Patients' recollections of therapeutic paralysis in the intensive care unit.

BACKGROUND: Neuromuscular blocking agents used for therapeutic purposes, such as facilitating mechanical ventilation and relieving life-threatening agitation, paralyze patients but leave them fully conscious. Aggressive sedation or analgesia is necessary to reduce awareness, relieve fear, produce comfort, decrease anxiety, induce unconsciousness, and minimize possible complications such as posttraumatic stress syndrome. Little information is available on the extent to which patients experience awareness during therapeutic paralysis. OBJECTIVES: To determine and describe the remembered experiences of critical care patients who were given neuromuscular blocking agents and sedatives and/or analgesics to facilitate mechanical ventilation, improve hemodynamic stability, and improve oxygenation. METHODS: A phenomenological approach with in-depth interviews with 11 patients was used. Data were analyzed by using the constant comparative approach. RESULTS: A total of 4 themes and 3 subthemes were identified. The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams. The second theme was loss of control; the 2 subthemes were (1) fighting or being tied down and (2) being scared. The third theme was almost dying, and the fourth theme was feeling cared for. CONCLUSIONS: Patients can remember having both negative and positive experiences during neuromuscular blockade. Steps to improve the experiences of patients receiving neuromuscular blockers include improving assessment parameters, developing and using sedation/analgesia guidelines, and investing in quality improvement programs to provide assessment of awareness during therapeutic paralysis and follow-up and referral as necessary. Ways to decrease the use of neuromuscular blockers would also be useful.     

In vivo and in vitro studies of the site of inhibitory action of omeprazole on adrenocortical steroidogenesis

Summary The site of omeprazole inhibition of adrenal steroidogenesis has been sought in vivo by analyzing the patterns of urinary steroid metabolite excretion after 6 days of treatment with placebo/omeprazole.Excretion rates of androsterone, aetiocholanolone, dehydroepiandrosterone, 11 hydroxyandrosterone, tetrahydrocortisone, tetrahydrocortisol and cortolone were reduced, indicating a block at an early step in steroidogenesis, possibly cholesterol side-chain cleavage. In vitro studies have confirmed this finding by measuring conversion of added precursors to cortisol in isolated bovine adrenocortical cells. Cortisol synthesis from added 20 hydroxycholesterol was inhibited by 83% in the presence of 100 µg omeprazole/ml. Conversion from pregnenolone and progesterone and their 17 hydroxylated derivatives was inhibited by 20–40% whereas cortisol production from added 11 deoxycortisol was not affected.These data suggest that omeprazole primarily inhibits cholesterol cleavage and does not inhibit 3 hydroxysteroid dehydrogenase, 17 hydroxylase or 11 hydroxylation; 21 hydroxylase activity may be marginally attenuated.     

Genetic analysis and attribution of microbial forensics evidence

Because of the availability of pathogenic microorganisms and the relatively low cost of preparing and disseminating bioweapons, there is a continuing threat of biocrime and bioterrorism. Thus, enhanced capabilities are needed that enable the full and robust forensic exploitation and interpretation of microbial evidence from acts of bioterrorism or biocrimes. To respond to the need, greater resources and efforts are being applied to the burgeoning field of microbial forensics. Microbial forensics focuses on the characterization, analysis and interpretation of evidence for attributional purposes from a bioterrorism act, biocrime, hoax or inadvertent agent release. To enhance attribution capabilities, a major component of microbial forensics is the analysis of nucleic acids to associate or eliminate putative samples. The degree that attribution can be addressed depends on the context of the case, the available knowledge of the genetics, phylogeny, and ecology of the target microorganism, and technologies applied. The types of genetic markers and features that can impact statistical inferences of microbial forensic evidence include: single nucleotide polymorphisms, repetitive sequences, insertions and deletions, mobile elements, pathogenicity islands, virulence and resistance genes, house keeping genes, structural genes, whole genome sequences, asexual and sexual reproduction, horizontal gene transfer, conjugation, transduction, lysogeny, gene conversion, recombination, gene duplication, rearrangements, and mutational hotspots. Nucleic acid based typing technologies include: PCR, real-time PCR, MLST, MLVA, whole genome sequencing, and microarrays.     

Functional stability of dorsolateral prefrontal neurons

Stable multiday recordings from the dorsolateral prefrontal cortex of 2 monkeys performing 2 Go/NoGo visual-discrimination tasks (one requiring well-learned responses, the other requiring learning) demonstrate that the majority of prefrontal neurons were "functionally stable". Recordings were made using a series of removable microdrives, each implanted for 3-6 mo, housing independently mobile electrodes. Action potential waveforms of 94 neurons were stable over 2-9 days; 66/94 (70%) of these cells responded each day, 22/94 (23%) never responded significantly, and 6/94 (6%) responded one day but not the next. Of 66 responsive neurons, 55 were selective for either Go or NoGo trials, individual stimuli, or eye movements. This selectivity was functionally stable (i.e., maintained) for 46/55 neurons across all recording days. Functional stability was also noted in terms of response strength (baseline firing rates compared with poststimulation firing rates) and event-related response timing. Two neurons with consistent responses in familiar testing conditions responded flexibly when the monkeys learned to make correct responses to novel stimuli. We conclude that the majority of prefrontal neurons were functionally stable during the performance of well-learned tasks. Such stability may be a general property of prefrontal neurons, given that neurons with 4 different types of task selectivity were found to be functionally stable. Conceptually similar studies based on long-term recordings in other cortical regions reached similar conclusions, suggesting that neurons throughout the brain are functionally stable.     

Use of modified resistogram to type Candida albicans isolated from cases of vaginitis and from faeces in the same geographical area.

Ninety strains of Candida albicans were isolated from vaginal swabs taken by general practitioners from cases of vaginal candidosis. One hundred and nine strains were also isolated from 300 specimens of faeces received from outpatients living in the same geographical area. These strains were typed using a modification of the resistotyping method. We were unable to find any significant differences between the two populations of strains. This suggests that no particular resistotype has an increased ability to cause vaginitis.     

Effect of lymphoid Leukosis virus on performance of layer hens and the identification of infected chickens by tests on Meconia

The effect of subclinical infection with lymphoid leukosis virus (LLV) on the productivity traits of layer hens was investigated. In hens that shed gs-antigen of LLV to albumen, onset of sexual maturity was delayed by a mean of 11 days and the number of eggs laid was reduced -by 68 per hen up to 75 weeks of age. Shedding hens laid on average 2 g lighter eggs and of lesser specific gravity. Thirty-four % less chickens were obtained in the reproduction programmes from LLV-shedders in comparison with non-shedders. LLV had no significant effect on fertility and hatchability. Reduced egg-related performance was only directly related to LLV-shedding and dams' shedding status had no effect on the egg-related performance of their LLV-free progeny. Dams' shedding status, however, correlated with higher mortality (10% higher) among their progeny. The percentage of non-layers was also higher in progeny of LLV-shedders. Meconia were highly suitable samples for identifying both transmitting dams and infected chickens but only if the test for infectious virus was performed. ELISA on meconia was less reliable than the test for virus and therefore is not recommended for the detection of residual of infected chickens in the flocks selected for reduced gs-antigen shedding.     

Concentration and turnover of intraperitoneal hyaluronan during inflammation

Aseptic peritonitis was induced in rabbits by intraperitoneal injection of irritating agents, mainly starch suspensions. The inflammatory response was followed in the peritoneal lavage fluid by cell counts (average increase about 800-fold the first day) and hyaluronan concentration (average increase about 200-fold on the second and third days). The turnover rate of hyaluronan was studied by injecting tritium-labeled hyaluronan intraperitoneally and by following the appearance of tritiated water in serum. In control animals given trace amounts of hyaluronan, half-lives of 1–14 h were recorded. When the labeled polysaccharide had been mixed with 10 mg/ml of unlabeled hyaluronan, the half-life was approximately one day. Rabbits with ongoing peritonitis exhibited half-lives between 1 and 16 h. It was concluded that there was a large individual variation in uptake kinetics, that the removal process could be receptor mediated, and that the increase in intraperitoneal hyaluronan in peritonitis mainly was due to an increased production of the polysaccharide rather than a decreased rate of removal.