Clinical practice guideline for the use of noninvasive positive pressure ventilation in COPD patients with acute respiratory failure

Noninvasive positive pressure ventilation has been demonstrated to be of benefit in preventing endotracheal intubation and reducing mortality in specific patients in the setting of acute exacerbations of chronic obstructive pulmonary disease. The successful application of noninvasive positive pressure ventilation depends on a multitude of factors, including patient selection, choice of interface, physician experience, and patient-ventilator synchrony. The use of clinical practice guidelines has been shown to improve the process and outcomes of care. This paper presents a guideline for the use of noninvasive positive pressure ventilation in the setting of acute ventilatory failure in patients with acute exacerbations of chronic obstructive pulmonary disease.     

Determination of 24 minor red blood cell antigens for more than 2000 blood donors by high-throughput DNA analysis

BACKGROUND: A "BeadChip" array permits reliable simultaneous DNA typing of single-nucleotide polymorphisms for minor blood groups. A high-throughput DNA analysis was studied as a routine method of phenotype prediction and software was developed to interpret and analyze the large volume of data points. STUDY DESIGN AND METHODS: DNA was extracted from whole blood of donors of known phenotypes and self-identified ethnicity. Analysis of single-nucleotide polymorphisms (SNPs) associated with 24 antigens of 10 blood group systems was performed with BeadChips (BioArray Solutions), and the results were compared to historical serologic typings. Phenotypes were predicted for individual samples, and phenotype prevalence was determined for ethnicities. The BeadChip was expanded to incorporate SNPs that silence the S antigen, validated, and tested with 369 DNA samples. A time-motion analysis was conducted. RESULTS: Results of BeadChip analyses were concordant with prediction of antigen negativity for 4,510 antigens. Eight discordant results were due to silencing of GYPB(S) and 16 were likely errors in recording serological results or data entry. The analyses produced 19,457 antigen-negative typings not serologically defined, identified 21 rare donors (Co(a-b+) [n = 1], Jo(a-) [n = 6], S-s-[n = 12], and K+k-[n = 2]), and determined allele frequencies and antigen prevalence for four ethnicities. The expanded panel detected 30 SS, 235 ss, 100 Ss, and 4 U- samples. The format processes 192 DNA samples (two plates) per 8-hour shift per technician, including automated data analysis and report generation. CONCLUSION: DNA analysis with BeadChip format, combined with computerized data entry and analysis, permits the prediction of minor blood group antigens.     

Missed opportunities for noninvasive positive pressure ventilation: a utilization review

BACKGROUND: Although noninvasive positive pressure ventilation (NPPV) improves outcomes in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), it may be underutilized outside the controlled trial setting. PURPOSE: The purpose of this study is to determine the proportion of patients who met criteria for a trial of NPPV but were emergently intubated and mechanically ventilated without receiving a trial of NPPV. METHODS: We retrospectively reviewed charts of patients who were intubated and ventilated or who received NPPV on admission to one intensive care unit and who had an intensive care unit admitting diagnosis of either exacerbation of COPD or CHF during the period from November 1998 to July 2003. RESULTS: Of the 243 patients who had an admitting diagnosis of COPD or CHF, 59 (24.3%) met explicit criteria for a trial of NPPV. Only 20 (33.9%) of 59 had a trial of NPPV. The remaining 39 (66%) of 59 did not receive a trial of NPPV and were intubated. INTERPRETATION: Nearly two thirds of patients who appeared to meet criteria for NPPV did not receive a trial of this intervention. There is an opportunity to improve the use of NPPV in these patients. Systematic knowledge translation strategies such as guideline implementation and interactive educational interventions may optimize the appropriate use of NPPV.     

Optimizing Sarcopenia to Strengthen Patient Outcomes After Lung and Esophageal Surgery

Annals of Surgical Oncology -     

DNR directives are established early in mechanically ventilated intensive care unit patients

Purpose

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

Methods

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

Results

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74yr(HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures].

Conclusion

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.     

Cytodiagnosis of submandibular sialadenitis with crystalloids mimicking metastasis

Sialomrgaly of suhmandibultir gland, whether inflammatory or neoplastic can be clinically mistaken for lymphoid metastasis especially when encountered in an elderly patient. Other than the neoptastic lesions and usual inflammatory lesions rarely amylase crystalloids can evoke a granulomatous response and can result in sialomegaly. We report an interesting case which presented as a submandibular swelling and was clinically diagnosed as metastasis where the diagnosis of granulomatous response to crystalloids was made at FNAC. The aim of this report is to bring an awareness of the existence of such lesions and to highlight the role of FNAC in diagnosis of such lesions in order to avoid unnecessary surgeries.     

Variant human pancreas: aberrant uncinate process or an extended mesenteric process

Variations in the morphology of pancreas are not very common. We observed a rare variant of the uncinate process of the pancreas that extended in the mesentery of the small intestine. After its origin from the lower part of the head of the pancreas, the mesenteric process (MP) passed over the third part of the duodenum to enter the mesentery of the jejunum and ileum and extended up to the level of the pelvic brim. The branches of the superior mesenteric vessels were embedded in the extended MP of the pancreas. This aberrant extension of the pancreas was drained by a narrow duct, which joined the main pancreatic duct inside the head. We did not observe a separate uncinate process arising from the head. On histology normal acini and endocrine cells were observed in the extension. This variant is important as symptoms of pancreatic disease from such extensions may be confused with other commonly encountered acute or chronic abdominal conditions.