Category Archives: Original Research

Predictors Of Mortality In Patients With ST-Segment Elevation Acute Myocardial Infarction And Resuscitated Out-Of-Hospital Cardiac Arrest

Andreea Bărcan, Monica Chițu*, Edvin Benedek, Nora Rat, Szilamer Korodi, Mirabela Morariu, Istvan Kovacs

University of Medicine and Pharmacy of Tirgu Mureș, Romania, Department of Internal Medicine, Clinic of Cardiology

DOI: 10.1515/jccm-2016-0001

Introduction: In patients with out-of-hospital cardiac arrest (OHCA) complicating an ST-segment elevation myocardial infarction (STEMI), the survival depends largely on the restoration of coronary flow in the infarct related artery. The aim of this study was to determine clinical and angiographic predictors of in-hospital mortality in patients with OHCA and STEMI, successfully resuscitated and undergoing primary percutaneous intervention (PCI).
Methods: From January 2013 to July 2015, 78 patients with STEMI presenting OHCA, successfully resuscitated, transferred immediately to the catheterization unit and treated with primary PCI, were analyzed. Clinical, laboratory and angiographic data were compared in 28 non-survivors and 50 survivors.
Results: The clinical baseline characteristics of the study population showed no significant differences between the survivors and non-survivors in respect to age (p=0.06), gender (p=0.8), the presence of hypertension (p=0.4), dyslipidemia (p=0.09) obesity (p=1), smoking status (p=0.2), presence of diabetes (p=0.2), a clinical history of acute myocardial infarction (p=0.7) or stroke (p=0.17). Compared to survivors, the non-survivor group exhibited a significantly higher incidence of cardiogenic shock (50% vs 24%, p=0.02), renal failure (64.3% vs 30.0%, p=0.004) and anaemia (35.7% vs 12.0%, p=0.02). Three-vessel disease was significantly higher in the non-survivor group (42.8% vs. 20.0%, p=0.03), while there was a significantly higher percentage of TIMI 3 flow postPCI in the infarct-related artery in the survivor group (80.% vs. 57.1%, p=0.03). The time from the onset of symptoms to revascularization was significantly higher in patients who died compared to those who survived (387.5 +/- 211.3 minutes vs 300.8 +/- 166.1 minutes, p=0.04), as was the time from the onset of cardiac arrest to revascularization (103.0 +/- 56.34 minutes vs 67.0 +/- 44.4 minutes, p=0.002). Multivariate analysis identified the presence of cardiogenic shock (odds ratio [OR]: 3.17, p=0.02), multivessel disease (OR: 3.0, p=0.03), renal failure (OR: 4.2, p=0.004), anaemia (OR: 4.07, p=0.02), need for mechanical ventilation >48 hours (OR: 8.07, p=0.0002) and a duration of stay in the ICU longer than 5 days (OR: 9.96, p=0.0002) as the most significant independent predictors for mortality in patients with OHCA and STEMI.
Conclusion: In patients surviving an OHCA in the early phase of a myocardial infarction, the presence of cardiogenic shock, renal failure, anaemia or multivessel disease, as well as a longer time from the onset of symptoms or of cardiac arrest to revascularization, are independent predictors of mortality. However, the most powerful predictor of death is the duration of stay in the ICU and the requirement of mechanical ventilation for more than forty-eight hours.

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Plasma Neutrophil Gelatinase Associated Lipocalin (NGAL) – Early Biomarker for Acute Kidney Injury in Critically Ill Patients

Raluca Fodor1, Bianca Grigorescu2*, Mihaly Veres2, Monica Orlandea2, Judita Badea2, Katalin Hlavathy2, Adrian Cioc2

1 Department of Anaesthesiology and Intensive Care, University of Medicine and Pharmacy, Tirgu Mures, Romania
2 Department of Anaesthesiology and Intensive Care, Emergency County Hospital, Tirgu Mures, Romania

DOI: 10.1515/jccm-2015-0023

Introduction: NGAL (Neutrophil Gelatinase Associated Lipocalin) is a biomarker recently introduced into clinical practice for the early diagnosis of acute kidney injury (AKI). The aim of this study was to correlate the plasmatic NGAL value determined at admission with clinical progression and severity of AKI in critically ill patients.
Material and method: Thirty two consecutive critically ill adult patients at risk of developing AKI (trauma, sepsis), admitted in Intensive Care Unit of the Clinical County Emergency Hospital Mures, between January to March 2015 were enrolled in the study. For each patient included in the study plasma NGAL levels were determined on admission, and these were correlated with the degree of AKI development (according to AKIN criteria) at 48 hours and 5 days post admission. The discriminatory power of NGAL, creatinine, creatinine clearance and corrected creatinine (depending on water balance) were determined using the ROC (receiver-operating characteristic) and likelihood ratios.
Results: ROC curve analysis showed a better discriminatory capacity in terms of early diagnosis of AKI for NGAL (AUC=0.81 for NGAL, AUC=0.59 for creatinine, AUC=0.62 for corrected creatinine, AUC=0.29 for creatinine clearance). The value of likelihood ratio was also significantly higher for NGAL (3.01±2.73 for NGAL, 1.27±1.14 for creatinine, 1.78±1.81 for corrected creatinine, and 0.48±0.33 for creatinine clearance).
Conclusions: NGAL biomarker has a better discrimination capacity for early prediction of acute kidney injury compared to previously used markers.

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An Evaluation of Serum Procalcitonin and C-Reactive Protein Levels as Diagnostic and Prognostic Biomarkers of Severe Sepsis

Janos Szederjesi1*, Emoke Almasy1, Alexandra Lazar1, Adina Huțanu2, Iudita Badea1, Anca Georgescu3

1 Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy Tirgu Mures, Romania
2 County Clinical Emergency Hospital Tirgu Mures, Romania
3 Department of Infectious Diseases, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/jccm-2015-0022

Background: Recommendations have been made, following the multicenter Surviving Sepsis Campaign study, to standardize the definition of severe sepsis with reference to several parameters such as haemodynamic stability, acid-base balance, bilirubin, creatinine, International Normalized Ratio (INR), urine output and pulmonary functional value of the ratio between arterial oxigen partial pressure and inspiratory oxigen concentration. Procalcitonin (PCT) is considered to be a gold standard biomarker for the inflammatory response, and recent studies have shown that it may help to discover whether a seriously ill person is developing sepsis. C-reactive protein (CRP) is also used as a marker of inflammation in the body, as its blood levels increase if there is any inflammation in the body.
The aim of this study was to evaluate serum procalcitonin and C-reactive protein levels as diagnostic and prognostic biomarkers of severe sepsis.
Material and method: Sixty patients, diagnosed as being “septic”, were admitted to the intensive care unit (ICU). Based on laboratory results and clinical findings a diagnosis of “severe sepsis“ was made, and correlated with PCT and CRP values. The APACHE II, SAPS II and SOFA severity scores were calculated, analyzed and correlated with PCT and CRP.
Results: Fifty two patients (86.67%) presented with criteria for severe sepsis. Multivariate correlation analysis indicated a significant positive association between procalcitonin and all severity scores (APACHEII p<0.0001, SOFA p<0.0001, SAPS II p<0.0001). CRP proved to be significantly correlated only with the SAPS II score (p=0.0145). Mortality rate was high, with 48 patients (80%) dying. There was no significant correlation between the levels of the PCT and CRP biomarkers and severe sepsis (p=0.2059 for PCT, p=0.6059 for CRP).
Conclusions: The procalcitonin levels are highly correlated with the severity scores (APACHE II, SAPS II, SOFA) regularly used in ICUs and therefore can be used for determining the severity of the septic process. Quantitive procalcitonin and C-reactive protein analysis was not shown to be useful in diagnosing severe sepsis. However, PCT and CRP can be used to predict the fatal progression of the septic patient.

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Health Care Professional’s Attitude Towards the Effective Management of Pain in the Critically Ill Neonate

Laura Mihaela Suciu1, Manuela Cucerea1, Marta Simon1, Andreea Avasiloaiei2, Olimpia Petrescu3, Suciu Bogdan Andrei4

1 Department of Pediatrics, University of Medicine and Pharmacy Tîrgu Mures, Romania
2 Department of Pediatrics, University of Medicine and Pharmacy Iasi, Romania
3 Department of Neonatology, County Hospital Brasov, Romania
4 Anatomy and Embryology Department, University of Medicine and Pharmacy Tîrgu Mures, Romania

DOI: 10.1515/jccm-2015-0018

Introduction: Over the past 25 years, caregiver’s knowledge of pain in newborn infants has advanced from the beliefs that newborn infants do not feel pain, to the knowledge that preterm infants experience more pain compare to older children and adults. However, caregivers know that pain exists in this population and research has supported that pain continues to be untreated up to 65% of the time.
Aim of the study: The purpose of this study was to investigate the attitude and knowledge of health care professionals from the area of Neonatology in Romania regarding procedural pain management in newborn infants.
Material and methods: The sample consisted of 85 physicians and nurses (110 invited) working in five Neonatal Care Centres. Data were collected using a self-completion, 17 items questionnaire designed for this study.
Results: With a response rate of 77.27% which was similar in nurses and physicians, respondents in our study were aware about the pain experience during procedural interventions, recognized the items of pain scales assessment, and are not comfortable with the parental presence during painful procedures. Twenty-five percent of nurses versus 9% of physicians reported rushed care as an important barrier of adequate non-pharmacological pain management (95% IC, 0.319-0.003)
Conclusions: The use of pain protocols for an effective management of pain during neonatal period is required.

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The Effect of the Antioxidant Drug “U-74389G” on Haemoglobin Levels Following a Hypoxemia/ Re-oxygenation Protocol in Rats

Constantinos Τsompos1, Constantinos Panoulis2, Konstantinos Τοutouzas3, George Ζografos3, Apostolos Papalois4

1 Department of Obstetrics & Gynecology, Mesologi County Hospital, Etoloakarnania, Greece
2 Department of Obstetrics & Gynecology, Aretaieion Hospital, Athens University, Attiki, Greece
3 Department of Surgery, Ippokrateion General Hospital, Athens University, Attiki, Greece
4 Experimental Research Center ELPEN Pharmaceuticals, S.A. Inc., Co.

DOI: 10.1515/jccm-2015-0017

Critically ill patients usually present with circulatory hypoxemia and this is associated with a poorer prognosis. The aim of this experimental study was to examine the effect of U-74389G with specific regard to a hypoxemia/re-oxygenation protocol, on mean blood haemoglobin (Hgb) levels in rats.
Materials and methods: Forty rats (mean weight 231.9 g) were used in the study. Hgb levels were measured at sixty minutes (groups A and C) and at 120 minutes (groups B and D) of re-oxygenation. U-74389G was administered only in groups C and D.
Results: U-74389G administration non-significantly increased the Hgb levels by 3.95+2.10% (p=0.0604). Re-oxygenation time non-significantly increased the Hgb levels by 3.39+2.12% (p=0.1285). U-74389G administration and re-oxygenation time together, significantly increased the Hgb levels by 2.55%+1.25% (p=0.0423).
Conclusions: Results of this study indicate that U-74389G administration, re-oxygenation time, but mainly their interaction significantly increase the Hgb levels within the studied time limits.

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The Use of Novel Adopters for Acute Rib Fixation in Critical Chest Trauma, Undertaken by Orthopaedic Surgeons: an Observational Cohort Study

Paul J. Jermin, James Perry, Sanjay Kalra, Elizabeth Flockton, Henry K. Rourke

Department of Orthopaedics, Royal Liverpool and Broadgreen University Hospitals, Liverpool, United Kingdom

DOI: 10.1515/jccm-2015-0016

Background: Surgical stabilisation of acute rib fractures has recently undergone rapid change in the UK with respect to what type of injury is surgically stabilised and who undertakes the operation. This paper presents a review of the literature on surgical fixation and presents our early clinical experience using a recently introduced stabilising system.
Methods: Data was prospectively collected from the first 10 patients undergoing surgical stabilisation of acute rib fractures using the Synthes Matrix RIB plating system. The data included demographics, Injury Severity Score, length of stay in Intensive Care, length of time on a ventilator, analgesic requirements, pneumonia rates and mortality. Patients were followed up until they were discharged from hospital.
Results: Patients had an average Injury Severity Score of 26 (16-57), the average number of ribs fractured was 8.2 (4-14), nine patients had flail chest and one had multiple fractures, mean time from injury to fixation was 2.8 days. In the reported cohort, there were no deaths, two pneumonias (one had pneumonia on presentation). The average length of stay on a ventilator was three days and the average length of stay in Intensive Care was ten days.
Conclusion: The early results of this procedure are encouraging. We feel that the modern implants will provide superior results to the highly variable implants that have previously been used. Our results support the literature, showing that with this system, there is a decrease in mortality and morbidity and a decrease in the length of time on a ventilator and stay in Intensive Care.

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New Targets for End-Stage Chronic Kidney Disease Therapy

Niki Prakoura, Panos Kavvadas, Christos Chatziantoniou

Inserm UMR S 1155 and University Pierre et Marie Curie, Paris,  France

DOI: 10.1515/jccm-2015-0015

Severe forms of chronic kidney disease can lead to a critical, end-stage condition, requiring renal replacement therapy, which may involve a form of dialysis or renal transplantation. Identification and characterization of novel markers and/or targets of therapy that could be applied in these critically ill patients remains the focus of the current research in the field of critical care medicine and has been the objective of our studies for some years past. To this end, we used models of renal vascular disease, Ang II, L-NAME or mice overexpressing renin, treated with AT1 antagonists at different stages of progression, to create cohorts of animals during progression, reversal or escape from therapy. Transcriptomic analysis and comparisons were performed and genes were selected according to the following criteria: a) not previously described in the kidney, b) highly upregulated during progression and returning to the normal levels during reversal, and c) producing proteins that are either circulating or membrane receptors.
The involvement of the selected genes in the mechanisms of renal disease was confirmed in additional models of renal disease, initiated in other compartments of the kidney such as glomeruli (administration of nephrotoxic serum) or the tubular interstitium (unilateral ureteral obstruction). The potential of the therapy was tested using mice lacking the expression of these genes and by in vivo administration of antisense oligonucleotides which blocked the transcription of the targeted genes. This strategy allowed the identification of periostin, an extracellular matrix protein normally involved in bone and tooth development, in addition to the discoidin domain receptor1 (DDR1) as potential targets of therapy against renal inflammation and fibrosis.

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Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine

Tiberiu Ezri1,4, Shmuel Evron1,4, Irina Petrov1, Pinhas Schechter2, Yitzhak Berlovich3, Mordechai Shimonov2

The Departments of Anesthesia1, Surgery2 and Management3, The Edith Wolfson Medical Center, Holon, Israel and Outcomes Research Consortium,4 Holon, Israel

DOI: 10.1515/jccm-2015-0009

Background: Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy.
Material and methods: We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization.
Results: Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization.
Conclusion: With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

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The Role of Angiopoietine-2 in the Diagnosis and Prognosis of Sepsis

Janos Szederjesi1, Emoke Almasy1, Alexandra Lazar1, Adina Huțanu2, Anca Georgescu3

1 University of Medicine and Pharmacy Tîrgu Mureş, Romania, Discipline of Intensive Care, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania
2 County Clinical Emergency Hospital Tirgu Mures, Romania, 50 Gheorghe Marinescu street Tirgu Mures, 540139, Romania
3 University of Medicine and Pharmacy Tîrgu Mureş, Romania, Discipline of Infectious Diseases, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

DOI: 10.1515/jccm-2015-0004

Introduction: Angiopoietin-2 (ANG-2) is a new biomarker whose blood-serum values increase in sepsis and its expression is elevated in line with the severity of the degree of inflammation. The aim of this study was to identify the diagnostic role of ANG-2 in patients with non-surgical sepsis addmitted to an intensive care unit.
Material and methods: This was a prospective randomized study including 74 patients admitted in the Clinic of Intensive Care of the County Clinical Emergency Hospital Tirgu Mureș, divided into two groups: Group S: patients with sepsis (n=40, 54%) and Group C: control, without sepsis (n=34, 46%). ANG-2 levels were determined in both groups.
Results: From the Group S, 14 patients (35%) had positive haemocultures. ANG-2 values varied between 1 and 43 ng/mL, with an average of 6.0 ng/mL in patients without sepsis and 10.38 ng/mL in patients with sepsis (p=0.021). A positive correlation between ANG-2 and SAPS II, SOFA and APACHE II severity scores was demonstrated, as was a positive correlation between serum levels of ANG-2 and procalcitonine. ANG-2 had a 5.71% specificity and 74.36% sensitivity for diagnosis of sepsis.
Conclusions: ANG-2 serum levels were elevated in sepsis, being well correlated with PCT values and prognostic scores. ANG-2 should be considered as a useful biomarker for the diagnosis and the prognosis of this pathology.

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The Value of the “Lab-Score” Method in Identifying Febrile Infants at Risk for Serious Bacterial Infections

Diana Aniela Moldovan1,2, Maria Despina Baghiu1,3, Alina Balas2, Sorana Teodora Truta1,2

1 University of Medicine and Pharmacy of Tirgu Mures, Gheorghe Marinescu street no.38, Tirgu Mures, 540139, Romania

2 Tîrgu Mures County Clinical Emergency Hospital, Emergency Department, Gheorghe Marinescu street no.50, Tirgu Mures, 540136, Romania

3 Tîrgu Mures Emergency Clinical County Hospital, Paediatric Clinic, Gheorghe Marinescu street no.50, Tirgu Mures, 540136, Romania

DOI: 10.1515/jccm-2015-0003

Introduction: Most children with fever without source will have a self limited viral infection though a small percent will develop a serious bacterial infection (SBI) like urinary tract infection, pneumonia, bacteraemia, meningitis or sepsis. The challenge facing practitioners is to distinguish between these two groups and currently biomarkers, like C-reactive protein (CRP) and Procalcitonin (PCT), are available for this purpose.
The aim of the current study was to identify SBI in infants with fever without an identifiable cause using the recently introduced “Lab-score” combining C-reactive protein, procalcitonin and urine dipstick results.
Methods: This survey is part of an observational study aimed at identifying children with fever without source at risk of SBI. Patients were recruited from the Emergency Department of Tîrgu Mures Emergency Clinical County Hospital, Romania, during 2013. SBI diagnosis was based on urine, blood and cerebrospinal fluid cultures and chest radiographs. For infants, aged 7 days to 12 months, CRP and PCT were determined and the “Lab-score” was calculated. Positive and negative likelihood ratios and post test probabilities were calculated for each parameter and score.
Results: Of the ninety infants included in the study, SBI was diagnosed in nineteen (21.11%). Ten had a urinary tract infection, seven had pneumonia, one had a urinary tract infection and bacteraemia, and one had sepsis. Positive and negative likelihood ratios for CRP (≥40.0 mg/L) and PCT (≥0.5 ng/mL) were 10.27/0.45 and 7.07/0.24 and post-test probabilities 73%/65%. For a “Lab-score” (≥3), positive and negative likelihood ratios were 10.43/0.28, and the post-test probability was 73%.
Conclusions: In our survey the “Lab-score” proved a strong predictor for the identification of febrile infants at risk of SBI, but showed no significant difference compared with CRP and PCT which both proved equally good predictors for SBI.

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