Mortality and its risk factors in critically ill patients with connective tissue diseases: A meta-analysis

Mortality in children and adolescents with autoimmune inflammatory rheumatic diseases admitted to the pediatric intensive care unit

BACKGROUND

This study aimed to describe the characteristics and outcomes of children and adolescents with autoimmune inflammatory rheumatic diseases (AIIRD) who were admitted to the pediatric intensive care unit (PICU). The accuracy of the Pediatric Risk of Mortality (PRISM) III and Pediatric Index of Mortality (PIM) 3 scores to predict the mortality were investigated.

METHODS

This was a retrospective cohort study. Children and adolescents with AIIRD aged ≤ 18 years who were admitted to the PICU at the largest university-based referral center in Thailand during July 2011 to June 2021 were included.

RESULTS

There were 122 PICU admissions from 74 patients; mean age of 12.0 ± 4.3 years, 74.3% female. Majority of AIIRD were systemic lupus erythematosus (SLE) (83.8%), followed by systemic juvenile idiopathic arthritis (5.4%), juvenile dermatomyositis (JDM) (2.7%) and microscopic polyangiitis (2.7%). The main cause of admission was combined infection and disease flare (29.5%). Pneumonia was the main site of infection. Acinetobacter baumanii was the most common causative agent. Macrophage activation syndrome occurred in 8 (6.5%) admissions. The mortality rate of PICU admissions was 14.8% from 18 deaths; 17 with SLE and 1 with JDM. Mechanical ventilation (aOR 24.07, 95%CI:1.33-434.91, P= 0.031), pneumothorax (aOR 24.08, 95%CI:1.76-328.86, P = 0.017 and thrombocytopenia (aOR 8.34, 95%CI:1.31-53.73, P = 0.025) were associated with mortality. The risk of mortality rate as predicted by the PRISM III score increased with a score ≥ 9. For the PIM 3 score, the risk of mortality increased if the score ≥ 3. The area under the ROC curve for the PRISM III and PIM 3 scores was 0.741 (95%CI: 0.633-0.849), P = 0.001 and 0.804 (95%CI: 0.685-0.924), P < 0.001, respectively. The model calibration using the Hosmer-Lemeshow goodness of fit test demonstrated a chi-square of 4.335, P = 0.826 for PRISM III and 7.987, P = 0.435 for PIM 3.

CONCLUSION

SLE was the main AIIRD that required admission to the PICU. Mechanical ventilation, pneumothorax and thrombocytopenia were associated with mortality in pediatric patients with AIIRD. The PRISM III and PIM 3 scores demonstrated good calibration, while the PIM 3 score provided better discrimination ability in the prediction of mortality for pediatric AIIRD.

Postoperative unexplained sigmoid stenosis in a patient with rectal cancer complicated with connective tissue disease: a case report and literature review

It is well established that host immunity plays a critical role in defending against colorectal cancer (CRC) progression. Connective tissue disease (CTD) encompasses a group of heterogeneous, immune-mediated disorders that present with diverse and often non-specific initial symptoms. Raynaud's phenomenon is a common feature, complicating early diagnosis. As CTD progresses, it can damage the skin, muscles, and blood vessels and may extend to the lungs, heart, kidneys, and other abdominal organs. Several studies have reported that CTD can lead to intestinal vascular occlusion and related inflammation, but the occurrence of related complications after intestinal surgery has been reported rarely. In this study, an elderly female patient with rectal cancer complicated with CTD was found to have unexplained proximal anastomotic stenosis during an attempt at fistula restoration 3 months after laparoscopy-assisted transanal total mesorectal excision (TaTME) and preventive terminal ileostomy, resulting in fistula failure. This case study aims to serve as a reference for clinicians in their future practice.

Proinflammatory Activation of Monocytes in Patients with Immunoinflammatory Rheumatic Diseases

The pathogenesis of immunoinflammatory rheumatic diseases (IRDs) is based on chronic inflammation, one of the key mechanisms of which may be abnormal activation of macrophages, leading to further disruption of the immune system.

OBJECTIVE

. The objective of this study was to evaluate the proinflammatory activation of circulating monocytes in patients with IRDs.

MATERIALS AND METHODS

. The study involved 149 participants (53 patients with rheumatoid arthritis (RA), 45 patients with systemic lupus erythematosus (SLE), 34 patients with systemic scleroderma (SSc), and 17 participants without IRDs) 30 to 65 years old. Basal and lipopolysaccharide (LPS)-stimulated secretion of monocytes was studied in a primary culture of monocytes obtained from blood by immunomagnetic separation. Quantitative assessment of the cytokines tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), as well as the chemokine monocyte chemoattractant protein-1 (MCP-1) was carried out in the culture fluid by ELISA. Proinflammatory activation of monocytes was calculated as the ratio of LPS-stimulated and basal secretions.

RESULTS

. It was shown that the basal secretion of all studied cytokines was significantly increased in all groups of patients with IRDs, except for the secretion of IL-1β in the SLE group, compared to the control. LPS-stimulated secretion of TNF-α was increased and MCP-1 was decreased in patients with IRDs compared to the control group; LPS-stimulated IL-1β secretion only in the SSc group significantly differed from the control group. In the RA group, monocyte activation was reduced for all cytokines compared to the control; in the SLE group, for TNF-α and MCP-1; in the SSc group, for MCP-1.

CONCLUSIONS

. The decrease in proinflammatory activation of monocytes in patients with IRDs is due to a high level of basal secretion of cytokines, which can lead to disruption of the adequate immune response in these diseases and is an important link in the pathogenesis of chronic inflammation.

Diagnosis and management of autoimmune diseases in the ICU

Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.

Trend of Intensive Care Unit Admission in Neurology-Neurosurgery Adult Patients in South Korea : A Nationwide Population-Based Cohort Study

OBJECTIVE

We aimed to examine trends in critically ill neurology-neurosurgery (NNS) patients who were admitted to the intensive care unit (ICU) in South Korea and identify risk factors for in-hospital mortality after ICU admission in NNS patients.

METHODS

This nationwide population-based retrospective cohort study enrolled adult NNS adult patients admitted to the ICU from 2010 to 2019 extracted from the National Health Insurance Service in South Korea. The critically ill NNS patients were defined as those whose main admission departments were neurology or neurosurgery at ICU admission. The number of ICU admission, age, and total cost for hospitalization from 2010 to 2019 in critically ill NNS patients were examined as trend information. Moreover, multivariable logistic regression modeling was used to identify risk factors for in-hospital mortality among critically ill NNS patients.

RESULTS

We included 845474 ICU admission cases for 679376 critically ill NNS patients in South Korea between January 1, 2010 to December 31, 2019. The total number of ICU admissions among NNS patients was 79522 in 2010, which increased to 91502 in 2019. The mean age rose from 62.8 years (standard deviation [SD], 15.6) in 2010 to 66.6 years (SD, 15.2) in 2019, and the average total cost for hospitalization per each patient consistently increased from 6206.1 USD (SD, 5218.5) in 2010 to 10745.4 USD (SD, 10917.4) in 2019. In-hospital mortality occurred in 75455 patients (8.9%). Risk factors strongly associated with increased in-hospital mortality were the usage of mechanical ventilator (adjusted odds ratio [aOR], 19.83; 95% confidence interval [CI], 19.42-20.26; p<0.001), extracorporeal membrane oxygenation (aOR, 3.49; 95% CI, 2.42-5.02; p<0.001), and continuous renal replacement therapy (aOR, 6.47; 95% CI, 6.02-6.96; p<0.001). In addition, direct admission to ICU from the emergency room (aOR, 1.38; 95% CI, 1.36-1.41; p<0.001) and brain cancer as the main diagnosis (aOR, 1.30; 95% CI, 1.22-1.39; p<0.001) are also potential risk factors for increased in-hospital mortality.

CONCLUSION

In South Korea, the number of ICU admissions increased among critically ill NNS patients from 2010 to 2019. The average age and total costs for hospitalization also increased. Some potential risk factors are found to increase in-hospital mortality among critically ill NNS patients.

Characteristics and outcome of critically ill patients with systemic rheumatic diseases referred to the intensive care unit

OBJECTIVES

Patients with systemic rheumatic diseases (SRDs) are at risk of admission to the intensive care unit (ICU). Data concerning these critically ill patients are limited to few retrospective studies.

METHODS

This is a single-centre retrospective study of patients with SRDs admitted to an ICU at the Vienna General Hospital between 2012 and 2020. Single-predictor and multiple logistic regression analysis was performed to identify potential outcome determinants.

RESULTS

A total of 144 patients accounting for 192 ICU admissions were included. Connective tissue diseases (CTDs), vasculitides and rheumatoid arthritis were the most common SRDs requiring ICU admission. Leading causes for ICU admission were respiratory failure and shock, as reflected by a high number of patients requiring mechanical ventilation (60.4%) and vasopressor therapy (72.9%). Overall, 29.2% of admissions were due to SRD-related critical illness. In 70.8% patients, co-existent SRD not responsible for the acute critical illness was documented. When comparing these subgroups, CTDs and vasculitides had a higher frequency in the patients with SRD-related critical illness. In a significantly higher proportion of patients in the SRD-related subgroup, diagnosis of SRD was made at the ICU. ICU and 6-month mortality in the overall population was 20.3% and 38.5%, respectively. Age, glucocorticoid therapy prior to hospital admission and disease severity were associated with poor outcome.

CONCLUSIONS

In this study, respiratory failure was the leading cause of ICU admission as reflected by high rates of required mechanical ventilation. Despite considerable severity of critical illness, survival rates were comparable to a general ICU population.

The risk of developing non-Hodgkin lymphoma and the mortality rate in primary Sjögren's syndrome: a single-centre, retrospective cohort study

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease that is manifested by the sensation of dry eyes and dry mouth. The higher incidence of non-Hodgkin lymphoma (NHL) among pSS has already been extensively researched. However, there are uncertanties whether the mortality risk in pSS patients and in pSS patients with NHL is increased. The purpose of this study was to describe the prevalence of NHL among pSS patients and to calculate their mortality risk. We retrospectively analysed data on 1367 patients treated in our rheumatology department under the ICD-10 code M35.0. The study finally recruited 155 patients who met the 2016 ACR/EULAR criteria for the diagnosis of pSS. Descriptive statistics was used in data analysis. We applied the indirect standardization by age to compare the incidence rate of NHL in our cohort to general population. Additionally, we compared the mortality in our study to the general population by calculating the standardized mortality ratio (SMR). The overall incidence rate of NHL was 440 per 100,000 patient-years. The SIR compared to the general population was 30.13 (95% CI 12.87-54.63). The overall mortality rate of pSS patients in our cohort was nearly identical to that of the general population (SMR = 0.98 [95% CI (0.47-1.69)]). This study confirms that there are significant differences in lymphoma prevalence, histology, and prognosis across the studied populations. Furthermore, this study found that patients with pSS have similar mortality risk as the general population, and no patient in our cohort died from NHL.

Nontypeable Hemophilus Influenza Meningitis in a Primary Sjögren's Syndrome Patient on Hydroxychloroquine

Primary Sjögren's syndrome is a multisystem autoimmune disease that less commonly requires immunosuppression compared to other systemic connective tissue diseases and classically has a poorer correlation with increased incidence of infections. Herein, we describe a 61-year-old female without predisposing factors diagnosed with the uncommon nontypeable Hemophilus influenza meningitis complicated by sepsis.

Hospitalizations for infections in primary Sjögren's syndrome patients: a nationwide incidence study

BACKGROUND

Primary Sjögren's syndrome (pSS) is an autoimmune disease with increased risk of infections. Here, we assessed whether pSS patients were at higher risk of hospitalization for community and opportunistic infections.

METHODS

We selected newly hospitalized pSS patients between 2011 and 2018, through a nationwide population-based retrospective study using the French Health insurance database. We compared the incidence of hospitalization for several types of infections (according to International Classification for Disease codes, ICD-10) between pSS patients and an age- and sex-matched (1:10) hospitalized control group. We calculated adjusted Hazard Ratios (aHR, 95% CI) adjusted on socio-economic status, past cardiovascular or lung diseases and blood malignancies factors.

RESULTS

We compared 25 661 pSS patients with 252 543 matched patients. The incidence of hospitalizations for a first community infection was increased in pSS patients [aHR of 1.29 (1.22-1.31), p < .001]. The incidence of hospitalization for bronchopulmonary infections was increased in pSS patients [aHR of 1.50 (1.34-1.69), p < .001, for pneumonia]. Hospitalizations for pyelonephritis and intestinal infections were increased [aHR of 1.55 (1.29-1.87), p < .001 and 1.18 (1.08-1.29), p < .001, respectively]. Among opportunistic infections, only zoster, and mycobacteria infections (tuberculosis and non-tuberculous) were at increased risk of hospitalization [aHR of 3.32 (1.78-6.18), p < .001; 4.35 (1.41-13.5), p = .011 and 2.54 (1.27-5.06), p = .008, respectively].

CONCLUSIONS

pSS patients are at higher risk of hospitalization for infections. The increased risk of hospitalization for mycobacterial infections illustrates the potential bilateral relationship between the two conditions. Vaccination against respiratory pathogens and herpes zoster virus may help prevent some hospitalizations in pSS patients.KEY MESSAGESPrimary Sjögren's syndrome (pSS) increases hospitalization risk for community infections: bronchopulmonary, skin, dental, ear-nose-throat, intestinal infections and pyelonephritis.Hospitalizations for zoster and mycobacterial infections are also increased in this population.Dedicated preventive measures and vaccination campaigns could decrease the burden of infections in pSS patients.