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Xie XM, Huang D, Chun S, Bai DX, Lu XY, Li Y, Hou CM, Ji WT, Gao J. Factors influencing thirst in ICU patients: A mixed methods systematic review. Intensive Crit Care Nurs 2024; 86:103811. [PMID: 39213788 DOI: 10.1016/j.iccn.2024.103811] [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: 08/17/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To systematically review the factors influencing thirst in ICU patients, providing a reference for effective management of thirst in ICU patients and the formulation of intervention measures. METHODS A total of 12 electronic databases were searched from inception to July 2023. The synthesis method of JBI mixed methods research systematic review was used. The quantitative studies were analyzed by Stata17.0 and RevMan 5.3 software, and the qualitative studies by meta-aggregation. RESULTS A total of 13 studies were included, including 2 qualitative studies and 11 quantitative studies. The quantitative study was carried out by meta-aggregation, extracting seven categories to form two synthesized findings. Quantitative meta-analysis revealed that 11 factors, including marital status, whether to use mechanical ventilation for the first time, air leakage, mechanical ventilation mode, simplified acute physiology score, respiratory rate, mask comfort, serum sodium concentration, breathing pattern, diuretics, and vasoactive drugs, were all associated with the occurrence of thirst in ICU patients. The qualitative and quantitative results were integrated into 5 categories, namely personal characteristics and lifestyle, disease factors, treatment factors, psychological factors, and nurse factors. CONCLUSIONS Thirst is a prevalent and severe issue among ICU patients, and effective interventions are required to address it. Considering its various causes, managing thirst in ICU patients should involve multiple levels of intervention. Treatment-related factors contribute significantly to thirst, and these factors should be taken into consideration when developing a thirst management strategy. Personal characteristics and lifestyle, psychological factors, drug-related factors, and nursing factors should be identified and optimized as soon as possible. IMPLICATIONS FOR CLINICAL PRACTICE Healthcare professionals should pay attention to thirst symptoms in ICU patients and promptly take effective preventive or intervention measures based on the influencing factors.
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Affiliation(s)
- Xue-Mei Xie
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dan Huang
- Fifth People's Hospital Affiliated to Chengdu University of Chinese Medicine, Chengdu, China
| | - Shuang Chun
- Chengdu First People's Hospital, Chengdu, China
| | - Ding-Xi Bai
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xian-Ying Lu
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yue Li
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Chao-Ming Hou
- Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wen-Ting Ji
- Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Jing Gao
- Chengdu University of Traditional Chinese Medicine, Chengdu, China.
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2
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Xiao W, Huang L, Guo H, Liu W, Zhang J, Liu Y, Hua T, Yang M. Development and validation of potential phenotypes of serum electrolyte disturbances in critically ill patients and a Web-based application. J Crit Care 2024; 82:154793. [PMID: 38548515 DOI: 10.1016/j.jcrc.2024.154793] [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: 06/11/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 06/01/2024]
Abstract
BACKGROUND Electrolyte disturbances are highly heterogeneous and severely affect the prognosis of critically ill patients. Our study was to determine whether data-driven phenotypes of seven electrolytes have prognostic relevance in critically ill patients. METHODS We extracted patient information from three large independent public databases, and clustered the electrolyte distribution of ICU patients based on the extreme value, median value and coefficient of variation of electrolytes. Three plausible clinical phenotypes were calculated using K-means clustering algorithm as the basic clustering method. MIMIC-IV was considered a training set, and two others have been designated as verification set. The robustness of the model was then validated from different angles, providing dynamic and interactive visual charts for more detailed characterization of phenotypes. RESULTS 15,340, 12,445 and 2147 ICU patients with electrolyte records during early ICU stay in MIMIC-IV, eICU-CRD and AmsterdamUMCdb were enrolled. After clustering, three reasonable and interpretable phenotypes are defined as α, β and γ according to the order of clusters. The α and γ phenotype, with significant differences in electrolyte distribution and clinical variables, higher 28-day mortality and longer length of ICU stay (p < 0.001), was further demonstrated by robustness analysis. The α phenotype has significant kidney injury, while the β phenotype has the best prognosis. In addition, the assignment methods of the three phenotypes were developed into a web-based tool for further verification and application. CONCLUSIONS Three different clinical phenotypes were identified that correlated with electrolyte distribution and clinical outcomes. Further validation and characterization of these phenotypes is warranted.
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Affiliation(s)
- Wenyan Xiao
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Lisha Huang
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Heng Guo
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Wanjun Liu
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Jin Zhang
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Yu Liu
- Key Laboratory of Intelligent Computing and Signal Processing, Anhui University, Ministry of Education, Hefei, Anhui 230601, PR China; School of Integrated Circuits, Anhui University, Anhui, Hefei 230601, PR China
| | - Tianfeng Hua
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Min Yang
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China.
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Bampa M, Miliou I, Jovanovic B, Papapetrou P. M-ClustEHR: A multimodal clustering approach for electronic health records. Artif Intell Med 2024; 154:102905. [PMID: 38908256 DOI: 10.1016/j.artmed.2024.102905] [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: 12/22/2023] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/24/2024]
Abstract
Sepsis refers to a potentially life-threatening situation where the immune system of the human body has an extreme response to an infection. In the presence of underlying comorbidities, the situation can become even worse and result in death. Employing unsupervised machine learning techniques, such as clustering, can assist in providing a better understanding of patient phenotypes by unveiling subgroups characterized by distinct sepsis progression and treatment patterns. More concretely, this study introduces M-ClustEHR, a clustering approach that utilizes medical data of multiple modalities by employing a multimodal autoencoder for learning comprehensive sepsis patient representations. M-ClustEHR consistently outperforms traditional clustering approaches in terms of several internal clustering performance metrics, as well as cluster stability in identifying phenotypes in the sepsis cohort. The unveiled patterns, supported by existing medical literature and clinicians, highlight the importance of multimodal clustering for advancing personalized sepsis care.
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Affiliation(s)
- Maria Bampa
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden.
| | - Ioanna Miliou
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
| | | | - Panagiotis Papapetrou
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
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Schneeweiss-Gleixner M, Haselwanter P, Schneeweiss B, Zauner C, Riedl-Wewalka M. Hypophosphatemia after Start of Medical Nutrition Therapy Indicates Early Refeeding Syndrome and Increased Electrolyte Requirements in Critically Ill Patients but Has No Impact on Short-Term Survival. Nutrients 2024; 16:922. [PMID: 38612956 PMCID: PMC11013904 DOI: 10.3390/nu16070922] [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: 02/05/2024] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Refeeding syndrome (RFS) is a potentially life-threatening complication in malnourished (critically ill) patients. The presence of various accepted RFS definitions and the inclusion of heterogeneous patient populations in the literature has led to discrepancies in reported incidence rates in patients requiring treatment at an intensive care unit (ICU). We conducted a prospective observational study from 2010 to 2013 to assess the RFS incidence and clinical characteristics among medical ICU patients at a large tertiary center. RFS was defined as a decrease of more than 0.16 mmol/L serum phosphate to values below 0.65 mmol/L within seven days after the start of medical nutrition therapy or pre-existing serum phosphate levels below 0.65 mmol/L. Overall, 195 medical patients admitted to the ICU were included. RFS was recorded in 92 patients (47.18%). The presence of RFS indicated significantly altered phosphate and potassium levels and was accompanied by significantly more electrolyte substitutions (phosphate, potassium, and magnesium). No differences in fluid balance, energy delivery, and insulin requirements were detected. The presence of RFS had no impact on ICU length of stay and ICU mortality. Screening for RFS using simple diagnostic criteria based on serum phosphate levels identified critically ill patients with an increased demand for electrolyte substitutions. Therefore, stringent monitoring of electrolyte levels is indicated to prevent life-threatening complications.
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Tackett N, Sawyers R, Glass C, Maniakhina L, Lombardozzi S, Redden D, Mack TJ, Mount M, Lombardozzi K. Hypophosphatemia, a Predictor of Outcomes in Critically Ill Trauma Patients. Am Surg 2024:31348241241625. [PMID: 38512846 DOI: 10.1177/00031348241241625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Affiliation(s)
- Nichole Tackett
- Edward Via College of Osteopathic Medicine-Carolinas Campus, Spartanburg, SC, USA
| | - Robyn Sawyers
- Edward Via College of Osteopathic Medicine-Carolinas Campus, Spartanburg, SC, USA
| | - Caleb Glass
- Edward Via College of Osteopathic Medicine-Carolinas Campus, Spartanburg, SC, USA
| | - Lana Maniakhina
- Edward Via College of Osteopathic Medicine-Carolinas Campus, Spartanburg, SC, USA
| | - Siena Lombardozzi
- Department of Surgery, Spartanburg Regional Healthcare System, Spartanburg, SC, USA
| | - David Redden
- Department of Surgery, Spartanburg Regional Healthcare System, Spartanburg, SC, USA
| | - Thomas J Mack
- Department of Surgery, Spartanburg Regional Healthcare System, Spartanburg, SC, USA
| | - Michael Mount
- Department of Surgery, Spartanburg Regional Healthcare System, Spartanburg, SC, USA
| | - Kristine Lombardozzi
- Department of Surgery, Spartanburg Regional Healthcare System, Spartanburg, SC, USA
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Sagar N, Lohiya S. A Comprehensive Review of Chloride Management in Critically Ill Patients. Cureus 2024; 16:e55625. [PMID: 38586759 PMCID: PMC10995984 DOI: 10.7759/cureus.55625] [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: 11/30/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Chloride, often overshadowed in electrolyte management, emerges as a crucial player in the physiological intricacies of critically ill patients. This comprehensive review explores the multifaceted aspects of chloride, ranging from its significance in cellular homeostasis to the consequences of dysregulation in critically ill patients. The pathophysiology of hyperchloremia and hypochloremia is dissected, highlighting their intricate impact on acid-base balance, renal function, and cardiovascular stability. Clinical assessment strategies, including laboratory measurements and integration with other electrolytes, lay the foundation for targeted interventions. Consequences of dysregulated chloride levels underscore the need for meticulous management, leading to an exploration of emerging therapies and interventions. Fluid resuscitation protocols, the choice between crystalloids and colloids, the role of balanced solutions, and individualized patient approaches comprise the core strategies in chloride management. Practical considerations, such as monitoring and surveillance, overcoming implementation challenges, and embracing a multidisciplinary approach, are pivotal in translating theoretical knowledge into effective clinical practice. As we envision the future, potential impacts on critical care guidelines prompt reflections on integrating novel therapies, individualized approaches, and continuous monitoring practices. In conclusion, this review synthesizes current knowledge, addresses practical considerations, and envisions future directions in chloride management for critically ill patients. By embracing a holistic understanding, clinicians can navigate the complexities of chloride balance, optimize patient outcomes, and contribute to the evolving landscape of critical care medicine.
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Affiliation(s)
- Nandhini Sagar
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sham Lohiya
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Al-Azayzih A, Al-Qerem W, Al-Azzam S, Muflih S, Al-Husein BA, Kharaba Z, Kanaan RJ, Rahhal D. Prevalence of Medication Associated with QTc Prolongation Used Among Critically Ill Patients. Vasc Health Risk Manag 2024; 20:27-37. [PMID: 38318252 PMCID: PMC10840412 DOI: 10.2147/vhrm.s438899] [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] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/19/2024] [Indexed: 02/07/2024] Open
Abstract
Background Acquired prolonged corrected QT (QTc) interval can lead to life-threatening Torsade de Pointes (TdP) arrhythmia. Multiple risk factors including medications, comorbidities, and electrolyte imbalances contribute significantly to acquired manifestations of the QTc prolongation. Critically ill patients are particularly more vulnerable to TdP due to complex medical conditions, aging, and polypharmacy. Objective This study aimed to assess the prevalence of TdP-associated medication prescribing, identify risk factors for QTc prolongation and TdP, and determine primary predictors of high TdP medication usage in critically ill patients in Jordan. Methods We conducted a retrospective cross-sectional analysis of electronic medical records for patients from King Abdullah University Hospital who were admitted to Intensive Care Unit (ICU) between (July 2012-July 2022). We collected data on patients' demographics, clinical characteristics, comorbidities, laboratory results, and prescribed medications. Medications were categorized into three TdP risk levels according to CredibleMeds® assessment tool. Data were analyzed using descriptive statistics and a binary logistic regression model. Results Of the 13,300 patients (58.2% male, median age 62 years). Prescribing prevalence for medications with known TdP risk was 19%, possible risk (24.7%), conditional risk (21.6%), and confirmed conditional risk (8.3%). Common comorbidities included hypertension (40.9%), diabetes (33.3%), and cancer (15.4%). Drugs with known TdP risk included citalopram, amiodarone, clarithromycin, and ciprofloxacin. A binary regression model revealed that as age increased, the odds of TdP associated medication prescribing decreased (OR = 0.989, p < 0.001), while patients on more than five medications had higher odds (OR = 4.281, p < 0.001). Conclusion The study identified a notable prevalence of prescribing for medications with QTc prolongation/TdP risk in critically ill patients. Healthcare providers in the ICU should exercise caution to minimize the inadvertent prescription of TdP associated medications especially among older patients and those with polypharmacy.
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Affiliation(s)
- Ahmad Al-Azayzih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Walid Al-Qerem
- Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman, Jordan
| | - Sayer Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Suhaib Muflih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Belal A Al-Husein
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Zelal Kharaba
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
- Honorary Associate Lecturer, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Roaa J Kanaan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Dania Rahhal
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Zhao B, Huepenbecker S, Zhu G, Rajan SS, Fujimoto K, Luo X. Comorbidity network analysis using graphical models for electronic health records. Front Big Data 2023; 6:846202. [PMID: 37663273 PMCID: PMC10470017 DOI: 10.3389/fdata.2023.846202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 07/25/2023] [Indexed: 09/05/2023] Open
Abstract
Importance The comorbidity network represents multiple diseases and their relationships in a graph. Understanding comorbidity networks among critical care unit (CCU) patients can help doctors diagnose patients faster, minimize missed diagnoses, and potentially decrease morbidity and mortality. Objective The main objective of this study was to identify the comorbidity network among CCU patients using a novel application of a machine learning method (graphical modeling method). The second objective was to compare the machine learning method with a traditional pairwise method in simulation. Method This cross-sectional study used CCU patients' data from Medical Information Mart for the Intensive Care-3 (MIMIC-3) dataset, an electronic health record (EHR) of patients with CCU hospitalizations within Beth Israel Deaconess Hospital from 2001 to 2012. A machine learning method (graphical modeling method) was applied to identify the comorbidity network of 654 diagnosis categories among 46,511 patients. Results Out of the 654 diagnosis categories, the graphical modeling method identified a comorbidity network of 2,806 associations in 510 diagnosis categories. Two medical professionals reviewed the comorbidity network and confirmed that the associations were consistent with current medical understanding. Moreover, the strongest association in our network was between "poisoning by psychotropic agents" and "accidental poisoning by tranquilizers" (logOR 8.16), and the most connected diagnosis was "disorders of fluid, electrolyte, and acid-base balance" (63 associated diagnosis categories). Our method outperformed traditional pairwise comorbidity network methods in simulation studies. Some strongest associations between diagnosis categories were also identified, for example, "diagnoses of mitral and aortic valve" and "other rheumatic heart disease" (logOR: 5.15). Furthermore, our method identified diagnosis categories that were connected with most other diagnosis categories, for example, "disorders of fluid, electrolyte, and acid-base balance" was associated with 63 other diagnosis categories. Additionally, using a data-driven approach, our method partitioned the diagnosis categories into 14 modularity classes. Conclusion and relevance Our graphical modeling method inferred a logical comorbidity network whose associations were consistent with current medical understanding and outperformed traditional network methods in simulation. Our comorbidity network method can potentially assist CCU doctors in diagnosing patients faster and minimizing missed diagnoses.
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Affiliation(s)
- Bo Zhao
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Sarah Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gen Zhu
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Suja S. Rajan
- Department of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Kayo Fujimoto
- Department of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Xi Luo
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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Gonuguntla V, Talwar V, Krishna B, Srinivasan G. Correlation of Serum Magnesium Levels with Clinical Outcome: A Prospective Observational Study in Critically Ill Patients Admitted to a Tertiary Care ICU in India. Indian J Crit Care Med 2023; 27:342-347. [PMID: 37214118 PMCID: PMC10196642 DOI: 10.5005/jp-journals-10071-24451] [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: 03/07/2023] [Accepted: 04/04/2023] [Indexed: 05/24/2023] Open
Abstract
Background We studied the incidence of magnesium (Mg) disturbances in patients admitted to a multidisciplinary intensive care unit (ICU) and correlated serum magnesium levels with clinical outcomes. Materials and methods The study was conducted on 280 critically ill patients aged above 18 years and admitted to the ICU. Serum magnesium levels at admission were correlated with mortality, need for and duration of mechanical ventilation, duration of ICU stay, presence of comorbid conditions, and electrolyte disturbances. Result There was a high incidence of Mg disturbances at admission among patients admitted to the ICU. The incidence of hypomagnesemia and hypermagnesemia was 40.9 and 13.9% respectively. The mean Mg level among patients who expired was 1.55 ± 0.68 mg/dL, and the association with outcome was found to be statistically significant (p = 0.001).Hypomagnesemia (HypoMg) was associated with significantly higher mortality (51.3%) as compared to normomagnesemia (NormoMg) (29.3%) and hypermagnesemia (HyperMg) (23.1%) (HypoMg vs NormoMg, HypoMg vs HyperMg, p = 0.001, 0.002 respectively). The need for mechanical ventilation was significantly higher in hypomagnesemic as compared to hypermagnesemia patients (p = 0.012). The association of baseline APACHE II and SOFA scores with serum Mg levels was statistically significant (p = 0.001 and 0.002 respectively).The incidence of gastrointestinal disorders was significantly higher among hypomagnesemia patients (HypoMg vs NormoMg, p = 0.023), while chronic kidney disease was significantly higher in hypermagnesemic patients (HypoMg vs HyperMg, p = 0.0009, NormoMg vs HyperMg, p = 0.0004). On comparing the incidence of electrolyte disorders between HypoMg, NormoMg, and HyperMg groups, it was found that hypokalemia and hypocalcemia (p = 0.0003 and 0.039 respectively) were associated with hypomagnesemia and hyperkalemia and hypercalcemia (p = 0.001 and 0.005 respectively) were associated with hypermagnesemia. Conclusion Our study highlights the role of Mg monitoring in critically ill patients admitted to the ICU and its value for a favorable outcome. We found that hypomagnesemia was significantly associated with adverse outcomes and higher mortality in critically ill patients. Intensivists should maintain a high index of suspicion for Mg disturbances and evaluate patients appropriately. How to cite this article Gonuguntla V, Talwar V, Krishna B, Srinivasan G. Correlation of Serum Magnesium Levels with Clinical Outcome: A Prospective Observational Study in Critically Ill Patients Admitted to a Tertiary Care ICU in India. Indian J Crit Care Med 2023;27(5):342-347.
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Affiliation(s)
- Vineesha Gonuguntla
- Department of Anaesthesia and Critical Care, Safdarjung Hospital, New Delhi, India
| | - Vandana Talwar
- Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College & Safdarjang Hospital, New Delhi, India
| | - Bhavya Krishna
- Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College & Safdarjang Hospital, New Delhi, India
| | - Gautham Srinivasan
- Department of Anaesthesia and Critical Care, Glenfield Hospital, Leicester, United Kingdom
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11
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Lin R, Li H, Chen L, He J. Prevalence of and risk factors for thirst in the intensive care unit: An observational study. J Clin Nurs 2023; 32:465-476. [PMID: 35199411 PMCID: PMC10078651 DOI: 10.1111/jocn.16257] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/13/2022] [Accepted: 02/08/2022] [Indexed: 01/17/2023]
Abstract
AIM AND OBJECTIVES This study investigated the incidence of thirst and contributing factors in intensive care unit (ICU) patients by analysing differences in physiologic, psychological, and disease- and environment-related parameters in ICU patients with vs without thirst. BACKGROUND Little is known about the factors that influence thirst, and there are no standardised methods for identifying at-risk patients in the ICU. Previous studies generalised the risk of thirst in ICU patients because of a lack of data on relevant variables. Here, we examined the factors contributing to thirst based on symptom management theory. DESIGN Prospective descriptive design. METHODS Physiologic, psychological, disease-related and environment-related data were collected for 301 patients from 4 ICUs (medical, surgical, cardiac and emergency ICUs) of a hospital from 15 December 2017-10 July 2019 through a screening interview, questionnaires and from electronic medical records. The data were analysed with descriptive statistics, the t-test and chi-squared test, and by logistic regression. Binary stepwise logistic regression was used to identify thirst-associated factors. The findings are reported according to the STROBE checklist for cross-sectional studies. RESULTS In total, 210/301 (69.8%) ICU patients experienced thirst. Risk factors were nil per os order (odds ratio [OR] = 4.10, 95% confidence interval [CI]: 1.44-11.69), surgery (OR = 2.96, 95% CI: 1.11-7.93), high glucose (OR = 3.36, 95% CI: 1.01-11.17) and greater disease severity (OR = 1.13, 95% CI: 1.02-1.24). CONCLUSION Thirst is common in ICU patients. Timely detection of patients' thirst and identification of those at high risk by ICU nurses can ensure the implementation of effective and safe interventions. RELEVANCE TO CLINICAL PRACTICE The results of this study highlight the need to evaluate thirst symptoms in patients with severe disease and develop relief strategies for fasting, perioperative, and hyperglycaemic patients and others who are at high risk of thirst.
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Affiliation(s)
- Rong Lin
- Research Center for Nursing Theory and Practice, Fujian Provincial Hospital, Fuzhou, China.,The School of Nursing, Fujian Medical University, Fuzhou, China.,Department of Nursing, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Hong Li
- Research Center for Nursing Theory and Practice, Fujian Provincial Hospital, Fuzhou, China.,The School of Nursing, Fujian Medical University, Fuzhou, China.,Department of Nursing, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Lili Chen
- Research Center for Nursing Theory and Practice, Fujian Provincial Hospital, Fuzhou, China.,The School of Nursing, Fujian Medical University, Fuzhou, China
| | - Jinyi He
- Intensive Care Unit, Fujian Provincial Hospital, Fuzhou, China
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12
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Wilson SM, Bohn MK, Madsen A, Hundhausen T, Adeli K. LMS-based continuous reference percentiles for 14 laboratory parameters in the CALIPER cohort of healthy children and adolescents. Clin Chem Lab Med 2023; 61:1105-1115. [PMID: 36639844 DOI: 10.1515/cclm-2022-1077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Marked physiological changes in growth and development present challenges in defining pediatric reference intervals for biomarkers of health and disease. Lambda, Mu, and Sigma (LMS)-based statistical modeling provides a continuous normal distribution by negating skewness and variation, and is commonly used to establish growth charts. Such LMS reference curves are suggested to enhance laboratory test result interpretation. The current study establishes LMS-based continuous reference percentiles for 14 biomarkers in the CALIPER cohort of healthy children and adolescents. METHODS Data from healthy children and adolescents aged 1-<19 years were used to establish continuous reference percentiles using a novel LMS-based statistical method, including 2.5th, 25th, 50th, 75th, and 97.5th percentiles. The LMS approach applies a Box-Cox data transformation and summarizes continuous distributions by age via three curves: skewness (Lambda), median (Mu), and coefficient of variation (Sigma). RESULTS LMS-based percentiles and z-scores were generated for 14 common pediatric biomarkers that demonstrate dynamic concentration patterns with age (e.g., alkaline phosphatase) and/or wherein the magnitude of difference from the population mean may be clinically relevant (e.g., triglycerides). The LMS model captured age- and sex-specific distributions accurately and was not substantially influenced by outlying points. CONCLUSIONS This is the first study to establish LMS-based continuous reference percentiles for biochemical markers in a healthy Canadian pediatric population. The current LMS-based approach builds upon previous continuous reference interval models by providing graded percentiles to improve test result interpretation, particularly with repeated measures over time. This method may assist in facilitating a patient-centered approach to laboratory medicine.
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Affiliation(s)
- Siobhan M Wilson
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, 1 King's College Cir, University of Toronto, Toronto, ON, Canada
| | - Mary Kathryn Bohn
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, 1 King's College Cir, University of Toronto, Toronto, ON, Canada
| | - Andre Madsen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Thomas Hundhausen
- Department of Medical Biochemistry, Southern Norway Hospital Trust, Kristiansand, Norway.,Department of Natural Sciences, University of Agder, Kristiansand, Norway
| | - Khosrow Adeli
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, 1 King's College Cir, University of Toronto, Toronto, ON, Canada
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13
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Obiagwu PN, Morrow B, McCulloch M, Argent A. Burden and severity of deranged electrolytes and kidney function in children seen in a tertiary hospital in Kano, northern Nigeria. PLoS One 2023; 18:e0283220. [PMID: 36930619 PMCID: PMC10022757 DOI: 10.1371/journal.pone.0283220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Derangement in serum electrolytes and kidney function is often overlooked, especially in resource-constrained settings, and associated with increased risk of morbidity and mortality. This study aimed to describe the burden of derangements in serum electrolytes and kidney function in children presenting to a tertiary hospital in Nigeria. METHODS The laboratory records of all children who had serum electrolytes urea and creatinine ordered on their first presentation to hospital between January 1 and June 30, 2017 were retrospectively reviewed. Basic demographic data including admission status (inpatient or outpatient) were recordedandserum levels of sodium, potassium, chloride and bicarbonate were assessed for derangements usingnormal values from established reference ranges. Results of repeat samples were excluded. Kidney function was classified based on the serum creatinine relative to normal values for age and sex. RESULTS During the study period, 1909 children (60.3% male); median (IQR) age 42 (11.9) months had serum chemistry and 1248 (65.4%) were admitted. Results of their first samples were analyzed. Electrolyte derangements were present in 78.6% of the samples most commonly hyponatraemia (41.1%), low bicarbonate(37.2%), hypochloraemia (33.5%) and hypokalemia(18.9%). Azotaemia was found in 20.1% of the results. Elevated serum creatinine levels were found in 399 children (24.7%), 24.1% of those being in the severe category. Children aged 5 years and younger accounted for 76.4% of those with derangement in kidney function. One hundred and eight outpatients (17.8%) had deranged kidney function. CONCLUSION Deranged serum electrolytes and kidney function were common in this cohort.
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Affiliation(s)
- Patience N. Obiagwu
- Department of Paediatrics, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Brenda Morrow
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mignon McCulloch
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Andrew Argent
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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14
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Eshetu B, Worede A, Fentie A, Chane E, Fetene G, Wondifraw H, Shimelis M, Girma M, Hadgu R, Demeke K, Fasil A. Assessment of Electrolyte Imbalance and Associated Factors Among Adult Diabetic Patients Attending the University of Gondar Comprehensive Specialized Hospital, Ethiopia: A Comparative Cross-Sectional Study. Diabetes Metab Syndr Obes 2023; 16:1207-1220. [PMID: 37131504 PMCID: PMC10149060 DOI: 10.2147/dmso.s404788] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/15/2023] [Indexed: 05/04/2023] Open
Abstract
Introduction Electrolyte imbalance refers to altered electrolyte levels that predominantly affect diabetic patients due to hyperglycemia which rise plasma osmolality and impaired renal function, contributing to a change in electrolyte level. Therefore, this study aimed to assess the prevalence of electrolyte imbalance and its associated factors among diabetic patients and healthy control groups attending the University of Gondar Comprehensive Specialized Hospital. Patients and Methods A comparative cross-sectional study was conducted on 130 diabetic patients and 130 diabetes-free controls. Sociodemographic, behavioral and clinical data were collected using a structured questionnaire. After measuring anthropometric parameters, 5mL of the blood sample was collected. Electrolytes were measured based on ion-selective electrode methods. Fasting blood glucose, and creatinine were measured by spectrophotometric enzyme hexokinase, and Jaffe reaction methods, respectively. The data was entered into Epi-data version 4.6 and analyzed using STATA version 14. Mann-Whitney U-tests and independent t-tests were used for comparison. Multiple logistic regression analysis was done to determine the factors associated with electrolyte imbalances. P-value <0.05 was considered statistically significant. Result The overall prevalence of electrolyte imbalance among diabetic patients and controls were 83.07% and 52.31%, respectively. The mean of Na+ and the median level of Mg2+ and Ca2+ were significantly decreased. However, the mean level of Cl- was significantly increased in diabetic patients as compared to control groups. In multivariable logistic regression: alcohol consumption AOR = 3.34 [1.02-10.9], no formal education AOR = 5.38 [1.14-25.4], hyperglycemia AOR = 6.32 [2.04-19.5], and urbanization AOR = 5.6 [1.44-22.3] showed significant association with electrolyte imbalance. Conclusion Diabetic patients have more likely to develop electrolyte imbalance than control groups. Diabetic participants showed significantly reduced Na+, Mg2+, and Ca2+ levels and significantly increasing CI- levels when compared to control groups. Hyperglycemia, alcohol drinking habits, urbanization, and no-formal education were statistically significantly associated with electrolyte imbalance.
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Affiliation(s)
- Bruktawit Eshetu
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Abebaw Worede
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Alemie Fentie
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Elias Chane
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getnet Fetene
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Habtamu Wondifraw
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mahider Shimelis
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mahider Girma
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Rishan Hadgu
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Kassaw Demeke
- University of Gondar Comprehensive Specialized Hospital, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Alebachew Fasil
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Correspondence: Alebachew Fasil, Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Po Box. 196, Gondar, Ethiopia, Tel +251-918733171, Email ;
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15
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Wang Z, Samsten I, Kougia V, Papapetrou P. Style-transfer counterfactual explanations: An application to mortality prevention of ICU patients. Artif Intell Med 2023; 135:102457. [PMID: 36628793 DOI: 10.1016/j.artmed.2022.102457] [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: 01/31/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 11/24/2022]
Abstract
In recent years, machine learning methods have been rapidly adopted in the medical domain. However, current state-of-the-art medical mining methods usually produce opaque, black-box models. To address the lack of model transparency, substantial attention has been given to developing interpretable machine learning models. In the medical domain, counterfactuals can provide example-based explanations for predictions, and show practitioners the modifications required to change a prediction from an undesired to a desired state. In this paper, we propose a counterfactual solution MedSeqCF for preventing the mortality of three cohorts of ICU patients, by representing their electronic health records as medical event sequences, and generating counterfactuals by adopting and employing a text style-transfer technique. We propose three model augmentations for MedSeqCF to integrate additional medical knowledge for generating more trustworthy counterfactuals. Experimental results on the MIMIC-III dataset strongly suggest that augmented style-transfer methods can be effectively adapted for the problem of counterfactual explanations in healthcare applications and can further improve the model performance in terms of validity, BLEU-4, local outlier factor, and edit distance. In addition, our qualitative analysis of the results by consultation with medical experts suggests that our style-transfer solutions can generate clinically relevant and actionable counterfactual explanations.
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Affiliation(s)
- Zhendong Wang
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden.
| | - Isak Samsten
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
| | - Vasiliki Kougia
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden; Faculty of Computer Science, University of Vienna, Vienna, Austria
| | - Panagiotis Papapetrou
- Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
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16
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Yun G, Baek SH, Kim S. Evaluation and management of hypernatremia in adults: clinical perspectives. Korean J Intern Med 2022; 38:290-302. [PMID: 36578134 PMCID: PMC10175862 DOI: 10.3904/kjim.2022.346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 12/30/2022] Open
Abstract
Hypernatremia is an occasionally encountered electrolyte disorder, which may lead to fatal consequences under improper management. Hypernatremia is a disorder of the homeostatic status regarding body water and sodium contents. This imbalance is the basis for the diagnostic approach to hypernatremia. We summarize the eight diagnostic steps of the traditional approach and introduce new biomarkers: exclude pseudohypernatremia, confirm glucose-corrected sodium concentrations, determine the extracellular volume status, measure urine sodium levels, measure urine volume and osmolality, check ongoing urinary electrolyte free water clearance, determine arginine vasopressin/copeptin levels, and assess other electrolyte disorders. Moreover, we suggest six steps to manage hypernatremia by replacing water deficits, ongoing water losses, and insensible water losses: identify underlying causes, distinguish between acute and chronic hypernatremia, determine the amount and rate of water administration, select the type of replacement solution, adjust the treatment schedule, and consider additional therapy for diabetes insipidus. Physicians may apply some of these steps to all patients with hypernatremia, and can also adapt the regimens for specific causes or situations.
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Affiliation(s)
- Giae Yun
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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17
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Molinero-Fernández Á, Casanova A, Wang Q, Cuartero M, Crespo GA. In Vivo Transdermal Multi-Ion Monitoring with a Potentiometric Microneedle-Based Sensor Patch. ACS Sens 2022; 8:158-166. [PMID: 36475628 PMCID: PMC9887649 DOI: 10.1021/acssensors.2c01907] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Microneedle sensor technology offers exciting opportunities for decentralized clinical analyses. A novel issue puts forward herein is to demonstrate the uniqueness of membrane-based microneedles to accomplish real-time, on-body monitoring of multiple ions simultaneously. The use of multi-ion detection is clinically relevant since it is expected to provide a more complete and reliable assessment of the clinical status of a subject concerning electrolyte disorders and others. We present a microneedle system for transdermal multiplexed tracing of pH, Na+, K+, Ca2+, Li+, and Cl-. The device consists of an array of seven solid microneedles externally modified to provide six indicator electrodes, each selective for a different ion, and a common reference electrode, all integrated into a wearable patch read in a potentiometric mode. We show in vitro measurements at the expected clinical levels, resulting in a fast response time, excellent reversibility and repeatability, and adequate selectivity. Close-to-Nernstian sensitivity, sufficient stability and resiliency to skin penetration guarantee the sensor's success in transdermal measurements, which we demonstrate through ex vivo (with pieces of rat skin) and in vivo (on-body measurements in rats) tests. Accuracy is evaluated by comparison with gold standard techniques to characterize collected dermal fluid, blood, and serum. In the past, interstitial fluid (ISF) analysis has been challenging due to difficult sample collection and analysis. For ions, this has resulted in extrapolations from blood concentrations (invasive tests) rather than pure measurements in ISF. The developed microneedle patch is a relevant analytical tool to address this information gap.
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Affiliation(s)
- Águeda Molinero-Fernández
- Department
of Chemistry, School of Engineering Sciences in Chemistry, Biotechnology
and Health, KTH Royal Institute of Technology, Teknikringen 30, SE-100 44Stockholm, Sweden
| | - Ana Casanova
- Department
of Chemistry, School of Engineering Sciences in Chemistry, Biotechnology
and Health, KTH Royal Institute of Technology, Teknikringen 30, SE-100 44Stockholm, Sweden
| | - Qianyu Wang
- Department
of Chemistry, School of Engineering Sciences in Chemistry, Biotechnology
and Health, KTH Royal Institute of Technology, Teknikringen 30, SE-100 44Stockholm, Sweden
| | - María Cuartero
- UCAM-SENS, Universidad Católica San Antonio de Murcia,
UCAM HiTech, Avda. Andres
Hernandez Ros 1, 30107Murcia, Spain,Department
of Chemistry, School of Engineering Sciences in Chemistry, Biotechnology
and Health, KTH Royal Institute of Technology, Teknikringen 30, SE-100 44Stockholm, Sweden,
| | - Gastón A. Crespo
- UCAM-SENS, Universidad Católica San Antonio de Murcia,
UCAM HiTech, Avda. Andres
Hernandez Ros 1, 30107Murcia, Spain,Department
of Chemistry, School of Engineering Sciences in Chemistry, Biotechnology
and Health, KTH Royal Institute of Technology, Teknikringen 30, SE-100 44Stockholm, Sweden,
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18
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Tonai K, Katayama S, Koyama K, Sata N, Tomioka Y, Imahase H, Nunomiya S. Association between hypomagnesemia and coagulopathy in sepsis: a retrospective observational study. BMC Anesthesiol 2022; 22:359. [PMID: 36424547 PMCID: PMC9685885 DOI: 10.1186/s12871-022-01903-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypomagnesemia reportedly has significant associations with poor clinical outcomes such as increased mortality and septic shock in patients with sepsis. Although the mechanism underlying these outcomes mostly remains unclear, some experimental data suggest that magnesium deficiency could potentiate coagulation activation in sepsis. However, in sepsis, the association between serum magnesium levels and coagulopathy, including disseminated intravascular coagulation (DIC), remains unknown. Thus, we aimed to investigate the relationship between serum magnesium levels and coagulation status and the association between hypomagnesemia and DIC in patients with sepsis. METHODS This retrospective observational study was conducted at the intensive care unit (ICU) of a university hospital from June 2011 to December 2017. Patients older than 19 years who met the Sepsis-3 definition were included. We categorized patients into three groups according to their serum magnesium levels: hypomagnesemia (< 1.6 mg/dL), normal serum magnesium level (1.6-2.4 mg/dL), and hypermagnesemia (> 2.4 mg/dL). We investigated the association between serum magnesium levels and overt DIC at the time of ICU admission according to the criteria of the International Society on Thrombosis and Haemostasis. RESULTS Among 753 patients included in this study, 181 had DIC, 105 had hypomagnesemia, 552 had normal serum magnesium levels, and 96 had hypermagnesemia. Patients with hypomagnesemia had a more activated coagulation status indicated by lower platelet counts, lower fibrinogen levels, higher prothrombin time-international normalized ratios, higher thrombin-antithrombin complex, and more frequent DIC than those with normal serum magnesium levels and hypermagnesemia (DIC: 41.9% vs. 20.6% vs. 24.0%, P < 0.001). The coagulation status in patients with hypomagnesemia was more augmented toward suppressed fibrinolysis than that in patients with normal serum magnesium levels and hypermagnesemia. Multivariate logistic regression revealed that hypomagnesemia was independently associated with DIC (odds ratio, 1.69; 95% confidence interval, 1.00-2.84; P = 0.048) after adjusting for several confounding variables. CONCLUSIONS Patients with hypomagnesemia had a significantly activated coagulation status and suppressed fibrinolysis. Hypomagnesemia was independently associated with DIC in patients with sepsis. Therefore, the treatment of hypomagnesemia may be a potential therapeutic strategy for the treatment of coagulopathy in sepsis.
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Affiliation(s)
- Ken Tonai
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Shinshu Katayama
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Kansuke Koyama
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Naho Sata
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Yoshihiro Tomioka
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Hisashi Imahase
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Shin Nunomiya
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
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19
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Fang CH, Ravindra V, Akhter S, Adibuzzaman M, Griffin P, Subramaniam S, Grama A. Identifying and analyzing sepsis states: A retrospective study on patients with sepsis in ICUs. PLOS DIGITAL HEALTH 2022; 1:e0000130. [PMID: 36812596 PMCID: PMC9931346 DOI: 10.1371/journal.pdig.0000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 09/20/2022] [Indexed: 11/12/2022]
Abstract
Sepsis accounts for more than 50% of hospital deaths, and the associated cost ranks the highest among hospital admissions in the US. Improved understanding of disease states, progression, severity, and clinical markers has the potential to significantly improve patient outcomes and reduce cost. We develop a computational framework that identifies disease states in sepsis and models disease progression using clinical variables and samples in the MIMIC-III database. We identify six distinct patient states in sepsis, each associated with different manifestations of organ dysfunction. We find that patients in different sepsis states are statistically significantly composed of distinct populations with disparate demographic and comorbidity profiles. Our progression model accurately characterizes the severity level of each pathological trajectory and identifies significant changes in clinical variables and treatment actions during sepsis state transitions. Collectively, our framework provides a holistic view of sepsis, and our findings provide the basis for future development of clinical trials, prevention, and therapeutic strategies for sepsis.
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Affiliation(s)
- Chih-Hao Fang
- Department of Computer Science, Purdue University, West Lafayette, IN, United States of America
- * E-mail: (C-HF); (AG)
| | - Vikram Ravindra
- Department of Computer Science, University of Cincinnati, Cincinnati, OH, United States of America
| | - Salma Akhter
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, United States of America
| | - Mohammad Adibuzzaman
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Paul Griffin
- Department of Industrial Engineering, Penn State University, University Park, PA, United States of America
| | - Shankar Subramaniam
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States of America
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, IN, United States of America
- * E-mail: (C-HF); (AG)
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20
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Campbell K, Mortimore G. The diagnosis and management of acute hyponatraemia in critical care. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:934-939. [PMID: 36227791 DOI: 10.12968/bjon.2022.31.18.934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Nurses working in critical care, consisting of the intensive care and high dependency units, will encounter a broad range of diseases and conditions. Therefore, a comprehensive knowledge and understanding of common presentations is required, especially for advanced clinical practitioners (ACPs). One of the most common electrolyte disturbances seen within these areas is hyponatraemia, affecting around 40% of patients in critical care and 30% of inpatients. It is important that ACPs working in this area are aware of the symptoms and recommended diagnosis and management.
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Affiliation(s)
- Karen Campbell
- Advanced Clinical Practitioner, Chesterfield Royal Hospital NHS Foundation Trust
| | - Gerri Mortimore
- Associate Professor in Advanced Clinical Practice, University of Derby
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21
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Lu J, Qi Z, Liu J, Liu P, Li T, Duan M, Li A. Nomogram Prediction Model of Serum Chloride and Sodium Ions on the Risk of Acute Kidney Injury in Critically Ill Patients. Infect Drug Resist 2022; 15:4785-4798. [PMID: 36045875 PMCID: PMC9420741 DOI: 10.2147/idr.s376168] [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: 06/01/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aims to investigate the effect of serum chloride and sodium ions on AKI occurrence in ICU patients, and further constructs a prediction model containing these factors to explore the predictive value of these ions in AKI. Methods The clinical information of patients admitted to ICU of Beijing Friendship Hospital Affiliated to Capital Medical University was collected for retrospective analysis. Logistic regression analysis was used to analyzing the influencing factors. A nomogram for predicting AKI risk was constructed with R software and validated by repeated sampling. Afterwards, the effectiveness and accuracy of the model were tested and evaluated. Results A total of 446 cases met the requirements of this study, of which 178 developed AKI during their stay in ICU, with an incidence rate of 39.9%. Hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine value and BE value at ICU admission before the diagnosis of AKI were identified as independent risk factors for developing AKI during ICU stay. These predictors were incorporated into the nomogram of AKI risk in critically ill patients, which was constructed by using R software. Receiver operating characteristic curve analysis was further used and showed that the area under the curve of the model was 0.7934 (95% CI 0.742–0.8447), indicating that the model had an ideal value. Finally, further evaluated its clinical effectiveness. The clinical effect curve and decision curve showed that most areas of the decision curve of this model were greater than 0, indicating that this model owned a certain clinical effectiveness. Conclusion The nomogram based on hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine and BE value in ICU can predict the individualized risk of AKI with satisfactory distinguishability and accuracy.
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Affiliation(s)
- Jiaqi Lu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhili Qi
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jingyuan Liu
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Pei Liu
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tian Li
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ang Li
- Beijing Ditan Hospital, Capital Medical University, Beijing, People's Republic of China
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22
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Weckx R, Goossens C, Derde S, Pauwels L, Vander Perre S, Van den Berghe G, Langouche L. Efficacy and safety of ketone ester infusion to prevent muscle weakness in a mouse model of sepsis-induced critical illness. Sci Rep 2022; 12:10591. [PMID: 35732826 PMCID: PMC9217969 DOI: 10.1038/s41598-022-14961-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/15/2022] [Indexed: 02/03/2023] Open
Abstract
In septic mice, 3-hydroxybutyrate-sodium-salt has shown to partially prevent sepsis-induced muscle weakness. Although effective, the excessive sodium load was toxic. We here investigated whether ketone ester 3-hydroxybutyl-3-hydroxybutanoate (3HHB) was a safer alternative. In a mouse model of abdominal sepsis, the effects of increasing bolus doses of 3HHB enantiomers on mortality, morbidity and muscle force were investigated (n = 376). Next, plasma 3HB- clearance after bolus d-3HHB was investigated (n = 27). Subsequently, in septic mice, the effect on mortality and muscle force of a continuous d,l-3HHB infusion was investigated (n = 72). In septic mice, as compared with placebo, muscle force was increased at 20 mmol/kg/day l-3HHB and at 40 mmol/kg/day d- and d,l-3HHB. However, severity of illness and mortality was increased by doubling the effective bolus doses. Bolus 3HHB caused a higher 3HB− plasma peak and slower clearance with sepsis. Unlike bolus injections, continuous infusion of d,l-3HHB did not increase severity of illness or mortality, while remaining effective in improving muscle force. Treatment of septic mice with the ketone ester 3HHB partly prevented muscle weakness. Toxicity of 3HHB administered as bolus was completely avoided by continuous infusion of the same dose. Whether continuous infusion of ketone esters represents a promising intervention to also prevent ICU-acquired weakness in human patients should be investigated.
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Affiliation(s)
- Ruben Weckx
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Chloë Goossens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Sarah Derde
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Lies Pauwels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium.
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23
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Yu W, Wang Z, Yu X, Zhao Y, Xie Z, Zhang K, Chi Z, Chen S, Xu T, Jiang D, Guo X, Li M, Zhang J, Fang H, Yang D, Guo Y, Yang X, Zhang X, Wu Y, Yang W, Wang D. Kir2.1-mediated membrane potential promotes nutrient acquisition and inflammation through regulation of nutrient transporters. Nat Commun 2022; 13:3544. [PMID: 35729093 PMCID: PMC9213538 DOI: 10.1038/s41467-022-31149-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/26/2022] [Indexed: 12/22/2022] Open
Abstract
Immunometabolism contributes to inflammation, but how activated macrophages acquire extracellular nutrients to fuel inflammation is largely unknown. Here, we show that the plasma membrane potential (Vm) of macrophages mediated by Kir2.1, an inwardly-rectifying K+ channel, is an important determinant of nutrient acquisition and subsequent metabolic reprogramming promoting inflammation. In the absence of Kir2.1 activity, depolarized macrophage Vm lead to a caloric restriction state by limiting nutrient uptake and concomitant adaptations in nutrient conservation inducing autophagy, AMPK (Adenosine 5'-monophosphate-activated protein kinase), and GCN2 (General control nonderepressible 2), which subsequently depletes epigenetic substrates feeding histone methylation at loci of a cluster of metabolism-responsive inflammatory genes, thereby suppressing their transcription. Kir2.1-mediated Vm supports nutrient uptake by facilitating cell-surface retention of nutrient transporters such as 4F2hc and GLUT1 by its modulation of plasma membrane phospholipid dynamics. Pharmacological targeting of Kir2.1 alleviated inflammation triggered by LPS or bacterial infection in a sepsis model and sterile inflammation in human samples. These findings identify an ionic control of macrophage activation and advance our understanding of the immunomodulatory properties of Vm that links nutrient inputs to inflammatory diseases.
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Affiliation(s)
- Weiwei Yu
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China.,Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, P. R. China
| | - Zhen Wang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China.,Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, P. R. China
| | - Xiafei Yu
- Department of Biophysics, and Department of Neurology of the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Yonghui Zhao
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, 430072, P. R. China
| | - Zili Xie
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, 430072, P. R. China
| | - Kailian Zhang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Zhexu Chi
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Sheng Chen
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Ting Xu
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Danlu Jiang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Xingchen Guo
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, 430072, P. R. China
| | - Mobai Li
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Jian Zhang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Hui Fang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Dehang Yang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Yuxian Guo
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Xuyan Yang
- Department of Rheumatology of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Xue Zhang
- Department of Pathology and Pathophysiology, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Yingliang Wu
- State Key Laboratory of Virology, College of Life Sciences, Wuhan University, Wuhan, 430072, P. R. China
| | - Wei Yang
- Department of Biophysics, and Department of Neurology of the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China.
| | - Di Wang
- Institute of Immunology and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China. .,Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, P. R. China.
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24
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Zheng WH, Yao Y, Zhou H, Xu Y, Huang HB. Hyperphosphatemia and Outcomes in Critically Ill Patients: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:870637. [PMID: 35665344 PMCID: PMC9156794 DOI: 10.3389/fmed.2022.870637] [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: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Serum phosphate level is often deranged during critical illness. Hyperphosphatemia, as a marker of disease severity, attracts more and more attention. This study aimed to evaluate the impact of hyperphosphatemia on clinical outcomes in critically ill patients. Methods We searched for relevant studies in PubMed, EMBASE, and the Cochrane database up to Jan 10, 2022. Two authors independently screened studies, extracted data, and assessed the study quality. Meta-analyses were performed to determine hyperphosphatemia prevalence and evaluate its relationship with prognosis and important clinical outcomes. We also conducted subgroup analysis and sensitivity analyses to explore the sources of heterogeneity. Results Ten studies with 60,358 patients met the inclusion criteria. These studies were moderate to high quality. The median prevalence of hyperphosphatemia was 30% (range from 5.6 to 45%). Patients with hyperphosphatemia had a significantly higher risk of all-cause mortality than those without (OR 2.85; 95% CI, 2.35 to 3.38, P < 0.0001). Subgroup analyses, sensitivity analyses, and regression analyses further confirmed these results. In addition, patients with hyperphosphatemia required more CRRT (OR 4.96; 95% CI, 2.43 to 10.2, P < 0.0001) but not significantly increased duration of mechanical ventilation (mean difference, MD 0.13, 95% CI −0.04 to 0.30; P = 0.138), length of stay in intensive care unit (ICU) (SMD 0.164 day, 95% CI −0.007 to 0.335; P = 0.06), and length of stay in hospital (SMD 0.005 day, 95% CI −0.74 to 0.75; P = 0.99). Conclusions Our results indicated that hyperphosphatemia was associated with all-cause mortality in critically ill patients. However, due to the retrospective design of the included studies, more prospective, well-designed research is required in the future. Systematic Review Registration [https://doi.org/10.37766/inplasy2021.12.0130], identifier [INPLASY2021120130].
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Affiliation(s)
- Wen-He Zheng
- Department of Critical Care Medicine, The Second People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yan Yao
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hua Zhou
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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25
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Induruwa I, Hennebry E, Hennebry J, Thakur M, Warburton EA, Khadjooi K. Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation? Eur J Intern Med 2022; 98:32-36. [PMID: 34763982 PMCID: PMC8948090 DOI: 10.1016/j.ejim.2021.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
Sepsis can lead to cardiac arrhythmias, of which the most common is atrial fibrillation (AF). Sepsis is associated with up to a six-fold higher risk of developing AF, where it occurs most commonly in the first 3 days of hospital admission. In many patients, AF detected during sepsis is the first documented episode of AF, either as an unmasking of sub-clinical AF or as a newly developed arrhythmia. In the short term, sepsis that is complicated by AF leads to longer hospital stays and an increased risk of inpatient mortality. Sepsis-driven AF can also increase an individual's risk of inpatient stroke by nearly 3-fold, compared to sepsis patients without AF. In the long-term, it is estimated that up to 50% of patients have recurrent episodes of AF within 1-year of their episode of sepsis. The common perception that once the precipitating illness is treated or sinus rhythm is restored the risk of stroke is removed is incorrect. For clinicians, there is a paucity of evidence on how to reduce an individual's risk of stroke after developing AF during sepsis, including whether to start anticoagulation. This is pertinent when considering that more patients are surviving episodes of sepsis and are left with post-sepsis sequalae such as AF. This review provides a summary on the literature available surrounding sepsis-driven AF, focusing on AF recurrence and ischaemic stroke risk. Using this, pragmatic advice to clinicians on how to better detect and reduce an individual's stroke risk after developing AF during sepsis is discussed.
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Affiliation(s)
- Isuru Induruwa
- Department of Stroke, Cambridge University Hospitals, Cambridge CB2 0QQ, United Kingdom; Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, United Kingdom.
| | - Eleanor Hennebry
- Department of Medicine, Royal Sussex County Hospital, Brighton BN2 5BE, United Kingdom
| | - James Hennebry
- Department of Medicine, Royal Sussex County Hospital, Brighton BN2 5BE, United Kingdom
| | - Mrinal Thakur
- Department of Stroke, Cambridge University Hospitals, Cambridge CB2 0QQ, United Kingdom
| | - Elizabeth A Warburton
- Department of Stroke, Cambridge University Hospitals, Cambridge CB2 0QQ, United Kingdom; Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Kayvan Khadjooi
- Department of Stroke, Cambridge University Hospitals, Cambridge CB2 0QQ, United Kingdom
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26
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Foss NB. Electrolyte and Acid-Base Disturbances in Emergency High-Risk Abdominal Surgery, a Retrospective Study. World J Surg 2022; 46:1325-1335. [PMID: 35262790 DOI: 10.1007/s00268-022-06499-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients undergoing emergency high-risk abdominal surgery potentially suffer from both systemic dehydration and hypovolaemia. Data on the prevalence and clinical impact of electrolyte disturbances in this patient group, specifically the differences in patients with intestinal obstruction (IO) versus perforated viscus (PV) are lacking. METHODS Adult patients undergoing emergency high-risk abdominal surgery in a standardized perioperative pathway were included in this retrospective single-center cohort study. Electrolytes and arterial blood gas analysis were measured during the early perioperative period. Prevalence and clinical impact of electrolyte disturbances were assessed. RESULTS A total of 354 patients were included in the study. Preoperative alkalemia dominated preoperatively, significantly more prevalent in IO (45 vs. 32%, p < .001), while acidosis was most pronounced postoperatively in PV (49 vs. 28%, p < .0001). Preoperative hypochloraemia and hypokalemia were more frequent in the IO (34 vs. 20% and 37 vs. 25%, respectively). Hyponatremia was highly prevalent in both IO and PV. Pre- and postoperative hypochloremia were independently associated with 30-day postoperative morbidity and mortality in patients with IO (OR 2.87 (1.35, 6.23) p = 0.006, OR 6.86 (1.71, 32.2) p = 0.009, respectively). Hypochloremic patients presented with reduced long-term survival as compared with the normo- and hyperchloremic patients (p < 0.05). Neither plasma sodium nor potassium showed a significant association with outcome. CONCLUSION These observations suggest that acute high-risk abdominal patients have frequent preoperative alkalosis shifting to postoperative acidosis. Both pre- and postoperative hypochloremia were independently associated with both impaired short- and long-term outcome in patients with intestinal obstruction, with potential implications for the choice of resuscitations fluids.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, Hvidovre, 2650, Copenhagen, Denmark.
| | - Henrik Kehlet
- Surgical Pathophysiology Unit, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, Hvidovre, 2650, Copenhagen, Denmark
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Zhang W, Gu Q, Gu Y, Zhao Y, Zhu L. Symptom management to alleviate thirst and dry mouth in critically ill patients: A randomised controlled trial. Aust Crit Care 2022; 35:123-129. [PMID: 34119409 DOI: 10.1016/j.aucc.2021.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/22/2021] [Accepted: 04/17/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Critically ill patients often experience coexisting symptoms. Thirst, in particular, appears to be an important symptom, having the highest prevalence, intensity, and induction of distress, and is significantly correlated with other symptoms. However, thirst and dry mouth are not usually assessed or treated. OBJECTIVES The aim of the study was to demonstrate the effectiveness of an intervention bundle to relieve thirst and dry mouth. METHODS The present study was a randomised controlled trial in which critically ill patients were allocated to an experimental or control group. The intervention bundles, including vitamin C sprays, peppermint water mouthwash, and a lip moisturiser, were provided to the experimental group for 3 days, whereas patients in the control group were exposed to the placebo interventions, including saline sprays, 40 °C water mouthwash, and wetting the lips with water. RESULTS A total of 61 patients were recruited to the study; 65.6% (n = 41) were men, and the average age was 64.2 ± 16.8 years. The average decrease in thirst intensity and oral mucosa situation scores after the interventions was larger in the experimental group patients relative to controls (1.27 and 0.36 vs. 0.19 and 0.1 points, respectively; p < 0.05). Being male, scoring highly on the Acute Physiology and Chronic Health Evaluation II scale, not receiving diuretics, and having higher serum sodium levels were potential predictors of thirst and oral dryness. CONCLUSIONS The interventional bundle used in this study was shown to be a promising approach that can relieve thirst intensity and dry mouth, which are pervasively distressful to critically ill patients. CLINICAL TRIAL REGISTRATION NUMBERS The study was registered on the www.Chictr.org.cn under the identification number ChiCTR1900022873.
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Affiliation(s)
- Weiqing Zhang
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiuying Gu
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yanting Gu
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yujin Zhao
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhu
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Lee B, Park H. Performance evaluation of the i‐Smart 300E cartridge for point‐of‐care electrolyte measurement in serum and plasma. J Clin Lab Anal 2022; 36:e24295. [PMID: 35156738 PMCID: PMC8993652 DOI: 10.1002/jcla.24295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Electrolytes are measured regularly in a variety of clinical settings because electrolyte imbalance can be life‐threatening. Although arterial blood‐gas analysis reports electrolyte levels, the result often is discrepant with results from serum and plasma samples. Since prompt and accurate measurement of serum electrolyte levels could allow early treatment, point‐of‐care (POC) electrolyte analyzers would be beneficial. We evaluated a POC electrolyte analyzer cartridge based on the Clinical and Laboratory Standard Institute (CLSI) guidelines. Methods Precision and linearity were assessed according to the CLSI EP05‐A3 and EP06‐A guidelines, respectively. A comparison study was conducted with both serum and plasma samples according to the CLSI EP09‐A3. For serum, results from the i‐Smart 300E analyzer were compared with results from the Nova 8 and i‐Smart 30 analyzers. For plasma, results were compared among the i‐Smart 300E, Nova 8, i‐Smart 30, and Cobas c702 analyzers. Results Coefficients of variation in the precision analysis were all less than 5%. Linearity assessment demonstrated a coefficient of determination between 0.999 and 1.000 for all analytes. The comparison study showed a high Pearson's correlation coefficient greater than 0.9 for all analytes, instruments, and specimens. Conclusions The i‐Smart 300E demonstrated good analytical performance. Its use could be beneficial in terms of both efficiency and clinical outcome in point‐of‐care testing (POCT) for electrolyte levels from serum and plasma samples.
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Affiliation(s)
- Beomki Lee
- Department of Laboratory Medicine and Genetics Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Hyung‐Doo Park
- Department of Laboratory Medicine and Genetics Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
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29
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Thongprayoon C, Radhakrishnan Y, Cheungpasitporn W, Petnak T, Qureshi F, Mao MA, Kashani KB. Association of Serum Phosphate Derangement With Mortality in Patients on Continuous Renal Replacement Therapy. Can J Kidney Health Dis 2022; 9:20543581221114697. [PMID: 35923184 PMCID: PMC9340369 DOI: 10.1177/20543581221114697] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: There is limited evidence on the association of serum phosphate with
mortality in patients receiving continuous renal replacement therapy
(CRRT). Objective: To assess the association of serum phosphate with mortality in critically ill
patients requiring CRRT for acute kidney injury (AKI). Design: A cohort study. Setting: A tertiary referral hospital in the United States. Patients: Acute kidney injury patients receiving CRRT from 2006 through 2015 in
intensive care units. Measurements: (1) Serum phosphate before CRRT and (2) mean serum phosphate during CRRT were
categorized into 3 groups; ≤2.4 (hypophosphatemia), 2.5 to 4.5 (normal serum
phosphate group), and ≥4.6 (hyperphosphatemia) mg/dL. Methods: Multivariable logistic regression was used to assess the association between
serum phosphate and 90-day mortality. Results: A total of 1108 patients were included in this study. Of these, 55% died
within 90 days after CRRT initiation. Before CRRT, 3%, 30%, and 66% had
hypophosphatemia, normophosphatemia, and hyperphosphatemia, respectively.
Before CRRT, both hypophosphatemia and hyperphosphatemia were significantly
associated with higher 90-day mortality with the adjusted odds ratio (OR) of
2.22 (95% confidence interval [CI]: [1.03, 4.78]) and 1.62 (95% CI: [1.21,
2.18]), respectively. During CRRT, 3%, 85%, and 12% had mean serum phosphate
in hypophosphatemia, normophosphatemia, and hyperphosphatemia range. During
CRRT, hyperphosphatemia was significantly associated with higher 90-day
mortality with adjusted OR of 2.22 (95% CI: [1.45, 3.38]). Limitations: Single center, observational design, lack of information regarding causes of
serum phosphate derangement. Conclusion: Most CRRT patients had hyperphosphatemia before CRRT initiation but maintain
normal serum phosphate during CRRT. Before CRRT, hypo- and
hyperphosphatemia, and during CRRT, hyperphosphatemia predicted higher
mortality. Trial registration: Not registered.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeshwanter Radhakrishnan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL, USA
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Tatucu-Babet OA, Nguo K, Lambell KJ, Romero L, Earthman CP, Ridley EJ. Doubly labelled water for determining total energy expenditure in adult critically ill and acute care hospitalized inpatients: A scoping review. Clin Nutr 2021; 41:424-432. [PMID: 35007811 DOI: 10.1016/j.clnu.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/24/2021] [Accepted: 12/10/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Doubly labelled water (DLW) is considered the reference standard method of measuring total energy expenditure (TEE), but there is limited information on its use in the Intensive Care Unit (ICU) and acute care setting. This scoping review aims to systematically summarize the available literature on TEE measured using DLW in these contexts. METHODS Four online databases (MEDLINE, Embase, Emcare and CINAHL) were searched up to Dec 12, 2020. Studies in English were included if they measured TEE using DLW in adults in the ICU and/or acute care setting. Key considerations, concerns and practical recommendations were identified and qualitatively synthesized. RESULTS The search retrieved 7582 studies and nine studies were included; one in the ICU and eight in the acute care setting. TEE was measured over 7-15-days, in predominantly clinically stable patients. DLW measurements were not commenced until four days post admission or surgery in one study and following a 10-14-day stabilization period on parenteral nutrition (PN) in three studies. Variable dosages of isotopes were administered, and several equations used to calculate TEE. Four main considerations were identified with the use of DLW in these settings: variation in background isotopic abundance; excess isotopes leaving body water as carbon dioxide or water; fluctuations in rates of isotope elimination and costs. CONCLUSION A stabilization period on intravenous fluid and PN regimens is recommended prior to DLW measurement. The DLW technique can be utilized in medically stable ICU and acute care patients, with careful considerations given to protocol design.
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Affiliation(s)
- Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 553 St Kilda Rd, Melbourne, Victoria, 3004, Australia.
| | - Kay Nguo
- Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Notting Hill, Victoria, 3168, Australia
| | - Kate J Lambell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 553 St Kilda Rd, Melbourne, Victoria, 3004, Australia; Nutrition Department, Alfred Hospital, Alfred Health, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, 55 Commercial Rd, 3004 Melbourne, VIC, Australia
| | - Carrie P Earthman
- Department of Behavioural Health and Nutrition, University of Delaware, Newark, NJ, USA
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 553 St Kilda Rd, Melbourne, Victoria, 3004, Australia; Nutrition Department, Alfred Hospital, Alfred Health, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
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31
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Prior fluid and electrolyte imbalance is associated with COVID-19 mortality. COMMUNICATIONS MEDICINE 2021; 1:51. [PMID: 35602191 PMCID: PMC9053234 DOI: 10.1038/s43856-021-00051-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 10/29/2021] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
The COVID-19 pandemic represents a major public health threat. Risk of death from the infection is associated with age and pre-existing comorbidities such as diabetes, dementia, cancer, and impairment of immunological, hepatic or renal function. It remains incompletely understood why some patients survive the disease, while others do not. As such, we sought to identify novel prognostic factors for COVID-19 mortality.
Methods
We performed an unbiased, observational retrospective analysis of real world data. Our multivariable and univariable analyses make use of U.S. electronic health records from 122,250 COVID-19 patients in the early stages of the pandemic.
Results
Here we show that a priori diagnoses of fluid, pH and electrolyte imbalance during the year preceding the infection are associated with an increased risk of death independently of age and prior renal comorbidities.
Conclusions
We propose that future interventional studies should investigate whether the risk of death can be alleviated by diligent and personalized management of the fluid and electrolyte balance of at-risk individuals during and before COVID-19.
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Hypernatremia subgroups among hospitalized patients by machine learning consensus clustering with different patient survival. J Nephrol 2021; 35:921-929. [PMID: 34623631 DOI: 10.1007/s40620-021-01163-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/17/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of this study was to characterize hypernatremia patients at hospital admission into clusters using an unsupervised machine learning approach and to evaluate the mortality risk among these distinct clusters. METHODS We performed consensus cluster analysis based on demographic information, principal diagnoses, comorbidities, and laboratory data among 922 hospitalized adult patients with admission serum sodium of > 145 mEq/L. We calculated the standardized difference of each variable to identify each cluster's key features. We assessed the association of each hypernatremia cluster with hospital and 1-year mortality. RESULTS There were three distinct clusters of patients with hypernatremia on admission: 318 (34%) patients in cluster 1, 339 (37%) patients in cluster 2, and 265 (29%) patients in cluster 3. Cluster 1 consisted of more critically ill patients with more severe hypernatremia and hypokalemic hyperchloremic metabolic acidosis. Cluster 2 consisted of older patients with more comorbidity burden, body mass index, and metabolic alkalosis. Cluster 3 consisted of younger patients with less comorbidity burden, higher baseline eGFR, hemoglobin, and serum albumin. Compared to cluster 3, odds ratios for hospital mortality were 15.74 (95% CI 3.75-66.18) for cluster 1, and 6.51 (95% CI 1.48-28.59) for cluster 2, whereas hazard ratios for 1-year mortality were 6.25 (95% CI 3.69-11.46) for cluster 1 and 4.66 (95% CI 2.73-8.59) for cluster 2. CONCLUSION Our cluster analysis identified three clinically distinct phenotypes with differing mortality risk in patients hospitalized with hypernatremia.
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33
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Umbrello M, Guglielmetti L, Formenti P, Antonucci E, Cereghini S, Filardo C, Montanari G, Muttini S. Qualitative and quantitative muscle ultrasound changes in patients with COVID-19-related ARDS. Nutrition 2021; 91-92:111449. [PMID: 34583135 PMCID: PMC8364677 DOI: 10.1016/j.nut.2021.111449] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/31/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Severe forms of the novel coronavirus-19 (COVID-19) are associated with systemic inflammation and hypercatabolism. The aims of this study were to compare the time course of the size and quality of both rectus femoris and diaphragm muscles between critically ill, COVID-19 survivors and non-survivors and to explore the correlation between the change in muscles size and quality with the amount of nutritional support delivered and the cumulative fluid balance. METHODS This was a prospective observational study in the general intensive care unit (ICU) of a tertiary care hospital for COVID-19. The right rectus femoris cross-sectional area and the right diaphragm thickness, as well as their echo densities were assessed within 24 h from ICU admission and on day 7. We recorded anthropometric and biochemical data, respiratory mechanics and gas exchange, daily fluid balance, and the number of calories and proteins administered. RESULTS Twenty-eight patients were analyzed (65 ± 10 y of age; 80% men, body mass index 30 ± 7.8 kg/m2). Rectus femoris and diaphragm sizes were significantly reduced at day 7 (median = -26.1 [interquartile ratio [IQR], = -37.8 to -15.2] and -29.2% [-37.8% to -19.6%], respectively) and this reduction was significantly higher in non-survivors. Both rectus femoris and diaphragm echo density were significantly increased at day 7, with a significantly higher increase in non-survivors. The change in both rectus femoris and diaphragm size at day 7 was related to the cumulative protein deficit (R = 0.664, P < 0.001 and R = 0.640, P < 0.001, respectively), whereas the change in rectus femoris and diaphragm echo density was related to the cumulative fluid balance (R = 0.734, P < 0.001 and R = 0.646, P < 0.001, respectively). CONCLUSIONS Early changes in muscle size and quality seem related to the outcome of critically ill COVID-19 patients, and to be influenced by nutritional and fluid management strategies.
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Affiliation(s)
- Michele Umbrello
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy.
| | - Luigi Guglielmetti
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Paolo Formenti
- U.O. Anestesia e Rianimazione I, Ospedale San Paolo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Edoardo Antonucci
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Sergio Cereghini
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Clelia Filardo
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Giulia Montanari
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Stefano Muttini
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
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Weckx R, Goossens C, Derde S, Pauwels L, Vander Perre S, Van den Bergh G, Langouche L. Identification of the toxic threshold of 3-hydroxybutyrate-sodium supplementation in septic mice. BMC Pharmacol Toxicol 2021; 22:50. [PMID: 34544493 PMCID: PMC8454128 DOI: 10.1186/s40360-021-00517-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 09/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In septic mice, supplementing parenteral nutrition with 150 mg/day 3-hydroxybutyrate-sodium-salt (3HB-Na) has previously shown to prevent muscle weakness without obvious toxicity. The main objective of this study was to identify the toxic threshold of 3HB-Na supplementation in septic mice, prior to translation of this promising intervention to human use. METHODS In a centrally-catheterized, antibiotic-treated, fluid-resuscitated, parenterally fed mouse model of prolonged sepsis, we compared with placebo the effects of stepwise escalating doses starting from 150 mg/day 3HB-Na on illness severity and mortality (n = 103). For 5-day survivors, also the impact on ex-vivo-measured muscle force, blood electrolytes, and markers of vital organ inflammation/damage was documented. RESULTS By doubling the reference dose of 150 mg/day to 300 mg/day 3HB-Na, illness severity scores doubled (p = 0.004) and mortality increased from 30.4 to 87.5 % (p = 0.002). De-escalating this dose to 225 mg still increased mortality (p ≤ 0.03) and reducing the dose to 180 mg/day still increased illness severity (p ≤ 0.04). Doses of 180 mg/day and higher caused more pronounced metabolic alkalosis and hypernatremia (p ≤ 0.04) and increased markers of kidney damage (p ≤ 0.05). Doses of 225 mg/day 3HB-Na and higher caused dehydration of brain and lungs (p ≤ 0.05) and increased markers of hippocampal neuronal damage and inflammation (p ≤ 0.02). Among survivors, 150 mg/day and 180 mg/day increased muscle force compared with placebo (p ≤ 0.05) up to healthy control levels (p ≥ 0.3). CONCLUSIONS This study indicates that 150 mg/day 3HB-Na supplementation prevented sepsis-induced muscle weakness in mice. However, this dose appeared maximally effective though close to the toxic threshold, possibly in part explained by excessive Na+ intake with 3HB-Na. Although lower doses were not tested and thus might still hold therapeutic potential, the current results point towards a low toxic threshold for the clinical use of ketone salts in human critically ill patients. Whether 3HB-esters are equally effective and less toxic should be investigated.
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Affiliation(s)
- Ruben Weckx
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Chloë Goossens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Sarah Derde
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Lies Pauwels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Greet Van den Bergh
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium.
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35
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Monnier S, Abdel-Sayed P, Roessingh ADB, Hirt-Burri N, Chemali M, Applegate LA, Raffoul W. Surgical Management Evolution Between 2 Massive Burn Cases at 17-Year Interval: Contribution of Cell Therapies in Improving the Surgical Care. Cell Transplant 2021; 29:963689720973642. [PMID: 33172295 PMCID: PMC7784608 DOI: 10.1177/0963689720973642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
We report the cases of 2 patients admitted to our hospital at a 17-year interval, both with 90% total body surface area (TBSA) burns. These two young patients were in good health before their accident, but major differences in time of intensive care and hospitalization were observed: 162 versus 76 days in intensive care unit and 18 versus 9.5 months for hospitalization, respectively. We have analyzed the different parameters side-by-side during their medical care and we have identified that the overall improved outcomes are mainly due to a better adapted fluid reanimation in combination with the evolution of the surgical management to encompass allogenic cellular therapy (Biological Bandages). Indeed, autologous cell therapy using keratinocytes has been used for over 30 years in our hospital with the same technical specifications; however, we have integrated the Biological Bandages and routinely used them for burn patients to replace cadaver skin since the past 15 years. Thus, patient 1 versus patient 2 had, respectively, 83% versus 80% TBSA for autologous cells, and 0% versus 189% for allogenic cells. Notably, it was possible that patient 2 was able to recover ∼6% TBSA with the use of Biological Bandages, by stimulating intermediate burn zones toward a spontaneous healing without requiring further skin grafting (on abdomen and thighs). The body zones where Biological Bandages were not applied, such as the buttocks, progressed to deeper-stage burns. Despite inherent differences to patients at their admission and the complexity of severe burn care, the results of these two case reports suggest that integration of innovative allogenic cell therapies in the surgical care of burn patients could have major implications in the final outcome.
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Affiliation(s)
- Sandra Monnier
- Service of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Switzerland.,Children and Adolescent Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Philippe Abdel-Sayed
- Service of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Switzerland.,Regenerative Therapy Unit, Lausanne University Hospital, Switzerland.,Both the authors are co-first authors
| | - Anthony de Buys Roessingh
- Children and Adolescent Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Nathalie Hirt-Burri
- Service of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Switzerland.,Regenerative Therapy Unit, Lausanne University Hospital, Switzerland
| | - Michèle Chemali
- Service of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Switzerland
| | - Lee Ann Applegate
- Service of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Switzerland.,Regenerative Therapy Unit, Lausanne University Hospital, Switzerland.,Both the authors are co-last authors
| | - Wassim Raffoul
- Service of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital, Switzerland.,Both the authors are co-last authors
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Roh H, Kim N, Lee Y, Park J, Kim BS, Lee MK, Park CI, Kim DH. Dual-Organ Transcriptomic Analysis of Rainbow Trout Infected With Ichthyophthirius multifiliis Through Co-Expression and Machine Learning. Front Immunol 2021; 12:677730. [PMID: 34305907 PMCID: PMC8296305 DOI: 10.3389/fimmu.2021.677730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/31/2021] [Indexed: 01/16/2023] Open
Abstract
Ichthyophthirius multifiliis is a major pathogen that causes a high mortality rate in trout farms. However, systemic responses to the pathogen and its interactions with multiple organs during the course of infection have not been well described. In this study, dual-organ transcriptomic responses in the liver and head kidney and hemato-serological indexes were profiled under I. multifiliis infection and recovery to investigate systemic immuno-physiological characteristics. Several strategies for massive transcriptomic interpretation, such as differentially expressed genes (DEGs), Poisson linear discriminant (PLDA), and weighted gene co-expression network analysis (WGCNA) models were used to investigate the featured genes/pathways while minimizing the disadvantages of individual methods. During the course of infection, 6,097 and 2,931 DEGs were identified in the head kidney and liver, respectively. Markers of protein processing in the endoplasmic reticulum, oxidative phosphorylation, and the proteasome were highly expressed. Likewise, simultaneous ferroptosis and cellular reconstruction was observed, which is strongly linked to multiple organ dysfunction. In contrast, pathways relevant to cellular replication were up-regulated in only the head kidney, while endocytosis- and phagosome-related pathways were notably expressed in the liver. Moreover, interestingly, most immune-relevant pathways (e.g., leukocyte trans-endothelial migration, Fc gamma R-mediated phagocytosis) were highly activated in the liver, but the same pathways in the head kidney were down-regulated. These conflicting results from different organs suggest that interpretation of co-expression among organs is crucial for profiling of systemic responses during infection. The dual-organ transcriptomics approaches presented in this study will greatly contribute to our understanding of multi-organ interactions under I. multifiliis infection from a broader perspective.
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Affiliation(s)
- HyeongJin Roh
- Department of Aquatic Life Medicine, College of Fisheries Science, Pukyong National University, Busan, South Korea
| | - Nameun Kim
- Department of Aquatic Life Medicine, College of Fisheries Science, Pukyong National University, Busan, South Korea
| | - Yoonhang Lee
- Department of Aquatic Life Medicine, College of Fisheries Science, Pukyong National University, Busan, South Korea
| | - Jiyeon Park
- Department of Aquatic Life Medicine, College of Fisheries Science, Pukyong National University, Busan, South Korea
| | - Bo Seong Kim
- Aquatic Disease Control Division, National Institute of Fisheries Science (NIFS), Busan, South Korea
| | - Mu Kun Lee
- Korean Aquatic Organism Disease Inspector Association, Busan, South Korea
| | - Chan-Il Park
- Department of Marine Biology & Aquaculture, College of Marine Science, Gyeongsang National University, Tongyeong, South Korea
| | - Do-Hyung Kim
- Department of Aquatic Life Medicine, College of Fisheries Science, Pukyong National University, Busan, South Korea
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Nazer LH, Brown ART, Awad W. Iatrogenic Toxicities in the Intensive Care Unit. Crit Care Clin 2021; 37:625-641. [PMID: 34053710 DOI: 10.1016/j.ccc.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Drug-induced iatrogenic toxicities are common in critically ill patients and have been associated with increased morbidity and mortality. Early recognition and management of iatrogenic toxicities is essential; however, the diagnosis is usually complicated by the underlying critical illness, comorbidities, and administration of multiple medications. This article reviews several types of iatrogenic toxicities associated with medications that are commonly used in critically ill patients. The mechanism of the iatrogenic toxicities, clinical presentation, and diagnosis, as well as management are discussed.
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Affiliation(s)
- Lama H Nazer
- King Hussein Cancer Center, Queen Rania Al-Abdallah Street, PO Box 1269, Amman 11941, Jordan.
| | - Anne Rain T Brown
- University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Wedad Awad
- King Hussein Cancer Center, Queen Rania Al-Abdallah Street, PO Box 1269, Amman 11941, Jordan
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38
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Wilson S, Bohn MK, Adeli K. POCT: An Inherently Ideal Tool in Pediatric Laboratory Medicine. EJIFCC 2021; 32:145-157. [PMID: 34421483 PMCID: PMC8343051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Point of care testing (POCT) is important in the provision of timely laboratory test results and continues to gain specific appreciation in the setting of pediatric healthcare. POCT platforms offer several advantages compared to central laboratory testing, including improved clinical outcomes, reduced time to diagnosis, length of stay, and blood volume requirements, as well as increased accessibility. These advantages are most pronounced in acute care settings such as pediatric emergency departments, intensive care units, and in remote settings, wherein rapid patient assessment and prognostication is essential to patient outcomes. The current review provides an overview and critical discussion of the evidence supporting clinical implementation of POCT systems in pediatric clinical decision-making, including but not limited to the diagnosis of viral and bacterial infection, identification of critical glucose and electrolyte dysregulation, and prognostication of post-operative inpatients. Important considerations for test result reporting and interpretation are also discussed, including analytical concordance between POCT systems and central laboratory analyzers as well as availability of pediatric reference intervals for key analytes on POCT systems. Notably, a paucity of evidence-based pediatric reference intervals for test interpretation for critical care parameters on POCT platforms is highlighted, warranting further study and unique consideration prior to clinical implementation.
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Affiliation(s)
- Siobhan Wilson
- Division of Clinical Biochemistry, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mary Kathryn Bohn
- Division of Clinical Biochemistry, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Khosrow Adeli
- Division of Clinical Biochemistry, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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39
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Al Harbi SA, Al-Dorzi HM, Al Meshari AM, Tamim H, Abdukahil SAI, Sadat M, Arabi Y. Association between phosphate disturbances and mortality among critically ill patients with sepsis or septic shock. BMC Pharmacol Toxicol 2021; 22:30. [PMID: 34049590 PMCID: PMC8161900 DOI: 10.1186/s40360-021-00487-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/30/2021] [Indexed: 11/11/2022] Open
Abstract
Objective The aim of this study is to examine the association of hypophosphatemia and hyperphosphatemia on the first day of ICU admission with mortality in septic critically ill patients. Methods In this retrospective cohort study, all adult patients who were admitted to the medical-surgical ICUs between 2014 and 2017 with sepsis or septic shock were categorized as having hypophosphatemia, normophosphatemia and hyperphosphatemia based on day 1 serum phosphate values. We compared the clinical characteristics and outcomes between the three groups. We used multivariate analysis to examine the association of hypophosphatemia and hyperphosphatemia with these outcomes. Results Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 865 (61%) normophosphatemia and 369 (26%) had hyperphosphatemia. The patients in the hyperphosphatemia group had significantly lower GCS, higher APACHE II scores, higher serum creatinine, increased use of vasopressors, and required more mechanical ventilation with lower PaO2/FiO2 ratio compared with the other two groups. In addition, the hyperphosphatemia group showed significantly higher ICU and hospital mortality in comparison with the other two groups. Conclusion Hyperphosphatemia and not hypophosphatemia on the first ICU admission day was associated with an increase in the ICU and hospital mortality in septic critically ill patients.
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Affiliation(s)
- Shmeylan A Al Harbi
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Hani Tamim
- Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon
| | - Sheryl Ann I Abdukahil
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. .,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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Tanemoto M. Lessons for the clinical nephrologist: a midsummer night's cluster of hypernatremia cases. J Nephrol 2021; 35:331-332. [PMID: 33856684 DOI: 10.1007/s40620-021-01047-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/02/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Masayuki Tanemoto
- Division of Nephrology, Department of Internal Medicine, International University of Health and Welfare School of Medicine, 13-1 Higashi-Kaigan-Cho, Atami, Shizuoka, 413-0012, Japan. .,Division of Nephrology, Shin-Kuki General Hospital, Saitama, Japan.
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Pourfridoni M, Abbasnia SM, Shafaei F, Razaviyan J, Heidari-Soureshjani R. Fluid and Electrolyte Disturbances in COVID-19 and Their Complications. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6667047. [PMID: 33937408 PMCID: PMC8060100 DOI: 10.1155/2021/6667047] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/11/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022]
Abstract
The novel coronavirus disease 2019 (COVID-19) is the cause of an acute respiratory illness which has spread around the world. The virus infects the host by binding to the angiotensin-converting enzyme 2 (ACE2) receptors. Due to the presence of ACE2 receptors in the kidneys and gastrointestinal (GI) tract, kidneys and GI tract damage arising from the virus can be seen in patients and can cause acute conditions such as acute kidney injury (AKI) and digestive problems for the patient. One of the complications of kidneys and GI involvement in COVID-19 is fluid and electrolyte disturbances. The most common ones of these disorders are hyponatremia, hypernatremia, hypokalemia, hypocalcemia, hypochloremia, hypervolemia, and hypovolemia, which if left untreated, cause many problems for patients and even increase mortality. Fluid and electrolyte disturbances are more common in hospitalized and intensive care patients. Children are also at greater risk for fluid and electrolyte disturbances complications. Therefore, clinicians should pay special attention to the fluid and electrolyte status of patients. Changes in fluid and electrolyte levels can be a good indicator of disease progression.
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Affiliation(s)
| | | | - Fateme Shafaei
- Student Research Committee, Jiroft University of Medical Sciences, Jiroft, Iran
| | - Javad Razaviyan
- Student Research Committee, Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Iran
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Abstract
Postoperative patients are susceptible to alterations in electrolyte homeostasis. Although electrolytes are replaced in critically ill patients, stable asymptomatic non-intensive care unit (ICU) patients often receive treatment of abnormal electrolytes. We hypothesize there is no proven benefit in asymptomatic patients. In 2016, using the electronic medical records and pharmacy database at a university academic medical center, we conducted a retrospective cost analysis of the frequency and cost of electrolyte analysis (basic metabolic panel [BMP], ionized calcium [Ca], magnesium [Mg], and phosphorus [P]) and replacement (potassium chloride [KCl], Mg, oral/iv Ca, oral/iv P) in perioperative patients. Patients without an oral diet order, with creatinine more than 1.4, age less than 16 years, admitted to the ICU, or with length of stay of more than 1 week were excluded. Nursing costs were calculated as a fraction of hourly wages per laboratory order or electrolyte replacement. One hundred thirteen patients met our criteria over 11 months. Mean length of stay was 4 days; mean age was 54 years; and creatinine was 0.67 ± 0.3. Electrolyte analysis laboratory orders (n = 1,045) totaled $6,978, and BMP was most frequently ordered accounting for 36% of laboratory costs. In total, 683 doses of electrolytes cost the pharmacy $1,780. Magnesium was most frequently replaced, followed by KCl, P, and Ca. Nursing cost associated with electrolyte analysis/replacement was $7,782. There is little evidence to support electrolyte analysis and replacement in stable asymptomatic noncritically ill patients, but their prevalence and cost ($146/case) in this study were substantial. Basic metabolic panels, pharmacy charges for potassium, and nursing staff costs accounted for the most significant portion of the total cost. Considering these data, further research should determine whether these practices are warranted.
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Reintam Blaser A, van Zanten ARH. Electrolyte disorders during the initiation of nutrition therapy in the ICU. Curr Opin Clin Nutr Metab Care 2021; 24:151-158. [PMID: 33394599 DOI: 10.1097/mco.0000000000000730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition. RECENT FINDINGS Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome. SUMMARY Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Arthur Raymond Hubert van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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44
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Zhang R, Zhang S, Wang Q. Trueness assessment of routine electrolytes measuring systems using the candidate reference method by ion chromatography. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:85-91. [PMID: 33570452 DOI: 10.1080/00365513.2020.1855469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Electrolytes for sodium, potassium, magnesium, and calcium are important serum ions that are frequently assayed in clinical laboratories. In this study, we assessed the trueness of routine analytical systems for four cations using an inexpensive candidate reference method aimed to promote the standardization of serum electrolyte detection. An ion chromatography (IC) method with Cesium as an internal standard was developed and evaluated. The residual clinical serum samples at Chaoyang Hospital were collected and prepared into three human serum pools of electrolytes, which were used for the trueness evaluation of five routine analytical systems. Furthermore, the agreement between routine methods and the IC method was verified using 40 individual human samples. The recovery rates of sodium, potassium, magnesium and calcium were 99.69%, 100.34%, 100.43% and 99.89%, respectively. The intra-batch standard deviation and intra-laboratory precision of NIST SRM 956c were all less than 1% for the four ions. The certified values were within the validation range, and the deviation between the results and the certified values were less than 0.5%. The three serum pools were homogeneous and stable. All routine systems aligned with the IC method for four cations and achieved the analytical quality specifications for potassium and magnesium at 3 different concentrations. The developed IC method is simple, practical, accurate, and precise, which can be used as a candidate reference method for serum electrolytes measurement. Five routine analytical systems for electrolytes measurement had the acceptable bias for potassium and magnesium and their results showed good concordance.
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Affiliation(s)
- Rui Zhang
- Department of Clinical Laboratory, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shunli Zhang
- Department of Clinical Laboratory, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qingtao Wang
- Department of Clinical Laboratory, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China.,Beijing Center for Clinical Laboratories, Beijing, People's Republic of China
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Counterfactual Explanations for Survival Prediction of Cardiovascular ICU Patients. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-77211-6_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mackney J, Harrold M, Jenkins S, Fehlberg R, Thomas L, Havill K, Jacques A, Hill K. Survivors of Acute Lung Injury Have Greater Impairments in Strength and Exercise Capacity Than Survivors of Other Critical Illnesses as Measured Shortly After ICU Discharge. J Intensive Care Med 2020; 37:202-210. [PMID: 33334223 DOI: 10.1177/0885066620981899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the physical function on ICU discharge in adults who survived an ICU admission for acute lung injury (ALI) with those admitted for a critical illness other than ALI. MATERIALS AND METHODS Two groups were recruited, (i) those who survived an ICU admission for ALI and, (ii) those who survived an ICU admission for a critical illness other than ALI. Within 7 days of discharge from ICU, in all participants, measures were collected of peripheral muscle strength, balance, walking speed and functional exercise capacity. RESULTS Recruitment was challenging and ceased prior to achieving the desired sample size. Participants with ALI (n = 22) and critical illness (n = 33) were of similar median age (50 vs. 57 yr, p = 0.09), sex proportion (males %, 45 vs. 58, p = 0.59) and median APACHE II score (21.5 vs. 23.0, p = 0.74). Compared with the participants with critical illness, those with ALI had lower hand grip (mean ± SD, 18 ± 9 vs. 13 ± 8 kg, p = 0.018) and shoulder flexion strength (10 ± 4 vs. 7 ± 3 kg, p = 0.047), slower 10-meter walk speed (median [IQR], 1.03 [0.78 to 1.14] vs. 0.78 [0.67 to 0.94] m/s, p = 0.039) and shorter 6-minute walk distance (265 [71 to 328] vs. 165 [53 to 220] m, p = 0.037). The Berg balance scores were similar in both groups. CONCLUSIONS Compared with survivors of a critical illness that is not ALI, those with ALI are likely to have greater physical impairment when measured shortly after discharge to the ward.
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Affiliation(s)
- Jennifer Mackney
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, 1649Curtin University, Perth, Australia.,School of Health Sciences, Faculty of Health and Medicine, 5982The University of Newcastle, Callaghan, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, 37024John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Meg Harrold
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, 1649Curtin University, Perth, Australia
| | - Sue Jenkins
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, 1649Curtin University, Perth, Australia.,Physiotherapy Department, Sir Charles Gairdner Hospital, Perth, Australia.,Institute for Respiratory Health, Sir Charles Gairdner Hospital, Perth, Australia
| | - Rachel Fehlberg
- School of Health Sciences, Faculty of Health and Medicine, 5982The University of Newcastle, Callaghan, New South Wales, Australia
| | - Lauren Thomas
- Physiotherapy Department, 37024John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Ken Havill
- Department of Intensive Care, 37024John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Angela Jacques
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, 1649Curtin University, Perth, Australia
| | - Kylie Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, 1649Curtin University, Perth, Australia.,Institute for Respiratory Health, Sir Charles Gairdner Hospital, Perth, Australia
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Adin D, Atkins C, Londoño L, Del Nero B. Correction of serum chloride concentration in dogs with congestive heart failure. J Vet Intern Med 2020; 35:51-57. [PMID: 33305873 PMCID: PMC7848309 DOI: 10.1111/jvim.15998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 11/20/2020] [Accepted: 12/01/2020] [Indexed: 12/03/2022] Open
Abstract
Background Hypochloremia associated with congestive heart failure (CHF) in dogs is likely multifactorial. Loop diuretics cause 1:2 sodium [Na+]:chloride [Cl−] loss, whereas water retention causes a 1:1 [Na+]:[Cl−] dilution. Mathematical [Cl−] correction separates these effects on [Cl−]. Hypothesis We hypothesized that corrected [Cl−] (c[Cl−]) would not differ from measured [Cl−] (m[Cl−]) in dogs with controlled CHF because of loop diuretics, and dogs with refractory CHF would have higher c[Cl−] than m[Cl−], indicating relative water excess. Animals Seventy‐one client‐owned dogs with acquired heart disease, without CHF (NO‐CHF), 76 with Stage C CHF and 24 with Stage D CHF. Methods Clinicopathological data from a previous study were retrospectively analyzed. Corrected [Cl−], m[Cl−], and differences were compared among NO‐CHF, Stage C CHF, and Stage D CHF, using the formula: c[Cl−] = (mid‐reference range [Na+]/measured [Na+]) × m[Cl−]. Results Corrected [Cl−] and m[Cl−] were lower in Stage D vs Stage C and NO‐CHF (all P < .0001). The c[Cl−] was higher than m[Cl−] in Stage D (P < .0001) but not Stage C or NO‐CHF. Median difference between c[Cl−] and m[Cl−] was higher for Stage D vs Stage C (P = .0003). No hypochloremic Stage D dogs had normal c[Cl−], but 11/24 had [Cl−] that was increased by >2 mmol/L. Conclusions and Clinical Importance Serum [Cl−] increased after mathematical correction in Stage D CHF dogs but not in Stage C and NO‐CHF dogs. Although c[Cl−] was higher than m[Cl−] in Stage D dogs supportive of relative water excess, hypochloremia persisted, consistent with concurrent loop diuretic effects on electrolytes. Future study correlating c[Cl−] to antidiuretic hormone concentrations is warranted.
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Affiliation(s)
- Darcy Adin
- University of Florida, College of Veterinary Medicine, Gainesville, Florida, USA
| | - Clarke Atkins
- North Carolina State University, College of Veterinary Medicine, Raleigh, North Carolina, USA
| | - Leonel Londoño
- University of Florida, College of Veterinary Medicine, Gainesville, Florida, USA
| | - Bruna Del Nero
- University of Florida, College of Veterinary Medicine, Gainesville, Florida, USA
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Alipoor E, Hosseinzadeh-Attar MJ, Rezaei M, Jazayeri S, Chapman M. White adipose tissue browning in critical illness: A review of the evidence, mechanisms and future perspectives. Obes Rev 2020; 21:e13085. [PMID: 32608573 DOI: 10.1111/obr.13085] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/15/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
Observational studies suggest better clinical outcomes following critical illness in patients with overweight and obesity (obesity paradox). An understanding of the morphologic, physiologic and metabolic changes in adipose tissue in critical illness may provide an explanation. Recent studies have demonstrated the transformation of white to brown-like adipocytes due to the "browning process," which has been of interest as a potential novel therapy in obesity during the last decade. The characteristics of the browning of white adipose tissue (WAT) include the appearance of smaller, multilocular adipocytes, increased UCP1 mRNA expression, mitochondrial density and respiratory capacity. These changes have been identified in some critical illnesses, which specifically refers to burns, sepsis and cancer cachexia in this study. The pathophysiological nature of WAT browning, underlying mechanisms, main regulators and potential benefits and harms of this process are interesting new areas that warrants further investigations. In this review, we discuss emerging scientific discipline of adipose tissue physiology in metabolic stress, available data, gaps of knowledge and future perspectives. Future investigations in this field may provide insights into the underlying mechanisms and clinical aspects of browning that may further our understanding of the proposed obesity paradox following critical illness, which may in turn open up opportunities for novel therapies to save lives and improve recovery.
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Affiliation(s)
- Elham Alipoor
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Hosseinzadeh-Attar
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Cardiac Primary Prevention Research Center (CPPRC), Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Rezaei
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Shima Jazayeri
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Marianne Chapman
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia.,National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
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Moonen EJ, Haakma JR, Peri E, Pelssers E, Mischi M, den Toonder JM. Wearable sweat sensing for prolonged, semicontinuous, and nonobtrusive health monitoring. VIEW 2020. [DOI: 10.1002/viw.20200077] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Emma J.M. Moonen
- Department of Mechanical Engineering Eindhoven University of Technology Eindhoven The Netherlands
- Institute for Complex Molecular Systems (ICMS) Eindhoven University of Technology Eindhoven The Netherlands
| | - Jelte R. Haakma
- Department of Electrical Engineering, Laboratory of Biomedical Diagnostics Eindhoven University of Technology Eindhoven The Netherlands
| | - Elisabetta Peri
- Department of Electrical Engineering, Laboratory of Biomedical Diagnostics Eindhoven University of Technology Eindhoven The Netherlands
| | - Eduard Pelssers
- Department of Mechanical Engineering Eindhoven University of Technology Eindhoven The Netherlands
- Philips Research Royal Philips High Tech Campus Eindhoven The Netherlands
| | - Massimo Mischi
- Department of Electrical Engineering, Laboratory of Biomedical Diagnostics Eindhoven University of Technology Eindhoven The Netherlands
| | - Jaap M.J. den Toonder
- Department of Mechanical Engineering Eindhoven University of Technology Eindhoven The Netherlands
- Institute for Complex Molecular Systems (ICMS) Eindhoven University of Technology Eindhoven The Netherlands
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50
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Renal Function is a Major Determinant of ICU-acquired Hypernatremia: A Balance Study on Sodium Handling. J Transl Int Med 2020; 8:165-176. [PMID: 33062593 PMCID: PMC7534501 DOI: 10.2478/jtim-2020-0026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objectives The development of ICU-acquired hypernatremia (IAH) is almost exclusively attributed to ‘too much salt and too little water’. However, intrinsic mechanisms also have been suggested to play a role. To identify the determinants of IAH, we designed a prospective controlled study. Methods Patients with an anticipated length of stay ICU > 48 hours were included. Patients with hypernatremia on admission and/or on renal replacement therapy were excluded. Patients without IAH were compared with patients with borderline hypernatremia (≥ 143 mmol/L, IAH 143) and more severe hypernatremia (≥ 145 mmol/L, IAH 145). Results We included 89 patients, of which 51% developed IAH 143 and 29% IAH 145. Sodium intake was high in all patients. Fluid balances were slightly positive and comparable between the groups. Patients with IAH 145 were more severely ill on admission, and during admission, their sodium intake, cumulative sodium balances, serum creatinine and copeptin levels were higher. According to the free water clearance, all the patients conserved water. On multivariate analysis, the baseline serum creatinine was an independent risk factor for the development of IAH 143 and IAH 145. Also, the copeptin levels remained significant for IAH 143 and IAH 145. Sodium intake remained only significant for patients with IAH 145. Conclusions Our data support the hypothesis that IAH is due to the combination of higher sodium intake and a urinary concentration deficit, as a manifestation of the renal impairment elicited by severe illness.
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