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1.
Crit Care Med ; 2024 Jun 26.
Artículo en Inglés | MEDLINE | ID: mdl-38920618

RESUMEN

OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN: Multicenter prospective before-and-after comparison design study. SETTING: Twenty-one PICUs. PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.

2.
Eur J Pediatr ; 2024 May 15.
Artículo en Inglés | MEDLINE | ID: mdl-38748253

RESUMEN

The role of inflammatory cytokines in children with moderate to severe TBI (m-sTBI) is still incompletely understood. We aimed to investigate the associations between early plasma expression profiles of inflammatory cytokines and clinical outcomes in children with m-sTBI. We prospectively recruited children admitted to the intensive care unit (ICU) of a tertiary pediatric hospital due to m-sTBI from November 2022 to May 2023. Plasma interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-17A, interferon (IFN)-α, IFN-γ and tumor necrosis factor (TNF)-α concentrations were detected by flow cytometry on admission and on days 5 to 7. The primary outcome was in-hospital mortality. The secondary outcome was the 6-month functional outcome assessed by the Glasgow Outcome Scale Extended-Pediatrics (GOS-E Peds) score, dichotomized as favorable (1-4) or unfavorable (5-8). Fifty patients and 20 healthy controls were enrolled. Baseline IL-6, IL-8 and IL-10 levels were significantly higher in TBI patients than in healthy controls. Twelve patients died in the hospital. Compared with survivors, nonsurvivors had significantly increased baseline IL-6 and IL-8 levels. Baseline IL-5, IL-6 and IL-8 levels were also significantly greater in children with unfavorable versus favorable outcomes. The area under the receiver operating characteristic curve (AUC) of the IL-6 and IL-8 levels and motor Glasgow Coma Scale (GCS) score for predicting in-hospital mortality was 0.706, 0.754, and 0.776, respectively. Baseline IL-1ß, IL-2, IL-4, IL-10, IL-12p70, IL-17A, IFN-γ, IFN-α and TNF-α levels were not associated with in-hospital mortality or an unfavorable 6-month outcome. On days 5 to 7, the IL-6 and IL-8 levels were significantly decreased in survivors but increased in nonsurvivors compared to their respective baselines. CONCLUSION: After m-sTBI, the plasma profiles of inflammatory cytokines are markedly altered in children. The trends of IL-6 and IL-8 expression vary among m-sTBI children with different outcomes. Elevated plasma IL-6 and IL-8 levels are related to in-hospital mortality and unfavorable 6-month outcomes. TRIAL REGISTRATION: This trial was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2200065505). Registered November 7, 2022. WHAT IS KNOWN: • Inflammation is an important secondary physiological response to TBI. WHAT IS NEW: • The plasma profiles of inflammatory cytokines are markedly altered in children with m-sTBI. Elevated IL-6 and IL-8 levels are related to mortality and unfavorable outcomes.

3.
Platelets ; 35(1): 2363242, 2024 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-38860550

RESUMEN

Septic shock is a life-threatening disease worldwide often associated with thrombocytopenia. Platelets play a crucial role in bridging the gap between immunity, coagulation, and endothelial cell activation, potentially influencing the course of the disease. However, there are few studies specifically evaluating the impact of thrombocytopenia on the prognosis of pediatric patients. Therefore, the study investigates effects of early thrombocytopenia in the prognosis of children with septic shock. Pediatric patients with septic shock from 2015 to 2022 were included monocentrically. Thrombocytopenia was defined as a platelet count of <100 × 109/L during the first 24 hours of septic shock onset. The primary outcome was the 28-day mortality. Propensity score matching was used to pair patients with different platelet counts on admission but comparable disease severity. A total of 419 pediatric patients were included in the analysis. Patients with thrombocytopenia had higher 28-day mortality (55.5% vs. 38.7%, p = .005) compared to patients with no thrombocytopenia. Thrombocytopenia was associated with reduced 28-PICU free days (median value, 0 vs. 13 days, p = .003) and 28-ventilator-free (median value, 0 vs. 19 days, p = .001) days. Among thrombocytopenia patients, those with platelet count ≤50 × 109/L had a higher 28-day mortality rate (63.6% vs. 45%, p = .02). Multiple logistic regression showed that elevated lactate (adjusted odds ratio (OR) = 1.11; 95% confidence interval (CI): 1.04-1.17; P <0.001) and white blood cell (WBC) count (OR = 0.97; 95% CI: 0.95-0.99; p = .003) were independent risk factors for the development of thrombocytopenia. Thrombocytopenia group had increased bleeding events, blood product transfusions, and development of organ failure. In Kaplan-Meier survival estimates, survival probabilities at 28 days were greater in patients without thrombocytopenia (p value from the log-rank test, p = .004). There were no significant differences in the type of pathogenic microorganisms and the site of infection between patients with and without thrombocytopenia. In conclusion, thrombocytopenia within 24 hours of shock onset is associated with an increased risk of 28-day mortality in pediatric patients with septic shock.


What is the context? Septic shock is a life-threatening disease worldwide, leading to higher mortality.Platelets play a crucial role in bridging the gap between immunity, coagulation, and endothelial cell activation.Although it is known that platelets are associated with prognosis, most studies have focused on adult populations. Limited data are available on the incidence of thrombocytopenia and its correlation with clinical outcomes , specifically, in pediatric patients with sepsis and septic shock. What is new? The present study suggests that thrombocytopenia within 24 hours of septic shock onset reflects a reliable tool for predicting the prognosis of septic shock in pediatric patients.Furthermore, elevated lactate and reduced white-blood-cell count were independent risk factors for the development of thrombocytopenia in pediatric patients with septic shock. What is the impact? This study suggests that thrombocytopenia within 24 hours of septic shock onset is associated with an increased risk of 28-day mortality and decreased ventilation-free, PICU-free days in pediatric patients with septic shock. In septic shock, thrombocytopenia is also associated with increased bleeding events, blood product transfusions, and organ dysfunction.


Asunto(s)
Choque Séptico , Trombocitopenia , Humanos , Trombocitopenia/complicaciones , Trombocitopenia/sangre , Choque Séptico/complicaciones , Choque Séptico/mortalidad , Choque Séptico/sangre , Masculino , Femenino , Pronóstico , Estudios Retrospectivos , Niño , Preescolar , Lactante , Recuento de Plaquetas/métodos
4.
Eur J Pediatr ; 182(12): 5315-5323, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-37733114

RESUMEN

The therapeutic efficacy of intravenous immuneglobulin (IVIG) on children with septic shock remains uncertain. Therefore, we endeavored to investigate the impact of administering intravenous immunoglobulin (IVIG) in the pediatric intensive care unit (PICU) on patient with septic shock. We retrospectively analyzed the data of children admitted to the PICU due to septic shock from January 2017 to December 2021 in a tertiary pediatric hospital. The main outcome was in-hospital mortality. Total 304 patients were enrolled. There were no significant differences in the PRISM-III score (11 vs. 12, P = 0.907), PIM-3 score (0.08 vs. 0.07, P = 0.544), pSOFA score (10 vs. 10, P = 0.852) between the No IVIG group and the IVIG group. Children who received IVIG required more continuous renal replacement therapy (CRRT) support (43% vs. 24%, P = 0.001) and longer duration of mechanical ventilation (MV) (6 vs. 3 days, P = 0.002), and longer length of stay (LOS) of PICU (7 vs. 4 days, P = 0.001) and LOS of hospital (18 vs. 11 days, P = 0.001) than children who did not receive. The 28-day survival analysis (P = 0.033) showed better survival rates in IVIG group, while the in-hospital mortality (43% vs. 52%, P = 0.136) was no significant difference. In the propensity score matched analysis, 71 pairs were established. The length of CRRT (2 vs. 3 days, P = 0.744), duration of mechanical ventilation (5 vs. 4 days, P = 0.402), LOS of PICU (7 vs. 5 days, P = 0.216), LOS of hospital (18 vs. 13 days, P = 0.290), in-hospital mortality (44% vs. 44%, P = 1.000) and 28-day survival analysis (P = 0.748) were not statistically different. After inverse probability weighted analysis, there was still no difference in mortality between the two groups (51% vs. 48%, P = 0.665). CONCLUSION: In children with septic shock, the use of intravenous immunoglobulin as an adjuvant therapy does not reduce in-hospital mortality. WHAT IS KNOWN: • Guidelines suggest against the routine use of intravenous immuneglobulin in children with septic shock. Some small observational studies have reported conflicting result. WHAT IS NEW: • The use of intravenous immunoglobulin as an adjuvant therapy does not reduce in-hospital mortality in children with septic shock.


Asunto(s)
Choque Séptico , Humanos , Niño , Choque Séptico/tratamiento farmacológico , Inmunoglobulinas Intravenosas/uso terapéutico , Estudios Retrospectivos , Unidades de Cuidado Intensivo Pediátrico , Puntaje de Propensión
5.
Respir Res ; 23(1): 301, 2022 Nov 04.
Artículo en Inglés | MEDLINE | ID: mdl-36333729

RESUMEN

PURPOSE: Acute respiratory distress syndrome (ARDS) is an acute and critical disease among children and adults, and previous studies have shown that the administration of corticosteroids remains controversial. Therefore, a meta-analysis of randomized controlled trials (RCTs) was performed to evaluate the safety and efficacy of corticosteroids. METHODS: The RCTs investigating the safety and efficacy of corticosteroids in ARDS were searched from electronic databases (Embase, Medline, and the Cochrane Central Register of Controlled Trials). The primary outcome was 28-day mortality. Heterogeneity was assessed using the Chi square test and I2 with the inspection level of 0.1 and 50%, respectively. RESULTS: Fourteen RCTs (n = 1607) were included for analysis. Corticosteroids were found to reduce the risk of death in patients with ARDS (relative risk (RR) = 0.78, 95% confidence interval (CI): 0.70-0.87; P < 0.01). Moreover, no significant adverse events were observed, compared to placebo or standard support therapy. Further subgroup analysis showed that variables, such as adults (RR = 0.78; 95% CI: 0.70-0.88; P < 0.01), non-COVID-19 (RR = 0.71; 95% CI: 0.62-0.83; P < 0.01), methylprednisolone (RR = 0.70; 95% CI: 0.56-0.88; P < 0.01), and hydrocortisone (RR = 0.79; 95% CI: 0.63-0.98; P = 0.03) were associated with 28-day mortality among patients who used corticosteroids. However, no association was found, regarding children (RR = 0.21; 95% CI: 0.01-4.10; P = 0.30). CONCLUSION: The use of corticosteroids is an effective approach to reduce the risk of death in ARDS patients. However, this effect is associated with age, non-COVID-19 diseases, and methylprednisolone and hydrocortisone use. Therefore, evidence suggests patients with age ≥ 18 years and non-COVID-19 should be encouraged during the corticosteroid treatment. However, due to substantial differences in the use of corticosteroids among these studies, questions still remain regarding the dosage, optimal corticosteroid agent, and treatment duration in patients with ARDS.


Asunto(s)
Hidrocortisona , Síndrome de Dificultad Respiratoria , Niño , Adulto , Humanos , Adolescente , Hidrocortisona/uso terapéutico , Síndrome de Dificultad Respiratoria/diagnóstico , Síndrome de Dificultad Respiratoria/tratamiento farmacológico , Corticoesteroides/efectos adversos , Metilprednisolona/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto
6.
Biochem Biophys Res Commun ; 556: 39-44, 2021 06 04.
Artículo en Inglés | MEDLINE | ID: mdl-33836346

RESUMEN

OBJECTIVE: To investigate the effect and significance of mammalian target of rapamycin (mTOR) inhibitors on the expression of α-SMA in lung injury induced by high volume fraction of inspired oxygen (hyperoxygen) in SD rat pups. METHODS: Seventy-two Sprague-Dawley rat pups (age: 3 weeks) were randomly divided into air + saline, hyperoxia + saline, hyperoxia + OSI-027, and hyperoxia + rapamycin groups. Animal models were constructed (n = 18). Hyperoxia was induced by continuous administration of 90% oxygen. Normal saline, OSI-027, and rapamycin are administered by intraperitoneal injection on 1d, 3d, 6d, 8d, 10d, 13d of the observation period, respectively. Following assessments were made on the 3rd, 7th, and 14th day of modeling: pathological changes in lung tissues, lung injury score, Western Blot to assess the distribution and expressions of mTOR, pS6K1, and α-SMA protein in lung tissues. RESULTS: In terms of time factors, the protein expressions of mTOR, pS6K1, and α-SMA increased with time. Except for the air group, the lung injury scores of the other groups increased with time, In terms of grouping factors, lung injury score in the air group was significantly lower than that in the other groups. In the hyperoxia group, the protein expressions of mTOR, PS6K1, and α-SMA were significantly higher than those in the other groups. The lung injury score in the hyperoxia group was significantly higher than that in the other groups. The lung injury score in the hyperoxia OSI group was significantly lower than that in the hyperoxia rapamycin group. CONCLUSION: In hyperoxia lung injury, inhibiting the activation of mTOR signaling pathway can effectively reduce the expression of α-SMA; however, only mTORC1/2 dual inhibitor OSI-027 exhibited an anti-proliferative effect, and alleviated hyperoxia-induced lung injury and fibrosis in SD rat pups.


Asunto(s)
Actinas/metabolismo , Hiperoxia/metabolismo , Imidazoles/farmacología , Lesión Pulmonar/metabolismo , Pulmón/efectos de los fármacos , Pulmón/metabolismo , Sirolimus/farmacología , Triazinas/farmacología , Animales , Femenino , Fibrosis/tratamiento farmacológico , Fibrosis/metabolismo , Fibrosis/patología , Hiperoxia/patología , Imidazoles/uso terapéutico , Pulmón/patología , Lesión Pulmonar/tratamiento farmacológico , Lesión Pulmonar/patología , Masculino , Diana Mecanicista del Complejo 1 de la Rapamicina/antagonistas & inhibidores , Diana Mecanicista del Complejo 1 de la Rapamicina/metabolismo , Diana Mecanicista del Complejo 2 de la Rapamicina/antagonistas & inhibidores , Diana Mecanicista del Complejo 2 de la Rapamicina/metabolismo , Ratas , Ratas Sprague-Dawley , Proteínas Quinasas S6 Ribosómicas/metabolismo , Transducción de Señal/efectos de los fármacos , Sirolimus/uso terapéutico , Serina-Treonina Quinasas TOR/metabolismo , Triazinas/uso terapéutico
7.
Pediatr Crit Care Med ; 22(12): 1083-1087, 2021 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-34560773

RESUMEN

OBJECTIVES: Enteral nutrition delivery is limited by intolerance and interruptions in critically ill children. Anticholinergic properties of frequently administered medications may contribute to altered gastric motility and enteral nutrition intolerance in this population. We examined the association between the anticholinergic burden of administered medications using the Anticholinergic Drug Scale and adequacy of enteral nutrition delivery. DESIGN: Secondary analysis of data from a previously characterized PICU cohort. SETTING: Multidisciplinary PICU in a quaternary academic medical center. PATIENTS: Younger than or equal to 18 years, on mechanical ventilation and received enteral nutrition within the first 3 days of PICU admission. MEASUREMENTS AND MAIN RESULTS: Daily Anticholinergic Drug Scale score, demographic data, and clinical data were obtained from the primary study. Percent enteral energy adequacy ([kcal delivered ÷ kcal prescribed] × 100) during the first 3 days of PICU admission was calculated. Forty-two patients received enteral nutrition, with median age (interquartile range) 5 years (1.09-12.54 yr), and 62% were male. Median Anticholinergic Drug Scale score was inversely correlated with energy adequacy, with a median 9% decline in energy adequacy per 1-point increase in Anticholinergic Drug Scale score (coefficient, -9.3; 95% CI, -13.43 to -5.27; R2 = 0.35; p < 0.0001). Median hours of enteral nutrition interruptions directly correlated with Anticholinergic Drug Scale score (coefficient, 1.5; 95% CI, 0.531-2.54; R2 = 0.19; p = 0.004). Severity score was greater in patients with less than or equal to 25% enteral energy adequacy and directly correlated with median Anticholinergic Drug Scale score. CONCLUSIONS: Anticholinergic burden from medications administered in the PICU is a potentially modifiable factor for suboptimal enteral nutrition delivery.


Asunto(s)
Enfermedad Crítica , Nutrición Enteral , Niño , Preescolar , Antagonistas Colinérgicos/efectos adversos , Enfermedad Crítica/terapia , Ingestión de Energía , Humanos , Unidades de Cuidado Intensivo Pediátrico , Masculino , Respiración Artificial
8.
Pediatr Crit Care Med ; 22(4): 401-411, 2021 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-33027240

RESUMEN

OBJECTIVES: Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes. DESIGN: A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017. SETTING: Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network. PATIENTS: We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46). CONCLUSIONS: Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Adolescente , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/terapia , Niño , Cuidados Críticos , Escala de Coma de Glasgow , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico , Estudios Retrospectivos
9.
Crit Care ; 24(1): 31, 2020 01 31.
Artículo en Inglés | MEDLINE | ID: mdl-32005285

RESUMEN

BACKGROUND: High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS. METHODS: Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect. RESULTS: A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS. CONCLUSION: The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.


Asunto(s)
Ventilación de Alta Frecuencia/normas , Mortalidad Hospitalaria/tendencias , Síndrome de Dificultad Respiratoria/terapia , Análisis de los Gases de la Sangre , Niño , Preescolar , Femenino , Ventilación de Alta Frecuencia/métodos , Ventilación de Alta Frecuencia/mortalidad , Humanos , Lactante , Masculino , Oportunidad Relativa , Pediatría/instrumentación , Pediatría/métodos , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/epidemiología , Síndrome de Dificultad Respiratoria/mortalidad , Estudios Retrospectivos
10.
Cytotherapy ; 21(6): 619-630, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30956007

RESUMEN

BACKGROUND: Insulin-like growth factor 2 (IGF2), an essential component of the stem cell niche, has been reported to modulate the proliferation and differentiation of stem cells. Previously, a continuous expression of IGF2 in tissues was reported to maintain the self-renewal ability of several types of stem cells. Therefore, in this study, we investigated the expression of IGF2 in adipose tissues and explored the effects of IGF2 on adipose-derived stromal cells (ADSCs) in vitro. METHODS: The expression pattern of IGF2 in rat adipose tissues was determined by gene expression and protein analyses. The effect of IGF2 on proliferation, stemness-related marker expression and adipogenic and osteogenic differentiation was systematically investigated. Furthermore, antagonists of IGF2-specific receptors-namely, BMS-754807 and picropodophyllin-were added to explore the underlying signal transduction mechanisms. RESULTS: IGF2 levels displayed a tendency to decrease with age in rat adipose tissues. After the addition of IGF2, isolated ADSCs displayed higher proliferation and expression of the stemness-related markers NANOG, OCT4 and SOX2 and greater differentiation potential to adipocytes and osteoblasts. Additionally, both type 1 insulin-like growth factor receptor (IGF-1R) and insulin receptor (IR) participated in the IGF2-mediated promotion of stemness in ADSCs. CONCLUSIONS: Our findings indicate that IGF2 could enhance the stemness of rat ADSCs via IGF-1R and IR and may highlight an effective method for the expansion of ADSCs for clinical application.


Asunto(s)
Tejido Adiposo/citología , Factor II del Crecimiento Similar a la Insulina/metabolismo , Receptor IGF Tipo 1/metabolismo , Receptor de Insulina/metabolismo , Células del Estroma/citología , Adipocitos/citología , Adipogénesis , Factores de Edad , Animales , Diferenciación Celular/efectos de los fármacos , Proliferación Celular , Células Cultivadas , Femenino , Factor II del Crecimiento Similar a la Insulina/genética , Factor II del Crecimiento Similar a la Insulina/farmacología , Osteoblastos/citología , Osteogénesis , Ratas Sprague-Dawley , Receptor IGF Tipo 1/genética , Receptor de Insulina/genética , Transducción de Señal , Células del Estroma/efectos de los fármacos , Células del Estroma/metabolismo
11.
Biochem Biophys Res Commun ; 495(2): 1620-1627, 2018 01 08.
Artículo en Inglés | MEDLINE | ID: mdl-29198702

RESUMEN

Oxidative stress is regarded as a key regulator in the pathogenesis of prolonged hyperoxia-induced lung injury, which causes injury to alveolar epithelial cells and eventually leads to development of bronchopulmonary dysplasia (BPD). Many studies have shown that hydrogen has a protective effect in a variety of cells. However, the mechanisms by which hydrogen rescues cells from damage due to oxidative stress in BPD remains to be fully elucidated. This study sought to evaluate the effects of hydrogen on hyperoxia-induced lung injury and to investigate the underlying mechanism. Primary type II alveolar epithelial cells (AECIIs) were divided into four groups: control (21% oxygen), hyperoxia (95% oxygen), hyperoxia + hydrogen, and hyperoxia + hydrogen + LY294002 (a PI3K/Akt inhibitor). Proliferation and apoptosis of AECIIs were assessed using MTS assay and flow cytometry (FCM), respectively. Gene and protein expression were detected by quantitative polymerase chain reaction (q-PCR) and western blot analysis. Stimulation with hyperoxia decreased the expression of P-Akt, P- FoxO3a, cyclinD1 and Bcl-2. Hyperoxic conditions increased levels of Bim, Bax, and Foxo3a, which induced proliferation restriction and apoptosis of AECIIs. These effects of hyperoxia were reversed with hydrogen pretreatment. Furthermore, the protective effects of hydrogen were abrogated by PI3K/Akt inhibitor LY294002. The results indicate that hydrogen protects AECIIs from hyperoxia-induced apoptosis by inhibiting apoptosis factors and promoting the expression of anti-apoptosis factors. These effects were associated with activation of the PI3K/Akt/FoxO3a pathway.


Asunto(s)
Células Epiteliales Alveolares/efectos de los fármacos , Células Epiteliales Alveolares/metabolismo , Hidrógeno/farmacología , Hiperoxia/tratamiento farmacológico , Hiperoxia/metabolismo , Lesión Pulmonar Aguda/tratamiento farmacológico , Lesión Pulmonar Aguda/metabolismo , Lesión Pulmonar Aguda/patología , Células Epiteliales Alveolares/patología , Animales , Apoptosis/efectos de los fármacos , Proteína 11 Similar a Bcl2/genética , Células Cultivadas , Ciclina D1/genética , Femenino , Proteína Forkhead Box O3/genética , Proteína Forkhead Box O3/metabolismo , Expresión Génica/efectos de los fármacos , Genes bcl-2/efectos de los fármacos , Hidrógeno/metabolismo , Hiperoxia/patología , Estrés Oxidativo/efectos de los fármacos , Fosfatidilinositol 3-Quinasas/metabolismo , Embarazo , Proteínas Proto-Oncogénicas c-akt/metabolismo , ARN Mensajero/genética , ARN Mensajero/metabolismo , Ratas , Ratas Sprague-Dawley , Transducción de Señal/efectos de los fármacos , Proteína X Asociada a bcl-2/genética
12.
Cell Mol Biol Lett ; 23: 4, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29416550

RESUMEN

BACKGROUND: Calcitonin gene-related peptide (CGRP) can protect against hyperoxia-induced lung injury, making the upregulation of CGRP a potential therapeutic approach for this type of injury. However, the effects of CGRP on the Wnt7b/ß-catenin signaling pathway are unclear. In this study, we investigated the roles of CGRP and the Wnt7b/ß-catenin signaling pathway in hyperoxia-induced lung injury. METHODS: Premature Sprague Dawley (SD) rats were exposed to 21, 40, 60 and 95% oxygen for 3, 7 and 14 days. The animals' body weights, survival rates and endogenous CGRP levels were measured. Lung samples were harvested for histological analyses and measurements of malondialdehyde (MDA) concentration and total antioxidant capacity (TAOC). We also assessed the MDA concentration and TAOC in the lung tissues after administration of 200 nmol/kg CGRP8-37 (a CGRP antagonist). Finally, alveolar epithelial type II (AEC II) cells were isolated from premature rats, exposed to 21 or 95% oxygen for 3, 7 and 14 days, and treated with 10- 8 mol/l exogenous CGRP. The protein expressions of Wnt7b and ß-catenin were assessed using western blotting, and TCF and c-myc mRNA expressions were assessed using qPCR. RESULTS: Rats exposed to 60 and 95% oxygen had significantly lower body weights and survival rates than the 21 and 40% groups, and the decrease was time dependent. Endogenous CGRP was elevated in the lung tissues of premature rats exposed to 95% oxygen. CGRP8-37 induced apparent inflammation in the lung tissue and alveolar structural remodeling. In addition, the expression levels of Wnt7b and ß-catenin were markedly increased after exposure for 3 days. They peaked at 7 days, then declined at 14 days. The levels of TCF/c-myc in AEC II cells increased significantly after CGRP treatment when compared with cells that had only undergone hyperoxia. CONCLUSIONS: CGRP protected against hyperoxia-induced lung injury in premature rats. This process involves the Wnt7b/ß-catenin signaling pathway.


Asunto(s)
Péptido Relacionado con Gen de Calcitonina/fisiología , Lesión Pulmonar/metabolismo , Vía de Señalización Wnt , Animales , Animales Recién Nacidos , Antioxidantes/análisis , Peso Corporal , Péptido Relacionado con Gen de Calcitonina/metabolismo , Células Cultivadas , Hiperoxia/complicaciones , Pulmón/química , Pulmón/metabolismo , Pulmón/patología , Lesión Pulmonar/etiología , Lesión Pulmonar/patología , Malondialdehído/análisis , Proteínas Proto-Oncogénicas c-myc/metabolismo , Ratas , Ratas Sprague-Dawley , Análisis de Supervivencia , Factores de Transcripción TCF/metabolismo , Proteínas Wnt/metabolismo , beta Catenina/metabolismo
13.
Pediatr Pulmonol ; 2024 May 10.
Artículo en Inglés | MEDLINE | ID: mdl-38726927

RESUMEN

OBJECTIVE: This study aims to explore the time threshold for defining prolonged mechanical ventilation (PMV) in children, along with its risk factors and outcomes. METHODS: A prospective cohort study was conducted on children aged 29 days-18 years, who were consecutively admitted to two Pediatric Intensive Care Units (PICUs) at Children's Hospital of Chongqing Medical University, from October 2020 to June 2021. The study included patients receiving mechanical ventilation (MV) for more than 2 days (each day >6 h). Participants were divided into five groups based on the duration of MV (2-7 days, 8-14 days, 15-21 days, 21-30 days, >30 days) to compare rates of extubation failure, all-cause mortality one month post-discharge, incidence of ventilator-associated pneumonia, tracheotomy rates, total hospital stay, PICU stay, and overall hospital costs. The most clinically and statistically significant outcome variables were selected. The Youden index was used to determine the MV duration with the most significant impact on overall outcomes, defining this as PMV. Baseline characteristics, treatment information, and outcomes were compared between PMV and non-PMV groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for PMV occurrence. RESULTS: A total of 382 subjects were included in the study. The distribution of children across the five MV duration groups was 44.2%, 27.7%, 10.7%, 8.9%, and 8.4% respectively. The rates of at least one extubation failure in each group were 5.9%, 10.4%, 41.5%, 41.2%, and 46.9% (p < .05). Statistically significant differences were observed among groups in terms of tracheotomy rates, all-cause mortality at 1 month postdischarge, median total hospital stay, median PICU stay, and hospital costs (p < .05). Defining PMV, the most appropriate time point calculated was 12.5 days, based on at least one extubation failure and/or death within 1 month postdischarge. Higher PIM-3 scores, weight for age <-2SD, admission for respiratory distress/insufficient ventilation and/or hemodynamic instability/shock/arrhythmia, noninvasive ventilation on the first day, and undergoing blood transfusion treatment were identified as risk factors for PMV (p < .05). CONCLUSION: In children, MV for ≥13 days significantly increases mortality rates, extubation failure and tracheotomy rates, duration of PICU and total hospital stay and costs. We suggest defining PMV as MV ≥13 days, particularly for children undergoing MV for respiratory illnesses. This definition can assist clinicians in developing appropriate treatment strategies by focusing on risk factors and providing reliable prognostic consultation to patients' families.

14.
Front Pediatr ; 11: 1086420, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37397150

RESUMEN

Objective: Introduce a novel protocol to prevent clotting and citrate accumulation (CA) from blood product transfusion (BPT) during continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in children. Methods: We prospectively compared fresh frozen plasma (FFP) and platelet transfusions between the two BPT protocols, direct transfusion protocol (DTP) and partial replacement of citrate transfusion protocol (PRCTP), in terms of the risks of clotting, citric accumulation (CA), and hypocalcemia. For DTP, blood products were directly transfused without any adjustment to the original RCA-CRRT regimen. For PRCTP, the blood products were infused into the CRRT circulation near the sodium citrate infusion point, and the dosage of 4% sodium citrate was reduced depending on the dosage of sodium citrate in the blood products. Basic information and clinical data were recorded for all children. Heart rate, blood pressure, ionized calcium (iCa) and various pressure parameters were recorded before, during and after BPT, as well as coagulation indicators, electrolytes, and blood cell counts before and after BPT. Results: Twenty-six children received 44 PRCTPs and 15 children received 20 DTPs. The two groups had similar in vitro ionized calcium (iCa) concentrations (PRCTP: 0.33 ± 0.06 mmol/L, DTP: 0.31 ± 0.04 mmol/L), total filter lifespan (PRCTP: 49.33 ± 18.58, DTP: 50.65 ± 13.57 h), and filter lifespan after BPT (PRCTP: 25.31 ± 13.87, DTP: 23.39 ± 11.34 h). There was no visible filter clotting during BPT in any of the two groups. The two groups had no significant differences in arterial pressure, venous pressure, and transmembrane pressure before, during, or after BPT. Neither treatment led to significant decreases in WBC, RBC, or hemoglobin. The platelet transfusion group and the FFP group each had no significant decrease in platelets, and no significant increases in PT, APTT, and D-dimer. The most clinically significant changes were in the DTP group, in which the ratio of total calcium to ionized calcium (T/iCa) increased from 2.06 ± 0.19 to 2.52 ± 0.35, the percentage of patients with T/iCa above 2.5 increased from 5.0% to 45%, and the level of in vivo iCa increased from 1.02 ± 0.11 to 1.06 ± 0.09 mmol/L (all p < 0.05). Changes in these three indicators were not significant in the PRCTP group. Conclusion: Neither protocol was associated with filter clotting during RCA-CRRT. However, PRCTP was superior to DTP because it did not increase the risk of CA and hypocalcemia.

15.
Front Pediatr ; 11: 1089849, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-36969287

RESUMEN

Background: Regional citrate anticoagulant (RCA) is recommended as the preferred anticoagulant regimen for continuous renal replacement therapy (CRRT) in adults; however, it is rarely reported in neonates due to concerns associated with their immature liver. Few studies have reported on the use of RCA to evaluate the safety and efficacy of RCA-CRRT in neonates. Method: In this retrospective observational study, we reviewed the clinical records of neonates who underwent RCA-CRRT at our pediatric intensive care unit between September 2015 to January 2021. Results: A total of 23 neonates underwent 57 sessions of RCA-CRRT. Their mean age was 10.1 ± 6.9 days and mean weight was 3.0 ± 0.7 kg (range, 0.95-4 kg). The mean filter life was 31.54 ± 19.58 h (range, 3.3-72.5 h). Compared to pretreatment values, the total-to-ionized calcium ratio (T/iCa) on RCA-CRRT increased (2.00 ± 34 0.36 vs. 2.19 ± 0.40, P = 0.056) as did the incidence of T/iCa levels >2.5 (11.4 vs. 14.3, P = 0.477), albeit not significantly. Using a post-treatment T/iCa threshold of 2.5, we divided all the cases into citrate accumulation (CA) and non-CA (NCA) groups. Compared with the NCA group, the CA group had significantly higher body weight (3.64 ± 0.32 kg vs. 2.95 ± 0.41 kg, P = 0.033) and significantly lower blood flow rate per body weight ml/kg/min (3.08 ± 0.08 vs. 4.07 ± 0.71, P = 0.027); however, there was no significant difference between the two groups in terms of age, corrected gestational age, the PRISM-III score, and biochemical tests. Conclusion: RCA-CRRT is safe and effective for neonates. After appropriate adjustments of the RCA-CRRT parameters, the incidence of CA was not higher in neonates than in children or adults, and CA was not found to be significantly correlated with age or corrected gestational age.

16.
Transl Pediatr ; 12(3): 344-353, 2023 Mar 31.
Artículo en Inglés | MEDLINE | ID: mdl-37035406

RESUMEN

Background: To study the association in moderate and severe pediatric traumatic brain injury (TBI) between hyperglycemia, hyperlactatemia, acidosis and unfavorable outcome, as assessed by Pediatric Cerebral Performance Category (PCPC) on discharge from the pediatric intensive care unit (PICU). Methods: Children <16 years old with TBI and Glasgow Coma Scale (GCS) ≤13 in an Asian multi-center PICU TBI cohort from January 2014 to October 2017 were included in this study. We defined unfavorable outcome as PCPC ≥3-moderate disability, severe disability, vegetative state, and death. We performed logistic regression to investigate the association between metabolic changes with unfavorable outcome. We divided hyperglycemia (glucose >11.1 mmol/L) during PICU admission into early-onset (within 24 h), late-onset (beyond 48 h) and persistent (throughout first 72 h). Results: Among the 305 children analyzed, 136 (44.6%) had unfavorable outcome. Children with unfavorable outcome were more likely to have early hyperglycemia (75/136, 55.1% vs. 33/169, 19.5%; P<0.001), high lactate levels >2.0 mmol/L (74/136, 54.4% vs. 56/169, 32.5%; P<0.001) and initial acidosis (85/136, 62.5% vs. 78/169, 56.1%; P=0.003) compared to those with favorable outcome. After adjusting for gender, GCS ≤8 and presence of polytrauma, early hyperglycemia [adjusted odds ratio (aOR) =3.68, 95% CI: 2.12-6.39, P<0.001] and late hyperglycemia (aOR =13.30, 95% CI: 1.64-107.8, P=0.015] were independently associated with unfavorable outcome. All children with persistent hyperglycemia died. Conclusions: We described unfavorable outcome in pediatric TBI especially with persistent hyperglycemia. Future trials should investigate the causal relationship between glycemic trends, early intervention and outcome in this cohort.

17.
Tohoku J Exp Med ; 227(2): 129-38, 2012 06.
Artículo en Inglés | MEDLINE | ID: mdl-22706400

RESUMEN

Therapies with prolonged exposure to high-concentration oxygen are common in the treatment of critical pulmonary and cardiac conditions in newborns. However, prolonged exposure to hyperoxia could result in lung damages and developmental disorders manifested as acute lung injury and bronchopulmonary dysplasia, respectively. Calcitonin gene-related peptide (CGRP) has been shown to have a broad regulatory effect on the respiratory system. In this study, we explored the protective effects of CGRP on the hyperoxia-induced lung damage. Newborn Sprague-Dawley rats were randomly divided into three groups: normoxia, hyperoxia, and hyperoxia with CGRP. Hyperoxia groups were exposed to 95% oxygen for 14 days and treated once every other day with saline or CGRP. Hyperoxia exposure reduced the survival rate to 73%, when compared with the 93% survival rate observed in the normoxia group. The survival rate was improved to 84% with CGRP treatment. Treatment with CGRP under hyperoxia significantly alleviated the hyperoxia-induced lung histomorphological changes and the increases in leukocyte counts and total protein levels in bronchoalveolar lavage fluid that reflect the pulmonary microvasular damages. CGRP treatment also restored the decreased activity of superoxide dismutase, while it decreased the increased level of malondialdehyde in the lung tissues. Importantly, CGRP treatment significantly decreased the magnitude of the hyperoxia-mediated increase in the expression levels of tumor necrosis factor-α mRNA and transforming growth factor-ß 1 protein. In conclusion, the hyperoxia-induced acute lung injury is associated with both oxidative stress and inflammatory responses, and CGRP may ameliorate the hyperoxia-induced lung injury by down-regulating these processes.


Asunto(s)
Péptido Relacionado con Gen de Calcitonina/metabolismo , Hiperoxia/complicaciones , Lesión Pulmonar/etiología , Lesión Pulmonar/prevención & control , Animales , Animales Recién Nacidos , Líquido del Lavado Bronquioalveolar , Péptido Relacionado con Gen de Calcitonina/genética , Femenino , Regulación de la Expresión Génica , Hiperoxia/genética , Hiperoxia/patología , Interleucina-6/genética , Interleucina-6/metabolismo , Recuento de Leucocitos , Pulmón/enzimología , Pulmón/patología , Lesión Pulmonar/genética , Lesión Pulmonar/patología , Malondialdehído/metabolismo , ARN Mensajero/genética , ARN Mensajero/metabolismo , Ratas , Ratas Sprague-Dawley , Superóxido Dismutasa/metabolismo , Análisis de Supervivencia , Factor de Crecimiento Transformador beta1/metabolismo , Factor de Necrosis Tumoral alfa/genética , Factor de Necrosis Tumoral alfa/metabolismo , Aumento de Peso
18.
Int J Oncol ; 60(3)2022 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-35119078

RESUMEN

Subsequently to the publication of the above article [and an already published Corrigendum that has indicated a corrected version of Fig. 6 (DOI: 10.3892/ijo.2020.5131; published online on October 12, 2020)], the authors have realized that some incorrect data were also included in Fig. 3 in their paper; essentially, Fig. 3A, which was intending to show the siRNA knockdown data for NFATc1 expression in xenograft tumor tissue via immunohistochemical staining, was inadvertently derived from the same data as that shown for Fig. 4F. The corrected version of Fig. 3, featuring the correct data for Fig. 3A, is shown below. The authors confirm that this error did not significantly influence either the results or the conclusions in their paper. The authors are grateful to the Editor of International Journal of Oncology for allowing them the opportunity to publish this corrigendum, and apologize to the readership for any inconvenience caused. [the original article was published in International Journal of Oncology 48: 1457­1466, 2016; DOI: 10.3892/ijo.2016.3355].

19.
Front Pediatr ; 10: 1001565, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-36313890

RESUMEN

Background: We assessed the outcomes and characteristics of culture-negative septic shock (CNSS) and culture-positive septic shock (CPSS) in pediatric intensive care unit (PICU). Methods: We performed a retrospective study on the data of children admitted to the PICU due to septic shock between January 2018 and December 2021. The primary outcome was in-hospital mortality. The secondary outcomes were the length of stay (LOS) of hospital, the need for mechanical ventilation (MV) and continue renal replacement therapy (CRRT). Results: Overall, 238 patients were enrolled. 114 patients (47.9%) had positive cultures (60 blood samples, 41 sputum samples, 17 pus samples, and 19 others), 18 of whom were cultured positive at two sites, 1 at three sites, and 3 had two different types of bacteria at same site. The in-hospital mortality was 47.1%. There were no significant differences in the in-hospital mortality (47.6% vs. 46.5%, P = 0.866), PRISM-III score (10 vs. 12, P = 0.409), PIM-3 score (0.08 vs. 0.07, P = 0.845), pSOFA score (10 vs. 10, P = 0.677) or the need for MV (64.5% vs. 68.4%, P = 0.524) and CRRT (29.8% vs. 34.2%, P = 0.470) between the CNSS group and the CPSS group. The Procalcitonin (8.89 ng/ml vs. 28.39 ng/ml, P = 0.001) and C-reactive protein (28 mg/L vs. 58 mg/L, P = 0.001) levels were significantly lower in the CNSS group than in the CPSS group, while WBC count (9.03 × 109/L vs. 5.02 × 109/L, P = 0.002) and serum sodium (137 mmol/L vs. 132 mmol/L, P = 0.001) was significantly higher in CNSS. The LOS of hospital was significantly longer (16 days vs. 11 days, P = 0.011) in the CPSS group than in the CNSS group, while the LOS of PICU (5 days vs. 4 days, P = 0.094) stay was not significantly different. Conclusion: Compared with children with CNSS, children with CPSS had higher PCT and CRP levels, but lower WBC count. Children with CPSS had longer LOS of hospital. However, positive or negative culture results were not associated with in-hospital mortality, the LOS of PICU, the need for MV or CRRT in children with septic shock.

20.
Front Pediatr ; 10: 830075, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35211431

RESUMEN

BACKGROUND: Prolonged mechanical ventilation (PMV) has become an enormous challenge in intensive care units (ICUs) around the world. Patients treated with PMV are generally in poor health. These patients represent a select cohort with significant morbidity, mortality, and resource utilization. The status of children who have undergone PMV in China is unknown. Our goal is to investigate the prevalence and characteristics of pediatric patients with PMV, as well as the risk factors of PMV in the pediatric intensive care unit (PICU). METHODS: The subjects were divided into two groups. The PMV group(MV ≥ 14 days) and the non-PMV group(2 days < MV <14 days). The baseline characteristics, treatments, mortality and other results between the two groups were compared. The risk factors associated with PMV were evaluated using univariate and multivariable analyses. RESULTS: Of the 382 children enrolled, 127 (33.2%) received prolonged mechanical ventilation. The most common cause of MV in the PMV group was acute lung disease (48.0%), followed by acute circulatory system disease (26.0%), acute neurological disease (15.0%), postoperative monitoring (10.2%), and others (0.8%). Comorbidities were more prevalent among the PMV group (P = 0.004). The patients with PMV had a higher rate of premature birth (24.4 vs. 14.1%, P = 0.013) and higher PIM3 score at admission [5.6(3.0-9.9) vs. 4.1(1.7-5.5), P < 0.001]. The use of inotropes/vasopressors (63.8 vs. 43.1%, P < 0.001) was more common in patients with PMV compared with those in the non-PMV group. In the PMV group, the rate of extubation failure (39.4 vs. 6.7%, P < 0.001) was higher than the non-PMV group. The median hospital stay [35(23.0-50.0)d vs. 20(14.0-31.0)d, P < 0.001], PICU stay [22(15.0-33.0)d vs. 9(6.0-12.0)d, P < 0.001], hospitalization costs [¥391,925(263,259-614,471) vs. ¥239,497(158,723-350,620), P < 0.001], and mortality after 1-month discharge (22.0 vs. 1.6%, P < 0.001) were higher in the PMV group. Multivariate analysis revealed that age <1 year old, a higher PIM3 score at admission, prematurity, the use of inotropes or vasopressors, extubation failure, and ventilator mode on the first day of MV were associated with PMV. CONCLUSIONS: The incidence and mortality of PMV in pediatric patients is surprisingly high. Premature infants or patients with severe disease or extubation failure are at higher risk of PMV. Patients with PMV exhibit a greater burden with regard to medical costs than those on non-PMV. It is important to establish specialized weaning units for mechanically ventilated patients with stable conditions.

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