Nasal intermittent positive pressure ventilation in acute exacerbations of chronic obstructive pulmonary disease — a preliminary study

AbstractTen patients (two male) suffering from acute exacerbations of long-standing chronic obstructive pulmonary disease and admitted in hypoxic, hypercapnic respiratory failure were treated with Nasal Intermittent Positive Pressure Ventilation (NIPPV) plus supplemental oxygen, on a general medical ward. The median (range) pH on admission was 7·30 (7·20–7·35), the median age was 67 years (47–77) with an FEV1 (percent of predicted) of 30 (17–39). On admission the median arterial oxygen tension (PaO2) was 4·71 kPa (3·45–6·26) on air, and the carbon dioxide tension (PaCO2) was 7·68 kPa (6·85–9·83). With controlled oxygen therapy there was no significant improvement in PaO2, but the median PaCO2 increased significantly to 9·75 kPa (7·04–11·70) (P < 0·05). By using NIPPV with supplemental oxygen it was possible to significantly improve the median PaO2 to 11·25 kPa (6·70–26·90) (P < 0·01) without worsening PaCO2 levels (8·96 kPa; 6·85–13·10). NIPPV was applied by a senior, respiratory physiotherapist and used intermittently depending on patient tolerance and clinical response. The median total time on NIPPV was 27 h, delivered over 1–5 days. One patient found the mask difficult to tolerate beyond a short period of time. NIPPV was well accepted on a general ward by nursing staff. Three patients later died with progressive hypercapnia, despite an initial response; with one of these patients also receiving intubation and mechanical ventilation. A further patient also received intubation and mechanical ventilation and was eventually discharged.NIPPV plus supplemental oxygen offers a method to correct hypoxaemia on a general medical ward without worsening hypercapnia for acute on chronic, hypoxic, hypercapnic respiratory failure, and warrants further investigation

Outcomes after Intensity-Modulated Compared with 3-Dimensional Conformal Radiotherapy with Chemotherapy for Squamous Cell Carcinoma of the Anal Canal

Purpose: We report our institution’s treatment techniques, disease outcomes, and complication rates after radiotherapy for the management of anal canal carcinoma with intensity-modulated radiotherapy (imrt) and concurrent chemotherapy relative to prior cases managed with 3-dimensional conformal radiotherapy (3D-crt). Methods: In a retrospective review of the medical records of 21 patients diagnosed with biopsy-proven stage i (23%), stage ii (27%), or stage iii (50%) squamous-cell carcinoma of the anal canal treated with curative chemotherapy and imrt between July 2009 and December 2014, patient outcomes were determined. Results for patients treated with 3D-crt by the same group were previously reported. The median initial radiation dose to the pelvic and inguinal nodes at risk was 45 Gy (range: 36–50.4 Gy), and the median total dose, including local anal canal primary tumour boost, was 59.4 Gy (range: 41.4–61.2 Gy). Patients received those doses over a median of 32 fractions (range: 23–34 fractions). Chemotherapy consisted of 2 cycles of concurrent fluorouracil–cisplatin (45%) or fluorouracil–mitomycin C (55%). Results: Median follow-up was 3.1 years (range: 0.38–6.4 years). The mean includes a patient who died of septic shock at 38 days. The 3-year rates of overall survival, metastasis-free survival, locoregional control, and colostomy-free survival were 95%, 100%, 100%, and 100% respectively. No patients underwent abdominoperitoneal resection after chemoradiotherapy or required diverting colostomy during or after treatment. Those outcomes compare favourably with the previously published series that used 3D-crt with or without brachytherapy in treating anal canal cancers. Of the 21 patients in the present series, 10 (48%) experienced acute grade 3, 4, or 5 toxicities related to treatment. Conclusions: The recommended use of imrt with concurrent chemotherapy as an improvement over 3D-crt for management of anal canal carcinoma achieves a high probability of local control and colostomy-free survival without excessive risk for acute or late treatment-related toxicities

Biomechanical approaches applied to the lower and upper limb for the measurement of spasticity: a systematic review of the literature

Purpose: To review and characterise biomechanical approaches for the measurement of spasticity as one component of the upper motor neurone syndrome.Method: Systematic literature searches based on defined constructs and a four-step review process of approaches used or described to measure spasticity, its association with function or associated phenomena. Most approaches were limited to individual joints and therefore, to reflect this trend, references were grouped according to which body joint(s) were investigated or whether it addressed a functional activity. For each joint, references were further sub-divided into the types of measurement method described.Results: A database of 335 references was established for the review process. The knee, ankle and elbow joints were the most popular, perhaps reflecting the assumption that they are mono-planar in movement and therefore simpler to assess. Seven measurement methods were identified: five involving passive movement (manual, controlled displacement, controlled torque, gravitational and tendon tap) and two involving active movement (voluntary and functional). Generally, the equipment described was in an experimental stage and there was a lack of information on system properties, such as accuracy or reliability. Patient testing was either by cohort or case studies. The review also conveyed the myriad of interpretations of the concept of spasticity.Conclusions: Though biomechanical approaches provide quantitative data, the review highlighted several limitations that have prevented them being established as an appropriate method for clinical application to measure spasticity