Kevin Chu

Systemic Inflammatory Response Syndrome, Quick Sequential Organ Function Assessment, and Organ Dysfunction: Insights From a Prospective Database of ED Patients With Infection

word count: 250 Text word count: 3182 SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients with infection. (Short title: “SIRS, qSOFA and Organ Dysfunction in Emergency”) Julian M WILLIAMS, MBBS 1, 2 Jaimi H GREENSLADE, PhD 1, 2 Juliet V McKENZIE, MBBS 1, 2BACKGROUND: A proposed revision of sepsis definitions has abandoned the systemic inflammatory response syndrome (SIRS), defined organ dysfunction as an increase in total Sequential Organ Function Assessment (SOFA) score of ≥ 2, and conceived “qSOFA” (quick SOFA) as a bedside indicator of organ dysfunction. We aimed to (1) determine the prognostic impact of SIRS, (2) compare the diagnostic accuracy of SIRS and qSOFA for organ dysfunction, and (3) compare standard (Sepsis‐2) and revised (Sepsis‐3) definitions for organ dysfunction in ED patients with infection. METHODS: Consecutive ED patients admitted with presumed infection were prospectively enrolled over 3 years. Sufficient observational data were collected to calculate SIRS, qSOFA, SOFA, comorbidity, and mortality. RESULTS: We enrolled 8,871 patients, with SIRS present in 4,176 (47.1%). SIRS was associated with increased risk of organ dysfunction (relative risk [RR] 3.5) and mortality in patients without organ dysfunction (OR 3.2). SIRS and qSOFA showed similar discrimination for organ dysfunction (area under the receiver operating characteristic curve, 0.72 vs 0.73). qSOFA was specific but poorly sensitive for organ dysfunction (96.1% and 29.7%, respectively). Mortality for patients with organ dysfunction was similar for Sepsis‐2 and Sepsis‐3 (12.5% and 11.4%, respectively), although 29% of patients with Sepsis‐3 organ dysfunction did not meet Sepsis‐2 criteria. Increasing numbers of Sepsis‐2 organ system dysfunctions were associated with greater mortality. CONCLUSIONS: SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. A qSOFA score ≥ 2 showed high specificity, but poor sensitivity may limit utility as a bedside screening method. Although mortality for organ dysfunction was comparable between Sepsis‐2 and Sepsis‐3, more prognostic and clinical information is conveyed using Sepsis‐2 regarding number and type of organ dysfunctions. The SOFA score may require recalibration.

SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients with infection.

word count: 250 Text word count: 3182 SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients with infection. (Short title: “SIRS, qSOFA and Organ Dysfunction in Emergency”) Julian M WILLIAMS, MBBS 1, 2 Jaimi H GREENSLADE, PhD 1, 2 Juliet V McKENZIE, MBBS 1, 2BACKGROUND: A proposed revision of sepsis definitions has abandoned the systemic inflammatory response syndrome (SIRS), defined organ dysfunction as an increase in total Sequential Organ Function Assessment (SOFA) score of ≥ 2, and conceived “qSOFA” (quick SOFA) as a bedside indicator of organ dysfunction. We aimed to (1) determine the prognostic impact of SIRS, (2) compare the diagnostic accuracy of SIRS and qSOFA for organ dysfunction, and (3) compare standard (Sepsis‐2) and revised (Sepsis‐3) definitions for organ dysfunction in ED patients with infection. METHODS: Consecutive ED patients admitted with presumed infection were prospectively enrolled over 3 years. Sufficient observational data were collected to calculate SIRS, qSOFA, SOFA, comorbidity, and mortality. RESULTS: We enrolled 8,871 patients, with SIRS present in 4,176 (47.1%). SIRS was associated with increased risk of organ dysfunction (relative risk [RR] 3.5) and mortality in patients without organ dysfunction (OR 3.2). SIRS and qSOFA showed similar discrimination for organ dysfunction (area under the receiver operating characteristic curve, 0.72 vs 0.73). qSOFA was specific but poorly sensitive for organ dysfunction (96.1% and 29.7%, respectively). Mortality for patients with organ dysfunction was similar for Sepsis‐2 and Sepsis‐3 (12.5% and 11.4%, respectively), although 29% of patients with Sepsis‐3 organ dysfunction did not meet Sepsis‐2 criteria. Increasing numbers of Sepsis‐2 organ system dysfunctions were associated with greater mortality. CONCLUSIONS: SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. A qSOFA score ≥ 2 showed high specificity, but poor sensitivity may limit utility as a bedside screening method. Although mortality for organ dysfunction was comparable between Sepsis‐2 and Sepsis‐3, more prognostic and clinical information is conveyed using Sepsis‐2 regarding number and type of organ dysfunctions. The SOFA score may require recalibration.

Race and Survival After Out-of-Hospital Cardiac Arrest in a Suburban Community ☆ ☆☆ ★ ★★

STUDY OBJECTIVE To determine whether race, when controlled for income, is an independent predictor of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA). METHODS Prospective OHCA data were collected over 4 years (1991-1994) from a convenience sample of OHCA patients transported to nine hospitals in three suburban counties. Race was determined from hospital and vital statistics records. The average household income was identified from ZIP codes and used as a marker of socioeconomic status. Demographic data and known predictors of survival were compared between blacks and whites. A logistic regression analysis was used to assess the association between race, income, and survival. RESULTS Of the 1,690 patients, 223 (13%) were blacks and 1,467 (87%) were whites. Average household income was less for blacks than for whites (

Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial

40,225 versus

Does race or socioeconomic status predict adverse outcome after out of hospital cardiac arrest: a multi-center study.

46,193; P < .001), but both populations were affluent by national standards (national percentile ranks were 73% and 88%, respectively). The populations were no different in percentage of witnessed arrests (57% versus 61%; P = .465). Blacks were younger (mean +/- SD, 62 +/- 16 versus 68 +/- 15 years; P < .001); less frequently received bystander CPR (11% versus 20%; P = .002); less often had ventricular tachycardia or ventricular fibrillation (37% versus 50%; P < .001); and had a shorter advanced life support call-response interval (median, 4 versus 6 minutes; P < .001). The odds ratio for survival (white/black) was .931 (95% confidence interval, .446 to 1.945). CONCLUSION Race was not found to predict adverse OHCA outcomes in this affluent population.

The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study

STUDY OBJECTIVE We assess the efficacy and safety of tamsulosin compared with placebo as medical expulsive therapy in patients with distal ureteric stones less than or equal to 10 mm in diameter. METHODS This was a randomized, double-blind, placebo-controlled, multicenter trial of adult participants with calculus on computed tomography (CT). Patients were allocated to 0.4 mg of tamsulosin or placebo daily for 28 days. The primary outcomes were stone expulsion on CT at 28 days and time to stone expulsion. RESULTS There were 403 patients randomized, 81.4% were men, and the median age was 46 years. The median stone size was 4.0 mm in the tamsulosin group and 3.7 mm in the placebo group. Of 316 patients who received CT at 28 days, stone passage occurred in 140 of 161 (87.0%) in the tamsulosin group and 127 of 155 (81.9%) with placebo, a difference of 5.0% (95% confidence interval -3.0% to 13.0%). In a prespecified subgroup analysis of large stones (5 to 10 mm), 30 of 36 (83.3%) tamsulosin participants had stone passage compared with 25 of 41 (61.0%) with placebo, a difference of 22.4% (95% confidence interval 3.1% to 41.6%) and number needed to treat of 4.5. There was no difference in urologic interventions, time to self-reported stone passage, pain, or analgesia requirements. Adverse events were generally mild and did not differ between groups. CONCLUSION We found no benefit overall of 0.4 mg of tamsulosin daily for patients with distal ureteric calculi less than or equal to 10 mm in terms of spontaneous passage, time to stone passage, pain, or analgesia requirements. In the subgroup with large stones (5 to 10 mm), tamsulosin did increase passage and should be considered.

CPR training in households of patients with chest pain

OBJECTIVE To assess whether socioeconomic status (SES) or race is associated with adverse outcome after an out-of-hospital cardiac arrest (OHCA). METHODS A convenience sample of OHCA of presumed cardiac origin from seven suburban cities in Michigan, 1991-1996. Median household income (HHI), utilizing patient home address and 1990 census tract data, was dichotomized above and below 1990 state median income. Patient race was dichotomized as black or white. Outcome was defined as survival to hospital discharge (DC). Multiple logistic regression and Pearsons chi2 values were used for analysis. RESULTS Of 1317 cases with complete data for analysis, the average age was 67.3 +/- 16.0, 939 (71.1%) were white, 587 (44.4%) arrests were witnessed (WIT), and 65 (4.9%) were DC alive. There was no significant difference between races with respect to WIT arrests, V(T)/V(F) arrest rhythms, and a small difference in EMS response interval. Whites were more likely to be above median HHI (57.1 vs. 26.2%, P < 0.001). Adjusted odds ratios for predictors of survival were WIT arrest (OR = 3.76, 95% CI (1.7, 8.2)), V(T)/V(F) (OR = 8.74, 95% CI (3.7, 10.8), but not race (OR = 0.68, 95% CI (0.3, 1.4)) or SES (OR = 1.51, 95% C1 0.8, 2.8). CONCLUSION In this population, neither race nor SES was independently associated with a worse outcome after OHCA.

Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department

OBJECTIVES To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays. METHODS Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results. RESULTS Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay. CONCLUSIONS The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk.

Impact of lay responder actions on out-of-hospital cardiac arrest outcome.

The objectives of this study are to (1). quantify prior cardiopulmonary resuscitation (CPR) training in households of patients presenting to the Emergency Department (ED) with or without chest pain or ischaemic heart disease (IHD); (2). evaluate the willingness of household members to undertake CPR training; and (3). identify potential barriers to the learning and provision of bystander CPR. A cross-sectional study was conducted by surveying patients presenting to the ED of a metropolitan teaching hospital over a 6-month period. Two in five households of patients presenting with chest pain or IHD had prior training in CPR. This was no higher than for households of patients presenting without chest pain or IHD. Just under two in three households of patients presenting with chest pain or IHD were willing to participate in future CPR classes. Potential barriers to learning CPR included lack of information on CPR classes, perceived lack of intellectual and/or physical capability to learn CPR and concern about causing anxiety in the person at risk of cardiac arrest. Potential barriers to CPR provision included an unknown cardiac arrest victim and fear of infection. The ED provides an opportunity for increasing family and community capacity for bystander intervention through referral to appropriate training.

Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study.

OBJECTIVES To compare the predictive ability of three risk stratification tools used to assess patients presenting to the ED with potential acute coronary syndrome. DESIGN Pre-planned analysis of an observational study. SETTING A single tertiary referral hospital. PARTICIPANTS 1495 patients presented with chest pain. 948 patients were screened and enrolled. Patients with at least 5 min of chest pain suggestive of ACS were eligible. INTERVENTIONS Subjects were risk categorised using the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines (HFA/CSANZ), the TIMI score and the GRACE score. Three strata of the TIMI and GRACE score were used to compare to the HFA/CSANZ risk categories. MAIN OUTCOME MEASUREMENT 30-Day cardiac event rates including cardiac death, acute myocardial infarction and unstable angina. RESULTS There were 152 events in 91 patients (9.6%). The discriminatory ability of the scores determined by the AUC was 0.83 (95% CI 0.79-0.87) for the GRACE score, 0.79 (95% CI 0.74-0.83) for TIMI score and 0.75 (95% CI 0.70-0.80) for HFA/CSANZ. The AUCs with three strata of the GRACE and TIMI scores were 0.76 (95% CI 0.72-0.81) and 0.68 (95% CI 0.62-0.73) respectively. CONCLUSIONS All three scores were similar in performance in quantifying risk in ED patients with possible ACS. The GRACE score identified a sizable low risk cohort with high sensitivity and NPV but complexity of this tool may limit its utility. Improved scores are needed to allow early identification of low- and high-risk patients to support improvements in patient flow and ED overcrowding.