Assessment of the components of fluid balance in patients with septic shock: a prospective observational study

BACKGROUND

The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours.

METHODS

In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness.

RESULTS

We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores.

CONCLUSIONS

Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.

Determinants of death in critically ill COVID-19 patients during the first wave of COVID-19: a multicenter study in Brazil

OBJECTIVE

To evaluate clinical outcomes and factors associated with mortality, focusing on secondary infections, in critically ill patients with COVID-19 in three Brazilian hospitals during the first pandemic wave.

METHODS

This was a retrospective observational study involving adult patients with COVID-19 admitted to one of the participating ICUs between March and August of 2020. We analyzed clinical features, comorbidities, source of SARS-CoV-2 infection, laboratory data, microbiology data, complications, and causes of death. We assessed factors associated with in-hospital mortality using logistic regression models.

RESULTS

We included 645 patients with a mean age of 61.4 years. Of those, 387 (60.0%) were male, 12.9% (83/643) had undergone solid organ transplant, and almost 10% (59/641) had nosocomial COVID-19 infection. During ICU stay, 359/644 patients (55.7%) required invasive mechanical ventilation, 225 (34.9%) needed renal replacement therapy, 337 (52.2%) received vasopressors, and 216 (33.5%) had hospital-acquired infections (HAIs), mainly caused by multidrug-resistant gram-negative bacteria. HAIs were independently associated with a higher risk of death. The major causes of death were refractory shock and multiple organ dysfunction syndrome but not ARDS, as previously reported in the literature.

CONCLUSIONS

In this study, most of our cohort required invasive mechanical ventilation and almost one third had HAIs, which were independently associated with a higher risk of death. Other factors related to death were Charlson Comorbidity Index, SOFA score at admission, and clinical complications during ICU stay. Nosocomial COVID-19 infection was not associated with death. The main immediate causes of death were refractory shock and multiple organ dysfunction syndrome.

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

OBJECTIVE

To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria.

METHODS

We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform.

RESULTS

The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database.

CONCLUSION

The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

OBJECTIVE

To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria.

METHODS

We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform.

RESULTS

The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database.

CONCLUSION

The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

Habilidades Sociais Educativas Parentais de Mães de Adolescentes Apontados Como Tendo Problemas de Comportamento

As habilidades sociais educativas parentais são estratégias que os pais utilizam para direcionar os comportamentos dos filhos diante de situações de interação social. O presente estudo trata-se de uma pesquisa exploratória descritiva que teve por objetivo avaliar as habilidades sociais educativas parentais de mães de adolescentes estudantes de uma escola pública, apontados como tendo problemas sociais de comportamento. Participaram do estudo 20 mães, selecionadas a partir de uma amostragem por conveniência que considerou a ocorrência de queixas pela escola sobre problemas de comportamento de seus filhos. Utilizou-se como instrumento de coleta de dados o Roteiro de Entrevista das Habilidades Sociais Educativas Parentais. Os resultados encontrados apresentaram uma frequência baixa de práticas parentais positivas, em detrimento a uma frequência mais alta de práticas parentais negativas desempenhadas pelas participantes dessa pesquisa. Dessa forma, pode-se concluir um déficit nas habilidades sociais educativas parentais das mães entrevistadas no presente estudo. Esse estudo sugere a necessidade de maior atenção sobre a elaboração e aplicação de programas de treinamentos de habilidades sociais educativas parentais para mães cuidadoras de adolescentes, visto que um possível melhoramento neste aspecto pode influenciar um aprimoramento das estratégias educativas parentais.

Effect of ScLL and 15d-PGJ2 on viability and cytokine release in LPS-stimulated fibroblasts: an in vitro study

This study evaluated the effect of a cyclopentenone-type PG, 15-Deoxy-Δ12,14-PG J2 (15d-PGJ2), and lectin (ScLL) on the viability of human gingival fibroblasts (HGFs), and on IL-6 and TGFβ-1 release by these fibroblasts, stimulated with lipopolysaccharide (LPS). HGFs were stimulated with LPS 10 μg/ml and treated with 15d-PGJ2 1 and 2 μg/ml, and ScLL 2 and 5 μg/ml, for 1 and 3h, and then evaluated for viability by MTT assay. Supernatant was collected to detect IL-6 and TGFβ-1 release, by ELISA. Positive control was cells kept in Dulbecco's Modified Eagle's Medium, and negative control was those kept in LPS. Data were analyzed by ANOVA and Dunnett's test (α = 0.05). No significant difference was found in viability among experimental groups at 1h (p > 0.05). Percentage of ScLL 5 µg/ml viable cells was similar to that of positive control at evaluated periods (p > 0.05), whereas the other groups had lower levels than the positive control (p < 0.05). IL-6 release was statistically higher for ScLL 5 μg/ml and 15d-PGJ2 2 µg/ml at 1h, compared with the other treated groups and positive control (p < 0.05). No significant differences were found among the groups at 3h (p > 0.05), except for ScLL 2 µg/ml and 15d-PGJ2 1 µg/ml, which showed lower IL-6 release compared with that of negative control (p < 0.05). No significant difference was found among the groups for TGFβ-1 release (p > 0.05). Results indicated that ScLL 5 μg/ml did not interfere in viability, and ScLL 2 µg/ml and 15d-PGJ2 1 µg/ml demonstrated reduced IL-6 release. Tested substances had no effect on TGFβ-1 release.

Effect of lectin (ScLL) on fibroblasts stimulated with LPS - an in vitro study

The lectin (ScLL) extracted from the Synadenium carinatum plant has been evaluated as an immunomodulator in diseases such as asthma, neosporosis and leishmaniasis. However, it has not yet been evaluated in the oral cavity. This study evaluated the effect of ScLL on viability, proliferation and release of IL-10 in human gingival fibroblasts (HGF) stimulated with lipopolysaccharide (LPS). HGF were stimulated with LPS 1 µg/ml and treated with ScLL in concentrations of 10, 5 and 2 µg/ml for 1 and 5 h, and evaluated by flow cytometry for viability, apoptosis (initial/advanced) and necrosis. The supernatant was collected to detect release of IL-10 by ELISA. The proliferation was assessed with the BrdU assay. Positive control consisted of cells maintained in Dulbecco's Modified Eagles Medium (DMEM), and the negative control, of those kept in tap water. Data were analyzed by ANOVA and Dunnett's test (α = 0.05). No significant difference was found for ScLL concentrations regarding viability or initial and advanced apoptosis (p=0.455). All the groups, including the positive control, had a significantly lower necrosis parameter than negative control at 5 h (p < 0.001). No difference was found for proliferation among the experimental groups (p = 0.832). ScLL at 5 and 2 µg/ml resulted in a lower release of IL-10 than positive and negative controls at 5 h (p = 0.047). The results indicated that ScLL concentrations tested were not cytotoxic, and had no effect on proliferation and release of IL-10 parameters. A thorough understanding of ScLL, regarding its immunomodulatory potential, may open the door to new perspectives for dentistry.

Activation of spleen cells by ArtinM may account for its immunomodulatory properties

ArtinM is a D-mannose-binding lectin extracted from Artocarpus heterophyllus that promotes interleukin-12 production by macrophages and dendritic cells. This property is considered responsible for T helper 1 immunity induced in vivo after ArtinM administration. In this study, we investigated the effect of native (jArtinM) and recombinant (rArtinM) forms of lectin on murine spleen cells and isolated T lymphocytes. We found that ArtinM binds to the surface of spleen cells. This interaction, which was blocked by D-mannose, induced cell activation, as manifested by increased mitochondrial activity, interleukin-2 production, and cell proliferation. We verified that a 30-times higher concentration of rArtinM was required to trigger optimal activation of spleen cells compared with that needed with jArtinM, although these proteins have identical sugar recognition properties and use the same signaling molecules to trigger cell activation. Because the distinction between native and recombinant is restricted to their tertiary structure (tetrameric and monomeric, respectively), we postulated that the multi-valence of jArtinM accounts for its superiority in promoting clustering of cell surface glycoreceptors and activation. The jArtinM and rArtinM activation effect exerted on spleen cells was reproduced on purified CD4⁺ T cells. Our results suggest that ArtinM interaction with T cells leads to responses that may act in concert with the interleukin-12 produced by antigen-presenting cells to modulate immunity toward the T helper 1 axis. Further studies are necessary to dissect ArtinM/T-cell interactions to more fully understand the immunomodulation induced by carbohydrate recognition.

Levels of Immunoglobulin A1 in Peri-Implant Fluid and Saliva from Patients with Mucositis: A Preliminary Study

There are no studies evaluating the possible use of immunoglobulin A1 (IgA1) as an early marker for peri-implant inflammation. The aim of this study was to evaluate the IgA1 levels in peri-implant sulcular fluid (PISF) and saliva of partially edentulous patients as an indicator of mucositis. Twenty-seven patients were examined to determine the peri-implant status based on probing depth and bleeding on probing. Saliva and PISF around dental implants were collected and the IgA1 levels were evaluated by Elisa assay. IgA1 in saliva and PISF of these patients were compared and their correlations with clinical parameters were evaluated. Differences in IgA1 levels in saliva (821.1 ± 290.6; 779.8 ± 401.5) and PISF (26.6 ± 20.7; 25.1 ± 20.5) of healthy and mucositis groups, respectively were not observed (p>0.05). Correlation between clinical parameters and IgA1 in saliva or PISF was not observed in healthy or mucositis groups (p=0.607; p=0.826, respectively). These results suggest that IgA1 cannot be used as an immunological marker of mucositis.

Would Nitric Oxide be an Effective Marker for Earlier Stages of Peri-Implant Disease? An Analysis in Human Peri-Implant Sulcular Fluid

Nitric oxide has an important effect on host immune response. However, little has been studied in relation to its potential as a possible diagnostic tool in peri-implant disease. The present study analyzed nitrite levels in the peri-implant sulcular fluid (PISF) of implants with mucositis and the correlation of these nitrite levels with clinical parameters using a simplified fluid collection methodology. Twenty-five partially edentulous patients showing peri-implant mucositis were evaluated, and the peri-implant status was determined based on current clinical parameters: probing depth (PD) and bleeding on probing (BOP). The sulcular fluid (SF) around teeth (control) and implants were collected, and the nitrite levels were evaluated using the Griess method. The mean probing depth (mm) was significantly higher (P &lt; .0001) in implants (2.852 ± 0.6484) than in control teeth (1.585 ± 0.3636). The mean total nitrite level (μM) was statistically higher (P = .0069) in implants with mucositis (14.34 ± 11.83) than in control teeth (9.316 ± 5.534). No correlation was observed between the total nitrite levels and the PD mean in the control group (P = .2558, r = −0.2361) or in the implant group (P = .1160, r = −0.3224), as well as the number of faces showing bleeding on probing (P = .8747, r = 0.0332). These results demonstrated that the nitrite levels were higher in inflamed areas. According to the methodology applied and results obtained, the higher nitrite levels in inflamed areas suggest that, in the future, nitrite could be used as a marker of peri-implant mucositis associated with clinical data to monitor the cure or evolution of the disease.

Cytotoxicity of bovine and porcine collagen membranes in mononuclear cells

This study compared the cytotoxicity and the release of nitric oxide induced by collagen membranes in human mononuclear cells. Peripheral blood was collected from each patient and the separation of mononuclear cells was performed by Ficoll. Then, 2x10(5) cells were plated in 48-well culture plates under the membranes in triplicate. The polystyrene surface was used as negative control. Cell viability was assessed by measuring mitochondrial activity (MTT) at 4, 12 and 24 h, with dosage levels of nitrite by the Griess method for the same periods. Data had non-normal distribution and were analyzed by the Kruskal-Wallis test (p<0.05). Statistically significant differences (p<0.05) were observed between the membranes and the control in the experimental period, although there was a significant reduction in viability over time (p<0.01). At 4 and 12 h, the porcine membrane induced a higher release of nitrite compared with the control and bovine membrane, respectively (p<0.01), and this difference was maintained at 24 h (p<0.05). This in vitro study showed that the porcine collagen membrane induces an increased production of proinflammatory mediators by mononuclear cells in the first hours of contact, decreasing with time.

In-vitro study of cellular viability and nitric oxide production by J774 macrophages stimulated by interferon gamma with ceramic, polycarbonate, and polyoxymethylene brackets

INTRODUCTION

Ceramic brackets are chemically inert in the oral cavity, whereas polycarbonate and polyoxymethylene brackets can degrade and release bisphenol-A and formaldehyde, respectively. More reliable tests are needed to assess the potential toxicity of these materials. In addition to traditional cytotoxicity tests, the study of nitric oxide (NO) cellular production stimulated by a specific material has been shown to be a reliable tool for evaluating cytotoxic potential. The purpose of this study was to assess, with esthetic brackets, cellular viability by 3,(4,5-dimethylthiazol-2-yl)-2,5diphenyltetrazolium bromide assay (Sigma, St. Louis, Mo) in the macrophage cell line J774 stimulated with interferon gamma. Interferon gamma is a key cytokine in the activation of macrophages, plays an important role in immunologic processes, and also quantifies NO production by these macrophages.

METHODS

Well plates were seeded with 2 x 104 J774 cells per well, in a volume of 100 microL, resuspended in Roswell Park Memorial Institute Supplemented Medium 1640. The macrophage cell line J774 was stimulated with interferon gamma. Ceramic, polycarbonate, and polyoxymethylene brackets were added and kept in the culture for 24, 48, or 72 hours in 5% carbon dioxide at 37 degrees C; the control samples did not include brackets. At the end of each incubation period, the supernatant was collected for posterior NO quantification, and the cells were evaluated for cytotoxicity.

RESULTS

Cellular viability in all groups was higher at 72 hours than at 24 hours. The final means in the bracket groups did not show significant differences compared with the control group. NO production was significantly greater in all groups at the final time than at the initial time. However, the brackets with the interferon gamma stimulation did not result in greater NO production than did the cells in the control group.

Preparation and antitubercular activities of alkylated amino alcohols and their glycosylated derivatives

A series of N- and C-alkylated amino alcohols and of their protected galactopyranosyl derivatives was synthesized and evaluated for antitubercular activity. Five of these compounds displayed good activity, with a MIC below 12.5mug/mL. The presence of the carbohydrate slightly affected the antibacterial activity.

Perfil de isotipos de imunoglobulinas e subclasses de IgG na leishmaniose tegumentar americana

O presente trabalho avaliou o perfil de anticorpos em amostras de soro de 37 pacientes com diagnóstico clínico confirmado ou compatível com leishmaniose tegumentar americana atendidos no Hospital de Clínicas da Universidade Federal de Uberlândia, MG. Os perfis das classes de imunoglobulinas e subclasses de IgG foram analisados pelo teste ELISA indireto, utilizando-se antígeno solúvel de Leishmania (Leishmania) amazonensis. A avidez dos anticorpos foi determinada pelo tratamento com uréia a 6 M, após incubação dos soros com o antígeno. Observou-se que 97%, 94,6%, 57,5 e 21,5% das amostras testadas apresentaram anticorpos anti-Leishmania das classes IgE, IgG, IgA e IgM, respectivamente e, os perfis das subclasses de IgG demonstraram, IgG1>IgG3>IgG2>IgG4. Os anticorpos IgE anti-Leishmania de alta avidez corresponderam a 44,4%. Por outro lado, IgG e IgA anti-Leishmania foram em sua maioria (62,8 e 47,8%, respectivamente), de média avidez. A variação do perfil de isotipos, bem como a avidez das imunoglobulinas refletiu a complexidade da resposta imune humoral contra a leishmaniose tegumentar americana.

Immunoblotting analyses using two-dimensional gel electrophoresis of Trypanosoma cruzi excreted-secreted antigens

Trypanosoma cruzi trypomastigotes excrete-secrete a complex mixture of antigenic molecules. This antigenic mixture denominated trypomastigote excreted-secreted antigens contains a 150-160 kDa band that shows excellent performance in Chagas' disease diagnosis by immunoblotting. The present study partially characterized by two-dimensional gel electrophoresis the immunoreactivity against the 150-160 kDa protein using sera samples from chagasic patients in different phases of the disease. Trypomastigote excreted-secreted antigen preparations were subjected to high-resolution two-dimensional (2D) gel electrophoresis followed by immunoblotting with sera from chagasic and non-chagasic patients. The 150-160 kDa protein presented four isoforms with isoelectric focusing ranging from 6.2 to 6.7. The four isoforms were recognized by IgM from acute phase and IgG from chronic phase sera of chagasic patients. The 150-160 kDa isoform with IF of approximately 6.4 became the immunodominant spot with the progression of the disease. No cross-reactivity was observed with non-chagasic or patients infected with Leishmania sp. In this study we provide basic knowledge that supports the validation of trypomastigote excreted-secreted antigens for serological diagnosis of Chagas' disease.

Detection of antibodies to the 97 kDa component of Toxoplasma gondii in samples of human serum

This study was carried out to investigate the immune response against 97 kDa (p97) molecular marker of Toxoplasma gondii that has been characterized as a cytosolic protein and a component of the excreted-secreted antigens from this parasite. A total of 60 serum samples from patients were analyzed by enzime-linked immunosorbent assay and Western blot for toxoplasmosis. These samples were organized in three groups, based on clinical symptoms and results of serological tests. Group I: 20 samples reactive to IgG and IgM (acute phase); group II: 20 non-reactive samples (control group); and group III: 20 samples reactive only to IgG (chronic phase). Western blot was performed with total antigenic extracts or with excreted and secreted antigen from T. gondii to identify the fraction correspondent to p97. It was observed that this cytosolic component from T. gondii stimulates the immunologic system to produce both IgM and IgG antibodies in the beginning of the acute infection and IgG throughout the chronic stage of the asymptomatic toxoplasmosis.