Combined ultrasound of m. quadriceps and diaphragm to determine the occurrence of sarcopenia and prolonged ventilation in a COVID-19 ICU cohort: The COVID-SARCUS trial

OBJECTIVE

The aim of this study was to determine the development of sarcopenia in a COVID-19 intensive care unit population by sequential quadriceps and diaphragm ultrasound and its relationship with hospital outcomes.

METHODS

We assessed muscle thickness, cross-sectional area, fascicle length, pennation angle, and echo intensity within 48 h after intubation, at days 5 and 10 and at discharge from the intensive care unit in 30 critically ill patients with confirmed COVID-19.

RESULTS

A different evolution of muscle thickness of the diaphragm and m. rectus femoris was observed; the changes between the two muscles were not correlated (Pearson's χ2 3.91, P = 0.419). The difference in muscle thickness was linked to the outcome for both m. rectus femoris and diaphragm, with the best survival seen in the group with stable muscle thickness. The greatest loss of muscle thickness occurred between days 5 and 10. The echo intensity was higher in the patients with increased muscle thickness, who also had a worse prognosis. There was a correlation between cross-sectional area on day 5 and handgrip strength (r = 0.290, P = 0.010). Only 31% of patients were able to return to their preadmission residence without any additional rehabilitation.

CONCLUSIONS

Muscle atrophy and decline in muscle strength appear in the earliest stages after admission to the intensive care unit and are related to functional outcome.

Thrombotic microangiopathy after traumatic brain injury: A case report and review of the literature

Key Clinical Message

This case report supports that trauma can rarely cause thrombotic microangiopathy (TMA). Early recognition is important due to a high mortality of untreated TMA, but diagnosis can be delayed by attributing lab abnormalities as due to blood loss.

Abstract

Major trauma can provoke coagulopathy, ranging from hypo- to hypercoagulation. Thrombotic microangiopathy (TMA), characterized by hemolytic anemia, renal failure, thrombocytopenia, and intravascular hemolysis, results in bleeding tendency but also microvascular thrombosis. We report a rare case of isolated traumatic brain injury leading to TMA treated with plasmapheresis.

Pre-admission ambient air pollution and blood soot particles predict hospitalisation outcomes in COVID-19 patients

BACKGROUND

Air pollution exposure is one of the major risk factors for aggravation of respiratory diseases. We investigated whether exposure to air pollution and accumulated black carbon (BC) particles in blood were associated with coronavirus disease 2019 (COVID-19) disease severity, including the risk for intensive care unit (ICU) admission and duration of hospitalisation.

METHODS

From May 2020 until March 2021, 328 hospitalised COVID-19 patients (29% at intensive care) were recruited from two hospitals in Belgium. Daily exposure levels (from 2016 to 2019) for particulate matter with aerodynamic diameter <2.5 µm and <10 µm (PM2.5 and PM10, respectively), nitrogen dioxide (NO2) and BC were modelled using a high-resolution spatiotemporal model. Blood BC particles (internal exposure to nano-sized particles) were quantified using pulsed laser illumination. Primary clinical parameters and outcomes included duration of hospitalisation and risk of ICU admission.

RESULTS

Independent of potential confounders, an interquartile range (IQR) increase in exposure in the week before admission was associated with increased duration of hospitalisation (PM2.5 +4.13 (95% CI 0.74-7.53) days, PM10 +4.04 (95% CI 1.24-6.83) days and NO2 +4.54 (95% CI 1.53-7.54) days); similar effects were observed for long-term NO2 and BC exposure on hospitalisation duration. These effect sizes for an IQR increase in air pollution on hospitalisation duration were equivalent to the effect of a 10-year increase in age on hospitalisation duration. Furthermore, for an IQR higher blood BC load, the OR for ICU admission was 1.33 (95% CI 1.07-1.65).

CONCLUSIONS

In hospitalised COVID-19 patients, higher pre-admission ambient air pollution and blood BC levels predicted adverse outcomes. Our findings imply that air pollution exposure influences COVID-19 severity and therefore the burden on medical care systems during the COVID-19 pandemic.

Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy: Is Metabolic Fear the Enemy of Logic? A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT.

METHODS

Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022.

RESULTS

Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52-4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99-2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67-8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22-0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22-21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89-1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8-1.02); p = 0.110).

CONCLUSION

regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.

METHODS

EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.

FINDINGS

Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.

INTERPRETATION

Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required.

FUNDING

None.

Cardiogeneticsbank@UZA: A Collection of DNA, Tissues, and Cell Lines as a Translational Tool

Cardiogeneticsbank@UZA is an academic hospital integrated biobank that collects aortic tissue, blood, cell lines (fibroblasts, vascular smooth muscle cells, peripheral blood mononuclear cells, and induced pluripotent stem cells), and DNA from patients with cardiogenetic disorders, for both diagnostic and research purposes. We adhere to a quality management system and have established standard protocols for the sampling and processing of all cardiogenetic patient related materials. Cardiogeneticsbank@UZA is embedded in the Biobanking and Biomolecular Resources Research Infrastructure Belgium (BBMRI.be) and samples from this biobank are available for commercial and academic researchers, through an established access procedure. Currently, the extremely valuable cardiogenetics collection consists of more than 8,700 DNA samples, 380 tissue samples, and 500 cell lines of 7,578 patients, and is linked with extensive clinical data. Some interesting potential research applications are discussed.

Nebulised hypertonic saline in children with bronchiolitis admitted to the paediatric intensive care unit: A retrospective study

AIM

Bronchiolitis is one of the most common lower respiratory tract infections in young children, associated with significant morbidity, but limited therapeutic options. Nebulised hypertonic saline (HS) has been a supportive treatment until current guidelines advised against its routine use. Accordingly, the University Hospital of Antwerp recently changed their policies to stop using it, allowing us to evaluate retrospectively if HS influences the duration of respiratory support. Because, to our knowledge, the effect of HS on children with severe bronchiolitis admitted to a paediatric intensive care unit (PICU) has not been studied yet, we aimed to investigate the effect in this specific patient group.

METHODS

Retrospective study including children up to the age of 2, admitted to the PICU with bronchiolitis from October 2013 until March 2016. The primary end point is the duration of respiratory support, including high flow nasal cannula, continuous positive airway pressure and invasive ventilation.

RESULTS

A total of 104 children admitted to the PICU with bronchiolitis were included, with an average age of 3.4 months. In respiratory syncytial virus (RSV) positive patients, the use of nebulised HS was correlated with a decrease in the duration of respiratory support and the length of stay by factors 0.72 (P = 0.01) and 0.81 (P = 0.04), respectively.

CONCLUSIONS

A significant correlation was found between the use of HS and a decreased duration of respiratory support and admission in the PICU in patients with RSV bronchiolitis. This finding may warrant new prospective studies investigating HS specifically in children with severe bronchiolitis.

EBV-associated hemophagocytic lymphohistiocytosis complicated by severe coagulation disorders and opportunistic infections: case report of a survivor

The possibility of hemophagocytic lymphohistiocytosis should always be kept in mind when examining/treating a patient with fever of unknown origin and sepsis‐like symptoms. Early diagnosis leading to prompt initiation of immunosuppressive therapy as well as aggressive supportive care, including correction of coagulation abnormalities and treatment of opportunistic infections, can decrease mortality.

Visualizing Cerebrovascular Autoregulation Insults and Their Association with Outcome in Adult and Paediatric Traumatic Brain Injury

OBJECTIVE

The aim of this study is to assess visually the impact of duration and intensity of cerebrovascular autoregulation insults on 6-month neurological outcome in severe traumatic brain injury.

MATERIAL AND METHODS

Retrospective analysis of prospectively collected minute-by-minute intracranial pressure (ICP) and mean arterial blood pressure data of 259 adult and 99 paediatric traumatic brain injury (TBI) patients from multiple European centres. The relationship of the 6-month Glasgow Outcome Scale with cerebrovascular autoregulation insults (defined as the low-frequency autoregulation index above a certain threshold during a certain time) was visualized in a colour-coded plot. The analysis was performed separately for autoregulation insults occurring with cerebral perfusion pressure (CPP) below 50 mmHg, with ICP above 25 mmHg and for the subset of adult patients that did not undergo decompressive craniectomy.

RESULTS

The colour-coded plots showed a time-intensity-dependent association with outcome for cerebrovascular autoregulation insults in adult and paediatric TBI patients. Insults with a low-frequency autoregulation index above 0.2 were associated with worse outcomes and below -0.6 with better outcomes, with and approximately exponentially decreasing transition curve between the two intensity thresholds. All insults were associated with worse outcomes when CPP was below 50 mmHg or ICP was above 25 mmHg.

CONCLUSIONS

The colour-coded plots indicate that cerebrovascular autoregulation is disturbed in a dynamic manner, such that duration and intensity play a role in the determination of a zone associated with better neurological outcome.

Introducing TOPMAST, the first double-blind randomized clinical trial specifically dedicated to perioperative maintenance fluid therapy in adults

BACKGROUND

Although prescribed to every patient undergoing surgery, maintenance fluid therapy is a poorly researched part of perioperative fluid therapy. The tonicity of the chosen solutions, could be an important cause of morbidity, with hyponatremia being a potential side effect of hypotonic solutions, where isotonic solution could lead to fluid overload.

METHODS

The TOPMAST-trial is an ongoing prospective single-center double-blind randomized trial comparing an isotonic and a hypotonic maintenance fluid strategy during and after surgery in patients undergoing different types of major thoracic surgery. Patients receive NaCl 0.9% in glucose 5% with an added 40 mmol L-1 of potassium chloride or a premixed solution containing 54 mmol L-1 sodium, 55 mmol L-1 chloride and 26 mmol of potassium at a rate of 27 mL per kg of body weight per day. The primary hypothesis is that isotonic maintenance solutions cause a more positive perioperative fluid balance than hypotonic fluids. Different secondary safety endpoints will be explored, especially the effect of the study treatments on the occurrence electrolyte disturbances (e.g. hyponatremia, hyperchloremia) and a set of clinical endpoints. Efficacy endpoints include the need for resuscitation fluids and assessment of renal and hormonal adaptive mechanisms. An anticipated 68 patients will be included between March 2017 and January 2018.

DISCUSSION

The study will provide the most comprehensive evaluation of clinically important outcomes associated with the choice of perioperative maintenance fluid therapy.

Cerebral Perfusion Pressure Insults and Associations with Outcome in Adult Traumatic Brain Injury

The definition of cerebral perfusion pressure (CPP) secondary insults in severe traumatic brain injury remains unclear. The purpose of the present study is to visualize the association of intensity and duration of episodes below or above CPP thresholds and outcome. The analysis was based on prospectively collected minute-by-minute intracranial pressure (ICP) and blood pressure data and outcome from 259 adult patients. The relationship of episodes of CPP below or above a certain threshold for certain duration with the 6-month Glasgow Outcome Score was visualized separately for episodes of active or deficient autoregulation (AR). In adults ≤65 years, an almost exponential transition curve separates the episodes of CPP associated with better outcomes from the episodes of low CPP associated with worse outcomes, indicating that lower CPP could only be tolerated for a brief time. Analysis of episodes of high CPP again showed a time-intensity dependent association with outcome. When combining the two plots, a safe CPP zone between 60 and 70 mm Hg could be delineated-however, only for AR active insults. The AR status predominantly affected the transition curve for insults of low CPP. Episodes with ICP >25 mm Hg were associated with poor outcome regardless of CPP. In the present study, the CPP pressure-time burden associated with poor outcome was visualized. A safe zone between 60 and 70 mm Hg could be identified for adults ≤65 years, provided AR was active and ICP was ≤25 mm Hg. Deficient AR reduces the tolerability for low CPP.

Retinal haemorrhages in a university hospital: not always abusive head injury

Retinal haemorrhages (RH) and subdural haematomas (SDH) are frequently seen in abusive head trauma (AHT). The aim of our study is to show that they are suggestive, but not pathognomonic for AHT. We performed an observational retrospective study on children, aged 1-18 months old, admitted to the Antwerp University Hospital with RH. History, physical examination, medical course, coagulation and metabolic tests, skeletal survey, head circumference, retinal findings, cerebral imaging, and evaluation reports by social services or civil/criminal courts were collected. Twenty-nine children with RH were included. Twenty three of them were found suspect of AHT. Three children of this group showed intraparenchymal haematomas/infarctions, 5 interhemispheric blood, 6 cerebral oedema, 7 ventricle compression, and 4 papilloedema. Seven of the 16 children with diffusion-weighted MRI images showed diffuse lesions. In 2 of the 6 children not suspect for AHT, an aetiology was found. None of the 4 remaining children showed the above-mentioned abnormalities. Three of these 4 cases showed an accelerated growth of the head circumference months before presentation. The majority of the children in all groups showed 'too numerous to count' (>20) RH (12 of the 23 'suspect' children, and 4 of the 6 'non-suspect' children). Results showed no differences between the groups concerning the location, distribution, or size of the RH. Infants with RH and/or SDH are not necessarily victims of AHT. Cerebral imaging and retinal findings can help differentiate suspect from non-suspect cases. Infants with a large head circumference could be predisposed to RH or SDH.

Delta-storage pool disease as a mimic of abusive head trauma in a 7-month-old baby: a case report

A seven-month-old baby was admitted to a hospital emergency department after collapsing suddenly while staying with his nanny. The baby displayed classic symptoms of shaken baby syndrome, including subdural haemorrhage, cytotoxic cerebral oedema, and bilateral retinal hemorrhages. Child protection services were informed, but both the parents and the nanny denied any involvement. In the subsequent weeks, the baby developed three other episodes of new subdural bleeding and a medico-legal investigation was started into the origin of the repeated subdural bleeding. Eventually, platelet aggregation tests and electron microscopy diagnosed a delta-storage pool disease; that is, a haemostatic disorder involving dense granules of the platelets. Initial minor blunt trauma may have resulted in subdural bleeding, while subsequent retinal haemorrhage could have been facilitated by the underlying haemostatic disorder. Delta-storage pool disease should be considered as a possible mimic of abusive head trauma similar to other rare conditions such as Menkes disease and type 1 glutaric aciduria.

Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study

PURPOSE

Despite their controversial role, corticosteroids (CS) are frequently administered to patients with H1N1 virus infection with severe respiratory failure secondary to viral pneumonia. We hypothesized that invasive pulmonary aspergillosis (IPA) is a frequent complication in critically ill patients with H1N1 virus infection and that CS may contribute to this complication.

METHODS

We retrospectively selected all adult patients with confirmed H1N1 virus infection admitted to the intensive care unit (ICU) of two tertiary care hospitals from September 2009 to March 2011. Differences in baseline factors, risk factors, and outcome parameters were studied between patients with and without IPA.

RESULTS

Of 40 critically ill patients with confirmed H1N1, 9 (23 %) developed IPA 3 days after ICU admission. Five patients had proven and four had probable IPA. Significantly more IPA patients received CS within 7 days before ICU admission (78 versus 23 %, p = 0.002). IPA patients also received significantly higher doses of CS before ICU admission [hydrocortisone equivalent 800 (360-2,635) versus 0 (0-0) mg, p = 0.005]. On multivariate analysis, use of CS before ICU admission was independently associated with IPA [odds ratio (OR) 14.4 (2.0-101.6), p = 0.007].

CONCLUSIONS

IPA was diagnosed in 23 % of critically ill patients with H1N1 virus infection after a median of 3 days after ICU admission. Our data suggest that use of CS 7 days before ICU admission is an independent risk factor for fungal superinfection. These findings may have consequences for clinical practice as they point out the need for increased awareness of IPA, especially in those critically ill H1N1 patients already receiving CS.

Visceral leishmaniasis in a child infected with the human immunodeficiency virus in a non-endemic region

We reported the case of a boy who fled from Chechnya to Belgium. He was diagnosed with a human immune deficiency virus (HIV)/Visceral leishmaniasis (VL) coinfection. In both countries, the prevalence of HIV-infected children is low and VL is not endemic. Migration of people results in confrontation with diseases that are not frequent in the countries of destination and becomes a challenge for pediatricians.

A retrospective observational study on the efficacy of colistin by inhalation as compared to parenteral administration for the treatment of nosocomial pneumonia associated with multidrug-resistant Pseudomonas aeruginosa

Background

Colistin is used as last treatment option for pneumonia associated with multidrug-resistant (MDR) Pseudomonas spp.. Literature about the best administration mode (inhalation versus parenteral treatment) is lacking.

Methods

A retrospective study of 20 intensive care patients with a pneumonia associated with MDR P. aeruginosa receiving colistin sulphomethate sodium (Colistineb^®) between 2007 and 2009 was performed. A strain was considered multidrug-resistant if it was resistant to at least 6 of the following antibiotics: piperacillin-tazobactam, ceftazidime, cefepime, meropenem, aztreonam, ciprofloxacin, and amikacin. The administration mode, predicted mortality based on the SAPS3 score, SOFA score at onset of the colistin treatment, clinical and microbiological response, and mortality during the episode of the infection were analysed. The non parametric Kruskal-Wallis and Fisher's Exact test were used for statistical analysis of respectively the predicted mortality/SOFA score and mortality rate.

Results

Six patients received colistin by inhalation only, 5 were treated only parenterally, and 9 by a combination of both administration modes. All patients received concomitant beta-lactam therapy. The mean predicted mortalities were respectively 72%, 68%, and 69% (p = 0.91). SOFA scores at the onset of the treatment were also comparable (p = 0.87). Clinical response was favorable in all patients receiving colistin by inhalation (6/6) and in 40% (2/5) of the patients receiving colistin parenterally (p = 0.06). In the patients with colistin administered both via inhalation and parenterally, clinical response was favorable in 78% of the patients (7/9) (p = 0.27 as compared to the treatment group receiving colistin only parenterally). When all patients with inhalation therapy were compared to the group without inhalation therapy, a favorable clinical response was present in respectively 87% and 40% (p = 0.06). In none of the patients, the Pseudomonas spp. was eradicated from the follow-up cultures.

All patients in the parenterally treated group died. None of the patients receiving colistin by inhalation, and 3 of 9 patients of the combination group eventually died (p = 0.002 and p = 0.03 respectively as compared to the group receiving colistin only parenterally).

Conclusions

Aerosolized colistin could be beneficial as adjunctive treatment for the management of pneumonia due to MDR P. aeruginosa.

Comparative analysis of two methods for wound bed area measurement

Wound bed area measurements are considered to be an essential part of the wound assessment process. Wound care professionals should be aware of the reliability and validity of the techniques they use. The purpose of this study was to assess whether wound care professionals are able to make as accurate and reproducible a measurement of the wound bed area using two methods for area measurement. Five wound care professionals independently assessed 2285 digital wound images for the wound bed area. Each image was measured in random order, three times, and in four angles by providing the rotated versions of each image (0°, 90°, 180° and 270°). Two techniques were compared: free hand drawing and closed polygon (CP) graph algorithm. Comparison of the two techniques showed differences that are, in our opinion, not acceptable in clinical practice when these techniques are used interchangeably and/or the measurements are carried out by different observers. Variations observed between wounds and observers seem related to the difference in perception of the wound bed margin. Our results indicate that repetition of CP graph area measurement results in the lowest difference in repetitive measurements. Study limitations are related to an incomplete consensus on definitions of wound, wound bed, wound edge and wound border. The development of an ontology related to wound images could aid to reduce these ambiguities.

Automatic colorimetric calibration of human wounds

Background

Recently, digital photography in medicine is considered an acceptable tool in many clinical domains, e.g. wound care. Although ever higher resolutions are available, reproducibility is still poor and visual comparison of images remains difficult. This is even more the case for measurements performed on such images (colour, area, etc.). This problem is often neglected and images are freely compared and exchanged without further thought.

Methods

The first experiment checked whether camera settings or lighting conditions could negatively affect the quality of colorimetric calibration. Digital images plus a calibration chart were exposed to a variety of conditions. Precision and accuracy of colours after calibration were quantitatively assessed with a probability distribution for perceptual colour differences (dE_ab). The second experiment was designed to assess the impact of the automatic calibration procedure (i.e. chart detection) on real-world measurements. 40 Different images of real wounds were acquired and a region of interest was selected in each image. 3 Rotated versions of each image were automatically calibrated and colour differences were calculated.

Results

1^st Experiment: Colour differences between the measurements and real spectrophotometric measurements reveal median dE_ab values respectively 6.40 for the proper patches of calibrated normal images and 17.75 for uncalibrated images demonstrating an important improvement in accuracy after calibration. The reproducibility, visualized by the probability distribution of the dE_ab errors between 2 measurements of the patches of the images has a median of 3.43 dE* for all calibrated images, 23.26 dE_ab for all uncalibrated images. If we restrict ourselves to the proper patches of normal calibrated images the median is only 2.58 dE_ab! Wilcoxon sum-rank testing (p < 0.05) between uncalibrated normal images and calibrated normal images with proper squares were equal to 0 demonstrating a highly significant improvement of reproducibility. In the second experiment, the reproducibility of the chart detection during automatic calibration is presented using a probability distribution of dE_ab errors between 2 measurements of the same ROI.

Conclusion

The investigators proposed an automatic colour calibration algorithm that ensures reproducible colour content of digital images. Evidence was provided that images taken with commercially available digital cameras can be calibrated independently of any camera settings and illumination features.

Clinical pharmacology of exogenously administered alkaline phosphatase

PURPOSE

To evaluate the clinical pharmacology of exogenous alkaline phosphatase (AP).

METHODS

Randomized, double-blind, placebo-controlled sequential protocols of (1) ascending doses and infusion duration (volunteers) and (2) fixed dose and duration (patients) were conducted at clinical pharmacology and intensive care units. A total of 103 subjects (67 male volunteers and 36 patients with severe sepsis) were administered exogenous, 10-min IV infusions (three ascending doses) or 24-72 h continuous (132.5-200 U kg(-1) 24 h(-1)) IV infusion with/without preceding loading dose and experimental endotoxemia for evaluations of pharmacokinetics, pharmacodynamics, safety parameters, antigenicity, inflammatory markers, and outcomes.

RESULTS

Linearity and dose-proportionality were shown during 10-min infusions. The relatively short elimination half-life necessitated a loading dose to achieve stable enzyme levels. Pharmacokinetic parameters in volunteers and patients were similar. Innate immunity response was not significantly influenced by AP, while renal function significantly improved in sepsis patients.

CONCLUSIONS

The pharmacokinetics of exogenous AP is linear, dose-proportional, exhibit a short half-life, and are not influenced by renal impairment or dialysis.

Glucose control and use of continuous glucose monitoring in the intensive care unit: a critical review

Stress hyperglycemia recently became a major therapeutic target in the Intensive Care Unit (ICU) since it occurs in most critically ill patients and is associated with adverse outcome, including increased mortality. Intensive insulin therapy to achieve normoglycemia may reduce mortality, morbidity and the length of ICU and in-hospital stay. However, obtaining normoglycemia requires extensive efforts from the medical staff, including frequent glucose monitoring and adjustment of insulin dose. Current insulin titration is based upon discrete glucose measurements, which may miss fast changes in glycemia and which does not give a full picture of overall glycemic control. Recent evidence suggests that continuous monitoring of glucose levels may help to signal glycemic excursions and eventually to optimize insulin titration in the ICU. In this review we will summarise monitoring and treatment strategies to achieve normoglycemia in the ICU, with special emphasis on the possible advantages of continuous glucose monitoring.

The Belgian PCB/dioxin crisis-8 years later An overview

In January 1999, 50kg polychlorinated biphenyls (PCBs) contaminated with 1g dioxins were accidentally added to a stock of recycled fat used for the production of 500tonnes animal feed in Belgium. Although signs of poultry poisoning were noticed by February 1999, the extent of the contamination was publicly announced only in May 1999, when it appeared that more than 2500 poultry and pig farms could have been involved. This has resulted in a major food crisis, known worldwide as the "Belgian PCB/dioxin crisis". The crisis was resolved by the implementation of a large food monitoring program for the seven PCB markers (PCBs 28, 52, 101, 118, 138, 153 and 180). When PCB concentrations exceeded the tolerance levels of 100, 200 or 1000ng/g fat for milk, meat or animal feed, respectively, the 17 toxic polychlorinated dibenzodioxins and furans (PCDD/Fs) congeners were also determined. By December 1999, more than 55,000 PCB and 500 dioxin analyses were already done by Belgian and international laboratories. The highest concentrations of PCBs and dioxins and the highest percentage of affected animals were found in poultry. Several important consequences of the food crisis were: (1) the introduction in 1999 of norms for PCBs in feedstuffs and food in Belgium followed by the introduction in 2002 of European harmonized norms for PCDD/Fs in animal feed and food of animal origin; (2) the systematic national monitoring of food of animal origin; and (3) the creation of the Federal Agency for Food Safety in Belgium. The human health risk following this major incident was assessed with contradictory results. It was suggested that, since only a limited proportion of the food chain was contaminated, it is unlikely that adverse effects were inflicted in the Belgian population. However, another assessment suggests that neurotoxic and behavioural effects in neonates, together with an increase in the number of cancers, may be observed.

Necrotizing pancreatitis due to poisoning with organophosphate pesticides

Several complications have been reported in relation to organophosphate poisoning. Pancreatitis due to cholinergic hypersecretion related to this type of poisoning, is however rare and has usually a subclinical course. Necrotizing pancreatitis has only been reported in 3 patients. We present a case of a young man who deliberately ingested the organophosphate dichlorvos and developed a necrotizing pancreatitis. A distal spleen and vessel preserving pancreatectomy was performed already 36 hours after ingestion. We believe that due to this very early surgery, this patient could be discharged as early as 12 days after surgery.

Systemic inflammation and reperfusion injury in patients with acute myocardial infarction

Despite early recanalization of an occluded infarct artery, tissue reperfusion remains impaired in more than one-third of the acute myocardial infarction (AMI) patients owing to a process of reperfusion injury. The role of systemic inflammation in triggering this phenomenon is unknown. Proinflammatory factors (hs-CRP, TNF-alpha ) and anti-inflammatory mediators (IL-1 receptor antagonist, IL-10) were measured in 65 patients during the acute phase of a myocardial infarction as well as in 11 healthy control subjects. Myocardial reperfusion injury was defined as the presence of persistent ST-segment elevation despite successful coronary intervention (> or = 50 of the initial value) and was observed in 28 patients. Systemic proinflammatory mediators (particularly hs-CRP and leukocytes) were higher in AMI patients compared to control subjects. Within the group of AMI patients, only serum TNF-alpha differed significantly between patients with versus without reperfusion injury: a median value of 25 versus 13 pg/mL was observed, respectively. Logistic regression analysis identified a high level of TNF-alpha as the most important independent determinant of reperfusion injury (P = .001), beyond total ischemic time (P = .01) and extent of jeopardized myocardium (P = .08). There was no correlation between the TNF-alpha level and the total ischemic time (P = .8) or the extent of jeopardized myocardium (P = .6). Systemic inflammation, in particular high levels of TNF-alpha , is strongly associated with the occurrence of reperfusion injury after successful recanalization. Our findings suggest that TNF-alpha is involved in the triggering and/or amplification of local inflammatory responses related to ischemia-reperfusion injury.

Fast identification of ten clinically important micro-organisms using an electronic nose

AIMS

To evaluate the electronic nose (EN) as method for the identification of ten clinically important micro-organisms.

METHODS AND RESULTS

A commercial EN system with a series of ten metal oxide sensors was used to characterize the headspace of the cultured organisms. The measurement procedure was optimized to obtain reproducible results. Artificial neural networks (ANNs) and a k-nearest neighbour (k-NN) algorithm in combination with a feature selection technique were used as pattern recognition tools. Hundred percent correct identification can be achieved by EN technology, provided that sufficient attention is paid to data handling.

CONCLUSIONS

Even for a set containing a number of closely related species in addition to four unrelated organisms, an EN is capable of 100% correct identification.

SIGNIFICANCE AND IMPACT OF THE STUDY

The time between isolation and identification of the sample can be dramatically reduced to 17 h.

Pentobarbital fails to reduce cerebral oxygen consumption early after non-hemorrhagic closed head injury in rats

It is unknown whether barbiturates suppress cerebral oxygen metabolism after cerebral trauma as they do in normal individuals. We evaluated the influence of pentobarbital on cerebral oxygen handling of normal rats and rats subjected to non-hemorrhagic closed head injury (CHI). Oxygen delivery was assessed by measuring cerebral perfusion and oxygen extraction, enabling the calculation of cerebral metabolic rate of oxygen (CMRO2). Mitochondrial function was assessed by studying changes in the oxidized cytochrome oxidase concentration. CHI caused changes in both systemic and cerebral hemodynamics. Cerebral blood flow was reduced to 66% of its control value, but the cerebral metabolic rate of oxygen remained unchanged. Pentobarbital administration induced a significant lowering of the cerebral oxygen consumption in normal rats associated with a secondary decrease in cerebral perfusion. In rats subjected to CHI, pentobarbital was unable to lower the cerebral metabolic demand and did not cause a further decrease in perfusion. Pentobarbital was unable to significantly modulate mitochondrial function in traumatized rats, whereas it exerted this effect in all control animals. We therefore conclude that, in rats subjected to CHI, pentobarbital is unable to perform its beneficial effects on the cerebral metabolism.

Thoracic trauma: an analysis of 187 patients

A retrospective analysis of 187 cases of thoracic trauma seen between January 1, 1994 and June 30, 1999 is presented. The majority of the patients were male (male-female ratio 2.9:1) and the average age at admission was 41.1 years. Blunt trauma, especially motor vehicle accidents (72.2%) and falls (17.1%), were the most frequent causes of chest injury (95.8%). We used the injury severity score (ISS) to assess the severity of trauma. The average ISS for the total group was 27.8 (ranges: 4-75). In only 17.6% of the patients an isolated thoracic trauma was present. Rib fractures (n = 133), pulmonary contusion (n = 110), pneumothorax (n = 78) and haemothorax (n = 65) were the most frequent lesions. Most patients (97.9%) were admitted to the intensive care department. A minority of the patients required thoracotomy (n = 19, 10.2%). Main indications for thoracotomy were pulmonary laceration (n = 5), aortic rupture (n = 3) and rupture of the diaphragm (n = 3). For the majority of cases, observation and/or tube thoracostomy (52.4%) and/or mechanical ventilation (61.0%) were sufficient. Pneumonia and adult respiratory distress syndrome were the most common complications (38.0 and 7.0% respectively). The overall mortality rate was 16.6%. Main causes of death were intracranial hypertension, sepsis combined with multiple organ failure, and hypovolaemic shock. For patients who did not survive the average ISS was 40.3. In a survival analysis the ISS was found to be the most significant determining survival (p < 0.0001), followed by neurotrauma (p = 0.05). Mortality after thoracic trauma remains relatively high, especially in case of associated neurotrauma. The ISS is a valuable score for assessing the severity of trauma and predicting outcome.

Determinants and prognostic implications of persistent ST-segment elevation after primary angioplasty for acute myocardial infarction: importance of microvascular reperfusion injury on clinical outcome

BACKGROUND

Despite early recanalization of an occluded infarct artery, reperfusion at the level of the microcirculation may remain impaired owing to a process of microvascular reperfusion injury.

METHODS AND RESULTS

Microvascular reperfusion injury was studied in 91 patients with acute myocardial infarction (AMI) by evaluation of the resolution of ST-segment elevation after successful PTCA. Impaired microvascular reperfusion, defined as the presence of persistent (>/=50% of initial value) ST-segment elevation (ST >/=50%) at the end of coronary intervention, was observed in 33 patients (36%) and was independently correlated with low systolic pressure on admission and high age. Patients >/=55 years of age with systolic pressures </=120 mm Hg were at high risk for development of impaired reperfusion compared with patients not meeting these criteria (72% versus 14%, P<0.001). Impaired microvascular reperfusion was associated with a more extensive infarction and worse clinical outcome at the 1-year follow-up: cardiac death rate, 15% versus 2% (ST >/=50% versus ST <50%, P=0.01); nonfatal MI rate, 9% versus 2% (P=0.1); and total major adverse cardiac event (MACE) rate, 45% versus 15% (P<0.005). ST >/=50% was the most important independent determinant of MACE with an adjusted risk ratio of 3.4.

CONCLUSIONS

Impaired microvascular reperfusion, as evidenced by ST >/=50% after successful recanalization, occurs in more than one third of our AMI patients, especially in older patients with low systolic pressure. Its detrimental implications on clinical outcome reinforce the need to develop adjunctive agents that attenuate the process of reperfusion injury.

Acute superior vena cava obstruction after rupture of a bronchial artery aneurysm

A patient was referred to our hospital with a superior vena cava syndrome after the rupture of a bronchial artery aneurysm. To our knowledge, this complication has not been reported before. An urgent thoracotomy was performed after embolization had failed.

Mediastinal thymic cyst

A symptomatic anterior mediastinal mass in a 44-year-old woman was found to be a benign thymic cyst. Complete excision was made by anterolateral thoracotomy. Congenital cysts are benign but differentiation from malignant cystic degeneration should be made.