A novel risk score for severe ARDS patients undergoing ECMO after retrieval from peripheral hospitals.

BACKGROUND: Extracorporeal Membrane Oxygenation in severe ARDS unresponsive to conventional protective ventilation is associated with elevated costs, resource and complications, and appropriate risk stratification of candidate patients could be useful to recognize those more likely to benefit from ECMO. We aimed to derive a new outcome prediction score for patients retrieved by our ECMO team from peripheral centers, including systematic echocardiographic evaluation before ECMO start. METHODS: Sixty-nine consecutive patients with refractory ARDS requiring ECMO transferred from peripheral centers to our ICU (a tertiary ECMO referral center), from 1 October 2009 to 31 December 2015, were assessed. RESULTS: All patients were transported on ECMO (distance, median 77, range 4-456 km) The mortality rate was 41% (28/69). Our new risk score included age ≥ 42 years, BMI < 31 kg/m2 , RV dilatation, and pH < 7.35. The proposed cut off (Youden's index method) of nine had a sensitivity of 96% and a specificity of 30% (AUC-ROC: 0.85, 95% CI: 0.76-0.94, P < 0.001). When assessing the discriminatory ability of our risk score in the population of local patients, survivors had a mean value of 15.4 ± 8.6, whereas non-survivors showed a mean value of 20.1 ± 7.4 (P < 0.001). CONCLUSIONS: Our new risk score shows good discriminatory ability both in patients retrieved from peripheral centers and in those implanted at our center. This score includes variables easily available at bedside, and, for the first time, a pathophysiologic element, RV dilatation.

Cerebral microemboli detected by transcranial doppler in patients treated with extracorporeal membrane oxygenation.

INTRODUCTION: Cerebrovascular complications rate in patients treated with extracorporeal membrane oxygenation (ECMO) is about 7%. Ischemic stroke may be caused by solid or gaseous microemboli due to thrombosis within the circuit or cannula. Transcranial Doppler (TCD) is the only method able to detect microembolic signals (MES) in real time. The objective of this study was to detect possible MES by TCD in patients treated with veno-venous (VV) and veno-arterial (VA) ECMO and to test for a relation between the number of MES and the 6-month clinical outcome of these patients. METHODS: This is a monocentric observational prospective study in patients consecutively admitted and treated with ECMO at our regional ECMO referral center in 18 months. TCD detection of MES was performed in patients upon initiation of treatment and then repeated during treatment. RESULTS: Two hundred and forty-eight TCD monitoring were performed in 42 VV and 11 VA ECMO patients. MES were detected in 26.2% of VV ECMO patients and in 81.8% of VA ECMO patients (P < 0.001). In both subgroups of patients, no correlation was found between MES detection and extracorporeal flow velocities or aPTT values. In VA ECMO patients, an inverse correlation between left ventricular ejection fraction and MES grading was found (P = 0.037). In both groups, no clinical neurological impairments correlated to MES detection were found at 6 months follow-up. CONCLUSIONS: MES were found in both ECMO configurations; independently from their pathophysiology, MES do not seem to influence clinical outcome. Multicenter studies are still required with more extensive cases to confirm these results.

Impact of age on the prognostic value of body mass index in ST-Elevation myocardial infarction.

BACKGROUND AND AIM: No data are so far available on the impact of age and obesity in ST-elevation myocardial infarction (STEMI) submitted to percutaneous coronary intervention (PCI). METHODS AND RESULTS: We assessed the impact of age on the prognostic value of body mass index (BMI) in 1268 consecutive STEMI patients admitted to our Intensive Cardiac Care Unit (ICCU). BMI categories were as follows: 37 "lean" patients (37/1268, 2.9%), 403 "normal" patients (403/1268, 31.8%), 656 "overweight" patients (656/1268, 51.7%), 172 "obese" patients (172/1268, 13.6%). Among patients aged <75 years, as BMI increased, the number of males and diabetic patients significantly increased (p < 0.001 and p = 0.004, respectively). Among STEMI patients aged ≥75 years, lean patients showed a higher in-ICCU mortality in respect to the other BMI categories but this did not reach statistical significance. BMI was an independent predictor of In-ICCU mortality in the whole population (lean vs. "normal": OR 3.47, 95%CI 1.08-11.14, p = 0.036) and it was associated with long term mortality only in patients <75 years since lean and overweight patients showed lower survival rate (lean vs. "normal": HR 9.25, 95%CI 3.09-27.63, p < 0.001; overweight vs. "normal": OR 2.10; 95%CI 1.04-4.23, p = 0.039). CONCLUSIONS: In our series, underweight is associated with the highest mortality across all age subgroups, while only in patients <75 years, overweight patients showed increased in-hospital mortality rate and a poorer long term survival rate. According to our data, the "so called obesity paradox" should be probably age-contextualized.

T Cell-based RAS Activity and Insulin Levels in Obese Subjects with Low Grade Inflammation.

BACKGROUND: Obesity is a major contributor to inflammation and oxidative stress that are key underlying causes for insulin resistance (IR) and diabetes. Accumulated evidence suggest that RAS may serve as a strong link between IR and obesity. We investigated RAS activity in circulating T cells by obese subjects with and without angiotensin (Ang) II stimulation in presence or not of IR and of low-grade inflammation. METHODS: We studied 29 obese and 10 healthy subjects. After T-lymphocytes isolation, mRNAs for angiotensin converting enzyme (ACE) and angiotensin 1-receptor (AT1-R) were quantified by reverse transcription polymerase chain reaction (RT-PCR). High-sensitivity C-reactive protein (hs-CRP), insulin and inflammatory cytokines serum levels, plasma renin activity (PRA) and ACE activity in cell pellet and supernatant, and angiotensin (Ang) II T cell content were also measured. RESULTS: Under baseline conditions, RAS gene expressions, ACE activity and Ang II levels in T cells, but not PRA, of obese subjects with or without IR and with or without hs-CRP ≥3mg/dl were higher than in controls (p < 0.05). The increase in all parameters induced by Ang II was significantly higher in T cells from the obese subjects with hs-CRP ≥3 mg/dl than in controls or in the obese subjects with hs-CRP <3 mg/dl. In the obese subjects with low grade inflammation and IR, the cytokine serum levels and T cells RAS gene expression was inversely correlated with insulin serum concentration. CONCLUSIONS: Low grade inflammation amplifies the T cell RAS response to Ang II stimulation. T cell RAS gene expressions and serum levels of inflammatory cytokines were inversely related with insulin serum concentration. A protective role of insulin towards the development of inflammatory events can be hypothesized.

The prognostic role of renal dysfunction in STEMI patients submitted to primary PCI with adjunctive thrombus aspiration.

AIM: The present investigation was aimed at assessing the prognostic impact of renal dysfunction rate in STEMI patients submitted to thrombectomy (TP). METHODS: Out of 1268 consecutive ST elevation myocardial infarction (STEMI) patients treated with pPCI from January 1rst 2004 to December 31th 2012 in our hospital 671 patients (52.9%) underwent adjunctive thrombus aspiration and constituted the study population. Patients were divided into three groups according to eGFR: group 1 included patients with eGFR>60 mL/min/m2, group 2 eGFR>30 mL/min/m2 and <60 mL/min/m2, group 3 eGFR<30 mL/min/m2. The rate of utilization of thrombectomy, the rate of pPCI failure and the incidence of major bleeding were assessed in each subgroup. Patients in group 3 and group 2 were less likely to be submitted to TP, while more than 50% of patients with normal eGFR underwent TP (overall P=0.019). The rate of pPCI failure was significantly higher in group 2 and 3 when compared to group 1 (P=0.002). Worsening renal failure was associated with a higher mortality rate both at ICCU and at 1 year follow-up (P<0.001 and P<0.001, respectively). A higher incidence of major bleedings was reported in group 2 and group 3, despite the lower administration of glycoprotein IIb/IIIa inhibitors (P<0.001). Moderate and severe renal impairment was associated with a higher mortality rate both at ICCU and at 1 year follow-up (P<0.001 and P<0.001, respectively). CONCLUSION: Thrombus aspiration is less like to be performed among patients with impaired renal function. Despite thrombus aspiration patients with reduced eGFR showed a higher incidence of pPCI failure.

Large and small airway responses to procaterol hydrochloride administered through different extension devices in asthmatic patients.

The effects of spacer devices on the magnitude and velocity of large and small airway bronchodilator responses in asthmatic patients who can correctly operate a metered dose inhaler (MDI) remain unclear. According to a double-blinded, randomized, crossover protocol, 14 asthmatic patients were studied on seven separate occasions. On each occasion, patients inhaled doubling methacholine concentrations until forced expiratory volume in 1 second (FEV1) had fallen by 20% of baseline. Changes in forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) were also evaluated. Subsequently, patients were administered 20 or 50 micrograms of procaterol from an MDI either alone or in conjunction with a small- or large-volume spacer device. Changes in FEV1 and FEF25-75 corrected for baseline forced vital capacity (isoFEF25-75) were assessed at 3-minute intervals for 15 minutes and at 30 minutes. Spontaneous recovery was similarly evaluated. The time required to attain significant increases in both FEV1 and isoFEF25-75 was calculated in bronchodilator trials. With 20 micrograms of procaterol, both spacers allowed larger and faster FEV1 increases than the MDI alone (P < 0.01); with 50 micrograms, the velocity and magnitude of FEV1 increases were further enhanced in trials with the MDI alone. The lower procaterol dose via the large-volume spacer determined larger and faster isoFEF25-75 increases than the higher dose via both the small-volume spacer and the MDI alone (P < 0.01). Spacers enhance bronchodilation even in patients using MDIs optimally. Compared with both the small-volume device and the MDI alone, the large-volume spacer allows faster and larger small airway dilation with less than half of the procaterol dose.

Kinetic of procalcitonin in patients with cardiogenic shock following acute myocardial infarction: preliminary data.

INTRODUCTION: Procalcitonin concentrations are considered as a component of the inflammatory response and as an acute-phase marker, after shock or tissue injury (i.e. burn, trauma, surgery) or infections and sepsis. No data are so far available on the dynamics of procalcitonin levels in patients with cardiogenic shock following ST-elevation myocardial infarction, with no clinical or laboratory sign of infection. METHODS: We evaluated procalcitonin values every day during intensive cardiac care staying in ten cardiogenic shock patients admitted to our intensive cardiac care unit. NT-pro Brain Natriuretic Peptide, C Reactive Protein and APACHE II score were also assessed. RESULTS: Six patients survived, whereas 4 patients died. A progressive reduction in procalcitonin values was observed in cardiogenic shock patients who survived, whereas the lack of changes in procalcitonin concentrations was documented in cardiogenic shock patients who died (survivors: slope = -3.76; dead: slope = -0.81, p=0.004). Furthermore, higher values of glycemia, NT-pro Brain Natriuretic Peptide and C Reactive Protein (as well as higher APACHE II scores) were detectable in dead patients in respect to survivors. CONCLUSIONS: In our preliminary study we observed that in patients with cardiogenic shock and no sign of infections a reduction of procalcitonin levels was detectable only in survivors. Moreover, higher values of NT- Brain Natriuretic Peptide, a marked systemic inflammation (higher values of C Reactive Protein) and higher severity score (as depicted by APACHE II) are associated with an ominous prognosis in cardiogenic shock patients.

Reduction in deep vein thrombosis incidence in intensive care after a clinician education program.

BACKGROUND: Deep vein thrombosis (DVT) is a major complication in intensive care units (ICU) but dedicated guidelines on its management are still lacking. OBJECTIVES AND METHODS: This study investigated the effect of a 1-year educational program for the implementation of DVT prophylaxis on the incidence of inferior limb DVT in a mixed-bed ICU that admits high-risk surgical and trauma patients, investigated during a first retrospective phase [126 patients, SAPS II score 42 (28-54)] and a following prospective phase [264 patients, SAPS II score II 41 (27-55)]. The role of baseline and time-dependent DVT risk factors in DVT occurrence was also investigated during the prospective phase. RESULTS: The educational program on implementation of DVT prophylaxis was associated with a significant decrease in DVT incidence from 11.9% to 4.5% (P < 0.01) and in the mean length of ICU stay (P < 0.01). Combined with pharmacological prophylaxis, the use of elastic compressive stockings significantly also increased in the prospective phase (P < 0.01). The duration of mechanical ventilation, vasopressor administration and neuromuscular block were significantly different between DVT-positive and DVT-negative patients (P < 0.01). Multivariate analysis identified neuromuscular block as the strongest independent predictor for DVT incidence. CONCLUSION: One-year ICU-based educational programs on implementation of DVT prophylaxis were associated with a significant decrease in the incidence of DVT and also in the length of stay in ICU.

An angiographic evaluation of restenosis rate at a six-month follow-up of patients with ST-elevation myocardial infarction submitted to primary percutaneous coronary intervention.

BACKGROUND: Percutaneous coronary intervention (PCI) is considered to be the optimal type of revascularization in patients with ST-segment elevation myocardial infarction (STEMI). However, the long-term effectiveness of this procedure can be reduced by restenosis. This investigation was aimed at a prospective evaluation, in a group of STEMI patients of "the real world" (not involved in randomised trials), of the angiographic restenosis rate at a 6-month follow-up, and at identifying the relationship between restenosis and the patients' characteristics. MATERIALS AND METHODS: Our study population consisted of 123 patients with STEMI submitted to primary PCI to then undergo stress echocardiography 3 months after PCI and an angiographic evaluation at a 6-month follow-up. RESULTS: a) In real life the restenosis rate is quite high (42.3%); b) no correlation was found between patients' clinical characteristics and restenosis; c) restenosis rate was higher in patients with bare metal stents than in those with drug-eluting stents (55.8% vs. 11.1%; p<0.001); in patients with longer stents (21.6+/-8.62 vs 18.1+/-6.34 mm, p=0.015) and when more than one stent was implanted. Moreover, a consistent number of patients showed restenosis though asymptomatic. CONCLUSIONS: Our data suggest that primary PCI is associated with a high incidence of angiographic restenosis. No correlation was found between patients' clinical characteristics and restenosis. The length and the number of implanted stents seem to be associated with a more probable restenosis at six-month angiographic evaluation. Drug-eluting stent implantation seems to be associated with a lower incidence of restenosis even in STEMI patients.