Search

Background: Intravenous fluids are recommended for the treatment of patients who are in septic shock, but higher fluid volumes have been associated with harm in patients who are in the intensive care unit (ICU)., Methods: In this international, randomized trial, we assigned patients with septic shock in the ICU who had received at least 1 liter of intravenous fluid to receive restricted intravenous fluid or standard intravenous fluid therapy; patients were included if the onset of shock had been within 12 hours before screening. The primary outcome was death from any cause within 90 days after randomization., Results: We enrolled 1554 patients; 770 were assigned to the restrictive-fluid group and 784 to the standard-fluid group. Primary outcome data were available for 1545 patients (99.4%). In the ICU, the restrictive-fluid group received a median of 1798 ml of intravenous fluid (interquartile range, 500 to 4366); the standard-fluid group received a median of 3811 ml (interquartile range, 1861 to 6762). At 90 days, death had occurred in 323 of 764 patients (42.3%) in the restrictive-fluid group, as compared with 329 of 781 patients (42.1%) in the standard-fluid group (adjusted absolute difference, 0.1 percentage points; 95% confidence interval [CI], -4.7 to 4.9; P = 0.96). In the ICU, serious adverse events occurred at least once in 221 of 751 patients (29.4%) in the restrictive-fluid group and in 238 of 772 patients (30.8%) in the standard-fluid group (adjusted absolute difference, -1.7 percentage points; 99% CI, -7.7 to 4.3). At 90 days after randomization, the numbers of days alive without life support and days alive and out of the hospital were similar in the two groups., Conclusions: Among adult patients with septic shock in the ICU, intravenous fluid restriction did not result in fewer deaths at 90 days than standard intravenous fluid therapy. (Funded by the Novo Nordisk Foundation and others; CLASSIC ClinicalTrials.gov number, NCT03668236.)., (Copyright © 2022 Massachusetts Medical Society.)

Objective: Recent reviews strongly discourage the routine use of gastric lavage in oral poisonings, but the authors suspected that gastric lavage might still be in widespread use in Denmark. We wished to estimate the extent to which gastric lavage in cases of medical drug poisoning, reported in inquiries to the Danish Poison Information Centre (DPIC) from 2007 to 2010, was performed according to international recommendations and whether adherence to recommendations improved over the period., Methods and Materials: Inquiries from hospital and emergency departments (EDs) concerning medical drug poisonings were identified in the DPIC database. Patients receiving gastric lavage prior to inquiry were identified, and demographic and poisoning characteristics were retrieved. Indication for gastric lavage was determined from a predefined set of criteria., Results: 10 740 inquiries from hospitals and EDs were identified, of which 1091 cases received gastric lavage. In logistic regression, the frequency of lavage fell significantly from 13.5% in 2007 to 7.9% in 2010 (odds ratio (OR) 0.547, confidence interval (CI) 0.455-0.659). All criteria for gastric lavage were fulfilled in 60 lavaged cases (5.5%), and the fraction did not improve significantly over the period (OR 1.717, CI 0.791-3.724). No individual criterion for lavage showed consistent improvement over the period., Conclusion: Gastric lavage is still widely used in Denmark, mostly on questionable grounds where the procedure is unlikely to be beneficial. Recommendations for gastrointestinal decontamination may need to be promoted more actively, and clinicians should be encouraged to seek toxicological advice before performing gastric lavage.

Development of the upper dentition in Alligator mississippiensis was investigated using a close series of accurately staged and aged embryos, hatchlings, and young juveniles up to 11 days posthatching, as well as some young and old adult specimens. Studies from scanning electron microscopy, light microscopy, acetate and computer reconstructions, radiography and macroscopy were combined to elucidate the details of embryonic dental development, tooth initiation pattern, dentitional growth, and erupted functional dentition. The results were compared with those from the lower jaw and related to the development of other craniofacial structures. Approximately 17 early teeth in each jaw half develop as surface teeth, of which 13 project for 1 to 12 days before sinking into the mesenchyme. The first three teeth initiate directly from the oral epithelium at Ferguson stages 14-15 (days 15-19 after egg laying), before there is any local trace of dental lamina formation. All other teeth develop from a dental prolamina or lamina; and with progressive lamina development, submerged teeth initiate from the aboral end leading to the formation of replacement teeth. All teeth form dentin matrix, but 12 early teeth do not form enamel. Approximately 20 embryonic teeth are resorbed, 6 are transitional, and 42 function for longer periods after hatching. The embryonic tooth initiation pattern (illustrated by defining a tooth position formula) does not support the previous models of Odontostichi, Zahnreihen, and Tooth Families, each of which postulates perfect regularity. Up to three interstitial tooth positions develop between sites of primary tooth initiation, and families with up to five generations at hatching are at first arbitrarily defined.