Management of severe tetanus in Afghanistan: lessons from the field.

INTRODUCTION: Tetanus is a rather rare disease in the Western countries thanks to widespread vaccination programs and the availability of prophylactics for patients with tetanus-prone injuries. The few cases that do occur are promptly managed in intensive care units (ICUs). However, tetanus is not so rare in developing countries, where access to a suitable level of care is limited. An unstable political situation can be a significant factor influencing patient outcomes. CASE REPORT: A ten-year-old boy presented at the EMERGENCY hospital in Lashkar-Gah (southern Afghanistan) with generalized tetanus after falling off his bicycle. In response to his rapidly deteriorating general conditions - respiratory failure and hemodynamic instability - the patient was urgently transferred by ambulance to the ICU at the EMERGENCY hospital in Kabul (northern Afghanistan). The patient was placed on mechanical ventilation while receiving intravenous sedation and pharmacologic paralysis for almost four weeks. A prolonged infusion of a high dose of magnesium sulphate and labetalol was also given to counteract autonomic dysfunction. Multiple complications related to the long stay in the ICU were observed and promptly addressed. During this period, several mass casualties took place in Kabul, which stretched the hospital's surge capacity. The patient was discharged and accompanied back to Lashkar-Gah three months after his admission to the hospital. CONCLUSION: This case report shows some of the many difficulties that arise when managing a patient with severe tetanus in a war zone where resources are limited.

Impact and Feasibility of Mechanical Ventilation at a Surgical Center in Sierra Leone: Experience From EMERGENCY's Hospital in Goderich.

OBJECTIVES: Despite the large burden of critically ill patients in developing countries, mechanical ventilation (MV) is scarce in these low-resource settings. In the absence of data, issues like costs and lack of training are often felt to outweigh the benefits of potential MV implementation in such places. We aimed to investigate the impact and feasibility of MV in a surgical ICU in West Africa. DESIGN: This is a 7-month retrospective observational study (from October 25, 2022, to May 25, 2023), covering all patients consecutively admitted to ICU. SETTING: The NGO EMERGENCY's hospital in Goderich, Freetown, Sierra Leone. The hospital is a referral center for acute care surgery. PATIENTS: Critical patients admitted to the hospital's ICU. INTERVENTIONS: Following brief, practical training of the nursing staff, one basic mechanical ventilator was installed at the hospital's ICU, under the supervision of two intensivists. Only patients with a body weight of over 15 kg and who met the "extreme criteria" for MV received this life-saving therapy. MEASUREMENTS AND MAIN RESULTS: Of the 195 files of patients admitted to ICU during the study period, 162 were analyzed. The median age was 16 (interquartile range 7-27) and 48.1% of the population were under 14 years. The most common cause of admission was trauma (58.6%), followed by acute abdomen (33.3%), caustic soda ingestion (6.2%), and burns (1.9%). Of the overall population, 26 patients (16%) underwent MV (88.5% trauma cases vs. 11.5% acute abdomen). Median time on MV was 24 hours (12-64). The mortality rate in the MV group was 30.8% (8/26), while in the overall study population, it was 11.7% (19/162). One potentially life-threatening event of tube obstruction was handled appropriately. CONCLUSIONS: This study strongly supports the implementation of MV in low-resource settings. In our experience, the consistent benefit of reduced mortality among critical patients largely outweighs the associated challenges.

Civilian war victims in Afghanistan: five-year report from the Kabul EMERGENCY NGO hospital.

BACKGROUND: Afghanistan has been plagued by war for more than 30 years, but little is known about the civilian cost of such a long-lasting conflict. In particular, the incidence of war injuries among civilians has largely been under-reported. EMERGENCY NGO's Surgical Centre for War Victims has been operating in Kabul since 2001, providing care free of charge to anyone injured in war. The primary aim of our study is to describe the population of patients admitted to our hospital in Kabul. METHODS: This is a 5-year retrospective analysis of all recorded hospital admissions at EMERGENCY NGO's hospital in Kabul, Afghanistan, from 1 January 2017 to 31 December 2021. RESULTS: During the study period, 16,053 patients were admitted. Of these, 85.7% were male and 17.5% were under 14 years old. The proportion of male patients increased progressively with the age ranges (from 63.4 to 89.0%). Bullet wounds were the most frequent kind of injury (55.6%), followed by shell, stab and mine wounds (32.2%, 8.3% and 3.9% respectively). Only 5.8% of patients arrived at our hospital within the "golden hour" following injury. No significant reduction in the hospitalization trend was observed over the study period. The overall in-hospital mortality rate was 4.41%, which bore no correlation to the number of admissions. CONCLUSIONS: This study provides for the first time epidemiology of war-related injuries in a hospital located in a place of long-standing conflict.

Rates and Determinants of Hospital-Acquired Infection among ICU Patients Undergoing Cardiac Surgery in Developing Countries: Results from EMERGENCY'NGO's Hospital in Sudan.

Introduction. Knowledge of local and regional antimicrobial resistance (AMR) is crucial in clinical decision-making, especially with critically ill patients. The aim of this study was to investigate the rate and pattern of infections in valvular heart disease patients admitted to the intensive care unit (ICU) at the Salam Centre for Cardiac Surgery in Khartoum, Sudan (run by EMERGENCY NGO). Methods. This is a retrospective, observational study from a single, large international referral centre (part of a Regional Programme), which enrolled patients admitted to the ICU between 1 January and 31 December 2019. Data collected for each patient included demographic data, operating theatre/ICU data and microbiological cultures. Results. Over the study period, 611 patients were enrolled (elective surgery n = 491, urgent surgery n = 34 and urgent medical care n = 86). The infection rate was 14.2% and turned out to be higher in medical than in surgical patients (25.6% vs. 12.4%; p = 0.002; OR = 2.43) and higher in those undergoing urgent surgery than those undergoing elective (29.4% vs. 11.2%; p = 0.004; OR = 3.3). Infection was related to (a) SOFA score (p < 0.001), (b) ICU length of stay (p < 0.001) and (c) days from ICU admission to OT (p = 0.003). A significant relationship between the type of admission (elective, urgent surgery or medical) and the presence of infections was found (p < 0.001). The mortality rate was higher among infected patients (infected vs. infection-free: 10.3% vs. 2.1%; p < 0.001; OR = 5.38; 95% CI: 2.16−13.4; p < 0.001). Conclusions. Hospital-acquired infections remain a relevant preventable cause of mortality in our particular population.

Kabul airport suicide bombing attack: Mass casualty management at the EMERGENCY NGO Hospital.

BACKGROUND: Terrorist attacks with large numbers of civilian victims are not uncommon in war-torn countries, and present a unique challenge for health care facilities with limited resources. However, these events are largely underreported and little is known about how the mass casualty events (MCEs) are handled outside of a military setting. METHODS: This study is a retrospective analysis of the MCE which ensued the Kabul Airport suicide attack (August 26, 2021) at the Kabul EMERGENCY NGO Hospital (Afghanistan). RESULTS: Within 6 hours, 93 causalities presented at our hospital. Of them, 36 severe injured were admitted. Mean age was 30.8 years (SD, 10.1 years). The most common injury mechanism was shell fragments. The most common injury site was head (63%; 23/36), followed by limbs (55.5%; 20/36) and thoracoabdominal region (30.5%; 11/36). Combined injuries occurred in 38.9% of cases. Patients receiving surgery presented more combined injuries in comparison with patients receiving only medical treatment (47.1% vs. 31.6%). Thoracoabdomen (25.0% vs. 15.4%) and/or extremity injury (42.9% vs. 28.6%) were more prevalent in the surgical group. Thirty major surgical procedures were carried out on 17 patients in the 9 hours following the first arrival. The rate of intensive care unit/high dependency unit admission was 36.1% and the 30-day in-hospital mortality was 16.6% (6/36). All deaths were recorded in the first 24 hours, and none of them received surgery. CONCLUSION: A large number of wounded patients must be anticipated after suicide bombing attacks. The authors report the challenges faced and key aspects of their management of MCEs. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Bergamo Field Hospital Confronting COVID-19: Operating Instructions.

The coronavirus disease (COVID-19) pandemic represented an unprecedented challenge for health care facilities, and innovative solutions were urgently required to overcome the high volume of critically ill infectious patients, limit in-hospital outbreaks, and limit the risk of occupational infection for health care workers (HCWs). Bergamo was the hardest-hit Italian province by COVID-19, and the local health care system had to undergo a profound and prompt reorganization. A COVID-19-only field hospital was rapidly set up meeting the standards for severe acute respiratory infection (SARI) treatment centers (https://apps.who.int/iris/handle/10665/331603). A zones partition, dedicated in-hospital pathways for HCWs, strict infection prevention and control (IPC) measures, and constant staff supervision were key components of our strategy to limit the risk of occupational infection for HCWs. Herein, we present the Bergamo field hospital layout enlightening fundamental IPC measures adopted as a valuable example of a SARI treatment center confronting COVID-19.

Covid-19 sequelae in working age patients: A systematic review.

Despite the SARS-CoV-2 pandemic not yet being under control, post-Covid-19 syndrome is already a challenging topic: long-term multiorgan sequelae, although increasingly described, have not yet been systematized. As post-Covid-19 syndrome can significantly impact both the working capacity and the relationship life of surviving patients, we performed a systematic review of the evidence published over the last year and currently available in medical literature search databases (MEDLINE/Pubmed) and searching clinical trial registries, to evaluate the available evidence among workers. From 31 publications that initially matched inclusion criteria, 13 studies have been considered suitable for relevance and age of subjects. A wide range of patients (16%-87%) have post-Covid syndrome; pneumological and neuropsychological symptoms were the most common disorders reported. The most frequent organic sequel found in post-Covid patients was pulmonary fibrosis. The number of symptoms during acute SARS-CoV-2 infection, severity of the disease, and high serum levels of d-dimer were related to high risk of post-Covid syndrome. In conclusion, post-Covid-19 syndrome can significantly impact the health conditions of surviving patients. Rehabilitation and follow-up in multidisciplinary rehabilitation programs should be considered for working-age patients.

SARS-CoV-2 Among Migrants Recently Arrived in Europe From Low- and Middle-Income Countries: Containment Strategies and Special Features of Management in Reception Centers.

Despite the "migrants and COVID-19" topic has been neglected since felt marginal concerning other aspects of the SARS-CoV-2 pandemic, it represents a relevant public health issue in the European countries. This report describes COVID-19 containment strategies adopted in a large Italian reception center hosting recently arrived asylum-seeker migrants. Risk assessment and prevention measures adopted were described. Geo-spatial epidemiological analysis of the outbreak was reported. Significant gaps in the knowledge of self-protection measures from contagious diseases and in the perception of the pandemic risk were observed in migrants; health promotion activities, targeted to remove cultural barriers and improve behaviors appropriate to individual protection, were able to fulfill this gap. In low-resource settings, especially in closed communities, the implementation of social distancing strategies, the systematic use of individual protection devices, and active syndromic surveillance are essential tools to limit the risk of outbreaks. In the event of an outbreak, it is relevant to rapidly activate containment procedures based on systematic screening, isolation, and quarantine, taking into consideration the limits of tracing contacts within a closed community. Not being able to trace certain contacts, the geo-spatial epidemiological analysis of cases distribution could be key in the management of the outbreak. Interestingly, positive cases identified in our facility were all clinically pauci-symptomatic or asymptomatic. Dedicated strategies are needed to minimize the chance of SARS-CoV-2 transmission in a limited space such as reception centers and a vulnerable population such as migrants.

Clinical Effects of Oral Bacteriotherapy on Anal HPV Infection and Related Dysplasia in HIV-Positive MSM: Results from the "HPVinHIV" Trial.

BACKGROUND: Anal HPV infection, anal dysplasia and, ultimately, anal cancer are particularly common in HIV-infected men who have sex with men. Treatment of anal dysplasia, aiming to prevent evolution to squamous cell carcinoma of the anus, is currently limited to direct ablation and/or application of topical therapy. The aim of the present study is to investigate the effect of oral bacteriotherapy (Vivomixx® in EU, Visbiome® in USA) on anal HPV infection and HPV-related dysplasia of the anal canal in HIV-infected men who have sex with men. METHODS: In this randomized, placebo-controlled, quadruple-blinded trial (NCT04099433), HIV-positive men who have sex with men with anal HPV infection and HPV-related dysplasia were randomized to receive oral bacteriotherapy or placebo for 6 months. Anal HPV test, anal cytology and high resolution anoscopy with biopsies of anal lesions were performed at baseline and at the end of the study. Safety and tolerability of oral bacteriotherapy were also evaluated. Interim analysis results were presented. RESULTS: 20 participants concluded the study procedures to date. No serious adverse events were reported. In respect to participants randomized to placebo, individuals in the experimental arm showed higher rate of anal dysplasia regression (p = 0.002), lower rate of onset of new anal dysplasia (p = 0.023) and lower rates of worsening of persistent lesions (p = 0.004). Clearance of anal HPV infection was more frequently observed in the bacteriotherapy group (p = 0.067). CONCLUSION: Being an interim analysis, we limit ourselves to report the preliminary results of the current study. We refer the conclusions relating to the possible effectiveness of the intervention to the analysis of the definitive data.

Lesson learned from the 2017 measles outbreak in Italy: report from an emergency department.

Measles is a preventable disease still responsible for a number of outbreaks worldwide. Although most adults with measles recover uneventfully, measles-related complications may occur. However, as to whether every complicated case requires hospital management is still a point of debate. In this study we described the rate, clinical features and severity of measles complications in patients admitted to the ED of a tertiary-care teaching hospital during the outbreak that took place in 2017. Some insights into the impact on the health care system are reported as well. A retrospective cohort study was performed. Medical records of adults discharged from January to December 2017 with diagnosis of "measles" were collected and analyzed. Out of 58,579 of ED admissions, 162 measles cases were enrolled. Acute measles infection was laboratory confirmed in 71.6% and deemed as possible/probable in 24.0% of cases. Three percent of patients were immunocompromised while 1.2% of cases occurred in pregnant women. Of all complications reported (37%), hepatitis was the most frequent (29%) followed by pneumonia (10.4%), keratitis (3.8%), thrombocytopenia (3.8%) and otitis media (0.6%). No significant clinical and laboratory difference emerged between complicated and non-complicated cases besides antibiotic prescription (80.0% vs 66.3%; p=0.039). The course of the disease was mild, and no life-threatening measles-related complications or critical care support were reported. One out of three measles cases may experience at least one measles-related complication. However, the course of the disease seems to be rather benign in young adults, and the widespread use of the ED and hospitalization observed seem an inappropriate approach to the issue.

Targeting Microbiome: An Alternative Strategy for Fighting SARS-CoV-2 Infection.

Respiratory and gastrointestinal symptoms are the predominant clinical manifestations of the coronavirus disease 2019 (COVID-19). Infecting intestinal epithelial cells, the severe acute respiratory syndrome coronavirus-2 may impact on host's microbiota and gut inflammation. It is well established that an imbalanced intestinal microbiome can affect pulmonary function, modulating the host immune response ("gut-lung axis"). While effective vaccines and targeted drugs are being tested, alternative pathophysiology-based options to prevent and treat COVID-19 infection must be considered on top of the limited evidence-based therapy currently available. Addressing intestinal dysbiosis with a probiotic supplement may, therefore, be a sensible option to be evaluated, in addition to current best available medical treatments. Herein, we summed up pathophysiologic assumptions and current evidence regarding bacteriotherapy administration in preventing and treating COVID-19 pneumonia.

Viral community acquired pneumonia at the emergency department: Report from the pre COVID-19 age.

The role of viruses in community acquired pneumonia (CAP) has been largely underestimated in the pre-coronavirus disease 2019 age. However, during flu seasonal early identification of viral infection in CAP is crucial to guide treatment and in-hospital management. Though recommended, the routine use of nasopharyngeal swab (NPS) to detect viral infection has been poorly scaled-up, especially in the emergency department (ED). This study sought to assess the prevalence and associated clinical outcomes of viral infections in patients with CAP during peak flu season. In this retrospective, observational study adults presenting at the ED of our hospital (Rome, Italy) with CAP from January 15th to February 22th, 2019 were enrolled. Each patient was tested on admission with Influenza rapid test and real time multiplex assay. Seventy five consecutive patients were enrolled. 30.7% (n = 23) tested positive for viral infection. Of these, 52.1% (n = 12) were H1N1/FluA. 10 patients had multiple virus co-infections. CAP with viral infection did not differ for any demographic, clinic and laboratory features by the exception of CCI and CURB-65. All intra-ED deaths and mechanical ventilations were recorded among CAP with viral infection. Testing only patients with CURB-65 score ≥2, 10 out of 12 cases of H1N1/FluA would have been detected saving up to 40% tests. Viral infection occurred in one-third of CAP during flu seasonal peak 2019. Since not otherwise distinguishable, NPS is so far the only reliable mean to identify CAP with viral infection. Testing only patients with moderate/severe CAP significantly minimize the number of tests.

Targeted HIV screening in the emergency department.

Despite considerable improvement in human immunodeficiency virus (HIV) knowledge and treatment in the last 3 decades, the overall number of people living with HIV (PLHIV) is still rising with up to one quarter being unaware of their HIV status. Early HIV diagnosis and treatment prolongs life, reduces transmission, improves quality of life, and is a cost-effective public health intervention. The emergency department (ED) sees a large number of patients from marginalized and traditionally underserved populations in whom HIV is known to be more prevalent and who may not attend traditional services because of either cultural reasons or because of a chaotic lifestyle. This article discusses the two main approaches to screening; 'Opt-out' screening offers testing routinely in all clinical settings, and 'Targeted' screening offers testing to individuals presenting with indicator conditions. There are many studies of 'Opt-out' ED HIV screening in urban areas of high-HIV prevalence. However, little is known about the effectiveness of 'targeted' HIV screening, especially in areas of low prevalence. This review discusses the background to HIV screening in the ED and reviews the evidence around 'targeted' HIV screening in adult EDs in different HIV prevalence settings, concluding that targeted HIV screening at the ED can be impactful, cost-effective, and well accepted in the ED population, but its long-term implementation requires extra funding and increased staffing resource limiting its application in low resource setting. Despite most evidence being from areas of high-HIV prevalence, targeted screening might also be appropriate in low-HIV prevalence areas.

Malaria in an asylum seeker paediatric liver transplant recipient: diagnostic challenges for migrant population.

Transplanted patients are particularly exposed to a major risk of infectious diseases due to prolonged immunosuppressive treatment. Over the last decade, the growing migration flows and the transplant tourism have led to increasing infections caused by geographically restricted organisms. Malaria is an unusual event in organ transplant recipients than can be acquired primarily or reactivation following immunosuppression, by transfusion of blood products or through the transplanted organ. We report a rare case of Plasmodium falciparum infection in a liver transplanted two years-old African boy who presented to one Italian Asylum Seeker Center on May 2019. We outlined hereby diagnostic challenges, possible aetiologies of post-transplantation malaria and finally we summarized potential drug interactions between immunosuppressive agents and antimalarials. This report aims to increase the attention to newly arrived migrants, carefully evaluating patients coming from tropical areas and taking into consideration also rare tropical infections not endemic in final destination countries.

The Pregnancy Outcomes Among Newly Arrived Asylum-Seekers in Italy: Implications of Public Health.

BACKGROUND: Migration has a significant impact on overall health and pregnancy outcome. Despite the fact that growing volume of migration flows significantly engaging the public health system of European host countries, there is a lack of evidence concerning pregnancy outcomes of newly arrived asylum-seeking women. METHODS: Data about pregnant asylum seekers hosted in the Italian Reception Centers between the 1 st June 2016 and the 1st June 2018 were retrospectively collected and analysed in the present study. We examined the following pregnancy outcomes: miscarriage, self-induced abortion, voluntary pregnancy termination, live-birth; and studied potentially related socio-demographic factors. RESULTS: Out of the 110 pregnant women living in the reception centers, 44 (40%) had eutocic delivery, 8 (7.3%) dystocic delivery, 15 (13.6%) miscarriage, 17 (15.5%) self-induced abortion and 26 (23.6%) underwent voluntary pregnancy termination. Nigerian women were at a significantly higher risk of abortive outcomes for voluntary pregnancy termination (p < 0.001), miscarriage (p = 0.049) and self-induced abortion (p < 0.001). Being unmarried was significantly associated with voluntary pregnancy termination and self-induced abortion. Women who chose to undergo unsafe abortion did not result to have significantly lower educational levels, compared to women who preferred medical abortion. CONCLUSION: This study offers first insights into pregnancy outcomes among asylum-seeking women in Italy. The country of origin and marital status seem to significantly impact on pregnancy outcome. We identified sub-groups of migrant women at increased risk of abortive outcomes, and highlight the need to improve care in order to promote migrant women's reproductive health.

The Role of Targeted HIV Screening in the Emergency Department: A Scoping Review.

BACKGROUND: Human immunodeficiency virus (HIV) infection continues to expand worldwide, and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing, especially in low-prevalence areas. OBJECTIVE: The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening of adult in EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings. DESIGN: Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A three-concept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed. RESULTS: The search provided 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies). CONCLUSIONS: Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence.

qSOFA as a new community-acquired pneumonia severity score in the emergency setting.

BACKGROUND: Quick Sequential Organ Failure Assessment (qSOFA) score is a bedside prognostic tool for patients with suspected infection outside the intensive care unit (ICU), which is particularly useful when laboratory analyses are not readily available. However, its performance in potentially septic patients with community-acquired pneumonia (CAP) needs to be examined further, especially in relation to early outcomes affecting acute management. OBJECTIVE: First, to compare the performance of qSOFA and CURB-65 in the prediction of mortality in the emergency department in patients presenting with CAP. Second, to study patients who required critical care support (CCS) and ICU admission. METHODS: Between January and December 2017, a 1-year retrospective observational study was carried out of adult (≥18 years old) patients presenting to the emergency department (ED) of our hospital (Rome, Italy) with CAP. The accuracy of qSOFA, qSOFA-65 and CURB-65 was compared in predicting mortality in the ED, CCS requirement and ICU admission. The concordance among scores ≥2 was then assessed for 30-day estimated mortality prediction. RESULTS: 505 patients with CAP were enrolled. Median age was 71.0 years and mortality rate in the ED was 4.7%. The areas under the curve (AUCs) of qSOFA-65, CURB-65 and qSOFA in predicting mortality rate in the ED were 0.949 (95% CI 0.873 to 0.976), 0.923 (0.867 to 0.980) and 0.909 (0.847 to 0.971), respectively. The likelihood ratio of a patient having a qSOFA score ≥2 points was higher than for qSOFA-65 or CURB-65 (11 vs 7 vs 6.7). The AUCs of qSOFA, qSOFA-65 and CURB-65 in predicting CCS requirement were 0.862 (95% CI 0.802 to 0.923), 0.824 (0.758 to 0.890) and 0.821 (0.754 to 0.888), respectively. The AUCs of qSOFA-65, qSOFA and CURB-65 in predicting ICU admission were 0.593 (95% CI 0.511 to 0.676), 0.585 (0.503 to 0.667) and 0.570 (0.488 to 0.653), respectively. The concordance between qSOFA-65 and CURB-65 in 30-day estimated mortality prediction was 93%. CONCLUSION: qSOFA is a valuable score for predicting mortality in the ED and for the prompt identification of patients with CAP requiring CCS. qSOFA-65 may further improve the performance of this useful score, showing also good concordance with CURB-65 in 30-day estimated mortality prediction.

Interplay between Nox2 Activity and Platelet Activation in Patients with Sepsis and Septic Shock: A Prospective Study.

BACKGROUND: Although preclinical studies highlighted the potential role of NADPH oxidase (NOX) in sepsis, only few studies evaluated the oxidative stress in patients with sepsis and septic shock. The objective of the study is to appraise the oxidative stress status and platelet function in patients with sepsis and septic shock compared to healthy controls. METHODS AND RESULTS: Patients with sepsis or septic shock admitted to the hospital Policlinico Umberto I (Sapienza University, Rome) underwent a blood sample collection within 1 hour from admission. Platelet aggregation, serum thromboxane B2 (TxB2), soluble NOX2-derived peptides (sNox2-dp), and hydrogen peroxide breakdown activity (HBA) were measured and compared to those of healthy volunteers. Overall, 33 patients were enrolled; of these, 20 (60.6%) had sepsis and 13 (39.4%) septic shock. Compared to healthy controls (n = 10, age 67.8 ± 3.2, male 50%), patients with sepsis and septic shock had higher platelet aggregation (49% (IQR 45-55), 60% (55.75-67.25), and 73% (IQR 69-80), respectively, p < 0.001), higher serum TxB2 (77.5 (56.5-86.25), 122.5 (114-131.5), and 210 (195-230) pmol/L, respectively, p < 0.001), higher sNox2-dp (10 (7.75-12), 19.5 (17.25-21), and 33 (29.5-39) pg/mL, respectively, p < 0.001), and lower HBA (75% (67.25-81.5), 50% (45-54.75), and 27% (21.5-32.5), respectively, p < 0.001). Although not statistically significant, a trend in higher levels of serum TxB2 and sNox2-dp in patients who died was observed. CONCLUSIONS: Patients with septic shock exhibit higher Nox2 activity and platelet activation than patients with sepsis. These insights joined to better knowledge of these mechanisms could guide the identification of future prognostic biomarkers and new therapeutic strategies in the scenario of septic shock.