Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial.

Rationale: Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown.Objectives: To compare the effect of balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis.Methods: Secondary analysis of patients from SMART (Isotonic Solutions and Major Adverse Renal Events Trial) admitted to the medical ICU with an International Classification of Diseases, 10th Edition, Clinical Modification System code for sepsis, using multivariable regression to control for potential confounders.Measurements and Main Results: Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical ICU with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality compared with 255 patients (31.2%) in the saline group (adjusted odds ratio [aOR], 0.74; 95% confidence interval [CI], 0.59-0.93; P = 0.01). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs. 40.1%; aOR, 0.78; 95% CI, 0.63-0.97) and a greater number of vasopressor-free days (20 ± 12 vs. 19 ± 13; aOR, 1.25; 95% CI, 1.02-1.54) and renal replacement therapy-free days (20 ± 12 vs. 19 ± 13; aOR, 1.35; 95% CI, 1.08-1.69) compared with the saline group.Conclusions: Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared with use of saline.Clinical trial registered with www.clinicaltrials.gov (NCT02444988).

Characterization of B-Cells in tonsils of patients diagnosed with pediatric autoimmune neuropsychiatric disorder associated streptococcus.

OBJECTIVE: To determine if Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) patients demonstrate a significantly different number of B-Cells or markers of activity when compared to recurrent Group A Streptococcus or Obstructive Sleep Apnea patients. STUDY DESIGN: Prospective Cohort Study. STUDY SETTING: Academic University Hospital. METHODS: Tonsil tissue was collected from twenty-two patients in the operating room and organized into three groups. Ten clinically diagnosed PANDAS, six Group A Streptococcus and six Obstructive Sleep Apnea patients were included in this study. Each tissue sample was extracted with MSD Tris Lysis Buffer and protein lysates were analyzed for CD 19, B-Cell Activating Factor and B-Cell Activating Receptor by western blot methods. RESULTS: Based on ANOVA analysis, there was no significant difference in the expression of B-Cell Activating Factor, B-Cell Activating Receptor or CD 19 when comparing the three study groups by western blot analysis methods. CONCLUSIONS: In this prospective cohort study, it appears that PANDAS patients do not demonstrate increased number of B-Cells, expression of B-Cell Activating Factor or B-Cell Activating Receptor when compared to Group A Streptococcus or Obstructive Sleep Apnea cohorts. As a result, further evaluation of the cell-mediated immune system is warranted to provide further insight into the pathophysiology of PANDAS. In addition, we must investigate if PANDAS patients only demonstrate increased B-Cell number or activity when undergoing an acute Tic/OCD exacerbation.

Pediatric head and neck complications of Streptococcus pneumoniae before and after PCV7 vaccination.

OBJECTIVE: To discuss pediatric head and neck complications of pneumococcal infections before and after the introduction of the PCV7 vaccine. STUDY DESIGN: Cross-sectional analysis of a national database. STUDY SETTING: Kids National Inpatient Database. METHODS: A retrospective review of the Kids National Inpatient Database yielded 31,738 pediatric reports involving complications of meningitis, mastoiditis, periorbital cellulitis, and Bezold abscesses due to Streptococcus pneumoniae diagnoses. Each report was analyzed for incidence, length of stay, mean hospital cost, and inpatient admittance from the emergency department. Finally, we calculated the expected annual incidence of each complication via variance-weighted analysis to determine the expected incidence if the vaccine was not administered. RESULTS: We identified a significant decrease in the incidence of several complications after the introduction of the PCV7 vaccine and also when comparing these findings to our predicted incidence calculations if the vaccine was not administered. Inpatient admittance from the emergency department for Bezold abscess, periorbital cellulitis, mastoiditis, and meningitis was significantly increased in the pediatric age group (ages 1-4; P < .05). Furthermore, there was a significant increase in the cost to provide care for each of the described conditions (P < .05). CONCLUSIONS: The PCV7 vaccine produced a measurable reduction in head and neck complications associated with S pneumoniae. However, our data suggest that these benefits were also met with increased inpatient admittance from the emergency department, hospital costs, and length of stay, each of which may be attributed to the selection of a more pathogenic subtype.