Association of Ang-2, vWF, and EVLWI with risk of mortality in sepsis patients with concomitant ARDS: A retrospective study.

BACKGROUND/PURPOSE: This study aimed to determine the potential effects of angiopoietin-2 (Ang-2), von Willebrand factor (vWF), and extravascular lung water index (EVLWI) on the risk of mortality in sepsis patients with concomitant acute respiratory distress syndrome (ARDS). METHODS: This retrospective study recruited 41 sepsis patients with concomitant ARDS from January 2015 to June 2018. Data of Ang-2 and vWF levels, EVLWI, and sequential organ failure assessment scores were collected at 0, 24, and 48 h after admission to the hospital. RESULTS: The length of intensive care unit stay (P = 0.041) and Acute Physiology and Chronic Health Evaluation-2 (APACHE II) score (P = 0.003) were associated with the risk of mortality. Furthermore, increased Ang-2 levels and EVLWI at 24 h and 48 h were associated with an increased risk of mortality. Moreover, the APACHE II score at hospital admission significantly predicted the risk of mortality (area under the curve [AUC], 0.834; 95% confidence interval [CI], 0.665-0.983). Finally, the models containing a combination of Ang-2 level and EVLWI at 24 h (AUC, 0.908; 95% CI, 0.774-0.996) and Ang-2 level and EVLWI at 48 h (AUC, 0.981; 95% CI, 0.817-1.000) had high diagnostic values for predicting risk of mortality. CONCLUSION: The study findings indicate that Ang-2 levels and EVLWI at 24 h and 48 h after admission are significantly associated with the risk of mortality.

The use of remifentanil in critically ill patients undergoing percutaneous dilatational tracheostomy: A prospective randomized-controlled trial.

Remifentanil was a µ-agonist, with a rapid onset, a powerful narcotic analgesic activity and a fast nonspecific esterases hydrolyzation and theoretically an ideal opioid for percutaneous dilatational tracheostomy (PDT). The present study discussed use of remifentanil in critically ill patients undergoing PDT. Ninety-nine patients were randomly assigned to the propofol/remifentanil group (PR group, n = 49) or the propofol group (P group, n = 50). Two patients (one in P group and one in PR group) were excluded and transferred to surgical way of tracheostomy because of uncontrolled bleeding. The primary outcomes were critical care pain observation (CPOT) scores during PDT; hemodynamic response and side effects, such as bleeding and muscle rigidity (MR). CPOT scores in P group were significantly higher than in PR group during incision and dilation stages (P < 0.05 and P < 0.01). Systolic blood pressure had a significant drop after a bolus of remifentanil in PR group compared with patients in P group (P < 0.056). The incidence of MR was significantly higher in PR group than in P group (P < 0.05). Recovery time in PR group was significantly shorter than in P group (P < 0.05). The occurrence of tachycardia, bleeding, vomiting, and nausea had no statistically differences in both groups. Patients in PR group were undergoing shorter recovery time and better experience of pain in PDT compared with patients in P group, but MR seemed to be higher in PR group. Remifentanil seemed to be a safe and effective opioid used in critically ill patients undergoing PDT.

Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study.

BACKGROUND: Poor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists' chest radiograph interpretations for ARDS diagnosis. METHODS: We conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force ("the panel") before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs. RESULTS: Overall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 ± 14.8% before training vs. 55.3 ± 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 ± 0.406 vs. 0.461 ± 0.575, p = 0.792), Fleiss's kappa (0.133 ± 0.575 vs. 0.178 ± 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470). CONCLUSIONS: The radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (registration number NCT01704066 ) on 6 October 2012.

Lung-protective Ventilation in Patients with Brain Injury: A Multicenter Cross-sectional Study and Questionnaire Survey in China.

BACKGROUND: Over the years, the mechanical ventilation (MV) strategy has changed worldwide. The aim of the present study was to describe the ventilation practices, particularly lung-protective ventilation (LPV), among brain-injured patients in China. METHODS: This study was a multicenter, 1-day, cross-sectional study in 47 Intensive Care Units (ICUs) across China. Mechanically ventilated patients (18 years and older) with brain injury in a participating ICU during the time of the study, including traumatic brain injury, stroke, postoperation with intracranial tumor, hypoxic-ischemic encephalopathy, intracranial infection, and idiopathic epilepsy, were enrolled. Demographic data, primary diagnoses, indications for MV, MV modes and settings, and prognoses on the 60th day were collected. Multivariable logistic analysis was used to assess factors that might affect the use of LPV. RESULTS: A total of 104 patients were enrolled in the present study, 87 (83.7%) of whom were identified with severe brain injury based on a Glasgow Coma Scale ≤8 points. Synchronized intermittent mandatory ventilation (SIMV) was the most frequent ventilator mode, accounting for 46.2% of the entire cohort. The median tidal volume was set to 8.0 ml/kg (interquartile range [IQR], 7.0-8.9 ml/kg) of the predicted body weight; 50 (48.1%) patients received LPV. The median positive end-expiratory pressure (PEEP) was set to 5 cmH2O (IQR, 5-6 cmH2O). No PEEP values were higher than 10 cmH2O. Compared with partially mandatory ventilation, supportive and spontaneous ventilation practices were associated with LPV. There were no significant differences in mortality and MV duration between patients subjected to LPV and those were not. CONCLUSIONS: Among brain-injured patients in China, SIMV was the most frequent ventilation mode. Nearly one-half of the brain-injured patients received LPV. Patients under supportive and spontaneous ventilation were more likely to receive LPV. TRIAL REGISTRATION: ClinicalTrials.org NCT02517073 https://clinicaltrials.gov/ct2/show/NCT02517073.

[An investigation on correlation of severity of brain injury with the expression of activin A and C-reactive protein].

OBJECTIVE: To determine the dynamic change in serum levels of activin A (ACTA) and C-reaction protein (CRP) in patients with brain injury, and to investigate its significance. METHODS: A prospective study was conducted. A total of 57 adult patients with brain injury occurring within 24 hours admitted to intensive care unit (ICU) of the First Affiliated Hospital of Zhengzhou University from August 2012 to June 2013 were enrolled. The patients were allocated into three groups according to their Glasgow coma scale (GCS) as follows: minor brain injury (GCS 13-15, n=17), moderate brain injury (GCS 9-12, n=18), heavy brain injury (GCS 3-8, n=22). The clinical and related laboratory data (reflecting the function of liver, kidney, lung, blood coagulability etc.) were recorded after ICU admission. At the same time, venous samples were collected on the day 1, 2, 3, 5, 7 after ICU admission for determination of ACTA with enzyme linked immunosorbent assay (ELISA) and CRP with fluorescence immunoassay technology. The correlation between ACTA and CRP was analyzed by linear correlation. The receiver operating characteristic (ROC) curve was plotted to analyze the accuracy of ACTA and CRP as a prognostic indicator in brain injury. Fifteen healthy persons were enrolled as the control group. RESULTS: The serum levels of ACTA and CRP in patients with minor, moderate and heavy brain injury were significantly higher than those in healthy control group [ACTA (µg/L): 23.96±3.55, 42.06±5.67, 52.32±4.46 vs. 13.66±2.45, all P<0.01; CRP (mg/L): 14.12±2.45, 23.05±2.85, 30.93±2.35 vs. 3.42±2.25, all P<0.01]. As the patients' condition worsening, levels of ACTA and CRP tended to elevate (all P<0.01). Levels of ACTA and CRP in minor, moderate and heavy brain injury groups were increased after ICU admission. On day 3, levels of serum ACTA and CRP reached the peak values [ACTA (µg/L):30.62±2.54, 51.35±2.55, 60.52±2.55; CRP (mg/L): 18.62±2.64, 30.35±2.25, 37.52±2.55], and then they lowered gradually. In minor and moderate brain injury groups, the levels of ACTA and CRP were slowly descending, and on day 7, they maintained at a lower level [ACTA (µg/L): 13.68±2.54, 37.74±2.55; CRP (mg/L): 6.68±2.44, 19.74±2.55]. On the contrary, the levels of ACTA and CRP in heavy brain injury group persistently maintained at a high level on day 7 [ACTA: (42.32±2.54) µg/L, CRP: (33.32±2.56) mg/L]. There were significant differences in ACTA and CRP among different degrees of brain injury groups (all P<0.01). There was a positive correlation between ACTA and CRP (r=0.958, P=0.007). ROC curve analysis showed that the sensitivity for brain injury prediction was 93.3% for ACTA with specificity 95.0%, area under ROC curve(AUC) 0.843, and the sensitivity for CRP was 89.1% with specificity 68.2%, AUC 0.723. CONCLUSIONS: Serum levels of ACTA and CRP in patients with brain injury are strongly correlated with the severity of the injury. Furthermore, ACTA is more sensitive than CRP in detecting early brain injury. Therefore, ACTA is a specific factor for detecting brain injury.

[The value of serum interleukin-18 and 10 in the evaluation of severity and prognosis in the early stage of sepsis].

OBJECTIVE: To observe the dynamic changes in levels of serum interleukins (IL-18, IL-10) in the early stage of sepsis, and to appraise their values in the evaluation of severity and prognosis of sepsis. METHODS: Prospective randomized controlled study was conducted. Thirty-eight patients with sepsis who stayed longer than 72 hours in intensive care unit (ICU) from December 2009 to August 2010 were enrolled as sepsis group. At the same time, 20 patients without sepsis served as control group. The patients were classified as survival (n=12) or death group (n=26) according to 28-day survival. The clinical laboratory examination data were recorded at 24, 48, 72 hours after admission to the ICU, and venous blood was obtained at the same time. The IL-18, IL-10 levels were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: The vital signs, blood routine, liver function, renal function, coagulation function, arterial blood gas, and electrolyte showed no significant difference between sepsis group and control group 24, 48, 72 hours after admission, the levels of IL-18 were lowered, IL-10 elevated, the IL-18/IL-10 ratio was lowered in the sepsis group, and all of them were higher than control group at each time point. The levels of IL-18, IL-10 in death group of patients with sepsis were all higher than those of survival group at 24, 48, and 72 hours [ IL-18 (ng/L): 108.36±18.54 vs. 91.66±21.49, 92.13±28.92 vs. 54.16±31.76, 91.78±17.33 vs. 76.04±22.09; IL-10 (ng/L): 99.42±12.10 vs. 77.20±9.47, 103.39±17.24 vs. 67.88±18.90, 118.99±11.20 vs. 99.20±12.46, P<0.05 or P<0.01]. IL-18/IL-10 ratios were all lowered in both non-survivors and survivors with sepsis at 24, 48, 72 hours, while the differences were not statistically significant (1.09±0.19 vs. 1.20±0.32, 0.92±0.18 vs. 0.98±0.29, 0.78±0.15 vs. 0.77±0.23, all P>0.05). CONCLUSION: The levels of serum IL-18, IL-10 were all elevated in the early stage of patients with sepsis, and in non-survivors they were higher than those of survivors. With the progress of the illness, IL-18 showed a lowering tendency, while IL-10 showed an elevation. The levels of serum IL-18 and IL-10 may be valuable in evaluating the severity of sepsis and prognosis of patients with sepsis.

[Logistic regression analysis of the risk factors of patients with sepsis in intensive care unit].

OBJECTIVE: To investigate the correlation of the data of patients with sepsis in intensive care unit (ICU) and their prognosis. METHODS: Clinical data of 450 cases with sepsis in ICU from January 2004 to December 2008 were retrospectively studied. Twenty-four possible prognostic factors including clinical, chemical examinations and scores contributing to the survival of these patients were analyzed with univariate and multivariate logistic regression analysis. RESULTS: Univariate logistic regression analysis: eight factors were non-risk factors for sepsis, including days of hospitalization [odds ratio (OR)=0.951, P<0.001], Glasgow coma score (GCS, OR=0.858 , P<0.001), mean arterial pressure (OR=0.991, P=0.041), platelet count (OR=0.997, P<0.001), total protein (OR=0.975,P=0.003), albumin (OR=0.955, P<0.001), arterial pH (OR=0.077,P=0.001), arterial oxygen pressure (OR=0.996, P=0.014). The risk factors for sepsis included acute physiology and chronic health evaluation II (APACHE II) score (OR=1.115, P<0.001), body temperature (OR=1.215, P=0.041), prothrombin time (OR=1.057, P=0.007), aspartate aminotransferase (OR=1.001, P=0.011), serum creatinine (OR=1.002, P=0.002), blood potassium level (OR=1.391, P=0.003), blood glucose (OR=1.051, P=0.002), and C-reactive protein (OR=1.245, P=0.001). Multivariate logistic regression analysis showed that risk factors of sepsis included APACHE II score (OR=1.094, P<0.001), days of hospitalization (OR=0.946, P<0.001), platelet count (OR=0.976, P=0.004), and albumin level (OR=0.957, P=0.017). CONCLUSION: APACHE II score, days of hospitalization, platelet count and albumin could predict the prognosis of sepsis.

[The application of disseminated intravascular coagulation score in sepsis].

OBJECTIVE: To study the relationship between the disseminated intravascular coagulation (DIC) score and assessment of illness and prognosis in sepsis. METHODS: A retrospective analysis of 315 patients with sepsis that admitted into the First Affiliated Hospital of Zhengzhou University hospital intensive care unit (ICU) from January 2005 to December 2008 was made. The patients were divided into survival group (194 cases) and death group (112 cases) according to the outcome within 28 days. The difference of the platelet (PLT) count, fibrinogen (Fib), prothrombin time (PT), and fibrin monomer were compared between two groups. The relationship between acute physiology and chronic health evaluation II (APACHE II) score, DIC score and prognosis were analyzed by univariate logistic regression analysis, then APACHE II score and DIC score in sepsis were evaluated. RESULTS: PLT count and Fib of the death group were lower than those of the survival group, PT, activated partial thrombin time (APTT), activated clotting time (ACT) and fibrin monomer of the death group were higher than those of the survival group. APACHE II score and DIC score of the death group were higher than those of the survival group (P<0.05 or P<0.01). There was a positive correlation among APACHE II score, DIC score and the prognosis of sepsis [DIC score: chi (2)=17.741, P<0.001, odds ratio (OR)=1.413, 95% confidence interval (CI) 1.203-1.659; APACHE II score: chi (2)=36.456, P<0.001, OR=1.109, 95%CI 1.072-1.147]. Area under the curve of APACHE II score (0.706) was higher than DIC score (0.611). CONCLUSION: APACHE II score and DIC score can be used as the prognostic factors of sepsis, but the value of DIC score was lower than APACHE II score in diagnosis and prognosis of sepsis.

[Study of inducing differentiation of bone marrow mesenchymal stem cells of rat into cardiac myocytes in vitro].

OBJECTIVE: To investigate the role of cardiac myocytes in the differentiation of bone marrow mesenchymal stem cells (MSCs) to cardiac myocytes and the biological properties in the course. METHODS: The bone marrow of the extremities of the rats was flushed, and bone marrow MSCs were obtained by method of density gradient centrifugation. They were cultured. The second passage of cultured MSCs were labelled with bromodeoxyuridine (BrdU). The cardiac myocytes were obtained from the apex of rat heart with trypsin digestion method, and they were cocultured with labeled MSCs. The developmental changes of bone marrow MSCs were observed under light microscope with immunohistochemical staining for BrdU and alpha-sarcomeric actin on the 3rd day, and electron microscopic examination on the 5th day. RESULTS: MSCs proliferated fast in primary culture and subculture, positive rate was (90.34+/-2.31)%, and there was statistical difference when it compared with control group [(4.07+/-1.35)%, P<0.01]. The morphology of MSCs changed significantly after coculture. There were new cells nuclei of which were positively stained for BrdU and its cytoplasm positive for actin. Under transmissive electron microscope, sarcomeres like structure and abnormal Z line were observed in cytoplasm. CONCLUSION: Cardiac myocytes can effectively induce bone marrow MSCs to differentiate into cardiac myocytes by coculturing.