Mechanical ventilation mode (volume × pressure) does not change the variables obtained by indirect calorimetry in critically ill patients

PurposeThe aim of the study was to analyze the difference between the results obtained by indirect calorimetry (IC) using volume-controlled and pressure-controlled mechanical ventilation in 2 different ventilators and to characterize the variables achieved by IC after well-defined changes in minute volume (Vm).Materials and MethodsProspective study of 20 critically ill patients under volume-controlled (n = 15) or pressure-controlled (n = 5) mechanical ventilation. Three IC measurements of 45 minutes each were taken; values of oxygen consumption (Vo₂), carbon dioxide production (Vco₂), Vm, resting energy expenditure (REE), and respiratory quotient (RQ) were obtained. For the last measurement, Vm was set at 20% above the baseline.ResultsThere were no differences between the results obtained by IC during volume-controlled and pressure-controlled mechanical ventilation. The most relevant changes in the variables obtained by IC before and after intervention in Vm were a significant increase in Vco₂ (from 165 to 177 mL·min^?1; P < .01), a decrease in Paco₂ (from 38.49 to 28.46 mm Hg; P < .01), and a rise in pH (from 7.41 to 7.49; P < .01). There were no alterations in Vo₂, REE, or RQ.ConclusionsVentilators and ventilation modes do not influence the IC measurements. The observed changes have no clinical effects and are reversible, provided that increased Vm is maintained for no longer than 45 minutes.     

Cell surface markers for T and B lymphocytes activation and adhesion as putative prognostic biomarkers for head and neck squamous cell carcinoma

The study population comprised HNSCC patients, risk-positive controls (tabagism and alcoholism habits), and risk-negative controls (without risk factors). Significant increases in the activation status of CD4⁺and CD8⁺ T-cells, and higher migration potentials of lymphocytes were observed in HNSCC patients compared with control groups. Although decreased frequency of CD19⁺-B lymphocytes was observed in HSNCC patients, a higher percentage of HLA-DR⁺CD19⁺-B lymphocytes was detected in these individuals as compared with other evaluated groups. Metastasis and tumor grading were the major pathological parameters associated with significant alterations in the expression of activation molecules on circulating CD4⁺ and CD8⁺ T-cells. A reduced frequency of CD38-expressing CD8⁺ T-cells was the most relevant biomarker associated with HNSCC aggressiveness. Performance analysis suggested a cut-off point for the CD8⁺CD38⁺/CD8⁺ T-cell ratio of 7.0 for segregating patients according to tumor grading. In contrast, a higher proportion of CD8⁺CD54⁺/CD8⁺ T-cells could represent a relevant biomarker associated with metastasis in HNSCC patients, and performance analysis suggested a cut-off point for the CD8⁺CD54⁺/CD8⁺ T-cell ratio of 30 for segregating patients according to absence or presence of metastasis. The results obtained can increment immunological aspects of HNSCC and provide tools for the determination of cut-off scores of clinically relevant immunophenotypic prognostic biomarkers.     

Reconstruction of full‐thickness cheek defect with chimeric facial artery free flap: A case report

Full‐thickness cheek defects represent a difficult challenge for reconstructive surgeons. Multiple techniques have been described, including local, regional, and free flaps. In this report, the reconstruction of a through and through left cheek defect, resulting from a self‐inflicted gunshot injury, with a chimeric facial artery free flap is presented. The patient underwent reconstruction with a chimeric full‐thickness facial artery free flap, with 9 × 3 cm diameter skin paddle and a 6 × 5 cm myomucosal paddle, was harvested on the contralateral cheek with a 7‐cm length of facial pedicle. The flap was transferred via a microsurgical technique and an end‐to‐end microsurgical anastomosis was performed between the donor and the contralateral facial vessels. The flap was transplanted successfully and there were no donor or recipient site complications with a satisfactory esthetic result 5 years after surgery. This technique may be a good reconstructive option for medium size, full‐thickness, cheek defects allowing a “like with like” reconstruction with minimal donor‐site morbidity.     

Management of midcheek masses and tumors of the accessory parotid gland

Tumors of the lateral wall of the mouth have different origins and behaviors. These lesions often arise from salivary tissues, such as the accessory parotid gland, but tumors can also originate from the muscles, buccal fat pad, or other structures. Surgical approaches are limited in this region by the presence of the facial nerve and the Stensen's duct. In this article, we present 9 cases of midcheek masses that were operated on via extra- or intraoral approaches. We discuss the problems related to the diagnosis of such tumors, as well as the indications and rationales for different treatment approaches.     

The use of IgG antibodies in conventional and non-conventional immunodiagnostic tests for early prognosis after treatment of Chagas disease

Treatment success of chronically infected Chagas disease patients is laborious and a positive prognosis often is made only after repetitive serological and/or parasitological examinations with continuous negative results. Recently, we have developed a non-conventional flow-cytometric method in order to detect immunoglobulin G antibodies against live trypomastigote forms of Trypanosoma cruzi and showed its usefulness in the prognosis of treatment success. In the present study, we investigated the performance of flow-cytometric anti-live trypomastigote IgG antibodies (FC-ALTA) and flow-cytometric anti-fixed epimastigote IgG antibodies (FC-AFEA), as well as conventional serological methods, for early monitoring of benznidazole treated Chagas disease patients, e.g. 5years after treatment. The analysis of individual FC-ALTA reactivity along the titration curve before and after treatment, we were able to show, that between 4% and 13% of treated patients under evaluation presented with reduced serological reactivity and segregated from the other patient groups. Similar results were obtained with semi-quantitative, conventional indirect hemagglutination or indirect immunofluorescence. Our data therefore suggest that the combined use of conventional and non-conventional serological methods could provide more suitable cure criteria in early post-therapeutic prognosis of Chagas disease.     

The levels of IL-17A and of the cytokines involved in Th17 cell commitment are increased in patients with chronic immune thrombocytopenia

Th17 cells have been associated with immune-mediated diseases in humans but it has still not been determined whether they play a role in immune thrombocytopenia. We evaluated representative cytokines of the Th17, Th1, Th2 and Treg cell commitment in the serum of patients with chronic immune thrombocytopenia, as well as the cell source of IL-17A. Higher levels of IL-17A and Th17-related cytokines, and an increased percentage of IL-17A producing CD4+ and neutrophils were observed in patients. The levels of cytokines involved in Th1 cell commitment IFN-γ, IL-2, IL12-p70 and the percentages of Th1 cells were also increased, but IL-4 was not detected. Although the concentrations of IL-10 were higher, the levels of TGF-β were similar in both groups. In conclusion, our results point to a putative role for Th-17 cells/IL-17A cytokine in the pathogenesis of chronic immune thrombocytopenia.     

Characterization of main cytokine sources from the innate and adaptive immune responses following primary 17DD yellow fever vaccination in adults

The mechanisms of immune response following yellow fever (YF-17DD) vaccination are still poorly understood. In this study, we have performed a longitudinal investigation (days 0, 7, 15 and 30) to characterize the cytokine profile of innate and adaptive immunity following YF-17DD first-time vaccination. Data from non-stimulated cultures demonstrated a prominent participation of the innate immunity with increased frequency of TNF-α⁺ neutrophils and IFN-γ⁺ NK-cells at day 7 besides TNF-α⁺ monocytes at day 7, day 15 and day 30. Increased frequency of IL-10⁺ monocytes was observed at day 15 and day 30, and decreased percentage of IL-4⁺ NK-cells were detected at day 7, day 15 and day 30. Time-dependent and oscillating cytokine pattern was observed in CD4⁺ T-cells, with low percentage of IL-12⁺, IL-4⁺ and IL-10⁺ cells at day 7 and increased frequency of TNF-α⁺ cells at day 15 besides IFN-γ⁺ and IL-5⁺ cells at day 15 and day 30. Later changes with increased percentage of IL-12⁺ and IL-5⁺CD8⁺ T-cells were observed at day 30. Increased frequency of IL-10⁺ B-cells was observed at day 15, when seroconversion was detected in all vaccinees. The overall cytokine analysis of non-stimulated leukocytes showed a transient shift towards a pro-inflammatory profile at day 7, mainly due to changes in the innate immunity, which draws back toward a mixed/regulatory pattern at day 15 and day 30. The changes induced by the in vitro YF-17DD vaccine-stimulation were mainly observed at day 0 and day 7 (before seroconversion) with minor changes at day 15 and day 30 (after seroconversion). These data support the hypothesis that a complex network with mixed pro/anti-inflammatory cytokine profile is associated with the establishment of the protective immunity following YF-17DD primo-vaccination, free of adverse events.     

Angioplastie carotidienne bilatérale chez une patiente avec infarctus cérébral sur maladie de Horton

Introduction

Giant cell arteritis is the most frequent vasculitis and can cause stroke in about 4% of the patients. The mechanism is often hemodynamic in relation with an arterial stenosis or occlusion. Optimal treatment remains to be defined. Outcome is often poor.

Case report

We report the case of a 78-year-old patient, with giant cell arteritis who developed neurological deterioration after the onset of the corticotherapy. Brain MRI revealed bilateral stroke caused by multiple preocclusive internal carotid stenosis. The patient was treated successfully with angioplasty and stenting.

Conclusion

Endovascular treatment could constitute an interesting alternative for patients with giant cell arteritis associated with neurological deterioration after a first episode of stroke because of hemodynamic instability or at stroke recurrence. For these patients, the usual medical treatment appears to be insufficient.