A prolonged observational study of tracheal tube displacements: Benchmarking an incidence <0.5-1% in a medical-surgical adult intensive care unit

Background and Aims:

Tracheal tubes are commonly used in intensive care unit (ICU) and lead to complications like displacements. The primary aim of the study was to evaluate if the rate of tracheal tube displacement benchmarked at <1% per patient and <0.5% per tracheal tube day, could be sustained over a prolonged period. The secondary aim was to document the patterns of all forms airway accident and to evaluate their consequences.

Subjects and Methods:

This was a prospective observational study of Intubated and ventilated patients in a General Medical-Surgical Adult ICU. The incidence of accidental extubation, self extubation, partial displacement and blockages of tracheal tubes were recorded.

Results:

The overall tracheal tube displacement rate was 61/10,112 (0.6%) per patient and 61/28,464 (0.22%) per tracheal tube day. There were 30 additional incidents of blockage, kinking or biting of the tracheal tube. Physiological consequences-69 were mild, 10 moderate, 12 major and one death. Of the 91 accidents, 30 were partly and 30 were completely preventable. 76 incidents involved an endotracheal tube (54 displaced, 12 blocked and 10 bitten-kinked) and 15 a tracheostomy tube (seven displaced and eight blocked). Accidents were more common in medical than surgical patients (medical = 48, cardiac surgical = 17 and other surgical/trauma = 26).

Conclusion:

Tracheal tube displacement rate in a mixed medical-surgical adult ICU was maintained below the pre-set benchmark of <1% per patient and <0.5% per intubated day over nearly a decade.     

Active hemorrhage into a postresection cavity detected by neuro-CT angiography

We describe a case demonstrating active extravasation of contrast material into a hematoma resection cavity during CT angiography (CTA) that necessitated emergent reexploration, decompression, and hemostatic control. Our case highlights the value of neuro-CTA in the immediate postoperative setting and describes another scenario where CTA has added value. Prompt recognition of contrast extravasation is critical to the diagnosis and ultimately affects the quality of patient care.     

Raloxifene reduces risk of vertebral fractures [corrected] in postmenopausal women regardless of prior hormone therapy

OBJECTIVE: We examined whether past use of hormone therapy influences the effects of raloxifene on the risk of new vertebral fracture, cardiovascular events, or breast cancer. STUDY DESIGN: The Multiple Outcomes of Raloxifene Evaluation (MORE) trial examined vertebral fracture incidence as the primary endpoint, breast cancer incidence as a secondary endpoint. Cardiovascular events were collected as secondary safety endpoints. POPULATION: The MORE trial enrolled 7705 postmenopausal women. Of the 7682 women who reported their previous HT use status, 29% used HT before screening. OUTCOMES MEASURED: Separate logistic regression models analyzed the relationships between prior HT use and the risk of vertebral fracture, cardiovascular events, or breast cancer. Interaction terms with P<.10 were considered to be statistically significant. Confidence intervals for relative risks (RR) were calculated using the Mantel-Haenszel method. RESULTS: Raloxifene 60 mg/d, the clinically approved dose for osteoporosis prevention and treatment, reduced the risk of vertebral fractures by 54% (RR=0.46) and 29% (RR=0.71) in women with and without prior HT use, respectively (interaction P=.05). A lower incidence of invasive breast cancer in women with prior HT use (RR=0.23) and in women without prior HT use [RR=0.31; interaction P=.60] was observed in women receiving raloxifene (pooled doses). Irrespective of prior HT use, women treated with raloxifene (pooled doses) had no change in incidence of cardiovascular events (interaction P=.56). CONCLUSIONS: The risk of vertebral fractures was lower in women treated with raloxifene, regardless of prior HT use, but there was a suggestion that the effect was greater in women who had used HT. Women randomized to receive raloxifene exhibited a decreased incidence of invasive breast cancer, compared with women receiving placebo. No change occurred in the incidence of cardiovascular events, regardless of prior HT use.     

Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization

Access to safe breast-feeding alternatives for HIV-infected mothers and their infants in many settings is limited. We compared the rates of early postpartum hospitalization of infants born to HIV-infected mothers using different infant-feeding practices in a large government hospital in Pune, India. From March 1, 2000 to November 30, 2001, infants born to HIV-infected mothers were followed in a postpartum clinic. All mothers had received a standard short course of antenatal zidovudine. Infant-feeding practices were assessed within 3 d of delivery, prior to postpartum hospital discharge. Sixty-two of 148 mothers (42%) were breast-feeding their infants. Eighty-six of the mothers (58%) were providing replacement feeding, primarily diluted cow, goat or buffalo milk (top feeding). Twenty-one of the 148 participating infants (14.2%) born during the study period required hospitalization within the 1st 6 mo of life and 6 infants required repeat hospitalization. All hospitalized infants were receiving replacement feeding with a rate of 0.093 hospitalizations per 100 person-days (95% CI, 0.062 to 0.136). The reasons for hospitalization included acute gastroenteritis (48.1%), pneumonia (18.5%), septicemia (11.1%) and jaundice (11.1%). A high risk for early postpartum hospitalization was seen in replacement-fed infants born to HIV-infected mothers in Pune, India. In settings such as India, where access to safe replacement feeding is limited, interventions making exclusive breast-feeding safer for HIV-infected mothers and infants are needed. Such interventions would be valuable additions to the very effective national prevention programs that currently rely on the provision of short-course zidovudine and nevirapine.     

Hypertrophic pachymeningitis in a patient with Takayasu arteritis: One more association?

Hypertrophic pachymeningitis (HP) is a rare chronic inflammatory disease of the dura mater, described in association with various infections, systemic vasculitides such as Wegener''s granulomatosis and giant cell arteritis. However, HP in association with Takayasu arteritis (TA) has not been described. We report a young woman who presented with headache, seizures, and right third and fourth cranial neuropathy. Magnetic resonance imaging of the brain showed HP in bifrontal and right temporal region extending to cavernous sinus. She was also found to have systemic hypertension, stenosis of left subclavian, and left renal artery with narrowing of abdominal aorta, satisfying the diagnostic criteria for TA. A detailed evaluation for secondary causes of HP failed to reveal an alternative etiology. This report describes an unusual association of HP in a patient with TA, also emphasizing that seizures and cranial neuropathy may further expand the spectrum of neurological manifestations in patients with TA.     

Estimating the response rate in the presence of measurement error

In clinical research, it is often of interest to estimate the response rate (i.e. the proportion of subjects who achieve a clinically meaningful threshold) for a particular variable. The standard estimator of the response rate is generally biased in the presence of measurement error. The estimation accounting for the measurement error utilizing fully nonparametric (NP) methods is complicated and may not be efficient. Therefore, we propose a model-based approach assuming a parametric model for the true value and only the first few moments for the measurement error. The estimator for the true response rate and the variance for the estimator are derived. An innovative method using bootstrap simulation is proposed to check the model assumption. Simulations show that the proposed estimator outperforms a fully NP estimator if the model assumption for X holds. This method is applied to address a commonly occurring question in osteoporosis regarding response to treatment in terms of longitudinal changes in bone mineral density (BMD). Bootstrap simulations showed that the model utilized is appropriate. The proposed method can also be applied in other fields of clinical research.     

Engineered silica nanocarriers as a high-payload delivery vehicle for antioxidant enzymes

Antioxidant enzymes for the treatment of oxidative stress-related diseases remain a highly promising therapeutic approach. As poor localization and stability have been the greatest challenges to their clinical translation, a variety of nanocarrier systems have been developed to directly address these limitations. In most cases, there has been a trade-off between the delivered mass of enzyme loaded and the carrier's ability to protect the enzyme from proteolytic degradation. One potential method of overcoming this limitation is the use of ordered mesoporous silica materials as potential antioxidant enzyme nanocarriers. The present study compared the loading, activity and retention activity of an anti-oxidant enzyme, catalase, on four engineered mesoporous silica types: non-porous silica particles, spherical silica particles with radially oriented pores and hollow spherical silica particles with pores oriented either parallel to the hollow core or expanded, interconnected bimodal pores. All these silica types, except non-porous silica, displayed potential for effective catalase loading and protection against the proteolytic enzyme, pronase. Hollow particles with interconnected pores exhibit protein loading of up to 50 wt.% carrier mass, while still maintaining significant protection against proteolysis.     

A randomized double-blind trial to compare the efficacy of teriparatide [recombinant human parathyroid hormone (1-34)] with alendronate in postmenopausal women with osteoporosis

Teriparatide (rDNA origin) injection [recombinant human PTH (1-34)] stimulates bone formation, increases bone mineral density (BMD), and restores bone architecture and integrity. In contrast, bisphosphonates reduce bone resorption and increase BMD. We compared the effects of teriparatide and alendronate sodium on BMD, nonvertebral fracture incidence, and bone turnover in 146 postmenopausal women with osteoporosis. Women were randomized to either once-daily sc injections of teriparatide 40 micro g plus oral placebo (n = 73) or oral alendronate 10 mg plus placebo injection (n = 73). Median duration of treatment was 14 months. At 3 months, teriparatide increased lumbar spine BMD significantly more than did alendronate (P < 0.001). Lumbar spine-BMD increased by 12.2% in the teriparatide group and 5.6% in the alendronate group (P < 0.001 teriparatide vs. alendronate). Teriparatide increased femoral neck BMD and total body bone mineral significantly more than did alendronate, but BMD at the one third distal radius decreased, compared with alendronate (P < or = 0.05). Nonvertebral fracture incidence was significantly lower in the teriparatide group than in the alendronate group (P < 0.05). Both treatments were well tolerated despite transient mild asymptomatic hypercalcemia with teriparatide treatment. In conclusion, teriparatide, a bone formation agent, increased BMD at most sites and decreased nonvertebral fractures more than alendronate.