Search

Clinical severity scores facilitate comparisons to understand risk factors for severe illness. For the 2022 multinational monkeypox clade IIb virus outbreak, we developed a 7-item Mpox Severity Scoring System (MPOX-SSS) with initial variables refined by data availability and parameter correlation. Application of MPOX-SSS to the first 200 patients diagnosed with mpox revealed higher scores in those treated with tecovirimat, presenting >3 days after symptom onset, and with CD4 counts <200 cells/mm3. For individuals evaluated repeatedly, serial scores were concordant with clinical observations. The pilot MPOX-SSS demonstrated good discrimination, distinguished change over time, and identified higher scores in expected groups. [ABSTRACT FROM AUTHOR]

Background: The assessment of severity is crucial in the management of community-acquired pneumonia (CAP). It remains unknown whether updating cut-off values of severity scoring systems orchestrate improvement in predictive accuracy. Methods: 3,212 patients with CAP were recruited to two observational prospective cohort studies. Three bettered scoring systems were derived from the corresponding well-established and extensively used pneumonia-specific severity scoring systems, i.e. pneumonia severity index, minor criteria and CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30/min, low blood pressure, and age ≥65 years) score, with the updating cut-off values for tachypnea and low blood pressure. Cronbach α was employed to determine construct validity. Discrimination was valued by calculating the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI). Results: Respiratory rate ≥22/min and systolic blood pressure ≤100 mm Hg were performed better than respiratory rate ≥30/min and hypotension for predicting mortality in the derivation cohort, respectively (AUROC, 0.823 vs 0.519, 0.688 vs 0.622; NRI, 0.61, 0.13). Bettered scoring systems orchestrated higher convergences, indicated by greater Cronbach α and more decrease in Cronbach α if the updating cut-off values were deleted. The six scoring systems agreed well with one another. Bettered- pneumonia severity index, minor criteria and CURB-65 score showed higher associations with severity and mortality rates and demonstrated greater predictive accuracies for mortality compared with the corresponding original systems (AUROC, 0.939 vs 0.883, 0.909 vs 0.871, 0.913 vs 0.859; NRI, 0.113, 0.076, 0.108; respectively). The validation cohort confirmed a similar pattern. Conclusions: Updating cut-off values of severity scoring systems for CAP orchestrate improvement in predictive accuracy, suggesting that it may facilitate the rationalization of clinical triage decision-making and further reduce mortality. The current studies provide the first known prospective evidence of potential benefit of the updating cut-off values of severity scoring systems for CAP in predictive accuracy. Updating cut-off values were performed better for predicting mortality. Bettered scoring systems orchestrated higher convergences. Bettered scoring systems demonstrated greater predictive accuracies for mortality. [ABSTRACT FROM AUTHOR]

AbstractBackground: The assessment of severity is crucial in the management of community-acquired pneumonia (CAP). It remains unknown whether updating cut-off values of severity scoring systems orchestrate improvement in predictive accuracy.Methods: 3,212 patients with CAP were recruited to two observational prospective cohort studies. Three bettered scoring systems were derived from the corresponding well-established and extensively used pneumonia-specific severity scoring systems, i.e. pneumonia severity index, minor criteria and CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30/min, low blood pressure, and age ≥65 years) score, with the updating cut-off values for tachypnea and low blood pressure. Cronbach α was employed to determine construct validity. Discrimination was valued by calculating the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI).Results: Respiratory rate ≥22/min and systolic blood pressure ≤100 mm Hg were performed better than respiratory rate ≥30/min and hypotension for predicting mortality in the derivation cohort, respectively (AUROC, 0.823 vs 0.519, 0.688 vs 0.622; NRI, 0.61, 0.13). Bettered scoring systems orchestrated higher convergences, indicated by greater Cronbach α and more decrease in Cronbach α if the updating cut-off values were deleted. The six scoring systems agreed well with one another. Bettered- pneumonia severity index, minor criteria and CURB-65 score showed higher associations with severity and mortality rates and demonstrated greater predictive accuracies for mortality compared with the corresponding original systems (AUROC, 0.939 vs 0.883, 0.909 vs 0.871, 0.913 vs 0.859; NRI, 0.113, 0.076, 0.108; respectively). The validation cohort confirmed a similar pattern.Conclusions: Updating cut-off values of severity scoring systems for CAP orchestrate improvement in predictive accuracy, suggesting that it may facilitate the rationalization of clinical triage decision-making and further reduce mortality. The current studies provide the first known prospective evidence of potential benefit of the updating cut-off values of severity scoring systems for CAP in predictive accuracy.Key messagesUpdating cut-off values were performed better for predicting mortality.Bettered scoring systems orchestrated higher convergences.Bettered scoring systems demonstrated greater predictive accuracies for mortality.

Severity scoring systems for ionizing radiation-induced gastrointestinal injury have been used in animal radiation models, human studies involving the use of radiation therapy, and human radiation accidents. Various radiation exposure scenarios (i.e. total body irradiation, total abdominal irradiation, etc.) have been used to investigate ionizing radiation-induced gastrointestinal injury. These radiation-induced gastrointestinal severity scoring systems are based on clinical signs and symptoms and gastrointestinal-specific biomarkers (i.e. citrulline, etc.). In addition, the time course for radiation-induced changes in blood citrulline levels were compared across various animal (i.e. mice, minipigs, Rhesus Macaque, etc.) and human model systems. A worksheet tool was developed to prioritize individuals with severe life-threatening gastrointestinal acute radiation syndrome, based on the design of the Exposure and Symptom Tool addressing hematopoietic acute radiation syndrome, to rescue individuals from potential gastrointestinal acute radiation syndrome injury. This tool provides a triage diagnostic approach to assist first responders to assess individuals suspected of showing gastrointestinal acute radiation syndrome severity to guide medical management, hence enhancing medical readiness for managing radiological casualties. [ABSTRACT FROM AUTHOR]

Background: Hemoglobin (Hb) H is generally recognized as mild thalassemia, despite its actual phenotypic diversity. A disease severity scoring system to guide initiation of regular transfusion among severely affected pediatric patients has not previously been reported. Methods: Patients with HbH were classified into transfusion‐dependent thalassemia (TDT) and non‐transfusion‐dependent thalassemia (NTDT) as a surrogate for disease severity. Alpha‐globin genotypes and relevant clinical parameters associated with TDT were identified. Univariate and multiple logistic regression analyses were performed to yield the most suitable severity scoring system. Results: From 246 patients with a median age of 14.3 (interquartile range 9.9–18.4) years initially enrolled into the study, the chance of having severe disease and developing TDT was remarkable only among patients with non‐deletional HbH, for whom the scoring system was developed. Univariate and multiple logistic regression analyses resulted in three retained parameters associated with TDT, β‐coefficients of which were used to develop the score. The final scoring system comprised age at diagnosis <2 years (score = 1), spleen size ≥3 cm (score = 1) and Hb at steady‐state <7 (score = 4) or 7–8 g/dL (score = 3). A cutoff score ≥4 was associated with severe disease likely requiring regular transfusion (sensitivity 89.3%, specificity 81.4%), given regular transfusion resulted in maintained growth. The scoring system was validated in the second cohort of 77 non‐deletional HbH, from which comparable sensitivity and specificity were obtained. Conclusion: The newly developed scoring system was practical and helpful to highlight severely affected pediatric non‐deletional HbH patients with potential needs of regular transfusion. This can be used as a guide for optimal treatment and disease monitoring in the future. [ABSTRACT FROM AUTHOR]

• This systematic review and meta-analysis addresses growing concerns about the validity of current mangled extremity scoring systems to accurately predict the potential for upper limb salvage. • Current scoring systems poorly predict salvageability of a mangled upper extremity and do not justify amputation. • A new scoring system designed specifically for a mangled upper extremity is needed to support surgeons and ER doctors when they must decide whether to perform limb salvage or primary amputation. The purpose of scoring systems is to aid in the decision-making process of whether to salvage or amputate mangled extremities, but their efficacy for upper limbs is uncertain. In this study, we examined the predictive potential of scoring systems for upper limb salvage. Two investigators undertook a systematic search of 3 leading databases for English or Japanese literature from 1985, when the first scoring system to evaluate mangled extremities was proposed, until January 2022. To be eligible, studies must have had upper extremity limb salvage or amputation as an outcome, and identified the scoring system used and treatment outcome in individual cases. Ten studies (N = 338) of the Mangled Extremity Scoring System (MESS) were ultimately included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95 % CI = 0.69–0.99) and 0.81 (0.65–0.91), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.95 (0.93–0.97). A subgroup analysis showed lower specificity in isolated vascular injuries. Scoring systems other than MESS were ineligible for the quantitative synthesis because none were examined in an adequate number of publications. The pooled sensitivity and specificity for MESS were comparable to those reported for the lower extremities. The specificity suggests that limb salvage was achieved in at least 20 % of the patients whose MESS was above the threshold beyond which amputation is indicated. Given the likelihood of upper extremity functional limitations following amputation and the drawbacks of prostheses, we conclude that current scoring systems poorly predict salvageability of a mangled upper extremity and should not be used to justify amputation. [ABSTRACT FROM AUTHOR]

Objective: The Acute Physiology and Chronic Health Evaluation (APACHE) is a severity scoring system used to predict healthcare outcomes and make inferences regarding quality of care. APACHE was designed and validated for use in general ICU populations, but its performance in specific subgroups of ICU patients is unproven. Quantitative performance referents for severity scoring systems like APACHE have not been established. This study compares the performance of APACHE IVa in several common subgroups of ICU patients to the performance of APACHE IVa and a referent scoring system applied in a general ICU population. Design: Observational cohort. Setting: Seventeen ICUs. Patients: Adult patients meeting criteria for APACHE IVa scoring. Intervention: We designed a “two-variable severity score” (2VSS) to provide “weak” reference values for explained variance (R2) and discriminant accuracy to use in our comparisons. R2 and AUROC were calculated for 2VSS and APACHE IVa outcome predictions in the overall cohort, and for APACHE IVa in subgroups with sepsis, acute myocardial infarction, coronary artery bypass grafting, stroke, gastrointestinal bleeding, trauma, or requiring mechanical ventilation. APACHE IVa subgroup performance was compared to APACHE VIa and 2VSS performance in the overall cohort. Measurements and Main Results: APACHE IVa out-performed 2VSS in our cohort of 66,821 ICU patients (R2: 0.16 vs 0.09; AUROC: 0.89 vs 0.77). However, APACHE IVa performance was significantly diminished in subgroups with sepsis, coronary artery bypass grafting, gastrointestinal bleeding or requiring mechanical ventilation compared to its performance in the overall cohort analysis. APACHE IVa performance in patients undergoing CABG (R2: 0.03, AUROC: 0.74) failed to surpass 2VSS performance referents. Conclusions: The performance of severity scoring systems like APACHE might be insufficient to provide valid inferences regarding quality of care in select patient subgroups. Our analysis of 2VSS provides quantitative referents that could be useful in defining acceptable performance.

The usefulness of existing pneumonia severity indices for predicting mortality in nursing and healthcare-associated pneumonia (NHCAP) is unclear. This study compared the usefulness of existing pneumonia severity indices for predicting mortality in NHCAP and community-acquired pneumonia (CAP). Consecutive hospitalized pneumonia patients including NHCAP and CAP patients were prospectively enrolled between October 2010 and November 2017. Admission pneumonia severity was assessed using CURB-65, Pneumonia Severity Index (PSI), A-DROP, Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) severe pneumonia criteria, and I-ROAD. The primary outcome was 30-day mortality. The discriminatory ability of each severity index was evaluated by receiver operating characteristic curve analysis. Overall, 828 patients had NHCAP, and 1330 patients had CAP. Thirty-day mortality was 12.8% and 5.6% in NHCAP and CAP patients, respectively. The area under the curve of PSI (0.717, 95% confidence interval 0.673–0.761) was the highest among all pneumonia severity indices, with significant differences compared with CURB-65 (0.651, 95% confidence interval 0.598–0.705, P = 0.02) and IDSA/ATS severe pneumonia criteria (0.659, 95% confidence interval 0.612–0.707, P = 0.03). The predictive abilities for 30-day mortality of the pneumonia severity indices, excluding PSI and I-ROAD, were significantly inferior for NHCAP than for CAP. PSI may be the most useful pneumonia severity score for predicting mortality in NHCAP. However, the predictive ability for mortality of each pneumonia severity score was worse for NHCAP than for CAP; therefore, the prognostic factors in NHCAP need to be identified for better management of NHCAP patients. [ABSTRACT FROM AUTHOR]

Objective The severity of Clostridioides difficile infection (CDI) is an important prognostic factor. The "MN criteria," proposed in Japan in 2017, attempted to remedy the shortfalls in the reported guidelines proposed globally to determine CDI severity. We therefore assessed the accuracy of the MN criteria and validated the important factors associated with predicting CDI severity. Methods Sixty-six CDI cases were investigated retrospectively at a Japanese University Hospital from January 2015 to December 2018. The fulminant cases were screened out, and the non-fulminant cases were classified according to their severity stages using the nine variables included in the MN criteria. Clinical events, such as death within 28 days, colectomy, and admission to the intensive care unit, were evaluated. First, the sensitivity and specificity of the MN criteria for predicting clinical events were determined. The relationships between clinical events and the explanatory variables were then evaluated through univariate and multivariate analyses. Results The screening of the fulminant cases and classification of the non-fulminant cases into mild/moderate and severe/super severe cases resulted in a sensitivity of 1.00 and a specificity of 0.89. Univariate and multivariate analyses revealed a significant association of the serum albumin (Alb) level as well as white blood cell (WBC) count with clinical events. Conclusion The findings provide evidence supporting the accuracy of the MN criteria in predicting CDI severity and show that the Alb and WBC are important variables in predicting CDI severity.

ABSTRACT Background and objective: The value of community-acquired pneumonia (CAP) severity scoring tools is almost exclusively reliant upon regular and accurate application in clinical practice. Until recently, the Australasian Therapeutic Guidelines has recommended the use of the Pneumonia Severity Index (PSI) in spite of poor user-friendliness. Methods: Electronic and postal survey of respiratory and emergency medicine physician and specialist registrar members of the Royal Australasian College was undertaken to assess the use of the PSI and the accuracy of its application to hypothetical clinical CAP scenarios. The confusion, urea, respiratory rate, blood pressure, age 65 or older (CURB-65) score was also assessed as a simpler alternative. Results: Five hundred thirty-six (228 respiratory, 308 emergency) responses were received. Only 12% of respiratory and 35% of emergency physicians reported using the PSI always or frequently. The majority were unable to accurately approximate PSI scores, with significantly fewer respiratory than emergency physicians recording accurate severity classes (11.8% vs 21%, OR 0.50, 95% CI: 0.37-0.68, P < 0.0001). In contrast, significantly more respiratory physicians were able to accurately calculate the CURB-65 score (20.4% vs 15%, OR 1.45, 95% CI: 1.10-1.91, P = 0.006). Conclusions: Australasian specialist physicians primarily responsible for the acute management of CAP report infrequent use of the PSI and are unable to accurately apply its use to hypothetical scenarios. Furthermore, respiratory and emergency physicians contrasted distinctly in their use and application of the two commonest severity scoring systems-the recent recommendation of two further alternative scoring tools by Australian guidelines may add to this confusion. A simple, coordinated approach to pneumonia severity assessment across specialties in Australasia is needed. [ABSTRACT FROM AUTHOR]

Abstract: Background: The aim of this study was to evaluate the peritoneal computed tomography (CT) attenuation values and relate them to the severity of peritonitis in patients with gastrointestinal tract (GI) perforations. Methods: A total of 56 consecutive patients with GI perforations who underwent CT scan and emergency laparotomy in our hospital were enrolled in this study. The CT attenuation values of the peritoneum were measured on a workstation by 2 independent investigators, and were investigated in relation to the severity of illness and hospital mortality. Results: Peritoneal CT attenuation values in hospital nonsurvivors were significantly lower than those in survivors. There was significant negative correlation between peritoneal CT attenuation values and sequential organ failure assessment score, acute physiology and chronic health evaluation II score, and the Mannheim peritonitis index. Conclusions: The evaluation of peritoneal CT attenuation values in patients with peritonitis is simple and can be used for objective assessment of the severity of peritonitis. [Copyright &y& Elsevier]