Thiago Martins Santos

Association of the immature platelet fraction with sepsis diagnosis and severity.

Management of Sepsis would greatly benefit from the incorporation of simple and informative new biomarkers in clinical practice. Ideally, a sepsis biomarker should segregate infected from non-infected patients, provide information about prognosis and organ-specific damage, and be accessible to most healthcare services. The immature platelet fraction (IPF) and immature reticulocyte fraction (IRF) are new analytical parameters of the complete blood count, that have been studied as biomarkers of several inflammatory conditions. Recently, a study performed in critically-ill patients suggested that IPF could be a more accurate sepsis biomarker than C-reactive protein (CRP) and procalcitonin. In this retrospective study we evaluated the performance of IPF and IRF as biomarkers of sepsis diagnosis and severity. 41 patients admitted to two intensive care units were evaluated, 12 of which with severe sepsis or septic shock, and 11 with non-complicated sepsis. Significantly higher IPF levels were observed in patients with severe sepsis/septic shock. IPF correlated with sepsis severity scores and presented the highest diagnostic accuracy for the presence of sepsis of all studied clinical and laboratory parameters. No significant differences were observed in IRF levels. Our results suggest that IPF levels could be used as a biomarker of sepsis diagnosis and severity.

A simplified ultrasound-based edema score to assess lung injury and clinical severity in septic patients

BACKGROUND Lung ultrasound (US) is an excellent tool to assess lung edema in a myriad of different clinical situations. We hypothesized that lung US might also be a good prognostic and management instrument in septic patients, regardless of disease severity. METHODS This was a prospective observational cohort study at an urban academic emergency department (ED). Inclusion criteria were as follows: septic patients, at least 18 years old, admitted at the ED of a tertiary hospital. A simplified lung edema scoring system (SLESS) was developed, and 6 thoracic regions were evaluated. Four different lung US patterns were considered, from normal aeration to total consolidation. To evaluate disease severity, the SLESS was compared with the Mortality in Emergency Department Sepsis Score and the third version of the Simplified Acute Physiology Score scoring systems. Aiming to assess the effect of the lung edema in the gas exchange, the SLESS was compared with the Pao2/fraction of inspired oxygen ratio. RESULTS Sixty-one patients were enrolled in a 3-month period. The SLESS had a good correlation with the Mortality in Emergency Department Sepsis Score and Simplified Acute Physiology Score (r = 0.53 and r = 0.55, respectively; P < .001 for both) and a negative correlation with the Pao2/fraction of inspired oxygen ratio (r = -0.62; P < .001). The SLESS also showed correlation with the respiratory rate (r = 0.45; P = .0003). The odds ratio for death related to the SLESS was 1.370 (95% confidence interval, 1.109-1.691; P = .0035). CONCLUSION The SLESS is an easy and practical scoring system. It might be a useful tool to predict severity of disease in sepsis patients. The SLESS might also be able to be correlated with the oxygen exchange.

Cognitive Load and Self-Determination Theories Applied to E-Learning: Impact on Students' Participation and Academic Performance

Background Emergency clerkships expose students to a stressful environment that require multiple tasks, which may have a direct impact on cognitive load and motivation for learning. To address this challenge, Cognitive Load Theory and Self Determination Theory provided the conceptual frameworks to the development of a Moodle-based online Emergency Medicine course, inspired by real clinical cases. Methods Three consecutive classes (2013–2015) of sixth-year medical students (n = 304) participated in the course, during a curricular and essentially practical emergency rotation. “Virtual Rounds” provided weekly virtual patients in narrative format and meaningful schemata to chief complaints, in order to simulate real rounds at Emergency Unit. Additional activities such as Extreme Decisions, Emergency Quiz and Electrocardiographic challenge offered different views of emergency care. Authors assessed student´s participation and its correlation with their academic performance. A survey evaluated students´ opinions. Students graduating in 2015 answered an online questionnaire to investigate cognitive load and motivation. Results Each student produced 1965 pageviews and spent 72 hours logged on. Although Clinical Emergency rotation has two months long, students accessed the online course during an average of 5.3 months. Virtual Rounds was the most accessed activity, and there was positive correlations between the number of hours logged on the platform and final grades on Emergency Medicine. Over 90% of students felt an improvement in their clinical reasoning and considered themselves better prepared for rendering Emergency care. Considering a Likert scale from 1 (minimum load) to 7 (maximum load), the scores for total cognitive load were 4.79±2.2 for Virtual Rounds and 5.56±1.96 for real medical rounds(p<0,01). Conclusions A real-world inspired online course, based on cognitive and motivational conceptual frameworks, seems to be a strong tool to engage students in learning. It may support them to manage the cognitive challenges involved in clinical care and increase their motivation for learning.

Fatal ischemic stroke following Tityus serrulatus scorpion sting in a patient with essential thrombocythemia

Abstract Context: Stroke following scorpion stings is rare. We report a fatal envenomation involving multiple, extensive brain infarcts in a patient with a previous diagnosis of essential thrombocythemia (ET) who was stung by Tityus serrulatus (T. serrulatus). Case details: A 44-year-old woman with a diagnosis of low-risk ET (platelets <1,000,000/mm3, age <60 years and no history of thrombosis; positive JAK2V617F mutation) was admitted to a local ED 1 h after being stung by T. serrulatus on the left foot. She developed signs of severe envenomation, including several episodes of profuse vomiting, pallor and confusion soon after the sting, followed by shock (BP: 90/60 to 60/40 mmHg) and was treated with scorpion antivenom, vasopressors and mechanical ventilation. A brain computed tomography (CT) scan (54-h poststing) revealed diffuse bilateral cerebellar hypodensity, with partial involvement of both occipital lobes and thalamus, obstructive hydrocephaly with signs of cerebrospinal fluid extravasation, and ascending transtentorial herniation, suggestive of bilateral ischemia involving the posterior cerebral circulation. External ventricular drainage resulted in no improvement and brain death was confirmed on day 10. Discussion: Several mechanisms have been proposed to explain stroke following scorpion stings, such as sympathetic stimulation, myocardial dysfunction, hypotension/shock, arrhythmias and coagulopathy. Ischemic stroke is one of the most serious complications of ET. The risk factors for thrombotic/ischemic events in patients with ET include age (≥60 years) and previous vascular events. Severe scorpion envenomation resulting in myocardial dysfunction and systemic inflammatory response syndrome may increase the overall risk of arterial thrombosis in this patient.

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial

Objective We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians. Design Randomised controlled trial. Setting A paediatric intensive care unit of a teaching hospital. Patients 80 children (aged 28 days to <14 years). Interventions Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique. Main outcome measures Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications. Results We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all). Conclusions Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience. Trial registration number RBR-4t35tk.

Journal Club Challenge: enhancing student participation through gamification

What problems were addressed? Health professionals must develop the ability to critically evaluate recent articles in the academic literature. The journal club is an essential, well-recognised, traditional teaching method that is used all over the world in different fields. Traditionally, scientific papers are selected by teachers and one of a group of participants is chosen to present each paper to his or her colleagues. Unfortunately, participants often fail to read the papers and as a result the task is left to those who have prepared a presentation. Consequently, teachers are demotivated by the small numbers of participants who engage in subsequent discussions. What was tried? Several educational strategies that use gamification as a means of enhancing student motivation and engagement have been developed. However, few of these strategies have been reported with reference to journal club activities. We created a new type of journal club according to the concepts of gamification, in which a competition based on the knowledge acquired by reading the articles is initiated in place of a formal presentation. Firstly, two scientific papers are sent to all participants before the journal club meeting. The participants are required to prepare different questions about the content of the papers before the meeting. At the beginning of journal club, participants are randomly allocated into two groups. Differences in the level of expertise of medical students and residents are balanced across the groups. All the questions created are divided into two boxes, one for each group, respectively. The game begins. In each round, the facilitator draws a member and one question from one group, and a member from the other group to answer. The member who asked the question must state whether or not the answer is correct. The facilitator will decide: (i) whether the first answer is correct, and (ii) whether any revision is correct. If the question is correctly answered, the answering group wins a point. If the question is incorrectly answered, the member of the group that created the question is required to give an answer. If that answer is correct, that person’s group wins a point. The total number of questions is planned to guarantee that all members will participate. The winning group receives a box of good chocolate, whereas the losing team receives a box of cheap chocolate in a nod to the maxim that chocolate is always chocolate. The result of the game is published on Facebook. What lessons were learned? All of the medical teachers who acted as facilitators in the Journal Club Challenge believed that the motivation and engagement of participants improved. As the process of motivation and engagement is complex and multifactorial, health professionals struggle to cope with all the demands of the clinical environment, which can hinder engagement with pedagogical activities. We believe that our activity showed that studying can be fun and increased participation in the journal club. The impact of the gamification on participants’ knowledge and competitiveness is unknown. Using gamification as a teaching tool is well accepted, especially in new generations of health professionals.

Inflammatory lung edema correlates with echocardiographic estimation of capillary wedge pressure in newly diagnosed septic patients

Purpose: Lung ultrasound is an accurate and accessible tool to quantify lung edema. Furthermore, left ventricle filling pressures (LVFP) can be assessed with transthoracic echocardiography (TTE) by the E/e′ ratio (E/e′). The present study aimed to assess the correlation between E/e′ and lung edema quantified by a simplified lung ultrasound score (LUS) in newly admitted septic patients. Materials and methods: In this prospective observational cohort, septic adult patients admitted at the emergency department of a tertiary hospital were included. LUS consisted of four different patterns of lung edema (from normal aeration to parenchymal consolidation). To compare lung edema with LVFP, E/e′ was calculated immediately before or within 5 min of fluid therapy. Results: Fifty patients were enrolled in 3 months. The LUS correlated with E/e′ (r = 0.58, P < 0.0001). The LUS also increased among E/e′ quartiles (Q) (Q1: E/e′ ≤ 4.49; Q2: 4.49 < E/e′ ≤ 5.49; Q3: 5.49 < E/e′ ≤ 7.11; Q4: >7.11; P = 0.0003 for Q1 and 4; 2 and 4); and LUS was significantly higher in abnormal (≥8) vs. normal (<8) values of E/e′ (11.29 vs 8.49, P = 0.007). Conclusion: In newly admitted septic patients, lung edema is positively correlated with LVFP prior to fluid therapy. This finding might help find future targets for fluid resuscitation in sepsis. HighlightsPoint of care ultrasound is sensitive to identify lung edema in recently admitted septic patients.Point of care ultrasound can be used to assess diastolic dysfunction in septic patients.Lung edema correlates positively with LVFP even before fluid therapy.Point of care ultrasound is a promising tool to guide fluid management.

Suspected infection in afebrile patients: Are they septic?

Abstract We prospectively evaluated afebrile patients admitted to an emergency department (ED), with suspected infection and only tachycardia or tachypnea. The white blood cell count (WBC) was obtained, and patients were considered septic if leukocyte count was >12,000 &mgr;L–1 or <4000 &mgr;L–1 or with >10% of band forms. Clinical data were collected to examine whether sepsis could be predicted. Seventy patients were included and 37 (52.86%) met sepsis criteria. Self-measured fever showed an odds ratio (OR) of 5.936 (CI95% 1.450–24.295; P = 0.0133) and increased pulse pressure (PP) showed an OR of 1.405 (CI95% 1.004–1.964; P = 0.0471) on multivariate analysis. When vital signs were included in multivariate analysis, the heart rate showed an OR of 2.112 (CI95% 1.400–3.188; P = 0.0004). Self-measured fever and mean arterial pressure <70 mm Hg had high positive likelihood ratios (3.86 and 2.08, respectively). The nomogram for self-measured fever showed an increase of sepsis chance from 53% (pretest) to approximately 80% (post-test). The recognition of self-measured fever, increased PP, and the intensity of heart rate response may improve sepsis recognition in afebrile patients with tachycardia or tachypnea. These results are important for medical assessment of sepsis in remote areas, crowded and low-resourced EDs, and low-income countries, where WBC may not be readily available.

Circulating levels of the angiogenesis mediators endoglin, HB-EGF, BMP-9 and FGF-2 in patients with severe sepsis and septic shock

Purpose: Endothelial barrier dysfunction is a hallmark of sepsis, and is at least partially mediated by pathways that regulate endothelial barrier assembly during angiogenesis. Not surprisingly, increased levels of key angiogenic proteins such as VEGF‐A and Angiopoietin‐2 have been described in sepsis. The purpose of this study was to investigate if additional pathways that regulate endothelial barrier integrity during angiogenesis could also be involved in the host response of sepsis. Material and methods: We evaluated circulating levels of four proteins involved in angiogenesis, not previously studied in sepsis, in a cohort of 50 patients with severe sepsis and septic shock. Results: Circulating levels of BMP‐9 and FGF‐2 were similar in patients and healthy volunteers. In contrast, patients with septic shock presented 1.5‐fold higher levels of endoglin (P = 0.004), and 2‐fold lower levels of Heparin‐Binding EGF‐like growth factor (HB‐EGF) (P = 0.002) when compared to healthy individuals. Of note, HB‐EGF deficiency has been recently demonstrated to be detrimental to survival in a murine model of sepsis. Conclusions: Endoglin and HB‐EGF could be involved in the host response of sepsis. Additional studies are warrant to investigate their role as biomarker or therapeutic targets in sepsis. HighlightsSevere sepsis and septic shock are associated with higher circulating endoglin levels.Severe sepsis and septic shock are associated with lower circulating HB‐EGF levels.FGF‐2 and BMP‐9 circulating levels are not changed in severe sepsis and septic shock.