Number of organ dysfunctions predicts mortality in emergency department patients with suspected infection: a multicenter validation study

End-of-life use of antibiotics: a survey on how doctors decide

OBJECTIVES

Infections are the main complications in terminal diseases. Many patients die using antibiotics, which raises questions about their real usefulness and role in unnecessary prolongation of suffering. This survey evaluated how doctors use antibiotics in palliative care.

METHODS

From June to August of 2016, an online survey was conducted with 224 doctors who provide palliative care. They had to decide whether to initiate antibiotics in fictitious scenarios involving patients with suspected infections (urinary tract infection, pneumonia, sepsis) in end-of-life (from cancer, dementia, malignant stroke with sequelae, advanced COPD, multiple organ failure). Then, they had to decide whether to stop, maintain, or extend antibiotics after non-response in 72 hours.

RESULTS

88-100% of doctors decided to initiate antibiotics in all situations, except in advanced dementia (55%), and most of them decided to maintain/extend antibiotics inadequately. Factors associated with maintaining/extending antibiotics inadequately were: longer time since graduation (over 13 years; significant in all 7 clinical situations; OR range: 2.45-10.11), and not having formal specialization in palliative care (statistically significant in 3 of 7 situations).

CONCLUSIONS

Most palliative care physicians in this study decided to initiate and maintain/extend antibiotics at the end-of-life.

Overexpressing TGF-β1 in mesenchymal stem cells attenuates organ dysfunction during CLP-induced septic mice by reducing macrophage-driven inflammation

Background

Sepsis remains a leading cause of death in critically ill patients. It is well known that mesenchymal stem cells (MSCs) are a promising therapy partly due to their paracrine-mediated immunoregulatory function. Previous study demonstrated that transforming growth factor-beta1 (TGF-β1) is an important cytokine secreted by MSCs and that it participates in MSC-mediated macrophage phenotype switch from pro-inflammatory to pro-resolution. In addition, the transformation of macrophage phenotype may be a potential treatment for sepsis. However, the therapeutic effect of overexpressing TGF-β1 in MSCs (MSC-TGF-β1) on sepsis is not well understood. Therefore, this study aimed to evaluate the effects of TGF-β1 overexpressing MSCs on organ injury in cecal ligation and puncture (CLP)-induced septic mice and to detect the changes in macrophage phenotype during this process.

Methods

Mouse MSCs stably transfected with TGF-β1 were constructed and injected into CLP-induced septic mice via tail vein. After 24 h, the mice were sacrificed; then, the histopathology of the organ was evaluated by hematoxylin-eosin (H&E) staining. Inflammatory cytokines were detected by ELISA. Macrophage infiltration and phenotype transformation in the tissues were determined by immunohistochemistry and flow cytometry. In addition, we performed adoptive transfer of mouse peritoneal macrophage pretreated with TGF-β1 overexpressing MSCs in septic mice.

Results

We found that infusion of TGF-β1 overexpressing MSCs attenuated the histopathological impairment of the organ, decreased the pro-inflammatory cytokine levels and inhibited macrophage infiltration in tissues. TGF-β1 overexpressing MSCs induced macrophage phenotypes changed from pro-inflammatory to pro-resolution in inflammatory environment. The adoptive transfer of mouse peritoneal macrophages pretreated with TGF-β1 overexpressing MSCs also relieved organ damage in CLP-induced septic mice.

Conclusion

Under septic conditions, TGF-β1 overexpressing MSCs can enhance the therapeutic effects of MSCs on organ injury and inflammation as a result of reduced macrophage infiltration and induced macrophages transformation, the adoptive transfer of macrophages treated with TGF-β1 overexpressing MSCs also relieved organ damage. This will provide new hope for the treatment of sepsis.

Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival.

DESIGN

This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults).

SETTING

Emergency department at Odense University Hospital, Denmark.

PARTICIPANTS

We included all adult patients who arrived from 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality.

RESULTS

We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%).

CONCLUSIONS

The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.

Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review

Introduction

Patients in an emergency department are diverse. Some are more seriously ill than others and some even arrive in multi-organ failure. Knowledge of the prevalence of organ failure and its prognosis in unselected patients is important from a diagnostic, hospital planning, and from a quality evaluation point of view, but is not reported systematically.

Objectives

To analyse the prevalence and prognosis of new onset organ failure in unselected acute patients at arrival to hospital.

Methods

A systematic review of studies of prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital. We searched PubMed, Cochrane Library, Embase and Cinahl, and read references in included studies. Two authors decided independently on study eligibility and extracted data. Results were summarised qualitatively.

Results

Four studies were included with a total of 678,960 patients. The number of different organ failures reported in the studies ranged from one to six, and the settings were emergency departments and wards. The definitions of organ failure varied between studies. The prevalence of organ failure was 7%, 14%, 14%, and 23%, and in-hospital mortality was 5%, 11% and 15% respectively. The relative risk of in-hospital mortality for patients with organ failure compared to patients without organ failure varied from 2.58 to 8.65. Numbers of organ failures per 1,000 visits varied from 71 to 256.

Conclusion

The results of this review indicate that clinicians have good reasons to be alert when a patient arrives to the emergency department; as a state of organ failure seems both frequent and highly severe.

However, most studies identified were performed in patients after a diagnosis was established, and only very few studies were performed in unselected patients.

Systematic review registration number

PROSPERO: CRD42017060871.

Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: protocol for a systematic review

BACKGROUND

Acutely ill patients are a heterogeneous group, and some of these suffer from organ failure. As the prognosis of organ failure improves with early treatment, it is important to identify these patients as early as possible. Most studies on organ failure have been performed in intensive care settings, or on selected groups of patients, where a high prevalence and mortality have been reported. Before patients arrive to the intensive care unit, or the general ward, most of them have passed through the emergency department (ED), where diagnosis and treatment has been initiated. The prevalence and prognosis of acutely ill patients, with organ failure, at arrival have been studied in some selected groups, but methods and results differ. This systematic review aims to identify, summarize, and analyze studies of prevalence and prognosis of new onset organ failure in acutely ill undifferentiated patients, at arrival to hospital. The result of the review will assist physicians working in an ED, when assessing patients' risk of organ failure and their associated prognosis.

METHODS

The information sources used are electronic databases, PubMed, Cochrane Library, EMBASE, and CINAHL; references in included studies and review articles; and authors' personal files. One author will perform the title and abstract screening and exclude obviously ineligible studies. By an independent full-text screening, two authors will decide on the eligibility for the remaining studies. Eligible studies will include an unselected group of acutely ill adult patients at arrival to hospital, with one or more organ failures (respiratory, renal, cerebral, circulatory, hepatic, or coagulation failure). Included studies will have assessed the prevalence or prognosis, defined as mortality or ICU transfer, of new onset organ failure. From included studies, bibliographical and study description data, patient characteristics, and data related to prevalence of organ failure and prognosis will be extracted. We will assess risk of bias in included studies using the Quality in Prognosis Studies tool for prognostic studies and the Newcastle-Ottawa Scale for observational studies. We expect heterogeneity and to conduct a qualitative synthesis of the results. If, however, heterogeneity is low, we will conduct a random effects meta-analysis stratified by basic study design.

DISCUSSION

This review will summarize and analyze studies of prevalence and prognosis of acutely ill patients, with organ failure at arrival to hospital, assist ED physicians assessing the risk of organ failure in unselected patients, and guide recommendations for further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017060871.