Presepsin and prognostic nutritional index are predictors of septic acute kidney injury, renal replacement therapy initiation in sepsis patients, and prognosis in septic acute kidney injury patients: a pilot study.

BACKGROUND: Sepsis is the most common cause of acute kidney injury (AKI) among critically ill patients. This study aimed to determine whether presepsin is a predictor of septic acute kidney injury, renal replacement therapy initiation (RRTi) in sepsis patients, and prognosis in septic AKI patients. METHODS: Presepsin values were measured immediately after ICU admission (baseline) and on Days 2, 3, and 5 after ICU admission. Glasgow Prognostic Score (GPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, Prognostic Index, and Prognostic Nutritional Index (PNI) were measured at baseline, and total scores ("inflammation-presepsin scores [iPS]") were calculated for category classification. Presepsin values, inflammation-based prognostic scores, and iPS were compared between patients with and without septic AKI or RRTi and between survivors and non-survivors. RESULTS: Receiver operating characteristic curve analyses identified the following variables as predictors of septic AKI and RRTi in sepsis patients: presepsin on Day 1 (AUC: 0.73) and Day 2 (AUC: 0.71) for septic AKI, and presepsin on Day 1 (AUC: 0.71), Day 2 (AUC: 0.9), and Day 5 (AUC: 0.96), Δpresepsin (Day 2 - Day 1) (AUC: 0.84), Δpresepsin (Day 5 - Day 1) (AUC: 0.93), and PNI (AUC: 0.72) for RRTi. Multivariate logistic regression analyses identified presepsin on Day 2 as a predictor of prognosis in septic AKI patients. CONCLUSIONS: Presepsin and PNI were found to be predictors of septic AKI, RRTi in sepsis patients, and prognosis in septic AKI patients.

Sudden, Sharp Turn in an AIDS Patient's Course Following the Onset of Fulminant Type 1 Diabetes.

A previously healthy 40-year-old Japanese male was urgently admitted with a 2-month history of dysphagia, 30-kg weight loss, and fever. Human immunodeficiency virus (HIV) antibodies and cytomegalovirus antigenemia were positive. Pneumocystis pneumonia and cytomegalovirus pneumonia were suspected. The patient was diagnosed with acquired immune deficiency syndrome (AIDS). Cytomegalovirus antigenemia became negative 20 days after the positive result. On hospital day 41, he experienced cardiopulmonary arrest. The clinical diagnosis was fulminant type 1 diabetes mellitus. He later developed hypoglycemia and was diagnosed with adrenal insufficiency accompanied by septic shock. He died of multiple organ failure 29 h post-admission to our ICU.

The Neutrophil to Lymphocyte Ratio Is Superior to Other Inflammation-Based Prognostic Scores in Predicting the Mortality of Patients with Pneumonia.

A neutrophil-to-lymphocyte ratio (NLR) > 7 is reportedly an independent marker of mortality in patients with bacteremia. However, no studies have shown an association between inflammation-based prognostic scores (including the Glasgow Prognostic Score, the NLR, the platelet-to-lymphocyte ratio, the Prognostic Nutritional Index, and the Prognostic Index) and mortality in patients with pneumonia. We retrospectively examined the cases of 33 patients diagnosed with pneumonia who were treated in the ICU of Osaka Medical College Hospital between January 2014 and June 2016. A multivariate analysis revealed that the NLR was a significant predictor of mortality in these pneumonia patients.

Presepsin is a more useful predictor of septic AKI and ARDS for very-old sepsis patients than for young sepsis patients in ICUs: a pilot study.

OBJECTIVE: Sepsis is a syndrome of life-threatening organ dysfunction. This study aimed to determine whether presepsin is a useful predictor of septic acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and shock in very-old sepsis patients aged 75 years in intensive care units (ICUs). RESULTS: A total of 83 adult patients diagnosed with sepsis were prospectively examined and divided into two groups: those aged 75 years and older (over 75 group) and those aged younger than 75 years (under 75 group). Presepsin values were measured after ICU admission. Inflammation-based prognostic scores were also examined. For category classification, total scores ("inflammation-presepsin scores [iPS]") were calculated. Presepsin values, inflammation-based prognostic scores, and iPS were compared between patients with septic AKI, ARDS, DIC, or shock and those without these disorders in the over 75 and under 75 groups. Areas under the curve of presepsin for predicting septic AKI and ARDS in the over 75 group were both > 0.7, which were significantly higher than those in the under 75 group. In conclusion, presepsin is a more useful predictor of septic AKI and ARDS for very-old sepsis patients (over 75 years) than for younger sepsis patients (under 75 years).

Risk Factors Associated with Mortality among Mechanically Ventilated Patients with Coronavirus Disease 2019 Pneumonia: A Multicenter Cohort Study in Japan (J-RECOVER Study).

Objective Mortality analyses of patients with coronavirus disease 2019 (COVID-19) requiring invasive mechanical ventilation in Japan are limited. The present study therefore determined the risk factors for mortality in patients with COVID-19 requiring invasive mechanical ventilation. Methods This retrospective cohort study used the dataset from the Japanese multicenter research of COVID-19 by assembling real-word data (J-RECOVER) study that was conducted between January 1 and September 31, 2020. Independent risk factors associated with in-hospital mortality were evaluated using a multivariate logistic regression analysis. Kaplan-Meier estimates of the survival were calculated for different age groups. A subgroup analysis was performed to assess differences in survival rates according to additional risk factors, including an older age and chronic pulmonary disease. Patients A total of 561 patients were eligible. The median age was 67 (interquartile range: 56-75) years old, 442 (78.8%) were men, and 151 (26.9%) died in the hospital. Results Age, chronic pulmonary disease, and renal disease were significantly associated with in-hospital mortality. Compared with patients 18-54 years old, the adjusted odds ratios of patients 55-64, 65-74, and 75-94 years old were 3.34 (95% CI, 1.34-8.31), 7.07 (95% CI, 3.05-16.40), and 18.43 (95% CI, 7.94-42.78), respectively. Conclusion Age, chronic pulmonary disease, and renal disease were independently associated with mortality in patients with COVID-19 requiring invasive mechanical ventilation, and age was the most decisive indicator of a poor prognosis. Our results may aid in formulating treatment strategies and allocating healthcare resources.

Presepsin and platelet to lymphocyte ratio predict the progression of septic subclinical acute kidney injury to septic acute kidney injury: a pilot study.

OBJECTIVE: This study aimed to determine whether presepsin and inflammation-based prognostic scores can predict the progression of septic subclinical acute kidney injury (AKI) to septic AKI among intensive care unit (ICU) patients. RESULTS: Presepsin values were measured immediately after ICU admission (baseline) and on Days 2, 3, and 5 after ICU admission. Glasgow Prognostic Score, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio (PLR), Prognostic Index, and Prognostic Nutritional Index were measured at baseline. Presepsin values and these indices were compared between septic AKI and septic subclinical AKI patients. There were 38 septic AKI patients and 21 septic subclinical AKI patients. Receiver operating characteristic curve analyses revealed the following cut-off values for AKI (relative to subclinical AKI): 708.0 (pg/ml) for presepsin on Day 1 (AUC, 0.69; sensitivity, 82%; specificity, 52%), 1283.0 (pg/ml) for presepsin on Day 2 (AUC, 0.69; sensitivity, 55%; specificity, 80%), and 368.66 for PLR (AUC, 0.67; sensitivity, 71%; specificity, 62%). Multivariate logistic regression analyses revealed PLR to be a predictor of septic subclinical AKI (odds ratio, 1.0023; 95% confidence interval, 1.0000-1.0046; p = 0.046). Presepsin and PLR predicted the progression of septic subclinical AKI to septic AKI and the prognosis of subclinical septic AKI patients.

[Examination of risk factors for deep vein thrombosis following total hip arthroplasty].

BACKGROUND: Deep vein thrombosis (DVT) is the main cause of pulmonary thrombolism (PE). Thus by preventing DVT, the risk of PE can be greatly reduced. METHODS: Patients were divided into two groups: a group of patients who were affected with DVT after total hip arthroplasty (THA) and a group of patients who were not affected. To examine the risk factor for DVT after THA, a comparative analysis between these two groups was performed. RESULTS: According to the multivariate logistic regression analysis, the preoperative elevated value of D-dimer is a significant risk factor which is only relative to the onset of DVT after THA. In addition, it was suggested that the preoperative value of D-dimer could be used as a means to rule out DVT after THA. CONCLUSIONS: It is useful to investigate the preoperative value of D-dimer as a predictive factor for the occurrence of DVT after THA.

[A case of respiratory insufficiency after resection of the aortic aneurysm and replacement with a synthetic conduit which recovered by airway pressure release ventilation].

We experienced a patient with respiratory insufficiency after resection of the aortic aneurysm and replacement with a synthetic conduit which recovered by airway pressure release ventilation (APRV) dramatically. A 44-year-old man diagnosed as aortic aneurysm of the descending thoracic aorta was admitted to our hospital and an operation was scheduled. The operation lasted for 19 hours and the time of general anesthesia was 23 hours. The immediate post-operative chest x-ray showed atelectasis of the right upper lobe, elevated right diaphragm and poor aeration of the lungs. A volume-limited mechanical ventilation was used for this patient postoperatively in ICU. But accumulation of carbon dioxide and poor oxygenation were observed. We started APRV by Bennet 840 (Tyco Healthcare, Tokyo). Specifically, we used Bilevel mode (PEEP 20/3 cmH20/3, inspiratory time 3.2 seconds, respiratory rate 15 times per minute, pressure support 20 cm H2O, FI(O2) 1.0). Promptly accumulation of carbon dioxide was improved and atelectasis of the right upper lobe vanished. Additionally, oxygenation was improved. He was weaned from a ventilator on postoperative day 5. We have demonstrated that APRV is an important tool that should be used to improve severe respiratory insufficiency.

Presepsin values and prognostic nutritional index predict mortality in intensive care unit patients with sepsis: a pilot study.

OBJECTIVE: Sepsis is a major cause of mortality for critically ill patients. This study aimed to determine whether presepsin values can predict mortality in patients with sepsis. RESULTS: Receiver operating characteristic (ROC) curve analysis, Log-rank test, and multivariate analysis identified presepsin values and Prognostic Nutritional Index as predictors of mortality in sepsis patients. Presepsin value on Day 1 was a predictor of early mortality, i.e., death within 7 days of ICU admission; ROC curve analysis revealed an AUC of 0.84, sensitivity of 89%, and specificity of 77%; and multivariate analysis showed an OR of 1.0007, with a 95%CI of 1.0001-1.0013 (p = 0.0320).

Urinary neutrophil gelatinase-associated lipocalin was a predictor from the day after intensive care unit entry, but not on the day of intensive care unit entry.

BACKGROUND AND AIMS: Sepsis is the main cause of death from infection. This study aimed to determine whether neutrophil gelatinase-associated lipocalin (NGAL) values better predict mortality in septic patients when combined with inflammation-based prognostic scores. MATERIAL AND METHODS: Forty-four adult patients diagnosed according to the Sepsis-3 definition and who were admitted to the ICU were prospectively examined from June 2018 to November 2018. Urine samples were collected from each patient with a urethral balloon bag to measure NGAL after ICU entry at the following time points: immediately after and 2, 3, and 4 days after ICU entry. The Glasgow Prognostic Score, the neutrophil to lymphocyte ratio (NLR), the platelet to lymphocyte ratio, the Prognostic Nutritional Index, the Prognostic Index (PI), the Sequential Organ Failure Assessment (SOFA), and quick SOFA were examined immediately after ICU entry. Predictors of mortality were assessed by receiver operating characteristics curve (ROC) analysis, log-rank test, and multivariate logistic regression analysis. RESULTS: NGAL on day 4 (AUC: 0.94) and ΔNGAL from day 4 to day 1 (AUC: 0.9) for 28-day mortality; NGAL on day 4 (AUC: 0.94) and inflammation-NGAL score (iNS) NGAL-PI (AUC: 0.69) for 60-day mortality; ΔNGAL from day 3 to day 1 (AUC: 0.82) for 90-day mortality; and iNS NGAL-NLR (AUC: 0.71) and iNS NGAL-PI (AUC: 0.68) for in-hospital mortality were found to be predictors of mortality by ROC curve analysis. NLR (p = 0.02) for 28-day mortality; NGAL on day 2 (p = 0.031), ΔNGAL from day 2 to day 1 (p = 0.013), and NLR (p < 0.0001) for 60-day mortality; NGAL on day 2 (p = 0.017), ΔNGAL from day 2 to day 1 (p = 0.014), and NLR (p = 0.033) for 90-day mortality; and NGAL on day 2 (p = 0.007) for in-hospital mortality were found to be predictors of mortality by log-rank test. iNS NGAL-NLR (OR, 0.024; p = 0.019) for 60-day mortality and NGAL from day 3 to day 1 (OR, 1.005; p = 0.013) for 90-day mortality were found to be predictors of mortality by multivariate logistic regression analysis. CONCLUSIONS: NGAL and ΔNGAL were predictors of mortality in sepsis patients on day 2 after ICU entry and thereafter, but not on day 1.

Presepsin Values Predict Septic Acute Kidney Injury, Acute Respiratory Distress Syndrome, Disseminated Intravascular Coagulation, and Shock.

BACKGROUND: Sepsis remains a major cause of mortality in critically ill patients. This study aimed to determine whether presepsin is a predictor of septic acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and shock. METHODS: A total of 83 adult patients diagnosed with sepsis were prospectively examined. Presepsin values were measured immediately after intensive care unit (ICU) admission and on Days 2, 3, and 5 after ICU admission. Glasgow Prognostic Score (GPS), neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, Prognostic Index, and Prognostic Nutritional Index were also examined at baseline. For category classification, total scores were calculated (hereafter, "inflammation-presepsin scores [iPS]") as follows: a score of 1 was assigned if the presepsin value and inflammation-based prognostic scores at baseline were above cutoffs determined by receiver operating characteristic (ROC) curve analysis for 28-day mortality; a score of 0 was assigned if they were below the cutoffs (total score range, 0-2 points). Presepsin values, inflammation-based prognostic scores, and iPS were compared between patients with septic AKI, ARDS, DIC, or shock and those without these disorders. RESULTS: ROC curve analyses identified the following variables as predictors: presepsin on Days 1 and 2 for septic AKI; presepsin on Days 1 to 3; and iPS-GPS for septic ARDS; and presepsin on Day 2 and Δpresepsin (Day 2-Day 1) for septic DIC. Multivariate analysis revealed presepsin on Day 2 to be a predictor of septic DIC. CONCLUSION: Presepsin is a predictor of septic AKI, ARDS, and DIC. Combining presepsin values with GPS improved the specificity for predicting septic ARDS relative to using baseline presepsin values alone.

Urinary neutrophil gelatinase-associated lipocalin values alone and combined with Prognostic Index predict septic AKI, DIC, and shock: a pilot study.

OBJECTIVE: Sepsis is a syndrome involving life-threatening organ dysfunction. The present study aimed to determine whether septic AKI, ARDS, DIC, and shock can be predicted more readily by combining uNGAL values and inflammation-based prognostic scores, over the use of uNGAL values alone. RESULTS: ROC curve analyses yielded the following cut-off values: AKI: 438.5 (ng/ml) for uNGAL at Day 1 (AUC, 0.8), 476.9 (ng/ml) for uNGAL at Day 2 (AUC, 0.86), 123.8 (ng/ml) for uNGAL at Day 3 (AUC, 0.81), 133.6 (ng/ml) for uNGAL at Day 4 (AUC, 0.78), 1.0 for iNS NGAL-NLR (AUC, 0.75), 2.0 for iNS NGAL-PI (AUC, 0.77), DIC; 648.5 (ng/ml) for uNGAL at Day 1 (AUC, 0.77); shock; 123.8 (ng/ml) for uNGAL at Day 3 (AUC, 0.71) and 9 for SOFA (AUC, 0.71). Multivariate logistic regression analyses revealed iNS NGAL-PI to be a significant independent predictor of AKI (OR, 20.62; 95% CI, 1.03-412.3; p = 0.048).

[Atrial septal defect of sinus venous type diagnosed by transesophageal echocardiography intraoperatively].

We encountered a patient with atrial septal defect (ASD) of sinus venous type which had not been diagnosed preoperatively. A 70-year-old-man with angina pectoris was admitted to our hospital and coronary artery bypass grafting was scheduled. After induction of general anesthesia with fentanyl, propofol, midazolam, and vecuronium, operation was going smoothly. However, we found an abnormal rise of the value of Sv(O2). Transesophageal echocardiography (TEE) demonstrated ASD of sinous venous type which had not been diagnosed preoperatively. For this incidental diagnosis, operation was performed to repair ASD and was finished successfully. He was discharged from the hospital on postoperative day 18 without complications. We have demonstrated in this report that TEE is an important tool which should be used routinely to diagnose cardiac diseases which have not been diagnosed preoperatively.

An educational program for decreasing catheter-related bloodstream infections in intensive care units: a pre- and post-intervention observational study.

BACKGROUND: Central venous catheters (CVCs) are commonly used in the management of critically ill patients. This study aimed to determine whether an educational program could reduce the rate of catheter-related bloodstream infections (CRBSIs) in intensive care units (ICUs). FINDINGS: All patients admitted to a medical ICU at a college affiliated with the Japan Society of Intensive Care Medicine between January 2008 and December 2014 were surveyed prospectively for the development of CRBSIs. A mandatory educational program (the intervention) targeting an infection control committee consisting of physicians was developed by a multidisciplinary task force to highlight correct practices for preventing CRBSIs. The program included a 30-min video-based introduction, 120-min lectures with a number of hands-on training sessions, a post-test, posters, safety check sheets, and feedback from the infection control committee. Lectures based on the education program were held every 3 months, and participants were free to choose when they attended the lectures. Each participant was required to view the 30-min introduction before attending the 120-min lectures and complete the post-test after each lecture. Safety check sheets were made to ascertain adherence to contents of the educational program. Posters describing the educational program were posted throughout the ICU. A pre- and post-intervention observational study design was employed, with the main outcome measure being yearly CRBSIs. We also calculated cost savings that resulted from improved CRBSI rates.During the 12-month pre-intervention period, four episodes of CRBSIs occurred in 1171 patient ICU-days (i.e., 3.4 per 1000 patient ICU-days). In the first year after the intervention, the rate of CRBSIs decreased to 0 in 1157 patient ICU-days (P ≤ 0.05). The estimated cost savings secondary to this decreased rate for the 1 year following introduction of the program was between 1850,000 and 27,000,000 yen ($14,800-$216,000). CONCLUSIONS: A program aimed at educating healthcare providers on the prevention of CRBSIs led to a dramatic decrease in the rate of primary bloodstream infections. This suggests that educational programs may substantially decrease medical care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training.

Bacillus cereus pneumonia in an immunocompetent patient: a case report.

BACKGROUND: Bacillus cereus (B. cereus) rarely causes lower respiratory tract infections, although most reported cases of B. cereus pneumonia are fatal despite intensive antibiotic therapy. We present a case of B. cereus pneumonia in an immunocompetent patient. CASE PRESENTATION: An 81-year-old woman was transferred from a district general hospital to our hospital for treatment of congestive heart failure. The patient presented with a nonproductive cough, dyspnea, edema in both lower extremities, orthopnea, fever, and occult blood in the stool. A chest radiograph indicated bilateral pleural effusion and pulmonary congestion. After diuretic therapy and chest drainage, bilateral pleural effusion and pulmonary congestion improved. On day 2, she experienced severe respiratory distress. B. cereus was isolated from two blood sample cultures. On day 4, her condition had progressed to severe respiratory distress (PaO2/FiO2 ratio = 108). A chest radiograph and computed tomography indicated extensive bilateral infiltrates. She was transferred to the intensive care unit and was intubated. B. cereus was also isolated from five blood sample cultures at that time. After isolating B. cereus, we switched antibiotics to a combination of imipenem and levofloxacin, which were effective. She had no history of immunodeficiency, surgery, ill close contacts, risk factors for HIV or tuberculosis, recent central venous catheter insertion, or anthrax vaccination. She improved and was discharged from the intensive care unit after several days. CONCLUSION: This is a rare case of B. cereus pneumonia in an immunocompetent patient, who subsequently recovered. Bacillus should be considered as a potential pathogen when immunocompetent patients develop severe pneumonia.

Sudden onset of artery dissection in a 32-year-old woman with vascular Ehlers-Danlos syndrome due to psychological stress of her mother's death: a case series.

BACKGROUND: Patients with vascular Ehlers-Danlos syndrome (EDS) are susceptible to significant vascular complications, such as aortic and visceral arterial ruptures, aneurysms, and dissection. We describe a case of repeated bleeding in a 57-year-old woman and a case of sudden onset of artery dissection in her daughter, both of whom were previously diagnosed with vascular EDS and managed at our institution. CASE PRESENTATION: A 57-year-old woman was admitted to our emergency department due to sudden onset of left low back pain. Her past history included vascular EDS. An urgent abdominal computed tomography (CT) scan revealed a left-sided retroperitoneal hematoma and left external iliac artery dissection. Stent graft repair was performed. Five hours postoperatively, cardiac arrest occurred and resuscitation attempts failed. The 32-year-old daughter with genetically diagnosed vascular EDS was notified of the death of her mother during the customary end-of-life conference. Six hours after her mother's death, she was admitted to our emergency department due to sudden onset of left low back pain. On examination, she was not in hypovolemic shock, and weak pulses were palpable in the bilateral dorsalis pedis. An urgent abdominal CT scan revealed a right-sided retroperitoneal hematoma around the right external iliac artery and left external iliac artery dissection. She was admitted to the intensive care unit and underwent conservative therapy consisting of bed rest and antihypertensive therapy with nicardipine. She developed no further vascular complications requiring surgical intervention and was discharged on the 21st hospital day. CONCLUSIONS: Vascular rupture can be fatal in patients with vascular EDS. This report underscores the importance of strategic management of vascular complications to prevent rupture, and the importance of psychological care for the bereaved family given the hereditary nature of vascular EDS.

Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio are superior to other inflammation-based prognostic scores in predicting the mortality of patients with gastrointestinal perforation.

BACKGROUND: The neutrophil to lymphocyte ratio (NLR) is gaining interest as an independent predictor of survival in patients with various clinical conditions. No study to date has reported an association between inflammation-based prognostic scores, including the Glasgow Prognostic Score (GPS), NLR, platelet to lymphocyte ratio (PLR), Prognostic Nutritional Index (PNI), and Prognostic Index (PI), and mortality in patients with gastrointestinal perforation (GIP). We compared the prognostic value of these measures. FINDINGS: A total of 32 patients with GIP were retrospectively enrolled. Patients were assessed according to the GPS, NLR, PLR, PI, and PNI. Multivariate analyses were performed to identify variables associated with mortality. Receiver operating characteristic (ROC) analyses were also performed. Overall survival rates (in-hospital mortality) were calculated using the Kaplan-Meier method, and differences in survival rates between groups were compared by the log-rank test. Multivariate analysis of significant variables revealed NLR (HR 1.257, 95% CI 1.035-1.527, P = 0.021) and PLR (HR 1.004, 95% CI 1.001-1.007, P = 0.016) at the time of admission to the intensive care unit to be independently associated with in-hospital mortality. AUC analysis revealed Sequential Organ Failure Assessment-Glasgow Coma Scale (SOFA-GCS) (0.73) to be superior to NLR (0.57) and PLR (0.58) for predicting mortality, and a high SOFA-GCS score was associated with reduced overall survival (P < 0.05). CONCLUSIONS: NLR and PLR were superior to other inflammation-based prognostic scores in predicting the mortality of patients with GIP.