Sural nerve sensory response in diabetic distal symmetrical polyneuropathy.

INTRODUCTION: The sural sensory nerve action potential (SNAP) amplitude is a measure of the number of axons. We tested the hypothesis that sural SNAP amplitude can be used as a marker in screening, severity evaluation, and follow-up of diabetic distal symmetrical polyneuropathy (DSPN). METHODS: Patients with type 2 diabetes underwent nerve conduction studies and were followed for 6 years. Composite amplitude scores (CASs) were determined to evaluate DSPN severity. RESULTS: Sural SNAP amplitudes were negatively correlated with CAS (r = -.790, P < .0001), and changes in sural SNAP amplitudes were negatively correlated with those of CAS after controlling for follow-up duration (r = -.531, P = .028). DISCUSSION: When a patient's baseline sural SNAP amplitude is above zero, it can be used as one measure of DSPN in screening, severity evaluation, and follow-up. However, if the patient's sural SNAP value is zero, CAS can be used as a follow-up measure.

Neuropsychiatric symptoms in Parkinson's disease: association with caregiver distress and disease severity.

OBJECTIVES: The condition of caregivers is important to the quality of care received by people with Parkinson's disease (PD), especially at the late disease stages. This study addresses the distress placed on caregivers by participants' neuropsychiatric symptoms at different stages of PD in Taiwan. METHODS: This prospective study enrolled 108 people with PD. All participants were examined with the Unified Parkinson's Disease Rating Scale (UPDRS), Neuropsychiatric Inventory (NPI), Mini-Mental State Examination (MMSE), Cognitive Abilities Screening Instrument (CASI), and Clinical Dementia Rating (CDR) scale. Caregiver distress was measured using the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D). Statistical analysis was used to explore the PD-related factors that contribute to caregiver distress. RESULTS: The mean follow-up interval in the 108 PD participants were 24.0 ± 10.2 months with no participant lost to follow-up due to death. NPI-distress (the sum of NPI caregiver distress scale across the 12 domains of the NPI) was positively correlated with NPI-sum (the total score across the 12 domains of the NPI) (r = 0.787, p < 0.001), CDR (r = 0.403, p < 0.001), UPRDS (r = 0.276, p = 0.004), and disease duration (r = 0.246, p = 0.002), but negatively correlated with CASI (r = -0.237, p = 0.043) and MMSE (r = -0.281, p < 0.001). Multiple linear regression analysis showed that only NPI-sum and disease duration were independently correlated with NPI-distress. CONCLUSION: The disease duration and NPI-sum are independent predictors of caregiver distress in Taiwanese populations with PD. Early detection and reduction of neuropsychiatric symptoms in people with PD can help decrease caregiver distress.

Increased circulating endothelial progenitor cells and improved short-term outcomes in acute non-cardioembolic stroke after hyperbaric oxygen therapy.

BACKGROUND: Acute ischemic stroke is a leading cause of mortality and long-term disability, and profiles of endothelial progenitor cells (EPCs) reflect the degree of endothelial impairment. This study tested the hypothesis that hyperbaric oxygen therapy (HBOT) both improves the clinical short-term outcomes and increases the number of circulating EPCs and antioxidant capacity. METHODS: The numbers of circulating EPCs [CD133+/CD34+ (%), KDR+/CD34+ (%)], biomarkers for oxidative stress (thiols and thiobarbituric acid-reactive substances), and clinical scores (National Institutes of Health Stroke Scale [NIHSS], Barthel index [BI], and modified Rankin Scale [MRS]) were prospectively evaluated in 25 patients with acute non-cardioembolic stroke under HBOT at two time points (pre- and post-HBOT). The biomarkers and clinical scores were compared with those of 25 age- and sex-matched disease controls. RESULTS: The numbers of KDR+/CD34+ (%) in the HBOT group following HBOT increased significantly, whereas the numbers of CD133+/CD34+ (%) also showed a tendency to increase without statistical significance. The mean high-sensitivity C-reactive protein levels showed significant decrease post-HBOT follow-up in the HBOT group. The changes in KDR+/CD34+EPC (%) numbers were positively correlated with changes in clinical outcomes scores (BI, NIHSS, and MRS) in the HBOT group. CONCLUSIONS: Based on the results of our study, HBOT can both improve short-term clinical outcomes and increase the number of circulating EPCs in patients with acute non-cardioembolic stroke.

Plasma nuclear and mitochondrial DNA levels as predictors of outcome in severe sepsis patients in the emergency room.

BACKGROUND AND AIM: The sensitivity and specificity of biomarkers and scoring systems used for predicting fatality of severe sepsis patients remain unsatisfactory. This study aimed to determine the prognostic value of circulating plasma DNA levels in severe septic patients presenting at the Emergency Department (ED). METHODS: Sixty-seven consecutive patients with severe sepsis and 33 controls were evaluated. Plasma DNA levels were estimated by real-time quantitative polymerase chain reaction assay using primers for the human ß-hemoglobin and ND2 gene. The patients' clinical and laboratory data on admission were analyzed. RESULTS: The median plasma nuclear and mitochondria DNA levels for severe septic patients on admission were significantly higher than those of the controls. The mean plasma nuclear DNA level on admission correlated with lactate concentration (γ = 0.36, p = 0.003) and plasma mitochondrial DNA on admission (γ = 0.708, p < 0.001). Significant prognostic factors for fatality included mechanical ventilation within the first 24 hours (p = 0.013), mean sequential organ failure assessment (SOFA) score on admission (p = 0.04), serum lactate (p < 0.001), and both plasma nuclear and mitochondrial DNA on admission (p < 0.001). Plasma mitochondrial DNA was an independent predictor of fatality by stepwise logistic regression such that an increase by one ng/mL in level would increase fatality rate by 0.7%. CONCLUSION: Plasma DNA has potential use for predicting outcome in septic patients arriving at the emergency room. Plasma mitochondrial DNA level on admission is a more powerful predictor than lactate concentration or SOFA scores on admission.

The Prognostic Value of Serum Soluble TREM-1 on Outcome in Adult Patients with Sepsis.

Increased soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) levels have been reported in patients with sepsis. We tested the hypotheses that serum sTREM-1 levels increase in the early phase of sepsis and decrease after sepsis under appropriate treatment and that sTREM-1 levels can predict therapeutic outcomes. One hundred and fifty-five patients prospectively underwent blood samples including biochemical data, sTREM-1, and biomarkers on endothelial dysfunction as well as clinical severity index examinations. Blood samples from Days 1, 4, and 7 after admission were checked. For comparison, 50 healthy subjects were selected as healthy control. Those patients who had sepsis had significantly higher sTREM-1 levels than those of healthy control. sTREM-1 levels positively correlated with biomarkers for endothelial dysfunction (ICAM-1, VCAM-1, and E-selectin) and lactate level as well as clinical severity index (maximum 24 h APACHE score and Sequential Organ Failure Assessment (SOFA) score) upon admission. sTREM-1 concentrations were significantly higher from Day 1 to Day 7 in the non-survivors than in the survivors. A stepwise logistic regression analysis showed only sTREM-1 level and maximum 24 h SOFA score upon admission were significantly associated with fatality. Area under the receiver operating characteristic curve analysis for the diagnostic accuracy of sTREM-1 in sepsis-related fatality gave a value of 0.726, with a cutoff value of 384.6 pg/mL (sensitivity = 80.8% and specificity = 61.5%). sTREM-1 level may be valuable in auxiliary diagnosis, and it can serve as a useful biomarker as a screening service and follow-up therapeutic outcomes in sepsis.

Impact of oxidative stress on treatment outcomes in adult patients with sepsis: A prospective study.

PURPOSE: Oxidative stress has been shown to reflect on the development of sepsis and disease severity. In the present study, we evaluated the effects of increased levels of oxidative stress and decreased antioxidant coactivity in patients with sepsis, and the importance of oxidative stress on treatment outcomes. METHODS: Biomarkers of oxidative stress (thiobarbituric acid-reactive substances [TBARS]) and antioxidant capacity (glutathione peroxidase [GPx] and glutathione content [thiol]) were prospectively evaluated along with biochemical and clinical data in 100 patients with sepsis on days 1, 4, and 7 after admission. RESULTS: The TBARS level of the non-survivor group was significantly higher than that of the survivor group on day 1 and day 4 and negatively correlated with thiol upon admission. However, thiol was positively correlated with lactate concentration. The TBARS and lactate levels upon admission were independent predictors of fatality. CONCLUSIONS: We conclude that a TBARS cut-off value of 18.30 µM can be used to predict fatality, and an increase in the TBARS concentration by 1 µM will increase the fatality rate by 0.94%. In the panel of biomarkers, the TBARS assay can be considered as a prognostic biomarker for the treatment of patients with sepsis.

The role of blink reflex R1 latency as an electrophysiological marker in diabetic distal symmetrical polyneuropathy.

OBJECTIVE: Studies showed a relatively prolonged blink R1 latency in patients with diabetic distal symmetrical polyneuropathy (DSPN) compared to that without DSPN. We tested the hypothesis that blink R1 latency would provide a diagnostic alternative to nerve conduction studies (NCS) in DSPN and act as a marker of the severity of NCS abnormalities in DSPN. METHOD: A total of 109 patients with type 2 diabetes underwent blink reflex studies and NCS. We used the composite amplitude scores of nerve conductions (CAS), which consisted of motor (tibial, peroneal and ulnar) and sensory (sural and ulnar) amplitudes for estimating the severity of NCS. RESULTS: Patients with DSPN had longer blink R1, R2, and contralateral R2 latencies (P < 0.0001, P = 0.001, and P = 0.031, respectively) and higher CAS (P < 0.0001). Area under curve on receiver operating characteristic curve analysis in diagnosing occurrence of DSPN in blink R1 latency was 0.772 (P < 0.0001). Multiple linear regression analysis showed that blink R1 latency was independently associated with CAS. CONCLUSION: Blink R1 latency may be valuable in auxiliary diagnosis and in determining the severity of NCS abnormalities in DSPN. SIGNIFICANCE: Blink R1 latency can be added as a supplemental marker of severity of NCS in DSPN, especially if the patient's sural amplitudes has a floor effect.

Metformin Affects Serum Lactate Levels in Predicting Mortality of Patients with Sepsis and Bacteremia.

This study determined if the use of metformin affected the prognostic value of hyperlactatemia in predicting 28-day mortality among patients with sepsis and bacteremia. We enrolled adult diabetic patients with sepsis and bacteremia. Of 590 patients, 162 and 162 metformin users and nonusers, respectively, were selected in propensity matching. The mean serum lactate levels in metformin users were higher than those in nonusers (4.7 vs. 3.9 mmol/L, p = 0.044). We divided the patients into four groups based on quick Sepsis-related Organ Failure Assessment (qSOFA) scores. No significant difference was found among nonusers with qSOFA score <2, nonusers with qSOFA score ≥2, and metformin users with qSOFA score <2. The lactate levels in metformin users with qSOFA score ≥2 were higher than those in other groups, and significant differences were found in both nonsurvivors (8.9 vs. 4.6 mmol/L, p = 0.027) and survivors (6.4 vs. 3.8 mmol/L, p = 0.049) compared with metformin users with qSOFA score <2. The best cut-off point to predict 28-day mortality in metformin users (5.9 mmol/L; area under the receiver operating characteristic curve (AUROC), 0.66; 95% confidence interval (CI), 0.55⁻0.77) was higher than that in nonusers (3.6 mmol/L; AUROC 0.63; 95% CI, 0.56⁻0.70). Metformin users had higher lactate levels than nonusers in increasing sepsis severity. Serum lactate levels could be useful in predicting mortality in patients using metformin, but higher levels are required to obtain more precise results.

Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection.

OBJECTIVE: The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality. PATIENTS AND METHODS: A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality. RESULTS: Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91). CONCLUSION: The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.

HbA1C Variability Is Strongly Associated With the Severity of Peripheral Neuropathy in Patients With Type 2 Diabetes.

Variability in HbA1c is associated with a higher risk of cardiovascular disease and microvascular complications in patients with type 2 diabetes. The present study evaluated the severity of somatic nerve dysfunction at different stages of chronic glycemic impairment, and its correlation with different cardio-metabolic parameters. The study was conducted on 223 patients with type 2 diabetes. We calculated the intrapersonal mean, standard deviation (SD), and coefficient of variation of HbA1c for each patient using all measurements obtained for 3 years prior to the study. Patients were divided into quartiles according to the SD of HbA1c, and we constructed composite scores of nerve conduction as the severity of peripheral neuropathy. Linear regression analysis was performed to evaluate the influence of independent variables on mean composite scores. Those with higher SD-HbA1c had a higher body mass index, mean and index HbA1c, triglyceride and uric acid level, urinary albumin excretion and albumin-creatinine ratio, proportion of insulin therapy, and prevalence of hypertension as the underlying diseases, but lower estimate glomerular filtration rate (eGFR). In addition, those with higher SD-HbA1c showed lower amplitudes and reduced motor nerve conduction velocity in tested nerves, and lower sensory nerve conduction velocity in the sural nerve. Furthermore, those with higher SD-HbA1c had higher composite scores of low extremities. Multiple linear regression analysis revealed that diabetes duration, SD-HbA1c, and eGFR were independently associated with mean composite scores. Based on our results, HbA1c variability plus chronic glycemic impairment is strongly associated with the severity of peripheral neuropathy in patients with type 2 diabetes. Aggressively control blood glucose to an acceptable range and avoid blood glucose fluctuations by individualized treatment to prevent further nerve damage.

α-1-Acid Glycoprotein Concentration as an Outcome Predictor in Adult Patients with Sepsis.

BACKGROUND: α-1-Acid glycoprotein (AGP) is an acute-phase protein that plays a role in first-line defense against infection and is therefore elevated in sepsis. We tested the hypothesis that AGP levels increase initially in sepsis and decrease after antimicrobial therapy and that these levels may predict treatment outcomes. METHODS: AGP, biomarkers widely used in clinical practice, and maximum 24-h acute physiology and chronic health evaluation (APACHE)-II scores upon emergency department (ED) admission were prospectively evaluated and compared. We further examined changes in AGP concentrations 1, 4, and 7 days after admission and determined the value of AGP that may be used to accurately and reliably predict the prognosis in patients with sepsis. RESULTS: Mechanical ventilation, white blood cell (WBC) counts, C-reactive protein (CRP) and lactate levels, maximum 24-h APACHE-II scores, and AGP concentrations were significantly higher upon admission in patients with sepsis who died. AGP and lactate concentrations were also significantly higher in non-survivors than in survivors on days 1, 4, and 7. As indicated by the stepwise logistic regression model analysis and area under the curve analysis, AGP was the best prognostic indicator, and the cut-off value for predicting fatality was 1307 µg/mL, and any increase 1-ng/mL in AGP concentration would increase the fatality rate by 0.5%. CONCLUSION: Based on our observations, AGP may be a good prognostic predictor in patients with sepsis. In addition, serial AGP levels meet the requirements for predicting outcomes in patients with sepsis.

Long-term effects of surgical treatment on baroreflex function in patients with obstructive sleep apnea: an 18-month follow-up.

OBJECTIVE: Depressed baroreflex sensitivity (BRS) is reported in obstructive sleep apnea (OSA). Improvement of BRS short-term after surgical treatment is also reported. We tested the hypothesis that surgical treatment not only improves clinical outcomes, but also improves BRS after 18 months. METHODS: Cardiovascular autonomic tests, polysomnography (PSG), and biochemical testing were prospectively evaluated in 54 OSA patients at three time points (preoperatively, 6 months and 18 months postoperatively) and compared with 20, age- and body mass index (BMI)-matched, healthy controls. RESULTS: The BRS increased after surgical treatment at 18-month follow-up, with results similar to the healthy control. Additionally, average O2, mO2 <90% (% per night), and lowest O2 showed an increase after surgical treatment at the 18-month follow-up. CONCLUSIONS: Besides improvement in clinical outcomes, depressed BRS in OSA patients is reversible and these patients have the potential for total recovery of baroreflex function after 18 months of treatment.

Diagnosis of Parapneumonia Pleural Effusion with Serum and Pleural Fluid Cell-Free DNA.

OBJECTIVE: As cell-free DNA levels in the pleural fluid and serum of parapneumonic pleural effusion (PPE) patients have not been thoroughly explored, we evaluated their diagnostic potential. METHODS: Twenty-two PPE and 16 non-PPE patients were evaluated. Serum and pleural fluids were collected, and cell-free DNA was quantified. All biomarkers were assessed for correlation with days after admission. Receiver operating characteristic (ROC) curve analysis was used to determine diagnostic accuracy and optimal cut-off point. RESULTS: Nuclear and mitochondrial DNA levels in the pleural fluid and nuclear DNA levels in serum of PPE patients were significantly higher than in those of the non-PPE patients. However, only cell-free DNA levels in pleural fluid correlated with days after admission among PPE patients (r= 0.464, 0.538, respectively). ROC curve analysis showed that nuclear and mitochondrial DNA in pleural fluid had AUCs of 0.945 and 0.889, respectively. With cut-off values of 134.9 and 17.8 ng/ml for nuclear and mitochondrial DNA in pleural fluid, respectively, 96% sensitivity and 81% specificity were observed for PPE diagnosis. CONCLUSION: Nuclear and mitochondrial DNA in pleural fluid possess PPE diagnostic potential and correlated with disease severity. Serum nuclear DNA could also be used to distinguish freshly admitted PPE patients (Day 1) from non-PPE patients, but with less accuracy.

Outcomes of adjunctive steroid therapy in adult patients with bacterial meningitis in Taiwan: A nationwide population-based epidemiologic study.

BACKGROUND: Although corticosteroids are an effective anti-inflammatory adjuvant therapy, the role of adjunctive steroid therapy in treating adult bacterial meningitis in Taiwan remains controversial. METHODS: Cases of acute bacterial meningitis were identified from the annual hospitalization discharge claims of the National Health Insurance Research Database using International Classification of Diseases, Ninth Revision codes from January 2000 to December 2013. Patients were classified into two groups: (1) steroid group (adjunctive steroids and empirical antibiotics) and (2) placebo group (empirical antibiotics only). RESULTS: There were 15,037 patients enrolled in this study; of these, 57% (7175/15,037) and 52% (7862/15,037) were placed in the placebo and steroid groups, respectively. The case-fatality rates were 11.5% (826/7175) in the placebo group and 19.9% (1562/7862) in the steroid groups during hospitalization (P = 0.77). Further, the hazard ratio (relative to placebo group) of in-hospital and one-year case fatality rate were 0.923 (95% confidence interval [CI]: 0.846-1.007, P = 0.073) and 1.514 (95% CI: 1.425-1.608, P < 0.0001) according to the multivariate Cox model after adjustment for age and sex. CONCLUSION: On the basis of these results, steroid group had a more fulminant clinical course (e.g., acute respiratory failure and pneumonia, etc.), and unfavorable outcomes than placebo group. Therefore, more prospective, randomized, double-blind trials are warranted to evaluate the efficacy of adjunctive steroid therapy in treating adult bacterial meningitis in Taiwan.

Close relationship between cardiovagal function and sural sensory nerve action potential in type 2 diabetes.

OBJECTIVE: Both diabetic distal symmetrical polyneuropathy (DSPN) and cardiac autonomic neuropathy (CAN) indicate the length-dependent pattern of disease. Decreased parasympathetic activity has been found in the early phase of CAN and sural sensory nerve action potential (SNAP) imply axonal loss in DSPN. METHOD: All patients with type 2 diabetes underwent cardiovascular autonomic function and nerve conduction studies (NCS). We constructed modified composite autonomic scoring scale (CASS) and composite score of NCS to measure the severity of CAN and DSPN, respectively. RESULTS: Patients with a longer duration of diabetes had a lower heart rate response to deep breathing (HR_DB), Valsalva ratio (VR), and baroreflex sensitivity (BRS), higher CASS, a higher percentage of CAN, lower sural SNAP, higher composite score of NCS, and a higher percentage of DSPN. Multiple linear regression analysis showed that only sural SNAPs were independently associated with mean HR_DB. CONCLUSION: Sural SNAP was closely correlated with parameters of cardiovagal functions in patients with different durations of diabetes. The percentage and severity of CAN and DSPN increase with longer duration of diabetes. SIGNIFICANCE: The independent association of sural sensory nerve action potential amplitude and heart rate response to deep breathing with type 2 diabetes is important because combined testing increases diagnostic sensitivity and specificity.

HbA1C Variability Is Strongly Associated With the Severity of Cardiovascular Autonomic Neuropathy in Patients With Type 2 Diabetes After Longer Diabetes Duration.

BACKGROUND: Variability in the glycated hemoglobin (HbA1c) level is associated with a higher risk of microvascular complications in patients with type 2 diabetes. We tested the hypothesis that HbA1c variability is not only strongly associated with the presence but also the degree of severity of cardiovascular autonomic neuropathy (CAN) in patients with long diabetes durations (more than 10 years). METHODS: For each patient, the intrapersonal mean, standard deviation (SD), and coefficient of variation (CV) for HbA1c were calculated using all measurements obtained 3 years before the study. We constructed the composite autonomic scoring scale (CASS) as a measure of the severity of cardiovascular autonomic functions. Stepwise logistic regression and linear regression analyses were performed to evaluate the presence of CAN and the influence of independent variables on the mean CASS, respectively. RESULTS: Those with CAN had a higher mean age, a higher low-density lipoprotein cholesterol (LDL-C), HbA1c-SD, HbA1c-CV, mean HbA1c, and index HbA1c, higher prevalence of retinopathy as the underlying disease, and lower high-density lipoprotein (HDL) levels. Stepwise logistic regression showed that HbA1c-SD and retinopathy were risk factors that were independently associated with the presence of CAN. Mean HbA1c, HbA1c-CV, HbA1c-SD, and index HbA1c were positively correlated with mean CASS, and a multiple linear regression analysis revealed that HbA1c-SD was independently associated with the mean CASS. CONCLUSION: HbA1c variability is strongly associated with not only the presence but also the degree of severity of CAN. A longitudinal study is required to confirm whether controlling blood glucose level is effective in reducing CAN progression.

Manifestations and Outcomes of Patients with Parkinson's Disease and Serious Infection in the Emergency Department.

BACKGROUND: Several comorbidities contribute to an increased risk of infections in Parkinson's disease (PD) as the disease progresses. However, few studies have examined the correlation between sepsis and PD. AIM: The aim of this study is to disclose the presentation and outcome of serious infection in patients with PD in the emergency department. METHODS: This retrospective cohort study enrolled patients with PD who had serious infection and were admitted to the emergency department between January 2007 and December 2013. For clinical comparison, we compared the clinical features, laboratory data, and outcomes with those of age- and sex-matched patients who had serious infection but not PD. RESULTS: There were a total of 1,200 episodes of infected PD patients and 2,400 age- and sex-matched infected patients without PD as disease controls. PD patients had fewer comorbidities and lower severity of infectious disease but longer hospital stays than control group patients. The incidences of respiratory tract and urinary tract infections were higher in PD patients. The levels of inflammatory and organ dysfunction biomarkers in PD were lower and compatible with the severity of infectious disease. A total of 86 (7.2%) infected PD patients died during the 28-day admission compared to 339 (14.1%) in non-PD patients. Serum C-reactive protein, bandemia, and lactate could be used to predict mortality in infected PD patients. CONCLUSIONS: In infected patients with PD, respiratory and urinary tract infections were the two most common infectious sources. Empiric therapy based on experience could treat both respiratory and urinary tract infections. Early diagnosis and treatment are essential for survival.

Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department.

Elderly people are more susceptible to sepsis and experience more comorbidities and complications than young adults. Serum lactate is a useful biomarker to predict mortality in patients with sepsis. Lactate production is affected by the severity of sepsis, organ dysfunction, and adrenergic stimulation. Whether the predictive ability of serum lactate will be different between non-elderly and elderly patients is unknown.A retrospective cohort study was conducted to compare the prognostic value of hyperlactatemia in predicting the mortality between elderly (≥65 years) and non-elderly (<65 years) patients with sepsis.This is a single-center retrospective observational cohort study conducted from January 2007 to December 2013 in southern Taiwan. All patients with sepsis, who used antibiotics, with blood culture collected, and with available serum lactate levels in the emergency department, were included in the analysis. We evaluated the difference in serum lactate level between the elderly and non-elderly septic patients by using multiple regression models.A total of 7087 patients were enrolled in the study. Elderly and non-elderly patients accounted for 62.3% (4414) and 40.2% (2673) of all patients, respectively. Statistically significant difference of serum lactate levels was not observed between elderly and non-elderly survivors (2.9 vs 3.0 mmol/L; P = .57); however, elderly patients had lower lactate levels than those within the 28-day in-hospital mortality (5.5 vs 6.6 mmol/L, P < .01). Multiple logistic regression revealed higher adjusted mortality risk in elderly and non-elderly patients with lactate levels of ≥4.0 mmol/L (odds ratio [OR], 4.98 and 5.82; P < .01, respectively), and lactate level between 2 and 4 mmol/L (OR, 1.57 and 1.99; P < .01, respectively) compared to that in the reference group with lactate levels of <2.0 mmol/L in each group. In receiver operating characteristic curve analysis, sensitivity rates for predicting mortality were 0.80 and 0.77 for non-elderly and elderly patients, respectively, by using serum lactate levels higher than 2.0 mmol/L.Septic elderly non-survivors had 1 mmol/L lower serum lactate level than those of the non-elderly non-survivors. Lactate >2 mmol/L still could provide enough sensitivity in predicting sepsis mortality in elder patients.

Concentration and value of endocan on outcome in adult patients after severe sepsis.

BACKGROUND: Endothelial dysfunction plays a central role in severe sepsis. Endocan is constitutively expressed in human endothelial cells when sepsis occurs. We tested the hypothesis that endocan concentrations are substantially increased in severe sepsis and decrease after antimicrobial therapy, and that endocan concentrations can predict treatment outcomes. METHODS: Biomarkers of the endothelium including endocan and cell adhesion molecules were prospectively evaluated in 153 patients with severe sepsis on days 1, 4, and 7 after admission along with biochemical and clinical data. RESULTS: Sepsis non-survivors had significantly higher endocan, ICAM-1, and VCAM-1 concentrations and lower platelet concentrations upon admission than the survivors. Non-survivors had significantly higher endocan and VCAM-1 concentrations than the survivors on serial analysis (days 1, 4, and 7). After stepwise logistic regression model and AUC analysis, endocan was revealed as a good predictor of outcome in severe sepsis, and the cut-off value for predicting fatality was 6.28 ng/ml. An increase in the endocan concentration by one ng/ml indicated an increase in fatality rate by 11.1%. CONCLUSIONS: Based on our results, serial endocan concentration meets the major requirements for predicting outcome in patients with severe sepsis. An assay of endocan concentration may be a good prognostic biomarker in the clinic for severe sepsis.

Effect of Baroreceptor Sensitivity on Outcomes in Patients with Acute Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Reduced baroreflex sensitivity (BRS) has been reported in patients with acute cardiovascular events. We tested the hypothesis that BRS is substantially reduced in patients with spontaneous intracerebral hemorrhage (ICH) and that BRS can predict treatment outcomes. METHODS: We examined BRS and other cardiovascular autonomic parameters in 35 patients with ICH over the course of 30 days. Cardiovascular autonomic parameters also were evaluated in 30 healthy volunteer subjects during the study period. Outcome was assessed at 30 days with the modified Rankin Scale (mRS). Good outcome was defined as an mRS <1, whereas patients defined as having a poor outcome had either an mRS ≥2 or died shortly after the stroke event. RESULTS: Twenty patients had a poor outcome, and 15 patients had a good outcome. BRS values in the patients with poor outcome group were lower in comparison with the healthy subjects, and BRS values in patients with poor outcomes were significantly lower than that those in patients with good outcomes on day 1, day 4, and day 10. BRS was associated independently with outcome and the cut-off value of BRS on day 1 in the poor outcome group was 6.79. CONCLUSIONS: Based on our results, BRS value at admission is a more powerful predictor of outcome than the Glasgow Coma Scale score at admission. An assay of BRS could be added as a biomarker for outcome prediction among patients with spontaneous ICH in clinical practice.