Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic: a matched analysis

BACKGROUND

The primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with coronavirus disease 2019 (COVID-19)-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior noninvasive respiratory support on outcomes.

METHODS

This is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICUs) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of ICU admission. Propensity score matching was used to achieve a balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different time-point (48 h from ICU admission) for early and delayed intubation.

RESULTS

Of the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After propensity score matching, patients with delayed intubation presented higher hospital mortality (27.3% versus 37.1%; p=0.01), ICU mortality (25.7% versus 36.1%; p=0.007) and 90-day mortality (30.9% versus 40.2%; p=0.02) compared with the early intubation group. Very similar findings were observed when we used a 48-h time-point for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth waves, respectively; first versus second, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (HFNC) (n=294) who were intubated earlier. The subgroup of patients undergoing noninvasive ventilation (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h.

CONCLUSIONS

In patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received HFNC.

The early use of sepsis scores to predict respiratory failure and mortality in non-ICU patients with COVID-19

This observational retrospective study aimed to investigate the usefulness of Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), National Early Warning Score (NEWS), and quick NEWS in predicting respiratory failure and death among patients with COVID-19 hospitalized outside of intensive care units (ICU). We included 237 adults hospitalized with COVID-19 who were followed-up on for one month or until death. Respiratory failure was defined as a PaO₂/FiO₂ ratio ≤200 mmHg or the need for mechanical ventilation. Respiratory failure occurred in 77 patients (32.5%), 29 patients (12%) were admitted to the ICU, and 49 patients (20.7%) died. Discrimination of respiratory failure was slightly higher in NEWS, followed by SOFA. Regarding mortality, SOFA was more accurate than the other scores. In conclusion, sepsis scores are useful for predicting respiratory failure and mortality in COVID-19 patients. A NEWS score ≥4 was found to be the best cutoff point for predicting respiratory failure.

A predictive score at admission for respiratory failure among hospitalized patients with confirmed 2019 Coronavirus Disease: a simple tool for a complex problem

Coronavirus Disease 2019 (COVID-19) pandemic has implacably stricken on the wellness of many countries and their health-care systems. The aim of the present study is to analyze the clinical characteristics of the initial wave of patients with COVID-19 attended in our center, and to identify the key variables predicting the development of respiratory failure. Prospective design study with concurrent data retrieval from automated medical records of all hospitalized adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rRT-PCR assay performed on respiratory samples from March 2nd to 18th, 2020. Patients were followed up to May 1st, 2020 or death. Respiratory failure was defined as a PaO₂/FiO₂ ratio ≤ 200 mm Hg or the need for mechanical ventilation (either non-invasive positive pressure ventilation or invasive mechanical ventilation). We included 521 patients of whom 416 (81%) had abnormal Chest X-ray on admission. Median age was 64.6 ± 18.2 years. One hundred eighty-one (34.7%) developed respiratory failure after a median time from onset of symptoms of 9 days (IQR 6-11). In-hospital mortality was 23.8% (124/521). The modeling process concluded into a logistic regression multivariable analysis and a predictive score at admission. Age, peripheral pulse oximetry, lymphocyte count, lactate dehydrogenase and C-reactive protein were the selected variables. The model has a good discriminative capacity with an area under the ROC curve of 0.85 (0.82-0.88). The application of a simple and reliable score at admission seems to be a useful tool to predict respiratory failure in hospitalized COVID-19 patients.

Analysis of the factors predicting clinical response to tocilizumab therapy in patients with severe COVID-19

Background

Controversy remains about the efficacy of tocilizumab (TCZ) for the treatment of severe COVID-19. We aimed to analyze the profile of TCZ-respondent patients.

Methods

We retrospectively analyzed a cohort of patients with severe COVID-19 who received off-label TCZ after recommendation by a local committee and were admitted to the University Hospital “12 de Octubre” until May 2020. The primary end point was a significant clinical improvement (SCI) on day 14 after administration of TCZ. Factors independently related to SCI were analyzed by multivariate logistic regression models.

Results

Of 428 (63.3%) patients treated with TCZ, 271 (63.3%) experienced SCI. After adjustment for factors related to unfavorable outcomes, TCZ administration within the first 48 hours from admission (odds ratio [OR]: 1.98, 95% confidence Interval [95% CI]: 1.1–3.55; P = 0.02) and ALT levels >100 UI/L at day 0 (OR: 3.28; 95% CI: 1.3–8.1; P = 0.01) were independently related to SCI. The rate of SCI significantly decreased according to the time of TCZ administration: 70.2% in the first 48 hours from admission, 58.5% on days 3-7, and 45.1% after day 7 (P = 0.03 and P = 0.001, respectively).

Conclusion

TCZ improves the prognosis of patients with COVID-19 the most if treatment starts within the first 48 hours after admission.

Effectiveness of anakinra for tocilizumab-refractory severe COVID-19: A single-centre retrospective comparative study

OBJECTIVES

A subgroup of patients with SARS-CoV-2 infection was thought to have developed cytokine release syndrome and were treated with tocilizumab; however, a significant percentage of patients evolved. This study aimed to determine the usefulness of anakinra as a rescue treatment for patients with tocilizumab-refractory COVID-19 disease.

METHODS

A prospective cohort of patients with COVID-19 pneumonia who received anakinra as salvage therapy after failure of tocilizumab were compared (1:1) with selected controls in a historical cohort of patients treated with tocilizumab. Cases and controls were matched by age, comorbidities, pulse oximetry oxygen saturation to fraction of inspired oxygen (SpO2/FiO2) ratio at baseline, and time elapsed since the initiation of treatment with tocilizumab. The primary outcome was the improvement in clinical status measured by a 6-point ordinal scale, from baseline to day 21.

RESULTS

The study included 20 cases and 20 controls (mean age 65.3 ± 12.8 years, 65% males). No differences were found in the clinical improvement rates at 7, 14 and 21 days of follow-up. The in-hospital mortality rate for patients receiving anakinra was 55% vs. 45% in the control group (P = 0.527).

CONCLUSIONS

Treatment with anakinra was not useful in improving the prognosis of patients with tocilizumab-refractory severe COVID-19.

Combination therapy with tocilizumab and corticosteroids for aged patients with severe COVID-19 pneumonia: A single-center retrospective study

Background

The role of combination immunomodulatory therapy with systemic corticosteroids and tocilizumab (TCZ) for aged patients with COVID-19-associated cytokine release syndrome remains unclear.

Methods

A retrospective single-center study was conducted on consecutive patients aged ≥65 years who developed severe COVID-19 between 03 March and 01 May 2020 and were treated with corticosteroids at various doses (methylprednisolone 0.5 mg/kg/12 h to 250 mg/24 h), either alone (CS group) or associated with intravenous tocilizumab (400–600 mg, one to three doses) (CS-TCZ group). The primary outcome was all-cause mortality by day +14, whereas secondary outcomes included mortality by day +28 and clinical improvement (discharge and/or a ≥2 point decrease on a 6-point ordinal scale) by day +14. Propensity score (PS)-based adjustment and inverse probability of treatment weights (IPTW) were applied.

Results

Totals of 181 and 80 patients were included in the CS and CS-TCZ groups, respectively. All-cause 14-day mortality was lower in the CS-TCZ group, both in the PS-adjusted (hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.17–0.68; P = 0.002) and IPTW-weighted models (odds ratio [OR]: 0.38; 95% CI: 0.21–0.68; P = 0.001). This protective effect was also observed for 28-day mortality (PS-adjusted HR: 0.38; 95% CI: 0.21–0.72; P = 0.003). Clinical improvement by day +14 was higher in the CS-TCZ group with IPTW analysis only (OR: 2.26; 95% CI: 1.49–3.41; P < 0.001). The occurrence of secondary infection was similar between both groups.

Conclusions

The combination of corticosteroids and TCZ was associated with better outcomes among patients aged ≥65 years with severe COVID-19.

[The early use of sepsis scores to predict respiratory failure and mortality in non-ICU patients with COVID-19]

El presente estudio retrospectivo observacional tiene como objetivo analizar la utilidad de las escalas SOFA (Sequential Organ Failure Assessment), qSOFA (Quick SOFA), NEWS (National Early Warning Score ) y Quick NEWS para predecir el fallo respiratorio y la muerte en pacientes con COVID-19 atendidos fuera de la Unidad de Cuidados Intensivos (UCI). Se incluyeron 237 adultos con COVID-19 hospitalizados seguidos durante un mes o hasta su fallecimiento. El fallo respiratorio se definió como un cociente PaO₂/FiO₂ ≤ 200 mmHg o la necesidad de ventilación mecánica. Setenta y siete pacientes (32,5%) desarrollaron fallo ventilatorio; 29 (12%) precisaron ingreso en UCI, y 49 fallecieron (20,7%). La discriminación del fallo ventilatorio fue algo mayor con la puntuación NEWS, seguida de la SOFA. En cuanto a la mortalidad, la puntuación SOFA fue más exacta que las otras escalas. En conclusión, las escalas de sepsis son útiles para predecir el fallo respiratorio y la muerte en COVID-19. Una puntuación ≥ 4 en la escala NEWS sería el mejor punto de corte para predecir fallo respiratorio.

Tocilizumab for the treatment of adult patients with severe COVID-19 pneumonia: A single-center cohort study

Coronavirus disease 2019 (COVID‐19) can lead to a massive cytokine release. The use of the anti‐interleukin‐6 receptor monoclonal antibody tocilizumab (TCZ) has been proposed in this hyperinflammatory phase, although supporting evidence is limited. We retrospectively analyzed 88 consecutive patients with COVID‐19 pneumonia that received at least one dose of intravenous TCZ in our institution between 16 and 27 March 2020. Clinical status from day 0 (first TCZ dose) through day 14 was assessed by a 6‐point ordinal scale. The primary outcome was clinical improvement (hospital discharge and/or a decrease of ≥2 points on the 6‐point scale) by day 7. Secondary outcomes included clinical improvement by day 14 and dynamics of vital signs and laboratory values. Rates of clinical improvement by days 7 and 14 were 44.3% (39/88) and 73.9% (65/88). Previous or concomitant receipt of subcutaneous interferon‐β (adjusted odds ratio [aOR]: 0.23; 95% confidence interval [CI]: 0.06‐0.94; P = .041) and serum lactate dehydrogenase more than 450 U/L at day 0 (aOR: 0.25; 95% CI: 0.06‐0.99; P = .048) were negatively associated with clinical improvement by day 7. All‐cause mortality was 6.8% (6/88). Body temperature and respiratory and cardiac rates significantly decreased by day 1 compared to day 0. Lymphocyte count and pulse oximetry oxygen saturation/FiO₂ ratio increased by days 3 and 5, whereas C‐reactive protein levels dropped by day 2. There were no TCZ‐attributable adverse events. In this observational single‐center study, TCZ appeared to be useful and safe as immunomodulatory therapy for severe COVID‐19 pneumonia.

COVID‐19 can lead to a hyperinflammatory state that mirrors the cytokine release syndrome.

The off‐labeluse of the anti‐interleukin‐6 receptor monoclonal antibody tocilizumab has been proposed to abrogate this deleterious inflammatory response, although the supporting evidence is scarce.

In the present single‐centre study comprising 88 consecutive patients with COVID‐19 pneumonia that received at least one dose of intravenous tocilizumab between March 16 and 27, 2020, the rates of clinical improvement (defined by discharge to home and/or a decrease of = 2 points on a six‐point ordinal scale) were 44.3% (39/88) and 73.9% (65/88) by days 7 and 14, respectively.

The previous or concomitant use of interferon‐β and baseline serum lactate dehydrogenase levels >450 U/L were negatively associated with clinical improvement by day 7. All‐cause mortality was 6.8%, with no tocilizumab‐attributable adverse events.

Evaluation of the match between anthropometric measures and school furniture dimensions in Chile

BACKGROUND

Students are exposed to the first systematic tasks or activities that a human being carries out in his/her life while at school. In this workplace situation, school furniture is a key factor for the adoption of proper body posture.

OBJECTIVE

The aim of this paper was to observe and determine the potential mismatch between school furniture dimensions and anthropometric characteristics of the students from the Valparaíso region of Chile.

METHODS

The sample consisted of 3,078 volunteer participants from 18 schools (public, semi-public, private). Eight anthropometric measures were gathered, together with six furniture dimensions. Mismatch analyses were carried out by using pre-defined mismatch criteria.

RESULTS

Many different types of school furniture were presented at the schools. Also, a high level of mismatch was registered for seat height, desk height and seat-to-desk clearance. Finally, the analysis of all considered dimensions together showed that there was a high level of cumulative mismatch.

CONCLUSIONS

It can be concluded that there were high levels of mismatch between the school furniture and student anthropometric characteristics and that this mismatch varied within the difference types of schools. This situation may have occurred because furniture acquisition was made without considering any ergonomic criteria.

Characteristics and outcomes of patients admitted to Spanish ICU: A prospective observational study from the ENVIN-HELICS registry (2006-2011)

OBJECTIVE

To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level.

DESIGN

Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study.

SETTING

Spanish ICU.

PATIENTS

Patients admitted for over 24h.

INTERVENTIONS

None.

VARIABLES

Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel and multivariate models were used for the analysis of mortality and were performed in each stratum of severity level.

RESULTS

The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients >79 years (11.2% vs. 12.7%, P<0.001). Also, the mean APACHE II score increased from 14.35±8.29 to 14.72±8.43 (P<0.001). The crude overall intra-UCI mortality remained unchanged (11.4%) but adjusted mortality rate in patients with APACHE II score between 11 and 25 decreased modestly in recent years (12.3% vs. 11.6%, odds ratio=0.931, 95% CI 0.883-0.982; P=0.008).

CONCLUSION

This study provides observational longitudinal data on case-mix of patients admitted to Spanish ICUs. A slight reduction in ICU mortality rate was observed among patients with intermediate severity level.

DRESS syndrome secondary to ibuprofen as a cause of hyperacute liver failure

Acute liver failure has a high mortality and its most frequent cause in Spain is viral infection. In this article, we present a case of fulminant liver failure. The failure is secondary to an idiosyncratic reaction to ibuprofen, an entity included in the DRESS syndrome. This syndrome plays a key role in the differential diagnosis of acute liver failure, since its unfortunate course often requires liver transplantation as the only useful therapeutic weapon. This case illustrates the need for an efficient coordination between hospitals as a key factor for improving the prognosis.

Diagnosis and classification of sporadic inclusion body myositis (sIBM)

Sporadic inclusion body myositis (sIBM) is the most common acquired muscle disease in elderly individuals, particularly men. Its prevalence varies among ethnic groups but is estimated at 35 per one million people over 50. Genetic as well as environmental factors and autoimmune processes might both have a role in its pathogenesis. Unlike other inflammatory myopathies, sIBM causes very slowly progressive muscular weakness and atrophy, having a distinctive pattern of muscle involvement and different forms of clinical presentation. In some cases a primary autoimmune disease coexists. Diagnosis is suspected on clinical grounds and is established by typical muscle pathology. As a rule sIBM is refractory to conventional forms of immunotherapy.

Effectiveness of liposomal amphotericin B in patients admitted to the ICU on renal replacement therapy

INTRODUCTION

This study was designed to compare the effectiveness of liposomal amphotericin B (L-AmB) in ICU patients with and without renal replacement therapy (RRT).

METHODS

Observational, retrospective, comparative and multicenter study conducted in critically ill patients treated with L-AmB for 3 or more days, divided into two cohorts depending on the use of RRT before or within the first 48 hours after starting L-AmB. Clinical and microbiological response at the end of treatment was evaluated.

RESULTS

A total of 158 patients met the inclusion criteria, 36 (22.8%) of which required RRT during the ICU stay. Patients with RRT as compared with those without RRT showed a higher APACHE II score on admission (21.4 vs 18.4, P = 0.041), greater systemic response against infection (P = 0.047) and higher need of supportive techniques (P = 0.002). In both groups, main reasons for the use of L-AmB were broad spectrum and hemodynamic instability. A higher daily dose of L-AmB was used in the RRT group (4.30 vs 3.84 mg/kg, P = 0.030) without differences in the total cumulative dose or treatment duration. There were no differences in the clinical response (61.1% vs 56.6%, P = 0.953) or microbiological eradication rate (74.1% vs 64.6%, P = 0.382). In patients with proven invasive fungal infection, satisfactory clinical response was obtained in 74.1% and microbiological eradication 85.7%.

CONCLUSIONS

Although the study sample is small, this study shows that L-AmB is effective in critically ill patients admitted to the ICU requiring RRT.

Impact of liposomal amphotericin B on renal function in critically ill patients with renal function impairment

OBJECTIVE

To assess the tolerability of liposomal amphotericin B (L-AmB) in critically ill patients with elevated serum creatinine concentrations (Cr) (> 1.5 mg/dL) at starting L-AmB therapy.

METHODS

Retrospective, multicenter, comparative study of two cohorts of critically ill patients treated with L-AmB during 3 or more days, the difference between them was the level of Cr at the beginning of treatment. A cutoff value of Cr of 1.5 mg/dL was established. Patients undergoing extrarenal depuration procedures before or 48 hours after starting L-AmB were excluded. The primary endpoint was the difference between Cr values at the end of treatment as compared with Cr at starting L-AmB. Secondary endpoints were treatment-related withdrawals, need of extrarenal depuration techniques, and treatment-related severe adverse events. Demographic data, underlying illness, indication of L-AmB therapy, concomitant risk factors of nephrotoxicity, and vital status at ICU and hospital discharge were recorded.

RESULTS

A total of 122 patients admitted to 26 ICUs (16 with Cr > 1.5 g/dL; 106 with normal Cr levels) were recruited. Main reasons for the use of L-AmB in both groups were the broad spectrum of the drug and the presence of hemodynamic instability. L-AmB was administered as first-line treatment in 68.8% of patients with elevated Cr and in 52.8% with normal Cr. The APACHE II score on ICU admission was 25 in patients with elevated Cr and 17 in those with normal Cr values (p < 0.001). Duration of treatment with L-AmB was 16 and 12 days in patients with elevate and normal Cr values, respectively, with a mean dose of 3.5 vs 3.9 mg/kg/day. The use of concomitant nephrotoxic drugs, mortality rate, and ICU and hospital length of stay were similar in both cohorts. In patients with renal function impairment at the initiation of L-AmB treatment, an absolute decrease of Cf-Ci of 1.08 mg/dL was observed (P < 0.001). A decrease of Cr levels to normal limits was observed in 50% of the patients; in 37.5% of patients there was a decrease but normal levels were not achieved, whereas a Cr increased occurred in only one (6.25%) patient. None of the patients required withdrawal of L-AmB or use of extrarenal depuration procedures. Treatment-related severe adverse events were not reported.

CONCLUSIONS

In critically ill patients with impaired renal function, the impact of L-AmB on renal function was minimal. L-AmB can be used for the treatment of fungal infections in critically ill patients independently of renal function at the initiation of treatment.

Safety of anidulafungin in solid organ transplant recipients

The aim of this study was the evaluation of the safety of anidulafungin in adult solid organ transplantation (SOT) recipients. During the study period (14 months), we included all consecutive SOT recipients from 14 centers who received anidulafungin for at least 48 hours for the treatment of invasive fungal infections (IFIs) or as prophylaxis. Relevant clinical and analytical information on clinical charts was reviewed. Clinical side effects, liver function tests, and serum creatinine levels were assessed at least weekly. The need for the modification of immunosuppressive drugs was also recorded by the investigators. All patients were followed for at least 1 week after the end of treatment (EOT) or until death. Eighty-six SOT recipients were evaluated (56 transplant recipients, 20 lung transplant recipients, 8 kidney transplant recipients, and 2 heart transplant recipients). Sixty-two patients (72%) received anidulafungin for prophylaxis, and 24 (28%) received anidulafungin for the treatment of IFIs [candidemia/invasive candidiasis (16) or invasive aspergillosis (8)]. At the baseline, only 5% of the patients were neutropenic (<500 neutrophils/mL). There was no need for the modification of immunosuppressive drug doses because of anidulafungin therapy. No patient discontinued anidulafungin because of severe adverse effects. While receiving anidulafungin, 1 patient developed mild liver toxicity, but the liver function normalized without the discontinuation of anidulafungin. At EOT, the median serum creatinine, aspartate aminotransferase, and alanine aminotransferase levels were significantly lower than the baseline levels, even in liver transplant recipients and patients who had higher baseline levels of serum creatinine. In conclusion, these results show that anidulafungin is a well-tolerated drug in SOT recipients.

[Prevention of invasive candidiasis in the critically ill non neutropenic patient]

Prevention of invasive candidiasis (IC) in the setting of critically ill non neutropenic patients should be based on evidenced-based recommendations, namely improved hand hygiene, optimal catheter care, and rational and reduced use of broad-spectrum antibiotics. Concomitant interventions aimed at reducing risk factors are important to decrease IC.

[Systemic antifungals. Pharmacodynamics and pharmacokinetics]

Invasive fungal infections are important causes of morbidity and mortality in critically ill non neutropenic patients. For many years, amphotericin B and flucytosine have been the only available antifungal agents for invasive fungal infections. Fortunately, the antifungal armamentarium has increased during the past two decades with the addition of several new agents. In addition to itraconazole and fluconazole, lipid formulations of amphotericin B, voriconazole, and caspofungin have been recently licensed. These various antifungal agents differ in their pharmacokinetic and pharmacodynamic profile.

Pallial oviduct of Pomacea canaliculata (Gastropoda): ultrastructural studies of the parenchymal cellular types involved in the metabolism of perivitellins

Seasonal variations in the morphology of the parenchymal mass and function of the albumen gland/capsule gland complex have been studied in Pomacea canaliculata, together with the cellular types involved in the synthesis and secretion of perivitellin fluid components. The two major parenchymal cell types, albumen secretory cells (AS) and labyrinthic cells (LC), undergo seasonal variations throughout the annual reproductive cycle, which is divided into three periods. Both cellular types show maximal development and structural complexity during the reproductive period (spring and summer). AS cells have a well-developed Golgi complex and rough endoplasmic reticulum and their secretory granules show electron-dense particles of about 20 nm (probably galactogen). These cells are uniquely involved in ovorubin and PV2 perivitellin synthesis and their secretory granules are the single storage site for these two major perivitellins, as revealed by immunoelectron microscopy. AS also possess calcium deposits that infiltrate the cytoplasmic matrix. The luminal surfaces of LC exhibit long cilia intermingled with sparce short microvilli. Basally, the plasma membrane shows deep irregular folds that extend through the cytoplasm up to the subapical region. Calcium deposits infiltrate the cytoplasm and accumulate in the extracellular space of the basal labyrinth. Nerve terminals seem to be involved in the regulation of parenchymal cell secretion. At the post-reproductive period, AS markedly change their aspect following the release of most of the secretory granules into the acinar lumen. LC decrease in volume, the number of their cilia decreases, their cytoplasmic folds are much thinner and their extracellular spaces lack calcium particles. At the pre-reproductive period (winter), AS and LC recover and prepare for the subsequent period.

Meta-analysis: role of Helicobacter pylori eradication in the prevention of peptic ulcer in NSAID users

AIM

To evaluate whether eradication of Helicobacter pylori prevents peptic ulcer in non-steroidal anti-inflammatory drug users by means of a meta-analysis.

MATERIAL AND METHODS

A systematic search was performed in MEDLINE, EMBASE, the Cochrane Controlled Trials Register and the AGA congress. Randomized trials comparing H. pylori eradication vs. non-eradication or eradication vs. a proton pump inhibitor in patients receiving a non-steroidal anti-inflammatory drug were selected.

RESULTS

Five studies and 939 patients were included in the analysis; 34 of 459 (7.4%) patients developed a peptic ulcer in the eradicated group vs. 64 of 480 (13.3%) in the control group. The odds ratio was 0.43 (95% confidence interval: 0.20-0.93). Sub-analyses showed a significant reduction of risk for non-steroidal anti-inflammatory drug-naive (odds ratio = 0.26; 95% confidence interval: 0.14-0.49) but not for previously treated patients (odds ratio = 0.95, 95% confidence interval: 0.53-1.72). Two studies with a total of 385 patients compared eradication vs. a proton pump inhibitor; five of 196 (2.6%) developed a peptic ulcer in the eradicated group vs. zero of 189 (0%) in the proton pump inhibitor group (odds ratio = 7.43; 95% confidence interval: 1.27-43.6).

CONCLUSION

Helicobacter pylori eradication reduces the incidence of peptic ulcer in the overall population receiving non-steroidal anti-inflammatory drugs. It appears to be especially effective when performed in non-steroidal anti-inflammatory drug-naïve patients. Nonetheless, eradication seems less effective than treatment with a maintenance proton pump inhibitor for preventing non-steroidal anti-inflammatory drug-associated ulcers.

[Bronchial carcinoid tumor: a retrospective analysis of 62 surgically treated cases]

OBJECTIVE

To evaluate the results of surgical treatment for lung carcinoid tumor.

PATIENTS AND METHOD

The medical records of 62 patients who underwent surgical intervention for lung carcinoid tumor between May 1985 and October 2000 were reviewed.

RESULTS

Fifty-two patients had typical carcinoid tumors and 10 had atypical carcinoid tumors. Hilar or mediastinal lymph node metastases were present in 9 patients. Distant metastasis occurred in 5 patients and was significantly more frequent in those with the atypical carcinoid histological subtype. The overall survival rate at 15 years was 70%, with a mean survival rate of 138 (SD 11) months, calculated with the Kaplan-Meier method. We found no statistically significant correlation between smoking and the development of carcinoid tumors.

CONCLUSIONS

Although carcinoid tumors behave like low-grade malignant tumors, they should be treated in the same way as other malignant lung tumors. Curative surgical resection is the technique of choice whenever possible.

[Video-assisted thoracoscopic sympathectomy for the treatment of facial flushing: ultrasonic scalpel versus diathermy]

OBJECTIVE

To evaluate the advantages of the ultrasonic scalpel compared to electrocoagulation in patients undergoing video-assisted thoracoscopic sympatholysis or sympathectomy for uncontrolled facial blushing.

METHODS

Two hundred bilateral video-assisted thoracoscopic procedures to interrupt transmission in the thoracic sympathetic nerve were performed in 100 patients with incapacitating facial blushing. In 2 cases, the video-assisted approach was chosen because of pleural symphysis. The mean age of patients was 34 years (range: 15 to 67). The sympathetic chain was interrupted from the lower portion of the first thoracic ganglion through the third.

RESULTS

All patients were discharged within 24 hours with the exception of one on whom an emergency thoracotomy had been performed. No complications were reported in the group in which a harmonic scalpel was used. One case of temporary Horner syndrome (4 months) and 3 cases of persistent chest pain (more than 2 weeks) were reported in the diathermy group. There were 9 cases of partial and asymptomatic pneumothorax that resolved without treatment or prolonged hospital stays.

CONCLUSION

Dissection of the sympathetic nerve is accomplished more reliably and with better visualization with the ultrasonic scalpel. Peripheral lesions in lung parenchyma and adjacent tissues (intercostal vessels and nerves) are avoided, as is Horner syndrome, which can be caused by dispersion of heat. Use of the ultrasonic scalpel would also lead to a lower incidence of postoperative neuralgia.

[Video-assisted lobectomy through the auscultatory triangle for the surgical treatment of bronchopulmonary carcinoma. Preliminary experience]

OBJECTIVE

To describe a technique for video-assisted lobectomy through the auscultatory triangle (VALAT) and to assess early and medium-term outcome of the procedure in patients with non-small cell bronchopulmonary carcinoma in stage I.

PATIENTS AND METHOD

Between April 1999 and May 2002 we performed 25 VALAT procedures (24 lobectomies and 1 bilobectomy) in 25 patients with a mean age of 63.6 years (range 39-80).

RESULTS

No deaths occurred during or after surgery. Conversion to conventional thoracotomy was necessary in two cases. One patient was re-operated to resolve hemothorax and one developed a bronchopleural fistula that was treated by pleural drainage. The mean hospital stay was 6.3 days. Twenty-three patients have been disease-free throughout a mean follow-up period of 11.5 months (range 1-36). The two-year actuarial survival rate (Kaplan-Meier) was 93% 7%.

CONCLUSIONS

VALAT is a safe procedure that nevertheless requires specific training. The rate of complications was low in our patient series and mortality was nil. The outcome for patients with stage I bronchogenic carcinoma over a two-year follow-up period has been comparable to results obtained with conventional thoracotomy.

Associations between empirical antimicrobial therapy at the hospital and mortality in patients with severe community-acquired pneumonia

INTRODUCTION

The aim of the study was to examine different antibiotic choices and their relation to outcomes.

METHODS

We reviewed patients with severe community-acquired pneumonia (SCAP) from two multicenter studies. Empirical antimicrobial regimens were classified as: macrolides alone (group M); macrolides plus betalactams (group MB); macrolides plus betalactam/betalactamase inhibitor (group MBI); every regimen including aminoglycosides (group A); non-pseudomonal third-generation cephalosporins alone (group C); another betalactam alone (first- and second-generation cephalosporins, or betalactam/betalactamase inhibitor) (group B); fluoroquinolones (group F); and other regimens (group Misc).

RESULTS

Initial distribution of regimens was: group MB: 261 patients; group A: 65 patients; group C: 31 patients; group B: 23 patients; group M: 18 patients; group MBI: 13 patients; group F: 11 patients; group Misc: 38 patients. The lowest overall mortality was associated with initial treatment with a macrolide plus other agent (or alone). No deaths were documented among the 13 patients receiving amoxicillin/clavulanate plus a macrolide. The excess mortality for initial treatment with group A was significantly higher (14.2%; CI 95% 27.3-1.1) than the overall mortality rate between patients receiving a macrolide plus other agents. No significant differences were documented when mortality was adjusted for intubated patients.

CONCLUSION

Clinicians select the empirical antibiotic regimen after classifying patients according to likely pathogens and prognosis. The inclusion of a macrolide as part of the initial therapeutic regimen for SCAP appears to be as safe and effective as alternative options. Addition of a macrolide agent to a betalactam/betalactamase inhibitor or using a macrolide alone was a marker for less severe disease.

Nonselective cation channels as effectors of free radical-induced rat liver cell necrosis

Necrosis, as opposed to apoptosis, is recognized as a nonspecific cell death that induces tissue inflammation and is preceded by cell edema. In non-neuronal cells, the latter has been explained by defective outward pumping of Na(+) caused by metabolic depletion or by increased Na(+) influx via membrane transporters. Here we describe a novel mechanism of swelling and necrosis; namely the influx of Na(+) through oxidative stress-activated nonselective cation channels. Exposure of liver epithelial Clone 9 cells to the free-radical donors calphostin C or menadione induced the rapid activation of an approximately 16-pS nonselective cation channel (NSCC). Blockage of this conductance with flufenamic acid protected the cells against swelling, calcium overload, and necrosis. Protection was also achieved by Gd(3+), an inhibitor of stretch-activated cation channels, or by isosmotic replacement of extracellular Na(+) with N-methyl-D-glucamine. It is proposed that NSCCs, which are ubiquitous although largely inactive in healthy cells, become activated under severe oxidative stress. The ensuing influx of Na(+) initiates a positive feedback of metabolic and electrolytic disturbances leading cells to their necrotic demise.

Cyclosporine A induces apoptosis in murine tubular epithelial cells: role of caspases

BACKGROUND

The pathogenesis of cyclosporine A (CsA) nephrotoxicity has not been completely elucidated.

METHODS

The ability of CsA to induce apoptosis in cultured murine tubular epithelial cells and its regulation by the cell microenvironment and inhibitors of caspases were studied.

RESULTS

This study found that CsA induces apoptotic death in murine proximal tubular epithelial MCT cells in a dose- (0.1 to 15 micrograms/ml) and time-dependent (24 to 72 hr) manner. Death caused by CsA is additive to apoptosis induced by deprivation of the survival factors present in serum. Primary cultures of murine tubular epithelial cells are also sensitive to CsA-induced apoptosis. Peptide inhibitors of caspases such as zVAD-fmk (which inhibits caspases 8 and 9) and DEVD-CHO (which inhibits caspase 3 and related caspases) prevented CsA-induced apoptosis in MCT cells, although zVAD-fmk was effective at lower concentrations.

CONCLUSION

These data suggest that tubular cell apoptosis mediated by caspases may play a role in CsA nephrotoxicity and that the microenvironment modulates resistance to CsA lethality as low local levels of survival factors may potentiate nephrotoxicity. Caspases my be new therapeutic targets in the management of nephrotoxic injury.

[Our experience in treating obstructive lesions of the main airway by Nd-Yag laser resection]

We performed 164 laser resections with a neodymiumyttrium-aluminum-garnet (Nd-Yag) laser in 116 patients between January 1992 and December 1997. Seventy-eight patients had malignant neoplasms, 5 had neoplasms of intermediate malignancy and 33 had inflammatory tracheal lesions. Eighteen resections were emergency procedures. All resections were performed with the patient under general anesthesia and preferably breathing spontaneously. Immediate results varied according to the nature and location of the lesion. Treatment was palliative for tumors showing intraluminal proliferation, providing successful reopening of the airway as shown endoscopically in 70% of patients. Mean survival of the 44 patients with malignant lesions who could be followed was 29 weeks, with a median of 15.19 (range, 1-120). The tracheas of patients with inflammatory stenosis were reopened rapidly and emergency tracheostomy was avoided in all cases. One patient with malignant tracheal tumors died during the procedure due to asphyxia related to tracheal hemorrhage.

[Sensory characterization of lupin pudding using surface response methodology]

Full fat sweet lupin flour (Lupinus albus c.v. Multolupa) with 39.6% protein and 13.0% lipid content, and carrageenan were used to incorporate them to commercial pudding formula with the specific purpose to prepare an optimized pudding for diabetic people. Using response surface methodology, several experimental pudding trails were prepared and sensorially assessed to optimize the variables that may influence the overall sensory quality of pudding meals. Different concentrations of lupin flour and carrageenan were tested simultaneously at three levels each parameter, requiring nine combinations to be analyzed for a panel of eleven trained judges. Appearance, aroma, taste, color, texture were tested to determine total sensory quality using a composite scoring test. It was concluded that appropriate concentration of lupin flour range from 7% to 11%, and carrageenan from 0.4% to 0.5% to be added to the pudding formulation. This result was confirmed by hedonic test of acceptability.

[Traumatic pulmonary pseudocysts]

Two cases of traumatic pulmonary pseudocysts in young patients are presented. Blunt chest injuries resulting from traffic accidents were the causes in both cases. Air cavities were seen on chest films 12 hours and one hour, respectively, after trauma. In both cases, self-limited hemoptysis preceded the appearance of an air-fluid level on X-rays. The diagnoses of pulmonary pseudocyst were made after excluding other possible cause and the outcomes were satisfactory after treatment of symptoms and associated lesions.

Hyponatremia and neuroleptic-induced obesity in rats

The weight gain and hyperphagia induced by chronic administration of sulpiride in female rats were not prevented by the concomitant administration of an extra source of sodium. In addition, serum sodium levels were not affected, but potassium levels were significantly reduced by sulpiride administered for 1 week. These results suggest that sulpiride-induced obesity in rats is not related to sodium imbalance. The mechanism for the decrease in serum potassium levels and its relation with sulpiride-induced weight gain warrant further investigation.

[Clinical trial of lovastatin versus gemfibrozil in the treatment of primary hypercholesterolemia]

A randomized, double-blind, 12 weeks comparison of Lovastatin and Gemfibrozil in the treatment of patients with primary hypercholesterolemia was performed in 31 patients. After a placebo and diet period (4 weeks), they were assigned to either Lovastatin 20 mg nightly or Gemfibrozil 600 mg twice daily, if their total serum cholesterol was < 300 mg/dl, and to either Lovastatin 40 mg nightly or Gemfibrozil 600 mg/12 if it was > 300 mg/dl. In both cases, the Lovastatin dose was doubled after 6 weeks, if serum cholesterol remained > 200 mg/dl. The dose of Gemfibrozil kept constant. Lovastatin reduced serum cholesterol from 354 +/- 91 mg/dl to 253 +/- 62 mg/dl (p < 0.001), LDL-cholesterol from 277 +/- 104 to 192 +/- 71 mg/dl (p < 0.001) and serum triglyceride level from 125 +/- 66 a 84 +/- 41 mg/dl. The corresponding reductions achieved by Gemfibrozil were: 343 +/- 86 to 290 +/- 72 mg/dl (p < 0.01), 264 +/- 89 to 217 +/- 67 mg/dl (p < 0.05) and 152 +/- 84 to 89 +/- 41 mg/dl (p < 0.001), respectively. Lovastatin therapy caused a 30.6% reduction in total cholesterol level, while Gemfibrozil achieved a 19.47%. There were no significant changes in HDL-cholesterol. Patients had no serious or clinically significant adverse effects. The current data suggest that Lovastatin (an inhibitor of HMG-Coa reductase) may provide one important means for lipid-lowering therapy in patients with primary hypercholesterolemia.