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Background: Ischaemic tissue injury caused by tissue hypoperfusion is one of the major consequences of sepsis. Phosphate concentrations are elevated in ischaemic tissue injury. This study was performed to investigate the association of phosphate concentrations with mortality in patients with sepsis., Methods: This was a retrospective cohort study of patients with sepsis conducted at an urban, tertiary care emergency department (ED) in Korea. Patients with sepsis arriving between March 2010 and April 2017 were stratified into four groups according to the initial phosphate concentration at presentation to the ED: group I (hypophosphataemia, phosphate <2 mg/dL), group II (normophosphataemia, phosphate 2-4 mg/dL), group III (mild hyperphosphataemia, phosphate 4-6 mg/dL), group IV (moderate to severe hyperphosphataemia, phosphate ≥6 mg/dL). Multivariable Cox proportional hazard regression analyses were performed to evaluate the independent association of initial phosphate concentration with 28-day mortality., Results: Of the 3034 participants in the study, the overall mortality rate was 21.9%. The 28-day mortality rates were group I (hypophosphataemia) 14.6%, group II 17.4% (normophosphataemia), group III (mild hyperphosphataemia) 29.2% and group IV (moderate to severe hyperphosphataemia) 51.4%, respectively (p<0.001). In the multivariable analyses, patients with severe hyperphosphataemia had a significantly higher risk of death than those with normal phosphate levels (HR 1.59; 95% CI 1.23 to 2.05). Mortality in the other groups was not significantly different from mortality in patients with normophosphataemia., Conclusions: Moderate to severe hyperphosphataemia was associated with 28-day mortality in patients with sepsis. Phosphate level could be used as a prognostic indicator in sepsis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Septic shock can be defined both by the presence of hyperlactatemia and need of vasopressors. Lactate levels should be measured after volume resuscitation (as per the Sepsis-3 definition). However, currently, no studies have evaluated patients who have been excluded by the new criteria for septic shock. The aim of this study was to determine the clinical characteristics and prognosis of these patients, based on their lactate levels after initial fluid resuscitation., Methods: This observational study was performed using a prospective, multi-center registry of septic shock, with the participation of 10 hospitals in the Korean Shock Society, between October 2015 and February 2017. We compared the 28-day mortality between patients who were excluded from the new definition (defined as lactate level <2 mmol/L after volume resuscitation) and those who were not (≥2 mmol/L after volume resuscitation), from among a cohort of patients with refractory hypotension, and requiring the use of vasopressors. Other outcome variables such as in-hospital mortality, intensive care unit (ICU) stay (days), Sequential Organ Failure Assessment (SOFA) scores and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were also analyzed., Results: Of 567 patients with refractory hypotension, requiring the use of vasopressors, 435 had elevated lactate levels, while 83 did not have elevated lactate levels (either initially or after volume resuscitation), and 49 (8.2%) had elevated lactate levels initially, which normalized after fluid resuscitation. Thus, these 49 patients were excluded by the new definition of septic shock. These patients, in whom perfusion was restored, demonstrated significantly lower age, platelet count, and initial and subsequent lactate levels (all p < 0.01). Similarly, significantly lower 28-day mortality was observed in these patients than in those who had not been excluded (8.2% vs 25.5%, p = 0.02). In-hospital mortality and the maximum SOFA score were also significantly lower in the excluded patients group (p = 0.03, both)., Conclusions: It seems reasonable for septic shock to be defined by the lactate levels after volume resuscitation. However, owing to the small number of patients in whom lactate levels were improved, further study is warranted.

Objective: The initiation of palliative care (PC) in the emergency department (ED) is effective in improving the quality of life for seriously ill patients. This study aimed to evaluate the prognostic value of the modified surprise question (mSQ), "Would you be surprised if this patient died in the next 30 days?" as a trigger for initiating PC in critically ill ED patients. Methods: We conducted a prospective cohort study over a 6-month period in an ED, during which 22 emergency residents answered the mSQ for critically ill ED patients (Korean Triage and Acuity Scale 1 or 2). The primary outcome was the accuracy of the positive mSQ (negative response to the mSQ) in predicting 30-day mortality, and logistic regression analysis was performed to identify the prognostic factors. Results: A total of 300 patients were enrolled, and the positive mSQ group included 118 (39.3%) patients. The 30-day mortality rate of the cohort was 10.0%. The sensitivity, specificity, positive predictive value, and negative predictive value of the positive mSQ were 83.3%, 65.6%, 21.2%, and 97.3%, respectively, with a c-statistic of 0.74 and a positive likelihood ratio of 2.42. In a multivariable analysis controlling for clinically relevant variables, the odds ratio for 30-day mortality of the positive mSQ was 4.76 (95% confidence interval, 1.61-14.09; P =.005). Conclusions: The mSQ may be valuable for identifying critically ill ED patients with an increased risk of 30-day mortality. Therefore, it may be utilized as a trigger for PC consultation in the ED. [ABSTRACT FROM AUTHOR]

Background: Early risk stratification is crucial due to septic patients' heterogeneity. Serum albumin level may reflect the severity of sepsis and host status. This study aimed to evaluate the prognostic ability of the initial sequential organ failure assessment (SOFA) score alone and combined with serum albumin levels for predicting 28-day mortality in patients with septic shock. Methods: We conducted an observational study using a prospective, multicenter registry of septic shock patients between October 2015 and May 2022 from 12 emergency departments in the Korean Shock Society and the results were validated by examining those from the septic shock cohort in Asan Medical Center. The primary outcome was 28-day mortality. The area under the receiver operating characteristic (ROC) curve was used to compare the predictive values of SOFA score alone and SOFA score combined with serum albumin level. Results: Among 5805 septic shock patients, 1529 (26.3%) died within 28 days. Mortality increased stepwise with decreasing serum albumin levels (13.6% in albumin ≥3.5, 20.7% in 3.5–3.0, 29.7% in 3.0–2.5, 44.0% in 2.5–2.0, 56.4% in <2.0). The albumin SOFA score was calculated by adding the initial SOFA score to the 4 points assigned for albumin levels. ROC analysis for predicting 28-day mortality showed that the area under the curve for the albumin SOFA score was 0.71 (95% CI 0.70–0.73), which was significantly higher than that of the initial SOFA score alone (0.68, 95% CI: 0.67–0.69). Conclusions: The combination of the initial SOFA score with albumin can improve prognostic accuracy for patients with septic shock, suggesting the albumin SOFA score may be used as an early mortality stratification tool. [ABSTRACT FROM AUTHOR]

To determine whether there is a difference in antibiotic administration time and prognosis in afebrile sepsis patients compared to febrile sepsis patients. This was retrospective multicenter observational study. Data collected from three referral hospitals. Data were collected from May 2014 through February 2016 under the SEPSIS-2 criteria and from March 2016 to April 2020 under the newly released SEPSIS-3 criteria. Patients were divided into two groups based on body temperature: afebrile (<37.3 °C) and febrile (≥37.3 °C). The relationship between initial body temperature and 28-day mortality were analyzed using multivariable logistic regression. The subgroup analysis was conducted on patients with complete Hour-1 bundle performance records. We included 4293 patients in this study. Initial body temperatures in 28-day survivors were significantly higher than in 28-day non-survivors (37.5 °C ± 1.2 °C versus 37.1 °C ± 1.2 °C, p < 0.01). Multivariable logistic regression analysis was performed in afebrile and febrile sepsis patients. Adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.76 (95% Confidence interval 1.46–2.12). As a result of performing the Hour-1 bundle, the number of patients who received antibiotics within 1 h was smaller in the afebrile sepsis patients (323/2076, 15.6%) than in the febrile sepsis patients (395/2156, 18.3%) (p = 0.02). In the subgroup analysis of patients with complete Hour-1 bundle performance records adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.68 (95% Confidence interval 1.34–2.11). The febrile sepsis patients received antibiotics faster than the afebrile sepsis patients (175.5 ± 207.9 versus 209.3 ± 277.9, p < 0.01). Afebrile sepsis patients were associated with higher 28-day mortality compared to their febrile counterparts and were delayed in receiving antibiotics. This underscores the need for improved early detection and treatment strategies for the afebrile sepsis patients. • Rapid identification of sepsis in afebrile patients who visit the ED is challenging • Mortality of afebrile patients with sepsis was higher than that of febrile patients • Increased mortality of afebrile patients was associated with delayed antibiotics use • Screening tools that can quickly identify sepsis patients without fever are needed [ABSTRACT FROM AUTHOR]

Purpose: Proper antibiotic administration is crucial for sepsis management. Given the escalating incidence of antimicrobial resistance, there is a pressing need for indicators of antimicrobial susceptibility with short turnaround times. This study aimed to investigate the potential of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) as an early biomarker for in vivo antibiotic susceptibility in patients with sepsis. Patients and Methods: We conducted a retrospective analysis of plasma samples from patients enrolled in a pre-established study designed to investigate prognostic biomarkers in patients with sepsis or septic shock. Baseline and 6 h sTREM-1 levels were examined using enzyme-linked immunosorbent assays. The primary outcome of the study was the comparison of percentage changes in sTREM-1 levels at the 6 h relative to baseline with respect to antibiotic susceptibility. Results: Of the 596 patients enrolled in the pre-established study, 29 with a median age of 75.8 and a 28-day mortality rate of 17.2% were included in the present analysis. Among these patients, 24 were classified into the susceptible group, whereas the remaining five were classified into the resistant group. The trend in plasma sTREM-1 levels differed with respect to antibiotic susceptibility. Moreover, percentage change in sTREM-1 levels at the 6 h relative to baseline was significantly higher in the resistant group (P = 0.028). Conclusion: The trend in plasma sTREM-1 levels in patients with sepsis differed with respect to antibiotic susceptibility, with a higher percentage change in patients treated with inappropriate antibiotics. These findings indicate the potential utility of sTREM-1 as an early biomarker of antibiotic susceptibility. [ABSTRACT FROM AUTHOR]

Background: In patients with out‐of‐hospital cardiac arrest (OHCA), low blood pressure after return of spontaneous circulation (ROSC) can be a sign of hemodynamic instability. We aimed to investigate whether systolic blood pressure (SBP) measured immediately after ROSC is associated with survival on admission. Methods: Patients with ROSC after OHCA between 2015 and 2018 were included. The primary outcome was survival on admission. Included patients were divided into three groups based on the SBP measured at the time of ROSC: group 1 (SBP ≤90 mmHg), group 2 (SBP 90–120 mmHg), and group 3 (SBP >120 mmHg). Multivariable logistic regression was used to investigate the relationship between the groups by SBP and outcomes. Results: In the final analysis, 519 patients were included. In the restrictive cubic spline curve, the probability of achieving survival on admission increased gradually from low SBP to approximately 120–130 mmHg, then plateaued at a higher SBP. In the multivariable logistic regression analysis, group 1 was independently associated with decreased survival on admission compared to group 2. There was no significant difference between groups 2 and 3. Conclusions: Low blood pressure (SBP ≤90 mmHg) at the time of ROSC was independently associated with a lower likelihood of survival on admission in patients with non‐traumatic OHCA. However, high blood pressure (SBP >120 mmHg) was not associated with a higher likelihood of survival. These suggest that low blood pressure measured in the prehospital phase can serve as an indicator predicting the poor short‐term prognosis of patients. [ABSTRACT FROM AUTHOR]

A reliable prognostic score for minimizing futile treatments in advanced cancer patients with septic shock is rare. A machine learning (ML) model to classify the risk of advanced cancer patients with septic shock is proposed and compared with the existing scoring systems. A multi-center, retrospective, observational study of the septic shock registry in patients with stage 4 cancer was divided into a training set and a test set in a 7:3 ratio. The primary outcome was 28-day mortality. The best ML model was determined using a stratified 10-fold cross-validation in the training set. A total of 897 patients were included, and the 28-day mortality was 26.4%. The best ML model in the training set was balanced random forest (BRF), with an area under the curve (AUC) of 0.821 to predict 28-day mortality. The AUC of the BRF to predict the 28-day mortality in the test set was 0.859. The AUC of the BRF was significantly higher than those of the Sequential Organ Failure Assessment score and the Acute Physiology and Chronic Health Evaluation II score (both p < 0.001). The ML model outperformed the existing scores for predicting 28-day mortality in stage 4 cancer patients with septic shock. However, further studies are needed to improve the prediction algorithm and to validate it in various countries. This model might support clinicians in real-time to adopt appropriate levels of care. [ABSTRACT FROM AUTHOR]

The prognostic value of low vitamin C levels has not been well investigated in patients with septic shock. We aimed to evaluate the association of vitamin C deficiency with mortality in patients with septic shock. We conducted a retrospective analysis of 165 patients with septic shock from a prospective multicenter trial and institutional sepsis registry between April 2018 and January 2020. The primary outcome was 28-day mortality. The patients were categorized into vitamin C deficiency and normal groups based on a vitamin C cutoff level of 11.4 mmol/L. Multivariable Cox regression analysis was performed to examine the association between vitamin C levels and 28-day mortality. A total of 165 patients was included for analysis and 77 (46.7%) had vitamin C deficiency. There was no significant difference in the 28-day mortality rate between the vitamin C deficiency group and the normal group (23.4% (n = 18/77) vs. 13.6% (n = 12/88), p = 0.083). Multivariable Cox proportional hazard analysis showed vitamin C deficiency to be associated with increased risk of 28-day mortality (adjusted hazard ratio, 2.65, 95% confidence interval (CI), 1.08–6.45; p = 0.032). Initial vitamin C deficiency was associated with a higher risk of 28-day mortality in patients with septic shock after adjusting for intravenous administration of vitamin C and thiamine, baseline characteristics, laboratory findings, and severity of illness. [ABSTRACT FROM AUTHOR]

Background: The Sepsis-3 criteria introduced the system that uses the Sequential Organ-Failure Assessment (SOFA) score to define sepsis. The cardiovascular SOFA (CV SOFA) scoring system needs modification due to the change in guideline-recommended vasopressors. In this study, we aimed to develop and to validate the modified CV SOFA score.Methods: We developed, internally validated, and externally validated the modified CV SOFA score using the suspected infection cohort, sepsis cohort, and septic shock cohort. The primary outcome was 28-day mortality. The modified CV SOFA score system was constructed with consideration of the recently recommended use of the vasopressor norepinephrine with or without lactate level. The predictive validity of the modified SOFA score was evaluated by the discrimination for the primary outcome. Discrimination was assessed using the area under the receiver operating characteristics curve (AUC). Calibration was assessed using the calibration curve. We compared the prognostic performance of the original CV/total SOFA score and the modified CV/total SOFA score to detect mortality in patients with suspected infection, sepsis, or septic shock.Results: We identified 7,393 patients in the suspected cohort, 4038 patients in the sepsis cohort, and 3,107 patients in the septic shock cohort in seven Korean emergency departments (EDs). The 28-day mortality rates were 7.9%, 21.4%, and 20.5%, respectively, in the suspected infection, sepsis, and septic shock cohorts. The model performance is higher when vasopressor and lactate were used in combination than the vasopressor only used model. The modified CV/total SOFA score was well-developed and internally and externally validated in terms of discrimination and calibration. Predictive validity of the modified CV SOFA was significantly higher than that of the original CV SOFA in the development set (0.682 vs 0.624, p < 0.001), test set (0.716 vs 0.638), and all other cohorts (0.648 vs 0.557, 0.674 vs 0.589). Calibration was modest. In the suspected infection cohort, the modified model classified more patients to sepsis (66.0 vs 62.5%) and identified more patients at risk of septic mortality than the SOFA score (92.6 vs 89.5%).Conclusions: Among ED patients with suspected infection, sepsis, and septic shock, the newly-developed modified CV/total SOFA score had higher predictive validity and identified more patients at risk of septic mortality. [ABSTRACT FROM AUTHOR]

Several studies have previously reported that a prolonged emergency department length of stay (EDLOS) is associated with poor outcomes in critically ill patients. This study was performed to investigate the relationship between the EDLOS and the neurologic outcome at 28 days in out-of-hospital cardiac arrest (OHCA) patients. We conducted a retrospective analysis of prospectively collected data from OHCA patients who achieved the return of spontaneous circulation (ROSC) in the EDs of three urban tertiary teaching hospitals from December 2013 to October 2020. Patients were divided into four groups according to the EDLOS, according to the quartile distribution: EDLOS <107 min, EDLOS 107–176 min, EDLOS 176–275 min, and EDLOS ≥275 min. Comparisons of outcomes among the groups and multivariable logistic regression analysis were performed. A total of 807 patients were included in the analysis. The proportions of patients with a good neurologic outcome at 28 days in the groups with EDLOS <107 min, EDLOS 107–176 min, EDLOS 176–275 min, and EDLOS ≥275 min were 37.0%, 29.8%, 26.9, and 20.4%, respectively (p < 0.001). In the multivariable analysis, the odds ratios for a poor neurologic outcome at 28 days in the groups with EDLOS 107–176 min, EDLOS 176–275 min, and EDLOS ≥275 min compared with the group with EDLOS <107 min were 1.19 (95% CI, 0.67–2.13), 1.73 (95% CI, 0.95–3.21), and 1.91 (95% CI, 1.03–3.57), respectively. An EDLOS longer than 275 min after the ROSC was independently associated with a poor neurologic outcome at 28 days. [ABSTRACT FROM AUTHOR]

Objectives: An index combining respiratory rate and oxygenation (ROX) has been introduced, and the ROX index is defined as the ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate. In sepsis, hypoxemia and tachypnea are commonly observed. We performed this study to investigate the association between the ROX index and 28-day mortality in patients with sepsis or septic shock.Methods: This retrospective study included 2862 patients. The patients were divided into three groups according to the ROX index: Group I (ROX index >20), Group II (ROX index >10 and ≤ 20), and Group III (ROX index ≤10).Results: The median ROX index was significantly lower in the nonsurvivors than in the survivors (12.8 and 18.2, respectively) (p < 0.001). The 28-day mortality rates in Groups I, II and III were 14.5%, 21.3% and 34.4%, respectively (p < 0.001). In the multivariable Cox regression analysis, Group III had an approximately 40% higher risk of death than Group I during the 28-day period (hazard ratio = 1.41, 95% confidence interval 1.13-1.76). The area under the curve of the ROX index was significantly higher than that of the quick Sequential Organ Failure Assessment score (p < 0.001).Conclusions: The ROX index was lower in nonsurvivors than in survivors, and a ROX index less than or equal to 10 was an independent prognostic factor for 28-day mortality in patients with sepsis or septic shock. Therefore, the ROX index could be used as a prognostic marker in sepsis. [ABSTRACT FROM AUTHOR]

Objective: Metabolic acidosis is commonly associated with the disease severity in patients with sepsis or septic shock. This study was performed to investigate the association between serum total carbon dioxide (TCO2) concentration and 28-day mortality in patients with sepsis.Methods: This study was a multicenter retrospective cohort study of patients with sepsis or septic shock. The relationships between serum TCO2 and 28-day mortality, bicarbonate, pH, lactate, and anion gap were determined with cubic spline curves. The patients were divided into four groups according to their serum TCO2 concentration: Group I (TCO2 > 20 mmol/l), Group II (15 < TCO2 ≤ 20 mg/dl), Group III (10 < TCO2 ≤ 15 mmol/l), and Group IV (TCO2 ≤ 10 mmol/l).Results: A total of 3168 patients were included in the analysis, and the overall mortality rate was 24.1%. Serum TCO2 concentrations below 20 mmol/l showed an almost linear correlation with mortality as well as with lactate, bicarbonate, and pH. The 28-day mortality rates of Group I, II, III, and IV were 18.3%, 23.6%, 32.6%, and 50.0%, respectively (p < .001). In Multivariable Cox proportional hazard regression analysis, the groups with lower serum TCO2 concentrations had a higher risk of 28-day mortality compared with Group I: Group II (Hazard ratio (HR), 1.35; 95% confidence interval (CI), 1.11-1.64), Group III (HR, 1.74; 95% CI, 1.37-2.21), and Group IV (HR, 2.72; 95% CI, 2.03-3.64).Conclusions: Serum TCO2 concentrations of 20 mmol/l or less were associated with 28-day mortality in patients with sepsis. [ABSTRACT FROM AUTHOR]

Background: To investigate whether the relationship between heart rate and neurological outcome is independent of therapeutic hypothermia (TH) and whether heart rate is related to hemodynamic instability post-cardiac arrest.Methods: Retrospective review of an out-of-hospital cardiac arrest registry was performed. The primary exposure was heart rate quartiles at 24 h post-cardiac arrest. The primary outcome was a poor neurological outcome, which was defined as having a cerebral performance category (CPC) of 3-5 at 28 days. Secondary outcomes were mean blood pressure and serum lactate at 24 h and Sequential Organ Failure Assessment (SOFA) scores at admission.Results: In total, 155 patients were enrolled. The proportion of patients with a poor CPC was significantly greater in higher heart rate quartiles; similar results were observed in patients who did and did not undergo TH. Serum lactate levels at 24 h were significantly higher in the 3rd and 4th quartile groups than in the 1st quartile group. Additionally, SOFA scores were significantly higher in the 4th quartile group than in the 1st and 3rd quartile groups.Conclusions: Relative tachycardia is associated with poor neurological outcomes in post-cardiac arrest patients, independent of TH, and with higher serum lactate levels and admission SOFA scores. [ABSTRACT FROM AUTHOR]

Background: The pneumococcal urinary antigen test (UAT) has been known to improve sensitivity and specificity for the diagnosis of pneumococcal pneumonia. Associations of UAT results with prognosis in community acquired pneumonia (CAP) are not known. We hypothesized that positive UAT is associated with a good prognosis, and incorporation of UAT into CRB65 would improve its prognostic performance. Methods: In this registry-based retrospective study, we analyzed CAP patients over a 10-year period beginning in April 2008. Patients who had UAT results were included in multivariable extended Cox-regression analyses to determine the association between UAT positivity and 30-day mortality. UAT results were incorporated for patients with a CRB65 score of 1 by subtracting 1 from the scoring system if the test was positive. The performance of the modified scoring systems was assessed with area under the receiver operating characteristic (AUROC) curves. Results: Among 5145 CAP patients, total 2280 patients had UAT results and were included in analyses. A positive UAT result was associated with a good prognosis after a week of hospitalization (aHR, 0.14; p = 0.007). After modification of CRB65 using UAT results, positive and negative predictive values for 30-day mortality were increased from 7.7 to 8.3 (p<0.001) and 98.9 to 99.1 (p = 0.010). The AUROC increased from 0.73 to 0.75 (p<0.001). Conclusions: Positive results on UAT could be considered as a good prognostic factor in CAP. UAT could be used as a useful tool in deciding whether to refer patients to the hospital, especially in moderate CAP with a CRB score of 1. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: This study aims to determine the association of commonly used biochemical markers, such as albumin and C-reactive protein (CRP), with mortality and the prognostic performance of these markers combined with the pneumonia severity index (PSI) for mortality and adverse outcomes in patients with community-acquired pneumonia (CAP). Materials and Methods: The data were gathered prospectively for patients hospitalized with CAP via the emergency department. Laboratory values, including CRP and albumin, clinical variables, and the PSI were measured. Primary outcomes were 28-day mortality and survival times. Secondary outcome was admission to the intensive care unit, vasopressor use, or the need for mechanical ventilation during the hospital stay. Results: A total of 424 patients were included. The 28-day mortality was 13.7%. C-reactive protein and albumin were significantly different between survivors and nonsurvivors. In logistic regression analysis, CRP and albumin were independently associated with 28-day mortality (P < .05). Receiver operating characteristic curves showed improved mortality prediction by adding CRP or albumin to the PSI scale. The Cox proportional hazards analysis showed that high serum albumin (≥3.3 mg/dL) had a hazard ratio of 0.5 (95% confidence interval, 0.3-0.9), and high CRP (≥14.3 mg/dL) had a hazard ratio of 2.0 (95% confidence interval, 1.1-3.4). For predicting secondary outcome, adding albumin to PSI increased areas under the curve significantly, but CRP did not. Conclusion: Albumin and CRP were associated with 28-day mortality in hospitalized patients with CAP, and these markers increased prognostic performance when combined with the PSI scale. [Copyright &y& Elsevier]

Background The prognostic role of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with community-acquired pneumonia (CAP) has not been evaluated. The aim of the present study was to investigate whether NT-proBNP level could predict mortality in hospitalised CAP patients. Methods We performed a structured medical record review of all hospitalised CAP patients from May 2003 to October 2006, and classified patients into the 30-day survival and non-survival group. Data included demographic and clinical characteristics, and laboratory findings including NT-proBNP levels. The APACHE II scores, PSI (pneumonia severity index) and CURB65 (confusion, urea, respiratory rate, blood pressure and aged 65 or more) scores were calculated. Comparisons between survivors and non-survivors were made with χ, non-parametric tests and logistic regression and ROC analysis were used to compare the ability of NT-proBNP (adjusted for age, heart failure and creatinine), APACHE II, PSI and CURB65 to predict mortality. Results Of 502 patients, 61 (12.2%) died within 30 days. NT-proBNP levels were measured in 167 patients and were significantly higher in non-survivors compared to survivors (median 841.7 (IQR 267.1–3137.3) pg/ml vs 3658.0 (1863.0–7025.0) pg/ml, p=0.019). NT-proBNP was an independent predictor of mortality (adjusted OR 1.53; 95% CI 1.16 to 2.02, p=0.002). The AUC for NT-proBNP was 0.712 (95% CI, 0.613 to 0.812), which was comparable to those of PSI (0.749, p=0.531) and CURB65 (0.698, p=0.693), but inferior to that of APACHE II (0.831, p=0.037). Adding NT-proBNP to APACHE II, PSI and CURB65 did not significantly increase the AUCs, respectively. Conclusions NT-proBNP level is an independent predictor of mortality in hospitalised CAP patients. The performance of NT-proBNP level is comparable to those of PSI and CURB65 in predicting mortality. [ABSTRACT FROM PUBLISHER]

Purpose: The probability of the return of spontaneous circulation (ROSC) and subsequent favourable outcomes changes dynamically during advanced cardiac life support (ACLS). We sought to model these changes using time-to-event analysis in out-of-hospital cardiac arrest (OHCA) patients.Methods: Adult (≥18 years old), non-traumatic OHCA patients without prehospital ROSC were included. Utstein variables and initial arterial blood gas measurements were used as predictors. The incidence rate of ROSC during the first 30min of ACLS in the emergency department (ED) was modelled using spline-based parametric survival analysis. Conditional probabilities of subsequent outcomes after ROSC (1-week and 1-month survival and 6-month neurologic recovery) were modelled using multivariable logistic regression. The ROSC and conditional probability models were then combined to estimate the likelihood of achieving ROSC and subsequent outcomes by providing k additional minutes of effort.Results: A total of 727 patients were analyzed. The incidence rate of ROSC increased rapidly until the 10th minute of ED ACLS, and it subsequently decreased. The conditional probabilities of subsequent outcomes after ROSC were also dependent on the duration of resuscitation with odds ratios for 1-week and 1-month survival and neurologic recovery of 0.93 (95% CI: 0.90-0.96, p<0.001), 0.93 (0.88-0.97, p=0.001) and 0.93 (0.87-0.99, p=0.031) per 1-min increase, respectively. Calibration testing of the combined models showed good correlation between mean predicted probability and actual prevalence.Conclusions: The probability of ROSC and favourable subsequent outcomes changed according to a multiphasic pattern over the first 30min of ACLS, and modelling of the dynamic changes was feasible. [ABSTRACT FROM AUTHOR]

Introduction: We developed a new neuroprognostication method for cardiac arrest (CA) using the relative volume of the most dominant cluster of low apparent diffusion coefficient (ADC) voxels and tested its performance in a multicenter setting. Methods: Adult (>15 years) out-of-hospital CA patients from three different facilities who underwent an MRI 12h after resuscitation were retrospectively analyzed. Patients with unknown long-term prognosis or poor baseline neurologic function were excluded. Average ADCs (mean and median), LADCV (relative volume of low-ADC voxels) and DC-LADCV (relative volume of most dominant cluster of low-ADC voxels) were extracted using different thresholds between 400 and 800 × 10(-6) mm(2) s(-1) at 10 × 10(-6) mm(2) s(-1) intervals. Area under the receiver operating characteristic curve (AUROC) and sensitivity for poor outcome (6-month cerebral performance category score >2) while maintaining 100% specificity were measured. Results: 110 patients were analyzed. Average ADCs showed fair performance with an AUROC of 0.822 (95% confidence interval [CI], 0.744-0.900) for the mean and 0.799 (95% CI, 0.716-0.882) for the median. LADCV showed better performance with a higher AUROC (maximum, 0.925) in an ADC threshold range of 400 to 690 × 10(-6) mm(2) s(-1). DC-LADCV showed the best performance with a higher AUROC (maximum, 0.955) compared with LADCV in an ADC threshold range of 600 to 680 × 10(-6) mm(2) s(-1). DC-LADCV had a high sensitivity for poor outcomes (>80%) in a wide threshold range from 400 to 580 × 10(-6) mm(2) s(-1) with a maximum of 89.2%. Conclusions: Quantitative analysis using DC-LADCV showed impressive performance in determining the prognosis of out-of-hospital CA patients in a multicenter setting. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Recent studies suggested quantitative analysis of diffusion-weighted magnetic resonance imaging as a promising tool for early prognostication of cardiac arrest patients. However, most of their methods involve significant manual image handling often subjective and difficult to reproduce. Therefore developing a computerized analysis method using easy-to-define characteristics would be useful. Methods: Comatose out-of-hospital cardiac arrest (OHCA) patients who underwent brain MRI between January 2008 and July 2012 were identified from an OHCA registry. Apparent diffusion coefficient (ADC) axial images were analyzed using a program to detect and characterize clusters of low ADC pixels from six brain regions including frontal, occipital, parietal, rolandic and temporal and basal ganglia region. Identified clusters were ranked according to size, mean ADC and minimum ADC to assess the regional maximum cluster size (MCS), lowest mean ADC (LMEAN) and lowest minimum ADC (LMIN). Their power to predict poor outcome, defined as 6-month CPC 3 or higher, was assessed by contingency table analyses. Results: 51 OHCA patients were eligible during the study period. The sensitivities of MCS, LMEAN and LMIN to detect poor outcome varied according to brain region from 62.5 to 90.0%, 50.0 to 72.5% and 42.5 to 82.5% with their specificities set to 100%, respectively. The MCS of occipital region showed most favorable test profile (sensitivity 90%, specificity 100%; AUROC 0.940, 95% confidence interval 0.874–1.000). Conclusion: The cluster-based computerized image analysis might be a simple but useful method for prediction of poor neurologic outcome. Future studies validating its prognostic performance are required. [Copyright &y& Elsevier]

Abstract: Objective: We sought to investigate the prognostic implication of early coagulopathy represented by initial DIC score in out-of-hospital cardiac arrest (OHCA). Methods: OHCA registry was analyzed to identify patients with ROSC without recent use of anticoagulant between 2008 and 2011. Patients were assessed for prehosptial factors, initial laboratory results and therapeutic hypothermia. Outcome variables were survival discharge, 6-month CPC and survival duration within the first week after ROSC. Logistic regression and Cox proportional hazards models were used for both univariable and multivariable analysis. Results: Among 273 eligible patients, initial DIC score was available in 252 (92.3%). Higher DIC score was associated with increased inhospital death (odds ratio [OR], 1.89 per unit; 95% confidence interval [CI], 1.48–2.41) and unfavorable long-term outcome (6-month CPC 3–5; OR, 2.21 per unit; 95% CI, 1.60–3.05). The adjusted ORs for both outcomes were 1.61 (95% CI, 1.17–2.22) and 1.84 (95% CI, 1.26–2.67), respectively. We categorized DIC score in five groups as <3, 3, 4, 5 and >5 and analyzed differential mortality risk using Cox proportional hazards model. Compared with reference group (DIC score<3), the adjusted HR for early mortality in each remaining group was 1.96 (95% CI, 1.13–3.40), 2.26 (95% CI, 1.27–4.02), 2.77 (95% CI, 1.58–4.85) and 4.29 (95% CI, 2.22–8.30), respectively (p-trend<0.001). The area under the receiver operating characteristic of DIC score for prediction of unfavorable long-term outcome was 0.79 (95% CI, 0.69–0.88). Conclusion: Increased initial DIC score in OHCA was an independent predictor for poor outcomes and early mortality risk. [Copyright &y& Elsevier]