Further validation of the Postpartum Depression Screening Scale

BACKGROUND: Up to 50% of all cases of postpartum depression go undetected. The Edinburgh Postnatal Depression Scale (EPDS) has been the only instrument available that was specifically designed to screen for this mood disorder. None of the items on the EPDS, however, are written in the context of new motherhood. OBJECTIVE: The purpose of this study was to further assess the construct validity of the newly designed Postpartum Depression Screening Scale (PDSS) along with its sensitivity, specificity, and predictive values. METHOD: A total sample of 150 mothers within 12 weeks postpartum participated in the study. Each mother completed in random order three questionnaires: The PDSS, EPDS, and The Beck Depression Inventory-II (BDI-II). Immediately after completing these three questionnaires, each woman was interviewed by a nurse psychotherapist using the Structural Clinical Interview for DSM-IV Axis 1 Disorders. RESULTS: Twelve percent (n = 18) of the mothers were diagnosed with major postpartum depression, 19% (n = 28) with minor postpartum depression, and 69% (n = 104) with no depression. The PDSS was strongly correlated with both the BDI-II (r = 0.81) and the EPDS (r = 0.79). The ability of the PDSS to explain variance in diagnostic classification of postpartum depression above that explained by the BDI-II and EPDS (i.e., incremental validity) was assessed using hierarchical regression. After explaining variance in group classification by the other two depression instruments, the PDSS explained an additional 9% of the variance in depression diagnosis. Using receiver operating characteristic (ROC) curves, a PDSS cut-off score of 80 (sensitivity 94% and specificity 98%) is recommended for major postpartum depression and a cut-off score of 60 (sensitivity 91% and specificity 72%) for major or minor depression. CONCLUSION: Based on the results of this psychometric testing, the PDSS is considered ready for use in routine screening of mothers.     

The Use of a Brief Depression Screen in Older Emergency Department Patients

Objectives: To determine the sensitivity and specificity of a brief two‐question depression screen for the detection of depression in older emergency department (ED) patients, and to determine the prevalence of depression in this population. Methods: This was a prospective, observational study. Participants included a convenience sampling of ED patients 70 years and older presenting to an urban teaching hospital over a 17‐month period. Exclusions were refusal to participate, inability to communicate, and critical illness. Subjects were screened for depression with the previously validated Short Form Geriatric Depression Scale (SFGDS). Standardized scores on the SFGDS were used to determine the prevalence of depression. Patients were then given a previously published two‐question depression screen, and results were compared with the SFGDS as the criterion standard. Sensitivity, specificity, and prevalence data are reported as proportions with 95% confidence intervals (95% CIs). Results: Two hundred sixty‐seven of 327 eligible patients were enrolled. Forty‐four (17%; 95% CI = 12% to 21%) scored positive for depression on the SFGDS. The sensitivity of the brief two‐question depression screen was 84% (37/44; 95% CI = 70% to 93%), with a specificity of 61% (136/223; 95% CI = 55% to 67%) using a cutoff score of at least one of two positive responses. Conclusions: Depression is fairly prevalent in older ED patients. The brief two‐question depression screen, using a cutoff score of at least one positive response, is promising for ED use. However, given lower specificity, patients scoring positive for depression should be followed up with a more specific tool such as the self‐administered SFGDS prior to referral for further evaluation and treatment.     

Postpartum depression screening scale: Spanish version

BACKGROUND: Postpartum depression is a global phenomenon. OBJECTIVE: The purpose of this study was to develop and psychometrically evaluate the Spanish version of the Postpartum Depression Screening Scale (PDSS). METHODS: Eight translators representing the predominant Hispanic groups in the United States translated the PDSS into a Spanish version. A total of 377 Hispanic mothers completed the PDSS-Spanish Version within 12 weeks postpartum at two sites: Connecticut and Texas. Confirmatory factor analysis and item response theory analysis were conducted to assess construct validity. RESULTS: For the total sample of 377 Hispanic women, the alpha reliability for the total PDSS was.95; dimension-level alphas ranged from.76 to.90. The total PDSS alphas by group were as follows: .94 (Mexican), .96 (Puerto Rican), and .93 (Other). Confirmatory factor analysis provided empirical support for the existence of the hypothesized constructs assessed by the PDSS. Item response theory analysis supported the adequacy of the construct definitions and confirmed that the response options for the Likert categories were an "ordered" attitude continuum in which higher responses corresponded to higher levels of "agreement" with the depressive symptomatology items. CONCLUSIONS: When compared to the original English PDSS, the reliability and validity psychometrics for the Spanish version were slightly lower, but still within the acceptable range.     

Detection of antinuclear antibodies by use of an enzyme immunoassay with nuclear HEp-2 cell extract and recombinant antigens: comparison with immunofluorescence assay in 307 patients

BACKGROUND: A new enzyme immunoassay (EIA) for automated detection of antinuclear antibodies (ANAs) uses a mixture of HEp-2 cell extracts and multiple recombinant nuclear antigens immobilized on beads. We compared this EIA and an immunofluorescence (IF) assay in a large group of patients and controls. METHODS: We studied 492 healthy individuals and 307 patients with connective tissue diseases (CTDs). Sera were tested by an automated EIA (COBAS Core HEp2 ANA EIA; Roche Diagnostics) and IF. Samples were also tested for eight disease-specific antibodies, including antibodies against U1RNP, Sm, SSA/Ro, SSB/La, Scl-70, Jo-1, dsDNA, and centromere. RESULTS: Areas under ROC curves for the EIA were greater than (P = 0.008-0.012) or numerically identical to areas for the IF method for each of six CTDs studied. ROC areas for EIA were 0.98 (95% confidence interval, 0.95-0.99), 0.99 (0.96-1.00), and 0.99 (0.98-1.00) in systemic lupus erythematosus (n = 111), systemic sclerosis (n = 39), and mixed connective tissue disease (n = 33), respectively. For all 258 CTD patients with conditions other than rheumatoid arthritis (RA), the sensitivity and specificity of the IF method at a cutoff dilution of 1:40 were 92% and 65%, respectively, vs 93% and 79% for the EIA at a cutoff of 0.6. For the IF method at a cutoff dilution of 1:160, sensitivity and specificity were 81% and 87%, respectively, vs 84% and 94%, respectively, for the EIA at a cutoff of 0.9. For 207 sera containing at least one of eight disease-specific ANAs, positivities for the EIA and the IF method were 97.1% and 97.6%, respectively, at cutoffs of 0.6 and 1:40 (P = 0.76). CONCLUSIONS: An EIA that can be performed by a fully automated instrument distinguishes CTDs (except RA) from healthy individuals with both higher sensitivity and specificity than the IF method when the cutoff index was set at 0.9. Moreover, it can be used to exclude the presence of disease-specific ANAs by setting the cutoff index at 0.6 with almost the same efficacy as the IF method.     

Plasma DNA as a prognostic marker in trauma patients

BACKGROUND: Recently, much interest has developed in the potential use of plasma DNA as a diagnostic and monitoring tool. We hypothesized that plasma DNA is increased in patients with trauma and may be prognostic in such patients. METHODS: We studied 84 patients who had sustained an acute blunt traumatic injury. We measured plasma DNA by a real-time quantitative PCR assay for the beta-globin gene. Blood samples were collected at a median time of 60 min following injury. Blood samples were also obtained from 27 control subjects. RESULTS: The median plasma DNA concentrations in the control, minor/moderate trauma (Injury Severity Score <16; n = 47), and major trauma (Injury Severity Score > or =16; n = 37) groups were 3154 kilogenome-equivalents/L, 13 818 kilogenome-equivalents/L, and 181 303 kilogenome-equivalents/L, respectively. Plasma DNA concentrations in patients with adverse outcomes, including acute lung injury, acute respiratory distress syndrome, and death, had 11. 6- to 12-fold higher plasma DNA concentrations than those who did not develop these complications. At a cutoff of 232 719 kilogenome-equivalents/L, the sensitivities of plasma DNA analysis for the prediction of acute lung injury, acute respiratory distress syndrome, and death were 100% (95% confidence interval, 100-100%), 100% (95% confidence interval, 100-100%), and 78% (95% confidence interval, 40-97%), respectively. The respective specificities were 81% (95% confidence interval, 71-89%), 80% (95% confidence interval, 70-88%), and 82% (95% confidence interval, 71-90%). CONCLUSIONS: Plasma DNA is increased after trauma and may be a potentially valuable prognostic marker for these patients.     

超声弹性评分联合实时超声弹性成像定量参数对良恶性甲状腺结节诊断价值分析

目的：探讨超声弹性评分联合弹性应变值[感兴趣区域（ROI）A值]对良、恶性甲状腺结节的诊断价值。方法对153例患者共计178个甲状腺结节进行超声弹性成像检查,计算弹性评分与ROI A值。以术后病理诊断为金标准,采用受试者工作特征曲线比较ROI A值、弹性评分与二者联合应用的诊断价值,并确定相应的最佳诊断界值。结果ROI A值诊断的最佳诊断界值为0．0017,此时灵敏度为82．46％、特异度为78．13％、准确度为80．90％、比值比为16．79;弹性评分诊断的最佳诊断界值为2．6,此时灵敏度为84．21％、特异度为81．25％、准确度为83．15％、比值比为23．11;以弹性评分2．6和ROI A值0．0017为界,二者联合诊断的灵敏度为78．95％、特异度为90．63％、准确度为84．15％、比值比为36．25。结论超声弹性评分联合实时超声弹性成像定量参数可以提高良、恶性甲状腺结节的诊断准确度。     

The measurement of disability-related stress in wheelchair users

OBJECTIVE: To measure disability-related stress through the development of the Physical Disability Stress Scale (PDSS) for wheelchair users. DESIGN: Cross-sectional. SETTING: General community. PARTICIPANTS: Sample of 119 wheelchair users with an acquired physical disability. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: General Health Questionnaire-28 (GHQ) and the World Health Organization Quality of Life (WHOQOL-BREF) (Australian version). RESULTS: Factor analysis of PDSS items revealed 4 main factors of disability-related stress: access accounted for 33.7% of the variance, physical for 8.4% of the variance, social for 7.9% of the variance, and burden of care for 7.2% of the variance. Internal consistencies for the 4 factors were within acceptable ranges (alpha range, .78-.83). Concurrent validity was shown with the PDSS factors predicting 7% to 23% of the variance in GHQ subscales and total score and 12% to 31% of the WHOQOL-BREF subscales. Participants scoring in the GHQ psychiatric group showed significantly higher stress levels on the physical, social, and burden of care factors of the PDSS compared with the GHQ nonpsychiatric group. CONCLUSIONS: The results suggest the PDSS factors are valid measures of disability-related stress with potential for clinical and research applications. Confirmatory factor analyses with larger sample sizes of wheelchair users are required to establish consistency in the measurement of disability-related stress.     

Development and validation of the Migraine Screen Questionnaire (MS-Q)

AIM: To develop and evaluate the clinimetric properties of a new migraine screening questionnaire: the Migraine Screen Questionnaire (MS-Q). BACKGROUND: Migraine is a public health problem requiring screening programs and tools to ensure early detection. METHODS: A questionnaire was developed based on the criteria of the International Headache Society (IHS) and a review of the literature by a committee of experts. Stage I: The original version of the MS-Q was distributed by mail and completed by Pfizer employees and self-administered to neurological patients; all subjects were afterward evaluated by a neurologist who was blinded to the MS-Q results, to establish an independent IHS diagnosis. Stage II: A final version of the MS-Q was administered to neurological patients to confirm clinimetric properties. Logistic regression and receiver-operator characteristic curve statistical methods were used and the 95% confidence interval, sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values, were estimated. RESULTS: Of the 605 subjects recruited, 465 were evaluable (325 in stage I and 140 in stage II). Of the original 15 items, 5 conformed the final version of the MS-Q: frequency and intensity of headache; a duration of between 4 hours and 3 days; nausea; sensitivity to light/noise; and disability. A cutoff point of > or = 4 points showed a sensitivity of 0.93 (95% CI = 0.87 to 0.99), specificity of 0.81 (95% CI = 0.72 to 0.91), PPV of 0.83 (95% CI = 0.75 to 0.91), and NPV of 0.92 (95% CI = 0.85 to 0.99). Cronbach's alpha coefficient = 0.82. CONCLUSIONS: The MS-Q showed adequate validity and reliability, and it could be a good screening tool for application to clinical practice and research.     

Postpartum depression: the reliability of telephone screening

PURPOSE: This study evaluated the reliability of screening women for symptoms of postpartum depression by a telephone assessment after hospital discharge. STUDY DESIGN: Correlational design with a convenience sample of women from a Midwestern community hospital. METHODS: One hundred and twenty-six women agreed to participate prior to hospital discharge and 106 women were in the final sample (response rate 84%). Telephone contact was made 8 weeks after discharge, when the Postpartum Depression Screening Scale was administered. RESULTS: Twenty-seven percent of the women screened had scores indicating moderate-to-severe depression (score range 60-128). Reliability coefficients were calculated on the data for the short and long forms of the PDSS, as well as for all seven subscales (alpha coefficients were .72 and .94, respectively, for the short- and long-form totals). Subscale scores for the 35-item form were as follows: sleeping/eating disturbances .80, anxiety/insecurity .77, emotional lability .82, mental confusion .80, loss of self .87, guilt/shame .82, and contemplating harming oneself.90. The correlation between the short-form total and the long-form total was r = .91 (p = < 01.) Studies using the PDSS as an in-person instrument were compared with scores for telephone screening, and the overall mean scores were similar. CONCLUSION: Telephone screening is a reliable method to screen for postpartum symptomatology that may occur later than the 6-week office visit. Women who are at risk, especially those who have a history of treatment for depression, current treatment for depression or increased anxiety, should be screened for postpartum depression symptomatology.     

3种评分系统在慢性阻塞性肺疾病急性加重期患者预后评估中应用的比较

目的比较简化英国胸科协会改良肺炎评分(CRB-65)、BAP-65及DECAF评分系统判断COPD急性加重期(AECOPD)患者预后的诊断效能。方法回顾性收集2017年1月—2018年12月于郑州大学第一附属医院呼吸内科住院治疗的181例AECOPD患者的临床资料及CRB-65、BAP-65、DECAF评分指标。根据患者转归情况,将患者分为病情平稳组(患者出院,121例)和病情危重组(患者转入ICU或死亡,60例),比较两组的临床资料和评分工具得分。以患者死亡和入住ICU为观察终点,分别计算CRB-65、BAP-65及DECAF评分系统判断患者预后的灵敏度、特异度及准确率。绘制3种评分的ROC曲线,并计算曲线下面积(AUC),寻找判断预后的最佳切点。结果病情危重组近1年的发作次数、CRB-65评分、DECAF评分及BAP-65评分级别均高于病情平稳组(t值分别为-4.899、-31.748、-34.611、7.227;P<0.001)。CRB-65评分、BAP-65评分及DECAF评分预测患者疾病转归的最佳截断点分别为≥3分、≥Ⅲ级、≥3分,灵敏度分别为70.00%、81.67%、90.00%,特异度分别为61.16%、77.69%、83.47%,准确率分别为64.09%、79.00%、85.63%。DECAF评分、BAP-65评分及CRB-65评分判断AECOPD患者预后的AUC分别为0.811(95%CI:0.845~0.948)、0.774(95%CI:0.707~0.869)及0.669(95%CI:0.595~0.779),DECAF评分判断AECOPD患者预后的AUC高于BAP-65评分和CRB-65评分(Z值分别为3.891、4.799;P值分别为0.026、0.005)。结论CRB-65、BAP-65及DECAF评分对预测AECOPD患者预后均有一定的临床价值,其中DECAF预测效能最高,CRB-65更方便快捷。     

定向-记忆-注意测验和简短老年人认知功能下降知情者问卷电话筛查痴呆

目的定向-记忆-注意测验(OMCT)是常识-记忆-注意测验(IMCT)的简短版本,16项的简短老年人认知功能下降知情者问卷(s-IQCODE)是26项完全版的缩减版本。本研究探讨它是否可以用于电话筛查及有什么优缺点。方法本研究包括65例痴呆患者和67例健康对照者。痴呆诊断标准参照DSM-IV。知情者陪同研究对象参加测试。OMCT和s-IQCODE都用于面访和电话访问。结果面访和电话访问的相关系数很高(r=0.883-0.957)。OMCT和s-IQCODE电话应用的信度也令人满意。根据教育程度确定的OMCT的界限值为:文盲14/15,小学10/11,中学及以上8/9。按照这个界限值敏感性和特异性分别为81.5%和82.1%。s-IQCODE的界限值为3.38/3.44,敏感性和特异性为86.1%和81.9%。结论量表的简短版本的效度与完全版没有太大的变化。电话筛查是早期发现痴呆的一个有效的方法。联合应用知情者问卷和简短认知测验可以弥补电话筛查的不足。     

两种筛查量表早期发现产后抑郁的效果对比

目的比较产后抑郁筛查量表（PDSS）和爱丁堡产后抑郁量表（EPDS）在产后抑郁筛查中的应用价值。方法采用PDSS、EPDS及美国精神障碍诊断与统计手册第4版轴Ⅰ障碍定式临床检查患者版（SCID—I／P）同时对445名产后6周的妇女进行评定,以SCID—I／P作为产后抑郁诊断金标准。结果两种量表的临界值分别为74分和10分。PDSS的灵敏度（93．33％）和特异度（94．75％）的组合较好。PDSS与EPDS的ROC曲线下面积分别为0．978和0．872,差异均有统计学意义（P均〈0．05）。结论与EPDS相比,PDSS具有较好的筛检价值,是早期发现产后抑郁患者的简单、快速、准确的筛查工具。     

Ultrasound Training for Emergency Physicians— A Prospective Study

OBJECTIVES: Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course. METHODS: In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered. RESULTS: In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4). CONCLUSIONS: Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.     

肾脏超声联合指标对非脓毒症危重患者急性肾损伤的预测价值

目的:探讨肾动脉阻力指数（renal resistive index,RRI）和肾能量多普勒超声（power Doppler ultrasound,PDU）半定量评分联合指标对入住重症监护室（intensive care unit,ICU）的非脓毒症患者发生急性肾损伤（acute kidney injury,AKI）的预测价值。方法:采用前瞻性观察性研究的方法,纳入2018年1月至2019年8月期间于沧州市中心医院急诊ICU住院的非脓毒症危重患者作为研究对象。记录一般资料;于入ICU 6 h内应用医学超声仪完成RRI和PDU半定量评分测量。入ICU第5天依据改善全球肾脏病预后组织（KDIGO）标准评估肾功能,按肾功能情况分为AKI 3期组（入ICU 5 d内进展为AKI 3期）和AKI 0~2期组（未发生AKI或发生AKI 1或2期）。分别在非脓毒症和急性心力衰竭患者中比较不同AKI分期两组间各指标的差异。计量资料两组间比较采用独立样本 t检验或Mann-Whiney秩和检验。计数资料两组间比较采用卡方检验。绘制受试者工作特征曲线（receiver operator characteristic,ROC）分析RRI、PDU评分、RRI-RDU/10、RRI/PDU和RRI+PDU对AKI 3期的预测价值。使用Delong检验方法比较每个预测因子之间ROC曲线下面积的差异。 结果:共纳入110例非脓毒症危重患者（无AKI 51例,AKI 1期21例,AKI 2期11例,AKI 3期27例）,其中急性心力衰竭患者63例（无AKI 21例,AKI 1期15例,AKI 2期7例,AKI 3期20例）。在非脓毒症患者及急性心力衰竭患者中,AKI 3期患者的急性生理学与慢性健康状况（APACHEⅡ）评分、序贯器官衰竭（sequential organ failure assessment,SOFA）评分、动脉乳酸水平、机械通气比例、血管活性药物比例、28 d病死率、肌酐、RRI、RRI-PDU/10、RRI/PDU、RRI+PDU及连续性肾脏替代治疗（continuous renal replacement therapy,CRRT）比例均明显高于AKI 0~2期患者（ P<0.05）;而尿量和PDU评分明显低于AKI 0~2期患者（ P<0.05）。非脓毒症患者中,RRI/PDU[曲线下面积(AUC)=0.915,95%可信区间( CI)：0.846~0.959, P<0.01）及RRI+PDU（AUC=0.914,95% CI：0.845~0.959, P<0.01）对AKI 3期的预测价值最高,且两者与RRI（AUC=0.804,95% CI：0.718~0.874, P<0.01）和PDU评分（AUC=0.868,95% CI：0.791~0.925, P<0.01）,差异均有统计学意义（均 P<0.05）;RRI/PDU预测AKI 3期的最佳临界值为0.355（灵敏度92.6%,特异度81.9%,约登指数0.745）;RRI-PDU/10（AUC=0.899,95% CI：0.827~0.948, P<0.01）对AKI 3期的预测价值亦优于RRI和PDU评分,但较RRI/PDU和RRI+PDU略差,仅RRI与RRI-PDU/10之间差异有统计学意义（ P<0.05）。在急性心力衰竭患者中,RRI/PDU（AUC=0.962,95% CI：0.880~0.994, P<0.01）及RRI+PDU（AUC=0.962,95% CI：0.880~0.994, P<0.01）对AKI 3期的预测价值亦最高,且两者与RRI（AUC=0.845,95% CI：0.731~0.924, P<0.01）和PDU评分（AUC=0.913,95% CI：0.814~0.969, P<0.01）两两间均差异有统计学意义（均 P<0.05）;RRI/PDU预测AKI 3期的最佳临界值为0.360（灵敏度95.0%,特异度90.7%,约登指数0.857）;RRI-PDU/10（AUC=0.950,95% CI:0.864~0.989, P<0.01）对AKI 3期的预测价值亦优于RRI和PDU评分,但较RRI/PDU和RRI+PDU略差,仅RRI与RRI-PDU/10之间差异有统计学意义（ P<0.05）。 结论:RRI和PDU评分的联合指标可有效预测非脓毒症患者发生AKI 3期,尤其在急性心力衰竭患者中表现更优。RRI与PDU评分的比值对AKI 3期的预测价值以及实用价值最好,建议临床推广应用。     

肾脏超声联合指标对非脓毒症危重患者急性肾损伤的预测价值

目的:探讨肾动脉阻力指数（renal resistive index,RRI）和肾能量多普勒超声（power Doppler ultrasound,PDU）半定量评分联合指标对入住重症监护室（intensive care unit,ICU）的非脓毒症患者发生急性肾损伤（acute kidney injury,AKI）的预测价值。方法:采用前瞻性观察性研究的方法,纳入2018年1月至2019年8月期间于沧州市中心医院急诊ICU住院的非脓毒症危重患者作为研究对象。记录一般资料;于入ICU 6 h内应用医学超声仪完成RRI和PDU半定量评分测量。入ICU第5天依据改善全球肾脏病预后组织（KDIGO）标准评估肾功能,按肾功能情况分为AKI 3期组（入ICU 5 d内进展为AKI 3期）和AKI 0~2期组（未发生AKI或发生AKI 1或2期）。分别在非脓毒症和急性心力衰竭患者中比较不同AKI分期两组间各指标的差异。计量资料两组间比较采用独立样本 t检验或Mann-Whiney秩和检验。计数资料两组间比较采用卡方检验。绘制受试者工作特征曲线（receiver operator characteristic,ROC）分析RRI、PDU评分、RRI-RDU/10、RRI/PDU和RRI+PDU对AKI 3期的预测价值。使用Delong检验方法比较每个预测因子之间ROC曲线下面积的差异。 结果:共纳入110例非脓毒症危重患者（无AKI 51例,AKI 1期21例,AKI 2期11例,AKI 3期27例）,其中急性心力衰竭患者63例（无AKI 21例,AKI 1期15例,AKI 2期7例,AKI 3期20例）。在非脓毒症患者及急性心力衰竭患者中,AKI 3期患者的急性生理学与慢性健康状况（APACHEⅡ）评分、序贯器官衰竭（sequential organ failure assessment,SOFA）评分、动脉乳酸水平、机械通气比例、血管活性药物比例、28 d病死率、肌酐、RRI、RRI-PDU/10、RRI/PDU、RRI+PDU及连续性肾脏替代治疗（continuous renal replacement therapy,CRRT）比例均明显高于AKI 0~2期患者（ P<0.05）;而尿量和PDU评分明显低于AKI 0~2期患者（ P<0.05）。非脓毒症患者中,RRI/PDU[曲线下面积(AUC)=0.915,95%可信区间( CI)：0.846~0.959, P<0.01）及RRI+PDU（AUC=0.914,95% CI：0.845~0.959, P<0.01）对AKI 3期的预测价值最高,且两者与RRI（AUC=0.804,95% CI：0.718~0.874, P<0.01）和PDU评分（AUC=0.868,95% CI：0.791~0.925, P<0.01）,差异均有统计学意义（均 P<0.05）;RRI/PDU预测AKI 3期的最佳临界值为0.355（灵敏度92.6%,特异度81.9%,约登指数0.745）;RRI-PDU/10（AUC=0.899,95% CI：0.827~0.948, P<0.01）对AKI 3期的预测价值亦优于RRI和PDU评分,但较RRI/PDU和RRI+PDU略差,仅RRI与RRI-PDU/10之间差异有统计学意义（ P<0.05）。在急性心力衰竭患者中,RRI/PDU（AUC=0.962,95% CI：0.880~0.994, P<0.01）及RRI+PDU（AUC=0.962,95% CI：0.880~0.994, P<0.01）对AKI 3期的预测价值亦最高,且两者与RRI（AUC=0.845,95% CI：0.731~0.924, P<0.01）和PDU评分（AUC=0.913,95% CI：0.814~0.969, P<0.01）两两间均差异有统计学意义（均 P<0.05）;RRI/PDU预测AKI 3期的最佳临界值为0.360（灵敏度95.0%,特异度90.7%,约登指数0.857）;RRI-PDU/10（AUC=0.950,95% CI:0.864~0.989, P<0.01）对AKI 3期的预测价值亦优于RRI和PDU评分,但较RRI/PDU和RRI+PDU略差,仅RRI与RRI-PDU/10之间差异有统计学意义（ P<0.05）。 结论:RRI和PDU评分的联合指标可有效预测非脓毒症患者发生AKI 3期,尤其在急性心力衰竭患者中表现更优。RRI与PDU评分的比值对AKI 3期的预测价值以及实用价值最好,建议临床推广应用。     

Towards prevention of acute lung injury: identification of emergency department patients at risk

ABSTRACT: BACKGROUND: Early identification of patients at risk of developing acute lung injury (ALI) is critical for potential preventive strategies. We aimed to derive and validate an acute lung injury prediction score (EDLIPS) in a multicenter sample of emergency department (ED) patients. METHODS: We performed a subgroup analysis of 4,361 ED patients enrolled in the previously reported multicenter observational study. ED risk factors and conditions associated with subsequent ALI development were identified and included in the EDLIPSmodel. Scores were derived and validated using logistic regression analyses. The model was assessed with the area under the receiver-operating curve (AUC) and compared to the original LIPS model (derived from a population of elective high-risk surgical and ED patients) and the Acute Physiology and Chronic Health Evaluation (APACHE II) score. RESULTS: The incidence of ALI was 7.0% (303/4361). EDLIPS discriminated patients who developed ALI from those who did not with an AUC of 0.78 (95% CI 0.75, 0.82), better than the APACHE II AUC 0.70 (p <= 0.001) and similar to the original LIPS score AUC 0.80 (p = 0.07). At an EDLIPS cutoff of 5 (range -0.5, 15) positive and negative likelihood ratios (95% CI) for ALI development were 2.74 (2.43, 3.07) and 0.39 (0.30, 0.49), respectively, with a sensitivity 0.72(0.64, 0.78), specificity 0.74 (0.72, 0.76), and positive and negative predictive value of 0.18 (0.15, 0.21) and 0.97 (0.96, 0.98). CONCLUSION: EDLIPS may help identify patients at risk for ALI development early in the course of their ED presentation. This novel model may detect at-risk patients for treatment optimization and identify potential patients for ALI prevention trials.     

Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery

A repeated measure design was used to evaluate additional psychometric qualities (sensitivity and specificity) of the Critical-Care Pain Observation Tool (CPOT), a previously validated tool, in intubated intensive care unit (ICU) adults after cardiac surgery recruited in a university cardiology health center in Canada. Patients were evaluated while conscious and intubated (n=99/105), and extubated (n=105). For each of these two testing periods, patients were evaluated using the CPOT at rest (pre-exposure), during a nociceptive procedure-turning (exposure), and 20 minutes after the procedure (postexposure). The patients' self-reports of pain were obtained while intubated and extubated. During the nociceptive exposure, the CPOT had a sensitivity of 86%, a specificity of 78%, a positive likelihood ratio (LR(+)) of 3.87 (1.63-9.23), and a negative LR (LR(-)) of 0.18 (0.09-0.33) and was effective for the screening of pain. It also showed good specificity (83% and 97%) but lower sensitivity (47% and 63%) during nonexposure conditions. The CPOT cutoff score was >2 during the nociceptive exposure. After extubation, patients' self-reports of pain intensity were associated with the positive CPOT cutoff score previously determined. The CPOT adequately classified most of the patients with severe pain. The CPOT seems to be a useful tool to detect pain in intubated postoperative ICU adults, especially during a nociceptive procedure. Sensitivity and specificity of the CPOT need to be further explored during other nociceptive procedures and with different critically ill populations.     

Verbal dyspnoea score predicts emergency department departure status in patients with shortness of breath

Objectives: We examined whether a previously validated verbal dyspnoea rating scale, and/or other demographic and clinical parameters, could predict ED departure status, among ED patients presenting with shortness of breath. Methods: In this prospective observational study, a convenience sample of patients presenting to an inner urban adult tertiary hospital ED with shortness of breath were assessed at triage using objective and subjective breathlessness parameters. These included respiratory rate, oxygen saturation, heart rate, systolic blood pressure and verbal dyspnoea scores. A verbal dyspnoea score for worst dyspnoea during the current episode and basic demographic and presentation characteristics were also collected. These variables were assessed as predictors of ED departure status (inpatient admission or ED discharge) using logistic regression. Results: From a sample of 253 participants, verbal dyspnoea scores ≥8 predicted inpatient admission 89% specificity (95% confidence interval [CI] 82.1–93.4), and scores ≤3 predicted discharge with 95% specificity (95% CI 89.5–98.0). For patients with shortness of breath as the primary complaint, the combination of verbal dyspnoea score ≥6, heart rate ≥94 bpm at triage and ambulance arrival predicted admission with 90% sensitivity (95% CI 82–95%) and 84% specificity (95% CI 73–92%). These same variables predicted admission for all patients with 84% sensitivity (95% CI 75.8–89.2) and 79% specificity (95% CI 71.5–85.5). Conclusion: Verbal dyspnoea score, alone and in combination with heart rate and arrival transport, can accurately predict admission. Once validated they might be useful in assessing, prioritizing and making rapid site of care decisions for breathless patients presenting to the ED.     

Pulmonary Embolism Risk Stratification: Pulse Oximetry and Pulmonary Embolism Severity Index

Background: Risk stratification of pulmonary embolism (PE) patients is important to determine appropriate management. Objectives: We evaluated two published risk-stratification tools in emergency department (ED) PE patients: a pulse oximetry cutoff below 92.5% oxygen (at 5280 feet elevation) and the Pulmonary Embolism Severity Index (PESI). Methods: Electronic medical records of all patients diagnosed with PE were abstracted to identify their triage vital signs, co-morbidities, and adverse short-term outcomes (AO) either requiring interventions (defined as respiratory failure, hypotension requiring pressors, and hemodynamic impairment requiring thrombolytics) or resulting in death. We applied these models to our ED PE patients and assessed their performance. Results: There were 168 PE patients identified, with an overall AO rate of 7.1% (12/168), including a 3.0% mortality rate. A room-air pulse oximetry cutoff of 92.5%, for values measured at 5280 feet, classified 89/136 patients as low risk, 1.1% of which had an AO, and 47/136 patients as high risk, of which 10.6% had AO. This pulse oximetry cutoff had a sensitivity of 83% (95% confidence interval [CI] 36–99%), specificity of 68% (95% CI 58–76%), and a negative predictive value (NPV) of 99% (95% CI 93–100%). PESI classified 91/168 patients as low risk (class I or II): 2.2% had AO but none died, and 77/168 were classified as high risk (class III, IV, or V), with an AO rate of 13.0%. A PESI cutoff score of II had a sensitivity of 83% (95% CI 52–98%), specificity of 57% (95% CI 49–65%), and NPV of 98% (95% CI 92–100%). Conclusion: Both PESI and pulse oximetry measurements are moderately accurate identifiers of low-risk patients with PE.     

Midregional pro-A-type natriuretic peptide measurements for diagnosis of acute destabilized heart failure in short-of-breath patients: comparison with B-type natriuretic peptide (BNP) and amino-terminal proBNP

BACKGROUND: The aim of the present study was to assess the utility of amino-terminal pro-A-type natriuretic peptide (NT-proANP) measurements for the emergency diagnosis of acute destabilized heart failure (HF), using a novel sandwich immunoassay covering midregional epitopes (MR-proANP). METHODS: The retrospective analysis comprised 251 consecutive patients presenting to the emergency department of a tertiary care hospital with dyspnea as a chief complaint. The diagnosis of acute destabilized HF was based on the Framingham score for HF plus echocardiographic evidence of systolic or diastolic dysfunction. A commercially available immunoluminometric assay was used for measurement of MR-proANP plasma concentrations. RESULTS: Median MR-proANP plasma concentrations were significantly higher in patients with dyspnea attributable to acute destabilized HF (338 pmol/L; n = 137) than in patients with dyspnea attributable to other reasons (98 pmol/L; n = 114; P <0.001). The area under the curve for MR-proANP was 0.876 (SE = 0.022; 95% confidence interval, 0.829-0.914), and the cutoff concentration with the highest diagnostic accuracy was 169 pmol/L (sensitivity, 89%; specificity, 76%; diagnostic accuracy, 83%). In the setting evaluated, diagnostic information obtained by MR-proANP measurements was similar to that obtained with B-type natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) measurements. CONCLUSIONS: MR-proANP measurements may be useful as an aid in the diagnosis of acute destabilized HF in short-of-breath patients presenting to an emergency department. The diagnostic value of MR-proANP appears to be comparable to that of BNP and NT-proBNP.