Letter to the editor

Should scoring rules be based on odds ratios or regression coefficients?

The goal of this study is to look into the factors that lead to death in patients with necrotizing soft tissue infections（NSTIs） in the intensive care unit and create a mortality risk model.

The clinical data of 106 patients with necrotizing soft tissue infections admitted to intensive care unit(ICU) of the First Affiliated Hospital of Wenzhou Medical University between January 2008 and December 2021 were retrospectively analyzed. Univariate analysis and multivariate analysis were performed to evaluate the risk factors impacting patient mortality. The regression coefficient in binary logistic regression analysis was converted into the item score in the model, and then the model score of each patient was calculated. Finally, an ROC curve was constructed to evaluate the efficiency of the model for predicting mortality. Thirteen patients with NSTIs admitted to ICU between January 2022 and November 2022 were used to validate the model.

The death group had 44 patients, while the survival group had 62 patients. The overall mortality was 41.5%. Binary logistic regression analysis showed that risk factors for mortality were age≥ 60 years(OR:4.419; 95%CI:1.093–17.862; P = 0.037), creatinine ≥ 132μmol/L(OR:11.166; 95%CI:2.234–55.816; P = 0.003), creatine kinase ≥ 1104 U/L(OR:4.019; 95%CI:1.134–14.250; P = 0.031), prothrombin time ≥ 24.4 s(OR:11.589; 95%CI:2.510–53.506; P = 0.002), and invasive mechanical ventilation (OR:17.404; 95%CI:4.586–66.052; P＜0.000). The AUC of the model for predicting mortality was 0.940 (95% CI:0.894–0.986). When the cut-off value for the model was 4 points, the sensitivity was 95.5% and the specificity was 83.9%.

The death risk model in this study for NSTIs patients in the intensive care unit shows high sensitivity and specificity. Patients with a score of ≥ 4 points have a higher risk of mortality.

Visual impairments are common in people with polyhandicap although they are poorly assessed. However, evaluation of the visual abilities of these people is critical to determining treatment for impairments.

To develop and validate an easy-to-use visual-behavioural scale for assessing the visual abilities of people with polyhandicap.

The development of the Visual Assessment for People with Polyhandicap (VA-PLH) involved 2 steps: i) construction of the scale and ii) field validation. Participant selection criteria were aged > 3 years, age at onset of cerebral lesion < 3 years, a combination of motor impairment and profound intellectual impairment associated with restricted mobility (Gross Motor Function Classification System levels [GMFCS] III, IV or V), and everyday life dependence (Functional Independency Measure [FIM] <55). Vision assessment by both an orthoptist and an ophthalmologist was the reference against which were analysed the items of the scale completed by local health care workers. Acceptability, validity, and reliability were analysed.

Amongst the 232 participants included, 217 had a complete assessment, and 33% were < 18 years of age. Ocular abnormalities were reported in 83% of participants. Visual ability was altered or insufficient in 60% of participants. The final version of the VA-PLH included 3 items related to visual reaction (Area Under Curve Receiver Operating Characteristic = 0.83). Participants were considered at-risk if they had at ≥ 1 of 3 signs present (sensitivity 83% and specificity 73%). The scale's reliability was satisfactory

The VA-PLH scale provides an easy-to-use, reliable and valid measure of visual status for people with polyhandicap and may be used both in clinical practice and clinical research. In addition, this study provides an overview of the diversity of visual impairments in a large population of people with polyhandicap, showing that most experience visual challenges.

Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some ‘non-high-risk’ patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in ‘non-high-risk’ AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality.

A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year.

Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death.

The majority of ‘non-high-risk’ patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients.

Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some ‘non-high-risk’ patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in ‘non-high-risk’ acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably ‘non-high-risk’ patients who are identified as being at increased risk of death.

To develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments.

We analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009–5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration.

The MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161).

Certain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.

Active infectious bovine respiratory disease (BRD) is an infection of the airways that needs to be diagnosed correctly so that appropriate treatment can be initiated. The simplest and most practical test to detect active BRD in dairy calves raised for veal is the detection and interpretation of clinical signs by producers or technicians. However, the clinical scoring system currently available for veal calves lacks sensitivity and specificity, contributing to economic losses and high use of antimicrobials. An accurate and reliable batch-level test to detect active BRD is essential to tailor antimicrobial use and reduce economic losses in veal calves. The objective of this study was therefore to develop and validate a new veal calf respiratory clinical scoring system (VcCRS), including reliable clinical signs (cough, ear droop or head tilt) and increased rectal temperature to detect active BRD in batches of veal calves housed individually, and to describe the accuracy of the scoring system for identifying batches of veal calves to treat. During 2017 to 2018, clinical examination, thoracic ultrasonography (TUS) and a haptoglobin concentration (Hap) were prospectively performed on 800 veal calves housed individually in Québec, Canada. Deep nasopharyngeal swabs were performed on 250 veal calves. A Bayesian latent class model accounting for imperfect accuracy of TUS and Hap was used to obtain weights for the clinical signs and develop the VcCRS. The VcCRS was then validated externally in 3 separate data sets. Finally, the applicability of the VcCRS at batch level was determined. We found that calves with 2 of the following findings—cough, unilateral or bilateral ear droop or head tilt, or increased rectal temperature ≥39.7°C—were considered positive and had a 31% chance of having active BRD. Without at least 2 of these 2 findings, a calf had a 100% chance of not having active BRD. At the batch level, we found that a batch with ≥3 positive calves among 10 calves sampled 2 wk after arrival at the fattening unit had a 94% chance of having an active BRD prevalence ≥10%. A batch with <3 positive calves had a 95% chance of not having an active BRD prevalence ≥10%. In this study, we developed a simple individual and batch-level score that is reliable across examiners and performs effectively in the detection of active BRD in veal calves. The implementation of this VcCRS in the veal calf industry would promote the elaboration of a protocol tailoring antimicrobial use.