Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

INTRACEREBRAL TOXOPLASMA AND CRYPTOCOCCAL COINFECTION IN IMMUNOCOMPROMISED PATIENT WITH SISTEMIC LUPUS ERYTHEMATOSUS.

Objectives: Despite a significant increase in the survival rate of patients with systemic lupus erythematosus (SLE), opportunistic infections represent a significant cause of morbidity and mortality. Risk factors include immunosuppressive theraphies as well as some manifestations of active SLE itself. Clinicians need to be aware about the possibility of polymicrobial infections which may cause diagnostic and therapeutic delay. Methods: We report a case of intracerebral coinfection with Cryptococcus neoformans and Toxoplasma gondii in a 29-years-old man with SLE and congenital IgA deficit, under treatment with steroids. The patient, suffering from one week of fever, vomit and diarrhea, was admitted to our hospital for a syncopal episod following which did not regain consciousness. A neurological consultancy took over stiffness in all four limbs and lockjaw, coma with decortication reaction to painful stimuli, mydriatic pupils. Brain MRI with gadolinium contrast showed the presence of interhemispheric multiple focal lesions enhancement. Results: Cerebrospinal fluid (CSF) examinations revealed 24 white blood cells/μl, glucose 1 mg/dl and protein 266 mg/dl. An India-ink preparation of CSF disclosed mucinous capsule of Cryptococcus as a translucent halo surrounding budding yeast. A latex agglutination test was positive for cryptococcal antigen at a diluition of 1:4096 and CSF culture grew C. neoformans. HIV serology was negative but lymphocyte and CD4 lymphocyte count were 308/μl and 190/μl, respectively. CD4/CD8 ratio was 2.00. He was treated with liposomal amphotericin B (2 mg/kg/die) and dexamethasone (32 mg/die). Because of severe immunosuprression, other opportunistic pathogens were investigated. A qualitative in house PCR resulted positive for T. gondii DNA (B1 gene) in CSF, peripheral blood mononuclear cells and serum. Anamnestic T. gondii serology was negative. The therapeutic regimen was promptly strengthened with cotrimoxazole (20mg/kg/die+100mg/Kg/die), but a new CT scan demonstrated a diffuse cerebral swelling. Because of severe general impairment, the patient died two days later. Conclusions: Patients with severe SLE under immunosuppressive treatment with steroids may undergo acute infections including those from virus, common bacteria and Mycobacteria, fungi (i.e C. neoformans) and parasites (i.e T. gondii) which can occur alone or rarely in combination. In this regard, only one case of intracerebral coinfection with Burkholderia pseudomalley and C. neoformans has been recently described. To our knowledge, the presented case is the first describing an intracerebral coinfection with both C. neoformans and T. gondii in a patient with SLE. Monitoring CD4 lymphocyte count is highly recommended in patients with SLE under immunosuppressive treatment; if lower than 200/μl, they should assume cotrimoxazole prophylaxis, as HIV+ patients. In case of detection of brain lesions, rapid molecular diagnosis for more than one opportunistic infection should be taken into account as failure to timely recognition of coinfections may lead to insufficient treatment and affect outcome

Percutaneous vertebroplasty and spinal cord compression: a case report

This report describes a 60-year-old woman with intensive back pain due to metastatic vertebral body collapse, who underwent percutaneous vertebroplasty. Subsequently, the patient developed metastatic lesion extrusion into the spinal canal because of pressure of the cement, with compression of the left anterolateral spinal cord. During percutaneous vertebroplasty procedure in patient with malignant tumors, the complication rate increases owing to the risk of leakage of cement resulting from the vertebral body destruction, but as also seen in our case, for the extrusion of the neoplastic tissue and increase of the pressure in the vertebral body due to the introduction of the cement

Valutazione dell'efficacia dell'emoperfusione nell'avvelenamento da Paraquat

avvelenamento da Paraqua

Clinical and analytical aspects of quetiapine ingestion: a case report

Clinical and analytical aspects of quetiapine ingestion: a case repor

ETHYLENE GLYCOL POISONING IN CATS: WHAT ARE THE PROGNOSTIC INDICATORS?

The correct management of some poisoned patients may require admission to the Intensive Care Unit (ICU). We studied ICU usage in poisoned patients and the related features

Gaschromatography-mass spectrometry (GC-MS) determination of quetiapine in two non-fatal poisoning: diagnosis of intoxication and drug elimination monitoring

References Gaschromatography-mass spectrometry (GC-MS) determination of quetiapine in two non-fatal poisoning: diagnosis of intoxication and drug elimination monitoring Background Quetiapine is a benzazepinic derivate and part of the family of atypical antipsychotics. Is currently marketed to treat schizophrenia and prescribed in association with other drugs acting in the CNS. After oral administration and gastrointestinal absorption is exstensively metabolised by the liver, primarily by cytochrome P450, but the mayor plasma metabolites are inactive, and less than 1% of the dose is excreted as unchanged drug in the urine and feces. We report two cases of quetiapine's non-fatal intoxication: Case 1: woman, 59 years old, admitted to Emergency after ingestion of 1,4 gr of quetiapine (Seroquel 25 mg, 56 tablets). Case 2: woman, 54 years old, admitted to Emergency after ingestion of an unknown quantity of quetiapine. In both cases the time elapsed between assumption and hospitalization was unknown and each patient has taken quetiapine for suicidal purposes. Blood, urine and gastric lavage were collected for each patient and sent to our laboratory. The collection continues until quetiapine's elimination from blood.

Over time relationship between platelet reactivity, myocardial injury and mortality in patients with SARS-CoV-2-associated respiratory failure

The aim of this study (NCT04343053) is to investigate the relationship between platelet activation, myocardial injury, and mortality in patients affected by Coronavirus disease 2019 (COVID-19). Fifty-four patients with respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were enrolled as cases. Eleven patients with the same clinical presentation, but negative for SARS-CoV-2 infection, were included as controls. Blood samples were collected at three different time points (inclusion [T1], after 7 ± 2 days [T2] and 14 ± 2 days [T3]). Platelet aggregation by light transmittance aggregometry and the circulating levels of soluble CD40 ligand (sCD40L) and P-selectin were measured. Platelet biomarkers did not differ between cases and controls, except for sCD40L which was higher in COVID-19 patients (p = .003). In COVID-19 patients, P-selectin and sCD40L levels decreased from T1 to T3 and were higher in cases requiring admission to intensive care unit (p = .004 and p = .008, respectively). Patients with myocardial injury (37%), as well as those who died (30%), had higher values of all biomarkers of platelet activation (p < .05 for all). Myocardial injury was an independent predictor of mortality. In COVID-19 patients admitted to hospital for respiratory failure, heightened platelet activation is associated with severity of illness, myocardial injury, and mortality. ClinicalTrials.gov number: NCT04343053

Early rehabilitation for severe acquired brain injury in intensive care unit: multicenter observational study

The increased survival after a severe acquired brain injury (sABI) raise the problem of making most effective the treatments in Intensive Care Unit (ICU)/Neurointensive Care Unit (NICU), also integrating rehabilitation care. Despite previous studies reported that early mobilization in ICU was effective in preventing complications and reducing hospital stay, few studies addressed the rehabilitative management of sABI patients in ICU/NICU