A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study.

BACKGROUND: A wide variability in the approach towards delirium prevention and treatment in the critically ill results from the dearth of prospective randomised studies. METHODS: We launched a two-stage prospective observational study to assess delirium epidemiology, risk factors and impact on patient outcome, by enrolling all patients admitted to our Intensive Care Unit (ICU) over a year. The first step - from January to June 2008 was the observational phase, whereas the second one from July to December 2008 was interventional. All the patients admitted to our ICU were recruited but those with pre-existing cognitive disorders, dementia, psychosis and disability after stroke were excluded from the data analysis. Delirium assessment was performed according with Confusion Assessment Method for the ICU twice per day after sedation interruption. During phase 2, patients underwent both a re-orientation strategy and environmental, acoustic and visual stimulation. RESULTS: We admitted a total of respectively 170 (I-ph) and 144 patients (II-ph). The delirium occurrence was significantly lower in (II-ph) 22% vs. 35% in (I-ph) (P=0.020). A Cox's Proportional Hazard model found the applied reorientation strategy as the strongest protective predictors of delirium: (HR 0.504, 95% C.I. 0.313-0.890, P=0.034), whereas age (HR 1.034, 95% CI: 1.013-1.056, P=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI: 2.247-4.032, P=0.018) were negative predictors. CONCLUSION: A timely reorientation strategy seems to be correlated with significantly lower occurrence of delirium.

Antibiotic prophylaxis of early onset pneumonia in critically ill comatose patients. A randomized study.

OBJECTIVE: To evaluate if a 3-day ampicillin-sulbactam prophylaxis can reduce the occurrence of early-onset pneumonia (EOP) in comatose mechanically-ventilated patients. DESIGN: This was a single-centre, prospective, randomised, open study. SETTING: A 10-bed general-neurological ICU in a 2,000-bed university hospital. PATIENTS AND PARTICIPANTS: Comatose mechanically-ventilated patients with traumatic, surgical or medical brain injury. INTERVENTIONS: Patients were randomized to either ampicillin-sulbactam prophylaxis (3 g every 6 h for 3 days) plus standard treatment or standard treatment alone. MEASUREMENTS AND RESULTS: Main outcome was the occurrence of EOP. Secondary outcome measures were occurrence of late-onset pneumonia, percentage of non-pulmonary infections and of emerging multiresistant bacteria, duration of mechanical ventilation and of ICU stay and ICU mortality. Interim analysis at 1 year demonstrated a statistically significant reduction of EOP in the ampicillin-sulbactam group, and the study was interrupted. Overall, 39.5% of the patients developed EOP, 57.9% in the standard treatment group and 21.0% in the ampicillin-sulbactam group (chi-square 5.3971; P =0.022). Relative risk reduction of EOP in patients receiving ampicillin-sulbactam prophylaxis was 64%; the number of patients to be treated to avoid one episode of EOP was three. No differences in other outcome parameters were found; however, the small sample size precluded a definite analysis. CONCLUSIONS: Antibiotic prophylaxis with ampicillin-sulbactam significantly reduced the occurrence of EOP in critically ill comatose mechanically ventilated patients. This result should encourage a large multicenter trial to demonstrate whether ampicillin-sulbactam prophylaxis reduces patient mortality, and whether antibiotic resistance is increased in patients receiving prophylaxis.

Photocatalytic degradation of 5-nitro-1,2,4-triazol-3-one NTO in aqueous suspension of TiO2. Comparison with Fenton oxidation.

5-nitro-1,2,4-triazol-3-one (NTO) is a powerful insensitive explosive, present in industrial waste waters. A remediation method based on photochemical decomposition and Fenton oxidation of NTO has been evaluated by monitoring the mineralization of 14C-labelled NTO. The TiO2-catalyzed photodegradation (lambda > 290 nm, TiO2 0.4 g/l, NTO 150 mg/l)) leads to the complete mineralization of NTO in 3 hours. This degradation involves a simultaneous denitrification and ring scission of NTO leading to nitrites, nitrates and carbon dioxide. No significant photo-degradation of NTO was detected in the absence of the catalyst. Long term irradiation over one week, leads to a complete degradation of concentrated NTO (5 g/l), suggesting that this method could be useful to clean-up NTO wastes. Fenton oxidation offers an efficient cost-effective method for NTO remediation. This reaction is faster that the TiO2 catalyzed photolysis and find application on the mineralization of high concentrations of NTO (15 g/l). Fenton oxidation provokes ring cleavage and subsequent elimination of the two carbon atoms of NTO as CO2. During this reaction, the nitro group is completely transformed into nitrates.

[Postoperative analgesia with PCA in 300 patients. A comparison of four therapeutic regimes]. / Analgesia postoperatoria con PCA in 300 pazienti. Quattro regimi terapeutici a confronto.

BACKGROUND: The results of patient-controlled analgesia (PCA) in 300 patients undergoing major operations in general surgery, urology, ENT and obstetrics-gynaecology are presented. METHODS: An i.v. basic infusion was used on which the patient was able to insert, at minimum intervals pre-established by the physician, boluses of 1/4 of the hourly dose; the drugs used were ketorolac (K), (110 patients-30 mg as a priming dose and 90 mg infused over the subsequent 24 hours), tramadol (90 patient-100 + 300 mg), buprenorphine (55 patients-0.3 + 0.9 mg) and a combination of ketorolac and buprenorphine (45 patients-30 mg of K as priming dose and 60 + 0.6 mg in infusion). during the first 24 hours at pre-established intervals the following data were recorded: efficacy of analgesia (by means of verbal and visual analogues), degree of consciousness, systolic and diastolic blood pressure and heart rate, as well as any onset of adverse side effects, such as drowsiness, nausea, vomiting, itching, urine retention, respiratory depression, gastralgia, pyrosis, allergic reactions, disorientation and excitement. RESULTS: The analgesic efficacy was confirmed by values of the verbal analogue lying between 1.2 and 0.8 in all the therapeutic schemes. The assessment of patients was carried out in the 24 hours following surgical operation, analysing analgesic efficacy and tolerability of the various treatments used. The number of self-administrations carried out by patients was superimposable among treatments and the 4 analgesic schemes determined a valid control of postoperative pain without influencing sensorial capacity. The safety of the various therapeutic schemes studied was also good, there were no variations in haemodynamic parameters and there was only a low incidence of side effects. CONCLUSIONS: On the basis of personal experience, patient controlled analgesia has been demonstrated to be an effective, reliable and flexible procedure for the control of postoperative pain.

Identical photosensitizing activities of a sulfonated aluminium phthalocyanine on human erythroleukemia cell lines susceptible or resistant to the cytotoxic activity of doxorubicin.

In this paper we report that a human erythroleukemia cell line made 100 times more resistant than the parental line to the cytostatic activity of doxorubicin and spontaneously 500-1000 times more resistant to the cytostatic activity of an unrelated drug, namely taxol, exhibits on the other hand unchanged susceptibility to the photosensitizing activity of a sulfonated phthalocyanine.

Study of the mode of action of some nitrodiphenyl ethers.

Nitrosoderivatives of the nitrodiphenyl ether herbicides (nitrofen, bifenox) have been studied. UV irradiation in different organic solvents gives degradation products. In buffered aqueous media, in the presence of chloroplasts and spin traps such as DMPO, hydroxy and peroxy radicals have been characterized. In organic media and in the presence of spin traps such as DMPO, PBN, 4-POBN, solvent radicals (.CHCl2, .CCl3, .CH2 [symbol: see text]) have been formed. Nitro-derivatives have been studied under UV irradiation and in the presence of tetramethylethylene (TME), alkenylhydroxylamines are formed which autoxidize in nitroxide radicals. The formation of the stable nitroxide radical occurs in the dark process after continuous irradiation. The intensity of the signal decreases strongly when a new irradiation is applied. Radical species, with analogous ESR spectral characteristics are formed on reaction with nitrodiphenyl ethers and fatty acids. The reactivity of these herbicides in micellar media (SDS, Brij 35, and CTAB) has been investigated. The kinetics of formation of the ESR signal corresponding to the photoreduction of the nitrodiphenyl ether in the presence of TME behave differently in a micellar environment as compared to solution. The intensity of the formation of the nitroxide increases under irradiation and decreases in the dark; the rotational correlation time tau c has been determined for each type of micelle. Synthetic nitrosodiphenyl ether made by the reduction of nitrodiphenyl ether using hydrogen gas and PtO2 as a catalyst gives the corresponding amine, which is oxidized with meta-chloroperbenzoic acid (m.CPBA). The nitrosodiphenyl ether in the presence of soja azolectin liposome containing a fluorescent probe has been analysed.(ABSTRACT TRUNCATED AT 250 WORDS)