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Yao H, Zhou Y, Geng Z, Gao F, Su D, Kang Y, Fu B. IMPLICATIONS OF YWHAH GENE EXPRESSION IN THE EARLY DETECTION OF SEPSIS. Shock 2024; 62:357-362. [PMID: 38904460 DOI: 10.1097/shk.0000000000002409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
ABSTRACT Sepsis, a complex and multifaceted condition, is a common occurrence with serious implications for critically ill patients in the intensive care unit (ICU). The YWHAH gene encodes the 14-3-3n protein, a member of the 14-3-3 protein family. While existing research primarily focuses on the role of 14-3-3n in conditions such as schizophrenia and various cancers, our study revealed that the expression of the YWHAH gene remained relatively stable in both infected individuals and healthy controls. Through Venn plot analysis following weighted gene correlation network analysis, we observed a potential association between elevated YWHAH expression and the transition from infection to sepsis. In a comprehensive analysis of public single-cell transcriptome databases, the expression of YWHAH was found to be distinctive in cases of sepsis and infection. These findings were corroborated through an in vitro analysis utilizing real-time polymerase chain reaction. This study represents the initial identification of variations in YWHAH gene expression between patients with infection and sepsis, potentially offering insights for the development of early detection and treatment strategies for sepsis.
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Affiliation(s)
| | - Yue Zhou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhengguang Geng
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fei Gao
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - De Su
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bao Fu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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Visser M, Rossi D, Bouma HR, ter Maaten JC. Exploiting the Features of Clinical Judgment to Improve Assessment of Disease Severity in the Emergency Department: An Acutelines Study. J Clin Med 2024; 13:1359. [PMID: 38592702 PMCID: PMC10931686 DOI: 10.3390/jcm13051359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/18/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Clinical judgment, also known as gestalt or gut feeling, can predict deterioration and can be easily and rapidly obtained. To date, it is unknown what clinical judgement precisely entails. The aim of this study was to elucidate which features define the clinical impression of health care professionals in the ED. METHOD A nominal group technique (NGT) was used to develop a consensus-based instrument to measure the clinical impression score (CIS, scale 1-10) and to identify features associated with either a more severe or less severe estimated disease severity. This single-center observational cohort study included 517 medical patients visiting the ED. The instrument was prospectively validated.. The predictive value of each feature for the clinical impression was assessed using multivariate linear regression analyses to adjust for potential confounders and validated in the infection group. RESULTS The CIS at the ED was associated with ICU admission (OR 1.67 [1.37-2.03], p < 0.001), in-hospital mortality (OR 2.25 [1.33-3.81], p < 0.001), and 28-day mortality (OR 1.33 [1.07-1.65], <0.001). Dry mucous membranes, eye glance, red flags during physical examination, results of arterial blood gas analysis, heart and respiratory rate, oxygen modality, triage urgency, and increased age were associated with a higher estimated disease severity (CIS). On the other hand, behavior of family, self-estimation of the patient, systolic blood pressure, and Glascow Coma Scale were associated with a lower estimated disease severity (CIS). CONCLUSION We identified several features that were associated with the clinical impression of health care professionals in the ED. Translating the subjective features and objective measurements into quantifiable parameters may aid the development of a novel triage tool to identify patients at risk of deterioration in the ED.
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Affiliation(s)
- Martje Visser
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
| | - Daniel Rossi
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
| | - Hjalmar R. Bouma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Jan C. ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
- Department of Aute Care, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
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Rahmatinejad Z, Peiravi S, Hoseini B, Rahmatinejad F, Eslami S, Abu-Hanna A, Reihani H. Comparing In-Hospital Mortality Prediction by Senior Emergency Resident's Judgment and Prognostic Models in the Emergency Department. BIOMED RESEARCH INTERNATIONAL 2023; 2023:6042762. [PMID: 37223337 PMCID: PMC10202605 DOI: 10.1155/2023/6042762] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/26/2022] [Accepted: 10/20/2022] [Indexed: 05/25/2023]
Abstract
Background A comparison of emergency residents' judgments and two derivatives of the Sequential Organ Failure Assessment (SOFA), namely, the mSOFA and the qSOFA, was conducted to determine the accuracy of predicting in-hospital mortality among critically ill patients in the emergency department (ED). Methods A prospective cohort research was performed on patients over 18 years of age presented to the ED. We used logistic regression to develop a model for predicting in-hospital mortality by using qSOFA, mSOFA, and residents' judgment scores. We compared the accuracy of prognostic models and residents' judgment in terms of the overall accuracy of the predicted probabilities (Brier score), discrimination (area under the ROC curve), and calibration (calibration graph). Analyses were carried out using R software version R-4.2.0. Results In the study, 2,205 patients with median age of 64 (IQR: 50-77) years were included. There were no significant differences between the qSOFA (AUC 0.70; 95% CI: 0.67-0.73) and physician's judgment (AUC 0.68; 0.65-0.71). Despite this, the discrimination of mSOFA (AUC 0.74; 0.71-0.77) was significantly higher than that of the qSOFA and residents' judgments. Additionally, the AUC-PR of mSOFA, qSOFA, and emergency resident's judgments was 0.45 (0.43-0.47), 0.38 (0.36-0.40), and 0.35 (0.33-0.37), respectively. The mSOFA appears stronger in terms of overall performance: 0.13 vs. 0.14 and 0.15. All three models showed good calibration. Conclusion The performance of emergency residents' judgment and the qSOFA was the same in predicting in-hospital mortality. However, the mSOFA predicted better-calibrated mortality risk. Large-scale studies should be conducted to determine the utility of these models.
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Affiliation(s)
- Zahra Rahmatinejad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Peiravi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Benyamin Hoseini
- Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Rahmatinejad
- Department of Health Information Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Medical Informatics, Amsterdam UMC Location University of Amsterdam, Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam UMC Location University of Amsterdam, Netherlands
| | - Hamidreza Reihani
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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van Wijk RJ, Quinten VM, van Rossum MC, Bouma HR, Ter Maaten JC. Predicting deterioration of patients with early sepsis at the emergency department using continuous heart rate variability analysis: a model-based approach. Scand J Trauma Resusc Emerg Med 2023; 31:15. [PMID: 37005664 PMCID: PMC10067229 DOI: 10.1186/s13049-023-01078-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Sepsis is a life-threatening disease with an in-hospital mortality rate of approximately 20%. Physicians at the emergency department (ED) have to estimate the risk of deterioration in the coming hours or days and decide whether the patient should be admitted to the general ward, ICU or can be discharged. Current risk stratification tools are based on measurements of vital parameters at a single timepoint. Here, we performed a time, frequency, and trend analysis on continuous electrocardiograms (ECG) at the ED to try and predict deterioration of septic patients. METHODS Patients were connected to a mobile bedside monitor that continuously recorded ECG waveforms from triage at the ED up to 48 h. Patients were post-hoc stratified into three groups depending on the development of organ dysfunction: no organ dysfunction, stable organ dysfunction or progressive organ dysfunction (i.e., deterioration). Patients with de novo organ dysfunction and those admitted to the ICU or died were also stratified to the group of progressive organ dysfunction. Heart rate variability (HRV) features over time were compared between the three groups. RESULTS In total 171 unique ED visits with suspected sepsis were included between January 2017 and December 2018. HRV features were calculated over 5-min time windows and summarized into 3-h intervals for analysis. For each interval, the mean and slope of each feature was calculated. Of all analyzed features, the average of the NN-interval, ultra-low frequency, very low frequency, low frequency and total power were different between the groups at multiple points in time. CONCLUSIONS We showed that continuous ECG recordings can be automatically analyzed and used to extract HRV features associated with clinical deterioration in sepsis. The predictive accuracy of our current model based on HRV features derived from the ECG only shows the potential of HRV measurements at the ED. Unlike other risk stratification tools employing multiple vital parameters this does not require manual calculation of the score and can be used on continuous data over time. Trial registration The protocol of this study is published by Quinten et al., 2017.
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Affiliation(s)
- Raymond J van Wijk
- Emergency Department, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Vincent M Quinten
- Emergency Department, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Mathilde C van Rossum
- Biomedical Signals and Systems, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
- Cardiovascular and Respiratory Physiology, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
| | - Hjalmar R Bouma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Jan C Ter Maaten
- Emergency Department, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Recognition of Critically Ill Patients by Acute Health Care Providers: A Multicenter Observational Study. Crit Care Med 2023; 51:697-705. [PMID: 36939246 DOI: 10.1097/ccm.0000000000005839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
OBJECTIVES Although the Modified Early Warning Score (MEWS) is increasingly being used in the acute care chain to recognize disease severity, its superiority compared with clinical gestalt remains unproven. Therefore, the aim of this study was to compare the accuracy of medical caregivers and MEWS in predicting the development of critical illness. DESIGN This was a multicenter observational prospective study. SETTING It was performed in a level-1 trauma center with two different sites and emergency departments (EDs) with a combined capacity of about 50.000 patients annually. PATIENTS It included all adult patients presented to the ED by Emergency Medical Services (EMS). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For all patients, the acute caregivers were asked several standardized questions regarding clinical predicted outcome (clinical gestalt), and the MEWS was calculated. The primary outcome was the occurrence of critical illness, defined as ICU admission, serious adverse events, and mortality within 72 hours. The sensitivity, specificity, and discriminative power of both clinical gestalt and MEWS for the occurrence of critical illness were calculated as the area under the receiver operating characteristic curve (AUROC). Among the total of 800 included patients, 113 patients (14.1%) suffered from critical illness. The specificity for predicting three-day critical illness for all caregivers (for EMS nurses, ED nurses, and physicians) was 93.2%; 97.3%, and 96.8%, respectively, and was significantly (p < 0.01) better than an MEWS score of 3 or higher (70.4%). The sensitivity was significantly lower for EMS and ED nurses, but not significantly different for physicians compared with MEWS. The AUROCs for prediction of 3-day critical illness by both the ED nurses (AUROC = 0.809) and the physicians (AUROC = 0.848) were significantly higher (p = 0.032 and p = 0.010, respectively) compared with MEWS (AUROC = 0.731). CONCLUSIONS For patients admitted to the ED by EMS, medical professionals can predict the development of critical illness within 3 days significantly better than the MEWS. Although MEWS is able to correctly predict those patients that become critically ill, its use leads to overestimation due to a substantial number of false positives.
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Vosseteig A, Jones P. Response to Re: Modified Sequential Organ Failure Assessment score for predicting mortality in emergency department patients with sepsis. Emerg Med Australas 2023; 35:528-529. [PMID: 36878636 DOI: 10.1111/1742-6723.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Anna Vosseteig
- Emergency Department, Tauranga Hospital, Tauranga, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Tschoellitsch T, Krummenacker S, Dünser MW, Stöger R, Meier J. The Value of the First Clinical Impression as Assessed by 18 Observations in Patients Presenting to the Emergency Department. J Clin Med 2023; 12:jcm12020724. [PMID: 36675651 PMCID: PMC9862625 DOI: 10.3390/jcm12020724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
The first clinical impression of emergency patients conveys a myriad of information that has been incompletely elucidated. In this prospective, observational study, the value of the first clinical impression, assessed by 18 observations, to predict the need for timely medical attention, the need for hospital admission, and in-hospital mortality in 1506 adult patients presenting to the triage desk of an emergency department was determined. Machine learning models were used for statistical analysis. The first clinical impression could predict the need for timely medical attention [area under the receiver operating characteristic curve (AUC ROC), 0.73; p = 0.01] and hospital admission (AUC ROC, 0.8; p = 0.004), but not in-hospital mortality (AUC ROC, 0.72; p = 0.13). The five most important features informing the prediction models were age, ability to walk, admission by emergency medical services, lying on a stretcher, breathing pattern, and bringing a suitcase. The inability to walk at triage presentation was highly predictive of both the need for timely medical attention (p < 0.001) and the need for hospital admission (p < 0.001). In conclusion, the first clinical impression of emergency patients presenting to the triage desk can predict the need for timely medical attention and hospital admission. Important components of the first clinical impression were identified.
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Affiliation(s)
- Thomas Tschoellitsch
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Stefan Krummenacker
- Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Martin W. Dünser
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Roland Stöger
- Praxis für Allgemein- und Familienmedizin, 4262 Leopoldschlag, Austria
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, 4020 Linz, Austria
- Correspondence:
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Komorowski M, Green A, Tatham KC, Seymour C, Antcliffe D. Sepsis biomarkers and diagnostic tools with a focus on machine learning. EBioMedicine 2022; 86:104394. [PMID: 36470834 PMCID: PMC9783125 DOI: 10.1016/j.ebiom.2022.104394] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
Abstract
Over the last years, there have been advances in the use of data-driven techniques to improve the definition, early recognition, subtypes characterisation, prognostication and treatment personalisation of sepsis. Some of those involve the discovery or evaluation of biomarkers or digital signatures of sepsis or sepsis sub-phenotypes. It is hoped that their identification may improve timeliness and accuracy of diagnosis, suggest physiological pathways and therapeutic targets, inform targeted recruitment into clinical trials, and optimise clinical management. Given the complexities of the sepsis response, panels of biomarkers or models combining biomarkers and clinical data are necessary, as well as specific data analysis methods, which broadly fall under the scope of machine learning. This narrative review gives a brief overview of the main machine learning techniques (mainly in the realms of supervised and unsupervised methods) and published applications that have been used to create sepsis diagnostic tools and identify biomarkers.
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Affiliation(s)
- Matthieu Komorowski
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom,Corresponding author.
| | - Ashleigh Green
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Kate C. Tatham
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom,Anaesthetics, Perioperative Medicine and Pain Department, Royal Marsden NHS Foundation Trust, 203 Fulham Rd, London, SW3 6JJ, United Kingdom
| | - Christopher Seymour
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Antcliffe
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom
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Veldhuis LI, Ridderikhof ML, Bergsma L, Van Etten-Jamaludin F, Nanayakkara PW, Hollmann M. Performance of early warning and risk stratification scores versus clinical judgement in the acute setting: a systematic review. J Accid Emerg Med 2022; 39:918-923. [PMID: 35944968 DOI: 10.1136/emermed-2021-211524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/19/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Risk stratification is increasingly based on Early Warning Score (EWS)-based models, instead of clinical judgement. However, it is unknown how risk-stratification models and EWS perform as compared with the clinical judgement of treating acute healthcare providers. Therefore, we performed a systematic review of all available literature evaluating clinical judgement of healthcare providers to the use of risk-stratification models in predicting patients' clinical outcome. METHODS Studies comparing clinical judgement and risk-stratification models in predicting outcomes in adult patients presenting at the ED were eligible for inclusion. Outcomes included the need for intensive care unit (ICU) admission; severe adverse events; clinical deterioration and mortality. Risk of bias among the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. RESULTS Six studies (6419 participants) were included of which 4 studies were judged to be at high risk of bias. Only descriptive analysis was performed as a meta-analysis was not possible due to few included studies and high clinical heterogeneity. The performance of clinical judgement and risk-stratification models were both moderate in predicting mortality, deterioration and need for ICU admission with area under the curves between 0.70 and 0.89. The performance of clinical judgement did not significantly differ from risk-stratification models in predicting mortality (n=2 studies) or deterioration (n=1 study). However, clinical judgement of healthcare providers was significantly better in predicting the need for ICU admission (n=2) and severe adverse events (n=1 study) as compared with risk-stratification models. CONCLUSION Based on limited existing data, clinical judgement has greater accuracy in predicting the need for ICU admission and the occurrence of severe adverse events compared with risk-stratification models in ED patients. However, performance is similar in predicting mortality and deterioration. PROSPERO REGISTRATION NUMBER CRD42020218893.
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Affiliation(s)
- Lars Ingmar Veldhuis
- Emergency Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands.,Anaesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Lyfke Bergsma
- Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | | | - Prabath Wb Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Markus Hollmann
- Anaesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Varney J, Motawea KR, Kandil OA, Hashim HT, Murry K, Shah J, Shaheen A, Akwari J, Awad AK, Rivera A, Mostafa MR, Swed S, Awad DM. Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis. Health Sci Rep 2022; 5:e582. [PMID: 35387313 PMCID: PMC8973268 DOI: 10.1002/hsr2.582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/11/2022] [Accepted: 03/09/2022] [Indexed: 11/14/2022] Open
Abstract
Background and Aims Some studies have suggested that earlier initiation of antibiotics has shown positive outcomes in sepsis patients. We aimed to do a systematic review and meta-analysis to evaluate the effect of prehospital administration of antibiotics on 28 days mortality and length of stay in hospital and intensive care unit for sepsis patients. Methods We formulated a search strategy and used it on search databases PubMed, Scopus, Web of Science, and Embase. We then screened the records for eligibility and included controlled studies, either clinical trials or cohort studies reporting prehospital antibiotic administration for sepsis patients. We excluded duplicates, books, conferences' abstracts, case reports, editorials, letters, author responses, not English studies, and studies with nonavailable full text. Animal and lab studies were also excluded. Results The total number of studies identified is 1811, 19 were eligible for systematic review and 4 for meta-analysis (three cohort and one clinical trial). The total number of sepsis patients in the four included studies in the 28 days mortality outcome was 3523 (1779 took prehospital antibiotics and 1744 did not take prehospital antibiotics). Of 1779 who took the antibiotics, 190 died, and of 1744 who did not take antibiotics, 292 died (95% confidence interval 0.68-0.97, p = 0.02). Conclusion This meta-analysis reveals that receiving prehospital antibiotics can significantly lower mortality in sepsis patients compared to patients who do not receive prehospital antibiotics. However, more clinical trials and multicenter prospective studies with high sample sizes are needed to get strong evidence supporting our findings.
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Affiliation(s)
- Joseph Varney
- School of MedicineAmerican University of the CaribbeanCupecoySint Maarten
| | | | | | | | | | - Jaffer Shah
- Medical Research CenterKateb UniveristyKabulAfghanistan
- New York State Department of HealthNew YorkUSA
| | - Ahmed Shaheen
- Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Joy Akwari
- School of MedicineAmerican University of the CaribbeanCupecoySint Maarten
| | | | - Amanda Rivera
- School of MedicineAmerican University of the CaribbeanCupecoySint Maarten
| | | | - Sarya Swed
- Faculty of MedicineAleppo universityAleppoSyria
| | - Dina M. Awad
- Faculty of MedicineAlexandria UniversityAlexandriaEgypt
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11
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Cardoso T, Rodrigues PP, Nunes C, Almeida M, Cancela J, Rosa F, Rocha-Pereira N, Ferreira I, Seabra-Pereira F, Vaz P, Carneiro L, Andrade C, Davis J, Marçal A, Friedman ND. Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients. Ann Intensive Care 2021; 11:180. [PMID: 34950977 PMCID: PMC8702585 DOI: 10.1186/s13613-021-00966-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important. Methods Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included. Results There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic. Conclusions To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00966-7.
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Affiliation(s)
- T Cardoso
- Intensive Care Unit (UCIP) and Hospital Infection Control Committee, Hospital de Santo António, Oporto University Hospital Center, University of Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.
| | - P P Rodrigues
- Department of Community Medicine, Information and Health Decision Sciences & CINTESIS, Faculty of Medicine, University of Porto, Rua Dr. Plácido Costa, s/n, 4200-450, Porto, Portugal
| | - C Nunes
- Intensive Care Unit and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852, Bragança, Portugal
| | - M Almeida
- Neurocritical Care Unit and Hospital Infection Control Committee, Hospital de São Marcos, Sete Fontes - São Vitor, 4710-243, Braga, Portugal.,Intensive Care Unit (UCIP), Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - J Cancela
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - F Rosa
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - N Rocha-Pereira
- Infectious Diseases Department, São João Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - I Ferreira
- Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - F Seabra-Pereira
- Intensive Care Unit (UCIP), Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.,Intensive Care Unit and Internal Medicine Department, Hospital da Prelada, Rua de Sarmento de Beires, 4250-449, Porto, Portugal
| | - P Vaz
- Internal Medicine Department and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852, Bragança, Portugal
| | - L Carneiro
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - C Andrade
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal.,Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - J Davis
- Department of Renal Medicine, Barwon Health, Geelong, VIC, 3220, Australia
| | - A Marçal
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal.,Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - N D Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, VIC, 3220, Australia
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12
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Flint M, Hamilton F, Arnold D, Carlton E, Hettle D. The timing of use of risk stratification tools affects their ability to predict mortality from sepsis. A meta-regression analysis. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17223.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Risk stratification tools (RSTs) are used in healthcare settings to identify patients at risk of sepsis and subsequent adverse outcomes. In practice RSTs are used on admission and thereafter as ‘trigger’ tools prompting sepsis management. However, studies investigating their performance report scores at a single timepoint which varies in relation to admission. The aim of this meta-analysis was to determine if the predictive performance of RSTs is altered by the timing of their use. Methods: We conducted a systematic review and meta-regression analysis of studies published from inception to 31 October 2018, using EMBASE and PubMed databases. Any cohort studies investigating the ability of an RST to predict mortality in adult sepsis patients admitted to hospital, from which a 2x2 table was available or could be constructed, were included. The diagnostic performance of RSTs in predicting mortality was the primary outcome. Sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver-operating curve (AUROC) were the primary measures, enabling further meta-regression analysis. Results: 47 studies were included, comprising 430,427 patients. Results of bivariate meta-regression analysis found tools using a first-recorded score were less sensitive than those using worst-recorded score (REML regression coefficient 0.57, 95% CI 0.07-1.08). Using worst-recorded score led to a large increase in sensitivity (summary sensitivity 0.76, 95% CI 0.67-0.83, for worst-recorded scores vs. 0.64 (0.57-0.71) for first-recorded scores). Scoring system type did not have a significant relationship with studies’ predictive ability. The most analysed RSTs were qSOFA (n=37) and EWS (n=14). Further analysis of these RSTs also found timing of their use to be associated with predictive performance. Conclusion: The timing of any RST is paramount to their predictive performance. This must be reflected in their use in practice, and lead to prospective studies in future.
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13
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Krishnan K, Wassermann TB, Tednes P, Bonderski V, Rech MA. Beyond the bundle: Clinical controversies in the management of sepsis in emergency medicine patients. Am J Emerg Med 2021; 51:296-303. [PMID: 34785486 DOI: 10.1016/j.ajem.2021.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 01/21/2023] Open
Abstract
Sepsis is a condition characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The emergency department (ED) serves as a crucial entry point for patients presenting with sepsis. Given the heterogeneous presentation and high mortality rate associated with sepsis and septic shock, several clinical controversies have emerged in the management of sepsis. These include the use of novel therapeutic agents like angiotensin II, hydrocortisone, ascorbic acid, thiamine ("HAT") therapy, and levosimendan, Additionally, controversies with current treatments in vasopressor dosing, and the use of and balanced or unbalanced crystalloid are crucial to consider. The purpose of this review is to discuss clinical controversies in the management of septic patients, including the use of novel medications and dosing strategies, to assist providers in appropriately determining what treatment strategy is best suited for patients.
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Affiliation(s)
- Kavita Krishnan
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America
| | - Travis B Wassermann
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America
| | - Patrick Tednes
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, Maywood, IL, 60153, United States of America
| | - Veronica Bonderski
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, Maywood, IL, 60153, United States of America
| | - Megan A Rech
- Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, 60153, United States of America; Department of Pharmacy, Loyola University Medical Center, Maywood, IL, 60153, United States of America.
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14
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Caramello V, Macciotta A, Beux V, De Salve AV, Ricceri F, Boccuzzi A. Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department. Med Intensiva 2021; 45:459-469. [PMID: 34717884 DOI: 10.1016/j.medine.2020.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/09/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. DESIGN, SETTING AND PARTICIPANTS We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. RESULTS Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. CONCLUSIONS We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.
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Affiliation(s)
- V Caramello
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy.
| | - A Macciotta
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy
| | - V Beux
- University of Turin, Italy
| | - A V De Salve
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - F Ricceri
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy; Unit of Epidemiology, Regional Health Service ASL TO3, Grugliasco, TO, Italy
| | - A Boccuzzi
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
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15
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Oliveira RADC, Imparato DO, Fernandes VGS, Cavalcante JVF, Albanus RD, Dalmolin RJS. Reverse Engineering of the Pediatric Sepsis Regulatory Network and Identification of Master Regulators. Biomedicines 2021; 9:biomedicines9101297. [PMID: 34680414 PMCID: PMC8533457 DOI: 10.3390/biomedicines9101297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 01/04/2023] Open
Abstract
Sepsis remains a leading cause of death in ICUs all over the world, with pediatric sepsis accounting for a high percentage of mortality in pediatric ICUs. Its complexity makes it difficult to establish a consensus on genetic biomarkers and therapeutic targets. A promising strategy is to investigate the regulatory mechanisms involved in sepsis progression, but there are few studies regarding gene regulation in sepsis. This work aimed to reconstruct the sepsis regulatory network and identify transcription factors (TFs) driving transcriptional states, which we refer to here as master regulators. We used public gene expression datasets to infer the co-expression network associated with sepsis in a retrospective study. We identified a set of 15 TFs as potential master regulators of pediatric sepsis, which were divided into two main clusters. The first cluster corresponded to TFs with decreased activity in pediatric sepsis, and GATA3 and RORA, as well as other TFs previously implicated in the context of inflammatory response. The second cluster corresponded to TFs with increased activity in pediatric sepsis and was composed of TRIM25, RFX2, and MEF2A, genes not previously described as acting in a coordinated way in pediatric sepsis. Altogether, these results show how a subset of master regulators TF can drive pathological transcriptional states, with implications for sepsis biology and treatment.
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Affiliation(s)
- Raffael Azevedo de Carvalho Oliveira
- Bioinformatics Multidisciplinary Environment–BioME, Instituto Metrópole Digital, Universidade Federal do Rio Grande do Norte, Natal 59078-400, Brazil; (R.A.d.C.O.); (D.O.I.); (V.G.S.F.); (J.V.F.C.)
| | - Danilo Oliveira Imparato
- Bioinformatics Multidisciplinary Environment–BioME, Instituto Metrópole Digital, Universidade Federal do Rio Grande do Norte, Natal 59078-400, Brazil; (R.A.d.C.O.); (D.O.I.); (V.G.S.F.); (J.V.F.C.)
| | - Vítor Gabriel Saldanha Fernandes
- Bioinformatics Multidisciplinary Environment–BioME, Instituto Metrópole Digital, Universidade Federal do Rio Grande do Norte, Natal 59078-400, Brazil; (R.A.d.C.O.); (D.O.I.); (V.G.S.F.); (J.V.F.C.)
| | - João Vitor Ferreira Cavalcante
- Bioinformatics Multidisciplinary Environment–BioME, Instituto Metrópole Digital, Universidade Federal do Rio Grande do Norte, Natal 59078-400, Brazil; (R.A.d.C.O.); (D.O.I.); (V.G.S.F.); (J.V.F.C.)
| | - Ricardo D’Oliveira Albanus
- Department of Computational Medicine & Bioinformatics, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Rodrigo Juliani Siqueira Dalmolin
- Bioinformatics Multidisciplinary Environment–BioME, Instituto Metrópole Digital, Universidade Federal do Rio Grande do Norte, Natal 59078-400, Brazil; (R.A.d.C.O.); (D.O.I.); (V.G.S.F.); (J.V.F.C.)
- Department of Biochemistry–DBQ–CB, Federal University of Rio Grande do Norte, Natal 59064-741, Brazil
- Correspondence:
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16
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Ter Avest E, van Munster BC, van Wijk RJ, Tent S, Ter Horst S, Hu TT, van Heijst LE, van der Veer FS, van Beuningen FE, Ter Maaten JC, Bouma HR. Cohort profile of Acutelines: a large data/biobank of acute and emergency medicine. BMJ Open 2021; 11:e047349. [PMID: 34266842 PMCID: PMC8286769 DOI: 10.1136/bmjopen-2020-047349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Research in acute care faces many challenges, including enrolment challenges, legal limitations in data sharing, limited funding and lack of singular ownership of the domain of acute care. To overcome these challenges, the Center of Acute Care of the University Medical Center Groningen in the Netherlands, has established a de novo data, image and biobank named 'Acutelines'. PARTICIPANTS Clinical data, imaging data and biomaterials (ie, blood, urine, faeces, hair) are collected from patients presenting to the emergency department (ED) with a broad range of acute disease presentations. A deferred consent procedure (by proxy) is in place to allow collecting data and biomaterials prior to obtaining written consent. The digital infrastructure used ensures automated capturing of all bed-side monitoring data (ie, vital parameters, electrophysiological waveforms) and securely importing data from other sources, such as the electronic health records of the hospital, ambulance and general practitioner, municipal registration and pharmacy. Data are collected from all included participants during the first 72 hours of their hospitalisation, while follow-up data are collected at 3 months, 1 year, 2 years and 5 years after their ED visit. FINDINGS TO DATE Enrolment of the first participant occurred on 1 September 2020. During the first month, 653 participants were screened for eligibility, of which 180 were approached as potential participants. In total, 151 (84%) provided consent for participation of which 89 participants fulfilled criteria for collection of biomaterials. FUTURE PLANS The main aim of Acutelines is to facilitate research in acute medicine by providing the framework for novel studies and issuing data, images and biomaterials for future research. The protocol will be extended by connecting with central registries to obtain long-term follow-up data, for which we already request permission from the participant. TRIAL REGISTRATION NUMBER NCT04615065.
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Affiliation(s)
- Ewoud Ter Avest
- Emergency medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Raymond J van Wijk
- Emergency medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sanne Tent
- Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sanne Ter Horst
- Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ting Ting Hu
- Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lisanne E van Heijst
- Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | - Jan Cornelis Ter Maaten
- Emergency Department & Department of internal medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hjalmar R Bouma
- Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
- Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands
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17
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Mignot-Evers L, Raaijmakers V, Buunk G, Brouns S, Romano L, van Herpt T, Gharbharan A, Dieleman J, Haak H. Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study. BMJ Open 2021; 11:e041024. [PMID: 34135028 PMCID: PMC8210661 DOI: 10.1136/bmjopen-2020-041024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 04/17/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To compare the daily practice of two emergency departments (ED) in the Netherlands, where systemic inflammatory response syndrome (SIRS) criteria and quick Sequential Organ Failure Assessment (qSOFA) score are used differently as screening tools for culture-positive sepsis. DESIGN A prospective cross-sectional multicentre study. SETTING Two EDs at two European clinical teaching hospitals in the Netherlands. PARTICIPANTS 760 patients with suspected infection who met SIRS criteria or had a qualifying qSOFA score who were treated at two EDs in the Netherlands from 1 January to 1 March 2018 were included. METHODS SIRS criteria and qSOFA score were calculated for each patient. The first hospital treated the patients who met SIRS criteria following the worldwide Surviving Sepsis Campaign protocol. At the second hospital, only patients who met the qualifying qSOFA score received this treatment. Therefore, patients could be divided into five groups: (1) SIRS+, qSOFA-, not treated according to protocol (reference group); (2) SIRS+, qSOFA-, treated according to protocol; (3) SIRS+, qSOFA+, treated according to protocol; (4) SIRS-, qSOFA+, not treated according to protocol; (5) SIRS-, qSOFA+, treated according to protocol. PRIMARY AND SECONDARY OUTCOME MEASURES To prove culture-positive sepsis was present, cultures were used as the primary outcome. Secondary outcomes were in-hospital mortality and intensive care unit (ICU) admission. RESULTS 98.9% met SIRS criteria and 11.7% met qSOFA score. Positive predictive values of SIRS criteria and qSOFA score were 41.2% (95% CI 37.4% to 45.2%) and 48.1% (95% CI 37.4% to 58.9%), respectively. HRs were 0.79 (95% CI 0.40 to 1.56, p=0.500), 3.42 (95% CI 1.82 to 6.44, p<0.001), 18.94 (95% CI 2.48 to 144.89, p=0.005) and 4.97 (95% CI 1.44 to 17.16, p=0.011) for groups 2-5, respectively. CONCLUSION qSOFA score performed as well as SIRS criteria for identifying culture-positive sepsis and performed significantly better for predicting in-hospital mortality and ICU admission. This study shows that SIRS criteria are no longer necessary and recommends qSOFA score as the standard for identifying culture-positive sepsis in the ED. TRIAL REGISTRATION NUMBER NL8315.
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Affiliation(s)
- Lisette Mignot-Evers
- Emergency Department, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Health Services Research, Maastricht University, Care and Public Health Research Institute, Maastricht, The Netherlands
| | | | - Gerba Buunk
- Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | - Steffie Brouns
- Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Lorenzo Romano
- Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | - Thijs van Herpt
- Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | | | - Jeanne Dieleman
- Máxima MC Academy, Máxima Medisch Centrum Veldhoven, Veldhoven, The Netherlands
| | - Harm Haak
- Department of Health Services Research, Maastricht University, Care and Public Health Research Institute, Maastricht, The Netherlands
- Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands
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18
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Gamboa-Antiñolo FM. Prognostic tools for elderly patients with sepsis: in search of new predictive models. Intern Emerg Med 2021; 16:1027-1030. [PMID: 33847904 DOI: 10.1007/s11739-021-02729-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/29/2021] [Indexed: 12/23/2022]
Abstract
As a tool to support clinical decision-making, Mortality Prediction Models (MPM) can help clinicians stratify and predict patient risk. There are numerous scoring systems for patients with sepsis that predict sepsis-related mortality and the severity of sepsis. But there are currently no MPMs for adults with sepsis who meet the criteria of "good." Clinicians are unlikely to use complex MPMs that require extensive or expensive data collection to impede workflow. Machine learning applied to minimal medical records of patients diagnosed with sepsis can be a useful tool. Progress is needed in the development and validation of clinical decision support tools that can assist in patient risk stratification, prognosis, discussion of patient outcomes, and shared decision making.
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19
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Molnár G, Gyarmathy VA, Takács J, Sándor S, Kiss B, Fazakas J, Kanizsai PL. Differentiating sepsis from similar groups of symptoms at triage level in emergency care. Physiol Int 2021. [PMID: 33769958 DOI: 10.1556/2060.2021.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 09/08/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Conditions that have similar initial presentations as sepsis may make early recognition of sepsis in an emergency room (ER) difficult. We investigated whether selected physiologic and metabolic parameters can be reliably used in the emergency department to differentiate sepsis from other disease states that mimic it, such as dehydration and stroke. METHODS Loess regression on retrospective follow-up chart data of patients with sepsis-like symptoms (N = 664) aged 18+ in a large ER in Hungary was used to visualize/identify cutoff points for sepsis risk. A multivariate logistic regression model based on standard triage data was constructed with its corresponding receiver operating characteristic (ROC) curve and compared with another model constructed based on current sepsis guidelines. RESULTS Age, bicarbonate, HR, lactate, pH, and body temperature had U, V, W, or reverse U-shaped associations with identifiable inflexion points, but the cutoff values we identified were slightly different from guideline cutoff values. In contrast to the guidelines, no inflexion points could be observed for the association of sepsis with SBP, DPB, MAP, and RR and therefore were treated as continuous variables. Compared to the guidelines-based model, the triage data-driven final model contained additional variables (age, pH, bicarbonate) and did not include lactate. The data-driven model identified about 85% of sepsis cases correctly, while the guidelines-based model identified only about 70% of sepsis cases correctly. CONCLUSION Our findings contribute to the growing body of evidence for the necessity of finding improved tools to identify sepsis at early time points, such as in the ER.
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Affiliation(s)
- G Molnár
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - V A Gyarmathy
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
- 2EpiConsult Biomedical Consulting and Medical Communications Agency,Dover, DE, USA
- 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Takács
- 4Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| | - S Sándor
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - B Kiss
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - J Fazakas
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - P L Kanizsai
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
- 5Department of Emergency Medicine, Clinical Centre, University of Pécs, Pécs, Hungary
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20
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Erdem H, Hargreaves S, Ankarali H, Caskurlu H, Ceviker SA, Bahar-Kacmaz A, Meric-Koc M, Altindis M, Yildiz-Kirazaldi Y, Kizilates F, Alsalman J, Cag Y, Kamal AHM, Dokmetas I, Dindar-Demiray EK, Shehata GA, Hasman H, Sadykova A, Llopis F, Ramosaco E, Logar M, Alay H, Kesmez-Can F, Ruch Y, Bulut D, Makek MJ, Marino A, Mahboob A, El-Kholy A, Abdallah D, Sefa-Sayar M, Karaali R, Aslan S, Dar RE, Abdalla E, Monzón-Camps H, Baljić R, Mgdalena DI, Naghili B, Abbas Dafalla ME, Alwashmi ASS, Carmen CR, Ramirez-Estrada S, Wojewodzka-Zelezniakowicz M, Akyildiz O, Zajkowska J, El-Sokkary R, Pandya N, Amer F, Alavi-Darazam I, Grgić S, Wegdan AA, El-Kholy J, Bulut-Avsar C, Kulzhanova S, Tasbakan M, Kumari HP, Dirani N, Koganti K, Konkayev AK, Petrov MM, Cascio A, Liskova A, Del Vecchio RF, Lambertenghi L, Mladenov N, Oncu S, Rello J. Managing adult patients with infectious diseases in emergency departments: international ID-IRI study. J Chemother 2021; 33:302-318. [PMID: 33734040 DOI: 10.1080/1120009x.2020.1863696] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We aimed to explore factors for optimizing antimicrobial treatment in emergency departments. A single-day point prevalence survey was conducted on January 18, 2020, in 53 referral/tertiary hospitals in 22 countries. 1957 (17%) of 11557 patients presenting to EDs had infections. The mean qSOFA score was 0.37 ± 0.74. Sepsis (qSOFA ≥ 2) was recorded in 218 (11.1%) patients. The mean qSOFA score was significantly higher in low-middle (1.48 ± 0.963) compared to upper-middle (0.17 ± 0.482) and high-income (0.36 ± 0.714) countries (P < 0.001). Eight (3.7%) patients with sepsis were treated as outpatients. The most common diagnoses were upper-respiratory (n = 877, 43.3%), lower-respiratory (n = 316, 16.1%), and lower-urinary (n = 201, 10.3%) infections. 1085 (55.4%) patients received antibiotics. The most-commonly used antibiotics were beta-lactam (BL) and BL inhibitors (n = 307, 15.7%), third-generation cephalosporins (n = 251, 12.8%), and quinolones (n = 204, 10.5%). Irrational antibiotic use and inappropriate hospitalization decisions seemed possible. Patients were more septic in countries with limited resources. Hence, a better organizational scheme is required.
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Affiliation(s)
| | - Sally Hargreaves
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Handan Ankarali
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Hulya Caskurlu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Sevil Alkan Ceviker
- Department of Infectious Diseases and Clinical Microbiology, Kutahya Evliya Celebi Research and Education Hospital, Kutahya, Turkey
| | - Asiye Bahar-Kacmaz
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Mustafa Altindis
- Department of Medical Microbiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | | | - Filiz Kizilates
- Department of Infectious Diseases and Clinical Microbiology, Antalya Training and Research Hospital, Health Sciences University, Antalya, Turkey
| | | | - Yasemin Cag
- Institute for Infection and Immunity, St George's University of London, London, UK
| | | | - Ilyas Dokmetas
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
| | | | | | - Hakan Hasman
- Emergency Department, Ankara Medicalpark Hospital, Ankara, Turkey
| | - Ainur Sadykova
- Department of Infectious and Tropical Diseases, City Clinical Infectious Hospital, Kazakh National Medical University, Almaty, Kazakhstan
| | - Ferran Llopis
- Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Ergys Ramosaco
- Infectious Diseases Clinic, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Mateja Logar
- Department of Infectious Diseases, UMC Ljubljana, Ljubljana, Slovenia
| | - Handan Alay
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Fatma Kesmez-Can
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Yvon Ruch
- Department of Infectious Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Dilek Bulut
- Department of Infectious Diseases and Clinical Microbiology, Van Training and Research Hospital, Van, Turkey
| | | | - Andrea Marino
- Department of Infectious Diseases, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Amjad Mahboob
- Bacha Khan Medical Complex Swabi, Khyber Pakhtunkhwa, Pakistan
| | | | - Dirar Abdallah
- Department of Intensive Care, Prime Hospital, Dubai, United Arab Emirates
| | - Merve Sefa-Sayar
- Department of Infectious Diseases and Clinical Microbiology, Van Training and Research Hospital, Van, Turkey
| | - Ridvan Karaali
- Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa School of Medicine, İstanbul Üniversitesi, Istanbul, Turkey
| | - Selda Aslan
- Department of Infectious Diseases and Clinical Microbiology, Cengiz Gokcek Maternity and Children's Hospital, Gaziantep, Turkey
| | - Razi Even Dar
- Department of Internal Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Esam Abdalla
- Department of Anesthesia & ICU, Assiut University Hospital, Assiut, Egypt
| | - Helena Monzón-Camps
- Emergency Department and Infectious Diseases, Hospital Universitary Mútua Terrassa, Terrassa, Spain
| | - Rusmir Baljić
- Clinic for Infectious Diseases, Sarajevo, Bosnia and Herzegovina
| | - Dumitru Irina Mgdalena
- Clinical Infectious Diseases Hospital, Ovidius University of Constanta, Constanta, Romania
| | - Behrouz Naghili
- Department of Infectious Diseases, Imam Reza Hospital, Tabriz, Iran
| | | | - Ameen S S Alwashmi
- Medical Laboratories Department, College of Applied Medical Sciences, Qassim University, Saudi Arabia
| | - Cernat Roxana Carmen
- Clinical Hospital for Infectious Diseases, Ovidius University Constanta, Constanta, Romania
| | | | | | - Ozay Akyildiz
- Department of Infectious Diseases and Clinical Microbiology, Adana Acibadem Hospital, Adana, Turkey
| | | | - Rehab El-Sokkary
- Medical Microbiology and Immunology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Fatma Amer
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ilad Alavi-Darazam
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Svjetlana Grgić
- Clinic for Infectious Disease, University Hospital Mostar, Mostar, Bosnia and Herzegovina
| | | | | | - Cansu Bulut-Avsar
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Ege University, Izmir, Turkey
| | - Sholpan Kulzhanova
- Department of Infectious Diseases, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Meltem Tasbakan
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Ege University, Izmir, Turkey
| | | | | | | | - Aidos K Konkayev
- Institution of Trauma and Orthopaedics, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Michael M Petrov
- Department of Microbiology and Immunology, Faculty of Pharmacy, Medical University, Plovdiv, Bulgaria
| | - Antonio Cascio
- Infectious and Tropical Diseases Section, Department PROMISE, University of Palermo, Palermo, Italy
| | | | | | | | | | - Serkan Oncu
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Jordi Rello
- Critical Care Department, Hospital Vall d'Hebron, Barcelona, Spain.,CIBERES, Madrid, Spain.,Universitat Autonma de Barcelona, Barcelona, Spain
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Tulli G, Toccafondi G. Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal. Diagnosis (Berl) 2021; 8:dx-2020-0142. [PMID: 33544477 DOI: 10.1515/dx-2020-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/13/2020] [Indexed: 11/15/2022]
Abstract
This is a first attempt to integrate the three pillars of infection management: the infection prevention and control (IPC), and surveillance (IPCS), antimicrobial stewardship (AMS), and rapid identification and management of sepsis (RIMS). The new 'Sepsis-3' definition extrapolates the diagnosis of sepsis from our previously slightly naïve concept of a stepwise evolving pattern. In doing so, however, we have placed the transition from infection toward sepsis in the domain of uncertainty and time-dependency. This now demands that clinical judgment be used in the risk stratification of patients with infection, and that pragmatic local solutions be used to prompt clinicians to evaluate formally for sepsis. We feel it is necessary to stimulate the development of a new generation of concepts and models aiming at embracing uncertainty. We see the opportunity for a heuristic approach focusing on the relevant clinical predictors at hand allowing to navigate the uncertainty of infection diagnosis under time constraints. The diverse and situated clinical approaches eventually emerging need to focus on the understanding of infection as the unbalanced interactions of host, pathogen, and environment. In order extend such approach throughout the patient journey we propose a holistic early warning system underpinned by the risk-based categories of hazards and vulnerabilities iteratively fostered by the information gathered by the infection prevention control and surveillance, clinical microbiology, and clinical chemistry services.
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Affiliation(s)
| | - Giulio Toccafondi
- Clinical Risk Management and Patient Safety Center - GRC, Florence, Italy
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Rothrock SG, Cassidy DD, Barneck M, Schinkel M, Guetschow B, Myburgh C, Nguyen L, Earwood R, Nanayakkara PW, Nannan Panday RS, Briscoe JG. Outcome of Immediate Versus Early Antibiotics in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis. Ann Emerg Med 2020; 76:427-441. [DOI: 10.1016/j.annemergmed.2020.04.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 01/01/2023]
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Liberski PS, Szewczyk M, Krzych ŁJ. Haemogram-Derived Indices for Screening and Prognostication in Critically Ill Septic Shock Patients: A Case-Control Study. Diagnostics (Basel) 2020; 10:diagnostics10090638. [PMID: 32867031 PMCID: PMC7555761 DOI: 10.3390/diagnostics10090638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/22/2020] [Accepted: 08/26/2020] [Indexed: 12/18/2022] Open
Abstract
This study aimed (1) to assess the diagnostic accuracy of neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte (PLR), monocyte-to-lymphocyte (MLR) and platelet count-to-mean platelet volume (PLT/MPV) ratios in predicting septic shock in patients on admission to the intensive care unit (ICU) and (2) to compare it with the role of C-reactive protein (CRP), procalcitonin (PCT) and lactate level. We also sought (3) to verify whether the indices could be useful in ICU mortality prediction and (4) to compare them with Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores. This retrospective study covered 138 patients, including 61 subjects with multi-organ failure due to septic shock (study group) and 77 sex- and age-matched controls. Septic patients had significantly higher NLR (p < 0.01) and NLR predicted septic shock occurrence (area under the ROC curve, AUROC = 0.66; 95% CI 0.58-0.74). PLR, MLR and PLT/MPV were impractical in sepsis prediction. Combination of CRP with NLR improved septic shock prediction (AUROC = 0.88; 95% CI 0.81-0.93). All indices failed to predict ICU mortality. APACHE II and SAPS II predicted mortality with AUROC = 0.68; 95% CI 0.54-0.78 and AUROC = 0.7; 95% CI 0.57-0.81, respectively. High NLR may be useful to identify patients with multi-organ failure due to septic shock but should be interpreted along with CRP or PCT. The investigated indices are not related with mortality in this specific clinical setting.
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Caramello V, Macciotta A, Beux V, De Salve AV, Ricceri F, Boccuzzi A. Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department. Med Intensiva 2020; 45:S0210-5691(20)30163-7. [PMID: 32591242 DOI: 10.1016/j.medin.2020.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/13/2020] [Accepted: 04/09/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. DESIGN, SETTING AND PARTICIPANTS We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. RESULTS Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. CONCLUSIONS We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.
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Affiliation(s)
- V Caramello
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy.
| | - A Macciotta
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy
| | - V Beux
- University of Turin, Italy
| | - A V De Salve
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - F Ricceri
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy; Unit of Epidemiology, Regional Health Service ASL TO3, Grugliasco, TO, Italy
| | - A Boccuzzi
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
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Clinical impression for identification of vulnerable older patients in the emergency department. Eur J Emerg Med 2020; 27:137-141. [DOI: 10.1097/mej.0000000000000632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Uffen JW, Oosterheert JJ, Schweitzer VA, Thursky K, Kaasjager HAH, Ekkelenkamp MB. Interventions for rapid recognition and treatment of sepsis in the emergency department: a narrative review. Clin Microbiol Infect 2020; 27:192-203. [PMID: 32120030 DOI: 10.1016/j.cmi.2020.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/17/2020] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sepsis is a major cause of morbidity and mortality worldwide. Early recognition and treatment of sepsis is associated with improved outcome. The emergency department (ED) is the department where patients with sepsis seek care. However, recognition of sepsis in the ED remains difficult. Different alert and triage systems, screening scores and intervention strategies have been developed to assist clinicians in early recognition of sepsis and to optimize management. OBJECTIVES This narrative review describes currently applied interventions or interventions we can start using today, such as screening scores, (automated) triage systems, sepsis teams and clinical pathways in sepsis care; and it summarizes evidence for the effect of implementation of these interventions in the ED on patient management and outcomes. SOURCES A systematic literature search was conducted in PubMed, resulting in 39 eligible studies. CONTENT The main sepsis interventions in the ED are (automated) triage systems, sepsis teams and clinical pathways, the most integrative being a clinical pathway. Implementation of any of these interventions in sepsis care will generally lead to increased protocol adherence. Presumably increased adherence to sepsis guidelines and bundles will lead to better patient outcomes, but the level of evidence to support this improvement is low, whereas implementation of interventions is often complex and costly. No studies comparing different interventions were identified. Two essential factors for success of interventions in the ED are obtaining the support from all professionals and providing ongoing education. The vulnerability of these interventions lies in the lack of accurate tools to identify sepsis; diagnosing sepsis ultimately still relies on clinical assessments. A lack of specificity or sepsis alerts may lead to alert fatigue and/or overtreatment. IMPLICATIONS The severity and poor outcome of sepsis as well as the frequency of its presentation in EDs make a structured, protocol-based approach towards these patients essential, preferably as part of a clinical pathway.
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Affiliation(s)
- J W Uffen
- Division of Acute Medicine, Department of Internal Medicine, University Medical Center Utrecht, the Netherlands.
| | - J J Oosterheert
- Division of Infectious Diseases, Department of Internal Medicine, University Medical Center Utrecht, the Netherlands
| | - V A Schweitzer
- Department of Microbiology, University Medical Center Utrecht, the Netherlands
| | - K Thursky
- Department of Infectious Disease, Royal Melbourne Hospital, Melbourne, Australia
| | - H A H Kaasjager
- Division of Acute Medicine, Department of Internal Medicine, University Medical Center Utrecht, the Netherlands
| | - M B Ekkelenkamp
- Department of Microbiology, University Medical Center Utrecht, the Netherlands
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Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection. Eur J Emerg Med 2020; 26:329-333. [PMID: 30138252 DOI: 10.1097/mej.0000000000000570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE After the third international consensus on sepsis released its new definitions, the prognostic value of quick sequential organ failure assessment (qSOFA) score has been confirmed in the emergency department. However, its validity in the prehospital setting remains unknown. The objective of the study was to assess its accuracy for prehospital patients cared by emergency physician-staffed ambulances (services mobiles d'urgence et de réanimation SMUR). PATIENTS AND METHODS This was a prospective observational multicenter cohort study (N = 6). All consecutive patients with prehospital clinical suspicion of infection by the emergency physician of the SMUR emergency medical service were included. Components of qSOFA were collected, and the patients were followed until hospital discharge. The primary end point was in-hospital mortality, censored at 28 days. Secondary end points included ICU admission longer than 72 h and a composite of 'death or ICU stay more than 72 h'. RESULTS We screened 342 patients and included 332 in the analysis. Their mean age was 73 years, 159 (48%) were women, and the most common site of infection was respiratory (73% of cases). qSOFA was at least 2 in 133 (40%) patients. The overall in-hospital mortality was 27%: 41% in patients with qSOFA of at least 2 versus 18% for qSOFA less than 2 (absolute difference 23%; 95% confidence interval: 13-33%, P < 0.001). The overall discrimination for qSOFA was poor, with an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.62-0.74). CONCLUSION In this large multicenter study, prehospital qSOFA presents a strong association with mortality in infected patient, though with poor prognostic performances in our severely ill sample.
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Prognosis of β-adrenergic blockade therapy on septic shock and sepsis: A systematic review and meta-analysis of randomized controlled studies. Cytokine 2019; 126:154916. [PMID: 31756644 DOI: 10.1016/j.cyto.2019.154916] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/21/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE β-adrenoceptor antagonist (β-blocker) may have potential in the treatment of septic shock and sepsis. However, the relevant research findings are still controversial. METHODS We conducted a systematic review and meta-analysis to explore the efficacy of β-blocker in patients with septic shock and sepsis. The primary sources of the reviewed studies through August 2018, with restriction on the language of English, were Pubmed and Embase. Randomized controlled trials (RCT) were included to evaluate the efficacy of β-blocker in the treatment of septic shock and sepsis. Meta analysis was performed using a random effect model. Two researchers independently searched articles, extracted data, and assessed the quality of the included studies. RESULTS A total of 6 studies related to 5 original RCTs were qualified for inclusion in this systematic review and meta-analysis with a total of 363 patients with sepsis and/or septic shock. β-blocker was associated with a significantly decreased 28-day mortality compared to usual treatment group as the control (RR = 0.59, 95%CI: 0.48, 0.74; P < 0.00001). Heart rate in β-blocker was significantly lower than that in the standard care group (SMD = -2.01, 95%CI: -3.03, -0.98; P = 0001). CONCLUSION β-blocker of esmolol is safe and effective in improving 28-day mortality and controlling ventricular rate in patients with sepsis after fluid resuscitation, and has no significant adverse effect on tissue perfusion.
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Klimpel J, Weidhase L, Bernhard M, Gries A, Petros S. The impact of the Sepsis-3 definition on ICU admission of patients with infection. Scand J Trauma Resusc Emerg Med 2019; 27:98. [PMID: 31685006 PMCID: PMC6829802 DOI: 10.1186/s13049-019-0680-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/21/2019] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated inflammation following an infection. However, the impact of this definition on patient care is not fully clear. This study investigated the impact of the current definition on ICU admission of patients with infection. Methods We performed a prospective observational study over twelve months on consecutive patients presented to our emergency department and admitted for infection. We analyzed the predictive values of the quick sequential organ failure assessment (qSOFA) score, the SOFA score and blood lactate regarding ICU admission. Results We included 916 patients with the diagnosis of infection. Median age was 74 years (IQR 62–82 years), and 56.3% were males. There were 219 direct ICU admissions and 697 general ward admissions. A qSOFA score of ≥2 points had 52.9% sensitivity and 98.3% specificity regarding sepsis diagnosis. A qSOFA score of ≥2 points had 87.2% specificity but only 39.9% sensitivity to predict ICU admission. A SOFA score of ≥2 points had 97.4% sensitivity, but only 17.1% specificity to predict ICU admission, while a SOFA score of ≥4 points predicted ICU admission with 82.6% sensitivity and 71.7% specificity. The area under the receiver operating curve regarding ICU admission was 0.81 (95 CI, 0.77–0.86) for SOFA score, 0.55 (95% CI, 0.48–0.61) for blood lactate, and only 0.34 (95% CI, 0.28–0.40) for qSOFA on emergency department presentation. Conclusions While a positive qSOFA score had a high specificity regarding ICU admission, the low sensitivity of the score among septic patients as well as among ICU admissions considerably limited its value in routine patient management. The SOFA score was the better predictor of ICU admission, while the predictive value of blood lactate was equivocal.
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Affiliation(s)
- Jenny Klimpel
- Medical ICU, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Lorenz Weidhase
- Medical ICU, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - André Gries
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical ICU, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
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Pedersen PB, Henriksen DP, Brabrand M, Lassen AT. Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study. BMJ Open 2019; 9:e032692. [PMID: 31666275 PMCID: PMC6830583 DOI: 10.1136/bmjopen-2019-032692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival. DESIGN This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults). SETTING Emergency department at Odense University Hospital, Denmark. PARTICIPANTS We included all adult patients who arrived from 1 April 2012 to 31 March 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality. RESULTS We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%). CONCLUSIONS The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital & Hospital of South West Jutland, Odense & Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
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Schinkel M, Paranjape K, Nannan Panday RS, Skyttberg N, Nanayakkara PWB. Clinical applications of artificial intelligence in sepsis: A narrative review. Comput Biol Med 2019; 115:103488. [PMID: 31634699 DOI: 10.1016/j.compbiomed.2019.103488] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/25/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
Many studies have been published on a variety of clinical applications of artificial intelligence (AI) for sepsis, while there is no overview of the literature. The aim of this review is to give an overview of the literature and thereby identify knowledge gaps and prioritize areas with high priority for further research. A literature search was conducted in PubMed from inception to February 2019. Search terms related to AI were combined with terms regarding sepsis. Articles were included when they reported an area under the receiver operator characteristics curve (AUROC) as outcome measure. Fifteen articles on diagnosis of sepsis with AI models were included. The best performing model reached an AUROC of 0.97. There were also seven articles on prognosis, predicting mortality over time with an AUROC of up to 0.895. Finally, there were three articles on assistance of treatment of sepsis, where the use of AI was associated with the lowest mortality rates. Of the articles, twenty-two were judged to be at high risk of bias or had major concerns regarding applicability. This was mostly because predictor variables in these models, such as blood pressure, were also part of the definition of sepsis, which led to overestimation of the performance. We conclude that AI models have great potential for improving early identification of patients who may benefit from administration of antibiotics. Current AI prediction models to diagnose sepsis are at major risks of bias when the diagnosis criteria are part of the predictor variables in the model. Furthermore, generalizability of these models is poor due to overfitting and a lack of standardized protocols for the construction and validation of the models. Until these problems have been resolved, a large gap remains between the creation of an AI algorithm and its implementation in clinical practice.
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Affiliation(s)
- M Schinkel
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, De Boelelaan 1118, 1081HZ, Amsterdam, the Netherlands
| | - K Paranjape
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, De Boelelaan 1118, 1081HZ, Amsterdam, the Netherlands
| | - R S Nannan Panday
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, De Boelelaan 1118, 1081HZ, Amsterdam, the Netherlands
| | - N Skyttberg
- Department of Learning, Informatics, Management and Ethics, Health Informatics Centre, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - P W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, De Boelelaan 1118, 1081HZ, Amsterdam, the Netherlands.
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Zhao M, Huang X. Downregulation of JKAP is correlated with elevated disease risk, advanced disease severity, higher inflammation, and poor survival in sepsis. J Clin Lab Anal 2019; 33:e22945. [PMID: 31206807 PMCID: PMC6757113 DOI: 10.1002/jcla.22945] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This study aimed to explore the association of JKAP with sepsis risk and investigate its correlation with disease severity, inflammatory cytokines, and survival in sepsis patients. METHODS A hundred and one sepsis patients along with 100 healthy controls were enrolled, and their blood serum samples were collected for JKAP and inflammatory cytokines measurement by enzyme-linked immunoassay. The difference in serum JKAP between sepsis patients and healthy controls was determined. Among sepsis patients, the correlation of JKAP with disease severity, laboratory indexes, inflammatory cytokines, 28-day mortality, and accumulating survival was analyzed. RESULTS JNK pathway-associated phosphatase level was decreased in sepsis patients compared with healthy controls and presented with good value in predicting decreased sepsis risk (AUC = 0.896 [95% CI: 0.851-0.941]). And its low expression was associated with advanced disease severity (APACHE II score and SOFA score) and systemic inflammation (CRP, PCT, TNF-α, IL-1β, IL-6, and IL-17) in sepsis patients. Additionally, JKAP level was decreased in deaths compared with survivors and had good value in distinguishing deaths from survivors (AUC = 0.742 [95% CI: 0.636-0.849]). Further, Kaplan-Meier curve analysis disclosed that JKAP high expression predicted more prolonged accumulating survival in sepsis patients. CONCLUSION JNK pathway-associated phosphatase is of good value in predicting lower sepsis risk, and its downregulation correlates with advanced disease severity, higher level of systemic inflammation, and poor survival in sepsis patients.
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Affiliation(s)
- Min Zhao
- Department of Emergency Medicine, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Xing Huang
- Department of Emergency Medicine, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
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Prognostic Accuracy of Quick SOFA is different according to the severity of illness in infectious patients. J Infect Chemother 2019; 25:943-949. [PMID: 31182332 DOI: 10.1016/j.jiac.2019.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/25/2019] [Accepted: 05/15/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Sepsis-3 proposed the quick Sequential Organ Failure Assessment (qSOFA) to identify sepsis patients likely to have poor outcome. The clinical utility of qSOFA still remains controversial because its predictive accuracy for mortality is quite different across the validation studies. We hypothesized that one of the major causes for these controversial findings was the heterogeneity in severity across the studies, and evaluated the association between severity of illness and the prognostic accuracy of qSOFA. MATERIALS AND METHODS This was a post hoc analysis of a prospective nationwide cohort of consecutive adult patients with sepsis in 59 intensive care units in Japan. Regression trees analysis for survival was used to classify patients according to severity of illness as determined by SOFA score on registration. We conducted receiver operating characteristic (ROC) analyses and evaluated the differences in the area under the ROC curve (AUROC). As a subgroup analysis, we conducted the above evaluations in emergency department (ED) and non-ED patients separately. RESULTS We included 1114 patients fulfilling the criteria and classified them into three subsets according to severity. The AUROC for mortality was significantly different according to the severity of illness (p = 0.007), with the highest AUROC being in the low-severity subset (patients with SOFA score ≤ 7). Interestingly, our subgroup analysis revealed that a significant difference in the AUROC of qSOFA was observed only in ED patients. CONCLUSION This study suggested that lower severity of illness was associated with the relatively higher prognostic accuracy of qSOFA, especially in ED patients.
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Liu YC, Luo YY, Zhang X, Shou ST, Gao YL, Lu B, Li C, Chai YF. Quick Sequential Organ Failure Assessment as a prognostic factor for infected patients outside the intensive care unit: a systematic review and meta-analysis. Intern Emerg Med 2019; 14:603-615. [PMID: 30725323 DOI: 10.1007/s11739-019-02036-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 01/17/2019] [Indexed: 12/15/2022]
Abstract
Quick Sequential Organ Failure Assessment (qSOFA) was proposed to replace SIRS as a new screening tool for the identification of septic patients at high mortality. However, researches from infected patients outside of ICU especially in Emergency Department (ED) drew contradictory conclusions on the prognostic value of qSOFA. This systematic review evaluated qSOFA as a prognostic marker of infected patients outside of ICU. The primary outcome was hospital mortality or 28- or 30-day mortality. Data were pooled based on sensitivity and specificity. Twenty-four trials with 121,237 participants were included. qSOFA had a poor sensitivity (0.58 [95% CI 0.47-0.67], 0.54 [95% CI 0.43-0.65]) and moderate specificity (0.69 [95% CI 0.48-0.84], 0.77 [95% CI 0.66-0.86]) for prediction of mortality in patients outside of ICU and ED patients only. Studies that used in-hospital mortality showed a higher sensitivity (0.61 [95% CI 0.50-0.71] vs 0.32 [95% CI 0.15-0.49]) and lower specificity (0.70 [95% CI 0.59-0.82] vs 0.92 [95% CI 0.85-0.99]) than studies that used 28 or 30-day mortality. Studies with overall mortality < 10% showed higher specificity (0.89 [95% CI 0.82-0.95] vs 0.62 [95% CI 0.48-0.76]) than studies with overall mortality ≥ 10%. There is no difference in the accuracy of diagnosis of sepsis between positive qSOFA scores and SIRS criteria. qSOFA was poor sensitivity and moderate specificity in predicting mortality of infected patients outside of ICU especially in ED. Combining qSOFA and SIRS may be helpful in predicting mortality.
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Affiliation(s)
- Yan-Cun Liu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China.
| | - Yuan-Yuan Luo
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China
| | - Xingyu Zhang
- Department of Surgery, Emory University School of Medicine, Atlanta, 30322, USA
| | - Song-Tao Shou
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China
| | - Yu-Lei Gao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China
| | - Bin Lu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China
| | - Chen Li
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China
| | - Yan-Fen Chai
- Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 An-Shan Road, Tianjin, 300052, People's Republic of China.
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Lo RSL, Leung LY, Brabrand M, Yeung CY, Chan SY, Lam CCY, Hung KKC, Graham CA. qSOFA is a Poor Predictor of Short-Term Mortality in All Patients: A Systematic Review of 410,000 Patients. J Clin Med 2019; 8:jcm8010061. [PMID: 30626160 PMCID: PMC6351955 DOI: 10.3390/jcm8010061] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND To determine the validity of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) in the prediction of outcome (in-hospital and 1-month mortality, intensive care unit (ICU) admission, and hospital and ICU length of stay) in adult patients with or without suspected infections where qSOFA was calculated and reported; Methods: Cochrane Central of Controlled trials, EMBASE, BIOSIS, OVID MEDLINE, OVID Nursing Database, and the Joanna Briggs Institute EBP Database were the main databases searched. All studies published until 12 April 2018 were considered. All studies except case series, case reports, and conference abstracts were considered. Studies that included patients with neutropenic fever exclusively were excluded. RESULTS The median AUROC for in-hospital mortality (27 studies with 380,920 patients) was 0.68 (a range of 0.55 to 0.82). A meta-analysis of 377,623 subjects showed a polled AUROC of 0.68 (0.65 to 0.71); however, it also confirmed high heterogeneity among studies (I² = 98.8%, 95%CI 98.6 to 99.0). The median sensitivity and specificity for in-hospital mortality (24 studies with 118,051 patients) was 0.52 (range 0.16 to 0.98) and 0.81 (0.19 to 0.97), respectively. Median positive and negative predictive values were 0.2 (range 0.07 to 0.38) and 0.94 (0.85 to 0.99), respectively.
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Affiliation(s)
- Ronson S L Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Mikkel Brabrand
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
- Department of Emergency Medicine, Hospital of South West Denmark, Finsensgade 35, DK-6700 Esbjerg, Denmark.
| | - Chun Yu Yeung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Suet Yi Chan
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Cherry C Y Lam
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Kevin K C Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
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Short-term mortality in older medical emergency patients can be predicted using clinical intuition: A prospective study. PLoS One 2019; 14:e0208741. [PMID: 30601815 PMCID: PMC6314634 DOI: 10.1371/journal.pone.0208741] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/21/2018] [Indexed: 11/20/2022] Open
Abstract
Background Older emergency department (ED) patients are at risk for adverse outcomes, however, it is hard to predict these. We aimed to assess the discriminatory value of clinical intuition, operationalized as disease perception, self-rated health and first clinical impression, including the 30-day surprise question (SQ: “Would I be surprised if this patient died in the next 30 days” of patients, nurses and physicians. Endpoints used to evaluate the discriminatory value of clinical intuition were short-term (30-day) mortality and other adverse outcomes (intensive/medium care admission, prolonged length of hospital stay, loss of independent living or 30-day readmission). Methods In this prospective, multicentre cohort study, older medical patients (≥65 years), nurses and physicians filled in scores regarding severity of illness and their concerns (i.e. disease perception and clinical impression scores) immediately after arrival of the patient in the ED. In addition, patients filled in a self-rated health score and nurses and physicians answered the SQ. Area under the curves (AUCs) of receiver operating characteristics (ROCs) were calculated. Results The median age of the 602 included patients was 79 years and 86.7% were community dwelling. Within 30 days, 66 (11.0%) patients died and 263 (43.7%) patients met the composite endpoint. The severity of concern score of both nurses and physicians yielded the highest AUCs for 30-day mortality (for both 0.75; 95%CI 0.68–0.81). AUCs for the severity of illness score and SQ of nurses and physicians ranged from 0.71 to 0.74 while those for the disease perception and self-rated health of patients ranged from 0.64 to 0.69. The discriminatory value of the scores for the composite endpoint was lower (AUCs ranging from 0.60 to 0.67). We used scores that have not been previously validated which could influence their generalisability. Conclusion Clinical intuition,—disease perception, self-rated health and first clinical impression—documented at an early stage after arrival in the ED, is a useful clinical tool to predict mortality and other adverse outcomes in older ED patients. Highest discriminatory values were found for the nurses’ and physicians’ severity of concern score. Intuition may be helpful for the implementation of personalised medical care in the future.
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Tan TL, Tang YJ, Ching LJ, Abdullah N, Neoh HM. Comparison of Prognostic Accuracy of the quick Sepsis-Related Organ Failure Assessment between Short- & Long-term Mortality in Patients Presenting Outside of the Intensive Care Unit - A Systematic Review & Meta-analysis. Sci Rep 2018; 8:16698. [PMID: 30420768 PMCID: PMC6232181 DOI: 10.1038/s41598-018-35144-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/30/2018] [Indexed: 12/29/2022] Open
Abstract
The purpose of this meta-analysis was to compare the ability of the qSOFA in predicting short- (≤30 days or in-hospital mortality) and long-term (>30 days) mortality among patients outside the intensive care unit setting. Studies reporting on the qSOFA and mortality were searched using MEDLINE and SCOPUS. Studies were included if they involved patients presenting to the ED with suspected infection and usage of qSOFA score for mortality prognostication. Data on qSOFA scores and mortality rates were extracted from 36 studies. The overall pooled sensitivity and specificity for the qSOFA were 48% and 86% for short-term mortality and 32% and 92% for long-term mortality, respectively. Studies reporting on short-term mortality were heterogeneous (Odd ratio, OR = 5.6; 95% CI = 4.6-6.8; Higgins's I2 = 94%), while long-term mortality studies were homogenous (OR = 4.7; 95% CI = 3.5-6.1; Higgins's I2 = 0%). There was no publication bias for short-term mortality analysis. The qSOFA score showed poor sensitivity but moderate specificity for both short and long-term mortality, with similar performance in predicting both short- and long- term mortality. Geographical region was shown to have nominal significant (p = 0.05) influence on qSOFA short-term mortality prediction.
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Affiliation(s)
- Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia.
| | - Ying Jing Tang
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Ling Jing Ching
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Noraidatulakma Abdullah
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Hui-Min Neoh
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
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Pedersen PB, Hrobjartsson A, Nielsen DL, Henriksen DP, Brabrand M, Lassen AT. Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review. PLoS One 2018; 13:e0206610. [PMID: 30383864 PMCID: PMC6211733 DOI: 10.1371/journal.pone.0206610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023] Open
Abstract
Introduction Patients in an emergency department are diverse. Some are more seriously ill than others and some even arrive in multi-organ failure. Knowledge of the prevalence of organ failure and its prognosis in unselected patients is important from a diagnostic, hospital planning, and from a quality evaluation point of view, but is not reported systematically. Objectives To analyse the prevalence and prognosis of new onset organ failure in unselected acute patients at arrival to hospital. Methods A systematic review of studies of prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital. We searched PubMed, Cochrane Library, Embase and Cinahl, and read references in included studies. Two authors decided independently on study eligibility and extracted data. Results were summarised qualitatively. Results Four studies were included with a total of 678,960 patients. The number of different organ failures reported in the studies ranged from one to six, and the settings were emergency departments and wards. The definitions of organ failure varied between studies. The prevalence of organ failure was 7%, 14%, 14%, and 23%, and in-hospital mortality was 5%, 11% and 15% respectively. The relative risk of in-hospital mortality for patients with organ failure compared to patients without organ failure varied from 2.58 to 8.65. Numbers of organ failures per 1,000 visits varied from 71 to 256. Conclusion The results of this review indicate that clinicians have good reasons to be alert when a patient arrives to the emergency department; as a state of organ failure seems both frequent and highly severe. However, most studies identified were performed in patients after a diagnosis was established, and only very few studies were performed in unselected patients. Systematic review registration number PROSPERO: CRD42017060871.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- * E-mail:
| | - Asbjørn Hrobjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark & Odense University Hospital, Odense, Denmark
| | | | - Daniel Pilsgaard Henriksen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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qSOFA score not predictive of in-hospital mortality in emergency patients with decompensated liver cirrhosis. Med Klin Intensivmed Notfmed 2018; 114:724-732. [PMID: 30132026 DOI: 10.1007/s00063-018-0477-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/27/2018] [Accepted: 07/08/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Quick sequential organ failure assessement (qSOFA) has been validated for patients with presumed sepsis and the general emergency department (ED) population. However, it has not been validated in specific subgroups of ED patients with a high mortality. We aimed to investigate the prognostic performance of qSOFA with respect to in-hospital mortality, intensive care unit (ICU) admission, and length of hospitalisation in patients with decompensated liver cirrhosis. Furthermore, we compared qSOFA to systemic inflammatory response syndrome (SIRS), model of end stage liver disease score (MELD), and Child-Pugh criteria and evaluated whether addition of sodium (Na+) levels to qSOFA increases its prognostic performance. METHODS This observational study included patients admitted with the diagnosis of decompensated liver cirrhosis. All patients with a complete set of vital parameters were included in this study. RESULTS A total of 186 patients were included. A positive qSOFA score was not associated with in-hospital mortality, ICU admission, or length of hospitalisation (all p > 0.15). MELD scores reliably predicted need for ICU admission and in-hospital mortality (both p < 0.01), but not the length of hospitalisation. qSOFA-Na+ only moderately increased the diagnostic performance of qSOFA with regard to need for ICU admission (AUCICU[qSOFA] = 0.504 vs. AUCICU[qSOFA-Na+] = 0.609, p = 0.03), but not for in-hospital mortality (AUCdeath[qSOFA] = 0.513 vs. AUCdeath[qSOFA-Na+] = 0.592, p = 0.054). CONCLUSION qSOFA does not predict in-hospital mortality, ICU admission or length of hospitalisation in patients with decompensated liver cirrhosis. Extension of qSOFA with a disease-specific component, the qSOFA-Na+, moderately increased the diagnostic ability of qSOFA.
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Prehospital antibiotics for sepsis: beyond mortality? THE LANCET RESPIRATORY MEDICINE 2018; 6:e8. [PMID: 29508708 DOI: 10.1016/s2213-2600(18)30061-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/11/2018] [Indexed: 11/21/2022]
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Song JU, Sin CK, Park HK, Shim SR, Lee J. Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:28. [PMID: 29409518 PMCID: PMC5802050 DOI: 10.1186/s13054-018-1952-x] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/12/2018] [Indexed: 01/14/2023]
Abstract
Background The usefulness of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in providing bedside criteria for early prediction of poor outcomes in patients with suspected infection remains controversial. We investigated the prognostic performance of a positive qSOFA score outside the intensive care unit (ICU) compared with positive systemic inflammatory response syndrome (SIRS) criteria. Methods A systematic literature search was performed using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Data were pooled on the basis of sensitivity, specificity, and diagnostic OR. Overall test performance was summarized using a hierarchical summary ROC and the AUC. Meta-regression analysis was used to identify potential sources of bias. Results We identified 23 studies with a total of 146,551 patients. When predicting in-hospital mortality in our meta-analysis, we identified pooled sensitivities of 0.51 for a positive qSOFA score and 0.86 for positive SIRS criteria, as well as pooled specificities of 0.83 for a positive qSOFA score and 0.29 for positive SIRS criteria. Discrimination for in-hospital mortality had similar AUCs between the two tools (0.74 vs. 0.71; P = 0.816). Using meta-regression analysis, an overall mortality rate ≥ 10% and timing of qSOFA score measurement could be significant sources of heterogeneity. For predicting acute organ dysfunction, although the AUC for a positive qSOFA score was higher than that for positive SIRS criteria (0.87 vs. 0.76; P < 0.001), the pooled sensitivity of positive qSOFA score was very low (0.47). In addition, a positive qSOFA score tended to be inferior to positive SIRS criteria in predicting ICU admission (0.63 vs. 0.78; P = 0.121). Conclusions A positive qSOFA score had high specificity outside the ICU in early detection of in-hospital mortality, acute organ dysfunction, and ICU admission, but low sensitivity may have limitations as a predictive tool for adverse outcomes. Because between-study heterogeneity was highly represented among the studies, our results should be interpreted with caution. Electronic supplementary material The online version of this article (10.1186/s13054-018-1952-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jae-Uk Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheol Kyung Sin
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Hye Kyeong Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik hospital, Inje University College of Medicine, Goyang-si, South Korea
| | - Sung Ryul Shim
- Institute for Clinical Molecular Biology Research, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Jonghoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Aran 13 gil 15, Jeju-si, Jeju Special Self-Governing Province, 63241, South Korea.
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Müller M, Guignard V, Schefold JC, Leichtle AB, Exadaktylos AK, Pfortmueller CA. Utility of quick sepsis-related organ failure assessment (qSOFA) to predict outcome in patients with pneumonia. PLoS One 2017; 12:e0188913. [PMID: 29267291 PMCID: PMC5739400 DOI: 10.1371/journal.pone.0188913] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 11/15/2017] [Indexed: 12/01/2022] Open
Abstract
Background Despite on-going advances in medical treatment, the burden of disease of pneumonia remains high. We aimed to determine the association of the qSOFA score with in-hospital mortality, length of hospitalisation, and admission to the intensive care unit (ICU) in patients with pneumonia. Further, in a subgroup analysis, the outcomes were compared for qSOFA in comparison to other risk scores, including the CURB-65 and SIRS scores. Methods In a retrospective analysis, admission data from the ED of the Bern University Hospital, Switzerland, were screened to identify patients admitted for pneumonia. In addition to clinical characteristics, qSOFA and CURB-65 scores and SIRS criteria were assessed and evaluated with respect to the defined study outcomes. Results 527 patients (median age 66 IQR 50–76) were included in this study. The overall in-hospital mortality was 13.3% (n = 70); 22.0% (n = 116) were transferred to the ICU. The median length of hospitalisation was 7 days (IQR 4–12). In comparison to qSOFA-negative patients, qSOFA-positive patients had increased odds ratios for in-hospital mortality (OR 2.6, 95%:1.4, 4.7, p<0.001) and ICU admission (3.5, 95% CI: 2.0. 5.8, p<0.001) and an increased length of stay (p<0.001). For ICU admission, the specificity of qSOPA-positivity (≥2) was 82.1% and sensitivity 43.0%. For in-hospital mortality, the specificity of qSOPA-positivity (≤2) was 88.9% and sensitivity 24.4%. In the subgroup analysis (n = 366). The area under the receiver operating curve for ICU admission was higher for qSOFA than for the CURB-65 score (p = 0.013). The evaluated scores did not differ significantly in their prognostication of in-hospital mortality (p>0.05). Conclusions The qSOFA score is associated with in-hospital mortality, ICU admission and length of hospitalisation in ED patients with pneumonia. Subgroup analysis revealed that qSOFA is superior to CURB-65 in respect to prognostication of ICU admission.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Viviane Guignard
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C. Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander B. Leichtle
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carmen A. Pfortmueller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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Quinten VM, van Meurs M, Renes MH, Ligtenberg JJM, Ter Maaten JC. Protocol of the sepsivit study: a prospective observational study to determine whether continuous heart rate variability measurement during the first 48 hours of hospitalisation provides an early warning for deterioration in patients presenting with infection or sepsis to the emergency department of a Dutch academic teaching hospital. BMJ Open 2017; 7:e018259. [PMID: 29151053 PMCID: PMC5702015 DOI: 10.1136/bmjopen-2017-018259] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/01/2017] [Accepted: 10/25/2017] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION One in five patients with sepsis deteriorates within 48 hours after hospital admission. Regrettably, a clear tool for the early detection of deterioration is still lacking. The SepsiVit study aims to determine whether continuous heart rate variability (HRV) measurement can provide an early warning for deterioration in patients presenting with suspected infection or sepsis to the emergency department (ED). METHODS AND ANALYSIS The protocol of a prospective observational study in the ED. We will include 171 adult medical patients presenting with suspected infection or sepsis and at least two systemic inflammatory response syndrome criteria. Patients with known pregnancy, cardiac transplantation or not admitted to our hospital are excluded.High sample frequency ECG signals (500 Hz), respiratory rate, blood pressure and peripheral oxygen saturation will be recorded continuously during the first 48 hours of hospitalisation using a bedside patient monitor (Philips IntelliVue MP70). Primary endpoint is patient deterioration, defined as the development of organ dysfunction, unplanned intensive care unit admission or in-hospital mortality. The ECG data will be used for offline HRV analysis. We will compare the HRV between two groups (deterioration/no deterioration) and analyse whether HRV provides an early warning for deterioration. Furthermore, we will create a multivariate predictive model for deterioration based on heart rate, respiratory rate and HRV. As planned secondary analyses, we (1) perform a subgroup analysis for patients with pneumosepsis and urosepsis and (2) determine whether HRV using lower sample frequencies (1 Hz or less) suffices to predict deterioration. ETHICS AND DISSEMINATION The Institutional Review Board of the University Medical Center Groningen granted a waiver for the study (METc 2015/164). Results will be disseminated through international peer-reviewed publications and conference presentations. A lay summary of the results will be provided to the study participants. TRIAL REGISTRATION NUMBER NTR6168; Pre-results.
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Affiliation(s)
- Vincent M Quinten
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pathology and Medical Biology, Medical Biology Section, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maurits H Renes
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jack J M Ligtenberg
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan C Ter Maaten
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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