Mortality difference between early-identified sepsis and late-identified sepsis

Objective@#The aim of the study was to compare the mortality rates of patients with early-identified (EI) sepsis and late-identified (LI) sepsis. @*Methods@#We performed a retrospective chart review of patients admitted to the emergency department and diagnosed with sepsis. EI sepsis was defined as patients with a Sequential Organ Failure Assessment (SOFA) score ≥2, based on 3 parameters of the SOFA score (Glasgow coma scale, mean arterial pressure, and partial pressure of oxygen/fraction of inspired oxygen ratio), measured within an hour of emergency department admission. The remaining patients were defined as LI sepsis. The primary outcome was in-hospital mortality. @*Results@#Of the total 204 patients with sepsis, 113 (55.4%) had EI sepsis. Overall mortality rate was 15.7%, and EI sepsis group had significantly higher mortality than LI sepsis (23.0% vs. 6.6%, P=0.003). The patients with EI sepsis, compared to those with LI sepsis, had higher SOFA score (median: 4 vs. 2, P<0.001); Acute Physiology and Chronic Health Evaluation (APACHE) II score (median: 14 vs. 10, P<0.001); were more likely to progress to septic shock within 6 hours after admission (17.7% vs. 1.1%, P<0.001); were more likely to be admitted to the intensive care unit (2.2% vs. 1.1%, P=0.001). @*Conclusion@#Mortality was significantly higher in the EI sepsis group than in the LI sepsis group.

Comparison of the diagnostic performance of initial serum procalcitonin, lactate, and C-reactive protein for predicting bacteremia in female patients with acute pyelonephritis

OBJECTIVE: The purpose of the present study was to compare the diagnostic performance of initial procalcitonin, lactate, and high-sensitive C-reactive protein (hsCRP) for predicting bacteremia in female patients with acute pyelonephritis (APN). METHODS: We conducted a retrospective study of female APN patients who visited the emergency department (ED) at the studied hospital between January 2015 and December 2016. The main outcome was bacteremia, which was reported via the first blood culture at ED. The patient demographics, co-morbidities, physiologies, and laboratory variables including initial procalcitonin, lactate, and hsCRP levels, were collected and analyzed to identify associations with the presence of bacteremia. The area under the receiver operating curve (AUROC) and sensitivity (SE)/specificity (SP) were calculated for each variable. RESULTS: During the study period, 282 patients were enrolled. A total of 105 (37.2%) patients had bacteremia. Escherichia coli was the most frequent pathogen. The AUROC was 0.70 (0.63–0.76), 0.70 (0.63–0.76), and 0.56 (0.49–0.63) for the procalcitonin, lactate, and hsCRP, respectively. At a cut-off value of 0.163 ng/mL, the procalcitonin level predicted bacteremia, with a SE/SP of 95.2%/22.6%, respectively. At a cut-off value of 0.7 mmol/L, the lactate level predicted bacteremia with a SE/SP of 96.2%/20.9%, respectively. The combination of a procalcitonin level >0.447 ng/mL or a lactate level >0.7 mmo/L was chosen, as they showed 100% SE and a 100% negative predictive value. CONCLUSION: The initial serum procalcitonin and lactate levels showed similar and fair discriminative performance for predicting bacteremia in female APN patients, while the hsCRP level showed poor performance. The combination of procalcitonin and lactate (procalcitonin level≤0.447 ng/mL and lactate≤0.7 mmol/L) can be used to identify patients at low risk of bacteremia.

Inflow and outflow type analysis of emergency department patients of the Honam region

OBJECTIVE: This study examined the inflow and outflow patterns of emergency department patients with si-gun-gu in the Gwangju, Jeonbuk, and Jeonnam areas. METHODS: Data from the Gwangju, Jeonbuk, and Jeonnam were extracted from the National Emergency Department Information System in 2016. The extracted data (on 42 areas in Gwangju, Jeonbuk, and Jeonnam) using the variables of the patient's address (zip code) and the emergency medical institution code (emergency medical institution address) were used to calculate the relevance index and commitment index. The calculated indices were classified into the regional types by applying NbClust and cluster analysis (K-means) of the R package. RESULTS: The relevance indices ranged from 12.5% to 90.4%, and the commitment indices ranged from 9.2% to 90.3%. The results of cluster analysis with the relevance indices and commitment indices revealed three types for 39 areas. In cluster 1, the relevance indices ranged from 43.5% to 61.6%, and the commitment indices ranged from 9.2% to 49.5%. Three out of the thirty-nine areas were classified as the inflow type. In cluster 2, the relevance indices ranged from 12.5% to 56.0% and the commitment indices ranged from 62.5% to 90.3%; 12 areas were classified as the outflow type. The areas in cluster 3 were classified as the self-sufficient type, with relevance indices ranging from 60.1% to 90.4% and commitment indices ranging from 59.0% to 89.7% for 24 areas. CONCLUSION: Three area types and 11 out of 12 areas classified as outflow types were found to be emergency medical vulnerable areas. The results of this study can be used to establish local emergency medical policies.

Change in peak expiratory flow rate after the head-tilt/chin-lift maneuver among young, healthy, and conscious volunteers

OBJECTIVE: The head-tilt/chin-lift (HT/CL) is a simple, routinely used maneuver to open the upper airway. Changes in the peak expiratory flow rate (PEFR) before and after the HT/CL maneuver have not been evaluated among conscious volunteers who are regarded as a control cohort.METHODS: Sixty healthy 20-year-old volunteers (30 males and 30 females) were enrolled. The supine position was defined as the position at which the ear-eye line was at a 10° angle to the horizontal. The HT/CL position was defined as the position at which the ear-eye line was at a 25° angle to the horizontal. PEFR was measured using a hand-held device with the subject in the supine position (pre-PEFR) and HT/CL position (post-PEFR), respectively. One set was defined as these two measurements. Five sets of measurements were performed on each subject (300 sets). The set with the maximal and minimal difference between pre-PEFR and post-PEFR were excluded from the analysis. We used a paired t-test to compare the mean pre-PEFR and post-PEFR values for the entire group and subgroups divided by sex, height, body weight, body mass index and response status.RESULTS: Overall, 360 measurements (180 sets) were analyzed. The mean pre-PEFR and post-PEFR were 316.1±87.6 and 346.5±94.7 L/min, respectively. Further, significant differences were observed for sex, height, body weight, and body mass index. In 10 subjects, post-PEFR was lower than pre-PEFR.CONCLUSION: PEFR increased by 9.6% after the HT/CL maneuver in young conscious subjects, but some subjects showed decreased PEFR after the HT/CL maneuver.

Comparison of the National Early Warning Score+Lactate score with the pre-endoscopic Rockall, Glasgow-Blatchford, and AIMS65 scores in patients with upper gastrointestinal bleeding

OBJECTIVE: We compared the predictive value of the National Early Warning Score+Lactate (NEWS+L) score with those of other parameters such as the pre-endoscopic Rockall score (PERS), Glasgow-Blatchford score (GBS), and albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 years score (AIMS65) among patients with upper gastrointestinal bleeding (UGIB). METHODS: We conducted a retrospective study of patients with UGIB during 2 consecutive years. The primary outcome was the composite of in-hospital death, intensive care unit admission, and the need for ≥5 packs of red blood cell transfusion within 24 hours. RESULTS: Among 530 included patients, the composite outcome occurred in 59 patients (19 in-hospital deaths, 13 intensive care unit admissions, and 40 transfusions of ≥5 packs of red blood cells within 24 hours). The area under the receiver operating characteristic curve of the NEWS+L score for the composite outcome was 0.76 (95% confidence interval, 0.70 to 0.82), which demonstrated a significant difference compared to PERS (0.66, 0.59–0.73, P=0.004), but not to GBS (0.70, 0.64–0.77, P=0.141) and AIMS65 (0.76, 0.70–0.83, P=0.999). The sensitivities of NEWS+L scores of 3 (n=34, 6.4%), 4 (n=92, 17.4%), and 5 (n=171, 32.3%) were 100%, 98.3%, and 96.6%, respectively, while the sensitivity of an AIMS65 score of 0 (n=159, 30.0%) was 91.5%. CONCLUSION: The NEWS+L score showed better discriminative performance than the PERS and comparable discriminative performance to the GBS and AIMS65. The NEWS+L score may be used to identify low-risk patients among patients with UGIB.