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Displaying 10 papers, 191 pages, start at 1, 80 Hits
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Conclusions

High in of respiratory virus is found in children with wheezing exacerbation. RV is the most important pathogen in recurrent wheezing patients. The RV induced wheezing is associated with high level of EOS, LYMP and WBC counts. It implies RV may associated with atopy and immunoreaction. The clinical symptom is not different between RV and other virus infection in short time. Background: Staphylococcus aureus is known to be the most frequent cause of skin infection or aggravating factor in atopic dermatitis patients. The colonization rate of S. aureus reaches to 90% of atopic dermatitis patients, which is much higher than in the healthy subjects. Until now, bacteria could be identified only through the bacterial culture technique, by which only 1% of total bacteria can be identified. Here, we performed metagenomic analysis to determine major colonizing bacteria in the skin of atopic dermatitis patients vs. healthy control subjects. Methods: Seventeen patients with atopic dermatitis and 6 healthy control subjects were enrolled. Skin washing fluids were obtained from the moistened gauze which loaded on the skin lesion in the cubital fossa of atopic dermatitis patients and on the same part of normal controls. After genomic DNA was extracted from the skin washing fluids, 16s ribosomal DNA was amplified using the universal primer, sequenced through the next generation sequencer, and then the sequenced data was analyzed using bioinformatics. Results: Staphylococcus spp. was dominant in the skin from atopic dermatitis patients, while it was undetectable in the control subject skins. The mean proportion of Staphylococcus in the total bacterial DNA of atopic dermatitis patients was 68%, however that was 0% in normal controls. Additional analysis for the species of Staphylococcus spp. revealed that most of Staphylococcus spp. was Staphylcoccus aureus. The following frequent bacteria were Pseudomonas and Streptococcus spp., and their proportions were 11% and 10% in the patients vs. 2% and 1% in the controls, respectively. On the other hand, Alcaligenaceae family and Sediminibacterium spp. were the most frequent bacteria in the skin of the controls, and their proportions were 39% and 13% in the controls vs. 0% and 0% in patients, respectively. Conclusions: Staphylcoccus aureus is the predominant colonizer in the atopic dermatitis skin through the metagenomic analysis of bacterial DNA. Background: The aim of this study was to estimate the efficacy and the safety of the combination of micronized cellulose powder and locally applied glucocorticoids on the symptoms of allergic rhinitis. Methods: This single blind controlled study was conducted in 120 subjects (2-60 years of age, mean age 38.5) with allergic rhinitis, 66 men and 54 women. All participants had a positive medical history for allergic rhinitis. They were randomized to 1 puff mometasone furoate followed by 1 puff of commercially available micronized cellulose powder in the morning, and only 1 puff micronized cellulose powder in the evening (test treatment, TT) or 1 puff mometasone furoate, Bid (reference treatment, RT). Participants were allowed to take oral antihistamine or eye drops they wished. The symptom scores were recorded before and after the treatment. Mean values for the sum of all scores were calculated. The pre-vs post-treatment differences were compared using t-test. Also the decrease of the symptom scores between groups were compared using t-test. The efficacies were analyzed using Chi-2 tests. Results: Both treatments could reduce the symptom scores significantly (P<0.001), and the improvement rates were similar (P=0.052). Total efficacies of RT and TT were 95% and 100% respectively without significant differences (P=0.244). There were no adverse reaction found in both groups. Conclusions: The combination of micronized cellulose powder and locally applied glucocorticoids could reduce the dose of glucocorticoids, and the treatment is safe.

A484

Long-Term Outcomes of Twenty-Four Adults with Primary Immunodeficiency from a Single Centre in Singapore Hiok Hee Chng Tan Tock Seng Hospital, Singapore World Allergy Organization Journal 2016, 9(Suppl 1):A484 Background: Primary immunodeficiency diseases (PID) in adults are often under-recognised resulting in delay in diagnosis and significant morbidity and mortality. We review the long-term outcomes of adults with PID from the Tan Tock Seng Hospital PID Registry. Methods: Chart review of adults with PID onset at age 18 years or above who were longitudinally followed-up from time of diagnosis between 1 Jan 1989 and 1 May 2015. Results: There were 24 patients, 13(54.2%) males and 11(45.8%) females. Eighteen(75%) were ethnic Chinese, 5(20.8%) Malay and 1 Indian. The mean±SD age at diagnosis was 46.3±17.9 years (range 18.4-69.1). By IUIS grouping, antibody deficiencies was most common (14 patients, 58.3%), comprising common variable immunodeficiency [CVID] (8), selective IgA deficiency alone (3), selective IgA with IgG2 and G4 deficiency (1), selective IgG2 and G4 deficiency alone (1) and hypogammaglobulinaemia (1, who had ring chromosome 18). Ten patients (41.7%) had other PIDs, namely immunodeficiency with thymoma (8), chronic mucocutaneous candidiasis [CMC] (1) and hyperIgE syndrome (1) . Half of the patients already had bronchiectasis and 7(29.2%) had chronic sinusitis at diagnosis of PID. Seronegative arthritis developed in 2 females, one was a year following diagnosis of CMC, and the other was coincident with diagnosis of CVID. Systemic lupus erythematosus predated the diagnosis of selective IgA deficiency by 7 years in one patient. There were 7(29.2%) deaths. Four(57.1%) of them had bronchiectasis at diagnosis, and died from chronic respiratory failure with or without pneumonia despite regular adequate IVIG replacement. A 47-year-old female with CVID, who was irregular with IVIG replacement, died from persistent Elizabethkingia meningoseptica bacteraemia and septic shock following consumption of frogs. Two other patients who died were males with thymoma and immunodeficiency; one from metastatic thymoma and the other from multiple infections associated with T cell defects (cytomegalovirus colitis and retinitis, disseminated candida esophagitis and hepatitis, ocular toxoplasmosis). Conclusions: The spectrum of adult PID patients managed in our centre is as reported elsewhere. Many of our patients present late with established sinopulmonary complications which contributed to their death. Breast feeding is recommended for the prevention of allergic diseases, particularly in high risk infants, but the evidence of a protective effect on food sensitization and food allergy(FA) remains elusive. The aim of this study is to investigate the association between breast feeding and food sensitization and FA in children under 2 years with atopic dermatitis Methods We reviewed the medical records of 384 children with atopic dermatitis under 2 years old who visited our pediatric allergic clinic between March 1, 2009 and December 31, 2014 . We assessed symptoms of FA, duration of breast feeding, history of parental allergic diseases, and other concomitant allergic diseases. Laboratory tests including serum total IgE, eosinophil(%), and specific IgE to egg white, milk, soy, wheat, and peanut were measured. On the basis of sensitization (IgE ≥ 0.35 KU/L) and clinical history, children were as having FA and having no FA. Having no FA group was divided with sensitized but tolerant, or not allergic/not sensitized.
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Conclusion

septicaemia 16 (34.8%), secondary pneumonia 24 (52.2%), deep vein thrombosis 11 (23.9%), acute renal failure 9 (19.6%), acute myocardial infraction 8 (17.4%), stress hyperglycaemia 8 (17.4%), pneumothorax 8 (17.4%), pulmonary embolism 7 (15.2%), cerebrovascular accidents 4 (8.7%) and pneumomediastinum 1 (2.2%), The in-ICU mortality was 54.3% (25/46). The median (IQR) length of mechanical ventilation was 12 (9-22) days. The median (IQR) lengths of stay in the hospital and ICU were 23.5 (15-36) days and 14.5 (7-22) days, respectively. Cox regression analysis showed that the male sex (P = 0.03), an APACHE II score > 15 (P = 0.003) and a history of congestive cardiac failure (0.017) were independent predictors for mortality among SARS ICU patients.
Conclusion About one in five probable SARS patients required ICU care. This group of critically ill SARS patients has high mortality and morbidity. The predictors for ICU mortality were male sex, APACHE II score > 15 and history of congestive cardiac failure. Objective This study aimed to describe patients with SARS who developed respiratory failure requiring ICU admission.

Results

There were no statistically significant differences in gender between the groups. Patients in groups B and C were older than those in group A (P < 0.05), the significance is even greater when comparing only groups A and B (P < 0.005). Duration of examination in the ER did not influence the accuracy of diagnosis, patients in groups B and C were even longer examined (P < 0.05). We have found that the proportion of patients with history of angina or MI was greater in group A than group B or C (55.1%, 31.1% and 31.3%, respectively) and this was statistically significant (P < 0.005). Smoking, high cholesterol, hypertension, and diabetes did not significantly differ between the groups. Interestingly, we have found that proportion of patients admitted during the afternoons, nights or weekends was higher in groups B and C than in group A (P < 0.05), although characteristics of these patients did not differ from those admitted during the 'ICU staff shift'. Following clinical evaluation including 12-lead ECG, all patients were subjected to routine laboratory testing (including liver and kidney functions, lipid profile, CBC, and random blood sugar). Specific laboratory tests included serum fibrinogen and plasma NO expressed as its metabolites, nitrites and nitrates (NOx), as measured by the Griess reaction.

Conclusions

Results Twenty-six patients died of AMI within 30 days. Univariate analysis indicated that histories of diabetes, prior myocardial infarction and cerebral infarction, high white blood cell count (≥ 10 × 10 9 /l), low left ventricular ejection fraction (< 50%), inhospital complications including arrhythmia, pump failure and pneumonia, as well as the therapy without aspirin were significantly associated with the inhospital mortality within 30 days. Multivariate logistic regression analysis, using mortality as the dependent variable and using the history, inhospital complications and so on as the independent variable, showed that the major determinants of the inhospital mortality were the histories of diabetes (odds ratio = 3.58, 95% confidence interval [CI] = 1.08-11.90) and cerebral infarction (odds ratio = 6.82, 95% CI = 1.55-29.98), and inhospital complication of pump failure (odds ratio = 13.11, 95% CI = 3.84-44.78).

Conclusion

Methods Eighty-two patients, with 28 of them suffering from sepsis, admitted in the ICU of a general hospital over a 5-month period, were included at random. The exclusion criteria were a history of dysthyroidism or treatment intake that affects thyroid function. The levels of AT, thyroid stimulating hormone (TSH), fT3, fT4, C reactive protein (CRP) and leukocyte count were measured at admission. These investigations concerning blood samples were part of the routine biological balance. APACHE II and SAPS II scores were calculated using data from the first 24 hours of the ICU stay. Patients were followed until ICU discharge or death to determine the survival rate. P < 0.05 and r < 0.05 were considered significant.

Methods

Methods Using a model of Jahangir and colleagues [1] , 14 patients with multiple injuries and history of asthma were included during their ICU stay (nine spontaneously breathing, five mechanically ventilated). Patients were randomised into two groups. Group 1 patients received an infusion of ketamine and midazolam. The two drugs were mixed in one syringe (50 mg ketamine and 5 mg midazolam). The mean rate of infusion for ketamine was 150-250 ng/kg/hour and for midazolam was 0.015-0.03 ng/kg/hour. Midazolam was added to eliminate the side effects of ketamine and for sedation. Group 2 patients received an infusion of ketamine only (0.2-0.4 mg/kg/hour). The following parameters of haemodynamics and ventilation were monitored: heart rate, mean arterial pressure, respiratory rate, arterial and end-expiratory PO 2 , arterial PO 2 , transcutaneous oxygen saturation SpO 2 , pulmonary compliance and resistance (in ventilated patients), and subjective perception of pain using the visual analogue scale (VAS 1-10 points), Ramsey sedation scale (wake and sleep levels), and rate of appearance of side effects. Ketamine in a mixture with midazolam led to insignificant changes in hemodynamics and only in group 2 patients were more significant changes noted (tachycardia and mild hypertension).

Results

In patients with an elevated cTnT, 60/62 sets of notes were assessed for glycaemic control. In these patients 38/60 (63.3%) had BM > 11.1 mmol/l and 59/60 (98.3%) had BM > 6.1 mmol/l. A past history of impaired glucose tolerance/diabetes mellitus was present in 12/38 (31.6%) of patients with an elevated BM > 11.1 mmol/l. Insulin therapy was not commenced in 6/38 patients with BM > 11.1 mmol/l. In 19/32 (59.4%) of patients prescribed insulin there was a delay in infusion commencement (median 3.5 hours, range 1-9 hours). Hypoglycaemia (BM < 2.2 mmol/l) was documented in 3/32 patients receiving insulin. The mortality rate was high in all patients with a raised BM (BM 6.1-11.1 mmol/l, mortality 12/21 (57.1%) vs 20/38 (52.6%) for BM > 11.1 mmol/l; NS). The one patient without an elevated BM survived.
Ninety-eight patients were included in the study: 51 received no insulin, 47 received insulin at some time during the first 24 hours of admission and patients were grouped accordingly. There were no patients with a history of diabetes in the 'no insulin' group and 10 in the 'insulin' group. The mean (SD) number of hours patients who received no insulin were recorded as having a blood glucose > 8.0 was 0.40 (1.41) and for the 47 patients who received insulin 4.74 (4.77). The mean (SD) total insulin dose in the first 24 hours for the 'insulin' group was 38.4 (57.3) IU. Mortality in the 'no insulin' group was 13.1% and in the 'insulin' group 19.1% (chi-square 1.238, P > 0.20). There were no deaths among the previously diagnosed diabetic patients. When these patients were excluded from the analysis the mortality was 13.1% and 32.1%, respectively (chisquare 2.78, P < 0.10, P > 0.05).

Methods

March 2002 and August 2003 were reviewed and 163 patients who had a short corticotropin stimulation test done during an ICU admission because of septic shock were identified. Our cohort was divided into those who received Etomidate or not before the corticotropin stimulation test. The incidence of relative adrenal insufficiency was compared between these two groups. Data collected included demographics, presence of relative adrenal insufficiency, presence of coagulopathy, the use of steroids or any medication known to interfere with cortisol synthesis, use of Etomidate and the time interval between the administration and the cosyntropin test, history of adrenal/pituitary disease, and mortality.

Results

None of the patients were on any medication known to interfere with the test. There was no patient with previous history of adrenal/pituitary disease. Of the 46 patients who received Etomidate, 36 (78%) were diagnosed as having relative adrenal insufficiency compared with 58/117 (50%) patients who did not (P = 0.0008). Relative adrenal insufficiency was noted in 79% of the patients who received Etomidate within 6 hours compared with 78% of the patients who received Etomidate later than 6 hours of the test (P = 0.9246). The mortality rate was 53% (50/94) in patients with relative adrenal insufficiency compared with 61% (42/69) in patients without relative adrenal insufficiency (P = 0.3287).

Materials and methods

We measured erythrocyte (E) and plasma (P) glutathione peroxidase (GPx), malondialdehyde (MDA) and superoxide dismutase (SOD) on the pretreatment period and the post-treatment period in 20 patients with acute exacerbation of COPD. Twenty healthy smokers and 20 nonsmokers having no history of lung disease served as control subjects.

Conclusions

Early laparoscopic surgical treatment improved the prognosis in these severe cases. Methods This study evaluated the predefined subgroup of 226 patients with a history of pulmonary disease included in a prospective randomized controlled trial of BNP testing for the emergency diagnosis of acute dyspnea. Patients were randomly assigned to a diagnostic strategy with (n = 119, BNP group) or without (n = 107, clinical group) the use of BNP levels provided by a rapid bedside assay. The time to discharge and the total cost of treatment were recorded as the primary endpoints.
Conclusion Used in conjunction with other clinical information, rapid measurement of BNP reduced the time to discharge and total treatment cost of patients with a history of pulmonary disease presenting with acute dyspnea. Introduction Prehospital rapid sequence intubation (RSI) is an intervention utilized for airway management in noncardiac arrested patients. We report patient outcomes following prehospital RSI utilized for medical emergencies.
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A124

Methods The analysis of 55 and medical history of patients with a diagnosis -ischemic stroke. It formed two groups -the addition of verticalization (Group 1 -32 persons) and without a verticalization (Group 2 -23 people). All patients were treated according to the Recommendations AHA / ASA 2013. All patients underwent mechanical ventilation respirators "Hamilton C2 " (Switzerland). In verticalization carried out by verticalization table «Beka Hospital» (Germany). All patients conducted severity rating scales for SOFA, NIHHS, CGS at admission and on the first, 3rd, 5th, 7th, 10th. At these stages were assessed respiratory status.

A155

Results Thirty patients with history of opium dependency were recruited during an 8-month period in 2 mixed medical-surgical ICU's. The protocol was effective to completely prevent the withdrawal syndrome in 24 patients (80 %). The average need to methadone was 14.5 ± 22.2 mg in the patients.The pain, sedation and delirium were evaluated and documented by the staff in 97, 98 % and 56 % of situations, respectively. Pain and sedation scores were within acceptable limits in 93 and 98 % of occasions, respectively. Delirium occurred in 2 patients during the ICU stay.

Results

Critical illness occurred in twenty patients with confirmed influenza; 12 A(H1N1) (60 %), 1 A(H3N2) (5 %), 4 A(non-subtyped) (20 %) and 3 B (15 %). The median age was 50 years (42.5-66.5); 14 patients (70 %) were under 65; 11 (55 %) were male. Thirteen (65 %) had comorbidities, including respiratory disease 5 (25 %), morbid obesity 3 (15 %) and malignancy or immunosuppression 3 (15 %). One was pregnant (5 %) and 8 (40 %) had a smoking history. Nine (45 %) were retrieved from outside the Ireland East Hospital Group. The mean APACHE (Acute Physiology and Chronic Health Evaluation) II Score and the mean SOFA (Sequential Organ Failure Assessment) score, on day one, were 17.85 ± 5.78 and 9.85 ± 3.33 respectively. Twenty (100 %) were mechanically ventilated, for a median of 17.5 days (9.5-32). Eighteen (90 %) satisfied the criteria for Acute Respiratory Distress Syndrome, with a mean PaO2/FIO2 ratio on day one of 13.35 ± 6.46. Fifteen (83.3 %) required rescue therapies for severe hypoxaemia, including extracorporeal life support (ECLS) in five (25 %), prone ventilation and inhaled nitric oxide. Sixteen (80 %) received vasopressors, and 12 (60 %) required renal replacement therapy. The median ICU length of stay was 18.5 days (11-42) and as of 31st March 2016, three (15 %) had died. Four (20 %) had documented early secondary infection, at less than 48 hours; streptococcus pneumoniae was the sole isolate (100 %). Seven (35 %) were treated for presumed late (greater than 48 hours) secondary infection; aspergillus fumigatus (28.6 %) and pansensitive staphylococcus aureus (42.9 %) were the most prevalent. All patients received a neuraminidase inhibitor: oseltamivir was prescribed in 19 (95 %), for a median of 7 days (7-9.75), with 3 (20 %) patients receiving the higher, 150 mg twice daily, dosing regime. Conclusion Seasonal influenza is a major public health concern. It is associated with severe morbidity, resulting in significant economic consequences, as well as a substantial burden on tertiary ICUs. In keeping with national trends, the predominant circulating virus was influenza A(H1N1) and secondary coinfection was common. Although traditional teaching emphasises S.aureus as a common coinfection in viral illness, our results highlight the importance of considering a broad spectrum of bacterial, viral and fungal microorganisms when prescribing empirically in the critically ill patient.

Method

After exclusion of patients with Impaired left ventricular systolic function, atrial fibrillation, pulmonary hypertension due to causes other than COPD, and those who had any contraindication to exercise test, thirty stable COPD patients were divided into laser and control groups (15 pts each). Medical treatment was optimized in each group with the addition of LLL in the laser group. In addition to history and physical examination, MMRC scale, 6 MWT, echocardiography with measurements of RV dimensions, TAPSE, and lateral tricuspid annulus tissue Doppler velocities were assessed in each patient before and after LLL. The LLL was done using the following parameters: Wave length: 905 nm, Output 5-20 mw & Frequency 500 HZ. Laser probe was placed on intercostal space corresponding to the site of lesion both anteriorly and posteriorly on chest wall and arm with standardized laser acupuncture points of application with a frequency of 5 sessions/week for 2 successive weeks.

Objectives

To present a pilot study where we describe 8 patients who required CRRT in the last month and determine the risk for the presence of renal angina at admission. Method Descriptive pilot study. We retrospectively analyzed all adults patients who required CRRT during March 2016 in which all data needed to evaluate the risk for renal angina was completed. We obtained and interpreted their demographics and laboratory results as well as their pre-medical history.

Results

All patients were male, with a mean age of 74 ± 12 (55-89). 3 patients died. The most common diagnosis was community acquired pneumonia (50 %), and second was acute on chronic cardiac failure (25 %). At admission they were all classified in the very high risk group. Also, the 8 patients had one or more mayor chronic criteria. The most frequent risk factors were hypertension history or hypotension at admission (75 % respectively), age and sepsis (62.5 % respectively). All patients had early elevation of serum creatinine (sCr) of at least 0.1 mg/dl. Average days between admission to the ICU and beginning of CRRT was 3.
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Introduction

Introduction We sought to study the characteristics and outcomes of ICU patients with carbapenem-resistant (CRKp) and carbapenem-sensitive (CSKp) K. pneumoniae infections. Fifty-one (49%) were males. The mean APACHE II score was 17.9 ± 6.9. The median duration of hospital stay until the infection was 28 days. Fortyeight patients (46.2%) had bacteremia, 27 (30%) urinary tract infections, 15 (14.4%) pneumonia, seven (6.7%) peritonitis and seven (6.7%) skin and soft tissue infections. Fifty-eight (56.9%) and 39 (39%) patients had previous and concurrent infections, respectively. Seventy-six patients (73.1%) died. The univariate analysis showed that prior hospitalization (P = 0.049), dialysis (P = 0.034), and history of urologic neoplasia (P = 0.041) were associated with the development of carbapenem-resistant infections. No independent risk factors were found in the multivariate analysis. APACHE II score (P = 0.003), need for dialysis (P = 0.034), shock prior and after the infection (P = 0.006 and P <0.001, respectively), respiratory distress prior and after the infection (P = 0.021 and P = 0.032, respectively), multiorgan failure prior and after the infection (P = 0.02 and P = 0.003, respectively), treatment failure (P <0.001), and acidosis after the development of infection (P = 0.003) were associated with death in the univariate analysis. Shock after the infection (P = 0.016) and treatment failure (P = 0.001) were independent predictors of mortality in the multivariate analysis. No diff erence in mortality was found between patients with CRKp and CSKp isolates.

Results

Conclusions The results of this study suggest that PT is safe in trauma patients without preoperative cervical spine clearance or with cervical injuries as compared with the OT group. Most of the PT cases were done without bronchoscopy assistance (95%). This fi nding suggests the need for further study to clarify the role of bronchoscopy assistance in PT. Introduction Mechanically ventilated (MV) patients are prone to develop ventilator-associated pneumonia. One of the major risk factors is microaspirations of supraglottic secretions past the endotracheal tube cuff (usually in polyvinyl (PV)). A novel polyurethane (PUE) cuff was designed to minimize these leakages. We therefore compared the sealing capacities of the two tubes in MV patients. Methods Twenty-nine consecutive MV patients (mean age ± SD: 68 ± 13, 21 males), were randomly allocated to receive either a PV (HI-LO Evac, Mallinckrodt) or a PUE (SEALGUARD Evac, Mallinckrodt) cuff ed endotracheal tube (size: 9 for men; 8 or 8.5 for women, as a rule). We excluded patients with emergency intubation, unstable haemodynamics, severe respiratory failure or patients with history of tracheal/laryngeal disease. In each patient, cuff pressure was maintained at 30 cmH 2 O, and ventilator parameters were set to plateau pressure ≤30 cmH 2 O; patients were fasting and placed in a strict semirecumbent position (45°). Radioactivity of tracheal aspirates was assessed sequentially (hourly samplings from T0 to T6 hours, then T8 hours and T12 hours) after injection of 74 MBq 99m Tc-DTPA diluted in 5 ml of 0.9% NaCl just above the cuff via the aspiration channel of the tube. Additionally, kinetics of respiratory tract contamination was followed by simultaneous pulmonary images using a scintillation camera. Data were blindly analysed by nuclear physicians. The study was approved by the hospital ethics committee and informed consent was obtained from relatives. Results Sixteen PUE and 13 PV cuff ed tubes were compared. The study was performed 3.2 ± 2.8 days after intubation and 8.3 ± 9.6 days after ICU admission (mean ± SD). Ventilator parameters were the following: volume control or pressure support but one on T tube, FiO 2 was 0.43 ± 0.14, PEEP 6 ± 2 cmH 2 O. Leakages were observed in 11/29 patients (38%), with similar rate of aspiration in PUE (5/16) and PV (6/13) groups (P = NS). Leakages were more frequently observed in female (7/8) than in male patients (4/21) (P <0.001). There was a trend to decreased frequency of aspiration in patients with larger tubes (size 9 vs 8.5: P = 0.062).

Introduction

Results Twenty-seven (27%) patients developed sepsis and nine (9%) developed septic shock. Factors associated with the development of sepsis were intraoperative blood transfusion (P = 0.013), duration of operation (P = 0.004) and a postoperative MEWS score greater than 3 (P = 0.0003). Using multivariate logistic regression analysis, a MEWS score greater than 3 after surgery was the only factor that remained signifi cantly associated with sepsis (odds ratio 4.89, P = 0.003). Although a high MEWS score was associated with sepsis after surgery, only fi ve (19%) patients who developed sepsis had an abnormal MEWS score prior to (mean 4.6 days) sepsis being diagnosed. In the post-CCO group 10 of the 27 patients were admitted to the ICU and 17 of these were treated in hematology ward, and nine of these received NIV (Figure 1 ). We defi ned six criteria for activation of the CCO team: radiological signs of pneumonia, organ increased by 116% (n = 65; type 1 MI: 54%; type 2 MI: 46%; P <0.05). Type 1 MI increased by 75%, which was refl ected by a 57% decrease of patients formerly classifi ed as instable angina. Of note, increases of MI diagnosis were mainly refl ected by a 200% increase of type 2 MI (for example, acute heart failure, tachycardia or hypertensive crisis). Numbers of patients with noncardiac chest pain were not signifi cantly changed with the use of the new cutoff point. AUC of admission cTnT levels were 0.76 and 0.96 for the cTnT fourth generation and cTnThs (P <0.05). At admission, sensitivity and specifi city of cTnThs were 93% and 94% for the detection of acute MI, while they were 32% and 96% using cTnT fourth generation. Conclusions Using lower cutoff points for the defi nition of MI as suggested by current recommendations, the rate of chest pain patients with acute MI doubled. Because the increased rate of patients categorized as acute MI is mainly refl ected MI type 2, the ED triage decision at lower cutoff levels of cTnT levels should include patient history, physical examination, 12-lead ECG and cardiac imaging.

Cytokine levels evaluation during acute isovolemic anemia

Conclusions Fluid replacement infl uences the cytokine measurements during acute isovolemic anemia expressed by serum TNF, IL-1, IL-6 and IL-10 increases, especially in GEL group. Introduction Community-acquired sepsis at an early stage is common, but haemodynamic alterations remain unclear. The aim of the study was to characterize cardiovascular alterations in patients of our ProFS (monocentric observational) study, which was to characterize patients with sepsis in the emergency department. Methods Systemic vascular resistance (SVR) and cardiac output (CO) were measured non-invasively using a TaskForce monitor (CNSystems, Graz, Austria) after admission, 24 hours and 72 hours. Indexed values were calculated (SVRI (dyn·second/cm 5 /m 2 ), CI (l/minute/m 2 )). Procalcitonin (PCT, ng/ml) was measured in serum. Results A sample of 64 patients of 208 included patients received haemodynamic examination. Mean age was 61.8 ± 18.0 years, 62.7% were male. Patients were divided by PCT <2 and ≥2. Age, gender and previous medical history were comparable in both groups. The heart rate was 99.8 ± 21.6 vs 104.6 ± 23.0/minute (P = NS) and the mean artery pressure was 89.5 ± 15.6 vs 81.6 ± 21.5 mmHg (P <0.01). Mean SVRI in patients with PCT <2 was 2,934 ± 1,045 vs 2,376 ± 842, P <0.05 at the time of admission. No diff erence was found after 24 hours (2,959 ± 1,002 vs 2,924 ± 1,324, P = NS) and 72 hours (3,123 ± 931 vs 3,556 ± 1,524, P = NS). On the contrary, for patients with PCT ≥2 the increase after 72 hours was signifi cant (P <0.05). Diff erences after admission could not be observed for CI between patients with PCT <2 vs ≥2. Mean values after admission were 2.7 ± 1.0 vs 2.8 ± 0.8, after 24 hours 2.5 ± 0.8 vs 2.5 ± 0.5, and after 72 hours 2.3 ± 0.7 vs 2.3 ± 0.6 (all: P = NS). See Figure 1 Conclusions Patients with community-acquired sepsis in the emergency department had an elevated SVRI. At the time of admission patients with high PCT had a signifi cantly lower SVRI than patients with low PCT. Cardiac index at the time of admission was at a lower limit of normal range in all patients. These fi ndings are in strong contrast to the classic pattern of sepsis on the ICU, where SVRI is keenly reduced and CI elevated. They implicate that patients with sepsis in the emergency department may benefi t more from application of fl uid and positive inotrope substances than from vasopressor. Introduction A multicentre, prospective, observational study conducted in four intensive therapy units (ITUs) in India from June 2006 to June 2009 to determine the incidence and outcome of severe sepsis among adult patients. Methods All patients admitted to the ITU were screened daily for SIRS, organ dysfunction and severe sepsis as defi ned by the ACCP and SCCM. Patient with severe sepsis were further studied. Results A total of 5,478 ITU admissions were studied. SIRS with organ dysfunction was found in 1,385 (25%) patients, of which 731 (52.77%) were due to sepsis. The incidence of severe sepsis was 16.45% of all admissions. Mean age of the study population was 58.17 years (SD 18.66), of which 57.71% were male. The median APACHE II score was 13 (IQR 13 to 14) with predominant (90.93%) medical admission. ITU mortality of all admissions was 12.08% and that of severe sepsis was 59.26%. Hospital mortality and 28-day mortality of severe sepsis were 65.2% and 64.6%, respectively. The standardized mortality ratio of severe sepsis patients was 1.45. Median duration of stay in the ITU for the severe sepsis cohort who survived was 13 days (IQR 11 to 17). The number of episodes where infection was the primary reason for admission to the ITU was 86.32%. Culture positivity was found in 61.6%. The lung was the predominant source of sepsis (57.45%). Gram-negative organisms were responsible for 72.45% of cases and Grampositive for 13.13%. The rest were parasitic, viral and fungal infection.
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References

Conclusions: Adherence to international guidelines need to be reinforced at ICU level. Priorities in middle income countries should focus on improving 1) full barrier precautions and 2) using chlorhexidine >0.5 % for skin preparation. Reduction of device exposure through daily assessment of CL need remains a priority in both settings. Almost all respondents consider measurement of CLABSI key to quality improvement, however less than a quarter actually report their CLABSI rate. Our study was limited by a non-random sample of ICU doctors and nurses. Introduction: Urinary tract infections are common problems in patients in ICU with increased mortality, costs and hospitalization. The best way to treat urinary tract infections is to prevent them. The mechanism of action for preventing bacterial adhesion for noble metal alloy-coated urinary catheter is the generation of a galvanic effect. The aim of this study was to evaluate the benefits of noble metal coated-catheter compared to silicone Foley catheter in patients admitted to our Toxicology-Intensive Care Unit for drug poisoning, with short-term catheterization. Methods: We enrolled 120 patients which were randomly assigned to one of the two groups: one group received noble metal alloycoated catheter (Group 1) and the other one received silicon Foley catheter (Group 2). We excluded all patients with urinary tract precontamination. Urine full examination and urine culture was taken at admission and on day 3 of catheterization. Results: The incidence of bacteriuria was 2 % with the noble metal alloy-coated catheter and 6.6 % with the silicone catheter (p < 0.05) after a mean period of 3 days' catheterization time. Age over 65 years (odds ratio 6.08) was significant risk factors for bacteriuria. The Gram negative bacteria of Escherichia coli and Klebsiella pneumoniae were the most uropathogenic bacteria. We observed significant association between urinary tract infection caused by Escherichia coli and female gender (p < 0.05). Conclusions: Noble metal alloy-coated catheters may decrease the incidence of urinary tract infections compared with silicon ones and in the meantime may lower the need for antibiotics. Also, we noticed that the incidence of bacteriuria increased with age in both groups, but remained lower in noble metal alloy-coated catheter group. Methods : The retrospective data analysis of patients treated in surgical and medical intensive care units with positive blood culture for Gram-negative rod during 2005-2012 years was carried out. Results: There were found 430 cases of Gram-negative rod monobacteremia, 77 (17.9 %) of them caused by Acinetobacter spp. There was no difference in gender, age, comorbidities, source of bacteremia, length of stay in intensive care unit for Acinetobacter spp. bacteremia (P > 0.05). Primary bacteremia was associated with surgical procedures (OR = 4.677, P = 0.03) and previously treatment in other hospital departments (OR = 1.02, P = 0.04). Acinetobacter spp. strain was associated with high resistance to antibiotics (P > 0.05), as: cefotaxim (n = 75, 97,4 %), ampicillin (n = 74, 96.1 %), cefuroxim and ceftazidim (n = 66, 85.7 %), gentamicin (n = 65, 84.4 %), piperacillin (n = 65, 84.4 %), piperacillin with tazobactam (n = 62, 80.5 %), ciprofloxacin (n = 59, 76.6 %), amikacin (n = 41, 53.2 %), ampicillin with sulbactam (n = 33, 42.9 %). The low resistance to carbapenems (n = 6, 7.8 %, P = 0.03) was estimated. Acinetobacter spp. strains were found to be mostly multi-drug-resistant, as resistant to > = 3 classes of antibiotics (n = 74, 96.1 %, P = 0.02), especially in postoperative patients (n = 37, 92.5 %, OR = 4.042, P = 0.04) and previously treated in other hospital departments (n = 41, 100 %, OR = 4.701, P = 0.03). Overall mortality rate of Acinetobacter spp. bacteremia was 84.4 %. Lethal outcome was associated with mechanical ventilation (n = 65, 100 %, OR = 4.105, P = 0.05), multi-drug-resistant strain (n = 64, 98,5 %, OR = 1.182, P = 0.013), elderly (n = 36, 90 %, OR = 1.662, P = 0.016), resistance to cefalosporins (n = 57, 86.4 %, OR = 2.367, P = 0.04), and alcohol abuse (n = 9, 81.8 %, OR = 3.926, P = 0.05). Conclusions: Acinetobacter spp. monobacteremia usually appears as caused by multi-drug-resistant > = 3 classes of antibiotics strain, but with low resistance to carbapenems, especially in postoperative patients and previously treated in other hospital departments. It has extremely high overall mortality rate. Mortality was associated with elderly, alcohol abuse, multi-drug-resistant strain and resistance to cefalosporins also mechanical ventilation. Conclusions: Both Group A and Group B streptococcal infections were associated with significant morbidity and mortality. The APA-CHE 2 score appeared to predict the mortality reliably in patients with Group A Streptococcal infections. In patients with Group B Streptococcal infections however observed mortality was significantly higher than the predicted mortality from the APACHE 2 score. ICU and hospital length of stay were broadly comparable for those of the general ICU population over that period (means 216 and 648 hours respectively). Introduction: The diagnosis of spontaneous bacterial peritonitis (SBP) is usually investigated by cytobacteriologic analysis.we purpose to evaluate the effectiveness of the urinary strips URITOP + TM for rapid diagnosis of SBP and emphasize the utility of inoculation of blood culture bottles withascitic fluid for an accurate identification of bacteria. Methods: Our study included 44 patients with cirrhosis and tense ascites. Immediately, after paracentesis a urine test strips was performed searching visually the presence of leukocytes and nitrites on the ascitic fluid. The reaction between this fluid and the strip induced a color change. The color of the leukocyte reagent area was then compared with the color chart of the bottle and the result was scored in function of the number of crosses. Besides biochemical and bacteriological analysis of the ascitic fluid was done including bedside inoculation of five millimeters of this fluid into aerobic and anaerobic blood culture bottles. Cultures of blood were also obtained from all patients. Results: SBP was diagnosed in 11 of the 44 samples. URITOP + TM test was positive in 8 cases. The reading of leukocytes strips revealed one cross, two crosses and three crosses in 15,4 %, 30,8 % and 15,4 % respectively. Nitrites were present in 69,5 % of cases. Blood and ascitic inoculation were positive in 46,2 % and 53,8 % respectively. The major bacteria isolated were gram-negative bacilli. We found a significant correlation between SBP and visual detection of white cells and nitrites (p < 10-3 for both parameters). A significant correlation was also found between SBP and both ascitic (p = 0,02) and blood (p = 0,006) inoculation. Both visual detection of leukocytes and asitic inoculation in blood culture bottles had a sensibility and a specificity of 100 %. Conclusions: Our study showed that URITOP + TM is a rapid and effective method in the early diagnosis of SBP. Besides the inoculation of blood culture bottles with ascitic fluid improves the detection of SBP and ameliorate consequently the prognosis. Introduction: Although it is well known that lymphedema of limbs is associated with higher possibility of developing cellulitis, the Introduction: Botulism is a rare paralytic illness caused by the action of a potent neurotropic exotoxin produced by Clostridium botulinum. C. botulinum species produce seven serologically distinct toxins, A-G. Human botulism is primarily caused by toxin types A, B or E. In Europe, most wound botulism is now associated with injectable drug use. Symptoms are of descending paralysis, bulbar palsies and respiratory failure. Methods: This is a review of the clinical, microbiological and public health aspects of an outbreak of botulism in Scotland from December 2014 to June 2015. Data was collected via prospective patient interview and clinical data collation. Results: 47 cases of wound botulism were reported: 23 probable, 17 confirmed, 5 discounted and two remain possible; Median age 42, range 24-55 years, 65 % were male. 98 % of cases presented with bulbar palsy but very few with descending limb weakness. 52 % of patients required surgical drainage of wound-related abscesses and 65 % required mechanical ventilation. All patients received 3-doses of trivalent anti-botulinum toxin therapy within 24 hours of clinical diagnosis. The diagnosis was microbiologically confirmed in 17 cases due to presence of C. botulinum type B neurotoxin detected by molecular assay in tissues and/or by serum bioassay. The C. botulinum strains from 10 cases showed a common profile on fAFLP typing, thereby confirming a link to a common source. All had a recent history of injecting heroin which was obtained either in, or sourced, via Glasgow. The source of infection remains unconfirmed but is thought to be due to contaminated heroin, or cutting agent. There were four deaths, botulism contributing to two. Police Scotland was closely involved in risk management through increased drug seizures throughout the region, reducing the supply of potentially 'contaminated' heroin. Public health measures included; risk communication via distributing postcards widely to PWIDs via drug agencies and needle exchange centres to increase awareness of signs and symptoms, advising smoking drugs as an alternative form of administration and the avoidance of muscle popping. Conclusions: This is the largest outbreak of botulism among PWIDs in Europe. Prompt identification of cases and appropriate clinical management resulted in low mortality amongst the cases. Interdisciplinary cooperation was integral in management of the outbreak. Introduction: Extended-spectrum-beta-lactamase-producing Enterobacteriaceae (ESBL-E) strains are considered to be important, since few antibiotics currently remain active against these bacteria. However, the implications associated with the surveillance of fecal carriers of ESBL-E among ICU patients are unclear. The aim of this study was to determine the efficacy of carrying out stool screening for ESBL-E.

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Conclusions: Although MSF is generally considered a benign disease we had a high ICU admission rate and a considerable mortality rate. We found that the SAPS II score, the leukocytes count and aPTT are predictors of death in patients with MSF admitted to the ICU. Introduction: The Middle East Respiratory Syndrome coronavirus (MERS-CoV) has caused several hospital outbreaks and frequently leads to severe critical illness. To learn from our experience, we described the response of our intensive care unit (ICU) to a MERS-CoV hospital outbreak. Methods: This observational study was conducted at a 1000-bed tertiary-care hospital in Riyadh, Saudi Arabia which had a MERS-CoV outbreak in Aug-Sep 2015. Our Intensive Care Department covered 5 ICUs with 60 single-bedded rooms. We described qualitatively and, as applicable, quantitatively, the response of intensive care services to the outbreak. The clinical course and outcomes of hospital workers who had MERS were noted. Results: A total of 62 critically ill MERS patients were cohorted in 3 ICUs during the outbreak with a peak census of 27 MERS patients on Aug 25, 2015 and the last new case on Sep 13, 2015. Most patients had multiorgan failure requiring support. Eight hospital employees had MERS requiring ICU admission for a median stay of 28 days: 7 developed acute respiratory distress syndrome, 4 were treated with proning, 4 needed continuous renal replacement therapy and one had extracorporeal membrane oxygenation. The hospital mortality of ICU MERS patients was 53 % (0 % for the hospital employees). All MERS patients were admitted in single negative pressure rooms, which were promptly increased from 14 to 38 rooms. The nurse-topatient ratio was~1.2:1. Infection prevention practices were intensified. For example, the consumption of surface disinfectants and hand hygiene gel increased by~30 % and an average of 17 N95 masks were used per patient/day. Family visits were restricted to 2 hours/ day and the ICU physicians communicated with the next of kin by phone daily. During the outbreak, 2 ICU nurses and 1 physician tested positive for MERS-CoV, had mild disease and recovered fully. Although most ICU staff expressed concerns about acquiring MERS, none refused to report to work. However, 27.0 % of nurses and 18.4 % of physicians working in the MERS ICUs had upper respiratory symptoms, but tested negative for MERS-CoV. The total sick leave duration was 138 days for nurses and 30 days for physicians. Conclusions: Our hospital outbreak of MERS-CoV resulted in many patients requiring organ support and prolonged ICU stay. Their mortality rate was high but lower than previously reported. The response to the outbreak required facility and staff management and proper implementation of infection control and prevention practices. (1). We included all cases containing data about age and gender (at minimum) and excluded cases reported as clusters. Data on age, gender, comorbidities, healthcare worker, contact with camels, contact with a laboratory confirmed MERS-CoV case, date of symptom onset and date of laboratory confirmation were retrieved and analyzed. Results: A total of 219 outbreak news reports were released by the WHO, 977 cases were include in our study; 68.8 % males: mean (SD) age was 53.2 years (17.9), and 31.2 % females: mean (SD) age was 53.2 years (18.4), where the youngest patient reported was 10 month and the oldest patient reported was 109 year old. Comorbidities were reported in 46.9 %: mean (SD) age was 60.1 (15.4) and 71.8 % male and 28.2 % female. Healthcare workers were reported to be 15.6 %, mean (SD) age was 38.6 (11.3) and 53.3 % male, 46.7 % female and 19.7 % of them had comorbidities. 12.1 % reported with history of camel contact; mean (SD) age was 56.7 (15.1) and 91.7 % male, 8.3 % female and 77.1 % of them had comorbidities. 25.3 % were reported to have contact with a laboratory confirmed MERS case: mean (SD) age was 43.9 (17.0), 63.0 % male 37.0 % female, 36.0 % reported to have comorbidities and 30.5 % were healthcare workers. Date of symptoms onset and date of laboratory confirmation were reported in 86.2 % and 56.5 % respectively. The overall mean (SD) of time from symptoms onset to date of laboratory confirmation was 5.2 days (4.2) (95 % CI, 4.8-5.5). Conclusions: Our study was based on publically available global surveillance data and has the advantages of a large sample demographic description.

Results:

Methods: Single center retrospective study conducted over one year, we enrolled all patients subjected to cardiac surgery (267), and patients with existing or prior AF were excluded. Patients were divided into two groups (group I) before and (group II) after implementing the CPG. Results: Both groups were matched regarding the age, gender, smoking history, preoperative ejection fraction, EuroSCORE, urgency of surgery and underlying surgery type valvular or coronary. There was a statically significant difference in POAF events was14.9 % in group I and vs 8.3 % in group II (P = 0.05). The overall total rate of Critical Care 2016, Volume 20 Suppl 2 POAF in all patients was 11.4 % that is below the rate in European centers. [1] Patients with POAF significantly required more inotropic support (p = 0.04), in addition they were associated with prolonged length of mechanical ventilation and ICU stay (p = 0.001 and 0.02 respectively).

Methods:

We report a unique case of extreme hypernatremia of 196 mmol/L and severe sepsis in a young 39-year-old adult with Huntington's dementia, which presented a challenge in fluid management. Results: The hypernatraemia was thought to be caused by chronic severe dehydration from poor intake and the sepsis was thought to have started as an inadequately treated urinary tract infection. The patient was initially treated aggressively with hypotonic saline and intravenous antibiotics, but was subsequently managed using a slower correction rate after identifying the chronic nature of the natremia. To our knowledge, this is the first reported case of extreme hypernatremia and severe sepsis manifesting concomitantly in such a young patient. Conclusions: We highlight the difficulties of balancing the risks and benefits of rapid versus slow fluid resuscitation in such complex clinical situations. We highlight the difficulty of balancing the risks and benefits of rapid fluid resuscitation, necessitated by severe sepsis and acute kidney injury, against the complexities of fluid resuscitation in correcting such an extreme hypernatremia. We advocate early identification of chronic hypernatremia and effective administration of intravenous fluids in the Emergency Department that is decided on a case-by-case basis. In cases of severe and extreme hypernatraemia in particular, accurate calculation of free water deficit is essential to manage the patient effectively. In line with this, we must ensure that such patients are always weighed on admission. Introductions: HAGMA is a commonly encountered acid-base disorder in clinic practice. Multiple mnemonics were proposed to cover the common underlying causes -"GOLDMARK(1)", "KUSMALE", "KAR-MEL" and, of course, "MUDPILES". The "I" in "MUDPILES" represents some rare causes of HAGMA including "I"ron, "I"soniazid and "I"nborn errors of metabolism. We present a rare case of HAGMA secondary to isoniazid (INH) overdose. Methods: A 41 year old male was intubated for status epilepticus. He had a medical history of pulmonary tuberculosis (pTB) and had been treated with a course of rifampicin, INH and ethambutol since 6 months ago. Results: Arterial blood gas in the Emergency Department showed severe metabolic and respiratory acidosis; pH 6.76, pCO2 80, pO2 62, HCO3 11, BE -24. The initial anion gap was 26. Physical examination was unremarkable except for fever and hypotension. Neurological examination did not reveal any lateralising signs. CT scan of the brain was normal. Mild renal impairment, and lactate acidosis resolved rapidly with initial fluid resuscitation. Serum and urine toxicology for commonly encountered drugs were also negative. Patient regained orientation on day 3 of intubation and was promptly extubated. Further history revealed that he had consumed a bottle of isoniazid tablets after an altercation with his wife the same night. Conclusions: Tuberculosis is endemic is South East Asia. INH is one of the four drugs used in the treatment of this disease. Side effects of isoniazid range from mild hepatotoxicity to the potentially fatal INH hepatitis. HAGMA refractory to conventional therapy is one of the hallmarks of INH toxicity. Though it is one of the rare causes of HAGMA, prompt diagnosis and treatment with high dose pyridoxine (2) reduces mortality and morbidity.
Introductions: Acute kidney injury (AKI) is independently associated with increased mortality in the critically ill, especially when renal replacement therapy (RRT) is required. "Early initiation" of RRT and its possible beneficial effect on mortality, has been the focus of many research protocols. However, published papers show no uniformity in the definition of early initiation. The main problem to determine this best moment of initiation is the lack of a distinctive parameter that can predict RRT requirement. The question rises if differences between patients with any stage of AKI and patients with RRT-requiring AKIN stage III can be identified looking at the "classical parameters" (serum creatinine (SCr), urea, potassium, bicarbonate, pH, cumulative fluid balance), plasma Neutrophil Gelatinase-Associated Lipocalin (pNGAL) and urinary output (UO) at the time of first rise in SCr (first AKI). Methods: This is a retrospective subset-analysis performed on the NGAL-study database [1] in adult critically ill patients with developing AKI. Data were collected and analyzed at the time of first AKI and at the highest level of serum creatinine (peak AKI). Mann-Whitney-U test was used to detect differences between both groups. Results: A total of 59 patients developed any stage of AKI during the first 7 days after ICU admission, 15 patients required RRT eventually. At the time of first AKI, pNGAL and UO were the only parameters that differed significantly (P = 0.02 and P = 0.04 respectively) between the two groups. The "classical parameters" showed a significant difference between groups later on at the time of peak AKI (=time of RRT initiation) (Fig. 37) . Conclusions: Critically ill patients with RRT requiring AKI have a significant lower urinary production and significant higher pNGAL concentration compared to patients with non-RRT requiring AKI at the time of first rise in SCr. The "classical parameters" fail to make this distinction at this very early stage of AKI. Therefore, plasma NGAL and UO might have the potential (perhaps in combination with the Furosemide stress test) to become valuable parameters in future prospective protocols that intend to study the value of early RRT initiation on hard outcome measures in critically ill patients. Introductions: The choice for the right renal replacement therapy (RRT) for severe acute kidney injury in critically ill patients has been investigated many times in the last two decades. Although some questions have been answered, in current practice many different approaches are still used in the ICU. The authors review the treatment of Acute Kidney Injury (AKI) in critically ill patients, indications for SLED and continuous renal replacement therapy (CRRT) in critically ill patients in four Portuguese ICUs. Methods: Prospective observational study conducted in 4 ICUs in 3 Portuguese hospitals for seven months. All patients with AKI who needed a renal replacement therapy were enrolled. Data on demographics and clinical characteristics of patients were collected at baseline. Results: 127 patients were enrolled, with an average age of 61,3 ± 15,26, and mortality rate was 46 %. 42 patients performed SLED (33,07 %), and 85 % performed CRRT (63,97 %). The most common indications for CRRT was fluid overload (47,76 %). Most of the patients start the both procedures in the first two days in ICU. Most of the patients (59 Ð 60 %) were in organ failure, using the RIFLE criteria when they started RRT. Patients in CRRT were more hemodynamically unstable (norepinephrine in CRRT Ð 1,99 ± 5,36 and in SLED -1,49 ± 4,56). Mortality rate Ð 52,94 % in CRRT and 30,95 in SLED. Conclusions: CRRT seems to be the ideal mode of renal replacement therapy for hemodynamically unstable with fluid overloaded. However, in expert hands, the two treatments provide similar outcomes and can be complementary. We wished to evaluate current practice in the region and consider the need for regional guidance on the management of acute kidney injury in our units. Methods: An electronic survey was sent to all the consultants in intensive care within the region. Responses were anonymously collecting using internet-based survey software. Questions were based upon the currently available guidance and evidence. Results: Invitations were sent to 139 consultants who have some intensive care commitment. There were 55 responses giving a response rate of 39.6 %. Unit size varied greatly, from under 10 beds, to over 20. The majority (43.6 %) had between 10 and 20 beds. 46.3 % of respondents had less than 10 patients receiving RRT per month, 40.7 % had between 10 and 25 patients per month and 13 % had more than 25 patients per month. 43 % gave positive comments regarding the support they receive from renal services. Some areas where interactions between renal physicians and critical care could be improved were identified. Only 67 % of respondents were aware of an up to date guideline for the use of RRT in their unit. 1.9 % of respondents preferentially use the subclavian vein for siting renal access lines. 9.3 % preferentially used the femoral veins. 31 % never have visits from a nephrologist. Conclusions: There is a wide variety in practice, with some areas where practices could be improved , notably awareness of guidelines available, choice of renal access line site, and working relationships between renal and critical care. As part of a quality improvement programme, we plan to create a regional best practice recommendations document that is relevant to the systems in which we work and specific to critical care. By doing this, we hope to improve outcomes for those receiving renal replacement therapy in our units. Introductions: Acute kidney injury necessitating continuous renal replacement therapy (CRRT) in critically ill patients is associated with high mortality. Timing of CRRT remains a matter of debate. We investigated the effect of timing of CRRT on 28-day mortality. Methods: A post-hoc analysis is performed on the multicenter data from the earlier published CASH study. In critically ill patients receiving CRRT, between 2005 and 2011, the effect of variables at initiation of CRRT on 28-day mortality were evaluated. Univariate and multivariate cox regression analysis were performed to determine renal and patient-specific variables associated with 28-day mortality. Results: Of the 139 patients evaluated for inclusion, 13 patients were excluded because of a history of chronic kidney disease, 5 patients were excluded because no creatinine at CRRT initiation was available, and 5 patients were excluded because an admission creatinine below 50 μmol/L. In the 116 included patients, 28-day mortality was 37 (32 %). In univariate proportional hazards cox regression analysis, ICU admission after cardiopulmonary resuscitation ( HR 4.403, p = 0.043), SOFA score ( HR 1.117, p = 0.024) and creatinine at CRRT initiation (HR 0.997, p = 0.020) were associated with 28-day mortality. Multivariate analysis demonstrated that age (HR 1.092, p = 0.050), admission weight ( HR 1.036, p = 0.016) ICU admission because of respiratory failure (HR 9.275, p = 0.29) and creatinine at CRRT initiation (HR 0.990, p = 0.022) were associated with 28-day mortality. After correction for disease severity scores, such as APACHE 2 score and SOFA score, and markers for fluid overload, such as hematocrit and cumulative fluid balance, creatinine at initiation remained associated with lower 28mortality. Even after correction for admission creatinine, only creatinine at initiation remained associated with 28-day mortality. In ROC curve analysis a CRRT initiation creatinin of 318 μmol/L was the best predictor for 28-day mortality. Conclusions: In this multicenter cohort, creatinine at CRRT initiation is an independent predictor of 28-day mortality, even after correction for admission creatinine, disease severity and hemodilution. Therefore these data argue in favour of a time-dependent effect of CRRT on 28day mortality. These data suggest that late CRRT initiation may have better outcome then earlier CRRT initiation. However further research is needed to confirm this hypothesis and reveal underlying mechanisms.

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Conclusions: Lung aeration score using lung ultrasound can predict weaning failure in critically ill patients. Our study showed that a LUS score of >18 has a good prediction value. However larger randomised controlled trials are required to validate this pilot study. Introduction: Clinicians are routinely faced with the challenges of managing the ventilatory care and weaning process during the clinical course of the illness. Almost 40 % of mechanical ventilation time is spent on weaning [1] and in the last decade, automatic ventilator control and ventilation modes were designed to help weaning from mechanical ventilation. In many studies automated weaning significantly decreased weaning time in critically ill patients when compared with physician controlled weaning process [2, 3] . We conducted a prospective randomized trial comparing automated weaning with a standardized weaning protocol in a multidisciplinary ICU. Methods: From April 2014 to Mars 2015, we enrolled critically ill adults requiring more than 48 hours of mechanical ventilation. Patients were randomized since admission considering availability of SmartCare equipped ventilators (8 Evita XL in our unit: 4 with SmartCare and 4 without). We included patients who tolerated at least 24 hours of pressure support with PEP equal or less than 5 cmH2O and were not ready to undergo a spontaneous breathing trial, they were assigned to be weaned either by SmartCare (SC Group) or by the physician controlled weaning according to local guidelines (PCW Group). Weaning duration, total duration of mechanical ventilation and the success of weaning were the primary endpoints. Results: Forty-four patients were enrolled, 22 in each group. There was no difference between the two groups concerning age, sex, neurological or respiratory history, diagnosis or severity at study entry. Weaning duration and total mechanical ventilation were similar between the two groups and were respectively 6 +/-7 days in PCW Group vs 5 +/-4 days in SC Group (p = 0.63) and 11 [3-37] days vs 10 [3-23] days in SC Group. In the PCW Group, we noted only one extubation failure and there were no reintubation in SC Group. Conclusions: Although automated weaning using SmartCare did not show significant benefit for patients concerning duration of mechanical ventilation and duration of weaning when compared to physiciancontrolled weaning according to local protocols; it has certainly offer a gain of time for the medical staff in an ICU where there is no respiratory physiotherapist neither critical care specialty nurses. Introduction: Mechanical ventilation (MV) is a therapy for vital support used in a significant proportion of critically ill patients. The right time to succesfully discontinue this therapy is a challenge for the intensivist The ecocardiographic evaluation of the diastolic dysfunction, the diaphragm and the lung have become an invaluable tool for weaning from MV protocols, especially in pacients with dificult or prolong weaning from MV. We propose a mathematichal model of an ultrasound protocol for weaning from MV that integrates the three modalities Methods: Based on current literature, we develop a score justified by a mathematical model based on inequations Results: When the risk of failure in the weaning process rises, for these reason the weaning process should be suspended. When the risk of failure is low and the weaning process should be continued.
Conclusions: The use of math models for decision making is of great importance, it sets an objective parameter within the existing evaluations. We proposed the use of inequations, to set intervals of solution with the three points of care for ultrasound guided weaning from MV. With this the inequations propose generate an area of certainty within the proposed values an the solution intervals. Introduction: Our aim was to assess diaphragm ultrasonography as a tool to predict the outcome of weaning. Methods: We enrolled 5 intubated patients who were admitted to our Intensive Care Unit at the Saint Antony Hospital of Padua; a Nutrivent nasogastric tube was placed in each to measure the diaphragm contractility as the transdiaphragmatic pressure (ÄPdi) with the following formula: ÄPdi = gastric pressure-esophageal pressure. We performed a diaphragmatic sonography with the M-mode technique. We calculated the diaphragm contraction speed as the slope (Scdi) of the curve provided by the diaphragm contraction during the inspiratory phase of the spontaneous breathing trials. The correlation between the mean ÄPdi and the mean Scdi was evaluated using the Pearson's method according with a linear regression analysis. Results: We found a significant correlation between the ÄPdi and the Scdi with a Pearson coefficient ñ = -0.851 and a linear determination index R = 0.718 as shown in Fig. 60 . Conclusions: the Scdi calculated during trials of spontaneous breathing represented a bedside, standardized and reproducible tool to predict the outcome of weaning. Methods of titrating PEEP to safely recruit the lungs have included achieving adequate SpO2, attaining best compliance, or increasing PEEP while monitoring esophageal manometry to establish a positive end-expiratory transpulmonary pressure (Ptp). Bedside ultrasonography is available and useful as a diagnostic tool in the care of critically ill patients. Preliminary work identified marked differences in excursions between the dorsal and ventral diaphragms during lung-protective tidal ventilation in ARDS patients. We hypothesize that lung recruitment in the supine patient may be detected non-invasively by increased dorsal diaphragmatic excursions, indicating that dependent lung regions may be recruiting with adequate PEEP. Methods: In this proof-of-concept study, we enrolled 7 ARDS patients treated with invasive mechanical ventilation and neuromuscular blockade in the supine position. We measured Ptp using esophageal manometry and ventral/dorsal diaphragm excursions using anatomic M-mode ultrasonography as the applied PEEP was changed (set by the treating physician) as follows: +3,+6, -3, and -6 cmH2O. A standard lung history was established by recruitment maneuvers between each PEEP change, and the sequence of PEEP changes was randomized for each subject. We used linear mixed effects models to evaluate for an association between applied PEEP and Ptp and dorsal diaphragmatic excursion (DDE). Results: Acceptable ultrasound images of diaphragm excursion were obtained in 6 of 7 patients; one patient had a large hepatic cyst precluding diaphragm ultrasound, data from this subject was excluded from the analysis. At enrollment, the mean(+/-SD) P/F ratio was 156 +/-61 mmHg, mean baseline PEEP was 12.7+/-2.2 cmH2O, and the mean SpO2 was 94+/-2.2 %. Ventral diaphragmatic excursions were unchanged by PEEP. Increasing PEEP resulted in corresponding increases in Ptp and DDE (p = .0006, p = .005). The transition from a negative to positive Ptp with increasing PEEP occurred as DDE was observed to markedly increase. Conclusions: This exploratory study suggests an association between Ptp and DDE as dorsal lung is recruited by increasing PEEP. If validated in a larger sample, ultrasound evaluation of dorsal diaphragmatic movement may be a non-invasive method for estimating lung recruitment in ARDS. Introduction: Pulse oximetry (SpO2) is intensively used as a surrogate for arterial oxygenation (SaO2) however, little is known about its accuracy in daily ICU practice. Disturbed perfusion may lead to a poor signal as indicated by a lower perfusion index value (PFI) and so compromise its accuracy. We studied SpO2 accuracy in its relationship to the PFI. Methods: In a 5 month period, 281 patients were retrospectively studied resulting in 1281 concomitantly measured values of SpO2 (Philips M1191BL/M1194A), SaO2 and PFI. Inotropic use, pH, MAP, mechanical ventilation and body temperature were studied as independent variables. PFI values were categorized as low or poor with PFI < 1.0, intermediate or moderate with 1.0 < PFI < 2.5 and as reliable or high with PFI > 2.5. Data collection: All SaO2, SpO2 and PFI measurements during the first 3 days after admittance were collected unless the patient was invasively ventilated, then all measurements were collected until extubation. Statistical analysis: A linear correlation of the SpO2 and SaO2 values was assessed by Pearson's method and the mean SpO2-SaO2 difference (Δ ) was assessed by using the Bland and Altman method. Results: Statistical analysis showed an overall correlation (r = 0.685; p < 0.01) between SaO2 and SpO2. The Bland and Altman analysis revealed that the limit of agreement within the general mean and ±2SD showed a Δ of ±6 % (Fig. 61) . Of all values SpO2 overestimated the SaO2 value in 48.2 % of all cases and underestimated SaO2 in 31.4 %. Over a wide range of PFI values (median 1.4, range 0.1-19.2) we found moderate agreement between SpO2 and SaO2 with slightly better agreement for higher PFI values (Fig. 62 ). Even with a PFI > 2.5, 15.9 % of all measurements showed a difference between SpO2 and SaO2 of more than ±2 %. The other independent variables showed only very weak associations (r < 0.2) with the Δ SpO2-SaO2, except for mechanical ventilation (ANOVA p = 0.002). Conclusions: We found a clinical relevant lack of agreement between SpO2 and SaO2 measurements. In contrast to general expectations SpO2 exceeds SaO2 in 48.2 % of all measurements. PFI is of little value as differences may be great as even with a high (good) PFI value, 15.9 % of concurrent measurements of SpO2 and SaO2 differ > ±2 %. These findings may influence daily practice on how to adjust mechanical ventilation by SpO2 measurements. (Fig. 63a) . Correlation was poor between the capnograph's RR & EtCO2 measurements: normal EtCO2 coincided with adequate RR just 24.9 % of the time & none of the low RR measurements were revealing of a high EtCO2 (Fig. 63b ). When using RR as a proxy for MV it was also noted that low MV is observed at a wide range of RRs, with only 15.5 % of all low MV events captured by a low EtCO2-based RR (Fig. 63c) .

Results

After controlling for age, gender, urbanization level, socioeconomic status, liver cirrhosis, hypertension, coronary artery disease, hyperlipidemia, malignancy, smoking, chronic obstructive pulmonary disease, obesity, history of alcohol intoxication, chronic renal insufficiency, biliary tract disease, chronic pancreatitis and Charlson Comorbidity Index score, the adjusted hazard ratio of pancreatic cancer was 2.48 (95 % confidence interval, 1.84¡X3.34) in patients with diabetes.
In patients with history of hyperglycemic crisis episodes, the hazard ratio of pancreatic cancer was significant higher. (hazard ratio, 3.60; 95 % confidence interval, 1.15¡X11.25)
Multiple risk factors have been identified for SAH including: Loss of consciousness, family history, hypertension, polycystic kidneys, excessive alcohol intake and smoking. The aetiology of SAH in the majority (>85 %) of patients is an aneurysm in the "Circle of Willis" [2] . CT sensitivity within eligible studies ranged from 91-100 % [2] , the largest study was of a prospective design and included 3132 patients and reported 100 % sensitivity if CT is performed within 6 hours of symptom onset [1] . Recent work in the UK including 2248 patients who underwent an LP concluded that an LP to be of low diagnostic yield with the investigation of choice in patients equivocal LP findings or recurrent symptoms was CT Angiography [2] .

Introduction

The cardiac Troponin test has a key role in the diagnosis, prognosis and risk stratification of acute coronary syndrome (ACS). Over utilization and inappropriate requests for it have created a heavy workload for laboratory staff, increased costs to the health care system, and unnecessarily increased the length of stay and costs for patients. The aim of this study was to make and standardize all requests of Troponin more accurate and scientific without causing any burden to the patients, doctors or laboratory section. Methods A total number of 1073 requested serum Troponin-T Tests in the Emergency department)ED) of Hamad General hospital were reviewed retrospectively during the period from start of October/ 2014 to end of December /2014, then a data analysis was done including sex, race, age, a proper history taking and physical examination in addition to electrocardiographic (ECG) records and any necessary aid can be helpful before making any decision for Troponin request, then our results were compared to other studies and international results.

Methods

Case report Results A 21-year-old male with a history of depression was admitted to our hospital emergency department two hours after the voluntary ingestion of a non-quantified amount of barium chloride, which the patient had procured and purchased online as a means for a suicide attempt. The clinical picture consisted of vomiting, diarrhea, and progressive generalized muscle weakness requiring tracheal intubation and mechanical ventilation, with subsequent ICU admission. Severe hypokalemia was documented (minimum K+ 1.2 mmol/L), complicated by frequent ventricular premature beats with prolonged QT interval (corrected value was 640 ms). Magnesium sulfate and a K+ infusion were administered, but serum K+ remained low. Serum K+ was then 2.2 mmol/L and barium levels were 0.04 mmol/L (toxic range). Continuous veno-venous hemodiafiltration (CVVHDF) was started. This resulted in a rapid decrease in barium levels and normalization of serum K+. Clinical improvement ensued with the correction of hypokalemia and restored muscular function, allowing spontaneous ventilation and extubation 6 hours later. Barium was persistently undetectable from 12 hours after the beginning of CVVHDF (<0.006 mmol/L). The patient was later transferred to the Psychiatry department, with an uneventful hospital stay.

P435

analysis, patients with renal disease were excluded as potential kidney donors and patients with lung disease as potential lung donors. Within the Eurotransplant region, 75 years is the maximum age for donation of kidneys, lungs and pancreas islet isolation in Maastricht category 3 deceased donors. For potential liver donors, a maximum age of 60 years was used and for whole pancreas donors 50 years. Results: Of 1811 obtained Belgian reports, a total of 186 potential donors with at least 1 suitable organ for donation remained. 6 patients with a history of kidney disease were excluded, leading to 360 potential kidney donations. For lung donation 31 patients were excluded leaving a potential of 155 lung donors. 113 patients between 60-79 years old were excluded, leaving 73 potential liver donors. For whole pancreas donation, the age group of 50-79 years was excluded, resulting in 30 potential pancreas donors. Conclusions: In this first analysis of Belgian data on euthanasia in order to explore the potential of organ donation after euthanasia, 10,3% of all euthanasia cases are potentially suitable patients for donation. Whether they are willing to donate is unclear and should be studied. If only a small percentage of these patients would consider donation, this could mean an increase in donation in Belgium and the Netherlands. Introduction: The ability to communicate well with patients and their relatives is a fundamental clinical skill in intensive care medicine and central to good medical practice. Communication at the bedside, even when the patient is unconscious or sedated, may often be recalled by critical care survivors and can impact upon long-term psychological outcomes [1] .The Intensive Care Society released guidelines for the provision of intensive care services and one area which was highlighted was the patient and relative perspective, the importance of effective communication with relatives and patients and valuable time spent talking to the patient [2] .The aim of this audit was to assess the communication skills on the daily ward rounds between the team leader, normally the on call Consultant, and the patient at the bedside. Methods: An observational study comprising of 32 daily ward rounds on the 14 bedded Critical Care Unit (CCU) at Whiston hospital between October and November 2015. An average of 11 patients per ward round were recorded including non-ventilated and ventilated patients. A data collection tool was used which assessed whether the Consultant leading the ward round introduced themselves, explained what their role was and introduced the rest of the team. Results: Out of the 348 patients who were on the CCU within this time period, the majority of these patients were not ventilated. Saying that it was found that only 53% of Consultants introduced themselves, 52% explained their role and 45% introduced the rest of the team. There seemed to be a significant difference in the communication between Consultants and ventilated patients, showing that only 16% introduced themselves, 14% explained their role and 11% introduced the rest of the team. Conclusions: The communication between patients and doctors within the CCU calls for vast improvement. Given the evidence as mentioned, it is imperative that strategies are put in place to help improve the results which were found. This would include a simple adjunct next to the bedside to help remind the Consultant about the importance of effective communication. It is worthwhile re-auditing once this implementation has been put in place to see whether communication has improved. Introduction: Communication with patients and families in critical care medicine (CCM) can be complex and challenging. Physicians benefit from dedicated communication teaching, although the ideal model has not been established. Our purpose was to develop and assess the impact of a communication skills curriculum for CCM fellows. Methods: Surveys including multiple choice and free-text questions were sent to all CCM fellows, staff physicians, nurses and social workers at our institution. The results informed the design of a longitudinal communication skills curriculum for CCM fellows. The effectiveness of the curriculum is being assessed through trends in clinician feedback. Results: The survey response rate was 7/7 fellows, 15/29 staff physicians, 56/404 nurses, and 1/5 social workers. More than 50% of non-fellow respondents identified that fellows ranked below expectations in counseling about the emotional impact of emergency situations; fellows reported they had the least amount of training in this area and were least comfortable addressing patient and family emotional issues. Staff physicians were least comfortable teaching and assessing fellows' capacity to address emotion, and had received the least amount of training in this area themselves. All non-trainee groups described fellows' focus on giving information over building rapport; fellows indicated their challenges may be related to the absence of a prior relationship with patients and families, and their own discomfort in talking about death and dying. Despite challenges in the relational aspects of communication, topics of greatest interest to fellows included organ donation, adverse events, conflict, and family meetings. Preferred learning methods included simulation and feedback in clinical practice. This data guided the development of a communication skills curriculum involving 5 formal sessions over a year, and structured feedback during CCM rotations. Each formal session consisted of a didactic presentation and simulated practice. One formal session was dedicated to basic principles of communication, which were incorporated into each of the topic-based sessions. A form to guide multidisciplinary preceptors in providing feedback to fellows in clinical practice was also developed and implemented. Preliminary data indicate that fellows value the curriculum and feedback; more objective curricular evaluation is ongoing. Conclusions: Kern's model has been valuable in developing a blended communication skills curriculum tailored to CCM fellows' needs. The curriculum has been received favorably. Introduction: Conflicts between healthcare professionals and patients' relatives are rather common in the intensive care unit (ICU). As a result of societies' increased ethnic diversity these conflicts more often involve actors with a different ethno-cultural background. However few is known about the specific nature of staff-family conflicts in a multiethnic ICU environment. In this study, we give an overview of some characteristics of conflicts between family members from ethnicminority groups and staff members and compare them to characteristics of staff-family conflict in general. Methods: Ethnographic fieldwork was done in 1 ICU of a multiethnic urban hospital in Belgium. During 6 months, data were collected through negotiated interactive observation, in-depth-interviews with staff, from patients' medical records, and by making notes in a logbook.
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Case report

A 39 year-old man, smoker, with no relevant medical history presented to the hospital for fever (39°C), chills, dry cough and intense myalgia that persisted after 7-day amoxicillin self-medication. The clinical exam revealed high fever, dyspnea on mild exertion and tachycardia. The lab tests showed intense acute inflammatory syndrome, leukocytosis with lymphocytosis, normochromic-normocytic anemia, moderate cytolysis, high value of N-terminal pro-brain natriuretic peptide (NT-proBNP) (3161 pg/mL) and high antibody titer for Echovirus 30. A chest X-ray showed lesions suggestive for right medial lobe pneumonia, while the cardiology consult with echocardiography diagnosed myocarditis and pericarditis, with an ejection fraction of 40 %. Given the critical state of the patient a bronchoscopy could not be performed at that time point. Before receiving the positive serology for Echovirus 30, his clinical state continued to deteriorate despite adequate cardiologic and antibiotic therapy (levofloxacin and ertapenem), so high-dose corticotherapy (24 milligrams of dexamethasone per day for 3 weeks) was added, with slow improvement of both clinical and biological parameters. After two months of apparently good health, he presented to the hospital for the same clinical and biological findings, but having stable cardiac function. The CT-scan revealed alveolar condensation in the right medial lobe and bronchoalveolar lavage fluid was suggestive for lymphocytic alveolitis. The repeated high dose corticotherapy lead to a slow but steady improvement. All autoimmune markers were negative, and cultures from both sputum and bronchoalveolar fluid were negative for bacteria and fungi. Conclusions After ruling out bacterial and immunological etiologies two times in a row, echovirus 30 remained the incriminated infectious agent of both lymphocytic alveolitis and cardiac complications. While literature data shows that severe enterovirus infections are mostly illustrated by aseptic meningitis, our case reveals how an echovirus 30 infection can be responsible for severe cardiac complications (myocarditis and pericarditis), but also for recurrent lymphocytic alveolitis, both in the same patient. Consent Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Although remarkable progress was made on brain imagistic investigations along with the diversification of antiviral therapy, herpetic encephalitis remains a brain disease with poor prognosis and high mortality risk. The purpose is to present a clinical case of herpetic encephalitis occurred in an adult immunocompetent female patient, with favorable evolution Case report The authors present the case of an adult patient, presenting six days prior to admission: headache, confusional syndrome, nausea, diarrhea, severe fatigue. The patient presented to the County Hospital, Timișoara where she is admitted to the Neurology Clinic. In order to put the correct diagnosis, biological investigations (blood cell identification, ESR, fibrinogen, blood glucose, C-reactive protein, urine analysis, blood cultures, serum urea and creatinine, urine culture, exudate lingual for yeast, etc.) and paraclinical investigations (cerebral computed tomography (CT), cerebral MRI, lumbar puncture) have been made. Based on clinical data in conjunction with the results of biological samples and laboratory investigations, the diagnosis of herpetic encephalitis is established and the patient is transferred to the Clinic of Infectious Diseases for therapeutic and clinical monitoring. Physical examination at admission to our clinic reveals: afebrile patient with moderate influenced general state, temporo-spatial disorientation, but without meningeal signs, tongue with whitish deposits, cardio-pulmonary and digestive systems with no pathological sings. Lumbar puncture was performed and antiviral and symptomatic treatment was set. WBC, RBC, PLT = normal values; neutrophils = 88.2 %, lymphocytes = 6.6 %; lumbar puncture: clear normotensive liquid, glucose = 73 mg/dL, proteins = 0.5 g/L, erythrocytes = 55, leukocytes = 0; cerebral MRI: cortico-subcortical lesion in the uncus, partial temporal lobe (anterior-internal), the left island with no capture, with aspect suggesting herpetic encephalitis. The result of the blood culture and CSF culture for bacterial flora and BK were negative, so the bacterial etiology was excluded. Lingual exudate for yeast Candida albicans was positive. The treatment consisted in: Acyclovir 250 mg, 3x2 fl/day, Ceftriaxone 1 g, 2x2g/day, Fluconazole 200 mg, 1tb/day, Dexamethasone, Mannitol, vitamin B6, symptomatic agents and solutions for hydro-electrolytic rebalancing. The patient's state was favorable, the headache remitted after three days and the confusional syndrome disappeared after six day of hospitalization.

Conclusions

We have identified a low prevalence of pneumococcal colonization in pediatric patients with influenza. However, when colonization was present, it associated a significantly longer hospital stay and a significantly higher number of complications, highlighting the need for close monitoring and screening for pneumococcal colonization in children. Background Varicella is a highly contagious infectious disease, frequently encountered during childhood, with general receptivity and most often, with self-limited evolution. There are cases when varicella can present severe complications, such as acute encephalitis, cerebellitis, and rarely myelitis. Often, the host has a previous immunosuppression, such complications being rare in patients with a normal immunological status. Case report We present the case of a 10 year old girl, diagnosed 7 days prior with varicella, without any significant medical history, admitted in the Pediatric Intensive Care Unit of the National Institute for Infectious Diseases "Prof. Dr. Matei Balș" for lower back pain, myalgias, muscle weakness, difficulty in walking. The onset of the symptoms was 3 days prior with an evolution towards exacerbation. Clinical exam upon admission confirmed varicella and furthermore, urinary retention with enlarged bladder, diminished patellar, right plantar clonus, decrease in muscle strength, myalgias, and paresthesias, coordination impairment in the lower limbs and asymmetric paraparesis predominantly on the right side. Workup was within the normal range. Myelitis was suspected and therefore a MRI of the head and spine was performed, which showed medullar inflammatory lesions in the cervicothoracic segment. Lumbar puncture was normal, except for a positive varicella-zoster virus PCR from CSF. Positive diagnosis consisted of cervicothoracic varicella-zoster virus myelitis. Treatment with acyclovir (60 mg/ kg/day), ceftriaxone 2 g/day, corticotherapy with methylprednisolone, human immunoglobulin, and iv fluids was promptly instituted for 14 days, with a slow favorable evolution. Paresthesias, motor deficit, urinary retention and sensitivity impairment resolved under treatment.

Background

In the absence of a clinically evident trauma it is difficult to diagnose a muscle hematoma which can be easily mistaken for a profound thrombophlebitis. Case report A 74 years old patient coming from the rural area, with a history of penile tumor with lymph nodes expansion (2008), operated on, diabetic and coronary patient, under treatment with Trombex for one year, is hospitalized accusing fever, dysuria, cloudy urine. Objective, without modifications on admission, paraclinically only a prostate hypertrophy is retained on ultrasound. Initially interpreted as urinary infection, therapy with ciprofloxacin is started after urine culture is collected. On the day of admission, the patient falls from his own height while going to the bathroom, without apparent trauma, without loss of consciousness. On the second day from admission, the patient accuses right lower back and right lower leg pain, without objective cutaneous modifications. The third day the pain centralizes on the right lower leg, with gradual evolution towards posterior edema, with positive Hoffman sign. The situation is interpreted as being deep vein thrombosis and, therefore, anticoagulant therapy is initiated. After three days of treatment the patient is afebrile, still presenting edema and pain in the calf, neutrophilic leukocytosis appears, inflammatory evidence increases, metabolic imbalance is present, urine culture is sterile. The treatment is changed to ceftriaxone. The ultrasound of the right lower leg section shows a fluid collection of 15/3.5 cm. Puncture is performed in the area of the collection but nothing externalizes. A vascular surgery consultation in Timișoara refutes the diagnosis of thrombophlebitis thus maintaining the suspicion of possibly infectious hematoma. The patient is transferred to the surgery ward where the suspicion is confirmed surgically and the collection is evacuated. Conclusions A calf muscle hematoma can be easily mistaken, clinically, for a profound thrombophlebitis in the absence of cutaneous modifications. For a correct diagnosis, extended investigation is needed since therapy is completely different in these two situations. Consent Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Background More than 15 million individuals are infected by the T-lymphotropic virus (HTLV) through the world, the first described human oncovirus. Etiologically linked to the adult T-cell leukemia/lymphoma (ATLL), the spread of the virus is endemic in Japan, Africa, Central and South America but little is known about the infection rates in Romania, where testing of blood-donors in the only structured epidemiologic ongoing program regarding the HTLV infection. Starting from the direct mutagenic effects of the virus, the present paper wants to raise awareness towards this endemic problem we are facing. Methods Under high clinical suspicion, the ATLL diagnosis was established in the Hematology department of the Clinical Hospital Colentina -Bucharest, from January 2014 to March 2016, by analyzing the lymphocyte morphology, immunophenotype, histology of the tissues affected in the pure lymphoma forms. The HTLV-1/2-specific antibodies were detected using an enzyme-linked immunosorbent assay (ELISA) and were confirmed by real-time PCR assay. For the confirmed cases we prospectively recorded the age, sex, immune status, the form and the severity of the disease, the response to the first, and if applied, to the second line of chemotherapy, in some instances in association with antiretroviral therapy. The epidemiological link to a possible HTLV infection source was explored using a standard questionnaire.
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Introduction Severe sepsis results in ~36,800 UK deaths each year [1] . Prior studies demonstrate the benefi t of early recognition and treatment of sepsis in reducing mortality [2] . The Sepsis Six [1] bundle aims to optimise the fi rst hour of sepsis management. We assessed the proportion of emergency department (ED) patients with severe sepsis receiving the Sepsis Six bundle and whether this was improved by a combination of staff education and use of Sepsis Six management stickers in patient notes. Methods A closed loop audit was completed in the ED at Ipswich Hospital, UK. Each cycle was 14 days with interventions made in a 4-week period between the two cycles. The interventions consisted of: Sepsis Six management stickers and posters placed in the ED; two training sessions for all ED nurses on sepsis recognition and management; a teaching session for all middle-grade doctors; and a trolley in the ED with equipment required for the Sepsis Six. The notes of all patients with lactate ≥2 mmol/l were retrospectively reviewed. Those with ≥2 systemic infl ammatory response syndrome criteria and a documented suspicion of infection were deemed to have severe sepsis. The times at which these patients had each of the Sepsis Six completed were recorded, as were the fi nal diagnosis and 7/28 day mortality. Results In Cycle 1, 31/106 patients met the criteria for severe sepsis, compared with 36/120 in Cycle 2. The delivery of the Sepsis Six interventions was highly variable. In Cycle 1 lactate levels and i.v. access had the highest 60-minute completion rates (90.3%, 83.9% respectively). Blood cultures and i.v. fl uid resuscitation were completed for 61.3% and 64.5% of patients within 60 minutes. Only 38.7% of septic patients were given i.v. antibiotics within 60 minutes. In total, 58.9% of patients received antibiotics in accordance with trust guidelines. High fl ow oxygen, catheters and fl uid balance charts had the lowest 60-minute completion rates (35.5%, 6.5%, 6.5% respectively). In Cycle 2, post intervention, there was no signifi cant change in the percentage of patients receiving the Sepsis Six bundle. Conclusion The low rates of Sepsis Six completion require improvement to meet the targets set out by the College of Emergency Medicine. Our results suggest that simple interventions are ineff ective in increasing Sepsis Six completion and thus lend support to the case for integrated interventions such as electronic recording and alert systems. References wound infection with the following 14 preoperative characteristics and perioperative parameters: age >75, female gender, diabetes mellitus (DM), insulin dependence, body mass index (BMI) >30, current smokers, COPD, cardiopulmonary bypass time (CBP) >120 minutes, use of steroids, emergency operation, prolonged mechanical ventilation (>48 hours), reintubation, transfusion with more than 3 units of red blood cells, and the postoperative use of non-invasive ventilation (NIV). The chi-square test was used for statistical analysis. Results A total of 35 patients (3.44%) were complicated by deep sternal wound infections. No statistical correlation was found with age >75, gender, DM, BMI >30, steroids, emergent operation, prolonged ventilation, CBP time >120 minutes, reintubation and NIV. Factors with statistical signifi cant correlation are presented in Table 1 . Conclusion Postoperative deep sternal wound infections have statistical signifi cant correlation with the following parameters: transfusion with >3 red blood cell units, history of COPD, insulin dependence and when the patient is a current smoker. Also there is a tendency for correlation with CBP time >120 minutes (P = 0.056).

Results

Methods We conducted a single-center, prospective study from January 2012 to November 2012. Clinicians prospectively estimated the anticipated duration of CVC at the time of line placement in an electronic procedure note. We collected demographics, past medical history, type of ICU, vital signs, laboratory values, SOFA score, mechanical ventilation and use of vasopressors at the time of placement. Continuous variables were compared with the Wilcoxon rank-sum test and categorical variables with the Fisher's exact test. Pearson's correlation coeffi cient was used to assess the correlation between estimated CVC time and actual time. Duration of CVC use was dichotomized into long (≥7 days) or short (<7 days), based on previous literature, and sensitivity and specifi city for predicting long duration was calculated. We performed a logistic regression analysis to identify variables associated with long CVC duration and calculated the area under the ROC curve (AUC). Results We enrolled 150 patients; median age was 65 (IQR: 52 to 74), 63 (42%) were female and mortality was 22%. Median time from CVC placement to removal was 5 (IQR: 3 to 8) days. The correlation between estimated CVC time and actual time was low (r = 0.36, P <0.001). Fortyeight (32%) patients had a long CVC duration. Clinician estimate had 46% sensitivity and 76% specifi city for predicting long duration of CVC. Of 30 variables tested, only temperature at the time of insertion was signifi cantly associated with long duration (OR: 1.30, 95% CI: 1.04 to 1.63, P = 0.02). The AUC for this model was 0.59 (95% CI: 0.49 to 0.69). Conclusion Our results suggest a low correlation between clinician prediction at time of insertion and actual duration of CVC. We did not fi nd any good predictors of long duration of CVC. Given our relatively low sample size, we may have been underpowered. It may not be feasible to identify patients at the time of insertion who may benefi t from antimicrobial-coated catheters.

Introduction

The ECRI Institute has identifi ed alarm fatigue as the number one health technology hazard [1] . A recent study on 461 ICU patients investigated 2,558,760 alarms [2] . In total, 88.8% of the annotated 12,671 arrhythmia alarms were false positives (FPs). It was concluded that the excessive number of alarms is 'a complex interplay of inappropriate user settings, patient conditions, and algorithm defi ciencies' . Nine conditions causing alarms, four of which were ECG algorithm related, were reported [2] . In this study, we investigated a new algorithm in which improvements targeting three of the reported four ECG-related conditions were implemented: low amplitude QRS; wide QRS; nonactionable ventricular tachycardia (VT). Methods The false alarm rate of the new algorithm (GE Carescape, 2012) was compared with that of the algorithm evaluated in the study (GE Solar, 2003) [2] on the collected ECG waveform data. User settings such as QRS detection sensitivity (high/normal) were not available. Therefore, normal sensitivity was assumed for both versions. With the old algorithm, 10 patients with low QRS amplitudes gave a signifi cantly higher number of FPs than were reported [2] . For those patients, both sensitivity modes were tested with the old algorithm. Sixty-six percent of patients with a pacemaker did not have the pacemaker mode selected [2] . Outlier patients in which false alarms were due to user settings (20 patients with a pacemaker) or patient condition (four patients with a bundle branch block) rather than algorithm defi ciency were excluded. Results Improved algorithm resulted in 66% reduction of FP alarms. When using the high-sensitivity mode for the 10 patients with low QRS, FP reduction was 18%. No compromises regarding detection of true events were found. Introduction Cardiac arrhythmias may be observed at any time during the ICU stay. The prognosis may suff er due to these arrhythmias. In our study, we aimed to evaluate incidence and risk factors of arrhythmias occurring in patients in the ICU. Methods Patients treated in the ICU were included in the study if they fulfi lled the following: age >18, no cardiac valvular disease, no cardiac surgery in the recent 6-month period, no history of myocardial infarction (MI), need for mechanical ventilation, and one or more organ failure. Demographic, hemodynamic and laboratory parameters, APACHE II score, presence of sepsis, acute renal failure, MI, and VIP during the ICU stay were recorded. Therapies used for arrhythmia and response to therapies were also recorded. Results Two hundred and fourteen patients were included in the study. Twenty-six percent (n = 56) of patients had arrhythmias. Incidence was higher in females (P = 0.045). Average age of arrhythmic patients was 69 (19 to 86), and they were older than nonarrhythmic patients (P <0.001). APACHE II scores were higher in arrhythmic patients (P = 0.001).

References

Methods Echocardiography was performed in 329 patients with ADHF and right ventricular function was assessed by measuring the right ventricular fractional area, and a right ventricular ejection fraction (RVEF) <35% was taken as the cutoff value for RV systolic dysfunction. The systolic pulmonary pressure (PASP) was calculated from the tricuspid regurgitation signal applying the modifi ed Bernoulli equation, Methods A total of 112 patients undergoing PPCI and MIH were compared with 32 comparable consecutive patients who underwent PPCI but no MIH. We hypothesized that combining both methods lead to better survival rate. MIH was induced (propofol, fentanyl, saline 4 ml/kg BW, 2°C) and maintained for 24 hours, targeting 32 to 34°C. Spontaneous rewarming was allowed (0.5°C). Results There were no signifi cant diff erences between the MIH and Control group in general characteristics, cardiac arrest circumstances and angiographic features. Except for decreases in heart rate during MIH, there was no diff erence between MIH and no MIH groups in arterial pressure, peak lactate (7.7 vs. 6.2 mmol/l; P = 0.36), need for vasopressors (57% vs. 41%; P = 0.09), aortic balloon counterpulsation (13% vs. 22%; P = 0.19), repeat cardioversion/defi brillation (17% vs. 25%; P = 0.30). There was lower incidence of inotropic use (36% vs. 59%; P = 0.01) and use of antiarrhythmics (11% vs. 53%; P = 0.002). There was no diff erence in FiO 2 during mechanical ventilation and in renal function. See Table 1 . Introduction Standard 12-lead electrocardiogram (ECG) is, with biomarkers, the most accurate method in the diagnosis of acute coronary syndrome (ACS). However, posterior (V7-V8-V9) and right (V3R-V4R-V5R) derivations are not systematically performed due to the time-consuming procedure involved, despite major therapeutic implications (fl uid loading instead of nitrates use in right ventricular involvement) and published guidelines [1] . Recently, an 18-lead ECG system, standard 12-lead ECG and six additional synthesized leads (assessing posterior and right ventricular areas) in only one recording procedure has been developed. The reliability of this material (ECG 2550; Nihon Kohden Co. Ltd, Japan) was already validated in this indication in an Asian population [2, 3] . Methods We conducted a prospective, observational study with patients admitted to our emergency department (ED), during a 6-month period. Requirement for ECG was guided by physician's discretion according to patient's history. All patients with chest pain, dyspnea, palpitations, disturbance of consciousness, malaise or abdominal complaint underwent synthesized 18-lead ECG within 10 minutes of ED arrival. The aim of the study was to evaluate the eff ectiveness of the synthesized 18-lead ECG as an ischemia triage tool in the ED, and particularly the ability to early detect a right ventricular involvement.

Introduction

The potential benefi ts of a protocol of intensive alveolar recruitment may be outweighed by its detrimental eff ects in hemodynamic stability after cardiac surgery. The aim of this study was to analyze the hemodynamic behavior of patients included in a trial of intensive alveolar recruitment after cardiac surgery. Methods In this randomized trial, we assigned adult patients with PaO 2 / FIO 2 <250 at a PEEP of 5 cmH 2 O to either intensive alveolar recruitment or a standard protocol, both using low-tidal volume ventilation (6 ml/ kg/ibw) after adequate volemia status. Our hypothesis was that an intensive alveolar recruitment protocol with controlled pressure of 15 cmH 2 O and PEEP of 30 cmH 2 O during 1 minute, repeated three times at 1-minute intervals between each maneuver, would not cause hemodynamic instability. Results In total, 163 patients were included in the standard and 157 in the intensive group. Patients of the intensive group had a signifi cant reduction of the MAP at T1, T2 and T3 (1 hour, 2 hours and 3 hours of the protocol), returning to baseline after T4 ( Figure 1 ). No patients had severe hypotension (MAP <65 mmHg) and the study was not stopped in any case. The length of the hospital stay was shorter among patients in the intensive group (10.9 (9.9 to 11.9) vs. 12.4 days (11.3 to 13.6); P = 0.045). Conclusion An intensive alveolar recruitment protocol did not result in hemodynamic instability in hypoxemic patients after cardiac surgery (NCT01502332). Introduction National University Hospital, Singapore, recently formed a Division of Critical Care -Respiratory Therapy. This service rapidly expanded to provide 24/7 Respiratory Therapy Services in the cardiothoracic intensive care unit (CTICU). One goal of service expansion was a reduction in duration of mechanical ventilation after cardiac surgery. We hypothesized that introduction of a teambased extubation protocol would reduce the duration of mechanical ventilation and ultimately aff ect ICU length of stay. Methods A multidisciplinary group created a team-based extubation protocol. The protocol was applied to all elective postoperative cardiac surgery patients. To assess the protocol's impact, data were collected in a registry 3 months before and 3 months after protocol initiation. Data collection included cardiopulmonary bypass time, McCormack airway assessment, ICU admission time, initial pH, lactate, inotropes upon arrival at the CTICU, blood gas analysis prior to extubation, time of extubation and length of stay. Patients were excluded from data analysis if they experienced events which contraindicated application of the protocol, such as signifi cant intraoperative or postoperative complications. These events were explicitly stated in the extubation protocol. Singapore's Domain-specifi c review board granted waiver of patient consent to analyze and present these data. Results A total of 201 patients undergoing elective open cardiac surgery were included; 99 patients before protocol implementation (pre-protocol) and 102 patients after implementation (post-protocol). There was no signifi cant diff erence in mean age (60 vs. 61 P = 0.823), gender (79.8% vs. 79.4% P = 1.00), EuroSCORE (26 vs. 32 P = 0.576) and proportion receiving bypass surgery (72% vs. 80% P = 0.206) or valve surgery (21% vs. 19% P = 0.722) between the two groups. Median extubation time was reduced by 3.5 hours (620 minutes vs. 408 minutes P <0.001). ICU length of stay was also reduced following introduction of the pre-protocol 48 hours versus 24 hours post protocol (P <0.05). Conclusion A team-based extubation protocol signifi cantly reduced the duration of mechanical ventilation and this translated to reduced ICU length of stay in patients undergoing elective open-heart surgery. Introduction Frailty is defi ned as a multidimensional syndrome involving loss of physical and cognitive reserve leading to greater vulnerability to adverse events [1] . Such events include susceptibility to unplanned hospital admissions, and death [1] [2] [3] . Frailty is associated with increased ICU and 6-month mortality, and reduced quality of life [4] . The aim of this study is to investigate the impact of baseline frailty on postoperative quality of life indicators and postoperative frailty following cardiothoracic surgery. Methods Adult patients undergoing cardiac surgery or thoracic surgery (involving thoracotomy) were included in this study. Baseline measures of frailty [4] and performance status were prospectively recorded using validated tools. Informed consent was obtained prior to inclusion. Outcome measures of APACHE II scores, duration of ventilation, length of ICU stay and mortality were recorded. Follow-up at 6 months was conducted by telephone to assess recovery patterns. Results A total of 120 patients were included in this study, including 100 patients who underwent cardiac surgery and 20 patients who underwent thoracic surgery. Eighty-fi ve patients (70.8%) were male. The mean age was 65.4 years (range 25 to 89 years). The mean baseline frailty score also varied widely within our cohort. Four patients died in the ICU following their surgery (3% ICU mortality rate). Mean length of ICU stay was 2.7 days (range 0 to 20 days), with a mean duration of ventilation of 20 hours (range 0 to 264 hours). Follow-up of these patients at 6 months following their surgery is currently underway. Conclusion Owing to advances in life expectancy, health and perioperative medicine, it has become more diffi cult to determine fi tness for major surgery. Our data suggest that frailty may be a useful prognostic measure to help inform such decisions. References The probability of placing IABP in the preoperative period has been calculated, making a propensity analysis to obtain two homogeneous groups treated with or without the IABP, based on personal history, functional status and type of surgery. Seventy-seven patients with preoperative IABP were matched with 77 patients without BCIAO with the nearest propensity score. We used the chi-square test or Student t test as needed and binary logistic regression for multivariate analysis so we can rule out possible confounding variables. We used the statistical package R v2.12 for MAC. Results A total of 8,026 were recorded, in 77 of them an IABP was inserted before the surgery. We performed a propensity score analysis by pairing 72 patients with and without BCIAO based on epidemiological factors and type of surgery. In the analysis of all-cause 30-day mortality, 27% of patients in whom IABP was inserted prior surgery died versus 13.1% of patients without IABP preoperative implantation (P = 0.043). A combined endpoint that included need for prolonged mechanical ventilation over 24 hours or reoperation or mediastinitis or stroke after surgery or 30-day mortality was performed and occurred in 58.3% of patients with preoperative IABP versus 41.7% without it (P = 0.046). When stratifi ed by preoperative risk (analyzed with EuroSCORE), no diff erence between groups was observed (P = 0.62, OR 0.75 (0.23 to 2.35)) for mortality rate and (P = 0.11, OR 0.47 (0.19 to 1.18)) for the combined endpoint. The patients with preoperative IABP implantation had a higher ICU length of stay (10.6 ± 7.7 vs. 4.6 ± 6.7, P = 0.046) with no diff erences in terms of overall hospital stay (21.8 ± 18.7 vs. 18.9 ± 22.08, NS). Conclusion The use of IABP prior to cardiac surgery in patients at high risk does not reduce the mortality rate nor the combined endpoint described above. ICU length of stay was greater in those patients in whom IABP was implanted prior to surgery; there were no diff erences in overall hospital stay.
Results EPO tended to increase in the hyperoxia group over time (P = 0.05), while it remained stable in the control group (P = 0.53) (Figure 1 ). ROS levels increased at t1 and decreased at t2, GSH tended to decrease at t1 and increased at t2 in the hyperoxia group. ). Therefore we used a rounded up cutoff value of 0.5 mg/l to examine the diagnostic accuracy of PATHFAST D-dimer to exclude PE. The correlation between PATHFAST and VIDAS results was particularly close for concentrations at or around the critical cutoff value of 0.5 mg/l. The correlation between PATHFAST and STRATUS results was particularly close in the patient group with VTE (r = 0.9694), whereas slightly lower results were obtained with STRATUS in the control group. With the widely used cutoff value 0.5 mg/l, PATHFAST demonstrated suitable sensitivity but not STRATUS. ROC analysis indicated that optimal cutoff values could be set at either 0.5 or 0.6 mg/l and at 0.3 or 0.4 mg/l for PATHFAST and STRATUS, respectively. Conclusion By use of the PATHFAST D-dimer assay only six of diagnoses were missed at the time of fi rst presentation compared with 10 diagnoses missed by the VIDAS D-dimer Exclusion assay, yielding higher sensitivity of the PATHFAST D-dimer assay compared with the VIDAS assay (90% vs. 83%). The STRATUS assays showed comparable performance and appeared to be suitable for the exclusion of VTE in the emergency room setting, whereas PATHFAST demonstrated superior sensitivity. Moreover, the PATHFAST analyzer allows simultaneous determination of D-dimer and cardiac troponin I within 16 minutes from whole blood samples. Therefore, this method might be useful at the point of care for early diagnostic assessment of patients with symptoms of PE or chest pain admitted to the ER or to the chest pain unit. Introduction Despite preventive anticoagulation therapy measures, venous thromboembolic disease is a major cause of morbidity and mortality among patients hospitalized in ICUs. In fact, pulmonary embolism is not only the most serious manifestation of the disease, but also one of the primary causes of sudden death. The aim of this study is to investigate the frequency of thromboembolism and pulmonary embolism in ICU hospitalized trauma and neurosurgical patients. Methods One hundred ICU patients, 51 postoperative neurosurgical and 49 trauma, were included in the study. Patients' demographic data as well as medical history, temperature, white blood cells and platelets counts were recorded on admission, the day of thrombosis diagnosis and the fi nal outcome of their treatment. Statistics were performed with SPSS-19. P <0.05 was considered signifi cant.

Computer versus paper insulin protocol for managing hyperglycemia in three ICUs

The number of skips in data acquisition was low, resulting in availability of real-time data during 95 (89 to 98)% of the connection time per sensor. Conclusion The point accuracy of the device was relatively low in critically ill patients. The device reliability was relatively good, although sensors were removed prematurely for a variety of reasons. Introduction Hyperglycemia is common and often multifactorial in critically ill patients. The association of hyperglycemia with adverse outcome has repeatedly been established in a variety of settings. The objective of this study was to investigate whether hyperglycemia on admission to the ICU impacts presentation and outcome of sepsis patients and whether this eff ect is diff erent for patients with a history of diabetes mellitus. Methods A two-center, prospective observational cohort study was conducted including all consecutive critically ill patients admitted to the ICU between January 2011 and July 2013. Sepsis patients were identifi ed using strict clinical and diagnostic criteria. The fi rst glucose measurement within a time window of 4 hours before up to 4 hours after ICU admission was categorized into euglycemia (71 to 140 mg/dl), mild hyperglycemia (141 to 200 mg/dl) or severe hyperglycemia (>200 mg/ dl), patients with hypoglycemia were excluded. A multivariable Cox proportional hazard model was used to determine the eff ect of admission hyperglycemia on mortality corrected for covariates. Results Of the 1,059 patients admitted with sepsis, 526 (55.8%) had admission glucose levels within the normal range, 270 (25.5%) had mild hyperglycemia and 202 (19.1%) severe hyperglycemia. Patients with severe hyperglycemia were older, had higher APACHE IV scores and were more often diabetics compared with euglycemic patients. Shock on admission was more common in patients admitted with euglycemia. Crude mortality increased with increased admission glucose and a Cox regression analysis showed increased risk for 30day (HR = 1.67, CI = 1.24 to 2.23), 60-day (HR = 1.42, CI = 1.08 to 1.87) and 90-day (1.31, CI = 1.02 to 1.70) mortality in patients admitted with severe hyperglycemia compared with euglycemia. The association between mortality and severe hyperglycemia on admission was only present in patients without known diabetes but not in patients with a history of diabetes (30-day mortality HR = 1.67, CI = 1.15 to 2.43 vs. 1.84, CI = 0.97 to 3.49). Severe hyperglycemia was associated with a blunted proinfl ammatory cytokine response (IL-6 and IL-8) on admission in patients without, but not in patients with diabetes. Conclusion Severe hyperglycemia on admission is associated with increased 30-day, 60-day and 90-day mortality in sepsis patients without a history of diabetes mellitus. microdialysis-based continuous glucose monitoring (CGM) (EIRUS®; Maquet Critical Care AB, Solna, Sweden). Methods Patients with an expected stay in the ICU of >48 hours needing an arterial catheter and a central venous catheter (CVC) were eligible. For a maximum of 3 days, during 8 hours per day, 125 μl blood was drawn from the arterial line every 15 minutes. Point accuracy was expressed using Clarke error grids, Bland-Altman plots and glucose prediction error analysis [4, 5] . Trend accuracy was expressed using continuous glucose error grid analysis [6] . Results Three-hundred and fi fty-four paired samples were obtained from seven patients (66 (59 to 79) years old, APACHE II score 23 (20 to 28), 51 (19 to 77) samples per patient). Point accuracy: 91% of paired values were in zone A, with the remaining 9% of the values in zone B in the Clarke error grid. In the Bland-Altman, bias was 5.4 mg/dl with an upper limit of agreement of 32.5 mg/dl and a lower level of agreement of -21.8 mg/dl. Glucose prediction error analysis showed that 91% of the values ≥75 mg/dl within 20% of the values measured by the blood gas analyzer were within range. Trend accuracy: in the rate error grid of the continuous glucose error grid analysis, 96% of the paired values were in zone A, 3.7% were in zone B and 0.3% were in zone C. Conclusion Point and trend accuracy of the tested microdialysis-based CGM are good in critically ill patients.

Reference

Introduction The objectives of this survey were to establish the prevalence of symptoms of post-traumatic stress in mixed staff groups working in adult and paediatric intensive care settings and to examine the main themes in staff descriptions of the most traumatic event they had experienced at work. Methods A total of 355 health professionals working on three adult and four paediatric units at two centres were asked to rate their current level of post-traumatic stress symptoms on the Trauma Screening Questionnaire (TSQ). Results Paediatric/neonatal intensive care staff were more likely to score above the clinical cutoff point for post-traumatic stress symptoms on the TSQ in relation to an incident at work than adult intensive care staff in this sample (PICU n = 33/193 (17%) vs. AICU n = 13/162 (8%), P <0.001). For the 172 staff who provided a description of the most traumatic event they had experienced, the following themes were in 88 (4.6%) cases. The mortality rate was 10.9%. The following factors were associated with mortality in univariate logistic regression: age, body mass index, past medical history, TBSA, FTBSA, intoxication (CO, CN), inhalation injury, fl ame burns, self-infl icted burns (all P <0.0001), sex (P <0.001), and admission date (P <0.01). Simple periodic regression showed a biannual seasonal eff ect on mortality, documented with a 1-year periodic (P <0.01) and a 6-month periodic (P = 0.01) dependency. Multivariate analysis with or without periodic terms identifi ed age, past medical history, TBSA, FTBSA, inhalation, intoxication and admission date as the only factors independently associated with mortality. Methods Twenty-two patients suff ering GP admitted to the ICU, between January 2002 and December 2012, were included. The Acute Physiology and Chronic Health Evaluation (APACHE) II prognostic score scale was used in order to assess the severity of illness on the fi rst ICU day. The Sequential Organ Failure Assessment (SOFA) score was used to measure organ dysfunction, and the Birmingham vasculitis activity score for Wegener granulomatosis (BVAS/WG) was used to assess vasculitis activity. The outcome measurements taken into account were ICU mortality and ICU length of stay. Results One patient was admitted twice during this period. The sample comprised 11 males and 11 females (50%, respectively). Featuring an average age of 52 years, 78% of them were admitted to the ICU because of respiratory failure, 50% were due to diff use alveoli hemorrhage, 36% due to sepsis, 4% hypovolemic shock and fi nally 4% because of tuberculosis. According to the BVAS/WG, 20 patients corresponded to severe disease, one to limited diseases and one to persistent disease. The average ICU length of stay was 20.6 days and as inpatients 43 days. While comparing the SOFA score between alive and deceased patients there was a 0.5-point diff erence (P = 0.077), 63% of the alive patients were diagnosed while they were in the ICU. Plasmapheresis was found to be a protector factor (P <0.05). Conclusion The BVAS/WG score was signifi cantly diff erent between alive and deceased patients. Plasmapheresis was found to be a survival predictor. This study has shown that both SOFA and APACHE II scores have no prognostic value in these patients.
14 section matches

Results

Introduction Most individuals infected with the 2009 pandemic H1N1 infl uenza A virus (IAV) (H1N1pdm) experienced uncomplicated fl u. However, in a small subset of patients the infection rapidly progressed to primary viral pneumonia (PVP) and a minority of them developed ARDS. Inherited and acquired variability in host immune responses may infl uence susceptibility and outcome of IAV infection. However, the molecular nature of such human factors remains largely elusive. Methods We report three adult relatives with the autosomal dominant GATA-2 defi ciency. P1 and his son P2 had a history of myelodysplastic syndrome and a few episodes of mild respiratory infections. They developed PVP by H1N1pdm which rapidly evolved to ARDS. They died at the age of 54 and 31, respectively. Results Patients were heterozygous for a novel R396L mutation in GATA2. Like other patients with GATA-2 defi ciency, the three relatives had absence of peripheral NK and B cells and monocytopenia. However a high number of plasma cells, which were found to be pauciclonal, were observed in peripheral blood from P1 during H1N1pdm infection. P1 and P2 had normal levels of immunoglobulins and IgG antibodies against common viruses. Microneutralization test showed that P1 produced normal titers of neutralizing antibodies against H1N1pdm and against the previous annual H1N1 strain. Our results suggest that a few clones of long-living memory B cells against IAV expanded in P1; and that these cells produced cross-reactive antibodies against H1N1pdm, similar to those recently described. During the fl u episode P1 had a strong increase of IFNγ-producing T cells and of IFNγ production. The Th1-related chemokines CXCL10 and CXCL9, as well as IFNγ, MCP-1 and IL-8, were strongly elevated in serum from P1 and P2 in the course of H1N1pdm infection. Conclusion GATA-2 defi ciency is the fi rst described Mendelian inborn error of immunity underlying severe IAV infection. Primary immunodefi ciencies predisposing to severe IAV infections may debut, even in adults without a history of previous severe infections. The massive IFNγ-mediated cytokine storm may explain the fatal course of H1N1pdm infection in our patients.
Results At 48 hours after PMX-F, signifi cantly decreased PCT from 17.5 (5.0; 40.9) to 7.1 (4.8; 13.0) ng/ml, P = 0.028, decreased CRP from 180 (133; 286) to 132 (68; 155) mg/l, P = 0.015 and SOFA score from 7.0 (3,0; 8.0) to 6.0 (3,0; 7.0), P = 0.007. At 24 hours after Alteco LPS, signifi cantly decreased PCT from 8.7 (3.0; 25.9) to 4.8 (2.1; 10.0) ng/ml. The 28-day mortality rate was 14.2% (n = 2) in the PMX-F group and 31.3% (n = 10) in the Alteco LPS group. Introduction Corticosteroid (CS) therapy in sepsis remains controversial and was fi rst introduced in sepsis management for its antiinfl ammatory property. CS has found a role in septic shock amelioration with inconsistent outcomes. The Surviving Sepsis Campaign (SSC) includes CS as a Level 2C recommendation in septic shock [1] . Adapting and practicing SSC guidelines vary between critical care units. Accordingly, a survey was conducted to elucidate the usage of CS for septic shock by UK critical care physicians (CCPs). Methods Following approval by the UK Intensive Care Society (ICS), the survey was publicised on the ICS website and its newsletter. Results A total of 81 intensivists responded to this online survey. Seventy-four (92.5%) CCPs prescribed CS only if the septic shock is poorly responsive to fl uid resuscitation and vasopressor therapy. Six (7.5%) initiated CS at the same time as vasopressor therapy. None initiated CS for patients with severe sepsis. No CS other than hydrocortisone is being used. The most commonly used intravenous regimen is 50 mg 6 hourly (65%) followed by 50 mg 8 hourly (11%). Only 10% of CCPs would prescribe it by infusion. Less commonly used regimens were 100 mg 8 hourly (6%) and 100 mg 6 hourly (5%). Only 5% would consider adding fl udrocortisone. Prior to initiating CS, 5% of CCPs would perform a short synacthen test, while 94% would not. The majority (89%) of CCPs would stop CS after resolution of shock state or when vasopressor infusion is terminated whilst 11% after a fi xed duration. Withdrawal of CS also diff ered, in that 25% tapered/weaned steroids, 31% stopped it abruptly and 44% of CCPs would base their CS cessation pattern on the clinical context. Only 46% of CCPs believe that CS is benefi cial whereas 44% were unsure of the benefi ts in septic shock. Only 29 (36%) responders indicated that their critical care unit had a written protocol for CS in septic shock. Conclusion The perceptions, usage and cessation of CS in septic shock vary but do appear to have shifted in the last decade. A UK survey in 2003 identifi ed that only 60% of ICUs used CS for septic shock and over 22% perform a short synacthen test [2] . It appears that many intensivists are using CS for septic shock, despite confl icting outcome data. We all strive to practice evidence-based medicine but until we have a robust, reliable and methodical randomised control trial that attempts to resolve the CS debate, practice will remain diverse on this subject, as refl ected by our survey. References Introduction From December 2009 to December 2010, 47 patients in Scotland presented with confi rmed anthrax infection manifested by soft tissue disease related to heroin injection. These cases represent the fi rst known outbreak of a recently recognized form of anthrax, termed injectional anthrax, which appears to be associated with a high mortality rate (28% in confi rmed cases from the UK outbreak). While epidemiologic data from this outbreak have been published, no report has systematically described fi ndings in patients at presentation or compared these fi ndings in nonsurvivors and survivors. Methods To better describe injectional anthrax, we developed a questionnaire and sent it to clinicians who had cared for confi rmed cases during the outbreak. Completed questionnaires describing 27 patients, 11 nonsurvivors and 16 survivors, were returned. Results In preliminary analysis of categorical data, a signifi cantly (Fisher exact test) greater proportion of patients with compared with without the following fi ndings did not survive; history of alcohol use (P = 0.05); the presence of lethargy (P = 0.01), confusion (P = 0.03), nausea (P = 0.04), abdominal pain (P = 0.02), or the need for vasopressors (P = 0.002), oxygen, mechanical ventilation, or steroids (all P = 0.004) at presentation; and excessive bleeding at surgery (P = 0.01). Initial analysis of continuous data demonstrated that, compared with survivors at presentation, nonsurvivors had signifi cantly (one-way ANOVA) increased respiratory rate, percent neutrophils on complete blood count, hemoglobin, INR, C-reactive protein, and bilirubin and signifi cantly decreased temperature, systolic blood pressure, platelets, sodium, albumin, calcium (corrected for albumin), base excess and bicarbonate (all P ≤0.05).
In multivariate analysis, the main predictors of DI (incidence = 11.3%) were related to the patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening), to pathology (severe hypoxia, coma) and to the operator (non-anesthesiologist). From the β-parameter, a sevenitem simplifi ed score (MACOCHA score; Introduction In mechanically ventilated neonates the fl ow-dependent resistance of the endotracheal tube (ETT) causes a noticeable pressure diff erence between airway and tracheal pressure [1] . This may potentially lead to retardation of the passive driven expiration and dynamic lung infl ation consecutively but more importantly increases . The aim of this study was to evaluate the correlation between NT-proBNP and CCE and the potential usefulness of such variables during the weaning process from MV. Methods Twenty-two long-term (>48 hours) mechanically ventilated patients capable of performing a weaning trial of spontaneous breathing (SBT) were enrolled in the study. Inclusion criteria were: age >18 years and equipment with a standard arterial catheter line. Exclusion criteria were: neuromuscular disease, tracheotomy, renal failure, and traumatic brain injury. During the weaning process, NT-proBNP plasma levels, CCE, and standard hemodynamic and ventilatory data were collected 30 minutes before extubation (T1), 2 hours (T2) and 12 hours later (T3). After removal of tracheal tube, patients with a history of heart failure received continuous positive airway pressure (CPAP group). Patients with normal cardiac function were maintained with spontaneous breathing (SB group).

Introduction

Methods The frequency of CEUS use in the multidisciplinary surgical ICU was retrospectively evaluated for the period from 1 September 2011 to 1 September 2012. Furthermore, contributions of this novel method to the management of critically ill ICU patients as well as its accuracy were assessed. Results In total, 33 CEUS studies were performed in critically ill ICU patients. The most frequent indications included: assessment of the liver perfusion, assessment of the pancreas and kidney perfusion after pancreas and kidney transplantation, assessment of the renal perfusion in acute kidney injury (AKI), assessment of active bleeding and assessment of the bowel perfusion. In all studies, the correct diagnosis was achieved and the transport of critically ill patients to the radiology department for further diagnostic procedures as well as application of iodinated contrast agents was avoided. In 16 cases signifi cant new fi ndings were detected. Twelve of them were missed by conventional standard Doppler ultrasound prior to CEUS. In assessment of seven cases with AKI, impaired or delayed perfusion and microcirculation of the kidney was observed in six patients. In three patients urgent surgical intervention was performed because of CEUS results. In three cases active bleeding was excluded at the bedside due to absence of contrast agent extravasation into hematoma (thigh and perihepatic) or into abdominal cavity, without need for complementary CT imaging or angiography. In one case the regular perfusion of intestinal anastomosis was confi rmed with no need for surgical exploration. None of patients undergoing CEUS manifested any adverse reactions or developed any complications associated with the imaging technique. Conclusion Contrast-enhanced ultrasonography clearly improves visualization of the perfusion in various tissues. It is very likely to be superior to standard Doppler ultrasound, and is safe and well tolerated in critically ill patients. Promising indications for the use of CEUS in the ICU may be the assessment of kidney microcirculation and assessment of liver perfusion in liver transplant and liver trauma patients. Introduction Even though invasive hemodynamic devices are usually used for assessment of septic shock victims, they cannot evaluate the heart function. LV dysfunction as well as right heart syndrome are not uncommon in sepsis and critical patients. Intensive care ultrasound discloses these data and leads to appropriate treatment. Methods The study was a prospective cross-sectional study. The measurement was performed within 24 hours of ICU admission. We excluded patients with history of COPD and pulmonary hypertension from any diseases. Only good-quality images acquired from subjects were included for analysis. The primary objective was to disclose how the hemodynamic changed in septic patients by ICU-US. Introduction Thermodilution (TD) is considered a gold standard for measurement of cardiac index (CI) in critically ill patients. The aim of this study is to compare intermittent bolus TD CI with intermittent automatic calibration CI (AutoCI) and two continuous CIs obtained by pulse contour analysis with PiCCO 2 (PiCCI) and Pulsiofl ex (PuCCI). Methods Interim results of an ongoing prospective multicentre study in 53 patients. Age 58.7 ± 15.4, SAPS II score 51.4 ± 14.7 and SOFA score 10 ± 3.2. All patients underwent PiCCO monitoring via a femoral line whilst a radial line was kept in place during four 8-hour time periods (in the fi rst two periods, the Pulsiofl ex was connected to a radial line; in the last two it was connected to a femoral line). In the fi rst and third periods, the Pulsiofl ex was calibrated with TDCI, for the second and fourth periods Pulsiofl ex was calibrated with AutoCI. Simultaneous PiCCI and PuCCI measurements were obtained every 2 hours while simultaneous TDCI and AutoCI were obtained every 8 hours. We also looked at the eff ects of 40 interventions.

Results

Introduction Vasodilation and increased skin blood fl ow (also sweating) are infl uential in heat dissipation during heat exposure and exercise. It is unclear how heat stress infl uences microcirculation. Side dark-fi eld imaging visualizes the blood fl ow at the capillary level and helps to assess perfusion heterogeneity. Clinical and experimental data show that the sublingual region is clinically relevant for detecting microcirculatory alterations and more represents central microcirculation than cutaneous perfusion. We hypothesize that whole body heat stress may increase capillary density. Methods Eight healthy men with no history of cold and/or heat injury were recruited to this study. Passive body heating was performed by continuous immersion up to the waist in the water bath at 44°C and continued until rectal temperature reached 39.5°C. Before, at the end of whole body heating and 1 hour after heating was ended, systemic hemodynamics and direct in vivo observation of the sublingual microcirculation were obtained with sidestream dark-fi eld imaging. Assessment of microcirculatory parameters of convective oxygen transport (microvascular fl ow index (MFI), proportion of perfused vessels (PPV)), and diff usion distance (perfused vessel density (PVD) and total vessel density (TVD)) was done using a semiquantitative method. Vessels were separated into large (mostly venules) and small (mostly capillaries) using a diameter cutoff value of 20 μm. Results Whole body heating resulted in signifi cantly increased heart rate (P = 0.012) and cardiac output (P = 0.046) in comparison with baseline variables. One hour after heating was ended, the heart rate Introduction Serial measurements of lactate over time may be a better prognosticator than a single lactate concentration [1] . Early lactateguided therapy also reduces ICU length of stay and ICU and hospital mortality [2] . This study aims to assess the prognostic value of the lactate clearance (LC) in the fi rst 24 hours in surgical patients.

Introduction

Results After exclusion criteria 62 females between the ages of 12 and 16 presented to the paediatric emergency department in Leicester with abdominal pain as the predominant admission symptom during a 12-month period. Documentation of the gynaecological history was poor (menstrual history 47%, sexual history 14%, contraception 8%), as was the performance of basic investigations (urine dipsticks 65%, pregnancy test 42%). Documentation was analysed with regard to discharge diagnosis. Ultrasound investigation was performed on seven of the patients but only once admitted to various specialities. No ultrasound was undertaken upon admission. Conclusion Improvement in documentation of minimum standards for these patients is needed. A multidisciplinary care pathway could improve outcome. Consideration should be given to whether early ultrasound investigation is appropriate and there is a further need for investigation as to whether this would improve longer term outcomes. Introduction BiPAP utilization for the treatment of severe refractory status asthmaticus patients has become an accepted therapy but is not well described for moderate exacerbations. We sought to analyze outcomes from our BiPAP quality database for children presenting in status asthmaticus at varying levels of severity. Methods PED status asthmaticus patients requiring BiPAP from 1 January 2010 to 31 August 2012 had a bedside interview and documentation of information at the time therapies were given. Incomplete data were collected retrospectively. All data were stored and analyzed using a RedCap database. Subjects were stratifi ed into severity groups based on asthma score at the time of BiPAP placement. Results There were 206 subjects in the moderate severity group and 197 in the severe group. Table 1 shows the groups were well matched and compares other pertinent data. Children with severe presentations were placed on BiPAP sooner (P <0.001) and remained on BiPAP longer (P <0.001). The moderate group had a longer wait until BiPAP placement. Tables 2 and 3 demonstrate higher initial BiPAP (IPAP/EPAP) settings with increasing age and severity. Figure 1 trends initiation and termination asthma scores stratifi ed by severity at BiPAP

References

Introduction In this case report, we describe a patient who presented with a cardiac arrest as a result of an obstructive shock, which progressed into cardiac arrest, caused by an acute para-esophageal gastric herniation. Methods Our patient, with a medical history of a laparoscopic repair of a symptomatic diaphragmatic hernia 6 months prior, presented herself at the emergency department with pain in the upper abdomen and nausea. The physical examination, laboratory tests and X-ray of the thorax were normal and she was sent home. Twenty-four hours later paramedics were summoned to our patient because of increased complaints. On arrival of the paramedics she had a normal electrocardiogram (ECG) and during the transfer from her bed to the stretcher she collapsed due to pulseless electric activity (PEA), for which cardiopulmonary resuscitation was started. Sinus rhythm and output was regained after several minutes and the patient was transported to the hospital. At arrival in the hospital, the X-ray of the thorax showed an intrathoracic stomach and a signifi cant mediastinal shift to the right. Results After emergency laparotomy, which concerned correcting the gastric herniation and resection of an ischemic part of stomach, the patient remained hemodynamically stable. Cardiac ischemia was ruled out based on ECG, laboratory fi ndings, cardiac ultrasound and cardiac computed tomography. The ultrasound in the emergency department did show a distended right ventricle and normal left function, which disappeared later (after repositioning the stomach), which is evidence for the mediastinal shift as a cause for the PEA. Conclusion We are the fi rst to describe a patient requiring cardiopulmonary resuscitation for progressive obstructive shock, due to an intrathoracic stomach. Especially after a laparoscopic repair of a diaphragmatic hernia, this is a rare cause for shock and cardiac arrest, which requires a diff erent medical approach.

Methods

This was an open, single-centre, prospective, nonrandomized clinical trial at a university hospital. All patients that needed prophylactic dosing of enoxaparine after cardiac surgery were duly informed and after giving written consent we included 44 patients with a mean Euroscore of 1.66. The demographic specifi cations, medical and surgical history of all patients were collected. Anti-Xa activity was measured at three diff erent points in time. We determined baseline, peak and trough anti-Xa activity: preoperatively, and respectively 4 hours after the third dose of enoxaparine and 30 minutes before the fourth dose. Each measurement was done with both techniques, the two-stage chromogenic assay at the laboratory (Biophen®) and the bedside assay (Hemochron® Jr). Results Our dose regimen of enoxaparine achieved in one-half of the included patients a suffi cient anti-Xa activity for prevention of thromboembolic events. One-half of the patients with insuffi cient anti-Xa activity had a body mass index over 30 kg/m 2 . Comparison of the bedside assay with the two-stage chromogenic assay by means of the Pearson's correlation coeffi cient showed correlation of the two tests if no variables were taken into account. In the Bland-Altman analysis we could not confi rm this correlation. Conclusion The bedside anti-Xa activity assay with a Hemochron device tends to show some correlation with the two-stage chromogenic assay, but insuffi cient to be used as an alternative, in this small but uniform patient population. Use of a standard dosing protocol for enoxaparine administration is prone for underdosage in post-cardiac surgery patients and may increase postoperative morbidity. References Introduction We hypothesized that higher doses of enoxaparin would improve thromboprophylaxis without increasing the risk of bleeding. Critically ill patients are predisposed to venous thromboembolism, leading to increased risk of adverse outcome [1] . Peak anti-factor Xa (anti-Xa) levels of 0.1 to 0.4 IU/ml, 4 hours post administration of enoxaparin, refl ect adequate thromboprophylaxis for medico-surgical patients.

References

Introduction Are safety guidelines being followed when administering procedural sedation in the emergency department? Between November 2004 and November 2008, the NPSA received 498 alerts of patients being given the wrong dose of midazolam for procedural sedation [1] . In the fi rst 5 years of midazolam use there were 86 deaths, most related to procedural sedation [2] . Methods We searched through the controlled drugs book in resuscitation over a 2-month period and found a list of patients who had received midazolam or fentanyl. From this, we could make a search for the relevant A and E notes for these patients. From these notes, we looked for (see shorthand in Table 1 ): verbal consent documentation (consent), past medical history recorded (pmhx), safe initial dose of midazolam (midaz), pre-procedure monitoring (pre), post-procedure monitoring (post), and monitoring for 1 hour before discharge (1hr). Following introduction of a reminder in the controlled drugs book/ sedation room and staff education, the case notes were analysed over another 2-month period (24 sets of notes) to assess practise against safety guidelines. Results See Table 1 (key for shorthand in Methods).
Introduction In light of the interest in the relationship between glycemia control in critically ill subjects and outcome, we set up a study to investigate whether benzodiazepine, commonly used in anesthesia and ICUs, interferes with glucose metabolism and to explore the mechanism. Methods A total of 40 sedated and paralyzed Sprague-Dawley rats (301 ± 55 g) were investigated in four consecutive studies. (1) To investigate the eff ects of diazepam on blood glucose, 15 rats were randomly assigned to intraperitoneal anesthesia with tiopenthal 80 mg/kg (DZP0), tiopenthal 40 mg/kg + diazepam 5 mg/kg (DPZ5) or tiopenthal 40 mg/kg + diazepam 15 mg/kg (DZP15). Blood levels of glucose (GEM premier 3000; IL) were measured at time intervals over 2 hours. (2) Ten animals randomized to DZP0 or DZP5 underwent an intravenous glucose tolerance test with glucose bolus (0.5 g/kg). Acute insulin response, the mean value of blood insulin (Insulin ELISA kit; Millipore) from 2 to 10 minutes after glucose bolus, was measured as index of insulin secretion. (3) A hyperinsulinemic euglycemic clamp obtained by a continuous intravenous infusion of insulin (130 mUI/ kg/minute) was run in 10 animals randomized to DZP0 or DZP5 and the glucose infusion rate (GIR, mg/kg/minute) was assessed [1] . (4) Introduction We report our experience in the use of isofl urane for prolonged sedation in severe ARDS patients. Prolonged sedation in the ICU may be diffi cult because of tolerance, drug dependence and withdrawal, drug interactions and side eff ects. Inhaled anesthetics have been proposed for sedation in ventilator-dependent ICU patients. AnaConDa is a device that allows a safety and easy administration of inhaled anesthetics in the ICU. Methods From January 2009 to June 2012, 15 patients were sedated with isofl urane by means of the AnaConDa device. We consider administration of isofl urane as a washout period from common sedative drugs in patients with (at least one of ): high sedative drug dosage (propofol ≥300 mg/hour or midazolam ≥8 mg/hour) to reach the target Richmond Agitation Sedation Score (RASS) or inadequate paralysis; two or more hypnotic drugs to reach the target RASS (propofol, midazolam, hydroxyzine, haloperidol, diazepam, quetiapine); and hypertriglyceridemia. During isofl urane administration previous hypnotic drugs were interrupted. We retrospectively collected data before, during and after administration of isofl urane: hemodynamic parameters, renal and hepatic function, level of sedation (RASS) and sedative drug dosage. All data are reported as mean ± standard deviation, otherwise as median (minimum to maximum). Results Mean age was 43 ± 12 years and SAPS II was 35.7 ± 11; 13 patients were treated with ECMO for severe ARDS and four had a history of drug abuse; median ICU length of stay was 41 (15 to 127) days and they were ventilated for 41 (12 to 114) days. Due to severe critical illness, target RASS was -4 for all patients, most of which were also paralysed. Isofl urane was administered in nine patients because of a high level of common sedative drugs, in fi ve patients due to the use of two or more hypnotic drugs and in one patient because of hypertrigliceridemia. Isofl urane administration lasted 5.6 ± 1.8 days.
During isofl urane administration no alteration in renal function or hemodynamic instability was recorded. After the isofl urane washout period we observed a reduction in sedative drug dosage in 10 patients while two patients were quickly weaned from mechanical ventilation and the target RASS raised to 0. In two patients isofl urane was precautionarily interrupted because of concomitant alteration of liver function and suspected seizures respectively. Conclusion Inhaled anesthetics could be successfully used in the ICU especially in case of an inadequate sedation plan; for example, in patients with a history of drug abuse or young severe ARDS patients that required deep sedation and paralysis for a long period. Introduction Pharmacological agents used to treat critically ill patients may alter mitochondrial function. The aim of the present study was to investigate whether fentanyl, a commonly used analgesic drug, interacts with hepatic mitochondrial function.

Introduction

Results Data were collected on 88 parturients admitted over 2 years including 40 (45%) who received magnesium and 48 (55%) who did not. Magnesium-treated women were younger (age: 31 ± 7 vs. 36 ± 5 years, P = 0.02). The baseline calcium concentrations were similar for the two groups (2.2 ± 0.2 vs. 2.2 ± 0.1 mmol/l, P = 0.85). Patients receiving magnesium had signifi cantly higher magnesium concentrations (2.1 ± 0.4 vs. 0.7 ± 0.2 mmol/l, P <0.001), and signifi cantly lower calcium concentrations during therapy (1.6 ± 0.3 vs. 1.9 ± 0.3 mmol/l, P <0.001). At discharge, the calcium levels were closer (magnesium treated 1.9 ± 0.2 vs. untreated 2.1 ± 0.1 mmol/l, P = 0.02). The albumin concentrations did not diff er between the two groups (magnesium treated 27 ± 13 vs. nontreated 33 ± 23 g/l, P = 0.134). Normal values: calcium 2.15 to 2.55 mmol/l, magnesium 0.7 to 0.95 mmol/l, albumin 35 to 50 g/l. Conclusion Magnesium therapy was associated with hypocalcemia. Potential causative mechanisms include a renal excretion interaction and magnesium-induced suppression of parathyroid hormone secretion. Physicians should be aware of the potential for symptomatic hypocalcemia during magnesium therapy. Introduction Disorders of sodium (Na + ) and water homeostasis are common in hospitalised patients. Hyponatremia in particular has been associated with worse hospital outcome and length of stay [1] . We aimed to defi ne the incidence of hyponatremia (serum Na + ≤134 mmol/l) in our intensive care population and to determine whether it was associated with ICU outcome or length of stay. Methods Demographics, APACHE II score, outcome data and admission sodium were retrieved from the Ward Watcher system in the Victoria Infi rmary ICU for 2,440 consecutive admissions from January 2005 to present. We divided patients into three groups depending on serum Na + (≤134 mmol/l, 135 to 144 mmol/l, ≥145 mmol/l) and compared APACHE II score, length of stay and ICU outcome between patients with a low versus a normal serum Na + . Data were analysed using the chi-squared test, Student's t test and the Mann-Whitney test where appropriate. Results Of the 2,440 patients studied, 1,993 had APACHE II data and serum Na + recorded and so were included for analysis. In total, 453 patients (22.7%) had a serum Na + ≤134 mmol/l and 1,388 patients (67.1%) had a serum Na + of 135 to 144 mmol/l. Patients with a low Na + had a higher mortality (OR = 1.48, 95% CI = 1.16 to 1.90, P <0.001), a higher APACHE II score (22 vs. 19, P <0.001) and higher mean age (60 years vs. 58 years, P <0.001) than patients with a normal serum Na + . Mean length of stay of patients with low serum Na + was also longer (5.1 days vs. 4.6 days) although this was not statistically signifi cant (P = 0.09). Conclusion In summary, hyponatremia is a useful index of severity of illness in our ICU population. Whether this is a direct adverse eff ect of low serum sodium levels, or if hyponatremia is simply a marker for 'sicker' patients, is not known. Reference Introduction The anion gap (AG) is used routinely in the assessment of metabolic acidosis, but can be misleading in patients with hypoalbuminemia and other disorders commonly encountered in intensive care. This approach to acid-base analysis relies on assessment of pH, pCO 2 , sodium, bicarbonate and chloride, and can lead to underestimation or overestimation of the true electrochemical status of a patient, as it does not include important ions such as lactate, calcium, magnesium, and albumin. The strong ion gap (SIG) is an alternative to the AG and is based upon Stewart's physical chemistry approach. However, the SIG is cumbersome to calculate. As such, a number of shortcut equations have been developed in an eff ort to approximate the SIG. We sought to compare three such equations, the Kellum corrected anion gap (KellAGc), the Moviat equation, and EZSIG, in an eff ort to evaluate precision and accuracy [1] [2] [3] . Methods We conducted a retrospective chart review of consecutive patients admitted to the ICU of George Washington University Medical Center from September 2010 to March 2011. Of the 1,516 patients screened, 200 met inclusion criteria, which included availability of all laboratory components to calculate the SIG, obtained within 1 hour of each other. Demographic data and serum values for pH, pCO 2 , albumin, lactate, sodium, potassium, chloride, bicarbonate, magnesium, phosphate, and calcium were collected. The AG, SIG, KellAGc, EZSIG, and Moviat equations were subsequently calculated and compared using Pearson correlation and Bland-Altman analysis. Results The mean SIG was 3.25 ± 3.5. Mean values for KellAGc, Moviat, and EZSIG were 4.5 ± 5.0, 1.77 ± 2.2, and 3.6 ± 3.7, respectively. Pearson correlation coeffi cients for KellAGc, Moviat, and EZSIG when compared with the SIG were r = 0.77, P = 0.0001; r = 0.88, P = 0.001; and r = 0.89, P = 0.001, respectively. In Bland-Altman analysis, the mean bias for the test equations versus the SIG were: KellAGc (1.25), Moviat (-1.48), and EZSIG (0.40). Conclusion While all three equations correlated highly with the SIG, the EZSIG and Moviat outperformed the KellAGc in Pearson and Bland-Altman analysis. The EZSIG had a smaller bias than the Moviat equation and a slightly better correlation (0.89 vs. 0.88). In the assessment of critically ill patients, EZSIG is a candidate scanning equation for the measurement of the SIG when all SIG components are not available. university-affi liated teaching hospital in Tunis. Patients admitted within the fi rst 24 hours post burn with greater than 10% total body surface area (TBSA) burned were enrolled in this study from 1 January 2009 to 30 June 2010. Exclusion criteria were pregnancy, history of adrenal insuffi ciency, or steroid therapy within 6 months prior to burns. A short corticotrophin test (250 μg) was performed, and cortisol levels were measured at baseline (CS T0) and 60 minutes post test. Adrenal insuffi ciency was defi ned by a response ≤9 μg/dl. Relative adrenal insuffi ciency was further defi ned by a baseline cortisol >20 μg/dl. Results Patients were assigned into two groups: G1 (RAI, n = 7) and G2 (absence AI, n = 11). Comparative study of the two groups shows the results presented in Table 1 . Conclusion RAI is common in severely burned patients during the acute phase, and is associated with shock. Further prospective controlled studies will be necessary to establish risk factors of RAI in severely burned patients and its impact on their prognosis.

Results

Introduction A recent study showed that hyperglycaemia (blood glucose ≥7.8 mmol/l) in nondiabetic patients hospitalised in a medical ICU is associated with increased risk of diabetes [1] . We investigated a large mixed ICU population to confi rm these results. Methods This study retrospectively included patients with negative history of diabetes admitted to ICUs during the year 2007. We excluded patients receiving steroids, with newly diagnosed diabetes and those with end-stage disease. Patients were followed-up 5 years after index admission. Diagnosis of diabetes within 6 months from the index admission was presumed as revealing DM at inclusion, which excluded the patient. Patients who were taking glucocorticoids during the followup period were excluded. Diabetics were identifi ed from ICD-9 documentation. Propensity score for death (pDead) was computed from either SAP1 (MIMICII) or APACHE III (HIDENIC) to assess the risk of death. Hypoglycemia was defi ned as AVG ≤60 mg/dl. AVG was computed as the area under the glucose curve throughout ICU admission. Mortality was examined within bins (each bin is categorized by a 10 mg/dl increase in AVG) and was compared between adjacent categories using a chi-square test. The same method was repeated among diabetics, nondiabetics, patients with lower (pDead greater than median) and higher (pDead lower than

Conclusion

The ICU is an environment where issues of consent, confi dentiality and disclosure of information occur daily. Staff feel they lack knowledge in these areas that is unaff ected by their experience. We need to ensure that all staff have the necessary knowledge to deal with these situations. Introduction Alcohol-related hospital and ICU admissions are known to have a huge impact on healthcare resources in the UK. Excessive use of alcohol is independently associated with sepsis, septic shock and hospital mortality among ICU patients. This study assesses the relationship between alcohol abuse and intensive care resource utilisation in a mixed medical, surgical and neurosurgical ICU. Methods A prospective survey of emergency alcohol-related admissions over a 1-year period was undertaken at a tertiary university adult general and neurosurgical ICU. All patients were screened for acute and chronic alcohol abuse on admission. Acute alcohol abuse was defi ned as being intoxicated with alcohol at the time of admission and chronic alcohol abuse was defi ned as chronic alcohol use exceeding recommended UK national guidelines on consumption. The amount of alcohol consumption was obtained, diagnosis on admission, ICU and hospital mortality, length of stay, and total cost were recorded. All patients were screened for alcohol-related comorbidities. Comparative retrospective data were obtained for the same time period for nonalcohol-related emergency ICU admissions. Data were analyzed using SPSS. Results In total, 7.7% of patients were admitted with a history of acute/chronic alcohol excess. Sixty-seven per cent of alcoholrelated admissions were due to acute alcohol excess. Neurosurgical patients admitted due to alcohol excess had higher ITU mortality than nonalcohol-related neurosurgical patients: 32.1% versus 14.39% (P = 0.02), respectively. Ninety-three per cent of alcohol-related neurosurgical admissions were caused by acute alcohol intoxication. The intensive care cost was signifi cantly higher for alcohol-related (£12,396 per patient) compared with nonalcohol-related neurosurgical admissions (£7,284 per patient). Of the medical patients admitted, 60% of these admissions were due to acute alcohol excess. The cost of intensive care treatment was lower for alcohol-related medical admissions.
10 section matches

Il programma "Ferrari

Epidemiological evidence shows that individuals who maintain a lifestyle with high mobility and physical activity have a remarkably lower risk of noncommunicable diseases, with a reduction of all-cause mortality. Regarding the association between physical inactivity and cancer incidence, in a recent meta-analysis including 12 prospective cohort studies with 1.44 million participants, leisure-time physical activity in relation to risk of 26 different cancer types has been examined 1 ; the study showed that increasing levels of leisure-time physical activity was associated with lower risks of 13 of the 26 cancers investigated, regardless of body size and smoking history. Moreover, several studies suggest that exposure to exercise following the diagnosis of certain solid tumors might lower the progression of the disease and reduce cancer-related mortality 2 . These findings open to new approaches in the methodologies for cancer progression control, introducing the exercise-oncology field. Recently, Hojman and colleagues 3 reviewed the current molecular evidence about the effect of exercise on cancer. The authors describe the role of exercise in controlling cancer progression through a direct effect on tumor intrinsic factors and the interplay with whole-body exercise effects. The tumor growth-inhibitory effects could be mediated by several different mechanisms, such as the release of several systemic factors (i.e., catecholamines, myokines, etc.) and sympathetic activation, modulated during the exercise performance. The acute effect of a single exercise bouts leads to intratumoral adaptations, contributing to slower tumor progression. Moreover, growth factors such as insulin and IGFs stimulate cancer cell proliferation through the activation of their respective receptor tyrosine kinases, which trigger the major signal transduction pathways (e.g. PI3K/AKT and MAPK pathways) 4 . Chronic exercise reduces growth factor availability in the systemic milieu, and presumably in the tumor microenvironment, induced by prolonged physical inactivity 5 . Our research group is currently evaluating if the systemic response to a high-intensity endurance cycling (HIEC) test session could modulate the proliferation and the tumorigenic potential of breast or prostate cancer cells, in vitro. The study design includes the use of serum samples collected before, immediately after, and after 2 and 24 hours the exercise bouts. Serum samples were then been used in cell culture assays to evaluate cell proliferation and colony formation in a three-dimensional cell growth assay: three-dimensional anchorage-independent growth assay in soft agar is a model used to evaluate malignant cell growth and it is considered a good hallmark of tumorigenesis. In a first pilot study, blood samples of 12 healthy and sedentary females have been collected before the HIEC sessions exercise (t0, at rest), immediately after (t1), 2-hours and 24-hours post (t2 and t3, respectively) and used to supplement the culture media of cells. Our results showed that immediately-after HIEC and the 2-hours post (t1 and t2) sera markedly reduced cell proliferation capacity of triple-negative breast cancer cells (TNBC), in comparison to that revealed in cells cultured with t0 sera. Moreover, the capacity of post-exercise-conditioned sera to induce tumorigenesis in soft agar was significantly lower in comparison to that revealed in cells cultured with t0 sera.
These encouraging results lead us to apply this model in women with a history of breast cancer. In collaboration with the OU of Oncology, "Santa Maria della Misericordia" hospital of Urbino, we are starting a project entitled "Movimento e Salute oltre la Cura" (Movement and Health beyond Care), MoviS (CESU approved n. 21, 10 th July 2019). The general objective of the project MoviS is to improve the quality of life (QoL) of breast cancer survivors (BCS). This proposal stems from the need to respond to the requests of numerous women with a history of breast cancer, which perceive their lifestyle as unhealthy but lack the necessary tools to move towards a correct diet and regular physical activity. The strongest evidence regarding lifestyle changes and cancer risk comes from the link with obesity; however, there is significant evidence that physical inactivity per se increases the risk of cancer and relapse regardless of body weight. Throughout the planned trial period, the food plan will be prescribed by the nutritionists of the IRCCS National Cancer Institute (INT) Milan following the guidelines indicated in the DianaWeb project 6 , based on the recommendations of the WCRF 2018 and on the Mediterranean diet. The exercise protocols will be designed according to the most recent internationally recognized guidelines for the prescription of physical activity with health and preventive purposes in cancer patients 7 , which are perfectly in line with the Italian guidelines on physical activity for these patients, recently published by the Ministry of Health. During the intermediate follow-up, various parameters will be evaluated, such as the QoL, the reduction of the 'fatigue', the reduction of body weight and the modifications induced on the relevant metabolic and clinical parameters in order to verify the beneficial effects of the prescribed exercise Within this project, we planned to collect serum samples before and after exercise sessions and use them in cell growth assays, in order to verify and quantify the efficacy of exercise in the inhibition of cell proliferation and tumorigenicity. Overall, the positive effects of the exercise-oncology on cancer progression control recently gained attention. Despite the anticancer component released in response to an acute exercise have not been fully understood, there is growing evidence that acute systemic changes can control cancer cell viability and proliferation. To move forward in the translational development of the use of precise exercise for cancer treatment, there is a need of additional studies on preclinical testing, preliminary safety, and efficacy trials, and definitive clinical exercise trials with survival endpoints 2 , with the aim of a controlled and personalized administration of acute exercise bouts by exercise experts.

Conclusioni

Nel futuro i professionisti sanitari della prevenzione saranno sempre più chiamati in prima persona nella gestione di situazioni critiche e appare chiaro che oggi più che mai è necessario che assumano il ruolo previsto nei profili professionali, ma per farlo nel modo migliore dobbiamo pensare alla loro formazione in modo sempre più incisivo e collegato alle necessità reali. Different strategies are available to fight cancer, as related to the natural history of the disease and to its stage. Primary prevention aims at avoiding cancer initiation and promotion both by minimizing exposures to carcinogenic agents and by favouring the intake of protective factors either with the diet and/or with pharmacological agents. Secondary prevention involves the early detection of the disease either by diagnosing cancer in selected individuals at an early stage or by implementing programs of oncological screenings in broad population strata. When a neoplastic disease becomes clinically manifest, the most suitable therapeutic protocols are followed by tertiary prevention measures in the framework of the management of cancer patients. Such a strategy is designed in order to prevent local relapses, invasion of the blood and lymph streams by malignant cells and metastasis in distant organs. All the above strategies have the common goal to decrease cancer mortality. However, such a goal is pursued via differentiated tools that are intrinsic in the nature of the intervention approach. Thus, reduction of cancer mortality by primary prevention, which is the only strategy addressed to healthy (or apparently healthy) individuals, is achieved by lowering the incidence of the disease. An objective of this type has already been shown to be feasible on a large scale either through risk assessment and risk management approaches (e.g., in the case of lung cancer) or through unintentional measures (e.g., in the case of gastric cancer, whose decline has been defined as an "unplanned triumph of medicine"). Obviously, the decrease in cancer incidence will also result in a decrease of cancer prevalence with years. On the other hand, both therapy and tertiary prevention will attenuate cancer mortality by decreasing its fatality thereby improving survival, which will also result in a greater cancer prevalence. As to oncological screenings, in principle these interventions tend to increase cancer incidence because they are designed in order to detect a greater number of cancer cases at an early stage, when they are more easily curable. This results in a greater survival and in an increased prevalence of the disease. For instance, extensive gastroscopy campaigns have been carried out in the Japanese and Korean populations for the detection of so-called "early gastric cancer", which resulted in an increase in the number of the diagnosed cases but also in a lower mortality and in a greater prevalence of gastric cancer. In some cases, an oncological screening may result in an excessive detection of cancer cases that, besides the risk of false positives, may involve the application of distressing treatments of cancer cases that would never have been detected during lifetime. This overdiagnosis problem has been emphasized several times regarding the elevations in PSA levels in the blood for the diagnosis of prostate cancer. In the case of breast cancer, during the 2003-2018 period there was in Italy a slight trend for an increase in the incidence, accompanied by a slight decrease in mortality. As to colorectal cancer, mortality was relatively stable during the same period, whereas an increase in cancer incidence until 2006 was followed by a more evident trend to a decrease. In any case, the fluctuations of cases of can-cers subjected to oncological screenings is not a rule, also because secondary prevention interventions are often coupled with primary prevention measures, such as improvement in lifestyle and hygienic conditions, control of sexually transmitted diseases, etc. In the case of uterine cervix carcinoma, primary prevention by vaccination is predicted to further lower both incidence and mortality for that cancer and other HPV-related cancers as well. In fact, HPV is responsible for the 100% of uterine cervix cancers, notwithstanding the fact that other factors, such as hormonal stimuli, oral contraceptives and cigarette smoking, may represent concausal factors. For the moment, taking into account that progression to invasive cervical cancer requires several decades, HPV vaccination has been shown to be successful in decreasing the incidence of HPV-related cervical intraepithelial neoplasias (CIN). The cancers that in Italy are subjected to oncological screenings as basic health care levels or LEA (essential levels of assistance), including breast cancer, colorectal cancer and uterine cervix cancer, bear a great epidemiological relevance worldwide. According to Globocan data, breast cancer causes the 11.6% of all cancer cases (2,088,849 new cases in 2018) , a figure that is almost equivalent to that of lung cancer. Colorectal cancer ranks 3 rd , with the 10.2% of all diagnosed cancers (1,849 518 new cases in 2018) . Uterine cervix cancer ranks 8 th , with the 3.2% of all cancers (569,847 new cases in 2018). Thus, these 3 cancers represent the 25% of all cancers worldwide. According to AIOM/AIRTUM estimates, the same cancers represent collectively an even greater proportion of all incident cancers in Italy (28.6% of the estimated 373,000 new cases of all cancers). In particular, breast cancer represented in 2018 the 14.2% of all cancer cases (52,800 new cases), colorectal cancer the 13.8% of all diagnosed cancers (51 300 new cases), and uterine cervix cancer the 0.6% of all cancers (2 400 new cases). For the incidence period 2005-2009, survival after 5 years was 87%, 65% and 68%, respectively. The numbers of deaths in 2015 (ISTAT data) were 12 381, 18 935 and 435, respectively, which accounted for a total of 31 751 annual deaths, i.e., the 17.8% of the 178,232 deaths for all cancers in Italy. The high incidence of breast cancer and colorectal cancer, associated with a more than average survival, justifies the high prevalence of these cancers in the population. In fact, there are as many as 799 198 women who are still alive in 2018 after diagnosis of breast cancer, 470 697 people who are still alive after diagnosis of colorectal cancer, and 56,063 women who are still alive after diagnosis of uterine cervix cancer. Therefore, there is a huge number of people (1,326,000 individuals) who are surviving after the diagnosis of these 3 cancers in Italy. These data provide evidence for the outstanding epidemiological importance of those cancers that are subjected to LEA measures in Italy. The strikingly lower incidence of uterine cervix cancer in Italy, as compared with the world situation, is a demonstration of the efficiency of cancer preventive measures.

Introduction

Recommendations in many countries, such as the United Kingdom, United States, Australia and Italy state that infants with a history of prematurity should receive routine immunization according to the same schedule used for full-term infants, based on their chronological age rather than corrected gestational age and regardless of their birth weight.
While several studies are available in term-born infants, data regarding vaccine safety and tolerability in preterm infants are limited, particularly after the schedule 2 + 1 for the hexavalent vaccines. After more than two years' use, we conducted a post-marketing surveillance of the DTaP2-IPV-HB-Hib vaccine safety in infants born with a history of prematurity in Apulia in 2017.

Conclusions

Our surveillance study showed that over 40% of infants with a history of prematurity received delayed hexavalent vaccination. The AEs to the DTaP2-IPV-HB-Hib vaccine were mainly local or mild. Preliminary results confirm the safety of this hexavalent vaccine also in preterm population. Further studies are needed in this respect, especially regarding the 2 + 1 schedule.

Methods

We conducted a cross-sectional study of 349 women from Southern Italy, with no history of severe diseases. Dietary patterns were derived by Food Frequency Questionnaire and Principal Component Analysis. LI-NE-1 methylation of leukocyte DNA was assessed by pyrosequencing.

Materials and methods

This cross-sectional analysis included 841 women, aged 25-64 years, with no history of severe diseases. Adherence to MD was assessed by Food Frequency Questionnaire and the Mediterranean Diet score (MDS) based on 9 components. Associations of social (i.e. educational level, employment and marital status, and parity) and behavioral (i.e. smoking habit, physical activity, and BMI) determinants with adherence to MD and its components were tested by multivariable logistic regression analysis and expressed as Odds ratio (OR) with 95% Confidence Interval (CI).

Methods

A case-cohort design nested in the Moli-sani cohort study was used. A subcohort of 1,146 subjects (mean ± SD age 55.3 ± 11.7 years; men 47.7%) was randomly selected from the whole study population (n = 24,325; recruitment years 2005-2010, Molise Region). All CVD events occurred during a median follow-up of 4.3 years (n = 534 validated myocardial infarctions or strokes; 5.1:1,000 person-years), were selected as case group. Biobank samples were used to genotype 14 single nucleotide polymorphisms (SNPs) in the genes NMU (encoding for Neuromedin U), NMUR1 and NMUR2 (receptors) and NMS (Neuromedin S). Methylation levels at 17 CpG sites of two NMU regions (promoter and intergenic) were measured using pyrosequencing. The laboratory analyses are on-going. The associations between SNPs (codominant model) or methylation sites (z-scores) and fatal or non-fatal CVD events were calculated (hazard ratios -HR, adjusted for age, sex, BMI, blood pressure, glucose, lipid levels and CVD history) using SAS software. Multivariate analyses (backward elimination) were performed and a score was computed using beta estimates of risk variants associated with the events at p < 0.1.

Materials and methods

We used data from 69 Italian women with a history of stage I-III breast cancer diagnosis who underwent surgery. The recruitment was supported by A.N.D.O.S. Onlus. Adherence to Mediterranean diet (MD) was evaluated by the 14-item Mediterranean Diet Assessment Tool. QoL was assessed using the European Organization for the Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30) and the Quality of Life Questionnaire Breast Cancer Module 23 (QLQ-BR23). Next, a literature search was conducted in the PubMed-Medline and Web of Science databases using the following terms: "Breast Cancer" AND "Quality of Life" AND "Diet".