Intensive Care Requirement Research Articles

On-site ERCP availability and cholangitis outcomes: Retrospective cohort study

AbstractEndoscopic retrograde cholangiopancreatography (ERCP) is important in acute cholangitis (AC) management but is not available at all hospitals. The association between on-site ERCP availability and cholangitis outcomes is unknown.We included adults diagnosed with AC at 27 hospitals in Ontario through the GEMINI network. We collected data on demographics, clinical and laboratory values, and interventions. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, intensive care unit (ICU) admission, readmission rates, and requirement for percutaneous or surgical decompression. We used multivariable regression analyses to assess the impact of on-site ERCP availability on the primary and secondary outcomes with adjustment for relevant variables.Our cohort included 4492 patients with a median age of 75. Patients at ERCP sites had higher unadjusted rates of undergoing ERCP (55.7% at ERCP sites, 40.8% at non-ERCP sites). Patients at ERCP sites compared with non-ERCP sites did not have significantly different in-hospital mortality (adjusted odds ratio [aOR] = 2.19, 95% confidence interval [CI] = 0.86–5.55). Compared with non-ERCP sites, patients at ERCP sites with underlying stricturing biliary disease or pancreaticobiliary malignancy (aOR = 1.94, 95% CI = 1.14–13.58) or severe cholangitis (aOR = 2.17, 95% CI = 1.17–4.02) had higher odds of in-hospital mortality. In a post-hoc propensity score-based analysis, there was no significant difference between patients at ERCP sites compared with those at non-ERCP sites for in-hospital mortality.Patients at ERCP sites compared with non-ERCP sites did not have significantly different mortality. Subgroups of patients with underlying stricturing biliary disease or pancreaticobiliary malignancy and severe cholangitis, who have higher mortality at ERCP sites, warrant further study.

Damage Control Laparotomy in Trauma Patients: A Level I Trauma Center Experience

Introduction: The surgical management of traumatic injury is an evolving and controversial topic. We present outcomes of laparotomy performed for blunt and penetrating trauma at a level I trauma center over a nearly 10-year period. Material and Methods: Retrospective single-center cohort study of patients who received either damage control laparotomy or definitive laparotomy with fascial closure at the time of index procedure. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, complications, intensive care requirements, and vasopressor use. Results: Out of 125 included patients, 69 received damage control laparotomy, and 56 received definitive laparotomy. Damage control laparotomy was associated with significantly higher mortality (20.9% vs 1.8%, p=.0015) and length of stay (16.1 vs. 9.3 days, p=.0005) than definitive laparotomy. Complications occurred significantly more frequently among damage control laparotomy patients (53.6% vs. 14.3%, p<.0001). Damage control laparotomy patients were substantially more likely to require intensive care unit admission, mechanical ventilation, and vasopressor support. Conclusion: Patients undergoing damage control laparotomy are at significantly increased risk for adverse outcomes, including increased in-hospital mortality, prolonged length of stay, more significant complication burden, and increased need for mechanical ventilation and pressure support as compared to patients undergoing definitive laparotomy.

Unmasking culprits: novel analysis identifies complement factors as potential therapeutic targets to mitigate inflammation during children's heart surgery

BackgroundCardiopulmonary bypass (CPB) causes systemic inflammation during pediatric cardiac surgery, which can contribute to post-operative organ dysfunction and prolonged recovery. This study aims to identify key inflammatory mediators related to this clinically significant immunologic response.MethodsPediatric patients were enrolled in a single-arm prospective clinical study (NCT05154864) and received standard cardiac operation, CPB and subzero-balance ultrafiltration. Arterial samples were taken before CPB initiation and immediately after weaning, and concentrations of 33 inflammatory mediators were assayed. A principal component analysis with hierarchical clustering (PCA-HCPC) included inflammatory mediator concentrations measured at the end of CPB, validated peak post-operative clinical scores, ventilation time and intensive care length of stay. Mahalanobis distance assessed statistical differences between clusters. Spearman’s correlation described the linear relationship between mediator concentrations at the end of CPB and intensive care length of stay. Results are median (IQR).ResultsForty consecutive patients were enrolled; the majority were male (58%), age of 7.3 (1.7–39.0) months and weight of 6.7 (4.6–14.9) kg. The PCA-HCPC revealed activated complement factors along with all peak clinical scores and prolonged intensive care requirements in the same cluster. Cytokine, chemokine, and leukocyte adhesion molecule concentrations were found in two other distinct clusters (Mahalanobis distance = 16.5; p = 0.004 and Mahalanobis distance = 17.4; p = 5.8 × 10–4). Mediator concentrations of C2 (Rho = 0.50; p = 0.001), C3 (Rho = 0.58; p = 1.1 × 10–4), C3b (Rho = 0.47; p = 0.002), C5 (Rho = 0.48; p = 0.002) and C5a (Rho = 0.63; 1.7 × 10–5) showed linear correlations with intensive care unit length of stay.ConclusionsActivated complement factors, but not pro-inflammatory cytokines or chemokines, were most related to cardiopulmonary dysfunction and prolonged recovery in this novel analysis. Investigation of therapies that inhibit complement to dampen CPB-associated inflammation and enhance recovery after pediatric cardiac surgery is warranted.Trial Registration ClinicalTrials.gov, NCT05154864

The dynamic role of soluble urokinase plasminogen activator receptor (suPAR) in monitoring coagulation dysfunction during COVID-19 progression: a review

COVID-19, caused by the severe acute respiratory syndrome coronavirus 2, has led to significant morbidity and mortality worldwide, with severe complications often involving coagulation dysfunction and thromboembolic events. Identifying reliable biomarkers for early detection and monitoring of these complications is crucial for improving patient outcomes. The soluble urokinase plasminogen activator receptor (suPAR) has emerged as a potential biomarker in this context, given its role in inflammation and immune response. Elevated suPAR levels correlate with disease severity and inflammatory markers, making it a valuable indicator of the complex interplay between inflammation and coagulation observed in COVID-19. Elevated suPAR levels have been linked to an increased risk of thromboembolic events, such as deep vein thrombosis and pulmonary embolism. Combining suPAR measurement with other coagulation markers, such as D-dimer, enhances the predictive accuracy for thrombotic complications. Furthermore, higher suPAR levels are associated with increased disease severity, intensive care requirements, and higher mortality rates, underscoring its significance in risk stratification and therapeutic decision-making. The integration of suPAR measurement into routine clinical practice for COVID-19 could significantly aid in early diagnosis, risk assessment, and monitoring of therapeutic interventions. By providing insights into the patient’s inflammatory and coagulation status, suPAR can guide the timely initiation of anticoagulant therapy and other treatments aimed at reducing thromboembolic complications. As research continues to validate suPAR’s utility across diverse populations and clinical settings, it holds promise for becoming an integral component of clinical management strategies to mitigate the morbidity and mortality associated with COVID-19.

Evaluation of maternal and fetal outcomes in pregnancies with maternal solitary kidney: A case-control study from a tertiary center.

There exists a prevailing concern regarding the heightened susceptibility of women with a solitary kidney to unfavorable consequences during pregnancy. Irrespective of the underlying etiology, individuals with a solitary kidney are advised to have regular annual screenings for blood pressure and urinalysis due to their increased susceptibility to developing proteinuria, hypertension, and renal failure. To investigate the risk of adverse pregnancy outcomes in women with a maternal solitary kidney by comparing maternal and fetal outcomes to those of healthy pregnant women. This retrospective, single-center study was conducted with 29 pregnant women with maternal solitary kidney and 60 healthy controls at a tertiary hospital. Obstetric data such as gestational hypertension, preeclampsia, preterm labor, birth week, mode of delivery, Apgar scores, and neonatal intensive care requirements, were compared between the groups. A binary logistic regression analysis was performed to determine the obstetric complications increased by the presence of maternal solitary kidney. The number of spontaneous abortions, serum creatinine and blood urea nitrogen levels were significantly higher in the patients with solitary kidney (p<0.05). The birth week was earlier among the patients with a solitary kidney compared to the controls (p=0.013). The preterm and cesarean delivery rates were also higher in the case group (p=0.002 and p=0.035, respectively). Thepregnant women with solitary kidney were found to have higher rates of gestational hypertension,preeclampsia, and maternal intensive care requirements (p=0.008, p=0.015, and p=0.008, respectively). Logistic regression analysis revealed a seven-fold increase in the rate of pretermlabor (1.45-37.64) and a three-fold increasein preeclampsia (1.27-22.08) among the pregnant women with a solitary kidney. Patients with solitary kidney are at high risk of encountering pregnancy complications, such as gestational hypertension, preeclampsia, and preterm labor. These pregnant women should be followed up carefully, starting from the first prenatal visit.

Postoperative outcomes after splenectomy: a 20-year single-center experience in Colombia.

Splenectomy indications are well documented; however, several infectious complications and potentially life-threatening conditions could arise after splenectomy. We aim to describe a 20-year single-center experience of postoperative outcomes after splenectomy and perform a subgroup analysis according to approach and surgical setting with a 30-day, 90-day, and 1-year follow-up. A retrospective cohort study was conducted between 2003 and 2023. We included all patients aged 18 years and older who underwent splenectomy. A description of clinical and operative variables with infectious outcomes was performed. Subgroup analyses were performed between open or laparoscopic approach and surgical setting. A total of 134 patients were included. Female patients constituted 52.99% (n = 71) of cases, with a mean age of 51.01 ± 20.79 years. The most frequent surgical indication for splenectomy was trauma in 31.34% (n = 42), and a laparoscopic approach was indicated in 41.79% (n = 56). Overwhelming post-splenectomy syndrome (OPSI) was evidenced in 2.24% (n = 3) of the population. Surgical characteristics such as operative time, intraoperative blood loss, and intensive care requirement and unit length of stay were higher in open and trauma patients. Our data describe the demographic, clinical and operative characteristics of patients undergoing splenectomy in Colombia, providing a solid basis for future research. The results obtained on overwhelming postsplenectomy syndrome (OPSI) and postoperative complications are comparable with those reported in the international literature, reinforcing the validity of our findings. Further prospective studies in this population are needed to optimize management strategies and improve clinical outcomes, particularly in higher risk subgroups.

Angioplasty with ductal stent: experience at Garrahan Hospital

To describe and evaluate the outcomes of ductal angioplasty with stent placement at a single high-complexity center during the period 2016-2022. A retrospective descriptive cross-sectional study was conducted, including patients under 3 months of age who underwent ductal stent implantation as initial palliative treatment. Demographic, clinical, and anatomical data were collected before the intervention. Mortality, intra- and post-procedural complications, need for re-intervention, intensive care requirements, and hospital stay were recorded. The characteristics at the time of definitive surgery are described. Discrete variables are presented as percentages, and continuous variables are presented with their medians and respective interquartile ranges. Twenty patients who underwent this treatment were reviewed, revealing a success rate of 80%. Complications due to stent dysfunction required surgical resolution. 95% of patients were dischargedfrom the institution after the procedure, and 17 patients reached a second definitive surgical stage. Three patients died afterthe procedure, but with no direct relation to it. Indications for ductal angioplasty with stent as an alternative treatment to systemic-pulmonary anastomosis by surgery are not yet fully defined; the strategy represents a valid alternative in appropriately selected patients. The presented experience shows results similar to international reference centers.

42 Clinical features and severity of COVID-19 with respiratory virus coinfections versus SARS-CoV-2 monoinfection in hospitalized children: A Canadian national surveillance study

Abstract Background The co-circulation of SARS-CoV-2 alongside other respiratory viruses has led to the risk of coinfections, potentially intensifying the severity of cases, especially in children. Objectives This study examined the epidemiology, clinical characteristics, and outcomes of SARS-CoV-2 respiratory virus coinfections in comparison to SARS-CoV-2 monoinfections in hospitalized children. Design/Methods A nationwide surveillance study was conducted to assess paediatric COVID-19-related hospitalizations across Canada from April 2020 to May 2022. Data were captured through two datasets covering ~90% of all Canadian tertiary-care paediatric beds: The Canadian Paediatric Surveillance Program and the Canadian Immunization Monitoring Program, ACTive. Coinfections were defined as the simultaneous detection of SARS-CoV-2 and ≥1 other respiratory virus. Severe infection was defined as intensive care, ventilatory, or hemodynamic support needs, organ systems complications, or death. Variables and outcomes were summarized and compared, and risk ratios were computed using Poisson regression, adjusting for age, gender, comorbid conditions, SARS-CoV-2 lineage, and vaccination status. Results Out of 1501 COVID-19-related hospitalizations, 163 (10.9%) had documented coinfections with 44/163 [27%] involving SARS-COV-2 plus ≥2 other respiratory viruses. The majority of SARS-CoV-2 monoinfections (1176/1501, 87.9%) and coinfections (139/163, 85.3%) belonged to the Omicron era (Figure A). RSV (66/163, 40.5%) and Enterovirus/rhinovirus (61/163, 37.4%) coinfections were the most common. Coinfection cases were significantly younger than monoinfection cases (median age 1.2 [IQR:0.3-3.3] vs 1.6 [IQR:0.3-7.0] years, p=0.04). Overall, severe disease was more common among cases with any coinfection (38.0%) than SARS-CoV-2 monoinfection (25.7%; adjusted risk ratio 1.45, 95% confidence interval 1.17-1.80) (Figure B). In particular, we observed that severe outcomes were significantly higher in SARS-CoV-2 coinfections compared to monoinfections during the Omicron era (Figure C-D). Overall, 26/61 (42.6%) Enterovirus/Rhinovirus and 20/66 (30.3%) RSV coinfections were associated with severe outcomes. Conclusion Children with documented coinfections had more severe respiratory disease compared to SARS-COV-2 monoinfections. However, children with severe COVID-19 may have been more likely tested for multiple viruses, leading to a risk of underestimation of coinfections among children with milder disease. Further work is needed to assess how different virus coinfections may affect children and which, if any, may be a predominant driver of disease severity. 1Severe disease was defined as intensive care, ventilatory, or hemodynamic support requirements, organ system complications, or death. 2Lineage was first assigned based on available genetic sequencing data. If missing, lineage was imputed based on the dominant circulating lineage at the provincial level according to the GISAID database.

Adjuvant non-opioid analgesics decrease in-hospital mortality in targeted patients with acute pancreatitis receiving opioids

Objectives Opioid administration in acute pancreatitis (AP) exacerbates its severity, prompting concerns regarding the increased requirement for intensive care and its potential impact on patient survival. We aimed to elucidate the influence of analgesic patterns on mortality among patients with AP hospitalized in the ICU. Methods We included 784 patients (198 receiving opioid monotherapy and 586 receiving opioid polytherapy) from the Medical Information Mart for Intensive Care database. The primary outcome was in-hospital mortality. Propensity score matching was used to account for baseline differences. We used Kaplan–Meier survival curves and multivariate regression models to indicate survival discrepancies and potential associations. Results Polytherapy group exhibited prolonged hospital survival (79.8 vs. 57.3 days, P &lt; 0.001); polytherapy was associated with decreasing in-hospital mortality adjusted for confounders (HR = 0.49, 95% CI: 0.26–0.92; P = 0.027). Stratification analysis indicated that patients receiving adjunctive acetaminophen had prolonged hospital survival (opioid vs. opioid + acetaminophen, P &lt; 0.001; opioid vs. opioid + NSAIDs + acetaminophen, P = 0.026). Opioid polytherapy benefited patients with APACHE III scores &gt;83 and those with mean oral morphine equivalent &gt;60 mg/day (HR = 0.17, 95% CI: 0.1–0.3, P &lt; 0.001 and HR = 0.32, 95% CI: 0.2–0.52, P &lt; 0.001, respectively). Conclusion Our findings suggest that an opioid-based analgesic regimen offers a survival advantage for patients with AP, particularly those in critical condition or with concerns about opioid use. This approach provides a viable clinical strategy for pain management. Further randomized clinical trials are warranted to validate these results.

Intraoperative Fluid Balance and Perioperative Complications in Ovarian Cancer Surgery.

Fluid overload and hypovolemia promote postoperative complications in patients undergoing cytoreductive surgery for ovarian cancer. In the present study, postoperative complications and anastomotic leakage were investigated before and after implementation of pulse pressure variation-guided fluid management (PPVGFM) during ovarian cancer surgery. A total of n = 243 patients with ovarian cancer undergoing cytoreductive surgery at the University Hospital Bonn were retrospectively evaluated. Cohort A (CA; n = 185 patients) was treated before and cohort B (CB; n = 58 patients) after implementation of PPVGFM. Both cohorts were compared regarding postoperative complications. Ultrasevere complications (G4/G5) were exclusively present in CA (p = 0.0025). No difference between cohorts was observed regarding severe complications (G3-G5) (p = 0.062). Median positive fluid excess was lower in CB (p = 0.001). This was independent of tumor load [peritoneal cancer index] (p = 0.001) and FIGO stage (p = 0.001). Time to first postoperative defecation was shorter in CB (CB: d2 median versus CA: d3 median; p = 0.001). CB had a shorter length of hospital stay (p = 0.003), less requirement of intensive medical care (p = 0.001) and postoperative ventilation (p = 0.001). CB received higher doses of noradrenalin (p = 0.001). In the combined study cohort, there were more severe complications (G3-G5) in the case of a PFE ≥ 3000ml (p = 0.034) and significantly more anastomotic leakage in the case of a PFE ≥ 4000ml (p = 0.006). Intraoperative fluid reduction in ovarian cancer surgery according to a PPVGFM is safe and significantly reduces ultrasevere postoperative complications. PFEs of ≥ 3000ml and ≥ 4000ml were identified as cutoffs for significantly more severe complications and anastomotic leakage, respectively.

-AI-assisted diagnostic potential of CT in bone oncology and its impact on clinical decision-making for intensive care

ObjectiveThis study evaluates the AI-assisted diagnostic potential of computed tomography (CT) for bone cancer and its influence on patient care during the pre- and post-treatment phases. It compares patient management approaches based on CT severity levels and identifies distinct CT phenotypes linked to disease severity. MethodologyWe retrospectively examined 50 patients diagnosed with bone cancer between December 2022 and June 2023. The CT scans were analyzed according to the Radiological Society of North America (RSNA) guidelines. This study was performed using the deep convolutional neutral network (DCNN) model to assist doctors in diagnosing bone tumors through CT scanning. Patients’ management approaches were compared based on the severity levels indicated by CT scans. ResultsFifty patients participated in this study, with a median age of 67.2 years, ranging from 32 to 89 years. Of them, 38 % were female and 62 % were male. In 2022, 19 individuals (13 males and 6 females, ages 32 to 84) were assessed, with a mean age of 59.9 years. In 2023, 31 individuals, aged 54 to 89 with a mean age of 71.6 years, were assessed; among them were 18 men and 13 women. SPECT scans revealed the following key diagnostic features: 85.9 % of patients exhibited bone lesions with ground-glass opacities, 88 % had multipolar involvement, 92.8 % had bilateral involvement, and 92.8 % showed peripheral involvement. The severity scores based on CT scans were significantly higher in patients requiring intensive care, with scores above 14 being more common in this group. ConclusionDistinct CT findings during the AI-assisted diagnosis and treatment of bone cancer provided prompt and sensitive examination capabilities. Notably, two CT phenotypes emerged, associated with large consolidation patterns and high severity scores, offering crucial insights into disease severity and aiding in clinical decision-making for intensive care requirements. The study underscores the importance of CT in the effective monitoring and management of bone cancer pre- and post-treatment.

Evaluation of Rockall and Blatchford Scores and Forrest Staging in Upper Gastrointestinal Bleeding

Objective: The study aimed to investigate the predictive value of Rockall and Blatchford scores and endoscopic Forrest staging in the need for transfusion and intensive care in upper gastrointestinal bleeding. Materials and Methods: This retrospective study was conducted on 294 patients with gastrointestinal bleeding who presented to the emergency department between January 1 and June 1, 2013. Results: The mean age of 294 patients was 58.73±21.30 years. The endoscopic diagnoses of the patients included peptic ulcer (43.5%, n=128), erosive gastritis (17.3%, n=51), and erosive bulbitis (12.6%, n=37). There was no statistically significant relationship between Forrest staging and Rockall and Blatchford scores (p=0.944, p=0.757). The need for blood transfusion was significantly more frequent in patients with a Rockall score of 5 and above and those with a high Blatchford score (p=0.004, p=0.001). Patients with a Rockall score of 5 and above were significantly more common among those referred to the intensive care unit (p=0.003). Conclusion: Pre-endoscopic Rockall and Blatchford scores and endoscopic Forrest staging can be used safely in predicting transfusion requirement, intensive care requirement, mortality risk, treatment and follow-up of patients with gastrointestinal bleeding, and thus may help to reduce health expenditures.

Predictive ability of the REMS and HOTEL scoring systems for mortality in geriatric patients with pulmonary embolism

BackgroundPulmonary embolism (PE) is an important cause of mortality and morbidity in the geriatric population. We aimed to compare the ability of the pulmonary embolism severity index (PESI), rapid emergency medicine score (REMS), and hypotension, oxygen saturation, low temperature, electrocardiogram change, and loss of independence (HOTEL) to predict prognosis and intensive care requirement in geriatric patient with PE.ResultsThe median age of 132 patients was 77 (71–82) years. PESI was higher in the non-survivor group [132 (113–172)] (P =0.001). The median REMS was 8 (7–10), and it was higher in the non-survivor group [10 (7.5–12.0)] (p = 0.005). The median HOTEL score was 1 (0–2) in the whole cohort and 2 (1–3) in the non-survivor group, indicating significant difference compared to the survivor group (P = 0.001). The area under the curve (AUC) values of HOTEL, REMS, and PESI were determined as 0.72, 0.65, and 0.71, respectively. For the prediction of intensive care requirement, the AUC values of HOTEL, REMS, and PESI were 0.76, 0.75, and 0.76, respectively, with no significant difference in pairwise comparisons (PESI vs. REMS: p = 0.520, HOTEL vs. PESI: P = 0.526, REMS vs. HOTEL: P = 0.669, overall test: P = 0.96, DeLong’s test). The risk ratios of HOTEL and PESI were parallel to each other [5.31 (95% confidence interval (CI): 2.53–11.13) and 5.34 (95% CI: 2.36–12.08), respectively].ConclusionHOTEL and REMS were as successful as PESI in predicting short-term mortality and intensive care requirement in geriatric patients with PE. These scores are also more practical since they have fewer parameters than PESI.

Predicting Factors of Worse Prognosis in COVID-19: Results from a Cross-sectional Study on 52 Inpatients Admitted to the Internal Medicine Department.

The initial phases of the COVID-19 pandemic posed a real need for clinicians to identify patients at risk of poor prognosis as soon as possible after hospital admission. The study aimed to assess the role of baseline anamnestic information, clinical parameters, instrumental examination, and serum biomarkers in predicting adverse outcomes of COVID-19 in a hospital setting of Internal Medicine. Fifty-two inpatients consecutively admitted to the Unit of Internal Medicine "Baccelli," Azienda Ospedaliero - Universitaria Policlinico of Bari (February 1 - May 31, 2021) due to confirmed COVID-19 were grouped into two categories based on the specific outcome: good prognosis (n=44), patients discharged at home after the acute phase of the infection; poor prognosis, a composite outcome of deaths and intensive care requirements (n=8). Data were extracted from medical records of patients who provided written informed consent to participate. The two study groups had similar demographic, anthropometric, clinical, and radiological characteristics. Higher interleukin 6 (IL-6) levels and leucocyte count, and lower free triiodothyronine (fT3) levels were found in patients with poor than those with good prognosis. Higher IL-6 levels and leucocyte count, lower fT3 concentration, and pre-existing hypercholesterolemia were independent risk factors of poor outcomes in our study population. A predicting risk score, built by assigning one point if fT3 < 2 pg/mL, IL-6 >25 pg/mL, and leucocyte count >7,000 n/mm3, revealed that patients totalizing at least 2 points by applying the predicting score had a considerably higher risk of poor prognosis than those scoring <2 points (OR 24.35 (1.32; 448), p = 0.03). The weight of pre-existing hypercholesterolemia did not change the risk estimation. Four specific baseline variables, one anamnestic (pre-existing hypercholesterolemia) and three laboratory parameters (leucocyte count, IL-6, and fT3), were significantly associated with poor prognosis as independent risk factors. To prevent adverse outcomes, the updated 4-point score could be useful in identifying at-risk patients, highlighting the need for specific trials to estimate the safety and efficacy of targeted treatments.

Postoperative Intensive Care Requirements of Pediatric Surgery Patients

Postoperative Intensive Care Requirements of Pediatric Surgery Patients

Comparison of the effectiveness of core genome multilocus sequence typing and polymerase chain reaction-based open reading frame typing in tracing nosocomial methicillin-resistant Staphylococcus aureus transmission

IntroductionA clonal shift from staphylococcal cassette chromosome mec (SCCmec) type II/ST5 methicillin-resistant Staphylococcus aureus (MRSA) to SCCmec type IV/clonal complex (CC)1 MRSA has occurred rapidly in Japan. Our previous research in a geriatric hospital found SCCmec type IV/CC1 MRSA prevalence in long-term care wards. Due to intensive personal care requirements, frequent contact with healthcare providers can potentially cause unintentional nosocomial MRSA transmission. We performed polymerase chain reaction-based open reading frame typing (POT) and core genome multilocus sequence typing (cgMLST) to investigate the occurrence of nosocomial transmission and to compare the results of these methods. MethodsPOT and whole genome sequencing were performed in 83 MRSA isolates. Commercial automated software (Ridom SeqSphere+) was used to perform cgMLST. MRSA isolates with 0–8 allelic differences were considered related, and medical records were consulted in these cases. ResultsSCCmec type IV/CC1 MRSA was the most frequently detected clone (n = 56, 67.5 %), which was divided into 14 POT types, followed by SCCmec type I/ST8 (n = 9) and SCCmec type IV/ST8 (n = 8). Identical POT types were found across 7 of 11 wards. However, cgMLST analysis identified only three cases (six strains) of high genetic similarity, indicating nosocomial transmission; only one involved SCCmec type IV/CC1 (two strains). The mean allelic difference in the core genomes between strains with identical POT types in the same ward was 55.3 ± 22.0. ConclusionsThe cgMLST method proved more effective for identifying nosocomial transmissions compared to POT, highlighting its utility in tracking MRSA spread in healthcare settings.

The Tanta University risk model could help identify patients with acute poisoning who would require intensive care unit level of care

Objective To independently validate the negative predictive value of the Tanta University risk model for intensive care requirements in poison center telephone consultations with other physicians. Methods This study included 400 consecutive patients with acute poisoning. Clinical and laboratory parameters were recorded during the initial consultation with the poison center. Patients who were already ventilated or on vasopressors at the time of consultation were excluded. The Tanta University risk model score was calculated from the data according to the following equation: Tanta University risk model score = 1.966*Glasgow Coma Scale + 0.329*oxygen saturation (percent) + 0.212*diastolic blood pressure (mmHg) − 0.27*respiratory rate (breaths/minute) + 0.33*standard bicarbonate (mmol/L). Twenty-four hours later, the patients’ courses were followed up by telephone. The Tanta University risk model was then compared to a composite endpoint indicating the requirement for admission to an intensive care unit (vasopressors, need for intubation, or death). Results Four hundred patients with acute poisoning were included. Thirty-seven patients had a complicated clinical course as defined by the composite endpoint. Receiver operating characteristic analysis revealed the area under the curve to be 0.87 (95 percent confidence interval 0.83–0.90). An unfavorable Tanta University risk model score was defined as less than 73.46, using a cut-off derived from a previous study of an unrelated series of patients with acute poisoning admitted to our service. Thirty-one of 37 patients with complicated courses had an unfavorable Tanta University risk model score compared to six patients with complicated courses among 306 patients with a favorable Tanta University risk model score (P < 0.0002, Fisher’s exact test). Sixty-three patients had an unfavorable Tanta University risk model score but an uneventful course. The negative predictive value of the Tanta University risk model was 0.98 (95 percent confidence interval 0.96–0.99), sensitivity was 0.84, and specificity 0.83. Conclusions In the present study of poison center telephone consultations, the Tanta University risk model was significantly related to the outcomes in patients with acute poisoning. Patients with a favorable Tanta University risk model score (greater than or equal to 73.46) were unlikely to need intensive care unit level of care.

Review article: Evaluation and care of the critically ill patient with cirrhosis.

The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.

SARS-CoV-2 among liver transplant recipients: Clinical course and mutational analysis

BackgroundVery limited literature on the clinical course of COVID-19 among liver transplant recipients (LT) is available from India. The present study aimed to evaluate the clinical and mutational profile of SARS-CoV-2 among LT. MethodologyThis was a retrospective study including LT cases in whom SARS-CoV-2 RT-PCR testing was requested between April 2020 and December 2022. Detailed mutational analysis was performed by comparing LT COVID-19 positive study group i.e. LT-CoV(+) with two control groups. One including COVID-19 positive with underlying chronic liver disease (CLD) i.e. CLD-CoV(+) and other including COVID-19 positive outpatients without any underlying LD i.e. NLD-CoV(+) ResultsAmong 213 cases, 48 (22.5 %) were positive [LT-CoV(+)] and the remaining 165 (77.5 %) were negative [LT-CoV(-)] for SARS-CoV-2. Of these, 49 % had mild, 14 % moderate and 37 % had severe COVID-19. Mortality was recorded in 11 (23 %) cases, the majority being non-vaccinated. Severe COVID-19 with intensive care requirement was significantly higher among recipients with >5 years since transplant compared to recipients with ≤5 years (p = 0.02). Among 40 samples subjected to whole genome sequencing, 19 (47.5 %) were Delta, 15 (37.5 %) Omicron, and 6 (15 %) were other variants. COVID-19 severity was significantly higher in LT-CoV(+/D) with no significant difference in mortality (p = 0.122). No significant differences in mutational load and in fraction of deleterious mutations were observed between LT-/CLD-/NLD-CoV(+) groups for either Delta or Omicron. ConclusionAn overall fatality rate of 23 % was recorded among LT recipients. Longer duration since transplant was associated with severe clinical course. However, no significant difference in mutation load between studied groups was observed.

Identifying factors predicting outcomes after major trauma in older patients: Prognostic systematic review and meta-analysis.

Trauma is the most common cause of morbidity and mortality in older people, and it is important to determine the predictors of outcomes after major trauma in older people. MEDLINE, Embase, and Web of Science were searched, and manual search of relevant papers since 1987 to February 2023 was performed. Random-effects meta-analyses were performed. The primary outcome of interest was mortality, and secondary outcomes were medical complications, length of stay, discharge destination, readmission, and intensive care requirement. Among 6,064 studies in the search strategy, 136 studies qualified the inclusion criteria. Forty-three factors, ranging from demographics to patient factors, admission measurements, and injury factors, were identified as potential predictors. Mortality was the commonest outcome investigated, and increasing age was associated with increased risk of in-hospital mortality (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07) along with male sex (OR, 1.40; 95% CI, 1.24-1.59). Comorbidities of heart disease (OR, 2.59; 95% CI, 1.41-4.77), renal disease (OR, 2.52; 95% CI, 1.79-3.56), respiratory disease (OR, 1.40; 95% CI, 1.09-1.81), diabetes (OR, 1.35; 95% CI, 1.03-1.77), and neurological disease (OR, 1.42; 95% CI, 0.93-2.18) were also associated with increased in-hospital mortality risk. Each point increase in the Glasgow Coma Scale lowered the risk of in-hospital mortality (OR, 0.85; 95% CI, 0.76-0.95), while each point increase in Injury Severity Score increased the risk of in-hospital mortality (OR, 1.07; 95% CI, 1.04-1.09). There were limited studies and substantial variability in secondary outcome predictors; however, medical comorbidities, frailty, and premorbid living condition appeared predictive for those outcomes. This review was able to identify potential predictors for older trauma patients. The identification of these factors allows for future development of risk stratification tools for clinicians. Systematic Review and Meta-Analysis; Level III.