Effect of statins on the clinical outcomes of patients with sepsis

Despite numerous attempts at novel intervention and tests to aid in earlier diagnosis and improved treatment, there has been an increased incidence of overall mortality related to sepsis, despite improvements in in-hospital mortality. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. Definitive evidence to support the routine use of statins in patients with sepsis has not yet been elicited. We retrospectively analysed data from patients who presented with sepsis, severe sepsis or septic shock, stratifiying them according to statin use into two groups (statin and no statin). Sequential Organ Failure Assessment was used to evaluate severity of illness. The primary outcome was hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, hospital and ICU length of stay, and mechanical ventilation and vasopressor therapy duration. Five hundred and sixty-eight patients were included. Patients with prior statin use (statin group) were older; more obese and had higher prevalence of smoking, diabetes and ischaemic heart disease. There was no difference in Sequential Organ Failure Assessment scores and mortality did not vary between the two groups (19.6 vs. 16.9%). Furthermore, secondary outcomes including ICU mortality, hospital and ICU length of stay, mechanical ventilation and vasopressor duration did not differ Multivariate analysis revealed age and Sequential Organ Failure Assessment score were independent predictors of survival, while history of statin use was not (p = 0.403). This current retrospective study did not find any benefit of statin use on primary and secondary outcomes of the patients admitted to an academic hospital with sepsis.     

Performance of sequential organ failure assessment, logistic organ dysfunction and multiple organ dysfunction score in severe sepsis within Chinese intensive care units

This study assessed the performance of Sequential Organ Failure Assessment, Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score in outcome prediction in severe sepsis. A total of 528 consecutive patients with a diagnosis of severe sepsis were enrolled from two surgical intensive care units of university hospitals in China. Clinical and laboratory data of patients were collected and admission and maximum values of each scoring system were calculated. Areas under the receiver operating characteristic curve, which were used to assess discrimination, were 0.80, 0.83 and 0.74 for admission Sequential Organ Failure Assessment, Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score respectively, and 0.91, 0.93 and 0.86 for corresponding maximum values respectively. Calibration assessed by the Hosmer-Lemeshow statistic was better with admission (chi2 = 18.2) and maximum Logistic Organ Dysfunction Score (chi2 = 19.6) than with admission (chi2 = 98.1) and maximum Multiple Organ Dysfunction Score (chi2 = 30.9). Brier Scores, indicating the overall performance of the scores, were 0.18, 0.17 and 0.22 for admission Sequential Organ Failure Assessment, Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score respectively, and 0.12, 0.10 and 0.15 for their maximum counterparts respectively. This study found good performance of both admission Sequential Organ Failure Assessment and Logistic Organ Dysfunction Score in severe sepsis, and a slightly weaker performance of admission Multiple Organ Dysfunction Score. Since poor calibration was observed in Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score, we suggest further study of customisation of these scores in critical illness with severe sepsis.     

Determination of protein phosphatase type 2A in monocytes from multiple trauma patients: a potential biomarker for sepsis

Background

Protein phosphatase type 2A (PP2A) can downregulate c-Jun N-terminal kinase (JNK) expression in monocytes stimulated by lipopolysaccharide. However, this effect has not been evaluated in patients with sepsis. We sought to determine whether PP2A/JNK pathway is involved in sepsis and whether PP2A expression can be associated with patient outcome.

Materials and methods

We measured PP2A, c-Jun, and JNK protein as well as PP2A and c-Jun messenger RNA in monocytes from trauma patients with (n = 24) or without (n = 22) sepsis 1 and 7 d after major trauma and from healthy volunteers (n = 15) by Western blotting and quantitative real-time polymerase chain reaction. Patient outcomes, including intensive care unit length of stay, Sequential Organ Failure Assessment score, and Multiple Organ Dysfunction score were compared between groups. Correlations between PP2A and c-Jun/JNK expression as well as patient outcomes were analyzed. Receiver operating characteristic analysis was performed to determine the diagnostic efficiency of PP2A for sepsis.

Results

PP2A protein and messenger RNA expression were significantly higher in septic patients compared with nonseptic patients or healthy volunteers. Conversely, the expressions of JNK and c-Jun were significantly reduced in septic patients and correlated inversely with PP2A expression. Furthermore, PP2A expression was positively associated with LOS, Sequential Organ Failure Assessment and Multiple Organ Dysfunction score at day 1 and day 7. Receiver operating characteristic curve yielded a high sensitivity (87.5%) of PP2A in discriminating septic versus nonseptic patients.

Conclusions

PP2A may serve as a negative regulator of the JNK pathway and a biomarker for sepsis.     

Extracorporeal Detoxification for Hepatic Failure Using Molecular Adsorbent Recirculating System: Depurative Efficiency and Clinical Results in a Long‐Term Follow‐Up

Acute liver failure and acute‐on‐chronic liver failure still show a poor prognosis. The molecular adsorbent recirculating system (MARS) has been extensively used as the most promising detoxifying therapy for patients with these conditions. Sixty‐four patients with life‐threatening liver failure were selected, and 269 MARS treatments were carried out as a bridge for orthotopic liver transplantation (OLT) or for liver function recovery. All patients were grouped according to the aim of MARS therapy. Group A consisted of 47 patients treated for liver function recovery (median age 59 years, range 23–82). Group B consisted of 11 patients on the waiting list who underwent OLT (median age 47 years, range 32–62). Group C consisted of 6 patients on the waiting list who did not undergo OLT (median age 45.5 years, range 36–54, P = 0.001). MARS depurative efficiency in terms of liver toxins, cytokines, and growth factors was assessed together with the clinical outcome of the patients during a 1‐year follow‐up. Total bilirubin reduction rate per session (RRs) for each MARS session was 23% (range 17–29); direct bilirubin RRs was 28% (21–35), and indirect bilirubin RRs was 8% (3–21). Ammonia RRs was 34% (12–86). Conjugated cholic acid RRs was 58% (48–61); chenodeoxycholic acid RRs was 34% (18–48). No differences were found between groups. Hepatocyte growth factor (HGF) values on starting MARS were 4.1 ng/mL (1.9–7.9) versus 7.9 ng/mL (3.2–14.1) at MARS end (P < 0.01). Cox regression analysis to determine the risk factors predicting patient outcomes showed that age, male gender, and Sequential Organ Failure Assessment score (but not Model for End‐stage Liver Disease score) were factors predicting death, whereas the number of MARS sessions and the ΔHGF proved protective factors. Kaplan–Meier survival analysis was also used; after 12 months, 21.3% of patients in Group A survived, while 90.9% were alive in Group B and 16.7% in Group C (log rank = 0.002). In conclusion, MARS was clinically well tolerated by all patients and significantly reduced hepatic toxins. Better survival rates were linked to an OLT program, but patients' clinical characteristics on starting MARS therapy were the main factors predicting survival. The role of HGF should be evaluated in larger clinical trials.     

Long-term outcome after 60 days of intensive care

Patients with a long stay in the intensive care unit because of chronic critical illness consume many resources, and yet their outcome may be poor. We evaluated the long-term outcome of patients spending more than 60 days in the intensive care unit. We performed a retrospective cohort and prospective follow-up study of 78 patients staying more than 60 days in the 19-26 bed mixed intensive care unit of a university hospital from November 1995 to January 2003. The mortality in the intensive care unit was 38%; at 1 and 5 years it was 56% and 67%, respectively. Advanced age, prior pulmonary disease, long duration of renal replacement therapy, a low oxygenation ratio and platelet count and high Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores on day 60 influenced long-term mortality. A Simplified Acute Physiology Score II of 50 or a Sequential Organ Failure Assessment score of 8 or higher was associated with 100% mortality during follow-up. The overall 5-year survival rate of 33% suggests that prolonged intensive care may be worth the effort in certain patients.     

Association of tumour necrosis factor‐α gene (T‐1031C,C‐863A,and C‐857T) polymorphisms with bladder cancer susceptibility and outcome after bacille Calmette‐Guérin immunotherapy

OBJECTIVE

To investigate the association of tumour necrosis factor‐α gene (TNF‐α) polymorphisms T‐1031C, C‐863A, and C‐857T with bladder cancer risk and recurrence after bacille Calmette‐Guérin (BCG) immunotherapy, as TNF‐α regulates inflammatory process influencing bladder cancer susceptibility and outcome of BCG immunotherapy.

PATIENTS AND METHODS

In all, 220 patients with bladder cancer and 206 controls were recruited. Genotyping was done using allele specific‐polymerase chain reaction.

RESULTS

A T‐1031C, CC genotype and haplotype ?1031C/?863C/?857T showed enhanced susceptibility to bladder cancer, with an odds ratio (OR) of 2.23 and 95% confidence interval (CI) of 1.17–4.26; and an OR of 6.05 and 95%CI of 2.46–14.90, respectively. A T‐1031C, CC genotype had a reduced risk of recurrence after BCG treatment (hazard ratio 0.38, 95%CI 0.14–0.98).

CONCLUSION

The present data suggests that T‐1031C (CC) genotype and C/C/T haplotype may confer risk for bladder cancer, moreover T‐1031C (CC) decreased the risk of recurrence after BCG immunotherapy.     

Nonthyroidal illness syndrome in enterocutaneous fistulas

Background

The aim of this study was to investigate the incidence, etiology, clinical outcomes, and prognosis of nonthyroidal illness syndrome (NTIS) in patients with enterocutaneous fistulas.

Methods

We prospectively collected 226 patients with enterocutaneous fistulas. Demographics, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment scores, C-reactive protein, body mass index, albumin, and thyroidal hormones were evaluated for each patient.

Results

The incidence of NTIS was 57.5% in patients with enterocutaneous fistulas. Age and the APACHE II and Sequential Organ Failure Assessment scores were significantly higher, whereas albumin was lower in the NTIS group compared with those in the euthyroid group. A decreased sum activity of deiodinases and a reduced ratio of total thyroxin/free thyroxin and total triiodothyronine/free triiodothyronine were observed in the NTIS group. Patients with NTIS suffered longer durations in the intensive care unit and higher possibilities of mechanical ventilation. The cumulative survival rate was significantly lower in the NTIS group.

Conclusions

NTIS was common, and patients with NTIS displayed worse clinical outcome and prognosis. A hypodeiodination condition and a potential thyroid hormone–binding dysfunction may play a role in the etiology of NTIS. A low serum albumin concentration and a high APACHE II score were risk factors of NTIS in enterocutaneous fistulas.     

'Safe' methaemoglobin concentrations are a mortality risk factor in patients receiving inhaled nitric oxide

Inhaled nitric oxide (iNO) can reduce pulmonary arterial hypertension and improve oxygenation in some patients with severe respiratory or heart failure. Despite this, iNO has not been found to improve survival. This study aimed to perform a local practice audit to assess the mortality predictors of critically ill patients who had received iNO as therapy for pulmonary hypertension and respiratory or heart failure. A retrospective audit in a single tertiary centre intensive care unit of patients receiving iNO was conducted between 2004 and 2009. The indications for iNO use, comorbidities, severity of illness, organ function, oxygenation, Sequential Organ Failure Assessment scores, patterns of iNO use, adverse events and outcomes were reviewed. In 215 patients receiving iNO, improvement in oxygenation after one hour from iNO commencement did not predict either intensive care unit (P = 0.36) or hospital (P = 0.72) mortality. The independent risk factors for intensive care unit mortality were worsening Sequential Organ Failure Assessment scores within 24 hours of commencing iNO (adjusted odds ratio 1.07, 95% confidence interval 1.05 to 1.18), the Charlson Comorbidity Score (adjusted odds ratio 1.49, 95% confidence interval 1.16 to 1.91) and the peak methaemoglobin concentration in arterial blood while receiving iNO (adjusted odds ratio 2.67, 95% confidence interval 1.42 to 4.96). Inhaled nitric oxide as salvage therapy for severe respiratory failure in critically ill patients is not routinely justified. Increased methaemoglobin concentration during iNO therapy, even when predominantly less than 3%, is associated with increased mortality.     

Optimizing utilization of kidneys from deceased donors over 60 years: Five‐year outcomes after implementation of a combined clinical and histological allocation algorithm

This 5 year observational multicentre study conducted in the Nord Italian Transplant programme area evaluated outcomes in patients receiving kidneys from donors over 60 years allocated according to a combined clinical and histological algorithm. Low‐risk donors 60–69 years without risk factors were allocated to single kidney transplant (LR‐SKT) based on clinical criteria. Biopsy was performed in donors over 70 years or 60–69 years with risk factors, allocated to Single (HR‐SKT) or Dual kidney transplant (HR‐DKT) according to the severity of histological damage. Forty HR‐DKTs, 41 HR‐SKTs and 234 LR‐SKTs were evaluated. Baseline differences generally reflected stratification and allocation criteria. Patient and graft (death censored) survival were 90% and 92% for HR‐DKT, 85% and 89% for HR‐SKT, 88% and 87% for LR‐SKT. The algorithm appeared user‐friendly in daily practice and was safe and efficient, as demonstrated by satisfactory outcomes in all groups at 5 years. Clinical criteria performed well in low‐risk donors. The excellent outcomes observed in DKTs call for fine‐tuning of cut‐off scores for allocation to DKT or SKT in high‐risk patients.     

Reliability of repeated arm‐crank cardiopulmonary exercise tests in patients with small abdominal aortic aneurysm

Arm‐crank ergometry may be useful in patients unable to pedal, for instance due to peripheral arterial disease. Twenty participants with small abdominal aortic aneurysm undertook two serial arm‐crank tests and then a pedal test, four of whom had indeterminate anaerobic thresholds, precluding analysis. The mean (SD) peak arm and leg oxygen consumptions in 16 participants were 13.71 (2.62) ml.kg^?1.min^‐1 and 16.82 (4.44) ml.kg^?1.min^‐1, with mean (SD) individual differences of 3.11 (2.48) ml.kg^?1.min^‐1, p = 0.0001. The respective values at the anaerobic thresholds were 7.83 (1.58) ml O₂.kg^?1.min^‐1 and 10.09 (3.15) ml O₂.kg^?1.min^‐1, with mean (SD) individual differences of 2.26 (2.34) ml O₂.kg^?1.min^‐1, p = 0.0001. The correlation coefficients (95%CI) for peak oxygen consumption and anaerobic threshold were 0.88 (0.62–1.0) and 0.70 (0.32–1.0). There were no significant differences in serial arm‐crank tests, with intracluster correlations (95%CI) of 0.87 (0.86–0.88) and 0.65 (0.61–0.69) for peak oxygen consumption and anaerobic threshold, respectively.     

Predictive value of quick SOFA and revised Baux scores in burn patients

Several scoring systems, such as the Baux score, help predict outcomes in burn patients. The quick Sequential Organ Failure Assessment (qSOFA) score (composed of a respiratory rate of 22/min or greater, systolic blood pressure of 100 mmHg or less, and altered mental status) is a new bedside index proposed to help identify patients with suspected infection at risk of complications. We hypothesized that qSOFA scores would be associated with in-hospital mortality, ICU admission, and length of stay (LOS) in patients with burns. We performed a retrospective review of all burn patients admitted between January 2010–March 2017 at an academic, suburban, hospital with a regional burn center. qSOFA scores were calculated as 1 point each for GCS<15, RR≥22, and SBP≤100. A qSOFA value of>2 was considered high risk. Revised Baux (rBaux) scores were calculated as age +%TBSA burned +17 (if inhalation injury). A rBaux score >140 was considered high risk. Univariate, multivariate and receiver operating characteristics analyses were performed to compare qSOFA and rBaux scores. There were 1039 burn admissions during the study period. Mean age was 30 ± 24 years, 66% were male. Mean TBSA was 10 ± 12%, mean injury severity score was 5 ± 8. Mean hospital LOS was 8 ± 24 days, 22 patients (2.1%) died. qSOFA scores were associated with mortality and ICU admission. Of all patients, 80 were high risk by qSOFA and 7 by Baux scores. ROC characteristics of qSOFA and Baux scores for predicting death were sensitivity 36% vs. 32%, specificity 94% vs. 100%, PPV 13% vs. 100%, and NPV 98% vs. 99% respectively. The AUC for qSOFA (0.68 [95% CI, 0.54–0.81]) was lower than for Baux (0.99 [95%CI, 0.99–1.00]). Youden’s index identified an optimal cutoff of 85 on the Baux score yielding sensitivity 100%, specificity 94%, PPV 27%, and NPV 100% for mortality. Our results indicate that while qSOFA scores were associated with outcomes, a rBaux score had greater predictive value. The optimal rBaux score for predicting all mortality and ICU admission was 85.     

The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta‐analysis and trial sequential analysis

We compared the efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. Our outcomes were: recovery time from second twitch to train‐of‐four ratio > 0.9; recovery time from post‐tetanic count 1–5 to train‐of‐four ratio > 0.9; and risk of composite adverse and serious adverse events. We searched for randomised clinical trials irrespective of publication status and date, blinding status, outcomes reported or language. We included 41 studies with 4206 participants. Time to reversal of neuromuscular blockade from second twitch to a train‐of‐four ratio > 0.9 was 2.0 min with sugammadex 2 mg.kg^?1 and 12.9 min with neostigmine 0.05 mg.kg^?1, with a mean difference (MD) (95%CI)) of 10.2 (8.5–12.0) (I² = 84%, 10 studies, n = 835, Grades of Recommendation, Assessment, Development and Evaluation (GRADE): moderate quality). Time to reversal of neuromuscular blockade from a post‐tetanic count of 1–5 to a train‐of‐four ratio > 0.9 was 2.9 min with sugammadex 4 mg.kg^?1 and 48.8 min with neostigmine 0.07 mg.kg^?1, with a MD (95%CI) of 45.8 (39.4–52.2) (I² = 0%, 2 studies, n = 114, GRADE: low quality). There were significantly fewer composite adverse events in the sugammadex group compared with neostigmine, with a risk ratio (95%CI) of 0.60 (0.49–0.74) (I² = 40%, 28 studies, n = 2298, number needed to treat (NNT): 8, GRADE: moderate quality). Specifically, the risk of bradycardia (RR (95%CI) 0.16 (0.07–0.34), n = 1218, NNT: 14, GRADE: moderate quality), postoperative nausea and vomiting (RR (95%CI) 0.52 (0.28–0.97), n = 389, NNT: 16, GRADE: low quality) and overall signs of postoperative residual paralysis (RR (95%CI) 0.40 (0.28–0.57), n = 1474, NNT: 13, GRADE: moderate quality) were all reduced. There was no significant difference regarding the risk of serious adverse events (RR 0.54, 95%CI 0.13–2.25, I² = 0%, n = 959, GRADE: low quality). Sugammadex reverses neuromuscular blockade more rapidly than neostigmine and is associated with fewer adverse events.     

A comparative study of four intensive care outcome prediction models in cardiac surgery patients

Background  

Outcome prediction scoring systems are increasingly used in intensive care medicine, but most were not developed for use in cardiac surgery patients. We compared the performance of four intensive care outcome prediction scoring systems (Acute Physiology and Chronic Health Evaluation II [APACHE II], Simplified Acute Physiology Score II [SAPS II], Sequential Organ Failure Assessment [SOFA], and Cardiac Surgery Score [CASUS]) in patients after open heart surgery.     

An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemic

Sequential Organ Failure Assessment (SOFA) score based triage of influenza A H1N1 critically ill patients has been proposed for surge capacity management as a guide for clinical decision making. We conducted a retrospective records review and SOFA scoring of critically ill patients with influenza A H1N1 in a mixed medical-surgical intensive care unit in an urban hospital. Eight critically ill patients with influenza A H1N1 were admitted to the intensive care unit. Their mean (range) age was 39 (26–52) years with a length of stay of 11 (3–17) days. All patients met SOFA score based triage admission criteria with a modal SOFA score of five. Five patients required invasive ventilation for a mean (range) of 5 (4–11) days. Five patients would have been considered for withdrawal of treatment using SOFA scoring guidelines at 48 h. All patients survived. We conclude that SOFA score based triage could lead to withdrawal of life support in critically ill patients who could survive with an acceptably low length of stay in the intensive care unit.     

Factors affecting Porcine Reproductive and Respiratory Syndrome virus time‐to‐stability in breeding herds in the Midwestern United States

The time needed to wean porcine reproductive and respiratory syndrome (PRRS) virus negative pigs consistently from a breeding herd after an outbreak is referred to as time‐to‐stability (TTS). TTS is an important measure to plan herd closure as well as to manage economic expectations. Weekly PRRS incidence data from 82 sow farms in six production systems located in the Midwestern United States were used for the analysis. The objective of this study was to evaluate the effect of recorded predictors on TTS in participant sow farms. The median TTS was 41.0 weeks (1st quartile 31.0 weeks–3rd quartile 55.0 weeks). In the final multivariable mixed‐effects Cox model, farms that experienced winter (hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.28–3.70) and autumn (HR 1.91, 95% CI 1.16–3.13) PRRS outbreaks achieved stability sooner than farms that experienced PRRS outbreaks during summer. No statistically significant difference (p = 0.76) was observed between the TTS of farms that had a PRRS outbreak during spring and summer (HR 1.09, 95% CI 0.62–1.91). Additionally, farms that had a PRRS outbreak associated with a 1‐7‐4 restriction fragment length polymorphism (RFLP) cut pattern took significantly longer to achieve stability (HR 0.44, 95% CI 0.27–0.72) compared to farms which had a non‐1‐7‐4 PRRS outbreak. Finally, farms that had a previous PRRS outbreak within a year achieved stability sooner (HR 2.18, 95% CI 1.23–3.86) than farms that did not have a previous PRRS outbreak within a year. This study provides information that may result useful for planning herd closure and managing expectations about the time needed to wean PRRS virus negative pigs in breading herds according to the season of the year when the outbreak occurred and the RFLP cut pattern associated with the outbreak virus.     

Comparison of the sequential organ failure assessment score with the King's College Hospital criteria and the model for end-stage liver disease score for the prognosis of acetaminophen-induced acute liver failure

Acetaminophen-induced acute liver failure (ALF) is a complex multiorgan illness. An assessment of the prognosis is essential for the accurate identification of patients for whom survival without liver transplantation (LT) is unlikely. The aims of this study were the comparison of prognostic models [King's College Hospital (KCH), Model for End-Stage Liver Disease, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II)] and the identification of independent prognostic indicators of outcome. We evaluated consecutive patients with severe acetaminophen-induced ALF who were admitted to the intensive care unit. At admission, demographic, clinical, and laboratory parameters were recorded. The discriminative ability of each prognostic score at the baseline was evaluated with the area under the receiver operating characteristic curve (AUC). In addition, using a multiple logistic regression, we assessed independent factors associated with outcome. In all, 125 consecutive patients with acetaminophen-induced ALF were evaluated: 67 patients (54%) survived with conservative medical management (group 1), and 58 patients (46%) either died without LT (28%) or underwent LT (18%; group 2). Group 1 patients had significantly lower median APACHE II (10 versus 14) and SOFA scores (9 versus 12) than group 2 patients (P < 0.001). The independent indicators associated with death or LT were a longer prothrombin time (P = 0.007), the inspiratory oxygen concentration (P = 0.005), and the lactate level at 12 hours (P < 0.001). The KCH criteria had the highest specificity (83%) but the lowest sensitivity (47%), and the SOFA score had the best discriminative ability (AUC = 0.79). In conclusion, for patients with acetaminophen-induced ALF, the SOFA score performed better than the other prognostic scores, and this reflected the presence of multiorgan dysfunction. A further evaluation of SOFA with the KCH criteria is warranted.     

Prevalence of fluoroquinolone‐resistant rectal flora in patients undergoing transrectal ultrasound‐guided prostate needle biopsy: A prospective multicenter study

Objectives

To estimate the prevalence of fluoroquinolone‐resistant rectal flora in patients undergoing transrectal ultrasound‐guided prostate needle biopsy and to identify the high‐risk groups.

Methods

From January 2015 to March 2016, rectal swabs of 557 men who underwent transrectal ultrasound‐guided prostate needle biopsy were obtained from five institutions. Clinical variables, including demographics, rectal swab culture results and infectious complications, were evaluated. Univariable and multivariable analyses were used to identify the risk factors for fluoroquinolone resistance of rectal flora and infectious complications.

Results

The incidence of fluoroquinolone‐resistant and extended‐spectrum beta‐lactamase production was 48.1 and 11.8%, respectively. The most common fluoroquinolone‐resistant bacteria was Escherichia coli (81% of total fluoroquinolone‐resistant bacteria, 39% of total rectal flora), and 16 (2.9%) patients had infectious complications. Univariable and multivariable analysis of clinical parameters affecting fluoroquinolone resistance showed no factor associated with fluoroquinolone resistance of rectal flora. The clinical parameter related to infectious complications after prostate biopsy was a history of operation within 6 months (relative risk 6.60; 95% confidence interval 1.99–21.8, P = 0.002).

Conclusions

These findings suggest that a risk‐based approach by history taking cannot predict antibiotic resistance of rectal flora, and physicians should consider targeted antibiotic prophylaxis or extended antibiotic prophylaxis for Korean patients undergoing transrectal ultrasound‐guided prostate biopsy because of high antibiotic resistance of rectal flora.     

No survival benefit to gaining private health insurance coverage for post‐lung transplant care in adults with cystic fibrosis

The use of public insurance is associated with diminished survival in patients with cystic fibrosis (CF) following lung transplantation. No data exist on benefits of gaining private health insurance for post‐transplant care among such patients previously using public insurance. The United Network for Organ Sharing database was used to identify first‐time lung transplant recipients participating in Medicare or Medicaid, diagnosed with CF, and transplanted between 2005 and 2015. Survival outcomes were compared between recipients gaining private insurance after transplantation and those maintaining public coverage throughout follow‐up. Since implementation of the lung allocation score, 575 adults with CF received lung transplantation funded by Medicare or Medicaid and contributed data on insurance status post‐transplant. There were 128 (22%) patients who gained private insurance. Multivariable analysis of time‐varying insurance status found no survival benefit of gaining private insurance (HR = 0.822; 95% CI = 0.525, 1.286; p = 0.390). Further analysis demonstrated that resuming public insurance coverage was detrimental, relative to gaining and keeping private insurance (HR = 2.315; 95% CI = 1.020, 5.258; p = 0.045). Survival disadvantages of lung transplant recipients with CF who have public health insurance were not ameliorated by a switch to private coverage for post‐transplant care.     

Protein C concentrations correlate with organ dysfunction and predict outcome independent of the presence of sepsis

BACKGROUND: Characterizing the evolution of protein C concentrations in critically ill patients may help in identifying high risk groups and potential therapeutic targets. The authors investigated the time courses of protein C concentrations and their relation to the presence of sepsis, organ dysfunction/failure, and outcome. METHODS: This observational cohort study, in a university hospital surgical intensive care unit (ICU), included 312 consecutive patients with an estimated ICU length of stay more than 48 h. Plasma protein C concentrations and parameters of organ dysfunction were measured daily until discharge or death. RESULTS: Protein C concentrations were below the lower limit of normal in 50.6% of patients (n = 158) on admission and decreased to a nadir within 3-4 days after admission before almost normalizing by 2 weeks thereafter, irrespective of the presence of sepsis, sex, source and type of admission, and type of surgery. The minimum protein C concentration was lower in patients with severe sepsis/septic shock (n = 54) than in those with sepsis (n = 63) and those who never had sepsis (n = 195), and was negatively correlated to the maximum Sequential Organ Failure Assessment score (R = 0.345, P < 0.001). Protein C levels were lower in nonsurvivors (n = 46; 14.7%) than in survivors, especially in the first 4 days after admission. In a multivariable analysis with ICU mortality as the dependent variable, a minimum protein C concentration less than 45% was an independent risk factor for ICU death. CONCLUSIONS: In critically ill surgical patients, protein C concentrations were generally low, associated with organ dysfunction/failure, and independently associated with a higher risk of ICU mortality.     

Reduced‐Dose Tacrolimus with Mycophenolate Mofetil vs. Standard‐Dose Tacrolimus in Liver Transplantation: A Randomized Study

We conducted a multicenter randomized study in liver transplantation to compare standard‐dose tacrolimus to reduced‐dose tacrolimus with mycophenolate mofetil to reduce the occurrence of tacrolimus side effects. Two primary outcomes (censored criteria) were monitored during 48 weeks post‐transplantation: occurrence of renal dysfunction or arterial hypertension or diabetes (evaluating benefit) and occurrence of acute graft rejection (evaluating risk). Interim analyses were performed every 40 patients to stop the study in the case of increased risk of graft rejection. One hundred and ninety‐five patients (control: 100; experimental: 95) had been included when the study was stopped. Acute graft rejection occurred in 46 (46%) and 28 (30%) patients in control and experimental groups, respectively (HR = 0.59; 95% CI: [0.37–0.94]; p = 0.024). Renal dysfunction or arterial hypertension or diabetes occurred in 80 (80%) and 61 (64%) patients in control and experimental groups, respectively (HR = 0.68; 95% CI: [0.49–0.95]; p = 0.021). Renal dysfunction occurred in 42 (42%) and 23 (24%) patients in control and experimental groups, respectively (HR = 0.49; 95% CI: [0.29–0.81]; p = 0.004). Leucopoenia (p = 0.001), thrombocytopenia (p = 0.017) and diarrhea (p = 0.002) occurred more frequently in the experimental group. Reduced‐dose tacrolimus with mycophenolate mofetil reduces the occurrence of renal dysfunction and the risk of graft rejection. This immunosuppressive regimen could replace full‐dose tacrolimus in adult liver transplantation.