Unusual cause of severe toxic methemoglobinemia in an infant: a case report

Toxic methemoglobinemia is an uncommon blood disorder induced by exposure to certain oxidizing agents and drugs. In severe cases, this condition may rapidly lead to major cardiopulmonary compromise and constitutes an emergency requiring prompt recognition and early management. We report an unusual case of severe toxic methemoglobinemia following wide cutaneous application of a pomade containing benzocaine, resorcin, and oxyquinoline (Nestosyl®) in an infant

International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009

Q3Artículo original95-106We report the results of the International Infection Control Consortium (INICC) surveillance study from January 2003 throughDecember 2008 in 173 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study, using Centersfor Disease Control and Prevention (CDC) US National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infec-tion Surveillance system [NNIS]) definitions for device-associated health care-associated infection, we collected prospective datafrom 155,358 patients hospitalized in the consortium’s hospital ICUs for an aggregate of 923,624 days. Although device utilizationin the developing countries’ ICUs was remarkably similar to that reported from US ICUs in the CDC’s NHSN, rates of device-asso-ciated nosocomial infection were markedly higher in the ICUs of the INICC hospitals: the pooled rate of central venous catheter(CVC)-associated bloodstream infections (BSI) in the INICC ICUs, 7.6 per 1000 CVC-days, is nearly 3-fold higher than the 2.0 per1000 CVC-days reported from comparable US ICUs, and the overall rate of ventilator-associated pneumonia (VAP) was also farhigher, 13.6 versus 3.3 per 1000 ventilator-days, respectively, as was the rate of catheter-associated urinary tract infection (CAUTI),6.3 versus 3.3 per 1000 catheter-days, respectively. Most strikingly, the frequencies of resistance ofStaphylococcus aureusisolatesto methicillin (MRSA) (84.1% vs 56.8%, respectively),Klebsiella pneumoniaeto ceftazidime or ceftriaxone (76.1% vs 27.1%, respec-tively),Acinetobacter baumanniito imipenem (46.3% vs 29.2%, respectively), andPseudomonas aeruginosato piperacillin (78.0%vs 20.2%, respectively) were also far higher in the consortium’s ICUs, and the crude unadjusted excess mortalities of device-relatedinfections ranged from 23.6% (CVC-associated bloodstream infections) to 29.3% (VAP)

International nosocomial infection control consortium (INICC) report, data summary of 36 countries, for 2004-2009

The results of a surveillance study conducted by the International Nosocomial Infection Control Consortium (INICC) from January 2004 through December 2009 in 422 intensive care units (ICUs) of 36 countries in Latin America, Asia, Africa, and Europe are reported. During the 6-year study period, using Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infection Surveillance system [NNIS]) definitions for device-associated health care-associated infections, we gathered prospective data from 313,008 patients hospitalized in the consortium's ICUs for an aggregate of 2,194,897 ICU bed-days. Despite the fact that the use of devices in the developing countries' ICUs was remarkably similar to that reported in US ICUs in the CDC's NHSN, rates of device-associated nosocomial infection were significantly higher in the ICUs of the INICC hospitals; the pooled rate of central line-associated bloodstream infection in the INICC ICUs of 6.8 per 1,000 central line-days was more than 3-fold higher than the 2.0 per 1,000 central line-days reported in comparable US ICUs. The overall rate of ventilator-associated pneumonia also was far higher (15.8 vs 3.3 per 1,000 ventilator-days), as was the rate of catheter-associated urinary tract infection (6.3 vs. 3.3 per 1,000 catheter-days). Notably, the frequencies of resistance of Pseudomonas aeruginosa isolates to imipenem (47.2% vs 23.0%), Klebsiella pneumoniae isolates to ceftazidime (76.3% vs 27.1%), Escherichia coli isolates to ceftazidime (66.7% vs 8.1%), Staphylococcus aureus isolates to methicillin (84.4% vs 56.8%), were also higher in the consortium's ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 7.3% (for catheter-associated urinary tract infection) to 15.2% (for ventilator-associated pneumonia). Copyright © 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012

OBJECTIVE: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients

Ring extensions with some finiteness conditions on the set of intermediate rings

summary:A ring extension $R\subseteq S$ is said to be FO if it has only finitely many intermediate rings. $R\subseteq S$ is said to be FC if each chain of distinct intermediate rings in this extension is finite. We establish several necessary and sufficient conditions for the ring extension $R\subseteq S$ to be FO or FC together with several other finiteness conditions on the set of intermediate rings. As a corollary we show that each integrally closed ring extension with finite length chains of intermediate rings is necessarily a normal pair with only finitely many intermediate rings. We also obtain as a corollary several new and old characterizations of Prüfer and integral domains satisfying the corresponding finiteness conditions

Réponse écophysiologiques des herbacées pérennes Stipa Lagascae et Dactylis glomerata en conditions de deficit hydrique du sol

International audiencePerennial herbaceous plants represent one of the most interesting resources but their persistence depends on their ability to cope with acute drought. Survival of plants under extreme conditions must therefore be studied to understand the strategies and mechanisms of perennial grasses from arid areas. The aim of the present study was to compare the adaptive responses of both species Stipa lagascae (cultivar Roemer and Schultz) and Dactylis glomerata (cultivar Kasbah). We analysed the impact of water deficit on phenology and growth through some physiological traits. We were particularly interested in the study of the assimilation rate A (µmol/m2/s) and the stomatal conductance gs (mol/ m2/s). The results show that water deficit affects the biological cycle and that there is a difference between species. At the physiological level, assimilation rate A (µmol/m2/s) is significantly affected (P<0.01) by water deficit for Dactylis glomerata. For Stipa lagascae, the assimilation rates in favourable conditions and under water deficit are comparable.Les plantes herbacées pérennes représentent l’une des plus importantes resources mais leur persistence depend de leur aptitude à supporter un deficit hydrique severe. Il est ainsi nécessaire d’étudier la survie des plantes dans des conditions extrêmes pour comprendre les stratégies et les mécanismes des herbacées pérennes des zones arides. L’objectif du présent travail est de comparer les réponses adaptatives de deux espèces Stipa lagascae (cultivar Roemer and Schultz) et Dactylis glomerata (cultivar Kasbah). Nous analysons l’effet du déficit hydrique sur la phénologie et la croissance à travers les caractères physiologiques. On s’est intéressé en particulier à l’étude du taux d’assimilation « A » (µmol/m2/s) et de la conductance stomatique « gs » (mol/m2/s). Les résultats montrent que le déficit hydrique affecte le cycle biologique et qu’il existe une différence entre les deux espèces. Au niveau physiologique, le taux d’assimilation « A » (%mol/m2/s) est significativement affecté (P<0,01) par la déficit hydrique chez Dactylis glomerata. Chez Stipa lagascae, les taux d’assimilation en conditions favorables et en déficit hydrique sont comparable