Urinary catecholamine excretion, cardiovascular variability, and outcomes in tetanus

Severe tetanus is characterized by muscle spasm and cardiovascular system disturbance. The pathophysiology of muscle spasm is relatively well understood and involves inhibition of central inhibitory synapses by tetanus toxin. That of cardiovascular disturbance is less clear, but is believed to relate to disinhibition of the autonomic nervous system. The clinical syndrome of autonomic nervous system dysfunction (ANSD) seen in severe tetanus is characterized principally by changes in heart rate and blood pressure which have been linked to increased circulating catecholamines. Previous studies have described varying relationships between catecholamines and signs of ANSD in tetanus, but are limited by confounders and assays used. In this study, we aimed to perform detailed characterization of the relationship between catecholamines (adrenaline and noradrenaline), cardiovascular parameters (heart rate and blood pressure) and clinical outcomes (ANSD, mechanical ventilation required, and length of intensive care unit stay) in adults with tetanus, as well as examine whether intrathecal antitoxin administration affected subsequent catecholamine excretion. Noradrenaline and adrenaline were measured by ELISA from 24-h urine collections taken on day 5 of hospitalization in 272 patients enrolled in a 2 × 2 factorial-blinded randomized controlled trial in a Vietnamese hospital. Catecholamine results measured from 263 patients were available for analysis. After adjustment for potential confounders (i.e., age, sex, intervention treatment, and medications), there were indications of non-linear relationships between urinary catecholamines and heart rate. Adrenaline and noradrenaline were associated with subsequent development of ANSD, and length of ICU stay

PHÂN TÍCH CHUỖI GIÁ TRỊ CÁ TRA TỈNH TIỀN GIANG

The research results on the catfish value chain of Tien Giang province show that there were five market channels, of which, the export market channel occupied 94.14% and the domestic market channel took a share of 5.86%. The analysis shows that catfish farming households achieved high economic efficiency, but processing and retail businesses were the actors who gained the largest added value. Enterprises played an important role in controlling the activities of other actors such as households and middlemen in the chain. The division of benefits among the actors was not reasonable, most of the profits belonged to the commercial stage. The research results suggest several solutions to improve the catfish value chain in Tien Giang province such as improving product quality, strengthening cooperation between actors, especially between businesses and households, building brand and market development for the chain.Kết quả nghiên cứu chuỗi giá trị cá tra tỉnh Tiền Giang cho thấy có 5 kênh thị trường. Trong đó, có hai kênh chính, kênh thị trường xuất khẩu chiếm 94,14% và kênh thị trường nội địa chiếm 5,86% tổng khối lượng sản phẩm. Kết quả phân tích chỉ ra hộ nuôi cá tra đạt hiệu quả kinh tế cao nhưng doanh nghiệp chế biến và người bán lẻ là tác nhân thu được giá trị gia tăng lớn nhất. Doanh nghiệp chế biến là tác nhân đóng vai trò quan trọng nhất, chi phối hầu hết các hoạt động của các tác nhân trong chuỗi. Việc phân phối lợi ích giữa các tác nhân chưa hợp lý, phần lớn lợi nhuận thuộc về khâu thương mại. Từ đó, để nâng cao chuỗi giá trị cá tra cần tập trung nâng cao chất lượng sản phẩm; tăng cường mối liên kết giữa các tác nhân; xây dựng thương hiệu và thị trường tiêu thụ sản phẩm

Human versus equine intramuscular antitoxin, with or without human intrathecal antitoxin, for the treatment of adults with tetanus: a 2 × 2 factorial randomised controlled trial

Background Intramuscular antitoxin is recommended in tetanus treatment, but there are few data comparing human and equine preparations. Tetanus toxin acts within the CNS, where there is limited penetration of peripherally administered antitoxin; thus, intrathecal antitoxin administration might improve clinical outcomes compared with intramuscular injection. Methods In a 2  × 2 factorial trial, all patients aged 16 years or older with a clinical diagnosis of generalised tetanus admitted to the intensive care unit of the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam, were eligible for study entry. Participants were randomly assigned first to 3000 IU human or 21 000 U equine intramuscular antitoxin, then to either 500 IU intrathecal human antitoxin or sham procedure. Interventions were delivered by independent clinicians, with attending clinicians and study staff masked to treatment allocations. The primary outcome was requirement for mechanical ventilation. The analysis was done in the intention-to-treat population. The study is registered at ClinicalTrials.gov, NCT02999815; recruitment is completed. Findings 272 adults were randomly assigned to interventions between Jan 8, 2017, and Sept 29, 2019, and followed up until May, 2020. In the intrathecal allocation, 136 individuals were randomly assigned to sham procedure and 136 to antitoxin; in the intramuscular allocation, 109 individuals were randomly assigned to equine antitoxin and 109 to human antitoxin. 54 patients received antitoxin at a previous hospital, excluding them from the intramuscular antitoxin groups. Mechanical ventilation was given to 56 (43%) of 130 patients allocated to intrathecal antitoxin and 65 (50%) of 131 allocated to sham procedure (relative risk [RR] 0·87, 95% CI 0·66–1·13; p=0·29). For the intramuscular allocation, 48 (45%) of 107 patients allocated to human antitoxin received mechanical ventilation compared with 48 (44%) of 108 patients allocated to equine antitoxin (RR 1·01, 95% CI 0·75–1·36, p=0·95). No clinically relevant difference in adverse events was reported. 22 (16%) of 136 individuals allocated to the intrathecal group and 22 (11%) of 136 allocated to the sham procedure experienced adverse events related or possibly related to the intervention. 16 (15%) of 108 individuals allocated to equine intramuscular antitoxin and 17 (16%) of 109 allocated to human antitoxin experienced adverse events related or possibly related to the intervention. There were no intervention-related deaths. Interpretation We found no advantage of intramuscular human antitoxin over intramuscular equine antitoxin in tetanus treatment. Intrathecal antitoxin administration was safe, but did not provide overall benefit in addition to intramuscular antitoxin administration