Prevalence and Risk Factors for Augmented Renal Clearance in a Population of Critically Ill Patients.

BACKGROUND: Critically ill patients show a high, albeit variable, prevalence of augmented renal clearance (ARC). This condition has relevant consequences on the elimination of hydrophilic drugs. Knowledge of risk factors for ARC helps in the early identification of ARC. The aims of this study were evaluation of (1) risk factors for ARC and (2) the prevalence of ARC in critically ill patients over a period of 1 year. METHODS: A retrospective cohort study was performed for all consecutive patients admitted to our intensive care unit (ICU). Augmented renal clearance was defined by a creatinine clearance ≥130 mL/min/1.73 m2. "Patient with ARC" was defined as a patient with a median of creatinine clearance ≥130 mL/min/1.73 m2 over the period of admission. Four variables were tested, Simplified Acute Physiology Score II (SAPS II), male gender, age, and trauma as cause for ICU admission. An analysis (patient based and clearance based) was performed with logistic regression. RESULTS: Of 475 patients, 446 were included in this study, contributing to 454 ICU admissions and 5586 8-hour creatinine clearance (8h-CLCR). Overall, the prevalence of patients with ARC was 24.9% (n = 113). In a subset of patients with normal serum creatinine levels, the prevalence was 43.0% (n = 104). Of the set of all 8h-CLCR measurements, 25.4% (1418) showed ARC. In the patient-based analysis, the adjusted odds ratio was: 2.0 (confidence interval [CI]:1.1-3.7; P < .05), 0.93 (CI: 0.91-0.94; P < .01), 2.7 (CI: 1.4-5.3; P < .01), and 0.98 (CI: 0.96 -1.01; P = .15), respectively, for trauma, age, male sex, and SAPS II. In the clearance-based analysis, the adjusted odds ratio were 1.7 (CI: 1.4-1.9; P < .01), 0.94 (CI: 0.932-0.942; P < .01), and 2.9 (CI: 2.4-3.4; P < .01), respectively, for trauma, age, and male sex. CONCLUSIONS: Trauma, young age, and male sex were independent risk factors for ARC. This condition occurs in a considerable proportion of critical care patients, which was particularly prevalent in patients without evidence of renal dysfunction.

Pathophysiology of acute fibrinous and organizing pneumonia - Clinical and morphological spectra.

Acute Fibrinous and Organizing Pneumonitis (AFOP) is a disease with histopathological pattern characterized by the presence of intra-alveolar fibrin in the form of fibrin "balls" and organizing pneumonia represented by inflammatory myofibroblastic polyps. Symptoms of this rare interstitial pulmonary disease can be either acute or sub-acute and it can rapidly progress to death. Diagnosis should be considered in the Intensive Care Unit (ICU) if patients' symptomatology and radiology correlates with non-responding or progressive pneumonia and when morphology, on biopsies, encompasses criteria of diffuse alveolar damage (DAD) and organizing pneumonia (OP) balancing in between. Three clinical cases of patients presenting severe lung disease requiring mechanical ventilation and prolonged intensive care fitted on the variable spectra of AFOP histopathology and had poor outcome: a 23 year-old women had AFOP in the context of antiphospholipid syndrome pulmonary compromise; a 35 year-old man developed a letal intensive care pneumonia with AFOP pattern registered in post-mortem biopsy; and a 79 year-old man died 21 days after intensive care unit treatment of a sub-pleural organizing pneumonia with intra-alveolar fibrin, seen in post-mortem biopsy. The predominance of acute fibrin alveolar deposition pattern is helpful in raising AFOP differential diagnosis while organizing pneumonia pattern establishes a wider range of diagnosis that can go till solitary pulmonary nodule, remaining indefinite to suggest diagnosis. The performance time of biopsy in a larger number of clinical cases may be helpful in establishing the evolutionary morphological pattern, taking in mind the poor outcome of the disease, deserving rapid diagnosis to define treatment.

Hepatic Abscess Induced by Fish Bone Migration: Two Case Reports.

Although foreign body ingestion is a common occurrence, perforation and penetration of the gastrointestinal tract is unusual and the development of a hepatic abscess is even more rare. The authors describe two cases of fish bone perforation of the gastrointestinal tract with hepatic perforation and abscess formation, from distinctive age groups and varying presentation, although both developed septic shock. The lack of history of ingestion of foreign bodies, non-specificity of both clinical presentation and complementary examinations all play a role in delaying the diagnosis and therefore in the prognosis itself.

Embora a ingestão de corpo estranho seja uma situação relativamente comum, a perfuração e penetração do trato gastrointestinal é pouco frequente e a formação de um abcesso hepático é ainda mais rara. Os autores descrevem dois casos de perfuração do trato gastrointestinal por espinha de peixe com formação de abcesso hepático, pertencentes a grupos etários distintos e com diferente apresentação clínica, embora ambos tenham desenvolvido choque séptico. A ausência de história de ingestão de corpo estranho, a inespecificidade dos resultados dos exames complementares e das manifestações clínicas contribuem para um atraso no diagnóstico e, também por isso, influenciam o próprio prognóstico.

Glutaminemia prognostic significance in critical surgical patients - An analysis of plasma aminogram profile.

BACKGROUND: Glutamine depletion is common in the critically-ill patients. Glutaminemia lower than 420 µmol/l has been considered as an independent predictive factor of mortality, but the indications for exogenous glutamine supplementation remain controversial. This study intends to determine the glutaminemia profile in critical surgical patients and to investigate its correlation with the severity indexes and the prognosis. METHODS: A prospective study of 28 adult critical surgical patients was performed. Plasma amino acid concentrations were quantified, by ion exchange chromatography, at the moment of admission and at the first and third days, and compared with those of 11 reference healthy individuals. Severity indexes and parameters of prognosis were registered. RESULTS: In critical surgical patients, mean glutaminemia at admission was lower than that of control individuals (385.1 ± 123.1 versus515 ± 57.9 µmol/l, p = 0.002) and decreased until the third day (p = 0.042). Prevalence of severe hypoglutaminemia (< 420 µmol/l) at admission was 64.3%. Baseline glutaminemia correlated with the Simplified Acute Physiology Score II (SAPS II score) (Pearson's correlation coefficient r = -39.4%, p = 0.042), and it was lower in cases of erythrocytes transfusion (339.9 ± 78.8 versus 454.9 ± 148.8 µmol/l, p = 0.013). Glutaminemia at the third day correlated with the duration of invasive ventilation support (r = -65%, p = 0 .012) and ICU stay (r = -66.5%, p = 0.009). Glutaminemia below 320 µmol/l, observed in 25% of the patients, was associated with higher in-hospital mortality (42.9 versus19%, statistically not significant [n.s.]) and lower actuarial survival (212.1 ± 77.9 versus 262.3 ± 32.4 days, n.s.). CONCLUSIONS: Those results underscore the relevance of hypoglutaminemia as an adverse predictive factor in the critical surgical patients. Determination of glutaminemia may contribute to a better definition of the indications for glutamine supplementation.

Glutaminemia prognostic significance in critical surgical patients. An analysis of plasma aminogram profile / Significado pronóstico de la glutaminemia en pacientes quirúrgicos críticos. Análisis del perfil del aminograma plasmático

Background: Glutamine depletion is common in the critically-ill patients. Glutaminemia lower than 420 μmol/l has been considered as an independent predictive factor of mortality, but the indications for exogenous glutamine supplementation remain controversial. This study intends to determine the glutaminemia profile in critical surgical patients and to investigate its correlation with the severity indexes and the prognosis. Methods: A prospective study of 28 adult critical surgical patients was performed. Plasma amino acid concentrations were quantified, by ion exchange chromatography, at the moment of admission and at the first and third days, and compared with those of 11 reference healthy individuals. Severity indexes and parameters of prognosis were registered. Results: In critical surgical patients, mean glutaminemia at admission was lower than that of control individuals (385.1 ± 123.1 versus 515 ± 57.9 μmol/l, p = 0.002) and decreased until the third day (p = 0.042). Prevalence of severe hypoglutaminemia (< 420 μmol/l) at admission was 64.3%. Baseline glutaminemia correlated with the Simplified Acute Physiology Score II (SAPS II score) (Pearson’s correlation coefficient r = -39.4%, p = 0.042), and it was lower in cases of erythrocytes transfusion (339.9 ± 78.8 versus 454.9 ± 148.8 μmol/l, p = 0.013). Glutaminemia at the third day correlated with the duration of invasive ventilation support (r = -65%, p = 0 .012) and ICU stay (r = -66.5%, p = 0.009). Glutaminemia below 320 μmol/l, observed in 25% of the patients, was associated with higher in-hospital mortality (42.9 versus 19%, statistically not significant [n.s.]) and lower actuarial survival (212.1 ± 77.9 versus 262.3 ± 32.4 days, n.s.). Conclusions: Those results underscore the relevance of hypoglutaminemia as an adverse predictive factor in the critical surgical patients. Determination of glutaminemia may contribute to a better definition of the indications for glutamine supplementation (AU)

Introducción: la hipoglutaminemia es común en los pacientes críticos, pero las indicaciones para la suplementación con glutamina exógena siguen siendo controvertidas. Este estudio pretende determinar el perfil de glutaminemia en pacientes quirúrgicos críticos e investigar su correlación con los índices de gravedad y el pronóstico. Métodos: se realizó un estudio prospectivo de 28 pacientes quirúrgicos críticos adultos. Las aminoacidemias se cuantificaron mediante cromatografía de intercambio iónico en el momento del ingreso y en el primer y tercer día, y se compararon con las de 11 individuos sanos. Se registraron índices de gravedad y de pronóstico. Resultados: en pacientes quirúrgicos críticos, la glutaminemia media en el ingreso fue inferior a la de los controles (385,1 ± 123,1 versus 515 ± 57,9 μmol/l, p = 0,002) y disminuyó hasta el tercer día (p = 0,042). La prevalencia de hipoglutaminemia severa (< 420 μmol/l) en el ingreso fue de 64,3%. La glutaminemia basal se correlacionó con el SAPS II (r = -39,4%, p = 0,042), y fue menor en los casos de transfusión de eritrocitos (339,9 ± 78,8 versus 454,9 ± 148,8 μmol/l, p = 0,013). La glutamina al tercer día se correlacionó con la duración de la ventilación invasiva (r = -65%, p = 0,012) y de la estancia en la UCI (r = -66,5%, p = 0,009). La glutaminemia < 320 μmol/l, observada en el 25% de los pacientes, se asoció con mayor mortalidad hospitalaria (42,9 versus 19%, n.s.) y menor supervivencia actuarial (212,1 ± 77,9 versus 262,3 ± 32,4 días, n.s.). Conclusiones: estos resultados refuerzan la importancia de hipoglutaminemia como un factor predictivo adverso en los pacientes quirúrgicos críticos. La determinación de glutaminemia puede contribuir a una mejor definición de las indicaciones para la suplementación (AU)

Intestinal dysfunction in the critical trauma patients - An early and frequent event.

BACKGROUND: Small-bowel dysfunction exerts a relevant prognostic impact in the critically ill patients. Citrullinemia has been used in the evaluation of the intestinal function and it is considered an objective parameter of the functional enterocyte mass. Present study proposes to determine the intestinal dysfunction prevalence and the citrullinemia kinetic profile in severe trauma patients and to investigate its correlation with severity indicators and clinical outcome. METHODS: A prospective study including 23 critical trauma patients was performed. Aminoacidemias were quantified, by ion exchange chromatography, at the admission and at the first and third days. Severity and outcome parameters were registered. RESULTS: In severe trauma patients, severe hypocitrullinemia (< 20 µmol/L) prevalence at admission was high (69.6%) and mean citrullinemia was low (19.5 ± 11.1 µmol/L). Baseline citrullinemia was inversely and significantly correlated with shock index (r = -55.1%, p = 0.008) and extent of invasive ventilation support (r = -42.7%, p = 0.042). Citrullinemia < 13.7 µmol/L at admission, observed in 17.4% of patients, was associated with higher shock index (1.27 ± 0.10 versus 0.75 ± 0.18, p = 0.0001) and longer duration of invasive ventilation support (20.3 ± 7 versus 11.2 ± 7.1 days, p = 0.029) and intensive care unit stay (22 ± 5.9 versus 12.2 ± 8.8 days, p = 0.048). A citrullinemia decrease in the first day after admittance superior to 12.7% constituted a significant predictive factor of in-hospital mortality (75 versus 14.3%, p = 0.044; odds ratio = 7.8; accuracy = 65.2%; specificity = 92.3%; negative predictive value = 85.7%] and lower actuarial survival (69.8 ± 41.6 versus 278.1 ± 37.4 days, p = 0.034). CONCLUSIONS: Those results confirm the high prevalence and the prognostic relevance of hypocitrullinemia, considered a biomarker of enterocyte dysfunction, in severe trauma patients.

Intestinal dysfunction in the critical trauma patients - An early and frequent event / Disfunción intestinal en los traumatizados críticos. Un suceso precoz y frecuente

Background: Small-bowel dysfunction exerts a relevant prognostic impact in the critically ill patients. Citrullinemia has been used in the evaluation of the intestinal function and it is considered an objective parameter of the functional enterocyte mass. Present study proposes to determine the intestinal dysfunction prevalence and the citrullinemia kinetic profi le in severe trauma patients and to investigate its correlation with severity indicators and clinical outcome. Methods: A prospective study including 23 critical trauma patients was performed. Aminoacidemias were quantified, by ion exchange chromatography, at the admission and at the first and third days. Severity and outcome parameters were registered. Results: In severe trauma patients, severe hypocitrullinemia (< 20 μmol/L) prevalence at admission was high (69.6%) and mean citrullinemia was low (19.5 ± 11.1 μmol/L). Baseline citrullinemia was inversely and significantly correlated with shock index (r = -55.1%, p = 0.008) and extent of invasive ventilation support (r = -42.7%, p = 0.042). Citrullinemia < 13.7 μmol/L at admission, observed in 17.4% of patients, was associated with higher shock index (1.27 ± 0.10 versus 0.75 ± 0.18, p = 0.0001) and longer duration of invasive ventilation support (20.3 ± 7 versus 11.2 ± 7.1 days, p = 0.029) and intensive care unit stay (22 ± 5.9 versus 12.2 ± 8.8 days, p = 0.048). A citrullinemia decrease in the first day after admittance superior to 12.7% constituted a significant predictive factor of in-hospital mortality (75 versus 14.3%, p = 0.044; odds ratio = 7.8; accuracy = 65.2%; specificity = 92.3%; negative predictive value = 85.7%] and lower actuarial survival (69.8 ± 41.6 versus 278.1 ± 37.4 days, p = 0.034). Conclusions: Those results confirm the high prevalence and the prognostic relevance of hypocitrullinemia, considered a biomarker of enterocyte dysfunction, in severe trauma patients (AU)

Introducción: la disfunción intestinal ejerce un importante impacto pronóstico en los pacientes críticamente enfermos. La citrulinemia se ha utilizado en la evaluación de la función intestinal. El presente estudio propone determinar la prevalencia de la disfunción intestinal y el perfil cinético de la citrulinemia en enfermos con trauma grave e investigar su correlación con la gravedad y la evolución clínica. Métodos: se realizó un estudio prospectivo incluyendo 23 pacientes traumatizados críticos. Las aminoacidemias se cuantificaron, mediante cromatografía de intercambio iónico, en la admisión y en el primer y tercer días. Se registraron los parámetros de gravedad y evolución clínica. Resultados: la prevalencia de la hipocitrulinemia grave (< 20 μmol/L) en la admisión fue alta (69,6%) y citrulinemia media fue baja (19,5 ± 11,1 μmol/L). La citrulinemia basal se correlacionó con el índice de choque (r = -55,1%, p = 0,008) y la duración de asistencia ventilatoria invasiva (r = -42,7%, p = 0,042). La citrulinemia < 13,7 μmol/L en la admisión se asoció con mayor índice de choque (1,27 ± 0,1 versus 0,75 ± 0,18, p = 0,0001) y mayor duración de ventilación invasiva (20,3 ± 7 versus 11,2 ± 7,1 días, p = 0,029) y hospitalización en la unidad de cuidados intensivos (22 ± 5,9 versus 12,2 ± 8,8 días, p = 0,048). La disminución de la citrulinemia en el primer día superior al 12,7% fue un factor predictor signifi cativo de mortalidad hospitalaria (75 versus 14,3%, p = 0,044; odds ratio = 7,8; precisión = 65,2%; especificidad = 92,3%; valor predictivo negativo = 85,7%] y menor supervivencia actuarial (69,8 ± 41,6 versus 278,1 ± 37,4 días, p = 0,034). Conclusiones: estos resultados confirman la alta prevalencia y la importancia pronóstica de la hipocitrulinemia, biomarcador de disfunción enterocitaria, en los pacientes con trauma severo (AU)

Rapidly Progressive Encephalopathy: Initial Diagnosis of Creutzfeldt Jakob Disease in an Intensive Care Unit.

Creutzfeldt-Jakob disease (CJD) is a rare, incurable and fatal condition that can only be confirmed through neuropathological investigation, such as brain biopsy or post-mortem study. However, a probable diagnosis can be made using clinical criteria. CJD manifests as rapidly progressive dementia with myoclonus and to a lesser extent visual impairment and cerebellar and pyramidal/extrapyramidal signs. We report the case of a previously independent adult male that met all the clinical criteria. Taken together, the investigation results suggested probable CJD. LEARNING POINTS: Creutzfeldt-Jakob disease (CJD) is a rare cause of dementia.The rapidly progressive neurological signs and symptoms suggest the diagnosis.Mortality rates are very high even with surgical treatment in these complex patients.

Performance, serologic and tracheal responses of laying hens exposed to F strain of Mycoplasma gallisepticum / Desempenho, sorologia e respostas traqueias de galinhas poedeiras expostas a cepa F de Mycoplasma gallisepticum

The F strain of Mycoplasma gallisepticum (MG-F) protects chickens against mycoplasma infections, in which monitoring is made by serology and histopathology of trachea. This trial used 90 chickens, being 30 unvaccinated (G1 group), 30 eye-drop vaccinated at 8 weeks of age with MG-F (Ceva Animal Health, São Paulo, SP, Brazil) (G2), and 30 immunized at 8 and 11 weeks of age (G3). Samples were obtained from chickens on the 8, 12, 15, 18, 20 and 24th weeks of age for the enzyme-linked immunosorbent assay (ELISA) test. Tracheal fragments were collected after necropsies on the 15 and 24th weeks of age. Up to 12 weeks, the ELISA reactions in optical density (OD) were 0.165 (G1), 0.151 (G2) and 0.151(G3), all below 0.20 and with no significant difference among groups (p > 0.05). After the 15th week, the ELISA reactions rose, yielding the following group averages by collecting dates: G1 (0.18, 0.19, 0.18, and 0.16), G2 (0.36, 0.49, 0.47, and 0.44) and G3 (0.41, 0.52, 0.59, 0.60), being the means in G2 and G3 not significantly different between than, but significantly different from G1. The initial weight (592.71, 621.33, and 594.40), the final weight (1,932.58, 1,987.59, and 1,875.20) and the weekly weight gain (11.65, 11.90, and 11.14) were not significantly different among groups. At necropsy the gross tracheal score means by group and dates were: 15th week (0.25, 0.61, and 0.54) and 24th week (0.54, 0.58, and 0.67), being these difference not significantly (p > 0.05). On microscopy, the tracheal score averages by groups G1, G2 and G3, respectively, were: 15th week (0.25, 0.32, and 0.47) and 24th week (0.07, 0.75, and 0.08). G2 yielded higher score average than G1 and G3 on the 24th week. Higher tracheal changes for G2 and G3 as compared to G1 could be ascribed to MG-F infection. There were no evident prejudicial effects on live weight, weight gain and tissue changes by applying one or two vaccination doses.(AU)

A cepa F de Mycoplasma gallisepticum (MG-F) protege as galinhas de micoplasmose, e sua monitorização é feita por sorologia e histopatologia de traqueia. Este estudo utilizou 90 frangos, sendo 30 não vacinados (grupo G1); 30 vacinados via gota ocular a 8 semanas de idade com MG-F (Ceva Saúde Animal, São Paulo, SP, Brasil) (G2); e 30 imunizados em 8 e 11 semanas de idade (G3). As amostras foram obtidas nas 8ª, 12ª, 15ª, 18ª, 20ª e 24ª semanas para ensaio de imunoabsorção enzimática (ELISA). Fragmentos traqueais foram coletados após necropsias nas 15ª e 24ª semanas. Até a 12ª semana, as reações de ELISA em densidade óptica (DO) foram 0,165 (G1), 0,151 (G2) e 0,151 (G3), todas abaixo de 0,20, e não houve diferença significativa entre os grupos (p > 0,05). Após a 15ª semana , a reação de ELISA subiu, produzindo as seguintes médias dos grupos por datas de coleta: G1 (0,18, 0,19, 0,18 e 0,16), G2 (0,36, 0,49, 0,47 e 0,44) e G3 (0,41, 0,52, 0,59, 0,60), sendo as médias de G2 e G3 não significativamente diferentes entre si, mas significativamente diferentes da de G1. O peso inicial (592,71, 621,33, 594,40), o peso final (1.932,58, 1.987,59, 1.875,20) e o ganho de peso semanal (11,65, 11,90, 11,14) não foram significativamente diferentes entre os grupos. Na necropsia, as médias do escore da macroscopia de traqueia por grupo e data foram: 15ª semana (0,25, 0,61 e 0,54) e 24ª semana (0,54, 0,58 e 0,67), e não se apresentou diferença significativa (p > 0,05). Na microscopia, a média de escores de traqueia por grupos G1, G2 e G3, respectivamente, foram: 15ª semana (0,25, 0,32 e 0,47) e 24ª semana (0,07, 0,75 e 0,08). G2 apresentou maior média de escore do que G1 e G3 na 24ª semana. Alterações traqueais mais elevadas para G2 e G3 em relação a G1 poderiam ser atribuídas à vacinação por MG-F. Não houve efeitos prejudiciais evidentes no peso vivo nem no ganho de peso, tampouco alterações teciduais na aplicação de uma ou duas doses de vacinação.(AU)

Argininemia and plasma arginine bioavailability - predictive factors of mortality in the severe trauma patients?

BACKGROUND: Arginine is an amino acid determinant in the metabolic, immune and reparative responses to severe trauma. The present study aims to determine argininemia and plasma arginine bioavailability (PAB) in critical trauma patients and to analyze its correlation with prognosis. METHODS: A prospective study of 23 critical trauma patients was undertaken. Aminoacidemias were determined, by ion exchange chromatography, at admission and in the first and third days and compared with those of 11 healthy individuals. PAB was calculated. Severity indexes and outcome parameters were recorded. RESULTS: Values of argininemia, citrullinemia and ornithinemia at the admission were significantly lower than those of the controls (arginine: 41.2 ± 20.6 versus 56.1 ± 11.9 µmol/L, P = 0.034). Hipoargininemia (<60 µmol/L) prevalence was 82.6 %. Mean PAB was 62.4 ± 25.6 %. Argininemia < 26 µmol/L constituted a significant predictive factor of in-hospital mortality [n = 4 (17.4 %); 75 versus 15.8 %, P = 0.04; odds ratio = 4.7; accuracy = 87 %] and lower actuarial survival (63.5 ± 43.9 versus 256.1 ± 33.3 days, P = 0.031). PAB <42 % [n = 6 (26.1 %)] was associated with higher lactacidemia levels (P = 0.033), higher in-hospital mortality (66.7 versus 11.8 %, P = 0.021; odds ratio = 5.7, accuracy = 82.6 %) and lower actuarial survival (87.2 ± 37.5 versus 261.4 ± 34.7 days, n.s.). Probability of in-hospital mortality was inversely and significantly related with PAB [61.8 ± 8.8 % (95 % CI 50.8-72.7) when PAB <41 % and 2.8 ± 1.9 % (95 % CI 1.9-8.3) when PAB > 81 %, P = 0.0001]. Charlson's index ≥1, APACHE II ≥19.5, SOFA ≥7.5, and glutaminemia < 320 µmol/L were also predictive factors of actuarial survival. CONCLUSIONS: Those results confirm the high prevalence of arginine depletion in severe trauma patients and the relevance of argininemia and PAB as predictive factors of mortality in this context.

Transmission, serologic and tissue responses in chickens vaccinated with Mycoplasma gallisepticum F strain (MG-F) / Transmissão, resposta sorológica e tecidual de poedeiras vacinadas com Mycoplasma gallisepticum cepa F

MG-F protects chickens from MG Mycoplasmosis and monitoring is done by serology (SAR and ELISA) and PCR. Histopathology is used to evaluate bird response to MG. This study evaluated MG-F profile vaccination in SPF chicken. This trial used 100 chickens, being 40 unvaccinated (G1), 40 eye-drop vaccinated at 8 weeks of age with MG-F ( Ceva Animal Health , São Paulo , SP , Brazil ) (G2) and 20 immunized by contact (G3) . Samples were obtained on the 8th, 12th, 15th, 18th, 20th and 24th week for SAR, ELISA and PCR. Fragments of trachea and air sac, for microscopy, were got after necropsies on the 15th and 24th week. Up to 12 weeks there was no significant difference among groups by SAR. SAR reactions appeared from the 15th week with these averages: G1 (1.7, 1.76 , 0.1, 0.15) , G2 (7.81, 7.65, 8.25, 6.29) and G3 (8.1, 8.5, 9.5, 6.16), while by ELISA it occurred after the 18th week with optical densities averages: G1 (0.19, 0.14, 0.16) , G2 (0.47, 0.45, 0.41) and G3 (0.55, 0.51, 0.51) . Positivity in G3 by PCR occurred seven weeks after exposure. At the 15th week the air sac score means were 0.20, 0.55, and 0.32 and 24th week were 0.15, 0.80 and 0.66 (p>0.05). For trachea, G2 (0.48) yielded higher score average than G1 (0.10) and G3 (0.00) on the 15th week. Changes in G3 were seen only at 24th week, being this average (1.00) significantly different (p<0,05) from G1 (0.08) and G2 (0.46). SAR and PCR detected MG-F in G3 earlier than ELISA...

Mycoplasma gallisepticum cepa F (MG-F) é altamente utilizada em vacinação de poedeiras. MG-F confere bons níveis de proteção às galinhas, deslocando MG de campo ou diminuindo o número deles no trato respiratório. Soroaglutinação Rápida (SAR), ELISA e PCR são testes no monitoramento da micoplasmose, enquanto a histopatologia, mesmo não sendo rotineira, é usada para avaliar a resposta das aves à infecção por MG. O objetivo deste estudo foi avaliar a transmissibilidade, soroconversão e alterações teciduais de MG-F em galinhas. Um total de 100 galinhas SPF foi utilizado, sendo 40 delas não vacinadas (G1), 40 vacinadas na 8ª semana de idade com MG-F (Ceva Saúde Animal, São Paulo/SP, Brasil) (G2) e 20 imunizadas por contato com aves do G2 (G3). Soros e suabes traqueais foram obtidos na 8ª, 12ª, 15ª, 18ª, 20ª, 24ª semana para monitoramento por SAR, ELISA e PCR. Fragmentos de traqueia e saco aéreo, para microscopia, foram feitas após necropsias na 15ª e 24ª semana. Até a 12ª semana não houve diferença significativa entre os grupos pela SAR. Houve reação a SAR a partir da 15ª semana com as seguintes médias: G1 (1,7; 1,76; 0,1; 0,15), G2 (7,81; 7,65; 8,25; 6,29) e G3 (8,1; 8,5; 9,5; 6,16), enquanto por ELISA a soroconversão ocorreu a partir da 18ª semana com médias de densidades óticas de G1 (0,19; 0,14; 0,16), G2 (0,47; 0,45; 0,41) e G3 (0,55; 0,51; 0,51). Todas as aves do G3 apresentaram positividade pela PCR sete semanas após exposição. Não houve diferença significativa entre as medias dos escores de saco aéreo entre os grupos, na 15ª semana (0,20; 0,55; 0,32) e 24ª semana (0,15; 0,80 e 0,66). Em relação à traqueia, G2 apresentou média maior na 15ª semana (0,48) que G3 (0,00) e G1 (0,10). Alterações em G3 foram observadas somente na 24ª semana onde as médias foram de 0,08(G1); 0,46 (G2) e 1,00 (G3), havendo significância (p<0,05) entre G1 e G3. SAR e PCR foram capazes de detectar a transmissão de MG-F de forma precoce em relação ao ELISA...

Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogram.

INTRODUCTION: Achievement of optimal vancomycin exposure is crucial to improve the management of patients with life-threatening infections caused by susceptible Gram-positive bacteria and is of particular concern in patients with augmented renal clearance (ARC). The aim of this study was to develop a dosing nomogram for the administration of vancomycin by continuous infusion for the first 24 hours of therapy based on the measured urinary creatinine clearance (8 h CLCR). METHODS: This single-center study included all critically ill patients treated with vancomycin over a 13-month period (group 1), in which we retrospectively assessed the correlation between vancomycin clearance and 8 h CLCR. This data was used to develop a formula for optimised drug dosing. The efficiency of this formula was prospectively evaluated in a second cohort of 25 consecutive critically ill patients (group 2). Vancomycin serum concentrations between 20 to 30 mg/L were considered adequate. ARC was defined as 8 h CLCR more than 130 ml/min/1.73 m(2). RESULTS: The incidence of ARC was 36% (n = 29/79) and 40% (10/25) in group 1 (n = 79) and 2 (n = 25), respectively. The mean serum vancomycin concentration on day 1 was 21.5 (6.4) and 24.5 (5.2) mg/L, for both groups respectively. On the treatment day, vancomycin plasma clearance was 5.12 (1.9) L/h in group 1 and correlated significantly with the 8 h CLCR (r(2) = 0.66; P < 0.001). The achievement of adequate vancomycin serum concentrations in group 2 was 84% (n = 21/25) versus 51% (n = 40/79) - P < 0.005. CONCLUSIONS: This new vancomycin nomogram enabled the achievement of adequate serum concentrations in 84% of the patients on the first day of treatment.

Accuracy of the estimation of glomerular filtration rate within a population of critically ill patients.

BACKGROUND: Accuracy of glomerular filtration rate (GFR) estimates has been questioned and several authors recommend routine use of measured renal creatinine clearance (CLCR) as a surrogate of GFR in the intensive care unit (ICU). Our purpose was to compare estimates of GFR using Cockroft-Gault (CG), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease Study (MDRD) equations with 8h-CLCR, within a population of critically ill patients with a wide range of measured CLCR. METHODS: Through a prospective, observational study of 54 patients with normal serum creatinine (sCr) admitted to ICU, daily 8h-CLCR (reference method) and GFR estimates (644 paired samples) were matched and compared. Augmented renal clearance (ARC) was defined as 8h-CLCR >130 ml/min/1.73 m(2). RESULTS: No significant difference was found between mean 8h-CLCR (135.5 ml/min/1.73 m(2)) and CG equation (135.7 ml/min/1.73 m(2)), but significant differences (p < 0.01) were found for the MDRD (124.4 ml/min/1.73 m(2)) and CKD-EPI (107.6 ml/min/1.73 m(2)) equations. Correlation between 8h-CLCR and all estimates was weak (R = 0.2, 0.19 and 0.34, respectively). We observed poor agreement in terms of precision (40.9, 39.8 and 33.4%, respectively). Analysing subgroups, we observed that all equations significantly underestimated 8h-CLCR >120 ml/min/1.73 m(2) and overestimated 8h-CLCR <120 ml/min/1.73 m(2) (p < 0.05). The incidence of ARC patients was 55.6%. CONCLUSIONS: Estimates of GFR using CG, CKD-EPI and MDRD formulae are flawed in the critically ill with normal sCr, significantly underestimating renal function in those with ARC and overestimating it in those with normal or decreased 8h-CLCR. Globally, the population exhibited ARC on more than half of the ICU admission days.

Using Py-GC/MS to fingerprint additives associated with paper mill effluent toxicity episodes.

Understanding the cause of effluent toxicity is an important requirement for its prevention, remediation and return to compliance. One component of the strategy entails identification and fingerprinting of additives or components in additives that may be the cause of the toxicity episodes. A number of additives used in pulp and papermaking are polymeric compounds that are suspect in effluent toxicity. Their analysis and detection is difficult as they are not amenable to analysis by normal techniques applicable to mill effluents such as gas chromatography. Py-GC/MS is a powerful analytical technique that can be used to fingerprint these additives. The presence of the additives is confirmed by fingerprint pyrograms of the additives (or components in the formulations of the additives) in conjunction with mass spectrometry. The technique has been used to fingerprint and quantify polymeric additives associated with mill effluent toxicity episodes.

Augmented renal clearance in septic patients and implications for vancomycin optimisation.

The aim of this study was to evaluate the effect of augmented renal clearance (ARC) on vancomycin serum concentrations in critically ill patients. This prospective, single-centre, observational, cohort study included 93 consecutive, critically ill septic patients who started treatment that included vancomycin by continuous infusion, admitted over a 2-year period (March 2006 to February 2008). ARC was defined as 24-h creatinine clearance (CL(Cr))>130 mL/min/1.73 m(2). Two groups were analysed: Group A, 56 patients with a CL(Cr)≤130 mL/min/1.73 m(2); and Group B, 37 patients with a CL(Cr)>130 mL/min/1.73 m(2). Vancomycin therapeutic levels were assessed on the first 3 days of treatment (D(1), D(2) and D(3)). Serum vancomycin levels on D(1), D(2) and D(3), respectively, were 13.1, 16.6 and 18.6 µmol/L for Group A and 9.7, 11.7 and 13.8 µmol/L for Group B (P<0.05 per day). The correlation between CL(Cr) and serum vancomycin on D(1) was -0.57 (P<0.001). ARC was strongly associated with subtherapeutic vancomycin serum concentrations on the first 3 days of treatment.

A comparison of estimates of glomerular filtration in critically ill patients with augmented renal clearance.

INTRODUCTION: Increasingly, derived estimates of glomerular filtration, such as the modification of diet in renal disease (MDRD) equation and Cockcroft-Gault (CG) formula are being employed in the intensive care unit (ICU). To date, these estimates have not been rigorously validated in those with augmented clearances, resulting in potentially inaccurate drug prescription. METHODS: Post-hoc analysis of prospectively collected data in two tertiary level ICU's in Australia and Portugal. Patients with normal serum creatinine concentrations manifesting augmented renal clearance (ARC) (measured creatinine clearance (CLCR) > 130 ml/min/1.73 m2) were identified by chart review. Comparison between measured values and MDRD and CG estimates were then undertaken. Spearman correlation coefficients (rs) were calculated to determine goodness of fit, and precision and bias were assessed using Bland-Altman plots. RESULTS: Eighty-six patients were included in analysis. The median [IQR] measured CLCR was 162 [145-190] ml/min/1.73 m2, as compared to 135 [116-171], 93 [83-110], 124[102-154], and 108 [87-135] ml/min/1.73 m2 estimated by CG, modified CG, 4-variable MDRD and 6-variable MDRD formulae. All of the equations significantly under-estimated the measured value, with CG displaying the smallest bias (39 ml/min/1.73 m2). Although a moderate correlation was noted between CLCR and CG (rs = 0.26, P = 0.017) and 4-variable MDRD (rs = 0.22, P = 0.047), neither had acceptable precision for clinical application in this setting. CG estimates had the highest sensitivity for correctly identifying patients with ARC (62%). CONCLUSIONS: Derived estimates of GFR are inaccurate in the setting of ARC, and should be interpreted with caution by the physician. A measured CLCR should be performed to accurately guide drug dosing.

B-type natriuretic peptide predicts long-term prognosis in a cohort of critically ill patients.

B-type natriuretic peptide is an important prognostic marker in heart failure. However, there are limited data for its value in non-cardiac intensive care unit patients, namely regarding long-term prognosis. We investigated the long-term prognostic value of BNP in a cohort of critically ill patients. This was a prospective and observational study, conducted in a tertiary university hospital 20-bed intensive care unit. We included 103 mechanically-ventilated patients admitted for a non-cardiac primary diagnosis; B-type natriuretic peptide samples were obtained on admission. A mean 14 (3-30) month follow up was available in 96.1% of patients who were discharged from hospital. Mean age was 60.7±19.0 years and mean APACHE II score was 16.2±7.2. APACHE II score and renal dysfunction increased with rising B-type natriuretic peptide, with more than 60% of patients having B-type natriuretic peptide levels of 100 pg/mL or over; echocardiography-derived left ventricular ejection fraction was lower in patients with higher B-type natriuretic peptide (P < 0.001). Long-term survivors had lower median B-type natriuretic peptide values (117.5[2-1668] pg/mL) compared with intensive care unit non-survivors (191.0[5-4945] pg/mL), P<0.001. After adjustment to APACHE II score, B-type natriuretic peptide levels of 300 pg/mL or over were independently associated with long-term mortality (odds-ratio 4.1 [95% CI 1.45-11.5], P=0.008). We conclude that in an unselected cohort of intensive care unit patients, admission B-type natriuretic peptide is frequently elevated, even without clinically apparent acute heart disease, and is a strong independent predictor of long-term mortality.

[Enteric nutrition and esophageal impactation: what relationship]. / Alimentação entérica e impactação alimentar esofágica: que relação?

INTRODUCTION AND OBJECTIVES: In the intensive care unit (ICU), enteral feeding is the method of choice for providing adequate nutrition in intubated patients. The oesophageal impactation (EI) by enteric nutrition (EN) results from solidification of the solution in esophagus lumen with formation of bezoar and although rare, is gradually becoming more common in clinical practice. In recent years some have been diagnosed cases of enteric nutrition impact, in an ICU. The authors seek to better understand their risk factors in order to prevent its occurrence. METHODS: Retrospective study of patients with endoscopic diagnosis of EI, in ICU, over a period of 3 years. RESULTS: There were 1367 patients in the ICU, 1003 did EN and 9 had a EI diagnosis. Mean age - 66 years, 7 males, all of them with invasive ventilation support. Mean ICU stay - 32 days, and EI at 20th day, 12 days after started EN. In all the cases, EN is due to the solidification of the EN solution in esophagus. 7 patients had esophageal reflux risk factors: 4 previously known and 3 identified after EI diagnosis. The endoscopic treatment was successful in 7 patients. CONCLUSION: The EI frequency is low. The ICU average delay (32 days) in this series is twice the total of patients admitted during this period (14,27 days), reflecting the greater severity of the patients studied. Several cases could be implicated in the etiology of that clinical entity. Whenever risk factors are present it should be considered both the endoscopic introduction of nasojejunal tube and specific positioning strategies, to prevent reflux and gastric estasis. Medical and endoscopic treatment solved the majority of related cases that are available in the literature; however, in some specific cases it was necessary to use surgical treatment.

Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary.

OBJECTIVE: The purpose of the conference was to provide clinical practice guidance in end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record. PARTICIPANTS: Presenters and jury were selected by the sponsoring organizations (American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, Société de Réanimation de Langue Française). Presenters were experts on the question they addressed. Jury members were general intensivists without special expertise in the areas considered. Experts presented in an open session to jurors and other healthcare professionals. EVIDENCE: Experts prepared review papers on their specific topics in advance of the conference for the jury's reference in developing the consensus statement. CONSENSUS PROCESS: Jurors heard experts' presentations over 2 days and asked questions of the experts during the open sessions. Jury deliberation with access to the review papers occurred for 2 days following the conference. A writing committee drafted the consensus statement for review by the entire jury. The 5 sponsoring organizations reviewed the document and suggested revisions to be incorporated into the final statement. CONCLUSIONS: Strong recommendations for research to improve end-of-life care were made. The jury advocates a shared approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the team, to decide on the reasonableness of the planned action. If a conflict cannot be resolved, an ethics consultation may be helpful. The patient must be assured of a pain-free death. The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double-effect" should not detract from the primary aim to ensure comfort.