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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter to the Editor &#8220;Usefulness of the PIRO system to predict mortality in patients with severe infection in the emergency department&#8221; by Dr&#46; Rubio Diaz and Dr&#46; Juli&#225;n-Jim&#233;nez&#46; We congratulate the authors who performed a replication study of &#8220;Validation of the Predisposition Infection Response Organ &#40;PIRO&#41; dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department&#8221;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> in a big cohort of septic patients from a Spanish Emergency Department &#40;ED&#41;&#46; The authors used the PIRO method &#40;by Howell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#41; at the admittance in their ED to predict 30 days mortality and ICU admittance and observed a 30 days mortality rate in their sample that is similar to the original study<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> and to other PIRO validation studies performed in the ED&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> in hospital wards<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;4</span></a> and in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recently Cardoso et al&#46; that validated the original PIRO score in a large cohort of septic patients at admittance in general ward and in ICU<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> obtaining similar results&#46; In my opinion the prognostic role of PIRO for mortality is confirmed by all these studies and it allow to recommend for its use in ED&#44; High Dependency Units and ICU settings aiming to stratify patients with sepsis by the risk of a poor outcome&#46; This categorization is useful to guide clinical management&#44; performing slightly better than the easier qSOFA&#59; however&#44; this complex and comprehensive prognostic staging system is also useful to categorize patients in trials&#44; creating homogeneous populations to evaluate treatment effectiveness without biases and to compare results of different studies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Both Caramello et al&#46; and Diaz et al&#46; studies showed a reduced performance of PIRO in predicting ICU admissions&#44; that was outperformed by SOFA in the first and by qSOFA and 5MPB-Toledo score in the second&#46; Considering the complexity of obtaining the PIRO calculation in the ED the authors are against its use in the ED to predict ICU admission&#46; Nevertheless&#44; although valuable for its simplicity&#44; in our study qSOFA showed a poor performance and many authors suggest improving qSOFA effectiveness by associating lactates<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> or inflammation markers<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> levels&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Indeed&#44; the usefulness of PIRO to predict ICU admission is lower than SOFA&#44; but this result could be biased by the fact that the clinical decision to admit in ICU is often based on the severity of organ disfunction&#44; strictly related to the SOFA score and described by the &#8220;O&#8221; component only&#46; On the contrary&#44; PIRO includes a more comprehensive evaluation of prognostic factors&#44; pertaining to the individual patient &#40;Predisposition&#44; assessing complexity and frailty&#41;&#44; the pathogen &#40;Infection and infection site&#41; and the immune response &#40;Response&#41;&#46; It is possible that PIRO stage III and IV could include many older and frail patients who are not eligible for invasive management&#46; The Predisposition&#44; Infection and Response factors&#44; on the contrary&#44; strongly affect morbidity&#44; mortality&#44; hospital length of stay and functional decline after the acute septic event&#44; thus PIRO could perform better in evaluating those outcomes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">I was really interested in reading about the 5MPB-Toledo score&#44; previously validated to predict bacteriaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> It includes comorbid conditions &#40;by Charlson comorbidity index&#41;&#44; infection markers &#40;procalcitonin&#41; immune response &#40;rise in leucocyte count&#41; and severity &#40;temperature and respiratory rate&#41;&#44; like a quick version of PIRO&#46; It could be interesting to evaluate if the variables included in the Toledo score are the strongest predictors of mortality among those included in PIRO&#46; I wonder if this tool could be internationally validated for mortality and ICU admission by further studies&#44; better defining the diagnostic and prognostic importance of this score&#46;</p></span>"
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Letter to the Editor
Reply to “Usefulness of the PIRO system to predict mortality in patients with severe infection in the emergency department”
Respuesta a “Utilidad del sistema PIRO para predecir mortalidad en el paciente con infección grave en el servicio de urgencias”
V. Caramelloa,
Autor para correspondencia
, A.V. De Salvea, A. Macciottab, A. Boccuzzia
a Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, regione Gonzole 10, 10043 Orbassano, Turin, Italy
b Department of Clinical and Biological Science, University of Turin, Orbassano (TO), Italy
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter to the Editor &#8220;Usefulness of the PIRO system to predict mortality in patients with severe infection in the emergency department&#8221; by Dr&#46; Rubio Diaz and Dr&#46; Juli&#225;n-Jim&#233;nez&#46; We congratulate the authors who performed a replication study of &#8220;Validation of the Predisposition Infection Response Organ &#40;PIRO&#41; dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department&#8221;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> in a big cohort of septic patients from a Spanish Emergency Department &#40;ED&#41;&#46; The authors used the PIRO method &#40;by Howell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#41; at the admittance in their ED to predict 30 days mortality and ICU admittance and observed a 30 days mortality rate in their sample that is similar to the original study<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> and to other PIRO validation studies performed in the ED&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> in hospital wards<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;4</span></a> and in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recently Cardoso et al&#46; that validated the original PIRO score in a large cohort of septic patients at admittance in general ward and in ICU<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> obtaining similar results&#46; In my opinion the prognostic role of PIRO for mortality is confirmed by all these studies and it allow to recommend for its use in ED&#44; High Dependency Units and ICU settings aiming to stratify patients with sepsis by the risk of a poor outcome&#46; This categorization is useful to guide clinical management&#44; performing slightly better than the easier qSOFA&#59; however&#44; this complex and comprehensive prognostic staging system is also useful to categorize patients in trials&#44; creating homogeneous populations to evaluate treatment effectiveness without biases and to compare results of different studies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Both Caramello et al&#46; and Diaz et al&#46; studies showed a reduced performance of PIRO in predicting ICU admissions&#44; that was outperformed by SOFA in the first and by qSOFA and 5MPB-Toledo score in the second&#46; Considering the complexity of obtaining the PIRO calculation in the ED the authors are against its use in the ED to predict ICU admission&#46; Nevertheless&#44; although valuable for its simplicity&#44; in our study qSOFA showed a poor performance and many authors suggest improving qSOFA effectiveness by associating lactates<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> or inflammation markers<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> levels&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Indeed&#44; the usefulness of PIRO to predict ICU admission is lower than SOFA&#44; but this result could be biased by the fact that the clinical decision to admit in ICU is often based on the severity of organ disfunction&#44; strictly related to the SOFA score and described by the &#8220;O&#8221; component only&#46; On the contrary&#44; PIRO includes a more comprehensive evaluation of prognostic factors&#44; pertaining to the individual patient &#40;Predisposition&#44; assessing complexity and frailty&#41;&#44; the pathogen &#40;Infection and infection site&#41; and the immune response &#40;Response&#41;&#46; It is possible that PIRO stage III and IV could include many older and frail patients who are not eligible for invasive management&#46; The Predisposition&#44; Infection and Response factors&#44; on the contrary&#44; strongly affect morbidity&#44; mortality&#44; hospital length of stay and functional decline after the acute septic event&#44; thus PIRO could perform better in evaluating those outcomes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">I was really interested in reading about the 5MPB-Toledo score&#44; previously validated to predict bacteriaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> It includes comorbid conditions &#40;by Charlson comorbidity index&#41;&#44; infection markers &#40;procalcitonin&#41; immune response &#40;rise in leucocyte count&#41; and severity &#40;temperature and respiratory rate&#41;&#44; like a quick version of PIRO&#46; It could be interesting to evaluate if the variables included in the Toledo score are the strongest predictors of mortality among those included in PIRO&#46; I wonder if this tool could be internationally validated for mortality and ICU admission by further studies&#44; better defining the diagnostic and prognostic importance of this score&#46;</p></span>"
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