Intensive Care Unit (ICU) patients almost uniformly suffer from sleep disruption. Even though the role of sleep disturbances is not still adequately understood, they may be related to metabolic, immune, neurological and respiratory dysfunction and could worsen the quality of life after discharge. A harsh ICU environment, underlying disease, mechanical ventilation, pain and drugs are the main reasons that underlie sleep disruption in the critically ill. Polysomnography is the gold standard in evaluating sleep, but it is not feasible in clinical practice; therefore, other objective (bispectral index score [BIS] and actigraphy) and subjective (nurse and patient assessment) methods have been proposed, but their adequacy in ICU patients is not clear. Frequent evaluation of neurological status with validated tools is necessary to avoid excessive or prolonged sedation in order to better titrate patient-focused therapy. Hypnotic agents like benzodiazepines can increase total sleep time, but they alter the physiological progression of sleep phases, and decrease the time spent in the most restorative phases compared to the phases normally mediated by melatonin; melatonin production is decreased in critically ill patients, and as such, exogenous melatonin supplementation may improve sleep quality. Sleep disruption and the development of delirium are frequently related, both because of sleep scarcity and inappropriate dosing with sedatives. Delirium is strongly related to increased ICU morbidity and mortality, thus the resolution of sleep disruption could significantly contribute to improved ICU outcomes. An early evaluation of delirium is strongly recommended because of the potential to resolve the underlying causes or to begin an appropriate therapy. Further studies are needed on the effects of strategies to promote sleep and on the evaluation of better sleep in clinical outcomes, particularly on the development of delirium.

Aim: To assess fundus autofluorescence (AF) for differential diagnosis of macular pseudoholes (MPH) and lamellar macular holes (LMH) evaluated by optical coherence tomography (OCT) as the “gold standard”. Methods: The files on 50 eyes of 46 consecutive patients diagnosed by OCT as having a foveal defect with residual retinal tissue at the bottom were reviewed. Retinal thickness was measured at the foveal centre and 750 μm temporally and nasally to differentiate further MPH and LMH. The corresponding corrected AF images were then evaluated. Eyes with either macular pucker or stage 1a impending macular hole served as controls. Results: OCT measurements allowed the classification of two different profiles: 28 eyes classified with MPH had macular centres and perifoveal retinas that were significantly thicker than the 22 eyes classified with LMH. The corrected value of the foveal AF intensity was not significantly different between the two groups. In addition, the AF did not correlate with the thickness of the retinal tissue at the base of either MPH or LMH eyes. None of the control eyes showed foveal AF. Conclusions: The findings suggest that OCT data must be interpreted with caution when differentiating between MPH and LMH. In this series, the two groups showed similar foveal AF. AF imaging may add useful information to the differential diagnosis of MPH from LMH: the presence of foveal AF is consistent with a loss of foveal tissue and therefore a diagnosis of LMH.

È ormai riconosciuto come il funzionamento del sistema cardiovascolare sia ampiamente determinato da atteggiamenti personali, emozioni, ansia e disagio psicologico [1] Questo determina, nella pratica clinica, la necessità di interventi per la modificazione di comportamenti a rischio e per la gestione di problematiche di tipo psicologico. Tra i vari possibili approcci hanno trovato ampio spazio le tecniche che consentono il raggiungimento di uno stato di rilassamento, vale a dire una distensione fisiologica che riporta l’organismo in una condizione di equilibrio dopo il verificarsi di episodi disturbanti. Le tecniche di rilassamento e l’ipnosi sono divenute particolarmente rilevanti nei programmi di trattamento volti alla gestione dello stress ed alla ricostituzione dell’equilibrio omeostatico, dal momento che un continuo stato di arousal può determinare, a lungo andare, danni o malfunzionamenti a carico del sistema cardiovascolare. Molto spesso, nel campo della riabilitazione cardiaca, gli interventi di tipo psicologico sono stati basati sul modello cognitivo-comportamentale, centrato sulla #x201C;ristrutturazione” di credenze negative, relative a sé e all’ambiente, che emergono in presenza di eventi stressanti [2, 3]. A confronto con queste tecniche, le procedure di rilassamento e l’ipnosi hanno una caratteristica distintiva: invece di cercare di promuovere un’analisi critica delle reazioni allo stress e al disagio psicologico, l’obiettivo è quello di “aggirare” i processi mentali razionali.

Acta Anaesthesiologica ScandinavicaVolume 50, Issue 5 p. 648-648 Fatal cerebral air embolism after endoscopic retrograde cholangiopancreatography L. Stabile, L. StabileSearch for more papers by this authorM. Cigada, Corresponding Author M. Cigada Dr Marco CigadaIstituto di Anestesia e Rianimazione Università degli Studi di Milano Azienda Ospedaliera San Paolo Via A. di Rudinì 8 20142 Milan Italy e-mail: [email protected]Search for more papers by this authorD. Stillittano, D. StillittanoSearch for more papers by this authorE. Morandi, E. MorandiSearch for more papers by this authorM. Zaffaroni, M. ZaffaroniSearch for more papers by this authorG. Rossi, G. RossiSearch for more papers by this authorG. Iapichino, G. IapichinoSearch for more papers by this author L. Stabile, L. StabileSearch for more papers by this authorM. Cigada, Corresponding Author M. Cigada Dr Marco CigadaIstituto di Anestesia e Rianimazione Università degli Studi di Milano Azienda Ospedaliera San Paolo Via A. di Rudinì 8 20142 Milan Italy e-mail: [email protected]Search for more papers by this authorD. Stillittano, D. StillittanoSearch for more papers by this authorE. Morandi, E. MorandiSearch for more papers by this authorM. Zaffaroni, M. ZaffaroniSearch for more papers by this authorG. Rossi, G. RossiSearch for more papers by this authorG. Iapichino, G. IapichinoSearch for more papers by this author First published: 25 April 2006 https://doi.org/10.1111/j.1399-6576.2006.00978.xCitations: 28Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume50, Issue5May 2006Pages 648-648 RelatedInformation

OBJECTIVE:To report the management of retinal angiomatous proliferation (RAP), a recently described intraretinal neovascular lesion occurring in age-related macular degeneration.METHODS:This was a retrospective review of consecutive patients with age-related macular degeneration who underwent treatment of RAP from January 1, 2000, through January 31, 2003. Inclusion criteria were age 55 years or older, signs of age-related macular degeneration, and diagnosis of RAP based on dynamic indocyanine green angiography. Baseline angiograms were reviewed and RAP was classified into the following 3 stages: stage 1, intraretinal neovascularization, early stage; stage 2, subretinal neovascularization, middle stage; and stage 3, choroidal neovascularization, late stage. Treatment and concomitant treatment results were assessed separately for each RAP stage. The clinical data were statistically analyzed (chi2 test and analysis of variance) for 2 main outcome measures--complete obliteration of the lesion and final visual acuity.RESULTS:Eighty-one patients (99 eyes) with 104 RAPs were identified. Forty-two lesions were at stage 1, 42 at stage 2, and 20 at stage 3. The following 5 treatments were performed: direct laser photocoagulation of the vascular lesion, laser photocoagulation of the feeder retinal arteriole, scatter "gridlike" laser photocoagulation, photodynamic therapy, and transpupillary thermotherapy. Complete obliteration of RAP was achieved in about 24 (57.1%) of the stage 1 lesions (direct laser photocoagulation of the vascular lesion, 73% success rate; photodynamic therapy, 45%), 11 (26.2%) of the stage 2 lesions (scatter gridlike laser photocoagulation, 38% success rate; direct laser photocoagulation of the vascular lesion, 17%), and only 3 (15.0%) of stage 3 lesions (P = .001). Predictive factors with a significant effect on final visual acuity were initial visual acuity (P = .003) and early lesion stage (P = .04). Best final visual acuity was 0.41 (mean, direct laser photocoagulation of the vascular lesion in stage 1) and 0.39 (mean, photodynamic therapy in stage 1), with a mean decrease of 2.5 and 3 lines from baseline, respectively.CONCLUSIONS:Treatment of RAP remains difficult. Early detection of the lesion and subsequent direct conventional laser photocoagulation seems to be associated with better anatomical and functional outcome. Once the vascular complex is well established, anatomical closure is rarely achieved. Further study is warranted to assess the long-term efficacy and the need for re-treatment.

STUDY OBJECTIVES:Noninvasive ventilation, although effective as treatment for patients with acute cardiogenic pulmonary edema when prolonged for hours, is of limited use in the emergency department (ED). The aim of the study was to determine whether a short attempt at noninvasive pressure support ventilation avoids ICU admittance and to identify lack of response prediction variables.DESIGN:Prospective inception cohort study.SETTING:ED of a university hospital.PATIENTS:Fifty-eight consecutive patients with cardiogenic pulmonary edema who had been unresponsive to medical treatment and were admitted between January 1999 and December 2000.INTERVENTIONS:Pressure support ventilation was instituted through a full-face mask until the resolution of respiratory failure. A 15-min "weaning test" was performed to evaluate clinical stability. Responder patients were transferred to a medical ward. Nonresponding patients were intubated and were admitted to the ICU.MAIN OUTCOME MEASURES:The included optimal length of intervention, the avoidance of ICU admittance, the incidence of myocardial infarction, and predictive lack of response criteria.RESULTS:Patients completed the trial (mean [+/- SD] duration, 96 +/- 40 min). None of the responders (43 patients; 74%) was subsequently ventilated or was admitted to the ICU. Two new episodes of myocardial infarction were observed. Thirteen of 58 patients died. A mean arterial pressure of < 95 mm Hg (odds ratio [OR], 10.6; 95% confidence interval [CI], 1.8 to 60.8; p < 0.01) and COPD (OR, 9.4; 95% CI, 1.6 to 54.0; p < 0.05) at baseline predicted the lack of response to noninvasive ventilation.CONCLUSIONS:A short attempt at noninvasive ventilation is effective in preventing invasive assistance. A 15-min weaning test can identify patients who will not need further invasive ventilatory support. COPD and hypotension at baseline are negative predictive criteria.

Objective: In normal subjects cerebral CO2 vasoreactivity is measured during spontaneous hyperventilation, breathholding, or adding CO2 to inspiratory gases. The correlation between CO2 and cerebral blood flow may, however, be invalidated by the effects of a modified respiratory pattern on venous return, sympathovagal balance, and cathecolamine release. Moreover, the duration of the test, usually not considered, may play an important role. This may justify the scattering of values found in literature. We evaluated a new standardized method for overcoming these confounding factors.Design: Experimental.Participants: Twenty-one healthy volunteers.Methods: Subjects were connected through a mouthpiece to a mechanical ventilator set in the intermittent positive pressure ventilation mode. The ventilator was fed by two 40-l tanks, one of which contained 5 % CO2. The inspiratory CO2 concentration was varied at fixed time intervals from 0 % to 5 % without modifying ventilator settings. End-tidal CO2 was measured at the mouthpiece. Mean blood velocity (Vm) and pulsatility index (PI) in the middle cerebral artery were measured by means of transcranial Doppler ultrasound.Results: The test was easily applicable and well tolerated. No hemodynamic alterations were observed during the tests. The correlation between CO2 and Vm was always linear and highly significant (R 2 > 0.8, p < 0.0001). A low intersubject variability was observed. No difference was found between the two hemispheres, nor between the sexes.Conclusions: The strict standardization of the technique, avoiding hemodynamic interference, may explain the low intersubject variability. The value of this technique in ventilated neurosurgical patients is still speculative, but it might allow the collecting of valuable data together with a reduction in exposure to CO2, and hence cerebral blood flow modifications.

OBJECTIVE:To describe a generalized myopathic disorder occurred in the convalescence phase of illness of a critically ill patient.SETTING:Neurological Intensive Care Unit.PATIENT:A 43-year-old man with acute leukoencephalopathy and severe sepsis complicated by sustained and prolonged cardiovascular, respiratory and renal failure. After 15 days of complete respiratory autonomy, the patient presented an acute ventilatory failure associated with generalized muscle weakness. Neither a relapse of sepsis nor neurological worsening were detected.MEASUREMENTS AND RESULTS:Electromyogram resulted in normal conduction velocity in both motor and sensitive nervous fibers. Muscular biopsy showed marked fiber size variability with several hypotrophic fibers type II fiber grouping, several areas of degeneration-necrosis with macrophage invasion, dishomogeneous oxidative enzymatic activity, no increase in glycogen or lipid content.CONCLUSIONS:These results excluded critical illness polyneuropathy and all the other known myopathies. Prolonged period of sepsis with multiple organ failure can result in a direct generalized myopathy. This possibility should be kept in mind while treating long term critically ill survivors.