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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Yessayan LT, Sharma P, Westover AJ, Szamosfalvi B, Humes HD. Extracorporeal Immunomodulation Therapy in Acute Chronic Liver Failure With Multiorgan Failure: First in Human Use. ASAIO J 2024; 70:e53-e56. [PMID: 37643314 PMCID: PMC10902198 DOI: 10.1097/mat.0000000000002033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Two patients presented with acute on chronic liver failure and multiorgan failure and, as typical for this disorder, they presented with hyperinflammation and anticipated high mortality rates. Both cases were diagnosed with hepatorenal syndrome (HRS). Under a FDA approved Investigational Device Exemption clinical trial, they underwent treatment with an extracorporeal cell-directed immunomodulatory device, called selective cytopheretic device. Both patients showed rapid clinical improvement associated with a decline in elevated blood cytokine concentrations and diminution of activation levels of circulating leukocytes. On follow-up, one patient was alive at day 90 after treatment and undergoing liver transplantation evaluation and the other patient had a successful liver transplantation 6 days after selective cytopheretic device therapy ended. These cases represent the first in human evaluation of extracorporeal cell-directed immunomodulation therapy in acute on chronic liver failure with successful clinical outcomes in a disorder with dismal prognosis.
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Affiliation(s)
- Lenar T Yessayan
- From the Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Weaver JMJ, Cooksley T. Response to: Immune-mediated toxicity leading to organ failure may achieve good outcomes from ICU admission. QJM 2024; 117:84. [PMID: 37471617 DOI: 10.1093/qjmed/hcad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Indexed: 07/22/2023] Open
Affiliation(s)
- J M J Weaver
- Department of Acute Medicine, The Christie, Wilmslow Road, Manchester, UK
- Department of Medical Oncology, The Christie, Wilmslow Road, Manchester, UK
| | - T Cooksley
- Department of Acute Medicine, The Christie, Wilmslow Road, Manchester, UK
- Department of Medical Oncology, The Christie, Wilmslow Road, Manchester, UK
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Wang G, Zhuo N, Liu Z. Immune-mediated toxicity leading to organ failure may achieve good outcomes from ICU admission. QJM 2024; 117:82-83. [PMID: 37471619 DOI: 10.1093/qjmed/hcad178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Indexed: 07/22/2023] Open
Affiliation(s)
- G Wang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - N Zhuo
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410000, China
| | - Z Liu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
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Werdan K, Nuding S, Kühnert D, Kolthoum R, Schott A, Quitter F, Wienke A, Sedding D. Treatment of patients with multiple organ dysfunction syndrome (MODS) with an electromagnetic field coupled to biorhythmically defined impulse configuration: the MicrocircMODS study. Clin Res Cardiol 2024; 113:260-275. [PMID: 37717230 PMCID: PMC10850207 DOI: 10.1007/s00392-023-02293-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND To potentially improve impaired vasomotion of patients with multiple organ dysfunction syndrome (MODS), we tested whether an electromagnetic field of low flux density coupled with a biorhythmically defined impulse configuration (Physical Vascular Therapy BEMER®, PVT), in addition to standard care, is safe and feasible and might improve disturbed microcirculatory blood flow and thereby improve global haemodynamics. METHODS In a prospective, monocentric, one-arm pilot study, 10 MODS patients (APACHE II score 20-35) were included. Patients were treated, in addition to standard care, for 4 days with PVT (3 treatment periods of 8 min each day; day 1: field intensity 10.5 μT; day 2:14 μT, day 3:17.5 μT; day 4:21.0 μT). Primary endpoint was the effect of PVT on sublingual microcirculatory perfusion, documented by microvascular flow index (MFI). Patient safety, adverse events, and outcomes were documented. RESULTS An increase in MFI by approximately 25% paralleled 4-day PVT, with the increase starting immediately after the first PVT and lasting over the total 4-day treatment period. Concerning global haemodynamics (secondary endpoints), halving vasopressor use within 24 h, and haemodynamic stabilisation paralleled 4-day PVT with an increase in cardiac index, stroke volume index, and cardiac power index by 30%-50%. No adverse events (AEs) or serious adverse events (SAEs) were classified as causally related to the medical product (PVT) or study. Three patients died within 28 days and one patient between 28 and 180 days. CONCLUSION PVT treatment was feasible and safe and could be performed without obstruction of standard patient care. An increase in microcirculatory blood flow, a rapid reduction in vasopressor use, and an improvement in global haemodynamics paralleled PVT treatment. Findings of this pilot study allowed forming a concept for a randomized trial for further proof.
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Affiliation(s)
- Karl Werdan
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany.
| | - Sebastian Nuding
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
- Hospital St. Elisabeth and St. Barbara, 06110, Halle (Saale), Germany
| | - Diethelm Kühnert
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
- , 04838, Zschepplin, Germany
| | - Ramzi Kolthoum
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
| | - Artjom Schott
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
| | | | - Andreas Wienke
- Institute of Medical Epidemiology, Biometry and Computer Science, Martin-Luther-University Halle-Wittenberg, Magdeburger Strasse 8, 06112, Halle (Saale), Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
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Kuklin V, Sovershaev M, Bjerner J, Keith P, Scott LK, Thomas OMT, Szpirt W, Rock G, Stegmayr B. Influence of therapeutic plasma exchange treatment on short-term mortality of critically ill adult patients with sepsis-induced organ dysfunction: a systematic review and meta-analysis. Crit Care 2024; 28:12. [PMID: 38178170 PMCID: PMC10768220 DOI: 10.1186/s13054-023-04795-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/29/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION The impact of therapeutic plasma exchange (TPE) on short-term mortality in adult patients with sepsis-induced organ dysfunction remains uncertain. The objective of the study is to assess the effect of adjunct TPE in this setting through a comprehensive literature review. METHODS The National Library of Medicine's Medline, Ovid (Embase), the Cochrane Library database and clinicaltrial.gov from January 01, 1966, until October 01, 2022, were searched for terms: therapeutic plasma exchange, plasmapheresis, sepsis, and septic shock. We reviewed, selected and extracted data from relevant randomized clinical trials (RCTs) and matched cohort studies (MCSs) comparing short-term mortality in critically ill adult septic patients treated with standard therapy versus those receiving adjunct TPE. Risk of bias was assessed in the RCTs using Cochrane Collaboration tool and in MCSs using ROBINS-I tool. Summary statistics, risk ratios (RRs), and confidence intervals (CIs) were calculated using random effects model. RESULTS This systematic review included 937 adult critically ill septic patients from five RCTs (n = 367) and fifteen MCSs (n = 570). Of these total, 543 received treatment with TPE in addition to standard care. The meta-analysis includes all five RCTs and only six MCSs (n = 627). The adjunct TPE treatment (n = 300) showed a significant reduction in short-term mortality (RR 0.59, 95% CI 0.47-0.74, I2 3%) compared to standard therapy alone (n = 327). The systematic review of all 20 trials revealed that adding TPE to the standard therapy of critically ill septic patients resulted in faster clinical and/or laboratory recovery. CONCLUSIONS Our comprehensive and up-to-date review demonstrates that adjunct TPE may provide potential survival benefits when compared to standard care for critically ill adult patients with sepsis-induced organ dysfunction. While results of this meta-analysis are encouraging, large well-designed randomized trials are required to identify the optimal patient population and TPE procedure characteristics prior to widespread adoption into practice.
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Affiliation(s)
- Vladimir Kuklin
- Department of Anaesthesiology and Intensive Care Medicine, Ahus University Hospital, Sykehusveien, 25, 1478, Lorenskog, Norway.
| | | | | | - Philip Keith
- Critical Care Medicine, Lexington Medical Center, West Columbia, SC, USA
| | - L Keith Scott
- Division of Trauma and Surgical Critical Care, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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Sarma D, Jentzer JC. Cardiogenic Shock: Pathogenesis, Classification, and Management. Crit Care Clin 2024; 40:37-56. [PMID: 37973356 DOI: 10.1016/j.ccc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Timershin AG, Kreshchenok DV, Konovalov SA, Mironov PI. [Prolonged spinal and sacral neurostimulation in children with pelvic organ dysfunction: preliminary analysis]. Zh Vopr Neirokhir Im N N Burdenko 2024; 88:31-38. [PMID: 38549408 DOI: 10.17116/neiro20248802131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To evaluate the clinical efficacy of long-term spinal and sacral programmable neurostimulation for pelvic organ dysfunction in patients with myelodysplasia and chronic dysfunction of the bladder and rectum. MATERIAL AND METHODS A retrospective study included 32 children aged 1-17 years (mean 10.7) with myelodysplasia, pelvic organ dysfunction and ineffective therapy including botulinum therapy and exclusion of tethered spinal cord syndrome. All children underwent comprehensive urodynamic examination with analysis of bladder and residual urine volume, mean flow rate, intravesical pressure and total urine volume, as well as electromyographic examination. Examination was carried out before surgery, after 6, 12 and 36 months. We applied urinary diary, NBSS questionnaire and urodynamic examination data. All patients underwent neurological examinations (neurological status, magnetic resonance imaging of the spinal cord, computed tomography and radiography of the spine, electroneuromyography). The study was conducted at the neurosurgical department of the Republican Children's Clinical Hospital in Ufa between 2014 and 2022. There were 32 implantations of epidural neurostimulators for pelvic organ dysfunctions. RESULTS Patients used epidural spinal and sacral stimulation up to 6 times a day for 10-15 min turning on the pulse generator. This method significantly increased urinary volume, decreased episodes of urinary leakage and fecal incontinence, residual volume after urination and number of periodic catheterizations compared to baseline data. Sixteen patients were very satisfied, 10 ones were moderately satisfied, and 2 patients were not satisfied with therapy. The number of bladder catheterizations per day decreased by 51.1%. Urine volume significantly increased from 131.5±16.1 to 236±16.7 ml, intravesical pressure decreased from 23.5±4.2 to 18.5±2.1 cm H2O (by 20.3%). CONCLUSION Chronic epidural spinal and sacral stimulation can improve the quality of life in patients with pelvic organ dysfunction. This technique may be effective for pelvic organ dysfunction caused by myelodysplasia.
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Affiliation(s)
- A G Timershin
- Republican Children's Clinical Hospital, Ufa, Russia
- Bashkir State Medical University, Ufa, Russia
| | | | - S A Konovalov
- Republican Children's Clinical Hospital, Ufa, Russia
| | - P I Mironov
- Bashkir State Medical University, Ufa, Russia
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Chen QT, Chen MH, Lin YK, Yeh RH, Lu CC, Hsiao PJ, Sung YF. Case report: Hemophagocytic lymphohistiocytosis complicated by multiple organ dysfunction syndrome following aseptic encephalitis. Front Immunol 2023; 14:1296575. [PMID: 38193074 PMCID: PMC10773876 DOI: 10.3389/fimmu.2023.1296575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially life-threatening condition caused by excessive immune activation. Secondary HLH is usually triggered by infection, most often from viral infection or malignancy. Here, we present a case of secondary HLH, complicated by multiple organ dysfunction syndrome triggered by critical aseptic encephalitis. A 27-year-old man without any underlying disease presented to our hospital with fever, disturbance of consciousness, and generalized seizures. The patient was diagnosed with aseptic encephalitis with super-refractory status epilepticus. Although antiseizure medications and immunoglobulins were administered, the patient developed multiple organ dysfunction syndrome. HLH was later diagnosed based on hypertriglyceridemia, hyperferritinemia, splenomegaly, cytopenia, and phagocytosis of nucleated cells, as shown by a blood smear of bone marrow aspiration. Treatment with pulse steroid therapy and plasmapheresis was initiated rather than chemotherapy because of the patient's critical condition. However, the patient died of profound shock and multiple organ failure. Diagnosis of HLH is challenging in patients with severe infections because of similar clinical manifestations and laboratory findings. The early recognition of HLH provides patients with the opportunity to receive appropriate treatment, which can lead to increased survival and remission rates.
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Affiliation(s)
- Quan-Ting Chen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Ming-Hua Chen
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yu-Kai Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ren-Hua Yeh
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Chi Lu
- Division of Rheumatology/Immunology and Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Hsiao
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Yueh-Feng Sung
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Langeslag J, Onland W, Visser D, Groenendaal F, de Vries L, van Kaam AH, de Haan TR. Predictive performance of multiple organ dysfunction in asphyxiated newborns treated with therapeutic hypothermia on 24-month outcome: a cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 109:41-45. [PMID: 37369599 DOI: 10.1136/archdischild-2023-325585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Perinatal asphyxia may be followed by multiple organ dysfunction (MOD) and is often included in prognostication of the individual patient, but evidence of discriminating accuracy is lacking. The aim of this study was to assess whether MOD in asphyxiated neonates during therapeutic hypothermia (TH) predicts mortality or neurodevelopmental impairment (NDI) at 24 months of age and which peripartum variables are associated with the onset of MOD. METHODS A retrospective analysis of a prospective cohort study of asphyxiated newborns undergoing TH was performed. MOD was defined as dysfunction of the brain (encephalopathy) combined with two or more organ systems. Outcome was routinely assessed by standardised developmental testing at the age of 24 months. The predictive accuracy of MOD on the combined outcome and its components (death and NDI) was expressed as areas under the receiver operating characteristic curves (AUROCs). The associations of peripartum variables and development of MOD were expressed as ORs and their CIs. RESULTS 189 infants (median gestation 40 (range 36-42 weeks) with moderate to severe hypoxic ischaemic encephalopathy were included. 47% developed MOD. The prediction of the combined 24-month outcome or its components showed AUROCs <0.70. Associated with MOD were pH at birth (OR 0.97, CI 0.95 to 0.99), lactate at birth (OR 1.09, CI 1.04 to 1.15), Base Excess (BE) at birth (OR 0.94, CI 0.90 to 0.99) and epinephrine administration during resuscitation (OR 2.09, CI 1.02 to 4.40). CONCLUSION MOD has a low discriminating accuracy in predicting mortality or NDI at 24 months age and might not be useful for prognostication. Signs of acid-base disturbance and adrenalin use at birth are associated with the development of MOD.
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Affiliation(s)
- Juliette Langeslag
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Douwe Visser
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Whilhelmina Children's Hospital, University Medical Center Utrecht, and Brain Center, Utrecht, The Netherlands
| | - Linda de Vries
- Department of Neonatology, Whilhelmina Children's Hospital, University Medical Center Utrecht, and Brain Center, Utrecht, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - T R de Haan
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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Jiang Z, Luo F, Liu Y, Sun X, Tan G, Chen Z, Chen Y. RESTRICTIVE FLUID RESUSCITATION IN SEPTIC SHOCK PATIENTS HAS LOWER MORTALITY AND ORGAN DYSFUNCTION RATES THAN STANDARD THERAPY. Shock 2023; 60:739-745. [PMID: 37962948 DOI: 10.1097/shk.0000000000002235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
ABSTRACT Background : The influence of restrictive fluid resuscitation and the early administration of vasopressors on the clinical outcomes in patients with septic shock are not fully understood. The purpose of this study was to evaluate the effects of restrictive fluid management on mortality and organ dysfunction in patients with septic shock. Methods : This study included consecutive patients with septic shock in need of fluid resuscitation. Based on the fluid management provided in the initial resuscitation phase, a comparison was made between a restrictive group and a standard fluid management group. The primary outcome was in-hospital death, whereas secondary outcomes included organ dysfunction and other adverse events. Results : A total of 238 patients were included in this study. Restrictive fluid management was administered to 59.2% of patients, whereas 40.8% received standard fluid management. Restrictive resuscitation was associated with a lower in-hospital mortality rate (24.8% vs. 52.6%), as well as a shorter median intensive care unit stay (8.0 vs. 11.0 days). The restrictive strategy was associated with a significantly lower prevalence of new-onset acute kidney injury (25.5% vs. 51.5%) and a decrease in the incidence of renal replacement therapy (20.6% vs. 40.2%). The standard group had a higher risk of the need for mechanical ventilation and a significantly lower median number of days without a ventilator than the restrictive group. The median duration of vasopressor-free days in the restrictive group was significantly longer than that in the standard group (25.0 vs. 18.0). The administration rate of inotropes in the restrictive group was significantly lower than that in the standard group. A multivariate logistic regression model showed that restrictive fluid management (odds ratio [OR], 0.312; 95% confidence interval [CI], 0.098-0.994) and vasopressor-free days (OR, 0.807; 95% CI, 0.765-0.851) protect against in-hospital death, whereas Acute Physiology and Chronic Health Evaluation II scores (OR, 1.121; 95% CI, 1.018-1.234) were independent risk factors for in-hospital death. Conclusions : Restrictive fluid resuscitation and early vasopressor protocol in patients with septic shock are associated with better outcomes, indicating that this regimen is feasible and safe.
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Affiliation(s)
- Zhizhao Jiang
- Department of Intensive Care Unit, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
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Johnson AK, McCurdy VJ, Gray-Edwards HL, Maguire AS, Cochran JN, Gross AL, Skinner HE, Randle AN, Shirley JL, Brunson BL, Bradbury AM, Leroy SG, Hwang M, Rockwell HE, Cox NR, Baker HJ, Seyfried TN, Sena-Esteves M, Martin DR. Life-Limiting Peripheral Organ Dysfunction in Feline Sandhoff Disease Emerges after Effective CNS Gene Therapy. Ann Neurol 2023; 94:969-986. [PMID: 37526361 DOI: 10.1002/ana.26756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 05/15/2023] [Accepted: 07/27/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE GM2 gangliosidosis is usually fatal by 5 years of age in its 2 major subtypes, Tay-Sachs and Sandhoff disease. First reported in 1881, GM2 gangliosidosis has no effective treatment today, and children succumb to the disease after a protracted neurodegenerative course and semi-vegetative state. This study seeks to further develop adeno-associated virus (AAV) gene therapy for human translation. METHODS Cats with Sandhoff disease were treated by intracranial injection of vectors expressing feline β-N-acetylhexosaminidase, the enzyme deficient in GM2 gangliosidosis. RESULTS Hexosaminidase activity throughout the brain and spinal cord was above normal after treatment, with highest activities at the injection sites (thalamus and deep cerebellar nuclei). Ganglioside storage was reduced throughout the brain and spinal cord, with near complete clearance in many regions. While untreated cats with Sandhoff disease lived for 4.4 ± 0.6 months, AAV-treated cats lived to 19.1 ± 8.6 months, and 3 of 9 cats lived >21 months. Correction of the central nervous system was so effective that significant increases in lifespan led to the emergence of otherwise subclinical peripheral disease, including megacolon, enlarged stomach and urinary bladder, soft tissue spinal cord compression, and patellar luxation. Throughout the gastrointestinal tract, neurons of the myenteric and submucosal plexuses developed profound pathology, demonstrating that the enteric nervous system was inadequately treated. INTERPRETATION The vector formulation in the current study effectively treats neuropathology in feline Sandhoff disease, but whole-body targeting will be an important consideration in next-generation approaches. ANN NEUROL 2023;94:969-986.
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Affiliation(s)
- Aime K Johnson
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Victoria J McCurdy
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Anatomy, Physiology & Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Heather L Gray-Edwards
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Anne S Maguire
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Anatomy, Physiology & Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - J Nicholas Cochran
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Amanda L Gross
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Anatomy, Physiology & Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Haleigh E Skinner
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Ashley N Randle
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Jamie L Shirley
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Brandon L Brunson
- Department of Anatomy, Physiology & Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Allison M Bradbury
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Anatomy, Physiology & Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Stanley G Leroy
- Department of Neurology and Gene Therapy Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Misako Hwang
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Hannah E Rockwell
- Biology Department, Boston College, Chestnut Hill, Massachusetts, USA
| | - Nancy R Cox
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Henry J Baker
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Pathobiology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Thomas N Seyfried
- Biology Department, Boston College, Chestnut Hill, Massachusetts, USA
| | - Miguel Sena-Esteves
- Department of Neurology and Gene Therapy Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Douglas R Martin
- Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
- Department of Anatomy, Physiology & Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
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14
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Shen Y, Wang X, Yao Y, Zhou X. Acute fatty liver of pregnancy causing multiple organ dysfunction syndrome in a Chinese intensive care unit. Nurs Crit Care 2023; 28:1170-1175. [PMID: 37114863 DOI: 10.1111/nicc.12916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023]
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare but severe condition associated with high rates of maternal and foetal morbidity and mortality. Timely discontinuation of pregnancy, professional supervision and appropriate management are helpful for a successful discharge. This article reports the presentation and nursing care of a pregnant woman who was diagnosed with AFLP and discharged from the intensive care unit (ICU) after a prolonged hospitalization. The patient was admitted to the ICU on the first day after a caesarean section, with deterioration of liver, kidney and coagulation function. On day 1 of ICU admission, she underwent transnasal high-flow oxygen therapy. Owing to worsening respiratory status and oxygen saturation <85%, the patient was intubated on day 3 in the ICU. Her urine output decreased significantly, her bilirubin level progressively increased, and she was treated with bilirubin adsorption and haemodialysis. Multiple organ dysfunction syndrome occurred, along with many other complications, including subarachnoid haemorrhage and lower extremity venous thrombosis. The patient was finally extubated on day 7, and haemodialysis was discontinued on day 42, with a daily urine output of approximately 2000 mL. The patient was discharged from the ICU 43 days after admission. Treatment and care activities under qualified nursing care, including managing haemorrhage and anticoagulation in haemodialysis, pain care based on psychological support, early rehabilitation and nutrition and providing appropriate care for respiratory support, contributed to the successful discharge of the patient from the ICU. During the patient's 43-day stay in the ICU, strict monitoring and personalized nursing care were implemented.
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Affiliation(s)
- Yan Shen
- Department of Nursing, Shanghai General Hospital, Shanghai, China
| | - Xujuan Wang
- Department of Nursing, Shanghai General Hospital, Shanghai, China
| | - Yeying Yao
- Department of Nursing, Shanghai General Hospital, Shanghai, China
| | - Xingmei Zhou
- Department of Nursing, Shanghai General Hospital, Shanghai, China
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15
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Abdelhay A, Mahmoud A, Mostafa M, Jain T, Elseidy S, Fahmawi S, Alkasem M, Ammari O. Delay in treatment of adult hemophagocytic lymphohistiocytosis is associated with worse in-hospital outcomes. Ann Hematol 2023; 102:2989-2996. [PMID: 37392369 DOI: 10.1007/s00277-023-05271-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/09/2023] [Indexed: 07/03/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by uncontrolled activation of the immune system leading to multiorgan failure. Timely initiation of HLH-specific treatment is believed to be essential and lifesaving. Due to the rarity of the condition in adults, there is no data available in the literature to investigate the effects of treatment delay in this age group. We used data from the National Inpatient Sample (NIS) to evaluate the inpatient practices of HLH treatment initiation over 13 years (2007-2019) and their association with clinically relevant inpatient outcomes. Patients were divided into early treatment group (<6 days) and late treatment group (≥ 6 days). We compared outcomes using multivariate logistic regression models adjusting for age, sex, race, and HLH-triggering conditions. There were 1327 and 1382 hospitalizations in the early and late treatment groups, respectively. Hospitalization in the late treatment group had higher rates of in-hospital mortality (OR 2.00 [1.65-2.43]), circulatory shock (OR 1.33 [1.09-1.63]), requiring mechanical ventilation (OR 1.41 [1.18-1.69]), venous thromboembolism (OR 1.70 [1.27-2.26]), infectious complications (OR 2.24 [1.90-2.64]), acute kidney injury (OR 2.27 [1.92-2.68]), and requiring new hemodialysis (OR 1.45 [1.17-1.81]). Additionally, we observed no significant trend in the mean time to treatment over the study period. This study shows the importance of early initiation of HLH treatment and highlights the adverse outcomes of treatment delay.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA.
| | - Amir Mahmoud
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Mariam Mostafa
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Tripti Jain
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Sheref Elseidy
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Suhib Fahmawi
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Mouaz Alkasem
- School of Medicine, University of Jordan, Amman, Jordan
| | - Omar Ammari
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
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16
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Hao S, Huang H, Ma RY, Zeng X, Duan CY. Multifaceted functions of Drp1 in hypoxia/ischemia-induced mitochondrial quality imbalance: from regulatory mechanism to targeted therapeutic strategy. Mil Med Res 2023; 10:46. [PMID: 37833768 PMCID: PMC10571487 DOI: 10.1186/s40779-023-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Hypoxic-ischemic injury is a common pathological dysfunction in clinical settings. Mitochondria are sensitive organelles that are readily damaged following ischemia and hypoxia. Dynamin-related protein 1 (Drp1) regulates mitochondrial quality and cellular functions via its oligomeric changes and multiple modifications, which plays a role in mediating the induction of multiple organ damage during hypoxic-ischemic injury. However, there is active controversy and gaps in knowledge regarding the modification, protein interaction, and functions of Drp1, which both hinder and promote development of Drp1 as a novel therapeutic target. Here, we summarize recent findings on the oligomeric changes, modification types, and protein interactions of Drp1 in various hypoxic-ischemic diseases, as well as the Drp1-mediated regulation of mitochondrial quality and cell functions following ischemia and hypoxia. Additionally, potential clinical translation prospects for targeting Drp1 are discussed. This review provides new ideas and targets for proactive interventions on multiple organ damage induced by various hypoxic-ischemic diseases.
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Affiliation(s)
- Shuai Hao
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002 China
| | - He Huang
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
| | - Rui-Yan Ma
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, 400037 China
| | - Xue Zeng
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
- Institute for Brain Science and Disease, Chongqing Medical University, Chongqing, 400010 China
| | - Chen-Yang Duan
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
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Eltahir M, Chaudhry H, Ibrahim EA, Mokhtar M, Jaouni H, Hassan IF, El-Menyar A, Shehatta AL. Thyroid Storm-Induced Refractory Multiorgan Failure Managed by Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case-Series. Am J Case Rep 2023; 24:e940672. [PMID: 37614021 PMCID: PMC10461322 DOI: 10.12659/ajcr.940672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/17/2023] [Accepted: 06/22/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Severe hyperthyroidism, including thyroid storm, can be precipitated by acute events, such as surgery, trauma, infection, medications, parturition, and noncompliance or stoppage of antithyroid drugs. Thyroid storm is one of the serious endocrinal emergencies that prompts early diagnosis and treatment. Early occurrence of multiorgan failure is an ominous sign that requires aggressive treatment, including the initiation of extracorporeal membrane oxygenation (ECMO) support as a bridge to stability and definitive surgical treatment. Most adverse events occur after failure of medical therapy. CASE REPORT We described 4 cases of fulminating thyroid storm that were complicated with multiple organ failure and cardiac arrest. The patients, 3 female and 1 male, were between 39 and 46 years old. All patients underwent ECMO support, with planned thyroidectomy. Three survived to discharge and 1 died after prolonged cardiac arrest and sepsis. All patients underwent peripheral, percutaneous, intensivist-led cannulation for VA-ECMO with no complications. CONCLUSIONS Early recognition of thyroid storm, identification of the cause, and proper treatment and support in the intensive care unit is essential. Patients with thyroid storm and cardiovascular collapse, who failed to improve with conventional supportive measures, had the worst prognosis, and ECMO support should be considered as a bridge until the effective therapy takes effect. Our case series showed that, in patients with life-threatening thyroid storm, VA-ECMO can be used as bridge to stabilization, definitive surgical intervention, and postoperative endocrine management. Interprofessional team management is essential, and early implantation of VA-ECMO is likely beneficial in patients with thyroid storm after failure of conventional management.
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Affiliation(s)
- Mugahid Eltahir
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hamza Chaudhry
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ezzeddin Abdulsalam Ibrahim
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Marwa Mokhtar
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hani Jaouni
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
- Department of Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Labib Shehatta
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
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18
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Cutuli SL, De Rosa S, Ferrer R, Ruiz-Rodriguez JC, Forfori F, Ronco C, Antonelli M. Endotoxin activity trend and multi-organ dysfunction in critically ill patients with septic shock, who received Polymyxin-B hemadsorption: A multicenter, prospective, observational study. Artif Organs 2023; 47:1361-1370. [PMID: 37767775 DOI: 10.1111/aor.14534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The baseline endotoxin activity (EAT0) may predict the outcome of critically ill septic patients who receive Polymyxin-B hemadsorption (PMX-HA), however, the clinical implications of specific EA trends remain unknown. METHODS Subgroup analysis of the prospective, multicenter, observational study EUPHAS2. We included 50 critically ill patients with septic shock and EAT0 ≥ 0.6, who received PMX-HA. The primary outcome of the study was the EA and SOFA score progression from T0 to 120 h afterwards (T120). Secondary outcomes included the EA and SOFA score progression in whom had EA at 48 h (EAT48) < 0.6 (EA responders, EA-R) versus who had not (EA non-responders, EA-NR). RESULTS Septic shock was mainly caused by 27 abdominal (54%) and 17 pulmonary (34%) infections, predominantly due to Gram negative bacteria (39 patients, 78%). The SAPS II score was 67.5 [52.8-82.3] and predicted a mortality rate of 75%. Between T0 and T120, the EA decreased (p < 0.001), while the SOFA score and the Inotropic Score (IS) improved (p < 0.001). In comparison with EA-NR (18 patients, 47%), the EA-R group (23 patients, 53%) showed faster IS improvement and lower requirement of continuous renal replacement therapy (CRRT) during the ICU stay. Overall hospital mortality occurred in 18 patients (36%). CONCLUSIONS In critically ill patients with septic shock and EAT0 ≥ 0.6 who received PMX-HA, EA decreased and SOFA score improved over 120 h. In whom high EA resolved within 48 h, IS improvement was faster and CRRT requirement was lower compared with patients with EAT48 ≥ 0.6.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, SODIR Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodriguez
- Intensive Care Department, Vall d'Hebron University Hospital, SODIR Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Francesco Forfori
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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Stahl K, Bode C, David S. Bridging patients with acute-on-chronic liver failure for transplantation: plasma exchange to stabilize multiorgan failure? Intensive Care Med 2023; 49:890-891. [PMID: 37178148 PMCID: PMC10354101 DOI: 10.1007/s00134-023-07092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg Straße 1, 30163, Hannover, Germany.
| | - Christian Bode
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Nephrology, Hannover Medical School, Hannover, Germany
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20
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De Rosa S, Cutuli SL, Lorenzin A, Zanella M. Sequential Extracorporeal Therapy in Sepsis. Contrib Nephrol 2023; 200:149-159. [PMID: 37290408 DOI: 10.1159/000527573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/16/2022] [Indexed: 06/10/2023]
Abstract
Sepsis is a life-threatening syndrome initiated by a dysregulated host response to infection. Maladaptive inflammatory burst damages host tissues and causes organ dysfunction, the burden of which has been demonstrated as the paramount predictor of worse clinical outcomes. In this setting, septic shock represents the most lethal complication of sepsis and implies profound alterations of both the cardiovascular system and cellular metabolism with consequent high mortality rate. Although an increasing amount of evidence attempts to characterize this clinical condition, the complexity of multiple interconnections between underlying pathophysiological pathways requires further investigations. Accordingly, most therapeutic interventions remain purely supportive and should be integrated in light of the continuous organ cross-talk, in order to match a patient's specific needs. In this context, different organ supports may be combined to replace multiple organ dysfunctions through the application of sequential extracorporeal therapy in sepsis (SETS). In this chapter, we provide an overview of sepsis-induced organ dysfunction, focusing on the pathophysiological pathways that are triggered by endotoxin. Based on the need to apply specific blood purification techniques in specific time windows with different targets, we suggest a sequence of extracorporeal therapies. Accordingly, we reported the hypothesis that sepsis-induced organ dysfunction may benefit the most from SETS. Finally, we point out basic principles of this innovative approach and describe a multifunctional platform that allows SETS, in order to make clinicians aware of this new therapeutic frontier for critically ill patients.
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Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione - UOC di Anestesia, Rianimazione, Terapia Intensiva e Tossicologia Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Monica Zanella
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
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21
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Regiroli G, Loi B, Pezza L, Sartorius V, Foti A, Barra PF, Centorrino R, Di Nardo M, De Luca D. Continuous Venovenous Hemofiltration Performed by Neonatologists With Cardio-Renal Pediatric Dialysis Emergency Machine to Treat Fluid Overload During Multiple Organ Dysfunction Syndrome: A Case Series. Pediatr Crit Care Med 2023; 24:e196-e201. [PMID: 36728157 DOI: 10.1097/pcc.0000000000003177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES A new device is available for neonates needing extracorporeal renal replacement therapy. We reviewed the use of this device (in continuous venovenous hemofiltration [CVVH] mode) in term or preterm neonates affected by multiple organ dysfunction syndrome (MODS) with fluid overload. DESIGN Case series. SETTING Academic specialized referral neonatal ICU (NICU) with expertise on advanced life support and monitoring. PATIENTS Neonates with MODS and fluid overload despite conventional treatments and receiving at least one CVVH session. INTERVENTION CVVH with the Cardio-Renal Pediatric Dialysis Emergency Machine. MEASUREMENTS AND MAIN RESULTS Ten (three preterm) neonates were treated using 18 consecutive CVVH sessions. All patients were in life-threatening conditions and successfully completed the CVVH treatments, which almost always lasted 24 hr/session, without major side effects. Three neonates survived and were successfully discharged from hospital with normal follow-up. CVVH reduced fluid overload (before versus after represented as a weight percentage: 23.5% [12-34%] vs 14.6% [8.2-24.1%]; p = 0.006) and lactate (before versus after: 4.6 [2.9-12.1] vs 2.9 mmol/L [2.3-5.5 mmol/L]; p = 0.001). CVVH also improved the Pa o2 to Fio2 (before vs after: 188 mm Hg [118-253 mm Hg] vs 240 mm Hg [161-309 mm Hg]; p = 0.003) and oxygenation index (before vs after: 5.9 [3.8-14.6] vs 4 [2.9-11]; p = 0.002). The average cost of CVVH in these patients was minor (≈3%) in comparison with the median total cost of NICU care per patient. CONCLUSIONS We have provided CVVH to critically ill term and preterm neonates with MODS. CVVH improved fluid overload and oxygenation. The cost of CVVH was minimal compared with the overall cost of neonatal intensive care.
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Affiliation(s)
- Giulia Regiroli
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Barbara Loi
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Lucilla Pezza
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Victor Sartorius
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Anna Foti
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Pasquale Fabio Barra
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children Hospital-IRCCS, Rome, Italy
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
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22
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Nakip ÖS, Kesici S, Terzi K, Orhan D, Bayrakcı B. Fatal thrombotic microangiopathy in an infant with COVID-19: a case report. Turk J Pediatr 2023; 65:667-671. [PMID: 37661682 DOI: 10.24953/turkjped.2022.1150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
BACKGROUND While macrovascular thrombosis is common in adult COVID-19 patients, thrombotic microangiopathy as a part of endothelitis might play an important role in severe organ dysfunction. Thrombocytopenia-associated multiple organ failure (TAMOF) is a thrombotic microangiopathy syndrome that is associated with endothelial damage. Herein, we aim to report a pediatric TAMOF case related to SARS-CoV-2 infection which has been scarcely reported to date. CASE A 7-month-old boy who became severely ill after being infected with SARS-CoV-2 required advanced critical care treatments such as continuous renal replacement therapy, therapeutic plasma exchange, and extracorporeal membrane oxygenation. A heart and lung biopsy obtained during sternotomy showed thrombotic microangiopathy. Despite early plasma exchange, mortality was inevitable because of severe liver failure. CONCLUSIONS This case report implies that SARS-CoV-2 infection could cause TAMOF in children. To the best of our knowledge, this is the second SARS-CoV-2-induced pediatric TAMOF case. More studies are needed to determine alternative treatments for patients with TAMOF who are resistant to conventional therapies.
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Affiliation(s)
- Özlem Sarıtaş Nakip
- Department of Pediatric Critical Care Medicine, Life Support Center, Hacettepe University Faculty of Medicine, Ankara
| | - Selman Kesici
- Department of Pediatric Critical Care Medicine, Life Support Center, Hacettepe University Faculty of Medicine, Ankara
| | - Kıvanç Terzi
- Department of Pediatric Critical Care Medicine, Life Support Center, Hacettepe University Faculty of Medicine, Ankara
| | - Diclehan Orhan
- Department of Pediatric Pathology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Benan Bayrakcı
- Department of Pediatric Critical Care Medicine, Life Support Center, Hacettepe University Faculty of Medicine, Ankara
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Weber AL, Pape T, Zender S, Seeliger B, Schmidt JJ, Busch M, Rath AK, Schneider A, Schmidt BMW, Fuge J, Wedemeyer H, David S, Stahl K. Therapeutic plasma exchange in patients with acute pancreatitis associated refractory shock and multi-organ failure. J Crit Care 2022; 72:154139. [PMID: 36027817 DOI: 10.1016/j.jcrc.2022.154139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Anna-Lena Weber
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Thorben Pape
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Steffen Zender
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany.
| | - Julius J Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Ann-Kathrin Rath
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.
| | - Jan Fuge
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany.
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
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Abstract
Sepsis is a clinical syndrome manifested by a dysregulation of the immune system triggered by an infection. The severity of illness is variable, which can include mild symptoms with no organ dysfunction to severe symptoms and multiorgan failure, eventually leading to death. Advances in bioinformatics have elucidated distinct sepsis endotypes and have allowed for a better understanding of the pathophysiologic mechanisms. As we learn more about these sepsis endotypes, more precise therapies will emerge for use as adjuncts to antibiotics. [Pediatr Ann. 2022;51(10):e387-e389.].
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Yamashita J, Nosaka T, Takahashi K, Naito T, Ofuji K, Matsuda H, Ohtani M, Hiramatsu K, Kobayashi M, Nakamoto Y. Cholesterol crystal embolism in multiple organs after transarterial chemoembolization for hepatocellular carcinoma: An autopsy case report. Medicine (Baltimore) 2022; 101:e30769. [PMID: 36181036 PMCID: PMC9524960 DOI: 10.1097/md.0000000000030769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) rarely causes cholesterol crystal embolism (CCE). In our case, the histological findings suggested that the onset of CCE occurred at different time points in different organs. PATIENT CONCERNS A 72-year-old Japanese woman with HCC underwent TACE. After TACE, serum creatinine level and eosinophil count gradually increased. Three months later, she was admitted to our department with a fever and back pain. DIAGNOSIS Laboratory examinations showed sepsis with disseminated intravascular coagulation. She was treated with antimicrobial agents and anticoagulants, but died of multiple organ failure. INTERVENTIONS An autopsy was performed to examine the cause of multiple organ failure after 3 months of TACE. OUTCOMES A mixture of both chronic phase emboli with intimal thickening and fibrosis and acute phase emboli with inflammatory cell infiltration were observed in the small intestine. Moreover, multiple intravascular cholesterol fissures were observed in the kidney, stomach, duodenum, colon, pancreas, and spleen, which were the vascular dominant organs of the celiac artery and superior mesenteric artery. These histological findings suggested that cholesterol crystals were continuously disseminated after TACE. LESSONS TACE for HCC may cause progressive CCE and damage in multiple organs. When progressive renal dysfunction, eosinophilia, or multiple organ dysfunction is observed after TACE, the CCE should be suspected.
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Affiliation(s)
- Junki Yamashita
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Takuto Nosaka
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kazuto Takahashi
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tatsushi Naito
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kazuya Ofuji
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hidetaka Matsuda
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masahiro Ohtani
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Katsushi Hiramatsu
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Motohiro Kobayashi
- Department of Tumor Pathology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
- *Correspondence: Yasunari Nakamoto, Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan (e-mail: )
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26
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Pappalardo F, Sanfilippo F, Murabito P, Maj G, Astuto M. Too Bad to Be True: What Can We Reasonably Expect for Treatments of Multiple Organ Failure? Crit Care Med 2022; 50:e728-e729. [PMID: 35984066 DOI: 10.1097/ccm.0000000000005578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Federico Pappalardo
- Department of CardioThoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
| | - Paolo Murabito
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
| | - Giulia Maj
- Department of CardioThoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
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27
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Yin Y, Cao Q, Ma B. [Inhibitory effect and mechanism of bone marrow mesenchymal stem cells on inflammation in rats with multiple organ dysfunction syndrome]. Xi Bao Yu Fen Zi Mian Yi Xue Za Zhi 2022; 38:673-678. [PMID: 35851079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective To observe the anti-inflammatory effect and mechanism of bone marrow mesenchymal stem cell (BMSC) on multiple organ dysfunction syndrome (MODS) rats. Methods SD rats were randomly divided into control group, model group and BMSC group, with 10 rats in each group. Rats in model group and BMSC group were intraperitoneally injected with 7 mg/kg lipopolysaccharide (LPS) to establish MODS models. Rat BMSCs were cultured in vitro, and the fourth generation cells were used for experiments. The rats in BMSC group were injected with 1×106 BMSCs through the tail vein, and the rats in control group and model group were injected with the same amount of normal saline through the tail vein. 72 hours after MODS model was established, blood oxygen partial pressure (PaO2) and arterial carbon dioxide partial pressure (PaCO2) were detected by blood gas analyzer. ELISA were used to detect the bilirubin (TB), albumin (ALB), serum creatinine (Scr), blood urea nitrogen (BUN), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and cyclic adenosine monophosphate (cAMP). HE staining was performed to observe pathological changes in lung, liver and kidney tissues. Western blot analysis was used to detect the protein expression of protein kinase A (PKA) and nuclear factor kappa-B p65 (NF-κB p65) in tissues of lung, liver and kidney. Results Compared with control group, PaO2 in model group and BMSC group significantly decreased, while the PaCO2 significantly increased. TB, Cr, BUN, TNF-α and IL-6 levels was found increased, and ALB and cAMP levels was found decreased, along with the decreased PKA protein expression levels in lung, liver and kidney tissues, and increased NF-κB p65 protein expression levels. Compared with model group, PaO2 in BMSC group increased significantly, while its PaCO2 decreased markedly. It's also detected decreased TB, Cr, BUN, TNF-α and IL-6 levels, increased ALB and cAMP levels, as well as increased PKA protein expression levels in lung, liver and kidney tissues, and decreased NF-κB p65 protein expression levels. Conclusion BMSCs can reduce the damaged organ function and inhibit the release of inflammatory factors in MODS rats. The mechanism may be related to the change of cAMP/PKA/NF-κB signaling pathway.
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Affiliation(s)
- Yantao Yin
- Emergency department of Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing 100176, China. *Corresponding author, E-mail:
| | - Qiumei Cao
- Emergency department of Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing 100176, China
| | - Bingchen Ma
- Emergency department of Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing 100176, China
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28
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Shock And Sepsis Society Of The Chinese Research Hospital A, War Wound And Trauma Society Of The Chinese People's Liberation Army P. [Chinese expert consensus on diagnosis and treatment of traumatic multiple organ dysfunction syndrome]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2022; 34:225-238. [PMID: 35574737 DOI: 10.3760/cma.j.cn121430-20220118-00076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Multiple organ dysfunction syndrome (MODS) is the main cause of high mortality in late stage of patients following major trauma. On the basis of literature retrieval and analysis, combined with evidence-based medicine and clinical trial reports together with expert experiences in clinical practice, we compiled this expert consensus, which focused on the pathophysiological mechanism, early prediction, diagnosis, treatment, and rehabilitation of traumatic MODS, in order to help clinicians understand the basic pathogenesis and standardize the clinical management. The pathogenic mechanisms of MODS after severe trauma mainly include excessive inflammatory response, immune dissonance, abnormal coagulation, and the dysregulated networks among multiple organs as well as systems. Early and accurate diagnosis, timely and appropriate organ support, and adjuvant therapy might effectively improve the poor outcomes of patients with traumatic MODS.
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29
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Silva CMS, Wanderley CWS, Veras FP, Sonego F, Nascimento DC, Gonçalves AV, Martins TV, Cólon DF, Borges VF, Brauer VS, Damasceno LEA, Silva KP, Toller-Kawahisa JE, Batah SS, Souza ALJ, Monteiro VS, Oliveira AER, Donate PB, Zoppi D, Borges MC, Almeida F, Nakaya HI, Fabro AT, Cunha TM, Alves-Filho JC, Zamboni DS, Cunha FQ. Gasdermin D inhibition prevents multiple organ dysfunction during sepsis by blocking NET formation. Blood 2021; 138:2702-2713. [PMID: 34407544 PMCID: PMC8703366 DOI: 10.1182/blood.2021011525] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/10/2021] [Indexed: 12/25/2022] Open
Abstract
Multiple organ dysfunction is the most severe outcome of sepsis progression and is highly correlated with a worse prognosis. Excessive neutrophil extracellular traps (NETs) are critical players in the development of organ failure during sepsis. Therefore, interventions targeting NET release would likely effectively prevent NET-based organ injury associated with this disease. Herein, we demonstrate that the pore-forming protein gasdermin D (GSDMD) is active in neutrophils from septic humans and mice and plays a crucial role in NET release. Inhibition of GSDMD with disulfiram or genic deletion abrogated NET formation, reducing multiple organ dysfunction and sepsis lethality. Mechanistically, we demonstrate that during sepsis, activation of the caspase-11/GSDMD pathway controls NET release by neutrophils during sepsis. In summary, our findings uncover a novel therapeutic use for disulfiram and suggest that GSDMD is a therapeutic target to improve sepsis treatment.
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Affiliation(s)
- Camila Meirelles S Silva
- Center for Research in Inflammatory Diseases
- Department of Biochemistry and Immunology
- Department of Pharmacology, and
| | - Carlos Wagner S Wanderley
- Center for Research in Inflammatory Diseases
- Department of Biochemistry and Immunology
- Department of Pharmacology, and
| | | | | | - Daniele C Nascimento
- Center for Research in Inflammatory Diseases
- Department of Biochemistry and Immunology
- Department of Pharmacology, and
| | - Augusto V Gonçalves
- Center for Research in Inflammatory Diseases
- Department of Cellular and Molecular Biology and Pathogenic Bioagents, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Timna V Martins
- Center for Research in Inflammatory Diseases
- Department of Biochemistry and Immunology
| | - David F Cólon
- Center for Research in Inflammatory Diseases
- Department of Biochemistry and Immunology
| | - Vanessa F Borges
- Center for Research in Inflammatory Diseases
- Department of Pharmacology, and
| | | | | | - Katiussia P Silva
- Center for Research in Inflammatory Diseases
- Institute of Biosciences, Sao Paulo State University, Botucatu, Sao Paulo, Brazil
| | | | | | | | - Valter S Monteiro
- Center for Research in Inflammatory Diseases
- Department of Biochemistry and Immunology
| | | | - Paula B Donate
- Center for Research in Inflammatory Diseases
- Department of Pharmacology, and
| | - Daniel Zoppi
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil; and
| | - Marcos C Borges
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil; and
| | | | - Helder I Nakaya
- Center for Research in Inflammatory Diseases
- Hospital Israelita Albert Einstein, Sao Paulo, Sao Paulo, Brazil
| | | | - Thiago M Cunha
- Center for Research in Inflammatory Diseases
- Department of Pharmacology, and
| | | | - Dario S Zamboni
- Center for Research in Inflammatory Diseases
- Department of Cellular and Molecular Biology and Pathogenic Bioagents, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Fernando Q Cunha
- Center for Research in Inflammatory Diseases
- Department of Pharmacology, and
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30
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Ciccarelli M, Dawson D, Falcao-Pires I, Giacca M, Hamdani N, Heymans S, Hooghiemstra A, Leeuwis A, Hermkens D, Tocchetti CG, van der Velden J, Zacchigna S, Thum T. Reciprocal organ interactions during heart failure: a position paper from the ESC Working Group on Myocardial Function. Cardiovasc Res 2021; 117:2416-2433. [PMID: 33483724 PMCID: PMC8562335 DOI: 10.1093/cvr/cvab009] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/20/2021] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
Heart failure-either with reduced or preserved ejection fraction (HFrEF/HFpEF)-is a clinical syndrome of multifactorial and gender-dependent aetiology, indicating the insufficiency of the heart to pump blood adequately to maintain blood flow to meet the body's needs. Typical symptoms commonly include shortness of breath, excessive fatigue with impaired exercise capacity, and peripheral oedema, thereby alluding to the fact that heart failure is a syndrome that affects multiple organ systems. Patients suffering from progressed heart failure have a very limited life expectancy, lower than that of numerous cancer types. In this position paper, we provide an overview regarding interactions between the heart and other organ systems, the clinical evidence, underlying mechanisms, potential available or yet-to-establish animal models to study such interactions and finally discuss potential new drug interventions to be developed in the future. Our working group suggests that more experimental research is required to understand the individual molecular mechanisms underlying heart failure and reinforces the urgency for tailored therapeutic interventions that target not only the heart but also other related affected organ systems to effectively treat heart failure as a clinical syndrome that affects and involves multiple organs.
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Affiliation(s)
- Michele Ciccarelli
- University of Salerno, Department of Medicine, Surgery and Dentistry, Via S. Allende 1, 84081, Baronissi(Salerno), Italy
| | - Dana Dawson
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2DZ, UK
| | - Inês Falcao-Pires
- Department of Surgery and Physiology, Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Mauro Giacca
- King’s College London, Molecular Medicine Laboratory, 125 Caldharbour Lane, London WC2R2LS, United Kingdom
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano, 99, 34149 Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume, 447, 34129 Trieste, Italy
| | - Nazha Hamdani
- Department of Clinical Pharmacology and Molecular Cardiology, Institute of Physiology, Ruhr University Bochum, Universitätsstraße 150, D-44801 Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Universitätsstraße 150, D-44801 Bochum, Germany
| | - Stéphane Heymans
- Centre for Molecular and Vascular Biology, KU Leuven, Herestraat 49, Bus 911, 3000 Leuven, Belgium
- Department of Cardiology, Maastricht University, CARIM School for Cardiovascular Diseases, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands
- ICIN-Netherlands Heart Institute, Holland Heart House, Moreelsepark 1, 3511 EP Utrecht, the Netherlands
| | - Astrid Hooghiemstra
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam UMC, Location VUmc, De Boelelaan 1089a, 1081HV, Amsterdam, The Netherlands
| | - Annebet Leeuwis
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
| | - Dorien Hermkens
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Jolanda van der Velden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081HZ Amsterdam, the Netherlands
| | - Serena Zacchigna
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume, 447, 34129 Trieste, Italy
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano, 99, 34149 Trieste, Italy
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
- REBIRTH Center for Translational Regenerative Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, Nicolai-Fuchs-Str. 1, D-30625 Hannover, Germany
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31
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Bhalerao A, Raut S, Noorani B, Mancuso S, Cucullo L. Molecular Mechanisms of Multi-Organ Failure in COVID-19 and Potential of Stem Cell Therapy. Cells 2021; 10:2878. [PMID: 34831101 PMCID: PMC8616204 DOI: 10.3390/cells10112878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 01/08/2023] Open
Abstract
As the number of confirmed cases and deaths occurring from Coronavirus disease 2019 (COVID-19) surges worldwide, health experts are striving hard to fully comprehend the extent of damage caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although COVID-19 primarily manifests itself in the form of severe respiratory distress, it is also known to cause systemic damage to almost all major organs and organ systems within the body. In this review, we discuss the molecular mechanisms leading to multi-organ failure seen in COVID-19 patients. We also examine the potential of stem cell therapy in treating COVID-19 multi-organ failure cases.
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Affiliation(s)
- Aditya Bhalerao
- Department of Biological and Biomedical Sciences, Oakland University, Rochester, MI 48309, USA
| | - Snehal Raut
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA
| | - Behnam Noorani
- Department of Pharmaceutical Sciences, Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Salvatore Mancuso
- Department of Biological and Biomedical Sciences, Oakland University, Rochester, MI 48309, USA
| | - Luca Cucullo
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA
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32
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Siddiqui RS, Ferman DA, Shi PA. Further evidence for the benefit of therapeutic plasma exchange for acute multi-organ failure syndrome refractory to red cell exchange in sickle cell disease. J Clin Apher 2021; 36:777-779. [PMID: 34191365 DOI: 10.1002/jca.21920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/04/2021] [Accepted: 06/20/2021] [Indexed: 11/12/2022]
Abstract
Acute multiorgan failure syndrome (MOFS) remains a significant cause of mortality in sickle cell disease (SCD) patients despite red cell exchange (RCE). In small case series and reports, therapeutic plasma exchange (TPE) has shown benefit in MOFS. As further support for consideration of this modality, we present two patients with SCD and MOFS refractory to RCE who were subsequently treated with TPE. Fresh frozen plasma was used as the replacement fluid. Despite estimated hospital mortality of 40% at the time of intensive care unit admission, both patients showed marked clinical improvement with TPE treatment. Our cases add to the evidence supporting the potential inclusion of MOFS secondary to acute SCD as an indication for TPE in the next edition of the American Society of Apheresis Guidelines on the Use of Therapeutic Apheresis in Clinical Practice.
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Affiliation(s)
- Raheel S Siddiqui
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, Jamaica, New York, USA
| | - Debra A Ferman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, Jamaica, New York, USA
| | - Patricia A Shi
- Clinical Services, New York Blood Center, New York, New York, USA
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, New York, USA
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33
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Slae M, Wilschanski M, Sanjines E, Abu-El-Haija M, Sellers ZM. International Survey on Severe Acute Respiratory Syndrome Coronavirus 2 and Acute Pancreatitis Co-occurrence in Children. Pancreas 2021; 50:1305-1309. [PMID: 34860816 PMCID: PMC8647781 DOI: 10.1097/mpa.0000000000001923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES It is unknown to what extent coronavirus 2019 (COVID-19) may co-occur with acute pancreatitis (AP) in children and how their clinical course may differ from children with AP alone. METHODS An online survey was sent to pediatric gastroenterologists to report on COVID-19 and AP cases from December 11, 2020, to February 26, 2021. RESULTS From 72 respondents (20 countries, 5 continents), 22 cases of positive COVID-19 infection and AP were reported. Patients were predominantly White or Hispanic/Latinx (73%), female (68%), and adolescents (68%). For 86% of patients, this was their first episode of AP. Sixty-eight percent of positive COVID-19 tests were polymerase chain reaction based. There was significant morbidity; 60% required intensive care, 45% had multiorgan involvement, and 24% developed shock. Eleven percent had pancreatic necrosis. Abnormal clotting and systemic inflammatory laboratories were common (31%-92% and 93%, respectively). Median length of symptomatic pancreatitis recovery was 1.8× longer than AP without COVID-19. CONCLUSIONS Coronavirus 2019 infection and AP co-occur primarily in children without a prior history of pancreatitis. Given the increased need for intensive care, multiorgan involvement, and potentially higher risk for pancreatic necrosis, pediatric providers should have a high level of suspicion for AP in children with COVID-19 infection.
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Affiliation(s)
- Mordechai Slae
- From the Division of Pediatric Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michael Wilschanski
- From the Division of Pediatric Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Elvi Sanjines
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA
| | | | - Zachary M Sellers
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA
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Krishnamoorthy V, Komisarow JM, Laskowitz DT, Vavilala MS. Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management. Chest 2021; 160:956-964. [PMID: 33460623 PMCID: PMC8448997 DOI: 10.1016/j.chest.2021.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/10/2020] [Accepted: 01/07/2021] [Indexed: 01/20/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Chapel Hill, NC; Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC.
| | - Jordan M Komisarow
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC; Department of Neurosurgery, Duke University, Chapel Hill, NC
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Díaz F, Cores C, Atenas O, Rodríguez N, Bustos R, Cruces P. Rationale of Therapeutic Plasma Exchange as Rescue Immunomodulatory Treatment for MIS-C With Multiorgan Failure. Pediatr Infect Dis J 2021; 40:e259-e262. [PMID: 34097663 DOI: 10.1097/inf.0000000000003169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 infection is an infrequent and poorly understood illness. It can present as severe multiorgan failure in children, potentially lethal. Immunomodulation is the empiric treatment because a dysregulated immune response is the primary pathophysiologic mechanism. We present an infant with severe MIS-C, refractory to usual treatment, successfully treated with plasmapheresis.
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Affiliation(s)
- Franco Díaz
- From the Hospital El Carmen de Maipú, Unidad de Paciente Crítico Pediátrico, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Santiago, Chile
- Instituto de Ciencias e Innovación en Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile
| | - Camila Cores
- From the Hospital El Carmen de Maipú, Unidad de Paciente Crítico Pediátrico, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Santiago, Chile
| | - Omar Atenas
- Hospital El Carmen de Maipú, Unidad de Diálisis, Santiago, Chile
| | - Nicolás Rodríguez
- Hospital El Carmen de Maipú, Unidad de Medicina Transfusional, Santiago, Chile
| | - Raúl Bustos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Pablo Cruces
- From the Hospital El Carmen de Maipú, Unidad de Paciente Crítico Pediátrico, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Santiago, Chile
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Centro de Investigación de Medicina Veterinaria, Universidad Andres Bello, Santiago, Chile
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Ventura-Espejo L, Gracia-Darder I, Escribá-Bori S, Amador-González ER, Martín-Santiago A, Ramakers J. Patient with H syndrome, cardiogenic shock, multiorgan infiltration, and digital ischemia. Pediatr Rheumatol Online J 2021; 19:104. [PMID: 34193201 PMCID: PMC8243620 DOI: 10.1186/s12969-021-00586-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/05/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND H syndrome (HS) is a rare autoinflammatory disease caused by a mutation in the solute carrier family 29, member 3 (SCL29A3) gene. It has a variable clinical presentation and little phenotype-genotype correlation. The pathognomonic sign of HS is cutaneous hyperpigmentation located mainly in the inner thighs and often accompanied by other systemic manifestations. Improvement after tocilizumab treatment has been reported in a few patients with HS. We report the first patient with HS who presented cardiogenic shock, multiorgan infiltration, and digital ischemia. CASE PRESENTATION 8-year-old boy born to consanguineous parents of Moroccan origin who was admitted to the intensive care unit during the Coronavirus Disease-2019 (COVID-19) pandemic with tachypnoea, tachycardia, and oliguria. Echocardiography showed dilated cardiomyopathy and severe systolic dysfunction compatible with cardiogenic shock. Additionally, he presented with multiple organ dysfunction syndrome. SARS-CoV-2 polymerase chain reaction (PCR) and antibody detection by chromatographic immunoassay were negative. A previously ordered gene panel for pre-existing sensorineural hearing loss showed a pathological mutation in the SCL29A3 gene compatible with H syndrome. Computed tomography scan revealed extensive alveolar infiltrates in the lungs and multiple poor defined hypodense lesions in liver, spleen, and kidneys; adenopathy; and cardiomegaly with left ventricle subendocardial nodules. Invasive mechanical ventilation, broad antibiotic and antifungal coverage showed no significant response. Therefore, Tocilizumab as compassionate use together with pulsed intravenous methylprednisolone was initiated. Improvement was impressive leading to normalization of inflammation markers, liver and kidney function, and stabilising heart function. Two weeks later, he was discharged and has been clinically well since then on two weekly administration of Tocilizumab. CONCLUSIONS We report the most severe disease course produced by HS described so far in the literature. Our patient's manifestations included uncommon, new complications such as acute heart failure with severe systolic dysfunction, multi-organ cell infiltrate, and digital ischemia. Most of the clinical symptoms of our patient could have been explained by SARS-CoV-2, demonstrating the importance of a detailed differential diagnosis to ensure optimal treatment. Although the mechanism of autoinflammation of HS remains uncertain, the good response of our patient to Tocilizumab makes a case for the important role of IL-6 in this syndrome and for considering Tocilizumab as a first-line treatment, at least in severely affected patients.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- COVID-19
- Cardiomyopathy, Dilated/diagnostic imaging
- Cardiomyopathy, Dilated/physiopathology
- Cardiomyopathy, Dilated/therapy
- Child
- Glucocorticoids/therapeutic use
- Hereditary Autoinflammatory Diseases/diagnosis
- Hereditary Autoinflammatory Diseases/genetics
- Hereditary Autoinflammatory Diseases/physiopathology
- Hereditary Autoinflammatory Diseases/therapy
- Humans
- Ischemia/physiopathology
- Ischemia/therapy
- Kidney Diseases/diagnostic imaging
- Kidney Diseases/physiopathology
- Kidney Diseases/therapy
- Liver Diseases/diagnostic imaging
- Liver Diseases/physiopathology
- Liver Diseases/therapy
- Lung Diseases/diagnostic imaging
- Lung Diseases/physiopathology
- Lung Diseases/therapy
- Lymphadenopathy/diagnostic imaging
- Lymphadenopathy/physiopathology
- Lymphadenopathy/therapy
- Male
- Methylprednisolone/therapeutic use
- Multiple Organ Failure/physiopathology
- Multiple Organ Failure/therapy
- Nucleoside Transport Proteins/genetics
- Pulse Therapy, Drug
- Respiration, Artificial
- SARS-CoV-2
- Shock, Cardiogenic/physiopathology
- Shock, Cardiogenic/therapy
- Splenic Diseases/diagnostic imaging
- Splenic Diseases/physiopathology
- Splenic Diseases/therapy
- Toes/blood supply
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- Laura Ventura-Espejo
- Paediatric Department, Hospital Universitario Son Espases, Carretera de Valldemosa, 79, 07120, Palma, Spain
| | - Inés Gracia-Darder
- Dermatology Department, Hospital Universitario Son Espases, Palma, Spain
| | - Silvia Escribá-Bori
- Paediatric Department, Hospital Universitario Son Espases, Carretera de Valldemosa, 79, 07120, Palma, Spain
| | | | | | - Jan Ramakers
- Paediatric Department, Hospital Universitario Son Espases, Carretera de Valldemosa, 79, 07120, Palma, Spain.
- Multidisciplinary Group for Research in Peadiatrics. Hospital Universitari Son Espases, Balearic Islands Health Research Institute (IdISBa), Carretera de Valldemossa, 79, 07120, Palma, Spain.
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Ramkumar M. Bearing witness in the time of COVID. The Lancet Respiratory Medicine 2021; 9:347-348. [PMID: 33581081 PMCID: PMC7906702 DOI: 10.1016/s2213-2600(21)00036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Mukund Ramkumar
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA.
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Fuhrmann V, Perez Ruiz de Garibay A, Faltlhauser A, Tyczynski B, Jarczak D, Lutz J, Weinmann-Menke J, Kribben A, Kluge S. Registry on extracorporeal multiple organ support with the advanced organ support (ADVOS) system: 2-year interim analysis. Medicine (Baltimore) 2021; 100:e24653. [PMID: 33607801 PMCID: PMC7899840 DOI: 10.1097/md.0000000000024653] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/10/2021] [Indexed: 12/31/2022] Open
Abstract
The objective of this registry is to collect data on real-life treatment conditions for patients for whom multiple organ dialysis with Advanced Organ Support (ADVOS) albumin hemodialysis is indicated.This registry was performed under routine conditions and without any study-specific intervention, diagnostic procedures, or assessments. Data on clinical laboratory tests, health status, liver function, vital signs, and examinations were collected (DRKS-ID: DRKS00017068). Mortality rates 28 and 90 days after the first ADVOS treatment, adverse events and ADVOS treatment parameters, including treatment abortions, were documented.This analysis was performed 2 years after the first patient was included on January 18, 2017. As of February 20, 2019, 4 clinical sites in Germany participated and enrolled 118 patients with a median age of 60 (IQR: 45, 69) of whom 70 were male (59.3%). Patients had a median SOFA Score of 14 (IQR: 11, 16) and a predicted mortality of 80%. The median number of failing organs was 3 (IQR: 2, 4).Four hundred twenty nine ADVOS treatments sessions were performed with a median duration of 17 hours (IQR: 6, 23). A 5.8% of the ADVOS sessions (25 of 429) were aborted due to device related errors, while 14.5% (62 of 429) were stopped for other reasons. Seventy nine adverse events were documented, 13 of them device related (all clotting, and all recovered without sequels).A significant reduction in serum creatinine (1.5 vs 1.2 mg/dl), blood urea nitrogen (24 vs 17 mg/dl) and bilirubin (6.9 vs 6.5 mg/dl) was observed following the first ADVOS treatment session. Blood pH, bicarbonate (HCO3-) and base excess returned to the physiological range, while partial pressure of carbon dioxide (pCO2) remained unchanged. At the time of the analysis, 28- and 90-day mortality were 60% and 65%, respectively, compared to an expected ICU-mortality rate of 80%. SOFA score was an independent predictor for outcome in a multivariable logistic regression analysis.The reported data show a high quality and completion of all participating centers. Data interpretation must be cautious due to the small number of patients, and the nature of the registry, without a control group. However, the data presented here show an improvement of expected mortality rates. Minor clotting events similar to other dialysis therapies occurred during the treatments.
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Affiliation(s)
- Valentin Fuhrmann
- Universitätsklinikum Hamburg-Eppendorf, Klinik für Intensivmedizin, Hamburg, Deutschland
- Universitätsklinikum Münster, Medizinische Klinik B für Gastroenterologie and Hepatologie, Münster
- Evangelisches Krankenhaus Duisburg-Nord, Klinik für Innere Medizin, Duisburg
| | | | | | | | - Dominik Jarczak
- Universitätsklinikum Hamburg-Eppendorf, Klinik für Intensivmedizin, Hamburg, Deutschland
| | - Jens Lutz
- Gemeinschaftsklinikum Mittelrhein, Innere Medizin Nephrologie-Infektiologie, Koblenz
| | - Julia Weinmann-Menke
- Universitätsmedizin Mainz, I. Medizinische Klinik and Poliklinik, Mainz, Germany
| | | | - Stefan Kluge
- Universitätsklinikum Hamburg-Eppendorf, Klinik für Intensivmedizin, Hamburg, Deutschland
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Abstract
Thrombocytopenia-associated multiple organ failure is a clinical phenotype encompassing a spectrum of syndromes associated with disseminated microvascular thromboses. Autopsies performed in patients that died with thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, or disseminated intravascular coagulation reveal specific findings that can differentiate these 3 entities. Significant advancements have been made in our understanding of the pathologic mechanisms of these syndromes. Von Willebrand factor and ADAMTS-13 play a central role in thrombotic thrombocytopenic purpura. Shiga toxins and the complement pathway drive the hemolytic uremic syndrome pathology. Tissue factor activity is vital in the development of disseminated intravascular coagulation.
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Affiliation(s)
- Trung C Nguyen
- Department of Pediatrics, Critical Care Medicine Section, Texas Children's Hospital/Baylor College of Medicine, 6651 Main Street, MC: E 1420, Houston, TX 77030, USA; The Center for Translational Research on Inflammatory Diseases (CTRID), The Michael E. DeBakey Veteran Administration Medical Center, Houston, TX 77030, USA.
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40
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Faqihi F, Alharthy A, Alodat M, Kutsogiannis DJ, Brindley PG, Karakitsos D. Therapeutic plasma exchange in adult critically ill patients with life-threatening SARS-CoV-2 disease: A pilot study. J Crit Care 2020; 60:328-333. [PMID: 32763058 PMCID: PMC9629267 DOI: 10.1016/j.jcrc.2020.07.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE We investigated the effect of therapeutic plasma exchange (TPE) on life-threatening COVID-19; presenting as acute respiratory distress syndrome (ARDS) plus multi-system organ failure and cytokine release syndrome (CRS). MATERIALS AND METHODS We prospectively enrolled ten consecutive adult intensive care unit (ICU) subjects [7 males; median age: 51 interquartile range (IQR): 45.1-55.9 years old] with life-threatening COVID-19 infection. All had ARDS [PaO2/FiO2 ratio: 110 (IQR): 95.5-135.5], septic shock, CRS and deteriorated within 24 h of ICU admission despite fluid resuscitation, antibiotics, hydroxychloroquine, ARDS-net and prone position mechanical ventilation. All received 5-7 TPE sessions (dosed as 1.0 to 1.5 plasma volumes). RESULTS All of the following significantly normalized (p < 0.05) following the TPE completion, when compared to baseline: Sequential Organ Function Assessment score, PaO2/FiO2 ratio, levels of lymphocytes, total bilirubin, lactate dehydrogenase, ferritin, C-reactive protein and interleukin-6. No adverse effects from TPE were observed. Acute kidney injury and pulmonary embolism were observed in 10% and 20% of patients, respectively. The duration of mechanical ventilation was 9 (IQR: 7 to 12) days, the ICU length of stay was 15 (IQR: 13.2 to 19.6) days and the mortality on day-28 was 10%. CONCLUSION TPE demonstrates a potential survival benefit and low risk in life-threatening COVID-19, albeit in a small pilot study.
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Affiliation(s)
- Fahad Faqihi
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; Critical Care Department, Al Imam Abdulrahman Al Feisal Hospital, Riyadh, Saudi Arabia
| | | | - Mohammed Alodat
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Demetrios J Kutsogiannis
- Department of Critical Care, Faculty of Medicine and Dentistry, the University of Alberta, Alberta, Canada.
| | - Peter G Brindley
- Department of Critical Care, Faculty of Medicine and Dentistry, the University of Alberta, Alberta, Canada.
| | - Dimitrios Karakitsos
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; Department of Internal Medicine, South Carolina University, School of Medicine, Columbia, SC, USA; Critical Care Department, Keck Medical School, USC, LA, CA, USA.
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Shankar R, Leimanis ML, Newbury PA, Liu K, Xing J, Nedveck D, Kort EJ, Prokop JW, Zhou G, Bachmann AS, Chen B, Rajasekaran S. Gene expression signatures identify paediatric patients with multiple organ dysfunction who require advanced life support in the intensive care unit. EBioMedicine 2020; 62:103122. [PMID: 33248372 PMCID: PMC7704404 DOI: 10.1016/j.ebiom.2020.103122] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/21/2020] [Accepted: 10/26/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) occurs in the setting of a variety of pathologies including infection and trauma. Some patients decompensate and require Veno-Arterial extra corporeal membrane oxygenation (ECMO) as a palliating manoeuvre for recovery of cardiopulmonary function. The molecular mechanisms driving progression from MODS to cardiopulmonary collapse remain incompletely understood, and no biomarkers have been defined to identify those MODS patients at highest risk for progression to requiring ECMO support. METHODS Whole blood RNA-seq profiling was performed for 23 MODS patients at three time points during their ICU stay (at diagnosis of MODS, 72 hours after, and 8 days later), as well as four healthy controls undergoing routine sedation. Of the 23 MODS patients, six required ECMO support (ECMO patients). The predictive power of conventional demographic and clinical features was quantified for differentiating the MODS and ECMO patients. We then compared the performance of markers derived from transcriptomic profiling including [1] transcriptomically imputed leukocyte subtype distribution, [2] relevant published gene signatures and [3] a novel differential gene expression signature computed from our data set. The predictive power of our novel gene expression signature was then validated using independently published datasets. FINDING None of the five demographic characteristics and 14 clinical features, including The Paediatric Logistic Organ Dysfunction (PELOD) score, could predict deterioration of MODS to ECMO at baseline. From previously published sepsis signatures, only the signatures positively associated with patient's mortality could differentiate ECMO patients from MODS patients, when applied to our transcriptomic dataset (P-value ranges from 0.01 to 0.04, Student's test). Deconvolution of bulk RNA-Seq samples suggested that lower neutrophil counts were associated with increased risk of progression from MODS to ECMO (P-value = 0.03, logistic regression, OR=2.82 [95% CI 0.63 - 12.45]). A total of 30 genes were differentially expressed between ECMO and MODS patients at baseline (log2 fold change ≥ 1 or ≤ -1 with false discovery rate ≤ 0.01). These genes are involved in protein maintenance and epigenetic-related processes. Further univariate analysis of these 30 genes suggested a signature of seven DE genes associated with ECMO (OR > 3.0, P-value ≤ 0.05, logistic regression). Notably, this contains a set of histone marker genes, including H1F0, HIST2H3C, HIST1H2AI, HIST1H4, HIST1H2BL and HIST1H1B, that were highly expressed in ECMO. A risk score derived from expression of these genes differentiated ECMO and MODS patients in our dataset (AUC = 0.91, 95% CI 0.79-1.00, P-value = 7e-04, logistic regression) as well as validation dataset (AUC= 0.73, 95% CI 0.53-0.93, P-value = 2e-02, logistic regression). INTERPRETATION This study demonstrates that transcriptomic features can serve as indicators of severity that could be superior to traditional methods of ascertaining acuity in MODS patients. Analysis of expression of signatures identified in this study could help clinicians in the diagnosis and prognostication of MODS patients after arrival to the Hospital.
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Affiliation(s)
- Rama Shankar
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Mara L Leimanis
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503, USA.
| | - Patrick A Newbury
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
| | - Ke Liu
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Jing Xing
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Derek Nedveck
- Office of Research, Spectrum Health, 15 Michigan Street NE, Grand Rapids, MI 49503, USA
| | - Eric J Kort
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; DeVos Cardiovascular Program, Van Andel Research Institute and Fredrik Meijer Heart and Vascular Institute/Spectrum Health, Grand Rapids, MI 49503, USA; Pediatric Hospitalist Medicine, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503, USA.
| | - Jeremy W Prokop
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Guoli Zhou
- Biomedical Research Informatics Core (BRIC), Clinical and Translational Sciences Institute (CTSI), Michigan State University, East Lansing, MI 48824, USA.
| | - André S Bachmann
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Bin Chen
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Surender Rajasekaran
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503, USA; Office of Research, Spectrum Health, 15 Michigan Street NE, Grand Rapids, MI 49503, USA.
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Bouadma L, Wiedemann A, Patrier J, Surénaud M, Wicky PH, Foucat E, Diehl JL, Hejblum BP, Sinnah F, de Montmollin E, Lacabaratz C, Thiébaut R, Timsit JF, Lévy Y. Immune Alterations in a Patient with SARS-CoV-2-Related Acute Respiratory Distress Syndrome. J Clin Immunol 2020; 40:1082-1092. [PMID: 32829467 PMCID: PMC7443154 DOI: 10.1007/s10875-020-00839-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/27/2020] [Indexed: 02/03/2023]
Abstract
We report a longitudinal analysis of the immune response associated with a fatal case of COVID-19 in Europe. This patient exhibited a rapid evolution towards multiorgan failure. SARS-CoV-2 was detected in multiple nasopharyngeal, blood, and pleural samples, despite antiviral and immunomodulator treatment. Clinical evolution in the blood was marked by an increase (2-3-fold) in differentiated effector T cells expressing exhaustion (PD-1) and senescence (CD57) markers, an expansion of antibody-secreting cells, a 15-fold increase in γδ T cell and proliferating NK-cell populations, and the total disappearance of monocytes, suggesting lung trafficking. In the serum, waves of a pro-inflammatory cytokine storm, Th1 and Th2 activation, and markers of T cell exhaustion, apoptosis, cell cytotoxicity, and endothelial activation were observed until the fatal outcome. This case underscores the need for well-designed studies to investigate complementary approaches to control viral replication, the source of the hyperinflammatory status, and immunomodulation to target the pathophysiological response. The investigation was conducted as part of an overall French clinical cohort assessing patients with COVID-19 and registered in clinicaltrials.gov under the following number: NCT04262921.
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Affiliation(s)
- Lila Bouadma
- APHP- Hôpital Bichat - Médecine Intensive et Réanimation des Maladies Infectieuses, Paris, France
- UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Inserm/Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Aurélie Wiedemann
- Vaccine Research Institute, Faculté de Médecine, INSERM U955, Université Paris-Est Créteil, Créteil, France
| | - Juliette Patrier
- APHP- Hôpital Bichat - Médecine Intensive et Réanimation des Maladies Infectieuses, Paris, France
| | - Mathieu Surénaud
- Vaccine Research Institute, Faculté de Médecine, INSERM U955, Université Paris-Est Créteil, Créteil, France
| | - Paul-Henri Wicky
- APHP- Hôpital Bichat - Médecine Intensive et Réanimation des Maladies Infectieuses, Paris, France
| | - Emile Foucat
- Vaccine Research Institute, Faculté de Médecine, INSERM U955, Université Paris-Est Créteil, Créteil, France
| | - Jean-Luc Diehl
- APHP, Hôpital Georges Pompidou, Médecine Intensive Reanimation, Paris, France
| | - Boris P Hejblum
- Univ. Bordeaux, Department of Public Health, Inserm Bordeaux Population Health Research Centre, Inria SISTM, UMR 1219, Vaccine Research Institute (VRI), Créteil, France
| | - Fabrice Sinnah
- APHP- Hôpital Bichat - Médecine Intensive et Réanimation des Maladies Infectieuses, Paris, France
| | - Etienne de Montmollin
- APHP- Hôpital Bichat - Médecine Intensive et Réanimation des Maladies Infectieuses, Paris, France
| | - Christine Lacabaratz
- Vaccine Research Institute, Faculté de Médecine, INSERM U955, Université Paris-Est Créteil, Créteil, France
| | - Rodolphe Thiébaut
- Univ. Bordeaux, Department of Public Health, Inserm Bordeaux Population Health Research Centre, Inria SISTM, UMR 1219, Vaccine Research Institute (VRI), Créteil, France
- CHU Bordeaux, Bordeaux, France
| | - J F Timsit
- APHP- Hôpital Bichat - Médecine Intensive et Réanimation des Maladies Infectieuses, Paris, France
- UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Inserm/Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Yves Lévy
- Vaccine Research Institute, Faculté de Médecine, INSERM U955, Université Paris-Est Créteil, Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Service Immunologie Clinique, Groupe Henri-Mondor Albert-Chenevier, Créteil, France.
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Dirim AB, Demir E, Ucar AR, Garayeva N, Safak S, Oto OA, Yazici H, Alibeyoglu AM, Orhun G, Cagatay AA, Turkmen A. Fatal SARS-CoV-2 infection in a renal transplant recipient. CEN Case Rep 2020; 9:409-412. [PMID: 32564306 PMCID: PMC7305930 DOI: 10.1007/s13730-020-00496-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/10/2020] [Indexed: 01/08/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) caused a pandemic that first discovered in Wuhan, China. While 10% of the patients have asymptomatic infection, 15-20% have lung involvement, 5-10% have multiple organ failure, and macrophage activation syndrome. Chronic respiratory diseases, diabetes mellitus, hypertension, and cancer are risk factors for mortality. Prognosis or optimal treatment strategy for renal transplant recipients in SARS-CoV-2 infection is still unknown. Besides fatal cases, there were also milder case reports. In addition, COVID-19 treatment and the maintenance immunosuppression strategy is still under debate. Antiviral therapies and drug interactions are special topics for these patients. To the best of our knowledge, favipiravir and anti-cytokine treatments have not been previously reported in a kidney transplant recipient with SARS-CoV-2 infection before. We report a case of SARS-CoV-2 infection in a kidney transplant recipient with fatal outcomes.
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Affiliation(s)
- Ahmet Burak Dirim
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Erol Demir
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ali Riza Ucar
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurana Garayeva
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Seda Safak
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Alpay Medet Alibeyoglu
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gunseli Orhun
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Arif Atahan Cagatay
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Liu X, Tang J, Xie R, Li W, Chen J, Guo Y, Zhang B, Zhang Y, Wang J, Peng C, Lei X, Luo Q, Zhang Q, Li Y. Clinical and Epidemiological Features of 46 Children <1 Year Old With Coronavirus Disease 2019 in Wuhan, China: A Descriptive Study. J Infect Dis 2020; 222:1293-1297. [PMID: 32761128 PMCID: PMC7454691 DOI: 10.1093/infdis/jiaa472] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/27/2020] [Indexed: 01/15/2023] Open
Abstract
The number of coronavirus disease 2019 (COVID-19) cases has exceeded 10 million. However, little is known about the epidemiology and clinical characteristics of COVID-19 infants. We collected medical information of 46 confirmed patients (<1 year old) and retrospectively analyzed epidemiological history, clinical symptoms, and laboratory test results. The median age was 5 (interquartile range, 2-7) months. Sixteen cases had fever and 27 cases had cough. Moderate disease was present in 40 cases and cardiac injury occurred in 38 cases, following by liver dysfunction in 20 cases and lymphocytosis in no cases. Of all infant patients, 2 received invasive mechanical ventilation and 1 died with multiple organ dysfunction syndrome.
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Affiliation(s)
- Xinghua Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianqiao Tang
- Department of Pediatrics, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Xie
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianying Chen
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Guo
- Wuhan Center for Disease Control and Prevention, Wuhan, China
| | - Bo Zhang
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Zhang
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juanjuan Wang
- Department of Rheumatology and Immunology, Anhui Provincial Children’s Hospital, Hefei, China
| | - Cao Peng
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao Lei
- Department of General Practice, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qunying Luo
- Department of General Practice, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiong Zhang
- Department of General Practice, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yunqiao Li
- Department of General Practice, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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45
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de Farias ECF, Justino MCA, de Mello MLFMF. MULTISYSTEM INFLAMMATORY SYNDROME IN A CHILD ASSOCIATED WITH CORONAVIRUS DISEASE 19 IN THE BRAZILIAN AMAZON: FATAL OUTCOME IN AN INFANT. Rev Paul Pediatr 2020; 38:e2020165. [PMID: 32876282 PMCID: PMC7450692 DOI: 10.1590/1984-0462/2020/38/2020165] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/18/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Recently, there have been reports of children with severe inflammatory syndrome and multiorgan dysfunction associated with elevated inflammatory markers. These cases are reported as presenting the Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19. In this study, we describe with parental permission a case of MIS-C in an infant with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CASE DESCRIPTION A seven-month-old infant, with SARS-CoV-2 infection and a history of extreme preterm birth and very low weight at birth, with an initial course of mild respiratory symptoms and abrupt progression to vasoplegic shock, myocarditis and hyperinflammation syndrome, shown by high levels of troponin I, ferritin, CRP, D-dimer and hypoalbuminemia. Despite the intensive care provided, the child developed multiple organ dysfunction and died. COMMENTS Patients with a history of extreme prematurity may present with MIS-C in the presence of COVID-19 and are a group of special concern.
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46
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Atluri S, Manocha V, Boddu N, Bhati S, Syed Z, Diwan S, Manchikanti L. Safety and Effectiveness of Intravascular Mesenchymal Stem Cells to Treat Organ Failure and Possible Application in COVID-19 Complications. Pain Physician 2020; 23:S391-S420. [PMID: 32942796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Although only a small percentage of patients with COVID-19 deteriorate to a critical condition, because of the associated high mortality rate and the sheer number of cases, it imposes a tremendous burden on the society and unprecedented strains the health care resources. Albeit lung is the primary organ involved resulting in acute respiratory distress syndrome (ARDS), many patients additionally present with secondary multiorgan failure. Unfortunately, there is no definitive or curative treatment for this condition, and the management has been predominantly confined to supportive care, which necessitates an urgent need for novel therapies. Mesenchymal stem cell (MSC) therapy has a vast array of preclinical data and early, preliminary clinical data that suggests its potential to regenerate and restore the function of damaged tissues and organs. To date, there has been no review of all the clinical trials that have assessed the safety and efficacy of MSC therapy in organ failure commonly seen in seriously complicated COVID-19 patients. OBJECTIVES To evaluate the effectiveness of MSC therapy in managing multiorgan failure, utilizing currently available literature. STUDY DESIGN A review of human randomized controlled trials (RCTs) and observational studies assessing the role of MSC therapy in managing multiorgan failure. METHODS PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1990 through May 2020. Studies that included embryonic stem cells, induced pluripotent stem cells, differentiated MSCs into specific lineage cells, and hematopoietic stem cells were excluded. Trials with intraorgan infiltration of MSC were also excluded. OUTCOME MEASURES The primary outcome evaluated the improvement in clinical assessment scores and indices of organ function. The secondary outcome assessed the safety of MSC therapy in the clinical trials. RESULTS Based on search criteria, 12 studies were found for lung, 52 for heart, 23 for liver, 16 for stroke, and 9 for kidney. Among the 6 studies that specifically assessed the effectiveness of MSC therapy in ARDS, 4 showed positive outcomes. Forty-one of the 52 trials that examined ischemic and nonischemic heart failure reported beneficial effects. Twenty of 23 trials for liver failure from different etiologies revealed favorable outcomes. Nine out of the 15 studies evaluating stroke had satisfactory effects. However, only 3 out of the 9 studies for kidney failure showed positive results. Nonexpanded bone marrow mononuclear cells were used in most of the negative studies. The incidence of disease worsening or major complications was extremely rare from MSC therapy. LIMITATIONS Among the studies evaluated, although there were many RCTs, there were also numerous case series. Additionally, most recruited a small number of patients. CONCLUSIONS MSC therapy seems to be promising to treat multiorgan failure from COVID-19. More studies are urgently needed to assess both safety and efficacy.
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Affiliation(s)
| | - Vivek Manocha
- Wright State University School of Medicine, Dayton, OH
| | | | | | - Zaid Syed
- Tristate Pain Management, Cincinnati, OH
| | | | - Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
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Abstract
BACKGROUND To investigate the effect of high-volume hemofiltration (HVHF) on Th17/Treg imbalance in patients with severe acute pancreatitis (SAP). METHODS Forty-two patients with SAP were randomly received 24 hours of continuous HVHF (n = 21) or without HVHF (n = 21). At day 28, all 42 patients were divided into survival group (n = 32) and non-survival group (n = 10). Venous blood samples collected at 0, 6, 12, and 24 hours during HVHF treatment (or equivalent time in non-HVHF group) were assessed by flow cytometry to detect Th17 and Treg cells. Concentrations of IL-6, IL-17, IL-10, and TGF-β1 were detected by enzyme-linked immunosorbent assay. RESULTS Th17%, Treg%, Th17/Treg, and levels of related cytokines were significantly higher in SAP patients than healthy controls (P < .05), and these changes were more pronounced in SAP patients with multiple organ failure than those with single organ failure (P < .05). After HVHF treatment, Th17%, Treg%, Th17/Treg, IL-6, IL-17, and IL-10 significantly reduced (P < .05), while there were no significant changes in non-HVHF group (P > .05). In addition, acute physiology and chronic health evaluation II and sequential organ failure assessment scores decreased markedly after HVHF treatment. Baselines of Th17%, Treg%, Th17/Treg, and related cytokines were significantly higher in non-survival group than survival group. Both acute physiology and chronic health evaluation I score and IL-6 level were positively correlated with Th17% before and after HVHF treatment (P < .01). CONCLUSIONS Th17/Treg imbalance is present in SAP and may be correlated with its severity and prognosis. HVHF effectively attenuates the Th17/Treg imbalance in SAP patients. The beneficial effect of HVHF on Th17/Treg imbalance is possibly associated with removing excess inflammatory mediators.
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Affiliation(s)
- Jiguang Guo
- Department of Nephrology,People's Hospital of Rongchang District
| | - Zhen Li
- Department of Nephrology, Yongchuan Hospital of Chongqing Medical University
| | - Dan Tang
- Department of Nephrology, Yongchuan Hospital of traditional Chinese Medicine, Chongqing, China
| | - Jianbin Zhang
- Department of Nephrology, Yongchuan Hospital of Chongqing Medical University
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Abstract
The real issue with the COVID-19 pandemic is that a rapidly increasing number of patients with life-threatening complications are admitted in hospitals and are not well-administered. Although a limited number of patients use the intensive care unit (ICU), they consume medical resources, safety equipment, and enormous equipment with little possibility of rapid recovery and ICU discharge. This work reviews effective methods of using filtration devices in treatment to reduce the level of various inflammatory mediators and discharge patients from the ICU faster. Extracorporeal technologies have been reviewed as a medical approach to absorb cytokines. Although these devices do not kill or remove the virus, they are a promising solution for treating patients and their faster removal from the ICU, thus relieving the bottleneck.
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Affiliation(s)
- Khaled Al Shareef
- Department of Medical Equipment Technology, College of Applied Medical Science, Majmaah University, Majmaah, Saudi Arabia
| | - Mohsen Bakouri
- Department of Medical Equipment Technology, College of Applied Medical Science, Majmaah University, Majmaah, Saudi Arabia,
- Department of Physics, College of Arts, Sebha University, Traghen, Libya,
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49
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Ronco C, Bagshaw SM, Bellomo R, Clark WR, Husain-Syed F, Kellum JA, Ricci Z, Rimmelé T, Reis T, Ostermann M. Extracorporeal Blood Purification and Organ Support in the Critically Ill Patient during COVID-19 Pandemic: Expert Review and Recommendation. Blood Purif 2020; 50:17-27. [PMID: 32454500 PMCID: PMC7270067 DOI: 10.1159/000508125] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 01/27/2023]
Abstract
Critically ill COVID-19 patients are generally admitted to the ICU for respiratory insufficiency which can evolve into a multiple-organ dysfunction syndrome requiring extracorporeal organ support. Ongoing advances in technology and science and progress in information technology support the development of integrated multi-organ support platforms for personalized treatment according to the changing needs of the patient. Based on pathophysiological derangements observed in COVID-19 patients, a rationale emerges for sequential extracorporeal therapies designed to remove inflammatory mediators and support different organ systems. In the absence of vaccines or direct therapy for COVID-19, extracorporeal therapies could represent an option to prevent organ failure and improve survival. The enormous demand in care for COVID-19 patients requires an immediate response from the scientific community. Thus, a detailed review of the available technology is provided by experts followed by a series of recommendation based on current experience and opinions, while waiting for generation of robust evidence from trials.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, University of Padova, Padova, Italy
- International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Division of Nephrology, Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Giessen, Germany
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Thomas Rimmelé
- Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- EA 7426 "Pathophysiology of Injury-induced Immunosuppression", Pi3, Hospices Civils de Lyon - BioMérieux - Claude Bernard University Lyon, Lyon, France
| | - Thiago Reis
- Department of Nephrology, Clinica de Doenças Renais de Brasilia, Brasilia, Brazil
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom,
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50
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Wang L, Zheng C, Zhao D. Successful management of germanium poisoning-induced multiple organ dysfunctions by combined blood purification therapy. Curr Med Res Opin 2020; 36:687-691. [PMID: 31951756 DOI: 10.1080/03007995.2020.1717452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Blood purification therapy has not been applied in the detoxification of germanium compounds. This report described a case of germanium poisoning with renal failure, liver dysfunction, and acute pancreatitis which was successfully treated by continuous venovenous hemodiafiltration (CVVHDF) combined with plasmapheresis.Case report: A 58-year-old male was admitted to a local hospital due to polydipsia, polyuria, and weight loss for 2 months. The patient was definitely diagnosed with germanium poisoning and was treated with blood purification therapy, CVVHDF combined with plasmapheresis. The blood and urinary germanium concentrations decreased rapidly during the first week after the combined blood purification therapy. The blood germanium concentration gradually reduced to within the normal range within the next three weeks and fluctuated at a normal level. However, the urinary germanium concentration exceeded the normal level after three months, indicating an accumulation of germanium in the organs and tissues. The patient's clinical symptoms ameliorated and the functions of kidney, liver and pancreatitis gradually recovered.Conclusion: Combined CVVHDF with plasmapheresis is an effective treatment for germanium poisoning and the associated multiple organ dysfunctions.
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Affiliation(s)
- Luyun Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
| | - Changlong Zheng
- Department of Emergency, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Daqiang Zhao
- Department of Organ Transplantation, Renmin Hospital, Wuhan University, Wuhan, China
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, USA
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