The SPEED (sepsis patient evaluation in the emergency department) score: a risk stratification and outcome prediction tool.

OBJECTIVES: The aim of the study was to identify covariates associated with 28-day mortality in septic patients admitted to the emergency department and derive and validate a score that stratifies mortality risk utilizing parameters that are readily available. METHODS: Patients with an admission diagnosis of suspected or confirmed infection and fulfilling at least two criteria for severe inflammatory response syndrome were included in this study. Patients' characteristics, vital signs, and laboratory values were used to identify prognostic factors for mortality. A scoring system was derived and validated. The primary outcome was the 28-day mortality rate. RESULTS: A total of 440 patients were included in the study. The 28-day hospital mortality rate was 32.4 and 25.2% for the derivation (293 patients) and validation (147 patients) sets, respectively. Factors associated with a higher mortality were immune-suppressed state (odds ratio 4.7; 95% confidence interval 2.0-11.4), systolic blood pressure on arrival less than 90 mmHg (3.8; 1.7-8.3), body temperature less than 36.0°C (4.1; 1.3-12.9), oxygen saturation less than 90% (2.3; 1.1-4.8), hematocrit less than 0.38 (3.1; 1.6-5.9), blood pH less than 7.35 (2.0; 1.04-3.9), lactate level more than 2.4 mmol/l (2.27; 1.2-4.2), and pneumonia as the source of infection (2.7; 1.5-5.0). The area under the receiver operating characteristic curve was 0.81 (0.75-0.86) in the derivation and 0.81 (0.73-0.90) in the validation set. The SPEED (sepsis patient evaluation in the emergency department) score performed better (P=0.02) than the Mortality in Emergency Department Sepsis score when applied to the complete study population with an area under the curve of 0.81 (0.76-0.85) as compared with 0.74 (0.70-0.79). CONCLUSION: The SPEED score predicts 28-day mortality in septic patients. It is simple and its predictive value is comparable to that of other scoring systems.

Failure to improve door-to-needle time by switching to emergency physician-initiated thrombolysis for ST elevation myocardial infarction.

INTRODUCTION: Achieving target door-needle times for ST elevation myocardial infarction remains challenging. Data on emergency department (ED) doctor-led thrombolysis in developing countries and factors causing delay are limited. OBJECTIVES: To assess the effect on door-needle times by transferring responsibility for thrombolysis to the ED doctors and to identify predictors of prolonged door-needle times. METHODOLOGY: Data on medical on-call team-led thrombolysis at a tertiary Asian hospital were prospectively collected from May 2007 to Aug 2008 (1st study period). In September 2008, ED doctors were empowered to perform thrombolysis. The practice change was accompanied by new guidelines, tick chart implementation, and training sessions. Data were then consecutively collected from September 2008 to May 2009 (2nd study period). Door-to-needle times for the 1st and 2nd study periods were compared. All cases were analysed for factors of delay by multiple logistic regression. RESULTS: 297 patients were thrombolysed, 169 by the medical on-call team during the 1st study period and 128 by the ED doctors during the 2nd study period. Median door-needle times were 54 and 48 min, respectively (p=0.76). Significant delays were predicted by 'incorrect initial ECG interpretation' (adjusted OR (aOR) 14.3), 'inappropriate triage' (aOR 10.4) and 'multiple referrals' (aOR 5.9). No cases of inappropriate thrombolysis were recorded. CONCLUSIONS: Transfer of responsibility for thrombolysis to the ED doctors did not improve door-needle times despite measures introduced to facilitate this change. Key causative factors for this failure were identified.

Are health professionals responsible for the shortage of organs from deceased donors in Malaysia?

The rate of organ donations from deceased donors in Malaysia is among the lowest in the world. This may be because of the passivity among health professionals in approaching families of potential donors. A questionnaire-based study was conducted amongst health professionals in two tertiary hospitals in Kuala Lumpur, Malaysia. Four hundred and sixty-two questionnaires were completed. 93.3% of health professionals acknowledged a need for organ transplantation in Malaysia. 47.8% were willing to donate their organs (with ethnic and religious differences). Factors which may be influencing the shortage of organs from deceased donors include: nonrecognition of brainstem death (38.5%), no knowledge on how to contact the Organ Transplant Coordinator (82.3%), and never approaching families of a potential donor (63.9%). There was a general attitude of passivity in approaching families of potential donors and activating transplant teams among many of the health professionals. A misunderstanding of brainstem death and its definition hinder identification of a potential donor. Continuing medical education and highlighting the role of the Organ Transplant Coordinator, as well as increasing awareness of the public through religion and the media were identified as essential in improving the rate of organ donations from deceased donors in Malaysia.

Complications associated with urinary diversion.

Radical cystectomy (RC) with subsequent urinary diversion has been assessed to be the most difficult surgical procedure in the field of urology. No randomized trials have been performed to compare the outcomes of noncontinent conduit diversion, neobladder construction and continent cutaneous diversion. Almost all studies are of level 3 evidence, meaning the recommendations given in this Review are of grade C only. Until recently, significant disparity in the quality of surgical complication reporting, as well as the lack of universally accepted reporting guidelines, definitions and grading systems, have made it impossible to compare the surgical morbidity and outcomes of RC. There is a clear case for the standardized reporting of complications. The Clavien system is a straightforward and validated instrument that has already been successfully adopted by several urological centers. Surgical morbidity following RC is significant and, when strict reporting guidelines are incorporated, much higher than previously published. Complications can occur up to 20 years after surgery, emphasizing the need for more long-term studies to determine the full morbidity spectrum. In general, renal function after construction of continent detubularized reservoirs compares favorably with ileal conduit diversion, although the literature is insufficient to recommend one over the other. The challenge of optimum care for elderly patients with comorbidities is best mastered at a high-volume hospital by a high-volume surgeon.