Anti-endotoxin antibodies consumption in cardiovascular collapse: Pathophysiological concerns

OBJECTIVE

Abnormal endotoxin activity in critically ill patients has been described in the absence of Gram-negative bacterial (GNB) infection. As disease severity seems to be crucial in the detection of this phenomenon, we decided to assess and compare endotoxin exposure in those patients representing the critical situation: septic shock and cardiogenic shock.

DESIGN

Prospective, observational non intervention study.

SETTING

Critical Care Department of a University tertiary hospital.

PATIENTS

Cardiogenic shock (CS) and septic shock (SS) patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Follow-up was performed for the first three days. Inflammatory biomarkers (C-reactive protein, procalcitonin and interleuquin-6) and IgM antiendotoxin-core antibodies titter (IgM EndoCAb) were daily analyzed. Sixty-two patients were included; twenty-five patients with SS and thirty-seven with CS. Microbial etiology was established in 23 SS patients (92%) and GNB were present in 13 cases (52%). Although infection was suspected and even treated in 30 CS patients (81%), any episode could be finally confirmed. EndoCAb consumption was more intense in SS patients, although twenty-two CS patients (59.5%) had IgM anti-endotoxin value below 10th percentile range for healthy people. No statistically significant difference in endotoxin exposure was detected between Gram-positive and Gram-negative infections in the SS group. Endotoxin exposure ability to distinguish between SS and CS was moderate (AUC 0.7892, 95% IC: 0.6564-0.9218).

CONCLUSIONS

In the severely ill patient some mechanisms take place allowing endotoxin incursion and therefore blurring the limits of diseases pathophysiology. Our work representatively shows how exposure to endotoxin was not fully capable of distinguishing between CS and SS.

Competency assessment of residents of Intensive Care Medicine through a simulation-based objective structured clinical evaluation (OSCE). A multicenter observational study

OBJECTIVES

The current official model of training in Intensive Care Medicine (ICM) in Spain is based on exposure to experiences through clinical rotations. The main objective was to determine the level of competency (I novice to V independent practitioner) achieved by the residents at the end of the 3rd year of training (R3) in ICM through a simulation-based OSCE. Secondary objectives were: (1) To identify gaps in performance, and (2) To investigate the reliability and feasibility of conducting simulation-based assessment at multiple sites.

DESIGN

Observational multicenter study.

SETTING

Thirteen Spanish ICU Departments.

PARTICIPANTS

Thirty six R3.

INTERVENTION

The participants performed on five, 15-min, high-fidelity crisis scenarios in four simulation centers. The performances were video recorded for later scoring by trained raters.

MAIN VARIABLES OF INTEREST

Via a Delphi technique, an independent panel of expert intensivists identified critical essential performance elements (CEPE) for each scenario to define the levels of competency.

RESULTS

A total of 176 performances were analyzed. The internal consistency of the check-lists were adequate (KR-20 range 0.64-0.79). Inter-rater reliability was strong [median Intraclass Correlation Coefficient across scenarios: 0.89 (0.65-0.97)]. Competency levels achieved by R3 were: Level I (18.8%), II (35.2%), III (42.6%), IV/V (3.4%). Overall, a great heterogeneity in performance was observed.

CONCLUSION

The expected level of competency after one year in the ICU was achieved only in half of the performances. A more evidence-based educational approach is needed. Multiple center simulation-based assessment showed feasibility and reliability as an evaluation method of competency.

TRIAL REGISTRATION

COBALIDATION. NCT04278976. (https://register.

CLINICALTRIALS

gov).

Acceptance and validity of the methods used to implement a competency based medical education programme in an Intensive Care Department of a teaching referral center

OBJECTIVES

1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE. 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes.

DESIGN

Prospective cohort study.

PARTICIPANTS

All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia.

INTERVENTION

CoBaTrICE implementation started in March 2016, it was based on: (1) Training the tutors in feedback techniques; (2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and (3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place.

METHODS

The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient.

RESULTS

The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity.

CONCLUSIONS

The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity.

Haemodialysis significantly reduces serum levetiracetam levels inducing epileptic seizures: Case report

WHAT IS KNOWN AND OBJECTIVE

Levetiracetam is used in the treatment of some forms of epilepsy. In renal impairment and patients on chronic haemodialysis, dose adjustment is required. We report a case.

CASE DESCRIPTION

This case report describes a woman on levetiracetam treatment who presented with generalized tonic-clonic seizures during a haemodialysis session. We report on treatment adjustment and on the impact of dialysis on levetiracetam levels.

WHAT IS NEW AND CONCLUSION

Haemodialysis reduces serum levetiracetam concentration and can lead to subtherapeutic levels. Close monitoring is necessary when dialysis is used on patients receiving anticonvulsant drugs that are extensively eliminated by the procedure.

Unique solubility of polyoxoniobate salts in methanol: coordination to cations and POM methylation

In methanolic solutions of A₄[{LM′}₂M₆O₁₉] ({LM′} = {Cp*Rh}²⁺, {Cp*Ir}²⁺, {(C₆H₆)Ru}²⁺; M = Nb, Ta; A = Na, K) formation of methoxo complexes [{LM′}₂M₆O_19−n(OMe)n] (n = 1–3) and coordination of CH₃OH to A⁺ take place.

Platinum polyoxoniobates

Coordination of {Pt(OH)₂}²⁺ fragments to Lindqvist type hexaniobates

Grafting {Cp*Rh}2+ on the surface of Nb and Ta Lindqvist-type POM

Structure of a new hybrid organometallic-pom complex [trans-{Cp*Rh}₂M₆O₁₉]⁴⁻ (M = Nb, Ta).

Preparation and Properties of the Full Series of Cuboidal Clusters [MoxW4-xSe4(H2O)12]n+ (n = 4−6) and Their Derivatives

Hydrothermal reactions between incomplete cuboidal cluster aqua complexes [M3Q4(H2O)9]4+ and M(CO)6 (M = Mo, W; Q = S, Se) offer easy access to the corresponding cuboidal clusters M4Q4. The complete series of homometal and mixed Mo/W clusters [Mo(x)W4-xQ4(H2O)12]n+ (x = 0-4, n = 4-6) has been prepared. Upon oxidation of the mixed-metal clusters, it is the W atom which is lost, allowing selective preparation of new trinuclear clusters [Mo2WSe4(H2O)9]4+ and [MoW2Se4(H2O)9]4+. The aqua complexes were converted by ligand exchange reactions into dithiophosphato and thiocyanato complexes, and crystal structures of [W4S4((EtO)2PS2)6], [MoW3S4((EtO)2PS2)6], [Mo4Se4((EtO)2PS2)6], [W4Se4((i-PrO)2PS2)6], and (NH4)6[W4Se4(NCS)12]-4H20 were determined. Cyclic voltammetry was performed on [Mo(x)W4-xCO4(H2O)12]n+, showing reversible redox waves 6+/5+ and 5+/4+. The lower oxidation states are more difficult to access as the number of W atoms increases. The [Mo2WSe4(H2O)9]4+ and [MoW2Se4(H2O)9]4+ species were derivatized into [Mo2WSe4(acac)3(py)3]+ and [MoW2Se4(acac)3(py)3]+, which were also studied by CV. When appropriate, the products were also characterized by FAB-MS and NMR (31P, 1H) data.

Vibrational coupling as diagnostic for intramolecular hydrogen bonds of carbohydrates in aqueous solution

The coupling of nuC-O and deltaO-D vibrations in the 1200-900 cm(-1) IR range leads to band shifting in opposite directions, which provides information on intramolecular hydrogen bonding of carbohydrates in aqueous solution. The aqueous solution IR spectra of 2-acetamide-1,6-anhydro-2-deoxy-D-glucopyranose and cis-1,2-cyclopentanediol and tetrahydrofuran-ethanol mixtures are reported. Frequency upshifting upon deuteration is observed for the nuC-O bands of both a hydrogen bond acceptor and donor in ether-hydroxyl and hydroxyl-hydroxyl contacts. The 1200-900 cm(-1) range can be used to reveal the presence of intramolecular hydrogen bonds in aqueous carbohydrates, unlike the OH stretching region, which cannot be used in this sense due to carbohydrate band masking by the strong nuOH IR absorption of water.