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Sozio E, Pieralli F, Azzini AM, Tintori G, Demma F, Furneri G, Sbrana F, Bertolino G, Fortunato S, Meini S, Bragantini D, Morettini A, Nozzoli C, Menichetti F, Concia E, Tascini C. A prediction rule for early recognition of patients with candidemia in Internal Medicine: results from an Italian, multicentric, case-control study. Infection 2018; 46:625-633. [PMID: 29949088 DOI: 10.1007/s15010-018-1162-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/05/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Increasing prevalence of candidemia in Internal Medicine wards (IMWs) has been reported in recent years, but risk factors for candida bloodstream infection in patients admitted to IMW may differ from those known in other settings. The aim of this study was to identify risk factors and define a prediction rule for the early recognition of the risk of candidemia in IMW inpatients. METHODS This was a multicentric, retrospective, observational case-control study on non-neutropenic patients with candidemia admitted to IMWs of four large Italian Hospitals. Each eligible patient with candidemia (case) was matched to a control with bacteremia. Stepwise logistic regression analyses were performed. RESULTS Overall, 300 patients (150 cases and 150 controls) were enrolled. The following factors were associated with an increased risk of candidemia and weighted to build a score: total parenteral nutrition (OR 2.45, p = 0.008; 1 point); central venous catheter (OR 2.19, p = 0.031; 1 point); peripherally inserted central catheter (OR 5.63, p < 0.0001; 3 points), antibiotic treatment prior (OR 2.06; p = 0.059; 1 point) and during hospitalization (OR2.38, p = 0.033; 1 point); neurological disability (OR 2.25, p = 0.01; 1 point); and previous hospitalization within 3 months (OR 1.56, p = 0.163; 1 point). At ROC curve analysis, a final score ≥ 4 showed 84% sensitivity, 76% specificity, and 80% accuracy in predicting the risk of candidemia. CONCLUSIONS The proposed scoring system showed to be a simple and highly performing tool in distinguishing bloodstream infections due to Candida and bacteria in patients admitted to IMW. The proposed rule might help to reduce delay in empirical treatment and improve appropriateness in antifungal prescription in septic patients.
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Affiliation(s)
- Emanuela Sozio
- Emergency Department, North-West District, Tuscany HealthCare, Spedali Riuniti Livorno, Viale Alfieri 36, 57100, Leghorn, Italy.
| | - Filippo Pieralli
- Intermediate Care Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Anna Maria Azzini
- Infectious Disease Unit, Azienda Ospedaliera Universitaria Integrata di Verona, p.Le LA Scuro, Verona, Italy
| | - Giancarlo Tintori
- Emergency Medicine Unit, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Federica Demma
- Health Economics and Outcome Research Department-EBMA Consulting, Milan, Italy
| | - Gianluca Furneri
- Health Economics and Outcome Research Department-EBMA Consulting, Milan, Italy
| | | | | | - Simona Fortunato
- Infectious Diseases Clinic, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Simone Meini
- Department of Internal Medicine, S.M. Annunziata Hospital, Florence, Italy
| | - Damiano Bragantini
- Infectious Disease Unit, Azienda Ospedaliera Universitaria Integrata di Verona, p.Le LA Scuro, Verona, Italy
| | - Alessandro Morettini
- Internal Medicine Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Carlo Nozzoli
- Internal Medicine Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Francesco Menichetti
- Infectious Diseases Clinic, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Ercole Concia
- Infectious Disease Unit, Azienda Ospedaliera Universitaria Integrata di Verona, p.Le LA Scuro, Verona, Italy
| | - Carlo Tascini
- First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
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Taylor BT, Mancini M. Discrepancy between clinician and research assistant in TIMI score calculation (TRIAGED CPU). West J Emerg Med 2014; 16:24-33. [PMID: 25671004 PMCID: PMC4307721 DOI: 10.5811/westjem.2014.9.21685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/28/2014] [Accepted: 09/04/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Several studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify emergency department (ED) patients with potential acute coronary syndromes (ACS). Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED providers functioning in their normal work capacity. We assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators. Methods This was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. We examined provider type, patient gender, and TIMI elements for their effects on TIMI risk score discrepancy. Results Of the 501 adult patients enrolled in the study, 29.3% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. In our low-risk population the majority of TIMI risk score differences were small; however, 12% of TIMI risk scores differed by two or more points. Conclusion TIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider.
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Affiliation(s)
- Brian T Taylor
- Lakeland HealthCare, Department of Emergency Medicine, St. Joseph MI, Department of Emergency Medicine, Saint Joseph, Michigan
| | - Michelino Mancini
- Lakeland HealthCare, Department of Emergency Medicine, St. Joseph MI, Department of Emergency Medicine, Saint Joseph, Michigan
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Fox KAA, FitzGerald G, Puymirat E, Huang W, Carruthers K, Simon T, Coste P, Monsegu J, Gabriel Steg P, Danchin N, Anderson F. Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score. BMJ Open 2014; 4:e004425. [PMID: 24561498 PMCID: PMC3931985 DOI: 10.1136/bmjopen-2013-004425] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Risk scores are recommended in guidelines to facilitate the management of patients who present with acute coronary syndromes (ACS). Internationally, such scores are not systematically used because they are not easy to apply and some risk indicators are not available at first presentation. We aimed to derive and externally validate a more accurate version of the Global Registry of Acute Coronary Events (GRACE) risk score for predicting the risk of death or death/myocardial infarction (MI) both acutely and over the longer term. The risk score was designed to be suitable for acute and emergency clinical settings and usable in electronic devices. DESIGN AND SETTING The GRACE risk score (2.0) was derived in 32 037 patients from the GRACE registry (14 countries, 94 hospitals) and validated externally in the French registry of Acute ST-elevation and non-ST-elevation MI (FAST-MI) 2005. PARTICIPANTS Patients presenting with ST-elevation and non-ST elevation ACS and with long-term outcomes. OUTCOME MEASURES The GRACE Score (2.0) predicts the risk of short-term and long-term mortality, and death/MI, overall and in hospital survivors. RESULTS For key independent risk predictors of death (1 year), non-linear associations (vs linear) were found for age (p<0.0005), systolic blood pressure (p<0.0001), pulse (p<0.0001) and creatinine (p<0.0001). By employing non-linear algorithms, there was improved model discrimination, validated externally. Using the FAST-MI 2005 cohort, the c indices for death exceeded 0.82 for the overall population at 1 year and also at 3 years. Discrimination for death or MI was slightly lower than for death alone (c=0.78). Similar results were obtained for hospital survivors, and with substitutions for creatinine and Killip class, the model performed nearly as well. CONCLUSIONS The updated GRACE risk score has better discrimination and is easier to use than the previous score based on linear associations. GRACE Risk (2.0) performed equally well acutely and over the longer term and can be used in a variety of clinical settings to aid management decisions.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, , UK
| | - Gordon FitzGerald
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Etienne Puymirat
- Department of Cardiology, European Hospital of Georges Pompidou, Paris, France
- Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
- University Paris Descartes, Paris, France
- INSERM U-970, Paris, France
| | - Wei Huang
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kathryn Carruthers
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, , UK
| | - Tabassome Simon
- Department of Pharmacology, Assistance Publique-Hôpitaux de Paris, Hôpital St Antoine, Unité de Recherche Clinique (URCEST), Paris, France
- INSERM U698, Paris, France
- Université Pierre et Marie Curie-Paris 06, Paris, France
- Hôpital du Haut Levêque, Pessac, Paris, France
- Université Bordeaux Segalen, Bordeaux, France
| | | | - Jacques Monsegu
- Department of Cardiology, Hôpital du Val de Grâce, Paris, France
| | - Philippe Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
- INSERM U 698, Paris, France
- Université Paris Diderot, Paris, France
| | - Nicolas Danchin
- Department of Cardiology, European Hospital of Georges Pompidou, Paris, France
- Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
- University Paris Descartes, Paris, France
- INSERM U-970, Paris, France
| | - Fred Anderson
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Huynh T, Kouz S, Yan AT, Danchin N, O'Loughlin J, Schampaert E, Yan RT, Rinfret S, Tardif JC, Eisenberg MJ, Afilalo M, Chong A, Dery JP, Nguyen M, Lauzon C, Mansour S, Ko DT, Tu JV, Goodman S. Canada Acute Coronary Syndrome Risk Score: a new risk score for early prognostication in acute coronary syndromes. Am Heart J 2013; 166:58-63. [PMID: 23816022 DOI: 10.1016/j.ahj.2013.03.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 03/17/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite the availability of several acute coronary syndrome (ACS) prognostic risk scores, there is no appropriate score for early-risk stratification at the time of the first medical contact with patients with ACS. The primary objective of this study is to develop a simple risk score that can be used for early-risk stratification of patients with ACS. METHODS We derived the risk score from the Acute Myocardial Infarction in Quebec and Canada ACS-1 registries and validated the risk score in 4 other large data sets of patients with ACS (Canada ACS-2 registry, Canada-GRACE, EFFECT-1, and the FAST-MI registries). The final risk score is named the Canada Acute Coronary Syndrome Risk Score (C-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of each of these variables: age ≥75 years, Killip >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min. The primary end points were short-term (inhospital or 30-day) and long-term (1- or 5-year) all-cause mortality. RESULTS The C-ACS has good predictive values for short- and long-term mortality of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation ACS. The negative predictive value of a C-ACS score ≥1 is excellent at ≥98% (95% CI 0.97-0.99) for short-term mortality and ≥93% (95% CI 0.91-0.96) for long-term mortality. In other words, a C-ACS score of 0 can potentially identify correctly ≥97% short-term survivors and ≥91% long-term survivors. CONCLUSION The C-ACS risk score permits rapid stratification of patients with ACS. Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.
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Affiliation(s)
- Thao Huynh
- Division of Cardiology, McGill Health University Center, Quebec, Canada.
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The use of integrated care pathways in the management of acute coronary syndrome. Resuscitation 2008. [DOI: 10.1016/j.resuscitation.2008.03.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lagerqvist B, Diderholm E, Lindahl B, Husted S, Kontny F, Ståhle E, Swahn E, Venge P, Siegbahn A, Wallentin L. FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease. Heart 2005; 91:1047-52. [PMID: 16020594 PMCID: PMC1769057 DOI: 10.1136/hrt.2003.031369] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To develop a scoring system for risk stratification and evaluation of the effect of an early invasive strategy for treatment of unstable coronary artery disease (CAD). DESIGN Retrospective analysis of a randomised study (FRISC II; fast revascularisation in instability in coronary disease). SETTING 58 Scandinavian hospitals. PATIENTS 2457 patients with unstable CAD from the FRISC II study. MAIN OUTCOME MEASURES One year rates of mortality and death/myocardial infarction (MI). METHODS Patients were randomly assigned to an early invasive or a non-invasive strategy. From the non-invasive cohort independent variables of death or death/MI were identified. RESULTS Seven factors, age > 70 years, male sex, diabetes, previous MI, ST depression, and increased concentrations of troponins and markers of inflammation (interleukin 6 or C reactive protein), were associated with an independent increased risk for death or death/MI. In patients with > or = 5 of these factors the invasive strategy reduced mortality from 15.4% (20 of 130) to 5.2% (7 of 134) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.15 to 0.78, p = 0.006). Death/MI was also reduced in patients with 3-4 factors from 15.7% (80 of 511) to 10.8% (58 of 538) (RR 0.69, 95% CI 0.50 to 0.94, p = 0.02). Neither death nor death/MI was reduced in patients with 0-2 risk factors. CONCLUSION In unstable CAD, this scoring system based on factors independently associated with an adverse outcome can be used shortly after admission to the hospital for risk stratification and for selection of patients to an early invasive treatment strategy.
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Affiliation(s)
- B Lagerqvist
- Department of Medical Sciences, Cardiology, University Hospital, Uppsala, Sweden.
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