Patient-management problem in the evaluation of intensive medicine.

INTRODUCTION: In intensive care medicine (ICM), the use of Patient-Management Problem (PMP) remains limited and no feedback from students is available. AIM: To compare the feasibility of employing PMP referring to clinical cases (CC) as assessment tools for appraising the knowledge and competencies in ICM students; and to gather the students' perception regarding this experience. METHODS: it was a cross-sectional randomized trial. Were included, external students in the 3rd year of the 2nd cycle of medical studies (3rd-SCMS) during their ICM externship. All the participants underwent two random draws (the 1st one for assessment tool to be started (PMP or CC) and the 2nd for the passage order for PMP. Two PMPs versus two grouped QCMs-CC were prepared and a satisfaction questionnaire was distributed. The main judgment criterion was the effect of each assessment tool on the students' decision-making process. This focused on the relevance of the elements provided by each technique, the implication and the difficulty felt. The secondary endpoint was the scores taken for each tool tested. RESULTS: 20 students were included. All participants had previous experience with PMPs and only nine were familiar with grouped MCQs-CC. PMP scores were 14.9 for the 1st theme and 15.8 for the 2nd theme. The median of the grouped MCQs-CC scores was 14 [12-16] for both. The scores didn't differ between the two techniques. For the 1st theme: the scores were negatively correlated (r=-0.58 and p=0.007). Students felt a better satisfaction for PMP evaluation (p<10-3), the elements provided by PMP were more relevant for decision-making process (p<10-3), the involvement was more felt with PMP (p<10-3) and difficulty was more felt with CCs (p<10-3). The effect of PMP was found to be significant on clinical reasoning (n=36), self-assessment (n=38), problem solving (n=40) and decision making (n=39). Students recommended strongly PMP as a tool of evaluation in ICM (p<10-3). CONCLUSION: scores were comparable between the two tested techniques. The positive perception of students regarding PMP encourages its generalization and teacher training must be strengthened.

Immunologic effect and clinical impact of erythromycin in septic patients: A randomized clinical trial.

To investigate the potential regulatory effect of erythromycin added to standard care in septic patients on sepsis biomarkers and clinical outcome. It was a single-blind randomized trial including critical septic patients. The primary endpoint was the change in the TNF/IL-10 ratio between days 0 and 6. Changes in other biomarkers, vasopressor use, and 28-day mortality were secondary endpoints. One hundred and ten patients were examined (erythromycin group, n = 55 versus placebo group, n = 55). Clinical features of the groups were well matched. Erythromycin addition had no beneficial effects on the TNF/IL-10 ratio or mortality (51% vs. 47%, p = 0.62). Both groups' serum TNF/IL-10 ratios did not significantly rise (from 0.48 [0.34-1.18] to 0.59 [0.21-1.10] vs. 0.65 [0.25-1.14] to 0.93 [0.24-1.88] in the erythromycin and placebo groups, respectively; p values = 0.86 and 0.12). Serum Procalcitonin (PCT) and CRP dropped considerably in the Erythromycin group, whereas only PCT showed a drop in the placebo group. On day 6, the non-survivors' serum TNF/IL-10 ratio was lower than that of the survivors (0.55 [0.17-1.04] vs 1.08 [0.4-2.28], p = 0.029). Neither the pro/anti-inflammatory imbalance nor the mortality were impacted by the addition of erythromycin to standard care in septic patients (ClinicalTrials.gov ID: NCT04665089 (11/12/2020)).

Healthcare-associated infections in critical COVID-19 patients in Tunis: epidemiology, risk factors, and outcomes.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic disrupted adherences to healthcare-associated infection (HAI) prevention protocols. Herein, we studied the characteristics of all HAIs occurring in critically ill COVID-19 patients. METHODS: A retrospective, single-center cohort of critical COVID-19 patients during 2021. Microbiological samples were collected if HAI was suspected. We analyzed all factors that could potentially induce HAI, using septic shock and mortality as endpoints. RESULTS: Sixty-four among 161 included patients (39.7%) presented a total of 117 HAIs with an incidence density of 69.2 per 1,000 hospitalization days. Compared to the prior COVID-19 period (2013-2019), the identification of HAI increased in 2021. HAIs were classified into ventilator-associated pneumonia (VAP; n=38), bloodstream infection (n=32), urinary tract infection (n=24), catheter-related infection (n=12), and fungal infection (n=11). All HAIs occurred significantly earlier in the post-COVID-19 period (VAP: 6 vs. 10 days, P=0.045, in 2017 and 2021). Acinetobacter baumannii (39.5%) and Klebsiella pneumoniae (27%) were the most commonly isolated pathogens that exhibited a multidrug-resistant (MDR) profile, observed in 89% and 64.5%, respectively. The HAI factors were laboratory abnormalities (odds ratio [OR], 6.4; 95% confidence interval [CI], 2.3-26.0), cumulative steroid dose (OR, 1.9; 95% CI, 1.3-4.0), and invasive procedures (OR, 20.7; 95% CI, 5.3-64.0). HAI was an independent factor of mortality (OR, 8.5; P=0.004). CONCLUSIONS: During the COVID-19 era, the incidence of HAIs increased and MDR isolates remained frequent. A severe biological inflammatory syndrome, invasive devices, and elevated cumulative steroid dosages were related to HAIs. HAI was a significant death factor.

Interleukin6 prediction of mortality in critically ill COVID19 patients: A prospective observational cohort study.

OBJECTIVE: The aim of this study is to explore the role of IL6 in predicting outcome in critically ill COVID-19 patients. Design Prospective observational cohort study. Setting 20-bed respiratory medical intensive care unit of Abderrahmen Mami Teaching Hospital between September and December 2020. METHODS: We included all critically ill patients diagnosed with COVID-19 managed in ICU. IL6 was measured during the first 24 hours of hospitalization. RESULTS: 71 patients were included with mean age of 64 ± 12 years, gender ratio of 22. Most patients had comorbidities, including hypertension (n = 32, 45%), obesity (n = 32, 45%) and diabetes (n = 29, 41%). Dexamethasone 6 mg twice a day was initiated as treatment for all patients. Thirty patients (42%) needed high flow oxygenation; 59 (83%) underwent non-invasive ventilation for a median duration 2 [1-5] days. Invasive mechanical ventilation was required in 44 (62%) patients with a median initiation delay of 1 [0-4] days. Median ICU length of stay was 11 [7-17] days and overall mortality was 61%. During the first 24 hours, median IL6 was 34.4 [12.5-106] pg/ml. Multivariate analysis shows that IL-6 ≥ 20 pg/ml, CPK < 107 UI/L, AST < 30 UI/L and invasive ventilation requirement are independent risk factors for mortality. CONCLUSIONS: IL-6 is a strong mortality predictor among critically ill COVID19 patients. Since IL-6 antagonist agents are costly, this finding may help physicians to consider patients who should benefit from that treatment.