Dyspnea and respiratory muscle strength in end-stage liver disease

AIM: To investigate the prevalence of chronic dyspnea and its relationship to respiratory muscle function in end-stage liver disease. METHODS: Sixty-eight consecutive, ambulatory, Caucasian patients with end-stage liver disease, candidates for liver transplantation, were referred for preoperative respiratory function assessment. Forty of these (29 men) were included in this preliminary study after applying strict inclusion and exclusion criteria. Seventeen of 40 patients (42%) had ascites, but none of them was cachectic. Fifteen of 40 patients (38%) had a history of hepatic encephalopathy, though none of them was symptomatic at study time. All patients with a known history and/or presence of co-morbidities were excluded. Chronic dyspnea was rated according to the modified medical research council (mMRC) 6-point scale. Liver disease severity was assessed according to the Model for end-stage liver disease (MELD). Routine lung function tests, maximum static expiratory (Pemax) and inspiratory (Pimax) mouth pressures were measured. Respiratory muscle strength (RMS) was calculated from Pimax and Pemax values. In addition, arterial blood gases and pattern of breathing (V_E: minute ventilation; V_T: tidal volume; V_T/T_I: mean inspiratory flow; T_I: duration of inspiration) were measured. RESULTS: Thirty-five (88%) of 40 patients aged (mean ± SD) 52 ± 10 years reported various degrees of chronic dyspnea (mMRC), ranging from 0 to 4, with a mean value of 2.0 ± 1.2. MELD score was 14 ± 6. Pemax, percent of predicted (%pred) was 105 ± 35, Pimax, %pred was 90 ± 29, and RMS, %pred was 97 ± 30. These pressures were below the normal limits in 12 (30%), 15 (38%), and 14 (35%) patients, respectively. Furthermore, comparing the subgroups of ascites to non-ascites patients, all respiratory muscle indices measured were found significantly decreased in ascites patients. Patients with ascites also had a significantly worse MELD score compared to non-ascites ones (P = 0.006). Significant correlations were found between chronic dyspnea and respiratory muscle function indices in all patients. Specifically, mMRC score was significantly correlated with Pemax, Pimax, and RMS (r = -0.53, P < 0.001; r = -0.42, P < 0.01; r = -0.51, P < 0.001, respectively). These correlations were substantially closer in the non-ascites subgroup (r = -0.82, P < 0.0001; r = -0.61, P < 0.01; r = -0.79, P < 0.0001, respectively) compared to all patients. Similar results were found for the relationship between mMRC vs MELD score, and MELD score vs respiratory muscle strength indices. In all patients the sole predictor of mMRC score was RMS (r = -0.51, P < 0.001). In the subgroup of patients without ascites this relationship becomes closer (r = -0.79, P < 0.001), whilst this relationship breaks down in the subgroup of patients with ascites. The disappearance of such a correlation may be due to the fact that ascites acts as a “confounding” factor. PaCO₂ (4.4 ± 0.5 kPa) was increased, whereas pH (7.49 ± 0.04) was decreased in 26 (65%) and 34 (85%) patients, respectively. PaO₂ (12.3 ± 0.04 kPa) was within normal limits. V_E (11.5 ± 3.5 L/min), V_T (0.735 ± 0.287 L), and V_T/T_I (0.449±0.129 L/s) were increased signifying hyperventilation in both subgroups of patients. V_T/T_I was significantly higher in patients with ascites than without ascites. Significant correlations, albeit weak, were found for PaCO₂ with V_E and V_T/T_I (r = -0.44, P < 0.01; r = -0.41, P < 0.01, respectively). CONCLUSION: The prevalence of chronic dyspnea is 88% in end-stage liver disease. The mMRC score closely correlates with respiratory muscle strength.     

原发性开角型青光眼视盘形态变化分析33例(英文)

目的:分析原发性开角型青光眼(POAG)视盘损害的进展和进展频率。方法:33例(66眼)POAG患者,男14例,女19例,年龄14 ～79岁,在随访的6a间(2000/2006),3次或更多次进行海德堡视网膜断层扫描仪Ⅱ(HRT Ⅱ)检查。对整体和节段的视盘参数进行回归分析判断视盘损害的进展。患者每年进行Octopus G1计算机视野分析检查一次。激光扫描视盘图像参数包括:盘沿面积(ra),杯盘比(C/D),盘沿体积(rv),平均视神经纤维层厚度(mRNFL)。扫描视神经的节段包括总体(G),颞侧(T),颞上(TS),颞下(TI),鼻侧(N),鼻上方(NS)和鼻下(NI)。结果:根据杯盘比C/D,总体上有34眼(51%)视盘损害进展,32眼(48%)没有进展。12眼(18%)颞侧(T),7眼(10.6%)颞上,14眼(21%)颞下,8眼(12%)鼻侧,7眼(10,6%)鼻上,13眼(20%)鼻下,视盘损害进展。5眼(8%)没有进展。结论:在鼻侧(N)及颞下方(TI)视盘损害进展最多,进展频率最高在颞下方(TI)和鼻下方(NI),频率最低在鼻上方(NI)。杯盘比C/D最敏感。节段扫描对POAG进展分析有重要意义。     

Expression of carcinoembryonic antigen by adenoma and carcinoma derived epithelial cell lines: possible marker of tumour progression and modulation of expression by sodium butyrate

We have used an indirect immunofluorescence assay to demonstratethe cell membrane expression of carcinoembryonic antigen (CEA)by a pre-malignant colorectal adenoma derived epithelial cellline (PC/AA) and three colorectal carcinoma cell lines (HT29,PC/JW and PC/JW/FI). The results obtained indicated that CEAmay be used as a marker for tumour progression up to the pointof malignant transformation, after which the selection for anaplasticvariants during continuous in vitro culture may result in thesubsequent reduction of cell membrane CEA expression. The percentageof PC/AA cells expressing cell membrane CEA increased from 23.1%of diploid early passage (passage 18) cells to 56.0% of aneuploidlate passage (passage 58) cells. Although non-tumorigenic, theproportion of PC/AA cells expressing cell membrane CEA at latepassage corresponded to that for the PC/JW carcinoma line (56.2%)and is further evidence for the progression of PC/AA in culture.A 3T3 feeder-independent variant of PC/JW (PC/JW/FI) demonstrateda similar percentage of CEA-positive cells as the parental linefor the first 21 passages without feeder support, but by passage27 without 3T3 feeders only 35.3% of cells stained positive.This could be restored to 62.0% by continuous treatment withsodium butyrate (2 mM). A differential growth response to sodiumbutyrate was noted for the pre-malignant adenoma cell line PC/AAand the carcinoma lines HT29 and PC/JW/FI. Concentrations ofsodium butyrate (2 mM) that killed early passage PC/AA cellsallowed the late passage PC/AA cells and the carcinoma linesto proliferate, raising the possibility of sodium butyrate actingas a tumour promotor in the human colorectum.     

H1N1 influenza: critical care aspects

During the Northern Hemisphere spring of 2009, a novel H1N1 influenza A virus emerged in Mexico, causing widespread human infection and acute critical respiratory illness. The 2009 H1N1 virus spread initially to the United States and Canada, with subsequent rapid global dissemination, leading the World Health Organization (WHO) to declare "a public health emergency of international concern" in April 2009, and upgrading the viral threat to pandemic status in June 2009. Despite initial fears, the severity of the 2009 H1N1 pandemic overall did not differ significantly from that of seasonal influenza. However, the demographics of those at risk of severe illness did differ (affecting children and young adults, rather than the very young and the very old). The 2009 H1N1 pandemic led to rapid implementation of health care initiatives, including the provision of critical care services, to limit the effect of the influenza outbreak on the community. This review focuses on the critical care response to the H1N1 pandemic and examines whether the implementation of critical care services as planned a priori matched the reality of the clinical workload and the patient burden that transpired during the 2009 H1N1 influenza pandemic.     

Sedation in digestive endoscopy: the Athens international position statements

Aliment Pharmacol Ther 2010; 32: 425–442

Summary

Background Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field. Aim To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy. Methods Thirty‐two position statements were reviewed during a 1 ½‐day meeting. Thirty‐two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence‐based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll. Results The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low‐risk patients undergoing endoscopic procedures. Conclusions While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.