The usefulness of confusion, urea, respiratory rate, and shock index or adjusted shock index criteria in predicting combined mortality and/or ICU admission compared to CURB-65 in community-acquired pneumonia

Haemogram indices are as reliable as CURB-65 to assess 30-day mortality in Covid-19 pneumonia

Background Mortality due to Covid-19 and severe community-acquired pneumonia (CAP) remains high, despite progress in critical care management. We compared the precision of CURB-65 score with monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) in prediction of mortality among patients with Covid-19 and CAP presenting to the emergency department. Methods We retrospectively analysed two cohorts of patients admitted to the emergency department of Canakkale University Hospital, namely (i) Covid-19 patients with severe acute respiratory symptoms presenting between 23 March 2020 and 31 October 2020, and (ii) all patients with CAP either from bacterial or viral infection within the 36 months preceding the Covid-19 pandemic. Mortality was defined as in-hospital death or death occurring within 30 days after discharge. Results The first study group consisted of 324 Covid-19 patients and the second group of 257 CAP patients. The non-survivor Covid-19 group had significantly higher MLR, NLR and PLR values. In univariate analysis, in Covid-19 patients, a 1-unit increase in NLR and PLR was associated with increased mortality, and in multivariate analysis for Covid-19 patients, age and NLR remained significant in the final step of the model. According to this model, we found that in the Covid-19 group an increase in 1-unit in NLR would result in an increase by 5% and 7% in the probability of mortality, respectively. According to pairwise analysis, NLR and PLR are as reliable as CURB-65 in predicting mortality in Covid-19. Conclusions Our study indicates that NLR and PLR may serve as reliable predictive factors as CURB-65 in Covid-19 pneumonia, which could easily be used to triage and manage severe patients in the emergency department.

Confusion, respiratory rate, shock index (CRSI-65) score in the emergency department triage may be a new severity scoring method for community-acquired pneumonia

Objectives:

To investigate whether confusion, respiratory rate, shock index-age ≥65 years (CRSI-65) score, consisting of basic physiological parameters, can be used for severity prediction in patients with community-acquired pneumonia.

Methods:

This is a prospective cohort and single-center study conducted in Bolu Abant Izzet Baysal University Hospital, Bolu, Turkey between January 2018 and June 2018. The study investigated CRSI-65 score in predicting 4-week mortality and the need for intensive care for patients with community-acquired pneumonia.

Results:

A total of 58 patients with community-acquired pneumonia admitted to the emergency department were included in this study. Of the patients, 62.1% were males (n=36), and the mean age of the patients was 72.87 ± 12.30 years. After 4 weeks of follow-up, CURB-65 and CRSI-65 scores showed similar results in predicting mortality with respect to specificity, sensitivity, and positive and negative predictive values. Area under the receiver operating characteristic curve was 0.926 for the CURB-65 (95% confidence interval [CI] 0.853-0.999) and 0.954 for the CRSI-65 (95% CI 0.899-0.999).

Conclusion:

Similar to the CURB-65 score, the CRSI-65 score appears to be useful in predicting 4-week mortality. The evaluation of CRSI-65 score can be used in emergency department triage, primary care, and non-hospital settings.

The use of the shock index to predict hemodynamic collapse in hypotensive sepsis patients: A cross-sectional analysis

Objectives:

Septic shock, defined as sepsis with hypotension not responding to fluid resuscitation or requiring vasopressor support, results in the worst outcomes in sepsis patients. This subtype of the patient is often difficult to detect. The shock index (SI) has demonstrated the potential for predicting hemodynamic compromise and collapse and predicting patient outcomes in multiple medical and surgical settings. In our study, we assessed the utility of the SI as a hemodynamic screening tool to identify patients likely to fail to respond to fluids and ultimately to be diagnosed with septic shock.

Methodology:

A single-center cross-sectional analysis of patients presenting with hypotension and septicemia over 1 year. The study was conducted using the electronic medical records of the emergency department patients presenting to King Saud University Medical City. The charts were reviewed from 2 May 2015 to 24 April 2016 using the local medical registry. The study was approved by the hospital institutional review board (IRB). Data extraction was performed using a standardized form.

Results:

The area under the curve was 0.77 (P < 0.001) for the prediction of hemodynamic collapse. An initial SI ≥0.875 had a sensitivity of 81% and a specificity of 72% for the identification of patients in whom fluid resuscitation would fail.

Conclusions:

Based on our findings, we found that the SI was a reliable screening tool for the identification of hypotensive patients with sepsis who would ultimately be diagnosed with septic shock.

Shock Index Predicts Outcome in Patients with Suspected Sepsis or Community-Acquired Pneumonia: A Systematic Review

Background: To improve outcomes for patients who present to hospital with suspected sepsis, it is necessary to accurately identify those at high risk of adverse outcomes as early and swiftly as possible. To assess the prognostic accuracy of shock index (heart rate divided by systolic blood pressure) and its modifications in patients with sepsis or community-acquired pneumonia. Methods: An electronic search of MEDLINE, EMBASE, Allie and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (WHO ITRP) was conducted from conception to 26th March 2019. Eligible studies were required to assess the prognostic accuracy of shock index or its modifications for outcomes of death or requirement for organ support either in sepsis or pneumonia. The methodological appraisal was carried out using the Downs and Black checklist. Evidence was synthesised using a narrative approach due to heterogeneity. Results: Of 759 records screened, 15 studies (8697 patients) were included in this review. Shock index ≥ 1 at time of hospital presentation was a moderately accurate predictor of mortality in patients with sepsis or community-acquired pneumonia, with high specificity and low sensitivity. Only one study reported outcomes related to organ support. Conclusions: Elevated shock index at time of hospital presentation predicts mortality in sepsis with high specificity. Shock index may offer benefits over existing sepsis scoring systems due to its simplicity.

CURB-65 Performance Among Admitted and Discharged Emergency Department Patients With Community-acquired Pneumonia

OBJECTIVES

Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP).

METHODS

A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0-5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality.

RESULTS

The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747-0.774). The C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0).

CONCLUSIONS

CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care.

Clinical differences between H3N2 and H1N1 influenza 2012 and lower respiratory tract infection found using a statistical classification approach

Background

Influenza A H1N1 and H3N2 are two influenza waves that have been identified in past years.

Methods

Data from 77 inpatients from three tertiary hospitals were included and statistical analysis was performed in three different clusters.

Results

Thirty-four patients (44.2%) had respiratory distress upon admission, 31.2% had a smoking history or were active smokers, 37.7% manifested disease symptoms, and 7.8% were obese (body mass index >41). The mean age of patients was 51.1 years. Cough was the most common symptom observed in 77.9% of the patients, accompanied by sputum production (51.9%) and fatigue (42.9%). Hemoptysis and vomiting were rarely recorded in the patients (9.1% and 16.9%, respectively). Oseltamivir administration varied between 0 and 10 days, giving a mean value of 2.2 days. In particular, 19 patients received no drug, 31 patients received drug for only for 1 day, 19 patients for 5 days, and 8 patients from 2 to 10 days.

Conclusion

Clusters of symptoms can be used to identify different types of influenza and disease severity. Patients with vaccination had pneumonia, whereas patients without vaccination had influenza A. Patients more than 54.5 years old had H3N2 and patients less than 54.5 years had H1N1. White blood cell count values increased from normal to elevated in H3N2 patients but still remained abnormal in lower tract infection and H1N1 patients.