...the current world-wide event has now been declared a pandemic by the World Health Organization (WHO). 9 Despite these efforts, as of February 25th, there were 78,064 confirmed infections, 8752 ...patients in serious condition, and 2715 reported mortalities in Mainland China alone. ...Chinese authorities estimate a total of 647,406 people who had close contact/proximity with infected people, and more than 79,000 individuals who are under medical observation. In this context, telemedicine represents an attractive, effective, and affordable option. ...this technology is of critical importance when one considers the consequences of health-care providers contracting COVID-19 as a result of direct exposure; something that can be especially devastating in low-resource areas or under the circumstances of massive stress to the existing health-care infrastructure and staff. 35,36,37 Using tailored approaches, TMS providers can remotely identify patients who may require further escalation of care. ...TMS can be a powerful gate-keeping and coordination mechanism to ensure more appropriate use of provider offices, emergency departments (EDs), and hospitals, as understood within the above broader context.
The incidence of death among patients admitted for severe sepsis or septic shock is high. Adrenomedullin (ADM) plays a central role in initiating the hyperdynamic response during the early stages of ...sepsis. Pilot studies indicate an association of plasma ADM with the severity of the disease. In the present study we utilized a novel sandwich immunoassay of bioactive plasma ADM in patients hospitalized with sepsis in order to assess the clinical utility.
We enrolled 101 consecutive patients admitted to the emergency department with suspected sepsis in this study. Sepsis was defined by fulfillment of at least two systemic inflammatory response syndrome (SIRS) criteria plus clinical suspicion of infection. Plasma samples for ADM measurement were obtained on admission and for the next four days. The 28-day mortality rate was recorded.
ADM at admission was associated with severity of disease (correlation with Acute Physiology and Chronic Health Evaluation II (APACHE II) score: r = 0.46; P <0.0001). ADM was also associated with 28-day mortality (ADM median (IQR): survivors: 50 (31 to 77) pg/mL; non-survivors: 84 (48 to 232) pg/mL; P <0.001) and was independent from and additive to APACHE II (P = 0.02). Cox regression analysis revealed an additive value of serial measurement of ADM over baseline assessment for prediction of 28-day mortality (P < 0.01). ADM was negatively correlated with mean arterial pressure (r = -0.39; P <0.0001), and it strongly discriminated those patients requiring vasopressor therapy from the others (ADM median (IQR): no vasopressors 48 (32 to 75) pg/mL; with vasopressors 129 (83 to 264) pg/mL, P <0.0001).
In patients admitted with sepsis, severe sepsis or septic shock plasma ADM is strongly associated with severity of disease, vasopressor requirement and 28-day mortality.
ST2 is a member of the interleukin (IL) 1 receptor family that exists in 2 forms, a transmembrane receptor (ST2L) and a soluble receptor (sST2). The ligand of ST2 is IL-33, known to be involved in ...reducing tissue fibrosis and myocyte hypertrophy in mechanically strained hearts. Through its ability to act as a decoy receptor, sST2 blocks the beneficial effects that occur when IL-33 attempts to bind to ST2L; experimentally, this leads to cardiac hypertrophy, fibrosis, and ventricular dysfunction. In patients with acutely decompensated heart failure, elevated concentrations of sST2 are strongly associated with the presence and severity of the diagnosis and powerfully predict increased risk of heart failure complications including arrhythmia, pump failure, or death, independent of natriuretic peptides and other established or emerging biomarkers. The role of sST2 measurement in acutely decompensated heart failure evaluation and management will be discussed.
In the emergency department (ED) and critically ill patients in general, acute kidney injury (AKI) is a common complication, and obtaining
timely information about kidney function is crucial for ...initiating protective measures as early as possible. Creatinine-based estimations of
the glomerular filtration rate are currently the standard of care, but they are imprecise, prone to errors, and have significant time delays
in the identification of reduced kidney function and kidney damage. Emerging research indicates that proenkephalin A 119-159 (penKid)
may overcome these drawbacks by indirectly assessing the hormone enkephalin, which stimulates kidney function. This approach offers
a more precise evaluation of the kidney. As a novel biomarker for detecting AKI, penKid can be measured immediately upon a patient’s
arrival at the ED or intensive care unit (ICU), allowing for the early prediction of declining renal function up to 48 h ahead of current
diagnostic practices. In summary, penKid offers rapid access to vital information about kidney function for physicians in the ED and ICU. This
information complements current diagnostic tools and enables early assessment of renal function. Consequently, penKid can assist clinicians
in various clinical scenarios, such as guiding the administration of nephrotoxic drugs or aiding decisions regarding the discontinuation of
renal replacement therapy.
Of huge importance now is to provide a fast, cost-effective, safe, and immediately available pharmaceutical solution to curb the rapid global spread of SARS-CoV-2. Recent publications on SARS-CoV-2 ...have brought attention to the possible benefit of chloroquine in the treatment of patients infected by SARS-CoV-2. Whether chloroquine can treat SARS-CoV-2 alone and also work as a prophylactic is doubtful. An effective prophylactic medication to prevent viral entry has to contain, at least, either a protease inhibitor or a competitive virus ACE2-binding inhibitor. Using bromhexine at a dosage that selectively inhibits TMPRSS2 and, in so doing, inhibits TMPRSS2-specific viral entry is likely to be effective against SARS-CoV-2. We propose the use of bromhexine as a prophylactic and treatment. We encourage the scientific community to assess bromhexine clinically as a prophylactic and curative treatment. If proven to be effective, this would allow a rapid, accessible, and cost-effective application worldwide.
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Biologically active adrenomedullin (bio-ADM) is an emerging biomarker for sepsis. We explored ...whether bio-ADM concentration could predict severity, organ failure, and 30-day mortality in septic patients.
In 215 septic patients (109 patients with sepsis; 106 patients with septic shock), bio-ADM concentration was measured at diagnosis of sepsis, using sphingotest bio-ADM (Sphingotec GmbH, Hennigsdorf, Germany) and analyzed in terms of sepsis severity, vasopressor use, and 30-day mortality. The number of organ failures, sequential (sepsis-related) organ failure assessment (SOFA) score, and 30-day mortality were compared according to bio-ADM quartiles.
Bio-ADM concentration was significantly higher in patients with septic shock, vasopressor use, and non-survivors than in patients with solitary sepsis, no vasopressor use, and survivors, respectively (all
<0.0001). Bio-ADM quartiles were associated with the number of organ failures (
<0.0001), as well as SOFA cardiovascular, renal, coagulation, and liver subscores (all
<0.05). The 30-day mortality rate showed a stepwise increase in each bio-ADM quartile (all
<0.0001). Bio-ADM concentration and SOFA score equally predicted the 30-day mortality (area under the curve: 0.827 vs 0.830).
Bio-ADM could serve as a useful and objective biomarker to predict severity, organ failure, and 30-day mortality in septic patients.
Bacterial resistance to antimicrobials is considered a major issue worldwide. This condition may account for treatment failure of urinary tract infections, which are among the most common infections ...both in community and healthcare settings. Therapy against uropathogens is generally administered empirically, possibly leading to unsuccessful therapy, recurrence and development of antibiotic resistance. The reduction in analytical time to obtain antimicrobial susceptibility test (AST) results could play a key role in reducing the cost of healthcare, providing information about antibiotic efficacy and thus preventing from either exploiting new and expensive antibiotics unnecessarily or using obsolete and ineffective ones. A more rational choice among treatment options would hence lead to more effective treatment and faster resolution. In this paper we evaluated the performance of a new Point Of Care Test (POCT) for the rapid prediction of antimicrobial susceptibility in urine samples performed without the need of a laboratory or specialized technicians. 349 patients were enrolled in two open-label, monocentric, non-interventional clinical trials in partnership with an Emergency Medicine ward and the Day Hospital of two large healthcare facilities in Rome. Antibiogram was carried out on 97 patients. Results from analysis of urine samples with the POCT were compared with those from routine AST performed on culture-positive samples, displaying high accuracy (>90%) for all tested antimicrobial drugs and yielding reliable results in less than 12 hours from urine collection thus reducing analytical and management costs.
Sepsis and septic shock have an enormous burden on healthcare systems, having more than 30 million people worldwide suffering from those diseases. As emergency providers we must be able to ...immediately recognize the presence of sepsis to improve the management of this disease and reduce its burden on patient’s lives and on the emergency departments. Biomarkers can play an important role in this attempt. Laboratory tests could help both to identify the presence of sepsis at patients’ arrival and to stratify the risk of progression to septic shock. A new biomarker in that regard is represented by Bioactive Adrenomedullin (BioADM), which mirrors vascular integrity, and is able to detect the physio pathological deterioration of the patients with sepsis that will progress into septic shock. Now, thanks to point-of-care testing devices, we are able to measure BioADM in whole blood in less than twenty minutes, which will help the physician making faster and more adequate therapeutical decisions beside patient’s bed. The good news is that BioADM will also serve as a target for a monoclonal antibody that will counteract the vascular disfunction in septic shock. In conclusion, coupling BioADM with other biomarkers already routinely used such as procalcitonin and lactate we can immediately change patient’s management in Sepsis improving our decision making and patient outcome.
The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring ...dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction.
Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines.
Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms.
PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI.
Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis.
Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses.
We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively.
Practice variability in initiation of dialysis. Imperfect harmonization of data across studies.
Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.
Display omitted
PDF
