Can rifaximin for hepatic encephalopathy be discontinued during broad-spectrum antibiotic treatment?

Hepatic encephalopathy(HE)is a formidable complication in patients with decompensated cirrhosis,often necessitating the administration of rifaximin(RFX)for effective management.RFX,is a gut-restricted,poorly-absorbable oral rifamycin derived antibiotic that can be used in addition to lactulose for the secondary prophylaxis of HE.It has shown notable reductions in infection,hospital readmission,duration of hospital stay,and mortality.However,limited data exist about the concurrent use of RFX with broad-spectrum antibiotics,because the patients are typically excluded from studies assessing RFX efficacy in HE.A pharmacist-driven quasi-experimental pilot study was done to address this gap.They argue against the necessity of RFX in HE during broad-spectrum antibiotic treatment,particularly in critically ill patients in intensive care unit(ICU).The potential for safe RFX discontinuation without adverse effects is clearly illuminated and valuable insight into the optimization of therapeutic strategies is offered.The findings also indicate that RFX discontinuation during broadspectrum antibiotic therapy was not associated with higher rates of delirium or coma,and this result remained robust after adjustment in multivariate analysis.Furthermore,rates of other secondary clinical and safety outcomes,including ICU mortality and 48-hour changes in vasopressor requirements,were comparable.However,since the activity of RFX is mainly confined to the modulation of gut microbiota,its potential utility in patients undergoing extensive systemic antibiotic therapy is debatable,given the overlapping antibiotic activity.Further,this suggests that the action of RFX on HE is class-specific(related to its activity on gut microbiota),rather than drug-specific.A recent double-blind randomized controlled(ARiE)trial provided further evidence-based support for RFX withdrawal in critically ill cirrhotic ICU patients receiving broad-spectrum antibiotics.Both studies prompt further discussion about optimal therapeutic strategy for patients facing the dual challenge of HE and systemic infections.Despite these compelling results,both studies have limitations.A prospective,multi-center evaluation of a larger sample,with placebo control,and comprehensive neurologic evaluation of HE is warranted.It should include an exploration of longer-term outcome and the impact of this protocol in non-critically ill liver disease patients.

Abdominal compartment syndrome:Often overlooked conditions in medical intensive care units

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome are well recognized entities among surgical patients.Nevertheless,a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units(ICU)and has been widely recognized as an independent risk factor for mortality.It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality.Frequently it is underdiagnosed and undertreated in this patient population.Elevated intraabdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure.When intraabdominal hypertension is not promptly recognized and treated,it leads to abdominal compartment syndrome,multiorgan dysfunction syndrome and death.Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis,shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension.This article presents an overview of the epidemiology,definitions,risk factors,pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.

Optic nerve sheath diameters in nontraumatic brain injury:A scoping review and role in the intensive care unit

BACKGROUND Neuromonitoring in medical intensive care units is challenging as most patients are unfit for invasive intracranial pressure(ICP)modalities or unstable to transport for imaging.Ultrasonography-based optic nerve sheath diameter(ONSD)is an attractive option as it is reliable,repeatable and easily performed at the bedside.It has been sufficiently validated in traumatic brain injury(TBI)to be incorporated into the guidelines.However,currently the data for non-TBI patients is inconsistent for a scientific recommendation to be made.AIM To compile the existing evidence for understanding the scope of ONSD in measuring ICP in adult non-traumatic neuro-critical patients.METHODS PubMed,Google Scholar and research citation analysis databases were searched for studies in adult patients with non-traumatic causes of raised ICP.Studies from 2010 to 2024 in English languages were included.RESULTS We found 37 articles relevant to our search.The cutoff for ONSD in predicting ICP varied from 4.1 to 6.3 mm.Most of the articles used cerebrospinal fluid opening pressure followed by raised ICP on computed tomography/magnetic resonance imaging as the comparator parameter.ONSD was also found to be a reliable outcome measure in cases of acute ischaemic stroke,intracerebral bleeding and intracranial infection.However,ONSD is of doubtful utility in septic metabolic encephalopathy,dysnatremias and aneurysmal subarachnoid haemorrhage.CONCLUSION ONSD is a useful tool for the diagnosis of raised ICP in non-traumatic neuro-critically ill patients and may also have a role in the prognostication of a subset of patients.

新型冠状病毒肺炎疫情下湖北省重症救治医疗设备配置情况

目的研究新型冠状病毒肺炎疫情下湖北省重症救治医疗设备配置情况,为医院进一步做好医疗资源常规配置和应急保障提供参考。方法选取重症救治医疗设备,以体外膜肺氧合(extracorporeal membrane oxygenator,ECMO)和呼吸机为例,结合医师、护士和床位数进行配置情况研究,分析突发公共卫生事件背景下医疗资源需求和供给的特征与变化。结果随着医疗物资统一调配和供应保障逐步强化,湖北省重症救治医疗设备ECMO和呼吸机实现了从最初的“十分紧缺”,到“紧平衡”,再到“基本满足”的转变,2020年3月初步实现供大于求。结论平时医疗设备基础配置仍待完善,在突发公共卫生事件背景下,需重视重症救治医疗设备尤其是ECMO和呼吸机等设备的合理配置。

Data mining in clinical big data:the frequently used databases,steps,and methodological models

Many high quality studies have emerged from public databases,such as Surveillance,Epidemiology,and End Results(SEER),National Health and Nutrition Examination Survey(NHANES),The Cancer Genome Atlas(TCGA),and Medical Information Mart for Intensive Care(MIMIC);however,these data are often characterized by a high degree of dimensional heterogeneity,timeliness,scarcity,irregularity,and other characteristics,resulting in the value of these data not being fully utilized.Data-mining technology has been a frontier field in medical research,as it demonstrates excellent performance in evaluating patient risks and assisting clinical decision-making in building disease-prediction models.Therefore,data mining has unique advantages in clinical big-data research,especially in large-scale medical public databases.This article introduced the main medical public database and described the steps,tasks,and models of data mining in simple language.Additionally,we described data-mining methods along with their practical applications.The goal of this work was to aid clinical researchers in gaining a clear and intuitive understanding of the application of data-mining technology on clinical big-data in order to promote the production of research results that are beneficial to doctors and patients.

Red blood cell distribution width improves the prediction of 28-daymortality for patients with sepsis-induced acute kidney injury:A retrospective analysis from MIMIC-IV database usingpropensity score matching

Background:The predictive value of red blood cell distribution width(RDW)for mortality in patients withsepsis-induced acute kidney injury(SI-AKI)remains unclear.The present study aimed to investigate the potentialassociation between RDW at admission and outcomes in patients with SI-AKI.Methods:The Medical Information Mart for Intensive Care(MIMIC)-IV(version 2.0)database,released in Juneof 2022,provides medical data of SI-AKI patients to conduct our related research.Based on propensity scorematching(PSM)method,the main risk factors associated with mortality in SI-AKI were evaluated using Coxproportional hazards regression analysis to construct a predictive nomogram.The concordance index(C-index)and decision curve analysis were used to validate the predictive ability and clinical utility of this model.Patientswith SI-AKI were classified into the high-and low-RDW groups according to the best cut-off value obtained bycalculating the maximum value of the Youden index.Results:A total of 7574 patients with SI-AKI were identified according to the filter criteria.Compared withthe low-RDW group,the high-RDW group had higher 28-day(9.49%vs.31.40%,respectively,P<0.001)and7-day(3.96%vs.13.93%,respectively,P<0.001)mortality rates.Patients in the high-RDW group were moreprone to AKI progression than those in the low-RDW group(20.80%vs.13.60%,respectively,P<0.001).Basedon matched patients,we developed a nomogram model that included age,white blood cells,RDW,combinedhypertension and presence of a malignant tumor,treatment with vasopressor,dialysis,and invasive ventilation,sequential organ failure assessment,and AKI stages.The C-index for predicting the probability of 28-day survivalwas 0.799.Decision curve analysis revealed that the model with RDW offered greater net benefit than that withoutRDW.Conclusion:The present findings demonstrated the importance of RDW,which improved the predictive ability ofthe nomogram model for the probability of survival in patients with SI-AKI.

Analysis of the correlation between the longitudinal trajectory of SOFA scores and prognosis in patients with sepsis at 72 hour after admission based on group trajectory modeling

Background:To identify the distinct trajectories of the Sequential Organ Failure Assessment(SOFA)scores at 72 h for patients with sepsis in the Medical Information Mart for Intensive Care(MIMIC)-IV database and determine their effects on mortality and adverse clinical outcomes.Methods:A retrospective cohort study was carried out involving patients with sepsis from the MIMIC-IV database.Group-based trajectory modeling(GBTM)was used to identify the distinct trajectory groups for the SOFA scores in patients with sepsis in the intensive care unit(ICU).The Cox proportional hazards regression model was used to investigate the relationship between the longitudinal change trajectory of the SOFA score and mortality and adverse clinical outcomes.Results:A total of 16,743 patients with sepsis were included in the cohort.The median survival age was 66 years(interquartile range:54-76 years).The 7-day and 28-day in-hospital mortality were 6.0%and 17.6%,respectively.Five different trajectories of SOFA scores according to the model fitting standard were determined:group 1(32.8%),group 2(30.0%),group 3(17.6%),group 4(14.0%)and group 5(5.7%).Univariate and multivariate Cox regression analyses showed that,for different clinical outcomes,trajectory group 1 was used as the reference,while trajectory groups 2-5 were all risk factors associated with the outcome(P<0.001).Subgroup analysis revealed an interaction between the two covariates of age and mechanical ventilation and the different trajectory groups of patients’SOFA scores(P<0.05).Conclusion:This approach may help identify various groups of patients with sepsis,who may be at different levels of risk for adverse health outcomes,and provide subgroups with clinical importance.