Questionnaire-based survey on structural quality of hospitals and nursing homes for the elderly, their staffing with infection control personal, and implementation of infection control measures in Germany

From January to May 2012, 1,860 hospitals throughout Germany received a questionnaire encompassing 77 items. Additionally, 300 outpatient care services and 310 nursing homes for elderly in Berlin also received a 10-item questionnaire asking on their implemented infection control practices. All questionnaires were anonymous. A total of 229 completed questionnaires from hospitals, 14 questionnaires from outpatient care services, and 16 questionnaires from nursing homes were eligible for further analysis.

The lack of Infection Control physicians was identified as the largest issue. In hospitals sized 400–999 beds a gap of 71%, and in hospitals sized ≥1,000 beds a gap of 17% was reported. Depending on the number of hospital beds, 13–29% of hospitals sized ≥100 beds reported not havening one infection control nurse. Since based on the number of beds in larger institutions or in facilities caring for high-risk patients several infection control nurses may be required, the deficiency in infection control nurses may even be higher, particularly in secondary and tertiary care facilities. Furthermore, the analysis revealed that the legal requirements for surveillance and reporting of notifiable infectious diseases have not yet been implemented in 11% of the facilities. The implementation of antibiotic strategies did show significant gaps. However, deficiencies in the implemented measures for the prevention of surgical site infections were less frequent. Yet 12% of the participants did not have a dedicated infection control concept for their surgical services. Eight percent of hospitals were not prepared for an outbreak management and 10% did not have established regulations for wearing surgical scrubs. Deficiencies in waste disposal and the control of air-conditioning systems were also noted. Based on the results of this survey, conclusions on the optimal resource allocation for further improvement of patient safety may be drawn.

While all participating nursing homes had some sort of infection control consultation, this only applied to 12 out of 16 outpatient nursing services. However, all 16 nursing services worked on the basis of an implemented infection control plan. Though legally binding hygiene recommendations have not yet been implemented for nursing homes, the necessity of infection control to assure patient safety has obviously been recognised throughout these services.

Burden and characteristics of influenza A and B in Danish intensive care units during the 2009/10 and 2010/11 influenza seasons

Influenza surveillance in Danish intensive care units (ICUs) was performed during the 2009/10 and 2010/11 influenza seasons to monitor the burden on ICUs. All 44 Danish ICUs reported aggregate data for incidence and point prevalence, and case-based demographical and clinical parameters. Additional data on microbiological testing, vaccination and death were obtained from national registers. Ninety-six patients with influenza A(H1N1)pdm09 were recorded in 2009/10; 106 with influenza A and 42 with influenza B in 2010/11. The mean age of influenza A patients was higher in 2010/11 than in 2009/10, 53 vs. 44 years (P = 0·004). No differences in other demographic and clinical parameters were detected between influenza A and B patients. In conclusion, the number of patients with severe influenza was higher in Denmark during the 2010/11 than the 2009/10 season with a shift towards older age groups in influenza A patients. Influenza B caused severe illness and needs consideration in clinical and public health policy.

["One cannot just look at the clock" - interviews with family doctors on ambulatory palliative care of tumour patients]

GOAL OF THE STUDY

In the study "possibilities and limits of ambulatory palliative care" there was a survey with family doctors about their own subjective views of ambulatory palliative care. The different parameters of home care, the role of caring relatives as well as burdening and supporting factors for family doctors occupied the focus in these interviews.

METHODS

With the help of the results from 9 qualitative interviews, a questionnaire was compiled and sent by post to all family doctors within 50 km (N=427). For analysis questionnaires were available from N=89 family doctors. Statements about various areas of outpatient palliative work were collected with Likert scales and open questions.

RESULTS

The personal overloads of the care-giving relatives, the inadequate payment and their own time pressures for the family doctors were the main obstacles in home care of palliative patients. On the other hand the family doctors considered as supporting factors for an ambulatory care: a good pain and symptom management, a high satisfaction of the patients and a good teamwork between the caring service and other people taking part in the care.

CONCLUSION

In order to minimise the time overload of family doctors and to focus the psycho-social distress of the caring relatives the expansion of non-medical offers should be supported, e. g., ambulatory hospice services and consultative forms of care by psychologists and religious personnel.

High sCD40L levels early after trauma are associated with enhanced shock, sympathoadrenal activation, tissue and endothelial damage, coagulopathy and mortality

BACKGROUND

Severe injury activates the sympathoadrenal, hemostatic and inflammatory systems, but a maladapted response may contribute to a poor outcome. Soluble CD40L is a platelet-derived mediator that links inflammation, hemostasis and vascular dysfunction.

OBJECTIVES

To investigate the association between the sCD40L level and tissue injury, shock, coagulopathy and mortality in trauma patients.

METHODS

A prospective, observational study of 80 trauma patients admitted to a Level I Trauma Center. Data on demography, biochemistry, Injury Severity Score (ISS) and 30-day mortality were recorded and admission plasma/serum analyzed for sCD40L and biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments [hcDNA], Annexin V, thrombomodulin and syndecan-1), coagulation activation/inhibition (PF1.2, TAT-complex, antithrombin, protein C, activated protein C, sEPCR, TFPI, von Willebrand factor [VWF], fibrinogen and factor [F] XIII), fibrinolysis (D-dimer, tissue plasminogen activator [tPA] and plasminogen activator inhibitor-1 [PAI-1]) and inflammation (interleukin-6 [IL-6] and sC5b-9). We compared patients stratified by median sCD40L level and investigated predictive values of sCD40L for mortality.

RESULTS

High circulating sCD40L was associated with enhanced tissue and endothelial damage (ISS, hcDNA, Annexin V, syndecan-1 and sTM), shock (pH, standard base excess), sympathoadrenal activation (adrenaline) and coagulopathy evidenced by reduced thrombin generation (PF1.2), hyperfibrinolysis (D-dimer), increased activated partial thromboplastin time (APTT) and inflammation (IL-6) (all P < 0.05). A higher ISS (P = 0.017), adrenaline (P = 0.049) and platelet count (P = 0.012) and lower pH (P =0.002) were associated with higher sCD40L by multivariate linear regression analysis. High circulating sCD40L (odds ratio [OR] 1.84 [95% CI 1.05-3.23], P = 0.034), high age (P = 0.002) and low Glasgow Coma Score (GCS) pre-hospital (P = 0.002) were independent predictors of increased mortality.

CONCLUSIONS

High early sCD40L levels in trauma patients reflect tissue injury, shock, coagulopathy and sympathoadrenal activation and predict mortality. As sCD40L has pro-inflammatory activity and activates the endothelium, sCD40L may be involved in trauma-induced endothelial damage and coagulopathy.

Initial fluid resuscitation of patients with septic shock in the intensive care unit

BACKGROUND

Fluid is the mainstay of resuscitation of patients with septic shock, but the optimal composition and volume are unknown. Our aim was to evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome associated with fluid volume.

METHODS

This was a prospective, cohort study of all patients with septic shock (n=132) admitted in six ICUs during a 3-month period. Patients were divided into two groups according to the overall median volume of resuscitation fluid administered during the first 24 h after the diagnosis. Baseline characteristics, other treatments, monitoring and outcome were compared between the groups.

RESULTS

The mean volume of resuscitation fluid was 4.9 l (median 4.0 l and SD 3.5). Patients in the higher volume group received more crystalloids (3.7 vs. 1.2 l, P<0.0001), colloids (1.8 vs. 0.9 l, P<0.0001), blood products (1.8 vs. 0.6 l, P=0.0004), a higher maximum vasopressor dose (0.37 vs. 0.21 μg/kg/min, P<0.0001) and had a higher initial plasma concentration of lactate (4.0 vs. 3.0 mM, P=0.009) compared with the lower volume group. Simplified acute physiology score II in the lower and higher dose group were 52 and 58 (P=0.07). There were no differences in 30-, 90- or 365-day mortality between the two fluid volume groups.

CONCLUSION

In the ICU, patients with septic shock were resuscitated with a combination of crystalloids, colloids and blood products. Although the more severely shocked patients received higher volumes of crystalloids, colloids and blood products, mortality did not differ between the groups.

National surveillance of pandemic influenza A(H1N1) infection-related admissions to intensive care units during the 2009-10 winter peak in Denmark: two complementary approaches

Surveillance of 2009 pandemic influenza A(H1N1) in Denmark was enhanced during the 2009–10 winter season with a system monitoring the burden of the pandemic on intensive care units (ICUs), in order to inform policymakers and detect shortages in ICUs in a timely manner. Between week 46 of 2009 and week 11 of 2010, all 36 relevant Danish ICUs reported in two ways: aggregate data were reported online and case-based data on paper. Cases to be reported were defined as patients admitted to an ICU with laboratory-confirmed 2009 pandemic influenza A(H1N1) infection or clinically suspected illness after close contact with a laboratory-confirmed case. Aggregate numbers of cases were reported weekly: during weeks 48-51 (the peak), reporting was daily. The case-based reports contained demographic and clinical information. The aggregate surveillance registered 93 new cases, the case-based surveillance 61, of whom 53 were laboratory confirmed. The proportion of beds used for influenza patients did not exceed 4.5% of the national capacity. Hospitals with cases used a median of 11% of bed capacity (range: 3–40%). Of the patients for whom information was available, 15 of 48 patients developed renal insufficiency, 19 of 50 developed septic shock and 17 of 53 died. The number of patients with pandemic influenza could be managed within the national bed capacity, although the impact on some ICUs was substantial. The combination of both reporting methods (collecting aggregate and case-based data) proved to be useful for monitoring the burden of the pandemic on ICUs.

Lactate concentrations in the rectal lumen in patients in early septic shock

BACKGROUND

Previously, we observed that rectal luminal lactate was higher in non-survivors compared with survivors of severe sepsis or septic shock persisting >24 h. The present study was initiated to further investigate this tentative association between rectal luminal lactate and mortality in a larger population of patients in early septic shock.

METHODS

A prospective observational multicentre study of 130 patients with septic shock at six general ICU's of university hospitals. Six to 24 h after the onset of septic shock, the concentration of lactate in the rectal lumen was estimated by a 4-h equilibrium dialysis. Dialysate concentrations of lactate were determined using an auto-analyser.

RESULTS

The overall 30-day mortality was 32%, with age and Simplified acute physiology scores II and sequential organ failure assessment scores being significantly higher in non-survivors. In contrast, there were no differences in concentrations of lactate in the rectal lumen [2.2 (1.4-4.1) and 2.8 (1.6-5.1) mmol/l (P=0.34)] (medians and 25th-75th percentiles) or arterial blood [2.1 (1.4-4.2) and 2.0 (1.3-3.2) mmol/l (P=0.15)] between non-survivors and survivors. The rectal-arterial difference of the lactate concentration was higher in survivors. There were no differences in blood pressure, noradrenaline dose or central venous oxygen saturation between the groups.

CONCLUSION

In this prospective, observational study of unselected patients with early septic shock, there was no difference in the concentration of lactate in the rectal lumen between non-survivors and survivors.

TRIAL REGISTRATION

Clinicaltrials.gov (no: NCT00197938).

[Palliative home care of cancer patients in the Leipzig region]

BACKGROUND

In many model regions of Germany, palliative home care can be improved for cancer patients over longer periods so that most of these patients could die at home. However, there is a shortage of ambulatory care for dying patients in regions without special agreements for this type of care.

METHODS

The aim of the study was to identify beneficial as well as impedimentary factors of outpatient palliative care. Therefore we interviewed 91 tumour patients and collected medical, psychosocial and sociodemographic data with standardized questionnaires.

RESULTS

Nearly half of the patients (43%) had moderate to strong pain during domestic care and felt depressed (44%) and anxious (26%). Home hospice services, social workers, and psychologists were rarely involved in home care. Ambulatory home care was often interrupted because of hospital stays.

CONCLUSION

Palliative symptom control in outpatients should be performed by qualified and interdisciplinary palliative-care teams, so that patients can receive more psychosocial support and hospital stays can be prevented.

Central venous oxygen saturation for the diagnosis of low cardiac output in septic shock patients

BACKGROUND

Simple diagnostic tests are needed to screen septic patients for low cardiac output because intervention is recommended in these patients. We assessed the diagnostic value of central venous oxygen saturation in the superior vena cava (ScvO(2)) for detecting low cardiac output in patients with septic shock.

METHODS

We conducted a prospective observational study in three general intensive care units (ICUs) of adult patients with septic shock, who were to have a catheter inserted for thermodilution measurement of cardiac index (CI(TD)). Paired measurements of CI(TD) and central venous oximetry values were obtained when the clinician first measured CI(TD).

RESULTS

We included 56 patients with septic shock and a mean sequential organ failure assessment score of 12 (range 3-20). Baseline CI(TD) was 3.5 l/min/m(2) (1.0-6.2) and ScvO(2) of 70% (33-87). The best cut-off of ScvO(2) for CI(TD)>2.5 l/min/m(2) (n=42) was a value >or=64% with positive and negative predictive values of 91% (95% confidence interval 79-98) and 91% (59-100), respectively. The diagnostic values were not improved by using instead central venous O(2) tension or the difference between arterial and central venous O(2) saturation.

CONCLUSIONS

This prospective, observational study found that a ScvO(2) measurement of >or=64% indicated CI(TD)>2.5 l/min/m(2) in ICU patients with septic shock.

Long-term physical outcome in patients with septic shock

BACKGROUND

Limited information is available on physical function after septic shock. The aim of the present study was to assess the physical outcome in survivors 1 year after septic shock.

METHODS

The outcome status of all 174 adult patients admitted to a mixed ICU with the diagnosis septic shock in a 1-year period was registered. Survivors were interviewed about physical function and socioeconomic status using a questionnaire including the Short Form-36 survey. The pre-ICU-admission Functional Comorbidity Index (FCI) was also registered.

RESULTS

Of the 80 survivors, two were still hospitalised; thus, 78 were invited to participate and 70 replied (inclusion-rate 88%). Patients were followed up at median 351 days after hospital discharge. At follow-up the patients had a markedly reduced physical component summary score (PCS) compared with age- and sex-adjusted general population controls (36 vs. 47, P<0.0001). This was also observed in patients with no comorbidity before ICU admission (34 vs. 47, P<0.001). There was a negative correlation (r=-0.27, P=0.03) between pre-ICU-admission FCI values and the PCS at follow-up. According to 81% of the patients, loss of muscle mass was the main cause of decreased physical function. Only 43% (10 vs. 23, P=0.01) of the previously employed had returned to work, and the number of patients in need of home-based personal assistance had doubled (10/20, P=0.04).

CONCLUSION

Physical function is substantially reduced in survivors of septic shock 1 year after discharge.

Effects of endotoxaemia on markers of permeability, metabolism and inflammation in the large bowel of healthy subjects

BACKGROUND

Increased permeability and increased luminal concentrations of L-lactate have previously been shown in the large bowel in septic patients. To advance these observations, a human model of colorectal barrier failure in sepsis is desirable. Therefore, we assessed the effects of endotoxaemia on markers of permeability, metabolism and inflammation in the large bowel in healthy subjects.

METHODS

Twelve healthy male subjects received intravenous endotoxin (2 ng/kg body weight) or saline in a paired cross-over design. Colorectal permeability was assessed after 3, 6, 9 and 12 h by the systemic recovery of luminally instilled (99m)Tc-diethylenetriaminepentaacetate. Luminal concentrations of L-lactate were assessed by equilibrium dialysis. Mucosal biopsies from the large bowel were sampled after 6 and 12 h, and the apoptotic ratio of the epithelium was assessed by terminal deoxynucleotidyl transferase-mediated desoxyuridinetriphosphate nick end-labelling (TUNEL) assay and the expression of inducible nitric oxide synthase (iNOS) mRNA by reverse transcriptase-polymerase chain reaction.

RESULTS

Systemic effects of endotoxaemia were observed, including fever, tachycardia and strongly increased plasma values of tumour necrosis factor-alpha. By contrast, the colorectal permeability, luminal lactate concentrations, mucosal infiltration of inflammatory cells, epithelial apoptotic ratio and expression of iNOS were all unaffected by endotoxin.

CONCLUSIONS

No effect of a single intravenous dose of endotoxin was observed on markers of large bowel permeability, metabolism and inflammation in healthy subjects. This suggests that this part of the gut is relatively resistant to the systemic inflammation induced by experimental endotoxaemia in humans.

Norepinephrine in low to moderate doses may not increase luminal concentrations of L-lactate in the gut in patients with septic shock

AIM

To investigate the effect of different doses of norepinephrine (noradrenaline) on luminal concentrations of L-lactate in the rectum and stomach in patients with fluid-resuscitated septic shock.

METHODS

This was a paired cross-over study in which the dose of norepinephrine was titrated to mean arterial blood pressures (MAPs) of 65 and 85 mmHg in random sequence. It was performed in a mixed intensive care unit at a university hospital. Eight patients with fluid-resuscitated septic shock requiring norepinephrine (>0.1 microg/kg/min) were included. Patients were treated with norepinephrine to a MAP of either 65 or 85 mmHg for 2 h. After a 'washout' period of 2 h, the dose of norepinephrine was titrated to the other endpoint of MAP for another 2 h. The concentrations of L-lactate in the rectal and gastric lumen were estimated by 1-h equilibrium dialysis during the second hour of the treatment periods.

RESULTS

MAP and central venous oxygen saturation were increased by increasing the dose of norepinephrine [median (range) (microg/kg/min): 0.07 (0.00-0.60) and 0.18 (0.11-1.00) at MAPs of 65 and 85 mmHg, respectively], whereas the metabolic markers were unaffected [luminal concentrations (mmol/l) of L-lactate in the rectum of 1.9 (0.8-6.4) and 1.8 (0.9-5.7) (P =0.94) and in the stomach of 1.1 (0.1-10.0) and 1.3 (0.3-9.7) (P =0.88) at MAPs of 65 and 85 mmHg, respectively].

CONCLUSION

In this small study, luminal concentrations of L-lactate in the rectum and stomach were unaffected by norepinephrine at low to moderate doses. These data suggest that norepinephrine may not increase luminal concentrations of l-lactate in the gut in patients with fluid-resuscitated septic shock.

Stroke volume variation does not predict fluid responsiveness in patients with septic shock on pressure support ventilation

BACKGROUND

Stroke volume variation (SVV)--as measured by the pulse contour cardiac output (PiCCO) system--predicts the cardiac output response to a fluid challenge in patients on controlled ventilation. Whether this applies to patients on pressure support ventilation is unknown.

METHODS

Thirty consecutive patients with septic shock were included. All were on pressure support ventilation, monitored using the PiCCO system and receiving 500 ml of colloid on clinical indications. Arterial pulse contour SVV and the transpulmonary thermodilution cardiac index were measured before and after fluid challenge.

RESULTS

Forty-seven per cent of the patients were defined as fluid responders by an observed increase of > 10% in the cardiac index after fluid. Prior to fluid challenge, the cardiac index was lower in responders compared with non-responders (mean +/- SD, 3.0 +/- 0.6 vs. 4.0 +/- 1.2 l/min/m2, P < 0.01). In contrast, pre-infusion values of SVV were similar between subsequent responders and non-responders (13 +/- 5 vs. 16 +/- 6%, P =0.26). The mean areas under the ROC curves were 0.77 (95% confidence interval, 0.60-0.94) and 0.52 (0.30-0.73) for pre-fluid cardiac index and SVV, respectively, indicating a predictive power of only the cardiac index.

CONCLUSIONS

SVV did not predict the response in cardiac output to fluid challenge in patients with septic shock on pressure support ventilation.

Increased concentrations of l -lactate in the rectal lumen in patients undergoing cardiopulmonary bypass †

BACKGROUND

Gut ischaemia may contribute to morbidity in patients after cardiopulmonary bypass (CPB), but little is known about the metabolic state of the large bowel in such patients. Therefore we estimated the concentrations of L-lactate and Pco(2) in rectal mucosa in patients undergoing cardiac surgery with or without the use of CPB.

METHODS

Patients undergoing coronary artery bypass grafting (CABG) (n=12) or off-pump CABG (n=10) were subjected to equilibrium dialysis of the rectal lumen during the procedure and in the first 4 h afterwards. Dialysate concentrations of L-lactate and Pco(2) were measured using an auto-analyser and compared with values obtained in healthy subjects (n=10).

RESULTS

During CPB, a 2- to 3-fold increase in luminal concentrations of L-lactate was observed (CABG vs off-pump CABG, P=0.05; CABG vs healthy subjects, P<0.01). The dialysate concentrations of L-lactate were higher than the mean systemic values (luminal-arterial gradient mean (sd) 0.9 (1.0) mmol litre(-1), P<0.05), and the two values were positively correlated (P<0.05). Luminal L-lactate concentrations remained elevated 4 h after the operation. In contrast, dialysate Pco(2) was equally high in patient and control groups and substantially higher than values observed in arterial blood.

CONCLUSIONS

Uncomplicated CPB is associated with moderate but sustained increases in luminal concentrations of L-lactate in the rectum, indicating metabolic dysfunction of the mucosa in the large bowel.

Activation of nuclear factor kappaB in colonic mucosa from patients with collagenous and ulcerative colitis

BACKGROUND AND AIMS

Expression of inducible nitric oxide synthase (iNOS) is greatly upregulated in the colonic mucosa of patients with collagenous and ulcerative colitis. As the transcription factor nuclear factor kappaB (NFkappaB) is a major inducer of iNOS gene expression, we compared activation and transcriptional activity of NFkappaB in colonic mucosal biopsies from these patients.

PATIENTS

Eight patients with collagenous colitis, six with relapsing ulcerative colitis, and eight with uninflamed bowel were studied.

METHODS

NFkappaB DNA binding activity was assessed by electrophoretic mobility shift assay and inhibitor of NFkappaB (IkappaB) kinase (IKK) activity by immunocomplex kinase assay. In vivo recruitment of NFkappaB to the iNOS promoter was determined by chromatin immunoprecipitation analysis and transcriptional activity by NFkappaB gene expression profiling arrays. Cells showing NFkappaB activation were identified by immunohistochemistry.

RESULTS

In collagenous and ulcerative colitis, as opposed to uninflamed bowel, IKKbeta activity and strong NFkappaB DNA binding gave rise to activation of identical NFkappaB subunits and recruitment of transcriptionally active p65 to the iNOS promoter. In collagenous colitis, activated NFkappaB was observed only in epithelial cells while up to 10% of lamina propria macrophages showed activation in ulcerative colitis.

CONCLUSIONS

In collagenous and ulcerative colitis, colonic mucosal NFkappaB is activated and recruited to the iNOS promoter in vivo via an IKKbeta mediated pathway. As collagenous colitis is not associated with tissue injury, these data challenge the prevailing view that activation of NFkappaB per se mediates tissue injury. Our results suggest that downstream inflammatory reactions leading to tissue damage originate in lamina propria immune cells, as increased NFkappaB activity in collagenous colitis was localised solely in epithelial cells, but present also in macrophages in ulcerative colitis.

Terlipressin increased the concentration of L-lactate in the rectal lumen in a patient with septic shock

Terlipressin--a long-acting analogue of vasopressin--has been described to restore blood pressure in patients with catecholamine-resistant septic shock without obvious complications. We administered low-dose terlipressin (a single i.v.-bolus of 0.5 mg) to a patient with severe, hyperdynamic septic shock requiring high dosage of noradrenalin. After terlipressin the dose of noradrenalin could be reduced by 2/3 to obtain the same blood pressure. Two hours after terlipressin, the cardiac index had decreased from 6.2 to 3.3 l min(-1) m(-2) and the concentration of L-lactate in the rectal lumen, as assessed by equilibrium dialysis, increased from 3.6 to 7.2 mmol l(-1). In contrast, the systemic concentration of L-lactate was unaffected around 2.8 mmol l(-1). After 8 h the effect of terlipressin started to decline, and after an additional 12 h the systemic haemodynamics, dose of noradrenalin and concentrations of rectal and systemic L-lactate were the same as prior to the administration of terlipressin. As a strong vasopressor, terlipressin may have further impaired the metabolic dysfunction in the rectal mucosa either directly via vasoconstriction of mucosal vessels or through decreased cardiac output in this patient with noradrenalin-treated septic shock.

High glucose impairs superoxide production from isolated blood neutrophils

OBJECTIVE

Superoxide (O(2)(-)), a key antimicrobial agent in phagocytes, is produced by the activity of NADPH oxidase. High glucose concentrations may, however, impair the production of O(2)(-) through inhibition of glucose-6-phosphate dehydrogenase (G6PD), which catalyzes the formation of NADPH. This study measured the acute effects of high glucose or the G6PD inhibitor dehydroepiandrosterone (DHEA) on the production of O(2)(-) from isolated human neutrophils.

DESIGN

Laboratory studies of short-term cultures of neutrophil granulocytes.

PARTICIPANTS

Healthy subjects.

INTERVENTIONS

Neutrophils were isolated from peripheral blood and incubated for 1 h in Krebs-Ringer buffer containing 5, 10, or 25 mM glucose, 5 mM glucose with 0, 5, or 20 mM mannitol, or 5 mM glucose with 0, 1, 10, or 100 micro M DHEA. O(2)(-) production was induced by N-formyl-methionyl-leucyl-phenylalanine and measured by the cytochrome c reduction assay. Potential scavenging of O(2)(-) by glucose, mannitol, or DHEA was assessed in a cell free system using the pyrogallol assay.

MEASUREMENTS AND RESULTS

Incubation of neutrophils with glucose dose-dependently reduced O(2)(-) production, which was 50% decreased at 25 mM glucose. Also DHEA reduced the production of O(2)(-) dose-dependently, whereas production rates were unaffected by mannitol. Neither glucose, mannitol, nor DHEA scavenged O(2)(-).

CONCLUSIONS

High extracellular glucose concentrations acutely reduce O(2)(-) production from activated neutrophils possibly through inhibition of G6PD. If this occurs in vivo, microbial killing by neutrophils may be impaired during acute hyperglycemia, as observed after major surgery, trauma, or severe infection.

Superoxide production and expression of NAD(P)H oxidases by transformed and primary human colonic epithelial cells

BACKGROUND

Superoxide (O(2)(-)) generation through the activity of reduced nicotinamide dinucleotide (NADH) or reduced nicotinamide dinucleotide phosphate (NADPH) oxidases has been demonstrated in a variety of cell types, but not in human colonic epithelial cells.

AIMS

To measure O(2)(-) production and effects of modulators of NAD(P)H oxidase activity and inhibitors of potential O(2)(-) generating enzymes in cultures of human colonic epithelial cells. Expression of the catalytic subunits of NAD(P)H oxidase, Nox1 and gp91(phox) (phox, phagocytic oxidase), and the membrane bound subunit p22(phox) was assessed.

METHODS

The transformed colonic epithelial cell lines (DLD-1, HT-29, and Caco-2) were studied at subconfluence, confluence, and after differentiation. Primary colonic epithelial cells were isolated from mucosal biopsies from the normal human colon. Extracellular O(2)(-) production was measured by the cytochrome c reduction assay or luminol enhanced luminescence. Nox1, gp91(phox), and p22(phox) mRNA expression was assessed in colonic epithelial cells and blood neutrophils by reverse transcriptase-polymerase chain reaction.

RESULTS

Production rates of O(2)(-) were higher in subconfluent transformed cells (mean (SEM) 35.8 (4.2) nmol/mg of protein/h) and primary cells (40.4 (5.9)) than in confluent transformed cells (6.0 (0.9); p<0.01). The oxidoreductase inhibitor diphenylene iodonium significantly inhibited O(2)(-) production whereas NADPH and NADH increased production rates. In contrast, O(2)(-) was unaffected by phorbol myristate ester, N(G)-nitro-L-arginine methyl ester, indomethacin, or allopurinol. Nox1 mRNA was expressed in all colonic epithelial cells whereas gp91(phox) was detected only in HT-29 cells and neutrophils. p22(phox) was expressed in all cell types.

CONCLUSIONS

Cultures of transformed and primary epithelial cells from human colon may produce extracellular O(2)(-) through an NAD(P)H oxidase expressing Nox1 and p22(phox).

Lactic acidosis in the rectal lumen of patients with septic shock measured by luminal equilibrium dialysis

BACKGROUND

Gut ischaemia may contribute to morbidity in sepsis, but little is known about the metabolic state of the gut mucosa in such patients.

METHODS

Nine patients with abdominal septic shock treated with norepinephrine, and ten healthy subjects, were subjected to equilibrium dialysis with a rectal balloon. pH, PCO(2) and concentrations of L-lactate were measured by auto-analyser.

RESULTS

In rectal dialysis fluid from patients with septic shock, acidosis was present (pH 7.23, 95% CI 7.11-7.36) and concentrations of L-lactate were approximately five times greater than controls (2.5-5.8 vs 0.5-1.2 mmol litre(-1)). The lactate concentration was related to the dose of norepinephrine (P<0.001). In contrast, values of dialysate PCO(2) did not differ significantly between patients and controls (6.4-11.0 vs 8.9-13.8 kPa).

CONCLUSIONS

The results suggest that, either lactic acidosis in rectal mucosa is related to shock severity, or that norepinephrine causes mucosal ischaemia. In any case, metabolic dysfunction is present in the rectal mucosa in patients with abdominal septic shock treated with norepinephrine.

Constitutive expression of inducible nitric oxide synthase in the normal human colonic epithelium

BACKGROUND

Inducible nitric oxide synthase (iNOS) in the human colon is considered expressed only in inflammatory states such as ulcerative or collagenous colitis. As subtle iNOS labelling was previously observed in some colonic mucosal biopsies from a heterogeneous group of controls with non-inflamed bowel, we studied whether bowel preparation with bisacodyl or polyethylene glycol prior to sigmoidoscopy might induce iNOS expression.

METHODS

Ten healthy, non-smoking male subjects were investigated. Mucosal biopsies were taken from the sigmoid colon prior to bowel preparation and again 12 h after rectal administration of bisacodyl or polyethylene glycol in randomized order. Expression of iNOS protein was quantified by Western blot analysis and localized by immunohistochemistry.

RESULTS

iNOS was expressed in the colonic mucosal biopsies from all subjects and localized in the epithelial cells, particularly at the luminal border of the epithelial cells and more pronounced in the crypt epithelium. The expression of iNOS was unaffected by bowel preparation with bisacodyl or polyethylene glycol.

CONCLUSIONS

iNOS is constitutively expressed in the normal colonic epithelium. The results suggest that synthesis of iNOS protein is unaffected by bowel preparation with the secretagogue laxative, bisacodyl, or polyethylene glycol.

Colonic production of nitric oxide gas in ulcerative colitis, collagenous colitis and uninflamed bowel

BACKGROUND

Nitric oxide (NO) produced in excess by the inflamed human colon is generally considered a pathway of mucosal damage. In an attempt to quantify colonic mucosal production of NO in various forms of colitis we performed 'steady-state' gas perfusion of whole colon in 11 patients with ulcerative colitis, 10 patients with collagenous colitis and 20 controls with uninflamed mucosa.

METHODS

The tip of a Teflon tube was placed in the caecum during colonoscopy. Subsequently, argon was infused at a constant rate for 70-180 min. Argon and NO in gas sampled from the rectum were measured by neutron activation analysis and the chemiluminescence technique, respectively.

RESULTS

The use of argon as a marker of colonic NO output was justified by complete recovery (96%+/-2; mean +/- s(x); n = 5) of argon in gas collected from the rectum and a constant output of NO at varying perfusion rates (25, 50 and 75 ml/min coefficient of variation 21%; n = 6). In patients with ulcerative colitis, colonic output of NO was 10-fold higher (P < 0.001) than in controls and positively correlated (P < 0.01) to indices of disease activity. In patients with collagenous colitis, colonic output of NO was 50-fold higher (P < 0.01) than in controls during periods with watery diarrhoea (n = 6), but within the range observed in ulcerative colitis in the absence of diarrhoea (n = 4).

CONCLUSIONS

Argon gas perfusion of whole colon using chemiluminescence technique for measurement of NO is a reliable method for quantification of colonic mucosal NO production. Increased colonic production of NO in collagenous colitis, which exceeds the output observed even in extensive ulcerative colitis, militates against the theory that NO per se is a cause of mucosal injury.

Expression of nitric oxide synthases and effects of L-arginine and L-NMMA on nitric oxide production and fluid transport in collagenous colitis

BACKGROUND AND AIMS

Luminal nitric oxide (NO) is greatly increased in the colon of patients with collagenous and ulcerative colitis. To define the source and consequence of enhanced NO production we have studied expression of NO synthase (NOS) isoforms and nitrotyrosine in mucosal biopsies from these patients. In addition, effects on colonic fluid transfer caused by manipulating the substrate of NOS were studied in patients with collagenous colitis.

PATIENTS

Eight patients with collagenous colitis, nine with active ulcerative colitis, and 10 with uninflamed bowel were included.

METHODS

Expression of NOS isoforms was quantified by western blotting. Inducible NOS (iNOS) and nitrotyrosine were localised by immunohistochemistry. Modulation of NOS activity by topical N(G)-monomethyl-L-arginine (L-NMMA) or L-arginine was assessed during perfusion of whole colon. Plasma and perfusate nitrite/nitrate (NOx) was measured by Griess' reaction.

RESULTS

Both in collagenous and ulcerative colitis, expression of iNOS was 10(2)-10(3) higher (p<0.001) than in uninflamed bowel and localised primarily to the epithelium. Endothelial NOS was evenly expressed in all groups while neuronal NOS was undetectable. Nitrotyrosine was markedly expressed in active ulcerative colitis but rarely detected in collagenous colitis and never in uninflamed bowel. In collagenous colitis, the output of NOx was markedly increased compared with uninflamed bowel (283 (58) v <37 nmol/min; p<0.01) and fluid was net secreted. L-NMMA reduced the output of NOx by 13-66% (95% confidence intervals) and secretion of fluid by 25-109% whereas L-arginine increased the output of NOx by 3-39% and secretion of fluid by 15-93%.

CONCLUSIONS

In collagenous colitis, as opposed to ulcerative colitis, upregulation of iNOS occurs in the absence of nitrotyrosine formation and mucosal damage. Excess generation of NO may be the primary cause of diarrhoea in this condition.

Cardiovascular and respiratory changes and convalescence in laparoscopic colonic surgery: comparison between carbon dioxide pneumoperitoneum and gasless laparoscopy

HYPOTHESIS

Gasless laparoscopy produces smaller cardiopulmonary and systemic changes than carbon dioxide (CO2) laparoscopy during colonic surgery.

DESIGN

Prospective randomized trial.

SETTING

Department of Surgery in a university hospital.

PATIENTS

Twenty-two patients scheduled for laparoscopic colonic resection; 5 patients were excluded because of conversion to open surgery (N = 17).

INTERVENTIONS

Patients were randomized to either gasless (n = 9) or conventional CO2 (n = 8) surgery.

MAIN OUTCOME MEASURES

Intraoperative assessment of hemodynamic factors and pulmonary function, and postoperative assessment of pain, pulmonary function, convalescence, and various injury factors were done several times until 30 days after surgery. Surgical complications were noted.

RESULTS

Descending aorta blood flow after 30 minutes (P=.03) and heart rate after 150 minutes were higher in the CO2 group (P=.009). Central venous pressure, PaCO2 inspiration pressure, and end tidal CO2 level were significantly higher in the CO2 group (P = .05, .03, .04, and .01, respectively). Patients in the CO2 group had less pain during mobilization and coughing (P = .008 and .006, respectively), and were significantly more fatigued (P = .04). No other important differences were observed in intraoperative hemodynamic factors, postoperative convalescence, immunocompetence, or pulmonary function.

CONCLUSION

No clinically important differences in cardiovascular and systemic response were observed between patients undergoing CO2 or gasless laparoscopy for colonic disease.

Review article: the potential role of nitric oxide in chronic inflammatory bowel disorders

The aetiology of the chronic inflammatory bowel diseases-ulcerative colitis and Crohn's disease-as well as 'microscopic colitis'-both collagenous (COC) and lymphocytic colitis (LC)-remains unknown. Autoimmune mechanisms, cytokine polymorphism, commensal bacteria, infectious agents and vascular impairment have all been proposed as playing important roles in the pathogenesis of this spectrum of diseases. A variety of proinflammatory mediators, including tumour necrosis factor alpha, interleukin-1beta, interferon gamma, leukotriene B4 and platelet activating factor, promote the adherence of phagocytes to the venular endothelium and extravasation of these cells into the colonic mucosa. In addition to large amounts of nitric oxide (NO), injurious peroxynitrite may be formed in the epithelium by the inducible nitric oxide synthase (iNOS), which is considered to elicit cytotoxicity by the generation of superoxide with reduced L-arginine availability. In active ulcerative colitis, and to a lesser extent in Crohn's disease, a greatly increased production of NO has been demonstrated by indirect and direct measurements. Surprisingly, even higher rates of production have been observed in COC-a condition which is never associated with injurious inflammation. The latter observation favours the notion that NO promotes mucosal integrity. Further evidence for a protective role of NO in chronic inflammatory bowel disorders is provided by the observation of increased susceptibility to the induction of experi mental colitis in 'knock-out' mice deficient in iNOS. Selective inhibitors of iNOS activity, as well as topical L-arginine, may therefore prove beneficial in inflammatory bowel disease by reducing the production of superoxide by iNOS, while only the former option may be expected to reduce diarrhoea in chronic inflammatory bowel disorders. Clearly, further experimental work needs to be done before testing topical L-arginine in human inflammatory bowel disease.

Changes in plasma potassium concentration during carbon dioxide pneumoperitoneum

Hyperkalaemia with ECG changes had been noted during prolonged carbon dioxide pneumoperitoneum in pigs. We have compared plasma potassium concentrations during surgery in 11 patients allocated randomly to undergo either laparoscopic or open appendectomy and in another 17 patients allocated randomly to either carbon dioxide pneumoperitoneum or abdominal wall lifting for laparoscopic colectomy. Despite an increasing metabolic acidosis, prolonged carbon dioxide pneumoperitoneum resulted in only a slight increase in plasma potassium concentrations, which was both statistically and clinically insignificant. Thus hyperkalaemia is unlikely to develop in patients with normal renal function undergoing carbon dioxide pneumoperitoneum for laparoscopic surgery.

Lower urinary tract symptoms in lumbar root compression syndromes: a prospective survey

STUDY DESIGN

A prospective, observational survey.

OBJECTIVES

To describe lower urinary tract symptoms in uncomplicated lumbar root compression syndromes with special reference to prevalence, nature, and severity, and to analyze whether the occurrence of lower urinary tract symptoms correlates with age, pain, analgesic intake, or the type and level of compression.

SUMMARY OF BACKGROUND DATA

Lower urinary tract symptoms with lumbar root compression are well known in the classic but rather rare cauda equina syndrome. However, micturition difficulties seem to be far more frequent in lumbar root compression syndromes.

METHODS

One hundred eight male patients admitted for surgery for lumbar disc herniation or spinal stenosis were investigated with an extensive questionnaire about their micturition.

RESULTS

Fifty-five percent had significant lower urinary tract symptoms. Eighty percent of the patients with spinal stenosis had symptoms. Thirty-three patients had irritative symptoms, 36 had obstructive symptoms, and 23 had retention symptoms. Twenty-four had severe symptoms. Median compression resulted in more symptoms than paramedian compression. There was no correlation between age, level of compression, drug intake, or pain score and lower urinary tract symptoms.

CONCLUSIONS

Lower urinary tract symptoms of mixed type occur with a high prevalence in male patients with lumbar root compression syndromes referred for neurosurgical evaluation and treatment.

[Can Doppler ultrasound replace strain gauge in the measurement of ankle blood pressure?]

Traditionally, strain gauge technique is used in Denmark to measure ankle blood pressure, a method requiring both time and well-trained personnel. In a study involving 90 limbs in 45 patients, this method was compared with ultrasonic technique using a portable 5 MHz Doppler. The reproducibility of Doppler ankle pressure measurement was similar to that found in strain gauge based studies. Two consecutive measurements may differ by 20 mmHg or in terms of ankle-brachial index by 0.15 before this is considered significant. No systematic variation was found between the two methods. Increasing difficulties were encountered with the Doppler technique at pressures below 50 mmHg. It is concluded that Doppler is a good alternative to strain gauge for measurement of ankle blood pressure.