Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death.

To assess and compare all current computed tomography angiography (CTA) scoring systems for the diagnostic workup of brain death (BD) to digital subtraction angiography (DSA) and clinical tests. Fifty-two patients with a clinical suspicion of BD underwent CTA and subsequently DSA. The diagnostic performance of all current CTA scoring systems was compared to that of DSA, in all patients with a suspicion of BD. A comparison to clinical tests was made only in DSA-positive for BD patients (n = 49), since in DSA-negative BD patients (n = 3) clinical tests were not performed. Further subgroup analysis was performed in relation to skull defects (SDs) stratification. Statistical analysis was conducted by applying statistics-contingency tables, Cochran's-Q test and McNemar's test. The CTA -10, and -7- and all 4-point scoring systems, showed overall sensitivities of 81,6%, 87.8% and 95.9% respectively and 100% specificity, when compared to DSA. In patients with a clinical verification of BD, the CTA -10 and -7-point scoring systems were significantly inferior to clinical tests (p = 0.004 and p = 0.031), while the 4-point scoring systems showed no such difference (p = 0.5). All 4-point scoring systems showed 100% sensitivity in patients with a minor SD or no SD. In patients with a major SD, all CTA scoring systems (- 10, - 7- and all 4-point) were less sensitive (62.5%, 62.5% and 75% respectively). The presence of a major SD was associated with an 8 × relative risk for false negative results in all 4-point scoring systems. CTA showed excellent diagnostic performance in patients with a suspicion of BD. The 4-point CTA scoring systems are the most sensitive for the diagnosis of BD, although in patients with a major SD patient, the role of CTA is ambiguous.

Differences in brand versus generic esmolol in the treatment of perioperative supraventricular tachycardia and hypertension: A pilot study.

BACKGROUND: Once a patent expires, generic analogue drugs are alternatives to brand name drugs. Because bioequivalence/biodistribution problems have been reported for many generic analogue drugs, we prospectively evaluated 31 patients to reveal the differences in the doses used and the efficacy and adverse events of two different intravenous esmolol formulations. METHODS: This was a prospective observational pilot study. Our aim was to reveal the possible differences in the required doses between two different formulations (brand name drug vs generic analogue drug) of intravenous esmolol in beats per minute, systolic blood pressure, diastolic blood pressure and mean arterial pressure in intra- and postoperative patients with supraventricular tachycardia and hypertension. The patients were categorised into two groups according to the medication they received (brand name drug or generic analogue drug). RESULTS: Esmolol was given to 31 patients (16 generic analogue drug and 15 brand name drug). Although there was a statistically significant difference in bolus (mg/kg) and continued (mg/kg/h) drug dose used (brand name drug/generic analogue drug, mean (standard deviation), 0.3 (0.1) vs 0.38 (0.1), p = 0.03 for bolus dose, and 0.22 (0.09) vs 0.29 (0.08) for continued dose at 10 min (p = 0.03), 0.19 (0.06) vs 0.24 (0.05) at 20 min (p = 0.01) and 0.14 (0.05) vs 0.18 (0.05) at 30 min (p = 0.02)), there were no time-related statistical significant differences in the reduction rates of the two drugs (p = 0.47). There were no time-related statistically significant differences between the two groups in systolic blood pressure, diastolic blood pressure, mean arterial pressure and beats per minute, nor in their adverse events. CONCLUSION: In this pilot study, smaller doses were given for controlling the patient's haemodynamics when a brand name drug was used. Because there were no significant time-related differences in the reduction rates of the two drugs nor in any haemodynamic differences between the two groups, optimal titration of the drug used could effectively control the patient's haemodynamics. The adverse events were also similar in both groups.

Molecular epidemiology and risk factors for colistin- or tigecycline-resistant carbapenemase-producing Klebsiella pneumoniae bloodstream infection in critically ill patients during a 7-year period.

A matched 1:2 case-control study was conducted among critically ill patients in order to identify the risk factors of colistin or tigecycline-resistant carbapenemase-producing Klebsiella pneumoniae (ColR-Kp, TigR-Kp) bacteraemia. MIC to colistin and tigecycline were determined by Etest. From 224 bacteraemic patients, 46.4% and 29.5% were resistant to colistin and tigecycline, respectively. PCR revealed that 199 isolates carried the blaKPC gene. PCR revealed that no isolate carried the mcr-1 gene. Risk factors for ColR-Kp bacteraemia as compared to patients with bacteraemia by a colistin-susceptible isolate or patients without carbapenemase-producing K. pneumoniae bacteraemia were colistin or tigecycline administration and tracheostomy, while TigR-Kp bacteraemia as compared to either patients with bacteraemia by tigecycline-susceptible isolate or patients without carbapenemase-producing K. pneumoniae bacteraemia were colistin or tigecycline administration, number of comorbidities and prior bacteraemia by a Gram-negative pathogen. Administration of colistin and tigecycline predisposed to development of bacteraemia by either ColR-Kp or TigR-Kp.