Egg cases of the graytail skate Bathyraja griseocauda and the cuphead skate Bathyraja scaphiops from the south-west Atlantic Ocean.

Egg cases of Bathyraja griseocauda were larger (140-142 mm in length) than those of Bathyraja scaphiops (88-90 mm in length) and their surface was relatively smooth, without denticles, prickles or any ornamentation. Egg cases of B. scaphiops had a relative coarse surface, covered with prickles of similar size. An identification key for the all described egg cases from Bathyraja occurring in the south-west Atlantic Ocean is provided.

The Bonfils fiberscope: a clinical evaluation of its learning curve and efficacy in difficult airway management.

BACKGROUND: This study evaluated the use of the Bonfils fiberscope by analyzing its learning curve, efficacy and safety during airway management. METHODS: This was a prospective observational study where five anesthetists, with differing levels of experience, were asked to use the Bonfils rigid fiberscope (Karl Storz) for a six-month period. They used the scope when performing endotracheal intubations in patients undergoing general anesthesia. The patients were excluded if various clinical indicators predicted that they might be difficult to intubate. The patient's head was kept in the neutral position to simulate the intubation of a trauma patient. Direct laryngoscopy with a Macintosh blade was performed to assign a Cormack and Lehane grade prior to attempting laryngoscopy with the Bonfils fiberscope. After intubating the patient with the Bonfils fiberscope, intubation time and any complications or failures noted after the procedure were recorded. RESULTS: The study included 216 patients, three of which were failed intubations. No complications occurred during the study period. The median intubation time was 21.4 s. The learning curve improved significantly after 20 intubations (P<0.05) and was affected by the operator's experience and aptitude with endoscopic viewing. Seventeen patients were deemed to have "unpredicted" difficult airways: 15 subjects with a Cormack grade 3 (6.9%) and two subjects with a Cormack 4 (0.9%). Median time to intubation in subjects with a Cormack <3 was 16 s (95% CI=10-29 s), and in subjects with a Cormack ≥3, it was 15 s (CI 95%=15-18 s) with P=0.703. CONCLUSION: The Bonfils fiberscope is an efficient, easy to use and safe device for endotracheal intubation.

Prospective multicenter study on epidemiology of acute kidney injury in the ICU: a critical care nephrology Italian collaborative effort (NEFROINT).

Acute kidney injury (AKI) is an independent risk factor for mortality in critically ill patients whose epidemiology has been made unclear in the past by the use of different definitions across various studies. The RIFLE consensus definition has provided a unifying definition for AKI leading to large retrospective studies in different countries. The present study is a prospective observational multicenter study designed to prospectively evaluate all incident admissions in 10 Intensive Care Units (ICUs) in Italy and the relevant epidemiology of AKI. A simple user-friendly web-based data collection tool was created with the scope to serve for this study and to facilitate future multicenter collaborative efforts. We enrolled 601 consecutive patients into the study; 25 patients with End-Stage Renal Disease were excluded leaving 576 patients for analysis. The median age was 66 (IQR 53-76) years, 59.4% were male, while median SAPS II and APACHE II scores were 43 (IQR 35-54) and 18 (IQR 13-24), respectively. The most common diagnostic categories for ICU admission were: respiratory (27.4%), followed by neurologic (17%), trauma (14.4%), and cardiovascular (12.1%). Crude ICU and hospital mortality were 21.7% and median ICU length of stay was 5 days (IQR 3, 14). Of 576 patients, 246 patients (42.7%) had AKI within 24 hours of ICU admission while 133 developed new AKI later during their ICU stay. RIFLE-initial class was Risk in 205 patients (54.1%), Injury in 99 (26.1%) and Failure in 75 (19.8%). Progression of AKI to a worse RIFLE class was seen in 114 patients (30.8% of AKI patients). AKI patients were older, with higher frequency of common risk factors. 116 AKI patients (30.6%) fulfilled criteria for sepsis during their ICU stay, compared to 33 (16.7%) of non-AKI patients (P<0.001). 48 patients (8.3%) were treated with renal replacement therapy (RRT) in the ICU. Patients were started on RRT a median of 2 (IQR 0-6) days after ICU admission. Among AKI patients, they were started on RRT a median of 1 (IQR 0-4) days after fulfilling criteria for AKI. Median duration of RRT was 5 (IQR 2-10) day. AKI patients had a higher crude ICU mortality (28.8% vs. non-AKI 8.1%, P<0.001) and longer ICU length of stay (median 7 days vs. 3 days [non-AKI], P<0.001). Crude ICU mortality and ICU length of stay increased with greater severity of AKI. Two hundred twenty five patients (59.4% of AKI patients) had complete recovery of renal function, with a SCr at time of ICU discharge which was ≤120% of baseline; an additional 51 AKI patients (13.5%) had partial renal recovery, while 103 (27.2%) had not recovered renal function at the time of death or ICU discharge. Septic patients had more severe AKI, and were more likely to receive RRT with less frequency of renal function recovery. Patients with sepsis had higher ICU mortality and longer ICU stay. The study confirms previous analyses describing RIFLE as an optimal classification system to stage AKI severity. AKI is indeed a deadly complication for ICU patients where the level of severity correlated with mortality and length of stay. The tool developed for data collection resulted user friendly and easy to implement. Some of its features including a RIFLE class alert system, may help the treating physician to collect systematically AKI data in the ICU and possibly may guide specific decision on the institution of renal replacement therapy.

The ability of PiCCO versus LiDCO variables to detect changes in cardiac index: a prospective clinical study.

BACKGROUND: Both PiCCO and LiDCO can provide dynamic preload parameters, pulse pressure variation (PPV) and stroke volume variation (SVV). The PiCCO device also provides a measure of intrathoracic blood volume index (ITBVI). We investigated the agreement between SVV and PPV, as well as the reliability of LiDCO- and PiCCO-measured SVV, PPV and ITBVI, in detecting fluid responsiveness before and after fluid challenge (FC). METHODS: We performed a prospective clinical study in University Hospital ICU. Nine adult ICU patients with cardiovascular instability were enrolled in the study. All patients were sedated and mechanically ventilated with intermittent positive pressure ventilation. The PiCCO and LiDCO systems were both connected to each patient. The PiCCO pulse waveform system was joined by a 5-French (Fr) thermistor-tipped arterial catheter inserted into the femoral artery. LiDCO measurements were performed through radial artery pulse contour analysis. Fluid challenge was performed using a rapid infusion of 7 mL/kg of 6% hydroxyethylstarch over 30 min. RESULTS: Measurements of CI, ITBVI, SVV, and PVV were made using both techniques before and after FC. Pre-FC cardiac index (CI) measurements were similar with both devices, although the reading was higher after FC with the PiCCO device (P<0.001). The correlation coefficient between PiCCO-CI and LiDCO-CI was 0.85 (95% CI: 0.69 to 0.93; P<0.001); for P-PPV and L-PPV, it was 0.74 (95% CI: 0.49 to 0.88; P<0.001). Only ITBV had a significant correlation with LiDCO-CI or PiCCO-CI. CONCLUSION: We found a narrow bias but less accurate precision in cardiac index values measured by a radial artery-site LiDCO catheter and a femoral artery-site PiCCO catheter, with poor agreement between radial and femoral-derived SVV and PPV measurements. ITBVI proved to be the best predictor of fluid responsiveness. The SVV does not seem to be reliable for preload optimization in ICU patients.

Successful early voriconazole treatment of Aspergillus infection in two non immunocompromised patients in Intensive Care Unit.

We report two cases of respiratory Aspergillus infection that occurred in patients admitted to the Intensive Care Unit of a teaching hospital during renovation works and treated with new triazole voriconazole (Vfend). The first patient was affected with cerebral hemorrhage, the second with polytrauma and both developed Aspergillus Pneumonia during their ICU stay. Bronchoalveolar lavage, dosage with anti-Aspergillus antibodies, antigen measurements and galactomannan research with Sanofi Platelia were performed. Therapy was carried out with voriconazole for 12 days. Chest X-ray and laboratory tests showed complete resolution after 12 days of therapy; clinical symptoms were negative after 4 days. Aspergillus infection can be observed frequently in non-immunocompromised patients during ward renovation or in hospitals near building areas. Since treatment is often unsuccessful, we preferred to immediately employ new agents to reduce the impact of this disease.

Correlation between hyperglycemia and mortality in a medical and surgical intensive care unit.

AIM: The aim of this study was to assess the correlation between hyperglycemia and mortality in a group of patients admitted to a medical and surgical ICU and to evaluate if the association between hyperglycemia and reason of ICU admission significantly worsens patients' outcomes. METHODS: A retrospective clinical study was conducted in the ICU of a University Hospital. Four-hundred and twelve adult patients admitted to our ICU were enrolled. The blood glucose level was measured at the time of admission and daily at 2-4 h intervals. When the glucose level exceeded 180 mg/dL, an insulin bolus or a continuous infusion were performed to maintain the glucose level at or below 180-200 mg/dL. RESULTS: Analysing the mean blood glucose levels of patients with the receiver operating characteristic (ROC) curve, it resulted that the blood glucose level of 141.7 mg/dL had higher sensitivity (76%) and specificity (56.5%) to discriminate the probability of death. In other words, in patients in whom the mean blood glucose levels were greater than 141.7 mg/dL, the probability of death was higher (26.62%) than in the group of patients in whom a strict blood glucose control was maintained (13.55%) (P = 0.0017). CONCLUSIONS: A strict blood glucose control seems to be crucial, even in a medical and surgical ICU. The need for intensive insulin therapy, even by means of continuous infusion of insulin, to obtain the normalization of blood glucose levels, appears essential.

A new and feasible model for predicting operative risk.

BACKGROUND: Although the POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) score can be used to calculate operative risk, its complexity makes its use unfeasible in the immediate clinical setting. The aim of this study was to create a new model, based on ASA status, to predict mortality. METHODS: Data were collected in two hospitals. All types of surgery were included except for cardiac surgery and Caesarean delivery. Age, sex and preoperative information, including the presence of cardiocirculatory and/or lung disease, renal failure, diabetes mellitus, hepatic disease, cancer, Glasgow Coma Score, ASA grade, surgical diagnosis, severity of the procedure and type of surgery (elective, urgent or emergency), were recorded for each patient. The model was developed using a data set incorporating data from 1936 surgical patients, and validated using data from a further 1849 patients. Forward stepwise logistic regression was used to build the model. Goodness of fit was examined using the Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve analyses were performed on both data sets to test calibration and discrimination. In the validation data set, the new model was compared with POSSUM and P-POSSUM for both calibration and discrimination, and with ASA alone to compare discrimination. RESULTS: The following variables were included in the new model: ASA status, age, type of surgery (elective, urgent, emergency) and degree of surgery (minor, moderate or major). Calibration and discrimination of the new model were good in both development and validation data sets. This new model was better calibrated in the validation data set (Hosmer-Lemeshow goodness-of-fit test: chi(2)=6.8017, P=0.7440) than either P-POSSUM (chi(2)=14.4643, P=0.1528) or POSSUM, which was not calibrated (chi(2)=31.8147, P=0.0004). POSSUM and P-POSSUM had better discrimination than the new model, although this was not statistically significant. Comparing the two ROC curves, the new model had better discrimination than ASA alone (difference between areas, 0.077, SE 0.034, 95% confidence interval 0.012-0.143, P=0.021). CONCLUSIONS: This new, ASA status-based model is simple to use and can be performed routinely in the operating room to predict operative risk for both elective and emergency surgery.

To verify four 5-year-old mathematical models to predict the outcome of ICU patients.

AIM: The aim of this study is to verify calibration and discrimination after 5 years in the case mix of patients admitted to the Intensive Care Unit (ICU) during the year 2000. In this way we want to perform a quality control of our ICU in order to justify the increased amount of money spent for intensive care. METHODS: A prospective study has been made on the 357 patients admitted to the ICU during the year 2000. The Apache II score was calculated within the first 24 hours and, depending on the length of stay in the ICU, on the 5(th), 10(th) and 15(th) day after ICU admission. On the basis of the 4 mathematical models death risk has been calculated for each of the 4 times. The Hosmer-Lemeshow test was performed for calibration and ROC curves for discrimination, always for each of the 4 mathematical models. RESULTS: The 1(st) model, at 24 hours from ICU admission, showed a bad calibration (p=0.000088), while the ROC curve was 0.744+/-0.32. Also the 2(nd) model, at the 5(th) day from admission, showed a bad calibration (p=0.000588), with ROC curve of 0.827+/-0.04. The 3(rd) model (10(th) day), was well calibrated (p=0.112247) and discriminating (ROC=0.888 +/-0.04). Finally the models at 15 days showed again a bad calibration (p=0.001422) but a very good discrimination (area=0.906+/-0.06). CONCLUSION: Developing mathematical models to predict mortality within ICUs can be useful to assess quality of care, even if these models should not be the only ICU quality controls, but must be accompanied by other indicators, looking at quality of life of the patients after ICU discharge.

[Mathematical model for the predictive value of a test in critically ill patients studies according to APACHE II score and pathology at admission]. / Modello matematico per la predizione dell'esito nei pazienti degenti in terapia intensiva articolato sul trend dell'APACHE II score e sulla patologia causa del ricovero.

OBJECTIVE: To find a predictive model for mortality at four different days from the admission for critically ill patients. DESIGN: Retrospective study on two consecutive series of critically ill patients admitted in ICU. SUBJECTS: 1254 critically ill patients, subdivided into two series of 813 (561 survivors and 252 non survivors) and 441 patients (291 survivors and 150 non survivors), respectively. INTERVENTIONS: None. MEASUREMENTS: All patients had APACHE II calculated within the first 24 hours from the admission in ICU and, if the patient was still in ICU, also at the 5th, 10th and 15th day from the admission. Casistics was subdivided into two unequal series, ratio 2:1, with a random selection made on each of the 6 considered years. On the 1st series, in 1st, 5th, 10th and 15th day, for mathematical predictive models were made, using stepwise logistic regression (BMDP, Los Angeles). In the 1st day the following independent variables were utilized: APACHE II score, the specific diagnosis at admission, fitted following Knaus' diagnostic criteria, united in 6 principal categories, while for the other 3 days the variation % of APACE II score as regards the previous day. RESULTS: For each of the considered day four mathematical models have been made. These models have been validated in both series in calibration from the Hosmer-Lemeshow Goodness-of-fit test and in discrimination from the ROC curves. For each day Y (Prob.% to die) = eLogit/1 + eLogit, where Logit = beta 0 (constant) + beta 1*APACHE II + beta 2*Variat.%APACE II (difference between actual APACHE II - APACHE II of the previous day/actual APACHE II) + beta k, (coefficient pertinent to pathology). CONCLUSIONS: The mathematical model, as other models do, stratifies enough the casistics according to the risk of death. Waiting for further studies to make more precise prognostic mathematical models, this one and others can help the clinical assessment in single patient evaluation.

[Functional urination disorders in patients recovering in an intensive care unit for more than 30 days]. / I disturbi funzionali della minzione in pazienti ricoverati in unità di terapia intensiva (ICU) per più di 30 giorni.

Patients in rest-homes, intensive care units, long hospitalization and dialysis and whoever stays in a hospital continuously or occasionally for long periods of time may run into the well-known and typical complications of prolonged hospitalization. We have studied the urologic aspect in all the cases of the Medical- Surgical Emergency Institute in the Hospital of Ancona (seated in Torrette), over the period 1990-96, in patients hospitalized for at least 30 days. All the patients were followed and studied with the same method, though taking into account their different pathological conditions. They were treated by the same medical and paramedical staff. The same antibiotic therapy and the same checkup were adopted for all of them. We have noticed that out of 122 patients the most frequent pathologies have been urinary infections (19%); while sepsis with different pathogenesis was recorded in 4% of the patients. The method of study applied during and after the hospitalization was used also in rehabilitation centres and included: urologic examination, rectal touch (in men), direct X-ray of the abdomen, ultrasound of the urinary tract, X-ray urography, if required; moreover urodynamic examination, MRI of encephalon and spinal marrow in patients with neurological lesions. The catheter was removed in all the patients and none of the following conditions were observed: vesical lithiasis, abscesses, fistulae in penoscrotal angle, urethrostenosis, injuries to renal emunctory. In conclusion we believe that the functional symptoms of minction--be they of obstructive or irritable nature--are not existent and that the urologic prognosis in long term patients in excellent, provided that prophylaxis is carried on against hospital urinary infections as their occurrence is very frequent and therapy is expensive. It can also be stated the patient hospitalized in ICU will not present damages to the urinary tract, even if he/she has been hospitalized because of injuries to the urinary tract, provided that the urologic tutoring, together with the action of the physician handling the Emergency, follow the rules for asepsis, the best biocompatible materials are use, infections are monitored, the extensions of cerebrospinal injuries are examined and therapeutic axioms, such as barren and clean intermittent catheterism, are finally adopted.