Degradomics in Neurotrauma: Profiling Traumatic Brain Injury

Degradomics has recently emerged as a subdiscipline in the omics era with a focus on characterizing signature breakdown products implicated in various disease processes. Driven by promising experimental findings in cancer, neuroscience, and metabolomic disorders, degradomics has significantly promoted the notion of disease-specific "degradome." A degradome arises from the activation of several proteases that target specific substrates and generate signature protein fragments. Several proteases such as calpains, caspases, cathepsins, and matrix metalloproteinases (MMPs) are involved in the pathogenesis of numerous diseases that disturb the physiologic balance between protein synthesis and protein degradation. While regulated proteolytic activities are needed for development, growth, and regeneration, uncontrolled proteolysis initiated under pathological conditions ultimately culminates into apoptotic and necrotic processes. In this chapter, we aim to review the protease-substrate repertoires in neural injury concentrating on traumatic brain injury. A striking diversity of protease substrates, essential for neuronal and brain structural and functional integrity, namely, encryptic biomarker neoproteins, have been characterized in brain injury. These include cytoskeletal proteins, transcription factors, cell cycle regulatory proteins, synaptic proteins, and cell junction proteins. As these substrates are subject to proteolytic fragmentation, they are ceaselessly exposed to activated proteases. Characterization of these molecules allows for a surge of "possible" therapeutic approaches of intervention at various levels of the proteolytic cascade.

Comparison of extracorporeal and conventional cardiopulmonary resuscitation: A meta-analysis of 2 260 patients with cardiac arrest

BACKGROUND

This meta-analysis aimed to determine whether extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), improves outcomes in adult patients with cardiac arrest (CA).

DATA RESOURCES

PubMed, EMBASE, Web of Science, and China Biological Medicine Database were searched for relevant articles. The baseline information and outcome data (survival, good neurological outcome at discharge, at 3-6 months, and at 1 year after CA) were collected and extracted by two authors. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using Review Manager 5.3.

RESULTS

In six studies 2 260 patients were enrolled to study the survival rate to discharge and long-term neurological outcome published since 2000. A significant effect of ECPR was observed on survival rate to discharge compared to CCPR in CA patients (RR 2.37, 95%CI 1.63-3.45, P<0.001), and patients who underwent ECPR had a better long-term neurological outcome than those who received CCPR (RR 2.79, 95%CI 1.96-3.97, P<0.001). In subgroup analysis, there was a significant difference in survival to discharge favoring ECPR over CCPR group in OHCA patients (RR 2.69, 95%CI 1.48-4.91, P=0.001). However, no significant difference was found in IHCA patients (RR 1.84, 95%CI 0.91-3.73, P=0.09).

CONCLUSION

ECPR showed a beneficial effect on survival rate to discharge and long-term neurological outcome over CCPR in adult patients with CA.

Indocyanine Green-001 (ICG-001) Attenuates Wnt/β-catenin-induces Myocardial Injury Following Sepsis

Objective:

To investigate the mechanistic pathway of both indocyanine green (ICG)-001 in attenuated endotoxemia-induced cardiac depression through downregulation cardiac Wnt/ β-catenin cell signaling.

Materials and Methods:

Adult (4–6 months) male Albino-Webster mice, their weights ranged from 25 to 30 g, were pretreated with ICG-001 i.p., following cecal ligation and puncture (CLP). Left ventricle (LV) function was assessed using a microcatheter system. Monocyte chemoattractant protein-1 (MCP-1) and cytokines mediators in plasma and myocardium were analyzed by enzyme-linked immunosorbent assay. Further, the cardiac Wnt protein measured by quantitative real-time polymerase chain reaction while β-catenin analysis through Western blotting procedure. The pathological changes and cells injury in the myocardium were examined using hematoxylin and eosin staining.

Results:

CLP mice displayed worse LV function. The exaggerated cardiac depression in CLP mice was associated with higher levels of MCP-1 and cytokines in plasma and myocardium together with greater cardiac levels of cardiac troponin-I and Wnt/β-catenin. Neutralization of sepsis by either ICG-001resulted in improved LV function and reductions in inflammatory mediators.

Conclusion:

Taken together, these data showed that ICG-001 improved LV function following sepsis through downregulation of Wnt/β-catenin and serve as a potential mechanistic pathway ICG-001 in therapeutic cardiac endotoxemia in animal model.

Dabigatran Therapy Resulting in the Resolution of Rivaroxaban-resistant Left Atrial Appendage Thrombi in Patients with Atrial Fibrillation

Patients with persistent atrial fibrillation (AF) and a large left atrium are at a high risk for thromboembolisms. Recently, direct oral anticoagulants (DOACs) have mainly been used for the prevention of cardiac embolisms caused by AF. Transesophageal echocardiography (TEE) is performed in order to exclude any left atrial appendage (LAA) thrombi. We herein report two cases of persistent AF, both of which were treated with rivaroxaban for more than two years. Since TEE identified mobile LAA thrombi with this treatment, we switched from rivaroxaban to the direct thrombin inhibitor dabigatran. Dabigatran resolved the LAA thrombi that had been refractory to rivaroxaban.

Efficacy of Rituximab in a Systemic Lupus Erythematosus Patient Presenting with Diffuse Alveolar Hemorrhage

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Although infrequent, its mortality is very high. While there are no established therapeutic guidelines, DAH has been traditionally managed with high-dose intravenous (IV) corticosteroids, cyclophosphamide, and plasma exchange. The efficacy of alternative therapies such as rituximab has been described only in a few cases. Herein, we report a 25-year-old Hispanic man who presented with acute-onset SLE manifested by polyarthralgia, nephritis, seizures, pancytopenia, severe hypocomplementemia, and elevated anti-dsDNA antibodies. His disease course was complicated by DAH. His condition was refractory to high-dose intravenous (IV) methylprednisolone pulses, IV cyclophosphamide, and plasmapheresis. Given the lack of clinical response, he was started on IV rituximab 375 mg/m² weekly for a total of four courses. He rapidly improved after the first two doses. Over the next seven months, he did not present recurrent pulmonary symptoms. Follow-up chest computed tomography did not show residual abnormalities. This case, together with other reports, suggests that rituximab is an effective therapeutic option for DAH in SLE.

N-Terminal Pro-Brain Natriuretic Peptide Concentrations After Hypertensive Intracerebral Hemorrhage: Relationship With Hematoma Size, Hyponatremia, and Intracranial Pressure

Introduction:

The role of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with hypertensive intracerebral hemorrhage (HICH) is poorly understood. This study aimed to investigate the secretion pattern of NT-proBNP in patients with HICH and to assess its relationship with hematoma size, hyponatremia, and intracranial pressure (ICP).

Methods:

This prospective study enrolled 147 isolated patients with HICH. Blood samples were obtained from each patient, and values of serum NT-proBNP, hematoma size, blood sodium, and ICP were collected for each patient.

Results:

The peak-to-mean concentration of NT-proBNP was 666.8 ± 355.1 pg/mL observed on day 4. The NT-proBNP levels in patients with hematoma volume >30 mL were significantly higher than those in patients with hematoma volume <30 mL ( P < .05). In patients with severe HICH, the mean concentration of NT-proBNP was statistically higher than that in patients with mild–moderate HICH ( P < .05), and the mean level of NT-proBNP in hyponatremia group was significantly higher than that in normonatremic group ( P < .05). In addition, the linear regression analysis indicated that serum NT-proBNP concentrations were positively correlated with ICP ( r = .703, P < .05) but negatively with blood sodium levels only in patients with severe HICH ( r = −.704, P < .05). The serum NT-proBNP levels on day 4 after admission were positively correlated with hematoma size ( r = .702, P < .05).

Conclusion:

The NT-proBNP concentrations were elevated progressively and markedly at least in the first 4 days after HICH and reached a peak level on the fourth day. The NT-proBNP levels on day 4 were positively correlated with hematoma size. There was a notable positive correlation between plasma NT-proBNP levels and ICP in patients with severe HICH. Furthermore, only in patients with severe HICH, the plasma NT-proBNP levels presented a significant correlation with hyponatremia, which did not occur in patients with mild–moderate HICH.

Renal water conservation determines the increase in body weight after surgery: A randomized, controlled trial

Background:

The present study was undertaken to identify factors that correlate with the gain in body weight after surgery.

Methods:

Twenty-one patients (median age of 49 years) were randomized to receive either Ringer × s acetate or 6% dextran 70 as their first infusion fluid during cholecystectomy or hysterectomy. Each patient's body weight was measured before the surgery and on the first postoperative morning. Blood and urine samples were analyzed for signs of stress, inflammation, and kidney injury. The fluid retention index (FRI), which reflects how strongly the kidneys excrete or retain fluid, was also calculated.

Results:

The body weight increased by a median of 0.4 kg in the crystalloid fluid group and by 1.0 kg in the colloid fluid group (maximum 2.5 kg, P < 0.01). This difference was due to less urinary excretion after surgery in the colloid group (P < 0.03). The increase in body weight did not correlate with the infused fluid volume, the plasma concentrations of C-reactive protein or cortisol, or the urinary excretion of albumin, cortisol, or neutrophil gelatinase-associated lipocalin. However, the body weight increased with the postoperative FRI score (r = 0.64; P < 0.003) and with the surgery-induced change in FRI score (r = 0.72; P < 0.002).

Conclusion:

How strongly the kidneys excrete or retain fluid, which can be assessed by urine sampling, was the strongest indicator of the increase in body weight during the day of surgery. The amount of fluid alone did not correlate with the gain in body weight.

Breviscapine reduces neuronal injury caused by traumatic brain injury insult: partly associated with suppression of interleukin-6 expression

Breviscapine, extracted from the herb Erigeron breviscapus, is widely used for the treatment of cardiovascular diseases, cerebral infarct, and stroke, but its mechanism of action remains unclear. This study established a rat model of traumatic brain injury induced by controlled cortical impact, and injected 75 μg breviscapine via the right lateral ventricle. We found that breviscapine significantly improved neurobehavioral dysfunction at 6 and 9 days after injection. Meanwhile, interleukin-6 expression was markedly down-regulated following breviscapine treatment. Our results suggest that breviscapine is effective in promoting neurological behavior after traumatic brain injury and the underlying molecular mechanism may be associated with the suppression of interleukin-6.

Challenges and Priorities for Pediatric Critical Care Clinician-Researchers in Low- and Middle-Income Countries

INTRODUCTION

There is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high.

MATERIALS AND METHODS

To inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis.

RESULTS

The majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation.

CONCLUSION

LMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success.

Perioperative fluid management: From physiology to improving clinical outcomes

Perioperative fluid management is a key component in the care of the surgical patient. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians. Historically, patients received large volumes of intravenous fluids perioperatively. The concept of goal directed therapy was then introduced, with the early studies showing significant improvements in morbidity and mortality. The current focus is on fluid therapy guided by an individual patient's physiology. A fluid challenge is commonly performed as part of an assessment of a patient's fluid responsiveness. There remains wide variation in how clinicians perform a fluid challenge and this review explores the evidence for how to administer an effective challenge that is both reliable and reproducible. The methods for monitoring cardiac output have evolved from the pulmonary artery catheter to a range of less invasive techniques. The different options that are available for perioperative use are considered. Fluid status can also be assessed by examining the microcirculation and the importance of recognising the possibility of a lack of coherence between the macro and microcirculation is discussed. Fluid therapy needs to be targeted to specific end points and individualised. Not all patients who respond to a fluid challenge will necessarily require additional fluid administration and care should be aimed at identifying those who do. This review aims to explain the underlying physiology and describe the evidence base and the changes that have been seen in the approach to perioperative fluid therapy.

ROS Signaling in the Pathogenesis of Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS)

The generation of reactive oxygen species (ROS) plays an important role for the maintenance of cellular processes and functions in the body. However, the excessive generation of oxygen radicals under pathological conditions such as acute lung injury (ALI) and its most severe form acute respiratory distress syndrome (ARDS) leads to increased endothelial permeability. Within this hallmark of ALI and ARDS, vascular microvessels lose their junctional integrity and show increased myosin contractions that promote the migration of polymorphonuclear leukocytes (PMNs) and the transition of solutes and fluids in the alveolar lumen. These processes all have a redox component, and this chapter focuses on the role played by ROS during the development of ALI/ARDS. We discuss the origins of ROS within the cell, cellular defense mechanisms against oxidative damage, the role of ROS in the development of endothelial permeability, and potential therapies targeted at oxidative stress.

Nephrotoxicity of High and Conventional Dosing Regimens of Colistin: A Randomized Clinical Trial

Nephrotoxicity has been a major long-standing concern about colistin.This study was designed to compare nephrotoxicity of high dose and conventional dose of colistin. A randomized open-labeled clinical trial on 40 patients with multi-drug resistant gram negative infections was designed. Patients were allocated into two equal-size groups receiving high (a loading dose of 9 million international units (MIU) and maintenance doses of 4.5 MIU every 12 h) and conventional dose (2 MIU every 8 h) of colistin. Blood samples were taken on day 1, 3, 5, 7 and 10 of treatment for measuring serum cystatin C (Cys C) levels. Incidence of acute kidney injury (AKI) was also evaluated based on RIFLE criteria. Mean ± sd of the difference between baseline and day 10 Cys C levels in high dose and conventional dose groups were 1.61 ± 0.90 and 1.32 ± 0.48, respectively (P = 0.30). Within group analysis showed increase in Cys C levels in both groups (P = 0.001),however, no significant difference in Cys C levels was seen in between groups analysis (P = 0.13). Prevalence of AKI based on RIFLE criteria was 60% and 15% in high dose and conventional dose groups, respectively (P = 0.003). Comparison of Cys C between AKI (mean ± sd) and non-AKI (mean ± sd) patients, irrespective of colistin dosage regimens, confirmed a significant difference (P < 0.0001). Although, colistin-induced nephrotoxicity, determined by Cys C levels, was not confirmed by our findings, however, higher incidence of AKI in high-dose group, defined by RIFLE criteria, along with higher levels of Cys C in AKI patients are supportive of the higher risk of renal toxicity associated with high-dose regimen of colistin. More RCTs with a larger sample size are recommended.

Tranexamic Acid Controlled Chronic Disseminated Intravascular Coagulation Associated with Aortic Dissection and Patent False Lumen for Three Years

The management of chronic disseminated intravascular coagulation (DIC) caused by aortic dissection has not yet been established. Even in cases where surgical correction is performed, therapeutic control of systemic hemorrhaging is still required. We herein report the successful treatment of a case of aortic dissection with a patent false lumen using tranexamic acid for acute exacerbation of chronic DIC. Oral administration of 1,500 mg tranexamic acid per day stabilized the coagulative and fibrinolytic parameters and relieved bleeding tendencies with no side effects. Heparin was administered periodically for the management of hemodialysis. This favorable result continued for up to 3 years.

Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure

Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.

Optimizing colistin dosing: Is a loading dose necessary?

PURPOSE

Published literature on the pharmacokinetics and effectiveness of colistin loading doses is reviewed.

SUMMARY

Colistin is increasingly used to treat infections caused by multidrug-resistant (MDR) gram-negative bacteria (GNB). A literature search identified seven reports on studies of colistin loading doses. All reviewed studies involved small samples of critically ill patients, with considerable variation in the colistin products and loading doses used. Pharmacokinetic studies indicated that because of the slow rate of conversion of the prodrug colistimethate sodium to the active drug colistin and the long half-life of colistin, it can take two to three days to attain adequate colistin concentrations without a loading dose. The clinical effectiveness of colistin loading doses was evaluated in two studies, neither involving the use of a comparator group. In one of those studies, clinical cure and bacteriological clearance were reported in 82.1% and 73.9% of cases, respectively; in the other, clinical resolution was reported in 77% of patients. Two studies were conducted to compare clinical outcomes of colistin loading-dose regimens and standard regimens with no loading dose; while use of a loading dose was associated with a higher cure rate (63.0% versus 41.3%, p = 0.04) in one study, no improvement in clinical outcomes was reported in the other study.

CONCLUSION

Published data on the effectiveness of colistin loading doses are limited. The available evidence suggests that it may be necessary to administer a colistin loading dose in severe and life-threatening infections due to MDR GNB.

[Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]

Modern intensive care medicine has led to increased survival rates even after severe life-threatening medical conditions. In self-critical and multidimensional outcome research, however, it must be considered that beyond survival rates treatment on intensive care units (ICU) can also be associated with high long-term rates of depressive, anxiety and posttraumatic stress disorders. Significant correlations with increased somatic morbidity and mortality, persisting cognitive impairments and significant deficits in health-related quality of life must also be taken into consideration. Empirical analysis of the risk factors reveals that a history of premorbid depression, sociodemographic and socioeconomic variables, age, female sex, personality traits, the underlying pathophysiological condition requiring ICU treatment, mode of sedation and analgesia, life support measures, such as mechanical ventilation, manifold traumatic experiences and memories during the stay in the ICU are all of particular pathogenetic importance. In order to reduce principally modifiable risk factors several strategies are illustrated, including well-reflected intensive care sedation and analgesia, special prophylactic medication regarding the major risk of traumatic memories and posttraumatic stress disorder (PTSD), psychological and psychotherapeutic interventions in states of increased acute stress symptoms and aids for personal memories and reorientation.

Neuroprotective Effects of the Glucagon-Like Peptide-1 Analog Exenatide After Out-of-Hospital Cardiac Arrest

Background:

In-hospital mortality in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA) is ≈50%. In OHCA patients, the leading cause of death is neurological injury secondary to ischemia and reperfusion. Glucagon-like peptide-1 analogs are approved for type 2 diabetes mellitus; preclinical and clinical data have suggested their organ-protective effects in patients with ischemia and reperfusion injury. The aim of this trial was to investigate the neuroprotective effects of the glucagon-like peptide-1 analog exenatide in resuscitated OHCA patients.

Methods:

We randomly assigned 120 consecutive comatose patients resuscitated from OHCA in a double-blind, 2-center trial. They were administered 17.4 μg exenatide (Byetta) or placebo over a 6-hour and 15-minute infusion, in addition to standardized intensive care including targeted temperature management. The coprimary end points were feasibility, defined as initiation of the study drug in >90% patients within 240 minutes of return of spontaneous circulation, and efficacy, defined as the geometric area under the neuron-specific enolase curve from 24 to 72 hours after admission. The main secondary end points included a composite end point of death and poor neurological function, defined as a Cerebral Performance Category score of 3 to 5 assessed at 30 and 180 days.

Results:

The study drug was initiated within 240 minutes of return of spontaneous circulation in 96% patients. The median blood glucose 8 hours after admission in patients receiving exenatide was lower than that in patients receiving placebo (5.8 [5.2–6.7] mmol/L versus 7.3 [6.2–8.7] mmol/L, P <0.0001). However, there were no significant differences in the area under the neuron-specific enolase curve, or a composite end point of death and poor neurological function between groups. Adverse events were rare with no significant difference between groups.

Conclusions:

Acute administration of exenatide to comatose patients in the intensive care unit after OHCA is feasible and safe. Exenatide did not reduce neuron-specific enolase levels and did not significantly improve a composite end point of death and poor neurological function after 180 days.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02442791.

Carbohydrate-binding protein CLEC14A regulates VEGFR-2- and VEGFR-3-dependent signals during angiogenesis and lymphangiogenesis

Controlled angiogenesis and lymphangiogenesis are essential for tissue development, function, and repair. However, aberrant neovascularization is an essential pathogenic mechanism in many human diseases, including diseases involving tumor growth and survival. Here, we have demonstrated that mice deficient in C-type lectin family 14 member A (CLEC14A) display enhanced angiogenic sprouting and hemorrhage as well as enlarged jugular lymph sacs and lymphatic vessels. CLEC14A formed a complex with VEGFR-3 in endothelial cells (ECs), and CLEC14A KO resulted in a marked reduction in VEGFR-3 that was concomitant with increases in VEGFR-2 expression and downstream signaling. Implanted tumor growth was profoundly reduced in CLEC14A-KO mice compared with that seen in WT littermates, but tumor-bearing CLEC14A-KO mice died sooner. Tumors in CLEC14A-KO mice had increased numbers of nonfunctional blood vessels and severe hemorrhaging. Blockade of VEGFR-2 signaling suppressed these vascular abnormalities and enhanced the survival of tumor-bearing CLEC14A-KO mice. We conclude that CLEC14A acts in vascular homeostasis by fine-tuning VEGFR-2 and VEGFR-3 signaling in ECs, suggesting its relevance in the pathogenesis of angiogenesis-related human disorders.

Physical methods for the treatment of fever in critically ill patients: a randomized controlled trial

OBJECTIVE

To evaluate the effects of physical methods of reducing body temperature (ice pack and warm compression) in critically ill patients with fever.

METHOD

A randomized clinical trial involving 102 adult patients with tympanic temperature ≥ 38.3°C of an infectious focus, and randomized into three groups: Intervention I - ice pack associated with antipyretic; Intervention II - warm compress associated with antipyretic; and Control - antipyretic. Tympanic temperature was measured at 15 minute intervals for 3 hours. The effect of the interventions was evaluated through the Mann-Whitney test and Survival Analysis. "Effect size" calculation was carried out.

RESULTS

Patients in the intervention groups I and II presented greater reduction in body temperature. The group of patients receiving intervention I presented tympanic temperature below 38.3°C at 45 minutes of monitoring, while the value for control group was lower than 38.3°C starting at 60 minutes, and those who received intervention II had values lower than 38.3°C at 75 minutes of monitoring.

CONCLUSION

No statistically significant difference was found between the interventions, but with the intervention group I patients showed greater reduction in tympanic temperature compared to the other groups. Brazilian Registry of Clinical Trials: RBR-2k3kbq.

OBJETIVO

Avaliar o efeito de métodos físicos (bolsa de gelo e compressa morna) na redução da temperatura corporal de pacientes críticos com febre.

MÉTODO

Ensaio clínico randomizado com 102 pacientes adultos e temperatura timpânica ≥ 38,3°C de foco infeccioso, aleatorizados em três grupos: Intervenção I ‒ bolsa de gelo associada a antitérmico; Intervenção II ‒ compressa morna associada a antitérmico; e Controle ‒ antitérmico. A temperatura timpânica foi mensurada em intervalos de 15 minutos durante 3 horas. O efeito das intervenções foi avaliado pelo teste Mann-Whitney e Análise de Sobrevivência. Cálculo do "Effect size" foi procedido.

RESULTADOS

Os pacientes dos grupos Intervenção I e II apresentaram maior redução na temperatura corporal. A partir de 45 minutos de acompanhamento o grupo de pacientes que recebeu a Intervenção I apresentou valor da temperatura timpânica inferior a 38,3°C, os do grupo controle valor menor que 38,3°C a partir de 60 minutos e os que receberam a Intervenção II, valor menor que 38,3°C com 75 minutos de acompanhamento.

CONCLUSÃO

Não foi encontrada diferença estatística significativa entre as intervenções, porém os pacientes do grupo Intervenção I apresentaram maior redução da temperatura timpânica em relação aos demais grupos. Registro Brasileiro de Ensaios Clínicos: RBR-2k3kbq.

Dexamethasone abrogates the antimicrobial and antibiofilm activities of different drugs against clinical isolates of Staphylococcus aureus and Pseudomonas aeruginosa

Staphylococcus aureus and Pseudomonas aeruginosa are part of the human microbiota and are also important bacterial pathogens, for which therapeutic options are lacking nowadays. The combined administration of corticosteroids and antimicrobials is commonly used in the treatment of infectious diseases to control inflammatory processes and to minimize potential toxicity of antimicrobials, avoiding sequelae. Although different pharmaceutical dosage forms of antimicrobials combined to corticosteroids are available, studies on the interference of corticosteroids on the pharmacological activity of antimicrobials are scarce and controversial. Here, we provide evidence of the interference of dexamethasone on the pharmacological activity of clinically important antimicrobial drugs against biofilms and planktonic cells of S. aureus and P. aeruginosa. Broth microdilution assays of minimal inhibitory concentration (MIC), minimum bactericidal concentration (MBC), and minimum biofilm eradication concentration (MBEC) of gentamicin, chloramphenicol, oxacillin, ceftriaxone and meropenem were conducted with and without the addition of dexamethasone. The effect of all drugs was abrogated by dexamethasone in their MIC, MBC, and MBEC, except gentamicin and meropenem, for which the MBC was not affected in some strains. The present study opens doors for more investigations on in vitro and in vivo effects and safety of the combination of antimicrobials and glucocorticoids.

Phenylephrine increases near-infrared spectroscopy determined muscle oxygenation in men

Phenylephrine increases mean arterial pressure (MAP) by enhanced total peripheral resistance (TPR) but near-infrared spectroscopy (NIRS) determined muscle oxygenation (S_mO₂) increases. We addressed that apparent paradox during supine rest and head-up tilt (HUT). Variables were determined ± phenylephrine in males during supine rest (n = 17) and 40° HUT (n = 7). MAP, stroke volume (SV), heart rate (HR), and TPR were derived by Modelflow^® and NIRS determined biceps S_mO₂ and (tibial) bone oxygenation (S_tibialO₂). For ten subjects, cardiac filling and the diameter of the inferior caval vein (ICV collapsibility index: ((ICV_expiration - ICV_inspiration)/ICV_expiration) × 100) were assessed by ultrasound. Pancreatic polypeptide (PP) and atrial natriuretic peptide (proANP) in plasma were determined by immunoassay. Brachial artery blood flow was assessed by ultrasound and skin oxygenation (S_skinO₂) monitored by white light spectroscopy. Phenylephrine increased MAP by 34% and TPR (62%; P < 0.001) during supine rest. The ICV collapsibility index decreased (24%; P < 0.001) indicating augmented cardiac preload although volume of the left atrium and ventricle did not change. SV increased (18%; P < 0.001) as HR decreased (24%; P < 0.001). ProANP increased by 9% (P = 0.002) with unaffected PP. Brachial artery blood flow tended to decrease while S_skinO₂ together with S_tibialO₂ decreased by 11% (P = 0.026) and 20% (P < 0.001), respectively. Conversely, phenylephrine increased S_mO₂ (9%) and restored the HUT elicited decrease in S_mO₂ (by 19%) along with SV (P = 0.02). Phenylephrine reduces skin and bone oxygenation and tends to reduce arm blood flow, suggesting that the increase in S_mO₂ reflects veno-constriction with consequent centralization of the blood volume.

How do we approach thrombocytopenia in critically ill patients?

A low platelet count is a frequently encountered haematological abnormality in patients treated in intensive treatment units (ITUs). Although severe thrombocytopenia (platelet count <20 × 10⁹ /l) can be associated with bleeding, even moderate-degree thrombocytopenia is associated with organ failure and adverse prognosis. The aetiology for thrombocytopenia in ITU is often multifactorial and correcting one aetiology may not normalise the low platelet count. The classical view for thrombocytopenia in this setting is consumption associated with thrombin-mediated platelet activation, but other concepts, including platelet adhesion to endothelial cells and leucocytes, platelet aggregation by increased von Willebrand factor release, red cell damage and histone release, and platelet destruction by the complement system, have recently been described. The management of severe thrombocytopenia is platelet transfusion in the presence of active bleeding or invasive procedure, but the risk-benefit of prophylactic platelet transfusions in this setting is uncertain. In this review, the incidence and mechanisms of thrombocytopenia in patients with ITU, its prognostic significance and the impact on organ function is discussed. A practical approach based on the authors' experience is described to guide management of a critically ill patient who develops thrombocytopenia.

Effects of tranexamic acid on platelet function and thrombin generation (ETAPlaT): WOMAN trial sub-study

Background. Postpartum haemorrhage (PPH) is a leading cause of maternal death. Tranexamic acid (TXA) has the potential to reduce bleeding and a large randomized placebo controlled trial of its effect in women with PPH (The WOMAN trial) is underway. TXA might also affect coagulation factors and platelets.  Objectives. To examine the effect of TXA on thrombin generation, platelet function, fibrinogen, D-dimer and coagulation factors in women with PPH.  Methods. We will conduct a sub-study within the WOMAN trial. Women with clinically diagnosed primary PPH after vaginal or caesarean delivery are eligible for inclusion. Blood samples will be collected at baseline and 30 minutes after the first dose of study treatment. Using platelet poor plasma we will measure thrombin generation, fibrinogen, D-dimer, factor V and VIII, and Von Willebrand factor. Platelet function will be evaluated in whole blood using Multiplate® tests. Outcomes. The primary outcome is the effect of TXA on thrombin generation. Secondary outcomes include the effect of TXA on platelet function, fibrinogen, D-dimer and coagulation factors.

Relationship between timing of cooling and outcomes in adult comatose cardiac arrest patients treated with targeted temperature management

AIM OF THE STUDY

Studies examining associations between time to target temperature and outcomes in cardiac arrest patients who underwent targeted temperature management (TTM) have shown inconsistent results. We examined these associations separately for time from restoration of spontaneous circulation to TTM initiation (pre-induction time) and time from TTM initiation to target temperature (induction time). Furthermore, we examined whether critical time thresholds exist if there is an association.

METHODS

This was a single-centre retrospective observational study including adult cardiac arrest patients treated with TTM from 2008 to 2015. We tested the associations of pre-induction time and induction time with outcomes at hospital discharge using multivariate logistic regression analysis. We then performed additional multivariate analyses, each with the significant timing variable at different binary cutoffs.

RESULTS

A total of 515 patients were analysed. At hospital discharge, 357 patients (69.3%) were alive, of whom 161 (31.3%) had a favourable neurologic outcome. In multivariate analysis, a shorter pre-induction time was independently associated with a favourable neurologic outcome (odds ratio [OR], 1.110; 95% confidence interval [CI], 1.025-1.202), whereas the induction time was not (OR, 0.954; 95% CI, 0.852-1.067). We found two pre-induction time thresholds (120 and 360min) that were associated with neurologic outcome.

CONCLUSION

We found that a shorter pre-induction time was independently associated with a favorable neurologic outcome at hospital discharge, whereas induction time was not. We also found two time thresholds at 120 and 360min, after which initiation of cooling was associated with a worse neurologic outcome.

Prophylactic versus clinically-driven antibiotics in comatose survivors of out-of-hospital cardiac arrest-A randomized pilot study

AIM

To investigate benefits of prophylactic antibiotics in comatose survivors of out-of-hospital cardiac arrest (OHCA).

METHODS

Patients without evidence of tracheobronchial aspiration on admission bronchoscopy were randomized to prophylactic Amoxicillin-Clavulanic acid 1.2g every 8h (P) or clinically-driven antibiotics (C) administered if signs of infection developed during initial 7days of intensive care unit (ICU) stay.

RESULTS

Among 83 patients enrolled between September 2013 and February 2015, tracheobronchial aspiration was documented in 23 (28%). Accordingly, 60 patients were randomized. Percentage of patients on antibiotics between days 1-5 was significantly greater in P group. White blood count, C-reactive protein, procalcitonin (PCT) and CD 64 significantly increased during the postresuscitation phase. Except for lower CRP and PCT in group P on day 6 (p<0.05), there was no significant differences. Mini BAL on day 3 was less often positive in group P (7% vs. 42%; p<0.01). There was no significant difference in other microbiological samples and X-ray signs of pneumonia cumulatively documented in 50% in both groups. Use of vasopressors/inotropes (93% in both groups), duration of mechanical ventilation (5.4±3.7 vs. 5.2±3.1 days), tracheal intubation (6.5±4.6 vs. 5.9±4.3 days), ICU stay (7.7±5.2 vs. 6.9±4.5 days), survival (73% vs. 73%) and survival with good neurological outcome (50% vs. 40%) were also comparable between P and C groups.

CONCLUSION

Bronchoscopy on admission documented tracheobronchial aspiration in 28% of comatose survivors of OHCA. In the absence of aspiration, prophylactic antibiotics did not significantly alter systemic inflammatory response, postresuscitation pneumonia, ICU treatment and outcome (ClinicalTrials.gov Identifier: NCT02899507).

Host cell surfaces induce a Type IV pili-dependent alteration of bacterial swimming

For most pathogenic bacteria, flagellar motility is recognized as a virulence factor. Here, we analysed the swimming behaviour of bacteria close to eukaryotic cellular surfaces, using the major opportunistic pathogen Pseudomonas aeruginosa as a model. We delineated three classes of swimming trajectories on both cellular surfaces and glass that could be differentiated by their speeds and local curvatures, resulting from different levels of hydrodynamic interactions with the surface. Segmentation of the trajectories into linear and curved sections or pause allowed us to precisely describe the corresponding swimming patterns near the two surfaces. We concluded that (i) the trajectory classes were of same nature on cells and glass, however the trajectory distribution was strikingly different between surface types, (ii) on cell monolayers, a larger fraction of bacteria adopted a swimming mode with stronger bacteria-surface interaction mostly dependent upon Type IV pili. Thus, bacteria swim near boundaries with diverse patterns and importantly, Type IV pili differentially influence swimming near cellular and abiotic surfaces.

Impact of Cushing's sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study

Background

Cushing’s reflex usually results from intracranial hypertension. Although Cushing’s sign can implicate severe traumatic brain injury (TBI) in injured patients, no major investigations have been made. The purpose of this study was to assess the predictability of life-threatening brain injury requiring immediate neurosurgical intervention (LT-BI) among trauma patients with Cushing’s sign in the prehospital setting.

Methods

This was a retrospective study using data from the Japan Trauma Data Bank from the period of 2010 to 2014. Patients 16 years old or older with blunt mechanisms of injury who were transported directly from the scene and Glasgow Coma Scale for eye opening of one in the prehospital setting were included. LT-BI was defined as patients requiring burr hole evacuation or craniotomy within 24 h of hospital arrival and patients who were non-survivors due to isolated severe TBI. Prehospital systolic blood pressure (pSBP) and heart rate (pHR) were assessed using area under the receiver operating characteristic curve (AUROC) and multiple logistic regression analysis to predict LT-BI.

Results

Of 6332 eligible patients, 1859 (29%) exhibited LT-BI. AUROC of LT-BI using pSBP and pHR was 0.666 (95% confidence interval (CI); 0.652–0.681, P < 0.001), and 0.578 (95% CI; 0.563–0.594, P < 0.001), respectively. AUROC of pSBP was the highest among the 60 ≤ pHR ≤ 99 subgroup, of which AUROC was 0.680 (95% CI; 0.662–0.699, P < 0.001).

Multiple logistic regression analysis showed that the higher the pSBP and the lower the pHR, the more likely that the patients had LT-BI. In a group with pSBP ≥ 180 mmHg and pHR ≤ 59 beats/min, the odds ratio and 95% CI of LT-BI after adjusting for age, sex, and severity of injuries to other body regions was 4.77 (2.85–7.97), P < 0.001 was compared with the reference group, which was defined as patients with normal vital signs.

Discussion

Our study has found that the combination of hypertension and bradycardia, which are the components of Cushing's sign without eye opening in the prehospital setting was a weak but a significant predictor of LT-BI, or death due to possible isolated severe TBI.

Conclusions

Prehospital Cushing’s sign with disturbed level of consciousness in trauma patients was a weak but significant predictor of the need for immediate neurosurgical intervention.

The role of tumour necrosis factor in hepatitis B infection: Jekyll and Hyde

Chronic hepatitis B (CHB) is a major health problem worldwide and is associated with significant long-term morbidity and mortality. The hepatitis B virus (HBV) is a hepatotropic virus that is capable of integrating in the host nucleus permanently resulting in lifelong infection. To date, there is no definitive cure for HBV, as our current treatments cannot eradicate the viral reservoir that has integrated in the liver. Elucidating the immunopathogenesis is key to finding a therapeutic target for HBV as the virus is not in itself cytopathic but the immune response to the virus causes the majority of the cellular injury. In most cases, the virus reaches a state of equilibrium with low viral replication constrained by host immunity. Multiple cytokines have been implicated in the pathogenesis of CHB. Tumor necrosis factor (TNF) has emerged as a key player; on one hand it can facilitate immune-mediated virological control but on the other hand it can cause collateral hepatocyte damage, cirrhosis and possibly promote hepatocellular carcinoma. In this review, we discuss the current understanding of the immunopathogenesis of HBV, focusing on TNF and whether it can be harnessed in therapeutic strategies to cure HBV infection.

Combining an antiviral with rituximab in EBV-related haemophagocytic lymphohistiocytosis led to rapid viral clearance; and a comprehensive review

Epstein-Barr virus (EBV)-related haemophagocytic lymphohistiocytosis (EBVr-HLH) has a better prognosis when the virus is rapidly cleared, but the best antiviral approach is controversial. We present a patient to whom the therapeutic standard rituximab was co-administered with valacyclovir and an HLH-specific treatment with favourable viral and clinical responses. We conducted an extensive literature review and contacted several world reference centres and experts to inquire about their approaches and experience. We conclude that antivirals are infrequently used for EBVr-HLH, despite their laboratory-proven and likely clinical beneficial effect on some EBV-related diseases. However, the role of antivirals remains obscure. Concerns about their lack of efficacy are based on observational data and reports of the cellular tropism of EBV. Therefore, the adjunct use of antivirals may be considered when myelotoxicity is not the primary concern, and related outcomes should be systematically recorded to produce higher quality evidence.

Fibrin/fibrinogen degradation products (FDP) at hospital admission predict neurological outcomes in out-of-hospital cardiac arrest patients

OBJECTIVE

This study aimed to test the hypothesis that coagulation, fibrinolytic markers and disseminated intravascular coagulation (DIC) score (International Society on Thrombosis and Haemostasis) at hospital admission of out-of-hospital cardiac arrest (OHCA) patients can predict neurological outcomes 1 month after cardiac arrest.

METHODS

In this retrospective, observational analysis, data were collected from the Sapporo Utstein Registry and medical records at Hokkaido University Hospital. We included patients who experienced OHCA with successful return of spontaneous circulation (ROSC) between 2006 and 2012 and were transferred to Hokkaido University Hospital. From medical records, we collected information about the following coagulation and fibrinolytic factors at hospital admission: platelet count; prothrombin time; activated partial thromboplastin time; plasma levels of fibrinogen, D-dimer, fibrin/fibrinogen degradation products (FDP), and antithrombin; and calculated DIC score. Favorable neurological outcomes were defined as a cerebral performance category 1-2.

RESULTS

We analyzed data for 315 patients. Except for fibrinogen level, all coagulation variables, fibrinolytic variables, and DIC score were associated with favorable neurological outcomes. In the receiver operating characteristic curve analysis, FDP level had the largest area under the curve (AUC; 0.795). In addition, the AUC of FDP level was larger than that of lactate level.

CONCLUSIONS

All of the coagulation and fibrinolytic markers, except for fibrinogen level, and DIC score at hospital admission, were associated with favorable neurological outcomes. Of all of the variables, FDP level was most closely associated with favorable neurological outcomes in OHCA patients who successfully achieved ROSC.

Fluid Therapy in Lung Disease

Fluid therapy is the cornerstone of supportive care in veterinary medicine. In dogs and cats with preexisting confirmed or suspected pulmonary disease, concerns may exist that the fluid therapy may impair gas exchange, either through increases in hydrostatic pressures or extravasation. Colloidal therapy is more likely to magnify lung injury compared with isotonic crystalloids. Radiographic evidence of fluid overload is a late-stage finding, whereas point-of-care ultrasound may provide earlier information that can also be assessed periodically at the patient side. Cases should be evaluated individually, but generally a conservative fluid therapy plan is preferred with close monitoring of its tolerance.

Reasons for death in patients with sepsis and septic shock

PURPOSE

Understanding the underlying cause of mortality in sepsis has broad implications for both clinical care and interventional trial design. However, reasons for death in sepsis remain poorly understood. We sought to characterize reasons for in-hospital mortality in a population of patients with sepsis or septic shock.

MATERIALS AND METHODS

We performed a retrospective review of patients admitted to the intensive care unit with sepsis or septic shock who died during their index admission. Reasons for death were classified into 6 categories determined a priori by group consensus. Interrater reliability was calculated and Fleiss κ reported. The associations between selected patient characteristics (eg, serum lactate) and reason for death were also assessed.

RESULTS

One hundred fifteen patients were included. Refractory shock (40%) and comorbid withdrawal of care (44%) were the most common reasons for death. Overall interrater agreement was substantial (κ = 0.61, P<.01). Lactate was higher in patients who died because of refractory shock as compared with those who died for other reasons (4.7 vs 2.8 mmol/L, P<.01).

CONCLUSION

In this retrospective cohort, refractory shock and comorbid withdrawal of care were the most common reasons for death. Following prospective validation, the classification methodology presented here may be useful in the design/interpretation of trials in sepsis.

Out of Hospital Cardiac Arrest: A Current Review of the Literature that Informed the 2015 American Heart Association Guidelines Update

Out-of-Hospital cardiac arrest affects over 300,000 individuals in the US per year and is the third leading cause of death for Americans. Given the extent of this public health problem, investigations are ongoing to improve upon outcomes for patients who suffer cardiac arrest. In 2015, the American Heart Association issued an update to the 2010 Cardiopulmonary and Emergency Cardiovascular Care Guidelines.1 In this manuscript, we reviewed the literature that informed the major changes to the guidelines and present a concise review of the current literature that informs how patients who suffer a cardiac arrest are cared for in the pre-hospital, emergency department and in-hospital environment. Additionally, the new AHA guideline on Maternal Resuscitation will also be described.