New Onset of Atrial Fibrillation in a Medical ICU: Prevalence and Risk Factors

Objectives: To evaluate the prevalence and the risk factors of new onset atrial fibrillation (AF) in a single medical ICU. Methods: A prospective observational study was conducted in a 10 bed single medical ICU over a period of 18 months. All patients with sinus rhythm admitted in the medical ICU were included. Those presenting with any arrhythmia on admission, having a PACEMAKER or having undergone a recent cardiothoracic surgery were excluded. Results: Of the 377 patients included on the study, atrial fibrillation occurred in 26 patients (7%). Patients who developed AF were older, had higher severity scores on admission, and required significantly more fluids, catecholamine, and mechanical ventilation. They had a longer ICU and hospital LOS. ICU mortality was significantly higher in AF patients. Five inde- pendent risk factors of AF were identified by multivariate analysis: advanced age, the presence of COPD, sepsis, car- diogenic shock, and hypoxemia. Conclusion: AF occurs in approximately 7% of medical critically ill patients and is associated with age, a history of COPD, the presence of sepsis, cardiogenic shock and hypoxemia. AF occurs in more critically ill patients and is associated with increased morbidity and mortality.

Iron metabolism imbalance at the time of listing increases overall and infectious mortality after liver transplantation

BACKGROUND Liver transplantation(LT)is the best treatment for patients with liver cancer or end stage cirrhosis,but it is still associated with a significant mortality.Therefore identifying factors associated with mortality could help improve patient management.The impact of iron metabolism,which could be a relevant therapeutic target,yield discrepant results in this setting.Previous studies suggest that increased serum ferritin is associated with higher mortality.Surprisingly iron deficiency which is a well described risk factor in critically ill patients has not been considered.AIM To assess the impact of pre-transplant iron metabolism parameters on posttransplant survival.METHODS From 2001 to 2011,553 patients who underwent LT with iron metabolism parameters available at LT evaluation were included.Data were prospectively recorded at the time of evaluation and at the time of LT regarding donor and recipient.Serum ferritin(SF)and transferrin saturation(TS)were studied as continuous and categorical variable.Cox regression analysis was used to determine mortality risks factors.Follow-up data were obtained from the local and national database regarding causes of death.RESULTS At the end of a 95-mo median follow-up,196 patients were dead,38 of them because of infections.In multivariate analysis,overall mortality was significantly associated with TS>75%[HR:1.73(1.14;2.63)],SF<100μg/L[HR:1.62(1.12;2.35)],hepatocellular carcinoma[HR:1.58(1.15;2.26)],estimated glomerular filtration rate(CKD EPI Cystatin C)[HR:0.99(0.98;0.99)],and packed red blood cell transfusion[HR:1.05(1.03;1.08)].Kaplan Meier curves show that patients with low SF(<100μg/L)or high SF(>400μg/L)have lower survival rates at 36 mo than patients with normal SF(P=0.008 and P=0.016 respectively).Patients with TS higher than 75%had higher mortality at 12 mo(91.4%±1.4%vs 84.6%±3.1%,P=0.039).TS>75%was significantly associated with infection related death[HR:3.06(1.13;8.23)].CONCLUSION Our results show that iron metabolism imbalance(either deficiency or overload)is associated with post-transplant overall and infectious mortality.Impact of iron supplementation or depletion should be assessed in prospective study.

Multiple pyogenic liver abscess

多重生脓肝脓肿很少被描述了。我们报导影响要求外科的排水的一个 38 岁的女人的多重生脓肝脓肿的一个致命的案例。进化被出现标记一腐败有多器官的吃惊系统失败。病人死了在外科以后的 48 h。疾病的原因，治疗学和结果被讨论。

TREM-1 expression during major abdominal surgery: Comment on the Gonzalez-Roldan et al paper

TO THE EDITOR I read with a great interest the paper by Gonzalez-Roldan et al. The authors reported on the pattern expression of TREM-1 during sepsis and major abdominal surgery as compared to healthy controls and concluded that

Potentiation of NETs release is novel characteristic of TREM-1 activation and the pharmacological inhibition of TREM-1 could prevent from the deleterious consequences of NETs release in sepsis

During sepsis,neutrophil activation induces endothelial cell(EC)dysfunction partly through neutrophil extracellular trap(NET)release.The triggering receptor expressed on myeloid cell-1(TREM-1)is an orphan immune receptor that amplifies the inflammatory response mediated by Toll-like receptor-4(TLR4)engagement.Although the key role of TLR4 signaling in NETosis is known,the role of TREM-1 in this process has not yet been investigated.Here,we report that TREM-1 potentiates NET release by human and murine neutrophils and is a component of the NET structure.In contrast,pharmacologic inhibition or genetic ablation of TREM-1 decreased NETosis in vitro and during experimental septic shock in vivo.Moreover,isolated NETs were able to activate ECs and impair vascular reactivity,and these deleterious effects were dampened by TREM-1 inhibition.TREM-1 may,therefore,constitute a new therapeutic target to prevent NETosis and associated endothelial dysfunction.

Oxygenation strategy during acute respiratory failure in immunocompromised patients

Acute respiratory failure(ARF)in immunocompromised patients remains challenging to treat.A large number of case require admission to intensive care unit(ICU)where mortality remains high.Oxygenation without intubation is important in this setting.This review summarizes recent studies assessing oxygenation devices for immunocompromised patients.Previous studies showed that non-invasive ventilation(NIV)has been associated with lower intubation and mortality rates.Indeed,in recent years,the outcomes of immunocompromised patients admitted to the ICU have improved.In the most recent randomized controlled trials,including immunocompromised patients admitted to the ICU with ARF,neither NIV nor high-flow nasal oxygen(HFNO)could reduce the mortality rate.In this setting,other strategies need to be tested to decrease the mortality rate.Early admission strategy and avoiding late failure of oxygenation strategy have been assessed in retrospective studies.However,objective criteria are still lacking to clearly discriminate time to admission or time to intubation.Also,diagnosis strategy may have an impact on intubation or mortality rates.On the other hand,lack of diagnosis has been associated with a higher mortality rate.In conclusion,improving outcomes in immunocompromised patients with ARF may include strategies other than the oxygenation strategy alone.This review discusses other unresolved questions to decrease mortality after ICU admission in such patients.

重症蝎子刺伤后的胃肠反应

Objectives-To evaluate the type and incidence of gastrointestinal manifestations secondary to scorpion envenomation and their prognostic significance. Patients and methods-All patients admitted to our ICU for scorpion envenomation were included in this retrospective chart review of a 13-year period (1990 -2002). Results-During the study period, 951 patients were admitted for scorpion envenomation and 72 (7.6%) died. Ages ranged from 0.5 to 90 years with a mean of 14.7 ±17.4 years. Gastrointestinal symptoms were present in 700 patients (73.6%): nausea in 24 (2.5%), vomiting in 687 (72.2%) and diarrhea in 41 patients (4.3 %). At univariate analysis, the presence of diarrhea was associated with a fatal outcome (P < 0.05). Diarrhea was also correlated with other indicators of severe envenomation and poor prognosis: respiratory failure (P = 0.01), neurological failure (P < 0.0001), liver failure (P < 0.0001) and low blood pressure requiring catecholamine support (P = 0.02). The multivariate analysis showed that young age (age less than 5 years), fever > 38.5°C, neurological failure and pulmonary edema were independent factors of severity. Digestive disorders were more frequent in children and in this subgroup diarrhea appeared to be associated with poor outcome. In a subset of patients for whom data were available, fatal cases demonstrated significantly higher liver enzymes levels on admission. Conclusion-In Tunisia, gastrointestinal symptoms are often observed in severe scorpion envenomations, especially in young patients. In children, diarrhea and elevated liver enzymes are associated with poor prognosis.