Hypocalcemic crisis

Calcium is an essential ion for normal cardiovascular and other organ functions. Direct ionized calcium measurement is the best method for diagnosing hypocalcemia in critically ill patients. The presence of ionized hypocalcemia implies a defect in the parathyroid-vitamin D axis. Prompt recognition and appropriate treatment of this disorder may be life saving.     

Nutrition modulation of cachexia/proteolysis.

Cachexia represents progressive wasting of muscle and adipose tissue and is associated with increased morbidity and mortality. Although anorexia usually accompanies cachexia, cachexia rarely responds to increased food intake alone. Our knowledge of the underlying mechanisms responsible for cachexia remains incomplete. However, most states of cachexia are associated with underlying inflammatory processes and/or cancer. These processes activate protein degradation and lipolytic pathways, resulting in tissue loss. In this article, we briefly review the pathophysiology of cachexia and discuss the role of specific nutrient supplements for the treatment of cachexia. The branched chain amino acid leucine, the leucine metabolite beta-hydroxy-beta-methylbutyrate, arginine, glutamine, omega-3 long chain fatty acids, conjugated linoleic acid, and polyphenols have demonstrated some efficacy in animal and/or human studies. Optimal treatment for cachexia is likely aimed at maximizing muscle and adipose synthesis while minimizing degradation.     

Catecholamines in anesthetic and surgical stress

The sympathetic nervous system is activated by a large variety of stresses and is important in the maintenance of cardiovascular and metabolic homeostasis. However, individual responses to sympathetic activation and circulating catecholamines vary widely.     

Hypothalamic-pituitary-adrenal insufficiency

Adrenal insufficiency is a common and underdiagnosed disorder that develops in critically ill patients. Most forms are acquired and will resolve with treatment of the underlying disease. Hypotension that is refractory to fluids and requires vasopressors is the most common presentation of adrenal insufficiency in the ICU. It is important to make the diagnosis of adrenal insufficiency, because current data suggest that treatment with glucocorticoids improves outcome. Diagnosis usually can be made on the basis of a stress cortisol level. Occasionally, when the level of stress is uncertain, the low-dose corticotropin stimulation test will be required for definitive diagnosis. A therapeutic trial with hydrocortisone should be started in patients with suspected adrenal insufficiency pending results of diagnostic testing.     

Logistic回归分析食管静脉曲张破裂出血的危险因素*

目的 探讨与肝硬化食管静脉曲张破裂出血（EVB）相关的危险因素,寻找一种有效预测EVB发生的无创检测指标。方法 回顾性分析168例肝硬化患者的临床资料,其中出血85例,非出血83例,对可能影响EVB发生的临床指标进行分析,将有显著性差异的因素进行单因素Logistic回归分析,然后对两组中有统计学意义的因素进行多因素非条件Logistic回归分析。结果 两组患者性别、年龄、病因分布差异均无统计学意义（P＞0.05）;出血患者门静脉直径（DPV）、脾静脉直径（DSV）和脾脏指数（SI）分别为（1.48±0.28） cm、（1.08±0.19） cm和（72.54±16.69）cm2,显著高于非出血组[分别为（1.34±0.29） cm、（1.18±0.25） cm和（66.98±19.21） cm2,P＜0.05];出血患者血Na+和血小板/脾长径比值分别为（139.45±3.41） mmol/L和（5.05±2.07）×109/L?cm-1,显著低于非出血组[分别为（140.66±4.41） mmol/L和（8.99±4.36）×109/L?cm-1,P＜0.05];出血组Child-Pugh分级与非出血组比较,差异有统计学意义（P＜0.05）;单因素Logistic回归分析显示两组间DPV、DSV、血小板计数与脾脏长径比值和Child-Pugh分级差异均有统计学意义（OR值分别为6.832、7.283、0.655、2.129,P＜0.05）,多因素非条件Logistic回归分析显示血小板计数与脾脏长径比值（OR=0.685,P=0.000）是肝硬化患者发生EVB的独立危险因素。结论 血小板计数与脾脏长径比值可作为肝硬化患者发生EVB的无创预测指标。     

Multicenter evaluation of a human monoclonal antibody to Enterobacteriaceae common antigen in patients with Gram-negative sepsis

OBJECTIVE: To evaluate in Gram-negative sepsis patients the human monoclonal immunoglobulin M antibody (MAB-T88) directed at the enterobacterial common antigen which is a specific surface antigen closely linked to lipopolysaccharide and shared by all members of the Enterobacteriaceae family of Gram-negative bacteria. DESIGN: Prospective, randomized, double-blinded, placebo-controlled, multicenter trial. SETTING: Thirty-three academic medical centers in the United States. PATIENTS: Patients were entered with a clinical diagnosis of sepsis, the presence of either shock or multiple organ dysfunction, and presumptive evidence for Gram-negative infection. INTERVENTIONS: Patients received a single intravenous infusion, over 30 mins, of either 300 mg of MAB-T88 formulated in albumin, or placebo (albumin). MEASUREMENTS AND MAIN RESULTS: The primary analysis group was prospectively identified as those patients with documented evidence of an infection with bacteria of the family Enterobacteriaceae at any site. The primary end point was survival within the first 28 days. A total of 826 patients were enrolled with 55% (n = 455) in the primary analysis group. There were no significant differences between the intervention and control primary analysis group study groups for sites of infection, severity of illness, underlying medical conditions, adequacy of antibiotic or surgical treatment, or other baseline variables except for a higher frequency of chronic renal failure in the MAB-T88 group (4.4% vs. 1.3%, p=.051). The average Acute Physiology and Chronic Health Evaluation II scores were 26.8 +/- 8.6 (mean +/- sd) in the MAB-T88-treated group and 26.5 +/- 8.3 in the placebo-treated group (p =.72). There was no significant difference between MAB-T88- and placebo-treated groups during the first 28-day all-cause mortality in the primary analysis group (34.2% vs. 30.8%, p=.44) or in all 826 patients enrolled (37.0% vs. 34.0%, p=.36). On subset analysis, the use of MAB-T88 was not associated with significant mortality trends. More adverse events were seen with the use of MAB-T88 in the bacteremic enterobacterial common antigen group (p <.05). CONCLUSIONS: Use of the human monoclonal antibody, MAB-T88, did not improve the mortality in patients with presumed Gram-negative sepsis or in those patients with proven enterobacterial common antigen infections. No subset trends were identified that would support further investigation of this agent in sepsis.