Critical care : the official journal of the Critical Care Forum
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Understanding the nature and biological basis of gender-determined differences in risk of and outcome from infection might identify new therapeutic targets, allow more individualised treatment, and facilitate better risk prediction and application of healthcare resources. Gender differences in behaviours, comorbidities, access to healthcare and biology may result in differences in acquiring infection, or in response to infection once acquired. ⋯ Studying sufficient patient numbers to explore this entire continuum while accounting for heterogeneity in type of infection and comorbidity is difficult because of the number of patients required. However, if true gender effects can be identified, examination of their biological or psychosocial causes will be warranted.
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Editorial Comment
Positioning of patients with acute respiratory distress syndrome: combining prone and upright makes sense.
Positional strategies have been proposed for mechanically ventilated patients with acute respiratory distress syndrome. Despite different physiological mechanisms involved, oxygenation improvement has been demonstrated with both prone and upright positions. ⋯ The combined positioning enhanced the response rate in terms of oxygenation. Other benefits, such as a reduction in ventilator-associated pneumonia and better enteral feeding tolerance, can potentially be expected.
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Editorial Comment
The good and the bad of diabetes mellitus in the critically ill.
Diabetes mellitus is increasingly prevalent and associated with significant end organ damage that one may presume to impact upon critical illness. However, Siegelaar and colleagues present data that suggest, excepting those patients admitted to a cardiac intensive care unit, the presence of diabetes mellitus is not associated with increased mortality in critically ill patients. ⋯ Nevertheless, the results are consistent with many risk-adjustment models used in the critically ill, and clinical practice that tolerates mild hyperglycaemia. Is it even possible that diabetes mellitus is protective?
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The rapid institution of therapeutic hypothermia after cardiac arrest has become an accepted practice. In the previous issue of Critical Care, Haugk and colleagues present a retrospective analysis of 13 years of experience with therapeutic hypothermia at their center that suggests an association between rate of cooling and less favorable neurological outcomes. The association most likely reflects easier cooling in patients more severely brain injured by their initial cardiac arrest, and should not lead clinicians to abandon or slow their efforts to achieve post-resuscitative cooling.
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Combining therapeutic doses of low-molecular-weight heparins and increasing doses of recombinant activated protein C - Drotrecogin alpha (activated), or DAA - is of theoretical interest with regard to the control of coagulation activation. The study by Dempfle and colleagues presents new data showing that endogenous activated protein C levels do not increase in nonseptic patients with pulmonary embolism. However, the results of the addition of these two treatments are puzzling, leaving unresolved the questionable clinical relevance of this combination and the possible increase in bleeding risk.