Neutrophil extracellular traps (NETs) are increased in the alveolar spaces of patients with ventilator-associated pneumonia

Background

Neutrophils release neutrophil extracellular traps (NETs) in response to invading pathogens. Although NETs play an important role in host defense against microbial pathogens, they have also been shown to play a contributing mechanistic role in pathologic inflammation in the absence of infection. Although a role for NETs in bacterial pneumonia and acute respiratory distress syndrome (ARDS) is emerging, a comprehensive evaluation of NETs in the alveolar space of critically ill patients has yet to be reported. In this study, we evaluated whether markers of NET formation in mechanically ventilated patients are associated with ventilator-associated pneumonia (VAP).

Methods

We collected bronchoalveolar lavage fluid from 100 critically ill patients undergoing bronchoscopy for clinically suspected VAP. Subjects were categorized by the absence or presence of VAP and further stratified by ARDS status. NETs (myeloperoxidase (MPO)-DNA complexes) and the NET-associated markers peroxidase activity and cell-free DNA were analyzed by enzyme-linked immunosorbent assay and colorimetric assays, respectively. Quantitative polymerase chain reaction of nuclear and mitochondrial DNA was used to determine the origin of the extruded DNA. Interleukin (IL)-8 and calprotectin were assayed as measures of alveolar inflammation and neutrophil activation. Correlations between NETs and markers of neutrophil activation were determined using Spearman’s correlation. We tested for associations with VAP and bacterial burden by logistic and linear regression, respectively, using log₁₀-transformed NETs.

Results

MPO-DNA concentrations were highly correlated with other measures of NET formation in the alveolar space, including cell-free DNA and peroxidase activity (r?=?0.95 and r?=?0.87, p?<?0.0001, respectively). Alveolar concentrations of MPO-DNA were higher in subjects with VAP and ARDS compared with those with ARDS alone (p?<?0.0001), and higher MPO-DNA was associated with increased odds of VAP (odds ratio 3.03, p?<?0.0001). In addition, NET concentrations were associated with bacterial burden (p?<?0.0001) and local alveolar inflammation as measured by IL-8 (r?=?0.89, p?<?0.0001).

Conclusions

Alveolar NETs measured by MPO-DNA complex are associated with VAP, and markers of NETosis are associated with local inflammation and bacterial burden in the lung. These results suggest that NETs contribute to inflammatory responses involved in the pathogenesis of VAP.

     

Olanzapine vs haloperidol: treating delirium in a critical care setting

Objective

To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.

Design

Prospective randomized trial

Setting

Tertiary care university affiliated critical care unit.

Patients

All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.

Interventions

Patients were randomized to receive either enteral olanzapine or haloperidol.

Measurements

Patient’s delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.

Main results

Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.

Conclusions

Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.

     

Low dose quetiapine induced galactorrhoea: a case report

Background

Quetiapine causes less prolactin elevation and/or galactorrhoea than other atypical antipsychotics.

Case Presentation

Ms AB had galactorrhoea and raised prolactin levels at only 100 mg of quetiapine daily.

Conclusion

Low dose quetiapine can also cause galactorrhoea.

     

Création d’un programme d’éducation thérapeutique en douleur chronique (PETDC) — Expérience Canadienne

Aims

Create an educational program in chronic pain (EPCP).

Material and methods

We used a four-step process to create the EPCP tailored to patient’s needs.

Results

Five groups of patients can benefit from the program annually. Based on their own assessment, patients stated that their knowledge of chronic pain improved between 2.8 to 24%. The satisfaction with the EPCP was 8.67/10.

Conclusion

Our EPCP helps patients gain and maintain the skills they need to best manage their lives with a chronic pain.

     

The Comprehensive Assessment of Left Ventricular Assist Devices by Echocardiography

Purpose of Review

Echocardiography is the imaging modality of choice for patient selection prior to left ventricular assist device (LVAD) implantation, assessment of device placement, optimization of device settings, diagnosis of device-related complications, and assessment of LV recovery. The key echocardiographic features of these devices will be highlighted in the following review.

Recent Findings

With increased utilization of LVADs as well as the development of centrifugal continuous-flow pumps, familiarity with echocardiographic imaging of LVADs is essential to optimal care of these complex patients.

Summary

All echocardiographic evaluations both before and after LVAD implantation should assess for biventricular function and cavity size, valvular function and pathology, intracardiac thrombi, intracardiac shunting, cannula position and flow, aortic pathology, and pericardial effusion. RAMP testing may be utilized when device complications are suspected.

     

Metoclopramide or domperidone improves post-pyloric placement of spiral nasojejunal tubes in critically ill patients: a prospective,multicenter, open-label,randomized, controlled clinical trial

IntroductionThe use of prokinetic agents on post-pyloric placement of spiral nasojejunal tubes is controversial. The aim of the present study was to examine if metoclopramide or domperidone can increase the success rate of post-pyloric placement of spiral nasojejunal tubes.MethodsA multicenter, open-label, randomized, controlled trial was conducted in seven hospitals in China between April 2012 and February 2014. Patients admitted to the intensive care unit and requiring enteral nutrition for more than three days were randomly assigned to the metoclopramide, domperidone or control groups (1:1:1 ratio). The primary outcome was defined as the success rate of post-pyloric placement of spiral nasojejunal tubes, assessed 24 hours after initial placement. Secondary outcomes included success rate of post-D1, post-D2, post-D3 and proximal jejunum placement and tube migration distance. Safety of the study drugs and the tubes during the entire study period were recorded.ResultsIn total, 307 patients were allocated to the metoclopramide (n = 103), domperidone (n = 100) or control group (n = 104). The success rate of post-pyloric placement after 24 hours in the metoclopramide, domperidone and control groups was 55.0%, 51.5% and 27.3%, respectively (P = 0.0001). Logistic regression analysis identified the use of prokinetic agents, Acute Physiology and Chronic Health Evaluation (APACHE) II score <20, Sequential Organ Failure Assessment (SOFA) score <12 and without vasopressor as independent factors influencing the success rate of post-pyloric placement. No serious drug-related adverse reaction was observed.ConclusionsProkinetic agents, such as metoclopramide or domperidone, are effective at improving the success rate of post-pyloric placement of spiral nasojejunal tubes in critically ill patients.

Trial registration

Chinese Clinical Trial Registry ChiCTR-TRC-12001956. Registered 21 February 2012.     

Optimal port placement planning method for laparoscopic gastrectomy

Purpose

In laparoscopic gastrectomy, as well as other laparoscopic surgery, the surgeon operates on target organs using a laparoscope and forceps inserted into the abdominal cavity through ports placed in the abdominal wall. Therefore, port placement is of vital significance in laparoscopic surgery. In this paper, we present a method for achieving optimal port placement in laparoscopic gastrectomy based on relationships between the locations of the ports and anatomical structures.

Methods

We utilize three angle conditions to determine the optimal port placement. Proper angles for the angle conditions are calculated from measurements obtained during laparoscopic gastrectomy. The port positions determined by surgeons experienced in laparoscopic gastrectomy are measured using a three-dimensional positional tracker. The locations of the blood vessels, as well as other vital anatomical structures that are also critical in laparoscopic gastrectomy, are identified from computed tomography images. The angle relationships between the port and blood vessel locations are analyzed using the obtained positional information. Optimal port placement is determined based on the angle conditions.

Results

We evaluated the proposed method using the positional information obtained during 26 laparoscopic gastrectomies. Our evaluation determined that the proposed method generates optimal port placement with average errors of 22.2 and 21.2 mm in the left- and the right-hand side ports for a lead surgeon. Experienced surgeons confirmed that the optimal port placement generated by the proposed method was sufficient for clinical use.

Conclusions

The proposed method provides optimal port placement in laparoscopic gastrectomy and enables a novice surgeon to determine port placement much like an experienced surgeon.

     

Visualization,measurement and modelling of the cochlea using rotating midmodiolar slice planes

Purpose

Cross-sectional visualization of anatomical structures in DICOM viewers is usually presented in parallel slices. For visualizing the inner ear, this concept is unfavourable due to the spiral shape of the cochlea. Radial slicing through its central axis (known as midmodiolar view) is advantageous. Therefore, a custom DICOM viewer was developed, which allows the visualization of the cochlea in a midmodiolar slice plane that rotates around the central axis of the cochlea, always cutting the latter radially.

Methods

The program was written in C++ using the open-source libraries ITK, VTK, GDCM and Qt. The rotation axis is defined by placing two points in the modiolus within a conventional slice visualization of the dataset. A midmodiolar visualization is calculated based on this axis. Scrolling the mouse wheel rotates slice plane around the axis, displaying midmodiolar slices at variable angles. Measurement options are provided as well as interactive placement of marker points whose coordinates can be exported for post-processing in other programs.

Results

The program can be used in multiple applications including the determination of cochlear dimensions, especially its length, and post-operative positions of cochlear implant (CI) electrode carriers. Computer-aided design models of the cochlea can be generated from exported marker points.

Conclusion

The proposed DICOM viewer directly focuses on the needs of cochlear visualization, thus making it a valuable tool in CI related research. The ease of use facilitates future clinical use, e.g. for pre-operative selection of optimal CI electrode carrier length based on the patient’s cochlear length.

     

Accuracy analysis in MRI-guided robotic prostate biopsy

Purpose

To assess retrospectively the clinical accuracy of an magnetic resonance imaging-guided robotic prostate biopsy system that has been used in the US National Cancer Institute for over 6 years.

Methods

Series of 2D transverse volumetric MR image slices of the prostate both pre (high-resolution T2-weighted)- and post (low-resolution)- needle insertions were used to evaluate biopsy accuracy. A three-stage registration algorithm consisting of an initial two-step rigid registration followed by a B-spline deformable alignment was developed to capture prostate motion during biopsy. The target displacement (distance between planned and actual biopsy target), needle placement error (distance from planned biopsy target to needle trajectory), and biopsy error (distance from actual biopsy target to needle trajectory) were calculated as accuracy assessment.

Results

A total of 90 biopsies from 24 patients were studied. The registrations were validated by checking prostate contour alignment using image overlay, and the results were accurate to within 2 mm. The mean target displacement, needle placement error, and clinical biopsy error were 5.2, 2.5, and 4.3 mm, respectively.

Conclusion

The biopsy error reported suggests that quantitative imaging techniques for prostate registration and motion compensation may improve prostate biopsy targeting accuracy.

     

Influence of Antibiotic Pressure on Five Plasmid-based Bioluminescent Gram-negative Bacterial Strains

Purpose

The present study aims to develop five Gram-negative bacteria expressing bacterial luciferase for use to evaluate the influence of different antibiotics on bacterial bioluminescence.

Procedures

The pBBR-lux plasmid was introduced into five Gram-negative bacteria; the bioluminescent signals and colony-forming unit (CFU)/ml of all the bioluminescent strains were monitored with six antibiotics at various concentrations.

Results

Dose-dependent bioluminescence signals can be used for rapid bacterial antibiotic susceptibility test (AST). All five bioluminescent bacterial strains have similar bioluminescence and CFU enhancement at sub-minimum inhibitory concentration (MIC) of six different antibiotics.

Conclusion

The bioluminescent signals and CFU enhancement at sub-MIC antibiotic concentrations should be of value in the research of new antibiotic drugs and bioluminescent imaging.

     

Sekundäre Steife der Schulter

Background

In addition to idiopathic shoulder stiffness, secondary shoulder stiffness in particular is often associated with extra-articular subacromial adhesions between the rotator cuff and the surrounding anatomical structures.

Objective

The aim of this article is to present clinical results and complications as well as the surgical technique of extra-articular release in the context of secondary shoulder stiffness.

Material and Methods

Selective review of the literature and presentation of own clinical experience.

Results

Intra-articular and extra-articular release are related to a high patient satisfaction and an improved range of motion. Exact knowledge of the extra-articular anatomy is necessary to prevent iatrogenic lesions of vessels, nerves and the rotator cuff. Compared to patients with a primary stiff shoulder, patients suffering from posttraumatic stiff shoulder benefit more from arthroscopic interventions with intracapsular and extracapsular release.

Conclusion

Restrictions in range of motion of the shoulder can be related to extra-articular adhesions. These adhesions need to be specifically addressed during arthroscopic treatment of stiff shoulders.

     

A Survey of auditory display in image-guided interventions

Purpose

This article investigates the current state of the art of the use of auditory display in image-guided medical interventions. Auditory display is a means of conveying information using sound, and we review the use of this approach to support navigated interventions. We discuss the benefits and drawbacks of published systems and outline directions for future investigation.

Methods

We undertook a review of scientific articles on the topic of auditory rendering in image-guided intervention. This includes methods for avoidance of risk structures and instrument placement and manipulation. The review did not include auditory display for status monitoring, for instance in anesthesia.

Results

We identified 15 publications in the course of the search. Most of the literature (60%) investigates the use of auditory display to convey distance of a tracked instrument to an object using proximity or safety margins. The remainder discuss continuous guidance for navigated instrument placement. Four of the articles present clinical evaluations, 11 present laboratory evaluations, and 3 present informal evaluation (2 present both laboratory and clinical evaluations).

Conclusion

Auditory display is a growing field that has been largely neglected in research in image-guided intervention. Despite benefits of auditory displays reported in both the reviewed literature and non-medical fields, adoption in medicine has been slow. Future challenges include increasing interdisciplinary cooperation with auditory display investigators to develop more meaningful auditory display designs and comprehensive evaluations which target the benefits and drawbacks of auditory display in image guidance.

     

Auditory feedback to support image-guided medical needle placement

Purpose

During medical needle placement using image-guided navigation systems, the clinician must concentrate on a screen. To reduce the clinician’s visual reliance on the screen, this work proposes an auditory feedback method as a stand-alone method or to support visual feedback for placing the navigated medical instrument, in this case a needle.

Methods

An auditory synthesis model using pitch comparison and stereo panning parameter mapping was developed to augment or replace visual feedback for navigated needle placement. In contrast to existing approaches which augment but still require a visual display, this method allows view-free needle placement. An evaluation with 12 novice participants compared both auditory and combined audiovisual feedback against existing visual methods.

Results

Using combined audiovisual display, participants show similar task completion times and report similar subjective workload and accuracy while viewing the screen less compared to using the conventional visual method. The auditory feedback leads to higher task completion times and subjective workload compared to both combined and visual feedback.

Conclusion

Audiovisual feedback shows promising results and establishes a basis for applying auditory feedback as a supplement to visual information to other navigated interventions, especially those for which viewing a patient is beneficial or necessary.

     

Two-Stage Revision Arthroplasty for the Treatment of Prosthetic Joint Infection

Purpose of Review

To review the diagnosis and treatment of prosthetic joint infection (PJI) with a focus on two-stage revision arthroplasty. The text will discuss different spacer constructs in total knee and total hip arthroplasty and will present clinical outcome data for these various options.

Recent Findings

There is no appreciable difference in infection eradication between mobile and static antibiotic spacers. Mobile spacers have shown improved knee range of motion after second-stage re-implantation.

Summary

Two-stage revision arthroplasty is the gold standard treatment for PJI. The first stage involves removal of all components, cement, and compromised soft tissues with placement of an antibiotic-impregnated spacer. Spacer options include both mobile and static spacers. Mobile spacers offer maintenance of ambulation and joint range of motion between staged procedures and have shown to be as effective in eradicating infection as static spacers.

     

Predictive factors for polypharmacy among child and adolescent psychiatry inpatients

Background

Aim was to determine the predictive factors for polypharmacy among inpatient children and adolescents with psychiatric disorders.

Methods

Blinded, case-note review of children and adolescents with ICD 10 diagnosis of psychiatric disorders on psychotropic medication was conducted. Data on demography, illness, and treatment was analyzed with univariate and multivariate techniques.

Results

Proscribing non-pharmacological interventions (OR = 4.7) and pro re nata medication (OR = 3.3), increased the risk of polypharmacy. Prescribing physical restraint reduced the risk of receiving multiple medications (OR = 0.3).

Conclusion

Proscribing non-pharmacological interventions, pro re nata medication and physical restraints increased polypharmacy.

     

Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis

Objective

To determine the efficacy of nasal continuous positive airway pressure (nCPAP) on respiratory distress symptoms and respiratory effort in young infants with acute respiratory syncytial virus bronchiolitis.

Design

Prospective study.

Setting

The paediatric intensive care unit of a university hospital.

Patients

Twelve infants less than 3 months of age, with severe respiratory distress.

Interventions

Respiratory distress was quantified with a specific scoring system. Oesophageal pressure (Pes) was measured during spontaneous ventilation before and after nCPAP, delivered through an infant-adapted ventilator. Simultaneous recording of gastric pressure (Pgas) was performed in the five oldest patients.

Measurements and results

The respiratory distress score decreased after nCPAP, particularly accessory muscles’ use and expiratory wheezing. The breathing pattern was modified, with shorter inspiratory and longer expiratory time. Pes swings and PTPes_insp, two indices of inspiratory effort, were reduced by 54 (±4)% and 59 (±5)%. PTPgas_exp, an indicator of expiratory muscles activity, was completely abolished. A significant correlation was observed between the respiratory distress score and Pes swings at baseline and after nCPAP.

Conclusions

In young infants with severe acute respiratory syncytial virus bronchiolitis, nCPAP rapidly unloads respiratory muscles and improves respiratory distress symptoms.

     

« Kit KAD » (kit pour accompagner la douleur) — une collaboration territoriale réussie. Création d’une offre éducative pour patients douloureux chroniques

Introduction

Patients and care providers came up with the idea of an educational tool for patients with chronic pain

Methodology

The educational sessions were developed over a five-year period, with four meetings per year.

Results

“Kit KAD” answers the problems faced by patients in pain in everyday life. The “Kit KAD” offers tools and session leaders and can be used by any team trained in PTE (patient therapeutic education).

Conclusion

The “Kit KAD” group, assisted on methodology by the Eastern region UTEP (Transversal Patient therapeutic Education Unit), created an innovative educational tool for patients in chronic pain.

     

Prevalence of hepatic lesion types defined by T2-weighted and dynamic gadolinium-enhanced MR imaging in patients with metastasized neuroendocrine tumors

Purpose

Identifying liver metastases from neuroendocrine tumors (NETs) is a pretherapeutic challenge in patients who are candidates for liver resection. The aims of our study are to characterize and determine the frequency of different MRI characteristics of liver metastases caused by NETs in a lesion-by-lesion analysis and to determine the frequency of monomorphous and polymorphous metastases in a patient-by-patient analysis.

Methods

This retrospective study involved 47 patients with liver metastases arising from histologically confirmed NETs. In a lesion-by-lesion analysis, we classified these metastases according to their MRI characteristics as follows: hypervascular lesions with homogeneous or peripheral enhancement, hypovascular lesions, pure cystic lesions, and mixed solid/cystic lesions. In the patient-by-patient analysis, we distinguished patients whose metastases had the same MRI characteristics from patients with mixed lesion characteristics.

Results

A total of 376 metastases were analyzed. Of these, 84.3% (n = 317) were hypervascular, with 51.9% showing homogeneous enhancement and 32.4% (n = 122) showing peripheral enhancement. Another 7.4% (n = 28) were hypovascular, 5.3% (n = 20) were pure cystic, and 2.9% (n = 11) were mixed solid/cystic. After excluding three patients with solitary lesions, 40.9% of patients (n = 18) had mixed-type lesions, consisting of hypervascular lesions with either homogeneous or peripheral enhancement in 27.3% of cases (n = 12), while 59.1% of patients (n = 26) had identical lesions.

Conclusion

Approximately 15% of metastases have atypical MRI characteristics and are either hypovascular or cystic. Metastases with different MRI characteristics coexist in 40% of patients.

     

Mobilitätseinschränkungen bei Altenheimbewohnern

Background

Pain, restriction of mobility and cognitive impairment are often present in old age and intensify each other.

Objectives

Is there a relationship between mobility, pain, cognitive capacity, diagnoses and number of prescribed medication for residents of nursing homes?

Methods

Subgroup analysis of the baseline data from an intervention study for optimization of the medication safety of 120 nursing home residents.

Results

Pain was presumed in 77.8% of the residents. Persons with cognitive impairment were more frequently affected. The results of the observational and self-reported pain assessment in cognitively impaired patients did not agree for two-thirds of the cases. A correlation between prevalence of pain, pain intensity and mobility could only be shown for persons without cognitive impairment. Half of the persons were unable to walk; 80% of the residents with analgesics as a permanent medication were more restricted in their mobility.

Conclusions

Cognitive impairment is associated with pain and reduced mobility, whereby self-rated pain did not concur with the observational pain assessment for two-thirds of the residents with cognitive impairment. This illustrates the difficulty of observational pain assessment.

     

Anonymisieren oder personalisieren?

Background

The subjective state of health with respect to pain and psyche was surveyed utilizing validated pain questionnaires in patients undergoing special pain therapy and represents the basis for targeted treatment measures.

Objective

The purpose of this study was to investigate the possible distortion of answers due to social desirability of responses in chronic pain patients.

Material and methods

During two survey periods assessing patient satisfaction using both anonymized and personalized questionnaires, the effects arising from socially desirable response patterns were analyzed. The sample consisted of chronic pain patients being treated in an inpatient therapy setting.

Results

In both periods of observation no significant impact on the response behavior of chronic pain patients was found in personalized or anonymized questionnaires.

Conclusion

The results of the study suggest that the responses of chronic pain patients with respect to their subjective state of health are not influenced by social desirability. Thus, scoring systems such as the German pain questionnaire will not be influenced by social desirability in chronic pain patients and can therefore be used as a part of diagnostics and therapy planning.