Evaluation of the efficacy of a sunscreen containing ultra-long UVA1 and other UVR broad-spectrum filters on skin barrier protection and melanin content reduction in Chinese adults: A single-center study.

Background and Aims: The protection for ultra-long UVA1 is lacked in the market, posing potential damage from ultra-long UVA1 irradiation. The study aims to evaluate the efficacy of a sunscreen containing multiple components, especially Mexoryl® 400 for improving skin barrier function and reducing melanin content. Methods: This single-center study included adults with sensitive and normal skin in China in November 2022. Participants received the test sunscreen for 4 weeks. Melanin and hemoglobin content, sebum secretion skin hydration, and trans-epidermal water loss were evaluated at T0d, T7d, and T28d. The self-assessment was done at T15min, T7d, and T28d. Results: Sixty participants were included, including 30 self-claimed sensitive skin in the sunscreen group. The sunscreen demonstrated significant improvements in skin parameters. Skin redness reduced by 9.84% at T28d, sebum content in the forehead area decreased by 22.70% at T28d, and skin stratum corneum hydration increased by 38.44% at T28d, p < 0.001 respectively. Most notably, skin melanin content significantly reduced by 13.49% after 4 weeks' usage (p < 0.001). No adverse reactions were reported in either group. Conclusions: The study sunscreen improved the skin condition by decreasing the melanin content, regulating skin barrier function, and achieving a balance of skin hydration and sebum secretion.

Efficacy and safety of a cream containing panthenol, prebiotics, and probiotic lysate for improving sensitive skin symptoms.

BACKGROUND: Sensitive skin is a common condition affecting a significant proportion of the population, and there is a growing demand for effective and safe management. AIM: To evaluate the efficacy and safety of a cream containing panthenol, prebiotics, and probiotic lysate as an optimal care for facial sensitive skin. METHODS: A total of 110 participants (64 in group A and 46 in group B) with facial sensitive skin applied the cream twice daily for 28 days. Group A evaluated their sensitive skin, product efficacy, and product use experience at D0 (15 min), D1, D14, and D28. In group B, skin barrier function-related indicators were measured at baseline and on D1, D7, D14, and D28. Dermatologists evaluated tolerance for all participants. RESULTS: After 28 days of use, in group A, 100% of participants reported mildness and comfort with product use. Participants demonstrated significant improvements in skin barrier function-related indicators, including increased stratum corneum moisture content, reduced erythema index, elevated sebum content, decreased trans-epidermal water loss, and diminished skin redness parameter a* value (all p < 0.05). Dermatologist evaluations revealed excellent tolerance among all participants. CONCLUSION: The panthenol-enriched cream with prebiotics and probiotic lysate exhibited substantial clinical efficacy in ameliorating facial sensitive skin conditions, coupled with a high safety profile.

Comprehensive assessment of the efficacy and safety of a clay mask in oily and acne skin.

BACKGROUND: Oily skin, characterized by excessive sebum production, can lead to acne and have psychosocial impacts due to changes in appearance. Recent research has shown interest in treatments for oil control, with kaolin and bentonite emerging as promising options. Despite their potential, comprehensive studies on these ingredients are still in the nascent stages. AIM: This study aimed to assess the efficacy of a clay mask (La Roche-Posay Effaclar Sebo-Controlling Mask) in reducing skin oiliness and acne, and its safety for use. METHODS: In this study, 75 adults with oily or combination skin were enrolled and provided with a clay mask for twice-weekly use over 4 weeks. Clinical assessments, using instruments like Sebumeter, Vapometer, and Corneometer, were conducted at baseline, and after 1, 2, and 4 weeks, evaluating acne lesions, skin irritation, sebum content, and skin hydration. Participant self-assessment questionnaires were also utilized for subjective evaluation. Statistical analyses were performed accordingly. RESULTS: The study revealed significant improvements in acne-related outcomes, sebum content, skin evenness, stratum corneum water content, and transepidermal water loss following the application of the clay mask. Pore area and porphyrin area showed no significant changes. Tolerance assessment showed reduced dryness and irritation, with self-assessment indicating high product acceptability and perceived oil control effectiveness. CONCLUSION: This study demonstrated the clay mask's efficacy in managing acne and oily skin, improving hydration and texture. Significant improvements in skin parameters and high product safety were observed, supporting its suitability.

Outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation: a prospective observational study.

PURPOSE: Descriptive information on referral patterns and short-term outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation (ECMO) is lacking. METHODS: We conducted a prospective single-centre observational cohort study of ECMO referrals to Toronto General Hospital (receiving hospital) for severe respiratory failure (COVID-19 and non-COVID-19), between 1 December 2019 and 30 November 2020. Data related to the referral, the referral decision, and reasons for refusal were collected. Reasons for refusal were grouped into three mutually exclusive categories selected a priori: "too sick now," "too sick before," and "not sick enough." In declined referrals, referring physicians were surveyed to collect patient outcome on day 7 after the referral. The primary study endpoints were referral outcome (accepted/declined) and patient outcome (alive/deceased). RESULTS: A total of 193 referrals were included; 73% were declined for transfer. Referral outcome was influenced by age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95 to 0.96; P < 0.01) and involvement of other members of the ECMO team in the discussion (OR, 4.42; 95% CI, 1.28 to 15.2; P < 0.01). Patient outcomes were missing in 46 (24%) referrals (inability to locate the referring physician or the referring physician being unable to recall the outcome). Using available data (95 declined and 52 accepted referrals; n = 147), survival to day 7 was 49% for declined referrals (35% for patients deemed "too sick now," 53% for "too sick before," 100% for "not sick enough," and 50% for reason for refusal not reported) and 98% for transferred patients. Sensitivity analysis setting missing outcomes to directional extreme values retained robustness of survival probabilities. CONCLUSION: Nearly half of the patients declined for ECMO consideration were alive on day 7. More information on patient trajectory and long-term outcomes in declined referrals is needed to refine selection criteria.

RéSUMé: OBJECTIF: On manque d'informations descriptives sur les schémas de références et les devenirs à court terme des patient·es atteint·es d'insuffisance respiratoire n'ayant pas pu recevoir une oxygénation par membrane extracorporelle (ECMO). MéTHODE: Nous avons réalisé une étude de cohorte observationnelle prospective monocentrique sur les références vers l'ECMO à l'Hôpital général de Toronto (hôpital d'accueil) pour insuffisance respiratoire grave (COVID-19 et non-COVID-19), entre le 1er décembre 2019 et le 30 novembre 2020. Les données relatives à la référence, à la décision de référence et aux motifs du refus ont été recueillies. Les motifs de refus ont été regroupés en trois catégories mutuellement exclusives sélectionnées a priori : « Trop malade maintenant ¼, « Trop malade avant ¼ et « Pas assez malade ¼. En ce qui concerne les références refusées, un sondage envoyé aux médecins traitant·es avait pour objectif de recueillir les devenirs des patient·es le jour 7 suivant la référence. Les critères d'évaluation principaux de l'étude étaient le résultat de la référence (accepté/refusé) et le devenir des patient·es (vivant·e/décédé·e). RéSULTATS: Au total, 193 références ont été incluses; le transfert a été refusé dans 73 % des cas. L'acceptation ou le refus de la référence était influencé par l'âge (rapport de cotes [RC], 0,97; intervalle de confiance [IC] à 95 %, 0,95 à 0,96; P < 0,01) et la participation d'autres membres de l'équipe ECMO à la discussion (RC, 4,42; IC 95 %, 1,28 à 15,2; P < 0,01). Les devenirs des patient·es étaient manquants pour 46 (24 %) des personnes référées (incapacité de localiser les médecins traitant·es ou incapacité des médecins de se souvenir du devenir). À l'aide des données disponibles (95 références refusées et 52 références acceptées; n = 147), la survie jusqu'au jour 7 était de 49 % pour les références refusées (35 % pour la patientèle jugée « trop malade maintenant ¼, 53 % pour celle « trop malade avant ¼, 100 % pour celle « pas assez malade ¼ et 50 % pour les cas où la raison du refus n'était pas déclarée) et 98 % pour les patient·es transféré·es. L'analyse de sensibilité établissant les résultats manquants à des valeurs extrêmes directionnelles a conservé la robustesse des probabilités de survie. CONCLUSION: Près de la moitié des patient·es pour lesquel·les un traitement sous ECMO a été refusé étaient en vie au jour 7. Davantage d'informations concernant la trajectoire et les devenirs à long terme des patient·es refusé·es sont nécessaires pour parfaire les critères de sélection.

Efficacy and safety of a facial serum and a mask containing salicylic acid and lipohydroxy acid in acne management: A randomized controlled trial.

BACKGROUND: Inflammatory and non-inflammatory acne lesions constitute a significant clinical challenge in acne subjects. AIM: To evaluate the efficacy and safety of a facial serum and a mask containing salicylic acid and lipohydroxy acid for improving skin conditions. METHODS: This randomized controlled trial included adults with comedones, post-inflammatory erythema (PIE) and/or hyperpigmentation (PIH) in Shanghai, China in July 2021. Participants were randomly assigned 1:1 to receive the study Serum + Mask or serum alone for 8 weeks. Acne severity, comedones, papules, pustules, PIE, PIH, skin pores, skin tone evenness, sebum secretion, skin hydration, and trans-epidermal water loss were evaluated at T0d, T1d, T7d, T14d, T28d, and T56d. RESULTS: Eighty-three participants were included, including 41 and 42 in the Serum + Mask and Serum groups, respectively. Acne severity, density of skin pores, skin tone evenness, PIH foci on face, PIE foci on nose, intensity of PIE and PIH, closed comedones on face, open comedones on nose, sebum secretion, and skin hydration were significantly improved from baseline after 8 weeks of treatment in both groups (all p < 0.05). Addition of the mask improved the number of closed comedones (-6.56 ± 0.39 vs. -5.19 ± 0.44, p = 0.022) and acne severity (-0.39 ± 0.08 vs. -0.12 ± 0.09, p = 0.026) substantially more than using the serum alone. No adverse reaction was reported in either group. CONCLUSIONS: The study serum improved skin conditions by regulating skin barrier function and achieving a balance of skin hydration and sebum secretion, removing comedones and improving PIE and PIH. Addition of the mask accelerated the effects without compromising safety.

Assessing the effect of cleansing products on artificially polluted human hairs and skin through in vivo and in vitro models.

OBJECTIVE: Based on in vivo data, in vitro models and new methods are created to mimic the impact of aerial pollution onto the hair surface and assess the efficacy of different formulae prototypes. MATERIAL AND METHODS: Two protocols are developed to mimic the pollution effect, in vitro, on purchased swatches, and in vivo, on scalps and forearms. First, with an artificial sebum mixed with Carbon Black particles, named "sebollution," we evaluated, through an instrumental color measurement, the cleansing efficacy of some shampoo on scalp and hair. The second protocol allowed to assess the interaction between hair care product deposit (shampoo, conditioner, mask, and leave-on) on hair and carbon black particles spread on fiber. The quantification of particle coverage allowed to evaluate the efficiency of a formula to limit the aerial pollution deposit on hair fiber. RESULTS: To simplify and accelerate the evaluation of 42 shampoo formulae, an extrapolation of the scalp cleaning process was validated on forearm. The respective cleanabilities were calculated and covered a large range of efficacy, from 5%, for a basic bland shampoo generally used to reset swatches, to a strong deep cleansing efficacy of 100%. On hair swatches, cleanability efficiencies of five shampoo were also evaluated to eliminate the deposited of sebollution, in a range of 40%-80%. To quantify the efficacy of preventing the deposition of carbon particle on hair surface, the percentage of coverage of 45 different products was measured, from 2% to 16%. The performance depended of the product category (shampoo, conditioner, mask, and leave-on), driven by the performance of the product deposit, and the capacity of this deposit to interact with aerial pollution. CONCLUSION: Three new protocols and evaluation methods are proposed to evaluate and quantify the performance of hair care product, to remove/clean, limit, and protect the hair fibers against the aerial pollution that could interact with hair, scalp and sebum. The validation of these approaches was done through the testing of a large panel of hair care product leading to a complete and sincere evaluation of cleansing and anti-deposit efficacy. Combining the knowledge acquired on pollution impact on hair and the development of specific way of evaluation, this work reinforced the rationale of using and developing new cosmetic products that reduced the impact of pollution upon some hair properties.

Organ donation in patients on extracorporeal membrane oxygenation: considerations for determination of death and withdrawal of life support.

The use of extracorporeal membrane oxygenation (ECMO) is increasing globally, although mortality in this setting remains high. Patients on ECMO may be potential organ donors in the context of withdrawal of life-sustaining measures (WLSM) or neurologic determination of death (NDD). Nevertheless, there are currently no Canadian standards to guide clinicians on NDD or WLSM for the purposes of organ donation in this patient population. Apnea testing remains fundamental to determining NDD and is an area where ECMO may alter routine procedures. In this review, we outline protocols for the performance of apnea testing and WLSM for patients supported with ECMO, highlighting important technical and physiologic considerations that may affect the determination of death. In addition, we review important considerations for NDD in ECMO, including management of potential confounders, strategies for controlling oxygen and carbon dioxide levels during apnea testing, and the appropriate use of ancillary tests to support NDD. In the context of ECMO support, there is limited evidence to guide NDD and WLSM for the purposes of organ donation. Drawing upon extensive clinical experience, we provide protocols for these processes and review other important considerations in an effort to maximize donor potential in this growing patient population.

RéSUMé: L'utilisation de l'oxygénation extracorporelle (ECMO) augmente dans le monde, malgré le fait que la mortalité associée demeure élevée. Les patients sous ECMO pourraient être des donneurs d'organes potentiels dans le cadre d'une interruption des mesures de maintien des fonctions vitales ou d'un diagnostic de décès neurologique (DDN). À l'heure actuelle il n'existe cependant aucune norme canadienne pour guider les cliniciens en matière de DDN ou d'interruption des mesures de maintien des fonctions vitales aux fins de dons d'organes dans cette population de patients. Le test d'apnée demeure fondamental pour poser un DDN mais il s'agit d'un domaine dans lequel l'ECMO pourrait modifier les interventions de routine. Dans ce compte rendu, nous décrivons des protocoles pour la réalisation d'un test d'apnée et l'interruption des mesures de maintien des fonctions vitales chez des patients sous ECMO. Nous soulignons certaines considérations techniques et physiologiques importantes qui pourraient avoir un impact sur le diagnostic de décès. En outre, nous passons en revue certaines considérations importantes pour le DDN sous ECMO, notamment la prise en charge de facteurs confondants potentiels, les stratégies pour contrôler les niveaux d'oxygène et de dioxyde de carbone pendant le test d'apnée, et l'utilisation adaptée de tests complémentaires pour appuyer le DDN. Dans le cadre d'un maintien des fonctions vitales sous ECMO, il n'existe que peu de données probantes pour guider le DDN et l'interruption des mesures de maintien des fonctions vitales aux fins d'un don d'organes. En nous fondant sur notre vaste expérience clinique, nous proposons des protocoles pour ces processus et passons en revue d'autres considérations importantes afin de maximiser le potentiel de dons dans cette population de patients grandissante.

Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth.

BACKGROUND: Although electronic cigarettes (e-cigarettes) were initially marketed as a potential smoking-cessation aid and a safer alternative to smoking, the long-term health effect of e-cigarette use ("vaping") is unknown. Vaping e-liquids expose the user to several potentially harmful chemicals, including diacetyl, a flavouring compound known to cause bronchiolitis obliterans with inhalational exposure ("popcorn worker's lung"). CASE DESCRIPTION: We report the case of a 17-year-old male who presented with intractable cough, progressive dyspnea and malaise after vaping flavoured e-liquids and tetrahydrocannabinol intensively. Initial physical examination showed fever, tachycardia, hypoxemia, and bibasilar inspiratory crackles on lung auscultation. Computed tomography of the chest showed diffuse centrilobular "tree-inbud" nodularity, consistent with acute bronchiolitis. Multiple cultures, including from 2 bronchoalveolar lavage samples, and biopsy stains, were negative for infection. He required intubation, invasive mechanical ventilation and venovenous extracorporeal membrane oxygenation (ECMO) for refractory hypercapnia. The patient's condition improved with high-dose corticosteroids. He was weaned off ECMO and mechanical ventilation, and discharged home after 47 days in hospital. Several months after hospital discharge, his exercise tolerance remained limited and pulmonary function tests showed persistent, fixed airflow obstruction with gas trapping. The patient's clinical picture was suggestive of possible bronchiolitis obliterans, thought to be secondary to inhalation of flavouring agents in the e-liquids, although the exact mechanism of injury and causative agent are unknown. INTERPRETATION: This case of severe acute bronchiolitis, causing near-fatal hypercapnic respiratory failure and chronic airflow obstruction in a previously healthy Canadian youth, may represent vaping-associated bronchiolitis obliterans. This novel pattern of pulmonary disease associated with vaping appears distinct from the type of alveolar injury predominantly reported in the recent outbreak of cases of vaping-associated pulmonary illness in the United States, underscoring the need for further research into all potentially toxic components of e-liquids and tighter regulation of e-cigarettes.

The Sedative Effect of Propranolol on Critically Ill Patients: A Case Series.

INTRODUCTION: Recent studies have examined the effectiveness of alpha-2 adrenergic agonists for controlling delirium and agitation. Propranolol, a non-selective beta-adrenergic antagonist with good penetration of the blood-brain barrier, has not been investigated for this purpose. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who were prescribed propranolol in our Medical Surgical ICU from January 1, 2010, to December 31, 2013. We recorded the sedation level and daily dose of sedatives, analgesics, and antipsychotics administered each day for 6 days after starting propranolol, and compared them to the day before starting propranolol. RESULTS: Sixty-four patients met inclusion criteria. Thirty-eight episodes met exclusion criteria, leaving 27 patients (31 episodes). The administration of propranolol was associated with significant reductions in fentanyl equivalents (65%, p = 0.009), midazolam equivalents (57%, p = 0.048), propofol (16%, p = 0.009), and haloperidol (44%, p = 0.024) on day 2 after starting propranolol compared with baseline. A stratified analysis showed that these decreases were seen regardless of clinical improvement or deterioration. CONCLUSION: The use of propranolol was associated with a significant reduction in doses of sedatives and analgesia. Further studies are needed to determine whether propranolol may be a useful adjuvant for managing delirium and agitation in the ICU.

Safety and Efficacy of Volatile Anesthetic Agents Compared With Standard Intravenous Midazolam/Propofol Sedation in Ventilated Critical Care Patients: A Meta-analysis and Systematic Review of Prospective Trials.

BACKGROUND: Inhalation agents are being used in place of intravenous agents to provide sedation in some intensive care units. We performed a systematic review and meta-analysis of prospective randomized controlled trials, which compared the use of volatile agents versus intravenous midazolam or propofol in critical care units. METHODS: A search was conducted using MEDLINE (1946-2015), EMBASE (1947-2015), Web of Science index (1900-2015), and Cochrane Central Register of Controlled Trials. Eligible studies included randomized controlled trials comparing inhaled volatile (desflurane, sevoflurane, and isoflurane) sedation to intravenous midazolam or propofol. Primary outcome assessed the effect of volatile-based sedation on extubation times (time between discontinuing sedation and tracheal extubation). Secondary outcomes included time to obey verbal commands, proportion of time spent in target sedation, nausea and vomiting, mortality, length of intensive care unit, and length of hospital stay. Heterogeneity was assessed using the I statistic. Outcomes were assessed using a random or fixed-effects model depending on heterogeneity. RESULTS: Eight trials with 523 patients comparing all volatile agents with intravenous midazolam or propofol showed a reduction in extubation times using volatile agents (difference in means, -52.7 minutes; 95% confidence interval [CI], -75.1 to -30.3; P < .00001). Reductions in extubation time were greater when comparing volatiles with midazolam (difference in means, -292.2 minutes; 95% CI, -384.4 to -200.1; P < .00001) than propofol (difference in means, -29.1 minutes; 95% CI, -46.7 to -11.4; P = .001). There was no significant difference in time to obey verbal commands, proportion of time spent in target sedation, adverse events, death, or length of hospital stay. CONCLUSIONS: Volatile-based sedation demonstrates a reduction in time to extubation, with no increase in short-term adverse outcomes. Marked study heterogeneity was present, and the results show marked positive publication bias. However, a reduction in extubation time was still evident after statistical correction of publication bias. Larger clinical trials are needed to further evaluate the role of these agents as sedatives for critically ill patients.

'Hidden risks' in legacy buildings.

Andrew Steel, managing director of air hygiene and water treatment specialist, Airmec, considers some of the key priorities for estates and facilities teams managing older healthcare estates to ensure that both the buildings, and the plant and equipment within them, are maintained in a safe, fit-for-purpose condition. He stresses the need both for accurate and proper risk assessment--particularly when 'legacy' buildings have been regularly adapted, updated, or refurbished over time, and, equally, to maintain up-to-date and comprehensive asset registers.

The use of volatile anesthetic agents for long-term critical care sedation (VALTS): study protocol for a pilot randomized controlled trial.

BACKGROUND: Sedatives are administered to 85% of intensive care unit (ICU) patients. The most commonly used sedatives are intravenous benzodiazepines and propofol. These agents are associated with over-sedation in 40 to 60% of patients, which can lead to prolonged intubation, delirium and drug-induced hypotension. Evidence is increasing that volatile anesthetic agents are associated with faster extubation times, improved cardiovascular stability with no end-organ toxicity in comparison to our standard intravenous agents for short-term critical care sedation. Use of volatile agents within the ICU is a novel technique using a specialized delivery and scavenging system, which requires staff training and cultural acceptance. This pilot randomized controlled trial aims to assess the safety and feasibility of delivering volatile agents for long-term patient sedation in the ICU with limited or no experience of this technique. METHODS/DESIGN: This is a prospective multicenter pragmatic pilot RCT that is blinded to the data analyst. This study aims to recruit 60 adult ICU patients requiring mechanical ventilation and sedation for more than 48 h. Patients will be randomized 2:1 to receive inhaled isoflurane (40 patients) or intravenous midazolam and/or propofol (20 patients) sedation. Sedation is titrated to a targeted Sedation Analgesia Score (SAS) using an explicit sedation-analgesia algorithm until extubation or tracheostomy. Primary safety and feasibility outcomes will assess atmospheric volatile concentration levels and adherence to our sedation-analgesia protocol. Secondary outcomes include time to extubation, duration of ventilation, quality of sedation, delirium, vasoactive drug support, length of stay, serum fluoride levels and mortality. DISCUSSION: This pilot project will serve as the basis for a larger RCT that will be powered for important clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01983800 (registration date 2 July 2013).

Partial liquid ventilation for preventing death and morbidity in adults with acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are syndromes of severe respiratory failure that are associated with substantial mortality and morbidity. Artifical ventilatory support is commonly required and may exacerbate lung injury. Partial liquid ventilation (PLV) has been proposed as a less injurious form of ventilatory support for these patients. Although PLV has been shown to improve gas exchange and to reduce inflammation in experimental models of ALI, a previous systematic review did not find any evidence to support or refute its use in humans with ALI and ARDS. OBJECTIVES: The primary objective of this review was to assess whether PLV reduced mortality (at 28 d, at discharge from the intensive care unit (ICU), at discharge from hospital and at one, two and five years) in adults with ALI or ARDS when compared with conventional ventilatory support.Secondary objectives were to determine how PLV compared with conventional ventilation with regard to duration of invasive mechanical ventilation, duration of respiratory support, duration of oxygen therapy, length of ICU stay, length of hospital stay, incidence of infection, long-term cognitive impairment, long-term health related quality of life, long- term lung function, long-term morbidity costs and adverse events. The following adverse events were considered: hypoxia (arterial PO2 <80 mm Hg), pneumothorax (any air leak into the pleural space requiring therapeutic intervention), hypotension (systolic blood pressure < 90 mm Hg sustained for longer than two minutes or requiring treatment with fluids or vasoactive drugs), bradycardia (heart rate < 50 beats per minute sustained for longer than one minute or requiring therapeutic intervention) and cardiac arrest (absence of effective cardiac output). SEARCH METHODS: In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL Issue 10, 2012, in The Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2012); EMBASE (Ovid SP, 1980 to November 2012) and CINAHL (EBSCOhost,1982 to November 2012) for published studies. In our original review, we searched until May 2004.Grey literature was identified by searching conference proceedings and trial registries and by contacting experts in the field. SELECTION CRITERIA: As in the original review, review authors selected randomized controlled trials that compared PLV with other forms of ventilation in adults (16 y of age or older) with ALI or ARDS, reporting one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit or stay in hospital; infection; long-term cognitive impairment or health-related quality of life; long-term lung function or cost. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated the quality of the relevant studies and extracted the data from included studies. MAIN RESULTS: In this updated review, one new eligible study was identified and included, yielding a total of two eligible studies (including a combined total of 401 participants). Of those 401 participants, 170 received 'high'-dose partial liquid ventilation (i.e. a mean dose of at least 20 mL/kg), 99 received 'low-dose' partial liquid ventilation (i.e. a dose of 10 mL/kg) and 132 received conventional mechanical ventilation (CMV). Pooled estimates of effect were calculated for all those who received 'high'-dose PLV versus conventional ventilation. No evidence indicated that 'high'-dose PLV either reduced mortality at 28 d (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.79 to 1.85, P = 0.37) or increased the number of days free of CMV at 28 d (mean difference (MD) -2.24, 95% CI -4.71 to 0.23, P = 0.08). The pooled estimate of effect for bradycardia in those who received PLV was significantly greater than in those who received CMV (RR 2.51, 95% CI 1.31 to 4.81, P = 0.005). Pooled estimates of effect for the following adverse events- hypoxia, pneumothorax, hypotension and cardiac arrest- all showed a nonsignificant trend towards a higher occurrence of these events in those treated with PLV. Because neither eligible study addressed morbidity or mortality beyond 28 d, it was not possible to determine the effect of PLV on these outcomes. AUTHORS' CONCLUSIONS: No evidence supports the use of PLV in ALI or ARDS; some evidence suggests an increased risk of adverse events associated with its use.

Be prepared should Legionella strike.

When measures to prevent Legionella fail, and a positive result is returned from the laboratory, there is an imperative to act fast to stamp infection out, but taking the right action requires a rigorous approach. So says Andrew Steel, managing director of Airmec, a provider of essential air and water services solutions. Here he explains the legal and other obligations of health estates managers in taking all possible steps to prevent a Legionella outbreak, and, when they do face one, sets out the key remedial steps, and outlines what regulators or HSE personnel will expect to see as 'evidence' that sufficient 'duty of care' has been taken.

Changes in end of life care 5 years after the introduction of a rapid response team: a multicentre retrospective study.

RATIONALE: Rapid response teams (RRTs) are intended to stabilize deteriorating patients on the ward, but recent studies suggest that RRTs may also improve end-of-life care (EOLC). We sought to study the effect of introducing an RRT on EOLC at our institutions, and compare the EOLC care received by patients who were consulted by the RRT with that of patients who were not consulted by the RRT. METHODS: Retrospective review of 450 consecutive deaths at 3 institutions. We compared demographic factors and EOLC received before (2005) and 5 years after (2010) the introduction of an RRT. We also compared these same factors for patients who died in 2010 with and without RRT consultation. RESULTS: There were no differences in the proportion of patients who had Patient/Family Conferences or orders to limit life support on the ward between 2005 and 2010. Although the RRT was consulted for 30% of patients eligible to be seen by the RRT, the RRT was involved in only 11.1% of Patient/Family Conferences that took place on the ward. The prevalence of palliative care consultation and orders for opioids as needed was higher in 2010 than 2005, but those seen by the RRT were less likely to receive a palliative care consultation (30.2% vs. 55.9%), spiritual care consultation (25.4% vs. 41.3%) or an order for sedatives as needed (44.4% vs. 65.0%) than those who were not seen by the RRT. There was no change in the proportion of patients admitted to the ICU in 2010 compared with 2005, and multivariable logistic regression showed that the year of death did not influence the likelihood of ICU admission based on any comorbid or demographic factors. CONCLUSIONS: The introduction of an RRT was not associated with significant improvements in EOLC at our institutions. However, almost 1/3 of dying patients were consulted by the RRT, suggesting that the RRT could play a role in facilitating improved EOLC for some inpatients.

Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: a multicentre retrospective study.

PURPOSE: Rapid response teams (RRTs) were created to stabilize acutely ill patients on the ward, but recent studies suggest that RRTs may improve end-of-life care (EOLC). To learn more about the role of the RRT in EOLC at our institutions, we conducted a retrospective review. METHODS: Retrospective review of 300 RRT consultations at 3 academic hospitals in Toronto, Canada. RESULTS: The typical consultation was for an elderly patient with chronic illness. More than 90% had a "full resuscitation" order at the time of consultation. One third were admitted to the intensive care unit within 48 hours of the RRT consultation, and 24.7% ultimately died. Twenty-seven (9.3%) had a patient/family conference on the ward within 48h of the RRT consultation, 24 (8.3%) of whom changed their resuscitation order as a result. Among those who changed their resuscitation order, fewer than 20% were referred to the palliative care or spiritual care service, or prescribed comfort medications as needed (pro re nata), within 48 h of the RRT consultation; 2 patients died without receiving any common EOLC orders, and 15 (63%) died before discharge. CONCLUSIONS: RRT consultation is an important milestone for many patients approaching EOL. RRTs frequently participate in EOL discussions and decision-making, but they may miss opportunities to facilitate EOLC.

The pathophysiology of perioperative lung injury.

The degree of perioperative lung injury that patients sustain results from a complex interaction between their current physiologic state, comorbidities, lifestyle choices, underlying surgical diagnosis, operative, and ultimately their cardiopulmonary interaction with a mechanical ventilator. This review addresses primarily the pathophysiology of perioperative lung injury with reference to ventilator-induced lung injury and acute respiratory distress syndrome.

Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients.

PURPOSE: Postoperative myocardial infarction causes hundreds of thousands of deaths annually, and "failure to rescue" is a leading cause of hospital mortality. Strategies to recognize cardiac injury are important to reduce the burden of cardiac-related morbidity. For these reasons, we chose to assess the association between postoperative troponin I elevations and 30-day in-hospital mortality and, secondarily, to compare the predictive value of regularly scheduled troponin estimates with troponin ordered in response to clinical indications. METHODS: We carried out a retrospective cohort analysis of 51,701 consecutive patients throughout 2003 to 2009. All patients were from a single university referral hospital and included all non-cardiac non-transplant surgery patients requiring overnight admission. Logistic regression was used to assess the risk-adjusted associations between troponin I and 30-day in-hospital mortality. RESULTS: The multivariable predictive model for death improved after troponin I was included. The receiver operating characteristic was 0.902 before troponin I vs 0.934 after troponin I (P<0.0001). The likelihood ratio for troponin was 3.0 (95% confidence interval 2.8 to 3.2) and evident in each surgical service. Increasing troponin I showed a dose-response associated with increased mortality, and compared with clinically based measurements, a regularly scheduled postoperative troponin protocol showed a threefold increase in the probability of detecting myocardial injury. However, troponin I was not found to improve the risk prediction model in the lowest risk patients (n=18,953; probability of death<0.02%) with one cardiac death. CONCLUSIONS: Postoperatively elevated troponin I is associated with 30-day in-hospital mortality in a dose-dependent manner. A postoperative measurement protocol provides a threefold increase in the ability to detect myocardial injury. Conversely, in patients with a low mortality risk, cardiac injury is low; there is minimal improvement in the ability to detect cardiac injury, and the rescue rates from cardiac injury are excellent. These findings suggest that a surveillance protocol of troponin I would be optimal when limited to moderate to high-risk patients.

Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways.

Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type of surgeries. The aim of this article was to identify and discuss potential advantages offerred by regional anesthesia and analgesia techniques to fast-track programs.In the first section, the impact of regional anesthesia on the main elements of fast-track surgery is addressed. In the second section, procedure-specific fast-track programs for colorectal, hernia, esophageal, cardiac, vascular, and orthopedic surgeries are presented. For each, regional anesthesia and analgesia techniques more frequently used are discussed. Furthermore, clinical studies, which included regional techniques as elements of fast-track methodologies, were identified. The impact of epidural and paravertebral blockade, spinal analgesia, peripheral nerve blocks, and new regional anesthesia techniques on main procedure-specific postoperative outcomes is discussed. Finally, in the last section, implementations required to improve the role of regional anesthesia in the context of fast-track programs are suggested, and issues not yet addressed are presented.