Rosemary essential oil potentiates the antitumour activity of 5-fluorouracil in human colorectal carcinoma cells.

OBJECTIVES: Improving response rates in colorectal cancer (CRC) is an urgent clinical need. This study aimed to explore the synergistic action of Lebanese rosemary essential oil (REO) and 5-fluorouracil (5-FU) in HCT116 CRC cells. METHODS: We tested the cell viability of monotherapy and combination therapy. The combination index was calculated using CompuSyn software to evaluate drug-drug interactions and the level of synergistic cytotoxicity. We also evaluated cell migration and cytopathology. Furthermore, cell apoptosis-related proteins (i.e. Bax and Bcl-2) were measured by Western blot analysis. KEY FINDINGS: The REO/5-FU combination synergistically reduced cell viability, effectively decreased cell migration, and increased the Bax/Bcl-2 ratio in HCT116 cells. This triggered a proapoptotic morphology and initiated an apoptotic cascade in HCT116 cells, as indicated by a higher Bax/Bcl-2 ratio. CONCLUSIONS: Our results provide evidence of the REO/5-FU combination as a better approach to improve 5-FU anticancer efficacy and allow the use of lower 5-FU doses due to the adjuvant effect of REO.

Care offered to people living with HIV: the social representations of nurses in a Moroccan university hospital / Soins offerts aux personnes vivant avec le VIH : représentations sociales des infirmières dans un centre hospitalo-universitaire marocain

Introduction: The social representations (SRs) of nurses on HIV/AIDS and the care provided to people living with HIV are diverse and different depending on the context. This study aims to understand the SRs of nurses on the disease and on the care provided. Method: A qualitative study conducted in 2018 with 50 nurses practicing in 11 specialized departments, belonging to seven Moroccan university hospitals. Results: The SRs of nurses recalled the beginnings of the emergence of HIV/AIDS with certain positions taken on the clinical conception of the disease. Prescribed care has been at the heart of professional representations, with an interest nevertheless little applied to relational care. Various behaviors and emotions were also represented around the caregiver-patient relationship. Discussion: In the health care setting, SRs of HIV/AIDS and the care provided give rise to models of care and relationships that go beyond technical knowledge and skills. Conclusion: Actions of individual commitment relating to professional and multidisciplinary meetings can change these representations and support nurses in the integration of sensitivity care, relating to positive affects toward these patients.

Introduction: Les représentations sociales (RS) des infirmières sur la maladie VIH-sida et les soins fournis aux personnes vivant avec le VIH sont diverses et différentes selon les contextes. L'étude vise la compréhension des RS des infirmières sur la maladie et sur les soins dispensés. Méthode: Il s'agit d'une étude qualitative réalisée en 2018 auprès de 50 infirmières pratiquant dans 11 services spécialisés, relevant de sept hôpitaux universitaires marocains. Résultats: Les RS des infirmières ont rappelé les débuts de l'émergence de la maladie VIH-sida avec certaines prises de positions sur sa conception clinique. Les soins prescrits ont été au cœur des représentations professionnelles, avec un intérêt néanmoins peu marqué pour les soins relationnels. Plusieurs conduites et émotions ont été représentées également autour de la relation soignant/soigné des infirmières face aux personnes vivant avec le VIH. Discussion: En milieu de soins, les RS sur la maladie VIH-sida et les soins dispensés donnent naissance à des modèles de soins et des relations qui vont au-delà des connaissances et capacités techniques. Conclusion: Des actions d'engagement individuel portant sur les rencontres professionnelles et multidisciplinaires peuvent changer ces représentations et accompagner les infirmières dans l'intégration des soins de sensibilité, portant sur des affects positifs envers les patients.

Trigeminal neuralgia secondary to onyx embolization of a right occipital arteriovenous malformation.

BACKGROUND: Trigeminal neuralgia is a debilitating chronic condition characterized by severe recurrent hemifacial pain which is often caused by compression of the trigeminal nerve by an adjacent vessel loop. Microvascular decompression (MVD) surgery is an effective procedure that can lead to full symptomatic relief. Intracranial arteriovenous malformations (AVMs) are primarily congenital abnormalities that may be asymptomatic or manifest as seizures or focal neurologic deficits. They may cause intracranial bleeding and hence are promptly treated, often by endovascular embolization. This procedure is safe but may have a multitude of unpredictable complications. CASE DESCRIPTION: A 33-year-old female presented with medically refractory trigeminal neuralgia secondary to Onyx embolization of a right occipital AVM 3 years prior. She underwent surgical exploration and MVD of the trigeminal nerve root which was found to be compressed by the previously embolized superior cerebellar artery. The procedure was successful and full symptomatic resolution was immediately achieved. CONCLUSION: Postprocedural trigeminal neuralgia is a procedural complication of Onyx endovascular embolization. It may be treated by MVD surgery regardless of the presence or absence of a compressive vascular loop on imaging.

Driving Pressure Is a Risk Factor for ARDS in Mechanically Ventilated Subjects Without ARDS.

BACKGROUND: Driving pressure (ΔP) has been described as a risk factor for mortality in patients with ARDS. However, the role of ΔP in the outcome of patients without ARDS and on mechanical ventilation has received less attention. Our objective was to evaluate the association between ΔP on the first day of mechanical ventilation with the development of ARDS. METHODS: This was a post hoc analysis of a multicenter, prospective, observational, international study that included subjects who were on mechanical ventilation for > 12 h. Our objective was to evaluate the association between ΔP on the first day of mechanical ventilation with the development of ARDS. To assess the effect of ΔP, a logistic regression analysis was performed when adjusting for other potential risk factors. Validation of the results obtained was performed by using a bootstrap method and by repeating the same analyses at day 2. RESULTS: A total of 1,575 subjects were included, of whom 65 (4.1%) developed ARDS. The ΔP was independently associated with ARDS (odds ratio [OR] 1.12, 95% CI 1.07-1.18 for each cm H2O of ΔP increase, P < .001). The same results were observed at day 2 (OR 1.14, 95% CI 1.07-1.21; P < .001) and after bootstrap validation (OR 1.13, 95% CI 1.04-1.22; P < .001). When taking the prevalence of ARDS in the lowest quartile of ΔP (≤9 cm H2O) as a reference, the subjects with ΔP > 12-15 cm H2O and those with ΔP > 15 cm H2O presented a higher probability of ARDS (OR 3.65, 95% CI 1.32-10.04 [P = .01] and OR 7.31, 95% CI, 2.89-18.50 [P < .001], respectively). CONCLUSIONS: In the subjects without ARDS, a higher level of ΔP on the first day of mechanical ventilation was associated with later development of ARDS. (ClinicalTrials.gov registration NCT02731898.).

Machine learning predicts mortality based on analysis of ventilation parameters of critically ill patients: multi-centre validation.

BACKGROUND: Mechanical Ventilation (MV) is a complex and central treatment process in the care of critically ill patients. It influences acid-base balance and can also cause prognostically relevant biotrauma by generating forces and liberating reactive oxygen species, negatively affecting outcomes. In this work we evaluate the use of a Recurrent Neural Network (RNN) modelling to predict outcomes of mechanically ventilated patients, using standard mechanical ventilation parameters. METHODS: We performed our analysis on VENTILA dataset, an observational, prospective, international, multi-centre study, performed to investigate the effect of baseline characteristics and management changes over time on the all-cause mortality rate in mechanically ventilated patients in ICU. Our cohort includes 12,596 adult patients older than 18, associated with 12,755 distinct admissions in ICUs across 37 countries and receiving invasive and non-invasive mechanical ventilation. We carry out four different analysis. Initially we select typical mechanical ventilation parameters and evaluate the machine learning model on both, the overall cohort and a subgroup of patients admitted with respiratory disorders. Furthermore, we carry out sensitivity analysis to evaluate whether inclusion of variables related to the function of other organs, improve the predictive performance of the model for both the overall cohort as well as the subgroup of patients with respiratory disorders. RESULTS: Predictive performance of RNN-based model was higher with Area Under the Receiver Operating Characteristic (ROC) Curve (AUC) of 0.72 (± 0.01) and Average Precision (AP) of 0.57 (± 0.01) in comparison to RF and LR for the overall patient dataset. Higher predictive performance was recorded in the subgroup of patients admitted with respiratory disorders with AUC of 0.75 (± 0.02) and AP of 0.65 (± 0.03). Inclusion of function of other organs further improved the performance to AUC of 0.79 (± 0.01) and AP 0.68 (± 0.02) for the overall patient dataset and AUC of 0.79 (± 0.01) and AP 0.72 (± 0.02) for the subgroup with respiratory disorders. CONCLUSION: The RNN-based model demonstrated better performance than RF and LR in patients in mechanical ventilation and its subgroup admitted with respiratory disorders. Clinical studies are needed to evaluate whether it impacts decision-making and patient outcomes. TRIAL REGISTRATION: NCT02731898 ( https://clinicaltrials.gov/ct2/show/NCT02731898 ), prospectively registered on April 8, 2016.

Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients.

BACKGROUND: The growing proportion of elderly intensive care patients constitutes a public health challenge. The benefit of critical care in these patients remains unclear. We compared outcomes in elderly versus very elderly subjects receiving mechanical ventilation. METHODS: In total, 5,557 mechanically ventilated subjects were included in our post hoc retrospective analysis, a subgroup of the VENTILA study. We divided the cohort into 2 subgroups on the basis of age: very elderly subjects (age ≥ 80 y; n = 1,430), and elderly subjects (age 65-79 y; n = 4,127). A propensity score on being very elderly was calculated. Evaluation of associations with 28-d mortality was done with logistic regression analysis. RESULTS: Very elderly subjects were clinically sicker as expressed by higher SAPS II scores (53 ± 18 vs 50 ± 18, P < .001), and their rates of plateau pressure < 30 cm H2O were higher, whereas other parameters did not differ. The 28-d mortality was higher in very elderly subjects (42% vs 34%, P < .001) and remained unchanged after propensity score adjustment (adjusted odds ratio 1.31 [95% CI 1.16-1.49], P < .001). CONCLUSIONS: Age was an independent and unchangeable risk factor for death in mechanically ventilated subjects. However, survival rates of very elderly subjects were > 50%. Denial of critical care based solely on age is not justified. (ClinicalTrials.gov registration NCT02731898.).

Frontal Sinus Morphometry in Relation to Surgically Relevant Landmarks in the Middle East Population: Can We Globalize?

BACKGROUND: The frontal bone is frequently approached during neurosurgical procedures. Feared complications of such surgeries include cerebrospinal fluid leak, among others, and frequently result from a breach of the frontal sinus. For this reason, the sinus should be avoided when possible. The supraorbital notch (SON) is a reliable and easily identifiable surgical landmark and its relation to the frontal sinus has been previously studied. However, the frontal sinus shows significant variability in size and shape between populations. METHODS: In the present study, we investigate the frontal sinus dimension and its relation to the SON in the Middle Eastern population. RESULTS: The analysis of a set of computed tomography scans reveals a significant variation in size between genders, and we subsequently provide neurosurgeons in the region with population-targeted, gender-specific risk maps. CONCLUSIONS: We finally conclude that a 2-cm margin rostral and lateral to the SON is safest.

Health-related Quality of Life Evaluated by MOS SF-36 in the Elderly Patients 1 Month before ICU Admission and 3 Months after ICU Discharge.

OBJECTIVES: The aims of this study were to evaluate changes in health-related quality of life (HRQoL) before ICU admission and after ICU discharge in elderly patients and to determine predictors of this HRQoL. MATERIALS AND METHODS: This prospective study has been realized in the medical ICU (August 2012-March 2013). All patients 65 years of age or older who were hospitalized for ≥48 hours in our medical ICU have been included. The HRQoL was assessed 1 month prior to ICU admission in all the patients at admission and 3 months after ICU discharge for survivors using the Arabic version of MOS SF-36 questionnaire. RESULTS: We enrolled 118 patients (66 M: 55.9% and 52 F: 44.1%). The mean age was 72 ± 6 years. ICU mortality rate was 47.5% and three-month mortality rate was 55.1%. The reliability and validity of MOS SF-36 were satisfactory. Among the 53 survivors at follow-up, the subscales of MOS SF-36 decreased significantly at 3 months after ICU stay except the "Bodily Pain". The physical component score (PCS) and mental component score (MCS) decreased also significantly. The independent factors strongly associated with PCS and its variations were: age (ß = -1.56, p = 0.001), prior functional status (ß = -22.10, p = 0.002) and SAPSII (ß = -0.16, p = 0.04). For MCS, these factors were: live alone (ß = 16.50, p = 0.006), previous functional status (ß = -9.09, p = 0.008) and existence of education level (ß = 2.98, p = 0.037). CONCLUSION: We demonstrated a fall in the physical and psychical aspects of HRQoL 3 months after ICU discharge in the elderly patients. In addition to factors such as age, prior functional status and severity of illness, family status and educational level seem decisive in the post-ICU HRQoL. HOW TO CITE THIS ARTICLE: Zeggwagh Z, Abidi K, Kettani MNZ, Iraqi A, Dendane T, Zeggwagh AA. Health-related Quality of Life Evaluated by MOS SF-36 in the Elderly Patients 1 Month before ICU Admission and 3 Months after ICU Discharge. Indian J Crit Care Med 2020;24(7):531-538.

Pediatric posterior fossa tumors outcomes: Experience in a tertiary care center in the Middle East.

BACKGROUND: Among all childhood cancers, brain tumors are second only to leukemia in incidence and are the most common solid pediatric tumors. More than 60 % of pediatric brain tumors are infra-tentorial. The first-line treatment for most infra-tentorial tumors in pediatric patients is surgical resection, with the goal of gross-total resection, relief of symptoms and hydrocephalus, and increased survival. The proximity to the fourth ventricle, and therefore, the cerebrospinal fluid (CSF) pathways, predisposes children with posterior fossa tumors to the development of obstructive hydrocephalus and multiple other co-morbidities pre and post-surgery. OBJECTIVES: This study aims to present our series of pediatric posterior fossa tumor surgeries in the Neurosurgical Department at the American University of Beirut Medical Center(AUBMC) and perform internal quality control for our single-institution consecutive series as one of the largest referral and tertiary care centers in the region. The second purpose of this retrospective study is to weigh the risks of surgery against the presumed advantages and to have specific knowledge about the complication rates, especially those related to the CSF pathway, comparing our results to those in the literature. METHODS: All pediatric patients (< 18 years of age), referred to our center from different regions in the middle east, and surgically treated for a posterior fossa tumor from June 2006 to June 2018 at the American University of Beirut Medical Center were included. A thorough review of all medical charts was performed to validate all the database records. RESULTS: The patient sample consisted of 64 patients having a mean age of 6.19 ±â€¯4.42 years and 59.37 % of whom were males. The most common tumor pathology was pilocytic astrocytoma (40.62 %) followed by medulloblastoma (35.93 %) and ependymoma. The most common type of tumor that was seen in patients that developed mutism postoperatively (n = 6, 9.37 %) was medulloblastoma (n = 4, 66.66 %). In this patient sample, 12.28 % (n = 7) of the patients developed hydrocephalus postoperatively.Midline tumors were more associated with the development of mutism(OR = 4.632, p = 0.306) and hydrocephalus (OR = 5.056, p = 0.135) postoperatively, albeit not statistically significantly.The presence of a preoperative shunt was shown to be protective against the development of CSF leak (OR = 0.636, p = 0.767), as none of the patients that came in with CSF diversion developed a CSF leak after their surgery. CONCLUSION: This study from a single center experience accompanied by a thorough literature review sheds light on the complications frequently encountered after posterior fossa tumor surgery in children. These included transient cerebellar mutism, CSF leak, and hydrocephalus as seen in some of our patients. Our findings highlight the need for prospective studies with well-defined protocols directed at assessing novel ways and approaches to minimize the risk of these complications.

Inter-country variability over time in the mortality of mechanically ventilated patients.

PURPOSE: Variations in clinical characteristics and management and in the mortality of mechanically ventilated patients have not been sufficiently evaluated. We hypothesized that mortality shows a variability associated with country after adjustment for clinical characteristics and management. METHODS: Analysis of four studies carried out at 6-year intervals over an 18-year period. The studies included 26,024 patients (5183 in 1998, 4968 in 2004, 8108 in 2010, and 7765 in 2016) admitted to 1253 units from 38 countries. The primary outcome was 28-day mortality. We performed analyses using multilevel logistic modeling with mixed-random effects, including country as a random variable. To evaluate the effect of management strategies on mortality, a mediation analysis was performed. RESULTS: Adjusted 28-day mortality decreased significantly over time (first study as reference): 2004: odds ratio 0.82 (95% confidence interval [CI] 0.72-0.93); 2010: 0.63 (95% CI 0.53-0.75); 2016: 0.49 (95% CI 0.39-0.61). A protective ventilatory strategy and the use of continuous sedation mediated a moderate fraction of the effect of time on mortality in patients with moderate hypoxemia and without hypoxemia, respectively. Logistic multilevel modeling showed a significant effect of country on mortality: median odds ratio (MOR) in 1998: 2.02 (95% CI 1.57-2.48); in 2004: 1.76 (95% CI 1.47-2.06); in 2010: 1.55 (95% CI 1.37-1.74), and in 2016: 1.39 (95% CI 1.25-1.54). CONCLUSIONS: These findings suggest that country could contribute, independently of confounder variables, to outcome. The magnitude of the effect of country decreased over time. Clinical trials registered with http://www.clinicaltrials.gov (NCT02731898).

The strategy for controlling COVID-19 in Kurdistan Regional Government (KRG)/Iraq: Identification, epidemiology, transmission, treatment, and recovery.

This study has carried out a mini-review on first wave of COVID-19 infection and its control by the Kurdistan Regional Government (KRG)/Iraq. COVID-19 infection, which was named by the International Committee of Taxonomy of Viruses (ICTV) as SARS-CoV-2, is a newly identified coronavirus. The last century has seen the outbreak of numerous life-threatening human pathogens including Nipah, Ebola, Zika, Chikungunya, Middle East respiratory syndrome coronavirus (MERS-CoV), severe acute respiratory syndrome coronavirus (SARS-CoV), and more recently a novel coronavirus has been observed. COVID-19 infection has so far spread to more than 186 countries around the world and KRG/Iraq has not been free from this virus. In this survey, the control of COVID-19 infection in KRG as a part of Iraq is discussed in detail. The methods of identification as well as the drugs that are currently in common use to reduce the wide distribution of COVID-19 infection and their effects in countries around the world are considered. So far, 714 positive cases have been reported by the ministry of health in Kurdistan Region Government-Iraq (KRG), among which there have been only 8 deaths, and 420 cases have recovered. Those who died had a previous history of a chronic disease such as diabetes, hypertension, heart disease, and hypercholesteremia. Alternative medicine based on natural green methods has been widely used by Kurdish people in past years for treatment of strong coughs. In the present study, some natural products which are cost free and effective in enhancing the body's resistance against the virus are considered. A surprising finding is that the patients in KRG have not in general had a severe cough, flu, or fever. The possible explanation may relate to the patients' strong immune systems, since none of them had a history of using alcohol and drugs, or of chronic disease. The epidemiology and transmission of the virus are discussed as well.

Extended Endonasal Endoscopic Complete Resection of a Solitary Intraorbital Myofibroma: A Case Report and Literature Review.

BACKGROUND: Infantile myofibromatosis is a rare benign disease of mesenchymal origin. It occurs mostly in infants but can occur in children and adults. It presents in 2 forms: solitary and multicentric. The presence of an orbital component, whether as a solitary lesion or as part of the multicentric disease, is even rarer. Surgery is required when these tumors behave aggressively and grow rapidly or when they are large enough to cause compression symptoms. Several surgical approaches have been described to resect such lesions. CASE DESCRIPTION: We present a case of a solitary intraorbital myofibroma extending into the optic canal in a 6-year-old girl that was completely resected via an extended endonasal endoscopic approach. CONCLUSIONS: This case report highlights the advantages of the extended endonasal endoscopic approach in terms of intraoperative and postoperative factors.

Easy prognostic assessment of concomitant organ failure in critically ill patients undergoing mechanical ventilation.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a life-threatening disease. We evaluated the prognostic utility of Model for End-stage Liver Disease excluding INR (MELD-XI) score for predicting mortality in a cohort of critically ill patients on mechanical ventilation. METHODS: In total, 11,091 mechanically ventilated patients were included in our post-hoc retrospective analysis, a subgroup of the VENTILA study (NCT02731898). Evaluation of associations with mortality was done by logistic and Cox regression analysis, an optimal cut-off was calculated using the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points). RESULTS: Peak-, plateau- and positive end-expiratory pressure were higher in patients with MELD-XI>12. Patients with MELD-XI>12 had higher driving pressures (14 ±â€¯6 cmH2O versus 13 ±â€¯6; p < 0.001). MELD-XI was associated with 28-day mortality after correction for relevant cofounders including SAPS II and ventilation pressures (HR 1.04 95%CI 1.03-1.05; p < 0.001. Patients with MELD-XI>12 evidenced both increased hospital (46% versus 27%; p < 0.001) and 28-day mortality (39% versus 22%). CONCLUSIONS: MELD-XI is independently associated with mortality and constitutes a useful and easily applicable tool for risk stratification in critically ill patients receiving mechanical ventilation. TRIAL REGISTRATION: NCT02731898, registered 4 April 2016.

International Analgesia, Sedation, and Delirium Practices: a prospective cohort study.

BACKGROUND: While understanding of critical illness and delirium continue to evolve, the impact on clinical practice is often unknown and delayed. Our purpose was to provide insight into practice changes by characterizing analgesia and sedation usage and occurrence of delirium in different years and international regions. METHODS: We performed a retrospective analysis of two multicenter, international, prospective cohort studies. Mechanically ventilated adults were followed for up to 28 days in 2010 and 2016. Proportion of days utilizing sedation, analgesia, and performance of a spontaneous awakening trial (SAT), and occurrence of delirium were described for each year and region and compared between years. RESULTS: A total of 14,281 patients from 6 international regions were analyzed. Proportion of days utilizing analgesia and sedation increased from 2010 to 2016 (p < 0.001 for each). Benzodiazepine use decreased in every region but remained the most common sedative in Africa, Asia, and Latin America. Performance of SATs increased overall, driven mostly by the US/Canada region (24 to 35% of days with sedation, p < 0.001). Any delirium during admission increased from 7 to 8% of patients overall and doubled in the US/Canada region (17 to 36%, p < 0.001). CONCLUSIONS: Analgesia and sedation practices varied widely across international regions and significantly changed over time. Opportunities for improvement in care include increasing delirium monitoring, performing SATs, and decreasing use of sedation, particularly benzodiazepines.

Low FODMAP diet in Egyptian patients with Crohn's disease in remission phase with functional gastrointestinal symptoms.

BACKGROUND AND AIM: Despite being in remission, functional gastrointestinal disease (FGID) in Crohn's disease (CD) patients can reduce their quality of life. The Egyptian daily diet contains a high amount of FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols). As the low FODMAP diet has been proven to be effective in irritable bowel syndrome worldwide, it was reasonable to take a step further and begin to study the effect of low FODMAP in Egyptian CD patients with FGID. The outcomes were assessed in terms of improvement in symptoms and hence the quality of life, and the factors that led to this improvement were also recorded. METHODS: In total, 100 CD patients with FGID in the remission stage who were already on a low-fiber diet (± lactose-free diet) were selected to follow the low FODMAP diet. A structured interview was performed after 3 months with a number of scored-scale questionnaires comparing symptoms before and after the diet and the impact on quality of life. Evaluation of the adherence, satisfaction, palatability, and affordability of the diet was performed. Different demographic data were also evaluated in correspondence with improvements in the quality of life. RESULTS: The mean score of FGID improvement was 38.45 ± 21.56%. The quality of life was significantly improved; 90% of female patients versus 49.4% males had a better quality of life. The households (not working) as well as those with morning jobs (6 hours) reported an increase in quality of life. Although the Egyptian low FODMAP diet was expensive (in terms of gluten-free wheat), 67% were adherent to it (18.16 ± 6.85). CONCLUSION: As a first step in Egypt, the low FODMAP diet was effective in improving the quality of life of CD patients with FGID.

Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome.

PURPOSE: To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome (ARDS). PATIENTS AND METHODS: We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in 1998, 2004, and 2010. We used multivariable logistic regression and a propensity score analysis to examine the association between hypercapnia and ICU mortality. MAIN OUTCOMES: We included 1899 patients with ARDS in this study. The relationship between maximum PaCO2 in the first 48 h and mortality suggests higher mortality at or above PaCO2 of ≥50 mmHg. Patients with severe hypercapnia (PaCO2 ≥50 mmHg) had higher complication rates, more organ failures, and worse outcomes. After adjusting for age, SAPS II score, respiratory rate, positive end-expiratory pressure, PaO2/FiO2 ratio, driving pressure, pressure/volume limitation strategy (PLS), corrected minute ventilation, and presence of acidosis, severe hypercapnia was associated with increased risk of ICU mortality [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.32 to 2.81; p = 0.001]. In patients with severe hypercapnia matched for all other variables, ventilation with PLS was associated with higher ICU mortality (OR 1.58, CI 95% 1.04-2.41; p = 0.032). CONCLUSIONS: Severe hypercapnia appears to be independently associated with higher ICU mortality in patients with ARDS. TRIAL REGISTRATION: Clinicaltrials.gov identifier, NCT01093482.

Association between ventilatory settings and development of acute respiratory distress syndrome in mechanically ventilated patients due to brain injury.

PURPOSE: In neurologically critically ill patients with mechanical ventilation (MV), the development of acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality, but the role of ventilatory management has been scarcely evaluated. We evaluate the association of tidal volume, level of PEEP and driving pressure with the development of ARDS in a population of patients with brain injury. MATERIALS AND METHODS: We performed a secondary analysis of a prospective, observational study on mechanical ventilation. RESULTS: We included 986 patients mechanically ventilated due to an acute brain injury (hemorrhagic stroke, ischemic stroke or brain trauma). Incidence of ARDS in this cohort was 3%. Multivariate analysis suggested that driving pressure could be associated with the development of ARDS (odds ratio for unit increment of driving pressure 1.12; confidence interval for 95%: 1.01 to 1.23) whereas we did not observe association for tidal volume (in ml per kg of predicted body weight) or level of PEEP. ARDS was associated with an increase in mortality, longer duration of mechanical ventilation, and longer ICU length of stay. CONCLUSIONS: In a cohort of brain-injured patients the development of ARDS was not common. Driving pressure was associated with the development of this disease.

Practices and perceived barriers regarding pain management among Emergency Department physicians: a nationwide multicenter survey in Moroccan hospitals.

Aim: To describe pain management practices in Moroccan emergency departments, and to identify perceived barriers among emergency department physicians regarding pain management. Methods: Eleven Moroccan emergency departments participated in the study. A nationwide survey was administered to physicians. The questionnaire covered physicians' characteristics, practices regarding pain management, and the perceived barriers to pain control. Results: A total of 86 questionnaires were analyzed. The participants' mean age was 41±7 years and 59.3% had more than 10 years working experience in emergency departments. The majority of participants were general physicians (87.2%) with no pain education (73.3%). Pain assessment in emergency departments was carried out by 59.3% of the physicians. Simple interrogatory assessment was the main tool (88.3%) with poor use of algometric scales (11.7%). Pain assessment results were not recorded in clinical charts in 93% of cases. Pain reassessment after treatment was carried out by 23.2% of respondents. Physicians had opiophobia in 80.2% of cases. None of the Moroccan emergency departments participating in the study have a written protocol for pain management. Barriers relating to medical staff and the health care system were the most commonly encountered hindrances that preclude emergency department physicians from proper pain management. Conclusions: Despite the availability of international guidelines, pain management practices are still sub-optimal in Moroccan emergency departments.

Impact of sedation and analgesia during noninvasive positive pressure ventilation on outcome: a marginal structural model causal analysis.

PURPOSE: There are limited data available about the role of sedation and analgesia during noninvasive positive pressure ventilation (NPPV). The objective of study was to estimate the effect of analgesic or sedative drugs on the failure of NPPV. METHODS: We studied patients who received at least 2 h of NPPV as first-line therapy in a prospective observational study carried out in 322 intensive care units from 30 countries. A marginal structural model (MSM) was used to analyze the association between the use of analgesic or sedative drugs and NPPV failure (defined as need for invasive mechanical ventilation). RESULTS: 842 patients were included in the analysis. Of these, 165 patients (19.6%) received analgesic or sedative drugs at some time during NPPV; 33 of them received both. In the adjusted analysis, the use of analgesics (odds ratio 1.8, 95% confidence interval 0.6-5.4) or sedatives (odds ratio 2.8, 95% CI 0.85-9.4) alone was not associated with NPPV failure, but their combined use was associated with failure (odds ratio 5.7, 95% CI 1.8-18.4). CONCLUSIONS: Slightly less than 20% of patients received analgesic or sedative drugs during NPPV, with no apparent effect on outcome when used alone. However, the simultaneous use of analgesics and sedatives may be associated with failure of NPPV.