Background: To determine the validity of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) in the prediction of outcome (in-hospital and 1-month mortality, intensive care unit (ICU) admission, and hospital and ICU length of stay) in adult patients with or without suspected infections where qSOFA was calculated and reported; Methods: Cochrane Central of Controlled trials, EMBASE, BIOSIS, OVID MEDLINE, OVID Nursing Database, and the Joanna Briggs Institute EBP Database were the main databases searched. All studies published until 12 April 2018 were considered. All studies except case series, case reports, and conference abstracts were considered. Studies that included patients with neutropenic fever exclusively were excluded. Results: The median AUROC for in-hospital mortality (27 studies with 380,920 patients) was 0.68 (a range of 0.55 to 0.82). A meta-analysis of 377,623 subjects showed a polled AUROC of 0.68 (0.65 to 0.71); however, it also confirmed high heterogeneity among studies (I2 = 98.8%, 95%CI 98.6 to 99.0). The median sensitivity and specificity for in-hospital mortality (24 studies with 118,051 patients) was 0.52 (range 0.16 to 0.98) and 0.81 (0.19 to 0.97), respectively. Median positive and negative predictive values were 0.2 (range 0.07 to 0.38) and 0.94 (0.85 to 0.99), respectively.
Background: We aim to compare the prognostic value of Quick Sepsis-Related Organ Failure Assessment (qSOFA) and the previous Systemic Inflammatory Response Syndrome (SIRS) criteria, the National Early Warning Score (NEWS) and along with their combinations in the emergency department (ED). Methods: This single-centre prospective study recruited a convenience sample of unselected ED patients triaged as category 2 (Emergency) and 3 (Urgent). Receiver Operating Characteristic analyses were performed to determine the Area Under the Curve (AUC), along with sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios for the various scores. Results: Of 1253 patients recruited, overall 30-day mortality was 5.7%. The prognostic value for prediction of 30-day mortality, with AUCs for qSOFA !2, SIRS !2, NEWS !5, qSIRS (qSOFA þ SIRS) !2 and NSIRS (NEWS þ SIRS) !5 of 0.56 (95%CI 0.53-0.58), 0.61 (95%CI 0.58-0.64), 0.61 (95%CI 0.58-0.64), 0.64 (95%CI 0.62-0.67) and 0.61 (95%CI 0.58-0.63), respectively. Using pairwise comparisons of ROC curves, NEWS !5 and qSIRS !2 were better than qSOFA !2 at predicting 30-day mortality. Conclusions: Among unselected emergency and urgent ED patients, the prognostic value for NEWS and qSIRS were greater than qSOFA, Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients. KEY MESSAGES NEWS !5 and qSIRS !2 were better than qSOFA !2 at predicting 30-day mortality in ED patients. Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients.
BackgroundSoft tissue injuries commonly present to the emergency department (ED), often with acute pain. They cause significant suffering and morbidity if not adequately treated. Paracetamol and ibuprofen are commonly used analgesics, but it remains unknown if either one or the combination of both is superior for pain control.ObjectivesTo investigate the analgesic effect of paracetamol, ibuprofen and the combination of both in the treatment of soft tissue injury in an ED, and the side effect profile of these drugs.MethodsDouble-blind, double dummy, placebo-controlled randomised controlled trial. 782 adult patients presenting with soft tissue injury without obvious fractures attending the ED of a university hospital in the New Territories of Hong Kong were recruited. Patients were randomised using a random number table into three parallel arms of paracetamol only, ibuprofen only and a combination of paracetamol and ibuprofen in a 1:1:1 ratio. The primary outcome measure was pain score at rest and on activity in the first 2 hours and first 3 days. Data was analysed on an intention to treat basis.ResultsThere was no statistically significant difference in pain score in the initial two hours between the three groups, and no clinically significant difference in pain score in the first three days.ConclusionThere was no difference in analgesic effects or side effects observed using oral paracetamol, ibuprofen or a combination of both in patients with mild to moderate pain after soft tissue injuries attending the ED.Trial registrationThe study is registered with ClinicalTrials.gov (no. NCT00528658).
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A short-cut review was carried out to establish the diagnostic accuracy of blood biomarkers as an alternative to imaging for the diagnosis of ischaemic stroke. Nine studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that that blood biomarkers are currently not suitable for the diagnosis of acute ischaemic stroke.
would increase the ED discharge rate and shorten ED length of stay for admitted patients.Methods: We performed a before and after study assessing the disposition of all patients > 35 years old who all patients presenting with chest pain or tightness to 2 hospitals who received a troponin in the ED. Prior to transition to the Roche 5 th generation troponin T (hsTnT), we conducted 2 town halls, in-services with EM, cardiology, emergency medicine and distributed a slide set to all providers. Expert physician advice was also made available to facilitate decisionmaking on an as needed basis. We used a 0-and 2-hour sampling strategy (unless the first value was <6 ng/L) and used cut-points of 19 and 53ng/L to define "ruled out" or "consistent with AMI." Indeterminate values were to be repeated every 2 hours, with rules for delta values provided to the treating care team. Data were collected for 1 year prior to and 2 months after transition to hsTnT. Our main outcome was disposition decision from the ED. Secondary outcome was time from presentation to admission/observation decision (out of concern that more discharges might result in longer ED stays). We present comparisons with 95% confidence intervals (CI) and standard statistical testing.Results: There were 5,234 presentations from 4,295 patients during the preperiod, and 831 presentations from 769 patients in the after period that met study criteria. They were similar with respect to age groups (73.8% versus 75.6% ages 36-64 respectively, p¼0.27), and race (39% white versus 41% white, p¼0.29), but the pre period had fewer males (51% male versus 54 % male, p¼0.02). Compared to the pre-period, after hsTnT conversion, the discharge rate increased (58.7% [55.3-62.2%] v 45.2% [43.8-46.6%] ; p<0.001) without a change in the median time to disposition decision for admitted/obs patients (199.75 min [192.2-207.7] v 199.1 min [177.1-221.8 ]; p¼0.96).Conclusions: The transition hsTnT resulted in an increased number of patients being discharged without increasing the time to admission/obs decision.
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