Desempenho do óxido nítrico na sepse: uma revisão de escopo / Desempeño del óxido nítrico en la sepsis: una revisión de alcance / Performance of nitric oxide in sepsis: a scoping review

Resumo Objetivo Mapear as evidências disponíveis sobre as ações do óxido nítrico na fisiopatologia da sepse e sua relação com a gravidade de pacientes sépticos. Método Revisão de escopo de acordo com a metodologia do Joanna Briggs Institute. Realizou-se busca por estudos que evidenciaram as ações do óxido nítrico na sepse e se o seu aumento está associado à gravidade de pacientes sépticos. Dois revisores independentes fizeram o mapeamento das informações utilizando um instrumento de extração de dados previamente elaborado. Os dados foram analisados quanto à sua relevância, sendo posteriormente extraídos e sintetizados. Resultados De 1342 estudos, 11 foram incluídos na revisão. O primeiro foi publicado em 2017 e o último, em 2022. A maioria foi desenvolvida nos Estados Unidos, na China e na Alemanha. Os estudos apresentaram informações referentes as ações do óxido nítrico, sintetizando sua biodisponibilidade e os inibidores endógenos relacionados a sua produção, além de abordarem a relação do óxido nítrico com a gravidade da sepse. Conclusão A produção de óxido nítrico fisiológico durante a sepse atua como protetor vascular, principalmente na microcirculação, porém, em altas concentrações, contribui para a disfunção vascular, que subverte a fisiologia da regulação da pressão arterial, causando profunda vasodilatação e hipotensão refratária e aumentando a gravidade de pacientes sépticos.

Resumen Objetivo Mapear las evidencias disponibles sobre las acciones del óxido nítrico en la fisiopatología de la sepsis y su relación con la gravedad de pacientes sépticos. Métodos Revisión de alcance de acuerdo con la metodología del Joanna Briggs Institute. Se realizó una búsqueda de estudios que evidenciaron las acciones del óxido nítrico en la sepsis y si su aumento estaba asociado a la gravedad de pacientes sépticos. Dos revisores independientes hicieron el mapeo de la información utilizando un instrumento de extracción de datos previamente elaborado. Los datos se analizaron respecto a su relevancia, para luego extraerlos y sintetizarlos. Resultados De 1342 estudios, se incluyeron 11 en la revisión. El primero fue publicado en 2017 y el último en 2022. La mayoría se realizó en Estados Unidos, China y Alemania. Los estudios presentaron información referente a las acciones del óxido nítrico, sintetizando su biodisponibilidad y los inhibidores endógenos relacionados con su producción, además de abordar la relación del óxido nítrico con la gravedad de la sepsis. Conclusión La producción de óxido nítrico fisiológico durante la sepsis actúa como protector vascular, principalmente en la microcirculación. Sin embargo, en altas concentraciones, contribuye a la disfunción vascular, que subvierte la fisiología de la regulación de la presión arterial, causa una profunda vasodilatación e hipotensión refractaria y aumenta la gravedad de pacientes sépticos. Registro da revisão de escopo no Open Science Framework: https://doi.org/10.17605/OSF.IO/MXDK2

Abstract Objective Map the available evidence on the actions of nitric oxide in the pathophysiology of sepsis and its relationship with the severity of sepsis in patients. Method Scoping review following the Joanna Briggs Institute methodology. A search was carried out for studies that highlighted the actions of nitric oxide in sepsis, informing whether its increase is associated with the severity of sepsis in patients. Two independent reviewers mapped the information using a previously designed data extraction instrument. The data was analyzed for its relevance and then extracted and synthesized. Results Eleven of 1342 studies were included in the review. The first of them was published in 2017 and the last in 2022. Most of them were developed in the USA, China, and Germany. Studies have reported the actions and bioavailability of nitric oxide and endogenous inhibitors related to its production, and related nitric oxide to the severity of sepsis. Conclusion The physiological production of nitric oxide during sepsis acts as a vascular protector, mainly in the microcirculation but contributes to vascular dysfunction in high concentrations, subverting the regulation of blood pressure, causing deep vasodilation and refractory hypotension, and increasing the severity of sepsis in patients. Registration of the scoping review in the Open Science Framework: https://doi.org/10.17605/OSF.IO/MXDK2

Isquemia mesentérica aguda: un desafío de la medicina. Reporte de un caso

La isquemia intestinal aguda es una emergencia vascular provocada por fenómenos oclusivos y no oclusivos de la circulación mesentérica arterial y venosa, de difícil diagnóstico y pronóstico ominoso. Su incidencia va en aumento paulatino con el decurso de los años, asociada fundamentalmente al envejecimiento de la población. La tasa de mortalidad es elevada a pesar de los avances en el campo de la imagenología. Suele diagnosticarse de forma tardía, cuando está establecido el daño isquémico intestinal de carácter irreversible. El elemento imprescindible e indispensable lo constituye el tiempo que trascurre hasta la cirugía, por lo que su diagnóstico sigue siendo un reto clínico. El tratamiento exige medidas médicas intensivas, al igual que cirugía de revascularización y resección del intestino necrosado. Por desdicha, el examen físico y los hallazgos de laboratorio no son sensibles ni específicos para su diagnóstico. Teniendo en cuenta estos elementos, se presenta el caso de una paciente de 38 años con clínica difusa de vómitos, diarrea y dolor abdominal progresivo, que requirió intervención quirúrgica de urgencia con diagnóstico transoperatorio de isquemia mesentérica aguda. Durante su estancia hospitalaria se relaparotomizó en dos ocasiones, mantuvo soporte ventilatorio e inotrópico por fallo multiorgánico en la Unidad de Cuidados Intensivos, mostrando una adecuada evolución posquirúrgica. El objetivo de esta presentación es enfatizar en la clínica como elemento fundamental para abordar de forma correcta esta entidad en un medio hospitalario de limitados recursos diagnósticos imagenológicos, al abordar conceptos teóricos recientes y facilitar una adecuada actuación en la toma de decisiones.

Acute intestinal ischemia is a vascular emergency caused by occlusive and non-occlusive phenomena of the mesenteric arterial and venous circulation of difficult diagnosis and ominous prognosis. Its incidence is gradually increasing over the years, mainly associated with the ageing of the population. The mortality rate is high despite advances in the field of imaging. It is usually diagnosed late, when irreversible ischemic intestinal damage is established. The essential and indispensable element is the time that elapses until surgery, so its diagnosis continues to be a clinical challenge. Treatment requires intensive medical measures, as well as revascularization surgery and resection of the necrotic intestine. Unfortunately, physical examination and laboratory findings are neither sensitive nor specific for its diagnosis. Taking these elements into account, the authors present the case of a 38-year-old female patient with diffuse symptoms of vomiting, diarrhea and progressive abdominal pain that required emergency surgery with intraoperative diagnosis of acute mesenteric ischemia. During her hospital stay, she underwent re-laparotomy twice, maintained ventilatory and inotropic support due to multi-organ failure in the Intensive Care Unit, showing an adequate post-surgical evolution. The objective of this presentation is to emphasize in the clinic as a fundamental element to correctly address this entity in a hospital environment with limited imaging diagnostic resources by addressing recent theoretical concepts and facilitating adequate action in decision-making.

Case report of scrub typhus complicated by hypokalemia and multiple organ dysfunction syndrome

ABSTRACT CONTEXT: Scrub typhus, caused by Orientia tsutsugamushi, has a wide range of clinical manifestations, including meningoencephalitis, acute renal failure, pneumonitis, myocarditis, and septic shock. However, there are no documented cases of scrub typhus with hypokalemia. In this report, we present a case of scrub typhus with hypokalemia and multiple organ failure syndrome, highlighting the importance of electrolyte imbalance in patients with scrub typhus. CASE REPORT: A 59-year-old woman presented to the emergency department with abdominal pain that had been present for 1 day. On admission, the physical examination and laboratory test results indicated that the patient had renal, liver, and circulatory failure, and hypokalemia. She developed meningitis and disseminated intravascular coagulation during hospitalization. She recovered with appropriate management, and was discharged on day 17. CONCLUSION: This report highlights the potential for atypical presentations of scrub typhus, including a previously undocumented association with hypokalemia. Although the contribution of hypokalemia to the patient's clinical course remains uncertain, this case underscores the importance of considering electrolyte imbalance in the management of patients with scrub typhus. Further research is warranted to better understand the relationship between scrub typhus and electrolyte imbalance.

Septic complications in patients of traumatic brain injury: An impact on clinical and functional outcome

Background: Septic complications in traumatic brain injury causes short- and long-term cerebral dysregulation by disruption of blood brain barrier, reduced brain perfusion, neuroinflammation and deposition of amyloid. Materials and methods: The present study attempted to observe patients of traumatic brain injury for the development of septic complications during the hospital stay. 89 patients were included in the study with different grades of brain injury (Injury Severity Score (ISS) range, 9-72). The patients were managed according to the trauma protocol and classified into 3 groups based on the severity of trauma (ISS 9-17 (moderate), 18-30 (severe), and >32 (most severe)). The patients were observed for the development of major septic complications during the course of their hospital stay, which impacted on the morbidity and mortality while determining the clinical and functional outcome at the end. Results: Mean age of the study population was 33.5 years. TBI was more common in younger age groups with severe grades of injury, those with multiplicity of head injuries, sepsis with a pulmonary focus, prolonged ICU and in-hospital stay together with high mortality. Septic complications were also more common in cases with higher grades of TBI and more prolonged hospital stay. Patients requiring intubation had a higher risk of developing infectious complications. 69 patients (77.5%) required intubation and mechanical ventilation. Pneumonia was the most common source of sepsis leading to the respiratory failure while the most common cause being aspiration at the time of injury Genitourinary complications were also common leading to urosepsis. Most common organisms isolated were Staphylococcus aureus, Acinetobacter, klebsiella and Pseudomonas. Conclusion: Traumatic brain injury (TBI) when complicated by sepsis and multi organ failure increases the mortality and morbidity with less favorable clinical and functional outcome together with increased duration of ICU and hospital stay.

A retrospective and comparative study between quick sequential organ failure assessment, CURB-65, and early warning scorings in COVID-19 patients to predict the disease severity and outcome

Background: Predicting the severity of COVID-19 infection in advance is the key to success of its treatment outcome. Various scoring systems are used to detect the severity of this disease but this study targets three simple scoring systems based on the vital parameters and basic routine laboratory tests. Aims and Objectives: The aim of the study was to assess the predictability of three scoring systems (Quick sequential organ failure assessment [q SOFA], CURB-65, and Early Warning scoring system) for disease severity at presentation in a rural-based tertiary care center. Materials and Methods: An observational, descriptive, retrospective, and cross-sectional study was conducted at Diamond Harbour Government Medical College Covid Hospital from January 2021 to January 2022 to assess the predictability of q SOFA, CURB-65, and Early Warning scoring system for disease severity at presentation. Results: The total number of participants was 561 among total admitted 1367 patients. A short descriptive analysis obtained from the variables to analyze the scorings howed among total sample collected, 57% were male and 43% were female. In this study, 87% of patients were survived and the rest 13% succumbed (death). There is no statistically significant difference in mortality between both genders. Age, pulse rate, and respiratory rate have a significant correlation with the outcome and altered sensorium is also highly associated with mortality. The accuracy was also found to be little higher for National Early Warning score (NEWS) score than CURB-65 scoring and q SOFA scoring (0.919, 0.914 and 0.907). Although all the scoring systems have high sensitivity (>90%) (CURB 65: Most sensitive [0.99]), the specificities of all three scoring systems are below 50%. Among these three-scoring systems, NEWS showed the highest specificity (0.492) than q SOFA (0.423) and CURB 65 (0.394). Conclusion: We suggest NEWS score and CURB-65 as a better predictor for in-hospital mortality in COVID-19 patients as it is significantly sensitive and reasonably specific. It can be recommended in less equipped hospitals where only basic laboratory facilities are available. qSOFA can be utilized where no laboratory facility is available like in safe home and isolation centers.

A clinical research on relationship between sepsis-induced coagulopathy and prognosis in patients with sepsis / 中华急诊医学杂志

Objective:To evaluate the prognostic value of sepsis-induced coagulopathy (SIC) in patients with sepsis.Methods:From January 2019 to December 2021, patients with sepsis admitted to the Intensive Care Unit of our hospital were retrospectively classified into the SIC group and non-SIC group according to SIC diagnostic criteria. The baseline clinical data, severity score, total length of hospital stay, length of ICU stay and 28-day survival were compared between the two groups. Kaplan-Meier was used to compare the 28-day survival of patients with sepsis between the two groups. Cox proportional hazard regression model was employed to analyze the risk factors of prognosis in patients with sepsis.Results:Totally 274 patients with sepsis were included in the analysis, including 139 patients in the SIC group and 135 patients in the non-SIC group. The two groups were compared in the perspectives of the Platelet count (PLT), prothrombin time (PT) , procalcitonin (PCT), D dimer, hematocrit, red blood cell distribution width, hemoglobin, acute kidney injury (AKI), the use of continuous renal replacement treatment (CRRT), the use of vasoactive drugs, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHEⅡ) score were compared between the two groups and the difference were statistically different (all P<0.05). Kaplan-Meier analysis showed that the 28-day mortality rate in the SIC group was significantly higher than that in the non-SIC group (32.4% vs. 14.1%, P<0.05). COX proportional hazard model showed that SIC score ( HR= 2.17, 95% CI: 1.15-3.91, P<0.05), APACHEⅡ score ( HR= 1.13, 95% CI: 1.09-1.17, P<0.05) and the use of vasoactive drugs ( HR=3.66, 95% CI: 1.53-8.75, P<0.05) were independent influencing factors for 28-day death in patients with sepsis. Conclusions:Patients with sepsis and SIC have more severe disease and increased mortality risk. SIC score exhibits good clinical value in predicting the prognosis of patients with sepsis.

Evaluation of age-adjusted Charlson comorbidity index on prognosis and application timing of Shenfu injection in elderly patients with septic shock / 中华急诊医学杂志

Objective:To evaluate the value of age-adjusted Charlson comorbidity index (aCCI) in the clinical prognosis of sepsis and septic shock in the elderly, and to further explore the role of aCCI in evaluating the timing of Shenfu injection in elderly patients with septic shock.Methods:Clinical data of elderly patients with sepsis and septic shock in Dongzhimen Hospital of Beijing University of Chinese Medicine from January 1, 2019 to January 1, 2022 were retrospectively analyzed. With the median aCCI score of all samples as the cutoff value, the patients were divided into the low aCCI score group and high aCCI score group. The prognosis of elderly patients with septic shock and the application timing of Shenfu injection with aCCI score and sequential organ failure assessment (SOFA) were compared.Results:A total of 61 patients were included, including 31 patients in the high aCCI score group. The proportion of septic shock in elderly sepsis patients was lower in the low aCCI score group ( P < 0.05). The aCCI score (95% CI: 1.229-2.615; P< 0.01) was more valuable than SOFA score (95% CI: 1.035-1.607; P< 0.05) in predicting septic shock in elderly patients with sepsis. The 28-day survival rate in the low aCCI score group was higher than that in the high aCCI score group ( P < 0.05). Both the SOFA score (95% CI: 1.010-1.364) and the aCCI score (95% CI: 1.072-10.501) were independent factors affecting the 28-day survival rate. The use of Shenfu injection was associated with 28-day survival outcome in elderly patients with septic shock (95% CI: 0.012-0.788; P < 0.05). Conclusions:aCCI score is more effective than SOFA score in assessing the risk of shock in elderly patients with septic shock, and has a certain predictive value for the survival and prognosis of elderly patients with sepsis. Shenfu injection may be beneficial to the survival and prognosis of elderly patients with septic shock, but it needs to be further verified by large-scale prospective studies.

Monitoreo de las insuficiencias orgánicas en pacientes graves con hemopatías malignas por el uso de las células CAR-T / Monitoring of organ failures in critically ill patients with blood malignancies by the use of CAR - T cell

Introducción: La inmunoterapia con células T modificadas con receptor quimérico antígeno específico es un tratamiento prometedor para hemopatías malignas. Sin embargo, la activación dirigida de la respuesta inmunitaria desata en ciertos casos complicaciones específicas graves y mortales. Objetivos: Describir el monitoreo de las complicaciones por el uso de las células T con receptor antígeno quimérico en pacientes graves con hemopatías malignas. Métodos: Se realizó una investigación bibliográfico documental acerca del tema. Se consultaron las bases de datos de SciELO y PubMed de los últimos cinco años. Conclusiones: Se describieron las complicaciones derivadas de la terapia con células inmunoefectoras, que aumentan el desarrollo de insuficiencias orgánicas, a través del síndrome de liberación de citoquinas y el síndrome de toxicidad neurológica. El tratamiento se basó en establecer medidas de monitorización y soporte, tratamiento con anticonvulsivantes, corticosteroides e ingreso en los servicios de medicina intensiva de forma precoz. Se disminuyó el riesgo en la aparición de complicaciones y muerte con un adecuado monitoreo de las insuficiencias orgánicas derivadas de la inmunoterapia de células T con receptor antígeno quimérico.

Introduction: Immunotherapy with T-cells modified with antigen-specific chimeric receptor is a promising treatment for malignant hemopathies. However, the targeted activation of the immune response in certain cases unleashes specific severe and fatal complications. Objectives: To describe the monitoring of complications from the use of CAR T-cells in critically ill patients with blood malignancies. Methods: A bibliographical-documentary research on the subject was carried out. The SciELO and Pubmed databases of the last five years were consulted. Conclusions: Complications derived from the therapy with immunoeffector cells are described, which increase the development of organ failures, through the cytokine release syndrome and the neurological toxicity syndrome. Treatment is based on monitoring and support measures, treatment with anticonvulsants, corticosteroids, and early admission to intensive care. With adequate monitoring of organ failure derived from chimeric antigen receptor T-cell immunotherapy, a decreased risk of complications and death in these patients was carried out.

Factores relacionados con la mortalidad en niños diagnosticados de leucemia linfoide aguda con insuficiencias orgánicas / High risk factors in pediatric patients diagnosed with acute lymphoid leukemia with organ failur

Introducción: Los pacientes pediátricos con leucemia linfoide aguda se estratifican en tres grupos de riesgo: bajo, intermedio y alto. Hay condiciones predictivas de muerte en este grupo de pacientes que incluyen indicadores clínicos y de laboratorio, que en relación con estos factores desarrollan durante la enfermedad insuficiencias orgánicas. Objetivo: Analizar los factores asociados con la mortalidad en pacientes pediátricos diagnosticados de leucemia linfoide aguda con insuficiencias orgánicas. Métodos: Se realizó una investigación bibliográfico-documental acerca del tema. Se consultó fundamentalmente artículos de los últimos 10 años de las bases de datos de SciELO y PubMed. Análisis y síntesis de la información: Se describe los factores de alto riesgo en pacientes pediátricos graves con insuficiencias orgánicas, desde aquellos ya establecidos en protocolos nacionales e internacionales; así como los propios que se desencadenan en los pacientes con disfunción orgánica y su relación en la evolución desfavorable del paciente. Conclusiones: Se encontró una relación entre los factores de alto riesgo en pacientes pediátricos diagnosticados de leucemia linfoide aguda con el desarrollo de insuficiencias orgánicas como complicaciones y muerte en estos grupos de enfermos.

Introduction: Pediatric patients with acute lymphoid leukemia are stratified into three risk groups: low, intermediate and high. There are conditions predictive of death in this group of patients that include clinical and laboratory indicators, which in relation to these factors develop organ insufficiencies during the disease. Objective: To relate the factors associated with mortality in pediatric patients diagnosed with acute lymphoid leukemia with organ failure. Methods: A bibliographic-documentary research on the subject was carried out. The Scielo and PubMed databases of the last ten years were fundamentally consulted. Analysis and synthesis of information: High-risk factors in severe pediatric patients with organ failure are described, from those already established in national and international protocols; as well as those that are triggered in patients with organic dysfunction and their relationship in the unfavorable evolution of the patient. Conclusions: A relationship was found between high risk factors in pediatric patients diagnosed with acute lymphoid leukemia with the development of organ failure as complications and death in these groups of patients.

Multisystem Inflammatory Syndrome in Children (MIS-C) temporally related to COVID-19: the experience at a pediatric reference hospital in Colombia / Síndrome inflamatória multissistêmica em criança associada à COVID-19: experiência em um hospital pediátrico de referência na Colômbia

Abstract Objective: This study aimed to describe the clinical characteristics and the different phenotypes of children with multisystem inflammatory syndrome in children (MIS-C) temporally related to COVID-19 and to evaluate the risk conditions that favored a greater severity of the disease during a 12-month period at a pediatric reference hospital in Colombia. Methods: A 12-month retrospective observational study of children under the age of 18 years who met criteria for MIS-C. Results: A total of 28 children presented MIS-C criteria. The median age was 7 years. Other than fever (100%) (onset 4 days prior to admission), the most frequent clinical features were gastrointestinal (86%) and mucocutaneous (61%). Notably, 14 (50%) children had Kawasaki-like symptoms. The most frequent echocardiographic abnormalities were pericardial effusion (64%), valvular involvement (68%), ventricular dysfunction (39%), and coronary artery abnormalities (29%). In addition, 75% had lymphopenia. All had at least one abnormal coagulation test. Most received intravenous immunoglobulin (89%), glucocorticoids (82%), vasopressors (54%), and antibiotics (64%). Notably, 61% had a more severe form of the disease and were admitted to an intensive care unit (median 4 days, mean 6 days); the severity predictors were patients with the inflammatory/MIS-C phenotype (OR 26.5; 95%CI 1.40-503.7; p=0.029) and rash (OR 14.7; 95%CI 1.2-178.7; p=0.034). Two patients had macrophage activation syndrome. Conclusions: Coronary artery abnormalities, ventricular dysfunction, and intensive care unit admission were frequent, which needs to highlight the importance of early clinical suspicion.

Resumo Objetivo: Descrever as características clínicas e os diferentes fenótipos de crianças com síndrome inflamatória multissistêmica na criança temporalmente relacionada com a COVID-19 (do inglês multisystem inflammatory syndrome in children — MIS-C) e avaliar as condições de risco que favorecem a maior gravidade da doença durante um período de 12 meses em um hospital pediátrico de referência na Colômbia. Métodos: Estudo retrospectivo de 12 meses de observação de crianças menores de 18 anos que cumprem os critérios para o MIS-C. Resultados: Vinte e oito crianças foram apresentadas com os critérios do MIS-C. A idade média era de sete anos, e 54% eram do sexo masculino. Para além da febre (100%) (com início quatro dias antes da admissão), as características clínicas mais frequentes eram gastrointestinais (86%) e mucocutâneas (61%). Quatorze crianças (50%) apresentavam sintomas semelhantes aos de Kawasaki. As anomalias ecocardiográficas mais frequentes foram derrame pericárdico (64%), envolvimento valvar (68%), disfunção ventricular (39%) e anomalias coronárias (29%). Tinham linfopenia 75% das crianças. Todas tinham algum teste de coagulação anormal. A maioria recebeu imunoglobulina intravenosa (89%), glucocorticoides (82%), vasopressores (54%) e antibióticos (64%). Tiveram envolvimento mais grave 61% dos pacientes, que precisaram ser internados em unidade de terapia intensiva (mediana de quatro dias, média de seis dias); os preditores de gravidade foram pacientes com fenótipo inflamatório/ MIS-C (odds ratio — OR 26,5; intervalo de confiança — IC95% 1,4-503,7; p=0,029) e erupção cutânea (OR 14,7; IC95% 1,2-178,7; p=0,034). Dois pacientes (7%) apresentavam síndrome de ativação macrofágica. Conclusões: Alteração da artéria coronária, disfunção ventricular e internação na unidade de terapia intensiva foram frequentes, o que nos alerta sobre a importância da suspeita clínica precoce.

Recognition of the clinical classification of acute－on－chronic liver failure： Redefinition from a new perspective of onset manifestations and dynamic outcomes / 临床肝胆病杂志

Acute－on－chronic liver failure （ACLF） refers to acute liver function decompensation on the basis of chronic liver diseases and is a complex clinical syndrome characterized by organ failure and high short－term mortality. ACLF is reversible and has diverse long－term outcomes and prognoses. The clinical classification of ACLF based on disease characteristics is of great significance for optimizing the management pathways for ACLF. With reference to the definition and clinical features of ACLF in the East and the West， this article redefines ACLF from the new perspective of onset manifestations and dynamic outcomes and proposes a new clinical classification of ACLF. The first classification of ACLF is based on the clinical features of intrahepatic and extrahepatic organ failure at disease onset， i.e.， type Ⅰ ACLF （liver failure on the basis of chronic liver diseases） and type Ⅱ ACLF （acute decompensation on the basis of chronic liver diseases comorbid with multiple organ failure）. The second classification is the dynamic clinical classification of ACLF based on clinical outcome， i.e.， type A （rapid progression）， type B （rapid recovery）， type C （slow progression）， type D （slow recovery）， and type E （slow persistence）. The proposed clinical classification of ACLF from the new perspective expects Eastern and Western scholars to have a more inclusive understanding of ACLF， narrow differences， optimize disease management paths， and rationally use medical resources， thereby providing a reference for clinicians.

Research progress in complications and their prevention and treatment strategies during extracorporeal membrane oxygenation support for severe trauma / 中华创伤杂志

Extracorporeal membrane oxygenation (ECMO) is a technique in which breathing and circulation are supported extracorporeally. Severe trauma may induce cardiopulmonary failure, for which ECMO can play an adjunctive role in the salvage treatment of circulatory and respiratory failure when conventional treatments are ineffective. Bypass with ECMO can rapidly improve the state such as circulatory failure and hypoxemia in critically ill patients in short term and can partially or fully replace their cardiopulmonary function in long term, winning valuable time for normal recovery of cardiopulmonary function. Because of the physical state of severe trauma patients and the ECMO equipment, there are still various complications clinically. Trauma patients show high risk of bleeding, vulnerability to wound infection and probability of combined organ injury and dysfunction, so more comprehensive measures for the prevention and treatment of complications during the use of ECMO therapy are required. The authors review the research progress in complications and corresponding prevention and treatment strategies during ECMO support for severe trauma, aiming to provide a reference to prevent and treat these complications.

Progress in the application of blood purification treatment mode in the treatment of wasp sting patients / 中国医师杂志

Wasp sting is a common emergency in mountainous areas of China, with rapid onset and progression, high mortality rate, and serious harm to public health. Wasp sting can cause mild local reactions in mild cases, and Anaphylaxis or even multiple organ dysfunction in severe cases, of which Acute kidney injury (AKI) is the most common and serious. Blood purification treatment is commonly used for wasp sting patients to maintain renal function, eliminate toxins, and maintain Internal environment stability. The commonly used clinical methods are Hemoperfusion (HP), plasma exchange (PE), and continuous renal replacement therapy (CRRT). At present, there is no clear recommendation for the blood purification treatment mode of wasp sting in China, and there is no clear guidance for its combined treatment mode. This article will review the single and combined use of blood purification treatment models for wasp stings, based on the latest clinical research.

Relationship between serum interleukin-6 and interleukin-10 levels and the clinical prognosis of severe acute pancreatitis / 中国基层医药

Objective:To investigate the relationship between serum interleukin-6 and interleukin-10 levels and clinical prognosis in patients with severe acute pancreatitis.Methods:Ninety-two patients with severe acute pancreatitis who received treatment in The Second People's Hospital of Liaocheng from August 2018 to July 2021 were included in this study. Serum interleukin (IL)-6 and IL-10 levels were detected. The Bedside Index of Severity in Acute Pancreatitis (BISAP) score was evaluated. Clinical interventions were performed. The relationship between serum IL-6 and IL-10 levels and the clinical prognosis of severe acute pancreatitis was investigated.Results:Serum IL-6 level [(103.75 ± 15.53) ng/L] was highest in patients who died. Serum IL-10 level [(97.33 ± 13.06) ng/L] was highest in patients with local complications. The highest number of patients with a prognostic outcome of death [26 (37.14%)] was found in patients with a BISAP score ≥ 3. Serum IL-6 level in patients with severe acute pancreatitis was positively correlated with the BISAP score ( r = 0.62, P < 0.05), and serum IL-6 level and BISAP score were negatively correlated with serum IL-10 level ( r = -0.57, -0.61, both P < 0.05). Conclusion:Increased or decreased serum IL-6 and IL-10 levels in patients with severe acute pancreatitis indicate that the patient's condition tends to worsen, and timely intervention according to serum IL-6 and IL-10 levels can improve the clinical prognosis of severe acute pancreatitis.

Comparing the Prognosticative Value of APACHE II and mSOFA Scores in Critically Ill Patients: A Prospective Study

Objective: Several predictive scoring systems measuring disease severity are used to predict outcomes, typically mortality, of critically ill patients in the intensive care unit (ICU). Two common validated predictive scoring systems include acute physiology and chronic health evaluation II (APACHE II) and modified sequential organ failure assessment score (mSOFA). To compare performance of APACHE II and mSOFA score in critically ill patients regarding the outcomes in the form of morbidity and mortality in ICU. Methods: This prospective observational clinical study was conducted on 100 patients over 6 months. For each patient, APACHE II score on day of admission and serial mSOFA scores on day 0, 3, 7 and 10 were calculated and compared. Results: The age of the non-survivors was significantly older than survivors was (57.1±11.76 and 54.28±15.16). [In our study we found that the mean length of ICU stay of non-survivors was (5.41±4.81) & survivors(8.63± 4.81) days.] In our study mortality rate was 40%.The APACHE II score with cut-off point of 23 demonstrated a sensitivity rate of 98.33% & specificity rate of 17.5%, accuracy of 66.00%. Serial mSOFA scores with cut-off of 11 on day0, day3, day7 better differentiated survivors from non-survivors with 98.3% sensitivity, 27.5% specificity and 70% accuracy. Conclusion: Both APACHE II and mSOFA scores can help ICU physicians as a significant predictive marker for mortality in critically ill patients. The serial measurement of mSOFA score in the first week is a better mortality predictor tool than APACHE II score in critically ill patients.

Application of insulin secretion index in disease assessment, multiple organ failure and prognosis prediction in patients with acute respiratory distress syndrome / 中国医师进修杂志

Objective:To investigate the effect of insulin secretion index (HOMA-β) in the evaluation of the condition of patients with acute respiratory distress syndrome (ARDS), multiple organ failure (MOF) and prognosis prediction.Methods:A retrospective analysis of the clinical data of 96 patients with ARDS hospitalized in Hangzhou Hospital of Zhejiang Medical Health Group from January 2019 to February 2021 was divided into MOF group (38 cases) and non-MOF group (58 cases). The baseline HOMA-β, oxygenation index, acute physiology and chronic health score Ⅱ (APACHE Ⅱ), sequential organ failure assessment (SOFA) and 28 d case fatality rate were collected and compared between the two groups. Compare the HOMA-β, oxygenation index, APACHE Ⅱ score, SOFA of ARDS patients with different survival prognosis. Logistic regression model analyzed the influence of HOMA-β, oxygenation index, APACHE Ⅱ, SOFA on the MOF and survival prognosis of ARDS patients. Pearson linear correlation method was used to analyze the relationship between HOMA-β and oxygenation index, APACHE Ⅱ, SOFA in ARDS patients. Receiver operating characteristic (ROC) curve was used to analyze the predictive power of HOMA-β on MOF and prognosis of ARDS patients.Results:The incidence of MOF and 28 d case fatality rate in 96 patients with ARDS were 39.58% (38/96) and 31.25% (31/96), respectively. The HOMA-β and oxygenation index in the MOF group were significantly lower than those in non-MOF group: 126.37 ± 28.75 vs. 178.52 ± 32.66, (125.41 ± 18.77) mmHg (1 mmHg = 0.133 kPa) vs. (153.62 ± 26.42) mmHg, while the APACHE Ⅱ, SOFA and 28 d case fatality rate were significantly higher than those in non-MOF group: (23.61 ± 4.68) points vs. (10.96 ± 2.85) points, (11.24 ± 1.65) points vs. (5.62 ± 0.87) points and 65.79% (25/38) vs. 10.34% (6/58), and there were statistical differences ( P<0.05). The HOMA-β and oxygenation index in dead ARDS patients were significantly lower than those in surviving ARDS patients: 89.62 ± 21.17 vs. 195.43 ± 35.64 and (121.66 ± 21.06) mmHg vs. (158.87 ± 28.71) mmHg, the APACHE Ⅱ and SOFA were significantly higher than those in surviving ARDS patients: (25.78 ± 5.42) points vs. (8.84 ± 2.51) points, (12.38 ± 1.22) points vs. (4.88 ± 0.83) points, and there were statistical differences ( P<0.05). Logistic regression model analysis showed that HOMA-β, oxygenation index, APACHE Ⅱ, SOFA of ARDS patients were all influencing factors of MOF and survival prognosis ( P<0.05). The results of Pearson linear correlation analysis showed that HOMA-β in ARDS patients was positively correlated with its oxygenation index ( P<0.05), and its APACHE Ⅱ and SOFA were negatively correlated ( P<0.05). ROC curve analysis results show that HOMA-β in ARDS patients has a high predictive power for their MOF and prognosis. Conclusions:The level of HOMA-β in ARDS patients is low, and it is closely related to its condition, MOF occurrence and survival prognosis. It can be used as a reference index for disease assessment and MOF and prognosis prediction of ARDS patients.

The predictive value of dynamic monitoring pediatric sequential organ failure assessment score for the prognosis in children with sepsis / 中国小儿急救医学

Objective:To dynamically monitor the pediatric sequential organ failure assessment(pSOFA) score of children in PICU at different time points, and to evaluate the predictive value of pSOFA score for the prognosis of children with sepsis.Methods:A multicenter prospective observational study was conducted to collect the data of children with sepsis admitted to the PICU of four children′s hospitals in Shanghai from December 2018 to December 2019(Children′s Hospital of Fudan University, Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Children′s Hospital Affiliated to Shanghai Jiaotong University School of Medicine, and Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine). We collected their pSOFA scores on the 1st, 3rd, and 7th day after sepsis diagnosis and the highest score.The patients were divided into survival group and death group according to the clinical outcomes at the time of leaving PICU.The clinical characteristics of two groups were compared.Receiver operating characteristic(ROC) curve were used to assess the resolution of the pSOFA score.Logistic regression was used to analyze the relationship between pSOFA score and sepsis mortality.Results:A total of 170 cases diagnosed sepsis were included, with a median age of 32.5(11.5, 83.2) months, and a median length of stay in PICU of 10(6, 21) days.Forty-two died and 128 survived.The medians of the 1st, 3rd, 7th day and the highest pSOFA score of the children in death group[10(7, 12) points, 9(5, 10) points, 7(4, 10) points, 11(7, 12) points, respectively] were higher than those in survival group[4(2, 8) points, 3(1, 6) points, 2(0, 5) points, 6(3, 8) points, respectively]( P<0.05). The area under the ROC curve of the pSOFA score predicting death on day 1 after sepsis diagnosis was greater than that on days 3, 7 and the highest pSOFA score[0.84(95% CI 0.79-0.91) vs.0.80(95% CI 0.71-0.89), 0.77(95% CI 0.65-0.89), 0.83(95% CI 0.77-0.90)], but the difference was not statistically significant( χ2=1.660, P=0.646). The pSOFA score on the first day of diagnosis had the best cut-off value of >6 points for predicting the risk of death from sepsis, with a sensitivity of 97.6% and a specificity of 53.9%.Logistic regression analysis of pSOFA score and childhood sepsis death showed that the OR values corresponding to the 1st, 3rd, 7th day of diagnosis and the highest pSOFA score were 1.58(95% CI 1.350-1.840), 1.39(95% CI 1.218-1.595), 1.38(95% CI 1.184-1.617) and 1.55(95% CI 1.333-1.800), respectively(all P<0.05). The 1-point increase in pSOFA score on the first day of diagnosis of sepsis was associated with a 58% increase in the hazard ratio for death, and each 1-point increase in the highest pSOFA score was associated with a 55% increase in the hazard ratio for death. Conclusion:The 1st, 3rd, 7th day of sepsis diagnosis and the highest pSOFA score could better predict the mortality risk of sepsis in children.Dynamic monitoring of the pSOFA score at different time points has a certain clinical value in predicting the progression and prognosis of children with sepsis.

The predictive value of dynamic monitoring pediatric sequential organ failure assessment score for the prognosis in children with sepsis / 中国小儿急救医学

Objective:To dynamically monitor the pediatric sequential organ failure assessment(pSOFA) score of children in PICU at different time points, and to evaluate the predictive value of pSOFA score for the prognosis of children with sepsis.Methods:A multicenter prospective observational study was conducted to collect the data of children with sepsis admitted to the PICU of four children′s hospitals in Shanghai from December 2018 to December 2019(Children′s Hospital of Fudan University, Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Children′s Hospital Affiliated to Shanghai Jiaotong University School of Medicine, and Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine). We collected their pSOFA scores on the 1st, 3rd, and 7th day after sepsis diagnosis and the highest score.The patients were divided into survival group and death group according to the clinical outcomes at the time of leaving PICU.The clinical characteristics of two groups were compared.Receiver operating characteristic(ROC) curve were used to assess the resolution of the pSOFA score.Logistic regression was used to analyze the relationship between pSOFA score and sepsis mortality.Results:A total of 170 cases diagnosed sepsis were included, with a median age of 32.5(11.5, 83.2) months, and a median length of stay in PICU of 10(6, 21) days.Forty-two died and 128 survived.The medians of the 1st, 3rd, 7th day and the highest pSOFA score of the children in death group[10(7, 12) points, 9(5, 10) points, 7(4, 10) points, 11(7, 12) points, respectively] were higher than those in survival group[4(2, 8) points, 3(1, 6) points, 2(0, 5) points, 6(3, 8) points, respectively]( P<0.05). The area under the ROC curve of the pSOFA score predicting death on day 1 after sepsis diagnosis was greater than that on days 3, 7 and the highest pSOFA score[0.84(95% CI 0.79-0.91) vs.0.80(95% CI 0.71-0.89), 0.77(95% CI 0.65-0.89), 0.83(95% CI 0.77-0.90)], but the difference was not statistically significant( χ2=1.660, P=0.646). The pSOFA score on the first day of diagnosis had the best cut-off value of >6 points for predicting the risk of death from sepsis, with a sensitivity of 97.6% and a specificity of 53.9%.Logistic regression analysis of pSOFA score and childhood sepsis death showed that the OR values corresponding to the 1st, 3rd, 7th day of diagnosis and the highest pSOFA score were 1.58(95% CI 1.350-1.840), 1.39(95% CI 1.218-1.595), 1.38(95% CI 1.184-1.617) and 1.55(95% CI 1.333-1.800), respectively(all P<0.05). The 1-point increase in pSOFA score on the first day of diagnosis of sepsis was associated with a 58% increase in the hazard ratio for death, and each 1-point increase in the highest pSOFA score was associated with a 55% increase in the hazard ratio for death. Conclusion:The 1st, 3rd, 7th day of sepsis diagnosis and the highest pSOFA score could better predict the mortality risk of sepsis in children.Dynamic monitoring of the pSOFA score at different time points has a certain clinical value in predicting the progression and prognosis of children with sepsis.

Combined monitoring of thrombelastography, coagulation function and mean platelet volume/platelet count ratio to evaluate the prognosis of patients with sepsis / 中华急诊医学杂志

Objective:To compare the value of difference between thromboelastogram (TEG), coagulation function and mean platelet volume (MPV)/platelet count (PLT) ratio in sepsis patients with short-term prognosis.Methods:A total of 271 patients with sepsis admitted to the Affiliated Hospital of Xuzhou Medical University from January 2020 to September 2021 were retrospectively analyzed. The clinical data of the patients were recorded, and the SOFA score and APACHE Ⅱ score were calculated. The patients were followed up within 28 days and were divided into the survival group and death group. The TEG, coagulation function and MPV/PLT ratio were compared between the two groups. The independent prognostic factors of Angle, CI, AT-Ⅲ, D-Di and MPV/PLT ratio were confirmed by Logistic regression analysis. The combination of Angle + CI + AT-Ⅲ + D-Di +MPV/PLT ratio was established, and the ROC curve was drawn to evaluate the prognostic value of Angle, CI, AT-Ⅲ and D-Di combined with MPV/PLT ratio in patients with sepsis.Results:The mortality rate of patients with sepsis was 42.4%. The D-Di and MPV/PLT ratio of the death group were significantly higher than those of the survival group, and the differences were statistically significant. Angle, CI and AT-III in the death group were significantly lower than those in the survival group, and the differences were statistically significant. Logistic regression analysis showed that Angle, CI, AT-Ⅲ, D-Di and MPV/PLT ratio were independent predictors of the prognosis of patients with sepsis (all P < 0.05) . The area under the curve of the combined detection of Angle, CI, AT-Ⅲ, D-DI and MPV/PLT ratio to evaluate the prognosis of sepsis at 28 days was 0.931, which was larger than that of Angle, CI, AT-Ⅲ, D-Di and MPV/PLT ratio alone (0.755, 0.790, 0.776, 0.729 and 0.746). The sensitivity and specificity of the combination of Angle, CI, AT-Ⅲ, D-Di and MPV/PLT ratio were 83.5% and 91.0%, which were also higher than those of the single index . Conclusions:Angle, CI, AT-Ⅲ, D-Di and MPV/PLT ratio are independent prognostic predictors of patients with sepsis. The combination of Angle, CI, AT-Ⅲ, D-Di and MPV/PLT ratio has high sensitivity and specificity in evaluating the prognosis of sepsis.

Influence of infection complications on the prognosis of patients with severe acute pancreatitis / 国际外科学杂志

Objective:To analyze the effects of infectious complications [infected pancreatic necrosis (IPN) and extra-pancreatic infection (EPI)] on the outcomes of patients with severe acute pancreatitis (SAP), and evaluate the differences in infection time, infection site and infecting species between SAP patients with infections complications.Methods:The clinical data of 66 SAP patients with combined infectious complications admitted to Xuanwu Hospital, Capital Medical University from January 2014 to December 2020 were retrospectively analyzed, and SAP patients were divided into IPN group ( n=7), EPI group ( n=14) and co-infection (EPI+ IPN) group ( n=45) according to the type of infection. Whether the study data conformed to a normal distribution was assessed by the Shapiro-Wilk test, normally distributed measures were expressed as mean ± standard deviation ( ± s), and ANOVA was used for comparison between groups; skewed measures were expressed as median (interquartile range) [ M ( Q1, Q3)], and the rank-sum test was used for comparison between groups. Bonferroni correction was used for multiple group comparisons ( P value significance level reduced to 0.017). Quantitative data were compared between groups using the χ2 test or Fisher's exact probability method. Results:There were no statistical differences between the three groups in terms of baseline data at admission (gender, age, etiology, modified CTSI score, degree of pancreatic necrosis, and number of organ failure) ( P>0.05), patients in the EPI group were referred earlier than the other two groups ( P<0.05). In clinical treatment, patients in the IPN group and co-infection group required multiple minimally invasive interventions compared with those in the EPI group ( P<0.05), and the number of patients requiring combined nutritional support, length of intensive care unit stay, and total length of hospital stay were higher in the co-infection group than in the other two groups ( P<0.05). In addition, 360 strains of pathogenic bacteria were cultured in this study, with Gram-negative bacteria being the most common, and patients with SAP were more likely to have EPI in the early stage of disease onset, with bacteremia and respiratory tract infections in the early stage (≤14 d), and bacteremia, urinary tract infections, and catheter-associated infections in the late stage (>14 d). Conclusions:Among patients with SAP, patients in the co-infection group had higher surgical intervention, nutritional support and length of hospital stay than those in the single infection group. It is advisable to prioritize EPI in SAP patients with suspected infections, and the common infectious strains in SAP patients are still predominantly Gram-negative bacteria, and clinicians need to adjust the treatment plan in a timely manner according to the changes in patients′ conditions.