WHAT WE ALREADY KNOW ABOUT THIS TOPICPatients undergoing thoracic surgery are at high risk for postoperative pulmonary complicationsThe feasibility of using point of care ultrasound to diagnose ...diaphragmatic dysfunction is unclear
WHAT THIS ARTICLE TELLS US THAT IS NEWPoint of care ultrasound can be used to detect diaphragmatic dysfunction after thoracic surgeryDiaphragmatic dysfunction may be associated with postoperative pulmonary complications
BACKGROUND:Postoperative diaphragmatic dysfunction after thoracic surgery is underestimated due to the lack of reproducible bedside diagnostic methods. We used point of care ultrasound to assess diaphragmatic function bedside in patients undergoing video-assisted thoracoscopic or thoracotomic lung resection. Our main hypothesis was that the thoracoscopic approach may be associated with lower incidence of postoperative diaphragm dysfunction as compared to thoracotomy. Furthermore, we assessed the association between postoperative diaphragmatic dysfunction and postoperative pulmonary complications.
METHODS:This was a prospective observational cohort study. Two cohorts of patients were evaluatedthose undergoing video-assisted thoracoscopic surgery versus those undergoing thoracotomy. Diaphragmatic dysfunction was defined as a diaphragmatic excursion less than 10 mm. The ultrasound evaluations were carried out before (preoperative) and after (i.e., 2 h and 24 h postoperatively) surgery. The occurrence of postoperative pulmonary complications was assessed up to 7 days after surgery.
RESULTS:Among the 75 patients enrolled, the incidence of postoperative diaphragmatic dysfunction at 24 h was higher in the thoracotomy group as compared to video-assisted thoracoscopic surgery group (29 of 35, 83% vs. 22 of 40, 55%, respectively; odds ratio = 3.95 95% CI, 1.5 to 10.3; P = 0.005). Patients with diaphragmatic dysfunction on the first day after surgery had higher percentage of postoperative pulmonary complications (odds ratio = 5.5 95% CI, 1.9 to 16.3; P = 0.001). Radiologically assessed atelectasis was 46% (16 of 35) in the thoracotomy group versus 13% (5 of 40) in the video-assisted thoracoscopic surgery group (P = 0.040). Univariate logistic regression analysis indicated postoperative diaphragmatic dysfunction as a risk factor for postoperative pulmonary complications (odds ratio = 5.5 95% CI, 1.9 to 16.3; P = 0.002).
CONCLUSIONS:Point of care ultrasound can be used to evaluate postoperative diaphragmatic function. On the first postoperative day, diaphragmatic dysfunction was less common after video-assisted than after the thoracotomic surgery and is associated with postoperative pulmonary complications.
Acute respiratory failure (ARF) is a leading cause, along with sepsis, of admission to the intensive care unit (ICU) of patients with active cancer. Presenting variable clinical severity, ARF in ...onco-hematological patients has differing etiologies, primarily represented by possibly opportunistic acute infectious pneumonia (de novo hypoxemic ARF), and decompensation in chronic cardiac or respiratory diseases (e.g., acute pulmonary edema or exacerbated chronic obstructive pulmonary disease). In these patients, orotracheal intubation is associated with a doubled risk of in-hospital mortality. Consequently, over the last three decades, numerous researchers have attempted to demonstrate and pinpoint the precise role of non-invasive ventilation (NIV) in the specific context of ARF in onco-hematological patients. While the benefits of NIV in the management of acute pulmonary edema or alveolar hypoventilation (hypercapnic ARF) are well-demonstrated, its positioning in de novo hypoxemic ARF is debatable, and has recently been called into question. In the early 2000s, based on randomized controlled trials, NIV was recommended as first-line treatment, one reason being that it allowed significantly reduced use of orotracheal intubation. In the latest randomized studies, however, the benefits of NIV in terms of survival orotracheal intubation have not been observed; as a result, it is no longer recommended in the management of de novo hypoxemic ARF in onco-haematological patients.
We evaluated the ability of an infrared photoplethysmography arterial waveform (continuous non-invasive arterial pressure, CNAP) to estimate arterial pulse pressure variation (PPV). We compared the ...ability of non-invasive PPV to predict fluid responsiveness with invasive PPV, respiratory variation of pulse contour-derived stroke volume, and changes in cardiac index induced by passive leg raising (PLR) and end-expiratory occlusion (EEO) tests.
We measured the responses of cardiac index (PiCCO) to 500 ml of saline in 47 critically ill patients with haemodynamic failure. Before fluid administration, we recorded non-invasive and invasive PPVs, stroke volume variation, and changes in cardiac index induced by PLR and by 15 s EEO. Logistic regressions were performed to investigate the advantage of combining invasive PPV, stroke volume variation, PLR, and EEO when predicting fluid responsiveness.
In eight patients, CNAP could not record arterial pressure. In the 39 remaining patients, fluid increased cardiac index by ≥15% in 17 ‘responders’. Considering the 195 pairs of measurements, the bias (sd) between invasive and non-invasive PPVs was −0.6 (2.3)%. The areas under the receiver operating characteristic (ROC) curves for predicting fluid responsiveness were 0.89 (95% confidence interval, 0.78–1.01) for non-invasive PPV compared with 0.89 (0.77–1.01), 0.84 (0.70–0.96), 0.95 (0.88–1.03), and 0.97 (0.91–1.03) for invasive pulse pressure, stroke volume variations, PLR, and EEO tests (no significant difference). Combining multiple tests did not significantly improve the area under the ROC curves.
Non-invasive assessment of PPV seems valuable in predicting fluid responsiveness.
. 1% per generation, rather than as fundamentally distinct taxa. Host races provide a convenient, although admittedly somewhat
arbitrary intermediate stage along the speciation continuum. They are a ...heuristic device to aid in evaluating the probability
of speciation by natural selection, particularly in sympatry. Speciation is thereby envisaged as having two phases: (i) the
evolution of host races from within polymorphic, panmictic populations; and (ii) further reduction of gene flow between host
races until the diverging populations can become generally accepted as species. We apply this criterion to 21 putative host
race systems. Of these, only three are unambiguously classified as host races, but a further eight are strong candidates that
merely lack accurate information on rates of hybridization or gene flow. Thus, over one–half of the cases that we review are
probably or certainly host races, under our definition.
Our review of the data favours the idea of sympatric speciation via host shift for three major reasons: (i) the evolution
of assortative mating as a pleiotropic by–product of adaptation to a new host seems likely, even in cases where mating occurs
away from the host; (ii) stable genetic differences in half of the cases attest to the power of natural selection to maintain
multilocus polymorphisms with substantial linkage disequilibrium, in spite of probable gene flow; and (iii) this linkage disequilibrium
should permit additional host adaptation, leading to further reproductive isolation via pleiotropy, and also provides conditions
suitable for adaptive evolution of mate choice (reinforcement) to cause still further reductions in gene flow. Current data
are too sparse to rule out a cryptic discontinuity in the apparently stable sympatric route from host–associated polymorphism
to host–associated species, but such a hiatus seems unlikely on present evidence. Finally, we discuss applications of an understanding
of host races in conservation and in managing adaptation by pests to control strategies, including those involving biological
control or transgenic parasite–resistant plants., The existence of a continuous array of sympatric biotypes—from polymorphisms, through ecological or host races with increasing
reproductive isolation, to good species—can provide strong evidence for a continuous route to sympatric speciation via natural
selection. Host races in plant–feeding insects, in particular, have often been used as evidence for the probability of sympatric
speciation. Here, we provide verifiable criteria to distinguish host races from other biotypes: in brief, host races are genetically
differentiated, sympatric populations of parasites that use different hosts and between which there is appreciable gene flow.
We recognize host races as kinds of species that regularly exchange genes with other species at a rate of more than
Reverse triggering (RT) is a dyssynchrony defined by a respiratory muscle contraction following a passive mechanical insufflation. It is potentially harmful for the lung and the diaphragm, but its ...detection is challenging. Magnitude of effort generated by RT is currently unknown. Our objective was to validate supervised methods for automatic detection of RT using only airway pressure (Paw) and flow. A secondary objective was to describe the magnitude of the efforts generated during RT.
We developed algorithms for detection of RT using Paw and flow waveforms. Experts having Paw, flow and esophageal pressure (Pes) assessed automatic detection accuracy by comparison against visual assessment. Muscular pressure (Pmus) was measured from Pes during RT, triggered breaths and ineffective efforts.
Tracings from 20 hypoxemic patients were used (mean age 65 ± 12 years, 65% male, ICU survival 75%). RT was present in 24% of the breaths ranging from 0 (patients paralyzed or in pressure support ventilation) to 93.3%. Automatic detection accuracy was 95.5%: sensitivity 83.1%, specificity 99.4%, positive predictive value 97.6%, negative predictive value 95.0% and kappa index of 0.87. Pmus of RT ranged from 1.3 to 36.8 cmH
0, with a median of 8.7 cmH
0. RT with breath stacking had the highest levels of Pmus, and RTs with no breath stacking were of similar magnitude than pressure support breaths.
An automated detection tool using airway pressure and flow can diagnose reverse triggering with excellent accuracy. RT generates a median Pmus of 9 cmH
O with important variability between and within patients.
BEARDS, NCT03447288.
Exacerbations of COPD (ECOPD) are a frequent cause of emergency room (ER) visits. Predictors of early outcome could help clinicians in orientation decisions. In the current study, we investigated ...whether mid-regional pro-adrenomedullin (MR-proADM) and copeptin, in addition to clinical evaluation, could predict short-term outcomes.
This prospective blinded observational study was conducted in 20 French centers. Patients admitted to the ER for an ECOPD were considered for inclusion. A clinical risk score was calculated, and MR-proADM and copeptin levels were determined from a venous blood sample. The composite primary end point comprised 30-day death or transfer to the intensive care unit or a new ER visit.
A total of 379 patients were enrolled in the study, of whom 277 were eventually investigated for the primary end point that occurred in 66 (24%) patients. In those patients, the median (interquartile range IQR) MR-proADM level was 1.02 nmol/L (0.77-1.48) versus 0.83 nmol/L (0.63-1.07) in patients who did not meet the primary end point (
=0.0009). In contrast, copeptin levels were similar in patients who met or did not meet the primary end point (
=0.23). MR-proADM levels increased with increasing clinical risk score category: 0.74 nmol/L (0.57-0.89), 0.83 nmol/L (0.62-1.12) and 0.95 nmol/L (0.75-1.29) for the low-, intermediate- and high-risk categories, respectively (
<0.001). MR-proADM was independently associated with the primary end point (odds ratio, 1.65; 95% confidence interval CI, 1.10-2.48;
=0.015). MR-proADM predicted the occurrence of primary end point with a sensitivity of 46% (95% CI, 33%-58%) and a specificity of 79% (95% CI, 74-84).
MR-proADM but not copeptin was significantly associated with outcomes at 30 days, even after adjustment for clinical risk category. Overall, MR-proADM, alone or combined with the clinical risk score, was a moderate strong predictor of short-term outcomes.
De Charybde en Scylla Angoulvant, A.; Anguel, N.; Dahane, N. ...
Journal de mycologie médicale,
September 2013, 2013-09-00, Letnik:
23, Številka:
3
Journal Article
Abstract Tuberculosis and lymphoma can share common features. We report the case of a non-HIV 60-year old man diagnosed with a severe form of disseminated tuberculosis in whom the atypical course of ...the disease under treatment led to investigations that unveiled the coexistence a non-Hodgkin lymphoma. This rare association has putative pathophysiological foundations. This justifies to raise the lymphoma hypothesis when a proved tuberculosis exhibits an atypical course.
The likelihood of sympatric speciation is enhanced when assortative mating is a by-product of adaptation to different habitats. Pleiotropy of this kind is recognized as important in parasites that ...use their hosts as a long-range cue for finding mates, but is generally assumed to have limited applicability for most other organisms. In the larch budmoth, Zeiraphera diniana (Lepidoptera: Tortricidae), sympatric host races feed on larch or pine. Zeiraphera diniana females attract males (call) by releasing host-independent long-range pheromones. Pheromone composition differs strongly between host races, but we show in an experimental field study that cross-attraction can occur at a rate of 0.03–0.38. Cross-attraction to larch females increases when they call from neighborhoods (8-m radius) rich in pine or from pine trees. Cross-attraction to pine females similarly increases when calling from neighborhoods rich in larch, but there is no significant effect of calling substrate. Males, as well as females, of this species preferentially alight on their own host, and in neighborhoods where their own host is common. This effect of tree species and host neighborhood on assortative mating is therefore due, at least in part, to the numbers of males of each host race present within approximately 200 m2 surrounding the female. This proximity effect is enhanced by the clumped distributions of the hosts themselves. Host chemistry might also affect pheromone production and/or response directly, but we have evidence neither for nor against this. This work provides empirical evidence that host adaptation has a pleiotropic effect on assortative mating in a species with host-independent long-range mating signals. Sympatric speciation via pleiotropy between ecological traits and assortative mating may thus be more common than generally supposed: Clumped resource distributions and habitat choice by adults are widespread. Corresponding Editor: S. Strauss
PDF
