ACE inhibitors and angiotensin receptor blockers differentially alter the response to angiotensin II treatment in vasodilatory shock

BACKGROUND

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blockers (ARB) medications are widely prescribed. We sought to assess how pre-admission use of these medications might impact the response to angiotensin-II treatment during vasodilatory shock.

METHODS

In a post-hoc subgroup analysis of the randomized, placebo-controlled, Angiotensin Therapy for High Output Shock (ATHOS-3) trial, we compared patients with chronic angiotensin-converting enzyme inhibitor (ACEi) use, and patients with angiotensin receptor blocker (ARB) use, to patients without exposure to either ACEi or ARB. The primary outcome was mean arterial pressure after 1-h of treatment. Additional clinical outcomes included mean arterial pressure and norepinephrine equivalent dose requirements over time, and study-drug dose over time. Biological outcomes included baseline RAS biomarkers (renin, angiotensin-I, angiotensin-II, and angiotensin-I/angiotensin-II ratio), and the change in renin from 0 to 3 h.

RESULTS

We included n = 321 patients, of whom, 270 were ACEi and ARB-unexposed, 29 were ACEi-exposed and 22 ARB-exposed. In ACEi/ARB-unexposed patients, angiotensin-treated patients, compared to placebo, had higher hour-1 mean arterial pressure (9.1 mmHg [95% CI 7.6-10.1], p < 0.0001), lower norepinephrine equivalent dose over 48-h (p = 0.0037), and lower study-drug dose over 48-h (p < 0.0001). ACEi-exposed patients treated with angiotensin-II showed similarly higher hour-1 mean arterial pressure compared to ACEi/ARB-unexposed (difference in treatment-effect: - 2.2 mmHg [95% CI - 7.0-2.6], pinteraction = 0.38), but a greater reduction in norepinephrine equivalent dose (pinteraction = 0.0031) and study-drug dose (pinteraction < 0.0001) over 48-h. In contrast, ARB-exposed patients showed an attenuated effect of angiotensin-II on hour-1 mean arterial pressure versus ACEi/ARB-unexposed (difference in treatment-effect: - 6.0 mmHg [95% CI - 11.5 to - 0.6], pinteraction = 0.0299), norepinephrine equivalent dose (pinteraction < 0.0001), and study-drug dose (pinteraction = 0.0008). Baseline renin levels and angiotensin-I/angiotensin-II ratios were highest in ACEi-exposed patients. Finally, angiotensin-II treatment reduced hour-3 renin in ACEi/ARB-unexposed and ACEi-exposed patients but not in ARB-exposed patients.

CONCLUSIONS

In vasodilatory shock patients, the cardiovascular and biological RAS response to angiotensin-II differed based upon prior exposure to ACEi and ARB medications. ACEi-exposure was associated with increased angiotensin II responsiveness, whereas ARB-exposure was associated with decreased responsiveness. These findings have clinical implications for patient selection and dosage of angiotensin II in vasodilatory shock. Trial Registration ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).

Angiotensin II treatment is associated with improved oxygenation in ARDS patients with refractory vasodilatory shock

BACKGROUND

The physiological effects of renin-angiotensin system modulation in acute respiratory distress syndrome (ARDS) remain controversial and have not been investigated in randomized trials. We sought to determine whether angiotensin-II treatment is associated with improved oxygenation in shock-associated ARDS.

METHODS

Post-hoc subgroup analysis of the Angiotensin Therapy for High Output Shock (ATHOS-3) trial. We studied patients who met modified Berlin ARDS criteria at enrollment. The primary outcome was PaO2/FiO2-ratio (P:F) at 48-h adjusted for baseline P:F. Secondary outcomes included oxygenation index, ventilatory ratio, PEEP, minute-ventilation, hemodynamic measures, patients alive and ventilator-free by day-7, and mortality.

RESULTS

Of 81 ARDS patients, 34 (42%) and 47 (58%) were randomized to angiotensin-II or placebo, respectively. In angiotensin-II patients, mean P:F increased from 155 mmHg (SD: 69) at baseline to 265 mmHg (SD: 160) at hour-48 compared with no change with placebo (148 mmHg (SD: 63) at baseline versus 164 mmHg (SD: 74) at hour-48)(baseline-adjusted difference: + 98.4 mmHg [95%CI 35.2-161.5], p = 0.0028). Similarly, oxygenation index decreased by - 6.0 cmH2O/mmHg at hour-48 with angiotensin-II versus - 0.4 cmH2O/mmHg with placebo (baseline-adjusted difference: -4.8 cmH2O/mmHg, [95%CI - 8.6 to - 1.1], p = 0.0273). There was no difference in PEEP, minute ventilation, or ventilatory ratio. Twenty-two (64.7%) angiotensin-II patients had sustained hemodynamic response to treatment at hour-3 versus 17 (36.2%) placebo patients (absolute risk-difference: 28.5% [95%CI 6.5-47.0%], p = 0.0120). At day-7, 7/34 (20.6%) angiotensin-II patients were alive and ventilator-free versus 5/47(10.6%) placebo patients. Day-28 mortality was 55.9% in the angiotensin-II group versus 68.1% in the placebo group.

CONCLUSIONS

In post-hoc analysis of the ATHOS-3 trial, angiotensin-II was associated with improved oxygenation versus placebo among patients with ARDS and catecholamine-refractory vasodilatory shock. These findings provide a physiologic rationale for trials of angiotensin-II as treatment for ARDS with vasodilatory shock.

TRIAL REGISTRATION

ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).

The impact of intensive care unit physician staffing change at a community hospital

Objectives

A high-intensity staffing model has been defined as either mandatory intensivist consultation or a closed intensive care unit in which intensivists manage all aspects of patient care. In the current climate of limited healthcare resources, transitioning to a closed intensive care unit model may lead to significant improvements in patient care and resource utilization.

Methods

This is a single-center, retrospective cohort study of all mechanically ventilated intensive care unit admissions in the pre-intensive care unit closure period of 1 October 2014 to 30 September 2015 as compared with the post-intensive care unit closure period of 1 November 2015 to 31 October 2016. Patient demographics as well as outcome data (duration of mechanical ventilation, length of stay, direct costs, complications, and mortality) were abstracted from the electronic health record. All data were analyzed using descriptive and inferential statistics. Regression analyses were used to adjust outcomes for potential confounders.

Results

A total of 549 mechanically ventilated patients were included in our analysis: 285 patients in the pre-closure cohort and 264 patients in the post-closure cohort. After adjusting for confounders, there was no significant difference in mortality rates between the pre-closure (40.7%) and post-closure (38.6%) groups (adjusted odds ratio = 0.82; 95% confidence interval = 0.56-1.18; p = 0.283). The post-closure cohort was found to have significant reductions in duration of mechanical ventilation (3.71-1.50 days; p < 0.01), intensive care unit length of stay (5.8-2.7 days; p < 0.01), hospital length of stay (10.9-7.3 days; p < 0.01), and direct hospital costs (US $16,197-US $12,731; p = 0.009). Patient complications were also significantly reduced post-intensive care unit closure.

Conclusion

Although a closed intensive care unit model in our analysis did not lead to a statistical difference in mortality, it did demonstrate multiple beneficial outcomes including reduced ventilator duration, decreased intensive care unit and hospital length of stay, fewer patient complications, and reduced direct hospital costs.

Corticosteroid use in ARDS and its application to evolving therapeutics for coronavirus disease 2019 (COVID-19): A systematic review

Data regarding the use of corticosteroids for treatment of acute respiratory distress syndrome (ARDS) are conflicting. As the coronavirus disease 2019 (COVID‐19) pandemic progresses, more literature supporting the use of corticosteroids for COVID‐19 and non‐COVID‐19 ARDS have emerged. Glucocorticoids are proposed to attenuate the inflammatory response and prevent progression to the fibroproliferative phase of ARDS through their multiple mechanisms and anti‐inflammatory properties. The purpose of this systematic review was to comprehensively evaluate the literature surrounding corticosteroid use in ARDS (non‐COVID‐19 and COVID‐19) in addition to a narrative review of clinical considerations of corticosteroid use in these patient populations. OVID Medline and EMBASE were searched. Randomized controlled trials evaluating the use of corticosteroids for COVID‐19 and non‐COVID‐19 ARDS in adult patients on mortality outcomes were included. Risk of bias was assessed with the Risk of Bias 2.0 tool. There were 388 studies identified, 15 of which met the inclusion criteria that included a total of 8877 patients. The studies included in our review reported a mortality benefit in 6/15 (40%) studies with benefit being seen at varying time points of mortality follow‐up (ICU survival, hospital, and 28 and 60 days) in the COVID‐19 and non‐COVID‐19 ARDS studies. The two non‐COVID19 trials assessing lung injury score improvements found that corticosteroids led to significant improvements with corticosteroid use. The number of mechanical ventilation‐free days significantly were found to be increased with the use of corticosteroids in all four studies that assessed this outcome. Corticosteroids are associated with improvements in mortality and ventilator‐free days in critically ill patients with both COVID‐19 and non‐COVID‐19 ARDS, and evidence suggests their use should be encouraged in these settings. However, due to substantial differences in the corticosteroid regimens utilized in these trials, questions still remain regarding the optimal corticosteroid agent, dose, and duration in patients with ARDS.

Implementation and evaluation of a virtual learning advanced pharmacy practice experience

BACKGROUND AND PURPOSE

The novel severe acute respiratory syndrome coronavirus 2 restricted student involvement in direct patient care. Virtual learning is an effective education strategy in pharmacy curriculums. This study aimed to evaluate student perceptions of virtual learning advanced pharmacy practice experiences (APPE) utilizing an electronic 12-question survey.

EDUCATIONAL ACTIVITY AND SETTING

Virtual learning was developed and implemented, and students were surveyed at the end of the APPE. The survey was comprised of one open-ended and 11 Likert scale questions. It assessed implementation and use of virtual learning in place of a standard on-site APPE.

FINDINGS

Responses were attained from 19 students. Questions regarding resources provided and virtual learning enabling autonomous, independent learning had the highest percent of strong agreement. No responses indicated strong disagreement. Three questions solicited >10% response rate of somewhat disagree, 16% associated with virtual learning helping the student become a better member of the healthcare team after graduation. Open-ended responses acknowledged appreciation of the virtual APPE and presented material. One in six students commented on the ability to apply the learned information to direct patient care. Feedback was delivered on consideration for increased utility of patient care-orientated applications to facilitate simulation of real-life patient cases.

SUMMARY

Students who completed the virtual APPE were satisfied overall. Virtual teaching modalities may be incorporated into APPEs, particularly when direct patient care access is limited, but should not be used to completely replace the experience gained during direct patient care.

Mesenteric venous thrombosis: A lethal complication of hyperglycemic crises

PURPOSE

Although hyperglycemic crises can lead to a hypercoagulable state, few instances of associated mesenteric venous thrombosis (MVT) have been reported. Worsening abdominal pain in the context of shock requiring vasopressor support should prompt urgent further investigation.

SUMMARY

A 44-year-old Hispanic male arrived at an emergency department with chief complaints of lethargy, polydipsia, and polyuria. His past medical history included type 2 diabetes, epilepsy, obesity, tobacco smoking, and noncompliance with his medications. On arrival the patient had a serum glucose concentration of >1,600 mg/dL, and hyperosmolar hyperglycemic syndrome (HHS) was diagnosed. The patient was admitted to the intensive care unit with respiratory failure and subsequently developed shock refractory to fluid resuscitation, necessitating vasopressor support. On hospital day 4, a computerized tomogram obtained for investigation of increasing abdominal tenderness revealed superior MVT and pneumatosis intestinalis. Despite an emergency laparotomy and enterectomy, the patient ultimately succumbed on hospital day 41 due to recurrent pneumonia complicated by acute respiratory distress syndrome and septic shock.

CONCLUSION

Shock that is refractory to aggressive fluid resuscitation, necessitating pressor support, in the setting of HHS or diabetic ketoacidosis should prompt investigation for the underlying source of shock. Other etiologies, including hypovolemic, cardiogenic, and obstructive shock, should be considered; however, infection is the leading trigger of hyperglycemic crises. Although rarely reported, MVT should be considered in the diagnostic algorithm in the absence of an identified infectious source. Prompt investigation should include use of diagnostic modalities such as computed tomography to assess for MVT.

Comparison of Melatonin and Zolpidem for Sleep in an Academic Community Hospital: An Analysis of Patient Perception and Inpatient Outcomes

Hospitalizations can significantly disrupt patient sleep patterns and contribute to insomnia, which places patients at a higher risk of altered mental status as well as other complications. Despite attempts to control environmental factors, deliriogenic medications are often prescribed for the management of hospital-related insomnia. The primary objective of this study is to compare patient-perceived effectiveness of zolpidem versus melatonin in hospitalized patients. All inpatients who received melatonin or zolpidem the previous night as asleep aid and had no acute psychological issues or history of substance abuse were eligible for participation in this single-center, prospective, observational cohort study. The Verran and Snyder-Halpern sleep scale was utilized to evaluate sleep perception in 3 domains: sleep disturbance, effectiveness, and supplementation. A total of 439 patients were screened and 100 patients met study criteria and consented to the study. In the melatonin and zolpidem groups, the estimated adjusted means for the total sleep effectiveness (206.8 mm, 95% confidence interval [CI], 168.7-253.5vs 187.4 mm, 95% CI, 152.8-229.7; P=.513), sleep disturbance(362.1 mm, 95% CI, 310.1-422.7 vs 339.54 mm, 95% CI, 290.8-396.4; P=.573), and sleep supplementation (111.4 mm, 95% CI, 86.3-143.8 vs 120.9 mm, 95% CI, 94.1-155.2; P=.661) domains were not statistically different. Both melatonin and zolpidem were well tolerated with grogginess and headache as the only reported adverse effects. Melatonin demonstrated no significant difference in patient-perceived sleep effectiveness, disturbance, supplementation, or adverse effects when compared to zolpidem.

Evaluation of treatment options for methicillin-resistant Staphylococcus aureus infections in the obese patient

Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a major cause of infection in both the hospital and community setting. Obesity is a risk factor for infection, and the prevalence of this disease has reached epidemic proportions worldwide. Treatment of infections in this special population is a challenge given the lack of data on the optimal antibiotic choice and dosing strategies, particularly for treatment of MRSA infections. Obesity is associated with various physiological changes that may lead to altered pharmacokinetic parameters. These changes include altered drug biodistribution, elimination, and absorption. This review provides clinicians with a summary of the literature pertaining to the pharmacokinetic and pharmacodynamic considerations when selecting antibiotic therapy for the treatment of MRSA infections in obese patients.

The Effect of the Instrumental Training Contingency on Susceptibility to Reinforcer Devaluation

Two experiments investigated performance of instrumental lever pressing by rats following post-conditioning devaluation of the sucrose reinforcer produced by establishing an aversion to it. In Experiment I rats responded less in an extinction test after being averted from the sucrose following training on a ratio schedule, but not following an equivalent amount of training on an interval schedule. This was true even though the devalued sucrose would not act as an effective reinforcer on either the ratio or interval schedule. Experiment II provided a further investigation of the insensitivity of interval responding to reinforcer devaluation by comparing test performance under simple extinction with responding when the devalued reinforcer was presented on either a response-contingent or non-contingent schedule during the test. Once again simple extinction performance was unaffected by prior reinforcer devaluation. Furthermore, neither non-contingent nor contingent presentations of the devalued reinforcer significantly depressed responding below the level seen in the extinction condition. Ratio, but not interval performance appears to be controlled by knowledge about the instrumental contingency that encodes specific properties of the training reinforcer.

Post-Conditioning Devaluation of an Instrumental Reinforcer has no Effect on Extinction Performance

The extent to which a representation of the reinforcer controls an instrumental response can be assessed by studying the effect of post-conditioning changes in the reinforcer value. In the first experiment rats were trained to press a lever for sucrose pellets on a variable-interval (VI) schedule. The sucrose was subsequently devalued by pairing with Lithium Chloride (LiCl). This had no effect on lever pressing in extinction, although it profoundly reduced reacquisition responding and consumption. In Experiment II rats were trained to shuttle between the two distinctive chambers of a choice-box, in which lever pressing was reinforced in one chamber by sucrose and in the other chamber by food pellets programmed on independent VI schedules. A LiCl-induced taste-aversion was conditioned to the sucrose, and although this markedly affected reacquisition, extinction responding in the sucrose chamber and chamber preference were unaffected. These results indicate that instrumental performance can be independent of the current value of the reinforcer, and are discussed with reference to stimulus-response theory and second-order Pavlovian conditioning.

Instrumental Responding following Reinforcer Devaluation

In two experiments, hungry rats were given instrumental lever-press training for an appetitive reinforcer and, in addition, were exposed to another type of food which was not contingent on lever pressing. In the first experiment, exposure to each type of food was on separate days, whereas in the second experiment rats were exposed to each type of food in strict alternation within each session. Subsequently, a food aversion was conditioned to the reinforcer for the experimental group and to the non-contingent food for the control group. In both experiments, animals with an aversion to the reinforcer responded less in an extinction test than animals with an aversion to the non-contingent food. Subsequent reacquisition tests confirmed that the aversion to the non-contingent food in the control group was of comparable strength with that to the reinforcer in the experimental group. The results were discussed in terms of whether the reinforcer is encoded in the associative structure set up by exposure to an instrumental contingency.

Variations in the Sensitivity of Instrumental Responding to Reinforcer Devaluation

In five experiments hungry rats were trained to make a lever press response for a sucrose reinforcer. That sucrose was subsequently devalued by conditioning a food-aversion to it, and the ability of the rats to integrate knowledge about the instrumental contingency with that gained from aversion training was assessed in an extinction test. Experiment I showed successful integration following limited but not extended instrumental training. Experiment II suggested that the crucial factor was the spacing of training; successful integration was seen after massed but not distributed training. The third experiment implicated distributed experience with the reinforcer, rather than distributed response practice, in failures of integration. Experiment IV showed that if the distribution of food-aversion learning was dissimilar to that of instrumental training then a failure of integration could result; this finding was able to account for the distribution of training effects seen in previous studies, but not the effect of extended training. Experiment V replicated the extended training effect seen in Experiment I, and provided evidence that this may reflect the degree of exposure to the reinforcer rather than the extent of response practice.

Assessment of low-dose i.v. ketamine infusions for adjunctive analgesia

PURPOSE

The results of a study evaluating all patients treated with adjunctive low-dose ketamine for analgesia over a three-year period are presented.

METHODS

A retrospective single-center analysis evaluated all adult patients who received adjunctive low-dose i.v. ketamine infusions from September 2010 to September 2013. Patients were excluded if they received concomitant oral ketamine, if ketamine was used to treat seizures, or if the patients received ketamine boluses without infusion. The primary endpoint was to identify the patient populations receiving low-dose intravenous ketamine. Secondary endpoints included an assessment of clinical variables and adverse events. Demographic information, level of care, clinical variables, adverse events, and patient outcomes were recorded.

RESULTS

A total of 460 patients were evaluated. Of these, 396 were included in this analysis. Ketamine was administered to 69.9% of the patients in association with a surgical procedure, as opposed to 30.1% who received ketamine for medical management of pain. The percentage of patients receiving intensive care unit level care was 24%. Before initiation of ketamine, patient-reported pain scores averaged 7.1 ± 2.63 S.D.; during the ketamine infusion, patient-reported pain scores averaged 6.42 ± 2.01 S.D.; (p < 0.001). In the safety analysis, hypertension occurred in 21.4% of patients, hypotension occurred in 15.1% of patients, and respiratory depression occurred in 6.3% of patients.

CONCLUSION

A retrospective review found that patients receiving continuous ketamine infusions in addition to opioid therapy saw a reduction in pain scores and experienced cardiovascular adverse effects in greater than 20% of cases.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care

OBJECTIVE

Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation.

DESIGN

BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles.

SETTING

Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients.

PARTICIPANTS

Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units.

RESULTS

Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified.

CONCLUSIONS

Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Bisphenol diglycidyl ethers and bisphenol A and their hydrolysis in drinking water

Epoxy coatings are commonly used to protect the interior (and exterior) surfaces of water mains and storage tanks and can be used on the interior surfaces of water pipes in homes, hospitals, hotels, and other buildings. Common major components of epoxies include bisphenols, such as bisphenol A (BPA) or bisphenol F (BPF), and their reactive prepolymers, bisphenol A diglycidyl ether (BADGE) and bisphenol F diglycidyl ether (BFDGE), respectively. There currently are health concerns about the safety of BPA and BPF due to known estrogenic effects. Determination of key bisphenol leachates, development of a hydrolysis model, and identification of stable hydrolysis products will aid in assessment of human bisphenol exposure through ingestion of drinking water. Liquid chromatography/mass spectrometry (LC/MS/MS) was used for quantitation of key analytes, and a pseudo-first order kinetic approach was used for modeling. In fill-and-dump studies on epoxy-coated pipe specimens, BADGE and a BPA-like compound were identified as leachates. The BADGE hydrolysis model predicts BADGE half-lives at pH 7 and 15, 25, 35, and 40 °C to be 11, 4.6, 2.0, and 1.4 days respectively; the BFDGE half-life was 5 days at pH 7 and 25 °C. The two identified BADGE hydrolysis products are BADGE-H2O and BADGE 2H2O, with BADGE 2H2O being the final end product under the conditions studied.

Improving Antibiotic De-Escalation in Suspected Ventilator-Associated Pneumonia: An Observational Study With a Pharmacist-Driven Intervention

BACKGROUND

Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care.

MATERIALS AND METHODS

We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients.

MAIN RESULTS

A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase.

CONCLUSIONS

Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.

Role of dexmedetomidine in adults in the intensive care unit: an update

PURPOSE

The role of dexmedetomidine for the management of pain, agitation, and delirium in adult patients in the intensive care unit (ICU) is reviewed and updated.

SUMMARY

Searches of MEDLINE (July 2006-March 2012) and an extensive manual review of journals were performed. Relevant literature with a focus on data published since our last review in 2007 was evaluated for topic relevance and clinical applicability. Optimal management of pain, agitation, and delirium in ICUs requires a systematic and multimodal approach aimed at providing comfort while maximizing outcomes. Dexmedetomidine is among multiple agents, including opioids, propofol, benzodiazepines, and antipsychotics, used to facilitate and increase patients' tolerability of mechanical ventilation. This article reviews the newest evidence available for dexmedetomidine use for sedation and analgesia in medical-surgical ICUs. Adverse effects associated with dexmedetomidine were similar among the studies examined herein. The most common adverse effects with dexmedetomidine were bradycardia and hypotension, in some cases severe enough to warrant the use of vasoactive support. Due to the adverse events associated with rapid dosage adjustment and bolus therapy, dexmedetomidine may not be the best agent for treating acute agitation.

CONCLUSION

In medical-surgical ICUs, dexmedetomidine may be a viable non-benzodiazepine option for patients with a need for light sedation. In cardiac surgery patients, dexmedetomidine appears to offer no advantage over propofol as the initial sedative. The role of dexmedetomidine in unique patient populations such as neurosurgical, trauma, and obstetrics is yet to be established.

Age-related blood pressure patterns and blood pressure variability among hemodialysis patients

BACKGROUND AND OBJECTIVES

Despite the high prevalence of cardiovascular disease among hemodialysis patients, the relationship between age and blood pressure (BP) is not well understood. It was postulated that the relationship of BP to age differs among hemodialysis patients versus the general population and that there is significant variability in dialysis unit BP measurements.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To explore this hypothesis, the patterns of systolic, diastolic, mean arterial, and pulse pressures in the general population using data from National Health and Nutrition Examination Survey participants (n = 9242) were compared with those in a cohort of hemodialysis patients (n = 9849).

RESULTS

In contrast to the increase in systolic BP with age in the general population, systolic BP was elevated in young hemodialysis patients and declined slightly among the elderly. The inverted "U"-shape relationship between age and diastolic BP in the general population was absent in hemodialysis patients. Diastolic BP was elevated among hemodialysis patients <50 yr of age and declined with advancing age. Mean arterial and pulse pressures were elevated among young hemodialysis patients and exhibited less age dependency than in the general population. Variability in BP within patients was similar to that between patients.

CONCLUSIONS

The relationship of BP to age differed from that in the general population. The variability in dialysis unit BP measurements may limit their use in managing hypertension and predicting outcomes. Nevertheless, dialysis unit BP measurements are necessary to minimize acute complications during the dialysis procedure.

Azacitidine-induced interstitial and alveolar fibrosis in a patient with myelodysplastic syndrome

A 71-year-old Caucasian man diagnosed with myelodysplastic syndrome developed interstitial and alveolar fibrosis after receiving a 7-day course of azacitidine therapy. The patient's pulmonary function began to deteriorate immediately after the administration of his chemotherapy regimen. Other potential causes of pulmonary toxicity were ruled out such as viral, fungal, and bacterial pathogens, as well as other concomitant drugs. To our knowledge, this is the first case report documenting biopsy-proven interstitial and alveolar fibrosis associated with azacitidine. The frequency of this adverse drug reaction is unknown but may become more evident with increasing exposure of the population to azacitidine.

Preinjury Behavioral and Emotional Problems Among Pediatric Burn Patients

Standardized behavior rating scales have been used in the routine care of children during medical visits because they provide an objective, norm-based index for the child's behavioral functioning. The purpose of this study was to examine behavior problems among children (aged 2.5-18 years) with burn injuries using the Behavioral Assessment System for Children, a multi-informant system of standardized rating scales that assesses clinical and adaptive behavior areas. Parents and youth (ages 8-18) completed the Behavioral Assessment System for Children with reference to the pediatric patient's behavioral functioning before hospital admission for a burn injury. In total, data were collected on 94 children. Results suggested that a substantial portion of the sample endorsed significantly elevated levels of behavioral difficulties across a broad range of problem behaviors. On the basis of parent report, preschoolers exhibited concerns related to hyperactivity, anxiety, aggression, and attention problems, whereas school-aged children were reported to have these same concerns as well as depression and conduct problems. Twenty percent of our adolescent sample (ages 12-18 years) were described to be experiencing even more internalizing and externalizing behavior problems relative to the two groups of their younger counterparts. Boys were found to contribute to the cause of their burn injury significantly more often than girls. The strengths, limitations, and clinical implications of our findings are discussed.

An assessment of burn prevention knowledge in a high burn-risk environment: restaurants

Our facility has seen an increase in the number of cases of children burned in restaurants. Fieldwork has revealed many unsafe serving practices in restaurants in our tristate area. The current research targets what appears to be an underexamined burn-risk environment, restaurants, to examine server knowledge about burn prevention and burn care with customers. Participants included 71 local restaurant servers and 53 servers from various restaurants who were recruited from undergraduate courses. All participants completed a brief demographic form as well as a Burn Knowledge Questionnaire. It was found that server knowledge was low (ie, less than 50% accuracy). Yet, most servers reported that they felt customer burn safety was important enough to change the way that they serve. Additionally, it was found that length of time employed as a server was a significant predictor of servers' burn knowledge (ie, more years serving associated with higher knowledge). Finally, individual items were examined to identify potential targets for developing prevention programs.

Use of a token reinforcement system to promote appropriate behavior at a pediatric burn summer camp

Child behavior management can be an important concern in conducting summer camps for pediatric burn patients, because many of these patients have a history of significant behavioral difficulties. To be efficient, a flexible camp-wide behavior management system, such as a token economy, would be ideal. In this article we discuss the concept and principles of a token reinforcement system and outline how this intervention was applied to our pediatric burn summer camp across 2 consecutive years. We also provide a description of modifications made for the second camp, based on counselor ratings of and our experience with the token system during the first camp. Results from counselor assessments indicated that after using the token system, counselors' perceptions of its utility (eg, effective in decreasing problem behavior in campers, useful in making behavior management easier) increased significantly across both years.

Changing patterns of severe craniomaxillofacial trauma in Auckland over eight years

BACKGROUND

This study was performed to review the changing pattern of incidence of severe craniomaxillofacial (CMF) trauma in Auckland over 8 years (1989-1997) and to audit the involvement of the regional plastic surgery service.

METHODS

A review of prospectively collected admission data of patients admitted to the Auckland Hospital Department of Critical Care Medicine (DCCM) with severe CMF trauma during 1997. A comparison is made with similar data from 1989. Injury severity was defined using the Injury Severity Score (ISS).

RESULTS

Twenty-six patients with severe CMF trauma were admitted to Auckland Hospital DCCM in 1997. Their average ISS was 35. Eighty per cent had a significant head injury. Sixty-two per cent had injuries due to road traffic accidents (RTA) and 42% had positive blood alcohol levels, including 37% of the RTA victims. Twenty-three per cent had their surgical care provided by the regional plastic surgery service. In 1989, 55 patients were admitted to DCCM with severe CMF trauma. The average ISS was 36. Ninety-five per cent had a significant head injury. Seventy-three per cent had injuries due to RTA and 55% had positive blood alcohol, including 60% of the RTA group.

CONCLUSIONS

Patients with severe CMF trauma make up a significant proportion of trauma admissions to DCCM and have a high incidence of life-threatening injuries. A multidisciplinary approach is essential. The nature and severity of these injuries has not changed over the last decade. There has been a clear decrease in the incidence of these injuries. This seems to be due to a profound decrease in the rate of RTA associated with alcohol intoxication.

Phoenix date palm injuries: a review of injuries from the Phoenix date palm treated at the Starship Children's Hospital

BACKGROUND

The purpose of this study was to review patients treated for penetrating Phoenix date palm injuries. Documentation of the clinical behaviour of these injuries was sought as they have different clinical outcomes to other foreign body injuries.

METHODS

Data was collected via a retrospective review of patient files and imaging studies of all patients with foreign body injury admitted to the Orthopaedic Service of Starship Children's Hospital between 1992 and 1997.

RESULTS

Of 250 patients admitted with foreign body injuries, 21 cases were identified as caused by the Phoenix date palm. The age range was 5 to 12 years. There was a median delay of 43 days between the time of injury and presentation to hospital. An average of 1.3 operations were performed on each patient. Ultrasound was used in 12 cases, foreign body was identified in 10 patients--a sensitivity of 83%. Intraoperative ultrasound was also found to be beneficial in three of these cases.

CONCLUSIONS

Phoenix date palm injuries often have a protracted course. The initial diagnosis and treatment of such injuries is often delayed. Fracturing and fragmentation of the barbs may occur and multiple surgical procedures may be required to remove all of the foreign material. The Phoenix date palm barbs may cause a severe tissue reaction with sterile granulomatous synovitis and bony pseudotumour formation. A high level of suspicion on history taking and surgical exploration is needed. Total synovectomy for delayed joint or tendon sheath involvement may be required when fragmentation has occurred. Ultrasound has higher sensitivity for detection of thorn foreign bodies than magnetic resonance imaging.

Measuring binge eating in adolescents: adolescent and parent versions of the questionnaire of eating and weight patterns

OBJECTIVE

This study investigated the psychometric properties of an adolescent version of the Questionnaire of Eating and Weight Patterns (QEWP-A).

METHOD

Male and female adolescents between 10-18 years completed the QEWP-A and measures of depression and eating attitudes. Height and weight were also measured. Parents completed a parental version (QEWP-P) that was referenced to their children. Adolescent and parent responses to the QEWP were independently categorized into no diagnosis (ND), nonclinical binge eating (NCB), and binge eating disorder (BED) groups.

RESULTS

Adolescent and parental agreement over the diagnostic categories was as follows: 81.6% for ND, 15.5% for NCB, and 25% for BED with an overall kappa of. 19. Adolescents with BED had significantly higher levels of depression than the other two groups with NCB being higher than ND. For eating attitudes, BED adolescents were more deviant than the other two groups who did not differ from one another.

DISCUSSION

The QEWP-A displayed adequate concurrent validity. The low overall agreement between adolescents and their parents was influenced by high and low base rates in the NCB and BED categories, respectively. This lack of agreement is consistent with other behavioral problems such as depression. The data suggest that parental perceptions of eating problems approximate those of their children when no problem is present. However, parents are not as likely to be aware of eating difficulties when they actually exist.

The Adolescent Behavior Checklist: development and initial psychometric properties of a self-report measure for adolescents with ADHD

Developed and provided initial psychometric properties on an adolescent, self-report questionnaire for attention deficit hyperactivity disorder (ADHD). The Adolescent Behavior Checklist (ABC) consists of 44 items that measure ADHD core symptoms and associated difficulties (e.g., conduct problems, academic problems, and social deficits). A total of 909 adolescents between the ages of 11 and 17 served as the standardization sample. Results indicated that the ABC was internally consistent. Principal components analysis revealed six factors for the ABC: Conduct Problems, Impulsivity/Hyperactivity, Poor Work Habits, Inattention, Emotional Lability, and Social Problems. Significant gender and race differences were obtained for some ABC factor scores, and initial standardization data were established based on this information. Initial convergent and divergent validity of the ABC was supported by the correlations obtained between factor scores and the subscale scores on the Child Behavior Checklist and Youth Self-Report. Using an additional sample of 81 adolescents, the stability of ABC scores across a 2-week interval was found to be satisfactory. Initial evidence for discriminant validity was established by comparing ABC scores for a sample of adolescents diagnosed with ADHD to the normative sample.

Circulating nucleated red blood cells following splenectomy in a patient with congenital dyserythropoietic anemia

A 24-year-old white female with a 10-year history of juvenile rheumatoid arthritis and splenomegaly developed numerous circulating nucleated red blood cells (NRBC) following splenectomy for chronic abdominal pain. Subsequent evaluation revealed the presence of a congenital dyserythropoietic anemia (CDA) with atypical features. Circulating NRBCs have been reported following splenectomy in three other cases of CDA, each of which had atypical features and did not fit into the customary classification of types I-IV. Follow-up of our patient at 4 years revealed no untoward consequences of persistent NRBCs in her circulation.