Department Of Critical Care Medicine Research Articles

Prognostic value of SOFA score and SIRS criteria for ICU mortality in adult sepsis patients admitted to the ICU of a tertiary care Hospital of Bangladesh

Background: Sepsis is one of the most common admission-diagnosis in intensive care unit (ICU). It is associated with rapid organ dysfunction with increased mortality. Different scoring systems {e.g. Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria} are commonly used to identify and predict prognosis of sepsis in ICU at present. The objective was to determine the prognostic value of SOFA score and SIRS criteria among sepsis patients.
 Methods: This was a prospective observational study, conducted in the department of Critical Care Medicine, BIRDEM General Hospital during the period of January, 2018 to July, 2019. Consecutive sampling was conducted in patients fulfilling the selection criteria. After admission of patients with sepsis from indoor or emergency department; SOFA score and SIRS criteria were calculated using physiological and laboratory parameters recorded within 24 hours of ICU admission. Standard criteria were applied, an increase of point of e” 2 in SOFA score, and/ or SIRS criteria was regarded as sepsis. Patients who were admitted in ICU other than sepsis., known cases of acute myocardial infarction (MI), trauma victims, acute stroke, pregnancy, end stage renal disease (ESRD), decompensated chronic liver disease (CLD), who developed sepsis after admission in ICU, readmitted cases were excluded. All patients were followed up daily. Outcome was measured in terms of ICU mortality.
 Results: A total 203 patients were analyzed. About one-third (29.6%) patients belonged to age group 61-70 years (mean age: 58.25 ± 15.03 years); with slightly male predominance (52.2%). Pneumonia (56%) was the most common on admission diagnosis followed by uro-sepsis (19.7%). SOFA score showed greater discrimination (AUROC, 0.900 [95% CI, 0.860-0.941]) (p value <0.001) than SIRS criteria (AUROC,0.406 [95% CI, 0.327-0.486]).
 Conclusion: SOFA score had higher prognostic value than SIRS criteria regarding ICU mortality in sepsis.
 Birdem Med J 2021; 11(2): 84-89

The diagnostic performance of galactomannan detection in invasive pulmonary aspergillosis with severe and critically ill influenza

Objective: To analyze the diagnostic performance of serum and bronchoalveolar lavage fluid (BALF) galactomannan (GM) test in invasive pulmonary aspergillosis(IPA) with severe and critically ill influenza. Methods: A retrospective study was performed for 157 patients with severe and critically ill influenza admitted to the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University from December 2017 to April 2019.Clinical characteristics and serum and BALF GM values were collected. The patients were divided into an IPA group (n=18) and a non-IPA group (n=139). The definition of IPA modified from AspICU algorithm taken as the gold standard (The corresponding clinical manifestations, imaging manifestations and microbiological diagnostic criteria should be met simultaneously), the performance of serum and BALF GM test and their combination to IPA with influenza were analyzed respectively and receiver operating characteristic curve (ROC) was drawn. Results: A total of 157 cases were enrolled, 95 were critically ill, and the mortality of IPA with influenza was 55.6%(10/18). The APACHE Ⅱ score, PSI score, urea nitrogen, influenza severity (Percentage of critically ill influenza) and invasive ventilator in IPA group were (16±6), (110±31), 10.7 (8.4, 17.8) mmol/L, 88.9% and 66.7%, respectively, which were significantly higher than those in non-IPA group [(10±5), (83±30), 5.2 (3.6, 7.6) mmol/L, 56.8% and 24.5%, P<0.05]. All patients received serum GM test and 32 patients performed BALF GM test at the same time. When the cut-off valve of serum GM test was 0.5 μg/L, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 66.7% (12/18), 95.0% (132/139), 63.2% (12/19) and 95.7% (132/138) respectively. When the cut-off value of BALF GM test was 1.0 μg/L, the sensitivity, specificity, PPV and NPV were 80%(8/10),86.4%(19/22),72.7%(8/11)and 90.5%(19/21)respectively. The BALF GM cut-off value of 0.88 μg/L showed the highest diagnostic efficacy for IPA, for which the sensitivity and specificity were 90%(9/10) and 86.4%(19/22). The areas under the ROC curve of serum GM, BALF GM, and the combination of them were 0.81, 0.85, and 0.94 respectively. The difference was statistically significant (P<0.05) and the combined diagnosis efficiency was higher. Conclusions: Critically ill influenza patients should be alert for IPA. The sensitivity of serum GM test in the diagnosis of IPA with influenza was low, while the NPV was high. The optimum BALF GM cut-off value was 0.88 μg/L. The combination with BALF and serum GM test can improve the diagnostic performance.

In Response.

Department of Anesthesiology and Critical Care Medicine, Department of Surgery, Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, [email protected] Funding: Support was provided solely from institutional and/or departmental sources.

The prognostic value of myoglobin difference in sepsis related chronic critical illness

Objective: To investigate the predictive value of myoglobin (Mb) for the prognosis of sepsis related chronic critical illness (CCI). Methods: Retrospective study was conducted on septic patients with the length of ICU stay equal or greater than 14 days, and sepsis-related organ failure assessment (SOFA) score equal or greater than 2 on the 14th day in ICU in the First Department of Critical Care Medicine at the First Affiliated Hospital of Sun Yat-sen University from January 2017 to March 2020. Patients' clinical and laboratory data were collected on the 1st and 14th day in ICU. The survival on day 28 in ICU was recorded. According to the myoglobin levels on day 1 and day 14, all subjects were divided into myoglobin elevation group and decline group. Kaplan-Meier survival curve was used to compare the cumulative survival rate at day 28. Cox regression analysis was used to analyze the independent risk factors of mortality. Receiver operating characteristic (ROC) curve was used to analyze the prognostic value of myoglobin. Results: A total of 131 patients with sepsis related CCI were recruited, including 58 patients in the elevation group and 73 in the decline group. The Mb level in elevation group on day 1 was significantly lower than that in decline group [172.40(59.99, 430.53) μg/L vs. 413.60(184.40, 1 328.50) μg/L, Z=3.749, P=0.000], and the Mb level on day 14 was the opposite change in two groups [483.65(230.38, 1 471.75)μg/L in elevation group vs. 132.20(76.86, 274.35)μg/L in decline group, Z=5.595, P=0.000]. Kaplan-Meier survival curve analysis showed that the 28-day cumulative survival rate of the elevation group was significantly lower than that of decline group (χ²=7.051, P=0.008). Cox ratio regression analysis suggested that elevated myoglobin was an independent risk factor for 28-day mortality in septic patients with CCI (OR=2.534, 95%CI 1.212-5.295, P=0.013). ROC curve analysis suggested that the sensitivity of myoglobin elevation in predicting mortality related to CCI within 28 days was 64.5%, and the specificity was 32.0% with area under the curve(AUC) 0.661(95%CI 0.550-0.773,P=0.007) and Jorden Index was 0.325. Conclusion: Elevated myoglobin, an independent risk factor for mortality within 28 days in ICU, can predict the prognosis of sepsis related chronic critical illness.

Risk factors and diagnostic methods of intensive care unit-acquired weakness

To explore the risk factors of intensive care unit-acquired weakness (ICU-AW) and the characteristics of Medical Research Council (MRC) score and electromyogram. A case control study was conducted. Patients with mechanical ventilation ≥ 7 days and MRC score admitted to department of respiratory and critical care medicine of China-Japan Friendship Hospital from September 2018 to January 2020 were enrolled, and they were divided into ICU-AW group (MRC score < 48) and non-ICU-AW group (MRC score ≥ 48) according to MRC score. The general situation, past medical history, related risk factors, MRC score, respiratory support mode, laboratory examination results, electromyogram examination results, ICU-AW related treatment, outcome and length of ICU stay were collected, and the differences between the two groups were compared. The risk factors of ICU-AW were analyzed by binary multivariate Logistic regression, and the characteristics of MRC score and electromyogram were analyzed. A total of 60 patients were enrolled in the analysis, including 17 patients in ICU-AW group and 43 patients in non-ICU-AW group. Univariate analysis showed that there were significant differences in acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) on the first day of ICU admission and the ratio of invasive mechanical ventilation between ICU-AW group and non-ICU-AW group [APACHE II score: 21 (18, 25) vs. 18 (15, 22), SOFA score: 7 (5, 12) vs. 5 (3, 8), BNP (ng/L): 364.3 (210.1, 551.2) vs. 160.1 (66.8, 357.8), BUN (mmol/L): 9.9 (6.2, 17.0) vs. 6.0 (4.8, 9.8), invasive mechanical ventilation ratio: 88.2% vs. 46.5%, all P < 0.05]. Binary multivariate Logistic regression analysis showed no independent risk factor for ICU-AW. The average MRC score of 17 ICU-AW patients was 33±11. The limb weakness was symmetrical, and the proximal limb weakness was the main manifestation. Electromyography examination showed that the results of nerve conduction examination in ICU-AW patients mainly revealed that the amplitude of compound muscle action potential (CMAP) and sensory nerve action potentials (SNAP) were decreased, and the conduction velocity was slowed down; needle electromyography showed increased area of motor unit potential (MUP), prolonged time limit and a large number of spontaneous potentials. Prognosis evaluation showed that compared with non-ICU-AW group, patients in ICU-AW group underwent more tracheotomy (70.6% vs. 11.6%), longer length of ICU stay (days: 57±52 vs. 16±8), and more rehabilitation treatment (58.8% vs. 14.0%), and the differences were statistically significant (all P < 0.01). The occurrence of ICU-AW may be related to high APACHE II score and SOFA score, high levels of BNP and BUN on the first day of ICU admission and the proportion of invasive mechanical ventilation, but the above factors are not independent risk factors for ICU-AW. The MRC score of ICU-AW patients was characterized by symmetrical limb weakness, mainly proximal limb weakness; in electromyography examination, the nerve conduction examination results mainly showed that CMAP and SNAP amplitude were decreased, and conduction velocity was slowed down; needle electromyography examination showed increased MUP area, prolonged duration and a large number of spontaneous potentials.

Risk Factors for Enterococcal Intra-Abdominal Infections and Outcomes in Intensive Care Unit Patients

Background: To investigate the risk factors for enterococcal intra-abdominal infections (EIAIs) and the association between EIAIs and outcomes in intensive care unit (ICU) patients. Methods: We reviewed retrospectively the records of patients with intra-abdominal infections admitted to the Department of Critical Care Medicine at Nanfang Hospital, Southern Medical University, China, from January 2011 to December 2018. Patients with intra-abdominal infections were divided into enterococcal and non-enterococcal groups based on whether enterococci were isolated from intra-abdominal specimens. Results: A total of 431 patients with intra-abdominal infections were included, of whom 119 were infected with enterococci and 312 were infected with non-enterococci. Enterococci were isolated in 27.6% of patients, accounting for 24.5% (129/527) of all clinical bacterial isolates. Post-operative abdominal infection (adjusted odds ratio [OR], 2.361; p = 0.004), intestinal infection (adjusted OR, 2.703; p < 0.001), Mannheim Peritonitis Index score (MPI; adjusted OR, 1.052; p = 0.015), and use of antibiotic agents within the previous 90 days (adjusted OR, 1.880; p = 0.025) were associated with an increased risk of EIAIs. Compared with patients without enterococcal infection, ICU patients with enterococcal infection had a higher risk of failure of initial clinical therapy (49.6% vs. 24.2%; p < 0.001) and longer hospital stays (33 days [19, 48] vs. 18 days [12, 29]; p < 0.001). Enterococcal infection was associated with increased 28-day mortality, in-hospital mortality, and ICU mortality. However, no difference was found in length of ICU stay between the two groups. Additionally, there was no difference in ICU mortality, hospital mortality, or 28-day mortality in patients infected with enterococcus who did or did not receive empirical anti-enterococcal therapy. Conclusion: Post-operative abdominal infection, intestinal infection, MPI score, and use of antibiotic agents within the previous 90 days were independent risk factors for enterococcal infection. Enterococcal infection was associated with reduced short-term survival in ICU patients.

Bin Cao—a leader in respiratory medicine

When Bin Cao was called by the Chinese Ministry of Health in January 2020 to travel from Beijing to Wuhan to assist with patients severely ill with acute respiratory infection, he was not fazed. It was not the first time he had received such a request. He recalls many similar occasions, including going to Jinan and Tibet in 2009 to look after patients infected with influenza A H1N1 and travelling to Shanghai and Nanjing in 2013 to care for patients with avian influenza H7N9. “I cannot remember how many times I was called to other cities to take care of the severely ill patients, not only me, but many doctors from teaching hospitals because we have the training and skills to provide help to local physicians”, says Cao who is Vice President and Director of the Department of Pulmonary and Critical Care Medicine at the China-Japan Friendship Hospital, Beijing, China, and Vice Director of China's National Center for Respiratory Medicine.

A comparison of arterial blood glucose and peripheral blood glucose levels in critically ill patients: measurements using the arterial blood gas analyzer and the rapid glucose meter.

This study explored the differences, correlation, and consistency between blood glucose levels measured using an arterial blood gas analyzer and a rapid blood glucose meter in critically ill patients. A total of 73 critically ill patients admitted to the Department of Critical Care Medicine, from October to December 2016 were enrolled in this study. The patient's arterial blood glucose was measured by arterial blood gas analyzer, while peripheral blood glucose was measured by a rapid blood glucose meter (via the non-infusion limb). The correlation between indicators was analyzed using the linear regression model. Bland-Altman was performed to evaluate the agreement of the two methods for measuring blood glucose. P<0.05 was considered statistically significant. The blood glucose values measured using the arterial blood gas analyzer was significantly different from the values obtained using the rapid blood glucose meter (P=0.000). Regression analysis showed that R2 was 0.857 and β was 0.324 (P=0.000). Bland-Altman plot analysis showed that arterial blood glucose values obtained using the arterial blood gas analyzer were higher than the peripheral blood glucose values obtained using the rapid blood glucose meter on the non-infused limb, with 2.74% of dots lying outside the 95% limit of agreement and the maximum absolute value (2.30 mmol/L) of blood glucose difference within the limit of agreement. The blood glucose levels measured using the two different methods showed good agreement. The difference in blood glucose values measured using the two different measurement methods was statistically significant, but the maximum absolute value (2.30 mmol/L) of blood glucose difference within the limit of agreement, which is acceptable in the clinical setting. In clinical care, it is not necessary to repeat a measure of the patient's capillary blood glucose (CBG) using the rapid blood glucose meter after the blood glucose levels have been measured with the arterial blood gas analyzer, thereby reducing the associated pain and inconvenience for the patients.

Combined prognostic value of serum lactic acid, procalcitonin and severity score for short-term prognosis of septic shock patients

To explore the value of lactic acid (Lac), procalcitonin (PCT), sequential organ failure assessment (SOFA) score and acute physiology and chronic health evaluation II (APACHE II) score in assessing the severity and predicting the prognosis in sepsis shock. A retrospectively study was conducted. Patients with septic shock hospitalized in the department of critical care medicine of the Affiliated Hospital of Jining Medical University from April 2015 to June 2019 were enrrolled. The patient's gender, age, body mass index (BMI), infection site, organ dysfunction status; Lac, PCT, C-reactive protein (CRP), heart rate and body temperature immediately after admission to the intensive care unit (ICU); APACHE II and SOFA scores within 24 hours, and 28-day prognosis were collected. According to the 28-day prognosis, the patients with septic shock were divided into the survival group and the death group, and the differences in the indicators between the groups were compared. Multivariate Logistic regression analysis was used to screen the risk factors of 28-day death in patients with septic shock; receiver operating characteristic curve (ROC curve) was used to analyze the value of Lac, PCT, SOFA, APACHE II, and age in predicting the 28-day prognosis of patients with septic shock. A total of 303 septic shock patients were enrolled, of which 124 cases survived and 179 died on the 28th day, and the 28-day mortality was 59.08%. (1) Compared with the survival group, patients in the death group were older (years old: 66.58±15.22 vs. 61.15±15.68), APACHE II, SOFA, proportion of lung infections, Lac increased [APACHE II score: 22.79±7.62 vs. 17.98±6.88, SOFA score: 9.42±3.51 vs. 5.65±1.59, proportion of lung infections: 53.63% (96/179) vs. 39.52% (49/124), Lac (mmol/L): 5.10±3.72 vs. 3.71±2.56], oxygenation index (PaO2/FiO2) and ICU body temperature decreased [PaO2/FiO2 (mmHg, 1 mmHg = 0.133 kPa): 198.94±80.15 vs. 220.68±72.06, ICU body temperature (centigrade): 37.47±1.08 vs. 37.80±1.14], and the differences were statistically significant (all P < 0.05). (2) Multivariate Logistic regression analysis results: after adjusted for potential confounding factors, APACHE II, PCT, Lac, age and SOFA were independent risk factors for death in patients with septic shock [APACHE II: odds ratio (OR) =1.05, 95% confidence interval (95%CI) was 1.01-1.10, P = 0.039; PCT: OR = 0.99, 95%CI was 0.98-1.00, P =0.012; Lac: OR = 1.23, 95%CI was 1.08-1.40, P = 0.002; age: OR = 1.03, 95%CI was 1.01-1.05, P = 0.009; SOFA score: OR =1.88, 95%CI was 1.59-2.22, P < 0.001]. (3) ROC curve analysis showed that APACHE II, Lac, age and SOFA could predict the prognosis of patients with septic shock [APACHE II: the area under the ROC curve (AUC) = 0.682 4, 95%CI was 0.621 7-0.743 1, P = 0.000; when the best cut-off value was 18.500, its sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 72.63%, 54.84%, 69.89%, 58.12%, 1.608 1 and 0.499 2, respectively. Lac: AUC = 0.604 5, 95%CI was 0.540 8-0.668 2, P = 0.002; when the best cut-off value was 3.550 mmol/L, the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 50.84%, 73.39%, 73.39%, 50.94%, 1.910 3 and 0.669 9, respectively. Age: AUC = 0.599 1, 95%CI was 0.535 4-0.662 7, P = 0.003; when the best cut-off value was 72.500 years old, the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 42.46%, 75.00%, 71.03%, 47.45%, 1.698 3 and 0.767 2, respectively. SOFA: AUC = 0.822 3, 95%CI was 0.776 7-0.867 9, P = 0.000; when the best cut-off value was 7.500, its sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 68.72%, 87.90%, 89.13%, 66.06%, 5.680 4, 0.355 9 respectively]. The combined prediction had a good sensitivity (72.63%) and specificity (84.86%), and AUC (0.876 5) was higher than that of a single variable, suggested that the multivariate combination was more accurate in predicting the short-term outcome of septic shock. Lac, PCT, SOFA score, APACHE II score and age were independent risk factors for death in patients with septic shock, and the accuracy of Lac, SOFA score, APACHE II score and age in predicting short-term prognosis of septic shock was better than that of single variable, and the diagnostic value was higher.

Clinical characteristics of pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare disease with non-specific and various clinical manifestations, often leading to misdiagnosis. This study aims to raise the awareness of this disease via summarizing the clinical characteristics, diagnosis, and therapy of PAP. We retrospectively analyzed clinical data of 25 hospitalized cases of PAP during 2008 and 2019 in the Department of Respiratory and Critical Care Medicine of the Second Xiangya Hospital of Central South University. Cough with unkown reason and dyspnea were common clinical manifastations of PAP. Five patients had a history of occupational inhalational exposure. Sixteen patients had typical image features including ground-glass opacification of alveolar spaces and thickening of the interlobular and intralobular septa, in typical shapes called crazy-paving and geographic pattern. Fourteen patients underwent pulmonary function tests, revealing a reduction in the diffusing capacity for carbon monoxide. The positive rate of transbronchial biopsy was 95%. Five patients received the whole lung lavage and the symptoms and imaging fcauters significantly relieved after five-years follow-up. PAP is characterized by radiographic pattern and pathology. Transbronchial lung biopsy is effective to make diagnosis of PAP. The whole lung lavage remains a efficient therapy.

Plasma mitochondrial DNA levels are associated with acute lung injury and mortality in septic patients

BackgroundMitochondrial DNA (mtDNA) is a critical activator of inflammation. Circulating mtDNA released causes lung injury in experimental models. We hypothesized that elevated plasma mtDNA levels are associated with acute lung injury (ALI) in septic patients.MethodsWe enrolled 66 patients with sepsis admitted to the Department of Critical Care Medicine of Peking Union Medical College Hospital between January 2019 and October 2019. Respiratory, hemodynamic and bedside echocardiographic parameters were recorded. Plasma mtDNA, procalcitonin, interleukin 6, and interleukin 8 levels were examined.ResultsPlasma mtDNA levels within 24 h after admission were significantly increased in the group of septic patients with ALI [5.01 (3.38–6.64) vs 4.13 (3.20–5.07) log copies/µL, p 0.0172]. mtDNA levels were independently associated with mortality (hazard ratio, 3.2052; 95% CI 1.1608–8.8500; p 0.0253) and ALI risk (odds ratio 2.7506; 95% CI 1.1647–6.4959; p 0.0210). Patients with high mtDNA levels had worse outcomes, and post hoc tests showed significant differences in 28-day survival rates. Increased mtDNA levels were seen in patients with abdominal infection.ConclusionsIncreased plasma mtDNA levels within 24 h after admission were significantly associated with ALI incidence and mortality in septic patients.

Prognostic Significance of Plasma Hepatocyte Growth Factor in Sepsis.

To assess any correlation of plasma hepatocyte growth factor (HGF) levels with relevant endothelial cell injury parameters and determine the prognostic value in septic patients. A prospective, observational study was conducted in patients with sepsis admitted to the Department of Critical Care Medicine at the Zhongda Hospital from November 2017 to March 2018. Plasma HGF levels were measured by enzyme-linked immunosorbent assay in the first 24 h after admission (day 1) and on day 3. The primary endpoint was defined as all-cause 28-day mortality. Furthermore, we analyzed the correlation of HGF with relevant endothelial cell injury markers. Eighty-six patients admitted with sepsis were included. HGF levels of nonsurvivors were elevated compared to those of survivors on day 1 (1940.62 ± 74.66 pg/mL vs. 1635.61 ± 47.49 pg/mL; P = 0.002) and day 3 (1824.82 ± 137.52 pg/mL vs. 1309.77 ± 83.49 pg/mL; P = 0.001) and showed a strong correlation with von Willebrand factor (r = 0.45, P < 0.0001), lactate (r = 0.35, P = 0.0011), pulmonary vascular permeability index (r = 0.38, P = 0.0241), first 24 h fluid administration (r = 0.38, P < 0.0001), and sequential organ failure assessment score (r = 0.40, P = 0.0001). Plasma HGF levels were able to prognostically discriminate between survivors and nonsurvivors on day 1 (AUC: 0.72, 95%CI: 0.60-0.84) and day 3 (AUC: 0.77, 95%CI: 0.63-0.91). HGF levels are associated with sepsis and correlated with established markers of endothelial cell injury. Elevated HGF levels in sepsis patients are an efficient indicator of poor prognosis. The study was registered in Clinical Trial (Registration Number: NCT02883231).

Expression of Inflammatory Factors in Critically Ill Patients with Urosepticemia and the Imaging Analysis of the Severity of the Disease.

Urine sepsis is a complex inflammatory response of the body to infection with a high fatality rate. It is one of the main causes of death in noncardiovascular intensive care units. Nevertheless, in daily clinical practice, early sepsis is often not detected. In this paper, discharged cases of urinary sepsis from the Department of Urology and Critical Care Medicine of a university hospital were collected as the observation group, and common urinary tract infection cases were selected as the control group. We sorted and summarized the discharged case information of the observation group and the control group. The results of the study showed that, after renal pelvis perfusion, the expression of HMGB1 protein and mRNA increased, and the expression of TLR4 increased; inhibiting HMGB1 can reduce the expression of inflammatory factors caused by perfusion and reduce the infiltration of neutrophils and macrophages caused by perfusion. In addition, r HMGB1 treatment can promote the expression of inflammatory factors caused by perfusion and aggravate the infiltration of neutrophils and macrophages caused by perfusion. We found that inhibition of HMGB1 can inhibit the expression of TLR4/My D88 signaling molecules and r HMGB1 treatment can enhance the expression of TLR4/My D88 signaling molecules.

The Clinical Characteristics of Patients With Nonneutropenic Invasive Pulmonary Aspergillosis.

Objective: The goal of this study was to reveal the clinical manifestations of nonneutropenic invasive pulmonary aspergillosis (IPA), which are different from those of neutropenic patients.Methods: The clinical data of patients with nonneutropenic IPA were collected at the Department of Respiratory and Critical Care Medicine, Jinling Hospital, from February 2009 to November 2019. We analyzed the general conditions, clinical manifestations, imaging findings, and laboratory tests of these IPA patients.Results: A total of 116 patients with nonneutropenic IPA (31 proven and 85 probable) were included. They had an average age of 59.8 years. The most common underlying disease was chronic obstructive pulmonary disease (COPD, n = 33). The common clinical symptoms included cough (93.1%, n = 108), expectoration (59.5%, n = 69), fever (57.8%, n = 67), hemoptysis (30.2%, n = 35), and dyspnea (40.5%, n = 47). The common CT imaging manifestations included consolidation (47.4%, n = 55), cavities (47.4%, n = 55), air crescent sign (14.7%, n = 17), and nodules (8.6%, n = 10). Multiple lesions (74.1%, n = 86) were more common than single lesions (17.2%, n = 20) and diffuse lesions (8.6%, n = 10). The positive rate of laboratory tests was 88.2% (30/34) for BALF galactomannan (GM), 55.4% (56/101) for serum GM, 45.3% (48/106) for 1,3-β-D-glucan (BDG), 43.3% (46/106) for sputum culture, and 36.4% (20/55) for BALF culture. Patients who had high serum GM level [GM optical density index (ODI) >1] were more likely to have severe respiratory symptoms and higher serum ferritin. Further investigation showed that there was a positive correlation between serum GM level and serum ferritin level.Conclusion: The clinical symptoms and radiological manifestations of nonneutropenic IPA are diverse and often lead to delayed diagnosis. It is important to become more vigilant of aspergillosis in nonneutropenic patients in order to achieve early diagnosis and treatment and to reduce mortality.

Analysis of correlation between fecal and alveolar lavage fluid flora of ventilator-associated pneumonia patients based on 16S rRNA sequencing technology

To investigate the changes and correlation of intestinal and pulmonary microecological structures in patients with ventilator-associated pneumonia (VAP). A prospective observational study was conducted. Thirty-one patients with VAP admitted to the department of critical care medicine of General Hospital of Ningxia Medical University from May 1st 2019 to May 1st 2020 were enrolled. Feces and alveolar lavage fluid samples from patients with the same day, feces and alveolar lavage specimen flora composition and the structure of biological information analysis by 16S rRNA sequencing technologies, the comprehensive sequencing results, and clinical data of patients were analyzed. (1) The diversity (abundance and diversity) of flora in the alveolar lavage fluid of VAP patients was higher than that of fecal flora. Among them, Ace index, Chao index and Shannon index describing the abundance of flora showed statistically significant differences [Ace index: 305.89 (214.39, 458.66) vs. 204.51 (165.15, 247.61), Chao index: 259.83 (194.20, 459.31) vs. 187.67 (153.28, 234.01), Shannon index: 3.01 (2.39, 3.54) vs. 2.55 (1.86, 2.95), all P < 0.05], but there was no significant difference in Simpson index describing diversity [0.14 (0.08, 0.27) vs. 0.19 (0.10, 0.33), P > 0.05]. (2) In the sequencing results of feces and alveolar lavage fluid of VAP patients, there were some intestinal related bacteria groups with high abundance, such as Escherichia-Shigella, Faecalibacterium, Bacteroides, and Lachnospira, etc. (3) In 31 VAP patients, suspicious pathogenic bacteria was found in 20 cases (6 cases of Streptococcus viridans, 5 cases of Escherichia coli, 3 cases of Klebsiella pneumoniae, 3 cases of Acinetobacter baumannii, 2 cases of Staphylococcus aureus, 1 case of Pseudomonas aeruginosa), and the same suspected pathogens also existed in the 17 patients' alveolar lavage and waste sequencing. (4) Fourteen VAP patients combined with sepsis, 14 patients without sepsis were selected for sample size matching. The results showed that, Jaccard similarity index to describe lung-correlation of intestinal flora in VAP with sepsis group was significantly elevated, and the difference was statistically significant (0.24±0.08 vs. 0.19±0.06, P < 0.01). There is a certain correlation between pulmonary and intestinal flora in VAP patients. In addition to the exclusion of pulmonary infection caused by environmental and upper respiratory micro-inhalation, the lower digestive tract may also be source of infection.

Study on the value of mitochondrial associated protein fumarylacetoacetate domain containing protein 1 and growth differentiation factor-15 in the diagnosis of sepsis: test results from the patients of a multicenter study

To investigate the diagnostic value of mitochondrial associated protein fumarylacetoacetate domain containing protein 1 (FAHD1) and growth differentiation factor-15 (GDF-15) in sepsis. Based on the database of the whole process of sepsis early warning, diagnosis and treatment management, which was established on the study of sepsis early warning and standardized diagnosis and treatment system, adult patients with suspected infection admitted to the department of critical care medicine of Zhejiang Hospital, Second Affiliated Hospital of Zhejiang University, the First Affiliated Hospital of Sun Yat-Sen University, West China Hospital of Sichuan University, Ningbo First Hospital from May 2014 to October 2015 were enrolled. The basic vital signs, and the main blood routine results, liver and kidney function, blood gas, acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) score at the time of diagnosis of patients with or without sepsis were analyzed. The preserved serum samples were taken, the levels of procalcitonin (PCT), C-reactive protein (CRP) were detected by electrochemiluminescence method, immunoturbidimetry respectively, and FAHD1 and GDF-15 were detected by enzyme linked immunosorbent assay (ELISA). Univariate and multivariate Logistic regression were used to analyze the risk factors for sepsis diagnose. The indexes' diagnostic efficacy in sepsis were analyzed by receiver operating characteristics curve (ROC curve). A total of 132 patients were enrolled, including 76 cases of sepsis and 56 cases of non-sepsis. Compared with the non-sepsis group, the heart rate in the sepsis group was increased (bpm: 116.4±17.8 vs. 97.4±19.1), while the mean arterial pressure (MAP), platelet count (PLT), arterial partial pressure of oxygen (PaO2) were significantly decreased [MAP (mmHg, 1 mmHg = 0.133 kPa): 65.8±9.7 vs. 74.7±10.3, PLT (×109/L): 120 (69, 204) vs. 163 (117, 239), PaO2 (mmHg): 83.0 (66.6, 108.0) vs. 108.0 (84.4, 130.0), all P < 0.05], direct bilirubin (DBil), serum creatinine (SCr), lactic acid (Lac), APACHE II score and SOFA score were significantly increased [DBil (μmol/L): 13.00 (5.55, 55.31) vs. 6.20 (2.20, 21.90), SCr (μmol/L): 118.00 (70.00, 191.73) vs. 77.20 (59.65, 110.86), Lac (mmol/L): 2.90 (1.50, 4.10) vs. 1.90 (1.20, 2.80), APACHE II score: 20.0 (16.0, 25.0) vs. 16.0 (10.0, 21.0), SOFA score: 12.0 (8.0, 16.0) vs. 8.0 (5.0, 13.0), all P < 0.05]. In addition, the serum levels of FAHD1, GDF-15, PCT and CRP in sepsis group were significantly higher than those in non-sepsis group [FAHD1 (μg/L): 3.96 (2.25, 5.92) vs. 2.47 (1.03, 3.54), GDF-15 (μg/L): 8.46 (4.37, 19.68) vs. 4.32 (1.74, 10.39), PCT (μg/L): 3.79 (1.37, 11.32) vs. 0.42 (0.12, 2.14), CRP (mg/L): 154.43 (61.33, 283.20) vs. 65.95 (28.15, 144.69), all P < 0.01]. Multivariate Logistic regression showed that serum FAHD1 [odds ratio (OR) = 1.135, 95% confidence interval (95%CI) was 1.045-1.234], GDF-15 (OR = 1.090, 95%CI was 1.029-1.155) and CRP (OR = 1.007, 95%CI was 1.002-1.011) were risk factors for sepsis (all P < 0.05). ROC curve analysis of sepsis showed that the areas under ROC curve (AUC) of serum mitochondrial associated proteins FAHD1 and GDF-15 were 0.727 (95%CI was 0.641-0.802) and 0.677 (95%CI was 0.588-0.757), respectively; and the AUC of classical infection indexes PCT and CRP were 0.767 (95%CI was 0.683-0.837) and 0.680 (95%CI was 0.59-0.760), respectively. There was no significant difference between the AUC of mitochondrial associated proteins and classical infection indexes. The combination of FAHD1, GDF-15, PCT and CRP had the largest AUC, which was 0.809 (95%CI was 0.730-0.874), and the sensitivity was 75.00%, and the specificity was 80.00%. Mitochondrial associated protein FAHD1 and GDF-15 are associated with sepsis, and the diagnostic efficiency is improved when combined with PCT and CRP, which might provide experimental basis for screening diagnostic markers of sepsis.

Metagenomic next-generation sequencing of radial ultrasound bronchoscopy-guided "cocktail" specimens as an efficient method for the diagnosis of focal pulmonary infections: a randomised study.

To investigate the value of metagenomic next-generation sequencing (mNGS) in the diagnosis of focal pulmonary infections by using radial ultrasound bronchoscopic "cocktail" specimens. From March 2019 to May 2020, 90 patients with focal pulmonary infections [locatable by a radial probe endobronchial ultrasound (RP-EBUS)] treated by the Department of Respiratory and Critical Care Medicine at the Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (Suzhou, China) were randomly allocated to the "cocktail" group, transbronchial brushing (TBBr) group or bronchoalveolar lavage fluid (BALF) group; 30 patients were assigned to each group. Using the extracted material, the diagnostic efficacy of the mNGS test for pathogen detection was compared across the three groups, and the effect of an antibiotic treatment on detection rate was assessed. The sensitivity of mNGS analysis in cocktail group, TBBr group and BALF group was 90% (27/30), 66.7 (20/30) and 50% (15/30), respectively. The analysis of the sensitivity of the positive test, the detection rate of multiple pathogens, and the effect of antibiotics on the detection rate by mMGS indicated that the "cocktail" group was significantly higher number of samples positive for pathogens than the TBBr group (P<0.05), and the TBBr group was significantly higher number of samples positive for pathogens than the BALF group (P<0.05). "Cocktail" specimens had high sensitivity in the identification of focal pathogens, and the use of antibiotics had little effect on the results of the mNGS analysis. These clinically valuable results can be used in the diagnosis and treatment of patients with focal pulmonary infections.

D-dimer Level is Correlated with Prognosis, Infarct Size, and NIHSS in Acute Ischemic Stroke Patients.

Stroke ranks the fourth leading disease causing adult mortality and disability. D-dimer (D-D) is the ultimate product of plasmin-mediated degradation of fibrin-rich thrombi. D-D is a simple readily accessible biomarker employed within the diagnostic algorithms for the exclusion of venous thromboembolism. The correlation between D-D infarct size in MRI brain, APACHE II score, and the National Institute of Health Stroke Scale (NIHSS) score in critically ill acute stroke patients has not been fully investigated before.ObjectiveWe aimed to investigate the diagnostic and prognostic value of elevated plasma D-D in critically ill patients admitted with acute cerebrovascular accidents. As far as we know, we are the first to investigate the correlation between plasma D-D levels and the ischemic lesion size in MRI brain and also APACHE II score and NIHSS in critically ill acute ischemic cerebrovascular patients.Setting and participantsA prospective, observational cohort study inside the Critical Care Medicine Department. Thirty patients with AIS were enrolled additionally to 1 healthy age- and sex-matched controls.InterventionsWe employed particle-enhanced, immunoturbidimetric assay to detect plasma D-D concentrations. D-D levels D0 and D1 were measured upon admission and 24 hours later, respectively. We reviewed the patient' s health records; additionally, demographic, clinical, laboratory, and neuroimaging information was abstracted.ResultsD-D concentrations were significantly higher in acute stroke patients compared to healthy controls. ROC curve analysis showed that elevated D-D level more than 310 ng/mL can predict infarct lesion size >1.5 cm in diffusion-weighted MRI brain with sensitivity and specificity (100 and 83%, respectively) and also admission D-D (D0) at cutoff concentration 350 ng/mL and D1 at cutoff value 370 ng/mL are predictors of complicated course with sensitivity and specificity (100 and 84.6%, respectively). There was no significant difference between D0 and D1 D-D levels (p-value >0.05).ConclusionThe plasma D-D biomarker can be a simple readily available test reliable predictor of infarct lesion size >1.5 cm in DW-MRI and outcome in union with the common practice instrumental tests.How to cite this articleAbbas NI, Sayed O, Samir S, Abeed N. D-dimer Level is Correlated with Prognosis, Infarct Size, and NIHSS in Acute Ischemic Stroke Patients. Indian J Crit Care Med 2021;25(2):193–198.

Analysis of prevalence and prognosis of type 2 diabetes mellitus in patients with acute exacerbation of COPD

BackgroundFor patients with acute exacerbation of COPD (AECOPD), type 2 diabetes mellitus (T2DM) as comorbidity have poor outcomes. However, data on the impact of previously diagnosed and new- diagnosed T2DM in such a patient population is lacking.MethodsInpatients diagnosed with AECOPD in the department of Pulmonary and Critical Care Medicine of The First Hospital of China Medical University during 2011–2017 were enrolled. Data on demography, prevalence of type 2 DM, other comorbidities, hospital stays and laboratory tests (including arterial partial pressure of oxygen [PaO2]) results were recorded. Results were compared with AECOPD patients having previously diagnosed and new-diagnosed type 2 diabetes. Markers associated with development of type 2 DM and the prognosis of AECOPD patients were identified.ResultsOf the 196 patients enrolled in this study, the overall prevalence of T2DM was 26%. The PaO2 in the newly diagnosed T2DM group was considerably lower versus non-diabetic group. The T2DM group had a longer hospital stay and higher troponin level versus the non-diabetic group. AECOPD patients with T2DM were found to be correlated with hypertension. Age, need for assisted ventilation, increased troponin, and elevated fasting blood glucose on admission were risk factors for death in hospitalized AECOPD patients.ConclusionsAECOPD patients had a higher prevalence of T2DM than the general population; T2DM comorbidity caused lower PaO2, longer hospital stays, and increased troponin. Poor blood glucose control may increase the risk of death in AECOPD patients.

Editorial introductions

Editorial introductions