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Pepe F, Fabiani G, Cogozzo C, Mazzilli V, Villanti M, Pini R, Innocenti F. HACOR score to predict NIV failure in patients with COVID-related hypoxemic respiratory failure managed in the ordinary ward and in the critical care setting. Intern Emerg Med 2024:10.1007/s11739-024-03628-1. [PMID: 38739206 DOI: 10.1007/s11739-024-03628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024]
Abstract
We evaluated the prevalence of non-invasive ventilation (NIV) failure among patients with COVID-19-related pneumonia, managed in the ordinary ward and in the HDU/ICU and we tested the prognostic role of the HACOR score in those different settings. This is a retrospective study, conducted in the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring NIV between March 2020 and May 2021, respectively managed in the ordinary ward (G1) and in the critical care setting (G2). Clinical parameters, HACOR and SOFA score were evaluated at Day 0 and after 1, 2 and 5 days of treatment. The primary outcome was NIV failure. 13% G1 patients and 40% G2 patients underwent endotracheal intubation (ETI). NIV was successful in 60% G1 AND 43% G2 patients (p < 0.001). In G1, compared to those with successful NIV, patients who underwent ETI, had a higher HACOR since the baseline evaluation (T0: 6 [5-6] vs 5 [3-6]; T1: 6 [5-6] vs 5 [3-6], all p < 0.05). An HACOR score > 5 was associated with an increased prevalence of ETI independent to an advanced age and a SOFA score > 5 both in G1 (T1: RR 4.87, 95% CI 1.462-16.275; T5: 3.630, 95% CI 0.979-13.462) and G2 (T0: 1.76, 95% CI 0.906-3.422; T1: 3.38, 95% CI 1.386-8.265). Among patients with COVID-related-ARF, NIV could be managed in the ordinary ward in a consistent proportion of patients and, among them, an HACOR score > 5 was independently associated with increased NIV failure from the earliest evaluations.
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Affiliation(s)
- Francesco Pepe
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Ginevra Fabiani
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Carolina Cogozzo
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Valerio Mazzilli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Villanti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
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Yang Y, Griffin K, Li X, Sharp E, Young L, Garcia L, Griswold J, Pappas D. Combined CD25, CD64, and CD69 Biomarker in 3D-Printed Multizone Millifluidic Device for Sepsis Detection in Clinical Samples. Anal Chem 2023; 95:12819-12825. [PMID: 37556314 DOI: 10.1021/acs.analchem.3c01797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Sepsis is a serious medical condition that arises from a runaway response to an infection, which triggers the immune system to release chemicals into the bloodstream. This immune response can result in widespread inflammation throughout the body, which may cause harm to vital organs and, in more severe cases, lead to organ failure and death. Timely and accurate diagnosis of sepsis remains a challenge in analytical diagnostics. In this work, we have developed and validated a sepsis detection device, utilizing 3D printing technology, which incorporates multiple affinity separation zones. Our device requires minimal operator intervention and utilizes CD64, CD69, and CD25 as the biomarker targets for detecting sepsis in liquid biopsies. We assessed the effectiveness of our 3D-printed multizone cell separation device by testing it on clinical samples obtained from both septic patients (n = 35) and healthy volunteers (n = 8) and validated its performance accordingly. Unlike previous devices using poly(dimethyl siloxane), the 3D-printed device had reduced nonspecific binding for anti-CD25 capture, allowing this biomarker to be assayed for the first time in cell separations. Our results showed a statistically significant difference in cell capture between septic and healthy samples (with p values of 0.0001 for CD64, CD69, and CD25), suggesting that 3D-printed multizone cell capture is a reliable method for distinguishing sepsis. A receiver operator characteristic (ROC) analysis was performed to determine the accuracy of the captured cell counts for each antigen in detecting sepsis. The ROC area under the curve (AUC) values for on-chip detection of CD64+, CD69+, and CD25+ leukocytes were 0.96, 0.92, and 0.88, respectively, indicating our diagnostic test matches clinical outcomes. When combined for sepsis diagnosis, the AUC value for CD64, CD69, and CD25 was 0.99, indicating an improved diagnostic performance due to the use of multiple biomarkers.
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Affiliation(s)
- Yijia Yang
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409, United States
| | - Kitiara Griffin
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409, United States
| | - Xiao Li
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409, United States
| | - Elizabeth Sharp
- Clinical Research Institute, Texas Tech Health Sciences Center, Lubbock, Texas 79409, United States
| | - Lane Young
- Clinical Research Institute, Texas Tech Health Sciences Center, Lubbock, Texas 79409, United States
| | - Liza Garcia
- Clinical Research Institute, Texas Tech Health Sciences Center, Lubbock, Texas 79409, United States
| | - John Griswold
- Department of Surgery, Texas Tech Health Sciences Center, Lubbock, Texas 79409, United States
| | - Dimitri Pappas
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas 79409, United States
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Fang Y, Zhong Q, Chen Y, Hang Y, Fang X, Xiao Y, Cao X, Zhu H, Luo H, Peng S, Gu S, Li F, Zhu J, Xiong J, Hu L. Ceftazidime/Avibactam, Polymyxin or Tigecycline as a Rescue Strategy for the Treatment of Carbapenem-Resistant Klebsiella pneumoniae in Bloodstream Infection: A Retrospective Cohort Study. Infect Drug Resist 2023; 16:2963-2971. [PMID: 37201125 PMCID: PMC10187681 DOI: 10.2147/idr.s409506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023] Open
Abstract
Objective To analyze the clinical characteristics, outcomes, and risk factors of patients treated with ceftazidime/avibactam, polymyxin, or tigecycline (CPT) compared with those receiving a conventional therapy (CT) (ie, imipenem, levofloxacin, or gentamicin). Methods A single-center retrospective cohort study included patients with carbapenem-resistant Klebsiella pneumoniae bloodstream infection (CRKP-BSI) treated at one Chinese tertiary hospital between March 2012 and November 2022 was performed. Clinical characteristics, outcomes, and risk factors of patients treated with CPT or CT were compared. Predictors of 30-day mortality of patients with CRKP-BSI were also analysed in our study. Results Among 184 recruited patients with CRKP-BSI, 39.7% (73/184) were treated with CPT, while 60.3% (111/184) were treated with CT. Compared to patients treated with CT, patients treated with CPT had worse conditions, as evidenced by a higher rate of underlying diseases and invasive procedures; however, they also had a better prognosis and lower rates of 14-day treatment failure (p = 0.024). In addition, univariate analysis and multivariate analysis showed that SOFA score [odds ratio (OR) = 1.310, 95% confidence interval (CI) 1.157-1.483; p < 0.001] and cold weather (OR = 3.658, 95% CI 1.474-9.081; p = 0.005) were independent risk factors for 30-day mortality. Conclusion Compared to CRKP-BSI patients treated with CT, patients treated with CPT had worse conditions but better prognoses. CRKP-BSI occurred more frequently in hot weather; however, higher 30-day mortality was associated with cold weather. A randomized trial is needed to confirm these observational results.
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Affiliation(s)
- Youling Fang
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
- School of Public Health, Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Qiaoshi Zhong
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Yanhui Chen
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Yaping Hang
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Xueyao Fang
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Yanping Xiao
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Xingwei Cao
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Hongying Zhu
- Clinical Laboratory of Ganzhou People’s Hospital, Ganzhou, Jiangxi, People’s Republic of China
| | - Hong Luo
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Suqin Peng
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Shumin Gu
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Fuxing Li
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Junqi Zhu
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Jianqiu Xiong
- Department of Nursing, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Longhua Hu
- Department of Jiangxi Provincial Key Laboratory of Medicine, Clinical Laboratory of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
- Correspondence: Longhua Hu; Jianqiu Xiong, Email ;
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Zhang F, Wan T, Liu X, Guo S. Prediction of short-term mortality in elderly patients with sepsis using immunoglobulin G2: An observational study. Heliyon 2022; 8:e12642. [PMID: 36619404 PMCID: PMC9816988 DOI: 10.1016/j.heliyon.2022.e12642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/06/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Sepsis is a global healthcare issue and continues to cause high mortality especially in elderly patients. The humoral immune system plays an important role in protecting from microbial contamination. The goal of this study is to investigate the immune status and prognostic evaluation of elderly patients with sepsis. Methods A single-center, prospective observational study has been conducted, with the endpoint being the 28-day mortality. Patients 65 years and older who met the diagnostic criteria of Sepsis-3 in the Emergency Department of Beijing Chao-Yang Hospital were divided into survivors and non-survivors groups. Levels of immunoglobulin (Ig) A, IgG, IgM and their subclasses as well as clinical indicators were collected upon enrollment, and the results were statistically analyzed. Results This study finally enrolled 106 elderly patients, including 68 survivors and 38 non-survivors. Compared with survivors, IgG2 level and IgG4 level were lower in non-survivors ( P < 0.05 ). IgG2 could be regarded as an independent predictor of the 28-day mortality in elderly septic patients. IgG2 had a higher predictive value than other immunoglobulins, lactate, procalcitonin, SOFA score and APACHE II score for mortality in elderly septic patients, and the ratio of IgG2 to IgG had a slightly larger area under the ROC curve compared to IgG2 only (AUC: 0.776 v.s. 0.741). Conclusion IgG subclasses play important roles in the prognosis of elderly septic patients, with IgG2 being the main component. IgG2 was found to outperform other immunoglobulins, lactate, procalcitonin, SOFA score and APACHE II score in terms of predicting the mortality. A complete immunological evaluation is helpful to guide the prognosis and treatment of patients with age-related infection.
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Quantification of diaphragmatic dynamic dysfunction in septic patients by bedside ultrasound. Sci Rep 2022; 12:17336. [PMID: 36243883 PMCID: PMC9569367 DOI: 10.1038/s41598-022-21702-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/30/2022] [Indexed: 01/10/2023] Open
Abstract
Although diaphragmatic dysfunction is an important indicator of severity of illness and poor prognosis in ICU patients, there is no convenient and practical method to monitor diaphragmatic function. This study was designed to analyze diaphragmatic dynamic dysfunction by bedside ultrasound in septic patients and provide quantitative evidence to assess diaphragm function systematically. This prospective observational study was conducted from October 2019 to January 2021 in the Department of Respiratory and Critical Care Medicine. 74 patients suffered from sepsis were recruited and divided into two groups, sepsis group 1 (2 ≤ SOFA ≤ 5, n = 41) and sepsis group 2 (SOFA > 5, n = 33). 107 healthy volunteers were randomly recruited as the control group. In all participants, the diaphragmatic thickness and excursion were measured directly and the dynamic parameters including thickening fraction (TF), EQB/EDB, Contractile velocity, and area under diaphragmatic movement curve (AUDMC) were calculated by bedside ultrasound during quiet breathing (QB) and deep breathing (DB). Each parameter among three groups was analyzed separately by covariance analysis, which was adjusted by age, sex, body mass index, MAP, hypertension, and diabetes. First, contractile dysfunction occurred before diaphragmatic atrophy both in sepsis group 1 and sepsis group 2. Second, compared with the control group, the dynamic parameters showed significant decrease in sepsis group 1 and more obvious change in sepsis group 2, including TF, EQB/EDB. Third, the maximum contractile velocity decreased in sepsis group 1, reflecting the damage of intrinsic contraction efficiency accurately. Finally, per breathing AUDMC in two septic groups were lower than those in control group. However, per minute AUDMC was compensated by increasing respiratory rate in sepsis group 1, whereas it failed to be compensated which indicated gradual failure of diaphragm in sepsis group 2. Diaphragmatic ultrasound can be used to quantitatively evaluate the severity of sepsis patients whose contractile dysfunction occurred before diaphragmatic atrophy. As dynamic parameters, TF and EQB/EDB are early indicator associated with diaphragmatic injury. Furthermore, maximum contractile velocity can reflect intrinsic contraction efficiency accurately. AUDMC can evaluate diaphragmatic breathing effort and endurance to overcome resistance loads effectively.
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Feng K, Dai W, Liu L, Li S, Gou Y, Chen Z, Chen G, Fu X. Identification of biomarkers and the mechanisms of multiple trauma complicated with sepsis using metabolomics. Front Public Health 2022; 10:923170. [PMID: 35991069 PMCID: PMC9387941 DOI: 10.3389/fpubh.2022.923170] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/14/2022] [Indexed: 12/02/2022] Open
Abstract
Sepsis after trauma increases the risk of mortality rate for patients in intensive care unit (ICUs). Currently, it is difficult to predict outcomes in individual patients with sepsis due to the complexity of causative pathogens and the lack of specific treatment. This study aimed to identify metabolomic biomarkers in patients with multiple trauma and those with multiple trauma accompanied with sepsis. Therefore, the metabolic profiles of healthy persons designated as normal controls (NC), multiple trauma patients (MT), and multiple trauma complicated with sepsis (MTS) (30 cases in each group) were analyzed with ultra-high performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UHPLC-Q-TOF/MS)-based untargeted plasma metabolomics using collected plasma samples. The differential metabolites were enriched in amino acid metabolism, lipid metabolism, glycometabolism and nucleotide metabolism. Then, nine potential biomarkers, namely, acrylic acid, 5-amino-3-oxohexanoate, 3b-hydroxy-5-cholenoic acid, cytidine, succinic acid semialdehyde, PE [P-18:1(9Z)/16:1(9Z)], sphinganine, uracil, and uridine, were found to be correlated with clinical variables and validated using receiver operating characteristic (ROC) curves. Finally, the three potential biomarkers succinic acid semialdehyde, uracil and uridine were validated and can be applied in the clinical diagnosis of multiple traumas complicated with sepsis.
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Affiliation(s)
- Ke Feng
- Department of Emergency, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wenjie Dai
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan, China
| | - Ling Liu
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan, China
| | - Shengming Li
- Department of Emergency, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yi Gou
- Department of Emergency, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhongwei Chen
- Department of Emergency, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Guodong Chen
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan, China
- *Correspondence: Guodong Chen
| | - Xufeng Fu
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan, China
- Xufeng Fu
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Innocenti F, Palmieri V, Stefanone VT, D'Argenzio F, Cigana M, Montuori M, Capretti E, De Paris A, Calcagno S, Tassinari I, Pini R. Comparison of Troponin I levels versus myocardial dysfunction on prognosis in sepsis. Intern Emerg Med 2022; 17:223-231. [PMID: 33730362 DOI: 10.1007/s11739-021-02701-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
In the context of sepsis, we tested the relationship between echocardiographic findings and Troponin, and their impact on prognosis. In this prospective study, we enrolled 325 septic patients (41% with shock), not mechanically ventilated, between October, 2012 and June, 2019 among those admitted to our High-Dependency Unit. By echocardiography within 24 h from the admission, sepsis-induced myocardial dysfunction (SIMD) was defined as left ventricular (LV) systolic dysfunction (speckle-tracking-based global longitudinal peak systolic strain, GLS, > - 14%) and/or right ventricular (RV) systolic dysfunction (Tricuspid Annular Plane Systolic Excursion, TAPSE < 16 mm). Troponin I levels were measured upon admission (T0) and after 24 h (T1); it was considered normal if > 0.1 ng/mL. Mortality was assessed at day-7 and day-28 end-points. One-hundred and forty-two patients had normal Troponin level at T0 and T1 (G1), 69 had abnormal levels at T0 or T1 (G2) and 114 showed abnormal Troponin levels at both T0 and T1 (G3). Compared to G1, patients in G3 had worse LV and RV systolic function (GLS - 11.6 ± 3.4% vs - 14.0 ± 3.5%, p < 0.001; TAPSE 18 ± 0.5 vs 19 ± 0.5 mm, p = 0.047) and greater day-28 (34% vs 20%, p = 0.015) mortality. In a Cox survival analysis including age, Troponin and SOFA score, mortality was predicted by the presence of SIMD (RR 3.24, 95% CI 1.72-6.11, p < 0.001) with no contribution of abnormal Troponin level. While abnormal Troponin levels were associated with SIMD diagnosed by echocardiography, only the presence of SIMD predicted the short- and medium-term mortality rate, without an independent contribution of increased Troponin levels.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy.
| | - Vittorio Palmieri
- Transplant Cardiosurgery Unit, Department of Cardiac Surgery and Transplant, Ospedale Dei Colli Monaldi-Cotugno-CTO, Naples, Italy
| | - Valerio Teodoro Stefanone
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Federico D'Argenzio
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Marco Cigana
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Michele Montuori
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Elisa Capretti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Anna De Paris
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Stefano Calcagno
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Irene Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
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Biscardi E, Carpinteri G, Castellino P, Malatino L. Use of CytoSorb in the emergency department-high dependency unit: A case report and a mini review. EMERGENCY CARE JOURNAL 2021. [DOI: 10.4081/ecj.2021.9825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Circulating inflammatory mediators and cytokines play a pivotal role in the progression of sepsis, leading in turn to septic shock, organ failure and resistance to standard therapy. Blood purification therapies may be adjuvant treatment for severe sepsis, but results have been shown to be so far controversial. Recently, CytoSorb has achieved promising outcomes on reduction of cytokine blood levels, improvement of clinical parameters and mortality in sepsis, as well as in other acute conditions. It is mostly used in Intensive Care Unit (ICU), in isolated hemoperfusion, or inserted in other circuits in addition to Continuous Renal Replacement Therapy (CRRT), heart-lung machines and extracorporeal membrane oxygenation. We report a case of septic shock occurred in our Emergency Department-High Dependency Unit (ED-HDU), resistant to standard therapy and improved after CytoSorb, so avoiding ICU hospitalization.
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Colussi G, Perrotta G, Pillinini P, Dibenedetto AG, Da Porto A, Catena C, Sechi LA. Prognostic scores and early management of septic patients in the emergency department of a secondary hospital: results of a retrospective study. BMC Emerg Med 2021; 21:152. [PMID: 34876007 PMCID: PMC8650550 DOI: 10.1186/s12873-021-00547-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Sequential Organ Failure Assessment (SOFA) and other illness prognostic scores predict adverse outcomes in critical patients. Their validation as a decision-making tool in the emergency department (ED) of secondary hospitals is not well established. The aim of this study was to compare SOFA, NEWS2, APACHE II, and SAPS II scores as predictors of adverse outcomes and decision-making tool in ED. METHODS Data of 121 patients (age 73 ± 10 years, 58% males, Charlson Comorbidity Index 5.7 ± 2.1) with a confirmed sepsis were included in a retrospective study between January 2017 and February 2020. Scores were computed within the first 24 h after admission. Primary outcome was the occurrence of either in-hospital death or mechanical ventilation within 7 days. Secondary outcome was 30-day all-cause mortality. RESULTS Patients older than 64 years (elderly) represent 82% of sample. Primary and secondary outcomes occurred in 40 and 44%, respectively. Median 30-day survival time of dead patients was 4 days (interquartile range 1-11). The best predictive score based on the area under the receiver operating curve (AUROC) was SAPS II (0.823, 95% confidence interval, CI, 0.744-0.902), followed by APACHE II (0.762, 95% CI 0.673-0.850), NEWS2 (0.708, 95% CI 0.616-0.800), and SOFA (0.650, 95% CI 0.548-0.751). SAPS II cut-off of 49 showed the lowest false-positive rate (12, 95% CI 5-20) and the highest positive predictive value (80, 95% CI 68-92), whereas NEWS2 cut-off of 7 showed the lowest false-negative rate (10, 95% CI 2-19) and the highest negative predictive value (86, 95% CI 74-97). By combining NEWS2 and SAPS II cut-offs, we accurately classified 64% of patients. In survival analysis, SAPS II cut-off showed the highest difference in 30-day mortality (Hazards Ratio, HR, 5.24, 95% CI 2.99-9.21, P < 0.001). Best independent negative predictors of 30-day mortality were body temperature, mean arterial pressure, arterial oxygen saturation, and hematocrit levels. Positive predictors were male sex, heart rate and serum sodium concentration. CONCLUSIONS SAPS II is a good prognostic tool for discriminating high-risk patient suitable for sub-intensive/intensive care units, whereas NEWS2 for discriminating low-risk patients for low-intensive units. Our results should be limited to cohorts with a high prevalence of elderly or comorbidities.
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Affiliation(s)
- GianLuca Colussi
- Division of Internal Medicine and Emergency Medicine Residency Program, Department of Medicine, University of Udine, 1st floor, Building n.8, Piazzale Santa Maria della Misericordia 1, 33100, Udine, UD, Italy.
| | - Giacomo Perrotta
- Division of Internal Medicine and Emergency Medicine Residency Program, Department of Medicine, University of Udine, 1st floor, Building n.8, Piazzale Santa Maria della Misericordia 1, 33100, Udine, UD, Italy
| | - Pierpaolo Pillinini
- Emergency Department, San Antonio Abate Hospital, ASUFC, 33028, Tolmezzo, Italy
| | | | - Andrea Da Porto
- Division of Internal Medicine and Emergency Medicine Residency Program, Department of Medicine, University of Udine, 1st floor, Building n.8, Piazzale Santa Maria della Misericordia 1, 33100, Udine, UD, Italy
| | - Cristiana Catena
- Division of Internal Medicine and Emergency Medicine Residency Program, Department of Medicine, University of Udine, 1st floor, Building n.8, Piazzale Santa Maria della Misericordia 1, 33100, Udine, UD, Italy
| | - Leonardo A Sechi
- Division of Internal Medicine and Emergency Medicine Residency Program, Department of Medicine, University of Udine, 1st floor, Building n.8, Piazzale Santa Maria della Misericordia 1, 33100, Udine, UD, Italy
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Brescia-COVID Respiratory Severity Scale (BRCSS) and Quick SOFA (qSOFA) score are most useful in showing severity in COVID-19 patients. Sci Rep 2021; 11:21807. [PMID: 34750412 PMCID: PMC8575935 DOI: 10.1038/s41598-021-01181-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/28/2021] [Indexed: 12/27/2022] Open
Abstract
In this study, we compare the predictive value of clinical scoring systems that are already in use in patients with Coronavirus disease 2019 (COVID-19), including the Brescia-COVID Respiratory Severity Scale (BCRSS), Quick SOFA (qSOFA), Sequential Organ Failure Assessment (SOFA), Multilobular infiltration, hypo-Lymphocytosis, Bacterial coinfection, Smoking history, hyper-Tension, and Age (MuLBSTA) and scoring system for reactive hemophagocytic syndrome (HScore), for determining the severity of the disease. Our aim in this study is to determine which scoring system is most useful in determining disease severity and to guide clinicians. We classified the patients into two groups according to the stage of the disease (severe and non-severe) and adopted interim guidance of the World Health Organization. Severe cases were divided into a group of surviving patients and a deceased group according to the prognosis. According to admission values, the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore were evaluated at admission using the worst parameters available in the first 24 h. Of the 417 patients included in our study, 46 (11%) were in the severe group, while 371 (89%) were in the non-severe group. Of these 417 patients, 230 (55.2%) were men. The median (IQR) age of all patients was 44 (25) years. In multivariate logistic regression analyses, BRCSS in the highest tertile (HR 6.1, 95% CI 2.105–17.674, p = 0.001) was determined as an independent predictor of severe disease in cases of COVID-19. In multivariate analyses, qSOFA was also found to be an independent predictor of severe COVID-19 (HR 4.757, 95% CI 1.438–15.730, p = 0.011). The area under the curve (AUC) of the BRCSS, qSOFA, SOFA, MuLBSTA, and HScore was 0.977, 0.961, 0.958, 0.860, and 0.698, respectively. Calculation of the BRCSS and qSOFA at the time of hospital admission can predict critical clinical outcomes in patients with COVID-19, and their predictive value is superior to that of HScore, MuLBSTA, and SOFA. Our prediction is that early interventions for high-risk patients, with early identification of high-risk group using BRCSS and qSOFA, may improve clinical outcomes in COVID-19.
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11
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Andreassen S, Møller JK, Eliakim-Raz N, Lisby G, Ward L. A comparison of predictors for mortality and bacteraemia in patients suspected of infection. BMC Infect Dis 2021; 21:864. [PMID: 34425790 PMCID: PMC8383375 DOI: 10.1186/s12879-021-06547-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Background Stratification by clinical scores of patients suspected of infection can be used to support decisions on treatment and diagnostic workup. Seven clinical scores, SepsisFinder (SF), National Early Warning Score (NEWS), Sequential Orgen Failure Assessment (SOFA), Mortality in Emergency Department Sepsis (MEDS), quick SOFA (qSOFA), Shapiro Decision Rule (SDR) and Systemic Inflammatory Response Syndrome (SIRS), were evaluated for their ability to predict 30-day mortality and bacteraemia and for their ability to identify a low risk group, where blood culture may not be cost-effective and a high risk group where direct-from-blood PCR (dfbPCR) may be cost effective. Methods Retrospective data from two Danish and an Israeli hospital with a total of 1816 patients were used to calculate the seven scores. Results SF had higher Area Under the Receiver Operating curve than the clinical scores for prediction of mortality and bacteraemia, significantly so for MEDS, qSOFA and SIRS. For mortality predictions SF also had significantly higher area under the curve than SDR. In a low risk group identified by SF, consisting of 33% of the patients only 1.7% had bacteraemia and mortality was 4.2%, giving a cost of € 1976 for one positive result by blood culture. This was higher than the cost of € 502 of one positive dfbPCR from a high risk group consisting of 10% of the patients, where 25.3% had bacteraemia and mortality was 24.2%. Conclusion This may motivate a health economic study of whether resources spent on low risk blood cultures might be better spent on high risk dfbPCR.
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Affiliation(s)
- Steen Andreassen
- Treat Systems ApS, Ålborg, Denmark. .,Department of Health Science and Technology, Aalborg University, Ålborg, Denmark.
| | - Jens Kjølseth Møller
- Department of Clinical Microbiology, University Hospital of Southern Denmark, Lillebælt Hospital, Vejle, Denmark
| | - Noa Eliakim-Raz
- Department of Medicine E, Beilinson Hospital, Rabin Medical Centre, Petah Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gorm Lisby
- Department of Clinical Microbiology, University Hospital of Copenhagen, Amager og Hvidovre Hospital, Hvidovre, Denmark
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12
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Sethi S, Iqbal M, Sabeen A, Sabir S, Almas A. Association of critical illness scores (q-SOFA and APACHE) and multimorbidity in patients admitted to internal medicine step down units. Clin Med (Lond) 2021; 20:s47-s48. [PMID: 32409368 DOI: 10.7861/clinmed.20-2-s47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Sher Sethi
- Aga Khan University Hospital, Karachi, Pakistan
| | | | | | - Sania Sabir
- Aga Khan University Hospital, Karachi, Pakistan
| | - Aysha Almas
- Aga Khan University Hospital, Karachi, Pakistan
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13
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Xie Y, Li B, Lin Y, Shi F, Chen W, Wu W, Zhang W, Fei Y, Zou S, Yao C. Combining Blood-Based Biomarkers to Predict Mortality of Sepsis at Arrival at the Emergency Department. Med Sci Monit 2021; 27:e929527. [PMID: 33630815 PMCID: PMC7923396 DOI: 10.12659/msm.929527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Our aim was to determine a useful combination of blood biomarkers that can predict 28-day mortality of sepsis upon arrival at the Emergency Department (ED). Material/Methods Based on Sepsis-3.0, 90 sepsis patients were enrolled and divided into survivor and nonsurvivor groups with day 28 as the study end point. After comparing the demographic data and clinical characteristics of patients, we evaluated the predictive validity of a combination of markers including interleukin-6 (IL-6), procalcitonin (PCT), and lactate at arrival at the ED. Independent risk factors were found by using univariate and multivariate logistic regression analyses, and the prognostic value of markers was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Results There were 67 (74.4%) survivors and 23 (25.6%) nonsurvivors. The levels of IL-6 (survivors vs nonsurvivors: median 205.30 vs 3499.00 pg/mL, P=0.012) and lactate (survivors vs nonsurvivors: median 2.37 vs 5.77 mmol/L, P=0.003) were significantly lower in survivor group compared with the nonsurvivor group. Markers including IL-6, PCT, lactate, and neutrophil-to-white blood cell ratio (NWR) were independent risk factors in predicting 28-day mortality due to sepsis. The combination of these 4 markers provided the best predictive performance for 28-day mortality of patients with sepsis, on arrival at the ED (AUC of 0.823, 95% confidence interval [CI] 0.723–0.924), and its accuracy, specificity, and sensitivity were 74.4% (95% CI 64.0–82.8%), 91% (95% CI 80.9–96.3%), and 65% (95% CI 42.8–82.8%), respectively. Conclusions The combination of IL-6, PCT, lactate, and NWR measurements is a potential predictor of 28-day mortality for patients with sepsis, at arrival at the ED. Further research is needed to confirm our findings.
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Affiliation(s)
- Yinjing Xie
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Binbin Li
- Emergency Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Ying Lin
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Fei Shi
- Emergency Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Weibu Chen
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Wenyuan Wu
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Wenjia Zhang
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Yun Fei
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Shiqing Zou
- Laboratory Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
| | - Can Yao
- Emergency Department, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China (mainland)
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14
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Mortality prediction using a novel combination of biomarkers in the first day of sepsis in intensive care units. Sci Rep 2021; 11:1275. [PMID: 33446739 PMCID: PMC7809407 DOI: 10.1038/s41598-020-79843-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023] Open
Abstract
Early identification of infection severity and organ dysfunction is crucial in improving outcomes of patients with sepsis. We aimed to develop a new combination of blood-based biomarkers that can early predict 28-day mortality in patients with sepsis or septic shock. We enrolled 66 patients with sepsis or septic shock and compared 14 blood-based biomarkers in the first 24 h after ICU admission. The serum levels of interleukin-6 (IL-6) (median 217.6 vs. 4809.0 pg/ml, P = 0.001), lactate (median 2.4 vs. 6.3 mmol/L, P = 0.014), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) (median 1596.5 vs. 32,905.3 ng/ml, P < 0.001), prothrombin time (PT) (median 15.6 vs. 20.1 s, P = 0.030), activated partial thrombin time (APTT) (median 45.1 vs. 59.0 s, P = 0.026), and international normalized ratio (INR) (median 1.3 vs. 1.8, P < 0.001) were significantly lower in the survivor group. IL-6, NT-proBNP, and INR provided the best individual performance in predicting 28-day mortality of patients with sepsis or septic shock. Furthermore, the combination of these three biomarkers achieved better predictive performance (AUC 0.890, P < 0.001) than conventional scoring systems. In summary, the combination of IL-6, NT-proBNP, and INR may serve as a potential predictor of 28-day mortality in critically ill patients with sepsis or septic shock.
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15
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López-Izquierdo R, del Brio-Ibañez P, Martín-Rodríguez F, Mohedano-Moriano A, Polonio-López B, Maestre-Miquel C, Viñuela A, Durantez-Fernández C, Villamor MÁC, Martín-Conty JL. Role of qSOFA and SOFA Scoring Systems for Predicting In-Hospital Risk of Deterioration in the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228367. [PMID: 33198151 PMCID: PMC7698163 DOI: 10.3390/ijerph17228367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/13/2022]
Abstract
The objective of this study was to analyze and compare the usefulness of quick sequential organ failure assessment score (qSOFA) and sequential organ failure assessment (SOFA) scores for the detection of early (two-day) mortality in patients transported by emergency medical services (EMSs) to the emergency department (ED) (infectious and non-infectious). We performed a multicentric, prospective and blinded end-point study in adults transported with high priority by ambulance from the scene to the ED with the participation of five hospitals. For each score, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve was calculated. We included 870 patients in the final cohort. The median age was 70 years (IQR 54–81 years), and 338 (38.8%) of the participants were women. Two-day mortality was 8.3% (73 cases), and 20.9% of cases were of an infectious pathology. For two-day mortality, the qSOFA presented an AUC of 0.812 (95% CI: 0.75–0.87; p < 0.001) globally with a sensitivity of 84.9 (95% CI: 75.0–91.4) and a specificity of 69.4 (95% CI: 66.1–72.5), and a SOFA of 0.909 (95% CI: 0.86–0.95; p < 0.001) with sensitivity of 87.7 (95% CI: 78.2–93.4) and specificity of 80.7 (95% CI: 77.4–83.3). The qSOFA score can serve as a simple initial assessment to detect high-risk patients, and the SOFA score can be used as an advanced tool to confirm organ dysfunction.
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Affiliation(s)
- Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain;
| | | | - Francisco Martín-Rodríguez
- Advanced Life Support Unit, Emergency Medical Services, Advanced Clinical Simulation Centre, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain
- Correspondence: ; Tel.: +34-686-452-313
| | - Alicia Mohedano-Moriano
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Begoña Polonio-López
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Clara Maestre-Miquel
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Antonio Viñuela
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Carlos Durantez-Fernández
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Miguel Á. Castro Villamor
- Advanced Clinical Simulation Centre, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain;
| | - José L. Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
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16
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Liu R, Greenstein JL, Fackler JC, Bembea MM, Winslow RL. Spectral clustering of risk score trajectories stratifies sepsis patients by clinical outcome and interventions received. eLife 2020; 9:58142. [PMID: 32959779 PMCID: PMC7508552 DOI: 10.7554/elife.58142] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022] Open
Abstract
Sepsis is not a monolithic disease, but a loose collection of symptoms with diverse outcomes. Thus, stratification and subtyping of sepsis patients is of great importance. We examine the temporal evolution of patient state using our previously-published method for computing risk of transition from sepsis into septic shock. Risk trajectories diverge into four clusters following early prediction of septic shock, stratifying by outcome: the highest-risk and lowest-risk groups have a 76.5% and 10.4% prevalence of septic shock, and 43% and 18% mortality, respectively. These clusters differ also in treatments received and median time to shock onset. Analyses reveal the existence of a rapid (30–60 min) transition in risk at the time of threshold crossing. We hypothesize that this transition occurs as a result of the failure of compensatory biological systems to cope with infection, resulting in a bifurcation of low to high risk. Such a collapse, we believe, represents the true onset of septic shock. Thus, this rapid elevation in risk represents a potential new data-driven definition of septic shock.
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Affiliation(s)
- Ran Liu
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, United States.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Baltimore, United States
| | - Joseph L Greenstein
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, United States
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, United States.,Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, United States
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, United States.,Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, United States
| | - Raimond L Winslow
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, United States.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Baltimore, United States
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17
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Wang ZH, Shu C, Ran X, Xie CH, Zhang L. Critically Ill Patients with Coronavirus Disease 2019 in a Designated ICU: Clinical Features and Predictors for Mortality. Risk Manag Healthc Policy 2020; 13:833-845. [PMID: 32765138 PMCID: PMC7381092 DOI: 10.2147/rmhp.s263095] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) is a worldwide pandemic outbreak with a high mortality. Prognostic factors of critically ill patients with COVID-19 have not been fully elucidated yet. Methods In the present study, 59 patients with COVID-19 from the intensive care unit of the Caidian Branch of Tongji Hospital were enrolled. Epidemiological, demographic, clinical, laboratory, radiological, treatment data, and clinical outcomes were collected. Prognostic factors were statistically defined. Results Of the 59 patients studied (67.4±11.3 years), 38 patients were male, 51 had underlying diseases, and 41 patients died during admission. Compared with the survivors, the deceased patients were of older age, had more smoking history, severer fatigue, and diarrhea, a higher incidence of multiple organ injuries, more deteriorative lymphopenia and thrombocytopenia, remarkably impaired cellular immune response, and strengthened cytokine release. Age higher than 70 (OR=2.76, 95% CI=1.45–5.23), arrhythmia (OR=4.76, 95% CI=1.59–14.25), and a Sequential Organ Failure Assessment (SOFA) score above 4 (OR=5.16, 95% CI=1.29–20.55) were identified as risk factors for mortality of patients. Conclusion Critically ill COVID-19 patients aged higher than 70, arrhythmia, or a SOFA score above 4 have a high risk of mortality, and need prior medical intervention.
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Affiliation(s)
- Zhao-Hua Wang
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Chang Shu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Xiao Ran
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Cui-Hong Xie
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Lei Zhang
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
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18
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Son J, Choi S, Huh JW, Lim CM, Koh Y, Kim KM, Shim JH, Lim YS, Hong SB. The quick sepsis-related organ failure score has limited value for predicting adverse outcomes in sepsis patients with liver cirrhosis. Korean J Intern Med 2020; 35:861-872. [PMID: 31645093 PMCID: PMC7373976 DOI: 10.3904/kjim.2018.229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/AIMS The quick Sepsis-related Organ Failure Assessment (qSOFA) is a newly developed risk stratification tool, which has been presented along with a new sepsis definition, to classify infected patients outside of the intensive care unit (ICU). We evaluated the clinical usefulness of qSOFA for predicting adverse outcomes in sepsis patients with liver cirrhosis. METHODS We performed a retrospective cohort study to assess the utility of qSOFA in sepsis patients with liver cirrhosis for whom medical emergency teams (METs) were activated in general wards at an academic tertiary care hospital between March 2008 and December 2015. qSOFA, Systemic inflammatory response syndrome (SIRS), modified early warning score (MEWS), and sequential (sepsis-related) organ failure assessment (SOFA) scores were calculated according to data at MET activation. RESULTS Of 188 patients, 69 (36.7%) had a qSOFA score of 0 or 1 point and 119 (63.3%) had ≥ 2 points. The areas under the receiver operating characteristic curve (AUROC) for ICU transfer on the SOFA (AUROC, 0.691; 95% confidence interval [CI], 0.615 to 0.767) or MEWS (AUROC, 0.663; 95% CI, 0.586 to 0.739) were significantly higher compared to those for qSOFA (AUROC, 0.589; 95% CI, 0.507 to 0.671) or SIRS (AUROC, 0.533; 95% CI, 0.451 to 0.616). CONCLUSION Our findings suggest that qSOFA score may have limited utility in predicting adverse outcomes in sepsis patients with liver cirrhosis at MET activation. Either MEWS or another screening tool is needed for detecting early sepsis in these patients.
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Affiliation(s)
- Jeongsuk Son
- Medical Emergency Team, Asan Medical Center, Seoul, Korea
| | - Sunhui Choi
- Medical Emergency Team, Asan Medical Center, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kang Mo Kim
- Department of Gastroenterology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyun Shim
- Department of Gastroenterology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Sang-Bum Hong, M.D. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3893 Fax: +82-2-2045-4039 E-mail:
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19
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Relationship Between Lipid Profile and Sepsis Outcome in Intensive Care Unit. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2020. [DOI: 10.5812/archcid.93533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Wang J, Sun Y, Teng S, Li K. Prediction of sepsis mortality using metabolite biomarkers in the blood: a meta-analysis of death-related pathways and prospective validation. BMC Med 2020; 18:83. [PMID: 32290837 PMCID: PMC7157979 DOI: 10.1186/s12916-020-01546-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of death in intensive care units (ICUs), but outcomes of individual patients are difficult to predict. The recently developed clinical metabolomics has been recognized as a promising tool in the clinical practice of critical illness. The objective of this study was to identify the unique metabolic biomarkers and their pathways in the blood of sepsis nonsurvivors and to assess the prognostic value of these pathways. METHODS We searched PubMed, EMBASE, Cochrane, Web of Science, CNKI, Wangfang Data, and CQVIP from inception until July 2019. Eligible studies included the metabolomic analysis of blood samples from sepsis patients with the outcome. The metabolic pathway was assigned to each metabolite biomarker. The meta-analysis was performed using the pooled fold changes, area under the receiver operating characteristic curve (AUROC), and vote-counting of metabolic pathways. We also conducted a prospective cohort metabolomic study to validate the findings of our meta-analysis. RESULTS The meta-analysis included 21 cohorts reported in 16 studies with 2509 metabolite comparisons in the blood of 1287 individuals. We found highly limited overlap of the reported metabolite biomarkers across studies. However, these metabolites were enriched in several death-related metabolic pathways (DRMPs) including amino acids, mitochondrial metabolism, eicosanoids, and lysophospholipids. Prediction of sepsis death using DRMPs yielded a pooled AUROC of 0.81 (95% CI 0.76-0.87), which was similar to the combined metabolite biomarkers with a merged AUROC of 0.82 (95% CI 0.78-0.86) (P > 0.05). A prospective metabolomic analysis of 188 sepsis patients (134 survivors and 54 nonsurvivors) using the metabolites from DRMPs produced an AUROC of 0.88 (95% CI 0.78-0.97). The sensitivity and specificity for the prediction of sepsis death were 80.4% (95% CI 66.9-89.4%) and 78.8% (95% CI 62.3-89.3%), respectively. CONCLUSIONS DRMP analysis minimizes the discrepancies of results obtained from different metabolomic methods and is more practical than blood metabolite biomarkers for sepsis mortality prediction. TRIAL REGISTRATION The meta-analysis was registered on OSF Registries, and the prospective cohort study was registered on the Chinese Clinical Trial Registry (ChiCTR1800015321).
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Affiliation(s)
- Jing Wang
- Department of Critical Care Medicine, Yantai Yuhuangding Hospital, Yantai, 264000, Shandong, China.,School of Medicine, University of California, San Diego, CA, 92103, USA
| | - Yizhu Sun
- Department of Critical Care Medicine, Yantai Yuhuangding Hospital, Yantai, 264000, Shandong, China
| | - Shengnan Teng
- Department of Critical Care Medicine, Yantai Yuhuangding Hospital, Yantai, 264000, Shandong, China
| | - Kefeng Li
- School of Medicine, University of California, San Diego, CA, 92103, USA.
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21
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Burdick H, Pino E, Gabel-Comeau D, McCoy A, Gu C, Roberts J, Le S, Slote J, Pellegrini E, Green-Saxena A, Hoffman J, Das R. Effect of a sepsis prediction algorithm on patient mortality, length of stay and readmission: a prospective multicentre clinical outcomes evaluation of real-world patient data from US hospitals. BMJ Health Care Inform 2020; 27:e100109. [PMID: 32354696 PMCID: PMC7245419 DOI: 10.1136/bmjhci-2019-100109] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/25/2019] [Accepted: 02/14/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe sepsis and septic shock are among the leading causes of death in the USA. While early prediction of severe sepsis can reduce adverse patient outcomes, sepsis remains one of the most expensive conditions to diagnose and treat. OBJECTIVE The purpose of this study was to evaluate the effect of a machine learning algorithm for severe sepsis prediction on in-hospital mortality, hospital length of stay and 30-day readmission. DESIGN Prospective clinical outcomes evaluation. SETTING Evaluation was performed on a multiyear, multicentre clinical data set of real-world data containing 75 147 patient encounters from nine hospitals across the continental USA, ranging from community hospitals to large academic medical centres. PARTICIPANTS Analyses were performed for 17 758 adult patients who met two or more systemic inflammatory response syndrome criteria at any point during their stay ('sepsis-related' patients). INTERVENTIONS Machine learning algorithm for severe sepsis prediction. OUTCOME MEASURES In-hospital mortality, length of stay and 30-day readmission rates. RESULTS Hospitals saw an average 39.5% reduction of in-hospital mortality, a 32.3% reduction in hospital length of stay and a 22.7% reduction in 30-day readmission rate for sepsis-related patient stays when using the machine learning algorithm in clinical outcomes analysis. CONCLUSIONS Reductions of in-hospital mortality, hospital length of stay and 30-day readmissions were observed in real-world clinical use of the machine learning-based algorithm. The predictive algorithm may be successfully used to improve sepsis-related outcomes in live clinical settings. TRIAL REGISTRATION NUMBER NCT03960203.
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Affiliation(s)
- Hoyt Burdick
- Cabell Huntington Hospital, Huntington, West Virginia, USA
- Marshall University School of Medicine, Huntington, West Virginia, USA
| | - Eduardo Pino
- Cabell Huntington Hospital, Huntington, West Virginia, USA
- Marshall University School of Medicine, Huntington, West Virginia, USA
| | | | - Andrea McCoy
- Cape May Regional Medical Center, Cape May Court House, New Jersey, USA
| | - Carol Gu
- Dascena Inc, Oakland, California, USA
| | | | - Sidney Le
- Dascena Inc, Oakland, California, USA
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22
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Marinucci C, Zardo F, Diella F, Cocito D, Ciancio A, Porta M, Zanone MM. A deceiving case of paraplegia. Intern Emerg Med 2020; 15:473-478. [PMID: 30815781 DOI: 10.1007/s11739-019-02059-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/20/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Claudia Marinucci
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Federica Zardo
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Francesco Diella
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Dario Cocito
- Department of Neurosciences, University of Turin, Via Cherasco 15, 10126, Turin, Italy
| | - Alessia Ciancio
- Division of Gastroenterology and Hepathology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Massimo Porta
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Maria Maddalena Zanone
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
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23
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Chen YX, Li R, Gu L, Xu KY, Liu YZ, Zhang RW. Prognostic Performance of SOFA, qSOFA, and SIRS in Kidney Transplant Recipients Suffering from Infection: A Retrospective Observational Study. Adv Ther 2020; 37:1100-1113. [PMID: 31981104 DOI: 10.1007/s12325-020-01225-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The prognostic performance of scoring systems for illness severity in infectious kidney transplant recipients (KTRs) is rarely reported. We investigated the ability of the scores for the quick Sequential Organ Failure Assessment (qSOFA), Sequential Organ Failure Assessment (SOFA) and Systemic Inflammatory Response Syndrome (SIRS) to predict in-hospital mortality, intensive care unit (ICU) admission and mechanical ventilation (MV) requirement. METHODS This was a second analysis of a retrospective observational study. Scores for SIRS, SOFA and qSOFA were calculated upon hospitalization (infection onset was before hospitalization) or on the day of infection onset (infection episodes were during hospitalization). The primary outcome was in-hospital mortality. The secondary outcomes were ICU admission and MV requirement. Binary logistic regression and area under the receiver operating characteristic curve (AUC) were employed to assess prognostic performance. RESULTS A total of 161 infectious episodes occurred in 97 KTRs. Forty patients (41%) experienced more than one episode. The SOFA score was available in 161 infections, and scores for qSOFA and SIRS were available in 160 infections. The SIRS score was not different between KTRs with opposite outcomes. The qSOFA score was higher in infections necessitating MV. The SOFA score was significantly higher in the deceased, those needing ICU admission, MV, and for those with positive etiology results. The SOFA score was the only independent predictor of in-hospital mortality, ICU admission, and MV requirement, and the AUCs were 0.879, 0.815, and 0.784, respectively. The optimum cutoff value of predicting the three outcomes was SOFA score ≥ 3. CONCLUSIONS The SOFA score (but not those for SIRS and qSOFA) independently predicted in-hospital mortality, ICU admission, and MV requirement in infectious KTRs.
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Affiliation(s)
- Yun-Xia Chen
- Department of Infectious Disease and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ran Li
- Department of Infectious Disease and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li Gu
- Department of Infectious Disease and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Kai-Yi Xu
- Department of Infectious Disease and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yong-Zhe Liu
- Department of Infectious Disease and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ren-Wen Zhang
- Department of Infectious Disease and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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24
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α-1-Acid Glycoprotein Concentration as an Outcome Predictor in Adult Patients with Sepsis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3174896. [PMID: 31309103 PMCID: PMC6594333 DOI: 10.1155/2019/3174896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/11/2019] [Accepted: 05/21/2019] [Indexed: 12/29/2022]
Abstract
Background α-1-Acid glycoprotein (AGP) is an acute-phase protein that plays a role in first-line defense against infection and is therefore elevated in sepsis. We tested the hypothesis that AGP levels increase initially in sepsis and decrease after antimicrobial therapy and that these levels may predict treatment outcomes. Methods AGP, biomarkers widely used in clinical practice, and maximum 24-h acute physiology and chronic health evaluation (APACHE)-II scores upon emergency department (ED) admission were prospectively evaluated and compared. We further examined changes in AGP concentrations 1, 4, and 7 days after admission and determined the value of AGP that may be used to accurately and reliably predict the prognosis in patients with sepsis. Results Mechanical ventilation, white blood cell (WBC) counts, C-reactive protein (CRP) and lactate levels, maximum 24-h APACHE-II scores, and AGP concentrations were significantly higher upon admission in patients with sepsis who died. AGP and lactate concentrations were also significantly higher in non-survivors than in survivors on days 1, 4, and 7. As indicated by the stepwise logistic regression model analysis and area under the curve analysis, AGP was the best prognostic indicator, and the cut-off value for predicting fatality was 1307 μg/mL, and any increase 1-ng/mL in AGP concentration would increase the fatality rate by 0.5%. Conclusion Based on our observations, AGP may be a good prognostic predictor in patients with sepsis. In addition, serial AGP levels meet the requirements for predicting outcomes in patients with sepsis.
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25
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Garbero RDF, Simões AA, Martins GA, Cruz LVD, von Zuben VGM. SOFA and qSOFA at admission to the emergency department: Diagnostic sensitivity and relation with prognosis in patients with suspected infection. Turk J Emerg Med 2019; 19:106-110. [PMID: 31321343 PMCID: PMC6612625 DOI: 10.1016/j.tjem.2019.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To evaluate the adequacy of SOFA and qSOFA for predicting unfavorable outcomes, and of qSOFA as a screening tool for sepsis in patients admitted to the emergency department (ED) of a Brazilian public hospital. METHODS This was a single-center retrospective study conducted on a cohort of patients admitted to a Brazilian public hospital between August 2016 and November 2017 due to suspected infection. Exclusion criteria were: age <18 years, admission to the ED after 24 h of hospitalization, lack of information in the medical records, advanced comorbidities, or request of limited invasive care. RESULTS A total of 184 patients were included; 84.24% had a SOFA score of 2 or higher. The relative risk of death, need for intensive care unit (ICU) and mechanical ventilation (MV) related to a positive SOFA on admission were: 5.17 (2.11-12.87), 1.45 (1.09-2.15) and 2.74 (1.63-5.16), respectively; sensitivity was 93.7% for death, 88.5% for ICU need and 93.6% for undergoing MV. The mean length of hospital stay was 38.83 days for patients with a positive SOFA score and 8.95 days for patients with a negative score (p = 0.02). The median SOFA value was higher for the patients who died; 41% of the patients had a positive qSOFA and its sensitivity for a positive SOFA was 46.4%. The relative risk of death, ICU and MV need related to qSOFA at admission were 1.83 (1.39-2.44), 0.98 (0.82-1.16) and 1.60 (1.23-1.97), respectively, and its sensitivity was 56.8% for death, 41.4% for ICU need and 53.6% for MV. CONCLUSION qSOFA did not perform well as a screening tool for sepsis and for predicting a poor prognosis in the ED. SOFA, on the other hand, showed reasonable sensitivity for predicting unfavorable outcomes and scores ≥2 were related to a poor prognosis.
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26
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Franchini S, Scarallo L, Carlucci M, Cabrini L, Tresoldi M. SIRS or qSOFA? Is that the question? Clinical and methodological observations from a meta-analysis and critical review on the prognostication of patients with suspected sepsis outside the ICU. Intern Emerg Med 2019; 14:593-602. [PMID: 30324278 DOI: 10.1007/s11739-018-1965-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/06/2018] [Indexed: 12/29/2022]
Abstract
The purpose of the study was to assess the prognostic performances, in terms of in-hospital mortality, of the quick sequential organ failure assessment (qSOFA) score and the systemic inflammatory response syndrome (SIRS) criteria applied to patients with suspected infection outside the ICU, and to critically reappraise the results and the clinical impact of the SEPSIS-3 study and of the subsequent trials. We performed bivariate meta-analysis, evaluation of the Bayesian post-test probabilities of death, and computation of the unidentified deaths for every 1000 screened cases (UDS1000). The use of qSOFA for screening instead of the SIRS implies a relevant increase in the UDS1000. However, this difference appears far smaller in the SEPSIS-3 study, largely due to an underestimation of SIRS sensitivity. The increment in the pre-test probability of death implied by a positive qSOFA is higher than that implied by a positivity of the SIRS. However, the included studies use highly variable definitions of "suspected sepsis" and carry very high levels of heterogeneity. SIRS overperforms qSOFA as a rule-out tool for mortality, while qSOFA shows a higher rule-in power. However, the evident lack of consistency across the published studies undermines the significance of both the meta-analytic approach and the reproducibility of the outcomes, and demands for a standardized definition of the target population.
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Affiliation(s)
- Stefano Franchini
- Emergency Department, Ospedale San Raffaele Scientific Institute, Pronto Soccorso, Via Olgettina 60, 20132, Milan, Italy.
| | - Luca Scarallo
- Faculty of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
| | - Michele Carlucci
- Emergency Department, Ospedale San Raffaele Scientific Institute, Pronto Soccorso, Via Olgettina 60, 20132, Milan, Italy
- Department of General and Emergency Surgery, Ospedale San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Cabrini
- Department of Anaesthesia and Intensive Care, Ospedale San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, Ospedale San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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27
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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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28
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Furukawa M, Kinoshita K, Yamaguchi J, Hori S, Sakurai A. Sepsis patients with complication of hypoglycemia and hypoalbuminemia are an early and easy identification of high mortality risk. Intern Emerg Med 2019; 14:539-548. [PMID: 30729384 PMCID: PMC6536472 DOI: 10.1007/s11739-019-02034-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/14/2019] [Indexed: 12/21/2022]
Abstract
Either hypoglycemia or hypoalbuminemia alone is an independent condition associated with increased risk of mortality in critical illness. This study evaluates whether the mortality risk increases in septic patients if these conditions are combined. Patients admitted to our hospital from 2008 to 2015 who satisfied the definition of sepsis were targeted (n = 336). We classified cases into three groups based on blood glucose (BG) level measured at admission: hypoglycemia (Hypo-G; BG < 80 mg/dl), intermediate glycemia (Inter-G; 80-199 mg/dl), and hyperglycemia (Hyper-G; ≥ 200 mg/dl) group, and then estimated mortality. We also compared the clinical data of these glycemic groups in combination with hypoalbuminemia (Hypo-A) or Inter-G with non-hypoalbuminemia (Inter-G + Nonhypo-A), as a secondary analysis. Diagnostic cut-off level of Hypo-A (< 2.8 mg/dl) was determined using the ROC curve between blood albumin and mortality. In Hypo-G group (n = 40), APACHE II/SOFA scores are significantly higher than in the Inter-G (n = 196) and Hyper-G groups (n = 100). Mortality is 52.5% in the Hypo-G and 60.0% in the Hypo-G with Hypo-A (Hypo-G + Hypo-A) groups. Significantly higher APACHE II or SOFA scores and mortality are observed in the Hypo-G + Hypo-A group compared to the Inter-G + Nonhypo-A group. A higher mortality risk is observed in cases with Hypo-G + Hypo-A (OR 5.065) than those with Hypo-G (OR 3.503), Inter-G (OR 1.175), Hyper-G (OR 1.756) or Hypo-A (OR 3.243), calculated by a single logistic-regression analysis. Hypo-G + Hypo-A in patients with sepsis is related to higher ICU mortality. Physicians should be keenly aware of these conditions to provide immediate intensive treatment after admission of septic patients.
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Affiliation(s)
- Makoto Furukawa
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Satoshi Hori
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
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29
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Innocenti F, Gori AM, Giusti B, Tozzi C, Donnini C, Meo F, Giacomelli I, Ralli ML, Sereni A, Sticchi E, Zari M, Caldi F, Tassinari I, Zanobetti M, Marcucci R, Pini R. Prognostic value of sepsis-induced coagulation abnormalities: an early assessment in the emergency department. Intern Emerg Med 2019; 14:459-466. [PMID: 30535649 DOI: 10.1007/s11739-018-1990-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023]
Abstract
To evaluate if the assessment of coagulation abnormalities at ED admission could improve prognostic assessment of septic patients. This report utilizes a portion of the data collected in a prospective study, with the aim to identify reliable biomarkers for an early sepsis diagnosis. In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis severe sepsis/septic shock. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24): D-dimer, thrombin-antithrombin complex (TAT) and prothrombin fragment F1 + 2 levels were analyzed. The primary end-points were day-7 and in-hospital mortality. Day-7 mortality rate was 16%. D-dimer (T0: 4661 ± 4562 µg/ml vs 3190 ± 7188 µg/ml; T6: 4498 ± 4931 µg/ml vs 2822 ± 5623 µg/ml; T24 2905 ± 2823 µg/ml vs 2465 ± 4988 µg/ml, all p < 0.05) and TAT levels (T0 29 ± 45 vs 22 ± 83; T6 21 ± 22 vs 15 ± 35; T24 16 ± 19 vs 13 ± 30, all p < 0.05) were higher among non-survivors compared to survivors. We defined an abnormal coagulation activation (COAG+) as D-dimer > 500 µg/ml and TAT > 8 ng/ml (for both, twice the upper normal value). Compared to COAG-, COAG+ patients showed higher lactate levels at the earliest evaluations (T0: 3.3 ± 2.7 vs 2.5 ± 2.3, p = 0.041; T6: 2.8 ± 3.4 vs 1.8 ± 1.6, p = 0.015); SOFA score was higher after 24 h (T24: 6.7 ± 3.1 vs 5.4 ± 2.9, p = 0.008). At T0, COAG+ patients showed a higher day-7 mortality rate (HR 2.64; 95% CI 1.14-6.11, p = 0.023), after adjustment for SOFA score and lactate level. Presence of abnormal coagulation at ED admission shows an independent association with an increased short-term mortality rate.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
| | - Anna Maria Gori
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Betti Giusti
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Camilla Tozzi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Chiara Donnini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Federico Meo
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Irene Giacomelli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maria Luisa Ralli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Alice Sereni
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Elena Sticchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Michela Zari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Caldi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Irene Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Zanobetti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
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30
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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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31
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Yuan W, Zhang W, Yang X, Zhou L, Hanghua Z, Xu K. Clinical significance and prognosis of serum tenascin-C in patients with sepsis. BMC Anesthesiol 2018; 18:170. [PMID: 30442110 PMCID: PMC6238343 DOI: 10.1186/s12871-018-0634-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022] Open
Abstract
Background Tenascin-C is a pro-inflammatory glycoprotein with various biological functions. High expression of tenascin-C is found in inflammation, tissue remodeling, and autoimmune diseases. However, its expression and clinical significance in sepsis remain unclear. This study was designed to investigate the relationship between serum tenascin-C levels and disease severity and prognosis in patients with sepsis. Methods A total of 167 patients with sepsis admitted to the ICU were enrolled. Lood samples were collected within 24 h of admission. Serum tenascin-C levels were measured by enzyme-linked immunosorbent assay (ELISA). Follow-up was performed to observe 30-day mortality. Results Serum tenascin-C levels were significantly elevated in patients with sepsis compared with non-sepsis controls (P < 0.001). Serum tenascin-C levels were higher in nonsurvivors (58 cases) who died within 30 days (34.5%) compared to survivors (109 cases) (P < 0.001). In patients with sepsis, serum tenascin-C levels were significantly positively correlated with SOFA scores (P = 0.011), serum creatinine (P = 0.006), C-reactive protein (CRP) (P = 0.001), interleukin-6 (IL-6) (P < 0.001), and tumor necrosis factor α (TNF-α) (P = 0.026). Logistic multivariate regression models showed that serum tenascin-C levels were independent contributor of 30-day mortality. Kaplan-Meier curves showed that septic patients with high levels of serum tenascin-C (≥56.9 pg/mL) had significantly higher 30-day mortality than those with lower serum tenascin-C (< 56.9 pg/mL) (P < 0.001). Conclusion Elevated serum tenascin-C was found in septic patients and associated with severity and poor prognosis.
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Affiliation(s)
- Weifang Yuan
- Department of Intensive Care Medicine, Seventh People's Hospital of Shanghai University of TCM, No.358 Datong Road, Gaoqiao Town, Pudong New District, Shanghai, 200137, China
| | - Wei Zhang
- Department of Emergency Surgery, Seventh People's Hospital of Shanghai University of TCM, Shanghai, 200137, China
| | - Xiaofang Yang
- Department of Intensive Care Medicine, Seventh People's Hospital of Shanghai University of TCM, No.358 Datong Road, Gaoqiao Town, Pudong New District, Shanghai, 200137, China
| | - Liyuan Zhou
- Department of Intensive Care Medicine, Seventh People's Hospital of Shanghai University of TCM, No.358 Datong Road, Gaoqiao Town, Pudong New District, Shanghai, 200137, China
| | - Ziwei Hanghua
- Department of Intensive Care Medicine, Seventh People's Hospital of Shanghai University of TCM, No.358 Datong Road, Gaoqiao Town, Pudong New District, Shanghai, 200137, China
| | - Kailiang Xu
- Department of Intensive Care Medicine, Seventh People's Hospital of Shanghai University of TCM, No.358 Datong Road, Gaoqiao Town, Pudong New District, Shanghai, 200137, China.
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Zhou Q, Wang M, Li S, Zhang J, Ma Q, Ding Y, Ge H, Shen N, Zheng Y, Sun Y. Impact of body mass index on survival of medical patients with sepsis: a prospective cohort study in a university hospital in China. BMJ Open 2018; 8:e021979. [PMID: 30209156 PMCID: PMC6144486 DOI: 10.1136/bmjopen-2018-021979] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate the impact of body mass index (BMI) on survival of a Chinese cohort of medical patients with sepsis. DESIGN A single-centre prospective cohort study conducted from May 2015 to April 2017. SETTING A tertiary care university hospital in China. PARTICIPANTS A total of 178 patients with sepsis admitted to the medical intensive care unit (ICU) were included. MAIN OUTCOME MEASURES The primary outcome was 90-day mortality while the secondary outcomes were in-hospital mortality, length of ICU stay and length of hospital stay. RESULTS The median age (IQR) was 78 (66-84) years old, and 77.0% patients were older than 65 years. The 90-day mortality was 47.2%. The in-hospital mortality was 41.6%, and the length of ICU stay and hospital stay were 12 (5-22) and 15 (9-28) days, respectively. Cox proportional hazard regression analysis identified that Sequential Organ Failure Assessment score (HR=1.229, p<0.001), Acute Physiology and Chronic Health Evaluation II score (HR=1.050, p<0.001) and BMI (HR=0.940, p=0.029) were all independently associated with the 90-day mortality. Patients were divided into four groups based on BMI (underweight 33 (18.5%), normal 98 (55.1%), overweight 36 (20.2%) and obese 11 (6.2%)). The 90-day mortality (66.7%, 48.0%, 36.1% and 18.2%, p=0.015) and in-hospital mortality (60.6%, 41.8%, 30.6% and 18.2%, p=0.027) were statistically different among the four groups. Differences in survival among the four groups were demonstrated by Kaplan-Meier survival analysis (p=0.008), with the underweight patients showing a lower survival rate. CONCLUSIONS BMI was an independent factor associated with 90-day survival in a Chinese cohort of medical patients with sepsis, with patients having a lower BMI at a higher risk of death.
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Affiliation(s)
- Qingtao Zhou
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Meng Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Shuo Li
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Yanling Ding
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Hongxia Ge
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Ning Shen
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Yaan Zheng
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Yongchang Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
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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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Rodriguez RM, Greenwood JC, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Speich KG, Valencia J, Kilgannon JH, Fernandez D, Baumann BM. Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness. Emerg Med J 2018; 35:350-356. [PMID: 29720475 DOI: 10.1136/emermed-2017-207383] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/06/2018] [Accepted: 03/28/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We sought to compare the quick sequential organ failure assessment (qSOFA) to systemic inflammatory response syndrome (SIRS), severe sepsis criteria and lactate levels for their ability to identify ED patients with sepsis with critical illness. METHODS We conducted this multicenter retrospective cohort study at five US hospitals, enrolling all adult patients admitted to these hospitals from their EDs with infectious disease-related illnesses from 1 January 2016 to 30 April 2016. We abstracted clinical variables for SIRS, severe sepsis and qSOFA scores, using values in the first 6 hours of ED stay. Our primary outcome was critical illness, defined as one or more of the composite outcomes of death, vasopressor use or intensive care unit (ICU) admission within 72 hours of presentation. We determined diagnostic test characteristics for qSOFA scores, SIRS, severe sepsis criteria and lactate level thresholds. MAIN RESULTS Of 3743 enrolled patients, 512 (13.7%) had the primary composite outcome. The qSOFA scores were ≥1, >2 and 3 in 1839 (49.1%), 626 (16.7%) and 146 (3.9%) patients, respectively; 2202 (58.8%) met SIRS criteria and 1085 (29.0%) met severe sepsis criteria. qSOFA ≥1 and SIRS had similarly high sensitivity [86.1% (95% CI 82.8% to 89.0%) vs 86.7% (95% CI 83.5% to 89.5%)], but qSOFA ≥1 had higher specificity [56.7% (95% CI 55.0% to 58.5%) vs 45.6% (43.9% to 47.3%); mean difference 11.1% (95% CI 8.7% to 13.6%)]. qSOFA ≥2 had higher specificity than severe sepsis criteria [89.1% (88.0% to 90.2%) vs 77.5% (76.0% to 78.9%); mean difference 11.6% (9.8% to 13.4%)]. qSOFA ≥1 had greater sensitivity than a lactate level ≥2 (mean difference 24.6% (19.2% to 29.9%)). CONCLUSION For patients admitted from the ED with infectious disease diagnoses, qSOFA criteria performed as well or better than SIRS criteria, severe sepsis criteria and lactate levels in predicting critical illness.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, San Francisco, California, USA
| | - Bryan Darger
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dawn Troeger
- Department of Medicine, Sutter Eden Medical Center, San Francisco, California, USA
| | - Soo Y Jung
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly G Speich
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Joel Valencia
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Danny Fernandez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Corrao G, Rea F, Di Martino M, De Palma R, Scondotto S, Fusco D, Lallo A, Belotti LMB, Ferrante M, Pollina Addario S, Merlino L, Mancia G, Carle F. Developing and validating a novel multisource comorbidity score from administrative data: a large population-based cohort study from Italy. BMJ Open 2017; 7:e019503. [PMID: 29282274 PMCID: PMC5770918 DOI: 10.1136/bmjopen-2017-019503] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To develop and validate a novel comorbidity score (multisource comorbidity score (MCS)) predictive of mortality, hospital admissions and healthcare costs using multiple source information from the administrative Italian National Health System (NHS) databases. METHODS An index of 34 variables (measured from inpatient diagnoses and outpatient drug prescriptions within 2 years before baseline) independently predicting 1-year mortality in a sample of 500 000 individuals aged 50 years or older randomly selected from the NHS beneficiaries of the Italian region of Lombardy (training set) was developed. The corresponding weights were assigned from the regression coefficients of a Weibull survival model. MCS performance was evaluated by using an internal (ie, another sample of 500 000 NHS beneficiaries from Lombardy) and three external (each consisting of 500 000 NHS beneficiaries from Emilia-Romagna, Lazio and Sicily) validation sets. Discriminant power and net reclassification improvement were used to compare MCS performance with that of other comorbidity scores. MCS ability to predict secondary health outcomes (ie, hospital admissions and costs) was also investigated. RESULTS Primary and secondary outcomes progressively increased with increasing MCS value. MCS improved the net 1-year mortality reclassification from 27% (with respect to the Chronic Disease Score) to 69% (with respect to the Elixhauser Index). MCS discrimination performance was similar in the four regions of Italy we tested, the area under the receiver operating characteristic curves (95% CI) being 0.78 (0.77 to 0.79) in Lombardy, 0.78 (0.77 to 0.79) in Emilia-Romagna, 0.77 (0.76 to 0.78) in Lazio and 0.78 (0.77 to 0.79) in Sicily. CONCLUSION MCS seems better than conventional scores for predicting health outcomes, at least in the general population from Italy. This may offer an improved tool for risk adjustment, policy planning and identifying patients in need of a focused treatment approach in the everyday medical practice.
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Affiliation(s)
- Giovanni Corrao
- National Centre for Healthcare Research & Pharmacoepidemiology, at the University of Milano-Bicocca, Milan, Italy
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Federico Rea
- National Centre for Healthcare Research & Pharmacoepidemiology, at the University of Milano-Bicocca, Milan, Italy
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Rossana De Palma
- Authority for Healthcare and Welfare, Emilia-Romagna Regional Health Service, Bologna, Italy
| | - Salvatore Scondotto
- National Centre for Healthcare Research & Pharmacoepidemiology, at the University of Milano-Bicocca, Milan, Italy
- Epidemiologic Observatory, Sicily Regional Health Service, Palermo, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Adele Lallo
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Mauro Ferrante
- Department of Culture and Society, University of Palermo, Palermo, Italy
| | - Sebastiano Pollina Addario
- National Centre for Healthcare Research & Pharmacoepidemiology, at the University of Milano-Bicocca, Milan, Italy
- Epidemiologic Observatory, Sicily Regional Health Service, Palermo, Italy
| | - Luca Merlino
- National Centre for Healthcare Research & Pharmacoepidemiology, at the University of Milano-Bicocca, Milan, Italy
- Epidemiologic Observatory, Lombardy Regional Health Service, Milan, Italy
| | - Giuseppe Mancia
- University of Milano-Bicocca, (Emeritus Professor), Milan, Italy
| | - Flavia Carle
- National Centre for Healthcare Research & Pharmacoepidemiology, at the University of Milano-Bicocca, Milan, Italy
- Center of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
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Nannan Panday RS, Minderhoud TC, Alam N, Nanayakkara PWB. Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review. Eur J Intern Med 2017; 45:20-31. [PMID: 28993097 DOI: 10.1016/j.ejim.2017.09.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/18/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND A wide array of early warning scores (EWS) have been developed and are used in different settings to detect which patients are at risk of deterioration. The aim of this review is to provide an overview of studies conducted on the value of EWS on predicting intensive care (ICU) admission and mortality in the emergency department (ED) and acute medical unit (AMU). METHODS A literature search was conducted in the bibliographic databases PubMed and EMBASE, from inception to April 2017. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility. RESULTS 42 studies were included. 36 studies reported on mortality as an endpoint, 13 reported ICU admission and 9 reported the composite outcome of mortality and ICU admission. For mortality prediction National Early Warning Score (NEWS) was the most accurate score in the general ED population and in those with respiratory distress, Mortality in Emergency Department Sepsis score (MEDS) had the best accuracy in patients with an infection or sepsis. ICU admission was best predicted with NEWS, however in patients with an infection or sepsis Modified Early Warning Score (MEWS) yielded better results for this outcome. CONCLUSION MEWS and NEWS generally had favourable results in the ED and AMU for all endpoints. Many studies have been performed on ED and AMU populations using heterogeneous prognostic scores. However, future studies should concentrate on a simple and easy to use prognostic score such as NEWS with the aim of introducing this throughout the (pre-hospital and hospital) acute care chain.
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Affiliation(s)
- R S Nannan Panday
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - T C Minderhoud
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - N Alam
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - P W B Nanayakkara
- Section Acute Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands.
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