Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department / Validación del sistema PIRO (predisposición, infección, respuesta, fallo orgánico) para la estratificación del pronóstico en pacientes con sepsis en el servicio de urgencias

Objective: There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. Design, setting and participants We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. Results Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716–0.824) vs. AUC 0.699 (0.64–0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715–0.819) vs AUC 0.709 (0.656–0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71–0.82) at 30 d, AUC 0.754 (0.701–0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. Conclusions We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting. (AU)

Objetivo: Existen muchos métodos diferentes para calcular la escala PIRO (predisposición, infección respuesta, fallo orgánico). Comparamos 3 métodos (PIRO1 [Howell], PIRO2 [Rubolotta] y PIRO3 [Rathour]) para estratificar la mortalidad y el ingreso con alto nivel de cuidados en pacientes con sepsis atendidos en el servicio de urgencias (SU) de un hospital italiano. Diseño, entorno y participantes Recopilamos datos clínicos prospectivos de 470 pacientes que llegaban con una infección al SU, con el fin de calcular la puntuación PIRO, de acuerdo con 3 métodos diferentes. Evaluamos las variables PIRO para la predicción de la mortalidad en un análisis monovariable. Calculamos y comparamos el área bajo la curva (AUC) característica de operación del receptor (ROC) de los 3 métodos PIRO, SOFA y qSOFA. Resultados La mayoría de las variables incluidas en las puntuaciones PIRO estaban relacionadas con la mortalidad en un análisis de una sola variable. El aumento de la puntuación PIRO se relacionó con una mortalidad más elevada. En cuanto a la mortalidad, PIRO1 presentó un rendimiento mejor que PIRO2 a los 30 días (AUC 0,77 [0,716-0,824] frente a AUC 0,699 [0,64-0,758]; p=0,03) y similares a los 60 días (AUC 0,767 [0,715-0,819] frente a AUC 0,709 [0,656-0,763]; p=0,55); PIRO1 presentó un rendimiento similar al de PIRO3 (AUC 0,765 [0,71-0,82] a los 30 días, AUC 0,754 [0,701-0,806] a los 60 días; p=NS). Tanto PIRO1 como PIRO3 presentaron un rendimiento similar al de SOFA para la mortalidad (AUC 0,758 [0,699-0,816) al cabo de 30 días y AUC 0,738 [0,681-0,795] al cabo de 60 días; p=NS). En cuanto al ingreso con alto nivel de cuidados, las puntuaciones PIRO resultaron ser inferiores a SOFA. Conclusiones Apoyamos el uso de la puntuación PIRO1, que resulta fácil de usar, y presenta el mejor rendimiento en cuanto a la mortalidad a largo plazo. PIRO2 resultó ser menos precisa y más compleja de usar ... (AU)

Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department.

OBJECTIVE: There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. DESIGN, SETTING AND PARTICIPANTS: We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. RESULTS: Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. CONCLUSIONS: We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.

False-negative real-time polymerase chain reaction tests in COVID-19 patients: an epidemiological analysis of 302 patients.

OBJECTIVES: Patients who arrive at the emergency department (ED) with COVID-19, who test negative at the first real-time polymerase chain reaction (RT-PCR), represent a clinical challenge. This study aimed to evaluate if the clinical manifestation at presentation, the laboratory and imaging results, and the prognosis of COVID-19 differ in patients who tested negative at the first RT-PCR compared with those who tested positive and also to evaluate if comorbid conditions patient-related or the period of arrival are associated with negative testing. STUDY DESIGN: We retrospectively collected clinical data of patients who accessed the ED from March 1 to May 15, 2020. METHODS: We compared clinical variables, comorbid conditions, and clinical outcomes in the two groups by univariate analysis and logistic regression. RESULTS: Patients who tested negative at the first RT-PCR showed a higher prevalence of cardiopathy, immunosuppression, and diabetes, as well as a higher leukocyte and lower lymphocyte counts compared with patients who tested positive. A bilateral interstitial syndrome and a typical pattern at computed tomography scan were prevalent in the test-negative group. Test-negative patients were more likely to be admitted to the hospital but less likely to need admission in a high level of care ward. The false-negative rate increased from March to May. CONCLUSION: False-negative RT-PCR COVID-19 patients present a similar spectrum of symptoms compared with positive cohort, but more comorbidities. Imaging helps to identify them. True positives had a higher risk of serious complications.

Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department.

OBJECTIVE: There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. DESIGN, SETTING AND PARTICIPANTS: We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. RESULTS: Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. CONCLUSIONS: We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.

Equine cheek tooth extraction: Comparison of outcomes for five extraction methods.

BACKGROUND: Post-operative complications are reported for all methods of equine cheek tooth extraction but not all methods carry the same risks. An outcome comparison for commonly used methods is needed so that clinicians can make informed treatment decisions. OBJECTIVES: We conducted a side-by-side comparison of five cheek tooth extraction methods, comparing types and incidence of complications among oral extraction, tooth repulsion (three surgical approaches) and lateral buccotomy techniques. STUDY DESIGN: Retrospective clinical study using hospital medical records. METHODS: Medical records of all horses undergoing cheek tooth extraction between 1997 and 2013 were reviewed. Logistic regression was used to determine the likelihood of various post-operative complications, comparing oral extraction, tooth repulsion by maxillary and mandibular trephination or maxillary sinus bone flap, and lateral buccotomy. RESULTS: The study included 137 horses and 162 cheek teeth extractions. Oral extraction was successful in 71% of patients in which it was attempted. Oral extraction (n = 55) had the lowest incidence of complications (20%) and repulsion by sinus bone flap (n = 20) the highest (80%). Complication rates for repulsion by maxillary (n = 19) and mandibular trephination (n = 28), and extraction by lateral buccotomy (n = 15) were 42, 54 and 53%, respectively. Cheek tooth repulsion by sinus bone flap significantly increased the odds of damage to adjacent teeth, post-operative sinusitis, damage to alveolar bone, delayed alveolar granulation and orosinus fistulation. Repulsion by maxillary trephination significantly increased the odds of superficial incisional surgical site infection; and extraction by lateral buccotomy significantly increased the odds of facial nerve neuropraxia. Post-operative pyrexia was more common in all repulsion methods. MAIN LIMITATIONS: Some clinically relevant differences may have been missed due to small group numbers in several categories. CONCLUSIONS: Oral extraction was associated with fewer post-operative complications than any other methods. Standing oral extraction remains the preferred choice, and recent surgical advances promise to further improve its success rate.

Do different characteristics of two emasculators make a difference in equine castration?

BACKGROUND: The Serra and Reimer emasculators are frequently used in equine orchiectomy. They differ in jaw profile and the mechanism by which they achieve haemostasis. OBJECTIVES: To investigate whether the haemostatic capacities of the Reimer and Serra emasculators in open and closed castration differ, to compare the haemostatic capacities of each emasculator in both open and closed castration, and to assess whether the tensile strength of the parietal tunic in closed castration differs according to whether a Reimer or Serra emasculator is used. STUDY DESIGN: Ex vivo randomised study. METHODS: Eighty equine cadaver testes were randomly assigned to two groups for, respectively, open and closed castration. Each group was divided into two subgroups for castration with a Serra or Reimer castrator, respectively. Testicular artery leaking pressure was measured by dye injection. In closed castration, the tensile strength of the parietal tunic was measured with a tensiometer. RESULTS: In open castration, the Reimer emasculator resisted significantly higher pressure (median: 706.1 mmHg; interquartile range [IQR]: 597.6-735.5 mmHg) than the Serra emasculator (median: 349.4 mmHg; IQR: 261.1-468.9 mmHg) (P<0.001), whereas no difference was found in closed castration (Serra emasculator, median: 382.5 mmHg [IQR: 294.2-568.2 mmHg]; Reimer emasculator, median: 419.2 mmHg [IQR: 294.2-616.0 mmHg]). The Reimer emasculator resisted significantly higher pressure in the open (median: 706.1 mmHg; IQR: 597.6-735.5 mmHg) compared with the closed (median: 419.2 mmHg; IQR: 294.2-616.0 mmHg) technique (P = 0.03). Parietal tunic tensile strength did not differ significantly by emasculator (mean ± s.d.: Serra, 12.65 ± 7.35; Reimer, 17.55 ± 11.76). MAIN LIMITATIONS: Limitations are inherent to the ex vivo study design. Post-surgery implications were investigated only in the short term and no account was taken of tissue inflammation and oedema, which may influence the integrity of the tissue. CONCLUSIONS: These results suggest it may be preferable to use a Reimer emasculator in open castration. In this ex vivo model of closed castration, no differences between the emasculators were observed.

Ex vivo comparison of the giant and transfixing knot in equine open and closed castration.

REASONS FOR PERFORMING STUDY: In equine castration, application of a ligature on the spermatic cord to prevent complications such as haemorrhage and evisceration has been reported with controversial results. Characteristics of commonly used knots have not been studied. OBJECTIVES: To compare the modified transfixing and giant knots and the emasculator in open and closed equine castration techniques. STUDY DESIGN: Ex vivo experiment. METHODS: A total of 144 testicles were randomly assigned to 2 groups for open or closed castration. Both groups were divided into 3 subgroups of 18 specimens each: emasculator only, emasculator plus giant knot and emasculator plus transfixing knot and the open castration group also contained 2 further subgroups of 18 testicles each: giant knot only and transfixing knot only. The length of suture material used was measured for each knot and the leaking pressure of the testicular artery measured using dye injection. In the closed castration group, parietal tunic tensile strength was measured with a tensiometer. RESULTS: Leaking pressure was higher in open compared with closed castration, with no significant difference among subgroups. In the closed castration group, minimum leaking pressure for the emasculator plus transfixing knot and emasculator only subgroups were close to standard physiological arterial pressures. The giant knot required less suture material than the transfixing knot. Parietal tunic tensile strength was higher when ligatures were applied. CONCLUSIONS: The giant and transfixing knot techniques have comparable haemostatic capability and parietal tunic tensile strength, but the giant knot requires less suture material. In open castration, using the emasculator alone may produce adequate haemostasis. In closed castration, using the giant knot in combination with the emasculator increases the bursting pressure and possibly reduces the incidence of haemorrhage. In closed castration, application of a ligature may reduce the risk of evisceration.

Natural killer cell activity and sensitivity to positive and negative modulation in uncomplicated obese subjects: relationships to leptin and diet composition.

BACKGROUND: Natural killer (NK) cells are a key component of innate immunity; their activity is modulated by cytokines and hormones and is influenced by diet. In obesity, a higher risk of cancer and infections has been demonstrated. Studies on NK cell activity have yielded inconsistent results; NK cell sensitivity to modulators has not been assessed before. OBJECTIVE: In this case-control study, we assessed both spontaneous NK cell activity and responsiveness to positive (interleukin (IL)-2) and negative (cortisol) modulators in uncomplicated obesity; we searched for correlations between NK cell activity and anthropometric, dietary and metabolic variables. METHODS: In all, 21 obese (six males/15 females) and 21 age- and sex-matched healthy nonobese subjects underwent clinical examination and dietary and laboratory analyses. Spontaneous and modulated NK activities of peripheral blood mononuclear cells were measured by enzyme-release cytotoxicity assay. RESULTS: Spontaneous NK cell activity was not different in obese subjects vs controls. IL-2 stimulated and cortisol inhibited NK cell activity in both populations. Cortisol-dependent inhibition was lower in the obese than in the control group (-24.4+/-2.9 vs -38.6+/-3.3%, P=0.002), but decreased sensitivity was restricted to women (P=0.0007). In obese subjects, cortisol-dependent inhibition negatively correlated with serum leptin levels (r=-0.54, P=0.02) and, in women, with body mass index (r=-0.63, P=0.01); IL-2-dependent stimulation positively correlated with dietary carbohydrates (r=0.61, P=0.005) and serum LDL levels (r=0.55, P=0.009) and negatively correlated with dietary lipids (r=-0.71, P=0.0006). CONCLUSION: Spontaneous and IL-2-inducible NK cell activity is normal in uncomplicated obesity. Sensitivity to IL-2 correlates with fat and carbohydrate intake. Sensitivity to glucocorticoids negatively correlates with serum leptin levels and is significantly diminished in obese women, in whom it correlates with body mass index.