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BA Prospects Chat
BA's Ben Badler will be here at 2 p.m. to chat about prospects.
BA's Ben Badler will be here at 2 p.m. to chat about prospects.
J.J. Cooper, Josh Norris and Kyle Glaser talk about the trade deadline.
Floyd Bannister was one of the most celebrated college pitchers ever
Player Bios, interviews, pictures and more at the Baseball America Prospect Pad!
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JJ Cooper and Hudson Belinsky discuss the Under Armour All-America Game.
BA's Vince Lara was here to chat about the Prospect Hot Sheet.
Jose De Leon is putting himself in position to help the big league club
Frazier spoke with BA's Josh Norris in the Prospect Pad
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Danny Goodwin made draft history as the No. 1 pick in two different drafts
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Defensively polished, Kelly has improved with the bat as well
Dozier has rebounded from an awful 2015 by shortening his swing
John Manuel stopped by to chat about prospects.
Ryne Stanek has hit triple digits this year as a starter
Keep track of all the Midseason Prospects Updates here
Robin Yount was 18 when Del Crandall spotted him for the first time
Ben Badler chatted about the new Prospect Hot Sheet
Mike Gerber is tapping into the right balance between bat control and power
John Manuel tosses up some playful questions to Pirates prospect Dovydas Neverau[...]
John Manuel speaks with Rangers first baseman Ronald Guzman in the BA Prospect P[...]
Ben Badler talks with Phillies righthander Ricardo Pinto in the BA Prospect Pad.


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Celebrations of the Spirit
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Girls' Ballet Tights - White
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In semi-opaque fabric with preformed points to avoid wrinkles in slippers. Reinforced crotch and double-cotton lined gusset for greater comfort and improved durability.
Reinforced flat waistband and gusset
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Predictors of septic shock in obstructive acute pyelonephritis
Tambo, Mitsuhiro
Okegawa, Takatsugu
Shishido, Toshihide
Higashihara, Eiji
Nutahara, Kikuo
World Journal of Urology
Acute pyelonephritis (APN) with obstructive uropathy is not uncommon and often causes serious conditions including sepsis and septic shock. We assessed the risk factors for septic shock in patients with obstructive APN associated with upper urinary tract calculi.
We retrospectively studied 69 patients with obstructive APN associated with upper urinary tract calculi who were admitted to our hospital. Emergency drainage for decompression of the renal collecting system was performed for empirical treatment in cases of failure of initial treatment and for severe cases. We assessed the risk factors for septic shock by multivariate logistic regression analysis.
Overall, 45 patients (65.2 %) underwent emergency drainage and 23 (33.3 %) patients showed septic shock. Poor performance status and the presence of diabetes mellitus (DM) in the septic shock group were more common than in the non-septic shock group (p = 0.012 and p = 0.011, respectively). The platelet count and serum albumin level in the septic shock group were significantly lower than in the non-septic shock group (p = 0.002 and p = 0.003, respectively). Positive rates of midstream urine culture and blood culture in the septic shock group were significantly higher than in the non-septic shock group (p = 0.022 and p = 0.001, respectively). Multivariate analysis showed that decreases in the platelet count (OR 5.43, p = 0.014) and serum albumin level (OR 5.88, p = 0.023) were independent risk factors for septic shock.
Patients with obstructive APN associated with upper urinary tract calculi who have decreases in platelet count and serum albumin level should be treated with caution against the development of septic shock.
Acute pyelonephritis; Upper urinary tract calculi; Septic shock; Platelets; Albumin
Related Articles
Clinical and epidemiological features and prognosis of complicated pyelonephritis: a prospective observational single hospital-based study
Buonaiuto, Veronica A
Marquez, Ignacio
De Toro, Inmaculada
Joya, Carolina
Ruiz-Mesa, Juan D
Seara, Raimundo
Plata, Antonio
Sobrino, Beatriz
Palop, Begoña
Colmenero, Juan D
BMC Infectious Diseases
Complicated pyelonephritis (cPN), a common cause of hospital admission, is still a poorly-understood entity given the difficulty involved in its correct definition. The aim of this study was to analyze the main epidemiological, clinical, and microbiological characteristics of cPN and its prognosis in a large cohort of patients with cPN.
We conducted a prospective, observational study including 1325 consecutive patients older than 14 years diagnosed with cPN and admitted to a tertiary university hospital between 1997–2013. After analyzing the main demographic, clinical and microbiological data, covariates found to be associated with attributable mortality in univariate analysis were included in a multivariate logistic regression model.
Of the 1325 patients, 689 (52%) were men and 636 (48%) women; median age 63 years, interquartile range [IQR] (46.5-73). Nine hundred and forty patients (70.9%) had functional or structural abnormalities in the urinary tract, 215 (16.2%) were immunocompromised, 152 (11.5%) had undergone a previous urinary tract instrumentation, and 196 (14.8%) had a long-term bladder catheter, nephrostomy tube or ureteral catheter. Urine culture was positive in 813 (67.7%) of the 1251 patients in whom it was done, and in the 1032 patients who had a blood culture, 366 (34%) had bacteraemia. Escherichia coli was the causative agent in 615 episodes (67%), Klebsiella spp in 73 (7.9%) and Proteus ssp in 61 (6.6%). Fourteen point one percent of GNB isolates were ESBL producers. In total, 343 patients (25.9%) developed severe sepsis and 165 (12.5%) septic shock. Crude mortality was 6.5% and attributable mortality was 4.1%. Multivariate analysis showed that an age >75 years (OR 2.77; 95% CI, 1.35-5.68), immunosuppression (OR 3.14; 95% CI, 1.47-6.70), and septic shock (OR 58.49; 95% CI, 26.6-128.5) were independently associated with attributable mortality.
cPN generates a high morbidity and mortality and likely a great consumption of healthcare resources. This study highlights the factors directly associated with mortality, though further studies are needed in the near future aimed at identifying subgroups of low-risk patients susceptible to outpatient management.
Urinary tract infection; Complicated; Epidemiology; Prognosis
Related Articles
Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study
Acosta, Colleen D.
Kurinczuk, Jennifer J.
Lucas, D. Nuala
Tuffnell, Derek J.
Sellers, Susan
Knight, Marian
PLoS Medicine
Marion Knight and colleagues conducted a national prospective case-control study in the UK from June 2011 through May 2012 to estimate the incidence, describe the causative organisms and sources of infection, and identify the risk factors for severe maternal sepsis.
Please see later in the article for the Editors' Summary
In light of increasing rates and severity of sepsis worldwide, this study aimed to estimate the incidence of, and describe the causative organisms, sources of infection, and risk factors for, severe maternal sepsis in the UK.
Methods and Findings
A prospective case-control study included 365 confirmed cases of severe maternal sepsis and 757 controls from all UK obstetrician-led maternity units from June 1, 2011, to May 31, 2012. Incidence of severe sepsis was 4.7 (95% CI 4.2–5.2) per 10,000 maternities; 71 (19.5%) women developed septic shock; and five (1.4%) women died. Genital tract infection (31.0%) and the organism Escherichia coli (21.1%) were most common. Women had significantly increased adjusted odds ratios (aORs) of severe sepsis if they were black or other ethnic minority (aOR = 1.82; 95% CI 1.82–2.51), were primiparous (aOR = 1.60; 95% CI 1.17–2.20), had a pre-existing medical problem (aOR = 1.40; 95% CI 1.01–1.94), had febrile illness or were taking antibiotics in the 2 wk prior to presentation (aOR = 12.07; 95% CI 8.11–17.97), or had an operative vaginal delivery (aOR = 2.49; 95% CI 1.32–4.70), pre-labour cesarean (aOR = 3.83; 95% CI 2.24–6.56), or cesarean after labour onset (aOR = 8.06; 95% CI 4.65–13.97). Median time between delivery and sepsis was 3 d (interquartile range = 1–7 d). Multiple pregnancy (aOR = 5.75; 95% CI 1.54–21.45) and infection with group A streptococcus (aOR = 4.84; 2.17–10.78) were associated with progression to septic shock; for 16 (50%) women with a group A streptococcal infection there was <2 h—and for 24 (75%) women, <9 h—between the first sign of systemic inflammatory response syndrome and a diagnosis of severe sepsis. A limitation of this study was the proportion of women with sepsis without an identified organism or infection source (16.4%).
For each maternal sepsis death, approximately 50 women have life-threatening morbidity from sepsis. Follow-up to ensure infection is eradicated is important. The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of early administration of high-dose intravenous antibiotics within 1 h of admission to hospital for anyone with suspected sepsis. Signs of severe sepsis in peripartum women, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, nearly 300,000 women worldwide die during pregnancy or labour, or shortly after. According to a recent World Health Organization estimate, sepsis (blood poisoning) is responsible for 10.7% of these maternal deaths. Sepsis is caused by an inappropriate immune response to an infection. Normally, when bacteria or other microbes enter the human body, the immune system efficiently destroys the invaders. In sepsis, the immune system goes into overdrive, and the chemicals it releases into the blood to combat infection trigger widespread inflammation. This inflammation leads to the formation of small blood clots and leaky blood vessels that block the flow of blood to the vital organs. In the most severe cases (septic shock), blood pressure falls to dangerously low levels, multiple organs fail, and the patient can die. Symptoms of sepsis include fever, rapid breathing, and a fast heart rate. Sepsis, which often progresses rapidly, can be treated in its early stages with antibiotics alone. People with severe sepsis need to be admitted to an intensive care unit, where their vital organs can be supported while the infection is treated.
Why Was This Study Done?
Deaths from maternal sepsis mainly occur in low- and middle-income countries, but the rate of such deaths is increasing in countries with advanced healthcare systems. In the UK, for example, the incidence (the number of cases) of fatal maternal sepsis has increased markedly over the past two decades, and although the absolute risk of maternal death from sepsis is low, increasing numbers of women are experiencing severe maternal sepsis. To avoid preventable maternal illness and death in the UK, it is essential that clinical management and infection control strategies for maternal sepsis are improved. Here, to learn more about the incidence of maternal sepsis, the causative organisms and sources of infection, and the risk factors for maternal sepsis in the UK, the researchers undertake a national case-control study of severe maternal sepsis. A case-control study compares the characteristics of individuals with and without a given disease.
What Did the Researchers Do and Find?
For this study, clinicians in all the UK obstetrician-led maternity units (obstetricians care for women throughout pregnancy, labour, and the post-labour period) sent information about every woman who developed severe sepsis between June 2011 and May 2012 (365 cases) and about two unaffected (control) women per case to the United Kingdom Obstetric Surveillance System (UKOSS). Using this information and data on the number of maternities in the UK during this 12-month period, the researchers calculated that the incidence of severe sepsis was 4.7 per 10,000 maternities. Seventy-one women with severe sepsis (19.5% of cases) developed septic shock, and five women (1.4% of cases) died. The most common source of sepsis (implicated in about a third of cases) was a genital tract infection. Statistical analyses identified several risk factors for severe maternal sepsis, including having a fever or taking antibiotics in the two weeks preceding sepsis and all types of operative delivery (including cesarean delivery). Importantly, although Escherichia coli was the most common causative organism in severe maternal sepsis (present in a fifth of cases), infection with group A streptococcus was strongly associated with progression to septic shock. Moreover, in half the women with a group A streptococcal infection, severe sepsis was diagnosed within two hours of the first signs of a systemic inflammatory response.
What Do These Findings Mean?
These findings show that for every death from maternal sepsis in the UK, about 50 women develop life-threatening severe sepsis, that the onset of severe sepsis is very rapid, and that women who have recently had an infection are at particularly high risk of developing maternal sepsis. Although some pregnant women who developed severe sepsis during the study period may not have been included in the study, these findings have important clinical implications for the management of maternal sepsis in the UK and elsewhere. The findings suggest that pregnant or recently pregnant women with an infection need closer attention than women who are not pregnant, and adequate follow-up to ensure eradication of the infection. The findings also highlight the importance of giving high-dose intravenous antibiotics to anyone with suspected sepsis within an hour of admission to hospital as recommended by the international Surviving Sepsis Campaign, an initiative that was developed to improve the management, diagnosis, and treatment of sepsis. Finally, these findings suggest that signs of severe sepsis, particularly in women with a confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001672.
The UK National Health Service Choices website has information about sepsis
The international Surviving Sepsis Campaign guidelines for the treatment of sepsis are available through the campaign's website
The Sepsis Alliance, a US not-for-profit organization, also provides information about sepsis for patients and their families (in English and Spanish), including information about maternal sepsis and several personal stories about maternal sepsis (see the stories of Alanna Basinger, Alisa Proctor, Sandy C, and Natalie Banathy)
The not-for profit UK Sepsis Trust is another useful source of information about sepsis that includes patient stories
MedlinePlus provides links to additional resources about sepsis (in English and Spanish)
UKOSS provides more information about its national case-control study on severe maternal sepsis in the UK
Related Articles
The Innate Immune Response in HIV/AIDS Septic Shock Patients: A Comparative Study
Amancio, Rodrigo T.
Japiassu, Andre M.
Gomes, Rachel N.
Mesquita, Emersom C.
Assis, Edson F.
Medeiros, Denise M.
Grinsztejn, Beatriz
Bozza, Patrícia T.
Castro-Faria, Hugo C.
Bozza, Fernando A.
PLoS ONE
In recent years, the incidence of sepsis has increased in critically ill HIV/AIDS patients, and the presence of severe sepsis emerged as a major determinant of outcomes in this population. The inflammatory response and deregulated cytokine production play key roles in the pathophysiology of sepsis; however, these mechanisms have not been fully characterized in HIV/AIDS septic patients.
We conducted a prospective cohort study that included HIV/AIDS and non-HIV patients with septic shock. We measured clinical parameters and biomarkers (C-reactive protein and cytokine levels) on the first day of septic shock and compared these parameters between HIV/AIDS and non-HIV patients.
We included 30 HIV/AIDS septic shock patients and 30 non-HIV septic shock patients. The HIV/AIDS patients presented low CD4 cell counts (72 [7-268] cells/mm3), and 17 (57%) patients were on HAART before hospital admission. Both groups were similar according to the acute severity scores and hospital mortality. The IL-6, IL-10 and G-CSF levels were associated with hospital mortality in the HIV/AIDS septic group; however, the CRP levels and the surrogates of innate immune activation (cytokines) were similar among HIV/AIDS and non-HIV septic patients. Age (odds ratio 1.05, CI 95% 1.02-1.09, p=0.002) and the IL-6 levels (odds ratio 1.00, CI 95% 1.00-1.01, p=0.05) were independent risk factors for hospital mortality.
IL-6, IL-10 and G-CSF are biomarkers that can be used to predict prognosis and outcomes in HIV/AIDS septic patients. Although HIV/AIDS patients are immunocompromised, an innate immune response can be activated in these patients, which is similar to that in the non-HIV septic population. In addition, age and the IL-6 levels are independent risk factors for hospital mortality irrespective of HIV/AIDS disease.
Related Articles
Acute Kidney Injury in Patients with Sepsis and Septic Shock: Risk Factors and Clinical Outcomes
Suh, Sang Heon
Kim, Chang Seong
Choi, Joon Seok
Bae, Eun Hui
Ma, Seong Kwon
Kim, Soo Wan
Yonsei Medical Journal
The aim of this study was to investigate clinical characteristics and risk factors of acute kidney injury (AKI) in patients with sepsis and septic shock. Additionally, we explored whether the severity of AKI affects on the clinical outcomes.
Materials and Methods
Data were collected retrospectively in a single center. Among 5680 patients who visited emergency department from January to December 2010, 992 patients with sepsis and septic shock were enrolled. Patients were divided into two groups, patients who developed AKI or not, to compare the baseline characteristics, and laboratory and physiologic data. Patients with AKI were subdivided according to its stages for survival analysis.
AKI was developed in 57.7% of patients. Multivariable logistic regression analysis revealed that development of septic AKI was associated with older age, pre-existing chronic kidney disease, use of angiotensin converting enzyme inhibitor or angiotensin receptor blocker, presence of shock, positive blood culture results, and low white blood cell and platelet counts. Hospital mortality was higher in AKI group. Crude Kaplan-Meier survival curves demonstrated reduced 30-day survival rate was significantly associated with the severity of acute kidney injury.
The development of septic AKI was associated with poor clinical outcomes. Furthermore, the severity of AKI was associated with increased mortality.
Acute kidney injury; mortality; risk factors; sepsis; septic shock
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Factors associated with septic shock and mortality in generalized peritonitis: comparison between community-acquired and postoperative peritonitis
Riché, Florence C
Dray, Xavier
Laisné, Marie-Josèphe
Matéo, Joaquim
Raskine, Laurent
Sanson-Le Pors, Marie-José
Payen, Didier
Valleur, Patrice
Cholley, Bernard P
Critical Care
The risk factors associated with poor outcome in generalized peritonitis are still debated. Our aim was to analyze clinical and bacteriological factors associated with the occurrence of shock and mortality in patients with secondary generalized peritonitis.
This was a prospective observational study involving 180 consecutive patients with secondary generalized peritonitis (community-acquired and postoperative) at a single center. We recorded peri-operative occurrence of septic shock and 30-day survival rate and analyzed their associations with patients characteristics (age, gender, SAPS II, liver cirrhosis, cancer, origin of peritonitis), and microbiological/mycological data (peritoneal fluid, blood cultures).
Frequency of septic shock was 41% and overall mortality rate was 19% in our cohort. Patients with septic shock had a mortality rate of 35%, versus 8% for patients without shock. Septic shock occurrence and mortality rate were not different between community-acquired and postoperative peritonitis. Age over 65, two or more microorganisms, or anaerobes in peritoneal fluid culture were independent risk factors of shock. In the subgroup of peritonitis with septic shock, biliary origin was independently associated with increased mortality. In addition, intraperitoneal yeasts and Enterococci were associated with septic shock in community-acquired peritonitis. Yeasts in the peritoneal fluid of postoperative peritonitis were also an independent risk factor of death in patients with septic shock.
Unlike previous studies, we observed no difference in incidence of shock and prognosis between community-acquired and postoperative peritonitis. Our findings support the deleterious role of Enterococcus species and yeasts in peritoneal fluid, reinforcing the need for prospective trials evaluating systematic treatment against these microorganisms in patients with secondary peritonitis.
Related Articles
Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute
Choudhuri, Anirban Hom
Uppal, Rajeev
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes.
The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery.
Retrospective, audit.
Materials and Methods:
The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group).
The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks.
Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.
Anastomotic leakage; post-leak sepsis; septic shock
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A rare association of emphysematous pyelonephritis with unrecognized diabetes and polycystic kidney
Azzini, A. M.
Sette, P.
Castellano, G.
Dorizzi, R. M.
Indian Journal of Nephrology
Emphysematous pyelonephritis (EPN) is a rare, severe, gas-forming infection for which the treatment of choice is often an immediate nephrectomy, although many reports exist of conservative treatment of cases with antibiotic therapy and percutaneous drainage of abscesses. It usually occurs in diabetic patients and less frequently in subjects with an obstruction of the corresponding renoureteral unit; other predisposing factors are not common. We report here the case of a 51 year-old woman with a rare association of unrecognized diabetes and bilateral polycystic kidney disease who developed monolateral EPN. She had an emergency right nephrectomy and was admitted to Intensive Care Unit (ICU) for septic shock after surgery, requiring intensive resuscitation. The patient was managed with Coupled Plasma Filtration Adsorption (CPFA). Her clinical conditions rapidly improved and the hemofiltration was soon suspended. Urine and blood cultures were positive for the same Escherichia coli, which was susceptible to all tested antibiotics. The patient was transferred to the Nephrology Division and was discharged from the hospital without further dialysis after 34 days. This case report is somewhat unique because of the unusual association between undetected diabetes and polycystic kidney as predisposing factors of a severe infection of the urinary tract.
Emphysematous pyelonephritis (EPN); diabetes mellitus; polycystic kidney; dialysis
Related Articles
Diagnostic value and prognostic evaluation of Presepsin for sepsis in an emergency department
Liu, Bo
Chen, Yun-Xia
Yin, Qin
Zhao, Yun-Zhou
Li, Chun-Sheng
Critical Care
Presepsin levels are known to be increased in sepsis. The aim of this study was to evaluate the early diagnostic and prognostic value of Presepsin compared with procalcitonin (PCT), Mortality in Emergency Department Sepsis (MEDS) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score in septic patients in an emergency department (ED) and to investigate Presepsin as a new biomarker of sepsis.
This study enrolled 859 consecutive patients with at least two diagnostic criteria for systemic inflammatory response syndrome (SIRS) who were admitted to Beijing Chao-yang Hospital ED from December 2011 to October 2012, and 100 age-matched healthy controls. Patients were stratified into four groups: SIRS, sepsis, severe sepsis, and septic shock. Plasma Presepsin and serum PCT were measured, and MEDS score and APACHE II score were calculated at enrollment. Comparisons were analyzed using the Kruskal-Wallis and Mann–Whitney U tests.
On admission, the median levels of plasma Presepsin increased with sepsis severity. The areas under the receiver operating characteristic (AUC) curves of Presepsin were greater than those of PCT in diagnosing sepsis, and predicting severe sepsis and septic shock. The AUC of Presepsin for predicting 28-day mortality in septic patients was slightly lower than that of PCT, MEDS score and APACHE II score. The AUC of a combination of Presepsin and MEDS score or APACHE II score was significantly higher than that of MEDS score or APACHE II score alone in predicting severe sepsis, and was markedly higher than that of Presepsin alone in predicting septic shock and 28-day mortality in septic patients, respectively. Plasma Presepsin levels in septic patients were significantly higher in non-survivors than in survivors at 28 days' follow-up. Presepsin, MEDS score and APACHE II score were found to be independent predictors of severe sepsis, septic shock and 28-day mortality in septic patients. The levels of plasma Presepsin were positively correlated with PCT, MEDS score and APACHE II score in every septic group.
Presepsin is a valuable biomarker for early diagnosis of sepsis, risk stratification, and evaluation of prognosis in septic patients in the ED.
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Survival Analysis of 314 Episodes of Sepsis in Medical Intensive Care Unit in University Hospital: Impact of Intensive Care Unit Performance and Antimicrobial Therapy
Degoricija, Vesna
Sharma, Mirella
Legac, Ante
Gradišer, Marina
Šefer, Siniša
Vučičević, Željko
Croatian medical journal
To evaluate epidemiology of sepsis in medical intensive care unit (ICU) in an university hospital, and the impact of ICU performance and appropriate empirical antibiotic therapy on survival of septic patients.
Observational, partly prospective study conducted over 6 years assessed all patients meeting the criteria for sepsis at ICU admission at the Sisters of Mercy Hospital in Zagreb. Clinical presentation of sepsis was defined according to 2001 International Sepsis Definitions Conference. Demographic data, admission category, source of infection, severity of sepsis, ICU or hospital stay and outcome, ICU performance, and appropriateness of empirical antibiotic therapy were analyzed.
The analysis included 314 of 5022 (6.3%) patients admitted to ICU during the study period. There were 176 (56.1%) ICU survivors. At the ICU admission, sepsis was present in 100 (31.8%), severe sepsis in 89 (28.6%), and septic shock in 125 (39.8%) patients with mortality rates 17%, 33.7%, 72.1%, respectively. During ICU treatment, 244 (77.7%) patients developed at least one organ dysfunction syndrome. Of 138 (43.9%) patients who met the criteria for septic shock, 107 (75.4) were non-survivors (P<0.001). Factors associated with in-ICU mortality were acquisition of sepsis at another department (odds ratio [OR] 0.06; 95% confidence interval [CI], 0.02-0.19), winter season (OR 0.42; 0.20-0.89), limited mobility (OR 0.28; 0.14-0.59), ICU length of stay (OR 0.82; 0.75-0.91), sepsis-related organ failure assessment (SOFA) score on day 1 (OR 0.80; 0.72-0.89), history of global heart failure (OR 0.33; 0.16-0.67), chronic obstructive pulmonary disease (COPD)-connected respiratory failure (OR 0.50; 0.27-0.93), septic shock present during ICU treatment (OR 0.03; 0.01-0.10), and negative blood culture at admission (OR 2.60; 0.81-6.23). Microbiological documentation of sepsis was obtained in 235 (74.8%) patients. Urinary tract infections were present in 168 (53.5%) patients, followed by skin or soft tissue infections in 58 (18.5%) and lower respiratory tract infections in 44 (14.0%) patients. Lower respiratory tract as focus of sepsis was connected with worse outcome (P<0.001). Empirical antibiotic treatment was considered adequate in 107 (60.8%) survivors and 42 (30.4%) non-survivors. Patients treated with adequate empirical antibiotic therapy had significantly higher survival time in hospital (log-rank, P = 0.001).
The mortality rate of sepsis was unacceptably high. The odds for poor outcome increased with acquisition of sepsis at another department, winter season, limited mobility, higher SOFA score on day 1, history of chronic global heart failure, COPD-connected respiratory failure, and septic shock present during ICU treatment, whereas longer ICU length of stay, positive blood culture, and adequate empirical antibiotic therapy were protective factors.
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Association between Mannose-Binding Lectin Deficiency and Septic Shock following Acute Pyelonephritis Due to Escherichia coli▿
Smithson, Alex
Muñoz, Ana
Suarez, Belen
Soto, Sara Maria
Perello, Rafael
Soriano, Alex
Martinez, Jose Antonio
Vila, Jordi
Horcajada, Juan Pablo
Mensa, Jose
Lozano, Francisco
Clinical and Vaccine Immunology
Structural and promoter MBL2 gene polymorphisms responsible for low MBL levels are associated with increased risk of infection. The objective of this study was to assess the possible association between polymorphisms of the MBL2 gene and the incidence of septic shock and bacteremia in patients with acute pyelonephritis due to Escherichia coli. The study included 62 female patients with acute pyelonephritis due to E. coli who required hospital admission, as well as 133 healthy control subjects. Six single-nucleotide polymorphisms (−550 G/C, −221 C/G, +4 C/T, codon 52 CGT/TGT, codon 54 GGC/GAC, and codon 57 GGA/GAA) in the MBL2 gene were genotyped by using a sequence-based typing technique. No significant differences were observed in the frequencies for low-expression MBL2 genotypes (O/O and LXA/O) between patients with acute pyelonephritis and healthy controls. Patients with acute pyelonephritis and septic shock had a higher incidence of low-expression MBL2 genotypes than patients with acute pyelonephritis without septic shock (odds ratio = 9.019, 95% confidence interval = 1.23 to 65.93; P = 0.03). No association was found between bacteremic acute pyelonephritis and low-expression MBL2 genotypes. We found that low-expression MBL2 genotypes predispose to septic shock but not to bacteremia in patients with E. coli-induced acute pyelonephritis. Determination of MBL2 polymorphisms could be useful for assessing the risk of septic shock in women undergoing acute pyelonephritis.
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The epidemiology of septic shock in French intensive care units: the prospective multicenter cohort EPISS study
Quenot, Jean-Pierre
Binquet, Christine
Kara, Fady
Martinet, Olivier
Ganster, Frederique
Navellou, Jean-Christophe
Castelain, Vincent
Barraud, Damien
Cousson, Joel
Louis, Guillaume
Perez, Pierre
Kuteifan, Khaldoun
Noirot, Alain
Badie, Julio
Mezher, Chaouki
Lessire, Henry
Pavon, Arnaud
Critical Care
To provide up-to-date information on the prognostic factors associated with 28-day mortality in a cohort of septic shock patients in intensive care units (ICUs).
Prospective, multicenter, observational cohort study in ICUs from 14 French general (non-academic) and university teaching hospitals. All consecutive patients with septic shock admitted between November 2009 and March 2011 were eligible for inclusion. We prospectively recorded data regarding patient characteristics, infection, severity of illness, life support therapy, and discharge.
Among 10,941 patients admitted to participating ICUs between October 2009 and September 2011, 1,495 (13.7%) patients presented inclusion criteria for septic shock and were included. Invasive mechanical ventilation was needed in 83.9% (n = 1248), inotropes in 27.7% (n = 412), continuous renal replacement therapy in 32.5% (n = 484), and hemodialysis in 19.6% (n = 291). Mortality at 28 days was 42% (n = 625). Variables associated with time to mortality, right-censored at day 28: age (for each additional 10 years) (hazard ratio (HR) = 1.29; 95% confidence interval (CI): 1.20-1.38), immunosuppression (HR = 1.63; 95%CI: 1.37-1.96), Knaus class C/D score versus class A/B score (HR = 1.36; 95%CI:1.14-1.62) and Sepsis-related Organ Failure Assessment (SOFA) score (HR = 1.24 for each additional point; 95%CI: 1.21-1.27). Patients with septic shock and renal/urinary tract infection had a significantly longer time to mortality (HR = 0.56; 95%CI: 0.42-0.75).
Our observational data of consecutive patients from real-life practice confirm that septic shock is common and carries high mortality in general ICU populations. Our results are in contrast with the clinical trial setting, and could be useful for healthcare planning and clinical study design.
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Pyelonephritis (acute) in non-pregnant women
Neumann, Ignacio
Moore, Philippa
Clinical Evidence
Pyelonephritis is usually caused by ascent of bacteria, most often Escherichia coli, from the bladder, and is more likely in people with structural or functional urinary tract abnormalities. The prognosis is good if pyelonephritis is treated appropriately, but complications include renal abscess, renal impairment, and septic shock.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: antibiotic treatments for acute pyelonephritis in women with uncomplicated infection; inpatient versus outpatient management in women with uncomplicated infection; and analgesia in uncomplicated acute pyelonephritis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found three systematic reviews, RCTs, or observational studies that met our inclusion criteria.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (intravenous), antibiotics (oral), antibiotics (switch therapy), inpatient versus outpatient management, non-steroidal anti-inflammatory drugs, simple analgesics (non-opioid), and urinary analgesics.
Key Points
Pyelonephritis is usually caused by ascent of bacteria from the bladder, most often Escherichia coli, and is more likely in people with structural or functional urinary tract abnormalities. The prognosis of acute uncomplicated pyelonephritis is good if pyelonephritis is treated appropriately, but complications include renal abscess, renal impairment, and septic shock.
We found no direct information about whether oral or intravenous antibiotics are better than no active treatment. However, consensus holds that these drugs are effective. We don't know how any one oral antibiotic regimen compares with another, or what the optimum duration of treatment is, although it may be sensible to continue treatment for at least 10 days. Broader spectrum antibiotics, such as quinolones, may be more effective compared with narrower spectrum antibiotics, such as ampicillin, amoxicillin, or trimethoprim–sulfamethoxazole (co-trimoxazole), in areas where resistance to these agents is common.We don't know whether any particular switch regimen (intravenous antibiotics followed by oral antibiotics) is better than another, or how switch antibiotic regimens compare with oral antibiotic regimens. We found no information from RCTs on the time to change from intravenous to oral antibiotics.We don't know which is the most effective intravenous antibiotic regimen, or the optimum duration of treatment.
We found no RCTs comparing inpatient with outpatient treatment. Clinical judgement of the severity of infection and the quality of ambulatory care should be considered in the decision to admit a patient into hospital.
We found no RCTs assessing the effects of simple analgesics, NSAIDs, or urinary analgesics on pain from uncomplicated pyelonephritis. NSAIDs may worsen renal function and should be used with caution in women with pyelonephritis.
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Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic
Vollans, Samuel R
Sehjal, Ranjit
Forster, James A
Rogawski, Karol M
Cases Journal
Emphysematous pyelonephritis (EPN) is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. 90% of cases are seen in association with diabetes mellitus. We report a case of undiagnosed ureteric obstruction in a type II diabetic, leading to EPN requiring emergency nephrectomy.
Case presentation
A 59-year-old type II tablet controlled diabetic woman presented complaining of a five day history of right sided abdominal pain associated with vomiting, abdominal distension and absolute constipation. There were no lower urinary tract symptoms. Past surgical history included an open appendectomy and an abdominal hysterectomy. On examination, she was haemodynamically stable, the abdomen was soft, distended, and tender in the right upper and lower quadrants with no bowel sounds. Investigations revealed a CRP of 365 and 2+ blood and nitrite positive on the urine dipstick. The AXR was reported as normal on admission, however when reviewed in retrospect revealed the diagnosis. She was managed, therefore, as having adhesional bowel obstruction and a simple UTI. After four days, a CT was organised as she was not settling. This showed a right pyohydronephrosis with gas in the collecting system secondary to an 8 mm obstructing ureteric calculus. The kidney was drained percutaneously via a nephrostomy and the patient was commenced on a broad spectrum intravenous antibiotics. Despite this, she went on to need an emergency nephrectomy for uncontrolled severe sepsis. She was discharged in good health 15 days later.
EPN carries a mortality of up to 40% with medical management alone. Early recognition of EPN in an obstructed kidney is essential to guide aggressive management, and in the presence of continued severe sepsis or organ dysfunction an urgent nephrectomy should be carried out. Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment. In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.
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A high angiopoietin-2/angiopoietin-1 ratio is associated with a high risk of septic shock in patients with febrile neutropenia
Luz Fiusa, Maiara Marx
Costa-Lima, Carolina
de Souza, Gleice Regina
Vigorito, Afonso Celso
Penteado Aranha, Francisco Jose
Lorand-Metze, Irene
Annichino-Bizzacchi, Joyce M
de Souza, Carmino Antonio
De Paula, Erich V
Critical Care
Endothelial barrier breakdown is a hallmark of septic shock, and proteins that physiologically regulate endothelial barrier integrity are emerging as promising biomarkers of septic shock development. Patients with cancer and febrile neutropenia (FN) present a higher risk of sepsis complications, such as septic shock. Nonetheless, these patients are normally excluded or under-represented in sepsis biomarker studies. The aim of our study was to validate the measurement of a panel of microvascular permeability modulators as biomarkers of septic shock development in cancer patients with chemotherapy-associated FN.
This was a prospective study of diagnostic accuracy, performed in two distinct in-patient units of a university hospital. Levels of vascular endothelial growth factor A (VEGF-A), soluble fms-like tyrosine kinase-1 (sFlt-1) and angiopoietin (Ang) 1 and 2 were measured after the onset of neutropenic fever, in conditions designed to mimic the real-world use of a sepsis biomarker, based on our local practice. Patients were categorized based on the development of septic shock by 28 days as an outcome.
A total of 99 consecutive patients were evaluated in the study, of which 20 developed septic shock and 79 were classified as non-complicated FN. VEGF-A and sFlt-1 levels were similar between both outcome groups. In contrast, Ang-2 concentrations were increased in patients with septic shock, whereas an inverse finding was observed for Ang-1, resulting in a higher Ang-2/Ang-1 ratio in patients with septic shock (5.29, range 0.58 to 57.14) compared to non-complicated FN (1.99, range 0.06 to 64.62; P = 0.01). After multivariate analysis, the Ang-2/Ang-1 ratio remained an independent factor for septic shock development and 28-day mortality.
A high Ang-2/Ang-1 ratio can predict the development of septic shock in cancer patients with febrile neutropenia.
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Risk factors and prognosis of critically ill cancer patients with postoperative acute respiratory insufficiency
Xing, Xue-zhong
Gao, Yong
Wang, Hai-jun
Yang, Quan-hui
Huang, Chu-lin
Qu, Shi-ning
Zhang, Hao
Wang, Hao
Xiao, Qing-ling
Sun, Ke-lin
World Journal of Emergency Medicine
This study aimed to investigate the risk factors and outcome of critically ill cancer patients with postoperative acute respiratory insufficiency.
The data of 190 critically ill cancer patients with postoperative acute respiratory insufficiency were retrospectively reviewed. The data of 321 patients with no acute respiratory insufficiency as controls were also collected. Clinical variables of the first 24 hours after admission to intensive care unit were collected, including age, sex, comorbid disease, type of surgery, admission type, presence of shock, presence of acute kidney injury, presence of acute lung injury/acute respiratory distress syndrome, acute physiologic and chronic health evaluation (APACHE II) score, sepsis-related organ failure assessment (SOFA), and PaO2/FiO2 ratio. Duration of mechanical ventilation, length of intensive care unit stay, intensive care unit death, length of hospitalization, hospital death and one-year survival were calculated.
The incidence of acute respiratory insufficiency was 37.2% (190/321). Multivariate logistic analysis showed a history of chronic obstructive pulmonary diseases (P=0.001), surgery-related infection (P=0.004), hypo-volemic shock (P<0.001), and emergency surgery (P=0.018), were independent risk factors of postoperative acute respiratory insufficiency. Compared with the patients without acute respiratory insufficiency, the patients with acute respiratory insufficiency had a prolonged length of intensive care unit stay (P<0.001), a prolonged length of hospitalization (P=0.006), increased intensive care unit mortality (P=0.001), and hospital mortality (P<0.001). Septic shock was shown to be the only independent prognostic factor of intensive care unit death for the patients with acute respiratory insufficiency (P=0.029, RR: 8.522, 95%CI: 1.243–58.437, B=2.143, SE=0.982, Wald=4.758). Compared with the patients without acute respiratory insufficiency, those with acute respiratory insufficiency had a shortened one-year survival rate (78.7% vs. 97.1%, P<0.001).
A history of chronic obstructive pulmonary diseases, surgery-related infection, hypovolemic shock and emergency surgery were risk factors of critically ill cancer patients with postoperative acute respiratory insufficiency. Septic shock was the only independent prognostic factor of intensive care unit death in patients with acute respiratory insufficiency. Compared with patients without acute respiratory insufficiency, those with acute respiratory insufficiency had adverse short-term outcome and a decreased one-year survival rate.
Acute respiratory insufficiency; Risk factors; Prognosis; Critical illness; Postoperative care; Septic shock; Chronic obstructive pulmonary disease; Survival
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Circulating immune parameters predicting the progression from hospital-acquired pneumonia to septic shock in surgical patients
von Dossow, Vera
Rotard, Koschka
Redlich, Uwe
Hein, Ortrud Vargas
Spies, Claudia D
Critical Care
Hospital-acquired pneumonia after surgery is one of the major causes of septic shock. The excessive inflammatory response appears to be responsible for the increased susceptibility to infections and subsequent sepsis. The primary aim of this study was to investigate immune parameters at the onset of pneumonia, before the development of subsequent septic shock. The secondary aim was to investigate the usefulness of these immune parameters in predicting progression from hospital-acquired pneumonia to septic shock.
This propective clinical study included 76 patients with the diagnosis of hospital-acquired pneumonia. Approval was obtained from the local institutional ethics committee and relatives of the patients gave informed consent. Of the 76 patients, 29 subsequently developed septic shock. All patients were included within 4 h of establishing the diagnosis of hospital-acquired pneumonia (first collection of blood samples and the analysis of immune mediators). In addition, we defined early (within 12 h of onset of septic shock) and late (within 72 to 96 h of onset) stages of septic shock for the collection of blood samples and the analysis of immune mediators. The immune parameters tumor necrosis factor-α, IL-1β, IL-6, IL-8 and IL-10 as well as the endothelial leucocyte adhesion molecule were analyzed.
In the pneumonia group with subsequent septic shock, levels of IL-1β, IL-6, IL-8 and IL-10 were significantly increased before the onset of septic shock compared to patients without subsequent septic shock. This progression was best predicted by IL-1β, IL-6, IL-8 and IL-10 (area under the curve ≥ 0.8).
At the onset of hospital-acquired pneumonia, a significant relevant systemic cytokine mediated response had already been initiated. It might, therefore, be possible to identify patients at risk for septic shock with these predictive markers during early pneumonia. In addition, immune modulating therapy might be considered as adjuvant therapy.
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Epidemiological and Clinical Characteristics of Community-Acquired Severe Sepsis and Septic Shock: A Prospective Observational Study in 12 University Hospitals in Korea
Park, Dae Won
Chun, Byung Chul
Kim, June Myung
Sohn, Jang Wook
Peck, Kyong Ran
Kim, Yang Soo
Choi, Young Hwa
Choi, Jun Yong
Kim, Sang Il
Eom, Joong Sik
Kim, Hyo Youl
Song, Joon Young
Song, Young Goo
Choi, Hee Jung
Kim, Min Ja
Journal of Korean Medical Science
A prospective multicenter observational study was performed to investigate the epidemiology and outcomes of community-acquired severe sepsis and septic shock. Subjects included 1,192 adult patients admitted to the 22 participating intensive care units (ICUs) of 12 university hospitals in the Korean Sepsis Registry System from April, 2005 through February, 2009. Male accounted for 656 (55%) patients. Mean age was 65.0 ± 14.2 yr. Septic shock developed in 740 (62.1%) patients. Bacteremia was present in 422 (35.4%) patients. The 28-day and in-hospital mortality rates were 23.0% and 28.0%, respectively. Men were more likely to have comorbid illnesses and acute organ dysfunctions, and had higher mortality and clinical severity compared to women. While respiratory sources of sepsis were common in men, urinary sources were predominant in women. In the multivariate logistic regression analysis, cancer (odds ratio 1.89; 95% confidence interval 1.13-3.17), urinary tract infection (0.25; 0.13-0.46), APACHE II score (1.05; 1.02-1.09), SOFA score on day 1 (1.13; 1.06-1.21) and metabolic dysfunction (2.24, 1.45-3.45) were independent clinical factors for gender-related in-hospital mortality. This study provided epidemiological and clinical characteristics of community-acquired severe sepsis and septic shock in ICUs in Korea, and demonstrated the impact of clinical factors on gender difference in mortality.
Epidemiology; Severe Sepsis; Septic Shock; Mortality; Risk Factor; Gender
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Emphysematous Cystitis: Report of an Atypical Case
De Baets, Karen
Baert, Joost
Coene, Luc
Claessens, Marc
Hente, Robert
Tailly, Geert
Case Reports in Urology
We report the atypical case of a nondiabetic 66-year old male with severe abdominal pain and vomiting who was found to have emphysematous cystitis. Of all gas-forming infections of the urinary tract emphysematous cystitis is the most common and the least severe. The major risk factors are diabetes mellitus and urinary tract obstruction. Most frequent causative pathogens are Escherichia coli and Klebsiella pneumoniae. The clinical presentation is nonspecific and ranges from asymptomatic urinary tract infection to urosepsis and septic shock. The diagnosis is made by abdominal imaging. Treatment consists of broad-spectrum antibiotics, bladder drainage, and management of the risk factors. Surgery is reserved for severe cases. Overall mortality rate of emphysematous cystitis is 7%. Immediate diagnosis and treatment is necessary because of the rapid progression to bladder necrosis, emphysematous pyelonephritis, urosepsis, and possibly fatal evolution.
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Simultaneous vs staged treatment of urolithiasis in patients undergoing radical prostatectomy
Viers, Boyd R
Tollefson, Matthew K
Patterson, David E
Gettman, Matthew T
Krambeck, Amy E
World Journal of Clinical Cases : WJCC
AIM: To assess the outcomes of men treated for urolithiasis at the time of radical prostatectomy.
METHODS: From 1991 to 2010, 22 patients were retrospectively identified who were treated simultaneously (n = 10) at radical prostatectomy, or (n = 12) within 120 d prior to prostatectomy, for urolithiasis. Clinical characteristics were reviewed including: type of prostatectomy and stone surgery, location and amount of stone burden, perioperative change in hemoglobin and creatinine, stent frequency, total hospital d, stone-free rates, additional stone procedures and complications. Long-term functional outcomes including stress urinary incontinence and bladder neck contracture were reported. Differences between cohorts (simultaneous vs staged treatment) were assessed.
RESULTS: Among men undergoing radical prostatectomy, primary stone procedures included 12 ureteroscopy, 6 shock wave lithotripsy, 2 open nephrolithotomy and 2 percutaneous nephrolithotomy. In staged shock wave lithotripsy there were 4 complications and 3 additional procedures vs 1 (P = 0.5) and 0 (P = 0.2) in the simultaneous cohort. Meanwhile in staged ureteroscopy there were 5 complications and 1 additional procedure vs 1 (P = 0.2) and 1 (P = 0.9) in the simultaneous cohort. Additional procedures for residual stones was greater among patients with asymptomatic upper tract calculi 3 (60%) relative to patients with symptomatic stones 2 (13%; P = 0.02). Likewise, patients with proximal or multiple calculi had a greater total hospital days 5.5 vs 4.1 (P = 0.04), additional procedures 6 vs 0 (P = 0.04) and lower stone-free rates 39% vs 89% (P = 0.02) relative to men with distal stones. Finally, there was no difference in the incidence of bladder neck contracture (P = 0.4) or stress urinary incontinence (P = 0.7) between cohorts.
CONCLUSION: Ureteroscopic treatment of symptomatic distal urolithiasis at radical prostatectomy appears to be safe and efficacious with a low rate of adverse postoperative outcomes.
Urolithiasis; Kidney stone; Prostate cancer; Radical prostatectomy
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Effects on management and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: a pilot study
Girardis, Massimo
Rinaldi, Laura
Donno, Lara
Marietta, Marco
Codeluppi, Mauro
Marchegiano, Patrizia
Venturelli, Claudia
Critical Care
The application in clinical practice of evidence-based guidelines for the management of patients with severe sepsis/septic shock is still poor in the emergency department, while little data are available for patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an in-hospital sepsis program on the adherence to evidence-based guidelines and outcome of patients with severe sepsis/septic shock admitted to the ICU.
This prospective observational cohort study included 67 patients with severe sepsis/septic shock admitted to a multidisciplinary ICU at a University Hospital from January 2005 to June 2007. Compliance to 5 resuscitation and 4 management sepsis interventions and in-hospital mortality were measured following an educational program on sepsis for physician and nurses of all hospital departments and hospital implementation of a specific protocol for recognition and management of patients with severe sepsis/septic shock, including an early consultation by a skilled 'sepsis team'.
During the study period, the compliance to all 9 interventions increased from 8% to 35% of the patients (P < 0.01). The implementation of resuscitation and management interventions was associated with a lower risk of in-hospital mortality (23% vs 68% and 27% vs 68%, P < 0.01). In the latter 2 semesters, after activation of the 'sepsis team', in-hospital mortality of ICU septic shock patients decreased by about 40% compared with the previous period (32% vs 79%, P < 0.01).
In our experience, an in-hospital sepsis program, including education of health-care personnel and process-changes, improved the adherence to guidelines and the survival rate of patients with severe sepsis/septic shock admitted to the ICU.
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Plasma IL-8 is not an effective risk stratification tool for adults with vasopressor-dependent septic shock
Calfee, Carolyn S.
Thompson, B. Taylor
Parsons, Polly E.
Ware, Lorraine B.
Matthay, Michael A.
Wong, Hector R.
Critical Care Medicine
Plasma interleukin-8 (IL-8) levels of < 220 pg/ml have an excellent negative predictive value (94–95%) for death at 28 days in children with septic shock and thus may be useful for risk stratification in clinical trial enrollment in this population. Whether plasma IL-8 would have similar utility in adults with septic shock is unknown.
Design, Setting, and Patients
Analysis of plasma IL-8 levels in 192 adults with vasopressor-dependent septic shock enrolled in clinical trials of acute lung injury conducted by the Acute Respiratory Distress Syndrome Network
Measurements and Main Results
Plasma IL-8 levels ≥ 220 pg/ml were significantly associated with death at 28 days in this cohort (odds ratio 2.92, 95% CI 1.42–5.99; p=0.001). However, in contrast to the findings in pediatric septic shock, a plasma IL-8 cutoff below 220 pg/ml had a negative predictive value for death of only 74% (95% CI 66–81%) in adults with septic shock. Receiver-operating characteristic analysis found an area under the curve of 0.59 for plasma IL-8, indicating that plasma IL-8 is a poor predictor of mortality in this group. In adults under age 40, a plasma IL-8 cutoff < 220 pg/ml had a negative predictive value of 92%.
In contrast to similar pediatric patients, plasma IL-8 levels are not an effective risk stratification tool in older adults with septic shock. Future studies of biomarkers for risk stratification in critically ill subjects will need to be replicated in multiple different populations before being applied in screening for clinical trials.
interleukin-8; acute lung injury; sensitivity; specificity; negative predictive value; risk stratification
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Long-term nephrostomy in an adult male spinal cord injury patient who had normal upper urinary tracts but developed bilateral hydronephrosis following penile sheath drainage: pyeloplasty and balloon dilatation of ureteropelvic junction proved futile: a case report
Vaidyanathan, Subramanian
Soni, Bakul M
Hughes, Peter L
Singh, Gurpreet
Mansour, Paul
Oo, Tun
Cases Journal
The consequences of spinal cord injury upon urinary bladder are readily recognised by patients and health care professionals, since neuropathic bladder manifests itself as urinary incontinence, or retention of urine. But health care professionals and persons with spinal cord injury may not be conversant with neuropathic dysmotility affecting the ureter and renal pelvis. We report an adult male patient with spinal cord injury, who developed bilateral hydronephrosis after he started managing neuropathic bladder by penile sheath drainage.
Case presentation
A male patient, born in 1971, sustained spinal cord injury following a motorbike accident in September 1988. In November 1988, intravenous urography showed normal upper tracts. He was advised spontaneous voiding with 2-3 catheterisations a day. In February 1995, this patient developed fever, chills and vomiting. Blood urea: 23.7 mmol/L; creatinine: 334 umol/L. Ultrasound revealed marked hydronephrosis of right kidney and mild hydronephrosis of left kidney. Bilateral nephrostomy was performed in March 1995. Right pyeloplasty was performed in May 1998. In July 2005, this patient developed urine infection and was admitted to a local hospital with fever and rigors. He developed septicaemia and required ventilation. Ultrasound examination of abdomen revealed bilateral hydronephrosis and multiple stones in left kidney. Percutaneous nephrostomy was performed on both sides. Subsequently, extracorporeal shock wave lithotripsy of left renal calculi was carried out. Right nephrostomy tube slipped out in January 2006; percutaneous nephrostomy was performed again. In June 2006, left ureteric antegrade stenting was performed and nephrostomy tube was removed. Currently, right kidney is drained by percutaneous nephrostomy and left kidney is drained by ureteric stent. This patient has indwelling urethral catheter.
It is possible that regular intermittent catheterisations along with anticholinergic medication right from the time of rehabilitation after this patient sustained paraplegia might have prevented the series of urological complications. Key components to successful management of external drainage of kidney in this patient are: [1] use of size 14 French pigtail catheter for long-term nephrostomy, [2] anchoring the catheter to skin to with Percufix catheter cuff to prevent accidental tug [3], replacing the nephrostomy dressing once a week by the same team in order to provide continuity of care, and [4] changing nephrostomy catheter every six months by a senior radiologist.
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Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study
Park, Hye Yun
Suh, Gee Young
Song, Jae-Uk
Yoo, Hongseok
Jo, Ik Joon
Shin, Tae Gun
Lim, So Yeon
Woo, Sookyoung
Jeon, Kyeongman
Critical Care
The use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock.
We retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality.
The study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54 to 71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8 to 19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours versus 10.4 hours; P = 0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P = 0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (P < 0.0001) and Sequential Organ Failure Assessment (SOFA) scores (P = 0.0007), dose of vasopressor at the time of initiation of low-dose corticosteroid therapy (P < 0.0001), need for mechanical ventilation (P = 0.0001) and renal replacement therapy (P < 0.0001), while the impaired adrenal reserve did not affect 28-day mortality (81% versus 82%; P = 0.8679). After adjusting for potential confounding factors, the time to initiation of low-dose corticosteroid therapy was still significantly associated with 28-day mortality (adjusted odds ratio (OR) 1.025, 95% confidence interval (CI) 1.007 to 1.044, P = 0.0075). The early therapy group (administered within 6 hours after the onset of septic shock, n = 66) had a 37% lower mortality rate than the late therapy group (administered more than 6 hours after the onset of septic shock, n = 112) (32% versus 51%, P = 0.0132).
Early initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.
Related Articles
Disease Progression in Hemodynamically Stable Patients Presenting to the Emergency Department With Sepsis
Glickman, Seth W.
Cairns, Charles B.
Otero, Ronny M.
Woods, Christopher W.
Tsalik, Ephraim L.
Langley, Raymond J.
van Velkinburgh, Jennifer C.
Park, Lawrence P.
Glickman, Lawrence T.
Fowler, Vance G.
Kingsmore, Stephen F.
Rivers, Emanuel P.
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
Aggressive diagnosis and treatment of patients presenting to the emergency department (ED) with septic shock has been shown to reduce mortality. To enhance the ability to intervene in patients with lesser illness severity, a better understanding of the natural history of the early progression from simple infection to more severe illness is needed.
The objectives were to 1) describe the clinical presentation of ED sepsis, including types of infection and causative microorganisms, and 2) determine the incidence, patient characteristics, and mortality associated with early progression to septic shock among ED patients with infection.
This was a multicenter study of adult ED patients with sepsis but no evidence of shock. Multivariable logistic regression was used to identify patient factors for early progression to shock and its association with 30-day mortality.
Of 472 patients not in shock at ED presentation (systolic blood pressure > 90 mm Hg and lactate < 4 mmol / L), 84 (17.8%) progressed to shock within 72 hours. Independent factors associated with early progression to shock included older age, female sex, hyperthermia, anemia, comorbid lung disease, and vascular access device infection. Early progression to shock (vs. no progression) was associated with higher 30-day mortality (13.1% vs. 3.1%, odds ratio [OR] = 4.72, 95% confidence interval [CI] = 2.01 to 11.1; p ≤ 0.001). Among 379 patients with uncomplicated sepsis (i.e., no evidence of shock or any end-organ dysfunction), 86 (22.7%) progressed to severe sepsis or shock within 72 hours of hospital admission.
A significant portion of ED patients with less severe sepsis progress to severe sepsis or shock within 72 hours. Additional diagnostic approaches are needed to risk stratify and more effectively treat ED patients with sepsis.
sepsis; outcomes; septic shock; progression; biomarkers
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At FITT Resources, we specialise in the supply of premium mechanical engineering products, parts and servicing for rotating and static equipment across a range of industries throughout Australia.
We supply and service a portfolio of internationally acclaimed products, including pumps, instrumentation, composites, filtration and sealing devices (including mechanical seals, packing and gasketting) from the world's leading manufacturers.
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Release Date:
December 30, 2008
Date Published:
December 30, 2008
Tells the story of Ted Bundy, a brilliant law student executed for killing three women, who confessed to killing thirty-five others, from the perspective of the former policewoman, crime writer, and unwitting personal friend.
Ann Rule's compelling account of the case of serial killer Ted Bundy has become a classic in the true crime category. Rule's account of Bundy's crimes, her insightful rendering of the psychology of a killer, and the dramatic police search for the man named "Ted" gains even more interest when it is revealed, to her and to her readers, that she actually knew Bundy years earlier. They had worked together in Seattle at a crisis clinic, where they became, for a time, good friends. Bundy was executed in 1989; Rule is now one of the top true crime writers in America.
Genre: True Crime
Sub-Genre: Murder / Serial Killers
- Genre: True Crime
- Subgenre: Murder / Serial Killers
- Publisher: Pocket Books
- Pages: 625
- Edition: Reprint
- Language: English
- Release Date: December 30, 2008
- Author: Ann Rule
other Info.
- Online Item #: 13228785
- Store Item Number (DPCI): 248-59-2247
- Item can be gift wrapped.
- Made in the USA or Imported


text:
Sony, car makers halt production after Japan earthquakes
They'll wait at least a few days before getting back to normal.
Carbon fiber strings protect buildings against earthquakes
You wouldn't need to ruin a building's design to keep it from falling down.
Drilling makes Oklahoma as earthquake-prone as California
The USGS' new model factors in man-made risks.
Android app turns your phone into an earthquake detector
MyShake makes you one part of a larger seismic warning system.
New game from 'Gears of War' creator breaks the moon
Lawbreakers is a free, post-catastrophe, sci-fi shooter. Just don't call it "post-apocalyptic."
LA's newer cell towers will keep working after earthquakes
Cellular networks are only trustworthy if they continue running in emergencies, and Los Angeles kn...
Facebook and Google help find Nepal earthquake survivors
The Nepal earthquake has caused an immeasurable amount of tragedy this weekend, but some internet...
Facebook 'Safety Check' lets friends know you're OK after a major disaster
Despite the frivolous nature of most social media interactions, Facebook's latest new feature is i...
See how the Napa earthquake affected Jawbone users' sleep
If you're one of the many iPhone users with a Jawbone UP strapped to your wrist, you might be used...


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Inside the world's biggest Maker Faire
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text: 388 FXUS63 KILX 210739 AFDILX Area Forecast Discussion National Weather Service Lincoln IL 239 AM CDT THU JUL 21 2016 .SHORT TERM...(Today and tonight) ISSUED AT 237 AM CDT Thu Jul 21 2016 Initial concern in the short term is around fog for early this morning. Winds are light and variable, with skies remaining mostly clear. Locally dense fog has formed in our eastern areas near Danville and Paris already, with another area of less dense fog farther south from Flora to Robinson and Lawrenceville. Dewpoints depressions range from 0 to 3 degrees across the board. See enough support to continue mention of fog through just after sunrise, but confidence not high on how much dense fog will occur. Next concern surrounds thunderstorm chances over the next 24 hours. The latest Day 1 QPF forecast from WPC expanded rainfall amounts from northern IL into central IL, with 1.20" of rain as far south as Peoria for the time frame between 7 am today and 7 am Friday. Radar analysis shows an active MCS in MN progressing to the E-SE, and most high resolution models progress that toward our forecast area later today. Some dissipate the line more than others, but it appears there is enough support for some storm activity to make it all the way to central IL either late this morning or early afternoon. Therefore, we added some precip chances to today`s forecast. Most coverage today should be isolated in nature. However, another complex of storms is projected to develop north of our area tonight and progress southward into our CWA. Current model trends show the higher potential being after 08z/3am tonight, and have expanded and increase PoPs after midnight into the chance category from Peoria and northward. The other concern today is how much any convection and cloud cover will hold down high temperatures. Guidance numbers were going about3- 4 degrees less hot than our previous forecast. Have not cut our forecast quite that drastically, but did lower todays highs a degree or two across the north and east where storm potential appears higher. Expect that even filtered sunshine under this strong of an upper ridge and warm low-mid layers should be enough to push highs into the low 90s. Lows tonight should be held up in the mid 70s by the very moist boundary layer, with patchy fog possible again. && .LONG TERM...(Friday through Wednesday) ISSUED AT 237 AM CDT Thu Jul 21 2016 Primary concern remains the intense heat. Will extend the Excessive Heat Warning into Sunday for areas from about Rushville-Danville southward, as the front continues to slow down a bit and is more likely to pass through Sunday evening. A little more in the way of clouds and scattered storms, which will keep the heat index more in the 105-110 range vs. the 109-112 on Friday and Saturday, but 850 mb temperatures are still around 24C at that range, and lesser clouds than expected could easily bump the heat index up a few notches. That being said, Friday could be a bit tricky with the heat, primarily over the northern CWA. Most of the model guidance continues to favor an MCS track over the central and northern Great Lakes, with some westward development/retrograding along a frontal boundary or leftover convective boundaries. The Canadian and ECMWF are more in line with that philosophy, along with the NAM to a lesser extent. The GFS is much further southeast and aggressive, given its CAPE`s in the vicinity of 6000 J/kg on the Peoria forecast sounding, but 700 mb temps near 12C suggest a significant cap. Have added some 30% PoP`s along and north of I-74 during the day, with mainly isolated storms at best elsewhere. Should the clouds be more widespread, highs in the mid 90s would be tough to attain, but the tropical dew points would still be present unless a cold pool from the northern storms tracks into the area. As the weekend begins, the upper flow becomes more west-east and subtle ripples may serve as a focus for some convection, addressed with the previous scattered PoP`s around 30% Saturday. The incoming front on Sunday may prove to be more of a catalyst with the rain chances, though. Much quieter as the new work week begins, and temperatures return closer to normal as high pressure drifts through the region. && .AVIATION...(For the 06Z TAFS through 06Z Thursday night) Issued at 1115 PM CDT Wed Jul 20 2016 The main concern will be with the potential for some MVFR vsbys in fog in the 09z-13z time frame. Plenty of low level moisture around due to the recent rains coupled with a very light wind regime and a mostly clear sky will lead to some patchy fog during the early morning hours. Once the fog lifts around 13z, some models were suggesting the threat for wdly scattered TSRA along a northward moving warm front around 12-13z. However, the high res convective allowing models have been struggling quite a bit in this saturated air mass with a different model solution shown with each model run. So confidence on that occurring is rather low at this time so will not include in this set of TAFs. Forecast soundings suggest some few to scattered cumulus to develop during the day on Thursday, but like today once the temperatures warmed aloft, the cumulus were few and far between and we think that will be the case on Thursday as 850-700 mb temps will be just as warm if not warmer than todays. Surface winds will once again be a non-factor this forecast period with light southerly winds tonight, with southerly winds increasing a bit to between 8 to 13 kts Thursday. && .ILX Watches/Warnings/Advisories... Excessive Heat Warning from noon today to 7 PM CDT Sunday for ILZ040>057-061>063-066>068-071>073. Excessive Heat Warning from noon today to 7 PM CDT Saturday for ILZ027>031-036>038. && $$ SHORT TERM...Shimon LONG TERM...Geelhart AVIATION...Smith


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Dumbo (Big Top Edition)
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Product Description
A Disney "classic" that actually is a classic, Dumbo should be part of your video collection whether or not you have children. The storytelling was never as lean as in Dumbo, the songs rarely as haunting (or just plain weird), the characters rarely so well defined. The film pits the "cold, cruel, heartless" world that can't accept abnormality against a plucky, and mute, hero. Jumbo Jr. (Dumbo is a mean-spirited nickname) is ostracized from the circus pack shortly after his delivery by the stork because of his big ears. His mother sticks up for him and is shackled. He's jeered by children (an insightful scene has one boy poking fun at Dumbo's ears, even though the youngster's ears are also ungainly), used by the circus folk, and demoted to appearing with the clowns. Only the decent Timothy Q. Mouse looks out for the little guy. Concerns about the un-PC "Jim Crow" crows, who mock Dumbo with the wonderful "When I See an Elephant Fly," should be moderated by remembering that the crows are the only social group in the film who act kindly to the little outcast. If you don't mist up during the "Baby Mine" scene, you may be legally pronounced dead. --Keith Simanton --This text refers to an out of print or unavailable edition of this title.
Special Features
Only 64 minutes long, Dumbo remains one of most charming and heartfelt films in the Disney canon. This DVD marks the 60th anniversary of its release: the attack on Pearl Harbor knocked Dumbo off the cover of Time. The clear, digitally restored print highlights the imaginative use of color in the film, especially in the dramatic sequence of the roustabouts raising the big top and the brilliantly surreal "Pink Elephants on Parade." In the "Celebrating Dumbo" featurette, young studio artists talk about loving the film but provide little information about its creation. The artists aren't identified in the small galleries of preproduction drawings and publicity stills. Animation historian John Canemaker provides a knowledgeable audio commentary, but the viewer longs for more of Joe Grant, the 93-year-old cowriter of Dumbo who continues to work at the Disney Studio. --Charles Solomon --This text refers to an out of print or unavailable edition of this title.See all Product Description
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Top Customer Reviews
At first glance, and in the context of Disney's own efforts up to then, Dumbo appears less artistic, more cartoony than the three earlier films. In the case of Dumbo, this art has been pared down to the absolute minimum, consistent with pleasing audiences and making money. And Dumbo did make a profit, and is credited for having saved the studio.
This 70th Anniversary Edition film comes in AVC/MPEG-4 1080p 1.37:1. Although this film was made with a lower budget compared to Fantasia or Pinocchio, and the restoration was not as detailed as Pinocchio and Sleeping Beauty, the final result is still a very pleasing and amazing picture. Colours are solid and vibrant at times. The transfer is so clear and sharp that strokes from a paintbrush are often noticeable, as well as slight aging of the print and faint blemishes. Dumbo here showcases deep blacks up through clean whites. (4.5/5)
Dumbo's soundtrack has been fully restored and given a brand new lossless DTS-HD Master Audio 7.1 mix that is spacious and dynamic.Read more ›
For the first time ever, in celebration of this landmark film's 70th anniversary, experience the daring adventures of the world's only flying elephant with a dazzling all-new digital restoration and brilliant 7.1 DTS-HD Master Audio and also the 5.1 Disney Enhanced High Definition Theatre Mix Sound. The inspirational tale of Dumbo, the courageous baby elephant who uses his sensational ears to soar to fame with the help of his clever best friend Timothy Q. Mouse, will thrill and delight audiences of all ages. And now, the award-winning music and empowering messages about friendship and belief in yourself reach new heights in this must-have Blu-ray high-definition presentation of Walt Disney s animated classic Dumbo! Narrated by John McLeish.
FILM FACT Part One: Awards and Nominations: 1941 Academy Awards®: Win: Original Music Score for Frank Churchill and Oliver Wallace. Nominated: Best Song for "Baby Mine" for Frank Churchill and Ned Washington. 1947 Cannes Film Festival: Win: Best Animation Design. Following the aerial montage of Dumbo, there is a newspaper montage. Next to the picture of the flying elephant, there is the headline "Bombers for Defense." It is a reference of the national defence during the ongoing World War II. There is also a reference to the fireside chats of Franklin D. Roosevelt.
FILM FACT Part Two: Songs and Performers: "Look Out for Mr.Read more ›
What I can say is that it is wonderful to find AMAZON.CA as a rich resource for obtaining thee early Disney masterpieces despite the marketing ploys of "Mr. Disney's" contemporary reps who insist on holding back redistribution/ release of these works.
There seems to be a loss of artistic integrity in our present world.
I look forward to purchasing more of these masterpieces from the past - but, as I've mentioned, I may not belong to the appropriate feedback audience.
I congratulate you on your "humane" decision to keep these wonderful works alive and available to the public. And they seem to be in pristine condition despite one glitch I had with the magnificent Fantasia/ Fantasia 2000 which, as I understand from feedback from many friends, is a movie so many peoples from all ages love. As a musician I consider it to be a magnificent wonder, combining so professionally and perfectly narrative, music, and art work.
Everyone knows the story already. Poor little Dumbo, with his big ears, is ridiculed and called a freak by the other elephants, harassed by kids going in to see the circus, separated from his mother, and eventually made into a clown, the very embodiment of his unhappy life. Only little Timothy Mouse befriends him, and his spirit of optimism and commitment to help Dumbo prove himself are needed more than ever when things go from bad to worse. In the end, the very thing that makes Dumbo different turns out to be the source of his greatest strength. The message of the film is pretty simple: believe in yourself, even when others put you down and, for heaven's sake, don't make fun of someone just because he looks different. Dumbo is also a story about love, particularly the love between a mother and child, and the importance of friendship.
Classic Disney films such as this are both wonderful and remarkable - yet so many of them are also sad. I imagine that children, while they will certainly understand the themes of this story, don't connect to the film on the same emotional level as I do as an adult.Read more ›
Most recent customer reviews
Disney flicks always good! You just fall in love with Dumbo.Published 3 months ago by Joeen Melchiorre
The Disney classic looks great on blu ray, can't wait to show my kids the magic of Disney and no better place to start then Dumbo!Published 4 months ago by Vaio
Bought this for my 2 year old great nephew,he loves it.The picture and sound are excellent.I ordered Dumbo on a Monday and it was delivered on Wednesday!Published 5 months ago by Larry S
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Hi, been watching since the Livestream Launch and the Hangout Felicia-bombs. Conisder G&S an example of a youtube network done just right.
Geek & SundryownerOff Topic -
Introduce yourself here!
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I have watching Tabletop from the start and am a keen player and reviewer of boardgames and RPGs. I also edit and proofread RPGs too.
+James Garrison You might want to check out the Hangout he just did. He addresses real RPG games in it: http://youtu.be/WNpmVQl4YR4
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This mare is a nice and a solid! She has nice confirmation, good straight legs, and a good back! Stands great for the Farrier and vet. Nice solid feet…$3,000
15.2 hand purebred mare. Started as a 4 year old with the basics. Used for trail and camping. Easy to train. Good with her face, ears, and feet. Could…$1,000
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Beautiful little rocky unbelievably sure footed never refuses anything .stands all day at the hitching post or trailer quietly. great with farrier no kick…$5,500
Chestnut/white tobiano cow bred gelding. Has had extensive groundwork from before weaned until now but not had someone on his back due to just turning…$3,500
CS Chrome Roan would be a great addition to any breeding program or for someone to finish out for roping/ranch work. She goes back to Hancock and Blue…$2,200
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Gamma Transformation by Sigmoid Function in Digital Camera System
Abstract:In a imaging system such as digital still camera, gamma transformation is important, because of the difference of dynamic range between natural scene and printer. We propose gamma transformation by sigmoid function adjusted by the peak position of histogram of lightness level. It is confirmed that the sigmoid transformation increases the clearness of image.
Document Type: Research Article
Publication date: January 1, 2000
For more than 25 years, NIP has been the leading forum for discussion of advances and new directions in non-impact and digital printing technologies. A comprehensive, industry-wide conference, this meeting includes all aspects of the hardware, materials, software, images, and applications associated with digital printing systems, including drop-on-demand ink jet, wide format ink jet, desktop and continuous ink jet, toner-based electrophotographic printers, production digital printing systems, and thermal printing systems, as well as the engineering capability, optimization, and science involved in these fields.
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