Evaluation of nociception in unconscious critically ill patients using a multimodal approach

This prospective observational study included 80 adults (>18 years) patients admitted to the intensive care unit who were unconscious (Glasgow Coma Scale [GCS] score <9 with a motor response <5) and receiving mechanical ventilation. A tetanic stimulation was used to assess nociception; automated pupillometry (Algiscan, ID-MED, France) was used to compute the pupillary pain index score (PPI), with a PPI > 4 considered as nociception. Concomitantly, the number of skin conductance fluctuations (NSCF) per second, measured using a Skin Conductance Algesimeter (SCA, MEDSTORM Innovation AS, Norway; > 0.27 fluctuations/sec indicating nociception), and the instantaneous Analgesia Nociception Index (iANI, MDoloris Medical Systems, France; <50 indicating nociception) were collected. Tetanic stimulation resulted in a median pupillary dilation of 16 [6-25]% and a PPI of 5 [2-7]. According to the PPI assessment, 44 patients (55%) had nociception, whereas 23 (29%) and 18 (23%) showed nociception according to the algesimeter and iANI assessment, respectively. No significant changes in measured physiologic variables were observed after the tetanic stimulation. There were no correlations between PPI, post-stimulation iANI, and SCA-derived variables. There were no differences in PPI, iANI, and SCA variables in patients with low and normal baseline EEG power at baseline. PERSPECTIVES: Detection of nociception varies across different devices in unconscious critically ill patients. Further studies are required to understand which method to implement for analgesic administration in this patient population.

Fever management in critically ill COVID-19 patients: a retrospective analysis

BACKGROUND

Fever has been reported as a common symptom in COVID-19 patients. The aim of the study was to describe the characteristics of COVID-19 critically ill patients with fever and to assess if fever management had an impact on some physiologic variables.

METHODS

This is a retrospective monocentric cohort analysis of critically ill COVID-19 patients admitted to the Department of Intensive Care Unit (ICU) of Erasme Hospital, Brussels, Belgium, between March 2020 and May 2020. Fever was defined as body temperature ≥ 38° C during the ICU stay. We assessed the independent predictors of fever during ICU stay. We reported the clinical and physiological variables before and after the first treated episode of fever during the ICU stay.

RESULTS

A total of 72 critically ill COVID-19 patients were admitted to the ICU over the study period and were all eligible for the final analysis; 53 (74%) of them developed fever, after a median of 4 [0-13] hours since ICU admission. In the multivariable analysis, male gender (OR 5.41 [C.I. 95% 1.34-21.92]; p=0.02) and low PaO2/FiO2 ratio (OR 0.99 [C.I. 95% 0.99-1.00]; p=0.04) were independently associated with fever. After the treatment of the first febrile episode, heart rate and respiratory rate significantly decreased together with an increase in PaO2 and SaO2.

CONCLUSIONS

In our study, male gender and severe impairment of oxygenation were independently associated with fever in critically ill COVID-19 patients. Fever treatment reduced heart rate and respiratory rate and improved systemic oxygenation.

Interleukine-6 in critically ill COVID-19 patients: A retrospective analysis

INTRODUCTION

Coronavirus disease 2019 (COVID-19) appeared in China in December 2019 and has spread around the world. High Interleukin-6 (IL-6) levels in COVID-19 patients suggest that a cytokine storm may play a major role in the pathophysiology and are considered as a relevant parameter in predicting most severe course of disease. The aim of this study was to assess repeated IL-6 levels in critically ill COVID-19 patients admitted to our Intensive Care Unit (ICU) and to evaluate their relationship with patient's severity and outcome.

METHODS

We conducted a retrospective study on patients admitted to the ICU with a diagnosis of COVID-19 between March 10 (i.e. the date of the first admitted patients) and April 30, 2020. Demographic, clinical and laboratory data were collected at admission. On the day of IL-6 blood concentration measurement, we also collected results of D-Dimers, C-Reactive Protein, white blood cells and lymphocytes count, lactate dehydrogenase (LDH) and ferritin as well as microbiological samples, whenever present.

RESULTS

Of a total of 65 patients with COVID-19 admitted to our ICU we included 41 patients with repeated measure of IL-6. There was a significant difference in IL-6 levels between survivors and non-survivors over time (p = 0.001); moreover, non survivors had a significantly higher IL-6 maximal value when compared to survivors (720 [349-2116] vs. 336 [195-646] pg/mL, p = 0.01). The IL-6 maximal value had a significant predictive value of ICU mortality (AUROC 0.73 [95% CI 0.57-0.89]; p = 0.01).

CONCLUSIONS

Repeated measurements of IL-6 can help clinicians in identifying critically ill COVID-19 patients with the highest risk of poor prognosis.

The Prognostic Role of Lactate Concentrations after Aneurysmal Subarachnoid Hemorrhage

Blood lactate concentrations are often used to assess global tissue perfusion in critically ill patients; however, there are scarce data on lactate concentrations after subarachnoid hemorrhage (SAH). We aimed to assess the prognostic role of serial blood lactate measurements on hospital mortality and neurological outcomes at 3 months after SAH. We reviewed all SAH patients admitted to the intensive care unit from 2007 to 2019 and recorded the highest daily arterial lactate concentration for the first 6 days. Patients with no lactate concentration were excluded. Hyperlactatemia was defined as a blood lactate concentration >2.0 mmol/L. A total of 456 patients were included: 158 (35%) patients died in hospital and 209 (46%) had an unfavorable outcome (UO) at 3 months. The median highest lactate concentration was 2.7 (1.8–3.9) mmol/L. Non-survivors and patients with UO had significantly higher lactate concentrations compared to other patients. Hyperlactatemia increased the chance of dying (OR 4.19 (95% CI 2.38–7.39)) and of having UO in 3 months (OR 4.16 (95% CI 2.52–6.88)) after adjusting for confounding factors. Therefore, initial blood lactate concentrations have prognostic implications in patients with SAH; their role in conjunction with other prognostic indicators should be evaluated in prospective studies.

Eosinopenia in COVID-19 Patients: A Retrospective Analysis

Objectives: The aim of this study was to assess the diagnostic role of eosinophils count in COVID-19 patients. Methods: Retrospective analysis of patients admitted to our hospital with suspicion of COVID-19. Demographic, clinical and laboratory data were collected on admission. Eosinopenia was defined as eosinophils < 100 cells/mm³. The outcomes of this study were the association between eosinophils count on admission and positive real-time reverse transcription polymerase chain reaction (rRT-PCR) test and with suggestive chest computerized tomography (CT) of COVID-19 pneumonia. Results: A total of 174 patients was studied. Of those, 54% had positive rRT-PCR for SARS-CoV-2. A chest CT-scan was performed in 145 patients; 71% showed suggestive findings of COVID-19. Eosinophils on admission had a high predictive accuracy for positive rRT-PCR and suggestive chest CT-scan (area under the receiver operating characteristic-ROC curve, 0.84 (95% CIs 0.78-0.90) and 0.84 (95% CIs 0.77-0.91), respectively). Eosinopenia and high LDH were independent predictors of positive rRT-PCR, whereas eosinopenia, high body mass index and hypertension were predictors for suggestive CT-scan findings. Conclusions: Eosinopenia on admission could predict positive rRT-PCR test or suggestive chest CT-scan for COVID-19. This laboratory finding could help to identify patients at high-risk of COVID-19 in the setting where gold standard diagnostic methods are not available.

ZnCl2 sustains the adriamycin-induced cell death inhibited by high glucose

Hyperglycemia, the condition of high blood glucose, is typical of diabetes and obesity and represents a significant clinical problem. The relationship between hyperglycemia and cancer risk has been established by several studies. Moreover, hyperglycemia has been shown to reduce cancer cell response to therapies, conferring resistance to drug-induced cell death. Therefore, counteracting the negative effects of hyperglycemia may positively improve the cancer cell death induced by chemotherapies. Recent studies showed that zinc supplementation may have beneficial effects on glycemic control. Here we aimed at evaluating whether ZnCl2 could counteract the high-glucose (HG) effects and consequently restore the drug-induced cancer cell death. At the molecular level we found that the HG-induced expression of genes known to be involved in chemoresistance (such as HIF-1α, GLUT1, and HK2 glycolytic genes, as well as NF-κB activity) was reduced by ZnCl2 treatment. In agreement, the adryamicin (ADR)-induced apoptotic cancer cell death was significantly impaired by HG and efficiently re-established by ZnCl2 cotreatment. Mechanistically, the ADR-induced c-Jun N-terminal kinase/stress-activated protein kinase (JNK/SAPK) phosphorylation, inhibited by HG, was efficiently restored by ZnCl2. The JNK involvement in apoptotic cell death was assessed by the use of JNK dominant-negative expression vector that indeed impaired the ZnCl2 ability to restore drug-induced cell death in HG condition. Altogether, these findings indicate that ZnCl2 supplementation efficiently restored the drug-induced cancer cell death, inhibited by HG, by both sustaining JNK activation and counteracting the glycolytic pathway.

MDR-1 polymorphisms (G2677T and C3435T) in B-chronic lymphocytic leukemia: an impact on susceptibility and prognosis

Patients with B-chronic lymphocytic leukemia present diverse clinical features, genetic abnormalities, variable response to treatment, and heterogeneous prognosis. Novel biological markers such as IgVH mutation, CD38, and ZAP-70 expression have shown to offer important prognostic information. An altered expression of the multidrug resistance 1 may represent an additional prognostic marker. Aim of our study was to evaluate two MDR-1 gene polymorphisms: G2677T polymorphism in exon 21 and C3435T polymorphism in exon 26, to evidence if polymorphisms influence the risk of development of B-CLL and whether genomic polymorphisms provide prognostic information on the clinical progression of the disease. A total of 125 patients with B-CLL and 125 healthy subjects were enrolled in this study. The mutant homozygous 2677 TT genotype was found to be associated with the occurrence of B-CLL and higher T allele frequency in patients with B-CLL when compared with controls was observed (P=0.009). When comparing the prognostic patients' characteristics, patients with 2677 GT genotype were statistically linked to the unmutated IgVH genes (r=0.209, P=0.01). Moreover, the same genotype was correlated with lymphocyte number (r=0.269, P=0.02). Finally for the 2677GT polymorphism, the heterozygous status was associated with higher hemoglobin levels (r=0.247, P=0.005). As far the C3435T MDR1 polymorphism, we were not able to identify any significant correlation with IgVH gene status or other variables. In conclusion, MDR1 gene polymorphism could be a factor predisposing to LLC. Moreover, our findings support the possibility of considering these genomic polymorphisms as prognostic markers in patients with B-CLL.

Neuropathic pain in temporomandibular joint disorders: case-control analysis by MR imaging

BACKGROUND AND PURPOSE

Temporomandibular joint disorders (TMJ-D) may be associated with the onset of neuropathic pain. The purpose of this study was to prospectively assess if, at the open-mouth position, the distance between the temporomandibular joint (TMJ) disk and the mandibular nerve is shorter in patients with TMJ-D and neuropathic pain vs patients with TMJ-D without neuropathic pain or in healthy people.

MATERIALS AND METHODS

After ethical committee approval, we evaluated by MR imaging 16 TMJs with TMJ-D and neuropathic pain, 16 TMJs with TMJ-D without neuropathic pain, and 16 TMJs of healthy volunteers. All of the subjects were informed about the study procedure. We evaluated the distance between the TMJ disk and the mandibular nerve at the oval foramen level. Furthermore, the presence within the TMJs of internal derangement, osteoarthrosis, joint effusion, and bone marrow edema was evaluated.

RESULTS

At the maximal open-mouth position, the distance between the TMJ disk and the mandibular nerve is shorter in patients with TMJ-D and neuropathic pain than in patients with TMJ-D without neuropathic pain or in healthy volunteers (P < .05). The imaging findings of TMJ internal derangement, effusion, osteoarthrosis, and bone marrow edema were present both in patients with TMJ-D without neuropathic pain and in patients with TMJ-D and neuropathic pain.

CONCLUSIONS

We suggest that a closer proximity between the TMJ disk and the mandibular nerve could be one of the causes of the onset of neuropathic pain in patients with TMJ-D and neuropathic pain.

Morphometric evaluation of the temporomandibular joint and the masticatory spaces: the role of high-definition MRI

AIM

The aim of this work was to describe the anatomy of the temporomandibular joint (TMJ), the masticator spaces and their possible variance by means of magnetic resonance imaging MRI.

METHODS

We evaluated one TMJ in each of 28 volunteers (14 males and 14 females) without temporomandibular disorders. The TMJ with mouth closed was evaluated on axial, coronal and sagittal planes obtained with a 1.5 Tesla magnetic resonance scanner. MRI scans of the anatomic patterns of the temporomandibular region were analyzed and compared with the classical anatomy notions reported in the literature. Morphometric evaluation of the temporomandibular region and the medial and lateral pterygoid muscles was carried out.

RESULTS

MRI anatomy of the TMJ, the masticator spaces and their possible variance were accurately described. In addition, morphometric evaluation of the TMJ and the masticator spaces was performed. Statistical analysis of the measurements showed that the length of the structures related to the glenoid fossa were usually longer in the female than in the males, whereas the condyle and masticator muscles were usually greater in the males than in the females. T-tests showed no significant differences (P > 0.05) between the measurements of the right and left TMJ.

CONCLUSIONS

In preoperative maxillofacial surgery assessment, MRI is a useful tool to reduce operating time, avert surgical complications and improve patient outcome.

Polyamines as physiological regulators of 14-3-3 interaction with the plant plasma membrane H+-ATPase

Polyamines are abundant polycationic compounds involved in many plant physiological processes such as cell division, dormancy breaking, plant morphogenesis and response to environmental stresses. In this study, we investigated the possible role of these polycations in modulating the association of 14-3-3 proteins with the H(+)-ATPase. In vivo experiments demonstrate that, among the different polyamines, spermine brings about 2-fold stimulation of the H(+)-ATPase activity and this effect is due to an increase in 14-3-3 levels associated with the enzyme. In vivo administration of polyamine synthesis inhibitors causes a small but statistically significant decrease of the H(+)-ATPase phosphohydrolytic activity, demonstrating a physiological role for the polyamines in regulating the enzyme activity. Spermine stimulates the activity of the H(+)-ATPase AHA1 expressed in yeast, in the presence of exogenous 14-3-3 proteins, with a calculated S(50) of 70 microM. Moreover, spermine enhances the in vitro interaction of 14-3-3 proteins with the H(+)-ATPase and notably induces 14-3-3 association with the unphosphorylated C-terminal domain of the proton pump. Comparison of spermine with Mg(2+), necessary for binding of 14-3-3 proteins to different target proteins, shows that the polyamine effect is stronger than and additive to that of the divalent cation.

The maize root plasma membrane H(+)-ATPase is regulated by a sugar-induced transduction pathway

H(+)-ATPase, the key enzyme for the energization of ion and nutrient transport across the plasma membrane, is activated by phosphorylation-dependent 14-3-3 binding. Since the involvement of 14-3-3 proteins in sugar sensing-regulated processes has recently emerged, here we address the question as to whether sugar sensing plays a role in the regulation of H(+)-ATPase. The data reported here show that sugar depletion inhibits the association of 14-3-3 proteins with H(+)-ATPase by hampering phosphorylation of the 14-3-3 binding site of the enzyme. By using non-metabolizable disaccharides, we show that H(+)-ATPase regulation by 14-3-3 proteins can involve a specific sugar perception and transduction mechanism.

[Computed tomography evaluation of urothelial carcinomas of the upper urinary tract]

Computed Tomography (CT) is an indispensable noninvasive method for staging transitional cell carcinomas of renal pelvis and ureter. Twenty-seven patients with upper urinary tract tumors were examined and the CT results correlated with histopathologic findings. These tumors exhibit three different development patterns: in our series we identified 17 intraluminal sessile lesions, 6 focal or concentric wall thickenings and finally 7 infiltrating masses; soft-tissue density lesions exhibited in all cases mild contrast enhancement (mean density increase: 38 HU). Even though the attenuation values of tumors do not allow the accurate demonstration of the depth of renal pelvis and ureteral wall invasion, CT can differentiate the lesions which are still confined within the external wall layers (CT1, 17 cases) from those invading the peripelvic-ureteral fat (CT2, 9 cases) or spreading to other organs as well as distant metastases (CT3, 4 cases). Delayed scans can also demonstrate intraluminal lesion extent and sometimes changes of patients' position allow better differentiation of wall outlines from peripheral fat. The overall staging accuracy of CT was 76.66% and its sensitivity was 93.33%. The assessment of lymph node metastases was the major cause of error in the CT evaluation of these tumors.

[Magnetic resonance in the study of the facial nerve: methodological approach and normal anatomy]

The authors report their experience in the study of facial nerve anatomy by means of MR Imaging. The seventh pair of cranial nerves was studied in 6 healthy and informed volunteers with a super-conductive MR unit at 0.5 T using surface and head coils. Slices were 3 mm thick and were acquired on the axial and sagittal planes, when the petrous and the mastoid bones were studied. The parotid gland was studied with 5-mm slices acquired on the axial, angled axial, and sagittal planes. In all cases T1-weighted images (TR 450, TE 30) were performed. If the above research protocol, which is relatively simple and direct, is applied, the whole course of the facial nerve up to its main distal branches can be almost completely demonstrated.

[Magnetic resonance in the evaluation of parametrial involvement in carcinoma of the cervix uteri]

Cervical carcinoma is one of the most frequent gynecologic malignancies. Its prognosis depends on both tumor volume at diagnosis and its stage. Staging accuracy is important not only for prognosis but also for optimal treatment planning. According to FIGO criteria, carcinomas without parametrial involvement (stage I and limited stage IIA disease) can be surgically treated. For more advanced stages, treatment, in most cases, consists of radiation therapy or chemotherapy alone. The authors evaluated MR accuracy in the diagnosis of parametrial involvement; to this purpose, 32 patients with histologically proven lesions were referred for MR imaging, which was performed with a 0.5 T superconductive magnet. Transverse and sagittal SE images were obtained with T2 weighting (TR 1800 ms, TE 30-100 ms); transverse and sometimes sagittal images were obtained with T1 weighting (TR 450/300 ms, TE 20/30). T1-weighted images distinguished neoplasm from cervical stroma or dense parametrial connective tissue in 40% of cases only. T2-weighted images, instead, demonstrated the difference in all cases, showing tumor as a hyperintense area in 90% of patients. Neoplastic involvement of pericervical connective tissue was diagnosed, with those sequences, on the basis of focal disruptions of the outer hypointense fibrous cervical stroma; findings were correlated with those from a previous clinical staging and in 26/32 patients with pathologic findings. MR accuracy in demonstrating parametrial involvement was 88%, sensitivity was 77% and specificity was 94%. Clinical staging accuracy in the evaluation of this parameter was 66%. In 6 cases with no surgical findings, MR confirmed extensive parametrial and vesical or rectal neoplastic involvement, as diagnosed at clinics. MR imaging, thanks to its multiplanar and multiparametric imaging capabilities is a very reliable technique in the preoperative staging of cervical carcinoma. Moreover, since clinical staging can sometimes underestimate pericervical connective spread, the higher accuracy of MR imaging can help avoid useless interventional procedures.