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BACKGROUND: Plasma cystatin C is a reliable marker to estimate kidney function; however, it is unknown whether this remains true in patients receiving continuous kidney replacement therapy (CKRT). Herein, we tested the hypothesis that lower concentrations of plasma cystatin C during the first three days of CKRT would predict kidney function recovery. METHODS: We performed a retrospective observational study of 72 patients from a 126-patient, single-center CKRT study. We studied two a priori defined cohorts of patients without advanced CKD who had acute kidney injury requiring CKRT (AKI-CKRT): 1) with early kidney function recovery defined as liberation from KRT within seven days of CKRT initiation versus 2) with delayed kidney function recovery defined as receipt of KRT for >21 days or death while on KRT. Subsequent analysis included patients with advanced CKD and intermediate kidney function recovery (liberation between 8 and 21 days). Cystatin C was then measured on stored plasma, urine, and dialysis effluent collected prior to CKRT initiation and on days 1, 2, and 3 of CKRT. RESULTS: Plasma cystatin C was significantly lower in patients with early kidney function recovery in comparison to patients with delayed kidney function recovery on days 1 (1.79 vs. 2.39mg/L), 2 (1.91 vs. 2.38mg/L) and 3 (2.04 vs. 2.67mg/L) of CKRT. Sieving coefficient and CKRT clearance of cystatin C were similar for patients with early and delayed kidney function recovery. The lowest plasma cystatin C concentration on days 1-3 of CKRT predicted early kidney function recovery with an area under the receiver operating curve of 0.77 (P = 0.002), positive likelihood ratio of 5.60 for plasma cystatin C <1.30mg/L, and negative likelihood ratio of 0.17 for plasma cystatin C ≥1.88mg/L. CONCLUSION: Lower plasma cystatin C concentrations during the first three days of CKRT are associated with early kidney function recovery.
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INTRODUCTION: Patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) may require continuous renal replacement therapy (CRRT) as a supportive intervention. While CRRT is effective at achieving solute control and fluid balance, the indiscriminate nature of this procedure raises the possibility that beneficial substances may similarly be removed. Hepcidin, an antimicrobial peptide with pivotal roles in iron homeostasis and pathogen clearance, has biochemical properties amenable to direct removal via CRRT. We hypothesized that serum hepcidin levels would significantly decrease after initiation of CRRT. METHODS: In this prospective, observational trial, we enrolled 13 patients who required CRRT: 11 due to stage 3 AKI, and 2 due to critical illness in the setting of ESKD. Plasma was collected at the time of enrollment, and then plasma and effluent were collected at 10:00 a.m. on the following 3 days. Plasma samples were also collected from healthy controls, and we compared hepcidin concentrations in those with renal disease compared to normal controls, evaluated trends in hepcidin levels over time, and calculated the hepcidin sieving coefficient. RESULTS: Plasma hepcidin levels were significantly higher in patients initiating CRRT than in normal controls (158 ± 60 vs. 17 ± 3 ng/mL respectively, p < 0.001). Hepcidin levels were highest prior to CRRT initiation (158 ± 60 ng/mL), and were significantly lower on day 1 (102 ± 24 ng/mL, p < 0.001) and day 2 (56 ± 14 ng/mL, p < 0.001) before leveling out on day 3 (51 ± 11 ng/mL). The median sieving coefficient was consistent at 0.82-0.83 for each of 3 days. CONCLUSIONS: CRRT initiation is associated with significant decreases in plasma hepcidin levels over the first 2 days of treatment regardless of indication for CRRT, or presence of underlying ESKD. Since reduced hepcidin levels are associated with increased mortality and our data implicate CRRT in hepcidin removal, larger clinical studies evaluating relevant clinical outcomes based on hepcidin trends in this population should be pursued.
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Lesión Renal Aguda , Terapia de Reemplazo Renal Continuo , Humanos , Terapia de Reemplazo Renal/métodos , Estudios Prospectivos , Hepcidinas , Estudios Retrospectivos , Enfermedad Crítica/terapiaRESUMEN
Bacterial pneumonia is a common clinical syndrome leading to significant morbidity and mortality worldwide. In the current study, we investigate a novel, multidirectional relationship between the pulmonary epithelial glycocalyx and antimicrobial peptides in the setting of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Using an in vivo pneumonia model, we demonstrate that highly sulfated heparan sulfate (HS) oligosaccharides are shed into the airspaces in response to MRSA pneumonia. In vitro, these HS oligosaccharides do not directly alter MRSA growth or gene transcription. However, in the presence of an antimicrobial peptide (cathelicidin), increasing concentrations of HS inhibit the bactericidal activity of cathelicidin against MRSA as well as other nosocomial pneumonia pathogens (Klebsiella pneumoniae and Pseudomonas aeruginosa) in a dose-dependent manner. Surface plasmon resonance shows avid binding between HS and cathelicidin with a dissociation constant of 0.13 µM. These findings highlight a complex relationship in which shedding of airspace HS may hamper host defenses against nosocomial infection via neutralization of antimicrobial peptides. These findings may inform future investigation into novel therapeutic targets designed to restore local innate immune function in patients suffering from primary bacterial pneumonia.NEW & NOTEWORTHY Primary Staphylococcus aureus pneumonia causes pulmonary epithelial heparan sulfate (HS) shedding into the airspace. These highly sulfated HS fragments do not alter bacterial growth or transcription, but directly bind with host antimicrobial peptides and inhibit the bactericidal activity of these cationic polypeptides. These findings highlight a complex local interaction between the pulmonary epithelial glycocalyx and antimicrobial peptides in the setting of bacterial pneumonia.
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Staphylococcus aureus Resistente a Meticilina , Neumonía Bacteriana , Ratones , Humanos , Animales , Catelicidinas/farmacología , Catelicidinas/uso terapéutico , Péptidos Catiónicos Antimicrobianos , Modelos Animales de Enfermedad , Neumonía Bacteriana/tratamiento farmacológico , Heparitina Sulfato , Oligosacáridos/uso terapéutico , AntibacterianosRESUMEN
Prior research has focused on host factors as mediators of exaggerated sepsis-associated morbidity and mortality in older adults. This focus on the host, however, has failed to identify therapies that improve sepsis outcomes in the elderly. We hypothesized that the increased susceptibility of the aging population to sepsis is not only a function of the host but also reflects longevity-associated changes in the virulence of gut pathobionts. We utilized two complementary models of gut microbiota-induced experimental sepsis to establish the aged gut microbiome as a key pathophysiologic driver of heightened disease severity. Further murine and human investigations into these polymicrobial bacterial communities demonstrated that age was associated with only subtle shifts in ecological composition but also an overabundance of genomic virulence factors that have functional consequence on host immune evasion. IMPORTANCE Older adults suffer more frequent and worse outcomes from sepsis, a critical illness secondary to infection. The reasons underlying this unique susceptibility are incompletely understood. Prior work in this area has focused on how the immune response changes with age. The current study, however, focuses instead on alterations in the community of bacteria that humans live with within their gut (i.e., the gut microbiome). The central concept of this paper is that the bacteria in our gut evolve along with the host and "age," making them more efficient at causing sepsis.
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Microbioma Gastrointestinal , Sepsis , Humanos , Animales , Ratones , Anciano , Microbioma Gastrointestinal/fisiología , Virulencia , Bacterias/genética , Envejecimiento , Sepsis/microbiologíaRESUMEN
Prior research has focused on host factors as mediators of exaggerated sepsis-associated morbidity and mortality in older adults. This focus on the host, however, has failed to identify therapies that improve sepsis outcomes in the elderly. We hypothesized that the increased susceptibility of the aging population to sepsis is not only a function of the host, but also reflects longevity-associated changes in the virulence of gut pathobionts. We utilized two complementary models of gut microbiota-induced experimental sepsis to establish the aged gut microbiome as a key pathophysiologic driver of heightened disease severity. Further murine and human investigations into these polymicrobial bacterial communities demonstrated that age was associated with only subtle shifts in ecological composition, but an overabundance of genomic virulence factors that have functional consequence on host immune evasion. One Sentence Summary: The severity of sepsis in the aged host is in part mediated by longevity-associated increases in gut microbial virulence.
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Coronavirus disease 2019 (COVID-19), the clinical syndrome associated with infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has impacted nearly every country in the world. Despite an unprecedented focus of scientific investigation, there is a paucity of evidence-based pharmacotherapies against this disease. Because of this lack of data-driven treatment strategies, broad variations in practice patterns have emerged. Observed hypercoagulability in patients with COVID-19 has created debate within the critical care community on the therapeutic utility of heparin. We seek to provide an overview of the data supporting the therapeutic use of heparin, both unfractionated and low molecular weight, as an anticoagulant for the treatment of SARS-CoV-2 infection. Additionally, we review preclinical evidence establishing biological plausibility for heparin and synthetic heparin-like drugs as therapies for COVID-19 through antiviral and anti-inflammatory effects. Finally, we discuss known adverse effects and theoretical off-target effects that may temper enthusiasm for the adoption of heparin as a therapy in COVID-19 without confirmatory prospective randomized controlled trials. Despite previous failures of anticoagulants in critical illness, plausibility of heparin for COVID-19 is sufficiently robust to justify urgent randomized controlled trials to determine the safety and effectiveness of this therapy.
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Anticoagulantes/uso terapéutico , Antivirales/uso terapéutico , Betacoronavirus/efectos de los fármacos , Trastornos de la Coagulación Sanguínea/tratamiento farmacológico , Infecciones por Coronavirus/tratamiento farmacológico , Heparina/uso terapéutico , Neumonía Viral/tratamiento farmacológico , Trastornos de la Coagulación Sanguínea/epidemiología , Trastornos de la Coagulación Sanguínea/virología , COVID-19 , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/transmisión , Infecciones por Coronavirus/virología , Humanos , Pandemias , Neumonía Viral/complicaciones , Neumonía Viral/transmisión , Neumonía Viral/virología , SARS-CoV-2 , Tratamiento Farmacológico de COVID-19RESUMEN
Introduction: Institutions have developed professionalism policies to help guide physician social media behavior in light of professionalism lapses that have resulted in serious consequences. Prior research has gathered perspectives on online professionalism; however, the public's views remain poorly understood. Importantly, the impact of physician social media behavior on patient trust is unknown. Methods: To determine whether patients' trust might change based on their physicians' social media behavior, we conducted a cross-sectional survey across three U.S. cities (n = 491). The survey assessed patient trust using hypothetical scenarios. Results: Most respondents reported they would have less trust if their physician posted racist comments online, wrote a disrespectful patient narrative, appeared intoxicated in a photograph, or wrote profanity. Respondent age and education impacted change in trust. Conclusions: We conclude that physicians' social media behavior may affect patient trust. Better understanding of how physicians' online presence impacts their relationships with patients can help guide policy and inform educational efforts.
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Actitud , Relaciones Médico-Paciente , Médicos , Profesionalismo , Medios de Comunicación Sociales , Confianza , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Intoxicación Alcohólica , Comunicación , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Racismo , Respeto , Encuestas y Cuestionarios , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Intravenous fluids, an essential component of sepsis resuscitation, may paradoxically worsen outcomes by exacerbating endothelial injury. Preclinical models suggest that fluid resuscitation degrades the endothelial glycocalyx, a heparan sulfate-enriched structure necessary for vascular homeostasis. We hypothesized that endothelial glycocalyx degradation is associated with the volume of intravenous fluids administered during early sepsis resuscitation. METHODS: We used mass spectrometry to measure plasma heparan sulfate (a highly sensitive and specific index of systemic endothelial glycocalyx degradation) after 6 h of intravenous fluids in 56 septic shock patients, at presentation and after 24 h of intravenous fluids in 100 sepsis patients, and in two groups of non-infected patients. We compared plasma heparan sulfate concentrations between sepsis and non-sepsis patients, as well as between sepsis survivors and sepsis non-survivors. We used multivariable linear regression to model the association between volume of intravenous fluids and changes in plasma heparan sulfate. RESULTS: Consistent with previous studies, median plasma heparan sulfate was elevated in septic shock patients (118 [IQR, 113-341] ng/ml 6 h after presentation) compared to non-infected controls (61 [45-79] ng/ml), as well as in a second cohort of sepsis patients (283 [155-584] ng/ml) at emergency department presentation) compared to controls (177 [144-262] ng/ml). In the larger sepsis cohort, heparan sulfate predicted in-hospital mortality. In both cohorts, multivariable linear regression adjusting for age and severity of illness demonstrated a significant association between volume of intravenous fluids administered during resuscitation and plasma heparan sulfate. In the second cohort, independent of disease severity and age, each 1 l of intravenous fluids administered was associated with a 200 ng/ml increase in circulating heparan sulfate (p = 0.006) at 24 h after enrollment. CONCLUSIONS: Glycocalyx degradation occurs in sepsis and septic shock and is associated with in-hospital mortality. The volume of intravenous fluids administered during sepsis resuscitation is independently associated with the degree of glycocalyx degradation. These findings suggest a potential mechanism by which intravenous fluid resuscitation strategies may induce iatrogenic endothelial injury.
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Endotelio/fisiopatología , Fluidoterapia/efectos adversos , Glicocálix/efectos de los fármacos , Sepsis/tratamiento farmacológico , Administración Intravenosa , Adulto , Anciano , Angiopoyetina 2/análisis , Angiopoyetina 2/sangre , Factor Natriurético Atrial/análisis , Factor Natriurético Atrial/sangre , Biomarcadores/análisis , Biomarcadores/sangre , Endotelio/efectos de los fármacos , Endotelio/metabolismo , Femenino , Fluidoterapia/métodos , Fluidoterapia/estadística & datos numéricos , Glicocálix/metabolismo , Heparitina Sulfato/análisis , Heparitina Sulfato/sangre , Humanos , Masculino , Espectrometría de Masas/métodos , Persona de Mediana Edad , Péptido Natriurético Encefálico/análisis , Péptido Natriurético Encefálico/sangre , Resucitación/efectos adversos , Resucitación/métodos , Resucitación/estadística & datos numéricos , Sepsis/sangre , Sepsis/fisiopatología , Sindecano-1/análisis , Sindecano-1/sangre , Trombomodulina/análisis , Trombomodulina/sangre , Activador de Tejido Plasminógeno/análisis , Activador de Tejido Plasminógeno/sangre , Receptor 1 de Factores de Crecimiento Endotelial Vascular/análisis , Receptor 1 de Factores de Crecimiento Endotelial Vascular/sangreRESUMEN
BACKGROUND: Severe acute kidney injury (AKI) is associated with subsequent infection. Whether AKI followed by a return to baseline creatinine is associated with incident infection is unknown. OBJECTIVE: We hypothesized that risk of both short and long term infection would be higher among patients with AKI and return to baseline creatinine than in propensity score matched peers without AKI in the year following a non-infectious hospital admission. DESIGN: Retrospective, propensity score matched cohort study. PARTICIPANTS: We identified 494 patients who were hospitalized between January 1, 1999 and December 31, 2009 and had AKI followed by return to baseline creatinine. These were propensity score matched to controls without AKI. MAIN MEASURES: The predictor variable was AKI defined by International Classification of Diseases, Ninth Revision (ICD-9) codes and by the Kidney Disease Improving Global Outcomes definition, with return to baseline creatinine defined as a decrease in serum creatinine level to within 10% of the baseline value within 7 days of hospital discharge. The outcome variable was incident infection defined by ICD-9 code within 1 year of hospital discharge. RESULTS: AKI followed by return to baseline creatinine was associated with a 4.5-fold increased odds ratio for infection (odds ratio 4.53 [95% CI, 2.43-8.45]; p<0.0001) within 30 days following discharge. The association between AKI and subsequent infection remained significant at 31-60 days and 91 to 365 days but not during 61-90 days following discharge. CONCLUSION: Among patients from an integrated health care delivery system, non-infectious AKI followed by return to baseline creatinine was associated with an increased odds ratio for infection in the year following discharge.
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Lesión Renal Aguda/sangre , Lesión Renal Aguda/complicaciones , Creatinina/sangre , Infecciones/sangre , Infecciones/complicaciones , Puntaje de Propensión , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Análisis de SupervivenciaRESUMEN
PURPOSE: Using the Delphi process, a panel of experienced preceptors achieved consensus on best practices to increase preceptor efficiency and effectiveness. METHODS: The Delphi panelists completed 3 survey rounds and a face-to-face meeting. Survey questions covered several topics, including preparation of students for rotations, preceptor efficiency and effectiveness, potential resident contributions to precepting, methods of developing critical-thinking skills and providing assessment and feedback, precepting time metrics, and barriers to preceptor effectiveness. Panel consensus was defined as agreement of ≥80%. RESULTS: Fifteen of 36 invited preceptors (42%) completed all 3 survey rounds. The expert panel reached consensus on 6 essentials for effective rotations, 8 precepting contributions that could be made by appropriately trained residents, precepting barriers, 4 strategies for teaching critical thinking, and 5 valuable characteristics of the One Minute Preceptor model. Panelists reported on time spent with students presenting new patient cases (median, 10 minutes per case), time devoted to assessment of students' clinical performance (median, 22 minutes per student weekly), and time dedicated to student professional development (median, 20 minutes per student weekly). CONCLUSION: Important strategies for preceptors identified by the panel included (1) a thorough orientation to logistics, expectations, and scheduling of activities, (2) using appropriately trained residents in student training, (3) providing opportunities for critical thinking and therapeutic decision-making, (4) giving frequent, quality feedback on clinical activities, and (5) giving feedback to learners on a regular basis.
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Atención Ambulatoria/métodos , Técnica Delphi , Servicios Médicos de Urgencia/métodos , Testimonio de Experto/métodos , Preceptoría/métodos , Estudiantes de Farmacia , Atención Ambulatoria/psicología , Atención Ambulatoria/normas , Servicios Médicos de Urgencia/normas , Testimonio de Experto/normas , Femenino , Humanos , Masculino , Preceptoría/normas , Estudiantes de Farmacia/psicología , PensamientoRESUMEN
Sepsis outcomes are heavily dependent on the development of septic organ injury, but no interventions exist to interrupt or reverse this process. microRNA-223 (miR-223) is known to be involved in both inflammatory gene regulation and host-pathogen interactions key to the pathogenesis of sepsis. The goal of this study was to determine the role of miR-223 as a mediator of septic kidney injury. Using miR-223 knockout mice and multiple models of experimental sepsis, we found that miR-223 differentially influences acute kidney injury (AKI) based on the model used. In the absence of miR-223, mice demonstrated exaggerated AKI in sterile models of sepsis (LPS injection) and attenuated AKI in a live-infection model of sepsis (cecal ligation and puncture). We demonstrated that miR-223 expression is induced in kidney homogenate after cecal ligation and puncture, but not after LPS or fecal slurry injection. We investigated additional potential mechanistic explanations including differences in peritoneal bacterial clearance and host stool virulence. Our findings highlight the complex role of miR-223 in the pathogenesis of septic kidney injury, as well as the importance of differences in experimental sepsis models and their consequent translational applicability.
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Lesión Renal Aguda/etiología , Modelos Animales de Enfermedad , MicroARNs/metabolismo , Sepsis/complicaciones , Lesión Renal Aguda/metabolismo , Animales , Lipopolisacáridos , Masculino , Staphylococcus aureus Resistente a Meticilina , Ratones Endogámicos C57BL , Ratones Noqueados , Sepsis/metabolismoRESUMEN
PURPOSE: To determine how adolescents and young adults (AYAs) use social media to share health information and to assess attitudes toward using social media to obtain health information and communicate with medical providers. METHODS: A cross-sectional study of AYAs, 12 years or older, attending a primary care adolescent and young adult clinic. Participants completed an anonymous survey about health-related social media use, personal health, and communication with their health care team. RESULTS: Of the 244 patients approached, 204 enrolled (83.6% participation rate). Almost all (98%) had used social media within the prior month, but only 51.5% had shared health information in these networks. These participants shared about mood (76.2%), wellness (57.1%), and acute medical conditions (41.9%). Those with self-reported poor health were more likely to share health information than other groups. Privacy was the most important factor determining which platform to use. Only 25% thought that social media could provide them with useful health information. Few AYAs connected with their health care team on social media and most did not want to use this method; texting was preferred. CONCLUSIONS: AYAs maintain their privacy on social media regarding their health. Those with self-perceived poor health are more likely to share health information, potentially biasing online content and impairing the generalizability of social media research. AYAs do not view social media as a useful source of health information, which may limit the utility of public health messages through these platforms, and it may not be adequate for communication between patients and their health care team.
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Comunicación en Salud , Difusión de la Información/métodos , Medios de Comunicación Sociales/estadística & datos numéricos , Adolescente , Niño , Estudios Transversales , Femenino , Estado de Salud , Humanos , Masculino , Atención Primaria de Salud , Privacidad , Encuestas y Cuestionarios , Adulto JovenRESUMEN
The endothelial glycocalyx is a heparan sulfate (HS)-rich endovascular structure critical to endothelial function. Accordingly, endothelial glycocalyx degradation during sepsis contributes to tissue edema and organ injury. We determined the endogenous mechanisms governing pulmonary endothelial glycocalyx reconstitution, and if these reparative mechanisms are impaired during sepsis. We performed intravital microscopy of wild-type and transgenic mice to determine the rapidity of pulmonary endothelial glycocalyx reconstitution after nonseptic (heparinase-III mediated) or septic (cecal ligation and puncture mediated) endothelial glycocalyx degradation. We used mass spectrometry, surface plasmon resonance, and in vitro studies of human and mouse samples to determine the structure of HS fragments released during glycocalyx degradation and their impact on fibroblast growth factor receptor (FGFR) 1 signaling, a mediator of endothelial repair. Homeostatic pulmonary endothelial glycocalyx reconstitution occurred rapidly after nonseptic degradation and was associated with induction of the HS biosynthetic enzyme, exostosin (EXT)-1. In contrast, sepsis was characterized by loss of pulmonary EXT1 expression and delayed glycocalyx reconstitution. Rapid glycocalyx recovery after nonseptic degradation was dependent upon induction of FGFR1 expression and was augmented by FGF-promoting effects of circulating HS fragments released during glycocalyx degradation. Although sepsis-released HS fragments maintained this ability to activate FGFR1, sepsis was associated with the downstream absence of reparative pulmonary endothelial FGFR1 induction. Sepsis may cause vascular injury not only via glycocalyx degradation, but also by impairing FGFR1/EXT1-mediated glycocalyx reconstitution.
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Endotelio Vascular/metabolismo , Factor 2 de Crecimiento de Fibroblastos/metabolismo , Glicocálix/metabolismo , Pulmón/metabolismo , Transducción de Señal , Animales , Ciego/patología , Heparitina Sulfato/metabolismo , Homeostasis , Ligadura , Masculino , Ratones Endogámicos C57BL , N-Acetilglucosaminiltransferasas/metabolismo , Polisacárido Liasas/metabolismo , Punciones , Receptor Tipo 1 de Factor de Crecimiento de Fibroblastos/metabolismo , Sepsis/patologíaRESUMEN
BACKGROUND: Patients with inflammatory bowel disease have a unique inflammatory response to infection given the pathogenesis of these diseases and the common use of immunosuppressive therapy. AIMS: The goal of this study is to determine severe sepsis outcomes in a subgroup of visits with the comorbidities of inflammatory bowel disease. METHODS: The 2012 National Inpatient Sample database was used to identify patients with explicitly coded diagnoses of severe sepsis or septic shock. Visits with chronic inflammatory bowel disease and other inflammatory diagnoses were identified using ICD-9 codes. Sepsis outcomes of interest were identified using ICD-9 codes. RESULTS: There were 92,296 visits for severe sepsis or septic shock in the analysis. In the control group, the in-hospital mortality rate was 26.5%. Ulcerative colitis visits had a higher mortality rate (34.9%) while Crohn disease visits had lower mortality (19.6%). After adjusting for potential confounders, ulcerative colitis was independently associated with higher mortality (odds ratio [OR] 1.61, 95% CI 1.35-1.93). Conversely, Crohn disease was independently associated with lower mortality (OR 0.78, 95% CI 0.63-0.97). CONCLUSIONS: Sepsis visits with Crohn disease had improved outcomes compared with the control group. Conversely, visits with ulcerative colitis had markedly worsened sepsis-related outcomes. Further investigation is needed to determine the mechanisms underlying these clinical differences.
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Enfermedades Inflamatorias del Intestino/mortalidad , Enfermedades Inflamatorias del Intestino/patología , Sepsis/mortalidad , Sepsis/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Colitis Ulcerosa/mortalidad , Colitis Ulcerosa/patología , Enfermedad de Crohn/mortalidad , Enfermedad de Crohn/patología , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVE: Infectious complications after ischemic stroke are frequent and lead to neurological deterioration, poor functional outcomes, and higher mortality. Local and systemic inflammatory responses to brain ischemia differ between males and females, but little is known about differences in poststroke susceptibility to infection by sex. The purpose of this study was to compare sex-related differences in the risk of hospital-acquired sepsis and pneumonia after acute ischemic stroke (AIS). MATERIALS AND METHODS: This is a retrospective, secondary analysis of the 2010-2011 California State Inpatient Database. Previously validated International Classification of Disease, Ninth Revision (ICD-9) codes were used to identify adult hospitalizations for AIS. The primary outcome was hospital-acquired sepsis or pneumonia, also identified using ICD-9 codes. Associations between sex and hospital-acquired sepsis or pneumonia were adjusted for baseline characteristics and comorbidities using multivariable logistic regression. RESULTS: There were 91,643 hospitalizations for AIS included in this analysis, of which 1027 had hospital-acquired sepsis and 1225 had hospital-acquired pneumonia. The in-hospital mortality without infection was 4.6%; the presence of hospital-acquired infections was associated with higher mortality for sepsis (32.7%) and pneumonia (21.9%). Female (versus male) sex was associated with lower adjusted odds of hospital-acquired sepsis (odds ratio [OR] .74, 95% confidence interval [CI] .65-.84) and pneumonia (OR .69, 95% CI .62-.78). This difference was similar across age strata. Among hospitalizations with either hospital-acquired sepsis or pneumonia, sex did not influence mortality. CONCLUSIONS: Female sex was associated with a lower risk of hospital-acquired sepsis and pneumonia after AIS. Further investigation is needed to determine the mechanisms underlying this clinical observation.
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Isquemia Encefálica/epidemiología , Infección Hospitalaria/epidemiología , Neumonía/epidemiología , Sepsis/epidemiología , Accidente Cerebrovascular/epidemiología , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidad , California/epidemiología , Comorbilidad , Infección Hospitalaria/diagnóstico , Infección Hospitalaria/mortalidad , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Neumonía/diagnóstico , Neumonía/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sepsis/diagnóstico , Sepsis/mortalidad , Factores Sexuales , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Factores de TiempoRESUMEN
The microcirculation is a series of arterioles, capillaries, and venules that performs essential functions of oxygen and nutrient delivery, customized to the unique physiologic needs of the supplied organ. The homeostatic microcirculatory response to infection can become harmful if overactive and/or dysregulated. Pathologic microcirculatory dysfunction can be directly visualized by intravital microscopy or indirectly measured via detection of circulating biomarkers. Although several treatments have been shown to protect the microcirculation during sepsis, they have not improved patient outcomes when applied indiscriminately. Future outcomes-oriented studies are needed to test sepsis therapeutics when personalized to a patient's microcirculatory dysfunction.