Objective Delirium is common in mechanically ventilated patients in the intensive care unit (ICU) and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside of the ICU setting, corticosteroids are a recognized risk factor for delirium, but their relationship with delirium in critically ill patients has not been fully evaluated. We hypothesized that systemic corticosteroid administration would be associated with a transition to delirium in mechanically ventilated patients with acute lung injury (ALI). Design Prospective cohort study Setting Thirteen ICUs in 4 hospitals in Baltimore, MD Patients 520 mechanically ventilated adult patients with ALI Measurements and Main Results Delirium evaluation was performed by trained research staff using the validated CAM-ICU screening tool. A total of 330 (64%) of the 520 patients had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was non-comatose), with a total of 2286 days of observation and a median (inter-quartile range [IQR]) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior non-delirious, non-comatose state. The probability of transitioning into delirium on any given day was 14%. Using multivariable Markov models with robust variance estimates, the following factors (adjusted odds ratio, 95% confidence interval) were independently associated with transition to delirium: older age (compared to <40 years old, 40-60 years (1.81, 1.26 to 2.62) and >=60 years (2.52, 1.65 to 3.87)) and administration of any systemic corticosteroid in the prior 24 hours (1.52, 1.05 to 2.21). Conclusions After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a non-delirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids in critically ill patients with ALI.

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In humans, gastric surgery results in in osteopenia via mechanisms that are insufficiently understood; surgery-induced changes in the hormonal axes involving the stomach, thyroid, and the parathyroids may play a role. To study this in more detail, we evaluated calcium (Ca), magnesium (Mg), and phosphorus (P) metabolism as well as physical, chemical, and histomorphometric bone parameters in rats rendered hypergastrinemic by fundectomy (FX). In independent experiments, the response to an oral Ca challenge was investigated in intact rats versus FX, and in thyroidectomized versus thyroid-intact FX rats. Sixteen weeks following FX, body weight was approximately 80% that of sham-operated controls. In urine, P excretion was elevated fivefold, the pH was significantly decreased, and cAMP excretion was elevated as compared with controls; serum parathyroid hormone (PTH), calcitonin, 25OHD, Ca, Mg, and P were normal; gastrin and 1,25(OH)2D were elevated. On the basis of bone ash mineral content, FX rats developed significant osteopenia, and histomorphometry indicated only slightly elevated bone turnover and mineralization. Following oral Ca, thyroid-intact FX rats developed hypercalcemia, serum gastrin decreased, and calcitonin increased significantly; in thyroidectomized FX rats, calcitonin remained at baseline levels although there was a similar degree of hypercalcemia; PTH decreased during the hypercalcemic period in both groups. Serum gastrin did not correlate with calcitonin or PTH, and in multivariate regression analysis the only predictor of serum 1, 25(OH)2D was urinary phosphorus. It was concluded that in the FX rat (1) osteopenia is not caused by intestinal Ca malabsorption, vitamin D, Ca deficiency, or secondary hyperparathyroidism; (2) osteopenia may be related to PTH-independent urinary hyperexcretion of P, followed by a rise of serum 1,25(OH)2D; (3) the existence of endocrine axes among gastrin, calcitonin, and PTH cannot be substantiated. FX osteopenia appears to be related to gastric acid abolition, and the reactive hypergastrinemia probably stabilizes the mass and turnover of bone.

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Ventilator-associated pneumonia (VAP) is a distinct clinical entity characterized by an onset after 48 hours of the application of mechanical ventilation (MV). Protocols exist to aid in the prevention of VAP, but this infection carries a devastating impact on patient morbidity and potentially mortality. Areas covered: In this review we present key concepts from existing guidelines to aid clinicians. Challenges remain in defining this disease and, most importantly appropriate empiric antimicrobial treatment is the main determinant of outcome. We highlight that the selection of initial antibiotics is critical, as VAP can by caused by a broad array of drug resistant organisms (DROs), the appropriate duration of treatment for VAP is an evolving concept, but may, in part, be guided by biomarkers, and provide focus on diagnostic challenges, initial therapies and treatment strategies for VAP. Both traditional and novel antimicrobials are presented, including developments in the modes of delivery. Expert commentary: The clinical approach to VAP continues to evolve. Recent evidence regarding the changes in microbiology, diagnostics approaches, and treatment strategies for VAP are important for clinicians to remain informed of to provide optimal patient care.

Introduction Sexual dysfunction is a frequent complication of visceral surgery after rectal resections as a result of carcinoma of the rectum. Aim The purpose of our study is to assess the incidence and form of sexual dysfunction in our own population of patients. Methods The study comprised all patients who had undergone surgery for carcinoma of the rectum at the Erlangen Surgery University Hospital, Germany, in the period 2000–04. All male patients were retrospectively surveyed and asked to complete standardized (International Index of Erectile Function 15) questionnaires regarding their pre- and postsurgical sexual function. One hundred and forty-five questionnaires could be analyzed. The statistical evaluation was conducted with aid of the SPSS statistics program. The univariate analysis was carried out with the chi-square test and the U-test (Mann–Whitney Test). Main Outcome Measures Erectile dysfunction, libido, and ability to have and sustain ejaculation and orgasm (both before and after surgery in each case) were among the dependent variables when compiling the data. The impact various surgical procedures and radiochemotherapy had on the severity of the sexual dysfunctions was analyzed. The scope of the postoperative urological care given was also assessed. Results Erectile dysfunction was confirmed in N=112 patients (77.3%) after surgery (P-value&lt;0.001). Other parameters such as orgasm capacity (4.1% vs. 16.5%), ejaculation ability (1.4% vs. 12.4%) and libido (3.4% vs. 22%) also showed a marked deterioration postoperatively. Postoperative erectile dysfunction was present in 77% of the patients with a colostomy and in 88.5% of the patients who had received neoadjuvant radiation. Conclusions Male erectile dysfunction is a frequent complication after rectal resection as a result of carcinoma of the rectum. The high incidence of sexual dysfunctions results from the radical nature of the procedure and from additional radiation or colostomy therapy. These patients need accompanying urological care for treatment of their sexual dysfunction.