: Definitions and outcomes. Emerg Med Australas 2017; 29:619-625. [PMID: 29094474 DOI: 10.1111/1742-6723.12886] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 09/19/2017] [Indexed: 01/21/2023]
Abstract
Sepsis has recently been redefined as acute organ dysfunction due to infection. The ED plays a critical role in identifying patients with sepsis. This is challenging due to the heterogeneity of the syndrome, and the lack of an objective standard diagnostic test. While overall mortality rates from sepsis appear to be falling, there is an increasing burden of morbidity among survivors. This largely reflects the growing proportion of older patients with comorbid illnesses among those treated for sepsis.
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Affiliation(s)
- Stephen Pj Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Julian M Williams
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Amith Shetty
- Department of Emergency Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Research in Critical Infection, Westmead Millennium Institute, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Simon Finfer
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nathan Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Centre, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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de Groot B, Stolwijk F, Warmerdam M, Lucke JA, Singh GK, Abbas M, Mooijaart SP, Ansems A, Esteve Cuevas L, Rijpsma D. The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study. Scand J Trauma Resusc Emerg Med 2017; 25:91. [PMID: 28893325 PMCID: PMC5594503 DOI: 10.1186/s13049-017-0436-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (<70 years). Methods This was an observational multi-centre study using an existing database in which ED patients who were hospitalized with a suspected infection were prospectively included. Patients were stratified by age < 70 and ≥70 years. We assessed the association with in-hospital mortality (primary outcome) and the area under the curve (AUC) with receiver operator characteristics of the Predisposition, Infection, Response, Organ dysfunction (PIRO), quick Sequential Organ Failure Assessment (qSOFA), Mortality in ED Sepsis (MEDS), and the Modified and National Early Warning (MEWS and NEWS) scores. Results In-hospital mortality was 9.5% ((95%-CI); 7.4–11.5) in the 783 included older patients, and 4.6% (3.6–5.7) in the 1497 included younger patients. In contrast to younger patients, disease severity scores in older patients associated poorly with mortality. The AUCs of all disease severity scores were poor and ranged from 0.56 to 0.64 in older patients, significantly lower than the good AUC range from 0.72 to 0.86 in younger patients. The MEDS had the best AUC (0.64 (0.57–0.71)) in older patients. In older and younger patients, the newly proposed qSOFA score (Sepsis 3.0) had a lower AUC than the PIRO score (sepsis 2.0). Conclusion The prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients. Electronic supplementary material The online version of this article (10.1186/s13049-017-0436-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bas de Groot
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands.
| | - Frank Stolwijk
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Mats Warmerdam
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Jacinta A Lucke
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Gurpreet K Singh
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Mo Abbas
- Department of emergency medicine, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Albinusdreef 2, 2300, RC, Leiden, The Netherlands.,Institute for Evidence-based Medicine in Old Age
- IEMO, Albinusdreef 2, 2300, RC, Leiden, The Netherlands
| | - Annemieke Ansems
- Department of emergency medicine, Albert Schweitzer Ziekenhuis, Albert Schweitzerplaats 25, 3318, AT, Dordrecht, the Netherlands
| | - Laura Esteve Cuevas
- Department of emergency medicine, Albert Schweitzer Ziekenhuis, Albert Schweitzerplaats 25, 3318, AT, Dordrecht, the Netherlands
| | - Douwe Rijpsma
- Department of emergency medicine, Rijnstate Ziekenhuis, Wagnerlaan 55, 6815, AD, Arnhem, the Netherlands
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GYM score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection. Eur J Emerg Med 2017; 24:183-188. [DOI: 10.1097/mej.0000000000000321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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57
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Ríos-Toro JJ, Márquez-Coello M, García-Álvarez JM, Martín-Aspas A, Rivera-Fernández R, Sáez de Benito A, Girón-González JA. Soluble membrane receptors, interleukin 6, procalcitonin and C reactive protein as prognostic markers in patients with severe sepsis and septic shock. PLoS One 2017; 12:e0175254. [PMID: 28380034 PMCID: PMC5381948 DOI: 10.1371/journal.pone.0175254] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/22/2017] [Indexed: 02/06/2023] Open
Abstract
Background The objective of this study was to explore the diagnostic and prognostic value of soluble triggering receptor expressed on myeloid cell 1 (sTREM-1), soluble cluster of differentiation 14 (sCD14), soluble cluster of differentiation 163 (sCD163), interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) serum levels for patients with severe sepsis and septic shock in an intensive care unit (ICU). Methods Fifty patients admitted at the ICU with the diagnosis of severe sepsis or septic shock were studied. SOFA and APACHE II scores as well as serum biomarkers were measured at days 0, 2 and 5. The influence of these variables on 28-day mortality was analyzed. Twenty healthy individuals served as controls. Results Baseline serum concentrations of sTREM-1, sCD163, IL-6 and PCT correlated with SOFA score. Only sTREM-1 levels correlated with APACHE II score. The 28-day mortality rate for all patients was 42%. The absence of risk factors for infection, presence of septic shock, baseline values of sCD14 and decrease of PCT and IL-6 from baseline to day 5 were variables associated to mortality in the univariate analysis. The unique independent factor associated to mortality in the multivariate analysis was a decrease of PCT higher than 50% from days 0 to 5. Conclusions Serum levels of sTREM-1 are correlated with the severity of sepsis. A 50% decrease of PCT was the unique variable associated with survival in the multivariate analysis.
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Affiliation(s)
| | - Mercedes Márquez-Coello
- Infectious Unit, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | | | - Andrés Martín-Aspas
- Infectious Unit, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | | | - Ana Sáez de Benito
- Biochemistry, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - José-Antonio Girón-González
- Infectious Unit, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
- * E-mail:
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Schleicher J, Conrad T, Gustafsson M, Cedersund G, Guthke R, Linde J. Facing the challenges of multiscale modelling of bacterial and fungal pathogen-host interactions. Brief Funct Genomics 2017; 16:57-69. [PMID: 26857943 PMCID: PMC5439285 DOI: 10.1093/bfgp/elv064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent and rapidly evolving progress on high-throughput measurement techniques and computational performance has led to the emergence of new disciplines, such as systems medicine and translational systems biology. At the core of these disciplines lies the desire to produce multiscale models: mathematical models that integrate multiple scales of biological organization, ranging from molecular, cellular and tissue models to organ, whole-organism and population scale models. Using such models, hypotheses can systematically be tested. In this review, we present state-of-the-art multiscale modelling of bacterial and fungal infections, considering both the pathogen and host as well as their interaction. Multiscale modelling of the interactions of bacteria, especially Mycobacterium tuberculosis, with the human host is quite advanced. In contrast, models for fungal infections are still in their infancy, in particular regarding infections with the most important human pathogenic fungi, Candida albicans and Aspergillus fumigatus. We reflect on the current availability of computational approaches for multiscale modelling of host-pathogen interactions and point out current challenges. Finally, we provide an outlook for future requirements of multiscale modelling.
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Affiliation(s)
| | | | | | | | | | - Jörg Linde
- Corresponding author: Jörg Linde, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany. Tel.: +49-3641-532-1290; E-mail:
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Li L, Hu B, Gong S, Yu Y, Yan J. Age and cigarette smoking modulate the relationship between pulmonary function and arterial stiffness in heart failure patients. Medicine (Baltimore) 2017; 96:e6262. [PMID: 28272233 PMCID: PMC5348181 DOI: 10.1097/md.0000000000006262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The aim of this study was to assess the relationship between arterial stiffness and pulmonary function in chronic heart failure (CHF).Outpatients previously diagnosed as CHF were enrolled between April 2008 and March 2010, and submitted to arterial stiffness measurement and lung function assessment. Spirometry was performed by measuring forced vital capacity (FVC), the fraction of predicted FVC, forced expiratory volume in 1 second (FEV1), the percentage of predicted FEV1 in 1 second, FEV1 to FVC ratio, and the percentage of predicted FEV1/FVC. Cardio-ankle vascular index (CAVI) was considered for the estimation of arterial stiffness.The 354 patients assessed included 315 nonsmokers, and were 68.2 ± 7.2 years' old. Unadjusted correlation analyses demonstrated CAVI was positively related to age (r = 0.3664, P < 0.0001), and negatively related to body mass index (BMI, r = -0.2040, P = 0.0001), E/A ratio (r = -0.1759, P = 0.0010), and FEV1 (r = -0.2987, P < 0.0001). Stepwise multivariate regression analyses showed age (r = 0.2391, P < 0.0001), BMI (r = -0.2139, P < 0.0001), smoking (r = 0.1211, P = 0.0130), E/A ratio (r = -0.1082, P = 0.0386), and FEV1 (r = -0.2550, P < 0.0001) were independent determinants of CAVI. In addition, there is a significant interaction between CAVI and forced expiratory volume in 1 second (FEV1) in relation to age (Pint < 0.0001) and smoking (Pint = 0.0001). Meanwhile, pulmonary function was not associated with BMI or E/A ratio.These findings demonstrated that reduced pulmonary function is associated with the increased CAVI, and had an interactive effect with age and smoking on CAVI in patients with CHF.
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Affiliation(s)
- Li Li
- Intensive Care Unit and Zheiiang Provincial Key Laboratory of Geriatrics, Zhejiang Hospital
| | - Bangchuan Hu
- Intensive Care Unit, Zhejiang Provincial People's Hospital, Hangzhou 310014, China
| | - Shijin Gong
- Intensive Care Unit and Zheiiang Provincial Key Laboratory of Geriatrics, Zhejiang Hospital
| | - Yihua Yu
- Intensive Care Unit and Zheiiang Provincial Key Laboratory of Geriatrics, Zhejiang Hospital
| | - Jing Yan
- Intensive Care Unit and Zheiiang Provincial Key Laboratory of Geriatrics, Zhejiang Hospital
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Gunes Ozaydin M, Guneysel O, Saridogan F, Ozaydin V. Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department? Turk J Emerg Med 2016; 17:25-28. [PMID: 28345070 PMCID: PMC5357089 DOI: 10.1016/j.tjem.2016.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/26/2016] [Accepted: 09/29/2016] [Indexed: 01/31/2023] Open
Abstract
Objectives Scoring systems have been used to risk stratify in intensive care units (ICU), but not routinely used in emergency departments. The aim of this study was to determine accuracy for predicting mortality in emergency medicine with Sequential Organ Failure Assessment (SOFA), Mortality in ED Sepsis (MEDS) score and Simplified Acute Physiology Score (SAPSII). Methods This is a prospective observational study. Patients presenting with evidence of sepsis were all included. SAPSII, MEDS, and SOFA scores were calculated. Analysis compared areas under the receiver operator characteristic (ROC) curves for 28-day mortality. Results Two hundred patients were included; consisting of 31 (14.3%) septic shock. 138 (69%) severe sepsis and 31 (15.5%) infection without organ dysfunction. 53 (26.5%) patients died within 28 days. Area under the ROC curve for mortality was 0.76 for MEDS (0.69–0.82), 0.70 for SAPSII (0.62–0.78); and 1.68 for SOFA (0.60–0.76) scores. Pair wise comparison of AUC between MEDS, SAPSII, SOFA and Lactate were not significant. Conclusion According to our results; SOFA, SAPSII and MEDS were not sufficient to predict mortality. Also this result, MEDS was better than other scoring system.
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Affiliation(s)
| | - Ozlem Guneysel
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Fatma Saridogan
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Vehbi Ozaydin
- Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
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Magnussen B, Oren Gradel K, Gorm Jensen T, Kolmos HJ, Pedersen C, Just Vinholt P, Touborg Lassen A. Association between Hypoalbuminaemia and Mortality in Patients with Community-Acquired Bacteraemia Is Primarily Related to Acute Disorders. PLoS One 2016; 11:e0160466. [PMID: 27611431 PMCID: PMC5017704 DOI: 10.1371/journal.pone.0160466] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 07/19/2016] [Indexed: 12/25/2022] Open
Abstract
We sought to investigate whether hypoalbuminaemia was mainly caused by acute or chronic factors in patients with community-acquired bacteraemia. In this population-based study, we considered 1844 adult cases of community-acquired bacteraemia that occurred in Funen, Denmark between 2000 and 2008. We used a stepwise prognostic predisposition-insult-response-organ dysfunction (PIRO) logistic regression model by initially including age and comorbidity, then added bacterial species, and finally sepsis severity. The models were furthermore analysed using receiver operating characteristic (ROC) curves. Outcomes comprised mortality incidence on days 0-30 and 31-365 after the bacteraemia episode. Each step was performed with and without baseline albumin level measured on the date of bacteraemia. In 422 patients, their latest albumin measurement taken 8-30 days before the date of bacteraemia was also used in the analysis together with the baseline albumin level. For each decrease of 1g/L in plasma albumin level, the odds ratios (95% confidence intervals) of mortality in the period of 0-30 days after bacteraemia were 0.86 (0.84-0.88) in both predisposition (P) and predisposition-insult (PI) models and 0.87 (0.85-0.89) in the full PIRO-model. The AUC values were 0.78 and 0.66 for mortality in the period of 0-30 days in the model comprising only predisposition factors with and without albumin levels added as a factor, respectively. The AUC values in the full PIRO-model were 0.81 and 0.73 with and without consideration of albumin levels, respectively. A higher proportion of patients died within 30 days if there was a decrease in the albumin level between days 8 and 30 before bacteraemia and the actual bacteraemia date. A single plasma albumin measurement on the bacteraemia date was a better prognostic predictor of short-term mortality than the sepsis severity score.
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Affiliation(s)
- Bjarne Magnussen
- Center for Clinical Epidemiology, South, Odense University Hospital, Sdr. Boulevard 29, entrance 101, 4th floor, 5000, Odense C, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, entrance 101, 4th floor, 5000, Odense C, Denmark
- * E-mail:
| | - Kim Oren Gradel
- Center for Clinical Epidemiology, South, Odense University Hospital, Sdr. Boulevard 29, entrance 101, 4th floor, 5000, Odense C, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, entrance 101, 4th floor, 5000, Odense C, Denmark
| | - Thøger Gorm Jensen
- Department of Clinical Microbiology, Odense University Hospital, J.B. Winsloews Vej 21, 2nd floor, 5000, Odense C, Denmark
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, J.B. Winsloews Vej 21, 2nd floor, 5000, Odense C, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Sdr. Boulevard 29, entrance 20, 5000, Odense C, Denmark
| | - Pernille Just Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Sdr. Boulevard 29, entrance 40, 5000, Odense C, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Kløvervænget 25, entrance 63-65, 5000, Odense C, Denmark
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Zhang Z, Smischney NJ, Zhang H, Van Poucke S, Tsirigotis P, Rello J, Honore PM, Sen Kuan W, Ray JJ, Zhou J, Shang Y, Yu Y, Jung C, Robba C, Taccone FS, Caironi P, Grimaldi D, Hofer S, Dimopoulos G, Leone M, Hong SB, Bahloul M, Argaud L, Kim WY, Spapen HD, Rocco JR. AME evidence series 001-The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital. J Thorac Dis 2016; 8:2654-2665. [PMID: 27747021 PMCID: PMC5059246 DOI: 10.21037/jtd.2016.08.03] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sepsis is a heterogeneous disease caused by an infection stimulus that triggers several complex local and systemic immuno-inflammatory reactions, which results in multiple organ dysfunction and significant morbidity and mortality. The diagnosis of sepsis is challenging because there is no gold standard for diagnosis. As a result, the clinical diagnosis of sepsis is ever changing to meet the clinical and research requirements. Moreover, although there are many novel biomarkers and screening tools for predicting the risk of sepsis, the diagnostic performance and effectiveness of these measures are less than satisfactory, and there is insufficient evidence to recommend clinical use of these new techniques. As a consequence, diagnostic criteria for sepsis need regular revision to cope with emerging evidence. This review aims to present the most updated information on diagnosis and early recognition of sepsis. Recommendations for clinical use of different diagnostic tools rely on the Grades of Recommendation Assessment, Development and Evaluation (GRADE) framework. Because most of the studies were observational and did not allow a reliable assessment of these tools, a two-step inference approach was employed. Future trials need to confirm or refute a particular index test and should directly explore relevant patient outcome parameters.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- Department of Critical Care Medicine, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | | | - Haibo Zhang
- Keenan Research Center for Biomedical Science of St. Michael’s Hospital, Departments of Anesthesia and Physiology, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Sven Van Poucke
- Departments of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Vall d’Hebron Institut of Research, Universitat Autonoma de Barcelona, Spain
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore and the Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Juliet June Ray
- DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Jiancang Zhou
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical Collegue, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - David Grimaldi
- Intensive Care Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Herbert D. Spapen
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Jose Rodolfo Rocco
- Department of Internal Medicine and Post-graduated Program, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Prucha M, Zazula R, Russwurm S. Immunotherapy of Sepsis: Blind Alley or Call for Personalized Assessment? Arch Immunol Ther Exp (Warsz) 2016; 65:37-49. [PMID: 27554587 DOI: 10.1007/s00005-016-0415-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/14/2016] [Indexed: 01/20/2023]
Abstract
Sepsis is the most frequent cause of death in noncoronary intensive care units. In the past 10 years, progress has been made in the early identification of septic patients and their treatment. These improvements in support and therapy mean that mortality is gradually decreasing, however, the rate of death from sepsis remains unacceptably high. Immunotherapy is not currently part of the routine treatment of sepsis. Despite experimental successes, the administration of agents to block the effect of sepsis mediators failed to show evidence for improved outcome in a multitude of clinical trials. The following survey summarizes the current knowledge and results of clinical trials on the immunotherapy of sepsis and describes the limitations of our knowledge of the pathogenesis of sepsis. Administration of immunomodulatory drugs should be linked to the current immune status assessed by both clinical and molecular patterns. Thus, a careful daily review of the patient's immune status needs to be introduced into routine clinical practice giving the opportunity for effective and tailored use of immunomodulatory therapy.
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Affiliation(s)
- Miroslav Prucha
- Department of Clinical Biochemistry, Hematology and Immunology, Hospital Na Homolce, Prague, Czech Republic.
| | - Roman Zazula
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and Thomayer Hospital, Prague, Czech Republic
| | - Stefan Russwurm
- Department of Anesthesiology and Intensive Care, University Hospital, Jena, Germany
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Validation of the anatomic severity score developed by the American Association for the Surgery of Trauma in small bowel obstruction. J Surg Res 2016; 204:428-434. [DOI: 10.1016/j.jss.2016.04.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 03/14/2016] [Accepted: 04/29/2016] [Indexed: 12/31/2022]
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Abstract
Waning immunity and declining anatomic and physiologic defenses render the elder vulnerable to a wide range of infectious diseases. Clinical presentations are often atypical and muted, favoring global changes in mental status and function over febrile responses or localizing symptoms. This review encompasses early recognition, evaluation, and appropriate management of these common infections specifically in the context of elders presenting to the emergency department. With enhanced understanding and appreciation of the unique aspects of infections in the elderly, emergency physicians can play an integral part in reducing the morbidity and mortality associated with these often debilitating and life-threatening diseases.
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Affiliation(s)
- Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO 63110, USA; Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St Louis, MO 63110, USA.
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67
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McConachie E, Giguère S, Barton MH. Scoring System for Multiple Organ Dysfunction in Adult Horses with Acute Surgical Gastrointestinal Disease. J Vet Intern Med 2016; 30:1276-83. [PMID: 27296454 PMCID: PMC5094519 DOI: 10.1111/jvim.14321] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 03/04/2016] [Accepted: 05/09/2016] [Indexed: 01/28/2023] Open
Abstract
Background The prevalence of multiple organ dysfunction syndrome (MODS) in horses with acute surgical gastrointestinal (GI) disease is unknown. Currently, there are no validated criteria to confirm MODS in adult horses. Objectives To develop criteria for a MODS score for horses with acute surgical colic (MODS SGI) and evaluate the association with 6‐month survival. To compare the MODS SGI score with a MODS score extrapolated from criteria used in people (MODS EQ). Animals Adult horses that required exploratory laparotomy (n = 62) for colic. Healthy adult horses undergoing elective surgical procedures (n = 12) established the reference range of some variables. Methods Prospectively, a MODS SGI score was developed based on organ‐specific criteria established from a literature review, data collection, and clinical judgment. Data for scoring each horse were collected on Days 1 and 2 postoperatively. Horses were scored retrospectively using both scoring criteria. The prognostic performance of the MODS SGI score and its overall performance compared with the MODS EQ score were assessed with receiver operating characteristic (ROC) curve analysis. Results The MODS SGI score had excellent performance for predicting 6‐month survival with an area under the ROC curve (AUC) of 0.95 (95% CI: 0.87–0.99). The AUC for the MODS SGI score was significantly higher than the MODS EQ (AUC: 0.76; 0.63–0.86). Conclusions and Clinical Importance The MODS SGI score predicts 6‐month survival from discharge in horses with acute surgical colic. The MODS SGI score performed better than a score extrapolated from human scoring systems.
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Affiliation(s)
- E McConachie
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - S Giguère
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - M H Barton
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA
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Cardiac Troponin Is a Predictor of Septic Shock Mortality in Cancer Patients in an Emergency Department: A Retrospective Cohort Study. PLoS One 2016; 11:e0153492. [PMID: 27077648 PMCID: PMC4831781 DOI: 10.1371/journal.pone.0153492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/30/2016] [Indexed: 12/27/2022] Open
Abstract
Background Septic shock may be associated with myocardial damage; however, the prognostic value of cardiac enzymes in cancer patients with septic shock is unknown. In this study, we evaluated the prognostic significance of cardiac enzymes in combination with established prognostic factors in predicting the 7-day mortality rate of patients with septic shock, and we constructed a new scoring system, Septic Oncologic Patients in Emergency Department (SOPED), which includes cardiac enzymes, to predict 7-day mortality rates. Methods and Findings We performed a retrospective cohort study of 375 adult cancer patients with septic shock who visited the emergency department of a comprehensive cancer center between 01/01/2004 and 12/31/2013. The 7-day and 28-day mortality rates were 19.7% and 37.6%, respectively. The creatine kinase myocardial band fraction and troponin-I were significantly higher in patients who died in ≤7 days and ≤28 days than in those who did not. In Cox regression models, troponin-I >0.05 ng/mL plus Predisposition, Infection, Response, and Organ Failure (PIRO2011) or Mortality in Emergency Department Sepsis (MEDS) score was a significant predictor of survival for ≤7 days. With our new SOPED scoring system, the receiver operating characteristic area under the curve was 0.836, higher than those for PIRO2011 and MEDS. Conclusions Troponin-I >0.05 ng/mL was an important predictor of short-term mortality (≤7 days). The SOPED scoring system, which incorporated troponin-I, was more prognostically accurate than were other scores for 7-day mortality. Large multicenter studies are needed to verify our results and prospectively validate the prognostic performance of the SOPED score.
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McCormack D, Ruderman A, Menges W, Kulkarni M, Murano T, Keller SE. Usefulness of the Mortality in Severe Sepsis in the Emergency Department score in an urban tertiary care hospital. Am J Emerg Med 2016; 34:1117-20. [PMID: 27061500 DOI: 10.1016/j.ajem.2016.03.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Mortality in Severe Sepsis in the Emergency Department (MISSED) score is a newly proposed scoring system. The goal of this study is to determine if the MISSED score is generalizable to an urban tertiary care hospital. METHODS This is a retrospective chart review conducted from July 2012 to June 2014. Inclusion criteria consisted of adult emergency department (ED) patients with severe sepsis, defined as lactate level 4mmol/L or greater. Demographics, lactate, international normalized ratio (INR), albumin, intensive care unit admission, and ED intubation were analyzed using χ(2) test, t test, and logistic regression. The MISSED score was calculated using the variables albumin 27g/L or less, INR 1.3 or greater, and age 65years or older and analyzed using the area under the curve. The primary outcome was inhospital mortality. RESULTS A total of 182 patients met inclusion criteria, and mortality was 32%. Patients in the mortality group had older age (58.1±17.2 vs 62.7±14.7; P=.07), higher lactate (5.9±2.7 vs 7.3±3.1; P<.01), lower albumin (34.3±8.3 vs 25.6±7.1; P<.0001), higher INR (1.4±0.6 vs 2.4±1.9; P<.0001), ED intubation (21% vs 56%; P<.0001), and intensive care unit admission (41% vs 78%; P<.0001). The regression model found that albumin of 27g/L or less (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.05-3.36), INR 1.3 or greater (OR, 8.3; 95% CI, 3.35-20.51), and ED intubation (OR, 5.6; 95% CI, 2.56-12.35) predicted mortality. The area under the curve for the MISSED score was 0.78 (95% CI, 0.73-0.85). CONCLUSION The MISSED score is useful for predicting mortality in ED patients with severe sepsis.
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Affiliation(s)
- Denise McCormack
- Department of Emergency Medicine, Rutgers University-New Jersey Medical School, Newark, NJ 07103.
| | - Avi Ruderman
- Department of Emergency Medicine, Rutgers University-New Jersey Medical School, Newark, NJ 07103.
| | - William Menges
- Rutgers University-School of Biomedical Sciences, Newark, NJ 07103.
| | - Miriam Kulkarni
- Department of Emergency Medicine, Rutgers University-New Jersey Medical School, Newark, NJ 07103.
| | - Tiffany Murano
- Department of Emergency Medicine, Rutgers University-New Jersey Medical School, Newark, NJ 07103.
| | - Steven E Keller
- Rutgers University-New Jersey Medical School, 183 South Orange Avenue Room E 1536, Newark, NJ 07103.
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Liu X, Ji W, Wang J, Pan T. Application strategy of PiCCO in septic shock patients. Exp Ther Med 2016; 11:1335-1339. [PMID: 27073445 PMCID: PMC4812159 DOI: 10.3892/etm.2016.3040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/29/2016] [Indexed: 12/14/2022] Open
Abstract
Septic shock, also known as infectious or toxic shock, is a medical condition caused by severe infection and sepsis. Early identification, timely diagnosis and effective treatments are imperative to prevent this medical condition. The aim of the present study was to examine the application of pulse index continuous cardiac output (PiCCO) technique in the treatment of septic shock patients. Fifty septic shock patients were randomly divided into the conventional detection group (group C, n=25) and the PiCCO detection group (group P, n=25). A central venous catheter and radial artery catheter were placed into the patients of group C and a central venous catheter and PiCCO catheter (through femoral artery) were placed in the patients of group P to detect haemodynamics, which was managed and treated according to early goal-directed therapy (EGDT). PiCCO was applied to monitor and guide the application of fluid resuscitation, vasoconstriction drugs (dopamine) and positive inotropic drugs (dobutamine). The EGDT qualified rate of patients from the two groups at the 6th h of treatment, changes of post-resuscitation relevant parameters [blood lactate level, central venous oxygen saturation (ScvO2), central venous pressure (CVP), mean arterial pressure (MAP) and urine volume], positive fluid balance quantity and the dosage of dopamine and dobutamine at the 6th, 24th and 48th h were observed. In comparison to group C, group P showed an increase in the EGDT qualified rate and ScvO2 at the 6th h of treatment while the blood lactate level was decreased. The positive fluid balance quantity at the 6th and 24th h and the dosage of dobutamine were increased while the dosage of dopamine was reduced (P<0.05). There was no statistical significance in terms of the differences of positive fluid balance quantity and the dosage of dopamine and dobutamine in the two groups at the 48th h of treatment (P>0.05). There was also no statistical significance in terms of the differences of CVP, MAP and urine volume in the two groups (P>0.05). In conclusion, under the monitoring and guidance of the PiCCO technique, EGDT treatment should be applied to septic shock patients together with early fluid resuscitation and positive inotropic drugs instead of using only vasoconstriction drug, which cause elevation of blood pressure.
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Affiliation(s)
- Xiaoyun Liu
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Wenli Ji
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Jifeng Wang
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Tao Pan
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
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Hifumi T, Fujishima S, Abe T, Kiriu N, Inoue J, Kato H, Koido Y, Kawakita K, Kuroda Y, Sasaki J, Hori S. Prognostic factors of Streptococcus pneumoniae infection in adults. Am J Emerg Med 2015; 34:202-6. [PMID: 26508390 DOI: 10.1016/j.ajem.2015.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/10/2015] [Accepted: 10/13/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The mortality of severe sepsis has markedly decreased since the implementation of the Surviving Sepsis Campaign guidelines. The next logical step is to examine the necessity of individualized management guidelines for targeted therapy against specific bacteria. Streptococcus pneumoniae is the leading cause of community-acquired severe sepsis; however, little is known regarding the prognostic factors in adult patients with S pneumoniae sepsis. We aimed to identify prognostic factors in patients with S pneumoniae sepsis and to explore a subgroup of patients at high risk for death with detailed Sequential Organ Failure Assessment (SOFA) score analysis. METHODS We retrospectively reviewed the records of patients with S pneumoniae infection treated between 1st January 2006 and 31st July 2012. We identified prognostic factors for 28-day mortality using univariate and multivariate logistic regression models. RESULTS Of 171 patients (median age, 72 years) with S pneumoniae infection who were included in this study, the 28-day mortality was 17% (29/171). The SOFA score (odds ratio, 2.25; 95% confidence interval, 1.60-3.18; P < .001) and bacteremia (odds ratio, 19.0; 95% confidence interval, 4.06-90.20; P < .001) were identified as prognostic factors for the 28-day mortality. In a subgroup analysis with a cutoff value of the SOFA score determined by receiver operating characteristic analysis, patients with bacteremia and a SOFA score of at least 7 had a significantly higher mortality than did patients without bacteremia and a SOFA score lower than 7 (84% vs 0%, respectively). CONCLUSIONS Bacteremia and a SOFA score at least 7 were independent prognostic factors of poor outcome in S pneumoniae sepsis.
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Affiliation(s)
- Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan.
| | - Seitaro Fujishima
- Center for General Internal Medicine and Education, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Takayuki Abe
- Center for Clinical Research, Department of Preventive Medicine and Public Health, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nobuaki Kiriu
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Junichi Inoue
- Division of Critical Care Medicine and Trauma, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan
| | - Hiroshi Kato
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Yuichi Koido
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan
| | - Junichi Sasaki
- Department of Emergency Medicine and Critical Care Medicine, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Shingo Hori
- Department of Emergency Medicine and Critical Care Medicine, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Although there is abundant literature detailing the impact of quality improvement in adult sepsis, the pediatric literature is lacking. Despite consensus definitions for sepsis, which patients along the sepsis spectrum should receive aggressive management and the exact onset of sepsis ('time zero') are not clearly established. In the adult emergency department (ED), sepsis onset is defined as the time of entry into the ED; however, this definition cannot be applied to hospitalized patients or patients who evolve during their ED course. Since the time of sepsis onset will dictate the timeliness of subsequent process measures, the variable definitions in the literature make it difficult to generalize findings among prior studies. RECENT FINDINGS Despite the variation in defining time zero, aggressive fluid administration, timely antibiotics, and compliance with sepsis bundles have been shown to improve mortality and to reduce hospital and intensive care length of stay. In addition, early identification tools show promise in beginning to define sepsis onset and retrospective search tools may allow improved case finding of those children of concern for sepsis. SUMMARY Quality improvement in pediatric sepsis is evolving. As we continue to define quality measures, we must standardize the definition of sepsis onset. This definition should be applicable to any treatment venue to ensure measures can be evaluated across all settings. In addition, we must delineate which patients along the sepsis spectrum should be candidates for timely interventions and standardize other outcome measures beyond mortality.
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Feng B, Mao ZR, Pang K, Zhang SL, Li L. Association of tumor necrosis factor α -308G/A and interleukin-6 -174G/C gene polymorphism with pneumonia-induced sepsis. J Crit Care 2015; 30:920-3. [PMID: 26025100 DOI: 10.1016/j.jcrc.2015.04.123] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/20/2015] [Accepted: 04/29/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE Sepsis is a lethal outcome of the inflammation and coagulation process. Human interleukin (IL)-6 and tumor necrosis factor (TNF) α are well-known inflammation factors closely associated with sepsis. In the present study, we aim to investigate the association of promoter-region polymorphisms IL-6 (-174G/C) rs1800795 and TNF-α (-308G/A) rs1800629 with pneumonia-induced sepsis. MATERIALS AND METHODS A total of 277 Chinese patients with severe pneumonia-induced sepsis were recruited into this study. All study participants were admitted to the intensive care unit until discharge or death in the First Affiliated Hospital of Zhengzhou University from July 2010 to July 2014. The patients were classified as severely septic, septic shock, and mortality. Clinical data and demographic information were recorded. TaqMan genotyping was performed to detect single nucleotide polymorphism distribution. RESULTS The genotype results demonstrated that carriers of the TNF-α rs1800629 A allele had a 4.28-fold higher risk for septic shock (adjusted odds ratio [OR], 4.28; 95% confidence interval [CI], 2.24-8.18; P < .01) compared with severe sepsis, and carriers of the IL-6 rs1800795 C allele had a 2.42-fold higher risk for septic shock (OR, 2.42; 95% CI, 1.08-5.45; P < .01) compared with severe sepsis. No significant difference of SNP distribution was found between the survivors and the nonsurvivors. After the results were adjusted for age and the outcomes of blood cultures, a multivariate logistic regression analysis showed similar results. Individuals with the TNF-α 308 rs1800629 A allele (adjusted OR, 2.96; 95% CI, 1.30-7.87) or the IL-6 rs1800795 C allele (adjusted OR, 1.87; 95% CI, 1.03-3.61) had a higher prevalence of septic shock. However, these SNP distribution differences were not associated with mortality. CONCLUSIONS In intensive care unit patients, the TNF-α -308A allele and the IL-6 rs1800795 allele variants were susceptibility risk factors for septic shock induced by pneumonia.
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Affiliation(s)
- Bo Feng
- Department of Emergency Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China; Department of Intensive Care Unit, The First Affiliated Hospital of Henan University of TCM, Zhengzhou, PR China
| | - Zheng-rong Mao
- Department of Intensive Care Unit, The First Affiliated Hospital of Henan University of TCM, Zhengzhou, PR China
| | - Kai Pang
- Department of Intensive Care Unit, The First Affiliated Hospital of Henan University of TCM, Zhengzhou, PR China
| | - Shao-lei Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Henan University of TCM, Zhengzhou, PR China
| | - Li Li
- Department of Emergency Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China.
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Chen K, Zhou QX, Shan HW, Li WF, Lin ZF. Prognostic value of CD4(+)CD25(+) Tregs as a valuable biomarker for patients with sepsis in ICU. World J Emerg Med 2015; 6:40-3. [PMID: 25802565 DOI: 10.5847/wjem.j.1920-8642.2015.01.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/10/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Sepsis is a common complication of infections, burns, traumas, surgeries, poisonings, and post-cardiopulmonary resuscitation. The present study aimed to investigate prognostic value of CD4(+)CD25(+) regulatory T cells (Treg) in peripheral blood of patients with sepsis. METHODS Periphery blood from 28 patients diagnosed with sepsis was collected on day 1 and 7 after hospitalization in the ICU of Shanghai Changzheng Hospital between December 2013 to April 2014. The blood was used for analyses of Treg ratio using flow cytometry and for analyses of blood routine test, C-reactive protein (CRP), bilirubin, procalcitonin (PCT), and coagulation. APACHE II and sequential organ failure assessment (SOFA) scores were also investigated. The results were compared between two outcome groups of survival or death to evaluate prognostic value for sepsis. RESULTS The patients had an average age of 60.36±15.03 years, APACHE II score 16.68±7.00, and SOFA score 7.18±3.78. Among the 28 patients, 12 had severe trauma (42.9%), 10 had septic shock (35.7%), and 9 (32.2%) died. The median ratio of Tregs was 2.10% (0.80%, 3.10%) in the survival group vs. 1.80% (1.15%, 3.65%) in the death group (Z=-0.148, P=0.883) on day 1; however it was significantly changed to 0.90% (0.30%, 2.80%) vs. 5.70% (2.60%, 8.30%) (Z=-2.905, P=0.004). CONCLUSION With better prospects for clinical application, dynamic monitoring of Tregs ratio in peripheral blood has potential value in predicting prognosis of sepsis.
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Affiliation(s)
- Kun Chen
- Emergency Department, Changzheng Hospital, Second Military Medical Univercity, Shanghai 200003, China
| | - Qiu-Xiang Zhou
- Emergency Department, Changzheng Hospital, Second Military Medical Univercity, Shanghai 200003, China
| | - Hong-Wei Shan
- Emergency Department, Changzheng Hospital, Second Military Medical Univercity, Shanghai 200003, China
| | - Wen-Fang Li
- Emergency Department, Changzheng Hospital, Second Military Medical Univercity, Shanghai 200003, China
| | - Zhao-Fen Lin
- Emergency Department, Changzheng Hospital, Second Military Medical Univercity, Shanghai 200003, China
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