Citations

Background: Acute kidney injury (AKI) is associated with significant short- and long-term morbidity and mortality. In critically ill patients with sepsis, AKI tends to be more severe, more likely to require kidney replacement therapy (KRT), with less chance of recovery. Consequently, critically ill patients with sepsis-associated AKI (SA-AKI) have extended intensive care unit (ICU) stays and higher mortality rates. This study evaluated the predictive value of clinical and transthoracic echocardiographic (TTE) parameters for recovery from moderate-to-severe SA-AKI in critically ill patients. Methods: This single-center historical cohort study was conducted at a tertiary academic medical center. We analyzed the data of all adults (age ≥ 18 years) admitted to the ICU at Mayo Clinic, Rochester, MN, from June 1, 2018, to December 31, 2020. We included all patients who developed sepsis within the initial 24 h of their ICU stay. Results: We identified 2,919 eligible septic patients with available TTE, among which 1,431 patients (49%) had moderate-to-severe SA-AKI. The mean age of the patients was 68 ± 15 years, and the male-to-female ratio was 1.3:1. The most common comorbidities were diabetes mellitus and chronic lung and kidney diseases. Clinical predictors associated with SA-AKI non-recovery were the presence of stage III AKI (HR 1.5, 95% CI 1.0-2.1, p = 0.03) and utilization of kidney replacement therapy (KRT) (HR 6.8, 95% CI 3.6-12.4, p = 0.01). On the other hand, higher TAPSE was the only TTE variable associated with SA-AKI recovery (HR 1.1; 95% CI 1.08-1.15; p = 0.01). Conclusion: Our data from a single-center provide new information on the clinical (AKI stage, utilization of KRT, BMI, and peak serum creatinine) and echocardiographic features (TAPSE) associated with improved recovery in SA-AKI. There is a definite knowledge gap in the current literature regarding optimizing recovery in moderate-to-severe SA-AKI. Larger, multi-center studies are required to confirm these findings.

ABSTRACT Objective: To identify and describe characteristics of patients with sepsis who could be treated with minimally invasive sepsis (MIS) approach without intensive care unit (ICU) admission and to develop a prediction model to select candidates for MIS approach. Methods: A secondary analysis of the electronic database of patients with sepsis at Mayo Clinic, Rochester, MN. Candidates for the MIS approach were adults with septic shock and less than 48 hours of ICU stay, who did not require advanced respiratory support and were alive at hospital discharge. Comparison group consisted of septic shock patients with an ICU stay of more than 48 hours without advanced respiratory support at the time of ICU admission. Results: Of 1795 medical ICU admissions, 106 patients (6%) met MIS approach criteria. Predictive variables (age >65 years, oxygen flow >4 L/min, temperature <37°C, creatinine >1.6 mg/dL, lactate >3 mmol/L, white blood cells >15 × 109/L, heart rate >100 beats/min, and respiration rate >25 breaths/min) selected through logistic regression were translated into an 8-point score. Model discrimination yielded the area under the receiver operating characteristic curve of 79% and was well fitted (Hosmer-Lemeshow P = 0.94) and calibrated. The MIS score cutoff of 3 resulted in a model odds ratio of 0.15 (95% confidence interval, 0.08–0.28) and a negative predictive value of 91% (95% confidence interval, 88.69–92.92). Conclusions: This study identifies a subset of low-risk septic shock patients who can potentially be managed outside the ICU. Once validated in an independent, prospective sample our prediction model can be used to identify candidates for MIS approach.

AbstractBackgroundBiological sex is increasingly recognized as a critical variable in health care. The authors reviewed the current literature regarding sex‐based differences in rhinology to summarize the data and identify critical knowledge gaps.MethodsA scoping review was conducted. Publications reporting sex‐based differences in anatomy, physiology, and pathology focusing on disease prevalence, disease burden, and outcomes in rhinology were identified.ResultsSeventy‐five relevant manuscripts were identified. While paranasal sinuses are of similar size at birth, they become larger in males leading to differences in ostium location. Females outperform males in olfactory identification but only in the 18‐ to 50‐year age group. Estrogen and progesterone administration can impact muscarinic and α1‐adrenergic nasal mucosa receptor density. Chronic rhinosinusitis (CRS) and CRS without nasal polyps are more prevalent in females while CRS with nasal polyps is more prevalent in males. CRS symptom burden is higher in females before and after endoscopic sinus surgery; however, no difference in endoscopic sinus surgery utilization was found based on sex. Allergic rhinitis is more common in males before puberty and in females after puberty. Epistaxis is more prevalent in males and postmenopausal females compared with premenopausal females, perhaps from differences in sex‐hormonal and hypertension status. In nasopharyngeal carcinoma, the incidence of sinus abnormalities was higher in males than females.ConclusionsAlthough many sex‐based differences exist in rhinology, further research is necessary to offer evidence‐based treatment guidelines. Gonadal hormones should be studied as a therapeutic in rhinologic pathology as baseline physiologic differences exist such as those found in nasal mucosa receptor density.

ObjectiveRNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well‐characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non‐eosinophilic chronic rhinosinusitis (CRS) versus controls.MethodsRNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status [with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP)] as well as tissue eosinophil levels per high power field (eos/hpf)[non‐eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS)]. The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared.ResultsCRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL‐17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf.ConclusionTissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms.Level of Evidence3 Laryngoscope, 133:2480–2489, 2023

Abstract Introduction Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and positive sinonasal bacterial cultures may be recalcitrant to topical therapy alone due to the additional local inflammatory burden associated with bacterial infection/colonization. Objective To evaluate sinonasal outcomes in CRSwNP patients with a positive perioperative bacterial culture, who were treated with postoperative intranasal corticosteroids (INCS) alone versus INCS in combination with a short-term course of oral corticosteroids (OCS). Methods This is a retrospective chart review of CRSwNP patients. A total of 59 patients met inclusion criteria, including positive perioperative bacterial culture and treatment with INCS with or without concomitant use of OCS. Two cohorts were formed based on the chosen postoperative medical treatment; 32 patients underwent postoperative INCS alone, while 27 underwent INCS plus a ≤ 2-week course of OCS. The 22-item sinonasal outcome test (SNOT-22) scores and Lund-Kennedy scores (LKS) were assessed preoperatively, and at 2-week, 4-week, and 4 to 6 months after endoscopic sinus surgery (ESS). Results There were no statistically significant differences in postoperative sinonasal symptoms or endoscopic scores between the cohorts treated with INCS plus OCS versus those prescribed INCS alone (p > 0.05). Our regression model failed to demonstrate a relationship between the use of OCS and better sinonasal outcomes at 2-week, 4-week, and 4 to 6 months after ESS (p > 0.05). Conclusion Our study suggests that in a cohort of CRSwNP patients with recent bacterial infections, the postoperative use of combined OCS and INCS did not result in a statistical improvement of endoscopic and symptomatic outcomes over INCS irrigation alone. However, both treatment groups had a clinically significant improvement based on the Minimal Clinically Important Difference.