Comparison of multiple definitions for ventilator-associated pneumonia in patients requiring mechanical ventilation for non-pulmonary conditions: preliminary data from PULMIVAP, an Italian multi-centre cohort study.

OBJECTIVES: To compare intensivist-diagnosed ventilator-associated pneumonia (iVAP) with four established definitions, assessing their agreement in detecting new episodes. METHODS: A multi-centric prospective study on pulmonary microbiota was carried out in patients requiring mechanical ventilation (MV). Data collected were used to compare hypothetical VAP onset according to iVAP with the study consensus criteria, the European Centre for Disease Control and Prevention definition, and two versions of the latter adjusted for leukocyte count and fever. RESULTS: In our cohort of 186 adult patients, iVAPs were 36.6% (68/186, 95% confidence interval 30.0-44.0%), with an incidence rate of 4.64/100 patient-MV-days, and median MV-day at diagnosis of 6. Forty-seven percent of patients (87/186) were identified as VAP by at least one criterion, with a median MV-day at diagnosis of 5. Agreement between intensivist judgement (iVAP/no-iVAP) and the criteria was highest for the study consensus criteria (50/87, 57.4%), but still one-third of iVAP were not identified and 9% of patients were identified as VAP contrary to intensivist diagnosis. VAP proportion differed between criteria (25.2-30.1%). CONCLUSIONS: Caution is needed when evaluating studies describing VAP incidence. Pre-agreed criteria and definitions that capture VAP's evolving nature provide greater consistency, but new clinically driven definitions are needed to align surveillance and diagnostic criteria with clinical practice.

Toxic elements at a disused mine district: Particle size distribution and total concentration in stream sediments and mine tailings.

Heavy metal and metalloid pollution at a disused pyrite mine was investigated. Five solid samples collected in the area (three stream sediments with different soil texture, a background soil sample and a mine tailing) were characterised by mineral and element composition, particle size distribution (by wet and dry sieving and laser diffraction) and total concentration by acid digestion (Mn, Zn, Cu, Pb, Hg, Cd, Sb and As). X-ray and element analyses denoted a common mineralogical and chemical composition of mainly quartz, clinochlore, muscovite, anorthite, and hematite. Particle size distributions of the five samples showed that stream sediments were characterised by larger percentage of sand range classes (2000-60 microm) while background sample and tailing are mainly characterised by gravel particles (>2000 microm). Wet and dry sieving procedures gave different particle size distributions, which can be interpreted by laser diffraction analysis and represented by Rosin-Rammler model. Concentrations of Zn, Cu and Cd were higher in the stream sediments than the tailing and background soil, while Mn, As, Sb and Hg are mainly concentrated in the tailing sample. Metal concentrations in the three stream sediment samples are correlated with both particle size dimensions (D(63.2)) and concentration of geochemical normalizers (iron and aluminium). These correlations are observed also for the pollutants that are mainly concentrated in tailing sample (Mn and As), denoting the importance of surface interactions also for the binding of these elements onto stream sediments.

An interrupted 34-CAG repeat SCA-2 allele in patients with sporadic spinocerebellar ataxia.

In spinocerebellar ataxia type 2 (SCA-2), a difference of three CAG repeats distinguishes normal alleles (14 to 31 repeats) from pathogenic alleles (34 to 57 repeats). All sequenced pathogenic alleles have a pure CAG repeat structure, whereas interrupted repeats have been seen exclusively in normal alleles. The authors present two patients with sporadic SCA with an interrupted 34-CAG repeat allele, (CAG)24(CAA)(CAG)9, who showed a phenotype compatible with SCA-2. The interrupted allele coding for a 34 pure polyglutamine tract may cause the SCA phenotype.

Myotonic dystrophy phenotype without expansion of (CTG)n repeat: an entity distinct from proximal myotonic myopathy (PROMM)?

Myotonic dystrophy (DM) is associated with an expansion of an unstable (CTG)n repeat in the 3' untranslated region of the DM protein kinase (DMPK) gene on chromosome 19q13.3. We studied six patients from two families who showed no expansions of the repeat, in spite of their clinical diagnosis of DM. These patients had multi-systemic manifestations that were distinguishable from those seen in other myotonic disorders, including proximal myotonic myopathy (PROMM). In one additional family, two symptomatic members showed no expanded (CTG)n repeats, while their affected relatives had the expanded repeats. DM haplotype analysis failed to exclude the DMPK locus as a possible site of mutation in each family; however, DMPK mRNA levels were normal. We conclude that a mutation(s) other than the expanded (CTG)n repeat can cause the DM phenotype. The mutation(s) in these families remain(s) to be mapped and characterized.

ECMO: an alternative support for acute respiratory failure caused by tuberculosis?

Late diagnosis of tuberculosis (TB) may result in the development of severe acute respiratory failure. High mortality rates with conventional ventilation have been reported. Extracorporeal membrane oxygenation (ECMO) may represent an effective alternative treatment. We report a case of complicated pulmonary TB in a man who successfully underwent 3 months of ECMO.

Management of acute respiratory complications from influenza A (H1N1) infection: experience of a tertiary-level Intensive Care Unit.

BACKGROUND: The novel influenza A (H1N1) pandemic was associated with an epidemic of critical illness. METHODS: We describe the clinical profiles of critically ill patients with severe complications due to microbiologically confirmed pandemic influenza A (H1N1) infection admitted to a medical ICU in Monza, Italy, over a 6-month period. RESULTS: From August 2009 to January 2010, 19 patients (13 adults and 6 children) required ICU admission. Nine subjects were referred to our hospital from other ICUs. In all patients, with the exception of a case of severe septic shock, the cause of ICU admission was acute respiratory failure. Other nonpulmonary organ failures were common. A trial of non-invasive ventilation was attempted in 13 cases and was successful in four of them. The majority of the patients required invasive mechanical ventilation. In the 7 most severely hypoxemic patients, we applied veno-venous ECLS, with a very high rate of success. The median ICU stay was 9 days (range 1-78 days). Sixteen out of 19 (84%) patients survived. CONCLUSION: In the majority of our patients, critical illness caused by pandemic influenza A (H1N1) was associated with severe hypoxemia, multiple organ failure, requirement for mechanical ventilation and frequent use of rescue therapies and ECLS support.

Intracranial pressure monitoring in pediatric bacterial meningitis: a fancy or useful tool? A case report.

Childhood meningitis is associated with high mortality and morbidity. In selected cases, the prompt institution of invasive intracranial pressure (ICP) monitoring and therapy may improve survival but few studies have evaluated the indications for ICP monitoring in this specific neurological disease. This article examines the case of a five-year-old child who was comatose when admitted to the hospital with unilateral dilated pupil, neck stiffness and fever (T 39 degrees C). The initial brain computed tomography scan was unremarkable. Dexamethasone and empirical antibiotic therapy for suspected meningitis was started and a lumbar puncture (LP) was performed. The LP opening pressure was 45 mmHg. Cerebrospinal fluid microscopy demonstrated Meningococcal meningitis. The likelihood of raised ICP, associated with third nerve palsy, prompted insertion of an intraparenchymal catheter for ICP monitoring. Intracranial hypertension was treated with medical therapy. ICP was controlled within 72 hours. On day nine, the ICP device was removed. On the same day, the child started to obey commands, was rapidly weaned from mechanical ventilation and was extubated. He was discharged from the Department on day 13 and after two weeks went home with residual dysmetria and mild motor impairment. This study indicates that ICP-targeted treatment in children improves the outcome of severe cases of bacterial meningitis. ICP monitoring could particularly be useful to optimize brain perfusion and provide relief from severe neurological impairment, which is associated with the clinical signs of meningitis and increased ICP levels.

How to improve ischemic stroke treatment in the fibrinolysis era.

In the last 15 years new therapeutic approaches have influenced the treatment of ischemic stroke victims. Aim of this review is to point out the elements of a modern approach to the acute stroke patient. The likelihood of saving ischemic cerebral tissue is time-dependent and the treatment goal is to minimise brain damage. The NINDS trial has documented a higher likelihood of better outcome if the fibrinolytic therapy is administered within 3 h of onset of symptoms. To reach this target several interventions are necessary. First of all, education is needed to diffuse public awareness of stroke warning signs. Moreover, out-of-hospital treatment should be optimised with rapid triage and transport to an hospital with a comprehensive stroke approach. The early hospital phase should comprehend a rapid evaluation and an urgent CT scan. After the verification of the inclusion/exclusion criteria, in a authorised SITS-MOST centre, the patient should receive fibrinolytic therapy. The diagnostic and the therapeutic phase should include rapid identification and treatment of secondary insults, as hyperthermia and hyperglycaemia, that have a negative influence on outcome. Despite advances in diagnosis and monitoring, fibrinolytic therapy is the only treatment with a proven efficacy in achieving a higher functional outcome. The narrow time-window is the reason for the need of rapid and well-organised out-of-hospital and in-hospital systems.

NAD+/NADP+-dependent malic enzyme: evidence of a NADP+ preferring activity in human skeletal muscle.

The L-malate NAD(P)+ oxidoreductase (decarboxylating) E.C.1.1.1.39 was purified from human skeletal muscle; the specific activity estimated in the presence of NAPD+ as coenzyme was approximately 15 mumol/min/mg. The apparent Vmax values for NAD+ (approximately 8 mumol/min/mg) and NADP+ (approximately 16 mumol/min/mg) show that the enzyme (in this tissue) is more active in the presence of NAPD+. This observation was confirmed by the estimation of enzymatic activity in competition experiments where both NAD+ and NADP+ were used together as coenzymes. The absence of pyruvate carboxylation and of oxalacetate decarboxylation activities demonstrates that the enzyme studied is E.C.1.1.1.39. In addition, the apparent Km values for NAD+ and NADP+ were calculated (15 and 0.05 mM, respectively). This paper provides the first demonstration of a NADP+ preferring activity of the enzyme in human skeletal muscle.

Novel mutations in the CHST6 gene causing macular corneal dystrophy.

Macular corneal dystrophy (MCD) is an autosomal recessive disease characterized by corneal opacities and caused by mutations in a carbohydrate sulfotransferase gene, known as CHST6. MCD type I patients show missense mutations in the CHST6-coding region, and MCD type II patients show a large deletion and replacement in the upstream region of CHST6. The objective of this study was to identify the genetic defect in CHST6 gene causing MCD in Italian families. We investigated MCD genotype by using polymerase chain reaction followed by direct sequencing, and results were confirmed by restriction analysis. An enzyme-linked immunosorbent assay was performed to assess the presence of sulfated keratan sulfate in the serum of MCD patients. Biochemical analysis revealed a MCD type I phenotype in two families and a type II phenotype in another family. Two novel missense mutations and a polymorphism in the coding region of CHST6 gene were identified in patients with MCD type I. In one MCD II family, a homozygous deletion in the upstream region of CHST6 gene was found.

Effect of myotonic dystrophy trinucleotide repeat expansion on DMPK transcription and processing.

The myotonic dystrophy (DM) mutation has been identified as an unstable, expanded (CTG)n repeat in the 3' untranslated region of a gene designated DM protein kinase (DMPK). Both decreased and increased levels of mutant DMPK mRNA as well as decreased levels of protein have been variously reported and invoked to explain disparate molecular bases of this dominantly inherited disease. Most recently, increased nucleosome binding to such expanded repeats has been interpreted as support for transcriptional repression. A quantitative allele-specific RT-PCR procedure was developed and applied to a spectrum of patient tissue samples and cell lines. Equal levels of unprocessed pre-mRNA were produced by the wildtype (+) and disease (DM) alleles in skeletal muscle and cell lines of heterozygous DM patients. Thus, any increased nucleosome binding had no effect at the level of transcriptional initiation and transcription of the mutant DMPK locus. In contrast, processed mRNA levels from the DM allele were reduced relative to the+allele as the size of the expansion increased. The unstable repeat, therefore, impairs post-transcriptional processing of DM allele transcripts. This phenomenon has profound effects on overall DMPK locus steady-state transcript levels in cells missing a wildtype allele and does not appear to be mediated by imprinting, decreased mRNA stability, generation of aberrant splice forms, or absence of polyadenylation of the mutant allele.