Utility of myxedema score as a predictor of mortality in myxedema coma.

OBJECTIVE: Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking. DESIGN AND METHODS: All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients. RESULTS: A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine. CONCLUSION: Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.

National Early Warning Score (NEWS) Outperforms Quick Sepsis-Related Organ Failure (qSOFA) Score for Early Detection of Sepsis in the Emergency Department.

Background: Prompt recognition of sepsis is critical to improving patients' outcomes. We compared the performance of NEWS and qSOFA scores as sepsis detection tools in patients admitted to the emergency department (ED) with suspicion of sepsis. Methodology: A single-center 12-month retrospective study comparing NEWS using the recommended cut-off of ≥5 and qSOFA as sepsis screening tools in a cohort of patients transported by emergency medical services (EMS) to the Lausanne University Hospital (LUH). We used the Sepsis-3 consensus definition. The primary study endpoint was the detection of sepsis. Secondary endpoints were ICU admission and 28-day all-cause mortality. Results: Among 886 patients admitted to ED by EMS for suspected infection, 556 (63%) had a complete set of vital parameters panel enabling the calculation of NEWS and qSOFA scores, of whom 300 (54%) had sepsis. For the detection of sepsis, the sensitivity of NEWS > 5 was 86% and that of qSOFA ≥ 2 was 34%. Likewise, the sensitivities of NEWS ≥ 5 for predicting ICU admission and 28-day mortality were higher than those of qSOFA ≥ 2 (82% versus 33% and 88% versus 37%). Conversely, the specificity of qSOFA ≥ 2 for sepsis detection was higher than that of NEWS ≥ 5 (90% versus 55%). The negative predictive value of NEWS > 5 was higher than that of qSOFA ≥ 2 (77% versus 54%), while the positive predictive value of qSOFA ≥ 2 was higher than that of NEWS ≥ 5 (80% versus 69%). Finally, the accuracy of NEWS ≥ 5 was higher than that of qSOFA ≥ 2 (72% versus 60%). Conclusions: The sensitivity of NEWS ≥ 5 was superior to that of qSOFA ≥ 2 to identify patients with sepsis in the ED and predict ICU admission and 28-day mortality. In contrast, qSOFA ≥ 2 had higher specificity and positive predictive values than NEWS ≥ 5 for these three endpoints.

Brixia and qSOFA Scores, Coagulation Factors and Blood Values in Spring versus Autumn 2021 Infection in Pregnant Critical COVID-19 Patients: A Preliminary Study.

(1) Background: From the recent variants of concern of the SARS-CoV-2 virus, in which the delta variant generated more negative outcomes than the alpha, we hypothesized that lung involvement, clinical condition deterioration and blood alterations were also more severe in autumn infection, when the delta variant dominated (compared with spring infections, when the alpha variant dominated), in severely infected pregnant patients. (2) Methods: In a prospective study, all pregnant patients admitted to the ICU of the Elena Doamna Obstetrics and Gynecology Hospital with a critical form of COVID-19 infection-spring group (n = 11) and autumn group (n = 7)-between 1 January 2021 and 1 December 2021 were included. Brixia scores were calculated for every patient: A score, upon admittance; H score, the highest score throughout hospitalization; and E score, at the end of hospitalization. For each day of Brixia A, H or E score, the qSOFA (quick sepsis-related organ failure assessment) score was calculated, and the blood values were also considered. (3) Results: Brixia E score, C-reactive protein, GGT and LDH were much higher, while neutrophil count was much lower in autumn compared with spring critical-form pregnant patients. (4) Conclusions: the autumn infection generated more dramatic alterations than the spring infection in pregnant patients with critical forms of COVID-19. Larger studies with more numerous participants are required to confirm these results.

Heparin-binding protein-enhanced quick SOFA score improves mortality prediction in sepsis patients.

Purpose: The Quick Sequential Organ Failure Assessment (qSOFA) score proposed by Sepsis-3 as a sepsis screening tool has shown suboptimal accuracy. Heparin-binding protein (HBP) has been shown to identify early sepsis with high accuracy. Herein, we aim to investigate whether or not HBP improves the model performance of qSOFA. Methods: We conducted a multicenter prospective observational study of 794 adult patients who presented to the emergency department (ED) with presumed sepsis between 2018 and 2019. For each participant, serum HBP levels were measured and the hospital course was followed. The qSOFA score was used as the comparator. The data was split into a training dataset (n = 556) and a validation dataset (n = 238). The primary endpoint was 30-day all-cause mortality. Results: Compared with survivors, non-survivors had significantly higher serum HBP levels (median: 71.5 ng/mL vs 209.5 ng/mL, p < 0.001). Serum level of HBP weakly correlated with qSOFA class (r 2 = 0.240, p < 0.001). Compared with the qSOFA model alone, the addition of admission HBP level to the qSOFA model significantly improved 30-day mortality discrimination (AUC, 0.70 vs. 0.80; P < 0.001), net reclassification improvement [26% (CI, 17-35%); P < 0.001], and integrated discrimination improvement [12% (CI, 9-14%); P < 0.001]. Addition of C-reactive protein (CRP) level or neutrophil-to-lymphocyte ratio (NLR) to qSOFA did not improve its performance. A web-based mortality risk prediction calculator was created to facilitate clinical implementation. Conclusion: This study confirms the value of combining qSOFA and HBP in predicting sepsis mortality. The web calculator provides a user-friendly tool for clinical implementation. Further validation in different patient populations is needed before widespread application of this prediction model.

Sepsis and Total Joint Arthroplasty.

The number of annual total joint arthroplasties (TJA) is increasing. Periprosthetic joint infections (PJI) occur when there is infection involving the prosthesis and surrounding tissue, which has the potential to develop into sepsis if left untreated. Sepsis in patients who have undergone TJA is life threatening and requires urgent treatment. If sepsis is due to PJI, the focus should be on early intravenous antibiotics with aspiration as soon as possible to diagnose the infection. Patients who develop sepsis after surgery for PJI are particularly at high risk for mortality and need to be treated in the intensive care unit.

Does qSOFA score predict ICU admission and outcomes in patients with obstructed infected ureteral stones?

INTRODUCTION: Obstructing stones with infection represent a true urologic emergency requiring prompt decompression. Historically the systemic inflammatory response syndrome (SIRS) criteria has been used to predict outcomes in patients with sepsis. The quick Sequential Organ Failure Assessment (qSOFA) score has been proposed as a prognostic factor in patients with acute pyelononephritis associated with nephrolithiasis. However there has been limited application of qSOFA to patients undergoing ureteral stenting with obstructive pyelonephritis. The purpose of this study was to evaluate the predictive value of the qSOFA score for postoperative outcomes following renal decompression in this patient population. MATERIALS AND METHODS: A retrospective review was conducted at three medical centers within one academic institution to identify patients with obstructive pyelonephritis secondary to ureteral stones. All patients underwent emergent ureteral stent placement for decompression. The primary outcome was the predictive value of preoperative qSOFA score ≥ 2 for intensive care unit (ICU) admission postoperatively. Univariate analysis and multivariate regression analysis were performed to identify factors associated with postoperative outcomes, with p < 0.05 considered significant. RESULTS: Of the 289 patients who had ureteral stents placed, 147 patients met inclusion criteria. Twenty-four (16.3%) patients required ICU admission and there were 3 (2%) mortalities, all of these within the ICU admission group. The sensitivity and specificity of the qSOFA score ≥ 2 for ICU admission was 70.8% and 79.5% respectively which outperformed SIRS criteria, which had a sensitivity and specificity of 100% and 33.6% respectively. CONCLUSION: A preoperative qSOFA score ≥ 2 was a significant predictor for postoperative ICU admission in patients undergoing ureteral stent placement for obstructive pyelonephritis. The qSOFA score can be used to determine which patients will require ICU admission.

Evaluation of clinical factors and three scoring systems for predicting mortality in perforated peptic ulcer patients, a retrospective study.

BACKGROUND/OBJECTIVE: Early identification of mortality risk in perforated peptic ulcer (PPU) patients is important for triage and risk stratification. This study aimed to compare clinical and laboratory factors and three scoring systems to predict mortality in PPU patients. METHODS: Retrospective data on PPU patients at M. Djamil Hospital who underwent emergency laparotomy repair surgery were collected from December 2018 to May 2021. The data included demographics, clinical characteristics, and three scoring systems. Data analysis used bivariate, multivariate, and ROC analysis. RESULTS: A total 72 patients were included and mortality rate was 52.8%. Bivariate analysis showed a significant association between age (p = 0.029), onset of illness (p = 0.001), alteration of consciousness (p = <0.001), respiratory rate (p = 0.04), duration of surgery (p = 0.040), preoperative shock (p = 0.049), preoperative creatinine (p = <0.001), Boey's scores (p = 0.002), ASA (p = 0.001), and qSOFA scores (p = <0.001) with mortality in PPU patients. From multivariate analysis, the strongest clinical factors associated with mortality were alteration of consciousness (p = <0.001) and preoperative creatinine (p = 0.001). Receiver Operating Characteristic (ROC) analysis showed the area under the curve (AUC) of Boey's Score 0.73, ASA classification 0.69, qSOFA score 0.77, alteration of consciousness 0.74, and preoperative creatinine 0.78. CONCLUSION: Preoperative creatinine and altered consciousness had the strongest association with mortality in PPU patients. The qSOFA score predicted mortality better than Boey's score and ASA classification. Preoperative creatinine was the best single predictor of mortality.

Comparison of the quick SOFA score with Glasgow-Blatchford and Rockall scores in predicting severity in patients with upper gastrointestinal bleeding.

INTRODUCTION: Upper gastrointestinal bleeding is one of the common causes of mortality and morbidity. The Rockall score (RS) and Glasgow-Blatchford score (GBS) are frequently used in determining the prognosis and predicting in-hospital adverse events, such as mortality, re-bleeding, hospital stay, and blood transfusion requirements. The quick Sepsis Related Organ Failure Assessment (qSOFA) score is easy and swift to calculate. The commonly used scores and the qSOFA score were compared and why and when these scores are most useful was investigated. METHOD: 133 patients admitted to the emergency department with upper gastrointestinal bleeding over the period of a year, were evaluated in this retrospective study. The RS, GBS and qSOFA score were calculated for each patient, and their relationship with in-hospital adverse events, such as length of hospitalization, rebleeding, endoscopic treatment, blood transfusion requirements, and mortality, was investigated. RESULTS: The mean overall GBS was 9.72 ± 3.72 (0-19), while that of patients who did not survive was 14.0 ± 1.1 (13-16), with an area under the curve (AUC) of 0.901, a cutoff value of 12.5, and specificity (Spe) and sensitivity (Sen) of 1 and 0.82, respectively. The median value of the GBS, in terms of transfusion need, was 7.12 ± 4.01 (0-15). (AUC = 0.752, cut-off = 9.5, Spe = 0.79, Sen = 0.69). The median value of the qSOFA score, in terms of intensive care need, was 1.73 ± 0.7 (0-3) (AUC = 0.921, cut-off = 0.5, Spe = 0.93, Sen = 0.79). The RS median, in terms of re-bleeding, was 8.22 ± 0.97 (6-9). CONCLUSION: Early use of risk stratification scores in upper gastrointestinal bleeding is important due to the high risk of morbidity and mortality. All scoring systems were effective in predicting mortality, the need for intensive care, and re-bleeding. The GBS had a greater predictive power in terms of mortality and transfusion need, the qSOFA score for intensive care need, and the RS for re-bleeding. The simpler, more efficient, and more easily calculated qSOFA score can be used to estimate the severity of patients with upper gastrointestinal bleeding.

Determination of the relationship between mortality and SOFA, qSOFA, MASCC scores in febrile neutropenic patients monitored in the intensive care unit.

PURPOSE: Febrile neutropenia (FN) is a hematological emergency. It is challenging and confusing for the clinicians to make the decision of the febrile neutropenic patients under chemotherapy to be monitored at intensive care unit (ICU). The aim of this study was to define the factors supporting decision-making for the critical patients with febrile neutropenia. METHODS: The data of 60 patients, who were taken to the ICU while they were under treatment in the Hematology Clinic with a diagnosis of febrile neutropenia, were analyzed retrospectively, in order to identify clinically useful prognostic parameters. RESULTS: The ICU mortality rate was 80%. Mortality was significantly associated with higher sequential organ failure assessment score (SOFA), quick sequential organ failure assessment score (qSOFA), and hematological SOFA (SOFAhem) scores on admission. All cases having SOFA score 10 and above and qSOFA score 2 and above died. In multivariate analysis, qSOFA score was found to be statistically significant in predicting mortality in regard to ICU admission (p = 0.004). CONCLUSION: Mortality of febrile neutropenic patients admitted to ICU is high. It would be appropriate to determine the extent of organ dysfunction instead of underlying disease, for making the decision of ICU admission. It should be noticed that the risk mortality is high for the FN cases with SOFA score 10 or above, qSOFA score 2 or above, and in need of mechanical ventilation and positive inotropic support; hence, early intervention is recommended. In our study, the most significant parameter in predicting ICU mortality was found to be qSOFA.

SIRS y qSOFA como Predictores de Mortalidad en Sepsis Pediátrica

Resumen Introducción: La sepsis pediátrica continúa siendo una causa importante de mortalidad en países de bajos y medianos ingresos, su reconocimiento temprano en emergencias requiere del uso de criterios que nos permitan predecir anticipadamente la gravedad del paciente. Objetivo: nuestro estudio pretende comparar los criterios de SIRS y qSOFA en cuanto a su capacidad discriminatoria en mortalidad en sepsis pediátrica. Métodos: realizamos un estudio multicéntrico, prospectivo en servicios de emergencias incluyendo niños con sospecha de sepsis subsecuentemente ingresados a UTIP, en los cuales se evaluaron los puntajes en SIRS y qSOFA comparándolos con los resultados al egreso. Resultados: se enrolaron 64 pacientes, admitidos en estadios de Sepsis (19%), Shock Séptico (20,6%) y con Disfunción Multiorgánica (60,4%), con una mortalidad respectivamente de 9,5%, 14,3% y 76,2%; en 33,9% de los casos se pudo rescatar algún germen. Evaluando los criterios SIRS vemos que la ausencia de ellos se asocia con mayor sobrevivencia (p=0,044; OR 0,618: IC95% 0,5020,761), Por otro lado, 2 o más criterios qSOFA se asocia con mayor mortalidad (p=0,047; OR 3,52: IC95% 1,090-11,371). Conclusión: ambos criterios utilizados para definir sepsis en pediatría demostraron su utilidad, el uso del score qSOFA dada a su estrecha relación con la mortalidad puede emplearse para anticipar alteraciones orgánicas potencialmente mortales.

Abstract Introduction: Pediatric sepsis continues to be one of the main causes of mortality in low and middle-income countries, its early recognition in emergencies requires the use of criteria that allow us to predict the severity of the patient. Objective: our study aims to compare the SIRS criteria and qSOFA regarding its discriminatory capacity in mortality in children with sepsis. Methods: a prospective multicenter study was carried out in emergency services enrolling children with suspected sepsis subsequently admitted to the PICU, in which the scores in qSOFA and SIRS were evaluated comparing them with the results at hospital discharge. Results: 64 patients were enrolled, admitted in emergency in Sepsis (19%), Septic Shock (20.6%) and with Multiple Organ Dysfunction (60.4%) stage, with a mortality respectively of 9.5% and 14.3% and 76.2%; germ could be rescued in 33.9% of the cases; Evaluating the SIRS criteria, we see that the absence of them is associated with lower mortality (p = 0.044; OR 0.618: 95% CI 0.502-0.761); otherwise, 2 or more qSOFA criteria are associated with higher mortality (p = 0.047 ; OR 3.52: 95% CI 1.090-11.371). Conclusion: both criteria used to define sepsis in pediatrics demonstrated their usefulness, the use of the qSOFA score given its close relationship with mortality can be used to anticipate life-threatening organ alterations.

SOFA and qSOFA usefulness for in-hospital death prediction of elderly patients admitted for suspected infection in internal medicine.

PURPOSE: To reduce intensive care unit overcrowding and optimize resources, elderly patients affected by suspected infection with declining clinical conditions could be managed in internal medicine departments with stepdown beds. However, commonly used prognostic scores, as Sequential Organ Failure Assessment (SOFA) or quick SOFA (qSOFA) have never been studied in this specific setting. The aim of this study was to evaluate the role and the accuracy of SOFA and qSOFA as prognostic scores in a population of elderly patients with suspected infection admitted to stepdown beds of two internal medicine departments. METHODS: Elderly patients admitted from the emergency department in the stepdown beds of two different internal medicine departments for suspected infection were assessed with SOFA and qSOFA scores at the admission. All patients were treated according to current guidelines. Age, sex, comorbidities, Charlson comorbidity index, SOFA and qSOFA were assessed. In-hospital death and length of hospital admission were also recorded. RESULTS: 390 subjects were enrolled. In-hospital death occurred in 144 (36.9%) patients; we observed that both SOFA (HR 1.189; 95% CI 1.128-1.253; p < 0.0001) and qSOFA (HR 1.803; 95% CI 1.503-2.164; p < 0.0001) scores were independently associated with an increased risk of in-hospital death. However, the accuracy of both SOFA (AUC: 0.686; 95% CI 0.637-0.732; p < 0.0001) and qSOFA (AUC: 0.680; 95% CI 0.641-0.735; p < 0.0001) in predicting in-hospital death was low in this population. CONCLUSION: Elderly patients admitted to stepdown beds for suspected infection experience a high rate of in-hospital death; both SOFA and qSOFA scores can be useful to identify a group of patients who can benefit from admission to an intermediate care environment, however their accuracy is low.

Prognostic values of SOFA score, qSOFA score, and LODS score for patients with sepsis.

BACKGROUND: Sepsis continues to carry a high rate of mortality, which makes effective and simple evaluation methods for predicting the prognosis of septic patients especially important. In this study, we retrospectively analyzed the relationships between three scoring systems including Sequential Organ Failure Assessment (SOFA) score, Quick SOFA (qSOFA) score, and Logistic Organ Dysfunction System (LODS) score and the prognoses of septic patients. METHODS: The baseline data, SOFA score, qSOFA score, LODS score, 28-day prognosis, and 90-day prognosis of patients who met the diagnostic criteria of sepsis were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Receiver operating characteristic (ROC) curves were drawn for various indicators, and comparisons were drawn between the areas under the ROC curves (AUC) of the different scoring systems. RESULTS: The 28-day AUC was 0.661 (0.652, 0.670) for SOFA, 0.558 (0.548, 0.568) for qSOFA, and 0.668 (0.658, 0.677) for LODS; AUC-qSOFA vs. AUC-LODS was 0.103 (0.087, 0.120) (P<0.001), and AUC-qSOFA vs. AUC-LODS was 0.110 (0.094, 0.125) (P<0.001). The 90-day AUC was 0.630 (0.621, 0.640) for SOFA, 0.551 (0.541, 0.560) for qSOFA, and 0.644 (0.635, 0.653) for LODS; AUC-SOFA vs. AUC-qSOFA was 0.079 (0.065, 0.094) (P<0.001), and AUC-qSOFA vs. AUC-LODS was 0.093 (0.079, 0.107) (P<0.001). CONCLUSIONS: SOFA score, qSOFA score, and LODS score can all be used to predict the prognosis of septic patients. LODS score and SOFA score have higher accuracy than qSOFA score; however, qSOFA is simpler to use, making it a more suitable tool in an emergency setting.

Predictors of mortality in emergency department patients with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment scale. / Factores predictivos de mortalidad en los pacientes con sepsis y un valor del indicador 'Quick Sequential Organ Failure Assessment' (qSOFA) de 2 o 3 puntos atendidos en un servicio de urgencias.

OBJECTIVES: To identify predictors of mortality after implementation of a treatment protocol in the first 3 hours for patients who come to our emergency department with sepsis scored 2 or 3 on the Quick Sequential Organ Failure Assessment (qSOFA) scale. MATERIAL AND METHODS: Our team identified adult emergency department patients with a diagnosis of sepsis on starting the morning shift between September 2018 and March 2019. We selected patients whose qSOFA score on arrival was 2 or 3. Variables were explored statistically to identify factors associated with mortality. RESULTS: A total of 90 patients with a mean (SD) age of 72 (16) years were included. Thirty-three (37%) died. Univariate analysis detected that the only qSOFA indicator that was significantly associated with mortality was altered mentation (level of consciousness), which was noted in 79% of patients who died versus 54% of survivors (P=.02). Other variables associated with higher mortality were age 70 years or older, an order to limit therapeutic interventions in emergencies, and lactic acid levels on first and second extractions. The treatment protocol was completed in 42% of the cases and compliance was associated with a lower mortality rate of 21% versus 54% when the protocol was not fully implemented (P=.003). Multivariate Cox regression analysis showed that risk for death was higher when the full protocol was not implemented within 3 hours of arrival (hazard ratio, 2.67; 95% CI, 1.15-6.21; P=.02). CONCLUSION: Full implementation of the protocol within 3 hours of hospital arrival favors survival in patients with sepsis and qSOFA scores of 2 or 3 on arrival. We recommend that emergency departments organize ways to train staff in the use of a sepsis treatment protocol and improve compliance.

OBJETIVO: Determinar los factores predictivos de mortalidad de los pacientes que acuden a urgencias con sepsis y tiene un qSOFA de 2 o 3 puntos tras la implementación de un paquete de medidas a cumplimentar en las primeras 3 horas. METODO: De septiembre de 2018 a marzo de 2019 el equipo investigador identificó a los pacientes adultos que se encontraban en urgencias en el inicio del turno de mañana con el diagnóstico de sepsis. De estos pacientes se seleccionaron los que en el momento de su llegada tenían un qSOFA de 2 o 3 puntos. Se realizó análisis estadístico para establecer los factores relacionados con mortalidad. RESULTADOS: Se incluyeron 90 pacientes con una edad media de 72 (DE 16) años. La mortalidad global fue de 33 pacientes (37%). En el análisis univariado de mortalidad, el único indicador del qSOFA con significación estadística fue el nivel de consciencia (79% vs 54%, p = 0,02). Otras variables relacionadas con mayor mortalidad fueron: edad igual o mayor de 70 años, orden de limitación del esfuerzo terapéutico en urgencias y valor de la primera y de la segunda determinación de lactato. El cumplimiento del paquete de medidas fue del 42% y se asoció a una menor mortalidad (21% vs 54%, p = 0,003). En el análisis multivariado mediante regresión de Cox, los pacientes en los que no se cumplimentó el paquete de medidas en las primeras 3 horas tuvieron mayor riesgo de mortalidad al final del episodio (HR = 2,67; IC95% = 1,15-6,21; p = 0,02). CONCLUSIONES: En los pacientes con sepsis y un qSOFA de 2-3 puntos a su llegada a urgencias el cumplimiento del paquete de medidas en las primeras 3 horas mejora la supervivencia. Es recomendable hacer los esfuerzos organizativos y docentes necesarios para mejorar el cumplimiento.

Quick-SOFA score ≥ 2 predicts prolonged hospital stay in geriatric patients with influenza infection.

PURPOSE: The quick Sepsis-Related Organ Failure Assessment (qSOFA) score was designed to predict mortality among sepsis patients. However, it has never been used to identify prolonged length of hospital stay (pLOS) in geriatric patients with influenza infection. We conducted this study to clarify this issue. METHODS: We conducted a retrospective case-control study, including geriatric patients (aged ≥ 65 years) with influenza infection visiting the emergency department (ED) of a medical center between January 01, 2010 and December 31, 2015. The included patients were divided into two groups on the basis of their qSOFA score: qSOFA < 2, and qSOFA ≥ 2. Data regarding demographics, vital signs, qSOFA score, underlying diseases, subtypes of influenza, and outcomes were included in the analysis. We investigated the association between qSOFA score ≥ 2 and pLOS (>9 days) via logistic regression. RESULTS: Four hundred and nine geriatric patients were included in this study with a mean age of 79.5 (standard deviation [SD], 8.3) years. The median length of stay (LOS) was 7.0 (interquartile range [IQR], 4-12) days, while the rate of pLOS (> 9 days) was 32%. The median LOS in the qSOFA ≥ 2 group, 11.0 (7-15) days, was longer than the qSOFA < 2 group, 6.0 (4-10) days (p-value <0.01). Logistic regression showed that qSOFA ≥ 2 predicts pLOS with an odds ratio of 3.78 (95% confidence interval, 2.04-6.97). CONCLUSION: qSOFA score ≥ 2 is a prompt and simple tool to predict pLOS in geriatric patients with influenza infection.

Accuracy of qSOFA for the diagnosis of sepsis-3: a secondary analysis of a population-based cohort study.

BACKGROUND: We aimed to evaluate the accuracy of quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) for the diagnosis of sepsis-3, and to analyze the prognosis of infected patients in wards over-diagnosed with qSOFA but missed by sepsis-3, and those missed by qSOFA but in accordance with sepsis-3 criteria. We also intended to validate the performance of qSOFA as one predictor of outcome in patients with suspicion of infection. METHODS: We reviewed the medical records of 1,716 adult patients with infection who were hospitalized from July 1st, 2012 to June 30th, 2014 in the Yuetan subdistrict of Beijing, China. Based on the sepsis-3 criteria and qSOFA score proposed by the Third International Consensus Definitions for Sepsis and Septic Shock, these patients were categorized into four groups: qSOFA(-)sepsis(-), qSOFA(+)sepsis(-), qSOFA(-)sepsis(+), and qSOFA(+)sepsis(+). Multivariate logistic regression analysis was used to determine the independent risk factors for in-hospital mortality. The area under the receiver operating characteristic curves (AUROCs) of the qSOFA(+) group were compared with the sepsis(+) group for in-hospital mortality, ICU admission, and invasive ventilation. RESULTS: Among the 1,716 patients with infection, there were 935 patients (54.5%) with sepsis, and 640 patients (37.3%) with qSOFA ≥2. There were 610 patients in the qSOFA(-)sepsis(-) group, 171 in the qSOFA(+)sepsis(-) group, 466 in the qSOFA(-)sepsis(+) group, and 469 in the qSOFA(+)sepsis(+) group. In the logistic regression analysis, increasing age, bedridden status, and malignancy were all independent risk factors of hospital mortality. Sepsis and qSOFA ≥2 were also independent risk factors of hospital mortality, with an adjusted OR of 3.85 (95% CI: 2.70-5.50) and 13.92 (95% CI: 9.87-16.93) respectively. qSOFA had a sensitivity of 50.2% and a specificity of 78.1% for sepsis-3. The false-positive [qSOFA(+)sepsis(-)] group had 38 patients (22.2%) die during hospitalization, and an adjusted OR of 9.20 (95% CI: 4.86-17.38). In addition, the false-negative [qSOFA(-)sepsis(+)] group had a hospital mortality rate of 7.3% (34/466) and an adjusted OR of 2.59 (95% CI: 1.39-4.83). In comparison, patients meeting neither qSOFA nor sepsis criteria had the lowest hospital mortality [2.6% (16/610)], whereas patients with both qSOFA ≥2 and sepsis had the highest hospital mortality [56.5% (265/469)], with an adjusted OR of 42.02 (95% CI: 24.31-72.64). The discrimination of in-hospital mortality using qSOFA (AUROC, 0.846; 95% CI, 0.824-0.868) was greater compared with sepsis-3 criteria (AUROC, 0.834; 95% CI, 0.805-0.863; P<0.001). CONCLUSIONS: In our analysis, the sensitivity(Se) of qSOFA for the diagnosis of sepsis was lower, and qSOFA score ≥2 might identify a group of patients at a higher risk of mortality, regardless of being septic or not.

Quick SOFA vs Rockall preendoscopy scores for risk assessment in patients with nonvariceal upper gastrointestinal bleeding: a retrospective cohort study.

BACKGROUND: Several scoring systems are used to evaluate the severity of nonvariceal upper gastrointestinal bleeding (NVUGB) and the risk of rebleeding or death. The most commonly used scoring systems include the Rockall score, Glasgow-Blatchford score, and Forrest classification. However, the use of simpler definitions, such as the quick Sequential Organ Failure Assessment (qSOFA) score, to make a clinical decision is reasonable in areas with limited time and/or material resources and in low- and middle-income countries. METHODS: Patients with NVUGB whose medical records included information required to calculate the qSOFA and Rockall preendoscopy scores at the time of bleeding in the emergency department or another non-intensive care unit department were included in the study. The area under the receiver operating characteristic curve (AUROC) and 95% confidence interval (95% CI) were estimated for the ability of the qSOFA and Rockall preendoscopy scores to predict mortality. RESULTS: The qSOFA and Rockall preendoscopic scores at the time of bleeding confirmation could be calculated for 218 patients. The mortality rate increased from 3.4% in patients with a qSOFA score = 0 to 88.9% in patients with a qSOFA score = 3 (P < 0.001). The AUROC for prediction of mortality was 0.836 (95% CI 0.748-0.924) for the qSOFA score and 0.923 (95% CI 0.884-0.981) for the Rockall preendocopy score (P = 0.059). CONCLUSIONS: An increase in the qSOFA score is associated with adverse outcomes in patients with NVUGB. The simple qSOFA score can be used to predict mortality in patients with NVUGB as an alternative when Rockall preendoscopy score is incomplete for which the comorbidity is unknown.

Can excretory phase computed tomography predict bacteremia in obstructive calculous pyelonephritis?

PURPOSE: Acute pyelonephritis (AP), a complication of urolithiasis, can be fatal if it progresses to septic shock. We aimed to evaluate the performance of excretory phase computed tomography (CT) in predicting bacteremia among AP patients with upper urinary tract calculi. METHODS: We reviewed medical records of 250 patients diagnosed with AP and upper urinary tract calculi and who were admitted to our institute. We analyzed 132 patients who underwent excretory phase CT. Excretory phase CT images were obtained 7 min after injection with the contrast agent. Obstruction was classified either as high or low grade. Univariate and multivariate analyses were performed to identify the risk factors of bacteremia. RESULTS: Of 132 patients, 73 (55.3%) had bacteremia. Escherichia coli was the most frequently identified pathogen in blood cultures. Univariate analysis demonstrated that high-grade obstruction on excretory phase CT and quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2 were correlated with bacteremia. In addition, the administration of vasopressors was significantly associated with bacteremia (31.5% vs. 6.8%; p < 0.001). Multivariate analysis identified high-grade obstruction on excretory phase CT [odds ratio (OR) 6.68; p < 0.001] and qSOFA score ≥ 2 (OR 3.59, p = 0.03) as independent risk factors for bacteremia. CONCLUSIONS: Excretory phase CT images can be used to predict bacteremia by evaluating the degree of ureteral obstruction. The evaluation of the passage of urine shown by excretory phase CT is critical in patients with AP associated with upper urinary tract calculi.

Mortality and detailed characteristics of pre-ICU qSOFA-negative patients with suspected sepsis: an observational study.

BACKGROUND: Recent studies have suggested that quick Sequential Organ Failure Assessment (qSOFA) scores have limited utility in early prognostication in high-mortality populations. The purpose of this study was to investigate the association between pre-ICU qSOFA scores and in-hospital mortality among patients admitted to the ICU with suspected sepsis. This study also aimed to describe detailed clinical characteristics of qSOFA-negative (< 2) patients. METHODS: This single center, observational study, conducted in a Japanese tertiary care teaching hospital between May 2012 and June 2016, enrolled all consecutive adult patients admitted to the ICU with suspected sepsis. We assessed pre-ICU qSOFA scores with the most abnormal vital signs during the 24-h period before ICU admission. The primary outcome was in-hospital mortality censored at 90 days. We analyzed the association between pre-ICU qSOFA scores and in-hospital mortality. RESULTS: Among 185 ICU patients with suspected sepsis, 14.1% (26/185) of patients remained qSOFA-negative at the time of ICU admission and 29.2% (54/185) of patients died while in hospital. In-hospital mortality was similar between the groups (qSOFA-positive [≥ 2]: 30.2% [48/159] vs qSOFA-negative: 23.1% [6/26], p = 0.642). The Cox proportional hazard regression model revealed that being qSOFA-positive was not significantly associated with in-hospital mortality (adjusted hazard ratio 1.35, 95% confidence interval 0.56-3.22, p = 0.506). Bloodstream infection, immunosuppression, and hematologic malignancy were observed more frequently in qSOFA-negative patients. CONCLUSIONS: Among ICU patients with suspected sepsis, we could not find a strong association between pre-ICU qSOFA scores and in-hospital mortality. Our study suggested high mortality and bacterial diversity in pre-ICU qSOFA-negative patients.

The values of SOFA score, qSOFA score and SIRS criteria in predicting the prognosis of adult patients with suspect infection / 中华急诊医学杂志

Objective To investigate the clinical values of SOFA score,qSOFA score and SIRS criteria in predicting the prognosis of patients with suspected infection in the emergency department.Methods From January 2015 to April 2017,487 patients aged over 18 years were suspected to be infected and admitted to hospital.SOFA,qSOFA,and SIRS scores were calculated.The mortality and the requirement of ICU treatment were used as prognostic factors for evaluating the validity of each score.The prognostic value of each scoring system was evaluated by the area under the receiver operating characteristic curve (AUROC).Results In 487 patients,the hospital mortality rate was 4.9％,and requirement of ICU treatment rate was 17％.SOFA score predicting hospital mortality and requirement of ICU treatment (AUROC 0.905) were superior to other scores (qSOFA-WBC:AUROC 0.778,qSOFA:AUROC 0.769,SIRS:AUROC 0.64).Compared with the SIRS criteria,patients with a score of ＞1 had higher qSOFA scores (94.47％),but lower sensitivity (44.86％);although SIRS criteria had a higher sensitivity (77.57％),they were less specific (42.63％).When qSOFA was added to the condition of leukocyte abnormalities (＜4× 109/L or ＞ 10× 109/L),the prognosis was improved and the sensitivity and specificity for prognosis were 73.83％ and 71.84％ (qSOFA-WBC score,＞1),respectively.In patients with qSOFA-WBC score,only 6 patients (negative predictive value of 94.2％) died or required ICU treatment.Conclusion The SOFA score is superior to qSOFA and SIRS in predicting the prognosis of patients with suspect infection,and qSOFA-WBC is superior to qSOFA and SIRS in predicting low risk.

Are you Ernest Shackleton, the polar explorer? Refining the criteria for delirium and brain dysfunction in sepsis.

The Third International Consensus Definitions for Sepsis and Septic Shock has recently defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunctions in this consensus definition were identified as an organ-specific Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score ≥ 2 points. The quick SOFA (qSOFA) considers altered mentation indicating brain dysfunction when the Glasgow Coma Scale (GCS) score is ≤13 or ≤14. However, concern has been expressed that the revised criteria may lead to a failure in recognizing the signs of potentially lethal organ dysfunction and thus sepsis. Patients with delirium have a fluctuating course, and GCS can be normal or only slightly reduced at the time when signs of delirium are already present. We here report an illustrative case showing how an acute, initially unrecognized, urinary tract infection caused acute brain dysfunction with profound behavioral and cognitive dysfunction despite normal GCS, hence not meeting the criteria for sepsis.