Talk:Sepsis/Archive 2

Update needed
This Cochrane review has been updated, newest publication needs to be consulted and cited. I can assist with access for an editor interested. - - MrBill3 (talk) 04:44, 8 December 2014 (UTC)

Plasma exchange
Insufficient evidence to recommend PLEX for septic shock. 10.1186/s13054-014-0699-2 JFW &#124; T@lk  22:32, 20 December 2014 (UTC)


 * And the benefit from albumin the SAFE trial was reproduced on meta-analysis. 10.1186/s13054-014-0702-y JFW &#124; T@lk  22:34, 20 December 2014 (UTC)

Reliability of source?
This is not strictly labeled as a review on PubMed and is called a "special communication" on JAMA Internal Medicine, but appears to be a secondary source. http://www.ncbi.nlm.nih.gov/pubmed/23752755 Thoughts? TylerDurden8823 (talk) 20:45, 23 December 2014 (UTC)


 * It is a secondary source, but not a great one. JFW &#124; T@lk  23:00, 23 December 2014 (UTC)
 * Can you expand on why? I kind of guessed this would be the reaction (and this is why I asked about it first), but I'm curious to hear thoughts on why this wouldn't be a great source. Is it because it's a short "special communication" and not really labeled a formal review? The journal JAMA Internal Medicine is good, no? TylerDurden8823 (talk) 23:44, 23 December 2014 (UTC)

Yes, JAMA Internal Medicine is pretty good. The paper in question seems to be heavy on opinion. We could cite it as a source to support a statement saying that "in some patient groups, particular interventions may be too aggressive and carry a higher risk of harm than is justified by their condition" or something along those lines. JFW &#124; T@lk  10:16, 4 June 2015 (UTC)

Proposal-a classification section
I don't know if a classification section has been proposed for this article before, but I was thinking about it when looking through the diagnosis section. Specifically, I was thinking we could put the following text into a classification section of its own instead of putting it in the diagnosis section.

Definitions[edit] According to the American College of Chest Physicians and the Society of Critical Care Medicine, there are different levels of sepsis:[9]

Systemic inflammatory response syndrome (SIRS) is the presence of two or more of the following: abnormal body temperature, heart rate, respiratory rate or blood gas, and white blood cell count. Sepsis is defined as SIRS in response to an infectious process.[20] Severe sepsis is defined as sepsis with sepsis-induced organ dysfunction or tissue hypoperfusion (manifesting as hypotension, elevated lactate, or decreased urine output).[1] Septic shock is severe sepsis plus persistently low blood pressure despite the administration of intravenous fluids.[1]

Thoughts? TylerDurden8823 (talk) 08:41, 17 February 2015 (UTC)
 * I often make "classification" a subsection of diagnosis. Doc James  (talk · contribs · email) 18:34, 17 February 2015 (UTC)
 * That's fair. I just wanted to put it out there. TylerDurden8823 (talk) 18:37, 17 February 2015 (UTC)

Electronic alerts based on EMR data
... do not work 10.1002/jhm.2347 (secondary source). JFW &#124; T@lk  10:06, 4 June 2015 (UTC)

EGDT
I think the edits made by are reasonable, but we desperately need a good secondary source that replaces the individual trials. The discussion should definitely cover EGDT, but in a broader sense. Better still, we need a bit of an explanation why EGDT doesn't work. JFW &#124; T@lk  18:16, 12 July 2015 (UTC)
 * Have added a review.  Doc James  (talk · contribs · email) 18:50, 12 July 2015 (UTC)


 * 10.1007/s00134-015-3822-1 is a meta-analysis of the EGDT trials. EGDT does not confer a mortality benefit but increases use of vasopressors and other ICU resources. JFW &#124; T@lk  09:06, 7 September 2015 (UTC)

Sepsis-associated immune dysfunction
How does CARS work? 10.1172/JCI82224 JFW &#124; T@lk  09:17, 5 January 2016 (UTC)
 * Title="Sepsis-induced immune dysfunction: can immune therapies reduce mortality?" but content needs subscription/payment. What does it say about CARS ?
 * CARS = Compensatory anti-inflammatory response syndrome.
 * The Compensatory Anti-inflammatory Response syndrome (CARS) in Critically ill patients(full text) mentions sepsis.
 * I guess we need to expand Compensatory anti-inflammatory response syndrome (which I created as a redirect for now). - Rod57 (talk) 01:08, 29 February 2016 (UTC)

New definitions in 2016
[http://www.pharmacypracticenews.com/Web-Only/Article/02-16/New-Definitions-Created-for-Sepsis-and-Septic-Shock/35399/ses=ogst New Definitions Created for Sepsis and Septic Shock. Feb 2016] says new definitions proposed? by US and Europe task force - Not clear when they might be adopted/used. - Rod57 (talk) 00:53, 29 February 2016 (UTC)


 * They should still be mentioned. JFW &#124; T@lk  14:30, 25 April 2016 (UTC)

Does sepsis increase long-term mortality
Not necessarily 10.1186/s13054-016-1276-7 JFW &#124; T@lk  14:30, 25 April 2016 (UTC)

Prehospital care
... has been poorly studied despite its importance in remote areas. 10.1136/emermed-2015-205261 JFW &#124; T@lk  09:37, 23 May 2016 (UTC)

Copyedit
Although comprehensive and well referenced, some of this article is written in very clunky English and it would benefit from a copyedit. I don't intend to do this myself as I don't want to run the risk of inadvertently modifying information. --Ef80 (talk) 13:47, 7 January 2017 (UTC)

"Septicaemia" got lost on the way
It redirects here, but is not mentioned anywhere (unless you count in the caption of the WWII propaganda poster). I am a layman, but judging by the paper quoted here below, they're not fully synonymous. So? Sepsis, septicaemia, sepsis syndrome, and septic shock: the correct definition and use. Thanks, Arminden
 * We say "The terms septicemia and blood poisoning referred to the microorganisms or their toxins in the blood and are no longer commonly used" in the lead
 * Added it to the body aswell  Doc James  (talk · contribs · email) 07:07, 31 July 2016 (UTC)

Hi, and thanks. I had given a search for "septicaemia" and it didn't show up. Because of the spelling! Will take care of it now. Cheers, ArmindenArminden (talk) 08:14, 31 July 2016 (UTC)


 * What is the name of the sysmptomes caused by wounding oneself with a contaminated object (eg: rusty nails and the like)? I expected the article for sepsis cover this accident as well as the onset of typical symtomes and the necessary steps to be taken in such cases. what I found instead, is an article with a very broad, generic idea of sepsis as contrasted to the old fashioned blood poisononing and with absolutely no practical information regarding the later. I appreciate science's developement, that implies now the meaning of sepsis in a much broader term than what i was told as a child about getting sick with blood poisoning when a wound caused by some a dirty, soiled, or rusty object is not given proper care, but i wish that the information regarding latter would be not hidden from the public. The poster used for illustration does mention "scratch" through which sepsis can be caused, which impies, that in those dark times people were aware of the dangers of "a rusty nail caused wound". Its sad, tht this is not available knowledge anymore. I think this article needs a section dealing with the "blood poisoning caused by a wound", even if the term itself fell out of favor.

176.63.176.112 (talk) 22:45, 29 December 2016 (UTC).

Well, I guess i was looking for Tetanus. Still, just to avoid confusion, the article probably could make a mention of both conditions and a warning against confusion of one with the other. 176.63.176.112 (talk) 23:08, 29 December 2016 (UTC).

No, the tetanus article does not deal with "blood poisoning from an infected wound", so I am still at loss. Probably the proverbial blood poisoning is just any kind of wound infection that could be caused by a wide variety of bacteria. I am still wondering, why this condition is not covered in any of the related articles. 176.63.176.112 (talk) 23:31, 29 December 2016 (UTC).
 * You are probably thinking of a systemic bacterial infection originating from a wound. 'Blood poisoning' is sometimes used to refer to this in popular conversation, even if there is no sepsis. Tetanus is something different and much more specific. --Ef80 (talk) 13:57, 7 January 2017 (UTC)

Norfolk doctor found a treatment for sepsis
This seems to be new, but untested.


 * Paul Marik now needs to design an actual randomised controlled trial. Ideally it should be factorial because steroids in sepsis remain very contentious. JFW &#124; T@lk  10:42, 29 March 2017 (UTC)

I agree now, though at first I didn't, about the need to produce new studies that replicate the result, that are larger, and more widespread, and that eventually are randomally controlled, double-blind clinical statistical studies. As I have heard, there have been way too many previous false hopes with sepsis. With that being said, it is a potentially cheap remedy for a very, very devastating problem, particularly if it isn't caught soon and if it gets too worse. I would not oppose a short mention, not a long or medium one, of it, under Other, until more data is available, because the new discovery may be authorized for use by some doctors even if it is not authorized by a government agency or has been through trials, in certain desperate situations.98.215.153.31 (talk) 01:09, 1 April 2017 (UTC)
 * High-quality double blind randomized controlled trials are absolutely necessary to test Dr. Marik's hypothesis before this idea can be accepted and implemented into medical practice. It would be great if it works but presently the proposed therapy remains unproven. It's premature to mention this in the article at this time. Tons of various therapies are being investigated for sepsis and septic shock and very few have panned out despite promising preliminary results. TylerDurden8823 (talk) 06:10, 1 April 2017 (UTC)

Yes, I agree. At least one or two (hopefully large and long-term) randomized double-blind controlled studies are needed. One level I study will be launched and is being planned, and other physicians are using studies with larger groups of patients, or are intervening with individual patients. I will follow the matter and let you all know if anything positive that is significant happens.98.215.153.31 (talk) 01:22, 3 April 2017 (UTC)


 * @TylerDurden8823, Well, I would like to question your statement. We all agree that Dr. Marik's preliminary research needs to go through more rigorious tests to be approved (therefore it is called preliminary), and he explicitly asked for that, plus looks like Stanford University has expressed interest in doing more research already.  However, his preliminary research is good enough to be used as an off-label use of combination of hydrocortisone with vitamin C, even if only like Pascal's Wager.  As Dr. Marik indicated, there are virtually no side effects, there is virtually no cost associated with this therapy, the preliminary stats are very encouraging, and the potential outcome is that people will not die.  (My understanding is that those 4 people out of 47 that died during the study died because of non-sepsis reasons.)
 * Marik is the chief of pulmonary and critical care at EVMS, where Catravas is the sr. associate dean for basic research, regents professor, director vascular biology center at Medical College of Georgia. I would assume that they want to keep their jobs, and do more research.  Your questioning their finding can be seen as questioning the credibility of research in medical schools in US, or at least labeling EVMS and Medical College of Georgia as a Voodoo following universities.
 * Lastly, maybe the issue is just the context used. I agree that this entry doesn't belong to the approved therapies section; however, the  Management / Other section already has some other not approved therapies, and is a perfect section to write about those preliminary findings. 50.148.168.19 (talk)  —Preceding undated comment added 02:04, 3 April 2017 (UTC)
 * All therapies must be subjected to rigorous testing regardless of where or whom they come from, even if that's Dr. Marik. This proposed treatment hasn't been adequately tested or discussed in secondary sources. I think it's too early to mention it. I'm not questioning Dr. Marik's credibility, his findings, or that of EVMS nor am I questioning that it would be a cost-effective therapy if it works. The fact remains that it simply hasn't yet undergone sufficiently rigorous testing. In my opinion, it's premature to discuss this in our sepsis article. We don't typically mention studies of this size (e.g., uncontrolled non-blinded pilot studies) even if someone notable like Dr. Marik led the effort. After Marik's proposed treatment undergoes this testing, it will be worth mentioning. That's how I see it. TylerDurden8823 (talk) 03:47, 3 April 2017 (UTC)
 * would agree(obviously) w/ TylerDurden8823 --Ozzie10aaaa (talk) 19:16, 3 April 2017 (UTC)
 * Again, there is no one who suggests that no further testing is needed, so no point harping on this subject. Although, you do question those preliminary findings from respected universities when you say "I think it's too early to mention it," "in my opinion, it's premature ...,", or "we don't typically mention ..."  You are just riding empty adjectives when you don't specify any criteria when per Wikipedia this information can be added.  The 'Others' section is designed exactly for that type of information that further could be either debunked, or promoted to the 'approved therapies' level.  Many people volunteered to add this info here (unfortunately in the wrong place, maybe wrongly worded), many people voiced their opinion that they want to see it here.   So, to me the respectable preliminary research is there, the quorum was met, and the consensus was reached to have it added.  50.148.168.19 (talk)  —Preceding undated comment added 04:21, 3 April 2017 (UTC)


 * I just found this article worth reading, especially the section that talks about the need of RCTs in this case, as well as the lack of level-I evidence for the current sepsis treatments. Also this article I would recommend to read.  Those two reads (IMO) provide additional support for inclusion of this provisional research in the 'Other' section. 50.148.168.19 (talk)
 * I strongly disagree with your assessment of those adjectives as "empty" and as critiquing the universities. That's a red herring. The other section uses WP:MEDRS-compliant secondary sources for other therapies that have been examined. There aren't any for this yet. The EM blog is interesting and I've read it before. The lack of level I evidence for other sepsis therapies isn't a good reason to mention this here. I still disagree with adding this material at this point.


 * There is strong precedent within WP:MED not to discuss treatments that are not supported with secondary sources. This is no exception. As an encyclopedia we should be adverse to discussing hyped treatments. I refer you to the dichloroacetate-for-cancer débâcle from a few years back. This was hyped sky-high and has since been shown to be a false dawn; DCA is still sold online unscrupulously by quacks.
 * Once there are some actual RCT data we can talk further. JFW &#124; T@lk  13:08, 3 April 2017 (UTC)


 * Sorry, but 'Tons of various therapies ...' is just an empty steatement, 'sufficiently rigorous testing' is another example, etc. All that sounds like you are spreading FUD to me.
 * Looks like right now the only potential holdup is the lack of secondary sources. I do understand the need for secondary sources, as well as RCA tests, please don't take me wrong, I am all for that where appropriate.  However, please re-read your 'there is strong precedent ...' statement - that is not a rule, but precedent that you are leaning on.  This therapy looks like qualifies as a precedent as well.  I also disagree with your comparison to DCA, as you are trying to use one extremely bad case as a guidance for everything else.  Why didn't you use eteplirsen as an example where RCTs are placebo level, implying that secondary sources and RCTs are meaningless in some cases.  Yes, eneplirsen is just another bad example but driving in a different direction.  This is not an expensive athlete's foot treatment with a 0.01 improvement over the placebo.  In those two links, people provided arguments why it may be seen controversial to do RCTs with this treatment (based on claims, there is almost no mortality).  Also, per those articles this isn't a futuristic theoretical treatment, it's something that's being done right now as standard-of-care' at several Virginia hospitals..'  Just reading that statement, it puts you in possition of trying to make Wikipedia holier-than-thou.   So, you do go against established universities, established hospitals, an emerging standard-of-care procedue, where you are beating the bushes about the rules and regulations, and position of power you want to display.  Again, we are not talking about placing this info into the 'approved therapies' section, but rather 'Others' which by definition is meant to talk about the new and experimental research. 50.148.168.19 (talk) 17:34, 3 April 2017 (UTC)
 * as indicated above, several times, it all goes back toIdentifying_reliable_sources_(medicine)--Ozzie10aaaa (talk) 23:42, 3 April 2017 (UTC)


 * I have to agree with you that it all goes back to that article. If you read that article, you would be siding with me, though.  Please, take a look at the 'Basic advice' section there, especially where a single primary source worth mentioning is described.  This is exactly what we are discussing here.  50.148.168.19 (talk) 02:40, 4 April 2017 (UTC)


 * The reason this "protocol" has been adopted in several Virginia hospitals is that the treatment is cheap and easy to administer with limited risk of complications. If this was a technological innovation or an expensive drug, there would be much more emphasis on conducting proper trials.
 * Several authors have now expressed concern on this page that we should not be discussing preliminary results, even despite the media coverage. You are free to request further comments by posting a message on WT:MED. JFW &#124; T@lk  10:24, 6 April 2017 (UTC)


 * Really? Do we need to go that low?  Let me see whether I understand what you just wrote.
 * By quoting the word protocol, you question whether it is a real protocol. So, now you are an expert to question what several ICUs in respectable hospitals can/should do, and are in position to ridicule that.
 * You stated that those hospitals adopted this protocol because it is cheap and easy to administer with limited risk of complications. Are those the main or only reasons to establish a protocol in your opinion?  If that is the case, hospitals would be administering biscuits as a panacea, as they cost nothing, can be self administered, and have no risk of complications - so perfectly fulfill your stated requirements.  How come, you refrained yourself from stating the main reasons why those hospitals implemented this protocol, even if you don't agree with those?
 * Not sure how to interpret your if this was a technological innovation or an expensive drug statement. However, as above you just sound as you are an expert in the field to dismiss those finding, because they don't suit your taste. That is a classic FUD to me.
 * Again we go with empty adjectives - proper trials. So far, there were no attempts in this thread to define what trials would be appropriate in this case, assuming that the preliminary findings are true.  If you are pushing RCTs, then looks like you don't understand ethical ramifications of those in high mortality in control groups, neither the ethical side of telling people to undergo such trials.
 * Yes, I can go with the 'argument' that several authors have expressed concerns, and counter it with the exact opposite, that also several authors expressed that they support to have it in this article.
 * You are also free to request further comments on WT:MED about RCTs and the need for secondary sources.
 * Having said that (what brings nothing to this discussion, but is being pushed ad nauseam), let's focus on the points that we can discuss. 50.148.168.19 (talk) 02:14, 9 April 2017 (UTC)

Based on the above exchange, I would suggest that we focus only on those issues below. 1. Need for secondary sources. Identifying reliable sources article, especially the second paragraph of Basic advice section (supplied by Ozzie...), permits to add such preliminary study to the article if:
 * a. it is permitted to add to an article primary research information before the scientific community has analyzed and commented on results - yes, we are in this situation
 * b. when conclusions are worth mentioning - that is the fact that we are arguing about it (besides all the findings from the study, what should be rather the primary reason)
 * c. as long as they are described as from a single study - yes, we do have an intention to describe it like that, and also place in 'Other' section of the article
 * Furthermore, that section provides guidance about what to do if there are no further studies in a reasonable amount of time.

2. Need for RCTs. Looking at Wikipedia's RCT article section Ethics we can see that:
 * a. RCTs should not be run or should be aborted if the control subjects have poorer outcomes
 * Per latest statements from Dr. Marik, that one hospital treated about 150 patients with one death due to sepsis (the reported four in the original trial were claimed not be due to sepsis), what gives the mortality ratio of 150:1 vs 3:1 (assumming 30% for sepsis, what is rather low). So, this condition is met.
 * b. where patients agreement may be difficult to get (in this case due to poorer outcomes) - I think that the ratios above speak why no one sane would like to risk a 30-70% possibility of dying where the new treatment possibilities are less than 1%

3. Serialized RCTs. Assuming that one could design a serialized RCT and find volunteers to potentially be in the a control group, after the first cycle of serialized test (one death in both cases) such trials should be aborted due to above #2.a reasons. (In my opinion, calls for RCT studies in this case sound like trying to force a Mengele type of tests/experiments.) Based on above, I would propose to use the text from the Identifying reliable sources article, i.e., change: A large, NIH-funded study published in 2010 found that selenium and Vitamin E supplements increased risk of prostate cancer; they were previously thought to prevent prostate cancer. to ''A preliminary study by Dr. Paul Marik published in 2016 found that hydrocortisone, vitamin C and thiamine therapy drastically reduced mortality rate in sepsis. During his preliminary study, the mortality rate was 8.5%, where in a similar group treated with standard therapies was 40.4%. There are currently no other studies that could either confirm or disprove this therapy.'' And add it to 'Other' section of the main article. Also, based on that Wikipedia's guiding article, we can potentially agree how long will we wait for more results before that entry will need to be taken down if there are no more publications about it. 50.148.168.19 (talk) 02:23, 9 April 2017 (UTC)
 * I was just reading this NPR piece which points out that hundreds of treatments just as exciting as this one have been previously identified but turned out not to be effective. (That's a bit more precise than "tons".  Yes, that fact should inspire doubt and uncertainty, and shouldn't be dismissed as FUD.  It also does not prove that this treatment is ineffective.)  Given that context, I think it's appropriate to assume this won't pan out, and ignore it unless it does actually hold up in a randomized controlled trial.  For some reason, this particular treatment has garnered national media attention, and that is a counter-argument for including it now (because "follow the sources" and because people will be looking here for more information about it).  That media attention might be fairly random (maybe one reporter noticed the story, thought it was important, and other outlets repeated it), or maybe the authors hyped up the result more than other more humble authors. With such an important disease, there is a huge temptation to make a splashy announcement and enjoy a considerable amount of (at least temporary) fame, if not profit.
 * Yes, this happens even at reputable institutions with well-meaning investigators; I'm sure some people aren't even seeking fame but see a positive result that seems life-saving and rush to spread the news without stopping to seriously think it might be a completely bogus finding. That's fine; we wouldn't want a breakthrough treatment to go unnoticed, and at some point nearly every treatment is just an unsupported hypothesis.  But that's what replication studies and RCTs are for - to separate really justified vs. unjustified excitement.


 * This treatment is nowhere near well-tested enough to justify skipping a randomized controlled study and just giving it to everyone on ethical grounds. Qualify evidence summarizes Identifying reliable sources (medicine) and warns us to avoid writing about results from single studies, especially those that have not had time for scientific articles criticizing them to be published.  For example, in this case, the methodology of how cases were classified into "dead from sepsis" vs. "dead from underlying disease" could be questioned, and that would produce just completely wrong results due to confirmation bias. That sort of problem is almost unavoidable when the study isn't blind, and this one certainly wasn't.  The sample size was also pretty low, so there's a relatively high probability the extremely good-looking results would have happened by chance, even if the treatment is 0% effective.


 * If mentioned in the article, I think the low quality of the study and the context should be clearly explained to readers to "qualify evidence" thoroughly; "preliminary" doesn't really explain how reliable or unreliable the study was, especially to non-scientific readers. To the above proposed text, I would add:


 * The study was not blinded, was not randomized, and used a small sample size, meaning that the unusually positive result could relatively easily have been due to bias on the part of the researchers, unrelated differences in the two populations being compared, or random chance. Similarly promising early results have been reported for hundreds of other sepsis therapies which upon further research turned out to be completely ineffective.


 * Those qualifications are pretty hefty, and do seem to indicate it's probably not worth mentioning. If we had to include hundreds of equally unconfirmed treatments in the article, it would be a big mess and not very helpful to readers.  Identifying reliable sources (medicine) considers a single study to be worth mentioning if it is a large, randomized controlled trial with a surprising result.  This study was neither large nor randomized, so I don't think it really what that page had in mind.  The next logical time to add mention of this treatment would be when the first study to replicate its positive result comes out, assuming that ever happens, especially if other scientists find it well-constructed. If you want to learn more about the "proper" design of a medical study, here is a great article. Our own Clinical study design could use a lot of improvement describing how studies can go wrong. "Proper" techniques are not those aligned with some arbitrary academic conventions - what people mean by that is studies with designs shown to be significantly more reliable than "improper" studies by mathematical analysis and centuries of empirical findings. -- Beland (talk) 09:02, 9 April 2017 (UTC)


 * yes sepsis is kind of like stroke. really hard to treat and every effort has gone down in flames. There is no way that this article should discuss this one until it is discussed in a review per MEDRS.  It may never be.  Jytdog (talk) 09:09, 9 April 2017 (UTC)


 * I wonder if it would be better to just mention the large number of treatments tested and failed, rather than point at any particular one, because that's actually a rather interesting and entirely verifiable fact. -- Beland (talk) 10:20, 9 April 2017 (UTC)
 * @Beland, Thank you for your feedback. I found this article to be worth reading.  As far as mention the large number ..., I think that it is too general, and applies to virtually anything.  50.148.168.19 (talk) 17:35, 9 April 2017 (UTC)


 * I suggest folks stop talking generally as that is not what this page is for; if anybody has an actual proposal for sourced content about Marik's suggested treatment, please propose it here so we can focus. Jytdog (talk) 21:17, 9 April 2017 (UTC)
 * That is what I was trying to do in those three points above - be relevant to that treatment. There are already two proposals for the text, one by me (below those three points), and one by Beland.  I would still propose mine (as it is verbatim per the example given in 'Identifying reliable sources' page); however, would not mind putting some extra language there.  50.148.168.19 (talk) 00:20, 10 April 2017 (UTC)
 * I just noticed the History section says "over 150 clinical trials of sepsis had been conducted in humans, almost of them supported by promising data in mice, and that all of them had failed". I think the article is probably fine as it is wither regard to unconfirmed treatments. -- Beland (talk) 17:57, 16 May 2017 (UTC)
 * How is that relevant to this discussion? Those hospitals are already using it as a standard protocol (not as trials).  All tests were done on humans, so why bring up mice?  Are we out of bullets here?  Again, the issue is about those three bullets above (when we can skip second sources, when RCTs may be non-ethical, how serialized RCTs work), and this topic satisfies all those three bullets.  50.161.49.33 (talk) 06:48, 23 May 2017 (UTC)
 * I think it's pretty clear there's a consensus not to add the material about Marik's solitary study now. This conversation isn't really productive or going anywhere anymore. Time will tell if this treatment works with replication studies and further trials (if/when they occur). TylerDurden8823 (talk) 07:03, 23 May 2017 (UTC)
 * Well yes but more relevant to WP is - we can discuss it in the article when it is discussed in a MEDRS source -  a literature review in a good journal for example. :) Jytdog (talk) 12:59, 23 May 2017 (UTC)

Diagnosis / Blood Cultures
Relating to Jytdog edit of Unseen remnant posting. Jytdog, can you please identify which sources in my recent edit are not high quality? I believe them to be. Thank you. — Preceding unsigned comment added by Unseen remnant (talk • contribs) 19:54, 6 October 2017 (UTC)
 * Please see WP:MEDDEF for the definition of "primary source". Several of them were primary sources.  We build content about health from secondary sources (as defined there).  if you are still unclear about what a "primary source" is after looking at the definitions there please let me know. Jytdog (talk) 20:25, 6 October 2017 (UTC)

I'd like to modify the diagnosis section a bit to include a sub-section on blood cultures, and I wanted to run it by you prior to making the change so that if there are any issues, you can tell me now, rather than having to remove my edits.

I believe these changes are necessary because blood cultures are increasingly recognized as an important part of sepsis detection and are generally regarded as part of the "gold standard" for diagnosis of sepsis. Recent research as well as statements by clinical organizations have focused on the need to reduce blood culture contamination as part of improving how sepsis is detected and subsequently treated. Another recent development that has caused increased medical interest in blood cultures has been the emphasis by clinical organizations and federal health authorities on reducing antimicrobial resistance and improving antimicrobial stewardship. These relate directly to sepsis, especially because inaccurate measuring of potential sepsis leads to overuse of antibiotics which carries safety risks for patients and has been demonstrated to increase the cost of care.

Hospitals are now required by the government to develop antimicrobial stewardship programs – a new requirement in which proper collection and analysis of blood cultures is important. As shown in the referenced peer-reviewed clinical journal articles (Garcia et al. and Hall et al.), meta-analyses and other large-scale reviews of blood culture contamination show the relationship to sepsis and the multifactorial causes of such blood culture contamination. These overview articles also demonstrate the patient-safety issues and healthcare cost concerns that are increasingly part of the research into and clinical practice of providing safe and appropriate blood cultures.

The section, as it now stands on Wikipedia, does not adequately address these recent developments and expressions of concern from policymakers about the need to obtain better diagnosis of sepsis and reduce blood culture contamination, which can delay timely detection of sepsis.

The sources I would be using would be:

Kim N, Kim M, Lee S, Yun NR, Kim K, Park SW, et al (February 2011). “Effect of routine sterile gloving on contamination rates in blood culture: a cluster randomized trial.” Ann Intern Med. 154(3): 145-151. doi: 10.7326/0003-4819-154-3-201102010-00003

Garcia RA, et al. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. Am J Infect Control 2015 Nov;43(11):1222-37. doi: 10.1016/j.ajic.2015.06.030. Epub 2015 Aug 19.

Hall KK, Lyman JA (October 2006). “Updated review of blood culture contamination.” Clin Microbiol Rev. 19(4): 788‐802.

If there is any problem with me making edits to this section, let me know. If I don't hear back in a day or two, I'll go ahead and make the edits and you can review them when you're available. Thank you. Unseen remnant (talk) 17:00, 26 October 2017 (UTC)
 * Okay this is a recent review article. What do you want to use it to say?
 * The first one is a primary source. The Hall ref is okay but getting a little older.
 * Remember we are a global encyclopedia so stuff like "Hospitals are now required by the government to develop antimicrobial stewardship programs" is simply not true on a global scale. Doc James  (talk · contribs · email) 18:08, 26 October 2017 (UTC)

I'd like to modify the Diagnosis section so that it reads as below with the references I included above.

Header: Diagnosis

Early diagnosis is necessary to properly manage sepsis, as initiation of rapid therapy is key to reducing mortality from severe sepsis. Within the first three hours of suspected sepsis, diagnostic studies should include white blood cell counts, measuring serum lactate, and obtaining appropriate cultures before starting antibiotics, so long as this does not delay their use by more than 45 minutes.

Subhead: Blood cultures

To identify the causative organism(s), at least two sets of blood cultures using bottles with media for aerobic and anaerobic organisms should be obtained, with at least one drawn through the skin and one drawn through each vascular access device (such as an IV catheter) in place more than 48 hours. Bacteria are present in the blood (bacteremia) in only about 30% of cases.

A blood culture is a test taken to determine if there are microorganisms in the blood that indicate the patient has a potentially serious infection. But under current protocols, blood cultures drawn through the skin can be unreliable for diagnosing sepsis and other infections. Researchers have concluded that 35-50% of blood cultures are false positives.

Contamination can occur during the blood culture procedure from a multitude of sources: if aseptic technique and sterility are not maintained; if bacteria are introduced when the syringe or collection supplies are assembled; if some bacteria on the patient’s skin survive surface antisepsis and are dislodged by the needle used to access the patient’s bloodstream; if microbes contaminate the tops of standard blood collection tubes; and from bacteria commonly found in the environment where blood cultures are collected.

Clinical confusion from false positives can lead to unnecessary and expensive clinical procedures, inappropriate and overuse of antibiotics, extended length of stay in hospitals and risk of hospital-acquired conditions. Unseen remnant (talk) 18:20, 26 October 2017 (UTC)
 * Do you want to draft it in your sandbox with the references in place? I will than look at it. Doc James  (talk · contribs · email) 18:30, 26 October 2017 (UTC)


 * Posted in my Sandbox. I added in references already on the page. References will be a bit cleaner in the main post but you'll get the gist of the edit I'd like to make. Any questions, let me know. Unseen remnant (talk) 20:11, 26 October 2017 (UTC)
 * Okay User:Unseen_remnant/sandbox Will review. Doc James  (talk · contribs · email) 21:10, 26 October 2017 (UTC)
 * User:Unseen remnant have done some formating and trimmed one of the primary sources.
 * You are wanting to add this as a section to diagnosis? Doc James  (talk · contribs · email) 21:24, 26 October 2017 (UTC)
 * I have made an additional change to the sandbox. The paragraph you removed can be justified with ref Garcia. Let me know if that works for you. If it does, it's good to post. Let me know if you'd like to post or if I should. Thanks. Unseen remnant (talk) 18:29, 27 October 2017 (UTC)
 * Blood cultures more confirm rather than diagnosis sepsis. Sepsis is a clinical diagnosis supported by some tests that can be rapidly gotten. Doc James  (talk · contribs · email) 21:20, 27 October 2017 (UTC)

External links modified
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 * Added tag to http://www.sassit.co.za/journals/icu/sepsis/mechanisms%20of%20sepsis%20induced%20mods.pdf
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 * Added archive https://web.archive.org/web/20100610082131/http://pediatrics.uchicago.edu/chiefs/PICU/documents/guidelines.pdf to http://pediatrics.uchicago.edu/chiefs/picu/documents/guidelines.pdf

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About the removal of SIRS criteria
Hi Doc James, according to the latest Surviving Sepsis Campaign and JAMA article guideline, SOFA is used to diagnose sepsis instead of SIRS. Therefore, can I remove the SIRS criteria and add SOFA or qSOFA instead in this article? Thanks. Cerevisae (talk) 06:05, 1 January 2018 (UTC)
 * Many are still using SIRS. qSOFA well new is still controversial.
 * We have and
 * Doc James (talk · contribs · email) 06:18, 1 January 2018 (UTC)
 * Thanks for your input. Cerevisae (talk) 11:13, 1 January 2018 (UTC)

The Archers
I am a bit doubtful about this addition:

On 23 February 2018, character Nic Grundy died suddenly from sepsis in the long-running BBC radio continuing drama/soap opera The Archers. At the time of this broadcast there had been an increased awareness of sepsis in the U.K. media and amongst health professionals, with sepsis described as the "biggest killer you never heard of". The drama reflected the random and rapid nature of the illness.
 * Culture

Not so sure about the impact claimed of a radio shift only really popular in the UK. JFW &#124; T@lk  20:46, 24 February 2018 (UTC)

Terminology
This ref says "Septicemia has been defined in the past as the presence of microorganisms or their toxins in the blood. However, this term has been used clinically and in the medical literature in a variety of ways, which has added to confusion and difficulties in data interpretation. Septicemia also does not adequately describe the entire spectrum of pathogenic organisms that may infect the blood. We therefore suggest that this term be eliminated from current usage."

Have adjusted to match.

Doc James (talk · contribs · email) 17:42, 30 September 2018 (UTC)

Redundant sentence
Is the sentence on Activated drotrecogin alfa needed in the lead. It is not mentioned elsewhere and seems irrelevant.--Iztwoz (talk) 18:47, 30 September 2018 (UTC)
 * Found later ref to this without 'activated' - changed link.--Iztwoz (talk) 07:46, 1 October 2018 (UTC)

Queen's University Student Editing Initiative
Hello! We are a group of medical students from Queen's University in Canada. We will be working to improve this page over the next month, as part of a class initiative. We look forward to working with the existing Wikipedia medical editing community, and welcome any feedback as we learn to edit! Thank you!

ShikhaSonu (talk) 18:13, 1 October 2018 (UTC)


 * Hello, we have compiled a list of suggestions to improve this article and would appreciate community feedback before we proceed with these edits. Here are our suggestions, with links to our proposed changes in our respective Sandboxes:


 * Thanks for posting these changes. It looks like many of the sandboxes listed below have had some feedback added. Please look at your sandbox talk page as well, some Wikipedians may leave you messages there. If you have any questions please do not hesitate to let me know. One of the main things that I notice in your comments is that some of these improvements could be re-worded to make them easier to understand for the general reader (someone without a medical background). I know that this can be difficult to do, especially when you are discussion methylation, etc. Be sure to also add Wikilinks where appropriate. Wikilinks are used the first time the term is used in the Wikipedia article. Thanks to all of you for your work and suggestions! JenOttawa (talk) 02:02, 7 November 2018 (UTC)


 * 1. We suggest further explaining the recommendation of crystalloid as the fluid of choice for fluid resuscitation https://en.wikipedia.org/wiki/User:Spicycheeseramen/sandbox
 * Comment added to sandbox.JenOttawa (talk) 02:13, 7 November 2018 (UTC)


 * 2. We suggest that the phrase "Treating fever in people with sepsis does not affect outcomes" as listed in the Other section of the article be clarified and put into better context.

https://en.wikipedia.org/wiki/User:Wikisgl-fish/sandbox Wikisgl-fish (talk) 23:12, 5 November 2018 (UTC)
 * Suggestions in sandbox talk page.JenOttawa (talk) 02:16, 7 November 2018 (UTC)
 * 3. We suggest further expanding on the use of paralytic agents in septic patients.

https://en.wikipedia.org/wiki/User:Nletofsky/sandbox Nletofsky (talk) 15:44, 6 November 2018 (UTC)
 * See sandbox for comments.JenOttawa (talk) 02:16, 7 November 2018 (UTC)
 * 4. We suggest updating the definitions of sepsis and septic shock.

https://en.wikipedia.org/wiki/User:CullyQ/sandbox CullyQ (talk) 00:37, 7 November 2018 (UTC)
 * I left a few notes in your sandbox.JenOttawa (talk) 02:03, 7 November 2018 (UTC)
 * 5. We suggest expanding on the cause for controversy when the SIRS criteria was replaced by qSOFA in the international guidelines.

https://en.wikipedia.org/wiki/User:ShikhaSonu/sandbox ShikhaSonu (talk) 03:41, 21 November 2018 (UTC)
 * 6. We suggest expanding on vasopressors and dobutamine, as well as adding appropriate references.

https://en.wikipedia.org/wiki/User:Qtcells/sandbox Qtcells (talk) 03:41, 21 November 2018 (UTC)


 * Thank you again for your time and your help, and please let us know of any suggestions you may have! Spicycheeseramen (talk) 19:48, 5 November 2018 (UTC)

Meaning of Septicemia Suggestion
Septicemia and Blood poisoning now redirect to Sepsis, though they do not mean the same thing as Sepsis. From 2005-2008 blood poisoning redirected to Bacteremia, which may be a better target for that phrase, but is too narrow for septicemia, as discussed below.

Bacteremia and Septic shock have their own articles. Septic syndrome has no article or redirect.

@TylerDurden8823 @Tom.Reding @Jfdwolff @Stevenfruitsmaak @Beoran @Maury_Markowitz

Septicemia is still actively used by medical experts, and an encyclopedia needs to say what the definition is and has been. The ICD10 manual uses septicemia as an overall term which includes sepsis and: Septicemic plague, Waterhouse-Friderichsen syndrome, meningococcemia, Meningococcal infection, Hypovolemic shock, Other shock, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, and Bacteremia. Google Scholar has 3,000 studies published so far this year (Jan-May 2019) using the term septicemia.

The Sepsis article and its sources say,
 * The terms "septicemia" and "blood poisoning" have been used in various ways and are no longer recommended.
 * panel defined sepsis as a systemic inflammatory response to infection, noting that sepsis could arise in response to multiple infectious causes and that septicemia was neither a necessary condition nor a helpful term https://www.nejm.org/doi/10.1056/NEJMra1208623
 * interpretations of these results have been obscured by the use of varying definitions for the following terms: infection, bacteremia, sepsis, septicemia, septic syndrome, and septic shock 7, 8, 9, 10, 11, 12. https://www.sciencedirect.com/science/article/pii/S001236921638415X
 * Septicemia has been defined in the past as the presence of microorganisms or their toxins in the blood. However, this term has been used clinically and in the medical literature in a variety of ways, which has added to confusion and difficulties in data interpretation. Septicemia also does not adequately describe the entire spectrum of pathogenic organisms that may infect the blood. We therefore suggest that this term be eliminated from current usage. https://www.sciencedirect.com/science/article/pii/S001236921638415X

None of the sources says septicemia means sepsis, so the words should not be used interchangeably.

I think septicemia needs its own short article, like the one on bacteremia, showing the ICD10 definition and the fact that some sources deprecate it. If the historical sources cited above show other definitions in the past, they also deserve to be included, along with their modern replacements. Even if it were obsolete, it would need a short article giving its multiple definitions and today's preferred terms, similar to other deprecated terms, like Apoplexy which now has subclasses, and Alienist which meant Psychiatrist. Numbersinstitute (talk) 18:43, 14 May 2019 (UTC)


 * I disagree completely. The problem with ICD-10 is that it only has a code for septicaemia and not sepsis, and this has caused massive difficulty with disease statistics.
 * Septic shock is a complication of sepsis. Bacteraemia is a laboratory diagnosis and may be asymptomatic. They are distinct from sepsis, and therefore need their own articles. Septicaemia, in contrast, is sepsis where bacteraemia is implied to be present (which is not universally the case). This is a matter of terminology rather than a differentiation in concepts. JFW &#124; T@lk  09:01, 15 May 2019 (UTC)
 * I don't think septicemia needs its own article. It's an outdated term that has definitely fallen out of favor. TylerDurden8823 (talk) 19:11, 15 May 2019 (UTC)

References need some work
Starting with the first reference cited (name=CDC2014Q). The link from the title, fails verification, the site has been updated and the page pointed to is a portal. Sub-pages of the portal may contain the information referenced but each fact should be cited to a specific location where said fact is sourced. The page the archive link points to contains the facts cited but it is from a page updated May 2014. The current sub page at CDC What is sepsis? was last updated August 2019.

Need to use the updated sub pages to source each fact with current data and link that points directly to that data.

I have moved the first 10 plus references out of the text and into the reflist template. MrBill3 (talk) 15:00, 15 January 2020 (UTC)

Suggested refs for the above.

Hope this is helpful. MrBill3 (talk) 15:32, 15 January 2020 (UTC)
 * Why move all the references to the end of the article? IMO they were fine in line...
 * The first reference was supported by an archived version. Yes people move around the content on their websites lots. Thankfully we have Internet Archives. Doc James  (talk · contribs · email) 10:23, 17 January 2020 (UTC)
 * I move them all to the end for several purposes. First it makes editing the content easier as it is more readable with just a tag instead of all the text of a ref in middle of a paragraph. It lets me check for duplicates and clean up. More of a personal preference but since I generally review all the references and do some verification I consider my perogative.
 * If there is an archived copy please provide the link in the reference. Yes things move but we need the ref to point to something that is actually there, even if in an archive. My thinking is that when the website was reorganized it is likely the content was updated and the article should reflect that. Best. MrBill3 (talk) 04:05, 6 February 2020 (UTC)

Lead image


The first one has been proposed. The second has been in the article a long time. I have seen hundreds of cases of sepsis and never one like that in the first picture. I use blood culture tubes in every case. Thus prefer the first image. Doc James (talk · contribs · email) 23:12, 5 February 2020 (UTC)


 * Another problem with image 1 is that it implies red distended skin is connected to sepsis, while the common signs and symptoms mentioned in the article are quite different. If we want a person, here is a photo from the US government, so not-copyrighted, which addresses treatment, not symptoms: https://medlineplus.gov/sepsis.html  Image 2 is already at the top of the page. Numbersinstitute (talk) 00:30, 6 February 2020 (UTC)
 * I concur the infant picture does not reflect usual or common course of sepsis, blood culture bottles do, but how boring. I'd like to see an ICU room with the equipment typically used for a sepsis case. MrBill3 (talk) 04:08, 6 February 2020 (UTC)
 * This image https://medlineplus.gov/sepsis.html may not be under an open license.
 * The NIH buys a lot of images. Doc James  (talk · contribs · email) 21:47, 6 March 2020 (UTC)
 * I like the image on that link showing someone getting IV fluid like that. It's true that it's not necessarily specific to sepsis, but it's certainly a very core part of its treatment and very common. It's also more interesting to look at to MrBill's point. TylerDurden8823 (talk) 05:30, 7 March 2020 (UTC)

Copvio
I have removed the section on mouse research because it is a copyvio of doi.org/10.1134/S0026893319050108. The material was introduced with this edit. Alexbrn (talk) 16:24, 8 July 2020 (UTC)

Research on pathophysiology
Under Host factors, under Pathophysiology, could mention research into the mechanism of vascular leakage : Researchers Uncover the Culprit behind Leaky Blood Vessels from Sepsis namely heat shock protein 27 (HSP27). Could mention maybe in a much expanded Research section ? - Rod57 (talk) 20:16, 2 September 2021 (UTC)

Wiki Education Foundation-supported course assignment
This article is or was the subject of a Wiki Education Foundation-supported course assignment. Further details are available on the course page. Student editor(s): Aives95.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 08:40, 18 January 2022 (UTC)

Wiki Education assignment: Epidemiology ENPH 450
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