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At least 1,693 records · Page 94Linked to original sources
PubMed2006

L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: the French controlled, randomized, double-blind, multicenter study.

OBJECTIVE: Glutamine (Gln)-supplemented total parenteral nutrition (TPN) improves clinical outcome after planned surgery, but the benefits of Gln-TPN for critically ill (intensive care unit; ICU) patients are still debated. DESIGN: Prospective, double-blind, controlled, randomized trial. SETTING: ICUs in 16 hospitals in France. PATIENTS: One-hundred fourteen ICU patients admitted for multiple trauma (38), complicated surgery (65), or pancreatitis (11). INTERVENTIONS: Patients were randomized to receive isocaloric isonitrogenous TPN via a central venous catheter providing 37.5 kcal and 1.5 g amino acids.kg-1.day-1 supplemented with either L-alanyl-L-glutamine dipeptide (0.5 g.kg-1.day-1; Ala-Gln group, n=58) or L-alanine+L-proline (control group, n=56) over at least 5 days. MEASUREMENTS AND MAIN RESULTS: Complicated clinical outcome was defined a priori by the occurrence of infectious complications (according to the criteria of the Centers for Disease Control and Prevention), wound complication, or death. The two groups were compared by chi-square test on an intention-to-treat basis. The two groups did not differ at inclusion for type and severity of injury (mean simplified acute physiology score II, 30 vs. 30.5; mean injury severity score, 44.9 vs. 42.3). Similar volumes of TPN were administered in both groups. Ala-Gln-supplemented TPN was associated with a lower incidence of complicated outcome (41% vs. 61%; p<.05), which was mainly due to a reduced infection rate per patient (mean, 0.45 vs. 0.71; p<.05) and incidence of pneumonia (10 vs. 19; p<.05). Early death rate during treatment and 6-month survival were not different. Hyperglycemia was less frequent (20 vs. 30 patients; p<.05) and there were fewer insulin-requiring patients (14 vs. 22; p<.05) in the Ala-Gln group. CONCLUSIONS: TPN supplemented with Ala-Gln dipeptide in ICU patients is associated with a reduced rate of infectious complications and better metabolic tolerance.

Analysis of Variance↗
PubMed2005

Toward a new payment system for inpatient rehabilitation. Part II: Reimbursing providers.

BACKGROUND: The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment. OBJECTIVES: We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855). RESEARCH DESIGN: We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis. RESULTS: We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions. CONCLUSION: For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Diagnosis-Related Groups↗
PubMed2003

Hemorrhagic shock induces an S 100 B increase associated with shock severity.

S 100 B is a glial marker of cerebral Injury. In a previous clinical study, we found an S 100 B increase within the first 24 h in patients with multiple trauma and hemorrhagic shock but without cerebral trauma. The aim of our current experimental study was to determine whether this posttraumatic S 100 B increase is caused by extracerebral soft tissue injury or by hemorrhagic shock and whether it is associated with the severity of hemorrhagic shock. Hemorrhagic shock was achieved by bleeding anesthetized rats to a mean arterial pressure (MAP) of 30-35 mmHg through a femoral catheter and maintaining this MAP until incipient decompensation. At incipient decompensation, MAP was either increased immediately to 40-45 mmHg (moderate shock) or was maintained until 40% of shed blood had been returned (severe shock), and then increased to 40-45 mmHg. Resuscitation was provided after 40-45 mmHg MAP had been maintained for 40 min. Soft tissue injury was achieved by midline laparotomy performed at the onset of hemorrhagic shock or without shock and was maintained for 30 min. Hemorrhagic shock caused an early S 100 B increase at the onset of decompensation. S 100 B remained increased for 24 h and was significantly higher after severe than after moderate shock. In contrast, soft tissue injury without hemorrhagic shock caused no S 100 B increase. The data presented demonstrate for the first time that the S 100 B increase is induced by hemorrhagic shock and is associated with the severity of shock.

Acidosis↗
PubMed2004

Cerebral vascular and metabolic response to sustained systemic inflammation in ovine traumatic brain injury.

Traumatic brain injury (TBI) is frequently accompanied by a systemic inflammatory response secondary to multiple trauma, shock, or infections. This study investigated the impact of sustained systemic inflammation on cerebral hemodynamics and metabolism in ovine traumatic brain injury. Fifteen sheep were investigated for 14 hours. Head injury was induced with a nonpenetrating stunner in anesthetized, ventilated animals. One group (TBI/Endo, n = 6) subsequently received a continuous endotoxin infusion for 12 hours, whereas a second group (TBI, n = 6) received the carrier. Three instrumented animals served as sham controls. Head impact significantly increased intracranial pressure from 9 +/- 4 mm Hg to 21 +/- 15 mm Hg (TBI/Endo) and from 10 +/- 3 mm Hg to 24 +/- 19 mm Hg (TBI) (means +/- SD). Internal carotid blood flow increased and cerebral vascular resistance decreased (P < 0.05) during the hyperdynamic inflammatory response between 10 and 14 hours in the TBI/Endo group, whereas these parameters were at baseline level in the TBI group. Intracranial pressure remained unchanged during this period, but increased during hypercapnia. The CMRO2, PaCO2, and arterial hematocrit values were identical among the groups between 10 and 14 hours. It is concluded that chronic endotoxemia in ovine traumatic brain injury was associated with cerebral vasodilation uncoupled from global brain metabolism. Different mechanisms appear to induce cerebral vasodilation in response to inflammation and hypercapnia.

Animals↗
PubMedDate not supplied

Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: preliminary results and complications.

Thirty-one femoral-shaft fractures in 30 patients were treated with interlocking intramedullary nails. The 19 boys and 11 girls ranged in age from 10 to 15 years (average age 12 + 3 years) at the time of injury. All fractures united, and the average leg-length discrepancy (comparing the injured to the uninjured extremity) was 0.51 cm. Two patients had overgrowth of > 2.5 cm; none had angular or rotational malunions. One patient developed asymptomatic segmental avascular necrosis of the femoral head, which was not seen on radiographs until 15 months after injury. All nails were removed at an average of 14 months after injury; no refracture or femoral neck fracture has since occurred. Intramedullary nailing is a reasonable alternative for the treatment of isolated femoral-shaft fractures in older adolescents and in younger adolescents with multiple trauma.

Adolescent↗
PubMed1984

A theoretical protocol for nutritional maintenance in head-injured patients.

Multiple trauma increases the nutritional needs of patients. Although head-injury victims present special problems, the modality of enteral nutritional offers specific advantages which avoid the complications of malnutrition. The success of enteral nutritional therapy is dependent on knowledgeable nursing assessment and intervention. Certainly, it is a therapeutic maneuver that should be considered in the care of the head-injured, multi-trauma patient.

Craniocerebral Trauma↗
PubMed2002

The effect of sensitization and coping style on post-traumatic stress symptoms and quality of life: two longitudinal studies.

The present study investigated the effects of multiple trauma exposure and coping style on post-traumatic stress symptoms and quality of life. It was hypothesized that sensitization would occur in subjects repeatedly exposed to life-threatening situations (study 1), and different coping styles would act as a resilience or facilitating factor in symptom development (study 2). The results showed that the single-exposure group revealed a decrease in trauma specific stress reactions from three weeks to four months, with a persistent reduction at 12-month follow-up, while the repeated-exposure group showed an increase in symptom reporting over the 12-month period. The same pattern emerged for perceived quality of life-measured by the General Health Questionnaire (GHQ-30). The second study revealed a correlation between scores on avoidant-focused coping style and the Impact of Event Scale-avoidance dimension, Post-traumatic Symptom Scale and GHQ-30. Furthermore, only subjects with a dominant coping style of emotion-focused or task-focused coping showed a reduction in trauma-specific symptom scores over time.

Adaptation, Psychological↗
PubMed1976

Psychiatric problems in intensive care. Five patients with acute confusional states and depression.

Five case histories are presented of patients with multiple trauma or severe infection, who developed psychiatric symptoms after an initially favourable response to intensive therapy. Alterations in the level of consciousness and behavioural pattern were observed, associated with the presence of acute depression, possibly primarily endogenous in origin. Following intravenous Clomipramine administration, considerable improvement was noted in all five patients, regarding both the depressive state and the clouding of consciousness. The importance of recognising psychiatric disorder in severly ill patients in an intensive therapy environment is stressed.

Adult↗
PubMedDate not supplied

Calcinosis cutis following trauma.

We report an 8-year-old boy who developed dystrophic calcinosis cutis that occurred following trauma. Multiple abrasions were observed in the inguinal folds after a soccer game. Subsequently, multiple papules with soft centers and white particles appeared in the same area. A biopsy specimen showed calcinosis cutis with transepidermal elimination of calcium. The causes of the underlying tissue damage associated with dystrophic calcinosis are discussed.

Calcinosis↗
PubMedDate not supplied

Suction catheter-assisted nasotracheal intubation.

This case series illustrates the use of a suction catheter to guide the passage of an endotracheal (ET) tube through the glottis, a technique modification which can be used when standard nasotracheal intubation is unsuccessful. The technique is appropriate for patients in whom airway management is urgent, but not emergent. Catheter-assisted nasotracheal intubation is useful when intubation is difficult because of excessive patient resistance to movement of the ET tube within the oropharynx. The clinical use of this technique is described for the following scenarios: overdose with obtundation, multiple trauma with agitation, and respiratory failure from pneumonia and pulmonary edema.

Adult↗
PubMed1990

Failure of ceftazidime-amikacin therapy for bacteremia and meningitis due to Klebsiella pneumoniae producing an extended-spectrum beta-lactamase.

A multiple trauma patient failed treatment with ceftazidime and amikacin for bacteremia and meningitis due to a Klebsiella pneumoniae strain that produced a novel, plasmid-mediated beta-lactamase. Both pre- and posttreatment isolates were resistant to ceftazidime (MIC, greater than or equal to 64 micrograms/ml) and various penicillins but not to other expanded-spectrum cephalosporins. The beta-lactamase had a pI of 5.25 and was encoded on a conjugal plasmid of approximately 150 kilobases. DNA hybridization studies indicated that the enzyme was a TEM derivative.

Adult↗
PubMed1989

Purtscher's retinopathy and fat embolism.

A 19-year-old woman who sustained multiple trauma but no head injury developed fulminant fat embolism syndrome (FES). Her neurological deterioration was associated with cerebral oedema and the concomitant Purtscher's type retinopathy. We suggest that the pathogenesis of the retinopathy and of the cerebral oedema are the same and that Purtscher's retinopathy and retinopathy of the FES are indistinguishable.

Adult↗
PubMed1984

The plasma kallikrein kinin system in severely ill and traumatised patients.

Serial estimations of plasma prekallikrein in four critically ill patients in intensive care showed reduced values in each case, suggesting activation of the plasma kallikrein kinin system. In contrast, samples taken early from 15 patients attending an accident and emergency department with multiple trauma showed significantly elevated plasma prekallikrein concentrations; the significance of this observation is at present unclear.

Adult↗
PubMed1988

Use of conjunctival oxygen monitoring in cardiac patients in the emergency unit.

Conjunctival oxygen monitoring (PcjO2) measures conjunctival tissue organ. It has proved useful in helping to evaluate hypovolemic multiple trauma patients, carotid artery surgery patients, as well as others. Little has been written about its use during medical resuscitations. This report reviews its accident and emergency department use in 13 cardiac arrest/life-threatening cardiac dysrhythmia patients. Nine patients expired and four patients survived. Accident and emergency department PcjO2 values in the group which expired averaged 6.3. Those patients who survived averaged 35.4. Subjects who maintained PcjO2 values below 20 did not survive. Furthermore, PcjO2 values taken within the first 8 min of accident and emergency department resuscitation appear to indicate outcome. Conjunctival oxygen monitoring may be useful in monitoring critically ill cardiac patients in the accident and emergency department.

Arrhythmias, Cardiac↗
PubMed2005

Chemokines in acute respiratory distress syndrome.

A characteristic feature of all inflammatory disorders is the excessive recruitment of leukocytes to the site of inflammation. The loss of control in trafficking these cells contributes to inflammatory diseases. Leukocyte recruitment is a well-orchestrated process that includes several protein families including the large cytokine subfamily of chemotactic cytokines, the chemokines. Chemokines and their receptors are involved in the pathogenesis of several diseases. Acute lung injury that clinically manifests as acute respiratory distress syndrome (ARDS) is caused by an uncontrolled systemic inflammatory response resulting from clinical events including major surgery, trauma, multiple transfusions, severe burns, pancreatitis, and sepsis. Systemic inflammatory response syndrome involves activation of alveolar macrophages and sequestered neutrophils in the lung. The clinical hallmarks of ARDS are severe hypoxemia, diffuse bilateral pulmonary infiltrates, and normal intracardiac filling pressures. The magnitude and duration of the inflammatory process may ultimately determine the outcome in patients with ARDS. Recent evidence shows that activated leukocytes and chemokines play a key role in the pathogenesis of ARDS. The expanding number of antagonists of chemokine receptors for inflammatory disorders may hold promise for new medicines to combat ARDS.

Animals↗
PubMed1998

Uncoupling of the autonomic and cardiovascular systems in acute brain injury.

We hypothesized that acute brain injury results in decreased heart rate (HR) variability and baroreflex sensitivity indicative of uncoupling of the autonomic and cardiovascular systems and that the degree of uncoupling should be proportional to the degree of neurological injury. We used HR and blood pressure (BP) power spectral analysis to measure neuroautonomic regulation of HR and BP and the transfer function magnitude (TF) between BP and HR as a measure of baroreflex modulation of HR. In 24 brain-injured patients [anoxic/ischemic injury (n = 7), multiple trauma (n = 6), head trauma (n = 5), central nervous system infection (n = 4), and intracranial hemorrhage (n = 2)], neurological injury and survival was associated with low-frequency (0.01-0.15 Hz) HR and BP power and TF. Brain-dead patients showed decreased low-frequency HR power [0. 51 +/- 0.36 (SE) vs. 2.54 +/- 0.14 beats/min2, P = 0.03] and TF [0. 61 +/- 0.16 (SE) vs. 1.29 +/- 0.07 beats . min-1 . mmHg-1, P = 0.05] compared with non-brain-dead patients. We conclude that 1) severity of neurological injury and outcome are inversely associated with HR and BP variability and 2) there is direct evidence for cardiovascular and autonomic uncoupling in acute brain injury with complete uncoupling during brain death.

Acute Disease↗
PubMed1987

Effects of high-frequency jet ventilation on arterial baroreflex regulation of heart rate.

Fifteen anesthetized mechanically ventilated patients recovering from multiple trauma were studied to compare the effects of high-frequency jet ventilation (HFJV) and continuous positive-pressure ventilation (CPPV) on arterial baroreflex regulation of heart rate. Systolic arterial pressure and right atrial pressure were measured using indwelling catheters. Electrocardiogram (ECG) and mean airway pressure were continuously monitored. Lung volumes were measured using two linear differential transformers mounted on thoracic and abdominal belts. Baroreflex testing was performed by sequential intravenous bolus injections of phenylephrine (200 micrograms) and nitroglycerin (200 micrograms) to raise or lower systolic arterial pressure by 20-30 Torr. Baroreflex regulation of heart rate was expressed as the slope of the regression line between R-R interval of the ECG and systolic arterial pressure. In each mode of ventilation the ventilatory settings were chosen to control mean airway pressure and arterial PCO2 (PaCO2). In HFJV a tidal volume of 159 +/- 61 ml was administered at a frequency of 320 +/- 104 breaths/min, whereas in CPPV a tidal volume of 702 +/- 201 ml was administered at a frequency of 13 +/- 2 breaths/min. Control values of systolic arterial pressure, R-R interval, mean pulmonary volume above apneic functional residual capacity, end-expiratory pulmonary volume, right atrial pressure, mean airway pressure, PaCO2, pH, PaO2, and temperature before injection of phenylephrine or nitroglycerin were comparable in HFJV and CPPV. Baroreflex regulation of heart rate after nitroglycerin injection was significantly higher in HFJV (4.1 +/- 2.8 ms/Torr) than in CPPV (1.96 +/- 1.23 ms/Torr).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗