Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Percentage Ratio as Predictors of In-hospital Mortality in Sepsis. An Observational Cohort Study.

Background: Sepsis remains a major public health problem with increased incidence of mortality. As early recognition and prompt treatment in the first 'golden hour' remain the cornerstone of the septic patient approach, there is a real need for rapid and cost-effective reliable markers. Objective: The aim of the study was to evaluate the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte percentage ratio (PL%R) in patients with sepsis who were initially treated in the Emergency Department and investigate their predictive ability regarding in-hospital mortality and performance comparing them to SOFA, APACHE II, and SAPS II score. Methods: A retrospective observational study in the Emergency Department and Internal Medicine Department in a Mediterranean University Hospital. A total of forty-three patients suffering from sepsis were enrolled in the study. Demographic information, past medical history with pre-existing co-morbidities, physical examination findings, and radiological data were reviewed. Neutrophil to lymphocyte ratio and platelets to lymphocyte percentage ratio was calculated from the complete blood count (CBC). Disease severity was evaluated by calculating SOFA, SAPS II and APACHE II score on admission. The outcome of patients was noted as a primary endpoint. Results: Values of NLR and PL%R were statistically significantly higher in the group of non-survivors and correlate with sepsis prognostic scores. Conclusion: Calculation of NLR and PL%R is easy, fast, and inexpensive in the assessment of patients with sepsis. Their role as prognostic indexes and their validity in the Emergency Department setting should be evaluated with large prospective studies.

Nasobiliary Drain Diverted through a Percutaneous Endoscopic Gastrostomy Tube: A Novel Approach to Nasobiliary Drainage.

Intractable pruritus is a common, debilitating symptom and a well-defined entity occurring in chronic cholestatic disorders. Treatment options include cholestyramine, rifampicin, naltrexone, gabapentin, and sertraline, as well as more interventional measures, such as plasmapheresis, extracorporeal albumin dialysis, nasobiliary drains (NBDs), and UVB phototherapy in patients who fail to respond to medical therapy. Despite the limited data, NBD seems to be a highly effective treatment in the relief of refractory cholestatic pruritus. In this article, we present the case of a 73-year-old woman with primary biliary cholangitis and intractable pruritus, refractory to medical treatment. The patient had a complete resolution of her symptoms following an NBD placement, in which, with a novel approach, the nasal end was redirected and exited through a percutaneous endoscopic gastrostomy port, significantly improving her quality of life.

Evaluation of Plasma Soluble Urokinase Plasminogen Activator Receptor Levels in Patients With COVID-19 and Non-COVID-19 Pneumonia: An Observational Cohort Study.

BACKGROUND: The respiratory system is the main system affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and a great number of infected people need hospitalization. Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker indicative of acute and chronic inflammation. Current literature supports that suPAR has great predictive ability for mortality in patients with coronavirus disease 2019 (COVID-19). The aim of this study was to compare the value of suPAR and other laboratory biomarkers in patients with chest infection and suspected COVID-19. METHODS: A total of 41 consecutive patients with chest infection were enrolled in the study and were assigned into two groups according to the real-time polymerase chain reaction (PCR) result for SARS-CoV-2. The two groups had no significant difference in baseline data (age, sex), arterial oxygen partial pressure (PO2)/fraction of inspired oxygen (FiO2) ratio and mortality. RESULTS: Among patients with chest infection who required hospitalization, suPAR was significantly higher on admission in those with COVID-19 when compared to patients with non-COVID-19. suPAR had a great prognostic ability for in-hospital mortality in the COVID-19 subgroup. CONCLUSIONS: A single measurement of suPAR on admission can provide prognostic information for patients with suspected COVID-19 pneumonia. In the subgroup of patients with positive real-time PCR result for SARS-CoV2, suPAR was significantly higher and had an excellent prognostic value for the in-hospital mortality.

The Use of Electroencephalography in Patients with Sepsis: a Review of The Literature.

Sepsis-associated encephalopathy (SAE) is the term used to define brain dysfunction related to infections that are principally located outside the central nervous system (CNS). A number of published studies report that electroencephalography (EEG) has been used in the evaluation of patients with sepsis, alone or usually in combination, to evoked potentials and neuroimaging. This was in an effort to assess if EEG can be a tool in the diagnosis and monitoring of the neurological status in sepsis patients. Although there is no specific test for the diagnosis and prognosis of sepsis related encephalopathy, our literature review suggests that EEG has a role in the assessment of this clinical entity. Due to its low cost and simplicity in its performance, EEG could be a potential aid in the assessment of sepsis neurological complications even in the early, subclinical stages of the syndrome. The aim of this review is to summarize the published literature regarding the application and utility of electroencephalography in adult patients with sepsis.

Relation Between Central Venous, Peripheral Venous and Arterial Lactate Levels in Patients With Sepsis in the Emergency Department.

BACKGROUND: Sepsis and multi-organ failure remain a major clinical problem with high morbidity and mortality worldwide. Lactate measurement remains part of the initial assessment and management of patients with sepsis. Although arterial blood is most commonly used for lactate measurement, there is increasing use of peripheral venous lactate for initial assessment and for monitoring of response to treatment in patients with sepsis. The aim of this study was to evaluate the relation between lactate levels measured from central line, peripheral vein and arterial line in patients treated for sepsis in the emergency department (ED). METHODS: This prospective study enrolled 31 patients with diagnosis of sepsis who were evaluated and treated in the ED of a university hospital. During initial resuscitation, blood samples from the artery, peripheral vein and central vein (when available) were collected and lactate concentrations were measured. Correlation between lactate values from the three different locations was assessed using Pearson correlation. Bland-Altman plots were used to evaluate agreement between lactate measurements in different sampling locations. All patients were eventually admitted to the Internal Medicine Department ward or to the intensive care unit (ICU) for further treatment. RESULTS: Our data showed strong, highly significant correlation between arterial and peripheral venous lactate levels (r = 0.880, P < 0.0001), between arterial and central venous blood lactate (r = 0.898, P < 0.0001) and between central and peripheral venous blood lactate (r = 0.941, P < 0.0001). CONCLUSIONS: In this study we observed strong correlation between arterial, central vein and peripheral vein lactate concentrations in 31 patients assessed and treated for sepsis. We suggest that lactate measurement in peripheral venous blood could be used for screening and for monitoring response to therapy in sepsis patients. However, because this is a small study in only 31 patients and published data are limited, larger studies are needed in order to confirm the validity of our findings.

The utility of brain natriuretic peptides in septic shock as markers for mortality and cardiac dysfunction: A systematic review.

OBJECTIVE: To conduct a systematic review evaluating the utility of brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) as biomarkers in adult patients with septic shock. MATERIALS AND METHODS: Pubmed/Medline databases were searched from inception to November 2018 using the search terms: (septic[Title/Abstract] AND shock[Title/Abstract]) AND bnp[Title/Abstract]) and (septic[Title/Abstract]) AND shock[Title/Abstract]) AND natriuretic[Title/Abstract]). No restriction was applied regarding date of publication. Comparative observational studies evaluating BNP and NT-proBNP in patients with septic shock aged ≥18 years were eligible for inclusion. Bibliographies from the extracted articles were also reviewed to identify additional relevant publications. RESULTS: In total, 46 studies met all eligibility criteria and were included. A strong body of literature has demonstrated that in patients with septic shock, increased values of BNP and NT-proBNP are associated with increased mortality. An increase from baseline BNP values has also been associated with increased mortality, whereas decreases from baseline values are not related to worse outcome. Brain natriuretic peptides have also been associated with cardiac dysfunction in patients with sepsis. Moreover, BNP values have been found to be significantly elevated in septic shock, regardless of cardiac dysfunction, and have been used to distinguish between septic and cardiogenic shock. Furthermore, BNP and NT-proBNP are significantly increased in patients with septic shock, compared to patients with sepsis and severe sepsis. CONCLUSIONS: BNP and NT-proBNP appear to be reliable predictors of outcome in septic shock.

The Role of Procalcitonin in the Diagnosis of Meningitis: A Literature Review.

OBJECTIVE: To review the current published literature on the use of procalcitonin as a diagnostic and prognostic marker in adult patients with meningitis. METHODS: We conducted a PubMed search to identify all relevant publications regarding the diagnostic and prognostic value of serum procalcitonin in patients with a known or suspected central nervous system infection. We also reviewed the bibliographies of all identified manuscripts in an attempt to identify additional relevant references. RESULTS: A significant body of evidence suggests that serum procalcitonin has a promising role and can be a useful biomarker in the assessment of patients with meningitis. CONCLUSIONS: Our literature review suggests that data on the role of Cerebrospinal Fluid (CSF) procalcitonin are limited, whereas serum procalcitonin (S⁻PCT) is probably a useful tool in the evaluation of patients with a known or suspected central nervous system infection and can help distinguish between bacterial and viral meningitis.

The use of IgM-enriched immunoglobulin in adult patients with sepsis.

The administration of intravenous immunoglobulins (IVIG) is one of the adjunct therapies investigated and applied to sepsis patients, with the first studies being published nearly four decades ago. Intravenous immunoglobulin preparations have several mechanisms of action e.g. antigen neutralization, Fc-receptor blockade on phagocytic cells, modulation of cytokine responses and modulation of immune cell functions. The currently available evidence suggesting the use of intravenous immunoglobulins in sepsis is weak, but results from recent trials and systematic metanalyses seem more promising for the use of intravenous IgM-enriched immunoglobulins (IVIgGM) in septic patients. Nevertheless, the results of studies examining its value are contradicting. The purpose of this review is to summarize and present, clearly and thoroughly, the currently available data regarding established and future potential clinical uses of IVIgGM in patients with sepsis.

The Use of Serum Procalcitonin as a Diagnostic and Prognostic Biomarker in Chronic Obstructive Pulmonary Disease Exacerbations: A Literature Review Update.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a major complication in COPD patients which can be triggered by bacterial or viral infections, environmental pollutants and other causes. Procalcitonin (PCT), a peptide that markedly increases in cases of bacterial infection, has been extensively investigated as a biomarker in the diagnosis, prognosis and treatment in patients with AECOPD. A number of studies published in the last decade, tried to investigate whether PCT levels can differentiate between bacterial and other causes of exacerbations, if they can be used as a guide for optimal antibiotic therapy and if they can be a tool in the assessment of the severity and the need for further interventions in the management of those patients. This review aims to gather, summarize and critically present all the available data to date.

Neutrophil-to-lymphocyte Ratio Relation to Sepsis Severity Scores and Inflammatory Biomarkers in Patients with Community-acquired Pneumonia: A Case Series.

BACKGROUND AND OBJECTIVES: Neutrophil to lymphocyte ratio (NLR) as calculated from the white cell differential blood count is considered a promising marker for the prognosis of patients with various diseases, including sepsis. This study was designed to assess the possible use of neutrophil-to-lymphocyte ratio in the prediction of survival outcomes in patients with community acquired pneumonia (CAP). A secondary objective was to compare the prognostic accuracy of NLR with the commonly used severity scores of sepsis SOFA, APACHE II and SAPS II. METHODS: This was a retrospective study based on data extracted from 26 patients suffering from acute CAP. The study period was from February 01, 2017 until April 30, 2017. All patients with CAP were presented in the Emergency Department (ED) of the University Hospital of Patras, Greece and were treated after admission in the Internal Medicine Department. The neutrophil-to-lymphocyte ratio (NLR) was calculated from the white blood cell count (WBC) values measured from a peripheral venous blood specimen drawn on admission. It was then compared with C-reactive protein (CRP) serum levels and the sepsis calculated prognostic scores APACHE II, SAPS II and SOFA. The impact of the above parameters was evaluated in relation to the final outcome. RESULTS: The mean period of hospitalization for the enrolled patients was 9.3 days (SD 5.8 days). Twenty-four patients (92.3%) got finally discharged from the hospital and two (7.7%) died during the hospitalization. Mean NLR and serum CRP values on admission were 10.2 ± 8.8 (min 1.4; max 34.7) and 11.4 ± 11 mg/dL (min 0.4; max 42.6) respectively. Based on the correlation analysis, serum CRP was more strongly positively correlated with NLR (r = 0.543, P = 0.004), than total WBC (r = 0.454, P = 0.02). None of the biomarkers of inflammation measured or computed in the study (CRP, WBC, NLR) showed any correlation with either the days of hospitalization or the sepsis prognostic scores. CONCLUSIONS: NLR shows a statistical significant correlation to the commonly used inflammatory markers CRP and total WBC in the small sample size of patients with CAP that we assessed. Although NLR is a simple, cheap and rapidly available measurement in the ED, future, larger prospective studies are warranted to confirm its possible value as a prognostic index in sepsis patients with CAP.

Correlation between neutrophil-to-lymphocyte ratio and severity scores in septic patients upon hospital admission. A series of 50 patients.

INTRODUCTION: The neutrophil-to-lymphocyte ratio (NLR) as calculated from the white cell differential blood count is a marker that has been used as a prognostic index when assessing patients suffering from several clinical syndromes, including sepsis. The aim of this study was to evaluate the relationship between NLR and the commonly used severity scores of sepsis SOFA, APACHE II and SAPS II in a population of emergency admitted adult patients with sepsis in a tertiary center. METHODS: A prospective observational study was conducted in the Emergency Department of the University Hospital of Patras, Greece, based on data extracted from 50 patients consecutively enrolled, suffering from sepsis of multiple origin. The study period was from May 01, 2017 until June 30, 2017. The NLR was calculated from the total white blood cell (WBC) count values measured from a peripheral venous blood specimen drawn on admission. C-reactive protein (CRP) was also measured. The sepsis severity prognostic scores APACHE II, SAPS II and SOFA were calculated for each patient. RESULTS: NLR was positively correlated with the sepsis severity prognostic scores on admission (SOFA, rs = 0.497, p < 0.001; APACHE II, rs = 0.411, p = 0.003; SAPS II, rs = 0.445, p = 0.001). Total WBC was also significantly correlated with the scores (SOFA, rs = 0.342, p = 0.015; APACHE II, rs = 0.384, p = 0.006; SAPS II, rs = 0.287, p = 0.043). Serum CRP did not show any significant correlation either to NLR or to the sepsis severity scores on admission. CONCLUSIONS: NLR is an easily calculated, cost-efficient index that could be used as a tool for clinicians when assessing sepsis patients in the Emergency Department. Although NLR measurement is simple, and rapidly available, future and larger prospective studies are warranted to confirm its definite value as a prognostic index in sepsis patients.

Procalcitonin as a diagnostic and prognostic marker in diabetic foot infection. A current literature review.

Diabetic foot ulcers (DFUs) are a very common cause of mortality and morbidity. The distinction between infected and non-infected DFU remains a very challenging task for clinicians in everyday practice. Even when infection is documented, the spectrum of diabetic foot infection is wide, ranging from cellulitis and soft tissue infection to osteomyelitis. Procalcitonin (PCT), a well-established sepsis biomarker, has been used in the diagnosis of several infections including osteomyelitis in patients with diabetes mellitus. This review gathers and presents all the relevant data, up until now, regarding the use of PCT as an assessment tool in diabetic patients with foot infection. Current evidence suggests that PCT levels could aid clinicians in distinguishing infected from non-infected DFUs as well as in the distinction between soft tissue infection and bone involvement, but further and larger studies are warranted to confirm these findings.

Electroencephalographic Abnormalities in Sepsis Patients in Correlation to the Calculated Prognostic Scores: A Case Series.

OBJECTIVE: To evaluate the electroencephalographic (EEG) findings and correlate EEG findings with inflammatory biomarkers and the sepsis prognostic scores SOFA, SAPS II and APACHE II in patients who present in the Emergency Department with sepsis without clinical central nervous system involvement. METHODS: The study included seventeen patients (< 70 years old) with sepsis without central nervous system involvement presenting in the Emergency Department of the University Hospital of Patras, Greece. All patients underwent neurologic examination and EEG analysis on admission to the hospital and were treated according to the international guideline protocols for sepsis. RESULTS: Six of seventeen sepsis patients had mild or moderate EEG abnormalities. We did not find any significant correlation between EEG abnormalities and inflammatory biomarkers (CRP, WBC) or commonly used prognostic sepsis scores. CONCLUSIONS: EEG could serve as a useful tool to identify brain alterations at an early stage in sepsis, before clinical sings of encephalopathy can be detected. However, the presence of EEG abnormalities does not correlate with sepsis severity as measured by the commonly used prognostic sepsis scores SOFA, APACHE II or SAPS II. Because this was a small single center observational study, large multi-center studies are warranted to confirm these findings.

Acute Abdominal Pain Assessment in the Emergency Department: The Experience of a Greek University Hospital.

BACKGROUND: Acute abdominal pain (AAP) is a common symptom in the emergency department (ED). Because abdominal pain can be caused by a wide spectrum of underlying pathology, evaluation of abdominal pain in the ED requires a comprehensive approach, based on patient history, physical examination, laboratory tests and imaging studies. The aim of this study was to investigate predictive factors for admission to the hospital in patients who presented to the ED with AAP as the main symptom. METHODS: This prospective observational study enrolled 125 patients who presented with AAP in the ED of the Patras University Hospital in western Greece. The sample of patients who enrolled in the study was representative of patients who receive care in this academic institution. All patients underwent clinical examination, laboratory testing and radiological assessment. Clinical and laboratory data were analyzed in an attempt to identify clinical or laboratory factors predicting hospital admission. RESULTS: Based on clinical, laboratory and radiologic evaluation, 37.6% of patients enrolled in the study were admitted to the hospital, whereas 62.4% were not admitted. Compared to patients who were not admitted, patients admitted to the hospital had higher age and significantly higher inflammatory markers, white blood count and C-reactive protein (CRP). Binary logistic regression analysis showed that abnormal imaging findings (odds ratio (OR) = 6.47, 95% confidence interval (CI): 2.11 - 19.77, P < 0.001) and elevated serum CRP levels (OR = 6.24, 95% CI: 2.16 - 18.03, P < 0.001) were significant predictive factors for hospital admission. CONCLUSIONS: Assessment of AAP remains a challenging problem in the ED. Comprehensive history combined with detailed clinical examination, appropriate laboratory testing and radiologic imaging facilitates effective assessment of patients who present in the ED with AAP and guides the decision to admit patients to the hospital for further care.

Renin Inhibition with Aliskiren: A Decade of Clinical Experience.

The renin-angiotensin-aldosterone system (RAAS) plays a key role in the pathophysiology of arterial hypertension as well as in more complex mechanisms of cardiovascular and renal diseases. RAAS-blocking agents like angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers, have long been key components in the treatment of essential hypertension, heart failure, diabetic nephropathy, and chronic kidney disease, showing benefits well beyond blood pressure reduction. Renin blockade as the first step of the RAAS cascade finally became possible in 2007 with the approval of aliskiren, the first orally active direct renin inhibitor available for clinical use and the newest antihypertensive agent on the market. In the last decade, many clinical trials and meta-analyses have been conducted concerning the efficacy and safety of aliskiren in comparison to other antihypertensive agents, as well as the efficacy and potential clinical use of various combinations. Large trials with cardiovascular and renal endpoints attempted to show potential benefits of aliskiren beyond blood pressure lowering, as well as morbidity and mortality outcomes in specific populations such as diabetics, heart failure patients, and post-myocardial infarction individuals. The purpose of this review is to present the currently available data regarding established and future potential clinical uses of aliskiren.

C-Reactive Protein and Frailty in the Elderly: A Literature Review.

Chronic inflammation is a well-established background process in many age-related diseases. Many recent studies investigate the use of various inflammatory biomarkers such as C-reactive protein (CRP), interleukin-6, and interleukin-1 as predictors of physical and cognitive performance among elders. The phenotype of frailty has also been associated with underlying inflammatory mechanisms. The aim of this article was to review the literature referring to the correlation of CRP serum levels and frailty in older individuals. We tried to identify all relevant publications regarding the relation of CRP as an index of frailty in the elderly and its potential use. Although many studies in the recent medical literature positively associate serum CRP levels and frailty in older individuals, some do not, and some raise some interesting questions and set the basis for future studies. The association of CRP and frailty in elder patients should be considered when clinicians interpret inflammatory biomarkers in various clinical settings in such patients. Well-designed, prospective clinical trials are warranted to better assess the role and pathophysiology of frailty in the elderly and its mechanisms as also the exact role of CRP as an inflammatory marker and as a prognostic index in this syndrome.

Nerve Injuries around the Shoulder.

Nerve injuries around the shoulder are common. They usually occur as a result of motor vehicle accidents, gunshot or athletic injuries, or overuse and chronic repetitive stress often observed in sports involving repetitive overhead or throwing activities. The mechanisms of nerve injury include direct pressure, repetitive microtrauma, and compression- or stretch-induced ischemia. The severity and extent of compression is related to the degree of the nerve injury. Several nerve injury grading systems have been developed, allowing for the correlation between microscopic changes occurring after the injury and the patient's symptoms; recovery and prognosis is related to the type and severity of the injury. Distinct clinical syndromes involving the shoulder joint area can develop after injuries to the axillary, musculocutaneous, suprascapular, long thoracic, and spinal accessory nerves, as well as the proximal brachial plexus trunks and the lower cervical nerve roots. When a patient complains of pain, weakness, or paresthesia in the absence of known bone, soft tissue, or vascular injury, nerve injury must be suspected. This article summarizes the most common nerve injuries around the shoulder and discusses the classification, mechanism, treatment, and prognosis for these injuries.