Association between aspirin therapy and the outcome in critically ill patients: a nested cohort study

Metabolic syndrome induces benefits in mice experiencing severe sepsis, comparable to the effects of low-dose aspirin pretreatment in septic mice lacking metabolic syndrome

BACKGROUND

Sepsis is a complex condition characterized by systemic host inflammation caused by an infection. Experimental and observational studies indicate that obesity, one of the components of metabolic syndrome (MetS), or aspirin (ASA) treatment could be associated with sepsis survival. However, the effects of ASA on septic mice with MetS-induced conditions have not been explored.

METHODS

Swiss mice were administered monosodium glutamate (MSG) (4 mg/kg) during their first 5 days of life for MetS induction, while the control mice received an equimolar saline solution. MetS was validated in male mice on their 60th day of life. ASA treatment was administered for 15 days prior to sepsis (40 mg/kg). On the 75th day, sepsis was induced in MetS and control mice through cecal ligation and puncture (CLP). The effects of ASA on septic mice with MSG-induced MetS were assessed by determining survival rates, quantification of nitric oxide (NO), and cytokine levels in the plasma, while correlating these data with hematological, blood glucose and cardiovascular parameters.

RESULTS

MetS was validated by Lee-Index (3 body weight/naso-anal length×1000), hypertension, and hyperglycemia in animals receiving MSG as neonates. In control animals, severe sepsis promoted hypoglycemia, which was associated with mortality, as well as increased plasma NO levels, hypotension, hematological alterations, and elevation of proinflammatory cytokines. In contrast, MetS and pre-treatment with ASA were able to prevent sepsis-related alterations.

CONCLUSIONS

MetS and ASA pre-treatment provided protection against severe sepsis. However, ASA was ineffective in mice with MetS undergoing severe sepsis.

Mendelian randomization analysis reveals causal associations of serum metabolites with sepsis and 28-day mortality

Metabolic disorder has been found to be an important factor in the pathogenesis and progression of sepsis. However, the causation of such an association between serum metabolites and sepsis has not been established. We conducted a two-sample Mendelian randomization (MR) study. A genome-wide association study of 486 human serum metabolites was used as the exposure, whereas sepsis and sepsis mortality within 28 days were set as the outcomes. In MR analysis, 6 serum metabolites were identified to be associated with an increased risk of sepsis, and 6 serum metabolites were found to be related to a reduced risk of sepsis. Furthermore, there were 9 metabolites positively associated with sepsis-related mortality, and 8 metabolites were negatively correlated with sepsis mortality. In addition, "glycolysis/gluconeogenesis" (p = 0.001), and "pyruvate metabolism" (p = 0.042) two metabolic pathways were associated with the incidence of sepsis. This MR study suggested that serum metabolites played significant roles in the pathogenesis of sepsis, which may provide helpful biomarkers for early disease diagnosis, therapeutic interventions, and prognostic assessments for sepsis.

Association between aspirin and mortality in critically ill patients with atrial fibrillation: a retrospective cohort study based on mimic-IV database

Background

Atrial fibrillation (AF) is a prevalent issue among critically ill patients, and the availability of effective treatment strategies for AF is limited.

Aim

The objective of this study was to evaluate the mortality rate associated with AF in critically ill patients who were either aspirin or non-aspirin users.

Methods

This cohort study incorporated critically ill patients with AF from the Medical Information Mart for Intensive Care database. The study compared incidences of 28-day mortality, 90-day mortality, and 1-year mortality between patients with and without aspirin prescriptions. To assess the association between aspirin and the endpoints, Kaplan-Meier analysis and Cox proportional hazards regression analyses were conducted.

Results

In this study, a total of 13,330 critically ill patients with atrial fibrillation (AF) were included, of which 4,421 and 8,909 patients were categorized as aspirin and non-aspirin users, respectively. The 28-day, 90-day, and 1-year mortality rates were found to be 17.5% (2,330/13,330), 23.9% (3,180/13,330), and 32.9% (4,379/13,330), respectively. The results of a fully-adjusted Cox proportional hazard model indicated that aspirin use was negatively associated with the risk of death after adjusting for confounding factors (28-day mortality, HR 0.64, 95% CI 0.55-0.74; 90-day mortality, HR 0.65, 95% CI 0.58-0.74; 1-year mortality, HR 0.67, 95%CI 0.6∼0.74). The results of the subgroup analysis indicate a more robust correlation, specifically among patients under the age of 65 and those without a history of congestive heart failure or myocardial infarction.

Conclusions

The utilization of aspirin may exhibit a correlation with a reduction in risk-adjusted mortality from all causes in critically ill patients diagnosed with atrial fibrillation. However, additional randomized controlled trials are necessary to elucidate and confirm this potential association.

Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients

BACKGROUND

The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thromboembolic incidents and leveraging anti-inflammatory properties against the increased risk of bleeding.

METHODS

This study involves a secondary analysis of data from a prospective cohort study focusing on patients diagnosed with severe sepsis or septic shock. We evaluated the outcomes of 203 patients, examining mortality rates and the requirement for transfusion. The cohort was divided into two groups: those whose antiplatelet therapy was sustained (n = 114) and those in whom it was discontinued (n = 89). To account for potential biases such as indication for antiplatelet therapy, propensity score matching was employed.

RESULTS

Therapy continuation did not significantly alter transfusion requirements (discontinued vs. continued in matched samples: red blood cell concentrates 51.7% vs. 68.3%, p = 0.09; platelet concentrates 21.7% vs. 18.3%, p = 0.82; fresh frozen plasma concentrates 38.3% vs. 33.3%, p = 0.7). 90-day survival was higher within the continued group (30.0% vs. 70.0%; p < 0.001) and the Log-rank test (7-day survivors; p = 0.001) as well as Cox regression (both matched samples) suggested an association between continuation of antiplatelet therapy < 7 days and survival (HR: 0.24, 95%-CI 0.10 to 0.63, p = 0.004). Sepsis severity expressed by the SOFA score did not differ significantly in matched and unmatched patients (both p > 0.05).

CONCLUSIONS

The findings suggest that continuing antiplatelet therapy in septic patients admitted to intensive care units could be associated with a significant survival benefit without substantially increasing the need for transfusion. These results highlight the importance of a nuanced approach to managing antiplatelet medication in the context of severe sepsis and septic shock.

The 125th Anniversary of Aspirin-The Story Continues

The year 2024 marks the 125th anniversary of aspirin, still one of the most frequently used drugs worldwide. Despite its veritable age, it is still relevant in pharmacotherapy and its use has spread to new areas over time. Due to aspirin's multiple pharmacological actions unified in one single molecule (i.e., analgesic, antipyretic, anti-inflammatory, antithrombotic, and antiviral effects), it continues to attract considerable attention in the scientific community and is subject to intense basic and clinical research. In fact, recent results confirmed aspirin's potential role as an antiviral drug and as an agent that can block harmful platelet functions in inflammatory/immunological processes. These features may open up new horizons for this ancient drug. The future of aspirin looks, therefore, bright and promising. Aspirin is not yet ready for retirement; on the contrary, its success story continues. This 125th anniversary paper will concisely review the various therapeutic uses of aspirin with a particular emphasis on the latest research results and their implications (e.g., use as an antiviral agent). In addition, the reader is provided with future perspectives for this remarkable drug.

Thromboinflammation in acute injury: infections, heatstroke, and trauma

Tissue microcirculation is essential for the maintenance of organ homeostasis. Following acute infections, activation of coagulation and inflammation, which are critical interconnected responses, lead to thromboinflammation and microthrombosis, thereby contributing to multiorgan dysfunction. Sepsis is the most common underlying disease and has been extensively studied. However, the COVID-19 pandemic further illustrated the pathomechanisms of diseases in which thromboinflammation plays a critical role. During thromboinflammation, injury to monocytes, neutrophils, platelets, and endothelial cells, along with coagulation and complement activation, was further characterized. Thrombin is pivotal in orchestrating thrombosis and inflammation and has long been considered a potential therapeutic target in sepsis. Although thromboprophylaxis for venous thromboembolism with heparins is part of standard management for COVID-19, it also potentially attenuates organ dysfunction due to thrombotic sequela. In contrast, the effectiveness of anticoagulation with heparin, antithrombin, or thrombomodulin to reduce mortality has not conclusively been proven in sepsis. Nonetheless, thromboinflammation has also been reported as an important pathophysiologic mechanism in other critical illnesses, including heatstroke, trauma, and ischemia/reperfusion injury, and may provide a potential therapeutic target for future clinical studies.

Aspirin intervention before ICU admission reduced the mortality in critically ill patients with acute kidney injury: results from the MIMIC-IV

Background: Aspirin, with its pleiotropic effects such as anti-inflammatory and anti-platelet aggregation, has been widely used for anti-inflammatory, analgesic, and cardiovascular diseases. However, the association between the use of aspirin before the intensive care unit (ICU) and clinical outcomes in critically ill patients with acute kidney injury (AKI) is unknown. Methods: Patients with AKI in this retrospective observational study were selected from the Marketplace for Medical Information in Intensive Care IV (MIMIC-IV). The association between aspirin intervention and 30-day mortality was assessed using Cox proportional hazards model. Logistic regression models were used to assess the association of aspirin intervention with the risks of intracranial hemorrhage, gastrointestinal bleeding and blood transfusion. The propensity score matching (PSM) method was adopted to balance the baseline variables. Sensitivity analysis was performed to validate the results by multiple interpolations for the missing data. Results: The study included 4237 pre-ICU aspirin users and 9745 non-users. In multivariate models, we found a decreased risk of mortality in those who received aspirin before ICU compared to those who did not (30-day:hazard ratio [HR], 0.70; 95% CI, 0.62-0.79; p < 0.001; 90-day:HR, 0.70; 95% CI, 0.63-0.77, p < 0.001; 180-day:HR, 0.72; 95%CI,0.65-0.79, p < 0.001). This benefit was consistent in the post-PSM analyses, sensitivity analyses, and subgroup analyses. Moreover, aspirin intervention was associated with a reduced risk of intracranial hemorrhage and gastrointestinal bleeding (HR, 0.16; 95% CI, 0.10-0.25; p < 0.001; HR, 0.59; 95% CI, 0.38-0.88, p = 0.012) after being adjusted by relating covariates, whereas with a increased risk of blood transfusion (HR, 1.28; 95% CI, 1.16-1.46; p < 0.001). Conclusion: Patients with AKI treated with aspirin before ICU admission might have reduced 30-day, 90-day and 180-day mortality without increasing the risk of intracranial hemorrhage (ICH) or gastrointestinal bleeding, but may increase the risk of transfusion.

Aspirin reduces the mortality risk of sepsis-associated acute kidney injury: an observational study using the MIMIC IV database

Introduction: Sepsis-associated acute kidney injury (SA-AKI) is a complication of sepsis and is characterized by high mortality. Aspirin affects cyclooxygenases which play a significant role in inflammation, hemostasis, and immunological regulation. Sepsis is an uncontrolled inflammatory and procoagulant response to a pathogen, but aspirin can inhibit platelet function to attenuate the inflammatory response, thus improving outcomes. Several studies have generated contradictory evidence regarding the effect of aspirin on patients with sepsis-associated acute kidney injury (SA-AKI). We conducted an analysis of the MIMIC IV database to investigate the correlation between aspirin utilization and the outcomes of patients with SA-AKI, as well as to determine the most effective dosage for aspirin therapy. Materials and methods: SA-AKI patients' clinical data were extracted from MIMIC-IV2.1. Propensity score matching was applied to balance the baseline characteristics between the aspirin group and the non-user group. Subsequently, the relationship between aspirin and patient death was analyzed by Kaplan-Meier method and Cox proportional hazard regression models. Results: 12,091 patients with SA-AKI were extracted from the MIMIC IV database. In the propensity score-matched sample of 7,694 individuals, lower 90-day mortality risks were observed in the aspirin group compared to the non-users group (adjusted HR: 0.722; 95%CI: 0.666, 0.783) by multivariable cox proportional hazards analysis. In addition, the Kaplan-Meier survival curves indicated a superior 90-day survival rate for aspirin users compared to non-users (the log-rank test p-value was 0.001). And the median survival time of patients receiving aspirin treatment was significantly longer than those not receiving (46.47 days vs. 24.26 days). In the aspirin group, the average ICU stay length was shorter than non-users group. (5.19 days vs. 5.58 days, p = 0.006). There was no significant association between aspirin and an increased risk of gastrointestinal hemorrhage (p = 0.144). Conclusion: Aspirin might reduce the average ICU stay duration and the 30-day or 90-day mortality risks of SA-AKI patients. No statistically significant difference in the risk of gastrointestinal hemorrhage was found between the aspirin group and the control group.

Aspirin Therapy and 28-Day Mortality in ICU Patients: A Retrospective Observational Study From Two Large Databases

PURPOSE

Aspirin is widely used in patients in the intensive care unit (ICU); nonetheless, its effects on these patients remain controversial. This retrospective analysis of data from clinical practice investigated the effects of aspirin on 28-day mortality in ICU patients.

METHODS

This retrospective study included data from patients in the Medical Information Mart for Intensive Care (MIMIC)-III database and the eICU-Collaborative Research Database (CRD). Patients aged 18 to 90 years and admitted to the ICU were eligible and were assigned to one of two groups according to whether they were given aspirin during their ICU stay. Multiple imputation was used for patients with >10% missing data. Multivariate Cox models and propensity score analysis were used to estimate the association of aspirin treatment with 28-day mortality among patients admitted to the ICU.

FINDINGS

In total, 146,191 patients were enrolled in this study, and 27,424 (18.8%) used aspirin. Aspirin treatment in ICU patients, especially in nonseptic patients, was associated with a lower 28-day all-cause mortality on multivariate Cox analysis (eICU-CRD, hazard ratio [HR] = 0.81, [95% CI, 0.75-0.87]; MIMIC-III, HR = 0.72 [95% CI, 0.68-0.76]). Aspirin treatment was associated with lower 28-day all-cause mortality after propensity score matching (eICU-CRD, HR = 0.80 [95% CI, 0.72-0.88]; MIMIC-III, HR = 0.80 [95% CI, 0.76-0.85]). However, on subgroup analysis, aspirin therapy was not associated with a lower 28-day mortality in patients without systemic inflammatory response syndrome (SIRS) symptoms or with sepsis in either database.

IMPLICATIONS

Aspirin treatment during the ICU stay was associated with a significantly reduced 28-day all-cause mortality, particularly in patients with SIRS symptoms but without sepsis. In patients with sepsis and with/without SIRS symptoms, beneficial effects were not clear, or more careful patient selection is required. (Clin Ther. 2023;45:XXX-XXX) © 2023 Elsevier Inc.

Effect of antiplatelet agents on Escherichia coli sepsis mechanisms: A review

Despite ever-increasing improvements in the prognosis of sepsis, this condition remains a frequent cause of hospitalization and mortality in Western countries. Sepsis exposes the patient to multiple complications, including thrombotic complications, due to the ability of circulating bacteria to activate platelets. One of the bacteria most frequently implicated in sepsis, Escherichia coli, a Gram-negative bacillus, has been described as being capable of inducing platelet activation during sepsis. However, to date, the mechanisms involved in this activation have not been clearly established, due to their multiple characteristics. Many signaling pathways are thought to be involved. At the same time, reports on the use of antiplatelet agents in sepsis to reduce platelet activation have been published, with variable results. To date, their use in sepsis remains controversial. The aim of this review is to summarize the currently available knowledge on the mechanisms of platelet activation secondary to Escherichia coli sepsis, as well as to provide an update on the effects of antiplatelet agents in these pathological circumstances.

Platelet p110β mediates platelet-leukocyte interaction and curtails bacterial dissemination in pneumococcal pneumonia

Phosphatidylinositol 3-kinase catalytic subunit p110β is involved in tumorigenesis and hemostasis. However, it remains unclear if p110β also regulates platelet-mediated immune responses, which could have important consequences for immune modulation during anti-cancer treatment with p110β inhibitors. Thus, we investigate how platelet p110β affects inflammation and infection. Using a mouse model of Streptococcus pneumoniae-induced pneumonia, we find that both platelet-specific p110β deficiency and pharmacologic inhibition of p110β with TGX-221 exacerbate disease pathogenesis by preventing platelet-monocyte and neutrophil interactions, diminishing their infiltration and enhancing bacterial dissemination. Platelet p110β mediates neutrophil phagocytosis of S. pneumoniae in vitro and curtails bacteremia in vivo. Genetic deficiency or inhibition of platelet p110β also impairs macrophage recruitment in an independent model of sterile peritonitis. Our results demonstrate that platelet p110β dysfunction exacerbates pulmonary infection by impeding leukocyte functions. Thereby, our findings provide important insights into the immunomodulatory potential of PI3K inhibitors in bacterial infection.

Stachydrine exhibits a novel antiplatelet property and ameliorates platelet-mediated thrombo-inflammation

BACKGROUND

Platelets are versatile anucleate cells involved in thrombosis as well as inflammation. Stachydrine (STA), a major bioactive compound extracted from Motherwort, has multiple pharmacological properties. Nevertheless, the significance of STA in platelet regulation and whether STA could ameliorate platelet-mediated thrombo-inflammation still remain elusive.

METHODS

Human platelets were used to assess the regulatory effects of STA on platelet activation and interactions with neutrophils in vitro. FeCl₃ injury-induced carotid/mesenteric thrombosis and collagen/epinephrine-induced pulmonary thromboembolism model were used to explore whether STA could regulate thrombosis in vivo. Furthermore, a cecal ligation and puncture-induced sepsis model was employed to investigate the role of STA in thrombo-inflammatory diseases.

RESULTS

STA markedly suppressed platelet activation represented by aggregation, secretion, αIIbβ3-mediated signaling events and calcium mobilization, etc. by inhibiting agonists-induced activation signaling and potentiating cGMP-dependent inhibitory signaling. Mice receiving STA-treated platelets were less susceptible to thrombosis in vivo. In addition, decreased platelet-neutrophil interactions including platelet-neutrophil aggregates and neutrophil extracellular traps, and alleviative sepsis-induced multiorgan damage were observed due to STA-mediated platelet inhibition.

CONCLUSION

This study suggested the potential therapeutic role of STA in thrombotic and thrombo-inflammatory disorders.

Transfusion of fresh washed platelets does not prevent experimental polymicrobial-induced septic shock in mice

INTRODUCTION

The specific role of platelets during sepsis is not yet fully understood, probably related to the paradox of platelets being potentially beneficial but also deleterious via their thrombotic functions.

OBJECTIVE

To evaluate the impact of thrombocytopenia on septic shock in mice and to investigate whether transfusion of fresh washed platelets, either fully functional or with impaired hemostatic properties, might have beneficial effects.

METHODS

Septic shock was induced by cecal ligation and puncture (CLP). Experimental depletion of circulating platelets was induced with a rat anti-mouse GPIbα monoclonal antibody. Transfusion of either wild-type washed platelets, platelets treated with the antiplatelet drugs acetylsalicylic acid (ASA) and clopidogrel, or GPIIbIIIa-deficient washed platelets treated with ASA and clopidogrel was performed 4 h after CLP surgery.

RESULTS

Depletion of circulating platelets negatively affected septic shock, worsening systemic inflammation, coagulopathy, organ damage, and mortality, raising the question of whether a higher platelet count could be protective. Transfusion of fully functional platelets or platelets with combined treatment with ASA and clopidogrel, with or without additional GPIIbIIIa deficiency, afforded an immediate return of circulating platelet counts to their initial values before surgery. However, transfusion of each of the three types of platelets did not prevent arterial hypotension, inflammatory response, coagulopathy, and organ damage during septic shock.

CONCLUSION

Depletion of circulating platelets negatively affects septic shock, while transfusion of washed platelets has no significant beneficial effect in mice.

Platelet P2Y 12 Receptor Deletion or Pharmacological Inhibition does not Protect Mice from Sepsis or Septic Shock

Introduction  Platelets are increasingly appreciated as key effectors during sepsis, raising the question of the usefulness of antiplatelet drugs to treat patients with sepsis.

Objective  Evaluate the potential contribution of the platelet P2Y ₁₂ receptor in the pathogenesis of polymicrobial-induced sepsis and septic shock in mice.

Methods  The effects of P2Y ₁₂ inhibition using clopidogrel treatment and of platelet-specific deletion of the P2Y ₁₂ receptor in mice were examined in two severity grades of cecal ligation and puncture (CLP) leading to mild sepsis or septic shock.

Results  Twenty hours after induction of the high grade CLP, clopidogrel- and vehicle-treated mice displayed a similar 30% decrease in mean arterial blood pressure (MAP) characteristic of shock. Septic shock-induced thrombocytopenia was not modified by clopidogrel treatment. Plasma concentrations of inflammatory cytokines and myeloperoxidase (MPO) were similarly increased in clopidogrel- and vehicle-treated mice, indicating comparable increase in systemic inflammation. Thrombin-antithrombin (TAT) complexes and the extent of organ damage were also similar. In mild-grade CLP, clopidogrel- and vehicle-treated mice did not display a significant decrease in MAP, while thrombocytopenia and plasma concentrations of TNFα, IL6, IL10, MPO, TAT and organ damage reached similar levels in both groups, although lower than those reached in the high grade CLP. Similarly, mice with platelet-specific deletion of the P2Y ₁₂ receptor were not protected from CLP-induced sepsis or septic shock.

Conclusion  The platelet P2Y ₁₂ receptor does not contribute to the pathogenesis of sepsis or septic shock in mice, suggesting that P2Y ₁₂ receptor antagonists may not be beneficial in patients with sepsis or septic shock.

Effect of aspirin on coronavirus disease 2019: A nationwide case-control study in South Korea

Several studies reported that aspirin can potentially help prevent infection and serious complications of coronavirus disease (COVID-19), but no study has elucidated a definitive association between aspirin and COVID-19. This study aims to investigate the association between aspirin and COVID-19.This case-control study used demographic, clinical, and health screening laboratory test data collected from the National Health Insurance Service database. Patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection until June 4, 2020, were matched with control patients using propensity score matching according to their SARS-CoV-2 status, the composite of complications, and death. The composite of complications included intensive care unit admission, use of vasopressors, high-flow oxygen therapy, renal replacement therapy, extracorporeal membrane oxygenation, and death. Exposure to aspirin was defined as having a prescription for aspirin for more than 14 days, including the index date. After matching, multivariable-adjusted conditional logistic regression analysis was performed. To confirm the robustness of this study, we used 2 study groups, 3 propensity score matching methods, and 3 models for conditional logistic regression analyses.The crude odds ratio and 95% confidence interval for SARS-CoV-2 infection between the groups without and with exposure to aspirin were 1.21 (1.04-1.41), but the adjusted odds ratios (95% confidence interval) were not significant. There was no association between aspirin exposure and COVID-19 status. Multiple statistical analyses, including subgroup analysis, revealed consistent results. Furthermore, the results of analysis for complications and death were not significant. Aspirin exposure was not associated with COVID-19-related complications and mortality in COVID-19 patients.In this nationwide population-based case-control study, aspirin use was not associated with SARS-CoV-2 infection or related complications. With several ongoing randomized controlled trials of aspirin in COVID-19 patients, more studies would be able to confirm the effectiveness of aspirin in COVID-19.

Platelets mediate serological memory to neutralize viruses in vitro and in vivo

Platelets contain virus-specific IgGs that potently diminish viral infection in vitro and in vivo. Release of platelet IgG is more efficient at virus neutralization than equal amounts of plasma IgG.

Hospitalization for acute coronary syndrome increases the long-term risk of pneumonia: a population-based cohort study

It is well established that the risk of acute coronary syndrome (ACS) increases after respiratory infection. However, the reverse association has not been evaluated. We tested the hypothesis that the long-term risk of pneumonia is increased after a new ACS event. A matched-cohort study was conducted using a nationally representative dataset. We identified patients with admission for ACS between 2004 and 2014, without a previous history of ACS or pneumonia. Incidence density sampling was used to match patients, on the basis of age and sex, to 3 controls who were also free from both ACS and pneumonia. We examined the incidence of pneumonia after ACS until the end of the cohort observation (Dec 31, 2014). The analysis cohort consisted of 5469 ACS cases and 16,392 controls (median age, 64 years; 68.3% men). The incidence rate ratios of the first and the total pneumonia episodes in the ACS group relative to the control group was 1.25 (95% confidence interval [CI], 1.11–1.41) and 1.23(95% CI 1.11–1.36), respectively. A significant ACS-related increase in the incidence of pneumonia was observed in the Cox-regression, shared frailty, and joint frailty model analyses, with hazard ratios of 1.25 (95% CI 1.09–1.42), 1.35 (95% CI 1.15–1.58), and 1.24 (95% CI 1.10–1.39), respectively. In this population-based cohort of patients who were initially free from both ACS and pneumonia, we found that hospitalization for ACS substantially increased the long term risk of pneumonia. This should be considered when formulating post-discharge care plans and preventive vaccination strategies in patients with ACS.

Multiple trauma including pelvic fracture with multiple arterial embolization: an autopsy case report

Background

Pelvic fracture with high energy trauma has a high mortality rate, especially in men. In addition, severe multiple trauma, major hemorrhage, and administration of red blood cells predict mortality in elderly patients with pelvic fracture. We herein report a rare case in which multiple arterial embolization occurred after pelvic fracture.

Case presentation

An 83-year-old male cyclist was transported to our hospital after being struck by a car. On arrival, he was diagnosed with multiple trauma, including rib fractures with hemothorax, lumbar fractures of the transverse process, and injuries in the right acetabulum, left adrenal gland, and liver. He underwent massive transfusion and transcatheter arterial embolization due to extravasation from the right superior gluteal artery and left adrenal gland. On the second day, owing to right lower leg ischemia, serum creatinine kinase and myoglobin levels were markedly elevated from the reference value; hence, a right above-knee amputation was performed 12 h after the accident. However, both protein levels remained high after amputation, resulting in acute renal injury, which was treated via hemodiafiltration on hospital day 3. In addition, sustained low efficiency hemodialysis and plasma exchange were performed on hospital day 4. Despite these treatments, the patient’s hemodynamics did not improve, and he died on hospital day 8. The autopsy revealed necropsy of the iliopsoas muscles and the digestive tract.

Conclusions

The causes of the patient’s death were considered to be persistent rhabdomyolysis and severe hypotension due to iliopsoas necrosis and peritonitis due to digestive tract necrosis. Multiple arterial embolization caused by consumption coagulopathy associated with multiple trauma may account for severe outcomes in this case.

Effects of antiplatelet therapy on the mortality rate of patients with sepsis: A meta-analysis

PURPOSE

Abnormal platelet activation plays an important role in the development of sepsis. The effect of antiplatelet drugs on the outcome of patients with sepsis remains unclear. This meta-analysis aimed to determine the effect of antiplatelet drugs on the prognosis of patients with sepsis.

MATERIALS AND METHODS

PubMed, Cochrane Library, CBM, and Embase were searched for all related articles published from inception to April 2018. The primary end point was mortality. Adjusted data were used and statistically analysed.

RESULTS

Ten cohort studies were included. The total number of patients with sepsis was 689,897. Data showed that the use of antiplatelet drugs could effectively reduce the mortality of patients with sepsis (odds ratio (OR) = 0.82, 95% CI: 0.81-0.83, p < 0.05). Seven studies used aspirin for antiplatelet therapy, and subgroup analysis showed that aspirin effectively reduced ICU or hospital mortality in patients with sepsis (OR = 0.60, 95% CI: 0.53-0.68, p < 0.05). A subgroup analysis on the timing of anti-platelet drug administration showed that antiplatelet drugs can reduce mortality when administered either before (OR = 0.78, 95% CI: 0.77-0.80) or after sepsis (OR = 0.59, 95% CI: 0.52-0.67).

CONCLUSIONS

Antiplatelet drugs, particularly aspirin, could be used to effectively reduce mortality in patients with sepsis.

Association between β-blocker use and mortality in critically ill patients: a nested cohort study

BACKGROUND

β-blockers have several indications in critically ill patients and are commonly used. The aim of this study is to examine the relationship between the use of β-blockers in critically ill patients and mortality.

METHODS

This was a nested cohort study in which all medical-surgical ICU patients (N = 523) enrolled in a randomized clinical trial of intensive insulin therapy (ISRCTN07413772) were grouped according to β-blocker use during ICU stay. To account for the indication of β-blockers, we constructed a propensity score using selected clinically-relevant and statistically-significant variables related to β-blocker exposure and outcome. The primary endpoints were all-cause ICU and hospital mortality. Secondary endpoints were the development of severe sepsis during ICU stay, ICU and hospital length of stay, and mechanical ventilation duration. Using multivariable models, we adjusted the associations of β-blockers and these outcomes to the propensity score.

RESULTS

Of the 523 patients enrolled in the study, 89 (17.0%) received β-blockers during their ICU stay. There were no significant associations between β-blocker therapy and ICU mortality (adjusted odds ratio [aOR] 1.56, 95% confidence interval [CI] 0.83-2.9, P = 0.16), hospital mortality (aOR 1.09, 95% CI 0.99-1.20, P = 0.73), the risk of ICU-acquired severe sepsis (aOR 1.67, 95% CI 0.95-2.97, P = 0.08), mechanical ventilation duration (P = 0.17), or ICU length of stay (P = 0.22). However, β-blocker use was associated with increased ICU and hospital mortality among nondiabetic patients (aOR 2.93, 95% CI 1.19-7.23, and 2.43, 95% CI 1.05-5.64, respectively).

CONCLUSIONS

Our study showed that β-blockers during the ICU stay had no significant association with mortality or morbidity. However, β-blocker therapy was associated with increased mortality in non-diabetic patients.

TRIAL REGISTRATION

ISRCTN07413772 ; (dated 13.07.2005).

Aspirin use and long-term rates of sepsis: A population-based cohort study

OBJECTIVE

Sepsis is the syndrome of life-threatening organ dysfunction resulting from dysregulated host response to infection. Aspirin, an anti-inflammatory agent, may play a role in attenuating the inflammatory response during infection. We evaluated the association between aspirin use and long-term rates of sepsis as well as sepsis outcomes.

METHODS

We analyzed data from 30,239 adults ≥45 years old in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The primary exposure was aspirin use, identified via patient interview. The primary outcome was sepsis hospitalization, defined as admission for infection with two or more systemic inflammatory response syndrome criteria. We fit Cox proportional hazards models assessing the association between aspirin use and rates of sepsis, adjusted for participant demographics, health behaviors, chronic medical conditions, medication adherence, and biomarkers. We used a propensity-matched analysis and a series of sensitivity analyses to assess the robustness of our results. We also examined risk of organ dysfunction and hospital mortality during hospitalization for sepsis.

RESULTS

Among 29,690 REGARDS participants with follow-up data available, 43% reported aspirin use (n = 12,869). Aspirin users had higher sepsis rates (hazard ratio 1.35; 95% CI: 1.22-1.49) but this association was attenuated following adjustment for potential confounders (adjusted HR 0.99; 95% CI: 0.88-1.12). We obtained similar results in propensity-matched and sensitivity analyses. Among sepsis hospitalizations, aspirin use was not associated with organ dysfunction or hospital death.

CONCLUSIONS

In the REGARDS cohort, baseline aspirin use was not associated with long-term rates of sepsis.

[Antipyretics in intensive care patients]

BACKGROUND

Antipyretics are among the most widely prescribed drugs in German hospitals. Despite this widespread use, their role for treatment of critically ill patients still remains unclear. In particular, the questionable positive effects of reducing fever are discussed.

OBJECTIVES

In this review we aimed to summarize and discuss current study results covering the use of antipyretics in critically ill patients. Suspected effects with regard to fever reduction and lethality should be considered.

MATERIALS AND METHODS

A selective literature search was carried out in the PubMed database. We reviewed the bibliographies of all work considered relevant.

RESULTS

There are only a few studies on the use of antipyretics in intensive care patients, which are difficult to compare systematically due to different designs, protocols and endpoints. All in all, the decrease in temperature was very low (0.3 °C) and showed even adverse effects on 28-days mortality in sepsis. In patients with sepsis and ASS medication, a decreased mortality has been shown in retrospective analysis.

CONCLUSIONS

The benefit of fever control using antipyretics in intensive care patients with regard to endpoints like lethality remains unclear. Randomized controlled trials with suitable protocols and endpoints are needed to provide a solid base for development of guidelines.

The preventive effect of antiplatelet therapy in acute respiratory distress syndrome: a meta-analysis

Background

Acute respiratory distress syndrome (ARDS) is a life-threatening condition with high mortality that imposes a serious medical burden. Antiplatelet therapy is a potential strategy for preventing ARDS in patients with a high risk of developing this condition. A meta-analysis was performed to investigate whether antiplatelet therapy could reduce the incidence of newly developed ARDS and its associated mortality in high-risk patients.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Medline, and the Web of Science were searched for published studies from inception to 26 October 2017. We included randomized clinical trials, cohort studies and case-control studies investigating antiplatelet therapy in adult patients presenting to the hospital or ICU with a high risk for ARDS. Baseline patient characteristics, interventions, controls and outcomes were extracted. Our primary outcome was the incidence of newly developed ARDS in high-risk patients. Secondary outcomes were hospital and ICU mortality. A random-effects or fixed-effects model was used for quantitative synthesis.

Results

We identified nine eligible studies including 7660 high-risk patients who received antiplatelet therapy. Based on seven observational studies, antiplatelet therapy was associated with a decreased incidence of ARDS (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.52–0.88; I² = 68.4%, p = 0.004). In two randomized studies, no significant difference was found in newly developed ARDS between the antiplatelet groups and placebo groups (OR 1.32, 95% CI 0.72–2.42; I² = 0.0%, p = 0.329). Antiplatelet therapy did not reduce hospital mortality in randomized studies (OR 1.15, 95% CI 0.58–2.27; I² = 0.0%; p = 0.440) or observational studies (OR 0.80, 95% CI 0.62–1.03; I² = 31.9%, p = 0.221).

Conclusions

Antiplatelet therapy did not significantly decrease hospital mortality in high-risk patients. However, whether antiplatelet therapy is associated with a decreased incidence of ARDS in patients at a high risk of developing the condition remains unclear.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1988-y) contains supplementary material, which is available to authorized users.

Quantifying the Effects of Prior Acetyl-Salicylic Acid on Sepsis-Related Deaths: An Individual Patient Data Meta-Analysis Using Propensity Matching

OBJECTIVE

The primary objective was to conduct a meta-analysis on published observational cohort data describing the association between acetyl-salicylic acid (aspirin) use prior to the onset of sepsis and mortality in hospitalized patients.

STUDY SELECTION

Studies that reported mortality in patients on aspirin with sepsis with a comparison group of patients with sepsis not on prior aspirin therapy were included.

DATA SOURCES

Fifteen studies described hospital-based cohorts (n = 17,065), whereas one was a large insurance-based database (n = 683,421). Individual-level patient data were incorporated from all selected studies.

DATA EXTRACTION

Propensity analyses with 1:1 propensity score matching at the study level were performed, using the most consistently available covariates judged to be associated with aspirin. Meta-analyses were performed to estimate the pooled average treatment effect of aspirin on sepsis-related mortality.

DATA SYNTHESIS

Use of aspirin was associated with a 7% (95% CI, 2-12%; p = 0.005) reduction in the risk of death as shown by meta-analysis with considerable statistical heterogeneity (I = 61.6%).

CONCLUSIONS

These results are consistent with effects ranging from a 2% to 12% reduction in mortality risk in patients taking aspirin prior to sepsis onset. This association anticipates results of definitive studies of the use of low-dose aspirin as a strategy for reduction of deaths in patients with sepsis.

A randomised trial on the effect of anti-platelet therapy on the systemic inflammatory response in human endotoxaemia

The use of acetylsalicylic acid (ASA) is associated with improved outcome in patients with sepsis, and P2Y₁₂ inhibitors have been suggested to also have immunomodulatory effects. Therefore, we evaluated the effects of clinically relevant combinations of antiplatelet therapy on the immune response in experimental endotoxaemia in humans in vivo. Forty healthy subjects were randomised to seven days of placebo, placebo with ASA, ticagrelor and ASA, or clopidogrel and ASA treatment. Systemic inflammation was elicited at day seven by intravenous administration of Escherichia coli endotoxin. ASA treatment profoundly augmented the plasma concentration of pro-inflammatory cytokines, but did not affect anti-inflammatory cytokines. Addition of either P2Y₁₂ antagonist to ASA did not affect any of the circulating cytokines, except for an attenuation of the ASA-induced increase in TNFα by ticagrelor. Systemic inflammation increased plasma adenosine, without differences between groups, and although P2Y₁₂ inhibition impaired platelet reactivity, there was no correlation with cytokine responses.

Effect of antiplatelet therapy on mortality and acute lung injury in critically ill patients: A systematic review and meta-analysis

Aim:

Platelet function is intricately linked to the pathophysiology of critical Illness, and some studies have shown that antiplatelet therapy (APT) may decrease mortality and incidence of acute respiratory distress syndrome (ARDS) in these patients. Our objective was to understand the efficacy of APT by conducting a meta-analysis.

Materials and Methods:

We conducted a meta-analysis using PubMed, Central, Embase, The Cochrane Central Register, the ClinicalTrials.gov Website, and Google Scholar. Studies were included if they investigated critically ill patients receiving antiplatelet therapy and mentioned the outcomes being studied (mortality, duration of hospitalization, ARDS, and need for mechanical ventilation).

Results:

We found that there was a significant reduction in all-cause mortality in patients on APT compared to control (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.70–0.97). Both the incidence of acute lung injury/ARDS (OR: 0.67; 95% CI: 0.57–0.78) and need for mechanical ventilation (OR: 0.74; 95% CI: 0.60–0.91) were lower in the antiplatelet group. No significant difference in duration of hospitalization was observed between the two groups (standardized mean difference: −0.02; 95% CI: −0.11–0.07).

Conclusion:

Our meta-analysis suggests that critically ill patients who are on APT have an improved survival, decreased incidence of ARDS, and decreased need for mechanical ventilation.

AspiriN To Inhibit SEPSIS (ANTISEPSIS) randomised controlled trial protocol

INTRODUCTION

Sepsis is a leading global cause of morbidity and mortality, and is more common at the extremes of age. Moreover, the cost of in-hospital care for elderly patients with sepsis is significant. There are indications from experimental and observational studies that aspirin may reduce inflammation associated with infection. This paper describes the rationale and design of the AspiriN To Inhibit SEPSIS (ANTISEPSIS) trial, a substudy of ASPirin in Reducing Events in the Elderly (ASPREE). ANTISEPSIS primarily aims to determine whether low-dose aspirin reduces sepsis-related deaths in older people. Additionally, it will assess whether low-dose aspirin reduces sepsis-related hospitalisations and sepsis-related Intensive Care Unit (ICU) admissions.

METHODS AND ANALYSIS

ASPREE is a double-blinded, randomised, placebo-controlled primary prevention trial that will determine whether daily low-dose aspirin extends disability-free longevity in 19 000 healthy older people recruited in Australia and the USA. The ANTISEPSIS substudy involves additional ASPREE trial data collection to assess the impact of daily low-dose aspirin on sepsis-related events in the 16 703 ASPREE participants aged 70 years and over, recruited in Australia. The intervention is a daily 100 mg dose of enteric-coated aspirin versus matching placebo, with 1:1 randomisation. The primary outcome for the ANTISEPSIS substudy is the incidence of sepsis-related death in eligible patients. The incidence of sepsis-related hospital and ICU admissions are secondary outcomes. ANTISEPSIS is to be conducted between 2012 and 2018.

DISCUSSION

This substudy will determine whether aspirin, an inexpensive and accessible therapy, safely reduces sepsis-related deaths and hospitalisations in older Australians. If shown to be the case, this would have profound effects on the health of older Australians.

TRIAL REGISTRATION NUMBER

Pre-results, ACTRN12613000349741.