No abstract

Background Distinguishing sepsis from other inflammatory syndromes continues to be a clinical challenge. The goal of risk stratification tools is to differentiate sepsis from other conditions. We compare the ability of quick sepsis-related organ failure assessment (qSOFA) and systemic inflammatory responses syndrome (SIRS) scores to predict prolonged length of stay (LOS) among patients who presented to the emergency department and hospital ward with acute pancreatitis (AP). Methods We compiled a retrospective database of all adult patients hospitalized for AP during 2015 - 2018 at a single tertiary care center. Independent t -tests, Pearson’s correlation and multiple regressions were performed with hospital LOS as the dependent variable, versus demographic characteristics and etiology of the pancreatitis as independent variables. Prolonged LOS was defined as > 5 days. Results The sensitivity and specificity of an SIRS score of 2 or greater for the detection of patients with prolonged LOS were 61% and 80%, respectively. The qSOFA score of 2 or greater corresponded to a diagnosis of significant AP with a specificity of 99% and a sensitivity of 4%. Multiple regression analysis demonstrated that each point increase in an SIRS score is associated with 2.24 days in additional hospital LOS. Interestingly, SIRS scores were found to correlate with the LOS, but not qSOFA. Conclusion The qSOFA is a tool designed to identify patients at high risk of mortality due to sepsis. The data suggest that as with sepsis, patients with AP who are triaged with only qSOFA could be underrecognized and subsequently undertreated. Secondarily, the data suggest that SIRS scoring has the potential to promptly predict how long patients with AP will stay in the hospital.

served as controls. Using samples from over 20 patients in four groups, we first conducted a discovery study to identify peptide variables that were significant across disease development (control vs. IPS) and time (day 0 vs. day of Dx or day 14 for controls). This revealed a set of 81 IPS-associated proteins that were verified by a number of methods, analyzed by ingenuity pathway analysis (IPA) and mapped to relevant immune pathways. IPA underscored a significant contribution of the acute phase response (TNFa / IL-6) signaling pathway during disease progression and revealed striking similarities between inflammation engendered during IPS in humans and mice. In the second verification analysis, we used only samples collected on day 0 from a larger cohort of patients to identify proteins that were effective variables for patient stratification. Identified peptides were subjected to predictive model building using the Ishwaran & Rao approach, which identified a set of robust plasma proteomic markers that could 1) predict the development of IPS, and 2) identify individuals who would ultimately respond to etanercept therapy. Analysis also revealed a number of novel proteins including attractin, lumican and LBP (the expression of which was verified by ELISA) that were significant in the discovery analysis and classifiers for disease development and or response to therapy. In sum, data generated in this translational research endeavor confirm previous clinical and experimental observations, provide new insights into the pathophysiology of IPS and identify a set of robust markers predictive for disease progression and response to therapy. As anti-TNF therapies are being developed as treatment for GVHD and other immune-mediated disorders, these results uncover a set of robust markers for patient stratification as a basis for individualized therapy that is ripe for further development.

Background Communication failures occur often in the inpatient setting. Efforts to understand and improve communication often exclude patients or are siloed by discipline. Objective We aimed to identify barriers and facilitators to effective communication within interdisciplinary inpatient internal medicine (IM) teams using a participatory research approach. Design We conducted a single‐center participatory mixed methods study using group‐level assessment (GLA) and concept mapping to iteratively engage stakeholders. Stakeholder groups included patients/families, IM faculty, IM residents, nurses and ancillary staff, and care managers. Stakeholder‐specific GLA sessions were conducted. Participants responded to prompts addressing interdisciplinary communication then worked in small groups to synthesize the qualitative data into unique ideas. A subset of each stakeholder group then sorted ideas through a concept mapping exercise. Multidimensional scaling and hierarchical cluster analysis were used to generate a concept map of the data. Results Participants generated 97 unique ideas that were then sorted. The research team chose an eight‐cluster concept map representing patient inclusion and engagement, processes and resources, team morale and inclusive dynamics, attitudes and behaviors, effective communication, barriers to communication, the culture of healthcare, and clear expectations. Three larger domains of patient inclusion and engagement, organizational conditions and role clarity, and team dynamics and behaviors were noted. Conclusion Use of a participatory research approach made it feasible to engage diverse stakeholders including patients. Our results highlight the need to identify context‐specific facilitators and barriers of interdisciplinary communication. The importance of clear expectations was identified as a prioritized area to target communication improvement efforts.