Comparison Accuracy in mSIRS, NEWS and qSOFA Score to Triage Sepsis Patients in The Emergency Department at a Hospital in Thailand

Objective: We aimed to apply the modified systemic inflammatory response syndrome (mSIRS), the quick sequential organ failure assessment score (qSOFA), and National Early Warning Score (NEWS) to triage suspected sepsis patients. Therefore, knowing the predictive performance of each scoring system, using given cut-points for triaging patients with suspected sepsis, could help predict the progression of sepsis.Material and Methods: This study is a single-center retrospective chart review. The study enrolled patients older than 18 years with suspected sepsis patient at the time they presented at the triage zone. The primary outcome was to determine which scoring system were the most accurate to triage sepsis patients. The secondary outcomes were predictions of mortality related to the scoring.Results: Considering the outcome to be represented by a SOFA score of ≥2, the area under the curve of the receiver operating characteristic curves for the entire range of mSIRS, qSOFA and NEWS were 0.494, 0.669 and 0.751, respectively. Using a cut point for qSOFA of ≥2 provided a low sensitivity of 36.2% and high specificity of 93.0%; whereas, using a cut point for NEWS of >4 provided a high sensitivity of 89.0% and low specificity of 33.0%.Conclusion: In summary, qSOFA is the most accurate scoring system for diagnosis sepsis which was consistent with previous study. However, qSOFA had the lowest sensitivity, so is not appropriate in a triage situation. Therefore, we decided to use NEWS as the triage tool because of its better sensitivity and acceptable specificity as we need to triage almost all possible cases.

Which chart and which cut-point: deciding on the INTERGROWTH, World Health Organization, or Hadlock fetal growth chart

Objective To determine how various centile cut points on the INTERGROWTH-21st (INTERGROWTH), World Health Organization (WHO), and Hadlock fetal growth charts predict perinatal morbidity/mortality, and how this relates to choosing a fetal growth chart for clinical use. Methods We linked antenatal ultrasound measurements for fetuses > 28 weeks’ gestation from the British Columbia Women’s hospital ultrasound unit with the provincial perinatal database. We estimated the risk of perinatal morbidity/mortality (decreased cord pH, neonatal seizures, hypoglycemia, and perinatal death) associated with select centiles on each fetal growth chart (the 3rd, 10th, the centile identifying 10% of the population, and the optimal cut-point by Youden’s Index), and determined how well each centile predicted perinatal morbidity/mortality. Results Among 10,366 pregnancies, the 10th centile cut-point had a sensitivity of 11% (95% CI 8, 14), 13% (95% CI 10, 16), and 12% (95% CI 10, 16), to detect fetuses with perinatal morbidity/mortality on the INTERGROWTH, WHO, and Hadlock charts, respectively. All charts performed similarly in predicting perinatal morbidity/mortality (area under the curve [AUC] =0.54 for all three charts). The statistically optimal cut-points were the 39th, 31st, and 32nd centiles on the INTERGROWTH, WHO, and Hadlock charts respectively. Conclusion The INTERGROWTH, WHO, and Hadlock fetal growth charts performed similarly in predicting perinatal morbidity/mortality, even when evaluating multiple cut points. Deciding which cut-point and chart to use may be guided by other considerations such as impact on workflow and how the chart was derived.

The Differences of the Acromiohumeral Interval Between Supine and Upright Radiographs of the Shoulder

Background: Acromiohumeral interval (AHI) is a measurement method to determine the superior migration of the humeral head in patients with rotator cuff tears.Hypothesis/Purpose: The purpose of this study was to compare the AHI measurement in supine shoulder and upright shoulder radiographs, as well as magnetic resonance imaging (MRI), as well as to report the sensitivity, specificity, and accuracy in detecting full thickness rotator cuff tears.Study Design: Diagnostic study.Methods: From July 2020 to May 2021, evaluation of 86 shoulder radiographs in both supine & upright Grashey views compared with the MRI of the affected shoulder. Measurements of the AHI obtained from both radiographs and MRIs was determined by two independent orthopaedic surgeons. The intraclass correlation of the AHI measurement was tested. The difference between the AHI in each view was determined.Result: The 86 shoulders were divided into 3 groups that included; 1) non-full thickness tear (50%), 2) full thickness (FT) tear 3 cm (33.7%), and 3) FT tear > 3 cm (16.3%). The mean difference of AHI noted was significantly lower in the supine radiographs than with the upright (1.34-1.37 mm.). The mean difference of the AHI was significantly lower in the MRI than the upright (1.62-1.87 mm.). AHI obtained from the supine radiographs and MRI had no significant differences. The area under the curve (AUC) of the upright and supine AHI in the diagnosis of the FT tears were at 0.649 and 0.642 accuracy. Upright AHI 7.09 mm. had 27.9% sensitivity and 100% specificity in diagnosing FT tears with 64% accuracy (p<0.001). The upright AHI cut off value of 9.52 mm. had 60.5% sensitivity, 67.4% specificity, and 64% accuracy (p=0.01). The supine AHI 6.56 mm. had 32.6% sensitivity, 100.0% specificity, and 66.3% accuracy (p<0.01). Supine AHI cut off value of 7.42 mm. had 41.9% sensitivity, 86.0% specificity, and 64.0% accuracy (p=0.004). The inter- and intra-rater reliability of AHI measurement in 3 views were of substantial to almost perfect agreement (0.668-0.824).Conclusion: The AHI in supine radiographs were significantly lower than upright shoulder radiographs in all groups as divided by severity of the rotator cuff tear and was comparable with the MRI. For AHI ≤ 7 mm. in upright shoulder radiographs remains as a good diagnostic test of full thickness rotator cuff tears, while this value was not relevant for use as the cut point in the supine radiographs and MRI shoulders.Level of evidence: Level III; Diagnostic studyClinical Relevance: The AHI measurement in supine and upright radiographs are reliable and reproducible. The AHI ≤ 7 mm. in upright shoulder radiographs remains as a good diagnostic test of full thickness rotator cuff tears, while this value was not relevant for use as the cut point in the supine radiographs and MRI shoulders.

Validity of urges to smoke measures in predicting smoking relapse during treatment in primary care

In the context of smoking cessation treatment in primary care, identifying patients at the highest risk of relapse is relevant. We explored data from a primary care trial to assess the validity of two simple urges to smoke questions in predicting long-term relapse and their diagnostic value. Of 295 patients who received behavioural support and varenicline, 180 were abstinent at week 9. In this subgroup, we measured time spent with urges to smoke (TSU) and strength of urges to smoke (SUT; both scales 1 to 6 = highest). We used separate regression models with TSU or SUT as predictor and relapse from week 9–26 or week 9–52 as an outcome. We also calculated the sensitivity (SP), specificity and positive predictive values (PPV) of TSU and SUT in correctly identifying patients who relapsed at follow-up. The adjusted odds ratios (aOR) for predicting relapse from week 9–26 were 1.74 per point increase (95% CI = 1.05–2.89) for TSU and 1.59 (95% CI = 1.11–2.28) for SUT. The aORs for predicting relapse from week 9–52 were 2.41 (95% CI = 1.33–4.37) and 1.71 (95% CI = 1.14–2.56), respectively. Applying a cut-point of ≥3 on TSU resulted in SP = 97.1 and PPV = 70.0 in week 9–26, and SP = 98.8 and PPV = 90.0 in week 9–52. Applying a cut-point of ≥4 on SUT resulted in SP = 99.0 and PPV = 85.7 in week 9–26, and SP = 98.8 and PPV = 85.7 in week 9–52. Both TSU and SUT were valid predictors of long-term relapse in patients under smoking cessation treatment in primary care. These simple questions may be useful to implement in primary care.Trial registration: Dutch Trial Register (NTR3067).

Heart Failure Probability and Early Outcomes of Critically Ill Patients With COVID-19: A Prospective, Multicenter Study

Background: The relationship between cardiac functions and the fatal outcome of coronavirus disease 2019 (COVID-19) is still largely underestimated. We aim to explore the role of heart failure (HF) and NT-proBNP in the prognosis of critically ill patients with COVID-19 and construct an easy-to-use predictive model using machine learning.Methods: In this multicenter and prospective study, a total of 1,050 patients with clinical suspicion of COVID-19 were consecutively screened. Finally, 402 laboratory-confirmed critically ill patients with COVID-19 were enrolled. A “triple cut-point” strategy of NT-proBNP was applied to assess the probability of HF. The primary outcome was 30-day all-cause in-hospital death. Prognostic risk factors were analyzed using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression, further formulating a nomogram to predict mortality.Results: Within a 30-day follow-up, 27.4% of the 402 patients died. The mortality rate of patients with HF likely was significantly higher than that of the patient with gray zone and HF unlikely (40.8% vs. 25 and 16.5%, respectively, P &lt; 0.001). HF likely [Odds ratio (OR) 1.97, 95% CI 1.13–3.42], age (OR 1.04, 95% CI 1.02–1.06), lymphocyte (OR 0.36, 95% CI 0.19–0.68), albumin (OR 0.92, 95% CI 0.87–0.96), and total bilirubin (OR 1.02, 95% CI 1–1.04) were independently associated with the prognosis of critically ill patients with COVID-19. Moreover, a nomogram was developed by bootstrap validation, and C-index was 0.8 (95% CI 0.74–0.86).Conclusions: This study established a novel nomogram to predict the 30-day all-cause mortality of critically ill patients with COVID-19, highlighting the predominant role of the “triple cut-point” strategy of NT-proBNP, which could assist in risk stratification and improve clinical sequelae.

Predictors of the chest CT score in COVID-19 patients: a cross-sectional study

Background Since the COVID-19 outbreak, pulmonary involvement was one of the most significant concerns in assessing patients. In the current study, we evaluated patient’s signs, symptoms, and laboratory data on the first visit to predict the severity of pulmonary involvement and their outcome regarding their initial findings. Methods All referred patients to the COVID-19 clinic of a tertiary referral university hospital were evaluated from April to August 2020. Four hundred seventy-eight COVID-19 patients with positive real-time reverse-transcriptase-polymerase chain reaction (RT-PCR) or highly suggestive symptoms with computed tomography (CT) imaging results with typical findings of COVID-19 were enrolled in the study. The clinical features, initial laboratory, CT findings, and short-term outcomes (ICU admission, mortality, length of hospitalization, and recovery time) were recorded. In addition, the severity of pulmonary involvement was assessed using a semi-quantitative scoring system (0–25). Results Among 478 participants in this study, 353 (73.6%) were admitted to the hospital, and 42 (8.7%) patients were admitted to the ICU. Myalgia (60.4%), fever (59.4%), and dyspnea (57.9%) were the most common symptoms of participants at the first visit. A review of chest CT scans showed that Ground Glass Opacity (GGO) (58.5%) and consolidation (20.7%) were the most patterns of lung lesions. Among initial clinical and laboratory findings, anosmia (P = 0.01), respiratory rate (RR) with a cut point of 25 (P = 0.001), C-reactive protein (CRP) with a cut point of 90 (P = 0.002), white Blood Cell (WBC) with a cut point of 10,000 (P = 0.009), and SpO2 with a cut point of 93 (P = 0.04) was associated with higher chest CT score. Lung involvement and consolidation lesions on chest CT scans were also associated with a more extended hospitalization and recovery period. Conclusions Initial assessment of COVID-19 patients, including symptoms, vital signs, and routine laboratory tests, can predict the severity of lung involvement and unfavorable outcomes.

Tri-Ponderal Mass Index Reference Values for Screening Metabolic Syndrome in Children and Adolescents: Results From Two National-Representative Cross-Sectional Studies in China and America

IntroductionTo ascertain the possible cut point of tri-ponderal mass index (TMI) in discriminating metabolic syndrome (MetS) and related cardio-metabolic risk factors in Chinese and American children and adolescents.MethodsA total of 57,201 Chinese children aged 7-18 recruited in 2012 and and 10,441 American children aged 12-18 from National Health and Nutrition Examination Survey (NHANES 2001-2014) were included to fit TMI percentiles. Participants were randomly assigned to a derivation set (75%) and validation set (25%). The cut points of TMI with the lowest misclassification rate under the premise of the highest area under curves (AUC) were selected for each sex, which were additionally examined in the validation set. All of data analysis was conducted between September and December in 2019.ResultsTMI showed good capacity on discriminating MetS, with AUC of 0.7658 (95% CI: 0.7544-0.7770) to 0.8445 (95% CI: 0.8349-0.8537) in Chinese and 0.8871 (95% CI: 0.8663-0.9056) to 0.9329 (95% CI: 0.9166-0.9469) in American children. The optimal cut points were 14.46 kg/m3 and 13.91 kg/m3 for Chinese boys and girls, and 17.08 kg/m3 and 18.89 kg/m3 for American boys and girls, respectively. The corresponding misclassification rates were 17.1% (95% CI: 16.4-17.8) and 11.2% (95% CI: 9.9-12.6), respectively. Performance of these cut points were also examined in the validation set (sensitivity 67.7%, specificity 82.4% in Chinese; sensitivity 84.4%, specificity 88.7% in American children).ConclusionsA sex- and ethnicity- specific single cut point of TMI could be used to distinguish MetS and elevated risk of cardio-metabolic factors in children and adolescents.

The Role of Procalcitonin in Predicting Risk of Mechanical Ventilation and Mortality among moderate to Severe COVID-19 Patients

BackgroundSerum procalcitonin (PCT) has become an emerging prognostic biomarker of disease progression in patients with COVID-19. This study aims to determine the optimal cut-off value of PCT with regards to important clinical outcomes, especially for mechanical ventilation and all-cause mortality among moderate to severe COVID-19 patients in Malaysia.MethodsA total of 319 moderate to severe COVID-19 patients hospitalized at the National Referral Hospital in December 2020 were included in the study retrospectively. Demographics, comorbidities, the severity of COVID-19 infection, laboratory and imaging findings, and treatment given were collected from the hospital information system for analysis. The optimal cut-point values for PCT were estimated in two levels. The first level involved 276 patients who had their PCT measured within 5 days following their admission. The second level involved 237 patients who had their PCT measured within 3 days following their admission. Further, a propensity score matching analysis was performed to determine the adjusted relative risk of patients with regards to various clinical outcomes according to the selected cut-point among 237 patients who had their PCT measured within 3 days. ResultsThe results showed that a PCT level of 0.2 ng/mL was the optimal cut-point for prognosis especially for mortality outcome and the need for mechanical ventilation. Before matching, patients with PCT ≥ 0.2ng/mL were associated with significantly higher odds in all investigated outcomes. After matching, patients with PCT > 0.2 ng/mL were associated with higher odds in all-cause mortality (OR: 4.629, 95% CI: 1.387 – 15.449, p = 0.0127) and non-invasive ventilation (OR: 2.667, 95% CI: 1.039 – 6.847, p = 0.0415). Furthermore, patients with higher PCT were associated with significantly longer days of mechanical ventilation (p = 0.0213). There was however no association between higher PCT level and the need for mechanical ventilation (OR: 2.010, 95% CI: 0.828 - 4.878, p = 0.1229).ConclusionOur study indicates that a rise in PCT above 0.2ng/ml is associated with an elevated risk in all-cause mortality, the need for non-invasive ventilation, and a longer duration of mechanical ventilation. The study offers concrete evidence for PCT to be used as a prognostication marker among moderate to severe COVID-19 patients.