Investigating the Utility of the SOFA Score and Creating a Modified SOFA Score for Predicting Mortality in the Intensive Care Units in a Tertiary Hospital in Jordan.

Background: The utility of the Sequential Organ Failure Assessment (SOFA) score in predicting mortality in the intensive care unit (ICU) has been demonstrated before, but serial testing in various settings is required to validate and improve the score. This study examined the utility of the SOFA score in predicting mortality in Jordanian ICU patients and aimed to find a modified score that required fewer laboratory tests. Methods: A prospective observational study was conducted at Jordan University Hospital (JUH). All adult patients admitted to JUH ICUs between June and December 2020 were included in the study. SOFA scores were measured daily during the whole ICU stay. A modified SOFA score (mSOFA) was constructed from the available laboratory, clinical, and demographic data. The performance of the SOFA, mSOFA, qSOFA, and SIRS in predicting ICU mortality was assessed using the area under the receiver operating characteristic curve (AUROC). Results: 194 patients were followed up. SOFA score (mean ± SD) at admission was significantly higher in non-survivors (7.5 ± 3.9) compared to survivors (2.4 ± 2.2) and performed the best in predicting ICU mortality (AUROC = 0.8756, 95% CI: 0.8117-0.9395) compared to qSOFA (AUROC = 0.746, 95% CI: 0.655-0.836) and SIRS (AUROC = 0.533, 95% CI: 0.425-0.641). The constructed mSOFA included points for the hepatic and CNS SOFA scores, in addition to one point each for the presence of chronic kidney disease or the use of breathing support; it performed as well as the SOFA score in this cohort or better than the SOFA score in a subgroup of patients with heart disease. Conclusion: SOFA score was a good predictor of mortality in a Jordanian ICU population and better than qSOFA, while SIRS could not predict mortality. Furthermore, the proposed mSOFA score which employed fewer laboratory tests could be used after validation from larger studies.

Knowledge, Attitude, and Practices toward Hepatitis B Infection among Healthcare Students-A Nationwide Cross-Sectional Study in Jordan.

The World Health Organization has estimated that around 66 thousand HBV infection cases are caused by needlestick injuries annually. Healthcare students should be aware of HBV transmission routes and preventive measures. This study assessed the knowledge, attitudes, and practices toward HBV among Jordanian healthcare students and its associated factors. A cross-national study was conducted from March to August 2022. The questionnaire was composed of four sections: participants' sociodemographics, knowledge, attitudes, and practices about HBV, and 2322 participants were enrolled. The collected responses were analyzed with SPSS software (version 25 (IBM Corp., Armonk, NY, USA)) using descriptive statistics, unpaired t-tests, chi-square tests, and multivariate regression analyses. A p-value ≤ 0.05 was considered statistically significant. The results showed that 67.9% were females, 26.4% were medical students, and 35.9% were in their 3rd year. Overall, 40% of the participants held high levels of knowledge and attitudes. Further, 63.9% of participants had good practices toward HBV. Gender, year of study, encountering HBV patients, college, and having extra HBV courses were associated with high levels of KAP. This study demonstrated insufficient knowledge and attitudes toward HBV; however, the practice level toward HBV among healthcare students was promising. Therefore, public health efforts should modify the knowledge and attitude gaps to reinforce awareness and minimize the risk of infection.

Knowledge, attitudes, and practices toward tuberculosis among Jordanian university students.

Background: Tuberculosis (TB) is one of the leading causes of death from infectious diseases worldwide with numerous undiagnosed and untreated cases, emphasizing the need for TB awareness to minimize transmission and initiate early treatment. Data regarding the knowledge, attitudes, and practices (KAP) toward TB among Jordanians is lacking but requires attention given the massive migration spells to Jordan from neighboring countries in the past decade. Methods: A descriptive cross-sectional study was conducted from May to June 2022. An online questionnaire was developed following World Health Organization (WHO) recommendations for TB KAP surveys and was distributed to Jordanian university students. The questionnaire documented sociodemographic data and measured participants' KAP toward TB. Descriptive and analytic statistics were used to report KAP levels and highlight relevant sociodemographic factors associated with better KAP. Results: 602 participants completed the survey; most were females (60.8%), in their first 3 years of school (84.4%), and from a healthcare field of study (57.0%). The knowledge section median score was 27 out of 51. Knowledge gaps in TB treatment, and to a lesser extent, TB transmission routes were identified. The attitudes section median score was 6 out of 9, attitudes were generally positive toward TB patients with no indication of a social stigma. The practice section median score was 6 out of 8, most participants would take the correct measures if they suspected being infected, yet around 41.0% were not confident that masks are important in preventing airborne diseases. Students in healthcare specialties had significantly better KAP scores and identifying as a smoker was associated with a lower practice score. Conclusion: Although university students displayed satisfactory KAP scores, the focus should be aimed at informing students from non-healthcare fields on TB transmission routes, treatment options, and the role of masks in preventing disease transmission.

Anti-SARS-Cov-2 S-RBD IgG Formed after BNT162b2 Vaccination Can Bind C1q and Activate Complement.

Background: The ability of vaccine-induced antibodies to bind C1q could affect pathogen neutralization. In this study, we investigated C1q binding and subsequent complement activation by anti-spike (S) protein receptor-binding domain (RBD) specific antibodies produced following vaccination with either the mRNA vaccine BNT162b2 or the inactivated vaccine BBIBP-CorV. Methods: Serum samples were collected in the period of July 2021-March 2022. Participants' demographic data, type of vaccine, date of vaccination, as well as adverse effects of the vaccine were recorded. The serum samples were incubated with S protein RBD-coated plates. Levels of human IgG, IgA, IgM, C1q, and mannose-binding lectin (MBL) that were bound to the plate, as well as formed C3d, and C5b-9 were compared between different groups of participants. Results: A total of 151 samples were collected from vaccinated (n = 116) and nonvaccinated (n = 35) participants. Participants who received either one or two doses of BNT162b2 formed higher levels of anti-RBD IgG and IgA than participants who received BBIBP-CorV. The anti-RBD IgG formed following either vaccine bound C1q, but significantly more C1q binding was observed in participants who received BNT162b2. Subsequently, C5b-9 formation was significantly higher in participants who received BNT162b2, while no significant difference in C5b-9 formation was found between the nonvaccinated and BBIBP-CorV groups. The formation of C5b-9 was strongly correlated to C1q binding and not to MBL binding, additionally, the ratio of formed C5b-9/bound C1q was significantly higher in the BNT162b2 group. Conclusion: Anti-RBD IgG formed following vaccination can bind C1q with subsequent complement activation, and the degree of terminal complement pathway activation differed between vaccines, which could play a role in the protection offered by COVID-19 vaccines. Further investigation into the correlation between vaccine protection and vaccine-induced antibodies' ability to activate complement is required.

Complement Terminal Pathway Activation is Associated with Organ Failure in Sepsis Patients.

BACKGROUND: Complement plays a pivotal role in the immune response to infection. Several studies demonstrated complement activation in sepsis, yet little is known of the relationship of complement terminal pathway activation and the clinical characteristics of sepsis patients. Therefore, we investigated serum C5, soluble C5b-9 (sC5b-9), and soluble CD59 (sCD59) and their relation to organ failure in sepsis patients in the intensive care unit (ICU). METHODS: In this prospective cohort study, all available patients admitted to the adult ICUs between June 2020 and January 2021 were included. Patients were divided into sepsis and non-sepsis groups according to the Sepsis-3 criteria, serum samples from both groups were investigated for the levels of C5, sC5b-9, and sCD59 using commercial sandwich ELISA kits. RESULTS: We analyzed 79 serum samples, 36 were from sepsis patients. We found that sepsis patients had significantly lower C5 (83.6± 28.4 vs 104.4± 32.0 µg/mL, p = 0.004) and higher sCD59 (380.7± 170.5 vs 288.9± 92.5 ng/mL, p = 0.016). sC5b-9, although higher in sepsis patients, did not reach statistical significance (1.5± 0.8 µg/mL vs 1.3± 0.7 µg/mL, p = 0.293). Sepsis patients who died during their ICU stay had significantly higher sCD59 compared to those who survived (437.0 ± 176.7 vs 267.8 ± 79.7 ng/mL, p = 0.003, respectively). Additionally, C5 and sCD59 both correlated to SOFA score in the sepsis group (rs = -0.44, P = 0.007 and = 0.43, P = 0.009, respectively), and a similar correlation was not found in the non-sepsis group. DISCUSSION: In sepsis patients, levels of C5 and sCD59, but not sC5b-9, correlated to the severity of organ damage measured by SOFA. A similar correlation was not found in non-sepsis patients. This indicated that organ damage associated with sepsis led to a more pronounced terminal pathway activation than in non-sepsis patients, it also indicated the potential of using C5 and sCD59 to reflect sepsis severity.

Evaluating Knowledge of Human Microbiota among University Students in Jordan, an Online Cross-Sectional Survey.

Human microbiota have a significant impact on the health of individuals, and reciprocally, lifestyle choices of individuals have an important effect on the diversity and composition of microbiota. Studies assessing microbiota knowledge among the public are lacking, although it is hypothesized that this knowledge can motivate healthier behavior. Hence, this study aimed to measure microbiota knowledge among university students, and the effect of this knowledge on behavioral beliefs. A descriptive cross-sectional study was conducted among students from various fields of study enrolled at the University of Jordan, using an online questionnaire. The questionnaire consisted of 3 parts: demographics, general knowledge of microbiota, and behavioral beliefs related to microbiota. Four hundred and two responses were collected from verified university students. Participants were divided into two groups depending on whether they took a formal microbiology course (45 h) or not. Results from those two groups were compared using appropriate statistical methods. Results showed that most participants, even those who did not take a formal microbiology course, displayed good knowledge of what microbiota is and how they can be influenced by personal and environmental factors. Participants who took a microbiology course had significantly higher microbiota knowledge scores and were more aware of the effect of antibiotics on microbiota. Participants' behavioral beliefs regarding their antibiotic use, but not their diet and lifestyle choices, were affected by their knowledge of microbiota. The study indicates that disseminating knowledge regarding microbiota and microbiology in general, can improve behaviors related to antibiotic use.

Characteristics of Adult Sepsis Patients in the Intensive Care Units in a Tertiary Hospital in Jordan: An Observational Study.

Sepsis is a global health issue that is commonly encountered in the intensive care unit (ICU) and is associated with high morbidity and mortality. Available data regarding sepsis in low- and middle-income countries (LMIC) is lacking compared to higher income countries, especially using updated sepsis definitions. The lack of recent data on sepsis in Jordan prompted us to investigate the burden of sepsis among Jordanian ICU patients. We conducted a prospective cohort study at Jordan University Hospital, a tertiary teaching hospital in the capital, Amman. All adult patients admitted to the adult ICUs between June 2020 and January 2021 were included in the study. Patients' clinical and demographic data, comorbidities, ICU length of stay (LOS), medical interventions, microbiological findings, and mortality rate were studied. Descriptive and inferential statistics were used to analyse data from patients with and without sepsis. We observed 194 ICU patients during the study period; 45 patients (23.3%) were diagnosed with sepsis using the Sepsis-3 criteria. Mortality rate and median ICU LOS in patients who had sepsis were significantly higher than those in other ICU patients (mortality rate, 57.8% vs. 6.0%, p value < 0.001, resp., and LOS 7 days vs. 4 days, p value < 0.001, resp.). Additionally, sepsis patients had a higher combined number of comorbidities (2.27 ± 1.51 vs. 1.27 ± 1.09, p value < 0.001). The use of mechanical ventilation, endotracheal intubation, and blood transfusions were all significantly more common among sepsis patients. A causative organism was isolated in 68.4% of sepsis patients with a prevalence of Gram-negative bacteria in 77.1% of cases. While the occurrence of sepsis in the ICU in Jordan is comparable to other regions in the world, the mortality rate of sepsis patients in the ICU remains high. Further studies from LMIC are required to reveal the true burden of sepsis globally.

Using chemiluminescence imaging of cells (CLIC) for relative protein quantification.

Cell physiology and cellular responses to external stimuli are partly controlled through protein binding, localization, and expression level. Thus, quantification of these processes is pivotal in understanding cellular biology and disease pathophysiology. However, it can be methodologically challenging. Immunofluorescence is a powerful technique, yet quantification by this method can be hampered by auto-fluorescence. Here we describe a simple, sensitive and robust chemiluminescence-based immunoassay (chemiluminescence imaging of cells; CLIC) for relative quantification of proteins. We first employed this method to quantify complement activation in cultured mammalian cells, and to quantify membrane protein expression, shedding, binding and internalization. Moreover, through specific membrane permeabilization we were able to quantify both cytosolic and nuclear proteins, and their translocation. We validated the CLIC quantification method by performing parallel experiments with other quantification methods like ELISA, qPCR, and immunofluorescence microscopy. The workflow of the immunoassay was found to be advantageous in certain instances when compared to these quantification methods. Since the reagents used for CLIC are common to other immunoassays with no need for specialized equipment, and due to the good linearity, dynamic range and signal stability inherent to chemiluminescence, we suggest that this assay is suitable for both small scale and high throughput relative protein quantification studies in whole cells.

EGFR modulates complement activation in head and neck squamous cell carcinoma.

BACKGROUND: The epidermal growth factor receptor (EGFR) is pivotal for growth of epithelial cells and is overexpressed in several epithelial cancers like head and neck squamous cell carcinoma (HNSCC). EGFR signalling is also involved in diverse innate immune functions in epithelia. We previously found a role for EGFR in modulating the complement system in skin, this prompted an investigation into EGFR role in complement modulation in HNSCC. METHODS: We used patient derived HNSCC cell lines with varying sensitivities to EGFR inhibitors, and generated EGFR inhibition resistant cell lines to study the role of EGFR in modulating complement in HNSCC. RESULTS: We found that HNSCC cell lines activate the complement system when incubated with human serum. This complement activation was increased in cell lines sensitive to EGFR inhibition following the use of the tyrosine kinase inhibitor Iressa. Sensitive cell line made resistant to EGFR-inhibitors displayed complement activation and a decrease in complement regulatory proteins even in the absence of EGFR-inhibitors. Complement activation did not cause lysis of HNSCC cells, and rather led to increased extracellular signal-regulated kinase (ERK) phosphorylation in one cell line. CONCLUSION: These data indicate that EGFR has a complement modulatory role in HNSCC, and that a prolonged EGFR-inhibition treatment in sensitive cancer cells increases complement activation. This has implications in understanding the response to EGFR inhibitors, in which resistance and inflammatory skin lesions are two major causes for treatment cessation.

A novel mechanism for NETosis provides antimicrobial defense at the oral mucosa.

Neutrophils are essential for host defense at the oral mucosa and neutropenia or functional neutrophil defects lead to disordered oral homeostasis. We found that neutrophils from the oral mucosa harvested from morning saliva had released neutrophil extracellular traps (undergone NETosis) in vivo. The NETosis was mediated through intracellular signals elicited by binding of sialyl Lewis(X) present on salival mucins to l-selectin on neutrophils. This led to rapid loss of nuclear membrane and intracellular release of granule proteins with subsequent neutrophil extracellular trap (NET) release independent of elastase and reduced NAD phosphate-oxidase activation. The saliva-induced NETs were more DNase-resistant and had higher capacity to bind and kill bacteria than NETs induced by bacteria or by phorbol-myristate acetate. Furthermore, saliva/sialyl Lewis(X) mediated signaling enhanced intracellular killing of bacteria by neutrophils. Saliva from patients with aphthous ulcers and Behçet disease prone to oral ulcers failed to induce NETosis, but for different reasons it demonstrated that disordered homeostasis in the oral cavity may result in deficient saliva-mediated NETosis.

The epidermal growth factor receptor is a regulator of epidermal complement component expression and complement activation.

The complement system is activated in response to tissue injury. During wound healing, complement activation seems beneficial in acute wounds but may be detrimental in chronic wounds. We found that the epidermal expression of many complement components was only increased to a minor extent in skin wounds in vivo and in cultured keratinocytes after exposure to supernatant from stimulated mononuclear cells. In contrast, the epidermal expression of complement components was downregulated in ex vivo injured skin lacking the stimulation from infiltrating inflammatory cells but with intact injury-induced epidermal growth factor receptor (EGFR)-mediated growth factor response. In cultured primary keratinocytes, stimulation with the potent EGFR ligand, TGF-α, yielded a significant downregulation of complement component expression. Indeed, EGFR inhibition significantly enhanced the induction of complement components in keratinocytes and epidermis following stimulation with proinflammatory cytokines. Importantly, EGFR inhibition of cultured keratinocytes either alone or in combination with proinflammatory stimulus promoted activation of the complement system after incubation with serum. In keratinocytes treated solely with the EGFR inhibitor, complement activation was dependent on serum-derived C1q, whereas in keratinocytes stimulated with a combination of proinflammatory cytokines and EGFR inhibition, complement activation was found even with C1q-depleted serum. In contrast to human keratinocytes, EGFR inhibition did not enhance complement component expression or cause complement activation in murine keratinocytes. These data demonstrate an important role for EGFR in regulating the expression of complement components and complement activation in human epidermis and keratinocytes and, to our knowledge, identify for the first time a pathway important for the epidermal regulation of complement activation.