Evaluation of Sleep Architecture using 24-hour Polysomnography in Patients Recovering from Critical Illness in an Intensive Care Unit and High Dependency Unit: a Longitudinal, Prospective, and Observational Study.

BACKGROUND AND OBJECTIVE: The sleep architecture of critically ill patients being treated in Intensive Care Units (ICU) and High Dependency Units (HDU) is frequently unsettled and inadequate both qualitatively and quantitatively. The study aimed to investigate and elucidate factors influencing sleep architecture and quality in ICU and HDU in a limited resource setting with financial constraints, lacking human resources and technology for routine monitoring of noise, light and sleep promotion strategies in ICU. METHODS: The study was longitudinal, prospective, hospital-based, analytic, and observational. Insomnia Severity Index (ISI) and the Epworth Sleepiness Scale (ESS) pre hospitalisation scores were recorded. Patients underwent 24-hour polysomnography (PSG) with the simultaneous monitoring of noise and light in their environments. Patients stabilised in ICU were transferred to HDU, where the 24-hour PSG with the simultaneous monitoring of noise and light in their environments was repeated. Following PSG, the Richards-Campbell Sleep Questionnaire (RCSQ) was employed to rate patients' sleep in both the ICU and HDU. RESULTS: Of 46 screened patients, 26 patients were treated in the ICU and then transferred to the HDU. The mean (SD) of the study population's mean (SD) age was 35.96 (11.6) years with a predominantly male population (53.2% (n=14)). The mean (SD) of the ISI and ESS scores were 6.88 (2.58) and 4.92 (1.99), respectively. The comparative analysis of PSG data recording from the ICU and HDU showed a statistically significant reduction in N1, N2 and an increase in N3 stages of sleep (p<0.05). Mean (SD) of RCSQ in the ICU and the HDU were 54.65 (7.70) and 60.19 (10.85) (p-value = 0.04) respectively. The disease severity (APACHE II) has a weak correlation with the arousal index but failed to reach statistical significance (coeff= 0.347, p= 0.083). CONCLUSION: Sleep in ICU is disturbed and persisting during the recovery period in critically ill. However, during recovery, sleep architecture shows signs of restoration.

The Susceptibility of MDR-K. Pneumoniae To Polymyxin B Plus Its Nebulised Form Versus Polymyxin B Alone in Critically Ill South Asian Patients.

INTRODUCTION: Critically ill patients in intensive care units are at high risk of dying not only from the severity of their illness but also from secondary causes such as hospital-acquired infections. USA national medical record-data show that approximately 10% of patients on mechanical ventilation in an intensive care unit developed ventilator-associated pneumonia. Polymyxin B has been used intravenously in the treatment of multi-drug resistant gram-negative infections, either as a monotherapy or with other potentially effective antibiotics, and the recent international guidelines have emphasised the use of nebulised polymyxin B together with intravenous polymyxin B to gain the optimum clinical outcome in ventilator-associated pneumonia cases caused by multi-drug resistant gram-negative infections. METHODS: One hundred and seventy-eight patients with ventilator-associated pneumonia due to multi-drug resistant K. pneumoniae were identified during the study period. Following the inclusion and exclusion criteria, 121 patients were enrolled in the study and randomly allocated to two study groups. Group 1 patients were treated with intravenous Polymyxin B plus nebulised polymyxin B (n=64) and Group 2 patients with intravenous Polymyxin B alone (n=57). The study aimed to compare the use of Polymyxin B plus its nebulised form to polymyxin B alone, in the treatment of MDR-K. pneumoniae associated ventilator-associated pneumonia in critically ill patients. RESULTS: In Group 1, a complete clearance of K. pneumoniae was found in fifty-nine patients (92.1%; n=64) compared to forty patients (70.1%, n=57) in the Group 2 (P<0.003). The average time till extubation was significantly higher in Group 2 compared to Group 1 (P<0.05). The total length-of-stay in the ICU was significantly higher in Group 2 compared to Group 1. (P<0.05). These results support the view that the Polymyxin B dual-route regime may be considered as an appropriate antibiotic therapy, in critically ill South Asian patients with ventilator-associated pneumonia.

Candida Spp. in Lower Respiratory Tract Secretions - A Ten Years Retrospective Study.

INTRODUCTION: Lower respiratory tract secretions (LRTS) like sputum and tracheal aspirates are frequently sent to the microbiology laboratory from patients with various respiratory pathologies. Improper collection techniques can lead to false-positive results, resulting in improper therapy. AIM OF THE STUDY: To determine the percentage of contaminated samples sent to the microbiology laboratory, to establish the prevalence of Candida spp. in non-contaminated samples and therefore, the presence of Candida spp. originating in lower respiratory tract infections. Material and. METHODS: A 10-year data survey was conducted to assess the differences in Candida prevalence from contaminated versus non-contaminated samples, assessed and categorised by Bartlett grading system, and to emphasise the importance of quality control for potentially contaminated samples. The data were analysed according to gender, age, referring departments, and the species of Candida. For the statistical analysis, Kruskal-Wallis and Fisher tests were used, and the alpha value was set for 0.5. RESULTS: The prevalence of Candida spp. in all analysed samples was 31.60%. After excluding the contaminated samples, the actual prevalence was 27.66%. Of all sputum samples, 31.6% were contaminated. Patients aged more than 40 years old were more prone to provide contaminated sputum samples. C. albicans is more prevalent in non-contaminated sputum samples. In both sputum and tracheal aspirates, the chances of identifying a single species are higher than the chances of identifying multiple species. CONCLUSIONS: The study emphasises the importance of assessing the quality of sputum samples because of the high number of improperly collected samples sent to the microbiology laboratory.

Impact of the Severity of Liver Injury in COVID-19 Patients Admitted to an Intensive Care Unit During the SARS-CoV2 Pandemic Outbreak.

INTRODUCTION: The World Health Organization (WHO) identified a novel coronavirus, originating in Wuhan, China, in December 2019, as a pneumonia causing pathogen. Epidemiological data in Romania show more than 450.000 confirmed patients, with a constant number of approximately 10% admission in intensive care unit. METHOD: A retrospective, observational study was conducted from 1st March to 30th October 2020, comprising 657 patients, confirmed as having COVID-19, and who had been admitted to the intensive care unit of the Mures County Clinical Hospital, Tîrgu Mures, Romania, which had been designated as a support hospital during the pandemic. Patients who presented at admission or developed abnormal liver function tests in the first seven days of admission, were included in the study; patients with pre-existing liver disease, were excluded. RESULTS: The mean (SD) age of patients included in the study was 59.41 (14.66) years with a male: female ratio of 1.51:1. Survivor status, defined as patients discharged from the intensive care unit, was significantly associated with parameters such as age, leukocyte count, albumin level, glycaemia level (p<0.05 for all parameters.). CONCLUSIONS: Liver injury expressed through liver function tests cannot solely constitute a prognostic factor for COVID-19 patients, but its presence in critically ill patients should be further investigated and included in future guideline protocols.

Accuracy of Diagnostic Tests.

Following the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, design, development, validation, verification and implementation of diagnostic tests were actively addressed by a large number of diagnostic test manufacturers. This paper deals with the biases and sources of variation which influence the accuracy of diagnostic tests, including calculating and interpreting test characteristics, defining what is meant by test accuracy, understanding the basic study design for evaluating test accuracy, understanding the meaning of Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value, and evaluating them numerically, and the ROC curve (or Receiver Operating Characteristic ) and the Area under the Curve (AUC).

The Diagnostic and Prognostic Role of Vascular Endothelial Growth Factor C in Sepsis and Septic Shock.

INTRODUCTION: Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool. MATERIAL AND METHODS: The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality. RESULTS: The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student's t-test.) Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml. CONCLUSIONS: VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.

A Comparison of Nosocomial Infection Density in Intensive Care Units on Relocating to a New Hospital.

BACKGROUND: The study aimed to investigate the changes in nosocomial infection density after patients were transferred to the intensive care unit (ICU) of a new-build hospital. METHODS: The types and rates of nosocomial infections were obtained for a one-year period retrospectively before leaving the old hospital premises and for a one-year periods after moving into the new hospital. The intensive care unit in the "old" premises was comprised of a 17-bedded hall, and thirty-three nurses shifted to work forty-eight hours a week, with each nurse assigned to provide care for two patients. The intensive care unit in the "new" premises consisted of single rooms, each with twenty-eight beds. RESULTS: The median nosocomial infection density decreased from 23 to 15 per 1000 in-patient days. The catheter-related urinary tract infection rate decreased from 7.5 to 2.6 per100 catheter days. CONCLUSIONS: Treatment of patients in the new hospital resulted in a decrease in nosocomial infection density.

Management of Pneumomediastinum Associated with H1N1 Pneumonia: A Case Report.

H1N1 is seen in tropical countries like India, occurring irrespective of the season. Complications of the disease are frequently encountered and there is little in the way or guidelines as to the how these should be managed. The treatment of one such complication, a recurrent pneumiomediastinum is the subject of the current paper. The management followed guidance for the treatment of a similar condition known as primary spontaneous pneumomediastinum, an uncommon condition resulting from alveolar rupture-otherwise known as the Macklin phenomenon.

Fatal Hypocalcaemia Due to Hungry Bone Syndrome with Secondary Refractory HyperParathyroidism After Parathyroidectomy: A Case Report.

INTRODUCTION: Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]. CASE REPORT: This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL. CONCLUSION: HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.

Abdominal Sepsis: An Update.

Despite the significant development and advancement in antibiotic therapy, life-threatening complication of infective diseases cause hundreds of thousands of deaths world. This paper updates some of the issues regarding the etiology and treatment of abdominal sepsis and summaries the latest guidelines as recommended by the Intra-abdominal Infection (IAI) Consensus (2017). Prognostic scores are currently used to assess the course of peritonitis. Irrespective of the initial cause, there are several measures universally accepted as contributing to an improved survival rate, with the early recognition of IAI being the critical matter in this respect. Immediate correction of fluid balance should be undertaken with the use of vasoactive agents being prescribed, if necessary, to augment and assist fluid resuscitation. The WISS study showed that mortality was significantly affected by sepsis irrespective of any medical and surgical measures. A significant issue is the prevalence of extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae in the clinical setting, and the reported prevalence of ESBLs intra-abdominal infections has steadily increased in Asia. Europe, Latin America, Middle East, North America, and South Pacific. Abdominal cavity pathology is second only to sepsis occurring in a pulmonary site. Following IAI (2017) guidelines, antibiotic therapy should be initiated as soon as possible after a diagnosis has been verified.

Light energy transmission through six different makes of ceramic orthodontic brackets.

OBJECTIVE: To measure Total Light Energy (TLE) Transmission through six makes of ceramic orthodontic brackets alone and bracket-plus-adhesive samples, using the MARC™-Resin Calibrator (RC). METHODS: Six makes, three each monocrystalline (M) and polycrystalline (P) were used; PureSapphire (M), SPA Aesthetic (M), Ghost (M), Mist (P), Reflections (P), and Dual Ceramic (P). The Ortholux™ Light Curing Unit (LCU) was used to cure the orthodontic adhesive Transbond™XT. The LCU's tip irradiance was measured and TLE transmitted through the ceramic bracket was obtained, then adhesive added to the bracket, and transmitted TLE measured through bracket-plus-adhesive samples. The LCU was set at five seconds as recommended for curing adhesive through ceramic brackets. RESULTS: Mean tip irradiance was 1859.2±16.2mW/cm2. The TLE transmitted through brackets alone ranged 1.7 to 3.9J/cm2, in the descending order: Ghost>Pure Sapphire>Reflections>Mist>SPA Aesthetics>Dual Ceramic. The TLE transmitted through bracket-plus-adhesive samples ranged 1.6 to 3.7J/cm2, in the descending order: Ghost>Mist>Reflections>Pure Sapphire>SPA Aesthetics>Dual Ceramic. TLE was reduced with the addition of adhesive (range -0.1 to -0.7J/cm2). There was a significant difference for Pure Sapphire, Reflections, and Mist (P<0.05), but not for SPA Aesthetics, Ghost, and Dual Ceramic. There was no overall significant difference between the monocrystalline and polycrystalline makes. The two best makes were of the monocrystalline type, concerning TLE transmission, but with the exception of polycrystalline Dual Ceramic; the next worst make was a monocrystalline bracket, SPA Aesthetics. CONCLUSION: Light energy attenuation through ceramic orthodontic brackets is make-dependent, with no overall difference between monocrystalline and polycrystalline brackets. Light energy is further attenuated with the addition of resin-based orthodontic adhesive.

Validation of the efficacy of age assessment by the Brothwell tooth wear chart, using skulls of known age at death.

OBJECTIVE: The present study aims to validate the efficacy of age assessment by the Brothwell tooth wear chart, uniquely using skulls of recorded known age at death. MATERIALS AND METHODS: Fifty Chinese skulls, of known age recorded at death, ranging from 16 to 62 years, were used. All the skulls were anonymized laid out, numbered 1-50, and using randomized tables. A 70-mm, ×3 magnification glass with light (Rolson, Ruscombe, Twyford, Berkshire, United Kingdom) was used to evaluate tooth wear patterns, and the age assessed using newly devised "age calculator" based on the Brothwell Chart. RESULTS: The recorded age at death versus the estimated age derived from the Brothwell chart was statistically compared the weighted kappa score = 0.877, suggestive of a "very good" strength of agreement. CONCLUSION: The Brothwell chart, based on tooth wear, can be used as a consistent method of age assessment, allowing for easier and more rapid data collection with no loss of overall accuracy.