Evolution of sexual functioning of men through treated and untreated depression

OBJECTIVES

Depression as well as a treatment by antidepressant are factors that may interfere with sexuality. Due to this complex relationship between depression, antidepressant and sexuality, it is difficult to incontestably establish the exclusive accountability of a treatment or of a psychiatric disorder on sexual dysfunctions. The main purpose of the SADD (for Sexuality, Anti-Depressant and Depression) study is to evaluate sexual dysfunctions in depressed men treated with antidepressant or not.

METHODS

Participants of this transversal, observational study were men aged over 18 years old, suffering from unipolar major depressive disorder and treated by a psychiatrist, with or without antidepressant. Assessment of sexual functioning through three times: euthymia (before depression), untreated depression and treated depression if applicable was performed based on the ASEX scale.

RESULTS

Seventy patients were included. Eight percent of euthymic patients presented a sexual dysfunction (average score on the ASEX=12.4) whereas 56% of untreated patients presented a sexual dysfunction (average total score on the ASEX=17.7) and 62% (34/55) of patients treated with antidepressant (average total score on ASEX=18.5) (P<0.001). Sexual functioning of men receiving treatment is not significantly different to that among men not receiving any antidepressant, even if patients treated with antidepressant reported that they had a better mood than those untreated.

CONCLUSIONS

Our results reveal a high prevalence of sexual dysfunction within the framework of major depressive disorder and its treatment and underlines the complex relationship between major depressive disorder, antidepressant and sexuality.

Fatal and life-threatening ADRs associated with paliperidone palmitate: an observational study in the French pharmacovigilance database

INTRODUCTION

Paliperidone palmitate (PP), a long-acting intramuscular formulation of paliperidone, has been marketed in Europe within the last 10 years and provides an important treatment option for patients with schizophrenia.Our aim was to describe PP-related adverse drug reactions (ADRs) leading to death or life-threatening events, specifying their main clinical and pharmacological characteristics.

METHODS

This observational study was a retrospective review of PP-related ADRs in the French pharmacovigilance database between January 1, 2013, and December 31, 2019.

RESULTS

Out of 473 PP-related ADRs, we identified 13 deaths and 14 life-threatening events. ADRs were primarily cardiorespiratory (n = 17; 63%). Other symptoms observed were mainly metabolic (n = 4), digestive (n = 4), and neurological (n = 4). Cardiorespiratory symptoms were generally observed within first 6 months after initiation of treatment (11 out of 17 cases), unlike metabolic disorders (all 4 cases 12-21 months after initiation). Cardiac arrests and sudden unexpected deaths occurred 10-14 days after the last PP once-monthly injection (23 cases) or 11-24 days after the last PP three-monthly injection (remaining 4 cases). No PP blood concentration assays were performed for these patients.

DISCUSSION

In this study, PP-related ADRs leading to death or life-threatening events mainly presented with cardiorespiratory symptoms and tended to occur in the first 6 months after the initiation of treatment and within postadministration periods aligned with peak plasma PP concentrations. The hypothesis of supratherapeutic drug concentrations following intramuscular PP injection must be raised.

CONCLUSION

PP-related ADRs leading to death or life-threatening events mainly presented with cardiorespiratory symptoms. Cardiac arrests and sudden unexpected deaths following initiation of PP treatment could be due to supratherapeutic drug concentrations. This study highlights the need to monitor blood concentrations of PP.Key pointsAdverse reactions to paliperidone palmitate can lead to death or life-threatening events.It is hypothesized that cardiac arrests and sudden unexpected deaths following initiation of paliperidone palmitate treatment could be due to supratherapeutic drug concentrations.This paper proposes the need to monitor blood concentrations of paliperidone palmitate in future studies.

A Multicenter Randomized Trial Assessing the Efficacy of Helium/Oxygen in Severe Exacerbations of Chronic Obstructive Pulmonary Disease

RATIONALE

During noninvasive ventilation (NIV) for chronic obstructive pulmonary disease (COPD) exacerbations, helium/oxygen (heliox) reduces the work of breathing and hypercapnia more than air/O₂, but its impact on clinical outcomes remains unknown.

OBJECTIVES

To determine whether continuous administration of heliox for 72 hours, during and in-between NIV sessions, was superior to air/O₂ in reducing NIV failure (25-15%) in severe hypercapnic COPD exacerbations.

METHODS

This was a prospective, randomized, open-label trial in 16 intensive care units (ICUs) and 6 countries. Inclusion criteria were COPD exacerbations with Pa_CO2 ≥ 45 mm Hg, pH ≤ 7.35, and at least one of the following: respiratory rate ≥ 25/min, Pa_O2 ≤ 50 mm Hg, and oxygen saturation (arterial [Sa_O2] or measured by pulse oximetry [Sp_O2]) ≤ 90%. A 6-month follow-up was performed.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was NIV failure (intubation or death without intubation in the ICU). The secondary endpoints were physiological parameters, duration of ventilation, duration of ICU and hospital stay, 6-month recurrence, and rehospitalization rates. The trial was stopped prematurely (445 randomized patients) because of a low global failure rate (NIV failure: air/O₂ 14.5% [n = 32]; heliox 14.7% [n = 33]; P = 0.97, and time to NIV failure: heliox group 93 hours [n = 33], air/O₂ group 52 hours [n = 32]; P = 0.12). Respiratory rate, pH, Pa_CO2, and encephalopathy score improved significantly faster with heliox. ICU stay was comparable between the groups. In patients intubated after NIV failed, patients on heliox had a shorter ventilation duration (7.4 ± 7.6 d vs. 13.6 ± 12.6 d; P = 0.02) and a shorter ICU stay (15.8 ± 10.9 d vs. 26.7 ± 21.0 d; P = 0.01). No difference was observed in ICU and 6-month mortality.

CONCLUSIONS

Heliox improves respiratory acidosis, encephalopathy, and the respiratory rate more quickly than air/O₂ but does not prevent NIV failure. Overall, the rate of NIV failure was low. Clinical trial registered with www.clinicaltrials.gov (NCT 01155310).

Noninvasive ventilation with helium-oxygen mixture in hypercapnic COPD exacerbation: aggregate meta-analysis of randomized controlled trials

When used as a driving gas during NIV in hypercapnic COPD exacerbation, a helium–oxygen (He/O₂) mixture reduces the work of breathing and gas trapping. The potential for He/O₂ to reduce the rate of NIV failure leading to intubation and invasive mechanical ventilation has been evaluated in several RCTs. The goal of this meta-analysis is to assess the effect of NIV driven by He/O₂ compared to air/O₂ on patient-centered outcomes in hypercapnic COPD exacerbation. Relevant RCTs were searched using standard procedures. The main endpoint was the rate of NIV failure. The effect size was computed by a fixed-effect model, and estimated as odds ratio (OR) with 95% confidence interval (CI). Additional endpoints were ICU mortality, NIV-related side effects, and the length and costs of ICU stay. Three RCTs fulfilled the selection criteria and enrolled a total of 772 patients (386 patients received He/O₂ and 386 received air/O₂). Pooled analysis showed no difference in the rate of NIV failure when using He/O₂ mixture compared to air/O₂: 17 vs 19.7%, respectively; OR 0.84, 95% CI 0.58–1.22; p = 0.36; I² for heterogeneity = 0%, and no publication bias. ICU mortality was also not different: OR 0.8, 95% CI 0.45–1.4; p = 0.43; I² = 5%. However, He/O₂ was associated with less NIV-related adverse events (OR 0.56, 95% CI 0.4–0.8, p = 0.001), and a shorter length of ICU stay (difference in means = −1.07 day, 95% CI −2.14 to −0.004, p = 0.049). Total hospital costs entailed by hospital stay and NIV gas were not different: difference in means = −279$, 95% CI −2052–1493, p = 0.76. Compared to air/O₂, He/O₂ does not reduce the rate of NIV failure in hypercapnic COPD exacerbation. It is, however, associated with a lower incidence of NIV-related adverse events and a shortening of ICU length of stay with no increase in hospital costs.

Benzodiazepine dependence in subjects with alcohol use disorders: what prevalence?

OBJECTIVE

To our knowledge, no studies have been conducted in France on benzodiazepine (BZD) dependence among outpatients with alcohol use disorders (AUD). Some international studies have been conducted on the consumption of BZD in this specific population, but the comparisons among them are difficult. We aimed to assess the current prevalence of probable benzodiazepine and BZD-like hypnotics (Z-drugs) dependence among outpatients seeking treatment for AUD.

METHODS

Participants were patients seeking treatment for AUD for the first time or repeating treatment after more than twelve months. Recruitment took place in seven addiction centres between January and December 2013 in the Nantes region (France). BZD/Z-drug dependence was assessed according to the DSM-IV diagnostic criteria for dependence. This information was gathered through a self-report questionnaire.

RESULTS

Among the 1005 patients included in this study, 413 were BZD/Z-drug users (41.1%). Among the 413 patients, 217 were probably dependent on at least one substance, which represents 21.6% of the total population and 52.5% of BZD/Z-drug users.

CONCLUSION

BZD/Z-drug dependence represents a public health concern. Prescribers should take the risks into account and keep treatment courses to a minimum.

Simultaneous determination of ceftaroline, daptomycin, linezolid and rifampicin concentrations in human plasma by on-line solid phase extraction coupled to high-performance liquid chromatography-tandem mass spectrometry

Methicillin-resistant Staphylococcus aureus infection is a serious clinical problem worldwide. Ceftaroline, daptomycin, linezolid in combination with rifampicin are particularly used in this indication. To allow monitoring of these antibiotics, an on-line solid phase extraction coupled to high-performance liquid chromatography-tandem mass spectrometry assay requiring a 100 μL aliquot of human plasma has been developed. Besides, significance of 25-O-desacetylrifampicin concentrations was evaluated. Sample pre-treatment is limited to protein precipitation with methanol. After centrifugation 10 μL of supernatant are injected into the chromatographic system, which consists of an on-line solid phase extraction followed by a separation on a phenyl-hexyl column and detected by a tandem mass spectrometer. Plasma drug concentrations were determined by multiple reaction monitoring in positive ion mode, and assay performance was evaluated. 25-O-Desacetylrifampicin activity, was compared to rifampicin using a microbiological method. Sample preparation using methanol precipitation followed by solid-phase extraction yielded good recovery and ionization efficiency, with chromatographic separation achieved within 3 min per sample. Within-run and between-run precisions ranged respectively from 1.22% to 9.35% and from 1.61% to 9.36%. Lower limits of quantification were 0.04 mg/L for linezolid, 0.1mg/L for rifampicin, 0.2mg/L for ceftaroline and 0.5mg/L for daptomycin. It appears that 25-O-desacetylrifampicin displays a substantial intrinsic bactericidal activity against S. aureus. This assay provides simple, rapid, sensitive and accurate quantification of the four antibiotic drugs and one metabolite and can be routinely used to monitor drug concentration in methicillin-resistant S. aureus infected patients.

Consommation de benzodiazépines chez le sujet âgé : quelles particularités ?

En décembre 2013, l’ANSM publiait un nouveau rapport sur l’état des lieux de la consommation des benzodiazépines et apparentés (BZD) en France[1]. D’après ce rapport, l’âge médian des consommateurs est de 56 ans et la consommation des BZD augmente avec l’âge. Cinquante-cinq pour cent des consommateurs les utilisent plus de 3 mois consécutifs et le temps d’exposition est plus élevé chez les sujets de plus de 65 ans. Afin de déterminer quelles sont les caractéristiques de la consommation des BZD chez les sujets âgés, nous avons réalisé une étude comparant deux groupes de consommateurs chroniques de BZD en Pays de la Loire : des sujets âgés de 65 ans ou plus (seniors) et des adultes de moins de 65 ans (adultes) [2,3]. Les sujets inclus consommaient au moins un traitement par BZD depuis 3 mois ou plus. Le questionnaire utilisé contenait des données socio-démographiques et médicales et une évaluation des modalités de consommation basée sur les items du DSM-IV et le comportement du patient (mode d’obtention, effet recherché…). Chez les seniors, la dose ou durée supérieure, les problèmes relationnels et les problèmes de santé sont moins fréquents que chez les adultes ; 35,2 % des seniors présentent 3 items du DSM-IV ou plus, versus 49,75 % des adultes. La consommation se caractérise chez les seniors par une tolérance plus fréquente, chez les adultes par des conséquences sociales et somatiques et une dose/durée supérieure à ce qui était prévu. Notre étude montre que les consommateurs chroniques de BZD n’ont pas le même profil en fonction de l’âge. Tandis que les adultes rapportent plus de pathologies psychiatriques, avec une consommation plus importante que prévue et qui entraîne des conséquences négatives au niveau social et somatique, les seniors décrivent une consommation plus ritualisée avec peu de conséquences négatives ressenties.

Progressive Organ Failure After Ingestion of Wild Garlic Juice

BACKGROUND

Wild garlic and related plants are increasingly sought after by fans of natural products. They can be confused with other plants containing colchicine and cause potentially fatal intoxications.

CASE REPORT

We report a case of accidental poisoning by Colchicum autumnale, which was mistaken for wild garlic (Allium ursinum). The patient initially presented with mild gastrointestinal symptoms, but progressed rapidly to agranulocytosis, paraparesis, and delirium before the causative agent was identified. The laboratory tests revealed rhabdomyolysis, coagulopathy, alteration of liver tests, and prerenal azotemia. Botanical examination confirmed the incriminated plant (Colchicum autumnale). Serum and urine analysis confirmed the presence of colchicine. The patient required intensive support therapy, and she fully recovered within 8 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Colchicine poisoning should be considered in the differential diagnosis of patients presenting with gastroenteritis after ingestion of wild garlic.

End-tidal carbon dioxide monitoring using a naso-buccal sensor is not appropriate to monitor capnia during non-invasive ventilation

Background

In acute respiratory failure, arterial blood gas analysis (ABG) is used to diagnose hypercapnia. Once non-invasive ventilation (NIV) is initiated, ABG should at least be repeated within 1 h to assess PaCO₂ response to treatment in order to help detect NIV failure. The main aim of this study was to assess whether measuring end-tidal CO₂ (EtCO₂) with a dedicated naso-buccal sensor during NIV could predict PaCO₂ variation and/or PaCO₂ absolute values. The additional aim was to assess whether active or passive prolonged expiratory maneuvers could improve the agreement between expiratory CO₂ and PaCO₂.

Methods

This is a prospective study in adult patients suffering from acute hypercapnic respiratory failure (PaCO₂ ≥ 45 mmHg) treated with NIV. EtCO₂ and expiratory CO₂ values during active and passive expiratory maneuvers were measured using a dedicated naso-buccal sensor and compared to concomitant PaCO₂ values. The agreement between two consecutive values of EtCO₂ (delta EtCO₂) and two consecutive values of PaCO₂ (delta PaCO₂) and between PaCO₂ and concomitant expiratory CO₂ values was assessed using the Bland and Altman method adjusted for the effects of repeated measurements.

Results

Fifty-four datasets from a population of 11 patients (8 COPD and 3 non-COPD patients), were included in the analysis. PaCO₂ values ranged from 39 to 80 mmHg, and EtCO₂ from 12 to 68 mmHg. In the observed agreement between delta EtCO₂ and deltaPaCO₂, bias was −0.3 mmHg, and limits of agreement were −17.8 and 17.2 mmHg. In agreement between PaCO₂ and EtCO₂, bias was 14.7 mmHg, and limits of agreement were −6.6 and 36.1 mmHg. Adding active and passive expiration maneuvers did not improve PaCO₂ prediction.

Conclusions

During NIV delivered for acute hypercapnic respiratory failure, measuring EtCO₂ using a dedicating naso-buccal sensor was inaccurate to predict both PaCO₂ and PaCO₂ variations over time. Active and passive expiration maneuvers did not improve PaCO₂ prediction.

Trial registration

ClinicalTrials.gov: NCT01489150.

A liquid chromatography-tandem mass spectrometry assay for quantification of rilpivirine and dolutegravir in human plasma

A liquid chromatography-tandem mass spectrometry assay requiring a 100μL aliquot of human plasma for simultaneous determination of rilpivirine, a second generation non-nucleoside reverse transcriptase inhibitors of HIV and dolutegravir, a novel integrase stand transfer inhibitors of HIV concentrations has been developed. Sample pre-treatment is limited to protein precipitation with a mixture of methanol and zinc sulfate. After centrifugation the supernatant is injected in the chromatographic system, which consists of on-line solid phase extraction followed by separation on a phenyl-hexyl column. This 2.5min method, with its simple sample preparation provides sensitive (the limit of quantitation is 25ng/mL for each compound), accurate and precise (the intra-day and inter-day imprecision and inaccuracy are lower than 15%) quantification of the plasma concentration of these drugs and can be used for therapeutic drug monitoring in patients infected with HIV.

[Prescription of methylphenidate for children: importance of recommendations to limit misuse]

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder appearing during childhood. Multimodal strategies have been developed to treat this disorder, some of them including medication. To this day in France, prescriptions are mainly based on methylphenidate. Ever since this drug was marketed in France in 1995, it has been subject to enhanced monitoring, mainly because of the risk of dependence, abuse, and misuse. The present study aims at assessing (1) whether the recommendations on methylphenidate use for children are being respected, (2) the extent of problematic use of methylphenidate, and (3) the impact of said recommendations being respected on the development of problematic consumption. We studied patients who were treated with methylphenidate in an academic child psychiatry department. We specifically developed a semistructured interview grid for this study. Both parents and children were interviewed. In almost three out of four cases, at least one recommendation had not been followed (52% of patients did not follow the recommendation of stopping use during weekends and holidays). We found an average of 1.6 (range, 0-5) recommendations that were not respected. In almost two out of three cases, the consumption of methylphenidate was problematic; for 40% of children, this meant the search for at least one effect other than the expected therapeutic effects, such as an intellectual, creative, or athletic boosting effect. Approximately one-third of parents also sought an effect other than therapeutic for their child. Conversely, if all of the prescription recommendations were followed, less problematic consumption was observed. Methylphenidate-based treatments must therefore be implemented after a specialist has evaluated the patient and be prescribed following the recommendations. In this context, the treatment's benefits are undeniable.

Mechanical ventilation and clinical practice heterogeneity in intensive care units: a multicenter case-vignette study

BACKGROUND

Observational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations.

METHODS

We conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated.

RESULTS

Forty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure.

CONCLUSIONS

Large clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.

Automated detection of patient-ventilator asynchrony: new tool or new toy?

Although severe patient-ventilator asynchrony is frequent during invasive and non-invasive mechanical ventilation, diagnosing such asynchronies usually requires the presence at the bedside of an experienced clinician to assess the tracings displayed on the ventilator screen, thus explaining why evaluating patient-ventilator interaction remains a challenge in daily clinical practice. In the previous issue of Critical Care, Sinderby and colleagues present a new automated method to detect, quantify, and display patient-ventilator interaction. In this validation study, the automatic method is as efficient as experts in mechanical ventilation. This promising system could help clinicians extend their knowledge about patient-ventilator interaction and further improve assisted mechanical ventilation.

Melanoma and rituximab: an incidental association?

Rituximab is an anti-CD20 monoclonal antibody increasingly used in haematology and rheumatology, but also in internal medicine and dermatology. It has a good tolerance profile without known increased risk of cancer. We report a case of nodular melanoma with a 4.8 mm Breslow thickness that appeared after 2 years of rituximab in a 45-year-old patient with non-Hodgkin lymphoma. Fifteen additional rituximab-associated melanoma cases in 13 patients have been identified in the literature and in the EudraVigilance database. These patients were treated for various indications and had melanomas, often aggressive, initially diagnosed at a metastatic stage in 31% of cases. Our work raises the question of rituximab accountability in melanoma onset in these immunosuppressed patients. A dermatological monitoring seems necessary in patients treated with rituximab, especially in case of risk factors for melanoma. In case of individual melanoma history, the benefit/risk ratio of initiating rituximab therapy should be carefully assessed.

Pharmacokinetics of ertapenem in burns patients

The aims of this study were to evaluate pharmacokinetic (PK) parameters of total and unbound ertapenem (ERT) in burns patients and to identify which covariates influence these PK parameters. ERT plasma concentrations were measured in burns patients (n = 8) who received a 0.5-h infusion of ERT (1000 mg) every 24 h. PK parameters were estimated by a non-compartmental approach and the influence of covariates was estimated by multivariate analysis using a population approach. Clearance (CL) and the volume of distribution (V) of total ERT were lower than the results for unbound ERT [CL, 22.2 ± 5.6 mL/min vs. 279.4 ± 208.2 mL/min; V, 9.7 ± 1.4L vs. 120.6 ± 130.6L (mean ± standard deviation)]. Creatinine clearance (CL(Cr)) and the burned surface area (BSA) were the covariates identified that significantly (P<0.01) affected the pharmacokinetics of total ERT [CL (L/h)=0.373 +{0.00666 x CL(Cr) (mL/min)}] and unbound ERT [peripheral volume of distribution (L) = 3.05 + {0.959 x BSA (% of the total body surface)}], respectively. The influences of albuminaemia, glomerular filtration and burn wound on ERT pharmacokinetics are proposed to explain these results. These first results support that the ERT plasma concentration should be closely monitored particularly for patients with high values of BSA and/or CL(Cr) to avoid suboptimal exposure.

Patient-ventilator asynchrony during noninvasive ventilation: a bench and clinical study

BACKGROUND

Different kinds of ventilators are available to perform noninvasive ventilation (NIV) in ICUs. Which type allows the best patient-ventilator synchrony is unknown. The objective was to compare patient-ventilator synchrony during NIV between ICU, transport—both with and without the NIV algorithm engaged—and dedicated NIV ventilators.

METHODS

First, a bench model simulating spontaneous breathing efforts was used to assess the respective impact of inspiratory and expiratory leaks on cycling and triggering functions in 19 ventilators. Second, a clinical study evaluated the incidence of patient-ventilator asynchronies in 15 patients during three randomized, consecutive, 20-min periods of NIV using an ICU ventilator with and without its NIV algorithm engaged and a dedicated NIV ventilator. Patient-ventilator asynchrony was assessed using flow, airway pressure, and respiratory muscles surface electromyogram recordings.

RESULTS

On the bench, frequent auto-triggering and delayed cycling occurred in the presence of leaks using ICU and transport ventilators. NIV algorithms unevenly minimized these asynchronies, whereas no asynchrony was observed with the dedicated NIV ventilators in all except one. These results were reproduced during the clinical study: The asynchrony index was significantly lower with a dedicated NIV ventilator than with ICU ventilators without or with their NIV algorithm engaged (0.5% [0.4%-1.2%] vs 3.7% [1.4%-10.3%] and 2.0% [1.5%-6.6%], P < .01), especially because of less auto-triggering.

CONCLUSIONS

Dedicated NIV ventilators allow better patient-ventilator synchrony than ICU and transport ventilators, even with their NIV algorithm. However, the NIV algorithm improves, at least slightly and with a wide variation among ventilators, triggering and/or cycling off synchronization.

Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator interaction during non-invasive ventilation delivered by face mask

PURPOSE

To determine if, compared to pressure support (PS), neurally adjusted ventilatory assist (NAVA) reduces patient-ventilator asynchrony in intensive care patients undergoing noninvasive ventilation with an oronasal face mask.

METHODS

In this prospective interventional study we compared patient-ventilator synchrony between PS (with ventilator settings determined by the clinician) and NAVA (with the level set so as to obtain the same maximal airway pressure as in PS). Two 20-min recordings of airway pressure, flow and electrical activity of the diaphragm during PS and NAVA were acquired in a randomized order. Trigger delay (T(d)), the patient's neural inspiratory time (T(in)), ventilator pressurization duration (T(iv)), inspiratory time in excess (T(iex)), number of asynchrony events per minute and asynchrony index (AI) were determined.

RESULTS

The study included 13 patients, six with COPD, and two with mixed pulmonary disease. T(d) was reduced with NAVA: median 35 ms (IQR 31-53 ms) versus 181 ms (122-208 ms); p = 0.0002. NAVA reduced both premature and delayed cyclings in the majority of patients, but not the median T(iex) value. The total number of asynchrony events tended to be reduced with NAVA: 1.0 events/min (0.5-3.1 events/min) versus 4.4 events/min (0.9-12.1 events/min); p = 0.08. AI was lower with NAVA: 4.9 % (2.5-10.5 %) versus 15.8 % (5.5-49.6 %); p = 0.03. During NAVA, there were no ineffective efforts, or late or premature cyclings. PaO(2) and PaCO(2) were not different between ventilatory modes.

CONCLUSION

Compared to PS, NAVA improved patient ventilator synchrony during noninvasive ventilation by reducing T(d) and AI. Moreover, with NAVA, ineffective efforts, and late and premature cyclings were absent.

Clinical review: Update on neurally adjusted ventilatory assist--report of a round-table conference

Conventional mechanical ventilators rely on pneumatic pressure and flow sensors and controllers to detect breaths. New modes of mechanical ventilation have been developed to better match the assistance delivered by the ventilator to the patient's needs. Among these modes, neurally adjusted ventilatory assist (NAVA) delivers a pressure that is directly proportional to the integral of the electrical activity of the diaphragm recorded continuously through an esophageal probe. In clinical settings, NAVA has been chiefly compared with pressure-support ventilation, one of the most popular modes used during the weaning phase, which delivers a constant pressure from breath to breath. Comparisons with proportional-assist ventilation, which has numerous similarities, are lacking. Because of the constant level of assistance, pressure-support ventilation reduces the natural variability of the breathing pattern and can be associated with asynchrony and/or overinflation. The ability of NAVA to circumvent these limitations has been addressed in clinical studies and is discussed in this report. Although the underlying concept is fascinating, several important questions regarding the clinical applications of NAVA remain unanswered. Among these questions, determining the optimal NAVA settings according to the patient's ventilatory needs and/or acceptable level of work of breathing is a key issue. In this report, based on an investigator-initiated round table, we review the most recent literature on this topic and discuss the theoretical advantages and disadvantages of NAVA compared with other modes, as well as the risks and limitations of NAVA.

Perception of non-invasive ventilation in adult Swiss intensive care units

The real utilisation scenario of non-invasive ventilation (NIV) in Swiss ICUs has never been reported. Using a survey methodology, we developed a questionnaire sent to the directors of the 79 adult ICUs to identify the perceived pattern of NIV utilisation. We obtained a response rate of 62%. The overall utilisation rate for NIV was 26% of all mechanical ventilations, but we found significant differences in the utilisation rates among different linguistic areas, ranging from 20% in the German part to 48% in the French part (p <0.01). NIV was mainly indicated for the acute exacerbations of COPD (AeCOPD), acute cardiogenic pulmonary edema (ACPE) and acute respiratory failure (ARF) in selected do-not-intubate patients. In ACPE, CPAP was much less used than bi-level ventilation and was still applied in AeCOPD. The first line interface was a facial mask (81%) and the preferred type of ventilator was an ICU machine with an NIV module (69%). The perceived use of NIV is generally high in Switzerland, but regional variations are remarkable. The indications of NIV use are in accordance with international guidelines. A high percentage of units consider selected do-not-intubate conditions as an important additional indication.

A statement on cefazolin immediate hypersensitivity: data from a large database, and focus on the cross-reactivities

BACKGROUND

More perioperative cefazolin use has resulted in an increased risk of cefazolin-associated reactions.

OBJECTIVE

The aim of this article is to study immediate reactions to cefazolin and attempt to determine possible allergic cross-reactivity with other ß-lactams using data from the Drug Allergy and Hypersensitivity Database (DAHD).

METHODS

All 25 cefazolin-associated reactions in the DAHD were reviewed. The cases identified were then investigated according to the European Network for Drug Allergy (ENDA) recommendations by skin testing and challenges.

RESULTS

A total of 10 individuals with proven IgE-mediated cefazolin hypersensitivity were identified between January 1999 and July 2009. All the index reactions were compatible with an acute IgE-mediated process, six with anaphylaxis, two with systemic allergic reactions without hypotension, and two with urticaria/angioedema. Cefazolin skin tests were positive in seven individuals and cefazolin challenges were positive in three more individuals. In the eight cefazolin allergic patients who had challenges with other ß-lactams, there was no positive reaction noted.

CONCLUSION AND CLINICAL RELEVANCE

In this cohort of patients with IgE-mediated reactions to cefazolin, a majority tolerated amoxicillin and several patients tolerated other cephalosporins. This implies that the R1 side-chain may play an essential role in IgE-mediated reactions to cefazolin. No clear rule to predict cross-reactivity with other ß-lactams could be determined. More research on IgE-mediated hypersensitivity to cefazolin and other cephalosporins is needed.