The non-invasive mechanical ventilation: the experience of the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena

Acute respiratory failure (ARF) is a deficiency of the respiratory system that causes an alteration of normal levels of oxygen and/or carbon dioxide in the blood. ARF may be due to alterations in gaseous diffusion in alveolar-capillary level (type “1” acute respiratory failure), or to alterations in the functioning of the respiratory pump (type “2” acute respiratory failure) or to an association of the above causes. ARF specific etiological treatment must be associated to oxygen administration, through ventilation, which may be spontaneous or mechanical (non-invasive or invasive). The actual study describes experience about non-invasive mechanical ventilation in the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena, from 2010 to 2014, examining clinical parameters and outcomes. Respiratory failure is a condition in which the respiratory system is not able to adequately carry out its gas exchange functions, such as oxygenation of the arterial blood and/or elimination of carbon dioxide from the venous blood. Conventionally, (1),(2),(3) respiratory failure is defined in case of: Partial pressure of arterial oxygen (PaO2) <60 mmHg; Partial pressure of carbon dioxide in the arterial blood (PCO2)> 45 mmHg; Association of both previous. You can distinguish two types of acute respiratory failure(4)(ARF): ARF type “1”, with gas exchange impairment and hypoxemia (associated with hypo/normocapnia). The pathophysiological mechanism behind is an important intrapulmonary shunt with changes in ventilation/perfusion ratio. Generally diseases responsible for this condition are acute pulmonary edema, ARDS, severe pneumonia and pulmonary embolism. ARF type “2”, with hypoventilation and hypercapnia. It is caused by a reduction of the ventilation volume/minute or by an increase of physiologic dead space. Among the most common diseases there are neuromuscular diseases, myopathies, chronic obstructive pulmonary disease (COPD), bronchial asthma and restrictive lung disease. The two types of respiratory failure are closely connected and can evolve into one another. The ARF therapy can be divided into: Etiological therapy: it is directed to the treatment of the specific cause that induced ARF, it can be delivered with inotropic agents, antibiotics, bronchodilators, steroids etc. Supportive therapy (or symptomatic): aimed at correcting hypoxemia and respiratory acidosis, is indicated in all respiratory insufficiencies and it is based on the administration of O2 and postural therapy. Ventilation can be spontaneous (delivered by low or high flow systems) or mechanical. Mechanical ventilation is classifiable under invasive ventilation (IMV) or non-invasive (NIV). The IMV provides the invasion of the patient’s airways to put them in communication with the respiratory system. It can be through tracheal intubation or tracheotomy and it’s a relevant method adopted by resuscitation intensive departments and partly by respiratory diseases departments. The NIV despite is a method that requires training and experience to be used optimally, it has the advantage to be used in emergency medicine departments and in other departments from specialists who are not resuscitators or pulmonologists. Moreover, compared to the IMV, the NIV offers the following advantages: reduction in the respiratory work, absence of complications related to prosthesis, possibility of avoiding sedation required for the IMV, conservation of laryngeal functions and cost reduction.(5) The NIV techniques most used in emergency medicine departments are CPAP (Continuous positive airway pressure) and BiPAP (or BiLevel - BiLevel positive airway pressure) CPAP provides a predetermined positive pressure, greater than atmospheric, which is maintained constant throughout the respiratory cycle, and it improves oxygenation by increasing the functional residual capacity, favouring the recruitment and the patency of the alveoli excluded from the ventilation and improving the relationship between ventilation and perfusion. The main indications for CPAP are acute cardiogenic pulmonary edema (ACPE), hypoxic and not hypercapnic ARF, obstructive sleep apnea syndrome (OSAS); atelectasis. (8),(9),(10) BiPAP provides two different levels of positive pressure, which are an inspiratory positive airway pressure (IPAP) and an expiratory positive airway pressure (EPAP). BiPAP facilitates the removal of air exhaled and prevents cases of re-breathing of CO2. It also reduces the patient's work of breathing. The main indications to BiPAP are hypercapnic ARF, chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, neuromuscular disorders, dysfunction of the respiratory center (sedation/intoxication), shock (cardiovascular/septic). (11), (12)Acute respiratory failure (ARF) is a deficiency of the respiratory system that causes an alteration of normal levels of oxygen and/or carbon dioxide in the blood. ARF may be due to alterations in gaseous diffusion in alveolar-capillary level (type “1” acute respiratory failure), or to alterations in the functioning of the respiratory pump (type “2” acute respiratory failure) or to an association of the above causes. ARF specific etiological treatment must be associated to oxygen administration, through ventilation, which may be spontaneous or mechanical (non-invasive or invasive). The actual study describes experience about non-invasive mechanical ventilation in the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena, from 2010 to 2014, examining clinical parameters and outcomes. Respiratory failure is a condition in which the respiratory system is not able to adequately carry out its gas exchange functions, such as oxygenation of the arterial blood and/or elimination of carbon dioxide from the venous blood. Conventionally, (1),(2),(3) respiratory failure is defined in case of: Partial pressure of arterial oxygen (PaO2) <60 mmHg; Partial pressure of carbon dioxide in the arterial blood (PCO2)> 45 mmHg; Association of both previous. You can distinguish two types of acute respiratory failure(4)(ARF): ARF type “1”, with gas exchange impairment and hypoxemia (associated with hypo/normocapnia). The pathophysiological mechanism behind is an important intrapulmonary shunt with changes in ventilation/perfusion ratio. Generally diseases responsible for this condition are acute pulmonary edema, ARDS, severe pneumonia and pulmonary embolism. ARF type “2”, with hypoventilation and hypercapnia. It is caused by a reduction of the ventilation volume/minute or by an increase of physiologic dead space. Among the most common diseases there are neuromuscular diseases, myopathies, chronic obstructive pulmonary disease (COPD), bronchial asthma and restrictive lung disease. The two types of respiratory failure are closely connected and can evolve into one another. The ARF therapy can be divided into: Etiological therapy: it is directed to the treatment of the specific cause that induced ARF, it can be delivered with inotropic agents, antibiotics, bronchodilators, steroids etc. Supportive therapy (or symptomatic): aimed at correcting hypoxemia and respiratory acidosis, is indicated in all respiratory insufficiencies and it is based on the administration of O2 and postural therapy. Ventilation can be spontaneous (delivered by low or high flow systems) or mechanical. Mechanical ventilation is classifiable under invasive ventilation (IMV) or non-invasive (NIV). The IMV provides the invasion of the patient’s airways to put them in communication with the respiratory system. It can be through tracheal intubation or tracheotomy and it’s a relevant method adopted by resuscitation intensive departments and partly by respiratory diseases departments. The NIV despite is a method that requires training and experience to be used optimally, it has the advantage to be used in emergency medicine departments and in other departments from specialists who are not resuscitators or pulmonologists. Moreover, compared to the IMV, the NIV offers the following advantages: reduction in the respiratory work, absence of complications related to prosthesis, possibility of avoiding sedation required for the IMV, conservation of laryngeal functions and cost reduction.(5) The NIV techniques most used in emergency medicine departments are CPAP (Continuous positive airway pressure) and BiPAP (or BiLevel - BiLevel positive airway pressure) CPAP provides a predetermined positive pressure, greater than atmospheric, which is maintained constant throughout the respiratory cycle, and it improves oxygenation by increasing the functional residual capacity, favouring the recruitment and the patency of the alveoli excluded from the ventilation and improving the relationship between ventilation and perfusion. The main indications for CPAP are acute cardiogenic pulmonary edema (ACPE), hypoxic and not hypercapnic ARF, obstructive sleep apnea syndrome (OSAS); atelectasis. (8),(9),(10) BiPAP provides two different levels of positive pressure, which are an inspiratory positive airway pressure (IPAP) and an expiratory positive airway pressure (EPAP). BiPAP facilitates the removal of air exhaled and prevents cases of re-breathing of CO2. It also reduces the patient's work of breathing. The main indications to BiPAP are hypercapnic ARF, chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, neuromuscular disorders, dysfunction of the respiratory center (sedation/intoxication), shock (cardiovascular/septic). (11), (12

Senescent adipocytes as potential effectors of muscle cells dysfunction: An in vitro model

Recently, there has been a growing body of evidence showing a negative effect of the white adipose tissue (WAT) dysfunction on the skeletal muscle function and quality. However, little is known about the effects of senescent adipocytes on muscle cells. Therefore, to explore potential mechanisms involved in age-related loss of muscle mass and function, we performed an in vitro experiment using conditioned medium obtained from cultures of mature and aged 3 T3-L1 adipocytes, as well as from cultures of dysfunctional adipocytes exposed to oxidative stress or high insulin doses, to treat C2C12 myocytes. The results from morphological measures indicated a significant decrease in diameter and fusion index of myotubes after treatment with medium of aged or stressed adipocytes. Aged and stressed adipocytes presented different morphological characteristics as well as a different gene expression profile of proinflammatory cytokines and ROS production. In myocytes treated with different adipocytes' conditioned media, we demonstrated a significant reduction of gene expression of myogenic differentiation markers as well as a significant increase of genes involved in atrophy. Finally, a significant reduction in protein synthesis as well as a significant increase of myostatin was found in muscle cells treated with medium of aged or stressed adipocytes compared to controls. In conclusion, these preliminary results suggest that aged adipocytes could influence negatively trophism, function and regenerative capacity of myocytes by a paracrine network of signaling

A case of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially fatal complication of pulmonary embolism (PE). Organized thrombus in the pulmonary artery causes a chronic obstruction, leading to a vascular system remodeling, an increase of pulmonary vascular resistance and a chronic pulmonary hypertension. Epidemiology is mostly unknown due to the difficult diagnostic process that often leads to a late diagnosis: findings of persistent pulmonary hypertension (PH), despite correct treatment of PE, lead to the diagnostic suspect. The first choice treatment is pulmonary endarterectomy (PEA) associated with lifelong anticoagulant therapy with vitamin K antagonist. We present the case of a 53-year-old male affected by dyspnea for months, admitted to a sub-intensive care unit for intermediate low-risk PE; echocardiography showed signs of PH persisting after anticoagulant therapy; after 2 months of specific treatment the diagnosis of CTEPH was confirmed and the patient was successfully treated with PEA

Adipokines and arterial stiffness in the elderly

Introduction: The aim of this study was to evaluate the relationship between adipokines and arterial stiffness in a group of 85 elderly subjects and the role of leptin and adiponectin on subclinical vascular damage, defined by a PWV> 10 m/s. Methods: In each subject, we evaluated anthropometry, body composition by DXA (fat mass, fat mass%, lean mass), metabolic variables, leptin, adiponectin, systolic, diastolic, mean arterial pressure and pulse pressure (SBP, DBP, MAP, PP), carotid-femoral pulse wave velocity (cfPWV) and carotid-radial pulse wave velocity (crPWV). Results: In the study population, significant associations were observed between cfPWV and crPWV, age, SBP, MAP, waist circumference, fat body mass and leptin. The study population was subdivided in 2 subgroups according to adipokine patterns: group 1 included patients with high adiponectin and low leptin, and group 2 patients had high leptin and low adiponectin. SBP, PP, cfPWV were significantly higher in subjects with high leptin and low adiponectin (group 2). Even after adjustment for gender, fat mass%, MAP, HDL cholesterol and triglycerides, cfPWV was higher in group 2 than group 1. In a logistic binary regression on the entire population, considering subclinical vascular damage as a dependent variable and age, gender, MAP, fat mass%, triglycerides, HDL cholesterol and category of subjects with high leptin and low adiponectin as independent variables, MAP and category of subjects with high leptin and low adiponectin were significant predictors (OR, respectively, 1.09 and 3.61). Conclusion: In conclusion, in the elderly, the presence at the same time of high leptin levels and low adiponectin levels seems to have synergic effects on arterial stiffness

The Fast, Luminous Ultraviolet Transient AT2018cow: Extreme Supernova, or Disruption of a Star by an Intermediate-Mass Black Hole?

Wide-field optical surveys have begun to uncover large samples of fast (t_rise < 5d), luminous (M_peak < -18), blue transients. While commonly attributed to the breakout of a supernova shock into a dense wind, the great distances to the transients of this class found so far have hampered detailed investigation of their properties. We present photometry and spectroscopy from a comprehensive worldwide campaign to observe AT2018cow (ATLAS18qqn), the first fast-luminous optical transient to be found in real time at low redshift. Our first spectra (<2 days after discovery) are entirely featureless. A very broad absorption feature suggestive of near-relativistic velocities develops between 3-8 days, then disappears. Broad emission features of H and He develop after >10 days. The spectrum remains extremely hot throughout its evolution, and the photospheric radius contracts with time (receding below R<10^14 cm after 1 month). This behaviour does not match that of any known supernova, although a relativistic jet within a fallback supernova could explain some of the observed features. Alternatively, the transient could originate from the disruption of a star by an intermediate-mass black hole, although this would require long-lasting emission of highly super-Eddington thermal radiation. In either case, AT2018cow suggests that the population of fast luminous transients represents a new class of astrophysical event. Intensive follow-up of this event in its late phases, and of any future events found at comparable distance, will be essential to better constrain their origins.Comment: Corrected Figure 8 / Table 4 to use final fits. Includes machine-readable photometry table (hopefully for real this time

GROWTH on GW190425: Searching thousands of square degrees to identify an optical or infrared counterpart to a binary neutron star merger with the Zwicky Transient Facility and Palomar Gattini IR

The beginning of the third observing run by the network of gravitational-wave detectors has brought the discovery of many compact binary coalescences. Prompted by the detection of the first binary neutron star merger in this run (GW190425 / LIGO/Virgo S190425z), we performed a dedicated follow-up campaign with the Zwicky Transient Facility (ZTF) and Palomar Gattini-IR telescopes. As it was a single gravitational-wave detector discovery, the initial skymap spanned most of the sky observable from Palomar Observatory, the site of both instruments. Covering 8000 deg$^2$ of the inner 99\% of the initial skymap over the next two nights, corresponding to an integrated probability of 46\%, the ZTF system achieved a depth of $\approx$\,21 $m_\textrm{AB}$ in $g$- and $r$-bands. Palomar Gattini-IR covered a total of 2200 square degrees in $J$-band to a depth of 15.5\,mag, including 32\% of the integrated probability based on the initial sky map. However, the revised skymap issued the following day reduced these numbers to 21\% for the Zwicky Transient Facility and 19\% for Palomar Gattini-IR. Out of the 338,646 ZTF transient "alerts" over the first two nights of observations, we narrowed this list to 15 candidate counterparts. Two candidates, ZTF19aarykkb and ZTF19aarzaod were particularly compelling given that their location, distance, and age were consistent with the gravitational-wave event, and their early optical lightcurves were photometrically consistent with that of kilonovae. These two candidates were spectroscopically classified as young core-collapse supernovae. The remaining candidates were photometrically or spectroscopically ruled-out as supernovae. Palomar Gattini-IR identified one fast evolving infrared transient after the merger, PGIR19bn, which was later spectroscopically classified as an M-dwarf flare. [abridged

GROWTH on S190425z: Searching Thousands of Square Degrees to Identify an Optical or Infrared Counterpart to a Binary Neutron Star Merger with the Zwicky Transient Facility and Palomar Gattini-IR

The third observing run by LVC has brought the discovery of many compact binary coalescences. Following the detection of the first binary neutron star merger in this run (LIGO/Virgo S190425z), we performed a dedicated follow-up campaign with the Zwicky Transient Facility (ZTF) and Palomar Gattini-IR telescopes. The initial skymap of this single-detector gravitational wave (GW) trigger spanned most of the sky observable from Palomar Observatory. Covering 8000 deg2 of the initial skymap over the next two nights, corresponding to 46% integrated probability, ZTF system achieved a depth of ≈21 m AB in g- and r-bands. Palomar Gattini-IR covered 2200 square degrees in J-band to a depth of 15.5 mag, including 32% integrated probability based on the initial skymap. The revised skymap issued the following day reduced these numbers to 21% for the ZTF and 19% for Palomar Gattini-IR. We narrowed 338,646 ZTF transient "alerts" over the first two nights of observations to 15 candidate counterparts. Two candidates, ZTF19aarykkb and ZTF19aarzaod, were particularly compelling given that their location, distance, and age were consistent with the GW event, and their early optical light curves were photometrically consistent with that of kilonovae. These two candidates were spectroscopically classified as young core-collapse supernovae. The remaining candidates were ruled out as supernovae. Palomar Gattini-IR did not identify any viable candidates with multiple detections only after merger time. We demonstrate that even with single-detector GW events localized to thousands of square degrees, systematic kilonova discovery is feasible