Nutritional interventions as modulators of the disease activity for idiopathic inflammatory myopathies: a scoping review.

Idiopathic inflammatory myopathies (IIMs) are chronic, autoimmune connective tissue diseases associated with significant morbidity and disability. Nutrients can activate the immune system and contribute to chronic low-grade inflammation (LGI). Chronic muscle inflammation leads to imbalanced pro-inflammatory and anti-inflammatory cytokines, causing inadequate nutrition, weight loss and muscle weakness during a negative cycle. Owing to its potential to modulate LGI in various diseases, the Mediterranean diet (Med Diet) has been extensively studied. This scoping review explores the nutritional implications and recommendations of the Med Diet as a treatment for immune-mediated diseases, focusing on the gaps in IIM nutritional interventions. A comprehensive literature search of the MEDLINE and EBSCO databases between September 2018 and December 2022 was performed. We identified that the Med Diet and its specific components, such as omega-3 (nω3) fatty acids, vitamin D and antioxidants, play a role in the dietary treatment of connective tissue-related autoimmune diseases. Nutritional interventions have demonstrated potential for modulating disease activity and warrant further exploration of IIMs through experimental studies. This review introduces a dietary therapeutic approach using the Med Diet and related compounds to regulate chronic inflammatory processes in IIMs. However, further clinical studies are required to evaluate the efficacy of the Med Diet in patients with IIMs. Emphasising a clinical-nutritional approach, this study encourages future research on the anti-inflammatory effects of the Med Diet on IIMs. This review highlights potential insights for managing and treating these conditions using a holistic approach.

Renal replacement therapy: a practical update.

Acute kidney injury (AKI) is defined as an abrupt decrease in kidney function, with the most severe form requiring some method of renal replacement therapy (RRT). The use of RRT is required in 5-10% of critically ill patients who develop severe AKI. Renal replacement therapy can be provided as either intermittent hemodialysis or one of the various modes of continuous renal replacement therapy (CRRT), with CRRT potentially conferring an advantage with respect to renal recovery and dialysis independence. There is no difference in mortality when comparing low (< 25 mL·kg-1·hr-1) vs high (> 40 mL·kg-1·hr-1) RRT dosing. Continuous renal replacement therapy may be run in different modes of increasing complexity depending on a given patient's clinical needs. Regional citrate anticoagulation is recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.

RéSUMé: L'insuffisance rénale aiguë (IRA) se définit par une réduction subite de la fonction rénale, et sa forme la plus grave nécessite un type de traitement substitutif. Le recours à un traitement substitutif de l'insuffisance rénale est nécessaire chez 5-10 % des patients critiques qui souffrent d'une IRA grave. Le traitement substitutif de l'insuffisance rénale peut prendre la forme d'une hémodialyse intermittente ou de l'un des divers modes de traitement substitutif de l'insuffisance rénale en continu, ce second type de traitement conférant potentiellement un avantage en matière de récupération de la fonction rénale et d'indépendance de la dialyse. Aucune différence de mortalité n'a été observée en comparant un traitement substitutif de l'insuffisance rénale à faible dose d'ultrafiltration (< 25 mL·kg−1·h−1) vs à dose élevée (> 40 mL·kg−1·h−1). Le traitement substitutif de l'insuffisance rénale en continu peut être réalisé selon différents modes de complexité croissante en fonction des besoins cliniques d'un patient donné. Une anticoagulation régionale au citrate est recommandée comme traitement de choix pour la majorité des patients critiques nécessitant un traitement substitutif de l'insuffisance rénale en continu.

The effect of enteral stimulation on the immune response of the intestinal mucosa and its application in nutritional support.

The intestine plays a fundamental role as a regulator of the mucosal immune response, mostly through the production and secretion of secretory Immunoglobulin A (sIgA) by the gut-associated lymphoid tissue (GALT). Enteral stimulation, a balance between the commensal microbiota and pathogenic microorganisms, in addition to an adequate nutritional status is required for the optimal immune function of the intestine. Fasting subjects or those supported only with parenteral nutrition, show a progressive anatomical and physiological deterioration of the GALT, triggering a series of alterations resulting in a decrease in the intestinal immune response, modification in the type of microbiota, and changes that lead to or aggravate malnutrition. Patients with malnutrition present an increase in the rate of nosocomial infections, hospital length of stay, and mortality. An adequate nutritional assessment at hospital admission and avoiding long periods of fasting are paramount to prevent these unfavorable outcomes. Herein, we present a mini-state of the art review on the role and importance of enteral stimulation by GALT-mediated immune response.

Secondary Hemophagocytic Lymphohistiocytosis: A Challenging Diagnosis in a Patient with Autoimmune Hepatitis.

BACKGROUND: We describe a case of secondary Hemophagocytic Lymphohistiocytosis (HLH) from autoimmune hepatitis mimicking severe sepsis in a man admitted to the intensive care unit. CASE PRESENTATION: A 34-year-old Pakistani male with a prior history of biopsy-proven autoimmune hepatitis presented to a regional hospital with severe fever, cytopenias, hyperferritinemia, hypertriglyceridemia, splenomegaly, and a bone marrow biopsy showing hemophagocytosis. After ruling out mimicking conditions, a diagnosis of HLH was made using the HLH-2004 diagnostic criteria. He was treated with dexamethasone and etoposide, without bone marrow transplantation (BMT) due to poor functional status. At one-year after follow-up, he had returned to his baseline functional status without recurrence. CONCLUSION: We describe a rare case of secondary HLH in the setting of autoimmune hepatitis. Broadly, this case report educates clinicians to consider this potentially missed diagnosis. This case also informs clinicians that treatment of secondary HLH with BMT may not be necessary for the management of secondary HLH due to autoimmune hepatitis. Finally, it provides a detailed description of the natural history of a single patient with secondary HLH due to autoimmune hepatitis.

Derivation of a PIRO Score for Prediction of Mortality in Surgical Patients With Intra-Abdominal Sepsis.

BACKGROUND: Mortality in patients with intra-abdominal sepsis remains high. Recognition and classification of patients with sepsis are challenging; about 70% of critical care specialists find the existing definitions confusing and not clinically useful. OBJECTIVE: To assess the usefulness of the predisposition, infection/injury, response, organ dysfunction (PIRO) concept in surgical intensive care patients with severe sepsis or septic shock due to an intra-abdominal source. METHODS: Data from 2005 through 2010 of a prospective observational cohort were reviewed retrospectively. RESULTS: Among 905 patients, overall mortality was 21.3%, but patients with septic shock had a mortality of 40.6%. The variables in each PIRO subset with P ≤ .10 were entered into a stepwise backward elimination logistic regression. A PIRO score was developed that included the following variables: age greater than 65 years; comorbid conditions; leukopenia; hypothermia; and cardiovascular, renal, respiratory, and central nervous system failure. One point was given for each feature detected. The mean score was significantly higher (P < .001) in non-survivors (3.9) than in survivors (2.3). When the data were distributed according to PIRO scores, mortality rate increased (P < .001). The area under the receiver operating characteristic curve indicated consistent mortality discrimination by PIRO scores (0.80; 95% CI, 0.79-0.83), outperforming the Acute Physiology and Chronic Health Evaluation II (0.72; 95% CI, 0.68-0.75) and the Sequential Organ Failure Assessment (0.72; 95% CI, 0.68-0.76) (P < .001). CONCLUSION: The PIRO score is useful for predicting mortality in patients with surgically related intra-abdominal sepsis.

Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria.

Background: Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods: All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results: Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions: No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration: https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.

Closed Or Open after Source Control Laparotomy for Severe Complicated Intra-Abdominal Sepsis (the COOL trial): study protocol for a randomized controlled trial.

Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. Methods: The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources. Discussion: Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only. Trial registration: ClinicalTrials.gov, NCT03163095.

[Pontine myelinolysis after a hypoglycemic episode]. / Mielinólisis pontina después de un evento de hipoglucemia.

A case of central pontine myelinolysis following hypoglycemia is reported. The case was a 26- year-old female. Diabetes mellitus was found when she was 8 years old and she has hypertension and renal failure. She suffered a severe hypoglycemia at an unknown time. After the episode she developed a vegetative state. A magnetic resonance scan showed features consistent with the presence of central pontine myelinolysis.