Introduction

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ICU acquired hypernatremia treated by enteral free water - A retrospective cohort study

Purpose: ICU acquired hypernatremia (IAH) is associated with increased morbidity and mortality, however treat-ment remains controversial. This study aims to determine the effect of enteral free water suppletion in patients with IAH. Materials and methods: Retrospective single center study in a tertiary ICU. Inclusion criteria: patients with IAH and treatment with enteral free water. Exclusion criteria: patients with renal replacement therapy, diabetic ketoacidosis or hyperosmolar hyperglycaemic state. Primary outcome: change in plasma sodium (in mmol/l) after 5 days treatment. Responders were defined as patients with a decrease in sodium level of 5 mmol/l or more. Results: In total 382 consecutive patients were included. The median sodium level at the start of water therapy was 149 mmol/l (IQR 147-150). The median volume of enteral water was 4423 ml (IQR 3349-5379 ml) after 5 days and mean sodium decrease was 1.87 mmol/l (SD 4.84). There was no significant correlation between the volume of enteral water and sodium decrease (r(2) = 0.01). Conclusions: Treatment with enteral free water did not result in a clinically relevant decrease in serum sodium level in patients with IAH. In addition, the volume of enteral free water and the use of diuretics was unrelated with sodium change over 5 days. (C) 2020 Elsevier Inc. All rights reserved

Eradication of Resistant and Susceptible Aerobic Gram-Negative Bacteria From the Digestive Tract in Critically Ill Patients; an Observational Cohort Study

BACKGROUND: Selective Decontamination of the Digestive tract (SDD) aims to prevent nosocomial infections, by eradication of potentially pathogenic micro-organisms from the digestive tract. OBJECTIVES: To estimate the rate of and the time to eradication of resistant vs. susceptible facultative aerobic gram-negative bacteria (AGNB) in patients treated with SDD. METHODS: This observational and retrospective study included patients admitted to the ICU between January 2001 and August 2017. Patients were included when treated with SDD (tobramycin, polymyxin B, and amphotericin B) and colonized in the upper or lower gastro-intestinal (GI) tract with at least one AGNB present on admission. Decontamination was determined after the first negative set of cultures (rectal and throat). An additional analysis was performed of two consecutive negative cultures. RESULTS: Of the 281 susceptible AGNB in the throat and 1,087 in the rectum on admission, 97.9 and 93.7%, respectively, of these microorganisms were successfully eradicated. In the upper GI-tract no differences in eradication rates were found between susceptible and resistant microorganisms. However, the median duration until eradication was significantly longer for aminoglycosides resistant vs. susceptible microorganisms (5 vs. 4 days, p < 0.01). In the lower GI-tract, differences in eradication rates between susceptible and resistant microorganisms were found for cephalosporins (90.0 vs. 95.6%), aminoglycosides (84.4 vs. 95.5%) and ciprofloxacin (90.0 vs. 95.2%). Differences in median duration until eradication between susceptible and resistant microorganisms were found for aminoglycosides and ciprofloxacin (both 5 days vs. 6 days, p = 0.001). Decontamination defined as two negative cultures was achieved in a lower rate (77–98% for the upper GI tract and 64–77% for the lower GI tract) and a median of 1 day later. CONCLUSION: The vast majority of both susceptible and resistant microorganisms are effectively eradicated from the upper and lower GI tract. In the lower GI tract decontamination rates of susceptible microorganisms are significantly higher and achieved in a shorter time period compared to resistant strains

Energetics of magnetic transients in a solar active region plage

Densely packed coronal loops are rooted in plages in the vicinity of active regions on the Sun. The photospheric magnetic features underlying these plages are patches of mostly unidirectional magnetic field extending several arcsec on the solar surface. We aim to explore the transient nature of the magnetic field, its mixed-polarity characteristics, and the associated energetics in plages using high resolution observations and simulations. We used photospheric Fe I 6173 {\AA} spectropolarimetric observations of a decaying active region obtained from the SST. These data were inverted to retrieve the photospheric magnetic field underlying the plage as identified in the EUV emission maps obtained from the SDO/AIA. To obtain better insight into the evolution of plages, we performed 3D radiation magnetohydrodynamic simulations of magnetoconvection using the MURaM code. The observations show transient magnetic flux emergence and cancellation events within the plage on timescales of a few 100 s and on spatial scales comparable to granules. These transient events occur at the footpoints of active region plage loops. In one case the coronal response at the footpoints of these loops is clearly associated with the underlying transient. The simulations also reveal similar magnetic flux emergence and cancellation events that extend to even smaller spatial and temporal scales. Individual simulated transient events transfer an energy flux in excess of 1 MW m$^{-2}$ through the photosphere. We suggest that the magnetic transients could play an important role in the energetics of active region plage. Both in observations and simulations, the opposite-polarity magnetic field brought up by transient flux emergence cancels with the surrounding plage field. Magnetic reconnection associated with such transient events likely conduits magnetic energy to power the overlying chromosphere and coronal loops.Comment: Published in A&A (abridged abstract

Enteral Vancomycin to Eliminate MRSA Carriership of the Digestive Tract in Critically Ill Patients

Background: Carriership with methicillin resistant Staphylococcus aureus (MRSA) is a risk for the development of secondary infections in critically ill patients. Previous studies suggest that enteral vancomycin is able to eliminate enteral carriership with MRSA. Data on individual effects of this treatment are lacking. Methods: Retrospective analysis of a database containing 15 year data of consecutive patients from a mixed medical-(cardio)surgical 18 bedded intensive care unit was conducted. All consecutive critically ill patients with enteral MRSA carriership detected in throat and/or rectal samples were collected. We analyzed those with follow-up cultures to determine the success rate of enteral vancomycin. Topical application of 2% vancomycin in a sticky oral paste was performed combined with a vancomycin solution of 500 mg four times daily in the nasogastric tube. This treatment was added to a regimen of selective digestive tract decontamination (SDD) to prevent ICU acquired infection. Results: Thirteen patients were included. The mean age was 65 years and the median APACHE II score was 21. MRSA was present in the throat in 8 patients and in both throat and rectum in 5 patients. In all patients MRSA was successfully eliminated from both throat and rectum, which took 2–11 days with a median duration until decontamination of 4 days. Secondary infections with MRSA did not occur. Conclusions: Topical treatment with vancomycin in a 2% sticky oral paste four times daily in the nasogastric tube was effective in all patients in the elimination of MRSA and prevented secondary MRSA infections

DAMPening COVID-19 Severity by Attenuating Danger Signals

COVID-19 might lead to multi-organ failure and, in some cases, to death. The COVID-19 severity is associated with a “cytokine storm.” Danger-associated molecular patterns (DAMPs) are proinflammatory molecules that can activate pattern recognition receptors, such as toll-like receptors (TLRs). DAMPs and TLRs have not received much attention in COVID-19 but can explain some of the gender-, weight- and age-dependent effects. In females and males, TLRs are differentially expressed, likely contributing to higher COVID-19 severity in males. DAMPs and cytokines associated with COVID-19 mortality are elevated in obese and elderly individuals, which might explain the higher risk for severer COVID-19 in these groups. Adenosine signaling inhibits the TLR/NF-κB pathway and, through this, decreases inflammation and DAMPs’ effects. As vaccines will not be effective in all susceptible individuals and as new vaccine-resistant SARS-CoV-2 mutants might develop, it remains mandatory to find means to dampen COVID-19 disease severity, especially in high-risk groups. We propose that the regulation of DAMPs via adenosine signaling enhancement might be an effective way to lower the severity of COVID-19 and prevent multiple organ failure in the absence of severe side effects