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Although radial probe endobronchial ultrasound (R-EBUS) has been used to investigate peripheral pulmonary lesions (PPLs), its diagnostic performance without fluoroscopy remains unclear. We sought to determine the diagnostic yield of R-EBUS-guided transbronchial biopsy (TBB) without fluoroscopy.We performed a systematic literature review using Pubmed, Embase, and the Cochrane Central Register. Then, we performed a proportional meta-analysis to determine the diagnostic yield of this modality. Subgroup and meta-regression analyses were used to identify factors affecting the performance of R-EBUS-guided TBB without fluoroscopy.We identified 31 studies consisting of a total of 6491 patients. Pooled overall diagnostic yield of R-EBUS-guided TBB without fluoroscopy was 0.70 (95% confidence interval [CI], 0.67-0.74). There was significant heterogeneity across studies (IR-EBUS-guided TBB without fluoroscopy appears to be a relatively useful tool with a low pneumothorax rate for the diagnosis of PPLs. Factors mentioned above may affect the diagnostic yield of this tool. Because of substantial between-study heterogeneity, our results should be interpreted with caution.

Rapid and accurate diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is essential to prevent the spread of the virus. We investigated the diagnostic accuracy of the Xpert Xpress and the ID NOW assays for rapid detection of SARS‐CoV‐2 using a systemic review and meta‐analysis approach. A systematic literature search was performed using PubMed, Embase, and the Cochrane COVID‐19 Study Register. The sensitivity and specificity of these tests for detecting viruses in patients with suspected SARS‐CoV‐2 infection were pooled. We used commercial and laboratory‐developed reverse transcription‐polymerase chain reactions as reference standards. The Quality Assessment of Diagnostic Accuracy Studies‐2 tool was used to assess the risk of bias. We identified 11 studies involving 1734 subjects for the Xpert Xpress assay and 10 studies involving 1778 subjects for the ID NOW assay. The pooled sensitivity and specificity of the Xpert Xpress assay for detection of SARS‐CoV‐2 were 0.99 (95% confidence interval [CI], 0.97 to 0.99) and 0.97 (95% CI, 0.95 to 0.98), respectively. The pooled sensitivity and specificity of the ID NOW assay were 0.79 (95% CI, 0.69 to 0.86) and 1.00 (95% CI, 0.98 to 1.00), respectively. The studies included in our analysis seemed to have low methodological quality. The Xpert Xpress assay showed excellent diagnostic accuracy for rapid detection of SARS‐CoV‐2. However, as the ID NOW assay showed relatively low sensitivity, this test might miss several positive samples., Highlights We examined the accuracy of two tests in rapid diagnosis of the SARS‐CoV‐2. The Xpert Xpress assay showed excellent diagnostic accuracy. The ID NOW assay had relatively low pooled sensitivity.

In this study, moving least square (MLS) shape functions are employed to reduce the cell-crossing error occurred in conventional material point method (MPM) when material particles pass through grid cell boundaries. The level of smoothness of MLS shape functions for mapping information from material particles to a background grid can be controlled by the support size of MLS weight functions. A simple method is proposed to reduce the computational cost for evaluating MLS shape functions at material particles by interpolating pre-computed MLS shape function values at sampling points in a grid cell. Numerical results show that the present method is very effective to reduce the cell-crossing error in MPM computations.

Background/aims Although pneumococcal urinary antigen tests (PUATs) have universally been used for the diagnosis of pneumococcal pneumonia, data on the efficacy of these exams are limited. The objective of our study was to investigate the clinical impact of the PUAT in patients with community-onset pneumonia (CO-pneumonia). Methods We conducted a retrospective cohort study of patients diagnosed with CO-pneumonia. Patients were classified according to their PUAT results and were matched using the propensity score-matching method. The primary outcome was 30-day mortality. Results A total of 1,257 patients were identified and 163 (13.0%) demonstrated positive PUAT results. The sensitivity and specificity values of PUAT for overall pneumococcal pneumonia were 56.5% and 91.4%, respectively. In the full cohort, there were no significant differences in 30-day mortality between the two groups (6.1% in the positive PUAT group vs. 8.2% in the negative PUAT group, p = 0.357). However, in the propensity-matched cohort, the 30-day mortality rates were lower in the positive PUAT group (5.6% vs. 17.4%, p = 0.001). With respect to secondary outcomes, the proportion of patients with potentially drug-resistant pathogens, changes in antibiotics, and failure rates of initial antibiotic therapy were significantly lower in the positive PUAT group than in the negative PUAT group of the propensity-matched cohort. Conclusion We found that the sensitivity of the index test was low and specificity was high in this clinical setting. And our findings suggest that positive PUAT results may be associated with favorable clinical outcomes in patients with CO-pneumonia.

Monoclonal antibodies against type 2 inflammatory pathways are currently promising therapeutics for severe asthma. The aim of this study was to determine how well type 2 (T2) inflammation-specific agents targeting interleukins reduce the rate of asthma exacerbations (AE) in patients with severe asthma.We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. A systematic literature search was conducted in PubMed, Embase, and the Cochrane Central Register. The primary outcome was the reduction rate of annualized AEs.We analyzed 17 studies comprising 11800 subjects. A total of 6197 patients received T2-specific agents (benralizumab, dupilumab, lebrikizumab, mepolizumab, reslizumab, and tralokinumab). Overall, T2-specific agents were significantly associated with a lower risk of AE, compared with placebo [rate ratio (RR) 0.58, 95% confidence interval (CI) 0.51 to 0.66]. Among all studied agents, only tralokinumab did not demonstrate a reduction in AE. The efficacy of T2-specific agents in reducing AE was maintained regardless of the pathway used. A subgroup analysis indicated that T2-specific agents further reduced the risk of AE in patients with eosinophil counts of ≥300 cells/µL (RR 0.41, 95% CI 0.32 to 0.53).Our findings suggest that T2-specific agents are significantly associated with a reduced rate of AE, compared with placebo. Their efficacy appears to be enhanced in patients with eosinophil counts of ≥300 cells/µL.

Objective Although the role of obesity-induced metabolic abnormalities in impaired lung function is well-established, the risk of impaired lung function among obese individuals without metabolic abnormalities, referred to metabolically-healthy obesity (MHO), is largely unexplored. Therefore, we evaluated the impact of MHO on lung function in a large health-screening cohort. Methods 114,143 subjects (65,342 men, mean age and BMI: 39.6 years and 23.6) with health examinations in 2019 were divided into four groups as follows: metabolically healthy non-obese (MHNO), MHO, metabolically unhealthy non-obese (MUHNO), and metabolically unhealthy obese (MUHO). Metabolic health was defined as fewer than two metabolic syndrome components. Obesity was defined as BMI ≥25 kg/m2. Adjusted odds ratios (aORs), using MHNO as a reference, were calculated to determine lung function impairment. Results Approximately one-third (30.6%) of the study subjects were obese. The prevalence of MHO was 15.1%. Subjects with MHO had the highest FEV1% and FVC% values but the lowest FEV1/FVC ratio (pp for trend = 0.173). Conclusions The MHO group had better lung function than other groups. However, longitudinal follow-up studies are required to validate our findings.

Background: Although the Quidel Sofia rapid influenza fluorescent immunoassay (FIA) is widely used to identify influenza A and B, the diagnostic accuracy of this test remains unclear. We compared the diagnostic performances of this test with reverse transcriptase-polymerase chain reaction.Methods: A systematic literature search was performed using MEDLINE, EMBASE, and the Cochrane Central Register. The sensitivity, specificity, diagnostic odds ratio (DOR), and a hierarchical summary receiver-operating characteristic curve (HSROC) of this test for identifying influenza A and B were pooled using meta-analysis. A sensitivity and subgroup analysis was used to identify potential sources of heterogeneity within the selected studies.Results: We identified seventeen studies comprising 8,334 patients. The pooled sensitivity, specificity, and DOR of the Quidel Sofia rapid influenza FIA to identify influenza A were 0.78 (95% CI, 0.71–0.83), 0.99 (95% CI, 0.98–0.99), and 251.26 (95% CI, 139.39–452.89), respectively. The pooled sensitivity, specificity, and diagnostic odds ratio of this test to identify influenza B were 0.72 (95% CI, 0.60–0.82), 0.98 (95% CI, 0.96-0.99), and 140.20 (95% CI, 55.92-351.54), respectively. The area under the HSROC for this test was similar for identification of influenza A and influenza B. Age was considered a probable source of heterogeneity.Conclusions: The pooled sensitivities of the Quidel Sofia rapid influenza FIA did not quite meet the target level (≥80%) for both influenza A and B. The interpretation of data should be carefully considered due to substantial between-study heterogeneity.

Objective: Bronchial hyperresponsiveness (BHR) is a representative feature of asthma. Although methacholine and mannitol are commonly used for bronchial challenge tests, the optimal roles of the two agents for assessing BHR remain unclear. We compared the diagnostic performance of methacholine and mannitol in bronchial challenge tests. Methods: A systematic literature search was performed using MEDLINE, EMBASE, and the Cochrane Central Register. The sensitivity, specificity, diagnostic odds ratio (DOR), and a hierarchical summary of the receiver-operating characteristic curve (HSROC) of the two agents for detecting BHR in asthma were pooled using meta-analysis. A meta-regression analysis was used to identify potential sources of heterogeneity within the selected studies. Results: We identified six studies comprising 565 patients. The pooled sensitivity, specificity, and DOR of methacholine were 0.61 (95%CI, 0.44-0.76), 0.93 (95%CI, 0.70–0.99), and 23.47 (95% CI, 2.51–219.89), respectively. The pooled sensitivity, specificity, and diagnostic odds ratio of mannitol were 0.50 (95%CI, 0.28–0.73), 0.97 (95% CI, 0.94–0.99), and 35.22 (95% CI, 8.82–140.62), respectively. The area under the HSROC for mannitol was higher than that for methacholine (0.97 vs. 0.81, p Conclusion: Although mannitol showed better diagnostic performance than methacholine for identifying BHR in asthma, substantial between-study heterogeneity necessitates caution when interpreting the data.

Background Once-daily inhaled corticosteroids (ICSs) are widely used as first-line therapy in patients with asthma. Objective To compare the efficacy of ICSs administered once daily in the morning or evening as determined by lung function. Methods Medline, Embase, and the Cochrane Central Register were searched for relevant clinical trials. The primary outcome was lung function assessed as trough forced expiratory volume in 1 second and peak expiratory flow at end point. Results Eight randomized clinical trials involving 1,234 patients were analyzed. The total number of patients treated with once-daily ICS in the morning and evening was 628 and 606, respectively. Pooled estimates showed that ICS administered once daily in the evening resulted in mild improvements in trough forced expiratory volume in 1 second (mean difference 0.05 L; 95% confidence interval 0.01–0.09; P = .026; I 2 = 22.5%) and morning peak expiratory flow (mean difference 13.92 L/min; 95% confidence interval 5.77–22.06; P = .001; I 2 = 13%) at end point compared with morning dosing. The change in use of rescue medicine and the incidence of adverse events with once-daily ICS were not significantly different between the 2 dosing times. Conclusion Compared with morning dosing, ICSs administered once daily in the evening seemed to provide some benefits in lung function for patients with asthma. However, because of methodologic limitations, further large-scale randomized clinical trials for dosing time of once-daily ICSs are needed.

Background Timely and accurate diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is crucial to reduce the risk of viral transmission. We investigated the diagnostic accuracy of rapid antigen detection tests (RADTs) in the diagnosis of SARS-CoV-2 infection. Methods A systematic literature search was performed using Pubmed, Embase, and the Cochrane Central Register. The sensitivity, specificity, diagnostic odds ratio (DOR), and a hierarchical summary receiver-operating characteristic curve (HSROC) of RADTs were pooled using meta-analysis. We used commercial and laboratory-developed reverse transcriptase-polymerase chain reaction (RT-PCR) as reference standards. Results We identified 24 studies comprising 14,188 patients. The overall pooled sensitivity, specificity, and DOR of RADTs for diagnosis of SARS-CoV-2 were 0.68 (95%CI, 0.59 – 0.76), 0.99 (95%CI, 0.99 – 1.00), and 426.70 (95% CI, 168.37 – 1081.65), respectively. RADTs and RT-PCR had moderate agreement with an estimated pooled Cohen's kappa statistic of 0.75 (95%CI, 0.74–0.77), and area under the HSROC of 0.98 (95%CI, 0.96 – 0.99). The pooled sensitivity of RADTs was significantly increased in subjects with viral load of Ct-value ≤25 or in those within 5 days after symptom onset than it was in subjects with lower viral loads or longer symptom duration. Conclusions The overall sensitivity of RADTs was inferior to that of the RT-PCR assay. The RADTs were more sensitive for samples of Ct-value ≤ 25 and might be suitable for subjects in the community within 5 days of symptom onset.

ObjectivesThough elevated ferritin level and decreased lung function both predispose people to cardio-metabolic disease, few reports have investigated the association between them. Furthermore, it remains unclear whether the association reflects a change in iron stores or an epiphenomenon reflecting metabolic stress. Therefore, we looked for possible associations between ferritin, iron, and transferrin saturation (TSAT) and lung function to clarify the role of iron-related parameters in healthy men.MethodsWe conducted a cohort study of 42,927 healthy Korean men (mean age: 38.6 years). Percent predicted forced expiratory volume in one second (FEV1%) and forced vital capacity (FVC%) were categorized into quartiles. Adjusted odds ratios (aORs) and 95% confidence intervals (using the highest quartile as reference) were calculated for hyperferritinemia, high iron, and high TSAT after controlling for potential confounders.ResultsThe median ferritin level was 199.8 (141.5-275.6) ng/mL. The prevalence of hyperferritinemia (defined as >300 ng/mL) was 19.3%. Subjects with hyperferritinemia had lower FEV1% and FVC% than those with normal ferritin level with a slight difference, but those were statistically significant (99.22% vs.99.61% for FEV1%, p = 0.015 and 98.43% vs. 98.87% for FVC, p = 0.001). However, FEV1/FVC ratio was not significantly different between groups (P = 0.797). Compared with the highest quartile, the aORs for hyperferritinemia across decreasing quartiles were 1.081 (1.005-1.163), 1.100 (1.007-1.200), and 1.140 (1.053-1.233) for FEV1% (p for trend = 0.007) and 1.094 (1.018-1.176), 1.101 (1.021-1.188), and 1.150 (1.056-1.252) for FVC% (p for trend = 0.001). However, neither FEV1% nor FVC% was associated with iron or TSAT.ConclusionsHyperferritinemia was associated with decreased lung function in healthy Korean men, but iron and TSAT were not. Longitudinal follow-up studies are required to validate our findings.

Background There has been no consensus regarding the discontinuation order of vasopressors in patients recovering from septic shock treated with concomitant norepinephrine (NE) and arginine vasopressin (AVP). The aim of this study was to compare the incidence of hypotension within 24 hours based on whether NE or AVP was discontinued first in order to determine the optimal sequence for discontinuation of vasopressors. Methods A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Central Register. The primary end-point was incidence of hypotension within 24 hours after discontinuation of the first vasopressor. Results We identified five studies comprising 930 patients, of whom 631 (67.8%) discontinued NE first and 299 (32.2%) discontinued AVP first. In pooled estimates, a random-effect model showed that discontinuation of NE first was associated with a significant reduction of the incidence of hypotension compared to discontinuing AVP first (31.8% vs. 54.8%; risk ratios, 0.35; 95% confidence interval, 0.16 to 0.76; P = 0.008; I2 = 90.7%). Although a substantial degree of heterogeneity existed among the trials, we could not identify the significant source of bias. In addition, there were no significant differences in intensive care unit (ICU) mortality, in-hospital mortality, 28-day mortality, or ICU length of stay between the groups. Conclusion Discontinuing NE prior to AVP was associated with a lower incidence of hypotension in patients recovering from septic shock. However, our results should be interpreted with caution, due to the considerable between-study heterogeneity., Graphical Abstract

There has been inconsistent relationships between serum vitamin D levels and lung function in previous studies. However, previous studies included patients with medical diseases, affecting both vitamin D levels and lung function. Considering this view of potential confounders, we investigated if vitamin D deficiency (VDD) is linked to lung function in health screening examinee without overt medical conditions. We conducted a cohort study on 68,457 healthy Koreans (36,759 males, mean age: 37.7 years) with a health examination in 2015. Measured forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were categorized in quartiles. To examine the relationships between VDD and lung function, adjusted odds ratios (aORs) for VDD were estimated by logistic regression. Median vitamin D level was 14.9 ng/mL. The prevalence of VDD (defined as

Background Pulmonary hypertension (PH) is common in patients with idiopathic pulmonary fibrosis (IPF) and is associated with poor outcomes. This study was performed to determine the clinical efficacy of PH-specific therapeutic agents for IPF patients. Methods We performed a systematic review and meta-analysis using MEDLINE, EMBASE, and the Cochrane Central Register. We searched randomized controlled trials (RCTs) without language restriction until November 2018. The primary outcome was all-cause mortality to end of study. Results We analyzed 10 RCTs involving 2,124 patients, 1,274 of whom received PH-specific agents. In pooled estimates, the use of PH-specific agents was not significantly associated with reduced all-cause mortality to end of study compared with controls (hazard ratio, 0.99; 95% confidence interval [CI], 0.92, 1.06; P = 0.71; I2 = 30%). When we performed subgroup analyses according to the type of PH-specific agent, sample size, age, forced vital capacity, diffusion lung capacity, and the extent of honeycombing, PH-specific agents also showed no significant association with a reduction in all-cause mortality. A small but significant improvement in quality of life, measured using the St. George Respiratory Questionnaire total score, was found in the PH-specific agent group (mean difference, −3.16 points; 95% CI, −5.34, −0.97; P = 0.005; I2 = 0%). We found no significant changes from baseline in lung function, dyspnea, or exercise capacity. Serious adverse events were similar between the two groups. Conclusion Although PH-specific agents provided small health-related quality-of-life benefits, our meta-analysis provides insufficient evidence to support their use in IPF patients., Graphical Abstract

Purpose We sought to elucidate the performance of a Quick Sequential Organ Function Assessment-65 (qSOFA-65) score in recognizing sepsis and to compare the qSOFA-65 score to systemic inflammatory response syndrome (SIRS) and qSOFA scores. Methods We performed a matched case-control study using propensity score matching. The number of patients meeting qSOFA-65, qSOFA, and SIRS positive criteria were calculated between the sepsis and non-sepsis groups. We compared the diagnostic performance of the three scoring systems in predicting sepsis. Results A total of 2441 patients were included in the study. In propensity matched cohorts, the percentage of patients who met qSOFA-65, qSOFA, and SIRS positive criteria were 46.7%, 14.3%, and 55.6%, respectively. The sensitivity and specificity scores for the qSOFA-65, qSOFA, and SIRS positive criteria for sepsis were 0.66 and 0.73, 0.28 and 0.97, and 0.66 and 0.55, respectively. The AUC value of qSOFA-65 positive criteria in predicting sepsis was significantly higher than that of qSOFA and SIRS positive criteria (adjusted AUC 0.688 vs. 0.630 vs. 0.596, respectively). Conclusions We found that qSOFA-65 was more likely to identify patients with sepsis on the initial ED visit relative to qSOFA or SIRS. This may have quality improvement implications in predicting sepsis.

Purpose Molecular testing in non-small cell lung cancer (NSCLC) aids in identifying oncogenic alterations. The aim of this study was to compare the rates of detection of oncogenic alterations and responsiveness to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) according to EGFR mutation status as determined by peptide nucleic acid (PNA) clamping or direct sequencing (DS). Materials and methods We performed a systematic literature search using MEDLINE, EMBASE, and the Cochrane Central Register. Data from included studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and receiver operating characteristic curves. A meta-regression analysis was conducted to identify potential sources of heterogeneity between selected studies. Results We identified 10 studies comprising 924 patients. Oncogenic alterations were detected in 340 of 924 cases (36.8%) with PNA clamping and in 250 of 924 (27.1%) with DS. The pooled sensitivities of PNA clamping and DS were 0.93 [95% confidence interval (CI): 0.90-0.95] and 0.69 (95% CI: 0.64-0.73), respectively. According to meta-regression analysis, none of the covariates were found to be significant sources of heterogeneity. With respect to treatment responses to EGFR-TKIs, there was no significant difference therein between EGFR mutations detected by PNA clamping and DS (53.4% vs. 50.8%; risk ratio, 0.99; 95% CI 0.83-1.19; p=0.874). Conclusion We demonstrated that PNA clamping has a higher sensitivity than DS for detecting oncogenic alterations in NSCLC. Our findings suggest that PNA clamping is a more useful method for clinical practice.

BackgroundDecreased lung function is associated with non-alcoholic fatty liver disease (NAFLD), based on linking mechanisms such as insulin resistance and systemic inflammation However, its association with the risk of developing NAFLD is unclear. Our aim was to investigate whether baseline lung function is associated with incident NAFLD in middle-aged healthy Koreans.MethodsA cohort study of 96,104 subjects (mean age: 35.7 years) without NAFLD were followed up from 2002 to 2015. NAFLD was diagnosed by ultrasound after the exclusion of other possible causes of liver diseases. Baseline percent predicted forced expiratory volume in one second (FEV1%) and forced vital capacity (FVC%) were categorized in quartiles. Adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) (using the highest quartile as reference) were calculated for incident NAFLD at follow-up, controlling for covariates and potential confounders.ResultsDuring 579,714.5 person-years of follow-up, 24,450 participants developed NAFLD (incidence rate, 42.2 per 1,000 person-years). The mean follow-up period was 5.9±3.4 years. Regardless of smoking history, the risk for incident NAFLD increased with decreasing quartiles of FEV1 (%) and FVC (%) in a dose-response manner (p for trendConclusionsReduced lung function was a risk factor for incident NAFLD in a large middle-aged Korean cohort with over half a million person-years of follow-up.

BACKGROUND AND OBJECTIVE Reduced lung function and high lipoprotein (a) (Lp(a)) levels are both recognized risk factors for cardiovascular disease. Few studies have investigated the association between serum Lp(a) and lung function in the general population. We evaluated the association between reduced lung function and high Lp(a) levels in healthy individuals without known medical disease diagnoses. METHODS We performed a cross-sectional study on 64 082 Korean health screening examinees (33 049 males, 38 ± 7 years) who underwent a health examination in 2015. RESULTS The median Lp(a) level was 12 (6-25)mg/dL. The prevalence of high Lp(a) (defined as >30 mg/dL) was 19.5%. Subjects with a high Lp(a) had both lower values of measured forced expiratory volume in 1 s (FEV1 ) and forced vital capacity (FVC; L) than those with a low Lp(a) (P

Background The usefulness of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in providing bedside criteria for early prediction of poor outcomes in patients with suspected infection remains controversial. We investigated the prognostic performance of a positive qSOFA score outside the intensive care unit (ICU) compared with positive systemic inflammatory response syndrome (SIRS) criteria. Methods A systematic literature search was performed using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Data were pooled on the basis of sensitivity, specificity, and diagnostic OR. Overall test performance was summarized using a hierarchical summary ROC and the AUC. Meta-regression analysis was used to identify potential sources of bias. Results We identified 23 studies with a total of 146,551 patients. When predicting in-hospital mortality in our meta-analysis, we identified pooled sensitivities of 0.51 for a positive qSOFA score and 0.86 for positive SIRS criteria, as well as pooled specificities of 0.83 for a positive qSOFA score and 0.29 for positive SIRS criteria. Discrimination for in-hospital mortality had similar AUCs between the two tools (0.74 vs. 0.71; P = 0.816). Using meta-regression analysis, an overall mortality rate ≥ 10% and timing of qSOFA score measurement could be significant sources of heterogeneity. For predicting acute organ dysfunction, although the AUC for a positive qSOFA score was higher than that for positive SIRS criteria (0.87 vs. 0.76; P

Paired forest plots of sensitivity and specificity of positive qSOFA score in identifying ICU admission in infected patients outside the intensive care unit. (PDF 170 kb)

Paired forest plots of sensitivity and specificity of positive qSOFA score in identifying organ dysfunction in infected patients outside the intensive care unit. (PDF 263 kb)

Summary for risk of bias of included studies and risk of bias graph for the included studies. (PDF 32 kb)

Study protocol, search strategies, and quality assessment. (PDF 115 kb)

Funnel plot for publication bias assessment of studies for (a) positive qSOFA score and (b) positive SIRS criteria score for the prediction of in-hospital mortality. (PDF 97 kb)

Paired forest plots of sensitivity and specificity of positive SIRS criteria score in identifying organ dysfunction in infected patients outside the intensive care unit. (PDF 83 kb)

Paired forest plots of sensitivity and specificity of positive SIRS criteria in identifying ICU admission in infected patients outside the intensive care unit. (PDF 107 kb)

Paired forest plots of sensitivity and specificity of positive SIRS criteria in predicting in-hospital mortality of infected patients outside the intensive care unit. (PDF 268 kb)

Summary receiver operating characteristic curves for (a) positive qSOFA score and (b) positive SIRS criteria for predicting ICU admission in infected patients outside the intensive care unit. (PDF 77 kb)