26 research outputs found
The effects of dexmedetomidine on circulatory of sepsis
No full textPurpose. The present experimental randomized controlled study was designed to evaluate systemic and peripheral circulatory effects of dexmedetomidine (DEX) in healthy and early stage endotoxemia swine models. The research question of the study was that DEX can offer hemodynamic stability during the course of endotoxemia. Methods. The study included 32 male pigs assigned to 4 groups: group A with no intervention, group B that received DEX at a dose of 0.8μg/kg, Group C where sepsis was induced by intravenous escherichia coli endotoxin and Group D where sepsis was induced with concurrent administration of DEX as in Group B. Using invasive monitoring changes in heart rate, mean blood pressure, central venous pressure, pulmonary artery pressures, pulmonary artery occlusion pressure and cardiac output, pulmonary vascular resistance and central venous oxygen saturation were measured in order to have a complete evaluation of the hemodynamic response to sepsis. Results. Heart rate was decreased causing a beneficial effect, while mean arterial pressure decrease was alleviated after DEX administration in septic animals. In addition, central venous pressure was stable in animals with sepsis after DEX infusion. Sepsis dramatically elevated pulmonary function indicators but DEX succeeded in ameliorating this effect. The important decrease measured in central venous oxygen saturation in both sepsis groups reflected the decreased perfusion of tissues that takes place at the end of early sepsis. Conclusions. Our findings support the hypothesis that DEX has beneficial effects on heart rate and pulmonary artery pressure, while reduction in systemic blood pressure occurs at acceptable levels.Σκοπός. Η παρούσα πειραματική τυχαιοποιημένη ελεγχόμενη μελέτη σχεδιάστηκε για να αξιολογήσει τα συστηματικά και περιφερικά κυκλοφορικά αποτελέσματα της δεξμεδετομιδίνης σε μοντέλα υγιούς και σηπτικούς χοίρων. Το ερευνητικό ερώτημα της μελέτης ήταν ότι η δεξμεδετομιδίνη μπορεί να προσφέρει αιμοδυναμική σταθερότητα κατά τη διάρκεια της σήψης. ΜέθοδοςΗ μελέτη περιελάμβανε 32 άρρενες χοίροι που διαχωρίστηκαν σε 4 ομάδες: ομάδα Α χωρίς καμία παρέμβαση, ομάδα Β που έλαβε δεξμεδετομιδίνη σε δόση 0,8 μg/kg, ομάδα Γ όπου η σήψη προκλήθηκε από την ενδοφλέβια χορήγηση ενδοτοξίνης Escherichia coli και ομάδα Δ όπου η σήψη επιτεύχθηκε με ταυτόχρονη χορήγηση της δεξμεδετομιδίνης, όπως στην ομάδα Β. Κατά τη διάρκεια του πειράματος καταγράφηκαν οι μεταβολές στον καρδιακό ρυθμό, τη μέση αρτηριακή πίεση, την κεντρική φλεβική πίεση, τις πιέσεις της πνευμονικής αρτηρίας, την πίεση απόφραξης της πνευμονικής αρτηρίας και την καρδιακή παροχή, την πνευμονική αγγειακή αντίσταση και τον κορεσμό του κεντρικού φλεβικού οξυγόνου. Αποτελέσματα. Ο καρδιακός ρυθμός μειώθηκε προκαλώντας ευεργετικό αποτέλεσμα, ενώ η μείωση της μέσης αρτηριακής πίεσης παρατηρήθηκε μετά τη χορήγηση της δεξμεδετομιδίνης στα σηπτικά πειραματόζωα. Επιπλέον, η κεντρική φλεβική πίεση ήταν σταθερή στα σηπτικά πειραματόζωα μετά από έγχυση δεξμεδετομιδίνης. Η κατάσταση της σήψης έδειξε δραματικά αυξημένους δείκτες πνευμονικής λειτουργίας, αλλά η δράση της δεξμεδετομιδίνης πέτυχε να βελτιώσει αυτή την επίδραση. Η σημαντική μείωση που μετρήθηκε στον κεντρικό φλεβικό κορεσμό οξυγόνου και στις δύο ομάδες της σήψης αντανακλούσε τη μειωμένη διάχυση ιστών που λαμβάνει χώρα στο τέλος της πρώιμης σήψης. Συμπεράσματα. Τα ευρήματά μας υποστηρίζουν την υπόθεση ότι η δεξμεδετομιδίνη έχει ωφέλιμες επιδράσεις στον καρδιακό ρυθμό και την πνευμονική αρτηριακή πίεση, ενώ η μείωση της συστηματικής αρτηριακής πίεσης συμβαίνει σε αποδεκτά επίπεδα
Treatment Options for Nosocomial Ventriculitis/Meningitis: A Case Report and Review of the Literature
No full textVentriculo-meningitis or nosocomial meningitis/ventriculitis is a severe nosocomial infection that is associated with devastating neurological sequelae. The cerebrospinal fluid isolates associated with the infection can be Gram-positive or -negative, while the Enterococcus spp. is rarely identified. We report a case of a 68-year-old woman with a past medical history of insulin-dependent diabetes mellitus, hypertension, and coronary artery disease. She was admitted to the intensive care unit following a scheduled sphenoid wing meningioma resection. Her course was complicated with left middle cerebral artery pseudoaneurysm and hemispheric hemorrhage, and an arterial stent and external ventricular drainage catheter were placed. Neurological evaluation showed a minimal conscious state. She presented high fever on the 35th intensive care unit day. Cerebrospinal fluid was sampled and the external ventricular catheter was removed. Enterococcus faecalis was isolated from the culture specimen. The patient received targeted treatment with an ampicillin plus ceftriaxone combination, and a follow-up culture confirmed the pathogen’s eradication. Although she was considered cured, she had a prolonged intensive care unit stay and finally died in the ward two months after the completion of treatment. This case highlights the first reported use of this combination in a severe, non-endocarditis, invasive enterococcal infection, while the review discusses treatment options for nosocomial ventriculitis/meningitis
Comparison between Magnification Techniques and Direct Vision in Thyroid Surgery: A Systematic Review and Meta-Analysis
No full textBackground and Objectives: The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques (surgical loupes or surgical microscope) are used for identification of RLN and parathyroid glands to diminish these complications although more evidence is necessary to assess their safety and efficacy in comparison with direct vision. Methods and Materials: Electronic databases (Pubmed, Cochrane Library, Scopus) as well as gray literature sources were searched for randomized controlled trials (RCTs) comparing the frequency of transient/permanent RLN injury and hypocalcemia after thyroid surgery by using magnification techniques and direct vision for identification of RLN and parathyroid glands until October 17, 2019. The main outcomes were transient/permanent RLN injury and hypocalcemia. For all outcomes, 95% confidence intervals (95% CI) were used. Statistical analysis was performed with RevMan 5.3. Results: Systematic review and meta-analysis included 3 RCTs with 437 patients overall. Magnification techniques did not significantly affect the risk of occurrence of transient RLN injury (OR = 0.38, 95% CI (0.11–1.35), I2 = 0%) and transient hypocalcemia (OR = 0.31, 95% CI (0.09–1.09), I2 = 23%) compared with direct vision. Included RCTs demonstrated only two patients with permanent hypocalcemia and another one with permanent RLN injury, who belonged to the direct vision group. Conclusion: The use of magnification techniques for identification of RLN and parathyroid glands seems to be as safe as direct vision. However, they do not decrease the risk of RLN injury and transient hypocalcemia after thyroid surgery compared with direct vision. Finally, further prospective research should be conducted as the sample among the studies was small
Pharmacologic and Non-Pharmacologic Interventions for HIV-Neuropathy Pain. A Systematic Review and a Meta-Analysis
No full textBackground and Objectives: Among HIV infection symptoms, sensory neuropathy (HIV-SN) remains a main cause of suffering, with incidence varying from 13–50%. So far, numerous pharmacological and non-pharmacological treatments have been tested, although few evidence-based analgesic options are available. We conducted an up-to-date systematic review and meta-analysis of the literature in order to evaluate the efficacy and safety of pharmacologic and non-pharmacologic treatments for pain control, in patients with HIV neuropathy. Materials and Methods: We searched MEDLINE, EMBASE, Scopus/Elsevier, The Cochrane Central Register of Controlled Trials (CENTRAL), USA Clinical Trials registry, and The International Web of Science up to April 2019. All randomized controlled trials evaluating efficacy and safety of non-pharmacologic and pharmacologic therapies were included. Efficacy was defined as pain reduction during the study period. Safety was estimated from adverse events. A meta-analysis was performed whenever possible. Results: 27 randomized controlled trials (RCTs) were included for analysis (7 evaluating non pharmacologic interventions, 20 pharmacologic therapies). Non-pharmacologic studies (n = 742) involved seven different therapeutic modalities. Only Acupuncture/Moxibustion showed pain reduction over placebo, Gracely Pain Scale Mean (SD): Acu/Moxa 0.85 (0.12), placebo 1.10 (0.09), p = 0.05. Pharmacologic studies, involving 2516 patients revealed efficacy for capsaicin 8% over placebo (mean difference −8.04 [95% CI: −14.92 −1.15], smoked cannabis (where pooling data for meta-analysis was not possible) and recombinant Nerve Growth Factor. Conclusion: Despite various modalities for pain control in HIV-SN, strongest evidence exists for capsaicin 8% and smoked cannabis, although of low methodological quality. Among non-pharmacologic modalities, only Acu/Moxa gave a marginal beneficial effect in one study, possibly limited by inherent methodological flaws
Late results of a randomized trial on the role of mild hypofractionated radiotherapy for the treatment of localized prostate cancer
No full textBackground: Prostate cancer is considered to be highly sensitive to changes in radiation therapy dose per fraction, specifically to hypofractionation. An increase in the fractionation dose could cause a higher increase to the prostate than to the normal tissues leading to better disease control with less toxicity. Here we present the results of a randomized trial comparing mild hypofractionation to conventional fractionation after a median of 3,6 years follow up. Patients and Methods: 139 patients were randomized to receive either hypofractionated radiotherapy with 2,25 Gy/fr to a total of 72 Gy (arm 1) or conventionally fractionated treatment with 2Gy/fr to a total of 74 Gy (arm 2). 72 patients were assigned to arm 1 and 67 to arm 2. Results: After a median follow up of 3,6 years, 23 patients (31,9%) from arm 1 developed grade≥ 2 acute genitourinary toxicity and 21 (31,3%) from arm 2 (p=0,79). The corresponding values from gastrointestinal were 15 (20,8%) and 12 (17,9%) (p=0,6). For late toxicity from GU, 8 patients (11,1%) developed grade≥ 2 symptoms in arm 1 and 7 (10,4%) in arm 2 (p=0,92). late GI toxicity grade≥ 2 was observed in 8 (11,1%) patients in arm 1 and 8 (11,9%) in arm 2 (p=0,88). In multivariate analysis, hormone therapy was significantly associated with late GI events, while acute toxicity from both GU and GI was a prognostic factor of late adverse reaction. Conclusion: No difference in the toxicity profile could be identified between hypofractionation and conventional fractionation. Our schedule of 2,25Gy/fr seems safe and tolerable by the patients with acceptable rates of acute and late toxicity. © The author(s)
A four-probiotic preparation for ventilator-associated pneumonia in multi-trauma patients: results of a randomized clinical trial
No full textThe role of probiotics in the prevention of ventilator-associated pneumonia (VAP) remains inconclusive. The aim of this study was to assess the efficacy of a probiotic regimen for VAP prophylaxis in mechanically ventilated multi-trauma patients, intubated immediately after the injurious insult. In a randomized, placebo-controlled study enrolling multi-trauma patients, patients expected to require mechanical ventilation for >10 days were assigned at random to receive prophylaxis with a probiotic formula (n= 59) or placebo (n= 53). The probiotic formula was a preparation of Lactobacillus acidophilus LA-5 [1.75 x10(9) colony-forming units (cfu)], Lactobacillus plantarum (0.5 x10(9) cfu), Bifidobacterium lactis BB-12 (1.75 x109 cfu) and Saccharomyces boulardii (1.5 x10(9) cfu) in sachets. Each patient received two sachets twice daily for 15 days: one through the nasogastric tube and one spread on the oropharynx. The incidence of VAP was the primary endpoint. The incidence of other infections and sepsis, and the duration of hospital stay were the secondary endpoints. Administration of probiotics reduced the incidence of VAP [11.9% vs 28.3%, hazard ratio (HR) 0.34, 95% confidence interval (CI) 0.13-0.92; P=0.034] and sepsis [6.8% vs 24.5%, odds ratio 0.22, 95% CI 0.07-0.74: P= 0.016]. Furthermore, probiotic prophylaxis reduced the time of stay in the intensive care unit (ICU) and the length of hospital stay. The prophylactic use of probiotics with a combination of enteral and topical application to the oropharynx had a positive effect on the incidence of VAP and sepsis, as well as on ICU and total hospital stay in patients receiving protracted mechanical ventilation. (C) 2021 The Authors. Published by Elsevier Ltd
Gender Differences in Obstructive Sleep Apnea: The Value of Sleep Questionnaires with a Separate Analysis of Cardiovascular Patients
No full textBackground: Gender affects the clinical presentation of obstructive sleep apnea (OSA). The classic OSA symptoms, such as sleepiness, snoring, and apnea, are not so frequent in women. Objectives: To evaluate possible gender differences in questionnaires used for OSA prediction, such as the Epworth Sleepiness Scale (ESS), STOP, STOP Bang (SB), Berlin Questionnaire (BQ), Athens Insomnia Scale (AIS), and Fatigue Scale (FS). Methods: 350 males were matched with 350 women referred to a sleep clinic, according to OSA severity. All responded to the questionnaires and underwent a sleep study. Cardiovascular disease (CVD) patients were separately analyzed. Results: ESS did not differ between genders. SB was higher in males, whereas STOP, BQ, AIS, and FS were higher in females. BQ presented the highest sensitivity in both genders, whereas STOP exhibited the highest specificity in males and ESS in females. AIS and FS were more sensitive and SB more specific in females, whereas BQ was more specific in males. For severe OSA, the predictive values of SB and BQ were almost similar for both genders; however AIS and FS were higher in women. CVD patients presented higher scores, independent of gender, except for AIS, which was higher in females. Conclusion: Gender-specific evaluation of questionnaires is necessary to prevent OSA under-diagnosis
a prospective cohort study
No full textFunding Information: The members of VIP1 and VIP2 study groups are listed in Additional file 1 and are listed in their individual PubMed records. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.Background: The Clinical Frailty Scale (CFS) is frequently used to measure frailty in critically ill adults. There is wide variation in the approach to analysing the relationship between the CFS score and mortality after admission to the ICU. This study aimed to evaluate the influence of modelling approach on the association between the CFS score and short-term mortality and quantify the prognostic value of frailty in this context. Methods: We analysed data from two multicentre prospective cohort studies which enrolled intensive care unit patients ≥ 80 years old in 26 countries. The primary outcome was mortality within 30-days from admission to the ICU. Logistic regression models for both ICU and 30-day mortality included the CFS score as either a categorical, continuous or dichotomous variable and were adjusted for patient’s age, sex, reason for admission to the ICU, and admission Sequential Organ Failure Assessment score. Results: The median age in the sample of 7487 consecutive patients was 84 years (IQR 81–87). The highest fraction of new prognostic information from frailty in the context of 30-day mortality was observed when the CFS score was treated as either a categorical variable using all original levels of frailty or a nonlinear continuous variable and was equal to 9% using these modelling approaches (p < 0.001). The relationship between the CFS score and mortality was nonlinear (p < 0.01). Conclusion: Knowledge about a patient’s frailty status adds a substantial amount of new prognostic information at the moment of admission to the ICU. Arbitrary simplification of the CFS score into fewer groups than originally intended leads to a loss of information and should be avoided. Trial registration NCT03134807 (VIP1), NCT03370692 (VIP2)publishersversionpublishe
The association of premorbid conditions with 6-month mortality in acutely admitted ICU patients over 80 years
No full textBackground Premorbid conditions influence the outcome of acutely ill adult patients aged 80 years and over who are admitted to the ICU. The aim of this study was to determine the influence of such premorbid conditions on 6 month survival. Methods Prospective cohort study in 242 ICUs from 22 countries including patients 80 years or above, admitted over a 6 months period to an ICU between May 2018 and May 2019. Only emergency (acute) ICU admissions in adult patients >= 80 years of age were eligible. Patients who were admitted after planned/elective surgery were excluded. We measured the Clinical Frailty Scale (CFS), the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), disability with the Katz activities of daily living (ADL) score, comorbidities and a Polypharmacy Score (CPS). Results Overall, the VIP2 study included 3920 patients. During ICU stay 1191 patients died (30.9%), and another 436 patients (11.1%) died after ICU discharge but within the first 30 days of admission, and an additional 895 patients died hereafter but within the first 6 months after admission (22.8%). The 6 months mortality was 64%. The median CFS was 4 (IQR 3-6). Frailty (CFS >= 5) was present in 26.6%. Cognitive decline (IQCODE above 3.5) was found in 30.2%. The median IQCODE was 3.19. A Katz ADL of 4 or less was present in 27.7%. Patients who surviving > 6 months were slightly younger (median age survivors 84 with IQR 81-86) than patients dying within the first 6 months (median age 84, IQR 82-87, p = 0.013), were less frequently frail (CFS > 5 in 19% versus 34%, p < 0.01) and were less dependent based on their Katz activities of daily living measurement (median Katz score 6, IQR 5-6 versus 6 points, IQR 3-6, p < 0.01). Conclusions We found that Clinical Frailty Scale, age, and SOFA at admission were independent prognostic factors for 6 month mortality after ICU admission in patients age 80 and above. Adding other geriatric syndromes and scores did not improve the model. This information can be used in shared-decision making. ClinicalTrials.gov: NCT03370692. Conclusions We found that Clinical Frailty Scale, age, and SOFA at admission were independent prognostic factors for 6 month mortality after ICU admission in patients age 80 and above. Adding other geriatric syndromes and scores did not improve the model. This information can be used in shared-decision making
Precision Immunotherapy to Improve Sepsis Outcomes: The ImmunoSep Randomized Clinical Trial
No full textSepsis is heterogeneous, and the optimal strategy for tailoring immunotherapy is uncertain.
To investigate whether precision immunotherapy guided by the presence of macrophage activation-like syndrome or sepsis-induced immunoparalysis improves organ dysfunction by day 9.
A randomized, double-blind, double-dummy, placebo-controlled clinical trial conducted in 6 countries. Patients with sepsis, defined by Sepsis-3, were included if they had community-acquired or hospital-acquired pneumonia or ventilator-associated pneumonia or bacteremia and sepsis and had displayed either macrophage activation-like syndrome (blood ferritin >4420 ng/mL) or sepsis-induced immunoparalysis (blood ferritin ≤4420 ng/mL and <5000 human leukocyte antigen DR receptors on CD45/CD14 monocytes). The first patient was enrolled August 5, 2021, and the last follow-up, April 29, 2024.
Eligible patients were randomized to receive standard care and precision immunotherapy or standard care and placebo. Those in the precision immunotherapy group with macrophage activation-like syndrome received anakinra intravenously (IV) and placebo subcutaneously, and those with sepsis-induced immunoparalysis received subcutaneous recombinant human interferon gamma and IV placebo. Those in the placebo group received both IV and subcutaneous placebo. Treatment was administered for up to 15 days.
The primary end point was a decrease of at least 1.4 points in the mean Sequential Organ Failure Assessment (SOFA) score from baseline by day 9. The SOFA score evaluates 6 organ systems, ranging from 0, no dysfunction, to 4, failure, and the total score ranges from 0, normal, to 24, most severe form of multiorgan failure. Key secondary outcomes included 28-day mortality.
Of 672 patients assessed for eligibility, 281 were randomized and 276 were included in the primary analysis population (mean [SD] age, 70 [13] years; 93 females [33.7%]; median baseline SOFA score, 9 [IQR, 7-11]). The SOFA decrease end point was attained by 46 of 131 patients (35.1%) in the precision immunotherapy group and by 26 of 145 patients (17.9%) in the placebo group (difference, 17.2% [95% CI, 6.8% to 27.2%]; P = .002). Mortality at 28 days was not statistically significantly different between groups. A total of 1069 serious treatment-emergent adverse events (88.8%) were reported; increased incidence of anemia was noted in the anakinra group; and hemorrhage in the recombinant human interferon gamma group.
Among patients with sepsis, precision immunotherapy targeting macrophage activation-like syndrome and sepsis-induced immunoparalysis improved organ dysfunction by day 9 compared with placebo.
ClinicalTrials.gov Identifier: NCT04990232
