Pub Date : 2024-11-04DOI: 10.1186/s13054-024-05114-8
Siyao Zeng, Yue Li, Zhipeng Yao, Junbo Zheng, Hongliang Wang
<p>The mpox virus is a zoonotic orthopoxvirus with a DNA genome. Based on genetic characteristics, the mpox virus is categorized into two main clades: clade I and clade II. Clade I is further subdivided into subclades Ia and Ib [1]. Clade I is predominantly found in Central Africa, while clade II primarily circulates in West Africa [2]. The clade IIb subclade of clade II caused the global mpox outbreak from 2022 to 2023, during which 86% of cases were among men who have sex with men (MSM) [1]. More than half of the reported mpox cases involve individuals who are co-infected with the human immunodeficiency virus (HIV) [3]. The 2024 mpox outbreak in the Democratic Republic of the Congo and neighboring countries is primarily caused by clade Ia [4]. Only in 2024, as of September 15, the Democratic Republic of the Congo has reported 25,757 cases of mpox, with 806 deaths [3]. In April 2024, scientists identified a new variant of clade I, named Ib, by analyzing samples collected in South Kivu Province, Democratic Republic of the Congo, from late 2023 to early 2024. Reports of infections caused by the Ib variant have increased over the past few months. The proportion of women infected with clade Ib was significantly higher (52%), with nearly one-third identifying as sex workers [1]. On August 15, Sweden reported its first case of mpox caused by the Ib variant. Thailand confirmed its first Ib variant mpox case on August 22 [4]. Compared to clade IIb, which caused the global mpox outbreak in 2022, clade Ia exhibits stronger human-to-human transmissibility and higher mortality and severity rates. As for the clade Ib, its characteristics remain unclear [5].</p><p>As the mpox outbreak intensifies, by August 31, 2024, a total of 106,310 confirmed cases have been reported across 123 countries worldwide, resulting in 234 laboratory-confirmed deaths [3]. In Africa, the confirmed and suspected mpox cases in 2024 have surpassed 17,500, far exceeding the 15,000 cases reported in 2023. In response to this escalating situation, the Africa Centers for Disease Control and Prevention (Africa CDC) declared mpox a “Public Health Emergency of Security Concern” (PHESC) for the first time on August 13, 2024. The following day, the World Health Organization (WHO) declared the mpox outbreak a “Public Health Emergency of International Concern” (PHEIC), urging global cooperation to prevent further spread [5]. The current mpox outbreak may pose new challenges for intensivists worldwide.</p><p>Mpox mainly spreads through transmission between animals and humans or from person to person. Animal-to-human transmission can happen through direct contact with an infected animal, being bitten or scratched, or consuming undercooked meat from an infected animal. Human-to-human transmission primarily occurs through direct contact with an infected individual’s skin or mucous membrane lesions, oral secretions, upper respiratory secretions (such as nasal discharge and mucus), and items contamina
mpox 病毒是一种具有 DNA 基因组的人畜共患正痘病毒。根据基因特征，痘病毒被分为两个主要支系：支系 I 和支系 II。支系 I 又分为支系 Ia 和支系 Ib [1]。支系 I 主要分布在中非，而支系 II 主要在西非流行 [2]。Ⅱ支系的Ⅱb亚支系导致了2022年至2023年的全球麻风腮疫情，其间86%的病例发生在男男性行为者（MSM）中[1]。在已报告的痘病病例中，超过一半的人同时感染了人类免疫缺陷病毒（HIV）[3]。2024 年在刚果民主共和国及其邻国爆发的 mpox 主要由 Ia 支原体引起 [4]。仅在 2024 年，截至 9 月 15 日，刚果民主共和国就报告了 25 757 例痘病病例，其中 806 人死亡[3]。2024 年 4 月，科学家通过分析 2023 年底至 2024 年初在刚果民主共和国南基伍省采集的样本，确定了 I 支系的一个新变种，命名为 Ib。在过去几个月中，由 Ib 变种引起的感染报告有所增加。感染 Ib 变体的女性比例明显更高（52%），其中近三分之一的人是性工作者[1]。8 月 15 日，瑞典报告了首例由 Ib 变种引起的麻风病病例。8 月 22 日，泰国确诊了首例 Ib 变种天花病例 [4]。与 2022 年导致全球痘疫情爆发的 IIb 支系相比，Ia 支系具有更强的人际传播性，死亡率和严重程度也更高。随着天花疫情的加剧，截至 2024 年 8 月 31 日，全球 123 个国家共报告 106 310 例确诊病例，234 人经实验室确诊死亡[3]。在非洲，2024 年的确诊和疑似水痘病例已超过 17 500 例，远远超过了 2023 年报告的 15 000 例。面对不断升级的形势，非洲疾病预防控制中心（Africa Centers for Disease Control and Prevention，ADC）于 2024 年 8 月 13 日首次宣布天花为 "安全关注的突发公共卫生事件"（Public Health Emergency of Security Concern，PHESC）。次日，世界卫生组织（WHO）宣布天花疫情为 "国际关注的突发公共卫生事件"（PHEIC），敦促全球合作防止疫情进一步扩散[5]。当前的天花疫情可能会给全球的重症医学专家带来新的挑战。天花主要通过人与动物或人与人之间的传播进行传播。动物与人之间的传播可通过直接接触受感染的动物、被咬伤或抓伤或食用受感染动物未煮熟的肉类而发生。人与人之间的传播主要是通过直接接触感染者的皮肤或粘膜病变、口腔分泌物、上呼吸道分泌物（如鼻涕和粘液）以及被病毒污染的物品（如床上用品）。性接触在传播中起着重要作用，尤其是在 IIb 族疫情和目前的 Ib 族疫情中。此外，长时间近距离接触呼吸道飞沫和母婴传播也是重要的传播途径[6]。在治疗麻风病人时，重症监护医生应穿戴适当的个人防护设备（PPE），包括 N95 呼吸器或同等设备、护眼设备、手套和防护服。应正确穿戴个人防护设备，确保完全覆盖暴露部位，以尽量减少污染。在支气管肺泡灌洗、插管或拔管等可能产生气溶胶的程序 (AGP) 中，建议使用电动空气净化呼吸器 (PAPR) 提供额外保护。在使用插管盒或视频喉镜等防护屏障进行这些操作时应格外小心，以尽量减少接触。在发生长时间密切接触的医疗环境中，尤其是在 AGP 过程中，传播的风险会增加。因此，遵守严格的个人防护设备协议至关重要[7]。为防止空气传播，最好使用带负压的空气传播隔离室（AIIRs）。在高风险环境中，尤其是免疫力严重低下的患者或患有播散性疾病的患者，可使用生物隔离室（BCUs）[7]。然而，必须注意的是，COVID-19 的管理在不同时期和不同地区有很大差异。因此，在流行性腮腺炎中，目前的指导原则强调坚持使用呼吸道防护用品（如 N95 或同等用品），尽量减少 AGPs，优化隔离程序以减少非医院传播[7]。
{"title":"What every intensivist needs to know about mpox","authors":"Siyao Zeng, Yue Li, Zhipeng Yao, Junbo Zheng, Hongliang Wang","doi":"10.1186/s13054-024-05114-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05114-8","url":null,"abstract":"<p>The mpox virus is a zoonotic orthopoxvirus with a DNA genome. Based on genetic characteristics, the mpox virus is categorized into two main clades: clade I and clade II. Clade I is further subdivided into subclades Ia and Ib [1]. Clade I is predominantly found in Central Africa, while clade II primarily circulates in West Africa [2]. The clade IIb subclade of clade II caused the global mpox outbreak from 2022 to 2023, during which 86% of cases were among men who have sex with men (MSM) [1]. More than half of the reported mpox cases involve individuals who are co-infected with the human immunodeficiency virus (HIV) [3]. The 2024 mpox outbreak in the Democratic Republic of the Congo and neighboring countries is primarily caused by clade Ia [4]. Only in 2024, as of September 15, the Democratic Republic of the Congo has reported 25,757 cases of mpox, with 806 deaths [3]. In April 2024, scientists identified a new variant of clade I, named Ib, by analyzing samples collected in South Kivu Province, Democratic Republic of the Congo, from late 2023 to early 2024. Reports of infections caused by the Ib variant have increased over the past few months. The proportion of women infected with clade Ib was significantly higher (52%), with nearly one-third identifying as sex workers [1]. On August 15, Sweden reported its first case of mpox caused by the Ib variant. Thailand confirmed its first Ib variant mpox case on August 22 [4]. Compared to clade IIb, which caused the global mpox outbreak in 2022, clade Ia exhibits stronger human-to-human transmissibility and higher mortality and severity rates. As for the clade Ib, its characteristics remain unclear [5].</p><p>As the mpox outbreak intensifies, by August 31, 2024, a total of 106,310 confirmed cases have been reported across 123 countries worldwide, resulting in 234 laboratory-confirmed deaths [3]. In Africa, the confirmed and suspected mpox cases in 2024 have surpassed 17,500, far exceeding the 15,000 cases reported in 2023. In response to this escalating situation, the Africa Centers for Disease Control and Prevention (Africa CDC) declared mpox a “Public Health Emergency of Security Concern” (PHESC) for the first time on August 13, 2024. The following day, the World Health Organization (WHO) declared the mpox outbreak a “Public Health Emergency of International Concern” (PHEIC), urging global cooperation to prevent further spread [5]. The current mpox outbreak may pose new challenges for intensivists worldwide.</p><p>Mpox mainly spreads through transmission between animals and humans or from person to person. Animal-to-human transmission can happen through direct contact with an infected animal, being bitten or scratched, or consuming undercooked meat from an infected animal. Human-to-human transmission primarily occurs through direct contact with an infected individual’s skin or mucous membrane lesions, oral secretions, upper respiratory secretions (such as nasal discharge and mucus), and items contamina","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-04DOI: 10.1186/s13054-024-05125-5
Ola Stenqvist
<p>In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.</p><p>In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).</p><p>Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.</p><h3>Background physiology</h3><p>The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properti
由于 EELV 的变化为 ΔPEEP/EL，因此在不考虑食管压力的情况下，可通过增加 PEEP 并确定 ΔEELV 来确定肺弹性为 ΔPEEP/ΔEELV。右图：累积 ΔPEEP 和累积 ΔPLEE 之间的相关图，计算公式为 ΔEELV x EL，[3,5,6,7,8,9,10,11,12]中逐级 PEEP，显示 PLEE 随 PEEP 的增加而增加。潮气量等于 ΔEELV 时的跨肺驱动压（ΔPL）等于 ΔPEEPFull size image图 2左侧面板：44 个 PEEP 步骤，平均 ΔPEEP 为 5.1 cmH2O，与图 1 中列出的研究相同。呼气末跨肺压的增加按 ΔEELV × EL 计算，其中 EL = (ΔPAW - ΔPES)/VT。呼气末食管压力变化（ΔPPLEE）的计算公式为 ΔPEEP - ΔPLEE。右图：在潮气量等于 PEEP 引起的呼气末肺容量变化（VT = ΔEELV）时，ΔPEEP 与跨肺驱动压力（由食管压力确定的 ΔPLconv）的比较。根据 ΔEELV 和相应潮气量的大小将数值分为三组。全尺寸图片潮气压力变化方程用于分离肺和胸壁力学，用于验证 PSMA 气道驱动压力 = ΔPAWE 食管驱动压力 = ΔPEST 肺驱动压力 = ΔPAW - ΔPES = ΔPL呼吸系统弹性：ERS = ΔPAW/VTC 胸壁弹性：ECW = ΔPES/VTLung elastance：EL = ΔPL/VT = ERS - ECWE呼气末气道压力：PAWEE = PEEP末期呼气肺容积变化：ΔEELV = ΔPEEP/ELE 末期呼气跨肺压力变化：ΔPLEE = ΔEELV × ELE末期呼气食管压力变化：ΔPESEE = ΔPAWEE - ΔPLEET数学推导基于PES的肺弹性为$${text{EL}} = Delta {text{PL}}/{text{VT}}$ 而基于PEEP的肺弹性为$${text{EL}} = Delta {text{PL}}/{text{VT}}$因此${text{PL}}/{text{VT}} = Delta {text{PEEP}}/Delta {text{EELV}}$Thus$Delta {text{PL}}/{text{VT}} = Delta {text{PEEP}}/Delta {text{EELV}}$(△{text{EELV}}={text{VT}})$$△{text{PL}}=△{text{PEEP}}$$因此、潮气量等于 ΔEELV 时的跨肺驱动压等于 ΔPEEP。由于呼气末跨肺压力（ΔPLEE）的增加也等于ΔPEEP，因此在一定肺容量下的跨肺压力是相同的，无论该肺容量是通过潮气量还是 PEEP 充气达到的。ΔEELV的总和为$$Δ{text/{PEEP}}/{text{EL}}$这两个体积之差构成了PEEP膨胀的第二阶段多呼阶段，即$$left( {Δ{text{PEEP }} times {{text{ ECW}}} right)/left( {{text{ERS }} times {{text{ EL}}} right)。times , Delta {text/{PEEP/ERS}}$第二阶段 PEEP 充气期间呼气末转肺压的增加值为$${text{EL }}times , left( {Delta {text{PEEP }} times {text{ ECW}}} right)/left( {{text{ERS }} times {text{ EL}}} right) , = {text{ECW }}因此，在 ΔEELV 增加的第二阶段多呼期间，跨肺压的增加等于增加 PEEP 后第一次呼气期间呼气末食管压的增加。这证明了在 PEEP 充气过程中，由于肋骨的弹出力，胸壁在呼气末从肺部卸载。图 3 左侧面板：离体肺中的 PEEP 步骤。气道压力（红色箭头）等于跨肺压力（蓝色箭头）。低 PEEP 时的潮气量为 500 毫升，ΔPAW 为 10 cmH2O。增加 PEEP 10 cmH2O 会导致 EELV 增加 500 毫升。低 PEEP 时的吸气末转肺（= 气道）P/V 点等于高 PEEP 时的呼气末转肺（= 气道）P/V 点（蓝色环表示）。在孤立肺中，肺弹性为 ∆PAW/VT 和 ∆PEEP/ ∆EELV。右图：原位 PEEP 阶跃。低 PEEP 水平的潮气量等于 PEEP 引起的呼气末肺容积变化。来自 ZEEP 的吸气末气道平台压力与离体肺的位置（蓝色环）相比右移（黑色箭头）。低 PEEP 水平的潮气量吸气末高原压与高 PEEP 水平的呼气末跨肺压之差等于潮气胸膜压变化（绿色箭头，ΔPPL）。 由于 EL/ERS 的平均比率（ΔPL/ΔAW）≈ 0.70，因此ΔEELV 平均等于潮气量。ΔEELV 是根据 PEEP 水平之间呼气潮气量的累积差值确定的，肺弹性的计算公式为 ΔPEEP/ΔEELV。跨肺驱动压力的计算公式为 PSM 导出 EL 乘以潮气量。为了考虑肺压/容积曲线的非线性，需要采用两级 PEEP 程序来评估从基线 PEEP 时的呼气末到最高 PEEP 水平时的吸气末高原压力曲线。根据两个较低 PEEP 推断出的潮气胸膜压力变化，对三个呼气末气道 P/V 点进行两度多项式拟合，并估算出程序中最高 PEEP 水平时的吸气末跨肺 P/V 点（图 4）：通过两级 PEEP 程序确定的肺 P/V 曲线（蓝色）。三个 PEEP 水平下的潮气道 P/V 曲线（红色箭头）。在两个最低 PEEP 水平下，分别确定吸气末气道高原压与同一容积水平下的肺转压之间的压力差，即胸膜压力的潮气变化。最高 PEEP 水平下的跨肺高原压是根据两个较低 PEEP 水平下的潮气胸膜压力变化推算出来的。最高 PEEP 水平下的跨肺高原压计算方法为气道高原压减去外推胸膜压力变化[14]。在重症监护室的 ARF 患者和手术室的肺热患者中，估计的跨肺高原压与食管压力测量的高原压之间的差异分别为 0.2 ± 1.4 和 0.1 ± 0.8 cmH2O [14，15]。右图：最佳 PEEP，即提供最低跨肺驱动压力的 PEEP 水平，可通过将曲线最陡峭的点确定为多项式二次导数的根，并将所需潮气量对称分布在该 P/V 点周围来确定[14]。根据多项式可以计算出呼气末容积对应的压力。由于潮气量肺 P/V 曲线（与容量和 PEEP 水平无关）叠加在总肺 P/V 曲线上，因此可以根据肺 P/V 曲线方程计算出任何 PEEP 和潮气量组合的跨肺驱动压力和高原压力。这样就可以估计 PEEP 和潮气量任何组合的机械后果，并确定呼吸机诱发肺损伤（VILI）的风险，以及何时可以使用更积极的设置来避免 ECMO 治疗，而不会有 VILI 的风险（图 5）。图 5 PEEP 无反应者和反应者的最佳拟合肺 P/V 曲线（浅灰色），肺总顺应性（CLoa）分别为 54 和 112 ml/cmH2O[14]。在 PEEP 为 8 和 13 cmH2O 时，VT 为 6 毫升/千克 IBW（70 千克 IBW 患者为 500 毫升）时的潮气肺 P/V 曲线（蓝色箭头）与总肺 P/V
{"title":"Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics","authors":"Ola Stenqvist","doi":"10.1186/s13054-024-05125-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05125-5","url":null,"abstract":"<p>In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.</p><p>In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).</p><p>Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.</p><h3>Background physiology</h3><p>The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properti","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs. This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied. Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light’s criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination. Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.
{"title":"Biochemical analysis of soft tissue infectious fluids and its diagnostic value in necrotizing soft tissue infections: a 5-year cohort study","authors":"Kai-Hsiang Wu, Po-Han Wu, Hung-Sheng Wang, Hsiu-Mei Shiau, Yung-Sung Hsu, Chih-Yi Lee, Yin-Ting Lin, Cheng-Ting Hsiao, Leng-Chieh Lin, Chia-Peng Chang, Pey-Jium Chang","doi":"10.1186/s13054-024-05146-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05146-0","url":null,"abstract":"Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs. This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied. Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light’s criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination. Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142562090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1186/s13054-024-05133-5
Masahiko Hara, Masatake Tamaki
<p>Non-invasive ventilation (NIV) is critical in the treatment of several respiratory diseases [1, 2]. However, interface air leakage and resultant pressure injury from tight-fitting can lead to intolerance or unsuccessful implementation of NIV [3, 4]. In response to these challenges, we have developed a new type of oronasal mask with full accordion cushioning designed to achieve effective sealing at lower pressures (Fig. 1 and Video. S1). Our mask incorporates six innovations: full accordion cushioning, turtle shell cover, nasal groove, folding function, visual pressure indicator, and soft medical-grade silicone (Videos. S2, S3, and S4). The mask is tapered toward the face, and it also incorporates multiple elastic adjustment lines to improve adaptability and fit, allowing the mask to “fold” snugly around the face. These elements enhance the mask’s ability to evenly distribute pressure and conform to different facial shapes, providing a secure fit at low pressures. The thickness of the accordion cushion decreases toward the face side, providing a visual indication of pressure application through the compression of the accordion valleys.</p><figure><figcaption><b data-test="figure-caption-text">Fig. 1</b></figcaption><picture><source srcset="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05133-5/MediaObjects/13054_2024_5133_Fig1_HTML.png?as=webp" type="image/webp"/><img alt="figure 1" aria-describedby="Fig1" height="433" loading="lazy" src="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05133-5/MediaObjects/13054_2024_5133_Fig1_HTML.png" width="685"/></picture><p>Structural and Functional Features of Our Novel Respiratory Mask with Full Accordion Cushioning. Overview of the mask (<b>A</b>). The rear view of the mask from the face side shows the nasal groove (<b>B</b>). Elastic adjustment lines are symmetrically aligned with six on the nasal side and eight on the chin side (<b>C</b>). An illustration of the mask in clinical use (<b>D</b>). A detailed view of the accordion structure, showing the five outermost ridges defined as accordion lines (<b>E</b>). These ridges are sequentially labeled from the face side (first line, purple) to the cover side (fifth line, blue). Mechanical testing provided visual cues for the estimated pressure at which the mask would adhere to the skin (<b>F</b>). See Video. S1 for the 3-dimensional computer-aided design data of the mask, Video. S2 for a frontal view of the mask in use, Video. S3 for a visualization of the nasal groove, and Video. S4 for the folding function</p><span>Full size image</span><svg aria-hidden="true" focusable="false" height="16" role="img" width="16"><use xlink:href="#icon-eds-i-chevron-right-small" xmlns:xlink="http://www.w3.org/1999/xlink"></use></svg></figure><p>To assess the mask’s performance, a mechanical bench test was conducted to evaluate sealing efficiency and to estimate skin pressure at various visual pressure ind
无创通气（NIV）是治疗多种呼吸系统疾病的关键[1, 2]。然而，界面漏气和紧身佩戴造成的压力损伤会导致患者不耐受或无法成功实施 NIV [3，4]。为了应对这些挑战，我们开发了一种新型口鼻面罩，其全风琴式缓冲设计可在较低压力下实现有效密封（图 1 和视频 S1）。我们的喉罩采用了六项创新技术：全风琴式缓冲、龟甲盖、鼻槽、折叠功能、可视压力指示器和医用软硅胶（视频 S2、S3 和 S4）。面罩朝向脸部呈锥形，还包含多条弹性调节线，以提高适应性和贴合度，使面罩能紧贴脸部 "折叠"。这些元素增强了面罩均匀分布压力和适应不同脸型的能力，在低压下也能提供安全的贴合。风琴式缓冲垫的厚度向脸部一侧减小，通过压缩风琴式凹谷提供压力应用的视觉指示。面罩概览（A）。从面罩背面看，可以看到鼻腔凹槽 (B)。弹性调节线对称排列，鼻侧六条，下巴侧八条（C）。面罩临床使用示意图（D）。手风琴结构的详细视图，显示最外侧的五条脊线被定义为手风琴线（E）。这些脊线从面部（第一条线，紫色）到盖面（第五条线，蓝色）依次标注。机械测试为面罩附着在皮肤上的估计压力提供了视觉提示（F）。参见视频。S1 为面具的三维计算机辅助设计数据，视频.S2 为面罩使用时的正面视图，视频.S3 为鼻槽的可视化，视频为评估面罩的性能，进行了机械台架测试，以评估密封效率，并估算各种视觉压力指示器情况下的皮肤压力。还进行了烟雾泄漏测试，以直观地确认密封性（视频 S5）。面罩能有效贴合各种人体模型的头部形状，并在估计皮肤压力为 2.2 mmHg 时实现完全密封。最外侧的脊线从面部开始依次标注。当第一条和第二条风琴线粘合时，估计皮肤压力为 5.3 ± 0.4 mmHg；当第一条至第三条线粘合时，估计皮肤压力为 10.8 ± 0.6 mmHg；当第一条至第四条线粘合时，估计皮肤压力为 16.8 ± 0.7 mmHg。林氏一致性相关系数为 0.987（95% 置信区间，0.963-0.995），表明不同观察者的测量结果高度一致。根据这些结果，我们开发了一种特殊的绑带（图 S1），可使面罩以最小的压力固定在面部，从而提高了可用性。该面罩在日本注册为医疗设备，产品名称为 "javalla"（iDevice, Inc.，日本大阪）。面罩的设计可重复使用，每个面罩最多可保证为 10 名患者提供耐用性。最初的临床反馈非常积极，强调了面罩的易贴合性和舒适性，而无需特定尺寸。一刀切的设计符合各种脸型，包括不同的鼻部轮廓，因此无需调整尺寸。用户反映漏气较少，不适感减轻，呼吸机报警减少。折叠功能使脸部无齿或脸颊凹陷的患者受益匪浅。在试销阶段，74 家医院中有 33 家（44.6%）采用了我们的产品，尽管其价格比他们最常用的面罩高出一倍多。然而，一些用户指出，他们需要学习如何放置面罩，担心面罩较松，以及保持呼吸机管道无张力（无重力）的重要性，以防止因面罩佩戴过软而脱落。此外，还观察到一些使用者倾向于将面罩固定得太紧，就像传统面罩一样，导致过度收紧，造成第 1 至第 4 条风琴线粘连。这种新型喉罩解决了 NIV 面临的关键挑战，如漏气和压力损伤，这往往与高发病率和医疗成本增加有关 [3，4]。当持续外力超过组织灌注压力（通常约为 30-35 mmHg）时，就会发生压力损伤[4, 5]。我们的面罩能够在低压下提供有效的密封，这表明它具有减少此类伤害发生的潜力。 如果文章的知识共享许可中没有包含材料，而您的使用意图又不符合法律规定或超出了许可使用范围，您需要直接从版权所有者处获得许可。要查看此许可的副本，请访问 http://creativecommons.org/licenses/by/4.0/.Reprints and permissionsCite this articleHara, M., Tamaki, M. Development and functional characterization of a novel respiratory mask with full accordion cushion to prevent air leaks and pressure injuries during non-invasive ventilation.https://doi.org/10.1186/s13054-024-05133-5Download citationReceived：13 October 2024Accepted：15 October 2024Published: 01 November 2024DOI: https://doi.org/10.1186/s13054-024-05133-5Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative.
{"title":"Development and functional characterization of a novel respiratory mask with full accordion cushioning to prevent air leaks and pressure injuries during non-invasive ventilation","authors":"Masahiko Hara, Masatake Tamaki","doi":"10.1186/s13054-024-05133-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05133-5","url":null,"abstract":"<p>Non-invasive ventilation (NIV) is critical in the treatment of several respiratory diseases [1, 2]. However, interface air leakage and resultant pressure injury from tight-fitting can lead to intolerance or unsuccessful implementation of NIV [3, 4]. In response to these challenges, we have developed a new type of oronasal mask with full accordion cushioning designed to achieve effective sealing at lower pressures (Fig. 1 and Video. S1). Our mask incorporates six innovations: full accordion cushioning, turtle shell cover, nasal groove, folding function, visual pressure indicator, and soft medical-grade silicone (Videos. S2, S3, and S4). The mask is tapered toward the face, and it also incorporates multiple elastic adjustment lines to improve adaptability and fit, allowing the mask to “fold” snugly around the face. These elements enhance the mask’s ability to evenly distribute pressure and conform to different facial shapes, providing a secure fit at low pressures. The thickness of the accordion cushion decreases toward the face side, providing a visual indication of pressure application through the compression of the accordion valleys.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05133-5/MediaObjects/13054_2024_5133_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"433\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05133-5/MediaObjects/13054_2024_5133_Fig1_HTML.png\" width=\"685\"/></picture><p>Structural and Functional Features of Our Novel Respiratory Mask with Full Accordion Cushioning. Overview of the mask (<b>A</b>). The rear view of the mask from the face side shows the nasal groove (<b>B</b>). Elastic adjustment lines are symmetrically aligned with six on the nasal side and eight on the chin side (<b>C</b>). An illustration of the mask in clinical use (<b>D</b>). A detailed view of the accordion structure, showing the five outermost ridges defined as accordion lines (<b>E</b>). These ridges are sequentially labeled from the face side (first line, purple) to the cover side (fifth line, blue). Mechanical testing provided visual cues for the estimated pressure at which the mask would adhere to the skin (<b>F</b>). See Video. S1 for the 3-dimensional computer-aided design data of the mask, Video. S2 for a frontal view of the mask in use, Video. S3 for a visualization of the nasal groove, and Video. S4 for the folding function</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>To assess the mask’s performance, a mechanical bench test was conducted to evaluate sealing efficiency and to estimate skin pressure at various visual pressure ind","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142562091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-31DOI: 10.1186/s13054-024-05149-x
Wenping Fan, Biyu Gui, Xiaolei Zhou, Li Li, Huaiyong Chen
Lung injury is closely associated with the heterogeneity, severity, mortality, and prognosis of various respiratory diseases. Effective monitoring of lung injury is crucial for the optimal management and improved outcomes of patients with lung diseases. This review describes acute and chronic respiratory diseases characterized by significant lung injury and current clinical tools for assessing lung health. Furthermore, we summarized the mechanisms of lung cell death observed in these diseases and highlighted recently identified biomarkers in the plasma indicative of injury to specific cell types and scaffold structure in the lung. Last, we propose an artificial intelligence-driven lung injury monitoring model to assess disease severity, and predict mortality and prognosis, aiming to achieve precision and personalized medicine.
{"title":"A narrative review on lung injury: mechanisms, biomarkers, and monitoring","authors":"Wenping Fan, Biyu Gui, Xiaolei Zhou, Li Li, Huaiyong Chen","doi":"10.1186/s13054-024-05149-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05149-x","url":null,"abstract":"Lung injury is closely associated with the heterogeneity, severity, mortality, and prognosis of various respiratory diseases. Effective monitoring of lung injury is crucial for the optimal management and improved outcomes of patients with lung diseases. This review describes acute and chronic respiratory diseases characterized by significant lung injury and current clinical tools for assessing lung health. Furthermore, we summarized the mechanisms of lung cell death observed in these diseases and highlighted recently identified biomarkers in the plasma indicative of injury to specific cell types and scaffold structure in the lung. Last, we propose an artificial intelligence-driven lung injury monitoring model to assess disease severity, and predict mortality and prognosis, aiming to achieve precision and personalized medicine.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142555848","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Previous studies examining sex differences in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) have indicated that women have favorable outcomes; however, detailed evidence remains lacking. We aimed to investigate sex differences in the backgrounds and outcomes of patients undergoing ECPR for OHCA.
Methods: This study was a secondary analysis of the registry from the SAVE-J II study, a retrospective multicenter study conducted in Japan from 2013 to 2018. Adult patients without external causes who underwent ECPR for OHCA were included. The primary outcome was a favorable neurological outcome (Cerebral Performance Status 1 or 2) at hospital discharge. We used multilevel logistic regression to evaluate the association of sex differences, adjusting for center-level (hospital) and individual-level variables (patient background, cardiac arrest situation, and in-hospital intervention factors). For sensitivity analyses, we performed three models of multilevel logistic regression when selecting confounders.
Results: Among the 1819 patients, 1523 (83.7%) were men, and 296 (16.3%) were women. The median age (61.0 vs. 58.0 years), presence of a witness (78.8% vs. 79.2%), and occurrence of bystander CPR (57.5% vs. 61.6%) were similar between groups. Women were more likely to present with an initial non-shockable rhythm (31.7% vs. 49.7%), as well as a non-shockable rhythm at hospital arrival (52.1% vs. 61.5%) and at ECMO initiation (48.1% vs. 57.1%). The proportion of favorable neurological outcomes was 12.3% in males and 15.9% in females (p = 0.10). Multilevel logistic regression analysis showed that the female sex was significantly associated with a favorable neurologic outcome at discharge (adjusted odds ratio: 1.60 [95% confidence interval: 1.05-2.43]; p = 0.03). This advantage in women was consistently observed in the sensitivity analyses.
Conclusions: The female sex is significantly associated with favorable neurological outcomes at hospital discharge in patients who received ECPR for OHCA.
{"title":"Sex differences in extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: nationwide multicenter retrospective study in Japan.","authors":"Akira Kawauchi, Yohei Okada, Makoto Aoki, Akihiko Inoue, Toru Hifumi, Tetsuya Sakamoto, Yasuhiro Kuroda, Mitsunobu Nakamura","doi":"10.1186/s13054-024-05086-9","DOIUrl":"10.1186/s13054-024-05086-9","url":null,"abstract":"<p><strong>Background: </strong>Previous studies examining sex differences in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) have indicated that women have favorable outcomes; however, detailed evidence remains lacking. We aimed to investigate sex differences in the backgrounds and outcomes of patients undergoing ECPR for OHCA.</p><p><strong>Methods: </strong>This study was a secondary analysis of the registry from the SAVE-J II study, a retrospective multicenter study conducted in Japan from 2013 to 2018. Adult patients without external causes who underwent ECPR for OHCA were included. The primary outcome was a favorable neurological outcome (Cerebral Performance Status 1 or 2) at hospital discharge. We used multilevel logistic regression to evaluate the association of sex differences, adjusting for center-level (hospital) and individual-level variables (patient background, cardiac arrest situation, and in-hospital intervention factors). For sensitivity analyses, we performed three models of multilevel logistic regression when selecting confounders.</p><p><strong>Results: </strong>Among the 1819 patients, 1523 (83.7%) were men, and 296 (16.3%) were women. The median age (61.0 vs. 58.0 years), presence of a witness (78.8% vs. 79.2%), and occurrence of bystander CPR (57.5% vs. 61.6%) were similar between groups. Women were more likely to present with an initial non-shockable rhythm (31.7% vs. 49.7%), as well as a non-shockable rhythm at hospital arrival (52.1% vs. 61.5%) and at ECMO initiation (48.1% vs. 57.1%). The proportion of favorable neurological outcomes was 12.3% in males and 15.9% in females (p = 0.10). Multilevel logistic regression analysis showed that the female sex was significantly associated with a favorable neurologic outcome at discharge (adjusted odds ratio: 1.60 [95% confidence interval: 1.05-2.43]; p = 0.03). This advantage in women was consistently observed in the sensitivity analyses.</p><p><strong>Conclusions: </strong>The female sex is significantly associated with favorable neurological outcomes at hospital discharge in patients who received ECPR for OHCA.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11526675/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142544185","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-30DOI: 10.1186/s13054-024-05142-4
Klaus Stahl, Georg F Lehner, Pedro David Wendel-Garcia, Benjamin Seeliger, Thorben Pape, Bernhard M W Schmidt, Heiko Schenk, Julius Schmitt, Andrea Sauer, Lennart Wild, Konrad Peukert, Christian Putensen, Christian Bode, Michael Joannidis, Sascha David
Background: Coagulopathy is part of the pathological host response to infection in sepsis. Higher plasma concentrations of both tissue factor (TF) and tissue factor pathway inhibitor (TFPI) are associated with occurrence of disseminated intravascular coagulation (DIC), multi-organ dysfunction and increased mortality in patients with sepsis. Currently no treatment approaches specifically targeting this axis are available. We hypothesize that therapeutic plasma exchange (TPE) might limit this coagulopathy by restoring the balance of plasma proteins.
Methods: This was a pooled post-hoc biobank analysis including 51 patients with early (shock onset < 24 h) and severe (norepinephrine dose > 0.4 μg/kg/min) septic shock, who were either receiving standard of care treatment (SOC, n = 14) or SOC + one single TPE (n = 37). Plasma concentrations of TF and TFPI were measured both at- and 6 h after study inclusion. The effect of TPE on concentrations of TF and TFPI was investigated and compared to SOC patients. Further, baseline TF and TFPI concentrations were used to modulate and predict clinical response to adjunctive TPE, indicated by longitudinal reduction of lactate concentrations over the first 24 h following study inclusion.
Results: TPE led to a significant reduction in circulating concentrations of both TF and TFPI while no difference was observed in the SOC group. Relative change of TF within 6 h was + 14 (-0.8 to + 30.4) % (p = 0.089) in the SOC and -18.3 (-32.6 to -2.2) % (p < 0.001) in the TPE group (between group p < 0.001). Similarly, relative change of TFPI was + 14.4 (-2.3 to + 30.9) % (p = 0.076) in the SOC and -20 (-32.8 to -7.9) % (p < 0.001) in the TPE group (between group p = 0.022). The ratio of TF to TFPI remained unchanged in both SOC and TPE groups. SOC patients exhibited an increase in lactate over the initial 24 h when TF and TFPI concentrations were higher at baseline. In contrast, patients undergoing TPE experienced a sustained longitudinal reduction of lactate concentrations across all levels of baseline TF and TFPI elevations. In a multivariate mixed-effects model, higher baseline TF (p = 0.003) and TFPI (p = 0.053) levels led to greater longitudinal lactate concentration reduction effects in the TPE group.
Conclusions: Adjunctive TPE in septic shock is associated with a significant removal of both TF and TFPI, which may contribute to the early hemodynamic improvement observed in septic shock patients receiving TPE. Higher baseline TF (and TFPI) plasma concentrations were identified as a putative predictor of treatment response that could be useful for predictive enrichment strategies in future clinical trials.
{"title":"Effect of therapeutic plasma exchange on tissue factor and tissue factor pathway inhibitor in septic shock.","authors":"Klaus Stahl, Georg F Lehner, Pedro David Wendel-Garcia, Benjamin Seeliger, Thorben Pape, Bernhard M W Schmidt, Heiko Schenk, Julius Schmitt, Andrea Sauer, Lennart Wild, Konrad Peukert, Christian Putensen, Christian Bode, Michael Joannidis, Sascha David","doi":"10.1186/s13054-024-05142-4","DOIUrl":"10.1186/s13054-024-05142-4","url":null,"abstract":"<p><strong>Background: </strong>Coagulopathy is part of the pathological host response to infection in sepsis. Higher plasma concentrations of both tissue factor (TF) and tissue factor pathway inhibitor (TFPI) are associated with occurrence of disseminated intravascular coagulation (DIC), multi-organ dysfunction and increased mortality in patients with sepsis. Currently no treatment approaches specifically targeting this axis are available. We hypothesize that therapeutic plasma exchange (TPE) might limit this coagulopathy by restoring the balance of plasma proteins.</p><p><strong>Methods: </strong>This was a pooled post-hoc biobank analysis including 51 patients with early (shock onset < 24 h) and severe (norepinephrine dose > 0.4 μg/kg/min) septic shock, who were either receiving standard of care treatment (SOC, n = 14) or SOC + one single TPE (n = 37). Plasma concentrations of TF and TFPI were measured both at- and 6 h after study inclusion. The effect of TPE on concentrations of TF and TFPI was investigated and compared to SOC patients. Further, baseline TF and TFPI concentrations were used to modulate and predict clinical response to adjunctive TPE, indicated by longitudinal reduction of lactate concentrations over the first 24 h following study inclusion.</p><p><strong>Results: </strong>TPE led to a significant reduction in circulating concentrations of both TF and TFPI while no difference was observed in the SOC group. Relative change of TF within 6 h was + 14 (-0.8 to + 30.4) % (p = 0.089) in the SOC and -18.3 (-32.6 to -2.2) % (p < 0.001) in the TPE group (between group p < 0.001). Similarly, relative change of TFPI was + 14.4 (-2.3 to + 30.9) % (p = 0.076) in the SOC and -20 (-32.8 to -7.9) % (p < 0.001) in the TPE group (between group p = 0.022). The ratio of TF to TFPI remained unchanged in both SOC and TPE groups. SOC patients exhibited an increase in lactate over the initial 24 h when TF and TFPI concentrations were higher at baseline. In contrast, patients undergoing TPE experienced a sustained longitudinal reduction of lactate concentrations across all levels of baseline TF and TFPI elevations. In a multivariate mixed-effects model, higher baseline TF (p = 0.003) and TFPI (p = 0.053) levels led to greater longitudinal lactate concentration reduction effects in the TPE group.</p><p><strong>Conclusions: </strong>Adjunctive TPE in septic shock is associated with a significant removal of both TF and TFPI, which may contribute to the early hemodynamic improvement observed in septic shock patients receiving TPE. Higher baseline TF (and TFPI) plasma concentrations were identified as a putative predictor of treatment response that could be useful for predictive enrichment strategies in future clinical trials.</p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8,"publicationDate":"2024-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11526504/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142544184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-30DOI: 10.1186/s13054-024-05127-3
Ludovic Gerard, Marylene Lecocq, Bruno Detry, Caroline Bouzin, Delphine Hoton, Joao Pinto Pereira, François Carlier, Thomas Plante-Bordeneuve, Sophie Gohy, Valérie Lacroix, Pierre-François Laterre, Charles Pilette
The airway epithelium (AE) fulfils multiple functions to maintain pulmonary homeostasis, among which ensuring adequate barrier function, cell differentiation and polarization, and actively transporting immunoglobulin A (IgA), the predominant mucosal immunoglobulin in the airway lumen, via the polymeric immunoglobulin receptor (pIgR). Morphological changes of the airways have been reported in ARDS, while their detailed features, impact for mucosal immunity, and causative mechanisms remain unclear. Therefore, this study aimed to assess epithelial alterations in the distal airways of patients with ARDS. We retrospectively analyzed lung tissue samples from ARDS patients and controls to investigate and quantify structural and functional changes in the small airways, using multiplex fluorescence immunostaining and computer-assisted quantification on whole tissue sections. Additionally, we measured markers of mucosal immunity, IgA and pIgR, alongside with other epithelial markers, in the serum and the broncho-alveolar lavage fluid (BALF) prospectively collected from ARDS patients and controls. Compared to controls, airways of ARDS were characterized by increased epithelial denudation (p = 0.0003) and diffuse epithelial infiltration by neutrophils (p = 0.0005). Quantitative evaluation of multiplex fluorescence immunostaining revealed a loss of ciliated cells (p = 0.0317) a trend towards decreased goblet cells (p = 0.056), and no change regarding cell progenitors (basal and club cells), indicating altered mucociliary differentiation. Increased epithelial permeability was also shown in ARDS with a significant decrease of tight (p < 0.0001) and adherens (p = 0.025) junctional proteins. Additionally, we observed a significant decrease of the expression of pIgR, (p < 0.0001), indicating impaired mucosal IgA immunity. Serum concentrations of secretory component (SC) and S-IgA were increased in ARDS (both p < 0.0001), along other lung-derived proteins (CC16, SP-D, sRAGE). However, their BALF concentrations remained unchanged, suggesting a spillover of airway and alveolar proteins through a damaged AE. The airway epithelium from patients with ARDS exhibits multifaceted alterations leading to altered mucociliary differentiation, compromised defense functions and increased permeability with pneumoproteinemia.
{"title":"Airway epithelium damage in acute respiratory distress syndrome","authors":"Ludovic Gerard, Marylene Lecocq, Bruno Detry, Caroline Bouzin, Delphine Hoton, Joao Pinto Pereira, François Carlier, Thomas Plante-Bordeneuve, Sophie Gohy, Valérie Lacroix, Pierre-François Laterre, Charles Pilette","doi":"10.1186/s13054-024-05127-3","DOIUrl":"https://doi.org/10.1186/s13054-024-05127-3","url":null,"abstract":"The airway epithelium (AE) fulfils multiple functions to maintain pulmonary homeostasis, among which ensuring adequate barrier function, cell differentiation and polarization, and actively transporting immunoglobulin A (IgA), the predominant mucosal immunoglobulin in the airway lumen, via the polymeric immunoglobulin receptor (pIgR). Morphological changes of the airways have been reported in ARDS, while their detailed features, impact for mucosal immunity, and causative mechanisms remain unclear. Therefore, this study aimed to assess epithelial alterations in the distal airways of patients with ARDS. We retrospectively analyzed lung tissue samples from ARDS patients and controls to investigate and quantify structural and functional changes in the small airways, using multiplex fluorescence immunostaining and computer-assisted quantification on whole tissue sections. Additionally, we measured markers of mucosal immunity, IgA and pIgR, alongside with other epithelial markers, in the serum and the broncho-alveolar lavage fluid (BALF) prospectively collected from ARDS patients and controls. Compared to controls, airways of ARDS were characterized by increased epithelial denudation (p = 0.0003) and diffuse epithelial infiltration by neutrophils (p = 0.0005). Quantitative evaluation of multiplex fluorescence immunostaining revealed a loss of ciliated cells (p = 0.0317) a trend towards decreased goblet cells (p = 0.056), and no change regarding cell progenitors (basal and club cells), indicating altered mucociliary differentiation. Increased epithelial permeability was also shown in ARDS with a significant decrease of tight (p < 0.0001) and adherens (p = 0.025) junctional proteins. Additionally, we observed a significant decrease of the expression of pIgR, (p < 0.0001), indicating impaired mucosal IgA immunity. Serum concentrations of secretory component (SC) and S-IgA were increased in ARDS (both p < 0.0001), along other lung-derived proteins (CC16, SP-D, sRAGE). However, their BALF concentrations remained unchanged, suggesting a spillover of airway and alveolar proteins through a damaged AE. The airway epithelium from patients with ARDS exhibits multifaceted alterations leading to altered mucociliary differentiation, compromised defense functions and increased permeability with pneumoproteinemia.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142541690","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-29DOI: 10.1186/s13054-024-05138-0
Chengjian Guan, Angwei Gong, Yan Zhao, Chen Yin, Lu Geng, Linli Liu, Xiuchun Yang, Jingchao Lu, Bing Xiao
New-onset atrial fibrillation (NOAF) is the most common arrhythmia in critically ill patients admitted to intensive care and is associated with poor prognosis and disease burden. Identifying high-risk individuals early is crucial. This study aims to create and validate a NOAF prediction model for critically ill patients using machine learning (ML). The data came from two non-overlapping datasets from the Medical Information Mart for Intensive Care (MIMIC), with MIMIC-IV used for training and subset of MIMIC-III used as external validation. LASSO regression was used for feature selection. Eight ML algorithms were employed to construct the prediction model. Model performance was evaluated based on identification, calibration, and clinical application. The SHapley Additive exPlanations (SHAP) method was used for visualizing model characteristics and individual case predictions. Among 16,528 MIMIC-IV patients, 1520 (9.2%) developed AF post-ICU admission. A model with 23 variables was built, with XGBoost performing best, achieving an AUC of 0.891 (0.873–0.888) in validation and 0.769 (0.756–0.782) in external validation. Key predictors included age, mechanical ventilation, urine output, sepsis, blood urea nitrogen, percutaneous arterial oxygen saturation, continuous renal replacement therapy and weight. A risk probability greater than 0.6 was defined as high risk. A friendly user interface had been developed for clinician use. We developed a ML model to predict the risk of NOAF in critically ill patients without cardiac surgery and validated its potential as a clinically reliable tool. SHAP improves the interpretability of the model, enables clinicians to better understand the causes of NOAF, helps clinicians to prevent it in advance and improves patient outcomes.
{"title":"Interpretable machine learning model for new-onset atrial fibrillation prediction in critically ill patients: a multi-center study","authors":"Chengjian Guan, Angwei Gong, Yan Zhao, Chen Yin, Lu Geng, Linli Liu, Xiuchun Yang, Jingchao Lu, Bing Xiao","doi":"10.1186/s13054-024-05138-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05138-0","url":null,"abstract":"New-onset atrial fibrillation (NOAF) is the most common arrhythmia in critically ill patients admitted to intensive care and is associated with poor prognosis and disease burden. Identifying high-risk individuals early is crucial. This study aims to create and validate a NOAF prediction model for critically ill patients using machine learning (ML). The data came from two non-overlapping datasets from the Medical Information Mart for Intensive Care (MIMIC), with MIMIC-IV used for training and subset of MIMIC-III used as external validation. LASSO regression was used for feature selection. Eight ML algorithms were employed to construct the prediction model. Model performance was evaluated based on identification, calibration, and clinical application. The SHapley Additive exPlanations (SHAP) method was used for visualizing model characteristics and individual case predictions. Among 16,528 MIMIC-IV patients, 1520 (9.2%) developed AF post-ICU admission. A model with 23 variables was built, with XGBoost performing best, achieving an AUC of 0.891 (0.873–0.888) in validation and 0.769 (0.756–0.782) in external validation. Key predictors included age, mechanical ventilation, urine output, sepsis, blood urea nitrogen, percutaneous arterial oxygen saturation, continuous renal replacement therapy and weight. A risk probability greater than 0.6 was defined as high risk. A friendly user interface had been developed for clinician use. We developed a ML model to predict the risk of NOAF in critically ill patients without cardiac surgery and validated its potential as a clinically reliable tool. SHAP improves the interpretability of the model, enables clinicians to better understand the causes of NOAF, helps clinicians to prevent it in advance and improves patient outcomes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142541691","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-28DOI: 10.1186/s13054-024-05109-5
Guoying Wang, Fen Liu, Linqing Xu, Xiaoming Zhou
<p>I am writing this letter in reference to a recent study published in <i>Critical Care</i> entitled “Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis” [1]. I would like to commend the authors for their comprehensive and in-depth study of this important topic. This systematic review and meta-analysis undoubtedly provides valuable insights into our understanding of the incidence, risk factors, and prognosis of nosocomial infection in extracorporeal membrane oxygenation (ECMO) patients. However, two issues require further consideration.</p><p>First, we note that the literature search deadline for this study was November 1, 2022, which may have resulted in missing some important data, especially given the significant increase in ECMO use in recent years and the impact of the COVID-19 pandemic. Several studies have been published so far at the end of 2022 that may have a significant impact on the conclusions of this article. For example, the retrospective study by Barbaro et al. [2] published in the Lancet, which included 4,812 patients with COVID-19 treated with ECMO at 349 medical centers worldwide in 2020, reported Bloodstream infection (733/4,812) and Urinary tract infection (335/4,812) incidence. In addition, Nesseler et al. [3] reported the incidence of healthcare-associated infections in patients with severe COVID-19 treated with ECMO and assessed the impact of nosocomial infections on mortality, finding that ECMO-associated nosocomial infections were not associated with hospital death (hazard ratio = 1.00; 95% confidence interval: 0.79–1.26; <i>P</i> = 0.986). Considering the rapid development of ECMO technology, the authors should consider updating their analysis, especially for studies related to COVID-19. This would make the review more comprehensive and provide up-to-date guidance for clinical practice.</p><p>Second, I note that the authors did not consider data conversion when performing meta-analysis of the prevalence of nosocomial infection, which may affect the accuracy and reliability of the results. Data transformation is an important methodological consideration when performing meta-analysis of proportions. Untransformed raw proportion data often do not conform to normal distribution assumptions and may lead to inaccurate confidence interval estimates. Commonly used transformation methods include logit transformation and Freeman-Tukey double arcsine transformation [4], which stabilize the variance and bring the data closer to a normal distribution, thereby improving the accuracy of meta-analysis [5]. Based on the data extracted by Ait Hssain et al. [1], we used the above two transformations separately to obtain different results (Fig. 1). Different summary estimates and confidence intervals may affect evaluation of the overall incidence of nosocomial infection in ECMO patients, which in turn affects clinical decisi
作者及工作单位 山东省东营市第二人民医院重症医学科 王国英 山东省济南市山东第一医科大学第一附属医院重症医学科&；山东济南千佛山医院呼吸与危重症医学科 刘芬 山东青岛红岛人民医院呼吸与危重症医学科 徐林青 山东济南山东第一医科大学附属省立医院科研部 周晓明 山东东营东营市人民医院药学部 周晓明 山东东营东营市人民医院药学部作者王国英查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者刘芬查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者徐林清查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者周晓明查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者供稿王国英、刘芬和徐林清撰写了手稿主文。周晓明审稿，所有作者均对最终稿件做出了贡献。通讯作者通讯作者：周晓明。利益冲突作者声明无利益冲突。伦理批准和参与同意不适用。出版者注释Springer Nature对出版地图中的管辖权主张和机构隶属关系保持中立。开放获取 本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可，该协议允许以任何媒介或格式进行任何非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享源自本文或本文部分内容的改编材料。本文中的图片或其他第三方材料均包含在文章的知识共享许可协议中，除非在材料的信用栏中另有说明。如果材料未包含在文章的知识共享许可协议中，且您打算使用的材料不符合法律规定或超出了许可使用范围，则您需要直接获得版权所有者的许可。如需查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articleWang, G., Liu, F., Xu, L. et al. Lack of up-to-date studies and data conversion may lead to biased results.https://doi.org/10.1186/s13054-024-05109-5Download citationReceived：21 September 2024Accepted: 23 September 2024Published: 28 October 2024DOI: https://doi.org/10.1186/s13054-024-05109-5Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative
{"title":"Lack of up-to-date studies and data conversion may lead to biased results","authors":"Guoying Wang, Fen Liu, Linqing Xu, Xiaoming Zhou","doi":"10.1186/s13054-024-05109-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05109-5","url":null,"abstract":"<p>I am writing this letter in reference to a recent study published in <i>Critical Care</i> entitled “Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis” [1]. I would like to commend the authors for their comprehensive and in-depth study of this important topic. This systematic review and meta-analysis undoubtedly provides valuable insights into our understanding of the incidence, risk factors, and prognosis of nosocomial infection in extracorporeal membrane oxygenation (ECMO) patients. However, two issues require further consideration.</p><p>First, we note that the literature search deadline for this study was November 1, 2022, which may have resulted in missing some important data, especially given the significant increase in ECMO use in recent years and the impact of the COVID-19 pandemic. Several studies have been published so far at the end of 2022 that may have a significant impact on the conclusions of this article. For example, the retrospective study by Barbaro et al. [2] published in the Lancet, which included 4,812 patients with COVID-19 treated with ECMO at 349 medical centers worldwide in 2020, reported Bloodstream infection (733/4,812) and Urinary tract infection (335/4,812) incidence. In addition, Nesseler et al. [3] reported the incidence of healthcare-associated infections in patients with severe COVID-19 treated with ECMO and assessed the impact of nosocomial infections on mortality, finding that ECMO-associated nosocomial infections were not associated with hospital death (hazard ratio = 1.00; 95% confidence interval: 0.79–1.26; <i>P</i> = 0.986). Considering the rapid development of ECMO technology, the authors should consider updating their analysis, especially for studies related to COVID-19. This would make the review more comprehensive and provide up-to-date guidance for clinical practice.</p><p>Second, I note that the authors did not consider data conversion when performing meta-analysis of the prevalence of nosocomial infection, which may affect the accuracy and reliability of the results. Data transformation is an important methodological consideration when performing meta-analysis of proportions. Untransformed raw proportion data often do not conform to normal distribution assumptions and may lead to inaccurate confidence interval estimates. Commonly used transformation methods include logit transformation and Freeman-Tukey double arcsine transformation [4], which stabilize the variance and bring the data closer to a normal distribution, thereby improving the accuracy of meta-analysis [5]. Based on the data extracted by Ait Hssain et al. [1], we used the above two transformations separately to obtain different results (Fig. 1). Different summary estimates and confidence intervals may affect evaluation of the overall incidence of nosocomial infection in ECMO patients, which in turn affects clinical decisi","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":15.1,"publicationDate":"2024-10-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142519506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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