Objective To compare pulmonary function, functional capacity, and clinical outcomes among conventional mechanical ventilation (CMV), early open-lung (EOL), and late open-lung (LOL) strategies after ...off-pump coronary artery bypass surgery (OPCAB). Design Prospective, randomized, and double-blinded study. Setting Two hospitals of the Federal University of Sao Paulo, Brazil. Participants Ninety-three patients undergoing elective first-time OPCAB. Interventions Patients were randomized into 3 groups: CMV (n=31); LOL (n=32) initiated upon intensive care unit (ICU) arrival; EOL (n = 30) initiated after intubation. Measuraments and Main Results Spirometry was performed at bedside preoperatively and on postoperative days (PODs) 1, 3, and 5. Partial pressure of arterial oxygen (PaO2 ) and pulmonary shunt fraction were evaluated presurgically and on POD 1; 6-minute walk test (6MWT) was performed presurgically and on POD 5. Both open-lung groups demonstrated higher forced vital capacity and forced expiratory volume in 1 second on PODs 1, 3 and 5 compared to the CMV group (p<0.05). Similar results were found in relation to the 6MWT distance. Shunt fraction was lower and PaO2 was higher in both open-lung groups (p<0.05). Open-lung groups had shorter intubation time and hospital stay as well as fewer respiratory events (p<0.05). No statistical difference was found relative to the aforementioned results when the EOL and LOL groups were compared. Conclusions Both open-lung strategies were able to promote higher pulmonary function preservation and greater recovery of functional capacity with better clinical outcomes after OPCAB. No difference in outcome was found when comparing initiation of OLS intraoperatively or after ICU arrival.
Exercise training (ET) improves functional capacity in chronic heart failure (HF). However, ET effects in acute HF are unknown.
To investigate the effects of ET alone or combined with noninvasive ...ventilation (NIV) compared with standard medical treatment during hospitalization in acute HF patients.
Twenty-nine patients (systolic HF) were randomized into three groups: control (Control - only standard medical treatment); ET with placebo NIV (ET+Sham) and ET+NIV (NIV with 14 and 8 cmH2O of inspiratory and expiratory pressure, respectively). The 6MWT was performed on day 1 and day 10 of hospitalization and the ET was performed on an unloaded cycle ergometer until patients' tolerance limit (20 min or less) for eight consecutive days. For all analyses, statistical significance was set at 5% (p < 0.05).
None of the patients in either exercise groups had adverse events or required exercise interruption. The 6MWT distance was greater in ET+NIV (Δ120 ± 72 m) than in ET+Sham (Δ73 ± 26 m) and Control (Δ45 ± 32 m; p < 0.05). Total exercise time was greater (128 ± 10 vs. 92 ± 8 min; p < 0.05) and dyspnea was lower (3 ± 1 vs. 4 ± 1; p < 0.05) in ET+NIV than ET+Sham. The ET+NIV group had a shorter hospital stay (17 ± 10 days) than ET+Sham (23 ± 8 days) and Control (39 ± 15 days) groups (p < 0.05). Total exercise time in ET+Sham and ET+NIV had significant correlation with length of hospital stay (r = -0.75; p = 0.01).
Exercise training in acute HF was safe, had no adverse events and, when combined with NIV, improved 6MWT and reduce dyspnea and length of stay.
Background
Active mobilization is not possible in patients under deep sedation and unable to follow commands. In this scenario, passive therapy is an interesting alternative. However, in patients ...with septic shock, passive mobilization may have risks related to increased oxygen consumption. Our objective was to evaluate the impact of passive mobilization on sublingual microcirculation and systemic hemodynamics in patients with septic shock.
Methods
We included patients who were older than 18 years, who presented with septic shock, and who were under sedation and mechanical ventilation. Passive exercise was applied for 20 min with 30 repetitions per minute. Systemic hemodynamic and microcirculatory variables were compared before (T0) and up to 10 min after (T1) passive exercise.
p
values <0.05 were considered significant.
Results
We included 35 patients (median age IQR 25–75%: 68 49.0–78.0 years; mean (±SD) Simplified Acute Physiologic Score (SAPS) 3 score: 66.7 ± 12.1; median IQR 25–75% Sequential Organ Failure Assessment (SOFA) score: 9 7.0–12.0). After passive mobilization, there was a slight but significant increase in proportion of perfused vessels (PPV) (T0 IQR 25–75%: 78.2 70.9–81.9%; T1 IQR 25–75%: 80.0 75.2–85.1 %;
p
= 0.029), without any change in other microcirculatory variables. There was a reduction in heart rate (HR) (T0 (mean ± SD): 95.6 ± 22.0 bpm; T1 (mean ± SD): 93.8 ± 22.0 bpm;
p
< 0.040) and body temperature (T0 (mean ± SD): 36.9 ± 1.1 °C; T1 (mean ± SD): 36.7 ± 1.2 °C;
p
< 0.002) with no change in other systemic hemodynamic variables. There was no significant correlation between PPV variation and HR (
r
= −0.010,
p
= 0.955), cardiac index (
r
= 0.218,
p
= 0.215) or mean arterial pressure (
r
= 0.276,
p
= 0.109) variation.
Conclusions
In patients with septic shock after the initial phase of hemodynamic resuscitation, passive exercise is not associated with relevant changes in sublingual microcirculation or systemic hemodynamics.
This article explores how strategic communication, public diplomacy, international governmental broadcasting, and social media networking can be brought together in a system of strategic influence ...and global engagement. The analysis offers a contrasting approach to various views of public diplomacy or strategic communication which privilege one form of governmental influence over others and treat partial aspects of national persuasion as complete pictures of government communication aimed at foreign audiences. Because so much of public diplomacy literature today emphasizes social media, it is necessary to determine how specific tools of influence such as international broadcasting, can be used in ways that fit new thinking in public diplomacy as well as continuously emerging new media ecologies.
Colorectal cancer (CRC) is a leading causes of cancer death among men and women. The purpose of this study was to determine the prevalence of oligopolyposis (≥20 synchronous colorectal adenomas) and ...its associated clinicopathological characteristics in Hispanics with incident CRC.
Pathology reports from individuals diagnosed with CRC (2007 to 2011) were obtained from the PR Central Cancer Registry. Colorectal polyp burden was calculated using pathology reports and the data was normalized to colon segment size. Comparisons of demographic and clinicopathological characteristics by synchronous oligopolyposis status (<20 vs. <= *20) were performed using the chi-square or Fisher's exact test. Multivariate logistic regression models were fitted to estimate the adjusted prevalence odds ratios (aPOR), with 95% confidence intervals (CI). All analyses were performed using Stata (v.12.0).
Analyses of 1,573 colectomy specimens was performed. Oligopolyposis was observed in 9.47% (149 of 1,573) of the subjects with incident CRC. Increasing age (aPOR50-64 = 1.72, 95% CI: 0.59-5.02; aPOR65-74 = 1.83, 95% CI: 0.64-5.27; aPOR≥75 = 2.67, 95% CI: 0.93-7.64) and proximal CRC tumor location (POR = 2.91, 95% CI:1.98-4.30) were significantly associated with having oligopolyposis at CRC diagnosis. However, subjects diagnosed with CRC at a regional stage (aPORRegional = 0.50, 95% CI: 0.32-0.79) or distant stage (aPORDistant = 0.45, 95% CI: 0.29-0.69) were less likely to have synchronous oligopolyposis (p<0.05).
Our findings suggest that genetic syndromes associated with colorectal polyposis may be implicated in a higher than expected number of CRC cases. Individuals with CRC and synchronous oligopolyposis should receive genetic counseling.
The Long Life of a Clip Lopez, Carmen; Mendez, Vanessa; Hefler, Henry
The American journal of gastroenterology,
10/2018, Letnik:
113, Številka:
Supplement
Journal Article
Recenzirano
Hemoclips are a very common and effective intervention used during colonoscopies to stop immediate bleeding. A recent survey of VA gastroenterologists reported that when hemostatic treatment was ...applied, 76% of physicians preferred a hemoclip.1 Although hemoclips are very common, there are no clear established guidelines for their use. Hemoclips typically fall off on their own within 1-2 weeks. However, there have been an increased number of cases where clips have been found as long as 2 years later.6,7 Here we describe a case of retained hemoclip for over one year and discuss the possible implications of such clips<./p> A 67 year old African American man with a history of multiple GI bleeds, iron deficiency anemia, CAD, paroxysmal Afib, and CVAs presented to the GI endoscopy suite for colonoscopy to evaluate iron deficiency anemia. One 10mm TA was removed by cold snare polypectomy in the cecum. Two TA in the ascending colon were also removed. No hemoclips were placed. Several days later, patient had significant GI bleed while on dual antiplatelet therapy after recent NSTEMI. EGD was normal. On colonoscopy, post-polypectomy sites seen in the cecum and ascending colon showed evidence of bleeding stigmata. 3 hemoclips were placed in the cecum and 1 was placed in ascending colon achieving hemostasis. Numerous hyperplastic polyps were also seen in the rectosigmoid colon with the plan to remove them in one year once off anti-platelets. On repeat colonoscopy 1 year later, 3 flat hyperplastic polyps were removed. Interestingly, a clip was also seen in the cecum at the site of the prior post polypectomy bleed. The case presented here is another example of hemoclips staying in place much longer than expected. While hemoclips can be excellent tools to achieve hemostasis, they are not completely benign. They are contraindications to MRI, and two years after endoscopy hemoclips would likely not have been considered. Abdominal radiographs have been suggested as a possible way to screen for retained clips prior to MRI.7 There has also been a case report of a GI bleed resulting from focal ulceration at the base of a retained clip, therefore these retained clips may pose as a risk factor for future bleeding.8 In scenarios where large polyps are removed, persistence of clips could interfere with detecting and treating any residual polyps<.sup>9 Therefore, it is important for physicians to consider these possible complications prior to placing hemoclips<./p>
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