Early Intensive Care Research Articles

66 Survival and school-age outcomes of extremely premature neonates with intraventricular hemorrhage

Abstract Background Extremely low gestational age (ELGA) neonates are at risk for intraventricular hemorrhage (IVH) and periventricular hemorrhagic infarction (PVHI). There is no clear consensus on the prognosis of these conditions. Objectives The aim of this study was to compare the survival, and the neurodevelopmental outcomes (NDO) at school-age for neonates with IVH and/or PVHI, to those without. Design/Methods This retrospective single-center study (2012-2017) included neonates less than 26 weeks gestational age (GA) who received resuscitation and early intensive care. Imaging data were collected from cranial US for the presence of IVH described by Papile grading. Survival was defined as survival to discharge. NDO were classified as no neurodevelopmental impairment (NDI), no NDI with multidisciplinary referrals, and the adverse outcome was defined as NDI at school-age. NDI included any diagnosis of cerebral palsy, global developmental delay, intellectual disability, visual or hearing impairment. Autism spectrum disorder (ASD) was included as an outcome of interest. Results 164 infants met inclusion criteria, of whom 156 survived resuscitation. Mean GA was 24 weeks and 6 days (SD 6 days) and mean birth weight 701g (SD 125g), grade I-II IVH was present in 43 (28%) infants, and grade III-IV IVH was present in 48 (31%) infants. Survival was 45% for those with bilateral grade III-IV IVH, 53% for unilateral grade III-IV IVH, 78% for bilateral grade I-II IVH, 80% for unilateral grade I-II IVH, and 81% for no IVH groups. 108 infants survived to discharge and 90 had complete follow up at school age. 30% of children had NDI and ASD was diagnosed in 12%. Logistic regression for adverse outcome demonstrated an adjusted odds-ratio (OR) 0.30 (95% CI 0.14, 0.56) for gestational age (p <0.001). The logistic regression resulted in adjusted OR 0.72 (95% CI 0.21, 2.37) for grade I-II IVH and OR 1.43 (95% CI 0.4, 5.03) for Grade III-IV IVH (p=0.63). Conclusion In neonates born ELGA, survival decreased with increasing severity of IVH. Decreasing GA, but not severity of IVH, was predictive of neurodevelopmental impairment. Extremely preterm infants born < 26 weeks are at high risk of NDI and of ASD.

Potential and place of efferent therapy in patients with myocardial infarction complicated by cardiogenic shock

Myocardial infarction complicated by cardiogenic shock (MI CS) is the terminal stage of the cardiovascular disease continuum, leading to the death of every second patient in its severe course. Over the past decades, there are no improvement in inhospital mortality rates for MI CS, despite the widespread introduction of early and effective revascularization methods and intensive care techniques. Recently, more and more data have emerged on the significant contribution of the systemic inflammatory response (SIR) to the pathogenesis of acute coronary syndrome and its complications. The characteristics and impact of SIR in MI CS on its course and outcome have not been sufficiently studied. One of the strategies to influence the SIR course, along with the use of anti-inflammatory therapy, is efferent treatment. However, despite all the above-mentioned fundamental prerequisites for the use of an extracorporeal therapy in CS patients, the introduction of these techniques into clinical guidelines and practice requires exploratory and multicenter randomized studies. This review article summarizes modern ideas and characterizes the existing possibilities of using efferent therapy in MI CS.

Impact of early refined nursing program on prognosis of middle-aged and elderly patients with cognitive dysfunction combined with cerebral infarction.

Cerebral infarction is a local or extensive necrosis of brain tissue. Subsequently, the corresponding neurological deficits appear. The incidence of cerebrovascular diseases in China is increasing gradually. After the onset of cerebrovascular disease, the most common sequelae include movement disorders, language disorders, and cognitive dysfunction. To investigate the effect of early refined nursing program on the prognosis of middle-aged and elderly patients with cerebral infarction combined with cognitive dysfunction. A retrospective study was conducted to divide 60 patients with cerebral infarction and cognitive impairment into an experimental group (n = 32) and a control group (n = 28). The experimental group received early intensive care every day, and the control group received daily routine care. The scores of the Mini-Mental State Examination (MMSE) and the Trail Making Test (TMT), as well as the latency and amplitude of the event-related potential P300, were used as main indicators to evaluate changes in cognitive function, and changes in BDNF, TGF-β, and GDNF expression were used as secondary indicators. Both groups experienced notable enhancements in MMSE scores, with the experimental group demonstrating higher scores than the control group (experimental: 28.75 ± 2.31; control: 25.84 ± 2.87). Moreover, reductions in TMT-A and TMT-B scores were observed in both groups (experimental: TMT-A 52.36 ± 6.18, TMT-B 98.47 ± 10.23; control: TMT-A 61.48 ± 7.92, TMT-B 112.63 ± 12.55), with the experimental group displaying lower scores. P300 Latency decreased (experimental: 270.63 ms ± 14.28 ms; control: 285.72 ms ± 16.45 ms), while amplitude increased (experimental: 7.82 μV ± 1.05 μV; control: 6.35 μV ± 0.98 μV) significantly in both groups, with superior outcomes in the experimental cohort. Additionally, the levels of the growth factors BDNF, TGF-β1, and GDNF surged (experimental: BDNF 48.37 ng/mL ± 5.62 ng/mL, TGF-β1 52.14 pg/mL ± 4.28 pg/mL, GDNF 34.76 ng/mL ± 3.89 ng/mL; control: BDNF 42.58 ng/mL ± 4.73 ng/mL, TGF-β1 46.23 pg/mL ± 3.94 pg/mL, GDNF 30.25 ng/mL ± 2.98 ng/mL) in both groups, with higher levels in the experimental group. For middle-aged and elderly patients with cerebral infarction and cognitive dysfunction, early refined nursing can significantly improve their cognitive function and prognosis.

Association Between Early Hyperoxemia Exposure and Intensive Care Unit Mortality in Intracerebral Hemorrhage: An Observational Cohort Analysis.

Supraphysiologic levels of oxygen could have potential adverse effects on the brain that may be dose and time dependent in patients with brain injury. We therefore aimed to assess whether exposure to excess supplemental oxygen, measured as time-weighted mean exposure to hyperoxemia, was associated with intensive care unit (ICU) mortality in patients with intracerebral hemorrhage (ICH). In this single-center retrospective cohort study, we included all patients admitted to our ICU with a diagnosis of primary spontaneous ICH. To provide a longitudinal measure of hyperoxemia exposure, we calculated the hyperoxemia dose, defined as the area under the partial pressure of oxygen in arterial blood (PaO2) time curve above the threshold PaO2 value of 100mm Hg (13.3kPa) divided by the number of hours of potential exposure. To provide consistent potential exposure windows and limit bias from informative censoring, nested subsets were created with progressively longer exposure periods (0-1day, 0-2days, 0-3days, 0-4days, 0-5days, 0-6days, 0-7days). We used multivariable Cox regression, with hyperoxemia dose as a time-dependent covariate, to model ICU mortality. Admission ICH and Acute Physiology and Chronic Health Evaluation II scores were included as predictor covariables. A step-function extended Cox model was also fitted. Between September 2019 and July 2022, 275 patients met the inclusion criteria, with 24,588 arterial blood gas results available for analysis. The mean age was 57.19years (± 13.99), 59.64% were male, 23.64% had an infratentorial origin of hemorrhage, and ICU mortality was 35.64%. Almost all patients (97.45%) were exposed to hyperoxemia during their ICU admission. Cox regression modeling showed an association between hyperoxemia dose and ICU mortality (hazard ratio 1.15, confidence interval 1.05-1.25, p = 0.003). This association was observed in the 0-1day subset in the step-function extended Cox model (hazard ratio 1.19, confidence interval 1.06-1.35, p = 0.005) but not in any of the subsequent exposure periods. In patients with ICH admitted to the ICU, we observed an association between hyperoxemia dose and ICU mortality. Further prospective study is required to inform guidance on early systemic oxygen targets in ICH.

Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center.

Sepsis is a major global health affecting millions worldwide, hence understanding its contributing factors becomes paramount. This cross-sectional study at a tertiary care center explores the relationship between iron profile, vitamin D levels, and outcomes in sepsis and septic shock patients. The primary objective was to explore the prevalence of iron profile and vitamin D parameters during early intensive care unit (ICU) admission and their association with 28-day mortality. Spanning 18 months, the study enrolled adult patients meeting sepsis or septic shock criteria at the ICU. Data collection included demographic information, clinical characteristics, and blood samples for iron profile and vitamin D levels at admission. Disease severity was assessed using sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scores, and treatment was administered as per surviving sepsis-3 guidelines. The research involved 142 participants, uncovering prevalent organisms such as Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Noteworthy connections to mortality were identified for factors including vasopressor support, ICU stay duration, SOFA score, and APACHE-II score. Interestingly, age, gender, and vitamin D levels showed no significant associations. However, the study did reveal a significant association between iron, ferritin, and transferrin saturation levels with increased 28-day mortality. Our study concluded that low Iron, elevated ferritin, and decreased transferrin saturation levels maintained associations with the outcome of interest. While no such relationship was established with vitamin D levels. These results suggest potential implications for patient management and prognosis, warranting further exploration in future research. Bairwa M, Jatteppanavar B, Kant R, Singh M, Choudhury A. Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center. Indian J Crit Care Med 2024;28(6):569-574.

Associations between serum 25-hydroxyvitamin D and prognosis of chronic kidney disease: a prospective cohort study.

25-hydroxyvitamin D [25(OH)D] deficiency is prevalent in patients with chronic kidney disease (CKD), the associations between serum 25(OH)D levels and mortality in patients with CKD remain unclear, and this study aimed to explore these associations further. 4989 participants with CKD were enrolled in the study, and the Cox regression model was used to assess the effects of serum 25(OH)D concentrations on mortality risk. A restricted cubic spline model was used to explore the dose-response relationships, and threshold effect analysis was performed based on inflection points identified by a two-piecewise linear regression model. In addition, subgroup and sensitivity analyses were employed. 1255 participants died during a mean follow-up period of 70months. Compared with the 25(OH)D-deficient group, the fully adjusted hazard ratios and 95% confidence intervals for the 25(OH)D-adequate group were 0.631 (0.545, 0.730) for all-cause mortality, 0.569 (0.435, 0.743) for cardiovascular mortality, 0.637 (0.461, 0.878) for hypertension mortality, and cancer mortality was 0.596 (0.426, 0.834). The inflection points of serum 25(OH)D concentration affecting all-cause and cardiovascular mortality were 89nmol/L, and 107nmol/L, respectively. Subgroup analyses and interaction tests suggested that the effects varied across populations. The results of sensitivity analyses indicated a reliable correlation. We found an association between serum 25(OH)D concentrations and the prognosis of patients with CKD as a reliable predictor of early intervention and intensive care.

Effect of maternal pre-pregnancy body mass index and gestational weight gain on birth weight and gestational age: An observational cross-sectional study

Background: Studies show that pre-pregnancy body mass index (ppBMI) and gestational weight gain (GWG) are associated with birth weight (BW), gestational age (GA), and neonatal morbidities. Higher BW leads to metabolic syndrome. Preterm and low BW (LBW) have short and long-term morbidities. Monitoring ppBMI and GWG is necessary as these are modifiable risk factors for obesity. In this study, we revisited these findings in an Indian scenario. Aims and Objectives: The primary objective is to study the association of BW and GA with ppBMI and GWG. The secondary objective is to study the association of ppBMI and GWG with cesarean section (CS), infant size, and early neonatal intensive care unit (NICU) requirement. Materials and Methods: This observational cross-sectional study was conducted over 1 year with 230 mothers, after Institutional Ethics Committee approval and informed consent. Data were collected using predesigned pro forma and analyzed by SPSS. Digital weighing scales, stadiometer, and fenton growth charts were used. Results: We found a positive linear correlation of ppBMI and GWG with BW. Obesity and excess GWG were associated with higher BW, large for GA, CS, and NICU stay. Overweight had more CS. Underweight and less GWG had a greater risk of LBW, preterm, and NICU stay. Less GWG had more small for GA. Conclusion: GWG and ppBMI are determinants of BW, GA, and neonatal morbidities. Further studies should focus on exercise and nutrition in pregnant and reproductive age women so that healthy babies with low-risk of obesity, metabolic syndrome, and neurodevelopmental disabilities are born.

Linking preoperative and early intensive care unit data for prolonged intubation prediction.

Prolonged intubation (PI) is a frequently encountered severe complication among patients following cardiac surgery (CS). Solely concentrating on preoperative data, devoid of sufficient consideration for the ongoing impact of surgical, anesthetic, and cardiopulmonary bypass procedures on subsequent respiratory system function, could potentially compromise the predictive accuracy of disease prognosis. In response to this challenge, we formulated and externally validated an intelligible prediction model tailored for CS patients, leveraging both preoperative information and early intensive care unit (ICU) data to facilitate early prophylaxis for PI. We conducted a retrospective cohort study, analyzing adult patients who underwent CS and utilizing data from two publicly available ICU databases, namely, the Medical Information Mart for Intensive Care and the eICU Collaborative Research Database. PI was defined as necessitating intubation for over 24 h. The predictive model was constructed using multivariable logistic regression. External validation of the model's predictive performance was conducted, and the findings were elucidated through visualization techniques. The incidence rates of PI in the training, testing, and external validation cohorts were 11.8%, 12.1%, and 17.5%, respectively. We identified 11 predictive factors associated with PI following CS: plateau pressure [odds ratio (OR), 1.133; 95% confidence interval (CI), 1.111-1.157], lactate level (OR, 1.131; 95% CI, 1.067-1.2), Charlson Comorbidity Index (OR, 1.166; 95% CI, 1.115-1.219), Sequential Organ Failure Assessment score (OR, 1.096; 95% CI, 1.061-1.132), central venous pressure (OR, 1.052; 95% CI, 1.033-1.073), anion gap (OR, 1.075; 95% CI, 1.043-1.107), positive end-expiratory pressure (OR, 1.087; 95% CI, 1.047-1.129), vasopressor usage (OR, 1.521; 95% CI, 1.23-1.879), Visual Analog Scale score (OR, 0.928; 95% CI, 0.893-0.964), pH value (OR, 0.757; 95% CI, 0.629-0.913), and blood urea nitrogen level (OR, 1.011; 95% CI, 1.003-1.02). The model exhibited an area under the receiver operating characteristic curve (AUROC) of 0.853 (95% CI, 0.840-0.865) in the training cohort, 0.867 (95% CI, 0.853-0.882) in the testing cohort, and 0.704 (95% CI, 0.679-0.727) in the external validation cohort. Through multicenter internal and external validation, our model, which integrates early ICU data and preoperative information, exhibited outstanding discriminative capability. This integration allows for the accurate assessment of PI risk in the initial phases following CS, facilitating timely interventions to mitigate adverse outcomes.

Predicting the risk of early intensive care unit admission for patients hospitalized with acute pancreatitis using supervised machine learning

Background Acute pancreatitis (AP) is a complex and life-threatening disease. Early recognition of factors predicting morbidity and mortality is crucial. We aimed to develop and validate a pragmatic model to predict the individualized risk of early intensive care unit (ICU) admission for patients with AP. Methods The 2019 Nationwide Readmission Database was used to identify patients hospitalized with a primary diagnosis of AP without ICU admission. A matched comparison cohort of AP patients with ICU admission within 7 days of hospitalization was identified from the National Inpatient Sample after 1:N propensity score matching. The least absolute shrinkage and selection operator (LASSO) regression was used to select predictors and develop an ICU acute pancreatitis risk (IAPR) score validated by 10-fold cross-validation. Results A total of 1513 patients hospitalized for AP were included. The median age was 50.0 years (interquartile range: 39.0–63.0). The three predictors that were selected included hypoxia (area under the curve [AUC] 0.78), acute kidney injury (AUC 0.72), and cardiac arrhythmia (AUC 0.61). These variables were used to develop a nomogram that displayed excellent discrimination (AUC 0.874) (bootstrap bias-corrected 95% confidence interval 0.824–0.876). There was no evidence of miscalibration (test statistic = 2.88; P = 0.09). For high-risk patients (total score >6 points), the sensitivity was 68.94% and the specificity was 92.66%. Conclusions This supervised machine learning-based model can help recognize high-risk AP hospitalizations. Clinicians may use the IAPR score to identify patients with AP at high risk of ICU admission within the first week of hospitalization.

Eficacia de las intervenciones fisioterápicas sobre la musculatura respiratoria mediante técnicas de entrenamiento respiratorio en el postoperatorio de trasplantados pulmonares: una revisión sistemática

IntroductionRespiratory muscles are a limiter of exercise capacity in lung transplant patients. It is necessary to know the effectiveness of specific respiratory muscle training techniques carried out in the management of adult lung transplant patients in the postoperative period. Material and methodsA systematic review of clinical trials was carried out, which included adult lung transplant patients undergoing post-transplant respiratory training. A search was carried out in the databases PubMed/Medline, EMBASE, Scopus, Web of Science, Cochrane Library between January 2012 and September 2023, using the terms: “breathing exercise”, “respiratory muscle training”, “inspiratory muscle training”, “respiratory exercise”, “pulmonary rehabilitation”, “lung rehabilitation”; in combination with “lung transplantation”, “lung transplant”, “posttransplant lung”. No language limit. ResultsEleven trials were included with a total of 639 patients analyzed. Most training programs begin upon hospital discharge (more than one month post-transplant), few do so early (Intensive Care Unit). The duration varies from 1-12 months post-transplant. The interventions were based on aerobic training and peripheral muscle strength. Some of them included breathing exercises and chest expansions. The most used outcome variable was submaximal exercise capacity measured with the 6-minute walk test. ConclusionsTraining the respiratory muscles of the adult transplant patient favors the improvement of exercise capacity and quality of life. Aerobic training, as well as strength training of the rest of the peripheral muscles, contribute to the improvement of respiratory muscles.

Public Awareness and Knowledge of Sepsis: A Cross-Sectional Survey of Adults in the Western Region of Saudi Arabia.

Sepsis is a condition in which the body responds improperly to harmful microorganisms and infections, which triggers a chain reaction throughout the body. It is a life-threatening medical emergency. Infections that lead to sepsis, in most cases, start in the lungs, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis rapidly leads to multi-organ failure and death. The risk factors for sepsis include a weakened immune system, being 65 years of age or older, and chronic medical conditions including diabetes, lung disease, and kidney disease. A thorough understanding of the warning signs and symptoms, as well as prompt medical attention, are required for successful sepsis management. Early detection, antimicrobial therapy, and intensive supportive care are the cornerstones of the best sepsis management. This study aimed to assess the public awareness and knowledge of sepsis in the Western region of Saudi Arabia. This was a cross-sectional study conducted from the beginning of June till the end of August 2023, among 425 Saudi adults in the Western region above the age of 18 years. Data collection was carried out by administering a questionnaire through an online platform. The questionnaire included demographic information, risk factors, symptoms, protective factors, and the source of information about sepsis. The data collected were reviewed, coded, and then fed into IBM SPSS Statistics software for Windows, Version 21 (released 2012; IBM Corp., Armonk, NY). The study found that almost half (47.8%) of participants were aware of bacterial septicemia, with the most common sources of awareness being the internet (48.3%) and healthcare professionals (47.8%). Low immunity (75.9%) and infection (39.4%) have been the most frequently reported risk factors. Fever (31.5%) was the most commonly reported symptom. Participants from Yanbu and Jeddah and those in the healthcare sector had significantly higher awareness levels. The majority of participants (93.1%) had poor knowledge about the risk factors and symptoms of septicemia, with only 3.4% having fair or good knowledge. Sociodemographic characteristics did not significantly affect knowledge about septicemia (P>0.05). In summary, this study reveals that while awareness of bacterial septicemia is relatively high among the sample population, knowledge about the risk factors and symptoms of the condition is low. The internet, healthcare professionals, and social media play significant roles in raising awareness about bacterial septicemia. Participants from Yanbu and Jeddah, students, and healthcare sector workers had higher awareness levels compared to other groups. However, overall knowledge levels regarding bacterial septicemia were poor across various demographic characteristics. This highlights the need for targeted educational interventions to improve knowledge and understanding of septicemia and its risk factors and symptoms among the general population. Further research is needed to identify the reasons for low knowledge levels and develop effective strategies to improve awareness about bacterial septicemia.

Unresponsive Low Mixed Venous Oxygen Saturation During Early Intensive Care Unit Stay is Associated With Increased Risk of Organ Dysfunction After Cardiac Surgery: A Single-Center Retrospective Study

The aim of the study was to determine if unresponsive mixed venous oxygen saturation (SvO2) values during early postoperative hours are associated with postoperative organ dysfunction. A single-center retrospective observational study. A university hospital. A total of 6,282 adult patients requiring cardiac surgery who underwent surgery in a University Hospital from 2007 to 2020. A pulmonary artery catheter was used to gather SvO2 samples after surgery at admission to the intensive care unit (ICU) and 4 hours later. For the analysis, patients were divided into 4 groups according to their SvO2 values. The rate of organ dysfunctions categorized according to the SOFA score was then studied among these subgroups. The crude mortality rate for the cohort at 1 year was 4.3%. Multiple organ dysfunction syndrome (MODS) was present in 33.0% of patients in the early postoperative phase. During the 4-hour initial treatment period, 43% of the 931 patients with low SvO2 on admission responded to goal-directed therapy to increase SvO2 >60%; whereas, in 57% of the 931 patients, the low SvO2 was sustained. According to the adjusted logistic regression analyses, the odds ratio for MODS (4.23 [95% CI 3.41-5.25]), renal- replacement therapy (4.97 [95% CI 3.28-7.52]), time on a ventilator (2.34 [95% CI 2.17-2.52]), and vasoactive-inotropic score >30 (3.62 [95% CI 2.96-4.43]) were the highest in the group with sustained low SvO2. Patients with SvO2 <60% at ICU admission and 4 hours later had the greatest risk of postoperative MODS. Responsiveness to a goal-directed therapy protocol targeting maintaining or increasing SvO2 ≥60% at and after ICU admission may be beneficial.

ROLE OF MODIFIED EARLY WARNING SCORE IN EVALUATING MORTALITY IN POSTOPERATIVE PERIOD

Objectives: The intent of the study is to analyze the role of modified early warning score (MEWS) in the assessment of the need of early intervention and surgical intensive care unit (SICU) admission in patients undergoing elective and emergency major surgical procedures. Methods: This prospective study incorporated 150 patients who underwent emergency or elective major surgical procedures, with monitoring of physiological parameters in the post-operative period with implementation of MEWS. The MEWS score of 1–3: Escalation of monitoring done. MEWS of 4–5: Escalation of monitoring, urgent assessment by the surgical team, shift of patient to intensive care unit (ICU) if required. MEWS of ≥6: Shift of patient to ICU with emergency assessment by the surgical/medical/ICU team. Outcomes were (1) improvement in patients’ clinical condition after early goal-directed therapies (frequent monitoring, shifting to ICU), (2) discharged alive from the hospital, and (3) patient death. Results: In our study, all the patients with MEWS from 1 to 7 were discharged alive and all the patients with a score above ≥8 were succumbed to death suggesting MEWS score of ≥8 implicates the strict need for SICU admission and an increased mortality of the patient in the post-operative period. MEWS improved communication between nursing staff, junior doctors with surgical team to “flag-up” and prioritize patients. Conclusion: The MEWS is an important risk management tool that is simple to implement and effective in identifying the early deterioration of the patients, which can be used as a routine protocol in post-operative period and assessing the need of ICU for further interventions.

Nonlinear Relationship Between Serum Total Cholesterol Levels and the Severity of Hypertriglyceridemic Acute Pancreatitis: A Cohort Study in China.

The relationship between total cholesterol (TC) levels and the severity of hypertriglyceridemic acute pancreatitis (HTGAP) remains unclear. The aim of this study was to investigate the relationship between the levels of TC at admission with the severity of HTGAP, in order to apply it as a reliable predictor at early stage in clinical practice. We performed a cohort study including 249 patients with AHTGP between November 2012 and April 2022 in XuanWu Hospital. Fasting TC was assayed within 24h of admission, age, gender, body mass index, hypertension, diabetes mellitus, drinking, smoking, neutrophil-lymphocyte ratio, C-reactive protein and glucose were recorded as confounding factors. To evaluate the relationship of TC and the severity of HTGAP, we used smooth curve fitting and a segmented regression model with adjustment of confounding factors to analyze the threshold effect between TC and SAP occurrence risk. 249 Patients were enrolled. The incidence of SAP was 25.3% (63/249). A nonlinear relationship between TC level and the severity of HTGAP. 6.09mmol/L was the optimal TC value associated with the lowest risk of SAP occurrence. Moreover, TC level was negatively correlated with risk of severe HTGAP occurrence for TC < 6.09mmol/L (OR 0.45, 95% CI 0.23-0.85, P = 0.014) and positively correlated for TC > 6.09mmol/L in HTGAP patients (OR 1.14, 95% CI 1.04-1.26, P = 0.006). We found that serum TC level is nonlinearly associated with the severity of HTGAP, and it can be a reliable predictor for early intervention and intensive care.

Evolution of Status of Trace Elements and Metallothioneins in Patients with COVID-19: Relationship with Clinical, Biochemical, and Inflammatory Parameters.

The inflammatory reaction and pathogenesis of COVID-19 may be modulated by circulating trace elements (Iron (Fe), Zinc (Zn), Copper (Cu), Manganese (Mn)) and Metallothioneins (MTs). Thus, the present study aimed to investigate their relationship with clinical, biochemical, and inflammatory parameters in patients with COVID-19 at the early Intensive Care Unit (ICU) phase. Critically ill patients (n = 86) were monitored from the first day of ICU admission until the third day of stay. Serum samples were used to assess mineral levels via Inductively Coupled Plasma Mass Spectrometry (ICP-MS) and MT levels via differential pulse voltammetry. Levels of Cu and MTs were significantly decreased after 3 days (p < 0.05), increasing the prevalence of Cu-deficient values from 50% to 65.3% (p = 0.015). Fe and Zn were shown to have a predictive value for mortality and severity. The present study suggests trace element deficiency may be a risk factor during early ICU treatment of COVID-19, as it is related to different biochemical and clinical parameters, indicating a possible beneficial effect of restoring proper levels of these micronutrients.

Course of Acute Pancreatitis Patients with Renal Failure According to Balthazar Classification.

There are criteria that include many organ systems to predict the prognosis in acute pancreatitis (AP) patients. In this study, we aimed to show how the course of the disease changes according to the Balthazar classification in AP patients presenting with renal failure. Our study included 352 patients who were admitted to the Emergency Service of our hospital and were diagnosed and hospitalized with AP. According to the Balthazar score, patients with scores of 0-2, 4-6, and 8-10 were evaluated as mild, moderate, and severe AP, respectively. Demographic data (age, gender) of all patients were documented. The etiology of AP was determined in all patients. Biliary, drug/toxic, alcohol, infections, hyperlipidemia, post-endoscopic retrograde cholangiopancreatography (ERCP), genetics, hypercalcemia, structural anomalies, and malignancy were evaluated as the etiology. Those without any underlying pathology were evaluated as idiopathic AP. The patients were divided into two groups as those with and without renal insufficiency. All patients underwent helical computed tomography (section 64, Aquilion; Toshiba Medical Systems, Tokyo) within the first 12 hours and between days 3 and 7. Pancreas, peripancreatic and extrapancreatic findings, and complications were examined. "The Statistical Package for the Social Sciences 19.0 (SPSS Armonk, NY: IBM Corp.)" was used for all analyses. Kolmogorov-Smirnov test and histograms were used to determine whether there was a normal distribution. The non-parametric data of the groups were compared using the Mann-Whitney U test and the parametric data using the ındependent t test. Chi-square test was used to test categorical data. Cases with P < 0.05 were considered statistically significant. : While 22 (6.2%) patients had renal insufficiency, 332 (95.8%) patients did not have renal insufficiency. In the evaluation made in terms of AP severity; according to Balthazar classification at admission, there was no difference in mild and moderate pancreatitis for kidney insufficiency in both groups, but it was significantly higher in the group with severe pancreatitis [2 (9.1%) versus 1 (0.3%), P < 0.001]. In the evaluation made after 72 hours; renal failure was significantly lower in the group with mild pancreatitis [11 (50.0%) versus 245 (73.8%), P: 0.016] and severe renal failure was significantly higher in severe pancreatitis [7 (31.8%) versus 13 (%) 3.9), P < 0.001]. Early intensive care unit admission and close follow-up and early treatment in AP patients change the course of the disease. In our study, we showed that serum creatinine level is an important parameter in the course of AP and has a predictive value for the course of the disease.

Extracorporeal Membrane Oxygenation in an Adolescent with Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children is a rare and potentially life-threatening disease that is associated with SARS-CoV-2 infection, characterized by hyperinflammation and multiorgan involvement. Cardiovascular involvement is common, including myocardial dysfunction often leading to cardiogenic shock. We present the case of a 17-year-old boy with fever, odynophagia, maculopapular rash and abdominal pain who developed a cardiogenic shock. Due to progressive deterioration of cardiac function despite optimized vasoactive support, veno-arterial extracorporeal membrane oxygenation support was initiated 12 hours after admission, with successful decannulation after seven days and discharge after 23 days, with normal cardiac function. The patient received corticosteroids and intravenous immunoglobulin. Early recognition and intensive care support are crucial for ensuring a successful outcome in severe cases of multisystem inflammatory syndrome. In cases of severe cardiogenic shock, extracorporeal membrane oxygenation support can be critical for survival and rapid recovery.

Association between the timing of ICU admission and mortality in patients with hospital-onset sepsis: a nationwide prospective cohort study

BackgroundBased on sparse evidence, the current Surviving Sepsis Campaign guideline suggests that critically ill patients with sepsis be admitted to the intensive care unit (ICU) within 6 h. However, limited ICU bed availability often makes immediate transfer difficult, and it is unclear whether all patients will benefit from early admission to the ICU. Therefore, the purpose of this study was to determine the association between the timing of ICU admission and mortality in patients with hospital-onset sepsis.MethodsThis nationwide prospective cohort study analyzed patients with hospital-onset sepsis admitted to the ICUs of 19 tertiary hospitals between September 2019 and December 2020. ICU admission was classified as either early (within 6 h) or delayed (beyond 6 h). The primary outcome of in-hospital mortality was compared using logistic regression adjusted for key prognostic factors in the unmatched and 1:1 propensity-score-matched cohorts. Subgroup and interaction analyses assessed whether in-hospital mortality varied according to baseline characteristics.ResultsA total of 470 and 286 patients were included in the early and delayed admission groups, respectively. Early admission to the ICU did not significantly result in lower in-hospital mortality in both the unmatched (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 0.99–1.85) and matched cohorts (aOR, 1.38; 95% CI, 0.94–2.02). Subgroup analyses showed that patients with increasing lactate levels (aOR, 2.10; 95% CI, 1.37–3.23; P for interaction = 0.003), septic shock (aOR, 2.06; 95% CI, 1.31–3.22; P for interaction = 0.019), and those who needed mechanical ventilation (aOR, 1.92; 95% CI, 1.24–2.96; P for interaction = 0.027) or vasopressor support (aOR, 1.69; 95% CI, 1.17–2.44; P for interaction = 0.042) on the day of ICU admission had a higher risk of mortality with delayed admission.ConclusionsAmong patients with hospital-onset sepsis, in-hospital mortality did not differ significantly between those with early and delayed ICU admission. However, as early intensive care may benefit those with increasing lactate levels, septic shock, and those who require vasopressors or ventilatory support, admission to the ICU within 6 h should be considered for these subsets of patients.

RENEB Inter-Laboratory Comparison 2021: The Gene Expression Assay.

Early and high-throughput individual dose estimates are essential following large-scale radiation exposure events. In the context of the Running the European Network for Biodosimetry and Physical Dosimetry (RENEB) 2021 exercise, gene expression assays were conducted and their corresponding performance for dose-assessment is presented in this publication. Three blinded, coded whole blood samples from healthy donors were exposed to 0, 1.2 and 3.5 Gy X-ray doses (240 kVp, 1 Gy/min) using the X-ray source Yxlon. These exposures correspond to clinically relevant groups of unexposed, low dose (no severe acute health effects expected) and high dose exposed individuals (requiring early intensive medical health care). Samples were sent to eight teams for dose estimation and identification of clinically relevant groups. For quantitative reverse transcription polymerase chain reaction (qRT-PCR) and microarray analyses, samples were lysed, stored at 20°C and shipped on wet ice. RNA isolations and assays were run in each laboratory according to locally established protocols. The time-to-result for both rough early and more precise later reports has been documented where possible. Accuracy of dose estimates was calculated as the difference between estimated and reference doses for all doses (summed absolute difference, SAD) and by determining the number of correctly reported dose estimates that were defined as ±0.5 Gy for reference doses <2.5 Gy and ±1.0 Gy for reference doses >3 Gy, as recommended for triage dosimetry. We also examined the allocation of dose estimates to clinically/diagnostically relevant exposure groups. Altogether, 105 dose estimates were reported by the eight teams, and the earliest report times on dose categories and estimates were 5 h and 9 h, respectively. The coefficient of variation for 85% of all 436 qRT-PCR measurements did not exceed 10%. One team reported dose estimates that systematically deviated several-fold from reported dose estimates, and these outliers were excluded from further analysis. Teams employing a combination of several genes generated about two-times lower median SADs (0.8 Gy) compared to dose estimates based on single genes only (1.7 Gy). When considering the uncertainty intervals for triage dosimetry, dose estimates of all teams together were correctly reported in 100% of the 0 Gy, 50% of the 1.2 Gy and 50% of the 3.5 Gy exposed samples. The order of dose estimates (from lowest to highest) corresponding to three dose categories (unexposed, low dose and highest exposure) were correctly reported by all teams and all chosen genes or gene combinations. Furthermore, if teams reported no exposure or an exposure >3.5 Gy, it was always correctly allocated to the unexposed and the highly exposed group, while low exposed (1.2 Gy) samples sometimes could not be discriminated from highly (3.5 Gy) exposed samples. All teams used FDXR and 78.1% of correct dose estimates used FDXR as one of the predictors. Still, the accuracy of reported dose estimates based on FDXR differed considerably among teams with one team's SAD (0.5 Gy) being comparable to the dose accuracy employing a combination of genes. Using the workflow of this reference team, we performed additional experiments after the exercise on residual RNA and cDNA sent by six teams to the reference team. All samples were processed similarly with the intention to improve the accuracy of dose estimates when employing the same workflow. Re-evaluated dose estimates improved for half of the samples and worsened for the others. In conclusion, this inter-laboratory comparison exercise enabled (1) identification of technical problems and corrections in preparations for future events, (2) confirmed the early and high-throughput capabilities of gene expression, (3) emphasized different biodosimetry approaches using either only FDXR or a gene combination, (4) indicated some improvements in dose estimation with FDXR when employing a similar methodology, which requires further research for the final conclusion and (5) underlined the applicability of gene expression for identification of unexposed and highly exposed samples, supporting medical management in radiological or nuclear scenarios.

Mortality Rates in Early versus Late Intensive Care Unit Readmission.

ICU readmission is associated with poor outcomes. Few studies have directly compared the outcomes of early versus late readmissions, especially in Saudi Arabia. To compare the outcomes between early and late ICU readmissions, mainly with regards to hospital mortality. This retrospective study included unique patients who, within the same hospitalization, were admitted to the ICU, discharged to the general wards, and then readmitted to the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 01, 2015, and June 30, 2022. Patients readmitted within 2 calendar days were grouped into the Early readmission group, while those readmitted after 2 calendar days were in the Late readmission group. A total of 997 patients were included, of which 753 (75.5%) belonged to the Late group. The mortality rate in the Late group was significantly higher than that in the Early group (37.6% vs. 29.5%, respectively; 95% CI: 1%-14.8%; P = 0.03). The readmission length of stay (LOS) and severity score of both groups were similar. The odds ratio of mortality for the Early group was 0.71 (95% CI: 0.51-0.98, P = 0.04); other significant risk factors were age (OR = 1.023, 95% CI: 1.016-1.03; P < 0.001) and readmission LOS (OR = 1.017, 95% CI: 1.009-1.026; P < 0.001). The most common reason for readmission in the Early group was high Modified Early Warning Score, while in the Late group, it was respiratory failure followed by sepsis or septic shock. Compared with late readmission, early readmission was associated with lower mortality, but not with lower LOS or severity score.