Management of sepsis during the early "golden hours"

Rapid response system and mortality in intensive care unit: a nationwide cohort study in South Korea

The beneficial effects of a rapid response system (RRS) on clinical outcomes in patients admitted to a ward have been established. However, the relationship between RRS implementation and clinical outcomes in patients in the intensive care unit (ICU) has not yet been established. Therefore, we aimed to investigate whether the RRS affects clinical outcomes in critically ill patients admitted to the ICU. As a nationwide, population-based cohort study, all adult patients who were admitted to the ICU from 1 January 2019 to 31 December 2021 in South Korea were included. Patients in hospitals with an RRS formed the RRS group; those in hospitals lacking an RRS constituted the non-RRS group. In total, 900,606 patients admitted to the ICU were included in the final analysis. Among them, 365,305 (40.6%) were assigned to the RRS group, and 535,301 (59.4%) were assigned to the non-RRS group. After propensity score (PS) matching, a total of 454,748 patients (227,374 in each group) were included in the final analysis. In the PS-matched cohort, the RRS group showed 8% (odds ratio [OR]: 0.92, 95% confidence interval [CI]: 0.91, 0.94; P < 0.001) and 11% (hazard ratio: 0.89, 95% CI: 0.88, 0.90; P < 0.001) lower in-hospital mortality rates and 1-year all-cause mortality rates than the non-RRS group, respectively. In addition, ICU readmission rates and the occurrence rate for adverse events during hospitalization in the RRS group were 3% (OR: 0.97, 95% CI: 0.95, 0.98; P < 0.001) and 21% (OR: 0.79, 95% CI: 0.78, 0.80; P < 0.001) lower than those in the non-RRS group, respectively. RRS deployment was linked to lower in-hospital and 1-year all-cause mortality rates, ICU readmission rates, and the occurrence of adverse events during hospitalization among ICU patients. The findings indicate that using the RRS could assist not only patients in the ward but also critically ill patients in the ICU.

Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians

Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.

Adequacy of cefepime concentrations in the early phase of critical illness: A case for precision pharmacotherapy

STUDY OBJECTIVE

In critically ill patients, adequacy of early antibiotic exposure has been incompletely evaluated. This study characterized factors associated with inadequate cefepime exposure in the first 24 h of critical illness.

DESIGN

Prospective cohort study.

SETTING

Academic Medical Center.

PATIENTS

Critically ill adults treated with cefepime. Patients with acute kidney injury or treated with kidney replacement therapy or extracorporeal membrane oxygenation were excluded.

INTERVENTION

None.

MEASUREMENTS

A nonlinear mixed-effects pharmacokinetic (PK) model was developed to estimate cefepime concentrations for each patient over time. The percentage of time the free drug concentration exceeded 8 mg/L during the first 24 h of therapy was calculated (%ƒT>8; appropriate for the susceptible breakpoint for Pseudomonas aeruginosa). Factors predictive of low %ƒT>8 were explored with multivariable regression.

MAIN RESULTS

In the 100 included patients, a one-compartment PK model was developed with first-order elimination with covariates for weight and estimated glomerular filtration rate based on creatinine and cystatin C (eGFRSCr-CysC). The median (interquartile range) %ƒT>8 for cefepime in the first 24 h of therapy based on this model was 85% (66%, 100%). Less than 100% ƒT>8 during first 24 h of therapy occurred in 70 (70%) individuals. Lower Sequential Organ Failure Assessment score (p = 0.032) and higher eGFRSCr-CysC (p < 0.001) predicted a lower %ƒT>8. Central nervous system infection source was protective (i.e., associated with a higher %ƒT>8; p = 0.008).

CONCLUSIONS

During early critical illness, cefepime concentrations were inadequate in a significant proportion of patients. Antimicrobial optimization is needed to improve the precision of pharmacotherapy in the critically ill patients.

Access to trauma center care: A statewide system-based approach

BACKGROUND

Timely access to specialized trauma care is a vital element in patient outcome after severe and critical injury requiring the skills of trauma teams in levels I and II trauma centers to avoid preventable mortality. We used system-based models to estimate timely access to care.

METHODS

Trauma system models consisted of ground emergency medical services, helicopter emergency medical services, and designated levels I to V trauma centers were constructed for five states. These models incorporated geographic information systems along with traffic data and census block group data to estimate population access to trauma care within the "golden hour." Trauma systems were further analyzed to identify the optimal location for an additional level I or II trauma center that would provide the greatest increase in access.

RESULTS

The population of the states studied totaled 23 million people, of which 20 million (87%) had access to a level I or II trauma center within 60 minutes. Statewide-specific access ranged from 60% to 100%. Including levels III to V trauma centers, access within 60 minutes increased to 22 million (96%), ranging from 95% to 100%. The addition of a levels I and II trauma center in an optimized location in each state would provide timely access to a higher trauma capability for an additional 1.1 million, increasing total access to approximately 21.1 million people (92%).

CONCLUSION

This analysis demonstrates that nearly universal access to trauma care is present in these states when including levels I to V trauma centers. However, concerning gaps remain in timely access to levels I and II trauma centers. This study provides an approach to determine more robust statewide estimates of access to care. It highlights the need for a national trauma system, one in which all components of state-managed trauma systems are assembled in a national data set to accurately identify gaps in care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Should hospital-onset Adult Sepsis Event surveillance be routine… or even mandatory?

Hospital-onset sepsis accounts for 10%-15% of all sepsis cases and is associated with very high mortality rates, yet to date most hospitals have paid little attention to tracking its incidence and outcomes. This contrasts sharply with the substantial effort that hospitals and regulatory agencies spend tracking and reporting a limited subset of healthcare-associated infections. The recent development of the Center for Disease Control and Prevention's hospital-onset Adult Sepsis Event (ASE) definition, however, provides a validated and standardized mechanism for facilities to identify patients with nosocomial sepsis using routinely available electronic health record data. Recent data have demonstrated that hospital-onset ASE surveillance identifies many infections that are largely missed by current reportable healthcare-associated infections and that are associated with much higher mortality rates. Expanding the breadth of surveillance to include these highly consequential infections could help identify new targets for prevention and quality improvement and ultimately catalyze better outcomes for hospitalized patients. More work is needed, however, to characterize the preventability of hospital-onset ASE, develop and validate robust case-mix adjustment tools, and facilitate widespread uptake in hospitals with limited resources.

Relationship between time of emergency department admission and adherence to the Surviving Sepsis Campaign bundle in patients with septic shock

BACKGROUND

Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock.

METHODS

We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED.

RESULTS

A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088-1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115-1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590-0.952, p = 0.018) and 0.714 (95% CI 0.564-0.904, p = 0.005), respectively.

CONCLUSION

Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

Opioids and Sepsis: Elucidating the Role of the Microbiome and microRNA-146

Sepsis has recently been defined as life-threatening organ dysfunction caused by the dysregulated host response to an ongoing or suspected infection. To date, sepsis continues to be a leading cause of morbidity and mortality amongst hospitalized patients. Many risk factors contribute to development of sepsis, including pain-relieving drugs like opioids, which are frequently prescribed post-operatively. In light of the opioid crisis, understanding the interactions between opioid use and the development of sepsis has become extremely relevant, as opioid use is associated with increased risk of infection. Given that the intestinal tract is a major site of origin of sepsis-causing microbes, there has been an increasing focus on how alterations in the gut microbiome may predispose towards sepsis and mediate immune dysregulation. MicroRNAs, in particular, have emerged as key modulators of the inflammatory response during sepsis by tempering the immune response, thereby mediating the interaction between host and microbiome. In this review, we elucidate contributing roles of microRNA 146 in modulating sepsis pathogenesis and end with a discussion of therapeutic targeting of the gut microbiome in controlling immune dysregulation in sepsis.

Oral Midodrine Administration During the First 24 Hours of Sepsis to Reduce the Need of Vasoactive Agents: Placebo-Controlled Feasibility Clinical Trial

Objectives:

Our preliminary data and observational studies suggested an increasing “off label” use of oral midodrine as a vasopressor sparing agent in various groups of critically ill patients, including those with sepsis. We designed this clinical trial to evaluate the feasibility of use of midodrine hydrochloride in early sepsis to reduce the duration for IV vasopressors and decrease ICU and hospital length of stay.

Design:

Pilot, two-center, placebo-controlled, double blinded randomized clinical trial.

Setting:

Medical ICUs at Mayo Clinic Rochester and Cleveland Clinic Abu Dhabi were the study sites.

Patients and Methods:

Adult patients (≥ 18 yr old) were included within 24 hours of meeting the Sepsis-3 definition if the mean arterial pressure remained less than 70 mm Hg despite receiving timely antibiotics and initial IV fluid bolus of 30 cc/kg.

Intervention:

Three doses of 10 mg midodrine versus placebo were administered.

Measurements and Main Results:

Total 32 patients were randomized into midodrine (n = 17) and placebo groups (n = 15). There were no major differences in baseline variables between the groups except for higher baseline creatinine in the midodrine group (2.0 ± 0.9 mg/dL) versus placebo group (1.4 ± 0.6 mg /dL), p = 0.03. The median duration of IV vasopressor requirement was 14.5 ± 8.1 hours in midodrine group versus 18.8 ± 7.1 hours in the placebo group, p value equals to 0.19. Patients in the midodrine group needed 729 ± 963 norepinephrine equivalent compared with 983 ± 1,569 norepinephrine equivalent in the placebo group, p value equals to 0.59. ICU length of stay was 2.29 days (interquartile range, 1.65–3.9 d) in the midodrine group, compared with 2.45 days (interquartile range, 1.6–3.2 d) in the placebo group, p value equals to 0.36. No serious adverse events were observed in either group.

Conclusions:

Phase II clinical trial powered for clinical outcomes (duration of vasopressor use, need for central venous catheter, and ICU and hospital length of stay) is justified.

ColistinDose, a Mobile App for Determining Intravenous Dosage Regimens of Colistimethate in Critically Ill Adult Patients: Clinician-Centered Design and Development Study

Background

Determining a suitable dose of intravenous colistimethate is challenging because of complicated pharmacokinetics, confusing terminology, and the potential for renal toxicity. Only recently have reliable pharmacokinetic/pharmacodynamic data and dosing recommendations for intravenous colistimethate become available.

Objective

The aim of this work was to develop a clinician-friendly, easy-to-use mobile app incorporating up-to-date dosing recommendations for intravenous colistimethate in critically ill adult patients.

Methods

Swift programming language and common libraries were used for the development of an app, ColistinDose, on the iPhone operating system (iOS; Apple Inc). The compatibility among different iOS versions and mobile devices was validated. Dosing calculations were based on equations developed in our recent population pharmacokinetic study. Recommended doses generated by the app were validated by comparison against doses calculated manually using the appropriate equations.

Results

ColistinDose provides 3 major functionalities, namely (1) calculation of a loading dose, (2) calculation of a daily dose based on the renal function of the patient (including differing types of renal replacement therapies), and (3) retrieval of historical calculation results. It is freely available at the Apple App Store for iOS (version 9 and above). Calculated doses accurately reflected doses recommended in patients with varying degrees of renal function based on the published equations. ColistinDose performs calculations on a local mobile device (iPhone or iPad) without the need for an internet connection.

Conclusions

With its user-friendly interface, ColistinDose provides an accurate and easy-to-use tool for clinicians to calculate dosage regimens of intravenous colistimethate in critically ill patients with varying degrees of renal function. It has significant potential to avoid the prescribing errors and patient safety issues that currently confound the clinical use of colistimethate, thereby optimizing patient treatment.

The Neutrophil: Constant Defender and First Responder

The role of polymorphonuclear neutrophils (PMNs) in biology is often recognized during pathogenesis associated with PMN hyper- or hypo-functionality in various disease states. However, in the vast majority of cases, PMNs contribute to resilience and tissue homeostasis, with continuous PMN-mediated actions required for the maintenance of health, particularly in mucosal tissues. PMNs are extraordinarily well-adapted to respond to and diminish the damaging effects of a vast repertoire of infectious agents and injurious processes that are encountered throughout life. The commensal biofilm, a symbiotic polymicrobial ecosystem that lines the mucosal surfaces, is the first line of defense against pathogenic strains that might otherwise dominate, and is therefore of critical importance for health. PMNs regularly interact with the commensal flora at the mucosal tissues in health and limit their growth without developing an overt inflammatory reaction to them. These PMNs exhibit what is called a para-inflammatory phenotype, and have reduced inflammatory output. When biofilm growth and makeup are disrupted (i.e., dysbiosis), clinical symptoms associated with acute and chronic inflammatory responses to these changes may include pain, erythema and swelling. However, in most cases, these responses indicate that the immune system is functioning properly to re-establish homeostasis and protect the status quo. Defects in this healthy everyday function occur as a result of PMN subversion by pathological microbial strains, genetic defects or crosstalk with other chronic inflammatory conditions, including cancer and rheumatic disease, and this can provide some avenues for therapeutic targeting of PMN function. In other cases, targeting PMN functions could worsen the disease state. Certain PMN-mediated responses to pathogens, for example Neutrophil Extracellular Traps (NETs), might lead to undesirable symptoms such as pain or swelling and tissue damage/fibrosis. Despite collateral damage, these PMN responses limit pathogen dissemination and more severe damage that would otherwise occur. New data suggests the existence of unique PMN subsets, commonly associated with functional diversification in response to particular inflammatory challenges. PMN-directed therapeutic approaches depend on a greater understanding of this diversity. Here we outline the current understanding of PMNs in health and disease, with an emphasis on the positive manifestations of tissue and organ-protective PMN-mediated inflammation.

COVID-19: An Archetype Innate Immunity Reaction and Modes of Treatment

The magnitude of the SARS-CoV-2 pandemic found health systems unprepared, not allowing for prompt evaluation, collaboration among specialities and treatment of severely ill patients admitted to intensive care units, with many of them having an unfortunate outcome. Current data demonstrate an acute immune dysregulation in severe forms of the disease. The above is concluded by clinical evolution and laboratory findings, indicating a severe inflammatory response of the innate immune system, initiating predominately with the involvement of the respiratory tract epithelial cells, occasionally progressing to thrombotic diathesis and related complications. Besides the clinical manifestations, the immune response expresses an extremely high acute phase reactants repertoire including hyperferritinemia, hyper-fibrinogenaemia, and a storm of cytokines that require an alternative view and collaboration with rheumatologists. Thrombotic diathesis in some cases may not attribute only to a possible disseminated intravascular coagulation, but also to an additional activation of adaptive immunity and the development of the antiphospholipid syndrome. Unifying speciality evaluation and treatment may improve patient outcomes by recognizing early the evolving syndromes, treating properly, in a stratifying manner, with medications that alleviate the inflammatory reaction. Corticosteroids, colchicine, hydroxychloroquine/chloroquine, and possibly potent immunosuppressants are in the armamentarium. Additionally, biologics that interrupt the innate immune dysfunction, such as IL-1, IL-6 and selective JAK inhibitors, are also used. Convalescent plasma therapy and human immunoglobulin may be restricted for those whom the proposed treatments are found inadequate. The above combined with antiretroviral medications may improve the outcome until the development of safe and effective vaccination.

Using Data Analytics to Predict Hospital Mortality in Sepsis Patients

Predictive analytics can be used to anticipate the risks associated with some patients, and prediction models can be employed to alert physicians and allow timely proactive interventions. Recently, health care providers have been using different types of tools with prediction capabilities. Sepsis is one of the leading causes of in-hospital death in the United States and worldwide. In this study, the authors used a large medical dataset to develop and present a model that predicts in-hospital mortality among Sepsis patients. The predictive model was developed using a dataset of more than one million records of hospitalized patients. The independent predictors of in-hospital mortality were identified using the chi-square automatic interaction detector. The authors found that adding hospital attributes to the predictive model increased the accuracy from 82.08% to 85.3% and the area under the curve from 0.69 to 0.84, which is favorable compared to using only patients' attributes. The authors discuss the practical and research contributions of using a predictive model that incorporates both patient and hospital attributes in identifying high-risk patients.

Nighttime and non-business days are not associated with increased risk of in-hospital mortality in patients with severe sepsis in intensive care units in Japan: The JAAM FORECAST study

PURPOSE

Hospital services are reduced during off-hour such as nighttime or weekend. Investigations of the off-hour effect on initial management and outcomes in sepsis are very limited. Thus, we tested the hypothesis that patients who were diagnosed with severe sepsis during the nighttime or on non-business days had altered initial management and clinical outcomes.

MATERIALS AND METHODS

Patients with severe sepsis from 59 ICUs between 2016 and 2017 were enrolled. The patients were categorized according to the diagnosis time or day and were then compared. The primary outcome was in-hospital mortality.

RESULTS

One thousand one hundred and forty-eight patients were analyzed; 769 daytime patients, vs. 379 nighttime patients, and 791 business day patients vs. 357 non-business day patients. There were no significant differences in in-hospital mortality between either daytime and nighttime (24.4% vs. 21.4%, P = .27; nighttime, adjusted odds ratio [OR] 1.17, 95% confidence interval [CI], 0.87-1.59, P = .30) or between business and non-business days (22.9% vs. 24.6%, P = .55; non-business day, adjusted OR 0.85, 95% CI 0.60-1.22, P = .85). Time to antibiotics was significantly shorter in the nighttime (114 vs. 89 min, P = .0055).

CONCLUSIONS

Nighttime and weekends were not associated with increased in-hospital mortality of severe sepsis.

Sulfasalazine treatment can cause a positive effect on LPS-induced endotoxic rats

The aim of this study, was to determine the effect of sulfasalazine for different periods of time reduces disseminated intravascular coagulation, inflammation and organ damages by inhibiting the nuclear factor kappa beta pathway. The study was performed with 30 Wistar albino rats and the groups were established as Control group, LPS group; endotoxemia was induced with LPS, SL5 group: sulfasalazine (300 mg/kg, single dose daily) was administered for 5 days before the LPS-induced endotoxemia, and LS group: sulfasalazine (300 mg/kg, single dose) was administered similtenously with LPS. Hemogram, biochemical, cytokine (IL-1β, IL-6, IL-10, TNF-α) and acute phase proteins (HPT, SAA, PGE2) analyzes and oxidative status values were measured from blood samples at 3 and 6 h after the last applications in the all groups. The rats were euthanized at 6 h and mRNA levels of BCL2 and BAX genes were examined from liver and brain tissues. Sulfasalazine reduced the increased IL-1β, IL-6, TNF-α and PGE₂ levels and significantly increased anti-inflammatory cytokine IL-10 levels. In addition, decreasing of ATIII level was prevented in the SL5 group, and decreasing of fibrinogen levels were prevented in the LS and SL5 groups within first 3 h. In LPS group, leukocyte and thrombocyte levels were decreased, however sulfasalazine application inhibited decreases of leukocyte levels in LS and SL5 groups. In addition, sulfasalazine inhibited the decrease of total antioxidant capacity and unchanged apoptosis in brain and liver. In conclusion, the use of sulfasalazine in different durations reduce the excessive inflammation of endotoxemia cases.

An evaluation of clinical order patterns machine-learned from clinician cohorts stratified by patient mortality outcomes

OBJECTIVE

Evaluate the quality of clinical order practice patterns machine-learned from clinician cohorts stratified by patient mortality outcomes.

MATERIALS AND METHODS

Inpatient electronic health records from 2010 to 2013 were extracted from a tertiary academic hospital. Clinicians (n = 1822) were stratified into low-mortality (21.8%, n = 397) and high-mortality (6.0%, n = 110) extremes using a two-sided P-value score quantifying deviation of observed vs. expected 30-day patient mortality rates. Three patient cohorts were assembled: patients seen by low-mortality clinicians, high-mortality clinicians, and an unfiltered crowd of all clinicians (n = 1046, 1046, and 5230 post-propensity score matching, respectively). Predicted order lists were automatically generated from recommender system algorithms trained on each patient cohort and evaluated against (i) real-world practice patterns reflected in patient cases with better-than-expected mortality outcomes and (ii) reference standards derived from clinical practice guidelines.

RESULTS

Across six common admission diagnoses, order lists learned from the crowd demonstrated the greatest alignment with guideline references (AUROC range = 0.86-0.91), performing on par or better than those learned from low-mortality clinicians (0.79-0.84, P < 10-5) or manually-authored hospital order sets (0.65-0.77, P < 10-3). The same trend was observed in evaluating model predictions against better-than-expected patient cases, with the crowd model (AUROC mean = 0.91) outperforming the low-mortality model (0.87, P < 10-16) and order set benchmarks (0.78, P < 10-35).

DISCUSSION

Whether machine-learning models are trained on all clinicians or a subset of experts illustrates a bias-variance tradeoff in data usage. Defining robust metrics to assess quality based on internal (e.g. practice patterns from better-than-expected patient cases) or external reference standards (e.g. clinical practice guidelines) is critical to assess decision support content.

CONCLUSION

Learning relevant decision support content from all clinicians is as, if not more, robust than learning from a select subgroup of clinicians favored by patient outcomes.

Prescription opioids are associated with higher mortality in patients diagnosed with sepsis: A retrospective cohort study using electronic health records

Sepsis continues to be a major problem for hospitalized patients. Opioids are widely used medications for pain management despite recent evidence revealing their adverse effects. The present study evaluates survival differences between opioid-treated patients and non-opioid-treated patients hospitalized with a diagnosis of sepsis. Clinical data was extracted from the University of Minnesota’s Clinical Data Repository, which includes Electronic Health Records (EHRs) of the patients seen at 8 hospitals. Among 5,994 patients diagnosed with sepsis, 4,540 opioid-treated patients and 1,454 non-opioid patients were included based on whether they are exposed to prescription opioids during their hospitalization. Cox proportional hazards regression showed that after adjustments for demographics, clinical comorbidities, severity of illness, and types of infection, opioid-treated patients had a significantly higher risk of death at 28 days.

Prospective Observational Study on Heart Rate Variability in Emergency Department Patients with Sepsis

Objective

To study the predictive value of heart rate variability in septic patients presented to the emergency department.

Design

Cross sectional study.

Setting

Emergency department.

Methods

Septic patients in the emergency department were recruited according to criteria. Heart rate variability data on time domain and frequency domain were generated from Holter records. Sequential Organ Failure Assessment, clinical progress and laboratory values were used to access the outcomes.

Results

Spectral power of total power (TP), low frequency (LF), very low frequency (VLF) and normalised low frequency (nLF) are shown to be significantly reduced in patients with sepsis who deteriorated (p=0.0070, 0.0032, 0.0005 and 0.0109 respectively). Cut off value 172.5 of VLF can identify all septic patients with potential deterioration.

Conclusions

Application of heart rate variability recording in emergency department is feasible and helpful in early identification of potentially deteriorating septic patients.

Mortality rates increase dramatically below a systolic blood pressure of 105-mm Hg in septic surgical patients

BACKGROUND

This study used a prospective surgical database, to investigate the level of systolic blood pressure (SBP) at which the mortality rates begin to increase in septic surgical patients.

METHODS

All acute, septic general surgical patients older than 15 years of age admitted between January 2012 and January 2015 were included in these analyses.

RESULTS

Of a total of 6,020 adult surgical patients on the database, 3,053 elective patients, 1,664 nonseptic, 52 duplicates, and 11 patients with missing SBP were excluded to leave a cohort of 1,232 acute, septic surgical patients. The median age (intraquartile range [IQR]): 48 (32 to 62) and roughly 50:50 sex ratio (620 female: 609 male). Most of the patients were African: 988 (80.2%) followed by Asians (128 or 10.4%). More than two-thirds (852 or 69.2%) of the patient cohort underwent some form of surgery, and 152 or 12.3% required intensive care unit (ICU) admission. The median length of ICU stay (IQR) was 2 (1 to 4.5) days. The median length of total hospital stay (IQR) was 4 (2 to 9) days. The median SBP (IQR) on admission was 122 (107 to 138). A total of 167 patients died (13.6%). Those that died did have a significantly lower mean SBP compared with the survivors (116 vs 125, P <. 001). Six of 10 patients (60%) with a SBP less than 70 died. The receiver operating characteristic analysis suggests an optimal SBP cut-off of 111 when predicting mortality (area under the receiver operating characteristic curve: .6 [.551, .65]). This cut-off yields a moderate sensitivity (70%), high positive predictive value (90%) but low specificity, and negative predictive value when predicting mortality. Based on this optimal cut-off, 388 or 31.5% of the patients would be classified as shocked. The inflection curve below with fitted nonlinear curve (95% confidence intervals) clearly shows the upward change in observed mortality frequency at lower systolic and base excess (ie base deficit) values. Shocked patients had a significantly higher frequency of mortality (20% vs 11%, P < .001), a significantly higher median lactate (1.9 vs 1.5, P < .001), and mean base deficit (-2.8 vs -1.0, P = .001). No significant difference in mean age, ICU admission, duration of ICU admission, and total length of hospital stay was observed by shocked status.

CONCLUSIONS

Our data suggest that patients who die have a significantly lower SBP and clinically significant hypotension in sepsis with regard to increased mortality risk begins at a level of ∼111-mm Hg. This finding needs to be incorporated into bundles of care for surgical sepsis.

Impact of positive fluid balance on mortality and length of stay in septic shock patients

BACKGROUND

Fluid management is important in critically patients. The aim of this study was to determine the relationship between fluid balance and adverse outcomes of septic shock.

METHODS

A retrospective study was conducted in the medical Intensive Care Unit (ICU) of a tertiary university hospital in Thailand, over a 7-year period.

RESULTS

A total of 1048 patients with an ICU mortality rate of 47% were enrolled. The median cumulative fluid intake at 24, 48, and 72 h from septic shock onset were 4.2, 7.7, and 10.5 L, respectively. Nonsurvivors had a significantly higher median cumulative fluid intake at 24, 48, and 72 h (4.6 vs. 3.9 L, 8.2 vs. 7.1 L, and 11.4 vs. 9.9 L, respectively, P < 0.001 for all). Nonsurvivors also had a significantly higher cumulative and mean fluid balance within 72 h (5.4 vs. 4.4 L and 2.8 vs. 1.6 L, P < 0.001 for both). In multivariate logistic regression analysis, mean fluid balance quartile within 72 h, was independently associated with an increase in ICU and hospital mortality. Quartile 3 and 4 have statistically significant increases in mortality compared with quartile 1 (odds ratio [95% confidence interval] 3.04 [1.9-4.48] and 4.16 [2.49-6.95] for ICU mortality and 2.75 [1.74-4.36] and 3.16 [1.87-5.35] for hospital mortality, respectively, P < 0.001 for all). In addition, the higher amount of mean fluid balance was associated with prolonged ICU stays.

CONCLUSIONS

Positive fluid balance over 3 days is associated with increased ICU and hospital mortality along with prolonged ICU stays in septic shock patients.

Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies.

Complement inhibition decreases early fibrogenic events in the lung of septic baboons

Acute respiratory distress syndrome (ARDS) induced by severe sepsis can trigger persistent inflammation and fibrosis. We have shown that experimental sepsis in baboons recapitulates ARDS progression in humans, including chronic inflammation and long-lasting fibrosis in the lung. Complement activation products may contribute to the fibroproliferative response, suggesting that complement inhibitors are potential therapeutic agents. We have been suggested that treatment of septic baboons with compstatin, a C3 convertase inhibitor protects against ARDS-induced fibroproliferation. Baboons challenged with 10⁹ cfu/kg (LD50) live E. coli by intravenous infusion were treated or not with compstatin at the time of challenge or 5 hrs thereafter. Changes in the fibroproliferative response at 24 hrs post-challenge were analysed at both transcript and protein levels. Gene expression analysis showed that sepsis induced fibrotic responses in the lung as early as 24 hrs post-bacterial challenge. Immunochemical and biochemical analysis revealed enhanced collagen synthesis, induction of profibrotic factors and increased cell recruitment and proliferation. Specific inhibition of complement with compstatin down-regulated sepsis-induced fibrosis genes, including transforming growth factor-beta (TGF-β), connective tissue growth factor (CTGF), tissue inhibitor of metalloproteinase 1 (TIMP1), various collagens and chemokines responsible for fibrocyte recruitment (e.g. chemokine (C-C motif) ligand 2 (CCL2) and 12 (CCL12)). Compstatin decreased the accumulation of myofibroblasts and proliferating cells, reduced the production of fibrosis mediators (TGF-β, phospho-Smad-2 and CTGF) and inhibited collagen deposition. Our data demonstrate that complement inhibition effectively attenuates collagen deposition and fibrotic responses in the lung after severe sepsis. Inhibiting complement could prove an attractive strategy for preventing sepsis-induced fibrosis of the lung.

Differences in compliance with Surviving Sepsis Campaign recommendations according to hospital entrance time: day versus night

Introduction

Higher compliance with Surviving Sepsis Campaign (SSC) recommendations has been associated with lower mortality. The authors evaluate differences in compliance with SSC 6-hour bundle according to hospital entrance time (day versus night) and its impact on hospital mortality.

Methods

Prospective cohort study of all patients with community-acquired severe sepsis admitted to the intensive care unit of a large university tertiary care hospital, over 3.5 years with a follow-up until hospital discharge. Time to compliance with each recommendation of the SSC 6-hour bundle was calculated according to hospital entrance period: day (08:30 to 20:30) versus night (20:30 to 08:30). For the same periods, clinical staff composition and the number of patients attending the emergency department (ED) was also recorded.

Results

In this period 300 consecutive patients were included. Compliance rate was (night vs. day): serum lactate measurement 57% vs. 49% (P = 0.171), blood cultures drawn 59% vs. 37% (P < 0.001), antibiotics administration in the first 3 hours 33% vs. 18% (P = 0.003), central venous pressure >8 mmHg 45% vs. 29% (P = 0.021), and central venous oxygen saturation (SvcO₂) >70%, 7% vs. 2% (P = 0.082); fluids were administered in all patients with hypotension in both periods and vasopressors were administered in patients with hypotension not responsive to fluids in 100% vs. 99%. Time to get specific actions done was also different (night vs. day): serum lactate measurement (4.5 vs. 7 h, P = 0.018), blood cultures drawn (4 vs. 8 h, P < 0.001), antibiotic administration (5 vs. 8 h, P < 0.001), central venous pressure (8 vs. 11 h, P = 0.01), and SvcO₂ monitoring (2.5 vs. 11 h, P = 0.222). The composition of the nursing team was the same around the clock; the medical team was reduced at night with a higher proportion of less differentiated doctors. The number of patients attending the Emergency Department was lower overnight. Hospital mortality rate was 34% in patients entering in the night period vs. 40% in those entering during the day (P = 0.281).

Conclusion

Compliance with SSC recommendations was higher at night. A possible explanation might be the increased nurse to patient ratio in that period. Adjustment of the clinical team composition to the patients' demand is needed to increase compliance and improve prognosis.

Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department

Sepsis is one of the most important causes of morbidity and mortality in patients presenting to the emergency department. SIRS criteria that define sepsis are not specific and do not reflect the severity of infection. We aimed to evaluate the ability of the modified mortality in emergency department sepsis (MEDS) score, the modified early warning score (MEWS) and the Charlson comorbidity index (CCI) to predict prognosis in patients who are diagnosed in sepsis. We prospectively investigated the value of the CCI, MEWS and modified MEDS Score in the prediction of 28-day mortality in patients presenting to the emergency department who were diagnosed with sepsis. 230 patients were enrolled in the study. In these patients, the 5-day mortality was 17 % (n = 40) and the 28-day mortality was 32.2 % (n = 74). A significant difference was found between surviving patients and those who died in terms of their modified MEDS, MEWS and Charlson scores for both 5-day mortality (p < 0.001, p = 0.013 and p = 0.006, respectively) and 28-day mortality (p < 0.001, p = 0.008 and p < 0.001, respectively). The area under the curve (AUC) for the modified MEDS score in terms of 28-day mortality was 0.77. The MEDS score had a greater prognostic value compared to the MEWS and CCI scores. The performance of modified MEDS score was better than that of other scoring systems, in our study. Therefore, we believe that the modified MEDS score can be reliably used for the prediction of mortality in sepsis.

Evaluation of prognostic value of selected biochemical markers in surgically treated patients with acute mediastinitis

BACKGROUND

Monitoring of biochemical markers of inflammation in acute mediastinitis (AM) can be useful in the modification of treatment. This study was a retrospective evaluation of selected biochemical parameters with negative impact on the prognosis in surgically treated patients.

MATERIAL/METHODS

There were 44 consecutive patients treated surgically due to AM of differentiated etiology. Selected biochemical markers (WBC, RBC, HGB, HCT, PLT, CRP, PCT, ionogram, protein and albumins) were assessed before surgery and on the 3rd day after surgery. ANOVA was applied to find factors influencing observations. Numerical data [laboratory parameters] were compared by means of medians.

RESULTS

The overall hospital mortality rate was 31.82%. In the group of dead patients, there were observed statistically significant lower mean preoperative values of RBC [p=0.0090], HGB [p=0.0286], HCT [p=0.0354], protein [p= 0.0037], albumins [p=0.0003] and sodium [p<0.0001] and elevated values of CRP [P=0.0107] and PCT p<0.0001]. High level of inflammatory markers on day 3 after surgery was found to increase the risk of death - for WBC (by 67%), for CRP (by 88%) and for PCT (by 100%).

CONCLUSIONS

Poor prognosis was more frequent in patients with preoperative high levels of CRP, PCT, anemia, hypoproteinemia and hyponatremia. The risk of death increases significantly if in the immediate postoperative period no distinct decrease in WBC count and of the CRP and PCT level is observed. In such a situation the patients should be qualified earlier for broadened diagnostic workup and for reoperation.

Possible interventional therapies in severe sepsis or septic shock

For many years, basic research with relatively straightforward pathophysiologic approaches has driven clinical trials using molecules that supposedly interfere positively with inflammatory processes. However, most of these trials have failed to demonstrate any outcome benefit. Indeed, we need to revisit current paradigms and to think about the possibility that outcome may be predetermined in severe sepsis or septic shock. In addition, an early diagnosis of sepsis prior to the onset of clinical decline is also of particular interest to health practitioners because this information increases the possibilities for early and specific treatment of this life threatening condition. Indeed, the time to initiate therapy is thought to be crucial and the major determent factor in surviving sepsis. Despite substantial progress in sepsis therapy, the gap between the discovery of new effective medical molecules and their implementation in the daily clinical practice of the intensive care unit remains a major hurdle. Fortunately, ongoing research continues to provide new information on the management of sepsis, in particular, severe sepsis or septic shock. High quality and effective management tools are necessary to bring evidence-based therapy to the bedside. On this basis, new therapies could be tested to reduce mortality rates with respect to recently published studies.

Application of a loading dose of colistin methanesulfonate in critically ill patients: population pharmacokinetics, protein binding, and prediction of bacterial kill

A previous pharmacokinetic study on dosing of colistin methanesulfonate (CMS) at 240 mg (3 million units [MU]) every 8 h indicated that colistin has a long half-life, resulting in insufficient concentrations for the first 12 to 48 h after initiation of treatment. A loading dose would therefore be beneficial. The aim of this study was to evaluate CMS and colistin pharmacokinetics following a 480-mg (6-MU) loading dose in critically ill patients and to explore the bacterial kill following the use of different dosing regimens obtained by predictions from a pharmacokinetic-pharmacodynamic model developed from an in vitro study on Pseudomonas aeruginosa. The unbound fractions of colistin A and colistin B were determined using equilibrium dialysis and considered in the predictions. Ten critically ill patients (6 males; mean age, 54 years; mean creatinine clearance, 82 ml/min) with infections caused by multidrug-resistant Gram-negative bacteria were enrolled in the study. The pharmacokinetic data collected after the first and eighth doses were analyzed simultaneously with the data from the previous study (total, 28 patients) in the NONMEM program. For CMS, a two-compartment model best described the pharmacokinetics, and the half-lives of the two phases were estimated to be 0.026 and 2.2 h, respectively. For colistin, a one-compartment model was sufficient and the estimated half-life was 18.5 h. The unbound fractions of colistin in the patients were 26 to 41% at clinical concentrations. Colistin A, but not colistin B, had a concentration-dependent binding. The predictions suggested that the time to 3-log-unit bacterial kill for a 480-mg loading dose was reduced to half of that for the dose of 240 mg.

Goal-directed therapy in small animal critical illness

Monitoring critically ill patients can be a daunting task even for experienced clinicians. Goal-directed therapy is a technique involving intensive monitoring and aggressive management of hemodynamics in patients with high risk of morbidity and mortality. The aim of goal-directed therapy is to ensure adequate tissue oxygenation and survival. This article reviews commonly used diagnostics in critical care medicine and what the information gathered signifies and discusses clinical decision making on the basis of diagnostic test results. One example is early goal-directed therapy for severe sepsis and septic shock. The components and application of goals in early goal-directed therapy are discussed.

Surviving sepsis: going beyond the guidelines

The Surviving Sepsis Campaign is a global effort to improve the care of patients with severe sepsis and septic shock. The first Surviving Sepsis Campaign Guidelines were published in 2004 with an updated version published in 2008. These guidelines have been endorsed by many professional organizations throughout the world and come regarded as the standard of care for the management of patients with severe sepsis. Unfortunately, most of the recommendations of these guidelines are not evidence-based. Furthermore, the major components of the 6-hour bundle are based on a single-center study whose validity has been recently under increasing scrutiny. This paper reviews the validity of the Surviving Sepsis Campaign 6-hour bundle and provides a more evidence-based approach to the initial resuscitation of patients with severe sepsis.

Tissue factor pathway inhibitor and P-selectin as markers of sepsis-induced non-overt disseminated intravascular coagulopathy

Inflammation and coagulation occur concomitantly in sepsis. Thrombin activates platelet that leads to P-selectin translocation, which upregulate tissue factor (TF) generation. Tissue factor pathway inhibitor (TFPI) is an anticoagulant that modulates coagulation induced by TF. The term non-overt disseminated intravascular coagulation (DIC) refers to a state of affairs prevalent before the occurrence of overt DIC. It was suggested that an initiation of treatment in non-overt DIC has better outcome than overt DIC. This study investigated the role of TFPI level, P-selectin, and thrombin activation markers in non-overt and overt DIC induced by sepsis and its relationship to outcome and organ dysfunction as measured by the Sequential Organ Failure Assessment (SOFA) score. It included 176 patients with sepsis. They were admitted to the pediatric intensive care unit (ICU).They included 144 cases of non-overt DIC and 32 cases of overt DIC. There was a significant difference in hemostatic markers, platelet count, partial thromboplastin time (PTT), P-selectin, thrombin activation markers, TFPI, and DIC score between overt and non-overt DIC in both groups. It was noticed that P-selectin was positively correlated with DIC score, fibrinogen consumption, fibrinolysis (D-dimer), thrombin activation markers, and TFPI. Tissue factor pathway inhibitor was significantly correlated with fibrinolysis, DIC score, and prothrombin fragment 1+2. Sequential Organ Failure Assessment score was correlated with DIC score and other hemostatic markers in patients with overt DIC. To improve the outcome of patients with DIC, there is a need to establish more diagnostic criteria for non-overt-DIC. Plasma levels of TFPI and P-selectin may be helpful in this respect.

An international survey: Public awareness and perception of sepsis

BACKGROUND

Sepsis is a common cause of death throughout the world. Early treatment improves outcome; however, treatment may be delayed if the patient does not present himself/herself for medical care until late in the disease process. Lack of knowledge about the syndrome may contribute to delay in presenting for medical care. However, we need to acknowledge the complexity of sepsis. General awareness of sepsis by the public may increase political pressure for research funding. Increased public awareness of acute myocardial infarction has contributed to reduced mortality over the last 50 yrs. This example provides a rationale for future efforts to increase the public awareness of sepsis.

OBJECTIVE

The survey was designed to gain insight into public perceptions and attitudes regarding sepsis.

DESIGN

Prospective, international survey performed using structured telephone interviews.

SUBJECTS

A total of 6021 interviewees, 5021 in Europe and 1000 in the United States.

MEASUREMENTS AND MAIN RESULTS

In Italy, Spain, the United Kingdom, France and the United States, a mean of 88% of interviewees had never heard of the term "sepsis". In Germany 53% of people knew the word sepsis. In Italy, Spain, United Kingdom, France, and United States, of people who recognized the term sepsis, 58% did not recognize that sepsis is a leading cause of death.

CONCLUSIONS

There is poor public awareness about the existence of a syndrome known as sepsis. Results of this questionnaire underscore the challenges in early management and treatment of infected patients at risk for developing sepsis syndrome.

Choque séptico puerperal por Streptococcus β-hemolítico e síndrome de Waterhouse-Friderichsen

É relatado caso excepcional de puérpera de 15 anos com choque séptico pelo Streptococcus beta-hemolítico do grupo A e síndrome de Waterhouse-Friderichsen, observado à necropsia. São revistos aspectos do diagnóstico, patogênese e evolução da infecção (sepse) puerperal associada à hemorragia e insuficiência das supra-renais.

Effects of vasopressin in septic shock

Septic shock continues to be one of the leading causes of death in the intensive care unit today. The confluence of many factors contributes to the deterioration of patients' condition in septic shock. Increased levels of nitric oxide, in part, mediate the cardiovascular effects of septic shock. Nitric oxide is major mediator of vasodilation and hypotension as well as myocardial depression. It also contributes to decreased production and release of endogenous vasopressin. Vasopressin effects are actualized by stimulation of V1, V2, and V3 receptors located in various parts of the body. The response is dose dependent. Endogenous vasopressin and angiotensin II act synergistically to preserve and restore blood pressure levels. Decreased circulating vasopressin contributes to adrenal insufficiency via hypothalamic-pituitary-adrenal axis suppression and increased catecholamine resistance to vasopressors. Exogenous vasopressin supplementation in physiologic doses has been shown to improve blood pressure levels and decrease vasopressor needs in patients with septic shock.

A method to determine spatial access to specialized palliative care services using GIS

Background

Providing palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular.

Methods

Catchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care.

Results

Whilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care.

Conclusion

Strategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners – and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems.

Inferior vena cava diameter correlates with invasive hemodynamic measures in mechanically ventilated intensive care unit patients with sepsis

Early optimization of fluid status is of central importance in the treatment of critically ill patients. This study aims to investigate whether inferior vena cava (IVC) diameters correlate with invasively assessed hemodynamic parameters and whether this approach may thus contribute to an early, non-invasive evaluation of fluid status. Thirty mechanically ventilated patients with severe sepsis or septic shock (age 60 +/- 15 years; APACHE-II score 31 +/- 8; 18 male) were included. IVC diameters were measured throughout the respiratory cycle using transabdominal ultrasonography. Consecutively, volume-based hemodynamic parameters were determined using the single-pass thermal transpulmonary dilution technique. This was a prospective study in a tertiary care academic center with a 24-bed medical intensive care unit (ICU) and a 14-bed anesthesiological ICU. We found a statistically significant correlation of both inspiratory and expiratory IVC diameter with central venous pressure (p = 0.004 and p = 0.001, respectively), extravascular lung water index (p = 0.001, p < 0.001, respectively), intrathoracic blood volume index (p = 0.026, p = 0.05, respectively), the intrathoracic thermal volume (both p < 0.001), and the PaO(2)/FiO(2) oxygenation index (p = 0.007 and p = 0.008, respectively). In this study, IVC diameters were found to correlate with central venous pressure, extravascular lung water index, intrathoracic blood volume index, the intrathoracic thermal volume, and the PaO(2)/FiO(2) oxygenation index. Therefore, sonographic determination of IVC diameter seems useful in the early assessment of fluid status in mechanically ventilated septic patients. At this point in time, however, IVC sonography should be used only in addition to other measures for the assessment of volume status in mechanically ventilated septic patients.

Prompt antibiotic administration and goal-directed hemodynamic support in patients with severe sepsis and septic shock

PURPOSE OF REVIEW

Treatment protocols targeting the rapid administration of appropriate antibiotics and hemodynamic support are now recognized as a key measure in the initial care of patients presenting with severe sepsis and septic shock. Strong evidence exists showing that time parameters, particularly in the emergency department, are as important as the nature of the treatment administered. The concept of sepsis bundles integrates evidence-based and time-sensitive issues, derived from international sepsis guidelines, to ensure that all eligible patients receive the right treatment as early as possible.

RECENT FINDINGS

Several studies have demonstrated that patients resuscitated according to sepsis bundles had a significantly lower mortality.

SUMMARY

It seems logical that timely and protocolized treatment for patients presenting with severe sepsis and septic shock will impact on outcome. It remains to be shown, however, whether translating evidence into clinical practice will increase adherence to the bundles and positively impact on survival.

Carbon monoxide in sepsis

Despite modern practices in critical care medicine, sepsis or systemic inflammatory response syndrome remains a leading cause of morbidity and mortality in the intensive care unit. Thus, the need to identify new therapeutic tools for the treatment of sepsis is urgent. In this context, carbon monoxide has become a promising therapeutic molecule that can potentially prevent uncontrolled inflammation in sepsis. In humans, carbon monoxide arises endogenously from the degradation of heme by heme oxygenase enzymes. Both endogenously synthesized and exogenously applied carbon monoxide can exert antiinflammatory and antiapoptotic effects in cells and tissues. Based on these properties, carbon monoxide, when applied at low concentration, conferred protection in a variety of cellular and rodent models of sepsis, and furthermore reduced morbidity and mortality in vivo. Therefore, application of carbon monoxide may have a major impact on the future of sepsis treatment. This review summarizes evidence for salutary effects of carbon monoxide in sepsis of various organs, including lung, heart, kidney, liver, and intestine, and discusses the potential translation of the data into human clinical trials.