Red cell distribution width as predictor for mortality in critically ill patients.

BACKGROUND: The objective of this study was to evaluate whether the red cell distribution width (RDW) is a significant risk factor for hospital mortality in critically ill patients and to investigate whether RDW is a parameter indicating inflammation, or a risk factor independent of inflammation. METHODS: We studied all patients admitted to a ten-bed mixed intensive care unit in the Netherlands between May 2005 and December 2011 for whom RDW was available, and who had not received a blood transfusion in the preceding three months. Inflammation was measured by C-reactive protein and leucocyte count. Analyses included correlation, logistic regression analysis, and receiveroperating characteristic (ROC) curves. RESULTS: We included 2915 patients, of whom 387 (13.3%) did not survive to hospital discharge. In univariate analysis higher RDW values were associated with increased hospital mortality. In multivariate analysis RDW remained an independent risk factor for mortality after correction for APACHE II score, age, admission type and mechanical ventilation (odds ratio 1.04, 95% confidence interval 1.02-1.06, for each femtolitre of RDW). Adding RDW to APACHE II, however, increased the area under the ROC curve marginally (from 0.845 to 0.849, p<0.001). RDW was not correlated with C-reactive protein and leucocyte count, refuting the hypothesis that the association between RDW and outcome is mediated through inflammation. CONCLUSION: In critically ill patients, the RDW on ICU admission was an independent predictor of mortality. Since RDW was not correlated with inflammation, the underlying mechanism of this association warrants further investigation.

Long-term survival after ICU treatment.

BACKGROUND: The aim of this paper was to study long-term survival in patients treated in the Intensive Care Unit (ICU) and who survived to hospital discharge. METHODS: This was a single-center retrospective cohort study of patients admitted to a mixed intensivist-led 10 bed ICU in a teaching hospital between 2004 and 2009 and discharged alive from the hospital with complete follow-up until January 1, 2011. RESULTS: A total of 3477 individual patients were admitted to the ICU, 491 (14.1%) of whom died in the hospital while 2986 survived to hospital discharge. In the first year after discharge 436 out of 2986 (14.6%) patients died. Mortality after hospital discharge was highest in the first three months. For patients discharged alive from the hospital the risk of dying during the first year increased significantly with age, APACHE II score at admission and being discharged to a place other than home. Sepsis on ICU admission, mechanical ventilation, renal replacement therapy during ICU treatment or admission type had no effect on one-year mortality rate. CONCLUSION: Patients who survive ICU treatment have a high risk of dying during the next year. This risk is almost as great the risk of dying during ICU and hospital treatment and increases with age and illness severity on admission to the ICU.

[Accelerated elimination using hemoperfusion in a patient with phenobarbital intoxication]. / Versnelde eliminatie door hemoperfusie bij een patiënte met fenobarbitalintoxicatie.

A 44-year-old female was found comatose after attempting suicide. Toxicological screening showed phenobarbital intoxication. The patient was treated symptomatically. After ten days her serum level of phenobarbital still had not decreased and she was not clinically recovered. The patient was transferred to another hospital for hemoperfusion to decrease the level of phenobarbital. After hemoperfusion the level of phenobarbital dropped significantly and the patient recovered neurologically. Phenobarbital has a long elimination half-life and for this reason it is advisable to use means to accelerate clearance until the clinical condition of the patient shows improvement. Multiple-dose activated charcoal effects the elimination of phenobarbital. If elimination needs to be speeded up, then hemoperfusion can be considered. If this technique is unavailable, hemodialysis is a good alternative.

[Irreversible coma following hypoglycemia in Sheehan syndrome with adrenocortical insufficiency]. / Irreversibel coma na hypoglykemie bij het syndroom van Sheehan met bijnierschorsinsufficiëntie.

A 24-year-old woman of Somali origin delivered at term after an uncomplicated pregnancy. Post-partum haemorrhage resulted in hypovolaemic shock which was treated by hysterectomy. Five days later she became comatose due to unrecognised hypoglycaemia which caused severe irreversible brain damage and status epilepticus. Treatment in the intensive care unit with artificial respiration, prednisolone, desmopressin, inotropic support, barbiturates and an anaesthetic under EEG guidance was unsuccessful. The patient died 28 days post-partum. The hypoglycaemia was due to a combination of (a) inadequate glucose intake and (b) lack of counter-regulatory mechanisms due to a deficiency of steroids and growth hormone as a result of loss of pituitary function (Sheehan syndrome) together with adrenocortical insufficiency. The combination of Sheehan syndrome and primary adrenocortical insufficiency has not been described previously in the literature.

Syndrome of inappropriate ADH secretion attributed to the serotonin re-uptake inhibitors, venlafaxine and paroxetine.

We report on 2 patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) which developed a few weeks after they had started treatment with venlafaxine and paroxetine, respectively. Due to the temporal relationship and the exclusion of other potential causes, a causal relationship between the use of the antidepressants and SIADH seems likely. Diagnostic criteria for SIADH and the role of drugs, especially serotonin re-uptake inhibitors, are discussed.

[Opinions of family physicians and specialists on vaccination against influenza]. / De opvattingen van huisartsen en specialisten over de vaccinatie tegen influenza.

About 50 percent of the patients who because of an underlying disease should be vaccinated annually against influenza, do not receive the vaccine. One of the major reasons is that they are not informed by their physicians about the need to be vaccinated. To understand the attitude of the physicians concerning influenza vaccination and the way the vaccination of these patients is organized, questionnaires were send to 250 general practitioners, 125 cardiologists and 125 pulmonologists in the Netherlands. Eighty-four percent of the questionnaires were returned. The results show that the physicians were well informed about the indications for vaccination. A minority of the physicians had doubts about the efficacy of the vaccine. Both specialists and general practitioners agreed that vaccination should be performed by the general practitioner. Instruction of the patients and application of the vaccine were generally rather well organized. It is to be expected, however, that improvement of the organization will enhance the rate of vaccination against influenza in the Netherlands.

[Implementation of influenza vaccination in 3 hospitals]. / De implementatie van influenzavaccinatie in drie ziekenhuizen.

In two general hospitals and one university hospital questionnaires were handed out to 646 outpatients who because of underlying diseases should be vaccinated annually against influenza. Questions concerned whether a patient was vaccinated, and if the vaccine had not been administrated, what the reason was. Answered questionnaires were received from 595 patients (92%). In the particular year 333 patients (56%) had received the vaccine. The majority of the immunized patients had received personal advice from their physician to have the vaccine. Lack of advice, the belief that vaccination is unnecessary, and fear of side effects were the most important reasons for not having the vaccine. We conclude that personal advice from the patients' physician, sending annual reminders to patients and offering the vaccine to patients in an easily accessible way, are the essential elements for a successful vaccination strategy.

Effect of amphotericin B, fluconazole and itraconazole on intracellular Candida albicans and germ tube development in macrophages.

Candida albicans may resist intracellular killing by macrophages through the formation of germ tubes. Antifungal drugs that inhibit intracellular germ tube formation could therefore facilitate host defence against C. albicans. We assessed the effects of amphotericin B and the new triazole drugs fluconazole and itraconazole on the multiplication and intracellular germ tube formation of C. albicans phagocytosed by murine peritoneal macrophages, and compared the findings with the effects of these drugs on C. albicans in the absence of macrophages. The fungicidal effect of amphotericin B against C. albicans in macrophages was less prominent than that found for extracellular candida. However, amphotericin B completely blocked germ tube formation of C. albicans both in macrophages and extracellularly. Fluconazole and itraconazole had little effect on the number of candida but significantly, although incompletely, inhibited germ tube formation both inside macrophages and extracellularly. The inhibition of intracellular germ tube formation by the triazoles may facilitate host defences against C. albicans and contribute to the efficacies of these drugs in vivo.