A multicentric prospective observational study of diagnosis and prognosis features in ICU mesenteric ischemia: the DIAGOMI study

BACKGROUND

Non-occlusive mesenteric ischemia (NOMI) is a challenging diagnosis and is associated with extremely high mortality in critically ill patients, particularly due to delayed diagnosis and when complicated by intestinal necrosis. Plasma citrulline and intestinal-fatty acid binding protein (I-FABP) have been proposed as potential biomarkers, but have never been studied prospectively in this setting. We aimed to investigate diagnostic features, the accuracy of plasma citrulline and I-FABP to diagnose NOMI and intestinal necrosis as well as prognosis.

METHODS

We conducted a prospective observational study in 3 tertiary ICU centers in consecutive patients with NOMI suspicion defined by at least two inclusion criteria among: new-onset or worsening circulatory failure, gastrointestinal dysfunction, biological signs and CT-scan signs of mesenteric ischemia. Diagnosis features and outcomes were compared according to NOMI, intestinal necrosis or ruled out diagnosis using stringent classification criteria.

RESULTS

Diagnosis of NOMI was suspected in 61 patients and confirmed for 33 patients, with intestinal necrosis occurring in 27 patients. Clinical digestive signs, routine laboratory results and CT signs of mesenteric ischemia did not discriminate intestinal necrosis from ischemia without necrosis. Plasma I-FABP was significantly increased in presence of intestinal necrosis (AUC 0.83 [0.70-0.96]). A threshold of 3114 pg/mL showed a sensitivity of 70% [50-86], specificity of 85% [55-98], a negative predictive value of 58% [36-93] and a positive predictive value 90% [67-96] for intestinal necrosis diagnosis. When intestinal necrosis was present, surgical resection was significantly associated with ICU survival (38.5%), whereas no patient survived without necrosis resection (HR = 0.31 [0.12-0.75], p = 0.01).

CONCLUSION

In critically ill patients with NOMI, intestinal necrosis was associated with extremely high mortality, and increased survival when necrosis resection was performed. Elevated plasma I-FABP was associated with the diagnosis of intestinal necrosis. Further studies are needed to investigate plasma I-FABP and citrulline performance in less severe forms of NOMI.

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

Association between previous health condition and outcome after cardiac arrest

INTRODUCTION

Overall survival of patients with out-of-hospital cardiac arrest (OHCA) remains low, even in those with return of spontaneous circulation (ROSC). In addition to usual prognostic characteristics, patients' medical history may also influence their outcome. This study aimed to investigate the role of pre-arrest comorbidities on hospital survival, neurological outcome and mode of death in OHCA patients with successful ROSC.

METHODS

From Jan 2012 to Sep 2017, all consecutive non-traumatic OHCA adults, admitted with a stable ROSC were included. Utstein characteristics, circumstances of arrest and interventions were prospectively recorded. Prior comorbidities were measured using the Charlson Comorbidity Index (CCI), and the population was divided into 3 groups (CCI 0, CCI 1-3 and CCI ≥ 4). The association of CCI with early and long-term mortality was assessed using logistic regression and association with withdrawal-of-life sustaining treatments (WLST) or another cause of death using multinomial regression.

RESULTS

During the study period, 777 patients were analyzed and 483 (62%) died before hospital discharge, with death rate of 49%, 60% and 70% in CCI 0, CCI 1-3 and CCI ≥ 4 respectively. After adjustment, an increase CCI was significantly associated with in-hospital mortality (OR = 2.47 [1.35-4.52], p = 0.001 for CCI 1-3; OR = 2.82 [1.49-5.33], p = 0.003 for CCI ≥ 4; ref = CCI 0). Other independent predictors were non-shockable rhythm (OR = 3.23 [2.08-5]), lack of bystander CPR (OR = 1.96 [1.22-3.13]), epinephrine dose ≥ 2 mg (OR = 5.56 [3.70-8.33]), CA to CPR ≥ 5 min (OR = 1.96 [1.28-3.03]) and CPR to ROSC ≥ 20 min (OR = 2.13 [1.39-3.23]). Using multinomial regression, an increase in CCI was associated with all modes of in-hospital death, particularly with WLST-related death (RRadj = 2.48 [1.26-4.90], p = 0.01 for CCI = 1-3 and 3.75 [1.85-8.7.58], p < 0.001 for CCI ≥ 4, reference CCI = 0).

CONCLUSION

Alteration of chronic health status, as assessed by an elevated CCI, was associated with a higher mortality and a worse neurological outcome in OHCA patients. Presence and burden of comorbidities should be considered in the evaluation of the prognosis in patients admitted in hospital after cardiac arrest.

Early abolition of cough reflex predicts mortality in deeply sedated brain-injured patients

Background

Deep sedation may hamper the detection of neurological deterioration in brain-injured patients. Impaired brainstem reflexes within the first 24 h of deep sedation are associated with increased mortality in non-brain-injured patients. Our objective was to confirm this association in brain-injured patients.

Methods

This was an observational prospective multicenter cohort study involving four neuro-intensive care units. We included acute brain-injured patients requiring deep sedation, defined by a Richmond Assessment Sedation Scale (RASS) < −3. Neurological assessment was performed at day 1 and included pupillary diameter, pupillary light, corneal and cough reflexes, and grimace and motor response to noxious stimuli. Pre-sedation Glasgow Coma Scale (GCS) and Simplified Acute Physiology Score (SAPS-II) were collected, as well as the cause of death in the Intensive Care Unit (ICU).

Results

A total of 137 brain-injured patients were recruited, including 70 (51%) traumatic brain-injured patients, 40 (29%) vascular (subarachnoid hemorrhage or intracerebral hemorrhage). Thirty patients (22%) died in the ICU. At day 1, the corneal (OR 2.69, p = 0.034) and cough reflexes (OR 5.12, p = 0.0003) were more frequently abolished in patients that died in the ICU. In a multivariate analysis, abolished cough reflex was associated with ICU mortality after adjustment to pre-sedation GCS, SAPS-II, RASS (OR: 5.19, 95% CI [1.92–14.1], p = 0.001) or dose of sedatives (OR: 8.89, 95% CI [2.64–30.0], p = 0.0004).

Conclusion

Early (day 1) cough reflex abolition is an independent predictor of mortality in deeply sedated brain-injured patients. Abolished cough reflex likely reflects a brainstem dysfunction that might result from the combination of primary and secondary neuro-inflammatory cerebral insults revealed and/or worsened by sedation.

Frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia after cardiac arrest

PURPOSE

Mesenteric ischaemia after successfully resuscitated cardiac arrest (CA) has been insufficiently studied. We aimed to assess the frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia (NOMI) after CA.

METHODS

We retrospectively included patients admitted to a CA centre with sustained return of spontaneous circulation between 2007 and 2017. NOMI was suspected based on clinical symptoms and classified as possible if no tests were feasible or the only test was a negative abdominal computed tomography (CT) scan and as confirmed if diagnosed by endoscopy, CT, or surgery.

RESULTS

Of 1343 patients, 82 (6%) had suspected NOMI, including 33 (2.5%) with confirmed NOMI. Investigations for suspected NOMI were done in 47/82 (57%) patients (CT, n = 30; lower digestive endoscopy, n = 14; and upper digestive endoscopy, n = 12); 11 patients underwent surgery. By multivariate analysis, factors associated with suspected NOMI were female sex (OR, 1.8; 95%CI, 1.1-2.9, p = 0.02), cardiovascular comorbidities (OR, 1.6; 95%CI, 1.0-2.7; p = 0.047), admission lactate >5 mmol/L (OR, 2.0; 95%CI, 1.2-3.4; p = 0.01), low flow >17 min (OR, 2.2; 95%CI, 1.3-3.8; p = 0.003), and inotropic score >7 μg/kg/min (OR, 1.8; 95%CI, 1.1-3.2; p = 0.03). ICU mortality was 96% (79/82), with 61% of patients dying from multi-organ failure (MOF) and 35% from post-anoxic brain injury. Of the eight patients who regained consciousness, 5 finally died from MOF, leaving 3 patients discharged alive from the ICU with a good neurologic outcome.

CONCLUSIONS

NOMI may affect 2.5-6% of patients after CA. Mortality was extremely high in patients, and very few survived with a good neurological outcome.

Cadmium-Induced Renal Cell Toxicity Is Associated With MicroRNA Deregulation

Cadmium is an environmental pollutant well known for its nephrotoxic effects. Nevertheless, mechanisms underlying nephrotoxicity continue to be elucidated. MicroRNAs (miRNAs) have emerged in recent years as modulators of xenobiotic-induced toxicity. In this context, our study aimed at elucidating whether miRNAs are involved in renal proximal tubular toxicity induced by cadmium exposure. We showed that cadmium exposure, in 2 distinct renal proximal tubular cell models (renal proximal tubular epithelial cell [RPTEC]/human telomerase reverse transcriptase [hTERT] and human kidney-2), resulted in cytotoxicity associated with morphological changes, overexpression of renal injury markers, and induction of apoptosis and inflammation processes. Cadmium exposure also resulted in miRNA modulation, including the significant upregulation of 38 miRNAs in RPTEC/hTERT cells. Most of these miRNAs are known to target genes whose coding proteins are involved in oxidative stress, inflammation, and apoptosis, leading to tissue remodeling. In conclusion, this study provides a list of dysregulated miRNAs which may play a role in the pathophysiology of cadmium-induced kidney damages and highlights promising cadmium molecular biomarkers that warrants to be further evaluated.

Local pesticide use intensity conditions landscape effects on biological pest control

Complex landscapes including semi-natural habitats are expected to favour natural enemies thereby enhancing natural pest biocontrol in crops. However, when considering a large number of situations, the response of natural biocontrol to landscape properties is globally inconsistent, a possible explanation being that local agricultural practices counteract landscape effects. In this study, along a crossed gradient of pesticide use intensity and landscape simplification, we analysed the interactive effects of landscape characteristics and local pesticide use intensity on natural biocontrol. During 3 years, using a set of sentinel prey (weed seeds, aphids and Lepidoptera eggs), biocontrol was estimated in 80 commercial fields located in four contrasted regions in France. For all types of prey excepted weed seeds, the predation rate was influenced by interactions between landscape characteristics and local pesticide use intensity. Proportion of meadow and length of interface between woods and crops had a positive effect on biocontrol of aphids where local pesticide use intensity was low but had a negative effect elsewhere. Moreover, the landscape proportion of suitable habitats for crop pests decreased the predation of sentinel prey, irrespectively of the local pesticide use intensity for weed seeds, but only in fields with low pesticide use for Lepidoptera eggs. These results show that high local pesticide use can counteract the positive expected effects of semi-natural habitats, but also that the necessary pesticide use reduction should be associated with semi-natural habitat enhancement to guarantee an effective natural biocontrol.

Influence of the emollient on emulsions containing lamellar liquid crystals: from molecular organization towards applicative properties

OBJECTIVE

The sensory perception of cosmetic emulsions is complex as it is governed by an important number of parameters like the choice of raw materials, their interactions, the structural organisation of the system, etc. The aim of the present work was to go further in the interpretation of the emollient-surfactant interactions, towards the emulsions applicative properties. For this purpose, two systems containing liquid crystals of the lamellar type were formulated, differing only in the selected emollient.

METHODS

First, the liquid crystals types were checked using different tools like the optical microscopy under the bright and polarized light, the wide-angle X rays diffraction and, finally, thermogravimetric analysis. Next, two sensory attributes, namely compression force and difficulty of spreading, were evaluated by a sensory panel. In addition to that, complementary instrumental characterizations (flow tests, textural analysis and contact angle measurements) were performed in order to understand how the panel could discriminate the products.

RESULTS

The results showed that isohexadecane emollient induces the α-gel structures, while caprylic capric triglycerides favour the formation of the lamellar liquid crystals near to α-gel. For the compression force, the results point out that there is no direct interaction between the oil phase and the skin. For this attribute, depending on its chemical structure, emollient impacts the human perception only by changing the lamellar phase type. Concerning the difficulty of spreading, both the emulsion structure and the emollient properties should be considered. Immediate perception is impacted by the emulsions destruction, making the droplet roll one on each other. Then, once the droplets monolayer is disrupted, the emollient comes into direct contact with the skin. In this case, the perception is governed by the direct affinity of the emollient with the skin, nonpolar emollients being easier to spread if compared to polar ones.

CONCLUSION

The sensory perception is guided not only by the choice of the raw materials but also by their interactions. It was shown that the chemical structure of the emollients affected the molecular organization of liquid crystals present in the emulsion and, consequently, directly or indirectly its sensory perception.

Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality

BACKGROUND

Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes.

PATIENTS AND METHODS

Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression.

RESULTS

Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm³, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm³, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality.

CONCLUSION

After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.

Argon attenuates multiorgan failure following experimental aortic cross-clamping

AIMS

Argon has been shown to prevent ischaemic injuries in several scenarios of regional ischaemia. We determined whether it could provide a systemic effect in a model of multiorgan failure (MOF) induced by aortic cross-clamping.

METHODS

Anaesthetized rabbits were submitted to aortic cross-clamping (30 min) and subsequent reperfusion (300 min). They were either ventilated with oxygen-enriched air throughout the protocol [fraction of inspired oxygen (FiO₂ ) = 30%; control group) or with a mixture of 30% oxygen and 70% argon (argon groups). In a first group treated with argon ('Argon-Total'), its administration was started 30 min before ischaemia and maintained throughout the protocol. In the two other groups, the administration was started either 30 min before ischaemia ('Argon-Pre') or at the onset of reperfusion ('Argon-Post'), for a total duration of 2 h. Cardiovascular, renal and inflammatory endpoints were assessed throughout protocol.

RESULTS

Compared with control, shock was significantly attenuated in Argon-Total and Argon-Pre but not Argon-Post groups (e.g. cardiac output = 62±5 vs. 29 ± 5 ml min^-1 kg^-1 in Argon-Total and control groups at the end of the follow-up). Shock and renal failure were reduced in all argon vs. control groups. Histopathological examination of the gut showed attenuation of ischaemic lesions in all argon vs. control groups. Blood transcription levels of interleukin (IL) 1β, IL-8, IL-10 and hypoxia-inducible factor 1α were not significantly different between groups.

CONCLUSION

Argon attenuated clinical and biological modifications of cardiovascular, renal and intestinal systems, but not the inflammatory response, after aortic cross-clamping. The window of administration was crucial to optimize organ protection.

Influence of body mass index on the prognosis of patients successfully resuscitated from out-of-hospital cardiac arrest treated by therapeutic hypothermia

BACKGROUND

Obesity prevalence has dramatically increased over recent years and is associated with cardiovascular diseases, but data are lacking on its prognostic impact in out-of-hospital cardiac arrest (OHCA) patients.

METHODS

Data of all consecutive OHCA patients admitted in two cardiac arrest centers from Paris and suburbs between 2005 and 2012 were prospectively collected. Patients treated by therapeutic hypothermia (TH) were included in the analysis. Logistic and Cox regression analyses were used to quantify the association between body mass index (BMI) at hospital admission and day-30 and 1-year mortality respectively.

RESULTS

818 patients were included in the study (median age 60.9 [50.8-72.7] year, 70.2% male). Obese patients (BMI>30kgm^-2) were older, more frequently male and evidenced more frequently cardiovascular risk factors than normally (18.5<BMI<25kgm^-2) or overweight patients (25<BMI<30kgm^-2). Post-resuscitation shock and therapeutic hypothermia failure were more frequent in obese patients. Overall mortality at day-30 and one-year was 63.8 and 67.2%, respectively. After multivariate adjustment, BMI>30kgm^-2 was independently associated with day-30 mortality (Odds ratio [OR] in comparison with normally weight patients 2.45; 95% confidence interval [95%CI: 1.32-4.56; p<0.01]). Obesity was not associated with one-year mortality (Hazard ratio [HR] 0.99, 95%CI 0.21,4.67; p=0.99) while underweight was associated with one-year mortality in this subgroup of patients (Hazard ratio [HR] 3.94, 95%CI 1.11,14.01; p=0.03).

CONCLUSION

In the present study, obesity was independently associated with day-30 mortality in successfully resuscitated ICU TH OHCA patients. Further studies are needed to understand the mechanisms that underpin this finding.

Structural and functional development of small intestine in intrauterine growth retarded porcine offspring born to gilts fed diets with differing protein ratios throughout pregnancy

Protein level in the maternal diet plays a crucial role in fetal programming during pregnancy. Low or high protein level increases the risk of intrauterine growth retardation (IUGR). The aim of this study was to investigate the structural and functional development of the small intestine in piglets from sows fed a control (C, 12.1% protein), a high protein (HP, 30% protein), or a low protein (LP, 6.5% protein) diet during pregnancy. Newborns were classified as IUGR (birth weight ≤1.18 kg) and non-IUGR (birth weight >1.18 kg). The piglets were euthanized on postnatal day (PD)1, PD28 and PD188. The LP diet in non-IUGR neonates resulted in decreased body weight on PD1. The LP and HP diets resulted in both decreased body weight and delayed catch-up growth in the IUGR piglets. The HP and LP-diets increased the length of villi on PD1 in non-IUGRs but not in IUGRs. At birth, the expressions of Ki67 and active caspase 3 in mid-jejunum epithelium of HP and LP non-IUGR neonates were significantly lower as compared to C non-IUGRs whilst in IUGRs the respective expressions were as high as in C non-IUGRs. The postnatal dynamics of brush border enzyme activities and vacuolated enterocytes disappearance showed significant drop in enterocyte maturation in IUGR as compared to non-IUGR neonates. In conclusion, both HP and LP diets led to retarded development of non-IUGR piglets. In IUGR piglets both HP and LP diets resulted in delayed catch-up growth, without adaptive changes in brush border digestive enzymes.

Effects of level of feed intake on pancreatic exocrine secretions during the early postweaning period in piglets1

The objective of this study was to determine the influence of the level of feed intake and a 2-d feed restriction period on the postweaning adaptation of pancreatic exocrine secretions. At 33 d of age, 18 piglets fitted with 2 permanent catheters (for pancreatic juice collection and reintroduction) were weaned and allocated to 1 of the following 2 dietary treatments for 5 d: restricted feed allocation (restricted) or gradually increasing feed allocation (control). Pancreatic juice was collected daily during both basal and prandial periods. The basal period was defined as the period from 1400 to 1700 h (i.e., 5 to 8 h after the morning meal), whereas the prandial period was defined as the period from 30 min before to 60 min after the morning meal (given at 0900). Digestive enzyme activities and antibacterial activity were determined. Pancreatic protein secretion was 44% less (P < 0.05) in restricted piglets than in control piglets during the basal period. Trypsin secretion was affected by feed-restriction of piglets. The meal did not affect protein and trypsin secretions in restricted piglets, whereas at d 3 postweaning, protein and trypsin secretions and trypsin specific activity in control piglets were 9-, 105-, and 25-fold greater (P < 0.001) during the first 30 min after the meal than before the meal. Lipase and amylase secretions were not affected by variations in feed intake. The secretion of antibacterial activity in restricted piglets was greater (P < 0.05) than that of control piglets only at d 5. The extended feed restriction period increased the basal secretion of antibacterial activity (P = 0.09) and postprandial secretion of amylase (P = 0.05). In conclusion, a low level of feed intake during the early postweaning period decreased pancreatic protein and trypsin secretions, whereas a 2-d feed restriction period enhanced secretions of amylase and antibacterial activity. In addition, our results indicate that during periods of dietary adaptation, such as at weaning, measurements of enzyme activities in the tissue do not accurately reflect the enzyme secretion.

INTACS inserts for treating keratoconus: one-year results

OBJECTIVE

To evaluate the use of INTACS micro-thin prescription inserts (Kera Vision, Inc., Fremont, CA) for the treatment of keratoconus.

DESIGN

Prospective, nonrandomized (self-controlled) comparative trial.

PARTICIPANTS/INTERVENTION

Ten patients from our prospective clinical study who had completed 12 months of follow-up were evaluated. All patients had keratoconus with clear central corneas and were contact lens intolerant. After reviewing corneal pachymetry and topography of individual patients, INTACS inserts of 0.45-mm thickness were placed in the inferior cornea to lift the cone and INTACS of 0.25-mm thickness were inserted superiorly to counterbalance and flatten the overall anterior corneal surface.

MAIN OUTCOME MEASURES

Differences between preoperative and postoperative uncorrected visual acuity, best spectacle-corrected visual acuity, manifest refraction, and keratometry values were statistically assessed. Changes in corneal ectasia were evaluated by reviewing corneotopographic maps.

RESULTS

No intraoperative complications occurred in this series of patients. Spherical equivalent error and refractive astigmatism were reduced with INTACS inserts treatment. Postoperative month 12 uncorrected visual acuity (logarithm of the minimum angle of resolution [logMAR] mean, 0.35, standard deviation [SD], 0.16 [approximately 20/50, approximately 2 lines]) was significantly better than preoperative (logMAR mean, 1.05; SD, 0.33 [approximately 20/200, approximately 3 lines]; P <or=0.05). Average best spectacle-corrected visual acuity at postoperative month 12 was improved by approximately two lines compared with baseline (logMAR mean, 0.22; SD, 0.12 [approximately 20/32, approximately 1 line]; logMAR mean, 0.38; SD, 0.13 [approximately 20/50, approximately 1 line], respectively). Topographic corneal shape (size and height of the cone) was improved for all subjects after insert placement.

CONCLUSIONS

INTACS micro-thin prescription inserts seem to provide a viable method for treating clear corneal keratoconus for patients who are contact lens intolerant. The corneal steepening and astigmatism associated with keratoconus were reduced, and visual acuity was improved with treatment in almost all eyes.

Correcting keratoconus with intracorneal rings

PURPOSE

To evaluate the potential of intrastromal corneal ring technology (Intacs, KeraVision) to correct keratoconus without central corneal scarring.

SETTING

Department of Ophthalmology, Brest University Hospital, Brest, France.

METHODS

In this prospective, noncomparative, interventional case series, Intacs segments were implanted in 10 keratoconic eyes with clear central corneas and contact lens intolerance after corneal pachymetry was checked. Segment thicknesses varied based on corneal topography analysis.

RESULTS

No intraoperative complications occurred. The mean follow-up was 10.6 months. Postoperative results revealed a reduction in astigmatism and spherical correction and an increase in topographical regularity and increased uncorrected visual acuity.

CONCLUSION

Intacs technology can reduce the corneal steepening and astigmatism associated with keratoconus.

Hyperadrenergic syndrome in severe tetanus: extreme rise in catecholamines responsive to labetalol

The hyperadrenergic syndrome that occurs in tetanus is characterised by hypertension, tachycardia, and increased systemic arteriolar resistance. A 74 year old man with tetanus was found to have very high catecholamine concentrations--as high as those in phaeochromocytoma--and the fluctuations in blood pressure and heart rate were measured to see whether they paralleled changes in the catecholamine values. A labetalol infusion of 0.25-1 mg/min gradually stabilised the cardiovascular disturbances and the patient recovered.

Procedure for Extraction and Cleanup of Plant Material Prior to Determination of Organophosphate Residues

A procedure has been developed for the extraction and cleanup of plant samples prior to the determination of organophosphate residues. It involves acetonitrile extraction, elution of the extract from polyethylene-coated alumina with slightly acidified 40% acetonitrile solution, partitioning of recovered material from water into chloroform, and final elution of the organophosphates from Magnesol with successive portions of chloroform, acetone, and methanol.

Quantitative recoveries (80—107%) by phosphorus determination after paper chromatography of 41 organophosphate standards were obtained from the cleanup procedure. Eight others either were not completely recovered or were recovered at a stage that was not applicable to the determination of residues in plant material. Quantitative i recoveries (80-100%) of 25 of these organophosphate compounds were obtained after extraction and cleanup from samples of lettuce.