Hospitalized acute patients with fever and severe infection have lower mortality than patients with hypo- or normothermia: a follow-up study

Predictive factors associated with short-term mortality in cats with feline infectious peritonitis treated with remdesivir or GS-441524 or both

BACKGROUND

Although most cats with feline infectious peritonitis (FIP) respond to treatment with remdesivir or GS-441524 or both with uneventful clinical courses, some die despite treatment.

OBJECTIVE

Identify predictive factors associated with short-term mortality in cats with FIP treated with IV remdesivir or PO GS-441524 or both.

ANIMALS

A total of 108 client-owned cats with FIP.

METHODS

Retrospective multicenter study using data collected from medical records. Factors associated with short-term mortality, defined as death within 84 days, were identified. Univariate analysis a t-test, Mann-Whitney U test, or Fisher's exact test and multivariate logistic regression were performed to assess patient characteristics and clinicopathological variables between survivors and nonsurvivors.

RESULTS

The short-term mortality rate was 12.0% (95% confidence interval [CI], 6.6%-19.7%). Univariate analysis identified plasma lactate dehydrogenase activity (LDH; P < .001) and bilirubin concentration (P = .001) as being significantly increased in nonsurvivors, whereas concentrations of albumin (P = .003), total protein (P = .03), sodium (P = .005), and potassium (P = .005) were significantly lower. Additionally, nonsurvivors were significantly less likely to be febrile (≥39.4°C; P = .006). Of these variables, only plasma LDH activity ≥323 U/L, a cut-point determined by receiver operating characteristic curve analysis, was significantly associated with short-term mortality by multivariate analysis (odds ratio, 15.30; 95% CI, 1.18-198.00; P = .04).

CONCLUSION

Increased plasma LDH activity might be useful for predicting short-term mortality, guiding monitoring, and establishing prognosis in cats with FIP.

Recognizing the roles of fever in host survival and in medical intervention in infectious diseases

Fever has roles both in host defense against infectious challenges and in guidance of medical intervention. These roles remain insufficiently acknowledged and considered by both health care providers and patients and their families. This review cites reports in support of both roles and provides recommendations regarding the clinician's approach to fever, as well as points relevant for education of patients and their families.

Let fever do its job: The meaning of fever in the pandemic era

Although fever is one of the main presenting symptoms of COVID-19 infection, little public attention has been given to fever as an evolved defense. Fever, the regulated increase in the body temperature, is part of the evolved systemic reaction to infection known as the acute phase response. The heat of fever augments the performance of immune cells, induces stress on pathogens and infected cells directly, and combines with other stressors to provide a nonspecific immune defense. Observational trials in humans suggest a survival benefit from fever, and randomized trials published before COVID-19 do not support fever reduction in patients with infection. Like public health measures that seem burdensome and excessive, fevers involve costly trade-offs but they can prevent infection from getting out of control. For infections with novel SARS-CoV-2, the precautionary principle applies: unless evidence suggests otherwise, we advise that fever should be allowed to run its course. Lay summary: For COVID-19, many public health organizations have advised treating fever with medicines such as acetaminophen or ibuprofen. Even though this is a common practice, lowering body temperature has not improved survival in laboratory animals or in patients with infections. Blocking fever can be harmful because fever, along with other sickness symptoms, evolved as a defense against infection. Fever works by causing more damage to pathogens and infected cells than it does to healthy cells in the body. During pandemic COVID-19, the benefits of allowing fever to occur probably outweigh its harms, for individuals and for the public at large.

Level of vital and laboratory values on arrival, and increased risk of 7-day mortality among adult patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim of the study was to provide evidence for, at which vital and laboratory values, increased risk of 7-day mortality in acute adult patients on arrival to an emergency department (ED).

DESIGN

A population-based cohort study.

SETTING

ED at Odense University Hospital, Denmark.

PARTICIPANTS

All patients ≥18 years with a first-time contact within the study period, 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 7-day all-cause mortality.Variables were first recorded vital and laboratory values included in risk stratification scores; respiratory frequency, blood pressure, heart rate, Glasgow Coma Scale, temperature, saturation, creatinine, PaO₂, platelet count and bilirubin. The association between values and mortality was described using a restricted cubic spline. A predefined 7-day mortality of 2.5% was chosen as a relevant threshold.

RESULTS

We included 40 423 patients, 52.5% women, median age 57 (IQR 38-74) years and 7-day mortality 2.8%. Seven-day mortality of 2.5% had thresholds of respiratory frequency <12 and >18/min, systolic blood pressure <112 and >192 mm Hg, heart rate <54 and >102 beats/min, temperature <36.0°C and >39.8°C, saturation <97%, Glasgow Coma Scale score <15, creatinine <41 and >98 µmol/L for PaO₂ <9.9 and >12.3 kPa, platelet count <165 and >327×10⁹/L and bilirubin >12 µmol/L.

CONCLUSION

Vital values on arrival, outside the normal ranges for the measures, are indicative of increased risk of short-term mortality, and most of the value thresholds are included in the lowest urgency level in triage and risk stratification scoring systems.

Safety of intraoperative hypothermia for patients: meta-analyses of randomized controlled trials and observational studies

BACKGROUND

Previous studies have shown that intraoperative hypothermia was associated with higher risks of clinical adverse events, but we found otherwise from recent evidences. This study aims to synthesize the existing evidence evaluating safety of intraoperative hypothermia.

METHODS

Articles, reviews, ongoing trials and grey literatures were retrieved from PubMed, The Cochrane Library, Clinical Trails and CNKI (a Chinese national database) till February 2nd, 2019. Both randomized controlled trials and observational studies compared incidences of all sorts of intra- and post-operative consequences between hypothermia and normothermia were included. Researches comparing different warming systems were excluded. We also examined risks of hypothermia using lowered standards (35.5 °C and 35 °C) from a Chinese trial (ChiCTR-IPR-17011099).

RESULTS

A total of 9 RCT studies and 11 observational studies were included. RCT-synthesized results showed that intraoperative hypothermia was associated with higher risks of bleeding (MD = 131.90, 95%CI: 117.42, 146.38), surgical site infection (RD = 0.14, 95%CI: 0.06, 0.21) and shivering (RD = 0.32, 95%CI: 0.06, 0.58) but with no significant differences in duration of surgery, hospital stay or mortality. Observational study-synthesized evidences showed that intraoperative hypothermia did not result in higher risks in any of these adverse events. Results didn't change even if the standard of hypothermia was lowered by 0.5-1.0 °C.

CONCLUSIONS

The study indicates that the synthesized risks resulted by intra-operative hypothermia might be overestimated and the eligibility of 36 °C to define hypothermia is not sensitive enough. Given body-temperature protection has not been popularized in China, it is still critical to normalize the hypothermia prevention at this stage.

The Emperor Has No Clothes? Searching for Dysregulation in Sepsis

The core conception of sepsis—that it is a dysregulated state—is a powerful and durable idea that has inspired decades of research. But is it true that the body’s response to sepsis is dysregulated? To answer that question, this review surveyed the history of trials of experimental sepsis treatments targeting the host response. Sepsis survival is not improved by blocking one or many immune pathways. Similarly, sepsis is resistant to treatment by normalizing one or many physiologic parameters simultaneously. The vast majority of interventions are either ineffective or harmful. With this track record of failure, it is time to consider the alternative hypothesis—regulation instead of dysregulation—and the possibility that sepsis traits are often functional, and that some physiologic alterations in sepsis do more good than harm, while others are neutral. This review discusses the implications of this perspective for the future of sepsis research.

The association between abnormal vital sign groups and undesirable patient outcomes

Introduction:

To determine the association between both abnormal individual vital signs and abnormal vital sign groups in the emergency department, and undesirable patient outcomes: hospital admission, medical emergency team calls and death.

Method:

We undertook a prospective cohort study in a tertiary referral emergency department (February–May 2015). Vital signs were collected prospectively in the emergency department and undesirable outcomes from the medical records. The primary outcomes were undesirable outcomes for individual vital signs (multivariate logistic regression) and vital sign groups (univariate analyses).

Results:

Data from 1438 patients were analysed. Admission was associated with tachycardia, tachypnoea, fever, ≥1 abnormal vital sign on admission to the emergency department, ≥1 abnormal vital sign at any time in the emergency department, a persistently abnormal vital sign, and vital signs consistent with both sepsis (tachycardia/hypotension/abnormal temperature) and pneumonia (tachypnoea/fever) (p < 0.05). Medical emergency team calls were associated with tachycardia, tachypnoea, ≥1 abnormal vital sign on admission (odds ratio: 2.3, 95% confidence interval: 1.4–3.8), ≥2 abnormal vital signs at any time (odds ratio: 2.4, 95% confidence interval: 1.2–4.7), and a persistently abnormal vital sign (odds ratio: 2.7, 95% confidence interval: 1.6–4.6). Death was associated with Glasgow Coma Score ≤13 (odds ratio: 6.3, 95% confidence interval: 2.5–16.0), ≥1 abnormal vital sign on admission (odds ratio: 2.6, 95% confidence interval: 1.2–5.6), ≥2 abnormal vital signs at any time (odds ratio: 6.4, 95% confidence interval: 1.4–29.5), a persistently abnormal vital sign (odds ratio: 4.3, 95% confidence interval: 2.0–9.0), and vital signs consistent with pneumonia (odds ratio: 5.3, 95% confidence interval: 1.9–14.8).

Conclusion:

Abnormal vital sign groups are generally superior to individual vital signs in predicting undesirable outcomes. They could inform best practice management, emergency department disposition, and communication with the patient and family.