Onset Of Shock Research Articles

Abstract 14592: Sepsis Cardiac Edema Related Reversible Injury (SCERRI)

Background: In human septic shock, radionuclide cine angiograms found depression of LVEF and dilatation of the LV (EDV). Peaking at 48h after shock onset, the changes reversed by day 10. Nonsurvivors paradoxically had normal EFs and EDVs. Subsequent TTE studies have not consistently reproduced these findings. To investigate this paradox, we reviewed published clinical studies of cardiac function during sepsis and performed serial CMRIs in a canine model of sepsis-induced cardiac changes. Methods: Clinical studies of sepsis reporting EFs and EDVs in survivors and nonsurvivors were identified from 1980 onward. Sedated purpose-bred beagles (25, 2 y/o) intra-bronchially challenged with S. aureus or saline had serial CMRIs and histology. Results: Mean EF at 24h ranged from 31-69% across 20 clinical studies. Over these studies survivors vs. nonsurvivors, mean EF differences were only 1% (p=0.15; I 2 5%). Twelve clinical sepsis studies reported mean EDVs and showed that survivors had larger EDVs than nonsurvivors (SMD 0.36, p<0.0001; I 2 57%). Like clinical studies, EFs in our S. aureus challenged animal model was similarly depressed in both survivors and nonsurvivors (41% vs. 45%, p=0.34). In animals like humans, LV EDV was significantly higher at 48h in survivors vs . nonsurvivors (40 vs. 30 ml p=0.02) while CVPs and PAOPs were similar throughout (p=ns). From 48 to 96h the septic animals EF recovers towards normal in survivors. CMRIs in septic animals vs. controls showed LV wall thinning with a progressive significant loss of dry mass (~ 1g/24h over 96h) and increased LV wall edema (2-4% total over 96h). There was no histological or biochemical evidence of myocyte necrosis, elevated troponins or BNPs, only endothelial and myocyte edema with mild myofilament loss. Conclusions: Septic shock results in ventricular wall changes not explained by loading conditions or myocardial necrosis. Sepsis-induced cardiac injury is associated with edema as demonstrated by both histopathology and CMRI. The unexpected, acute loss of LV dry mass occurred even as edema increased and the EF recovered, consistent with an adaptive, reparative process. Determining how dry mass is lost and which cells and tissues are affected may clarify mechanisms of cardiac injury and repair in septic shock.

Building a resilient organization through a pre‐shock strategic emphasis on innovation

AbstractWhy are some firms more resilient when systemic shocks like the Global Financial Crisis (GFC) or COVID‐19 pandemic set in? We approach this question by arguing that a firm's pre‐shock strategic emphasis on innovation can mitigate the consequences of such shocks by facilitating stability and flexibility, major components of organizational resilience, as the shock sets in. We test our arguments empirically by analyzing data from 2003 to 2011 on as many as 994 firms from the S&P 1500 to identify the causes of their resilience during the 2008 GFC. Our findings indicate that pre‐shock product introductions and, to some extent, top management's focus on innovation can facilitate stability and flexibility when a shock occurs, while R&D intensity and patents, other dimensions of a strategic emphasis on innovation, do so only when firm profitability before the shock is low. In this way, we direct innovation research's attention to the additional performance benefits of innovation activities when shocks occur and reveal which dimensions of a strategic emphasis on innovation buffer the negative consequences of a shock, thus providing insights into how innovation helps firms be resilient. Further, our theorizing and empirical findings unveil an intriguing paradox: While existing research tends to find positive associations between innovation and profitability in “regular” times, strong pre‐shock profitability impairs innovation's ability to unfold its effects fully at shock onset.

Primary Carnitine Deficiency: Rare Cause of Paediatric Dilated Cardiomyopathy, Often Underdiagnosed

Primary carnitine deficiency (PCD) is an autosomal recessive disorder of fatty acid beta-oxidation. Which results from a defect in the transport of carnitine and is one of the rare treatable etiologies of metabolic cardiomyopathies. Affected patients may present with acute metabolic decompensation in infancy or severe cardiomyopathy in childhood. There have also been reports of dramatic sudden infant death syndrome. Early disease detection and treatment with L-carnitine can be lifesaving. We present in this report, a severe case of decompensation of previously undiagnosed dilated cardiomyopathy in a 14-year-old boy, who presented to the pediatric emergency department with acute heart failure, initially suspected to be viral myocarditis. Chest x-ray showed cardiomegaly, echocardiographic findings included hypokinetic dilated cardiomyopathy with reduced ejection fraction at 22%, the respiratory multiplex PCR came back in favor of a SARS-CoV-2 infection, Laboratory test results showed hepatic failure and a low rate of free and total plasma carnitine. His clinical condition deteriorated rapidly, with the onset of cardiogenic shock leading up to his death in the intensive care unit before carnitine therapy was initiated. The aim of this case report is to highlight the importance of searching for a metabolic cause, particularly primary carnitine deficiency, for early treatment and improved prognosis of the disease.

Immunosuppressive effects of circulating bile acids in human endotoxemia and septic shock: patients with liver failure are at risk

BackgroundSepsis-induced immunosuppression is a frequent cause of opportunistic infections and death in critically ill patients. A better understanding of the underlying mechanisms is needed to develop targeted therapies. Circulating bile acids with immunosuppressive effects were recently identified in critically ill patients. These bile acids activate the monocyte G-protein coupled receptor TGR5, thereby inducing profound innate immune dysfunction. Whether these mechanisms contribute to immunosuppression and disease severity in sepsis is unknown. The aim of this study was to determine if immunosuppressive bile acids are present in endotoxemia and septic shock and, if so, which patients are particularly at risk.MethodsTo induce experimental endotoxemia in humans, ten healthy volunteers received 2 ng/kg E. coli lipopolysaccharide (LPS). Circulating bile acids were profiled before and after LPS administration. Furthermore, 48 patients with early (shock onset within < 24 h) and severe septic shock (norepinephrine dose > 0.4 μg/kg/min) and 48 healthy age- and sex-matched controls were analyzed for circulating bile acids. To screen for immunosuppressive effects of circulating bile acids, the capability to induce TGR5 activation was computed for each individual bile acid profile by a recently published formula.ResultsAlthough experimental endotoxemia as well as septic shock led to significant increases in total bile acids compared to controls, this increase was mild in most cases. By contrast, there was a marked and significant increase in circulating bile acids in septic shock patients with severe liver failure compared to healthy controls (61.8 µmol/L vs. 2.8 µmol/L, p = 0.0016). Circulating bile acids in these patients were capable to induce immunosuppression, as indicated by a significant increase in TGR5 activation by circulating bile acids (20.4% in severe liver failure vs. 2.8% in healthy controls, p = 0.0139).ConclusionsCirculating bile acids capable of inducing immunosuppression are present in septic shock patients with severe liver failure. Future studies should examine whether modulation of bile acid metabolism can improve the clinical course and outcome of sepsis in these patients.Graphical abstract

INITIATION TIMING OF VASOPRESSOR IN PATIENTS WITH SEPTIC SHOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Background: Vasopressor plays a crucial role in septic shock. However, the time for vasopressor initiation remains controversial. We conducted a systematic review and meta-analysis to explore its initiation timing for septic shock patients. Methods: PubMed, Cochrane Library, Embase, and Web of Sciences were searched from inception to July 12, 2023, for relevant studies. Primary outcome was short-term mortality. Meta-analysis was performed using Stata 15.0. Results: Twenty-three studies were assessed, including 2 randomized controlled trials and 21 cohort studies. The early group resulted in lower short-term mortality than the late group (OR [95% CI] = 0.775 [0.673 to 0.893], P = 0.000, I2 = 67.8%). The significance existed in the norepinephrine and vasopressin in subgroup analysis. No significant difference was considered in the association between each hour's vasopressor delay and mortality (OR [95% CI] = 1.02 [0.99 to 1.051], P = 0.195, I2 = 57.5%). The early group had an earlier achievement of target MAP ( P < 0.001), shorter vasopressor use duration ( P < 0.001), lower serum lactate level at 24 h ( P = 0.003), lower incidence of kidney injury ( P = 0.001), renal replacement therapy use ( P = 0.022), and longer ventilation-free days to 28 days ( P < 0.001). Conclusions: Early initiation of vasopressor (1-6 h within septic shock onset) would be more beneficial to septic shock patients. The conclusion needs to be further validated by more well-designed randomized controlled trials.

Patterns of inflammatory immune responses in patients with septic shock receiving vitamin C, hydrocortisone, and thiamine: clustering analysis in Korea.

Sepsis is characterized by heterogeneous immune responses that may evolve during the course of illness. This study identified inflammatory immune responses in septic patients receiving vitamin C, hydrocortisone, and thiamine. This was a single-center, post-hoc analysis of 95 patients with septic shock who received the vitamin C protocol. Blood samples were drawn on days 1-2, 3-4, and 6-8 after shock onset. Group-based multi-trajectory modeling was used to identify immune trajectory groups. The median age was 78 years (interquartile range, 70-84 years), and 56% were male. Clustering analysis identified group 1 (n=41), which was characterized by lower interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-10 levels, and these levels remained stationary or mildly increased until day 7. Conversely, group 2 (n=54) expressed initially higher IL-6, TNF-α, and IL-10 levels that decreased rapidly by day 4. There was a nonsignificant increase in lymphocyte count and a decrease in C-reactive protein level until day 7 in group 2. The intensive care unit mortality rate was significantly lower in group 2 (39.0% vs. 18.5%, P=0.03). Group 2 also had a significantly higher decrease in the mean (standard deviation) vasopressor dose (norepinephrine equivalent: -0.09±0.16 μg/kg/min vs. -0.23±0.31 μg/kg/min, P<0.001) and Sequential Organ Failure Assessment score (0±5 vs. -4±3, P=0.002) between days 1 and 4. There may be different subphenotypes in septic patients receiving the vitamin C protocol.

Fermi-GBM Discovery of GRB 221009A: An Extraordinarily Bright GRB from Onset to Afterglow

We report the discovery of GRB 221009A, the highest flux gamma-ray burst (GRB) ever observed by the Fermi Gamma-ray Burst Monitor (Fermi-GBM). This GRB has continuous prompt emission lasting more than 600 s, which smoothly transitions to afterglow emission visible in the Fermi-GBM energy range (8 keV–40 MeV), and total energetics higher than any other burst in the Fermi-GBM sample. By using a variety of new and existing analysis techniques we probe the spectral and temporal evolution of GRB 221009A. We find no emission prior to the Fermi-GBM trigger time (t 0; 2022 October 9 at 13:16:59.99 UTC), indicating that this is the time of prompt emission onset. The triggering pulse exhibits distinct spectral and temporal properties suggestive of the thermal, photospheric emission of shock breakout, with significant emission up to ∼15 MeV. We characterize the onset of external shock at t 0 + 600 s and find evidence of a plateau region in the early-afterglow phase, which transitions to a slope consistent with Swift-XRT afterglow measurements. We place the total energetics of GRB 221009A in context with the rest of the Fermi-GBM sample and find that this GRB has the highest total isotropic-equivalent energy (E γ,iso = 1.0 × 1055 erg) and second highest isotropic-equivalent luminosity (L γ,iso = 9.9 × 1053 erg s–1) based on its redshift of z = 0.151. These extreme energetics are what allowed us to observe the continuously emitting central engine of Fermi-GBM from the beginning of the prompt emission phase through the onset of early afterglow.

Towards a Lightweight Classifier to Detect Hypovolemic Shock.

Predicting the ability of an individual to compensate for blood loss during hemorrhage and detect the likely onset of hypovolemic shock is necessary to permit early clinical intervention. Towards this end, the compensatory reserve metric (CRM) has been demonstrated to directly correlate with an individual's ability to maintain compensatory mechanisms during loss of blood volume from onset (one-hundred percent health) to exsanguination (zero percent health). This effort describes a lightweight, three-class predictor (good, fair, poor) of an individual's compensatory reserve using a linear support-vector machine (SVM) classifier. A moving mean filter of the predictions demonstrates a feasible model for implementation of real-time hypovolemia monitoring on a wearable device, requiring only 408 bytes to store the models' coefficients and minimal processor cycles to complete the computations.

The effect of fluid therapy during the first 12 hours after septic shock onset in pediatric patients

The effect of fluid therapy during the first 12 hours after septic shock onset in pediatric patients

Immediate Norepinephrine in Endotoxic Shock: Effects on Regional and Microcirculatory Flow.

To investigate the effects of immediate start of norepinephrine versus initial fluid loading followed by norepinephrine on macro hemodynamics, regional splanchnic and intestinal microcirculatory flows in endotoxic shock. Animal experimental study. University translational research laboratory. Fifteen Landrace pigs. Shock was induced by escalating dose of lipopolysaccharide. Animals were allocated to immediate start of norepinephrine (i-NE) ( n = 6) versus mandatory 1-hour fluid loading (30 mL/kg) followed by norepinephrine (i-FL) ( n = 6). Once mean arterial pressure greater than or equal to 75 mm Hg was, respectively, achieved, successive mini-fluid boluses of 4 mL/kg of Ringer Lactate were given whenever: a) arterial lactate greater than 2.0 mmol/L or decrease less than 10% per 30 min and b) fluid responsiveness was judged to be positive. Three additional animals were used as controls (Sham) ( n = 3). Time × group interactions were evaluated by repeated-measures analysis of variance. Hypotension was significantly shorter in i-NE group (7.5 min [5.5-22.0 min] vs 49.3 min [29.5-60.0 min]; p < 0.001). Regional mesenteric and microcirculatory flows at jejunal mucosa and serosa were significantly higher in i-NE group at 4 and 6 hours after initiation of therapy ( p = 0.011, p = 0.032, and p = 0.017, respectively). Misdistribution of intestinal microcirculatory blood flow at the onset of shock was significantly reversed in i-NE group ( p < 0.001), which agreed with dynamic changes in mesenteric-lactate levels ( p = 0.01) and venous-to-arterial carbon dioxide differences ( p = 0.001). Animals allocated to i-NE showed significantly higher global end-diastolic volumes ( p = 0.015) and required significantly less resuscitation fluids ( p < 0.001) and lower doses of norepinephrine ( p = 0.001) at the end of the experiment. Pulmonary vascular permeability and extravascular lung water indexes were significantly lower in i-NE group ( p = 0.021 and p = 0.004, respectively). In endotoxemic shock, immediate start of norepinephrine significantly improved regional splanchnic and intestinal microcirculatory flows when compared with mandatory fixed-dose fluid loading preceding norepinephrine. Immediate norepinephrine strategy was related with less resuscitation fluids and lower vasopressor doses at the end of the experiment.

Superiority of compensatory reserve measurement compared with the Shock index for early and accurate detection of reduced central blood volume status.

Shock index (SI) equals the ratio of heart rate (HR) to systolic blood pressure (SBP) with clinical evidence that it is more sensitive for trauma patient status assessment and prediction of outcome compared with either HR or SBP alone. We used lower body negative pressure (LBNP) as a human model of central hypovolemia and compensatory reserve measurement (CRM) validated for accurate tracking of reduced central blood volume to test the hypotheses that SI: (1) presents a late signal of central blood volume status; (2) displays poor sensitivity and specificity for predicting the onset of hemodynamic decompensation; and (3) cannot identify individuals at greatest risk for the onset of circulatory shock. We measured HR, SBP, and CRM in 172 human subjects (19-55 years) during progressive LBNP designed to determine tolerance to central hypovolemia as a model of hemorrhage. Subjects were subsequently divided into those with high tolerance (HT) (n = 118) and low tolerance (LT) (n = 54) based on completion of 60 mm Hg LBNP. The time course relationship between SI and CRM was determined and receiver operating characteristic (ROC) area under the curve (AUC) was calculated for sensitivity and specificity of CRM and SI to predict hemodynamic decompensation using clinically defined thresholds of 40% for CRM and 0.9 for SI. The time and level of LBNP required to reach a SI = 0.9 (~60 mm Hg LBNP) was significantly greater ( p < 0.001) compared with CRM that reached 40% at ~40 mm Hg LBNP. Shock index did not differ between HT and LT subjects at 45 mm Hg LBNP levels. ROC AUC for CRM was 0.95 (95% CI = 0.94-0.97) compared with 0.91 (0.89-0.94) for SI ( p = 0.0002). Despite high sensitivity and specificity, SI delays time to detect reductions in central blood volume with failure to distinguish individuals with varying tolerances to central hypovolemia. Diagnostic Test or Criteria; Level III.

Effect of early vasopressin combined with norepinephrine on short-term mortality in septic shock: A retrospective study based on the MIMIC-IV database

BackgroundSeptic shock is a leading cause of death in intensive care units (ICUs), with short-term mortality rates of 35–40%. Vasopressin (AVP) is a second-line vasoactive agent for septic shock, and recent studies suggest that early AVP use can be beneficial. However, differences between early initiation of AVP combined with norepinephrine (NE) and nonearly AVP with NE are unclear. A retrospective cohort research was designed to explore the effects of early AVP initiation versus nonearly AVP initiation. MethodsThis retrospective single-center cohort study included adult patients with septic shock from the MIMIC (Medical Information Mart for Intensive Care)-IV database. According to whether AVP was used early in the ICU (intensive care unit), patients were assigned to the early- (within 6 h of septic shock onset) and non-early-AVP (at least 6 h after septic shock onset) groups. The primary outcome was 28-day mortality. The secondary outcomes were ICU and hospital mortality, the numbers of vasopressor-free and ventilation-free days at 28 days, ICU length of stay (LOS), hospital LOS, sequential organ failure assessment (SOFA) score on days 2 and 3, and renal replacement therapy (RRT) use on days 2 and 3. Univariate and multivariate cox proportional-hazards regression, propensity-score matching were used to analyze the differences between the groups. ResultsThe study included 531 patients with septic shock: 331 (62.5%) in the early-AVP group and 200 (37.5%) in the non-early-AVP group. For 1:1 matching, 158 patients in the early-AVP group were matched with the same number of patients with nonearly AVP. Regarding the primary outcome, there was no significant difference between the early- and non-early-AVP groups in 28-day mortality (hazard ratio [HR] = 0.91, 95% confidence interval [CI] = 0.68–1.24). For the secondary outcomes, there were no differences between the early- and non-early-AVP groups in ICU mortality (HR = 0.95, 95% CI = 0.67–1.35), hospital mortality (HR = 0.95, 95% CI = 0.69–1.31), the numbers of vasopressor-free and ventilation-free days at 28 days, ICU LOS, hospital LOS, SOFA score on days 2 and 3, and RRT use on days 2 and 3. ConclusionsThere was no difference in short-term mortality between early AVP combined with NE and nonearly AVP with NE in septic shock.

EXCHANGE-2: investigating the efficacy of add-on plasma exchange as an adjunctive strategy against septic shock—a study protocol for a randomized, prospective, multicenter, open-label, controlled, parallel-group trial

BackgroundSepsis is as a life-threatening organ dysfunction caused by a dysregulated host response to an infection. The mortality of sepsis and particular of septic shock is very high. Treatment mostly focuses on infection control but a specific intervention that targets the underlying pathological host response is lacking to the present time.The investigators hypothesize that early therapeutic plasma exchange (TPE) will dampen the maladaptive host response by removing injurious mediators thereby limiting organ dysfunction and improving survival in patients with septic shock. Although small prospective studies demonstrated rapid hemodynamic stabilization under TPE, no adequately powered randomized clinical trial has investigated hard outcomes.MethodsThis is a randomized, prospective, multicenter, open-label, controlled, parallel-group interventional trial to test the adjunctive effect of TPE in patients with early septic shock. Patients with a refractory (defined as norepinephrine (NE) ≥ 0.4 μg/kg/min ≥ 30 min OR NE 0.3 μg/kg/min + vasopressin) and early (shock onset < 24 h) septic shock will be included. The intervention is a standard TPE with donor fresh frozen plasma (1.2 × individual plasma volume) performed within 6 h after randomization and will be compared to a standard of care (SOC) control arm. The primary endpoint is 28 days mortality for which the power analysis revealed a group size of 137 / arm (n = 274) to demonstrate a benefit of 15%. The key secondary objective will be to compare the extent of organ failure indicated by mean SOFA over the first 7 days as well as organ support-free days until day 28 following randomization. Besides numerous biological secondary, safety endpoints such as incidence of bleeding, allergic reactions, transfusion associated lung injury, severe thrombocytopenia, and other severe adverse events will be assessed during the first 7 days. For exploratory scientific analyses, biomaterial will be acquired longitudinally and multiple predefined scientific subprojects are planned. This study is an investigator-initiated trial supported by the German Research Foundation (DFG, DA 1209/7–1), in which 26 different centers in Germany, Switzerland, and Austria will participate over a duration of 33 months.DiscussionThis trial has substantial clinical relevance as it evaluates a promising adjunctive treatment option in refractory septic shock patients suffering from an extraordinary high mortality. A positive trial result could change the current standard of care for this septic subgroup. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications.Trial registrationClinicalTrials.gov NCT05726825, Registered on 14 February 2023.

Echocardiographic profiles and hemodynamic response after vasopressin initiation in septic shock: A cross-sectional study

PurposeVasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response. MethodsThis retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%. ResultsOf 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference −16%; 95% CI −30%,−2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04–1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e[0.81–0.1*t]; at t = 0, HR 2.24; 95% CI 1.08–4.64). ConclusionsPre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.

Use of norepinephrine in preterm neonates with dopamine-resistant shock: a retrospective single-centre cross-sectional study

BackgroundNorepinephrine (NE) is recommended for children and full-term neonates (born at >37 gestational weeks) with septic shock. Meanwhile, data on the effectiveness of NE in preterm neonates are still limited....

Identification of Molecular Markers for Early Detection of Sluggish Fermentation Associated with Heat Shock during Alcoholic Fermentation

Problematic fermentations frequently drive economic losses and logistic problems in the winemaking industry. Previous studies have determined thermal conditions leading to problematic fermentations, selecting two contrasting yeast strains for further transcriptomic analysis. Saccharomyces cerevisiae SBB11 showed strong thermosensitivity towards heat shock, while S. cerevisiae PDM was found to be thermotolerant. The aim of this study was to select genes with significantly upregulated expression to be later used as biomarkers for early detection of sluggish fermentation associated with heat shock. Candidate genes were selected from previously obtained RNA-seq data. Alcoholic fermentations were conducted with 4 S. cerevisiae strains SBB11, PDM, M2 and ICV D21. Heat shocks on day 3 of alcoholic fermentation were applied at 36 and 40 °C for 16 h. S. cerevisiae cells were collected at different times after heat shock onset for qPCR analysis of candidate gene expression over time. Three genes showed promising results; SSA1, MGA1 and OPI10 significantly increased expression with respect to the control. The selected genes showed increased expression during the first 9 h post heat shock and are proposed for early detection of sluggish fermentations associated with heat shock.

Diagnosis and treatment of pediatric septic shock in pediatric intensive care units from hospitals of different levels

Objective: To investigate the differences in clinical characteristics, diagnosis, and treatment of pediatric septic shock in pediatric intensive care unit (PICU) among hospitals of different levels. Methods: This retrospective study enrolled 368 children with septic shock treated in the PICU of Beijing Children's Hospital, Henan Children's Hospital, and Baoding Children's Hospital from January 2018 to December 2021. Their clinical data were collected, including the general information, location of onset (community or hospital-acquired), severity, pathogen positivity, consistence of guideline (the rate of standard attainment at 6 h after resuscitation and the rate of anti-infective drug administration within 1 h after diagnosis), treatment, and in-hospital mortality. The 3 hospitals were national, provincial, and municipal, respectively. Furthermore, the patients were divided into the tumor group and the non-tumor group, and into the in-hospital referral group and the outpatient or emergency admission group. Chi-square test and Mann-Whitney U test were used to analyze the data. Results: The 368 patients aged 32 (11, 98) months, of whom 223 were males and 145 females. There were 215, 107, and 46 patients with septic shock, with males of 141, 51, and 31 cases, from the national, provincial, and municipal hospitals, respectively. The difference in pediatric risk of mortality Ⅲ (PRISM Ⅲ) scores among the national,provincial and municipal group was statistically significant (26(19, 32) vs.19(12, 26) vs. 12(6, 19), Z=60.25,P<0.001). The difference in community acquired septic shock among the national,provincial and municipal group was statistically significant (31.6%(68/215) vs. 84.1%(90/107) vs. 91.3%(42/46), χ2=108.26,P<0.001). There were no significant differences in compliance with guidelines among the 3 groups (P>0.05). The main bacteria detected in the national group were Klebsiella pneumoniae (15.4% (12/78)) and Staphylococcus aureus (15.4% (12/78)); in the provincial group were Staphylococcus aureus (19.0% (12/63)) and Pseudomonas aeruginosa (12.7% (8/63)), and in the municipal group were Streptococcus pneumoniae (40.0% (10/25)) and Enteric bacilli (16.0% (4/25)). The difference in the proportion of virus and the proportion of 3 or more initial antimicrobials used among the national,provincial and municipal group was statistically significant (27.7% (43/155) vs. 14.9% (13/87) vs. 9.1% (3/33), 22.8%(49/215) vs. 11.2%(12/107) vs. 6.5%(3/46), χ2=8.82, 10.99, both P<0.05). There was no difference in the in-hospital mortality among the 3 groups (P>0.05). Regarding the subgroups of tumor and non-tumor, the national group had higher PRISM Ⅲ (31(24, 38) vs. 22 (21, 28) vs.16 (9, 22), 24 (18, 30) vs. 17(8, 24) vs. 10 (5, 16), Z=30.34, 10.45, both P<0.001), and it was the same for the subgroups of in-hospital referral and out-patient or emergency admission (29 (21, 39) vs. 23 (17, 30) vs. 15 (10, 29), 23 (17, 29) vs. 18 (10, 24) vs. 11 (5, 16), Z=20.33, 14.25, both P<0.001) as compared to the provincial and municipal group. There was no significant difference in the in-hospital mortality among the 2 pairs of subgroups (all P>0.05). Conclusion: There are differences in the severity, location of onset, pathogen composition, and initial antibiotics of pediatric septic shock in children's hospitals of different levels, but no differences in compliance with guidelines and in-hospital survival rate.

Never Forget the First Time: The Persistent Effects of Corruption and the Rise of Populism in Italy

The article studies the long-term impact of corruption on trust toward institutions. Previous studies have demonstrated that exposure to corruption may lower institutional trust over the short term. Whether those short-term effects translate into a persistent effect is not known. We study the onset of a corruption shock that took place in Italy between 1992 and 1994. Using recent data collected by the Organization for Economic Cooperation and Development, we find that young first-time voters exposed to the corruption scandal and its political consequences in the early 1990s still today have significantly lower institutional trust and were more likely to choose populist parties at the 2018 national elections.

Serotype Distribution and Antimicrobial Resistance of Streptococcus agalactiae Isolates in Nonpregnant Adults with Streptococcal Toxic Shock Syndrome in Japan in 2014 to 2021.

The incidence of streptococcal toxic shock syndrome (STSS) due to group B Streptococcus (GBS) has been increasing annually in Japan and is becoming a serious challenge. Furthermore, in recent years, penicillin- or clindamycin-resistant strains used in treating streptococcal toxic shock syndrome have been reported. However, no report analyzed >100 isolates of group B Streptococcus causing streptococcal toxic shock syndrome. Therefore, we aimed to perform serotyping and antimicrobial susceptibility testing of 268 isolated group B Streptococcus strains from streptococcal toxic shock syndrome cases involving nonpregnant adult patients in Japan between 2014 and 2021. The most prevalent serotype was Ib, followed by serotypes V, III, and Ia. Seven isolates were resistant to penicillin G, and 17.9% (48 isolates) were resistant to clindamycin. Of the penicillin-resistant group B Streptococcus isolates, 71.4% (5 isolates) were clindamycin resistant. In addition, group B Streptococcus strains resistant to penicillin and clindamycin were isolated from patients with streptococcal toxic shock syndrome. Therefore, before these strains become prevalent, introduction of the group B Streptococcus vaccine is essential for disease prevention. IMPORTANCE Group B Streptococcus (GBS) has been increasingly associated with invasive disease in nonpregnant adults. Such infections are responsible for substantial morbidity and mortality, particularly in individuals with underlying chronic conditions. Streptococcal toxic shock syndrome (STSS) is a severe invasive infection characterized by the sudden onset of shock, multiorgan failure, and high mortality. In this study, we assessed 268 GBS-related STSS cases in nonpregnant adults in Japan between 2014 and 2021. Serotype Ib was the most prevalent, followed by serotypes V, III, and Ia, which were identified in more than 80% of STSS isolates. We found that 48 clindamycin-resistant strains and 7 penicillin G-resistant strains were isolated between 2014 and 2021. We believe that our study makes a significant contribution to the literature because we show that the GBS vaccine, particularly the hexavalent conjugate vaccine, is important to reduce the number of patients with STSS.

Understanding the Role of Ureteral Access Sheath in Preventing Post-Operative Infectious Complications in Stone Patients Treated with Ureteroscopy and Ho:YAG Laser Lithotripsy: Results from a Tertiary Care Referral Center.

The use of ureteral access sheaths (UAS) limits the irrigation-induced increase in intrarenal pressure during ureteroscopy (URS). We investigated the relationship between UAS and rates of postoperative infectious complications in stone patients treated with URS. Data from 369 stone patients treated with URS from September 2016 to December 2021 at a single institution were analyzed. UAS (10/12 Fr) placement was attempted in case of intrarenal surgery. The chi-square test was used to assess the relationship between the use of UAS and fever, sepsis, and septic shock. Univariable and multivariable logistic regression analyses tested the association of patients' characteristics and operative data and the rate of postoperative infectious complications. Full data collection of 451 URS procedures was available. Overall, UAS was used in 220 (48.8%) procedures. As for postoperative infectious sequalae, we recorded fever (n = 52; 11.5%), sepsis (n = 10; 2.2%), and septic shock (n = 6; 1.3%). Of those, UAS was not used in 29 (55.8%), 7 (70%), and 5 (83.3%) cases, respectively (all p > 0.05). At multivariable logistic regression analysis, performing URS without UAS was not associated with the risk of having fever and sepsis, but it increased the risk of septic shock (OR = 14.6; 95% CI = 1.08-197.1). Moreover, age-adjusted CCI score (for fever-OR = 1.23; 95% CI = 1.07-1.42, sepsis-OR = 1.47; 95% CI = 1.09-1.99, and septic shock-OR = 1.61; 95% CI = 1.08-2.42, respectively), history of fever secondary to stones (for fever-OR = 2.23; 95% CI = 1.02-4.90) and preoperative positive urine culture (for sepsis-OR = 4.87; 95% CI = 1.12-21.25) did emerge as further associated risk factors. The use of UAS emerged to prevent the onset of septic shock in patients treated with URS, with no clear benefit in terms of fever and sepsis. Further studies may help clarify whether the reduction in fluid reabsorption load mediated by UAS is protective against life-threatening conditions in case of infectious complications. The patients' baseline characteristics remain the main predictors of infectious sequelae in a clinical setting.