- Email: [email protected]
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Research Forum Abstracts rhythm-control medication (8%, class I antiarrhythmics; 6%, class III antiarrhythmics; and 11%, Sotalol) and 73% were taking rate-control medication (53%, beta blockers; 23%, calcium channel blockers; and 13%, digoxin). Overall, AF converted to SR in significantly more patients given RSD1235 than were given placebo, regardless of whether they received background medication (51.1% vs 3.8%; P⬍ .0001). The AF-to-SR conversion effect of RSD1235 was not affected by use of beta blockers or calcium channel blockers (Table). RSD1235 was numerically more efficacious in patients who were taking sotalol and numerically less efficacious in those taking digoxin or class I or III antiarrhythmics. Because the numbers of patients taking these medications were small, further study is necessary to determine the clinical significance of these findings. The background use of rate- or rhythm-control medications did not affect the incidence of adverse events. Conclusions: RSD1235 effectively converted acute AF lasting 3 h to 7 d to SR in patients who used concomitant oral rate- or rhythm-control medication.
variable were: terminal illness ⫽ 4.4 (95% CI: 1.5-12.8); tachypnea or hypoxia ⫽ 3.2 (95% CI: 1.0-9.9); presence of septic shock ⫽ 6.1 (95% CI: 2.2-16.6); platelet count ⬍ 150,000 cells/mm 3 ⫽ 6.3 (95% CI: 2.4-16.9); band percentage ⬎ 5 ⫽ 3.7 (95% CI: 1.3-10.7); age ⬎ 65 years ⫽ 2.0 (95% CI: 0.8-5.0); lower respiratory tract infection ⫽ 1.6 (95% CI: 0.6-4.1); nursing home resident ⫽ 1.3 (95% CI: 0.5-3.5); and altered mental status ⫽ 4.9 (95% CI: 1.9-12.8). Serum lactate concentrations were available for 105 (45%) patients, and the median concentration was 2.5 (IQR: 1.5 - 4.2; range 0.6 - 20.0) mmol/L. A score of 0 was assigned for a lactate concentrations ⬍ 4 mmol/L, 1 for concentrations ranging from 4 to 8 mmol/L, and 2 for concentrations ⬎ 8 mmol/L. The AUC for the modified MEDS Score was 0.92 (95% CI: 0.82 - 1.0) and the AUC for the original MEDS Score was 0.87 (95% CI: 0.82 - 0.92). Conclusions: The modified MEDS Score demonstrated a slight, but not significant, improvement in the prediction of mortality in patients who present to the ED with sepsis.
150
Is the Mortality in Emergency Department Sepsis (MEDS) Score Reliably Applied by Emergency Physicians?
Sankoff J, Haukoos J/University of Colorado Health Sciences Center, Denver, CO; Denver Health and Hospital Authority, Denver, CO
149
Predictive Accuracy of a Sepsis-Related Mortality Score in the Emergency Department: A Modification of the Mortality in Emergency Department Sepsis (MEDS) Score
Sankoff J, Deitch K, Goyal M, Gaieski DF, Haukoos J/University of Colorado Health Sciences Center, Denver, CO; Albert Einstein Medical Center, Philadelphia, PA; Hospital of the University of Pennsylvania, Philadelphia, PA; Denver Health and Hospital Authority, Denver, CO
Background: Sepsis is a leading cause of mortality in critically ill patients who present to the emergency department (ED). Recent diagnostic, resuscitative, and therapeutic advances have led to modest improvements in outcomes of patients with sepsis. Prediction of mortality has been difficult and limited by use of scoring systems that require data acquired after hospitalization. The previously derived and validated MEDS Score provides emergency physicians with a relatively simple predictive score that uses nine clinical variables available in the ED and that predicts 28-day mortality at the time of ED presentation. Study Objective: To determine if different weighting of MEDS Score variables and the inclusion of serum lactate concentration would improve the MEDS Score’s predictive accuracy. Methods: This was a prospective cohort study performed at two university-based hospitals and one urban county hospital. Patients were enrolled if they met the definition for the systemic inflammatory response syndrome or for sepsis as outlined by the American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) Consensus Conference and were admitted to the hospital. Each MEDS Score variable was collected in the ED and the primary outcome (28-day mortality) was ascertained prospectively. Odds ratios were calculated for each of the individual MEDS Score variables with respect to mortality and were used to modify the weight of each MEDS Score variable. Serum lactate concentrations were collected and incorporated into the modified score. Test performance of the modified MEDS Score was assessed using the area under the receiver operating characteristic curve (AUC) and compared to the original MEDS Score. Results: A total of 235 patients were enrolled in this study and the overall mortality rate was 9% (95% CI: 5% - 13%). Odds ratios for each MEDS Score
Volume , . : October
Background: Sepsis is a leading cause of death among critically ill patients who present to the emergency department (ED). New therapies and management strategies have emerged that have demonstrated a modest survival benefit for patients with sepsis, especially when initiated early in their disease courses. Until recently, no specific criteria have existed that predict short-term mortality in patients with sepsis using data available in the ED. The MEDS Score was derived and validated in order to provide emergency physicians with the ability to risk stratify such patients early in their disease courses. This score is based on easily identifiable historical, physical, and laboratory findings available in the ED that in sum predict 28-day mortality. However, for this score to be useful, it must not only be accurate but must also be consistently applied by emergency physicians. Study Objective: To assess agreement of the overall MEDS Score and its nine individual components when applied by emergency physicians. Methods: This was a prospective-retrospective cohort study performed at a university-based, tertiary care medical center as part of a larger multi-centered prospective study to validate the MEDS Score. Eligible patients had to meet the definitions for the systemic inflammatory response syndrome (SIRS) or for sepsis as outlined by the American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) Consensus Conference. The treating emergency physician completed a closed-response data collection instrument indicating the presence or absence of the nine MEDS Score criteria (i.e., terminal illness, tachypnea or hypoxia, septic shock, platelet count ⬍ 150,000 cells/mm 3, band percentage ⬎ 5, age ⬎ 65 years, lower respiratory tract infection, nursing home resident, and altered mental status). Each medical record was then reviewed by a blinded investigator and each MEDS Score variable was ascertained. Tests of agreement were performed for the overall score as well as each of its individual components. Results: Seventy-five patients were included in this part of the study. The spearman rank correlation coefficient for the overall MEDS Score was 0.93 (95% CI: 0.86-0.97). Kappa coefficients for the nine MEDS Score variables ranged from 0.641.0 (95% CI: 0.40-1.0). The presence or absence of a terminal illness had the lowest kappa values (0.64). The presence or absence of bandemia had a kappa value of 0.82, and the remaining variables all had kappa values that exceeded 0.9. Conclusion: The MEDS Score is relatively reliable when applied by emergency physicians. Modification of the score to exclude the presence or absence of a terminal illness may improve overall inter-rater reliability of this score.
151
A Prospective Clinical Trial Evaluating Urinary 5Hydroxyindoleacetic Acid (5HIAA) Levels in the Diagnosis of Acute Appendicitis
Hernandez R, Jain A, Rosiere L, Henderson S/LAC-USC Medical Center, Los Angeles, CA
Study Objectives: To investigate the role of urinary 5HIAA in diagnosing acute appendicitis. Diagnosis of acute appendicitis, the most common specific etiology of an acute abdomen in the United States, is based on clinical presentation and physical
Annals of Emergency Medicine S47
variable were: terminal illness ⫽ 4.4 (95% CI: 1.5-12.8); tachypnea or hypoxia ⫽ 3.2 (95% CI: 1.0-9.9); presence of septic shock ⫽ 6.1 (95% CI: 2.2-16.6); platelet count ⬍ 150,000 cells/mm 3 ⫽ 6.3 (95% CI: 2.4-16.9); band percentage ⬎ 5 ⫽ 3.7 (95% CI: 1.3-10.7); age ⬎ 65 years ⫽ 2.0 (95% CI: 0.8-5.0); lower respiratory tract infection ⫽ 1.6 (95% CI: 0.6-4.1); nursing home resident ⫽ 1.3 (95% CI: 0.5-3.5); and altered mental status ⫽ 4.9 (95% CI: 1.9-12.8). Serum lactate concentrations were available for 105 (45%) patients, and the median concentration was 2.5 (IQR: 1.5 - 4.2; range 0.6 - 20.0) mmol/L. A score of 0 was assigned for a lactate concentrations ⬍ 4 mmol/L, 1 for concentrations ranging from 4 to 8 mmol/L, and 2 for concentrations ⬎ 8 mmol/L. The AUC for the modified MEDS Score was 0.92 (95% CI: 0.82 - 1.0) and the AUC for the original MEDS Score was 0.87 (95% CI: 0.82 - 0.92). Conclusions: The modified MEDS Score demonstrated a slight, but not significant, improvement in the prediction of mortality in patients who present to the ED with sepsis.
150
Is the Mortality in Emergency Department Sepsis (MEDS) Score Reliably Applied by Emergency Physicians?
Sankoff J, Haukoos J/University of Colorado Health Sciences Center, Denver, CO; Denver Health and Hospital Authority, Denver, CO
149
Predictive Accuracy of a Sepsis-Related Mortality Score in the Emergency Department: A Modification of the Mortality in Emergency Department Sepsis (MEDS) Score
Sankoff J, Deitch K, Goyal M, Gaieski DF, Haukoos J/University of Colorado Health Sciences Center, Denver, CO; Albert Einstein Medical Center, Philadelphia, PA; Hospital of the University of Pennsylvania, Philadelphia, PA; Denver Health and Hospital Authority, Denver, CO
Background: Sepsis is a leading cause of mortality in critically ill patients who present to the emergency department (ED). Recent diagnostic, resuscitative, and therapeutic advances have led to modest improvements in outcomes of patients with sepsis. Prediction of mortality has been difficult and limited by use of scoring systems that require data acquired after hospitalization. The previously derived and validated MEDS Score provides emergency physicians with a relatively simple predictive score that uses nine clinical variables available in the ED and that predicts 28-day mortality at the time of ED presentation. Study Objective: To determine if different weighting of MEDS Score variables and the inclusion of serum lactate concentration would improve the MEDS Score’s predictive accuracy. Methods: This was a prospective cohort study performed at two university-based hospitals and one urban county hospital. Patients were enrolled if they met the definition for the systemic inflammatory response syndrome or for sepsis as outlined by the American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) Consensus Conference and were admitted to the hospital. Each MEDS Score variable was collected in the ED and the primary outcome (28-day mortality) was ascertained prospectively. Odds ratios were calculated for each of the individual MEDS Score variables with respect to mortality and were used to modify the weight of each MEDS Score variable. Serum lactate concentrations were collected and incorporated into the modified score. Test performance of the modified MEDS Score was assessed using the area under the receiver operating characteristic curve (AUC) and compared to the original MEDS Score. Results: A total of 235 patients were enrolled in this study and the overall mortality rate was 9% (95% CI: 5% - 13%). Odds ratios for each MEDS Score
Volume , . : October
Background: Sepsis is a leading cause of death among critically ill patients who present to the emergency department (ED). New therapies and management strategies have emerged that have demonstrated a modest survival benefit for patients with sepsis, especially when initiated early in their disease courses. Until recently, no specific criteria have existed that predict short-term mortality in patients with sepsis using data available in the ED. The MEDS Score was derived and validated in order to provide emergency physicians with the ability to risk stratify such patients early in their disease courses. This score is based on easily identifiable historical, physical, and laboratory findings available in the ED that in sum predict 28-day mortality. However, for this score to be useful, it must not only be accurate but must also be consistently applied by emergency physicians. Study Objective: To assess agreement of the overall MEDS Score and its nine individual components when applied by emergency physicians. Methods: This was a prospective-retrospective cohort study performed at a university-based, tertiary care medical center as part of a larger multi-centered prospective study to validate the MEDS Score. Eligible patients had to meet the definitions for the systemic inflammatory response syndrome (SIRS) or for sepsis as outlined by the American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) Consensus Conference. The treating emergency physician completed a closed-response data collection instrument indicating the presence or absence of the nine MEDS Score criteria (i.e., terminal illness, tachypnea or hypoxia, septic shock, platelet count ⬍ 150,000 cells/mm 3, band percentage ⬎ 5, age ⬎ 65 years, lower respiratory tract infection, nursing home resident, and altered mental status). Each medical record was then reviewed by a blinded investigator and each MEDS Score variable was ascertained. Tests of agreement were performed for the overall score as well as each of its individual components. Results: Seventy-five patients were included in this part of the study. The spearman rank correlation coefficient for the overall MEDS Score was 0.93 (95% CI: 0.86-0.97). Kappa coefficients for the nine MEDS Score variables ranged from 0.641.0 (95% CI: 0.40-1.0). The presence or absence of a terminal illness had the lowest kappa values (0.64). The presence or absence of bandemia had a kappa value of 0.82, and the remaining variables all had kappa values that exceeded 0.9. Conclusion: The MEDS Score is relatively reliable when applied by emergency physicians. Modification of the score to exclude the presence or absence of a terminal illness may improve overall inter-rater reliability of this score.
151
A Prospective Clinical Trial Evaluating Urinary 5Hydroxyindoleacetic Acid (5HIAA) Levels in the Diagnosis of Acute Appendicitis
Hernandez R, Jain A, Rosiere L, Henderson S/LAC-USC Medical Center, Los Angeles, CA
Study Objectives: To investigate the role of urinary 5HIAA in diagnosing acute appendicitis. Diagnosis of acute appendicitis, the most common specific etiology of an acute abdomen in the United States, is based on clinical presentation and physical
Annals of Emergency Medicine S47