Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury

Purpose

Assess the relationship between optic nerve sheath diameter (ONSD) measured on bedside portable computed tomography (CT) scans and simultaneously measured intracranial pressure (ICP) in patients with severe traumatic brain injury.

Methods

Retrospective cohort study of 57 patients admitted between 2009 and 2013. Linear and logistic regression were used to model the correlation and discrimination between ONSD and ICP or intracranial hypertension, respectively.

Results

The cohort had a mean age of 40 years (SD 16) and a median admission Glasgow coma score of 7 (IQR 4–10). The between-rater agreement by intraclass coefficient was 0.89 (95 % CI 0.83–0.93, P < 0.001). The mean ONSD was 6.7 mm (SD 0.75) and the mean ICP during CT was 21.3 mmHg (SD 8.4). Using linear regression, there was a strong correlation between ICP and ONSD (r = 0.74, P < 0.001). ONSD had an area under the curve to discriminate elevated ICP (≥20 mmHg vs. <20 mmHg) of 0.83 (95 % CI 0.73–0.94). Using a cutoff of 6.0 mm, ONSD had a sensitivity of 97 %, specificity of 42 %, positive predictive value of 67 %, and a negative predictive value of 92 %. Comparing linear regression models, ONSD was a much stronger predictor of ICP (R ² of 0.56) compared to other CT features (R ² of 0.21).

Conclusions

Simultaneous measurement of ONSD on CT and ICP were strongly correlated and ONSD was discriminative for intracranial hypertension. ONSD was much more predictive of ICP than other CT features. There was excellent agreement between raters in measuring ONSD.     

Sonographic diameter of optic nerve sheath in differentiation of ischemic and hemorrhagic strokes; a diagnostic accuracy study

Introduction

Differentiating between ischemic and hemorrhagic types is of special importance in the treatment process of patients with stroke. The present study was designed with the aim of evaluating the diagnostic accuracy of ultrasonographic optic nerve sheath diameter (ONSD) in differentiation of ischemic from hemorrhagic stroke.

Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure

Background

The safety of fiberoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure has not been extensively evaluated. We aimed to measure the incidence of intubation and the need to increase ventilatory support following FOB and to identify predictive factors for this event.

Methods

A prospective multicenter observational study was carried out in eight French adult intensive care units. The study included 169 FOB performed in patients with a PaO₂/FiO₂ ratio ??300. The main end-point was intubation rate. The secondary end-point was rate of increased ventilatory support defined as an increase in oxygen requirement >50?%, the need to start noninvasive positive pressure ventilation (NI-PPV) or increase NI-PPV support.

Results

Within 24?h, an increase in ventilatory support was required following 59 bronchoscopies (35?%), of which 25 (15?%) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD; OR 5.2, 95?% CI 1.6?C17.8; p?=?0.007) or immunosuppression (OR 5.4, 95?% CI 1.7?C17.2; p?=?0.004] were significantly associated with the need for intubation in the multivariable analysis. None of the baseline physiological parameters including the PaO₂/FiO₂ ratio was associated with intubation.

Conclusions

Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD and immunosuppression are associated with the need for invasive ventilation in the 24?h following bronchoscopy.     

Mottling score predicts survival in septic shock

Background

Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock.

Methods

We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa?=?0.87, 95% CI (0.72?C0.97)].

Results

Sixty patients were included. The SOFA score was 11.5 (8.5?C14.5), SAPS II was 59 (45?C71) and the 14-day mortality rate 45% [95% CI (33?C58)]. Six?hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p?=?0.001], arterial lactate level [<1.5 OR 1; between 1.5 and 3 OR 3.8 (0.7?C29.5); >3 OR 9.6 (2.1?C70.6), p?=?0.01] and mottling score [score 0?C1 OR 1; score 2?C3 OR 16, 95% CI (4?C81); score 4?C5 OR 74, 95% CI (11?C1,568), p?<?0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred (p?<?0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p?=?0.0005).

Conclusion

The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.     

Long-term clinical outcomes following sirolimus-eluting stent implantation in patients with acute myocardial infarction. A meta-analysis of randomized trials

Objectives

The aim of this study was to perform a meta-analysis of randomized trials, evaluating the long-term outcomes of sirolimus-eluting stents (SES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI).

Background

Despite short-term outcomes of patients with STEMI undergoing primary percutaneous coronary intervention indicate a benefit of SES in terms of reintervention, several concerns remain on the long-term safety and efficacy of SES.

Methods

A systematic literature search of electronic resources, through October 2011, was performed using specific search terms. Included trials were randomized studies comparing SES to BMS in STEMI patients, with a follow-up ≥3?years.

Results

Seven trials were included, with a total of 2,364 patients. At a median follow-up of 3?years, SES significantly reduced the risk of target-vessel revascularization when compared with BMS [odds ratio (OR), 0.44; 95?% confidence interval (CI), 0.34–0.57; p?<?0.0001], without increasing the risk of mortality (OR 0.78; 95?% CI, 0.57–1.08; p?=?0.14), reinfarction (OR 0.91; 95?% CI, 0.61–1.35, p?=?0.64) and early to late stent thrombosis (OR 0.77; 95?% CI, 0.49–1.20; p?=?0.25). However after the first year, SES did not further reduce target-vessel revascularization (OR 1.06; 95?% CI, 0.64–1.74; p?=?0.83) and increased the risk of very late stent thrombosis (OR 2.81; 95?% CI, 1.33–5.92; p?=?0.007).

Conclusions

At long-term follow-up, SES compared to BMS use in STEMI patients reduces the risk of target-vessel revascularization, without increasing the risk of death and reinfarction. However, the strong SES efficacy is counterbalanced by a significant risk of very late stent thrombosis.     

Impact of hypoxic hepatitis on mortality in the intensive care unit

Purpose

Hypoxic hepatitis (HH) is a form of hepatic injury following arterial hypoxemia, ischemia, and passive congestion of the liver. We investigated the incidence and the prognostic implications of HH in the medical intensive care unit (ICU).

Methods

A total of 1,066 consecutive ICU admissions at three medical ICUs of a university hospital were included in this prospective cohort study. All patients were screened prospectively for the presence of HH according to established criteria. Independent risk factors of mortality in this cohort of critically ill patients were identified by a multivariate Poisson regression model.

Results

A total of 118 admissions (11%) had HH during their ICU stay. These patients had different baseline characteristics, longer median ICU stay (8 vs. 6?days, p?p?p?p?p?=?0.359).

Conclusions

Hypoxic hepatitis (HH) occurs frequently in the medical ICU. The presence of HH is a strong risk factor for mortality in the ICU in patients requiring vasopressor therapy.     

Accuracy of plethysmographic indices as predictors of fluid responsiveness in mechanically ventilated adults: a systematic review and meta-analysis

Purpose

To systematically review the accuracy of the variation in pulse oxymetry plethysmographic waveform amplitude (?POP) and the Pleth Variability Index (PVI) as predictors of fluid responsiveness in mechanically ventilated adults.

Methods

MEDLINE, Scopus and the Cochrane Database of Systematic Reviews were screened for clinical studies in which the accuracy of ?POP/PVI in predicting the hemodynamic response to a subsequent fluid bolus had been investigated. Random-effects meta-analysis was used to summarize the results. Data were stratified according to the amount of fluid bolus (large vs. small) and to the study index (?POP vs. PVI).

Results

Ten studies in 233 patients were included in this meta-analysis. All patients were in normal sinus rhythm. The pooled area under the receiver operating characteristic curve (AUC) for identification of fluid responders was 0.85 [95?% confidence interval (CI) 0.79–0.92]. Pooled sensitivity and specificity were 0.80 (95 % CI 0.74–0.85) and 0.76 (0.68–0.82), respectively. No heterogeneity was found within studies with the same amount of fluid bolus, nor between studies on ?POP and those on PVI. The AUC was significantly larger in studies with a large bolus amount than in those with a small bolus [0.92 (95 % CI 0.87–0.96) vs. 0.70 (0.62–0.79); p?p?=?0.08 and 0.86 (95 % CI 0.75–0.93) vs. 0.68 (0.56–0.77) (small bolus), p?=?0.02], respectively.

Conclusions

Based on our meta-analysis, we conclude that ?POP and PVI are equally effective for predicting fluid responsiveness in ventilated adult patients in sinus rhythm. Prediction is more accurate when a large fluid bolus is administered.     

Contrast-enhanced ultrasonography with Sonazoid? for the evaluation of bowel ischemia

Purpose

To determine the usefulness of contrast-enhanced ultrasonography with the contrast agent Sonazoid? for the detection of bowel ischemia.

Methods

From March 2007 to February 2009, 65 patients (35 men and 30 women, mean age 70.4?±?16.1?years) were enrolled. Fifty-three patients complained of acute abdominal pain with small bowel dilatation (n?=?40) or reduced bowel peristalsis (n?=?13). Twelve patients were clinically suspected of having bowel ischemia. After Sonazoid? injection, bowel segments were scanned using harmonic imaging, and the signal intensities were classified as normal or diminished. The definitive diagnosis was confirmed by surgery in 30 patients, autopsy in 6, endoscopy in 3, angiography in 1, and clinical follow-up in 25.

Results

All 50 patients with normal signal intensities were confirmed not to have bowel ischemia. In the 15 patients with diminished signal intensities, 14 patients were confirmed to have bowel ischemia, resulting in an overall sensitivity of 100% [95% confidence interval (CI) 80.7–100%], a specificity of 98% [95% CI 89.5–99.9%], a positive predictive value of 93% (95% CI 68.1–99.8%), and a negative predictive value of 100% (95% CI 94.1–100%).

Conclusion

Contrast-enhanced ultrasonography with Sonazoid? is a highly sensitive and specific method for the diagnosis of bowel ischemia.     

Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department

Purpose

We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department.

Methods

We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case.

Results

Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen’s k = 0.710 (95 % CI, 0.614–0.806), p < 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932–1.000), p < 0.0001 and Ra = 0.978.

Conclusions

Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.     

Sickle cell disease,sickle trait and the risk for venous thromboembolism: a systematic review and meta-analysis

Background

Globally, sickle cell disease (SCD) is one of the most common haemoglobinopathy. Considered a public health problem, it leads to vessel occlusion, blood stasis and chronic activation of the coagulation system responsible for vaso-occlussive crises and venous thromboembolism (VTE) which may be fatal. Although contemporary observational studies suggest a relationship between SCD or sickle trait (SCT) and VTE, there is lack of a summary or meta-analysis data on this possible correlation. Hence, we propose to summarize the available evidence on the association between SCD, SCT and VTE including deep vein thrombosis (DVT) and pulmonary embolism (PE).

Methods

We searched PubMed and Scopus to identify all cross-sectional, cohort and case-control studies reporting on the association between SCD or SCT and VTE, DVT or PE in adults or children from inception to April 25, 2017. For measuring association between SCD or SCT and VTE, DVT, or PE, a meta-analysis using the random-effects method was performed to pool weighted odds ratios (OR) of risk estimates.

Results

From 313 records initially identified from bibliographic databases, 10 studies were eligible and therefore included the meta-analysis. SCD patients had significantly higher risk for VTE (pooled OR 4.4, 95%CI 2.6–7.5, p?<?0.001), DVT (OR 1.1, 95% CI 1.1–1.2, p?<?0.001) and PE (pooled OR 3.7, 95% CI 3.6–3.8, p?<?0.001) as compared to non SCD-adults. A higher risk of VTE (OR 33.2, 95% CI 9.7–113.4, p?<?0.001) and DVT (OR 30.7, 95% CI 1.6–578.2, p =?0.02) was found in pregnant or postpartum women with SCD as compared to their counterparts without SCD. Compared to adults with SCT, the risk of VTE was higher in adults with SCD (pooled OR 3.1, 95% CI 1.8–5.3, p?<?0.001), and specifically in SCD pregnant or postpartum women (OR 20.3, 95% CI 4.1–102, p?=?0.0003). The risk of PE was also higher in adults with SCD (OR 3.1, 95% CCI 1.7–5.9, p?=?0.0004) as compared to those with SCT. The risk of VTE was higher in individuals with SCT compared to controls (pooled OR 1.7, 95% CI 1.3–2.2, p?<?0.0001), but not in pregnant or postpartum women (OR 0.9, 95% CI 0.3–2.9, p?=?0.863). Compared to controls, SCT was associated with a higher risk of PE (pooled OR 2.1, 95% CI 1.2–3.8, p?=?0.012) but not of DVT (pooled OR 1.2, 95% CI 0.9–1.7, p?=?0.157).

Conclusion

Individuals with SCD, especially pregnant or postpartum women, might have a higher risk of VTE compared to the general population. SCT might also increases the risk of VTE. However, currently available data are not sufficient to allow a definite conclusion. Further larger studies are needed to provide a definitive conclusion on the association between SCD, SCT and VTE.

     

Placeboresponder in randomisierten, kontrollierten Medikamentenstudien des Fibromyalgiesyndroms

Background

The superiority of true drug treatment over placebo in reducing symptoms of fibromyalgia syndrome (FMS) is small. Drug placebo treatment of functional somatic syndromes (FSS) such as FMS has been discussed. We determined the magnitude of placebo responders in drug trials with FMS patients to substantiate further research on placebo treatment of FSS.

Material and methods

CENTRAL, MEDLINE, Scopus, and the databases of the U.S. National Institutes of Health and the Pharmaceutical Research and Manufacturers of America were searched for randomized, double-blind, placebo-controlled trials with a parallel design and treatment duration of ???12?weeks in FMS patients from inception to 31?December?2010. The magnitude of placebo responders was assessed by the pooled estimate of patients with a 30% and 50% reduction in pain.

Results

Thirty studies with 3,846?patients on placebo were included. The pooled estimate of a 30% placebo pain reduction was 30.8% (95% confidence interval (CI) 29.4?C32.3%) and of a 50% placebo pain reduction was 18.8% (95% CI 17.5?C20.1%). The pooled estimate of the risk ratio of 30% pain reduction by true drug versus placebo was 1.38 (95% CI 1.27?C1.49). The pooled estimate of the risk ratio of 50% pain reduction by true drug versus placebo response was 1.57 (95% CI 1.36?C1.81).

Conclusion

The magnitude of responders to placebo in drug trials of FMS is substantial. The efficacy, safety, and costs of drugs recommended for FMS therapy and open-label placebo should be compared in large multinational trials sponsored by public institutions. The English full-text version of this article is available at SpringerLink (under ??Supplemental??).     

Variants at the promoter of the interleukin-6 gene are associated with severity and outcome of pneumococcal community-acquired pneumonia

Purpose

Conflicting results about the role of genetic variability at IL6, particularly the -174 G/C single nucleotide polymorphism (SNP), in sepsis have been reported. We studied the genetic variability at IL6 in patients with community-acquired pneumonia (CAP) and pneumococcal CAP (P-CAP).

Methods

This was a multicenter, prospective observational study. IL6 -174 was analyzed in 1,227 white Spanish patients with CAP (306 with P-CAP). IL6 1753 C/G (N?=?750), 2954 G/C (N?=?845), and haplotypes defined by these SNPs were also studied.

Results

In CAP patients the genotype -174 GG were associated with protection against acute respiratory distress syndrome (ARDS) (p?=?0.008, OR?=?0.4, 95% CI 0.2?C0.8). No other significant associations were observed. However, in patients with P-CAP multivariate analysis adjusted for age, gender, co-morbidity, hospital of origin, and severity (pneumonia severity index, PSI) showed that the IL6 -174 GG genotype was protective against the development of ARDS (p?=?0.002, OR?=?0.25, 95% CI 0.07?C0.79), septic shock (p?=?0.006, OR?=?0.46, 95% CI 0.18?C0.79), and multiple organ dysfunction syndrome (p?=?0.02, OR?=?0.53, 95% CI 0.27?C0.89). P-CAP patients homozygous for IL6 -174 G also showed a higher survival in a logistic regression analysis adjusted for age, gender, co-morbidity, hospital of origin, and PSI (p?=?0.048, OR?=?0.27, 95% CI 0.07?C0.98).

Conclusions

Our results indicate that the IL-6 -174 GG genotype is associated with lower severity and mortality in patients with P-CAP. This effect was higher than that observed in patients with CAP irrespective of the causal pathogen involved. Our results highlight the importance of the causal pathogen in genetic epidemiological studies in sepsis.     

Central venous-arterial pCO2 difference as a tool in resuscitation of septic patients

Purpose

To investigate the interchangeability of mixed and central venous-arterial carbon dioxide differences and the relation between the central difference (pCO₂ gap) and cardiac index (CI). We also investigated the value of the pCO₂ gap in outcome prediction.

Methods

We performed a post hoc analysis of a well-defined population of 53 patients with severe sepsis or septic shock. Mixed and central venous pCO₂ were determined earlier at a 6 h interval (T = 0 to T = 4) during the first 24 h after intensive care unit (ICU) admittance. The population was divided into two groups based on pCO₂ gap (cut off value 0.8 kPa).

Results

The mixed pCO₂ difference underestimated the central pCO₂ difference by a mean bias of 0.03± 0.32 kPa (95 % limits of agreement: ?0.62–0.58 kPa). We observed a weak relation between pCO₂ gap and CI. The in hospital mortality rate was 21 % (6/29) for the low gap group and 29 % (7/24) for the high gap group; the odds ratio was 1.6 (95 % CI 0.5–5.5), p = 0.53. At T = 4 the odds ratio was 5.3 (95 % CI 0.9–30.7); p = 0.08.

Conclusions

From a practical perspective, the clinical utility of central venous pCO₂ values is of potential interest in determining the venous-arterial pCO₂ difference. The likelihood of a bad outcome seems to be enhanced when a high pCO₂ gap persists after 24 h of therapy.     

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza?A infection

Introduction

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza?A infection, although relatively common, remains controversial.

Methods

Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry.

Results

Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p?p?p?=?0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0?C4.8, p?Conclusions Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza?A infection did not result in better outcomes and was associated with increased risk of superinfections.     

Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

Purpose

To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA.

Methods

Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires.

Results

Nine hundred patients received a CTPA during 3?years. For 328 CTPAs performed during the 1-year study period, 140 (43?%) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93?%), elevated D-dimers (66?%), fear of missing PE (55?%), and Wells/simplified revised Geneva score (53?%). A positive answer for “fear of missing PE” was inversely associated with positive CTPA (OR 0.36, 95?% CI 0.14–0.92, p?=?0.033), and “Wells/simplified revised Geneva score” was associated with positive CTPA (OR 3.28, 95?% CI 1.24–8.68, p?=?0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5?%, OR 2.12, 95?% CI 1.36–3.29, p?p?=?0.067).

Conclusion

Reasons for CTPA reflecting defensive behavior—such as “fear of missing PE”—were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines.     

End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test

Purpose

In stable ventilatory and metabolic conditions, changes in end-tidal carbon dioxide (EtCO₂) might reflect changes in cardiac index (CI). We tested whether EtCO₂ detects changes in CI induced by volume expansion and whether changes in EtCO₂ during passive leg raising (PLR) predict fluid responsiveness. We compared EtCO₂ and arterial pulse pressure for this purpose.

Methods

We included 65 patients [Simplified Acute Physiology Score (SAPS)?II?=?57?±?19, 37 males, under mechanical ventilation without spontaneous breathing, 15?% with chronic obstructive pulmonary disease, baseline CI?=?2.9?±?1.1?L/min/m²] in whom a fluid challenge was decided due to circulatory failure and who were monitored by an expiratory-CO₂ sensor and a PiCCO2 device. In all patients, we measured arterial pressure, EtCO₂, and CI before and after a fluid challenge. In 40 patients, PLR was performed before fluid administration. The PLR-induced changes in arterial pressure, EtCO₂, and CI were recorded.

Results

Considering the whole population, the fluid-induced changes in EtCO₂ and CI were correlated (r ²?=?0.45, p?=?0.0001). Considering the 40 patients in whom PLR was performed, volume expansion increased CI ??15?% in 21 ??volume responders.?? A PLR-induced increase in EtCO₂ ??5?% predicted a fluid-induced increase in CI ??15?% with sensitivity of 71?% (95?% confidence interval: 48?C89?%) and specificity of 100 (82?C100)?%. The prediction ability of the PLR-induced changes in CI was not different. The area under the receiver-operating characteristic (ROC) curve for the PLR-induced changes in pulse pressure was not significantly different from 0.5.

Conclusion

The changes in EtCO₂ induced by a PLR test predicted fluid responsiveness with reliability, while the changes in arterial pulse pressure did not.     

Prevalence and risk factors for insomnia among breast cancer patients on aromatase inhibitors

Purpose

Insomnia is increasingly recognized as a major symptom outcome in breast cancer; however, little is known about its prevalence and risk factors among women receiving aromatase inhibitors (AIs), a standard treatment to increase disease-free survival among breast cancer patients.

Methods

A cross-sectional survey study was conducted among postmenopausal women with stage 0?CIII breast cancer receiving adjuvant AI therapy at an outpatient breast oncology clinic of a large university hospital. The insomnia severity index (ISI) was used as the primary outcome. Multivariate logistic regression analyses were performed to evaluate risk factors.

Results

Among 413 participants, 130 (31.5?%) had subthreshold insomnia on the ISI, and 77 (18.64?%) exceeded the threshold for clinically significant insomnia. In a multivariate logistic regression model, clinically significant insomnia was independently associated with severe joint pain (adjusted odds ratio (AOR) 4.84, 95?% confidence interval (CI) 1.71?C13.69, P?=?0.003), mild/moderate hot flashes (AOR 2.28, 95?% CI 1.13?C4.60, P?=?0.02), severe hot flashes (AOR 2.29, 95?% CI 1.23?C6.81, P?=?0.015), anxiety (AOR 1.99, 95?% CI 1.08?C3.65, P?=?0.027), and depression (AOR 3.57, 95?% CI 1.48?C8.52, P?=?0.004). Age (>65 vs. <55?years; AOR 2.31; 95?% CI 1.11?C4.81; P?=?0.026) and time since breast cancer diagnosis (<2 vs. 2?C5?years; AOR 1.94; 95?% CI 1.02?C3.69; P?=?0.045) were also found to be significant risk factors. Clinical insomnia was more common among those who used medication for treating insomnia and pain.

Conclusions

Insomnia complaints exceed 50?% among AI users. Clinically significant insomnia is highly associated with joint pain, hot flashes, anxiety and depression, age, and time since diagnosis.     

Onset of Bronchodilation with Fluticasone/Formoterol Combination Versus Fluticasone/Salmeterol in an Open-Label, Randomized Study

Introduction

The inhaled corticosteroid, fluticasone propionate (fluticasone), and the long-acting beta₂-agonist, formoterol fumarate (formoterol), have been combined in a single aerosol inhaler (fluticasone/formoterol). In a randomized, open-label study, fluticasone/formoterol showed similar efficacy to fluticasone/salmeterol after 12 weeks of treatment. This post-hoc analysis compared the onset of bronchodilation with the two treatments.

Methods

Adults with mild-to-moderate-severe persistent asthma were randomized to fluticasone/formoterol (100/10 or 250/10 ??g twice daily [b.i.d.]) or fluticasone/salmeterol (100/50 or 250/50 ??g b.i.d.) for 12 weeks. The onset of bronchodilation (the first post-dose time point at which the forced expiratory volume in 1 second [FEV₁] was ??12% greater than the pre-dose value), responder rates (the proportion of patients achieving bronchodilation), and changes in FEV₁ were assessed at days 0 (baseline) and 84.

Results

Fluticasone/formoterol (n = 101) provided more rapid onset of bronchodilation than fluticasone/salmeterol (n = 101) over the first 120 min post-dose on days 0 (hazard ratio [HR] = 1.47 [95% CI 1.05?C2.05]) and 84 (HR = 1.77 [95% CI 1.14?C2.73]). The odds of a patient achieving bronchodilation within 5 min of dosing were almost four-times higher with fluticasone/formoterol than with fluticasone/salmeterol on day 0 (odds ratio [OR] = 3.97 [95% CI 1.96?C8.03]) and almost 10-times higher on day 84 (OR = 9.58 [95% CI 2.14?C42.90]); the odds of achieving bronchodilation within 120 min post-dose were approximately twofold higher with fluticasone/formoterol on both days. The overall percentage increase in least-squares (LS) mean FEV1 during the 120-min post-dose period was significantly greater with fluticasone/formoterol than fluticasone/salmeterol on days 0 (LS mean treatment difference: 4.70% [95% CI 1.57?C7.83]; P = 0.003) and 84 (2.79% [95% CI 0.65?C4.93]; P = 0.011).

Conclusion

These analyses showed that fluticasone/formoterol provided a faster onset of bronchodilation than fluticasone/salmeterol, which was maintained over 12 weeks of treatment. This benefit may facilitate treatment adherence among patients with asthma.     

Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample

Purpose

Necrotising soft tissue infection (NSTI) is a deadly disease associated with a significant risk of mortality and long-term disability from limb and tissue loss. The aim of this study was to determine the effect of hyperbaric oxygen (HBO₂) therapy on mortality, complication rate, discharge status/location, hospital length of stay and inflation-adjusted hospitalisation cost in patients with NSTI.

Methods

This was a retrospective study of 45,913 patients in the Nationwide Inpatient Sample (NIS) from 1988 to 2009.

Results

A total of 405 patients received HBO₂ therapy. The patients with NSTI who received HBO₂ therapy had a lower mortality (4.5 vs. 9.4 %, p?=?0.001). After adjusting for predictors and confounders, patients who received HBO₂ therapy had a statistically significantly lower risk of dying (odds ratio (OR) 0.49, 95 % confidence interval (CI) 0.29–0.83), higher hospitalisation cost (US$52,205 vs. US$45,464, p?=?0.02) and longer length of stay (LOS) (14.3?days vs. 10.7?days, p?Conclusions This retrospective analysis of HBO₂ therapy in NSTI showed that despite the higher hospitalisation cost and longer length of stay, the statistically significant reduction in mortality supports the use of HBO₂ therapy in NSTI.