Early evaluation of coagulase negative staphylococcus in blood samples of intensive care unit patients

Of 2160 intensive care unit patients, 36 patients with positive blood cultures had coagulasenegative staphylococcus in one blood bottle, whereas the organism was present in two or more bottles in 38 cases. The groups were not significantly different in 27 clinical variables, obtained at the time of their first positive blood culture. There was also no significant difference in the antimicrobial sensitivities. No initial clinical data supported the classification of coagulase-negative staphylococcus as either pathogen or contaminant.When the 74 patients with blood culture positive coagulase-negative staphylococcus were compared with three control groups (absent septicemia, probable septicemia and proven septicemia) they were not different from those with probable septicemia. A discriminant analysis was performed comparing patients with absent septicemia and with proven septicemia in an attempt to classify patients with isolates of coagulase-negative staphylococcus in one of these groups at an early stage. Patients with two or more positive blood cultures were not statistically classified more frequently as septicemic than patients with one blood bottle positive for this organism. However, patients categorized as septicemic had a significantly higher mortality (59%) than those classified as non-septicemic (35%) (p<0.05).     

Oxygenation remains unaffected by increased inspiration-to-expiration ratio but impairs hemodynamics in surfactant-depleted piglets

Objectives Prolongation of inspiratory time is used to reduce lung injury in mechanical ventilation. The aim of this study was to isolate the effects of inspiratory time on airway pressure, gas exchange, and hemodynamics, while ventilatory frequency, tidal volume, and mean airway pressure were kept constant.Design Randomized experimental trial.Setting Experimental laboratory of a University Department of Anesthesiology and Intensive Care.Animals Twelve anesthetised piglets.Interventions After lavage the reference setting was pressure-controlled ventilation with a decelerating flow; IE was 11, and PEEP was set to 75% of the inflection point pressure level. The IE ratios of 1.51, 2.31, and 41 were applied randomly. Under open lung conditions, mean airway pressure was kept constant by reduction of external PEEP.Measurement and results Gas exchange, airway pressures, hemodynamics, functional residual capacity (SF₆ tracer), and intrathoracic fluid volumes (double indicator dilution) were measured. Compared to the IE of 11, PaCO₂ was 8% lower, with IE 2.31 and 41 (p0.01) while PaO₂ remained unchanged. The decrease in inspiratory airway pressure with increased inspiratory time was due to the response of the pressure-regulated volume-controlled mode to an increased IE ratio. Stroke index and right ventricular ejection fraction were depressed at higher IE ratios (SI by 18% at 2.31, 20% at 41; RVEF by 10% at 2.31, 13% at 41;p0.05).Conclusion Under open lung conditions with an increased IE ratio, oxygenation remained unaffected while hemodynamics were impaired.This study was supported by the Swedish Medical Research Council (project 4252), the Swedish Heart-Lung Foundation, Stockholm, Sweden, and the Laerdal Foundation for Acute Medicine, Stavanger, Norway     

Elastase and granzymes during meningococcal disease in children: correlation to disease severity

Objective To investigate the levels of human neutrophil elastase and lymphocyte-derived granzymes A and B in relation to disease severity in children with meningococcal disease.Design Clinical observational cohort study.Setting Paediatric intensive care unit.Patients All patients with meningococcal disease during the study period were included.Measurements and results Blood sampling was done on the day of admission and on days 3 and 7. Assays for elastase and granzymes were done with ELISA. Sixty-one patients were included: 19 having distinct meningitis; 17 meningitis and shock; and 25 fulminant septicaemia. On admission levels of elastase were increased in all patients, being highest in those with fulminant septicaemia and lowest in those with distinct meningitis. Granzyme A (although marginally) and granzyme B levels were only increased in patients with shock. In 20 of the 28 patients admitted for 3 days elastase decreased from admission (rapid-decrease group). In the remaining 8 patients, elastase started to decrease after 2 days (slow-decrease group). Patients of the slow-decrease group had a higher temperature up to day 4, needed more respiratory support (mean airway pressure in cm H₂O on days 3 and 4: p=0.02 and p<0.01, respectively), and more circulatory support (>2 inotropic agents on day 3; p=0.04) compared with the rapid-decrease group.Conclusions Human neutrophil elastase and granzyme B are related with disease severity during the initial phase of meningococcal disease and prolonged neutrophil activation is associated with the extent of organ dysfunction during the period thereafter.     

Protective effect of β-glucan on lung injury after cecal ligation and puncture in rats

Objective Understanding the biological mediators involved in the complex inflammatory response of sepsis and acute lung injury offers the possibility of future investigations targeting treatment based on these mediators. This study investigated whether macrophage activator -glucan has a protective effect on acute lung injury in an experimental model of sepsis.Design and setting Experimental study in an experimental research center.Materials 30 rats randomized into three groups (sham, sepsis, and -glucan).Interventions Cecal ligation and puncture were performed in the -glucan and sepsis groups. The -glucan group was given a single intraperitoneal dose of -glucan (4 mg/kg) following cecal ligation.Measurements and results Rats treated with -glucan had fewer circulating neutrophils, more blood monocytes, and higher serum interleukin 6 levels than septic animals. The percentages of neutrophils and lymphocytes from the bronchoalveolar lavage fluid and the myeloperoxidase activity measured in the lung tissue were lower in the -glucan group than in the sepsis group. Less alveolar hemorrhage and neutrophil infiltration were observed in lungs from animals in the -glucan group in the septic groups.Conclusions In this rat model of intra-abdominal sepsis -glucan treatment partially protected against secondary lung injury, decreased lung hemorrhages, and lung neutrophilia. These results suggest that -glucan protects against sepsis-associated lung damage.     

The “lung pulse”: an early ultrasound sign of complete atelectasis

Objective Complete atelectasis can be immediately generated by selective intubation. A dynamic lung ultrasound sign can be described as the association of absent lung sliding with the perception of heart activity at the pleural line, a sign which was called lung pulse. We examined whether this sign be used promptly to confirm complete atelectasis due to selective intubation.Design and setting Prospective study in the medical intensive care unit of a university-affiliated teaching hospital.Patients Consecutive patients with no history of respiratory disorders and needing intubation were enrolled. Fifteen patients with selective intubation of the right lung were compared with 30 patients with nonselective intubation and 15 healthy volunteers.Interventions The lung pulse was sought at the left anterolateral chest wall in intubated patients. Healthy subjects were studied during breathing and apnea.Results A left lung pulse was immediately present in 14 of 15 patients with right selective intubation, and absent, with normal lung sliding, in all 30 correctly intubated patients and in all 15 healthy subjects during breathing. All healthy subjects exhibited a lung pulse in apnea. The lung pulse had a sensitivity of 93% and a specificity of 100% for the diagnosis of complete atelectasis following selective intubation in patients without previous respiratory disorders.Conclusions The lung pulse is a sign of complete atelectasis which is observable immediately before radiological changes. Its absence which is correlated with the absence of selective intubation and of conserved lung inflation can eliminate the need for confirmation radiography.Electronic Supplementary Supplementary material is available in the online version of this article at .     

Early prediction of prognosis in out-of-hospital cardiac arrest

Of 347 victims of out-of-hospital cardiac arrest 196 (56.5%) died before and 109 (31.4%) after admission to hospital, while 42 patients (12.1%) were discharged alive. The 37 patients (10.7%) discharged without severe hypoxic brain damage were assigned to the group with good, the remaining 310 patients to the group with poor outcome. From results of stepwise logistic regression, a score was derived to specifically identify victims with poor prognosis (values in brackets=score points; cutpoint: score>3 points): age70 (0), 71–80 (1), >80 (2); ECG ventricular fibrillation (0), other (1); no aspiration (0), aspiration (1); pupils round (0), not round (1); gasping (0), apnea (1); bystander resuscitation — yes (0), no (1). Evaluation of the score revealed a specificity of 100% (0.95 confidence interval: 80%–100%) and predictive value of 100% (0.95 confidence interval: 95%–100%). A predictive score for specific identification of victims with poor prognosis can contribute to decision making in out-of-hospital cardiac arrest.     

The Cognitive Content of Naturally Occurring Worry Episodes

Fifty-seven participants were selected to represent a wide range on the dimension of worry proneness. They monitored and listed their worrisome thoughts in a diary for 7 days, and rated the uncontrollability of each recorded worry episode. Content analysis revealed that 48% of worrisome thoughts could be categorized as reflecting a problem-solving process, 17% as anticipation of future negative outcomes, 11% as rumination, and 5% as reflecting palliative thoughts and self blame. The extent of negative outcome anticipation or problem solving did not covary with worry severity. Higher trait worry proneness and more frequent and uncontrollable worrying during the monitoring period were associated with more rumination and fewer reports of successful solutions to problems. The results suggest that worry consists largely of attempted problem solving, and that one possible mechanism in the emergence of pathological worry may be a failure to bring problem solving to a satisfactory conclusion.     

New aspects of pulmonary mechanics: ‘slowly” distensible compartments of the respiratory system,identified by a PEEP step maneuver

Objective The aims of the present study were 1) to evaluate a method for identification of slowly distensible compartments of the respiratory system (rs), which are characterized by long mechanical time constants (RC) and 2) to identify slowly distensible rs-compartments in mechanically ventilated patients.Design Prospective studyon a physical lung model.Setting Intensive Care Unit, University Hospital, Tübingen.Patients and participants 19 patients with severe lung injury (acute respiratory distress syndrome, ARDS) and on 10 patients with mild lung injury.Measurements and results Positive end-expiratory pressure (PEEP)-increasing and-decreasing steps of about 5 cmH₂O were applied and the breath-by-breath differences of inspiratory and expiratory volumes (V) were measured. The sequence of Vs were analyzed in terms of volume change in the fast compartment (V_fast), the slow compartment (V_slow), total change in lung volume (VL) and mechanical time constant of the slow compartment (RC_slow). Thirty-eight measurements in a lung model revealed a good correlation between the preset V_slow/VL and V_slow/VL measured: r²=0.91 The V_slow/VL measured amounted to 0.94±0.15 of V_slow/VL in the lung model. RC_slow measured was 0.92±0.43 of the RC_slow reference. Starting from a PEEP level of 11 cmH₂O PEEP-increasing and PEEP-decreasing steps were applied to the mechanically ventilated patients. Three out of ten patients with mild lung injury (30%) and 7/19 patients with ARDS (36.8%) revealed slowly distensible rscompartments in a PEEP-increasing step, whereas 15/19 ARDS patients and 1/10 patients with mild lung injury showed slowly distensible rs-compartments in a PEEP-decreasing step (78.9% vs 10%,P<0.002, chi-square test).Conclusions The gas distribution properties of the respiratory system can be easily studied by a PEEP-step maneuver. The relative contribution of the slow units to the total increase of lung volume following a PEEP step could be adequately assessed. Slowly distensible rs-compartments could be detected in patients with severe and mild lung injury, however significantly more ARDS patients revealed slow rs-compartments in PEEP-decreasing steps. The influence of slowly distensible rs-compartments on pulmonary gas exchange is unknown and has yet to be studied.The work was performed at the Klinik für Anaesthesiologie und Transfusionsmedizin der Universität Tübingen     

The influence of premature ventricular contractions on left ventricular function in asymptomatic children without structural heart disease: an echocardiographic evaluation

Background: Isolated monomorphic premature ventricular contractions (PVCs) are not uncommon in the pediatric population. The degree of cardiac dysfunction caused by PVCs in children without structural heart disease is unknown. Purpose: To investigate the influence of PVCs on echocardiographic left ventricular (LV) systolic function in children without structural heart disease. Methods: Forty asymptomatic children with isolated monomorphic PVCs without structural heart disease were selected. The median age was 6 years, range of 3–12 years. The following subgroups were compared: frequent vs. infrequent PVCs (> or 10/min); short vs. long coupling interval (RR/RR ratio or >0.6); and short vs. long QT interval (QT or >400 ms). Using echocardiography the left ventricular ejection fraction (LVEF in percentage) and cardiac index (CI in L/min/m²) were measured for both normal sinus beats (SB-LVEF and CI), PVCs (PVC-LVEF and CI) and the average LVEF and CI were calculated. All values were expressed as means ± SD. Results: In all children LV dimensions and the SB-LVEF and CI were within normal limits. The PVC-LVEF (48 ± 5) and PVC-CI (1.57 ± 0.19) were significantly decreased and the average CI was 2.41 ± 0.29. In 27 pts with >10 PVCs/min the average LVEF and CI decreased to 53 ± 5 and 2.08 ± 0.24 respectively. In 16 pts with PVCs and a short coupling interval (RR/RR 0.6) the PVC-LVEF and PVC-CI was 43 ± 0.03 and 1.50 ± 0.14, which was significantly lower than in 24 pts with a long coupling interval (58 ± 4, 1.88 ± 0.11). In 11 pts with a prolonged QT interval (>400 ms) the PVC-LVEF and PVC-CI was significantly lower than in the 29 children with a shorter QT interval, 41 ± 5 vs. 55 ± 4 and 1.46 ± 0.13 vs. 1.86 ± 0.15 respectively (all p < 0.01). Conclusion: In asymptomatic children with isolated monomorphic PVCs the average ejection fraction and cardiac output is markedly reduced if PVCs are frequent (>10/min), have a short coupling interval or a prolonged QT interval.     

Implications for Treatment of Sexual Offenders of the Ward and Hudson Model of Relapse

A group of 59 child abusers were classified as having either an avoidant (n = 15) or an approach (n = 44) goal regarding deviant sexual activity with children. Level of distorted beliefs about sexual activity with children (cognitive distortions) and distorted beliefs about their own victims (victim blaming attitudes) in both groups were measured before and after treatment. Results indicate that there was an overall reduction in the level of these distorted beliefs at the posttreatment stage in the approach group. Reductions were not found in the avoidant offenders as men in this group did not have distorted beliefs prior to treatment. Results are discussed in terms of appropriate targeting of treatment.