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Frattari A, Polilli E, Rapacchiale G, Coladonato S, Ianniruberto S, Mazzotta E, Patarchi A, Battilana M, Ciulli R, Moretta A, Visocchi L, Savini V, Spacone A, Zocaro R, Carinci F, Parruti G. Predictors of bacteremia and death, including immune status, in a large single-center cohort of unvaccinated ICU patients with COVID-19 pneumonia. Eur J Med Res 2023; 28:219. [PMID: 37400898 DOI: 10.1186/s40001-023-01166-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 06/11/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND We investigated the possible role of the immune profile at ICU admission, among other well characterized clinical and laboratory predictors of unfavorable outcome in COVID-19 patients assisted in ICU. METHODS Retrospective analysis of clinical and laboratory data collected for all consecutive patients admitted to the ICUs of the General Hospital of Pescara (Abruzzo, Italy), between 1st March 2020 and 30th April 2021, with a confirmed diagnosis of COVID-19 respiratory failure. Logistic regressions were used to identify independent predictors of bacteremia and mortality. RESULTS Out of 431 patients included in the study, bacteremia was present in N = 191 (44.3%) and death occurred in N = 210 (48.7%). After multivariate analysis, increased risk of bacteremia was found for viral reactivation (OR = 3.28; 95% CI:1.83-6.08), pronation (3.36; 2.12-5.37) and orotracheal intubation (2.51; 1.58-4.02). Increased mortality was found for bacteremia (2.05; 1.31-3.22), viral reactivation (2.29; 1.29-4.19) and lymphocytes < 0.6 × 103c/µL (2.32; 1.49-3.64). CONCLUSIONS We found that viral reactivation, mostly due to Herpesviridae, was associated with increased risk of both bacteremia and mortality. In addition, pronation and intubation are strong predictors of bacteremia, which in turn together with severe lymphocytopenia due to SARS-CoV2 was associated with increased mortality. Most episodes of bacteremia, even due to Acinetobacter spp, were not predicted by microbiological evidence of colonization.
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Affiliation(s)
| | - Ennio Polilli
- Clinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | | | | | | | - Elena Mazzotta
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | | | | | - Raffaella Ciulli
- Unit of Intensive Care, Pescara General Hospital, Pescara, Italy
| | - Angelo Moretta
- Unit of Intensive Care, Pescara General Hospital, Pescara, Italy
| | - Lina Visocchi
- Unit of Intensive Care, Pescara General Hospital, Pescara, Italy
| | - Vincenzo Savini
- Microbiology and Virology Unit, Pescara General Hospital, Pescara, Italy
| | | | - Rosamaria Zocaro
- Unit of Intensive Care, Pescara General Hospital, Pescara, Italy
| | - Fabrizio Carinci
- Department of Statistical Sciences, Università Di Bologna, Bologna, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy.
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Pham T, Heunks L, Bellani G, Madotto F, Aragao I, Beduneau G, Goligher EC, Grasselli G, Laake JH, Mancebo J, Peñuelas O, Piquilloud L, Pesenti A, Wunsch H, van Haren F, Brochard L, Laffey JG, Acharya SP, Amin P, Arabi Y, Aragao I, Bauer P, Beduneau G, Beitler J, Berkius J, Bugedo G, Camporota L, Cerny V, Cho YJ, Clarkson K, Estenssoro E, Goligher E, Grasselli G, Gritsan A, Hashemian SM, Hermans G, Heunks LM, Jovanovic B, Kurahashi K, Laake JH, Matamis D, Moerer O, Molnar Z, Ozyilmaz E, Panka B, Papali A, Peñuelas Ó, Perbet S, Piquilloud L, Qiu H, Razek AA, Rittayamai N, Roldan R, Serpa Neto A, Szuldrzynski K, Talmor D, Tomescu D, Van Haren F, Villagomez A, Zeggwagh AA, Abe T, Aboshady A, Acampo-de Jong M, Acharya S, Adderley J, Adiguzel N, Agrawal VK, Aguilar G, Aguirre G, Aguirre-Bermeo H, Ahlström B, Akbas T, Akker M, Al Sadeh G, Alamri S, Algaba A, Ali M, Aliberti A, Allegue JM, Alvarez D, Amador J, Andersen FH, Ansari S, Apichatbutr Y, Apostolopoulou O, Arabi Y, Arellano D, Arica M, Arikan H, Arinaga K, Arnal JM, Asano K, Asín-Corrochano M, Avalos Cabrera JM, Avila Fuentes S, Aydemir S, Aygencel G, Azevedo L, Bacakoglu F, Badie J, Baedorf Kassis E, Bai G, Balaraj G, Ballico B, Banner-Goodspeed V, Banwarie P, Barbieri R, Baronia A, Barrett J, Barrot L, Barrueco-Francioni JE, Barry J, Bauer P, Bawangade H, Beavis S, Beck E, Beehre N, Belenguer Muncharaz A, Bellani G, Belliato M, Bellissima A, Beltramelli R, Ben Souissi A, Benitez-Cano A, Benlamin M, Benslama A, Bento L, Benvenuti D, Berkius J, Bernabe L, Bersten A, Berta G, Bertini P, Bertram-Ralph E, Besbes M, Bettini LR, Beuret P, Bewley J, Bezzi M, Bhakhtiani L, Bhandary R, Bhowmick K, Bihari S, Bissett B, Blythe D, Bocher S, Boedjawan N, Bojanowski CM, Boni E, Boraso S, Borelli M, Borello S, Borislavova M, Bosma KJ, Bottiroli M, Boyd O, Bozbay S, Briva A, Brochard L, Bruel C, Bruni A, Buehner U, Bugedo G, Bulpa P, Burt K, Buscot M, Buttera S, Cabrera J, Caccese R, Caironi P, Canchos Gutierrez I, Canedo N, Cani A, Cappellini I, Carazo J, Cardonnet LP, Carpio D, Carriedo D, Carrillo R, Carvalho J, Caser E, Castelli A, Castillo Quintero M, Castro H, Catorze N, Cengiz M, Cereijo E, Ceunen H, Chaintoutis C, Chang Y, Chaparro G, Chapman C, Chau S, Chavez CE, Chelazzi C, Chelly J, Chemouni F, Chen K, Chena A, Chiarandini P, Chilton P, Chiumello D, Cho YJ, Chou-Lie Y, Chudeau N, Cinel I, Cinnella G, Clark M, Clark T, Clarkson K, Clementi S, Coaguila L, Codecido AJ, Collins A, Colombo R, Conde J, Consales G, Cook T, Coppadoro A, Cornejo R, Cortegiani A, Coxo C, Cracchiolo AN, Crespo Ramirez M, Crova P, Cruz J, Cubattoli L, Çukurova Z, Curto F, Czempik P, D'Andrea R, da Silva Ramos F, Dangers L, Danguy des Déserts M, Danin PE, Dantas F, Daubin C, Dawei W, de Haro C, de Jesus Montelongo F, De Mendoza D, de Pablo R, De Pascale G, De Rosa S, Decavèle M, Declercq PL, Deicas A, del Carmen Campos Moreno M, Dellamonica J, Delmas B, Demirkiran O, Demirkiran H, Dendane T, di Mussi R, Diakaki C, Diaz A, Diaz W, Dikmen Y, Dimoula A, Doble P, Doha N, Domingos G, Dres M, Dries D, Duggal A, Duke G, Dunts P, Dybwik K, Dykyy M, Eckert P, Efe S, Elatrous S, Elay G, Elmaryul AS, Elsaadany M, Elsayed H, Elsayed S, Emery M, Ena S, Eng K, Englert JA, Erdogan E, Ergin Ozcan P, Eroglu E, Escobar M, Esen F, Esen Tekeli A, Esquivel A, Esquivel Gallegos H, Ezzouine H, Facchini A, Faheem M, Fanelli V, Farina MF, Fartoukh M, Fehrle L, Feng F, Feng Y, Fernandez I, Fernandez B, Fernandez-Rodriguez ML, Ferrando C, Ferreira da Silva MJ, Ferreruela M, Ferrier J, Flamm Zamorano MJ, Flood L, Floris L, Fluckiger M, Forteza C, Fortunato A, Frans E, Frattari A, Fredes S, Frenzel T, Fumagalli R, Furche MA, Fusari M, Fysh E, Galeas-Lopez JL, Galerneau LM, Garcia A, Garcia MF, Garcia E, Garcia Olivares P, Garlicki J, Garnero A, Garofalo E, Gautam P, Gazenkampf A, Gelinotte S, Gelormini D, Ghrenassia E, Giacomucci A, Giannoni R, Gigante A, Glober N, Gnesin P, Gollo Y, Gomaa D, Gomero Paredes R, Gomes R, Gomez RA, Gomez O, Gomez A, Gondim L, Gonzalez M, Gonzalez I, Gonzalez-Castro A, Gordillo Romero O, Gordo F, Gouin P, Graf Santos J, Grainne R, Grando M, Granov Grabovica S, Grasselli G, Grasso S, Grasso R, Grimmer L, Grissom C, Gritsan A, Gu Q, Guan XD, Guarracino F, Guasch N, Guatteri L, Gueret R, Guérin C, Guerot E, Guitard PG, Gül F, Gumus A, Gurjar M, Gutierrez P, Hachimi A, Hadzibegovic A, Hagan S, Hammel C, Han Song J, Hanlon G, Hashemian SM, Heines S, Henriksson J, Herbrecht JE, Heredia Orbegoso GO, Hermans G, Hermon A, Hernandez R, Hernandez C, Herrera L, Herrera-Gutierrez M, Heunks L, Hidalgo J, Hill D, Holmquist D, Homez M, Hongtao X, Hormis A, Horner D, Hornos MC, Hou M, House S, Housni B, Hugill K, Humphreys S, Humbert L, Hunter S, Hwa Young L, Iezzi N, Ilutovich S, Inal V, Innes R, Ioannides P, Iotti GA, Ippolito M, Irie H, Iriyama H, Itagaki T, Izura J, Izza S, Jabeen R, Jamaati H, Jamadarkhana S, Jamoussi A, Jankowski M, Jaramillo LA, Jeon K, Jeong Lee S, Jeswani D, Jha S, Jiang L, Jing C, Jochmans S, Johnstad BA, Jongmin L, Joret A, Jovanovic B, Junhasavasdikul D, Jurado MT, Kam E, Kamohara H, Kane C, Kara I, Karakurt S, Karnjanarachata C, Kataoka J, Katayama S, Kaushik S, Kelebek Girgin N, Kerr K, Kerslake I, Khairnar P, Khalid A, Khan A, Khanna AK, Khorasanee R, Kienhorst D, Kirakli C, Knafelj R, Kol MK, Kongpolprom N, Kopitko C, Korkmaz Ekren P, Kubisz-Pudelko A, Kulcsar Z, Kumasawa J, Kurahashi K, Kuriyama A, Kutchak F, Laake JH, Labarca E, Labat F, Laborda C, Laca Barrera MA, Lagache L, Landaverde Lopez A, Lanspa M, Lascari V, Le Meur M, Lee SH, Lee YJ, Lee J, Lee WY, Lee J, Legernaes T, Leiner T, Lemiale V, Leonor T, Lepper PM, Li D, Li H, Li O, Lima AR, Lind D, Litton E, Liu N, Liu L, Liu J, Llitjos JF, Llorente B, Lopez R, Lopez CE, Lopez Nava C, Lovazzano P, Lu M, Lucchese F, Lugano M, Lugo Goytia G, Luo H, Lynch C, Macheda S, Madrigal Robles VH, Maggiore SM, Magret Iglesias M, Malaga P, Mallapura Maheswarappa H, Malpartida G, Malyarchikov A, Mansson H, Manzano A, Marey I, Marin N, Marin MDC, Markman E, Martin F, Martin A, Martin Dal Gesso C, Martinez F, Martínez-Fidalgo C, Martin-Loeches I, Mas A, Masaaki S, Maseda E, Massa E, Mattsson A, Maugeri J, McCredie V, McCullough J, McGuinness S, McKown A, Medve L, Mei C, Mellado Artigas R, Mendes V, Mervat MKE, Michaux I, Mikhaeil M, Milagros O, Milet I, Millan MT, Minwei Z, Mirabella L, Mishra S, Mistraletti G, Mochizuki K, Moerer O, Moghal A, Mojoli F, Molin A, Molnar Z, Montiel R, Montini L, Monza G, Mora Aznar M, Morakul S, Morales M, Moreno Torres D, Morocho Tutillo DR, Motherway C, Mouhssine D, Mouloudi E, Muñoz T, Munoz de Cabo C, Mustafa M, Muthuchellappan R, Muthukrishnan M, Muttini S, Nagata I, Nahar D, Nakanishi M, Nakayama I, Namendys-Silva SA, Nanchal R, Nandakumar S, Nasi A, Nasir K, Navalesi P, Naz Aslam T, Nga Phan T, Nichol A, Niiyama S, Nikolakopoulou S, Nikolic E, Nitta K, Noc M, Nonas S, Nseir S, Nur Soyturk A, Obata Y, Oeckler R, Oguchi M, Ohshimo S, Oikonomou M, Ojados A, Oliveira MT, Oliveira Filho W, Oliveri C, Olmos A, Omura K, Orlandi MC, Orsenigo F, Ortiz-Ruiz De Gordoa L, Ota K, Ovalle Olmos R, Öveges N, Oziemski P, Ozkan Kuscu O, Özyilmaz E, Pachas Alvarado F, Pagella G, Palaniswamy V, Palazon Sanchez EL, Palmese S, Pan G, Pan W, Panka B, Papanikolaou M, Papavasilopoulou T, Parekh A, Parke R, Parrilla FJ, Parrilla D, Pasha T, Pasin L, Patão L, Patel M, Patel G, Pati BK, Patil J, Pattnaik S, Paul D, Pavesi M, Pavlotsky VA, Paz G, Paz E, Pecci E, Pellegrini C, Peña Padilla AG, Perchiazzi G, Pereira T, Pereira V, Perez M, Perez Calvo C, Perez Cheng M, Perez Maita R, Pérez-Araos R, Perez-Teran P, Perez-Torres D, Perkins G, Persona P, Petnak T, Petrova M, Pham T, Philippart F, Picetti E, Pierucci E, Piervincenzi E, Pinciroli R, Pintado MC, Piquilloud L, Piraino T, Piras S, Piras C, Pirompanich P, Pisani L, Platas E, Plotnikow G, Porras W, Porta V, Portilla M, Portugal J, Povoa P, Prat G, Pratto R, Preda G, Prieto I, Prol-Silva E, Pugh R, Qi Y, Qian C, Qin T, Qiu H, Qu H, Quintana T, Quispe Sierra R, Quispe Soto R, Rabbani R, Rabee M, Rabie A, Rahe Pereira MA, Rai A, Raj Ashok S, Rajab M, Ramdhani N, Ramey E, Ranieri M, Rathod D, Ray B, Redwanul Huq SM, Regli A, Reina R, Resano Sarmiento N, Reynaud F, Rialp G, Ricart P, Rice T, Richardson A, Rieder M, Rinket M, Rios F, Rios F, Risso Vazquez A, Rittayamai N, Riva I, Rivette M, Roca O, Roche-Campo F, Rodriguez C, Rodriguez G, Rodriguez Gonzalez D, Rodriguez Tucto XY, Rogers A, Romano ME, Rørtveit L, Rose A, Roux D, Rouze A, Rubatto Birri PN, Ruilan W, Ruiz Robledo A, Ruiz-Aguilar AL, Sadahiro T, Saez I, Sagardia J, Saha R, Saha R, Saiphoklang N, Saito S, Salem M, Sales G, Salgado P, Samavedam S, Sami Mebazaa M, Samuelsson L, San Juan Roman N, Sanchez P, Sanchez-Ballesteros J, Sandoval Y, Sani E, Santos M, Santos C, Sanui M, Saravanabavan L, Sari S, Sarkany A, Sauneuf B, Savioli M, Sazak H, Scano R, Schneider F, Schortgen F, Schultz MJ, Schwarz GL, Seçkin Yücesoy F, Seely A, Seiler F, Seker Tekdos Y, Seok Chan K, Serano L, Serednicki W, Serpa Neto A, Setten M, Shah A, Shah B, Shang Y, Shanmugasundaram P, Shapovalov K, Shebl E, Shiga T, Shime N, Shin P, Short J, Shuhua C, Siddiqui S, Silesky Jimenez JI, Silva D, Silva Sales B, Simons K, Sjøbø BÅ, Slessor D, Smiechowicz J, Smischney N, Smith P, Smith T, Smith M, Snape S, Snyman L, Soetens F, Sook Hong K, Sosa Medellin MÁ, Soto G, Souloy X, Sousa E, Sovatzis S, Sozutek D, Spadaro S, Spagnoli M, Spångfors M, Spittle N, Spivey M, Stapleton A, Stefanovic B, Stephenson L, Stevenson E, Strand K, Strano MT, Straus S, Sun C, Sun R, Sundaram V, SunPark T, Surlemont E, Sutherasan Y, Szabo Z, Szuldrzynski K, Tainter C, Takaba A, Tallott M, Tamasato T, Tang Z, Tangsujaritvijit V, Taniguchi L, Taniguchi D, Tarantino F, Teerapuncharoen K, Temprano S, Terragni P, Terzi N, Thakur A, Theerawit P, Thille AW, Thomas M, Thungtitigul P, Thyrault M, Tilouch N, Timenetsky K, Tirapu J, Todeschini M, Tomas R, Tomaszewski C, Tonetti T, Tonnelier A, Trinder J, Trongtrakul K, Truwit J, Tsuei B, Tulaimat A, Turan S, Turkoglu M, Tyagi S, Ubeda A, Vagginelli F, Valenti MF, Vallverdu I, Van Axel A, van den Hul I, van der Hoeven H, Van Der Meer N, Van Haren F, Vanhoof M, Vargas-Ordoñez M, Vaschetto R, Vascotto E, Vatsik M, Vaz A, Vazquez-Sanchez A, Ventura S, Vermeijden JW, Vidal A, Vieira J, Vilela Costa Pinto B, Villagomez A, Villagra A, Villegas Succar C, Vinorum OG, Vitale G, Vj R, Vochin A, Voiriot G, Volta CA, von Seth M, Wajdi M, Walsh D, Wang S, Wardi G, Ween-Velken NC, Wei BL, Weller D, Welsh D, Welters I, Wert M, Whiteley S, Wilby E, Williams E, Williams K, Wilson A, Wojtas J, Won Huh J, Wrathall D, Wright C, Wu JF, Xi G, Xing ZJ, Xu H, Yamamoto K, Yan J, Yáñez J, Yang X, Yates E, Yazicioglu Mocin O, Ye Z, Yildirim F, Yoshida N, Yoshido HHL, Young Lee B, Yu R, Yu G, Yu T, Yuan B, Yuangtrakul N, Yumoto T, Yun X, Zakalik G, Zaki A, Zalba-Etayo B, Zambon M, Zang B, Zani G, Zarka J, Zerbi SM, Zerman A, Zetterquist H, Zhang J, Zhang H, Zhang W, Zhang G, Zhang W, Zhao H, Zheng J, Zhu B, Zumaran R. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. Lancet Respir Med 2023; 11:465-476. [PMID: 36693401 DOI: 10.1016/s2213-2600(22)00449-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. METHODS WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. FINDINGS Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. INTERPRETATION In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. FUNDING European Society of Intensive Care Medicine, European Respiratory Society.
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Affiliation(s)
- Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Fabiana Madotto
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Aragao
- Department of Intensive Care Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Gaëtan Beduneau
- Normandie University, UNIROUEN, UR 3830, CHU Rouen, Department of Medical Intensive Care, F-76000 Rouen, France
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute University Health Network, Toronto, Canada
| | - Giacomo Grasselli
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Jon Henrik Laake
- Department of Anaesthesiology and Department of Research and Development, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway
| | - Jordi Mancebo
- Department of Intensive Care Medicine, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonio Pesenti
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Frank van Haren
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospitals, Galway, Ireland; School of Medicine, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.
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Ferrieri A, Bosco D, Polilli E, Ciulli R, Visocchi L, Mincione L, Iacoe R, Zocaro R, Frattari A. Inadvertent intrathecal drug injection while treating low back pain: a case report and review of the literature. J Med Case Rep 2023; 17:76. [PMID: 36797753 PMCID: PMC9935243 DOI: 10.1186/s13256-023-03754-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/02/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Undesired intrathecal injections represent an important subset of medical errors, albeit rare. Clinical effects depend on the type and concentration of drug(s) injected. Here we report on the case of a healthy woman with persistent low back pain, treated with a paravertebral injection of lidocaine, thiocolchicoside, and L-acetylcarnitine at an orthopedic practice. CASE REPORT A 42-year-old Caucasian woman, with no relevant past medical history, received a lumbar paravertebral injection of lidocaine, thiocolchicoside, and L-acetylcarnitine for persistent low back pain. Approximately 30 minutes after injection, she experienced quick neurological worsening. Upon arrival at the Emergency Department, she was comatose, with fixed bilateral mydriasis, trismus, and mixed acidosis; seizures ensued in the first hours; slow progressive amelioration was observed by day 6; retrograde amnesia was the only clinical relevant remaining symptom by 6 months. CONCLUSIONS To our knowledge, this is the first reported case of inadvertent intrathecal thiocolchicoside injection in an adult patient, as well as the first in the neurosurgical literature. Our experience suggests that injection therapy for low back pain should be administered in adequate settings, where possible complications may be promptly treated.
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Affiliation(s)
- Alessandro Ferrieri
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Donatella Bosco
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Ennio Polilli
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | - Raffaella Ciulli
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Lina Visocchi
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Lucrezia Mincione
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Rosa Iacoe
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Rosamaria Zocaro
- grid.461844.bAnestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara, PE Italy
| | - Antonella Frattari
- Anestesia and Intensive Care Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124, Pescara, PE, Italy.
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Polilli E, Frattari A, Esposito JE, Angelini G, Di Risio A, Mazzotta E, Coladonato S, Di Iorio G, Parruti G, Tocco P. SOX-1 antibodies in a patient with Crohn's disease: a case report. BMC Neurol 2022; 22:404. [PMID: 36324062 PMCID: PMC9628059 DOI: 10.1186/s12883-022-02923-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The anti-SOX-1 antibodies have been mainly associated with Lambert-Eaton Myasthenic Syndrome (LETMS) and Small-Cell Lung Cancer (SCLC). In this report, we describe the interesting case of a patient with serum anti-SOX-1 antibodies and Crohn's Disease (CD) with ensuing neurological symptoms. CASE PRESENTATION A Caucasian 67-year-old female was admitted to the Emergency Department with seizures, vertigo, emesis, nausea, postural instability and recurrent falls, over a period of 10 days. She had been affected by Crohn's Disease since 1991. A CT scan failed to detect any ischemic or haemorrhagic lesion. A brain MRI revealed signs of leukoencephalopathy. Western blot analysis of her serum revealed a high titre of the onconeural antibody anti-SOX1, consistent with a neurological, cerebellar type, paraneoplastic syndrome. In spite of multiple efforts to unmask a possible underlying malignancy, no neoplastic lesion cropped up during hospitalization. Her clinical conditions progressively deteriorated, up to respiratory failure; a few days later she died, due to ensuing septic shock and Multiple Organ Failure. CONCLUSIONS Our experience may usher and reveal a new role of anti-neural antibodies, so far reckoned an early indicator of associated malignancy, suggesting that neurological syndromes associated with such antibodies may complicate also chronic Gastrointestinal (GI) diseases. As of now, testing for anti-neuronal antibodies appeared unnecessary within the diagnostic assessment of gastroenterological disorders, which may lead to overlooking incident neurologic autoimmune diseases. Further exploration of such research hypothesis in clinical grounds appears intriguing.
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Affiliation(s)
- Ennio Polilli
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara PE, Pescara, Italy
| | - Antonella Frattari
- grid.461844.bIntensive Care Unit, Pescara General Hospital, Pescara, Italy
| | - Jessica Elisabetta Esposito
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara PE, Pescara, Italy
| | - Gilda Angelini
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara PE, Pescara, Italy
| | - Annalisa Di Risio
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara PE, Pescara, Italy
| | - Elena Mazzotta
- grid.461844.bInfectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Simona Coladonato
- grid.461844.bInfectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Giancarlo Di Iorio
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Via Fonte Romana, 8, 65124 Pescara PE, Pescara, Italy
| | - Giustino Parruti
- grid.461844.bInfectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Pierluigi Tocco
- grid.461844.bNeurology and Stroke Unit, Pescara General Hospital, Pescara, Italy
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Polilli E, Frattari A, Esposito JE, D’Amato M, Rapacchiale G, D’Intino A, Albani A, Di Iorio G, Carinci F, Parruti G. Reliability of predictive models to support early decision making in the emergency department for patients with confirmed diagnosis of COVID-19: the Pescara Covid Hospital score. BMC Health Serv Res 2022; 22:1062. [PMID: 35986291 PMCID: PMC9390116 DOI: 10.1186/s12913-022-08421-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background The hospital management of patients diagnosed with COVID-19 can be hampered by heterogeneous characteristics at entry into the emergency department. We aimed to identify demographic, clinical and laboratory parameters associated with higher risks of hospitalisation, oxygen support, admission to intensive care and death, to build a risk score for clinical decision making at presentation to the emergency department. Methods We carried out a retrospective study using linked administrative data and laboratory parameters available in the initial phase of the pandemic at the emergency department of the regional reference hospital of Pescara, Abruzzo, Italy, March–June 2020. Logistic regression and Cox modelling were used to identify independent predictors for risk stratification. Validation was carried out collecting data from an extended timeframe covering other variants of concern, including Alpha (December 2020–January 2021) and Delta/Omicron (January–March 2022). Results Several clinical and laboratory parameters were significantly associated to the outcomes of interest, independently from age and gender. The strongest predictors were: for hospitalisation, monocyte distribution width ≥ 22 (4.09; 2.21–7.72) and diabetes (OR = 3.04; 1.09–9.84); for oxygen support: saturation < 95% (OR = 11.01; 3.75–41.14), lactate dehydrogenase≥237 U/L (OR = 5.93; 2.40–15.39) and lymphocytes< 1.2 × 103/μL (OR = 4.49; 1.84–11.53); for intensive care, end stage renal disease (OR = 59.42; 2.43–2230.60), lactate dehydrogenase≥334 U/L (OR = 5.59; 2.46–13.84), D-dimer≥2.37 mg/L (OR = 5.18; 1.14–26.36), monocyte distribution width ≥ 25 (OR = 3.32; 1.39–8.50); for death, procalcitonin≥0.2 ng/mL (HR = 2.86; 1.95–4.19) and saturation < 96% (HR = 2.74; 1.76–4.28). Risk scores derived from predictive models using optimal thresholds achieved values of the area under the curve between 81 and 91%. Validation of the scoring algorithm for the evolving virus achieved accuracy between 65 and 84%. Conclusions A set of parameters that are normally available at emergency departments of any hospital can be used to stratify patients with COVID-19 at risk of severe conditions. The method shall be calibrated to support timely clinical decision during the first hours of admission with different variants of concern. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08421-4.
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Polilli E, Frattari A, Esposito JE, Stanziale A, Giurdanella G, Di Iorio G, Carinci F, Parruti G. Monocyte distribution width (MDW) as a new tool for the prediction of sepsis in critically ill patients: a preliminary investigation in an intensive care unit. BMC Emerg Med 2021; 21:147. [PMID: 34809558 PMCID: PMC8607630 DOI: 10.1186/s12873-021-00521-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 10/19/2021] [Indexed: 12/19/2022] Open
Abstract
Background Monocyte Distribution Width (MDW), a simple proxy marker of innate monocyte activation, can be used for the early recognition of sepsis along with Procalcitonin. This study explored the added value of MDW as an early predictor of ensuing sepsis in patients hospitalised in an Intensive Care Unit. Methods We performed an observational prospective monocentric study to estimate the analytical performance of MDW in detecting ensuing sepsis in a sample of consecutive patients assisted in an Intensive Care Unit for > 48 h for any reason. Demographic and clinical characteristics, past medical history and other laboratory measurements were included as potential predictors of confirmed sepsis in multivariate logistic regression. Results A total of 211 patients were observed, 129 of whom were included in the final sample due to the suspect of ensuing sepsis; of these, 74 (57%) had a confirmed diagnosis of sepsis, which was best predicted with the combination of MDW > 23.0 and PCT > 0.5 ng/mL (Positive Predictive Value, PPV: 92.6, 95% CI: 82.1–97.9). The best MDW cut-off to rule out sepsis was ≤20.0 (Negative Predictive Value, NPV: 86.4, 95% CI: 65.1–97.1). Multivariate analyses using both MDW and PCT found a significant association for MDW > 23 only (OR:17.64, 95% CI: 5.53–67.91). Conclusion We found that values of MDW > 23 were associated with a high PPV for sepsis, whereas values of MDW ≤ 20 were associated with a high NPV. Our findings suggest that MDW may help clinicians to monitor ICU patients at risk of sepsis, with minimal additional efforts over standard of care.
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Affiliation(s)
- Ennio Polilli
- Clinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | | | | | - Andrea Stanziale
- Postgraduate School of Clinical Pathology, University of Chieti, Chieti, Italy
| | | | | | - Fabrizio Carinci
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy.
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Polilli E, Esposito JE, Frattari A, Trave F, Sozio F, Ferrandu G, Di Iorio G, Parruti G. Circulating lymphocyte subsets as promising biomarkers to identify septic patients at higher risk of unfavorable outcome. BMC Infect Dis 2021; 21:780. [PMID: 34372784 PMCID: PMC8351421 DOI: 10.1186/s12879-021-06481-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early recognition of patients hospitalized for sepsis at higher risk of poor clinical outcome is a mandatory task and many studies suggested that indicators of the immune status may be useful for this purpose. We performed a retrospective, monocentric cohort study to evaluate whether lymphocyte subsets may be useful in predicting in-hospital mortality of septic patients. METHODS Data of all consecutive patients with a diagnosis of sepsis at discharge and an available peripherical blood lymphocyte subset (CD4, CD8, CD16/CD56 and CD19) analysis at hospital entry were retrospectively collected between January 2015 and August 2018. Clinical characteristics of patients, past medical history and other laboratory parameters were also considered. RESULTS Two-hundred-seventy-eight septic patients, 171 (61.5%) males, mean age 63.2 ± 19.6 years, were enrolled. Total counts of lymphocytes, CD4 T cells, CD8 T cells and B cells were found significantly lower in deceased than in surviving patients. At univariate analyses, CD4 T cells/µL (OR 0.99 for each incremental unit, 95%CI 0.99-1.10, p < 0.0001), age (OR 1.06, 95%CI 1.04-1.09, p < 0.0001), procalcitonin (OR 1.01, 95%CI 1.01-1.02, p < 0.0001) and female gender (OR 2.81, 95%CI 1.49-5.28, p = 0.001) were associated with in-hospital mortality. When a dichotomic threshold of < 400/µL for CD4 T cells as a dependent variable was considered in multivariate models, age (OR 1.04; 95%CI 1.01-1.09, p = 0.018); female gender (OR 3.18; 95%CI 1.40-7.20, p = 0.006), qSOFA (OR 4.00, 95%CI 1.84-8.67, p < 0.001) and CD4 T cells < 400/µL (OR 5.3; 95%CI 1.65-17.00, p = 0.005) were the independent predictors. CONCLUSIONS In adjunct to biomarkers routinely determined for the prediction of prognosis in sepsis, CD4 T lymphocytes, measured at hospital entry, may be useful in identifying patients at higher risk of in-hospital death.
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Affiliation(s)
- Ennio Polilli
- Clinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | | | | | - Francesca Trave
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Federica Sozio
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | | | | | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy.
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Quaglietta A, Nicolucci A, Posata R, Frattari A, Parruti G, Accorsi P. Impact of Covid-19 epidemic on the activities of a blood centre, transfusion support for infected patients and clinical outcomes. Transfus Med 2020; 31:160-166. [PMID: 33269544 PMCID: PMC7753726 DOI: 10.1111/tme.12742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/29/2020] [Accepted: 11/16/2020] [Indexed: 12/16/2022]
Abstract
Objectives We evaluated how the Severe Acute Respiratory disease from Coronavirus 2 (SARS‐CoV‐2) epidemic impacted transfusion services, transfusion support required by Covid‐19 patients and their clinical outcome. Background In Italy, the first confirmed case of SARS‐CoV‐2 infection was registered on 21 February 2020. As of 20 April, about 250 000 cases were registered, 1143 of which were in the province of Pescara. Methods We compared transfusion services provided by the blood centre of Pescara between 1 March and 20 April 2019 and between 1 March and 20 April 2020. We assessed the number and type of blood components donated, those transfused in the various hospital departments and those transfused to Covid‐19 patients. Results Compared to 2019, we documented a decrease of 32% in the number of donations. The number of transfusions increased by 139% in the infectious diseases department (IDD), dedicated to Covid‐19 patients, and by 76% in the intensive care unit (ICU), whereas it markedly decreased in the other departments. Of 299 patients with Covid‐19, 60 were transfused (20.1%). Transfused patients in the ICU were significantly younger than those in IDD and had a lower number of lymphocytes, lower post‐transfusion increment of haemoglobin levels and higher D‐dimer and C reactive protein values. Mortality rate was 60.7% among transfused patients in the ICU and 39.0% among those in the IDD (p = 0.02). Conclusion The Covid‐19 epidemic had a profound impact on transfusion activities. The important blood demand for Covid‐19 patients was satisfied because of the reduction in activities in other hospital wards. Covid‐19‐positive transfused patients showed a very poor prognosis.
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Affiliation(s)
- Anna Quaglietta
- Department of Haematolgy and Oncology, Center of Transfusion Medicine, Pescara General Hospital, Pescara, Italy
| | - Antonio Nicolucci
- Department of Clinical Epidemiology, Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Raffaella Posata
- Department of Medical, Oral and Biotechnological Sciences, Unit of Clinical Molecular Biology and Predictive Medicine, University G. d'Annunzio of Chieti-Pescara, Chieti-Pescara, Italy
| | - Antonella Frattari
- Department of Emergency, Unit of Anesthesia and Intensive Care, Pescara General Hospital, Pescara, Italy
| | - Giustino Parruti
- Department of Medicine, Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Patrizia Accorsi
- Department of Haematolgy and Oncology, Center of Transfusion Medicine, Pescara General Hospital, Pescara, Italy
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Abstract
Background and Objectives: Operative laparoscopy is generally performed under general anesthesia. Local anesthesia and conscious sedation may be useful in select short procedures. In the present study, we evaluated safety and efficacy of operative laparoscopy under conscious sedation. Methods: Retrospective observational study evaluating patients undergoing gynecologic laparoscopy. Laparoscopy under conscious sedation was performed for each patient with umbilical direct insertion of a 12-mm port, followed by 2 ancillary ports at 1 cm medially to the anterior superior iliac spine. Conversion to conventional laparoscopy or laparotomy was recorded. Conscious sedation was obtained using Remifentanil and Propofol, administered by an infusion system based on pharmacokinetic and pharmacodynamic models. Local anesthesia was administered at port insertion sites and for paracervical block. Pain intensity was evaluated with the Visual Analog Scale (VAS). Adverse events and drug concentrations throughout the procedure were retrieved. Results: Our study population included 166 patients. They underwent laparoscopic unilateral versus bilateral salpingo-oophorectomy, ovarian cystectomy, bilateral salpingo-oophorectomy and omentectomy for a borderline ovarian tumor, myomectomy; or underwent surgery for unexplained infertility evaluation, pelvic pain, staging of ovarian cancer. Mean duration of pneumoperitoneum was 22.3 ± 7.2 min. Rate of conversion to laparoscopy under general anesthesia was 17/166 (10.2%) and there were only 3 cases of patients with low tolerability to the procedure. No severe adverse events occurred. Hospital discharge occurred in all unconverted cases after 6 to 18 h. Conclusions: Operative laparoscopy under conscious sedation and local anesthesia appears to be a feasible technique in gynecologic surgery with no adverse patient outcomes.
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Affiliation(s)
- Maurizio Rosati
- Unit of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
| | - Silvia Bramante
- Unit of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
| | - Fiorella Conti
- Unit of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
| | - Antonella Frattari
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Pescara, Italy
| | - Maria Rizzi
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Pescara, Italy
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Potere N, Di Nisio M, Cibelli D, Scurti R, Frattari A, Porreca E, Abbate A, Parruti G. Response to: 'Correspondence on 'Interleukin-6 blockade with subcutaneous tocilizumab in severe COVID-19 pneumonia and hyperinflammation: a case-control study' by Potere et al' by Buckley. Ann Rheum Dis 2020; 81:e195. [PMID: 32873552 DOI: 10.1136/annrheumdis-2020-218715] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy.,VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Università degli Studi Gabriele d'Annunzio, Chieti-Pescara, Italy.,Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rosa Scurti
- Geriatric Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
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11
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Potere N, Di Nisio M, Cibelli D, Scurti R, Frattari A, Porreca E, Abbate A, Parruti G. Response to: 'Rational use of tocilizumab in COVID-19' by Jain and Sharma. Ann Rheum Dis 2020; 81:e215. [PMID: 32737108 DOI: 10.1136/annrheumdis-2020-218626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/25/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy.,VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Università degli Studi Gabriele d'Annunzio, Chieti-Pescara, Italy.,Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, Netherlands
| | | | - Rosa Scurti
- Geriatric Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, Università degli Studi Gabriele d'Annunzio, Chieti, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
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12
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Potere N, Di Nisio M, Cibelli D, Scurti R, Frattari A, Porreca E, Abbate A, Parruti G. Interleukin-6 receptor blockade with subcutaneous tocilizumab in severe COVID-19 pneumonia and hyperinflammation: a case-control study. Ann Rheum Dis 2020; 80:1-2. [PMID: 32647027 DOI: 10.1136/annrheumdis-2020-218243] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, "G D'Annunzio" University, Chieti, Italy.,VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G' D'Annunzio" University, Chieti-Pescara, Italy.,Department of Vascular Medicine, Amsterdam Medical Center, Amsterdam, The Netherlands
| | | | - Rosa Scurti
- Geriatric Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, "G D'Annunzio" University, Chieti, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
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13
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Frattari A, Savini V, Polilli E, Di Marco G, Lucisano G, Corridoni S, Spina T, Costantini A, Nicolucci A, Fazii P, Viale P, Parruti G. Control of Gram-negative multi-drug resistant microorganisms in an Italian ICU: Rapid decline as a result of a multifaceted intervention, including conservative use of antibiotics. Int J Infect Dis 2019; 84:153-162. [PMID: 31204003 DOI: 10.1016/j.ijid.2019.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Gram-negative Multi-Drug-Resistant Organisms (GNMDROs) cause an increasing burden of disease in Intensive Care Units (ICUs). We deployed a multifaceted intervention to control selection and transmission of GNMDROs and to estimate at which rate GNMDROs would decline with our interventional bundle. METHODS Interventions implemented in 2015: in-ward Antimicrobial-Stewardship-Program for appropriate management of antimicrobial prescription; infection monitoring with nasal/rectal swabs and repeated procalcitonin assays; 24 h microbiological support (since 2016); prevention of catheter-related infections, VAPs and in-ward GNMDROs transmission; education of ICU personnel. In May 2017, epidemiological, clinical and microbiological data were collected and retrospectively analyzed. Rates of resistance in Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii, as well as percentages of resistance among all Gram-negative bacteria were compared during the study period. RESULTS Of 668 patients, at least one isolate was obtained from 399 patients. The proportions of patients with infection and with Gram-negative isolates were even across the 5 semesters (p = 0.8). For Klebsiella pneumoniae, the number of strains resistant to carbapenems fell from 94% to 6% (p < 0.001). Significant drops were also observed for Pseudomonas aeruginosa and Acinetobacter baumannii. Percentages of resistance for all Gram-negative isolates fell from 91% to 13% (p < 0.0001). The reduction in antibiotic prescription translated in a considerable reduction of pharmacy costs. Multivariate models confirmed that the hospitalization semester was the most relevant independent predictor of resistance among Gram-negative bacteria. CONCLUSIONS Our experience provides further evidence that a multi-faceted intervention, aimed to reduce selection and transmission of GNMDROs with efficient microbiological support, may yield remarkable results in a short time interval.
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Affiliation(s)
- Antonella Frattari
- Unit of Anesthesia and Intensive Care, Pescara General Hospital, Pescara, Italy
| | - Vincenzo Savini
- Unit of Clinical Microbiology, Pescara General Hospital, Pescara, Italy
| | - Ennio Polilli
- Unit of Clinical Pathology, Pescara General Hospital, Pescara, Italy
| | - Graziano Di Marco
- Unit of Management Control, Local Health Unit Direction, Pescara General Hospital, Pescara, Italy
| | - Giuseppe Lucisano
- Unit of Biostatistics, CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | | | - Tullio Spina
- Unit of Anesthesia and Intensive Care, Pescara General Hospital, Pescara, Italy
| | | | - Antonio Nicolucci
- Unit of Biostatistics, CORESEARCH - Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Paolo Fazii
- Unit of Clinical Microbiology, Pescara General Hospital, Pescara, Italy
| | - Pierluigi Viale
- Cathedra of Infectious Diseases, Alma Mater University, Boulogne, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy.
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14
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Parruti G, Frattari A, Polilli E, Savini V, Sciacca A, Consorte A, Cibelli DC, Agostinone A, Di Masi F, Pieri A, Cacciatore P, Di Iorio G, Fazii P, Spina T. Cure of recurring Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae septic shock episodes due to complicated soft tissue infection using a ceftazidime and avibactam-based regimen: a case report. J Med Case Rep 2019; 13:20. [PMID: 30665450 PMCID: PMC6341597 DOI: 10.1186/s13256-018-1934-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 11/25/2018] [Indexed: 02/05/2023] Open
Abstract
Background Infections caused by multidrug-resistant Enterobacteriaceae are hard to treat and life-threatening due to reduced therapeutic options. Systemic infections caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae strains have increased in many European regions, becoming frequent in many clinical settings, and are associated with high mortality. The co-formulation of ceftazidime, a third-generation cephalosporin, with avibactam, a new suicide inhibitor beta-lactamase inhibitor able to block most Klebsiella pneumoniae carbapenemases, has been recently licensed, with promising results in patients with limited or absent therapeutic options. Little is known, however, as to the efficacy of such a combination in patients with soft tissue infections caused by multidrug-resistant Klebsiella pneumoniae carbapenemase-producing strains of Klebsiella pneumoniae. Case presentation A Caucasian 53-year-old man with paraplegia suffered multiple vertebral fractures due to a car crash. He was treated with external fixators that became infected early after insertion and were repeatedly and inefficiently treated with multiple antibiotics. He suffered repeated septic episodes caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae strains with a multidrug-resistant profile. Meropenem, tigecycline, and colistin combinations allowed only temporary improvements, but septic shock episodes recurred, in spite of removal of infected external fixators. After approval of pre-marketing prescription by our local Ethics Committee, full clinical resolution was obtained with a compassionate treatment using meropenem and ceftazidime/avibactam in combination for 16 days. Conclusions Our experience provides additional evidence that ceftazidime/avibactam, possibly in combination with meropenem rescued by avibactam, may be an efficacious treatment option also for complicated skin and soft tissue infections caused by multidrug-resistant strains of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae.
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Affiliation(s)
- Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy.
| | - Antonella Frattari
- Anaesthesia and Intensive Care Unit, Pescara General Hospital, Pescara, Italy
| | - Ennio Polilli
- Clinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | - Vincenzo Savini
- Microbiology and Virology Unit, Pescara General Hospital, Pescara, Italy
| | - Antonina Sciacca
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy
| | - Augusta Consorte
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy
| | | | - Adriana Agostinone
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy
| | - Francesco Di Masi
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy
| | - Alessandro Pieri
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy
| | - Pierluigi Cacciatore
- Infectious Diseases Unit, Pescara General Hospital, Via Fonte Romana 8, 65124, Pescara, Italy
| | | | - Paolo Fazii
- Microbiology and Virology Unit, Pescara General Hospital, Pescara, Italy
| | - Tullio Spina
- Anaesthesia and Intensive Care Unit, Pescara General Hospital, Pescara, Italy
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15
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Frattari A, Polilli E, Primiterra V, Savini V, Ursini T, Di Iorio G, Parruti G. Analysis of peripheral blood lymphocyte subsets in critical patients at ICU admission: A preliminary investigation of their role in the prediction of sepsis during ICU stay. Int J Immunopathol Pharmacol 2018; 32:2058738418792310. [PMID: 30114952 PMCID: PMC6100127 DOI: 10.1177/2058738418792310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A better knowledge of factors predicting the development of sepsis in patients
hospitalized in intensive care unit (ICU) might help deploy more targeted
preventive and therapeutic strategies. In addition to the known clinical and
demographic predictors of septic syndromes, in this study, we investigated
whether measuring T and B lymphocyte subsets upon admission in the ICU may help
individualize the prediction of ensuing sepsis during ICU stay. Between May 2015
and December 2016, we performed a prospective cohort study evaluating peripheral
blood lymphocyte T-CD4+ (T-helper cells), T-CD8+ (cytotoxic T-cells), T-CD56 +
(natural killer cells), and T-CD19+ (B-lymphocytes), using flow cytometry on
blood samples collected 2 days after admission in the ICU. We enrolled 176
patients, 65.3% males, with mean age of 61.1 ± 15.4 years. At univariate
analyses, higher percentages of CD19 B-cells were significantly associated with
ensuing sepsis (20.5% (15.7–27.7)% vs 16.9% (11.3–22)%, P = 0.0001), whereas median interquartile range (IQR) proportions
of CD4 T-cells (41.2% (33.4–50.6)% vs 40% (35–47)%, P = 0.5), CD8 T-cells (21.1% (15.8–28.2)% vs 19.6% (14.6–25.1)%,
P = 0.2) and CD56 T-cells (1.7% (0.9–3.1)% vs
1.45% (0.7–2.3)%, P = 0.4) did not reveal any
significant association. An unexpected, highly significant inverse correlation
of CD8 T-cells and CD19 B-cells proportions, however, was observed, suggesting
that patients with lower CD19 and higher CD8 proportions might be somehow
protected from ensuing sepsis. We therefore studied the ability of the CD8/CD19
ratio to predict ensuing sepsis in our sample. In final models of multivariate
logistic regression, the following independent associations were found: previous
antibiotic exposure (odds ratio (OR): 3.8 (95% confidence interval (CI):
1.35–10.87), P = 0.01), isolation of at least one
multi-drug resistant organism at any time during ICU stay (OR: 8.4 (95% CI:
3.47–20.6), P < 0.0001), decreasing age (OR:
0.9 (95% CI: 0.93–0.99), P = 0.02) and a CD8/CD19
ratio >2.2 (OR: 10.3 (95% CI: 1.91–55.36), P = 0.007). Our data provide preliminary evidence that immune
characterization of critically ill patients on ICU admission may help
personalize the prediction of ensuing sepsis during their ICU stay. Further
polycentric evaluation of the true potential of this new tool is warranted.
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Affiliation(s)
| | - Ennio Polilli
- 2 Unit of Clinical Pathology, Pescara General Hospital, Pescara, Italy
| | | | - Vincenzo Savini
- 3 Unit of Clinical Microbiology, Pescara General Hospital, Pescara, Italy
| | - Tamara Ursini
- 4 Unit of Infectious Diseases, Pescara General Hospital, Pescara, Italy
| | | | - Giustino Parruti
- 4 Unit of Infectious Diseases, Pescara General Hospital, Pescara, Italy
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16
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Frattari A, Savini V, Polilli E, Cibelli D, Talamazzi S, Bosco D, Consorte A, Fazii P, Parruti G. Ceftolozane-tazobactam and Fosfomycin for rescue treatment of otogenous meningitis caused by XDR Pseudomonas aeruginosa: Case report and review of the literature. IDCases 2018; 14:e00451. [PMID: 30263888 PMCID: PMC6156803 DOI: 10.1016/j.idcr.2018.e00451] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 11/18/2022] Open
Abstract
Infections due to XDR Pseudomonas are at increased risk of complications and death. CNS involvement may be due to poor CNS penetration of drugs with residual activity. XDR-PA meningitis ensued during treatment with colistin for pneumonia and bacteremia. CNS involvement by XDR-PA was timely suspected and quickly documented on CSF. High dose C-T and Fosfomycin provided rapid control of meningitis.
Extensively drug resistant Pseudomonas aeruginosa (XDR-PA) strains with limited or absent residual antimicrobial susceptibility cause a growing burden of difficult-to treat infections. Treatment options are even more limited for patients with central nervous system (CNS) involvement, as colistin-based regimens are hampered by poor blood brain barrier penetration, being often associated with insufficient clinical and microbiological success. New treatment options are awaited, but evidence from prospective evidence-based evaluations is still lacking. Here we report a case of breakthrough otogenous meningitis caused by XDR-PA in a young patient treated with meropenem and colistin for XDR-PA bloodstream infection and pneumonia after a car-crash polytrauma. The patient was treated with off-label, high-dose ceftolozane-tazobactam and high-dose fosfomycin after characterization of CNS XDR-PA isolates, with rapid clinical and microbiological resolution of meningitis. Our experience, although based on a single case, lands preliminary support to the concept that rescue regimens including ceftolozane-tazobactam and fosfomycin may be considered for XDR-PA CNS infections in patients without alternative therapeutic options.
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Affiliation(s)
| | - Vincenzo Savini
- Clinical Microbiology Unit, Pescara General Hospital, Pescara, Italy
| | - Ennio Polilli
- Clinical Pathology Laboratory, Pescara General Hospital, Pescara, Italy
| | | | | | - Donatella Bosco
- Intensive Care Unit, Pescara General Hospital, Pescara, Italy
| | - Augusta Consorte
- Infectious Disease Unit, Pescara General Hospital, Pescara, Italy
| | - Paolo Fazii
- Clinical Microbiology Unit, Pescara General Hospital, Pescara, Italy
| | - Giustino Parruti
- Infectious Disease Unit, Pescara General Hospital, Pescara, Italy
- Corresponding author at: Unit of Infectious Diseases, Pescara General Hospital, Via Fonte Romana 8, Pescara, Italy.
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17
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Frattari A, Parruti G, Erasmo R, Guerra L, Polilli E, Zocaro R, Iervese G, Fazii P, Spina T. Recurring septic shock in a patient with blunt abdominal and pelvic trauma: how mandatory is source control surgery?: a case report. J Med Case Rep 2017; 11:49. [PMID: 28222811 PMCID: PMC5320692 DOI: 10.1186/s13256-017-1206-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/07/2017] [Indexed: 12/29/2022] Open
Abstract
Background In critically ill patients with colonization/infection of multidrug-resistant organisms, source control surgery is one of the major determinants of clinical success. In more complex cases, the use of different tools for sepsis management may allow survival until complete source control. Case presentation A 42-year-old white man presented with traumatic hemorrhagic shock. Unstable pelvic fractures led to emergency stabilization surgery. Fever ensued with diarrhea, followed by septic shock. Two weeks later, an abdominal computed tomography scan revealed suprapubic and ischiatic abscesses at surgical sites, as well as dilated bowel. Debridement of both surgical sites, performed with vacuum-assisted closure therapy, yielded isolates of carbapenem and colistin-resistant Klebsiella pneumoniae. Antibiotic treatment was de-escalated after 21 days; 4 days later fever, leukocytosis, hypotension and acute renal failure relapsed. Blood purification techniques were started, for the removal of endotoxin and inflammatory mediators, with sequential hemodialysis. Clinical improvement ensued; blood cultures yielded Candida albicans and multidrug-resistant Acinetobacter baumannii; panresistant carbapenemase-producing Klebsiella pneumoniae grew from wound swabs. In spite of shock reversal, our patient remained febrile, with diarrhea. Control blood cultures yielded Candida albicans, Acinetobacter baumannii and carbapenem-resistant Klebsiella pneumoniae. His abdominal pain increased, paralleled by a right flank palpable mass. Colonoscopy revealed patchy serpiginous ulcers. At exploratory laparotomy, an inflammatory post-traumatic pseudotumor of his right colon was removed. Blood cultures turned negative after surgery. Septic shock, however, relapsed 4 days later. A blood purification cycle was repeated and combination antimicrobial therapy continued. Surgical wounds and blood cultures were persistently positive for carbapenem-resistant Klebsiella pneumoniae. Removal of pelvic synthesis media was therefore anticipated. Three weeks later, clinical, microbiological, and biochemical evidence of infection resolved. Conclusions High quality intensive assistance for sepsis episodes needs a clear plan of cure, aimed to complete infection source control, in a complex multidisciplinary interplay of specialists and intensive care physicians.
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Affiliation(s)
- Antonella Frattari
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
| | - Giustino Parruti
- Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Rocco Erasmo
- Unit of Orthopedics and Traumatology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Luigi Guerra
- Unit of Orthopedics and Traumatology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Ennio Polilli
- Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Rosamaria Zocaro
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Giuliano Iervese
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Paolo Fazii
- Unit of Microbiology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Tullio Spina
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
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Abstract
Introduction: Conscious sedation has traditionally been used for laparoscopic tubal ligation. General anesthesia with endotracheal intubation may be associated with side effects, such as nausea, vomiting, cough, and dizziness, whereas sedation offers the advantage of having the patient awake and breathing spontaneously. Until now, only diagnostic laparoscopy and minor surgical procedures have been performed in patients under conscious sedation. Case Description: Our report describes 5 cases of laparoscopic salpingo-oophorectomy successfully performed with the aid of conventional-diameter multifunctional instruments in patients under local anesthesia. Totally intravenous sedation was provided by the continuous infusion of propofol and remifentanil, administered through a workstation that uses pharmacokinetic–pharmacodynamic models to titrate each drug, as well as monitoring tools for levels of conscious sedation and local anesthesia. We have labelled our current procedure with the acronym OLICS (Operative Laparoscopy in Conscious Sedation). Four of the patients had mono- or bilateral ovarian cysts and 1 patient, with the BRCA1 gene mutation and a family history of ovarian cancer, had normal ovaries. Insufflation time ranged from 19 to 25 minutes. All patients maintained spontaneous breathing throughout the surgical procedure, and no episodes of hypotension or bradycardia occurred. Optimal pain control was obtained in all cases. During the hospital stay, the patients did not need further analgesic drugs. All the women reported high or very high satisfaction and were discharged within 18 hours of the procedure. Discussion and Conclusion: Salpingo-oophorectomy in conscious sedation is safe and feasible and avoids the complications of general anesthesia. It can be offered to well-motivated patients without a history of pelvic surgery and low to normal body mass index.
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Affiliation(s)
| | | | | | - Maria Rizzi
- Anesthesia and Intensive Care, Santo Spirito Hospital, Pescara, Italy
| | | | - Tullio Spina
- Anesthesia and Intensive Care, Santo Spirito Hospital, Pescara, Italy
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Scuteri A, Modestino A, Frattari A, Di Daniele N, Tesauro M. Occurrence of Hypotension in Older Participants. Which 24-hour ABPM Parameter Better Correlate With? J Gerontol A Biol Sci Med Sci 2012; 67:804-10. [DOI: 10.1093/gerona/glr232] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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