Pattern of end-of-life decisions in two Tunisian intensive care units: the role of culture and intensivists' training

Purpose  

End-of-life (EOL) decisions are not well studied in developing countries. We report EOL decision patterns in two Tunisian intensive care units [ICUs, medical (MICU) and surgical (SICU)] belonging to the same teaching hospital.     

A Systems Biology Approach Provides Deeper Insights into Differentially Expressed Genes in Taxane-Anthracycline Chemoresistant and Non-Resistant Breast Cancers

Objective: To date, numerous studies have been conducted to search for reasons for chemoresistance and differences in survival rates of patients receiving chemotherapy. We have sought to identify differentially expressed genes (DEGs) between predicted chemotherapy resistance and sensitive phenotypes by a network as well as gene enrichment approach. Methods: Functional modules were explored with network analysis of DEGs in predicted neoadjuvant taxane-anthracycline resistance versus sensitive cases in the GSE25066 dataset, including 508 samples. A linear model was created by limma package in R to establish DEGs. Results: A gene set related to phagocytic vesicle membrane was found to be up-regulated in chemoresistance samples. Also, we found GO_CYTOKINE_ACTIVITY and GO_GROWTH_FACTOR BINDING to be up-regulated gene sets with the chemoresistance phenotype. Growth factors and cytokines are two groups of agents that induce the immune system to recruit APCs and promote tolerogenic phagocytosis. Some hub nodes like S100A8 were found to be important in the chemoresistant tumor cell network with associated high rank genes in GSEA. Conclusions: Functional gene sets and hub nodes could be considered as potential treatment targets. Moreover, by screening and enrichment analysis of a chemoresistance network, ligands and chemical agents have been found that could modify significant gene sets like the phagocytic vesicle membrane functional gene set as a key to chemoresistance. They could also impact on down- or up-regulated hub nodes.     

Pain distress: the negative emotion associated with procedures in ICU patients

Purpose

The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain.

Methods

Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0–10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects.

Results

A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs]?=?4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR?=?1.18), ETS (RR?=?1.45), tracheal suctioning (RR?=?1.38), CTR (RR?=?1.39), wound drain removal (RR?=?1.56), and arterial line insertion (RR?=?1.41); certain pain behaviors (RR?=?1.19–1.28); pre-procedural pain intensity (RR?=?1.15); and use of opioids (RR?=?1.15–1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR]?=?1.05); pre-hospital anxiety (OR?=?1.76); receiving pethidine/meperidine (OR?=?4.11); or receiving haloperidol (OR?=?1.77) prior to the procedure.

Conclusions

Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient’s pain experience.

     

Late-presenting developmental dysplasia of the hip in Jordanian males: A retrospective hospital based study

Objectives:

To describe the pattern of developmental dysplasia of the hip (DDH) in late presenting Jordanian male patients and identify the risk factors and associated findings.

Methods:

This is a retrospective study of 1145 male patients who attended the Pediatric Orthopedic Clinic for a DDH check up. This study was carried out in the Orthopedic Section, Special Surgery Department, Faculty of Medicine, The University of Jordan, Amman, Jordan between March 2011 and October 2014. Data was collected from medical records, and x-ray measurements were evaluated.

Results:

Of the 1145 male patients, 43 (3.75%) with 70 involved hips were diagnosed with late- presenting DDH. Being a first-born baby resulted in 41.9% increased risk for DDH. Cesarian delivery was significantly associated with an increased risk of hip dislocation (p=0.004) while normal delivery was significantly associated with acetabular dysplasia (p=0.004). No predictable risk factors were found in 44.2% patients with DDH. Bilateral cases were more common than unilateral cases: (26 [60.5%] versus 17 [39.5%]). Limited abduction was a constant finding in all dislocated hips (p<0.001). Associated conditions, such as club foot and congenital muscular torticollis were not observed.

Conclusion:

Cesarian section is a significant risk for dislocated hips while normal delivery is significantly associated with acetabular dysplasia. Bilateral DDH is more common than the unilateral. Club foot and torticollis were not observed in this series.Developmental dysplasia of the hip (DDH) is a widespread term first used by Klisic1 in 1989, which indicates an extensive variety of vibrant abnormalities present in the immature hip joint in children. Approximately, one in every 1,000 child is delivered with a dislocated hip joint, while every 10 in 1,000 children are delivered with subluxation or dysplasia of the hip joint. The DDH represents a wide spectrum of anatomical abnormalities, which range from slight hip instability to frank dislocation of the hip joint, as well as the mal-development of the acetabulum. These abnormalities are not always apparent clinically at birth, so high index of suspicion should be raised when there are positive risk factors. Early diagnosis and treatment are crucial for optimal outcome and the key to stay out of trouble in dealing with these patients. Developmental dysplasia of the hips is usually developmental and can occur during the first year of a child’s life. Developmental dysplasia of the hip is an evolving process and the clinical examination shows different signs based on the spectrum of the DDH and the age of the patient. In accordance with the clinical practice guideline of the “American Academy of Pediatrics”, no considerable sign was observed, which indicates the pathognomonic for hip dislocation.2 Therefore, the clinical examination is neither 100% sensitive, nor specific to diagnose DDH.3 Developmental dysplasia of the hip is more common in female patients, and has been well studied and analyzed regarding its incidence, presentation, and the associated risk factors.4 First-born infants have a higher incidence of DDH4,5 as well as those born with breech presentation.4 Since the neonatal hips are primarily a cartilaginous structure, it is difficult to observe with standard radiographic techniques, therefore, nowadays ultrasonograms are very popular. It is currently considered a safe tool for young infants and can shed light on pathological changes that cannot be seen using the standard radiological techniques. Only few studies addressed the issue of late-presenting DDH in male children. Kosar et al6 had studied this spectrum in male infants and showed no statistical significance presented between risk factors and DDH in male cases. Jordanians are an ethnically distinct and homogenous population that has not been studied before. In spite of the improvement in screening methods, late diagnosis of DDH occurs and is of great concern for the family and the treating physician. In this study, we investigated the risk factors, the clinical, and radiological findings associated with DDH in late-presenting Jordanian male children.     

Direct vs. mediated effects of scorpion venom: an experimental study of the effects of a second challenge with scorpion venom

Objective To assess the respective roles of venom and of catecholamines following scorpion envenomation and to verify whether a second challenge with scorpion venom induces the same consequences than a first one.Design and setting Controlled animal study in a university research laboratory.Subjects Anesthetized and ventilated dogs.Interventions Fifteen dogs received intravenously a sublethal dose of scorpion venom (0.05 mg/kg). In the reenvenomated group (n=5) a second venom challenge with one-half sublethal venom dose was performed 30 min after the first one. The control group (n=10) received saline. Five additional animals served as sham.Measurements and results Plasma toxin and catecholamine levels and a set of usual hemodynamic measurements were repeatedly measured in the first hour following envenomation. In the reenvenomated group another set of measurements was performed 5 min after the second challenge. Changes in toxin, catecholamines, and the main hemodynamic parameters were compared between the study groups. Initial peak toxin levels were similar in the two groups. They induced a striking increase in circulating catecholamines, a fall in heart rate, and an increase in mean arterial and pulmonary artery occluded pressures and in systemic vascular resistance. In the reenvenomated group the second challenge with scorpion venom achieved a toxin blood level similar to the first peak. However, it was not associated with a significant effect either on catecholamines release or on hemodynamics. Subsequent trends in hemodynamic changes were similar to those observed in the control group.Conclusions These data emphasize the limited role of direct effects of scorpion venom on the cardiovascular system and the key role of catecholamines.This research was supported by grants from Secretariat dEtat à la Recherche Scientifique (UR/06/02) and Ministère de la Santé Publique (Tunisia), Institut Français de Coopération (Coopération inter-hospitalière).     

Determination of survival and hazard functions for pemphigus patients in Kerman, a southern province of Iran

BACKGROUND: Pemphigus has in the past been associated with a high mortality rate. However, with the discovery of corticosteroids, patient median survival has improved. Our purpose was to assess median survival after confirmed diagnosis of pemphigus in patients in Kerman, a southern province of Iran. METHODS: All patients who were either admitted to the hospital or treated as outpatients in Kerman from 22 September 1987 to 22 September 1999 and who had confirmed pemphigus were included in the study. Survival was estimated using the Kaplan-Meier method, and the following variables were evaluated in a univariate analysis for an association with survival: age, sex, type of pemphigus, and type of therapy. RESULTS: A total of 55 patients (38 female and 17 male) were identified. No significant differences were found between genders. The mean age at the time of diagnosis was 46.0 years. Older groups had a lower survival rate than younger groups (P < 0.001). The majority (82%) of cases were vulgaris/vegetans, and no significant differences were found in 10-year survival for type of pemphigus (P > 0.05). The patients who had been treated with corticosteroids alone had longer median survival times than those who had been treated with corticosteroids plus azathioprine (P < 0.001). A total of 11 patients died; the median follow-up time for those still alive was 5.9 years (range 2-12 years). Estimated survival at 2, 6 and 10 years was 92.7, 86.8 and 61.5%, respectively. CONCLUSION: Overall median survival rate in patients with pemphigus was 10 years, regardless of gender or subtype of pemphigus. Survival was adversely affected by late onset. Those patients treated with immunosuppressives and corticosteroids also appeared to have reduced survival times when compared to those treated with corticosteroids alone.