Prognostic accuracy of qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients presenting with suspected infection to the emergency department (PASSEM) Multicenter prospective external validation cohort study protocol.

BACKGROUND: Early identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department. METHODS AND ANALYSIS: PASSEM study is an international prospective external validation cohort study. For 9 months, each participating center will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalization. We will collect patients' demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., ≥72 hours), and 30- as well as 90-days all-cause mortality. The study started in December 2021 and planned to enroll 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses. DISCUSSION: PASSEM study will be the first international multicenter prospective cohort study that designated to externally validate qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients with suspected infection presenting to the ED in the Middle East region. STUDY REGISTRATION: The study is registered at ClinicalTrials.gov (NCT05172479).

Detection and diagnosis of posterior circulation calcification: An interobserver agreement study.

Background: Posterior cerebral ischemic stroke and its underlying causes can be easily misdiagnosed in routine practice. Therefore, more than a third of positive cases can be easily missed during routine CT image reporting unless expert neuroimaging radiologists carefully report it. Objective: To assess the inter-rater agreement level between senior residents and general radiologists and a specialized expert neuroradiologist when detecting and diagnosing posterior cerebral circulation calcification. Methods: This was a cross-sectional observational study. A total of fifteen senior radiology residents (SRRs) and fifteen general radiologists (GRs) at four different hospitals in Riyadh, Saudi Arabia, were included in the study. A total of four CT-scanned brain cases with the presence of posterior circulation calcification (PCC) with different degrees of severity and one brain case with negative PCC were selected. These cases were predefined by expert neuroradiologists at our center. The cases were uploaded into the picture archiving and communication systems (PACS) at four different centers as outsider cases. These cases were then randomly assigned to the participating SRRs and GRs for reporting. All radiologists were blinded to the findings of the cases. Inter-observer agreement was assessed using the weighted kappa coefficient of agreement (k) between the two groups. Results: The cerebral calcification misdiagnosis rate for the SRRs and GRs was > 93% for most of the positive cases. There was 1) poor inter-observer agreement between the SRRs and GRs for the detection of severe posterior cerebral calcification(PCC) in a negative stroke case (agreement for misdiagnosis, k = 0.93; correct diagnosis, k = 0.00), 2) poor inter-observer agreement for mild PCC in a negative stroke case (agreement for misdiagnosis, k = 0.93; correct diagnosis, k = 0.00), 3) moderate PCC in a positive posterior stroke case (agreement for misdiagnosis, k = 0.92; correct diagnosis, k = 0.00), and 4) poor interobserver agreement for severe PCC in a positive posterior cerebral stroke case (agreement for misdiagnosis, k = 0.846; correct diagnosis, k = 0.00). There was excellent agreement between the SRRs and GRs when reporting negative cases of PCC and stroke. Conclusion: Our study concluded that most of the SRRs and GRs missed the diagnosis of posterior cerebral calcification in the presented cases.