Indocyanine green plasma disappearance rate as dynamic liver function test in critically ill patients.

BACKGROUND: Indocyanine green (ICG) is a water-soluble fluorescent dye that is bound to plasma protein when administered intravenously. Removal of ICG from the blood depends on hepatic blood flow, function of the parenchymal cells and biliary excretion. ICG elimination is described as a useful dynamic liver function test. METHODS: In this review, we looked at the most recent literature to clarify why ICG is useful in critically ill patients, the validity of the ICG plasma disappearance rate (ICG-PDR) measured transcutaneously and whether ICG-PDR has any prognostic value. CONCLUSION: In conclusion, measuring ICG-PDR is a valuable method for dynamic assessment of liver function, and is found to be a valuable prognostic tool in predicting survival for septic patients, patients presenting with acute liver failure and critically ill patients.

COVID-19 as a mediator of interferon deficiency and hyperinflammation: Rationale for the use of JAK1/2 inhibitors in combination with interferon.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) elicits an interferon (IFN) deficiency state, which aggravates the type I interferon deficiency and slow IFN responses, which associate with e.g. aging and obesity. Additionally, SARS-CoV-2 may also elicit a cytokine storm, which accounts for disease progression and ultimately the urgent need of ventilator support. Based upon several reports, it has been argued that early treatment with IFN-alpha2 or IFN-beta, preferentially in the early disease stage, may prohibit disease progression. Similarly, preliminary studies have shown that JAK1/2 inhibitor treatment with ruxolitinib or baricitinib may decrease mortality by dampening the deadly cytokine storm, which - in addition to the virus itself - also contributes to multi-organ thrombosis and multi-organ failure. Herein, we describe the rationale for treatment with IFNs (alpha2 or beta) and ruxolitinib emphasizing the urgent need to explore these agents in the treatment of SARS-CoV-2 - both as monotherapies and in combination. In this context, we take advantage of several safety and efficacy studies in patients with the chronic myeloproliferative blood cancers (essential thrombocythemia, polycythemia vera and myelofibrosis) (MPNs), in whom IFN-alpha2 and ruxolitinib have been used successfully for the last 10 (ruxolitinib) to 30 years (IFN) as monotherapies and most recently in combination as well. In the context of these agents being highly immunomodulating (IFN boosting immune cells and JAK1/2 inhibitors being highly immunosuppressive and anti-inflammatory), we also discuss if statins and hydroxyurea, both agents possessing anti-inflammatory, antithrombotic and antiviral potentials, might be inexpensive agents to be repurposed in the treatment of SARS-CoV-2.

Blood pressure and plasma catecholamines in acute and prolonged hypoxia: effects of local hypothermia.

This study measured the pressor and plasma catecholamine response to local hypothermia during adaptation to hypobaric hypoxia. Eight healthy men were studied at rest and after 10 and 45 min of local cooling of one hand and forearm as well as after 30 min of rewarming at sea level and again 24 h and 5 days after rapid, passive transport to high altitude (4,559 m). Acute mountain sickness scores ranged from 5 to 16 (maximal attainable score: 20) on the first day but were reduced to 0-8 by the fifth day. Systolic blood pressure, heart rate, and plasma epinephrine increased on day 1 at altitude compared with sea level but declined again on day 5, whereas diastolic and mean blood pressures continued to rise in parallel with plasma norepinephrine. With local cooling, an increased vasoactive response was seen on the fifth day at altitude. Very high pressures were obtained, and the pressure elevation was prolonged. Heart rate increased twice as much on day 5 compared with the other two occasions. Thoracic fluid index increased with cooling on day 5, suggesting an increase in pulmonary vascular resistance. In conclusion, prolonged hypoxia seems to elicit an augmented pressor response to local cooling in the systemic and most likely also the pulmonary circulation.

Polyurethane film (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study.

As it has been shown that re-epithelialization of partial skin thickness wounds can be accelerated if the wound is kept moist, a prospective, randomized clinical study compared the water vapour-semipermeable polyurethane film, Opsite, with the conventional impregnated gauze dressing, Jelonet, in the treatment of outpatient partial skin thickness burns. Fifty-five patients were included: 30 were treated with the polyurethane film and 25 with the conventional dressing. The patients were followed at regular intervals until healing had occurred and were seen 3 months later for evaluation of residual scars and pigmentation. The burns treated with polyurethane films healed with a median of 10 days, while the conventionally treated burns healed with a median of 7 days (P greater than 0.05). Residual scars were noted in 21 per cent of the patients treated with polyurethane films and in 8 per cent treated conventionally (P greater than 0.05). Prophylactic methods should be publicly stressed since one-quarter of the patients were children of 3 years or less who were scalded by split hot liquids. Furthermore the patients' wounds were only briefly cooled before attending medical care. With small burns we advise that cooling should be prolonged until the pain fades then professional assistance should be sought.

Clinical variability of possible malignant hyperthermia as revealed by two cases.

Two cases of possible clinical malignant hyperthermia are described. The variability of the clinical symptoms and signs is discussed and the necessity of performing the diagnostic in vitro muscle contracture test is emphasized.

Percutaneous osteosynthesis with two screws in treating femoral neck fractures.

In a consecutive, retrospective study, 182 patients were followed 1 year after surgical treatment of a fractured femoral neck. The patients were admitted on alternate days to the neighboring departments of orthopedic surgery O and phi, respectively. In Department O, the patients were submitted to sliding screw-plate (SSP) osteosynthesis, while patients in Department phi were treated with two percutaneously introduced screws. Our results showed that double-screw osteosynthesis can be performed significantly quicker and with less blood loss than application of SSP. Healing of the fractures in the two groups did not differ significantly, nor did the cumulative rate of failure or the frequency of secondary surgical procedures. We find that, judged from these parameters, percutaneously introduced double-screw osteosynthesis is at least as effective as SSP osteosynthesis.

[Patient related diagnostic delay in breast tumor. A prospective study]. / Patientrelateret diagnoseforsinkelse ved tumor mammae. En prospektiv undersøgelse.

In 209 patients referred with the diagnosis of tumour of the breast, the patient delay (PD) was registered together with the demographic and clinical conditions concerning the patient according to a meticulous questionnaire. In addition, the histological diagnosis and possible regional spread were registered. A total of 126 patients (60%) sought advice within one month of the commencement of symptoms. No statistically significant connection could be demonstrated between PD and age, marital status, education and occupational situation. No significant connection could be demonstrated between the size of the tumour, time of seeking advice and PD. A total of 115 patients (55%) had malignant tumours. The frequency of regional spread was found to be significantly greater in patients with PD longer than four weeks. Regular self-examination of the breast was undertaken by 92 (46%) of the patients and this was significantly more frequent in married or cohabiting patients, in patients with long education and in patients with employment outside the home. It did not prove possible to demonstrate briefer PD, lesser size of tumour and fewer cases of regional spread in patients who undertook self-examination of the breast but further research is required here.

[The national patient registry. Evaluation of data quality]. / Landspatientregisteret. Evaluering af datakvaliteten.

The Danish National Patient Register, which includes information on all patients admitted to hospitals, has been evaluated as concerns the quality of the data included. The material examined consisted of a representative sample of 1094 patients from departments all over the country (gynaecology and obstetrics, medicine, surgery and paediatrics). Recoding of data, clinical as well as administrative, based on copies of the case records from the hospitals was carried out by two clinically working physicians (registrars). For the administrative data e.g. length of stay, satisfactory concordance was found. The validity of clinical information depended on clinical speciality and degree of diagnostic specificity. Based on the international classification the agreement on the three digit diagnostic level was better than on the five digit diagnostic level. For surgery the agreement was better than for medicine. The agreement between the diagnostic information (primary diagnosis) and the recoder in choosing primary diagnosis varied from 66-83 percent on the five digit level and between 73-89 percent on the three digit diagnostic level. If cases where the diagnosis in the registry could be regarded as an acceptable alternative were included, the agreement between the registry and recoding was 75-90%. In a subsample of the material double coding by the two coders was carried out and it was remarkable that, taken as a whole, the degree of agreement between the two coders was of the same size as between recoder and the registry. It is anticipated, however, that introduction of ICD-10 with more clear-cut rules for choice of primary diagnosis in morbidity coding will contribute to better validity and consequently improved hospital statistics.

Increased concentrations of L-lactate in the rectal lumen in patients undergoing cardiopulmonary bypass.

BACKGROUND: Gut ischaemia may contribute to morbidity in patients after cardiopulmonary bypass (CPB), but little is known about the metabolic state of the large bowel in such patients. Therefore we estimated the concentrations of L-lactate and Pco(2) in rectal mucosa in patients undergoing cardiac surgery with or without the use of CPB. METHODS: Patients undergoing coronary artery bypass grafting (CABG) (n=12) or off-pump CABG (n=10) were subjected to equilibrium dialysis of the rectal lumen during the procedure and in the first 4 h afterwards. Dialysate concentrations of L-lactate and Pco(2) were measured using an auto-analyser and compared with values obtained in healthy subjects (n=10). RESULTS: During CPB, a 2- to 3-fold increase in luminal concentrations of L-lactate was observed (CABG vs off-pump CABG, P=0.05; CABG vs healthy subjects, P<0.01). The dialysate concentrations of L-lactate were higher than the mean systemic values (luminal-arterial gradient mean (sd) 0.9 (1.0) mmol litre(-1), P<0.05), and the two values were positively correlated (P<0.05). Luminal L-lactate concentrations remained elevated 4 h after the operation. In contrast, dialysate Pco(2) was equally high in patient and control groups and substantially higher than values observed in arterial blood. CONCLUSIONS: Uncomplicated CPB is associated with moderate but sustained increases in luminal concentrations of L-lactate in the rectum, indicating metabolic dysfunction of the mucosa in the large bowel.

Leiomyomatosis peritonealis disseminata.

Leiomyomatosis peritonealis disseminata (LPD) is a benign entity in which numerous small grey-white nodules consisting of smooth-muscle cells are found scattered in the peritoneal cavity. LPD has only been found in women, predominantly in their late reproductive age. It has, with a few exceptions, been asymptomatic and is most often an incidental finding at laparotomy performed in order to excise a leiomyomatous uterus or during Caesarean section. Although the disorder is rare, it is alarming to the surgeon, who may be faced unexpectedly with it peroperatively. Since it is grossly indistinguishable from diffuse carcinomatosis of the peritoneum, several unnecessary radical procedures have resulted. We report a case in which not only the gross-pathological features found during surgery, but also the clinical course, as well as the preoperative investigations were highly suggestive of frank malignancy. A survey of the literature is also presented. It is emphasized that in all cases regression has occurred regardless of the therapeutic action taken.

Plica mediopatellaris--arthroscopic resection under local anesthesia.

A consecutive series of 28 patients (31 knees) with a symptomatic mediopatellar plica without concomitant lesions excised arthroscopically under local anaesthesia in the outpatient department is described. The results were classified as excellent or good in 26/31 cases after a median follow-up period of 15 months. It is concluded that excising a fibrosed mediopatellar plica large enough to cover the medial femoral condyle during flexion is followed by good results; local anaesthesia is sufficient and economical, and arthroscopic excision under local anaesthesia carries a low morbidity.

Fracture of the proximal metaphysis of the tibia in children.

Forty children seen consecutively with fractures of the proximal tibial metaphysis were reviewed to assess the frequency of the types of fracture and likelihood of developing progressive valgus deformity. The incidence of this fracture was 5.6 per 100,000 children per year. There were 17 fissure and buckle fractures, 15 greenstick fractures and 8 complete fractures. Valgus deformity was not seen after fissure or buckle fractures. Only 15 per cent of the greenstick and complete fractures progressed to valgus deformity. Predisposing factors were a young age and persistent valgus at the fracture site at union.

Epiphyseal fractures of the proximal tibia.

During a 12-year period there were 15 patients with proximal tibial epithyseal fractures. Eleven were examined at follow-up with a mean observation time of 7 years (range 3.5-12.5). Five patients with type IV or type V lesions had concomitant avulsion fractures of the tibial insertion of the anterior cruciate ligament, two being displaced. Eight out of twelve patients had concomitant ligamentous injuries. At follow-up two patients complained of instability, confirmed by clinical examination. Another two patients had symptom-free anterior laxity. Serious angular deformity was found in two patients, while important leg length discrepancy was observed in one. Degenerative changes of the knee joint were found in three patients. An active reconstructive approach is recommended, and attention is drawn to concomitant ligamentous injuries which, it seems, in the past have tended to be underestimated.

Preoperative evaluation of intubation conditions in patients scheduled for elective surgery.

Prediction of a difficult airway is a continuing problem. Several tests have been developed in order to overcome this problem. It has been proposed that using more than one test could increase the degree of predictability. One hundred patients scheduled for general surgery were successfully evaluated using three methods: 1. The size of the tongue in relation to the oral cavity (Mallampati gradation). 2. The thyromental and the mandibular length. 3. The atlanto-occipital angle. Seven patients had a difficult laryngoscopy and were difficult to intubate. It was possible to predict differenties in all seven patients, but it was found that only the Mallampati gradation and the atlanto-occipital angle contributed significantly to predictability. The cost of predicting further difficulties in all patients with a difficult laryngoscopy was a false positive prediction in a further 13 patients who had no problems with laryngoscopy or intubation. By increasing the specificity of the tests the number of false positive classifications could be reduced to 10 patients, but this would have led to the missing of one patient with a difficult laryngoscopy.

Injuries in high-skilled and low-skilled soccer: a prospective study.

Fifty-five male soccer players organized in three teams, one high and two lower ranking, were followed prospectively during 1 year to register the rate, type and severity of injuries in highly skilled and low-skilled players. The injury rate of the low-skilled players was significantly higher than that of the better players. The reason for this is that low-skilled players play in more competitions. and this is where injuries tend to occur. When we stratified on game/practice, the low-skilled players' excess risk disappeared and no difference was found in the severity of injuries. Different ways of collecting data in epidemiological studies of soccer are discussed and it is concluded that the most precise and accurate collection of data can only be obtained by direct supervision and examination of soccer players in the field.

Epidemiology of knee injuries in children.

We analyzed 91 consecutive metaphyseal fractures, physeal injuries, and ligament ruptures in children aged 0-14 years. In the younger children, metaphyseal fractures dominated, whereas teenager had ligament rupture associated with low-energy trauma and physeal injury with high-energy trauma.

Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws.

In a prospective, randomized trial, 104 consecutive patients with displaced femoral neck fractures were allocated either to fixation with a sliding screw plate or 4 ASIF cancellous bone screws. The patients were reexamined at fixed intervals to determine the time of union. The 2-year-cumulated rate of union was 64 per cent in the plate group and 84 per cent in the screw group.

Somatostatin attenuates the hyperthermia induced increase in neutrophil concentration.

This study was designed to test the hypothesis that the immune changes seen during in vivo whole body hyperthermia are mediated by elevations in the plasma concentrations of either catecholamines, growth hormone or beta-endorphins. Eight healthy volunteers were immersed in a hot water bath (WI; water temperature 39.5 degrees C) for 2 h during which their rectal temperature rose to 39.5 degrees C. In a single blind, randomized, cross-over study the stress hormone effects were blocked one at a time by administration of propranolol, somatostatin or naloxone; the results were compared to those obtained during saline infusion (control). Blood samples were collected before, at the end of 2 h of WI (body temperature 39.5 degrees C), and 2 h later. Hormone blockade did not abolish the hyperthermia-induced recruitment of natural killer (NK) cells to the blood, and no influence was observed on the percentages or concentrations of any other subpopulations of blood mononuclear cells, except that the number of cluster designation (CD)3+ cells slightly increased after hyperthermia only in the propranolol experiment. Furthermore, the NK cell activity, both unstimulated and interferon-alpha or interleukin-2 stimulated, did not differ from the control situation. It is of interest, however, that somatostatin partly abolished the hyperthermia induced increase in the neutrophil number. Based on these data and previous results showing that growth hormone infusion increases the concentration of neutrophils in the blood, it is suggested that growth hormone is at least partly responsible for hyperthermia induced neutrocytosis.