RBM3 regulates temperature sensitive miR-142-5p and miR-143 (thermomiRs), which target immune genes and control fever

Fever is commonly used to diagnose disease and is consistently associated with increased mortality in critically ill patients. However, the molecular controls of elevated body temperature are poorly understood. We discovered that the expression of RNA-binding motif protein 3 (RBM3), known to respond to cold stress and to modulate microRNA (miRNA) expression, was reduced in 30 patients with fever, and in THP-1-derived macrophages maintained at a fever-like temperature (40°C). Notably, RBM3 expression is reduced during fever whether or not infection is demonstrable. Reduced RBM3 expression resulted in increased expression of RBM3-targeted temperature-sensitive miRNAs, we termed thermomiRs. ThermomiRs such as miR-142–5p and miR-143 in turn target endogenous pyrogens including IL-6, IL6ST, TLR2, PGE2 and TNF to complete a negative feedback mechanism, which may be crucial to prevent pathological hyperthermia. Using normal PBMCs that were exogenously exposed to fever-like temperature (40°C), we further demonstrate the trend by which decreased levels of RBM3 were associated with increased levels of miR-142–5p and miR-143 and vice versa over a 24 h time course. Collectively, our results indicate the existence of a negative feedback loop that regulates fever via reduced RBM3 levels and increased expression of miR-142–5p and miR-143.

An outbreak investigation of scrub typhus in Western Province, Solomon Islands, 2014

OBJECTIVE

To identify the etiology and risk factors of undifferentiated fever in a cluster of patients in Western Province, Solomon Islands, May 2014.

METHODS

An outbreak investigation with a case control study was conducted. A case was defined as an inpatient in one hospital in Western Province, Solomon Islands with high fever (> 38.5 °C) and a negative malaria microscopy test admitted between 1 and 31 May 2014. Asymptomatic controls matched with the cases residentially were recruited in a ratio of 1:2. Serum samples from the subjects were tested for rickettsial infections using indirect micro-immunofluorescence assay.

RESULTS

Nine cases met the outbreak case definition. All cases were male. An eschar was noted in five cases (55%), and one developed pneumonitis. We did not identify any environmental factors associated with illness. Serum samples of all five follow-up cases (100%) had strong-positive IgG responses to scrub typhus. All but one control (10%) had a moderate response against scrub typhus. Four controls had low levels of antibodies against spotted fever group rickettsia, and only one had a low-level response to typhus group rickettsia.

DISCUSSION

This outbreak represents the first laboratory-confirmed outbreak of scrub typhus in the Western Province of Solomon Islands. The results suggest that rickettsial infections are more common than currently recognized as a cause of an acute febrile illness. A revised clinical case definition for rickettsial infections and treatment guidelines were developed and shared with provincial health staff for better surveillance and response to future outbreaks of a similar kind.

Short-Term Anticoagulant Therapy and Thrombus Location Are Independent Risk Factors for Delayed Recanalization of Deep Vein Thrombosis

Background

Prompt recanalization of the vein containing the thrombus is an important goal during the initial treatment of DVT, and risk factors for delayed recanalization in patients with deep vein thrombosis (DVT) in the lower extremities need to be determined.

Material/Methods

A total of 174 patients with DVT in lower extremities were recruited from June 2014 to March 2015 at our hospital. Duplex ultrasound scanning was conducted for all patients at 1 and 6 months after baseline evaluation. We divided the patients into recanalization and non-recanalization groups and analyzed risk factors for delayed recanalization.

Results

The univariate analysis revealed that an oral anticoagulant time of less than 3 months and venous thrombus location were risk factors for delayed recanalization (P<0.01). However, age, gender, hypertension, diabetes, pulmonary embolism, incidence factors, the use of catheter-directed thrombolytic (CDT) drugs, and inferior vena cava filter (IVCF) implantation had no influence on the incidence of delayed recanalization in patients with DVT (P>0.05). The multivariate analysis showed that patients with an anticoagulant time of less than 3 months had a lower incidence of recanalization than those with an anticoagulant time of more than 3 months (OR=2.358, P<0.05). The risk of delayed recanalization in patients with proximal DVT was 7 times higher than that in patients with distal DVT.

Conclusions

Duration of anticoagulant treatment of less than 3 months and venous thrombus location are independent risk factors for delayed recanalization of DVT in the lower extremities.

Postoperative complications of spine surgery

A variety of surgical approaches are available for the treatment of spine diseases. Complications can arise intraoperatively, in the immediate postoperative period, or in a delayed fashion. These complications may lead to severe or even permanent morbidity if left unrecognized and untreated [1-4]. Here we review a range of complications in the early postoperative period from more benign complications such as postoperative nausea and vomiting (PONV) to more feared complications leading to permanent loss of neurological function or death [5]. Perioperative pain management is covered in a separate review (Chapter 8).

Development and validation of clinical performance assessment in simulated medical emergencies: an observational study

BACKGROUND

Critical illness is a time-sensitive process which requires practitioners to process vast quantities of data and make decisions rapidly. We have developed a tool, the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN), aimed at enhancing care delivery in such situations. To determine the efficacy of CERTAIN and similar cognitive aids, we developed rubric for evaluating provider performance in a simulated medical resuscitation environments.

METHODS

We recruited 18 clinicians with current valid ACLS certification for evaluation in three simulated medical scenarios designed to mimic typical medical decompensation events routinely experienced in clinical care. Subjects were stratified as experienced or novice based on prior critical care training. A checklist of critical actions was designed using face validity for each scenario to evaluate task completion and performance. Simulation sessions were video recorded and scored by two independent raters. Construct validity was assessed under the assumption that experienced clinicians should perform better than novice clinicians on each task. Reliability was assessed as percentage agreement, kappa statistics and Bland-Altman plots as appropriate.

RESULTS

Eleven experts and seven novices completed evaluation. The overall agreement on common checklist item completion was 84.8 %. The overall model achieved face validity and was consistent with our construct, with experienced clinicians trending towards better performance compared to novices for accuracy and speed of task completion.

CONCLUSIONS

A standardized video assessment tool has potential to provide a valid and reliable method to assess 12 performances of clinicians facing simulated medical emergencies.

Dialysis Patients with Implanted Drug-Eluting Stents Have Lower Major Cardiac Events and Mortality than Those with Implanted Bare-Metal Stents: A Taiwanese Nationwide Cohort Study

OBJECTIVE

To investigate the efficacy and long-term clinical benefits of DES for dialysis patients.

BACKGROUND

It is unclear whether percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is associated with lower rates of major adverse cardiovascular events (MACE) or mortality compared to bare-metal stents (BMS).

METHODS

From a nationwide cohort selected from Taiwan's National Health Insurance Research Database, we enrolled 2,835 dialysis patients who were hospitalized for PCI treatment with stent implantation from Dec 1, 2006. Follow-up was from the date of index hospitalization for PCI until the first MACE, date of death, or December 31, 2011, whichever came first.

RESULTS

A total of 738 patients (26.0%) had DES implanted, and 2,097 (74%) had BMS implanted. The medium time to the first MACE was 0.53 years (interquartile range: 0.89 years; range: 0-4.62 years). At 1-year follow-up, patients treated with BMS had significantly, non-fatal myocardial infarction (MI), all-cause mortality, and composite MACE compared to those treated with DES. The overall repeat revascularization with coronary artery bypass graft (CABG), non-fatal MI, all-cause mortality, and composite MACE were significantly lower in patients treated with DES than those treated with BMS. Multivariate cox regression analysis showed that older age, history of diabetes, history of heart failure, history of stroke, and DES vs. BMS were independent significant predictors of MACE.

CONCLUSIONS

DES implantation conferred survival benefits in dialysis patients compared with BMS implantation.

Frequency of fluid overload and usefulness of bioimpedance in patients requiring intensive care for sepsis syndromes

Guideline-directed therapy for sepsis calls for early fluid resuscitation. Often patients receive large volumes of intravenous fluids. Bioimpedance vector analysis (BIVA) is a noninvasive technique useful for measuring total body water. In this prospective observational study, we enrolled 18 patients admitted to the intensive care unit for the treatment of sepsis syndromes. Laboratory data, clinical parameters, and BIVA were recorded daily. All but one patient experienced volume overload during the course of treatment. Two patients had >20 L of excess volume. Volume overload is clinically represented by tissue edema. Edema is not a benign condition, as it impairs tissue oxygenation, obstructs capillary blood flow, disrupts metabolite clearance, and alters cell-to-cell interactions. Specifically, volume overload has been shown to impair pulmonary, cardiac, and renal function. A positive fluid balance is a predictor of hospital mortality. As septic patients recover, volume excess should be aggressively treated with the use of targeted diuretics and renal replacement therapies if necessary.

Biofilm formation in total hip arthroplasty: prevention and treatment

This review assesses the current knowledge on treatments, pathogenesis and the prevention of infections associated with orthopaedic implants, with a focus on total hip arthroplasty.

Pediatric Acute Respiratory Distress Syndrome: Fluid Management in the PICU

The administration of an appropriate volume of intravenous fluids, while avoiding fluid overload, is a major challenge in the pediatric intensive care unit. Despite our efforts, fluid overload is a very common clinical observation in critically ill children, in particular in those with pediatric acute respiratory distress syndrome (PARDS). Patients with ARDS have widespread damage of the alveolar-capillary barrier, potentially making them vulnerable to fluid overload with the development of pulmonary edema leading to prolonged course of disease. Indeed, studies in adults with ARDS have shown that an increased cumulative fluid balance is associated with adverse outcome. However, age-related differences in the development and consequences of fluid overload in ARDS may exist due to disparities in immunologic response and body water distribution. This systematic review summarizes the current literature on fluid imbalance and management in PARDS, with special emphasis on potential differences with adult patients. It discusses the adverse effects associated with fluid overload and the corresponding possible pathophysiological mechanisms of its development. Our intent is to provide an incentive to develop age-specific fluid management protocols to improve PARDS outcomes.

Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery

The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.

Venovenous Extracorporeal Life Support in Single-Ventricle Patients with Acute Respiratory Distress Syndrome

There is new and growing experience with venovenous extracorporeal life support (VV ECLS) for neonatal and pediatric patients with single-ventricle physiology and acute respiratory distress syndrome (ARDS). Outcomes in this population have been defined but could be improved; survival rates in single-ventricle patients on VV ECLS for respiratory failure are slightly higher than those in single-ventricle patients on venoarterial ECLS for cardiac failure (48 vs. 32-43%), but are lower than in patients with biventricular anatomy (58-74%). To that end, special consideration is necessary for patients with single-ventricle physiology who require VV ECLS for ARDS. Specifically, ARDS disrupts the balance between pulmonary and systemic blood flow through dynamic alterations in cardiopulmonary mechanics. This complexity impacts how to run the VV ECLS circuit and the transition back to conventional support. Furthermore, these patients have a complicated coagulation profile. Both venous and arterial thrombi carry marked risk in single-ventricle patients due to the vulnerability of the pulmonary, coronary, and cerebral circulations. Finally, single-ventricle palliation requires the preservation of low resistance across the pulmonary circulation, unobstructed venous return, and optimal cardiac performance including valve function. As such, the proper timing as well as the particular conduct of ECLS might differ between this population and patients without single-ventricle physiology. The goal of this review is to summarize the current state of knowledge of VV ECLS in the single-ventricle population in the context of these special considerations.

Argument against the Routine Use of Steroids for Pediatric Acute Respiratory Distress Syndrome

Steroids have a plausible mechanism of action of reducing severity of lung disease in acute respiratory distress syndrome (ARDS) but have failed to show consistent benefits in patient-centered outcomes. Many studies have confounding from the likely presence of ventilator-induced lung injury and steroids may have shown benefit because administration minimized ongoing inflammation incited by injurious ventilator settings. If steroids have benefit, it is likely for specific populations that fall within the heterogeneous diagnosis of ARDS. Those pediatric patients with concurrent active asthma or reactive airway disease of prematurity, in addition to ARDS, are the most common group likely to derive benefit from steroids, but are poorly studied. With the information currently available, it does not appear that the typical adult or pediatric patient with ARDS derives benefit from steroids and steroids should not be given on a routine basis.

Tumor Lysis-like Syndrome in Eosinophilic Disease of the Lung: A Case Report and Review of the Literature

Tumor lysis syndrome (TLS) is a metabolic disorder that is generally associated with a malignancy leading to hyperuricemia, hyperphosphatemia, and acute kidney injury. On the other hand, we sometimes encounter these phenomena in nonmalignant disease, which has been referred to as tumor lysis-like syndrome in some studies. We herein experienced a case in which tumor lysis-like syndrome occurred in the course of therapy for eosinophilic disease of the lung, a nonmalignant disease. Even in nonmalignant disease, massive cell lysis induced by therapy can cause phenomena such as TLS or tumor lysis-like syndrome.

Current concepts in the management of acute pancreatitis

Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.

Extracorporeal Life Support for Pediatric Heart Failure

Extracorporeal life support (ECLS) represents an essential component in the treatment of the pediatric patient with refractory heart failure. Defined as the use of an extracorporeal system to provide cardiopulmonary support, ECLS provides hemodynamic support to facilitate end-organ recovery and can be used as a salvage therapy during acute cardiorespiratory failure. Support strategies employed in pediatric cardiac patients include bridge to recovery, bridge to therapy, and bridge to transplant. Advances in extracorporeal technology and refinements in patient selection have allowed wider application of this therapy in pediatric heart failure patients.

Antimicrobial Effect of Imipenem-Functionalized Fe2O3 Nanoparticles on Pseudomonas aeruginosa Producing Metallo β-lactamases

BACKGROUND

Resistant strains of Pseudomonas aeruginosa to imipenem was medical treatment problem, especially in burnt units of hospitals.

OBJECTIVES

This study was conducted to evaluate the antimicrobial effect of Fe₂O₃ nanoparticles alone and functionalized with imipenem on P. aeruginosa starins producing metallo β-lactamases (MBL).

MATERIALS AND METHODS

A disk diffusion method was used to isolate a clinical P. aeruginosa producing Metallo β-lactamases with imipenem resistance. The minimum inhibitory concentration (MIC) of Fe₂O₃ nanoparticles and imipenem were calculated against the bacteria. The antimicrobial effect of nanoparticles functionalized with the antibiotic was determined. Standard strain of P. aeruginosa ATCC: 27853 was used as control.

RESULTS

The clinical sample was resistant to imipenem (up to 28 μg.mL^-1). Similarly, MIC of the nanoparticles against the isolate was 160 μg.mL^-1. Subsequently, the combination of 16 pg.mL^-1 of antibiotic with 80 μg.mL^-1 of Fe₂O₃ nanoparticles were able to inhibit the growth of the isolate.

CONCLUSIONS

Fe₂O₃ nanoparticles functionalized with imipenem can impair antibiotic resistance mechanisms of bacteria as it can make the imipenem resistant the aforementioned bacterium more susceptible to weaker concentrations of antibiotic. It also has its own antibacterial effect in certain concentrations.

Hemostasis Achieved Endoscopically for Diverticular Bleeding from the Horizontal Portion of the Duodenum

Diverticulum of the horizontal portion of the duodenum is a rare cause of upper gastrointestinal (GI) bleeding. Since it is difficult to access the horizontal portion of the duodenum by standard upper GI endoscopy, only a very few cases of endoscopic hemostasis have been reported. Herein, we report a case of diverticular bleeding from the horizontal portion of the duodenum for which hemostasis was achieved using a small-caliber colonoscope, which has an insertion part designed with a passive-bending function/high-force transmission and a transparent tip hood.

Bloodstream infections in older patients

Bloodstream infections (BSIs) are both common and fatal in older patients. We describe data from studies evaluating older patients hospitalized with BSIs. Most older patients with BSIs present "typically" with either fever or leukocytosis. The most common source of BSI in older patients is the urinary tract, and accordingly, Gram-negative organisms predominate. A significant part of these BSIs may thus be preventable by removal of unnecessary urinary catheters. Increased long term mortality is reported following BSIs in older patients, however, data on other long-term outcomes, including functional capacity, cognitive decline and others are lacking. Management of BSIs may include less invasive procedures due to the fragility of older patients. This approach may delay the diagnosis and treatment in some cases. Older patients are probably under-represented in clinical trials assessing treatment of bacteremia. Physicians treating older patients should consider the relevance of these studies' outcomes.

Advances in Intracranial Pressure Monitoring and Its Significance in Managing Traumatic Brain Injury

Intracranial pressure (ICP) measurements are essential in evaluation and treatment of neurological disorders such as subarachnoid and intracerebral hemorrhage, ischemic stroke, hydrocephalus, meningitis/encephalitis, and traumatic brain injury (TBI). The techniques of ICP monitoring have evolved from invasive to non-invasive-with both limitations and advantages. Some limitations of the invasive methods include short-term monitoring, risk of infection, restricted mobility of the subject, etc. The invasiveness of a method limits the frequency of ICP evaluation in neurological conditions like hydrocephalus, thus hampering the long-term care of patients with compromised ICP. Thus, there has been substantial interest in developing noninvasive techniques for assessment of ICP. Several approaches were reported, although none seem to provide a complete solution due to inaccuracy. ICP measurements are fundamental for immediate care of TBI patients in the acute stages of severe TBI injury. In severe TBI, elevated ICP is associated with mortality or poor clinical outcome. ICP monitoring in conjunction with other neurological monitoring can aid in understanding the pathophysiology of brain damage. This review article presents: (a) the significance of ICP monitoring; (b) ICP monitoring methods (invasive and non-invasive); and (c) the role of ICP monitoring in the management of brain damage, especially TBI.

Clinical evaluation of the use of an intracardiac electrocardiogram to guide the tip positioning of peripherally inserted central catheters

The use of peripherally inserted central catheters (PICCs) provides important central venous accesses for clinical treatments, tests and monitoring. Compared with the traditional methods, intracardiac electrocardiogram (ECG)-guided method has the potential to guide more accurate tip positioning of PICCs. This study aimed to clinically evaluate the effectiveness of an intracardiac ECG to guide the tip positioning by monitoring characteristic P-wave changes. In this study, eligible patients enrolled September 2011 to May 2012 according to the inclusion and exclusion criteria received the catheterization monitored by intracardiac ECG. Then chest radiography was performed to check the catheter position. The results revealed that, with 117 eligible patients, all bar one patient who died (n = 116) completed the study, including 60 males and 56 females aged 51.2 ± 15.1 years. Most (n = 113, > 97%) had characteristic P-wave changes. The intracardiac ECG-guided positioning procedure achieved correct placement for 112 patients (96.56%), demonstrating 99.12% sensitivity and 100% specificity. In conclusion, the intracardiac ECG can be a promising technique to guide tip positioning of PICCs. However, since the sample size in this study is limited, more experience and further study during clinical practice are needed to demonstrate achievement of optimal catheterization outcomes.

Comparison of Unplanned Intensive Care Unit Readmission Scores: A Prospective Cohort Study

PURPOSE

Early discharge from the intensive care unit (ICU) may constitute a strategy of resource consumption optimization; however, unplanned readmission of hospitalized patients to an ICU is associated with a worse outcome. We aimed to compare the effectiveness of the Stability and Workload Index for Transfer score (SWIFT), Sequential Organ Failure Assessment score (SOFA) and simplified Therapeutic Intervention Scoring System (TISS-28) in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU.

METHODS

We conducted a prospective cohort study in a single tertiary hospital in southern Brazil. All adult patients admitted to the ICU for more than 24 hours from January 2008 to December 2009 were evaluated. SWIFT, SOFA and TISS-28 scores were calculated on the day of discharge from the ICU. A stepwise logistic regression was conducted to evaluate the effectiveness of these scores in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU. Moreover, we conducted a direct accuracy comparison among SWIFT, SOFA and TISS-28 scores.

RESULTS

A total of 1,277 patients were discharged from the ICU during the study period. The rate of unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU was 15% (192 patients). In the multivariate analysis, age (P = 0.001), length of ICU stay (P = 0.01), cirrhosis (P = 0.03), SWIFT (P = 0.001), SOFA (P = 0.01) and TISS-28 (P<0.001) constituted predictors of unplanned ICU readmission or unexpected death. The SWIFT, SOFA and TISS-28 scores showed similar predictive accuracy (AUC valueswere 0.66, 0.65 and 0.67, respectively; P = 0.58) [corrected].

CONCLUSIONS

SWIFT, SOFA and TISS-28 on the day of discharge from the ICU have only moderate accuracy in predicting ICU readmission or death. The present study did not find any differences in accuracy among the three scores.

Can procalcitonin levels indicate the need for adjunctive therapies in sepsis?

After decades of extensive experimental and clinical research, septic shock and the related multiple organ dysfunction still remain the leading cause of mortality in intensive care units (ICUs) worldwide. Defining sepsis is a difficult task, but what is even more challenging is differentiating infection-induced from non-infection-induced systemic inflammatory response-related multiple organ dysfunction. As conventional signs of infection are often unreliable in intensive care, biomarkers are used, of which one of the most frequently investigated is procalcitonin. Early stabilisation of vital functions via adequate supportive therapy and antibiotic treatment has resulted in substantial improvements in outcome over the last decades. However, there are certain patients who may need extra help, hence modulation of the immune system and the host's response may also be an important therapeutic approach in these situations. Polyclonal intravenous immunoglobulins have been used in critical care for decades. A relatively new potential approach could be attenuation of the overwhelming cytokine storm by specific cytokine adsorbents. Both interventions have been applied in daily practice on a large scale, with firm pathophysiological rationale but weak evidence supported by clinical trials. The purpose of this review is to give an overview on the pathophysiology of sepsis as well as the role and interpretation of biomarkers and their potential use in assisting adjunctive therapies in sepsis in the future.

Leg Swelling Caused by Heterotopic Ossification Mimicking Deep Vein Thrombosis in a Paraplegic Patient

Leg swelling in patients with paraplegia due to spinal cord injury (SCI) occurs for various reasons, including heterotopic ossification (HO), deep vein thrombosis (DVT), fracture, or cellulitis. The clinical presentations of these conditions may overlap in part or in whole and it may occasionally be difficult to distinguish. Of these conditions, DVT and subsequent pulmonary embolism remain significant causes of morbidity and mortality in patients with SCI. Therefore, a prompt diagnostic work-up, particularly for DVT, is essential in patients with SCI, who present with leg swelling. Here, we report a case of leg swelling in a paraplegic patient, resulting from HO mimicking DVT and discuss the differential diagnosis.

Electrophysiological Monitoring of Brain Injury and Recovery after Cardiac Arrest

Reliable prognostic methods for cerebral functional outcome of post cardiac-arrest (CA) patients are necessary, especially since therapeutic hypothermia (TH) as a standard treatment. Traditional neurophysiological prognostic indicators, such as clinical examination and chemical biomarkers, may result in indecisive outcome predictions and do not directly reflect neuronal activity, though they have remained the mainstay of clinical prognosis. The most recent advances in electrophysiological methods--electroencephalography (EEG) pattern, evoked potential (EP) and cellular electrophysiological measurement--were developed to complement these deficiencies, and will be examined in this review article. EEG pattern (reactivity and continuity) provides real-time and accurate information for early-stage (particularly in the first 24 h) hypoxic-ischemic (HI) brain injury patients with high sensitivity. However, the signal is easily affected by external stimuli, thus the measurements of EP should be combined with EEG background to validate the predicted neurologic functional result. Cellular electrophysiology, such as multi-unit activity (MUA) and local field potentials (LFP), has strong potential for improving prognostication and therapy by offering additional neurophysiologic information to understand the underlying mechanisms of therapeutic methods. Electrophysiology provides reliable and precise prognostication on both global and cellular levels secondary to cerebral injury in cardiac arrest patients treated with TH.

Spontaneous Tumor Lysis Syndrome in Small-Cell Lung Cancer: A Rare Complication

Tumor lysis syndrome (TLS) is a life-threatening condition which consists of a constellation of electrolyte imbalances, acute renal failure, seizure, and arrhythmias. It is most commonly seen with hematologic malignancies after the initiation of chemotherapy. However, it can also occur spontaneously, prior to treatment with cytotoxic agents. TLS has been rarely described with non-hematologic solid tumors, and it is even more uncommon to have spontaneous tumor lysis syndrome (STLS) in solid tumors. To our knowledge, only two cases of STLS in small-cell lung cancer (SCLC) were reported in the literature. Herein, we present the case of a patient with metastatic SCLC who developed STLS. Our case highlights that in the setting of metastatic solid tumors, STLS must be in the differential diagnosis, to allow prompt initiation of prophylaxis and treatment.

Molecular mechanisms in lipopolysaccharide-induced pulmonary endothelial barrier dysfunction

The confluent pulmonary endothelium plays an important role as a semi-permeable barrier between the vascular space of blood vessels and the underlying tissues, and it contributes to the maintenance of circulatory fluid homeostasis. Pulmonary endothelial barrier dysfunction is a pivotal early step in the development of a variety of high mortality diseases, such as acute lung injury (ALI). Endothelium barrier dysfunction in response to inflammatory or infectious mediators, including lipopolysaccharide (LPS), is accompanied by invertible cell deformation and interendothelial gap formation. However, specific pharmacological therapies aiming at ameliorating pulmonary endothelial barrier function in patients are still lacking. A full understanding of the fundamental mechanisms that are involved in the regulation of pulmonary endothelial permeability is essential for the development of barrier protective therapeutic strategies. Therefore, this review summarizes several important molecular mechanisms involved in LPS-induced changes in pulmonary endothelial barrier function. As for barrier-disruption, the activation of myosin light chain kinase (MLCK), RhoA and tyrosine kinases; increase of calcium influx; and apoptosis of the endothelium lead to an elevation of lung endothelial permeability. Additionally, the activation of Rac1, Cdc42, protease activated receptor 1 (PAR1) and adenosine receptors (ARs), as well as the increase of cyclic AMP and sphingosine-1-phosphate (S1P) content, protect against LPS-induced lung endothelial barrier dysfunction. Furthermore, current regulatory factors and strategies against the development of LPS-induced lung endothelial hyper-permeability are discussed.

The Tools of the Trade - Uses of Flexible Bronchoscopy

Bronchoscopes have markedly improved the diagnosis as well as therapy in pediatric pulmonary disorders. Two types of bronchoscopes are available; flexible and rigid, with their own advantages and disadvantages. Depending on the clinical need and availability of skills, choice is made between the two. Typically, rigid scopes are largely used by the surgeons (pediatric or otolayngologists) while flexible bronchoscope stays in the domain of the pediatric pulmonologist and intensivists. Rigid scopes may be more versatile than flexible bronchoscopes in removing the foreign bodies from the airway. Flexible bronchoscopes on the other hand can even be introduced through an endotracheal tube. At times, use of both scopes may be required in a given patient for optimal results. Bronchoscopes give us a means to visualize the inside of the airway, which can be very informative for assessing various pathologies affecting the airways. Apart from the visualization of the parts of the airway tree and their structure as well as patency, it can also be used to take tissue biopsy specimens, collect secretions from the airways and bronchoalveolar lavage which can also get cellular elements from the distal alveoli. In the past few decades, more and more instruments are being used for expanding the utility of flexible bronchoscope for interventions ranging from bronchial toilet, foreign body removal, airway stenting and lasers or cryotherapy for airway lesions. The perinatologists have opened up more vistas and thrown newer challenges for using fiberoptic bronchoscopy (FB) for in utero tracheal occlusion in cases with diaphragmatic hernia. The vast applications of this tool makes it very relevant to pulmonary investigations and therapeutics.

Pros and cons of using biomarkers versus clinical decisions in start and stop decisions for antibiotics in the critical care setting

INTRODUCTION

Patients in the intensive care unit (ICU) frequently receive prolonged or even unnecessary antibiotic therapy, which selects for antibiotic-resistant bacteria. Over the last decade there has been great interest in biomarkers, particularly procalcitonin, to reduce antibiotic exposure.

METHODS

In this narrative review, we discuss the value of biomarkers and provide additional information beyond clinical evaluation in order to be clinically useful and review the literature on sepsis biomarkers outside the neonatal period. Both benefits and limitations of biomarkers for clinical decision-making are reviewed.

RESULTS

Several randomized controlled trials (RCTs) have shown the safety and efficacy of procalcitonin to discontinue antibiotic therapy in patients with severe sepsis or septic shock. In contrast, there is limited utility of procalcitonin for treatment initiation or withholding therapy initially. In addition, an algorithm using procalcitonin for treatment escalation has been ineffective and is probably associated with poorer outcomes. Little data from interventional studies are available for other biomarkers for antibiotic stewardship, except for C-reactive protein (CRP), which was recently found to be similarly effective and safe as procalcitonin in a randomized controlled trial. We finally briefly discuss biomarker-unrelated approaches to reduce antibiotic duration in the ICU, which have shown that even without biomarker guidance, most patients with sepsis can be treated with relatively short antibiotic courses of approximately 7 days.

CONCLUSIONS

In summary, there is an ongoing unmet need for biomarkers which can reliably and early on identify patients who require antibiotic therapy, distinguish between responders and non-responders and help to optimize antibiotic treatment decisions among critically ill patients. Available evidence needs to be better incorporated in clinical decision-making.

Sequential invasive-noninvasive mechanical ventilation weaning strategy for patients after tracheostomy

BACKGROUND

Because the continuity and integrity of the trachea are likely damaged to some extent after tracheostomy, the implementation of sequential ventilation has certain difficulties, and sequential invasive-noninvasive ventilation on patients after tracheostomy is less common in practice. The present study aimed to investigate the feasibility of invasive-noninvasive sequential weaning strategy in patients after tracheostomy.

METHODS

Fifty patients including 24 patients with withdrawal of mechanical ventilation (conventional group) and 26 patients with sequential invasive-noninvasive weaning by directly plugging of tracheostomy (sequential group) were analyzed retrospectively after appearance of pulmonary infection control (PIC) window. The analysis of arterial blood gases, ventilator-associated pneumonia (VAP) incidence, the total duration of mechanical ventilation, the success rate of weaning and total cost of hospitalization were compared between the two groups.

RESULTS

Arterial blood gas analysis showed that the sequential weaning group was better than the conventional weaning group 1 and 24 hours after invasive ventilation. The VAP incidence was lowered, the duration of mechanical ventilation shortened, the success rate of weaning increased, and the total cost of hospitalization decreased.

CONCLUSION

Sequential invasive-noninvasive ventilator weaning is feasible in patients after tracheostomy.

Restructuring an evolving Irish trauma system: What can we learn from Europe and Australia?

AIM

Major trauma is a leading cause of mortality and disability. Internationally, major trauma centres and comprehensive trauma networks are associated with improved outcomes. This study aimed to examine selected international trauma systems in Europe and Australia to identify common themes that may aid reconfiguration of the Irish trauma service.

METHODS

An electronic search strategy was utilised using Medline, and a search of the grey literature using Google and Google Scholar. Search terms included "trauma systems", "trauma care", "major trauma centre" and "trauma network". Relevant articles were reviewed and data summarised in a narrative format.

RESULTS

Republic of Ireland currently lacks designated major trauma centres and surrounding trauma networks. Lessons from international models and data from the on-going national trauma audit may guide reconfiguration. Well-functioning trauma systems internationally bear striking similarities, and involve a hub and spoke model. This model has a central major trauma centre, surrounded by a co-ordinated trauma network with trauma units. Concentration of major trauma into high volume centres is key, but these centres must be adequately resourced to deliver a high quality service. Investment in and co-ordination of prehospital care is essential to overcome geographical impediments to centralising trauma care. Funding of rehabilitation infrastructure and resources is also an integral part of a well-functioning trauma system. Trauma outcome data is key to informing trauma system design, with dissemination of this data and public engagement critical for change.

CONCLUSION

International models of trauma care provide valuable lessons for countries currently in process of reconfiguring trauma services.

Dual antiplatelet therapy with clopidogrel and aspirin for secondary stroke prevention

Stroke is a major public health concern worldwide, and 25 % of stroke victims would have another stroke. Although administration of antiplatelet agents has been confirmed to be one of the major approaches for secondary prevention of noncardioembolic stroke, the short-term or long-term use of aspirin plus clopidogrel for secondary stroke prevention remains to be controversial. This article aims at providing a comprehensive review of the evidence on the use of aspirin plus clopidogrel for secondary stroke prevention, with special focus on important studies that may impact clinical practice of treating patients with stroke or transient ischemic attack.

Tumor lysis syndrome in the emergency department: challenges and solutions

Tumor lysis syndrome (TLS) is the most common oncologic emergency. It is caused by rapid tumor cell destruction and the resulting nucleic acid degradation during or days after initiation of cytotoxic therapy. Also, a spontaneous form exists. The metabolic abnormalities associated with this syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute kidney injury. These abnormalities can lead to life-threatening complications, such as heart rhythm abnormalities and neurologic manifestations. The emergency management of overt TLS involves proper fluid resuscitation with crystalloids in order to improve the intravascular volume and the urinary output and to increase the renal excretion of potassium, phosphorus, and uric acid. With this therapeutic strategy, prevention of calcium phosphate and uric acid crystal deposition within renal tubules is achieved. Other measures in the management of overt TLS are prescription of hypouricemic agents, renal replacement therapy, and correction of electrolyte imbalances. Hyperkalemia should be treated quickly and aggressively as its presence is the most hazardous acute complication that can cause sudden death from cardiac arrhythmias. Treatment of hypocalcemia is reserved for patients with electrocardiographic changes or symptoms of neuromuscular irritability. In patients who are refractory to medical management of electrolyte abnormalities or with severe cardiac and neurologic manifestations, early dialysis is recommended.

Extracorporeal life support for severe acute respiratory distress syndrome

PURPOSE OF REVIEW

To provide a summary of the recent literature on extracorporeal membrane oxygenation (ECMO) in adults with severe acute respiratory distress syndrome (ARDS), focusing on advances in equipment, current conventional and unconventional indications, complications, and future applications.

RECENT FINDINGS

ECMO use has increased during the past 5 years. Advances in cannulation, circuit design, and patient selection have made it a safer therapeutic option in severe ARDS, and its use has become more widespread for nonconventional indications.

SUMMARY

High-quality evidence for the routine use of ECMO for management of adult patients with severe ARDS is still lacking. An ongoing randomized controlled trial (ECMO to rescue lung injury in severe ARDS) will contribute valuable data to guide clinical decisions to opt for this supportive therapy.

Diagnosis and treatment of peritoneal metastasis of gastric cancer

As the main reason of death in patients with gastric cancer, peritoneal metastasis is still a major problem to be solved. As we all know, peritoneal metastasis is the main form of advanced gastric cancer and gastric cancer recurrence, which involves a complex, multi-stage, multifactorial pathological process. The diagnosis and treatment of peritoneal metastasis of gastric cancer are particularly difficult. The good news is that through active exploration and clinical research, several important achievements have been made and gradually bring the gospel to clinical patients. This paper will review the recent progress in the diagnosis and treatment of peritoneal metastasis of gastric cancer.

CD1d- and MR1-Restricted T Cells in Sepsis

Dysregulated immune responses to infection, such as those encountered in sepsis, can be catastrophic. Sepsis is typically triggered by an overwhelming systemic response to an infectious agent(s) and is associated with high morbidity and mortality even under optimal critical care. Recent studies have implicated unconventional, innate-like T lymphocytes, including CD1d- and MR1-restricted T cells as effectors and/or regulators of inflammatory responses during sepsis. These cell types are typified by invariant natural killer T (iNKT) cells, variant NKT (vNKT) cells, and mucosa-associated invariant T (MAIT) cells. iNKT and vNKT cells are CD1d-restricted, lipid-reactive cells with remarkable immunoregulatory properties. MAIT cells participate in antimicrobial defense, and are restricted by major histocompatibility complex-related protein 1 (MR1), which displays microbe-derived vitamin B metabolites. Importantly, NKT and MAIT cells are rapid and potent producers of immunomodulatory cytokines. Therefore, they may be considered attractive targets during the early hyperinflammatory phase of sepsis when immediate interventions are urgently needed, and also in later phases when adjuvant immunotherapies could potentially reverse the dangerous state of immunosuppression. We will highlight recent findings that point to the significance or the therapeutic potentials of NKT and MAIT cells in sepsis and will also discuss what lies ahead in research in this area.

How the cortico-thalamic feedback affects the EEG power spectrum over frontal and occipital regions during propofol-induced sedation

Increasing concentrations of the anaesthetic agent propofol initially induces sedation before achieving full general anaesthesia. During this state of anaesthesia, the observed specific changes in electroencephalographic (EEG) rhythms comprise increased activity in the δ- (0.5-4 Hz) and α- (8-13 Hz) frequency bands over the frontal region, but increased δ- and decreased α-activity over the occipital region. It is known that the cortex, the thalamus, and the thalamo-cortical feedback loop contribute to some degree to the propofol-induced changes in the EEG power spectrum. However the precise role of each structure to the dynamics of the EEG is unknown. In this paper we apply a thalamo-cortical neuronal population model to reproduce the power spectrum changes in EEG during propofol-induced anaesthesia sedation. The model reproduces the power spectrum features observed experimentally both in frontal and occipital electrodes. Moreover, a detailed analysis of the model indicates the importance of multiple resting states in brain activity. The work suggests that the α-activity originates from the cortico-thalamic relay interaction, whereas the emergence of δ-activity results from the full cortico-reticular-relay-cortical feedback loop with a prominent enforced thalamic reticular-relay interaction. This model suggests an important role for synaptic GABAergic receptors at relay neurons and, more generally, for the thalamus in the generation of both the δ- and the α- EEG patterns that are seen during propofol anaesthesia sedation.

Principles of Fluid Management

Fluid therapy is the most common intervention received by acutely ill hospitalized patients; however, important questions on its optimal use remain. Its prescription should be patient and context specific, with clear indications and contradictions, and have the type, dose, and rate specified. Any fluid therapy, if provided inappropriately, can contribute unnecessary harm to patients. The quantitative toxicity of fluid therapy contributes to worse outcomes; this should prompt greater bedside attention to fluid prescription, fluid balance, development of avoidable complications attributable to fluid overload, and for the timely deresuscitation of patients whose clinical status and physiology allow active fluid mobilization.

Melting Temperature Mapping Method: A Novel Method for Rapid Identification of Unknown Pathogenic Microorganisms within Three Hours of Sample Collection

Acquiring the earliest possible identification of pathogenic microorganisms is critical for selecting the appropriate antimicrobial therapy in infected patients. We herein report the novel “melting temperature (Tm) mapping method” for rapidly identifying the dominant bacteria in a clinical sample from sterile sites. Employing only seven primer sets, more than 100 bacterial species can be identified. In particular, using the Difference Value, it is possible to identify samples suitable for Tm mapping identification. Moreover, this method can be used to rapidly diagnose the absence of bacteria in clinical samples. We tested the Tm mapping method using 200 whole blood samples obtained from patients with suspected sepsis, 85% (171/200) of which matched the culture results based on the detection level. A total of 130 samples were negative according to the Tm mapping method, 98% (128/130) of which were also negative based on the culture method. Meanwhile, 70 samples were positive according to the Tm mapping method, and of the 59 suitable for identification, 100% (59/59) exhibited a “match” or “broad match” with the culture or sequencing results. These findings were obtained within three hours of whole blood collection. The Tm mapping method is therefore useful for identifying infectious diseases requiring prompt treatment.

Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country

Background

Critical care saves lives of the young with reversible disease. Little is known about critical care services in low-income countries. In a setting with a shortage of doctors the actions of the nurse bedside are likely to have a major impact on the outcome of critically ill patients with rapidly changing physiology. Identification of severely deranged vital signs and subsequent treatment modifications are the basis of modern routines in critical care, for example goal directed therapy and rapid response teams. This study assesses how often severely deranged vital signs trigger an acute treatment modification on an Intensive Care Unit (ICU) in Tanzania.

Methods

A medical records based, observational study. Vital signs (conscious level, respiratory rate, oxygen saturation, heart rate and systolic blood pressure) were collected as repeated point prevalences three times per day in a 1-month period for all adult patients on the ICU. Severely deranged vital signs were identified and treatment modifications within 1 h were noted.

Results

Of 615 vital signs studied, 126 (18%) were severely deranged. An acute treatment modification was in total indicated in 53 situations and was carried out three times (6%) (2/32 for hypotension, 0/8 for tachypnoea, 1/6 for tachycardia, 0/4 for unconsciousness and 0/3 for hypoxia).

Conclusions

This study suggests that severely deranged vital signs are common and infrequently lead to acute treatment modifications on an ICU in a low-income country. There may be potential to improve outcome if nurses are guided to administer acute treatment modifications by using a vital sign directed approach. A prospective study of a vital sign directed therapy protocol is underway.