a qualitative approach

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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

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

Learning multiple rules simultaneously: affixes are more salient than reduplications

Language learners encounter numerous opportunities to learn regularities, but need to decide which of these regularities to learn, because some are not productive in their native language. Here, we present an account of rule learning based on perceptual and memory primitives (Endress, Dehaene-Lambertz, & Mehler, 2007; Endress, Nespor, & Mehler, 2009), suggesting that learners preferentially learn regularities that are more salient to them, and that the pattern of salience reflects the frequency of language features across languages. We contrast this view with previous artificial grammar learning research, which suggests that infants “choose” the regularities they learn based on rational, Bayesian criteria (Frank & Tenenbaum, 2011; Gerken, 2006, 2010). In our experiments, adult participants listened to syllable strings starting with a syllable reduplication and always ending with the same “a!x” syllable, or to syllable strings starting with this “a!x” syllable and ending with the “reduplication.” Both a!xation and reduplication are frequently used for morphological marking across languages. We find three crucial results. First, participants learned both regularities simultaneously. Second, a!xation regularities seemed easier to learn than reduplication regularities. Third, regularities in sequence o↵sets were easier to learn than regularities at sequence onsets. We show that these results are inconsistent with previous Bayesian rule learning models, but mesh well with the perceptual or memory primitives view. Further, we show that the pattern of salience revealed in our experiments reflects the distribution of regularities across languages. Ease of acquisition might thus be one determinant of the frequency of regularities across languages

Management of gallbladder polyps

OBJECTIVE: Appropriate treatment and timing hinge on whether the lesion is benign or malignant. Study: A five years retrospective descriptive analysis was performed. Location : Department of General Surgery in Hospitals of the University of Coimbra. Patients: We present a series of 93 consecutive patients who had elective surgery for known gallbladder polyps, treated from January 2003 to December 2007. METHODS: An analysis was performed using clinical and radiological files of patients electively treated for gallbladder polyp. Ninety-three consecutive patients were evaluated, treated and followed in a Department of General Surgery in a Central Hospital in that period. Biographic, clinical and radiological data were compiled. RESULTS: In 91 patients a benign lesion was found. Two (2.16%) patients had adenocarcinoma. Among benign polyps, 73 (78,5%) were cholesterol polyps, 14 (15%) were hyper-plastic and 2 (2.19%) were premalignant adenomas. Mean diameter of benign polyps, excluding adenomas, was 6 mm. In 40 (43%) patients, multiple lesions were found. The mean diameter in the subset of malignant and premalignant polyps was 18.8 mm, in all instances these were found to be single lesions; and mean age at presentation was 57,7 years. CONCLUSION: Cholecystectomy is the appropriate surgical treatment for gallbladder polyps, when removal is warranted. Patients benefitting from surgery are those who are symptomatic, whose polyps exceed 10 mm in diameter and , have shown to be enlarging, to be sessile or broad-based, to have long pedicles;and also have . infundibular polyps, coexisting gallstones or changes on the gallbladder wall appearance at ultrasonograph

Mixing, hypersalinity and gradients in Hervey Bay, Australia

Hervey Bay, a large coastal embayment situated off the central eastern coast of Australia, is a shallow tidal area (average depth = 15 m), close to the continental shelf. It shows features of an inverse estuary, due to the high evaporation rate (approx. 2 m/year), low precipitation (less than 1 m/year) and on average almost no freshwater input from rivers that drain into the bay. The hydro- and thermodynamical structure of Hervey Bay and their variability are presented here for the first time, using a combination of four-dimensional modelling and observations from field studies. The numerical studies are performed with the Coupled Hydrodynamical Ecological model for RegioNal Shelf seas (COHERENS). Due to the high tidal range (> 3.5 m) the bay is considered as a vertically well-mixed system and therefore only horizontal fronts a likely. Recent field measurements, but also the numerical simulations indicate characteristic features of an inverse/hypersaline estuary with low salinities (35.5 psu) in the open ocean and peak values (> 39.0 psu) in the head water of the bay. The model further predicts a nearly persistent mean salinity gradient of 0.5 psu across the bay (with higher salinities close to the shore)