Scorpion envenomation: state of the art Abroug, Fekri; Ouanes-Besbes, Lamia; Tilouche, Nejla ...
Intensive care medicine,
03/2020, Letnik:
46, Številka:
3
Journal Article
Recenzirano
Scorpion envenomation is common in the tropical and subtropical regions. It poses a major public health problem with some patients having serious clinical manifestations and severe complications ...including death. Old World and New World scorpions are usually contrasted because of differences in venom composition, clinical presentation and severity, and, accordingly, different therapeutic approaches. The majority of scorpion stings are either dry or result in low amounts of injected venom, thus explaining why up to 95% of scorpion stings ensue only in local signs. For a clinical envenomation to occur, it has been suggested that the interaction between the quantity of venom introduced in the body of the prey and the distribution volume should ensue in a critical threshold of scorpion toxin plasma concentration. In this case, there is a massive release of neurohormonal mediators (mainly catecholamine), with systemic vasoconstrictor effects eliciting a sharp increase in systemic arterial pressure and LV-filling pressure and decreased cardiac output. This early phase of cardiac dysfunction, also called “vascular phase”, is followed by a severe cardiomyopathy, a form of Takotsubo cardiomyopathy, involving both ventricles and reversible in days to weeks. The more comprehensive understanding of the disease pathophysiology has allowed for a well-codified symptomatic treatment, thus contributing to a substantial reduction in the death toll of scorpion envenomation over the past few decades. The standard intensive-care treatment (when available) overcomes envenomation’s consequences such as acute pulmonary edema and cardiogenic shock. Even though it continues to inspire many evaluative studies, immunotherapy seems less attractive because of the major role held by mediators in the pathogenesis of envenomation, and unfavorable pharmacokinetic properties to existing sera compared to venom. Meta-analyses of controlled trials of immunotherapy in severe scorpion envenomation reached similar conclusions: there is an acceptable level of evidence in favor of the use of scorpion antivenom (Fab’
2
) against
Centruroides sp.
in USA/Mexico, while there is still a need for a higher level of evidence for immunotherapy in the Old World envenomation.
Scorpion envenomation is a life-threatening accident encountered in tropical and subtropical areas. It remains an under-reported disease but around 1.2 million stings are yearly recorded around the ...world, ensuing in 3250 deaths as a consequence of acute heart and respiratory failure) 1. The great majority (>90%) of stings by the Old World scorpions (North Africa, India, and theMiddle East) are so-called dry stings, resulting in localized discomfort. When systemic envenomation occurs, several systems may be affected, including the gastrointestinal, neurological, inflammatory systems, etc. 2. Life-threatening presentations with acute heart failure features occur in less than 1% of cases. In what follows, we will strive to show how the little research dedicated to this neglected disease has led to significant scientific advances both through the derived experimental modelof the widespread Takotsubo syndrome and by the proliferation of venom-derived drugs.
Baseline characteristics and management have changed over time in patients requiring mechanical ventilation; however, the impact of these changes on patient outcomes is unclear.
To estimate whether ...mortality in mechanically ventilated patients has changed over time.
Prospective cohort studies conducted in 1998, 2004, and 2010, including patients receiving mechanical ventilation for more than 12 hours in a 1-month period, from 927 units in 40 countries. To examine effects over time on mortality in intensive care units, we performed generalized estimating equation models.
We included 18,302 patients. The reasons for initiating mechanical ventilation varied significantly among cohorts. Ventilatory management changed over time (P < 0.001), with increased use of noninvasive positive-pressure ventilation (5% in 1998 to 14% in 2010), a decrease in tidal volume (mean 8.8 ml/kg actual body weight SD = 2.1 in 1998 to 6.9 ml/kg SD = 1.9 in 2010), and an increase in applied positive end-expiratory pressure (mean 4.2 cm H2O SD = 3.8 in 1998 to 7.0 cm of H2O SD = 3.0 in 2010). Crude mortality in the intensive care unit decreased in 2010 compared with 1998 (28 versus 31%; odds ratio, 0.87; 95% confidence interval, 0.80-0.94), despite a similar complication rate. Hospital mortality decreased similarly. After adjusting for baseline and management variables, this difference remained significant (odds ratio, 0.78; 95% confidence interval, 0.67-0.92).
Patient characteristics and ventilation practices have changed over time, and outcomes of mechanically ventilated patients have improved. Clinical trials registered with www.clinicaltrials.gov (NCT01093482).
ObjectiveTo assess the prevalence of anxiety and depressive symptoms and the associated risk factors among Tunisian medical residents.DesignCross-sectional survey.SettingFaculty of Medicine, ...Tunis.ParticipantsAll Tunisian medical residents brought together between 14 and 22 December 2015 to choose their next 6-month rotation.InterventionThe items of the Hospital Anxiety and Depression (HAD) questionnaire were employed to capture the prevalence of anxiety and/or depression among the residents. The statistical relationships between anxiety and depression (HAD score) and sociodemographic and work-related data were explored by Poisson regression.Results1700 out of 2200 (77%) medical residents (mean age: 28.5±2 years, female: 60.8%) answered the questionnaire. The mean working hours per week was 62±21 hours; 73% ensured a mean of 5.4±3 night shifts per month; and only 8% of them could benefit from a day of safety rest. Overall, 74.1% of the participating residents had either definite (43.6%) or probable (30.5%) anxiety, while 62% had definite (30.5%) or probable (31.5%) depression symptoms, with 20% having both definite anxiety and definite depression. The total HAD score was significantly associated with the resident’s age (OR=1.014, 95% CI 1.006 to 1.023, p=0.001); female gender (OR=1.114, 95% CI 1.083 to 1.145, p<0.0001); and the heavy burden of work imposed on a weekly or monthly basis, as reflected by the number of night shifts per month (OR=1.048, 95% CI 1.016 to 1.082, p=0.03) and the number of hours worked per week (OR=1.008, 95% CI 1.005 to 1.011, p<0.0001). Compared with medical specialties, the generally accepted difficult specialties (surgical or medical-surgical) were associated with a higher HAD score (OR=1.459, 95% CI 1.172 to 1.816, p=0.001).ConclusionTunisian residents experience a rate of anxiety/depression substantially higher than that reported at the international level. This phenomenon is worrying as it has been associated with an increase in medical errors, work dissatisfaction and attrition. The means of improving the well-being of Tunisian medical residents are explored, emphasising those requiring immediate implementation.
Objective
To compare the effects of ventilation in prone and in supine position in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS).
Design
Meta-analysis of randomised ...controlled trials.
Data sources
BioMedCentral, PubMed, CINAHL, and Embase (to November 2007), with additional information from authors.
Measurements and results
From selected randomised controlled trials comparing positioning in ALI/ARDS we extracted data concerning study design, disease severity, clinical outcomes, and adverse events. Five trials including 1,372 patients met the inclusion criteria for mortality analysis; one trial was added to assess the effects on acquisition of ventilator-associated pneumonia (VAP). The included trials were significantly underpowered and enrolled patients with varying severity. Prone positioning duration and mechanical ventilation strategy were not standardised across studies. Using a fixed-effects model, we did not find a significant effect of prone positioning (proning) on mortality (odds ratio 0.97, 95% confidence interval 0.77–1.22). The PaO
2
/FiO
2
ratio increased significantly more with proning (weighted means difference 25 mmHg,
p
< 0.00001). Proning was associated with a non-significant 23% reduction in the odds of VAP (
p
= 0.09), and with no increase in major adverse airway complications: OR 1.01, 95% CI 0.71–1.43. Length of intensive care unit stay was marginally and not significantly increased by proning.
Conclusions
Prone position is not associated with a significant reduction in mortality from ALI/ARDS despite a significant increase in PaO
2
/FiO
2
, is safe, and tends to decrease VAP. Published studies exhibit substantial clinical heterogeneity, suggesting that an adequately sized study optimising the duration of proning and ventilation strategy is warranted to enable definitive conclusions to be drawn.
Recent literature in mechanical ventilation includes strong evidence from randomized trials. Little information is available regarding the influence of these trials on usual clinical practice.
To ...describe current mechanical ventilation practices and to assess the influence of interval randomized trials when compared with findings from a 1998 cohort.
A prospective international observational cohort study, with a nested comparative study performed in 349 intensive care units in 23 countries. We enrolled 4,968 consecutive patients receiving mechanical ventilation over a 1-month period. We recorded demographics and daily data related to mechanical ventilation for the duration of ventilation. We systematically reviewed the literature and developed 11 practice-change hypotheses for the comparative cohort study before seeing these results. In assessing practice changes, we only compared data from the 107 intensive care units (1,675 patients) that also participated in the 1998 cohort (1,383 patients).
In 2004 compared with 1998, the use of noninvasive ventilation increased (11.1 vs. 4.4%, P < 0.001). Among patients with acute respiratory distress syndrome, tidal volumes decreased (7.4 vs. 9.1 ml/kg, P < 0.001) and positive end-expiratory pressure levels increased slightly (8.7 vs. 7.7 cm H(2)O, P = 0.02). More patients were successfully extubated after their first attempt of spontaneous breathing (77 vs. 62%, P < 0.001). Use of synchronized intermittent mandatory ventilation fell dramatically (1.6 vs. 11%, P < 0.001). Observations confirmed 10 of our 11 practice-change hypotheses.
The strong concordance of predicted and observed practice changes suggests that randomized trial results have advanced mechanical ventilation practices internationally.
Purpose
Variations in clinical characteristics and management and in the mortality of mechanically ventilated patients have not been sufficiently evaluated. We hypothesized that mortality shows a ...variability associated with country after adjustment for clinical characteristics and management.
Methods
Analysis of four studies carried out at 6-year intervals over an 18-year period. The studies included 26,024 patients (5183 in 1998, 4968 in 2004, 8108 in 2010, and 7765 in 2016) admitted to 1253 units from 38 countries. The primary outcome was 28-day mortality. We performed analyses using multilevel logistic modeling with mixed-random effects, including country as a random variable. To evaluate the effect of management strategies on mortality, a mediation analysis was performed.
Results
Adjusted 28-day mortality decreased significantly over time (first study as reference): 2004: odds ratio 0.82 (95% confidence interval CI 0.72–0.93); 2010: 0.63 (95% CI 0.53–0.75); 2016: 0.49 (95% CI 0.39–0.61). A protective ventilatory strategy and the use of continuous sedation mediated a moderate fraction of the effect of time on mortality in patients with moderate hypoxemia and without hypoxemia, respectively. Logistic multilevel modeling showed a significant effect of country on mortality: median odds ratio (MOR) in 1998: 2.02 (95% CI 1.57–2.48); in 2004: 1.76 (95% CI 1.47–2.06); in 2010: 1.55 (95% CI 1.37–1.74), and in 2016: 1.39 (95% CI 1.25–1.54).
Conclusions
These findings suggest that country could contribute, independently of confounder variables, to outcome. The magnitude of the effect of country decreased over time.
Clinical trials registered with
http://www.clinicaltrials.gov
(NCT02731898).
In 2013 in Tunisia, 3 persons in 1 family were infected with Middle East respiratory syndrome coronavirus (MERS-CoV). The index case-patient's respiratory tract samples were negative for MERS-CoV by ...reverse transcription PCR, but diagnosis was retrospectively confirmed by PCR of serum. Sequences clustered with those from Saudi Arabia and United Arab Emirates.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The role of antibiotics in treatment of patients with moderate exacerbations of chronic obstructive pulmonary disease (COPD) is uncertain, but such treatment might be useful in very severe episodes. ...Our objective was to assess the effects of ofloxacin in patients with exacerbations of COPD who required mechanical ventilation.
We did a prospective, randomised, double-blind, placebo-controlled trial in 93 patients with acute exacerbation of COPD who required mechanical ventilation. Patients were randomly assigned to receive oral ofloxacin 400 mg once daily (n=47) or placebo (46) for 10 days. Primary endpoints were death in hospital and need for an additional course of antibiotics, both separately and in combination. Analysis was by intention to treat.
Three patients dropped out of the study. Two (4%) patients receiving ofloxacin died in hospital and ten (22%) did so in the placebo group (absolute risk reduction 17·5%, 95% Cl 4·3–30·7, p=0·01). Treatment with ofloxacin significantly reduced the need for additional courses of antibiotics (28·4%, 12·9–43·9, p=0·0006). The combined frequency of death in hospital and need for additional antibiotics was significantly lower in patients assigned to ofloxacin than in those receiving placebo (45·9%, 29·1–62·7, p<0·0001). The duration of mechanical ventilation and hospital stay was significantly shorter in the ofloxacin group than in the placebo group (absolute difference 4·2 days, 95% Cl 2·5–5·9; and 9·6 days, 3·4–12·8, respectively).
New fluoroquinolones, such as ofloxacin, are beneficial in the treatment of COPD exacerbation requiring mechanical ventilation.
Mechanical Ventilation (MV) is a complex and central treatment process in the care of critically ill patients. It influences acid-base balance and can also cause prognostically relevant biotrauma by ...generating forces and liberating reactive oxygen species, negatively affecting outcomes. In this work we evaluate the use of a Recurrent Neural Network (RNN) modelling to predict outcomes of mechanically ventilated patients, using standard mechanical ventilation parameters.
We performed our analysis on VENTILA dataset, an observational, prospective, international, multi-centre study, performed to investigate the effect of baseline characteristics and management changes over time on the all-cause mortality rate in mechanically ventilated patients in ICU. Our cohort includes 12,596 adult patients older than 18, associated with 12,755 distinct admissions in ICUs across 37 countries and receiving invasive and non-invasive mechanical ventilation. We carry out four different analysis. Initially we select typical mechanical ventilation parameters and evaluate the machine learning model on both, the overall cohort and a subgroup of patients admitted with respiratory disorders. Furthermore, we carry out sensitivity analysis to evaluate whether inclusion of variables related to the function of other organs, improve the predictive performance of the model for both the overall cohort as well as the subgroup of patients with respiratory disorders.
Predictive performance of RNN-based model was higher with Area Under the Receiver Operating Characteristic (ROC) Curve (AUC) of 0.72 (± 0.01) and Average Precision (AP) of 0.57 (± 0.01) in comparison to RF and LR for the overall patient dataset. Higher predictive performance was recorded in the subgroup of patients admitted with respiratory disorders with AUC of 0.75 (± 0.02) and AP of 0.65 (± 0.03). Inclusion of function of other organs further improved the performance to AUC of 0.79 (± 0.01) and AP 0.68 (± 0.02) for the overall patient dataset and AUC of 0.79 (± 0.01) and AP 0.72 (± 0.02) for the subgroup with respiratory disorders.
The RNN-based model demonstrated better performance than RF and LR in patients in mechanical ventilation and its subgroup admitted with respiratory disorders. Clinical studies are needed to evaluate whether it impacts decision-making and patient outcomes.
NCT02731898 ( https://clinicaltrials.gov/ct2/show/NCT02731898 ), prospectively registered on April 8, 2016.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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