Endogenous Carboxyhemoglobin Level Variation in COVID-19 and Bacterial Sepsis: A Novel Approach?

BACKGROUND: The increased production of carbon monoxide (CO) in sepsis has been proven, but the blood level variations of carboxyhemoglobin (COHb) as a potential evolutionary parameter of COVID-19 and sepsis/septic shock have yet to be determined. This study aims to evaluate the serum level variation of COHb as a potential evolutionary parameter in COVID-19 critically ill patients and in bacterial sepsis. MATERIALS AND METHOD: A prospective and observational study was conducted on two groups of patients: the bacterial sepsis group (n = 52) and the COVID-19 group (n = 52). We followed paraclinical parameters on Day 1 (D1) and Day 5 (D5) of sepsis/ICU admission for COVID-19 patients. RESULTS: D1 of sepsis: statistically significant positive correlations between: COHb values and serum lactate (p = 0.024, r = 0.316), and total bilirubin (p = 0.01, r = 0.359). In D5 of sepsis: a statistically significant positive correlations between: COHb values and procalcitonin (PCT) (p = 0.038, r = 0.402), and total bilirubin (p = 0.023, r = 0.319). D1 of COVID-19 group: COHb levels were statistically significantly positively correlated with C-reactive protein CRP values (p = 0.003, r = 0.407) and with PCT values (p = 0.022, r = 0.324) and statistically significantly negatively correlated with serum lactate values (p = 0.038, r = -0.285). CONCLUSION: COHb variation could provide rapid information about the outcome of bacterial sepsis/septic shock, having the advantages of a favorable cost-effectiveness ratio, and availability as a point-of-care test.

The Diagnostic and Prognostic Role of Vascular Endothelial Growth Factor C in Sepsis and Septic Shock.

INTRODUCTION: Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool. MATERIAL AND METHODS: The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality. RESULTS: The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student's t-test.) Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml. CONCLUSIONS: VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.

The role of interleukin-6 as an early predictor of sepsis in a murine sepsis model.

AIM: Evaluating the role of interleukin-6 (IL-6) as an early predictor of sepsis in a murine model. MATERIALS AND METHODS: The study divided 26 Wistar rats into two experimental groups in which sepsis was induced through the intraperitoneal injection of different Escherichia coli cultures [Group 1: Extended-spectrum beta-lactamase (ESBL)-producing culture and Group 2: Standardized ATCC35218 culture] and a control group. IL-6 levels were determined at 5 and 24 hours post-inoculation and immunohistochemistry (IHC) was performed on tissue samples from the sacrificed animals. RESULTS: Mean plasma IL-6 levels in Group 1 peaked at 5 hours [37.4 pg∕mL; standard deviation (SD) = 2.4 pg∕mL] and decreased at 24 hours (34 pg∕mL; SD=3.2 pg∕mL) after inoculation. IL-6 levels in Group 1 were elevated compared to Group 2, at 5 hours (33.7 pg∕mL; SD=3.3 pg∕mL; p=0.019) and non-significantly so at 24 hours (32.5 pg∕mL; SD=2.4 pg∕mL; p=0.233). The results did not show an increase over control levels at either 5 hours (37.6 pg∕mL; SD=3.4 pg∕mL) or 24 hours (40.8 pg∕mL; SD=2.9 pg∕mL) after inoculation. The IHC shows a varying degree of IL-6 expression across all organ types studied. No statistically significant correlations were found between the tissue level quantification of IL-6 and serum values at 24 hours in either group. CONCLUSIONS: For an early stage of infection/inflammation, serum levels of IL-6 are not correlated with tissue-level inflammation disproving a potential role of IL-6 as a very precocious diagnostic and predictor test. Accumulation of IL-6 in lung, kidney and spleen tissue can be observed from the beginning of inflammation.

Comparative oncological outcomes and survival following surgery for low rectal cancer - a single center experience.

In patients with low rectal cancer, intersphincteric resection (ISR) technique is a better alternative of abdominoperineal resection (APR), but is recommended to be done in non-locally advanced stages (=T2) only. The aim of this study was to evaluate the long-term oncological outcome and survival rate in patients with early and locally advanced stages that underwent ISR, as compared to APR. In order to assess the quality of life and prognosis of patients with low rectal cancer, the 5-year follow-up was done in 72 consecutive cases diagnosed in pT1-T4 stage that underwent ISR or APR. Histopathological and clinical parameters were compared between the two included groups. Although the quality of life was better in patients which underwent ISR, the 5-year overall survival rate was not found to be influenced by the used surgical technique (71% for ISR and 58% for APR) either by the histological grade of differentiation (p=0.62), independently from the T stage (p=0.61). Regardless of the type of surgery, the independent prognostic factors proved to be lymph node status (p=0.001), lymph node ratio (p=0.001), and clinical stage (p=0.0001). Lymph node status remains the most important prognostic factor of patients with low rectal cancer. Independently from the histological subtype and depth of tumor infiltration, good oncological results can be obtained when performing ISR in selected cases.

Improving Clinical Performance of an Interprofessional Emergency Medical Team Through a One-day Crisis Resource Management Training.

INTRODUCTION: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates. THE AIM OF THE STUDY: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team. MATERIAL AND METHODS: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises. RESULTS: An improvement was seen in most of the measured clinical parameters. CONCLUSION: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

Improving nontechnical skills of an interprofessional emergency medical team through a one day crisis resource management training.

Errors are frequent in healthcare, but Emergency Departments are among the highest risk areas due to frequent changes in team composition, complexity and variety of cases, and difficulties encountered in managing multiple patients simultaneously.Crisis resource management (CRM) training has been associated with decreased error rates in the aviation industry as well as in certain areas of acute medical care, such as anesthesia and emergency medicine. In this study, we assessed whether a single day CRM training, combining didactic and simulation sessions, improves nontechnical skills (NTS) of interprofessional emergency medical teams.Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through 2 in situ simulated exercises. The exercises were videotaped and were evaluated by 2 assessors who were blinded as to whether it was the initial or the final exercise. They used a new tool designed specifically for the assessment of emergency physicians' NTS. The intervention consisted of one-day training, combining didactic and simulation sessions, followed by an instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.A significant improvement (P < 0.05) was shown for all the NTS assessed, in all professional categories involved, regardless of the duration of prior work experience in the Emergency Department.This study shows that even a short intervention, such as a single day CRM training, can have a significant impact in improving NTS, and can potentially improve patient safety.

Predictive factors for postoperative deformity in thoracolumbar burst fractures: a statistical approach.

OBJECTIVE: To assess, using statistical analysis, if and to what extent the final outcome of surgical treatment for burst fractures depends on operation type, fracture level and initial deformity severity. METHODS: A database of 287 patients with single-vertebral-level thoracic and lumbar spine fractures analysed using simple and multiple linear regression analyses models. The dependent variable was last follow-up (LFU) kyphotic angle and the predictor variables were operation type [anterior approach (AA), posterior short-segment fixation (PSSF) and posterior monosegmental fixation (PMF)], fracture level (T11-L1, L2-L3 and L4-L5) and preoperative kyphotic angle. The models were applied on either the whole sample or on the operation type subgroups. RESULTS: In simple linear regression analysis models, fracture level accounted for 32% and 18% of the variation in LFU kyphotic angle in the AA and PMF subgroups, respectively. In the multiple linear regression models for the same subgroups, up to 40% of the variation in LFU kyphotic angle was accounted for by fracture level. Surgical treatment, as predictor variable, indicated that patients treated by PSSF developed a post-surgical kyphotic angle 8.51° more severe than those treated by AA. However, the model accounted for only 2% of the variation in LFU kyphotic angle. Simple linear regressions performed on each subgroup with preoperative kyphotic angle as the independent variable revealed that the variable accounted for 15% (PSSF subgroup), 17% (AA subgroup) and 34% (PMF subgroup) of the variation in LFU kyphotic angle. CONCLUSION: All valid regression models displayed modest explanatory power, suggesting that factors other than those taken into consideration are involved.