Predictive value of tetrapolar body impedance measurements for hydration status in critically ill patients

Objective To design and evaluate a simple and rapid method to predict body hydration status in critically ill patients.Design Prospective, consecutive sample.Setting Medical intensive care unit of a university hospital.Patients 31 consecutive patients.Methods All patients were classified daily for hydration status by the attending physician based on clinical impression, weight changes and laboratory measurements. The hydration status was scored as dehydrated, euvolemic or edematous. The total body impedance was measured daily by a tetrapolar impedance technique.Results Resistances >700 were found in dehydrated subjects and resistances of <400 in edematous patients. Weight gain was observed in dehydrated and weight loss in edematous patients. A discriminant analysis was used to create a predictive model for hydration using the daily impedance and weight measurements. If a cutoff point of 60% for the predicted classification was used to categorize the patient's hydration as dehydrated, euvolemic and edematous, no false positive predictions were observed for the dehydrated or the edematous state.Conclusion Impedance measurements are in close agreement with the clinical impression of hydration of critically ill patients. Future investigations must elucidate the clinical importance.     

Serum MIP-1α and IL-8 in septic patients

We studied blood MIP-1 and IL-8 in 38 septic patients and 5 healthy volunteers. Both chemokines were undetectable in the healthy volunteers. In sepsis, serum MIP-1 was detected in 45% of the patients and IL-8 in 84%. The levels of MIP-1, but not of IL-8, correlated with CRP, IL-6 and TNF levels. Complication, including various organ failures and mortality, showed no correlation with serum MIP-1 levels. In contrast, we found increased levels of serum IL-8 in septic patients with disseminated intravascular coagulation, central nervous system (CNS) dysfunction or renal failure, and the mortality rate was higher in the IL-8-detectable group than in the IL-8 undetectable group (50% vs 0%,p<0.05). In conclusion, the production of both MIP-1 and IL-8 was increased and initially detectable levels of circulating IL-8 predicted high mortality in sepsis.Objective To determine the significance of the C-C chemokine MIP-1 and the C-X-C chemokine IL-8 in sepsis.Design Prospective study.Setting Clinical investigation, emergency department and general intensive care unit of university hospital.Patients and participants 38 septic patients and 5 healthy volunteers were studied. Sepsis was diagnosed following the criteria formulated by ACCP/SCCM.Interventions 10–20 ml of blood was drawn from each patient at the time of initial diagnosis of sepsis.Measurements and results MIP-1 and IL-8 were determined by sand-wich ELISA. Both chemokines were undetectable in the healthy volunteers. In sepsis, serum MIP-1 was detected in 45% of the patients and IL-8 was detected in 84%. The levels of MIP-1, but not of IL-8, correlated with CRP, IL-6 and TNF levels. Complications, including various organ failures and mortality, showed no correlation with serum MIP-1 levels. In contrast, we found increased levels of serum IL-8 in patients with disseminated intravascular coagulation (DIC) (p<0.05), central nervous system (CNS) dysfunction (p<0.05), renal failure (p<0.01) and the mortality rates were higher in the IL-8 detectable group than in the IL-8 undetectable group (50% vs 0%,p<0.05).Conclusions The production of MIP-1 and IL-8 was increased in sepsis. Furthermore, an initially detectable level of circulating IL-8, but not MIP-1, predicted a high mortality in sepsis diagnosed according to the ACCP/SCCM criteria.This study was supported in part by a Grant-in-Aid from the Japanese Ministry of Education, Science and Culture, the Waxman Institute Research Fund and the Keio Fukuzawa Fund     

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     

Surfactant adjunctive therapy forPneumocystis carinii pneumonitis in an infant with acute lymphoblastic leukaemia

We report successful treatment of adult respiratory distress syndrome (ARDS) with artificial surfactant (40mg/kg, Colfosceril Palmitate, Exosurf, Wellcome) in an infant with severePneumocystis carinii pneumonitis.     

Phyto News

Phyto News est la revue commentée de communications dans le domaine de la plante médicinale (recherche pharmacologique et clinique), qui nous semble présenter un intérêt médical ou pharmaceutique tel quil puisse permettre de faire progresser dautres études qui aboutiront à une application thérapeutique. Il est cependant important davertir les lecteurs que dune découverte ou dune démonstration pharmacologique ne découle pas immédiatement la justification de lutilisation médicale.

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Phyto News is a commented review of papers about medicinal plant research all around the world. The papers must contain information leading to medicinal progress in phytotherapy practice or development in the pharmaceutical area. The reader is reminded that not all discoveries will have immediate use in medicine, but each may give ideas for further investigations.

     

Effects of the heat-moisture exchangers on dynamic hyperinflation of mechanically ventilated COPD patients

In recent years the use of devices called Heat and Moisture Exchangers (HME) has become widespread as gas conditioners for ICU patients requiring mechanical ventilation. As an important variation of the resistive properties of the HME, related to flow and duration of use, has recently been pointed out during in vitro studies, the use of these devices in COPD patients could increase the levels of auto PEEP and dynamic hyperinflation. In this study we have compared the levels of auto PEEP and difference in functional residual capacity ( FRC) in a group of COPD patients, requiring controlled mechanical ventilation (CMV), at basal conditions and after the insertion into the circuit of three HMEs (Dar Hygrobac, Pall Ultipor, Engstrom Edith) at random: the results obtained excluded a significant increase of auto PEEP and (FRC) both with new HMEs and after 12 h of continuous use.     

Plantes et vieillissement, données actuelles*

Résumé: Le vieillissement résulte dune suite de mécanismes biologiques sacconpagnant de modifications physiologiques, anatomiques et psychologiques.Après avoir rappelé ses manifestations physiologiques (cérébrales, hormonales, cutanées, cardio-vasculaires, troubles de lappareil locomoteur), lauteur sélectionne, daprès des critères scientifiques, différentes plantes capables de contribuer à ralentir le processus de sénescence de lorganisme ou de combattre les effets du vieillissement. Ces végétaux ont fait lobjet de publications dans des revues scientifiques internationales principalement au cours de ces cinq dernières années. Dossier: Phytothérapie et vieillissement* Communication présentée lors du 5^e colloque de la revue Phytothérapie: les Avancées en Phytothérapie, janvier 2004.     

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.     

The patients’ perceptions of migraine and chronic daily headache: a qualitative study

This study aimed to gain insight into the management of migraine and chronic daily headache (CDH) from the patients perspective. This article outlines the patients perceptions of migraine and chronic daily headache. Thirteen semi–structured interviews were carried out with patients suffering from IHS migraine. Five patients, due to their headache frequency of more than 15 headache days per month, were classed as CDH patients. The data were transcribed verbatim and analysed in accordance with the grounded theory methodology. The main themes were: headaches, impact and headaches related to health issues. The theme headaches was sub-divided into their pain and symptoms, differentiating between their headaches and perceptions of headaches as barriers and facilitators to management. The patients perceptions of migraine and CDH were sometimes conflicting and influenced the patients management behaviours. The qualitative methodology may help to inform doctors, other healthcare professionals and headache researchers about the patients perspective and possibly develop future headache research, care and education.     

Left ventricular function after acute myocardial infarction

10 patients with their first AMI were studied within the first 48 hours and again after 3 weeks. Central and peripheral haemodynamics (CI, SV, SW, TPR) were examined, including indices of contractility (dp/dlmax) and wall stiffness (P/V, relation P/V to P) of the left ventricle.In the early phase CI and SW, as well as LV dp/dt_max were depressed in accordance with symptoms of LV failure. P/V was increased. Elevation of LVEDP correlated well with ventricular gallop rhythm, but less consistently with LV functional disturbance.During convalescence CI increased uniformly, both in digitalized and non-digitalized individuals. In contrast heart rate, aortic pressure, LVEDP and dp/dt_max remained unchanged. The increase of CI, SV and SW was accompanied by a fall of TPR and P/V. LV wall stiffness was still elevatedabove normal after 3 weeks. The improvement of cardiac pumping during infarct convalescence may have been effected through a fall of TPR and LV wall stiffness. Recovery of depressed contractile performance was generally not observed, and does therefore not seem to contribute to recuperation.Herrn Prof. Dr. med. P. Schölmerich zum 60. Geburtstag.     

Self-efficacy expectancies versus outcome expectancies as determinants of performance deficits and depressive affect

To compare the depression etiologies specified by self-efficacy theory versus the revised learned helplessness theory, 108 male and female undergraduates were assigned randomly to either high, low, or no self response expectancy manipulations and high, low, or no response outcome expectancy manipulations. Expectancies were modified by combinations of easy or difficult anagrams and graphs showing that most or few students solved the anagrams. Males exhibited performance deficits and depressed affect following manipulations only if self response expectancy had been set low and other response expectancy had been set high. Contrary to revised learned helplessness theory, no performance deficit or depressive affect occurred when both self response and response outcome expectancies were low. Females' performance and affect were not changed by combined low self response and high response outcome manipulations. Repeated subject ratings of self response and response outcome expectancies during manipulations suggest that females set their self response expectancies low before manipulations to avoid depression. Expectancy ratings also showed that self response expectancies correlated more strongly with performance than did response outcome expectancies.We thank Katherine Acosta, Michael Davis, Larry McFarland, and Janine Tronolone for their assistance as experimenters.     

Transthoracic electrical impedance during extracorporeal hemodialysis in acute respiratory failure (“Shocked lung syndrome”)

The alteration (Z ₀ ) of transthoracic electrical impedance (TEI) during extracorporeal hemodialysis (EHD) was investigated in two Groups of patients with acute renal and acute respiratory failure, that differed with respect to the severity of respiratory insufficiency. Group I had moderate respiratory failure (Fi _{O 2} 0.31±0.10, Pa _{0 2} 84±14 mmHg), and Group II had severe respiratory failure (Fi _{0 2} 0.75±0.17, Pa _{O O} 77±14 mmHg). There was a significant correlation between increase in TEI (Z₀) and decrease in body weight (BW) in each individual patient, but the slope of regression lines was remarkably flattened in Group II. In Group I, TEI was 1.9±0.9 , the calculated TEI for 500 gr decrease in BW (Z_{0–500 gr}) was 0.59±0.21 , and a significant correlation existed between pooled data of Z₀ and BW. In Group II TEI increased less significantly, TEI was 0.6±0.3 (P<0.001), Z_{0–500 gr} was 0.26±0.27 (P<0.01), and there was no correlation between pooled data of Z₀ and BW. Increase of TEI in Group II could be completely attributed to increase in hematocrit. It is concluded that patients of Group I with acute renal failure and moderate respiratory failure lost intrathoracic fluid during EHD, whereas patients of Group II with severe respiratory failure did not. TEI during EHD may serve as a test for detection of fixed fluid within the pulmonary interstitium indicating a poor prognosis of the acute respiratory failure.     

Phyto News

Phyto News est la revue commentée de communications dans le domaine de la plante médicinale (recherche pharmacologique et clinique), qui nous semble présenter un intérêt médical ou pharmaceutique tel quil puisse permettre de faire progresser dautres études qui aboutiront à une application thérapeutique. Il est cependant important davertir les lecteurs que dune découverte ou dune démonstration pharmacologique ne découle pas immédiatement la justification de lutilisation médicale.

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Phyto News is a commented review of papers about medicinal plant research all around the world. The papers must contain information leading to medicinal progress in phytoterapy practice or development in the pharmaceutical area. The reader is reminded that not all discoveries will have immediate use in medicine, but each may give ideas for further investigations.

     

Impact of Kendall,Hollon, Beck,Hammen, and Ingram (1987) on treatment of the continuity issue in “depression” research

The article, Issues and Recommendations Regarding Use of the Beck Depression Inventory (Kendall, Hollon, Beck, Hammen, & Ingram, 1987), has had a major impact on depression research. A majority of studies using only the BDI in nonclinical samples now refer to the construct measured as dysphoria rather than depression. This word change, however, is not always accompanied by other changes in research design and interpretation that would seem warranted by the concerns that initially prompted the dysphoria recommendation, such as the nonspecificity of high BDI scores to major depression. Researchers typically continue to derive hypotheses from depression theory, use only the BDI to measure dysphoria rather than purer markers of negative affectivity, cite as a limitation of their findings the danger of assuming continuity between subclinical and clinical depression, and sometimes lapse into depression terminology. Alternative suggestions are made for considering how the particular goals of a study might lead to various ways of handling the continuity issue.We are grateful to Tony Ahrens, Diane Arnkoff, and anonymous reviewers for feedback on earlier drafts.     

Phytothérapie et Internet

À lheure dune mise en question des politiques de santé publique et dun regain de faveur pour des thérapeutiques jugées plus naturelles, la phytothérapie suscite un intérêt croissant qui se mesure au nombre des sites Internet consacrés à la médecine par les plantes. Mais aujourdhui la masse dinformations disponibles et labsence totale de contrôle de la qualité de ces informations rendent de plus en plus difficiles les recherches documentaires sur les «autoroutes de linformation». Dans cette nouvelle rubrique Phytothérapie & Internet seront signalés les sites qui semblent présenter le plus dintérêt pour nos lecteurs.

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At a time when the politics of public health are being challenged and natural treatments are witnessing a popularity revival, phytotherapy is arousing a growing interest that can be measured by the number of Internet sites devoted to plants based medicine.However, the large amount of available information and the total absence of quality controls concerning the information these sites give, make documentary research increasingly difficult on these information motorways. In this new section, Phytotherapy & Internet, the sites that present the most interest for our readers are mentioned.

     

The effects of PEEP on arterial oxygenation

The effect of positive end expiratory pressure (PEEP) on arterial oxygenation depends on many factors. Two of the most important are the quality and the quantity of the physiological shunt. The quality depends on the mixed venous oxygen tension, and the quantity on the shunt fraction. Each of these factors may rise or fall with PEEP, depending on the pulmonary and circulatory state of the patient. Their ultimate balance influences the change in arterial oxygen tension.     

Stories from doctors of patients with pain. A qualitative research on the physicians’ perspective

Goal of work .The aim of this study was to explore the physicians internal representation of the doctor–patient relationship in the dramatic field of the patient with pain.Methods Using an open narrative format, 151 physicians were asked to Tell us about an episode during your professional experience in which you found yourself in difficulty whilst confronting a patient who was in pain. The narrations were examined in accordance with a clinical-interpretive method.Main results Three perspectives of observation were identified, namely: the biological perspective, the professional perspective, and the personal perspective. The biological perspective is about the biological model and the depersonalization of pain. In the professional perspective, the narrative concerns the patient as a person and the reattribution of the pain to the suffering person. The personal perspective is about the emotional-relational explosion within the meeting between the doctor as human being and the patient as human being. Most of the narrations did not strictly connect to one or another of the perspectives, but each story seemed a journey without peace back and forth among the perspectives.Conclusions The professional perspective seemed to be the only place in which physicians could stop, a space not extreme in which they seemed to express the need for education about the management of the professional relationship with the other person.     

Elevated serum bleomycin-detectable iron concentrations in patients with sepsis syndrome

Objective To determine serum bleomycin-detectable free iron in patients with septic shock and to relate these findings to both outcome and a marker of free radical damage.Design A prospective observational study.Setting A nine-bed intensive care unit in a university teaching hospital.Patients Sixteen consecutive patients with septic shock, defined as: (1) Clinical evidence of acute infection; (2) hypo- or hyperthermia (<35.6° or >38.3°C); (3) tachypnoea (>20 breaths/min or ventilated); (4) tachycardia (>90 beats min); (5) shock (systolic pressure <90 mmHg) or on inotropes. Fourteen patients also had secondary organ dysfunction.Measurements and results Bleomycin-detectable iron concentrations were elevated in all patients (37.2±11.0 mol/l vs 5.1±3.3 mol/l in healthy subjects,P<0.0001), but there was no difference between patients who died and those who survived (39.2±9.3 and 36.2±12.3 mol/l, respectively). Thiobarbituric acid reactive substances 9an index of lipid peroxidation) were higher in those who died (3.33±2.29 mol/l) than in the surviving patients (0.99±0.14 mol/l,P<0.01) or healthy subjects (0.92±0.39 mol/l,P<0.01). Free iron did not correlate with thiobarbituric acid-reactive substances. However, a significant correlation was found between lipid peroxidation and clinical severity (APACHE II) score (r=0.54,P<0.05).Conclusions The present study provides evidence of lipid peroxidation in patients who die with septic shock. The data suggest that ironcatalysed hydroxyl radical generation does not form an important contribution to this lipid peroxidation in patients with sepsis.     

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