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Nie X, Deng W, Zhou H, Wang Z. Long noncoding RNA MCM3AP-AS1 attenuates sepsis-induced cardiomyopathy by improving inflammation, oxidative stress, and mitochondrial function through mediating the miR-501-3p/CADM1/STAT3 axis. Int Immunopharmacol 2024; 128:111500. [PMID: 38237222 DOI: 10.1016/j.intimp.2024.111500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 12/17/2023] [Accepted: 01/03/2024] [Indexed: 02/08/2024]
Abstract
Oxidative stress and inflammation are highly important for sepsis-mediated myocardial damage. The long noncoding RNA (lncRNA) MCM3AP-AS1 is involved in inflammatory diseases, but its function in acute myocardial injury during sepsis has not been fully elucidated. LPS and cecal ligation and puncture (CLP) were used to construct in vitro and in vivo sepsis-induced myocardial damage models, respectively. qRT-PCR was used to evaluate alterations in MCM3AP-AS1 and miR-501-3p alterations. After the MCM3AP-AS1 and miR-501-3p knockdown or overexpression models were established, the viability, apoptosis, inflammation, oxidative stress, and mitochondrial function of the myocardial cells were examined. Dual luciferase activity assay, RNA immunoprecipitation, and fluorescence in situ hybridization (FISH) confirmed the correlation among MCM3AP-AS1, miR-501-3p, and CADM1. Previous studies revealed that MCM3AP-AS1 was downregulated in sepsis patients, myocardial cells treated with LPS, and in the CLP mouse sepsis model, whereas miR-501-3p expression was increased. MCM3AP-AS1 overexpression hampered myocardial damage mediated by LPS and abated inflammation, oxidative stress, and mitochondrial dysfunction in myocardial cells and THP-1 cells. In contrast, MCM3AP-AS1 knockdown or miR-501-3p overexpression promoted all the effects of LPS. In vivo, MCM3AP-AS1 overexpression increased the survival rate of CLP mice; ameliorated myocardial injury; decreased the levels of TNF-α, IL-1β, IL-6, iNOS, COX2, ICAM1, VCAM1, PGE2, and MDA; and increased the levels of SOD, GSH-PX, Nrf2, and HO-1. Mechanistic studies demonstrated that MCM3AP-AS1 acted as a competitive endogenous RNA to repress miR-501-3p, enhance CADM1 expression, and dampen STAT3/nuclear factor-kappaB (NF-κB) activation. MCM3AP-AS1 suppresses myocardial injury elicited by sepsis by mediating the miR-501-3p/CADM1/STAT3/NF-κB axis.
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Affiliation(s)
- Xiangbi Nie
- Department of Emergency, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, NanChang 330006, Jiangxi, China
| | - Wu Deng
- Department of Emergency, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, NanChang 330006, Jiangxi, China
| | - Han Zhou
- Department of Emergency, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, NanChang 330006, Jiangxi, China
| | - Zenggeng Wang
- Department of Emergency, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, NanChang 330006, Jiangxi, China.
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Mounier R, Diop S, Kallel H, Constantin JM, Roujansky A. Tidal volume in mechanically ventilated patients: Searching for Cinderella's shoe rather than 6 mL/kg for all. Anaesth Crit Care Pain Med 2024; 43:101356. [PMID: 38365168 DOI: 10.1016/j.accpm.2024.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/18/2024]
Affiliation(s)
- R Mounier
- Department of Anaesthesiology and Critical Care, Georges Pompidou European Hospital, Paris, France; Université Paris, Paris, France; INSERM U955, Équipe 15, Institut Mondor de la Recherche Biomédicale, Université Paris-Est-Créteil, France.
| | - S Diop
- Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, France; Cardiothoracic Intensive Care Unit. Marie Lannelongue Hospital, Paris Saint Joseph Hospital, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, France
| | - H Kallel
- Réanimation Polyvalente, Centre Hospitalier de Cayenne, Cayenne, French Guiana; Tropical Biome et Immunopathologie CNRS UMR-9017, Inserm U 1019, Université de Guyane, French Guiana
| | - J M Constantin
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University, GRC 29, AP-HP, DMU DREAM, Paris, France
| | - A Roujansky
- Réanimation Polyvalente, Centre Hospitalier de Cayenne, Cayenne, French Guiana; Tropical Biome et Immunopathologie CNRS UMR-9017, Inserm U 1019, Université de Guyane, French Guiana
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Kang C, Choi S, Jang EJ, Joo S, Jeong JH, Oh SY, Ryu HG, Lee H. Prevalence and outcomes of chronic comorbid conditions in patients with sepsis in Korea: a nationwide cohort study from 2011 to 2016. BMC Infect Dis 2024; 24:184. [PMID: 38347513 PMCID: PMC10860243 DOI: 10.1186/s12879-024-09081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Chronic comorbid conditions are common in patients with sepsis and may affect the outcomes. This study aimed to evaluate the prevalence and outcomes of common comorbidities in patients with sepsis. METHODS We conducted a nationwide retrospective cohort study. Using data from the National Health Insurance Service of Korea. Adult patients (age ≥ 18 years) who were hospitalized in tertiary or general hospitals with a diagnosis of sepsis between 2011 and 2016 were analyzed. After screening of all International Classification of Diseases 10th revision codes for comorbidities, we identified hypertension, diabetes mellitus (DM), liver cirrhosis (LC), chronic kidney disease (CKD), and malignancy as prevalent comorbidities. RESULTS Overall, 373,539 patients diagnosed with sepsis were hospitalized in Korea between 2011 and 2016. Among them, 46.7% had hypertension, 23.6% had DM, 7.4% had LC, 13.7% had CKD, and 30.7% had malignancy. In-hospital mortality rates for patients with hypertension, DM, LC, CKD, and malignancy were 25.5%, 25.2%, 34.5%, 28.0%, and 33.3%, respectively, showing a decreasing trend over time (P < 0.001). After adjusting for baseline characteristics, male sex, older age, use of mechanical ventilation, and continuous renal replacement therapy, LC, CKD, and malignancy were significantly associated with in-hospital mortality. CONCLUSIONS Hypertension is the most prevalent comorbidity in patients with sepsis, and it is associated with an increased survival rate. Additionally, liver cirrhosis, chronic kidney disease, and malignancy result in higher mortality rates than hypertension and DM, and are significant risk factors for in-hospital mortality in patients with sepsis.
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Affiliation(s)
- Christine Kang
- Departments of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
| | | | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, South Korea
| | - Somin Joo
- Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jae Hoon Jeong
- Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Seung-Young Oh
- Departments of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ho Geol Ryu
- Departments of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
- Departments of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, South Korea
| | - Hannah Lee
- Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.
- Departments of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, South Korea.
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Kallimath A, Garegrat R, Patnaik S, Singh Y, Soni NB, Suryawanshi P. Hemodynamic effects of noradrenaline in neonatal septic shock: a prospective cohort study. J Trop Pediatr 2024; 70:fmae001. [PMID: 38324898 DOI: 10.1093/tropej/fmae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND The incidence of neonatal septic shock in low-income countries is 26.8% with a mortality rate of 35.4%. The evidence of the hemodynamic effects of noradrenaline in neonates remains sparse. This study was carried out to evaluate the effects of noradrenaline in neonates with septic shock. METHODS This was a single-center prospective cohort study in a tertiary care hospital's level III neonatal intensive care unit. Neonates with septic shock and those who received noradrenaline as a first-line vasoactive agent were included. Clinical and hemodynamic parameters were recorded before and after one hour of noradrenaline infusion. The primary outcomes were: response at the end of one hour after starting noradrenaline infusion and mortality rate. RESULTS A total of 21 babies were analyzed. The cohort comprised 17 preterm neonates. The mean age of presentation with septic shock was 74.3 h. Resolution of shock at one hour after starting noradrenaline was achieved in 76.2% of cases. The median duration of hospital stay was 14 days. The mean blood pressure improved after the initiation of noradrenaline from 30.6 mm of Hg [standard deviation (SD) 6.1] to 37.8 mm of Hg (SD 8.22, p < 0.001). Fractional shortening improved after noradrenaline initiation from 29% (SD 13.5) to 45.1% (SD 21.1, p < 0.001). The mortality rate was 28.6% in our study. CONCLUSION Noradrenaline is a potential drug for use in neonatal septic shock, with improvement in mean blood pressure and fractional shortening; however, further studies with larger sample sizes are needed to confirm our findings before it can be recommended as first-line therapy in neonatal septic shock.
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Affiliation(s)
- Aditya Kallimath
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Reema Garegrat
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Suprabha Patnaik
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Yogen Singh
- Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA 92345, USA
| | - Naharmal B Soni
- Department of Neonatology, Sidra Medicine, 26999 Doha, Qatar
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
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Jouffroy R, Holub M, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Vivien B, Gueye-Ngalgou P. Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting. Am J Emerg Med 2024; 76:48-54. [PMID: 37995523 DOI: 10.1016/j.ajem.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock. METHODS From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed. RESULTS Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]. CONCLUSION In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France; Centre de recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, France; EA 7329 - Institut de Recherche Médicale et d'Épidémiologie du Sport - Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
| | - Matthieu Holub
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, Paris 75013, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa Gueye-Ngalgou
- SAMU 972 CHU de Martinique Pierre Zobda, Quitman Hospital, Fort-de-France Martinique, France
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Sistanizad M, Salarian S, Kouchek M, Shojaei S, Miri M, Masbough F. Effect of calcitriol supplementation on infectious biomarkers in patients with positive systemic inflammatory response: A Randomized Controlled Trial. Ann Med Surg (Lond) 2024; 86:875-880. [PMID: 38333320 PMCID: PMC10849351 DOI: 10.1097/ms9.0000000000001643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/10/2023] [Indexed: 02/10/2024] Open
Abstract
Background Sepsis is one of the common causes of hospitalization of patients in intensive care units. A significant role for vitamin D in sepsis has been proposed, which is due to its active metabolite, calcitriol. Aims Evaluate the effect of calcitriol supplementation on infectious biomarkers, including procalcitonin and presepsin. Methods Patients with sepsis were divided into intervention and control group. Patients in the intervention group received intravenous calcitriol daily for 3 days. The serum levels of procalcitonin and presepsin were evaluated on days 0, 3, and 5 after administration. Results Fifty-two SIRS-positive patients were evaluated. Baseline characteristics, changes in Sequential Organ Failure Assessment (SOFA) score and blood levels of vitamin D were not significantly different between the two groups. Procalcitonin levels on day 5 and the differences between day 5 and 0 were significantly lower in the intervention group (P = 0.02). Presepsin on the third and fifth days in the intervention group was reduced, but in the control group, there was an ascending trend. However, there was no significant difference between the two groups on days 3 and 5 (P = 0.17 and P = 0.06, respectively) or between days 3 as well as 5 and the baseline presepsin level (P = 0.93 and P = 0.92, respectively). The ICU length of stay and 28-day mortality did not differ significantly either between the two arms of the study. Conclusions Finally, the results of this study showed that the administration of intravenous calcitriol could reduce the levels of procalcitonin but did not have a significant effect on presepsin.
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Affiliation(s)
- Mohammad Sistanizad
- Department of Clinical Pharmacy, School of Pharmacy
- Prevention of Cardiovascular Disease Research Center
| | - Sara Salarian
- Department of Critical Care Medicine, Imam Hossein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehran Kouchek
- Department of Critical Care Medicine, Imam Hossein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedpouzhia Shojaei
- Department of Critical Care Medicine, Imam Hossein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - MirMohammad Miri
- Department of Critical Care Medicine, Imam Hossein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Jouffroy R, Gille S, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK. J Emerg Med 2024; 66:144-153. [PMID: 38336569 DOI: 10.1016/j.jemermed.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging. OBJECTIVE The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU). METHODS From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality. RESULTS SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10-6). CONCLUSIONS SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt, France; Intensive Care Unit, Anaesthesiology, Service d'Aide Médicale Urgente, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; EA 7329-Institut de Recherche Médicale et d'Épidémiologie du Sport, Institut National du Sport, de l'Expertise et de la Performance, Paris, France
| | - Sonia Gille
- SAMU 972, University Hospital of Martinique, Pierre Zobda Quitman Hospital, Fort-de-France Martinique, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France; Emergency Department, Service Mobile d'Urgence et Reanimation, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, Service Mobile d'Urgence et Reanimation, La Pitié-Salpêtrière Hospital, Paris, France
| | | | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoît Vivien
- Intensive Care Unit, Anaesthesiology, Service d'Aide Médicale Urgente, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Papa Gueye
- SAMU 972, University Hospital of Martinique, Pierre Zobda Quitman Hospital, Fort-de-France Martinique, France
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Syryca F, Pellegrini C, Gollreiter M, Nicol P, Mayr NP, Alvarez-Covarrubias HA, Altaner N, Rheude T, Holdenrieder S, Schunkert H, Kastrati A, Joner M, Xhepa E, Trenkwalder T. Incidence of systemic inflammatory response syndrome and patient outcome following transcatheter edge-to-edge mitral valve repair. Clin Res Cardiol 2024; 113:276-287. [PMID: 37870627 PMCID: PMC10850015 DOI: 10.1007/s00392-023-02316-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVES Systemic inflammatory response syndrome (SIRS) is a common finding after cardiovascular interventions. Data on the incidence of SIRS and its impact on outcome in patients undergoing transcatheter edge-to-edge mitral valve repair (MV-TEER) for mitral regurgitation (MR) is lacking. METHODS From January 2013 to December 2020, 373 patients with moderate or severe MR undergoing MV-TEER were included. SIRS was defined as at least two of the following criteria within 48 h after the procedure: leucocyte count > 12.0 or < 4.0 × 109/l, respiratory rate > 20 breaths per minute or PaCO2 ≤ 4.3 kPa/32 mmHg, heart rate > 90 bpm and temperature > 38.0 °C or < 36.0 °C. The primary endpoint was 3-years all-cause mortality. RESULTS SIRS was observed in 49.6% (185/373) of patients. Patients who developed SIRS presented more frequently with NYHA III/IV at baseline [SIRS: 82.4% (149/185) vs. no SIRS: 79.0% (147/188); p = 0.029]. Patients who developed SIRS spent more days on ICU (p < 0.001) and overall length of stay was longer (p < 0.001). Relevant residual MR, defined as MR ≥ III in-hospital, was present more often in patients who developed SIRS [SIRS: 11.3% (20/177) vs. no SIRS: 3.93% (7/178), p = 0.036]. At 3 years, all-cause mortality in the entire population was 33.5% (125/373) with an increased all-cause mortality in patients with SIRS compared to patients without SIRS (HR 1.49, [CI 95% 1.04, 2.13]; p = 0.0264). In the multivariate analysis development of SIRS (HR 1.479 [CI 95% 1.016, 2.154]; p = 0.041) was identified as predictor for 3-years all-cause mortality. CONCLUSIONS SIRS is a common finding after MV-TEER occurring in approximately half of patients. SIRS after MV-TEER was associated with a longer in-hospital stay. In addition, we observed an increased 3-years all-cause mortality in patients with SIRS.
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Affiliation(s)
- Finn Syryca
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Costanza Pellegrini
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Marie Gollreiter
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Philipp Nicol
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - N Patrick Mayr
- Institute of Anaesthesiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | | | - Niklas Altaner
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Tobias Rheude
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Stefan Holdenrieder
- Institute of Laboratory Medicine, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Heribert Schunkert
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Erion Xhepa
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Teresa Trenkwalder
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany.
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
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Li Z, Zhou J, Cui S, Hu S, Li B, Liu X, Zhang C, Zou Y, Hu Y, Yu Y, Shen B, Yang B. Activation of sigma-1 receptor ameliorates sepsis-induced myocardial injury by mediating the Nrf2/HO1 signaling pathway to attenuate mitochondrial oxidative stress. Int Immunopharmacol 2024; 127:111382. [PMID: 38141412 DOI: 10.1016/j.intimp.2023.111382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Sepsis is a condition that triggers the release of large amounts of reactive oxygen species and inflammatory factors in the body, leading to myocardial injury and cardiovascular dysfunction - an important contributor to the high mortality rate associated with sepsis. Although it has been demonstrated that the sigma-1 receptor (S1R) is essential for preventing oxidative stress, its effectiveness in treating sepsis is yet unknown. AIM This study aimed to investigate the role and mechanisms of S1R activation in sepsis-induced myocardial injury. METHODS A model of sepsis-induced myocardial injury was constructed by performing cecum ligation and puncture(CLP) surgery on rats. Flv or BD1047 were intraperitoneally injected into rats for one consecutive week before performing CLP, and then intraperitoneally injected into the rats again 1 h after the surgery.The effects of Flv and BD1047 were detected by HE staining, immunofluorescence staining, IHC staining, echocardiography measurements,TUNEL, oxidative stress detection, TEM, flow cytometry and western blot. We further validated the mechanism in vitro using neonatal rat cardiomyocites and H9C2 cells. RESULTS S1R protein level was reduced in the hearts of septic rats, whereas administration of Flv, an S1R activator, ameliorated myocardial injury, mitochondrial oxidative stress, and pathological manifestations of sepsis. On the other hand, administration of the S1R inhibitor BD1047 exacerbated the mitochondrial oxidative stress, and apoptosis, as well as symptoms and pathological manifestations of sepsis. In addition, we found that up-regulation of S1R activated the Nrf2/HO1 signaling pathway and promoted nuclear translocation of Nrf2, which activated downstream proteins to generate antioxidant factors, such as HO1, in turn alleviating oxidative stress and countering myocardial damage. CONCLUSION By scavenging ROS accumulation and reducing mitochondrial oxidative stress via the Nrf2/HO1 signaling pathway, activation of S1R improves cardiac function, mitigates death of cardiomyocytes, and attenuates sepsis-induced myocardial injury.
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Affiliation(s)
- Zixuan Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Jining Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Shengyu Cui
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Shan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Bin Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Xin Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Cui Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Ying Zou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Yiqian Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Yi Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Bo Shen
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China.
| | - Bo Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China; Hubei Key Laboratory of Cardiology, Wuhan 430060, China.
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Mei J, Zhang X, Sun X, Hu L, Song Y. Optimizing the prediction of sepsis-associated encephalopathy with cerebral circulation time utilizing a nomogram: a pilot study in the intensive care unit. Front Neurol 2024; 14:1303075. [PMID: 38274881 PMCID: PMC10808420 DOI: 10.3389/fneur.2023.1303075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024] Open
Abstract
Background Sepsis-associated encephalopathy (SAE) is prevalent in intensive care unit (ICU) environments but lacks established treatment protocols, necessitating prompt diagnostic methods for early intervention. Traditional symptom-based diagnostics are non-specific and confounded by sedatives, while emerging biomarkers like neuron-specific enolase (NSE) and S100 calcium-binding protein B (S100B) have limited specificity. Transcranial Doppler (TCD) indicators, although is particularly relevant for SAE, requires high operator expertise, limiting its clinical utility. Objective This pilot study aims to utilize cerebral circulation time (CCT) assessed via contrast-enhanced ultrasound (CEUS) as an innovative approach to investigate the accuracy of SAE prediction. Further, these CCT measurements are integrated into a nomogram to optimize the predictive performance. Methods This study employed a prospective, observational design, enrolling 67 ICU patients diagnosed with sepsis within the initial 24 h. Receiver operating characteristic (ROC) curve analyses were conducted to assess the predictive accuracy of potential markers including NSE, S100B, TCD parameters, and CCT for SAE. A nomogram was constructed via multivariate Logistic Regression to further explore the combined predictive potential of these variables. The model's predictive performance was evaluated through discrimination, calibration, and decision curve analysis (DCA). Results SAE manifested at a median of 2 days post-admission in 32 of 67 patients (47.8%), with the remaining 35 sepsis patients constituting the non-SAE group. ROC curves revealed substantial predictive utility for CCT, pulsatility index (PI), and S100B, with CCT emerging as the most efficacious predictor, evidenced by an area under the curve (AUC) of 0.846. Multivariate Logistic Regression identified these markers as independent predictors for SAE, leading to the construction of a nomogram with excellent discrimination, substantiated by an AUC of 0.924 through bootstrap resampling. The model exhibited satisfactory concordance between observed and predicted probabilities, and DCA confirmed its clinical utility for the prompt identification of SAE. Conclusion This study highlighted the enhanced predictive value of CCT in SAE detection within ICU settings. A novel nomogram incorporating CCT, PI, and S100B demonstrated robust discrimination, calibration, and clinical utility, solidifying it as a valuable tool for early SAE intervention.
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Affiliation(s)
- Jiangjun Mei
- Department of Ultrasonography, Shanghai Pudong New Area Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Xiajing Zhang
- School of Medical Devices, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Xuesong Sun
- Department of Ultrasonography, Shanghai Pudong New Area Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Lihua Hu
- Department of Ultrasonography, Shanghai Pudong New Area Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Ye Song
- Department of Ultrasonography, Shanghai Pudong New Area Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
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Yi X, Jin D, Huang S, Xie Z, Zheng M, Zhou F, Jin Y. Association between lactate-to-albumin ratio and 28-days all-cause mortality in patients with sepsis-associated liver injury: a retrospective cohort study. BMC Infect Dis 2024; 24:65. [PMID: 38195421 PMCID: PMC10775525 DOI: 10.1186/s12879-024-08978-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 01/02/2024] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND The mortality rate of sepsis-associated liver injury (SALI) is relatively high, but there is currently no authoritative prognostic criterion for the outcome of SALI. Meanwhile, lactate-to-albumin ratio (LAR) has been confirmed to be associated with mortality rates in conditions such as sepsis, heart failure, and respiratory failure. However, there is a scarcity of research reporting on the association between LAR and SALI. This study aimed to elucidate the association between LAR and the 28-day mortality rate of SALI. METHODS In this retrospective cohort study, data were obtained from the Medical Information Mart for Intensive Care IV (v2.2). Adult patients with SALI were admitted to the intensive care unit in this study. The LAR level at admission was included, and the primary aim was to assess the relationship between the LAR and 28-day all-cause mortality. RESULTS A total of 341 patients with SALI (SALI) were screened. They were divided into a survival group (241) and a non-survival group (100), and the 28-day mortality rate was 29.3%. Multivariable Cox regression analysis revealed that for every 1-unit increase in LAR, the 28-day mortality risk for SALI patients increased by 21%, with an HR of 1.21 (95% CI 1.11 ~ 1.31, p < 0.001). CONCLUSIONS This study indicates that in patients with SALI, a higher LAR is associated with an increased risk of all-cause mortality within 28 days of admission. This suggests that LAR may serve as an independent risk factor for adverse outcomes in SALI patients.
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Affiliation(s)
- Xiaona Yi
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Dongcai Jin
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Shanshan Huang
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Zhenye Xie
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Meixia Zheng
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Fen Zhou
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Yuhong Jin
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China.
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Smith TN, Choi C, Rattan P, Piccolo Serafim L, Kassmeyer BA, Lennon RJ, Gajic O, Olson JC, Kamath PS, Gallo De Moraes A, Simonetto DA. Serum lactate and mean arterial pressure thresholds in patients with cirrhosis and septic shock. Hepatol Commun 2024; 8:e0353. [PMID: 38180993 PMCID: PMC10781124 DOI: 10.1097/hc9.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/06/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The Sepsis-3 guidelines have incorporated serum lactate levels of >2 mmol/L in septic shock definition to account for higher observed mortality. Further evidence is needed to support this threshold in cirrhosis, as well as target mean arterial pressure (MAP) during resuscitation. METHODS This observational cohort study investigated the association between initial serum lactate and resuscitation MAP levels on in-hospital mortality in patients with and without cirrhosis. Patients admitted to the intensive care unit for the treatment of septic shock between 2006 and 2021 in a quaternary academic center were included. Patients with cirrhosis documented on imaging and International Classification of Disease codes (n=595) were compared to patients without cirrhosis (n=575). The association of intensive care unit admission lactate levels and median 2-hour MAP with in-hospital mortality and the need for continuous renal replacement therapy was assessed. The association between median 24-hour MAP and in-hospital mortality was analyzed post hoc. RESULTS Within the cirrhosis group, admission lactate levels of 2-4 and >4 mmol/L were associated with increased in-hospital mortality compared to lactate <2 mmol/L [adjusted odds ratio (aOR): 1.69, CI: 1.03-2.81, aOR: 4.02, CI: 2.53-6.52]. Median 24-hour MAP 60-65 and <60 mm Hg were also associated with increased in-hospital mortality compared with MAP >65 mm Hg (aOR: 2.84, CI: 1.64-4.92 and aOR: 7.34, CI: 3.17-18.76). In the noncirrhosis group, associations with in-hospital mortality were weaker for lactate 2-4 and >4 mmol/L (aOR: 1.32, CI: 0.77-2.27 and aOR: 2.25, CI: 1.40-3.67) and median 24-hour MAP 60-65 and <60 mm Hg (aOR: 1.70, CI: 0.65-4.14 and aOR: 4.41, CI: 0.79-29.38). CONCLUSIONS These findings support utilizing lactate >2 mmol/L in the definition of septic shock, as well as a target MAP of >65 mm Hg during resuscitation in patients with cirrhosis.
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Affiliation(s)
- Thomas N. Smith
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Chansong Choi
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Puru Rattan
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Blake A. Kassmeyer
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ryan J. Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jody C. Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Alice Gallo De Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Douglas A. Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Kundu A, Ghosh P, Bishayi B. Vitexin along with verapamil downregulates efflux pump P-glycoprotein in macrophages and potentiate M1 to M2 switching via TLR4-NF-κB-TNFR2 pathway in lipopolysaccharide treated mice. Immunobiology 2024; 229:152767. [PMID: 38103391 DOI: 10.1016/j.imbio.2023.152767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/22/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
The lipopolysaccharide, a microbial toxin, is one of the major causative agents of sepsis. P-gp expression and its functions are altered during inflammation. LPS has been known to impair the functions of P-gp, an efflux transporter. But the effect of LPS on P-gp expression in murine peritoneal macrophages is poorly understood. Molecular docking studies reveal that vitexin is a potent substrate and verapamil a potent inhibitor of P-gp. In the present experimental study, the curative potential of vitexin as a fruit component and verapamil treated as a control inhibitor of P-gp was examined in a murine LPS sepsis model. The effects of vitexin and verapamil on P-gp expression in macrophages correlating with changes in macrophage polarization and associated functional responses during LPS induced sepsis were studied. Peritoneal macrophages of LPS (10 mg/kg body weight) challenged mice exhibited elevated levels of H2O2, superoxide, and NO in parallel with lower antioxidant activity. LPS treatment increased P-gp expression through increased TLR4/expression. However, LPS challenged mice treated with vitexin (5 mg/kg body weight) + verapamil (5 mg/kg body weight) showed higher anti-oxidant enzyme activity (SOD, CAT and GRx) resulting in reduced oxidative stress. This combination treatment also elevated TNFR2, concomitant with down-regulation of TLR4, NF-κB and P-gp expression in murine peritoneal macrophages, resulting in a switch from M1 to M2 polarisation of macrophages and reduced inflammatory responses. In conclusion, combined vitexin and verapamil treatment could be used as a promising therapy to regulate P-gp expression and protection against LPS mediated sepsis and inflammatory damages.
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Affiliation(s)
- Ayantika Kundu
- Department of Physiology, Immunology Laboratory, University of Calcutta, University Colleges of Science and Technology, 92 APC Road, Calcutta 700009, West Bengal, India
| | - Pratiti Ghosh
- Department of Physiology, Immunology Laboratory, University of Calcutta, University Colleges of Science and Technology, 92 APC Road, Calcutta 700009, West Bengal, India.
| | - Biswadev Bishayi
- Department of Physiology, Immunology Laboratory, University of Calcutta, University Colleges of Science and Technology, 92 APC Road, Calcutta 700009, West Bengal, India.
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Carlotta N, Nitin M, Dave B, Bhaskar Kumar S. Gram negative bacteria related urinary tract infections: spectrum of antimicrobial resistance over 9 years in a University tertiary referral Hospital. Ther Adv Infect Dis 2024; 11:20499361241228342. [PMID: 38312849 PMCID: PMC10838025 DOI: 10.1177/20499361241228342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/09/2024] [Indexed: 02/06/2024] Open
Abstract
Objective Overuse of antibiotics has led to an increase in antimicrobial resistance (AMR) worldwide, with a negative impact on the healthcare system and the patients. In this context, our study aims to assess the current AMR patterns of urinary tract infections (UTIs) associated to Gram-negative bacteria. Thus, we provide useful information for doctors dealing with prophylactic and therapeutic empiric therapies. Materials and methods We retrospectively analysed more than 650,000 urine cultures collected in the Microbiology Department of a referral University Hospital of Southern England from January 2014 to December 2022. Results AMR spectra for 164,059 Gram-negative associated (UTIs) were analysed. The lowest percentage of resistance was found for Amikacin (2.30%), Gentamicin (5.89%) and Co-Amoxiclav (10.49%). Over a 9-year time, there was no significant change in resistance to Amikacin (2.04% in 2014 compared to 2.18% in 2022; p = 0.602) and to Fosfomycin (11.50% in 2014 versus 16.65% in 2022; p = 0.577). Overall, the trend of AMR significantly rose for Cefalexin (17.96-18.42%; p < 0.0001), Co-amoxiclav (9.46-12.69%; p < 0.0001), Nitrofurantoin (10.20-14.18%; p < 0.0001) and Piperacillin/Tazobactam (14.52-18.96%; p < 0.0001). Gram-negative resistance spectrum towards Ciprofloxacin (11.83-9.01%; p < 0.0001), Gentamicin (6.29-5.26%; p < 0.0001), Pivmecillinam (26.88-11.02%; p < 0.0001), Trimethoprim (36.72-29.23%; p < 0.0001) and Ampicillin/Amoxicillin (65.20-57.99%; p < 0.0001) significantly decreased. Conclusion Despite the application of national and international guidelines for prophylaxis and treatment of UTIs, the spectrum of resistance for the most common antibiotics is still changing. Clinicians in primary and secondary care must keep that in mind when prescribing antibiotics for suspected UTI and sepsis associated with Gram-negative infections Up-to-date therapeutic strategies can help implement treatment of UTI, reducing selection of multi-resistant pathogens and providing more accurate care for patients. Future studies will be required to help clinicians and keep the guidelines updated.
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Affiliation(s)
- Nedbal Carlotta
- Department of Urology, University Hospital Southampton NHS Trust, Southampton SO16 6YD, UK
| | - Mahobia Nitin
- Department of Infection, University Hospital Southampton NHS Trust, Southampton, UK
| | - Browning Dave
- Department of Infection, University Hospital Southampton NHS Trust, Southampton, UK
| | - Somani Bhaskar Kumar
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
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Martinez K, Aronson B. Development and evaluation of a sepsis simulation with undergraduate nursing students. NURSE EDUCATION TODAY 2024; 132:106031. [PMID: 37979244 DOI: 10.1016/j.nedt.2023.106031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/13/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND In 2016, the Centers for Disease Control found that more than 1.5 million people develop sepsis each year and about 250,000 Americans die from it. Early identification and treatment of sepsis can decrease mortality and morbidity, yet studies have shown student nurses are not prepared to rescue deteriorating patients. METHOD The purpose of this pilot study was to create and test a response to rescue simulation for use with undergraduate nursing students. The simulation depicted a patient deteriorating from sepsis. The Martinez Sepsis Competency Evaluation Tool (MSCET) developed to rate student behaviors during the simulation. Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing model was used post simulation. RESULTS The overall content validity of the MSCET was 0.88. Each item that scored a I-CVI of 0.78 or less were revised. The total percentage of behaviors met was 68 %. The inter-rater reliability of the MSCET conciseness was 0.47 (X = 67.508, df = 48, p ≤ .05). CONCLUSION The results indicate the simulation based experience was effective in preparing students to care for patients with early signs of sepsis. Students were complimentary about the experience, and preliminary data on the MSCET psychometrics were positive. Limitations of the study and recommendations for further revision of the simulation were made.
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Affiliation(s)
- Kelly Martinez
- Southern Connecticut State University, College of Health and Human Services, Department of Nursing, 501 Crescent Street, New Haven, CT 06515, United States of America.
| | - Barbara Aronson
- Southern Connecticut State University, College of Health and Human Services, Department of Nursing, 501 Crescent Street, New Haven, CT 06515, United States of America
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Wendel-Garcia PD, Eberle B, Kleinert EM, Hilty MP, Blumenthal S, Spanaus K, Fodor P, Maggiorini M. Effects of enhanced adsorption haemofiltration versus haemoadsorption in severe, refractory septic shock with high levels of endotoxemia: the ENDoX bicentric, randomized, controlled trial. Ann Intensive Care 2023; 13:127. [PMID: 38095800 PMCID: PMC10721780 DOI: 10.1186/s13613-023-01224-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Endotoxin adsorption is a promising but controversial therapy in severe, refractory septic shock and conflicting results exist on the effective capacity of available devices to reduce circulating endotoxin and inflammatory cytokine levels. METHODS Multiarm, randomized, controlled trial in two Swiss intensive care units, with a 1:1:1 randomization of patients suffering severe, refractory septic shock with high levels of endotoxemia, defined as an endotoxin activity ≥ 0.6, a vasopressor dependency index ≥ 3, volume resuscitation of at least 30 ml/kg/24 h and at least single organ failure, to a haemoadsorption (Toraymyxin), an enhanced adsorption haemofiltration (oXiris) or a control intervention. Primary endpoint was the difference in endotoxin activity at 72-h post-intervention to baseline. In addition, inflammatory cytokine, vasopressor dependency index and SOFA-Score dynamics over the initial 72 h were assessed inter alia. RESULTS In the 30, out of 437 screened, randomized patients (10 Standard of care, 10 oXiris, 10 Toraymyxin), endotoxin reduction at 72-h post-intervention-start did not differ among interventions (Standard of Care: 12 [1-42]%, oXiris: 21 [10-51]%, Toraymyxin: 23 [10-36]%, p = 0.82). Furthermore, no difference between groups could be observed neither for reduction of inflammatory cytokine levels (p = 0.58), nor for vasopressor weaning (p = 0.95) or reversal of organ injury (p = 0.22). CONCLUSIONS In a highly endotoxemic, severe, refractory septic shock population neither the Toraymyxin adsorber nor the oXiris membrane could show a reduction in circulating endotoxin or cytokine levels over standard of care. Trial registration ClinicalTrials.gov. NCT01948778. Registered August 30, 2013. https://clinicaltrials.gov/study/NCT01948778.
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Affiliation(s)
- Pedro David Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Barbara Eberle
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Eva-Maria Kleinert
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | | | - Katharina Spanaus
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland
| | - Patricia Fodor
- Institute of Intensive Care Medicine, Triemli Hospital, Zurich, Switzerland
| | - Marco Maggiorini
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Toenges R, Steiner M, Weber CF, Miesbach W. Investigation of acquired dysfibrinogenaemia in adult patients with sepsis using fibrinogen function vs. concentration ratios: a cross-sectional study. Front Med (Lausanne) 2023; 10:1294301. [PMID: 38152302 PMCID: PMC10752225 DOI: 10.3389/fmed.2023.1294301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Inherited or acquired molecular abnormalities form a clinically heterogeneous group of fibrinogen disorders called dysfibrinogenaemia. Apart from a pediatric case report and in contrast to other clinical conditions, acquired dysfibrinogenaemia has not been previously reported in septic patients. Methods In an observational cohort study, 79 adult septic patients were investigated for the presence of acquired dysfibrinogenaemia at the time of their admission to the intensive care unit (ICU) of the University Hospital Frankfurt. Following established recommendations, fibrinogen clotting activity vs. antigen ratios were analyzed using Clauss fibrinogen, prothrombin-derived fibrinogen, and radial immunodiffusion (RID) fibrinogen concentration. Results Prothrombin-derived fibrinogen levels were highest (527 ± 182 mg/dL) followed by Clauss fibrinogen (492 ± 209 mg/dL) and radial immunodiffusion fibrinogen (426 ± 159 mg/dL). Very few cases demonstrated hypofibrinogenaemia making overt disseminated intravascular coagulation (DIC) unlikely in the cohort investigated. Clauss/RID fibrinogen ratios were lower (1.17 ± 0.19) compared to prothrombin time-derived/RID ratios (1.35 ± 0.33). Using the Clauss/RID dataset, 21% of patients (16/76 patients) demonstrated values below a threshold ratio for suspected acquired dysfibrinogenaemia arbitrarily set at 1.0. In contrast, prothrombin-derived ratios were below the threshold in only 7% (4/58 patients). Discussion The results point to the presence of acquired dysfibrinogenaemia in part of adult septic patients. If confirmed in further studies, this may form part of a specific laboratory signature of a sepsis-associated coagulation phenotype.
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Affiliation(s)
- Rosa Toenges
- Department of Medicine, Hemostaseology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | | | - Christian Friedrich Weber
- Department for Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- Department for Anesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Hamburg, Germany
| | - Wolfgang Miesbach
- Department of Medicine, Hemostaseology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
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Blum CA, Roethlisberger EA, Cesana-Nigro N, Winzeler B, Rodondi N, Blum MR, Briel M, Mueller B, Christ-Crain M, Schuetz P. Adjunct prednisone in community-acquired pneumonia: 180-day outcome of a multicentre, double-blind, randomized, placebo-controlled trial. BMC Pulm Med 2023; 23:500. [PMID: 38082273 PMCID: PMC10712075 DOI: 10.1186/s12890-023-02794-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Several trials and meta-analyses found a benefit of adjunct corticosteroids for community-acquired pneumonia with respect to short-term outcome, but there is uncertainty about longer-term health effects. Herein, we evaluated clinical outcomes at long term in patients participating in the STEP trial (Corticosteroid Treatment for Community-Acquired Pneumonia). METHODS This predefined secondary analysis investigated 180-day outcomes in 785 adult patients hospitalized with community-acquired pneumonia included in STEP, a randomised, placebo-controlled, double-blind trial. The primary endpoint was time to death from any cause at 180 days verified by telephone interview. Additional secondary endpoints included pneumonia-related death, readmission, recurrent pneumonia, secondary infections, new hypertension, and new insulin dependence. RESULTS From the originally included 785 patients, 727 were available for intention-to-treat analysis at day 180. There was no difference between groups with respect to time to death from any cause (HR for corticosteroid use 1.15, 95% CI 0.68 to 1.95, p = 0.601). Compared to placebo, corticosteroid-treated patients had significantly higher risks for recurrent pneumonia (OR 2.57, 95% CI 1.29 to 5.12, p = 0.007), secondary infections (OR 1.94, 95% CI 1.25 to 3.03, p = 0.003) and new insulin dependence (OR 8.73, 95% CI 1.10 to 69.62, p = 0.041). There was no difference regarding pneumonia-related death, readmission and new hypertension. CONCLUSIONS In patients with community-acquired pneumonia, corticosteroid use was associated with an increased risk for recurrent pneumonia, secondary infections and new insulin dependence at 180 days. Currently, it is uncertain whether these long-term adverse effects outweigh the short-term effects of corticosteroids in moderate CAP. TRIAL REGISTRATION This trial was registered with ClinicalTrials. gov, number NCT00973154 before the recruitment of the first patient. First posted: September 9, 2009. Last update posted: April 21, 2015.
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Affiliation(s)
- Claudine A Blum
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland.
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland.
- Hormonpraxis Aarau, 5000, Aarau, Switzerland.
| | - Eva A Roethlisberger
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Nicole Cesana-Nigro
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
- Stoffwechselzentrum, Bürgerspital, 4500, Solothurn, Switzerland
| | - Bettina Winzeler
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Matthias Briel
- CLEAR-Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, 4031, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Beat Mueller
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
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Cutuli SL, Carelli S, Cascarano L, Cicconi S, Silvestri D, Cicetti M, Vallecoccia MS, Pintaudi G, Tanzarella ES, Grieco DL, Antonelli M, De Pascale G. Clinical implications of endotoxin activity and Polymyxin-B hemoperfusion in critically ill patients with septic cardiomyopathy: A single-center, retrospective, observational study. Artif Organs 2023; 47:1865-1873. [PMID: 37737449 DOI: 10.1111/aor.14645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND To explore the association between endotoxin activity (EA) and septic cardiomyopathy (SCM), the relationship between endotoxin removal by Polymyxin-B hemoperfusion (PMX-HP) and recovery from SCM (R-SCM), and the correlation between R-SCM and the 28-day mortality in septic patients admitted to the intensive care unit (ICU). METHODS Observational study that included patients admitted to two ICUs of a tertiary university hospital between April 2011 and December 2019, who received PMX-HP for sepsis/septic shock. The SCM and R-SCM were assessed by transthoracic echocardiography. RESULTS Among 148 patients, SCM was diagnosed in 60 (46%) of them and had no relationship with median EA (SCM group: 0.73; no-SCM group: 0.66, p = 0.48). Recovery from SCM was observed in 24 patients (49%) and was independently associated with the PMX-HP (OR 4.19, 95%CI [1.22, 14.3]; p = 0.02) and the SAPS2 II score (OR 0.94, 95%CI [0.9, 0.98]; p = 0.006). In the SCM group, the 28-day mortality was 60% and was independently predicted by R-SCM (OR 0.02, 95%CI [0.001, 0.3] p = 0.005) and SAPS II score (OR 1.11, 95%CI [1.01, 1.23] p = 0.037). CONCLUSIONS In septic patients, EA was not associated with SCM. However, endotoxin removal by Polymyxin-B hemoperfusion was associated with recovery from cardiomyopathy, which was a predictor of lower 28-day mortality.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Carelli
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura Cascarano
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sandra Cicconi
- Department of Anesthesiology and Intensive Care Medicine, Infermi Hospital, Rimini, Italy
| | - Davide Silvestri
- Department of Anesthesiology and Intensive Care Medicine, S. Luca Hospital, Lucca, Italy
| | - Marta Cicetti
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloisa Sofia Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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Yang C, Wei H, Zhan H, Luan T, Wan W, Yuan S, Chen J. Effect of preoperative prophylactic antibiotic use on postoperative infection after percutaneous nephrolithotomy in patients with negative urine culture: a single-center randomized controlled trial. World J Urol 2023; 41:3687-3693. [PMID: 37804339 DOI: 10.1007/s00345-023-04623-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/06/2023] [Indexed: 10/09/2023] Open
Abstract
PURPOSE To compare the effects of different preoperative antibiotic prophylaxis (ABP) regimens on the incidence of sepsis after percutaneous nephrolithotomy (PCNL) in patients with negative urine culture. METHODS A single-center, randomized controlled trial (June 2022-December 2023) included 120 patients with negative preoperative urine cultures for upper urinary tract stones who underwent PCNL (chictr.org.cn; ChiCTR2200059047). The experimental group and the control group were respectively given different levofloxacin-based preoperative ABP regimes, including 3 days before surgery and no ABP before surgery. Both groups were given a dose of antibiotics before the operation. The primary outcome was differences in the incidence of postoperative sepsis. RESULTS A total of 120 subjects were included, including 60 patients in the experimental group and 60 patients in the control group. The baseline characteristics of the two groups were comparable and intraoperative characteristics also did not differ. The sepsis rate was not statistically different between the experimental and control groups (13.3% vs.13.3%, P = 1.0). A multivariate logistic regression analysis revealed that body mass index (BMI) (OR = 1.3; 95% CI = 1.1-1.6; P = 0.003) and operating time (OR = 1.1; 95% CI = 1.0-1.1; P = 0.012) were independent risk factors of sepsis. CONCLUSION Our study showed that prophylactic antibiotic administration for 3 days before surgery did not reduce the incidence of postoperative sepsis in patients with negative urine cultures undergoing PCNL. For this subset of patients, we recommend that a single dose of antibiotics be given prior to the commencement of surgery seems adequate.
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Affiliation(s)
- Chadanfeng Yang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China
| | - Hairong Wei
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China
| | - Hui Zhan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China
| | - Ting Luan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China
| | - Weiming Wan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China
| | - Shunhui Yuan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China
| | - Jian Chen
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, 374 Dianmian Avenue, Wuhua District, Kunming, NO, China.
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71
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Chen JJ, Lai PC, Lee TH, Huang YT. Blood Purification for Adult Patients With Severe Infection or Sepsis/Septic Shock: A Network Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1777-1789. [PMID: 37470680 PMCID: PMC10645104 DOI: 10.1097/ccm.0000000000005991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVES This study aimed to conduct a comprehensive and updated systematic review with network meta-analysis (NMA) to assess the outcome benefits of various blood purification modalities for adult patients with severe infection or sepsis. DATA SOURCES We conducted a search of PubMed, MEDLINE, clinical trial registries, Cochrane Library, and Embase databases with no language restrictions. STUDY SELECTION Only randomized controlled trials (RCTs) were selected. DATA EXTRACTION The primary outcome was overall mortality. The secondary outcomes were the length of mechanical ventilation (MV) days and ICU stay, incidence of acute kidney injury (AKI), and kidney replacement therapy requirement. DATA SYNTHESIS We included a total of 60 RCTs with 4,595 participants, comparing 16 blood purification modalities with 17 interventions. Polymyxin-B hemoperfusion (relative risk [RR]: 0.70; 95% CI, 0.57-0.86) and plasma exchange (RR: 0.61; 95% CI, 0.42-0.91) were associated with low mortality (very low and low certainty of evidence, respectively). Because of the presence of high clinical heterogeneity and intransitivity, the potential benefit of polymyxin-B hemoperfusion remained inconclusive. The analysis of secondary outcomes was limited by the scarcity of available studies. HA330 with high-volume continuous venovenous hemofiltration (CVVH), HA330, and standard-volume CVVH were associated with shorter ICU stay. HA330 with high-volume CVVH, HA330, and standard-volume CVVH were beneficial in reducing MV days. None of the interventions showed a significant reduction in the incidence of AKI or the need for kidney replacement therapy. CONCLUSIONS Our NMA suggests that plasma exchange and polymyxin-B hemoperfusion may provide potential benefits for adult patients with severe infection or sepsis/septic shock when compared with standard care alone, but most comparisons were based on low or very low certainty evidence. The therapeutic effect of polymyxin-B hemoperfusion remains uncertain. Further RCTs are required to identify the specific patient population that may benefit from extracorporeal blood purification.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou Main Branch, Taoyuan City, Taiwan
| | - Pei-Chun Lai
- Education Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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72
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Ingalls EM, Yost S, Waters CD. Systematic Review of Piperacillin-Tazobactam and Vancomycin Y-Site Compatibility: Consideration of Concentration and Solution Variability. Hosp Pharm 2023; 58:557-563. [PMID: 38560538 PMCID: PMC10977070 DOI: 10.1177/00185787231169455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Simultaneous administration of vancomycin and piperacillin-tazobactam (VPT) poses significant challenges related to physical and chemical compatibility, as well as clinical practice. A systematic review of available literature related to VPT Y-site compatibility was performed. Data was collected from primary and tertiary sources. Seven articles were included in addition to one internal assessment and one review article and information from tertiary drug databases. The literature supports the simultaneous administration via Y-site of piperacillin-tazobactam 33.75 mg/mL in normal saline (NS) and vancomycin 4 to 8 mg/mL in NS. The same drug products at differing concentrations, diluents, storage conditions, or preparations outside of this recommendation should be considered incompatible.
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Affiliation(s)
| | - Sarah Yost
- Intermountain Healthcare Drug Information Services, Murray, UT, USA
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Whitehouse T, Hossain A, Perkins GD, Gordon AC, Bion J, Young D, McAuley D, Singer M, Lord J, Gates S, Veenith T, MacCallum NS, Yeung J, Innes R, Welters I, Boota N, Skilton E, Ghuman B, Hill M, Regan SE, Mistry D, Lall R. Landiolol and Organ Failure in Patients With Septic Shock: The STRESS-L Randomized Clinical Trial. JAMA 2023; 330:1641-1652. [PMID: 37877587 PMCID: PMC10600724 DOI: 10.1001/jama.2023.20134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality. Objectives To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support. Design, Setting, and Participants An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm. Intervention Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion. Main Outcomes and Measures The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group. Results The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event. Conclusion and Relevance Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock. Trial Registration EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.
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Affiliation(s)
- Tony Whitehouse
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Anower Hossain
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Gavin D. Perkins
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine & Intensive Care, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Julian Bion
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, United Kingdom
| | - Duncan Young
- Kadoorie Centre for Critical Care Research, Nuffield Division of Anaesthesia, University of Oxford, Oxford, United Kingdom
| | - Danny McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, United Kingdom
| | - Mervyn Singer
- Centre for Intensive Care Medicine, Department of Medicine and Wolfson Institute for Biomedical Research, University College, London, United Kingdom
| | - Janet Lord
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Tonny Veenith
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Niall S. MacCallum
- University College London Hospitals NHS Foundation Trust, Gower Street, London, United Kingdom
| | - Joyce Yeung
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Richard Innes
- Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | - Nafisa Boota
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Emma Skilton
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Belinder Ghuman
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Maddy Hill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Scott E. Regan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Kempsell-Smith M, Fitzsimons C. Managing the deteriorating child with suspected group A Streptococcus infection. Nurs Child Young People 2023; 35:35-42. [PMID: 37599641 DOI: 10.7748/ncyp.2023.e1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 08/22/2023]
Abstract
Group A Streptococcus bacteria can cause various pyogenic infections such as tonsillitis, pharyngitis, scarlet fever, impetigo, erysipelas, cellulitis and pneumonia. Most group A Streptococcus infections in children are mild and respond positively to treatment with antibiotics. However, some children develop severe infection accompanied by complications such as sepsis and will require urgent treatment, which may include non-invasive or invasive ventilation and the administration of fluids and vasoactive agents. In some instances, for example if there are no beds available in the paediatric intensive care unit, these interventions may be undertaken in a ward setting. This article gives an overview of group A Streptococcus infection, including two rare but severe complications, streptococcal toxic shock syndrome and necrotising fasciitis. It uses a fictionalised case study to examine the management of the deteriorating child with suspected group A Streptococcus infection, including respiratory support, haemodynamic support and symptom management.
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Affiliation(s)
| | - Claire Fitzsimons
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
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75
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Dincer B, Cinar I, Erol HS, Demirci B, Terzi F. Gossypin mitigates oxidative damage by downregulating the molecular signaling pathway in oleic acid-induced acute lung injury. J Mol Recognit 2023; 36:e3058. [PMID: 37696682 DOI: 10.1002/jmr.3058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/16/2023] [Accepted: 08/29/2023] [Indexed: 09/13/2023]
Abstract
One of the leading causes of acute lung injury, which is linked to a high death rate, is pulmonary fat embolism. Increases in proinflammatory cytokines and the production of free radicals are related to the pathophysiology of acute lung injury. Antioxidants that scavenge free radicals play a protective role against acute lung injury. Gossypin has been proven to have antioxidant, antimicrobial, and anti-inflammatory properties. In this study, we compared the role of Gossypin with the therapeutically used drug Dexamethasone in the acute lung injury model caused by oleic acid in rats. Thirty rats were divided into five groups; Sham, Oleic acid model, Oleic acid+Dexamethasone (0.1 mg/kg), Oleic acid+Gossypin (10 and 20 mg/kg). Two hours after pretreatment with Dexamethasone or Gossypin, the acute lung injury model was created by injecting 1 g/kg oleic acid into the femoral vein. Three hours following the oleic acid injection, rats were decapitated. Lung tissues were extracted for histological, immunohistochemical, biochemical, PCR, and SEM imaging assessment. The oleic acid injection caused an increase in lipid peroxidation and catalase activity, pathological changes in lung tissue, decreased superoxide dismutase activity, and glutathione level, and increased TNF-α, IL-1β, IL-6, and IL-8 expression. However, these changes were attenuated after treatment with Gossypin and Dexamethasone. By reducing the expression of proinflammatory cytokines and attenuating oxidative stress, Gossypin pretreatment provides a new target that is equally effective as dexamethasone in the treatment of oleic acid-induced acute lung injury.
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Affiliation(s)
- Busra Dincer
- Department of Pharmacology, Faculty of Pharmacy, Ondokuz Mayis University, Samsun, Turkey
| | - Irfan Cinar
- Department of Pharmacology, Faculty of Medicine, Kastamonu University, Kastamonu, Turkey
| | - Huseyin Serkan Erol
- Department of Biochemistry, Faculty of Veterinary Medicine, Kastamonu University, Kastamonu, Turkey
| | - Beste Demirci
- Department of Anatomy, Faculty of Veterinary Medicine, Kastamonu University, Kastamonu, Turkey
| | - Funda Terzi
- Department of Pathology, Faculty of Veterinary Medicine, Kastamonu University, Kastamonu, Turkey
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Adam J, Rupprecht S, Künstler ECS, Hoyer D. Heart rate variability as a marker and predictor of inflammation, nosocomial infection, and sepsis - A systematic review. Auton Neurosci 2023; 249:103116. [PMID: 37651781 DOI: 10.1016/j.autneu.2023.103116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/11/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The autonomic nervous system interacts with the immune system via the inflammatory response. Heart rate variability (HRV), a marker of autonomic activity, is associated with inflammation, and nosocomial infections/sepsis, and has clinical implications for the monitoring of at-risk patients. Due to the vagal tone's influence on anti-inflammatory immune response, this association may predominately be reflected by vagally-mediated HRV indices. However, HRV's predictive significance on inflammation/infection remains unclear. METHODS 843 studies examining the associations/prognostic value of HRV indices on inflammation, and nosocomial infection/sepsis were screened in this systematic review. According to inclusion and exclusion criteria, 68 associative studies and 14 prediction studies were included. RESULTS HRV and pro-inflammatory state were consistently associated in healthy subjects and patient groups. Pro-inflammatory state was related to reduced total power HRV including vagally- and non-vagally-mediated HRV indices. Similar, compared to controls, HRV reductions were observed during nosocomial infections/sepsis. Only limited evidence supports the predictive value of HRV in the development of nosocomial infections/sepsis. Reduced very low frequency power HRV showed the highest predictive value in adults, even with different clinical conditions. In neonates, an increased heart rate characteristic score, combining reduced total power HRV, decreased complexity, and vagally-dominated asymmetry, predicted sepsis. CONCLUSIONS Pro-inflammatory state is related to an overall reduction in HRV rather than a singular reduction in vagally-mediated HRV indices, reflecting the complex autonomic-regulatory changes occurring during inflammation. The potential benefit of using continuous HRV monitoring for detecting nosocomial infection-related states, and the implications for clinical outcome, need further clarification.
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Affiliation(s)
- Josephine Adam
- Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Sven Rupprecht
- Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Erika C S Künstler
- Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Dirk Hoyer
- Department of Neurology, Jena University Hospital, Jena, Germany
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Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review. Chest 2023; 164:1216-1227. [PMID: 37479058 PMCID: PMC10635838 DOI: 10.1016/j.chest.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023] Open
Abstract
TOPIC IMPORTANCE This review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock. REVIEW FINDINGS Patients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation. SUMMARY Experimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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Liang Y, Ruan W, Jiang Y, Smalling R, Yuan X, Eltzschig HK. Interplay of hypoxia-inducible factors and oxygen therapy in cardiovascular medicine. Nat Rev Cardiol 2023; 20:723-737. [PMID: 37308571 PMCID: PMC11014460 DOI: 10.1038/s41569-023-00886-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/14/2023]
Abstract
Mammals have evolved to adapt to differences in oxygen availability. Although systemic oxygen homeostasis relies on respiratory and circulatory responses, cellular adaptation to hypoxia involves the transcription factor hypoxia-inducible factor (HIF). Given that many cardiovascular diseases involve some degree of systemic or local tissue hypoxia, oxygen therapy has been used liberally over many decades for the treatment of cardiovascular disorders. However, preclinical research has revealed the detrimental effects of excessive use of oxygen therapy, including the generation of toxic oxygen radicals or attenuation of endogenous protection by HIFs. In addition, investigators in clinical trials conducted in the past decade have questioned the excessive use of oxygen therapy and have identified specific cardiovascular diseases in which a more conservative approach to oxygen therapy could be beneficial compared with a more liberal approach. In this Review, we provide numerous perspectives on systemic and molecular oxygen homeostasis and the pathophysiological consequences of excessive oxygen use. In addition, we provide an overview of findings from clinical studies on oxygen therapy for myocardial ischaemia, cardiac arrest, heart failure and cardiac surgery. These clinical studies have prompted a shift from liberal oxygen supplementation to a more conservative and vigilant approach to oxygen therapy. Furthermore, we discuss the alternative therapeutic strategies that target oxygen-sensing pathways, including various preconditioning approaches and pharmacological HIF activators, that can be used regardless of the level of oxygen therapy that a patient is already receiving.
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Affiliation(s)
- Yafen Liang
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Wei Ruan
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yandong Jiang
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Richard Smalling
- Department of Cardiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xiaoyi Yuan
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Holger K Eltzschig
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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79
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Li X, Luo T, Yan H, Xie L, Yang Y, Gong L, Tang Z, Tang M, Zhang X, Huang J, Zheng M, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Proteomic Analysis of Pediatric Hemophagocytic Lymphohistiocytosis: a Comparative Study with Healthy Controls, Sepsis, Critical Ill, and Active Epstein-Barr virus Infection to Identify Altered Pathways and Candidate Biomarkers. J Clin Immunol 2023; 43:1997-2010. [PMID: 37653176 PMCID: PMC10661879 DOI: 10.1007/s10875-023-01573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/20/2023] [Indexed: 09/02/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterized by excessive activation of the immune system, along with uncontrolled proliferation of activated macrophages and lymphocytes. The clinical features of HLH often overlap with the clinical features of other severe inflammatory conditions such as sepsis, hindering accurate and timely diagnosis. In this study, we performed a data-independent acquisition mass spectrometry-based plasma proteomic analysis of 33 pediatric patients with HLH compared with four control groups: 39 healthy children, 43 children with sepsis, 39 children hospitalized in the pediatric intensive care unit without confirmed infections, and 21 children with acute Epstein-Barr virus infection. Proteomic comparisons between the HLH group and each of the control groups showed that HLH was characterized by alterations in complement and coagulation cascades, neutrophil extracellular trap formation, and platelet activation pathways. We identified eight differentially expressed proteins in patients with HLH, including plastin-2 (LCP1), vascular cell adhesion protein 1, fibrinogen beta chain, fibrinogen gamma chain, serum amyloid A-4 protein, extracellular matrix protein 1, apolipoprotein A-I, and albumin. LCP1 emerged as a candidate diagnostic marker for HLH with an area under the curve (AUC) of 0.97 in the original cohort and an AUC of 0.90 (sensitivity = 0.83 and specificity = 1.0) in the validation cohort. Complement C1q subcomponent subunit B was associated with disease severity in patients with HLH. Based on comparisons with multiple control groups, this study provides a proteomic profile and candidate biomarkers of HLH, offering researchers novel information to improve the understanding of this condition.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province & Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ting Luo
- Pediatrics Research Institute of Hunan Province & Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- General Emergency Ward & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Longlong Xie
- Pediatrics Research Institute of Hunan Province & Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Yufan Yang
- Pediatrics Research Institute of Hunan Province & Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ling Gong
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Zhexuan Tang
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Minghui Tang
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children's Hospital, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit & Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China.
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Şahin A, Bayrakçı S, Aslan S. An analysis of lactate/albumin, procalcitonin/albumin, and blood urea nitrogen/albumin ratios as a predictor of mortality in uroseptic patients. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230422. [PMID: 37909614 PMCID: PMC10610782 DOI: 10.1590/1806-9282.20230422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/30/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the ratios of lactate/albumin, procalcitonin/albumin, and blood urea nitrogen/albumin to predict 14- and 28-day mortality in uroseptic patients. Urosepsis is a disease with high mortality, and early diagnosis and treatment are important. METHODS Patients with urosepsis who were admitted to the intensive care unit between January 2021 and September 2022, had a follow-up of at least 28 days, and met the inclusion criteria were evaluated retrospectively. RESULTS The mean age was 70.23 (15.66) years and 84 (53.85%) were males. The number of non-survivors were 75 (48%) in the 14-day mortality group and 97 (62.1%) in the 28-day mortality group. Based on the 14-day mortality data, the blood urea nitrogen/albumin ratio was higher in non-survivors vs. survivors (median, 15.88 vs. 9.62), and the lactate/albumin ratio was higher (median, 0.96 vs. 0.52, p<0.01, all). Based on the 28-day mortality data, the blood urea nitrogen/albumin ratio was higher in non-survivors vs. survivors (median, 14.78 vs. 8.46), and the lactate/albumin ratio was higher (median, 0.90 vs. 0.50, p<0.01, all). CONCLUSION It is very difficult to determine the prognosis of patients admitted to the emergency department with the diagnosis of urosepsis. The lactate/albumin ratio and the blood urea nitrogen/albumin ratio can be used as early prognostic markers for both 14-day and 28-day mortality until more reliable markers are identified.
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Affiliation(s)
- Ahmet Şahin
- Dr. Ersin Arslan Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology – Gaziantep, Turkey
| | - Sinem Bayrakçı
- Dr. Ersin Arslan Training and Research Hospital, Department of Intensive Care Unit – Gaziantep, Turkey
| | - Selda Aslan
- Dr. Ersin Arslan Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology – Gaziantep, Turkey
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Yan L, Wu H, Guan S, Ma W, Fu Y, Ji P, Lian Z, Zhang L, Xing Y, Wang B, Liu G. The Effects of Mammary Gland ATIII Overexpression on the General Health of Dairy Goats and Their Anti-Inflammatory Response to LPS Stimulation. Int J Mol Sci 2023; 24:15303. [PMID: 37894983 PMCID: PMC10607088 DOI: 10.3390/ijms242015303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Antithrombin III is an important anticoagulant factor with anti-inflammatory properties. However, few studies have explored its anti-inflammatory actions in ATIII overexpressed transgenic animals. In this study, the dairy goats with mammary overexpression of ATIII were used to investigate their general health, milk quality and particularly their response to inflammatory challenge. The results showed that transgenic goats have a normal phenotype regarding their physiological and biochemical parameters, including whole blood cells, serum protein levels, total cholesterol, urea nitrogen, uric acid, and total bilirubin, compared to the WT. In addition, the quality of milk also improved in transgenic animals compared to the WT, as indicated by the increased milk fat and dry matter content and the reduced somatic cell numbers. Under the stimulation of an LPS injection, the transgenic goats had elevated contents of IGA, IGM and superoxide dismutase SOD, and had reduced proinflammatory cytokine release, including IL-6, TNF-α and IFN-β. A 16S rDNA sequencing analysis also showed that the transgenic animals had a similar compositions of gut microbiota to the WT goats under the stimulation of LPS injections. Mammary gland ATIII overexpression in dairy goats is a safe process, and it did not jeopardize the general health of the transgenic animals; moreover, the compositions of their gut microbiota also improved with the milk quality. The LPS stimulation study suggests that the increased ATIII expression may directly or indirectly suppress the inflammatory response to increase the resistance of transgenic animals to pathogen invasion. This will be explored in future studies.
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Affiliation(s)
- Laiqing Yan
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Hao Wu
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Shengyu Guan
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Wenkui Ma
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Yao Fu
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Pengyun Ji
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Zhengxing Lian
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Lu Zhang
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Yiming Xing
- State Key Laboratory of Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing 100193, China;
| | - Bingyuan Wang
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
| | - Guoshi Liu
- State Key Laboratory of Animal Biotech Breeding, National Engineering Laboratory for Animal Breeding, Key Laboratory of Animal Genetics and Breeding of the Ministry of Agriculture, Beijing Key Laboratory of Animal Genetic Improvement, College of Animal Science and Technology, China Agricultural University, Beijing 100193, China; (L.Y.); (H.W.); (S.G.); (W.M.); (Y.F.); (P.J.); (Z.L.); (L.Z.)
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Malli IA, Mohamud MS, Al-Nasser S. Enhancing Medical Students' Confidence and Knowledge in Antibiotic Prescription and Administration through Virtual Education: A Quasi-Experimental Study. Antibiotics (Basel) 2023; 12:1546. [PMID: 37887247 PMCID: PMC10604531 DOI: 10.3390/antibiotics12101546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/01/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a worldwide health concern that necessitates antibiotic stewardship. Medical students significantly impact future healthcare practices; thus, their trust in antibiotic prescription and administration is crucial. This research aims to assess medical students' levels of confidence and knowledge in these areas before and after exposure to virtual antibiotic stewardship education. METHODS A one-group pretest-posttest design was conducted with medical students from King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Participants were enrolled in the WHO-online antibiotic stewardship course. RESULTS The group's baseline confidence and background knowledge were reported to be lower than what was offered after introducing the virtual course. The McNemar-Bowker test showed a significant difference in students' confidence in pre-course and post-course scores (Z = 20, p < 0.002); the matched paired t-test revealed a significant difference in students' knowledge scores (M = 7.66 verses M = 5.36, Z = 3.54, p = 0.001). In the sample, 70% of the students were unfamiliar with antibiotic stewardship; thus, the analysis revealed a significant difference in their familiarity before and after enrolling in the online course (30 vs. 100, p < 0.001). CONCLUSION Medical students experience low confidence in the safe practice of the antibiotic stewardship program. The WHO-online antibiotic stewardship course is considered a valuable resource that can be used in a formative medical curriculum. Thus, educators and the academic curriculum must promote practical strategies to minimize antibiotic stewardship literacy and increase antibiotic prescribing and administration quality. Introducing antibiotic stewardship across the medical curriculum and establishing educational courses are some strategies that can be undertaken to ensure that future doctors are well-educated in the principles and practices of the appropriate use of antibiotic stewardship.
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Affiliation(s)
- Israa Abdullah Malli
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 22384, Saudi Arabia
| | - Mohamud Salaad Mohamud
- Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London W6 8RP, UK
- Research and Development, Somali Centers for Public Health, London NW2 1TB, UK
| | - Sami Al-Nasser
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia
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83
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Toro L, Rojas V, Conejeros C, Ayala P, Parra-Lucares A, Ahumada F, Almeida P, Silva MF, Bravo K, Pumarino C, Tong AM, Pinto ME, Romero C, Michea L. A Combined Biomarker That Includes Plasma Fibroblast Growth Factor 23, Erythropoietin, and Klotho Predicts Short- and Long-Term Morbimortality and Development of Chronic Kidney Disease in Critical Care Patients with Sepsis: A Prospective Cohort. Biomolecules 2023; 13:1481. [PMID: 37892163 PMCID: PMC10604443 DOI: 10.3390/biom13101481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 10/29/2023] Open
Abstract
Acute Kidney Injury (AKI) is a frequent complication in intensive care unit (ICU) patients that increases mortality and chronic kidney disease (CKD) development. AKI is associated with elevated plasma fibroblast growth factor 23 (FGF23), which can be modulated by erythropoietin (EPO) and Klotho. We aimed to evaluate whether a combined biomarker that includes these molecules predicted short-/long-term outcomes. We performed a prospective cohort of ICU patients with sepsis and previously normal renal function. They were followed during their inpatient stay and for one year after admission. We measured plasma FGF23, EPO, and Klotho levels at admission and calculated a combined biomarker (FEK). A total of 164 patients were recruited. Of these, 50 (30.5%) had AKI at admission, and 55 (33.5%) developed AKI within 48 h. Patients with AKI at admission and those who developed AKI within 48 h had 12- and 5-fold higher FEK values than non-AKI patients, respectively. Additionally, patients with higher FEK values had increased 1-year mortality (41.9% vs. 18.6%, p = 0.003) and CKD progression (26.2% vs. 8.3%, p = 0.023). Our data suggest that the FEK indicator predicts the risk of AKI, short-/long-term mortality, and CKD progression in ICU patients with sepsis. This new indicator can improve clinical outcome prediction and guide early therapeutic strategies.
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Affiliation(s)
- Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile; (L.T.)
- Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
- Centro de Pacientes Críticos, Clinica Las Condes, Santiago 7591047, Chile
| | - Verónica Rojas
- Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Carolina Conejeros
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile; (L.T.)
| | - Patricia Ayala
- Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Alfredo Parra-Lucares
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
| | - Francisca Ahumada
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
| | - Paula Almeida
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
| | - María Fernanda Silva
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
| | - Karin Bravo
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
| | - Catalina Pumarino
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
| | - Ana María Tong
- Clinical Laboratory, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - María Eugenia Pinto
- Clinical Laboratory, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Carlos Romero
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile
| | - Luis Michea
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380456, Chile; (L.T.)
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago 8380456, Chile
- Laboratorio de Fisiologia Integrativa, Facultad de Medicina Universidad de Chile, Santiago 8380456, Chile
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84
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Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R, Ahuja V, Berry N, Bhat N, Dutta U, Ghoshal UC, Jain A, Jalihal U, Jayanthi V, Kumar A, Nijhawan S, Poddar U, Ramesh GN, Singh SP, Zargar S, Bhatia S. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian J Gastroenterol 2023; 42:601-628. [PMID: 37698821 DOI: 10.1007/s12664-023-01428-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/10/2023] [Indexed: 09/13/2023]
Abstract
Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, 632 004, India.
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ramit Mahajan
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | | | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | | | - Richard Kirubakaran
- Center of Biostatistics and Evidence Based Medicine, Vellore, 632 004, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Neha Berry
- BLK Institute of Digestive and Liver Disease, New Delhi, 201 012, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Uday Chand Ghoshal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ajay Jain
- Choithram Hospital and Research Center, Indore, 452 014, India
| | | | - V Jayanthi
- Sri Ramachandra Medical College, Chennai, 600 116, India
| | - Ajay Kumar
- Institute of Digestive and Liver Diseases, BLK - Max Superspeciality Hospital, New Delhi, 201 012, India
| | | | - Ujjal Poddar
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Shivram P Singh
- Kalinga Gastroenterology Foundation, Cuttack, 753 001, India
| | - Showkat Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, 190 011, India
| | - Shobna Bhatia
- Sir H N Reliance Foundation Hospital, Mumbai, 400 004, India
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Volpicelli G, Fierro C, Vetrugno L, Maggiore SM, Fraccalini T. The most influential articles in critical care medicine. Anaesth Crit Care Pain Med 2023; 42:101238. [PMID: 37121358 DOI: 10.1016/j.accpm.2023.101238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Torino, Italy.
| | - Carmen Fierro
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Via dei Vestini, 66100, Chieti, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Via dei Vestini, 66100, Chieti, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Via dei Vestini, 66100, Chieti, Italy
| | - Thomas Fraccalini
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Torino, Italy
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Patton MJ, Liu VX. Predictive Modeling Using Artificial Intelligence and Machine Learning Algorithms on Electronic Health Record Data: Advantages and Challenges. Crit Care Clin 2023; 39:647-673. [PMID: 37704332 DOI: 10.1016/j.ccc.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The rapid adoption of electronic health record (EHR) systems in US hospitals from 2008 to 2014 produced novel data elements for analysis. Concurrent innovations in computing architecture and machine learning (ML) algorithms have made rapid consumption of health data feasible and a powerful engine for clinical innovation. In critical care research, the net convergence of these trends has resulted in an exponential increase in outcome prediction research. In the following article, we explore the history of outcome prediction in the intensive care unit (ICU), the growing use of EHR data, and the rise of artificial intelligence and ML (AI) in critical care.
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Affiliation(s)
- Michael J Patton
- Medical Scientist Training Program, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Hugh Kaul Precision Medicine Institute at the University of Alabama at Birmingham, 720 20th Street South, Suite 202, Birmingham, Alabama, 35233, USA.
| | - Vincent X Liu
- Kaiser Permanente Division of Research, Oakland, CA, USA.
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Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Ganapathy AS, Patel NT, Wiley AP, Lane MR, Jordan JE, Johnson MA, Adams JY, Neff LP, Williams TK. Precision Automated Critical Care Management: Closed-loop critical care for the treatment of distributive shock in a swine model of ischemia-reperfusion. J Trauma Acute Care Surg 2023; 95:490-496. [PMID: 37314508 PMCID: PMC10545062 DOI: 10.1097/ta.0000000000004054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Goal-directed blood pressure management in the intensive care unit can improve trauma outcomes but is labor-intensive. Automated critical care systems can deliver scaled interventions to avoid excessive fluid or vasopressor administration. We compared a first-generation automated drug and fluid delivery platform, Precision Automated Critical Care Management (PACC-MAN), to a more refined algorithm, incorporating additional physiologic inputs and therapeutics. We hypothesized that the enhanced algorithm would achieve equivalent resuscitation endpoints with less crystalloid utilization in the setting of distributive shock. METHODS Twelve swine underwent 30% hemorrhage and 30 minutes of aortic occlusion to induce an ischemia-reperfusion injury and distributive shock state. Next, animals were transfused to euvolemia and randomized into a standardized critical care (SCC) of PACC-MAN or an enhanced version (SCC+) for 4.25 hours. SCC+ incorporated lactate and urine output to assess global response to resuscitation and added vasopressin as an adjunct to norepinephrine at certain thresholds. Primary and secondary outcomes were decreased crystalloid administration and time at goal blood pressure, respectively. RESULTS Weight-based fluid bolus volume was lower in SCC+ compared with SCC (26.9 mL/kg vs. 67.5 mL/kg, p = 0.02). Cumulative norepinephrine dose required was not significantly different (SCC+: 26.9 μg/kg vs. SCC: 13.76 μg/kg, p = 0.24). Three of 6 animals (50%) in SCC+ triggered vasopressin as an adjunct. Percent time spent between 60 mm Hg and 70 mm Hg, terminal creatinine and lactate, and weight-adjusted cumulative urine output were equivalent. CONCLUSION Refinement of the PACC-MAN algorithm decreased crystalloid administration without sacrificing time in normotension, reducing urine output, increasing vasopressor support, or elevating biomarkers of organ damage. Iterative improvements in automated critical care systems to achieve target hemodynamics in a distributive-shock model are feasible.
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89
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Li H, Fan S, Lu D, Zhou J. A New Scoring System for Predicting Mortality in Hematological Malignancies with Sepsis: A Derivation and Validation Study. Cancer Manag Res 2023; 15:1073-1083. [PMID: 37794881 PMCID: PMC10546994 DOI: 10.2147/cmar.s428930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
Objective This study aimed to derive and validate a prognostic scoring system to identify patients with hematological malignancies (HMs) and sepsis who have a high mortality rate. Methods Cohorts for derivation and validation were created from all data. Using univariate and multivariate analysis, the independent variables connected to 28-day mortality in the derivation cohort were found. A receiver operating characteristic (ROC) curve was used to compare the predictive power and determine their cutoff points. These risk variables were given a score weighted by risk prediction function, and a new scoring system was also developed. The area under the ROC curve (AUROC) and sensitivity and specificity for mortality of the risk category of the new scoring system were compared with Sequential Organ Failure Assessment (SOFA) score. Results 90 (45.22%) of the 199 patients passed away within 28 days. Ninety-nine patients made up the derivation cohort, with 47 (47.47%) fatalities. Ages in the non-survival group were higher (61.47 ± 14.53 vs 55.13 ± 15.66) than in the survival group. As independent predictors of death, multivariable analysis identified SOFA score (OR 1.442, 95% CI 1.035, 2.009), age (OR 1.242, 95% CI 1.026, 1.503), and prothrombin time (PT) (OR 1.213, 95% CI 1.030, 1.430). The AUROC with 95% CI of the new scoring system and its sensitivity and specificity to mortality were virtually all superior to SOFA score in both derivation and validation cohorts: AUROC (0.757 vs 0.716), Sensitivity (75 vs 67.3%), and Specificity (68.1% vs 63.8%) are the Derivation cohort; Validation cohort: Sensitivity (91.2% vs 84.2%), AUROC (0.792 vs 0.733), and Specificity (58.1% vs 58.1%). The model was correctly calibrated, according to the Hosmer-Lemeshow test. Conclusion The new scoring system was more accurate in predicting 28-day mortality among patients with HMs and sepsis than the SOFA score.
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Affiliation(s)
- Haitao Li
- Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Shengjin Fan
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Dongxue Lu
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Jin Zhou
- Harbin Medical University, Harbin, 150001, People’s Republic of China
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90
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Frank HE, Evans L, Phillips G, Dellinger RP, Goldstein J, Harmon L, Portelli D, Sarani N, Schorr C, Terry KM, Townsend SR, Levy MM. Assessment of implementation methods in sepsis: study protocol for a cluster-randomized hybrid type 2 trial. Trials 2023; 24:620. [PMID: 37773067 PMCID: PMC10543317 DOI: 10.1186/s13063-023-07644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Sepsis is the leading cause of intensive care unit (ICU) admission and ICU death. In recognition of the burden of sepsis, the Surviving Sepsis Campaign (SSC) and the Institute for Healthcare Improvement developed sepsis "bundles" (goals to accomplish over a specific time period) to facilitate SSC guideline implementation in clinical practice. Using the SSC 3-h bundle as a base, the Centers for Medicare and Medicaid Services developed a 3-h sepsis bundle that has become the national standard for early management of sepsis. Emerging observational data, from an analysis conducted for the AIMS grant application, suggest there may be additional mortality benefit from even earlier implementation of the 3-h bundle, i.e., the 1-h bundle. METHOD The primary aims of this randomized controlled trial are to: (1) examine the effect on clinical outcomes of Emergency Department initiation of the elements of the 3-h bundle within the traditional 3 h versus initiating within 1 h of sepsis recognition and (2) examine the extent to which a rigorous implementation strategy will improve implementation and compliance with both the 1-h bundle and the 3-h bundle. This study will be entirely conducted in the Emergency Department at 18 sites. A secondary aim is to identify clinical sepsis phenotypes and their impact on treatment outcomes. DISCUSSION This cluster-randomized trial, employing implementation science methodology, is timely and important to the field. The hybrid effectiveness-implementation design is likely to have an impact on clinical practice in sepsis management by providing a rigorous evaluation of the 1- and 3-h bundles. FUNDING NHLBI R01HL162954. TRIAL REGISTRATION ClinicalTrials.gov NCT05491941. Registered on August 8, 2022.
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Affiliation(s)
- Hannah E Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Gary Phillips
- Biostatistical Consultant, Center for Biostatistics, The Ohio State University, Retired From, Columbus, OH, USA
| | - RPhillip Dellinger
- Critical Care Division, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jessyca Goldstein
- Division of Pulmonary, Critical Care and Sleep Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lori Harmon
- Society of Critical Care Medicine, Mount Prospect, IL, USA
| | - David Portelli
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Nima Sarani
- Department of Emergency Medicine, University of Kansas Health System, Kansas City, KS, USA
| | - Christa Schorr
- Cooper Research Institute, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Durcan E, Hacioglu A, Karaca Z, Unluhizarci K, Gonen MS, Kelestimur F. Hypothalamic-Pituitary Axis Function and Adrenal Insufficiency in COVID-19 Patients. Neuroimmunomodulation 2023; 30:215-225. [PMID: 37703857 PMCID: PMC10614450 DOI: 10.1159/000534025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
The outbreak of COVID-19 has affected more than half a billion people worldwide and caused more than 6 million deaths since 2019. The responsible virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily affects the lungs, but it has multisystemic effects. It is well known that dysfunction of multiple endocrine organs may occur during or after COVID-19. Impairment of the hypothalamic-pituitary-adrenal (HPA) axis is of utmost importance as it may lead to death if went undiagnosed. SARS-CoV-2 may cause both primary and secondary adrenal insufficiencies (AIs). The clinical manifestations of AI are generally non-specific and might be attributed to the complications caused by the infection itself. The underlying pathogenetic mechanisms were explained by the immunogenic, vascular effects of the infection or the direct effects of the virus. The diagnosis of AI in critically ill patients with COVID-19 is not straightforward. There is lack of consensus on the cut-off values of basal serum cortisol levels and stimulation tests during the disease. Here we review the literature with a special regard on the evaluation of the HPA axis in patients with COVID-19. We conclude that the possibility of AI should always be kept in mind when dealing with patients with COVID-19, and repeated basal cortisol measurements and the ACTH stimulation test results could guide the clinician during the diagnostic process.
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Affiliation(s)
- Emre Durcan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aysa Hacioglu
- Department of Endocrinology, Medical School, Erciyes University, Kayseri, Turkey
| | - Zuleyha Karaca
- Department of Endocrinology, Medical School, Erciyes University, Kayseri, Turkey
| | - Kursad Unluhizarci
- Department of Endocrinology, Medical School, Erciyes University, Kayseri, Turkey
| | - Mustafa Sait Gonen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Medical School, Yeditepe University, Istanbul, Turkey
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Fang D, Li Y, He B, Gu D, Zhang M, Guo J, Ren H, Li X, Zhang Z, Tang M, Li X, Yang D, Xu C, Hu Y, Wang H, Jose PA, Han Y, Zeng C. Gastrin attenuates sepsis-induced myocardial dysfunction by down-regulation of TLR4 expression in macrophages. Acta Pharm Sin B 2023; 13:3756-3769. [PMID: 37719375 PMCID: PMC10502292 DOI: 10.1016/j.apsb.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 09/19/2023] Open
Abstract
Myocardial dysfunction is the most serious complication of sepsis. Sepsis-induced myocardial dysfunction (SMD) is often associated with gastrointestinal dysfunction, but its pathophysiological significance remains unclear. The present study found that patients with SMD had higher plasma gastrin concentrations than those without SMD. In mice, knockdown of the gastrin receptor, cholecystokinin B receptor (Cckbr), aggravated lipopolysaccharide (LPS)-induced cardiac dysfunction and increased inflammation in the heart, whereas the intravenous administration of gastrin ameliorated SMD and cardiac injury. Macrophage infiltration plays a significant role in SMD because depletion of macrophages by the intravenous injection of clodronate liposomes, 48 h prior to LPS administration, alleviated LPS-induced cardiac injury in Cckbr-deficient mice. The intravenous injection of bone marrow macrophages (BMMs) overexpressing Cckbr reduced LPS-induced myocardial dysfunction. Furthermore, gastrin treatment inhibited toll-like receptor 4 (TLR4) expression through the peroxisome proliferator-activated receptor α (PPAR-α) signaling pathway in BMMs. Thus, our findings provide insights into the mechanism of the protective role of gastrin/CCKBR in SMD, which could be used to develop new treatment modalities for SMD.
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Affiliation(s)
- Dandong Fang
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210000, China
| | - Yu Li
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Bo He
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Daqian Gu
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Mingming Zhang
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Jingwen Guo
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Hongmei Ren
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Xinyue Li
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Ziyue Zhang
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Ming Tang
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Xingbing Li
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Donghai Yang
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Chunmei Xu
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Yijie Hu
- Department of Cardiac Surgery, Daping Hospital, Third Military Medical University, Chongqing 400010, China
| | - Hongyong Wang
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Pedro A. Jose
- Division of Renal Disease & Hypertension, the George Washington University School of Medicine & Health Sciences, Washington, DC 20237, USA
| | - Yu Han
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
| | - Chunyu Zeng
- Department of Cardiology, Daping Hospital, the Third Military Medical University (Army Medical University), Chongqing 400000, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing 400010, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, the Third Military Medical University, Chongqing 400010, China
- Cardiovascular Research Center of Chongqing College, Chinese Academy of Sciences, University of Chinese Academy of Sciences Chongqing 400010, China
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Shahnoor H, Divi R, Addi Palle LR, Sharma A, Contractor B, Krupanagaram S, Batool S, Ali N. The Effects of Restrictive Fluid Resuscitation on the Clinical Outcomes in Patients with Sepsis or Septic Shock: A Meta-Analysis of Randomized-Controlled Trials. Cureus 2023; 15:e45620. [PMID: 37868575 PMCID: PMC10588294 DOI: 10.7759/cureus.45620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
This study aims to assess the impact of a restrictive resuscitation strategy on the outcomes of patients with sepsis and septic shock. This meta-analysis was conducted in accordance with the recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. A systematic search was performed in databases, including PubMed, Web of Science, EMBASE, and the Cochrane Library, covering the period from the inception of the database to August 2023, with no limitations on the language of publication. Outcomes assessed in the meta-analysis included mortality, duration of intensive care unit (ICU) stay in days, duration of mechanical ventilation in days, acute kidney injury (AKI) or the need for renal replacement therapy (RRT), and length of hospital stay in days. Overall, 12 studies met the inclusion criteria and were included in the present meta-analysis. The findings of this study indicate that although the risk of mortality was lower in fluid restriction compared to the control group, the difference was statistically insignificant (risk ratio (RR): 0.98; 95% confidence interval (CI): 0.9-1.05; P value: 0.61). Additionally, the duration of mechanical ventilation was significantly shorter in the restrictive fluid group compared to its counterparts (mean difference (MD): -1.02; 95% CI: -1.65 to -0.38; P value: 0.003). There were no significant differences found in relation to the duration of ICU stays, the incidence of AKI, the requirement for RRT, or the length of hospital stays measured in days.
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Affiliation(s)
- Husna Shahnoor
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Rachana Divi
- Medicine and Surgery, GSL Medical College, Hyderabad, IND
| | | | - Ashutosh Sharma
- Medicine, Kathmandu Medical College and Teaching Hospital, Kathmandu, NPL
| | - Bianca Contractor
- Internal Medicine, Smt. NHL Municipal Medical College, Ahmedabad, IND
| | | | - Saima Batool
- Internal Medicine, Hameed Latif Hospital, Lahore, PAK
| | - Neelum Ali
- Internal Medicine, University of Health Sciences, Lahore, PAK
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Kislal FM, Polat CC, Ergül E, Açıkalın AA, Güven D, Gündoğan E, Sarıcı D. Can lactate be valuable in early diagnosis and prognosis of neonatal sepsis? Niger J Clin Pract 2023; 26:1319-1325. [PMID: 37794545 DOI: 10.4103/njcp.njcp_54_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background Sepsis monitoring tissue perfusion is crucial for detecting circulatory failure early, implementing the right treatments, and assessing response. Insufficient oxygenation leads to a rise in lactate level and has been shown to be useful in predicting mortality and morbidity in newborns. There have not been many studies on how lactate measurement affects neonatal sepsis diagnosis and prognosis. Aim The aim of our study was to determine the impact of lactate on early diagnosis and prognosis in neonatal sepsis. Materials and Methods Eighty-seven newborns diagnosed with neonatal sepsis at a neonatal intensive care unit between January 2010 and July 2021 were included in the study. Venous blood gas, lactate, and C-reactive protein (CRP) levels and complete blood count on the first, second, and third day of hospitalization were noted. Lactate values were correlated with other variables to determine the impact of hyperlactatemia on morbidity and to determine factors affecting the length of stay. IBM SPSS Statistics version 22.0 for Windows was used to analyze the data (SPSS Inc., Chicago, IL, United States). Results A strong negative correlation between lactate and oxygenation and perfusion indicators (HCO3, BE, PaO2) during the therapeutic process was observed. With treatment, the initial measured lactate value decreased, and a significant increase in CRP and oxygen saturation was observed, which was interpreted as the observation of an early lactate response to infection before a CRP response. The initial lactate level, as well as the change in lactate levels, was not, however, significantly correlated with the length of stay. Conclusion Lactate can be used in the early diagnosis of neonatal sepsis and for determining prognosis.
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Affiliation(s)
- F M Kislal
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - C C Polat
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - E Ergül
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - A A Açıkalın
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - D Güven
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - E Gündoğan
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - D Sarıcı
- Department of Neonatology, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
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95
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Hu X, Zhang J, Wang P, Dai X. Practice and effect evaluation of early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department: a retrospective cohort study. JBI Evid Implement 2023; 21:269-276. [PMID: 36917161 DOI: 10.1097/xeb.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE To explore the practice and effect evaluation of the early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department. METHODS A total of 239 sepsis patients, who were treated in the emergency department of our hospital from January to September 2020, were selected as the participants of this study, and a retrospective analysis was performed. According to different methods of fluid resuscitation, they were divided into an improved group and a control group. One hundred and twelve patients who received restrictive fluid resuscitation were in the improved group; another 127 patients who received adequate fluid resuscitation were in the control group. The ICU stay time, ventilator use time, and 28-day mortality rate of the two groups were observed. The hemodynamic indices, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and complications of the two groups before and after treatment were compared. RESULTS After treatment, in the improved group, the APACHE II and SOFA scores were lower than in the control group, fluid replacement decreased, lactate clearance increased, ICU admission time shortened and the proportion of ventilator time to ICU admission time decreased. The incidence of acute respiratory distress syndrome (ARDS), cTn I and brain natriuretic peptic in the improved group were significantly lower than those in the control group. From the dimension within the group, the APACHE II score, SOFA score, heart rate and shock index were lower after treatment than before treatment in both the improved and control groups. CONCLUSION Restricted fluid resuscitation can effectively alleviate the condition of emergency sepsis patients, improve hemodynamics, reduce the incidence of ARDS, and prevent patient deaths. It is worthy of clinical application.
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Affiliation(s)
- Xiaqing Hu
- Department of Emergency, Ningbo First Hospital, Ningbo, Zhejiang Province, China
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96
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Wang L, Fu B, Xiang Z, Chen X, Chen J, Qin Y, Sheng H, Zhou X, Li Q, Huang B. Establishment of growth stimulating gene 2 protein time-resolved fluorescence immunoassay and its application in sepsis. J Immunol Methods 2023; 520:113534. [PMID: 37558124 DOI: 10.1016/j.jim.2023.113534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/19/2023] [Accepted: 08/05/2023] [Indexed: 08/11/2023]
Abstract
AIM This study aimed to establish a highly sensitive time-resolved fluorescence immunoassay of growth stimulating express gene 2 protein (ST2-TRFIA) and evaluate its application value for sepsis. METHODS Two types of ST2 monoclonal specific antibodies against different epitopes of antigen molecule were used as coating and Eu3+-labeled antibodies. The double-antibody sandwich method was used in establishing ST2-TRFIA, and the methodology was evaluated. The established ST2-TRFIA was used in detecting ST2 concentration in the plasma samples of healthy controls and sepsis. RESULTS The linear range of ST2-TRFIA was 1.446-500 ng/mL. Plasma ST2 concentrations detected through ST2-TRFIA were consistent with the results of fluorescence quantitative immunochromatography (ρ = 0.946). The plasma ST2 concentrations of patients with sepsis were significantly higher than those of healthy controls (P < 0.01). CONCLUSION This study successfully established a highly sensitive ST2-TRFIA, which was highly comparable to commercially available fluorescent quantitative immunochromatographic kits and can facilitate the timely diagnosis of sepsis.
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Affiliation(s)
- Lu Wang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Benqi Fu
- Sichuan Friendship Hospital, Chengdu, China
| | - Zhongyi Xiang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Xindong Chen
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Jianye Chen
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Yuan Qin
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Huiming Sheng
- Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiumei Zhou
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China.
| | - Qian Li
- Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China.
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97
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Argenti G, Ishikawa G, Fadel CB. The Direct Effects of Norepinephrine Administration on Pressure Injuries in Intensive Care Patients: A Retrospective Cohort Study. Adv Skin Wound Care 2023; 36:1-12. [PMID: 37603319 DOI: 10.1097/asw.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To estimate the direct effects of norepinephrine administration on pressure injury (PI) incidence in intensive care patients. METHODS This is a secondary and exploratory analysis of a retrospective cohort study of intensive care patients discharged in 2017 to 2018. Observational cases only included patients who received primary PI preventive care during intensive care (N = 479). As a first-choice vasopressor drug, norepinephrine administration was approximated with days of norepinephrine. Linear path models were examined from norepinephrine administration to PI development. The identification of confounding variables and instrumental variables was grounded on directed acyclic graph theory. Direct effects were estimated with instrumental variables to overcome bias from unobserved variables. As models were re-specified with data analysis, the robustness of path identification was improved by requiring graph invariance with sample split. RESULTS Norepinephrine caused PI development from one stage to another after 4.0 to 6.3 days of administration in this cohort as a total effect (90% CI). The direct effect was estimated to advance the stage of PI at a rate of 0.140 per day of norepinephrine administered (standard error, 0.029; P < .001). The direct effect accounted for about 70% of the total effect on PI development. CONCLUSIONS Estimations with instrumental variables and structural equation modeling showed that norepinephrine administration directly and substantially affected hospital-acquired PI incidence in intensive care patients in this cohort.
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Affiliation(s)
- Graziela Argenti
- Graziela Argenti, MSc, RN, is Professor, Department of Nursing, Universidade Estadual de Ponta Grossa, Brazil. Gerson Ishikawa, DEng, is Associate Professor, Department of Production Engineering, Universidade Tecnologica Federal do Parana, Ponta Grossa. Also at Universidade Estadual de Ponta Grossa, Cristina Berger Fadel, DMD, is Associate Professor, Department of Dentistry. Acknowledgment: This research project was submitted and registered as CAAE 21591719.7.0000.0105 in PlataformaBrasil of Conselho Nacional de Saude and approved by the research ethics committee of Universidade Estadual de Ponta Grossa (resolution 3.604.604). The authors have disclosed no financial relationships related to this article. Submitted May 2, 2022; accepted in revised form December 1, 2022
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98
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Alosaily YA, Alfallaj JM, Alabduljabbar JS, Alfehaid EF, Alfayez OM, Elrasheed M. Appropriateness of proton pump inhibitors use in noncritically ill hospitalized children in a tertiary hospital in Saudi Arabia. Saudi Pharm J 2023; 31:101723. [PMID: 37608963 PMCID: PMC10440568 DOI: 10.1016/j.jsps.2023.101723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023] Open
Abstract
Background Studies assessing the appropriate use of proton pump inhibitors (PPIs) for hospitalized noncritically ill pediatric patients are lacking. Therefore, this study aimed to assess the suitability of PPI prescriptions in noncritically ill pediatric patients. Methods This cross sectional retrospective study was conducted at a maternity hospital in Qassim, Saudi Arabia from November 2020 to January 2021. All noncritically ill hospitalized children aged 14 years and below who received PPIs were included. The endpoints included the number and percentage of patients who appropriately received PPIs in general and in each age category. The collected data were analyzed using Microsoft Excel (version 2208, Microsoft Corp., Redmond, WA, USA). Results In total, 332 medical records were screened, of which 246 were included. Of all patients, 49.2% were children and 50.8% were infants, with the average age at admission being 5.39 ± 5.4 years years. More than half of the patients were female, and the average weight of patients was 19.8 kg. Omeprazole was appropriately used in 95 (38.5%) patients. Based on age groups, omeprazole was appropriately used in 66.3% of children and 38.4% of infants. Conclusion The use of omeprazole in noncritically ill pediatrics was only deemed appropriate in 38.6% of the study population. This result indicates that this medication was overused in the institution. Additional research is required to confirm this on a nationwide scale.
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Affiliation(s)
- Yousif A. Alosaily
- Pharmacy Department, Maternity and Children Hospital Buraydah, Qassim, Saudi Arabia
| | | | | | | | - Osamah M. Alfayez
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
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99
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Islam KR, Prithula J, Kumar J, Tan TL, Reaz MBI, Sumon MSI, Chowdhury MEH. Machine Learning-Based Early Prediction of Sepsis Using Electronic Health Records: A Systematic Review. J Clin Med 2023; 12:5658. [PMID: 37685724 PMCID: PMC10488449 DOI: 10.3390/jcm12175658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/13/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Sepsis, a life-threatening infection-induced inflammatory condition, has significant global health impacts. Timely detection is crucial for improving patient outcomes as sepsis can rapidly progress to severe forms. The application of machine learning (ML) and deep learning (DL) to predict sepsis using electronic health records (EHRs) has gained considerable attention for timely intervention. METHODS PubMed, IEEE Xplore, Google Scholar, and Scopus were searched for relevant studies. All studies that used ML/DL to detect or early-predict the onset of sepsis in the adult population using EHRs were considered. Data were extracted and analyzed from all studies that met the criteria and were also evaluated for their quality. RESULTS This systematic review examined 1942 articles, selecting 42 studies while adhering to strict criteria. The chosen studies were predominantly retrospective (n = 38) and spanned diverse geographic settings, with a focus on the United States. Different datasets, sepsis definitions, and prevalence rates were employed, necessitating data augmentation. Heterogeneous parameter utilization, diverse model distribution, and varying quality assessments were observed. Longitudinal data enabled early sepsis prediction, and quality criteria fulfillment varied, with inconsistent funding-article quality correlation. CONCLUSIONS This systematic review underscores the significance of ML/DL methods for sepsis detection and early prediction through EHR data.
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Affiliation(s)
- Khandaker Reajul Islam
- Department of Physiology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Johayra Prithula
- Department of Electrical and Electronics Engineering, University of Dhaka, Dhaka 1000, Bangladesh
| | - Jaya Kumar
- Department of Physiology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mamun Bin Ibne Reaz
- Department of Electrical and Electronic Engineering, Independent University, Bangladesh Bashundhara, Dhaka 1229, Bangladesh
| | - Md. Shaheenur Islam Sumon
- Department of Biomedical Engineering, Military Institute of Science and Technology (MIST), Dhaka 1216, Bangladesh
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100
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Sekhon MS, Stukas S, Hirsch-Reinshagen V, Thiara S, Schoenthal T, Tymko M, McNagny KM, Wellington C, Hoiland R. Neuroinflammation and the immune system in hypoxic ischaemic brain injury pathophysiology after cardiac arrest. J Physiol 2023. [PMID: 37639379 DOI: 10.1113/jp284588] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Hypoxic ischaemic brain injury after resuscitation from cardiac arrest is associated with dismal clinical outcomes. To date, most clinical interventions have been geared towards the restoration of cerebral oxygen delivery after resuscitation; however, outcomes in clinical trials are disappointing. Therefore, alternative disease mechanism(s) are likely to be at play, of which the response of the innate immune system to sterile injured tissue in vivo after reperfusion has garnered significant interest. The innate immune system is composed of three pillars: (i) cytokines and signalling molecules; (ii) leucocyte migration and activation; and (iii) the complement cascade. In animal models of hypoxic ischaemic brain injury, pro-inflammatory cytokines are central to propagation of the response of the innate immune system to cerebral ischaemia-reperfusion. In particular, interleukin-1 beta and downstream signalling can result in direct neural injury that culminates in cell death, termed pyroptosis. Leucocyte chemotaxis and activation are central to the in vivo response to cerebral ischaemia-reperfusion. Both parenchymal microglial activation and possible infiltration of peripherally circulating monocytes might account for exacerbation of an immunopathological response in humans. Finally, activation of the complement cascade intersects with multiple aspects of the innate immune response by facilitating leucocyte activation, further cytokine release and endothelial activation. To date, large studies of immunomodulatory therapies have not been conducted; however, lessons learned from historical studies using therapeutic hypothermia in humans suggest that quelling an immunopathological response might be efficacious. Future work should delineate the precise pathways involved in vivo in humans to target specific signalling molecules.
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Veronica Hirsch-Reinshagen
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Michael Tymko
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Kelly M McNagny
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Biomedical Research Centre, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
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