Enhanced versus standard hydration in acute ischaemic stroke: REVIVE - a randomised clinical trial.

RATIONALE: Early neurological deterioration (END) within 72 hours of stroke onset is associated with poor prognosis. Optimising hydration might reduce the risk of END. AIMS: To determine in acute ischaemic stroke patients if enhanced hydration versus standard hydration reduced the incidence of major (primary) and minor (secondary) END, as whether it increased the incidence of early neurological improvement (secondary), at 72 hours after admissionSample Size Estimate: 244 participants per arm. METHODS AND DESIGN: A prospective, double-blinded, multicentre, parallel-group, randomised controlled trial conducted at 4 hospitals from April 2014 to July 2020, with data analysed in August 2020. The sample size estimated was 488 participants (244 per arm). Ischaemic stroke patients with measurable neurological deficits of onset within 12 hours of emergency department presentation and blood urea nitrogen/creatinine (BUN/Cr) ratio ≥15 at point of admission were enrolled and randomised to 0.9% sodium chloride infusions of varying rates - enhanced hydration (20 mL/kg body weight, one-third given via bolus and remainder over 8 hours) versus standard hydration (60 mL/hour for 8 hours), followed by maintenance infusion of 40-80 mL/hour for the subsequent 64 hours. The primary outcome measure was the incidence of major early neurological deterioration at 72 hours after admission, defined as an increase in National Institutes of Health Stroke Scale of ≥4 points from baseline. RESULTS: 487 participants were randomised (median age 67 years; 287 females). At 72 hours: 7 (2.9%) in the enhanced-hydration arm and 5(2.0%) in the standard-hydration developed major early neurological deterioration (p=0.54). The incidence of minor early neurological deterioration and early neurological improvement did not differ between treatment arms. CONCLUSIONS AND RELEVANCE: Enhanced hydration ratio did not reduce END or improve short term outcomes in acute ischaemic stroke. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02099383, https://clinicaltrials.gov/study/NCT02099383).

The timing of last hemodialysis influences the prognostic value of serum lactate levels in predicting mortality of end-stage renal disease patients with sepsis in the emergency department.

ABSTRACT: Sepsis is a life-threatening condition, and serum lactate levels have been used to predict patient prognosis. Studies on serum lactate levels in patients undergoing regular hemodialysis who have sepsis are limited. This study aimed to determine the predictive value of serum lactate levels for sepsis-related mortality among patients who underwent last hemodialysis at three different times before admission to the emergency department (ED).This retrospective cohort study was conducted from January 2007 to December 2013 in southern Taiwan. All hemodialysis patients with sepsis, receiving antibiotics within 24 hours of sepsis confirmation, admitted for at least 3 days, and whose serum lactate levels were known were examined to determine the difference in the serum lactate levels of patients who underwent last hemodialysis within 4 hours (Groups A), in 4-12 hours (Group B), and beyond 12 hours (Group C) before visited to the ED. All the continuous variables, categorical variables and mortality were compared by using Kruskal-Wallis test or Mann-Whitney test, the χ2 or Fisher exact tests, and multiple logistic regression model, respectively.A total of 490 patients were enrolled in the study, and 8.0% (39), 21.5% (84), and 74.9% (367) of the patients were in Group A, Group B and Group C, respectively; the serum lactate levels (2.91 vs 2.13 vs 2.79 mmol/L, respectively; P = .175) and 28-day in-hospital mortality (17.9% vs 14.6% vs 22.9%) showed no statistically significant difference between 3 groups. The association between serum lactate levels and 28-day in-hospital mortality was reliable in Group B (P = .002) and Group C (P < .001), but it was unreliable in Group A (P = .629).Serum lactate level has acceptable sensitivity in predicting 28-day in-hospital mortality among patients with sepsis who undergo last hemodialysis after 4 hours, but is not reliable when the last hemodialysis takes place within 4 hours.

Liver cirrhosis affects serum lactate level measurement while assessing disease severity in patients with sepsis.

BACKGROUND: Elevated serum lactate is associated with higher mortality in sepsis, whereas liver dysfunction is associated with higher serum lactate levels. We assessed the predictive ability of serum lactate in patients with liver cirrhosis and sepsis. METHODS: This retrospective study included 12 281 cases of suspected infection with initial serum blood lactate drawn during January 2007-December 2013. RESULTS: Using one-to-two propensity score matching analysis, 1053 and 2106 septic patients with and without underlying liver cirrhosis, respectively, were successfully matched. Lactate levels of survivors and nonsurvivors were 2.58 and 5.93 mmol/L, respectively, in patients without liver cirrhosis (WLC), 2.96 and 7.29 mmol/L, respectively, in patients with nondecompensated liver cirrhosis (NDLC), and 4.08 and 7.16 mmol/L, respectively, in patients with decompensated liver cirrhosis (DLC). In receiver operating characteristic curve analysis, the sensitivity and specificity for predicting mortality were 0.81 and 0.55, respectively, in the WLC group, 0.85 and 0.45, respectively, in the NDLC group, and 0.86 and 0.33, respectively, in the DLC group, using serum lactate levels >2.0 mmol/L. CONCLUSIONS: The serum lactate level can be used to predict the severity of sepsis in patients with liver cirrhosis; however, its specificity would be lower at a cutoff of 2.0 mmol/L.

Does inappropriate initial antibiotic therapy affect in-hospital mortality of patients in the emergency department with Escherichia coli and Klebsiella pneumoniae bloodstream infections?

Extended-spectrum ß-lactamase (ESBL)-positive bloodstream infection (BSI) is on the rise worldwide. The purpose of this study is to evaluate the impact of inappropriate initial antibiotic therapy (IIAT) on in-hospital mortality of patients in the emergency department (ED) with Escherichia coli and Klebsiella pneumoniae BSIs. This retrospective single-center cohort study included all adult patients with E. coli and K. pneumoniae BSIs between January 2007 and December 2013, who had undergone a blood culture test and initiation of antibiotics within 6 h of ED registration time. Multiple logistic regression was used to adjust for bacterial species, IIAT, time to antibiotics, age, sex, quick Sepsis Related Organ Failure Assessment (qSOFA) score ⩾ 2, and comorbidities. A total of 3533 patients were enrolled (2967 alive and 566 deceased, in-hospital mortality rate 16%). The patients with K. pneumoniae ESBL-positive BSI had the highest mortality rate. Non-survivors had qSOFA scores ⩾ 2 (33.6% vs 9.5%, P < 0.001), more IIAT (15.0% vs 10.7%, P = 0.004), but shorter mean time to antibiotics (1.70 vs 1.84 h, P < 0.001). A qSOFA score ⩾ 2 is the most significant predictor for in-hospital mortality; however, IIAT and time to antibiotics were not significant predictors in multiple logistic regression analysis. In subgroup analysis divided by qSOFA scores, IIAT was still not a significant predictor. Severity of the disease (qSOFA score ⩾ 2) is the key factor influencing in-hospital mortality of patients with E. coli and K. pneumoniae BSIs. The time to antibiotics and IIAT were not significant predictors because they in turn were affected by disease severity.

Metformin Affects Serum Lactate Levels in Predicting Mortality of Patients with Sepsis and Bacteremia.

This study determined if the use of metformin affected the prognostic value of hyperlactatemia in predicting 28-day mortality among patients with sepsis and bacteremia. We enrolled adult diabetic patients with sepsis and bacteremia. Of 590 patients, 162 and 162 metformin users and nonusers, respectively, were selected in propensity matching. The mean serum lactate levels in metformin users were higher than those in nonusers (4.7 vs. 3.9 mmol/L, p = 0.044). We divided the patients into four groups based on quick Sepsis-related Organ Failure Assessment (qSOFA) scores. No significant difference was found among nonusers with qSOFA score <2, nonusers with qSOFA score ≥2, and metformin users with qSOFA score <2. The lactate levels in metformin users with qSOFA score ≥2 were higher than those in other groups, and significant differences were found in both nonsurvivors (8.9 vs. 4.6 mmol/L, p = 0.027) and survivors (6.4 vs. 3.8 mmol/L, p = 0.049) compared with metformin users with qSOFA score <2. The best cut-off point to predict 28-day mortality in metformin users (5.9 mmol/L; area under the receiver operating characteristic curve (AUROC), 0.66; 95% confidence interval (CI), 0.55⁻0.77) was higher than that in nonusers (3.6 mmol/L; AUROC 0.63; 95% CI, 0.56⁻0.70). Metformin users had higher lactate levels than nonusers in increasing sepsis severity. Serum lactate levels could be useful in predicting mortality in patients using metformin, but higher levels are required to obtain more precise results.

Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection.

OBJECTIVE: The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality. PATIENTS AND METHODS: A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality. RESULTS: Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91). CONCLUSION: The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.

Manifestations and Outcomes of Patients with Parkinson's Disease and Serious Infection in the Emergency Department.

BACKGROUND: Several comorbidities contribute to an increased risk of infections in Parkinson's disease (PD) as the disease progresses. However, few studies have examined the correlation between sepsis and PD. AIM: The aim of this study is to disclose the presentation and outcome of serious infection in patients with PD in the emergency department. METHODS: This retrospective cohort study enrolled patients with PD who had serious infection and were admitted to the emergency department between January 2007 and December 2013. For clinical comparison, we compared the clinical features, laboratory data, and outcomes with those of age- and sex-matched patients who had serious infection but not PD. RESULTS: There were a total of 1,200 episodes of infected PD patients and 2,400 age- and sex-matched infected patients without PD as disease controls. PD patients had fewer comorbidities and lower severity of infectious disease but longer hospital stays than control group patients. The incidences of respiratory tract and urinary tract infections were higher in PD patients. The levels of inflammatory and organ dysfunction biomarkers in PD were lower and compatible with the severity of infectious disease. A total of 86 (7.2%) infected PD patients died during the 28-day admission compared to 339 (14.1%) in non-PD patients. Serum C-reactive protein, bandemia, and lactate could be used to predict mortality in infected PD patients. CONCLUSIONS: In infected patients with PD, respiratory and urinary tract infections were the two most common infectious sources. Empiric therapy based on experience could treat both respiratory and urinary tract infections. Early diagnosis and treatment are essential for survival.

Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department.

Elderly people are more susceptible to sepsis and experience more comorbidities and complications than young adults. Serum lactate is a useful biomarker to predict mortality in patients with sepsis. Lactate production is affected by the severity of sepsis, organ dysfunction, and adrenergic stimulation. Whether the predictive ability of serum lactate will be different between non-elderly and elderly patients is unknown.A retrospective cohort study was conducted to compare the prognostic value of hyperlactatemia in predicting the mortality between elderly (≥65 years) and non-elderly (<65 years) patients with sepsis.This is a single-center retrospective observational cohort study conducted from January 2007 to December 2013 in southern Taiwan. All patients with sepsis, who used antibiotics, with blood culture collected, and with available serum lactate levels in the emergency department, were included in the analysis. We evaluated the difference in serum lactate level between the elderly and non-elderly septic patients by using multiple regression models.A total of 7087 patients were enrolled in the study. Elderly and non-elderly patients accounted for 62.3% (4414) and 40.2% (2673) of all patients, respectively. Statistically significant difference of serum lactate levels was not observed between elderly and non-elderly survivors (2.9 vs 3.0 mmol/L; P = .57); however, elderly patients had lower lactate levels than those within the 28-day in-hospital mortality (5.5 vs 6.6 mmol/L, P < .01). Multiple logistic regression revealed higher adjusted mortality risk in elderly and non-elderly patients with lactate levels of ≥4.0 mmol/L (odds ratio [OR], 4.98 and 5.82; P < .01, respectively), and lactate level between 2 and 4 mmol/L (OR, 1.57 and 1.99; P < .01, respectively) compared to that in the reference group with lactate levels of <2.0 mmol/L in each group. In receiver operating characteristic curve analysis, sensitivity rates for predicting mortality were 0.80 and 0.77 for non-elderly and elderly patients, respectively, by using serum lactate levels higher than 2.0 mmol/L.Septic elderly non-survivors had 1 mmol/L lower serum lactate level than those of the non-elderly non-survivors. Lactate >2 mmol/L still could provide enough sensitivity in predicting sepsis mortality in elder patients.

The influence of emergency department crowding on the efficiency of care for acute stroke patients.

OBJECTIVE: To investigate the impact of emergency department (ED) crowding (number of ED patients) and number of ED staff on the efficiency of the ED care process for acute stroke patients. DESIGN: Retrospective cohort study conducted from 1 May 2008 to 31 December 2013. SETTING: Largest primary stroke center (3000-bed tertiary academic hospital) in southern Taiwan. PARTICIPANTS: Patients aged 18-80 years presenting to the ED with acute stroke symptoms ≤3 h from symptom onset (n = 1142). MAIN OUTCOME MEASURES: Door-to-assessment time (DTA), door-to-computed tomography completion time (DTCT) and door-to-needle time (DTN). RESULTS: Of the 785 patients with ischemic stroke, 90 (11.46%) received thrombolysis. In the multivariate regression analysis, the number of ED patients and the number of attending physicians were significantly associated with delayed DTA and DTCT but not DTN. Initial assessment by a resident was also associated with delayed DTA and DTCT. The number of nurses was associated with delayed DTCT and DTN. CONCLUSIONS: Although ED crowding was not associated with delayed DTN, it predicted delayed DTA and DTCT in thrombolysis-eligible stroke patients. The number of attending physicians affected initial assessment and DTCTs, whereas the number of nurses impacted thrombolytic administration times.

Influence of CT utilisation on patient flow in the emergency department: a retrospective 1-year cohort study.

OBJECTIVE: CT, an important diagnostic tool in the emergency department (ED), might increase the ED length of stay (LOS). Considering the issue of ED overcrowding, it is important to evaluate whether CT use delays or facilitates patient disposition in the ED. DESIGN: A retrospective 1-year cohort study. SETTING: 5 EDs within the same healthcare system dispersed nationwide in Taiwan. PARTICIPANTS: All adult non-trauma patients who visited the 5 EDs from 1 July 2011 to 30 June 2012. INTERVENTIONS: Patients were grouped by whether or not they underwent a CT scan (CT and non-CT groups, respectively). PRIMARY AND SECONDARY OUTCOME MEASURES: The ED LOS and hospital LOS between patients who had and had not undergone CT scans were compared by stratifying different dispositions and diagnoses. RESULTS: CT use prolonged patient ED LOS among those who were directly discharged from the ED. Among patients admitted to the observation unit and then discharged, patients diagnosed with nervous system disease had shorter ED LOS if they underwent a CT scan. CT use facilitated patient admission to the general ward. CT use also accelerated patients' admission to the intensive care unit (ICU) for patients with nervous system disease, neoplasm and digestive disease. Finally, patients admitted to the general wards had shorter hospital LOS if they underwent CT scans in the ED. CONCLUSIONS: CT use did not seem to have delayed patient disposition in ED. While CT use facilitated patient disposition if they were finally hospitalised, it mildly prolonged ED LOS in cases of patients discharged from the ED.

The value of serial serum cell adhesion molecules in predicting acute kidney injury after severe sepsis in adults.

BACKGROUND: Septic acute kidney injury (AKI) is a common complication of severe sepsis. We tested the hypothesis that serum cell adhesion molecule levels are substantially increased in early septic AKI and decreased after antimicrobial therapy and their level can predict prognosis. METHODS: Seventy-two nontraumatic, nonsurgical adult patients with severe sepsis admitted to the emergency department were evaluated. Serum adhesion molecules were collected and assessed. We evaluated their relationship with early septic AKI compared with other clinical predictors and biomarkers. RESULTS: Forty-five patients (62.5%) experienced early septic AKI. Patients with septic AKI also were more likely to experience septic shock and respiratory failure and had higher in-hospital mortality. Stepwise logistic regression model revealed that E-selectin level, septic shock, and respiratory failure were independently associated with septic AKI and each 1ng/ml increase in serum E-selectin level increased the risk of septic AKI by 1%. Furthermore, the E-selectin levels in the septic AKI group were significantly higher than those in the non-AKI group at two different times (days 1 and 4). CONCLUSION: WE show that early septic AKI implies a higher mortality in severe sepsis patients and that E-selectin level at presentation is a powerful predictor of early septic AKI.

Circulating endothelial progenitor cells may predict outcomes in adult patients with severe sepsis in the emergency department.

BACKGROUND: Dysfunctional and decreased numbers of endothelial progenitor cells (EPCs) may play an essential role in the initiation of organ dysfunction caused by severe sepsis. We evaluated the role of serial circulating EPCs in outcomes of patients with severe sepsis. METHODS: In total, 101 adult patients with severe sepsis and septic shock were evaluated. Circulating levels of EPCs (CD133(+)/CD34(+) and KDR(+)/CD34(+) cells) were determined at different time points. RESULTS: The levels of CD133(+)/CD34(+) and KDR(+)/CD34(+) EPCs were significantly higher in the severe sepsis group than in the healthy controls. Levels of CD133(+)/CD34(+) EPCs were significantly higher in the mortality group than in the survival group on day 1 of admission (p<0.05), but decreased significantly with time among non-survivors (p<0.05), and were lowest on day 4 at the emergency department. The Sequential Organ Failure Assessment score and number of CD133(+)/CD34(+) EPCs on admission were independently associated with in-hospital mortality. CONCLUSION: The level of CD133(+)/CD34(+) EPCs on admission is independently associated with in-hospital mortality, and the trend of a sharp decrease in the number of EPCs is related to outcomes in patients with severe sepsis.

An analysis of closed medical litigations against the obstetrics departments in Taiwan from 2003 to 2012†.

OBJECTIVE: To examine the epidemiologic data of closed medical claims from Taiwanese civil courts against obstetric departments and identify high-risk diseases. DESIGN: A retrospective descriptive study. SETTING/STUDY PARTICIPANTS: The verdicts from the national database of the Taiwan judicial system that pertained to obstetric departments were reviewed. Between 2003 and 2012, a total of 79 closed medical claims were included. MAIN OUTCOME MEASURES: The epidemiologic data of litigations including the results of adjudication and the disease and outcome of the alleged injury. RESULTS: A majority of the disputes (65.9%) were fetus-related. Four disease categories accounted for 78.5% of all claims including (i) perinatal maternal complications (25.3%); (ii) errors in antenatal screening or ultrasound diagnoses (21.5%); (iii) fetal hypoxemic-ischemia encephalopathy (16.5%); and (iv) brachial plexus injury (15.2%). Six cases (7.6%) resulted in an indemnity payment with a mean amount of $109 205. Fifty-one cases (64.6%) were closed in the district court. The mean incident-to-litigation closure time was 52.9 ± 29.3 months. All cases with indemnity payments were deemed negligent or were at least determined to be controversial by a medical appraisal, while all defendants whose care was judged as appropriate by a medical appraisal won their lawsuits. CONCLUSIONS: Almost 93% of clinicians win their cases but spend 4.5 years waiting for final adjudication. The court ruled against the clinician only if there was no appropriate response during a complication or if there was no follow-up or further testing for potential critical diseases.

The prognostic value of leukocyte apoptosis in patients with severe sepsis at the emergency department.

BACKGROUND AND AIM: Cell apoptosis in critically ill patients plays a pivotal role in the pathogenesis of sepsis. This study aimed to determine the prognostic value of leukocyte apoptosis in patients with severe sepsis. METHODS: Leukocyte apoptosis was determined by flow cytometry. The values of annexin V, APO2.7, and 7-amino-actinomycin D (7AAD) for each subtype of leukocyte were analyzed in 87 patients with severe sepsis and 27 controls. RESULTS: The percentages of apoptosis (APO2.7 [%]) in the leukocyte subsets were significantly higher in the patients with severe sepsis than in the controls. The percentages of APO2.7 in leukocyte apoptosis, APO2.7 in lymphocytes apoptosis, and annexin V+7AAD in monocytes apoptosis were significantly higher in non-survivors than in survivors. Levels of APO2.7 in lymphocytes apoptosis, annexin V+7AAD in monocytes apoptosis, and serum lactate were all independently predictive of mortality. CONCLUSION: Leukocyte apoptosis is significantly higher in patients with severe sepsis. The percentages of late lymphocyte and monocyte apoptosis may be predictive of outcome in such patients. Aside from serum lactate, APO2.7 level in lymphocyte apoptosis is also a useful predictor of outcome on admission to the emergency department.

Serum adhesion molecules as outcome predictors in adult severe sepsis patients requiring mechanical ventilation in the emergency department.

BACKGROUND AND AIM: Serum adhesion molecules play a pivotal role in the pathogenesis of sepsis syndrome. This study aimed to evaluate the prognostic value of serum adhesion molecules in patients with severe sepsis and mechanical ventilation (MV) at the emergency department. METHODS: Eighty-seven consecutive patients with severe sepsis, including 35 with MV, were evaluated. Serum samples were collected for analysis of serum adhesion molecules. The patients' clinical and laboratory data on admission were also recorded. RESULTS: The maximum 24-h APACHE II and 24-h SOFA scores were significantly higher in the severe sepsis patients requiring MV than in patients without MV (p=0.02 and p<0.001). Mortality rate was significantly higher in severe sepsis patients requiring MV than in patients without MV (40% [14/35] vs. 9.6% [5/52], p=0.001). Both VCAM-1 level (p=0.03) and lactate concentration (p=0.04) on admission had significant differences between survivors and non-survivors in patients requiring MV. In the logistic regression model, only VCAM-1 level (p=0.049) was independently predictive of mortality. By correlation analysis, lactate concentration significantly correlated with the mean VCAM-1 level on admission (γ=0.484, p=0.004). The area under the ROC curve for VCAM-1 level was 0.747 (p=0.02, 95% CI: 0.576-0.918). The cut-off value of VCAM-1 level for predicting hospital mortality in severe sepsis patients receiving MV was 1870ng/mL, with 77% sensitivity and 71% specificity; then the likelihood ratio equals 2.7. CONCLUSIONS: In this study, VCAM-1 level is a more powerful outcome predictor of hospital mortality in severe sepsis patients requiring MV than lactate concentration and other conventional parameters on admission. This suggests that increased plasma VCAM-1 concentration may be useful in identifying who are at risk of hospital mortality among severely septic patients requiring MV.

Elevated serum vascular cell adhesion molecule-1 is associated with septic encephalopathy in adult community-onset severe sepsis patients.

BACKGROUND AND AIM: Septic encephalopathy (SE) is a common complication of severe sepsis. Increased concentrations of circulating soluble adhesion molecules are reported in septic patients. This study aimed to determine whether serum adhesion molecules are associated with SE. METHODS: Seventy nontraumatic, nonsurgical adult patients with severe sepsis admitted through ER were evaluated. Serum adhesion molecules were assessed for their relationship with SE, and compared with other clinical predictors and biomarkers. RESULTS: Twenty-three (32.8%) patients had SE. SE group had higher in-hospital mortality (40% versus 11%, P = 0.009) and their sVCAM-1, sICAM-1, and lactate levels on admission were also higher than non-SE group. By stepwise logistic regression model, sVCAM-1, age, and maximum 24-hours SOFA score were independently associated with septic encephalopathy. The AUC analysis of ROC curve of different biomarkers showed that sVCAM-1 is better to predict SE. The sVCAM-1 levels in the SE group were significantly higher than those of the non-SE group at three time periods (Days 1, 4, and 7). CONCLUSIONS: Septic encephalopathy implies higher mortality in nontraumatic, nonsurgical patients with severe sepsis. VCAM-1 level on presentation is a more powerful predictor of SE in these patients than lactate concentration and other adhesion molecules on admission.

Serum adhesion molecules as predictors of bacteremia in adult severe sepsis patients at the emergency department.

BACKGROUND: Bacteremia is a severe bacterial infection with significant mortality. Clinical parameters that reliably predict it are less elucidated. We assessed the potential of serum adhesion molecules for predicting bacteremia and compare it with current available infection biomarkers to determine a more timely predictor of adult severe sepsis patients on admission to the emergency department (ED). METHODS: Sixty-seven consecutive non-traumatic, non-surgical adult patients with severe sepsis admitted to the ED were evaluated. Serum samples were collected and assessed while serum adhesion molecules were analyzed. RESULTS: Thirty-one (46.2%) study patients had bacteremia. There were significant differences in both sICAM-1 and sE-selectin on admission between bacteremic and non-bacteremic patients. By stepwise logistic regression model, only sE-selectin was independently associated with bacteremia and any 1 ng/ml increase in level increased bacteremia rate by 0.8%. The cut-off value of sE-selectin level for predicting bacteremia was 117 ng/ml (84% sensitivity and 69% specificity). CONCLUSION: Although serum cell adhesion markers are not specific for predicting bacteremia in septic patients, higher mean serum cell adhesion molecules levels on admission may imply both more severe infection and presence of bacteremia. Assay of serum adhesion molecules may be added as an infectious marker among the panel of bacteremic parameters in clinical practice, especially since early diagnosis and prompt antimicrobial therapy are essentially for survival.

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician.

OBJECTIVES: The aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention. METHODS: A before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a "team norm" imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011-September 30, 2011) and after (October 1, 2011-January 30, 2012) intervention were compared. RESULTS: Patients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention. CONCLUSIONS: The intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly.

Killip classification and glucose level in patients with acute myocardial infarction.

OBJECTIVE: Killip classification is a valuable prognostic stratification for patients with acute myocardial infarction. Patients with high initial glucose levels also have adverse outcomes. We hypothesize that an increase in the Killip classification rank of patients with acute myocardial infarction might be associated with increase in initial glucose levels. METHODS: In a retrospective cohort study, patients receiving percutaneous coronary angiography after an acute myocardial infarction were enrolled. Patients were accorded Killip classifications, and the data were compared using the χ(2) and 1-way analysis of variance tests. RESULTS: The study was conducted on 246 eligible subjects. Higher initial glucose levels were associated with higher rate of hospitalization within 1 year as well as mortality (P < .05). Glucose levels among the 4 Killip classes were different (P < .05). CONCLUSION: Patients ranked in the higher Killip classes had higher glucose levels than those ranked in the lower classes.