Article

The comparison of early identification scores in sepsis

Correspondence / American Journal of Emergency Medicine 38 (2020) 827848 845

Norihiko Tsuchiya 2

Department of Urology, Yamagata University Faculty of Medicine,

Yamagata, Japan E-mail addresses: [email protected]

Received 17 September 2019

Accepted 19 September 2019 https://doi.org/10.1016/j.ajem.2019.09.017

References

  1. Fukuhara H, Ichiyanagi O, Midorikawa S, Kakizaki H, Kaneko H, Tsuchiya N. Internal val- idation of a scoring system to evaluate the probability of Ureteral stones: the CHOKAI score. Am J Emerg Med 2017;35:1859-66. https://doi.org/10.1016/j.ajem.2017.06.023.
  2. Fukuhara H, Kobayashi T, Takai S, et al. External validation of the CHOKAI score for the prediction of ureteral stones: a Multicenter prospective observational study. Am J Emerg Med 2019. https://doi.org/10.1016/j.ajem.2019.07.018.

    The comparison of early identification scores in sepsis

    1. Discussion

    We appreciate the review of our article [1] comparing Systemic In- flammatory Response Syndrome (SIRS), Sepsis-related Organ Failure Assessment (qSOFA), and the National Early Warning Score for the early identification of severe sepsis and septic shock (SS/SS) in the Emergency Department. However, the concerns raised were, in gen- eral, beyond the scope of our study.

    First, we agree that the comparison to the Thrombosis and Inflam- mation Based Score (TIPS) [2] developed by Li et al. would be interesting and worth investigating. However, similar to several other scoring sys- tems that did not receive a comprehensive evaluation, the TIPS consists of laboratory values (i.e. procalcitonin and D-dimer). Our intended goal was the detection of sepsis at the time of triage. Therefore, we limited our comparison to scores that did not largely rely on laboratory values and focused on parameters that were routinely collected at the time of triage (e.g. vital signs). The TIPS not only relies on laboratory values, but procalcitonin and D-dimer were not routinely collected for our sep- tic patient cohort nor the cohort in general upon arrival to the ED. Sub- sequent studies with a broader scope could include the TIPS score for comparison and would be worthwhile.

    Second, we did not report “results of clinical classical evaluation score, SOFA and APACHE II, about predicting sepsis-related death.” Again, our paper was not a systematic review of the existing scores and our stated goal was to detect sepsis at the time of triage; therefore, comparison to the Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores was out of scope. There are many previous studies that have evaluated the APACHE II and SOFA scores for predicting sepsis-related mortality [3-5]. We did conduct a comparison of the existing components of sev- eral classic sepsis scores in Table 1 of our paper, including the Mortality in Emergency Department (MEDS), SOFA, Multiple organ dysfunction Score (MODS), APACHE II, and Simplified Acute Physiology Score II (SAPS II); however, this table meant to serve as an illustration for why these scoring systems were not viable as early predictors for sepsis in an ED triage setting due to the timing of their constituent variables.

    Third, we did not evaluate the secondary endpoints of 1) mechanical ventilation, 2) ICU admission, and 3) other long-term follow-ups. Me- chanical ventilation and ICU admission are important prognostic out- comes and it is a fair comment that we could have included these endpoints in our analysis. The primary outcome we evaluated was the diagnosis of severe sepsis and septic shock (SS/SS). Secondary outcomes

    2 Department of Urology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, Yamagata city, Yamagata Prefecture, 998-9585, Japan.

    we evaluated were (1) septic shock, (2) sepsis-related mortality, and 3) All-cause in-hospital mortality. Our overall goal in this study was to aid in the early identification of sepsis diagnosis. Detection of sepsis at tri- age may aid the clinician in initiating the mainstays of sepsis treatment: fluids, early antibiotics, source control, and cardiopulmonary optimiza- tion. On the other hand, mechanical ventilation, requires a different evaluation and a separate set of variables. Of note, our main conclusion was that NEWS was the most accurate scoring system for the detection of all sepsis endpoints compared to SIRS and qSOFA. We conjecture that NEWS would also outperform SIRS and qSOFA in the prediction of me- chanical ventilation as it includes the level of consciousness, any supple- mental oxygen, oxygen saturation, and a finer gradation of respiratory rate-all variables that are important in the prediction of mechanical ventilation. Unfortunately, data on additional long-term follow up were not available in this retrospective cohort.

    Finally, it was noted that the three scores (SIRS, qSOFA and NEWS) in

    Table 2 are not normally distributed and should not be presented as mean (SD). This is an astute and fair point; if presented again, we would have reported medians and interquartile ranges (IQR). However, we disagree that difference tests should be recalculated. The purpose of Table 2 was to compare “Included patients” (n = 115,734) with “Pa- tients with SS/SS” (n = 930) and we correctly report that these two groups differ in the three scores with p-values of b0.001. According to the Central Limit Theorem, given the large size of our groups, these scores approximate to the normal distribution regardless of the under- lying distribution and a z-test would be appropriate.

    Author contributions

    MAW and OAU wrote the body of the response and all authors con- tributed substantially to its revision.

    Declaration of Competing Interest

    OAU reports no conflict of interest. AAU reports no conflict of inter- est. MAW reports no conflict of interest.

    Omar A. Usman

    Medical Service, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo

    Alto, CA 94304, United States E-mail address: [email protected].

    Asad A. Usman Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, United States E-mail address:[email protected].

    Michael A. Ward Department of EmergencyMedicine, University of Wisconsin-Madison, 800 University Dr. Suite 310, Madison, WI 53705, United States Corresponding author at: 800 University Dr., Suite 310, Madison, WI

    53705, United States.

    E-mail address: [email protected].

    2 October 2019

    https://doi.org/10.1016/j.ajem.2019.10.008

    References

    Usman OA, Usman AA, Ward MA. Comparison of SIRS, qSOFA, and NEWS for the early iden- tification of sepsis in the Emergency Department. The. Am J Emerg Med 2019;37:1490-7.

  3. Li D, Zhou Y, Yu J, Yu H, Xia Y, Zhang L, et al. Evaluation of a novel prognostic score based on thrombosis and inflammation in patients with sepsis: a retrospective cohort study. Clin Chem Lab Med (CCLM) 2018;56:1182-92. https://doi.org/10.1515/cclm-2017-0863.

    846 Correspondence / American Journal of Emergency Medicine 38 (2020) 827848

    Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system. risk prediction of hospital mortality for critically ill hospital- ized adults. Chest 1991;100:1619-36. https://doi.org/10.1378/chest.100.6.1619.

  4. Macdonald SPJ, Arendts G, Fatovich DM, Brown SGA. Comparison of PIRO, SOFA, and MEDS scores for Predicting Mortality in Emergency Department Patients With Severe Sepsis and Septic Shock. Acad Emerg Med 2014;21:1257-63. https://doi.org/10.1111/acem.12515.
  5. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis- 3). JAMA 2016;315:801. https://doi.org/10.1001/jama.2016.0287.

    The comparison ofearly identification scores in sepsis

    To the Editor,

    We have read the article by Usman et al. [1] with great interest pub- lished in American Journal of Emergency Medicine. The authors compared quick Sepsis-related Organ Failure Assessment , Systemic In- flammatory Response Syndrome (SIRS), and the National Early Warning Score for identification of severe sepsis and septic shock (SS/ SS). NEWS was found to be the most accurate score for evaluation of sepsis endpoints. This is quite inspiring because it is very important to use simple risk stratification tools during Emergency Department triage. However, some concerns seem to be interpreted.

    Firstly, we totally agree with the author’s insight that early risk iden- tification for sepsis patients is crucial. Indeed, in our previous study, we developed an thrombosis and inflammation based score (TIPS) to iden- tified outcomes of sepsis patients [2]. The TIPS was consisted of two in- flammatory thrombosis indicators (procalcitonin and D-dimer) and its predicting ability was similar to the Acute Physiology and Chronic Health Evaluation II (APACHE II). Furthermore, we found that the C- index for TIPS was significantly better than modified early warning score (0.713 vs. 0.629, P b 0.001) to assess sepsis 28 day mor- tality. Thus, we deem that the comparison between TIPS and these 3 simple screening scores in this article would be very interesting and worth investigating.

    Secondly, one drawback is that the results of clinical classical evalu- ation score, SOFA and APACHE II, about predicting sepsis-related death were not given in this study. Same regret is the in-hospital complication such as mechanical ventilation, admitted to ICU, were also not analyzed. The results of long-term follow-up are also expected.

    Thirdly, it seems that the three scores (SIRS, qSOFA and NEWS) in Table 2 were not normal distributed. Maybe it shouldn’t be pre- sented as mean (SD), and the difference test was suggests recalculation.

    Declaration of Competing Interest

    None.

    Acknowledgement

    This work was supported financially by grants from National Clinical Research Center for Geriatrics, West China hospital, Sichuan University (Z20191009); Sichuan Science and Technology Program (No. 2019JDRC0105, 2018RZ0139, and 2017SZ0190); 1o3o5 Project for Disci- plines of Excellence-Clinical Research Incubation Project, Sichuan Uni- versity West China Hospital (No. 2018HXFH001, and 2018HXFH027).

    Yisong Cheng

    Yu Jia Dongze Li*

    Department of Emergency Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China

    *Corresponding author.E-mail address: [email protected] (D. Li) https://doi.org/10.1016/j.ajem.2019.10.009

    References

    Usman OA, Usman AA, Ward MA. Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department. Am J Emerg Med 2019;37(8): 1490-7. https://doi.org/10.1016/j.ajem.2018.10.058.

  6. Li D, Zhou Y, Yu J, et al. Evaluation of a novel prognostic score based on thrombosis and inflammation in patients with sepsis: a retrospective cohort study. Clin Chem Lab Med 2018;56(7):1182-92. https://doi.org/10.1515/cclm-2017-0863.

    Selling poison by the bottle: Availability of dangerous substances found on eBay(R)

    During the 19th century, many new poisonous substances came onto the market to aid in controlling undesirable plant life and pests, for use as cleaning agents, and for medicinal purposes [1]. Poison bottles were often made with distinctive coloring and/or patterns or marked with certain raised shapes in order to warn individuals of the contents and to make adults aware of the necessity to keep them away from children [1]. While this warning was necessary, it wasn’t until the 1930s that medical and other professionals realized these attributes actually made the bottles more attractive to children, thus resulting in the adoption of utilizing less embellished, clear bottles with safer, child resistant lids [1,2]. The older bottles with unique markings and colors make these antique items desir- able to modern day collectors. There are forums and websites that make these bottles easily accessible to the public and it has been previously found that these poisonous product containers are readily available [3]. Many of these bottles still hold their original contents. The common prac- tice of selling full or partially full poison bottles places people at risk for se- rious poisonings following unintentional or intentional exposures [3]. Our objective was to quantify the wide variety of dangerous poisons for sale to the general public on a popular online auction Web site.

    Over an 8-month period in 2018-2019, weekly listings on the online

    auction Web site eBay(R) were searched using the term ”poison bottles”. Products advertised as containing any of their original contents were in- cluded. Exclusion criteria were listings in which the seller stated that the original contents would be discarded prior to shipping. Product name, toxic ingredient(s), the amount of the product in the container, and relative toxicity rating were recorded using structured abstraction forms. Toxicity ratings were based on known median oral lethal dose (LD50) of each ingre- dient and determined by The National Institute for Occupational Safety and Health (NIOSH) data and statistics and Clinical Toxicology of Commercial Prod- ucts [4,5]. Descriptive statistics were used to summarize the data.

    A total of 283 individual products were identified during the study pe- riod; 140 (49%) were liquids, 84 (30%) were in solid/tablet form, and 59 (21%) were powders. Bottles were full for 136 items (48%) and partially full for the remaining 147. At least 31 (11%) of the containers were de- scribed by the seller as cracked or poorly sealed. Overall, 155 products (55%) contained 33 ingredients rated as “extremely toxic” (Table 1). Ex- amples include barium, cyanide, mercury, and morphine. Eighty-one products (29%) were rated as “moderately toxic” with an LD50 from 50 to 500 mg/kg. These products included digitalis, homatropine, silver ni- trite, and warfarin. The remaining 47 products contained ingredients that were classified as ”moderately-slightly toxic” with LD50 of 500 mg/ kg or greater. Examples of these include adrenalin, ammonia, and iodine. Overall, poisons for sale included heavy metals (arsenic, mercury, lead), controlled substances (codeine, morphine), pharmaceutical grade toxins (strychnine, pilocarpine), insecticides (nicotine), herbal extracts (henbane, hemlock) and beauty aids (belladonna, scopol-

    amine). Sellers included both private individuals and businesses.

    While the products we identified were, in most cases, advertised as being sold for the nostalgic appeal of their containers, as a previous study mentioned there is no guarantee that purchasers of these products would not irresponsibly discard the contents or use them in some way [3]. Given the results of this and other observational studies, closer scrutiny of the existing rules, protocols, and guidelines regarding the sale of poison-

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