The association between prolonged capillary refill time and microcirculation changes in children with sepsis

BACKGROUNDS

In children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis.

METHODS

This was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]-a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes.

RESULTS

A total of 132 children with sepsis were included, with a median age of two years (IQR 0.6-12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09-6.34; p = 0.02) and fewer 4-6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06-6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO2 difference (DCO2) had an abnormal PBR (aOR 1.13, 95% CI 1.01-1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64-0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58-1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94-0.99; p < 0.05).

CONCLUSIONS

We found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.

The association between hypoalbuminemia and microcirculation, endothelium, and glycocalyx disorders in children with sepsis

OBJECTIVE

The objective of this study was to evaluate the association between serum albumin levels and microcirculation changes, glycocalyx degradation, and the clinical outcomes of interest.

METHODS

Observational, prospective study in children with sepsis. The primary outcome was the association between hypoalbuminemia and microcirculation disorders, endothelial activation and glycocalyx degradation using a perfused boundary region (PBR) (abnormal >2.0 μm on sublingual video microscopy) or plasma biomarkers (syndecan-1, angiopoietin-2).

RESULTS

A total of 125 patients with sepsis were included. The median age was 2.0 years (IQR 0.5-12.5). Children with hypoalbuminemia had more abnormal microcirculation with a higher PBR (2.16 μm [IQR 2.03-2.47] vs. 1.92 [1.76-2.28]; p = .01) and more 4-6 μm capillaries recruited (60% vs. 40%; p = .04). The low albumin group that had the worst PBR had the most 4-6 μm capillaries recruited (rho 0.29; p < .01), 48% higher Ang-2 (p = .04), worse annexin A5 (p = 0.03) and no syndecan-1 abnormalities (p = .21). Children with hypoalbuminemia and a greater percentage of blood volume in their capillaries needed mechanical ventilation more often (56.3% vs. 43.7%; aOR 2.01 95% CI 1.38-3.10: p < .01).

CONCLUSIONS

In children with sepsis, an association was found between hypoalbuminemia and microcirculation changes, vascular permeability, and greater endothelial glycocalyx degradation.

ScribeMD: Mixed-methods analysis of a pen pal program in undergraduate medical education

Introduction: A growing emphasis on humanistic medical care has led to the development of programs to imbue more humanistic values into training physicians. The ScribeMD intra-class pen pal program is a narrative medicine tool designed to meet this need with a focus on the journey through medical education. This study intends to evaluate the efficacy of this novel program on the participants' professional identity formation (PIF), emotional intelligence development (EID), and narrative competency improvement (NCI).Methods: This program evaluation involved quantitative and qualitative survey solicitations from first and second-year medical student participants and controls. An efficacy-triangulation model was developed as a quantitative outcome-measuring tool linking objective, writing prompts, and survey data.Results: The quantitative results showed statistically significant improvements in line with the Efficacy Triangulation Model in the participant group. Qualitatively, reflective and insight-driven gains were elicited, as were notable themes of personal and community improvements.Conclusion: ScribeMD poses a unique avenue for the development of more humanistic physicians during their medical education. We recommend additional development of the Efficacy Triangulation Model as well as the program design itself. We also recommend the piloting of this program in other healthcare-education settings both with medical education and other health professions.

TG/HDL-C RATIO AS CARDIO-METABOLIC BIOMARKER EVEN IN NORMAL WEIGHT WOMEN

CONTEXT

Despite that the Triglycerides/High Density Lipoprotein Cholesterol (TG/HDL-C) ratio has been associated with insulin resistance and cardiovascular disease, some outcomes differ between populations.

OBJECTIVE

The objective of this study was to evaluate the association between TG/HDL-C ratio and cardio-metabolic risk factors in both obese and normal weight women.

DESIGN

Cross sectional, from January to December of 2015.

SUBJECTS AND METHODS

Two hundred and fifty three women aged 40 to 60 years. Anthropometric and laboratory measurements were performed. Insulin resistance was measured by the homeostasis model assessment for insulin resistance (HOMA-IR). All participants underwent a Doppler ultrasound to measure intima-media thickness of carotid artery (cIMT).

RESULTS

TG/HDL-C ratio correlated with body mass index (r=0.194, p=0.01), and visceral adipose tissue (r=0.193, p=0.002). Additionally, TG/HDL-C correlated with glucose (r=0.367, p=0.001), insulin (r=0.354, p=0.001) and HOMA-IR (r=0.396 p=0.001). TG/HDL-C was associated with prediabetes, Odds Ratio (OR) was 1.83 (95%CI 1.07-3.13) and insulin resistance 3.27 (95%CI 1.78-6.01), and this risk remains in normal weight women 4.7 (95%CI 1.2-17.81) for prediabetes and 4.38 (95%CI 1.42-13.84) for insulin resistance. No significant risk for cIMT.

CONCLUSION

A TG/HDL-C ratio ≥ 3.0 is a potential risk factor for prediabetes and insulin resistance in women 40-60 years, even in normal weight women.

[Validation of the Spanish version of the QOLIE-10 quality of life in epilepsy questionnaire]

INTRODUCTION

Epilepsy patients not only have to deal with the disease itself but also the side effects of some treatments, fear about sudden occurrence of seizures, stigmatization, and restrictions in activities of daily living. For this reason, it is accepted that seizure control is only one feature of the clinical management of epilepsy, since cognitive, physical and psychological deterioration also affects quality of life. It is essential to have measurement tools that rapidly and accurately evaluate the complex aspects included in the concept of quality of life in persons with epilepsy. This study has aimed to validate the specific Health-Related Quality of Life (HRQoL) questionnaire for epileptic patients, QOLIE-10 (Quality of Life in Epilepsy Inventory-10), a reduced version having easier clinical application than the QOLIE-31 in a Spanish population.

METHODS

Naturalistic, prospective, national and multicenter study, in which 21 Spanish neurologists took part. Patients with partial or generalized epilepsy from 18 to 50 years, who were under monotherapy with lamotrigine or valproic acid and clinically stables, were included. Two visits were carried out, one basal visit and a 6, month follow-up visit. Sociodemographic, clinical (ti-me since diagnosis, previous treatment, current treatment and perceived adverse events) and social variables (QOLIE-31, QOLIE-10) were collected.

RESULTS

A total of 107 patients were included. Mean age was 30.4 (deviation standard [DE]: 9.1) years and 61.7% were women. Mean time since epilepsy diagnosis was 8 (SD: 8.1) years. A total of 84.1% of the patients answered all the items correctly (feasibility). The Kaiser- Myer-Olkin measure was 0.822, with an associated pvalue<0.001 (content validity). QOLIE-10 scores did not show any relationship with the type of seizures (p>0.05), either globally or for its different domains (cross-sectional validity). The mean score went from 73.9 (SD: 15.7) to 75.5 (SD: 14.9) between the two visits, equivalent to an increase of HRQoL of 1.6 (SD: 7.6) points (p=0.37) (longitudinal validity). A Cronbach's alpha coefficient of 0.811 was obtained (internal consistency). Interclass correlation coefficients were higher than 0.7 (reliability). In the overall score the effect size obtained was of 0.10 (responsiveness to change).

CONCLUSIONS

The Spanish version of the QOLIE-10 has been shown to be feasible, valid, reliable and responsive to changes. The QOLIE-10 is a useful tool to measure HRQoL in usual clinical practice.

[Toxic effects of ammonium metavanadate on the growth and number of the offspring of Swiss albino mice]

The present research show, an statistical study of the effects of ammonium metavanadate (AMV) on size, weight and number of offsprings of 56 albino swiss mice (male and female) was carried out. These mice ingested AMV in concentration of 100 and 200 ppm "ad libitum" since birth, continuing throughout breasting until mating. The control group received water free from the metal. The statistical results, obtained by the Duncan and Tukey method, were the following: a significant drop in body size in 200 ppm concentration of AMV, and in tail size in a concentrations of 100 and 200 ppm. A significant increase was observed in the number of the offsprings on the groups treated with AMV on a concentration of 200 ppm with respect to the control group.

Regulation by prostaglandin E2 of interleukin release by T lymphocytes in mucosa

Regulation of immune cell activation in lymphocyte-bearing human tissues is a pivotal host function, and metabolites of arachidonic acid (prostaglandin E2 in particular) have been reported to serve this function at non-mucosal sites. However, it is unknown whether prostaglandin E2 is immunoregulatory for the large lymphocyte population in the lamina propria of intestine; whether low (nM) concentrations of prostaglandin E2 modulate immune responses occurring there; and whether adjacent inflammation per se abrogates prostaglandin E2's regulatory effects. To address these issues, intestine-derived lymphocytes and T hybridoma cells were assessed, T cell activation was monitored by release of independently quantitated lymphokines, and dose-response studies were performed over an 8-log prostaglandin E2 concentration range. IL-3 release by normal intestinal lamina propria mononuclear cells was reduced (up to 78%) in a dose-dependent manner by prostaglandin E2, when present in as low a concentration as 10(-10) M. PGE2 also inhibited (by > or = 60%) mucosal T lymphocytes' ability to destabilize the barrier function of human epithelial monolayers. Further, with an intestine-derived T lymphocyte hybridoma cell line, a prostaglandin E2 dose-dependent reduction in IL-3 and IL-2 (90 and 95%, respectively) was found; this was true for both mitogen- and antigen-driven T cell lymphokine release. Concomitant [3H] thymidine uptake studies suggested this was not due to a prostaglandin E2-induced reduction in T cell proliferation or viability. In contrast, cells from chronically inflamed intestinal mucosa were substantially less sensitive to prostaglandin E2, e.g., high concentrations (10(-6) M) of prostaglandin E2 inhibited IL-3 release by only 41%. We conclude that prostaglandin E2 in nM concentrations is an important modulator of cytokine release from T lymphocytes derived from the gastrointestinal tract, and it may play a central role in regulation of lamina propria immunocyte populations residing there.