Coagulation Disorders and Bleedings in Critically Ill Patients With Hemophagocytic Lymphohistiocytosis

Reactive hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition related to a cytokine storm leading to multiorgan dysfunction. A better understanding of coagulation disorders, frequently reported in HLH patients, may improve outcomes.Critically ill HLH patients managed in a multidisciplinary national reference center were retrospectively included. Relationships between coagulation disorders, severe bleedings, and outcomes were assessed.One hundred and seventeen patients fulfilled the HLH 2004 criteria. The most common HLH etiology was hematologic conditions (73%), followed by infectious diseases (20%), systemic rheumatic diseases (5%), and undetermined HLH etiology (3%). All patients exerted thrombocytopenia. Coagulation disorders were diagnosed in 79 (68%) patients (61 had hypofibrinogenemia < 1.5 g/L, 51 had prothrombin time [PT] < 50%). The worst median value throughout ICU stay was 52% (38–65) for PT with a factor V level of 35% (27–43), 1.59 (1.30–2.09) for the activated partial thromboplastin time (APTT) ratio, and 2.33 g/L (1.13–3.86) for the fibrinogen level. Disseminated intravascular coagulation (DIC) was found in 50% of patients. Coagulation disorders were more frequent in immunocompromised patients, those with histological/cytological feature of hemophagocytosis, those with the highest ferritin concentrations, and in patients with HLH not related to infection. These patients were more prone to receive mechanical ventilation, vasopressors, or renal replacement therapy. Twenty-six (22%) patients presented severe bleeding complications, including 5 patients dying from hemorrhagic shock. Strikingly, the only coagulation parameter significantly associated with severe bleeding was low fibrinogen with a cutoff value of 2 g/L (P = 0.03). Overall, 33 (28%) patients died in the ICU and hospital mortality was 44%. Coagulation disorders were associated with higher mortality, especially fibrinogen < 2 g/L (P = 0.04) and PT value (P = 0.03). The occurrence of bleeding complications was not associated with higher risk of hospital death. Risk factors associated with mortality by multivariate analysis were fibrinogen level < 2 g/L (OR 2.42 [1.08–5.41]), SOFA score > 6 (OR 3.04 [1.32–6.98]), and age > 46 years (OR 2.26 [1.02–5.04]).Up to two-third of critically ill HLH patients present with coagulation disorders. Hypofibrinogenemia or DIC was found in half of the patients and low PT in 40%. These patients require more life support and have a higher mortality rate. Fibrinogen <2 g/L is associated with the occurrence of severe bleeding and mortality.     

Impact of Admission Systolic Blood Pressure and Antecedent Hypertension on Short-Term Outcomes After ST-Segment Elevation Myocardial Infarction: Strobe-Compliant Article

We evaluated the combined effect of admission systolic blood pressure (SBP) and antecedent hypertension on short-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Data were derived from a multicenter survey of 7303 consecutive patients with STEMI. Patients were divided into 4 groups according to different blood pressure status: high SBP without hypertension, high SBP with hypertension, low SBP without hypertension, and low SBP with hypertension. The primary endpoints were 7 and 30-day all-cause mortality. The prevalence of hypertension was 40.7%, and the best cutoff of admission SBP for predicting 30-day mortality was 108 mmHg by receiver-operating characteristic curve. Patients with hypertension were older, more often female, also had longer onset-to-admission time, more comorbidities, and higher Killip class. Patients with both low SBP (≤108 mmHg) and hypertension group had significantly higher 7 and 30-day mortality than those in other groups (all P < 0.001). After multivariate adjustment, low SBP with hypertension group was still an independent risk factor for predicting 7-day mortality (hazard ratios [HR] 1.86, 95% confidence interval [CI] 1.41–2.46; P < 0.001) and 30-day mortality (HR 1.88, 95% CI 1.46–2.43; P < 0.001). In patients with SBP > 108 mmHg, a history of hypertension could increase the risk of 30-day mortality by 27% (HR 1.00 vs 1.27, P = 0.012), while in patients with SBP ≤ 108 mmHg, this increased risk reached to 37% (HR 1.51 vs 1.88, P < 0.001). In conclusion, low admission SBP was the relatively dominant contributor for predicting 7 and 30-day all-cause mortality, and a concurrent antecedent hypertension increased the corresponding risk of mortality.     

Hospitalization for Pneumonia is Associated With Decreased 1-Year Survival in Patients With Type 2 Diabetes: Results From a Prospective Cohort Study

Diabetes mellitus is a frequent comorbid conditions among patients with pneumonia living in the community.The aim of our study is to evaluate the impact of hospitalization for pneumonia on early (30 day) and late mortality (1 year) in patients with type 2 diabetes mellitus.Prospective comparative cohort study of 203 patients with type 2 diabetes hospitalized for pneumonia versus 206 patients with diabetes hospitalized for other noninfectious causes from January 2012 to December 2013 at Policlinico Umberto I (Rome). Enrolled patients were followed up to discharge and up to 1 year after initial hospital admission or death.Overall, 203 patients with type 2 diabetes admitted to hospital for pneumonia were compared to 206 patients with type 2 diabetes admitted for other causes (39.3% decompensated diabetes, 21.4% cerebrovascular diseases, 9.2% renal failure, 8.3% acute myocardial infarction, and 21.8% other causes). Compared to control patients, those admitted for pneumonia showed a higher 30-day (10.8% vs 1%, P < 0.001) and 1-year mortality rate (30.3% vs 16.8%, P < 0.001). Compared to survivors, nonsurvivor patients with pneumonia had a higher incidence of moderate to severe chronic kidney disease, hemodialysis, and malnutrition were more likely to present with a mental status deterioration, and had a higher number of cardiovascular events during the follow-up period. Cox regression analysis found age, Charlson comorbidity index, pH < 7.35 at admission, hemodialysis, and hospitalization for pneumonia as variables independently associated with mortality.Hospitalization for pneumonia is associated with decreased 1-year survival in patients with type 2 diabetes, and appears to be a major determinant of long-term outcome in these patients.     

Impact of Admission White Blood Cell Count on Short- and Long-term Mortality in Patients With Type A Acute Aortic Dissection: An Observational Study

Studies have shown inflammation is involved in the development of acute aortic dissection (AAD). The hypothesis that white blood cell count (WBCc) on admission may have an impact on the short- and long-term outcomes of type A AAD was tested in a large-scale, prospective observational cohort study.From 2008 to 2010, a total of 570 consecutive patients with type A AAD in Fuwai hospital were enrolled and were followed up. Baseline characteristics and WBCc on admission were collected. The primary outcomes were 30-day and long-term all-cause mortality.During a median of 1.89 years of follow-up, the 30-day and long-term all-cause mortality were 10.7% and 6.5%, respectively. Univariate Cox regression analysis identified admission WBCc as an independent predictor of 30-day mortality when considered as a continuous variable or as a categorical variable using the cutoff of 11.0  × 10⁹ cells/L (all P < 0.05). After adjustment for age, sex, C-reactive protein, d-dimer, and surgical intervention, elevated admission WBCc (>11.0 × 10⁹ cells/L) remained an independent predictor of 30-day mortality of AAD (hazard ratio = 3.31, 95% confidence interval 1.38–7.93, P = 0.007). No impact of admission WBCc was observed on the long-term all-cause mortality.In conclusion, elevated admission WBCc may be valuable as a predictor of 30-day mortality, and may be useful in the risk stratification of type A AAD during hospitalization.     

Postoperative Fluid Overload is a Useful Predictor of the Short-Term Outcome of Renal Replacement Therapy for Acute Kidney Injury After Cardiac Surgery

To analyze the predictive value of postoperative percent fluid overload (PFO) of renal replacement therapy (RRT) for acute kidney injury (AKI) patients after cardiac surgery.Data from 280 cardiac surgery patients between 2005 January and 2012 April were collected for retrospective analyses. A receiver operating characteristic (ROC) curve was used to compare the predictive values of cumulative PFO at different times after surgery for 90-day mortality.The cumulative PFO before RRT initiation was 7.9% ± 7.1% and the median PFO 6.1%. The cumulative PFO before and after RRT initiation in intensive care unit (ICU) was higher in the death group than in the survival group (8.8% ± 7.6% vs 6.1% ± 5.6%, P = 0.001; −0.5[−5.6, 5.1]% vs 6.9[2.2, 14.6]%, P < 0.001). The cumulative PFO during the whole ICU stay was 14.3% ± 15.8% and the median PFO was 10.7%. The areas under the ROC curves to predict the 90-day mortality by PFO at 24 hours, cumulative PFO before and after RRT initiation, and PFO during the whole ICU stay postoperatively were 0.625, 0.627, 0.731, and 0.752. PFO during the whole ICU stay ≥7.2% was determined as the cut-off point for 90-day mortality prediction with a sensitivity of 77% and a specificity of 64%. Kaplan–Meier survival estimates showed a significant difference in survival among patients with cumulative PFO ≥ 7.2% and PFO < 7.2% after cardiac surgery (log-rank P < 0.001).Postoperative cumulative PFO during the whole ICU stay ≥7.2% would have an adverse effect on 90-day short-term outcome, which may provide a strategy for the volume control of AKI-RRT patients after cardiac surgery.     

Study on the preventive effect of intravenous esomeprazole in the management of nonvarices upper gastrointestinal bleeding

This retrospective study investigated the preventive effect of intravenous esomeprazole (IVEO) in the prevention of nonvarices upper gastrointestinal bleeding (NUGIB).This study enrolled 130 patients with NUGIB and all of them underwent successful endoscopic hemostasis, of which 65 cases received routine management and IVEO (Group A) and the other 65 cases received routine management alone (Group B). The primary outcome (recurrent bleeding rate within 72-hour, 7-day, and 30-day), and secondary outcomes ((all-cause mortality, bleeding-related mortality, blood transfused, hospital stay (day), and incidence of adverse events)) were compared between 2 groups.Patients in the group A showed lower recurrent bleeding rate within 72-hour(P < .05), 7-day (P < .05), and 30-day (P < .05), than that of patients in the group B. However, no significant differences were identified in all-cause mortality(P = .26), bleeding-related mortality (P = .57), blood transfused (P = .33), and hospital stay (P = .74) between 2 groups. In addition, both groups had similar safety profile.This study found that routine management and IVEO was superior to the routine management alone for preventing the recurrent bleeding rate after successful endoscopic hemostasis in patients with NUGIB.     

Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune,Western India

Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.     

Effect of Weekend Admissions on the Treatment Process and Outcomes of Internal Medicine Patients: A Nationwide Cross-Sectional Study

Many studies address the effect of weekend admission on patient outcomes. This population-based study aimed to evaluate the relationship between weekend admission and the treatment process and outcomes of general internal medicine patients in Taiwan.A total of 82,340 patients (16,657 weekend and 65,683 weekday admissions) aged ≥20 years and admitted to the internal medicine departments of 17 medical centers between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. A generalized estimating equation (GEE) analysis was used to compare patients admitted on weekends and those admitted on weekdays.Patients who were admitted on weekends were more likely to undergo intubation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.16–1.39; P < 0.001) and/or mechanical ventilation (OR, 1.25; 95% CI, 1.15–1.35; P < 0.001), cardio-pulmonary resuscitation (OR: 1.45; 95% CI: 1.05–2.01; P = 0.026), and be transferred to the intensive care unit (ICU) (OR: 1.16; 95% CI: 1.03–1.30; P = 0.015) compared with those admitted on weekdays. Weekend-admitted patients also had higher odds of in-hospital mortality (OR: 1.19; 95% CI: 1.09–1.30; P < 0.001) and hospital treatment cost (OR: 1.04; 95% CI: 1.01–1.06; P = 0.008) than weekday-admitted patients.General internal medicine patients who were admitted on weekends experienced more intensive care procedures and higher ICU admission, in-hospital mortality, and treatment cost. Intensive care utilization may serve as early indicator of poorer outcomes and a potential entry point to offer preventive intervention before proceeding to intensive treatment.     

The clinical characters and prognosis of COVID-19 patients with multiple organ dysfunction

To depict the clinical characters and prognosis of coronavirus disease 2019 patients who developed multiple organ dysfunction syndrome (MODS).A cohort consisted of 526 patients, which including 109 patients complicated MODS, was retrospectively analyzed to examine the clinical characteristics and risk factors of MODS.Among the 526 novel coronavirus-infected pneumonia patients, 109 patients developed multiple organ failure, the incidence rate was 20.7%. Among all 109 patients with MODS, 81.7% were over 60 years old, and 63.3% were male. The most common symptoms were fever (79.8%), dyspnea (73.4%), and fatigue (55.0%). Compared with patients non-MODS patients, there were 70 cases of MODS patients with one or more underlying diseases (64.2% vs 41.0%, P < .001). Respiratory failure (92.7%), circulatory failure (52.0%), and liver function injury (30.9%) were the most common symptoms within the spectrum of MODS. Invasive ventilator, noninvasive ventilator, and high-flow respiratory support treatment for patients in MODS patients were higher than those in the non-MODS group (P < .001). The antiviral therapy and 2 or more antibacterial drug treatments in MODS patients were higher than those in the non-MODS group (P < .001). The median hospital stay of all patients was 16 days (interquartile range [IQR], 9-26), of which 20 days (IQR, 11.5-30.5) in the MODS patients, which was approximately 4 days longer than that of non-MODS patients. In addition, our data suggested that lymphocyte counts <1.0 ∗ 109/L, Troponin T > 0.014 ng/mL and lower oxygenation index were risk factors for MODS. In the early stage of hospital admission, higher inflammatory indexes and lactic acid concentration were associated with increased risk of death.MODS often leads to poor prognosis in coronavirus disease 2019. Our data suggested the importance of early identification of MODS. We recommend close monitoring and timely supportive therapy for patients with high risks, stopping the disease progression before it was too late.     

Usefulness of Glycemic Gap to Predict ICU Mortality in Critically Ill Patients With Diabetes

Stress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes.We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG = [(28.7 × HbA1c) − 46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score.We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P < 0.001). Critically ill patients with diabetes and a glycemic gap ≥80 mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80 mg/dL (P < 0.001). Incorporation of the glycemic gap into the APACHE-II score increased the discriminative performance for predicting ICU mortality by increasing the area under the ROC curve from 0.755 to 0.794 (NRI = 13.6%, P = 0.0013).The glycemic gap can be used to assess the severity and prognosis of critically ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality.     

Trefoil factor-2, an early predictor for acute gastrointestinal injury in patients with acute pancreatitis

Acute gastrointestinal injury (AGI) is commonly present in patients with acute pancreatitis (AP). It is often difficult to predict gastrointestinal function in the early stage due to lack of reliable markers. We aimed to assess whether early plasma trefoil factor 2 (TFF-2) is a potential predictor for AGI.Fifty one patients were included for the onset of AP (from developing abdominal pain) within 72 hours in this prospective observational single-center study from January 2013 to July 2015. Among them 23 patients were classified as mild, 17 as moderately severe, and 11 as severe according to 2012 Atlanta classification. Plasma samples were collected only once at admission to the ICU. Twenty samples of healthy adults were also collected as control. The TFF-2 levels were determined by using a human TFF-2 enzyme-linked immunoassay. AGI grades from 1st to 7th day after admission were observed.The plasma TFF-2 levels among AP patients in early stage were significantly higher than healthy controls (766.41 ng/mL vs 94.37 ng/mL, P < .0001). The correlations between TFF-2 levels and AGI grades from 1st to 4th day after admission were positive (r = 0.47, 0.43, 0.42, 0.40 respectively, P < .05). As a predictor of acute gastrointestinal failure, plasma TFF-2 was superior to others: Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, procalcitonin, C-reactive protein, serum calcium. In addition, TFF-2 increased along with the severity of AP (r = 0.554, P < .0001) and associated with Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, C-reactive protein, serum calcium.The plasma TFF-2 levels were increased in patients in early stage of AP and correlated with AGI grades and disease severity in our study. TFF-2 might be a potential predictor for acute gastrointestinal failure in patients with AP.     

Beta-lactam allergy labeling in intensive care units: An observational,retrospective study

This retrospective study aimed to describe the association between the “β-lactam allergy” labeling (BLAL) and the outcomes of a cohort of intensive care unit (ICU) patients.Retrospective cohort study.Seven ICU of the Aix Marseille University Hospitals from Marseille in France.We collected the uses of the label “β-lactam allergy” in the electronic medical files of patients aged 18 years or more who required more than 48 hours in the ICU with mechanical ventilation and/or vasopressors admitted to 7 ICUs of a single institution.We retrospectively compared the patients with this labeling (BLAL group) with those without this labeling (control group).The primary outcome was the duration of ICU stay. Among the 7146 patients included in the analysis, 440 and 6706 patients were classified in the BLAL group and the control group, respectively. The prevalence of BLAL was 6.2%. In univariate and multivariate analyses, BLAL was weakly or not associated with the duration of ICU and hospital stays (respectively, 6 [3–14] vs 6 [3–14] days, standardized beta −0.09, P = .046; and 18 [10–29] vs 15 [8–28] days, standardized beta −0.09, P = .344). In multivariate analysis, the ICU and 28-day mortality rates were both lower in the BLAL group than in the control group (aOR 0.79 95% CI [0.64–0.98] P = .032 and 0.79 [0.63–0.99] P = .042). Antibiotic use differed between the 2 groups, but the outcomes were similar in the subgroups of septic patients in the BLAL group and the control group.In our cohort, the labeling of a β-lactam allergy was not associated with prolonged ICU and hospital stays. An association was found between the labeling of a β-lactam allergy and lower ICU and 28-day mortality rates.Trial registration: Retrospectively registered.     

Severe Extra-Cerebral Anticoagulant-Related Bleeding in Intensive Care Unit: A Retrospective Study From 2000 to 2013

Bleeding is the most frequent complication of anticoagulant therapy, responsible for a number of hospitalizations or deaths. However, studies describing the management and prognosis factors of extra-cerebral anticoagulant-related bleedings in intensive care unit (ICU) are lacking.Retrospective observational study in an 18-bed ICU in a tertiary teaching hospital. From January 2000 to December 2013, all consecutive patients, older than 18 years, admitted for severe anticoagulant-related bleeding (SAB) except intracerebral site were included.A total of 100 patients were included, the mean age was 77 ± 11 years and 62% were women. SAB incidence in ICU doubled over 10 years (P = 0.03). In ICU, the average length of stay was 5 ± 6 days and mortality was 30%. Nonsurviving patients had a higher SAPS II (78 ± 24 vs 53 ± 24, P < 0.0001), a higher SOFA (9.0 ± 3.6 vs 4.7 ± 3.4, P < 0.0001) and received more frequently support therapy such as mechanical ventilation (87% vs 16%, P < 0.0001) and vasopressors (90% vs 27%, P < 0.0001). The volume of blood-derived products transfused was more important in nonsurvivors mainly during the first 24 hours of resuscitation. Rapid anticoagulant reversal therapy was associated with better prognosis (ICU survivors 66% vs 39%, Fisher test P = 0.04). Anterior abdominal wall was identified as a frequent site of bleeding (22%) due to epigastric artery injury during subcutaneous injection of heparin and was associated with a large mortality (55%).Extra-cerebral SAB is a life-threatening complication that requires rapid resuscitation and anticoagulant reversal therapy. Injection of heparin should be done carefully in the subcutaneous tissue thereby avoiding artery injury.     

Risk Factors for Long-Term Mortality and Progressive Chronic Kidney Disease Associated With Acute Kidney Injury After Cardiac Surgery

The aim of the study was to evaluate risk factors for long-term mortality and progressive chronic kidney disease (CKD) after cardiac surgery in patients with normal preoperative renal function and postoperative acute kidney injury (AKI). From April 2009 to December 2012, we prospectively enrolled 3245 cardiac surgery patients of our hospital. The primary endpoints included survival rates and the secondary endpoint was the incidence of progressive chronic kidney disease (CKD) in a follow-up period of 2 years. Acute kidney injury was staged by KDIGO classification. Progressive CKD was defined as GFR ≤ 30 mL/min/1.73 m² or end-stage renal disease (ESRD) (starting renal replacement therapy or renal transplantation).The AKI incidence was 39.9% (n = 1295). The 1 and 2 year overall survival (OS) rates of AKI patients were significantly lower than that for non-AKI patients (85.9% and 82.3% vs 98.1% and 93.7%, P < 0.001), even after complete recovery of renal function during 2 years after intervention (P < 0.001). The 2-year overall survival (OS) rates of patients with AKI stage 1, 2, and 3 were 89.9%, 78.6%, and 61.4% (P < 0.001), respectively. Multivariate Cox regression analysis of factors for 2-year survival rates revealed that besides age (P < 0.001), chronic cardiac failure (P < 0.001), diabetes (P < 0.001), cardiopulmonary bypass time (P < 0.01), and length of intensive care unit (ICU) stay (P = 0.004), AKI was a significant risk factor for reducing 2-year survival rates even after complete recovery of renal function (P < 0.001). The accumulated progressive CKD prevalence was significantly higher in AKI than in non-AKI patients (6.8% vs 0.2%, P < 0.001) in the 2 years after surgery. Even with complete recovery of renal function at discharge, AKI was still a risk factor for accumulated progressive CKD (RR 1.92, 95% CI 1.37–2.69).The 2-year mortality and progressive CKD incidence even after complete recovery of renal function were significantly increased in cardiac surgery patients with postoperative AKI.     

Predictors of prolonged vancomycin-resistant enterococci colonization in acute stroke patients admitted to an intensive care unit: A retrospective cohort study

To investigate the factors affecting the duration of vancomycin-resistant enterococci (VRE) colonization in stroke patients.A total of 52 stroke patients with VRE colonization were enrolled. We divided the groups into several factors and confirmed whether each factor affected VRE colonization. Independent t test, bivariate correlation analysis, and Cox proportional hazards model were used to confirm statistical significance.Among 52 patients, 28 were ischemic stroke and 24 were hemorrhagic stroke. The mean duration of the VRE colonization was 39.08 ± 44.22 days. The mean duration of VRE colonization of the ischemic stroke patients was 25.57 ± 30.23 days and the hemorrhagic stroke patients was 54.83 ± 52.75 days. The mean intensive care unit (ICU) care period was 15.23 ± 21.98 days. Independent sample t test showed the hemorrhagic stroke (P < .05), use of antibiotics (P < .01), oral feeding (P < .01) were associated with duration of VRE colonization. Bivariate correlation analysis showed duration of ICU care (P < .001) was associated with duration of VRE colonization. Cox proportional hazard model showed oral feeding (P = .001), use of antibiotics (P = .003), and duration of ICU care (P = .001) as independent factors of duration of VRE colonization.Careful attention should be given to oral feeding, duration of ICU care, and use of antibiotics in stroke patients, especially hemorrhagic stroke patients, for intensive rehabilitation at the appropriate time.     

The Risk of Septicemia in End-Stage Renal Disease With and Without Renal Transplantation: A Propensity-Matched Cohort Study

End-stage renal disease (ESRD) is a well-known risk factor for septicemia. Renal transplantation (RTx) is the treatment of choice for ESRD. However, RTx recipients should undergo long-term immunosuppressive therapy. The aim of this study was to evaluate the risk of septicemia in ESRD patients with and without RTx.This cohort study used the National Health Insurance (NHI) data of Taiwan from 2000 to 2010. The RTx group consisted of 3286 RTx recipients. The non-RTx comparison group also consisted of 3286 subjects with ESRD matched by propensity scores for age, sex, index date, comorbidities, and medications. The subjects were followed until the end of 2011 to evaluate the septicemia risk.The risk of septicemia was lower in the RTx group than the non-RTx group, with an adjusted hazard ratio of 0.73 [95% confidence interval (CI) = 0.64–0.84, P < 0.001]. In addition, we observed insignificantly lower intensive care unit (ICU) admission rate (35.8% vs. 39.8%) and lower 30-day all-cause mortality rate (17.2% vs. 18.5%) in the RTx group than the non-RTx group. However, the mean cost for septicemia in the RTx group was insignificantly higher than the non-RTx group (7175 vs. 6421 USD, P = 0.39).RTx recipients had a significantly reduced risk of developing septicemia compared to the propensity-matched non-RTx ESRD patients. The ICU admission and 30-day all-cause mortality rates also slightly decreased in RTx recipients but without statistical significance.     

An Elevated Percentage of Reticulated Platelet Is Associated With Increased Mortality in Septic Shock Patients

Microcirculatory changes and coagulation disturbances are thought to play a key role in sepsis. Some evidence suggests that the percentage of reticulated platelets (RP%) may be a valuable and cost-effective sepsis screening parameter. This was a prospective study in surgical patients to investigate the potential value of RP% as a predictor of mortality in septic shock patients.This was a prospective study conducted in a surgical critical care center of a Chinese tertiary care hospital. Consecutive septic shock patients were enrolled at admission. Age- and sex-matched non-septic patients were recruited as control patients. RP% was determined by flow cytometry in 68 septic shock patients and 68 controls.Compared with survivors, septic patients who died presented with a significantly higher RP% (P < 0.001). The area under the receiver-operating characteristic curve for the RP% association with mortality was 0.867 (95 % CI 0.780–0.953, P < 0.001). Kaplan–Meier survival curves showed that mortality risk was significantly different when patients were stratified based on RP% (P < 0.001). This association was preserved in a multi-logistic regression analysis that included clinical confounders (P < 0.014).This prospective study demonstrates that increased RP% identifies septic shock patients who have a high risk of death. RP% has the potential to act as a marker for patient stratification in future clinical trials.     

Acute reduction of erector spinae muscle cross-sectional area is associated with ICU-AW and worse prognosis in patients with mechanical ventilation in the ICU: A prospective observational study

Background:To investigate the values of erector spinae muscle cross-sectional area (ESMcsa) loss for diagnosing intensive care unit-acquired weakness (ICU-AW) and predicting the 60-day survival status in patients with mechanical ventilation.Methods:Patients who were admitted into the intensive care unit (ICU) and received invasive mechanical ventilation therapy from June 2018 to June 2020 were selected. And they were divided into an ICU-AW group and a non-ICU-AW group, which were compared based on the ESMcsa and The British Medical Research Council muscle strength score (MRC-score) on the 1st and 7th day of ICU admission. The receiver operating characteristic curve was employed to measure the values of the ESMcsa Loss and ESMcsa Loss Ratio on the 7th day in order to diagnose ICU-AW in patients with mechanical ventilation. The survival curves of the patients were plotted to analyze the ESMcsa Loss Ratio values for predicting the 60-day survival status.Results:A total of 104 patients were enrolled, they were divided into the ICU-AW group (n = 56) and the non-ICU-AW group (n = 48). The mechanical ventilation time, ICU stay time, and hospital stay time of the ICU-AW group were all significantly higher than those of the non-ICU-AW group. On the 1st day, no significant difference in the ESMcsa or MRC-score between the 2 groups of patients was observed. On the 7th day, the ESMcsa and MRC-score of the ICU-AW group were significantly lower than those of the non-ICU-AW group. The ESMcsa Loss and ESMcsa Loss Ratio were both significantly negatively correlated with the MRC-score. The ESMcsa Loss and ESMcsa Loss Ratio on the 7th day were both valuable for the prediction of ICU-AW in patients with mechanical ventilation (areas under the receiver operating characteristic curve = 0.904, 0.835, and 0.889, P < .001). The survival rate of the patients in the high- and low-ESMcsa Loss Ratio groups were 60.0% and 80.0% (P < .05).Conclusions:As suggested by the ESMcsa Loss Ratios of the patients with mechanical ventilation on the 7th day of ICU admission, it offers a desirable objective indicator for the diagnosis of ICU-AW, and provides certain values for predicting the 60-day survival status of patients with mechanical ventilation in the ICU.     

The timing of last hemodialysis influences the prognostic value of serum lactate levels in predicting mortality of end-stage renal disease patients with sepsis in the emergency department

Sepsis is a life-threatening condition, and serum lactate levels have been used to predict patient prognosis. Studies on serum lactate levels in patients undergoing regular hemodialysis who have sepsis are limited. This study aimed to determine the predictive value of serum lactate levels for sepsis-related mortality among patients who underwent last hemodialysis at three different times before admission to the emergency department (ED).This retrospective cohort study was conducted from January 2007 to December 2013 in southern Taiwan. All hemodialysis patients with sepsis, receiving antibiotics within 24 hours of sepsis confirmation, admitted for at least 3 days, and whose serum lactate levels were known were examined to determine the difference in the serum lactate levels of patients who underwent last hemodialysis within 4 hours (Groups A), in 4–12 hours (Group B), and beyond 12 hours (Group C) before visited to the ED. All the continuous variables, categorical variables and mortality were compared by using Kruskal-Wallis test or Mann-Whitney test, the χ² or Fisher exact tests, and multiple logistic regression model, respectively.A total of 490 patients were enrolled in the study, and 8.0% (39), 21.5% (84), and 74.9% (367) of the patients were in Group A, Group B and Group C, respectively; the serum lactate levels (2.91 vs 2.13 vs 2.79 mmol/L, respectively; P = .175) and 28-day in-hospital mortality (17.9% vs 14.6% vs 22.9%) showed no statistically significant difference between 3 groups. The association between serum lactate levels and 28-day in-hospital mortality was reliable in Group B (P = .002) and Group C (P < .001), but it was unreliable in Group A (P = .629).Serum lactate level has acceptable sensitivity in predicting 28-day in-hospital mortality among patients with sepsis who undergo last hemodialysis after 4 hours, but is not reliable when the last hemodialysis takes place within 4 hours.