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

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

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

Community Structure of Shallow Water Alcyonacea (Anthozoa: Octocorallia) from the Southern Tropical Eastern Pacific

Alcyonacea are sessile invertebrates, which can significantly shape the boundary layer in coral reefs and rocky habitats. Ecological aspects in this taxon have been well studied in the Caribbean, Mediterranean, and Indo-Pacific. With few recent exceptions, studies in the Eastern Pacific focused on taxonomy. We present a quantitative assessment of Alcyonacea communities from the southern Tropical Eastern Pacific, based on video transects in the Marine Reserve El Pelado. Seventeen species from the Plexauridae (8), Gorgoniidea (8), and Clavularidae (1) were identified, comprising 6963 colonies dominated by Muricea (86.7%), particularly M. plantaginea (48.6%). The overwhelming dominance of M. plantaginea was the most striking and previously unreported community trait, which contributed to a moderate Shannon entropy (n = 31, H mean 1.40, SD 0.22), equitability (n = 31, HE mean 0.16, SD 0.4), and species diversity expressed as effective number of species (n = 31, mean 4.16, SD 0.87). Few common species overprinted a more variable and subtle community pattern among rarer species, suggested in agglomerative hierarchical cluster analyses. Four species (M. plantaginea, M. purpurea, M. fruticosa and Leptogorgia alba) had the strongest influence on site groupings in the correspondence analysis between a principal component analysis of a Hellinger-transformed Alcyonacea species matrix and substrate categories, with filamentous turf algae and crustose coralline algae being the main determinants of site differentiation. Muricea plantaginea’s qualities of a keystone species, and the eurytopic and stenoecious distribution traits among some species are discussed. The invasive Carijoa riisei was confirmed as biological thereat to other Alcyonacea, and possible physiological distribution limitations are indicated

Tropical Ungulates of Argentina

Argentina has an extensive and diverse terrain classified into 11 ecoregions. Seven of these ecoregions, occupying the north and north-central parts of the country, house the 11 tropical ungulate species found here. The ecoregions are lowland and subtropical, some beginning in the tropics, some extending to temperate climates. The principal topographical characteristics, hydrology, climate, vegetation and fauna are described for these seven ecoregions. Each of the 11 species is then treated in detail with respect to its ecology and conservation. Emphasis is placed on distribution, habitat and density, feeding ecology, threats and conservation in Argentina, based on the most recent studies. Data on reproductive biology and behaviour are included where information is relatively recent and unlikely to be covered elsewhere. The species include the following: the Brazilian tapir (Tapirus terrestris), found in northern subtropical ecoregions, three species of peccary (Tayassu pecari, Pecari tajacu and Parachoerus wagneri) from northern subtropical and drier regions, of which the Chacoan peccary (P. wagneri) is endemic while the other two species have more extensive distributions. The guanaco (Lama guanicoe) occurs only in relict populations in the ecoregions considered. The taruca (Hippocamelus antisensis) occupies the eastern boundary between the Yungas and drier, high altitude ecoregions. Three species of brocket deer (Mazama americana, M. gouazoubira and M. nana) occupy the northern tropical, subtropical and Chacoan areas. The marsh deer (Blastocerus dichotomus), the largest South American deer, has small populations occupying wetlands from the northern border to the Parana delta, while the pampas deer (Ozotocerus bezoaticus) is found in four isolated populations from Ibera to Buenos Aires province. Argentina represents the southern limit to the distribution of all these species and thus threats are often magnified. Ongoing conservation activities include the maintenance of protected areas, promotion (difusion, education, sensitization), investigation and the reintroduction of some species of formerly extinct ungulates into the Ibera wetlands area.Fil: Black Decima, Patricia. Universidad Nacional de Tucumán; ArgentinaFil: Camino, Micaela. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Nordeste. Centro de Ecología Aplicada del Litoral. Universidad Nacional del Nordeste. Centro de Ecología Aplicada del Litoral; ArgentinaFil: Cirignoli, Sebastian. Centro de Investigaciones del Bosque Atlántico; ArgentinaFil: de Bustos, Soledad. Fundación Biodiversidad; ArgentinaFil: Matteucci, Silvia Diana. Universidad de Buenos Aires. Facultad de Arquitectura y Urbanismo. Grupo de Ecología del Paisaje y Medio Ambiente; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Perez Carusi, Lorena Cynthia. Administración de Parques Nacionales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Varela, Diego Martin. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Nordeste. Instituto de Biología Subtropical. Universidad Nacional de Misiones. Instituto de Biología Subtropical; Argentina. Centro de Investigaciones del Bosque Atlántico; Argentin

Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome: Insights from the LUNG SAFE Study

Rationale: Noninvasive ventilation (NIV) is increasingly used in patients with acute respiratory distress syndrome (ARDS). The evidence supporting NIV use in patients with ARDS remains relatively sparse. Objectives: To determine whether, during NIV, the categorization of ARDS severity based on the PaO2/FIO2Berlin criteria is useful. Methods: TheLUNGSAFE(Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) study described the management of patients with ARDS. This substudy examines the current practice of NIV use in ARDS, the utility of the PaO2/FIO2ratio in classifying patients receiving NIV, and the impact of NIV on outcome. MeasurementsandMain Results:Of2,813 patients with ARDS,436 (15.5%) were managed with NIV on Days 1 and 2 following fulfillment of diagnosticcriteria.Classification of ARDS severity based on PaO2/FIO2ratio was associated with an increase in intensity of ventilatory support, NIV failure, and intensive care unit (ICU) mortality. NIV failure occurred in 22.2% of mild, 42.3% of moderate, and 47.1% of patients with severe ARDS. Hospital mortality in patients with NIV success and failure was 16.1% and 45.4%, respectively. NIV use was independently associated with increased ICU (hazard ratio, 1.446 [95% confidence interval, 1.159-1.805]), but not hospital, mortality. In a propensity matched analysis, ICU mortality was higher in NIV than invasively ventilated patients with a PaO2/FIO2lower than 150 mm Hg. Conclusions:NIV was used in 15% of patients with ARDS,irrespective of severity category. NIV seems to be associated with higher ICU mortality in patients with a PaO2/FIO2lower than 150 mm Hg

The International Network for Evaluating Outcomes (iNeo) of neonates: evolution, progress and opportunities

Neonates born very preterm (before 32 weeks’ gestational age), are a significant public health concern because of their high-risk of mortality and life-long disability. In addition, caring for very preterm neonates can be expensive, both during their initial hospitalization and their long-term cost of permanent impairments. To address these issues, national and regional neonatal networks around the world collect and analyse data from their constituents to identify trends in outcomes, and conduct benchmarking, audit and research. Improving neonatal outcomes and reducing health care costs is a global problem that can be addressed using collaborative approaches to assess practice variation between countries, conduct research and implement evidence-based practices. The International Network for Evaluating Outcomes (iNeo) of neonates was established in 2013 with the goal of improving outcomes for very preterm neonates through international collaboration and comparisons. To date, 10 national or regional population-based neonatal networks/datasets participate in iNeo collaboration. The initiative now includes data on >200,000 very preterm neonates and has conducted important epidemiological studies evaluating outcomes, variations and trends. The collaboration has also surveyed >320 neonatal units worldwide to learn about variations in practices, healthcare service delivery, and physical, environmental and manpower related factors and support services for parents. The iNeo collaboration serves as a strong international platform for Neonatal-Perinatal health services research that facilitates international data sharing, capacity building, and global efforts to improve very preterm neonate care

Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study

Noninvasive ventilation (NIV) is increasingly used in patients with acute respiratory distress syndrome (ARDS). The evidence supporting NIV use in patients with ARDS remains relatively sparse