The role of quick Sepsis-related Organ Failure Assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier’s Gangrene Severity Index: Analysis of 69 patients

Objective:Fournier’s gangrene is a rare but life-threatening infection disease with high mortality rate.The quick Sepsis-related Organ Failure Assessment(qSOFA)is a new and simpler scoring system that may identify patients with suspected infection who are at greater risk for a poor outcome.The purpose of this study was to find out role of qSOFA in determining prognosis of Fournier’s gangrene patients.Methods:This study is a case control with retrospective review of Fournier’s gangrene patients treated at Hasan Sadikin Hospital from January 2013 to December 2017 who met inclusion criteria.Participants were divided into two groups according to qSOFA score as high qSOFA(2-3)and low qSOFA(0-1).Results:From 69 patients,the mortality rate was 24.6%.The sensitivity of qSOFA score to predict mortality was 88.2%;the specificity was 94.2%;positive predictive value was 83.3%;negative predictive value was 96.1%;positive likelihood ratio was 15.2;negative likelihood ratio was 0.12;and the area under the receiver operating characteristic curve of qSOFA was 94.2%.There was significant association between qSOFA scale and mortality with p-value of 0.0001.The qSOFA score has strong positive correlation with Fournier’s Gangrene Severity Index(p<0.0001,r=0.704).Conclusion:qSOFA scoring system has a high prognostic value and can be used to determine prognosis of Fournier’s gangrene patients.

Clinical study of neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in hypertriglyceridemia-induced acute pancreatitis and acute biliary pancreatitis with persistent organ failure

BACKGROUND The neutrophil-to-lymphocyte ratio(NLR)and platelet-to-lymphocyte ratio(PLR)are novel inflammatory indicators that can be used to predict the severity and prognosis of various diseases.We categorize acute pancreatitis by etiology into acute biliary pancreatitis(ABP)and hypertriglyceridemia-induced acute pancreatitis(HTGP).AIM To investigate the clinical significance of NLR and PLR in assessing persistent organ failure(POF)in HTGP and ABP.METHODS A total of 1450 patients diagnosed with acute pancreatitis(AP)for the first time at Shanxi Bethune Hospital between January 2012 and January 2023 were enrolled.The patients were categorized into two groups according to the etiology of AP:ABP in 530 patients and HTGP in 241 patients.We collected and compared the clinical data of the patients,including NLR,PLR,and AP prognostic scoring systems,within 48 h of hospital admission.RESULTS The NLR(9.1 vs 6.9,P<0.001)and PLR(203.1 vs 160.5,P<0.001)were significantly higher in the ABP group than in the HTGP group.In the HTGP group,both NLR and PLR were significantly increased in patients with severe AP and those with a SOFA score≥3.Likewise,in the ABP group,NLR and PLR were significantly elevated in patients with severe AP,modified computed tomography severity index score≥4,Japanese Severity Score≥3,and modified Marshall score≥2.Moreover,NLR and PLR showed predictive value for the development of POF in both the ABP and HTGP groups.CONCLUSION NLR and PLR vary between ABP and HTGP,are strongly associated with AP prognostic scoring systems,and have predictive potential for the occurrence of POF in both ABP and HTGP.

Bedside index for severity in acute pancreatitis:comparison with other scoring systems in predicting severity and organ failure

BACKGROUND:The early identification of severe acute pancreatitis is important for the management and for improving outcomes.The bedside index for severity in acute pancreatitis(BISAP)has been considered as an accurate method for risk stratification in patients with acute pancreatitis.This study aimed to evaluate the comparative usefulness of the BISAP.METHODS:We retrospectively analyzed 303 patients with acute pancreatitis diagnosed at our hospital from March 2007to December 2010.BISAP,APACHE-II,Ranson criteria,and CT severity index(CTSI)of all patients were calculated.We stratified the number of patiants with severe pancreatitis,pancreatic necrosis,and organ failure as well as the number of deaths by BISAP score.We used the area under the receiveroperating curve(AUC)to compare BISAP with other scoring systems,C-reactive protein(CRP),hematocrit,and body mass index(BMI)with regard to prediction of severe acute pancreatitis,necrosis,organ failure,and death.RESULTS:Of the 303 patiants,31(10.2%)were classified as having severe acute pancreatitis.Organ failure occurred in 23(7.6%)patients,pancreatic necrosis in 40(13.2%),and death in6(2.0%).A BISAP score of 2 was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis,organ failure,and mortality.AUCs for BISAP predicting severe pancreatitis and death were 0.80 and 0.86,respectively,which were similar to those for APACHE-II(0.80,0.87)and Ranson criteria(0.74,0.74)and greater than AUCs for CTSI(0.67,0.42).The AUC for organ failure predicted by BISAP,APACHE-II,Ranson criteria,and CTSI was 0.93,0.95,0.84 and 0.57,respectively.AUCs for BISAP predicting severity,organ failure,and death were greater than those for CRP(0.69,0.80,0.72),hematocrit(0.45,0.35,0.14),and BMI(0.41,0.47,0.17).CONCLUSION:The BISAP predicts severity,death,and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria,CTSI,CRP,hematocrit,and BMI.

Risk factors of organ failure in cholangitis with bacteriobilia

AIM: To identify the risk factors for organ failure(OF) in cholangitis with bacteriobilia.METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.RESULTS: There were 24 cases(13.2%) of OF and five deaths(2.7%). Bile culture was positive for microbial growth in 130 out of 138(94.2%) patients. In multivariate analysis of 130 patients with positivebile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase(ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation:(2.7 × ESBL organisms in blood cultures) +(1.8 × pre-existing renal dysfunction) +(1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific(99.1%) and had a positive predictive value of 86.2%.CONCLUSION: ESBL organisms in blood cultures, preexisting renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.

Effect of Early Hemofiltration on Pro- and Anti-inflammatory Responses and Multiple Organ Failure in Severe Acute Pancreatitis

The effects of early hemofiltration on the serum levels of cytokines, pro- and anti-inflammatory balance and organ function in pigs with severe acute pancreatits (SAP) were studied. SAP pig model was induced by retrograde injection of artificial bile into the pancreatic duct. The pigs were randomly divided into SAP hemofiltration treatment group (HF group, n=8) and SAP non-hemofiltration treatment group (NHF group, n=8). In the HF group, the animals were subjected to high-volume and zero-balance hemofiltration therapy. The results showed that as compared with NHF group, MAP, CVP and PaO 2/FiO 2 were significantly increased (P<0.01), while HR, urinary protein content, serum ALT level, pulmonary coefficient and lung wet/dry ratio obviously decreased (P<0.05) in HF group. Under a light microscope, the pulmonary histologic scoring was lower that in HF group (P<0.01) and the lesions of renal and liver tissues were milder. However, there was no significant difference in the pancreatic histologic scoring between the two groups. Six h after establishment of the model, the serum levels of TNF-α, IL-1β were lower, while the IL-10/TNF-α ratio was higher in HF group (all P<0.05). It was suggested that early hemofiltration could effectively remove the serum cytokines TNF-α and IL-1β in SAP pigs, elevate the ratio of IL-10/TNF-α, improve hemodynamics and alleviate the lesions of lung, kidney and liver tissues.

Comparison of different versions of the quick sequential organ failure assessment for predicting in-hospital mortality of sepsis patients:A retrospective observational study

BACKGROUND:The quick sequential organ failure assessment(qSOFA)is recommended to identify sepsis and predict sepsis mortality.However,some studies have recently shown its poor performance in sepsis mortality prediction.To enhance its effectiveness,researchers have developed various revised versions of the qSOFA by adding other parameters,such as the lactate-enhanced qSOFA(LqSOFA),the procalcitonin-enhanced qSOFA(PqSOFA),and the modified qSOFA(MqSOFA).This study aimed to compare the performance of these versions of the qSOFA in predicting sepsis mortality in the emergency department(ED).METHODS:This retrospective study analyzed data obtained from an electronic register system of adult patients with sepsis between January 1 and December 31,2019.Receiver operating characteristic(ROC)curve analyses were performed to determine the area under the curve(AUC),with sensitivity,specificity,and positive and negative predictive values calculated for the various scores.RESULTS:Among the 936 enrolled cases,there were 835 survivors and 101 deaths.The AUCs of the LqSOFA,MqSOFA,PqSOFA,and qSOFA were 0.740,0.731,0.712,and 0.705,respectively.The sensitivity of the LqSOFA,MqSOFA,PqSOFA,and qSOFA were 64.36%,51.40%,71.29%,and 39.60%,respectively.The specificity of the four scores were 70.78%,80.96%,61.68%,and 91.62%,respectively.The LqSOFA and MqSOFA were superior to the qSOFA in predicting in-hospital mortality.CONCLUSIONS:Among patients with sepsis in the ED,the performance of the PqSOFA was similar to that of the qSOFA and the values of the LqSOFA and MqSOFA in predicting in-hospital mortality were greater compared to qSOFA.As the added parameter of the MqSOFA was more convenient compared to the LqSOFA,the MqSOFA could be used as a candidate for the revised qSOFA to increase the performance of the early prediction of sepsis mortality.

Failure behavior of protective organic coatings under corrosive conditions

Recent research activities on the formation of micro-defects and porosity in organic coatings were reviewed. The mechanisms of aggressive ionic conduction through organic coatings were analyzed. The micro-mechanisms for the failure behavior of coatings under corrosive environments were discussed in detail. These mechanisms included blistering (i. e. osmotic blistering, anodic blistering and cathodic blistering) in the coating, wet-adhesion loss at the substrate/coating interface, cathodic delamination of coating from the substrate. Based on these researches, it was found that the failure behavior of organic coatings is closely related to the micro-defects in coatings, regardless of the failure mode. Additionally, the general failure mode of a coating system was proposed to interpret the failure behavior of organic in corrosion environments. The topics discussed can provide some insights into the development of a methodology for designing fail-safe coating systems.

Early versus delayed intervention in necrotizing acute pancreatitis complicated by persistent organ failure

Background:Current guidelines for the treatment of patients with necrotizing acute pancreatitis(NAP)recommend that invasive intervention for pancreatic necrosis should be deferred to 4 or more weeks from disease onset to allow necrotic collections becoming“walled-off”.However,for patients showing signs of clinical deterioration,especially those with persistent organ failure(POF),it is controversial whether this delayed approach should always be adopted.In this study,we aimed to assess the impact of differently timed intervention on clinical outcomes in a group of NAP patients complicated by POF.Methods:All NAP patients admitted to our hospital from January 2013 to December 2017 were screened for potential inclusion.They were divided into two groups based on the timing of initial interven-tion(within 4 weeks and beyond 4 weeks).All the data were extracted from a prospectively collected database.Results:Overall,131 patients were included for analysis.Among them,100(76.3%)patients were in-tervened within 4 weeks and 31(23.7%)underwent delayed interventions.As for organ failure prior to intervention,the incidences of respiratory failure,renal failure and cardiovascular failure were not signifi-cantly different between the two groups(P>0.05).The mortality was not significantly different between the two groups(35.0%vs.32.3%,P=0.83).The incidences of new-onset multiple organ failure(8.0%vs.6.5%,P=1.00),gastrointestinal fistula(29.0%vs.12.9%,P=0.10)and bleeding(35.0%vs.35.5%,P=1.00),and length of ICU(30.0 vs.22.0 days,P=0.61)and hospital stay(42.5 vs.40.0 days,P=0.96)were com-parable between the two groups.Conclusion:Intervention within 4 weeks did not worsen the clinical outcomes in NAP patients compli-cated by POF.

Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis

AIM To assess differences in clinical outcomes of isolated renal failure(RF) compared to other forms of organ failure(OF) in patients with severe acute pancreatitis(SAP).METHODS Using a prospectively maintained database of patients with acute pancreatitis admitted to a tertiary medical center between 2003 and 2016, those with evidence of persistent OF were classified to renal, respiratory, cardiovascular, or multi-organ(2 or more organs). Data regarding demographics, comorbidities, etiology of acute pancreatitis, and clinical outcomes were prospectively recorded. Differences in clinical outcomes after development of isolated RF in comparison to other forms of OF were determined using independent t and Mann-Whitney U tests for continues variables, and χ~2 test for discrete variables.RESULTS Among 500 patients with acute pancreatitis, 111 patients developed persistent OF: mean age was 54 years, and 75(67.6%) were male. Forty-three patients had isolated OF: 17(15.3%) renal, 25(21.6%) respiratory, and 1(0.9%) patient with cardiovascular failure. No differences in demographics, etiology of acute pancreatitis, systemic inflammatory response syndrome scores, or development of pancreatic necrosis were seen between patients with isolated RF vs isolated respiratory failure. Patients with isolated RF were less likely to require nutritional support(76.5% vs 96%, P = 0.001), ICU admission(58.8% vs 100%, P = 0.001), and had shorter mean ICU stay(2.4 d vs 15.7 d, P < 0.001), compared to isolated respiratory failure. None of the patients with isolated RF or isolated respiratory failure died.CONCLUSION Among patients with SAP per the Revised Atlanta Classification, approximately 15% develop isolated RF. This subgroup seems to have a less protracted clinical course compared to other forms of OF. Isolated RF might be weighed less than isolated respiratory failure in risk predictive modeling of acute pancreatitis.

Adult-onset Still's disease evolving with multiple organ failure and death:A case report and review of the literature

BACKGROUND Adult-onset Still’s disease(AOSD)is a rare systemic inflammatory disease,which is characterized by daily fever and arthritis,with an evanescent rash and neutrophilic leukocytosis.To date,there has been no definite laboratory or imaging test available for diagnosing AOSD;the diagnosis is one of exclusion,which can be very challenging.In particular,AOSD patients may experience different complications affecting their clinical picture,management,and prognosis.The treatment of AOSD remains largely empirical and involves therapeutic agents.CASE SUMMARY We report the case of a 36-year-old woman who presented with fever,red rash,arthralgia,and sore throat.Her serum ferritin level and white blood cell count were markedly elevated,and the first diagnosis 22 years prior was"juvenile rheumatoid arthritis of systemic type".The patient was treated with prednisone,sulfasalazine,methotrexate,and leflunomide.After remission of her symptoms,the patient stopped taking the medications,and the disease recurred.Ultimately,the patient was diagnosed with adult-onset Still's disease.Relapse occurred several times due to self-medication withdrawal,and an interleukin-6 antagonist(tocilizumab/Actemra)was administered to control the disease.Recently,she was hospitalized because an incision did not heal,and the patient suddenly developed high fever and diarrhea during hospitalization.The patient's disease progressed violently and quickly developed into macrophage activation syndrome,disseminated intravascular coagulation,shock,and multiple organ failure.The patient had sudden cardiac arrest,and she died despite emergency rescue efforts.CONCLUSION AOSD patients need regular follow-up in the long-term treatment process,and must press formulary standard medication,and do not voluntarily withdraw or reduce the dose.Otherwise it may cause disease back-and-forth or serious lifethreatening complications.Meanwhile,strict management of trauma,infections,tumors,and other diseases may contribute to improved outcomes in patients with complications.

Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis

BACKGROUND Acute pancreatitis(AP)is a common surgical condition,with severe AP(SAP)potentially lethal.Many prognostic indices,including;acute physiology and chronic health evaluation II score(APACHE II),bedside index of severity in acute pancreatitis(BISAP),Glasgow score,harmless acute pancreatitis score(HAPS),Ranson’s score,and sequential organ failure assessment(SOFA)evaluate AP severity and predict mortality.AIM To evaluate these indices'utility in predicting severity,intensive care unit(ICU)admission,and mortality.METHODS A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed.The demographic,clinical profile,and patient outcomes were collected.SAP was defined as per the revised Atlanta classification.Values for APACHE II score,BISAP,HAPS,and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform.Data with<10%missing data was imputed via mean substitution.Other patient information such as demographics,disease etiology,and patient outcomes were also derived from electronic medical records.RESULTS The mean age was 58.7±17.5 years,with 58.7%males.Gallstones(n=404,61.9%),alcohol(n=38,5.8%),and hypertriglyceridemia(n=19,2.9%)were more common aetiologies.81(12.4%)patients developed SAP,20(3.1%)required ICU admission,and 12(1.8%)deaths were attributed to SAP.Ranson’s score and APACHE-II demonstrated the highest sensitivity in predicting SAP(92.6%,80.2%respectively),ICU admission(100%),and mortality(100%).While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP(13.6%,24.7%respectively),ICU admission(40.0%,25.0%respectively)and mortality(50.0%,25.5%respectively).However,SOFA demonstrated the highest specificity in predicting SAP(99.7%),ICU admission(99.2%),and mortality(98.9%).SOFA demonstrated the highest positive predictive value,positive likelihood ratio,diagnostic odds ratio,and overall accuracy in predicting SAP,ICU admission,and mortality.SOFA and Ranson’s score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP(0.966,0.857 respectively),ICU admission(0.943,0.946 respectively),and mortality(0.968,0.917 respectively).CONCLUSION The SOFA and 48-h Ranson’s scores accurately predict severity,ICU admission,and mortality in AP,with more favorable statistics for the SOFA score.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage:Retrospective cohort study

BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.

Changes of thromboxane and prostacyclin in the pathogenesis of multiple organ failure in severe burns

Fifty-seven severely burned patients were divided into 2 groups:16 withmultiple organ failure（MOF）,and 41 without MOF.It was found that the levelof thromboxane B2（TXB2）and the ratio between TXB2 and 6-keto-prostaglandinF1α(TBX2/6-keto-PGF1α)in plasma and in visceral tissues were increased and re-mained significantly high in the first 5～7 d postburn in patients with MOF but notso in those without MOF.The circulatory platelet aggregate ratio（CPAR）wasmarkedly decreased in the same period in MOF group.Myocardial enzymes（CPK,LDH,and GOT）were markedly increased in the first 3d and remainedsignificantly high within 7 d postburn.Degeneration,structural destruction,edema,hemorrhage and thrombosis were revealed in cardiac,pulmonary,renal andhepatic tissues succumbing to functional failure.Thirteen out of the 16 cases de-veloped MOF during the 3rd to 7th day posthurn and 11 died in that period.These findings substantiate that persistent increase of thromboxane andthromboxane/prostacyclin ratio is closely related to the origin and development ofMOF after burn injury.

Case Report: A Severe Hypernatremia with Multiple Organ Failure, about a Clinical Observation

A hypernatremia severity is often associated with a poor prognosis, especially if it is associated with multiple organ failure. In a country with very limited resources, the prognosis may be favorable in the absence of renal replacement. We report the case of a 63 years old woman, hypertensive and diabetic, admitted to the ICU for unconsciousness. Clinically, neurological examination notes a Glasgow of 8/15 (Y2, V2, M4) and a left hemiplegia. Temperature was 39°C. Diuresis was 100 ml during the first 24 hours. Blood pressure was 90/60 mmHg, tachycardia at 133/min. Cardiac auscultation is normal. Vascular axes were weakly perceptible. Oxygen saturation was 95%. The skin examination notes a dry skin and mucous membranes, a flattening of the superficial veins, sunken eyes and a persistent skin fold. There is no hepatomegaly or splenomegaly, or jaundice. Biological point of view note natremia: 176 mmol/L;osmolarity: 390 mosmol/kg;creatinin: 300 μmol/L;glycemia > 6 g/L;transaminases 217 UI. Diagnostics: malignant hypernatremia with a high plasma osmolarity associated with an acute anuric renal failure, hydro electrolytic disorders, an abnormal liver function, a fever of central origin and a stroke. The treatment consisted of a correction of the electrolyte disorders by infusion of isotonic and hypotonic fluids with insulin. In a country with very limited resources, the severe hypernatremia prognosis associated with anuric acute renal failure may be favorable in the absence of renal replacement.

Lifetime prediction and failure analysis of organic coatings by EIS

Organic coatings are widely used to control the corrosion of steel structure. The anticorrosive property of these coatings depends on their barrier properties, making a separation between the corrosive medium and the substrate. But unavoidable completely small pores, cracks and other defects in organic coatings may cause ions, water, gases, and other corrosive species penetrate and distribute in the coatings, causing accumulation and swelling of coatings, so leading to the degradation of coatings. In addition, water affects the permeation of oxygen and other corrosive medium, consequently the presence of such substances at coating-metal interface promotes corrosion of metal substrate. So the absorbability of the coatings to water may be one of the most important factors in undercoating corrosion. In recent years, electrochemical impedance spectroscopy (EIS) has been established and frequently used as a non-destructive testing method for assessing the performance of organic coatings, especially for the determination of the water content in organic coatings, since the capacitance of the coatings is sensitive to the penetration of water. So from EIS it can extract a wealth of information on the electrochemical corrosion of coated steels, especially, it can be utilized to assess organic coatings used under particular surroundings. The principle, methods and application of EIS on evaluating life-span and analyzing failure mechanism of organic coatings are also introduced briefly. Combining other analysis techniques such as XRD, SEM and FTIR with electrochemical technique, it will blaze a way in studying degradation mechanism of organic coatings and estimating their lifetime.

A case report of melioidosis pneumonia with multiple organ failure

Objective:To analyze the clinical and follow-up data of patients with multiple organ failure of melioidosis pneumonia,to strengthen the understanding of melioidosis,and to provide references for the diagnosis and treatment of clinicians,especially doctors in Hai nan province with high incidence,so as to reduce misdiagnosis,improve the diagnosis rate and reduce the mortality.Methods:The clinical symptoms,signs,laboratory examination and follow-up of patients with multiple organ failure were analyzed retrospectively.Results:Multiple organ failure with melioidosis pneumonia was easily misdiagnosed,Treatment cycle is long,easy to relapse.Conclusion:It is very important to analyze and differentiate the anthrax with multiple organ failure,especially in Hai nan province,which can improve the diagnosis rate and reduce the mortality.

Knowledge about the Quick Sequential Organ Failure Assessment and Recognition of Sepsis: A Survey among Emergency Nurses

The purpose of this study was to assess the knowledge of emergency nurses of quick Sequential Organ Failure Assessment(qSOFA)score,screening tool,and recognition,and importance of sepsis.A multicenter study including 110 ED nurses from six hospitals in Qingdao was conducted.A validated questionnaire was used to evaluate ED nurses’knowledge about qSOFA,sepsis 3.0,and early sepsis screening tool with qSOFA.The scores of knowledge about sepsis 3.0 and qSOFA were lower.The scores of the different characteristics of nurses were statistically different(P<0.05).Col1egues,self-study,and school were the main source of knowledge about sepsis.Manager should improve the cognition of sepsis and strengthen staff training about sepsis in ED.

Current approach to disseminated intravascular coagulation related to sepsis-organ failure type

Disseminated intravascular coagulation(DIC) is a syndrome characterized by the systemic activation of blood clotting, which generates large amount of intravascular thrombin and fibrin. Various diseases may cause acceleration of the clotting cascade, inactivate the endogenous anticoagulants and modify fibrinolysis, having thus the formation of micro thrombi in the systemic circulation. The abnormalities in the hemostatic system in patients with DIC result from the sum of pathways that generate both hypercoagulability and augmented fibrinolysis. When the hypercoagulability state prevails, the main manifestation is organic failure. This subtype of DIC is often referred as "organ impairment" type, frequently seen in patients suffering from severe sepsis. To identify the underlying infection, early initiation of culture-based antimicrobial treatment, and to resolve any infection source promptly are keystone actions of DIC related to sepsis prevention and treatment. These should be combined with specific treatment related to each DIC subtype. In the context of septic shock, DIC is associated to increased severity, greater number and seriousness of organ failures, more frequent side-effects from treatment itself, and worse outcomes. Therefore, we ought to review the information available in the literature about approach and management of DIC in severe sepsis.

Multi-organ failure with atypical liver granulomas following intravesical Bacillus Calmette-Guerin instillation

Bacillus Calmette-Guerin(BCG) intravesical instillation has been adopted in the treatment of patients with superficial bladder cancer.BCG-induced disseminated infection,though rare,has been associated with the histological finding of epithelioid granulomas in different organs,including the liver.We report the case of an adult patient with multi-organ failure,who developed sepsis,acute respiratory failure and acute hepatic failure with encephalopathy whose liver biopsy confirmed the presence of atypical,granulomatous-like lesions.Recovery was observed only after empirical therapy for Mycobacterium bovis with isoniazid,rifampicin,ethambutol and steroids was introduced.This case highlights the importance of a thorough patient assessment in order to exclude other more common causes of hepatic granulomas and to confirm diagnosis.Histological findings may be non-specific when the liver is involved in BCGinduced disseminated infection.