[Impact of noninvasive ventilation failure upon patient prognosis. Subanalysis of a multicenter study]

OBJECTIVE

Noninvasive ventilation (NIV) constitutes first-line treatment for the exacerbation of obstructive pulmonary disease and cardiogenic lung edema. Several studies suggest that NIV failure could increase the risk of mortality, mainly due to the delay in tracheal intubation. We aimed to evaluate the negative impact of NIV failure in routine practice among Spanish ICUs.

PATIENTS

A subanalysis was made of the multicenter validation of the Sabadell Score study, extracting patients with acute respiratory failure requiring either invasive or noninvasive mechanical ventilation, with the exclusion of patients presenting "do not resuscitate and/or do not intubate" orders.

VARIABLES

We recorded demographic parameters, ICU-specific treatments and the development of acute renal failure or infections during ICU stay. Patients were followed-up on until hospital discharge or death. The statistic analysis included Cox multiple logistic regression.

RESULTS

We analyzed 4132 patients, of whom 1602 (39%) received only invasive mechanical ventilation (IMV), while 529 (13%) received NIV. The latter succeeded in 50% of the patients, but the other 50% required intubation. NIV failure was more common in neurological and postsurgical patients. Mortality was lower than predicted in NIV patients (22% vs. 33%) and similar to predicted in IMV patients (27% vs. 29%). Mortality was lower than predicted in patients in whom NIV proved successful (12% vs. 28%), and in those in whom NIV failed (32% vs. 38%).

CONCLUSION

NIV failure and the need of intubation as routinely used do not seem to imply a poorer patient prognosis.

Environmental assay on the effect of poultry manure application on soil organisms in agroecosystems

This paper reports the effects produced on the organisms of the soil (plants, invertebrates and microorganisms), after the application of two types of poultry manure (sawdust and straw bed) on an agricultural land. The test was made using a terrestrial microcosm, Multi-Species Soil System (MS3) developed in INIA. There was no difference in the germination for any of the three species of plants considered in the study. The biomass was increased in the wheat (Triticum aestivum) coming from ground treated with both kinds of poultry manure. Oilseed rape (Brasica rapa) was not affected and regarding vetch (Vicia sativa) only straw poultry manure showed significant difference. For length only Vicia sativa was affected showing a reduction when straw was exposed to poultry manure. When the effect on invertebrates was studied, we observed a reduction in the number of worms during the test, especially from the ground control (13.7%), higher than in the ground with sawdust poultry manure (6.7%), whereas in the ground with straw poultry manure, there was no reduction. The biomass was affected and at the end of the test it was observed that while the reduction of worms in the ground control was about 48%, the number of those that were in the ground with sawdust poultry manure or straw poultry manure decreased by 41% and 22% respectively. Finally, the effects on microorganisms showed that the enzymatic activities: dehydrogenase (DH) and phosphatase and basal respiration rate increased at the beginning of the test, and the differences were statistically significant compared with the values of the control group. During the test, all these parameters decreased (except DH activities) but they were always higher than in the ground control. This is why it is possible to deduce that the contribution of poultry manure caused an improvement in the conditions of fertilization and also for the soil.

[Fever in a patient with a central vein catheter]

A 75-year old male, operated on three weeks earlier due to descending colon cancer and reoperated 9 days later due to suture dehiscence, began with fever without clinical focality suggestive of surgical bed infection. The patient has a bilumen catheter in the right jugular vein, through which he receives different medications and parenteral nutrition. How can catheter-related infection be diagnosed? What should be done with the catheter? When and which antibiotics are appropriate to begin treatment? What risk factors for resistant bacteria should be considered? How should S. aureus bacteraemia be treated? Is it possible to reduce the rates of catheter-related infection? These and other questions are answered in this article and a working algorithm is presented.

Longitudinal studies of ischemic penumbra by using 18F-FDG PET and MRI techniques in permanent and transient focal cerebral ischemia in rats

At present, the goal of stroke research is the identification of a potential recoverable tissue surrounding the ischemic core, suggested as ischemic penumbra, with the aim of applying a treatment that attenuates the growth of this area. Our purpose was to determine whether a combination of imaging techniques, including (18)F-FDG PET and MRI could identify the penumbra area. Longitudinal studies of (18)F-FDG PET and MRI were performed in rats 3 h, 24 h and 48 h after the onset of ischemia. A transient and a permanent model of focal cerebral ischemia were performed. Regions of interest were located, covering the ischemic core, the border that progresses to infarction (recruited tissue), and the border that recovers (recoverable tissue) with early reperfusion. Analyses show that permanent ischemia produces severe damage, whereas the transient ischemia model does not produce clear damage in ADC maps at the earliest time studied. The only significant differences between values for recoverable tissue, (18)F-FDG (84±2%), ADC (108±5%) and PWI (70±8%), and recruited tissue, (18)F-FDG (77±3%), ADC (109±4%) and PWI (77±4%), are shown in (18)F-FDG ratios. We also show that recoverable tissue values are different from those in non-infarcted tissue. The combination of (18)F-FDG PET, ADC and PWI MRI is useful for identification of ischemic penumbra, with (18)F-FDG PET being the most sensitive approach to its study at early times after stroke, when a clear DWI deficit is not observed.

Anti-angiogenic treatment (sunitinib) for disseminated malignant haemangiopericytoma: a case study and review of the literature

INTRODUCTION

A meningeal haemangiopericytoma (HP) is a mesenchymal tumour that makes up less than 1% of all CNS tumours. HPs arise from pericytes and present high rates of recurrence and distant metastasis. The primary treatment option is surgery. When the disease is disseminated, chemotherapy produces a weak and short-lived response; therefore, new drugs are needed.

CASE PRESENTATION

We describe the case of a 65-year-old woman with a 13-year history of recurrent HP. After local treatment with radiotherapy, she developed metastases that required systemic treatment, and treatment with sunitinib, an oral inhibitor of the vascular endothelial growth factor receptor and the platelet-derived growth factor receptor, was initiated. As a result, radiological stabilisation of the systemic disease was maintained for over 12 months.

CONCLUSIONS

Anti-angiogenic agents can be useful for treating disseminated HP, but further studies are needed to confirm their possible role in controlling metastatic disease.

Association of tumor PDGFR-α and PDGFR-β expression and survival after resection of hepatocellular carcinoma

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Background: Hepatocellular carcinoma (HCC) proliferates through angiogenic pathways mediated, in part, by vascular endothelial growth factor receptor 2 (VEGFR2) and platelet-derived growth factor receptors (PDGFR) α and β. We hypothesized that overexpression of these proteins is associated with decreased survival after resection.

Methods: 57 patients with available tissue for analysis who underwent liver resection for HCC between 8/00 and 3/08 at one institution were identified from a prospectively maintained database. Tumors were assessed by immunohistochemistry for VEGFR2, PDGFR-α, and PDGFR-β expression and were graded by a single pathologist. Primary outcome was overall survival (OS).

Results: Median age was 64 yrs; 65% were male. Median F/U was 25 mo, and OS was 26 mo. Median tumor size and number were 7 cm and 1, respectively. Macro- and microvascular invasion were present in 9% and 42% of patients, respectively. 25% had tumors that met Milan criteria. 9% had positive resection margins. 35% of patients had cirrhosis and the median nonadjusted MELD score was 7.5. Tumors exhibited differential expression of VEGFR2 (low: 79%, high: 21%), PDGFR-α (low: 93%, high: 7%), and PDGFR-β (low: 96%, high: 4%). After excluding all 30-day deaths (n=7), high PDGFR-α and β expression were independently associated with decreased OS (8.7 vs 29.1 mo, p=0.01; 2.8 vs 28.8 mo, p<0.001; respectively). When adjusted for tumor burden, margin status, and MELD score on independent multivariate analyses, both PDGFR-α and β expression were predictive of decreased survival (Table).

Conclusions: High PDGFR-α and PDGFR-β expression are independently associated with decreased overall survival after resection of HCC. This finding may help to select patients who would benefit from targeted inhibitor therapy in the adjuvant setting.

[Table: see text]

No significant financial relationships to disclose.

[Intestinal transplant: in what phase are we?]

OBJECTIVE

To analyze the evolution of Small Bowel Transplantation program since the beginning of the program.

MATERIAL AND METHODS

[corrected] All children who underwent intestinal transplantation between 1997 and 2009 were retrospectively reviewed: epidemiological data, status before transplant, surgical technique, immunosupression, results, survival and long.term quality of life were analysed.

RESULTS

Fifty-two intestinal transplants were performed in 46 children (20 isolated bowel, 20 combined liver and intestine, and 12 multivisceral); median age was 32m (range 7m-19a); weight 12,3 kg (range 3,9-60); 31 had short gut syndrome, 8 dismotility, 5 intractable diarrhea, and two were miscellaneous. Intestinal adaptation was initially attempted in 26 patients, without success, 20 were directly listed for transplant. The modality of transplant was modified in 17 while listed. Baseline immunosupression consisted of tacrolimus and steroids, although 5 required conversion to Sirolimus later. Six died during the first month, due to sepsis/multiorganic failure (poor status at transplant); 13 died during the long-term follow-up. Acute rejection was seen in 20, chronic rejection in 3, PTLD in 8 (6 died) and GVHD in 5 patients (3 died). Overall survival after 5 years of follow-up is 65,2 % (51,7% for the graft). From 2006 to 2008, overall patient/graft survival at 6 m, 1 and 3 years after transplant is 88,7/84,1, 81,2/81,2 and 81,2/71,1%, respectively. After a median follw-up of 39 +/- 29 months, 27 patients are alive (59%), off TPN, (70% had their ostomy taken down), go to school, are scarcely hospitalized and enjoy a good quality of life.

CONCLUSIONS

Intestinal transplantation has consolided itself as a good choice for irreversible intestinal failure, being feasible to achieve a normal life. Although overall survival diminishes over time, the center experience has improved the results. These patients need a very close follow-up, once transplant is over, in order to get an early diagnose of immunological complications.

Influence of trial registration on reporting quality of randomized trials: study from highest ranked journals

OBJECTIVE

To evaluate the reporting quality of key methodological items of randomized control trials (RCTs) in 55 of the highest ranked journals.

STUDY DESIGN AND SETTING

A list of the highest top ranked journals was identified, and a search for detecting RCTs in those journals was made. Two hundred sixty four journals were screened and 55 of them were identified having at least one RCT. Three RCTs were randomly selected a priori from each journal; 148 RCTs were finally included. RCTs were assessed by two reviewers using the Consolidated Standards of Reporting Trials (CONSORT) statement.

RESULTS

Only 11 (8%) RCTs had all items adequately reported. In addition, 36% of RCTs reported that the study was registered in any trial registry. We found a significant difference in the quality of reporting for baseline characteristics, recruitment, participant's flow, and randomization implementation between those studies having reported the registration of their RCT in a trial registry and those that have not. Adherence to key methodological items of the CONSORT statement was as follows: sample size determination (60%), sequence generation (49%), allocation concealment (40%), and blinding (25%).

CONCLUSIONS

Reporting of varied CONSORT items remains suboptimal. Registration in a trial registry was associated with improved reporting. Further efforts to enhance RCT registration could contribute to this improvement.

Human adipose-derived mesenchymal stem cells reduce inflammatory and T cell responses and induce regulatory T cells in vitro in rheumatoid arthritis

OBJECTIVES

Adult mesenchymal stem cells were recently found to suppress effector T cell and inflammatory responses and have emerged as attractive therapeutic candidates for immune disorders. In rheumatoid arthritis (RA), a loss in the immunological self-tolerance causes the activation of autoreactive T cells against joint components and subsequent chronic inflammation. The aim of this study is to characterise the immunosuppressive activity of human adipose-derived mesenchymal stem cells (hASCs) on collagen-reactive T cells from patients with RA.

METHODS

The effects of hASCs on collagen-reactive RA human T cell proliferation and cytokine production were investigated, as well as effects on the production of inflammatory mediators by monocytes and fibroblast-like synoviocytes from patients with RA.

RESULTS

hASCs suppressed the antigen-specific response of T cells from patients with RA. hASCs inhibited the proliferative response and the production of inflammatory cytokines by collagen-activated CD4 and CD8 T cells. In contrast, the numbers of IL10-producing T cells and monocytes were significantly augmented upon hASC treatment. The suppressive activity of hASCs was cell-to-cell contact dependent and independent. hASCs also stimulated the generation of FoxP3 protein-expressing CD4(+)CD25(+) regulatory T cells, with the capacity to suppress collagen-specific T cell responses. Finally, hASCs downregulated the inflammatory response and the production of matrix-degrading enzymes by synovial cells isolated from patients with RA.

CONCLUSIONS

The present work identifies hASCs as key regulators of immune tolerance, with the capacity to suppress T cell and inflammatory responses and to induce the generation/activation of antigen-specific regulatory T cells.