Implementation of “CODE SEPSIS” for septic patients at Al Wakra Hospital: A practice improvement initiative

Introduction: Sepsis is a major cause of hospitalization with a high mortality rate. Early recognition and management of sepsis have shown to improve mortality outcomes. A proactive alert system for improving the response of the interdisciplinary team may decrease the time to intervention and improve patient outcomes.

Objective: The study evaluated the impact of an early alert system, “CODE SEPSIS”, on adherence to the sepsis management bundle and time to intervention among patients at risk for sepsis.

Method: Patients presenting to the Emergency Department (ED) and meeting two or more criteria on the sepsis screening tool were intended to trigger an overhead alert known as CODE SEPSIS, which was activated based on the physician's decision. Data were retrospectively collected over a 3-month period for all hospitalized adult patients with confirmed sepsis (age above 18 years). We evaluated the time from ED presentation to diagnostic and treatment interventions. A data collection tool was designed to record information.

Results: A total of 36 sepsis patients were identified, among which 18 were classified as CODE SEPSIS and 18 were classified as non-CODE SEPSIS. We found that the CODE SEPSIS group showed greater improvement than the non-CODE SEPSIS group from ED presentation to intravenous catheter insertion (37.3 to 31.5 minutes, 15.6%), fluid administration (41 to 39 minutes, 4.9%), microbiological workup (91 to 33 minutes, 63.7%), lactate level (69 to 66 minutes, 4.3%), prescribing antimicrobial therapy (92 to 44 minutes, 52%), and administration of antimicrobial therapy (88 to 46 minutes, 47.7%). Patients in the non-CODE SEPSIS group showed a 1-day decrease in length of hospital stay.

Conclusion: The CODE SEPSIS alert system developed at Al Wakra Hospital promoted early and standardized management among patients at risk for sepsis, which may lead to improved patient outcomes.

Modeling the temporal variability of zinc concentrations in zinc roof runoff-experimental study and uncertainty analysis

This study investigates the temporal variability of zinc concentrations from zinc roof runoff. The influence of rainfall characteristics and dry period duration is evaluated by combining laboratory experiment on small zinc sheets and in situ measurements under real weather conditions from a 1.6-m(2) zinc panel. A reformulation of a commonly used conceptual runoff quality model is introduced and its ability to simulate the evolution of zinc concentrations is evaluated. A systematic and sharp decrease from initially high to relatively low and stable zinc concentrations after 0.5 to 2 mm of rainfall is observed for both experiments, suggesting that highly soluble corrosion products are removed at early stages of runoff. A moderate dependence between antecedent dry period duration and the magnitude of zinc concentrations at the beginning of a rain event is evidenced. Contrariwise, results indicate that concentrations are not significantly influenced by rainfall intensities. Simulated rainfall experiment nonetheless suggests that a slight effect of rainfall intensities may be expected after the initial decrease of concentrations. Finally, this study shows that relatively simple conceptual runoff quality models may be adopted to simulate the variability of zinc concentrations during a rain event and from a rain event to another.

Synthetic fibers in atmospheric fallout: A source of microplastics in the environment?

Sources, pathways and reservoirs of microplastics, plastic particles smaller than 5mm, remain poorly documented in an urban context. While some studies pointed out wastewater treatment plants as a potential pathway of microplastics, none have focused on the atmospheric compartment. In this work, the atmospheric fallout of microplastics was investigated in two different urban and sub-urban sites. Microplastics were collected continuously with a stainless steel funnel. Samples were then filtered and observed with a stereomicroscope. Fibers accounted for almost all the microplastics collected. An atmospheric fallout between 2 and 355 particles/m(2)/day was highlighted. Registered fluxes were systematically higher at the urban than at the sub-urban site. Chemical characterization allowed to estimate at 29% the proportion of these fibers being all synthetic (made with petrochemicals), or a mixture of natural and synthetic material. Extrapolation using weight and volume estimates of the collected fibers, allowed a rough estimation showing that between 3 and 10 tons of fibers are deposited by atmospheric fallout at the scale of the Parisian agglomeration every year (2500 km(2)). These results could serve the scientific community working on the different sources of microplastic in both continental and marine environments.

Long-term oncological and functional outcomes of prostate sparing cystectomy: Single tertiary care institution experience

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Background: To analyze the oncological and functional outcome of Prostate Sparing Cystectomy (PSC) in the treatment of Bladder Cancer (BC) in a single tertiary care referral institution. Methods: At our institution, we treated 147 patients (1992 – 2014) with PSC for muscle invasive BC and recurrent high grade non-muscle invasive BC. Out of these, 64 patients received a standardized PSC technique featuring a Millin adenomectomy between 2001 – 2014 and composed the population of the study. Inclusion criteria were: Normal prostate examination and prostate specific antigen (PSA) +/- negative transrectal ultrasound guided biopsies; Frozen section negative for cancer in prostatic urethra prostate base, distal ureters and trigone. Oncological outcome was evaluated with Overall survival (OS); Cancer-specific survival (CSS); Recurrence-free survival (RFS). Functional outcomes: Continence - being pad-free or leak-free requiring ≤ 1 pad per day/night. Sexual function was assessed by self- reported erectile function sufficient for intercourse with or without medical treatment. Results: Median age was 62 years (IQR 55-67,5) with a median follow-up of 70 months (IQR 46-103). Thirty one (48,4%) patients ≤ pT1, 19 (29,7%) pT2, 14 (21,9%) ≥ pT3 at pathological diagnosis. Lymphadenectomy was performed in 95,3% of the cases. Positive lymph nodes were found in 4.9% patients and 3.1% patients showed positive surgical margins. Ten patients (15,7%) had Clavien grade 3–5 complications.The 5 and 10-y survival rates were OS: 84,7% and 68,3%; CSS: 84,7% and 77,5%; RFS: 76% and 65,5% respectively. No case of recurrence at the remnant prostatic urothelium was observed. Pad-free and leak-free continence, were achieved in 85.9% and 93.8% for daytime continence respectively, with 50% and 85,9% for night continence, respectively. Erectile function was maintained in 56,3%. Prostate cancer was diagnosed in 3 (4,7%) patients, 2 at the pathology report of the adenomectomy followed with active surveillance, and 1 was diagnosed during the follow up being treated with brachytherapy. Conclusions: PSC appears to be an oncologically safe procedure with adequate functional outcomes in treating selected patients with BC.

Influence of effluent organic matter on copper speciation and bioavailability in rivers under strong urban pressure

This study focuses on spatiotemporal variations in the type of dissolved organic matter (DOM) and copper binding ability both upstream and downstream of Paris. It also compares the relative influence of both natural DOM upstream of Paris and effluent dissolved organic matter (EfDOM) output from a wastewater treatment plant (WWTP) on trace metal speciation and bioavailability in aquatic systems. In addition to the typical high- and low-affinity binding sites, a third family of very high-affinity binding sites has been highlighted for EfDOM. In receiving waters downstream of Paris during low-flow periods, the percentage of high- and very high-affinity sites originating from EfDOM reaches nearly 60 %. According to the speciation computation, the free copper concentration upstream of Paris exceeds the downstream Paris concentration by a factor of 2 to 4. As regards copper bioavailability, the highest EC50tot values were observed for EfDOM and downstream DOM, with a very low aromaticity and low UV absorbance. This finding suggests that specific ultraviolet absorbance (SUVA) is unlikely to be useful in assessing metal speciation and toxicity in aquatic systems subject to strong urban pressures. These results also highlight that the copper speciation computation for surface water exposed to considerable human pressures should include not only the humic and/or fulvic part of dissolved organic carbon but more hydrophilic fractions as well, originating for example from EfDOM.

The molecular characterisation of Escherichia coli K1 isolated from neonatal nasogastric feeding tubes

BACKGROUND

The most common cause of Gram-negative bacterial neonatal meningitis is E. coli K1. It has a mortality rate of 10-15 %, and neurological sequelae in 30-50 % of cases. Infections can be attributable to nosocomial sources, however the pre-colonisation of enteral feeding tubes has not been considered as a specific risk factor.

METHODS

Thirty E. coli strains, which had been isolated in an earlier study, from the residual lumen liquid and biofilms of neonatal nasogastric feeding tubes were genotyped using pulsed-field gel electrophoresis, and 7-loci multilocus sequence typing. Potential pathogenicity and biofilm associated traits were determined using specific PCR probes, genome analysis, and in vitro tissue culture assays.

RESULTS

The E. coli strains clustered into five pulsotypes, which were genotyped as sequence types (ST) 95, 73, 127, 394 and 2076 (Achman scheme). The extra-intestinal pathogenic E. coli (ExPEC) phylogenetic group B2 ST95 serotype O1:K1:NM strains had been isolated over a 2 week period from 11 neonates who were on different feeding regimes. The E. coli K1 ST95 strains encoded for various virulence traits associated with neonatal meningitis and extracellular matrix formation. These strains attached and invaded intestinal, and both human and rat brain cell lines, and persisted for 48 h in U937 macrophages. E. coli STs 73, 394 and 2076 also persisted in macrophages and invaded Caco-2 and human brain cells, but only ST394 invaded rat brain cells. E. coli ST127 was notable as it did not invade any cell lines.

CONCLUSIONS

Routes by which E. coli K1 can be disseminated within a neonatal intensive care unit are uncertain, however the colonisation of neonatal enteral feeding tubes may be one reservoir source which could constitute a serious health risk to neonates following ingestion.

Successful local thrombolytic therapy in subacute budd-chiari syndrome: Case report and review

Introduction: Management of Budd-Chiari syndrome (BCS) includes different interventions and surgical procedures. There is limited data regarding catheterdirected thrombolysis when treating this condition but it appears to be helpful in the case illustrated below. Case report: A 29 year-old woman was referred to our center with one month history of right upper abdominal pain, progressive abdominal distension and intermittent fever not associated with rigors. There was no history of oral contraceptive use. She had mild right upper quadrant tenderness and abdominal distention with moderate elevation of liver enzymes. Her serology was negative for viral hepatitis, autoimmune or cholestatic liver disease. Computed tomography (CT) angiogram of the abdomen showed a large amount of ascites with extensive thrombosis of the inferior vena cava (IVC) involving the hepatic and left renal veins. There was also complete occlusion of the left common iliac vein confirmed by venogram. An infusion catheter was placed through the thrombosed segment of the IVC and right hepatic artery. Thrombolytic therapy was started with the injection of 5 mg of recombinant tissue plasminogen activator (t-PA) as a loading dose followed by 0.3 mg per hour. Enoxaparin and oral warfarin were started simultaneously and once the target INR was reached, enoxaparin was stopped and warfarin continued indefinitely. Ascites was well controlled with diuretics and large-volume paracentesis. A follow up venogram showed partial recanalization of IVC and hepatic veins. A repeat CT scan after 14 weeks showed complete resolution of the thrombus. After 28 months, she is asymptomatic with normal liver function tests and total resolution of the ascites. Conclusions: The data on local thrombolysis is limited and the agents and doses are not uniform among reported cases. This case report shows that it can be considered in acute BCS with partial obstruction, followed by angioplasty or TIPS if unsuccessful.

Effect of Topical Insulin on Second-Degree Burns in Diabetic Rats

The healing process is complex in diabetic wounds, and the healing mechanism of burn wounds is different from that of incisional or excisional wounds. Data from our previous study indicated that topical insulin cream reduced wound closure time in diabetic rats. Our aim was to investigate the effect of topical insulin cream on wound healing following second-degree burns in control and diabetic rats. Rats were divided into four groups: control (nondiabetic) rats treated with placebo (CP), control (nondiabetic) rats treated with topical insulin cream (CI), diabetic rats treated with placebo (DP), and diabetic rats treated with topical insulin cream (DI). The wounds were assessed at 4 time points (1, 7, 14, and 26 days) post-wounding for morphometric analysis of wound sections stained with hematoxylin/eosin, α-smooth muscle actin, and Picrosirius red to evaluate general aspects of the wound, inflammatory infiltrate, blood vessels, and Types I and III collagen fibers. Histological analysis showed that topical insulin cream increased the inflammatory cell infiltrate in the DI group (at 7 and 14 days postburn, p < .05) and blood vessels (at 14 days postburn, p < .05) to levels similar to those of groups CP and CI. Wounds treated with topical insulin cream (CI and DI groups) showed significantly stronger staining for fibrillar collagen than wounds of the DP group. The use of topical insulin may reduce the duration of the inflammatory phase; improve wound reepithelialization, tissue granulation, and wound contraction; and increase collagen deposition in second-degree burns in healthy and diabetic animals.

Predictive Role of Admission Lactate Level in Critically Ill Patients with Acute Upper Gastrointestinal Bleeding

BACKGROUND

The predictive role of lactate in critically ill patients with acute upper gastrointestinal bleeding (UGIB) remains to be elucidated.

OBJECTIVE

The primary objective of this study was to assess the value of lactate level on admission to predict in-hospital death in patients with UGIB admitted to the intensive care unit (ICU). The secondary objective was to assess whether lactate level adds predictive value to the clinical Rockall score in these patients.

METHODS

This was a retrospective cohort study that included 133 patients with acute UGIB admitted to the ICU. Inclusion criteria were age > 18 years and presence of UGIB on admission to the ICU.

RESULTS

Mean age was 55.4 years old and 64.7% were male. The most common cause of gastrointestinal bleeding was peptic ulcer disease, followed by erosive esophagitis/gastritis. The in-hospital mortality was 22.6%. Median lactate level in survivors and nonsurvivors was 2.0 (interquartile range [IQR] 1.2-4.2 mmol/L) and 8.8 (IQR 3.4-13.3 mmol/L; p < 0.01), respectively. The receiver operating characteristic (ROC) area to predict in-hospital death for clinical Rockall score and lactate level (0.82) was significantly higher than the ROC area for the clinical Rockall score alone (0.69) (p < 0.01).

CONCLUSIONS

In patients admitted to the ICU with acute UGIB, lactate level on admission has a high sensitivity but low specificity for predicting in-hospital death. Lactate level adds to the predictive value of the clinical Rockall score. Given its high sensitivity, lactate level can be used in addition to other prediction tools to predict outcomes in patients with UGIB.