Can passive leg raise predict the response to fluid resuscitation in ED?

OBJECTIVE: Passive leg raise (PLR) can be used as a reversible preload challenge to stratify patients according to preload response. We aim to evaluate the accuracy of PLR, monitored by a non-invasive cardiac output monitor in predicting to response to fluid resuscitation in emergency department (ED). METHODS: We recruited adult patients planned to receive a resuscitation fluid bolus. Patients were monitored using a thoracic electrical bioimpedance (TEB) cardiac output monitor (Niccomo, Medis, Germany). A 3-min PLR was carried out before and after fluid infusion. Stroke volume changes (ΔSV) were calculated and a positive response was defined as ≥ 15% increase. RESULTS: We recruited 39 patients, of which 37 were included into the analysis. The median age was 63 (50-77) years and 19 patients were females. 17 patients (46%) were fluid responders compared to 11 (30%) with positive response to PLR1. ΔSV with PLR1 and fluid bolus showed moderate correlation (r = 0.47, 95% confidence interval, CI 0.17-0.69) and 62% concordance rate. For the prediction of the response to a fluid bolus the PLR test had a sensitivity of 41% (95% CI 22-64) and specificity of 80% (95% CI 58-92) with an area under the curve of 0.59 (95% CI 0.41-0.78). None of the standard parameters showed a better predictive ability compared to PLR. CONCLUSION: Using TEB, ΔSV with PLR showed a moderate correlation with fluid bolus, with a limited accuracy to predict fluid responsiveness. The PLR test was a better predictor of fluid responsiveness than the parameters commonly used in emergency care (such as heart rate and blood pressure). These data suggest the potential for a clinical trial in sepsis comparing TEB monitored, PLR directed fluid management with standard care.

Intensivists’ perceptions and attitudes towards infectious diseases management in the ICU: An international survey / Percepciones y actitudes de los intensivistas hacia el manejo de enfermedades infecciosas en la UCI: una encuesta internacional

Objective Exploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. Design Online international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. Setting International study conducted in 78 countries. Participants Physicians working in ICU. Interventions None. Main variables of interest Practice variations were assessed according to respondents’ countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents’ characteristics and their perceptions regarding adequacy of training. Results 466 intensivists with a median practice of 10 years (interquartile range, 5–19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28–0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39–0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34–0.79) or medicine (OR: 0.49, 95% CI: 0.32–0.76) were associated with less training satisfaction. Conclusion ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists’ perspective, ID training and knowledge need improvement (AU)

Objetivo Explorar la práctica de enfermedades infecciosas (EI) en unidad de cuidados intensivos (UCI) para identificar lagunas y oportunidades. Diseño Encuesta internacional online. Ÿmbito Estudio internacional. Participantes Médicos que trabajan en UCI. Intervenciones Ninguna. Principales variables de interés Las variaciones de la práctica se evaluaron de acuerdo con la clase de ingresos de los países encuestados, la formación previa y los años de práctica. Se utilizaron análisis de regresión logística ordinal para estimar las asociaciones entre las características de los encuestados y sus percepciones con respecto a la adecuación de la capacitación. Resultados Cuatrocientos sesenta y seis intensivistas completaron la encuesta. Un tercio de los intensivistas informó que no tenía un programa de optimización de antimicrobianos y el 40% no tenía rondas microbiológicas regulares en su UCI. Los intensivistas eran mayoritariamente los iniciadores de la terapia antibiótica inicial que en el 70% de los casos estaba basada en guías clínicas y protocolos. La regresión logística ordinal multivariante mostró que los países de ingresos bajos a medianos (OR: 0,41; IC del 95%: 0,28-0,61), práctica en la UCI ≤10 años (OR: 0,55; IC del 95%: 0,39-0,79) y entrenamiento dual con anestesiología (OR: 0,52; IC del 95%:0,34–0,79) o medicina (OR: 0,49; IC del 95%: 0,32–0,76) se asociaron con una menor satisfacción con la capacitación en EI. Conclusiones La práctica en EI es heterogénea en todas las UCI, mientras que el programa de optimización de antimicrobianos no se implementa universalmente. Desde la perspectiva de los intensivistas, es necesario mejorar la formación y el conocimiento en EI (AU)

Intensivists' perceptions and attitudes towards infectious diseases management in the ICU: An international survey.

OBJECTIVE: Exploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. DESIGN: Online international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. SETTING: International study conducted in 78 countries. PARTICIPANTS: Physicians working in ICU. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Practice variations were assessed according to respondents' countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents' characteristics and their perceptions regarding adequacy of training. RESULTS: 466 intensivists with a median practice of 10 years (interquartile range, 5-19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28-0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39-0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34-0.79) or medicine (OR: 0.49, 95% CI: 0.32-0.76) were associated with less training satisfaction. CONCLUSION: ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists' perspective, ID training and knowledge need improvement.

Intensivists' perceptions and attitudes towards infectious diseases management in the ICU: An international survey.

OBJECTIVE: Exploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. DESIGN: Online international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. SETTING: International study conducted in 78 countries. PARTICIPANTS: Physicians working in ICU. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Practice variations were assessed according to respondents' countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents' characteristics and their perceptions regarding adequacy of training. RESULTS: 466 intensivists with a median practice of 10 years (interquartile range, 5-19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28-0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39-0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34-0.79) or medicine (OR: 0.49, 95% CI: 0.32-0.76) were associated with less training satisfaction. CONCLUSION: ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists' perspective, ID training and knowledge need improvement.

Epidemiology and predictors of recurrence of Marjolin's ulcer: experience from Mansoura Universityxs.

INTRODUCTION Marjolin's ulcer (MU) is an uncommon malignancy occurring on top of old scars. Once thought to be more common in Caucasians, is now detected increasingly in Africa. METHODS This was a retrospective study of patients with MU attending a tertiary centre within Mansoura University (Egypt) from 2004 to 2015. An institutional-based registry of skin and soft-tissue malignancies in this period revealed 560 cases, from which there were 26 cases of MU. RESULTS The most common underlying cause of MU was burns (92% of patients), followed by trauma. A predilection towards males was detected. The latent period was 4-70 (median, 25) years. Recurrence occurred in 12 cases, with multiple recurrences occurring in 5 cases. MU recurrence was noted as early as 3 months and as late as 25 years after surgery. CONCLUSIONS Young patients with MU are at higher risk of recurrence and should be followed up closely. A thorough search for nodal metastasis (especially in those with high-grade tumours) should be done. Wide local excision and leaving wounds to heal by secondary intention seems to be a viable treatment option.

Serum Fetuin A Levels: Are They a Reliable Marker for Hepatic Steatosis and Regional Adiposity in Renal Transplant Recipients?

BACKGROUND: Fetuin A is a protein expressed in the liver and it is an important inhibitor of ectopic calcification. High levels of fetuin A correlate with insulin resistance, hepatic steatosis, and regional adiposity in the general population. The association between hepatic steatosis and fetuin A level in renal transplant recipients (RTRs) remains unclear. AIM: The aim of this study was to explore the relationships between fetuin A, hepatic steatosis, and regional adiposity in RTRs. METHODS: Data from 44 patients with normal renal functions were included, all subjected to history taking for clinical data, assessment of central obesity and regional adiposity, assessment of hepatic steatosis using abdominal ultrasound (US), and measurements of serum fetuin A concentration using enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: Our study included 20 females (45.4%) and 24 males (54.6%) with mean age of 41.26 ± 11.2 years. Twenty-four subjects had hepatic steatosis. Fetuin A level in RTRs with hepatic steatosis with a mean of 1642.92 ± 358.91 is significantly higher (P < .001) than those without hepatic steatosis with a mean of 711.74 ± 57.85. Serum fetuin A level was positively correlated with regional adiposity (P = .021) and hepatic steatosis grade (P = .017). Fetuin A level increased with increased duration after renal transplantation (P < .001). The best cutoff value for detecting entrance into phase 3 or 4 steatosis is fetuin of 1862 with sensitivity of 88.9% and specificity of 87.7%. CONCLUSIONS: Fetuin A is positively correlated with hepatic steatosis and regional adiposity in RTRs. Fetuin increases with increased duration after renal transplantation. Accordingly it may be used as a marker for hepatic steatosis and regional adiposity in these patients.

The new rHuEPO alpha (epotin) in the management of anemia of end-stage renal disease in patients on maintenance hemodialysis.

Recombinant human erythropoietin has proved to be effective to treat anemia of end-stage renal disease (ESRD). The aim of this study was to assess the efficacy and safety profile of Epotin, a rHuEPO produced in the Middle East. One hundred thirty patients with Hct