Objective: disease (CVD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Studies have shown an association between aortic stiffness, a non-traditional risk factor, and high rate of mortality in CKD patients. Using a CKD animal model with vascular calcification, we reported that interleukin-6 (IL-6) may be involved in the process of vascular calcification. Therefore, the aims of the study were 1) to investigate the association between IL-6 and aortic stiffness and 2) to evaluate the impact of IL-6 on mortality in CKD patients. Design and method: In this observational study, we enrolled 351 CKD patients on dialysis (226 on hemodialysis (HD), 56 with peritoneal dialysis (PD) and 69 before kidney transplantation (KTx)). Aortic stiffness and its hemodynamic complications were determined non-invasively by the assessment of carotid-femoral pulse wave velocity (cf-PWV), augmentation index (Aix) and central pulse pressure (PP). Interleukin-6 was measured in plasma by ELISA. Survival analysis was performed on 282 HD and PD patients using Kaplan-Meier and Cox regression after a median follow-up of 38 months. Results: Interleukin-6 was positively associated with aortic stiffness adjusted for mean blood pressure determined by cf-PWV (Standardized β = 0.270; P < 0.001), AIx (Standardized β = 0.224; P < 0.001) and central PP (Standardized β = 0.147; P = 0.003). In a multivariate linear regression model adjusted for age, diabetes, hypertension, CVD, smoking and mean blood pressure, IL-6 was still positively associated with cf-PWV (Standardized β = 0.090; P = 0.037). During follow-up, 192 deaths occurred. The group of patients with higher levels of IL-6 had a hazard ratio for mortality of 1.7 (95% CI: 1.3–2.3; P < 0.001). Adjustment for clinical cofounders (age, CVD, hypertension, diabetes and smoking) did not change the relationship (HR = 1.426; 95% CI:1.06–1.92; P = 0.019). The impact of IL-6 on mortality decreased when adding cf-PWV (HR = 1.388; 95% CI:1.03–1.87; P = 0.032) in the previous model suggesting that the detrimental role of IL-6 on mortality may involve aortic stiffness. Conclusions: This study reveals a positive relationship between IL-6, aortic stiffness and mortality in CKD patients. Our results, together with our previous findings in an experimental animal model, indicated that IL-6 may represents a novel therapeutic target of CKD-related-CVD.
Aortic stiffness, measured by carotid-femoral pulse wave velocity (cf-PWV), is used for the prediction of cardiovascular risk. This mini-review describes the nonlinear relationship between cf-PWV and operational blood pressure, presents the proposed methods to adjust for this relationship, and discusses a potential place for aortic-brachial PWV ratio (a measure of arterial stiffness gradient) as a blood pressure-independent measure of vascular aging.PWV is inherently dependent on the operational blood pressure. In cross-sectional studies, PWV adjustment for mean arterial pressure (MAP) is preferred, but still remains a nonoptimal approach, as the relationship between PWV and blood pressure is nonlinear and varies considerably among individuals due to heterogeneity in genetic background, vascular tone, and vascular remodeling. Extrapolations from the blood pressure-independent stiffness parameter β (β0) have led to the creation of stiffness index β, which can be used for local stiffness. A similar approach has been used for cardio-ankle PWV to generate a blood pressure-independent cardio-ankle vascular index (CAVI). It was recently demonstrated that stiffness index β and CAVI remain slightly blood pressure-dependent, and a more appropriate formula has been proposed to make the proper adjustments. On the other hand, the negative impact of aortic stiffness on clinical outcomes is thought to be mediated through attenuation or reversal of the arterial stiffness gradient, which can also be influenced by a reduction in peripheral medium-sized muscular arteries in conditions that predispose to accelerate vascular aging. Arterial stiffness gradient, assessed by aortic-brachial PWV ratio, is emerging to be at least as good as cf-PWV for risk prediction, but has the advantage of not being affected by operating MAP.The negative impacts of aortic stiffness on clinical outcomes are proposed to be mediated through attenuation or reversal of arterial stiffness gradient. Aortic-brachial PWV ratio, a measure of arterial stiffness gradient, is independent of MAP.
Abstract Objectives The objective was to compare the efficacy of an oral sucrose versus placebo in reducing pain in infants 1 to 3 months of age during intravenous ( IV ) cannulation in the emergency department. Methods A randomized, double‐blind, placebo clinical trial was conducted. Participants were randomly allocated to receive 2 mL of an oral 88% sucrose solution or 2 mL of a placebo solution orally. The outcome measure were mean difference in pain score at 1 minute post– IV cannulation assessed by the Face, Legs, Activity, Cry, and Consolability Pain Scale ( FLACC ) and the Neonatal Infant Pain Scale ( NIPS ), crying time, and variations in heart rate. Results Eighty‐seven participants completed the study, 45 in the sucrose group and 42 in the placebo group. There was no statistical difference in variations in both the FLACC score (p = 0.49) and the NIPS score (p = 0.36) between the two groups as per the Mann‐Whitney U‐test. With the same test, median crying times following IV cannulation were statistically significantly different between both groups (17 seconds in the sucrose group vs. 41 seconds in the placebo group, p = 0.04). Mean changes in heart rate 1 minute after IV cannulation were similar in both groups (16 ± 4 beats/min for sucrose vs. 18 ± 4 beats/min for placebo, p = 0.74). Side effects were similar for both groups and no adverse events were reported. Conclusions Administration of an oral sucrose solution in infants 1 to 3 months of age during IV cannulation did not lead to statistically significant changes in pain scores. However, the cry time was significantly reduced.
The Confusion Assessment Method for the ICU (CAM- ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are recommended for routine delirium screening. However, literature about delirium assessment in traumatic brain injury (TBI) remains scarce. The aim of our study was to evaluate the validity and reliability of the CAM-ICU and the ICDSC for delirium assessment in patients with mild to moderate TBI.
Abstract Background Acute gastroenteritis is an important reason for emergency department (ED) consultation in children. Ondansetron is reported to be effective in reducing vomiting in children with gastroenteritis, leading to less intravenous rehydration and hospital admission. Objectives The aim of this study was to assess the effectiveness of triage nurse-initiated administration of ondansetron for children with suspected gastroenteritis in the paediatric ED to reduce the number of patients requiring observation following the first physician assessment. Design/Methods This was a randomized controlled trial performed in a tertiary care paediatric ED. All children 6 months to 17 years old who presented to the ED with at least four episodes of non-billous, non-bloody vomiting in the previous 24 hours and the last vomiting occurring within the previous 2h were eligible. The intervention consisted of administration of a liquid formulation of an adapted to weight dose of ondansetron at triage compared to a color- and taste-matched placebo. The primary outcome was the number of patients requiring observation after the first physician’s evaluation. Secondary outcomes were the number of episodes of vomiting after receiving the intervention, length of stay in the ED, comfort, and the proportion of children who returned for a medical visit within 48 hours. A sample size of 248 participants was initially identified to have a power of 90% to find a 20% difference in the proportion of children needing observation following physician evaluation. Results Because of multiple external factors, including the COVID-19 pandemic, recruitment was stopped before the expected sample size was reached. A total of 91 patients were included and randomized to receive ondansetron (n= 44) or a placebo (n=47) just after triage. The baseline characteristics of the participants was similar between the two groups. A total of 40 (45%) participants were discharged immediately after the first evaluation by the treating physician. This was similar for both groups 44% vs. 45%; (95% CI for the difference -20 to 19%). There was no difference between the two groups for the total length of stay (median 232 vs. 227 minutes; p= 0.677) and for the length of stay after being seen by the physician (72 vs. 68 minutes; p=0.821). There was no statistical difference between the two groups in the number of vomiting episodes (difference of 15%; 95% CI -2, 31), and proportion of participants needing a rescue medication (difference: 19%; 95%CI:-0.6 to 36%) or an intravenous rehydration (difference: 8; 95%CI:-6, 22). Conclusion This study failed to demonstrate any benefit in using ondansetron at triage for children with presumed gastroenteritis.
Background: Trying to differentiate serious bacterial infection (SBI) from a self-limiting illness in febrile infants seen in the pediatric emergency department (PED) is a significant challenge. The aim of the study was to determine the prevalence of dehydration and its relationship to SBI in febrile full-term newborns under 1 week of age seen in a PED. Methods: A retrospective observational study was carried out on all children younger than 8 days of age with fever who presented to a single, tertiary care, PED from January 2009 to April 2014. Dehydration was defined as plasma sodium >150 mmol/L or >10% loss of birth weight. SBI was defined by the presence of a positive culture in the blood, urine, cerebrospinal fluid; osteoarticular infection; bacterial enteritis; or pneumonia. The primary analysis was the proportion of children with dehydration. A secondary analysis compared proportion of infection according to hydration status. Results: Of the 895 children under 8 days of age who visited the PED, 69 consulted for fever. Seven patients were excluded because they were transferred from another hospital. Sixty-two eligible patients were included in the final analysis. Of these, 17 (27%) were dehydrated according to our definition. Only 2 patients had an SBI while 2 others had a final diagnosis of viral myocarditis and encephalitis, respectively. None of the 4 children with serious infection fulfilled our definition of dehydration, and all had a plasma sodium level lower than 145 mmol/L. Conclusions: Dehydration is frequently associated with fever in infants younger than 8 days of age seen in a PED. Early identification of dehydration may be useful in limiting the aggressive intervention in some of these infants.
