First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (n = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3–4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants’ neurologic affiliation was associated with performance of fewer checks (regression coefficient −0.49; p = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways.

The Impact of Selenium Supplementation on Trauma Patients—Systematic Review and Meta-Analysis

This study aimed to assess current evidence regarding the effect of selenium (Se) supplementation on the prognosis in patients sustaining trauma. MEDLINE, Embase, and Web of Science databases were searched with the following terms: “trace element”, “selenium”, “copper”, “zinc”, “injury”, and “trauma”. Seven studies were included in the meta-analysis. The pooled results showed that Se supplementation was associated with a lower mortality rate (OR 0.733, 95% CI: 0.586, 0.918, p = 0.007; heterogeneity, I2 = 0%). Regarding the incidence of infectious complications, there was no statistically significant benefit after analyzing the four studies (OR 0.942, 95% CI: 0.695, 1.277, p = 0.702; heterogeneity, I2 = 14.343%). The patients with Se supplementation had a reduced ICU length of stay (standard difference in means (SMD): −0.324, 95% CI: −0.382, −0.265, p < 0.001; heterogeneity, I2 = 0%) and lesser hospital length of stay (SMD: −0.243, 95% CI: −0.474, −0.012, p < 0.001; heterogeneity, I2 = 45.496%). Se supplementation after trauma confers positive effects in decreasing the mortality and length of ICU and hospital stay.

Postoperative fever after liver resection: Incidence, risk factors, and characteristics associated with febrile infectious complication

Purpose To evaluate the incidence and risk factors of postoperative fever (POF) after liver resection. In patients with POF, predictors of febrile infectious complications were determined. Methods A total of 797 consecutive patients undergoing liver resection from January 2015 to December 2019 were retrospectively investigated. POF was defined as body temperature ≥ 38.0°C in the postoperative period. POF was characterized by time of first fever, the highest temperature, and frequency of fever. The Institut Mutualiste Montsouris (IMM) classification was used to stratify surgical difficulty, from grade I (low), grade II (intermediate) to grade III (high). Postoperative leukocytosis was defined as a 70% increase of white blood cell count from the preoperative value. Multivariate analysis was performed to identify risk factors for POF and predictors of febrile infectious complications. Results Overall, 401 patients (50.3%) developed POF. Of these, 10.5% had the time of first fever > postoperative day (POD) 2, 25.9% had fever > 38.6°C, and 60.6% had multiple fever spikes. In multivariate analysis, risk factors for POF were: IMM grade III resection (OR 1.572, p = 0.008), Charlson Comorbidity Index score > 3 (OR 1.872, p < 0.001), and serum albumin < 3.2 g/dL (OR 3.236, p = 0.023). 14.6% patients developed infectious complication, 21.9% of febrile patients and 7.1% of afebrile patients (p < 0.001). Predictors of febrile infectious complications were: fever > 38.6°C (OR 2.242, p = 0.003), time of first fever > POD2 (OR 6.002, p < 0.001), and multiple fever spikes (OR 2.039, p = 0.019). Sensitivity, specificity, positive predictive value and negative predictive value for fever > 38.6°C were 39.8%, 78.0%, 33.7% and 82.2%, respectively. A combination of fever > 38.6°C and leukocytosis provided high specificity of 95.2%. Conclusion In this study, we found that IMM classification, CCI score, and serum albumin level related with POF development in patients undergone liver resection. Time of first fever > POD2, fever > 38.6°C, and multiple fever spikes indicate an increased risk of febrile infectious complication. These findings may aid decision-making in patients with POF who require further diagnostic workup.

Caloric adequacy of parenteral nutrition and its influence on the clinical outcome of hospitalised patients

Background: The adaptation of Parenteral Nutrition (PN) to actual energy requirements of hospitalised patients is essential, since excessive and insufficient nutritional intake have been associated with poor clinical outcomes. Aim: To evaluate the adaptation of prescribed PN to the estimated nutritional requirements using three predictive equations and the influence of excessive/insufficient nutrient intake on patient clinical outcomes (nutritional parameters, metabolic and infectious complications). Methods: Prospective, observational study in hospitalised patients nutritionally assessed. Data was collected the first and fifth/sixth day of PN with clinical (infection, length of hospital stay), biochemical (visceral proteins, cholesterol, glucose, triglycerides, lymphocytes, CRP) and anthropometric parameters (skin folds, height, weight). Theoretical requirements were calculated using Harris-Benedict (HB), Mifflin-St Jeor (MF) and 25 Kcal/Kg/day formulas. The HB formula was used to compare estimated and provided requirements. Results: A total of 94 patients (mean: 72 ± 13.7 years old) were included with initial mean weight and height of 69.2 Kg and 162.8 cm, respectively (mean BMI: 26.1 Kg/m2). No statistically significant differences were found between the actual (1620 Kcal/day) and estimated caloric mean calculated with HB (1643 Kcal/day) and MF (1628 Kcal/day). When comparing with the caloric estimation, 31.9% of patients were underfed, while 14.9% were overfed. Intergroup analysis demonstrated significant variations in albumin, prealbumin, glucose, cholesterol, triglycerides and MUAC, with a significant increase of hyperglycaemia (+37.86; p < 0.05) and hypertriglyceridemia (+63.10; p < 0.05), being higher in overfed patients. Conclusion: In our study, inadequate nutrient intake was associated with a higher degree of hyperglycaemia and hypertriglyceridemia, without positive impact on anthropometric parameters.

Induction and Maintenance Treatment of Lupus Nephritis: A Comprehensive Review of Meta-Analyses

Background: Lupus nephritis (LN) is present in over 50% of patients with systemic lupus erythematosus (SLE) which is managed with immunosuppressive and immunomodulatory therapies. However, several novel therapeutic approaches for LN are under investigation due to the adverse effects spectrum of conventional therapy; Methods: We performed a comprehensive review of meta-analyses aggregating the comparative efficacies of various pharmacotherapies for LN. We conducted a literature search and retrieved a total of 23 meta-analyses and network meta-analyses for summarization. Pharmacotherapies were evaluated across six major outcomes: remission, relapse, mortality, end stage kidney disease (ESKD) progression, infection, and malignancy. Result: Calcineurin inhibitors (CNI), particularly tacrolimus (TAC), in combination with glucocorticoids (GC) outperformed cyclophosphamide (CPA) with GC in the rate of remission, either complete or partial remission, and in terms of infectious complications. In maintenance therapy, MMF was superior to azathioprine (AZA) as the MMF-treated patients had lower relapse rate. Interpretation: This review aggregates evidence of therapy for clinicians and sheds light on comparative efficacies of alternative LN treatments. As more promising agents are entering the market, such as voclosporin, belimumab, and obinutuzumab, LN management might undergo significant changes during the next years.

Immune Reconstitution After Allogeneic Haematopoietic Cell Transplantation: From Observational Studies to Targeted Interventions

Immune reconstitution (IR) after allogeneic haematopoietic cell transplantation (HCT) represents a central determinant of the clinical post-transplant course, since the majority of transplant-related outcome parameters such as graft-vs.-host disease (GvHD), infectious complications, and relapse are related to the velocity, quantity and quality of immune cell recovery. Younger age at transplant has been identified as the most important positive prognostic factor for favourable IR post-transplant and, indeed, accelerated immune cell recovery in children is most likely the pivotal contributing factor to lower incidences of GvHD and infectious complications in paediatric allogeneic HCT. Although our knowledge about the mechanisms of IR has significantly increased over the recent years, strategies to influence IR are just evolving. In this review, we will discuss different patterns of IR during various time points post-transplant and their impact on outcome. Besides IR patterns and cellular phenotypes, recovery of antigen-specific immune cells, for example virus-specific T cells, has recently gained increasing interest, as certain threshold levels of antigen-specific T cells seem to confer protection against severe viral disease courses. In contrast, the association between IR and a possible graft-vs. leukaemia effect is less well-understood. Finally, we will present current concepts of how to improve IR and how this could change transplant procedures in the near future.

USAGE OF PARAMEDIAN APPROACH FOR CONTINUOUS AMBULATORY PERITONEAL DIALYSIS CATHETER INSERTION TECHNIQUE AND COMPLICATION

Objective: This study aims to review the usage and complication of paramedian approach for CAPD catheter insertion. Material & Methods: This is a retrospective study. All ESRD patients ongoing CAPD at the Dialysis Clinic of Zainoel Abidin General Hospital in Aceh, Indonesia between January 1, 2009 and December 31, 2018 were included in the present study. Complication outcomes included mechanical and infectious complications are documented and reviewed. Results: A total of 190 ESRD patients had been performed CAPD catheter insertion using paramedian approach in this period. Out of these patients, complication occurred in 31 cases (16.32%). All the complication that occurred in this study are 5 cases of leakage (2.63%), 9 cases of infection (4.74%), 8 cases of drainage problem (4.21%), 9 cases of malposition (4.74%), and no case of bowel perforation. From total of 9 cases of infections, 1 patient had peritonitis from the catheter insertion. The other infection was exit site infection. Conclusion: CAPD catheter insertion using paramedian approach is safe with low complication rates. It could decrease post-operative complications and can be recommended for CAPD catheter insertion technique due to its safety.

Infectious outcomes of fibrin sheath disruption in tunneled dialysis catheters

Background and objectives: Fibrin sheath (FS) formation around tunneled central venous catheters (CVC) increases the risk of catheter-related bloodstream infections due to bacterial adherence to a biofilm. We sought to investigate whether FS disruption (FSD) at the time of CVC removal or exchange affects infectious outcomes in patients with CVC-related infections. Design, setting, participants, and measurements: Retrospective cohort study of 307 adult maintenance hemodialysis patients aged 18 years or older at a single center academic-based hemodialysis program (UHN, Toronto) who developed CVC-related infections requiring CVC removal or exchange between January 2000 and January 2019. Exposure was FSD at the time of CVC removal or exchange. Outcomes were infectious metastatic complications, recurrent infection with the same organism within 1 year, or death due to infection. We created a Markov Multi-State Model (MMSM) to assess patients’ trajectories through time as they transitioned between states. A time-to-event analysis was performed, adjusted for clinically relevant factors. Results: There was no significant relationship between FSD status at the time of CVC removal, the development of infectious complications in the multivariable model (adjusted HR = 0.71, 95% CI 0.09−5.80, p = 0.76), or mortality from infection (HR = 0.84, 95% CI 0.34−2.11, p = 0.73). Conclusions: FSD at the time of CVC removal was not associated with increased risk of infectious complications or death due to infection. Further prospective study is needed to determine whether FSD contributes to reducing CVC infectious related complications.

Efficacy and Safety of Faecal Microbiota Transplantation for Acute Pancreatitis: A Randomised, Controlled Study

Aims: We investigated whether faecal microbiota transplantation (FMT) decreases intra-abdominal pressure (IAP) and improves gastrointestinal (GI) dysfunction and infectious complications in acute pancreatitis (AP).Methods: In this first randomised, single-blind, parallel-group, controlled study, we recruited and enrolled consecutive patients with AP complicated with GI dysfunction. Eligible participants were randomly assigned to receive faecal transplant (n = 30) or normal saline (n = 30) via a nasoduodenal tube once and then again 2 days later. The primary endpoint was the rate of IAP decline; secondary endpoints were GI function, infectious complications, organ failure, hospital stay and mortality. Analyses were based on intention to treat.Results: We enrolled 60 participants and randomly assigned them to the FMT (n = 30) or control (n = 30) group. Baseline characteristics and disease severity were similar for both groups. IAP decreased significantly 1 week after intervention in both groups, with no difference in the IAP decline rate between FMT and Control group [0.1 (−0.6, 0.5) vs. 0.2 (−0.2, 0.6); P = 0.27]. Normal gastrointestinal failure (GIF) scores were achieved in 12 (40%) patients in the FMT group and 14 (47%) in the control group, with no significant difference (P = 0.60). However, D-lactate was significantly elevated in the FMT group compared to the control group, as calculated by the rate of decline [−0.3 (−3.7, 0.8) vs. 0.4 (−1.1, 0.9); P = 0.01]. Infectious complications occurred in 15 (50%) and 16 (53.33%) patients in the FMT and control groups, respectively (P = 0.80). However, interleukin-6 (IL-6) was significantly elevated in the FMT group compared to the control group, as calculated by the rate of decline [0.4 (−3.6, 0.9) vs. 0.8 (−1.7, 1.0); P = 0.03]. One participant experienced transient nausea immediately after FMT, but no serious adverse events were attributed to FMT.Conclusion: FMT had no obvious effect on IAP and infectious complications in AP patients, though GI barrier indictors might be adversely affected. Further multi-centre studies are needed to confirm our findings. The study was registered at https://clinicaltrials.gov (NCT02318134).

Post-Ureteroscopy Infections Are Linked to Pre-Operative Stent Dwell Time over Two Months: Outcomes of Three European Endourology Centres

Background: The aim of this study is to investigate outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and stone treatment to identify a time cut-off. Material and Methods: Three tertiary referral centres in Europe retrospectively collected outcomes of ureteroscopy and laser fragmentation (URSL) for all patients with pre-operative indwelling ureteric stents over a period of up to 5 years. Data was collected on patient details, stone demographics, stent dwell time, complications and stone free rate (SFR). Matching for age, sex, operative time, stone size and post-operative stent insertion. To examine for a threshold effect, monthly cut-offs were used to compare post-ureteroscopic febrile UTIs. Binomial logistic regression was used (SPSS v.24) with a significance level set at 0.0036. The risk ratio (RR) with a 95% confidence interval (CI) and the number needed to harm (NNH) are reported. Results: There were 467 patients with a pre-operative stent for analysis. These patients (n = 315) were matched to non-stented controls after excluding 152 patients to achieve adequate matching. There was a significant difference in rates of post-ureteroscopic febrile UTI between stented vs non-stented patients (RR = 2.67, 95% CI: 1.10–6.48, p = 0.03). On adjustment, a dwell time of more than two months was associated with an increased risk of post-ureteroscopic febrile UTI (RR = 3.94, 95% CI: 1.30–12.01, p = 0.02), this increased risk rose with longer dwell time. At stent time longer than four months was associated with a significantly increased risk of post-ureteroscopic febrile UTI (5% vs. 15%, RR = 3.09, 95% CI: 1.56–6.10, p = 0.001), with the number needed to harm at 10. Conclusions: Overall infectious complication rates from URSL are low. The risk of post-operative UTI after four months of dwell time is nearly tripled compared to less than four months.