7 research outputs found

    Significado do ponto de inflexão inferior da curva pressão-volume em pacientes com insuficiência respiratória aguda: avaliação por tomografia computadorizada

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    OBJECTIVE: The goal of this study was to assess lung morphology in patients with acute lung injury according to the presence or the absence of a lower inflection point on the lung pressure-volume curve and to compare the effects of positive endexpiratory pressure (PEEP).MATERIALS AND METHODS: Eight patients with and six without a lower inflection point (LIP) underwent a computed tomography performed at zero end-expiratory pressure (ZEEP) and at two levels of PEEP: PEEP1 = LIP + 2 cmH2O e PEEP2 = LIP + 7 cmH2O, or PEEP1 = 10 cmH2O and PEEP2 = 15 cmH2O in the absence of LIP and, based on the analysis of the lung density histograms, the gas-tissue ratio and the lung areas volumes were calculated (nonaerated, poorly aerated, normally aerated and overdistended volumes).RESULTS: In the ZEEP condition, patients with and without LIP presented similar total lung volume, volume of gas, and volume of tissue, although the percentage ofnormally aerated lung was lower and the percentage of poorly aerated lung was greater in patients with LIP than in patients without it. Lung density histograms ofpatients with LIP showed an unimodal distribution with a peak at 7 Housenfield units (HU), while histograms of patients without LIP had a bimodal distribution, with a first peak at -727 HU, and a second at 27 HU. Lung compliances were lower in patients with LIP whereas all other cardiorespiratory parameters were similar in the two groups. In both groups, PEEP induced an alveolar recruitment that was associated with lung overdistension only in patients without LIP.CONCLUSIONS: The evaluation of the pressure-volume curve in patients with acute lung injury allows us to divide them into two groups according to the presence or absence of LIP. This division is associated with the differences in lung morphology and in the responses to PEEP application in terms of alveolar recruitment andoverdistention, the latter being defined as the occurrence of pulmonary parenchyma under -900 HU. In patients with LIP, gas and tissue are more homogeneously distributed within the lungs and increasing levels of PEEP result in additional alveolarrecruitment without lung overdistention. In patients without LIP, normally aerated areas coexist with nonareted lung areas and increasing levels of PEEP result in lung overdistention rather than in additional alveolar recruitment.OBJETIVO: O objetivo deste estudo foi avaliar, através de tomografia computadorizada, a morfologia pulmonar em pacientes com lesão pulmonar aguda de acordo com a presença ou ausência de ponto de inflexão inferior (Pinf) nas curvas pressão-volume e comparar os efeitos da pressão expiratória final positiva (PEEP).MATERIAIS E MÉTODOS: Oito pacientes com e seis sem Pinf foram submetidos a tomografias computadorizadas realizadas em zero de pressão expiratória final positiva(ZEEP) e em dois níveis de PEEP: PEEP1 = Pinf+2 cmH2O e PEEP2 = Pinf+7 cmH2O, ou PEEP1 = 10 cmH2O e PEEP2 = 15 cmH2O na ausência de Pinf e, a partir da análise dos histogramas de densidade pulmonares, foram calculados a razão gás-tecido e os volumes pulmonares regionais (volumes não-aerado, pobremente aerado, normalmente aerado e hiperdistendido).RESULTADOS: Os pacientes com e sem Pinf apresentaram, em ZEEP, valores similares de volume pulmonar total e volume de gás e tecido, mas a porcentagem de pulmão normalmente ventilado foi menor e a de pulmão pobremente ventilado maior em pacientes com Pinf do que em pacientes sem Pinf. Os histogramas de densidade pulmonares de pacientes com Pinf mostraram uma distribuição unimodal com um pico em 7 unidades Hounsfield (UH), enquanto os pacientes sem Pinf tinham uma distribuição bimodal com um primeiro pico em -727 UH e um segundo em 27 UH. A complacência do sistema respiratório era menor em pacientes com Pinf, enquanto todos os outros parâmetros cardiorrespiratórios eram similares nosdois grupos. Em ambos os grupos, PEEP induziu recrutamento alveolar, o qual foi associado à hiperdistensão pulmonar apenas nos pacientes sem Pinf.CONCLUSÕES: A avaliação das curvas pressão-volume em portadores de lesão pulmonar aguda permite dividi-los em dois grupos, de acordo com a presença ouausência de ponto de inflexão inferior. Esta divisão associa-se com diferenças na morfologia pulmonar e nas respostas à aplicação de PEEP em termos de recrutamento alveolar e hiperdistensão, definindo-se esta última como a ocorrência de parênquima pulmonar abaixo de -900 UH. Em pacientes com Pinf, gás e tecido estão mais homogeneamente distribuídos no interior dos pulmões, e níveis crescentes de PEEP resultam em recrutamento alveolar adicional sem hiperdistensão. Em pacientes sem Pinf, regiões pulmonares normalmente ventiladas coexistem com regiões não-ventiladas, e a aplicação de PEEP, embora cause recrutamento, acarretatambém hiperdistensão, que aumenta com níveis crescentes de PEEP

    Significado do ponto de inflexão inferior da curva pressão-volume em pacientes com insuficiência respiratória aguda: avaliação por tomografia computadorizada

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    OBJECTIVE: The goal of this study was to assess lung morphology in patients with acute lung injury according to the presence or the absence of a lower inflection point on the lung pressure-volume curve and to compare the effects of positive endexpiratory pressure (PEEP).MATERIALS AND METHODS: Eight patients with and six without a lower inflection point (LIP) underwent a computed tomography performed at zero end-expiratory pressure (ZEEP) and at two levels of PEEP: PEEP1 = LIP + 2 cmH2O e PEEP2 = LIP + 7 cmH2O, or PEEP1 = 10 cmH2O and PEEP2 = 15 cmH2O in the absence of LIP and, based on the analysis of the lung density histograms, the gas-tissue ratio and the lung areas volumes were calculated (nonaerated, poorly aerated, normally aerated and overdistended volumes).RESULTS: In the ZEEP condition, patients with and without LIP presented similar total lung volume, volume of gas, and volume of tissue, although the percentage ofnormally aerated lung was lower and the percentage of poorly aerated lung was greater in patients with LIP than in patients without it. Lung density histograms ofpatients with LIP showed an unimodal distribution with a peak at 7 Housenfield units (HU), while histograms of patients without LIP had a bimodal distribution, with a first peak at -727 HU, and a second at 27 HU. Lung compliances were lower in patients with LIP whereas all other cardiorespiratory parameters were similar in the two groups. In both groups, PEEP induced an alveolar recruitment that was associated with lung overdistension only in patients without LIP.CONCLUSIONS: The evaluation of the pressure-volume curve in patients with acute lung injury allows us to divide them into two groups according to the presence or absence of LIP. This division is associated with the differences in lung morphology and in the responses to PEEP application in terms of alveolar recruitment andoverdistention, the latter being defined as the occurrence of pulmonary parenchyma under -900 HU. In patients with LIP, gas and tissue are more homogeneously distributed within the lungs and increasing levels of PEEP result in additional alveolarrecruitment without lung overdistention. In patients without LIP, normally aerated areas coexist with nonareted lung areas and increasing levels of PEEP result in lung overdistention rather than in additional alveolar recruitment.OBJETIVO: O objetivo deste estudo foi avaliar, através de tomografia computadorizada, a morfologia pulmonar em pacientes com lesão pulmonar aguda de acordo com a presença ou ausência de ponto de inflexão inferior (Pinf) nas curvas pressão-volume e comparar os efeitos da pressão expiratória final positiva (PEEP).MATERIAIS E MÉTODOS: Oito pacientes com e seis sem Pinf foram submetidos a tomografias computadorizadas realizadas em zero de pressão expiratória final positiva(ZEEP) e em dois níveis de PEEP: PEEP1 = Pinf+2 cmH2O e PEEP2 = Pinf+7 cmH2O, ou PEEP1 = 10 cmH2O e PEEP2 = 15 cmH2O na ausência de Pinf e, a partir da análise dos histogramas de densidade pulmonares, foram calculados a razão gás-tecido e os volumes pulmonares regionais (volumes não-aerado, pobremente aerado, normalmente aerado e hiperdistendido).RESULTADOS: Os pacientes com e sem Pinf apresentaram, em ZEEP, valores similares de volume pulmonar total e volume de gás e tecido, mas a porcentagem de pulmão normalmente ventilado foi menor e a de pulmão pobremente ventilado maior em pacientes com Pinf do que em pacientes sem Pinf. Os histogramas de densidade pulmonares de pacientes com Pinf mostraram uma distribuição unimodal com um pico em 7 unidades Hounsfield (UH), enquanto os pacientes sem Pinf tinham uma distribuição bimodal com um primeiro pico em -727 UH e um segundo em 27 UH. A complacência do sistema respiratório era menor em pacientes com Pinf, enquanto todos os outros parâmetros cardiorrespiratórios eram similares nosdois grupos. Em ambos os grupos, PEEP induziu recrutamento alveolar, o qual foi associado à hiperdistensão pulmonar apenas nos pacientes sem Pinf.CONCLUSÕES: A avaliação das curvas pressão-volume em portadores de lesão pulmonar aguda permite dividi-los em dois grupos, de acordo com a presença ouausência de ponto de inflexão inferior. Esta divisão associa-se com diferenças na morfologia pulmonar e nas respostas à aplicação de PEEP em termos de recrutamento alveolar e hiperdistensão, definindo-se esta última como a ocorrência de parênquima pulmonar abaixo de -900 UH. Em pacientes com Pinf, gás e tecido estão mais homogeneamente distribuídos no interior dos pulmões, e níveis crescentes de PEEP resultam em recrutamento alveolar adicional sem hiperdistensão. Em pacientes sem Pinf, regiões pulmonares normalmente ventiladas coexistem com regiões não-ventiladas, e a aplicação de PEEP, embora cause recrutamento, acarretatambém hiperdistensão, que aumenta com níveis crescentes de PEEP

    Overweight is associated to a better prognosis in metastatic colorectal cancer: A pooled analysis of FFCD trials

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    IF 7.191 (2017)International audienceBACKGROUND:Previous studies showed that high and low body mass index (BMI) was associated with worse prognosis in early-stage colorectal cancer (CRC), and low BMI was associated with worse prognosis in metastatic CRC (mCRC). We aimed to assess efficacy outcomes according to BMI.PATIENTS AND METHODS:A pooled analysis of individual data from 2085 patients enrolled in eight FFCD first-line mCRC trials from 1991 to 2013 was performed. Comparisons were made according to the BMI cut-off: Obese (BMI ≥30), overweight patients (BMI ≥ 25), normal BMI patients (BMI: 18.5-24) and thin patients (BMI <18.5). Interaction tests were performed between BMI effect and sex, age and the addition of antiangiogenics to chemotherapy.RESULTS:The rate of BMI ≥25 patients was 41.5%, ranging from 37.6% (1991-1999 period) to 41.5% (2000-2006 period) and 44.8% (2007-2013 period). Comparison of overweight patients versus normal BMI range patients revealed a significant improvement of median overall survival (OS) (18.5 versus 16.3 months, HR = 0.88 [0.80-0.98] p = 0.02) and objective response rate (ORR) (42% versus 36% OR = 1.23 [1.01-1.50] p = 0.04) but a comparable median progression-free survival (PFS) (7.8 versus 7.2 months, HR = 0.96 [0.87-1.05] p = 0.35). Subgroup analyses revealed that overweight was significantly associated with better OS in men. OS and PFS were significantly shorter in thin patients.CONCLUSION:Overweight patients had a prolonged OS compared with normal weight patients with mCRC. The association of overweight with better OS was only observed in men. The pejorative prognosis of BMI <18.5 was confirmed.Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserve

    Myocardial Injury after Noncardiac Surgery : a Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes

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    [The effect of low-dose hydrocortisone on requirement of norepinephrine and lactate clearance in patients with refractory septic shock].

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