Quick Sequential Organ Failure Assessment Research Articles

Prediction of Poor Outcome Using the Urea to Albumin Ratio in Thoracic Empyema

Purpose: The prognostic performance of urea-to-albumin ratio (UAR) has been assessed in various pulmonary and nonpulmonary conditions, but never in thoracic empyema. Therefore, our aim was to determine whether this marker has the ability to predict outcome in such patients.Methods: A single-center retrospective study was conducted in a Clinic of Thoracic Surgery at a University Hospital between January 2021 and October 2023. A total of 84 patients who underwent emergency surgery due to thoracic empyema were involved. Serum levels of urea and albumin at admission were used to calculate UAR. We analyzed area under receiver operating characteristics (AUROC) curves of UAR, systemic inflammatory response syndrome (SIRS) and quick-sequential organ failure assessment (qSOFA), and compared their prognostic performance.Results: The identified in-hospital mortality was 10.7%. The UAR showed the best ability to prognosticate mortality compared to qSOFA (AUROC = 0.828 vs 0.747) and SIRS (AUROC = 0.828 vs 0.676). We established a sensitivity of 87.5% and specificity of 74.2% at optimal cut-off value UAR > 51.1 for prediction of adverse outcome.Conclusion: In patients with thoracic empyema urea-to-albumin ratio showed significant prognostic performance and a potential for clinical application as a low cost and widely available predictor of death.

Serum lactate dehydrogenase improves significantly quick-Sequential Organ Failure Assessment score as a predictor of mortality in patients with thoracic empyema: A retrospective analysis

Serum lactate dehydrogenase improves significantly quick-Sequential Organ Failure Assessment score as a predictor of mortality in patients with thoracic empyema: A retrospective analysis

Time‑dependent ROC curve analysis to determine the predictive capacity of seven clinical scales for mortality in patients with COVID‑19: Study of a hospital cohort with very high mortality.

Clinical data from hospital admissions are typically utilized to determine the prognostic capacity of Coronavirus disease 2019 (COVID-19) indices. However, as disease status and severity markers evolve over time, time-dependent receiver operating characteristic (ROC) curve analysis becomes more appropriate. The present analysis assessed predictive power for death at various time points throughout patient hospitalization. In a cohort study involving 515 hospitalized patients (General Hospital Number 1 of Mexican Social Security Institute, Colima, Mexico from February 2021 to December 2022) with COVID-19, seven severity indices [Pneumonia Severity Index (PSI) PaO2/FiO2 arterial oxygen pressure/fraction of inspired oxygen (Kirby index), the Critical Illness Risk Score (COVID-GRAM), the National Early Warning Score 2 (NEWS-2), the quick Sequential Organ Failure Assessment score (qSOFA), the Fibrosis-4 index (FIB-4) and the Viral Pneumonia Mortality Score (MuLBSTA were evaluated using time-dependent ROC curves. Clinical data were collected at admission and at 2, 4, 6 and 8 days into hospitalization. The study calculated the area under the curve (AUC), sensitivity, specificity, and predictive values for each index at these time points. Mortality was 43.9%. Throughout all time points, NEWS-2 demonstrated the highest predictive power for mortality, as indicated by its AUC values. PSI and COVID-GRAM followed, with predictive power increasing as hospitalization duration progressed. Additionally, NEWS-2 exhibited the highest sensitivity (>96% in all periods) but showed low specificity, which increased from 22.9% at admission to 58.1% by day 8. PSI displayed good predictive capacity from admission to day 6 and excellent predictive power at day 8 and its sensitivity remained >80% throughout all periods, with moderate specificity (70.6-77.3%). COVID-GRAM demonstrated good predictive capacity across all periods, with high sensitivity (84.2-87.3%) but low-to-moderate specificity (61.5-67.6%). The qSOFA index initially had poor predictive power upon admission but improved after 4 days. FIB-4 had a statistically significant predictive capacity in all periods (P=0.001), but with limited clinical value (AUC, 0.639-0.698), and with low sensitivity and specificity. MuLBSTA and IKIRBY exhibited low predictive power at admission and no power after 6 days. In conclusion, in COVID-19 patients with high mortality rates, NEWS-2 and PSI consistently exhibited predictive power for death during hospital stay, with PSI demonstrating the best balance between sensitivity and specificity.

Usefulness of the qSOFA score for predicting hospital mortality in cancer patients

Usefulness of the qSOFA score for predicting hospital mortality in cancer patients

Prognostic Accuracy of Screening Tools for Clinical Deterioration in Adults With Suspected Sepsis in Northeastern Thailand: A Cohort Validation Study.

We sought to assess the performance of commonly used clinical scoring systems to predict imminent clinical deterioration in patients hospitalized with suspected infection in rural Thailand. Patients with suspected infection were prospectively enrolled within 24 hours of admission to a referral hospital in northeastern Thailand between 2013 and 2017. In patients not requiring intensive medical interventions, multiple enrollment scores were calculated including the National Early Warning Score (NEWS), the Modified Early Warning Score, Between the Flags, and the quick Sequential Organ Failure Assessment score. Scores were tested for predictive accuracy of clinical deterioration, defined as a new requirement of mechanical ventilation, vasoactive medications, intensive care unit admission, and/or death approximately 1 day after enrollment. The association of each score with clinical deterioration was evaluated by means of logistic regression, and discrimination was assessed by generating area under the receiver operating characteristic curve. Of 4989 enrolled patients, 2680 met criteria for secondary analysis, and 100 of 2680 (4%) experienced clinical deterioration within 1 day after enrollment. NEWS had the highest discrimination for predicting clinical deterioration (area under the receiver operating characteristic curve, 0.78 [95% confidence interval, .74-.83]) compared with the Modified Early Warning Score (0.67 [.63-.73]; P < .001), quick Sequential Organ Failure Assessment (0.65 [.60-.70]; P < .001), and Between the Flags (0.69 [.64-.75]; P < .001). NEWS ≥5 yielded optimal sensitivity and specificity for clinical deterioration prediction. In patients hospitalized with suspected infection in a resource-limited setting in Southeast Asia, NEWS can identify patients at risk of imminent clinical deterioration with greater accuracy than other clinical scoring systems.

Prevalence and predictors of multidrug-resistant bacteremia in liver cirrhosis.

Improved knowledge of local epidemiology and predicting risk factors of multidrug-resistant (MDR) bacteria are required to optimize the management of infections. This study examined local epidemiology and antibiotic resistance patterns of liver cirrhosis (LC) patients and evaluated the predictors of MDR bacteremia in Korea. This was a retrospective study including 140 LC patients diagnosed with bacteremia between January 2017 and December 2022. Local epidemiology and antibiotic resistance patterns and the determinants of MDR bacteremia were analyzed using logistic regression analysis. The most frequently isolated bacteria, from the bloodstream, were Escherichia coli (n = 45, 31.7%) and Klebsiella spp. (n = 35, 24.6%). Thirty-four isolates (23.9%) were MDR, and extended-spectrum beta-lactamase E. coli (52.9%) and methicillin-resistant Staphylococcus aureus (17.6%) were the most commonly isolated MDR bacteria. When Enterococcus spp. were cultured, the majority were MDR (MDR 83.3% vs. 16.7%, p = 0.003), particularly vancomycin-susceptible Enterococcus faecium. Antibiotics administration within 30 days and/or nosocomial infection was a significant predictor of MDR bacteremia (OR: 3.40, 95% CI: 1.24-9.27, p = 0.02). MDR bacteremia was not predicted by sepsis predictors, such as positive systemic inflammatory response syndrome (SIRS) or quick Sequential Organ Failure Assessment (qSOFA). More than 70% of strains that can be treated with a third-generation cephalosporin have been cultured. In cirrhotic patients, antibiotic administration within 30 days and/or nosocomial infection are predictors of MDR bacteremia; therefore, empirical administration of broad-spectrum antibiotics should be considered when these risk factors are present.

Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities

ObjectiveIn this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. DesignThis retrospective cohort study was conducted between 2016 and 2021. SettingTwo university hospitals in Brazil. ParticipantsPatients with sepsis. InterventionsSeveral clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. Main variable of interestIn-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. ResultsA total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. ConclusionsSeveral risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.

Diastolic/systolic blood pressure ratio for predicting febrile children with sepsis and progress to septic shock in the emergency department

ObjectiveGiven the scarcity of studies analyzing the clinical predictors of pediatric septic cases that would progress to septic shock, this study aimed to determine strong predictors for pediatric emergency department (PED) patients with sepsis at risk for septic shock and mortality.MethodsWe conducted chart reviews of patients with ≥ 2 age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) criteria to recognize patients with an infectious disease in two tertiary PEDs between January 1, 2021, and April 30, 2022. The age range of included patients was 1 month to 18 years. The primary outcome was development of septic shock within 48 h of PED attendance. The secondary outcome was sepsis-related 28-day mortality. Initial important variables in the PED and hemodynamics with the highest and lowest values during the first 24 h of admission were also analyzed.ResultsOverall, 417 patients were admitted because of sepsis and met the eligibility criteria for the study. Forty-nine cases progressed to septic shock within 48 h after admission and 368 were discharged without progression. General demographics, laboratory data, and hemodynamics were analyzed by multivariate analysis. Only the minimum diastolic blood pressure/systolic blood pressure ratio (D/S ratio) during the first 24 h after admission remained as an independent predictor of progression to septic shock and 28-day mortality. The best cutoff values of the D/S ratio for predicting septic shock and 28-day mortality were 0.52 and 0.47, respectively.ConclusionsThe D/S ratio is a practical bedside scoring system in the PED and had good discriminative ability in predicting the progression of septic shock and in-hospital mortality in PED patients. Further validation is essential in other settings.

Comparison of SOFA and qSOFA Scores in Predicting Infection and Mortality in HDU and ICU Patients at a Tertiary Care Center

Objective: The objective of this study is to compare the sensitivity and specificity of the SOFA (Sequential Organ Failure Assessment) and qSOFA (Quick Sequential Organ Failure Assessment) in predicting infection and mortality in ICU (intensive care unit) and HDU (high dependency unit) patients admitted at a tertiary care center of excellence. Study Design and Setting: Prospective observational non-interventional study. Anesthesia Department of Combined Military Hospital, Rawalpindi from Jan 2023-Jun 2023. Methodology: Patients in both ICU (n=220) and HDU (n=220) setups admitted with a suspicion of sepsis were evaluated for onset of sepsis and mortality. Primary variables studied were the sensitivity and specificity for both scores for predicting infection and mortality in the ICU and HDU. Positive predictive value for both scores were calculated as secondary variable. Results: While assessing the primary variables, the sensitivity of SOFA for predicting infection in the ICU was 25.6% with a specificity of 85.3% versus a sensitivity of 76.8% and specificity of 59.0% for qSOFA. In the HDU, It showed sensitivity and specificity with PPV for SOFA being 64.7%, 95.1% and 64.7% versus 79.3%, 85.3% and 46.9% for qSOFA respectively. While assessing for mortality, SOFA values in the ICU for sensitivity, specificity and PPV were 81.8%, 93.5% and 69.2% versus 88.8%, 58.3% and 90.9% for qSOFA respectively. Conclusion: We conclude that qSOFA to be good predictor of mortality in the HDU and SOFA with good specificity for infection and mortality in the ICU

Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department.

Sepsis has a high incidence and a poor prognosis. Early recognition is important to facilitate timely initiation of adequate care. Sepsis screening tools, such as the (quick) Sequential Organ Failure Assessment ((q)SOFA) and National Early Warning Score (NEWS), could help recognize sepsis. These tools have been validated in a general immunocompetent population, while their performance in immunocompromised patients, who are particularly at risk of sepsis development, remains unknown. This study is a post hoc analysis of a prospective observational study performed at the emergency department. Inclusion criteria were age ≥ 18years with a suspected infection, while ≥ two qSOFA and/or SOFA criteria were used to classify patients as having suspected sepsis. The primary outcome was in-hospital mortality. 1516 patients, of which 40.5% used one or more immunosuppressives, were included. NEWS had a higher prognostic accuracy as compared to qSOFA for predicting poor outcome among immunocompromised sepsis patients. Of all tested immunosuppressives, high-dose glucocorticoid therapy was associated with a threefold increased risk of both in-hospital and 28-day mortality. In contrast to NEWS, qSOFA underestimates the risk of adverse outcome in patients using high-dose glucocorticoids. As a clinical consequence, to adequately assess the severity of illness among immunocompromised patients, health care professionals should best use the NEWS.

Dynamic Assessment of Modified Quick Sequential Organ Failure Assessment in Acutely Deteriorated Patients with Chronic Liver Disease.

Quick sequential organ failure assessment (qSOFA) has been suggested to identify those who have poor outcomes in patients with suspected infection. We aimed to evaluate the ability of the modified qSOFA (m-qSOFA) to identify high-risk patients in acutely deteriorated patients with chronic liver disease (CLD), especially acute-on-chronic liver failure (ACLF). We used the data of both Korean Acute-on-Chronic Liver Failure (KACLiF) and Asian Pacific Association for the Study of the Liver ACLF Research Consortium (AARC) cohorts. qSOFA was modified by replacing the Glasgow Coma Scale with hepatic encephalopathy, and m-qSOFA≥2 was considered high. Patients with high m-qSOFA had a significantly lower 1-month transplant-free survival (TFS) in both cohorts and higher organ failure development in KACLiF than patients with low m-qSOFA (Ps<0.05). Subgroup analysis by ACLF showed that patients with high m-qSOFA had lower TFS than patients with low m-qSOFA. m-qSOFA was an independent prognostic factor (hazard ratios (HR)=2.604, 95% confidence interval (CI) 1.353-5.013, P=0.004 in KACLiF and HR=1.904, 95% CI 1.484-2.442, P<0.001 in AARC). The patients with low m-qSOFA at baseline but high m-qSOFA on the 7th day had a significantly lower 1-month TFS than the patients with high m-qSOFA at baseline but low m-qSOFA on the 7th day (52.6% vs. 89.4%, P<0.001 in KACLiF and 26.9% vs. 61.5%, P<0.001 in AARC). Baseline and dynamic changes in m-qSOFA were useful to identify patients with a high risk of organ failure development and short-term mortality among CLD patients with acute deterioration.

Value of modified qSOFA, glucose and lactate in predicting prognosis in children with sepsis in the PICU

The purpose was to investigate how well age-adjusted modified quick Sequential Organ Failure Assessment (qSOFA) scores paired with blood glucose and lactate levels predict the outcomes of septicemic children in the pediatric intensive care unit (PICU). One hundred children who were diagnosed with sepsis and septic shock in the PICU of Henan Children’s Hospital were eligible, and other 20 patients in the same hospital at different times were selected as a validation set. Respiratory rate (RR), heart rate (HR), capillary refill time (CRT), and Alert, Voice, Pain, Unresponsive (AVPU) scale were included in the age-adjusted modified qSOFA scoring criteria for scoring. The primary outcome was 28-day all-cause mortality. The predictive values were evaluated by the ROC curve. In the sepsis group, 50 patients were male, and 50 patients were female. The 28-day all-cause mortality rate was 52%. Fifty-one patients with age-adjusted modified qSOFA scores >1. The serum lactate level was 2.4 mmol/L, and the blood glucose level was 9.3 mmol/L. The AUCs for the age-adjusted modified qSOFA score, serum lactate and blood glucose levels for the prediction of 28-day all-cause mortality in children with sepsis were 0.719, 0.719 and 0.737, respectively. The cut-off values were one point, 3.8 mmol/L and 10 mmol/L, respectively. The AUC of the age-adjusted modified qSOFA score for the validation set of was 0.925. When the three indices were combined, the AUC was 0.817, the Hosmer–Lemeshow goodness-of-fit test showed χ 2 = 2.428 and p = .965. When children with sepsis are admitted to the ICU, we recommend performing rapid scoring and rapid bedside lactate and glucose testing to determine the early prognosis.

Association between chest X-ray score and clinical outcome in COVID-19 patients: A study on modified radiographic assessment of lung edema score (mRALE) in Indonesia.

Radiological examinations such as chest X-rays (CXR) play a crucial role in the early diagnosis and determining disease severity in coronavirus disease 2019 (COVID-19). Various CXR scoring systems have been developed to quantitively assess lung abnormalities in COVID-19 patients, including CXR modified radiographic assessment of lung edema (mRALE). The aim of this study was to determine the relationship between mRALE scores and clinical outcome (mortality), as well as to identify the correlation between mRALE score and the severity of hypoxia (PaO2/FiO2 ratio). A retrospective cohort study was conducted among hospitalized COVID-19 patients at Dr. Soetomo General Academic Hospital Surabaya, Indonesia, from February to April 2022. All CXR data at initial admission were scored using the mRALE scoring system, and the clinical outcomes at the end of hospitalization were recorded. Of the total 178 COVID-19 patients, 62.9% survived after completing the treatment. Patients within non-survived had significantly higher quick sequential organ failure assessment (qSOFA) score (p<0.001), lower PaO2/FiO2 ratio (p=0.004), and higher blood urea nitrogen (p<0.001), serum creatinine (p<0.008) and serum glutamic oxaloacetic transaminase (p=0.001) levels. There was a significant relationship between mRALE score and clinical outcome (survived vs deceased) (p=0.024; contingency coefficient of 0.184); and mRALE score of ≥2.5 served as a risk factor for mortality among COVID-19 patients (relative risk of 1.624). There was a significant negative correlation between the mRALE score and PaO2/FiO2 ratio based on the Spearman correlation test (r=-0.346; p<0.001). The findings highlight that the initial mRALE score may serve as an independent predictor of mortality among hospitalized COVID-19 patients as well as proves its potential prognostic role in the management of COVID-19.

Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities

ObjectiveIn this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. DesignThis retrospective cohort study was conducted between 2016 and 2021. SettingTwo university hospitals in Brazil. ParticipantsPatients with sepsis. InterventionsSeveral clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. Main variable of interestIn-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. ResultsA total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. ConclusionsSeveral risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.

Epidemiology of Febrile Neutropenic and Bacteremic Patients in the Extensively Drug-Resistant Era

Background: Appropriate empiric antibiotic use is of utmost importance in febrile neutropenic patients. This study analyzed positive blood culture reports from febrile neutropenic patients and provided a new empirical antibiotic treatment approach. Methods: This study retrospectively enrolled febrile neutropenic patients with hematological or solid organ malignancies who had positive blood cultures at the Bahrain Oncology Center within January 2019 to August 2021. Microbiological data were used to draw inferences for rational antimicrobial treatment. The quick sequential organ failure assessment (qSOFA) score was employed to classify the severity status. The t-test was used to compare univariate and multivariate sensitivity values for two dependent proportions. Results: A total of 73 episodes of bacteremia were detected in 53 patients. Among these, 54 episodes (74%) were caused by gram-negative organisms. The most commonly isolated organisms were Escherichia coli (30%), Klebsiella pneumonia (22%), and coagulase-negative staphylococci (11%). The rate of extensively drug-resistant strains among K. pneumoniae was 44% (n = 7). Among gram-negative microorganisms, the susceptibility rates for monotherapies were reported for ceftazidime (56%), piperacillin/tazobactam (76%), cefepime (54%), meropenem (80%), and ceftazidime-avibactam (91%). The susceptibility rates for tigecycline-based combinations exceeded 90% overall. Conclusions: Clinical severity and local epidemiological data should be considered in the management of febrile neutropenia. New antibiotics and tigecycline should be considered for combination therapy in selected cases due to the increasing resistance observed.

Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study.

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomesafter emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conductedin a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis?

Quick Sequential Organ Failure Assessment (qSOFA) is recommended to identify sepsis. Odontogenic infection (OI) can progress to sepsis, causing systematic inflammatory complications or organ failure. The purpose of the study was to measure the association between OI location and risk for sepsis at admission. This retrospective cohort study included subjects treated for OI at Baylor University Medical Center in Dallas, TX, from January 9, 2019 to July 30, 2022. Subjects > 18years old who were treated under general anesthesia were included. OI limited to periapical, vestibular, buccal, and/or canine spaces were excluded from the sample. The primary predictor variable was OI anatomic location (superficial or deep). Superficial OI infection includes submental, submandibular, sublingual, submasseteric, and/or superficial temporal spaces. Deep OI includes pterygomandibular, deep temporal, lateral pharyngeal, retropharyngeal, pretracheal, and/or prevertebral. The primary outcome variable was risk for sepsis measured using a qSOFA score (0 to 3). A higher score (>0) indicates the patient has a high risk for sepsis. Covariates were demographics, clinical, laboratory, and radiological findings, antibiotic route, postoperative endotracheal intubation, tracheostomy, intensive care unit, admission, and length of stay. Descriptive and bivariate analyses were performed. A χ2 test was used for categorical variables. The Mann-Whitney U test was used for continuous variables. Statistical significance was P<.05. The sample was composed of 168 subjects with a mean age of 42.8±21.5 and 69 (48.6%) subjects were male. There were 11 (6.5%) subjects with a qSOFA score > 0. The relative risk of a qSOFA > 0 for a deep OI is 5.4 times greater than for a superficial OI (136 (95.8) versus 21 (80.8%): RR (95% confidence interval): 5.4 (1.51 to 19.27), P=.004). After adjusting for age, sex, American Society of Anesthesiologists score, and involved anatomical spaces, there was a significant correlation between laterality and the number of involved anatomical spaces and qSOFA score (odd ratio=9.13, 95% confidence interval: 2.48 to 33.55, adjusted P= <.001). The study findings suggest that the OI location is associated with the qSOFA score >0.

Comparison of eight prehospital early warning scores in life-threatening acute respiratory distress: a prospective, observational, multicentre, ambulance-based, external validation study

A myriad of early warning scores (EWSs) exist, yet there is a need to identify the most clinically valid score to be used in prehospital respiratory assessments to estimate short-term and midterm mortality, intensive-care unit admission, and airway management in life-threatening acute respiratory distress. This is a prospective, observational, multicentre, ambulance-based, external validation study performed in 44 ambulance services and four hospitals across three Spanish provinces (ie, Salamanca, Segovia, and Valladolid). We identified adults (ie, those aged 18 years and older) discharged to the emergency department with suspected acute respiratory distress. The primary outcome was 2-day all-cause in-hospital mortality, for all the patients or according to prehospital respiratory conditions, including dyspnoea, chronic obstructive pulmonary disease (COPD), COVID-19, other infections, and other conditions (asthma exacerbation, haemoptysis, and bronchoaspirations). 30-day mortality, intensive-care unit admission, and invasive and non-invasive mechanical ventilation were secondary outcomes. Eight EWSs, namely, the National Early Warning Score 2, the Modified Rapid Emergency Medicine Score, the Rapid Acute Physiology Score, the Quick Sequential Organ Failure Assessment Score, the CURB-65 Severity Score for Community-Acquired Pneumonia, the BAP-65 Score for Acute Exacerbation of COPD, the Quick COVID-19 Severity Index, and the Modified Sequential Organ Failure Assessment (mSOFA), were explored to determine their predictive validity through calibration, clinical net benefit as determined through decision curve analysis, and discrimination analysis (area under the curve of the receiver operating characteristic [AUROC], compared with Delong's test). Between Jan 1, 2020, and Nov 31, 2022, 902 patients were enrolled. The global 2-day mortality rate was 87 (10%); in proportion to various respiratory conditions, the rates were 35 (40%) for dyspnoea, nine (10%) for COPD, 13 (15%) for COVID-19, 28 (32%) for other infections, and two (2%) for others conditions. mSOFA showed the best calibration, a higher net benefit, and the best discrimination (AUROC 0·911, 95% CI 0·86-0·95) for predicting 2-day mortality, and its discrimination was statistically significantly more accurate (p<0·0001) compared with the other scores. The performance of mSOFA for predicting 2-day mortality was higher than the other scores when considering the prehospital respiratory conditions, and was also higher for the secondary outcomes, except for non-invasive mechanical ventilation. Our results showed that mSOFA outperformed other EWSs. The inclusion of mSOFA in prehospital decision making will entail a quick identification of patients in acute respiratory distress at high risk of deterioration, allowing prioritisation of resources and patient care. Gerencia Regional de Salud, Public Health System of Castilla y León (GRS Spain). For the Spanish translation of the abstract see Supplementary Materials section.

Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients

ObjectiveCompare physician gestalt to existing screening tools for the identification of sepsis in the initial minutes of presentation when time sensitive treatments must be initiated. MethodsThis prospective observational study conducted with consecutive encounter sampling took place in the emergency department of an academic, urban, safety net hospital between September 2020 and May 2022. The study population included critically ill emergency department patients excluding traumas, transfers, and self-evident diagnoses. Emergency physician gestalt was measured using a visual analog scale (VAS) from 0-100 at 15 and 60 minutes after patient arrival. The primary outcome was an explicit sepsis hospital discharge diagnosis. Clinical data were recorded up to 3 hours to compare Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA), Modified Early Warning Score (MEWS) and a logistic regression machine learning model utilizing Least Absolute Shrinkage and Selection Operator (LASSO) for variable selection. The screening tools were compared utilizing ROC analysis and calculation of AUC. Results2,484 patient-physician encounters involving 59 attending physicians were analyzed. 275 patients (11%) received an explicit sepsis discharge diagnosis. When limited to available data at 15 minutes, initial VAS (AUC 0.90; 95% CI 0.88-0.92) outperformed all tools including LASSO (0.84, 95% CI 0.82-0.87), qSOFA (0.67; 95% CI 0.64-0.71), SIRS (0.67; 95% 0.64-0.70), SOFA (0.67; 95% CI 0.63-0.70) and MEWS (0.66; 95% CI 0.64-0.69). Expanding to data available at 60 minutes did not meaningfully change results. ConclusionsAmong adults presenting to an emergency department with an undifferentiated critical illness, physician gestalt in the first 15 minutes of the encounter outperformed other screening methods in identifying sepsis.

Modification of qSOFA Increases Mortality Prediction Accuracy in Sepsis Patients

The Quick Sequential Organ Failure Assessment (qSOFA) is a simple parameter, however, its sensitivity as a mortality predictor is low. This study aimed to improve the predictor performance of qSOFA for in-hospital mortality. This study was a retrospective single-centered cohort using medical record data. This study included 150 patients aged 18-80 years old, who experienced sepsis and received ICU care between September 2021 and August 2022. qSOFA and modified ROX index (mROX) were calculated based on the most severe condition recorded in the emergency department (ED). Each variable's area under the receiver operating characteristic (AUROC) curve, sensitivity, and specificity were compared to predict in-hospital mortality. qSOFA scores ≥2 and mROX values ≤3.20 were independent factors that increased the risk of in-hospital mortality (OR 3.69 and 21.50; p 0.004 and 0.005, respectively). The combination of qSOFA scores ≥2 and mROX value ≤3.20 as in-hospital mortality predictors resulted in AUROC 0.791 with a sensitivity of 71.7% and specificity of 75.7%. The AUROC, sensitivity, and specificity of the combination of qSOFA and mROX were higher than qSOFA (0.766, 70.8%, 70.3%) or mROX (0.760, 68.1%, 67.6%) alone. In conclusion, the combination of qSOFA scores ≥2 and mROX values ≤3.20 increase the sensitivity and specificity for predicting in-hospital mortality in sepsis patients.