Evaluation of peak inspiratory pressure, tidal volume and respiratory rate during ventilation of premature lambs using a self-inflating bag

OBJECTIVE: To evaluate the peak inspiratory pressure, tidal volume and respiratory rate achieved during manual ventilation of premature lambs, using a self-inflating bag. METHODS: In this descriptive, experimental study, five pairs of physicians, selected at random among 35 neonatologists working at a neonatal intensive care unit and with experience in the resuscitation of newborn infants, ventilated five intubated premature lambs using a self-inflating bag. Pressure and flow monitor signals were passed through a transducer and digitized for recording and analysis. Tidal volume and pressure curves were obtained from the integral of flow rate, at peak, during the last 50 seconds of every fifth minute, and analyzed. RESULTS: Median pressure was 39.8 (IQ25-75% 30.2-47.2) cmH2O; being below 20 in 1.1% of cases and above 40 in 49.1%. Seven out of 10 physicians produced more than six pressure peaks of over 40 cmH2O. Median tidal volume/kg was 17.8 (IQ25-75% 14.1-22.4) mL, being below 5 mL in 0.1% of cases and greater than or equal to 20 mL in 37.7%. All of the physicians propelled five or more ventilation cycles with tidal volume/kg of 20 mL or more. Respiratory rate was between 30 and 60 cycles/minute in 65.9% of cases, being below 30 in 6.8% of cases and over 60 in 27.3% of cases. CONCLUSIONS: There was major variation in peak inspiratory pressure and tidal volume/kg values, which were in many cases elevated, attaining levels that habitually cause biotrauma, while respiratory rates were adequate in the majority of cases.OBJETIVO: Avaliar o pico de pressão inspiratória, o volume corrente e a freqüência respiratória obtidos durante ventilação manual de carneiros prematuros, utilizando balão auto-inflável. MÉTODOS: Estudo experimental descritivo em que cinco duplas de médicos selecionados aleatoriamente entre 35 neonatologistas que trabalham em unidade de terapia intensiva neonatal e experientes em reanimação de recém-nascidos ventilaram cinco carneiros prematuros intubados, utilizando balão auto-inflável. Os sinais de pressão e fluxo eram captados, convertidos por meio de transdutores e digitalizados para armazenamento e análise. Foram avaliadas curvas de pressão e de volume corrente, este a partir da integral do fluxo, em suas medidas de pico, nos 50 segundos finais de cada 5 minutos. RESULTADOS: A mediana da pressão foi de 39,8 (IQ25-75% 30,2-47,2) cmH2O; foi menor que 20 em 1,1% das vezes e maior que 40 em 49,1%. Sete em 10 médicos propiciaram mais de seis picos de pressão maiores que 40 cmH2O. A mediana do volume corrente/kg foi de 17,8 (IQ25-75% 14,1-22,4) mL, sendo menor que 5 mL em 0,1% das vezes e igual ou maior que 20 mL em 37,7%. Todos os médicos impuseram cinco ou mais ciclos ventilatórios com volume corrente/kg de 20 mL ou mais. A freqüência situou-se entre 30 e 60 ciclos/minuto em 65,9% das vezes, sendo menor que 30 em 6,8% e maior que 60 em 27,3% das vezes. CONCLUSÃO: Ocorreu grande variabilidade nos valores do pico de pressão inspiratória e do volume corrente/kg, sendo muitas vezes elevados e alcançando níveis indutores de biotrauma; para a freqüência respiratória, os valores foram adequados na maioria das vezes.Universidade de BrasíliaUnBUniversidade Federal de São Paulo (UNIFESP)UnB Hospital Universitário da UnBUniversidade de São Paulo Faculdade de Medicina Instituto da Criança do Hospital das ClínicasUNIFESPSciEL

Evaluation of peak inspiratory pressure and respiratory rate during ventilation of an infant lung model with a self-inflating bag

OBJETIVO: Avaliar o pico de pressão inspiratória e a freqüência ventilatória obtidos por médicos quando da utilização de balão auto-inflável neonatal em modelo de pulmão. MÉTODOS: Quinze médicos ventilaram simuladores de pulmão de recém-nascidos a termo e pré-termo, sendo os desfechos captados através de um monitor de ventilação. RESULTADOS: As medianas dos picos de pressão foram 23 (intervalo interquartil, 15-47) e 26 (intervalo interquartil, 14-51) cmH2O, sendo menor que 20 em 41,2 e 35,8% das vezes; maior que 40 em 29,7 e 33,6% das vezes e entre 27 e 33 cmH2O em 8,2 e 6,5% das vezes, para o pulmão de termo e de pré-termo, respectivamente. As medianas das freqüências ventilatórias foram de 45 (intervalo interquartil, 36-57) e 48 (intervalo interquartil, 39-55,5) ciclos por minuto, sendo menor que 30 em 9,3 e 6,7% das vezes e maior que 60 em 12 e 13,3% das vezes, respectivamente, para o pulmão de termo e de pré-termo. As diferenças nas medianas não foram estatisticamente significantes. CONCLUSÃO: A ventilação utilizando o balão auto-inflável promoveu adequação para a freqüência ventilatória em aproximadamente 80% das vezes, e os médicos não conseguiram promover ventilação com mínima variabilidade na pressão, alcançando níveis diferentes daqueles definidos no curso de reanimação neonatal em 70% das vezes. Essa situação independeu da ventilação do pulmão-teste análogo ao sistema respiratório de recém-nascidos a termo ou pré-termo.OBJECTIVE: To evaluate the peak inspiratory pressure and ventilation rate achieved by physicians when using a neonatal self-inflating bag on a lung model. METHODS: Fifteen physicians ventilated full term and preterm infant lung simulators while the outcomes were captured by a ventilation monitor. RESULTS: Median peak pressures in cmH2O for full term and preterm lungs were 23 (interquartile range: 15-47) and 26 (interquartile range: 14-51), being less than 20 in 41.2 and 35.8% of the pressure curves analyzed, more than 40 in 29.7 and 33.6%, and between 27 and 33 cmH2O in 8.2 and 6.5% of the curves, respectively. Median ventilation rates were 45 (interquartile range: 36-57) and 48 (interquartile range: 39-55.5) cycles per minute, being more than 30 in 9.3 and 6.7% of pressure curves and more than 60 in 12 and 13.3% of pressure curves, for the full term and preterm lungs, respectively. The differences between these medians were not statistically significant. CONCLUSIONS: Ventilation rates achieved with the self-inflating bag were adequate in approximately 80% of pressure curves analyzed, but the physicians were unable to provide ventilation with minimal pressure variation, producing pressures that diverged from those defined by the neonatal resuscitation training course in 70% of the curves. This was irrespective of whether they were ventilating the lung model analogous to preterm or full term infant lungs

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Avaliação do pico de pressão, do volume corrente e da freqüência respiratória durante ventilação de carneiros prematuros utilizando balão auto-inflável Evaluation of peak inspiratory pressure, tidal volume and respiratory rate during ventilation of premature lambs using a self-inflating bag

OBJETIVO: Avaliar o pico de pressão inspiratória, o volume corrente e a freqüência respiratória obtidos durante ventilação manual de carneiros prematuros, utilizando balão auto-inflável. MÉTODOS: Estudo experimental descritivo em que cinco duplas de médicos selecionados aleatoriamente entre 35 neonatologistas que trabalham em unidade de terapia intensiva neonatal e experientes em reanimação de recém-nascidos ventilaram cinco carneiros prematuros intubados, utilizando balão auto-inflável. Os sinais de pressão e fluxo eram captados, convertidos por meio de transdutores e digitalizados para armazenamento e análise. Foram avaliadas curvas de pressão e de volume corrente, este a partir da integral do fluxo, em suas medidas de pico, nos 50 segundos finais de cada 5 minutos. RESULTADOS: A mediana da pressão foi de 39,8 (IQ25-75% 30,2-47,2) cmH2O; foi menor que 20 em 1,1% das vezes e maior que 40 em 49,1%. Sete em 10 médicos propiciaram mais de seis picos de pressão maiores que 40 cmH2O. A mediana do volume corrente/kg foi de 17,8 (IQ25-75% 14,1-22,4) mL, sendo menor que 5 mL em 0,1% das vezes e igual ou maior que 20 mL em 37,7%. Todos os médicos impuseram cinco ou mais ciclos ventilatórios com volume corrente/kg de 20 mL ou mais. A freqüência situou-se entre 30 e 60 ciclos/minuto em 65,9% das vezes, sendo menor que 30 em 6,8% e maior que 60 em 27,3% das vezes. CONCLUSÃO: Ocorreu grande variabilidade nos valores do pico de pressão inspiratória e do volume corrente/kg, sendo muitas vezes elevados e alcançando níveis indutores de biotrauma; para a freqüência respiratória, os valores foram adequados na maioria das vezes.<br>OBJECTIVE: To evaluate the peak inspiratory pressure, tidal volume and respiratory rate achieved during manual ventilation of premature lambs, using a self-inflating bag. METHODS: In this descriptive, experimental study, five pairs of physicians, selected at random among 35 neonatologists working at a neonatal intensive care unit and with experience in the resuscitation of newborn infants, ventilated five intubated premature lambs using a self-inflating bag. Pressure and flow monitor signals were passed through a transducer and digitized for recording and analysis. Tidal volume and pressure curves were obtained from the integral of flow rate, at peak, during the last 50 seconds of every fifth minute, and analyzed. RESULTS: Median pressure was 39.8 (IQ25-75% 30.2-47.2) cmH2O; being below 20 in 1.1% of cases and above 40 in 49.1%. Seven out of 10 physicians produced more than six pressure peaks of over 40 cmH2O. Median tidal volume/kg was 17.8 (IQ25-75% 14.1-22.4) mL, being below 5 mL in 0.1% of cases and greater than or equal to 20 mL in 37.7%. All of the physicians propelled five or more ventilation cycles with tidal volume/kg of 20 mL or more. Respiratory rate was between 30 and 60 cycles/minute in 65.9% of cases, being below 30 in 6.8% of cases and over 60 in 27.3% of cases. CONCLUSIONS: There was major variation in peak inspiratory pressure and tidal volume/kg values, which were in many cases elevated, attaining levels that habitually cause biotrauma, while respiratory rates were adequate in the majority of cases