Mass spectrometry-based assay for the molecular diagnosis of glioma : Concomitant detection of chromosome 1p/19q codeletion, and IDH1, IDH2, and TERT mutation status

The World Health Organization recently revised the diagnosis of glioma, to integrate molecular parameters, including IDH mutations and codeletion (loss of heterozygosity; LOH) of chromosome arms 1p/19q, into the definitions of adult glioma histological subtypes. Mutations in the TERT promoter may also be useful for glioma diagnosis and prognosis. The integration of molecular markers into routine diagnosis requires their rapid and reliable assessment. We propose a MassARRAY (MS)-based test that can identify 1p/19q codeletion using quantitative SNP genotyping and, simultaneously, characterize hotspot mutations in the IDH1, IDH2, and TERT genes in tumor DNA. We determined the reliability of the MS approach testing 50 gliomas and comparing the MS results with those obtained by standard methods, such as short tandem repeat genotyping, array comparative genomic hybridization (array-CGH) and Fluorescence In Situ Hybridization (FISH) for 1p/19q codeletion and Sanger sequencing for hotspots mutations. The results indicate that MS is suitable for the accurate, rapid, and cost-effective evaluation of chromosome deletions combined with hotspot mutation detection. This MS approach could be similarly exploited in evaluation of LOH in other situations of clinical and/or research importance

Increase of oxygen consumption during a progressive decrease of ventilatory support is lower in patients failing the trial in comparison with those who succeed

Background: The aim of this study was to test the hypothesis that, during weaning from mechanical ventilation, when the pressure support level is reduced, oxygen consumption increases more in patients unable to sustain the decrease in ventilatory assistance (weaning failure). Methods: Patients judged eligible for weaning were enrolled. Starting from 20 cm H2O, pressure support was decreased in 4-cm H2O steps, lasting 10 min each, until 0 cm H2O; this level was kept for 1 h. The average oxygen consumption from the last 3 min of each step, along with other ventilatory variables, was measured by indirect calorimetry (M-CAiOVX "metabolic module," Engstrom Carestation; GE Healthcare, Madison, WI) and recorded. Patients were defined as belonging to the failure group if, at any moment, they developed signs of respiratory distress according to standard criteria, or to the success group otherwise. Results: Twenty-eight patients were studied. In most patients, the minimum oxygen consumption was not recorded at the highest pressure support applied. Sixteen patients were able to complete the weaning trial successfully, whereas 12 failed it; the success group had a minimum oxygen consumption lower than failure group (mean \uc2\ub1 SD: 174 \uc2\ub1 44 vs. 215 \uc2\ub1 53 ml/min, P < 0.05). Moreover, although respiratory drive (assessed by P0.1) increased more in the failure group, this group had a lower increase in oxygen consumption, contradicting our hypothesis. Conclusions: Patients failing a decremental pressure support trial, in comparison with those who succeed, had an higher baseline oxygen consumption and were not able to increase their oxygen consumption in response to an increased demand. \uc2\ua9 2010, the American Society of Anesthesiologists, Inc

Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: A bench-top study

Purpose: Standard polyvinylchloride (PVC) endotracheal tube (ETT) cuffs do not protect from aspiration across the cuff, a leading cause of ventilator-associated pneumonia (VAP). In a long-lasting in vitro study we compared the effect of different cuff materials (PVC, polyurethane, and guayule latex), shapes (cylindrical, conical), and positive end expiratory pressures (PEEP) in reducing fluid leakage across the cuff. Methods: We compared fluid leakage across a cylindrical double-layer guayule latex prototype cuff, three cylindrical PVC cuffs (Mallinckrodt Hi-Lo, Mallinckrodt HighContour, Portex Ivory), one conical PVC cuff (Mallinckrodt TaperGuard), and two polyurethane cuffs (Mallinckrodt SealGuard, conical; Microcuff, cylindrical). Ten centimeters of dyed water was poured above the cuffs inflated (pressure 30 cmH2O) in a vertical cylinder (diameter 20 mm). A respiratory circuit connected the bottom of the cylinder to a breathing bag inflated at four pressures (PEEP = 0, 5, 10, 15 cmH2O). Pictures were taken every 60 s for 24 h to measure leakage as a reduction in the water column above the cuff. Five new ETTs of each type were tested. Results: The guayule latex cuffs showed no leakage at all the PEEP levels. Both the cylindrical and conical polyurethane cuffs showed limited leakage (2.1 \uc2\ub1 1.8 cm of water) only for PEEP zero. The PVC cuffs showed reduced leakage with increasing PEEP: 8.4 \uc2\ub1 1.5, 7.8 \uc2\ub1 2.2, 2.2 \uc2\ub1 1.0, and 0 cm of water at 0, 5, 10, and 15 cmH2O, respectively. Among all the PVC cuffs, the conical shape ensured higher sealing properties. Conclusions: The guayule latex cuffs always prevented fluid leakage; the polyurethane and PVC cuffs required incremental levels of PEEP to prevent fluid leakage ever-present at zero PEEP. \uc2\ua9 Copyright jointly held by Springer and ESICM 2010

Extracorporeal membrane oxygenation for interhospital transfer of severe acute respiratory distress syndrome patients: A 5-year experience

Purpose: Transfer of severely hypoxic patients is a high-risk procedure. Extracorporeal Membrane Oxygenation (ECMO) allows safe transport of these patients to tertiary care institutions. Our ECMO transportation program was instituted in 2004; here we report results after 5 years of activity. Methods: This is a clinical observational study. Criteria for ECMO center activation were: potentially reversibile respiratory failure, PaO2&lt;50 mmHg with FiO2&gt;0.6 for &gt;12 hours, PEEP &gt;5 cmH20, Lung Injury Score (LIS) \ue2\u89\ua53 or respiratory acidosis with pH&lt;7.2, no intracranial bleeding, and no absolute contraindication to anticoagulation. If eligible, a skilled crew applied ECMO at the referral hospital. Transportation was performed with a specially equipped ambulance. Results: Sixteen patients were possible candidates for ECMO transfer. Two patients were excluded while 14 (mean\uc2\ub1SD, age 35.4\uc2\ub118.6, SOFA 8.4\uc2\ub13.7, Oxygenation Index 43.7\uc2\ub113.4) were transported to our institution (distance covered 102\uc2\ub1114 km, global duration of transport 589\uc2\ub1186 minutes). Two patients improved after iNO-trial and were transferred and subsequently managed without ECMO. The remaining 12 patients were transferred on veno-venous ECMO with extracorporeal blood flow 2.7\uc2\ub11 L\uc2\ub7min-1, gas flow 3.8\uc2\ub11.8 L\uc2\ub7min-1, and FiO21. Data were recorded 30 minutes before and 60 minutes after initiation of ECMO. ECMO improved PCO2(75\uc2\ub123 vs. 53\uc2\ub19 mmHg, p&lt;0.01) thus improving pH (7.28\uc2\ub10.13 vs. 7.39\uc2\ub10.05, p&lt;0.01) and allowing a reduction in respiratory rate (35\uc2\ub114 vs. 10\uc2\ub14 breaths/min, p&lt;0.01), minute ventilation (10.1\uc2\ub13.8 vs. 3.7\uc2\ub11.7 L\uc2\ub7min-1, p&lt;0.01), and mean airway pressure (26\uc2\ub16.5 vs. 22\uc2\ub15 cmH2O, p&lt;0.01). No major clinical or technical complications were observed. Conclusions: ECMO effectively enabled high-risk ground transfer of severely hypoxic patients. \uc2\ua9 2011 Wichtig Editore

Respiratory pattern during neurally adjusted ventilatory assist in acute respiratory failure patients

Purpose: To investigate the effect of a wide range of assistance levels during neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) on respiratory pattern, breathing variability, and incidence of tidal volumes (VT) above 8 and 10 ml/kg in acute respiratory failure patients. Methods: Eight increasing NAVA levels (0.5, 1, 1.5, 2, 2.5, 3, 4, and 5 cmH2O/\uce\ubcV) and four increasing pressure support (PSV) levels (4, 8, 12, and 16 cmH2O) were applied to obtain 10 min of stable recordings in 15 patients. Results: One out of 15 patients did not sustain the NAVA levels of 3, 4, and 5 cmH2O/\uce\ubcV and was excluded. The 5 cmH2O/\uce\ubcV NAVA level was not tolerated by three patients and it was excluded. Increasing NAVA levels were associated with decreased diaphragm electrical activity (EAdi), and, at variance with PSV, with small changes in VT, no changes in respiratory rate (RR), and increases in VTand EAdi variability. At high NAVA levels, an increase in VTvariability was associated with increased incidence of VTabove 8 and 10 ml/kg and an uncomfortable respiratory pattern in some patients. Conclusions: Increasing NAVA levels were associated with no effect on RR, small increase in VT, and increase in VTand EAdi variability. Effective decrease in EAdi occurred at NAVA levels below 2-2.5 cmH2O/\uce\ubcV, while preserving respiratory variability and low risks of VTabove 8 or 10 ml/kg. \uc2\ua9 2011 jointly held by Springer and ESICM

Performance of different continuous positive airway pressure helmets equipped with safety valves during failure of fresh gas supply

Purpose: We assessed the performance of different continuous positive airway pressure (CPAP) helmets equipped with a safety valve during discontinuation of fresh gas flow. Methods: This was a physiological study of five healthy volunteers. We delivered CPAP (fresh gas flow 60 l/min, FiO260%, PEEP 5 cmH2O) with three different helmets in a random sequence: 4Vent (R\uc3\ubcsch), HelmHAR-cp (Harol) and CaStar CP210 (StarMed). For each helmet we randomly applied, for up to 4 min, three disconnections of fresh gas flow: helmet inlet (Dinlet), flowmeter (Dflowmeter) and gas source (Dsource). We continuously recorded from a nostril: end-tidal CO2(PetCO2), inspiratory CO2(PiCO2), fraction of inspired oxygen (FiO2) and respiratory rate (RR). Results: During every disconnection we observed an increase in PiCO2and PetCO2with a drop in FiO2, while RR did not change. FiO2decreased more quickly in the CaStar, equipped with the largest safety valve, during Dsourceand Dflowmeter, while FiO2decreased more quickly during Dinletin CaStar and in 4Vent. PiCO2resulted in a lower increase in CaStar during Dsourceand Dflowmetercompared to 4Vent. PetCO2in CaStar increases more slowly compared to 4Vent during Dsourceand more slowly compared to the other two helmets during Dflowmeter. During Dinletsimilar degrees of CO2rebreathing and PetCO2were recorded among all the helmets. Conclusions: To minimize CO2rebreathing during disconnection of the fresh gas supply while performing helmet CPAP, it is desirable to utilize large helmets with a large anti-suffocation valve. Monitoring and alarm systems should be employed for safe application of helmet CPAP. \uc2\ua9 2011 jointly held by Springer and ESICM

Contrast-enhanced mammography BI-RADS: a case-based approach to radiology reporting

Abstract Contrast-enhanced mammography (CEM) is a relatively recent diagnostic technique increasingly being utilized in clinical practice. Until recently, there was a lack of standardized reporting for CEM findings. However, this has changed with the publication of a supplement in the Breast Imaging Reporting and Data System (BI-RADS). A comprehensive understanding of CEM is essential for further enhancing its role in both screening and managing patients with breast malignancies. CEM can also be beneficial for problem-solving, improving the management of uncertain breast findings. Practitioners in this field should become more cognizant of how and when to employ this technique and interpret the various CEM findings. This paper aims to outline the key findings in the updated version of the BI-RADS specifically dedicated to CEM. Additionally, it will present some clinical cases commonly encountered in clinical practice. Critical relevance statement Standardized reporting and a thorough understanding of CEM findings are pivotal for advancing the role of CEM in screening and managing breast cancer patients. This standardization contributes significantly to integrating CEM as an essential component of daily clinical practice. Key points • A complete knowledge and understanding of the findings outlined in the new BI-RADS CEM are necessary for accurate reporting. • BI-RADS CEM supplement is intuitive and practical to use. • Standardization of the CEM findings enables more accurate patient management. Graphical Abstrac