Sepsis as a Challenge for Personalized Medicine.

Sepsis is a clinical syndrome of systemic inflammation induced by infection, now defined as life-threatening organ dysfunction caused by a dysregulated immune response to infection [...].

SepsEast Registry indicates high mortality associated with COVID-19 caused acute respiratory failure in Central-Eastern European intensive care units.

The coronavirus disease (COVID-19) pandemic caused unprecedented research activity all around the world but publications from Central-Eastern European countries remain scarce. Therefore, our aim was to characterise the features of the pandemic in the intensive care units (ICUs) among members of the SepsEast (Central-Eastern European Sepsis Forum) initiative. We conducted a retrospective, international, multicentre study between March 2020 and February 2021. All adult patients admitted to the ICU with pneumonia caused by COVID-19 were enrolled. Data on baseline and treatment characteristics, organ support and mortality were collected. Eleven centres from six countries provided data from 2139 patients. Patient characteristics were: median 68, [IQR 60-75] years of age; males: 67%; body mass index: 30.1 [27.0-34.7]; and 88% comorbidities. Overall mortality was 55%, which increased from 2020 to 2021 (p = 0.004). The major causes of death were respiratory (37%), cardiovascular (26%) and sepsis with multiorgan failure (21%). 1061 patients received invasive mechanical ventilation (mortality: 66%) without extracorporeal membrane oxygenation (n = 54). The rest of the patients received non-invasive ventilation (n = 129), high flow nasal oxygen (n = 317), conventional oxygen therapy (n = 122), as the highest level of ventilatory support, with mortality of 50%, 39% and 22%, respectively. This is the largest COVID-19 dataset from Central-Eastern European ICUs to date. The high mortality observed especially in those receiving invasive mechanical ventilation renders the need of establishing national-international ICU registries and audits in the region that could provide high quality, transparent data, not only during the pandemic, but also on a regular basis.

Association between use of enhanced recovery after surgery protocols and postoperative complications in colorectal surgery in Europe: The EuroPOWER international observational study.

STUDY OBJECTIVE: Assess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes. DESIGN: Prospective cohort study. SETTING: European centers (185 hospitals) across 21 countries. PATIENTS: A total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020. INTERVENTIONS: Routine perioperative care. MEASUREMENTS: Twenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences. RESULTS: A total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79-1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5-9] vs. 8 [6-10] days; OR 0.82; 95%CI, 0.78-0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%-65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53-0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02-0.42; P = 0.002) and shorter hospital stay (6 [4-8] vs. 7 [5-10] days; OR 0.74; 95%CI, 0.69-0.79; P < 0.001). CONCLUSIONS: Treatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.

Elevated jugular venous oxygen saturation after cardiac arrest.

BACKGROUND: We performed a retrospective analysis of our earlier study on cerebral oxygenation monitoring by jugular venous oximetry (SjvO2) in patients of out-of-hospital cardiac arrest (OHCA). The study was focused on high SjvO2 values (≥75%) and their association with neurological outcomes and serum neuron-specific enolase (NSE) concentration. METHOD: Forty OHCA patients were divided into (i) high (Group I), (ii) normal (Group II), and (iii) low (Group III) SjvO2, with the mean SjvO2 ≥ 75%, 55-74% and <55% respectively. The neurological outcome was evaluated using the Cerebral Performance Category scale (CPC) on the 90th day after cardiac arrest (post-CA). NSE concentration was determined after ICU admission and then at 24, 48, and 72 hours (h) post-CA. RESULTS: High mean SjvO2 occurred in 67% of patients, while no patients had low mean SjvO2. The unfavourable outcome was significantly more common in Group I than Group II (74% versus 23%, p < 0.01). Group I patients had significantly higher median NSE than Group II at 48 and 72 h post-CA. A positive correlation was found between SjvO2 and PaCO2. Each 1 kPa increase in CO2 led to an increase of SjvO2 by 2.2 %+/-0.66 (p < 0.01) in group I and by 5.7%+/-1.36 (p < 0.0001) in group II. There was no correlation between SjvO2 and MAP or SjvO2 and PaO2. CONCLUSION: High mean SjvO2 are often associated with unfavourable outcomes and high NSE at 48 and 72 hours post-CA. Not only low but also high SjvO2 values may require therapeutic intervention.

Predictive model using hemoglobin, albumin, fibrinogen, and neutrophil-to-lymphocyte ratio to distinguish patients with colorectal cancer from those with benign adenoma.

Colorectal cancer (CRC) is associated with inflammation, activation of coagulation, and mild anemia. Hematological parameters reflecting ongoing cancer may have the potency to be effective for early diagnostics of CRC. The aim of this study was to examine the validity and relationship between some biochemical and hematological parameters for the early diagnosis of CRC. We designed a prospective observational cohort study to analyze whether these laboratory markers have the potency to distinguish benign tumors from malignant before planned surgery. The clinical data were collected from 208 patients with suspected benign or malignant colorectal tumors who were eligible for elective surgery between September 2018 and January 2020. Blood samples were collected one day before surgery, examined parameters included: complete blood count, hemoglobin (HGB) concentration, albumin (ALB), C-reactive protein (CRP), interleukin-6 (IL-6), and fibrinogen (FG). Absolute neutrophil and lymphocyte counts were used for the calculation of the neutrophil-to-lymphocyte ratio (NLR). The diagnosis was confirmed by histopathological examination. The 197 patients were divided into the group of benign (B group = 52 patients) or malignant tumors (CRC group = 145 patients). ROC curves and cut-off values of NLR, HGB, FG, and ALB concentration, serum CRP and IL-6 levels. In the cohort of 197 adult patients submitted for the elective colorectal surgery, the complete blood samples drawn one day before surgery showed significant differences between patients with benign tumors and colorectal carcinoma: HGB (mean 139.9 g/l vs. 129.9; p<0.001), FG (mean 3.36 g/l vs. 3.94 g/l; p<0.001), ALB (mean 43.4 g/l vs. 41.1 g/l; p=0.001), NLR (mean 2.73 vs. 3.88; p=0.016), respectively. CRP (mean 2.9 mg/l vs. 4.4 mg/l; p=0.011), thrombocyte count (mean 235×109/l vs. 265×109/l; p<0.029). Differences in IL-6 concentrations were not significant (2.9 pg/ml vs. 4.15 pg/ml; p=0.052). Using multivariable logistic regression analysis, four valid parameters (HGB, FG, ALB, and NLR) were suitable for the construction of a diagnostic predictive model for the identification of CRC. In conclusion, a panel of routinely examined blood parameters like HGB, FG, ALB, and NLR has the potency to distinguish patients with benign tumors from malignant by applying a diagnostic predictive model for early laboratory detection of CRC.

Acute appendicitis: Clinical anatomy of the new palpation sign.

INTRODUCTION: Currently, diagnosis of acute appendicitis (AA) is challenging. Here, we aim to propose using the new palpation sign to diagnose AA and establish the effectiveness of clinical examination using a proprietary diagnostic palpation procedure. MATERIALS AND METHODS: We retrospectively analyzed 2,883 patients of all ages who were examined for suspected AA, of whom 532 patients required surgical intervention, using the new palpation sign. Patients were divided into three age categories. Based on the correlation between clinical data and histological findings, clinical examination finding was defined as false negative, false positive, and positive. Pearson correlation analysis was performed to assess the correlation between patients' sex and age distribution and clinical and histological findings. RESULTS: There was a strong correlation (r > .95) for distribution of total number of examined patients (distributed in groups by sex and age) versus false-positive clinical findings, total number of examined patients (distributed in groups by sex and age) versus positive clinical findings, and total number of examined patients (distributed in groups by age) versus histology in phlegmonous and gangrenous appendicitis. Correlations (r = .94 and .90) were observed for distribution of total number of examined patients (distributed in groups by age) versus negative histological findings and Byron's obliterating appendicopathy. Pearson's chi-squared test showed no significant difference between expected and observed frequencies of both clinical and histologic findings. CONCLUSIONS: The new palpation sign can be used to diagnose early and later stage appendicitis, especially in children and young women, and is very effective in indicating surgery for AA.

Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients?

Cerebral protection against secondary hypoxic-ischemic brain injury is a key priority area in post-resuscitation intensive care management in survivors of cardiac arrest. Nevertheless, the current understanding of the incidence, diagnosis and its' impact on neurological outcome remains undetermined. The aim of this study was to evaluate jugular bulb oximetry as a potential monitoring modality to detect the incidences of desaturation episodes during post-cardiac arrest intensive care management and to evaluate their subsequent impact on neurological outcome. We conducted a prospective, observational study in unconscious adult patients admitted to the intensive care unit who had successful resuscitation following out of hospital cardiac arrest of presumed cardiac causes. All the patients were treated as per European Resuscitation Council 2015 guidelines and they received jugular bulb catheter. Jugular bulb oximetry measurements were performed at six hourly intervals. The neurological outcomes were evaluated on 90th day after the cardiac arrest by cerebral performance categories scale. Forty patients met the eligibility criteria. Measurements of jugular venous oxygen saturation were performed for 438 times. Altogether, we found 2 incidences of jugular bulb oxygen saturation less than 50% (2/438; 0.46%), and 4 incidences when it was less than 55% (4/438; 0.91%). The study detected an association between SjVO2 and CO2 (r = 0.26), each 1 kPa increase in CO2 led to an increase in SjvO2 by 3.4% + / - 0.67 (p < 0.0001). There was no association between SjvO2 and PaO2 or SjvO2 and MAP. We observed a statistically significant higher mean SjvO2 (8.82% + / - 2.05, p < 0.0001) in unfavorable outcome group. The episodes of brain hypoxia detected by jugular bulb oxygen saturation were rare during post-resuscitation intensive care management in out of hospital cardiac arrest patients. Therefore, this modality of monitoring may not yield any additional information towards prevention of secondary hypoxic ischemic brain injury in post cardiac arrest survivors. Other factors contributing towards high jugular venous saturation needs to be considered.