sCXCL16 as a prognostic biomarker for COVID-19 outcome.

As elevated levels of the soluble CXCL16 (sCXCL16) chemokine have been reported in severe coronavirus disease 2019 (COVID-19) patients, this study examined whether sCXCL16 concentration on the first day of hospitalization predicted death in COVID-19 patients. A total of 76 patients with COVID-19 were admitted to the Military Hospital of Tunis, Tunisia, between October 2020 and April 2021, and later classified as survivors or nonsurvivors based on their outcomes. At admission, the groups were matched by age, gender, comorbidities, and the percentage of patients with moderate conditions. On the first day of admission, serum's sCXCL16 concentrations were measured using a magnetic-bead assay. There was an eightfold increase in serum sCXCL16 levels in the nonsurvivors' group (3661.51 ± 2464.87 pg/mL vs. 454.3 ± 338.07 pg/mL, p < 0.0001). For the optimal cutoff value of sCXCL16 at 2095 pg/mL, we found a 94.6% sensitivity and a 97.4% specificity, with an area under curve of 0.981 (p = 5.03E-08; 95% confidence interval [95% CI]: 0.951-1.0114). Considering the risk of death at a concentration above the threshold, the unadjusted odds ratio was 36 (p < 0.0001). The adjusted odd ratio was estimated at 1.003 (p < 0.0001; 95% CI: 1.002-1.004). Finally, there was a significant difference between survival and nonsurvival groups in leukocyte numbers (p = 0.006), lymphocytes (p = 0.001), polymorphonuclear neutrophils (p = 0.001), and C-reactive protein levels (p = 0.007), except for monocytes (p = 0.881). Based on these results, sCXCL16 level could be used for detecting nonsurvival COVID-19 patients. Therefore, we recommend assessing this marker in hospitalized COVID-19 patients.

Risk of mishaps during intrahospital transport of critically ill patients.

BACKGROUND: Mishaps are common during transport and may have major impacts on patients. AIMS: The main objectives of our study are: first to determine the incidence of complications during intra hospital transports (IHT) of critically ill patients, and second, to determine their risk factors. METHODS: All intra hospital transports for diagnostic and therapeutic purposes of patients consecutively admitted in an 18-bed medical surgical intensive care unit in an university hospital, have been studied prospectively during a period of six months (September 1st 2012 to February 28th 2013). RESULTS: Of 184 transports observed (164 patients), 85 (46.2%) were associated with mishaps. Eighty two mishaps were patient-related (44.5%).Oxygen desaturation (30 cases), agitation (24 cases) and hemodynamic instability (15 cases) were predominantly. One case of cardiac arrest and 3 cases of accidental extubation were occurred during IHT. Seventy three systems-based mishaps were noted (39.6%). Emergency transports, mechanical ventilation and positive end-expiratory pressure (PEEP) ≥ 6 cmH2O were independent risk factors for a higher rate of mishaps. In our study, complications did not statistically increase ventilator-associated pneumonia. CONCLUSION: This study confirms that IHT of critically-ill patients still involves considerable risks and mishaps incidence remains high.

Ultrasound-guided spinal anesthesia in an obese patient.

We describe the case of 62-year-old man with a body mass index of 53, hypertension, diabetes mellitus and obstructive sleep apnea that was proposed for transurethral resection of prostate under spinal anesthesia. The surface landmark-guided approach was difficult and was abandoned after many unsuccessful attempts. Spinal anesthesia was achieved in one attempt with ultrasound guidance using the midline approach at the identified level. The trajectory was determined from the transducer angle.

Publication of pediatric theses defended at the Tunis Faculty of Medicine: A 15-year study.

INTRODUCTION: The valorisation of thesis through its publication is necessary to enhance its visibility. Few data exist concerning the characteristics of theses defended at the Tunis faculty of medicine. AIM: Examine the publication rate of pediatric theses and identify factors associated with an increased publication rate. METHODS: We conducted a cross-sectional descriptive bibliometric study of pediatric theses defended at the Faculty of Medicine of Tunis over 15 years, from 2006 to 2020. Theses were retrieved from the catalog of the faculty library. Publications had been searched in databases "Pub Med ", and "Google Scholar" until December2021. RESULTS: The study involved 235 pediatric theses. Sixty-eight theses were published, representing 29% of the total. The main topics of published theses were neonatology (16%) and hematology (15%). The language of publication was French and English in 55% and 45% of cases, respectively. All publications in Q1 and Q2 journals were written in English. The only independent factor predicting publication of theses was the very honourable mention with congratulations of the jury and proposal for the thesis prize (p=0,007). CONCLUSION: Additional assessments will be necessary to identify the obstacles to the publication of theses.

Enhancing Student Success: Implementing Mentoring Programs in Academic Settings: Focus on the Faculty of Medicine of Tunis.

In order to improve the learning outcomes, skills, sense of belonging and well-being of their students, faculties around the world have chosen to implement mentoring programs for their learners. Given the complexity of implementing this approach, our objectives in this review are, on the one hand, to discuss and support the principles and recommendations of a mentoring project in an academic setting and, on the other hand, to present the vision of the Faculty of Medicine of Tunis regarding this mentoring approach.

A four-Axis-Method to Evaluate a Part of an Undergraduate Medical Students' Curriculum.

Introduction: The evaluation of programs in faculties of medicine enables them to adequately reach their mission objectives, and social responsibilities and to correct their potential lacune. Few publications have described the process of internal evaluation of a program performed by the organizational members. The authors aimed to describe a practical method called the four-axis method to assess curriculum using a practical example. Methods: The authors performed a descriptive study, highlighting the application of a particular method of evaluation of a program called the four-axis method. It consisted of the assessment of the pedagogical alignment [1], teaching techniques and evaluation tests [2], students' viewpoints and needs [3], and the teachers' opinions and needs [4]. To contextualize this method, the authors described a practical experience of the assessment of a multidisciplinary theme (theme 16), which is taught during the second year of medical education. Was performed the evaluation from January 2020 to January 2021. The population studied consisted of the tutors implicated in the teaching of the theme and the students in the second year of medical education who accepted to answer the satisfaction questionnaires. The students and tutors who did not fill out the questionnaires were excluded. No statistical tests were needed because of the descriptive nature of the study. Results: The most relevant results highlighted that 48.4% of the teachers did not systematically use bioclinical cases involving interactions between students; also, 42.4% of the students believed that the teaching sessions didn't introduce practical examples giving rise to interactions between them. Therefore, the 4-axis-based analysis indicated that weaknesses were mostly attributed to the lack of homogeneity in the teaching methods and techniques which showed the teachers' difficulties in integrating clinical data into their teaching so that they can help the students to assimilate the fundamental data. Conclusion: The authors' used a particular approach since it focused both on an objective evaluation of the teaching methods and the evaluation tests and the students' and teachers' viewpoints and needs. The major limitation of this approach was the fact that it could not integrate the educational environment that could impact the students' performances.

Prognostic Value of ISS and TRISS Scores in Tunisian Terrorism Victims.

INTRODUCTION: Injuries caused by terrorism attacks are one of the urgent problems of the society and the health system. In this work, we aimed to assess the injury severity score (ISS) and trauma injury severity score (TRISS) in Tunisian military combatants injured during terrorism attacks. MATERIALS AND METHODS: A total of 153 victims of terrorism admitted to the Military Hospital of Tunis between January 2012 and January 2017 were included. Among them, 107 survived and 46 died (43 victims died at the terrorist attack scene and 3 died in the hospital). All dead patients were autopsied. Injury severity scores and TRISSs were then calculated by 2 professors in the anesthesia-resuscitation department, and the agreement level was assessed using the Bland and Altman curve. RESULTS: We obtained a strong agreement between the 2 experts when assessing the TRISS and ISS. Using the Bland and Altman curve, an agreement between the 2 experts was obtained between 0 to 40 and 60 to 75 for the ISS and between 0 to 25 and 75 to 100 for the TRISS. Moreover, we detected a high level of ISS and TRISS, especially in deceased victims compared to survivors (P <.001). To predict mortality, we revealed by the receiver operating characteristic curve high sensitivity and specificity (more than 90%) before day 28 of hospital stay as well as for ISS and TRISS. Regarding the mechanism of injury, patients injured by gunshot have higher ISSs and TRISSs than those injured by explosion (P < .001). CONCLUSIONS: Injury severity scores and TRISSs showed a high reliability to predict the mortality rate in Tunisian victims of terrorism.

Humoral and cellular response of two different vaccines against SARS-CoV-2 in a group of healthcare workers: An observational study.

On March 13, 2021, Tunisia started a widespread immunization program against SARS-CoV-2 utilizing different vaccinations that had been given emergency approval. Herein, we followed prospectively a cohort of participant who received COVID-19 vaccine (Pfizer BioNTech and Sputnik-Gameleya V). The goal of this follow-up was to define the humoral and cellular immunological profile after immunization by assessing neutralizing antibodies and IFN- γ release. 26 vaccinated health care workers by Pfizer BioNTech (n=12) and Sputnik-Gameleya V (n=14) were enrolled from June to December 2021 in Military hospital of Tunis. All consenting participants were sampled for peripheral blood after three weeks of vaccination. The humoral response was investigated by the titer of anti-SARS-CoV-2 immunoglobulin G (IgG) antibodies to S1 protein. The CD4 and CD8 T cell responses were evaluated by the QuantiFERON® SARS-CoV-2 (Qiagen® Basel, Switzerland). Regardless the type of vaccine, the assessment of humoral and cellular response following vaccination showed a strong involvement of the later with expression of IFN-γ as compared to antibodies secretion. Moreover, we showed that people with past SARS-CoV-2 infection developed high levels of antibodies than those who are not previously infected. However, no significant difference was detected concerning interferon gamma (IFN-γ) expression by CD4 and CD8 T cells in health care worker (HCW) previously infection or not with COVID-19 infection. Analysis of immune response according to the type of vaccine, we found that Pfizer BioNTech induced high level of humoral response (91.66%) followed by Sputnik-Gameleya V (64.28%). However, adenovirus vaccine gave a better cellular response (57.14%) than mRNA vaccine (41.66%). Regarding the immune response following vaccine doses, we revealed a significant increase of neutralizing antibodies and IFN-γ release by T cells in patients fully vaccinated as compared to those who have received just one vaccine. Collectively, our data revealed a similar immune response between Pfizer BioNTech and Sputnik-Gameleya V vaccine with a slight increase of humoral response by mRNA vaccine and cellular response by adenovirus vaccine. It's evident that past SARS-CoV-2 infection was a factor that contributed to the vaccination's increased immunogenicity. However, the administration of full doses of vaccines (Pfizer BioNTech or Sputnik-Gameleya V) induces better humoral and cellular responses detectable even more than three months following vaccination.

The Design and Validation of a Self-Assessment Questionnaire of Critical Appraisal of Medical Literature Skills in Medical Students.

Introduction: Critical appraisal of medical literature is a challenging step of the evidence-based medicine practice. Many assessment questionnaires have been published in the literature, but they have mainly focused on all the evidence-based medicine practice process. The authors aimed to develop and validate a questionnaire assessing the critical appraisal skills of medical students from the same Faculty. Methods: The questionnaire was developed by item generation through a review of the literature and an expert committee. The questionnaire was validated in terms of content validity and construct validity. Fitness of data for analysis was checked through Kaiser-Meyer-Olkin (KMO) and Bartlett's sphericity. Construct validity was carried out using a principal axis exploratory factor analysis (EFA) with 'varimax' rotation to study the internal structure of the questionnaire and to extract the test major factors. The questionnaire was administrated to a cohort of under and postgraduate medical students (n=84) to evaluate the test reliability and select the best items. The reliability of the questionnaire was assessed by Cronbach's alpha coefficient to evaluate the internal consistency. The correlations between the self-confidence and satisfaction dimension score, the critical thinking dimension score, the learning style dimension score, the Fresno-adapted test scores and the total score were assessed using the Spearman's correlation test. Results: The questionnaire consisted of 31 items. A factorial analysis grouped the items into 3 dimensions that consisted of the self-confidence and satisfaction dimension, the critical thinking dimension and the learning style dimension. Cronbach's alpha accounted for 0.95, CI95% [0.9-1] for the entire questionnaire. The factor analysis explained 79.51% of the variance. The external validity assessment based on a Spearman's correlation study highlighted a weak correlation between the total scores and the critical thinking dimension and the self-perception and satisfaction dimension. Conclusion: In spite of the limitations of this study, mainly the small number of the students recruited, the questionnaire seems to measure with adequate reliability the competences of under and postgraduate medical students.

A qualitative study about critical appraisal of medical literature learning among medical students.

INTRODUCTION: Skills in critical appraisal of medical literature are compulsory to achieve in medical practice. This step is the third step of the evidence-based medicine process whose main role is to bridge a gap between scientific evidence and practice. Acquiring skills in critical appraisal of the literature has been reported to be challenging for the trainees with different limits according to their levels, backgrounds or specialties. AIM: To assess the limits and factors influencing the practice of appraising literature of different students from the same faculty. This faculty included training of biostatistics and preventive medicine in the curriculum during the first 2 years of medical education without linking this learning to the evidence-based medicine practice. METHODS: The authors performed a qualitative study including volunteers who attended voluntarily the same training about critical appraisal of medical literature. The study was based on a satisfaction questionnaire fulfilled by all the participants at the end of the training and on an individual semi-structured interviews programmed 3 months after the training. The satisfaction questionnaire was rated by the authors. The authors proceeded also to a content analysis of the interviews following 3 steps: pre-analysis, treatment of the results, and interpretation. RESULTS: All the participants (95) fulfilled the questionnaire. The satisfaction's mean score revealed a general moderate satisfaction. Eleven students agreed to be interviewed: Five students from the third year of medical education, 2 students from the second year of medical education, 2 postgraduate students and 2 family doctors. The main themes discussed by the interviewees consisted of training organization, the assessment, the impact on research and the impact on the care process. CONCLUSION: To promote EBM learning, medical students first need to actively participate to interactive learning, introduced early and gradually into the curriculum and integrating all specialties including postgraduate students.

Is critical thinking potential correlated to critical appraisal skills of medical literature?

INTRODUCTION: Critical appraisal of medical literature is a mandatory skill to practice evidence-based medicine. The relation between the critical appraisal skills and the critical thinking potential has been rarely assessed in the literature. AIM: To assess the relation of critical thinking potential to critical appraisal of medical literature competencies. Besides, they tried to highlight the variation of the critical thinking potential according to the students' level. METHODS: The authors conducted a mixed study associating a quantitative and a qualitative approach. The study included second year (SYME), third year (TYME) and postgraduate medical students (CME) and family doctors (FD) from the same faculty of medicine. All the students received the same active training focused on critical appraisal of medical literature. They were asked to fulfil a pre-requisite test and a self-assessment questionnaire before the training session and a final test after the training. The self-assessment questionnaire was conceived by an expert committee and assessed the main characteristics of critical thinking consisting of sensitivity to context, self-correction and search for criteria. Three months after the training, the students were interviewed using a semi-structured interview. The SPSS software 16.0 was used. RESULTS: In our study, 58.9% of the students presented a high critical thinking potential profile. Their scores varied according to their levels with better scores in SYME and FD and intermediate scores in TYME and CME. The pre-requisite test scores varied according to the critical thinking profile and the level. On the other hand, final test scores didn't differ according to the critical thinking profile or the level. CONCLUSION: Our results put emphasis on the variation of the critical thinking potential according to the students' levels. The better results of the SYME students in comparison to those in the TYME put emphasis on the necessity of changing curriculum in order to enhance the sensitivity and the inclination of the students.

Comparison of ultrasound-guided internal jugular vein and supraclavicular subclavian vein catheterization in critically ill patients: a prospective, randomized clinical trial.

BACKGROUND: The aim of this study was to compare the effectiveness and safety of ultrasound-guided out-of-plane internal jugular vein (OOP-IJV) and in-plane supraclavicular subclavian vein (IP-SSCV) catheterization in adult intensive care unit. METHODS: A total of 250 consecutive patients requiring central venous catheterization, were randomly assigned to undergo either ultrasound-guided OOP-IJV or IP-SSCV cannulation. All catheterizations were carried out by three physicians. The primary outcome was the first attempt success rate. Ultrasound scanning time, venous puncture time, insertion time, overall access time, number of puncture attempts, number of needle redirections, success rate, guidewire advancing difficulties, venous collapse and adverse events were also documented. RESULTS: The first attempt success rate was significantly higher in IP-SSCV group (83.2%) compared to OOP-IJV group (63.2%) (p = 0.001). The IP-SSCV group was associated with a longer ultrasound scanning time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a shorter insertion time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038). In the IP-SCCV group, we recorded a fewer number of puncture attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), needle redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), difficulties in guidewire advancement (2.4% vs. 27.4%; p < 0.001), venous collapse (2.4%, vs. 18.4%; p < 0.001) and adverse events (8.8% vs. 13.6%; p = 0.22). CONCLUSIONS: The IP-SSCV approach is an effective and a safe alternative to the classic OOP-IJV catheterization in critical adult patients. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03879954. Registered March 19, 2019-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03879954 .

[Effects of 15 mcg intrathecal clonidine added to bupivacaine and sufentanil for labor analgesia]. / Effets de l'adjonction de 15 mcg de clonidine en intrathécal au cours du travail obstétrical.

BACKGROUND: For the combined spinal epidural analgesia for labour, 30 mcg of subarachnoid clonidine has proved its effectiveness to extend the analgesia, but increased severe hemodynamic effects. AIM: To assess the effectiveness and the safety of 15 mcg intra thecal clonidine for labour analgesia. METHODS: Four months, prospective, randomised, simple blind Study, including ASA I or II women, with mono foetal pregnancy. Patients were randomised in 2 groups: SB Group received intra thecal isobaric bupivacaine 2.5 mg and sufentanil 5 mcg and SBC Group received 15 mcg clonidine added to the same doses of bupivacaïne and sufentanil. Epidural analgesia was used when VAS is more than 30. Studied parameters were: delay of installation, duration of analgesia, VAS score, hemodynamic parameters and the incidence of maternal and neonatal side effects. RESULTS: Sixty pregnant women were included (27 in SBC Group and 33 in SB group). The duration of initial analgesia was significantly longer in the SBC group (145 ± 43 min) compared with the SB group (98 ± 28 min). The delay of analgesia, sensory level and motor block level were similar. There was neither significant increase of the low incidence of blood pressure nor of the ephedrine consumption. The abnormalities of fetal heart rate, the mode of delivery and the incidence of side effects were also similar. CONCLUSION: The addition of 15 mcg intra thecal clonidine to the bupivacaine and the sufentanil during combined spinal epidural analgesia for obstetrical labour results in extended significantly duration of analgesia without increasing side effects.

Performance of Sepsis-3 Definitions in a Middle Income Country Intensive Care Unit.

BACKGROUND: Since they were first published in 2016, Sepsis-3 definitions have not been universally accepted. Rather, they have become a source of controversy because the clinical and laboratory parameters used had been derived mainly from patients hospitalized in Intensive Care Units (ICU) in the United States. PURPOSE: The aim of this study was to evaluate the performance of the Sepsis-3 definitions for the prediction of ICU-mortality in a Tunisian ICU population as compared to the 2003 Consensus Definitions (Sepsis-2 definitions). METHOD: The study, conducted in an 18-bed medical-surgical ICU at the Military Hospital of Tunis (Tunisia), was retrospective in nature. From January 2012 to January 2016, all patients admitted to the ICU for sepsis, severe sepsis, or septic shock as defined according to the 2003 Consensus Definitions (Sepsis-2 consensus) were eligible for this study. The new Sepsis-3 definition was then used to classify the included patients. The primary area of interest was ICU mortality, defined as death before ICU discharge. RESULTS: A total of 1080 patients were included during the recruitment period. When Sepsis-2 definitions were used, there was a difference in mortality only between septic shock and sepsis patients. Sepsis-3 definitions show that mortality increased from 16 % among no-dysfunction-infected patients to 30 % among patients with qSOFA ≥ 2 and 44% and 46% for sepsis or septic shock patients, respectively. CONCLUSIONS: Sepsis-3 definitions were better than sepsis-2 definitions at stratifying mortality among septic patients admitted to an ICU of a middle-income country (Tunisia).

Progress and impact of the publications of the Faculty of Medicine of Tunis: A 55 years study.

BACKGROUND: Over the past few years, efforts have been made to ensure that the teachers of the Faculty of Medicine of Tunis (FMT) cite their affiliation to the FMT and the University of Tunis El Manar in addition to their hospital institutions and their research structure in their publications. AIMS: In this study, we proposed to evaluate the FMT's membership in the publications of its teachers, to identify the different types of publications and to estimate the real number. METHODS: In this bibliometric cross-sectional study, we retrieved the FMT publications indexed in medline/pubmed database (1964-June2019). We have chosen the keywords corresponding to the publications of group1 (referenced FMT) and group2 (referenced FMT or annexed hospital-university institutions). Next, we calculated the rate of group1 on group2 and sorted the different types of items in group2. Finally, We estimated, after randomization, the actual number of FMT publications for a 99% confidence interval (99% CI). RESULTS: For groups 1 and 2, 1477 and 5194 publications were retrieved, respectively. The FMT membership rate averaged 28% ranging from 4% (1990-2010) to 44% (2011-2019). Of the FMT publications, 30% were free of charge and 55% were original articles. After a draw for 300 group2 publications, the estimated number of total FMT publications was between 4519 and 4934 for a 99% CI. CONCLUSIONS: It is essential to mention its affiliation to «the Faculty of Medicine of Tunis¼ and to «the University of Tunis El Manar¼ in order to improve the visibility and ranking of our two academic institutions.

Postoperative analgesia after wound infiltration with Dexmedetomidine and Ropivacaine versus Ropivacaine alone for lumbar discectomies: a randomized-controlled trial.

INTRODUCTION: Current LA may provide solid analgesic effect however, their analgesic advantages might be limited by their short life. Several reviews highlight the potential role of ?2-adrenergic receptors agonists like dexmedetomidine (DEX) for postoperative pain control. AIM: Compare the analgesic efficacy of the sole LA: ropivacaine (R) with the combination of both: ropivacaine and DEX (RD) for wound infiltration (WI) in lumbar discectomies. METHODS: Prospective, randomized, double-blind, controlled study in nature. Adult patients undergoing elective lumbar discectomies were randomly allocated into two groups: group (R) received 2mg/kg with ropivacaine: 4.75 mg/ml in WI, group RD received the same dose of ropivacaine as the first group adding 0.5 ug/kg of DEX. Visual analog scale (VAS) at 0, 2, 6, 12, 18, and 24 hours (h); time to first rescue analgesia, total post-operative opiate dose was assessed during the first 24 h postoperatively. RESULTS: VAS values at all time intervals were significantly lower (p< 10-3) in the RD group as compared with the R group. The median time to first rescue analgesia was significantly shorter in the R group 8h [7-12] than RD group 21 h [18-24]. The median (interquartile range) opioid use was 3 [3-6] morphine mg equivalents in the R group and 0 [0-2] morphine mg equivalents in the RD group. The first time to mobilization was significantly shorter in RD group (22±03 h) than R group (27±06 h).

Spinal anesthesia for endoscopic urological surgery--low dose vs. varying doses of hyperbaric bupivacaine.

BACKGROUND AND OBJECTIVE: The aim of this study is to compare the efficiency of low dose vs. varying doses of hyperbaric bupivacaine in spinal anesthesia for endoscopic urological procedures. METHODS: Sixty consecutive patients were studied in a randomized prospective manner. They received either of 5 (Gr I), 7.5 (Gr II) or 10 mg (Gr III) of hyperbaric bupivacaine 0.5% combined with 25 microg of fentanyl, through a 25-gauge W hitacre spinal needle placed in the L3-L4 interspace. Characteristics of sensory and motor block, dose of ephedrine required, secondary effects, the patients, and the surgeons satisfaction, were noted. RESULTS: The maximum number of blocked segments was 14 +/- 1 (Gr I), 15 +/- 2 (Gr II) and 16 +/- 2 (Gr III). Time to T12 regression was significantly shorter for Gr I (53 +/- 13 min) than for Gr II (69 +/- 20 min) or Gr III (94 +/- 14 min). Bromage 3 block was not found in Gr I compared to 4 patients in Gr II and 15 patients in Gr III. The duration of motor block was shorter in Gr 1(51 +/- 18 min) than in Gr II (86 +/- 19 min) and in Gr III (138 +/- 21 min). Ephedrine was used for 16 patients in Gr III (9.8 +/- 12.2 mg), 5 patients in Gr II (3.7 +/- 7.8 mg) and 2 patients in Gr I (0.5 +/- 1.5 mg). The difference is statistically significant between Gr III and the other groups. CONCLUSIONS: These results suggest that the use of a low dose of bupivacaine (5 mg) added to fentanyl (25 microg) for endoscopic urological surgery, resulted in short-acting sensory block, without motor block and a lower incidence of cardiovascular side effects, as compared to either of 7.5 or 10 mg bupivacaine with 25 microg fentanyl.

Effects of Levosimendan on Cellular Metabolic Alterations in Patients With Septic Shock: A Randomized Controlled Pilot Study.

INTRODUCTION: Mitochondrial dysfunction and consequent cellular energetic failure play a key role in the development of sepsis-related organs failure. Evidence suggests that the pleiotropic effects of levosimendan may positively affect cellular metabolism during septic shock. OBJECTIVES: To investigate changes in the concentration of glucose, lactate, pyruvate, and glycerol in the extracellular fluid of the skeletal muscle following levosimendan administration in patients with septic shock. METHODS: The study was designed as a prospective, double-blind, controlled, clinical pilot trial and performed in a multidisciplinary intensive care unit. After achieving normovolemia and a mean arterial pressure of at least 65 mm Hg, 20 septic shock patients were randomized to receive either levosimendan 0.2 µg/kg/min (n = 10), or dobutamine 5 µg/kg/min as active comparator (n = 10). Interstitial tissue concentrations of lactate, pyruvate, glucose, and glycerol were obtained by using muscle microdialysis. All measurements, including data from right heart catheterization, were obtained at baseline and every 6 h for the following 72 h after randomization.The trial is registered with Clinicaltrials.gov, number NCT02963454. RESULTS: Compared with dobutamine, levosimendan increased interstitial tissue pyruvate concentration (153.3 ±â€Š73 and 187. 2 ±â€Š13.5 vs. 210.7 ±â€Š76.2 and 161 ±â€Š64.6; P < 0.05), and lactate clearance (55 vs. 10). Lactate/pyruvate ratio was lower in the levosimendan group at the end of study period (37. 7 ±â€Š18.9 and 29.3 ±â€Š12.7 vs. 10.9 ±â€Š4.5 and 31.4 ±â€Š13. 2; P < 0.05). CONCLUSION: Although we investigated a small number of patients, our preliminary results suggest that levosimendan may improve cellular metabolic alterations in patients with septic shock.

Successful treatment of a Carbapenem-resistant Klebsiella pneumoniae carrying bla OXA-48 , bla VIM-2 , bla CMY-2 and bla SHV- with high dose combination of imipenem and amikacin.

We describe a case of 58-year-old man with septic shock due to Carbapenem-resistant Klebsiella pneumoniae (CR-Kp) bloodstream infections (BSI) who was successfully treated with a high dose association of amikacin and imipenem combined with continuous venovenous hemodiafiltration (CVVHDF). A Klebsiella pneumoniae (Kp) was isolated from the catheter culture and from two blood samples, drawn from the catheter before removal and from a peripheral vein. The Kp was intermediate to Amikacin (MIC = 16 µg/ml) and was resistant to all other antibiotics including Imipenem (MIC = 4 µg/ml), Colistin (MIC = 16 µg/ml) and Tigecycline (MIC = 4 µg/ml) according to the Clinical and Laboratory Standards Institute (CLSI) published in 2011. PCR amplification and sequencing verified the presence of blaOXA-48, blaVIM-2, blaCMY-2 and blaSHV-1 genes. Amikacin was given at a dose of 30 mg/kg (2.5 g) in a 30 min infusion and the dose of imipenem was increased to 1 g every 6 h despite patient's altered renal function (Creatinine Clearance = 25 ml/min). To avoid amikacin nephrotoxicity and to allow the use of high doses of imipenem, continuous venovenous hemodiafiltration (CVVHDF) (blood flow, 200 ml/h; dialysate, 1000 ml/h; ultrafiltrate, 2000 ml/h) was initiated 1 h after the start of the amikacin infusion and continued thereafter. The patient improved hemodynamically and norepinephrine was stopped five days after antibiotherapy adaptation.