Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients

Background:The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients.Methods:An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%.Results:At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial.Conclusion:Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.     

Year in review 2013: Critical Care - metabolism

Novel insights into the metabolic alterations of critical illness, including new findings on association between blood glucose at admission and poor outcome, were published in Critical Care in 2013. The role of diabetic status in the relation of the three domains of glycemic control (hyperglycemia, hypoglycemia, and glycemic variability) was clarified: the association between mean glucose, high glucose variability, and ICU mortality was stronger in the non-diabetic than in diabetic patients. Improvements in the understanding of pathophysiological mechanisms of stress hyperglycemia were presented. Novel developments for the management of glucose control included automated closed-loop algorithms based on subcutaneous glucose measurements and microdialysis techniques. In the field of obesity, some new hypotheses that could explain the ‘obesity paradox’ were released, and a role of adipose tissue in the response to stress was suggested by the time course of adipocyte fatty-acid binding protein concentrations. In the field of nutrition, beneficial immunological effects have been associated with early enteral nutrition. Early enteral nutrition was significantly associated with potential beneficial effects on the phenotype of lymphocytes. Uncertainties regarding the potential benefits of small intestine feeding compared with gastric feeding were further investigated. No significant differences were observed between the nasogastric and nasojejunal feeding groups in the incidence of mortality, tracheal aspiration, or exacerbation of pain. The major risk factors to develop diarrhea in the ICU were described. Finally, the understanding of disorders associated with trauma and potential benefits of blood acidification was improved by new experimental findings.     

Diversity-Oriented Synthesis Yields a New Drug Lead for Treatment of Chagas Disease

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Induced membrane for treatment of critical sized bone defect: a review of experimental and clinical experiences

Purpose

The purpose of this study was to review experimental and clinical experiences about the use of an induced membrane to address critical bone size defect of the limbs.

Methods

From a review of published experimental and clinical data and from our clinical experience, we present the key data about the use of an induced membrane to address critical bone size defect of the limbs.

Results

After reviewing the concept of critical sized bone defect, we present the different indications of an induced membrane, the key points of the surgical technique and the strategy of bone grafting given the indication, localization and importance of the critical sized bone defect. Finally, we discuss the perspective of the use of an induced membrane with various bone substitutes.

Conclusions

The use of an induced membrane to treat critical sized bone defects of the limbs is a simple, reliable and reproducible technique. Certain technical steps should be pointed out and observed with great caution in order to avoid any pitfalls. This technique will probably be a key step for facilitating bone inclusion of new bone substitutes proposed by recent bioengineering.     

Construction of a High Titer Infectious HIV-1 Subtype C Proviral Clone from South Africa

The Human Immunodeficiency Virus type 1 (HIV-1) subtype C is currently the predominant subtype worldwide. Cell culture studies of Sub-Saharan African subtype C proviral plasmids are hampered by the low replication capacity of the resulting viruses, although viral loads in subtype C infected patients are as high as those from patients with subtype B. Here, we describe the sequencing and construction of a new HIV-1 subtype C proviral clone (pZAC), replicating more than one order of magnitude better than the previous subtype C plasmids. We identify the env-region for being the determinant for the higher viral titers and the pZAC Env to be M-tropic. This higher replication capacity does not lead to a higher cytotoxicity compared to previously described subtype C viruses. In addition, the pZAC Vpu is also shown to be able to down-regulate CD4, but fails to fully counteract CD317.     

Lipid peroxidation in all-in-one admixtures for preterm neonates: impact of amount of lipid, type of lipid emulsion and delivery condition

Aim: To evaluate the effect of lipid emulsion composition and delivery condition on lipid peroxidation in typical all‐in‐one parenteral admixtures for preterm neonates. Methods: Malonedialdehyde (MDA) concentrations were assessed in different all‐in‐one admixtures. We evaluated the effects of fat blend (three lipid emulsions) and the amount of lipids, as well as the effects of protecting bags and/or tubing from ambient light and storage for 72 h. MDA was measured by liquid chromatography/mass spectrometry. Results: Three hundred and sixty samples were collected from 114 admixtures. Neither the type of lipid (p = 0.43) nor the interaction between light and type of lipid (p = 0.49) had any influence on final MDA concentrations, but the increase in MDA concentration at 24 h (T₂₄) was related to light exposure (p < 0.001). The increase in MDA concentration was related to the increase in lipid amount in the admixture at T₀ (r = 0.77) and T₂₄ (r = 0.86). MDA concentrations in solutions stored for 72 h showed no significant increase, with no difference between the three lipid emulsions (p = 0.69). Conclusion: All‐in‐one admixtures may be interesting for the parenteral nutrition of preterm neonates. Protection from light and restricting the amount of lipid to what is required for appropriate energy provision are essential to limit lipid peroxidation.     

Pertinence of the self-report mother-to-infant bonding scale in the neonatal unit of a maternity ward

Objective

To assess the relevance of the self-report Mother-to-Infant Bonding Scale (MIBS) to evaluate mother-infant bonding in the neonatal unit of a maternity ward.

Material and methods

Forty-eight hours after delivery, 78 mothers responded to the MIBS, the Edinburgh Postnatal Depression Scale (EPDS), the Adult Attachment Questionnaire (AAQ), and the Mother's Assessment of the Behavior of her Infant (MABI) questionnaire. They were then interviewed 24 h later by a pediatric psychiatrist, who assessed the mother-infant relationship. The neonatology nurses also filled out the MIBS, imagining the mothers' responses, and responded anonymously to questionnaires on the use of the MIBS in their daily practice.

Results

MIBS satisfactorily detected difficulties in mother-child bonding: the area under the ROC curve was 0.93, with a sensitivity of 0.9 and a specificity of 0.8 for a threshold score ≥ 2. MIBS was independent of EPDS (r = 0.11, p = 0.29) and AAQ (r = 0.05, p = 0.63). However, it was influenced by the infant's behavioral characteristics (r = 0.3, p = 0.01). MIBS scores of the mothers and nurses showed low correlation (r = 0.31, p = 0.004) and the item-by-item responses were rarely concordant. Fully 100% of the nurses stated that the MIBS was helpful in evaluating mother-child bonding and 85% of the mothers found it beneficial.

Conclusion

New mothers need to express their feelings about their babies, as hospital staff observation of mother-infant interactions is not sufficiently reliable for assessing the attachment process. The self-report MIBS is a useful tool for detecting difficulties in early mother-infant bonding.