The Association of qSOFA, SOFA, and SIRS with Mortality in Emergency Department Pneumonia

Objective: To determine the association between 30-day mortality with Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), and quick SOFA (qSOFA) in emergency department patients with pneumonia. Secondary outcomes included the association of sepsis scores with hospital admission and direct ICU admission. Methods: This is a secondary analysis of a pneumonia population conducted in the emergency department of 3 tertiary care medical centers and 4 community hospitals. Adult immunocompetent patients diagnosed with pneumonia were included from 3 twelve-month periods spanning December 2009 to October 2015. We generated area under the receiver operating characteristic curve (AUC) values for each sepsis score for our primary outcome of 30-day mortality and secondarily for hospital admission and direct ICU admission. We also created logistic regression models to assess associations of individual score components to the outcomes. Results:We studied 6931 patients with mean (SD) age 58 (20) years, and 30 day all-cause mortality rate 7%. Hospital and ICU admission rate was 63% and 16% respectively. Sepsis by SIRS was present in 70% of patients. Only respiratory rate and white blood count of the SIRS criteria were associated with 30-day mortality (OR=2.42 [1.94, 3.03] and 2.06 [1.68, 2.54] respectively, both p Conclusions: In emergency department patients with pneumonia, qSOFA outperformed SIRS in relation to 30-day mortality. Secondary outcomes also showed better performance of qSOFA in hospital and ICU admission compared to SIRS. SOFA performed better than qSOFA and SIRS for all outcomes except ICU admission

Defective Presynaptic Choline Transport Underlies Hereditary Motor Neuropathy

The neuromuscular junction (NMJ) is a specialized synapse with a complex molecular architecture that provides for reliable transmission between the nerve terminal and muscle fiber. Using linkage analysis and whole-exome sequencing of DNA samples from subjects with distal hereditary motor neuropathy type VII, we identified a mutation in SLC5A7, which encodes the presynaptic choline transporter (CHT), a critical determinant of synaptic acetylcholine synthesis and release at the NMJ. This dominantly segregating SLC5A7 mutation truncates the encoded product just beyond the final transmembrane domain, eliminating cytosolic-C-terminus sequences known to regulate surface transporter trafficking. Choline-transport assays in both transfected cells and monocytes from affected individuals revealed significant reductions in hemicholinium-3-sensitive choline uptake, a finding consistent with a dominant-negative mode of action. The discovery of CHT dysfunction underlying motor neuropathy identifies a biological basis for this group of conditions and widens the spectrum of disorders that derive from impaired NMJ transmission. Our findings compel consideration of mutations in SLC5A7 or its functional partners in relation to unexplained motor neuronopathies

Pneumococcal urinary antigen test use in diagnosis and treatment of pneumonia in seven Utah hospitals

The pneumocococcal urine antigen test increases specific microbiological diagnosis over conventional culture methods in pneumonia patients. Data are limited regarding its yield and effect on antibiotic prescribing among patients with community-onset pneumonia in clinical practice. We performed a secondary analysis of 2837 emergency department patients admitted to seven Utah hospitals over 2 years with international diagnostic codes version 9 codes and radiographic evidence of pneumonia. Mean age was 64.2 years, 47.2% were male and all-cause 30-day mortality was 9.6%. Urinary antigen testing was performed in 1110 (39%) patients yielding 134 (12%) positives. Intensive care unit patients were more likely to undergo testing, and have a positive result (15% versus 8.8% for ward patients; p<0.01). Patients with risk factors for healthcare-associated pneumonia had fewer urinary antigen tests performed, but 8.4% were positive. Physicians changed to targeted antibiotic therapy in 20 (15%) patients, de-escalated antibiotic therapy in 76 patients (57%). In 38 (28%) patients, antibiotics were not changed. Only one patient changed to targeted therapy suffered clinical relapse. Length of stay and mortality were lower in patients receiving targeted therapy. Pneumococcal urinary antigen testing is an inexpensive, noninvasive test that favourably influenced antibiotic prescribing in a “real world”, multi-hospital observational study

Patient demographics and baseline characteristics.

All data reported as median (interquartile range) or n(%) unless specified otherwise.</p

Gram stain results for blood, respiratory, and urine cultures of patients with positive culture results.

Gram stain results for blood, respiratory, and urine cultures of patients with positive culture results.</p

Odds ratios and log odds coefficients from the best performing models to predict septic cardiomyopathy (SCM) and sepsis-related cardiogenic shock (SeRCS) within a cohort of patients with septic shock.

Odds ratios and log odds coefficients from the best performing models to predict septic cardiomyopathy (SCM) and sepsis-related cardiogenic shock (SeRCS) within a cohort of patients with septic shock.</p

Most frequently occurring features sets, where the feature set length was greater than one for predicting septic cardiomyopathy (SCM) and sepsis-related cardiogenic shock (SeRCS).

Most frequently occurring features sets, where the feature set length was greater than one for predicting septic cardiomyopathy (SCM) and sepsis-related cardiogenic shock (SeRCS).</p