Jan C. ter Maaten’s research while affiliated with University of Groningen Medical Center and other places

Background Early sepsis diagnosis is essential to allow timely initiation of adequate care. The TriVerity™ Test, performed on the Myrna™ Instrument, is the first rapid high-multiplex host-response mRNA diagnostic test that supports clinical decision-making by evaluating the likelihood of bacterial and/or viral infections and severity of illness. We present findings of the first, proof of concept, real-world evaluation in an emergency department (ED). Methods Blood was collected in PAXgene ® Blood RNA tubes from adult patients visiting the ED with suspicion of infection between 4th December 2023 and 22nd January 2024. TriVerity was performed within 1 h (RNA extraction and amplification of 29 host mRNAs using LAMP technology on the Myrna Instrument within approximately 30 min). TriVerity generates three diagnostic scores (likelihood of bacterial infection, viral infection, and illness severity), each classified into five discrete interpretation bands (very low, low, moderate, high, and very high). Post hoc chart reviews were performed after hospital discharge to clinically adjudicate the infection status (consensus and forced adjudication). Results Among 60 patients, there were 20 (33%) bacterial infections, 15 (25%) viral infections, 11 (18%) bacterial–viral coinfections and 14 (23%) did not have an infection under forced adjudication. Under consensus adjudication, bacterial results demonstrated 95% rule-in specificity and 95% rule-out sensitivity. Viral results demonstrated rule-in specificity 100% and 92% rule-out sensitivity. Since only three patients were admitted to the ICU or died in this cohort, we cannot draw firm conclusions about the predictive value of the test for severe endpoints. Conclusions TriVerity is a rapid whole-blood host-response test to reliably detect the presence or absence of bacterial and/or viral infections, as well as to assess illness severity in patients presenting to the ED. Its quick turnaround time aligns with the ED workflow, offering timely insights for clinical decision-making. Results from upcoming large-scale validation studies will provide more detailed results on the diagnostic and prognostic accuracy of the test.

Background Point-of-care ultrasound (POCUS) can potentially be used in the triage of patients with elbow injuries. However, the diagnostic accuracy of POCUS performed by non-radiologists for the exclusion of elbow fractures is yet unknown. This study aimed to investigate the diagnostic potential of POCUS of the posterior fatpad performed by non-radiologists in the workup of adult patients presenting with elbow injuries. Methods A multicentre, prospective cohort study was conducted between January 2021 and August 2022 in four EDs to determine the diagnostic accuracy of an elevated posterior fatpad on POCUS to demonstrate or exclude an elbow fracture in patients presenting with elbow injuries to the ED. The study population consisted of a convenience sample. In patients ≥16 years of age with an elbow injury for which an X-ray was ordered, POCUS was performed by emergency physicians trained in ultrasound. POCUS (index test) results were compared with X-ray outcomes (reference standard) to determine the diagnostic accuracy of POCUS. Results A total of 215 patients were included, 143 (67%) of whom had a fracture confirmed on X-ray. POCUS was positive based on a visualised elevated posterior fatpad in 127 (59%) patients. An elevated posterior fatpad on POCUS had a sensitivity of 91% (95% CIs 85% to 95%), a specificity of 93% (95% CI 85% to 98%), a negative likelihood ratio of 0.10 (95% CI 0.06 to 0.16) and a positive likelihood ratio of 13.09 (95% CI 5.61 to 30.54) for the presence of an elbow fracture. Post hoc review of the images by expert sonographers improved sensitivity to 96% (95% CI 91% to 99%). Conclusion POCUS of the posterior fatpad is a promising adjunct to physical examination to determine the need for further diagnostic studies in the triage of patients with elbow injuries. Sensitivity after a limited training is high, but not perfect, and can likely further be improved with additional training.

Background As iatrogenic hyperoxia has been related to adverse outcomes in critically ill patients, guidelines advise to titrate oxygen to physiological levels. In the prehospital setting where partial arterial oxygen (PaO 2 ) values are often not readily available, titration of oxygen is based on peripheral oxygen saturations (SpO2). In this study we aimed to investigate the efficacy of SpO 2 guided oxygen titration in the prevention of hyperoxia. Methods In a retrospective observational cohort study of patients included in the Acutelines data- and biobank of the University Medical Center Groningen between September 2020 and March 2023, we collected blood gas samples and triage data of sequentially included patients who received oxygen at the moment they were presented in the emergency department (ED). PaO 2 values were compared to (concurrently measured) SpO 2 values, and to patient- and treatment characteristics and P/F ratios were calculated in order to investigate the efficacy of SpO 2 based oxygen titration for various subgroups. Results Blood gas samples were obtained for 1042 patients, of which 178 (17.1%) had hyperoxia (PaO 2 levels > 13.5 kPa). SpO 2 readings were available for 170 of these, 68 of which (40%) had SpO 2 values above the recommended target range (94–98%; 88–92% for patients with COPD) whereas 102 patients (60%) had SpO2 values within- or even below the recommended target range. Many of these patients (44.1%) received oxygen through a low-flow device (nasal canula), and these patients almost invariably (84.4%) were not compromised in their ventilation (P/F ratio’s > 300). Conclusion When oxygen is titrated based on SpO 2 levels, this results in hyperoxemia in a significant proportion of the patients. Health care providers should especially be reluctant to administer (low flow) oxygen as a standard of care to patients who do not have clear respiratory compromise, as these patients are at a high risk of developing (occult) hyperoxia.

Purpose Sepsis is a leading cause of morbidity and mortality globally. The lack of specific prognostic markers necessitates tools for early risk identification in patients with suspected infections in emergency department (ED). This study evaluates the prognostic accuracy of various Early Warning Scores (EWS)—MEWS, NEWS, NEWS-2, and qSOFA—for in-hospital mortality, 30-day mortality, and ICU admission, considering the site of infection. Methods A retrospective analysis was conducted using data from the Acutelines cohort, which included data collected from patients admitted to the University Medical Centre Groningen ED between September 2020 and July 2023. Patients were included if they had an ICD-10 code for infection. EWS were calculated using clinical data within 8 h post-admission. Predictive performance was assessed using AUC-ROC, calibration by the Hosmer-Lemeshow test and calibration curves, and operative characteristics like sensitivity and specificity. Results A total of 1661 patients were analyzed, with infections distributed as follows: lower respiratory tract (32.9%), urinary tract (30.7%), abdominal (12.5%), skin and soft tissue (9.5%), and others (8.2%). The overall in-hospital mortality was 6.7%, and ICU admission was 7.1%. The highest AUC-ROC for in-hospital mortality prediction was observed with NEWS and NEWS-2 in abdominal infections (0.86), while the lowest was for qSOFA in skin and soft tissue infections (0.57). Predictive performance varied by infection site. Conclusions The study highlights the variability in EWS performance based on infection site, emphasizing the need to consider the source of infection in EWS development for sepsis prognosis. Tailored or hybrid models may enhance predictive accuracy, balancing simplicity and specificity.