Attitudes of Dutch intensive care unit clinicians towards oxygen therapy.

BACKGROUND: Over the last decade, there has been an increasing awareness for the potential harm of the administration of too much oxygen. We aimed to describe self-reported attitudes towards oxygen therapy by clinicians from a large representative sample of intensive care units (ICUs) in the Netherlands. METHODS: In April 2019, 36 ICUs in the Netherlands were approached and asked to send out a questionnaire (59 questions) to their nursing and medical staff (ICU clinicians) eliciting self-reported behaviour and attitudes towards oxygen therapy in general and in specific ICU case scenarios. RESULTS: In total, 1361 ICU clinicians (71% nurses, 24% physicians) from 28 ICUs returned the questionnaire. Of responding ICU clinicians, 64% considered oxygen-induced lung injury to be a major concern. The majority of respondents considered a partial pressure of oxygen (PaO2) of 6-10 kPa (45-75 mmHg) and an arterial saturation (SaO2) of 85-90% as acceptable for 15 minutes, and a PaO2 7-10 kPa (53-75 mmHg) and SaO2 90-95% as acceptable for 24-48 hours in an acute respiratory distress syndrome (ARDS) patient. In most case scenarios, respondents reported not to change the fraction of inspired oxygen (FiO2) if SaO2 was 90-95% or PaO2 was 12 kPa (90 mmHg). CONCLUSION: A representative sample of ICU clinicians from the Netherlands were concerned about oxygen-induced lung injury, and reported that they preferred PaO2 and SaO2 targets in the lower physiological range and would adjust ventilation settings accordingly.

Trends in practice of blood glucose control in critically ill patients in the Netherlands.

BACKGROUND: Publication of the Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial in 2009 and several observational studies caused a change in the recommendations for blood glucose control in intensive care patients. We evaluated local trends in blood glucose control in intensive care units in the Netherlands before and after the publication of the NICE-SUGAR trial and the revised Surviving Sepsis Campaign (SSC) guidelines in 2012. METHODS: Survey focusing on the timing of changes in thresholds in local guidelines for blood glucose control and interrupted time-series analysis of patients admitted to seven intensive care units in the Netherlands from September 2008 through July 2014. Statistical process control was used to visualise and analyse trends in metrics for blood glucose control in association with the moment changes became effective. RESULTS: Overall, the mean blood glucose level increased and the median percentage of blood glucose levels within the normoglycaemic range and in the hypoglycaemic range decreased, while the relative proportion of hyperglycaemic measurements increased. Changes in metrics were notable after publication of the NICE-SUGAR trial and the SSC guidelines but more frequent after changes in local guidelines; some changes seemed to appear independent of changes in local guidelines. CONCLUSION: Local guidelines for blood glucose practice have changed in intensive care units in the Netherlands since the publication of the NICE-SUGAR trial and the revised SSC guidelines. Trends in the metrics for blood glucose control suggest new, higher target ranges for blood glucose control.

Descending mediastinitis in Epstein-Barr virus infection.

Our case report describes a previously healthy 34-year-old male who develops a descending mediastinitis as a complication of an Epstein-Barr virus (EBV) infection. The mediastinitis was suspected to have developed by a breakthrough of a peritonsillar abscess through the space between the alar and prevertebral space.

Stroma-conditioned medium and sufficient prestimulation improve fibronectin fragment-mediated retroviral gene transfer into human primitive mobilized peripheral blood stem cells through effects on their recovery and transduction efficiency.

Mobilized peripheral blood stem cells (PBSC) are an attractive vehicle for cancer gene therapy. However these stem cells may have a reduced proliferative capacity due to previous cytotoxic chemotherapy treatment of the patient. In addition, primitive hematopoietic stem cells (HSC) from mobilized peripheral blood are almost exclusively quiescent, which makes it hard to induce proliferation in vitro and thus to improve stable transduction of introduced genes into a sufficiently large number of primitive stem cells. In this study CD34-selected mobilized PBSC from lymphoma and myeloma patients were used as target cells for retroviral-mediated gene transfer using a clinically relevant cell- and serum-free supernatant transduction protocol. We have investigated various parameters that may contribute to an improvement of the poor transduction efficiency of the primitive HSC, including prestimulation time, the use of the carboxy-terminal fibronectin fragment CH-296, as well as stromal cell line conditioned media. Retroviral supernatant transduction in combination with CH-296 increased significantly the gene transfer efficiency as compared to supernatant alone and made the use of polycations redundant. Gene transfer of primitive HSC (cobblestone area forming cell (CAFC) week 6) was specifically improved when this procedure was preceded by a 5-day pre-culture period as compared to a 2-day transduction procedure. However, irrespective of the numerical recovery, the CAFC week 6 after retroviral transduction produced less long-term culture colony-forming cells, suggesting a loss of individual stem cell quality. The addition of stroma-conditioned media during the pre-culture period did not affect the individual CAFC quality or transduction efficiency, but increased greatly the recovery of the total number of transduced and untransduced HSC leading to larger grafts containing higher numbers of transduced stem cells.

Comparison of intravascular ultrasonic findings after coronary balloon angioplasty evaluated in vitro with histology.

This study investigated whether vascular damage and quantitative changes observed with intravascular ultrasound at the most stenotic site are representative of the ultimate outcome after coronary balloon angioplasty. Atherosclerotic coronary arteries (n = 40) were studied in vitro with intravascular ultrasound. From each vascular specimen, 10 corresponding intravascular ultrasound cross sections obtained before and after balloon angioplasty were selected for comparison with their histologic counterpart. Morphologic and quantitative data obtained from all cross sections were compared with data derived from the most stenotic site. The incidence of vascular damage (i.e., dissection, plaque rupture, and media rupture) at the most stenotic site was lower than that seen for each vascular specimen. The sensitivity of intravascular ultrasound in detecting these morphologic features for each vascular specimen was high for dissection and media rupture (79% and 76%, respectively), and low for plaque rupture (37%). After balloon angioplasty, quantitative changes seen at the most stenotic site were greater than those in all cross sections: free lumen area +58% versus +29%, media-bound area +17% versus +12%, and plaque area reduction -9% versus -6%, respectively. The increase in free lumen area was caused predominantly by media-bound area increase (81%) and to a lesser extent by plaque area decrease (19%). This study revealed that a higher incidence of vascular damage is found when the whole segment is analyzed rather than 1 single cross section at the most stenotic site. Quantitative effects of coronary balloon angioplasty seen with intravascular ultrasound were greater at the most stenotic site than at all cross sections.

Causes of high astigmatism after penetrating keratoplasty.

We retrospectively evaluated the factors which might have caused excessive corneal astigmatism after penetrating keratoplasty (PKP) in 29 eyes, in which surgical correction of astigmatism was indicated. In 18 eyes high astigmatism (5 diopters or more) existed before suture removal probably due to graft elevation (3x), wound dehiscence (3x), wound configuration abnormalities such as ovality/overcut (8x), and a thin recipient cornea (2x). The cause was unknown in 2 eyes. In 19 eyes the astigmatism considerably increased after all sutures were removed; astigmatism increased an average of 8.8 diopters (range, 5 to 16.5 D). Ten of these 19 patients showed graft elevation, despite the fact that the sutures were only removed after an average 22.9 months. In 3 other patients the astigmatism gradually increased over the years, long after suture removal; two of these showed graft elevation. The study demonstrates the possible instability of keratoplasty wounds, the change in astigmatism after suture removal, and the late apparently spontaneous changes in astigmatism after PKP in some eyes.

Effect of donor cornea preservation in tissue culture and in McCarey-Kaufmann medium on corneal graft rejection and visual acuity.

In a retrospective study the rate of rejection and clouding of the donor cornea for other reasons was investigated in 230 penetrating keratoplasties performed between 1984-1986. Donor corneas were stored in McCarey-Kaufmann Medium (MK) at 4 degrees C or in a modified Minimal Essential Medium (MEM) at 31 degrees C. No statistical differences in rejection rate, cloudiness due to other causes or visual acuity was found between MEM- and MK-stored donor corneas.

Corneal graft survival in HLA-A- and HLA-B-matched transplantations in high-risk cases with retrospective review of HLA-DR compatibility.

In 107 HLA-A- and HLA-B-matched corneal transplantations performed in high-risk patients, the 3-year graft survival was 60.5%. The criteria used for the definition of high risk were vascularization of the recipient cornea and/or one or more previous failed grafts; they were also the indications for HLA typing and matching. Donor/recipient compatibility was defined by the presence of only 0 or 1 HLA-A or HLA-B mismatches. When non-immunological factors leading to graft failure were excluded, the 3-year survival was 76.3%. During that follow-up period, a total of 33 grafts failed; in 13 cases, the cause was allograft rejection. When only first transplants were considered, a 3-year graft survival of 81.0% was observed. Retrospective DR typing was possible in 33 cases. Because only three graft rejections occurred in that group, we were unable to assess the importance of DR compatibility on the survival of corneal allografts.

Long-term results of corneal wedge resections for the correction of high astigmatism.

We retrospectively evaluated 41 corneal wedge resections, performed for the correction of high astigmatism in 40 patients who were spectacle and contact lens intolerant. Keratometric astigmatism decreased from an average of 11.7 diopters (range 5 to 22.5 D) preoperatively to 3.5 diopters (range 0 to 10 D) postoperatively, representing a mean reduction of 8.2 D (range 0 to 16.5), or 70%. The length of follow-up averaged 11 months. Twenty-five, 15 and 9 cases had a follow-up of at least 3, 5 and 10 years, respectively. In 16 cases the keratometry readings remained stable over the years. However, in 1 case of Fuchs' endothelial dystrophy (follow-up 13 years) and 5 cases of keratoconus (follow-up 3, 4, 12, 13 and 14 years) the astigmatism gradually increased during the various follow-up periods. In 3 other cases the astigmatism gradually decreased over the years. Corneal wedge resection is an effective technique for managing high corneal astigmatism. The results remain stable over the years except in some patients with keratoconus.