Kidney function assessment in the critically ill child: is it time to leave creatinine behind?

The accurate diagnosis of acute kidney injury (AKI) is especially problematic in critically ill patients in whom renal function is in an unsteady state, rendering creatinine-based baseline assessment measures of renal function potentially inadequate. Herrero-Morin and colleagues performed a cross-sectional analysis of the ability of cystatin C and β₂ microglobulin to reflect creatinine clearance in pediatric patients with AKI. The aim of this commentary is to review the current state of AKI clinical and translational research in the light of the results presented in that study.     

The shrunken pore syndrome is associated with declined right ventricular systolic function in a heart failure population – the HARVEST study

The close relationship between heart and kidney diseases was studied with respect to the ‘Shrunken pore syndrome’ that is characterized by a difference in renal filtration between cystatin C and creatinine. Patients were retrieved from the HeARt and brain failure inVESTigation trail (HARVEST) which is an ongoing study undertaken in individuals hospitalized for the diagnosis of heart failure. Ninety-five of 116 patients who underwent transthoracic echocardiograms (TTE) were eligible for this study. We used four different formulas for estimated glomerular filtration rate (eGFR); CKD-EPI_creatinine, CKD-EPI_{cystatin C}, LMrev and CAPA. Presence of the syndrome was defined as eGFR _{cystatin C}?≤?60% of eGFR _creatinine and absence of the syndrome as eGFR _{cystatin C}?>90% and?<110% of eGFR _creatinine. In a linear regression model, adjusted for age and sex, and the ‘Shrunken pore syndrome’ defined by the equation pair CAPA and LMrev and the equation pair CKD-EPI_{cystatin C} and CKD-EPI_creatinine, echocardiographic parameters were studied. The ‘Shrunken pore syndrome’ showed statistically significant associations with measurements of right ventricular (RV) systolic function; (TAPSE and RV S’) (according to the equation pair CKD-EPI_{cystatin C} and CKD-EPI_creatinine). In conclusion, heart failure patients with the ‘Shrunken pore syndrome’ are at increased risk of having RV systolic dysfunction whilst heart failure patients without ‘Shrunken pore syndrome’ seem protected. These findings may indicate common pathophysiological events in the kidneys and the heart explaining the observed increased risk of mortality in subjects with the ‘Shrunken pore syndrome’.     

Risk stratification in patients with STEMI: is it finally time to look at the left atrium?

The International Journal of Cardiovascular Imaging -     

Mortality associated with early changes in ARDS severity in COVID–19 patients – Insights from the PRoVENT–COVID study

PurposeWe investigated changes in ARDS severity and associations with outcome in COVID–19 ARDS patients.MethodsWe compared outcomes in patients with ARDS classified as ‘mild’, ‘moderate’ or ‘severe’ at calendar day 1, and after reclassification at calendar day 2. The primary endpoint was 28–day mortality. We also identified which ventilatory parameters had an association with presence of severe ARDS at day 2. We repeated the analysis for reclassification at calendar day 4.ResultsOf 895 patients, 8.5%, 60.1% and 31.4% had mild, moderate and severe ARDS at day 1. These proportions were 13.5%, 72.6% and 13.9% at day 2. 28–day mortality was 25.3%, 31.3% and 32.0% in patients with mild, moderate and severe ARDS at day 1 (p = 0.537), compared to 28.6%, 29.2% and 44.3% in patients reclassified at day 2 (p = 0.005). No ventilatory parameter had an independent association with presence of severe ARDS at day 2. Findings were not different reclassifying at day 4.ConclusionsIn this cohort of COVID–19 patients, ARDS severity and mortality between severity classes changed substantially over the first 4 days of ventilation. These findings are important, as reclassification could help identify target patients that may benefit from alternative approaches.     

A time to weep and a time to laugh: humour in the nurse–patient relationship in an adult cancer setting

Purpose

The literature highlights the value of humour in health-care settings. Humour impacts on the physiological, psychosocial and cognitive well-being of a person. The diagnosis of cancer is extremely stressful, and treatments are difficult. Patients and nurses may use humour as a coping mechanism to contend with the stresses caused directly or indirectly by cancer. This study investigated the use of humour during interactions between patients and nurses in an adult cancer ward.

Methods

This study used a modified ethnographic methodology that included fieldwork participant observation and informal interviews (n?=?30 h) and formal interviews (n?=?10). In total, 9 nurses and 12 patients participated in participant observation. From these, five nurses and five patients were interviewed. Data were analysed using thematic analysis.

Results

Findings highlighted the importance of humour in the nurse–patient relationship. Patients consciously use humour during nurse–patient interactions in an attempt to help nurses cope with the stress they encounter in clinical practice. Patients perceive having a sense of humour as a positive nurse attribute. Nurses expressed concerns regarding compromising professionalism when using humour and felt the need for guidance from senior staff. Constant assessment and reflection help ensure humour is used appropriately in the adult health-care setting.

Conclusion

The benefits of humour are recognised by both adult cancer patients and nurses. A deeper understanding of patient and nurse perceptions of the use of humour can inform strategies for its therapeutic use in the clinical setting.     

Knee crepitus is not associated with the occurrence of total knee replacement in knee osteoarthritis – a longitudinal study with data from the Osteoarthritis Initiative

Objective(s)To investigate whether the presence of knee crepitus is associated with the occurrence of total knee replacement (TKR), quality of life and deficits in physical function at long-term.MethodsSetting – This observational study uses longitudinal data (up to 4-year follow-up) from the Osteoarthritis Initiative (OAI). Participants – 4566 participants. Main Outcome Measure(s) – Logistic regression models were used to test if baseline knee crepitus is associated with the occurrence of TKR. Linear mixed models with adjustment for confounding variables (age, gender, BMI and Kellgren–Lawrence grade) were used to test the association between baseline knee crepitus and longitudinal changes in the pain, self-reported physical function, quality of life and performance-based function.ResultsThe presence of knee crepitus at baseline does not predict the occurrence of TKR at 36 months (p = 0.58 and 0.67 for right and left knees, respectively). The crepitus group presented a slightly knee extension strength decline from baseline to 48 months (p = 0.03 for the right and 0.01 for the left knee; between group difference = 2% for both right [95%CI = −0.12; −0.01] and left knees [95%CI = −0.13; −0.02]).ConclusionThe presence of knee crepitus is not associated with the occurrence of TKR in the following three years. Knee crepitus is associated with slightly declines in knee extension strength, but this does not seem to affect physical function and quality of life at long-term.     

Infectious complications in patients with hematological malignancies consulted by the Infectious Diseases team: a retrospective cohort study (1997–2001)

In order to identify the characteristics of patients with hematological malignancies (HM) in the presence/suspicion of any accompanying infectious disease, and to find the predictors of mortality in this group, hospital charts of patients with HM consulted by the Infectious Diseases (ID) team for signs/symptoms of any infection between January 1, 1997 and December 31, 2001 were retrospectively reviewed. A total of 1,132 consultations were done for 641 patients: 59.4% of the patients were male and the mean (±standard deviation) age of the study participants was 47.9±1.4 years. The most common underlying diseases were non-Hodgkins lymphoma (30.9%), acute myelogenous leukemia (26.2%), and multiple myeloma (10.9%). Clinically and microbiologically documented infections and fever of unknown origin were observed in 43.3%, 38.1%, and 18.5% of the participants, respectively. Bloodstream infections were detected in 134 episodes (20.9%): 56.5% were caused by gram-negative microorganisms. In logistic regression analysis, the presence of pneumonia (OR 7.56, 95% CI 4.84–12.486), invasive fungal infection (OR 4.12, 95% CI 1.78–9.55), relapse or recent diagnosis of the underlying disease (OR 2.82, 95% CI 1.53–5.21) and neutropenia (OR 2.70, 95% CI 1.70–4.31) were identified as statistically significant predictors of mortality.     

Improving sleep hygiene behavior in adults living with HIV/AIDS: a randomized control pilot study of the SystemCHANGETM–HIV intervention

AimThe aim of this study was to test the feasibility of a novel, evidence-based intervention SystemCHANGE–HIV on sleep outcomes.BackgroundInsomnia and sleep disturbances affect an estimated 74% of people living with HIV (PLWH) and is a distressing consequence of HIV disease.MethodsWe conducted a two-group randomized control study with 40 PLWH. Outcomes included change in: sleep duration, sleep fragmentation index, sleep efficiency, and self-reported sleep quality.ResultsParticipants rated the intervention as highly feasible. The intervention group experienced a 10 minute/night increase in sleep time, a 2.3%-point increase in sleep efficiency, a 2.0%-point decrease in sleep fragmentation, relative to the control group, based on the model estimates of the treatment effect.ConclusionsA behavioral change intervention focusing on sleep is feasible in PLWH. The intervention group had improved sleep compared to the control group. Future work should test the efficacy of a refined SystemCHANGE–HIV on sleep.     

What is the optimal time for measuring glucose concentration to detect steroid-induced hyperglycemia in patients with rheumatic diseases?

ObjectiveCorticosteroids may cause hyperglycemia and diabetes mellitus (DM). Development of DM during long-term steroid use has been well studied; however, data regarding the short-term effects of steroid therapy are scarce. In this study, we aimed to detect the actual time of short-term steroid-induced hyperglycemia in patients without previous impaired glucose metabolism, and the ideal time (which day and in relation to meals) of glucose measurement.MethodsThe 7-point blood glucose (BG) measurements of patients who were commenced moderate to high-dose steroids (≥15 mg/day prednisolone or its equivalent) due to rheumatological diseases during the first 5 days of steroid therapy were recorded. Fasting BG ≥ 7 mmol/L (126 mg/dL) or random BG ≥ 11.1 mmol/L (200 mg/dL) were considered as overt DM in accordance with the 2016 American Diabetes Association guideline, and post-meal BG ≥10 mmol/L (180 mg/dL) was considered as steroid-induced hyperglycemia.ResultsFifteen males (mean age: 44 ± 16 years) and 35 females (mean age: 41 ± 12 years) were recruited to the study. One thousand seven hundred fifty fasting, pre-meal, and 2-hours post-meal BG concentrations were analyzed. Twenty-one (42%) patients developed steroid-induced DM and 39 (78%) developed steroid-induced hyperglycemia. The highest glucose concentrations were detected on the 3rd day of steroid therapy and 2-h after meals (p < .0001).ConclusionIntermediate to high-dose steroid therapy causes hyperglycemia after lunch and dinner on the 3rd day of treatment. This time period should be taken into consideration in the detection and treatment of steroid-induced hyperglycemia.     

Factors associated with health-related quality of life 6 years after ICU discharge in a Finnish paediatric population: a cohort study

Purpose

Long-term data are urgently needed in children after intensive care. The aim of this study was to measure health-related quality of life 6 years after intensive care in a paediatric intensive care population.

Methods

This national, multicentre study enrolled all children and young people admitted to intensive care units (ICUs) in Finland in 2009 and 2010. The data concerning ICU stay were collected retrospectively from the ICU data registries and combined with prospective data from Paediatric Quality of Life Inventory (PedsQL 4.0) questionnaires, the generic 15D, 16D or 17D instrument, and data regarding children’s chronic diagnoses and need for healthcare support.

Results

The questionnaires were answered by 1109 of 3682 living children and adolescents admitted to an ICU, response rate was 30.1%. Among the responders, 90 children (8.4%) had poor (under ??2?SD) PedsQL scores. Children with low scores had a higher rate of chronic diagnoses (94.4% vs. 47.6%), medication on a daily basis (78.7% vs. 29.4%) and a greater need for healthcare services (97.7% vs. 82.2%) than those with normal scores. Diagnoses associated with poor quality of life were asthma, epilepsy, cerebral palsy and other neurological diseases, chromosomal alterations, cancer and long-term pain. These children were mostly admitted electively, and less frequently on an emergency basis, but no other significant differences were found during the intensive care stay.

Conclusions

The long-term quality of life after paediatric intensive care is good for the majority of children and young people, and it is dependent on the number of chronic diagnoses and the burden of the chronic disease, especially neurological diseases.

     

Propensity to high-fat diet-induced obesity in mice is associated with the indigenous opportunistic bacteria on the interior of Peyer’s patches

Indigenous opportunistic bacteria on the interior of the Peyer’s patches play a key role in the development of the mucosal immune, but their population composition has been ignored. The present study was conducted to test the hypothesis that the changes in the composition of indigenous opportunistic bacteria in the Peyer’s patches are associated with obesity. C57BL/6J-male mice had been fed either a control diet or a high-fat diet. After 25 weeks, mice in high-fat diet exhibit either an obesity-prone (OP) or an obesity-resistant (OR) phenotype. Control diet group (CT) and OR group had a significant larger bacteria diversity than that in the OP group. Allobaculum and Lactobacillus were significantly decreased in high-fat diet induced OP mice compared with CT and OR mice, whereas Rhizobium and Lactococcus was significantly increased. The result of quantitative real-time PCR was consistent with that of 454 pyrosequencing. Significant correlations between mRNA expression of inflammation marks and the top 5 abundance genera bacteria on the interior of Peyer’s patches were observed by Pearson’s correlation analysis. Taken together, the indigenous opportunistic bacteria on the interior of Peyer’s patches plays a major role in the development of inflammation for an occurrence of obesity.     

Additional red blood cell alloantibodies after blood transfusions in a nonhematologic alloimmunized patient cohort: is it time to take precautionary measures?

BACKGROUND: Red blood cell (RBC) alloimmunization is common in transfused patients. Most studies report on the rate of alloimmunization in chronically transfused patients, which can be as high as 60 percent. Less is known on the incidence of clinically relevant antibodies in accidentally transfused patients. Because the probability of repeat transfusion increases with longer life expectancy, it was wondered to which extend non-chronically transfused alloimmunized patients are prone to form additional antibodies after repeat transfusion events. STUDY DESIGN AND METHODS: A 20-year retrospective multicenter study was performed analyzing additional alloantibody formation, against the RH, KEL, FY, JK, and MNS blood group systems. RESULTS: After additional transfusions, 21.4 percent of 653 patients produced additional antibodies, resulting in 157 new antibody specificities. At the end of the study 33.4 percent of patients had multiple antibodies. Eighty of 140 patients (57%) who formed additional antibodies did so after one transfusion episode of a median of 2 units of RBCs. Based on the antigen profile of 316 patients, 83 percent of antibodies could have been prevented by extended matching for the C, E, c, K, Fy(a), and Jk(a) antigens. Considering the current available donors in our region, 1 to 10 percent of potential donors would be available for 39 percent of patients and greater than 10 percent of potential donors for 61 percent of patients. CONCLUSION: It has been shown that nonhematooncologic alloimmunized patients are high antibody responders, with a more than 20 times increased risk to form antibodies compared to first-time alloimmunization risk. If extended matching for C, c, E, K, Fy(a), and Jk(a) antigens in the future is considered, this group should be taken into account.     

Multi-detector row CT as a ��one-stop�� examination in the preoperative evaluation of the morphology and function of living renal donors: preliminary study

We designed to investigate the feasibility of multi-detector row computerized tomography (CT) as a “one-stop” examination for the simultaneous preoperative evaluation of the morphology and function of living renal donors. 21 living renal donors were examined by 64-slice spiral CT with a three-phase enhancement CT scan and two inserted dynamic scans. The maximum intensity projection (MIP), multi-planar reformation (MPR), and volume reconstruction (VR) procedures were performed to compare the renal parenchyma, renal vessels, and collecting system with operational findings. The known Patlak equation was used to calculate the glomerular filtration rate (GFR); exact GFR information was acquired by single photon emission computed tomography (SPECT). Our results as following, there were 3 cases of artery variation and 3 cases of vein variation. CT findings all corresponded with the operation, and the sensitivity, positive predictive value, specialty, and negative predictive value of CT were all 100%. The r of the GFR values estimated from CT is 0.894 (left) (P < 0.001) and 0.881 (right) (P < 0.001). In conclusions, our findings demonstrate that 64-slice spiral CT may offer a “one-stop” examination to replace SPECT in the preoperative evaluation of living renal donors to simultaneously provide information regarding both anatomy and the GFR of living renal donors.