Prognostic Value of the Time-to-Positivity in Blood Cultures from Septic Shock Patients with Bacteremia Receiving Protocol-Driven Resuscitation Bundle Therapy: A Retrospective Cohort Study.

INTRODUCTION: To evaluate the prognostic value of the time-to-positivity in patients with culture-positive septic shock. METHODS: Retrospective study using a prospective data registry was performed at the emergency department of a tertiary hospital. Consecutive adult patients with septic shock (N = 2499) were enrolled between 2014 and 2018. Bacteremia was defined using blood cultures, and viral and fungal pathogens were excluded. The primary outcome was the 28-day mortality. RESULTS: In 803 (46.7%) septic shock patients with bacteremia, median TTP was 10.1 h. The most prevalent isolated bacterial pathogens were Escherichia coli (40.8%) and Klebsiella (23.4%). Although the TTP correlated with a higher sequential organ failure assessment score (Spearman's rho = -0.12, p < 0.01), it showed no significant difference between the 28-day survivors and non-survivors (10.2 vs. 9.4 days, p = 0.35). In subgroup analysis of the Escherichia coli and Klebsiella bacteremia cases, a shorter TTP showed prognostic value for predicting the 28-day mortality. The optimal TTP cut-off for Escherichia coli and Klebsiella was 10 h and 8 h, respectively. CONCLUSIONS: The prognostic value of the TTP in septic shock patients receiving bundle therapy may be limited and its clinical interpretation should only be made on a pathogen-specific basis.

C-reactive Protein for Stroke Detection in the Emergency Department in Patients With Dizziness Without Neurological Deficits.

Background: Stroke diagnosis can be challenging in patients with dizziness without neurologic deficits. The aim of this study was to evaluate the predictive value of C-reactive protein (CRP) for identifying acute stroke in such patients. Methods: Data from adult patients (>18 years) admitted to the emergency department from August 2019 to February 2020 were evaluated. The study subjects were 1,188 patients presenting with dizziness without neurological deficits whose serum CRP level was measured within 2 h of arriving at the emergency department and who underwent brain magnetic resonance imaging. The relationship between CRP and acute stroke was analyzed using univariable and multivariable models. Results: Acute stroke was detected in 53 (4.4%) patients (40 with brain infarction, 10 with vertebrobasilar insufficiency, 2 with intracerebral hemorrhage, and 1 with subarachnoid hemorrhage). The CRP levels did not differ significantly between the acute stroke and non-stroke groups [0.10 (0.10-0.31) vs. 0.10 (0.10-0.16), P = 0.074]. The area under receiver operating characteristic curve of CRP for acute stroke was not statistically significant (0.567, P = 0.101). On multivariable analysis, the following variables were associated with acute stroke: age (odds ratio [OR], 1.041; 95% confidence interval [CI], 1.011-1.071), history of cerebrovascular accidents (OR, 1.823; 95% CI, 1.068-3.110), white blood cell count (OR, 1.126; 95% CI, 1.017-1.248), and hemoglobin (OR, 1.316; 95% CI, 1.056-1.640). However, CRP (P = 0.183) was not associated with acute stroke. Conclusion: Serum CRP levels do not have significant discriminative value for identifying acute stroke in patients with dizziness without definite neurologic deficits.

Stroke prediction in patients presenting with isolated dizziness in the emergency department.

Diagnosing stroke in patients experiencing dizziness without neurological deficits is challenging for physicians. The aim of this study was to evaluate the prevalence of acute stroke in patients who presented with isolated dizziness without neurological deficits at the emergency department (ED), and determine the relevant stroke predictors in this population. This was an observational, retrospective record review of consecutive 2215 adult patients presenting with dizziness at the ED between August 2019 and February 2020. Multivariate analysis was performed to identify risk factors for acute stroke. 1239 patients were enrolled and analyzed. Acute stroke was identified in 55 of 1239 patients (4.5%); most cases (96.3%) presented as ischemic stroke with frequent involvement (29.1%) of the cerebellum. In the multivariate analysis, the history of cerebrovascular injury (odds ratio [OR] 3.08 [95% confidence interval {CI} 1.24 to 7.67]) and an age of > 65 years (OR 3.01 [95% CI 1.33 to 6.83]) were the independent risk factors for predicting acute stroke. The combination of these two risks showed a higher specificity (94.26%) than that of each factor alone. High-risk patients, such as those aged over 65 years or with a history of cerebrovascular injury, may require further neuroimaging workup in the ED to rule out stroke.