Using behavioral observations in freestalls and at milking to improve pain detection in dairy cows after lipopolysaccharide-induced clinical mastitis

This study aimed to determine the effect of lipopolysaccharide (LPS)-induced mastitis with or without nonsteroidal anti-inflammatory drug (NSAID) on dairy cows' clinical, physiological, and behavioral responses in the milking parlor and freestalls as well as the specificity (Sp) and sensitivity (Se) of behavioral responses in detecting cows with LPS-induced mastitis. Twenty-seven cows received an intramammary infusion of 25 µg of Escherichia coli LPS in 1 healthy quarter. Following LPS infusion, 14 cows received a placebo (LPS cows), and 13 cows received 3 mg/kg of body weight of ketoprofen i.m. (LPS+NSAID cows). Cow response to the challenge was monitored at regular intervals from 24 h before to 48 h postinfusion (hpi) through direct clinical observations, markers of inflammation in milk, and via point-in-time direct behavioral observations in the barn and at milking. In LPS cows, infusion induced a significant increase of plasma cortisol levels at 3 and 8 hpi, milk cortisol levels at 8 hpi, somatic cell counts from 8 to 48 hpi, IL-6 and IL-8 at 8 hpi, milk amyloid A (mAA) and haptoglobin at 8 and 24 hpi, rectal temperature at 8 hpi, and respiratory rate at 8 hpi. Their rumen motility rate decreased at 8 and 32 hpi. Compared with before the challenge, significantly more LPS cows stopped feeding/ruminating and pressed their tail between their legs at 3 and 5 hpi, increased feeding/ruminating at 24 hpi, and had the tendency to be less responsive, dropping their head, and dropping their ears at 5 hpi. At milking, compared with before challenge, significantly more LPS cows lifted their hooves at forestripping at 8 hpi. The 2 groups showed similar patterns of response for milk cortisol, somatic cell count, respiratory rate, mAA, haptoglobin, and IL-6, IL-1β, and IL-8. Compared with LPS cows, LPS+NSAID cows had significantly lower plasma cortisol levels at 3 hpi, their rectal temperature decreased at 8 hpi, their rumen motility rate increased at 8 and 32 hpi, and their heart rate increased at 32 hpi. Compared with LPS cows, a significantly larger proportion of LPS+NSAID cows were feeding/ruminating, a lower proportion had ears down at 5 hpi, and a larger proportion lied down at 24 hpi. At milking, whatever the phase of milking, for "hoof to belly," 9 out of 14 cows did not show this behavior before infusion (Sp = 64%) and 14/14 did not kick during pre-infusion milking (Sp = 100%). Regarding sensitivity, at maximum, 5 cows out of 14 (Se = 36%) displayed "hoof to belly" after infusion. For "lifting hoof," 14/14 did not show hoof-lifting before infusion (Sp = 100%) and 6/14 displayed it after infusion (Se = 43%) at forestripping only. In the freestall barn, 9 behaviors had a Sp >75% (at minimum, 10/14 did not show the behavior) whatever the time point but Se < 60% (at maximum, 8/14 displayed the behavior). Finally, "absence of feeding and ruminating" had Sp of 86% (12/14 ate/ruminated) and Se of 71% (10/14 did not eat/ruminate) at 5 hpi. This study shows that feeding/ruminating, tail position, and reactivity at forestripping could be used as behavioral indictors for early detection of mastitis-related pain in dairy cows.

[Organ transplantation during SARS-CoV-2 epidemic : the 2020-2021 Liege transplant Center experience]

The «Severe Acute Respiratory Syndrome coronavirus 2» (SARS-CoV-2) pandemic has disrupted medical care and intra-hospital organization during 2020, both in Belgium and throughout the world. Solid organ transplantation was not spared and in Belgium, the number of organ donors and transplants overall decreased by 20 % for livers and by 33 % for hearts between 2019 and 2020. The aim of this article is to summarize the experience acquired in 2020 and 2021 on the organizational and medical implications of the coronavirus disease 2019 (COVID-19) pandemic with regard to the care of patients transplanted or awaiting for organ transplants, and to draw conclusions both for the aftermath of COVID-19 but also for future pandemics. Vaccination against SARS-CoV-2 is highly recommended and particularly important in organ transplant recipients, even if the response rate is lower than in the non-transplanted population. A third injection is now advised in immunosuppressed patients.

[The first wave of COVID-19 in Intensive care]

In December 2019, in Wuhan, a new human infectious pathology was born, COVID-19, consisting above all in pneumoniae, induced by the coronavirus named SARS-CoV-2 because of the respiratory distress it caused (SARS for severe acute respiratory syndrome, and CoV for Coronavirus). A real health and planetary crisis has appeared, much more substantial than that linked to SARS-CoV-1 in 2002-2004 and to MERS-CoV (Middle East Respiratory Syndrome Coronavirus) in 2012. In addition to respiratory damage that can be dramatic, this pathology is complicated by the frequency of cardiovascular, renal and coagulation diseases. Health care systems have had to adapt urgently, in the absence of hindsight from the pathology, and without effective therapeutic weapons. Through this review of the literature, we detail our local practices for the overall management of patients hospitalized in Intensive care.

[Deceased organ donation in 2020]

The success of solid organ transplantation induced an increased need for grafts and the necessary registration of transplant candidates on long waiting lists. Many patients die while waiting for transplantation, even in Belgium where the donation rates have been high these last years. In order to fight this lack of donor organs, the transplant centers widened donation criteria for brain dead donors, including older age and potential transmissible diseases. In addition, programs of donation after circulation death have been developed, first for kidneys, then for livers and recently for the hearts. Organ donation after euthanasia is also regularly performed in Belgium. All these policies lead to the fact that organ donation rates stay high in Belgium, and particularly in the Liege region, but efforts are still ahead if we aim to reduce waiting list mortalities.

[Acute respiratory distress syndrome]

Since its first description in 1967, a lot of progress has been made in understanding the pathophysiology, diagnosis and management of acute respiratory distress syndrome (ARDS). This nosological entity is based on the appearance of a diffuse alveolar damage associating pulmonary epithelial barrier disruption with an alveolar filling, both responsible of profound hypoxemia and important morbi-mortality. Nowadays, ARDS remains a frequent syndrome, associated with various etiologies. Diagnosis is based on the occurrence of acute hypoxic respiratory failure not explained by cardiac insufficiency or volume overload, within 7 days after a recognized risk factor, and in the presence of bilateral pulmonary opacities not fully explained by effusions, atelectasis or nodules on the chest radiography. Survivors present an increased risk of developing cognitive decline, depression, post-traumatic stress, and typical ICU related side-effects such as polyneuropathy and sarcopenia. In this context and not withstanding significant recent progress in the field of mechanical ventilation and extra-corporeal respiratory assistance, early diagnosis remains essential to identify patients with ARDS in order to offer them the most appropriate therapy.

[Post-intensive care syndrome : the issue of life after survival]

Post-intensive care syndrome is characterized by physical, cognitive and psychological complications, occurring independently of the initial critical illness. Despite prevention measures during acute care, approximately one third of the survivors may present post-intensive care deficits with significant medical, social or economic consequences. Those patients need to be detected and treated, in order to enhance recovery.

End of life care in the operating room for non-heart-beating donors: organization at the University Hospital of Liège

Non-heart-beating (NHB) organ donation has become an alternative source to increase organ supply for transplantation. A NHB donation program was implemented in our institution in 2002. As in many institutions the end of life care of the NHB donor (NHBD) is terminated in the operating room (OR) to reduce warm ischemia time. Herein we have described the organization of end of life care for these patients in our institution, including the problems addressed, the solution proposed, and the remaining issues. Emphasis is given to our protocol elaborated with the different contributors of the chain of the NHB donation program. This protocol specifies the information mandatory in the medical records, the end of life care procedure, the determination of death, and the issue of organ preservation measures before NHBD death. The persisting malaise associated with NHB donation reported by OR nurses is finally documented using an anonymous questionnaire.

[Hypovitaminosis D and burn injury]

Vitamin D deficiency is common in adults and even in children, appearing to be more frequent than expected.Accumulating data about the pleiotropic effects of vitamin D have raised renewed interest in this hormone. Severe burn injury represents a unique trauma leading to major systemic dysfunctions such as bone loss, mineral disruptions, myopathy, or immunosuppression. Moreover, burn patients are at high risk of hypovitaminosis D. In this context, vitamin D supplementation could help counteract post-burn sequelae. The aim of the present review is to summarize the current knowledge on vitamin D with a special focus on burn related hypovitaminosis D.

Measuring end expiratory lung volume after cardiac surgery

BACKGROUND

The aim of this study was to evaluate the interest of end expiratory volume (EELV) measurement after cardiac surgery.

METHODS

After stabilization, four EELV measurements were performed at one hour intervals during three hours using the nitrogen washout technique. EELV was compared to the predicted functional residual capacity (FRC) volume. The relationships between EELV and static compliance of the respiratory system, the PaO2/FiO2 ratio and the body mass index were studied. In addition, a recruitment maneuver was performed using a fixed 45 cm H2O pressure control ventilation during 2 minutes between the second and third EELV measurement in half of the patients. Forty one patients were enrolled and 21 of them received the recruitment maneuver (RM).

RESULTS

Measured EELV corresponded to 52% of the predicted value. It remained stable during the whole study period. EELV correlated well with the PaO2/FiO2 ratio (r2 = 0.40, p <0.0001) and with compliance of the respiratory system (r2 = 0.525, p < 0.0001). EELV was inversely correlated to the body mass index (r2 = 0.165, p = 0.008). RM did not significantly improve EELV.

CONCLUSIONS

EELV is profoundly reduced after cardiac surgery. Measuring EELV is a new tool that is now available during mechanical ventilation. It seems to bring some new robust and possibly useful information. Recruitment maneuvers using sighs does not modify this volume.

Comparison between two intraoperative intravenous loading doses of paracetamol on pain after minor hand surgery: two grams versus one gram

BACKGROUND

Paracetamol (acetaminophen) is widely used for postoperative analgesia at a recommended dose of 1 g every six hours in adult patients. Increasing the loading dose to 2 g was suggested to improve immediate postoperative analgesia without increased toxicity in healthy adult patients. We tested the hypothesis that a loading dose of 2 g of intravenous paracetamol results in better postoperative analgesia after surgery as compared with a dose of 1 g.

METHODS

Sixty adult patients scheduled for minor hand surgery under intravenous regional anaesthesia were randomized into two groups. The first group received 1 g of intravenous paracetamol before surgery while the second group received 2 g. Verbal numeric pain score, analgesic consumption, first night sleep quality, and patient's satisfaction were recorded during the first 24 hours.

RESULTS

Verbal numeric pain scores during the first 24 hours after surgery were significantly lower in the 2 g paracetamol group as compared to the 1 g paracetamol group. No differences were found between the two groups with regard to rescue analgesic consumption, sleep quality and patient's satisfaction.

CONCLUSIONS

An intraoperative loading dose of 2 g paracetamol improves postoperative analgesia after minor hand surgery as compared to 1 g paracetamol.

[Extracorporeal membrane oxygenation (ECMO) in ICU patients suffering from cardiogenic shock, refractory hypoxemia or cardiac arrest]

ExtraCorporeal Membrane Oxygenation (ECMO) is a cardiopulmonary assistance device able to support patients in cardiac arrest, refractory cardiogenic shock or refractory hypoxemia otherwise sentenced to death. Recent technical progresses, early indication decision, bedside multidisciplinary implant, specific complications screening and echocardiographic weaning testing are crucial points to allow success of this exceptional technique.

Functional connectivity in the default network during resting state is preserved in a vegetative but not in a brain dead patient

Recent studies on spontaneous fluctuations in the functional MRI blood oxygen level-dependent (BOLD) signal in awake healthy subjects showed the presence of coherent fluctuations among functionally defined neuroanatomical networks. However, the functional significance of these spontaneous BOLD fluctuations remains poorly understood. By means of 3 T functional MRI, we demonstrate absent cortico-thalamic BOLD functional connectivity (i.e. between posterior cingulate/precuneal cortex and medial thalamus), but preserved cortico-cortical connectivity within the default network in a case of vegetative state (VS) studied 2.5 years following cardio-respiratory arrest, as documented by extensive behavioral and paraclinical assessments. In the VS patient, as in age-matched controls, anticorrelations could also be observed between posterior cingulate/precuneus and a previously identified task-positive cortical network. Both correlations and anticorrelations were significantly reduced in VS as compared to controls. A similar approach in a brain dead patient did not show any such long-distance functional connectivity. We conclude that some slow coherent BOLD fluctuations previously identified in healthy awake human brain can be found in alive but unaware patients, and are thus unlikely to be uniquely due to ongoing modifications of conscious thoughts. Future studies are needed to give a full characterization of default network connectivity in the VS patients population.

Diagnostic and prognostic use of bispectral index in coma, vegetative state and related disorders

PRIMARY OBJECTIVE

This study investigates (1) the utility of the bispectral index (BIS) to distinguish levels of consciousness in severely brain damaged patients and, particularly, disentangle vegetative state (VS) from minimally conscious state (MCS), as compared to other EEG parameters; (2) the prognostic value of BIS with regards to recovery after 1 year.

RESEARCH DESIGN

Multi-centric prospective study.

METHOD AND PROCEDURES

Unsedated patients recovering from coma were followed until death or transferal. Automated electrophysiological and standardized behavioural assessments were carried out twice a week. EEG recordings were categorized according to level of consciousness (coma, VS, MCS and Exit MCS). Outcome was assessed at 1 year post-insult.

MAIN OUTCOMES AND RESULTS

One hundred and fifty-six EEG epochs obtained in 43 patients were included in the analyses. BIS showed a higher correlation with behavioural scales as compared to other EEG parameters. Moreover, BIS values differentiated levels of consciousness and distinguished VS from MCS while other EEG parameters did not. Finally, higher BIS values were found in patients who recovered at 1 year post-insult as compared to patients who did not recover.

CONCLUSION

EEG-BIS recording is an interesting additional method to help in the diagnosis as well as in the prognosis of severely brain injured patients recovering from coma.

Different beliefs about pain perception in the vegetative and minimally conscious states: a European survey of medical and paramedical professionals

Pain management in severely brain-damaged patients constitutes a clinical and ethical stake. At the bedside, assessing the presence of pain and suffering is challenging due to both patients' physical condition and inherent limitations of clinical assessment. Neuroimaging studies support the existence of distinct cerebral responses to noxious stimulation in brain death, vegetative state, and minimally conscious state. We here provide results from a European survey on 2059 medical and paramedical professionals' beliefs on possible pain perception in patients with disorders of consciousness. To the question "Do you think that patients in a vegetative state can feel pain?," 68% of the interviewed paramedical caregivers (n=538) and 56% of medical doctors (n=1166) answered "yes" (no data on exact profession in 17% of total sample). Logistic regression analysis showed that paramedical professionals, religious caregivers, and older caregivers reported more often that vegetative patients may experience pain. Following professional background, religion was the highest predictor of caregivers' opinion: 64% of religious (n=1009; 850 Christians) versus 52% of nonreligious respondents (n=830) answered positively (missing data on religion in 11% of total sample). To the question "Do you think that patients in a minimally conscious state can feel pain?" nearly all interviewed caregivers answered "yes" (96% of the medical doctors and 97% of the paramedical caregivers). Women and religious caregivers reported more often that minimally conscious patients may experience pain. These results are discussed in terms of existing definitions of pain and suffering, the remaining uncertainty on the clinical assessment of pain as a subjective first-person experience and recent functional neuroimaging findings on nociceptive processing in disorders of consciousness. In our view, more research is needed to increase our understanding of residual sensation in vegetative and minimally conscious patients and to propose evidence-based medical guidelines for the management of possible pain perception and suffering in these vulnerable patient populations.

[Contribution of functional neuroimaging studies to the understanding of the mechanisms of general anesthesia]

Since the early beginning of anesthesia, almost 2 centuries ago, ignorance has prevailed regarding the cerebral mechanisms of the loss of consciousness induced by general anesthesia. The recent contribution of functional brain imaging studies has allowed considerable progress in that domain. Similarly, the study of brain function under general anesthesia is currently a major tool for the understanding of conscious phenomena. This functional approach leads to conceptual changes about the functioning brain and may ultimately provide tracks for new treatments and practical applications. All these aspects are reviewed in this paper, at the light of the most recent literature.

Cerebral subarachnoid blood migration consecutive to a lumbar haematoma after spinal anaesthesia

We report the case of a woman who received spinal anaesthesia for peripheral vascular surgery of the lower limbs and subsequently developed a spinal subarachnoid haematoma. Interestingly, low back pain was the only symptom of this spinal subarachnoid haemorrhage. During the following days, blood migrated from the spinal haematoma towards the cerebral subarachnoid spaces. The patient presented with stupor, nausea and vomiting that resolved within 2 weeks with conservative treatment.

[Life with Locked-In syndrome]

The Locked-In Syndrome (LIS) is classically caused by an anterior pontine vascular lesion and characterized by quadriplegia and anarthria with preserved consciousness and intellectual functioning. We here review the definition, etiologies, diagnosis and prognosis of LIS patients and briefly discuss the few studies on their quality of life and the challenging end-of-life decisions that can be encountered. Some clinicians may consider that LIS is worse than being in a vegetative or in a minimally conscious state. However, preliminary data from chronic LIS survivors show a surprisingly preserved self-scored quality of life and requests of treatment withdrawal or euthanasia, though not absent, are infrequent.

[Predicting prognosis in post-anoxic coma]

Most patients who remain comatose for a few hours after a period of global cerebral ischemia have a poor prognosis. Early identification of these patients is desirable to reduce uncertainty about treatment and non-treatment decisions, and to improve relationships with the family. The absence of pupillary light response and corneal reflexes, absent or stereotyped extension motor response to noxious stimulation (3 days after insult); myoclonus status epilepticus; absence of cortical N20 response on somatosensory evoked potential studies; generalised suppression or burst-suppression EEG and serum neuron-specific enolase above 33 microg/L (sampled 1-3 days after insult) have been shown to predict poor outcome. We here propose an algorithm to help intensive care physicians' clinical decision making in post-anoxic coma.

[Pain assessment in non-communicative patients]

Pain is a subjective experience. Its assessment is based on the subject's direct verbal report. This method of assessment is, however, impossible in patients who cannot communicate their feelings. In this context, indirect measurements such as behavioral observations or physiological measurements are needed. To facilitate the assessment of pain in non-communicative patients, numerous standardized behavioral scales have been developed. The aim of this review is to discuss the main validated pain scales employed in end-stage dementia, newborn and preverbal children, and severely brain damaged patients with a disorder of consciousness such as coma, the vegetative state or the minimally conscious state.

Revelations from the unconscious: studying residual brain function in coma and related states

The purpose of our research is to contribute to a better understanding of the residual brain function of patients who survive an acute brain damage but remain in a coma, vegetative state, minimally conscious state or locked-in syndrome. The diagnosis, prognosis, therapy and medical management of these patients remain difficult. These studies are also of interest scientifically, as they help to elucidate the neural correlates of human consciousness. We here review our studies on bedside behavioral evaluation scales, electrophysiology and functional neuroimaging in these disorders of consciousness and conclude by discussing methodological and ethical issues and current concepts of the standards for care and quality of life in these challenging conditions.

RGTA OTR4120, a heparan sulfate mimetic, is a possible long-term active agent to heal burned skin

Burn-related skin fibrosis leads to loss of tissue function and hypertrophic scar formation with damaging consequences for the patient. There is therefore a great need for an efficient agent to treat burned skin. We report that ReGeneraTing Agent (RGTA) reduces burn-induced skin alteration. The tissue-regenerating effect of RGTA OTR4120 was evaluated after 1-6 days and after 10 months in a rat skin burn model. This effect was also examined in vitro using fibroblasts isolated from control and 6-day-old burned skins. We measured production of dermal collagen I, III, and V and activities of metalloproteinases 2 and 9 (MMP-2 and MMP-9). Ratio of collagen III over collagen I production increased 6 days after the burn, because of a decrease in collagen I production. After 10 months, ratio of collagen III over collagen I in burn sites was still increased compared with control skin, because of an increase in collagen III production. Both abnormalities were corrected by OTR4120. OTR4120 increased pro- and active MMP-2 and MMP-9, compared with healthy and burned controls and therefore accelerated remodeling. Similar data were obtained with cultured fibroblasts from healthy and burned skins. OTR4120 enhanced healing in short- and long-term after burns, reducing the formation of fibrotic tissue, and then represents a potential agent to improve burned skin healing.

[Behavioural assessment and functional neuro-imaing in vegetative state patients]

Currently, there remains a high rate of misdiagnosis of the vegetative state. This should incite clinicians to use the most sensitive "coma scales" to detect signs of consciousness in these patients. The gold standard remains the Glasgow Coma Scale (GCS, Teasdale and Jennet, 1974), with the Glasgow Liège Scale (GLS, Born, 1988) adding standardized assessment of brainstem reflexes. New sensible behavioral assessment tools for use in the acute neurocritical care setting include the Full Outline of UnResponsiveness (FOUR, Wijdicks et al., 2005). The Coma Recovery Scale-Revised (CRS-R, Giacino and Kalmar, 2004) specifically tests the diagnostic criteria differentiating vegetative from minimally conscious patients. Detecting signs of consciousness also depends on the employed methodology. We showed that for the assesment of the presence of visual pursuit, using a moving mirror is better suited than using a moving object or person. The clinical diagnosis can be confirmed by cerebral positron emission tomography studies objectively quantifying residual metabolic activity in vegetative and minimally conscious patients. Ongoing studies evaluate the prognostic value of functional magnetic resonance imaging studies in these challenging patient populations.

Impact of operator expertise on collection of the APACHE II score and on the derived risk of death and standardized mortality ratio

We assessed the impact of operator expertise on collection of the APACHE II score, the derived risk of death and standardized mortality ratio in 465 consecutive patients admitted to a multi-disciplinary tertiary hospital ICU. Research coordinators and junior clinical staff independently collected the APACHE II variables; experts (senior clinical staff) rescored 20% of the records. Agreement was moderate between junior clinical staff and research coordinators or senior clinical staff for most variables of the acute physiology score (weighted kappa<0.6); agreement between research coordinators and senior clinical staff data collectors was good (weighted kappa >0.75). The APACHE II score and its derived risk of death (ROD) were significantly lower using the junior clinical staff dataset compared to research coordinators and senior clinical staff (APACHE II score: 13.4+/-9.2 vs 16.8+/-8.5 vs 17.1+/-7 7, P<0.001; ROD: 14.7%+/-22.4% vs 21.6%+/-22.6% vs 20.8%+/-22.4%, P<0.01 respectively). The discriminative capacity was not altered by the lack of agreement (area under Receiver Operator Characteristic curve >0.8) but calibration of ROD from the junior clinical staff dataset was poor (Goodness-of-fit: P= 0.001). The standardized mortality ratio (SMR) was higher with the junior clinical staff dataset (SMR: 1.22, 95% CI: 0.96-1.52 vs 0.87, 95% CI: 0.70-1.06 vs 0.76, 95% CI: 0.40-1.3 calculated from junior clinical staff research coordinators and senior clinical staff datasets respectively). We conclude that the expertise of data collectors significantly influences the APACHE II score, the derived risk of death and the standardized mortality ratio. Given the importance of such scores, ICUs should be provided with sufficient resources to train and employ dedicated data collectors.

["Fulminant" endocarditis due to Staphyloccocus aureus]

We report two cases of "fulminant" endocarditis due to Staphyloccoccus aureus. In both cases, the echocardiographic and bacteriologic diagnosis was esthablished in a clinical picture of severe sepsis and thrombocytopenia evolving after a fever of less than 3 days duration.

Effect of hydroxyethylstarch on renal function in cardiac surgery: a large scale retrospective study

BACKGROUND

Recent reports indicated negative effects of hydroxyethylstarch (HES) on renal function. The goal of this large scale retrospective study was to detect whether there was an association between postoperative deterioration of renal function and the use of HES 200 kD, 0.5 DS in the cardiac surgery setting.

METHODS

Retrospective analysis of daily collected data in 3124 patients who underwent coronary artery bypass and/or valvular surgery. Three groups were compared according to differences in fluid therapy: --GEL: gelatin was used as priming fluid of extracorporeal circulation (ECC) and for postoperative filling (n = 1276). --MIX: HES was used as priming fluid of ECC an gelatin was used for postoperative filling (n = 1008). --HES: HES was used as priming fluid of ECC and for postoperative filling (n = 840).

MAIN RESULTS

There were no significant differences in postoperative serum creatinine concentrations between the 3 groups: GEL: 12,2 +/- 0,5 mg/l; MIX: 12,3 +/- 0.5 mg/l; HES: 12,3 +/- 0.6 mg/l. The need for postoperative extrarenal epuration was not significantly different between the 3 periods: GEL: 2,9%; MIX: 3,1%; HES: 3,8%.

CONCLUSION

The use of HES 200 kD, 0.5 DS in cardiac surgery does not seem to be associated with a clinically significant deterioration of postoperative renal function.

Bronchoalveolar lavage fluids of ventilated patients with acute lung injury activate NF-κB in alveolar epithelial cell line: role of reactive oxygen/nitrogen species and cytokines

In human alveolar epithelial cell line, we investigated the binding activity of NF-kappaB induced by the bronchoalveolar lavage fluids (BALs) from ventilated patients with acute lung injury (ALI), in correlation with the concentrations of inflammatory cytokines, RNOS, and the severity of the ALI. In BALs obtained in 67 patients (16 bronchopneumonia, 14 infected ARDS, 20 ARDS, and 17 ALI patients without bronchopneumonia and no ARDS), we measured endotoxin, IL-1beta, IL-8, and nitrated proteins (NTP), the activity of myeloperoxidase, and the capacity to activate the NF-kappaB in alveolar A549 cells by electrophoretic mobility shift and supershift assays. The neutrophil counts and mean IL-1beta, IL-8, myeloperoxidase, and NTP values were increased in bronchopneumonia and infected ARDS groups compared to ARDS and ALI without bronchopneumonia and no ARDS groups (P<0.001). The number of neutrophils was correlated to those of IL-1beta, IL-8, myeloperoxidase, NTP, and endotoxin in all groups (P<0.0001). NF-kappaB activity was induced in alveolar like cells by BALs in all groups, was higher in bronchopneumonia and infected ARDS groups (P<0.02), and was correlated to IL-1beta (P=0.0002), IL-8 (P=0.02), NTP (P=0.014), myeloperoxidase (P=0.016), and neutrophil counts (P=0.003). BALs of bronchopneumonia and infected ARDS patients had increased inflammatory mediators (compared to ARDS and ALI without bronchopneumonia and no ARDS patients) that correlated to neutrophil counts and to the NF-kappaB-binding activity. These mediators and NF-kappaB activation may induce an amplification of inflammatory phenomena. By in vitro studies, we confirmed that NO-derived species (10(-6) to 10(-5)M peroxynitrite and 10(-5)M nitrites) and myeloperoxidase (at concentration equivalent to that found in BALs) can participate in the NF-kappaB activation.

Bronchoalveolar lavage fluids of patients with lung injury activate the transcription factor nuclear factor-kappaB in an alveolar cell line

In bronchoalveolar lavage (BAL) fluid from ventilated patients, cytotoxic oxidant activity is correlated with neutrophil activation. The aim of the present study was to investigate the hypothesis that BAL fluid induces activation of the transcription nuclear factor-kappaB (NF-kappaB) in human alveolar cells, in correlation with inflammatory mediators. We measured endotoxin, inflammatory cytokines [interleukin-1beta (IL-1beta), IL-8], nitrated proteins and the activity of myeloperoxidase (MPO) in BAL fluid from ventilated patients developing bronchopneumonia ( n =19 samples) or with acute respiratory distress syndrome (ARDS) ( n =14), and from ARDS/infection-free patients ( n =11). We also exposed alveolar cells to the BAL fluid or to human MPO, H(2)O(2) or HOCl, and tested nuclear extracts for the activation of NF-kappaB. IL-1beta, IL-8, nitrated protein, MPO and endotoxin levels were significantly higher in BAL fluid from patients with bronchopneumonia than in that from the ARDS and ARDS/infection-free groups. A correlation was observed between IL-8 and MPO values ( r =0.82). The level of NF-kappaB activity induced by the BAL fluid was correlated with levels of IL-1beta ( P <0.001), IL-8 ( P <0.005) and MPO ( P <0.002), and with the neutrophil count ( P <0.002), and was higher for BAL fluid from the bronchopneumonia group. NF-kappaB activation by MPO was also demonstrated. The activation of NF-kappaB by BAL fluid, especially that from bronchopneumonia patients, suggests that a similar phenomenon may occur in vivo, leading to potential amplification of the inflammatory reaction.

[Severity scoring systems in the the ICU. Description, utilization, and potential]

Severity scoring systems are of great interest for the intensive care physicians. They provide major objective information regarding their patients and their medical practice. Scoring systems have been regularly improved over the two last decades. The different existing systems present advantages and disadvantages which influence their use in the intensive care. These scoring systems offer a wide range of analysis, however they are often underused. In this paper we suggest recommendations that could help to maximise the information provided by these systems.

[Cutaneous infections contracted during sports and recreational activities]

Going in for sports is at increased risk for cutaneous infections that can be viral, bacterial, mycotic and parasitic in nature. The specific conditions of sports practice have a major influence on their occurrence. Other factors such as age, gender and genetic predisposition can also play a role. The cutaneous infections should be the target of preventive measures. To assume the worse, they should be recognized and treated without delay in order to avoid the more or less prolonged arrest of the sports activity and the disease transmission to partners.

Human plasmin enzymatic activity is inhibited by chemically modified dextrans

Some synthetic dextran derivatives that mimic the action of heparin/heparan sulfate were shown to promote in vivo tissue repair when added alone to wounds. These biofunctional mimetics were therefore designated as "regenerating agents" in regard to their in vivo properties. In vitro, these biopolymers were able to protect various heparin-binding growth factors against proteolytic degradation as well as to inhibit the enzymatic activity of neutrophil elastase. In the present work, different dextran derivatives were tested for their capacity to inhibit the enzymatic activity of human plasmin. We show that dextran containing carboxymethyl, sulfate as well as benzylamide groups (RG1192 compound), was the most efficient inhibitor of plasmin amidolytic activity. The inhibition of plasmin by RG1192 can be classified as tight binding hyperbolic noncompetitive. One molecule of RG1192 bound 20 molecules of plasmin with a K(i) of 2.8 x 10(-8) m. Analysis with an optical biosensor confirmed the high affinity of RG1192 for plasmin and revealed that this polymer equally binds plasminogen with a similar affinity (K(d) = 3 x 10(-8) m). Competitive experiments carried out with 6-aminohexanoic acid and kringle proteolytic fragments identified the lysine-binding site domains of plasmin as the RG1192 binding sites. In addition, RG1192 blocked the generation of plasmin from Glu-plasminogen and inhibited the plasmin-mediated proteolysis of fibronectin and laminin. Data from the present in vitro investigation thus indicated that specific dextran derivatives can contribute to the regulation of plasmin activity by impeding the plasmin generation, as a result of their binding to plasminogen and also by directly affecting the catalytic activity of the enzyme.

Nitrated proteins in bronchoalveolar lavage fluid of patients at risk of ventilator-associated bronchopneumonia

The study was designed to identify markers of oxidative injury, related to the nitric oxide derived cascade, in bronchoalveolar lavage (BAL) fluid from intensive care patients suspected of ventilator-associated pneumonia (VAP) and/or acute respiratory distress syndrome (ARDS). Thirty-eight patients developing VAP and/or ARDS (VAP/ARDS group) were compared to 20 ventilated patients without VAP/ARDS (control group). Myeloperoxidase (MPO) and elastase, taken as markers of neutrophil activation were measured by enzymatic techniques, and nitrated proteins (NTPs) by an immunological method. The cytotoxicity of the BAL fluid was tested using cultured human epithelial alveolar cells by the release of pre-incorporated 51Cr. Mean NTP concentration and, MPO and elastase activities were different between the VAP/ARDS and control groups (p<0.05 for NTPs; p<0.005 for MPO; p<0.005 for elastase). NTP concentration correlated with MPO and elastase activity and neutrophil number (r=0.93, 0.91 and 0.87, respectively), but not to protein concentration and arterial oxygen tension/inspiratory oxygen fraction. The cytotoxicity of BAL correlated with NTP concentration (r=0.92) and MPO activity (r=0.89). It was concluded that the concentrations of nitrated proteins in bronchoalveolar lavage fluid correlated with the oxidant activity of neutrophils and that, bronchoalveolar lavage fluid cytotoxicity was correlated with the nitrated protein concentration and may be mediated by oxidants.

Correlation between endotoxin level and bacterial count in bronchoalveolar lavage fluid of ventilated patients

OBJECTIVE

To assess the predictive value of the endotoxin level in the bronchoalveolar lavage (BAL) and to propose to the clinician a guide in the diagnosis of gram-negative bacterial (GNB) pneumonia.

DESIGN

Retrospective and prospective studies to investigate the relation between endotoxin level and quantitative bacterial culture of BAL and to test the predictive value of a defined threshold.

SETTING

University hospital general intensive care unit.

PATIENTS

In the first part of the study, 77 consecutive ventilated patients with clinical suspicion of nosocomial pneumonia between January 1995 and January 1996. In the second part of the study, 93 consecutive ventilated patients studied prospectively between February 1996 and April 1997.

MEASUREMENTS AND MAIN RESULTS

Quantitative cultures for aerobic bacteria were performed directly from the fluid. Bacterial species were determined with standard techniques. The detection of endotoxin in BAL was made using a quantitative chromogenic Limulus assay. In the retrospective analysis, a significant correlation between quantitative GNB cultures and BAL endotoxin levels was observed (r2 = 0.60, p < .0001). An endotoxin level > or = 4 endotoxin units/mL (EU/mL) distinguishes patients with a significant GNB count from colonized patients with a sensitivity of 92.6%, a specificity of 81.4% and a correct classification rate of 84.9%. In the prospective analysis, the 4 EU/mL threshold permits identification of infected patients with a sensitivity of 82.2%, a specificity of 95.6%, and a correct classification rate of 90.3%. The receiver operating characteristic curve analysis showed that the Limulus assay still had a good discrimination power in the prediction of significant bacterial count in BAL fluid.

CONCLUSIONS

Endotoxin detection immediately after bronchoscopy is a distinct advantage to the clinician because antimicrobial gram-negative therapy may be immediately justified according to the results.

Biometry of the capsular ligaments of the wrist

The aim of our study was to measure the length, width and inclination in the coronal plane of the capsular ligaments, and to express these measurements as a ratio in order to determine the correlation between these parameters and the bone index. The capsular ligaments were studied from 15 cadaveric upper limbs. We identified 11 volar and 2 dorsal intracapsular ligaments. For each ligament, we measured the length to its middle and to its proximal and distal edge, the width at its average portion, and the inclination in the frontal plane. There was a difference between the proximal or distal length and the middle length for four ligaments. In these cases, however, there was a significant correlation between the proximal or distal length and the middle length. The length of capitate, the length of the third metacarpal bone, and the carpal height were significantly correlated with four ligaments. There were correlations between the length of one ligament and that of all others. There was no correlation between the inclination of the radius and the inclination of ligaments in the coronal plane. Nevertheless, there were six significant correlations between the inclination of one ligament and that of all others.

[Transverse fracture of the upper sacrum with major displacement. CT reconstruction: case report]

PURPOSE OF THE STUDY

Transverse fractures of the upper sacrum are rare. We report a case with major displacement and neurological impairment. The use of 3D computed tomography (CT) reconstruction to facilitate preoperative planning and surgical procedure is discussed.

MATERIALS AND METHODS

A 49-year-old depressive woman jumped from the second floor in an attemp to commit suicide. She presented an absence of motor reponse in L5 region on both sides, hypoesthesia of S1 dermatome, perineal problems including saddle hypoesthesia and a hypotonic anal sphincter. Radiologic investigation showed a transverse fracture of the upper sacrum with major displacement. CT with 3D reconstruction visualized the course of the different fracture lines on the different levels of the sacrum. Open reduction, extensive laminectomy and internal fixation were performed 6 days following the injury.

RESULTS

After a 1-year post-operative follow up, complete neurological recovery with normal walking and full perineal sphincter control was observed.

DISCUSSION AND CONCLUSION

Fractures of the upper sacrum with major displacement are exceptional. They require well prepared surgical management. CT series with 3D reconstruction allow an analysis of the course of the different sagittal fracture lines to facilitate surgical planning.

Total elbow arthroplasty in rheumatoid arthritis: 20 GSBIII prostheses followed 2-5 years

From 1993 to 1996, we implanted 20 primary GSB IlI prostheses in 17 patients with rheumatoid arthritis. The Mayo Clinic performance index for the elbow was used for the evaluation. The average follow-up was 3 (2-5) years. At the follow-up examination, 12 elbows had an excellent result and 8 a good result. The median performance index increased from 30 (15-53) points to 95 (80-100) points. The subjective assessment was excellent for 11 elbows, good for 8 and poor for 1.2 elbows had radiographic loosening with a progressive radiolucent line and a change in the orientation of the prosthesis.

Hemodynamic effects of epinephrine associated to an epidural clonidine-bupivacaïne mixture during combined lumbar epidural and general anesthesia

Clonidine or epinephrine are frequently combined to epidural local anesthetics to strengthen sensory block and prolong analgesia. Both drugs impair the hemodynamic profile of central neural blockade but the effects of their combination on arterial pressure and heart rate are not known and were examined in this double-blind prospective randomised study. Forty four patients scheduled for lumbar disc surgery were allocated to two groups. Epidural anesthesia was obtained by administration of 150 micrograms clonidine in 15 ml bupivacaine 0.25% solution without (group C) or with (group C + E) 37.5 micrograms epinephrine. Systolic, mean, diastolic arterial pressure and heart rate were measured throughout the study. Combined epidural and general anesthesia induced a significant decrease in arterial pressure and heart rate in both groups. SAP and MAP decreased significantly less in the patients receiving epinephrine. Low dose epidural epinephrine decreases arterial pressure instability during combined epidural and general anesthesia.

Fibroblast growth factor-2 has opposite effects on human breast cancer MCF-7 cell growth depending on the activation level of the mitogen-activated protein kinase pathway

In human breast cancer MCF-7 and MCF-7ras cells, we demonstrated that whereas insulin had a mitogenic effect on both cell lines, fibroblast growth factor-2 (FGF-2) had opposite effects, stimulating MCF-7 and inhibiting MCF-7ras cell proliferation. The inhibitory signal induced by FGF-2 was related to sustained mitogen-activated protein kinase (MAPK) activation in MCF-7ras cells, while transient MAPK activation was associated with MCF-7 cell proliferation. FGF-2 was further used in combination with insulin or cAMP. In MCF-7 cells, insulin and cAMP reversed the mitogenic effect of FGF-2. In MCF-7ras cells, insulin did not modify the inhibitory effect of FGF-2, but cAMP markedly enhanced it. These effects were also associated with an increased level and duration of MAPK activation. PD98056 abolished the effect of FGF-2 on DNA synthesis in both cell lines, demonstrating that the dual effect of FGF-2 on cell proliferation is dependent on the activity of the extracellular-signal-regulated kinase 1 and 2 (ERK1/2) signalling pathway.