Health inequities in the diagnosis and outcome of sepsis in Argentina: a prospective cohort study.

BACKGROUND: Socioeconomic variables impact health outcomes but have rarely been evaluated in critical illness. Low- and middle-income countries bear the highest burden of sepsis and also have significant health inequities. In Argentina, public hospitals serve the poorest segment of the population, while private institutions serve patients with health coverage. Our objective was to analyze differences in mortality between public and private hospitals, using Sepsis-3 definitions. METHODS: This is a multicenter, prospective cohort study including patients with sepsis admitted to 49 Argentine ICUs lasting 3 months, beginning on July 1, 2016. Epidemiological, clinical, and socioeconomic status variables and hospital characteristics were compared between patients admitted to both types of institutions. RESULTS: Of the 809 patients included, 367 (45%) and 442 (55%) were admitted to public and private hospitals, respectively. Those in public institutions were younger (56 ± 18 vs. 64 ± 18; p < 0.01), with more comorbidities (Charlson score 2 [0-4] vs. 1 [0-3]; p < 0.01), fewer education years (7 [7-12] vs. 12 [10-16]; p < 0.01), more frequently unemployed/informally employed (30% vs. 7%; p < 0.01), had similar previous self-rated health status (70 [50-90] vs. 70 [50-90] points; p = 0.30), longer pre-admission symptoms (48 [24-96] vs. 24 [12-48] h; p < 0.01), had been previously evaluated more frequently in any healthcare venue (28 vs. 20%; p < 0.01), and had higher APACHE II, SOFA, lactate levels, and mechanical ventilation utilization. ICU admission as septic shock was more frequent in patients admitted to public hospitals (47 vs. 35%; p < 0.01), as were infections caused by multiresistant microorganisms. Sepsis management in the ICU showed no differences. Twenty-eight-day mortality was higher in public hospitals (42% vs. 24%; p < 0.01) as was hospital mortality (47% vs. 30%; p < 0.01). Admission to a public hospital was an independent predictor of mortality together with comorbidities, lactate, SOFA, and mechanical ventilation; in an alternative prediction model, it acted as a correlate of pre-hospital symptom duration and infections caused by multiresistant microorganisms. CONCLUSIONS: Patients in public hospitals belonged to a socially disadvantaged group and were sicker at admission, had septic shock more frequently, and had higher mortality. Unawareness of disease severity and delays in the health system might be associated with late admission. This marked difference in outcome between patients served by public and private institutions constitutes a state of health inequity.

Predictive Validity of Sepsis-3 Definitions and Sepsis Outcomes in Critically Ill Patients: A Cohort Study in 49 ICUs in Argentina.

OBJECTIVES: The new Sepsis-3 definitions have been scarcely assessed in low- and middle-income countries; besides, regional information of sepsis outcomes is sparse. Our objective was to evaluate Sepsis-3 definition performance in Argentina. DESIGN: Cohort study of 3-month duration beginning on July 1, 2016. SETTINGS: Forty-nine ICUs. PATIENTS: Consecutive patients admitted to the ICU with suspected infection that triggered blood cultures and antibiotic administration. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were classified as having infection, sepsis (infection + change in Sequential Organ Failure Assessment ≥ 2 points), and septic shock (vasopressors + lactate > 2 mmol/L). Patients on vasopressors and lactate less than or equal to 2 mmol/L (cardiovascular dysfunction) were analyzed separately, as those on vasopressors without serum lactate measurement. Systemic inflammatory response syndrome was also recorded. Main outcome was hospital mortality. Of 809 patients, 6% had infection, 29% sepsis, 20% cardiovascular dysfunction, 40% septic shock, and 3% received vasopressors with lactate unmeasured. Hospital mortality was 13%, 20%, 39%, 51%, and 41%, respectively (p = 0.000). Independent predictors of outcome were lactate, Sequential Organ Failure Assessment score, comorbidities, prior duration of symptoms (hr), mechanical ventilation requirement, and infection by highly resistant microorganisms. Area under the receiver operating characteristic curves for mortality for systemic inflammatory response syndrome and Sequential Organ Failure Assessment were 0.53 (0.48-0.55) and 0.74 (0.69-0.77), respectively (p = 0.000). CONCLUSIONS: Increasing severity of Sepsis-3 categories adequately tracks mortality; cardiovascular dysfunction subgroup, not included in Sepsis-3, has distinct characteristics. Sequential Organ Failure Assessment score shows adequate prognosis accuracy-contrary to systemic inflammatory response syndrome. This study supports the predictive validity of Sepsis-3 definitions.

[Creutzfeldt-Jakob encephalopathy with mutation E200K. Report of a "sporadic" case]. / Encefalopatía de Creutzfeldt--Jakob con mutacion E200K. A propósito de un caso reportado como 'esporádico'.

INTRODUCTION: Creutzfeldt Jakob disease (CJD) has the highest incidence of the whole group of transmissible spongiform encephalopathies or prion diseases, which have the unique feature among all pathologies, to be able to appear as infectious/iatrogenic, sporadic or hereditary, being common to all, the deposition of an abnormal prion protein (PrPSc,CJres) in the central nervous system. More than 20 mutations of the gene (PRNP) that encodes the prion protein have been described. We here report a case of CJD(E200K) refered as probable 'sporadic' according to WHO. METHODS: clinical, pathologic, and molecular features of the disease were characterized using EEG, neuropathology, prionprotein (PrP) Western blot and gene (PRNP) analysis. RESULTS: The patient developed visual hallucinations, myoclonus, memory loss, tremor, disbasia and generalized convulsives seizures dying six months after onset. On neuropathologic examination, spongiform changes were observed and PrP immunopositivity detected. Western blot analysis showed the presence of proteinaseK (PK)-resistant PrP (PrPres) with the nonglycosylatedisoform of approximately 21 kd, and DNA restriction fragment length polymorphism (RFLP) analysis showed the E200K mutation. DISCUSSION: The PRNP(E200K) mutation is the most frequent cause of the hereditary-familial CJD (fCJD). Clusters of this variety have been described in Chileans, Slovaks from Orava, Jews Israelies of Libyan origin, and Japanese. There was no available data of affected relatives of the patient which have suggested he was fCJD, but due to his Chilean origin PRNP studies were carried out. In fact the clinical and pathology of this familial form, with remarkable exceptions, resembles sporadic cases but has a greater incidence, in these groups than sporadic in the general population. CONCLUSION: This patient, although clinically reported as probable 'sporadic', after molecular characterization resulted a CJD(E200K) probably belonging to the Chilean cluster.

Encefalopatía de Creutzfeldt - Jakob con mutación E200K: a propósito de un caso reportado como 'esporádico' / Creutzfeldt-Jakob encephalopathy with mutation E2000K: report of a \"Sporadic\" case

La encefalopatía de Creutzfeldt Jakob (ECJ), es la de mayor incidencia dentro del grupo de las encefalopatías espongiformes transmisibles o enfermedades por priones, las que tienen como característica única entre todas las patologías, la de poder presentarse como esporádica, infecciosa/ iatrogénica, o hereditaria.Se han descrito mas de 20 mutaciones del gen (PRNP) que codifica la proteína prion, capaces de generar la ECJ en su forma hereditaria o familiar (fECJ). Se comunica un caso que fue referido como CJ 'esporádico' probable según criterios de la OMS y resultó después del estudio molecular, CJ familiar E200K.