Category Archives: JCCM 2024, Vol. 10, Issue 1

Optimizing Nutrient Uptake in the Critically Ill: Insights into Malabsorption Management

DOI: 10.2478jccm-2024-0012

It has already been stated that nutritional support represents a crucial component in the care of critically ill patients [1]. Prolonged negative energy balance during intensive care stay was confirmed as an independent risk factor for mortality. High metabolic demand encountered for critically ill patients may cause significant energy deficits responsible for increased risk of infection, prolonged mechanical ventilation and ICU stay [2-4].
Aditionally, providing nutritional support in ICU patients is often deemd challenging, as enteral feeding intolerance devolps secondary to gastrointestinal dysfunction [5]. Exccesive antimicrobial usage along with associated risk of nosocomial diarrhea may further exacerbate feeding intolerance. [More]

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User’s Search for Information: A Multi-Language Cross-Sectional Assessment of Websites about Healthcare-Associated Infections

DOI: 10.2478jccm-2024-0011

Introduction: Healthcare-associated infections have a significant impact on public health, and many patients and their next-of-kin are seeking information on the internet. The study aimed to assess the quality of online written content about healthcare-associated infections available in English, Romanian, and Hungarian languages.
Materials and methods: The study sample included 75 websites, 25 for each language subgroup. The assessment involved examining the general characteristics, adherence to established credibility criteria, and the completeness and accuracy of informational content. The evaluation was conducted using a topic-specific, evidence-based benchmark. Two evaluators independently graded completeness and accuracy; scores were recorded on a scale from 0 to 10. A comparative analysis of websites was performed, considering pertinent characteristics, and potential factors influencing information quality were subjected to testing. The statistical significance was set at 0.05.
Results: For the overall study sample, the average credibility, completeness, and accuracy scores were 5.1 (SD 1.7), 2.4 (SD 1.5), and 5.9 (SD 1.0), respectively. Pairwise comparison tests revealed that English websites rated significantly higher than Romanian and Hungarian websites on all three quality measures (P<0.05). Website specialization, ownership, and main goal were not associated with credibility or content ratings. However, conventional medicine websites consistently scored higher than alternative medicine and other websites across all three information quality measures (P<0.05). Credibility scores were positively but weakly correlated with completeness (rho=0.273; P=0.0176) and accuracy scores (rho=0.365; P=0.0016).
Conclusions: The overall quality ratings of information about healthcare-associated infections on English, Romanian, and Hungarian websites ranged from intermediate to low. The description of information regarding the symptoms and prevention of healthcare-associated infections was notably unsatisfactory. The study identified website characteristics possibly associated with higher-quality online sources about healthcare-associated infections, but additional research is needed to establish robust evidence.

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Feeding Intolerance in Critically Ill Patients with Enteral Nutrition: A Meta-Analysis and Systematic Review

DOI: 10.2478/jccm-2024-0007

Background: Feeding intolerance is a common yet serious complication in critically ill patients undergoing enteral nutrition. We aimed to conduct a meta-analysis to evaluate the risk factors of feeding intolerance in critically ill patients undergoing enteral nutrition, to provide insights to the clinical enteral nutrition treatment and care.
Methods: Two researchers systematically searched PubMed, Medline, Web of Science, Cochrane Library,, Wanfang and Weipu databases about the studies on the risk factors of feeding intolerance in severe patients with enteral nutrition up to August 15, 2023. Literature screening, data extraction and quality evaluation were carried out independently by two researchers, and Meta analysis was carried out with RevMan 5.3 software and Stata 15.0 software.
Results: 18 studies involving 5564 enteral nutrition patients were included. The results of meta-analyses showed that age < 2 years old, age > 60 years old, APACHE II score ≥ 20, Hypokalemia, starting time of enteral nutrition > 72 hours, no dietary fiber, intra-abdominal pressure > 15mmHg, central venous pressure > 10cmH2O and mechanical ventilation were the risk factors of feeding intolerance in critically ill patients undergoing EN (all P<0.05). No publication biases were found amongst the included studies.
Conclusion: The incidence of feeding intolerance in critically ill patients undergoing enteral nutrition is high, and there are many influencing factors. Clinical medical workers should take effective preventive measures according to the risk and protective factors of patients to reduce the incidence of feeding intolerance and improve the prognosis of patients.

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Neonatal Resuscitation Practices in Romania: A Survey of the Romanian Association of Neonatology (ANR) and the Union of European Neonatal and Perinatal Societies (UENPS)

DOI: 10.2478jccm-2024-0010

Introduction: This study is part of a European survey on delivery room practices endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Romanian Association of Neonatology (ANR). The aim of our study was to evaluate the current neonatal resuscitation practices in Romanian maternity hospitals and to compare the results between level III and level II centers.
Material and Methods: The questionnaire was distributed through ANR by email link to heads of neonatal departments of 53 Romanian maternity hospitals with more than one thousand of births per year between October 2019 and September 2020, having 2018 as the reference year for data collection.
Results: The overall response rate to the questionnaire was 62.26% (33/53), 83.33% (15/18) for level-III centers and 51.43% (18/35) for level-II centers. Of the responding centers, 18 (54,54%) were academic hospitals, 15 (83,33%) were level III and 3 (16,67%) level II hospitals. In 2018, responding centers reported 81.139 births representing 42.66% of all Romanian births (190.170). There were significant differences between level-III and level-II maternity hospitals regarding the number of births in 2018 (3028.73±1258.38 vs 1983.78±769.99; P=0.006), lowest GA of routinely assisted infants in delivery room (25.07±3.03 weeks vs 30.44±3.28, P<0.001), inborn infants with BW<1500 admitted to neonatal intensive care unit (NICU) in 2018 (66.86±39.14 g vs 22.87±31.50 g; P=0.002), and antenatal counseling of parents before the delivery of a very preterm infant or an infant with expected problems (60% vs 22.2%; P=0.027). There were no significant differences of thermal and umbilical cord management, positive pressure delivery, heart rate assessment between responding centers.
Conclusion: The adherence to new guidelines was high among responding centers regarding thermal and umbilical cord management, initial FiO2, but aspects like antenatal counseling, EKG monitoring, laryngeal mask, and heated/humidified gases availability and administration, and simulation-based training require further implementation.

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Retrospective Study of the Use of Heparins in Pregnant Women and in vitro Testing on the HCT 116 Colorectal Carcinoma Cell Line

DOI: 10.2478jccm-2024-0009

Introduction: Pregnant women manifest an increased risk of developing coagulation disorders. Unfractionated heparin (HEP) and low-molecular-weight heparin (LMWHep) are considered as selective medication in the case of pregnancy which needs anticoagulant treatment. In addition to anticoagulant properties, HEP and its derivatives manifest other properties including anti-cancer potential. According to Globocan’s latest data, colorectal cancer (CRC) is the second most encountered form of malignancy in the case of women, manifesting some special particularities, as confusion of symptoms from cancer with symptoms encountered normally in pregnant women (such as constipation or rectal bleeding), delayed diagnosis because of limitations imposed both for the fetus and for the mother, and the need for special treatment.
Aim: The aim of the present work is to follow the incidence and safety of consumption of HEP and LMWHep in the case of pregnant women and to analyze their potential on the HCT 116 colorectal carcinoma cells.
Results: Analyzing the consumption of heparins in case of pregnant women hospitalized from 01.01.2022 to 31.12.2022 at the Pius Brînzeu” Emergency Clinical Hospital from Timisoara, Obstetrics and Gynecology Clinic I, it was observed that 44,6% of the patients were administered the following medication and no administration risks were observed. When tested on HCT 116 cells, heparins manifested a significant anti-migratory effect (with wound healing rates of 2,6%, when tested with HEP 100 UI concentration and 14.52% wound healing rates in case of fraxiparine 100 UI). In addition, different signs of apoptosis were observed, suggesting the pro-apoptotic potential of the tested substances.
Conclusions: Heparins remain the preferred medication to be administered to pregnant women with the potential for coagulation disorders, showing a high safety profile. Testing on the cancerous line of colorectal carcinoma highlights important properties that stimulate future studies, to establish the anti-tumor potential and the exact mechanism of action.

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Weaning Outcome is Associated with ELWI and Impaired Diastolic Function

DOI: 10.2478jccm-2024-0008

Objectives: To evaluate hemodynamic profiles of critical care patients undergoing spontaneous t-piece trial (SBT) and present weaning failure.
Methods: Prospective observational study conducted in ready-to-wean non-cardiac ICU patients. Clinical, echocardiographic and thermodilution-derived variables were recorded before and after a 2-hour SBT. Weaning from mechanical ventilation was defined as preservation of spontaneous breathing for 48 hours following successful SBT.
Results: Fourteen patients succeeded weaning, five manifested T-trial-failure and six late-failure. Weaning outcome was significantly associated with ELWI(Extravascular lung-water index), global-end-diastolic index and impaired diastolic function, as indicated by pre-T Doppler early wave velocities (E/Em); Fifty-six percent of participants presented ELWI≥7mL/kg when fulfilling predetermined criteria for weaning. ELWI, impaired pulmonary permeability and left ventricular diastolic dysfunction were independent determinants of ELWI.
Conclusions: ELWI before SBT and impaired diastolic function (as indicated by pre-T E/Em) might be weaning outcome determinants and their assessment may allow better risk stratification in weaning decision making.

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Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores

DOI: 10.2478/jccm-2023-0033

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages.
Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores. The toolkit includes the pim3 and pelod2 commands and is compatible with Stata versions 12 and above. It features robust data validation, error messaging, a graphical interface, and support for SI and Imperial units. The toolkit’s accuracy was validated through unit testing and synthetic data, comparing results with existing implementations.
Results: In performance tests, the toolkit exhibited a median processing time of 21.82 seconds for PELOD-2, 14.06 seconds for PIM-3, and 9.74 seconds for Simplified PIM-3, when applied to datasets of 10,000,000 records. It consistently achieved 100% accuracy in both synthetic data tests and manual spot checks.
Conclusion: The toolkit decreases processing time and improves accuracy in calculating pediatric critical care severity scores such as PELOD-2, PIM-3, and Simplified PIM-3. Its application in large datasets and validation highlights its utility as a tool for streamlining pediatric critical care research.

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Neutrophil-to-Lymphocyte Ratio and Thrombocyte-to-Lymphocyte Ratio as a Predictor of Severe and Moderate/Mild Acute Respiratory Distress Syndrome Patients: Preliminary Results

DOI: 10.2478/jccm-2024-0005

Introduction: Acute respiratory distress syndrome (ARDS) represents a major cause of mortality in the intensive care unit (ICU). The inflammatory response is escalated by the cytokines and chemokines released by neutrophils, therefore the search for quantifying the impact of this pathophysiological mechanism is imperative. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) are indicators of systemic inflammation, widely accessible, inexpensive, and uncomplicated parameters.
Methods: We conducted a prospective study between March 2023 and June 2023 on patients which presented Berlin criteria for the diagnosis of ARDS during the first 24 hours from admission in the ICU. We included 33 patients who were divided into two groups: one group of 11 patients with severe ARDS and the second group of 22 patients with moderate/mild ARDS. The study evaluated demographic characteristics, leukocyte, lymphocyte, neutrophil, and platelet counts, as well as NLR and PLR values from complete blood count, and severity scores ( APACHE II score and SOFA score). We investigated the correlation of NLR and PLR in the two main groups (severe and moderate/mild acute respiratory distress syndrome patients).
Results: For the NLR ratio statistically significant differences between the the two groups are noted: Severe ARDS 24.29(1.13-96) vs 15.67(1.69-49.71), p=0.02 For the PLR ratio, we obtained significant differences within the group presenting severe ARDS 470.3 (30.83-1427) vs. the group presenting mild/moderate ARDS 252.1 (0-1253). The difference between the two groups is statistically significant (0.049, p<0.05). The cut-off value of NLR resulted to be 23.64, with an Area Under the Curve (AUC) of 0.653 (95% CI: 0.43-0.88). The best cut-off value of PLR was performed to be 435.14, with an Area Under the Curve (AUC) of 0.645 (95% CI: 0.41-0.88).
Conclusion: Our study showed that NLR and PLR ratios 24 hours in patients with moderate/severe ARDS diagnosis can be a good predictor for severity of the disease. These biomarkers could be used in clinical practice due to their convenience, inexpensiveness, and simplicity of parameters. However, further investigations with larger populations of ARDS patients are necessary to support and validate these current findings.

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Simplified Diagnosis of Urosepsis by Emergency Ultrasound Combined with Clinical Scores and Biomarkers

DOI: 10.2478/jccm-2024-0006

Background: Urosepsis is a life-threatening medical condition due to a systemic infection that originates in the urinary tract. Early diagnosis and treatment of urosepsis are critical to reducing mortality rates and preventing complications. Our study was aimed at identifying a fast and reliable method for early urosepsis diagnosis and severity assessment by combining prognostic scores such as SOFA and NEWS with ultrasound examination and serum markers PCT and NLR.
Methods: We performed a single-center prospective observational study in the Craiova Clinical Emergency Hospital. It initially analysed 204 patients admitted for sepsis of various origins in our hospital between June and October 2023. Those with urological conditions that were suspected to have urosepsis have been selected for the study so that finally 76 patients were included as follows: the severe cases with persistent hypotension requiring vasopressor were enrolled in the septic shock group (15 patients – 19.7%), while the rest were included in the sepsis group (61 patients – 80.3%). Mortality rate in our study was 10.5% (8/76 deaths due to sepsis).
Results: Both prognostic scores SOFA and NEWS were significantly elevated in the septic shock group, as were the sepsis markers PCT and NLR. We identified a strong significant positive correlation between the NEWS and SOFA scores (r = 0.793) as well as PCT and NLR (r=0.417). Ultrasound emergency evaluation proved to be similar to CT scan in the diagnosis of urosepsis (RR = 0.944, p=0.264). ROC analysis showed similar diagnostic performance for both scores (AUC = 0.874 for SOFA and 0.791 for NEWS), PCT and NLR (AUC = 0.743 and 0.717).
Conclusion: Our results indicate that an accurate and fast diagnosis of urosepsis and its severity may be accomplished by combining the use of simpler tools like emergency ultrasound, the NEWS score and NLR which provide a similar diagnosis performance as other more complex evaluations.

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