[Quality indicators in an intensive care unit: a two-year healthcare-associated infection surveillance program]

OBJECTIVE

To estimate quality healthcare indicators in an intensive care unit (ICU).

METHODS

A prospective observational study was conducted on all patients referred to the medical ICU of Ramón y Cajal hospital (Madrid) for more than 48 hours, from January 1 2008 to December 31 2009.

RESULTS

A total of 503 patients were included, of whom 7.4% developed a healthcare-associated infection (HAI) attributable to their stay in the ICU. The median length of stay was 5 days. A ventilator-associated pneumonia (VAP) was observed in 1.9% of patients, with a VAP rate of 3.8 per 1,000 ventilator-days. A catheter-associated urinary tract infection (CAUTI) was found in 3.6% of the patients, with a CAUTI rate of 4.5 per 1,000 catheter-days. The cumulative incidence of central line-associated bloodstream infection (CLABSI) was 1.8%, with a CLABSI rate of 2.2 per 1,000 central line-days.

CONCLUSIONS

Our results are similar to those of other studies using the same methodology. An HAI surveillance system is a key factor for implementing a healthcare quality improvement system. The obtained indicators allow intra-comparison over time and with other similar hospitals, the monitoring of infection control measures, and thus an effective improvement in healthcare quality and patient safety.

Erlotinib and chemoradiation in patients with surgically resected locally advanced squamous cell carcinoma of the head and neck: a GICOR phase I trial

BACKGROUND

Standard treatment of advanced squamous cell carcinoma of the head and neck (SCCHN) is concurrent chemoradiation. Erlotinib is an oral tyrosine kinase inhibitor of epidermal growth factor receptor, which has shown activity in SCCHN. Phase I study aims to determine the maximum tolerated dose and dose-limiting toxicity (DLT) of adding erlotinib to chemoradiation therapy in patients with surgically resected locally advanced SCCHN.

PATIENTS AND METHODS

Inclusion criteria--SCCHN patients with T3 or T4 primary lesion (except T3N0 with negative resection margins); pathologic N2-N3 disease; poor prognostic findings; age 18-70 years; Eastern Cooperative Oncology Group performance status of zero to one; no evidence of metastasis; adequate organic function and written informed consent. Study design--dose-escalating phase I study with three cohorts of three to six patients each that received increasing doses of erlotinib (100-150 mg/day p.o.) and cisplatin (30-40 mg/m(2) i.v., day 1) for 7 weeks. Radiotherapy--standard regimen of 1.8 Gy daily (5 fractions/week) to a maximum total dose of 63 Gy in 7 weeks.

RESULTS

Thirteen male (median age: 57 years) were enrolled. Overall, the regimen was well tolerated. Two of three patients treated at dose level III (erlotinib: 150 mg/day; cisplatin: 40 mg/m(2)) developed DLT consisting of grade 3 infection and grade 3 mucositis. Other toxic effects included diarrhea, asthenia, and rash. Recommended dose for additional studies: erlotinib 150 mg/day p.o.; cisplatin 30 mg/m(2)/week i.v.

CONCLUSION

Erlotinib can be safely combined with chemoradiation without requiring dose reduction of chemo- or radiotherapy in this postsurgical population.

Recombinant activated factor VII as treatment for uncontrolled mucosal haemorrhage

We report the use of a haemostatic drug (recombinant activated factor VII (rFVIIa)) in a patient who presented a slow but constant bleed in oesophageal mucosa (which required frequent red blood cell transfusion) due to ingestion of caustic products. The administration of rFVIIa ceased bleeding and allowed mucosal cicatrisation and patient haemodynamic stabilisation and clinical recovery.

The profile of fatty acids in frontal cortex of rats depends on the type of fat used in the diet and correlates with neuropeptidase activities

The kind of fat in the diet modifies the profile of fatty acids in brain and also affects aminopeptidase activities in tissues. Although modifications in brain fatty acids, neurotransmitters, or enzymes due to dietary fat composition have been reported, no direct relationship has yet been described between specific brain fatty acid changes and neuropeptide metabolism following the fat composition of the diet. We investigated the lipid profile and some neuropeptidase activities in the frontal cortex of adult male rats after a period in which diets were supplemented with fatty acids differing in their degrees of saturation such as fish oil (rich in polyunsaturated fatty acids, PUFAs), olive oil (rich in monounsaturated fatty acids, MUFAs), and coconut oil (rich in saturated fatty acids, SAFAs). It is observed that the diet composition affects fatty acid distribution in the brain. Although there is no change of global aminopeptidase/neuropeptidase, their activities in the brain correlate positively or negatively with the dietary fat composition. It is hypothesized that fatty acid in the diet modifies membrane fluidity, peptidases tertiary structure, and therefore, the availability and function of neuropeptides. The present results support the notion that cognitive functions may be modulated depending on the type of fat used in the diet.

The interstitial lymphatic peritoneal mesothelium axis in portal hypertensive ascites: when in danger, go back to the sea

Portal hypertension induces a splanchnic and systemic low-grade inflammatory response that could induce the expression of three phenotypes, named ischemia-reperfusion, leukocytic, and angiogenic phenotypes.During the splanchnic expression of these phenotypes, interstitial edema, increased lymph flow, and lymphangiogenesis are produced in the gastrointestinal tract. Associated liver disease increases intestinal bacterial translocation, splanchnic lymph flow, and induces ascites and hepatorenal syndrome. Extrahepatic cholestasis in the rat allows to study the worsening of the portal hypertensive syndrome when associated with chronic liver disease. The splanchnic interstitium, the mesenteric lymphatics, and the peritoneal mesothelium seem to create an inflammatory pathway that could have a key pathophysiological relevance in the production of the portal hypertension syndrome complications. The hypothetical comparison between the ascitic and the amniotic fluids allows for translational investigation. From a phylogenetic point of view, the ancestral mechanisms for amniotic fluid production were essential for animal survival out of the aquatic environment. However, their hypothetical appearance in the cirrhotic patient is considered pathological since ultimately they lead to ascites development. But, the adult human being would take advantage of the potential beneficial effects of this “amniotic-like fluid” to manage the interstitial fluids without adverse effects when chronic liver disease aggravates.

Emission polarization control in semiconductor quantum dots coupled to a photonic crystal microcavity

We study the optical emission of single semiconductor quantum dots weakly coupled to a photonic-crystal micro-cavity. The linearly polarized emission of a selected quantum dot changes continuously its polarization angle, from nearly perpendicular to the cavity mode polarization at large detuning, to parallel at zero detuning, and reversing sign for negative detuning. The linear polarization rotation is qualitatively interpreted in terms of the detuning dependent mixing of the quantum dot and cavity states. The present result is relevant to achieve continuous control of the linear polarization in single photon emitters.

Hypothalamic and plasmatic angiotensin metabolism in L-NAME treated rats

In order to study the interaction between the renin-angiotensin system (RAS) and nitric oxide (NO), we analyzed the activity of aspartyl- (AspAP), glutamyl- (GluAP), alanyl- (AlaAP), and cystinylaminopeptidase (CysAP) enzymes involved in the RAS cascade, in the hypothalamus, and plasma of normotensive adult male rats after the inhibition of NO production with the NO synthase inhibitor L-NAME (L-N (G)-nitroarginine methyl ester). L-NAME treatment produced a significant increase of systolic blood pressure (SBP). In plasma, while GluAP activity decreased significantly, suggesting a lower Ang III formation, the other aminopeptidases did not change after L-NAME treatment. In hypothalamus, the activities of AspAP and CysAP were not affected after L-NAME treatment. In contrast, GluAP and AlaAP increased significantly. These results suggested mainly a higher formation of Ang III, but also higher levels of Ang IV in the hypothalamus of L-NAME treated rats. Both peptides have hypertensive properties at central level. On the contrary, Ang III may counteract the hypertensive action of Ang II at the periphery. Therefore, the increased SBP in L-NAME treated rats may be due in part to the increased activity of GluAP and AlaAP in hypothalamus and to a decreased activity of GluAP in plasma.

Most Frequent Errors in Judo Uki Goshi Technique and the Existing Relations among Them Analysed through T-Patterns

The purpose of this study is to provide a tool, based on the knowledge of technical errors, which helps to improve the teaching and learning process of the Uki Goshi technique. With this aim, we set out to determine the most frequent errors made by 44 students when performing this technique and how these mistakes relate. In order to do so, an observational analysis was carried out using the OSJUDO-UKG instrument and the data were registered using Match Vision Studio (Castellano, Perea, Alday and Hernández, 2008). The results, analyzed through descriptive statistics, show that the absence of a correct initial unbalancing movement (45,5%), the lack of proper right-arm pull (56,8%), not blocking the faller's body (Uke) against the thrower's hip -Tori- (54,5%) and throwing the Uke through the Tori's side are the most usual mistakes (72,7%). Through the sequencial analysis of T-Patterns obtained with the THÈME program (Magnusson, 1996, 2000) we have concluded that not blocking the body with the Tori's hip provokes the Uke's throw through the Tori's side during the final phase of the technique (95,8%), and positioning the right arm on the dorsal region of the Uke's back during the Tsukuri entails the absence of a subsequent pull of the Uke's body (73,3%). Key PointsIn this study, the most frequent errors in the performance of the Uki Goshi technique have been determined and the existing relations among these mistakes have been shown through T-Patterns.The SOBJUDO-UKG is an observation instrument for detecting mistakes in the aforementioned technique.The results show that those mistakes related to the initial imbalancing movement and the main driving action of the technique are the most frequent.The use of T-Patterns turns out to be effective in order to obtain the most important relations among the observed errors.

Hepatectomies in the rat: A look at the caudate process through microsurgery

Hepatectomies in the rat can be improved using microsurgical techniques. The distribution variations of the vascular and biliar lobular branches of the liver are observed under magnification with an operative microscope and, therefore their dissection, ligation and section are more accurate. The vascularization and bile drainage of the caudate process, a liver sector located between the right lateral and the caudate lobes, can be identified using microsurgery. The viability of the animal's evolution after different types (90%, 95%, 97%) of subtotal hepatectomies depends on an effective identification of these vascular and biliary branches.

Myocardial protection by isoflurane vs. sevoflurane in ultra-fast-track anaesthesia for off-pump aortocoronary bypass grafting

BACKGROUND AND OBJECTIVES

Volatile anaesthetics have gained more popularity recently due to the potential for cardiac protection. Ultra-fast-track anaesthesia implies the immediate extubation after cardiac surgery. The purpose of this prospective randomized double-blind controlled study is to compare the cardioprotective effects of sevoflurane and isoflurane in off-pump cardiac bypass surgery.

METHODS

Forty patients undergoing elective off-pump cardiac bypass surgery with high thoracic epidural analgesia and immediate extubation at the end of surgery were randomized into two groups. During surgery, anaesthesia was provided with either 1 minimum alvelolar anaesthetic concentration of sevoflurane or 1 minimum alvelolar anaesthetic concentration of isoflurane. Troponin-T, creatine kinase-MB, left ventricular wall motion anomalies, time to extubation, respiratory functions and haemodynamic parameters were compared between the two groups by analysis of variance.

RESULTS

All patients were successfully extubated in the operating theatre with minimal postoperative pain. Serial creatine kinase-MB and troponin-T concentrations were not significantly different between the two volatile agents. Haemodynamic stability throughout surgery and contractility was not different between groups. However, extubation time was significantly shorter with sevoflurane (10 +/- 5 min) compared to isoflurane (18 +/- 4 min).

CONCLUSION

This study indicates that during off-pump cardiac bypass surgery, sevoflurane and isoflurane provide the same ischaemic cardioprotective effects. There is no difference for heart contractility and haemodynamic values during and after off-pump cardiac bypass surgery between the two agents. Sevoflurane allows a more rapid recovery from anaesthesia, but this does not translate into better pulmonary function or haemodynamics. Both agents are similar in ultra-fast-track off-pump cardiac bypass surgery.

Phase I/II study of concurrent erlotinib and chemoradiation for post-resected locally advanced squamous head and neck cancer (HNSCC): A GICOR study

16544

Background: Concurrent chemoradiation is considered the optimal treatment for advanced HNSCC, including post-resected status. Erlotinib is an oral EGFR TKI, with activity in recurrent and metastatic HNSCC.The Spanish Group of Clinical Research in Radiation Oncology (GICOR) leads a phase I/II study to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of adding erlotinib (e) to chemoradiation to patients (p) with surgically resected locally advanced HNSCC Methods: p had surgically resected advanced HNSCC, with a least one of the following criteria: T3 or T4 primary lesion (except T3N0 with negative resection margins), pathologic N2-N3 disease, and poor prognostic findings (i.e. extranodal spread, positive resection margins, perineural or perivascular involvement). Additional eligibility criteria included: age 18–70 y; life expectancy = 12 w; PS 0–1; no evidence of metastasis; adequate organic function; and written informed consent. Dose-escalating phase I study consisted on 3 cohorts of 3–6 p each, with increasing doses of erlotinib (100–150 mg po qd) and cisplatin (30–40 mg/m2, iv, d 1) for 7 w. Radiotherapy was delivered as a fixed standard regimen of daily 1.8 Gy (5 fractions/w) to a total dose of 63 Gy in high risk areas along 7 w. Results: By the time of this analysis, 7 p have entered the phase I component of the study. Median age: 52 y; male 100%. Complete data for 4 pats included in cohort 1 (e 100 mg/d, c 30 mg/m2) are available. One p withdrew prematurely the study due to a grade 2 toxicity (not considered DLT) and was considered unevaluable by the Scientific Committee. Among evaluable p, 2 developed mucositis (1g.3), vomiting (g.1) and nausea (g.1). All p developed skin rash (mild in all the cases). Haematological toxicities were single cases of anaemia, leukopenia and thrombocytopenia (g.1). All 3 p completed 7 weeks of treatment and no dose reduction was required. No DLT as per protocol has been described and study went subsequently further to cohort 2. Conclusions: This study demonstrates the safe addition of erlotinib to chemoradiotherapy in the treatment of this p population. Full data from the phase I study will be presented.

No significant financial relationships to disclose.

Plasma aminopeptidase activities in Parkinson's disease

Parkinson's disease (PD) is an age-related neurodegenerative disease characterized by a progressive motor disorder, but frequently is accompanied by autonomic symptoms such as hypotension. Together with the decrease of dopamine, significant decreases in aminopeptidase activities have been reported in PD brains. However, up to date there are no studies about changes of aminopeptidase activities in plasma of PD patients. We studied plasma activities of alanyl-, aspartyl-(AspAP), cystinyl-(CysAP) and glutamyl-aminopeptidase (GluAP) in two groups of subjects: control (n=41) and PD (n=48). Plasma activities of AspAP, CysAP, and GluAP showed significant decreases of 24.9% (p<0.05), 39.4% (p<0.01) and 33.3% (p<0.01), respectively, in PD group. These aminopeptidases are involved in the metabolism of circulating peptides such as the ones of the renin-angiotensin system. The importance of aminopeptidases in striatal dopamine content and in neuroendocrine system in PD is discussed.