Clinical features and risk factors for secondary hemophagocytic lymphohistiocytosis in elderly patients with severe SARS-CoV-2 infection: a multicenter retrospective cohort study / 中华危重病急救医学

Objective:To explore the incidence of secondary hemophagocytic lymphohistiocytosis (sHLH) in elderly patients with severe SARS-CoV-2 infection, and to analyze and summarize its clinical features and risk factors for early identification of high-risk groups.Methods:A retrospective cohort study was conducted. From January to May 2020, No. 960 Hospital of People's Liberation Army, the Second Hospital Affiliated to Cheeloo College of Medicine of Shandong Province, the First Rehabilitation Hospital of Shandong Province, the Public Health Clinical Center Affiliated to Shandong University, and Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine received 248 patients over 60 years old who were diagnosed with severe SARS-CoV-2 infection during their assistance to Hubei or support for diagnosis and treatment of SARS-CoV-2 infection in Shandong Province. The clinical data of patients were collected. According to the hemophagocytic lymphohistiocytosis diagnosis scoring (HScore) criteria, the patients were divided into sHLH group (HScore > 169) and non-sHLH group (HScore < 98). The demographic data, clinical features, laboratory results, the proportion of organ failure and 60-day mortality of patients were collected and compared between the two groups. The risk factors of sHLH and 60-day death were evaluated through binary multivariate Logistic regression analysis in elderly patients with severe SARS-CoV-2 infection. The receiver operator characteristic curve (ROC curve) was plotted to analyze the diagnostic value of indicators only or combined for sHLH.Results:Among 248 elderly patients with severe SARS-CoV-2 infection, 82 patients with incomplete data and untraceable clinical outcomes, and 35 patients with HScore of 98-169 were excluded. Finally, 131 patients were enrolled in the final follow-up and statistics, including 25 patients in the sHLH group and 106 patients in the non-sHLH group. Compared with the non-sHLH group, plasma albumin (ALB), hemoglobin (Hb), lymphocyte count (LYM), platelet count (PLT), fibrinogen (Fib) and prealbumin (PAB) in the sHLH group were significantly reduced, while alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), MB isoenzyme of creatine kinase (CK-MB), serum creatinine (SCr), C-reactive protein (CRP), D-dimer, ferritin (Fer), lactate dehydrogenase (LDH), procalcitonin (PCT), cardiac troponin I (cTnI), triglycerides (TG), interleukin-6 (IL-6), total bilirubin (TBil) were significantly higher. The fever and fatigue in the sHLH group were more severe than those in the non-sHLH group, and the patients in the sHLH group had higher rates of shock, acute kidney injury, liver dysfunction, and cardiac injury than the non-sHLH group. The 60-day mortality of patient in the sHLH group was significantly higher than that in the non-sHLH group [84.0% (21/25) vs. 40.6% (43/106), P < 0.01]. Binary multivariate Logistic regression analysis showed that high Fer [odds ratio ( OR) = 0.997, 95% confidence interval (95% CI) was 0.996-0.998], D-dimer ( OR = 0.960, 95% CI was 0.944-0.977), LDH ( OR = 0.998, 95% CI was 0.997-0.999) and TG ( OR = 0.706, 95% CI was 0.579-0.860) were independent risk factors for sHLH in elderly patients with severe SARS-CoV-2 infection (all P < 0.01), while elevated Fer ( OR = 1.001, 95% CI was 1.001-1.002), LDH ( OR = 1.004, 95% CI was 1.002-1.005) and D-dimer ( OR = 1.036, 95% CI was 1.018-1.055) were independent risk factors for 60-day death of patients (all P < 0.01). The death risk of the sHLH patients was 7.692 times higher than that of the non-sHLH patients ( OR = 7.692, 95% CI was 2.466-23.987, P = 0.000). ROC curve analysis showed that a three-composite-index composed of LDH, D-dimer and TG had good diagnostic value for sHLH in elderly patients with severe SARS-CoV-2 infection [area under the ROC curve (AUC) = 0.920, 95% CI was 0.866-0.973, P = 0.000]. Conclusions:Elderly patients with severe SARS-CoV-2 infection complicated by sHLH tend to be critically ill and have refractory status and worse prognosis. High Fer, LDH, D-dimer and TG are independent risk factors for sHLH, and are highly suggestive of poor outcome. The comprehensive index composed of LDH, D-dimer and TG has good diagnostic value, and can be used as an early screening tool for sHLH in elderly patients with severe SARS-CoV-2 infection.

Comparison of Charlson's weighted index of comorbidities with the chronic health score for the prediction of mortality in septic patients / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Comorbidity is one of the most important determinants of short-term and long-term outcomes in septic patients. Charlson's weighted index of comorbidities (WIC) and the chronic health score (CHS), which is a component of the acute physiology and chronic health evaluation (APACHE) II, are two frequently-used measures of comorbidity. In this study, we assess the performance of WIC and CHS in predicting the hospital mortality of intensive care unit (ICU) patients with sepsis.</p><p><b>METHODS</b>A total of 338 adult patients with sepsis were admitted to a multisystem ICU between October 2010 and August 2012. Clinical data were collected, including age, gender, underlying diseases, key predisposing causes, severity-of-sepsis, and hospital mortality. The APACHE II, CHS, acute physiology score (APS), sequential organ failure assessment (SOFA) and WIC scores were assessed within the first 24 hours of admission. Univariate and multiple Logistic regression analyses were used to compare the performance of WIC and CHS. The area under the receiver operating characteristic curve (AUC) was used to predict hospital mortality over classes of risk.</p><p><b>RESULTS</b>Of all the enrolled patients, 224 patients survived and 114 patients died. The surviving patients had significantly lower WIC, CHS, APACHE II, and SOFA scores than the non-surviving patients (P < 0.05). Combining WIC or CHS with other administrative data showed that the hospital mortality was significantly associated with age, severe sepsis, key predisposing causes such as pneumonia, a history of underlying diseases such as hypertension and congestive cardiac failure, and WIC, CHS and APS scores (P < 0.05). The AUC for the hospital mortality were 0.564 (95% confidence interval (CI) 0.496-0.631) of CHS, 0.663 (95% CI 0.599-0.727) of WIC, 0.770 (95% CI 0.718-0.822) of APACHE II, 0.856 (95% CI 0.815-0.897) of the CHS combined with other administrative data, and 0.857 (95% CI 0.817-0.897) of the WIC combined with other administrative data. The diagnostic value of WIC was better than that of CHS (P = 0.0015).</p><p><b>CONCLUSIONS</b>The WIC and CHS scores might be independent determinants for hospital mortality among ICU patients with sepsis. WIC might be an even better predictor of the mortality of septic patients with comorbidities than CHS.</p>

The effects of rhubarb on expression of glucocorticoids receptor and peripheral blood lymphocytes in burning-induced septic rats / 中国中西医结合急救杂志

Objective To investigate the effects of rhubarb on the expression of glucocorticoids receptor (GR)and peripheral blood lymphocytes in burning-induced septic rats. Methods Sixty-six male healthy Sprague-Dawley(SD)rats were randomly divided into sham operated control group(n=18),sepsis model group(n=24) and rhubarb treatment group(n=24),each group was further randomly divided into 12,24 and 72 hours subgroups according to different time points. The model of scald sepsis was replicated by scald injury induced by boiling water at the rat back accounting for 30% total body surface area(Ⅲ grade of scald),and administration of endotoxin (5 mg/kg)into the peritoneal cavity 12 hours after scald injury. After the successful establishment of septic models, the rats in the rhubarb treatment group were immediately infused with 50 mg/kg rhubarb powder dissolved in 1 mL saline through a gastric tube,while the rats in sham operated control group and sepsis model group received saline by the same way as a substitute for rhubarb. The the binding capacity of GR of peripheral blood leucocyte and binding activity of GR of hepatocyte were analyzed by radiation ligands binding assay. The CD4+,CD8+as well as CD4+/CD8+ ratio in peripheral blood lymphocytes were detected by flow cytometer. Results The binding capacity of GR of peripheral blood leucocyte and binding activity of GR of hepatocyte were significantly decreased in a time-dependent manner in sepsis model group compared to those of the sham operated control group,while in the rhubarb treatment group they were increased in a time-dependent manner after interference of rhubarb, and they were higher than those in the model group at the same time points〔leukocyte GR binding capacity (locus/cell)at 12,24,72 hours :1 515.38±300.44,1 859.63±258.26,1 890.50±307.88 vs. 1 122.63±225.39, 1 008.88±150.41,724.38±91.19;hepatocyte GR binding capacity(fmol/mg):210.19±26.26,258.01±20.98, 283.38±38.21 vs. 153.11±30.07, 129.83±26.89, 94.08±14.30, all P<0.01〕. Compared with the sham operated control group,the CD4+ and CD8+ were decreased in various degrees at 12 hours and 24 hours in the septic group, at 24 hours the differences being statistically significant (P<0.01 and P<0.05). CD4+/CD8+ratios were decreased significantly at all time points,the differences were statistically significant at 24 hours and 72 hours(both P<0.01). The CD4+ T cell and CD4+/CD8+ ratio at all the time points were increased at various degrees in the rhubarb treatment group,and the differences from those in the sepsis model group at 24 hours and 72 hours were statistically significant (1.58±0.69, 1.56±0.49 vs. 1.02±0.41, 1.01±1.68, both P<0.01). Conclusion Rhubarb can modulate the binding capacity of GR of peripheral blood leucocyte and the binding activity of GR of hepatocyte,and via its influence on the number of peripheral leucocytes,the immune dysfunction in the sepsis processes is improved.

Combination of Weighted index of comorbidities and sepsis-related organ failure assessment score in death risk evaluation of septic patients / 中华危重病急救医学

Objective To predict the risk of 28-day mortality in septic patients in intensive care unit (ICU) with the combination of Weighted index of comorbidities (WIC) and sepsis-related organ failure assessment (SOFA) score.Methods The clinical data of adult severe sepsis/septic shock patients in Department of Emergency Medicine of Changzheng Hospital and Department of Critical Care Medicine of Jinan Military General Hospital from October 2011 to February 2013 were analyzed retrospectively.The etiological factor,past history,having severe sepsis or not were recorded.Age score,WIC score,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and SOFA score were calculated at or 24 hours after admission.The logistic regression was used and the receiver operating characteristic curve (ROC curve) was drawn to calculate the patients' outcome.Results In 310 enrolled patients,223 (71.9％) patients survived and 87 (28.1％) died.Univariate analysis showed that the P values of the age score,WIC score,APACHE Ⅱ score and SOFA score,chronic cardiac insufficiency,type 2 diabetes,cerebrovascular disease,tumor,multiple injury,pulmonary infection and having severe sepsis or not were all less than 0.2.The above 11 variables were put into the multivariate logistic regression equation 1,of which predicted probability was reserved.It revealed that 5 variables were independently associated with 28-day prognosis,of which influence power in descending order were SOFA score [odds ratio (OR) =1.308,95％ confidence interval (95％ CI):1.158-1.478,P=0.000],having severe sepsis or not (OR =0.206,95％ CI:0.100-0.424,P=0.000),APACHE Ⅱ score (OR =1.090,95％CI:1.021-1.164,P=0.010),WICscore (OR=1.441,95％CI:1.067-1.947,P=0.017),agescore (OR=1.228,95％CI:1.027-1.468,P=0).024),the Walswere 18.554,18.369,6.725,5.662,5.067,respectively.The 3 variables,age score,WIC score and SOFA score,were brought into the multivariate logistic regression equation 2,of which predicted probability was reserved too.It revealed that age score (OR=1.330,95％CI:1.145-1.546,P=0.000),WIC score (OR =1.496,95％ CI:1.145-1.546,P=0.000) and SOFA score (OR =1.429,95％ CI:1.303-1.567,P=0.000),were independently associated with the septic patients' 28-day prognosis.There was no significant difference in the area under receiver operating characteristic curve (AUC) between the SOFA score and APACHE Ⅱ score (0.784 vs.0.780,Z=0.014,P=0.989).However,compared with APACHE Ⅱ score,the AUC of equation 1 (0.888) and 2 (0.851) were much more (Z=4.333,P=0.000; Z=2.669,P=0.008).Conclusion The sensitivity of 28-day prognosis by WIC score was improved greatly with the combination of SOFA score and age score.

Weighted index of comorbidities evaluates the impact of underlying diseases on hospital mortality of pneumonia patients / 中华急诊医学杂志

Objective To estimate the validity of Charlson' s weighted index of comorbidities (WIC) used to predicting 28-day mortality among ICU pneumonia patients with underlying diseases.Methods Aretrospective analysis of 160 adult patients with pneumonia admitted to a multi-discipline ICU of Shanghai Changzheng hospital between October 2010 and February 2012 was carried out.Clinical data were collected including age,gender,community acquired pneumonia (CAP) or hospital acquired pneumonia (HAP),underlying diseases,severity-of-sepsis,and 28-day mortality.WIC scores,acute physiology and chronic health evaluation (APACHE) Ⅱ,and sepsis related organ failure assessment (SOFA) were assessed within the first 24 hours after admission.Logistic regression analyses were used to evaluate the predictors for outcome.The receiver operating characteristic curve (ROC) was used to compare the performance of these scores between different methods.Results Of 160 enrolled patients,76 (48.8％) were CAP,82 (51.2％) HAP,and 106 (66.3％) male,54 (33.7％) female,and 99 (61.9％) patients survived and 61 (38.1％) died.The average age was (62.4 ± 17.3) years old.Compared with survivors,WIC,APACHE Ⅱ and SOFA scores were significantly higher in death group (P ＜ 0.05).The multivariate logistic regression revealed that risk of death depends predominantly on age (OR =1.049,95％ CI:1.011-1.088,P =0.011),WIC (OR =1.725,95％ CI:1.194-2.492,P =0.004),APACHE Ⅱ score (OR =1.175,95％CI:1.058-1.305,P =0.003),SOFA score (OR =1.277,95％ CI:1.048-1.556,P =0.015),presence of ARDS (OR =0.081,95％ CI:0.008-0.829,P =0.034),and complicated with severe sepsis (OR =0.149,95％ CI:0.232-0.622,P =0.004).The area under the receiver operating characteristics curve in predicting mortality was 0.639 (0.547-0.730) for the WIC,0.782 (0.709-0.856) for APACHE Ⅱ score,0.79 (0.714-0.866) for SOFA score and 0.842 (0.777-0.907) for the merger of three.Conclusions In pneumonia patients of ICU,WIC is a useful approach to predicting 28-day mortality,and the risk of death significantly depends on co-morbidities.

Value of critical care medicine scoring systems and procalcitonin in evaluation of severe multiple trauma / 中华创伤杂志

Objective To compare the value of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ),sequential organ failure assessment (SOFA) and procalcitonin (PCT) in assessment of severe multiple trauma. Methods A retrospective study was carried out on clinical data of patients with severe multiple trauma who were admitted to ICU from July 1 st 2010 to October 31 st 2011.PCT detection,APECHE Ⅱ and SOFA scoring were routinely performed for all the patients within 24 hours,and were performed again one week later for the patients who were complicated with sepsis within one week.Results The score of APACHE Ⅱ and SOFA in septic shock group was higher than that in severe septic and septic groups (P ＜0.01 ),while PCT level among septic,severe septic and septic shock groups had no statistical difference (P ＞ 0.05).To determine the predicting accuracy of APECHE Ⅱ score,SOFA score and PCT,receiver operating characteristic curve (ROC) was constructed.The areas under the curve (AUC) for APECHE Ⅱ score,SOFA score and PCT in predicting the emergence of sepsis on admission was 0.615,0.663 and 0.160 respectively.AUC for APECHE Ⅱ score,SOFA score and PCT in predicting the occurrence of death among the severe multiple trauma patients on admission was 0.576,0.571 and 0.619 respectively.AUC for APECHE Ⅱ,SOFA and PCT in predicting the death of patients complicated with sepsis at one week after admission was 0.746,0.837 and 0.600 respectively. Conclusions Among the APACHE Ⅱ score,SOFA score and PCT,APACHE Ⅱ and SOFA score are better than PCT in assessing the infection severity of sepsis.SOFA score is the best in predicting the occurrence of sepsis,while PCT is the worst.PCT is the best in predicting the occurrence of death of severe multiple trauma patients,while SOFA score is the worst.SOFA score is better than APACHE Ⅱ score and PCT in predicting the occurrence of death of the patients complicated with sepsis.