Time Of Emergency Department Presentation Research Articles

Computed tomography in patients with sepsis presenting to the emergency department: exploring its role in light of patient outcomes.

This study aimed to explore the role of CT in septic patients presenting to the emergency department (ED). We performed a retrospective secondary analysis of 192 septic patients from a prospective observational study, i.e., the "LIFE POC" study. Sepsis was diagnosed in accordance with the Sepsis-3 definition. Clinical and radiological data were collected from the hospital administration and radiological systems. Information on mortality and morbidity was collected. Time-to-CT between CT scan and sepsis diagnosis (ttCTsd) was calculated. Diagnostic accuracy was assessed with the final sepsis source as reference standard. The reference standard was established through the treating team of the patient based on all available clinical, imaging, and microbiological data. Sixty-two of 192 patients underwent a CT examination for sepsis focus detection. The final septic source was identified by CT in 69.4% (n = 43). CT detected septic foci with 81.1% sensitivity (95% CI, 68.0-90.6%) and 55.6% specificity (95% CI, 21.2-86.3%). Patients with short versus long ttCTsd did not differ in terms of mortality (16.1%, n = 5 vs 9.7, n = 3; p = 0.449), length of hospital stay (median 16 d, IQR 9 d 12 h-23 d 18 h vs median 13 d, IQR 10 d 00 h-24 d 00h; p = 0.863), or duration of intensive care (median 3d 12h, IQR 2 d 6 h-7 d 18 h vs median 5d, IQR 2 d-11 d; p = 0.800). Our findings show a high sensitivity of CT in ED patients with sepsis, confirming its relevance in guiding treatment decisions. The low specificity suggests that a negative CT requires further ancillary diagnostic tests for focus detection. The timing of CT did not affect morbidity or mortality outcomes. In patients with sepsis who present to the ED, CT can be used to identify infectious foci on the basis of clinical suspicion, but should not be used as a rule-out test. Scientific evidence for the optimal timing of CT beyond clinical decision-making is currently missing, as potential mortality benefits are clouded by differences in clinical severity at the time of ED presentation. • In patients with sepsis who present to the ED, CT for focus identification has a high sensitivity and can thereby be valuable for patient management. • As the specificity is considerably lower, a thorough microbiological assessment is important in these cases. • The timing of CT did not affect morbidity and mortality outcomes in this study, which might be due to variability in clinical severity at the time of ED presentation.

P404 Monocyte distribution width differentiates bacterial gastroenteritis from Acute Severe Ulcerative Colitis in patients presenting with diarrhoea

Abstract Background Monocyte distribution width (MDW) is a haematological parameter that can be generated by newer generation blood analysers on routine full blood examination. It reflects the variation in the size of monocytes and is elevated in the setting of infection, however its utility in inflammatory disorders in unknown. We aimed to assess whether MDW can help differentiate bacterial gastroenteritis from Acute Severe Ulcerative Colitis (ASUC) among patients presenting to the Emergency Department (ED) with diarrhoea. We further aimed to assess whether MDW correlated with disease activity and clinical outcomes in ASUC. Methods We conducted a retrospective cohort study comprising three patient groups: (1) ASUC, (2) bacterial gastroenteritis and (3) a control group of patients without active inflammation. The control group consisted of outpatients with chronic hepatitis B in immune control phase with normal liver transaminases and suppressed viral load < 2000 IU/mL. Clinical outcomes, routine biomarkers and MDW were recorded. Results A total of 176 patients were identified (53 ASUC, 70 bacterial gastroenteritis and 53 controls). At time of ED presentation, patients with bacterial gastroenteritis had the highest MDW (median 23.6, IQR 20.7-25.8) compared to ASUC (19.0, IQR 17.9-21.2) and controls (16.8, IQR 15.9-18.0; P<0.001). On receiver operator characteristic curve analysis, MDW discriminated bacterial gastroenteritis from ASUC with an area under the curve (AUC) of 0.78 (95% CI 0.70-0.87, P<0.001). Using Youden’s index, a MDW threshold > 22.3 had 64.3% sensitivity, 84.6% specificity, 63.8% negative predictive value and 84.9% positive predictive value for bacterial gastroenteritis. Of the 53 patients with ASUC, 25 responded to intravenous hydrocortisone while 28 were steroid non-responders and required infliximab (IFX). 24 patients responded to IFX rescue, while the 4 IFX non-responders received tofacitinib sequential therapy. In ASUC, MDW correlated positively with established markers of disease activity including CRP (Spearman rank correlation, rho=0.54, P<0.001), platelet count (rho=0.36, P=0.009) and faecal calprotectin (rho=0.35, P=0.02). A lower MDW on the day of IFX administration appeared to predict IFX response (AUC 0.80, 95% CI 0.61-1.00, P=0.002). At follow-up (median 85 days), MDW was predictive of biochemical remission with a faecal calprotectin < 100 µg/g (AUC 0.80, 95% CI 0.64-0.95, P<0.001). Conclusion MDW is a novel biomarker that may help distinguish ASUC from bacterial gastroenteritis at time of ED presentation in patients with diarrhoea. In ASUC, MDW correlates with existing markers of activity and may help predict IFX response.

Use of antibiotics and outcomes of patients presenting to emergency department with non-neutropenic fever and/or suspected infection.

e18693 Background: Current guidelines are clear about antibiotic choices for cancer patients presenting to emergency department (ED) with febrile neutropenia. However, there is little known about antibiotic use and outcomes of cancer patients who present to ED with non-neutropenic fever. The objective of this study was to identify antibiotic prescribing pattern of patients with solid tumor malignancies who presented to Juravinski Hospital (JH) emergency department (ED) with non-neutropenic fever or/and suspected infection. Methods: A retrospective cohort review was completed. All patients with solid tumor malignancies followed by an oncologist at Juravinski Cancer Centre (JCC) who presented to JH ED with non-neutropenic fever or suspected infection from July 1 to December 31, 2020 were identified from an electronic database. Patients’ baseline characteristics, antibiotics used, and outcome information were collected. The primary outcome was proportion of patients who received broad spectrum antibiotic(s) (either Piperacillin and Tazobactam, a Carbapenem, or/and Cefepime) during ED visit or hospital admission. Results: A total of 581 patients were identified and 275 met inclusion criteria. Median age was 71 years, with 46% male. Most common cancer types were breast (21%), lung (18%), gastrointestinal (16%), and genitourinary (13%). Most patients had advanced cancer [stage 4 (59%), stage 3 (14%)], and 37% were on active systemic treatment at the time of ED presentation. A source of infection was identified in 68% of patients, which included 83/187 (44%) respiratory, 32/187 (17%) cutaneous or soft tissue, 24/187 (13%) genitourinary, 20/187 (11%) gastrointestinal, 14/187 (5%) hepatobiliary, and 12/187 iatrogenic (4%). Majority of ED visits (73%) resulted in hospital admission. Median duration of hospital stay was 6 days, and death occurred in 12% of the admitted patients. Broad-spectrum intravenous antibiotics were used in 47% of patients, and most of the time (78%) was the first antibiotic type given after arrival in ED. Conclusions: In our single-centre study, nearly half of patients with solid tumor malignancies who presented to ED with non-neutropenic fever or/and suspected infection received broad spectrum intravenous antibiotics typically recommended in febrile neutropenia protocols. These data suggest a need for quality improvement strategies to improve antibiotic stewardship for patients with solid tumour malignancies presenting to ED with non-neutropenic fever.

The Use of the Initial National Early Warning Score 2 at the Emergency Department as a Predictive Tool of In-Hospital Mortality in Hemodialysis Patients.

Background The diagnosis of sepsis in the emergency department (ED) is difficult due to the ambiguous nature of its expression and its non-specific symptoms. Multiple scoring tools have been utilized to detect the severity and prognosis of sepsis. This study aimed to evaluate the use of the initial National Early Warning Score 2 (NEWS-2) at the ED as a predictive tool of in-hospital mortality in hemodialysis patients. Methodology We performed a retrospective, observational study to review the records of hemodialysis patients admitted to King Abdulaziz Medical City in Riyadh with suspected sepsis from the 1st of January to the 31st of December 2019 using a convenient sampling technique. Results The results showed that NEWS-2 had a higher sensitivity in predicting sepsis compared to the Quick Sequential Organ Failure Assessment (qSOFA)(16.28% vs. 11.54%). However, qSOFA had a higher specificity in predicting sepsis compared to the NEWS-2 scoring system (81.16% vs. 74.14%). It was found that the NEWS-2 scoring system was more sensitive in predicting mortality compared to qSOFA (26% vs. 20%). However, qSOFA was more specific in predicting mortality compared to NEWS-2 (88.50% vs. 82.98%). Conclusions Our findings demonstrated that the initial NEWS-2 is a subpar screening tool for sepsis and in-hospital mortality in hemodialysis patients. The use of qSOFA at the time of ED presentation was found to have a relatively higher specificity in predicting sepsis and mortality when compared to NEWS-2. To assess the application of the initial NEWS-2 in the ED setting, additional research should be conducted.

Addressing COVID-19 Disparities Between Hispanic and Non-Hispanic White Populations of Arizona

Introduction: The coronavirus disease (COVID-19) pandemic1,2 contributed to over 1.03 million deaths in the United States (U.S.) and 30,768 deaths in Arizona3. Nationwide, Hispanics are at increased risk for infection, hospitalization, and death, when compared to non-Hispanic White (NHW)4. Although Hispanic COVID-19 disparities are clear in the U.S., study of Hispanic COVID-19 disparities in Arizona are less clear. Objective: To compare COVID-19 interventions and clinical outcomes between Hispanic and NHW populations in rural and urban healthcare settings of Arizona. Methods: A retrospective cohort of COVID-19 patients from January 1, 2020 through June 17, 2022 admitted to hospitals affiliated with the Midwestern University Graduate Medical Education consortium were assessed. Data was abstracted to counterbalance NHW and minority patients by date of admission. Data collected included patient demographics, presenting symptoms, vital signs, laboratory values at the time of emergency department presentation, treatment modalities, and clinical outcomes. Results: A total of 627 patients were analyzed with 31.7% (199/627) identifying as Hispanic, 41.8% (262/627) female, and 61.9% (388/627) allocated to the rural hospital group. No difference in mortality was seen in the rural or urban setting and there was no difference in administered COVID-19 therapeutics. Kaplan-Meier curves were parallel between Hispanic and NHW patients who survived COVID-19 with no difference in the length of stay (LOS) days. Kaplan-Meier curves differed between Hispanics and NHW patients who expired from COVID-19 with Hispanics at a greater LOS prior to mortality. Differences between Hispanic and NHW mortality patients included Hispanics presenting at a younger age, increased CRP elevations, and a greater delay between symptom onset and COVID-19 testing. Hispanics who expired were more likely to present with shortness of breath, hypoxia, and a documented bacterial infection during hospitalization as compared to Hispanics who survived. Conclusion: Following admission, patients regardless of Hispanic or NHW identification, received equitable care in our Arizona subset which resulted in comparable rates of mortality. Hispanics initially presented at increased disease severity, which is suggestive of factors outside of the hospital, prior to admission, responsible for the disparities seen at the national level with variation between states.

Epigenetic aging and PTSD outcomes in the immediate aftermath of trauma.

Psychological trauma exposure and posttraumatic stress disorder (PTSD) have been associated with advanced epigenetic age. However, whether epigenetic aging measured at the time of trauma predicts the subsequent development of PTSD outcomes is unknown. Moreover, the neural substrates underlying posttraumatic outcomes associated with epigenetic aging are unclear. We examined a multi-ancestry cohort of women and men (n = 289) who presented to the emergency department (ED) after trauma. Blood DNA was collected at ED presentation, and EPIC DNA methylation arrays were used to assess four widely used metrics of epigenetic aging (HorvathAge, HannumAge, PhenoAge, and GrimAge). PTSD symptoms were evaluated longitudinally at the time of ED presentation and over the ensuing 6 months. Structural and functional neuroimaging was performed 2 weeks after trauma. After covariate adjustment and correction for multiple comparisons, advanced ED GrimAge predicted increased risk for 6-month probable PTSD diagnosis. Secondary analyses suggested that the prediction of PTSD by GrimAge was driven by worse trajectories for intrusive memories and nightmares. Advanced ED GrimAge was also associated with reduced volume of the whole amygdala and specific amygdala subregions, including the cortico-amygdaloid transition and the cortical and accessory basal nuclei. Our findings shed new light on the relation between biological aging and trauma-related phenotypes, suggesting that GrimAge measured at the time of trauma predicts PTSD trajectories and is associated with relevant brain alterations. Furthering these findings has the potential to enhance early prevention and treatment of posttraumatic psychiatric sequelae.

The efficacy of low molecular weight heparin is reduced in COVID-19.

A significant degree of mortality and morbidity in COVID-19 is through thromboembolic complications, only partially mitigated by anticoagulant therapy. Reliable markers of infection severity are not fully established. This study investigated whether visco-elastic biomarkers predict disease severity on presentation to the Emergency Department (ED) and how they measure response to anticoagulationMETHODS:Patients testing positive for COVID-19 at a large University Teaching Hospital ED were recruited at presentation. Multiple blood samples were taken throughout hospital admission to monitor disease progression with end outcome recorded. Visco-elastic markers, fractal dimension (df) and Time to Gel Point (TGP) which measure the properties of the incipient clot were compared in patients with and without anticoagulation by Low Molecular Weight Heparin (LMWH). TGP and df did not predict severity of infection with COVID-19. Although LMWH prolonged TGP, there was no change in df indicating LMWH did not change clot microstructure. Therapeutic efficacy of LMWH appears blunted in COVID-19 infection. This may be due to the inflammatory state creating a resistance to LMWH activity, which may explain why LMWH appears less effective in COVID-19 compared to other disease states. COVID-19 was not predicted by visco-elastic testing at the time of ED presentation.

Factors leading to delayed presentation among patients presenting with ST-elevation Myocardial Infarction in Emergency Department of a tertiary care hospital.

The duration between the onset of myocardial infarction and first intervention plays a pivotal role in saving the life of the patients. Objective: To determine the frequency of various pre-hospital factors causing delay among patients presenting with STEMI in the emergency department of a teaching hospital. Methods: This is a descriptive observational study conducted at the Cardiology Department, Rawalpindi Institute of Cardiology (RIC), Rawalpindi from March to August 2019. A total of 142 patients presenting with ST-elevation myocardial infarction (STEMI) to the Emergency Department (ED) of RIC were enrolled. Electrocardiograms (ECGs) were reviewed for confirmation of STEMI and find the type of MI. Echo-cardiography was done to find out the ejection fraction (EF) of the left ventricle. Type of reperfusion therapy either thrombolytic therapy or primary percutaneous coronary intervention (PCI), time of symptom onset, and time of presentation in ED of RIC were noted. Patients were divided into four major groups depending upon the possible factors for delayed presentation: 1) Misinterpretation of symptoms, 2) Ignorance Of reporting urgently or waiting for symptoms to resolve, 3) Transportation problem and 4) First presentational facility where thrombolytic unavailable. Data were analyzed using the Statistical Package for Social Sciences (SPSS) v.23.0 (IBM, Armonk, U.S.). Results: The mean age was 53.2(SD=15.5). Out of 142 patients, most of them were males 130(91.5%). In our study, the majority 46.5% had a primary level of education. Transportation problems were the main reason for delayed presentation accounting for 45(34.5%), followed by misinterpretation of symptoms 40(28.2%), patients first presented at a facility where thrombolytic therapy was unavailable 27(19%) and patients were either ignorant of reporting urgently to a hospital or they waited for symptoms to resolve 26(18.3%). There was a significant difference in point of the first consultation, MI type, and time duration of delayed presentation among groups (P<.05). Conclusion: Transportation problems and misinterpretation of symptoms are the main reasons for the delay in getting reperfusion treatment for ST-elevation MI. Providing better primary care facilities available to rural areas as well as targeted awareness campaigns will greatly help in this regard.

Antiretroviral therapy non-adherence among HIV-positive patients presenting to an emergency department in Johannesburg, South Africa: Associations and reasons.

Suboptimal antiretroviral therapy (ART) adherence is associated with viral resistance, opportunistic infections and increased mortality. To determine the rates of ART non-adherence and its associations, and also the reasons for ART non-adherence, among HIV-positive patients presenting to a major central hospital emergency department (ED). Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 7July 2017 and 18 October 2018 were prospectively enrolled. Self-reported adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire (ACTG-AQ). Of the 1 224 consecutive HIV-positive participants enrolled, 761 (75.2%) were on ART at the time of ED presentation. Of these, 245 (32.2%) were non-adherent as per the ACTG-AQ. Participants not yet on ART prior to ED presentation had significantly higher in-hospital mortality than participants on ART (odds ratio 1.69; 95% confidence interval 1.21 - 2.34; p=0.002). Younger age, male sex, CD4 count <100cells/µL, lack of viral suppression, a high National Early Warning Score 2 (≥7 points) and length of hospital stay ≥7 days were significantly associated with ART non-adherence (p<0.05). Forgetfulness (13.9%) and lack of social support, depression/stress/mental illness, and lack of money for transport to collect medications (9.9% each) were the most common reasons given for ART non-adherence. Of HIV-positive patients presenting to the ED, a high proportion were either not yet initiated on ART or ART non-adherent. HIV programmes should focus on HIV-positive ED attendees with the aim of identifying high-risk patients and providing adequate ART adherence support.

The Impact of Night-time Emergency Department Presentation on Upper Gastrointestinal Hemorrhage Outcomes.

The aim was to investigate the impact of night-time emergency department (ED) presentation on outcomes of patients admitted for acute upper gastrointestinal hemorrhage (UGIH). The relationship between time of ED presentation and outcomes of gastrointestinal hemorrhage is unclear. Using the 2016 and 2017 Florida State Inpatient Databases which provide times of ED arrival, we identified and categorized adults hospitalized for UGIH to daytime (07:00 to 18:59 h) and night-time (19:00 to 06:59 h) based on the time of ED presentation. We matched both groups with propensity scores, and assessed their clinical outcomes including all-cause in-hospital mortality, in-hospital endoscopy utilization, length of stay (LOS), total hospitalization costs, and 30-day all-cause readmission rates. Of the identified 38,114 patients with UGIH, 89.4% (n=34,068) had acute nonvariceal hemorrhage (ANVH), while 10.6% (n=4046) had acute variceal hemorrhage (AVH). Compared with daytime patients, ANVH patients admitted at night-time had higher odds of in-hospital mortality (odds ratio: 1.32; 95% confidence interval: 1.06-1.60), lower odds of in-patient endoscopy (odds ratio: 0.83; 95% confidence interval: 0.77-0.90), higher total hospital costs ($9911 vs. $9545, P <0.016), but similar LOS and readmission rates. Night-time AVH patients had a shorter LOS (5.4 vs. 5.8 d, P =0.045) but similar mortality rates, endoscopic utilization, total hospitalization costs, and readmission rates as daytime patients. Patients arriving in the ED at night-time with ANVH had worse outcomes (mortality, hospitalization costs, and endoscopy utilization) compared with daytime patients. However, those with AVH had comparable outcomes irrespective of ED arrival time.

Frailty Assessment in the Emergency Department for Risk Stratification of COVID-19 Patients Aged ≥80 Years

ObjectivesTo evaluate, in a cohort of adults aged ≥80 years, the overlapping effect of clinical severity, comorbidities, cognitive impairment, and frailty, for the in-hospital death risk stratification of COVID-19 older patients since emergency department (ED) admission. DesignSingle-center prospective observational cohort study. Setting and ParticipantsThe study was conducted in the ED of a teaching hospital that is a referral center for COVID-19 in central Italy. We enrolled all patients with aged ≥80 years old consecutively admitted to the ED between April 2020 and March 2021. MethodsClinical variables assessed in the ED were evaluated for the association with all-cause in-hospital death. Evaluated parameters were severity of disease, frailty, comorbidities, cognitive impairment, delirium, and dependency in daily life activities. Cox regression analysis was used to identify independent risk factors for poor outcomes. ResultsA total of 729 patients aged ≥80 years were enrolled [median age 85 years (interquartile range 82-89); 346 were males (47.3%)]. According to the Clinical Frailty Scale, 61 (8.4%) were classified as fit, 417 (57.2%) as vulnerable, and 251 (34.4%) as frail. Severe disease [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.31-2.59], ≥3 comorbidities (HR 1.54, 95% CI 1.11-2.13), male sex (HR 1.46, 95% CI 1.14-1.87), and frailty (HR 6.93, 95% CI 1.69-28.27) for vulnerable and an overall HR of 12.55 (95% CI 2.96-53.21) for frail were independent risk factors for in-hospital death. Conclusions and ImplicationsThe ED approach to older patients with COVID-19 should take into account the functional and clinical characteristics of patients being admitted. A sole evaluation based on the clinical severity and the presence of comorbidities does not reflect the complexity of this population. A comprehensive evaluation based on clinical severity, multimorbidity, and frailty could effectively predict the clinical risk of in-hospital death for patients with COVID-19 aged ≥80 years at the time of ED presentation.

Direct Comparison of Clinical Characteristics, Outcomes, and Risk Prediction in Patients with COVID-19 and Controls-A Prospective Cohort Study.

Most studies investigating early risk predictors in coronavirus disease 19 (COVID-19) lacked comparison with controls. We aimed to assess and directly compare outcomes and risk predictors at time of emergency department (ED) presentation in COVID-19 and controls. Consecutive patients presenting to the ED with suspected COVID-19 were prospectively enrolled. COVID-19-patients were compared with (i) patients tested negative (overall controls) and (ii) patients tested negative, who had a respiratory infection (respiratory controls). Primary outcome was the composite of intensive care unit (ICU) admission and death at 30 days. Among 1081 consecutive cases, 191 (18%) were tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and 890 (82%) were tested negative (overall controls), of which 323 (30%) had a respiratory infection (respiratory controls). Incidence of the composite outcome was significantly higher in COVID-19 (23%) as compared with the overall control group (10%, adjusted-HR 2.45 (95%CI, 1.61–3.74), p < 0.001) or the respiratory control group (10%, adjusted-HR 2.93 (95%CI, 1.66–5.17), p < 0.001). Blood oxygen saturation, age, high-sensitivity troponin, c-reactive protein, and lactate dehydrogenase were identified as the strongest predictors of poor outcome available at time of ED presentation in COVID-19 with highly comparable prognostic utility in overall and respiratory controls. In conclusion, patients presenting to the ED with COVID-19 have a worse outcome than controls, even after adjustment for differences in baseline characteristics. Most predictors of poor outcome in COVID-19 were not restricted to COVID-19, but of comparable prognostic utility in controls and therefore generalizable to unselected patients with suspected COVID-19.

Development and validation of a cellular host response test as an early diagnostic for sepsis

Sepsis must be diagnosed quickly to avoid morbidity and mortality. However, the clinical manifestations of sepsis are highly variable and emergency department (ED) clinicians often must make rapid, impactful decisions before laboratory results are known. We previously developed a technique that allows the measurement of the biophysical properties of white blood cells as they are stretched through a microfluidic channel. In this study we describe and validate the resultant output as a model and score—the IntelliSep Index (ISI)—that aids in the diagnosis of sepsis in patients with suspected or confirmed infection from a single blood draw performed at the time of ED presentation. By applying this technique to a high acuity cohort with a 23.5% sepsis incidence (n = 307), we defined specific metrics—the aspect ratio and visco-elastic inertial response—that are more sensitive than cell size or cell count in predicting disease severity. The final model was trained and cross-validated on the high acuity cohort, and the performance and generalizability of the model was evaluated on a separate low acuity cohort with a 6.4% sepsis incidence (n = 94) and healthy donors (n = 72). For easier clinical interpretation, the ISI is divided into three interpretation bands of Green, Yellow, and Red that correspond to increasing disease severity. The ISI agreed with the diagnosis established by retrospective physician adjudication, and accurately identified subjects with severe illness as measured by SOFA, APACHE-II, hospital-free days, and intensive care unit admission. Measured using routinely collected blood samples, with a short run-time and no requirement for patient or laboratory information, the ISI is well suited to aid ED clinicians in rapidly diagnosing sepsis.

29 Bedside Point-of-Care Measurement of a Novel Biomarker SPLA2-IIA for Prediction of Sepsis: Midpoint Analysis

Sepsis, the systemic response to infection, is a common but potentially life-threatening process that can be difficult to diagnose. In the emergency department (ED), various measures, such as systemic inflammatory response syndrome (SIRS) and q-SOFA criteria, lactate, and procalcitonin, help determine sepsis and whether its source is bacterial. However, there is currently no known marker that results in the ED to confirm diagnosis. While delaying antibiotics for bacterial sepsis results in worse outcomes, giving unnecessary antibiotics is also harmful, so rapid, accurate diagnosis is critical. Group II Secretory Phospholipase A2 (sPLA2-IIA) is a novel biomarker that has shown some promise in small studies as a tool to detect bacterial sepsis. Our objective was to determine if a point-of-care (POC) sPLA2-IIA assay can predict sepsis in patients meeting SIRS/q-SOFA criteria. Adult, non-pregnant patients who met SIRS and/or q-SOFA criteria and received a sepsis workup in a single tertiary academic ED were enrolled from May 2019 to March 2020, when the study was temporarily suspended under IRB guidance to reduce COVID-19 exposure. Each time a lactate was drawn in the ED from an enrolled patient, a separate blood sample was collected simultaneously and run by a trained researcher on a POC machine to measure the sPLA2-IIA value. Patients who were subsequently admitted to the ICU had additional sPLA2-IIA values drawn with lactates. SPLA2-IIA data did not affect patient care, and the medical team was blinded to the results except when the researcher was also the primary physician for that patient in the ED. Our primary endpoints were whether sPLA2-IIA could predict sepsis, bacterial sepsis, and bacteremia. Secondary endpoints were ICU stay, hospital length of stay (LOS), in-hospital mortality, and 90-day mortality. Potential confounders noted included elevated troponin, pancreatitis, antibiotic use at time of ED presentation, immunosuppression, steroid use, and comorbid inflammatory conditions. 226 patients ages 18-101 (mean 66) were analyzed, composed of 184 patients with sepsis (ED impression correct 80.5%), 152 with bacterial sepsis (ED impression correct 70.8%), and 37 with bacteremia. See table for data on the ability of sPLA2-IIA to detect sepsis, bacterial sepsis, and bacteremia. All patients with sPLA2-IIA>201 had a final diagnosis of sepsis, and all patients with sPLA2-IIA>225 had a final diagnosis of bacterial sepsis. No significant difference was found after stratifying for potential confounders. sPLA2-IIA was not found to be predictive of ICU stay, hospital LOS, or mortality. Correlations between sPLA2-IIA and lactate (r=0.2688, p<0.00001) and between sPLA2-IIA and neutrophil-lymphocyte ratio (r=0.2717, p=0.000035) were poor. A moderate correlation was found between sPLA2-IIA and procalcitonin (r=0.4418, p=0.00001). At midpoint analysis, sPLA2-IIA≤20 shows good sensitivity to rule out sepsis, bacterial sepsis, and bacteremia; sPLA2-IIA>200 shows excellent specificity to detect sepsis and bacterial sepsis.

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services

ObjectivesRoutine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation. MethodsCross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017–July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care. ResultsThere were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%–8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%–23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services. ConclusionsPatients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.

Monocyte distribution width enhances early sepsis detection in the emergency department beyond SIRS and qSOFA

BackgroundThe initial presentation of sepsis in the emergency department (ED) is difficult to distinguish from other acute illnesses based upon similar clinical presentations. A new blood parameter, a measurement of increased monocyte volume distribution width (MDW), may be used in combination with other clinical parameters to improve early sepsis detection. We sought to determine if MDW, when combined with other available clinical parameters at the time of ED presentation, improves the early detection of sepsis.MethodsA retrospective analysis of prospectively collected clinical data available during the initial ED encounter of 2158 adult patients who were enrolled from emergency departments of three major academic centers, of which 385 fulfilled Sepsis-2 criteria, and 243 fulfilled Sepsis-3 criteria within 12 h of admission. Sepsis probabilities were determined based on MDW values, alone or in combination with components of systemic inflammatory response syndrome (SIRS) or quick sepsis-related organ failure assessment (qSOFA) score obtained during the initial patient presentation (i.e., within 2 h of ED admission).ResultsAbnormal MDW (> 20.0) consistently increased sepsis probability, and normal MDW consistently reduced sepsis probability when used in combination with SIRS criteria (tachycardia, tachypnea, abnormal white blood count, or body temperature) or qSOFA criteria (tachypnea, altered mental status, but not hypotension). Overall, and regardless of other SIRS or qSOFA variables, MDW > 20.0 (vs. MDW ≤ 20.0) at the time of the initial ED encounter was associated with an approximately 6-fold increase in the odds of Sepsis-2, and an approximately 4-fold increase in the odds of Sepsis-3.ConclusionsMDW improves the early detection of sepsis during the initial ED encounter and is complementary to SIRS and qSOFA parameters that are currently used for this purpose. This study supports the incorporation of MDW with other readily available clinical parameters during the initial ED encounter for the early detection of sepsis.Trial registrationClinicalTrials.gov, NCT03145428. First posted May 9, 2017. The first subjects were enrolled June 19, 2017, and the study completion date was January 26, 2018.

Serum netrin-1 levels at presentation and delayed neurological sequelae in unintentional carbon monoxide poisoning

Objectives: The early identification of patients with a high risk of developing delayed neurological sequelae (DNS) can improve the quality of care in carbon monoxide (CO) poisoning cases. The aim of this study is to investigate whether the serum netrin-1 levels measured at presentation to the emergency department (ED) predicted the development of DNS after acute CO intoxication.Methods: This prospective observational study was conducted between 1 August 2018 and 31 July 2019 in a single tertiary hospital. The patients with acute CO intoxication and serum netrin-1 levels measured at the time of ED presentation were included in the study. All patients were followed up for six weeks regarding the development of DNS. The patients were divided into two groups, including those who developed DNS (DNS group) and those who did not (non-DNS group).Results: A total of 183 patients were included in the study, and 54 (29.5%) developed DNS. The median serum netrin-1 level at ED presentation was significantly lower in the DNS group (391.5 pg/mL [263.0–550.5]) than in the non-DNS group (626.0 pg/mL [505.9–755.6]) (p < .001). Multivariate analysis revealed that a low serum netrin-1 level (adjusted odds ratio [AOR]: 8.02, 95% CI: 2.45–26.20), low Glasgow coma scale (GCS) score at ED presentation (AOR: 0.81, 95% CI: 0.68–0.97), long CO exposure time (AOR: 1.96, 95% CI: 1.49–2.56), and the presence of acute brain lesions (AOR: 8.24, 95% CI: 2.37–28.58) on diffusion-weighted imaging were independent predictors of DNS. Serum netrin-1 levels less than 432 pg/mL predicted the development of DNS with a sensitivity of 68.5% (95% CI: 54.4%-80.5%) and a specificity of 86.0% (95% CI: 78.8%-91.5%).Conclusions: Low serum netrin-1 levels were significantly associated with the development of DNS. Therefore, serum netrin-1 at ED presentation can help identify patients at risk of developing DNS following discharge.

Analysis of the Patients Who Admitted To A Turkish Emergency Department During COVID-19 Pandemic

Background and aim:In this study, it was aimed to review patients who presented to a Turkish emergency department (ED) with fever and at least one symptom and finding of acute respiratory infection (cough, shortness of breath) in Sisli Hamidiye Etfal Education and Research Hospital Tertiary Medical Care Center during COVID-19 pandemic.Methods:This retrospective, descriptive, observational study included patients presented between March 10, 2020 and April 25, 2020. The patients were classified into two groups according to RT-PCR test result: RT-PCR (+) and RT-PCR (-). The demographic characteristics and clinical endpoint-related factors were analyzed in the patients.Results:The study included 840 patients; 461 men (54.9%) and 379 women (45.1%). RT-PCR test was positive in 345 patients (41.0%). The most common comorbidity was hypertension (HT) in 119 patients (34.5%); followed by diabetes mellitus (DM) in 61 patients (18.3%). At time of ED presentation, there was mild clinical manifestation in 72.2%, whereas moderate in 21.7% and severe in 6.1% of patients with positive RT-PCR testing. Of the patients with positive RT-PCR testing, 64 patients (18.6%) were discharged from ED while 255 patients (73.9%) were admitted to COVID clinic and 26 were admitted to COVID intensive care unit (ICU). Of the patients admitted, 299 patients (86.7%) were discharged while 46 patients (13.3%) died due to multi-organ failure (MOF) (50%), acute respiratory distress syndrome (ARDS) (32.6%), acute pulmonary embolism (APE) (10.9%) and acute coronary syndrome (ACS) (6.5%).Conclusions:The RT-PCR positivity rate seemed lower in our study when compared to literature. In addition, mortality rate was lower in our study when compared to other countries.

Pulmonary Embolism Testing Among Emergency Department Patients Who Are Pulmonary Embolism Rule-out Criteria Negative.

Previous studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE-related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients ("PERC-negative") who do not require D-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED. We prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics. Of the 3,024 study patients, 54.8% (95% confidence interval= 53%-56.5%) were female and the mean age was 51.7 (51.1-52.3) years. A total of 17.5% (16.2%-18.9%) of study patients were PERC-negative and 33.7% (32%-35.4%) of all patients underwent testing for PE. A total of 25.5% (22%-29.4%) of PERC-negative patients had PE testing compared to 35.4% (33.6%-37.3%) of PERC-positive patients (p<0.001).A total of 7.2% (5.3%-9.7%) of PERC-negative patients had advanced imaging without a D-dimer compared to 19.2% (17.8%-20.8%) of PERC-positive patients (p<0.001). In multivariate analysis, factors associated with PE testing in PERC-negative patients included age, white non-Hispanic race/ethnicity, pleuritic chest pain, and a complaint of both chest pain and shortness of breath. Two PERC-negative patients (0.4%) were diagnosed with an acute PE in the ED compared to 2.2% of PERC-positive patients (p=0.008). The overall testing yield for PE was 1.6% (0.4%-9.2%) among PERC-negative patients versus 6.3% (4.9%-8.1%) among PERC-positive patients (p=0.017). In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without D-dimer risk stratification. Future areas of research may include evaluating factors that lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.

Association Between Acute Kidney Disease and Intravenous Dye Administration in Patients With Acute Stroke: A Population-Based Study.

Computed tomographic angiography and conventional angiography provide timely vascular anatomic information in patients with stroke. However, iodinated contrast dye may cause acute kidney injury (AKI). Within a large, biracial population, we examined in-hospital incidence of new or worsening kidney disease in patients with stroke and its association with administration of intravenous dye. All adult residents of the Greater Cincinnati/Northern Kentucky region with acute ischemic stroke or intracerebral hemorrhage who presented to an emergency department in 2010 were included. Prevalence of unsuspected kidney disease at the time of emergency department presentation and the incidence of AKI after admission in 2 groups of patients-those who did and those who did not receive intravenous dye-were determined. In 2010, 2299 patients met inclusion criteria (89% ischemic stroke and 11% intracerebral hemorrhage); mean age 69 years (SD 15), 22% black, and 54% women. Among these patients, 37% had kidney disease at baseline, including 22% (516/2299) in whom this was unsuspected. Two percent (2%; 15/853) of patients with baseline kidney disease developed AKI during the hospital stay. Of those with no baseline kidney disease, 1% (14/14 467) developed AKI. There was no association between dye administration and new or worsening kidney disease. Although 22% of patients in the Greater Cincinnati/Northern Kentucky stroke population had unsuspected kidney disease, the incidence of new or worsening kidney disease was low, and AKI was not associated with dye administration. These findings confirm single-center reports that the risk of severe renal complications after contrast dye is small.