Monocyte distribution width (MDW) performance as an early sepsis indicator in the emergency department: comparison with CRP and procalcitonin in a multicenter international European prospective study.

BACKGROUND: Early sepsis diagnosis has emerged as one of the main challenges in the emergency room. Measurement of sepsis biomarkers is largely used in current practice to improve the diagnosis accuracy. Monocyte distribution width (MDW) is a recent new sepsis biomarker, available as part of the complete blood count with differential. The objective was to evaluate the performance of MDW for the detection of sepsis in the emergency department (ED) and to compare to procalcitonin (PCT) and C-reactive protein (CRP). METHODS: Subjects whose initial evaluation included a complete blood count were enrolled consecutively in 2 EDs in France and Spain and categorized per Sepsis-2 and Sepsis-3 criteria. The performance of MDW for sepsis detection was compared to that of procalcitonin (PCT) and C-reactive protein (CRP). RESULTS: A total of 1,517 patients were analyzed: 837 men and 680 women, mean age 61 ± 19 years, 260 (17.1%) categorized as Sepsis-2 and 144 patients (9.5%) as Sepsis-3. The AUCs [95% confidence interval] for the diagnosis of Sepsis-2 were 0.81 [0.78-0.84] and 0.86 [0.84-0.88] for MDW and MDW combined with WBC, respectively. For Sepsis-3, MDW performance was 0.82 [0.79-0.85]. The performance of MDW combined with WBC for Sepsis-2 in a subgroup of patients with low sepsis pretest probability was 0.90 [0.84-0.95]. The AUC for sepsis detection using MDW combined with WBC was similar to CRP alone (0.85 [0.83-0.87]) and exceeded that of PCT. Combining the biomarkers did not improve the AUC. Compared to normal MDW, abnormal MDW increased the odds of Sepsis-2 by factor of 5.5 [4.2-7.1, 95% CI] and Sepsis-3 by 7.6 [5.1-11.3, 95% CI]. CONCLUSIONS: MDW in combination with WBC has the diagnostic accuracy to detect sepsis, particularly when assessed in patients with lower pretest sepsis probability. We suggest the use of MDW as a systematic screening test, used together with qSOFA score to improve the accuracy of sepsis diagnosis in the emergency department. Trial Registration ClinicalTrials.gov (NCT03588325).

Characteristics of patients who died in the hospital emergency service during the SARS-CoV-2 pandemic: a retrospective cohort study in a tertiary hospital in Spain.

The objective of this study is to analyze the characteristics of patients who died in the Hospital Emergency Department (HED) of a Spanish third-level hospital, with a special focus on those who died due to SARS-CoV-2. A retrospective cohort study was conducted, including all patients over 18 years old who died in the Hospital Emergency Department (HED) of a Spanish third-level hospital located in Badalona, Spain, from Jun 2019 to Dec 2020. Various sociodemographic, clinical, and diagnostic variables of the patients were analyzed to identify potential risk factors associated with mortality. During the first wave of the COVID-19 pandemic, a total of 72 patients died in the HED, representing a 42% increase compared to the pre-pandemic period. Of the deceased patients, 11% were attributed to SARS-CoV-2. Furthermore, it was found that patients who died from SARS-CoV-2 during the first wave were significantly younger than those in the second wave, with an average age of 78.6 ± 3.1 years in the first wave and 91.8 ± 4.8 years in the second wave. No significant differences were found regarding gender or associated comorbidities. Overall, the mortality rate at the HED in relation to COVID-19 was low, and infected patients died at younger ages during the first wave compared to the second wave.

Evaluation of emergency department visits prior to an HIV diagnosis: Missed opportunities.

OBJECTIVE: There is a high rate of occult infection and late diagnosis in HIV. Hospital emergency departments (ED) are an important point of health care. The present work aims to know the number of missed opportunities for HIV diagnosis occurring in the ED. METHOD: Retrospective multicenter cohort study that included all patients diagnosed with HIV infection in 2019 in 27 Spanish hospitals in 7 different autonomous communities. All ED consultation episodes in the 5 years prior to diagnosis were reviewed to find out the reason for consultation and whether this represented a missed opportunity for HIV diagnosis. RESULT: Seven hundred twenty-three patients were included, and 352 (48.7%, 95%CI: 45.1%-52.3%) had at least one ED visit during the 5 years prior to diagnosis (median 2, p25-p75: 1-4). One hundred and eighteen patients (16.3%, 95%CI: 13.8%-19.2%) had a missed diagnostic opportunity. The main consultations were drug use [145 (15%)], sexually transmitted infections [91 (9.4%)] and request for post-exposure HIV prophylaxis [39 (4%)]. One hundred and fifty-five (42.9%) of the 352 had less than 350 CD4/mm3 when the HIV diagnosis was established. In patients with previous ED visits, the mean time to diagnosis from this visit was 580 (SD 647) days. CONCLUSIONS: Sixteen percent of patients diagnosed with HIV missed the opportunity to be diagnosed in the 5 years prior to diagnosis, highlighting the need to implement ED screening measures different from current ones to improve these outcomes.

[Sepsis Code in emergency department: Performance of q-SOFA score compared to SIRS score]. / Activación del Código Sepsis en urgencias: rendimiento de la escala q-SOFA respecto los criterios SIRS.

INTRODUCTION: The early diagnosis and treatment of sepsis remains a challenge in hospital emergency departments. OBJECTIVE: The objective was to evaluate the performance of the qSOFA (quick Sequential related Organ Failure Assessment) for activating a Sepsis Code in the emergency department, compared to applying previous criteria based on SIRS (Systemic Inflammatory Response Syndrome). METHODS: Patients ≥18years were included who consulted an emergency department of a tertiary hospital over two periods of time (May-October 2015), using SIRS criteria (SIRS Group) and over the same months in 2017 using qSOFA criteria (qSOFA Group). RESULTS: One hundred and five episodes were analysed: 70 corresponded to the SIRS Group and 55 to the qSOFA Group. The groups were comparable in terms of history, with a greater presence of neoplastic disease in the qSOFA Group. No differences were observed in the form of presentation, the action taken in the emergency department, admissions to critical care units, use of vasopressors or mean hospital stay between the two groups. A higher 30-day mortality rate was observed in the qSOFA group (21.81% vs. 4.3%; P=.003). In the multivariate study, neoplastic disease was noteworthy as an independent factor of poor prognosis (OR 5.36; P=.01), and activation using the SIRS criteria as a factor of good prognosis (OR .15; P=.021). CONCLUSIONS: The activation of the Sepsis Code using qSOFA criteria results in a reduction in detection, with greater associated mortality. Other complementary tools need to be sought for the early detection of sepsis in the emergency department.

Activation of a code sepsis in the emergency department is associated with a decrease in mortality. / La activación de un código sepsis en urgencias se asocia a una menor mortalidad.

OBJECTIVES: To evaluate the impact of a code sepsis (CS) activation, complying with recommendations, the evolution of patients with severe sepsis in the emergency room and determine independent factors associated to mortality. METHOD: All patients attending the emergency room with severe sepsis during a 6-month period were included. Complying with Surviving Sepsis Campaign recommendations, patients' average stay, intensive care admissions and 30-day mortality were assessed. Two groups were compared: CS activation (A) and no activation (NA). RESULTS: A total of 114 episodes were found, 61.4% belonging to group A and 38.6% to NA. Patients in group A presented hypotension more frequently (61.5% vs 34.4%; P=.005). Patients in group NA more frequently had lactate levels of >3mmol/L (48.3% vs 80%; P=.01), and abdominal focus of sepsis (34.3% vs 13%; P=.01). In group A, blood cultures were more frequently drawn in the first hour (95% vs 41.7%; P<.001), early antibiotic was administered (76.9% vs 25%; p=.005) and fluid replacement carried out (54.5% vs 18.2%; P=.01). Global achievement of CS objectives was higher in group A (31.4% vs 9.1%; P=.006). In group NA more patients were admitted to the intensive care unit (10% vs 36.4%; P<.001), had longer average stays (10.2 days SD 6.9 vs 14.4 days SD 5.8; P<.001) and a higher mortality rate (4.3% vs 34.1%; P<.001). CRP>200mg/l (OR 33.7; P<.001) and the no activation of CS (OR 13.3; p=.001) resulted in being independent factors associated with mortality. CONCLUSIONS: The implementation of a CS improves compliance with SSC recommendations and decreases intensive care admissions, average stays and mortality.