Focus on immunocompromised patients

Botany, traditional uses, phytochemistry, pharmacology, edible uses, and quality control of Lablab semen Album: A systematic review

ETHNOPHARMACOLOGICAL RELEVANCE

Lablab Semen Album (lablab), the white and dried mature fruit of Lablab purpureus in the Lablab genus of the Fabaceae family, is a renowned traditional medicinal herb with a long history of use in China. In Chinese medicine, lablab is often combined with other drugs to treat conditions such as weak spleen and stomach, loss of appetite, loose stools, excessive leucorrhoea, summer dampness and diarrhea, chest tightness, and abdominal distension.

MATERIALS AND METHODS

Comprehensive information on lablab was gathered from databases including Web of Science, Science Direct, Google Scholar, Springer, PubMed, CNKI, Wanfang, and ancient materia medica.

RESULTS

Lablab, a member of the lentil family, thrives in warm and humid climates, and is distributed across tropical and subtropical regions worldwide. Traditionally, lablab is used to treat various ailments, such as spleen and stomach weakness, loss of appetite, and diarrhea. Phytochemical analyses reveal that lablab is a rich source of triterpenoid saponins, glucosides, volatile components, polysaccharides, and amino acids. Lablab extracts exhibit diverse biological activities, including hypolipidemic, hypoglycemic, immunomodulatory, antioxidant, hepatoprotective, antitumoral, antiviral properties, and more. Besides its medicinal applications, lablab is extensively used in the food industry due to its high nutrient content. Additionally, the quality of lablab can be regulated by determining the levels of key chemical components pivotal to its medicinal effects, ensuring the herb's overall quality.

CONCLUSION

Lablab is a promising medicinal and edible plant ingredient with diverse pharmacological effects, making it a valuable ingredient for food, pharmaceuticals, and animal husbandry. However, it has inherent toxicity if not properly prepared. Additionally, some traditional uses and pharmacological activities lack scientific validation due to incomplete methods, unclear results, and insufficient clinical data. Thus, further in vivo and in vitro studies on its pharmacology, pharmacokinetics, and toxicology, along with clinical efficacy evaluations, are needed to ensure lablab's safety and effectiveness. As an important traditional Chinese medicine, lablab deserves more attention.

Case Series of HIV-Associated Oral Lesions Across Different Clinical Stages in People Living with HIV

Introduction

Human immunodeficiency virus (HIV) impairs immune function leading to oral mucosal lesions. While highly active antiretroviral therapy (HAART) has reduced the incidence of HIV-associated oral lesions (HIV-OLs), these lesions can still manifest across all HIV stages due to various patient-related factors.

Purpose

To evaluate the occurrence of HIV-OLs and clinical characteristics across all HIV stages in people living with HIV (PLWH).

Patients and Methods

Five patients aged 7 to 60 with canker sores visited the Oral Medicine Clinic. One newly diagnosed patient with stage II HIV had not yet started ART, while others in stages I, III, and IV were already receiving ART. Diagnosed oral lesions included recurrent intraoral herpes (RIH) in patients with stages I, II, and III; linear gingival erythema (LGE) in stages I; acute pseudomembranous candidiasis (APC) and oral hairy leukoplakia (OHL) in stages II; traumatic ulcers in stages III; erythema multiforme (EM) and angular cheilitis (AC) in stages IV. Potential risk factors for these oral lesions included poor oral hygiene, low CD4+ T-cell counts, detectable viral load, non-adherence to ART, smoking, medication use for systemic diseases, nutritional deficiency, and comorbidities.

Results

Treatment included antiviral for RIH; antifungal for APC and AC; topical corticosteroid and antiseptic mouthwash for oral ulcers and improving oral hygiene; application of normal saline-soaked gauze dressing followed by topical steroid for EM; petroleum jelly for dry lips; and multivitamins. Lesions improved over 5-15 days. Addressing risk factors involved improving oral hygiene, treating comorbidities, promoting weight gain, smoking cessation, and starting ART for those untreated.

Conclusion

Oral lesions are prevalent throughout the stages of HIV and are influenced by immune status, medication adherence, and overall health, underscoring the need for holistic care to enhance the quality of life, potentially alter HIV progression, and reduce morbidity through integrated oral health assessments in routine care.

A Nomogram Based on Comorbidities and Infection Location to Predict 30 Days Mortality of Immunocompromised Patients in ICU: A Retrospective Cohort Study

Background

The existing comorbidity indexes, like Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI), do not take infection factors into account for critically ill patients with immunocompromise, bringing about a decrease of prediction accuracy. Therefore, we attempted to incorporate infection location into the analysis to construct a rapid comorbidity scoring system independent of laboratory tests.

Methods

Data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database. A total of 3904 critically ill patients with immunocompromise admitted to ICU were enrolled and assigned into training or validation sets according to the date of ICU admission. The predictive nomogram was constructed in the training set based on logistic regression analysis and then undergone validation in the validation set in comparison with SOFA, CCI and ECI.

Results

Factors eligible for the nomogram included patient’s age, gender, ethnicity, underlying disease of immunocompromise like metastatic cancer and leukemia, possible infection on admission including pulmonary infection, urinary tract infection and blood infection, and one comorbidity, coagulopathy. The nomogram we developed exhibited better discrimination than SOFA, CCI and ECI with an area under the receiver operating characteristic curve (AUC) of 0.739 (95% CI 0.707–0.771) and 0.746 (95% CI 0.713–0.779) in the training and validation sets, respectively. Combining the nomogram and SOFA could bring a new prediction model with a superior predictive effect in both sets (training set AUC = 0.803 95% CI 0.777–0.828, validation set AUC = 0.818 95% CI 0.783–0.854). The calibration curve exhibited coherence between the nomogram and ideal observation for two cohorts (p>0.05). Decision curve analysis revealed the clinical usefulness of the nomogram in both sets.

Conclusion

We established a nomogram that could provide an accurate assessment of 30 days ICU mortality in critically ill patients with immunocompromise, which can be employed to evaluate the short-term prognosis of those patients and bring more clinical benefits without dependence on laboratory tests.

Critical illness in patients with hematologic malignancy: a population-based cohort study

PURPOSE

To describe the modern incidence and predictors of ICU admission for adult patients newly diagnosed with a hematologic malignancy.

METHODS

We conducted a population-based cohort study of adults with a new diagnosis of hematologic malignancy (April 1, 2006-March 31, 2017) in Ontario, Canada. We described the baseline demographic, clinical and laboratory predictors of ICU admission and subsequent mortality. The primary outcome was the incidence of ICU admission within 1 year of hematologic malignancy diagnosis. We assessed the predictors of ICU admission using Cox-proportional models that accounted for the competing risk of death and reported as subdistribution hazard ratios (sHR) with 95% confidence intervals (CI).

RESULTS

A total of 87,965 patients (mean [SD] age, 67.8 (15.7) years) were included. The 1-year incidence of ICU admission was 13.9% (median time 35 days), ranging from 7.3% (indolent lymphoma) to 22.5% (acute myeloid leukemia). After multivariable adjustment, compared to indolent lymphoma, acute myeloid leukemia (sHR, 3.09; 95% CI 2.84-3.35), aggressive non-Hodgkin lymphoma (sHR, 2.47; 95% CI 2.31-2.65) and acute lymphoblastic leukemia (sHR, 2.46; 95% CI 2.15-2.80) had the highest risk of ICU admission. Comorbidities such as cardiovascular disease (sHR, 2.09; 95% CI 2.01-2.19), chronic obstructive pulmonary disease (sHR, 1.33; 95% CI 1.26-1.39) and baseline laboratory abnormalities (anemia, thrombocytopenia and high creatinine) were also associated with ICU admission. Among ICU patients, 36.7% required invasive mechanical ventilation and in-hospital mortality was 31%.

CONCLUSION

Critical illness in patients with a newly diagnosed hematologic malignancy is frequent, occurring early after diagnosis. Certain baseline characteristics can help identify those patients at the highest risk.

Efficacy and safety of corticosteroids for septic shock in immunocompromised patients: A cohort study from MIMIC

BACKGROUND

Corticosteroids have been widely used as adjunct therapy for septic shock for many decades, but both the efficacy and safety remain unclear. The study was designed to investigate overall benefits and potential risks of corticosteroids in immunocompromised patients with septic shock.

METHODS

The Medical Information Mart for Intensive Care III (MIMIC-III) database was employed to conduct a cohort study. Immunocompromised patients with septic shock were enrolled and categorized by whether exposure to intravenous corticosteroids. Cox Proportional-Hazards models were used to control for confounders and assess the relationship between corticosteroids use and mortality.

RESULTS

A total of 866 patients were enrolled in this study, including 395 in the corticosteroids group and 471 in the non-corticosteroids group. Corticosteroids infusion was not associated with improved 30-day mortality in overall immunocompromised population [34.7% vs 32.1%; adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.87-1.43, p = 0.37]. The mortality effects were similar in 90-day, 180-day, 1-year and hospital mortality. For the subgroup of patients with metastatic cancer, corticosteroids infusion was associated with a statistically significant increase in the 30-day mortality risk (HR 1.58, 95% CI 1.06-2.37; p = 0.02). Corticosteroids had adverse effects on hemodynamic stability, prolonged ICU and hospital duration, and increased risk of hyperglycemia.

CONCLUSIONS

Corticosteroids therapy for the maintenance of blood pressure was not associated with improved mortality or hemodynamic stability in overall immunocompromised population with septic shock. Future randomized clinical trials are required to validate the effects of corticosteroids for septic shock in the special immunocompromised population.

Albumin replacement therapy in immunocompromised patients with sepsis - Secondary analysis of the ALBIOS trial

BACKGROUND

The best fluid replacement strategy and the role of albumin in immunocompromised patients with sepsis is unclear.

METHODS

We performed a secondary analysis of immunocompromised patients enrolled in the ALBIOS trial which randomized patients with severe sepsis or septic shock to receive either 20% albumin (target 30 g per liter or more) and crystalloid or crystalloid alone during ICU stay.

RESULTS

Of 1818 patients originally enrolled, 304 (16.4%) were immunocompromised. One-hundred-thirty-nine (45.7%) patients were randomized in the albumin while 165 (54.2%) in the crystalloid group. At 90 days, 69 (49.6%) in the albumin group and 89 (53.9%) in the crystalloids group died (hazard ratio - HR - 0.94; 95% CI 0.69-1.29). No differences were observed with regards to 28-day mortality, SOFA score (and sub-scores), length of stay in the ICU and in the hospital, proportion of patients who had developed acute kidney injury or received renal replacement therapy, duration of mechanical ventilation. Albumin was not independently associated with a higher or lower 90-day mortality (HR 0.979, 95% CI 0.709-1.352) as compared to crystalloid.

CONCLUSION

Albumin replacement during the ICU stay, as compared with crystalloids alone, did not affect clinical outcomes in a cohort of immunocompromised patients with sepsis.

Prevention of pathogen transmission during ultrasound use in the Intensive Care Unit: Recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group (USIG)

ICU ultrasonography constitutes important part of modern car patient care. Current standards and practice of infection control and prevention are inadequate. This purpose of this document is to adapt and expand the 2017 Australasian Society for Ultrasound in Medicine (ASUM) and the Australasian College for Infection Prevention Control (ACIPC) guidelines on minimum standards for reprocessing/cleaning of ultrasound transducers to the specifics of intensive care medicine and provide advice to the ICU practitioners and health care administrators. It considers the medical, administrative, financial and practical controversies surrounding implementation, and addresses emerging issues of care for patients with confirmed or suspected Corona Virus Disease 2019 (COVID-19).

Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency

Background

Risk factors affecting the prognosis of acute respiratory distress syndrome (ARDS) in adults were investigated. The aim was to identify new predictors for ARDS patient prognosis, including those with clinical, pathophysiological, and atypical immunodeficiency.

Methods

ARDS patients were retrospectively included. The patients were grouped and analysed according to different oxygenation index grades and prognosis, and factors influencing prognosis and survival were examined. Adolescent patients, patients with typical immunodeficiency and patients who died within 24 h after being diagnosed with ARDS were excluded. The predictive value for mortality was determined by Cox proportional hazard analysis.

Results

In total, 201 patients who fulfilled the Berlin definition of ARDS were included. The severity of critical illness on the day of enrolment, as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.016), Sequential Organ Failure Assessment (SOFA) score (P = 0.027), and PaO₂/FiO₂ (P = 0.000), worsened from mild to severe ARDS cases. Compared with survivors, non-survivors were significantly older and had higher APACHE II and SOFA scores. Moreover, significantly lower lymphocyte/neutrophil ratios and leukocyte counts were found among non-survivors than survivors (P = 0.008, P = 0.012). A moderate positive correlation between the lymphocyte/neutrophil and PaO₂/FiO₂ ratios (P = 0.023) was observed. In predicting 100-day survival in patients with ARDS, the area under the curve (AUC) for the lymphocyte/neutrophil ratio was significantly higher than those for the PaO₂/FiO₂ ratio alone, body mass index (BMI) alone, and the lymphocyte count alone (P = 0.0062, 0.0001, and 0.0154). Age (per log₁₀ years), BMI < 24, SOFA score, leukocyte count, and the lymphocyte/neutrophil ratio were independent predictors of 28-day mortality in ARDS patients. Additionally, ARDS patients with a lymphocyte/neutrophil ratio < 0.0537 had increased 28-day mortality rates (P = 0.0283). Old age affected both 28-day and 100-day mortality rates (P = 0.0064,0.0057).

Conclusions

Age (per log₁₀ years), BMI < 24, SOFA score, lymphocytes, and the lymphocyte/neutrophil ratio were independent predictors of 100-day mortality in patients with ARDS. The lymphocyte/neutrophil ratio may represent a potential molecular marker to evaluate atypical immunosuppression or impairment in patients with ARDS.

Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database

Background

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients.

Methods

We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents.

Results

Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio.

Conclusions

Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge.

Trial registration

ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2079-9) contains supplementary material, which is available to authorized users.