Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Aerosolized Plus Intravenous Polymyxin B Versus Colistin in the Treatment of Pandrug-Resistant Klebsiella Pneumonia-mediated Ventilator-Associated Pneumonia: A Retrospective Cohort Study in Bangladesh

Background

Pandrug-resistant Klebsiella pneumoniae ventilator associated pneumonia (VAP) is associated with high rate of mortality in intensive care unit (ICU) and has been recognized as a difficult-to-treat infection worldwide. Polymyxin B or colistin-based combination therapies are frequently used worldwide though microbial eradication rate is not promising.

Aim

The aim of this study is to compare the clinical outcome of intravenous with aerosolized polymyxin B versus colistin in the treatment of pandrug-resistant K. pneumoniae VAP.

Methods

This retrospective cohort study was conducted on 222 mechanically ventilated patients admitted from May 11, 2019 to October 19, 2020. K. pneumoniae isolates were resistant to all available antibiotics, including polymyxins in culture sensitivity tests. As treatment, polymyxin B and colistin was administered in intravenous and aerosolized form concurrently twice daily in 106 patients and 116 patients in PMB and CLN group, respectively for 14 days. Survival rate, safety, and clinical outcomes were compared among the groups. The Cox proportional-hazard model was performed to calculate hazard ratio (HR) with 95% confidence intervals (CI).

Results

Patients in PMB group showed more microbial eradication than the patients CLN group [68.1% (n=116)/83% (n=106), respectively; P <0.05). The median day of intubation and ICU stay in PMB group was shorter than that in CLN group [10 (IQR: 9-12.25) vs. 14 (IQR: 11-19), P <0.05; 12 (IQR: 10-14) vs. 15 (IQR: 9-18.5), P=0.072, respectively] with reduced 60-day all-cause mortality rate [15% (n=106) vs. 21.55% (n=116)]. Polymyxin B improved survival compared to colistin (multivariate HR: 0.662; 95% CI=0.359-1.222, P=0.195).

Conclusions

Concurrent administration of intravenous and aerosolized polymyxin B in patients with pandrug-resistant K. pneumoniae-associated VAP revealed better microbial eradication, reduced the length of intubation and ICU stay, and improved survival rate compared to colistin.

A226 EFFECT OF PHYSICAL ACTIVITY AMONG INDIVIDUALS WITH QUIESCENT OR MILDLY ACTIVE INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW

Background

Individuals with quiescent inflammatory bowel diseases (IBD) can continue to have several symptoms. Physical activity (PA) can improve immunological response and psychological health.

Purpose

We performed a systematic review of trials investigating the safety and efficacy of PA as an adjunct therapy to manage persistent symptoms in quiescent or mildly active IBD.

Method

We searched for randomised controlled trials (RCTs) and nonrandomised non-controlled trials (non-RCTs) in eight databases, trial registries and conference proceedings, published in English between 2011 and 2021. We focused on trials in adults (>18 years) using any form of PA as an adjunct therapy to medical therapy. Outcomes of interest were health-related quality of life, fatigue, joint pain, abdominal pain, stress, anxiety, and depression.

Result(s)

From 10,862 retrieved citations, we identified seven RCTs and one non-RCT that met our inclusion criteria. All trials deemed PA safe for individuals with quiescent or mildly active IBD. Clinical heterogeneity was noted among the trials for all outcomes. Six RCTs utilized parallel-group design while one utilized a cross-over design. Seven trials provided partially or fully supervised PA interventions, and one provided no supervision. All trials used different types of PA, which varied between running, resistance training, yoga, and aerobic exercises. The trials used different parameters to measure PA intensity including Peak Power Output, Resistance Intensity Scale for Exercise, percentage of maximum heart rate, ability to talk while running. Heterogeneity was noted in the duration and frequency of PA.

Conclusion(s)

Even though PA is safe for individuals with quiescent or mildly active IBD, heterogeneity in available trials make it difficult to ascertain precise estimates of treatment effect. This also presents a challenge when determining the specific modes of PA that are beneficial for individuals with quiescent or mildly active IBD. This highlights the need for standardization of the definitions of parameters involved in PA in IBD research.

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Disclosure of Interest

None Declared

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

Therapeutic safety and efficacy of triple-immunosuppressants versus dual-immunosuppressants in severe-to-critical COVID-19: a prospective cohort study in Bangladesh

BACKGROUND

Hyperinflammation-induced respiratory failure is a leading cause of mortality in COVID-19 infection. Immunosuppressants such as, Baricitinib and interleukin inhibitors are the drug-of-choice to suppress cytokine storm in COVID-19. Here, we compared the therapeutic safety and efficacy of triple-immunosuppressants with dual-immunosuppressants in patients with severe-to-critical COVID-19.

METHODS

This study was conducted on 103 confirmed COVID-19 patients. Of 103 patients, 49 (N) and 54 (N) patients received dual-immunosuppressants (baricitinib plus two doses of secukinumab) and triple immunosuppressants (baricitinib plus single dose of tocilizumab and secukinumab) in group A and group B, respectively. Groups were compared in terms of clinical outcome, critical support-requirement, survival, re-hospitalisation, and adverse events (AEs).

RESULTS

Patients in group B achieved normal blood oxygen saturation level (SpO₂) earlier than the patients of group A [4 day (IQR: 3-12) vs 5 day (IQR: 5-14), p < .05]. The requirement of intensive care unit (ICU) and mechanical ventilation (MV) support was less in group B than group A [16.7%/28.6%, 11.1%/18.4%, respectively p < .05]]. The incidence of COVID-19 acute respiratory distress syndrome and 60-day all cause mortality was reduced in group B compared to group A [0.43 (0.19-0.98), p < .05; 0.35 (0.08-1.44), p > .05]. The 60-day re-hospitalisation rate was two-fold high in group A than group B (p = .024). Immunosuppressant-associated adverse events and secondary bacterial/fungal infections were relative high in patients of group B.

CONCLUSIONS

Triple-immunosuppressants in severe-to-critical COVID-19 infection exhibited better clinical outcome; reduced ICU and MV requirement; shorter hospital stay with deceased 60-day all cause mortality and re-hospitalisation compared to dual-immunosuppressants.

Sepsis Management in Southeast Asia: A Review and Clinical Experience

Sepsis is a life-threatening condition that causes a global health burden associated with high mortality and morbidity. Often life-threatening, sepsis can be caused by bacteria, viruses, parasites or fungi. Sepsis management primarily focuses on source control and early broad-spectrum antibiotics, plus organ function support. Comprehensive changes in the way we manage sepsis patients include early identification, infective focus identification and immediate treatment with antimicrobial therapy, appropriate supportive care and hemodynamic optimization. Despite all efforts of clinical and experimental research over thirty years, the capacity to positively influence the outcome of the disease remains limited. This can be due to limited studies available on sepsis in developing countries, especially in Southeast Asia. This review summarizes the progress made in the diagnosis and time associated with sepsis, colistin resistance and chloramphenicol boon, antibiotic abuse, resource constraints and association of sepsis with COVID-19 in Southeast Asia. A personalized approach and innovative therapeutic alternatives such as CytoSorb® are highlighted as potential options for the treatment of patients with sepsis in Southeast Asia.

Neuroendocrine tumors and Survival- a meta-analysis

Introduction/Objective

Neuroendocrine tumors (NET) are a rare group of epithelial neoplasm present in gastrointestinal tract (GI) (67.5%), bronchopulmonary tree (25.3-30%) and in 15% cases primary sites cannot be identified. Although endoscopic screening, improvement in pathological techniques and early detection have shown improvement in NET survival rates, the prognosis is very poor. In this study we aimed to evaluate the effect of Gastrointestinal pancreatic NETs (GEP NETs) grade on overall survival.

Methods/Case Report

We searched observational studies describing the overall survival or prognostic factors of primary GEP NETs from May 2011 -May 2021 following PRISMA guidelines. Studies describing the effect of primary grade 3 GEP NETs on overall survival were included. Meta-analysis was performed and pooled hazard ratio and their 95% confidence interval (95%CI) were obtained. The forest plots were created using random effects models and sensitivity analysis was performed to account for the heterogeneity.

Results (if a Case Study enter NA)

Seven studies with 7692 confirmed patients were included. In our meta-analysis grade 3 GEP NET were associated with higher odds of poor survival (pooled HR: 2.73; 95% CI: 1.36–5.47; p = 0.005), with 92% heterogeneity between studies (p &lt; 0.0001). To account for heterogeneity, sensitivity analysis was performed by removing two outlying studies (Fathi et al. and Foubert et al.) on funnel plots. The results after sensitivity analysis did not change and still showed significant association of grade 3 with poor survival (pooled HR: 4.53; 95% CI: 3.54–5.78; p &lt; 0.00001), with no heterogeneity between studies (p = 0.72; I2 = 0%).

Conclusion

Our meta-analysis found that grade 3 GEP NETs is associated with poor survival and additional future studies are needed to identify other risk factors associated with poor survival in GEP NETs to improve the mortality.

Impact of high dose of baricitinib in severe COVID-19 pneumonia: a prospective cohort study in Bangladesh

PURPOSE

Hyperinflammation in severe COVID-19 infection increases the risk of respiratory failure and one of the cogent reasons of mortality associated with COVID-19. Baricitinib, a janus kinases inhibitor, can potentially suppress inflammatory cascades in severe COVID-19 pneumonia.

METHODS

The objective of this study was to compare the clinical outcomes of high dose of baricitinib with its usual dose in patients with severe COVID-19 pneumonia. This prospective cohort study was conducted on 238 adult patients with severe COVID-19 pneumonia. Eight milligram and 4 mg of baricitinib was given orally to 122 patients in the high dose (HD) group and 116 patients the usual dose (UD) group, respectively daily for 14 days, and clinical outcomes were compared among the groups.

RESULTS

Blood oxygen saturation level was stabilized (≥94% on room air) earlier in the HD group compared to the UD group [5 (IQR: 4-5)/8 (IQR: 6-9), P < 0.05]. Patients in the HD group required intensive care unit (ICU) and intubation supports more in the UD group than that in patients of the HD group [17.2%/9%, P < 0.05; 11.2%/4.1%, P > 0.05; N = 116/122, respectively]. The 30-day mortality and 60-day rehospitalization rate were higher in the UD group than the HD group [6%/3.3%, P < 0.01; 11.9%/7.6%, P > 0.05; N = 116/122, respectively].

CONCLUSION

The daily high dose of baricitinib in severe COVID-19 results in early stabilization of the respiratory functions, declined requirements of critical care supports, reduced rehospitalization with mortality rate compared to its daily usual dose.

Additional baricitinib loading dose improves clinical outcome in COVID-19

Pneumonia associated with coronavirus disease 2019 (COVID-19) has been accounted for high mortality rate in severe COVID-19 worldwide, and additional serious scarcity of standard and effective anti-inflammatory drug in COVID-19 pneumonia management is a big challenge. Baricitinib, a Janus kinase (JAK) inhibitor, is a promising drug in COVID-19 pneumonia. This study aims to compare the clinical outcome of moderate-to-severe COVID-19 pneumonia treated with baricitinib with or without a loading dose. This prospective case-control study enrolled 37 adult patients where 17 patients (control) received baricitinib at 4 mg oral daily dose and 20 patients (case) received an additional single 8 mg oral loading dose. The median day to gain blood oxygen saturation level ≥95% (in room air) and return in normal breathing function were lower in case group than the control group. The requirement of intensive care unit and mechanical ventilation support was higher in the control group than in the case group [29.4% (N = 17)/10% (N = 20), P < 0.05; 11.8% (N = 17)/5% (N = 20), P > 0.05), respectively]. Thus, an additional loading dose of baricitinib revealed better clinical outcome of patients with COVID-19 pneumonia.

Intravenous N-acetylcysteine in severe cutaneous drug reaction treatment: A case series

Drug-induced serious adverse reaction is an unpleasant event with high rate of mortality. Stevens-Johnson Syndrome and toxic epidermal necrolysis are most common among the serious adverse drug reactions. There is no selective drug therapy for the management of serious adverse drug reactions-associated mucocutaneous blisters. The use of N-acetylcysteine in the treatment of mucocutaneous blisters has limited evidence worldwide. Three cases of toxic epidermal necrolysis or Stevens-Johnson Syndrome-associated mucocutaneous blisters are presented in this study where intravenous N-acetylcysteine (600 mg, every 8 h) was given in early hospitalization hours for the treatment of mucocutaneous fluid-filled blisters. Here, one patient with toxic epidermal necrolysis received intravenous immunoglobulin along with intravenous N-acetylcysteine and the other two patients (toxic epidermal necrolysis/Stevens-Johnson Syndrome) received only N-acetylcysteine intravenously. In response, mucocutaneous fluid-filled blisters stopped progressing within 48 h and were healed within 2 weeks of admission in the intensive care unit. Thus, intravenous N-acetylcysteine with or without having intravenous immunoglobulin in the treatment of serious adverse drug reactions-associated mucocutaneous blisters may be an effective therapeutic option for better clinical outcome.

Extensive Pneumocephalus Caused by Multidrug-Resistant Klebsiella pneumoniae

Pneumocephalus is a life-threatening event associated with different infectious diseases and trauma. Klebsiella pneumoniae is a gas-forming organism that can cause pneumocephalus. A woman aged 56 years presented with a history of septic shock and community-acquired pneumonia. She was supported by mechanical ventilation in intensive care unit. Multidrug-resistant K. pneumoniae was detected in her blood and tracheal aspirate. Her level of consciousness reduced, and clinical condition was deteriorating. The computed tomography scan of the brain revealed abundant pneumocephalus entities. Multidrug-resistant K. pneumoniae was found in her cerebrospinal fluid while on appropriate antibiotic therapy. She died from acute stroke during her treatment.

A young adult with post-traumatic breathlessness, unconsciousness and rash

A 23-year-old Bangladeshi male was referred to our hospital for gradual worsening of breathlessness over 3 h, developed following a road-accident about 14 h previously. He had a close fracture of mid-shaft of his right tibia, which was immobilised with back slab at the previous healthcare facility. During presentation at the emergency department, he was conscious and oriented (Glasgow coma scale 15/15), tachycardic (heart rate 132 per min), blood pressure 100/70 mmHg, tachypnoeic (respiratory rate 34 per min) with oxygen saturation 89% on room air, and afebrile. Chest examination revealed restricted chest movement, hyper-resonant percussion notes and reduced breath sound on the left, and diffuse crackles on both sides.

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Pre-symptomatic targeted treatment of patent ductus arteriosus in preterm newborns: A systematic review and meta-analysis

BACKGROUND

A clinically significant patent ductus arteriosus (PDA) is associated with significant morbidity and mortality in premature newborns. Symptomatic PDAs are often treated with prostaglandin synthesis inhibitors (PSI), but controversy remains if PSIs should also be used to manage early, asymptomatic PDAs.

OBJECTIVE

To systematically identify, critically appraise, and evaluate the efficacy and safety of pharmacological management of pre-symptomatic PDA in preterm newborns after confirmed patency by echocardiography.

STUDY DESIGN

Systematic review and meta-analysis.

SEARCH METHODS

We searched MEDLINE (Ovid), EMBASE (Ovid), Cochrane Central Register of Controlled Trials (Wiley), from date of inception to February 2017. Supplemental searching was performed in Scopus and Web of Science to identify additional relevant citations. We also searched conference proceedings, reference lists of relevant articles and the WHO International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) that compared the use of indomethacin or ibuprofen to placebo for treatment of pre-symptomatic PDA in preterm newborns (<32 weeks gestational age and <1500gms).

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials, assessed risk of bias and extracted trial-level data. Outcomes are reported as risk ratios from random-effects models. Absolute risk reduction (ARR) is additionally reported for significant outcomes.We included seven trials (466 newborns). Targeted medical treatment did not significantly reduce mortality rates (RR 0.85, 95% CI 0.50 to 1.43; ARR -2.38%, 95% CI -8.04% to 3.29%; I2 0% 6 studies; 442 newborns), but it did significantly reduce the overall incidence of developing symptomatic PDA (RR 0.39, 95% CI 0.21 to 0.73; ARR -34.3%, 95% CI -50.8% to -17.8%; I2 0%; 3 studies; 97 newborns) compared to placebo. Other efficacy or safety outcomes were not significantly different.

CONCLUSIONS

Targeted medical treatment of pre-symptomatic PDA decreases the incidence of developing symptomatic PDA, but not neonatal mortality. Further studies are essential to confirm these results.

Bloodstream infection with pandrug-resistant Alcaligenes faecalis treated with double-dose of tigecycline

Introduction

Alcaligenes faecalis is a species of gram-negative, rod-shaped, aerobic bacteria commonly found in the environment. A. faecalis-associated nosocomial infections are common in hospitalized patients, but serious life threatening infections are rare. Here, we report a rare case of BSI with A. faecalis resistant to all available antibiotics; successfully treated with double-dose of tigecycline.

Presentation of case

A 60-year-old female presented with A. faecalis bloodstream infection, where the organism was completely resistant to all commercially available antibiotics including polymyxins and tigecycline. The physical condition of the patient was deteriorating and there were no active antibiotics available to prescribe based on sensitivities. Despite the organism's resistance to tigecycline, double-dose of tigecycline therapy (100 mg twice daily, intravenously after a 200 mg single intravenous loading dose) was prescribed intentionally for the treatment of this infection. The organism was completely eradicated from the bloodstream of that patient within the 5 days of therapy-initiation.

Discussion

Double-dose of tigecycline maintains a higher serum drug concentration rather than the standard dose, and in this case, double-dose of tigecycline completely cleared the pandrug-resistant A. faecalis from the blood where initially, that organism was resistant to tigecycline. Previously, A. faecalis isolates were found resistant to fluoroquinolones, but here it was found very rarely resistant to even reserve antibiotics, polymyxins, carbapenems and tigecycline.

Conclusion

Pandrug-resistant A. faecalis-associated bloodstream infection is a very uncommon case and double-dose of tigecycline may be an effective option to treat it.

Spontaneous calf haematoma in severe dengue

We report a case of spontaneous calf muscle haematoma, formed during the recovery phase of dengue haemorrhagic fever, which, to the best of our knowledge, has never been encountered before. A 45-year-old man presented with features of severe dengue and got admitted to our intensive care unit. He was treated with intravenous fluid therapy and supportive measures, and gradually improved, initially. However, during the recovery phase, he suddenly developed painful left calf, which was found tender, hot and swollen on physical examination. Colour Doppler ultrasound revealed left calf haematoma. As the patient rapidly developed local compartmental syndrome, surgical evacuation of the haematoma followed by urgent fasciotomy was performed. He recovered without further complication and was discharged home. At follow-up after 2 months, he remained well.

Expanded dengue syndrome: three concomitant uncommon presentations in the same patient

We report a case of expanded dengue syndrome, where three uncommon presentations occurred concomitantly. A patient with dengue haemorrhagic fever presented initially with acute acalculous cholecystitis along with acute pancreatitis, but later on, during resolution of pancreatitis and cholecystitis, developed pancytopenia, most likely due to haemophagocytic syndrome. Such presentations, besides being rare themselves, have not been reported to occur concomitantly, in the same patient, during the same disease process.

Vitamin D and Dental Caries in Children

The purpose of this study was to assess the relationship between vitamin D status and dental caries in Canadian school-aged children participating in the Canadian Health Measures Survey (CHMS). The CHMS was a national cross-sectional study involving physical assessments, laboratory analysis, and interviews. Analysis was restricted to data for 1,017 children 6 to 11 y of age. Outcome variables included the presence of caries and overall total caries score (dmft/DMFT index). Levels of 25-hydroxyvitamin D (25(OH)D) were measured from serum samples obtained from participants. Bivariate analysis, logistic regression for the presence of caries, and multiple linear regression for total caries scores were used. Significance was set at P ≤ 0.05. Overall, 56.4% of children experienced caries, and the mean dmft/DMFT score was 2.47 (95% CI 2.09 to 2.84). The unadjusted odds of children with 25(OH)D levels ≥75 nmol/L having experienced caries was 0.57 (95% CI 0.39 to 0.82), while the odds for caries at the ≥50 nmol/L level was 0.56 (95% CI 0.39 to 0.89). After controlling for other covariates, backward logistic regression revealed that the presence of caries was significantly associated with 25(OH) levels <75 nmol/L and <50 nmol/L, lower household education, not brushing twice daily, and yearly visits to the dentist. Similarly, multiple linear regression revealed that total dmft/DMFT caries scores were also associated with 25(OH)D concentrations <75 nmol/L, not brushing twice daily, lower household education, and yearly visits to the dentist. Data from a cross-sectional, nationally representative sample of Canadian children suggest that there is an association between caries and lower serum vitamin D. Improving children’s vitamin D status may be an additional preventive consideration to lower the risk for caries.

Subsequent pancreatitis and haemothorax in a patient of expanded dengue syndrome

We report a case of expanded dengue syndrome, where two different presentations occurred subsequently. A patient of dengue haemorrhagic fever initially was admitted with acute pancreatitis, complicated with left pancreatic effusion, but later on, during resolution of pancreatitis and effusion, developed spontaneous right haemothorax. Such presentations, besides being rare themselves, have not been reported to occur subsequently, in the same patient, during the same disease process.

Strategies to achieve coronary arterial plaque stabilization

Acute coronary syndromes result from fissure, erosion or rupture of a vulnerable atherosclerotic plaque. The characteristics of a vulnerable plaque include a large lipid pool, an abundance of inflammatory cells and mediators, a reduced smooth muscle cell and collagen content and a thin overlying fibrous cap. Potential therapeutic strategies at achieving plaque stabilization have targeted these features. Lipid lowering agents, beta-adrenergic blockers, angiotensin converting enzyme inhibitors and antioxidants have been shown to reduce the incidence of acute coronary syndromes, presumably through plaque stabilization. Matrix metalloproteinase inhibitors as well as macrolide antibiotics and gene therapy approaches show promise in achieving plaque stabilization. The evidence supporting plaque stabilization by these agents and the mechanisms by which these agents stabilize plaques are discussed in detail in this review.

Sorbitol, myo-inositol, and rod outer segment phagocytosis in cultured hRPE cells exposed to glucose. In vitro model of myo-inositol depletion hypothesis of diabetic complications

The "myo-inositol depletion hypothesis" remains a leading but still controversial contender among proposed pathogenetic mechanisms for the chronic complications of diabetes. The multifaceted interrelationships among altered tissue myo-inositol content and metabolism and tissue function have been difficult to elucidate in diabetic animal models due in part to the complex, heterogeneous nature of tissues prone to diabetic complications. The retinal pigment epithelium consists of a homogenous cell monolayer that exhibits related alterations in myo-inositol metabolism and function in diabetic animals. Nontransformed human retinal pigment epithelial (hRPE) cells, which retain their general phenotypic and morphological characteristics during monolayer culture in vitro, were examined for parallel alterations in myoinositol metabolism and cell function when grown under carefully controlled conditions in medium containing hyperglycemic concentrations of glucose. Exposure of hRPE cells to 20-40 mM glucose produced time- and dose-dependent increases in sorbitol content and decreases in myo-inositol content that were partially blocked by the aldose reductase inhibitor sorbinil. myo-Inositol was taken up by two Na-dependent transport systems, at least one of which was competitively inhibited by glucose. Exposure to 20 mM glucose impaired the ability of hRPE cells to take up human retinal rod outer segments, an important physiological function of these cells. The impairment of rod outer segment uptake by high glucose levels was prevented by an aldose reductase inhibitor or elevated medium myo-inositol that corrected the fall in myo-inositol content. Thus, hRPE cells provide a new in vitro model in which to examine the biochemical-functional interrelationships of the myo-inositol depletion hypothesis.

The effects of glaucoma medications on Tenon's capsule and conjunctiva in the rabbit

Glaucoma filtering surgery fails most frequently due to fibrosis at the episcleral-conjunctival/Tenon's capsule interface. Sherwood et al have suggested that chronic topical antiglaucoma medications increase conjunctival inflammatory cells, which could increase the likelihood of fibrosis and subsequent bleb failure. In a pilot study in a rabbit model, we placed timolol, pilocarpine, and epinephrine, or a combination of all three, in one eye of 24 animals twice daily for 7 months. The fellow eye received distilled water. Microscopic examination revealed no statistically significant change in the number of acute or chronic inflammatory cells, fibroblasts, or goblet cells in the treated as compared with the control eyes. A longer duration of drug administration, or drug administration followed by surgical intervention, may be required to produce an effect on the conjunctiva and Tenon's capsule, if such an effect exists.

Time course of thymoxamine reversal of phenylephrine-induced mydriasis

We conducted a randomized, double-masked, paired comparison of 0.1% thymoxamine vs placebo for the reversal of phenylephrine-induced mydriasis. Mydriasis was induced with 2.5% phenylephrine in each eye of 74 subjects (148 eyes). Each subject then received 0.1% thymoxamine in one eye and placebo in the other eye. Pupillary measurements were obtained at regular intervals during the ensuing 8 hours. At all intervals, a greater percentage of thymoxamine-treated eyes returned to baseline pupillary diameters compared with placebo-treated eyes (P less than or equal to .01). For subjects in whom both pupils returned to baseline, thymoxamine-treated eyes returned to baseline in a mean of 2.2 hours, vs 5.2 hours for placebo (P less than .0001). Among thymoxamine-treated eyes, those with light irides responded more rapidly than those with dark irides, returning to baseline in 1.6 vs 2.8 hours, respectively (P = .0046). After constriction to baseline pupillary diameter had been achieved, no patients experienced a rebound dilation.

Effects of pupillary dilation on automated perimetry in normal patients

The effects of pupillary dilation (tropicamide 1%) on automated static threshold perimetry were studied in 18 normal subjects using the Humphrey field analyzer 30-2 and STATPAC programs. The mean defect worsened by 0.83 decibels (standard deviation, 0.92 decibels) in dilated fields as compared with baseline visual fields (P = 0.001). These findings indicate that pupillary dilation in healthy subjects who are not receiving ocular medications produces statistically significant declines in threshold sensitivities. Valid comparison of results from serial visual field testing, therefore, depends on control of or adjustment for the effect of pupillary dilation.

Effects of pupillary constriction on automated perimetry in normal eyes

The authors studied the effects of pupillary constriction (pilocarpine 2%) on automated static threshold perimetry in 20 normal subjects using the Humphrey Field Analyzer 30-2 and STATPAC programs. The mean defect (MD) worsened by an average of 0.67 decibels (dB) (standard deviation, 0.67 dB) in constricted fields compared with baseline visual fields (P less than or equal to 0.001). Independent comparisons of the unweighted means of threshold values for the central 30 degrees, 24 degrees, and 10 degrees were also done and showed significant reductions in sensitivity after constriction (P less than or equal to 0.001). These findings indicate that changes in pupillary diameter may produce significant declines in threshold sensitivities and support the importance of consistent pupillary diameters on serial automated visual field examinations.

The effects of exercise on intraocular pressure in pigmentary glaucoma patients

Previous studies of normal volunteers and open-angle glaucoma patients have shown that exercise temporarily lowers intraocular pressure. However, two case reports have described pigmentary dispersion syndrome patients who developed symptomatic increased intraocular pressure after exercise. We evaluated the intraocular pressure response to exercise in ten pigmentary glaucoma patients. An exercise protocol was designed to increase the likelihood of lens zonule-iris pigment epithelium contact. Intraocular pressure measurements during the first two hours after exercise showed no statistically significant elevation of mean intraocular pressure. The pressure rose 6 mm Hg and 7 mm Hg respectively at 15 minutes in two eyes, but returned to baseline by 30 minutes. Our results suggest that exercise may not significantly increase the clinical intraocular pressure in pigmentary glaucoma patients.

Bone metastases in pheochromocytoma: comparative studies of efficacy of imaging

Bone is the most common site of metastasis from pheochromocytoma. Now that the effects of hypercatecholaminemia can be adequately controlled with adrenergic blockade, pathologic fractures are becoming an increasingly significant cause of morbidity in patients with metastatic pheochromocytoma. Bone metastases from pheochromocytoma have not been extensively reevaluated since the advent of computed tomography (CT), high-resolution bone scintigraphy, and iodine 131 MIBG scintigraphy. Plain radiographs, CT scans, bone scans, and I-131 MIBG scans of 38 patients with pheochromocytoma bone metastasis were reviewed. The axial skeleton was the most common site of metastasis. Metastases typically appeared expansile and mixed lytic-sclerotic on radiographs. Bone scintigraphy was the most sensitive modality for detecting bone metastasis, with 74% of all alleged lesions being identified. In screening for bone metastasis from pheochromocytoma, bone scanning in conjunction with I-131 MIBG scanning is recommended, followed by scan- and symptom-directed radiography and - where a question still exists - CT.

An analysis of "ablation of thyroid remnants" with I-131 in 511 patients from 1947-1984: experience at University of Michigan

Between January 1947 and June 1983, 511 patients were given treatment doses of I-131 after surgery for thyroid cancer in the presence of I-131 uptake in thyroid remnants. Thirty-four patients were removed from the study leaving 462 patients with a 99% follow-up at 1 or more yr, with a mean follow-up of 15 yr. Of 267 patients with radioiodine uptake confined to the thyroid bed, 233 (87%) had ablation from the first dose of I-131 ranging from 100 to greater than 200 mCi. The higher the percent uptake, the more difficult it was to achieve ablation. In the percentages of successful ablation, there were no significant differences between I-131 doses of: 100-149 mCi, 150-174 mCi, 179-199 mCi, and 200 mCi or more. The 100-149 mCi ablative dose may furnish "adjuvant" therapy for occult metastases.