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Ergin B, Kapucu A, Chawla L, Ince C. Synthetic Angiotensin II ameliorates alterations of systemic hemodynamics, microcirculatory deterioration, and renal damage in septic rats. Microvasc Res 2024; 155:104709. [PMID: 38936768 DOI: 10.1016/j.mvr.2024.104709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Bulent Ergin
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Aysegul Kapucu
- Department of Zoology, Faculty of Science, University of Istanbul, Istanbul, Turkey
| | - Lakhmir Chawla
- UC San Diego Health, University of California, San Diego, United States of America
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
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Kwak H, Kwon WY, Jo YH, Kim S, Suh GJ, Kim KS, Jung YS, Lee HJ, Kim JY. Afebrile status at the time of emergency department visit is associated with delayed antibiotic therapy in patients with sepsis (revised). Am J Emerg Med 2024; 83:69-75. [PMID: 38976929 DOI: 10.1016/j.ajem.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 06/11/2024] [Accepted: 06/16/2024] [Indexed: 07/10/2024] Open
Abstract
OBJECTIVES To determine whether there is a difference in antibiotic administration time and prognosis in afebrile sepsis patients compared to febrile sepsis patients. METHODS This was retrospective multicenter observational study. Data collected from three referral hospitals. Data were collected from May 2014 through February 2016 under the SEPSIS-2 criteria and from March 2016 to April 2020 under the newly released SEPSIS-3 criteria. Patients were divided into two groups based on body temperature: afebrile (<37.3 °C) and febrile (≥37.3 °C). The relationship between initial body temperature and 28-day mortality were analyzed using multivariable logistic regression. The subgroup analysis was conducted on patients with complete Hour-1 bundle performance records. RESULTS We included 4293 patients in this study. Initial body temperatures in 28-day survivors were significantly higher than in 28-day non-survivors (37.5 °C ± 1.2 °C versus 37.1 °C ± 1.2 °C, p < 0.01). Multivariable logistic regression analysis was performed in afebrile and febrile sepsis patients. Adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.76 (95% Confidence interval 1.46-2.12). As a result of performing the Hour-1 bundle, the number of patients who received antibiotics within 1 h was smaller in the afebrile sepsis patients (323/2076, 15.6%) than in the febrile sepsis patients (395/2156, 18.3%) (p = 0.02). In the subgroup analysis of patients with complete Hour-1 bundle performance records adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.68 (95% Confidence interval 1.34-2.11). The febrile sepsis patients received antibiotics faster than the afebrile sepsis patients (175.5 ± 207.9 versus 209.3 ± 277.9, p < 0.01). CONCLUSIONS Afebrile sepsis patients were associated with higher 28-day mortality compared to their febrile counterparts and were delayed in receiving antibiotics. This underscores the need for improved early detection and treatment strategies for the afebrile sepsis patients.
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Affiliation(s)
- Hyeongkyu Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Public Health and Medical Service, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Sola Kim
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea; Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hui Jai Lee
- SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Slek C, Magnin M, Allaouchiche B, Bonnet JM, Junot S, Louzier V, Victoni T. Association between cytokines, nitric oxide, hemodynamic and microcirculation in a porcine model of sepsis. Microvasc Res 2024; 156:104730. [PMID: 39111365 DOI: 10.1016/j.mvr.2024.104730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/07/2024] [Accepted: 08/04/2024] [Indexed: 08/11/2024]
Abstract
Systemic inflammation and hemodynamic or microvascular alterations are a hallmark of sepsis and play a role in organs hypoperfusion and dysfunction. Pimobendan, an inodilator agent, could be an interesting option for inotropic support and microcirculation preservation during shock. The objectives of this study were to evaluate effect of pimobendan on cytokine and nitric oxide (NO) release and investigate whether changes of macro and microcirculation parameters are associated with the release of cytokines and NO in pigs sepsis model. After circulatory failure, induced by intravenous inoculation of live Pseudomonas aeruginosa, eight animals were treated with pimobendan and eight with placebo. Pimobendan did not affect cytokines secretion (TNF-α, IL-6 and IL-10), but decreased time-dependently NO release. Data of macro and microcirculation parameters, NO and TNF- α recorded at the time of circulatory failure (Thypotension) and the time maximum of production cytokines was used for analyses. A positive correlation was observed between TNF-α and cardiac index (r = 0.55, p = 0.03) and a negative with systemic vascular resistance (r = -0.52, p = 0.04). Positive correlations were seen both between IL-10, 30 min after resuscitation (T30min), and systolic arterial pressure (r = 0.57, p = 0.03) and cardiac index (r = 0.67, p = 0.01), and also between IL-6, taken 2 h after resuscitation and systolic arterial pressure (r = 0.53, p = 0.04). Negative correlations were found between IL-10 and lactate, measured resuscitation time (r = -0.58, p = 0.03). Regarding microcirculation parameters, we observed a positive correlation between IL-6 and IL-10 with the microvascular flow index (r = 0.52, p = 0.05; r = 0.84, p = 0.0003) and a negative correlation with the heterogeneity index with TNF-α and IL-10 (r = -0.51, p = 0.05; r = -0.74, p = 0.003) respectively. NO derivatives showed a positive correlation with temperature gradient (r = 0.54, p = 0.04). Pimobendan did not show anti-inflammatory effects in cytokines release. Our results also, suggest changes of macro- and microcirculation are associated mainly with low levels of IL-10 in sepsis.
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Affiliation(s)
- Charlotte Slek
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France.
| | - Mathieu Magnin
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France.
| | - Bernard Allaouchiche
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France; Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Jeanne Marie Bonnet
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France.
| | - Stéphane Junot
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France.
| | - Vanessa Louzier
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France.
| | - Tatiana Victoni
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis-, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy-l'Étoile, France.
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Eltobgy M, Johns F, Farkas D, Leuenberger L, Cohen SP, Ho K, Karow S, Swoope G, Pannu S, Horowitz JC, Mallampalli RK, Englert JA, Bednash JS. Longitudinal transcriptomic analysis reveals persistent enrichment of iron homeostasis and erythrocyte function pathways in severe COVID-19 ARDS. Front Immunol 2024; 15:1397629. [PMID: 39161760 PMCID: PMC11330807 DOI: 10.3389/fimmu.2024.1397629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/17/2024] [Indexed: 08/21/2024] Open
Abstract
Introduction The acute respiratory distress syndrome (ARDS) is a common complication of severe COVID-19 and contributes to patient morbidity and mortality. ARDS is a heterogeneous syndrome caused by various insults, and results in acute hypoxemic respiratory failure. Patients with ARDS from COVID-19 may represent a subgroup of ARDS patients with distinct molecular profiles that drive disease outcomes. Here, we hypothesized that longitudinal transcriptomic analysis may identify distinct dynamic pathobiological pathways during COVID-19 ARDS. Methods We identified a patient cohort from an existing ICU biorepository and established three groups for comparison: 1) patients with COVID-19 ARDS that survived hospitalization (COVID survivors, n = 4), 2) patients with COVID-19 ARDS that did not survive hospitalization (COVID non-survivors, n = 5), and 3) patients with ARDS from other causes as a control group (ARDS controls, n = 4). RNA was isolated from peripheral blood mononuclear cells (PBMCs) at 4 time points (Days 1, 3, 7, and 10 following ICU admission) and analyzed by bulk RNA sequencing. Results We first compared transcriptomes between groups at individual timepoints and observed significant heterogeneity in differentially expressed genes (DEGs). Next, we utilized the likelihood ratio test to identify genes that exhibit different patterns of change over time between the 3 groups and identified 341 DEGs across time, including hemoglobin subunit alpha 2 (HBA1, HBA2), hemoglobin subunit beta (HBB), von Willebrand factor C and EGF domains (VWCE), and carbonic anhydrase 1 (CA1), which all demonstrated persistent upregulation in the COVID non-survivors compared to COVID survivors. Of the 341 DEGs, 314 demonstrated a similar pattern of persistent increased gene expression in COVID non-survivors compared to survivors, associated with canonical pathways of iron homeostasis signaling, erythrocyte interaction with oxygen and carbon dioxide, erythropoietin signaling, heme biosynthesis, metabolism of porphyrins, and iron uptake and transport. Discussion These findings describe significant differences in gene regulation during patient ICU course between survivors and non-survivors of COVID-19 ARDS. We identified multiple pathways that suggest heme and red blood cell metabolism contribute to disease outcomes. This approach is generalizable to larger cohorts and supports an approach of longitudinal sampling in ARDS molecular profiling studies, which may identify novel targetable pathways of injury and resolution.
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Affiliation(s)
- Moemen Eltobgy
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Finny Johns
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Daniela Farkas
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Laura Leuenberger
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Sarah P. Cohen
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Kevin Ho
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Sarah Karow
- Clinical Trials Management Office, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Gabrielle Swoope
- Clinical Trials Management Office, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Sonal Pannu
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Jeffrey C. Horowitz
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Rama K. Mallampalli
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Joshua A. Englert
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
| | - Joseph S. Bednash
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
- The Center for RNA Biology, College of Medicine, The Ohio State University, Columbus, OH, United States
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5
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Aghayan AH, Mirazimi Y, Fateh K, Keshtkar A, Rafiee M, Atashi A. Therapeutic Effects of Mesenchymal Stem Cell-Derived Extracellular Vesicles in sepsis: a Systematic Review and Meta-Analysis of Preclinical Studies. Stem Cell Rev Rep 2024; 20:1480-1500. [PMID: 38814410 DOI: 10.1007/s12015-024-10741-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Sepsis is a life-threatening disorder with no definitive cure. Preclinical studies suggest that extracellular vesicles derived from mesenchymal stromal cells (EV-MSCs) can mitigate inflammatory conditions, potentially leading to increased survival and reduced organ dysfunction during sepsis. Our aim to conduct this systematic review and meta-analysis is assessing the EV-MSCs therapeutic efficacy in sepsis. METHODS PubMed, Embase, Scopus, WOS and ProQuest databases and also Google Scholar search engine were searched for published articles. We used hazard ratio (HR) and standardized mean difference (SMD) as effect sizes to evaluate the therapeutic effect of EV-MSCs on survival rate and determine their effect on reducing organ dysfunction, respectively. Finally, we employed GRADE tool for preclinical animal studies to evaluate certainty of the evidence. RESULTS 30 studies met the inclusion criteria for our article. Our meta-analysis results demonstrate that animals treated with MSC-EVs have better survival rate than untreated animals (HR = 0.33; 95% CI: 0.27-0.41). Our meta-analysis suggests that EV-MSCs can reduce organ dysfunctions in sepsis, such as the lung, kidney, and liver. Additionally, EV-MSCs decrease pro-inflammatory mediators like TNF-α, IL-1β, and IL-6. CONCLUSION Our results indicate that EV-MSCs can be as promising therapy for sepsis management in animal models and leading to increased survival rate and reduced organ dysfunction. Furthermore, our study introduces a novel tool for risk of bias assessment and provides recommendations based on various analysis. Future studies with aiming to guide clinical translation can utilize the results of this article to establish stronger evidence for EV-MSC effectiveness.
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Affiliation(s)
- Amir Hossein Aghayan
- Student Research Committee, Department of Medical Laboratory Sciences, School of Paramedical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Yasin Mirazimi
- Student Research Committee, Department of Medical Laboratory Sciences, School of Paramedical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Kosar Fateh
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbasali Keshtkar
- Department of Health Sciences Education Development, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rafiee
- Department of Medical Laboratory Sciences, School of Paramedical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Amir Atashi
- Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Shahroud University of Medical Sciences, Shahroud, Iran.
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Ribeiro-do-Valle CC, Luz AG, Pacagnella RC, Cecatti JG. Surviving maternal sepsis: Clinical, laboratory, and treatment features. Int J Gynaecol Obstet 2024; 166:753-759. [PMID: 38379448 DOI: 10.1002/ijgo.15440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To describe clinical, laboratory, and antibiotic treatment characteristics in pregnant or recently pregnant women diagnosed with maternal sepsis. METHODS A retrospective cohort study was conducted in a Brazilian tertiary hospital from March 2014 until February 2018. The hospital implemented a Sepsis Protocol, based on the Brazilian Ministry of Health recommendation. All women who were pregnant or recently pregnant (up to 42 days postpartum), and who presented with suspected sepsis were included. Unconfirmed infections were excluded. Three hundred sixty-five women were included and divided into three groups according to sepsis severity (SEPSIS-2): sepsis, severe sepsis, and septic shock. Clinical, laboratory, and management characteristics were described and compared. RESULTS Pregnancy-related and respiratory tract infections were the greater causes of maternal sepsis, and the urinary tract was the major cause of septic shock. We found almost total compliance with blood culture sample collection, and samples were positive in 10.8% of the cases, and in 41% of septic shock patients. Escherichia coli was the most common pathogen found and it was resistant to third-generation cephalosporins in none of the blood cultures and 3.3% of the urine cultures. Using the AWaRe (Access, Watch and Reserve) classification groups of antibiotics, Access and Watch antibiotics were used in virtually all women. We did not find any fatal maternal outcomes. CONCLUSION Maternal sepsis is seldom the result of resistant microorganisms in this setting and the use of Access group antibiotics is widely possible. Health professionals' awareness of and institutional policies for maternal sepsis are crucial to its adequate treatment and better outcomes.
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Affiliation(s)
| | - Adriana G Luz
- Department of Obstetrics and Gynecology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - José G Cecatti
- Department of Obstetrics and Gynecology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
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Bilsen MP, Conroy SP, Schneeberger C, Platteel TN, van Nieuwkoop C, Mody L, Caterino JM, Geerlings SE, Köves B, Wagenlehner F, Kunneman M, Visser LG, Lambregts MMC. A reference standard for urinary tract infection research: a multidisciplinary Delphi consensus study. THE LANCET. INFECTIOUS DISEASES 2024; 24:e513-e521. [PMID: 38458204 DOI: 10.1016/s1473-3099(23)00778-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/15/2023] [Accepted: 12/07/2023] [Indexed: 03/10/2024]
Abstract
The absence of a consensus-based reference standard for urinary tract infection (UTI) research adversely affects the internal and external validity of diagnostic and therapeutic studies. This omission hinders the accumulation of evidence for a disease that imposes a substantial burden on patients and society, particularly in an era of increasing antimicrobial resistance. We did a three-round Delphi study involving an international, multidisciplinary panel of UTI experts (n=46) and achieved a high degree of consensus (94%) on the final reference standard. New-onset dysuria, urinary frequency, and urinary urgency were considered major symptoms, and non-specific symptoms in older patients were not deemed indicative of UTI. The reference standard distinguishes between UTI with and without systemic involvement, abandoning the term complicated UTI. Moreover, different levels of pyuria were incorporated in the reference standard, encouraging quantification of pyuria in studies done in all health-care settings. The traditional bacteriuria threshold (105 colony-forming units per mL) was lowered to 104 colony-forming units per mL. This new reference standard can be used for UTI research across many patient populations and has the potential to increase homogeneity between studies.
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Affiliation(s)
- Manu P Bilsen
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands.
| | - Simon P Conroy
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Caroline Schneeberger
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, Netherlands; Department of Public Health and Primary Care, The Hague Health Campus, Leiden University Medical Center, The Hague, Netherlands
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Geriatrics Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Suzanne E Geerlings
- Amsterdam UMC, Department of Internal Medicine, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Bela Köves
- Department of Urology, University of Szeged, Szeged, Hungary
| | - Florian Wagenlehner
- Clinic for Urology, Paediatric Urology and Andrology, Justus Liebig University, Giessen, Germany
| | - Marleen Kunneman
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands; Knowledge and Evaluation Research Unit, Mayo Clinic Rochester, Rochester, MN, USA
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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8
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Han D, Kang SH, Um YW, Kim HE, Hwang JE, Lee JH, Jo YH, Jung YS, Lee HJ. Temperature trajectories and mortality in hypothermic sepsis patients. Am J Emerg Med 2024; 84:18-24. [PMID: 39047342 DOI: 10.1016/j.ajem.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/07/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVES Hypothermia is associated with poor outcomes in sepsis patients, and hypothermic sepsis patients exhibit temperature alterations during initial treatment. The objective of this study was to classify hypothermic sepsis patients based on body temperature trajectories and investigate the associations of these patients with 28-day mortality. METHODS This was a retrospective analysis of prospectively collected data from adult sepsis or septic shock patients who visited three emergency departments between August 2014 and December 2019. Hypothermic sepsis was defined as an initial body temperature <36 °C. delta temperature was calculated by subtracting the 0 h body temperature from the 6 h body temperature. We divided the patients into three groups according to delta temperature: Group A (delta temperature ≤ 0), Group B (0 < delta temperature ≤ 1) and Group C (delta temperature > 1). The primary outcome was 28-day mortality, and a multivariable Cox proportional hazards regression model was generated. RESULTS Among 7344 patients with sepsis or septic shock, 325 hypothermic patients were included in the analysis, and the overall mortality rate was 36%. While initial body temperature was not different between survivors and nonsurvivors, survivors exhibited a higher body temperature at 6 h. The 28-day mortality rates for Groups A, B and C were 53.1%, 36.0%, and 30.0%, respectively, and Group A had significantly higher mortality than Group C did (p < 0.05). Group C demonstrated a 44.2% decrease in 28-day mortality compared to Group A (adjusted hazard ratio of 0.558; 95% confidence interval of 0.330-0.941). CONCLUSIONS In hypothermic sepsis patients, an increase of 1 °C or more in body temperature after the initial 6 h is associated with a reduced risk of 28-day mortality.
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Affiliation(s)
- Dongkwan Han
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Seung Hyun Kang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Young Woo Um
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Hee Eun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ji Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Republic of Korea.
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Republic of Korea
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9
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Engoren M, Arslanian-Engoren C. Risk factors for readmission after sepsis and its association with mortality. Heart Lung 2024; 68:195-201. [PMID: 39032421 DOI: 10.1016/j.hrtlng.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Sepsis is associated with an approximately 20 % 30-day readmission rate and with subsequent mortality. OBJECTIVES To determine the demographics, comorbidities that had been documented prior to sepsis onset, processes of care, commonly administered laboratory tests measured near discharge, and post-sepsis infections that may be associated with readmission and, secondarily, whether readmission is an independent risk factor for 90-day mortality. METHODS Using a database of patients who met Sepsis-3 criteria divided into Construction and Validation groups, we used logistic regression to estimate the factors independently associated with readmission within 30 days after discharge and proportional hazard regression to estimate the factors independently associated with 90-day mortality. RESULTS Of the 30,798 patients ≥ 18 years at our combined referral and community hospital and were discharged alive who met Sepsis-3 criteria between July 10, 2009 and September 7, 2019, 5943 (19 %) were readmitted within 30 days. Thirteen thousand, four hundred forty-four (44 %) of the patients were female, 25,293 (82 %) White, 3523 (11 %) Black, and the mean age was 59 ± 17 years. Among the readmitted patients, 894 (15 %) died within 90 days from the original discharge compared to 11 % (p < 0.001) who had not been readmitted. Seven comorbidities, five processes of care (presepsis platelet transfusion, postsepsis platelet transfusion, operation, ICU length of stay, and hospital length of stay), five culture results, two discharge laboratory values, and discharge location were associated with readmission. The model had good discrimination, 0.770 ± 0.004 (Construction Group) and 0.748 ± 0.006 (Validation Group) and good relevancy (area under the precision recall curve), 0.390 ± 0.004 (Construction group) and 0.476 ± 0.005 (Validation group). Readmission within 30 days was independently associated with a 56 % higher risk of death (HR=1.562, 95 % CI=1.434, 1.703, p < 0.001) within 90 days from discharge. CONCLUSIONS Comorbidities, abnormal laboratory values, processes of care, and post-sepsis onset culture results, but not demographic characteristics, were associated with 30-day readmission. Readmission was associated with 90-day mortality.
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Affiliation(s)
- Milo Engoren
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI 48109, United States.
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Carelli S, Posteraro B, Torelli R, De Carolis E, Vallecoccia MS, Xhemalaj R, Cutuli SL, Tanzarella ES, Dell'Anna AM, Lombardi G, Cammarota F, Caroli A, Grieco DL, Sanguinetti M, Antonelli M, De Pascale G. Prognostic value of serial (1,3)-β-D-glucan measurements in ICU patients with invasive candidiasis. Crit Care 2024; 28:236. [PMID: 38997712 PMCID: PMC11241937 DOI: 10.1186/s13054-024-05022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/06/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND To determine whether a decrease in serum (1,3)-β-D-glucan (BDG) was associated with reduced mortality and to investigate the performance of BDG downslope in predicting clinical outcome in invasive candidiasis. METHODS Observational cohort study in ICU patients over a ten-year period (2012-2022) in Italy. Proven invasive candidiasis with at least 2 BDG determinations were considered. RESULTS In the study population of 103 patients (age 47 [35-62] years, SAPS II score 67 [52-77]) 68 bloodstream and 35 intrabdominal infections were recorded. Serial measurements showed that in 54 patients BDG decreased over time (BDG downslope group) while in 49 did not (N-BDG downslope group). Candida albicans was the pathogen most frequently isolated (61%) followed by C. parapsilosis (17%) and C. glabrata (12%), in absence of any inter-group difference. Invasive candidiasis related mortality was lower in BDG downslope than in N-BDG downslope group (17% vs 53%, p < 0.01). The multivariate Cox regression analysis showed the association of septic shock at infection occurrence and chronic liver disease with invasive candidiasis mortality (HR [95% CI] 3.24 [1.25-8.44] p = 0.02 and 7.27 [2.33-22.66] p < 0.01, respectively) while a BDG downslope was the only predictor of survival (HR [95% CI] 0.19 [0.09-0.43] p < 0.01). The area under the receiver operator characteristic curve for the performance of BDG downslope as predictor of good clinical outcome was 0.74 (p = 0.02) and our model showed that a BDG downslope > 70% predicted survival with both specificity and positive predictive value of 100%. CONCLUSIONS A decrease in serum BDG was associated with reduced mortality and a steep downslope predicted survival with high specificity in invasive candidiasis.
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Affiliation(s)
- Simone Carelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy.
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Brunella Posteraro
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Torelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena De Carolis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Sole Vallecoccia
- Anesthesia and Intensive Care Unit, Department of Emergency and Critical Care, Santa Maria Nuova Hospital, Florence, Italy
| | - Rikardo Xhemalaj
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Maria Dell'Anna
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabiola Cammarota
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Caroli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Kim J, Phan C, Adams J, Cortes-Puch I, Stocking J, Liu A, Ren Y, Taylor S, Yoneda KY. Endobronchial Phenylephrine in Airway Bleeding During Bronchoscopy Does not Cause Hypertension: A Retrospective Observational Study. J Bronchology Interv Pulmonol 2024; 31:e0968. [PMID: 38745445 PMCID: PMC11101147 DOI: 10.1097/lbr.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 03/11/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Bleeding is a known complication during bronchoscopy, with increased incidence in patients undergoing a more invasive procedure. Phenylephrine is a potent vasoconstrictor that can control airway bleeding when applied topically and has been used as an alternative to epinephrine. The clinical effects of endobronchial phenylephrine on systemic vasoconstriction have not been clearly evaluated. Here, we compared the effects of endobronchial phenylephrine versus cold saline on systemic blood pressure. METHODS In all, 160 patients who underwent bronchoscopy and received either endobronchial phenylephrine or cold saline from July 1, 2017 to June 30, 2022 were included in this retrospective observational study. Intra-procedural blood pressure absolute and percent changes were measured and compared between the 2 groups. RESULTS There were no observed statistical differences in blood pressure changes between groups. The median absolute change between the median and the maximum intra-procedural systolic blood pressure in the cold saline group was 29 mm Hg (IQR 19 to 41) compared with 31.8 mm Hg (IQR 18 to 45.5) in the phenylephrine group. The corresponding median percent changes in SBP were 33.6 % (IQR 18.8 to 39.4) and 28% (IQR 16.8 to 43.5) for the cold saline and phenylephrine groups, respectively. Similarly, there were no statistically significant differences in diastolic and mean arterial blood pressure changes between both groups. CONCLUSIONS We found no significant differences in median intra-procedural systemic blood pressure changes comparing patients who received endobronchial cold saline to those receiving phenylephrine. Overall, this argues for the vascular and systemic safety of phenylephrine for airway bleeding as a reasonable alternative to epinephrine.
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Affiliation(s)
- Jeremy Kim
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Chinh Phan
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Jason Adams
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
- University of California, Davis Health IT Data Center of Excellence (Data CoE), Sacramento, CA, USA
| | - Irene Cortes-Puch
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
- University of California, Davis Health IT Data Center of Excellence (Data CoE), Sacramento, CA, USA
| | - Jaqueline Stocking
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Anna Liu
- University of California, Davis Health IT Data Center of Excellence (Data CoE), Sacramento, CA, USA
| | - Yunyi Ren
- Department of Public Health Sciences, Division of Biostatistics, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Sandra Taylor
- Department of Public Health Sciences, Division of Biostatistics, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Ken Y. Yoneda
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
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Siqueira Santos MM, Sganzerla D, Pereira IJ, Rosa RG, Granja C, Teixeira C, Azevedo L. Long-Term Mortality and Health-Related Quality of Life After Continuous Versus Intermittent Renal Replacement Therapy in ICU Survivors: A Secondary Analysis of the Quality of Life After ICU Study. J Intensive Care Med 2024; 39:636-645. [PMID: 38196312 PMCID: PMC11151712 DOI: 10.1177/08850666231224392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Purpose: We assessed long-term outcomes in intensive care unit (ICU) survivors with acute kidney injury (AKI) submitted to intermittent or continuous renal replacement therapy (RRT) for comparisons between groups. Methods: The multicenter prospective cohort study included 195 adult ICU survivors with an ICU stay >72 h in 10 ICUs that had at least one episode of AKI treated with intermittent RRT (IRRT) or continuous RRT (CRRT) during ICU stay. The main outcomes were mortality and health-related quality of life (HRQoL). Hospital readmissions and physical dependence were also assessed. Results: Regarding RRT, 83 (42.6%) patients received IRRT and 112 (57.4%) received CRRT. Despite the similarity regarding sociodemographic characteristics, pre-ICU state of health and type of admission between groups, the risk of death (23.5% vs 42.7%; P < .001), the prevalence of sepsis (60.7%) and acute respiratory distress syndrome (17%) were higher at ICU admission among CRRT patients. The severity of critical illness was higher among CRRT patients, regarding the need for mechanical ventilation (75.0% vs 50.6%, P = .002) and vasopressors (91.1% vs 63.9%, P < .001). One year after ICU discharge, 67 of 195 ICU survivors died (34.4%) and, after adjustment for confounders, there were no significant differences in mortality when comparing IRRT and CRTT patients (34.9% vs 33.9%; P = .590), on HRQoL in both physical (41.9% vs 42.2%; P = .926) and mental dimensions (57.6% vs 56.6%; P = .340), and on the number of hospital readmissions and physical dependence. Conclusions: Our study suggests that among ICU survivors RRT modality (IRRT vs CRRT) in the ICU does not impact long-term outcomes after ICU discharge.
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Affiliation(s)
- Mariana Martins Siqueira Santos
- MEDCIDS – Medicina da Comunidade, Informação e Decisão em Saúde, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS@RISE – Centre for Health Technology and Services Research & Associate Laboratory – Health Research Network, University of Porto, Porto, Portugal
| | | | - Isabel Jesus Pereira
- MEDCIDS – Medicina da Comunidade, Informação e Decisão em Saúde, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Polyvalent Intensive Care Medicine Service, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
- CriticalMed – Critical Care & Emergency Medicine, CINTESIS – Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Regis Goulart Rosa
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Research Unit, INOVA Medical, Porto Alegre, Brazil
| | - Cristina Granja
- Faculty of Medicine, University of Porto, Porto, Portugal
- CriticalMed – Critical Care & Emergency Medicine, CINTESIS – Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Intensive Care Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Anaesthesiology Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Cassiano Teixeira
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Intensive Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Post-Graduation Program in Rehabilitation Sciences, Universidade Federalde Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Luís Azevedo
- MEDCIDS – Medicina da Comunidade, Informação e Decisão em Saúde, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS@RISE – Centre for Health Technology and Services Research & Associate Laboratory – Health Research Network, University of Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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13
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Thampi SJ, Basheer A, Thomas K. Calcitriol in Sepsis-A Single-Centre Randomised Control Trial. J Clin Med 2024; 13:3823. [PMID: 38999389 PMCID: PMC11242284 DOI: 10.3390/jcm13133823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis is a significant cause of hospital admission and the leading reason for admission to the ICU and is associated with high mortality. Vitamin D has shown promising immunomodulatory effects by upregulating the antimicrobial peptide, cathelicidin. However, previous studies analysing the use of calcitriol in sepsis have shown variable results and did not utilise APACHE II (Acute Physiology and Chronic Health Evaluation II) scores as endpoints. This study evaluates the efficacy of intramuscular calcitriol in patients admitted to the ICU with sepsis, focusing on its impact on APACHE II scores. The primary aim was to determine if intramuscular calcitriol improved APACHE II scores from day 1 to day 7 or discharge from the ICU, whichever was earlier. Secondary outcomes included 28-day mortality, ventilator days, vasopressor days, ICU stay length, adverse events, and hospital-acquired infections in ICU patients. Methods: This was a triple-blinded phase III randomised control trial. A total of 152 patients with suspected sepsis were block-randomised to receive either intramuscular calcitriol (300,000 IU) (n = 76) or a placebo (n = 76). The trial was registered with the Clinical Trials Registry-India (CTRI No: CTRI 2019/01/17066) following ethics committee approval and was not funded. Results: There was no significant difference in APACHE II scores between the calcitriol and placebo groups from day 1 to day 7 (p = 0.382). There were no significant changes in 28-day mortality (14.4% vs. 17%, p = 0.65), number of days on a ventilator (5 vs. 5, p = 0.84), number of days on vasopressors (3 vs. 3, p = 0.98), length of ICU stay (10 days vs. 11 days, p = 0.78), adverse events (27.6% vs. 19.7%, p = 0.25), and hospital-acquired infections (17.1% vs. 15.8%, p = 0.82). Conclusions: There was no effect of intramuscular calcitriol in patients admitted to the ICU with sepsis.
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Affiliation(s)
- Siddhant Jeevan Thampi
- Department of Acute Medicine, Sheffield Teaching Hospitals NHS Trust, Sheffield S5 7AU, UK
| | - Aneesh Basheer
- Department of Internal Medicine, Dr. Moopen’s Medical College, Wayanad 673577, India;
| | - Kurien Thomas
- Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Puducherry 605014, India;
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14
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Peng KW, Chang ML, Chien RN, Chen YC, Tian YC, Peng YS, Huang HC, Fang JT, Lee FY, Yang CW, Tsai MH. Pulmonary Vascular Permeability and Extravascular Lung Water Index in Patients with Liver Cirrhosis and Septic Shock. J Clin Med 2024; 13:3796. [PMID: 38999366 PMCID: PMC11242845 DOI: 10.3390/jcm13133796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/08/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Backgrounds and Aims: Patients with cirrhosis are susceptible to sepsis and septic shock. Cirrhotic patients also have increased capillary permeability and are prone to developing volume overload. Patients with septic shock may have an enhanced pulmonary vascular permeability index (PVPI) and extravascular lung water index (EVLWI), both of which are associated with an unfavorable prognosis. It is plausible that pre-existing hyperpermeability may deteriorate when cirrhotic patients develop septic shock. However, it remains unknown whether PVPI and EVLWI can predict the prognosis of cirrhotic patients with septic shock. Pulse Indicator Continuous Cardiac Output (PiCCO) is an established tool to measure PVPI and EVLWI. Therefore, we conducted this retrospective study to investigate the prognostic significance of PVPI and EVLWI in cirrhotic patients with septic shock using PiCCO monitoring. Methods: We included 83 patients with liver cirrhosis and septic shock. EVLW indexed to actual body weight (aEVLWI), EVLW indexed to predicted body weight (pEVLWI), PVPI, disease severity scores, and other biomarkers were analyzed. We collected the PiCCO data on the first 2 days. Results: The overall 28-day mortality was 43.4%. The values of PVPI, aEVLWI, and pEVLWI on day 2 (PVPID2, aEVLWID2, EVLWID2) were significantly higher in non-survivors. The discriminating power of PVPID2 and EVLWID2 to predict 28-day mortality was tested using the area under a ROC curve. The areas under ROC curves (mean ± SEM) were 0.713 ± 0.061 and 0.650 ± 0.063 for PVPID2 and pEVLWID2. In the multivariate analysis, PVPID2, bilirubin, and lactate were independent factors which predicted 28-day mortality. Conclusions: Higher levels of PVPID2 and pEVLWID2 are associated with higher 28-day mortality rates in cirrhotic patients with septic shock. PVPI and pEVLWI may be useful to guide fluid management in this clinical setting.
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Affiliation(s)
- Kang-Wei Peng
- Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (K.-W.P.); (M.-L.C.)
| | - Ming-Ling Chang
- Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (K.-W.P.); (M.-L.C.)
| | - Rong-Nan Chien
- Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (K.-W.P.); (M.-L.C.)
| | - Yung-Chang Chen
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (Y.-C.T.); (C.-W.Y.)
| | - Ya-Chung Tian
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (Y.-C.T.); (C.-W.Y.)
| | - Yun-Shing Peng
- Department of Internal Medicine, Chang Gung Memorial Hospital, Chia-Yi 613, Taiwan
| | - Hui-Chun Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine, Yang-Ming University School of Medicine, Taipei 112, Taiwan; (H.-C.H.)
- Division of General Medicine, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine, Yang-Ming University School of Medicine, Taipei 112, Taiwan
| | - Ji-Tseng Fang
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (Y.-C.T.); (C.-W.Y.)
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine, Yang-Ming University School of Medicine, Taipei 112, Taiwan; (H.-C.H.)
| | - Chih-Wei Yang
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (Y.-C.T.); (C.-W.Y.)
| | - Ming-Hung Tsai
- Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (K.-W.P.); (M.-L.C.)
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Lehner GF, Tobiasch AK, Perschinka F, Mayerhöfer T, Waditzer M, Haller V, Zassler B, Maier S, Ulmer H, Joannidis M. Associations of tissue factor and tissue factor pathway inhibitor with organ dysfunctions in septic shock. Sci Rep 2024; 14:14468. [PMID: 38914630 PMCID: PMC11196691 DOI: 10.1038/s41598-024-65262-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024] Open
Abstract
Coagulopathy, microvascular alterations and concomitant organ dysfunctions are hallmarks of sepsis. Attempts to attenuate coagulation activation with an inhibitor of tissue factor (TF), i.e. tissue factor pathway inhibitor (TFPI), revealed no survival benefit in a heterogenous group of sepsis patients, but a potential survival benefit in patients with an international normalized ratio (INR) < 1.2. Since an increased TF/TFPI ratio determines the procoagulant activity specifically on microvascular endothelial cells in vitro, we investigated whether TF/TFPI ratio in blood is associated with INR alterations, organ dysfunctions, disseminated intravascular coagulation (DIC) and outcome in septic shock. Twenty-nine healthy controls (HC) and 89 patients with septic shock admitted to a tertiary ICU were analyzed. TF and TFPI in blood was analyzed and related to organ dysfunctions, DIC and mortality. Patients with septic shock had 1.6-fold higher levels of TF and 2.9-fold higher levels of TFPI than HC. TF/TFPI ratio was lower in septic shock compared to HC (0.003 (0.002-0.005) vs. 0.006 (0.005-0.008), p < 0.001). Non-survivors had higher TFPI levels compared to survivors (43038 (29354-54023) vs. 28041 (21675-46582) pg/ml, p = 0.011). High TFPI levels were associated with acute kidney injury, liver dysfunction, DIC and disease severity. There was a positive association between TF/TFPI ratio and troponin T (b = 0.531 (0.309-0.754), p < 0.001). A high TF/TFPI ratio is exclusively associated with myocardial injury but not with other organ dysfunctions. Systemic TFPI levels seem to reflect disease severity. These findings point towards a pathophysiologic role of TF/TFPI in sepsis-induced myocardial injury.
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Affiliation(s)
- Georg Franz Lehner
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Katharina Tobiasch
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabian Perschinka
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Timo Mayerhöfer
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Markus Waditzer
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Viktoria Haller
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Birgit Zassler
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Sarah Maier
- Institute of Medical Statistics and Informatics, Medical University Innsbruck, Schöpfstrasse 41/1, 6020, Innsbruck, Austria
| | - Hanno Ulmer
- Institute of Medical Statistics and Informatics, Medical University Innsbruck, Schöpfstrasse 41/1, 6020, Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Bowyer L, Cutts BA, Barrett HL, Bein K, Crozier TM, Gehlert J, Giles ML, Hocking J, Lowe S, Lust K, Makris A, Morton MR, Pidgeon T, Said J, Tanner HL, Wilkinson L, Wong M. SOMANZ position statement for the investigation and management of sepsis in pregnancy 2023. Aust N Z J Obstet Gynaecol 2024. [PMID: 38922822 DOI: 10.1111/ajo.13848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static. AIMS To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis. MATERIALS AND METHODS A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement. RESULTS This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes. CONCLUSION Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.
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Affiliation(s)
- Lucy Bowyer
- Department of Obstetrics, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Briony A Cutts
- Department of Obstetric Medicine, Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, Victoria, Australia
| | - Helen L Barrett
- Department of Obstetric Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Kendall Bein
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Timothy M Crozier
- Department of Intensive Care, Monash Health, Department of Intensive Care Services, Eastern Health, Melbourne, Victoria, Australia
| | - Jessica Gehlert
- Department of Obstetrics and Gynaecology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Michelle L Giles
- Department of Obstetrics and Gynaecology, Department of Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Jennifer Hocking
- Australian Breastfeeding Association, Melbourne, Victoria, Australia
| | - Sandra Lowe
- Department of Obstetric Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Karin Lust
- Department of Obstetric Medicine, Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Angela Makris
- Department of Nephrology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Mark R Morton
- Women's and Babies Division, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Tara Pidgeon
- Emergency Department, St Vincent's Private Hospital, Toowoomba, Queensland, Australia
| | - Joanne Said
- Department of Maternal Fetal Medicine, Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, Victoria, Australia
| | - Helen L Tanner
- Department of Obstetric Medicine, Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Lucille Wilkinson
- Department of Medicine, Northland District Health Board, Auckland, New Zealand
| | - Maggie Wong
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
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17
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You WJ, Lian TT, Qian O, Wei JJ, Zhuang ZH. Retrospective study of 189 cases of acute perforated peptic ulcer: safety and efficacy of over-the-scope-clip based endoscopic closure. Surg Endosc 2024:10.1007/s00464-024-10982-w. [PMID: 38886229 DOI: 10.1007/s00464-024-10982-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/02/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND To compare the clinical outcomes in patients with acute perforated peptic ulcer (PPU) treated with over-the-scope clip (OTSC), non-surgical, and surgical interventions, and to explore the effectiveness and safety of OTSC closure. METHODS Hospital stay, antibiotic use, diet resumption time, and mortality rate were analyzed retrospectively. Binary Logistic regression analysis was used to identify the risk factors influencing PPU complicated with sepsis. RESULTS Patients were divided into three treatment groups: OTSC (n = 62), non-surgical (n = 72), and surgical (n = 55) groups. The median time (IQR) from symptom onset to admission was 9.0 (4-23) h. 88.71% (55/62) of the patients in In the OTSC group underwent OTSC closure within 24 h (median [IQR] time: 14.5 [7.00-30.25] h). The perforation diameters in the OTSC and surgical groups were 9.87 mm ± 5.97 mm and 8.55 mm ± 6.17 mm, respectively. The median (IQR) hospital stays in the OTSC (9.50 [7.00-12.25] days) and non-surgical group (9.00[7.00-13.00]days) were similar (p > 0.05), but shorter than that in surgical group (12.00[10.00-16.00]days), (p < 0.05). The median duration of antibiotic use was shorter in the OTSC group (7.00[3.00-10.00]) than in the non-surgical group (9.00[7.00-11.00]) and surgical group (11.00[9.00-13.00]) ( p < 0.05); and the time to resume oral feeding was shorter in the OTSC group (4.00[2.00-5.25]) than in the non-surgical group (7.00[6.13-9.00]) and surgical group (8.00[6.53-10.00]), respectively ( p < 0.05). No mortality difference among groups (p = 0.109) was found. Lower albumin level at admission, older age, and elevated creatinine levels were associated with increased sepsis risk, with OR(95%CI) of 0.826 (0.687-0.993), 1.077 (1.005-1.154), and 1.025 (1.006-1.043), respectively (all p < 0.05). CONCLUSION OTSC closure improves clinical outcomes of acute PPU patients without sepsis. Age, hypoalbuminemia, and baseline renal dysfunction increase the risk of sepsis, while mortality was associated with sepsis and multiorgan dysfunction.
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Affiliation(s)
- Wei-Jia You
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Fuzhou, 350004, Fujian, China
| | - Ting-Ting Lian
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Fuzhou, 350004, Fujian, China
| | - Ou Qian
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Fuzhou, 350004, Fujian, China
| | - Jing-Jing Wei
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Fuzhou, 350004, Fujian, China
| | - Ze-Hao Zhuang
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Fuzhou, 350004, Fujian, China.
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18
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Rhee C, Chen T, Kadri SS, Lawandi A, Yek C, Walker M, Warner S, Fram D, Chen HC, Shappell CN, DelloStritto L, Klompas M. Trends in Empiric Broad-Spectrum Antibiotic Use for Suspected Community-Onset Sepsis in US Hospitals. JAMA Netw Open 2024; 7:e2418923. [PMID: 38935374 PMCID: PMC11211962 DOI: 10.1001/jamanetworkopen.2024.18923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024] Open
Abstract
Importance Little is known about the degree to which suspected sepsis drives broad-spectrum antibiotic use in hospitals, what proportion of antibiotic courses are unnecessarily broad in retrospect, and whether these patterns are changing over time. Objective To describe trends in empiric broad-spectrum antibiotic use for suspected community-onset sepsis. Design, Setting, and Participants This cross-sectional study used clinical data from adults admitted to 241 US hospitals in the PINC AI Healthcare Database. Eligible participants were aged 18 years or more and were admitted between 2017 and 2021 with suspected community-onset sepsis, defined by a blood culture draw, lactate measurement, and intravenous antibiotic administration on admission. Exposures Empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) and/or antipseudomonal β-lactam agent use. Main Outcomes and Measures Annual rates of empiric anti-MRSA and/or antipseudomonal β-lactam agent use and the proportion that were likely unnecessary in retrospect based on the absence of β-lactam resistant gram-positive or ceftriaxone-resistant gram-negative pathogens from clinical cultures obtained through hospital day 4. Annual trends were calculated using mixed-effects logistic regression models, adjusting for patient and hospital characteristics. Results Among 6 272 538 hospitalizations (median [IQR] age, 66 [53-78] years; 443 465 male [49.6%]; 106 095 Black [11.9%], 65 763 Hispanic [7.4%], 653 907 White [73.1%]), 894 724 (14.3%) had suspected community-onset sepsis, of whom 582 585 (65.1%) received either empiric anti-MRSA (379 987 [42.5%]) or antipseudomonal β-lactam therapy (513 811 [57.4%]); 311 213 (34.8%) received both. Patients with suspected community-onset sepsis accounted for 1 573 673 of 3 141 300 (50.1%) of total inpatient anti-MRSA antibiotic days and 2 569 518 of 5 211 745 (49.3%) of total antipseudomonal β-lactam days. Between 2017 and 2021, the proportion of patients with suspected sepsis administered anti-MRSA or antipseudomonal therapy increased from 63.0% (82 731 of 131 275 patients) to 66.7% (101 003 of 151 435 patients) (adjusted OR [aOR] per year, 1.03; 95% CI, 1.03-1.04). However, resistant organisms were isolated in only 65 434 cases (7.3%) (30 617 gram-positive [3.4%], 38 844 gram-negative [4.3%]) and the proportion of patients who had any resistant organism decreased from 9.6% to 7.3% (aOR per year, 0.87; 95% CI, 0.87-0.88). Most patients with suspected sepsis treated with empiric anti-MRSA and/or antipseudomonal therapy had no resistant organisms (527 356 of 582 585 patients [90.5%]); this proportion increased from 88.0% in 2017 to 91.6% in 2021 (aOR per year, 1.12; 95% CI, 1.11-1.13). Conclusions and Relevance In this cross-sectional study of adults admitted to 241 US hospitals, empiric broad-spectrum antibiotic use for suspected community-onset sepsis accounted for half of all anti-MRSA or antipseudomonal therapy; the use of these types of antibiotics increased between 2017 and 2021 despite resistant organisms being isolated in less than 10% of patients treated with broad-spectrum agents.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tom Chen
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Alexander Lawandi
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Quebec, Canada
| | - Christina Yek
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Morgan Walker
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Sarah Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | | | - Claire N. Shappell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Laura DelloStritto
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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19
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Lane RD, Richardson T, Scott HF, Paul RM, Balamuth F, Eisenberg MA, Riggs R, Huskins WC, Horvat CM, Keeney GE, Hueschen LA, Lockwood JM, Gunnala V, McKee BP, Patankar N, Pinto VL, Sebring AM, Sharron MP, Treseler J, Wilkes JJ, Workman JK. Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis. JAMA Netw Open 2024; 7:e2413955. [PMID: 38837160 PMCID: PMC11154154 DOI: 10.1001/jamanetworkopen.2024.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/07/2024] [Indexed: 06/06/2024] Open
Abstract
Importance Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes. Objective To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis. Design, Setting, and Participants This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024. Exposure The number of minutes from emergency department arrival to antibiotic administration. Main Outcomes and Measures The primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome. Results A total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes. Conclusions and Relevance In this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.
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Affiliation(s)
- Roni D. Lane
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City
| | | | - Halden F. Scott
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Raina M. Paul
- Pediatric Emergency Medicine, Children’s Hospital of Orange County, Orange, California
| | - Fran Balamuth
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Matthew A. Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruth Riggs
- Children’s Hospital Association, Lenexa, Kansas
| | - W. Charles Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Christopher M. Horvat
- Department of Critical Care Medicine, UPMC, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Grant E. Keeney
- Department of Pediatric Emergency Medicine, Mary Bridge Children’s Hospital, Tacoma, Washington
| | - Leslie A. Hueschen
- Division of Emergency Medicine, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City, Kansas City
| | - Justin M. Lockwood
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Vishal Gunnala
- Division of Critical Care Medicine, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Bryan P. McKee
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio
| | - Nikhil Patankar
- Pediatric Critical Care, Baptist St Anthony’s Health System, Amarillo, Texas
| | - Venessa Lynn Pinto
- Division of Pediatric Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Sebring
- Division of Pediatric Critical Care, Department of Pediatrics, Atrium Health Levine Children’s, Charlotte, North Carolina
| | - Matthew P. Sharron
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Jennifer Treseler
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Jennifer J. Wilkes
- Division of Cancer and Blood Disorders, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jennifer K. Workman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City
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20
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Alkhunaizi FA, Smith N, Brusca SB, Furfaro D. The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review. CHEST CRITICAL CARE 2024; 2:100071. [PMID: 38993934 PMCID: PMC11238736 DOI: 10.1016/j.chstcc.2024.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.
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Affiliation(s)
- Fatimah A Alkhunaizi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nikolhaus Smith
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Samuel B Brusca
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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21
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Parker MJ, Foster G, Fox-Robichaud A, Choong K, Mbuagbaw L, Thabane L. Statistical analysis plan for the SQUEEZE trial: A trial to determine whether septic shock reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy vs. usual care (SQUEEZE). CRIT CARE RESUSC 2024; 26:123-134. [PMID: 39072232 PMCID: PMC11282343 DOI: 10.1016/j.ccrj.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/11/2024] [Accepted: 02/23/2024] [Indexed: 07/30/2024]
Abstract
Background The SQUEEZE trial is a multicentred randomized controlled trial which seeks to determine the optimal approach to fluid resuscitation in paediatric septic shock. SQUEEZE also includes a nested translational study, SQUEEZE-D, investigating the value of plasma cell-free DNA for prediction of clinical outcomes. Objective To present a pre-specified statistical analysis plan (SAP) for the SQUEEZE trial prior to finalizing the trial data set and prior to commencing data analysis. Design SQUEEZE is a pragmatic, two-arm, open-label, prospective multicentre randomized controlled trial. Setting Canadian paediatric tertiary care centres. Participants Paediatric patients with suspected sepsis and persistent signs of shock in need of ongoing resuscitation. Sample size target: 400 participants. Interventions The trial is designed to compare a fluid-sparing resuscitation strategy to usual care. Main outcome measures The primary outcome for the SQUEEZE trial is the time to shock reversal (in hours). The primary outcome analysis will assess the difference in time to shock reversal between the intervention and control groups, reported as point estimate with 95% confidence intervals. The statistical test for the primary analysis will be a two-sided t-test. Secondary outcome measures include clinical outcomes and adverse events including measures of organ dysfunction and mortality outcomes. Results The SAP presented here is reflective of and where necessary clarifies in detail the analysis plan as presented in the trial protocol. The SAP includes a mock CONSORT diagram, figures and tables. Data collection methods are summarized, primary and secondary outcomes are defined, and outcome analyses are described. Conclusions We have developed a statistical analysis plan for the SQUEEZE Trial for transparency and to align with best practices. Analysis of SQUEEZE Trial data will adhere to the SAP to reduce the risk of bias. Registration ClinicalTrials.gov identifiers: Definitive trial NCT03080038; Registered Feb 28, 2017. Pilot Trial NCT01973907; Registered Oct 27, 2013.
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Affiliation(s)
- Melissa J. Parker
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children's Hospital and McMaster University, 1280 Main St W. HSC 3E-20, Hamilton, L8S 4K1, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children, and University of Toronto, 555 University Avenue, Toronto, M5G 1X8, Ontario, Canada
| | - Gary Foster
- Biostatistics Unit,/FSORC, St Joseph's Healthcare Hamilton, 3rd floor Martha Wing. 50 Charlton Avenue East, Hamilton, L8N 4A6, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, McMaster University, DBRI, Rm C5-106 & 107, 237 Barton Street East, Hamilton, L8L 2X2, Ontario, Canada
| | - Karen Choong
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children's Hospital and McMaster University, 1280 Main St W. HSC 3E-20, Hamilton, L8S 4K1, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
- Biostatistics Unit,/FSORC, St Joseph's Healthcare Hamilton, 3rd floor Martha Wing. 50 Charlton Avenue East, Hamilton, L8N 4A6, Canada
| | - Lehana Thabane
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children's Hospital and McMaster University, 1280 Main St W. HSC 3E-20, Hamilton, L8S 4K1, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
- Department of Anesthesia, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
- Biostatistics Unit,/FSORC, St Joseph's Healthcare Hamilton, 3rd floor Martha Wing. 50 Charlton Avenue East, Hamilton, L8N 4A6, Canada
| | - With the SQUEEZE Trial Steering Committee and on behalf of the SQUEEZE Trial Investigators, the Canadian Critical Care Trials Group, Pediatric Emergency Research Canada, and the Canadian Critical Care Translational Biology Group
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children's Hospital and McMaster University, 1280 Main St W. HSC 3E-20, Hamilton, L8S 4K1, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children, and University of Toronto, 555 University Avenue, Toronto, M5G 1X8, Ontario, Canada
- Department of Anesthesia, McMaster University, 1200 Main St W. Hamilton, L8N 3Z5, Ontario, Canada
- Biostatistics Unit,/FSORC, St Joseph's Healthcare Hamilton, 3rd floor Martha Wing. 50 Charlton Avenue East, Hamilton, L8N 4A6, Canada
- Department of Medicine, McMaster University, DBRI, Rm C5-106 & 107, 237 Barton Street East, Hamilton, L8L 2X2, Ontario, Canada
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22
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Webster RE, Belfer JJ, Schmidt KJ. Evaluation of Basal Plus Versus Sliding Scale Insulin Therapy on Glucose Variability in Critically Ill Patients Without Preexisting Diabetes. Ann Pharmacother 2024; 58:565-571. [PMID: 37700565 DOI: 10.1177/10600280231197255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND There is limited evidence evaluating the impact of insulin treatment strategies on glucose variability in critically ill patients without preexisting diabetes. OBJECTIVE Compare basal plus insulin (BPI) and sliding scale insulin (SSI) impact on glycemic control outcomes in critically ill patients without preexisting diabetes experiencing hyperglycemia. METHODS This multicenter, retrospective review analyzed critically ill patients with hyperglycemia who received either BPI or SSI. Patients with a hemoglobin A1C >6.5% during the admission of interest or in the previous 3 months, or a diagnosis of diabetes at the time of discharge were excluded. The primary outcome was glucose variability during the intensive care unit (ICU) admission. Secondary outcomes included hypoglycemia frequency, frequency of goal glucose levels, mortality, and length of stay. RESULTS The analysis included 228 patients (39 in BPI, 189 in SSI). Average glucose variability was higher in the BPI group compared with the SSI group (85.8 mg/dL ± 33.1 vs 70.2 mg/dL ± 30.7; P = 0.009), which remained when controlling for baseline confounding (-12.1 [5.6], 95% CI -23.2 to -0.99; P = 0.033). Hypoglycemia incidence was similar between groups. BPI patients had a lower incidence of glucose values within goal range than SSI patients (P = 0.046). There was no difference in length of stay or hospital mortality. CONCLUSIONS AND RELEVANCE The use of SSI compared with a BPI regimen may result in reduced glycemic variability in critically ill patients without preexisting diabetes. Future prospective studies, with a larger sample size, are warranted to confirm our exploratory findings and characterize clinically significant benefits.
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Affiliation(s)
- Rachel E Webster
- Department of Pharmacy, Trinity Health Grand Rapids, Grand Rapids, MI, USA
| | - Julie J Belfer
- Department of Pharmacy, Trinity Health Grand Rapids, Grand Rapids, MI, USA
| | - Kyle J Schmidt
- Department of Pharmacy, Trinity Health Grand Rapids, Grand Rapids, MI, USA
- College of Pharmacy, Ferris State University, Big Rapids, MI, USA
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23
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Liu J, Song K, Lin B, Chen Z, Zuo Z, Fang Y, He Q, Yao X, Liu Z, Huang Q, Guo X. HMGB1 promotes neutrophil PD-L1 expression through TLR2 and mediates T cell apoptosis leading to immunosuppression in sepsis. Int Immunopharmacol 2024; 133:112130. [PMID: 38648712 DOI: 10.1016/j.intimp.2024.112130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024]
Abstract
Neutrophils and T lymphocytes are closely related to occurrence of immunosuppression in sepsis. Studies have shown that neutrophil apoptosis decreases and T lymphocyte apoptosis increases in sepsis immunosuppression, but the specific mechanism involved remains unclear. In the present study, we found Toll-like Receptor 2 (TLR2) and programmed death-ligand 1 (PD-L1) were significantly activated in bone marrow neutrophils of wild-type mice after LPS treatment and that they were attenuated by treatment with C29, an inhibitor of TLR2. PD-L1 activation inhibits neutrophil apoptosis, whereas programmed death protein 1 (PD-1)activation promotes apoptosis of T lymphocytes, which leads to immunosuppression. Mechanistically, when sepsis occurs, pro-inflammatory factors and High mobility group box-1 protein (HMGB1) passively released from dead cells cause the up-regulation of PD-L1 through TLR2 on neutrophils. The binding of PD-L1 and PD-1 on T lymphocytes leads to increased apoptosis of T lymphocytes and immune dysfunction, eventually resulting in the occurrence of sepsis immunosuppression. In vivo experiments showed that the HMGB1 inhibitor glycyrrhizic acid (GA) and the TLR2 inhibitor C29 could inhibit the HMGB1/TLR2/PD-L1 pathway, and improving sepsis-induced lung injury. In summary, this study shows that HMGB1 regulates PD-L1 and PD-1 signaling pathways through TLR2, which leads to immunosuppression.
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Affiliation(s)
- Jinlian Liu
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Ke Song
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Bingqi Lin
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Zhenfeng Chen
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Zirui Zuo
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Yixing Fang
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Qi He
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Xiaodan Yao
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Zhifeng Liu
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of PLA, 2. Guangdong Branch Center, National Clinical Research Center for Geriatric Diseases (Chinese PLA General Hospital), Guangzhou, Guangdong, China.
| | - Qiaobing Huang
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China.
| | - Xiaohua Guo
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangdong Provincial Key Laboratory of Proteomics, State Key Laboratory of Organ Failure Research, National Experimental Education Demonstration Center for Basic Medical Sciences, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China.
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Tang Z, Zhu Y, Hu X, Lui K, Li S, Song X, Cai C, Guan X. Improving Intestinal Barrier Function in Sepsis by Partially Hydrolysed Guar Gum via the Suppression of the NF-κB/MLCK Pathway. Mol Biotechnol 2024:10.1007/s12033-024-01180-z. [PMID: 38789715 DOI: 10.1007/s12033-024-01180-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 04/12/2024] [Indexed: 05/26/2024]
Abstract
Partially hydrolyzed guar gum (PHGG) protects against intestinal barrier dysfunction and can ameliorate some intestinal diseases. However, whether PHGG has a role in protecting intestinal barrier function (IBF) during sepsis remains unclear. This study aimed to investigate the role and probable mechanism of PHGG in the intestinal mucosa in sepsis. A rat sepsis model was constructed using cecal ligation and puncture (CLP). FITC-dextran 4 (FD-4) flux, serum inflammatory mediator levels, tight junction (TJ) levels, jejunum mucosa pathology, and epithelial intercellular junction ultrastructure were monitored to evaluate the effect of PHGG on IBF. Caco-2 monolayers were used to study the impact and mechanism of PHGG on lipopolysaccharide (LPS)-induced barrier dysfunction in vitro. The expression of zonula occludens protein-1 and occludin and the location of P65 were studied by immunofluorescence. Nuclear factor kappa B (NF-κB) and myosin light chain kinase 3 (MLCK) pathway-related protein expression was verified by quantitative reverse transcriptase polymerase chain reaction or western blotting. The results indicated that the jejunal mucosa structure was destroyed, the villi were disrupted and shortened, and neutrophil infiltration was evident in the septic rats. Compared to Sham group, spetic rats had increased Chiu's score, serum inflammatory mediator levels, and FD-4 flux but decreased TJ and gap junction density. In addition, the expression of MLCK, p-MLC, and TJ proteins and the expression of P65 in the nucleus were increased in septic rats. Furthermore, compared to those in the Control group, LPS-treated Caco-2 cells showed lower cell viability and transepithelial electrical resistance, while had higher FD-4 flux and the expression of MLCK, p-MLC, TJ proteins and P65 in the nucleus. PHGG pretreatment reversed the above effects induced by CLP or LPS treatment. Moreover, SN50, an NF-κB inhibitor, attenuated the above effects of LPS on Caco-2 cells. Overall, PHGG reduced inflammation, increased TJ protein expression and localization, and relieved damage to the TJ structure and intestinal permeability through suppression of the NF-κB/MLCK pathway. This study provides new insights into the role of PHGG in sepsis therapy.
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Affiliation(s)
- Zhaoxia Tang
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Yanping Zhu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Xiaoguang Hu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Kayin Lui
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Shuhe Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Xiaodong Song
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Changjie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China.
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510080, China.
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Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ 2024; 385:e077190. [PMID: 38777357 PMCID: PMC11109902 DOI: 10.1136/bmj-2023-077190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour. DESIGN Population based study. SETTING All NHS hospitals in Scotland. PARTICIPANTS 567 216 women in labour at 24+0 to 42+6 weeks' gestation between 1 January 2007 and 31 December 2019, delivering vaginally or through unplanned caesarean section. MAIN OUTCOME MEASURES The primary outcome was SMM, defined as the presence of ≥1 of 21 conditions used by the US Centers for Disease Control and Prevention (CDC) as criteria for SMM, or a critical care admission, with either occurring at any point from date of delivery to 42 days post partum (described as SMM). Secondary outcomes included a composite of ≥1 of the 21 CDC conditions and critical care admission (SMM plus critical care admission), and respiratory morbidity. RESULTS Of the 567 216 women, 125 024 (22.0%) had epidural analgesia during labour. SMM occurred in 2412 women (4.3 per 1000 births, 95% confidence interval (CI) 4.1 to 4.4). Epidural analgesia was associated with a reduction in SMM (adjusted relative risk 0.65, 95% CI 0.50 to 0.85), SMM plus critical care admission (0.46, 0.29 to 0.73), and respiratory morbidity (0.42, 0.16 to 1.15), although the last of these was underpowered and had wide confidence intervals. Greater risk reductions in SMM were detected among women with a medical indication for epidural analgesia (0.50, 0.34 to 0.72) compared with those with no such indication (0.67, 0.43 to 1.03; P<0.001 for difference). More marked reductions in SMM were seen in women delivering preterm (0.53, 0.37 to 0.76) compared with those delivering at term or post term (1.09, 0.98 to 1.21; P<0.001 for difference). The observed reduced risk of SMM with epidural analgesia was increasingly noticeable as gestational age at birth decreased in the whole cohort, and in women with a medical indication for epidural analgesia. CONCLUSION Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.
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Affiliation(s)
- Rachel J Kearns
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Aizhan Kyzayeva
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Lucy O E Halliday
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, University of Bristol, Bristol, UK
| | - Martin Shaw
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
- Department of Medical Physics and Bioengineering, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
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Zhang Z, Guo L, Jia L, Duo H, Shen L, Zhao H. Factors contributing to sepsis-associated encephalopathy: a comprehensive systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1379019. [PMID: 38835794 PMCID: PMC11148246 DOI: 10.3389/fmed.2024.1379019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
Background This study aims to systematically assess the risk factors, the overall strength of association, and evidence quality related to sepsis-associated encephalopathy. Methods A systematic search was conducted in the Cochrane Library, PubMed, Web of Science, and Embase for cohort or case-control studies published up to August 2023 on risk factors associated with sepsis-related encephalopathy. The selected studies were screened, data were extracted, and the quality was evaluated using the Newcastle-Ottawa Scale. Meta-analysis was performed using RevMan 5.3 software. The certainty of the evidence was assessed using the GRADE criteria. Results A total of 13 studies involving 1,906 participants were included in the analysis. Among these studies, 12 were of high quality, and one was of moderate quality. Our meta-analysis identified six risk factors significantly associated with Serious Adverse Events (SAE). These included APACHE II, SOFA, age, tau protein, and IL-6, which were found to be risk factors with significant effects (standard mean difference SMD: 1.24-2.30), and albumin, which was a risk factor with moderate effects (SMD: -0.55). However, the certainty of evidence for the risk factors identified in this meta-analysis ranged from low to medium. Conclusion This systematic review and meta-analysis identified several risk factors with moderate to significant effects. APACHE II, SOFA, age, tau protein, IL-6, and albumin were associated with sepsis-related encephalopathy and were supported by medium- to high-quality evidence. These findings provide healthcare professionals with an evidence-based foundation for managing and treating hospitalized adult patients with sepsis-related encephalopathy.
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Affiliation(s)
- Zhiyang Zhang
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang, China
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang, China
| | - Li Guo
- Department of Neonatal, Shijiazhuang Fourth Hospital, Shijiazhuang, China
| | - Lijing Jia
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang, China
| | - Hong Duo
- Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Limin Shen
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang, China
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang, China
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Wen C, Zhang X, Li Y, Xiao W, Hu Q, Lei X, Xu T, Liang S, Gao X, Zhang C, Yu Z, Lü M. An interpretable machine learning model for predicting 28-day mortality in patients with sepsis-associated liver injury. PLoS One 2024; 19:e0303469. [PMID: 38768153 PMCID: PMC11104601 DOI: 10.1371/journal.pone.0303469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 04/25/2024] [Indexed: 05/22/2024] Open
Abstract
Sepsis-Associated Liver Injury (SALI) is an independent risk factor for death from sepsis. The aim of this study was to develop an interpretable machine learning model for early prediction of 28-day mortality in patients with SALI. Data from the Medical Information Mart for Intensive Care (MIMIC-IV, v2.2, MIMIC-III, v1.4) were used in this study. The study cohort from MIMIC-IV was randomized to the training set (0.7) and the internal validation set (0.3), with MIMIC-III (2001 to 2008) as external validation. The features with more than 20% missing values were deleted and the remaining features were multiple interpolated. Lasso-CV that lasso linear model with iterative fitting along a regularization path in which the best model is selected by cross-validation was used to select important features for model development. Eight machine learning models including Random Forest (RF), Logistic Regression, Decision Tree, Extreme Gradient Boost (XGBoost), K Nearest Neighbor, Support Vector Machine, Generalized Linear Models in which the best model is selected by cross-validation (CV_glmnet), and Linear Discriminant Analysis (LDA) were developed. Shapley additive interpretation (SHAP) was used to improve the interpretability of the optimal model. At last, a total of 1043 patients were included, of whom 710 were from MIMIC-IV and 333 from MIMIC-III. Twenty-four clinically relevant parameters were selected for model construction. For the prediction of 28-day mortality of SALI in the internal validation set, the area under the curve (AUC (95% CI)) of RF was 0.79 (95% CI: 0.73-0.86), and which performed the best. Compared with the traditional disease severity scores including Oxford Acute Severity of Illness Score (OASIS), Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score II (SAPS II), Logistic Organ Dysfunction Score (LODS), Systemic Inflammatory Response Syndrome (SIRS), and Acute Physiology Score III (APS III), RF also had the best performance. SHAP analysis found that Urine output, Charlson Comorbidity Index (CCI), minimal Glasgow Coma Scale (GCS_min), blood urea nitrogen (BUN) and admission_age were the five most important features affecting RF model. Therefore, RF has good predictive ability for 28-day mortality prediction in SALI. Urine output, CCI, GCS_min, BUN and age at admission(admission_age) within 24 h after intensive care unit(ICU) admission contribute significantly to model prediction.
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Affiliation(s)
- Chengli Wen
- Department of Intensive Care Medicine, Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Xu Zhang
- Luzhou Key Laboratory of Human Microecology and Precision Diagnosis and Treatment, Luzhou, China
| | - Yong Li
- Southwest Medical University, Luzhou, China
| | - Wanmeng Xiao
- Luzhou Key Laboratory of Human Microecology and Precision Diagnosis and Treatment, Luzhou, China
- Department of Gastroenterology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Qinxue Hu
- Department of Intensive Care Medicine, Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Xianying Lei
- Department of Intensive Care Medicine, Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Tao Xu
- Department of Intensive Care Medicine, Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Sicheng Liang
- Luzhou Key Laboratory of Human Microecology and Precision Diagnosis and Treatment, Luzhou, China
- Department of Gastroenterology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Xiaolan Gao
- Department of Intensive Care Medicine, Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Chao Zhang
- Luzhou Key Laboratory of Human Microecology and Precision Diagnosis and Treatment, Luzhou, China
| | - Zehui Yu
- Laboratory Animal Center, Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Luzhou Key Laboratory of Human Microecology and Precision Diagnosis and Treatment, Luzhou, China
- Department of Gastroenterology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
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28
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Liu J, Hui Q, Lu X, Li W, Li N, Chen Y, Zhang Q. Predictive value of laboratory indicators for in-hospital death in children with community-onset sepsis: a prospective observational study of 266 patients. BMJ Paediatr Open 2024; 8:e002329. [PMID: 38754894 PMCID: PMC11097807 DOI: 10.1136/bmjpo-2023-002329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to identify predictors of sepsis-associated in-hospital mortality from readily available laboratory biomarkers at onset of illness that include haematological, coagulation, liver and kidney function, blood lipid, cardiac enzymes and arterial blood gas. METHODS Children with sepsis were enrolled consecutively in a prospective observational study involving paediatric intensive care units (PICUs) of two hospitals in Beijing, between November 2016 and January 2020. The data on demographics, laboratory examinations during the first 24 hours after PICU admission, complications and outcomes were collected. We screened baseline laboratory indicators using the Least Absolute Shrinkage and Selection Operator (LASSO) analysis, then we constructed a mortality risk model using Cox proportional hazards regression analysis. The ability of risk factors to predict in-hospital mortality was evaluated by receiver operating characteristic (ROC) curves. RESULTS A total of 266 subjects were enrolled including 44 (16.5%) deaths and 222 (83.5%) survivors. Those who died showed a shorter length of hospitalisation, and a higher proportion of mechanical ventilation, complications and organ failure (p<0.05). LASSO analysis identified 13 clinical parameters related to prognosis, which were included in the final Cox model. An elevated triglyceride (TG) remained the most significant risk factor of death (HR=1.469, 95% CI: 1.010 to 2.136, p=0.044), followed by base excess (BE) (HR=1.131, 95% CI: 1.046 to 1.223, p=0.002) and pH (HR=0.95, 95% CI: 0.93 to 0.97, p<0.001). The results of the ROC curve showed that combined diagnosis of the three indicators-TG+BE+pH-has the best area under the curve (AUC) (AUC=0.77, 95% CI: 0.69 to 0.85, p<0.001), with a 68% sensitivity and 80% specificity. CONCLUSION Laboratory factors of TG, BE and pH during the first 24 hours after intensive care unit admission are associated with in-hospital mortality in PICU patients with sepsis. The combination of the three indices has high diagnostic value.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
- Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qin Hui
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Xiuxiu Lu
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Wei Li
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Ning Li
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Yuanmei Chen
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Qi Zhang
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
- Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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29
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Teja B, Berube M, Pereira TV, Law AC, Schanock C, Pang B, Wunsch H, Walkey AJ, Bosch NA. Effectiveness of Fludrocortisone Plus Hydrocortisone versus Hydrocortisone Alone in Septic Shock: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Am J Respir Crit Care Med 2024; 209:1219-1228. [PMID: 38271488 PMCID: PMC11146553 DOI: 10.1164/rccm.202310-1785oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/25/2024] [Indexed: 01/27/2024] Open
Abstract
Rationale: The use of hydrocortisone in adult patients with septic shock is controversial, and the effectiveness of adding fludrocortisone to hydrocortisone remains uncertain. Objectives: To assess the comparative effectiveness and safety of fludrocortisone plus hydrocortisone, hydrocortisone alone, and placebo or usual care in adults with septic shock. Methods: A systematic review and a Bayesian network meta-analysis of peer-reviewed randomized trials were conducted. The primary outcome was all-cause mortality at last follow-up. Treatment effects are presented as relative risks (RRs) with 95% credible intervals (CrIs). Placebo or usual care was the reference treatment. Measurements and Main Results: Among 7,553 references, we included 17 trials (7,688 patients). All-cause mortality at last follow-up was lowest with fludrocortisone plus hydrocortisone (RR, 0.85; 95% CrI, 0.72-0.99; 98.3% probability of superiority, moderate-certainty evidence), followed by hydrocortisone alone (RR, 0.97; 95% CrI, 0.87-1.07; 73.1% probability of superiority, low-certainty evidence). The comparison of fludrocortisone plus hydrocortisone versus hydrocortisone alone was based primarily on indirect evidence (only two trials with direct evidence). Fludrocortisone plus hydrocortisone was associated with a 12% lower risk of all-cause mortality compared with hydrocortisone alone (RR, 0.88; 95% CrI, 0.74-1.03; 94.2% probability of superiority, moderate-certainty evidence). Conclusions: In adult patients with septic shock, fludrocortisone plus hydrocortisone was associated with lower risk of all-cause mortality at last follow-up than placebo and hydrocortisone alone. The scarcity of head-to-head trials comparing fludrocortisone plus hydrocortisone versus hydrocortisone alone led our network meta-analysis to rely primarily on indirect evidence for this comparison. Although we undertook several sensitivity analyses and assessments, these findings should be considered while also acknowledging the heterogeneity of included trials.
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Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine and
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Megan Berube
- The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Tiago V. Pereira
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Anica C. Law
- The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Carly Schanock
- Medical College of Wisconsin Libraries, Milwaukee, Wisconsin
| | - Brandon Pang
- The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Hannah Wunsch
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York; and
| | - Allan J. Walkey
- Division of Health Systems Sciences, Medical School, University of Massachusetts, Boston, Massachusetts
| | - Nicholas A. Bosch
- The Pulmonary Center, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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30
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Wang CP, Hsieh MS, Hu SY, Huang SC, Tsai CA, Shen CH. Risk Factors and Scoring Systems to Predict the Mortality Risk of Afebrile Adult Patients with Monomicrobial Gram-Negative Bacteremia: A 10-Year Observational Study in the Emergency Department. Diagnostics (Basel) 2024; 14:869. [PMID: 38732284 PMCID: PMC11083546 DOI: 10.3390/diagnostics14090869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/10/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The mortality rate of afebrile bacteremia has been reported to be as high as 45%. This investigation focused on the risk factors and predictive performance of scoring systems for the clinical outcomes of afebrile patients with monomicrobial gram-negative bacteria (GNB) in the emergency department (ED). METHODS We conducted a retrospective analysis of afebrile adult ED patients with monomicrobial GNB bacteremia from January 2012 to December 2021. We dissected the demographics, clinical pictures, and laboratory investigations. We applied five scoring systems and three revised systems to predict the clinical outcomes. RESULTS There were 600 patients included (358 males and 242 females), with a mean age of 69.6 ± 15.4 years. The overall mortality rate was 50.17%, reaching 68.52% (74/108) in cirrhotic patients. Escherichia coli was the leading pathogen (42.83%). The non-survivors had higher scores of the original MEDS (p < 0.001), NEWS (p < 0.001), MEWS (p < 0.001), qSOFA (p < 0.001), and REMS (p = 0.030). In univariate logistic regression analyses, several risk factors had a higher odds ratio (OR) for mortality, including liver cirrhosis (OR 2.541, p < 0.001), malignancy (OR 2.259, p < 0.001), septic shock (OR 2.077, p = 0.002), and male gender (OR 0.535, p < 0.001). The MEDS demonstrated that the best predictive power with the maximum area under the curve (AUC) was measured at 0.773 at the cut-off point of 11. The AUCs of the original NEWS, MEWS, qSOFA, and REMS were 0.663, 0.584, 0.572, and 0.553, respectively. We revised the original MEDS, NEWS, and qSOFA by adding red cell distribution width, albumin, and lactate scores and found a better predictive power of the AUC of 0.797, 0.719, and 0.694 on the revised MEDS ≥11, revised qSOFA ≥ 3, and revised NEWS ≥ 6, respectively. CONCLUSIONS The original MEDS, revised MEDS, revised qSOFA, and revised NEWS were valuable tools for predicting the mortality risk in afebrile patients with monomicrobial GNB bacteremia. We suggested that clinicians should explore patients with the risk factors mentioned above for possible severe infection, even in the absence of fever and initiate hemodynamic support and early adequate antibiotic therapy in patients with higher scores of the original MEDS (≥11), revised MEDS (≥11), revised NEWS (≥6), and revised qSOFA (≥3).
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Affiliation(s)
- Chung-Pang Wang
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-P.W.); (C.-H.S.)
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan 330, Taiwan;
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-P.W.); (C.-H.S.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40201, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
| | - Shih-Che Huang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Lung Cancer Research Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Che-An Tsai
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Chia-Hui Shen
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-P.W.); (C.-H.S.)
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Shi M, Wei Y, Guo R, Luo F. Integrated Analysis Identified TGFBI as a Biomarker of Disease Severity and Prognosis Correlated with Immune Infiltrates in Patients with Sepsis. J Inflamm Res 2024; 17:2285-2298. [PMID: 38645878 PMCID: PMC11027929 DOI: 10.2147/jir.s456132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/26/2024] [Indexed: 04/23/2024] Open
Abstract
Background Sepsis is a major contributor to morbidity and mortality among hospitalized patients. This study aims to identify markers associated with the severity and prognosis of sepsis, providing new approaches for its management and treatment. Methods Data were mined from the Gene Expression Omnibus (GEO) databases and were analyzed by multiple statistical methods like the Spearman correlation coefficient, Kaplan-Meier analysis, Cox regression analysis, and functional enrichment analysis. Candidate indicator' associations with immune infiltration and roles in sepsis development were evaluated. Additionally, we employed techniques such as flow cytometry and neutral red staining to evaluate its impact on macrophage functions like polarization and phagocytosis. Results Twenty-eight genes were identified as being closely linked to the severity of sepsis, among which transforming growth factor beta induced (TGFBI) emerged as a distinct marker for predicting clinical outcomes. Notably, reductions in TGFBI expression during sepsis correlate with poor prognosis and rapid disease progression. Elevated expression of TGFBI has been observed to mitigate abnormalities in sepsis-related immune cell infiltration that are critical to the pathogenesis and prognosis of the disease, including but not limited to type 17 T helper cells and activated CD8 T cells. Moreover, the protein-protein interaction network revealed the top ten genes that interact with TGFBI, showing significant involvement in the regulation of the actin cytoskeleton, extracellular matrix-receptor interactions, and phagosomes. These are pivotal elements in the formation of phagocytic cups by macrophages, squaring the findings of the Human Protein Atlas. Additionally, we discovered that TGFBI expression was significantly higher in M2-like macrophages, and its upregulation was found to inhibit lipopolysaccharide-induced polarization and phagocytosis in M1-like macrophages, thereby playing a role in preventing the onset of inflammation. Conclusion TGFBI warrants additional exploration as a promising biomarker for assessing illness severity and prognosis in patients with sepsis, considering its significant association with immunological and inflammatory responses in this condition.
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Affiliation(s)
- Mingjie Shi
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, Guangdong, People’s Republic of China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, People’s Republic of China
| | - Yue Wei
- Department of Ultrasound, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, People’s Republic of China
| | - Runmin Guo
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, Guangdong, People’s Republic of China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, People’s Republic of China
| | - Fei Luo
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, Guangdong, People’s Republic of China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, People’s Republic of China
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Hao D, Guo L, Wang Q, Ito M, Huang B, Mineo C, Shaul PW, Li XA. Relative Adrenal Insufficiency Is a Risk Factor for Pediatric Sepsis: A Proof-of-Concept Study. J Infect Dis 2024; 229:1166-1177. [PMID: 37633660 PMCID: PMC11011189 DOI: 10.1093/infdis/jiad369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 08/28/2023] Open
Abstract
Glucocorticoid (GC) therapy had been strongly recommended for pediatric sepsis (grade 1A). However, the recommendation was changed to grade 2C in 2020 due to weak evidence. About 32.8% of patients with pediatric septic develop relative adrenal insufficiency (RAI). But whether GC therapy should be determined by RAI status is controversial. This study utilized 21-day-old SF1CreSRBIfl/fl mice as the first pediatric RAI mouse model to assess the pathogenesis of RAI and evaluate GC therapy. RAI mice exhibited a substantially higher mortality rate in cecal ligation and puncture and cecal slurry-induced sepsis. These mice featured persistent inflammatory responses and were effectively rescued by GC therapy. RNA sequencing analysis revealed persistent inflammatory responses in RAI mice, caused by transcriptional dysregulation of AP-1 and NF-κB, and cytokine-induced secondary inflammatory response. Our findings support a precision medicine approach to guide GC therapy for pediatric patients based on the status of RAI.
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Affiliation(s)
- Dan Hao
- Department of Pharmacology and Nutritional Sciences
| | - Ling Guo
- Saha Cardiovascular Research Center
| | | | - Misa Ito
- Department of Pharmacology and Nutritional Sciences
| | - Bin Huang
- Division of Cancer Biostatistics, College of Medicine, University of Kentucky, Lexington
| | - Chieko Mineo
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Philip W Shaul
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Xiang-An Li
- Department of Pharmacology and Nutritional Sciences
- Saha Cardiovascular Research Center
- Lexington VA Healthcare System
- Department of Physiology, College of Medicine, University of Kentucky, Lexington
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Zhu C, Xu S, Jiang R, Yu Y, Bian J, Zou Z. The gasdermin family: emerging therapeutic targets in diseases. Signal Transduct Target Ther 2024; 9:87. [PMID: 38584157 PMCID: PMC10999458 DOI: 10.1038/s41392-024-01801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
The gasdermin (GSDM) family has garnered significant attention for its pivotal role in immunity and disease as a key player in pyroptosis. This recently characterized class of pore-forming effector proteins is pivotal in orchestrating processes such as membrane permeabilization, pyroptosis, and the follow-up inflammatory response, which are crucial self-defense mechanisms against irritants and infections. GSDMs have been implicated in a range of diseases including, but not limited to, sepsis, viral infections, and cancer, either through involvement in pyroptosis or independently of this process. The regulation of GSDM-mediated pyroptosis is gaining recognition as a promising therapeutic strategy for the treatment of various diseases. Current strategies for inhibiting GSDMD primarily involve binding to GSDMD, blocking GSDMD cleavage or inhibiting GSDMD-N-terminal (NT) oligomerization, albeit with some off-target effects. In this review, we delve into the cutting-edge understanding of the interplay between GSDMs and pyroptosis, elucidate the activation mechanisms of GSDMs, explore their associations with a range of diseases, and discuss recent advancements and potential strategies for developing GSDMD inhibitors.
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Affiliation(s)
- Chenglong Zhu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
- School of Anesthesiology, Naval Medical University, Shanghai, 200433, China
| | - Sheng Xu
- National Key Laboratory of Immunity & Inflammation, Naval Medical University, Shanghai, 200433, China
| | - Ruoyu Jiang
- School of Anesthesiology, Naval Medical University, Shanghai, 200433, China
- Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Naval Medical University, Shanghai, 200433, China
| | - Yizhi Yu
- National Key Laboratory of Immunity & Inflammation, Naval Medical University, Shanghai, 200433, China.
| | - Jinjun Bian
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
| | - Zui Zou
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
- School of Anesthesiology, Naval Medical University, Shanghai, 200433, China.
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Kumar NR, Balraj TA, Shivashankar KK, Jayaram TC, Prashant A. Inflammaging in Multidrug-Resistant Sepsis of Geriatric ICU Patients and Healthcare Challenges. Geriatrics (Basel) 2024; 9:45. [PMID: 38667512 PMCID: PMC11049875 DOI: 10.3390/geriatrics9020045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
Multidrug-resistant sepsis (MDR) is a pressing concern in intensive care unit (ICU) settings, specifically among geriatric patients who experience age-related immune system changes and comorbidities. The aim of this review is to explore the clinical impact of MDR sepsis in geriatric ICU patients and shed light on healthcare challenges associated with its management. We conducted a comprehensive literature search using the National Center for Biotechnology Information (NCBI) and Google Scholar search engines. Our search incorporated keywords such as "multidrug-resistant sepsis" OR "MDR sepsis", "geriatric ICU patients" OR "elderly ICU patients", and "complications", "healthcare burdens", "diagnostic challenges", and "healthcare challenges" associated with MDR sepsis in "ICU patients" and "geriatric/elderly ICU patients". This review explores the specific risk factors contributing to MDR sepsis, the complexities of diagnostic challenges, and the healthcare burden faced by elderly ICU patients. Notably, the elderly population bears a higher burden of MDR sepsis (57.5%), influenced by various factors, including comorbidities, immunosuppression, age-related immune changes, and resource-limited ICU settings. Furthermore, sepsis imposes a significant economic burden on healthcare systems, with annual costs exceeding $27 billion in the USA. These findings underscore the urgency of addressing MDR sepsis in geriatric ICU patients and the need for tailored interventions to improve outcomes and reduce healthcare costs.
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Affiliation(s)
- Nishitha R. Kumar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India; (N.R.K.); (K.K.S.)
| | - Tejashree A. Balraj
- Department of Microbiology, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India;
| | - Kusuma K. Shivashankar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India; (N.R.K.); (K.K.S.)
| | - Tejaswini C. Jayaram
- Department of Geriatrics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India;
| | - Akila Prashant
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India; (N.R.K.); (K.K.S.)
- Department of Medical Genetics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India
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Canning ML, Barras M, McDougall R, Yerkovich S, Coombes I, Sullivan C, Whitfield K. Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach. Int J Clin Pharm 2024; 46:451-462. [PMID: 38240963 DOI: 10.1007/s11096-023-01681-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/28/2023] [Indexed: 03/24/2024]
Abstract
BACKGROUND Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes. AIM To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service. METHOD A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed. RESULTS Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days. CONCLUSION Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.
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Affiliation(s)
- Martin Luke Canning
- Pharmacy Department, The Prince Charles Hospital, Rode Rd, Chermside, QLD, 4032, Australia.
| | - Michael Barras
- Princess Alexandra Hospital, Woolloongabba, Australia
- The University of Queensland, Woolloongabba, Australia
| | - Ross McDougall
- Pharmacy Department, The Prince Charles Hospital, Rode Rd, Chermside, QLD, 4032, Australia
| | - Stephanie Yerkovich
- Menzies School of Health Research, Casuarina, Australia
- Queensland University of Technology, Brisbane, Australia
| | - Ian Coombes
- The University of Queensland, Woolloongabba, Australia
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Clair Sullivan
- The University of Queensland, Woolloongabba, Australia
- Digital Metro North, Herston, Australia
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Yoo KH, Choi SH, Suh GJ, Chung SP, Choi HS, Park YS, Jo YH, Shin TG, Lim TH, Kim WY, Lee J. The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs. Am J Emerg Med 2024; 78:1-7. [PMID: 38176175 DOI: 10.1016/j.ajem.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024] Open
Abstract
PURPOSE Early identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock. MATERIALS AND METHODS We included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated. RESULTS Of the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th-75th percentiles, 61-78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69-0.74 and 0.669; 95% CI: 0.65-0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16-4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25-3.17). CONCLUSION The results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.
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Affiliation(s)
- Kyung Hun Yoo
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Department of Emergency Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Han Sung Choi
- Department of Emergency Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Department of Emergency Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
| | - Juncheol Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Department of Emergency Medicine, Hanyang University Hospital, Seoul, Republic of Korea.
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Rigouzzo A, Jonard M, Lepercq J. [Maternal mortality due to genital tract infection in France, 2016-2018]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:252-258. [PMID: 38382839 DOI: 10.1016/j.gofs.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in genital-tract infections related-deaths noted in the 2013-2015 report continues for the 2016-2018 period, but this 2010-2018 increase remains at the limit of statistical significance given the low number of cases (p 0.08). The 13 deaths from direct infectious causes for the 2016-2018 period were due to 4 cases of puerperal toxic shock syndrome (Streptococcus A beta hemolyticus or Clostridium group bacilli), 6 sepsis caused by intrauterine infection due to E. Coli and 3 cases of septic shock from intrauterine origin and no documented bacteria. In this 2016-2018 triennium, the quality of care concerning women who died of direct infections was considered non-optimal in 85% (11/13). Death was considered possibly or probably avoidable in 9/13 cases (69%), which made it one of the most avoidable causes of maternal mortality. Preventable factors related to the medical management were the most frequent (9/13), with in particular a diagnostic failure or delayed diagnosis leading to a delay in the introduction of medical treatment. The others contributory factors to these deaths were related to the organization of healthcare (delayed transfer, lack of communication between practitioners) as well as factors related to patient social and/or mental vulnerability.
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Affiliation(s)
- Agnès Rigouzzo
- Département d'anesthésie-réanimation, hôpital Trousseau, 22, avenue du Dr-Arnold-Netter, 75012 Paris, France.
| | - Marie Jonard
- Service de réanimation polyvalente pôle de soins critiques, centre hospitalier, Lens, France
| | - Jacques Lepercq
- Service de gynécologie-obstétrique Port-Royal, hôpital Cochin, 12, boulevard du Port-Royal, 75014 Paris, France
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Jiang Z, Liu L, Du L, Lv S, Liang F, Luo Y, Wang C, Shen Q. Machine learning for the early prediction of acute respiratory distress syndrome (ARDS) in patients with sepsis in the ICU based on clinical data. Heliyon 2024; 10:e28143. [PMID: 38533071 PMCID: PMC10963609 DOI: 10.1016/j.heliyon.2024.e28143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/28/2024] [Accepted: 03/12/2024] [Indexed: 03/28/2024] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a fatal outcome of severe sepsis. Machine learning models are helpful for accurately predicting ARDS in patients with sepsis at an early stage. Objective We aim to develop a machine-learning model for predicting ARDS in patients with sepsis in the intensive care unit (ICU). Methods The initial clinical data of patients with sepsis admitted to the hospital (including population characteristics, clinical diagnosis, complications, and laboratory tests) were used to predict ARDS, and screen out the crucial variables. After comparing eight different algorithms, namely, XG boost, logistic regression, light GBM, random forest, GaussianNB, complement NB, support vector machine (SVM), and K nearest neighbors (KNN), rebuilding a prediction model with the best one. When remodeling with the best algorithm, 10% was randomly selected to test, and the remaining was trained for cross-validation. Using the area under the curve (AUC), sensitivity, accuracy, specificity, positive and negative predictive value, F1 score, kappa value, and clinical decision curve to evaluate the model's performance. Eventually, the application in the model illustrated by the SHAP package. Results Ten critical features were screened utilizing the lasso method, namely, PaO2/PAO2, A-aDO2, PO2(T), CRP, gender, PO2, RDW, MCH, SG, and chlorine. The prior ranking of variables demonstrated that PaO2/PAO2 was the most significant variable. Among the eight algorithms, the performance of the Gaussian NB algorithm was significantly better than that of the others. After remodeling with the best algorithm, the AUC in the training and validation sets were 0.777 and 0.770, respectively, and the algorithm performed well in the test set (AUC = 0.781, accuracy = 78.6%, sensitivity = 82.4%, F1 score = 0.824). A comparison of the overlap factors with those of previous models revealed that the model we developed performs better. Conclusion Sepsis-associated ARDS can be accurately predicted early via a machine learning model based on existing clinical data. These findings are helpful for accurate identification and improvement of the prognosis in patients with sepsis-associated ARDS.
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Affiliation(s)
- Zhenzhen Jiang
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Leping Liu
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lin Du
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Shanshan Lv
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Fang Liang
- Department of Hematology and Critical Care Medicine, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yanwei Luo
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qin Shen
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, China
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Su L, Liu S, Yang Y, Jiang H, Ye X, Weng L, Zhu W, Tian X, Long Y. Positive fluid balance and poor outcomes after initial intensive care unit admission in sepsis resuscitation: a retrospective study. Arch Med Sci 2024; 20:464-475. [PMID: 38757044 PMCID: PMC11094850 DOI: 10.5114/aoms/172160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 05/18/2024] Open
Abstract
Introduction Fluid resuscitation of patients with sepsis is crucial. This study explored the role of fluid balance in the early resuscitation of sepsis patients in the intensive care unit (ICU). Material and methods A retrospective study of patients with sepsis using the Peking Union Medical College Hospital Intensive Care Medical Information System and Database from January 2014 to June 2020 was performed. Based on the survival status on day 28, the training cohort was divided into an alive group (n = 1,803) and a deceased group (n = 429). Univariate and multivariate analyses were used to identify risk factors, and the integrated learning XGBoost algorithm was used to construct a model for predicting outcomes. ROC and Kaplan-Meier survival curves were used to evaluate the effectiveness of the model. A verification cohort (n = 433) was used to verify the model. Results Univariate analysis showed that fluid balance is an important covariate. Based on the scatterplot distribution, a significant difference in mortality was determined between groups stratified with a balance of 1000 ml. There were associations in the multivariate analysis between poor outcomes and sex, PO2/FiO2, serum creatinine, FiO2, platelets, respiratory rate, SPO2, temperature, and total fluid volume (1000 ml). Among these variables, total fluid balance (1000 ml) had an OR of 1.98 (CI: 1.41-2.77, p < 0.001). Therefore, the model was built with these nine factors using XGBoost. Cross validation was used to verify generalizability. This model performed better than the SOFA and APACHE II models. The result was well verified in the verification cohort. A causal forest model suggested that patients with hypoxemia may suffer from positive fluid balance. Conclusions Sepsis fluid resuscitation in the ICU should be a targeted and goal-oriented treatment. A new prognostic prediction model was constructed and indicated that a 6-hour positive fluid balance after ICU initial admission is a risk factor for poor outcomes in sepsis patients. A 6-hour fluid balance above 1000 ml should be performed with caution.
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Affiliation(s)
- Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yingying Yang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huizhen Jiang
- Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiangyang Ye
- Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Li Weng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Weiguo Zhu
- Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinlun Tian
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Wang C, Liu J, Wu Q, Wang Z, Hu B, Bo L. The role of TIM-3 in sepsis: a promising target for immunotherapy? Front Immunol 2024; 15:1328667. [PMID: 38576606 PMCID: PMC10991702 DOI: 10.3389/fimmu.2024.1328667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Sepsis remains a significant cause of mortality and morbidity worldwide, with limited effective treatment options. The T-cell immunoglobulin and mucin domain-containing molecule 3 (TIM-3) has emerged as a potential therapeutic target in various immune-related disorders. This narrative review aims to explore the role of TIM-3 in sepsis and evaluate its potential as a promising target for immunotherapy. We discuss the dynamic expression patterns of TIM-3 during sepsis and its involvement in regulating immune responses. Furthermore, we examine the preclinical studies investigating the regulation of TIM-3 signaling pathways in septic models, highlighting the potential therapeutic benefits and challenges associated with targeting TIM-3. Overall, this review emphasizes the importance of TIM-3 in sepsis pathogenesis and underscores the promising prospects of TIM-3-based immunotherapy as a potential strategy to combat this life-threatening condition.
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Affiliation(s)
- Changli Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jinhai Liu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qi Wu
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhi Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Baoji Hu
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Lulong Bo
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
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Kothari DJ, Sheth SG. Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room. World J Gastroenterol 2024; 30:1475-1479. [PMID: 38617458 PMCID: PMC11008414 DOI: 10.3748/wjg.v30.i11.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/22/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, resulting in 300000 admissions per year with an estimated cost of over $2.6 billion annually. The severity of AP is determined by the presence of pancreatic complications and end-organ damage. While moderate/severe pancreatitis can be associated with significant morbidity and mortality, the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%. Despite favorable outcomes, the majority of mild AP patients are admitted, contributing to healthcare cost and burden. In this Editorial we review the performance of an emergency department (ED) pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations, resource utilization, and costs after several years of implementation of the pathway. We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital, and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway. We conclude that by implementing innovative clinical pathways which are established and reproducible, selected AP patients can be safely discharged from the ED, reducing hospitalizations and healthcare costs, without compromising clinical outcomes. We also identify a subset of patients most likely to succeed in this pathway.
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Affiliation(s)
- Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
| | - Sunil G Sheth
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Wang L, Ma X, Qiu Y, Chen Y, Gao S, He H, Su L, Dai S, Guo Y, Wang W, Shan G, Hu Y, Liu D, Yin Z, Yin C, Zhou X. Association of medical care capacity and the patient mortality of septic shock: a cross-sectional study. Anaesth Crit Care Pain Med 2024; 43:101364. [PMID: 38460889 DOI: 10.1016/j.accpm.2024.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/29/2023] [Accepted: 02/23/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Hospitals with higher septic shock case volume demonstrated lower hospital mortality. We conducted this study to investigate whether this phenomenon was only caused by the increase in the number of admissions or the need to improve the medical care capacity in septic shock at the same time. METHODS Seven-hundred and eighty-seven hospitals from China collected in a survey from January 1, 2021 to December 31, 2021. Medical care capacity for septic shock was explored by patients with septic shock in intensive care units (ICU) divided into beds, intensivists, and nurses respectively. MAIN RESULTS The proportion of ICU patients with septic shock was negatively associated with the patient mortality of septic shock (Estimate [95%CI], -0.2532 [-0.5038, -0.0026]) (p-value 0.048). The ratios of patients with septic shock to beds, intensivists, and nurses were negatively associated with mortality of septic shock (Estimate [95%CI], -0.370 [-0.591, -0.150], -0.136 [-0.241, -0.031], and -0.774 [-1.158, -0.389]) (p-value 0.001, 0.011 and < 0.001). Severe pneumonia, the most common infection that caused a septic shock, correlated positively with its mortality (Estimate [95%CI], 0.1002 [0.0617, 0.1387]) (p-value < 0.001). CONCLUSIONS Hospitals with higher medical care capacity for septic shock were associated with lower hospital mortality.
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Affiliation(s)
- Lu Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xudong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing 100044, China
| | - Yehan Qiu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yujie Chen
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Sifa Gao
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing 100044, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shabai Dai
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yanhong Guo
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing 100044, China
| | - Wenhu Wang
- Intensice Care Unit, The People's Hospital of Zizhong, Neijiang, Sichuang 641000, China
| | - Guangliang Shan
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing 100730, China
| | - Yaoda Hu
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing 100730, China
| | - Dawei Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhi Yin
- Intensice Care Unit, The People's Hospital of Zizhong, Neijiang, Sichuang 641000, China.
| | - Chang Yin
- National Institute of Hospital Administration, Beijing 100730, China.
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China; Information Center Department/Department of Information Management, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China.
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Wang DH, Jia HM, Zheng X, Xi XM, Zheng Y, Li WX. Attributable mortality of ARDS among critically ill patients with sepsis: a multicenter, retrospective cohort study. BMC Pulm Med 2024; 24:110. [PMID: 38438849 PMCID: PMC10913263 DOI: 10.1186/s12890-024-02913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/18/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Both sepsis and acute respiratory distress syndrome (ARDS) are common severe diseases in the intensive care unit (ICU). There is no large-scale multicenter study to clarify the attributable mortality of ARDS among septic patients. This study aimed to evaluate the excess mortality of ARDS in critically ill patients with sepsis. METHODS The data were obtained from a multicenter, prospective cohort study in 18 Chinese ICUs between January 2014 and August 2015. The study population was septic patients after ICU admission. The patients were categorized into two groups: those who developed ARDS (ARDS group) within seven days following a sepsis diagnosis and those who did not develop ARDS (non-ARDS group). Applying propensity score matching (PSM), patients were matched 1:1 as ARDS and non-ARDS groups. Mortality attributed to ARDS was calculated. Subsequently, we conducted a survival analysis to estimate the impact of ARDS on mortality. The primary endpoint was 30-day mortality after sepsis diagnosis. RESULTS 2323 septic patients were eligible, 67.8% developed ARDS. After PSM, 737 patients with ARDS were matched 1:1 with 737 non-ARDS patients. ARDS's overall 30-day attributable mortality was 11.9% (95% CI 7.5-16.3%, p < 0.001). Subgroup analysis showed that the 30-day attributable mortality of mild, moderate, and severe ARDS was 10.5% (95% CI 4.0-16.8%, p < 0.001), 11.6% (95% CI 4.7-18.4%, p < 0.001) and 18.1% (95% CI 4.5-30.9%, p = 0.006), respectively. ARDS was an independent risk factor for 30-day mortality, with adjusted hazard ratios of 1.30 (95% CI 1.03-1.64, p = 0.027), 1.49 (95% CI 1.20-1.85, p < 0.001), and 1.95 (95% CI 1.51-2.52, p < 0.001) for mild, moderate, and severe ARDS, respectively. CONCLUSIONS The overall 30-day attributable mortality of ARDS among critically ill patients with sepsis was 11.9%. Compared with mild and moderate ARDS, severe ARDS contributed more to death. ARDS was significantly associated with an increase in the 30-day mortality.
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Affiliation(s)
- Dong-Hui Wang
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, China
| | - Hui-Miao Jia
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, China
| | - Xi Zheng
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, China
| | - Xiu-Ming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Yue Zheng
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, China.
| | - Wen-Xiong Li
- Department of Surgical Intensive Care Unit, Beijing Chao-yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, China.
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Dao L, Liu H, Xiu R, Yao T, Tong R, Xu L. Gramine improves sepsis-induced myocardial dysfunction by binding to NF-κB p105 and inhibiting its ubiquitination. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 125:155325. [PMID: 38295663 DOI: 10.1016/j.phymed.2023.155325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/16/2023] [Accepted: 12/27/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Sepsis and its associated heart failure are among the leading causes of death. Gramine, a natural indole alkaloid, can be extracted from a wide variety of raw plants, and it exhibits therapeutic potential in pathological cardiac hypertrophy. However, the effect of gramine on inflammatory cardiomyopathy, particularly sepsis-induced myocardial injury, remains an unexplored area. PURPOSE To determine the role of gramine in sepsis-induced myocardial dysfunction and explore its underlying mechanism. STUDY DESIGN AND METHODS In mice, sepsis was established by intraperitoneally injecting lipopolysaccharide (LPS, 10 mg/kg). Subsequently, the effects of gramine administration (50 or 100 mg/kg) on LPS-triggered cardiac dysfunction in mice were investigated. For in vitro studies, isolated primary cardiomyocytes were used to assess the effect of gramine (25 or 50 µM) on LPS-induced apoptosis and inflammation. Additionally, molecular docking, co-immunoprecipitation and ubiquitination analyzes were conducted to explore the underlying mechanisms. RESULTS Gramine visibly ameliorated sepsis-induced cardiac dysfunction, inflammatory response, and mortality in vivo. Moreover, it significantly alleviated LPS-induced apoptotic and inflammatory responses in vitro. Furthermore, target prediction for gramine using the SuperPred website indicated that the nuclear factor NF-κB p105 subunit was one of the molecules ranked in priority order with a high model accuracy and a high probability score. Molecular docking studies demonstrated that gramine effectively docked to the death domain of NF-κB p105. Mechanistic studies revealed that gramine suppressed the processing of NF-κB p105 to p50 by inhibiting NF-κB p105 ubiquitination. Additionally, the protective effect of gramine on cardiac injury was almost abolished by overexpressing NF-κB p105. CONCLUSION Gramine is a promising bioactive small molecule for treating sepsis-induced myocardial dysfunction, which acts by docking to NF-κB p105 and inhibiting NF-κB p105 ubiquitination, thus preventing its processing to NF-κB p50. Therefore, gramine holds potential as a clinical drug for treating myocardial depression during sepsis.
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Affiliation(s)
- Ling Dao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, Henan 450052, China
| | - Hengdao Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, Henan 450052, China
| | - Ruizhen Xiu
- Department of Radiology, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Tianbao Yao
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Renyang Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Beijing 100020, China.
| | - Longwei Xu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, Henan 450052, China.
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Rodrigues N, Costa C, Branco C, Martins C, Lopes JA. Acute kidney injury in multiple myeloma patients undergoing autologous hematopoietic stem cell transplant: a cohort study. J Nephrol 2024; 37:419-428. [PMID: 38019417 PMCID: PMC11043152 DOI: 10.1007/s40620-023-01809-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/14/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Autologous hematopoietic stem cell transplant plays an important role in multiple myeloma (MM) treatment. Increasing incidence of MM and growing awareness of acute kidney injury (AKI) as a complication of hematopoietic stem cell transplant results in the need to better understand AKI in these patients. We aimed to evaluate incidence, risk factors and 5-year prognostic impact of AKI in MM patients undergoing autologous hematopoietic stem cell transplant. METHODS Retrospective cohort study. AKI was defined by the KDIGO classification using creatinine and urinary output criteria. We used survival analysis methods considering competing events for risk factors and disease-free survival, Cox proportional regression for overall survival and stepwise regression methods for multivariable models. RESULTS We analyzed data regarding 143 patients. The cumulative incidence of AKI and moderate-to-severe AKI was 49.7% and 14.1%, respectively. Factors with independent impact on AKI were obesity (HR: 1.83, 95% CI 1.07-3.11; p = 0.026), Hematopoietic cell transplantation-specific comorbidity index (HCT-CI) ≥ 2 (HR: 1.85, 95% CI 1.08-3.17), chronic kidney disease (CKD) (HR: 2.06, 95% CI 1.05-4.04), amyloidosis (HR: 2.25, 95% CI 1.25-4.06), mucositis grade 3-4 (HR: 2.19, 95% CI 1.25-3.86) and exposure to nephrotoxic drugs (HR: 2.0856, 95% CI 1.04-4.19). Moderate-to-severe AKI had an impact (HR: 1.62, 95% CI 1.15-2.31) on 5-year overall survival. CONCLUSION Acute kidney injury affects almost half of MM patients undergoing autologous hematopoietic stem cell transplantation, and reduction in urinary output allows early diagnosis in almost a quarter of the patients. Obesity, HCT-CI ≥ 2, CKD, amyloidosis, mucositis grade 3-4 and exposure to nephrotoxic drugs are significant risk factors. Moderate-to-severe AKI is associated with lower 5-year overall survival.
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Affiliation(s)
- Natacha Rodrigues
- Division of Nephrology and Renal Transplantation, Centro Hospitalar Universitário Lisboa Norte, EPE, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal.
| | - Claudia Costa
- Division of Nephrology and Renal Transplantation, Centro Hospitalar Universitário Lisboa Norte, EPE, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
| | - Carolina Branco
- Division of Nephrology and Renal Transplantation, Centro Hospitalar Universitário Lisboa Norte, EPE, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
| | - Carlos Martins
- Division of Haematology, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisbon, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Centro Hospitalar Universitário Lisboa Norte, EPE, Avenida Professor Egas Moniz, 1649-035, Lisbon, Portugal
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Ho L, Chen X, Kwok YL, Wu IXY, Mao C, Chung VCH. Methodological quality of systematic reviews on sepsis treatments: A cross-sectional study. Am J Emerg Med 2024; 77:21-28. [PMID: 38096636 DOI: 10.1016/j.ajem.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/22/2023] [Accepted: 12/04/2023] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Systematic reviews (SRs) offer updated evidence to support decision-making on sepsis treatments. However, the rigour of SRs may vary, and methodological flaws may limit their validity in guiding clinical practice. This cross-sectional study appraised the methodological quality of SRs on sepsis treatments. METHODS We searched MEDLINE, EMBASE, and Cochrane Database for eligible SRs on randomised controlled trials on sepsis treatments with at least one meta-analysis published between 2018 and 2023. We extracted SRs' bibliographical characteristics with a pre-designed form and appraised their methodological quality using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. We applied logistic regressions to explore associations between bibliographical characteristics and methodological quality ratings. RESULTS Among the 102 SRs, two (2.0%) had high overall quality, while respectively four (3.9%), seven (6.9%) and 89 (87.3%) were of moderate, low, and critically low quality. Performance in several critical methodological domains was poor, with only 32 (31.4%) considering the risk of bias in primary studies in result interpretation, 22 (21.6%) explaining excluded primary studies, and 16 (15.7%) applying comprehensive searching strategies. SRs published in higher impact factor journals (adjusted odds ratio: 1.19; 95% confidence interval: 1.05 to 1.36) was associated with higher methodological quality. CONCLUSIONS The methodological quality of recent SRs on sepsis treatments is unsatisfactory. Future reviewers should address the above critical methodological aspects. More resources should also be allocated to support continuous training in critical appraisal among healthcare professionals and other evidence users.
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Affiliation(s)
- Leonard Ho
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Xi Chen
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Yan Ling Kwok
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Irene X Y Wu
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China; Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, Hunan, China
| | - Chen Mao
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Vincent Chi Ho Chung
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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Sungurlu S, Balk RA. The Role of Biomarkers in the Diagnosis and Management of Pneumonia. Infect Dis Clin North Am 2024; 38:35-49. [PMID: 38280766 DOI: 10.1016/j.idc.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Biomarkers are used in the diagnosis, severity determination, and prognosis for patients with community-acquired pneumonia (CAP). Selected biomarkers may indicate a bacterial infection and need for antibiotic therapy (C-reactive protein, procalcitonin, soluble triggering receptor expressed on myeloid cells). Biomarkers can differentiate CAP patients who require hospital admission and severe CAP requiring intensive care unit admission. Biomarker-guided antibiotic therapy may limit antibiotic exposure without compromising outcome and thus improve antibiotic stewardship. The authors discuss the role of biomarkers in diagnosing, determining severity, defining the prognosis, and limiting antibiotic exposure in CAP and ventilator-associated pneumonia patients.
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Affiliation(s)
- Sarah Sungurlu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University Medical Center, Rush Medical College, 1725 West Harrison Street Suite 054, Chicago, IL 60612, USA
| | - Robert A Balk
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University Medical Center, Rush Medical College, 1725 West Harrison Street Suite 054, Chicago, IL 60612, USA.
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Hay RE, Martin DA, Rutas GJ, Jamal SM, Parsons SJ. Measuring evidence-based clinical guideline compliance in the paediatric intensive care unit. BMJ Open Qual 2024; 13:e002485. [PMID: 38429064 PMCID: PMC10910644 DOI: 10.1136/bmjoq-2023-002485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Evidence-based clinical care guidelines improve medical treatment by reducing error, improving outcomes and possibly lowering healthcare costs. While some data exist on individual guideline compliance, no data exist on overall compliance to multiple nuanced guidelines in a paediatric intensive care setting. METHODS Guideline compliance was observed and measured with a prospective cohort at a tertiary academic paediatric medical-surgical intensive care unit. Adherence to 19 evidence-based clinical care guidelines was evaluated in 814 patients, and reasons for non-compliance were noted along with other associated outcomes. MEASUREMENTS AND MAIN RESULTS Overall facility compliance was unexpectedly high at 77.8% over 4512 compliance events, involving 826 admissions. Compliance varied widely between guidelines. Guidelines with the highest compliance were stress ulcer prophylaxis (97.1%) and transfusion administration such as fresh frozen plasma (97.4%) and platelets (94.8%); guidelines with the lowest compliance were ventilator-associated pneumonia prevention (28.7%) and vitamin K administration (34.8%). There was no significant change in compliance over time with observation. Guidelines with binary decision branch points or single-page decision flow diagrams had a higher average compliance of 90.6%. Poor compliance was more often observed with poor perception of guideline trustworthiness and time limitations. CONCLUSIONS Measuring guideline compliance, though onerous, allowed for evaluation of current clinical practices and identified actionable areas for institutional improvement.
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Affiliation(s)
- Rebecca E Hay
- Pediatric Critical Care, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
- Pediatric Critical Care, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Dori-Ann Martin
- Pediatric Critical Care, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Gary J Rutas
- Pediatric Critical Care, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Shelina M Jamal
- Pediatric Critical Care, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Simon J Parsons
- Pediatric Critical Care, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
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Jouffroy R, Négrello F, Limery J, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality. BMC Infect Dis 2024; 24:213. [PMID: 38365608 PMCID: PMC10873999 DOI: 10.1186/s12879-024-09104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. RESULTS Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. CONCLUSION A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital- Assistance Publique Hôpitaux Paris, 9 avenue Charles De Gaulle, 92100, Boulogne-Billancourt, Paris, France.
- IRMES - Institute for Research in Medicine and Epidemiology of Sport, INSEP, Paris, France.
- INSERM U-1018, Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM, Paris Saclay University, Villejuif, France.
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France.
- UR5_3 PC2E, University of the Antilles, French West Indies, France.
| | - Florian Négrello
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| | - Jean Limery
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
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50
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Wu MY, Hou YT, Chung JY, Yiang GT. Reverse shock index multiplied by simplified motor score as a predictor of clinical outcomes for patients with COVID-19. BMC Emerg Med 2024; 24:26. [PMID: 38355419 PMCID: PMC10865660 DOI: 10.1186/s12873-024-00948-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM). METHODS All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden's index. RESULTS After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33-60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively. CONCLUSIONS Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.
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Affiliation(s)
- Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, 970, Taiwan
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
| | - Yueh-Tseng Hou
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, 970, Taiwan
| | - Jui-Yuan Chung
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
- School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, 970, Taiwan.
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