Case report:Multiple abscesses caused by Porphyromonas gingivalis diagnosed by metagenomic next-generation sequencing

Background

Extraoral infection by Porphyromonas gingivalis (P. gingivalis) is extremely rare and challenging to diagnose because the fastidious pathogen is difficult to culture by traditional methods. We report the first case of a patient with multiple abscesses in muscles and the brain with dura empyema due to P. gingivalis, which was diagnosed by metagenomic next-generation sequencing (mNGS).

Case presentation

A 65-year-old male patient was admitted to our hospital for multiple lumps in his body. Brain magnetic resonance imaging (MRI) and lower-limb computed tomography (CT) revealed multiple abscesses in the brain and muscles. A diagnosis of P. gingivalis infection was made based on mNGS tests of blood, cerebrospinal fluid (CSF), and pus samples, as the traditional bacterial culture of these samples showed negative results. Target antibiotic therapy with meropenem and metronidazole was administered, and CT-guided percutaneous catheter drainage of abscesses in both thighs was performed. The size of muscle abscesses reduced significantly and neurological function improved. The patient was followed up for 4 months. No abscesses re-appeared, and the remaining abscesses in his backside and both legs were completely absorbed. He can speak fluently and walk around freely without any neurological deficits.

Conclusion

Metagenomic next-generation sequencing is helpful for early diagnosis and subsequent treatment of P. gingivalis-associated multiple abscesses.

Comparison of a direct aspiration first pass technique vs. stent retriever thrombectomy for the treatment of acute large vessel occlusion stroke in the anterior circulation with atrial fibrillation

Objectives

The stent retriever thrombectomy (SRT) and a direct aspiration first-pass technique (ADAPT) are the two main mechanical thrombectomy (MT) techniques for acute ischemic stroke. Few data are available for comparing the therapeutic effects associated with the two mechanical thrombectomy techniques in acute ischemic stroke with atrial fibrillation. The purpose of this study was to compare the efficacy and safety of both techniques for the treatment of acute large vessel occlusion stroke in the anterior circulation with atrial fibrillation.

Methods

Retrospective analysis was performed in stroke patients with atrial fibrillation admitted to Guangzhou Red Cross Hospital from January 2018 to June 2022 who received mechanical thrombectomy by either SRT or ADAPT. Comparisons were made with regards to the initial traits, course of therapy, effectiveness indicators, and complications of these individuals. The primary outcome is recanalization rate.

Results

In this study, after screening 431 patients, 92 eligible patients, with 48 patients received SRT and 44 patients received ADAPT, were included. There was no significant difference in the recanalization rate between the two groups (SRT 87.5% vs. ADAPT 84.1%, P = 0.639). Compared with SRT, patients in ADAPT group had a shorter puncture to recanalization time [33.5 min (27.0-59.5) vs. 50.5 min (31.5-91.5), P = 0.009], a higher first pass success recanalization rate (54.5 vs. 33.3%, p = 0.040), and a higher rate of patients with improvement of NIHSS scores ≥4 at discharge (84.1 vs. 56.3%, P = 0.004). However, distal embolization occurred more frequently in the ADAPT group than that in SRT group (50.0 vs. 22.9%, P = 0.007). There was no significant difference between the two groups in the 3-month mRS score, symptomatic cerebral hemorrhage, or mortality.

Conclusions

Compared with SRT, ADAPT has similar recanalization rate for the treatment of acute large vessel occlusion stroke in the anterior circulation with atrial fibrillation. However, ADAPT might be more effective in terms of shorter puncture to recanalization time and higher first pass success recanalization rate. Further studies are needed for confirming our results.

YTHDF1 alleviates sepsis by upregulating WWP1 to induce NLRP3 ubiquitination and inhibit caspase-1-dependent pyroptosis

Pyroptosis is inflammation-associated caspase-1-dependent programmed cell death, which confers a crucial role in sepsis. The present study intends to investigate the regulatory network and function of the microarray-predicted YTHDF1 in caspase-1-dependent pyroptosis of sepsis. Peripheral blood of patients with sepsis was collected to determine WWP1 and YTHDF1 expression. An in vitro sepsis cell model was induced in RAW264.7 cells using lipopolysaccharide (LPS) and ATP and an in vivo septic mouse model by cecal ligation and perforation (CLP). After gain- and loss-of-function assays in vitro and in vivo, TNF-α and IL-1β levels and the cleavage of gasdermin-D (GSDMD) were detected by ELISA and Western blot assay, followed by determination of lactate dehydrogenase (LDH) activity. Immunoprecipitation and meRIP assay were performed to detect the ubiquitination of NLRP3 and the m6A modification of WWP1 mRNA. The binding of WWP1 to YTHDF1 was explored using RIP-RT-qPCR and dual luciferase gene reporter assay. It was noted that WWP1 and YTHDF1 were downregulated in clinical sepsis samples, LPS + ATP-treated RAW264.7 cells, and CLP-induced mice. The ubiquitination of NLRP3 was promoted after overexpression of WWP1. WWP1 translation could be promoted by YTHDF1. Then, WWP1 or YTHDF1 overexpression diminished LDH activity, NLRP3 inflammasomes and caspase-1-mediated cleavage of GSDMD in LPS + ATP-induced RAW264.7 cells. Overexpressed YTHDF1 restrained inflammatory response in CLP-induced mice. Collectively, the alleviatory effect of m6A reader protein YTHDF1 may be achieved through promotion of NLRP3 ubiquitination and inhibition of caspase-1-dependent pyroptosis by upregulating WWP1.

SAPS III is superior to SOFA for predicting 28-day mortality in sepsis patients based on Sepsis 3.0 criteria

INTRODUCTION

The discrimination and calibration accuracy of prediction models tends to become poor over time. The performance of predictive models should be reevaluated periodically. The aim of this study was to reassess the discrimination of the six commonly used models for predicting 28-day mortality in patients with sepsis based on the Sepsis 3.0 criteria.

METHODS

Patient data were extracted from the fourth edition of the Medical Information Mart for Critical Care (MIMIC IV) database. The systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Oxford Acute Severity of Illness Score (OASIS), Logistic Organ Dysfunction System (LODS), and Simplified Acute Physiology Score II (SAPS II) and III (SAPS III) scores were calculated and collected. The area under the receiver operating characteristic curve (AUROC) was used to compare the discrimination abilities of the models using non-parametric Wilcoxon statistics. The Delong method was used to perform pairwise comparisons of the AUROCs of the models. Multiple subgroup analyses for age, body mass index, and sex were performed with regard to the 28-day mortality prediction of the models.

RESULTS

A total of 12 691 patients were included. The mean age of the patients was 65.97 ± 15.77 years; 7673 patients (60.50%) were male. The mean SIRS, SOFA, OASIS, SAPS II, LODS, and SAPS III scores were higher in the non-survivor group than in the survivor group. The discrimination for 28-day mortality with the SAPS III (AUROC 0.812, 95% confidence interval (CI) 0.802-0.822) and LODS (AUROC 0.804, 95% CI 0.743-0.765) models was superior to that of the SIRS (AUROC 0.575, 95% CI 0.562-0.589), SOFA (AUROC 0.612, 95% CI 0.598-0.626), OASIS (AUROC 0.753, 95% CI 0.742-0.764), and SAPS II (AUROC 0.754, 95% CI 0.743-0.765) models. The Youden index of the SAPS III model was 0.484, which was the highest among the models. Subgroup analyses showed similar results to the overall results.

CONCLUSIONS

The discrimination for 28-day mortality with the SAPS III and LODS models was superior to that of the SIRS, SOFA, OASIS, and SAPS II models. The SAPS III model showed the best discrimination capacity for 28-day mortality compared with the other models.

The effect of dobutamine in sepsis: a propensity score matched analysis

BACKGROUND

The use of dobutamine in patients with sepsis is questionable currently. As the benefit of dobutamine in septic patients is unclear, we aimed to evaluate whether the use of dobutamine was associated with decreased hospital mortality in sepsis patients.

METHODS

Based on the analysis of MIMIC III public database, we performed a big-data, real world study. According to the use of dobutamine or not, patients were categorized as the dobutamine group or non dobutamine group.We used propensity score matched (PSM) analysis to adjust for confoundings. The primary outcome was hospital mortality.

RESULTS

In the present study, after screening 38,605 patients, 2826 patients with sepsis were included. 121 patients were in dobutamine group and 2165 patients were in non dobutamine group. Compared with patients in non-dobutamine group, patients in dobutamine group had a lower MAP, higher HR, higher RR, higher severity of illness scores. 72 of 121 patients (59.5%) in the dobutamine group and 754 of 2165 patients (34.8%) in the non-dobutamine group died in the hospital, which resulted in a significant between-group difference (OR 1.56, 95% CI 1.01-2.40; P = 0.000). For the secondary outcomes, patients in dobutamine group received more MV use, more renal replacement therapy use, had longer ICU stay durations and more cardiac arrhythmias than those in non-dobutamine group. After adjusting for confoundings between groups by PSM analysis, hospital mortality was consistently higher in dobutamine group than that in non-dobutamine group (60.2% vs. 49.4%, OR 1.55, 95% CI 1.01-2.37; P = 0.044).

CONCLUSIONS

Among patients with sepsis, our study showed that the use of dobutamine was not associated with decreased hospital mortality. Further large scale, randomized controlled studies are warrented to confirm our findings.

Incidence, prognosis, and risk factors of sepsis-induced cardiomyopathy

BACKGROUND

At present, large-scale studies on the clinical characteristics of sepsis-induced cardiomyopathy (SIC) are lacking.

AIM

To investigate the clinical characteristics of SIC.

METHODS

Based on the analysis of the MIMIC-III public database, we performed a large-scale retrospective study involving sepsis patients who were admitted to the intensive care unit (ICU) and had no concomitant cardiac disease. We used propensity score matching analysis and multivariate logistic regression to ensure the robustness of the results. The primary outcome was hospital mortality, and the secondary outcomes included the number of patients who received mechanical ventilation or renal replacement therapy during their hospital stay, the number of patients administered with vasopressors, the length of ICU stay, and the length of hospital stay.

RESULTS

In the present study, after screening 38605 patients, 3530 patients with sepsis were included. A total of 997 patients met the SIC diagnostic criteria, and the incidence of SIC was 28.20% (95% confidence interval [CI]: 26.80%-29.70%). Compared to patients in the non-SIC group, patients in the SIC group were of older age and had a higher Simplified Acute Physiology Score (SAPS)-I score, SAPS-II score, and Elixhauser comorbidity index (ECI). A total of 367 (36.8%) of 997 patients in the SIC group and 818 (32.3%) of 2533 patients in the non-SIC group died in the hospital, which resulted in a significant between-group difference (odds ratios = 1.22, 95%CI: 1.05-1.42; P = 0.011). For the secondary outcomes, more patients in the SIC group received mechanical ventilation and vasopressors. Multivariate logistic regression analysis showed that age, male sex, ECI, hemoglobin level, diabetes, and mechanical ventilation use on the first day of ICU admission were risk factors for SIC.

CONCLUSION

Compared with non-SIC patients, hospital mortality is higher in SIC patients.

The effect of dobutamine vs milrinone in sepsis: A big data, real-world study

BACKGROUND

The use of dobutamine in patients with sepsis is questionable. Some studies reported milrinone was used as an alternative inotropic agent. We aim to evaluate whether milrinone is better than dobutamine in patients with sepsis.

METHODS

Based on the analysis of MIMIC III public database, we performed a big data, real-world study. According to the use of dobutamine or milrinone, patients were categorised as the dobutamine group or milrinone group. We used propensity score matched (PSM) analysis to adjust for confoundings. The primary outcome was hospital mortality.

RESULTS

In this study, after screening 38 605 patients, 235 patients with sepsis were included. One hundred and eighty-three patients were in the dobutamine group and 52 patients were in the milrinone group. For the primary outcome of hospital mortality, there was no significant between-group difference (73/183 in dobutamine group vs 23/52 in milrinone group, OR 0.84, 95% CI 0.45-1.56; P = .574). After adjusting for confoundings between groups by PSM analysis, hospital mortality was consistent with the overall result (50% vs 41.3%, OR 1.42, 95% CI 0.68-2.97; P = .349). For the secondary outcomes, more patients in milrinone group received RRT use (46.2% vs 22.4%, P = .001), had longer length of ICU stay (20.97 ± 22.84 days vs 11.10 ± 11.54 days, P = .004) and hospital stay (26.14 ± 25.13 days vs 14.51 ± 13.11 days, P = .002) than those in dobutamine group.

CONCLUSIONS

Compared with dobutamine, the use of milrinone did not decrease hospital mortality in patients with sepsis. Furthermore, milrinone was associated with more RRT therapy, longer length of ICU stay and hospital stay than dobutamine.

Extracorporeal membrane oxygenation versus mechanical ventilation alone in adults with severe acute respiratory distress syndrome: A systematic review and meta-analysis

BACKGROUND

COVID-19 can lead to acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is considered to be a salvage strategy for severe ARDS. However, the effect of ECMO therapy on severe ARDS remains inconclusive. We aimed to evaluate the effects of ECMO for adults with severe ARDS.

METHODS

We searched six databases (EMBASE, Medline, the Cochrane Library, Web of Science, Wanfang databases and CNKI) from inception to May 2020 to screen relevant high-quality observational studies and randomised controlled trials. We used the random effects model for outcome calculation. Trial sequential analysis (TSA), heterogeneity, sensitivity analysis and publication bias were explored. The primary outcome was 90-day mortality.

RESULTS

Seven studies (two RCTs and five observational studies) with a total of 867 patients were included. Compared with MV therapy alone, ECMO therapy significantly reduced the mortality at 90 days (based on RCT studies, Risk Ratio [RR] 0.74, 95% confidence Interval (CI) 0.59-0.93, P = .01, I²  = 0%, moderate quality; based on observational studies, RR 0.61, 95% CI 0.46-0.81, P < .001, I²  = 0%, low quality) and at 30 and 60 days. TSA results were consistent with the primary outcome. Furthermore, device-related adverse events were similar between the ECMO group and MV alone group (RR, 2.09; 95% CI, 0.27-16.03, P = .48, I²  = 0%, moderate quality).

CONCLUSIONS

This study showed that the ECMO group exhibited a significantly lower mortality rate compared with the MV alone group at 90, 30 and 60 days for severe ARDS patients.

The Development of Critical Care Medicine in China: From SARS to COVID-19 Pandemic

BACKGROUND

Critical care medicine is a branch of medical science that deals with the characteristics and regularity of life-threatening processes initiated by any injury or disease and, accordingly, relevant treatment for patients with critical illness. Conceptions of critical care medicine in China stemmed in the early 1970s. Ever since the establishment of the first intensive care unit (ICU) along with the increasingly incomparable role of ICU in medical practices, critical care medicine has become an indispensable part of the Chinese medical and health system. Currently, critical care medicine as a secondary clinical discipline and a well-constructed science is in sustainable development on the way towards systematization and standardization.

METHODS

The gross domestic product (GDP) and population data were obtained from the National Bureau of Statistics. The number of ICUs, ICU beds, and hospital beds and other data regarding ICU staffing and facility resources were obtained from the Yearbook of Health in the People's Republic of China and National Bureau of Statistics. The mortality rates of SARS and COVID-19 and the number of health workers aiding Hubei amid COVID-19 pandemic were obtained from the National Health Commission. Findings. Critical care medicine in mainland China has made significant strides: both quantity and quality are progressing at a fast pace after SARS in 2003. Although there exist some disparities in healthcare personnel and medical resources, they have not hindered the country from mobilizing its healthcare workers and resources against a public health emergency.

Oxygen therapy versus conservative therapy in suspected uncomplicated myocardial infarction without hypoxemia: A meta-analysis of randomized controlled studies

Background:

The effect of oxygen therapy in patients with suspected uncomplicated myocardial infarction and without hypoxemia at baseline was uncertain.

Objectives:

We aimed to perform a rigorous and comprehensive meta-analysis to robustly quantify the efficacy of oxygen therapy in patients with suspected uncomplicated myocardial infarction and without hypoxemia at baseline.

Methods:

We searched EMBASE, MEDLINE, Web of Science, and the Cochrane Library from inception to August 2018. Two researchers screened studies and collected the data independently. Randomized controlled trials were included. The main outcome was mortality at the longest duration of follow-up.

Results:

Seven studies involving 7732 patients (median = 157 patients; range = 72–6629 patients; interquartile range = 136–441 patients; oxygen therapy group = 3856 patients; conservative group = 3876 patients) were included. Compared with conservative therapy, oxygen therapy did not significantly reduce mortality at the longest follow-up (risk ratio = 0.97; 95% confidence interval = 0.68 to 1.40; z = 0.15; p = 0.88), at discharge (risk ratio = 1.04; 95% confidence interval = 0.48 to 2.26; z = 0.11; p = 0.91), 30 days (risk ratio = 1.08; 95% confidence interval = 0.78 to 1.49; z = 0.44; p = 0.66), and 6 months (risk ratio = 0.93; 95% confidence interval = 0.73 to 1.17; z = 0.66; p = 0.51) in patients with suspected uncomplicated myocardial infarction and without hypoxemia at baseline. Furthermore, there was no significant difference between two groups with regard to infarct size (standard mean difference = 0.15, confidence interval = –0.13 to 0.44; z = 1.07, p = 0.28), cardiac troponin levels (standard mean difference = 0.30, confidence interval = –0.09 to 0.69; z = 1.51, p = 0.13), in hospital reinfarction (risk ratio = 1.49, confidence interval = 0.80 to 2.78; z = 1.25, p = 0.21), and new-onset atrial fibrillation (risk ratio = 0.91, confidence interval = 0.69 to 1.18; z = 0.72, p = 0.47). Multiple subgroup analysis, sensitivity analysis, and trial sequential analysis were consistent with overall findings.

Conclusion:

Compared with conservative therapy, oxygen therapy did not decrease the mortality at the longest duration of follow-up, discharge, 30 days, and 6 months in patients with suspected uncomplicated myocardial infarction and without hypoxemia at baseline. Furthermore, large-scale, multicenter studies are needed to confirm our results.

Registration:

PROSPERO, number CRD42017078807.

Management of an Adult with Goodpasture's Syndrome Following Brain Trauma with Extracorporeal Membrane Oxygenation: A Case Report

A 22-year-old man suffered from acute pulmonary hemorrhage and deteriorated renal function occurred within 3 days after traumatic brain injury. Mechanical ventilation cannot correct his severe hypoxemia, therefore, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated and finally resolved his hypoxemia. Concomitantly, continuous renal replacement therapy was performed to improve his kidney function. Although no anti-glomerular basement membrane (anti-GBM) antibody was detected in serum, Goodpasture's syndrome was considered. After treated with methylprednisolone pulse therapy and plasmapheresis, his renal function was significantly improved. ECMO was eventually discontinued after 60 hours of treatment and extubated on day 10. He was discharged home with normal pulmonary and renal functions.

High-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients after planned extubation: a systematic review and meta-analysis

BACKGROUND

The effect of high-flow nasal cannula (HFNC) therapy in patients after planned extubation remains inconclusive. We aimed to perform a rigorous and comprehensive systematic meta-analysis to robustly quantify the benefits of HFNC for patients after planned extubation by investigating postextubation respiratory failure and other outcomes.

METHOD

We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library from inception to August 2018. Two researchers screened studies and collected the data independently. Randomized controlled trials (RCTs) and crossover studies were included. The main outcome was postextubation respiratory failure.

RESULTS

Ten studies (seven RCTs and three crossover studies; HFNC group: 856 patients; Conventional oxygen therapy (COT) group: 852 patients) were included. Compared with COT, HFNC may significantly reduce postextubation respiratory failure (RR, 0.61; 95% CI, 0.41, 0.92; z = 2.38; P = 0.02) and respiratory rates (standardized mean differences (SMD), - 0.70; 95% CI, - 1.16, - 0.25; z = 3.03; P = 0.002) and increase PaO₂ (SMD, 0.30; 95% CI, 0.04, 0.56; z = 2.23; P = 0.03). There were no significant differences in reintubation rate, length of ICU and hospital stay, comfort score, PaCO₂, mortality in ICU and hospital, and severe adverse events between HFNC and COT group.

CONCLUSIONS

Our meta-analysis demonstrated that compared with COT, HFNC may significantly reduce postextubation respiratory failure and respiratory rates, increase PaO₂, and be safely administered in patients after planned extubation. Further large-scale, multicenter studies are needed to confirm our results.

Gastric versus postpyloric enteral nutrition in elderly patients (age ≥ 75 years) on mechanical ventilation: a single-center randomized trial

BACKGROUND

The risk of ventilator-associated pneumonia (VAP) is reduced when postpyloric enteral nutrition (EN) is administered compared to when gastric EN is administered in specific populations. In the present study, we tested the hypothesis that postpyloric EN is superior to gastric EN in reducing the incidence of VAP in elderly patients (age ≥ 75 years) who are admitted to the intensive care unit (ICU) and require mechanical ventilation.

METHODS

We performed a single-center randomized clinical trial involving elderly patients (age ≥ 75 years) who were admitted to the ICU and required mechanical ventilation. The patients were randomly assigned to either the postpyloric EN group or the gastric EN group. The primary outcome was the VAP rate.

RESULTS

Of the 836 patients screened, 141 patients were included in the study (70 in the postpyloric EN group and 71 in the gastric EN group). The patients in the postpyloric EN group were 82.0 (75.0-99.0) years old (male 61.4%), and those in the gastric EN group were 82.0 (75.0-92.0) years old (male 63.4%). The Acute Physiology and Chronic Health Evaluation II scores were 28.09 ± 6.75 in the postpyloric EN group and 27.80 ± 7.60 in the gastric EN group (P = 0.43). VAP was observed in 8 of 70 patients (11.4%) in the postpyloric EN group and in 18 of 71 patients (25.4%) in the gastric EN group, which resulted in a significant between-group difference (OR 0.38, 95% CI 0.15-0.94; P = 0.04). In the postpyloric EN group, there were significant reductions in vomiting (12 patients in the postpyloric EN group vs 29 patients in the gastric EN group; OR 0.30, 95% CI 0.14-0.65; P = 0.002) and abdominal distension (18 patients in the postpyloric EN group vs 33 patients in the gastric EN group; OR 0.40, 95% CI 0.20-0.81; P = 0.01). No significant differences were observed between the two groups regarding mortality and other secondary outcomes.

CONCLUSIONS

Our study demonstrated that, compared with gastric EN, postpyloric EN reduced the VAP rate among elderly patients who were admitted to the ICU and required mechanical ventilation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-16008485 . Registered on 17 May 2016.

High-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients with acute respiratory failure: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acute respiratory failure (ARF) is a common and life-threatening medical emergency in patients admitted to the hospital. Currently, there is a lack of large-scale evidence on the use of high-flow nasal cannulas (HFNC) in patients with ARF. In this systematic review and meta-analysis, we evaluated whether there were differences between HFNC therapy and conventional oxygen therapy (COT) for treating patients with ARF.

METHODS

The EMBASE, Medline, and Wanfang databases and the Cochrane Library were searched. Two investigators independently collected the data and assessed the quality of each study. Randomized controlled trials that compared HFNC therapy with COT in patients with ARF were included. RevMan 5.3 was used to conduct the meta-analysis.

RESULTS

Four studies that involved 703 patients with ARF were included, with 371 patients in the HFNC group and 332 patients in the COT group. In the overall estimates, there were no significant differences between the HFNC and COT groups in the rates of escalation of respiratory support (RR, 0.68; 95% CI, 0.37, 1.27; z = 1.20, P = 0.23), intubation (RR, 0.74; 95% CI, 0.55, 1.00; z = 1.95, P = 0.05), mortality (RR, 0.82; 95% CI, 0.36, 1.88; z = 0.47, P = 0.64), or ICU transfer (RR, 1.09; 95% CI, 0.57, 2.09; z = 0.26, P = 0.79) during ARF treatment. However, the subgroup analysis showed that HFNC therapy may decrease the rate of escalation of respiratory support (RR, 0.71; 95% CI, 0.53, 0.97; z = 2.15, P = 0.03) and the intubation rate (RR, 0.71; 95% CI, 0.53, 0.97; z = 2.15, P = 0.03) when ARF patients were treated with HFNC therapy for ≥24 h compared with COT.

CONCLUSIONS

HFNC therapy was similar to COT in ARF patients. The subgroup analysis showed that HFNC therapy may decrease the rate of escalation of respiratory support and the intubation rate when ARF patients were treated with HFNC for ≥24 h compared with COT. Further high-quality, large-scale studies are needed to confirm our results.

Varying Presentations and Outcomes of Septic Shock: Should Septic Shock Be Stratified?

Recent studies have revealed there are three presentations of septic shock in patients: refractory hypotension without hyperlactatemia, hyperlactatemia without refractory hypotension, and both refractory hypotension and hyperlactatemia. In this study, we sought to identify differences in the outcomes of septic shock patients with these three presentations. We performed a secondary analysis of a large-scale, multicenter, controlled trial. The septic shock patients were categorized into the following three groups according to the presence or absence of refractory hypotension and hyperlactatemia: a hypotension group (refractory hypotension without hyperlactatemia), a hyperlactatemia group (hyperlactatemia without refractory hypotension), and a typical group (both refractory hypotension and hyperlactatemia). The 90-day all-cause mortality was compared among these three groups. A total of 1588 septic shock patients were enrolled in the present study, including 854 (53.8%) in the hypotension group, 477 (30.0%) in the hyperlactatemia group, and 257 (16.2%) in the typical group. The 90-day all-cause mortality were 12.3 per cent for the patients in the hypotension group, 23.1 per cent for those in the hyperlactatemia group, and 31.9 per cent for those in the typical group, these differences among the three groups were significant (Pearson's χ2 = 58.49, P < 0.001). And also, there was a significant difference between hyperlactatemia group and typical group (Pearson's χ2 = 6.77, P < 0.05). In this study, we demonstrated that the three different presentations of septic shock resulted in significantly different outcomes, suggesting that septic shock should be stratified.

High-flow nasal cannula oxygen therapy vs conventional oxygen therapy in cardiac surgical patients: A meta-analysis

INTRODUCTION

The use of high-flow nasal cannula (HFNC) for the treatment of many diseases has gained increasing popularity. In the present meta-analysis, we aimed to assess the efficacy and safety of HFNCs compared with conventional oxygen therapy (COT) in adult postextubation cardiac surgical patients.

METHOD

We reviewed the Embase, PubMed, Cochrane Central Register of Controlled Trials, Wanfang databases, and the China National Knowledge Infrastructure. Two investigators independently collected the data and assessed the quality of each study. RevMan 5.3 was used for the present meta-analysis.

RESULTS

We included 495 adult postextubation cardiac surgical patients. There was no significant heterogeneity among the studies. Compared with COT, HFNCs were associated with a significant reduction in the escalation of respiratory support (risk ratio, 0.61; 95% confidence interval [CI], 0.46-0.82; z = 3.32, P < .001). There were no significant differences in the reintubation rate (risk ratio, 0.96; 95% CI, 0.04-24.84; z = 0.02, P = .98) or length of intensive care unit stay (weighted mean difference, 0.13; 95% CI, -0.88 to 7.92; z = 1.57, P = .12) between the 2 groups. No severe complications were reported in either group.

CONCLUSIONS

The HFNC could reduce the need for escalation of respiratory support compared with COT, and it could be safely administered in adult postextubation cardiac surgical patients.

Nasogastric Nutrition versus Nasojejunal Nutrition in Patients with Severe Acute Pancreatitis: A Meta-Analysis of Randomized Controlled Trials

Introduction. Previous studies have shown that the nasogastric (NG) route seems equivalent to the nasojejunal (NJ) route in patients with severe acute pancreatitis (SAP). However, these studies used a small sample size and old criteria for diagnosing SAP, which may include some patients with moderate SAP, according to the newly established SAP criteria (Atlanta 2012 classification). Based on the changes in the criteria for classifying SAP, we performed an up-to-date meta-analysis. Method. We reviewed the PubMed, EMbase, China National Knowledge Infrastructure, Wanfang Database, and Cochrane Central Register of Controlled Trials electronic databases. We included randomized controlled trials comparing NG and NJ nutrition in patients with SAP. We performed the meta-analysis using the Cochrane Collaborations' RevMan 5.3 software. Results. We included four randomized controlled trials involving 237 patients with SAP. There were no significant differences in the incidence of mortality, infectious complications, digestive complications, achievement of energy balance, or length of hospital stay between the NG and NJ nutrition groups. Conclusions. NG nutrition was as safe and effective as NJ nutrition in patients with SAP. Further studies are needed to confirm our results.

Endoscopy versus fluoroscopy for the placement of postpyloric nasoenteric tubes in critically ill patients: A meta-analysis of randomized controlled trials

INTRODUCTION

Early postpyloric nasoenteric nutrition is considered an accepted method of nutritional support in critically ill patients. Both endoscopy and fluoroscopy placement of postpyloric nasoenteric tubes (PNTs) have the highest percentages of placement success rate. We aimed to evaluate the differences in efficacy and safety between endoscopy and fluoroscopy methods for the placement of PNTs in critically ill patients.

METHOD

We searched MEDLINE, Embase, and electronic databases of Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing endoscopy and fluoroscopy placement of PNTs in critically ill patients. Two reviewers assessed the quality of each study and collected data independently. We performed the meta-analysis with Cochrane Collaboration RevMan 5.3.

RESULTS

Three randomized controlled trials involving 243 patients were included. There were no significant differences in the placement success rate (RR, 0.99; 95% CI, 0.93, 1.06; z = 0.20, P = .84,) or procedure time (standardized mean difference, -0.08; 95% CI, -6.93, 6.77; z = 0.02, P = .98) between the 2 groups. No severe complications (digestive tract hemorrhage, perforation, respiratory problems, hemodynamic instability, or death) were noted in the three studies. There was a slight difference in the incidence of minor complications (RR, 8.12; 95% CI, 1.07, 61.53; z = 2.03, P = .04) between the 2 groups.

CONCLUSIONS

Endoscopy and fluoroscopy placement of PNTs can be accurately and safely performed in critically ill patients. Endoscopy may be at least equally as safe as fluoroscopy for the placement of PNTs.

[The dose-dependent protective effect of curcumin on hepatocyte of rats with sepsis]

OBJECTIVE

To observe the protective effect of different doses of curcumin on hepatocytes of rats with sepsis.

METHODS

100 healthy male Sprague-Dawley (SD) rats were randomly divided into sham operation group, sepsis group, and low, medium, high dose curcumin intervention groups (L-cur, M-cur, H-cur groups), with 20 rats in each group. The animal model of sepsis was reproduced by cecal ligation and puncture (CLP) method, and in the sham operation group the cecum was just taken out and returned. In the L-cur, M-cur, H-cur groups curcumin was immediately injected after CLP with a dose of 50, 100, 150 mg/kg, respectively, and the rats in sham operation group and sepsis group were given the same amount of normal saline. Five rats in each group were sacrificed at 2, 6, 12, 24 hours after operation, and the hepatic tissues and blood samples were obtained. The pathological changes in hepatic tissues were observed under a microscope, and hepatocytes apoptosis and apoptosis index (AI) of hepatocytes were determined with transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) method, and the levels of serum procalcitonin (PCT), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were determined with enzyme linked immunosorbent assay (ELISA) method.

RESULTS

Microscopic examination showed that the damage degree of hepatic tissues was significantly increased in sepsis group; the number of apoptotic cells and damage degree of hepatic tissues were increased gradually over time. The damage degree of hepatic tissues in curcumin groups was lessened as compared with sepsis group, especially in M-cur group. There were no significant changes in AI and serum PCT, TNF-α, and IL-1β levels at any of the time points tested in the sham operation group. The AI, serum PCT, TNF-α, and IL-1β levels in the sepsis group were significantly higher than those in the sham operation group from 2 hours after operation on [AI: (23.59±2.00)% vs. (2.02±0.13)%, PCT (μg/L): 2.41±0.21 vs. 0.81±0.01, TNF-α (ng/L): 217.28±14.24 vs. 80.02±2.26, IL-1β (ng/L): 61.84±3.21 vs. 25.78±1.29, all P < 0.05], and they showed a gradually increasing tendency. AI reached peak value at 24 hours after operation [(52.05±1.31)%]; PCT, TNF-α and IL-1β reached the peak values at 12 hours after operation [(8.68±0.58) μg/L, (314.13±14.39) ng/L, (132.24±2.58) ng/L, respectively]. Curcumin intervention significantly reduced the levels of AI, TNF-α, PCT and IL-1β in hepatocytes of septic rats, especially in M-cur group [AI: (11.56±0.96)% vs. (23.59±2.00)% at 2 hours, (30.35±1.20)% vs. (52.05±1.31)% at 24 hours; PCT (μg/L): 1.13±0.19 vs. 2.41±0.21 at 2 hours, 5.09±0.42 vs. 8.68±0.58 at 12 hours; TNF-α (ng/L): 124.73±7.47 vs. 217.28±14.24 at 2 hours, 168.68±6.95 vs. 314.13±14.39 at 12 hours; IL-1β (ng/L): 35.05±1.00 vs. 61.84±3.21 at 2 hours, 84.06±3.42 vs. 132.24±2.58 at 12 hours; all P < 0.05].

CONCLUSIONS

Curcumin can inhibit the inflammatory reaction of hepatocytes of rats, prevent apoptosis, and protect the hepatocytes of rats with sepsis. The concentration of curcumin with the most significant effect is 100 mg/kg, which is the medium dosage.

Therapeutic hypothermia versus normothermia in adult patients with traumatic brain injury: a meta-analysis

INTRODUCTION

Many single-center studies and meta-analyses demonstrate that therapeutic hypothermia (TH), in which the body temperature is maintained at 32-35°C, exerts significant neuroprotection and attenuates secondary intracranial hypertension after traumatic brain injury (TBI). In 2015, two well-designed multi-center, randomized controlled trials were published that did not show favorable outcomes with the use of TH in adult patients with TBI compared to normothermia treatment (NT). Therefore, we performed an updated meta-analysis to assess the effect of TH in adult patients with TBI.

METHODS

We reviewed the PubMed, EMbase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Databases. We included randomized controlled trials that compared TH and NT in adult patients with TBI. Two reviewers assessed the quality of each study and independently collected the data. We performed the meta-analysis using the Cochrane Collaboration's RevMan 5.3 software.

RESULTS

We included 18 trials involving 2177 patients with TBI. There was no significant heterogeneity among the studies. TH could not decrease mortality at 3 months post-TBI (RR 0.95; 95 % CI 0.59, 1.55; z = 0.19, P = 0.85) or 6 months post-TBI (RR 0.96; 95 % CI 0.76, 1.23; z = 0.29, P = 0.77). There were no significant differences in unfavorable clinical outcomes when TH was compared to NT at 3 months post-TBI (RR 0.79; 95 % CI 0.56, 1.12; z = 1.31, P = 0.19) or 6 months post-TBI (RR 0.80; 95 % CI 0.63, 1.00; z = 1.92, P = 0.05). TH was associated with a significant increase in pneumonia (RR 1.51; 95 % CI 1.12, 2.03; z = 2.72, P = 0.006) and cardiovascular complications (RR 1.75; 95% CI 1.14, 2.70; z = 2.54, P = 0.01).

CONCLUSIONS

Therapeutic hypothermia failed to demonstrate a decrease in mortality and unfavorable clinical outcomes at 3 or 6 months post-TBI. Additionally, TH might increase the risk of developing pneumonia and cardiovascular complications.

Effect of glutamine on caspase-3 mRNA and protein expression in the myocardium of rats with sepsis

: Apoptosis and caspase-3 play an important role in the pathogenesis of sepsis. In this study, the authors monitored myocardial apoptosis and investigated caspase-3 protein expression change in rats with sepsis. In addition, we investigated the protective effect of glutamine (Gln) on myocardial injury in septic rats. A rat model of sepsis was established by intraperitoneal injection of lipopolysaccharide (LPS). Rats were divided into control group, endotoxin (LPS) group and LPS + Gln group, which were further divided into 4 subset groups (0, 6, 12 and 24 hour subgroups; n = 6). The rate of myocardial apoptosis, caspase-3 mRNA expression and caspase-3 protein expression were examined. Data were analyzed using the F-test or linear correlation test. The results revealed that the rate of myocardial apoptosis in the LPS group was significantly higher than that in the control group (P < 0.05). Compared with the control group, LPS group has an upregulated caspase-3 mRNA expression level. However, the caspase-3 protein was low expressed (P < 0.05). The LPS + Gln group has significant lower myocardial apoptosis rate compared with the LPS group (P < 0.05). In addition, caspase-3 mRNA expression levels and caspase-3 protein expression levels were lower in the LPS + Gln group (P < 0.05). We found that Gln reduces the extent of myocardial apoptotic cell death by decreasing the gene and protein expression of caspase-3. Therefore, Gln may be used to prevent the onset of sepsis at an early stage.

[Effect of trimetazidine on renal function in patients with shock]

OBJECTIVE

To investigate the effects of trimetazidine on renal function in patients with shock.

METHODS

A prospective randomized controlled double-blind study was conducted. 128 patients with shock admitted to intensive care unit (ICU) of Guangzhou Red Cross Hospital from April 2011 to April 2013 were enrolled and randomly divided into control group and trimetazidine treatment group, each n=64. All patients received anti-shock treatment, while the patients in trimetazidine group received trimetazidine treatment (20 mg orally, tid) for 7 days, and patients in control group received placebo (10 mL of sterile water for injection, tid) for 7 days. The urinary output, serum creatinine (SCr), blood urea nitrogen (BUN), cystatin C, and creatinine clearance (CCr) reflecting renal function were recorded in both groups, and the values were compared before treatment, 48 hours after treatment, and 1 week after the treatment. At the same time, dynamic mean arterial pressure (MAP) was monitored, and 48-hour and 1-week mortality rates were recorded.

RESULTS

There was no significant difference in results in all the renal function parameters before the treatment between two groups. The levels of SCr, BUN, cystatin C were gradually decreased after treatment in both groups, but CCr and MAP were gradually increased. Compared with the control group, cystatin C at 48 hours after treatment was significantly decreased, while CCr was significantly increased in treatment group (cystatin C: 0.85±0.81 mg/L vs. 1.01±0.91 mg/L, t=2.562, P=0.017; CCr: 0.93±0.64 mL/s vs. 0.69±0.40 mL/s, t=2.155, P=0.033). SCr and BUN at 1 week after treatment were significantly decreased in treatment group (SCr: 94.23±88.31 μmol/L vs. 104.99±98.37 μmol/L, t=2.921, P=0.003; BUN: 9.46±8.24 mmol/L vs. 11.87±8.65 mmol/L, t=2.611, P=0.010). Urine output per hour and MAP was improved after treatment in both groups, and no significant difference was found between treatment group and control group (urine output: 48 hours after treatment 55.67±31.43 mL vs. 45.34±11.79 mL, t=0.934, P=0.323; 1 week after treatment 71.67±37.23 mL vs. 75.35±22.88 mL, t=1.280, P=0.210; MAP: 48 hours after treatment 72.13±33.24 mmHg vs. 69.28±39.98 mmHg, t=1.408, P=0.179; 1 week after treatment 71.44±21.98 mmHg vs. 72.32±31.11 mmHg, t=1.184, P=0.252]. Mortality rate in treatment group was lowered compared with control group, however no statistical significance was found [48 hours after treatment: 31.2% (20/64) vs. 32.8% (21/64), χ2=0.084, P=0.785; 1 week after treatment: 32.8% (21/64) vs. 35.9% (23/64), χ2=2.084, P=0.173].

CONCLUSIONS

Trimetazidine can improve renal function in patients with shock.

The inhibitory effect of salvianolic acid B on TGF-β1-induced proliferation and differentiation in lung fibroblasts

Salvianolic acid B (Sal B), one of the major water-soluble compounds of Danshen (a popular Chinese herb), possesses many of the biological activities, such as antifibrogenic effect in liver and renal diseases. Transforming growth factor-β1 (TGF-β1) plays a central role in the development of pulmonary fibrosis by stimulating extracellular matrix (ECM) accumulation and activating fibroblasts. Here, we investigated the effects of Sal B on cell proliferation, collagen synthesis, endogenous TGF-β1 production, and α-smooth muscle actin (α-SMA, a marker of myofibroblasts) expression in human lung fibroblasts stimulated by TGF-β1 in vitro. The cell proliferation rates were analyzed by MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide) assay. The expression of TGF-β1 and type I collagen at both the mRNA and protein levels was detected by reverse transcription polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA), and radioimmunoassay, respectively. The α-SMA expression was detected by Western blot. TGF-β1 treatment of lung fibroblasts increased cell proliferation rates, and enhanced the expression level of type I collagen, endogenous TGF-β1 production, and α-SMA expression (P < .05). The treatment with only Sal B did not affect the proliferation and differentiation of lung fibroblasts. Interestingly, Sal B was found to inhibit TGF-β1-induced cell proliferation, expression of type I collagen, endogenous TGF-β1 production, and α-SMA expression in lung fibroblasts. Moreover, the inhibitory effect of Sal B on TGF-β1-induced proliferation and differentiation in lung fibroblasts was more significant when treated with high-dose Sal B (1 μmol/L versus 10 μmol/L, P < .05). These data demonstrate that Sal B inhibits TGF-β1-induced cell proliferation and differentiation in vitro experiment.

[Domestic imipenem cilastatin sodium for the treatment of severe aspiration pneumonia, a curative effect observation]

OBJECTIVE

To evaluate the efficacy and safety of domestic imipenem cilastatin sodium for the treatments of severe aspiration pneumonia.

METHODS

A randomize, open, parallel-controlled trial was conducted. Sixty-eight patients with severe aspiration pneumonia were divided into trial group (n=36) and control group (n=32) by random distribution method. The application of trial group domestic imipenem cilastatin sodium was 1.0 g intravenous drip, every 6-8 hours for 7-14 days. The control group application with imported injection imipenem cilastatin sodium was 1.0 g intravenous drip, every 6-8 hours for 7-14 days. The highest daily temperature (T), heart rate (HR), breathing rate (RR), pulse blood oxygen saturation (SpO(2)), blood oxygen partial pressure (PaO(2)), inhaled oxygen concentration (FiO(2)), oxygenation index (PaO(2)/FiO(2)), airway peak pressure (Paw), minute ventilation (MV) and white blood count (WBC), pro calcitonin (PCT), high-sensitivity C-reactive protein (hs-CRP) index before and 1, 3, 7 days after treatment, and liver and kidney function, chest X-rays, and sputum cultures of drug sensitive test were conducted. And the effectiveness and safety were determined according to the standards.

RESULTS

After treatment indexes of the two groups were obviously improved, i. e. T, HR, RR, Paw, MV, the WBC, PCT, CRP were gradually declined, PaO(2)/FiO(2) was gradually raised. There were statistical significance before and 3 days after treatment in the trial and the control group [T: 37.35±0.91 centigrade vs. 38.43±1.06 centigrade, 37.28±0.88 centigrade vs. 38.35±1.11 centigrade; HR: 90.25±10.60 bpm vs. 118.94±15.46 bpm, 89.31±11.17 bpm vs. 124.34±17.87 bpm; RR: 25.14±3.17 bpm vs. 32.28±4.49 bpm, 24.81±2.43 bpm vs. 33.13±4.17 bpm; Paw: 23.03±3.04 cm H(2)O vs. 33.22±4.59 cm H(2)O, 22.75±3.22 cm H(2)O vs. 33.63±4.79 cm H(2)O; MV: 8.67±1.26 L/min vs. 11.80±2.01 L/min, 8.88±1.45 L/min vs. 13.21±2.90 L/min; WBC: 11.26±1.96 ×10(9)/L vs. 14.57±3.10 ×10(9)/L, 12.28±3.38 ×10(9)/L vs. 15.25±4.93 ×10(9)/L; PCT: 6.90±5.46 μg/L vs. 16.97±7.93 μg/L, 6.17±6.13 μg/L vs. 21.26±11.54 μg/L; CRP: 85.50±37.91 mg/L vs. 120.17±45.47 mg/L, 94.31±38.51 mg/L vs. 142.34±53.57 mg/L; PaO(2)/ FiO(2): 182.06±40.88 mm Hg vs. 98.67±20.62 mm Hg, 184.09±43.78 mm Hg vs. 96.22±22.59 mm Hg, all P<0.05]. There was no significant change in SpO(2) before and after treatment in two groups. And the total clinical effective rate in trial and control group were 83.4% and 81.2%, adverse reaction rate were 13.9% and 9.4%, bacterial removal rate were 90.3% and 87.0% respectively, and there was no significant difference between the two groups (all P>0.05).

CONCLUSION

Domestic imipenem cilastatin sodium can effectively control severe aspiration pneumonia, and it is safe and effective antibiotics.