Patients aged over 90 are being admitted to intensive care units (ICUs) with increasing frequency. The appropriateness of such decisions still remains controversial due to questionable outcome, ...limited resources and costs. Our objective was to determine the clinical characteristics and outcome in elderly patients (≥ 90 years) admitted in a medical ICU, with an additional focus on medico-economic implications.
We reviewed the charts of all patients (≥ 90 years) admitted to our ICU. We compared them with all other ICU patients (< 90 years), sought to identify ICU mortality predictors and also performed a long-term survival follow-up.
In the study group of 317 stays: median age was 92 years (IQR: 91-94 years); most patients were female (71.3%.). Acute respiratory failure (52.4%) was the main admission diagnosis; mean SAPS II was 55.6±21.3; half the stays (49.2%) required mechanical ventilation (duration: 7.2±8.8 days); withholding and withdrawing decisions were made for 33.4% of all stays. ICU and hospital mortality rates were 35.7% and 42.6% respectively. Mechanical ventilation (OR = 4.83, CI95%: 1.59-15.82) was an independent predictor of ICU mortality whereas age was not (OR = 0.88, CI95%: 0.72-1.08). Social security reimbursement was significantly lower in the study group compared with all other ICU stays, both per stay (13,160 vs 22,092 Euros, p< 0.01) and per day of stay (p = 0.03).
Among critically ill elderly patients (≥ 90 years), chronological age was not an independent factor of ICU mortality. ICU care-related costs in this population should not be considered as a limiting factor for ICU admission.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Long chain n-3 fatty acid supplementation may modulate septic shock-induced host response to pathogen-induced sepsis. The composition of lipid emulsions for parenteral nutrition however remains a ...real challenge in intensive care, depending on their fatty acid content. Because they have not been assessed yet, we aimed at determining the respective effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) during septic shock-induced vascular dysfunction.
In a peritonitis-induced septic shock model, rats were infused with EPA, DHA, an EPA/DHA mixture or 5% dextrose (D5) during 22 hours. From H18, rats were resuscitated and monitored during 4 hours. At H22, plasma, aorta and mesenteric resistance arteries were collected to perform ex vivo experiments.
We have shown that septic rats needed an active resuscitation with fluid challenge and norepinephrine treatment, while SHAM rats did not. In septic rats, norepinephrine requirements were significantly decreased in DHA and EPA/DHA groups (10.6±12.0 and 3.7±8.0 μg/kg/min respectively versus 17.4±19.3 μg/kg/min in D5 group, p<0.05) and DHA infusion significantly improved contractile response to phenylephrine through nitric oxide pathway inhibition. DHA moreover significantly reduced vascular oxidative stress and nitric oxide production, phosphorylated IκB expression and vasodilative prostaglandin production. DHA also significantly decreased polyunsaturated fatty acid pro-inflammatory mediators and significantly increased several anti-inflammatory metabolites.
DHA infusion in septic rats improved hemodynamic dysfunction through decreased vascular oxidative stress and inflammation, while EPA infusion did not have beneficial effects.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Momentum is growing around a proposed treaty governing the international transfer of small arms and light weapons. Those promoting the new instrument emphasize the existing obligations of States, ...under the law of State responsibility, not to aid or assist another State in violating international law. This article explores the extent to which the prohibition of “complicity” is a sufficient basis for requiring States to consider the end-use of the weapons they transfer. It offers suggestions for strengthening the effectiveness of the current draft treaty in a way that places respect for international humanitarian law and human rights at its core.
Purpose
The Doppler-based resistive index (RI) and semi-quantitative evaluation of renal perfusion using color Doppler (SQP) have shown promising results for predicting persistent acute kidney injury ...(AKI) in preliminary studies. This study aimed at evaluating the performance of RI and SQP to predict short-term renal prognosis in critically ill patients.
Methods
Prospective multicenter cohort study including unselected critically ill patients. Renal Doppler was performed at admission to the intensive care unit. The diagnostic performance of RI and SQP to predict persistent AKI at day 3 was evaluated.
Results
Overall, 371 patients were included, of whom 351 could be assessed for short-term renal recovery. Two thirds of the included patients had AKI (
n
= 233; 66.3%), of whom 136 had persistent AKI (58.4%). Doppler-based RI was higher and SQP lower in AKI patients and according to AKI recovery. Overall performance in predicting persistent AKI was however poor with area under ROC curve of respectively 0.58 (95% CI 0.52–0.64) and 0.59 (95% CI 0.54–0.65) for RI and SQP. Optimal cutoff was respectively 0.71 and 2 for RI and SQP. At optimal cutoff, sensitivity and specificity were 50% (95% CI 41–58%) and 68% (62–74%) for RI and 39% (32–45%) and 75% (66–82%) for SQP.
Conclusion
Although statistically associated with AKI occurrence, RI and SQP perform poorly in predicting persistent AKI at day 3. Further studies are needed to adequately describe factors influencing Doppler-based assessment of renal perfusion and to delineate whether these indicators may be useful at the bedside.
Clinicaltrial.gov
NCT02355314.
Adrenomedullin (ADM) regulates vascular tone and endothelial permeability during sepsis. Levels of circulating biologically active ADM (bio-ADM) show an inverse relationship with blood pressure and a ...direct relationship with vasopressor requirement. In the present prospective observational multinational Adrenomedullin and Outcome in Sepsis and Septic Shock 1 (, AdrenOSS-1) study, we assessed relationships between circulating bio-ADM during the initial intensive care unit (ICU) stay and short-term outcome in order to eventually design a biomarker-guided randomized controlled trial.
AdrenOSS-1 was a prospective observational multinational study. The primary outcome was 28-day mortality. Secondary outcomes included organ failure as defined by Sequential Organ Failure Assessment (SOFA) score, organ support with focus on vasopressor/inotropic use, and need for renal replacement therapy. AdrenOSS-1 included 583 patients admitted to the ICU with sepsis or septic shock.
Circulating bio-ADM levels were measured upon admission and at day 2. Median bio-ADM concentration upon admission was 80.5 pg/ml IQR 41.5-148.1 pg/ml. Initial SOFA score was 7 IQR 5-10, and 28-day mortality was 22%. We found marked associations between bio-ADM upon admission and 28-day mortality (unadjusted standardized HR 2.3 CI 1.9-2.9; adjusted HR 1.6 CI 1.1-2.5) and between bio-ADM levels and SOFA score (p < 0.0001). Need of vasopressor/inotrope, renal replacement therapy, and positive fluid balance were more prevalent in patients with a bio-ADM > 70 pg/ml upon admission than in those with bio-ADM ≤ 70 pg/ml. In patients with bio-ADM > 70 pg/ml upon admission, decrease in bio-ADM below 70 pg/ml at day 2 was associated with recovery of organ function at day 7 and better 28-day outcome (9.5% mortality). By contrast, persistently elevated bio-ADM at day 2 was associated with prolonged organ dysfunction and high 28-day mortality (38.1% mortality, HR 4.9, 95% CI 2.5-9.8).
AdrenOSS-1 shows that early levels and rapid changes in bio-ADM estimate short-term outcome in sepsis and septic shock. These data are the backbone of the design of the biomarker-guided AdrenOSS-2 trial.
ClinicalTrials.gov, NCT02393781 . Registered on March 19, 2015.
This study aimed at evaluating the performance of Doppler-based resistive index (RI) and semi-quantitative evaluation of renal perfusion using color-Doppler (SQP) to predict de novo AKI in the ...subgroup of critically ill patients without AKI at admission.
This study is an ancillary analysis of a prospective multicenter cohort study. Consecutive ICU patients requiring mechanical ventilation were included. Renal Doppler was performed at ICU admission. The diagnostic performance of RI and SQP to predict de novo AKI at day 3 was evaluated.
Among the 371 patients of the prospective cohort, 118 without AKI at study inclusion were included. Thirty-four patients (29%) developed an AKI. Neither RI (0.64 UI 0.57–0.70 vs 0.67 0.62–0.70 in no AKI and de novo AKI group respectively, p = 0.177) nor SQP (2 2, 3 vs 2 1–3 in no AKI and de novo AKI group respectively, p = 0.061) were associated with AKI occurrence. Overall performance in predicting de novo AKI was null to poor with area under ROC curve of respectively 0.60 (95% CI 0.49–0.65) and 0.58 (95% CI 0.47–0.60) for RI and SQP. Similar results were obtained after adjustment for confounders.
These results confirm the poor performance of Doppler-based indices in predicting renal prognosis of ICU patients.
•Renal Doppler is known to poorly predict renal recovery in unselected ICU patients.•This study focused on ICU patients with no overt renal dysfunction at admission.•In these patients, renal Doppler failed to predict de novo AKI.•Renal Doppler seems to be a useless tool to predict renal prognosis in ICU.
We reviewed the charts of all patients (greater than or equal to 90 years) admitted to our ICU. We compared them with all other ICU patients (< 90 years), sought to identify ICU mortality predictors ...and also performed a long-term survival follow-up. In the study group of 317 stays: median age was 92 years (IQR: 91-94 years); most patients were female (71.3%.). Acute respiratory failure (52.4%) was the main admission diagnosis; mean SAPS II was 55.6±21.3; half the stays (49.2%) required mechanical ventilation (duration: 7.2±8.8 days); withholding and withdrawing decisions were made for 33.4% of all stays. ICU and hospital mortality rates were 35.7% and 42.6% respectively. Mechanical ventilation (OR = 4.83, CI95%: 1.59-15.82) was an independent predictor of ICU mortality whereas age was not (OR = 0.88, CI95%: 0.72-1.08). Social security reimbursement was significantly lower in the study group compared with all other ICU stays, both per stay (13,160 vs 22,092 Euros, p< 0.01) and per day of stay (p = 0.03). Among critically ill elderly patients (greater than or equal to 90 years), chronological age was not an independent factor of ICU mortality. ICU care-related costs in this population should not be considered as a limiting factor for ICU admission.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Means of warfare Taylor, Terence; Maier, Charles S; Schmitt, Michael N ...
International review of the Red Cross (2005),
09/2005, Letnik:
87, Številka:
859
Journal Article
β2‐adrenergic receptor (β2‐AR) agonists are used for the treatment of asthma and chronic obstructive pulmonary disease, but also play a role in other complex disorders including cancer, diabetes and ...heart diseases. As the cellular and molecular mechanisms in various cells and tissues of the β2‐AR remain vastly elusive, we developed tools for this investigation with high temporal and spatial resolution. Several photoswitchable β2‐AR agonists with nanomolar activity were synthesized. The most potent agonist for β2‐AR with reasonable switching is a one‐digit nanomolar active, trans‐on arylazopyrazole‐based adrenaline derivative and comprises valuable photopharmacological properties for further biological studies with high structural accordance to the native ligand adrenaline.
β2‐adrenergic receptor agonists are used for the treatment of asthma, but also play a role in heart diseases. Several photoswitchable β2‐receptor agonists with nanomolar activity were synthesized and one adrenaline derivative is a one‐digit nanomolar, trans‐on, full agonist for the β2‐receptor. It represents a novel molecular probe for biological studies with high structural similarity to native adrenaline.
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