Malnutrition is present in 20-50% of hospitalized patients, and nutritional care is a challenge. The aim was to evaluate whether the implementation of a nutritional strategy would influence ...nutritional care performance in a university hospital.
This was a prospective quality improvement program implementing guidelines for nutritional care, with the aim of improving nutritional practice. The Nutrition Risk Screening (NRS) 2002 was used. Point prevalence surveys over 2 years to determine whether nutritional practice had improved.
In total, 3604 (70%) of 5183 eligible patients were screened and 1230 (34%) were at nutritional risk. Only 53% of the at-risk patients got nutritional treatment and 5% were seen by a dietician. The proportion of patients screened increased from the first to the eighth point prevalence survey (P=0.012), but not the proportion of patients treated (P=0.66). The four initial screening questions in NRS 2002 identified 92% of the patients not at nutritional risk.
Implementation of nutritional guidelines improved the screening performance, but did not increase the proportion of patients who received nutritional treatment. Point prevalence surveys were useful to evaluate nutritional practice in this university hospital. In order to improve practice, we suggest using only the four initial screening questions in NRS 2002 to identify patients not at risk, better education in nutritional care for physicians and nurses, and more dieticians employed. Audit of implementation of guidelines, performed by health authorities, and specific reimbursement for managing nutrition may also improve practice.
Whole-saliva IgA appears like an attractive noninvasive readout for intestinal immune induction after enteric infection or vaccination, but has failed to show consistent correlation with established ...invasive markers and IgA in feces or intestinal lavage. For reference, we measured antibodies in samples from 30 healthy volunteers who were orally infected with wild-type enterotoxigenic Escherichia coli. The response against these bacteria in serum, lavage, and lymphocyte supernatants (antibody-in-lymphocyte-supernatant, ALS) was compared with that in targeted parotid and sublingual/submandibular secretions. Strong correlation occurred between IgA antibody levels against the challenge bacteria in sublingual/submandibular secretions and in lavage (r=0.69, P<0.0001) and ALS (r=0.70, P<0.0001). In sublingual/submandibular secretions, 93% responded with more than a twofold increase in IgA antibodies against the challenge strain, whereas the corresponding response in parotid secretions was only 67% (P=0.039). With >twofold ALS as a reference, the sensitivity of a >twofold response for IgA in sublingual/submandibular secretion was 96%, whereas it was only 67% in the parotid fluid. To exclude that flow rate variations influenced the results, we used albumin as a marker. Our data suggested that IgA in sublingual/submandibular secretions, rather than whole saliva with its variable content of parotid fluid, is a preferential noninvasive proxy for intestinal immune induction.
Patent Blue V (PBV) is injected in order to map sentinel nodes during cancer staging procedures. Anaphylactic reactions, allegedly IgE antibody mediated, have been reported. The aim of the study was ...to explore the immunological mechanism of anaphylaxis to PBV. PBV allergen threshold basophil sensitivity, CD-sens, was performed on cells from nine patients diagnosed as having had adverse reactions to PBV. The mechanisms of the CD-sens were studied by immunological and immuno-chemical methods. Five of the nine patients had a positive CD-sens to PBV which was completely eliminated by washing the cells in phosphate buffered saline before allergen challenge. However, the positive CD-sens was completely reconstituted by incubating the cells in plasma or serum of that patient or the other PBV-anaphylactic patients for 15 min at room temperature. In some patients the factor mediating CD-sens was completely or partially destroyed by heating at +56°C for 30 min or being exposed to the low pH used for elution from anti-Ig columns. A 1000-fold excess of monoclonal IgE blocked the reconstitution by approximately 50%. Anaphylactic reactions to PBV are mediated by IgE antibodies giving a classical CD-sens reaction. However, the allergenic configuration seems to constitute a structure completely dependent on PBV, as a hapten, linked to a, so far, unknown carrier that seems to be unique for patients having experienced a PBV-induced reaction. Further studies are needed to characterize the postulated carrier.
We report a patient with severe anaphylactic shock immediately after injection of i.v. fluorescein. The patient recovered without sequela. Immunoglobulin E (IgE) mechanism was highly suggestive with ...significant increase in serum tryptase, positive basophil allergen threshold sensitivity (CD‐sens) and histamine release tests towards fluorescein. This is, to our knowledge, the first report where CD‐sens has been used to aid in diagnosing an IgE‐mediated anaphylactic shock caused by fluorescein.
Introduction
supraglottic airway devices remain, despite advances in video laryngoscopy, important tools in the management of unexpected difficult airways. Intubation through a functioning ...supraglottic airway device with the aid of a fiberoptic bronchoscope is a well‐known technique usually performed in apnoea. With a simple modification, the patient can be ventilated during this procedure.
Methods
In this observational study, Tracheal intubation Assisted by Bronchoscopy And Sad during Continuous Oxygenation (TABASCO) was performed as part of department training routine in 26 elective, fasted patients. A supraglottic airway device was used as a conduit for an endotracheal tube.
Results
All patients were easily intubated and ventilation was maintained during the procedure. The gap between the outer diameter of the fiberoptic bronchoscope and the inner diameter of the endotracheal tube was more than 2 mm in 25 of 26 patients. Effective ventilation was confirmed by clinical signs, capnography and pressure‐volume curves. No signs of airtrapping occurred.
Discussion
No adverse events were observed during this form of airway management in this small series of elective and fasted patient when performed by an anaesthesiologist experienced in fiberoptic intubation. A gap between fiberoptic bronchoscope and endotracheal tube inner lumen seems to be prerequisite for easy ventilation through the supraglottic airway. In trained hands, this technique can be a means to secure an airway with an intubating bronchoscope without pausing ventilations. A prerequisite for this is a well‐functioning supraglottic airway device.
Group B streptococcus (GBS) imposes a major health threat to newborn infants. Little is known about the molecular basis of GBS-induced sepsis. Both heat-inactivated whole GBS bacteria and a ...heat-labile soluble factor released by GBS during growth (GBS-F) induce nuclear translocation of NF-kappaB, the secretion of TNF-alpha, and the formation of NO in mouse macrophages. Macrophages from mice with a targeted disruption of MyD88 failed to secrete TNF-alpha in response to both heat-inactivated whole bacteria and GBS-F, suggesting that Toll-like receptors (TLRs) are involved in different aspects of GBS recognition. Immune cell activation by whole bacteria differed profoundly from that by secreted GBS-F. Whole GBS activated macrophages independently of TLR2 and TLR6, whereas a response to the secreted GBS-F was not observed in macrophages from TLR2-deficient animals. In addition to TLR2, TLR6 and CD14 expression were essential for GBS-F responses, whereas TLR1 and TLR4 or MD-2 did not appear to be involved. Heat lability distinguished GBS-F from peptidoglycan and lipoproteins. GBS mutants deficient in capsular polysaccharide or beta-hemolysin had GBS-F activity comparable to that of wild-type streptococci. We suggest that CD14 and TLR2 and TLR6 function as coreceptors for secreted microbial products derived from GBS and that cell wall components of GBS are recognized by TLRs distinct from TLR1, 2, 4, or 6.
Purpose
We assessed the predefined long-term outcomes in patients randomised in the Transfusion Requirements in Septic Shock (TRISS) trial.
Methods
In 32 Scandinavian ICUs, we randomised 1005 ...patients with septic shock and haemoglobin of 9 g/dl or less to receive single units of leuko-reduced red cells when haemoglobin level was 7 g/dl or less (lower threshold) or 9 g/dl or less (higher threshold) during ICU stay. We assessed mortality rates 1 year after randomisation and again in all patients at time of longest follow-up in the intention-to-treat population (
n
= 998) and health-related quality of life (HRQoL) 1 year after randomisation in the Danish patients only (
n
= 777).
Results
Mortality rates in the lower- versus higher-threshold group at 1 year were 53.5 % (268/501 patients) versus 54.6 % (271/496) relative risk 0.97; 95 % confidence interval (CI) 0.85–1.09;
P
= 0.62; at longest follow-up (median 21 months), they were 56.7 % (284/501) versus 61.0 % (302/495) (hazard ratio 0.88; 95 % CI 0.75–1.03;
P
= 0.12). We obtained HRQoL data at 1 year in 629 of the 777 (81 %) Danish patients, and mean differences between the lower- and higher-threshold group in scores of physical HRQoL were 0.4 (95 % CI −2.4 to 3.1;
P
= 0.79) and in mental HRQoL 0.5 (95 % CI −3.1 to 4.0;
P
= 0.79).
Conclusions
Long-term mortality rates and HRQoL did not differ in patients with septic shock and anaemia who were transfused at a haemoglobin threshold of 7 g/dl versus a threshold of 9 g/dl. We may reject a more than 3 % increased hazard of death in the lower- versus higher-threshold group at the time of longest follow-up.
Background: Local anaesthetics (LA) are generally considered safe with respect to allergy. However, various clinical reactions steadily occur. Even though most reactions are manifestations of ...reflexes to perceptive stimuli, uncertainty often remains regarding a possible allergic mechanism. This uncertainty later leads to an avoidance of local anaesthesia and unnecessarily painful interventions, resource‐consuming general anaesthesia or even the risk of re‐exposure to other yet unidentified allergens. In the present study, follow‐up procedures at an allergy clinic were analysed to examine the frequency of identified causative agents and pathogenetic mechanisms and evaluate the strength of the diagnostic conclusions.
Method: The medical records of 135 cases with alleged allergic reactions to LA were reviewed. Diagnoses were based on case histories, skin tests, subcutaneous challenge tests and in vitro IgE analyses.
Results: Two events (1.5%) were diagnosed as hypersensitivity to LA, articaine–adrenaline and tetracaine–adrenaline, respectively. Ten reactions (7%) were diagnosed as IgE‐mediated allergy to other substances including chlorhexidine, latex, triamcinolone and possibly hexaminolevulinate. As challenge testing was not consistently performed with the culprit LA compound, follow‐ups were short of definitely refuting hypersensitivity in 61% of the cases. The reported clinical manifestations were in general diagnostically unspecific, but itch and generalised urticaria were most frequent in test‐positive cases.
Conclusion: Reactions during local anaesthesia are rarely found to be an IgE‐mediated LA allergy. Whenever the clinical picture is compatible with allergy, other allergens should also be tested.
Background
In this statistical analysis plan, we aim to provide details of the pre‐defined statistical analyses of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP‐ICU) trial. The aim of ...the SUP‐ICU trial is to assess benefits and harms of stress ulcer prophylaxis with a proton pump inhibitor in adult patients in the intensive care unit (ICU).
Methods
The SUP‐ICU trial is an investigator‐initiated, international, multicentre, randomised, blinded, parallel‐group trial of intravenously pantoprazole 40 mg once daily vs. placebo in 3350 acutely ill adult ICU patients at risk of gastrointestinal bleeding. The primary outcome measure is 90‐day mortality. Secondary outcomes include the proportion of patients with clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection or myocardial ischaemia, days alive without life support, serious adverse reactions, 1‐year mortality, and a health economic analysis. Two formal interim analyses will be performed. The statistical analyses will be conducted according to the outlined pre‐defined statistical analysis plan. The primary analysis will be a logistic regression analysis adjusted for stratification variables comparing the two intervention groups in the intention‐to‐treat population. In a secondary analysis, we will additionally adjust the primary outcome for potential random differences in baseline characteristics. The conclusion will be based on the intention‐to‐treat population.
Conclusion
Stress ulcer prophylaxis is standard of care in ICUs worldwide, but has never been tested in large high‐quality randomised placebo‐controlled trials. The SUP‐ICU trial will provide important high‐quality data on the balance between the benefits and harms of stress ulcer prophylaxis in adult critically ill patients.
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