Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey

Contains fulltext : 89741.pdf (publisher's version ) (Open Access)INTRODUCTION: Use of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians. METHODS: A survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires. RESULTS: In all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0). CONCLUSIONS: Although perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies. TRIAL REGISTRATION: ISRCTN35176830

The phenotype of Floating-Harbor syndrome: Clinical characterization of 52 individuals with mutations in exon 34 of SRCAP

Background: Floating-Harbor syndrome (FHS) is a rare condition characterized by short stature, delays in expressive language, and a distinctive facial appearance. Recently, heterozygous truncating mutations in SRCAP were determined to be disease-causing. With the availability of a DNA based confirmatory test, we set forth to define the clinical features of this syndrome. Methods and results. Clinical information on fifty-two individuals with SRCAP mutations was collected using standardized questionnaires. Twenty-four males and twenty-eight females were studied with ages ranging from

Natural clusters of tuberous sclerosis complex (TSC)-associated neuropsychiatric disorders (TAND): new findings from the TOSCA TAND research project.

BACKGROUND: Tuberous sclerosis complex (TSC)-associated neuropsychiatric disorders (TAND) have unique, individual patterns that pose significant challenges for diagnosis, psycho-education, and intervention planning. A recent study suggested that it may be feasible to use TAND Checklist data and data-driven methods to generate natural TAND clusters. However, the study had a small sample size and data from only two countries. Here, we investigated the replicability of identifying natural TAND clusters from a larger and more diverse sample from the TOSCA study. METHODS: As part of the TOSCA international TSC registry study, this embedded research project collected TAND Checklist data from individuals with TSC. Correlation coefficients were calculated for TAND variables to generate a correlation matrix. Hierarchical cluster and factor analysis methods were used for data reduction and identification of natural TAND clusters. RESULTS: A total of 85 individuals with TSC (female:male, 40:45) from 7 countries were enrolled. Cluster analysis grouped the TAND variables into 6 clusters: a scholastic cluster (reading, writing, spelling, mathematics, visuo-spatial difficulties, disorientation), a hyperactive/impulsive cluster (hyperactivity, impulsivity, self-injurious behavior), a mood/anxiety cluster (anxiety, depressed mood, sleep difficulties, shyness), a neuropsychological cluster (attention/concentration difficulties, memory, attention, dual/multi-tasking, executive skills deficits), a dysregulated behavior cluster (mood swings, aggressive outbursts, temper tantrums), and an autism spectrum disorder (ASD)-like cluster (delayed language, poor eye contact, repetitive behaviors, unusual use of language, inflexibility, difficulties associated with eating). The natural clusters mapped reasonably well onto the six-factor solution generated. Comparison between cluster and factor solutions from this study and the earlier feasibility study showed significant similarity, particularly in cluster solutions. CONCLUSIONS: Results from this TOSCA research project in an independent international data set showed that the combination of cluster analysis and factor analysis may be able to identify clinically meaningful natural TAND clusters. Findings were remarkably similar to those identified in the earlier feasibility study, supporting the potential robustness of these natural TAND clusters. Further steps should include examination of larger samples, investigation of internal consistency, and evaluation of the robustness of the proposed natural clusters

Truncating SRCAP variants outside the Floating-Harbor syndrome locus cause a distinct neurodevelopmental disorder with a specific DNA methylation signature

Truncating variants in exons 33 and 34 of the SNF2-related CREBBP activator protein (SRCAP) gene cause the neurodevelopmental disorder (NDD) Floating-Harbor syndrome (FLHS), characterized by short stature, speech delay, and facial dysmorphism. Here, we present a cohort of 33 individuals with clinical features distinct from FLHS and truncating (mostly de novo) SRCAP variants either proximal (n = 28) or distal (n = 5) to the FLHS locus. Detailed clinical characterization of the proximal SRCAP individuals identified shared characteristics: developmental delay with or without intellectual disability, behavioral and psychiatric problems, non-specific facial features, musculoskeletal issues, and hypotonia. Because FLHS is known to be associated with a unique set of DNA methylation (DNAm) changes in blood, a DNAm signature, we investigated whether there was a distinct signature associated with our affected individuals. A machine-learning model, based on the FLHS DNAm signature, negatively classified all our tested subjects. Comparing proximal variants with typically developing controls, we identified a DNAm signature distinct from the FLHS signature. Based on the DNAm and clinical data, we refer to the condition as "non-FLHS SRCAP-related NDD.'' All five distal variants classified negatively using the FLHS DNAm model while two classified positively using the proximal model. This suggests divergent pathogenicity of these variants, though clinically the distal group presented with NDD, similar to the proximal SRCAP group. In summary, for SRCAP, there is a clear relationship between variant location, DNAm profile, and clinical phenotype. These results highlight the power of combined epigenetic, molecular, and clinical studies to identify and characterize genotype-epigenotype-phenotype correlations.Genetics of disease, diagnosis and treatmen

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Determination of the relation between alterations of total body water and thoracic fluid content during ultrafiltration by bioelectrical impedance analysis

Total body impedance (TBI) is used to monitor alterations in total body water (TBW), e.g. during haemodialysis.However, 80%of the TBI signal is due to the resistance in extremities. Therefore TBI measurements give littleinformation about alterations in thoracic fluid content (TF). Measuring both total body impedance and thoracic impedance (THI) can be a useful method to monitor TBW and TF changes during haemodialysis. In this study TBI and THI measurements were performed during 30 dialysis sessions and also in one group of 24 control subjects with normal tissue hydration. During haemodialysis TBI and THI significantly increased, demonstrating a decrease of TBW and TF. The ratio THI/TBI did not differ significantly during haemodialysis, indicating a similar effect of ultrafiltration on TBW and TF. The finding that TF decreased during haemodialysis was rather surprising, whereas pulmonary oedema is not an evident clinicalproblem in patients on maintenance haemodialysis treatment. THI measurements after dialysis proved to be signifiantlyhigher in comparison to the control subjects. This finding supports the hypothesis that the decrease in TF during dialysis is partly due to the sudden ultrafiltration-induced hypo-volaemia leading to a fall in thoracic blood volume

Noninvasive imaging of the cardiopulmonary circulation in chronic obstructive pulmonary disease

PH leading to cor pulmonale, defined as right ventricular hypertrophy secondary to diseases that affect the structure or function of the lungs is often observed in patients with COPD. Evaluation of the development of cor pulmonale and monitoring of cardiac function in the course of the disease are, therefore, clinically important. Measurement of right ventricular and pulmonary artery pressures by means of right sided heart catheterization is often utilized to diagnose secondary pulmonary hypertension in COPD patients. However, the amputation of the pulmonary vascular bed must be higher than 50%-60% to induce resting PH2 and, hence, PH occurs only in the late course of the disease. Therefore, there is a search for new techniques that are able to visualize cardiopulmonary hemodynamic changes in an early stage of the disease and make it possible to evaluate possible effects of therapy. This review covers a number of imaging techniques, which can be used for this purpose

Bioelectrical impedance analysis: Clinical tool in assessing total body water and thoracic fluid

Bioelectrical impedance analysis forms a non-invasive fool for defection of body fluids. Total body measurement gives total body water (TBW) and, in case of multifrequency analysis, of intra- and extracellular fluid volume. The thoracic approach measures thoracic fluid (TF). The set-up of both techniques is discussed. An overview is given of the clinical usefulness of the total body technique to monitor fluid changes and the process of refill during hemodialysis and to detect dry weight. The simultaneous measurement of TBW and TF was applied to obtain a more detailed picture of the body fluids. In a group of healthy subjects the age dependency of both variables was shown. During hemodialysis TBW and TF showed a major and comparable decrease. Fluid retention during cardiac surgery led to a slightly more pronounced increase of TF than of TBW. The combination of both impedance techniques offers clinicians a means to monitor alterations in fluid status in patients in more detail

Non-invasive evaluation of left ventricular function by means of impedance cardiography

Background: Simple, accurate, continuous non-invasive cardiac monitoring during the peri- and postoperative periods for patients at risk of cardiac failure would be very useful. Electrical impedance cardiography (EIC) has been proposed as an accurate method for non-invasive measurement of cardiac function. However, in recent years the accuracy of EIC in stroke Volume (SV) measurement has been questioned and this prevented global acceptance of the method. Beside SV, EIC is capable of measuring several other left ventricular contractility indices, which are measured directly from the impedance signal. The aim of this study was to compare these variables with the echocardiographically derived left ventricular wall motion score (WMS) as the reference method. Methods: In a group of eight coronary artery disease patients we performed a pharmacologically (dobutamine) induced stress test. Echocardiographic and impedance cardiographic recordings were performed simultaneously during four levels of dobutamine infusion. WMS was derived from the simultaneously displayed four-stage echocardiographic image. Results: Analysis of variance showed that the majority of indices changed significantly during the test. Direct correlation with the wall motion score gave very satisfactory results over all stages with the RZ time (r = 0.75, P < 0.001) and Heather index (r = -0.78, P < 0.001). Other correlations were substantially lower. Conclusion: The Heather index has to be preferred as indicator of the left ventricular performance. Since EIC is capable of giving continuous information of the left ventricular performance, it might be a valuable method for peri- and postoperative monitoring

Validation study of stroke volume measurement by means of Electrical Impedance Tomography

ECG-gated Electrical Impedance Tomography (EIT) has been developed to monitor blood volume changes. The aim of this study was to compare stroke volume measurements by EIT with established methods of thermodilution and Magnetic Resonance Imaging (MRI). After right cardiac catheterization, EIT measurements were performed in 26 patients. Regression analysis was used to analyze the relation between the EIT results and stroke volume. From the regression line an equation was derived to estimate stroke volume (in ml) by EIT. In a group of eleven healthy subjects this equation was validated to MRI. A strong correlation was found between EIT and stroke volume measured by the thermodilution method (r = 0.86). The reproducibility coefficient for EIT measurements was 0.98. The average standard deviation between stroke volume measured by EIT and MRI is 5.4 ml, the mean difference between both methods is 0.7 ml and the coefficient of variation is 8.4%. We conclude that EIT is a valid and reproducible method for the assessment of stroke volume in healthy controls and cardiological patients