Francesca Foltran

Early Use of Polymyxin B Hemoperfusion in Abdominal Septic Shock: The EUPHAS Randomized Controlled Trial

CONTEXT Polymyxin B fiber column is a medical device designed to reduce blood endotoxin levels in sepsis. Gram-negative-induced abdominal sepsis is likely associated with high circulating endotoxin. Reducing circulating endotoxin levels with polymyxin B hemoperfusion could potentially improve patient clinical outcomes. OBJECTIVE To determine whether polymyxin B hemoperfusion added to conventional medical therapy improves clinical outcomes (mean arterial pressure [MAP], vasopressor requirement, oxygenation, organ dysfunction) and mortality compared with conventional therapy alone. DESIGN, SETTING, AND PATIENTS A prospective, multicenter, randomized controlled trial (Early Use of Polymyxin B Hemoperfusion in Abdominal Sepsis [EUPHAS]) conducted at 10 Italian tertiary care intensive care units between December 2004 and December 2007. Sixty-four patients were enrolled with severe sepsis or septic shock who underwent emergency surgery for intra-abdominal infection. INTERVENTION Patients were randomized to either conventional therapy (n=30) or conventional therapy plus 2 sessions of polymyxin B hemoperfusion (n=34). MAIN OUTCOME MEASURES Primary outcome was change in MAP and vasopressor requirement, and secondary outcomes were PaO(2)/FIO(2) (fraction of inspired oxygen) ratio, change in organ dysfunction measured using Sequential Organ Failure Assessment (SOFA) scores, and 28-day mortality. RESULTS MAP increased (76 to 84 mm Hg; P = .001) and vasopressor requirement decreased (inotropic score, 29.9 to 6.8; P < .001) at 72 hours in the polymyxin B group but not in the conventional therapy group (MAP, 74 to 77 mm Hg; P = .37; inotropic score, 28.6 to 22.4; P = .14). The PaO(2)/FIO(2) ratio increased slightly (235 to 264; P = .049) in the polymyxin B group but not in the conventional therapy group (217 to 228; P = .79). SOFA scores improved in the polymyxin B group but not in the conventional therapy group (change in SOFA, -3.4 vs -0.1; P < .001), and 28-day mortality was 32% (11/34 patients) in the polymyxin B group and 53% (16/30 patients) in the conventional therapy group (unadjusted hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.20-0.94; adjusted HR, 0.36; 95% CI, 0.16-0.80). CONCLUSION In this preliminary study, polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamics and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal gram-negative infections. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00629382.

Foreign bodies in the airways: A meta-analysis of published papers

BACKGROUND Very recently, some attempts have been made to start a systematic collection of foreign bodies (FB) in view of using them to characterize the risk of chocking in terms of size, shape and consistency of the FB. However, most of the epidemiologic evidence on foreign bodies in children comes from single-center retrospective studies, without any systematic geographical and temporal coverage. This paper is aimed at providing an estimate of the distribution of foreign bodys injuries in children according to gender, age, type of FB, site of obstruction, clinical presentation, diagnostic/therapeutic procedures, complications, as emerging from a meta-analytic review of published papers. METHODS A free text search on PubMed database ((foreign bodies) OR (foreign body)) AND ((aspiration) OR (airways) OR (tracheobronchial) OR (nasal) OR (inhalation) OR (obstruction) OR (choking) OR (inhaled) OR (aspirations) OR (nose) OR (throat) OR (asphyxiation)) AND ((children) OR (child)) finalized to identify all English written articles referring to foreign body inhalation over a 30 years period (1978-2008) was performed. The target of the analysis has been defined as the proportion of injuries as reported in the studies, stratified according to children demographic characteristics, type of FB, site of obstruction. The pooled proportions of FB were calculated using the DerSimonian and Laird approach. RESULTS 1699 papers were retrieved and 1063 were judged pertinent; 214 English written case series were identified, among them 174 articles were available and have been included in the analysis. Airway foreign body most commonly occurs in young children, almost 20% of children who have inhaled foreign bodies being between 0 and 3 years of age. Organic FB, particularly nuts, are the most documented objects while, among inorganic FBs, the greatest pooled proportion has been recorded for magnets, which can be particularly destructive in each location. Non specific symptoms or a complete absence of symptoms are not unusual, justifying mistaken or delayed diagnosis. Acute and chronic complications seem to occur in almost 15% of patients. CONCLUSIONS Even if an enormous heterogeneity among primary studies seems to exist and even if the absence of variables standardized definitions across case series, including class age definition and symptoms and signs descriptions, seriously impairs studies comparability, our results testify the relevant morbidity associated with foreign body inhalation in children, stressing the importance of preventive measures.

Inhaled foreign bodies in children: A global perspective on their epidemiological, clinical, and preventive aspects†

While several articles describe clinical management of Foreign Bodies injuries in the upper air tract, little epidemiological evidence is available from injury databases.

Understanding the influence of the snack definition on the association between snacking and obesity: a review

The aim of the present study is to understand how different definitions of snacking influence the estimated probability of obesity in the presence of concurrent risk factors. Factors influencing obesity were evaluated by reviewing the relevant literature through a PUBMED search. Six different modalities to define snack consumption were identified. A Bayesian network model in which nodes represent the variables that the retrieved studies indicate as affecting the probability of obesity was implemented and used to estimate the individual risk of developing obesity taking into account the concurrent effect of the considered risk factors. For a subject with a given profile of factors, the probability of obesity varies according to the chosen definition of snacking, up to maximum of 70%. The variability of the probability of obesity attributable to the chosen definition of snacking is very high and may threaten any conclusion about the effect of snacking, which may be related to the specific definitions adopted in the study.

Effect of alcohol consumption in prenatal life, childhood, and adolescence on child development

The effects of alcohol consumption in adults are well described in the literature, while knowledge about the effects of alcohol consumption in children is more limited and less systematic. The present review shows how alcohol consumption may negatively influence the neurobiological and neurobehavioral development of humans. Three different periods of life have been considered: the prenatal term, childhood, and adolescence. For each period, evidence of the short-term and long-term effects of alcohol consumption, including neurodevelopmental effects and associations with subsequent alcohol abuse or dependence, is presented.

Foreign Bodies Causing Asphyxiation in Children: The Experience of the Buenos Aires Paediatric ORL Clinic

Inhalation or aspiration of a foreign body (FB) occurs relatively frequently in young children. The size, shape, type and site of arrest of the FB lead to variability in the clinical picture. The present study included data from 65 cases of FB inhalation presenting over 1 year at the Childrens Hospital Gutierrez, Buenos Aires, Argentina, compared with information from four well-known published case series chosen as representative of other cultural and geographical backgrounds: the USA, Europe, North Africa (Egypt) and Asia (India). The mean age of children studied was 4.03 years. Injuries happened mainly at home (53 cases [81.54%]) and under adult supervision (59 cases [90.77%]). The most frequently inhaled FB was nuts, however, in contrast to previous reports, the majority of incidents involved inhalation of an inorganic, rather than an organic (food) FB. Complications included pneumonia (three cases), atelectasis (two cases) and pneumonitis (one case). No deaths were recorded. These data suggest that children play with objects inappropriate for their age, such as pins and nails, that adults may not be aware of the choking risks, and that more effort is required in educating caregivers about these risks.

Nasal foreign bodies: the experience of the Buenos Aires pediatric otolaryngology clinic

Objective:  The aim of the present paper is to present nasal foreign cases observed at the Childrens Hospital Gutierrez in Buenos Aires, Argentina, over a 4‐year period and to compare the main findings with data from other case series.

Xenon Anesthesia Improves Respiratory Gas Exchanges in Morbidly Obese Patients

Background. Xenon-in-oxygen is a high density gas mixture and may improve PaO2/FiO2 ratio in morbidly obese patients uniforming distribution of ventilation during anesthesia. Methods. We compared xenon versus sevoflurane anesthesia in twenty adult morbidly obese patients (BMI > 35) candidate for roux-en-Y laparoscopic gastric bypass and assessed PaO2/FiO2 ratio at baseline, at 15 min from induction of anaesthesia and every 60 min during surgery. Differences in intraoperative and postoperative data including heart rate, systolic and diastolic pressure, oxygen saturation, plateau pressure, eyes opening and extubation time, Aldrete score on arrival to the PACU were compared by the Mann-Whitney test and were considered as secondary aims. Moreover the occurrence of side effects and postoperative analgesic demand were assessed. Results. In xenon group PaO2-FiO2 ratio was significantly higher after 60 min and 120 min from induction of anesthesia; heart rate and overall remifentanil consumption were lower; the eyes opening time and the extubation time were shorter; morphine consumption at 72 hours was lower; postoperative nausea was more common. Conclusions. Xenon anesthesia improved PaO2/FiO2 ratio and maintained its distinctive rapid recovery times and cardiovascular stability. A reduction of opioid consumption during and after surgery and an increased incidence of PONV were also observed in xenon group.

Monitoring the performance of intensive care units using the variable life-adjusted display: a simulation study to explore its applicability and efficiency

RATIONALE, AIMS AND OBJECTIVES Graphical monitoring tools are needed for real-time quality evaluation in intensive care unit. The variable life-adjusted display (VLAD) provides a directly interpretable assessment indicating whether the overall performance is better or worse than expected on the basis of the predicted risk of failure. The aim of this study is to quantify the ability of VLAD charts to early recognize a worsening in clinical performance. METHODS A Monte Carlo experiment simulating the sequence of successes and failures of an intensive care unit is performed; the predicted mortality is calculated by means of the Simplified Acute Physiology Score 3 admission score. From a given position in the admissions sequence, we increased the probability of death; we calculated: (i) the surveillance system delay in responding to the mortality increase; (ii) the percentage of cases where the VLAD has been able to give an alarm within the first 5, 10, 20 and 60 deaths occurred after the increase of probability of death; and (iii) the percentage of false declarations of increase (anticipated alarms). RESULTS The frequency distribution of the alarm delays shows VLAD was not always able to early detect mortality increase. Only a very small number of anticipated alarms were given. CONCLUSIONS Variable life-adjusted display ability to signal is mild and strictly correlated with the institution volume of activity. Therefore, the use of VLAD seems to be not always advisable, and an integration between VLAD and other well-documented tools as CUSUM charts could be preferable.

Nutritional profiles in a public health perspective: a critical review.

Nutritional profiling is defined as ‘the science of categorizing foods according to their nutritional composition’ and it is useful for food labelling and regulation of health claims. The evidence for the link between nutrients and health outcomes was reviewed. A reduced salt intake reduces blood pressure, but only a few randomized controlled trials have verified the effect of salt on overall and cardiovascular mortality. Evidence linking a reduced fat intake with cardiovascular mortality and obesity is generally non-significant. Studies that have examined the relationship between obesity and diet have produced contrasting results. A simulation exercise that demonstrated that the impact of a reduced salt and fat intake on overall mortality would be negligible in the European population was carried out. Consideration of the literature and the results of this simulation exercise suggest that the introduction of nutritional profiles in Europe would be expected to have a very limited impact on health outcomes.