Predictive factors of mortality due to polymicrobial peritonitis with Candida isolation in peritoneal fluid in critically ill patients

BACKGROUND: Candida peritonitis (CP) is generally considered to be a severe disease, but its impact on outcome in critically ill patients remains unknown. HYPOTHESIS: The predictive factors of mortality due to CP can be determined by study of a population of patients with CP. DESIGN: A retrospective review of a prospective surgical intensive care unit (ICU) database of patients (January 1, 1994, through December 31, 2000). SETTING: University hospital in Paris, France. PATIENTS: Eighty-three patients with generalized CP. MAIN OUTCOME MEASURES: Demographic and microbiologic data and outcome were collected, and nonsurvivors were compared with survivors. RESULTS: Overall ICU mortality due to CP was 43 (52%) of 83 patients. In a stepwise multivariate logistic regression, the following 4 variables were independently associated with mortality: APACHE II (Acute Physiology and Chronic Health Evaluation II) score on admission of at least 17 (odds ratio [OR], 28.4; 95% confidence interval [CI], 5.7-142.5; P<.001), respiratory failure on admission (OR, 10.6; 95% CI, 2.2-51.2; P =.003), upper gastrointestinal tract site of peritonitis (OR, 7.7; 95% CI, 1.7-34.7; P =.007), and results of direct examination of peritoneal fluid that were positive for Candida (OR, 4.7; 95% CI, 1.2-19.7; P =.002). CONCLUSIONS: These results confirm the severity of CP in ICU patients and emphasize the prognostic value of direct examination of peritoneal fluid for Candida in this context.     

Amniotic fluid beta-endorphin: a prognostic marker for gastroschisis?

Purpose: The aim of this work was to study amniotic fluid [beta ]-endorphin as a potential predictor for postnatal morbidity in gastroschisis. Methods: Beta-endorphin was assayed in 43 amniotic fluid samples from 13 pregnant women with fetal gastroschisis undergoing diagnostic amniocentesis or therapeutic amnioinfusion and compared with 33 controls. Within the gastroschisis group, the authors investigated the relationship between postnatal morbidity and the peak value of amniotic fluid [beta ]-endorphin (AFBE). Results: Ten AFBE values in 6 cases of gastroschisis were above the upper limit of the 95% confidence interval derived from controls. Postnatal morbidity was significantly higher when peak AFBE exceeded 10 [mu ]g/L (n = 4 pregnancies) compared with below 5 [mu ]g/L (n = 9 pregnancies), as shown by mean duration of mechanical ventilation (15.2 v 3 days; P = .01), of parenteral feeding (77 v. 18.7 days; P = .04), and of hospitalization (84 v 32.2 days; P = .04). There was no statistically significant association between postnatal morbidity markers and prenatal dilation of fetal bowel. Conclusions: The most severe cases of gastroschisis are associated with high levels of AFBE. The authors speculate that this fetal hormonal response could result from stress or pain caused by prenatal bowel damage.     

Effect of apelin on glomerular hemodynamic function in the rat kidney

Apelin is a vasoactive peptide identified as the endogenous ligand of an orphan G protein-coupled receptor called APJ. Apelin and its receptor have been found in the brain and the cardiovascular system. Here we show that the apelin receptor mRNA is highly expressed in the glomeruli while its level of expression is lower in all nephron segments including collecting ducts that express vasopressin V2 receptors. Intravenous injection of apelin 17 into lactating rats induced a significant diuresis. Apelin receptor mRNA was also found in endothelial and vascular smooth muscle cells of glomerular arterioles. Apelin administration caused vasorelaxation of angiotensin II-preconstricted efferent and afferent arterioles as shown by an increase in their diameter. Activation of endothelial apelin receptors caused release of nitric oxide which inhibited angiotensin II-induced rise in intracellular calcium. In addition, it appears that apelin had a direct receptor-mediated vasoconstrictive effect on vascular smooth muscle. These results show that apelin has complex effects on the pre- and post glomerular microvasculature regulating renal hemodynamics. Its role on tubular function (if any) remains to be determined.     

Surgical treatment of AO type C distal humeral fractures: internal fixation with a Y-shaped reconstruction (Lambda) plate

Although surgical repair is considered the standard treatment for intraarticular distal humeral fractures, most investigators have assessed its results using dual-plate fixation in 2 planes. The purpose of this study was to determine the functional outcome of open reduction and internal fixation of these complex fractures using Y-shaped reconstruction plates. We identified 17 patients who had operative treatment for Arbeitsgemeinschaft Für Osteosynthesefragen (AO) type 1, 3-C fractures using a Y-shaped Lambda plate (Zimmer, Warsaw, IN). Patients were recalled for follow-up that included recording of a complete history, physical examination, radiographic evaluation, and completion of a limb-specific questionnaire. The mean duration of follow-up was 37.3 months. The average loss of extension was 13 degrees , and the average arc of flexion-extension was 112 degrees . As determined by the Mayo Elbow Performance Index, 6 were graded excellent; 8, good; 3, fair; and none, poor. Surgical repair of intraarticular distal humeral fractures by open reduction and internal fixation with a Lambda plate is an effective procedure that allows for stable osteosynthesis without loss of reduction or fixation as a basis for good functional outcome.     

Gastric banding interferes with esophageal motility and gastroesophageal reflux

BACKGROUND: Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). HYPOTHESIS: Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. DESIGN: Before-after trial in patients undergoing GB. SETTING: University teaching hospital. PATIENTS AND METHODS: Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. MAIN OUTCOME MEASURES: Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. RESULTS: There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. CONCLUSIONS: Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.     

Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial

Jean-Jacques Parienti, MD, DTM&H; Marina Thirion, MD; Bruno Mégarbane, MD, PhD; Bertrand Souweine, MD, PhD; Abdelali Ouchikhe, MD; Andrea Polito, MD; Jean-Marie Forel, MD; Sophie Marqué, MD; Benoît Misset, MD; Norair Airapetian, MD; Claire Daurel, MD; Jean-Paul Mira, MD, PhD; Michel Ramakers, MD; Damien du Cheyron, MD, PhD; Xavier Le Coutour, MD; Cédric Daubin, MD; Pierre Charbonneau, MD; for Members of the Cathedia Study Group

JAMA. 2008;299(20):2413-2422.

Context  Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access.

Objective  To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization.

Design, Setting, and Patients  A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy.

Intervention  Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites.

Main Outcome Measures  Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection.

Results  Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%], respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term < .001). Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days; HR, 2.10; 95% CI, 1.13-3.91; P = .017) in the lowest tercile (BMI <24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days; HR, 0.40; 95% CI, 0.23-0.69; P < .001) in the highest tercile (BMI >28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42).

Conclusion  Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma.

Trial Registration  clinicaltrials.gov Identifier: NCT00277888

     

Estimation of intraocular pressure in rabbits with commonly used tonometers.

BACKGROUND AND OBJECTIVES: To validate accuracy and reproducibility of the Perkins tonometer, pneumatonometer, and Tono-Pen XL (Medtronic Solan, Jacksonville, FL) in estimating intraocular pressure (IOP) in rabbits. MATERIALS AND METHODS: IOP was increased from 5 to 50 mm Hg in 5-mm increments. Measurements were compared to readings of two digital manometers simultaneously measuring real IOP in the anterior chamber and vitreous cavity. Interobserver accuracy was evaluated using 4 eyes with the Perkins tonometer. RESULTS: The Perkins tonometer and Tono-Pen XL underestimated IOP and were more accurate at pressures less than 30 mm Hg. No statistically significant difference was found between real IOP and Tono-Pen XL readings. The pneumatonometer overestimated pressures in the low ranges but was accurate at pressures greater than 40 mm Hg. The Tono-Pen XL had more variability than the Perkins tonometer and pneumatonometer at high IOP. CONCLUSIONS: None of the tonometers are accurate or reproducible in estimating IOP in rabbits over the tested range. Pneumatonometry, although not very accurate, has the advantage of having acceptable variability.     

Design of melt-recyclable poly(ε-caprolactone)-based supramolecular shape-memory nanocomposites

A novel poly(epsilon-caprolactone) (PCL) supramolecular network exhibiting shape-memory behavior was successfully constructed with pendant UPy units that are highly able to dimerize. The dynamic network was obtained by a simple and versatile strategy consisting of chain-extension reaction between α,ω-dihydroxyoligoPCL and hydroxylated UPy units in the presence of hexamethylene diisocyanate as a coupling agent and further intermolecular dimerization of the UPy along the polyurethane backbone. ¹H NMR analyses confirmed the dynamic features of the system, and DMTA in tensile mode was investigated to assess the SMP properties. Recyclability was also assessed by taking advantage of these supramolecular networks. Further addition of cellulose nanocrystals into the polymer network enabled adjustment of the extent of the net-points and therefore the SMP features. As confirmed by dispersion tests in solution and SEM observations, these bio-based nanofillers were homogeneously distributed in the network via supramolecular interaction between the hydroxyl groups present on their surface and UPy moieties along the polyurethane backbone. Thus, the here developed nanomaterials might reveal applicability in areas where a combination of SMP and biocompatibility is needed.

Novel melt-recyclable poly(ε-caprolactone)/cellulose nanocrystals supramolecular nanocomposite networks with shape-memory behavior have been successfully constructed by playing with UPy chemistry.     

New insights on IgA vasculitis with underlying solid tumor: a nationwide French study of 30 patients

Clinical Rheumatology - IgA vasculitis (IgAV) frequently occurs during or after a mucosal infection; it also rarely occurs in patients with cancer. We hypothesized that cancer could impact the...