Septic patients without obvious signs of infection at baseline are more likely to die in the ICU.

OBJECTIVE: Early identification of sepsis is mandatory. However, clinical presentation is sometimes misleading given the lack of infection signs. The objective of the study was to evaluate the impact on the 28-day mortality of the so-called "vague" presentation of sepsis. DESIGN: Single centre retrospective observational study. SETTING: One teaching hospital Intensive Care Unit. SUBJECTS: All the patients who presented at the Emergency Department (ED) and were thereafter admitted to the Intensive Care Unit (ICU) with a final diagnosis of sepsis were included in this retrospective observational three-year study. They were classified as having exhibited either "vague" or explicit presentation at the ED according to previously suggested criteria. Baseline characteristics, infection main features and sepsis management were compared. The impact of a vague presentation on 28-day mortality was then evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 348 included patients, 103 (29.6%) had a vague sepsis presentation. Underlying chronic diseases were more likely in those patients [e.g., peripheral arterial occlusive disease: adjusted odd ratio (aOR) = 2.01, (1.08-3.77) 95% confidence interval (CI); p = 0.028], but organ failure was less likely at the ED [SOFA score value: 4.7 (3.2) vs. 5.2 (3.1), p = 0.09]. In contrast, 28-day mortality was higher in the vague presentation group (40.8% vs. 26.9%, p = 0.011), along with longer time-to-diagnosis [18 (31) vs. 4 (11) h, p < 0.001], time-to-antibiotics [20 (32) vs. 7 (12) h, p < 0.001] and time to ICU admission [71 (159) vs. 24 (69) h, p < 0.001]. Whatever, such a vague presentation independently predicted 28-day mortality [aOR = 2.14 (1.24-3.68) 95% CI; p = 0.006]. CONCLUSIONS: Almost one third of septic patient requiring ICU had a vague presentation at the ED. Despite an apparent lower level of severity when initially assessed, those patients had an increased risk of mortality that could not be fully explained by delayed diagnosis and management of sepsis.

Gender equity in medical publications: nurses have smashed the glass ceiling.

INTRODUCTION: Gender equity has become a major concern in many professional fields. The rate of women as authors has to be interpreted according to the rate of women in the related professions. In this perspective, studying nurses' population should be of particular interest since, worldwide, nurses are mostly women. Then, our aim was to study gender disparity in nurses' publications. METHODS: We selected the three main journals dedicated to nurse publications: International Journal of Nursing Studies, Journal of Nursing Scholarship, and European Journal of Cardiovascular Nursing. We included 20 recent consecutive papers from each journal. For each paper, the number of authors, their gender, and rank were recorded. Primary endpoint: overall rate of women as authors. Secondary endpoints: rate of women as first, last, second, and third authors. RESULTS: Sixty papers including 322 authors were analysed. Overall rate of women authors: 74%. Overall rate of women as first author: 82%. Overall rate of women as last author: 72%. Overall rate of women as second and third authors: respectively, 80% and 70%. CONCLUSION: Almost three-quarters of the authors in these main scientific journals of nursing studies were female. This rate is lower than the gender rate in the nursing profession.

Type 1 or Type 2 Myocardial Infarction in Patients with a History of Coronary Artery Disease: Data from the Emergency Department.

A type 2 myocardial infarction (T2MI) is the result of an imbalance between oxygen supply and demand, without acute atherothrombosis. T2MI is frequent in emergency departments (ED), but has not been extensively evaluated in patients with previously known coronary artery disease (CAD). Our study assessed the incidence and characteristics of T2MI compared to type 1 (T1MI) in CAD patients admitted to an ED. Among 33,669 consecutive patients admitted to the ED, 2830 patients with T1MI or T2MI were systematically included after prospective adjudication by the attending clinician according to the universal definition. Among them, 619 (22%) patients had a history of CAD. Using multivariable analysis, CAD history was found to be an independent predictive factor of T2MI versus T1MI (odds ratio (95% confidence interval) = 1.38 (1.08-1.77), p = 0.01). Among CAD patients, those with T2MI (n = 254) were older (median age: 82 vs. 72 years, p < 0.001), and had more frequent comorbidities and more frequent three-vessel disease at the coronary angiography (56% vs. 43%, p = 0.015). Percutaneous coronary intervention was by far less frequent after T2MI than after T1MI (28% vs. 67%, p < 0.001), and in-hospital mortality was twice as high in T2MI (15% vs. 7% for T1MI, p < 0.001). Among biomarkers, the C reactive protein (CRP)/troponin Ic ratio predicted T2MI remarkably well (C-statistic (95% confidence interval) = 0.84 (0.81-0.87, p < 0.001). In a large unselected cohort of MI patients in the ED, a quarter of patients had previous CAD, which was associated with a 40% higher risk of T2MI. CRP/troponin ratios could be used to help distinguish T2MI from T1MI.

Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection.

OBJECTIVE: After the third international consensus on sepsis released its new definitions, the prognostic value of quick sequential organ failure assessment (qSOFA) score has been confirmed in the emergency department. However, its validity in the prehospital setting remains unknown. The objective of the study was to assess its accuracy for prehospital patients cared by emergency physician-staffed ambulances (services mobiles d'urgence et de réanimation SMUR). PATIENTS AND METHODS: This was a prospective observational multicenter cohort study (N = 6). All consecutive patients with prehospital clinical suspicion of infection by the emergency physician of the SMUR emergency medical service were included. Components of qSOFA were collected, and the patients were followed until hospital discharge. The primary end point was in-hospital mortality, censored at 28 days. Secondary end points included ICU admission longer than 72 h and a composite of 'death or ICU stay more than 72 h'. RESULTS: We screened 342 patients and included 332 in the analysis. Their mean age was 73 years, 159 (48%) were women, and the most common site of infection was respiratory (73% of cases). qSOFA was at least 2 in 133 (40%) patients. The overall in-hospital mortality was 27%: 41% in patients with qSOFA of at least 2 versus 18% for qSOFA less than 2 (absolute difference 23%; 95% confidence interval: 13-33%, P < 0.001). The overall discrimination for qSOFA was poor, with an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.62-0.74). CONCLUSION: In this large multicenter study, prehospital qSOFA presents a strong association with mortality in infected patient, though with poor prognostic performances in our severely ill sample.

Short-Term Prognosis of Myocardial Injury, Type 1, and Type 2 Myocardial Infarction in the Emergency Unit.

BACKGROUND: Type 2 myocardial infarction and nonischemic myocardial injury, corresponding to troponin elevation without atherothrombosis, are emerging concepts suspected of being common in emergency departments (ED). However, their respective frequencies, risk profiles, and short-term prognoses remain to be investigated. METHODS: Among all the patients admitted from January 2014 to December 2016 in a university hospital ED (n = 33,669), those with elevated conventional troponin Ic (≥0.10 µg/L) (n = 4436, 13%) were systematically adjudicated as having type 1 or type 2 myocardial infarction in the presence of symptoms or signs of myocardial ischemia (typical chest pain or electrocardiographic changes) or myocardial injury without such signs. RESULTS: Among the 4436 patients included, 1453 (33%) were classified as having myocardial injury, 947 (21%) as having type 2 and 2036 (46%) as having type 1 myocardial infarction. Compared with type 1 patients, patients with type 2 myocardial infarction and myocardial injury were markedly older (respective median ages: 67, 81, and 84 years; P < .001) with more frequent comorbidities. In multivariate analysis, myocardial injury was associated with a lower risk of cardiovascular death (odds ratio 43; 95% confidence interval, 0.29-0.65; P < .001) but a higher risk of all-cause in-hospital death (odds ratio 1.43; 95% confidence interval, 1.02-2.00; P = .037). Systolic blood pressure <90mm Hg and heart rate >100 beats per minute at admission were strongly associated with all-cause mortality, and the troponin rate was associated with cardiovascular mortality in all groups. CONCLUSIONS: In a large study of patients with elevated troponins in an ED, myocardial injury and type 2 myocardial infarction were frequent and associated with a worse in-hospital prognosis than type 1 myocardial infarction resulting from noncardiovascular events.

Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department.

Importance: An international task force recently redefined the concept of sepsis. This task force recommended the use of the quick Sequential Organ Failure Assessment (qSOFA) score instead of systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk of mortality. However, these new criteria have not been prospectively validated in some settings, and their added value in the emergency department remains unknown. Objective: To prospectively validate qSOFA as a mortality predictor and compare the performances of the new sepsis criteria to the previous ones. Design, Settings, and Participants: International prospective cohort study, conducted in France, Spain, Belgium, and Switzerland between May and June 2016. In the 30 participating emergency departments, for a 4-week period, consecutive patients who visited the emergency departments with suspected infection were included. All variables from previous and new definitions of sepsis were collected. Patients were followed up until hospital discharge or death. Exposures: Measurement of qSOFA, SOFA, and SIRS. Main Outcomes and Measures: In-hospital mortality. Results: Of 1088 patients screened, 879 were included in the analysis. Median age was 67 years (interquartile range, 47-81 years), 414 (47%) were women, and 379 (43%) had respiratory tract infection. Overall in-hospital mortality was 8%: 3% for patients with a qSOFA score lower than 2 vs 24% for those with qSOFA score of 2 or higher (absolute difference, 21%; 95% CI, 15%-26%). The qSOFA performed better than both SIRS and severe sepsis in predicting in-hospital mortality, with an area under the receiver operating curve (AUROC) of 0.80 (95% CI, 0.74-0.85) vs 0.65 (95% CI, 0.59-0.70) for both SIRS and severe sepsis (P < .001; incremental AUROC, 0.15; 95% CI, 0.09-0.22). The hazard ratio of qSOFA score for death was 6.2 (95% CI, 3.8-10.3) vs 3.5 (95% CI, 2.2-5.5) for severe sepsis. Conclusions and Relevance: Among patients presenting to the emergency department with suspected infection, the use of qSOFA resulted in greater prognostic accuracy for in-hospital mortality than did either SIRS or severe sepsis. These findings provide support for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria in the emergency department setting. Trial Registration: clinicaltrials.gov Identifier: NCT02738164.

Impact of diverting general practitioner's after-hour calls to emergency medical dispatch centers in patients with acute myocardial infarction.

OBJECTIVE: The aim of this study was to analyze the impact of diverting off-hour calls to Emergency Medical Dispatch Centers (EMDC) on time delays and revascularization procedures for patients with ST-segment elevation myocardial infarction (STEMI) in a French region. METHODS: A total of 3376 consecutive patients admitted for acute STEMI were included from the RICO survey (a French regional survey for acute myocardial infarction). Patients were retrospectively classified into two groups: before (2001-2004) and after EMDC (2005-2008) implementation and followed up for mortality as primary outcomes. In addition, we examined the impact of the diversion on the delay to definitive care. RESULTS: During the study, 1781 (53%) patients were evaluated before and 1595 (47%) after the EMDC implementation. Access to healthcare facilities was similar for the two groups. The rate of off-hour calls remained stable over time. The median delay from first medical intervention to hospital admission decreased from 75 to 60 min. The off-hour median interval from door to primary percutaneous coronary intervention dropped from 152 to 98 min. The multivariate analyses showed that EMDC implementing reduced preadmission delays even when adjusting for potential confounders. Moreover, EMDC implementing was associated with a fall in 30-day mortality by 60% in patients admitted during off hours and undergoing primary percutaneous coronary intervention (10 vs. 4%). CONCLUSION: In a real world setting, improving the quality of prehospital organization was effective not only on reducing delays but also on improving access to revascularization. Our results showed the beneficial impact of EMDC implementing on management of STEMI.