Diagnosis and management for urosepsis

Urosepsis is defined as sepsis caused by a urogenital tract infection. Urosepsis in adults comprises approximately 25% of all sepsis cases, and is in most cases due to complicated urinary tract infections. The urinary tract is the infection site of severe sepsis or septic shock in approximately 10–30% of cases. Severe sepsis and septic shock is a critical situation, with a reported mortality rate nowadays still ranging from 30% to 40%. Urosepsis is mainly a result of obstructed uropathy of the upper urinary tract, with ureterolithiasis being the most common cause. The complex pathogenesis of sepsis is initiated when pathogen or damage‐associated molecular patterns recognized by pattern recognition receptors of the host innate immune system generate pro‐inflammatory cytokines. A transition from the innate to the adaptive immune system follows until a T_H2 anti‐inflammatory response takes over, leading to immunosuppression. Treatment of urosepsis comprises four major aspects: (i) early diagnosis; (ii) early goal‐directed therapy including optimal pharmacodynamic exposure to antimicrobials both in the plasma and in the urinary tract; (iii) identification and control of the complicating factor in the urinary tract; and (iv) specific sepsis therapy. Early adequate tissue oxygenation, adequate initial antibiotic therapy, and rapid identification and control of the septic focus in the urinary tract are critical steps in the successful management of a patient with urosepsis, which includes early imaging, and an optimal interdisciplinary approach encompassing emergency unit, urological and intensive‐care medicine specialists.     

Influence of smoking on interleukin-1beta level, oxidant status and antioxidant status in gingival crevicular fluid from chronic periodontitis patients before and after periodontal treatment

Toker H, Akp?nar A, Ayd?n H, Poyraz O. Influence of smoking on interleukin‐1beta level, oxidant status and antioxidant status in gingival crevicular fluid from chronic periodontitis patients before and after periodontal treatment. J Periodont Res 2012; 47: 572–577. © 2012 John Wiley & Sons A/S Background and Objective: The aim of this study was to evaluate the impact of smoking on the relationship between interleukin‐1 (IL‐1β) and oxidation in patients with periodontitis and response to nonsurgical periodontal therapy. Material and Methods: Data were obtained from 30 patients with generalized chronic periodontitis (15 smokers and 15 nonsmokers) and from 10 periodontally healthy controls. IL‐1β level, total oxidant status (TOS) and total antioxidant status (TAS) were recorded in gingival crevicular fluid. Probing depth, clinical attachment level, gingival and plaque indices and bleeding on probing were also measured. The gingival crevicular fluid and clinical parameters were recorded at baseline and 6 wk after periodontal treatment. Results: The study showed statistically significant improvement of clinical parameters in both smokers and nonsmokers after periodontal treatment. Moreover, the baseline IL‐1β levels were significantly higher in smokers compared with nonsmokers (p < 0.05). After periodontal treatment, the IL‐1β levels were significantly reduced in both smokers and nonsmokers (p < 0.05). There were no significant differences in TOS and TAS between periodontitis patients and healthy controls at baseline and 6 wk after periodontal treatment. The level of IL‐1β in gingival crevicular fluid was positively correlated with TOS in both smokers and nonsmokers. Conclusions: Periodontal treatment improved the clinical parameters in both smokers and nonsmokers. The results confirm that periodontal therapy has an effect on IL‐1β levels in gingival crevicular fluid, but not on TOS and TAS.     

Examining professional boundaries between nurses and physicians in neonatal intensive care units

Background

Medical and technological developments, financial constraints and a shortage of physicians have made it necessary to re-examine professional boundaries between physicians and nurses. Israel’s manpower shortage in Neonatal Intensive Care Units (NICUs) has changed the responsibility and authority of nurses. However, these changes have not evolved into a uniform policy defining the division of responsibility between physicians and nurses. This study was designed to examine the work processes and actual division of labor between NICU physicians and nurses; the attitude of physicians and nurses to greater empowerment of the nursing role; and to suggest a model to regulate work processes and develop the role of neonatal nurse specialists in NICUs.

Methods

Open interviews with NICU physician-directors and head nurses and a cross-sectional survey of some 50% of the physicians and nurses at 22 hospital NICUs (N?=?430).

Results

Main problems of NICUs: physician shortage, deficient infrastructures, fragmented work processes. Nurses do not perform many practices allowed to them due to the need for organizational approval and their own unawareness. Conversely, they sometimes conduct procedures and make decisions outside of their authority.Most physicians agree that nurse graduates of Post-Basic Education training (PBE) should be authorized to independently perform such activities as resuscitation and medication balancing while reserving invasive procedures for physicians. It is widely agreed that broadening the authority of nurses would improve the quality of NICU care even though it would increase the nursing workload.

Conclusions

The study provides important input into decisions about authorizing nurses over complete practice areas rather than isolated activities; the need to remove institutional restrictions on tasks currently permitted to nurses; introducing teamwork from within the NICUs, and expanding nursing decision-making. The study reveals that there is a basis on which to to build the role of the neonatal nurse,since most NICU nurses have the suitable academic and clinical training.

     

Interleukin-3 treatment of rhesus monkeys leads to increased production of histamine-releasing cells that express interleukin-3 receptors at high levels

To understand the hematopoietic and nonhematopoietic responses to interleukin-3 (IL-3), expression of cell-surface IL-3 receptors (IL-3R) was examined on bone marrow (BM) cells and peripheral blood (PB) cells of rhesus monkeys during the course of in vivo IL-3 treatment. Whereas IL-3R expression is low in untreated monkeys, IL-3 administration led to a gradual increase in both low- and high-affinity binding sites for IL-3. This increase reflected the total number of cells expressing IL- 3Rs, as detected by flow cytometry using biotinylated IL-3. Most of these IL-3R+ cells in both BM and PB could be characterized as basophilic granulocytes that contained high levels of histamine. In contrast to the effect on these differentiated cells, IL-3 administration did not significantly alter the low level IL-3R expression on immature, CD34+ cells. Further flow cytometric analysis using biotinylated growth factors showed that the IL-3R+ basophils also expressed receptors for granulocyte-macrophage colony-stimulating factor (GM-CSF), but not for IL-6 or Kit ligand. These findings indicated that the IL-3R+ cells included neither monocytes, which express GM-CSFRs and IL-6Rs abundantly, nor mast cells, which express c- kit. By combining flow cytometric and Scatchard data, it was calculated that the basophils contain as many as 1 to 2 x 10(3) high-affinity IL- 3Rs and 15 to 30 x 10(3) low-affinity sites. The finding that in vivo IL-3 treatment leads to the production of large numbers of cells that express high levels of IL-3R and are capable of producing histamine provides an explanation for the often severe allergic reactions that occur during prolonged IL-3 administration. It also indicates that IL- 3, in addition to its direct effects on hematopoietic cells, may also stimulate hematopoiesis through the release of secondary mediators such as histamine by IL-3-responsive mature cells.     

Lithium,Inositol and Mitochondria

Our recent DNA-microarray and proteomics studies searching for pathways affected both by chronic lithium treatment and by knockout of each of two genes (IMPA1 or Slc5a3) encoding for proteins related to inositol metabolism, indicated up-regulation of mitochondria-related genes and autophagy-related proteins in the frontal cortex. Differently from previously reported observations of aberrant mitochondrial function in bipolar patients which leave a causality relationship between mitochondrial dysfunction and bipolar disorder an open question, the behavioral results of our recent report following rotenone treatment tempt us to speculate that mitochondrial dysfunction predisposes manic behavior and that drugs targeted to ameliorate mitochondrial function are potential preventers of bursting manic episodes. However, the promiscuity of the involvement of mitochondrial dysfunction and impaired autophagy in the pathophysiology of psychiatric and neurodegenerative disorders raises questions regarding the credibility and relevance of these findings.     

A randomized controlled trial of preinsertion ultrasound guidance for spinal anaesthesia in pregnancy: outcomes among obese and lean parturients

Purpose

The present study was conducted to examine if preinsertion lumbar ultrasound scanning helps with performance of spinal puncture, as a tool for decreasing the number of puncture attempts and spinal procedure time and increasing the success rate. We hypothesized that ultrasound can facilitate neuraxial blockade, particularly in pregnant women with difficult topographic anatomy.

Methods

One hundred (50 lean, BMI <30 kg/m², and 50 obese, BMI ≥30 kg/m²) parturients scheduled for cesarean delivery were divided into ultrasound and control groups. Subarachnoid block was performed with prepuncture ultrasound examination in lean parturients (group 1, n = 25) and in obese parturients (group 2, n = 25), and subarachnoid block was performed without prepuncture ultrasound examination in lean parturients (group 3, n = 25) and in obese parturients (group 4, n = 25). The number of puncture attempts and puncture levels were recorded.

Results

A lower number of puncture attempts and fewer puncture levels were detected in ultrasound (US) groups (p < 0.001). First attempt success rate under US guidance was 92 % in comparison to 44 % using a conventional technique in obese parturients (p < 0.001). In 52 % of the lean patients and in 54.2 % of the obese patients, the intercristal line was at the L3–L4 and at the L2–L3 interspace, respectively. The duration of spinal procedure was shorter in US groups (22 vs. 52 s, p = 0.031). We found a high correlation between ultrasound and needle depth (r = 0.709, p < 0.001).

Conclusions

We found a high level of success in the prepuncture ultrasound-determined insertion point. The ultrasound imaging technique can be a reliable guide to facilitate spinal anesthesia, especially in obese parturients.