Dapagliflozin in patients with critical illness: rationale and design of the DEFENDER study

BACKGROUND

Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated.

METHODS

DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study.

CONCLUSION

DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients.

CLINICALTRIALS.GOV REGISTRY

NCT05558098.

Application of ventilator-associated events (VAE) in ventilator-associated pneumonia (VAP) notified in Brazil (IMPACTO MR-PAV): a protocol for a cohort study

INTRODUCTION

Certain criteria for ventilator-associated events (VAE) definition might influence the type of an event, its detection rate and consequently the resource expenditure in intensive care unit. The Impact of Infections by Antimicrobial-Resistant Microorganisms - Ventilator-Associated Pneumonia (IMPACTO MR-PAV) aims to evaluate the incidence and diagnostic accuracy of ventilator-associated pneumonia (VAP) using the current criteria for VAP surveillance in Brazil versus the VAE criteria defined by the US National Healthcare Safety Network-Center for Diseases Control and Prevention (CDC) criteria.

METHODS AND ANALYSIS

The study will be conducted in around 15 centres across Brazil from October 2022 to December 2023. Trained healthcare professionals will collect data and compare the incidence of VAP using both the current criteria for VAP surveillance in Brazil and the VAE criteria defined by the CDC. The accuracy of the two criteria for identifying VAP will also be analysed. It will also characterise other events associated with mechanical ventilation (ventilator-associated condition, infection-related ventilator-associated complication) and adjudicate VAP reported to the Brazilian Health Regulatory Agency (ANVISA) using current epidemiological diagnostic criteria.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board under the number 52354721.0.1001.0070. The study's primary outcome measure will be the incidence of VAP using the two different surveillance criteria, and the secondary outcome measures will be the accuracy of the two criteria for identifying VAP and the adjudication of VAP reported to ANVISA. The results will contribute to the improvement of VAP surveillance in Brazil and may have implications for other countries that use similar criteria.

TRIAL REGISTRATION NUMBER

NCT05589727; Clinicaltrials.gov.

Clinical characteristics and outcomes of patients with COVID-19 admitted to the intensive care unit during the first and second waves of the pandemic in Brazil: a single-center retrospective cohort study

OBJECTIVE

To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic.

METHODS

In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic.

RESULTS

In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves.

CONCLUSION

In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.

Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial

Objective:

The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care.

Methods:

The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia.

Conclusion:

According to the trial’s best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results.

ClinicalTrials.gov registration: NCT03920501

Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial

OBJECTIVE

The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care.

METHODS

The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia.

CONCLUSION

According to the trial's best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results.ClinicalTrials.gov registration: NCT03920501.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study

Objective:

To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit.

Methods:

Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge.

Results:

During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support.

Conclusion:

Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

Patient-level costs in intensive care: a case report of a standardized and scalable approach

Background

Intensive care units (ICU) costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs (Value-Based Healthcare).

Methods

Case report of a costing methodology implementation, in a 15-bed ICU, in a public, teaching hospital at Teresina/Piauí-Brazil (as part of a broader initiative, with 10 hospitals from all Brazilian regions). All costs incurred during ICU stay were measured from the hospital perspective, applying absorption costing method, by using a standardized approach and a specific central IT system. The study was carried out from Oct/19-Sep/20, including 613 patients, and a team of 10 researchers working with 4 teams of the local hospital (costs, IT, ICU and managers).

Results

ICU fixed costs (personnel, overheads, energy/water, depreciation, non-tracked drugs/medical materials), were divided by service capacity (total bed-hours) for calculation of the costs/minute. Costs were then allocated in the patient level multiplying costs/minute by the ICU length of stay. Variable costs (lab/image tests, transfusions, hemodialysis, and traceable medical materials/drugs) were directly allocated, multiplying the unit cost by the volume consumed per patient. A mini-survey applied 1-year after showed that both cost researchers and hospital staff agreed on the main challenges in measuring patient-level costs (fragmented process; fixed costs available only at the hospital level; lack of control on cost-drivers; indirect costs not considered; any reference for lab/image costs) and that the approach was sufficient to overcome them. The local team also reported increased awareness about the importance of patient-level costs after the experience.

Conclusions

The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Key messages

ICU costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs. The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Regional venous-arterial CO2 to arterial-venous O2 content difference ratio in experimental circulatory shock and hypoxia

Background

Venous–arterial carbon dioxide (CO₂) to arterial–venous oxygen (O₂) content difference ratio (Cv-aCO₂/Ca-vO₂) > 1 is supposed to be both sensitive and specific for anaerobic metabolism. What regional hemodynamic and metabolic parameters determine the ratio has not been clarified.

Objectives

To address determinants of systemic and renal, spleen, gut and liver Cv-aCO₂/Ca-vO₂.

Methods

Post hoc analysis of original data from published experimental studies aimed to address effects of different fluid resuscitation strategies on oxygen transport, lactate metabolism and organ dysfunction in fecal peritonitis and endotoxin infusion, and from animals in cardiac tamponade or hypoxic hypoxia. Systemic and regional hemodynamics, blood flow, lactate uptake, carbon dioxide and oxygen-derived variables were determined. Generalized estimating equations (GEE) were fit to assess contributors to systemic and regional Cv-aCO₂/Ca-vO₂.

Results

Median (range) of pooled systemic Cv-aCO₂/Ca-vO₂ in 64 pigs was 1.02 (0.02 to 3.84). While parameters reflecting regional lactate exchange were variably associated with the respective regional Cv-aCO₂/Ca-vO₂ ratios, only regional ratios were independently correlated with systemic ratio: renal Cv-aCO₂ /Ca-vO₂ (β = 0.148, 95% CI 0.062 to 0.234; p = 0.001), spleen Cv-aCO₂/Ca-vO₂ (β = 0.065, 95% CI 0.002 to 0.127; p = 0.042), gut Cv-aCO₂/Ca-vO₂ (β = 0.117, 95% CI 0.025 to 0.209; p = 0.013), liver Cv-aCO₂/Ca-vO₂ (β = − 0.159, 95% CI − 0.297 to − 0.022; p = 0.023), hepatosplanchnic Cv-aCO₂/Ca-vO₂ (β = 0.495, 95% CI 0.205 to 0.786; p = 0.001).

Conclusion

In a mixed set of animals in different shock forms or during hypoxic injury, hepatosplanchnic Cv-aCO₂/Ca-vO₂ ratio had the strongest independent association with systemic Cv-aCO₂/Ca-vO₂, while no independent association was demonstrated for lactate or hemodynamic variables.

Intensive care unit patients' opinion on enrollment in clinical research: A multicenter survey

Background

In most emergency situations or severe illness, patients are unable to consent for clinical trial enrollment. In such circumstances, the decision about whether to participate in a scientific study or not is made by a legally designated representative.

Objective

To address the willingness of patients admitted to the intensive care unit (ICU) to be enrolled in a scientific study as volunteers, and to assess the agreement between patients’ and their legal representatives’ opinion concerning enrollment in a scientific study.

Methods

This survey was conducted in two hospitals in São Paulo, Brazil. Patients (≥18 years) with preserved cognitive functions accompanied by a surrogate admitted to the ICU were eligible for this study. A survey containing 28 questions for patients and 8 questions for surrogates was applied within the first 48h from ICU admission. The survey for patients comprised three sections: demographic characteristics, opinion about participation in clinical research and knowledge about the importance of research. The survey for legal representatives contained two sections: demographic characteristics and assessment of legal representatives’ opinion in authorizing patients to be enrolled in research.

Results

Between January 2017 and May 2018, 208 pairs of ICU patients and their respective legal representatives answered the survey. Out of 208 ICU patients answering the survey, 73.6% (153/208) were willing to be enrolled in the study as volunteers. Of those patients, 65.1% (97/149) would continue participating in a research even if their legal representative did not support their enrollment. Agreement between patients’ and surrogates’ opinion concerning participation was poor [Kappa = 0.11 (IC95% -0.02 to 0.25)]. If a consent for study participation had been obtained, 69.1% (103/149) of patients would continue participating in the study until its conclusion, and 23.5% (35/149) would allow researchers to use data collected to date, but would withdraw from the study on that occasion.

Conclusion

The majority of patients admitted to the ICU were willing to be enrolled in a scientific study as volunteers, also after a deferred informed consent procedure has been used. Nevertheless, contradictory opinions between patients and their and their legal representatives’ concerning enrollment in a scientific study were often observed.

Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

Quality improvement model (IHI) as a strategy to implement a sepsis protocol in a public hospital in Brazil

A major challenge for hospitals in low-income and middle-income countries is to improve management of patients diagnosed with sepsis. The objective of the present study was to evaluate the Institute for Healthcare Improvement (IHI) Model as a strategy to implement a managed sepsis protocol aimed at reducing sepsis mortality. We performed a longitudinal, prospective, non-randomised study using PDSA cycles for translating and implementing improvement actions and tools. Baseline case mortality/case fatality data were collected, and compliance rates were evaluated according to the Surviving Sepsis Campaign guidelines (3-hour care-bundle). Sepsis multidisciplinary work teams were designated and were responsible to develop Driver Diagrams and implement process changes in the intensive care unit, wards and emergency department. Satisfaction levels of healthcare professionals were assessed (balance variables). The study was carried out in a public quaternary hospital, in São Paulo city, Brazil (Hospital Municipal da Vila Santa Catarina). The number of patients with sepsis studied was 416 who were followed over a 15-month period. The data analyses were carried out by statistical process control. Case fatality rates were kept below a prespecified target of 25% (15.9%) during the period. Satisfaction level of the participating staff was high (95.2%) and 71% of participants reported no work overload. The IHI model was found to be a feasible and useful strategy for implementing a sepsis management clinical protocol.

Efficiency in the operational process: reduction of incorrect entries and guarantee of compliance in the rendering of accounts

Objective

To verify the impact of the Lean Six Sigma methodology in reducing incorrect entries of non-appropriated revenues and expenses.

Methods

Process for the review and application of the Lean Six Sigma methodology between December 2015 and September 2016, in a high-complexity general hospital in the city of São Paulo (SP).

Results

A total of 3,756,814 (100%) entries were audited between December 2015 and September 2016. The Sigma level evolved over the course of the process and increased from 3.44 Sigma in December 2015 to 5.92 Sigma in September 2016. Entries classified as non-appropriated revenues and expenses were brought down to 0% at the end of the study.

Conclusion

The use of the Lean Six Sigma methodology was efficient in reducing incorrect entries, calculating costs, ensuring compliance in rendering of accounts and accurately determining cost-outcome ratios.

Esmolol Administration to Control Tachycardia in an Ovine Model of Peritonitis

BACKGROUND

Excessive adrenergic signaling may be harmful in sepsis. Using β-blockers to reduce sympathetic overactivity may modulate sepsis-induced cardiovascular, metabolic, immunologic, and coagulation alterations. Using a randomized ovine fecal peritonitis model, we investigated whether administration of a short-acting β-blocker, esmolol, could control tachycardia without deleterious effects on hemodynamics, renal perfusion, cerebral perfusion, cerebral metabolism, or outcome.

METHODS

After induction of fecal peritonitis, 14 anesthetized, mechanically ventilated, and hemodynamically monitored adult female sheep were randomly assigned to receive a continuous intravenous infusion of esmolol to control heart rate between 80 and 100 bpm (n = 7) or a saline infusion (control group, n = 7). Esmolol was discontinued when the mean arterial pressure decreased below 60 mm Hg. Fluid resuscitation was titrated to maintain pulmonary artery occlusion pressure at baseline values. Left renal blood flow and cerebral cortex perfusion and metabolism were monitored in addition to standard hemodynamic variables.

RESULTS

Esmolol was infused for 11 (9-14) hours; the target heart rate (80-100 bpm) was achieved between 3 and 8 hours after feces injection. In the first 5 hours after the start of the infusion, the decrease in heart rate was compensated by an increase in stroke volume index; later, stroke volume index was not statistically significantly different in the 2 groups, so that the cardiac work index was lower in the esmolol than in the control group. Hypotension (mean arterial pressure <60 mm Hg) occurred earlier (10 [8-12] vs 14 [11-20] hours; P= .01) in the esmolol group than in the control animals. Renal blood flow decreased earlier in the esmolol group, but there were no differences in urine output, cerebral cortex perfusion, metabolism, or survival between the groups.

CONCLUSIONS

In this ovine model of abdominal sepsis, early control of tachycardia by esmolol was associated with a transient increase in stroke volume, followed by earlier hypotension. There were no significant effects of esmolol on cerebral perfusion, metabolism, urine output, or survival.

Time course of blood lactate levels, inflammation, and mitochondrial function in experimental sepsis

Background

A decrease in blood lactate levels (Lac) >10% during the first hours of resuscitation in sepsis is associated with better outcomes, but the mechanisms are unclear. Our objective was to investigate the relationship between the time course of Lac, inflammatory response, and mitochondrial respiration during experimental sepsis.

Methods

Original data from two previously published studies were reanalyzed. In cohort 1, pigs were randomized to be resuscitated for 48 h starting at 6, 12, and 24 h, respectively, after fecal peritonitis induction (n = 8 each). Animals were categorized according to the decrease in Lac during the first 6 h of resuscitation (early if ≥10% [Lac ≥10%] or late if <10% or increased [Lac <10%]), and systemic hemodynamics, inflammatory parameters, and mitochondrial function were compared between groups. In a second group of animals with fecal peritonitis and 24 h of resuscitation (n = 16, cohort 2), abdominal regional Lac exchange was measured, and animals were categorized according to the decrease in Lac as in cohort 1.

Results

Overall mortality was 20% (4 of 20) in the Lac ≥10% group and 60% (12 of 20) in the Lac <10% group (p = 0.022). In cohort 1, systemic hemodynamics were similar in the Lac ≥10% (n = 13) and Lac <10% (n = 11) groups. Plasma interleukin-6 levels increased during unresuscitated sepsis and decreased during resusciation in both groups, but they were lower at study end in the Lac ≥10% group (p = 0.047). Complexes I and II maximal (state 3) and resting (state 4) isolated brain mitochondrial respiration at study end was higher in the Lac ≥10% group than in the Lac <10% group, whereas hepatic, myocardial, and skeletal muscle mitochondrial respiration was similar in both groups. In cohort 2, mesenteric, total hepatic, and renal blood flow at study end was higher in the Lac ≥10% group (n = 7) than in the Lac <10% group (n = 9), despite similar cardiac output. Hepatic lactate influx and uptake in the Lac ≥10% group were approximately 1.5 and 3 times higher, respectively, than in the Lac <10% group (p = 0.066 for both).

Conclusions

A decrease in Lac >10% during early resuscitation (6 h) after abdominal sepsis is associated with lower levels of plasma interleukin-6 and improved brain but not hepatic or muscle mitochondrial respiration. Blood flow redistribution to abdominal organs in animals with early decrease in Lac concentrations increases the potential to both deliver and extract Lac.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1691-4) contains supplementary material, which is available to authorized users.

Early management of sepsis

Increased awareness of the signs and symptoms of sepsis and an emphasis on the importance of early treatment have helped to improve survival rates from this serious and frequent condition in recent years. With no specific, effective anti-sepsis therapies available, management focuses on early source control with adequate and appropriate antibiotics and removal of any source of infection, rapid resuscitation, hemodynamic stabilization and organ support. Use of dedicated teams to care for patients with sepsis can help optimize early management.

Assessment of nursing perceptions of three insulin protocols for blood glucose control in critically ill patients

OBJECTIVE

To evaluate nurses' perception regarding three different blood glucose control protocols for critically ill patients.

METHODS

As part of a randomized trial comparing three blood glucose control protocols in critically ill patients (Computer-Assisted Insulin Protocol, Leuven Protocol, and conventional treatment), all nurses participating in the study were asked to fill in a questionnaire to assess their perceptions of efficacy, complexity, feasibility, and safety (as to the occurrence of hypoglycemic episodes), an to indicate which protocol they would like to see adopted as the standard one in the Intensive Care Unit they worked.

RESULTS

Sixty nurses answered the questionnaires. Computer-Assisted Insulin Protocol was considered the most efficient protocol to maintain blood glucose levels within the target range by 58% of the nurses, compared to 22% for Leuven Protocol (p<0.001) and 40% for conventional treatment (p=0.04). Computer-Assisted Insulin Protocol was considered easier to use than Leuven Protocol (p<0.001) and as easy as conventional treatment (p=0.78). Out of the nurses, 37% considered Computer-Assisted Insulin Protocol more feasible than Leuven Protocol and conventional treatment. A total of 51% of nurses chose Leuven Protocol as the protocol more often associated with hypoglycemia, while 27% chose Computer-Assisted Insulin Protocol and 8% conventional treatment. Finally, 56% of the nurses selected Computer-Assisted Insulin Protocol as the protocol they would like to see adopted as the standard one in the Intensive Care Unit they were based, as compared to 22% that selected Leuven Protocol and 15% that selected conventional treatment.

CONCLUSION

Computer-Assisted Insulin Protocol was considered more efficacious, easier to use and safer than Leuven Protocol by nurses. The complexity and feasibility of Computer-Assisted Insulin Protocol were considered similar to conventional treatment. Most nurses chose of Computer-Assisted Insulin Protocol as the protocol they would like to see adopted in their Intensive Care Units.

Impact of Plasma-Lyte pH 7.4 on acid-base status and hemodynamics in a model of controlled hemorrhagic shock

OBJECTIVE

Intravenous infusion of crystalloid solutions is a cornerstone of the treatment of hemorrhagic shock. However, crystalloid solutions can have variable metabolic acid-base effects, perpetuating or even aggravating shock-induced metabolic acidosis. The aim of this study was to compare, in a controlled volume-driven porcine model of hemorrhagic shock, the effects of three different crystalloid solutions on the hemodynamics and acid-base balance.

METHODS

Controlled hemorrhagic shock (40% of the total blood volume was removed) was induced in 18 animals, which were then treated with normal saline (0.9% NaCl), Lactated Ringer's Solution or Plasma-Lyte pH 7.4, in a blinded fashion (n = 6 for each group). Using a predefined protocol, the animals received three times the volume of blood removed.

RESULTS

The three different crystalloid infusions were equally capable of reversing the hemorrhage-induced low cardiac output and anuria. The Lactated Ringer's Solution and Plasma-Lyte pH 7.4 infusions resulted in an increased standard base excess and a decreased serum chloride level, whereas treatment with normal saline resulted in a decreased standard base excess and an increased serum chloride level. The Plasma-Lyte pH 7.4 infusions did not change the level of the unmeasured anions.

CONCLUSION

Although the three tested crystalloid solutions were equally able to attenuate the hemodynamic and tissue perfusion disturbances, only the normal saline induced hyperchloremia and metabolic acidosis.

Legionnaires' disease: when an 'outbreak' is not an outbreak

During August 2006, there was a large increase in non-travel related legionella cases throughout England and in the Netherlands.

Differential esterase expression in leaves of Manihot esculenta Crantz infected with Xanthomonas axonopodis pv. manihotis

The polyacrylamide gel electrophoresis system (PAGE) and inhibition tests for biochemical characterization of alpha- and beta-esterases were used to obtain a functional classification of esterases in plants and to show a differential expression of esterases as markers of pathogenesis in cassava plants (Manihot esculenta Crantz). The characterization of alpha- and beta-esterases from leaves of M. esculenta by the PAGE system was possible using an extraction solution containing two phenol-complexing agents (PVP-40 and sodium metabisulfite), three antioxidant agents (EDTA, beta-mercaptoethanol, and DTT), and one quinone reducer (ascorbic acid). Fourteen esterase isozymes were detected in young unexpanded leaves of M. esculenta cultivars. The inhibition pattern of alpha- and beta-esterases of M. esculenta showed that Est-9 is an arylesterase, and in the unexpanded leaves of the M. esculenta plants infected with Xanthomonas axonopodis pv. manihotis, the Est-7 beta-esterase showed the characteristic staining of an alpha/beta-esterase. This diffrential expression of Est-7 isozyme in young unexpanded leaves of cassava plants can be used as a marker of pathogenesis after infection with X. axonopodis pv. manihotis.

Maxillary lateral incisor with two root canals: fusion, gemination or dens invaginatus?

Endodontic retreatment of a maxillary right lateral incisor with two root canals is described. The diagnosis of fusion, gemination or dens invaginatus could not be made, due to conflicting findings, and to previous root canal treatment that erased the original configuration of the pulp chamber.

[Cryptococcus neoformans isolated from patients with AIDS]

Cryptococcosis is considered the most frequent fungal systemic opportunist infection in patients with AIDS. C. neoformans var. neoformans infects the patients with AIDS more often than C. neoformans var. gattii which has been rarely isolated from patients with AIDS. Even in endemic regions of C. neoformans var. gattii, the variety of neoformans is still the most common agent diagnosed in cryptococcosis of patients with AIDS. Cerebrospinal fluid (CSF) from fifty patients with neurocryptococcosis associated with AIDS were studied. The fungi were isolated in agar Sabouraud medium, and were identified by microscopic and macroscopic examination by agar Sabouraud, agar niger and Christensen's urea medium. The variety was determined based on a color characteristic reaction on glycine-L-canavanina-bromothymol blue agar. From all of the fifty patients' cerebrospinal fluid (CSF) we were able to recover C. neoformans. The isolates were identified as C. neoformans var. neoformans in 47 patients and as C. neoformans var. gattii. in the 3 remaining patients. These findings suggest that both varieties, gattii and neoformans, are agents of neurocryptococcosis in patients with AIDS.

Intercomparison of calibration procedures for 192Ir HDR sources in Brazil

The lack of well established dosimetry protocols for HDR sources is a point of great concern regarding the uniformity of procedures within a particular country and worldwide. The main objective of this paper is to report the results from ten institutions of an intercomparison of calibration procedures for 192Ir HDR sources currently in use in Brazil. The treatment irradiator of one institution was calibrated by a reference system and used by all participants with their own measuring electrometers and ionization chambers under the same experimental conditions. Two methods were used: the calibration jig and the well-type ionization chamber. Each participant was allowed to use their own method and formalism. The results of this exercise were very positive since this was the first time in Brazil that a group of users gathered to share their experience and openly discuss the physical concepts behind the calibration procedures. The results were all within +/-3.0%, except one case where -4.6% was observed and later identified as a problem with the Nk value for x-rays. Though the magnitude of the deviations found was generally acceptable considering the diversity of formalisms currently in use, a proposal is now being prepared to be adopted as a national protocol. The identification of the institutions was left out for the sake of confidentiality.

Mitochondrial association of a plus end-directed microtubule motor expressed during mitosis in Drosophila

The kinesin superfamily is a large group of proteins (kinesin-like proteins [KLPs]) that share sequence similarity with the microtubule (MT) motor kinesin. Several members of this superfamily have been implicated in various stages of mitosis and meiosis. Here we report our studies on KLP67A of Drosophila. DNA sequence analysis of KLP67A predicts an MT motor protein with an amino-terminal motor domain. To prove this directly, KLP67A expressed in Escherichia coli was shown in an in vitro motility assay to move MTs in the plus direction. We also report expression analyses at both the mRNA and protein level, which implicate KLP67A in the localization of mitochondria in undifferentiated cell types. In situ hybridization studies of the KLP67A mRNA during embryogenesis and larval central nervous system development indicate a proliferation-specific expression pattern. Furthermore, when affinity-purified anti-KLP67A antisera are used to stain blastoderm embryos, mitochondria in the region of the spindle asters are labeled. These data suggest that KLP67A is a mitotic motor of Drosophila that may have the unique role of positioning mitochondria near the spindle.

Motor activity and mitotic spindle localization of the Drosophila kinesin-like protein KLP61F

The KLP61F gene product is essential for Drosophila development. Mutations in KLP61F display a mitotic arrest phenotype caused by a failure in the proper separation of duplicated centrosomes (Heck et al., 1993). Sequence analysis of KLP61F identified it as a member of the bimC family of kinesin-like microtubule motor proteins. Here we report that KLP61F is distinct from KRP130, a kinesin-like protein recently purified from Drosophila embryos and suggested to be the product of the KLP61F gene (Cole et al., 1994). We also characterized recombinant KLP61F and found that it possesses microtubule-stimulated ATPase and microtubule translocation activities in vitro. In addition, we have used an affinity-purified, KLP61F-specific antiserum to localize native KLP61F and an epitope-tagged KLP61F fusion protein during various stages of mitosis in Drosophila syncytial blastoderm embryos. From early prophase through anaphase, KLP61F is coincident with the distribution of tubulin. Together these results confirm the existence of multiple bimC-like kinesins in Drosophila and suggest that KLP61F function is intrinsic to the mitotic spindle.

An inverse PCR screen for the detection of P element insertions in cloned genomic intervals in Drosophila melanogaster

We developed a screening approach that utilizes an inverse polymerase chain reaction (PCR) to detect P element insertions in or near previously cloned genes in Drosophila melanogaster. We used this approach in a large scale genetic screen in which P elements were mobilized from sites on the X chromosome to new autosomal locations. Mutagenized flies were combined in pools, and our screening approach was used to generate probes corresponding to the sequences flanking each site of insertion. These probes then were used for hybridization to cloned genomic intervals, allowing individuals carrying insertions in them to be detected. We used the same approach to perform repeated rounds of sib-selection to generate stable insertion lines. We screened 16,100 insert bearing individuals and recovered 11 insertions in five intervals containing genes encoding members of the kinesin superfamily in Drosophila melanogaster. In addition, we recovered an insertion in the region including the Larval Serum Protein-2 gene. Examination by Southern hybridization confirms that the lines we recovered represent genuine insertions in the corresponding genomic intervals. Our data indicates that this approach will be very efficient both for P element mutagenesis of new genomic regions and for detection and recovery of "local" P element transposition events. In addition, our data constitutes a survey of preferred P element insertion sites in the Drosophila genome and suggests that insertion sites that are mutable at a rate of approximately 10(-4) are distributed every 40-50 kb.

[Visualization of thrombi in the left auricular appendix using transesophageal echocardiography. Apropos of a clinical case]

A case of Transesophageal Echocardiography (T.E.E.) Assessment of "Rheumatic Mitral Stenosis" is presented. T.E.E. has been recently referred as having superior resolution than transthoracic Echocardiography on the detection of thrombi. In the presented case a thrombi was detected in the left atrial appendage. This fact has allowed a better planning of surgery.

[Surgery for infectious endocarditis]

OBJECTIVE

to assess the experience of both departments in the surgical therapy of infective endocarditis--indications and results.

DESIGN

retrospective analysis on clinical data, surgery and follow up.

SETTING

patients (pts) studied in the Cardiology Department and Cardiothoracic Surgery Department of the Santa Marta Hospital in Lisbon.

PATIENTS AND INTERVENTIONS

sequential sample of 28 patients (11 females, 17 males, mean age 39 years) submitted to surgery between 1978 and 1987 for infective endocarditis.

MEASUREMENTS AND RESULTS

the indications for surgery were: heart failure (15 pts), "resistant" infection (8 pts), emboli (4 pts) and "large" vegetations shown by echocardiography (2 pts). Surgical mortality -27.5%. Four patients developed periprosthetic leaks. There was an improvement in functional class of the survivals.

CONCLUSION

the indications for surgery were heart failure, "resistant" infection, emboli and "large" vegetations. There was a high surgical mortality, namely in the patients with resistant infection, severe heart failure and periprosthetic leaks. In the follow up there was a net improvement of functional class. The morbidity is due to the periprosthetic leaks, which induced most of the reoperations.

[Infective endocarditis of pulmonary valve. Considerations apropos of a case associated with interventricular communication and aortic insufficiency ]

We report the case of a 23 year old patient in whom heart disease was detected in childhood. He began to have suddenly fever and symptoms of right side heart failure. There were signs of aortic regurgitation, a systodiastolic murmur in the left parasternal region and a diastolic murmur in the left 4th intercostal space. The bidimensional and Doppler Echocardiogram showed a saccular dilatation in the right ventricular outflow tract. He was submitted to catheterisation which confirmed aortic regurgitation and detected ventricular septal defect and pulmonary hypertension. During surgery, a subaortic ventricular septal defect was seen as well as a dilatation of the right coronary aortic cusp which prolapsed through the defect to the right ventricular outflow tract. Vegetations were seen in the pulmonary valve. The aortic valve and a pulmonary cusp were excised and a Björk Shiley aortic prosthetic valve was inserted. The septal defect was closed. The patient is still alive, symptomless, with 40 months of follow up. We discuss some problems related to this case, particularly the surgical indication and the rarity of the morphology discovered.

[Isolated hypoplasia of the right ventricle--apropos of a case]

OBJECTIVE

To report one case of a rare heart disease (Isolated Hypoplasia of the Right Ventricle) and discuss the methodology used to propose surgery with goal. Good follow up results.

DESIGN

To report a case.

SETTING

One patient studied in the Cardiology Department of the Santa Marta Hospital, Lisbon, and submitted to surgery in the Cardiothoracic Surgery Department of the same Hospital.

PATIENT

A 22 years old woman, who had cyanosis since birth, normal cardiac auscultatory findings, pulmonary oligohemia in the chest Roentgenogram and right atrial strain on the Electrocardiogram.

INTERVENTIONS

She had an echocardiogram (M1 Mode and 2D) and catheterised, with pressure and oximetry measurements. During the latter procedure, the atrial septal defect was occluded for 20 minutes with a Fogarty catheter and pressure and oximetries were reevaluated. She was later operated.

MEASUREMENTS AND RESULTS

The Echocardiogram showed right ventricular hypoplasia, with a normally inserted tricuspid valve and a dilated right atrium. The hemodynamic study confirmed the presence of an atrial septal defect with right to left shunt, normal pulmonary artery pressure, no gradients and giant "a" wave in the right auriculogram. The right ventriculography showed right ventricular inflow hypoplasia. The occlusion of the atrial septal defect with the balloon catheter decreased the peripheral insaturation, without a significant increase in the right ventricular pressure. With this information, surgery was proposed (closure of the atrial septal defect), with good results (4 years of follow-up).

CONCLUSION

The interruption of the shunt with a balloon allows us to see if the right ventricle can handle properly the volume load. With this information surgery can be suggested. It may be rather simple as in this case.