Quick Sepsis-related Organ Failure Assessment score is not sensitive enough to predict 28-day mortality in emergency department patients with sepsis: a retrospective review

OBJECTIVE: To test the hypothesis that the quick Sepsis-related Organ Failure Assessment (qSOFA) score, derived from vital signs taken during triage and recommended by current sepsis guidelines for screening patients with infections for organ dysfunction, is not sensitive enough to predict the risk of mortality in emergency department (ED) sepsis patients.METHODS: Patients diagnosed with severe sepsis and septic shock using the old definition between May 2014 and April 2015 were retrospectively reviewed in three urban tertiary hospital EDs. The sensitivities of systemic inflammatory response syndrome (SIRS) criteria, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores ≥2 were compared using McNemar’s test. Diagnostic performances were evaluated using specificity, positive predictive value, and negative predictive value.RESULTS: Among the 928 patients diagnosed with severe sepsis or septic shock using the old definition, 231 (24.9%) died within 28 days. More than half of the sepsis patients (493/928, 53.1%) and more than one-third of the mortality cases (88/231, 38.1%) had a qSOFA score <2. The sensitivity of a qSOFA score ≥2 was 61.9%, which was significantly lower than the sensitivity of SIRS ≥2 (82.7%, P<0.001) and SOFA ≥2 (99.1%, P<0.001). The specificity, positive predictive value, and negative predictive value of a qSOFA score ≥2 for 28-day mortality were 58.1%, 32.9%, and 82.2%, respectively.CONCLUSION: The current clinical criteria of the qSOFA are less sensitive than the SIRS assessment and SOFA to predict 28-day mortality in ED patients with sepsis.

SEALONE (Safety and Efficacy of Coronary Computed Tomography Angiography with Low Dose in Patients Visiting Emergency Room) trial: study protocol for a randomized controlled trial

OBJECTIVE: Chest pain is one of the most common complaints in the emergency department (ED). Cardiac computed tomography angiography (CCTA) is a frequently used tool for the early triage of patients with low- to intermediate-risk acute chest pain. We present a study protocol for a multicenter prospective randomized controlled clinical trial testing the hypothesis that a low-dose CCTA protocol using prospective electrocardiogram (ECG)-triggering and limited-scan range can provide sufficient diagnostic safety for early triage of patients with acute chest pain. METHODS: The trial will include 681 younger adult (aged 20 to 55) patients visiting EDs of three academic hospitals for acute chest pain or equivalent symptoms who require further evaluation to rule out acute coronary syndrome. Participants will be randomly allocated to either low-dose or conventional CCTA protocol at a 2:1 ratio. The low-dose group will undergo CCTA with prospective ECG-triggering and restricted scan range from sub-carina to heart base. The conventional protocol group will undergo CCTA with retrospective ECG-gating covering the entire chest. Patient disposition is determined based on computed tomography findings and clinical progression and all patients are followed for a month. The primary objective is to prove that the chance of experiencing any hard event within 30 days after a negative low-dose CCTA is less than 1%. The secondary objectives are comparisons of the amount of radiation exposure, ED length of stay and overall cost. RESULTS AND CONCLUSION: Our low-dose protocol is readily applicable to current multi-detector computed tomography devices. If this study proves its safety and efficacy, dose-reduction without purchasing of expensive newer devices would be possible.

Differences in Tetanus Antibody Titer between Homeless Patients and General Patients

PURPOSE: Homeless patients usually live outside and are therefore frequently exposed to injury and tetanus infection. Thus, after visits to an emergency department (ED) due to injury, homeless patients need to be vaccinated for the prevention of tetanus infection with tetanus immunoglobulin regardless of tetanus antibody titer or previous vaccination history. Because the exact history of previous tetanus vaccination in homeless patients is unclear, the tetanus antibody titer between homeless patients and general patients was assessed. METHODS: Subjects who visited the ED after injury from October 2008 to February 2010 were enrolled. All participants answered questions on age, gender, previous vaccination or prophylaxis history, and military service. The Tetanus Immunoglobulin G ELISA (Enzyme-linked immunosorbent assay) method was used for the analysis of serum samples. Propensity score-matched analysis was used to control for age, gender, previous vaccination or prophylaxis history, and military service. RESULTS: A total of 1325 samples were analyzed. There was 83 samples from homeless patients and 1242 samples from general patients. After matched analysis using the propensity score, 56 subjects were matched. The geometric mean titer of tetanus antibody was 0.204+/-0.392 IU/mL in homeless patients and 0.105+/-0.143 IU/mL in general patients (p=0.078). The proportion of patients with a safe tetanus antibody titer was 66.1 percent of homeless patients and 23.2 percent of general patients (p<0.001). CONCLUSION: Homeless patients had a higher mean titer and a statistically higher proportion had a safe titer compared to general patients.

Differences in Tetanus Antibody Titer between Homeless Patients and General Patients

PURPOSE: Homeless patients usually live outside and are therefore frequently exposed to injury and tetanus infection. Thus, after visits to an emergency department (ED) due to injury, homeless patients need to be vaccinated for the prevention of tetanus infection with tetanus immunoglobulin regardless of tetanus antibody titer or previous vaccination history. Because the exact history of previous tetanus vaccination in homeless patients is unclear, the tetanus antibody titer between homeless patients and general patients was assessed. METHODS: Subjects who visited the ED after injury from October 2008 to February 2010 were enrolled. All participants answered questions on age, gender, previous vaccination or prophylaxis history, and military service. The Tetanus Immunoglobulin G ELISA (Enzyme-linked immunosorbent assay) method was used for the analysis of serum samples. Propensity score-matched analysis was used to control for age, gender, previous vaccination or prophylaxis history, and military service. RESULTS: A total of 1325 samples were analyzed. There was 83 samples from homeless patients and 1242 samples from general patients. After matched analysis using the propensity score, 56 subjects were matched. The geometric mean titer of tetanus antibody was 0.204+/-0.392 IU/mL in homeless patients and 0.105+/-0.143 IU/mL in general patients (p=0.078). The proportion of patients with a safe tetanus antibody titer was 66.1 percent of homeless patients and 23.2 percent of general patients (p<0.001). CONCLUSION: Homeless patients had a higher mean titer and a statistically higher proportion had a safe titer compared to general patients.