A lung computed tomography assessment of positive end-expiratory pressureinduced lung overdistention

OBJETIVO: O objetivo do presente estudo foi determinar o limite tomográfico da hiperdistensão pulmonar em indivíduos normais, bem como avaliar o recrutamento e a hiperdistensão pulmonares induzidos pela pressão expiratória final positiva em pacientes com lesão pulmonar aguda. MATERIAIS E MÉTODOS: Inicialmente, o limite da hiperdistensão pulmonar foi determinado em seis voluntários sadios, nos quais tomografias computadorizadas espiraladas de tórax foram obtidas em capacidade residual funcional e em capacidade pulmonar total mais pressão positiva de 30 cm H2O. Posteriormente, foram avaliados seis pacientes com lesão pulmonar aguda nos quais as tomografias foram obtidas em zero de pressão expiratória final positiva e em pressão expiratória final positiva. As tomografias computadorizadas foram realizadas do ápex ao diafragma, e os volumes pulmonares quantificados por análise dos histogramas de densidade RESULTADOS: A análise dos histogramas de densidade em voluntários sadios em capacidade residual funcional mostrou histogramas monofásicos, com um pico em -791 + 12 UH. Em capacidade pulmonar total, o volume pulmonar aumentou em 79 + 35% e o pico das densidades pulmonares caiu para -886 + 26 UH. Mais de 70% do aumento no volume pulmonar foi localizado abaixo de -900 UH, sugerindo que este valor possa ser definido como o limite da hiperdistensão. Os pacientes com lesão pulmonar aguda mostraram em zero de pressão expiratória final positiva uma distribuição monofásica (n=3) ou bifásica (n=3), com densidades pulmonares médias situadas em 319 + 34 UH. Com a aplicação de pressão expiratória final positiva, o volume pulmonar aumentou em 47 + 19%, enquanto que as densidades pulmonares caíram para -538 + 171 UH. Pressão expiratória final positiva induziu um recrutamento alveolar de 320 + 160 ml e uma hiperdistensão de 238 + 320 ml. CONCLUSÕES: O limite de hiperdistensão em voluntários sadios foi de -900 UH. Este limite pode ser usado em pacientes com lesão pulmonar aguda para diferenciar recrutamento alveolar de hiperdistensão pressão expiratória final positiva induzidos.OBJECTIVE: The aim of the present study was to establish the tomographic limit of lung overdistention in normal individuals as well as to assess positive end-expiratory pressure-induced overdistention and alveolar recruitment in patients with acute lung injury. MATERIALS AND METHODS: Lung distention was first determined in six healthy volunteers in whom computed tomographic sections were obtained at functional residual capacity and total lung capacity with a positive airway pressure of 30 cmH2O. Tomographic scans at zero end-expiratory pressure and positive end-expiratory pressure were performed in six patients with acute lung injury. Computed tomographies were performed from the apex to the diaphragm and lung volumes were quantified by the analysis of the density histograms RESULTS: Analysis of the density histograms in healthy volunteers was monophasic with a peak at -791 ± 12 Housenfield units. In total lung capacity, lung volume increased by 79 ± 35% and the peak of lung density decreased to -886 ±26 Housenfield units. More than 70% of the increase in lung volume was located below -900 Housenfield units, suggesting that this value can be considered as the threshold separating normal aeration from overdistention. In patients with acute lung injury, at zero end-expiratory pressure the distribution of density histograms was either monophasic (n=3) or biphasic (n=3), with mean density of -319 ± 34 Housenfield units. With positive end-expiratory pressure application, lung volume increased by 47 ± 19%, while lung density decreased to -538 ± Housenfield units. Positive endexpiratory pressure induced a mean alveolar recruitment of 238 ±320 ml. CONCLUSIONS: The limit of overdistention in healthy individuals was -900 Housenfield units. This threshold can be used in patients with acute lung injury for differentiating alveolar recruitment from lung overdistention

Quality Indicators for Colonoscopy Procedures: A Prospective Multicentre Method for Endoscopy Units

BACKGROUND AND AIMS: Healthcare professionals are required to conduct quality control of endoscopy procedures, and yet there is no standardised method for assessing quality. The topic of the present study was to validate the applicability of the procedure in daily practice, giving physicians the ability to define areas for continuous quality improvement. METHODS: In ten endoscopy units in France, 200 patients per centre undergoing colonoscopy were enrolled in the study. An evaluation was carried out based on a prospectively developed checklist of 10 quality-control indicators including five dependent upon and five independent of the colonoscopy procedure. RESULTS: Of the 2000 procedures, 30% were done at general hospitals, 20% at university hospitals, and 50% in private practices. The colonoscopies were carried out for a valid indication for 95.9% (range 92.5-100). Colon preparation was insufficient in 3.7% (range 1-10.5). Colonoscopies were successful in 95.3% (range 81-99). Adenoma detection rate was 0.31 (range 0.17-0.45) in successful colonoscopies. CONCLUSION: This tool for evaluating the quality of colonoscopy procedures in healthcare units is based on standard endoscopy and patient criteria. It is an easy and feasible procedure giving the ability to detect suboptimal practice and differences between endoscopy-units. It will enable individual units to assess the quality of their colonoscopy techniques

Traces of past activity in the Galactic Centre

The Milky Way centre hosts a supermassive Black Hole (BH) with a mass of ~4*10^6 M_Sun. Sgr A*, its electromagnetic counterpart, currently appears as an extremely weak source with a luminosity L~10^-9 L_Edd. The lowest known Eddington ratio BH. However, it was not always so; traces of "glorious" active periods can be found in the surrounding medium. We review here our current view of the X-ray emission from the Galactic Center (GC) and its environment, and the expected signatures (e.g. X-ray reflection) of a past flare. We discuss the history of Sgr A*'s past activity and its impact on the surrounding medium. The structure of the Central Molecular Zone (CMZ) has not changed significantly since the last active phase of Sgr A*. This relic torus provides us with the opportunity to image the structure of an AGN torus in exquisite detail.Comment: Invited refereed review. Chapter of the book: "Cosmic ray induced phenomenology in star forming environments" (eds. Olaf Reimer and Diego F. Torres

Sarcopenia Predicts Early Dose-Limiting Toxicities and Pharmacokinetics of Sorafenib in Patients with Hepatocellular Carcinoma

BACKGROUND: Sorafenib induces frequent dose limiting toxicities (DLT) in patients with advanced hepatocellular carcinoma (HCC). Sarcopenia has been associated with poor performance status and shortened survival in cancer patients. PATIENTS AND METHODS: The characteristics of Child Pugh A cirrhotic patients with HCC receiving sorafenib in our institution were retrospectively analyzed. Sorafenib plasma concentrations were determined at each visit. Toxicities were recorded during the first month of treatment, and sarcopenia was determined from baseline CT-scans. RESULTS: Forty patients (30 males) were included. Eleven (27.5%) were sarcopenic. Eighteen patients (45%) experienced a DLT during the first month of treatment. Sarcopenic patients experienced significantly more DLTs than non-sarcopenic patients did (82% versus 31%, p = 0.005). Grade 3 diarrhea was significantly more frequent in sarcopenic patients than in non-sarcopenic patients (45.5% versus 6.9%, p = 0.01), but not grade 3 hand foot syndrome reaction (9% versus 17.2%, p = 1). On day 28, median sorafenib AUC (n = 17) was significantly higher in sarcopenic patients (102.4 mg/l.h versus 53.7 mg/l.h, p = 0.013). CONCLUSIONS: Among cirrhotic Child Pugh A patients with advanced HCC, sarcopenia predicts sorafenib exposure and the occurrence of DLT within the first month of treatment