The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs.

PURPOSE: Early identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock. MATERIALS AND METHODS: We included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated. RESULTS: Of the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th-75th percentiles, 61-78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69-0.74 and 0.669; 95% CI: 0.65-0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16-4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25-3.17). CONCLUSION: The results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.

Prognostic factors for late death in septic shock survivors: a multi-center, prospective, registry-based observational study.

Septic shock patients who survive past the acute period are associated with an increased risk of long-term mortality. However, factors for predicting late death remain unclear. We aimed to investigate the prognostic factors associated with late mortality in septic shock patients with 28-day survival after admission. This retrospective observational study used a prospective, multi-center registry of septic shock patients between October 2015 and December 2019 involving 12 emergency departments (EDs) from the Korean Shock Society. Adult septic shock patients visiting the ED with 28-day survival after admission were included. Among 4624 septic shock patients, 3588 (77.6%) who survived past day 28 were analyzed. The 90-day mortality rate was 14.2%. Non-survivors were older (66.8 vs. 68.9 years; p = 0.032) and had higher lactate levels (3.7 vs. 4.0 mmol/L; p = 0.028) than survivors. Pulmonary and hepatobiliary infections and a history of malignancy (27.7 vs. 57.5%; p < 0.001) were more frequent in the non-survivor group than in the survivor group. Independent risk factors for late death on multivariate regression analysis were age; malignancy; and hemoglobin, blood urea nitrogen, and albumin levels. The length of intensive care unit stay and Sequential Organ Failure Assessment score were independently associated with late death. Approximately, one-seventh of septic shock patients who survived past day 28 of admission died by day 90. Physicians must pay attention to survivors with these risk factors during the post-acute period as they have an increased mortality risk.

Biomarker Analysis for Combination Therapy of Vitamin C and Thiamine in Septic Shock: A Post-Hoc Study of the ATESS Trial.

INTRODUCTION: We evaluated the effects of vitamin C and thiamine administration on biomarkers in patients with septic shock. METHODS: This was a post-hoc analysis of the Ascorbic Acid and Thiamine Effect in Septic Shock (ATESS) trial, a multicenter, double-blind, randomized controlled trial. Patients were randomized to either a treatment group (intravenous vitamin C and thiamine for 48 h) or a control group. Interleukin (IL)-6, IL-10, angiopoietin-II (AP2), and S100ß were assessed at baseline and at 72 h. The primary outcomes were the biomarker levels at 72 h, and the secondary outcome was reduction rate. RESULTS: Forty-five patients were assigned to the treatment group and 52 were assigned to the control group. Baseline biomarker levels and at 72 h were not significantly different between the treatment and the placebo groups. The reduction rates were not significantly different between the two groups. These outcome variables showed fair diagnostic accuracy for predicting 28-day mortality according to the area under the receiver operating characteristic curve. CONCLUSION: Vitamin C and thiamine administration during the early phase of septic shock did not significantly change prognostic biomarker levels of IL-6, IL-10, AP2, and S100ß. TRIAL REGISTRATION: NCT, ClinicalTrials.gov NCT03756220, ATESS. Registered 28 November 2018, https://clinicaltrials.gov/ct2/show/NCT03756220.

Development and validation of the VitaL CLASS score to predict mortality in stage IV solid cancer patients with septic shock in the emergency department: a multi-center, prospective cohort study.

BACKGROUND: Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores. METHODS: This multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score's performance was compared to that of the previous severity scores. RESULTS: New scoring system for 28-day mortality was based on six variables (score range, 0-8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%). CONCLUSIONS: The VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.

Predictive performance of plasma neutrophil gelatinase-associated lipocalin for neurologic outcomes in out-of-hospital cardiac arrest patients treated with targeted temperature management: A prospective observational study.

Few studies have demonstrated the prognostic potential of neutrophil gelatinase-associated lipocalin (NGAL) in post-cardiac arrest patients. This study evaluated the usefulness of plasma NGAL in predicting neurologic outcome and mortality in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). A prospective observational study was conducted between October 2013 and April 2016 at a single tertiary hospital. We enrolled 75 patients treated with TTM and collected their demographic data, cardiopulmonary resuscitation-related information, data on plasma NGAL concentration, and prognostic test results. Plasma NGAL was measured at 4 hours after return of spontaneous circulation (ROSC). The primary endpoint was the neurologic outcome at discharge and the secondary outcome was 28-day mortality. Neurologic outcomes were analyzed using a stepwise multivariate logistic regression while 28-day mortality was analyzed using a stepwise Cox regression. The predictive performance of plasma NGAL for neurologic outcome was measured by the area under the receiver operating characteristic curve and the predictability of 28-day mortality was measured using Harrell C-index. We also compared the predictive performance of plasma NGAL to that of other traditional prognostic modalities for outcome variables. Thirty patients (40%) had good neurologic outcomes and 53 (70.7%) survived for more than 28 days. Plasma NGAL in patients with good neurologic outcomes was 122.7 ±â€Š146.7 ng/ml, which was significantly lower than that in the poor neurologic outcome group (307.5 ±â€Š269.6 ng/ml; P < .001). The probability of a poor neurologic outcome was more than 3.3-fold in the NGAL >124.3 ng/ml group (odds ratio, 3.321; 95% confidence interval [CI], 1.265-8.721]). Plasma NGAL in the survived group was significantly lower than that in the non-survived group (172.7 ±â€Š191.6 vs 379.9 ±â€Š297.8 ng/ml; P = .005). Plasma NGAL was significantly correlated with 28-day mortality (hazard ratio 1.003, 95% CI 1.001-1.004; P < .001). The predictive performance of plasma NGAL was not inferior to that of other prognostic modalities except electroencephalography. Plasma NGAL is valuable for predicting the neurologic outcome and 28-day mortality of patients with OHCA at an early stage after ROSC.This study was registered at ClinicalTrials.gov on November 19, 2013 (Identifier: NCT01987466).

The usefulness of C-reactive protein and procalcitonin to predict prognosis in septic shock patients: A multicenter prospective registry-based observational study.

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184-2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.

A Delta Neutrophil Index for the Prediction of Contrast-Induced Nephropathy in Patients With St-Elevation Myocardial Infarction Followed By Percutaneous Coronary Intervention.

PURPOSE: We assessed the usefulness of the delta neutrophil index (DNI), reflecting immature granulocytes, to stratify risk for developing contrast-induced nephropathy (CIN) in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) in a clinical setting. METHODS: This study retrospectively analyzed prospective data of eligible adult patients admitted to the emergency department (ED) with STEMI followed by PCI. We determined DNI at multiple time points and analyzed the development of CIN and in-hospital mortality according to CIN incidence. RESULTS: Overall, 564 patients with STEMI followed by PCI were included. Of these, 58 patients (10.3%) had CIN. Areas under the curve for predictability of CIN using the DNI within 2 h after PCI (I) and 24 h on ED admission (24) among patients with CIN were 0.775 (P < 0.001) and 0.751 (P < 0.001), respectively. Multivariable logistic regression demonstrated that increased DNI values at time I (odds ratio [OR], 1.632; 95% confidence interval [CI], 1.357-1.964; P < 0.001) and time 24 (OR, 1.503; 95% CI, 1.272-1.777; P < 0.001) were strong independent factors for predicting CIN among patients with STEMI who underwent PCI. Increasing predictability of CIN was closely associated with DNI more than 1.8% on ED admission (OR, 12.494; 95% CI, 6.540-23.87; P < 0.001) and more than 1.9% at time 24 (OR, 10.45; 95% CI, 5.769-18.928; P < 0.001). CONCLUSION: The DNI is easily obtained as part of the complete blood count measurement without requiring additional cost or time. High DNI independently predicts the development of CIN in patients with acute STEMI followed by PCI.

Usefulness of the delta neutrophil index as an ancillary test in the emergency department for the early diagnosis of suspected acute promyelocytic leukemia.

The delta neutrophil index (DNI) reflects the fraction of circulating immature granulocytes. We evaluated the usefulness of DNI values in patients with acute myeloid leukemia (AML) to distinguish the acute stage of acute promyelocytic leukemia (APL). We analyzed patients retrospectively who were first diagnosed with AML upon admission to the emergency department (ED). Thirty of the 134 patients (22.4%) were diagnosed with APL on ED admission. The univariate analysis and multivariate logistic regression models revealed that DNI values differed significantly between APL and non-APL AML patients on days 0, 1 and 2. Increased predictability for APL was associated with a DNI greater than 24.2% on ED admission, greater than 23.6% on day 1 and greater than 44% on day 2 in patients with AML. DNI values of patients with AML could discriminate the acute stage of APL from AML for immediate initiation of all-trans retinoic acid therapy.

Effect of Adipose-Derived Mesenchymal Stem Cell Administration and Mild Hypothermia Induction on Delayed Neuronal Death After Transient Global Cerebral Ischemia.

OBJECTIVES: Global cerebral ischemia is a cause of poor prognosis after resuscitation from cardiac arrest. Various attempts have been made to minimize global cerebral ischemia but none been more effective than mild hypothermia induction. A few studies have shown the effect of mesenchymal stem cells on global cerebral ischemia, but no studies have compared this effect with mild hypothermia or assessed any possible interaction. We aimed to show the effect of mesenchymal stem cells on delayed neuronal death after global cerebral ischemia and to compare this effect with mild hypothermia. DESIGN: Experimental study. SETTING: Animal research laboratory. SUBJECTS: Adult male Sprague-Dawley rats weighing 250-300 g. INTERVENTIONS: Rats were subjected to 7 minutes of transient global cerebral ischemia and randomized into four groups: control, mild hypothermia, injection of human adipose-derived mesenchymal stem cells, and combined application of mild hypothermia and mesenchymal stem cells, along with four sham groups treated identically. Rats were euthanized 7 days after global cerebral ischemia. MEASUREMENTS AND MAIN RESULTS: Degree of neuronal death in hippocampus was significantly higher in control than in other groups. The number of activated microglia was higher in control group than in other groups and was higher in mild hypothermia than shams, mesenchymal stem cells, mild hypothermia/mesenchymal stem cells. Degree of blood-brain barrier disruption and the count of infiltrated neutrophils were significantly higher in control than in other groups. Degree of oxidative injury was significantly higher in control than other groups. It was higher in mild hypothermia than sham groups, mesenchymal stem cells, mild hypothermia/mesenchymal stem cells and was higher in mesenchymal stem cells group than sham groups. Significantly, worse functional results were found in control than in other groups. CONCLUSIONS: Administration of mesenchymal stem cells after transient global cerebral ischemia has a prominent protective effect on delayed neuron death, even compared with mild hypothermia.

Adipose-derived mesenchymal stem cells reduce neuronal death after transient global cerebral ischemia through prevention of blood-brain barrier disruption and endothelial damage.

Global cerebral ischemia (GCI) is the leading cause of a poor prognosis even after successful resuscitation from cardiac arrest. Therapeutic induction of hypothermia (TH) is the only proven therapy-and current standard care-for GCI after cardiac arrest; however, its application has been significantly limited owing to technical difficulties. Mesenchymal stem cells (MSCs) are known to suppress neuronal death after cerebral ischemia. The prevention of blood-brain barrier (BBB) disruption has not been suggested as a mechanism of MSC treatment but has for TH. We evaluated the therapeutic effect of MSC administration on BBB disruption and neutrophil infiltration after GCI. To evaluate the therapeutic effects of MSC treatment, rats were subjected to 7 minutes of transient GCI and treated with MSCs immediately after reperfusion. Hippocampal neuronal death was evaluated at 7 days after ischemia using Fluoro-Jade B (FJB). BBB disruption, endothelial damage, and neutrophil infiltration were evaluated at 7 days after ischemia by immunostaining for IgG leakage, Rat endothelial antigen-1, and myeloperoxidase (MPO). Rats treated with MSCs showed a significantly reduced FJB+ neuron count compared with the control group. They also showed reduced IgG leakage, endothelial damage, and MPO+ cell counts. The present study demonstrated that administration of MSCs after transient GCI provides a dramatic protective effect against hippocampal neuronal death. We hypothesized that the neuroprotective effects of MSC treatment might be associated with the prevention of BBB disruption and endothelial damage and a decrease in neutrophil infiltration.

Diagnostic radiation exposure of injury patients in the emergency department: a cross-sectional large scaled study.

In contrast to patients with underlying cancer or chronic disease, injury patients are relatively young, and can be expected to live their natural lifespan if injuries are appropriately treated. Multiple and repeated diagnostic scans might be performed in these patients during admission. Nevertheless, radiation exposure in injury patients has been overlooked and underestimated because of the emergent nature of such situations. Therefore, we tried to assess the cumulative effective dose (cED) of injury patients in the emergency department. We included patients who visited the emergency department (ED) of a single tertiary hospital due to injury between February 2010 and February 2011. The cED for each patient was calculated and compared across age, sex and injury mechanism. A total of 11,676 visits (mean age: 28.0 years, M:F = 6,677:4,999) were identified. Although CT consisted of only 7.8% of total radiologic examinations (n=78,025), it accounted for 87.1% of the total cED. The mean cED per visit was 2.6 mSv. A significant difference in the cED among injury mechanisms was seen (p<0.001) and patients with traffic accidents and fall down injuries showed relatively high cED values. Hence, to reduce the cED of injury patients, an age-, sex- and injury mechanism-specific dose reduction strategy should be considered.

The usefulness of rapid point-of-care creatinine testing for the prevention of contrast-induced nephropathy in the emergency department.

BACKGROUND: Renal dysfunction is the most important factor to consider when predicting a patient's risk of developing contrast-induced nephropathy (CIN). Measurement of creatinine (Cr) via rapid point-of-care blood urea nitrogen/creatinine testing (POCT-BUN/Cr) to determine CIN risk could potentially reduce the time required to achieve an accurate diagnosis and to initiate and complete treatment in the emergency department (ED). The aim of our study was to compare the results of POCT-BUN/Cr and reference laboratory tests for BUN and serum Cr. MATERIALS AND METHODS: A retrospective analysis of suspected stroke patients who presented between November 2009 and November 2010, and had BUN and Cr levels measured by POCT-BUN/Cr, and the reference laboratory tests performed with the blood sample which was transferred to the central laboratory by an air-shoot system. Two assays were conducted on the whole blood (POCT) and serum (reference) by trained technicians. The time interval from arrival at the ED to reporting of the results was assessed for both assays via a computerised physician order entry system. RESULTS: The mean standard deviation (SD) interval from arrival at the ED to reporting of the results was 11.4 (4.9) min for POCT-BUN/Cr and 46.8 (38.5) min for the serum reference laboratory tests (p<0.001). Intra-class correlation coefficient (ICC) analysis demonstrated a high level of agreement (the consistency agreement) between POCT and the serum reference tests for both BUN (ICC=0.914) and Cr (ICC=0.980). CONCLUSIONS: This study suggests that POCT-BUN/Cr results correlate well with those of serum reference tests in terms of BUN and Cr levels and, in turn, predicting CIN. POCT-BUN/Cr is easily performed with a rapid turnaround time, suggesting its use in the ED may have substantial clinical benefit.

Comparison of GlideScope(®) versus Macintosh laryngoscope for the removal of a hypopharyngeal foreign body: a randomized cross-over cadaver study.

OBJECTIVE: This study aimed to evaluate whether GlideScope(®) is an effective and acceptable method for the removal of a hypopharyngeal foreign body. METHODS: This was a prospective study conducted in 28 first year emergency residents with little prior airway management experience. Participants extracted hypopharyngeal foreign bodies using a Macintosh laryngoscope and GlideScope(®) with Magill and Sponge forceps. The primary endpoints were extraction time and success rate with each device. Participant preferences were also assessed. RESULTS: The cumulative success rate in relation to time to extraction was significantly higher with the Macintosh laryngoscope than with the GlideScope(®) (p<0.001) regardless of the extraction device. Significantly fewer attempts were required for the first successful extraction with the Macintosh laryngoscope versus GlideScope(®) with Magill forceps (p=<0.001) and Sponge forceps (p=<0.001). The time for successful foreign body extraction using GlideScope(®) was significantly lower when using Magill (median 46 s, IQR 28-75 s) forceps than Sponge forceps (median 79 s, IQR 41-88 s). CONCLUSIONS: In this cadaver model, the Macintosh laryngoscope appeared to be more efficient and preferred than GlideScope(®) for extracting hypopharyngeal airway foreign bodies that are associated with fatal asphyxiation.

Use of bedside sonography for diagnosing acute epiglottitis in the emergency department: a preliminary study.

OBJECTIVES: The purpose of this study was to investigate the ability of sonography to identify acute epiglottitis in the emergency department. METHODS: Fifteen patients with a final diagnosis of acute epiglottitis from indirect laryngoscopy by an otolaryngologist were enrolled in the study. To compare the normal epiglottis and acute epiglottitis, 15 healthy volunteers were assigned to a control group. The sonographic appearances of the epiglottitis and the pre-epiglottic space were recorded. The anteroposterior diameter of the epiglottis at the midpoint and both edges in a transverse view was measured in all participants. RESULTS: A statistically significant difference (P < .001) was observed in the anteroposterior diameter of the epiglottis at the midpoint and both lateral edges between the patients and healthy volunteers. However, there was overlap in the ranges for the midpoint but no overlap in both lateral edges between groups. The upper-limit value for the healthy control group was 3.2 mm at both lateral edges, whereas the cutoff values of the right and left edges were 3.7 and 3.6 mm, respectively, according to the lower-limit value for the epiglottitis group. CONCLUSIONS: The anteroposterior diameter of the epiglottis was significantly different between the patients with epiglottitis and the healthy volunteers. Because of this significant difference in the anteroposterior diameter of the epiglottis, sonography can be used as a rapid, noninvasive, and effective diagnostic tool for identifying cases of epiglottitis in the emergency department.