The association between prolonged capillary refill time and microcirculation changes in children with sepsis.

BACKGROUNDS: In children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis. METHODS: This was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]-a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes. RESULTS: A total of 132 children with sepsis were included, with a median age of two years (IQR 0.6-12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09-6.34; p = 0.02) and fewer 4-6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06-6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO2 difference (DCO2) had an abnormal PBR (aOR 1.13, 95% CI 1.01-1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64-0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58-1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94-0.99; p < 0.05). CONCLUSIONS: We found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.

The association between hypoalbuminemia and microcirculation, endothelium, and glycocalyx disorders in children with sepsis.

OBJECTIVE: The objective of this study was to evaluate the association between serum albumin levels and microcirculation changes, glycocalyx degradation, and the clinical outcomes of interest. METHODS: Observational, prospective study in children with sepsis. The primary outcome was the association between hypoalbuminemia and microcirculation disorders, endothelial activation and glycocalyx degradation using a perfused boundary region (PBR) (abnormal >2.0 µm on sublingual video microscopy) or plasma biomarkers (syndecan-1, angiopoietin-2). RESULTS: A total of 125 patients with sepsis were included. The median age was 2.0 years (IQR 0.5-12.5). Children with hypoalbuminemia had more abnormal microcirculation with a higher PBR (2.16 µm [IQR 2.03-2.47] vs. 1.92 [1.76-2.28]; p = .01) and more 4-6 µm capillaries recruited (60% vs. 40%; p = .04). The low albumin group that had the worst PBR had the most 4-6 µm capillaries recruited (rho 0.29; p < .01), 48% higher Ang-2 (p = .04), worse annexin A5 (p = 0.03) and no syndecan-1 abnormalities (p = .21). Children with hypoalbuminemia and a greater percentage of blood volume in their capillaries needed mechanical ventilation more often (56.3% vs. 43.7%; aOR 2.01 95% CI 1.38-3.10: p < .01). CONCLUSIONS: In children with sepsis, an association was found between hypoalbuminemia and microcirculation changes, vascular permeability, and greater endothelial glycocalyx degradation.

Cardiac Myxomas As Chameleons: A Scoping Review of Their Paraneoplastic Presentations.

This scoping review aims to explore the relationship between cardiac myxomas (CMs) and paraneoplastic syndromes (PS). CMs are the most common tumors in the heart, with the majority located in the left atrium, and are often associated with a triad of obstructive, embolic, and constitutional symptoms. However, they can also present with unrelated symptoms that are part of a PS. This study performed a thorough literature search of 11 databases and included 12 papers in the final review. All of the patients were diagnosed with atrial myxoma, which initially presented as a PS. Surgery was the curative measure in all cases and resulted in remission in every case, with patients reporting resolution of symptoms at follow-up. The majority of patients in the study were female, with comorbid rheumatologic conditions often present. This study highlights the heterogeneity of presentations of CMs and their associated PS.

Capillary refill time in sepsis: A useful and easily accessible tool for evaluating perfusion in children.

The international sepsis guidelines emphasize the importance of early identification along with the combined administration of fluids, antibiotics and vasopressors as essential steps in the treatment of septic shock in childhood. However, despite these recommendations, septic shock mortality continues to be very high, especially in countries with limited resources. Cardiovascular involvement is common and, in most cases, determines the outcomes. Early recognition of hemodynamic dysfunction, both in the macro and microcirculation, can help improve outcomes. Capillary refill time (CRT) is a useful, available and easily accessible tool at all levels of care. It is a clinical sign of capillary vasoconstriction due to an excessive sympathetic response which seeks to improve blood redistribution from the micro- to the macrocirculation. An important reason for functionally evaluating the microcirculation is that, in septic shock, the correction of macrocirculation variables is assumed to result in improved tissue perfusion. This has been termed "hemodynamic coherence." However, this coherence often does not occur in advanced stages of the disease. Capillary refill time is useful in guiding fluid resuscitation and identifying more seriously affected sepsis patients. Several factors can affect its measurement, which should preferably be standardized and performed on the upper extremities. In this review, we seek to clarify a few common questions regarding CRT and guide its correct use in patients with sepsis.

Pneuma: receta colonial eficaz en el tratamiento de la disnea / Pneuma: colonial prescription effective in treatment of dyspnea

Objetivo: el archivo histórico Cipriano Rodríguez Santa María de la Universidad de La Sabana cuenta con múltiples recetas médicas empleadas por médicos y boticarios en el Nuevo Reino de Granada. Una de ellas prescribe el cacao para disminuir síntomas generados por afecciones del sistema respiratorio. Objetivos: describir el análisis de una receta médica empleada entre los siglos XVIII y XIX para el tratamiento del ahogo y describir la propiedad fitoterapéutica del cacao conocida gracias a la evidencia científica actual. Materiales y métodos: búsqueda documental en el Archivo Histórico Cipriano Rodríguez Santamaría de la Biblioteca Octavio Arizmendi Posada de la Universidad de La Sabana. Transcripción y análisis del documento denominado "Ahogo" y revisión de la literatura científica actual, así como de los textos originales, sin límite de tiempo. Resultados: la receta médica describe las características del cacao (Theobroma cacao) como agente fitoterapéutico con propiedades antiinflamatorias, analgésicas, antioxidantes e inmunomoduladoras aportadas por componentes como los ácidos oleico, esteárico, palmítico y flavonoides entre otros. La teobromina ejerce efectos broncodilatadores y antitusivosConclusiones: el legado histórico colonial conservado en los archivos locales permite comprender racionalmente las propiedades de los agentes herbarios empleados para enfermedades y síntomas asociados. Existe evidencia científica que respalda el uso del cacao para disminuir la sintomatología asociada con el ahogo. Pese a ello, la escasa o nula descripción de la posología y los efectos secundarios, dificulta analizar la eficacia de esta tradición. En consecuencia, no se puede establecer su eficacia científicamente.

Objetive: The Cipriano Rodríguez Santamaria Historical Archive at Universidad de La Sabana includes multiple medical prescriptions used by physicians and apothecaries in the New Kingdom of Granada. Among them, cocoa was prescribed to relieve symptoms generated by respiratory diseases. Objectives: to describe the analysis of a medical prescription used between the 18th and 19th centuries to treat shortness of breath ("ahogo") and to describe the phytotherapeutic properties of cocoa through current scientific evidence. Materials and Methods: a documentary search in the Cipriano Rodríguez Santamaria Historical Archive: Octavio Arizmendi Posada Library, Universidad de La Sabana. Transcription and analysis of the document named "ahogo" and review of the current scientific literature, as well as, of the original texts, with no time limit. Results: the medical prescription describes the characteristics of cocoa (Theobroma cacao) as a phytotherapeutic agent featuring anti-inflammatory, analgesic, antioxidant and immunomodulatory properties provided by components such as oleic, stearic, palmitic and flavonoid acids, among others. Theobromine exerts a bronchodilator and antitussive effect. Conclusions: the colonial historical legacy preserved in local archives allows a rational understanding of the properties of herbal agents as treatment for diseases and their symptoms. There is scientific evidence supporting the use of cocoa to reduce the symptoms associated with dyspnea. However, little or no description of dosage and side effects makes it difficult to analyze the efficacy of this tradition. Consequently, its efficacy cannot be scientifically established.

Changes in dominant Escherichia coli and antimicrobial resistance after 24 hr in fecal matter.

Intestinal bacteria carry antimicrobial resistance (AMR) genes in mobile genetic elements which have the potential to spread to bacteria in other animal hosts including humans. In fecal matter, Escherichia coli can continue to multiply for 48 hr after being excreted, and in certain environments, E. coli survive long periods of time. It is unclear the extent to which AMR in E. coli changes in the environment outside of its host. In this study, we analyzed changes in the population structure, plasmid content, and AMR patterns of 30 E. coli isolates isolated from 6 chickens (cloacal swabs), and 30 E. coli isolates from fecal samples (from the same 6 chickens) after 24 hr of incubation. Clonality of isolates was screened using the fumC gene sequence and confirmed in a subset of isolates (n = 14) by multi-locus sequence typing. Major shifts in the population structure (i.e., sequence types) and antibiotic resistance patterns were observed among the numerically dominant E. coli isolates after 24 hr. Four E. coli clones isolated from the cloaca swabs and the corresponding fecal samples (after 24 hr incubation) showed different antibiotic resistance patterns. Our study reveals that fecal matter in the environment is an intermediate habitat where rapid and striking changes occur in E. coli populations and antibiotic resistance patterns.

First case of New Delhi metallo-ß-lactamase in Klebsiella pneumoniae from Ecuador: An update for South America.

OBJECTIVES: To describe a clinical case of Klebsiella pneumoniae harboring a New Delhi metallo-ß-lactamase (NDM) plasmid in Ecuador and to present a map of reports of NDM isolates in South America. METHODS: The modified Hodge test, carbapenem inactivation method, imipenem-EDTA disk method (synergy), and Rapidec Carba NP test were used to identify antibiotic resistance mechanisms. The presence of resistance genes was explored with a conjugation assay, and molecular confirmation of NDM was performed by PCR and DNA sequencing. Plasmid characterization was conducted by PCR-based replicon typing. A literature review was performed in Google Scholar and PubMed to identify reports from South America. RESULTS: An HIV-infected patient, who had never traveled abroad, developed a bloodstream infection caused by K. pneumoniae ST147 harboring the NDM-1 resistance gene in a plasmid from the IncA/C group. Local circulation of NDM has also been described in other South American countries, in particular in Colombia and Brazil, although published scientific records were not found for other countries. CONCLUSIONS: This report presents the first evidence of autochthonous circulation of the NDM-1 resistance gene harbored by an IncA/C plasmid isolated from a K. pneumoniae ST147 in Ecuador. Efforts should be implemented to monitor and characterize the spatial and temporal distribution of NDM in Ecuador and other countries of South America.