Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock

Objective Central venous oxygen saturation (ScvO₂) in initial resuscitation is included in the Surviving Sepsis Campaign guidelines. ScvO₂ monitoring has also been suggested to be comparable to mixed venous oxygen saturation (SvO₂) for clinical purposes. The aim of our study was to assess the correlation and agreement of ScvO₂ and SvO₂ and compare ScvO₂–SvO₂ difference to lactate, oxygen-derived and hemodynamic parameters in early septic shock in ICU after initial resuscitation.Design and setting Prospective clinical study with 16 patients with septic shock at two university hospital ICUs. A dose of norepinephrine over 0.1 μg/kg/min was required for inclusion.Measurements and results Five paired ScvO₂ and SvO₂ samples at 6-h intervals, altogether 72 samples, were collected during 24 h. The mean SvO₂ was below the mean ScvO₂ at all time points. Bias of difference was 4.2% and 95% limits of agreement ranged from –8.1% to 16.5%. The difference correlated significantly to CI and DO₂.Conclusions The difference between paired ScvO₂ and SvO₂ varies highly. Therefore, SvO₂ may not be estimated on the basis of ScvO₂ in treatment of septic shock after resuscitation period in ICU.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Racial/ethnic differences in FIM scores and length of stay for underinsured patients undergoing stroke inpatient rehabilitation

OBJECTIVE: To explore racial/ethnic differences in FIM data from admission to discharge in underinsured patients undergoing inpatient stroke rehabilitation. DESIGN: This is a retrospective analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database of an inpatient rehabilitation unit of a county hospital in a large urban city. Data included 171 adult patients admitted to the stroke rehabilitation unit between January 2000 and October 2003. Main outcome measures included admission and discharge total FIM score, FIM gain, FIM efficiency, and length of stay (LOS). Data were analyzed using chi analyses, t tests, univariate analysis of variance, binary logistic regression, and hierarchical multiple regression. RESULTS: Data from 68 Hispanic, 83 black, and 20 white patients were included in the study. Univariate tests revealed that race/ethnicity groups differed significantly on admission FIM score (F=5.38, P<0.005), FIM gain (F=4.35, P<0.014), and FIM efficiency (F=3.42, P<0.035). Post hoc pairwise comparisons revealed that Hispanics had lower admission FIM scores than blacks (58.9 vs. 68.9). However, Hispanics had higher FIM gain scores than blacks (26.8 vs. 21.5). Race/ethnicity was not significantly related to age, gender, side of stroke, type of stroke, time from onset of stroke to rehabilitation admission, discharge FIM score, or LOS. Multiple regression analyses revealed that after controlling for all other available factors, race/ethnicity accounted for a significant amount of additional variance in admission FIM score (5.8%) and FIM efficiency (4.6%), but not in discharge FIM score, FIM gain, or LOS. Race/ethnicity was not predictive of discharge disposition. CONCLUSIONS: Differences in functional independence at admission to poststroke rehabilitation and the average daily improvement in function are related, in part, to patients' race/ethnicity. Differences in change in functional independence from admission to discharge (FIM gain) are not related to race/ethnicity once other factors, particularly admission FIM score, are taken into account. Future studies should identify reasons why Hispanics have lower admission FIM scores because demographic and stroke-related variables were not related to ethnicity yet have outcomes similar to blacks and whites at discharge.     

Inflammatory and Cytotoxic Potential of the Airborne Particle Material Assessed by Nasal Lavage and Cell Exposure Methods

Exposure to bioaerosols in moisture-damaged indoor environments has been shown to be a potential health risk. The aim of the present study was to evaluate the inflammatory and cytotoxic potential of airborne particle material using both the nasal lavage (NAL) method and a cell exposure study. A 24-h sample collection for airborne particles was performed using personal sampling and microenvironmental measurements in homes and an 8-h sample collection in the working places of the studied subjects. At the end of the sampling period, the production of nitric oxide, tumor necrosis factorα, interleukin (IL)-1β, IL-4, and IL-6 was analyzed in the NAL samples of the subjects. The same mediators, excluding IL-4, were measured in the cell culture medium of mouse RAW264.7 macrophages, which were exposed to the pooled filter extracts representing personal, home, and workplace exposure of each individual during the 24 h before the NAL. Samplings were repeated after 2 wk. The subjects were divided into groups of "low exposure" and "high exposure" according to the concentrations of viable fungi, viable bacteria, or total microbial amount in the pooled extract. Cytokine levels in the NAL samples of subjects with high microbial exposure were slightly increased compared to the corresponding values of the subjects with low exposure. Filter samples collected from the subjects with high microbial exposure induced a significant increase in the production of cytokines in the RAW264.7 macrophages, as compared to those from the subjects with low exposure. The within-subject variation was low in all of the cytokine measurements, but the correlation between the studied methods was poor. In conclusion, both of the methods discriminate at the group level between subjects with high and low microbial exposure. Sampling of airborne particle material and exposure of the mammalian cells to the obtained samples seems to be highly applicable in the environmental monitoring, whereas examination of the exposed subjects directly, for example by using the NAL method, is essential when association between exposure and health effects is evaluated.     

An integrative systematic review of interprofessional education on diabetes

ABSTRACT

Interprofessional education (IPE) aims at enhancing the ability of healthcare professionals from different disciplines to work together effectively, improving the quality of patient care. An interprofessional approach is essential in diabetes management, but there is only limited evidence of the effects of diabetes-specific IPE. The aim of this integrative review is to gather all relevant recent data on the outcomes of IPE on diabetes management. The search in the CINAHL, Medline and PsycINFO databases resulted in 1136 potential studies. An inductive content analysis was used to synthesize the key findings of the 14 studies found to fulfill the inclusion criteria of the systematic review. Two main categories and four subcategories of findings were identified. Firstly, the achieved outcomes included individual gain (e.g., learner´s confidence and motivation to treat patients with diabetes) and external benefits (e.g., benefits for the patient). Secondly, the experiences of IPE included both challenges (e.g., competing interests of different professions) and strengths (e.g., practical approach to diabetes management). In conclusion, the findings indicate that both learners and patients with diabetes benefit from IPE on diabetes management. Educators are encouraged to adopt practical IP approaches in diabetes education. However, it is necessary to estimate the resources available. More research is needed on the cost-effectiveness, long-term effects, and patient perspective of IPE on diabetes management.     

High indoor microbial levels are associated with reduced Th1 cytokine secretion capacity in infancy

Background: Exposure to microbes and their components may affect the maturation of the immune system. We examined the association of house dust microbial content with cytokine-producing capacity at birth and at the age of 1 year. Methods: Production of TNF-α, IFN-γ, IL-5, IL-8 and IL-10 at birth (n = 228) and at the age of 1 year (n = 200) following 24- and 48-hour whole-blood stimulation with staphylococcal enterotoxin B (SEB), lipopolysaccharide and the combination of phorbol ester and ionomycin was measured. Concentrations of ergosterol (marker for fungal biomass), muramic acid (marker for Gram-positive bacteria) and 3-hydroxy fatty acids with a carbon chain length from 10 to 14 (marker for Gram-negative bacteria) in living room floor dust were analyzed using gas chromatography-tandem mass spectrometry. Five single microbial species or groups were determined using a quantitative polymerase chain reaction method. Results: A high total level of the studied Gram-positive bacteria in general or Mycobacterium spp. in house dust was associated with decreased SEB-stimulated IFN-γ production, especially at the age of 1 year. The total level of indoor fungi analyzed (Penicillium spp., Aspergillus spp. and Paecilomyces variotii group, Trichoderma viride/atroviride/koningii,Wallemia sebi) was also inversely associated with IFN-γ production at the age of 1 year, but this association did not remain significant after adjustment for potential confounders. A few associations were found between microbial exposures and other measured cytokines. Conclusions: High indoor microbial exposures may affect immune development in early life by reducing T helper type 1 cytokine secretion capacity. The observed hyporesponsiveness may reflect the adaptation of the immune system to environmental antigens. In future, more attention should be paid especially to the immunomodulatory role of exposures to Gram-positive bacteria.