Higher effective oronasal versus nasal continuous positive airway pressure in obstructive sleep apnea: Effect of mandibular stabilization

BACKGROUND:

In some individuals with obstructive sleep apnea (OSA), oronasal continuous positive airway pressure (CPAP) leads to poorer OSA correction than nasal CPAP. The authors hypothesized that this results from posterior mandibular displacement caused by the oronasal mask.

OBJECTIVE:

To test this hypothesis using a mandibular advancement device (MAD) for mandibular stabilization.

METHODS:

Subjects whose OSA was not adequately corrected by oronasal CPAP at pressures for which nasal CPAP was effective were identified. These subjects underwent polysomnography (PSG) CPAP titration with each nasal and oronasal mask consecutively, with esophageal pressure and leak monitoring, to obtain the effective pressure (Peff) of CPAP for correcting obstructive events with each mask (maximum 20 cmH₂O). PSG titration was repeated using a MAD in the neutral position. Cephalometry was performed.

RESULTS:

Six subjects with mean (± SD) nasal Peff 10.4±3.0 cmH₂O were studied. Oronasal Peff was greater than nasal Peff in all subjects, with obstructive events persisting at 20 cmH₂O by oronasal mask in four cases. This was not due to excessive leak. With the MAD, oronasal Peff was reduced in three subjects, and Peff <20 cmH₂O could be obtained in two of the four subjects with Peff >20 cmH₂O by oronasal mask alone. Subjects’ cephalometric variables were similar to published norms.

CONCLUSION:

In subjects with OSA with higher oronasal than nasal Peff, this is partially explained by posterior mandibular displacement caused by the oronasal mask. Combination treatment with oronasal mask and MAD may be useful in some individuals if a nasal mask is not tolerated.     

Hemodynamic Effects of Noninvasive Ventilation in Patients with Venocapillary Pulmonary Hypertension

Background

The hemodynamic effects of noninvasive ventilation with positive pressure in patients with pulmonary hypertension without left ventricular dysfunction are not clearly established.

Objectives

Analyze the impact of increasing airway pressure with continuous positive airway pressure on hemodynamic parameters and, in particular, on cardiac output in patients with variable degrees of pulmonary hypertension.

Methods

The study included 38 patients with pulmonary hypertension caused by mitral stenosis without left ventricular dysfunction or other significant valvulopathy. The hemodynamic state of these patients was analyzed in three conditions: baseline, after continuous positive pressure of 7 cmH₂O and, finally, after pressure of 14 cmH₂O.

Results

The population was composed of predominantly young and female individuals with significant elevation in pulmonary arterial pressure (mean systolic pressure of 57 mmHg). Of all variables analyzed, only the right atrial pressure changed across the analyzed moments (from the baseline condition to the pressure of 14 cmH₂O there was a change from 8 ± 4 mmHg to 11 ± 3 mmHg, respectively, p = 0.031). Even though there was no variation in mean cardiac output, increased values in pulmonary artery pressure were associated with increased cardiac output. There was no harmful effect or other clinical instability associated with use application of airway pressure.

Conclusion

In patients with venocapillary pulmonary hypertension without left ventricular dysfunction, cardiac output response was directly associated with the degree of pulmonary hypertension. The application of noninvasive ventilation did not cause complications directly related to the ventilation systems.     

Airway pressure and transpulmonary pressure during high-frequency oscillation for acute respiratory distress syndrome

High-frequency oscillation is a novel form of ventilation increasingly being used to treat refractory hypoxic respiratory failure resulting from acute lung injury or acute respiratory distress syndrome. Although there is no known relationship between airway pressure and transpulmonary pressure during conventional mechanical ventilation, no study has attempted to determine transpulmonary pressure during high-frequency oscillation.

BACKGROUND:

High-frequency oscillation (HFO) is used for the treatment of refractory hypoxic respiratory failure.

OBJECTIVE:

To demonstrate that the mean transpulmonary pressure (P_L) cannot be inferred from mean airway pressure (mPaw).

METHODS:

In seven patients already undergoing HFO for refractory acute respiratory distress syndrome, esophageal pressure (Pes) was measured using an esophageal balloon catheter. Pleural pressure (Ppl) and P_L were calculated from Pes.

MAIN RESULTS:

In the seven patients (mean [± SD] age 59±9 years) treated with HFO at 5±1 Hz and amplitude 75±10 cmH₂O, the mPaw was 27±6 cmH₂O, Ppl was 9±6 cmH₂O and P_L was 18±11 cmH₂O. Successful catheter placement and measurement of Pes occurred in 100% of subjects. There was no correlation between P_L and mPaw. The majority of subjects required hemodynamic support during the use of HFO; the frequency and degree of support during the study period was no different than that before the study.

CONCLUSION:

The present report is the first to describe measuring Pes and calculating Ppl during HFO for acute respiratory distress syndrome. While both current guidelines and recent trials have titrated treatment based on mPaw and oxygenation, there is wide variability in P_L during HFO and P_L cannot be predicted from mPaw.     

Chest compression with a higher level of pressure support ventilation: effects on secretion removal,hemodynamics, and respiratory mechanics in patients on mechanical ventilation

OBJECTIVE:

To determine the efficacy of chest compression accompanied by a 10-cmH₂O increase in baseline inspiratory pressure on pressure support ventilation, in comparison with that of aspiration alone, in removing secretions, normalizing hemodynamics, and improving respiratory mechanics in patients on mechanical ventilation.

METHODS:

This was a randomized crossover clinical trial involving patients on mechanical ventilation for more than 48 h in the ICU of the Porto Alegre Hospital de Clínicas, in the city of Porto Alegre, Brazil. Patients were randomized to receive aspiration alone (control group) or compression accompanied by a 10-cmH₂O increase in baseline inspiratory pressure on pressure support ventilation (intervention group). We measured hemodynamic parameters, respiratory mechanics parameters, and the amount of secretions collected.

RESULTS:

We included 34 patients. The mean age was 64.2 ± 14.6 years. In comparison with the control group, the intervention group showed a higher median amount of secretions collected (1.9 g vs. 2.3 g; p = 0.004), a greater increase in mean expiratory tidal volume (16 ± 69 mL vs. 56 ± 69 mL; p = 0.018), and a greater increase in mean dynamic compliance (0.1 ± 4.9 cmH₂O vs. 2.8 ± 4.5 cmH₂O; p = 0.005).

CONCLUSIONS:

In this sample, chest compression accompanied by an increase in pressure support significantly increased the amount of secretions removed, the expiratory tidal volume, and dynamic compliance. (ClinicalTrials.gov Identifier:{"type":"clinical-trial","attrs":{"text":"NCT01155648","term_id":"NCT01155648"}}NCT01155648 [http://www.clinicaltrials.gov/])     

The effects of cyclooxygenase and nitric oxide synthase inhibition on cardiodynamic parameters and coronary flow in isolated rat hearts

BACKGROUND:

Despite the widespread clinical use of cyclooxygenase (COX) inhibitors, dilemmas regarding the potential impact of these drugs on the cardiovascular system persist.

OBJECTIVE:

To estimate the effects of different COX inhibitors (meloxicam, acetylsalicylic acid [ASA] and SC-560) on cardiac function and coronary flow in isolated rat hearts, with special focus on the L-arginine/nitric oxide system.

METHODS:

The hearts of eight-week-old male Wistar albino rats (n=72; 12 rats per group; body mass 180 g to 200 g) were retrogradely perfused according to the Langendorff technique at gradually increased perfusion pressure (40 cmH₂O to 120 cmH₂O). After control experiments, the hearts were perfused with the following drugs: 100 μM ASA, alone or in combination with 30 μM N(ω)-nitro-L-arginine monomethyl ester (L-NAME), 0.3 μM meloxicam with or without 30 μM L-NAME, 3 μM meloxicam with or without 30 μM L-NAME, 30 μM L-NAME and 0.25 μM SC-560. In the control and experimental groups, the following parameters of heart function were continuously recorded: maximum rate of left ventricular pressure development, minimum rate of left ventricular pressure development, systolic left ventricular pressure, diastolic left ventricular pressure, heart rate and mean blood pressure. Coronary flow was measured flowmetrically. The amount of released NO₂⁻ was determined spectrophotometrically in coronary venous effluent.

RESULTS:

While meloxicam and SC-560 were found to have an adverse influence on cardiac function and coronary perfusion, ASA did not negatively affect the intact model of the heart.

CONCLUSION:

It appeared that interaction between COX and the L-arginine/nitric oxide system truly exists in coronary circulation and may explain the causes of the observed effects.     

Evaluation of manual resuscitators used in ICUs in Brazil

OBJECTIVE:

To evaluate the performance of manual resuscitators (MRs) used in Brazil in accordance with international standards.

METHODS:

Using a respiratory system simulator, four volunteer physiotherapists employed eight MRs (five produced in Brazil and three produced abroad), which were tested for inspiratory and expiratory resistance of the patient valve; functioning of the pressure-limiting valve; and tidal volume (V_T) generated when the one-handed and two-handed techniques were used. The tests were performed and analyzed in accordance with the American Society for Testing and Materials (ASTM) F920-93 criteria.

RESULTS:

Expiratory resistance was greater than 6 cmH₂O . L⁻¹ . s⁻¹ in only one MR. The pressure-limiting valve, a feature of five of the MRs, opened at low pressures (< 17 cmH₂O), and the maximal pressure was 32.0-55.9 cmH₂O. Mean V_T varied greatly among the MRs tested. The mean V_T values generated with the one-handed technique were lower than the 600 mL recommended by the ASTM. In the situations studied, mean V_T was generally lower from the Brazilian-made MRs that had a pressure-limiting valve.

CONCLUSIONS:

The resistances imposed by the patient valve met the ASTM criteria in all but one of the MRs tested. The pressure-limiting valves of the Brazilian-made MRs usually opened at low pressures, providing lower V_T values in the situations studied, especially when the one-handed technique was used, suggesting that both hands should be used and that the pressure-limiting valve should be closed whenever possible.     

The usefulness of Wi-Fi based digital chest drainage system in the post-operative care of pneumothorax

Background

Chest drainage systems are usually composed of chest tube and underwater-seal bottle. But this conventional system may restrict patients doing exercise and give clinicians obscure data about when to remove tubes because there is no objective indicator. Recently developed digital chest drainage systems may facilitate interpretation of the grade of air leak and make it easy for clinicians to decide when to remove chest tubes. In addition, with combination of wireless internet devices, monitoring and managing of drainage system distant from the patient is possible.

Methods

Sixty patients of primary pneumothorax were included in a prospective randomized study and divided into two groups. Group I (study) consisted of digital chest drainage system while in group II (control), conventional underwater-seal chest bottle system was used. Data was collected from January, 2012 to September, 2013 in Eulji University Hospital, Daejeon, Korea.

Results

There was no difference in age, sex, smoking history and postoperative pain between two groups. But the average length of drainage was 2.2 days in group I and 3.1 days in group II (P<0.006). And more, about 90% of the patients in group I was satisfied with using new device for convenience.

Conclusions

Digital system was beneficial on reducing the length of tube drainage by real time monitoring. It also had advantage in portability, loudness and gave more satisfaction than conventional system. Moreover, internet based digital drainage system will be a good method in thoracic telemedicine area in the near future.     

Acute Effects of Continuous Positive Air way Pressure on Pulse Pressure in Chronic Heart Failure

Background

Patients with heart failure (HF) have left ventricular dysfunction and reduced mean arterial pressure (MAP). Increased adrenergic drive causes vasoconstriction and vessel resistance maintaining MAP, while increasing peripheral vascular resistance and conduit vessel stiffness. Increased pulse pressure (PP) reflects a complex interaction of the heart with the arterial and venous systems. Increased PP is an important risk marker in patients with chronic HF (CHF). Non-invasive ventilation (NIV) has been used for acute decompensated HF, to improve congestion and ventilation through both respiratory and hemodynamic effects. However, none of these studies have reported the effect of NIV on PP.

Objective

The objective of this study was to determine the acute effects of NIV with CPAP on PP in outpatients with CHF.

Methods

Following a double-blind, randomized, cross-over, and placebo-controlled protocol, twenty three patients with CHF (17 males; 60 ± 11 years; BMI 29 ± 5 kg/cm², NYHA class II, III) underwent CPAP via nasal mask for 30 min in a recumbent position. Mask pressure was 6 cmH₂O, whereas placebo was fixed at 0-1 cmH₂O. PP and other non invasive hemodynamics variables were assessed before, during and after placebo and CPAP mode.

Results

CPAP decreased resting heart rate (Pre: 72 ± 9; vs. Post 5 min: 67 ± 10 bpm; p < 0.01) and MAP (CPAP: 87 ± 11; vs. control 96 ± 11 mmHg; p < 0.05 post 5 min). CPAP decreased PP (CPAP: 47 ± 20 pre to 38 ± 19 mmHg post; vs. control: 42 ± 12 mmHg, pre to 41 ± 18 post p < 0.05 post 5 min).

Conclusion

NIV with CPAP decreased pulse pressure in patients with stable CHF. Future clinical trials should investigate whether this effect is associated with improved clinical outcome.     

Determining optimal fluid and air leak cut off values for chest drain management in general thoracic surgery

Background

Chest drain duration is one of the most important influencing aspects of hospital stay but the management is perhaps one of the most variable aspects of thoracic surgical care. The aim of our study is to report outcomes associated with increasing fluid and air leak criteria of protocol based management.

Methods

A 6-year retrospective analysis of protocolised chest drain management starting in 2007 with a fluid criteria of 3 mL/kg increasing to 7 mL/kg in 2011 to no fluid criteria in 2012, and an air leak criteria of 24 hours without leak till 2012 when digital air leak monitoring was introduced with a criteria of <20 mL/min of air leak for more than 6 hours. Patient data were obtained from electronic hospital records and digital chest films were reviewed to determine the duration of chest tube drainage and post-drain removal complications.

Results

From 2009 to 2012, 626 consecutive patients underwent thoracic surgery procedures under a single consultant. A total of 160 did not require a chest drain and data was missing in 22, leaving 444 for analysis. The mean age [standard deviation (SD)] was 57±19 years and 272 (61%) were men. There were no differences in the incidence of pneumothoraces (P=0.191), effusion (P=0.344) or re-interventions (P=0.431) for drain re-insertions as progressively permissive criteria were applied. The median drain duration dropped from 1-3 days (P<0.001) and accordingly hospital stay reduced from 4-6 days (P<0.001).

Conclusions

Our results show that chest drains can be safely removed without fluid criteria and air leak of less than 20 mL/min with median drain duration of 1 day, associated with a reduced length of hospital stay.     

Acute lung injury induced by the intravenous administration of cigarette smoke extract

OBJECTIVE:

To investigate the acute effects of intravenous administration of cigarette smoke extract (CSE) on histological, inflammatory, and respiratory function parameters in rats, as well as to compare this potential acute lung injury (ALI) model with that with the use of oleic acid (OA).

METHODS:

We studied 72 Wistar rats, divided into four groups: control (those injected intravenously with saline); CSE (those injected intravenously with CSE and saline); OA (those injected intravenously with saline and OA); and CSE/OA (those injected intravenously with CSE and OA).

RESULTS:

Mean lung compliance was significantly lower in the OA and CSE/OA groups (2.12 ± 1.13 mL/cmH₂O and 1.82 ± 0.77 mL/cmH₂O, respectively)than in the control group (3.67 ± 1.38 mL/cmH₂O). In bronchoalveolar lavage fluid, the proportion of neutrophils was significantly higher in the OA and CSE/OA groups than in the control group, as was the activity of metalloproteinases 2 and 9. Pulmonary involvement, as assessed by morphometry, was significantly more severe in the OA and CSE/OA groups (72.9 ± 13.8% and 77.6 ± 18.0%, respectively) than in the control and CSE groups (8.7 ± 4.1% and 32.7 ± 13.1%, respectively), and that involvement was significantly more severe in the CSE group than in the control group.

CONCLUSIONS:

The intravenous administration of CSE, at the doses and timing employed in this study, was associated with minimal ALI. The use of CSE did not potentiate OA-induced ALI. Additional studies are needed in order to clarify the potential role of this model as a method for studying the mechanisms of smoking-induced lung injury.     

Midterm results of “treat and repair” for adults with non-restrictive ventricular septal defect and severe pulmonary hypertension

Background

A non-restrictive ventricular septal defect (VSD) can cause intracardiac left to right shunt, which leads to increased pulmonary vascular resistance (PVR) and pulmonary hypertension causes bi-directional or even right-left shunt, namely the Eisenmenger’s syndrome. For patients with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger’s syndrome, traditional VSD repair carries high mortality and poor prognosis. Recently, targeted drug therapy was used to decrease pulmonary circulation resistance in these patients before they receive defect repair surgery, namely “treat and repair” strategy, however, there is few reports about the midterm result of this strategy in adults with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger’s syndrome.

Methods

In this study, we used this strategy to treat 41 adult VSD patients who received bosentan as the targeted therapy to decrease their PVR before and after repair surgery.

Results

A total of 39 patients were followed up for an average of 37 months. None of the patients died during follow-up. Among them, 36 cases continued targeted drug therapy, whose mean pulmonary artery pressure (mPAP) was significantly reduced, including 31 cases with mPAP <50 mmHg, and the valve of tap hole was closed. Besides, the SpO₂ was significantly elevated.

Conclusions

These results demonstrated that “treat-and-repair” strategy may be a viable approach for the adults with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger’s syndrome.     

The protective effects of glutamine in a rat model of ventilator-induced lung injury

Background

The mortality rate of patients with acute respiratory distress syndrome (ARDS) is still high despite the use of protective ventilatory strategies. We sought to examine the pharmacological effects of glutamine (GLN) in a two-hit model of endotoxin-induced inflammation followed by ventilator-induced lung injury (VILI). We hypothesized that the administration of GLN ameliorates the VILI.

Methods

Sprague-Dawley rats were anesthetized and given lipopolysaccharide (LPS) intratracheally as a first hit to induce lung inflammation, followed 24 h later by a second hit of mechanical ventilation (MV) with either low tidal volume (6 mL/kg) with 5 cmH₂O of positive end-expiratory pressure (PEEP) or high tidal volume (22 mL/kg) with zero PEEP for 4 h. GLN or lactated Ringer’s solution as the placebo was administered intravenously 15 min prior to MV.

Results

In the LPS-challenged rats ventilated with high tidal volume, the treatment with GLN improved lung injury indices, lung mechanics and cytokine responses compared with the placebo group.

Conclusions

The administration of GLN given immediately prior to MV may be beneficial in the context of reducing VILI.     

CMS Reimbursement Reform and the Incidence of Hospital-Acquired Pulmonary Embolism or Deep Vein Thrombosis

BACKGROUND

In October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for the marginal cost of treating certain preventable hospital-acquired conditions.

OBJECTIVE

This study evaluates whether CMS’s refusal to pay for hospital-acquired pulmonary embolism (PE) or deep vein thrombosis (DVT) resulted in a lower incidence of these conditions.

DESIGN

We employ difference-in-differences modeling using 2007–2009 data from the Nationwide Inpatient Sample, an all-payer database of inpatient discharges in the U.S. Discharges between 1 January 2007 and 30 September 2008 were considered “before payment reform;” discharges between 1 October 2008 and 31 December 2009 were considered “after payment reform.” Hierarchical regression models were fit to account for clustering of observations within hospitals.

PARTICIPANTS

The “before payment reform” and “after payment reform” incidences of PE or DVT among 65–69-year-old Medicare recipients were compared with three different control groups of: a) 60–64-year-old non-Medicare patients; b) 65–69-year-old non-Medicare patients; and c) 65–69-year-old privately insured patients. Hospital reimbursements for the control groups were not affected by payment reform.

INTERVENTION

CMS payment reform for hospital-based reimbursement of patients with hip and knee replacement surgeries.

MAIN MEASURES

The outcome was the incidence proportion of hip and knee replacement surgery admissions that developed pulmonary embolism or deep vein thrombosis.

KEY RESULTS

At baseline, pulmonary embolism or deep vein thrombosis were present in 0.81 % of all hip or knee replacement surgeries for Medicare patients aged 65–69 years old. CMS payment reform resulted in a 35 % lower incidence of hospital-acquired pulmonary embolism or deep vein thrombosis in these patients (p = 0.015). Results were robust to sensitivity analyses.

CONCLUSION

CMS’s refusal to pay for hospital-acquired conditions resulted in a lower incidence of hospital-acquired pulmonary embolism or deep vein thrombosis after hip or knee replacement surgery. Payment reform had the desired direction of effect.KEY WORDS: payment reform, pay-for-performance, hospital-acquired conditions, pulmonary embolism, deep vein thrombosis     

Care of the liver transplant patient

OBJECTIVE:

To provide an approach to the care of liver transplant (LT) patients, a growing patient population with unique needs.

METHODS:

A literature search of PubMed for guidelines and review articles using the keywords “liver transplantation”, “long term complications” and “medical management” was conducted, resulting in 77 articles.

RESULTS:

As a result of being on immunosuppression, LT recipients are at increased risk of infections and must be screened regularly for metabolic complications and malignancies.

DISCUSSION:

Although immunosuppression is key to maintaining allograft health after transplantation, it comes with its own set of medical issues to follow. Physicians following LT recipients must be aware of the greater risk for hypertension, diabetes, dyslipidemia, renal failure, metabolic bone disease and malignancies in these patients, all of whom require regular monitoring and screening. Vaccination, quality of life, sexual function and pregnancy must be specifically addressed in transplant patients.     

Immunoglobulin G4-related pancreatic and biliary diseases

BACKGROUND:

Autoimmune pancreatitis and autoimmune cholangitis are new clinical entities that are now recognized as the pancreaticobiliary manifestations of immunoglobulin (Ig) G4-related disease.

OBJECTIVE:

To summarize important clinical aspects of IgG4-related pancreatic and biliary diseases, and to review the role of IgG4 in the diagnosis of autoimmune pancreatitis (AIP) and autoimmune cholangitis (AIC).

METHODS:

A narrative review was performed using the PubMed database and the following keywords: “IgG4”, “IgG4 related disease”, “autoimmune pancreatitis”, “sclerosing cholangitis” and “autoimmune cholangitis”. A total of 955 articles were retrieved; of these, 381 contained relevant data regarding the IgG4 molecule, pathogenesis of IgG-related diseases, and diagnosis, management and long-term follow-up for patients with AIP and AIC. Of these 381 articles, 66 of the most pertinent were selected.

RESULTS:

The selected studies demonstrated the increasing clinical importance of both AIP and AIC, which can mimic pancreatic cancer and cholangiocarcinoma, respectively. IgG4 titration in tissue or blood cannot be used alone to diagnose all IgG4-related diseases; however, it is often a useful adjunct to clinical, radiological and histological features. AIP and AIC respond to steroids; however, relapse is common and long-term maintenance treatment often required.

CONCLUSIONS:

A review of the diagnosis and management of both AIC and AIP is timely and pertinent to clinical practice because the amount of information regarding these conditions has increased substantially in the past few years, resulting in significant impact on the clinical management of affected patients.     

Meta-analysis of the diagnostic yield and safety of electromagnetic navigation bronchoscopy for lung nodules

Objective

This meta-analysis is to evaluate the overall diagnostic yield and accuracy of electromagnetic navigation bronchoscopy (ENB)-based targeted biopsies in detecting peripheral lesions.

Methods

A systematic search in PubMed was performed using “electromagnetic navigation bronchoscopy” crossed with “peripheral lesions” and “lung nodules”. Test performance characteristics with the use of forest plots, summary receiver operating characteristic curves (SROCs) and bivariate random effects were summarized using Meta-Disc software. Adverse events and complications were recorded if reported.

Results

A total of 17 studies (1,106 patients with peripheral lung lesions) were included in this analysis. The pooled sensitivity, specificity, positive likelihood ratios (PLRs), negative likelihood ratios (NLRs), and diagnostic odds ratios (DORs) of ENB was 82%, 100%, 19.36, 0.23, and 97.62, respectively. The area under the curve (AUC) for the SROC was 0.9786. No procedure-related complication was found.

Conclusions

ENB is an effective and safe procedure in diagnosing peripheral lung lesions.     

The use of risk scores for stratification of non-ST elevation acute coronary syndrome patients

OBJECTIVE:

To review the methods available for the risk stratification of non-ST elevation (NSTE) acute coronary syndrome (ACS) patients and to evaluate the use of risk scores for their initial risk assessment.

DATA SOURCES:

The data of the present review were identified by searching PUBMED and other databases (1996 to 2008) using the key terms “risk stratification”, “risk scores”, “NSTEMI”, “UA” and “acute coronary syndrome”.

STUDY SELECTION:

Mainly original articles, guidelines and critical reviews written by major pioneer researchers in this field were selected.

RESULT:

After evaluation of several risk predictors and risk scores, it was found that estimating risk based on clinical characteristics is challenging and imprecise. Risk predictors, whether used alone or in simple binary combination, lacked sufficient precision because they have high specificity but low sensitivity. Risk scores are more accurate at stratifying NSTE ACS patients into low-, intermediate- or high-risk groups. The Global Registry of Acute Cardiac Events risk score was found to have superior predictive accuracy compared with other risk scores in ACS population. Treatments based according to specific clinical and risk grouping show that certain benefits may be predominantly or exclusively restricted to higher risk patients.

CONCLUSION:

Based on the trials in the literature, the Global Registry of Acute Cardiac Events risk score is more advantageous and easier to use than other risk scores. It can categorize a patient’s risk of death and/or ischemic events, which can help tailor therapy to match the intensity of the patient’s NSTE ACS.     

National Patterns in Diabetes Screening: Data from the National Health and Nutrition Examination Survey (NHANES) 2005–2012

BACKGROUND

There are few current population-based estimates of the patterns of diabetes screening in the United States. The American Diabetes Association (ADA) recommends universal screening of adults ≥ 45 years, and high-risk adults < 45 years, but there is no current assessment of ADA guideline performance in detecting diabetes and prediabetes. Furthermore, data on racial/ethnic patterns of screening are limited.

OBJECTIVE

Our aim was to estimate diabetes screening prevalence for the US adult population and specifically for those who meet ADA criteria; to report the prevalence of prediabetes and diabetes among these groups; and to determine if high-risk race/ethnicity was associated with reported screening.

DESIGN

This was a Cross-sectional survey.

PARTICIPANTS

Non-pregnant adults (≥ 21 years) without diabetes or prediabetes who participated in the National Health and Nutrition Examination Survey (NHANES) in 2005–2012 (n = 17,572) were included in the study. “Screening-recommended” participants, classified by ADA criteria, included (1) adults ≥ 45 years and (2) “high-risk” adults < 45 years. “Screening-not-recommended” participants were adults < 45 years who did not meet criteria.

MAIN MEASURES

Diabetes screening status was obtained by self-report. We used calibrated HbA_1c and/or fasting glucose levels to define undiagnosed diabetes and prediabetes.

KEY RESULTS

Seventy-six percent of the study population (approximately 136 million US adults) met ADA criteria. Among them, less than half (46.2 %) reported screening; undiagnosed diabetes affected 3.7 % (5 million individuals), and undiagnosed prediabetes affected 36.3 % (49 million people.) African Americans were more likely to report screening, both among adults ≥ 45 years and among “high risk” younger adults (OR 1.27 and 1.36, respectively.) Hispanic participants were also more likely to report screening (OR 1.31 for older adults, 1.42 for younger adults.) The screening rate among “screening-not-recommended” adults was 29.6 %; the prevalence of diabetes and prediabetes were 0.4 and 10.2 %, respectively.

CONCLUSIONS

In a nationally representative sample, 76 % of adults met ADA screening criteria, of whom fewer than half reported screening. Limitations include cross-sectional design and screening self-report.KEY WORDS: diabetes screening, prediabetes, NHANES, ADA, disparities     

Prophylactic use of noninvasive positive pressure ventilation in post-thoracic surgery patients: A prospective randomized control study

Objective

Prospective randomized controlled study was conducted to explore the effects and safety of prophylactic use of noninvasive positive pressure ventilation (NPPV) in post-thoracic surgery (PTS) patients, especially on the lung re-expansion, lung function change and postoperative pulmonary complications (PPCs).

Methods

Fifty PTS patients met the inclusion criterion were enrolled in the study. All subjects were randomly divided into conventional treatment (control) group and NPPV group. NPPV group received intermittent NPPV therapy in first three days of PTS. BiPAP ventilator was used with S/T mode in the study. The average IPAP was (13±3.2)cmH₂O (ranged from 7 to 18 cmH₂O) and EPAP was 4cmH₂O. Total ventilation time was (13.5±4.9) hours (ranged from 6.5 to 23 hours). PPCs rate, lung re-expansion, the volume of residual cavity, lung function and tolerance to NPPV were assessed with chest roentgenography, CT scan, lung function testing and clinical evaluation before and one week after surgery.

Results

1. There was no significant difference of total PPCs rate during hospitalization between the two groups (5/23 in NPPV group vs 6/27 in control group, P= 0.967). Multiple factorial logistic regression analysis showed that COPD was a risk factor for PPCs (B=1.705, P=0.027). 2. Compared with control group, NPPV therapy reduced inadequate lung expansion rate (3/23 vs 13/27, P=0.008) and volume of residual cavity calculated with CT scan [(31.9±71.7)ml vs (63.6±78.3)ml, P=0.02]. However, there were no significant difference in the change of lung function parameters after operation between the two groups (all P>0.05). No significant adverse effects of NPPV were found in the present study.

Conclusions

In the current study of prophylactic application of NPPV in post-thoracic surgery patients, the use of NPPV resulted in improved lung re-expansion, but had no significant effects on post-operative pulmonary complications and lung functions.     

A Novel Algorithm to Quantify Coronary Remodeling Using Inferred Normal Dimensions

Background

Vascular remodeling, the dynamic dimensional change in face of stress, can assume different directions as well as magnitudes in atherosclerotic disease. Classical measurements rely on reference to segments at a distance, risking inappropriate comparison between dislike vessel portions.

Objective

to explore a new method for quantifying vessel remodeling, based on the comparison between a given target segment and its inferred normal dimensions.

Methods

Geometric parameters and plaque composition were determined in 67 patients using three-vessel intravascular ultrasound with virtual histology (IVUS-VH). Coronary vessel remodeling at cross-section (n = 27.639) and lesion (n = 618) levels was assessed using classical metrics and a novel analytic algorithm based on the fractional vessel remodeling index (FVRI), which quantifies the total change in arterial wall dimensions related to the estimated normal dimension of the vessel. A prediction model was built to estimate the normal dimension of the vessel for calculation of FVRI.

Results

According to the new algorithm, “Ectatic” remodeling pattern was least common, “Complete compensatory” remodeling was present in approximately half of the instances, and “Negative” and “Incomplete compensatory” remodeling types were detected in the remaining. Compared to a traditional diagnostic scheme, FVRI-based classification seemed to better discriminate plaque composition by IVUS-VH.

Conclusion

Quantitative assessment of coronary remodeling using target segment dimensions offers a promising approach to evaluate the vessel response to plaque growth/regression.