Background
Thirty percent of Covid‐19 patients admitted to intensive care units present with thrombotic complications despite thromboprophylaxis. Bed rest, obesity, hypoxia, coagulopathy, and acute ...excessive inflammation are potential mechanisms reported by previous studies. Better understanding of the underlying mechanisms leading to thrombosis is crucial for developing more appropriate prophylaxis and treatment strategies.
Objective
We aimed to assess fibrinolytic activity and thrombin generation in 78 Covid‐19 patients.
Patients and Methods
Forty‐eight patients admitted to the intensive care unit and 30 patients admitted to the internal medicine department were included in the study. All patients received thromboprophylaxis. We measured fibrinolytic parameters (tissue plasminogen activator, PAI‐1, thrombin activatable fibrinolysis inhibitor, alpha2 anti‐plasmin, and tissue plasminogen activator‐modified ROTEM device), thrombin generation, and other coagulation tests (D‐dimer, fibrinogen, factor VIII, antithrombin).
Results and Conclusions
We observed two key findings: a high thrombin generation capacity that remained within normal values despite heparin therapy and a hypofibrinolysis mainly associated with increased PAI‐1 levels. A modified ROTEM is able to detect both hypercoagulability and hypofibrinolysis simultaneously in Covid‐19 patients with thrombosis.
Purpose
Identifying modifiable factors for sepsis-associated encephalopathy may help improve patient care and outcomes.
Methods
We conducted a retrospective analysis of a prospective multicenter ...database. Sepsis-associated encephalopathy (SAE) was defined by a score on the Glasgow coma scale (GCS) <15 or when features of delirium were noted. Potentially modifiable risk factors for SAE at ICU admission and its impact on mortality were investigated using multivariate logistic regression analysis and Cox proportional hazard modeling, respectively.
Results
We included 2513 patients with sepsis at ICU admission, of whom 1341 (53%) had sepsis-associated encephalopathy. After adjusting for baseline characteristics, site of infection, and type of admission, the following factors remained independently associated with sepsis-associated encephalopathy: acute renal failure adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) 1.19–1.67, hypoglycemia <3 mmol/l (aOR = 2.66, 95% CI 1.27–5.59), hyperglycemia >10 mmol/l (aOR = 1.37, 95% CI 1.09–1.72), hypercapnia >45 mmHg (aOR = 1.91, 95% CI 1.53–2.38), hypernatremia >145 mmol/l (aOR = 2.30, 95% CI 1.48–3.57), and
S. aureus
(aOR = 1.54, 95% CI 1.05–2.25). Sepsis-associated encephalopathy was associated with higher mortality, higher use of ICU resources, and longer hospital stay. After adjusting for age, comorbidities, year of admission, and non-neurological SOFA score, even mild alteration of mental status (i.e., a score on the GCS of 13–14) remained independently associated with mortality (adjusted hazard ratio = 1.38, 95% CI 1.09–1.76).
Conclusions
Acute renal failure and common metabolic disturbances represent potentially modifiable factors contributing to sepsis-associated encephalopathy. However, a true causal relationship has yet to be demonstrated. Our study confirms the prognostic significance of mild alteration of mental status in patients with sepsis.
Abstract Purpose Amongst trauma patients, early coagulopathy is common on hospital admission. No studies have evaluated the initial coagulation status in the pre-hospital setting. We hypothesise that ...the coagulopathic process begins at the time of trauma. We studied the on-scene and on hospital arrival coagulation profile of trauma patients. Methods Prospective, observational study investigating the on-scene coagulation profile and its time course. We studied 45 patients at the scene of the accident, before fluid administration, and on hospital admission and classified their coagulopathy using the International Society on Thrombosis and Haemostasis score during a 2-month period. Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, factors II, V and VII activity, fibrin degradation products, antithrombin and protein C activities, platelet counts and base deficit were measured. Results The median injury severity score was 25 (13–35). On-scene, coagulation status was abnormal in 56% of patients. Protein C activities were decreased in the trauma-associated coagulopathy group ( p = .02). Drops in protein C activities were associated with changes in activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor V and antithrombin activities. Only factor V levels decreased significantly with the severity of the trauma. On hospital admission, coagulation status was abnormal in 60% of patients. The on-scene coagulopathy was spontaneously normalised only in 2 patients whereas others had the same or a poorer coagulopathy status. All parameters of coagulation were significantly abnormal comparing to the on-scene phase. Decreases in protein C activities were related to the coagulation status ( p < .0001) and changes in other coagulation parameters. Patients with base deficit ≤−6 mmol/L had changes in antithrombin, factor V and protein C activities but no significant coagulopathy. Conclusion Coagulopathy occurs very early after injury, before fluid administration, at the site of accident. Coagulation and fibrinolytic systems are activated early. The incidence of coagulopathy is high and its severity is related to the injury and not to hypoperfusion.
Background
Increase in mortality and in recurrent infections in the year following ICU discharge continues in survivors of septic shock, even after total clinical recovery from the initial septic ...event and its complications. This supports the hypothesis that sepsis could induce persistent long-term immune dysfunctions. To date, there is almost no data on ICU discharge and long-term evolution of sepsis-induced immunosuppression in septic shock survivors. The aim of this study was to assess the persistence of sepsis-induced immunosuppression by measuring expression of human leukocyte antigen DR on monocytes (mHLA-DR), CD4+ T cells, and regulatory T cells (Treg) at ICU discharge and 6 months after ICU discharge in patients admitted to the ICU for septic shock.
Methods
In this prospective observational study, septic shock survivors with no preexisting immune suppression or treatment interfering with the immune system were included. mHLA-DR, CD4+ T cells, and Treg expression were assessed on day 1–2, 3–4, and 6–8 after ICU admission, at ICU discharge, and 6 months after ICU discharge.
Results
A total of 40 patients were enrolled during their ICU stay: 21 males (52.5%) and 19 females, median age 68 years (IQR 58–77), median SOFA score on day 1–2 was 8 (IQR 7–9), and median ICU length of stay was 11 days (IQR 7–24). Among these 40 patients, 33 were studied at ICU discharge and 15 were disposed for blood sampling 6 months after ICU discharge. On day 1–2, mHLA-DR expression was abnormally low for all patients median 4212 (IQR 2640–6047) AB/C and remained abnormally low at ICU discharge for 75% of them median 10,281 (IQR 7719–13,035) AB/C. On day 3–4, 46% of patients presented CD4+ lymphopenia median 515 (IQR 343–724) mm
−3
versus 34% at ICU discharge median 642 (IQR 459–846) mm
−3
. Among patients with a 6-month blood sample, normal values of mHLA-DR were found for all patients median 32,616 (IQR 24,918–38,738) AB/C except for one and only another one presented CD4+ lymphopenia.
Conclusions
While immune alterations persist at ICU discharge, there is, at cellular level, no persistent immune alterations among septic shock survivors analyzed 6 months after ICU discharge.
The Métis of Canada were included as an Aboriginal people in the Constitution Act of 1982, but in the intervening decades we have observed a great disparity in the political and legal treatment of ...the various Métis communities by the federal and provincial governments. The Métis of the Ottawa River are a telling case, reflective of the disparities entrenched by the provincial border separating Ontario and Québec. In chronicling the history of this particular Métis community, primarily through unpublished sources, we demonstrate that there is a shared Métis experience and identity in Canada, but that a contiguous community has been arbitrarily divided by a provincial boundary whereby the community is recognized on one side of the divide but not the other.
The impact of prevention strategies and risk factors for early-onset (EOP) versus late-onset (LOP) ventilator-associated pneumonia (VAP) are still debated.
To evaluate, in a multicenter cohort, the ...risk factors for EOP and LOP, as the evolution of prevention strategies.
7,784 patients with mechanical ventilation (MV) for at least 48 hours were selected into the multicenter prospective OUTCOMEREA database (1997-2016). VAP occurring between the 3rd and 6th day of MV defined EOP, while those occurring after defined LOPs. We used a Fine and Gray subdistribution model to take the successful extubation into account as a competing event.
Overall, 1,234 included patients developed VAP (EOP: 445 (36%); LOP: 789 (64%)). Male gender was a risk factor for both EOP and LOP. Factors specifically associated with EOP were admission for respiratory distress, previous colonization with multidrug-resistant Pseudomonas aeruginosa, chest tube and enteral feeding within the first 2 days of MV. Antimicrobials administrated within the first 2 days of MV were all protective of EOP. ICU admission for COPD exacerbation or pneumonia were early risk factors for LOP, while imidazole and vancomycin use within the first 2 days of MV were protective factors. Late risk factors (between the 3rd and the 6th day of MV) were the intra-hospital transport, PAO2-FIO2<200 mmHg, vasopressor use, and known colonization with methicillin-resistant Staphylococcus aureus. Among the antimicrobials administered between the 3rd and the 6th day, fluoroquinolones were the solely protective one.Contrarily to LOP, the risk of EOP decreased across the study time periods, concomitantly with an increase in the compliance with bundle of prevention measures.
VAP risk factors are mostly different according to the pneumonia time of onset, which should lead to differentiated prevention strategies.
This article challenges the ideological position that denies the historical existence of Métis in Québec. Responding to accusations such that Eastern Métis are “zombies” with no “living” traditions, ...this paper has two objectives. First, it explores some political and juridical elements that help explain the emergence of such reactionary rhetoric. It then presents the oral tradition of Marie-Louise Riel, reported as protecting the Métis leader in the Outaouais region during his political exile. Through the exploration of this oral history, we offer examples of Eastern-Western Métis kinship and solidarity that defy the territorial reification of Métis culture as being a West-only phenomenon. Together, the evidence compiled and reviewed offers compelling reasons to assert that the Outaouais Métis are bearers of a distinct identity—an identity that many of their descendants still value today.
Following the 2010 Deepwater Horizon accident of a massive blow-out in the Gulf of Mexico, scientists from government, industry, and academia collaborated to advance oil spill modeling and share best ...practices in model algorithms, parameterizations, and application protocols. This synergy was greatly enhanced by research funded under the Gulf of Mexico Research Initiative (GoMRI), a 10-year enterprise that allowed unprecedented collection of observations and data products, novel experiments, and international collaborations that focused on the Gulf of Mexico, but resulted in the generation of scientific findings and tools of broader value. Operational oil spill modeling greatly benefited from research during the GoMRI decade. This paper provides a comprehensive synthesis of the related scientific advances, remaining challenges, and future outlook. Two main modeling components are discussed: Ocean circulation and oil spill models, to provide details on all attributes that contribute to the success and limitations of the integrated oil spill forecasts. These forecasts are discussed in tandem with uncertainty factors and methods to mitigate them. The paper focuses on operational aspects of oil spill modeling and forecasting, including examples of international operational center practices, observational needs, communication protocols, and promising new methodologies.
The Métis of Canada were included as an Aboriginal people in the Constitution Act of 1982, but in the intervening decades we have observed a great disparity in the political and legal treatment of ...the various Métis communities by the federal and provincial governments. The Métis of the Ottawa River are a telling case, reflective of the disparities entrenched by the provincial border separating Ontario and Quebec. In chronicling the history of this particular Métis community, primarily through unpublished sources, we demonstrate that there is a shared Métis experience and identity in Canada, but that a contiguous community has been arbitrarily divided by a provincial boundary whereby the community is recognized on one side of the divide but not the other.
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