Infections in critically ill burn patients

Severe burn patients are one subset of critically patients in which the burn injury increases the risk of infection, systemic inflammatory response and sepsis. The infections are usually related to devices and to the burn wound. Most infections, as in other critically ill patients, are preceded by colonization of the digestive tract and the preventative measures include selective digestive decontamination and hygienic measures. Early excision of deep burn wound and appropriate use of topical antimicrobials and dressings are considered of paramount importance in the treatment of burns. Severe burn patients usually have some level of systemic inflammation. The difficulty to differentiate inflammation from sepsis is relevant since therapy differs between patients with and those without sepsis. The delay in prescribing antimicrobials increases morbidity and mortality. Moreover, the widespread use of antibiotics for all such patients is likely to increase antibiotic resistance, and costs. Unfortunately the clinical usefulness of biomarkers for differential diagnosis between inflammation and sepsis has not been yet properly evaluated. Severe burn injury induces physiological response that significantly alters drug pharmacokinetics and pharmacodynamics. These alterations impact antimicrobials distribution and excretion. Nevertheless the current available literature shows that there is a paucity of information to support routine dose recommendations.

[Qualitative research about euthanasia concept, between Spanish doctors]

BACKGROUND AND OBJECTIVES

The decriminalisation of euthanasia and assisted medical suicide has generated a continuous debate. The terminological confusion is one of the main difficulties in obtaining medical practice consensus. The objective of this study was to determine whether the terms of Euthanasia and physician assisted suicide are used with the same meaning by doctors in Extremadura (Spain).

MATERIAL AND METHOD

A qualitative study was conducted using two focus groups in which doctors from different specialties who attended a large number of terminal patients participated. No other focus group was required due to saturation. The sessions were tape recorded and transcribed by two experts in qualitative methodology. Atlas.ti software was used for the analysis. We were advised by the "Health Care at the end of life" Group of the Organizacion Médica Colegial of Spain.

RESULTS

Terminological confusion was verified in: 1) The mixture of etymological, functional and social concepts, 2) the term Passive Euthanasia, 3) the association between euthanasia and physician assisted suicide, 4) the confusion with the equivalent "wish to hasten death", and 5) the difficulty of differentiating sedation with Euthanasia. There was consensus on some aspects: a) Full voluntariness, b) the condition of terminal illness, and c) the condition of unbearable symptoms.

CONCLUSIONS

Conceptual variability persists in relation to the concept of Euthanasia, and is particularly noticeable in the persistence of the concept of passive euthanasia. It would be desirable to achieve a common language to assign a precise meaning to these words to help doctors in their professional practice.

Stressed neurons protect themselves by a tissue-type plasminogen activator-mediated EGFR-dependent mechanism

In the central nervous system, tissue-type plasminogen activator (tPA) has been associated with both pro-death and prosurvival actions on neurons. In most cases, this has been related to exogenous tPA. In the present study, we addressed the influence of endogenous tPA. We first observed an increased transcription of tPA following either in vivo global brain ischemia in rats or in vitro oxygen glucose deprivation (OGD) on mice and rats hippocampal slices. Hippocampal slices from tPA-deficient mice were more sensitive to OGD than wild-type slices. Pharmacological approaches targeting the known receptors of tPA revealed that only the inhibition of phosphorylation of epidermal growth factor receptors (EGFRs) prevented the neuroprotective effect of endogenous tPA. This study shows that ischemic hippocampal neurons overproduce endogenous tPA as an intend to protect themselves from ischemic death, by a mechanism involving an activation of EGFRs. Thus, strategies contributing to promote either endogenous production of tPA or its associated EGFR-linked signaling pathway may have beneficial effects following brain injuries such as stroke.

[Cost-effectiveness analysis of aflibercept in combination with FOLFIRI in the treatment of patients with metastatic colorectal cancer]

OBJECTIVES

To estimate the incremental cost per life-year gained (LYG) of aflibercept in combination with FOLFIRI as second-line treatment in metastatic colorectal cancer (mCRC) patients previously treated with oxaliplatin.

METHODS

Based on clinical trial VELOUR results, a three-state Markov model (stable disease, progression and death) with 2-week cycle duration was designed. Transition to health state «progression» implied the interruption of second-line treatment and administration of a third-line treatment (post-second line chemotherapy). Cost estimation included disease management cost (pharmaceutical, adverse event management, administration costs, etc.). Both cost and outcomes were discounted (3% annually). Sensitivity analyses (SA) were performed to test model robustness.

RESULTS

Administration of aflibercept + FOLFIRI as second-line treatment provided 1.78 LYG (21 life-months gained). With FOLFIRI 1.43 LYG (17 months) were obtained. The cost of the clinical management of aflibercept + FOLFIRI implied an additional investment of Euros 13,564 compared with FOLFIRI for a lifetime horizon, being total costs for aflibercept + FOLFIRI of Euros 38,346, compared to Euros 24,782 with FOLFIRI. In the cost-effectiveness analysis Euros 38,931/LYG was obtained with aflibercept in combination with FOLFIRI versus FOLFIRI.

CONCLUSION

Aflibercept in combination with FOLFIRI increased overall survival versus FOLFIRI, so it is an effective strategy in the treatment of patients with mCRC. Aflibercept in combination with FOLFIRI is an efficient strategy for second-line mCRC treatment from the National Health System perspective.

Preoperative levosimendan. A new way for organoprotection

Preoperative use of levosimendan in cardiac surgery patients is one of the most attractive therapeutic alternatives in subjects with left or right ventricular dysfunction. Our review explores the pharmacological bases and clinical evidence for the use of levosimendan, with the intention of making a series of recommendations regarding its use in preoperative optimization prior to cardiac surgery. We carried out a survey of 102 Spanish anesthesiologists in order to shed light on the grey areas regarding the use of this drug prior to surgery. Our findings suggest that levosimendan is recommended for patients with severe left or right ventricular dysfunction, moderate left ventricular dysfunction in which Intra-aortic Balloon Counterpulsation (IABC) is necessary and severe pulmonary hypertension. Administration of levosimendan prior to surgical cardiac intervention without an initial bolus reduces the likelihood of complications.

Basophils are recruited to inflamed lungs and exacerbate memory Th2 responses in mice and humans

BACKGROUND

Although the contribution of basophils as inducers or amplifiers of Th2 responses is still debated, prolonged basophil/CD4 T cell interactions were observed in lungs but not lymph nodes (LNs) of parasite-infected mice. However, the impact of basophils on the function of tissue CD4 effector T cells remains unknown.

METHODS

Basophils were purified from the lungs of ovalbumin (OVA)-sensitized and OVA-challenged (OVA-immunized) mice or human peripheral blood for in vivo and in vitro functional studies. Pulmonary basophils were adoptively transferred to OVA-sensitized hosts to assess airway inflammation in bronchoalveolar lavage fluid (BALF) and Th2 responses in lung explants and draining LNs. Basophils were co-cultured with effector T cells or Ag-specific naïve T cells alone or in combination with dendritic cells (DCs); IL-4 production was determined by flow cytometry and ELISA.

RESULTS

Basophils accumulated in lungs of OVA-immunized mice. Adoptive transfer of basophils to OVA-sensitized hosts enhanced lung IL-4 and IL-13 release while co-administration of OVA further aggravated airway inflammation and Th2 responses in LNs. Mechanistic in vitro studies revealed that pulmonary basophils interacted with lung CD4 effectors, in the absence of DCs, to increase T cell survival and Th2 cytokine expression at the single cell level but amplified OVA-loaded DC-driven Th2 differentiation. Finally, human basophils augmented in vitro IL-4 expression in effector memory CD4 T cells that include CRTH2(+) cells through IL-4 and TCR-independent pathways.

CONCLUSIONS

Basophils may worsen Th2 inflammatory disorders through direct interactions with pathogenic CD4 T cells as well as by enhancing DC-induced Th2 cell development.

Anaesthetic and cardiorespiratory effects of a constant-rate infusion of alfaxalone in desflurane-anaesthetised sheep

A prospective, randomised, blinded controlled study was performed to determine the anaesthetic and cardiorespiratory effects of a constant-rate infusion (CRI) of alfaxalone in 12 sheep anaesthetised with desflurane, and undergoing experimental orthopaedic surgery. Sheep were sedated with dexmedetomidine (4 μg/kg, intravenously) and butorphanol (0.3 mg/kg, intravenously). Anaesthesia was induced with alfaxalone (1 mg/kg/minute to effect, intravenously) and maintained with desflurane in oxygen and alfaxalone 0.07 mg/kg/minute or saline for 150 minutes (range 150-166 minutes). The anaesthetic induction dose of alfaxalone, the desflurane expiratory fraction required for anaesthetic maintenance, cardiorespiratory measurements and blood-gases were recorded at predetermined intervals. Quality of sedation, anaesthetic induction and recovery were assessed. The alfaxalone induction dose was 1.7 mg/kg (1.2 to 2.6 mg/kg). The desflurane expiratory fraction was lower (22 per cent) in sheep receiving alfaxalone CRI (P=0). Also, heart rate (P=0), cardiac index (P=0.002), stroke index (P=0) and contractility (P=0) were higher, and systemic vascular resistance (P=0.002) was lower. Although respiratory rate tended to be higher with alfaxalone, there was no difference in PCO2 between the groups. Recovery times were significantly longer in sheep given alfaxalone (25.4 v 9.5 minutes) but recovery quality was similar. Alfaxalone reduced requirements of desflurane and maintained similar cardiorespiratory function, but recovery time was more prolonged.

[Complete regression of melanocytic nevi: correlation between clinical, dermoscopic, and histopathologic findings in 13 patients]

BACKGROUND

The complete regression of melanocytic tumors, confirmed by histology, has rarely been reported in the literature. It is very difficult to determine the malignant or benign nature of a regressed tumor, and on occasions, the only indication of malignancy is the subsequent development of metastasis.

MATERIAL AND METHODS

We performed a descriptive study of melanocytic nevi that had undergone complete, histologically confirmed regression prior to excision in the dermatology department of our hospital over a period of 3 years. We included only lesions in which dermoscopy performed prior to regression showed features that suggested benignity. We assessed various clinical, dermoscopic, histologic, and immunohistochemical features.

RESULTS

The mean time to complete regression was 6.4 months. The main dermoscopic patterns observed were reticular and mixed reticular/globular. Unlike what is generally seen in melanomas, the main histologic finding was the presence of fine or lamellar fibrosis. In all cases, there was a predominance of CD8+ T cells.

CONCLUSIONS

The clinical, dermoscopic, and histologic features of the melanocytic nevi studied suggest the existence of a highly characteristic form of tumor regression characterized by very rapid regression and the involvement of a cytotoxic mechanism.

[Low-fluence photodynamic therapy in chronic central serous chorioretinopathy]

OBJECTIVE

To evaluate safety and efficacy of low-fluence photodynamic therapy (LFPDT) with verteporfin in patients affected with chronic central serous chorioretinopathy (CCSC), in terms of visual acuity (VA) and macular morphology measured with optical coherence tomography (OCT).

METHODS

A retrospective, non-randomized and interventionist analysis was performed on 16 eyes in 15 patients with CCSC treated with LFPDT. Best corrected visual acuity (BCVA) with ETDRS optotypes and central foveal thickness (CFT) in OCT were evaluated as outcome measures.

RESULTS

The mean follow-up was 10.8 months. The mean BCVA improved from 58.12 to 68.68 ETDRS letters, and CFT decreased from 280.5 to 172.18 microns, with subretinal fluid resolution in 14 eyes (87.5%), two of them after a second LFTPD. No complications related to treatment were recorded.

CONCLUSIONS

LFPDT with verteporfin can be useful in CCSC to stabilise or improve BCVA, reabsorb subretinal fluid and reduce CFT. Randomised studies with a longer follow-up are required to assure the role of this treatment and to optimise parameters for higher efficacy and safety in CCSC patients.

Results of drug hypersensitivity evaluations in a large group of children and adults

BACKGROUND

Proven IgE or T-cell mediated drug hypersensitivity reactions (DHRs) seem less common in children compared with adults. However, this has never been proved by data.

OBJECTIVE

To determine and compare proven DHR prevalence in children and adults.

METHODS

Using the DAHD (Drug Allergy and Hypersensitivity Database) cohort, children with proven DHRs were compared with adults. The international EAACI-ENDA recommendations were followed. Patients were divided into four groups: index reaction and test during childhood (C/C), index reaction at childhood and test at adulthood (C/A), index reactions at childhood and adulthood and test at adulthood (CA/A), index reaction and test at adulthood (A/A).

RESULTS

A total of 3275 patients (67.9% female), comprising a total of 4370 patient-episodes, were evaluated (74.5% belonged to the A/A group). Prevalence of positive tests was 15.2% (95%CI, 14.1-16.2) for all tested classes, 10.6% (8.3-13.0) for C/C, 10.6% (7.5-13.6) for C/A, 22.1% (12.8-31.3) for CA/A and 16.5% (15.2-17.8) for A/A. The prevalence was lower in group C/C compared with groups A/A (P < 0.0001) and CA/A (P = 0.003). It was also lower in group C/A compared with the two latter groups (respectively P = 0.003 and P = 0.005). Significant differences were found for maculopapular exanthemas only, and not for urticaria/angiœdema and anaphylaxis. The difference was mainly observed with β-lactams and not for NSAIDs.

CONCLUSION AND CLINICAL RELEVANCE

Suspicions of DHRs are less likely to be confirmed in children.