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     

The sex killer

Thirteen sex killers were compared to 13 nonsex killers and 13 nonhomicidal sexually aggressive men on sexual history, substance abuse, history of violence, mental illness and personality, brain pathology and endocrine abnormalities. There were more similarities among the three groups than differences. Among the findings, the presence of transvestism and the early appearance of sadism differentiated the sex killers from the other two groups. Sex killers also killed by strangulation more often than nonsex killers and more often victimized a female stranger. The sex killer was more often diagnosed as antisocial personality and sadist than the other two groups. They were more often considered psychotic at the time of their offence and more often considered not guilty by reason of insanity. Directions for future research are noted.     

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.     

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.     

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.     

The activity of grepafloxacin in two murine models of <Emphasis Type="Italic">Mycobacterium avium</Emphasis> infection

The activity against Mycobacterium avium complex (MAC) of varying doses of grepafloxacin (GRE; 25mg/kg, 50mg/kg, 100mg/kg, and 200mg/kg) were compared to clarithromycin (CLA; 100mg/kg and 200mg/kg), ethambutol (EMB; 100mg/kg), and rifabutin (RBT; 10mg/kg) using an intranasal (IN) infection model compared to an intravenous (IV) infection model. Beige mice (C57BL6/J-Lyst bg J/+) were infected intranasally with about 10⁶ organisms and for the IV model about 10⁷ organisms. Treatment for both models was started 1 week postinfection and given by gavage 5 days/week for 4 weeks. At the initiation of therapy, an early control group was killed to determine the initial organism load. Three days following the completion of therapy, drug-treated groups of mice and the late control group were killed and the response to therapy measured. The most effective agents were CLA and RBT. GRE and EMB had modest activities in both the IN and the IV models. A matched comparison between IN and IV challenges for each of the agents used revealed greater suppression of MAC in the IN model compared to the IV model.     

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).     

Plaidoyer pour la tisane médicinale

Résumé: La tisane nest pas uniquement un apport deau. Il sagit dune préparation médicinale utile en médecine et en phytothérapie. Elle doit obéir à certains critères pour être de qualité : qualité de la plante, temps dinfusion, conditions dutilisation, correction du goût. La teneur en principe actif est variable, mais elle est effective, quoiquelle dépende de plusieurs facteurs qui en déterminent lefficacité. Des exemples de tisanes pour la pédiatrie sont donnés.     

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.     

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.     

Shock and the kidney: Pathophysiology and pharmacological support

This article reviews current knowledge as to the physiological mechanisms that control renal vascular resistence. The contribution of both extrinsic and intrinsic neuro-humoral regulation of both blood flow and glomerular filtration rate are described. The changes that occur both to the renal blood flow and glomerular filtration rate in the pathophysiological situation of pre-renal uraemia as well as acute tubular necrosis are described. Within this setting pharmacological manoeuvres that may improve both renal blood flow and glomerular filtration rate are discussed. In addition, the indications for and general principles of haemo- and peritoneal dialysis are described.     

Les plantes immunostimulantes adjuvantes de la thérapeutique antitumorale*

Résumé: Dans cet article, lauteur examine si les plantes immunostimulantes peuvent jouer un rôle dans la thérapie des états cancéreux. Les plantes immunostimulantes à effet global sont des plantes agissant par leurs polysaccharides immuno-actifs. Celles-ci ont aussi des activités anticanreuses spécifiques selon des expérimentations sur lanimal liées à des constituants différents. Par ailleurs ces mêmes plantes sont souvent aussi adaptogènes. Il est possible de conclure que lutilisation en paralèlle dun traitement anticancéreux conventionnel semble indiquée.* Communication présentée lors de la 11e Journée universitaire de lAMPP (juin 2003) : Cancer et autres pathologies graves, nutrition, phytothérapie     

L’arganier, <Emphasis Type="Italic">Argania spinosa</Emphasis> L. (skeels), usage thérapeutique,cosmétique et alimentaire*

Résumé: Nous avons entrepris cette étude sur les multiples usages de larganier Argania spinosa L. (skeels), en particulier lusage thérapeutique et cosmétique de ses différentes parties. Pour ce, nous avons mis au point un questionnaire détaillé pour le recueil des informations concernant lutilisation des racines, de lécorce, des feuilles, des fleurs, des pulpes des amandons, de lhuile et du tourteau dans la cosmétique et la thérapie traditionnelle marocaine. Létude est menée dans les régions rurales du Sud-Ouest marocain, ciblant les tradipraticiens, des herboristes, des femmes ressources et des paysans. La population de létude est constituée de personnes âgées de plus de 40 ans ayant gardé des contacts directs ou indirects avec larganier.*extrait du mémoire de phytothérapie, Dumenat,Université de médecine de Paris XIII.     

Assessment of left ventricular diastolic function with Doppler tissue imaging: effects of preload and place of measurements

Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 ± 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E, A) from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p < 0.001, p = 0.007, p < 0.001, respectively) after hemodialysis. Mitral annulus E wave velocities and E/A ratios obtained from five different sides of the annulus also changed significantly (p < 0.001 for all); however, there was no change in the A wave velocity (p > 0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E velocities and E/A ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E, r = 0.329, p = 0.009 and E/A ratio, r = 0.286, p = 0.04; for septal side E, r = 0.376, p = 0.003 and E/A ratio, r = 0.297, p = 0.019; for anterior side E, r = 0.342, p = 0.007 and E/A ratio, r = 0.268, p = 0.035; for posterolateral side E, r = 0.423, p = 0.001 and E/A ratio, r = 0.343, p = 0.007; and for inferior side E, r = 0.326, p = 0.01 and E/A ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.     

Pharmacokinetics of panipenem/betamipron in patients with end-stage renal disease

Panipenem/betamipron (Carbenin), a parenteral carbapenem antibiotic, is used for the treatment of severe and intractable bacterial infections caused by gram-positive and gram-negative bacteria. Because 30% of panipenem and most of the betamipron are excreted in the urine in an unchanged form, renal function is the important determinant of the dosage regimen of panipenem/betamipron. In this study, the pharmacokinetics of panipenem/betamipron were investigated in patients with end-stage renal disease (ESRD) undergoing hemodialysis treatment to establish an appropriate dose regimen. We further attempted to predict the in vivo clearance in patients undergoing hemodialysis based on the in vitro dializability. The pharmacokinetics of panipenem/betamipron were investigated in eight patients after a 1-h intravenous infusion of panipenem/betamipron (500mg/500mg). The in vitro extraction ratios of panipenem/betamipron through a high-flux dialyzer were obtained, and compared with those obtained in vivo. The clearances of panipenem in patients were 9.53 ± 1.26l/h with hemodialysis, and 2.92 ± 0.238l/h without hemodialysis. In contrast, those of betamipron were 4.18 ± 0.643l/h and 0.615 ± 0.511l/h, respectively. The clearance of panipenem with hemodialysis were predicted well from in vitro extraction ratios, while that of betamipron was overestimated about 1.4-fold, probably due to high plasma protein binding and the binding difference between patients and healthy subjects. After comparing the pharmacokinetic behavior of panipenem in patients with ESRD and that of a surrogate marker of efficacy, we recommend that these patients be treated with 500mg/500mg of panipenem/betamipron once daily, which gives a similar clinical result in a patient with normal renal function.     

MDMA induced hyperthermia: Report of a fatality and review of current therapy

Ingestion of 3,4-methylene dioxymethamphetamine (MDMA), commonly known as Ecstasy, can produce toxicity that is characterised by hyperthermia, coagulopathy, rhabdomyolysis and renal failure. We report a fatality associated with MDMA ingestion and briefly review the current literature on MDMA-induced hyperthermia.