Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome

RATIONALE: The hypothesis that lung collapse is detrimental during the acute respiratory distress syndrome is still debatable. One of the difficulties is the lack of an efficient maneuver to minimize it. OBJECTIVES: To test if a bedside recruitment strategy, capable of reversing hypoxemia and collapse in > 95% of lung units, is clinically applicable in early acute respiratory distress syndrome. METHODS: Prospective assessment of a stepwise maximum-recruitment strategy using multislice computed tomography and continuous blood-gas hemodynamic monitoring. MEASUREMENTS AND MAIN RESULTS: Twenty-six patients received sequential increments in inspiratory airway pressures, in 5 cm H(2)O steps, until the detection of Pa(O(2)) + Pa(CO(2)) >or= 400 mm Hg. Whenever this primary target was not met, despite inspiratory pressures reaching 60 cm H(2)O, the maneuver was considered incomplete. If there was hemodynamic deterioration or barotrauma, the maneuver was to be interrupted. Late assessment of recruitment efficacy was performed by computed tomography (9 patients) or by online continuous monitoring in the intensive care unit (15 patients) up to 6 h. It was possible to open the lung and to keep the lung open in the majority (24/26) of patients, at the expense of transient hemodynamic effects and hypercapnia but without major clinical consequences. No barotrauma directly associated with the maneuver was detected. There was a strong and inverse relationship between arterial oxygenation and percentage of collapsed lung mass (R = - 0.91; p < 0.0001). CONCLUSIONS: It is often possible to reverse hypoxemia and fully recruit the lung in early acute respiratory distress syndrome. Due to transient side effects, the required maneuver still awaits further evaluation before routine clinical application.     

Pleural plaques in asbestos-exposed workers: reproducibility of a new high-resolution CT visual semiquantitative measurement method

OBJECTIVE: To assess the reproducibility of a new high-resolution computed tomography (CT) visual semiquantitative method for pleural plaques in asbestos-exposed workers. MATERIAL AND METHODS: We performed thin-section CT in 752 chrysotile asbestos mining workers and ex-workers. Institutional review board approval and signed written informed consent from subjects were obtained. Two readers independently evaluated the 752 CT scans and identified 57 workers (mean age +/- SD, 61.8 years +/- 8.1; range, 37 to 81 years) who had pleural plaques and no other pleural or parenchymal abnormality. Three independent radiologists then quantified the plaque burden in these 57 workers using a scoring system based on the evaluation of the maximum thickness of parietal pleural plaques and percentage of parietal pleural surface involvement. We also calculated the proportion between the number of CT slices with diaphragmatic plaques and the total number of slices in which the diaphragm was seen (pdiaph). The intraobserver and interobserver agreements were analyzed using weighted Kappa coefficient. RESULTS: Interobserver agreements were good for the pleural plaque score (k = 0.61, 0.75, and 0.79) and ranged from good (k = 0.61) to excellent (k = 0.86) for the pdiaph. Intraobserver agreements ranged from good to excellent for the pleural plaque score (k = 0.79 and 1.00) and for the pdiaph (k = 0.79 and 0.93). CONCLUSION: The method proposed for high-resolution CT pleural plaque quantification in asbestos-exposed workers has a high reproducibility.     

Abdominal Surgery in Nonagenarians: Short-Term Results

PURPOSE: To determine the short-term results of abdominal surgery in nonagenarians. METHODS: Retrospective analyses of 193 patients aged 90 and older operated on for abdominal complaints during a 15-year period (1990-2004) in a 500-bed tertiary care institutional hospital and 100-bed rural institutional hospital in Spain. The factors analyzed included the following: perioperative risk, diagnosis, operative procedures, timing of operation (elective or emergency), morbidity, mortality, and length of hospital stay. RESULTS: The most common diagnoses were hernia in 69 cases, colorectal cancer in 39, and biliary lithiasis in 24. One hundred and thirty-seven patients (71%) were operated on on an emergency basis. Forty-seven patients died (24%), with mortality rates of 9% (5/56) and 31% (42/137) respectively, for elective and emergency surgery. None of the 15 patients classified as grade I according to the criteria of the American Society of Anesthesiologists (ASA) died and only 3 out of 63 (5%) died who were ASA grade II. Eighty patients (41%) had postoperative complications. Local morbidity was 16% (n = 30), and systemic morbidity was 30% (n = 58). CONCLUSIONS: Our results support the notion that elective and acute abdominal surgery in nonagenarians can be performed with acceptable rates of mortality and morbidity. Mortality for surgery in nonagenarians is strongly related to the perianesthetic risk (ASA grade), emergency operation, and seriousness of the disease in question.     

Efavirenz related compounds preparation by hydrolysis procedure: setting reference standards for chromatographic purity analysis

A simple procedure for obtaining and purifying two degradation products of efavirenz (amino alcohol and quinoline derivatives) from drug substance hydrolysis is described. These impurities are known to exhibit very different UV absorbance properties from those of the parent compound, making determination using a quantitation factor (QF) inaccurate. The obtained hydrolysis products were characterized by physicochemical methods to assure identity, purity and strength. Quinoline derivative was of high purity degree (100%) and amino alcohol was 98.74% pure. Both were set as reference standards in chromatographic related compounds test for efavirenz drug substance and tablets analyses.     

Fluorescence spectroscopy to diagnose hepatic steatosis in a rat model of fatty liver

Background: Steatosis is diagnosed on the basis of the macroscopic aspect of the liver evaluated by the surgeon at the time of organ extraction or by means of a frozen biopsy. Aim: In the present study, the applicability of laser‐induced fluorescence (LIF) spectroscopy was investigated as a method for the diagnosis of different degrees of steatosis experimentally induced in rats. Material and methods: Rats received a high‐lipid diet for different periods of time. The animals were divided into groups according to the degree of induced steatosis diagnosis by histology. The concentration of fat in the liver was correlated with LIF by means of the steatosis fluorescence factor (SFF). Results: The histology classification, according to liver fat concentration was, Severe Steatosis, Moderate Steatosis, Mild Steatosis and Control (no liver steatosis). Fluorescence intensity could be directly correlated with fat content. It was possible to estimate an average of fluorescence intensity variable by means of different confidence intervals (P=95%) for each steatosis group. SFF was significantly higher in the Severe Steatosis group (P<0.001) compared with the Moderate Steatosis, Mild Steatosis and Control groups. Conclusion: The various degrees of steatosis could be directly correlated with SFF. LIF spectroscopy proved to be a method capable of identifying the degree of hepatic steatosis in this animal model, and has the potential of clinical application for non‐invasive evaluation of the degree of steatosis.     

Coronary Heart Disease and Dyslipidemia: A Cross-Sectional Evaluation of Prevalence, Current Treatment, and Clinical Control in a Large Cohort of Spanish High-Risk Patients: The PRINCEPS Study

The authors assessed a large cohort of patients with coronary heart disease (CHD) or at high risk for developing CHD in terms of lipid profile, lipid-lowering treatment, and attainment of National Cholesterol Education Program (NCEP) target low-density lipoprotein cholesterol (LDL-C) levels. The investigation was a cross-sectional study involving Spanish outpatients treated in primary or secondary care facilities. From a total of 26,598 attending patients, 12,128 with CHD or CHD risk equivalents were recruited by 1875 physicians; 49% had CHD and 69% had multiple risk factors. Only 25% of patients attained LDL-C values <100 mg/dL, 76.6% patients received lipid-lowering therapy (statins in 95.4% of cases), and 54% of physicians considered that a treatment change was required (the most frequent choice was the addition of ezetimibe to current statin therapy). In this large cohort of high-risk coronary patients, only 25% attained a target LDL-C of <100 mg/dL. These results highlight a need for improved patient care and physician awareness/training.