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Background: Implementing best practice guidelines for ventilator-associated pneumonia (VAP) and central line-associated blood stream infection (CLA-BSI) has variable success. Our institution was concerned with high rates of VAP and CLA-BSI. This retrospective study was undertaken to see whether implementation of the below practices would reduce the rates of VAP and CLA-BSI without resorting to more expensive interventions such as subglottic endotracheal (ET) tube suctioning or silver-impregnated ET tubes. We utilized easily collectable data (standardized infection ratios [SIRs]) to rapidly assess whether interventions already in place were successful. This avoided cumbersome data collection and review., Methods: Retrospective data review calculated SIRs using National Healthcare Safety Network benchmarks. Rates and SIRs were compared using z tests with P values <.05 considered statistically significant. This data review attempted to examine the impact of education campaigns, staff meetings, in-services, physician checklist, nurse checklist, charge nurse checklist implementation, and chlorhexidine gluconate oral care addition to the VAP bundle. Additionally, central line insertion required nursing supervision, a checklist, and physician signature., Results: The incidence rate of VAP went from 9.88 occurrences/1000 vent days in 2009 to 0 occurrences/1000 vent days in 2010 (P < .001). The CLA-BSI occurrences/1000 line days were 2.86 in 2009 and 0.97 in 2010 (P = .0187). The SIR for VAP was 4.12 in 2009 and 0 in 2010 (P < .001). For CLA-BSI, the SIR was 1.1 in 2009 and 0.37 in 2010 (P = .04)., Conclusions: Efforts to improve physician, patient, and staff education, and checklist implementation resulted in a decrease in VAP and CLA-BSI. This study confirms the applicability of best practice guidelines and suggests a benefit to the use of checklists. We utilize a practical approach for examining the success of these changes.

Probiotics are living microorganisms which have demonstrated many benefits in prevention, mitigation, and treatment of various disease states in critically ill populations. These diseases include antibiotic-associated diarrhea, Clostridium difficile diarrhea, ventilator-associated pneumonia, clearance of vancomycin-resistant enterococci from the GI tract, pancreatitis, liver transplant, major abdominal surgery, and trauma. However, their use has been severely limited due to a variety of factors including a general naïveté within the physician community, lack of regulation, and safety concerns. This article focuses on uses for probiotics in prevention and treatment, addresses current concerns regarding their use as well as proposing a protocol for safe use of probiotics in the critically ill patient.

The 22 risk factors suggested by the Centers for Disease Control and Prevention (CDC) to predict patients at risk for Mycobacterium tuberculosis have not been evaluated in hospitalised patients with community-acquired pneumonia (CAP). We evaluated which of the CDC risk factors best predict M. tuberculosis in these patients. To our knowledge, this is the first time a score has been developed assessing these risk factors. This was a secondary analysis of 6976 patients hospitalised with CAP enrolled in the Community-Acquired Pneumonia Organization International Cohort Study. Using Poisson regression, we selected the subset of risk factors that best predicted the presence of CAP due to M. tuberculosis. This subset was compared to the CDC risk factors using receiver operating characteristic (ROC) curve analysis. Five risk factors were found to best predict CAP due to M. tuberculosis: night sweats, haemoptysis, weight loss, M. tuberculosis exposure and upper lobe infiltrate. The area under the ROC curve for all CDC risk factors was 71% and 89% for the subset of five risk factors. The CDC-suggested risk factors are poor at predicting the presence of M. tuberculosis in hospitalised patients with CAP. With a subset of five risk factors identified in this study, we developed a new score, which will improve our capacity to isolate patients at risk of CAP due to M. tuberculosis at the time of hospitalisation.

The expanding understanding of the biochemical and physiologic role of micronutrients, commonly referred to as vitamins and minerals, is driving the identification of their consequences in both deficiency and toxicity. Neural tissue is quite sensitive to physiologic changes, and as such, micronutrient deficiencies can have significant and profound effects on the functioning of both the central and peripheral nervous systems. Understanding which micronutrients can affect the nervous system can aid physician identification of these neurological symptoms and signs, leading to diagnostic testing and appropriate therapy.

Background: Despite a previous meta-analysis that concluded that central venous pressure should not be used to make clinical decisions regarding fluid management, central venous pressure continues to be recommended for this purpose., Aim: To perform an updated meta-analysis incorporating recent studies that investigated indices predictive of fluid responsiveness. A priori subgroup analysis was planned according to the location where the study was performed (ICU or operating room)., Data Sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles., Study Selection: Clinical trials that reported the correlation coefficient or area under the receiver operating characteristic curve (AUC) between the central venous pressure and change in cardiac performance following an intervention that altered cardiac preload. From 191 articles screened, 43 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, and included healthy controls (n = 1) and ICU (n = 22) and operating room (n = 20) patients., Data Extraction: Data were abstracted on study characteristics, patient population, baseline central venous pressure, the correlation coefficient, and/or the AUC between central venous pressure and change in stroke volume index/cardiac index and the percentage of fluid responders. Meta-analytic techniques were used to summarize the data., Data Synthesis: Overall 57% ± 13% of patients were fluid responders. The summary AUC was 0.56 (95% CI, 0.54-0.58) with no heterogenicity between studies. The summary AUC was 0.56 (95% CI, 0.52-0.60) for those studies done in the ICU and 0.56 (95% CI, 0.54-0.58) for those done in the operating room. The summary correlation coefficient between the baseline central venous pressure and change in stroke volume index/cardiac index was 0.18 (95% CI, 0.1-0.25), being 0.28 (95% CI, 0.16-0.40) in the ICU patients, and 0.11 (95% CI, 0.02-0.21) in the operating room patients., Conclusions: There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned.

Nutrition therapy is an essential aspect of patient care and an important determinant of outcomes in the ICU. Nutrition can impact respiratory function in a myriad of ways. Under- and overfeeding are two well-established ways by which nutrition impinges on respiratory function. Route of feeding, method of feeding, and carbohydrate composition of the diet are also other key factors regarding nutrition that influence outcomes in ICU patients. Recent studies are now elucidating the role of immune therapy in patients with acute respiratory distress syndrome. In the ICU, nutrition dogmas, such as the necessity of checking gastric residual volumes or utilizing full-calorie enteric feeds, as opposed to trophic feeds, are constantly being challenged by innovative clinical studies. Basic research brings the prospect of testing new approaches for ICU patients, such as the use of antioxidants to prevent diaphragm weakness in these patients. In this review article, we evaluate the recent observational and randomized control trials to critically appraise the evidence regarding nutrition in the ICU.

Delirium is characterized by a disturbance of consciousness with accompanying change in cognition. Delirium typically manifests as a constellation of symptoms with an acute onset and a fluctuating course. Delirium is extremely common in the intensive care unit (ICU) especially amongst mechanically ventilated patients. Three subtypes have been recognized: hyperactive, hypoactive, and mixed. Delirium is frequently undiagnosed unless specific diagnostic instruments are used. The CAM-ICU is the most widely studied and validated diagnostic instrument. However, the accuracy of this tool may be less than ideal without adequate training of the providers applying it. The presence of delirium has important prognostic implications; in mechanically ventilated patients it is associated with a 2.5-fold increase in short-term mortality and a 3.2-fold increase in 6-month mortality. Nonpharmacological approaches, such as physical and occupational therapy, decrease the duration of delirium and should be encouraged. Pharmacological treatment for delirium traditionally includes haloperidol; however, more data for haloperidol are needed given the paucity of placebo-controlled trials testing its efficacy to treat delirium in the ICU. Second-generation antipsychotics have emerged as an alternative for the treatment of delirium, and they may have a better safety profile. Dexmedetomidine may prove to be a valuable adjunctive agent for patients with delirium in the ICU.

Purpose: We hypothesized that the Model for End-Stage Liver Disease (MELD) score at admission to the intensive care unit (ICU) can predict in-hospital mortality for patients with liver cirrhosis. We also tested the MELD-natremia (Na) score and compared the predictive value of the 2 models., Materials and Methods: This is a retrospective cohort study. A total of 441 consecutive patients with liver cirrhosis admitted to the ICU were included. The MELD and MELD-Na scores and other variables were obtained upon patients' admission to the ICU., Results: The area under the receiver operating characteristic curve to predict in-hospital mortality was 0.77 (95% confidence interval, 0.73-0.82) for the MELD score and 0.77 (95% confidence interval, 0.73-0.81) for the MELD-Na score., Conclusion: The MELD scoring system provides useful prognostic information for critically ill patients with liver cirrhosis admitted to an ICU. The MELD and MELD-Na scores had similar predictive value., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: Several studies have raised concern regarding the possible association between proton-pump inhibitors (PPIs) and Clostridium difficile infection (CDI). We aimed to perform a systematic review of incident and recurrent CDI in PPI users, and to evaluate the relative impact of concurrent antibiotic use, or switching acid suppression to histamine-2-receptor antagonists (H2RAs)., Methods: We searched MEDLINE and EMBASE from inception to December 2011 for controlled observational studies that reported on the risk of CDI with and without PPI use. We performed random effects meta-analysis and assessed statistical heterogeneity using the I(2) statistic., Results: We included 42 observational studies (30 case-control, 12 cohort) totalling 313,000 participants overall. Pooled analysis of 39 studies showed a statistically significant association between PPI use and risk of developing CDI, odds ratio (OR) 1.74 (95% confidence interval (CI) 1.47-2.85, P<0.001, I(2)=85%) compared with non-users. A pooled analysis of three studies showed a significant associated risk of recurrent CDI associated with PPIs, OR 2.51 (95% CI 1.16-5.44, P=0.005, I(2)=78%). Subgroup analysis failed to fully clarify the source of the substantial statistical heterogeneity. Adjusted indirect comparison demonstrated that use of H2RAs as an alternative carried a lower-risk OR 0.71 (95% CI 0.53-0.97) compared with PPIs. Conversely, concomitant use of PPI and antibiotics conferred a greater-risk OR 1.96 (95% CI 1.03-3.70) above that of PPIs alone. For PPI and antibiotics, the Rothman's synergy index was 1.36 and attributable proportion of risk from interaction 0.19, indicating an increased risk from interaction beyond the effects of each drug alone., Conclusions: Despite the substantial statistical and clinical heterogeneity, our findings indicate a probable association between PPI use and incident and recurrent CDI. This risk is further increased by concomitant use of antibiotics and PPI, whereas H2RAs may be less harmful.

Purpose: Statins have potential anti-inflammatory effects, but the association between statin use and lower incidence of pneumonia is unclear. We have therefore performed a systematic review on the risk of pneumonia in statin users versus non-users., Methods: MEDLINE and EMBASE were searched in December 2010 for controlled observational studies that reported on the risk of pneumonia in statin users. We performed a random effects meta-analysis and assessed heterogeneity using the I² statistic., Results: A total of 451 citations were screened, and ultimately nine studies (4 case-control, 4 retrospective cohort, 1 prospective cohort) with more than 3 million participants were included in the meta-analysis. Pooled analysis of seven studies that reported unadjusted data failed to show a significantly reduced risk of pneumonia [odds ratio (OR) 0.94, 95% confidence interval (CI) 0.84-1.06, p = 0.33, I² = 79%] in statin users as compared to non-users. However, a significant reduction in the likelihood of pneumonia associated with statin use (n = 8 studies, OR 0.85, 95% CI 0.75-0.97, p = 0.02, I² = 81%) was found in the meta-analysis of adjusted data. Both analyses were limited by substantial statistical heterogeneity. Sensitivity analysis failed to fully clarify the source of heterogeneity, but cohort studies seemed to be less heterogenous (n = 5 studies, OR 0.92, 95% CI 0.84-1.01, I² = 43%)., Conclusion: Our findings indicate that the purported benefit of statins in preventing pneumonia is inconsistent, and of low magnitude, with upper bounds of the confidence interval being close to null. In view of the substantial statistical and clinical heterogeneity in the dataset, there is no convincing evidence to support the therapeutic application of statins for reducing the risk of pneumonia.

Background: There is debate as to the vasopressor agent of choice in patients with septic shock. According to current guidelines either dopamine or norepinephrine may be considered as the first-line agent for the management of refractory hypotension of septic shock., Objective: The aim of this systematic review was to evaluate randomized clinical trials which compared norepinephrine versus dopamine in critically ill patients with septic shock or in a population of critically ill patients with shock predominantly secondary to sepsis., Data Sources: MEDLINE, Embase, Scopus, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles., Study Selection: Randomized clinical trials that compared norepinephrine with dopamine in critically ill adults with sepsis and reported the 28-day or in-hospital mortality., Data Extraction: We abstracted data on study design, study setting, patient population, 28-day mortality or in-hospital mortality, rate of arrhythmias, hospital length of stay, and ICU length of stay., Data Synthesis: Six studies met our inclusion criteria. These studies included a total of 2043 participants, with 995 in the norepinephrine and 1048 in the dopamine groups. There were 479 (48%) deaths in the norepinephrine group and 555 (53%) deaths in the dopamine group. There was statistically significant superiority of norepinephrine over dopamine for the outcome of in-hospital or 28-day mortality: pooled RR: 0.91 (95% CI 0.83 to 0.99; P = .028). We also found a statistically significant decrease in the rate of cardiac arrhythmias in the norepinephine group as compared to the dopamine group: pooled RR: 0.43 (95% CI 0.26 to 0.69; P ≤ .001). A subgroup analysis that pooled studies in which all the randomized patients had septic shock demonstrated that norepinephrine improved in-hospital or 28-day mortality; however, the results were no longer statistically significant., Conclusions: The analysis of the pooled studies that included a critically ill population with shock predominantly secondary to sepsis showed superiority of norepinephrine over dopamine for in-hospital or 28-day mortality.

Background: Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy. Research revealed that the risk of catheter-related complications varied according to the site of CVA. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review was originally published in 2007 and was updated in 2011., Objectives: 1. Our primary objective was to establish whether the jugular, subclavian or femoral CVA routes resulted in a lower incidence of venous thrombosis, venous stenosis or infections related to CVA devices in adult patients.2. Our secondary objective was to assess whether the jugular, subclavian or femoral CVA routes influenced the incidence of catheter-related mechanical complications in adult patients; and the reasons why patients left the studies early., Search Methods: We searched CENTRAL (The Cochrane Library 2011, Issue 9), MEDLINE, CINAHL, EMBASE (from inception to September 2011), four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) (from inception to November 2011), Google Scholar and bibliographies of published reviews. The original search was performed in December 2006. We also contacted researchers in the field. There were no language restrictions., Selection Criteria: We included randomized controlled trials comparing central venous catheter insertion routes., Data Collection and Analysis: Three authors assessed potentially relevant studies independently. We resolved disagreements by discussion. Dichotomous data on catheter-related complications were analysed. We calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model., Main Results: We identified 5854 citations from the initial search strategy; 28 references were then identified as potentially relevant. Of these, we Included four studies with data from 1513 participants. We undertook a priori subgroup analysis according to the duration of catheterization, short-term (< one month) and long-term (> one month) defined according to the Food and Drug Administration (FDA).No randomized controlled trial (RCT) was found comparing all three CVA routes and reporting the complications of venous stenosis.Regarding internal jugular versus subclavian CVA routes, the evidence was moderate and applicable for long-term catheterization in cancer patients. Subclavian and internal jugular CVA routes had similar risks for catheter-related complications. Regarding femoral versus subclavian CVA routes, the evidence was high and applicable for short-term catheterization in critically ill patients. Subclavian CVA routes were preferable to femoral CVA routes in short-term catheterization because femoral CVA routes were associated with higher risks of catheter colonization (14.18% or 19/134 versus 2.21% or 3/136) (n = 270, one RCT, RR 6.43, 95% CI 1.95 to 21.21) and thrombotic complications (21.55% or 25/116 versus 1.87% or 2/107) (n = 223, one RCT, RR 11.53, 95% CI 2.80 to 47.52) than with subclavian CVA routes. Regarding femoral versus internal jugular routes, the evidence was moderate and applicable for short-term haemodialysis catheterization in critically ill patients. No significant differences were found between femoral and internal jugular CVA routes in catheter colonization, catheter-related bloodstream infection (CRBSI) and thrombotic complications, but fewer mechanical complications occurred in femoral CVA routes (4.86% or 18/370 versus 9.56% or 35/366) (n = 736, one RCT, RR 0.51, 95% CI 0.29 to 0.88)., Authors' Conclusions: Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications.

Background: Observational studies have suggested an association between HIV infection and emphysema., Aims: The primary aim of this study was to estimate the prevalence of obstructive lung disease in HIV-infected patients seen in an outpatient infectious disease clinic. The secondary aim was to estimate the prevalence of Obstructive Lung Disease (OLD) in smokers and non smokers in this population., Methods: This was a prospective cross-sectional study. Consecutive patients who were seen for routine HIV care underwent spirometry and answered the St. George's Respiratory Questionnaire (SGRQ). Further, we collected information from the charts on demographics, co-morbidities, CD4 cell count, and HIV viral load (current, baseline, etc)., Results: This study included 98 HIV-infected patients with mean age of 45 years, (SD: 11) and 84% male. They were seen from November 2008 to May 2009 at Thomas Jefferson University in Philadelphia. According to established criteria, spirometry results were classified as normal in 69% and obstructive in 16.3%. Among those who never smoked, the prevalence of obstructive lung disease on spirometry was 13.6%. The prevalence of obstruction in HIV patients with a history of smoking was 18.5%. Current and ever smokers comprised 21.4% and 55% of the patients respectively. The mean SGRQ total score was 7. The mean SGRQ score in active smokers was 17 and 15 in those subjects with a prior history of smoking. The mean SGRQ score among patients with obstruction in spiromerty was 27.7 in patients with obstruction on spirometry., Conclusion: This urban population of HIV-infected persons has a relatively high prevalence of obstructive lung disease as assessed by spirometry. Furthermore, the high prevalence of obstructive lung disease in never smokers may suggest a possible association between HIV infection and emphysema. In addition the SGRQ total score was comparatively higher in patients with obstruction on spirometry. Our data suggests that potentially all patients with HIV should be screened a for OLD., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Patients with chronic obstructive pulmonary disease (COPD) are at an increased risk of infections such as pneumonia. Pneumonia among patients with COPD carries a higher risk of mortality. Inhaled corticosteroids are among the most widely used agents in patients with COPD. They are usually indicated in patients with severe COPD in combination with a long-acting β-agonist to reduce the frequency of exacerbations. Apart from their local effects in the lungs, inhaled corticosteroids may be systemically absorbed and have immunosuppressive effects. Although, the strength of the association between inhaled corticosteroids and pneumonia is modest (≈ 60% increased relative risk), this effect is consistent across clinical trials, meta-analyses of clinical trials, and observational studies. Observational studies also confirm a dose-response effect. Whether this increased risk of pneumonia translates into an increased risk of mortality is unknown. Although all the links in the causal chain have yet to be elucidated, converging lines of evidence suggest that clinicians should carefully balance the risk of pneumonia associated with inhaled corticosteroids, along with their benefits on exacerbations, in determining the optimal choice of therapy for patients with COPD.

Purpose: To evaluate the influence of malignancy on the decision to limit life-sustaining therapy in the intensive care unit (ICU)., Methods: At the day of patients' admission to the ICU, we prospectively collected information on demographics, acute physiology and chronic health evaluation (APACHE) II score, and features related to malignancy. We retrospectively collected information on in-hospital survival and decision to withhold or withdraw life-sustaining treatment., Results: This study included 122 adult critically ill patients. After adjusting for age and APACHE II score, patients with malignancy had 3.02 (95% CI 1.19 to 7.62) higher odds of having life-sustaining therapy withdrawn or withheld as compared to patients without active malignancy., Conclusion: Our study showed that critically ill patients with malignancy are more likely to have their life-sustaining therapy withheld or withdrawn than those without malignancy after adjusting for severity of disease. This finding may be related to a perception that critically ill patients with malignancy have worse prognosis as compared with those without malignancy.

Background: Adult-onset asthma and periocular xanthogranuloma is an uncommon and recently described disease. Little is known about the condition because only a few case reports and series are available., Objective/methods: To describe the clinical manifestations, lung physiology, and response to systemic treatment of three patients with adult-onset asthma and periocular xanthogranuloma, followed by a review of the literature., Results: Three men, with an age at diagnosis ranging from 48 to 51 years, presented with right periorbital swelling, asthma and chronic rhinosinusitis. The patients' lung physiology was consistent with airway obstruction. Diagnosis was established by periorbital biopsy. All patients received oral corticosteroids for their periorbital swelling, without significant clinical response. Two patients received oral methotrexate, with nearly complete resolution of periorbital swelling. A third patient received oral azathioprine, without clinical response. The three patients had improvement of their asthma with inhaled steroids/long-acting bronchodilator, and immunosuppressive medication., Conclusion: A triad consisting of periorbital swelling, asthma and chronic rhinosinusitis should raise the suspicion of adult-onset asthma and periocular xanthogranuloma. Oral methotrexate should be considered as an alternative to corticosteroids in the treatment of this disorder.

Objectives: : A systematic review of the literature to determine the ability of dynamic changes in arterial waveform-derived variables to predict fluid responsiveness and compare these with static indices of fluid responsiveness. The assessment of a patient's intravascular volume is one of the most difficult tasks in critical care medicine. Conventional static hemodynamic variables have proven unreliable as predictors of volume responsiveness. Dynamic changes in systolic pressure, pulse pressure, and stroke volume in patients undergoing mechanical ventilation have emerged as useful techniques to assess volume responsiveness., Data Sources: : MEDLINE, EMBASE, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles., Study Selection: : Clinical studies that evaluated the association between stroke volume variation, pulse pressure variation, and/or stroke volume variation and the change in stroke volume/cardiac index after a fluid or positive end-expiratory pressure challenge., Data Extraction and Synthesis: : Data were abstracted on study design, study size, study setting, patient population, and the correlation coefficient and/or receiver operating characteristic between the baseline systolic pressure variation, stroke volume variation, and/or pulse pressure variation and the change in stroke index/cardiac index after a fluid challenge. When reported, the receiver operating characteristic of the central venous pressure, global end-diastolic volume index, and left ventricular end-diastolic area index were also recorded. Meta-analytic techniques were used to summarize the data. Twenty-nine studies (which enrolled 685 patients) met our inclusion criteria. Overall, 56% of patients responded to a fluid challenge. The pooled correlation coefficients between the baseline pulse pressure variation, stroke volume variation, systolic pressure variation, and the change in stroke/cardiac index were 0.78, 0.72, and 0.72, respectively. The area under the receiver operating characteristic curves were 0.94, 0.84, and 0.86, respectively, compared with 0.55 for the central venous pressure, 0.56 for the global end-diastolic volume index, and 0.64 for the left ventricular end-diastolic area index. The mean threshold values were 12.5 +/- 1.6% for the pulse pressure variation and 11.6 +/- 1.9% for the stroke volume variation. The sensitivity, specificity, and diagnostic odds ratio were 0.89, 0.88, and 59.86 for the pulse pressure variation and 0.82, 0.86, and 27.34 for the stroke volume variation, respectively., Conclusions: : Dynamic changes of arterial waveform-derived variables during mechanical ventilation are highly accurate in predicting volume responsiveness in critically ill patients with an accuracy greater than that of traditional static indices of volume responsiveness. This technique, however, is limited to patients who receive controlled ventilation and who are not breathing spontaneously.

Background: Patients with pulmonary embolism (PE) have a high risk of death, and it is important to recognize factors associated with higher mortality. Recently, several biomarkers have been studied for risk stratification in patients with PE., Objectives: Evaluate the available evidence on (a) the accuracy of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) for the diagnosis of right ventricular dysfunction and (b) their value as a prognostic factor of all-cause in-hospital or short-term mortality in patients with PE., Data Sources: MEDLINE, Embase, and citation review of relevant primary and review articles., Selection Criteria: We selected studies evaluating the accuracy of BNP or NT-proBNP for the diagnosis of right ventricular dysfunction. We also selected studies that reported data on BNP or NT-proBNP as a predictor of short-term mortality in patients with PE., Results: Sixteen studies met our inclusion criteria. The pooled diagnostic odds ratio for the diagnosis of right ventricular dysfunction in pulmonary embolism was 39.45 (95% CI; 15.54-100.12) and 24.73 (95% CI 2.02-302.37) for BNP and NT-proBNP, respectively. The pooled odds ratio for all-cause in-hospital or short-term mortality was 6 (95% CI 1.31-27.43; p: 0.021) and 16.12 (95% CI 3.1-83.68; p: 0.001) for BNP (cutoff: 100 pg/ml) and NT-proBNP (cutoff: 600 ng/L), respectively., Conclusion: The results of this meta-analysis indicate that BNP and NT-proBNP are associated with the diagnosis of right ventricular dysfunction (RVD) in patients with an acute PE and are significant predictors of all-cause in-hospital or short-term mortality in these patients.

Objective: To analyze the available evidence regarding the effect that corticosteroids have on the prevention of fat embolism syndrome after long bone fracture of the lower limbs or pelvic fracture., Methods: In March of 2007, we performed a search of various electronic databases, including Medline, the Excerpta Medica database, the Cochrane Library, the Latin American and Caribbean Health Sciences Literature database and the Scientific Electronic Library Online. We selected randomized controlled trials that compared the effect of corticosteroids with that of placebo (or standard care) on the prevention of fat embolism syndrome after long bone fracture of the lower limbs or pelvic fracture. References from the studies included were also reviewed., Results: Six studies were included. The pooled relative risk for developing fat embolism syndrome was 0.16 (95% CI: 0.08-0.35) in the corticosteroid group as compared with the control group. The pooled relative risk for developing hypoxemia was 0.34 (95% CI: 0.19-0.59) in the corticosteroid group as compared with the control group., Conclusion: The analysis of evidence showed that corticosteroids decrease the risk of developing fat embolism syndrome and hypoxemia after long bone fracture of the lower limbs.

The operation of transposition of tibialis posterior into tibialis anterior is indicated in irreparable lesions of the peroneal nerve. The authors present a critical review of 16 cases submitted to this operation during the last 5 years using the Barr technique. This is described in detail. Evaluation of the overall results shows this to be an excellent procedure in such cases.

A ten-year follow-up on forty-two patients (a total of forty-three hands) operated on by arthrodesis of the trapeziometacarpal joint for degenerative arthritis shows relief of pain, maintenance of stability and mobility of the first ray and good function of the operated hands. Patients were pleased with the results. Arthrodesis is a safe and conservative method of treatment.

We present a case with a serious loss of substance and function of the hand repaired by multiple surgical procedures to reconstruct a first metacarpal with a proximal articular surface stabilised by palmaris longus tendon to provide a stable proximal articulation to a mobile segment.