Naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation: A retrospective, single-center cohort study

INTRODUCTION

There are few reports describing the association of naldemedine with defecation in critically ill patients with opioid-induced constipation. The purpose of this study was to determine whether naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation.

METHODS

In this retrospective cohort study, patients admitted to the Intensive Care Unit (ICU) without defecation for 48 hours while receiving opioids were eligible for enrollment. The primary endpoint was the time of the first defecation within 96 hours after inclusion. Secondary endpoints included presence of diarrhea, duration of mechanical ventilation, ICU length of stay, ICU mortality, and in-hospital mortality. The Cox proportional hazard regression analysis with time-dependent covariates was used to evaluate the association naldemedine with earlier defecation.

RESULTS

A total of 875 patients were enrolled and were divided into 63 patients treated with naldemedine and 812 patients not treated. Defecation was observed in 58.7% of the naldemedine group and 48.8% of the no-naldemedine group during the study (p = 0.150). The naldemedine group had statistically significantly prolonged duration of mechanical ventilation (8.7 days vs 5.5 days, p < 0.001) and ICU length of stay (11.8 days vs 9.2 days, p = 0.001) compared to the no-naldemedine group. However, the administration of naldemedine was significantly associated with earlier defecation [hazard ratio:2.53; 95% confidence interval: 1.71-3.75, p < 0.001].

CONCLUSION

The present study shows that naldemedine is associated with earlier defecation in critically ill patients with opioid-induced constipation.

Reducing the effect of immortal time bias affects the analysis of prevention of delirium by suvorexant in critically ill patients: A retrospective cohort study

BACKGROUND

Studies assessing the effect of suvorexant on delirium prevention included patients treated before development of delirium, which can introduce immortal time bias. The objective of the present study was to evaluate the effect of suvorexant on delirium, comparing patients treated before the onset of delirium with patients treated within 72h of admission using the same dataset.

METHODS

Data from adult patients admitted to the ICU from August 2018 to July 2021 were retrospectively analyzed. In "any time before" analysis, the incidence of delirium was compared for patients who received suvorexant at any time during their ICU stay (suvorexant) (unless delirium developed before treatment) with patients who either did not receive suvorexant or received suvorexant after development of delirium (control). This design was used in previously published studies. In "within 72h" analysis, the incidence of delirium was compared for patients who received suvorexant within 72 hours of admission (suvorexant) and patients who did not receive suvorexant or received it more than 72 hours after admission (control). Patients who developed delirium during the initial 72 hours were excluded from "within 72h" analysis (N = 799).

RESULTS

"Within 72h" analysis included 1,255 patients, and "any time before" analysis included 2,054 patients (of 6599 admissions). The unadjusted hazard ratio of "any time before" analysis was 0.16 and the 95% confidence interval was 0.13-0.21 (p<0.01). The adjusted hazard ratio was 0.21, and the 95% confidence interval was 0.16-0.27 (p<0.01). "Within 72h" analysis had an unadjusted hazard ratio of 0.54 and the 95% confidence interval was 0.36-0.82 (p<0.01). However, this association lost statistical significance after adjustment for potential confounders (adjusted hazard ratio 1.02, 95% confidence interval 0.65-1.59, p = 0.93).

CONCLUSION

Reducing the effect of immortal time bias led to a significantly reduced effect of suvorexant for the prevention of delirium.

ARDS Clinical Practice Guideline 2021

Background

The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021.

Methods

The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method.

Results

Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO₂ (PaO₂) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D).

Conclusions

This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00615-6.

ARDS clinical practice guideline 2021

BACKGROUND

The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021.

METHODS

The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method.

RESULTS

Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO₂ (PaO₂) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D).

CONCLUSIONS

This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Respiratory support strategy in adults with acute hypoxemic respiratory failure: a systematic review and network meta-analysis

Introduction

Network meta-analyses (NMAs) of respiratory management strategies for acute hypoxemic respiratory failure (AHRF) have been reported, but no previous study has compared noninvasive ventilation (NIV), high-flow nasal oxygen (HFNO), standard oxygenation therapy (SOT), and invasive mechanical ventilation (IMV) for de novo AHRF. Therefore, we conducted an NMA to assess the effectiveness of these four respiratory strategies in patients with de novo AHRF.

Methods

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults aged ≥18 years with AHRF and RCTs that compared two different oxygenation techniques (SOT, NIV, HFNO, or IMV) were selected. A frequentist-based approach with multivariate random-effects meta-analysis was used. The outcomes were mortality and intubation rates.

Results

Among the 14,263 records initially identified, 25 studies (3302 patients) were included. In the analysis of mortality, compared to SOT, NIV (risk ratio [RR], 0.76; 95% confidence interval [CI], 0.61–0.95) reduced mortality; however, IMV (RR, 1.01; 95% CI, 0.57–1.78) and HFNO (RR, 0.89; 95% CI, 0.66–1.20) did not. For assessments of the intubation incidence, compared to SOT, NIV use (RR, 0.63; 95% CI, 0.51–0.79) was associated with a reduction in intubation, but HFNO (RR, 0.82; 95% CI, 0.61–1.11) was not significant.

Conclusions

Our NMA demonstrated that only NIV showed clinical benefits compared with SOT as an initial respiratory strategy for de novo AHRF. Further investigation, especially comparison with HFNO, is warranted.

Trial registration

PROSPERO (registration number: CRD42020213948, 11/11/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40981-022-00525-4.

Association between timing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients: a multicenter retrospective cohort study

Background

Post-extubation dysphagia (PED) is recognized as a common complication in the intensive care unit (ICU). Speech and language therapy (SLT) can potentially help improve PED; however, the impact of the timing of SLT initiation on persistent PED has not been well investigated. This study aimed to examine the timing of SLT initiation and its effect on patient outcomes after extubation in the ICU.

Methods

We conducted this multicenter, retrospective, cohort study, collecting data from eight ICUs in Japan. Patients aged ≥ 20 years with orotracheal intubation and mechanical ventilation for longer than 48 h, and those who received SLT due to PED, defined as patients with modified water swallowing test scores of 3 or lower, were included. The primary outcome was dysphagia at hospital discharge, defined as functional oral intake scale score < 5 or death after extubation. Secondary outcomes included dysphagia or death at the seventh, 14th, or 28th day after extubation, aspiration pneumonia, and in-hospital mortality. Associations between the timing of SLT initiation and outcomes were determined using multivariable logistic regression.

Results

A total of 272 patients were included. Of them, 82 (30.1%) patients exhibited dysphagia or death at hospital discharge, and their time spans from extubation to SLT initiation were 1.0 days. The primary outcome revealed that every day of delay in SLT initiation post-extubation was associated with dysphagia or death at hospital discharge (adjusted odds ratio (AOR), 1.09; 95% CI, 1.02–1.18). Similarly, secondary outcomes showed associations between this per day delay in SLT initiation and dysphagia or death at the seventh day (AOR, 1.28; 95% CI, 1.05–1.55), 14th day (AOR, 1.34; 95% CI, 1.13–1.58), or 28th day (AOR, 1.21; 95% CI, 1.07–1.36) after extubation and occurrence of aspiration pneumonia (AOR, 1.09; 95% CI, 1.02–1.17), while per day delay in post-extubation SLT initiation did not affect in-hospital mortality (AOR, 1.04; 95% CI, 0.97–1.12).

Conclusions

Delayed initiation of SLT in PED patients was associated with persistent dysphagia or death. Early initiation of SLT may prevent this complication post-extubation. A randomized controlled study is needed to validate these results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03974-6.

Efficacy of non-invasive and invasive respiratory management strategies in adult patients with acute hypoxaemic respiratory failure: a systematic review and network meta-analysis

Background

Although non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure. In the previous meta-analyses, the effect of non-invasive ventilation was not evaluated according to ventilation modes in those patients. Furthermore, no meta-analyses comparing non-invasive respiratory management strategies with invasive mechanical ventilation (IMV) have been reported. We performed a network meta-analysis to compare the efficacy of non-invasive ventilation according to ventilation modes with high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and IMV in adult patients with AHRF.

Methods

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults with AHRF and randomized controlled trials (RCTs) comparing two different respiratory management strategies (continuous positive airway pressure (CPAP), pressure support ventilation (PSV), HFNO, SOT, or IMV) were reviewed.

Results

We included 25 RCTs (3,302 participants: 27 comparisons). Using SOT as the reference, CPAP (risk ratio [RR] 0.55; 95% confidence interval [CI] 0.31–0.95; very low certainty) was associated significantly with a lower risk of mortality. Compared with SOT, PSV (RR 0.81; 95% CI 0.62–1.06; low certainty) and HFNO (RR 0.90; 95% CI 0.65–1.25; very low certainty) were not associated with a significantly lower risk of mortality. Compared with IMV, no non-invasive respiratory management was associated with a significantly lower risk of mortality, although all certainties of evidence were very low. The probability of being best in reducing short-term mortality among all possible interventions was higher for CPAP, followed by PSV and HFNO; IMV and SOT were tied for the worst (surface under the cumulative ranking curve value: 93.2, 65.0, 44.1, 23.9, and 23.9, respectively).

Conclusions

When performing non-invasive ventilation among patients with de novo AHRF, it is important to avoid excessive tidal volume and lung injury. Although pressure support is needed for some of these patients, it should be applied with caution because this may lead to excessive tidal volume and lung injury.

Trial registration protocols.io (Protocol integer ID 49375, April 23, 2021). 10.17504/protocols.io.buf7ntrn.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03835-8.

Effect of skin antiseptic solutions on the incidence of catheter-related bloodstream infection: a systematic review and network meta-analysis

BACKGROUND

The most effective skin antiseptic solution to reduce the incidence of catheter-related bloodstream infections (CRBSI) remains unknown.

AIM

To compare solutions with different chlorhexidine (CHG)-based concentrations and povidone-iodine (PVI) in adults with a central venous catheter (CVC) or arterial catheter, and identify an association with the incidence of CRBSI.

METHODS

This study evaluated randomized controlled trials comparing CHG and PVI antiseptic agents in patients aged ≥18 years with an underlying illness and a CVC or arterial catheter. The primary outcome was CRBSI rate. Network meta-analysis was performed by a frequentist-based approach with multi-variate random effects meta-analysis, and the effect size was expressed as relative risk (RR) with 95% confidence interval (CI).

FINDINGS

The search yielded 1511 records, of which five studies (2815 catheters) were included in the network meta-analysis. The risk of CRBSI was significantly lower with 1% CHG-alcohol than with 0.5% CHG-alcohol (RR 0.40, 95% CI 0.16-0.98; high certainty) or 10% PVI-aqueous (RR 0.31, 95% CI 0.15-0.63; high certainty). There was no significant difference in the risk of CRBSI between 1% CHG-alcohol and 2% CHG-aqueous (RR 0.35, 95% CI 0.12-1.04; moderate certainty) or other antiseptic solutions. The hierarchy of efficacy in reducing CRBSI was 1% CHG-alcohol, 0.5% CHG-alcohol, 2% CHG-aqueous and 10% PVI-aqueous.

CONCLUSION

Antiseptic agents containing 1% CHG-alcohol were more strongly associated with reduced risk for CRBSI compared with agents containing 0.5% CHG-alcohol or 10% PVI-aqueous.

Validity of an under-mattress sensor for objective sleep measurement in critically ill patients: a prospective observational study

Background

Considering the adverse effects of sleep disturbance in critical care settings, accurate assessment could aid therapy; however, methodological inadequacies mean that no viable option is currently available. Research in healthy population has recently shown that a non-wearable sleep measurement device placed under the mattress of the bed could be beneficial in intensive care settings. Therefore, we aimed to validate this device compared with polysomnography (PSG) and to assess how it related to subjective sleep evaluations.

Methods

This observational study measured the sleep of critically ill adult patients. The primary goal was to validate the Nemuri SCAN (NSCAN; Paramount Bed Co., Ltd., Tokyo, Japan) against the reference standard PSG for 24 h. The secondary goal was to evaluate the association between the objective parameters obtained from NSCAN and PSG and the subjective report data obtained using the Richards–Campbell Sleep Questionnaire (RCSQ) for the nighttime.

Results

Eleven participants were evaluated. The median of the total sleep time scored by PSG was 456.0 (353.0–517.5) min during the nighttime and 305.0 (186.2–542.5) min during the daytime. PSG over 24 h revealed significant decreases in restorative sleep, with excessive daytime sleep, but with a normal quantity of nighttime sleep. The agreement, sensitivity, and specificity rates (with 95% confidence intervals) for the NSCAN compared with PSG were 68.4% (67.9–69.0%), 90.1% (89.7–90.6%), and 38.7% (37.9–39.7%), respectively. The median RCSQ value when subjectively evaluating nighttime sleep was 68.0 (26.3–83.5); this showed no correlation with the NSCAN sleep parameters, despite a positive correlation with the ratio of the stage N2 isolated or combined with restorative sleep in the PSG assessment.

Conclusions

NSCAN had moderate agreement, high sensitivity, and poor specificity in intensive care settings, which is most likely due to its inability to identify immobile wakefulness often observed in critically ill patients or sleep depth. This remains a barrier to its use in the assessment of subjective sleep quality.

Trial registration

This investigation was part of an interventional trial registered with the University Hospital Medical Information Network Individual Clinical Trials Registry (UMIN000026350, http://www.umin.ac.jp/icdr/index-j.html) on March 1, 2017.

P6466Novel index with combined echocardiographic parameter and CT parameter (pPAT) is useful for screening pulmonary hypertension in Systemic Sclerosis Patients

Background

Systemic sclerosis (SSc) patients with pulmonary arterial hypertension (PAH) had poor survival rate. Usual index of estimating PH is tricuspid regurgitate jet pressure gradient (TRPG). Accurate assessment of PAH is important for the management of SSc patients. However, estimated mean pulmonary arterial pressure (mPAP) using TRPG by echocardiography does not always reflect actual mPAP by right heart catheterization (RHC) in SSc patients. On the other hand, recent reports have shown that rPA, a ratio of diameter of pulmonary artery to ascending aorta (PA/Ao) calculated by computed tomography (CT), was associated with mPAP. However, both index are not sufficient for evaluation of PH. We hypothesized that the product of TRPG and rPA (pPAT) could estimate mPAP of SSc patients more accurately than TRPG or rPA.

Purpose

We investigated the usefulness of the product of TRPG and rPA for detecting actual mPAP in SSc patients.

Methods

Thirty-six SSc patients who suspected PH were enrolled retrospectively. We defined PH as resting mPAP from RHC of >25 mmHg. We measured both a widest pulmonary artery diameter and an adjacent ascending aorta diameter at the same level of the bifurcation of the main pulmonary artery using CT images.

Results

The average age was 67 years old and average mPAP by RHC was 24.7 mmHg. Mean TRPG and mean rPA were 35.1 mmHg and 1.06, respectively. Furthermore, mean pPAT was 37.9. We found pPAT had a stronger correlation with actual mPAP (r=0.848, p<0.001) than TRPG (r=0.754, p<0.001) or rPA (r=0.584, p<0.001). On ROC analysis, pPAT predicted PH with high accuracy for a cut-off of 33.1. In order to evaluate the usefulness of pPAT, we compared false-negative patients between two cutoff values of TRPG 34 mmHg described in ESC guideline and pPAT 33.1. Among the patients with TRPG <34mmHg, 4 patients (18%) had PH. In contrast, when screening PH using pPAT, the diagnosis of PH was missed in only one patient.

Figure 1

Conclusion

The product of TRPG and PA/Ao (pPAT) could be a novel and useful noninvasive index for identifying PH in SSc patients.

P5974Prognostic value of global tangential strain by three-dimensional echocardiography heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy

Background

In the current clinical guidelines, cardiac resynchronization therapy (CRT) is recommended in heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms as Class I indication. In terms of HF patients with intermediate ECG criteria, prediction for benefit of CRT is still controversial in routine echocardiography.

Purpose

The aim was to assess whether three-dimensional (3D) echocardiographic indexes of global LV function at baseline has a prognostic value following CRT implantation in patients who fulfilled with intermediate ECG criteria.

Methods

We studied 62 HF patients who fulfilled with the indication criteria of CRT implantation according to current the clinical guidelines. In addition to routine two-dimensional echo, 3D echo dataset was acquired for determination of 3D global tangential strain (GTS) and 3D global longitudinal strain (GLS). We tracked predefined unfavorable outcomes for 3 years after CRT implantation: death, hospitalization due to worsening HF.

Results

LBBB with QRS width ≥150ms was evident in 26 of 62 patients (aged 68±11 years with 160±26 ms of QRS duration and 29±7% of LV ejection fraction), and the other 36 patients only fulfilled intermediate ECG criteria (QRS width 120–149ms or non-LBBB). Unfavorable events occurred in 21 patients (34%). The median GTS was −15.4%. Although GLS was not predictive, GTS greater than −15.4% had high probability of unfavorable outcomes over 3 years (Log-rank, p<0.05). There is no difference in the probability of unfavorable outcomes between LBBB and intermediate ECG criteria. Baseline GTS in patients with intermediate ECG criteria was associated with unfavorable outcomes: −12.6±2.6% vs. −17.3±3.8% (p<0.05). Outcome was better in the intermediate ECG criteria patients with GTS ≤−15.4% than in those with LBBB and in those with intermediate ECG criteria patients with GTS >−15.4% (Log-rank: p<0.05, p<0.0001, respectively).

Conclusions

Baseline GTS by 3D echocardiography is useful for predicting outcome over 3 years after CRT implantation regardless of the ECG criteria for CRT indication.

Suvorexant is associated with a low incidence of delirium in critically ill patients: a retrospective cohort study

BACKGROUND

Benzodiazepine use is a risk factor for the development of delirium in adult intensive care unit (ICU) patients. Suvorexant is an alternative to benzodiazepines to induce sleep, but the incidence of delirium in critically ill patients is unknown. We undertook this retrospective study to investigate the incidence of delirium in patients who receive suvorexant in the ICU.

METHODS

This retrospective cohort study was conducted in a closed 12-bed ICU at a tertiary teaching hospital. Patients admitted to the ICU for 72 h or longer between January and June 2015 were evaluated for delirium using the Confusion Assessment Method for the Intensive Care Unit tool. We evaluated the incidence of delirium in patients who received suvorexant and those who did not. To adjust for confounding factors, multivariable logistic regression analysis was conducted.

RESULTS

Study subjects included 118 patients, with a median age of 72 years and a median Acute Physiology and Chronic Health Evaluation II score of 18 points. Eighty-two patients (69.5%) were admitted after cardiovascular surgery. In the suvorexant group, there were fewer post-cardiovascular surgical patients and more medical patients. The duration of mechanical ventilation during ICU stay was longer in the suvorexant group, and sedatives and sleep inducers other than suvorexant were used more frequently in the suvorexant group. The incidence of delirium was 43.8% in the suvorexant group and 58.8% in the non-suvorexant group (P = 0.149). After adjustment for risk factors using multivariable logistic regression analysis, suvorexant was associated with a lower incidence of delirium (odds ratio = 0.23, 95% confidence interval: 0.07-0.73; P = 0.012).

CONCLUSIONS

Suvorexant was associated with decreased odds of transitioning to delirium in critically ill patients. The use of suvorexant may lower the incidence of delirium in ICU patients. Future prospective studies are warranted.

Interruption of enteral nutrition in the intensive care unit: a single-center survey

BACKGROUND

Interruption of enteral nutrition (EN) in the intensive care unit (ICU) occurs frequently for various reasons including feeding intolerance and the conduct of diagnostic and therapeutic procedures. However, few studies have investigated the details of EN interruption practices including reasons for and duration of interruptions. There is no standard protocol to minimize EN interruptions.

METHODS

This is a retrospective review of 100 patients in the ICU staying more than 72 h and receiving EN in a 12-bed, medical/surgical ICU in a tertiary care center in 2013. Data collected include total time designated for EN; the number of EN interruption episodes; reason for each interruption categorized as diagnostic study, therapeutic intervention, or gastrointestinal (GI) event, and their individual subcategories; duration of each interruption; and the presence of written orders for interruptions.

RESULTS

One hundred patients staying in the ICU for at least 72 h and receiving EN were included. There were 567 episodes of EN interruption over a median ICU length of stay of 17.1 (interquartile range 8.0-22.0) days. There were a median of three EN interruption episodes per patient. EN interruption was performed for undetermined reasons (166 episodes, 29%), airway manipulation (103 episodes, 18%), GI events (78 episodes, 14%), and intermittent dialysis (71 episodes, 13%). Median duration of EN interruption in all patients was 5.5 (3.0-10.0) h. The cumulative interruption time corresponds to 19% of the total time designated for EN. Duration of EN interruption varied according to reason, including airway manipulation (9.0 [5.0-21.0] h), tracheostomy (9.5 [7.5-14.0] h), and GI events (6.5 [3.0-14.0] h). The average calorie deficits due to interruptions were 11.5% of daily target calories. Only 60 episodes (12%) had clear written orders for interruption.

CONCLUSIONS

Based on this single-center retrospective chart review, interruption of EN in the ICU is frequent, reasons for and duration of interruption varied, and airway procedures are associated with a relatively longer duration of interruption. Documentation and orders were frequently missing. These results warrant development of a protocol for EN interruption.

Motor and cognitive function analysis for home discharge using the Functional Independence Measure in patients undergoing cardiac rehabilitation at a long-term acute-care hospital

BACKGROUND

Although numerous studies on Functional Independence Measure (FIM) analysis in stroke, orthopedic disease, and spinal cord injury patients have been conducted, it has rarely been done in patients undergoing cardiac rehabilitation (CR).

AIM

To verify whether the Functional Independence Measure (FIM) score, and its subscale motor FIM and cognitive FIM, during inpatient CR can be a predictor of a patient's readiness for home discharge by establishing an FIM cutoff value.

DESIGN

A retrospective, observational cohort study

SETTING

This study was conducted at a long-term acute-care hospital.

POPULATION

Participants were in-hospital patients undergoing CR (N.=949).

METHODS

Measurements included motor FIM, cognitive FIM, CR period, FIM gain per week, and discharge disposition. The strongest predictor for home discharge was analyzed by using multiple logistic regression analysis, and the cutoff value of the FIM score for home discharge was determined by using receiver operating characteristic (ROC) curves.

RESULTS

Discharge to home was possible in 723 patients (76.2%), whereas 226 patients (23.8%) had other outcomes. In univariate analysis, a motor FIM gain per week of five points was achieved in the home discharge group. Multiple logistic regression analysis revealed that Body Mass Index, number of comorbidities, motor FIM at discharge, cognitive FIM gain, and CR period were predictive factors with 89.6% predictive ability. ROC curve analysis showed that the cutoff value was a discharge motor FIM score of 63/64 points with 0.912 areas under the curve.

CONCLUSION

Discharge motor FIM and cognitive FIM gain were predictive factors for home discharge. A motor FIM gain per week of five points and discharge motor FIM score of 64 points at the end of inpatient CR may be important predictors of a patient's readiness for discharge to home.

CLINICAL REHABILITATION IMPACT

The findings of this study indicate an alternative goal to the activities of daily living in inpatients with cardiovascular disease.

[Autopsy case of light chain deposition disease presented by nephrotic syndrome]

An eighty-one-year-old male with lower leg edema and proteinuria was diagnosed as having nephrotic syndrome and was hospitalized for a detailed examination. Kidney biopsy and immunostaining revealed nodular glomerulosclerosis and deposition of lambda chains, respectively. Because these findings indicate the occurrence of light chain deposition disease (LCDD), the underlying disease was found to be multiple myeloma BJ-lambda. After the administration of melphalan and prednisolone, followed by further addition of zoledronic acid, the patient's nephrosis remitted. However, renal dysfunction gradually deteriorated further and hemodialysis was instituted. He eventually died of gastrointestinal bleeding and biliary infection. The period of time from the initial diagnosis to death was thirty months. Autopsy revealed pervasive infiltration of plasma cells and light chain deposition in multiple organs. The uncontrollable gastrointestinal bleeding appears to have been caused by light chain deposition in the vascular walls of a bile duct. Although medical treatment for elderly LCDD cases depends on chemotherapy alone, it is difficult to obtain a complete remission with melphalan and prednisolone, according to the literature. Reports on the validities of biological agents, such as bortezomib, are beginning to appear, and accumulation of further therapeutic experience is eagerly awaited.

Chronic toxicity and carcinogenicity of N-[N-[3-(3-hydroxy-4-methoxyphenyl) propyl]-α-aspartyl]-L-phenylalanine 1-methyl ester, monohydrate (advantame) in the rat

Groups of 55 male and 55 female Han Wistar rats were administered advantame (98.9-99.8% purity) in the diet at concentrations of 0, 2000, 10,000, or 50,000 ppm for 104 weeks, following parental exposure to the same levels from prior to mating and throughout gestation. Additional groups of 20 rats/sex and 10 rats/sex were dosed for a period of 52 weeks and constituted the toxicity and reversibility phases of the study. Achieved doses of advantame over the carcinogenicity study were 0, 97, 488, and 2621 mg/kg body weight/day in males and 0, 125, 630, and 3454 mg/kg body weight/day in females, respectively. A high incidence of a pale and swollen anus and changes in fecal composition were observed in the high-dose groups. There was no effect of treatment on mortality. Body weight gain in the high-dose males (50,000 ppm) was slightly reduced compared to controls after 52 and 104 weeks of treatment; the decrease was not considered to be of toxicological significance, but due to the non-nutritive nature of the high dietary concentration of advantame. During the toxicity phase, food conversion efficiency was slightly decreased in both sexes, at the 50,000 ppm dose level. Given the non-nutritive content of the diet, this finding was not considered biologically significant. There were no relationships between treatment and the results of hematological or urinalysis investigations. Clinical chemistry evaluations showed consistently lower plasma urea concentrations in both sexes treated at 50,000 ppm, which was reversed during the 6-week recovery phase following 52 weeks of treatment, indicating a lack of permanent effects. Terminal investigations at both the 52 and 104-week revealed a number of intergroup differences in absolute and/or relative organ weights; however, the differences did not show dose-response relationships, were minor in nature, and/or occurred only in one sex, and were not associated with any pathological findings, and they were considered not to be treatment-related. Evaluation of the histopathology of the carcinogenicity phase animals revealed an increased incidence of pancreatic islet cell carcinomas in males (incidence rates of 0/55, 1/55, 2/55, and 3/55 in the 0, 2000, 10,000, or 50,000 ppm groups, respectively) and of mammary gland adenomas in the high-dose females (incidence rates of 0 in the control through 10,000 ppm dose groups and 4/41 in the 50,000 ppm dose group). The incidence rates of these tumors did not attain statistical significance and/or remained within background historical control values, and they were considered to be unrelated to advantame treatment. The no-observed-adverse-effect level was considered to be 50,000 ppm in the diet, the highest concentration tested, equivalent to 2621 and 3454 mg/kg body weight/day in males and females, respectively. Advantame was concluded to be without carcinogenic activity.

In vitro and in vivo assessment of the mutagenic activity of N-[N-[3-(3-hydroxy-4-methoxyphenyl) propyl]-α-aspartyl]-L-phenylalanine 1-methyl ester, monohydrate (advantame)

Advantame (N-[N-[3-(3-hydroxy-4-methoxyphenyl) propyl]-α-aspartyl]-L-phenylalanine 1-methyl ester, monohydrate), an N-substituted analogue of aspartame, has been developed as a high-intensity sweetener. It is approximately 100 and 20,000 times sweeter than aspartame and sucrose, respectively. In this study the safety of advantame has been evaluated using a series of in vitro and in vivo genotoxicity assays including, bacterial mutation, mammalian cell mutation, and mouse micronucleus tests. Advantame did not induce reverse mutations in Salmonella typhimurium and Escherichia coli at concentrations of up to 5000 μg/plate. In the mammalian cell mutation assay, advantame did not induce mutation at the Hprt locus of L5178Y mouse lymphoma cells in two independent experiments, either in the absence or presence of S9. In vivo, there was no effect on the incidence of micronucleated immature or mature erythrocytes in bone marrow after oral administration of the test substance at any dose level (up to 2000 mg/kg body weight) or sampling time (24 and 48 h). The results of these studies demonstrate that advantame is without genotoxic potential.

A two-generation reproductive toxicity study of the high-intensity sweetener advantame in CD rats

Rats received diets containing 0, 2000, 10,000, or 50,000 ppm advantame (N-[N-[3-(3-hydroxy-4-methoxyphenyl) propyl]-α-aspartyl]-L-phenylalanine 1-methyl ester, monohydrate) for 2 generations. F(0) animals (30/sex/group) were treated from 10 weeks before pairing. Males continued until week 16; females through gestation and lactation. Once weaned, F(1) animals (25/sex/group) continued receiving the same diet until F(2) pups were weaned. Mean advantame intakes from each of the diets were 164, 833, and 4410 mg/kg bw/day among F(0) males, and 204, 1036, and 5431 mg/kg bw/day among F(1) males. F(0) and F(1) females had comparable intakes up to lactation, when intakes increased (up to 8447 mg/kg bw/day from 50,000 ppm diet). No treatment-related effects on mortality, body weights, reproduction, litter observations, or postnatal offspring development were noted. Atypical coloration of the feces and cage liners seen with test diets was attributed to excretion of test material/metabolites in the feces and urine. Slightly higher food consumption was seen in F(0) and F(1) animals, especially males, receiving 50,000 ppm. However, these differences were considered to be a secondary response to the high levels of non-nutritive material in the diet. The no-observed-adverse-effect level for reproductive and developmental toxicity was considered to be 50,000 ppm, the highest dietary concentration tested.

Pressure-derived collateral flow index as a parameter of microvascular dysfunction in acute myocardial infarction

OBJECTIVES

The goal of this study was to examine the implications of the pressure-derived collateral flow index (CFIp) in acute myocardial infarction (AMI).

BACKGROUND

Higher CFIp is associated with less severe myocardial ischemia during angioplasty in the non-infarcted heart. It remains unknown whether CFIp also identifies collateral function in AMI patients with and without no-reflow phenomenon.

METHODS

The study population included 48 patients with a first AMI. After successful percutaneous transluminal coronary angioplasty (PTCA) stent, we measured mean aortic pressure (Pa), central venous pressure (Pv) and coronary wedge pressure (Pcw) of the infarct-related artery to calculate: CFIp = (Pcw - Pv)/(Pa - Pv). Myocardial contrast echocardiography (MCE) was performed with the intracoronary injection of microbubbles to assess myocardial perfusion. Left ventriculograms at days 1 and 28 were provided for the measurement of the regional wall motion (RWM, SD/chord).

RESULTS

There was no difference in CFIp among subsets based on angiographic collateral grades (grade 0, 1, 2, 3; 0.28 +/- 0.07, 0.27 +/- 0.09, 0.27 +/- 0.08, 0.23 +/- 0.08, p = NS). The CFIp was significantly higher in patients with MCE no-reflow (n = 16) than in those with MCE reflow (n = 32) (0.34 +/- 0.07 vs. 0.23 +/- 0.06, p < 0.01). There was a significant inverse correlation between the extent of functional improvement (DeltaRWM[28 d-1 d]) and CFIp (r = 0.56, p < 0.01), implying that higher CFIp is associated with worse functional improvement.

CONCLUSIONS

In AMI, CFIp is unlikely to reflect collateral function but seems to increase with the severity of microvascular dysfunction. Because higher CFIp was associated with poorer functional recovery, it provides a simple and useful estimate of clinical outcomes in AMI.

Long-term administration of amlodipine prevents decompensation to diastolic heart failure in hypertensive rats

OBJECTIVES; We assessed the effects of long-term amlodipine administration in a diastolic heart failure (DHF) rat model with preserved systolic function as well as the relationship between changes in left ventricular (LV) myocardial stiffening and alterations in extracellular matrix.

BACKGROUND

Although the effect of long-term administration of amlodipine has been shown to be disappointing in patients with systolic failure, the effect is unknown in those with DHF.

METHODS

Dahl salt-sensitive rats fed a high-salt diet for seven weeks were divided into three groups: eight untreated rats (DHF group), eight rats given high-dose amlodipine (10 mg/kg/day; HDA group) and seven rats given low-dose amlodipine (1 mg/kg/day; LDA group).

RESULTS

High-dose administration of amlodipine decreased systolic blood pressure and controlled excessive hypertrophy, without a decrease in the collagen content, and prevented the elevation of LV end-diastolic pressure at 19 weeks. Low-dose administration of amlodipine with subdeppressive effects did not control either hypertrophy or fibrosis; however, it prevented myocardial stiffening and, hence, the elevation of LV end-diastolic pressure. The ratio of type I to type III collagen messenger ribonucleic acid levels was significantly lower in both the HDA and LDA groups than in the DHF group.

CONCLUSIONS

Long-term administration of amlodipine prevented the transition to DHF both at the depressor and subdepressor doses. Amlodipine did not decrease the collagen content, but attenuated myocardial stiffness, with inhibition of the phenotype shift from type III to type I collagen. Thus, amlodipine may exert beneficial effects through amelioration of collagen remodeling in the treatment of DHF.

Ventricular production of natriuretic peptides and ventricular structural remodeling in hypertensive heart failure

OBJECTIVES

Brain natriuretic peptide (BNP) is a strong predictor of left ventricular (LV) hypertrophy (LVH) and dysfunction. However, our recent studies suggested that LVH is not necessarily associated with enhanced production of BNP in hypertension. This study aimed to clarify the relation of the characteristics of hypertrophy with the degree of gene expression of BNP in the developmental process of hypertensive heart failure.

METHODS

Serial changes in LV geometry, histology and atrial natriuretic peptide (ANP) and BNP mRNA levels, were assessed in a hypertensive heart failure model using Dahl salt-sensitive rats (n = 24). We further studied effects of alpha1-receptor antagonist (doxazosin: 1 mg/kg per day, n = 5) and angiotensin II type 1 receptor (AT1R) antagonist (candesartan cilexetil: 1 mg/kg per day, n = 5).

RESULTS

The BNP mRNA level was not elevated at the compensatory hypertrophic stage when ANP mRNA level was elevated. BNP mRNA level was increased with further progression of hypertrophy and development of fibrosis. AT1R blockade prevented such fibrosis and further progression of hypertrophy with normalization of BNP mRNA levels. Compensatory hypertrophy was not suppressed; therefore, ANP mRNA level, although decreased, was still beyond the normal level. The alpha1-receptor blockade slightly attenuated LV hypertrophy with a slight decrease in ANP mRNA levels. LV fibrosis was not prevented, and the BNP mRNA level was not decreased.

CONCLUSIONS

BNP gene expression is not enhanced by initial compensatory hypertrophy, but is enhanced by LV fibrosis and late stage progression of hypertrophy dependent on AT1R-mediated signaling pathway.

[Anesthetic management of a patient with Dyggve-Melchior-Clausen syndrome]

The Dyggve-Melchior-Clausen syndrome (DMCS) is a rare autosomal recessive skeletal dysplasia characterized by short-trunk dwarfism and mental retardation. A 49-year-old male with DMCS underwent resection arthroplasty for contracture of the right hip joint under general anesthesia using thiamylal, nitrous oxide, sevoflurane, and vecuronium. Although he was assumed to have difficult airway due to short neck, macroglossia, and disturbance of neck flexion, tracheal intubation was not difficult. No complications including malignant hyperthermia were observed during the 95 min of the operation.

Dynamic change in collateral flow associated with myocardial ischemia in humans

BACKGROUND

This study sought to investigate how collateral flow changes during myocardial ischemia in patients.

METHODS

Myocardial contrast echocardiography (MCE) and rapid atrial pacing were performed in 20 patients with angiographically evidenced coronary collaterals from the right coronary artery (RCA) to the occluded left anterior descending coronary artery. Sonicated contrast medium was injected into the RCA before and immediately after atrial pacing to determine the peak background-subtracted contrast intensity (PI) in the collateral territory (PIA) and its ratio to PI in the control territory (PI ratio) as parameters of collateral blood flow. Lactate production in the coronary circulation during pacing was determined to assess myocardial ischemia in the collateral territory.

RESULTS

PIA showed a significant correlation with regional wall motion either before (r(squared)=-0.64, P<0.01) or after pacing (r(squared)=-0.65, P<0.01). Similarly, PI ratio was significantly correlated with regional wall motion either before (r(squared)=-0.54, P<0.05) or after pacing (r(squared)=-0.64, P<0.01). Rapid atrial pacing decreased both PIA and PI ratio significantly greater in patients with lactate production than in those without (PIA: -67+/-53 vs. -15+/-34%, P<0.05; PI ratio: -68+/-49 vs. -8.2+/-32%, P<0.05, respectively), while neither PIA nor PI ratio differ between the two groups of patients before pacing (PIA: 13.8+/-19. vs. 16.2+/-13.3U, P=0.75; PI ratio: 0.70+/-0.71 vs. 0.87+/-0.65, P=0.58, respectively).

CONCLUSIONS

We concluded that (1) collateral flow determined by MCE was closely associated with regional cardiac function, and (2) not the amount of collateral flow at rest, but pacing-induced change of collateral flow seemed to be a determinant of regional ischemia in patients with coronary collaterals.

Determination of coronary zero flow pressure by analysis of the baseline pressure-flow relationship in humans

The present study seeks to estimate the difference between coronary zero flow pressure (Pzf) by analysis of the baseline pressure-flow relationship and the Pzf calculated during a long diastole in humans. Although Pzf is likely to provide meaningful information about the characteristics of coronary circulation, there are no available data on Pzf in humans because Pzf is overestimated when it is calculated during normal cardiac cycles. Actual Pzf was determined in 15 subjects by analyzing the coronary pressure-flow relationship during a long cardiac cycle induced by an intracoronary adenosine triphosphate (ATP) infusion, and it was compared with the Pzf calculated during a normal cardiac cycle in order to estimate the difference. Pzf calculated during a normal cardiac cycle was 47 +/- 15 mmHg, which decreased to 36 +/- 9mmHg after intracoronary administration of ATP (0.05 mg) whereas actual Pzf was 21 +/- 7 mmHg. Pzf calculated in a pressure-flow relationship during a normal cardiac cycle under vasodilation correlated well with that during a long diastole (r = 0.75, p < 0.01), although it was 15 +/- 6 mmHg greater than the actual Pzf. It was concluded that Pzf during a normal cardiac cycle could be used to anticipate Pzf.

Prediction of wall motion recovery from the left anterior descending coronary artery velocity pattern recorded by transthoracic doppler echocardiography in patients with anterior wall myocardial infarction retrospective and prospective studies

The diastolic deceleration slope of coronary flow velocity is steeper in patients with substantial 'no reflow' phenomenon than in those without it. This study investigated whether functional outcomes in patients with anterior wall acute myocardial infarction (AMI) can be predicted by analyzing the coronary flow velocity pattern recorded with transthoracic Doppler (TTD) echocardiography. Coronary blood flow velocity in the distal left anterior descending coronary artery was recorded with TTD at day-2 after primary percutaneous transluminal coronary angioplasty/Stent in 51 patients with anterior AMI and the diastolic deceleration half time (DHT, ms) was measured. The wall motion score index (WMSI) was measured at day-1 and -21. In the retrospective study, the DHT was much shorter in those with a poor outcome than in those with good outcome (152 +/- 109 vs 395 +/- 128 ms, p<0.05). Receiver-operating characteristic analysis documented that DHT > or = 300 ms is a suitable cut-off point (sensitivity of 83% and specificity of 93%). In the prospective study (n=30), AWMSI(dl-d21) was significantly higher in those with a DHT > or = 300 ms than those without (0.3 > or = 0.5 vs 1.6 > or = 0.7, p<0.001). DHT correlated significantly with AWMSI(dl-d21) (r=0.76, p<0.001). Patients with a shorter DHT of diastolic coronary flow velocity have a poorer functional outcome among patients with anterior AMI. The TTD-determined DHT is a useful predictor of myocardial viability after an anterior AMI.

Renin angiotensin system-dependent hypertrophy as a contributor to heart failure in hypertensive rats: different characteristics from renin angiotensin system-independent hypertrophy

OBJECTIVES

This study aimed to characterize the difference between renin angiotensin system (RAS)-dependent and RAS-independent hypertrophy and their differential contribution to the transition to heart failure.

BACKGROUND

Hypertensive left ventricular (LV) hypertrophy develops with RAS activation in the heart; however, LV hypertrophy develops even without RAS activation.

METHODS

Left ventricular geometry and function were assessed in Dahl salt-sensitive rats placed on an 8% NaCl diet from seven weeks old (hypertensive rats) and in those placed on an 0.3% NaCl diet (control rats, n = 8). The hypertensive rats were randomized to no treatment (n = 8) or treatment with the angiotensin type 1 receptor (AT1R) antagonist candesartan (1 mg/kg per day, n = 10) after the baseline echocardiography study.

RESULTS

From 7 to 13 weeks, AT1R blockade at a subdepressor dose did not restrain the development of LV hypertrophy but prevented narrowing of LV diastolic dimension, leading to the normalization of abnormally decreased end-systolic wall stress in the untreated rats. Progressive development of LV hypertrophy in spite of lower than normal end-systolic wall stress (excessive hypertrophy) after 13 weeks was suppressed by the AT1R blockade. Elevation of LV end-diastolic pressure and prolongation of Tau were associated with histological evidence of myocyte hypertrophy and massive interstitial fibrosis in the untreated rats, and none of these was evident in the treated rats.

CONCLUSIONS

Renin-angiotensin system activation and AT1R signaling may be dispensable for the development of early adaptive LV hypertrophy and closely linked to the transition to heart failure.