Search

Background Epidemiologic studies are needed for monitoring population-level trends in sepsis. This study examines sepsis-causing microorganisms from 2006 to 2014 in the United States using data from the Nationwide Inpatient Sample database. Methods 7 860 686 adults hospitalized with sepsis were identified using a validated ICD-9 coding approach. Associated microorganisms were identified by ICD-9 code and classified by major groups (Gram-positive, Gram-negative, fungi, anaerobes) and specific species for analysis of their incidence and mortality. Results The rate of sepsis incidence has increased for all four major categories of pathogens, while the mortality rate decreased. In 2014, Gram-negative pathogens had a higher incidence than Gram-positives. Anaerobes increased the fastest with an average annual increase of 20.17% (p Conclusions Gram-negative pathogens have replaced Gram-positives as the leading cause of sepsis in the United States in 2014 during the study period (2006-2014). The incidence of anaerobic sepsis has an annual increase of 20%, while the mortality of fungal sepsis has not decreased at the same rate as other microorganisms. These findings should inform the diagnosis and management of septic patients, as well as the implementation of public health programs.

OBJECTIVES: Acute bronchiolitis commonly causes respiratory failure in children ≤ 2 years, and is particularly severe in those with Down syndrome (DS). Obstructive sleep apnea (OSA), common in DS, is also associated with respiratory complications. However, it is unknown whether OSA is associated with worse outcomes in children with and without DS, hospitalized with bronchiolitis. We hypothesized that in children with bronchiolitis, OSA is associated with worse outcomes in those with DS, independent of DS-related comorbidities. METHODS: Hospital discharge records of children with bronchiolitis aged ≤ 2 years were obtained for 1997–2012 from the Kid’s Inpatient Database. The primary outcome was invasive mechanical ventilation (IMV), and secondary outcomes were non-invasive mechanical ventilation (NIMV), length of hospital stay, and inflation-adjusted cost of hospitalization (IACH). Multivariable regression was conducted to ascertain the associations between OSA and primary and secondary outcomes accounting for DS-associated comorbidities. RESULTS: There were 928,961 hospitalizations for bronchiolitis. The DS group with bronchiolitis (n=8,697) was more likely to have OSA [241 (2.77%) vs 1,293 (0.14%), p

Objective Ultrasound has an excellent diagnostic accuracy for fractures that is reportedly comparable to plain radiographs. We aim to summarize the diagnostic accuracy of ultrasound for upper extremity fractures in children. Methods Databases were searched from inception through November 2019 using pre-defined index terms, including “ultrasound,” “fractures of upper extremities” and “children”. The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for fractures was conducted using the random-effects bivariate model. Subgroup analysis of fracture site (elbow vs non-elbow fractures) was also performed. Meta-regression was performed to determine if the site of fracture affected the diagnostic accuracy. Results Thirty-two studies were identified in the meta-analysis. Ultrasound for fractures of the upper extremities has a sensitivity: 0.95 (95% CI: 0.93–0.97), specificity: 0.95 (95% CI: 0.91–0.98), positive likelihood ratio: 21.1 (95% CI: 10.8–41.5) and negative likelihood ratio: 0.05 (95% CI: 0.03–0.07), with an area under ROC (AUROC) curve of 0.98 (95% CI: 0.97–0.99). Subgroup analysis for elbow fracture showed ultrasound has a sensitivity: 0.95 (95% CI: 0.86–0.98), specificity: 0.87 (95% CI: 0.76–0.94), positive likelihood ratio: 7.3 (95% CI: 3.7–14.4) and negative likelihood ratio: 0.06 (95% CI: 0.02–0.16), with an AUROC of 0.96 (95% CI: 0.94–0.97). Meta-regression suggested the fracture sites would affect diagnostic accuracy of ultrasound (elbow vs non-elbow, p Conclusions Current evidence suggests ultrasound has excellent diagnostic accuracy for non-elbow upper extremity fractures in children, serving as an alternative diagnostic modality to plain radiographs.

OBJECTIVE To determine the impact of obstructive sleep apnea (OSA) on asthma exacerbation severity in children hospitalized for asthma exacerbation. HYPOTHESIS OSA is associated with greater use of invasive mechanical ventilation (IMV) and noninvasive mechanical ventilation (NIMV) in children hospitalized for asthma exacerbation. STUDY DESIGN A retrospective cohort study. PATIENT-SUBJECT SELECTION Hospitalization records of children aged 2-18 years admitted for acute asthma exacerbation were obtained for 2000, 2003, 2006, 2009, and 2012 from the Kids' Inpatient Database. METHODOLOGY The primary exposure was OSA, the primary outcome was IMV, and secondary outcomes were NIMV, length of hospital stay (LOS), and inflation-adjusted cost of hospitalization. Multivariable logistic regression, negative binomial, and linear regression were conducted to ascertain the impact of OSA on primary and secondary outcomes. Exploratory analyses investigated the impact of obesity on primary and secondary outcomes. RESULTS Among 564,467 hospitalizations for acute asthma exacerbation, 4209 (0.75%) had OSA. Multivariable regression indicated that OSA was associated with IMV (adjusted odds ratio [OR], 5.33 [95% confidence interval, CI: 4.35-6.54], p

Congenital syphilis represents an important public health challenge in the United States, and its prevalence has been increasing for the past 10 years because of many factors. The diagnosis can be difficult given its various and nonspecific clinical manifestations in newborns, and the possibility of false negative results during prenatal care. The prozone phenomenon, caused by an excess of antibody, which interferes with the regular screening tests, is a cause of false negative tests. This could delay the diagnosis and increase morbidity and mortality in the newborn. We present a case of congenital syphilis in a 3-month-old infant whose mother had prenatal care and negative tests for syphilis, which contributed to the late diagnosis. In the face of clinical findings suggestive of congenital syphilis and negative maternal syphilis tests healthcare providers should consider the possibility of maternal false negative test caused by the prozone phenomenon.

Objective: The predictive role of procalcitonin for childhood bacterial pneumonia, a leading cause of death, is unclear. We aimed to evaluate the diagnostic accuracy of procalcitonin for childhood ...

Background It is unclear whether multiple respiratory viral infections are associated with more severe bronchiolitis requiring pediatric intensive care unit (PICU) admission. We aimed to identify the association between multiple respiratory viral infections and PICU admission among infants with bronchiolitis. Methods We performed a 1:1 case-control study enrolling previously healthy full-term infants (≤12 months) with bronchiolitis admitted to the PICU as cases and those to the general pediatric ward as controls from 2015 to 2017. Multiplex polymerase chain reaction (PCR) was used for detection of the respiratory viruses. We summarized the characteristics of infants admitted to the PICU and the general pediatric unit. Multivariable logistic regression analysis was used to fit the association between multiple respiratory viral infections (≥2 strains) and PICU admission. Results A total of 135 infants admitted to the PICU were compared with 135 randomly selected control infants admitted to the general pediatric unit. The PICU patients were younger (median: 2.2 months, interquartile range: 1.3–4.2) than the general ward patients (median: 3.2 months, interquartile range: 1.6–6.4). Respiratory syncytial virus (74.1%), rhinovirus (28.9%), and coronavirus (5.9%) were the most common viruses for bronchiolitis requiring PICU admission. Patients with bronchiolitis admitted to the PICU tended to have multiple viral infections compared with patients on the general ward (23.0% vs. 10.4%, P

BACKGROUND Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x-ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta-analysis. METHODS We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. We used QUADAS-2 to appraise the included studies' methodologic quality. We employed a random-effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta-regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers. RESULTS Twenty-five studies (n = 3,353) were included in the meta-analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta-regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p

Objectives: Predictors for post-sepsis myocardial infarction (MI) and stroke are yet to be identified due to the competing risk of death. Methods: This study included all hospitalized patients with sepsis from National Health Insurance Research Database of Taiwan between 2000 and 2011. The primary outcome was the first occurrence of MI and stroke requiring hospitalization within 180 days following hospital discharge from the index sepsis episode. The association between predictors and post-sepsis MI and stroke were analyzed using cumulative incidence competing risk model that controlled for the competing risk of death. Results: Among 42 316 patients with sepsis, 1012 (2.4%) patients developed MI and stroke within 180 days of hospital discharge. The leading 5 predictors for post-sepsis MI and stroke are prior cerebrovascular diseases (hazard ratio [HR]: 2.02, 95% confidence interval [CI]: 1.74-2.32), intra-abdominal infection (HR: 1.94, 95% CI: 1.71-2.20), previous MI (HR: 1.81, 95% CI: 1.53-2.15), lower respiratory tract infection (HR: 1.62, 95% CI: 1.43-1.85), and septic encephalopathy (HR: 1.61, 95% CI: 1.26-2.06). Conclusions: Baseline comorbidities and sources of infection were associated with an increased risk of post-sepsis MI and stroke. The identified risk factors may help physicians select a group of patients with sepsis who may benefit from preventive measures, antiplatelet treatment, and other preventive measures for post-sepsis MI and stroke.

Introduction: Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology. It is the leading cause of pediatric acquired heart disease in developed countries. Growing evidence points to the role of immunoregulatory abnormalities for its causation. Hypothesis: It is hypothesized that a history of allergic diseases is associated with the development of KD in children. Methods: A systematic review and meta-analysis of observational studies was performed to ascertain the association between history of allergic diseases and KD. Major electronic databases were searched from inception through March 2020 using pre-defined index terms such as “allergic disease”, “Kawasaki disease” and “children”. Random effects model was used to derive pooled estimates of odds ratios (OR) and 95% confidence intervals (CI). The Newcastle-Ottawa Scale was used for qualitative assessment. This study was reported according to MOOSE (Meta-analyses Of Observational Studies in Epidemiology). Results: Of 854 articles identified, 8 studies were considered eligible. History of allergic diseases was significantly associated with the development of KD (OR 1.99; 95% CI 1.26-2.73). On subgroup analysis of case-control studies (n=6), allergic diseases remained significantly associated with KD (OR 1.61; 95% CI 1.10-2.12). However, subgroup analysis with allergic diseases limited to asthma (n=5) revealed no significant association with KD (OR 1.17; 95% CI 0.45-1.90). Qualitative assessment found minimal concerns for bias. Conclusions: The available evidence suggests a strong association between history of allergic diseases and development of Kawasaki disease among children.

BACKGROUND: Opioids have been shown to increase risk of pneumonia among susceptible population. However, the effect of opioid abuse on the outcome of pneumonia has not been evaluated at the population level. We aimed to compare the outcomes of pneumonia among patients with opioid use disorder and patients without substance use disorder using a large population database. METHODS: We assembled a pneumonia cohort composed of 11,186,564 adult patients from the National Inpatient Sample (NIS; 2005–2014). Patients with opioid disorder were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. We compared health-related and economic outcomes between patients with and without opioid disorders using propensity score matching (PSM) analysis to balance baseline differences. The survival differences between two groups of patients were assessed using a Cox proportional hazard model. We further explored the possibility of effect modification by interaction analyses in different populations. RESULTS: After PSM, patients with opioid use disorder were at increased risk of ventilator use (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.08 to 1.38, p = 0.0014) and associated with increased length of hospital stay by 0.59 days (95% CI: 0.35 to 0.83, p < 0.001), compared with those without substance use disorder. Patients with opioid use also had higher daily (228.00 USD, 95% CI: 180.51 to 275.49, p < 0.001) and total (1,875.72 USD, 95% CI: 1,259.63 to 2,491.80, p < 0.001) medical costs. Subgroup analyses showed similar results. CONCLUSIONS: Compared with patients without any drug dependence, patients with opioid use disorders had increased risk of complications and resource utilization. This study adds evidence for increased risk for pneumonia complications in the growing patients with opioid use disorders.

Study ObjectivesObstructive sleep apnea (OSA) is associated with cardiovascular and cerebrovascular morbidity. Patients with sickle cell disease (SCD) are at increased risk for both neurologic complications (NC) and OSA. However, the relationship between OSA and SCD complications is unclear. We hypothesized that there would be an association between OSA diagnosis and SCD complications.MethodsHospital discharge records of patients with SCD aged < 19 years were obtained for the years 1997, 2000, 2003, 2006, 2009, and 2012 from the Kid’s Inpatient Database. The primary outcome, NC, a composite of stroke, transient ischemic attack, and seizures. Secondary outcomes included acute chest syndrome (ACS), vaso-occlusive crisis, length of hospital stay, and inflation-adjusted cost of hospitalization. Multivariable regression was conducted to ascertain the association of OSA with primary and secondary outcomes. Analyses were adjusted for the use of noninvasive mechanical ventilation (NIMV) to determine its role as NC risk modifier.ResultsThere were 203,705 SCD discharges included in the analysis, of which 2,820 (1.4%) and 4,447 (2.2%) also included OSA and NC diagnoses. Multivariable logistic regression indicated that OSA was associated with NC (adjusted odds ratio [OR], 1.50 [95% CI 1.02–2.21], p = 0.039) and ACS (OR, 1.34 [95% CI 1.08–1.67], p = 0.009) in children with SCD. In the multivariable analysis adjusted for NIMV, the significant association between OSA and NC was no longer observed (OR, 1.39 [95% CI 0.94–2.05], p = 0.100).ConclusionsOSA is associated with a 50% increase of odds of NC in children with SCD in this nationwide dataset. The use of NIMV to treat OSA may modify the risk of OSA-associated NC.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is associated with neurologic morbidity and mortality. We investigated whether cerebral regional oxygen saturation (rSO(2)) is associated with neurologic outcomes and survival in children on ECMO. METHODS: This was a retrospective observational study of children ages 1 day to 20 years who underwent ECMO with routine cerebral rSO(2) monitoring in the pediatric intensive care unit at a single academic center between February 2008 and September 2014. We collected all serial rSO(2) values recorded in the electronic medical record during the ECMO course. Favorable outcome was defined as survival with Pediatric Cerebral Performance Category (PCPC) ≤2 at hospital discharge or no decline from baseline PCPC. RESULTS: We reviewed data from 153 patients who underwent 156 ECMO runs. The median age was 12.5 days (interquartile range [IQR], 2 days – 15 months). Ninety-nine (64%) patients survived to hospital discharge, and 82/99 (83%) survivors had favorable neurologic outcome by discharge PCPC. Neuroimaging studies were obtained in 135 (87%) patients, 59 (44%) of which showed abnormal findings. Ninety-two (59%) patients had any rSO(2) ≤50%, 60 (38%) had any rSO(2) decline >20% from baseline, and 26 (17%) had any rSO(2) decline >20% from the reading 1 h prior. Any rSO(2) ≤50% and any rSO(2) decline >20% from baseline were each associated with unfavorable outcome at hospital discharge (multivariable-adjusted odds ratio [OR], 2.82 [95% CI, 1.10–7.25] and 4.52 [95% CI, 1.76–11.58], respectively). rSO(2) decline >20% from the reading 1 h prior was not significantly associated with the outcomes. CONCLUSION: Among children in one institution who underwent routine clinical rSO(2) monitoring during ECMO, rSO(2) decline was associated with unfavorable short-term neurologic outcome and death after adjusting for potential confounders. The effectiveness of initiating early preventative measures in these high-risk patients needs further study.

Aim The aim of this study was to investigate the trend of incidence and outcome of paediatric sepsis in a population-based database. Methods Children with sepsis were identified from the 23 million nationwide health insurance claims database of Taiwan. Sepsis was defined by the presence of single ICD-9 code for severe sepsis or septic shock or a combination of ICD-9 codes for infection and organ dysfunction. We analysed the trend of incidence, mortality and source of infection in three age groups: infant (28 days to 1 year), child (1-9 years) and adolescent (10-18 years). Results From 2002 to 2012, we identified 38 582 paediatric patients with sepsis, of which 21.3% were infants, 52.8% were children and 25.8% were adolescents. The incidence of sepsis was 336.4 cases per 100 000 population in infants, 3.3 times higher than in children (101.5/100 000 cases) and 7.3 times higher than in adolescents (46.2/100 000 cases). While sepsis incidence decreased from 598.0 to 336.4 cases per 100 000 people in the infant population, it remained relatively unchanged in children and adolescents. For 90-day mortality, there were significant decreases in all three age groups (absolute decrease of 5.0% for infants, 3.7% for children and 14.4% for the adolescents). In the infant population, we observed a decrease in the incidence of lower respiratory tract infections, while the incidence of urinary tract infections remained unchanged. Conclusions The incidence and mortality of sepsis among paediatric patients have decreased substantially between 2002 and 2012, especially among infants. The widespread use of Haemophilus influenzae and pneumococcal vaccines in infants could be a possible explanation.

Background Several clinical trials on hypertonic fluid administration have been completed, but the results have been inconclusive. The objective of this study is to summarize current evidence for treating hypovolemic patients with hypertonic solutions by performing a systematic review and meta-analysis. Methods Major electronic databases were searched from inception through June 2014. We included only randomized controlled trials involving hemorrhagic shock patients treated with hypertonic solutions. After screening 570 trials, 12 were eligible for the final analysis. Pooled effect estimates were calculated with a random effect model. Results The 12 studies included 6 trials comparing 7.5% hypertonic saline (HS) with 0.9% saline or Ringer's lactate solution and 11 trials comparing 7.5% hypertonic saline with dextran (HSD) with isotonic saline or Ringer's lactate. Overall, there were no statistically significant survival benefits for patients treated with HS (relative risk [RR], 0.96; 95% confidence interval [CI], 0.82-1.12) or HSD (RR, 0.92; 95% CI, 0.80-1.06). Treatment with hypertonic solutions was also not associated with increased complications (RR, 1.03; 95% CI, 0.78-1.36). Subgroup analysis on trauma patients in the prehospital or emergency department settings did not change these conclusions. There was no evidence of significant publication bias. Meta-regression analysis did not find any significant sources of heterogeneity. Conclusions Current evidence does not reveal increased mortality when the administration of isotonic solutions is compared to HS or HSD in trauma patients with hemorrhagic shock. HS or HSD may be a viable alternative resuscitation fluid in the prehospital setting. Further studies are needed to determine the optimum volume and regimen of intravenous fluids for the treatment of trauma patients.

Objective We aim to summarize current evidence on the value of point-of-care (POC) focused echocardiography in the assessment of short-term survival in patients with cardiac arrest. Methods PubMed and EMBASE were searched from inception to July 2016 for eligible studies that evaluated the utility of POC echocardiography in patients with cardiac arrest. Modified QUADAS was used to appraise the quality of included studies. A random-effect bivariate model and a hierarchical summary receiving operating curve were used to summarize the performance characteristics of focused echocardiography. Results Initial search identified 961 citations of which 15 were included in our final analysis. A total of 1695 patients had POC echocardiography performed during resuscitation. Ultrasonography was mainly utilized to detect spontaneous cardiac movement (SCM) and identify reversible causes of cardiac arrest. Subcostal, apical and parasternal views were used to identify cardiac tamponade, pulmonary embolism, and pleural view for tension pneumothorax. Results of meta-analysis showed that SCM detected by focused echocardiography had a pooled sensitivity (0.95, 95%CI: 0.72–0.99) and specificity (0.80, 95%CI: 0.63–0.91) in predicting return of spontaneous circulation (ROSC) during cardiac arrest, with a positive likelihood ratio of 4.8 (95% CI: 2.5–9.4) and a negative likelihood ratio of 0.06 (95%CI: 0.01–0.39). Conclusion POC focused echocardiography can be used to identify reversible causes and predict short-term outcome in patients with cardiac arrest. In patients with a low pretest probability for ROSC, absence of SCM on echocardiography can predict a low likelihood of survival and guide the decision of resuscitation termination.

Background It remains unclear whether sepsis-related cardiovascular complications have an adverse impact on survival independent of pre-existing comorbidities. To investigate the survival impact of post-sepsis cardiovascular complications among sepsis survivors, we conducted a population-based study using the National Health Insurance Database of Taiwan. Methods We identified sepsis patients from the National Health Insurance Research Database of Taiwan using ICD-9-CM codes involving infection and organ dysfunction between 2000 and 2011. Post-sepsis incident myocardial infarction (MI) and stroke were ascertained by ICD-9-CM codes and antiplatelet treatment. We constructed a non-sepsis comparison cohort using propensity score matching to ascertain the association between sepsis and cardiovascular complications. Furthermore, we compared the 180-day mortality and 365-day mortality between patients surviving sepsis with or without post-sepsis MI or stroke within 70 days of hospital discharge. We constructed Cox regression models adjusting for pre-existing comorbidities to evaluate the independent survival impact of post-sepsis MI or stroke among sepsis survivors. Results We identified 42,316 patients hospitalized for sepsis, from which we matched 42,151 patients 1:1 with 42,151 patients hospitalized without sepsis. Compared to patients hospitalized without sepsis, patients hospitalized with sepsis had an increased risk of MI or stroke (adjusted odds ratio 1.72, 95% CI 1.60–1.85). Among 42,316 patients hospitalized for sepsis, 486 (1.15%) patients developed incident stroke and 108 (0.26%) developed incident MI within 70 days of hospital discharge. Compared to sepsis survivors without cardiovascular complications, sepsis survivors with incident MI or stroke had a higher mortality rate at 180 days (11.68% vs. 4.44%, P = 0.003) and at 365 days (16.75% vs. 7.11%, P = 0.005). Adjusting for age, sex, and comorbidities, post-sepsis MI or stroke was independently associated with increased 180-day (adjusted hazard ratio [HR] 2.16, 95% CI 1.69–2.76) and 365-day (adjusted HR 1.90, 95% CI 1.54–2.32) mortality. Conclusions Compared to sepsis patients without incident MI or stroke, sepsis patients with incident MI or stroke following hospital discharge had an increased risk of mortality for up to 365 days of follow-up. This increased risk cannot be explained by pre-sepsis comorbidities. Electronic supplementary material The online version of this article (10.1186/s13054-019-2579-2) contains supplementary material, which is available to authorized users.

Objective It is unclear whether point-of-care ultrasound (POCUS) by emergency medicine physicians is as accurate as radiology-performed ultrasound (RADUS). We aim to summarize the diagnostic accuracy of ultrasonography for intussusception and to compare the performance between POCUS and RADUS. Methods Databases were searched from inception through February 2018 using pre-defined index terms. Peer-reviewed primary studies that investigated the diagnostic accuracy of ultrasound for intussusception in children were included. The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for intussusception was conducted using the random-effects bivariate model. Subgroup analysis (POCUS vs RADUS) was also performed. Meta-regression was utilized to determine if the diagnostic accuracy between POCUS and RADUS was significantly different. Results Thirty studies (n = 5249) were included in the meta-analysis. Ultrasonography for intussusception has a sensitivity: 0.98 (95% CI: 0.96–0.98), specificity: 0.98 (95% CI: 0.95–0.99), positive likelihood ratio: 43.8 (95% CI: 18.0–106.7) and negative likelihood ratio: 0.03 (95% CI: 0.02–0.04), with an area under ROC (AUROC) curve of 0.99 (95% CI: 0.98–1.00). Meta-regression suggested no significant difference in the diagnostic accuracy for intussusception between POCUS and RADUS (AUROC: 0.95 vs 1.00, p = 0.128). Conclusions Current evidence suggested POCUS has a high diagnostic accuracy for intussusception not significantly different from that of RADUS.

Appendix 1. Codes associated with infection. The ICD-9-CM codes utilized to identify infections. Appendix 2. Codes associated with organ dysfunction. The ICD-9-CM codes utilized to identify organ dysfunction. (DOCX 29 kb)

Supplemental Material, 5._supplemental_table_01312019 for Risk Factors for Myocardial Infarction and Stroke Among Sepsis Survivors: A Competing Risks Analysis by Yueh-Che Hsieh, Po-Yang Tsou, Yu-Hsun Wang, Christin Chih-Ting Chao, Wan-Chien Lee, Meng-tse Gabriel Lee, Jiunn-Yih Wu, Shy-Shin Chang, Po-Yen Chen and Chien-Chang Lee in Journal of Intensive Care Medicine

Supplemental Material, 6._appendix for Risk Factors for Myocardial Infarction and Stroke Among Sepsis Survivors: A Competing Risks Analysis by Yueh-Che Hsieh, Po-Yang Tsou, Yu-Hsun Wang, Christin Chih-Ting Chao, Wan-Chien Lee, Meng-tse Gabriel Lee, Jiunn-Yih Wu, Shy-Shin Chang, Po-Yen Chen and Chien-Chang Lee in Journal of Intensive Care Medicine

Table S2. Comparison of incidence (events/1000 person) of MI/stroke in sepsis and propensity score-matched non-sepsis cohort. Representation of the multivariable logistic regression analysis summarizing the association between sepsis and incidence of MI, stroke and MI/stroke while accounting for potential confounders. Abbreviations: MI, myocardial infarction; PS, propensity score; OR, odds ratio. (DOCX 15 kb)

Table S3. Comparison of mortality of MI/stroke in sepsis and propensity score-matched non-sepsis cohorts. Representation of the survival analysis results using Cox regression model summarizing survival impact of sepsis on the mortality of MI, stroke and MI/stroke while accounting for potential confounders. Abbreviations: MI, myocardial infarction; HR, hazard ratio. (DOCX 15 kb)

Objective This study aimed to undertake a systematic review and meta-analysis to summarize evidence on the diagnostic value of ultrasonography for the assessment of endotracheal tube placement in adult patients. Methods The major databases, PubMed, EMBASE, and the Cochrane Library, were searched for studies published from inception to June 2014. We selected studies that used ultrasonography to confirm endotracheal tube placement. The search was limited to human studies, and had no publication date or country restrictions. Exclusion criteria included case reports, comments, reviews, guidelines and animal studies. Two reviewers extracted and verified the data independently. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic (HSROC) curves, and bivariate random effect models. Meta-regression analysis was performed to explore the source of heterogeneity. The methodological quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Results A total of 12 eligible studies involving adult patients and cadaveric models were identified from 1488 references. For detection of esophageal intubation, the pooled sensitivity was 0.93 (95%CI: 0.86–0.96) and the specificity was 0.97 (95%CI: 0.95–0.98). The area under the summary ROC curve was 0.97 (95%CI: 0.95–0.98). The positive and negative likelihood ratios were 26.98 (95%CI: 19.32–37.66) and 0.08 (95%CI: 0.04–0.15), respectively. Conclusions Current evidence supports that ultrasonography has high diagnostic value for identifying esophageal intubation. With optimal sensitivity and specificity, ultrasonography can be a valuable adjunct in this aspect of airway assessment, especially in situations where capnography may be unreliable.