A lung-protective ventilatory strategy with low tidal volume (VT) has been proposed for use in acute respiratory distress syndrome (ARDS). Alveolar derecruitment may occur during the use of a ...lung-protective ventilatory strategy and may be prevented by recruiting maneuvers. This study examined the hypothesis that the effectiveness of a recruiting maneuver to improve oxygenation in patients with ARDS would be influenced by the elastic properties of the lung and chest wall.
Twenty-two patients with ARDS were studied during use of the ARDSNet lung-protective ventilatory strategy: VT was set at 6 ml/kg predicted body weight and positive end-expiratory pressure (PEEP) and inspiratory oxygen fraction (Fio2) were set to obtain an arterial oxygen saturation of 90-95% and/or an arterial oxygen partial pressure (Pao2) of 60- 80 mmHg (baseline). Measurements of Pao2/Fio2, static volume-pressure curve, recruited volume (vertical shift of the volume-pressure curve), and chest wall and lung elastance (EstW and EstL: esophageal pressure) were obtained on zero end-expiratory pressure, at baseline, and at 2 and 20 min after application of a recruiting maneuver (40 cm H2O of continuous positive airway pressure for 40 s). Cardiac output (transesophageal Doppler) and mean arterial pressure were measured immediately before, during, and immediately after the recruiting maneuver. Patients were classified a priori as responders and nonresponders on the basis of the occurrence or nonoccurrence of a 50% increase in Pao2/Fio2 after the recruiting maneuver.
Recruiting maneuvers increased Pao2/Fio2 by 20 +/- 3% in nonresponders (n = 11) and by 175 +/- 23% (n = 11; mean +/- standard deviation) in responders. On zero end-expiratory pressure, EstL (28.4 +/- 2.2 vs. 24.2 +/- 2.9 cm H2O/l) and EstW (10.4 +/- 1.8 vs. 5.6 +/- 0.8 cm H2O/l) were higher in nonresponders than in responders (P < 0.01). Nonresponders had been ventilated for a longer period of time than responders (7 +/- 1 vs. 1 +/- 0.3 days; P < 0.001). Cardiac output and mean arterial pressure decreased by 31 +/- 2 and 19 +/- 3% in nonresponders and by 2 +/- 1 and 2 +/- 1% in responders (P < 0.01).
Application of recruiting maneuvers improves oxygenation only in patients with early ARDS who do not have impairment of chest wall mechanics and with a large potential for recruitment, as indicated by low values of EstL.
Abstract
Background
Gaucher disease (GD) is a rare autosomal recessive inherited disorder caused by the lysosomal enzyme acid β‐glucosidase deficiency. Many patients experience a critical delay in ...the diagnosis of up to 8–10 years due to its rarity and variability in signs and symptoms, with the consultation of several specialists.
Patients and Methods
This prospective observational study analyzed the prevalence of GD in 600 patients with monoclonal gammopathy of uncertain significance (MGUS) from January 2018 until February 2022.
Results
The mean age of participants was 66 years, with a mean monoclonal component of 0.58 g/dL. In 433 MGUS patients with available data, anemia (hemoglobin level < 10 g/dL) was present in 31 patients (7%), and thrombocytopenia (platelet count <100.000/mm
3
) in 24 (5.5%).
Of 600 MGUS patients tested for acid β‐glucosidase enzyme activity, 7 patients (1.2%) had activity below 2.5 nmol/h/mL. In comparison,
GBA
gene analysis was executed in 110 patients. It revealed 4 patients (0.7%) affected by GD (3 patients with compound heterozygous mutation and 1 with homozygous mutation), with a prevalence of 1 every 150 MGUS patients. Furthermore, 12 out of the remaining 106 evaluated patients (11%) were carriers of a single heterozygous mutation while having regular enzyme activity.
Conclusions
The clinical heterogeneity of GD and frequent lack of awareness among physicians often lead to diagnostic delays and severe clinical manifestations. The role of MGUS in the presence of at least one clinical sign, such as low platelet count, organomegaly, bone pain, or bleeding tendency, could aid in initiating GD screening with DBS, thus reducing the period between symptom onset and the diagnosis of this rare disease.
The aim of the study was to describe the characteristics of subjects accessing the emergency rooms for suicidal behavior during the first epidemic wave of COVID-19 in three Emergency Departments ...(EDs) in Lombardy (Italy). A retrospective chart review was conducted for the period 8 March–3 June 2020, and during the same time frame in 2019. For all subjects accessing for suicidality, socio-demographic and clinical data were collected and compared between the two years. The proportion of subjects accessing for suicidality was significantly higher in 2020 than in 2019 (13.0 vs. 17.2%, p = 0.03). No differences between the two years were found for sex, triage priority level, history of substance abuse, factor triggering suicidality and discharge diagnosis. During 2020 a greater proportion of subjects did not show any mental disorders and were psychotropic drug-free. Women were more likely than men to receive inpatient psychiatric treatment, while men were more likely to be discharged with a diagnosis of acute alcohol/drug intoxication. Our study provides hints for managing suicidal behaviors during the still ongoing emergency and may be primary ground for further studies on suicidality in the course of or after massive infectious outbreaks.
BACKGROUND: Proper air ventilation and filtration in Operating Rooms (OR) are two prevention measures to avoid Surgical Site Infections (SSI), which cause increase of hospital staying, cost and ...death. For identifying how system ventilation variations may impact on the quality of OR air, ad hoc researches need be conducted. The aim is to study how a mobile air particle filtering system may impact on the air quality of the OR when placed in two different positions.
METHODS: This descriptive study was conducted during April-May 2018 in an Italian University Hospital. We measured inflow and outflow air ventilations of both an OR and a mobile novel air decontamination-recirculation system unit having a patented crystalline ultraviolet C reactor and a high efficiency particulate air filter. OR was redesigned using the software Solidworks 2017 3D. Using experimental data, the interaction of airflows was graphically simulated by placing the device both next to the main OR entrance, with its airflow towards the surgical bed, and next to the latter, with the airflow towards the main entrance.
RESULTS: The device has been able to modify the main flow of a normal air diffusion from the ceiling vents and has created a low pressure effect that drags the air into contact with potentially contaminated surfaces. Air contamination can occur when OR door is opened. If the device is positioned with its air intake next to the door, entry of particulate is facilitated, reducing the effectiveness of the positive pressure inside the OR. To avoid possible contamination caused by the device airstream, we have oriented its air intake towards the operating table. if the door is opened, the airstream helps to prevent the entry of contaminants.
CONCLUSIONS: Different positioning of extra flows can significantly impact on air dynamic. Ad-hoc environmental measures are necessary for the most efficient positioning of the device.
In patients with acute respiratory distress syndrome (ARDS), a focal distribution of loss of aeration in lung computed tomography predicts low potential for alveolar recruitment and susceptibility to ...alveolar hyperinflation with high levels of positive end-expiratory pressure (PEEP).
We tested the hypothesis that, in this cohort of patients, the table-based PEEP setting criteria of the National Heart, Lung, and Blood Institute's ARDS Network (ARDSnet) low tidal volume ventilatory protocol could induce tidal alveolar hyperinflation.
In 15 patients, physiologic parameters and plasma inflammatory mediators were measured during two ventilatory strategies, applied randomly: the ARDSnet and the stress index strategy. The latter used the same ARDSnet ventilatory pattern except for the PEEP level, which was adjusted based on the stress index, a monitoring tool intended to quantify tidal alveolar hyperinflation and/or recruiting/derecruiting that occurs during constant-flow ventilation, on a breath-by-breath basis.
In all patients, the stress index revealed alveolar hyperinflation during application of the ARDSnet strategy, and consequently, PEEP was significantly decreased (P < 0.01) to normalize the stress index value. Static lung elastance (P = 0.01), plasma concentrations of interleukin-6 (P < 0.01), interleukin-8 (P = 0.031), and soluble tumor necrosis factor receptor I (P = 0.013) were significantly lower during the stress index as compared with the ARDSnet strategy-guided ventilation.
Alveolar hyperinflation in patients with focal ARDS ventilated with the ARDSnet protocol is attenuated by a physiologic approach to PEEP setting based on the stress index measurement.
This study sought to compare, in high-risk patients with 3+ to 4+ mitral regurgitation (MR) dichotomized by baseline echocardiographic features, acute, 30-day, and 12-month outcomes following ...percutaneous mitral valve repair using the MitraClip.
The feasibility and mid-term outcomes after MitraClip implantation in patients with echocardiographic features different from the EVEREST (Endovascular Valve Edge-to-Edge Repair) I and II trials have been scarcely studied.
Clinical and echocardiographic outcomes through 12-month follow-up of consecutive patients who underwent MitraClip implantation were obtained from an ongoing prospective registry. Two different groups, divided according to baseline echocardiographic criteria (investigational group EVERESTOFF and control group EVERESTON), were compared.
Seventy-eight patients were included in EVERESTOFF and 93 patients in EVERESTON groups. Important and comparable acute reductions in MR and no clip-related complications were revealed. The primary safety endpoint at 30 days was comparable between groups (2.6% vs. 6.5%, respectively, p = 0.204); in addition, MR reduction was mostly sustained, whereas equivalent improvement in New York Heart Association functional class were demonstrated. Kaplan-Meier freedom from death, surgery for mitral valve dysfunction, or grade ≥3+ MR at 12 months was demonstrated in 71.4% and 76.2%, respectively, in the EVERESTOFF and EVERESTON groups (log rank p = 0.378). Significant improvements in ejection fraction and reduction in left ventricle volumes were demonstrated in both groups over time, but the baseline between-group differences were sustained.
MitraClip implantation in patients with expanded baseline echocardiographic features, compared with the control group, was associated with similar rates of safety and efficacy through 12-month follow-up. Further validation of our findings is warranted.
Many workers are exposed to the effects of heat and often to extreme temperatures. Heat stress has been further aggravated during the COVID-19 pandemic by the use of personal protective equipment to ...prevent SARS-CoV-2 infection. However, workers’ risk perception of heat stress is often low, with negative effects on their health and productivity. The study aims to identify workers’ needs and gaps in knowledge, suggesting the adaptation of measures that best comply with the needs of both workers and employers. A cross-sectional online questionnaire survey was conducted in Italy in the hottest months of 2020 (June–October) through different multimedia channels. The data collected were analyzed using descriptive statistics; analytical tests and analysis of variance were used to evaluate differences between groups of workers. In total, 345 questionnaires were collected and analyzed. The whole sample of respondents declared that heat is an important contributor to productivity loss and 83% of workers did not receive heat warnings from their employer. In this context, the internet is considered as the main source of information about heat-related illness in the workplace. Results highlight the need to increase workers’ perception of heat stress in the workplace to safeguard their health and productivity. About two-thirds of the sample stated that working in the sun without access to shaded areas, working indoors without adequate ventilation, and nearby fire, steam, and hot surfaces, represent the main injuries’ risk factors.
A study devoted to assessing the neutronic performance of the SORGENTINA-RF fusion neutron source is here presented. The calculation is performed considering the characteristics of the accelerated ...mixed deuterium/tritium ion beam from the ion source, the transport of ions into the titanium layer that constitutes the ion beam target, their implantation and the fusion reaction cross section. An investigation has been done by varying the ion composition of the beam in order to assess if and to what extent diatomic and triatomic ion species affect the neutron emission rate of the plant. This calculation is also instrumental to evaluate the cost-effectiveness of equipping the ion source with a filtering system to remove secondary ions from the beam.
Background / Aims The rapid decline in hepatitis C virus RNA is crucial for determining the outcome of therapy in patients with genotype 1 chronic hepatitis C. However, the variables influencing the ...early phase of viral decay are still largely unexplored. We aimed to assess which pre-treatment variable may predict rapid virologic response (RVR) and sustained virologic response (SVR). Methods We evaluated 90 consecutive non-diabetic patients with genotype 1 chronic hepatitis C without cirrhosis, treated with peginterferon alpha-2b plus ribavirin. Viral load (COBAS Amplicore, Roche) was measured at 1, 4 and 12 weeks after starting treatment, and then 24 weeks after the end of treatment. Results The overall SVR was 47%. The SVR in patients with RVR was 100%. Age, GGT levels, viral load, steatosis, fibrosis and HOMA-IR were significantly associated with RVR in univariate analysis. After logistic regression, HOMA-IR proved to be the strongest independent predictor of RVR (OR 0.37, 95% CI: 0.16–0.89; p = 0.027), whereas fibrosis had a weaker independent association with RVR (OR 0.32, 95% CI: 0.1–1.04; p = 0.057). Among the eight pre-treatment variables, both BMI and steatosis were significantly associated with HOMA-IR, either in univariate or in multivariate analyses. Conclusions Our data suggest that insulin resistance is strongly associated with RVR, thus reflecting the important role played by metabolic factors in the early phase of viral kinetics. HOMA-IR would appear to be a useful tool in predicting RVR and should be evaluated at baseline in all chronic hepatitis C patients before initiating antiviral treatment.
Surgical site infections are the second major cause of hospital acquired infections, accounting for a large part of overall annual medical costs. Airborne particulate is known to be a potential ...carrier of pathogenic bacteria. We assessed a mobile air particle filter unit for improvement of air quality in an operating room (OR). A new mobile air decontamination and recirculation unit, equipped with a crystalline ultraviolet C (Illuvia® 500 UV) reactor and a HEPA filter, was tested in an OR. Airborne particulate was monitored in four consecutive phases: I) device OFF and OR at rest; II) device OFF and OR in operation; III) device ON and OR in operation; IV) device OFF and OR in operation. We used a particle counter to measure airborne particles of different sizes: ≥0.3, ≥0.5, ≥1, ≥3, ≥5, >10 µm. Activation of the device (phases III) produced a significant reduction (p < 0.05) in airborne particulate of all sizes. Switching the device OFF (phase IV) led to a statistically significant increase (p < 0.05) in the number of particles of most sizes: ≥0.3, ≥0.5, ≥1, ≥3 µm. The device significantly reduced airborne particulate in the OR, improving air quality and possibly lowering the probability of surgical site infections.
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