Early ICU energy deficit: Is it a risk factor for ventilator-associated pneumonia?

Better comprehension of the interactions between pathogens and host nutritional status offers an attractive field of research to optimize preventive strategies against VAP and to guide optimal selection of the initial antibiotic regimen taking into consideration that ventilator-associated pneumonia [VAP] is the most frequent nosocomial infection in mechanically ventilated patients hospitalized in the ICU. Therefore, we aimed to investigate the pattern of energy balance in mechanically ventilated patients who experienced VAP. Fifty adult patients intubated at ICU admission and mechanically ventilated 96 h before a first VAP episode were included in our study for analysis. Systematic precise nutritional intake was calculated from ICU admission to the day of BAL to assess the early level of energy balance and its impact on the pathogenesis of VAP. VAP microbiology was assessed with quantitative cultures of BAL. Energy balance was expressed as cumulated [kcal or kcal/kg] from ICU admission to day of BAL and was calculated on the time of BAL as follows: cumulated energy delivered - cumulated REE. Among the 50 BAL cultures, 25 contained Staphylococcus aureus [methicillin-suscepti-ble S. aureus [MSSA], n = 16; methicillin-resistant S. aureus [MRSA], n = 9] whereas 10 grew P aeruginosa, 2 grew Enterobacteriaceae, 3 Streptococcus pneumoniae, 2 Acinetobacter baumannii. Six polymicrobial BAL cultures contained other pathogens: Enterobacteriaceae [n = 5], S. pneumo-niae [n = 6], H. influenzae [n = 4]. Patients with S. aureus VAP had a significantly higher mean energy deficit than those S. flwrews-negative BAL cultures [-10707.56 +/- 1988.47 vs -9337.48 +/- 835.69, P = 0.002] However, Energy balance was not statistically significantly associated with the methicillin resistance of S. aureus strains [-10611.56 +/- 1865.8 kcal for 16 patients with MSSA VAP vs -10607.65 +/- 1976.7 kcal in nine patients with MRSA VAP, P = .879]. Early negative energy balance is an independent determinant of S. aureus VAP in mechanically ventilated patients. Feeding prescriptions based on limiting the energy deficit during the first week of ICU stay could be a way to optimize S. aureus VAP prevention

Antioxidant enzyme activities in hepatic tissue from children with chronic cholestatic liver disease

To study the oxidative stress status in children with cholestatic chronic liver disease by determining activities of glutathione peroxidase [GPx], superoxide dismutase [SOD] and catalase [CAT] in liver tissue. A total of 34 children suffering from cholestatic chronic liver disease were studied. They were selected from the Hepatology Clinic, Cairo University, and compared with seven children who happened to have incidental normal liver biopsy. The patients were divided into three groups: extrahepatic biliary atresia [n=13], neonatal hepatitis [n=15] and paucity of intrahepatic bile ducts [n=6]; GPx, SOD and CAT levels were measured in fresh liver tissue using ELISA. In the cholestatic patients, a significant increase was found in mean levels of SOD, GPx and CAT in hepatic tissue compared to control children. The three enzymes significantly increased in the extrahepatic biliary atresia group, whereas in the groups of neonatal hepatitis and paucity of intrahepatic bile ducts, only GPx and CAT enzymes were significantly increased. Oxidative stress could play a role in the pathogenesis of cholestatic chronic liver diseases. These preliminary results are encouraging to conduct more extensive clinical studies using adjuvant antioxidant therapy

Endosonography as a predictive tool for first esophagogastric variceal bleeding

The development of portosystemic collaterals is the central pathophysiological event that leads to variceal bleeding in patients with liver cirrhosis. Endosonography [EUS] is useful to evaluate the fine details of the vascular structures at the gastroesophageal junction. EUS may give a promising chance for predicting upper gastrointestinal bleeding in cirrhotic patients. To evaluate the value of extraluminal gastroesophageal vascular collaterals as predictors of first variceal bleeding. A total of 50 cirrhotic patients with no history of previous upper GI bleeding were recruited into this cohort study. After thorough history taking and clinical examination, they were subjected to upper endoscopy and EUS for assessing the number and size of peri- and para-mural collaterals and perforating vessels. All participants were followed up for 24 months for upper gastrointestinal bleeding. Eighteen out of 50 patients [36%] had at least one attack of upper GI bleeding during the follow up period. All patients had one or more type of extraluminal venous collaterals. Gastric varices [P = 0.02], perigastric collaterals [P = 0.03] and perforators [P = 0.02] were independent risk factors for first variceal bleeding. The presence of 3 or more paraesophageat collaterals and the presence of perforators were significantly higher in bleeders compared to non-bleeders [P = 0.034]. Perigastric and paragastric collateral size were significantly larger in bleeders than non bleeders [P = 0.019 and 0.038 respectively]. Perigastric and paragastric collaterals size more than or equal to 2 mm and 6.20 mm respectively were associated with significantly increased risk of first variceal bleeding. Peri-esophageal and para-esophageal collaterals although present in large diameters in all bleeders than non bleeders, did not reach a statistical significant level EUS may be a promising tool for predicting first variceal bleeding in cirrhotic patients thus justifying primary prevention by band ligation or sclerotherapy

Leptin and insulin levels in umbilical cord blood of infants of diabetic mothers-relation to fetal birth weight

Diabetes mellitus is a common medical condition complicating pregnancy. The present study is planned to estimate the level of insulin and leptin in cord blood of infants of diabetic mothers to find if there is a relation between circulating levels of leptin as well as insulin in umbilical cord of these infants and their birth weight and length. Twenty four controlled and 32 uncontrolled diabetic women, beside 20 healthy nondiabetic women and their full term infants constituted the subjects of the present work. Patients and controls were selected from attendants of the Obstetric and Gynecology Outpatient Clinic of EI-Galaa Hospital, Ministry of Health, Cairo. Assessment of the glycemic state [controlled or uncontrolled] was performed by estimation of glycosylated hemoglobin [HbA1c]. Thorough clinical examination of the infants including birth weight, BMI and height was done. Cord blood was collected from the neonates delivered to those mothers immediately after clamping the cord and serum levels of insulin and leptin were measured. Results demonstrated that cord blood insulin and leptin levels are increased in infants of uncontrolled diabetics more than infants of controlled diabetics and infants of nondiabetic controls. Also, significant increase in body weight and body mass index in infants of uncontrolled diabetics more than infants of controlled diabetic and infants of nondiabetic controls was found. A significant positive correlation was found between umbilical cord plasma insulin and leptin levels and body weight, length, body mass index and maternal HbA1c in all groups. No significant difference of umbilical cord plasma leptin and insulin levels was found between male and female infants of all groups

Comparative study between variceal ligation by detachable snare versus banding in bleeding esophageal varices

Varcial bleeding is a very serious complication with a reported mortality rate of 20-50%. Patients who have had a vatriceal hemorrhage are usually treated by endoscopic injection sclerotherapy or band ligation to eradicate the varices. Endoloop ligation is a new technique invented to achieve hemostatis and variceal eradiation. This work included fifty patients with acute esophageal ariceal bleeding, 25 patients were managed by band ligation and the other 25 patients were managed by endoloop ligation. The number of patients who rebelled during the follow-up was smaller in the endoloop group [12%] compared to the band group [28%], yet, this difference did not reach statistical significance. Also, no statistically significant difference was found between the two groups regarding the number of patients who showed complete varicea eradication, the number of active sessions needed to reach variceal eradiation or the incidence of variceal recurrence by the end of follow-up period of six months. It was found that the total cost of endoloop sessions' needed for variceal obliteration was 1163.9 l.e for erach patient, while it was 12.9.9 l.e for band ligaion. Also, the endoloop showed technical advanced over band application including better field of vision, more tight application, good results on junctional varices, and no strain exerted by the device on the endoscope. We can conclude that endoloop ligation is a new promising technique for managing bleeding esophageal varices

Auditory cognition - heart beats physiological axis

Electrocardiogram [ECG] tracings were recorded from normal 28 male subjects in response to an attentive auditory task. Data regarding the changes in ECG that occur on listening to the rare tone bursts were calculated and compared with those on listening to frequent tone bursts. P wave showed longer duration and lower amplitude, in response to rare stimuli, indicating longer, but weaker atrial contraction. QRS complex and P-R interval did not show significant differences between the listening of the two types of stimuli. T wave showed shorter duration and lower amplitude on listening to rare stimuli indicating faster and less ventricular relaxation. The present work denoted that not only passive hearing, but also the active listening had changes in the cardiac cycle

Pulmonary function testing in children with chronic liver disease

Hepatopulmonary syndrome [HPS] is a rare but severe complication in children with chronic liver disease [CLD] that may necessitate "urgent" liver transplantation. This study aimed at studying the feasibility and usefulness of pulmonary function testing [PFT] in the diagnosis of lung affections in a group of Egyptian children with chronic liver disease [CLD] in order to diagnose HPS in them. Twenty five Egyptian children [aged 10-16 years with a mean of 12.4 +/- 1.8 years] with different causes of CLD and 8 age-matched, healthy controls were subjected to arterial blood gas analysis, PFT and measurement of mean pulmonary artery pressure [MPAP]. Arterial oxygen pressure [Pa0[2]] less than 80 mmHg was present in 10 patients, forced expiratory volume in I second [FEV[1]] less than 80% predicted in 15, forced vital capacity [FVC] less than 80% predicted in 15 and the ratio FEV[1]:FVC less than 65% predicted in 20. Carbon monoxide diffusion capacity [DL[CO]] was less than 80% predicted in 15 patients and 4 controls. Hypoxemia occurred in 60% of patients with decreased DL[co] but none of controls. MPAP was significantly lower in patients than controls, it increased with exercise but not significantly. Neither portal hypertension nor sclerotherapy showed a significant relation to hypoxemia, or low MPAP. Also the duration of CLD, its histological severity and grading of fibrosis were not related to any of the pulmonary function tests. Arterial hypoxemia is present in CLD. PFT was rather "tedious" but non-invasive investigation in children with CLD. It did demonstrate obstructive airway as well as diffusion defects in these children. Therefore we may recommend PFT in the work-up of children with CLD, particularly if liver transplantation is contemplated

study of the effect of fentanyl on haemodynamic status in experimentally preconditioned myocardium of anaesthetized cats

This work is an experimental trial to study the effect of fentanyl on the preconditioned myocardium when exposed to ischemia. Experiments were carried out on 18 cats in vivo. The cases were classified equally into: Group I [preconditioned group] subjected to two 5-minute occlusions [with 20 minutes apart] of LAD followed by prolonged occlusion for 25 minutes [occlusion [3]]. Group II subjected to IV fentanyl in a dose of 150 mug/kg followed by 100 mug/kg/hour. In group III, while fentanyl was given as in group II, cats were subjected to preconditioning and ischemia as in group I. Arterial blood pressure, heart rate and ST segment changes were recorded in each group. The results showed that during occlusion [3], the heart rate dropped by 32% in group III vs 23.6% in group I. The mean systolic and diastolic blood pressure showed no significant change between the two groups. The ST segment elevation decreased from 1.7 +/- 0.35 in group I to 0.1 +/- 0.08 mv in group III. So, fentanyl seemed to have a protective effect on the ischemic myocardium that is reflected in stabilization of the hemodynamic status of the anesthetized cats