Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database

Background: Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF). Methods: An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples. Results: Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest. Conclusions: In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS. Trial registration: NCT02010073. Registered on 12 December 2013

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries

Background: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. Methods: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Results: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. Conclusions: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Spontaneous Breathing in Early Acute Respiratory Distress Syndrome: Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study

OBJECTIVES: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity. DESIGN: Planned secondary analysis of a prospective, observational, multicentre cohort study. SETTING: International sample of 459 ICUs from 50 countries. PATIENTS: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days. INTERVENTIONS: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92-1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93-1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0-22] vs 8 [0-20]; p = 0.014) and shorter duration of ICU stay (11 [6-20] vs 12 [7-22]; p = 0.04). CONCLUSIONS: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required

Sea-land limits: a case study

The limits between sea and land were estimated at "Pulso" beach located in the Southeastern Brazilian shelf (&#966; = 23°33/17.4886"S; &#923; = 045° 13'13.0504"W - WGS84), between the island of São Sebastião and the city of Ubatuba, SP, Brazil. The relative sea level of the year 1831 at "Pulso" beach, as per Brazilian law Number 9760 dated from 1946, was estimated and materialized. The retro-estimation allowed the demarcation of the Legal Sea-Land Limits at "Pulso" beach as per the terms of the law. The accuracy of the procedure for the transference of the long-term sea level from the research station of Ubatuba to "Pulso" beach was assessed by parallel work of geometrical leveling referred to the IBGE (Brazilian Institute of Geography and Statistics) geodetic network. The motivation, the hypotheses (Brest, Cananeia and IPCC) and the methods here used are described, together with a short history of the Legal Sea-Land Limits. The results indicated that the legal Sea-Land Limits at "Pulso" beach are well within the beach area. They were determined as per law 9760, and there is the need to reactivate the national network of sea level gauge.<br>Os limites entre mar e terra foram estimados na praia chamada Pulso, localizada na costa sudeste do Brasil (&#966; = 23°33'17, 4886"S; &#923; = 045°13'13, 0504"W) entre a Ilha de São Sebastião e a cidade de Ubatuba, no Estado de São Paulo, SP, Brasil. O nível relativo do mar do ano de 1831 na praia do Pulso, ou "Praia do Pulso" (PP), foi estimado e materializado, de acordo com a Lei brasileira Número 9760 de 1946. A acurácia do procedimento foi acompanhada por trabalho paralelo de nivelamento geométrico referido ao sistema nacional de geodésia do IBGE (Instituto Brasileiro de Geografia e Estatística). A motivação, as hipóteses (Brest, Cananeia e IPCC) e os métodos utilizados são descritos, acompanhados por um breve histórico dos "Terrenos de Marinha". Os resultados indicaram que os limites em (PP) estão bem dentro da área da praia. Eles fora deterinados de acordo co a Lei No. 9760 e há a necessidade de reativar a rede nacional de medidores do nível do mar

Subsurface deposition of Cu-rich massive sulphide underneath a Palaeoproterozoic seafloor hydrothermal system—the Red Bore prospect, Western Australia

The Proterozoic Bryah and Yerrida basins of Western Australia contain important base and precious metal deposits. Here we present microtextural data, trace element and S isotope analyses of massive sulphide mineralisation hosted in Palaeoproterozoic subvolcanic rocks (dolerite) recently discovered at Red Bore. The small-scale high-grade mineralisation, which extends from the sub-surface to at least 95 m down-hole, is dominated by massive chalcopyrite and contains minor pyrite and Bi-Te-(Se) phases. Massive sulphide mineralisation is surrounded by discontinuous brecciated massive magnetite, and a narrow (< 2 m) alteration halo, which suggests very focussed fluid flow. Laser ablation ICP-MS analyses indicate that chalcopyrite contains up to 10 ppm Au and in excess of 100 ppm Ag. Sulphur isotope analyses of pyrite and chalcopyrite indicate a narrow range of δ34SVCD (− 0.2 to + 4.6 ‰), and no significant mass-independent fractionation (− 0.1 < Δ33S < + 0.05 ‰). Re-Os isotope analyses yield scattered values, which suggests secondary remobilisation. Despite the geographical proximity and the common Cu-Au-Ag association, the mineralisation at Red Bore has significant differences with massive sulphide mineralisation at neighbouring DeGrussa, as well as other massive sulphide deposits around the world. These differences include the geometry, sub-volcanic host rocks, extreme Cu enrichment and narrow δ34S ranges. Although a possible explanation for some of these characteristics is leaching of S and metals from the surrounding volcanic rocks, we favour formation as a result of the release of a magmatic fluid phase along very focussed pathways, and we propose that mixing of this fluid with circulating sea water contributed to sea floor mineralisation similar to neighbouring VHMS deposits. Our data are permissive of a genetic association of Red Bore mineralisation with VHMS deposits nearby, thus suggesting a direct connection between magmatism and mineralising fluids responsible for VHMS deposition at surface. Therefore, the Red Bore mineralisation may represent the magmatic roots of a VHMS system