The prognostic utility of Lactate/Albumin*Age score in septic patient with normal lactate level.

Background: A previous study has shown that the lactate/albumin*age (LAA) score is useful for predicting mortality in patients with sepsis admitted to the ICU. We aimed to evaluate the clinical significance of the LAA score in patients with sepsis who presented to the emergency department (ED). Methods: This retrospective observational study used data from the Korean Shock Society Registry collected between January 2017 and December 2021. The prognostic performance of the LAA score for predicting the 28-day mortality was evaluated. Lactate and albumin levels were measured immediately after arrival to the ED. Results: Of the 5346 patients with sepsis, data from 3240 were analyzed. The area under the receiver operating characteristic curve (AUROC) of the LAA score (0.737, 95 % confidence interval (CI) 0.716-0.757), was higher than that of lactate (0.699, 95 % CI 0.677-0.720, p < 0.001), lactate/albumin (LA) ratio (0.730, 95 % CI 0.709-0.751, p = 0.016), and Sequential Organ Failure Assessment (SOFA) score (0.698, 95 % confidence interval 0.676-0.720, p = 0. 004), and Acute Physiology and Chronic Health Evaluation (APACHE) II scores (0.672; 95 % confidence interval 0.649-0.694, p < 0.001). The optimal cut-off value for the LAA score was 119.9. In the Kaplan-Meier analysis according to the optimal cutoff value, the 28-day mortality rates were higher in the high LAA score group (log-rank test, p < 0.001). The LAA score was independently associated with 28-day mortality in the multivariate Cox proportional hazards model (adjusted hazard ratio 2.07, 95 % CI 1.76-2.43, p < 0.001). In the normal (<2 mmol/L) lactate group, the AUROC value for LAA score was higher than LA ratio (normal group 0.674 vs 0.634, p < 0.004). In patients over 65 years old, LAA score (0.731) showed a higher AUROC value than LA ratio (0.725). (p < 0.001). Conclusion: The LAA score may be used as an independent predictor of mortality in patients with sepsis in the emergency department. Our results show that it performs better than serum lactate alone, LA ratio, and SOFA and APACHE II scores. While this suggests that the LAA could provide clinicians with a useful tool for timely early intervention and care planning in patients with a poor prognosis, further validation in large multicenter prospective studies are necessary to confirm its reliability and practicality as a readily available and objective biomarker.

Impact of Point-of-Care Lactate Testing for Sepsis on Bundle Adherence and Clinical Outcomes in the Emergency Department: A Pre-Post Observational Study.

Background: The early diagnosis and prompt treatment of sepsis can enhance clinical outcomes. This study aimed to assess the relationship between point-of-care testing (POCT) for lactate levels and both adherence to the Surviving Sepsis Campaign (SSC) guidelines and mortality rates among sepsis patients in the emergency department (ED). We hypothesized that bedside lactate POCT would lead to better clinical outcomes. Methods: We conducted a pre-post observational study utilizing data from a prospectively collected sepsis registry. Following the introduction of lactate POCT, lactate levels were determined using both the central laboratory pathway and a POCT device. We then compared the characteristics and clinical outcomes between the periods before and after the introduction of POCT lactate measurement. Results: The analysis included a total of 1191 patients. The introduction of bedside lactate POCT led to a significant reduction in the time taken to obtain lactate results (from 53 to 33 min) and an increase in the rate of subsequent lactate measurements (from 82.1% to 88.2%). Lactate POCT did not significantly affect adherence to the overall SSC guidelines bundle (47.5% vs. 45.0%) or reduce 30-day mortality rates (31.1% vs. 31.4%). However, bedside lactate POCT could decrease extremely delayed lactate measurements. Conclusions: Bedside lactate POCT successfully reduced the time to obtain lactate results. Although lactate POCT did not lead to improved adherence to the overall SSC guidelines bundle or affect short-term mortality rates in sepsis patients, it may have an advantage in a specific situation such as overcrowded ED where there are subsequent or multiple measurements required.

Artificial intelligence for predicting shockable rhythm during cardiopulmonary resuscitation: In-hospital setting.

AIM OF THE STUDY: This study aimed to develop an artificial intelligence (AI) model capable of predicting shockable rhythms from electrocardiograms (ECGs) with compression artifacts using real-world data from emergency department (ED) settings. Additionally, we aimed to explore the black box nature of AI models, providing explainability. METHODS: This study is retrospective, observational study using a prospectively collected database. Adult patients who presented to the ED with cardiac arrest or experienced cardiac arrest in the ED between September 2021 and February 2024 were included. ECGs with a compression artifact of 5 s before every rhythm check were used for analysis. The AI model was designed based on convolutional neural networks. The ECG data were assigned into training, validation, and testing sets on a per-patient basis to ensure that ECGs from the same patient did not appear in multiple sets. Gradient-weighted class activation mapping was employed to demonstrate AI explainability. RESULTS: A total of 1,889 ECGs with compression artifacts from 172 patients were used. The area under the receiver operating characteristic curve (AUROC) for shockable rhythm prediction was 0.8672 (95% confidence interval [CI]: 0.8161-0.9122). The AUROCs for manual and mechanical compression were 0.8771 (95% CI: 0.8054-0.9408) and 0.8466 (95% CI: 0.7630-0.9138), respectively. CONCLUSION: This study was the first to accurately predict shockable rhythms during compression using an AI model trained with actual patient ECGs recorded during resuscitation. Furthermore, we demonstrated the explainability of the AI. This model can minimize interruption of cardiopulmonary resuscitation and potentially lead to improved outcomes.

Ischemia-Modified Albumin, Lactate, and Combination for Predicting Mortality in Patients with Septic Shock in the Emergency Department.

Ischemia-modified albumin (IMA) is produced during ischemia and reactive oxygen species production. This study aimed to evaluate the association between IMA and mortality in a larger population and the prognostic value of the combination of IMA and lactate for predicting mortality in septic shock patients in the emergency department. This retrospective observational study included adult septic shock patients between October 2019 and December 2021. A multivariable Cox proportional hazards model was performed. IMA was significantly higher in the non-surviving group than in the surviving group (89.1 ± 7.2 vs. 83.8 ± 6.2 U/mL, p < 0.001). IMA was independently associated with 28-day mortality after adjustments (adjusted hazard ratio [aHR]: 1.075, 95% confidence interval [CI]: 1.016-1.138, p = 0.012). The area under the ROC curve (AUROC) of IMA was 0.712 (95% CI: 0.648-0.775, p < 0.001) and was comparable to that of lactate. The AUROC of the combination of IMA and lactate was 0.838 (95% CI: 0.786-0.889, p < 0.001). The group with both high lactate and high IMA levels showed an extremely high risk of mortality than other groups (86.1%; aHR 8.956, 95% CI 4.071-19.70, p < 0.001). The elevation of IMA was associated with mortality in septic shock patients. The combination of IMA and lactate can be a helpful tool for early risk stratification of septic shock patients.

Mortality case due to minimal bentazone intoxication.

Bentazone is a widely used herbicide and is considered a moderate hazard. Fatalities are rarely reported, with reports of deaths occurring in doses of 200 ml or more. In some literature, it is accompanied by generalized rigidity. Malignant hyperthermia (MH) is a pharmacogenetic diseases that presents a hypermetabolic response to anesthetic gases or depolarizing muscle relaxant due to calcium channel dysfunction. The classic symptom of MH include hyperthermia and muscle rigidity. In this article, we report a case of a 65-year-old man who died 4 hours after presenting to the emergency department after taking approximately 75 ml of Basagran M60 (bentazone 33.6%, 25.2 g). This is the smallest dose (364 mg/kg) reported in a fatal case to date. Electrocardiogram changes, including QRS widening and QT prolongation, were present, and hypocalcemia was confirmed. We propose the possibility that bentazone intoxication causes patient deterioration by a mechanism similar to malignant hyperthermia.

Thigh muscle mass evaluated by point-of-care ultrasound is associated with short-term mortality in patients with sepsis in the emergency department.

Muscle mass depletion is associated with mortality and morbidity in various conditions including sepsis. However, few studies have evaluated muscle mass using point-of-care ultrasound in patients with sepsis. This study aimed to evaluate the association between thigh muscle mass, evaluated using point-of-care ultrasound with panoramic view in patients with sepsis in the emergency department, and mortality. From March 2021 to October 2022, this prospective observational study used sepsis registry. Adult patients who were diagnosed with sepsis at the emergency department and who underwent point-of-care ultrasounds for lower extremities were included. The thigh muscle mass was evaluated by the cross-sectional area of the quadriceps femoris (CSA-QF) on point-of-care ultrasound using panoramic view. The primary outcome was 28 day mortality. Multivariable Cox proportional hazard model was performed. Of 112 included patients with sepsis, mean CSA-QF was significantly lower in the non-surviving group than surviving group (49.6 [34.3-56.5] vs. 63.2 [46.9-79.6] cm2, p = 0.002). Each cm2 increase of mean CSA-QF was independently associated with decreased 28 day mortality (adjusted hazard ratio 0.961, 95% CI 0.928-0.995, p = 0.026) after adjustment for potential confounders. The result of other measurements of CSA-QF were similar. The muscle mass of the quadriceps femoris evaluated using point-of-care ultrasound with panoramic view was associated with mortality in patients with sepsis. It might be a promising tool for determining risk factors for mortality in sepsis patients in the early stages of emergency department.

Age and sex-related differences in outcomes of OHCA patients after adjustment for sex-based in-hospital management disparities.

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) survival differences due to sex remain controversial. Previous studies adjusted for prehospital variables, but not sex-based in-hospital management disparities. We aimed to investigate age and sex-related differences in survival outcomes in OHCA patients after adjustment for sex-based in-hospital management disparities. METHODS: This retrospective observational study used a prospective multicenter OHCA registry to review data of patients from October 2015 to December 2020. The primary outcome was good neurological outcome defined as cerebral performance category score 1 or 2. We performed multivariable logistic regression and restricted cubic spline analysis according to age. RESULTS: Totally, 8988 patients were analyzed. Women showed poorer prehospital characteristics and received fewer coronary angiography, percutaneous coronary interventions, targeted temperature management, and extracorporeal membrane oxygenation than men. Good neurological outcomes were lower in women than in men (5.8% vs. 12.2%, p < 0.001). After adjustment for age, prehospital variables, and in-hospital management, women were more likely to have good neurological outcomes than men (adjusted odds ratio [aOR] 1.37, 95% confidence interval [CI] 1.07-1.74, p = 0.012). The restricted cubic spline curve showed a reverse sigmoid pattern of adjusted predicted probability of outcomes and dynamic associations of sex and age-based outcomes. CONCLUSIONS: Women with OHCA were more likely to have good neurological outcome after adjusting for age, prehospital variables, and sex-based in-hospital management disparities. There were non-linear associations between sex and survival outcomes according to age and age-related sex-based differences.

Predicting septic shock in patients with sepsis at emergency department triage using systolic and diastolic shock index.

INTRODUCTION: Identifying patients with at a high risk of progressing to septic shock is essential. Due to systemic vasodilation in the pathophysiology of septic shock, the use of diastolic blood pressure (DBP) has emerged. We hypothesized that the initial shock index (SI) and diastolic SI (DSI) at the emergency department (ED) triage can predict septic shock. METHOD: This observational study used the prospectively collected sepsis registry. The primary outcome was progression to septic shock. Secondary outcomes were the time to vasopressor requirement, vasopressor dose, and severity according to SI and DSI. Patients were classified by tertiles according to the first principal component of shock index and diastolic shock index. RESULTS: A total of 1267 patients were included in the analysis. The area under the receiver operating characteristic curve (AUC) for predicting progression to septic shock for DSI was 0.717, while that for SI was 0.707. The AUC for predicting progression to septic shock for DSI and SI were significantly higher than those for conventional early warning scores. Middle tertile showed adjusted Odd ratio (aOR) of 1.448 (95% CI 1.074-1.953), and that of upper tertile showed 3.704 (95% CI 2.299-4.111). CONCLUSION: The SI and DSI were significant predictors of progression to septic shock. Our findings suggest an association between DSI and vasopressor requirement. We propose stratifying lower tertile as being at low risk, middle tertile as being at intermediate risk, and upper tertile as being at high risk of progression to septic shock. This system can be applied simply at the ED triage.

Sex differences in in-hospital management in patients with sepsis and septic shock: a prospective multicenter observational study.

Sex differences in the in-hospital management of sepsis exist. Previous studies either included patients with sepsis that was defined using previous definitions of sepsis or evaluated the 3-h bundle therapy. Therefore, this study sought to assess sex differences in 1-h bundle therapy and in-hospital management among patients with sepsis and septic shock, defined according to the Sepsis-3 definitions. This observational study used data from Korean Shock Society (KoSS) registry, a prospective multicenter sepsis registry. Adult patients with sepsis between June 2018 and December 2021 were included in this study. The primary outcome was adherence to 1-h bundle therapy. Propensity score matching (PSM) and multivariable logistic regression analyses were performed. Among 3264 patients with sepsis, 3129 were analyzed. PSM yielded 2380 matched patients (1190 men and 1190 women). After PSM, 1-h bundle therapy was performed less frequently in women than in men (13.0% vs. 19.2%; p < 0.001). Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently in women than in men (25.4% vs. 31.6%, p < 0.001), whereas adequate fluid resuscitation was performed more frequently in women than in men (96.8% vs. 95.0%, p = 0.029). In multivariable logistic regression analysis, 1-h bundle therapy was performed less frequently in women than in men [adjusted odds ratio (aOR) 1.559; 95% confidence interval (CI) 1.245-1.951; p < 0.001] after adjustment. Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently to women than men (aOR 1.339, 95% CI 1.118-1.605; p = 0.002), whereas adequate fluid resuscitation was performed more frequently for women than for men (aOR 0.629, 95% CI 0.413-0.959; p = 0.031). Invasive arterial blood pressure monitoring was performed less frequently in women than in men. Resuscitation fluid, vasopressor, steroid, central-line insertion, ICU admission, length of stay in the emergency department, mechanical ventilator use, and renal replacement therapy use were comparable for both the sexes. Among patients with sepsis and septic shock, 1-h bundle therapy was performed less frequently in women than in men. Continuous efforts are required to increase adherence to the 1-h bundle therapy and to decrease sex differences in the in-hospital management of patients with sepsis and septic shock.

The mortality of patients with sepsis increases in the first month of a new academic year.

OBJECTIVE: Many studies have examined the July effect. However, little is known about the July effect in sepsis. We hypothesized that the July effect would result in worse outcomes for patients with sepsis. METHODS: Data from patients with sepsis, collected prospectively between January 2018 and December 2021, were analyzed. In Korea, the new academic year starts on March 1, so the "July effect" appears in March. The primary outcome was 30-day mortality. Secondary outcomes included adherence to the Surviving Sepsis Campaign bundle. Outcomes in March were compared to other months. A multivariate Cox proportional hazard regression was performed to adjust for confounders. RESULTS: We included 843 patients. There were no significant differences in sepsis severity. The 30-day mortality in March was higher (49.0% vs. 28.5%, P<0.001). However, there was no difference in bundle adherence in March (42.2% vs. 48.0%, P=0.264). The multivariate Cox proportional hazard regression showed that the July effect was associated with 30-day mortality in patients with sepsis (adjusted hazard ratio, 1.925; 95% confidence interval, 1.405-2.638; P<0.001). CONCLUSION: The July effect was associated with 30-day mortality in patients with sepsis. However, bundle adherence did not differ. These. RESULTS: suggest that the increase in mortality during the turnover period might be related to unmeasured in-hospital management. Intensive supervision and education of residents caring for patients with sepsis is needed in the beginning of training.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department.

OBJECTIVES: Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax. METHODS: Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis. RESULTS: A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax. CONCLUSIONS: Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Diagnostic and prognostic value of presepsin and procalcitonin in non-infectious organ failure, sepsis, and septic shock: a prospective observational study according to the Sepsis-3 definitions.

BACKGROUND: We investigated the diagnostic and prognostic value of presepsin among patients with organ failure, including sepsis, in accordance with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). METHODS: This prospective observational study included 420 patients divided into three groups: non-infectious organ failure (n = 142), sepsis (n = 141), and septic shock (n = 137). Optimal cut-off values of presepsin to discriminate between the three groups were evaluated using receiver operating characteristic curve analysis. We determined the optimal cut-off value of presepsin levels to predict mortality associated with sepsis and performed Kaplan-Meier survival curve analysis according to the cut-off value. Cox proportional hazards model was performed to determine the risk factors for 30-day mortality. RESULTS: Presepsin levels were significantly higher in sepsis than in non-infectious organ failure cases (p < 0.001) and significantly higher in patients with septic shock than in those with sepsis (p = 0.002). The optimal cut-off value of the presepsin level to discriminate between sepsis and non-infectious organ failure was 582 pg/mL (p < 0.001) and between sepsis and septic shock was 1285 pg/mL (p < 0.001). The optimal cut-off value of the presepsin level for predicting the 30-day mortality was 821 pg/mL (p = 0.005) for patients with sepsis. Patients with higher presepsin levels (≥ 821 pg/mL) had significantly higher mortality rates than those with lower presepsin levels (< 821 pg/mL) (log-rank test; p = 0.004). In the multivariate Cox proportional hazards model, presepsin could predict the 30-day mortality in sepsis cases (hazard ratio, 1.003; 95% confidence interval 1.001-1.005; p = 0.042). CONCLUSIONS: Presepsin levels could effectively differentiate sepsis from non-infectious organ failure and could help clinicians identify patients with sepsis with poor prognosis. Presepsin was an independent risk factor for 30-day mortality among patients with sepsis and septic shock.

Specification of Subject Sex in Oncology-Related Animal Studies.

BACKGROUND: Growing evidence for clinically significant differences between the sexes has attracted the attention of researchers. However, failures to report a test animal sex and balance the sex ratios of study samples remain widespread in preclinical investigations. We analyzed the sex-reporting rate and sex distributions of test animals in published oncology studies. METHODS: We selected five oncology journals included in the Scientific Citation Index (SCI) based on impact factors. We identified preclinical investigations with in vivo mouse experiments published in 2015 for inclusion in our study sample. We classified each article by whether or not it reported test subject sex, and by which sex was included. We also recorded whether there were justifications for using one particular sex in single-sex studies (e.g., anatomical reasons) and whether sex-based analyses were conducted for both-sex studies. RESULTS: We surveyed a total of 382 articles. Half (50.3%) failed to report test animal sex. Among articles that did report sex, 91.7% were single-sex studies, of which 69.4% did not provide any justifications for using the sex included in the study. Relatively few studies 15.7 studies included animals of both sexes, and only 2.3 studies conducted sex-based analyses. These findings are consistent with those of previous research that used other methods to collect data from the literature such as text mining, but our analysis of the provision of justifications for using one sex versus the other is a novel feature. CONCLUSIONS: Many researchers overlook test subject sex as a factor, but test animal sex should be reported in all preclinical investigations to enhance the reproducibility of research and avoid faulty conclusions drawn from one-sided studies.