Vibration Response Imaging: evaluation of rater agreement in healthy subjects and subjects with pneumonia

<p>Abstract</p> <p>Background</p> <p>We evaluated pulmonologists variability in the interpretation of Vibration response imaging (VRI) obtained from healthy subjects and patients hospitalized for community acquired pneumonia.</p> <p>Methods</p> <p>The present is a prospective study conducted in a tertiary university hospital. Twenty healthy subjects and twenty three pneumonia cases were included in this study. Six pulmonologists blindly analyzed images of normal subjects and pneumonia cases and evaluated different aspects of VRI images related to the quality of data aquisition, synchronization of the progression of breath sound distribution and agreement between the maximal energy frame (MEF) of VRI (which is the maximal geographical area of lung vibrations produced at maximal inspiration) and chest radiography. For qualitative assessment of VRI images, the raters' evaluations were analyzed by degree of consistency and agreement.</p> <p>Results</p> <p>The average value for overall identical evaluations of twelve features of the VRI image evaluation, ranged from 87% to 95% per rater (94% to 97% in control cases and from 79% to 93% per rater in pneumonia cases). Inter-rater median (IQR) agreement was 91% (82-96). The level of agreement according to VRI feature evaluated was in most cases over 80%; intra-class correlation (ICC) obtained by using a model of subject/rater for the averaged features was overall 0.86 (0.92 in normal and 0.73 in pneumonia cases).</p> <p>Conclusions</p> <p>Our findings suggest good agreement in the interpretation of VRI data between different raters. In this respect, VRI might be helpful as a radiation free diagnostic tool for the management of pneumonia.</p

Changes in sleep quality and physical condition levels of persons with chronic renal failure

Chronic Renal Failure is an important disease entity. The hemodialysis (HD) patients present with many comorbidities that increase morbidity. The objectives of this study were to investigate: a) the effect of Obstructive Sleep Apnea Hypopnea Syndrome (OSAS) on comorbidities and quality of life of dialysis patients and b) the effect of a systematic aerobic exercise programme in the general hemodialysis population, but especially in hemodialysis patients with OSAS. In this thesis three experimental studies were conducted. All received institutional and hospital ethics approvals and subjects gave their written informed consent for participation. The first study investigated the effect of OSAS on health indices of HD patients (such as body composition, functional capacity, nutritional status, quality of sleep). The second study investigated the effects of sleep quality (including the presence of Periodic Leg Movement Syndrome- PLMS and of OSAS) on heart function indices in HD patients. The third study examined the effects of 6-month aerobic exercise program on HD patients’ wellbeing and sleep quality. looked for before and after. The results of the 1st study revealed that the presence of OSAS in HD patients is associated with the presence of central obesity and muscle disorders. The 2nd study revealed, for the first time, that the PLMS is a statistically significant contributor of structural and functional abnormalities of the left heart in HD patients. and Sleep Apnea, are potential risk factors for cardiovascular diseases and found functional significant contributor for abnormalities of the left heart. The 3rd study showed that a 6-month aerobic exercise program results in significantly positive changes in body composition, sleep quality indicators and levels of functional capacity. However, while a trend for improvement of heart function indices was seen this was not statistically significant, possibly due to the small number of subjects completing all measurements. In conclusion, this thesis presents for the first time critical data in the field. In summary, we have shown that chronic aerobic exercise during dialysis can be a safe and effective feasible treatment in reducing symptoms of sleep apnea, while chronic exercise can improve the functional capacity and quality of life of these patients. Moreover, we demonstrated the effectiveness of the exercise programme on improving sleep quality in these patients and a non statistical trend for positive changes in cardiac function indices of hemodialysis patients. Finally, as demonstrated through the results of the present study, the most effective approach for improving muscle formation and muscular atrophy in these patients is a combination of aerobic exercise and adequate Haemodialysis technique.Η Χρόνια Νεφρική Ανεπάρκεια (ΧΝΑ) αποτελεί μια σημαντική νοσολογική οντότητα. Οι νεφροπαθείς ασθενείς είναι δέσμιοι της νόσου που συνοδεύεται από αυξημένη συνοσηρότητα. Στόχοι της παρούσας διατριβής ήταν να διερευνήσει: α) την επίδραση του Συνδρόμου Αποφρακτικών Απνοιών Ύπνου (ΣΑΑΥ) στην συνοσηρότητα και την ποιότητα ζωής των αιμοκαθαιρόμενων νεφροπαθών και β) την επίδραση της συστηματικής άσκησης στο γενικό πληθυσμό των ασθενών με ΧΝΑ αλλά κυρίως στους υπνο-απνοϊκούς αιμοκαθαιρόμενους ασθενείς. Στην παρούσα διδακτορική διατριβή διεξήχθησαν τρεις πειραματικές μελέτες οι οποίες έλαβαν έγκριση δεοντολογίας από την επιτροπή δεοντολογίας του τμήματος και την επιστιμονική επιτροπή του ΠΓΝ Λάρισας: Η πρώτη μελέτη εξέτασε την επίδραση των υπνικών απνοιών σε δείκτες υγείας των αιμοκαθαιρόμενων ασθενών όπως η μυϊκή σύσταση, η λειτουργική ικανότητα,η ποιότητα θρέψης,η ποιότητα ύπνου και άλλες μεταβλητές. Η δεύτερη μελέτη εξέτασε την επίδραση της ποιότητας ύπνου ( συμπεριλαμβανομένης της παρουσίας ή όχι της αισθητικοκινητικής διαταραχής ¨περιοδικές κινήσεις των κάτω άκρων¨ (Periodic Leg Movement Syndrome) PLMS και του ΣΑΑΥ), σε δείκτες της καρδιακής λειτουργίας των νεφροπαθών. Η τρίτη μελέτη εξέτασε την επίδραση της θεραπευτικής άσκησης στην ευρωστία και την ποιότητα ύπνου. Η πρώτη μελέτη ανέδειξε ότι οι αιμοκαθαιρόμενοι ασθενείς με αυξημένο δείκτη απνοιών υποπνοιών εμφανίζουν σημαντικά αυξημένα επίπεδα κεντρικής παχυσαρκίας και μυϊκές διαταραχές,. Η δεύτερη μελέτη αποκάλυψε ότι διαταραχές οι οποίες είναι πολύ συχνές στους νεφροπαθείς (PLMS και ΣΑΑΥ) είναι δυνητικοί παράγοντες αυξημένου καρδιαγγειακού κινδύνου και φάνηκε ότι το PLMS αποτελεί και στατιστικά σημαντικό παράγοντα για δομικές και λειτουργικές ανωμαλίες της αριστερής καρδιάς. Η τρίτη μελέτη έδειξε ότι μετά από ένα 6μηνο συμμετοχής σε πρόγραμμα αερόβιας άσκησης επέρχονται θετικές μεταβολές στη σωματική και μυϊκή σύσταση, στους δείκτες ποιότητας ύπνου και στα επίπεδα λειτουργικής ικανότητας. Ωστόσο αν και παρατηρήθηκε τάση βελτίωσης στους δείκτες καρδιακής λειτουργίας αυτή δεν ήταν στατιστικά σημαντική (p>0,05) λόγω μικρής συμμετοχής των αιμοκαθαιρόμενων ασθενών στον επαναλληπτικό υπερηχοκαρδιογραφικό έλεγχο. Συμπερασματικά, η παρούσα διδακτορική διατριβή παρουσιάζει για πρώτη φορά σημαντικά δεδομένα στον χώρο. Εν ολίγοις, φαίνεται ότι η χρόνια αερόβια άσκηση κατά τη διάρκεια της αιμοκάθαρσης μπορεί να αποτελέσει μια ασφαλή και αποτελεσματική εφαρμόσιμη θεραπεία για τη μείωση των συμπτωμάτων του ΣΑΑΥ, ενώ παράλληλα η χρόνια άσκηση μπορεί να βελτιώσει την ευρωστία και την ποιότητα ζωής των ασθενών αυτών. Επιπλέον, δείξαμε τη θετική επίδραση της άσκησης στη βελτίωση του ύπνου των ασθενών αυτών καθώς και μια τάση για θετικές μεταβολές της καρδιακής λειτουργίας των αιμοκαθαιρόμενων ασθενών. Τέλος, όπως αποδεικνύεται μέσα από τα αποτελέσματα της παρούσης διατριβής, η αποτελεσματικότερη προσέγγιση για την βελτίωση της μυϊκής σύστασης και της μυϊκής ατροφίας των ασθενών είναι αυτή του συνδυασμού αερόβιας άσκησης και επαρκούς κάθαρσης

The impact of N-acetylcysteine and ascorbic acid in contrast-induced nephropathy in critical care patients: an open-label randomized controlled study

Abstract Background The aim was to investigate whether the use of N-acetylcysteine and ascorbic acid reduce contrast-induced nephropathy incidence in critical care patients. Methods This was a one-center, two-arm, prospective, randomized, open-label, controlled trial in the Intensive Care Unit of the University Hospital of Larissa, Greece. Patients with stable renal function, who underwent non urgent contrast-enhanced computed tomography for diagnostic purposes, were included in the study. Patients in the treatment group (NacA, n = 60) received intravenously N-acetylcysteine (1200 mg) and ascorbic acid (2 g) dissolved separately in 100 ml of normal saline 2 hours before, and at 10 hours and 18 hours following the infusion of contrast agent, while control group patients (CG, n = 64) received only normal saline. All patients received additional hydration. Contrast-induced nephropathy was defined as relative increase by 25% of the baseline values of serum creatinine. Results Contrast-induced nephropathy in NacA and CG were 18.33% and 15.6%, respectively (p = 0.81). The percentage change median (interquartile range (IR)) of serum cystatin-C (mg/L) from baseline in patients who underwent contrast-induced tomography, were 37.23% (28.53) and 93.20% (46.90) in NacA and in CG, respectively (p = 0.03). The 8-isoprostane serum levels in NacA were significantly lower compared to CG at 2 hours (p = 0.012) and 24 hours (p = 0.006) following radiocontrast infusion. Multivariate analysis revealed that contrast-induced nephropathy was independently associated with a higher baseline ratio of serum urea/creatinine (odds ratio, 1.02; 95 CI%, 1.00–1.05) and with the use of nephrotoxic medications (odds ratio, 0.24; 95 CI%, 0.06–0.94). Conclusion Intravenous administration of N-acetylcysteine and ascorbic acid failed to reduce contrast-induced nephropathy in critically ill patients who underwent contrast-enhanced computed tomography, despite a significant reduction of 8-isoprostane levels in treated patients. Trial registration ClinicalTrials.gov, NCT01017796 . Registered on 20 November 2009

Ventilator-Associated Tracheobronchitis Increases the Length of Intensive Care Unit Stay

OBJECTIVE. To investigate prospectively the clinical course and risk factors for ventilator-associated tracheobronchitis (VAT) and the impact of VAT on intensive care unit (ICU) morbidity and mortality. DESIGN. Prospective cohort study. SETTING. University Hospital Larissa, Larissa, Greece PATIENTS. Critical care patients who received mechanical ventilation for more than 48 hours were prospectively studied between 2009 and 2011. METHODS. The modified Clinical Pulmonary Infection Score, white blood cell count, and C-reactive protein level were systematically assessed every 2 days for the first 2 weeks of ICU stay. Bronchial secretions were assessed daily. Quantitative cultures of endotracheal secretions were performed on the first ICU day for every patient and every 2 days thereafter for the first 2 weeks or more at the discretion of the attending physicians. Definition of VAT was based on previously published criteria. RESULTS. A total of 236 patients were observed; 42 patients (18%) presented with VAT. Gram-negative pathogens, which were usually multidrug resistant, were responsible for 92.9% of cases. Patients with a neurosurgical admission presented with VAT significantly more often than did other ICU patients (28.5% vs 14.1%; P = .02). The occurrence of VAT was a significant risk factor for increased duration of ICU stay (OR [95% CI], 3.04 [1.35-6.85]; P = . 01). Age (OR [95% CI], 1.04 [1.015-1.06]; P = .02), Acute Physiology and Chronic Health Evaluation II score (OR [95% CI], 1.08 [1.015-1.16]; P = .02), and C-reactive protein level at admission (OR [95% CI], 1.05 [1.01-1.1]; P = .02) were independent factors for ICU mortality. CONCLUSIONS. VAT is a nosocomial infection that might be associated with prolonged stay in the ICU, especially in neurocritical patients. VAT was not associated with increased mortality in our study

Additional file 1: Table S1. of The impact of N-acetylcysteine and ascorbic acid in contrast-induced nephropathy in critical care patients: an open-label randomized controlled study

Classification of participants renal function according to RIFLE criteria at the entry study. Table S2. Medications with potential impact on renal function received by participants according to treatment group. Table S3. Univariate analysis of characteristics of survivors and non survivors. Table S4. CIN based on serum creatinine or cystatin-C changes or RIFLE score (between the day of radiocontrast material infusion and the day of CIN diagnosis). Table S5. Medications with potential impact on renal function received by participants according to the presence of CIN or not. Table S6. Fluid balance of patients included in the study according to the presence of CIN or not. (DOC 110 kb

The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years)

Purpose: Very old critical ill patients are a rapid expanding group in the ICU. Indications for admission, triage criteria and level of care are frequently discussed for such patients. However, most relevant outcome studies in this group frequently find an increased mortality and a reduced quality of life in survivors. The main objective was to study the impact of frailty compared with other variables with regards to short-term outcome in the very old ICU population. Methods: A transnational prospective cohort study from October 2016 to May 2017 with 30 days follow-up was set up by the European Society of Intensive Care Medicine. In total 311 ICUs from 21 European countries participated. The ICUs included the first consecutive 20 very old (≥ 80 years) patients admitted to the ICU within a 3-month inclusion period. Frailty, SOFA score and therapeutic procedures were registered, in addition to limitations of care. For measurement of frailty the Clinical Frailty Scale was used at ICU admission. The main outcomes were ICU and 30-day mortality and survival at 30 days. Results: A total of 5021 patients with a median age of 84 years (IQR 81–86 years) were included in the final analysis, 2404 (47.9%) were women. Admission was classified as acute in 4215 (83.9%) of the patients. Overall ICU and 30-day mortality rates were 22.1% and 32.6%. During ICU stay 23.8% of the patients did not receive specific ICU procedures: ventilation, vasoactive drugs or renal replacement therapy. Frailty (values ≥ 5) was found in 43.1% and was independently related to 30-day survival (HR 1.54; 95% CI 1.38–1.73) for frail versus non-frail. Conclusions: Among very old patients (≥ 80 years) admitted to the ICU, the consecutive classes in Clinical Frailty Scale were inversely associated with short-term survival. The scale had a very low number of missing data. These findings provide support to add frailty to the clinical assessment in this patient group. Trial registration: ClinicalTrials.gov (ID: NCT03134807)

Sepsis at ICU admission does not decrease 30-day survival in very old patients: a post-hoc analysis of the VIP1 multinational cohort study

Background: The number of intensive care patients aged ≥ 80 years (Very old Intensive Care Patients; VIPs) is growing. VIPs have high mortality and morbidity and the benefits of ICU admission are frequently questioned. Sepsis incidence has risen in recent years and identification of outcomes is of considerable public importance. We aimed to determine whether VIPs admitted for sepsis had different outcomes than those admitted for other acute reasons and identify potential prognostic factors for 30-day survival. Results: This prospective study included VIPs with Sequential Organ Failure Assessment (SOFA) scores ≥ 2 acutely admitted to 307 ICUs in 21 European countries. Of 3869 acutely admitted VIPs, 493 (12.7%) [53.8% male, median age 83 (81-86) years] were admitted for sepsis. Sepsis was defined according to clinical criteria; suspected or demonstrated focus of infection and SOFA score ≥ 2 points. Compared to VIPs admitted for other acute reasons, VIPs admitted for sepsis were younger, had a higher SOFA score (9 vs. 7, p &lt; 0.0001), required more vasoactive drugs [82.2% vs. 55.1%, p &lt; 0.0001] and renal replacement therapies [17.4% vs. 9.9%; p &lt; 0.0001], and had more life-sustaining treatment limitations [37.3% vs. 32.1%; p = 0.02]. Frailty was similar in both groups. Unadjusted 30-day survival was not significantly different between the two groups. After adjustment for age, gender, frailty, and SOFA score, sepsis had no impact on 30-day survival [HR 0.99 (95% CI 0.86-1.15), p = 0.917]. Inverse-probability weight (IPW)-adjusted survival curves for the first 30 days after ICU admission were similar for acute septic and non-septic patients [HR: 1.00 (95% CI 0.87-1.17), p = 0.95]. A matched-pair analysis in which patients with sepsis were matched with two control patients of the same gender with the same age, SOFA score, and level of frailty was also performed. A Cox proportional hazard regression model stratified on the matched pairs showed that 30-day survival was similar in both groups [57.2% (95% CI 52.7-60.7) vs. 57.1% (95% CI 53.7-60.1), p = 0.85]. Conclusions: After adjusting for organ dysfunction, sepsis at admission was not independently associated with decreased 30-day survival in this multinational study of 3869 VIPs. Age, frailty, and SOFA score were independently associated with survival

Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

PURPOSE: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU. METHODS: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up. RESULTS: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries. CONCLUSIONS: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country. TRIAL REGISTRATION: ClinicalTrials.gov (ID: NTC03134807)