Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

BACKGROUND

Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.

METHODS

Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.

RESULTS

Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.

CONCLUSIONS

During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis.

Procalcitonin and C-reactive protein to rule out early bacterial coinfection in COVID-19 critically ill patients

PURPOSE

Although the prevalence of community-acquired respiratory bacterial coinfection upon hospital admission in patients with coronavirus disease 2019 (COVID-19) has been reported to be < 5%, almost three-quarters of patients received antibiotics. We aim to investigate whether procalcitonin (PCT) or C-reactive protein (CRP) upon admission could be helpful biomarkers to identify bacterial coinfection among patients with COVID-19 pneumonia.

METHODS

We carried out a multicentre, observational cohort study including consecutive COVID-19 patients admitted to 55 Spanish intensive care units (ICUs). The primary outcome was to explore whether PCT or CRP serum levels upon hospital admission could predict bacterial coinfection among patients with COVID-19 pneumonia. The secondary outcome was the evaluation of their association with mortality. We also conducted subgroups analyses in higher risk profile populations.

RESULTS

Between 5 February 2020 and 21 December 2021, 4076 patients were included, 133 (3%) of whom presented bacterial coinfection. PCT and CRP had low area under curve (AUC) scores at the receiver operating characteristic (ROC) curve analysis [0.57 (95% confidence interval (CI) 0.51-0.61) and 0.6 (95% CI, 0.55-0.64), respectively], but high negative predictive values (NPV) [97.5% (95% CI 96.5-98.5) and 98.2% (95% CI 97.5-98.9) for PCT and CRP, respectively]. CRP alone was associated with bacterial coinfection (OR 2, 95% CI 1.25-3.19; p = 0.004). The overall 15, 30 and 90 days mortality had a higher trend in the bacterial coinfection group, but without significant difference. PCT ≥ 0.12 ng/mL was associated with higher 90 days mortality.

CONCLUSION

Our study suggests that measurements of PCT and CRP, alone and at a single time point, are not useful for ruling in or out bacterial coinfection in viral pneumonia by COVID-19.

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.

Key Factors Associated With Pulmonary Sequelae in the Follow-Up of Critically Ill COVID-19 Patients

INTRODUCTION

Critical COVID-19 survivors have a high risk of respiratory sequelae. Therefore, we aimed to identify key factors associated with altered lung function and CT scan abnormalities at a follow-up visit in a cohort of critical COVID-19 survivors.

METHODS

Multicenter ambispective observational study in 52 Spanish intensive care units. Up to 1327 PCR-confirmed critical COVID-19 patients had sociodemographic, anthropometric, comorbidity and lifestyle characteristics collected at hospital admission; clinical and biological parameters throughout hospital stay; and, lung function and CT scan at a follow-up visit.

RESULTS

The median [p₂₅-p₇₅] time from discharge to follow-up was 3.57 [2.77-4.92] months. Median age was 60 [53-67] years, 27.8% women. The mean (SD) percentage of predicted diffusing lung capacity for carbon monoxide (D_LCO) at follow-up was 72.02 (18.33)% predicted, with 66% of patients having D_LCO<80% and 24% having D_LCO<60%. CT scan showed persistent pulmonary infiltrates, fibrotic lesions, and emphysema in 33%, 25% and 6% of patients, respectively. Key variables associated with D_LCO<60% were chronic lung disease (CLD) (OR: 1.86 (1.18-2.92)), duration of invasive mechanical ventilation (IMV) (OR: 1.56 (1.37-1.77)), age (OR [per-1-SD] (95%CI): 1.39 (1.18-1.63)), urea (OR: 1.16 (0.97-1.39)) and estimated glomerular filtration rate at ICU admission (OR: 0.88 (0.73-1.06)). Bacterial pneumonia (1.62 (1.11-2.35)) and duration of ventilation (NIMV (1.23 (1.06-1.42), IMV (1.21 (1.01-1.45)) and prone positioning (1.17 (0.98-1.39)) were associated with fibrotic lesions.

CONCLUSION

Age and CLD, reflecting patients' baseline vulnerability, and markers of COVID-19 severity, such as duration of IMV and renal failure, were key factors associated with impaired D_LCO and CT abnormalities.

Prognostic implications of comorbidity patterns in critically ill COVID-19 patients: A multicenter, observational study

Background

The clinical heterogeneity of COVID-19 suggests the existence of different phenotypes with prognostic implications. We aimed to analyze comorbidity patterns in critically ill COVID-19 patients and assess their impact on in-hospital outcomes, response to treatment and sequelae.

Methods

Multicenter prospective/retrospective observational study in intensive care units of 55 Spanish hospitals. 5866 PCR-confirmed COVID-19 patients had comorbidities recorded at hospital admission; clinical and biological parameters, in-hospital procedures and complications throughout the stay; and, clinical complications, persistent symptoms and sequelae at 3 and 6 months.

Findings

Latent class analysis identified 3 phenotypes using training and test subcohorts: low-morbidity (n=3385; 58%), younger and with few comorbidities; high-morbidity (n=2074; 35%), with high comorbid burden; and renal-morbidity (n=407; 7%), with chronic kidney disease (CKD), high comorbidity burden and the worst oxygenation profile. Renal-morbidity and high-morbidity had more in-hospital complications and higher mortality risk than low-morbidity (adjusted HR (95% CI): 1.57 (1.34-1.84) and 1.16 (1.05-1.28), respectively). Corticosteroids, but not tocilizumab, were associated with lower mortality risk (HR (95% CI) 0.76 (0.63-0.93)), especially in renal-morbidity and high-morbidity. Renal-morbidity and high-morbidity showed the worst lung function throughout the follow-up, with renal-morbidity having the highest risk of infectious complications (6%), emergency visits (29%) or hospital readmissions (14%) at 6 months (p<0.01).

Interpretation

Comorbidity-based phenotypes were identified and associated with different expression of in-hospital complications, mortality, treatment response, and sequelae, with CKD playing a major role. This could help clinicians in day-to-day decision making including the management of post-discharge COVID-19 sequelae.

Funding

ISCIII, UNESPA, CIBERES, FEDER, ESF.

Methodology of a Large Multicenter Observational Study of Patients with COVID-19 in Spanish Intensive Care Units

INTRODUCTION

The COVID-19 pandemic created tremendous challenges for health-care systems. Intensive care units (ICU) were hit with a large volume of patients requiring ICU admission, mechanical ventilation, and other organ support with very high mortality. The Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBERES), a network of Spanish researchers to investigate in respiratory disease, commissioned the current proposal in response to the Instituto de Salud Carlos III (ISCIII) call.

METHODS

CIBERESUCICOVID is a multicenter, observational, prospective/retrospective cohort study of patients with COVID-19 admitted to Spanish ICUs. Several work packages were created, including study population and ICU data collection, follow-up, biomarkers and miRNAs, data management and quality.

RESULTS

This study included 6102 consecutive patients admitted to 55 ICUs homogeneously distributed throughout Spain and the collection of blood samples from more than 1000 patients. We enrolled a large population of COVID-19 ICU-admitted patients including baseline characteristics, ICU and MV data, treatments complications, and outcomes. The in-hospital mortality was 31%, and 76% of patients required invasive mechanical ventilation. A 3-6 month and 1 year follow-up was performed. Few deaths after 1 year discharge were registered. Low anti-SARS-CoV-2 S antibody levels predict mortality in critical COVID-19. These antibodies contribute to prevent systemic dissemination of SARS-CoV-2. The severity of COVID-19 impacts the circulating miRNA profile. Plasma miRNA profiling emerges as a useful tool for risk-based patient stratification in critically ill COVID-19 patients.

CONCLUSIONS

We present the methodology used in a large multicenter study sponsored by ISCIII to determine the short- and long-term outcomes in patients with COVID-19 admitted to more than 50 Spanish ICUs.

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background

Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies.

Methods

In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality.

Findings

Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H₂O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001).

Interpretation

Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Funding

No funding.

Home range and movements of Amazon river dolphins Inia geoffrensis in the Amazon and Orinoco river basins

Studying the variables that describe the spatial ecology of threatened species allows us to identify and prioritize areas that are critical for species conservation. To estimate the home range and core area of the Endangered (EN) Amazon river dolphin Inia geoffrensis, 23 individuals (6&female;, 17&male;) were tagged during the rising water period in the Amazon and Orinoco river basins between 2017 and 2018. The satellite tracking period ranged from 24 to 336 d (mean ± SE = 107 ± 15.7 d), and river dolphin movements ranged from 7.5 to 298 km (58 ± 13.4 km). Kernel density estimates were used to determine minimum home ranges at 95% (K95 = 6.2 to 233.9 km2; mean = 59 ± 13.5 km2) and core areas at 50% (K50 = 0.6 to 54.9 km2; mean = 9 ± 2.6 km2). Protected areas accounted for 45% of the K50 estimated core area. We observed dolphin individuals crossing country borders between Colombia and Peru in the Amazon basin, and between Colombia and Venezuela in the Orinoco basin. Satellite tracking allowed us to determine the different uses of riverine habitat types: main rivers (channels and bays, 52% of recorded locations), confluences (32%), lagoons (9.6%), and tributaries (6.2%). Satellite monitoring allowed us to better understand the ecological preferences of the species and demonstrated the importance of maintaining aquatic landscape heterogeneity and spatial connectivity for effective river dolphin conservation.

Células-tronco mesenquimais de origem adiposa na fase de proliferação do processo de cicatrização de queimaduras frias

RESUMO A criocirurgia tem sido utilizada no tratamento de diferentes enfermidades de sistemas e órgãos. Contudo, são relatados efeitos adversos, como cicatrização lenta, cicatrizes extensas, disfunção estética e funcional. As lesões que ocorrem naturalmente pela exposição ao frio extremo, comumente, resultam em gangrena. O presente trabalho teve como objetivo avaliar a influência das células-tronco mesenquimais de origem adiposa (ADSCs) na fase de proliferação da cicatrização de feridas cutâneas. Por meio da aplicação do nitrogênio líquido pela técnica do spray aberto, realizou-se a indução de uma ferida, de aproximadamente 15mm de diâmetro, na região dorsal de cada rato. A ferida recebeu o tratamento de acordo com o grupo ao qual pertencia: 1) aplicação das ADSCs no 15º dia (grupo tratado); 2) aplicação da solução cloreto de sódio 0,9% no 15º dia (grupo sham); 3) nenhuma intervenção até o momento da eutanásia (grupo controle). O grupo tratado com as ADSCs apresentou as maiores taxas de contração média das feridas e obteve diferença estatisticamente significativa em relação ao grupo sham quanto à neovascularização. A terapia com as ADSCs proporcionou uma relevante evolução clínica das feridas, podendo ser constatada ao final do período de avaliação por cicatrizes mais estreitas e compridas.

Mercury in Populations of River Dolphins of the Amazon and Orinoco Basins

In the Amazon and Orinoco basins, mercury has been released from artisanal and industrial gold mining since the Colonial time, as well as a result of deforestation and burning of primary forest, that release natural deposits of methyl mercury, affecting the local aquatic vertebrate fauna. This study reports the presence of mercury in river dolphins' genera Inia and Sotalia. Mercury concentrations were analysed in muscle tissue samples collected from 46 individuals at the Arauca and Orinoco Rivers (Colombia), the Amazon River (Colombia), a tributary of the Itenez River (Bolivia) and from the Tapajos River (Brazil). Ranges of total mercury (Hg) concentration in muscle tissue of the four different taxa sampled were: I. geoffrensis humboldtiana 0.003-3.99 mg kg^-1 ww (n = 21, M_e = 0.4), I. g. geoffrensis 0.1-2.6 mg kg^-1 ww (n = 15, M_e = 0.55), I. boliviensis 0.03-0.4 mg kg^-1 ww (n = 8, M_e = 0.1) and S. fluviatilis 0.1-0.87 mg kg^-1 ww (n = 2, M_e = 0.5). The highest Hg concentration in our study was obtained at the Orinoco basin, recorded from a juvenile male of I. g. humboldtiana (3.99 mg kg^-1 ww). At the Amazon basin, higher concentrations of mercury were recorded in the Tapajos River (Brazil) from an adult male of I. g. geoffrensis (2.6 mg kg^-1 ww) and the Amazon River from an adult female of S. fluviatilis (0.87 mg kg^-1 ww). Our data support the presence of total Hg in river dolphins distributed across the evaluated basins, evidencing the role of these cetaceans as sentinel species and bioindicators of the presence of this heavy metal in natural aquatic environments.

Effectiveness of In-office Hydrogen Peroxide With Two Different Protocols: A Two-center Randomized Clinical Trial

Objectives:

The aim of this study was to compare the bleaching efficacy and tooth sensitivity (TS) of a 38% hydrogen peroxide bleaching agent used for in-office bleaching, applied under different time protocols: a 40-minute application or two 20-minute applications.

Methods and Materials:

Forty-four patients from Brazil and Colombia, with right superior canines darker than C2, were selected for this multicenter, single-blind, randomized trial. The teeth were bleached in two sessions, with a one-week interval between them, in a split-mouth design. The bleaching agent was applied in two 20-minute (2×20) applications or one 40-minute (1×40) application in each session according to the manufacturer's instructions. The color changes were evaluated by using subjective (Vita Classical and Vita Bleachedguide) and objective (Easyshade Spectrophotometer) methods at baseline and 30 days after the second session. Tooth sensitivity was recorded up to 48 hours with a 0-10 visual analog scale. Also, the pH values during the application of bleaching were recorded. Color change in shade guide units and ΔE were analyzed by using the Student t-test (α=0.05). The absolute risk and intensity of TS were evaluated with the McNemar test, the Wilcoxon signed-rank test, and the Friedman test, respectively (α= 0.05).

Results:

Significant whitening was observed in both groups after 30 days of clinical evaluation. The use of a 40-minute application did not significantly influence the absolute risk of TS (68%, 95% confidence interval [CI] = 53-80) as well as the intensity of TS compared with the acid bleaching gel (absolute risk of 82%, 95% CI = 68-91). The pH values did not differ significantly between groups and at the different assessment periods (p=0.42).

Conclusion:

The use of a 40-minute in-office bleaching agent gel application produced the same whitening degree and TS that the two 20-minute bleaching agent applications did. The former preferably should be applied because one 40-minute application does not require gel refreshing.

Training in intensive care medicine. A challenge within reach

The medical training model is currently immersed in a process of change. The new paradigm is intended to be more effective, more integrated within the healthcare system, and strongly oriented towards the direct application of knowledge to clinical practice. Compared with the established training system based on certification of the completion of a series or rotations and stays in certain healthcare units, the new model proposes a more structured training process based on the gradual acquisition of specific competences, in which residents must play an active role in designing their own training program. Training based on competences guarantees more transparent, updated and homogeneous learning of objective quality, and which can be homologated internationally. The tutors play a key role as the main directors of the process, and institutional commitment to their work is crucial. In this context, tutors should receive time and specific formation to allow the evaluation of training as the cornerstone of the new model. New forms of objective summative and training evaluation should be introduced to guarantee that the predefined competences and skills are effectively acquired. The free movement of specialists within Europe is very desirable and implies that training quality must be high and amenable to homologation among the different countries. The Competency Based training in Intensive Care Medicine in Europe program is our main reference for achieving this goal. Scientific societies in turn must impulse and facilitate all those initiatives destined to improve healthcare quality and therefore specialist training. They have the mission of designing strategies and processes that favor training, accreditation and advisory activities with the government authorities.

Complications after patello-femoral versus total knee replacement in the treatment of isolated patello-femoral osteoarthritis. A meta-analysis

PURPOSE

Both patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) are successful in treating isolated patellofemoral osteoarthritis, but the complication rates after PFA are concerning. We performed a meta-analysis to compare the incidence of complications, re-operations, and revision following PFA and TKA for patellofemoral osteoarthritis.

METHODS

We systematically identified publications with patients who underwent PFA or TKA for patellofemoral osteoarthritis with minimum 1.5 year follow-up. Demographics, implant (TKA, first [1G] or second-generation [2G] PFA), complications, and cause of re-operations were extracted. Random-effects meta-analysis was used to pool incidence data, which was compared between groups using logistic regression to adjust for length of follow-up.

RESULTS

Twenty-eight observational studies and no randomized trials were included in this meta-analysis, which limits its generalizability. There was a higher likelihood of any re-operation (odds ratio 8.06) and revision (OR 8.11) in PFA compared to TKA. Re-operation (OR 4.33) and revision (OR 4.93) were more likely in 1G-PFA than 2G-PFA. When comparing 2G-PFA to TKA, there was no significant difference in re-operation, revision, pain, or mechanical complications.

CONCLUSIONS

Patients who undergo PFA rather than TKA are more likely to experience complications and require re-operation or revision, but subgroup analysis suggests a relation to implant design. There is no significant difference in re-operation, revision, pain, or mechanical complications between 2G-PFA and TKA.

LEVEL OF EVIDENCE

Systematic review of Level III therapeutic studies, Level III.

Aspirin challenge/desensitisation before coronary stenting in subjects with history of hypersensitivity. A pragmatic approach

BACKGROUND

Aspirin hypersensitivity may represent a major problem in patients with ischemic coronary disease who need a stenting procedure. In those patients, clinically unsettled reasonably quick desensitisation procedures are needed. In our study we attempted to select the most suitable procedure on the basis of characteristics and severity of ASA hypersensitivity.

METHODS

Thirty patients with a history of mild reactions to anti-inflammatory doses of aspirin (> 325 mg) were considered at low risk and underwent a tolerance test in 5 steps. Thirty-one patients, with a history of severe reactions to anti-platelet doses of aspirin 0 mg) underwent a slow desensitisation in 12 steps, reaching a cumulative dose of 150 mg ASA in 220 minutes.

RESULTS

In the first group, 29 patients tolerated the challenge. One developed urticaria, thus underwent challenge/desensitisation and achieved tolerance. In the second group, 3 patients did not tolerate the procedure and had to discontinue. CONCLUSION. Our approach to aspirin hypersensitivity in patients needing coronary stenting, based on a severity stratification, allowed to achieve an effective tolerance to aspirin in the majority of subject in a reasonable short time.

Coronary stenting for ST-elevation myocardial infarction vs. other indications in patients on oral anticoagulation: any difference in in-hospital management and outcome?

AIM

The aim of this paper was to compare the in-hospital management and outcome of patients on oral anticoagulation (OAC) undergoing coronary artery stenting (PCI-S) for ST-elevation myocardial infarction (STEMI) vs. other indications.

METHODS

One hundred and sixteen patients on OAC at the time of PCI-S who were prospectively enrolled in a multi-center, observational registry, were evaluated. Patients were segregated according to whether PCI-S was performed for STEMI (group 1) or other indications, such as non ST-elevation acute coronary syndromes, stable angina, silent ischemia, etc. (group 2), and the pharmacological and procedural management, as well as the in-hospital outcome, were compared.

RESULTS

No significant differences were observed in vascular access site, sheath size and type of stent implanted, nor was significantly different the use of glycoprotein IIb/IIIa inhibitors, and the use and dose of intravenous unfractionated heparin. Although not statistically different, the in-hospital occurrence of death (3.7% vs. 1.1%; OR 3.3; 95% confidence intervals [CI] 0.2-56.0), stent thrombosis (3.7% vs. 1.1%; OR 3.3; 95% CI 0.2-56.0) and major bleeding (7.4% vs. 2.2%; OR 3.4; 95% CI 0.4-25.9) was consistently about 3-fold higher in group 1.

CONCLUSION

The in-hospital pharmacological and procedural management of OAC patients undergoing PCI-S for STEMI vs. other indications appears not different. Although not significantly different however, the in-hospital occurrence of major bleeding, as well as of death and stent thrombosis, appears substantially higher in patients treated for STEMI, warranting therefore further larger, prospective studies.

A decade of land use contributes to changes in the chemistry, biochemistry and bacterial community structures of soils in the Cerrado

The bacterial community structures (BCSs) of Cerrado soils cultivated under conventional tillage (CT), no-tillage (NT) and under native Cerrado (NC) vegetation were evaluated using PCR/DGGE of bacterial 16S rRNA (rrs) and rpoB genes and of Pseudomonas group genes. Soil chemical analysis, microbial biomass and the enzyme activities were also evaluated and correlated with the BCS measurements. The multivariate ordinations of DGGE profiles showed differences between the BCS of the NC area and those from cultivated areas. The BCSs of the CT and NT areas also differed in all DGGE fingerprints, including changes in the profile of Pseudomonas populations, indicating that agricultural systems can also be responsible for changes within specific microbial niches, although the clearest differences were found in the rpoB profiles. The MRPP analysis demonstrated significant differences between the BCSs from different soil layers of NT areas based on all gene fingerprints and those of NC areas based on bacterial 16S rRNA and rpoB genes fingerprints. No differences were observed in the microbial fingerprints of CT samples from different depths, indicating that ploughing affected the original BCS stratification. The BCS from NC areas, based on all gene fingerprints, could be related to higher levels of soil acidity and higher amounts of MBC and of phosphatase activity. In contrast, the BCSs from cultivated areas were related to higher levels of Ca + Mg, P and K, likely as a result of a history of chemical fertilisation in these areas. The relationships between rpoB and Pseudomonas BCSs and all chemical and biochemical properties of soils were significant, according to a Mantel test (P < 0.05), indicating that the different changes in soil properties induced by soil use or management may drive the formation of the soil BCS.

Optical and structural properties of an Eu implanted gallium nitride quantum dots/aluminium nitride superlattice

GaN/AIN structures made of GaN quantum dots (QDs) separated by AIN spacer layers, were doped with Europium by ion implantation. Rutherford Backscattering/Channelling measurements showed that Eu is incorporated mainly on near-substitutional cation sites within the superlattice region. Only slight deterioration of the crystal quality and no intermixing of the different layers are observed after implantation and annealing. After thermal annealing, photoluminescence associated with Eu3+ ions was observed. From its behaviour under different photon energy excitation and sample temperature we concluded that the Eu-related emitting centres are located inside the GaN QDs or dispersed in the GaN and AIN buffer or spacer layers. The 624 nm PL line, associated with Eu-doped GaN QDs, shows very low thermal quenching, suggesting recombination of confined carriers through rare-earth ion excitation.

Ferromagnetism induced in rutile single crystals by argon and nitrogen implantation

The magnetic properties of Ar- and N-implanted single crystalline TiO(2) rutile were studied and correlated with the induced disorder in order to clarify the influence of defects in the magnetic behaviour. Nominal fluences of 1 × 10(17) and 2 × 10(17) cm(-2) and an implantation energy of 100 keV were used. The as-implanted single crystals exhibited ferromagnetic behaviour up to 380 K. Annealing at 1073 K induced recovery of the lattice structure and the decrease of the ferromagnetic moment in the case of Ar-implanted samples, but the magnetic moment did not change significantly for the samples implanted with nitrogen. No impurities, other than the implanted species were detected and consequently the ferromagnetic behaviour is attributed to defects created during implantation, which in the case of nitrogen remained in the lattice even after partial recovery of the structure.

The discoidin domain receptor 1 as a novel susceptibility gene for schizophrenia

Evidence suggests that myelin alterations could predispose to schizophrenia. Reduced expression of several myelin genes has been observed in schizophrenia patients. Recently, we identified the discoidin domain receptor 1 (DDR1; located at human chromosome 6p21.3) as a myelin gene in the mouse model and in a human oligodendroglial cell line. In the present study we screened for single nucleotide polymorphisms (SNPs) in the DNA from 100 schizophrenia patients. We identified a novel mutation within exon 10 that produces the amino-acid substitution N502S in the a-d isoforms, and M475V in the e isoform. However the frequency of the mutation (2%) was similar in schizophrenia patients and in control subjects. In a case-control assessment with 389 schizophrenic patients and 615 controls, we identified one SNP (SNP9, rs1049623) associated with schizophrenia (odds ratio=1.44, 95% confidence interval: 1.15-1.79, adjusted P=0.0016). This association was confirmed in haplotype analysis; the SNPs 9-10-11 (rs1049623, rs2267641 and rs2239518) haplotype remaining significant even after adjustment for multiple testing (adjusted P=0.0136). Of note was a strong gender dependence in the association, that is, statistical significance restricted to men (adjusted P-value=0.0002). Regression analysis of DDR1 mRNA expression in peripheral blood lymphocytes from schizophrenia patients showed that the presence of the G allele significantly decreased the relative number of mRNA copies in a dose-dependent manner (P=0.003). These data suggest that the risk haplotype tags a cis-acting variant involved in the transcription regulation system of the gene. In conclusion, we propose the DDR1 as a new susceptibility gene for schizophrenia.

Anomalous ion channeling in AlInN/GaN bilayers: determination of the strain state

Monte Carlo simulations of anomalous ion channeling in near-lattice-matched AlInN/GaN bilayers allow an accurate determination of the strain state of AlInN by Rutherford backscattering or channeling. Although these strain estimates agree well with x-ray diffraction (XRD) results, XRD composition estimates are shown to have limited accuracy, due to a possible deviation from Vegard's law, which we quantify for this alloy. As the InN fraction increases from 13% to 19%, the strain in AlInN films changes from tensile to compressive with lattice matching predicted to occur at [InN] = 17.1%.

Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial

STUDY OBJECTIVE

Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF.

DESIGN

A randomized, multicenter, controlled trial.

SETTING

Seven multipurpose ICUs.

PATIENTS

Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation.

INTERVENTION

The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube.

MEASUREMENTS AND RESULTS

Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p = 0.09) and complications occurred in 52% and 70% (p = 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days.

CONCLUSIONS

NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.

Epitaxy and magnetic properties of surfactant-mediated growth of bcc cobalt

High resolution core level photoemission spectroscopy, photoelectron diffraction, and x-ray magnetic circular dicroism (XMCD) have been used to characterize the structural and magnetic properties of bcc-cobalt films grown on GaAs(110) substrates by using Sb as a surfactant. We have unambiguously disentangled the surfactant role played by the Sb which improves the crystallinity and reduces the lattice distortion of the metallic films as well as changes the interdiffusion process at the interface compared to the Co/GaAs(110) system. As a consequence of these combined effects, an improvement on the magnetic response of the grown Co thin films has been observed by XMCD measurements.

Reaction of arylphosphines with singlet oxygen: intra- vs intermolecular oxidation

[reaction--see text] The chemistry of singlet oxygen with all three isomers of tris(methoxyphenyl)phosphine has been studied. For the severely hindered ortho isomer, intramolecular rearrangement to form phenyl diphenyl phosphinate is preferred to formation of phosphine oxide at low concentration in aprotic solvents. In protic solvents, no intramolecular reactivity is observed. A detailed kinetic analyses has been undertaken. There is no physical quenching, regardless of solvent. Mechanistic implications of these findings are discussed.

Absence of genetic abnormalities in fibroadenomas of the breast determined at p53 gene mutations and microsatellite alterations

Genesis of breast cancer is a multistage process involving accumulation of genetic alterations, but little is known about the implication of genetic alterations in benign breast disease (BBD) lesions. Among benign lesions of the breast, one of the most common is fibroadenoma. The relationship between fibroadenoma and breast cancer is not clear. Some epidemiological studies show an association with breast cancer risk, whereas recent reports show no increased risk. In a previous study, we analyzed genetic alterations in a group of BBD lesions composed namely of fibroadenomas unaffected by breast cancer, and we found no evident implication of several loci by Southern blot method. However, genetic alterations, including p53 gene mutations, loss of heterozygosity, microsatellite instability, and cytogenetic chromosomal aberrations, have been reported recently to occur in fibroadenomas. Thus, we reexamined our BBD population for p53 gene mutations and for microsatellite alterations with 13 markers using a PCR-based method. Our results show that no molecular alterations were detected in these BBD lesions composed namely of fibroadenomas unaffected by breast cancer. Neither p53 gene mutations, determined at exons 5-9, nor microsatellite alterations tested with a very sensitive method were found in these lesions. Therefore, molecular results obtained in our study support recent epidemiological data showing that fibroadenoma does not constitute a significant increase in the relative risk of later contracting breast cancer.

Comparative genotyping of Candida albicans bloodstream and nonbloodstream isolates at a polymorphic microsatellite locus

Molecular typing studies have shown that the predominant form of reproduction of Candida albicans is clonal and that, in a majority of situations, persistent or recurrent infections are due to a unique strain. Characterization of distinct subpopulations and correlation with clinical features may thus be important to understanding the pathogenesis of candidiasis. In a clonal model, a unique polymorphic marker may identify populations with different biological properties. We therefore compared 48 bloodstream isolates and 48 nonbloodstream matched strains of C. albicans at the elongation factor 3-encoding gene (CEF3) polymorphic microsatellite locus of C. albicans. Sizing of the alleles was performed by automated capillary electrophoresis. A new, 137-bp allele was characterized, and seven nondescribed combinations were observed, resulting in 15 and 11 distinct CEF3 profiles in bloodstream and control strains, respectively. Genotypes 126-135, 130-136, and 131-131 accounted for 60.4% of both bloodstream and control strains. Four bloodstream isolates but no control strains displayed the 135-135 combination. None of the other genotypes was present at an increased frequency in bloodstream isolates. Bloodstream and nonbloodstream strains of C. albicans thus have a heterogeneous structure at the CEF3 locus, with three major and multiple minor allelic combinations.

Enhancement of mdr1 gene expression in normal tissue adjacent to advanced breast cancer

In the present study, mdr1 gene expression was investigated by a sensitive reverse transcriptase-PCR assay in advanced breast cancer and in corresponding adjacent normal tissues obtained before and after treatment with primary chemotherapy. Comparatively to normal tissues, a significant induction of mdr1 expression was observed in untreated tumors (p = 0.0222). Similarly, a significant induction of mdr1 expression was revealed when treated samples were compared to untreated counterparts (p = 0.0222), but no differences were detected between tumor and normal samples (p = 0.3199). Noteworthy, a significant induction of mdr1 gene expression occurred in treated normal samples comparatively to untreated ones (p = 0.0037), and this induction was even more important in normal than in tumoral tissue (p = 0.0627). However, neither the basal expression nor the induction of mdr1 were correlated with subsequent response to chemotherapy or with survival. Thus, in agreement with previous reports, our data show that chemotherapy induce mdr1 gene expression in breast cancer cells, but they also indicate that a similar phenomenon occurs in adjacent normal tissues. Therefore, our results strongly suggest that mdr1 gene overexpression is not a characteristic of breast malignant cells, but rather constitutes a general phenomenon occurring both in normal and tumor cells which could explain at least in part the absence of relationship between mdr1 expression and the clinical outcome of breast cancer patients.

Cognitive-behavioral treatment of school phobia

OBJECTIVE

To conduct a controlled group outcome investigation of the efficacy of cognitive-behavioral treatment for school phobia.

METHOD

Fifty-six children with school phobia were randomly assigned to 12 weeks of cognitive-behavioral therapy or an attention-placebo control condition. Pre- and posttreatment school attendance, self-reported anxiety and depression, and diagnostic status were compared.

RESULTS

Both the experimental and control treatments were equally effective at returning children to school. Both treatments also were effective in reducing children's anxiety and depressive symptoms. Follow-up revealed no differences between groups when the children reentered school the next school year.

CONCLUSIONS

Overall, results suggest that psychosocial treatments are effective at returning school-phobic children to school and that the highly structured cognitive-behavioral approach may not be superior to more traditional educational and supportive treatment methods.

[Thromboxane A2 production in the pathogenesis of diabetic complications]

BACKGROUND AND AIMS

Thromboxane B2, a stable metabolite of thromboxane A2, was studied in type 2 diabetic patients to evaluate the role played by prostaglandins in the onset of vascular complications.

METHODS

The study was carried out in 30 subjects, 20 of whom were diabetics and 10 controls. Thromboxane B2 was assayed using the "Biotrak Thromboxane B2" kit.

RESULTS

In the first group of control subjects, the mean value of TXB2 was 6.39 +/- 0.89 pg/ml; in the second group, including diabetic patients without vascular complications, TXB2 levels were 8.89 +/- 1.51; in the third, consisting of diabetic patients with microangiopathy, the mean level was 46.28 +/- 6.82; in the fourth, including patients with micro- and macroangiopathy, the mean level was 98.78 +/- 17.15; the fifth group, with a mean value of 41.00 +/- 9.86, included diabetic patients with cerebral vasculopathy. Thromboxane B2 was correlated with glycemia but the results were not statistically significant (r = 0.28; p < 0.05). The correlation with the years since onset of diabetes was positive and statistically significant (r = 0.49; p < 0.05).

CONCLUSIONS

In conclusion, the authors emphasise that TXB2 is present in the circulation in diabetes in steadily increasing quantities over time since the onset of diabetes, leading to chronic vasoconstriction which in turn leads to a deterioration of vascular lesions in the districts where hypoglycemia has already caused the activation of neurotransmitter hormones with consequent slowing down of the blood flow and progressive tissue hypoxia.

Anxious children in adulthood: a prospective study of adjustment

OBJECTIVE

To prospectively examine psychosocial functioning in young adulthood for children and adolescents with anxiety disorders.

METHOD

This 8-year prospective study compared psychosocial functioning in young adults (mean age 22 years) who had histories of early-onset anxiety disorders, comorbid anxiety and depressive disorders, or no history of psychiatric illness (NPI). Follow-up interviews assessed subjects' residential, educational, occupational, and marital status; utilization of mental health services; and psychological status

RESULTS

Anxious subjects without histories of depression were less likely than NPI controls to be living independently. Anxious-depressed subjects were less likely than controls to be working or in school; more likely than purely anxious subjects to utilize mental health services; and more likely than both anxious and control subjects to report psychological problems, most frequently depression.

CONCLUSIONS

Overall, results suggest that children with anxiety disorders are relatively well adjusted in young adulthood. However, a history of comorbid depression is prognostic of a more negative outcome.

Detecting hibernated myocardium with SPECT and thallium-glucose-insulin infusion

Because thallium kinetics, like potassium kinetics, may be affected by serum insulin levels, we performed two pilot studies to identify severely ischemic myocardium using different protocols based on the infusion of a thallium, insulin, potassium and glucose solution. Results were compared with those obtained with two currently used protocols based on rest injection or reinjection of 201Tl.

METHODS

In the first study (Protocol 1) of 15 men with a previous large myocardial infarction, perfusion was evaluated by SPECT in 20 segments after a 30-min infusion of 201Tl (111 MBq), insulin (5 U) and potassium (10 mEq) in 10% glucose solution (250 ml). Imaging was repeated 30 min later and the results were compared with those obtained from stress and 3-hr reinjection images. In the second study (Protocol 2), 15 patients were evaluated randomly at rest and 3 hr later (rest-redistribution). On a separate day, the patients were then re-evaluated after infusion of 201Tl (111 MBq), potassium (10 mEq) and insulin (5 U) in 5% glucose (250 ml); images were obtained 90 and 180 min postinjection.

RESULTS

In Protocol 1, radiotracer activity in segments with no uptake during stress was detected in 35% with the reinjection technique and 58% with the insulin solution protocol. In Protocol 2, 31% of segments revealed thallium activity after insulin infusion but not at rest or rest-redistribution. Serum measurements showed high insulin levels (444 +/- 138 in Protocol 1, 125 +/- 33 mU/ml in Protocol 2), although glucose levels were not significantly altered (149 +/- 32 versus 71 +/- 20 mg/dl, respectively). Potassemia was not affected and the patients tolerated the tests satisfactorily.

CONCLUSION

These results confirm that continuous infusion of 201Tl with a low dose of insulin in a glucose/potassium chloride solution is safe and may enhance cellular uptake of the radiotracer in severe ischemic regions, thereby improving viable myocardium detection.

A new family with chorioretinal dystrophy, spinocerebellar ataxia and hypogonadotropic hypogonadism (Boucher-Neuhäuser syndrome)

A family is described in which two brothers have spinocerebellar ataxia, hypogonadotropic hypogonadism and chorioretinal dystrophy. This report provides further evidence to support the previous suggestion that this triad of manifestations represents a specific single-gene disorder, designated Boucher-Neuhäuser syndrome. Analysis of affected individuals shows that neurological signs usually develop during adolescence or young adulthood (range: early childhood-fourth decade) and are slowly progressive or non-progressive, whereas ophthalmologic manifestations have an age of onset which varies from the first to the sixth decade of life and a pronounced variability in progression.

Autonomic neuropathy in the skin: a histological study of the sympathetic nerve fibres in diabetic anhidrosis

In diabetics with the anhidrotic syndrome, autonomic nerve fibres were studied in skin biopsies using argentic techniques and light microscopy. The Minor test was used to differentiate normal from anhidrotic skin areas. In the anhidrotic areas, histology of the nerve fibres showed beading, spindle-shaped thickening and fragmentation adjacent to the sweat glands. These changes were similar to those observed in two patients who had previously undergone lumbar sympathectomy. No abnormalities of the sympathetic nerve endings could be found in biopsies taken from normal areas of the forearm of the same patients. We conclude that the diabetic anhidrotic syndrome, a form of diabetic autonomic neuropathy, is due to a lesion of the sympathetic nerve supply to the skin. It is suggested that the Minor test or a skin biopsy should be performed in diabetic patients who are being considered for surgical sympathectomy.

[Ultrastructural study of the follicular cells of the adenohypophysis of the chicken]

As in other species, a network of follicular cells linked together by functional complexes can be observed by electron microscopy in the adenohypophysis of the chick. No secretory granules are seen in the follicular cells. They are connected with each other by thin and long processes inserted between the glandular cells and the perivascular spaces. They limit, by their follicular pole, submicroscopic cavities of irregular size and shape. They are empty or occupied by a material of variable density. These cells exist very precociously in the embryo but their characteristic organisation to form a network is observed only on the 16th day of incubation. Our experimental study made it possible to evoke, as a number of other authors, that they play a role in the functions of support, exchange, transport of secretory material or phagocytosis.

[Immunocytochemical study of corticotropic cells in the adenohypophysis of the chick embryo]

Corticotrophin cells of the pituitary have been studied immunocytologically with I.S. anti-A.C.T.H. (1-24) and I.S. anti-A.C.T.H. (17-39). These sera show differentiated cells as soon as the 8th of incubation. These cells remain located within the anterior part of the adenohypophysis. They are not "revelated" by I.S. anti-beta-M.S.H. and I.S. anti-beta-LPH.