Using procalcitonin to guide antimicrobial duration in sepsis: asking the same questions will not bring different answers

In the previous issue of Critical Care, Dr Bellomo and colleagues reported an observational study of the relationship between nutritional intake and survival in the RENAL randomized controlled trial. In summary, the total energy intake in a very large and severely ill patient population was low. Higher average daily caloric energy intake was not associated with improved survival. The study illustrates the complexity of the interaction between disease and nutrition.     

Socioeconomic status and birth weight: comparison of an area-based measure with the Registrar General's social class

OBJECTIVE: To compare the relation of birth weight with socioeconomic status measured by an area-based measure of material deprivation and by the Registrar General's social class. SETTING: West Midlands Health Region 1991-93. STUDY DESIGN: Retrospective cohort study. METHOD: Birthweight data by enumeration district deciles ranked by Townsend Deprivation Index based on 1991 census data for all live births in the West Midlands Health Region were studied in three consecutive whole year birth cohorts, 1991 to 1993 and by Registrar General's social class in a 10% sample of live births (within marriage and jointly registered, provided by the Office of National Statistics) in the same region for the same period. Estimated proportions of births < 2500 g and < 3500 g "attributable" to social inequalities were compared for both socioeconomic status measures. The proportion of infants in each birthweight group were calculated for both measures. Relative risk (95% confidence intervals) of birth in each birthweight group for lowest versus highest socioeconomic status groups were calculated. RESULTS: The estimated proportions of births < 2500 g "attributable" to social inequalities were 30% using the area-based measure and 27% using the Registrar General's social class. For births < 3500 g, the estimated proportions were 12% for the area-based measure and 7% for social class. There was a positive linear relation between the proportion of babies weighing > or = 3500 g and increasing socio-economic status measured by either method. Gradients in the opposite direction were noted for the proportion of babies born in the other birth weight groups. Relative risk of birth weight < 3500 g was 1.30 (95% CIs 1.28, 1.32) for most versus least deprived decile and 1.17 (95% CIs 1.10, 1.25) for social class V versus I. For birth weight < 2500 g the risks were 1.99 (95% CIs 1.85, 2.18) and 2.04 (95% CIs 1.53, 2.73) respectively and for birth weight < 1500 g, 2.11 (95% CIs 1.73, 2.57) for most versus least deprived decile (numbers too small for analysis in the Office of National Statistics sample). CONCLUSION: A substantial proportion of births < 2500 g and < 1500 g are statistically "attributable" to social inequality. The results demonstrate that, using either socioeconomic measure, the likelihood of being born weighing > or = 3500 g, the most advantageous group, is substantially greater in the socially advantaged. Using the area-based measure, an estimated 12% of births < 3500 g could be ascribed to social inequalities whereas the same figure using social class was 7%. These findings suggest that this proxy measure of socioeconomic status may be a better discriminator in the study of pregnancy outcomes in this population than classification by occupational social class. Another advantage is its almost universal availability in routine records and its universal population coverage.     

Percutaneous transhepatic choledochoenterostomy in a patient with a biliary obstruction

A needle guide was used to create a fistula from an obstructed common bile duct to the duodenum in a patient with a large tumor of the head of the pancreas. The tortuosity and severity of the stricture prevented the use of routine guide wire passage. A 5-F hyperalimentation catheter was also placed, in addition to the biliary drainage stent.     

Management of pelvic ring fractures in limited resources country: a retrospective study

Purpose

Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country.

Methods

We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient’s management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score.

Results

From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score.

Conclusion

The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment.

     

Endocannabinoids and pregnancy

Acylethanolamides such as anandamide (AEA), and monoacylglycerols like 2-arachidonoylglycerol are endocannabinoids that bind to cannabinoid, vanilloid and peroxisome proliferator-activated receptors. These compounds, their various receptors, the purported membrane transporter(s), and related enzymes that synthesize and degrade them are collectively referred to as the “endocannabinoid system (ECS)”. Poorly defined cellular and molecular mechanisms control the biological actions of the ECS. Over the last decade evidence has been emerging to suggest that the ECS plays a significant role in various aspects of human reproduction. In this review, we summarize our current understanding of this role especially the involvement of AEA and related ECS elements in regulating oogenesis, embryo oviductal transport, blastocyst implantation, placental development and pregnancy outcomes, and sperm survival, motility, capacitation and acrosome reaction. Additionally, the possibility that plasma and tissue AEA and other cannabinoids may represent reliable diagnostic markers of natural and assisted reproduction and pregnancy outcomes in women will be discussed.