Hypophosphatemia attenuates improvements in vitality after intravenous iron treatment in patients with inflammatory bowel disease.

PURPOSE: Iron deficiency anemia is common in people with inflammatory bowel disease (IBD), causing deterioration in quality of life, which can be reversed by treatment that increases iron stores and hemoglobin levels. The present post hoc analyses estimate health state utility values for patients with IBD after treatment with ferric derisomaltose or ferric carboxymaltose and evaluate the health domains driving the changes. METHODS: SF-36v2 responses were recorded at baseline and day 14, 35, 49, and 70 from 97 patients enrolled in the randomized, double-blind, PHOSPHARE-IBD trial (ClinicalTrials.gov ID: NCT03466983), in which patients with IBD across five European countries were randomly allocated to either ferric derisomaltose or ferric carboxymaltose. Changes in SF-36v2 scale scores and SF-6Dv2 health utility values were analyzed by mixed models. RESULTS: In both treatment arms, SF-6Dv2 utility values and all SF-36v2 scale scores, except Bodily Pain, improved significantly (p = < 0.0001). The improvement in SF-6Dv2 utility values showed no significant treatment group difference. The improvement in utility values was completely explained by improvement in Vitality scores. Vitality scores showed significantly larger improvement with ferric derisomaltose versus ferric carboxymaltose (p = 0.026). Patients with the smallest decrease in phosphate had significantly larger improvements in Vitality scores at each time point (p = < 0.05 for all comparisons) and overall (p = 0.0006). CONCLUSIONS: Utility values improved significantly with intravenous iron treatment. Improvement in utility values was primarily driven by Vitality scores, which showed significantly greater improvement in the ferric derisomaltose arm. Smaller decreases in phosphate were associated with significantly higher Vitality scores, suggesting that quality of life improvement is attenuated by hypophosphatemia. The utility values can inform future cost-utility analysis.

Evaluation of a method for isocapnic hyperventilation: a clinical pilot trial.

BACKGROUND: Isocapnic hyperventilation (IHV) is a method that shortens time to extubation after inhalation anaesthesia using hyperventilation (HV) without lowering airway CO2 . In a clinical trial on patients undergoing long-duration sevoflurane anaesthesia for major ear-nose-throat (ENT) surgery, we evaluated the utility of a technique for CO2 delivery (DCO2 ) to the inspiratory limb of a closed breathing circuit, during HV, to achieve isocapnia. METHODS: Fifteen adult ASA 1-3 patients were included. After end of surgery, mechanical HV was started by doubling baseline minute ventilation. Simultaneously, CO2 was delivered and dosed using a nomogram developed in a previous experimental study. Time to extubation and eye opening was recorded. Inspired (FICO2 ) and expired (FETCO2 ) CO2 and arterial CO2 levels were monitored during IHV. Cognition was tested pre-operatively and at 20, 40 and 60 min after surgery. RESULTS: A DCO2 of 285 ± 45 ml/min provided stable isocapnia during HV (13.5 ± 4.1 l/min). The corresponding FICO2 level was 3.0 ± 0.3%. Time from turning off the vaporizer (1.3 ± 0.1 MACage) to extubation (0.2 ± 0.1 MACage) was 11.3 ± 1.8 min after 342 ± 131 min of anaesthesia. PaCO2 and FETCO2 remained at normal levels during and after IHV. In 85% of the patients, post-operative cognition returned to pre-operative values within 60 min. CONCLUSIONS: In this cohort of patients, a DCO2 nomogram for IHV was validated. The patients were safely extubated shortly after discontinuing long-term sevoflurane anaesthesia. Perioperatively, there were no adverse effects on arterial blood gases or post-operative cognition. This technique for IHV can potentially be used to decrease emergence time from inhalation anaesthesia.

Isocapnic hyperventilation provides early extubation after head and neck surgery: A prospective randomized trial.

BACKGROUND: Isocapnic hyperventilation (IHV) shortens recovery time after inhalation anaesthesia by increasing ventilation while maintaining a normal airway carbon dioxide (CO2 )-level. One way of performing IHV is to infuse CO2 to the inspiratory limb of a breathing circuit during mechanical hyperventilation (HV). In a prospective randomized study, we compared this IHV technique to a standard emergence procedure (control). METHODS: Thirty-one adult ASA I-III patients undergoing long-duration (>3 hours) sevoflurane anaesthesia for major head and neck surgery were included and randomized to IHV-treatment (n = 16) or control (n = 15). IHV was performed at minute ventilation 13.6 ± 4.3 L/min and CO2 delivery, dosed according to a nomogram tested in a pilot study. Time to extubation and eye-opening was recorded. Inspired (FICO2 ) and expired (FETCO2 ) CO2 and arterial CO2 levels (PaCO2 ) were monitored. Cognition was tested preoperatively and at 20, 40 and 60 minutes after surgery. RESULTS: Time from turning off the vapourizer to extubation was 13.7 ± 2.5 minutes in the IHV group and 27.4 ± 6.5 minutes in controls (P < .001). Two minutes after extubation, PaCO2 was 6.2 ± 0.5 and 6.2 ± 0.6 kPa in the IHV and control group respectively. In 69% (IHV) vs 53% (controls), post-operative cognition returned to pre-operative values within 40 minutes after surgery (NS). Incidences of pain and nausea/vomiting did not differ between groups. CONCLUSIONS: In this randomized trial comparing an IHV method with a standard weaning procedure, time to extubation was reduced with 50% in the IHV group. The described IHV method can be used to decrease emergence time from inhalation anaesthesia.

Target temperature 34 vs. 36°C after out-of-hospital cardiac arrest - a retrospective observational study.

BACKGROUND: Intensive care for comatose survivors of cardiac arrest includes targeted temperature management (TTM) to attenuate cerebral reperfusion injury. A recent multi-center clinical trial did not show any difference in mortality or neurological outcome between TTM targeting 33°C or 36°C after out-of-hospital-cardiac-arrest (OHCA). In our institution, the TTM target was changed accordingly from 34 to 36°C. The aim of this retrospective study was to analyze if this change had affected patient outcome. METHODS: Intensive care registry and medical record data from 79 adult patients treated for OHCA with TTM during 2010 (n = 38; 34°C) and 2014 (n = 41; 36°C) were analyzed for mortality and neurological outcome were assessed as cerebral performance category. Student's t-test was used for continuous data and Fischer's exact test for categorical data, and multivariable logistic regression was applied to detect influence from patient factors differing between the groups. RESULTS: Witnessed arrest was more common in 2010 (95%) vs. 2014 (76%) (P = 0.03) and coronary angiography was more common in 2014 (95%) vs. 2010 (76%) (P = 0.02). The number of patients awakening later than 72 h after the arrest did not differ. After adjusting for gender, hypertension, and witnessed arrest, neither 1-year mortality (P = 0.77), nor 1-year good neurological outcome (P = 0.85) differed between the groups. CONCLUSION: Our results, showing no difference between TTM at 34°C and TTM at 36°C as to mortality or neurological outcome after OHCA, are in line with the previous TTM-trial results, supporting the use of either target temperature in our institution.

Effect of a chlorhexidine-containing brush-on gel on peri-implant mucositis.

OBJECTIVE: The aim was to evaluate the effect of a chlorhexidine-containing brush-on gel when used as supplement to oral hygiene instructions and mechanical debridement, on peri-implant mucositis in adults. MATERIALS AND METHODS: The study group consisted of 38 adults (48-87 years.) with peri-implant mucositis that were consecutively enrolled in three private clinics after informed consent. The study employed a double-blind controlled design with two parallel arms. After baseline registrations, oral hygiene reinforcement and mechanical debridement, the patients were randomly allocated to either a test group with once daily tooth brushing with an oral care brush-on gel containing 0.2% chlorhexidine digluconate (Cervitec Gel) or a control gel group. The duration of the intervention was 12 weeks. The primary outcome was bleeding on probing (BOP) and secondary endpoints were local plaque score (LPS) and pocket probing depth (PPD). RESULTS: The groups were balanced at baseline. The daily use of the chlorhexidine-containing gel resulted in reduced BOP after 4 and 12 weeks compared with the control group (P < 0.05). The PPD was significantly reduced (P < 0.05) after 12 weeks compared to baseline in the test group, but not in the control group. No side effects or adverse events were reported. CONCLUSION: The present findings indicated moderate but significant improvements of clinical parameters when mechanical debridement was combined with a self-applied oral care brush-on gel for the management of peri-implant mucositis.

Isocapnic hyperventilation shortens washout time for sevoflurane - an experimental in vivo study.

BACKGROUND: Isocapnic hyperventilation (IHV) is a method that fastens weaning from inhalation anaesthesia by increasing airway concentration of carbon dioxide (CO2 ) during hyperventilation (HV). In an animal model, we evaluated a technique of adding CO2 directly to the breathing circuit of a standard anaesthesia apparatus. METHODS: Eight anaesthetised pigs weighing 28 ± 2 kg were intubated and mechanically ventilated. From a baseline ventilation of 5 l/min, HV was achieved by doubling minute volume and fresh gas flow. Respiratory rate was increased from 15 to 22/min. The CO2 absorber was disconnected and CO2 was delivered (DCO2 ) to the inspiratory limb of a standard breathing circuit via a mixing box. Time required to decrease end-tidal sevoflurane concentration from 2.7% to 0.2% was defined as washout time. Respiration and haemodynamics were monitored by blood gas analysis, spirometry, electric impedance tomography and pulse contour analysis. RESULTS: A DCO2 of 261 ± 19 ml/min was necessary to achieve isocapnia during HV. The corresponding FICO2 -level remained stable at 3.1 ± 0.3%. During IHV, washout of sevoflurane was three times faster, 433 ± 135 s vs. 1387 ± 204 s (P < 0.001). Arterial CO2 tension and end-tidal CO2 , was 5.2 ± 0.4 kPa and 5.6 ± 0.4%, respectively, before IHV and 5.1 ± 0.3 kPa and 5.7 ± 0.3%, respectively, during IHV. CONCLUSIONS: In this experimental in vivo model of isocapnic hyperventilation, the washout time of sevoflurane anaesthesia was one-third compared to normal ventilation. The method for isocapnic hyperventilation described can potentially be transferred to a clinical setting with the intention to decrease emergence time from inhalation anaesthesia.

A simple method for isocapnic hyperventilation evaluated in a lung model.

BACKGROUND: Isocapnic hyperventilation (IHV) has the potential to increase the elimination rate of anaesthetic gases and has been shown to shorten time to wake-up and post-operative recovery time after inhalation anaesthesia. In this bench test, we describe a technique to achieve isocapnia during hyperventilation (HV) by adding carbon dioxide (CO2) directly to the breathing circuit of a standard anaesthesia apparatus with standard monitoring equipment. METHODS: Into a mechanical lung model, carbon dioxide was added to simulate a CO2 production (V(CO2)) of 175, 200 and 225 ml/min. Dead space (V(D)) volume could be set at 44, 92 and 134 ml. From baseline ventilation (BLV), HV was achieved by doubling the minute ventilation and fresh gas flow for each level of V(CO2), and dead space. During HV, CO2 was delivered (D(CO2)) by a precision flow meter via a mixing box to the inspiratory limb of the anaesthesia circuit to achieve isocapnia. RESULTS: During HV, the alveolar ventilation increased by 113 ± 6%. Tidal volume increased by 20 ± 0.1% during IHV irrespective of V(D) and V(CO2) level. D(CO2) varied between 147 ± 8 and 325 ± 13 ml/min. Low V(CO2) and large V(D) demanded a greater D(CO2) administration to achieve isocapnia. The FICO2 level during IHV varied between 2.3% and 3.3%. CONCLUSION: It is possible to maintain isocapnia during HV by delivering carbon dioxide through a standard anaesthesia circuit equipped with modern monitoring capacities. From alveolar ventilation, CO2 production and dead space, the amount of carbon dioxide that is needed to achieve IHV can be estimated.

Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine.

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.

Survey of central venous catheterisation practice in Sweden.

BACKGROUND: Clinical guidelines on central venous catheterisation were introduced by the Swedish Society of Anaesthesiology and Intensive Care Medicine in 2011. The purpose of this study was to investigate current national practice and assess to what extent these guidelines influence clinical routines in Swedish operating wards and intensive care units. METHODS: An invitation to participate in an online survey regarding central venous catheterisation was sent to 65 departments of anaesthesiology and intensive care medicine in Sweden. The survey aimed at investigating routine standards (part 1) and 24-h clinical practice (part 2). RESULTS: Forty-seven (72%) and 49 (75%) of 65 departments took part in parts 1 and 2, respectively, and 73% adhered to the national guidelines. Many units monitored mechanical (42%) and infectious (69%) complications. Ultrasound was used by more than 50%. Checklists for insertion were used by 22%. Physicians inserted most catheters. No serious complications were reported during the 24-h study period. Ninety-seven non-tunnelled, 17 venous ports, 9 tunnelled and 8 peripheral central venous catheters were inserted. Ninety-three (71%) catheters were inserted in operating rooms, and 31 (24%) in intensive care units. Catheterisations were followed up by chest X-ray in most departments. CONCLUSION: Knowledge of the Swedish guidelines was adequate, and most participating departments had local catheterisation routines. We could identify some variation in practice, but overall adherence to the guidelines was good. Nevertheless, monitoring of procedures and complications of cannulation and maintenance could be in need of improvement.

Oral clefts and behavioral health of young children.

OBJECTIVES: This study examined the behavioral health of young children with oral clefts, and effects of satisfaction with facial appearance, cleft team care, number of cleft-related surgeries, and socioeconomic status (SES). SUBJECTS AND METHODS: The study included a population-based sample of 104 children aged 2-12 years with isolated oral clefts from the state of Iowa. Behavior was evaluated with the Child Behavior Checklist or the Pediatric Behavior Scale 30, depending on age, compared with normative samples. RESULTS: Risks of behavioral problems were not significantly different from normative samples except for higher inattention/hyperactivity risks at age 6-12 years. Low satisfaction with facial appearance was associated with behavioral problems in all domains, except aggression. Team-care effects were not associated with behavioral problems. Number of cleft-related surgeries was associated with increased anxiety/depression and somatic symptom risks. Higher SES was associated with reduced inattention/hyperactivity, aggressive/oppositional behavior, and somatic symptoms. CONCLUSIONS: Most children with oral clefts may have similar behavioral health outcomes to unaffected children, except for increased inattention/hyperactivity risks at older ages. However, low satisfaction with facial appearance, increased exposure to surgeries, and lower SES may significantly increase behavioral problems. Also, the findings emphasize the need to study the representation of behavioral health professionals on cleft teams and access to behavioral health care.

Complications associated with peripheral or central routes for central venous cannulation.

We undertook a review of studies comparing complications of centrally or peripherally inserted central venous catheters. Twelve studies were included. Catheter tip malpositioning (9.3% vs 3.4%, p = 0.0007), thrombophlebitis (78 vs 7.5 per 10,000 indwelling days, p = 0.0001) and catheter dysfunction (78 vs 14 per 10,000 indwelling days, p = 0.04) were more common with peripherally inserted catheters than with central catheter placement, respectively. There was no difference in infection rates. We found that the risks of tip malpositioning, thrombophlebitis and catheter dysfunction favour clinical use of centrally placed catheters instead of peripherally inserted central catheters, and that the two catheter types do not differ with respect to catheter-related infection rates.

Positive end-expiratory pressure-induced changes in end-expiratory lung volume measured by spirometry and electric impedance tomography.

BACKGROUND: A bedside tool for monitoring changes in end-expiratory lung volume (ΔEELV) would be helpful to set optimal positive end-expiratory pressure (PEEP) in acute lung injury/acute respiratory distress syndrome patients. The hypothesis of this study was that the cumulative difference of the inspiratory and expiratory tidal volumes of the first 10 breaths after a PEEP change accurately reflects the change in lung volume following a PEEP alteration. METHODS: Changing PEEP induces lung volume changes, which are reflected in differences between inspiratory and expiratory tidal volumes measured by spirometry. By adding these differences with correction for offset, for the first 10 breaths after PEEP change, cumulative tidal volume difference was calculated to estimate ΔEELV(VT) ((i-e)) . This method was evaluated in a lung model and in patients with acute respiratory failure during a PEEP trial. In patients, ΔEELV(VT) ((i-e)) were compared with simultaneously measured changes in lung impedance, by electric impedance tomography (EIT), using calibration vs. tidal volume to estimate changes in ΔEELV(EIT) . RESULTS: In the lung model, there was close correlation (R(2) = 0.99) between ΔEELV(VT) ((i-e)) and known lung model volume difference, with a bias of -4 ml and limits of agreement of 42 and -50 ml. In 12 patients, ΔEELV(EIT) was closely correlated to ΔEELV(VT) ((i-e)) (R(2) = 0.92), with mean bias of 50 ml and limits of agreement of 131 and -31 ml. Changes in EELV estimated by EIT (ΔEELV(EIT) ) exceeded measurements by spirometry (ΔEELV(VT) ((i-e)) ), with 15 (±15)%. CONCLUSIONS: We conclude that spirometric measurements of inspiratory-expiratory tidal volumes agree well with impedance changes monitored by EIT and can be used bedside to estimate PEEP-induced changes in EELV.

Prolonged moderate pressure recruitment manoeuvre results in lower optimal positive end-expiratory pressure and plateau pressure.

BACKGROUND: In acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), recruitment manoeuvres (RMs) are used frequently. In pigs with induced ALI, superior effects have been found using a slow moderate-pressure recruitment manoeuvre (SLRM) compared with a vital capacity recruitment manoeuvre (VICM). We hypothesized that the positive recruitment effects of SLRM could also be achieved in ALI/ARDS patients. Our primary research question was whether the same compliance could be obtained using lower RM pressure and subsequent positive end-expiratory pressure (PEEP). Secondly, optimal PEEP levels following the RMs were compared, and the use of volume-dependent compliance (VDC) to identify successful lung recruitment and optimal PEEP was evaluated. PATIENTS AND METHODS: We performed a prospective randomised cross-over study where 16 ventilated patients with early ALI/ARDS each were subjected to the two RMs, followed by decremental PEEP titration. Volume-dependent initial, middle and final compliance (C(ini) , C(mid) and C(fin) ) were determined. Electric impedance tomography and end-expiratory lung volume measurements were used to follow lung volume changes. RESULTS: The maximum response in compliance, PaO2/FIO2, venous admixture and C(ini) /C(fin) after recruitment, during decremental PEEP, was at significantly lower PEEP and plateau pressure after SLRM than VICM. Fewer patients responded in gas exchange after the SLRM, which was not the case for lung mechanics. The response in C(ini) was more pronounced than in conventional compliance. CONCLUSIONS: The same compliance increase is achieved with SLRM as with VICM, and lower PEEP can be used, with correspondingly lower plateau pressures. VDC seems promising to identify successful recruitment and optimal PEEP.

A new non-radiological method to assess potential lung recruitability: a pilot study in ALI patients.

INTRODUCTION: Potentially recruitable lung has been assessed previously in patients with acute lung injury (ALI) by computed tomography. A large variability in lung recruitability was observed between patients. In this study, we assess whether a new non-radiological bedside technique could determine potentially recruitable lung volume (PRLV) in ALI patients. METHODS: Sixteen mechanically ventilated patients with early ALI/ARDS were subjected to a recruitment manoeuvre and decremental PEEP titration. Electric impedance tomography, together with measurements of end-expiratory lung volume (EELV) and tracheal pressure, were used to determine PRLV. The method defines fully recruited open lung volume (OLV) as the volume reached at the end of two consecutive vital capacity manoeuvres to 40 cmH2O. It also uses extrapolation of the baseline alveolar pressure/volume curve up to 40 cmH2O, the volume reached being the non-recruited lung volume. The difference between the fully recruited and the non-recruited volume was defined as PRLV. RESULTS: We observed a considerable heterogeneity among the patients in lung recruitability, PRLV range 11-47%. In a post hoc analysis, dividing the patients into two groups, a high and a low PRLV group, we found at baseline before the recruitment manoeuvre that the high PRLV group had lower compliance and a lower fraction of EELV/OLV. CONCLUSIONS: Using non-invasive radiation-free bedside methods, it may be possible to measure PRLV in ALI/ARDS patients. It is possible that this technique could be used to determine the need for recruitment manoeuvres and to select PEEP level on the basis of lung recruitability.

End-expiratory lung volume and ventilation distribution with different continuous positive airway pressure systems in volunteers.

BACKGROUND: Continuous positive airway pressure (CPAP) has been shown to improve oxygenation and a number of different CPAP systems are available. The aim of this study was to assess lung volume and ventilation distribution using three different CPAP techniques. METHODS: A high-flow CPAP system (HF-CPAP), an ejector-driven system (E-CPAP) and CPAP using a Servo 300 ventilator (V-CPAP) were randomly applied at 0, 5 and 10 cmH2O in 14 volunteers. End-expiratory lung volume (EELV) was measured by N2 dilution at baseline; changes in EELV and tidal volume distribution were assessed by electric impedance tomography. RESULTS: Higher end-expiratory and mean airway pressures were found using the E-CPAP vs. the HF-CPAP and the V-CPAP system (P<0.01). EELV increased markedly from baseline, 0 cmH2O, with increased CPAP levels: 1110±380, 1620±520 and 1130±350 ml for HF-, E- and V-CPAP, respectively, at 10 cmH2O. A larger fraction of the increase in EELV occurred for all systems in ventral compared with dorsal regions (P<0.01). In contrast, tidal ventilation was increasingly directed toward dorsal regions with increasing CPAP levels (P<0.01). The increase in EELV as well as the tidal volume redistribution were more pronounced with the E-CPAP system as compared with both the HF-CPAP and the V-CPAP systems (P<0.05) at 10 cmH2O. CONCLUSION: EELV increased more in ventral regions with increasing CPAP levels, independent of systems, leading to a redistribution of tidal ventilation toward dorsal regions. Different CPAP systems resulted in different airway pressure profiles, which may result in different lung volume expansion and tidal volume distribution.

Linoleic acid, a dietary n-6 polyunsaturated fatty acid, and the aetiology of ulcerative colitis: a nested case-control study within a European prospective cohort study.

OBJECTIVE: Dietary linoleic acid, an n-6 polyunsaturated fatty acid, is metabolised to arachidonic acid, a component of colonocyte membranes. Metabolites of arachidonic acid have pro-inflammatory properties and are increased in the mucosa of patients with ulcerative colitis. The aim of this investigation was to conduct the first prospective cohort study investigating if a high dietary intake of linoleic acid increases the risk of developing incident ulcerative colitis. DESIGN AND SETTING: Dietary data from food frequency questionnaires were available for 203 193 men and women aged 30-74 years, resident in the UK, Sweden, Denmark, Germany or Italy and participating in a prospective cohort study, the European Prospective Investigation into Cancer and Nutrition (EPIC). These participants were followed up for the diagnosis of ulcerative colitis. Each case was matched with four controls and the risk of disease calculated by quartile of intake of linoleic acid adjusted for gender, age, smoking, total energy intake and centre. RESULTS: A total of 126 participants developed ulcerative colitis (47% women) after a median follow-up of 4.0 years (range, 1.7-11.3 years). The highest quartile of intake of linoleic acid was associated with an increased risk of ulcerative colitis (odds ratio (OR) = 2.49, 95% confidence interval (CI) = 1.23 to 5.07, p = 0.01) with a significant trend across quartiles (OR = 1.32 per quartile increase, 95% CI = 1.04 to 1.66, p = 0.02 for trend). CONCLUSIONS: The data support a role for dietary linoleic acid in the aetiology of ulcerative colitis. An estimated 30% of cases could be attributed to having dietary intakes higher than the lowest quartile of linoleic acid intake.

A Scandinavian survey of drug administration through inhalation, suctioning and recruitment maneuvers in mechanically ventilated patients.

BACKGROUND: The aim was to describe current practices for drug administration through inhalation, endotracheal suctioning and lung recruitment maneuvers in mechanically ventilated patients in Scandinavian intensive care units (ICUs). METHODS: We invited 161 ICUs to participate in a web-based survey regarding (1) their routine standards and (2) current treatment of ventilated patients during the past 24 h. In order to characterize the patients, the lowest PaO(2) with the corresponding highest FiO(2), and the highest PaO(2) with the corresponding lowest FiO(2) during the 24-h study period were recorded. RESULTS: Eighty-seven ICUs answered and reported 186 patients. Positive end-expiratory pressure (PEEP) levels (cmH(2)O) were 5-9 in 65% and >10 in 31% of the patients. Forty percent of the patients had heated humidification and 50% received inhalation of drugs. Endotracheal suctioning was performed >7 times during the study period in 40% of the patients, of which 23% had closed suction systems. Twenty percent of the patients underwent recruitment maneuvers. The most common recruitment maneuver was to increase PEEP and gradually increase the inspiratory pressure. Twenty-six percent of the calculated PaO(2)/FiO(2) ratios varied >13 kPa for the same patient. CONCLUSION: Frequent use of drug administration through inhalation and endotracheal suctioning predispose to derecruitment of the lungs, possibly resulting in the large variations in PaO(2)/FiO(2) ratios observed during the 24-h study period. Recruitment maneuvers were performed only in one-fifth of the patients during the day of the survey.

Bronchoscopic suctioning may cause lung collapse: a lung model and clinical evaluation.

OBJECTIVE: To assess lung volume changes during and after bronchoscopic suctioning during volume or pressure-controlled ventilation (VCV or PCV). DESIGN: Bench test and patient study. PARTICIPANTS: Ventilator-treated acute lung injury (ALI) patients. SETTING: University research laboratory and general adult intensive care unit of a university hospital. INTERVENTIONS: Bronchoscopic suctioning with a 12 or 16 Fr bronchoscope during VCV or PCV. MEASUREMENTS AND RESULTS: Suction flow at vacuum levels of -20 to -80 kPa was measured with a Timeter(trade mark) instrument. In a water-filled lung model, airway pressure, functional residual capacity (FRC) and tidal volume were measured during bronchoscopic suctioning. In 13 ICU patients, a 16 Fr bronchoscope was inserted into the left or the right main bronchus during VCV or PCV and suctioning was performed. Ventilation was monitored with electric impedance tomography (EIT) and FRC with a modified N(2) washout/in technique. Airway pressure was measured via a pressure line in the endotracheal tube. Suction flow through the 16 Fr bronchoscope was 5 l/min at a vacuum level of -20 kPa and 17 l/min at -80 kPa. Derecruitment was pronounced during suctioning and FRC decreased with -479+/-472 ml, P<0.001. CONCLUSIONS: Suction flow through the bronchoscope at the vacuum levels commonly used is well above minute ventilation in most ALI patients. The ventilator was unable to deliver enough volume in either VCV or PCV to maintain FRC and tracheal pressure decreased below atmospheric pressure.

Antagonistic activities of lactic acid bacteria in food and feed fermentations.

Many factors contribute to a successful natural fermentation of carbohydrate-rich food and feed products. Metabolic activities of lactic acid bacteria (LAB) play a leading role. Their ability to rapidly produce copious amounts of acidic end products with a concomitant pH reduction is the major factor in these fermentations. Although their specific effects are difficult to quantitate, other LAB metabolic products such as hydrogen peroxide and diacetyl can also contribute to the overall antibiosis and preservative potential of these products. The contribution of bacteriocins is also difficult to evaluate. It is suggested that they may play a role in selecting the microflora which initiates the fermentation. Bacteriocins are believed to be important in the ability of LAB to compete in non-fermentative ecosystems such as the gastrointestinal tract. During the past few decades interest has arisen in the use of the varied antagonistic activities of LAB to extend the shelf-life of protein-rich products such as meats and fish. Recent findings indicate that the newly discovered Lactobacillus reuteri reuterin system may be used for this purpose.

Incidence, clinical presentation and mortality of liver cirrhosis in Southern Sweden: a 10-year population-based study.

BACKGROUND: In Sweden, the most common causes of liver cirrhosis are alcohol overconsumption and hepatitis C. However, recent data on the clinical characteristics of Swedish patients with cirrhosis are scarce. AIMS: To determine the incidence, clinical presentation, aetiological spectrum and survival rates of liver cirrhosis in Southern Sweden from 2001 to 2011. METHODS: We used population-based medical registries to conduct a cohort study of all patients with liver cirrhosis in the southernmost region of Sweden with a population of 1.17 million. Medical records and histopathology data were reviewed. Patients were classified according to aetiology, and clinical parameters were registered. Patients were followed until death or December 2014. RESULTS: A total of 1317 patients with cirrhosis were identified. The crude annual incidence of cirrhosis was estimated at 14.1/100 000. The most common aetiology was alcohol overconsumption with or without additional causes of cirrhosis (58%) followed by HCV alone (13%) and cryptogenic cirrhosis (12%). At diagnosis, ascites occurred in 43%, variceal bleeding in 6% and overt encephalopathy in 4%. The median follow-up was 4.3 years. The total 1-, 5- and 10-year survival rates were 79%, 47% and 27% respectively. Survival rates were better for women than for men. A 10-year cumulative incidence of transplantation was 7.3%. Mortality was worst for alcoholic cirrhosis with concomitant HCV when adjusted for age and gender. CONCLUSIONS: Sweden continues to have a low incidence of cirrhosis compared with other European countries. Mortality varies with gender, aetiology and severity at diagnosis. Patients with alcoholic cirrhosis with concomitant HCV infection fare worst.