Mapping peripheral and abdominal sarcopenia acquired in the acute phase of COVID-19 during 7 days of mechanical ventilation.

Our aim was to map acquired peripheral and abdominal sarcopenia in mechanically ventilated adults with COVID-19 through ultrasound measurements. On Days 1, 3, 5 and 7 after admission to critical care, the muscle thickness and cross-sectional area of the quadriceps, rectus femoris, vastus intermedius, tibialis anterior, medial and lateral gastrocnemius, deltoid, biceps brachii, rectus abdominis, internal and external oblique, and transversus abdominis were measured using bedside ultrasound. A total of 5460 ultrasound images were analyzed from 30 patients (age: 59.8 ± 15.6 years; 70% men). Muscle thickness loss was found in the bilateral anterior tibial and medial gastrocnemius muscles (range 11.5-14.6%) between Days 1 and 3; in the bilateral quadriceps, rectus femoris, lateral gastrocnemius, deltoid, and biceps brachii (range 16.3-39.1%) between Days 1 and 5; in the internal oblique abdominal (25.9%) between Days 1 and 5; and in the rectus and transversus abdominis (29%) between Days 1 and 7. The cross-sectional area was reduced in the bilateral tibialis anterior and left biceps brachii (range 24.6-25.6%) between Days 1 and 5 and in the bilateral rectus femoris and right biceps brachii (range 22.9-27.7%) between Days 1 and 7. These findings indicate that the peripheral and abdominal muscle loss is progressive during the first week of mechanical ventilation and is significantly higher in the lower limbs, left quadriceps and right rectus femoris muscles in critically ill patients with COVID-19.

Accuracy of Algorithms and Visual Inspection for Detection of Trigger Asynchrony in Critical Patients : A Systematic Review.

OBJECTIVE: This study aimed to summarize the accuracy of the different methods for detecting trigger asynchrony at the bedside in mechanically ventilated patients. METHOD: A systematic review was conducted from 1990 to 2020 in PubMed, Lilacs, Scopus, and ScienceDirect databases. The reference list of the identified studies, reviews, and meta-analyses was also manually searched for relevant studies. The reference standards were esophageal pressure catheter and/or electrical activity of the diaphragm. Studies were assessed following the QUADAS-2 recommendations, while the review was prepared according to the PRISMA criteria. RESULTS: One thousand one hundred and eleven studies were selected, and four were eligible for analysis. Esophageal pressure was the predominant reference standard, while visual inspection and algorithms/software comprised index tests. The trigger asynchrony, ineffective expiratory effort, double triggering, and reverse triggering were analyzed. Sensitivity and specificity ranged from 65.2% to 99% and 80% to 100%, respectively. Positive predictive values reached 80.3 to 100%, while the negative predictive values reached 92 to 100%. Accuracy could not be calculated for most studies. CONCLUSION: Algorithms/software validated directly or indirectly using reference standards present high sensitivity and specificity, with a diagnostic power similar to visual inspection of experts.

Patient-ventilator asynchrony in conventional ventilation modes during short-term mechanical ventilation after cardiac surgery: randomized clinical trial.

INTRODUCTION AND AIM: Studies regarding asynchrony in patients in the cardiac postoperative period are still only a few. The main objective of our study was to compare asynchronies incidence and its index (AI) in 3 different modes of ventilation (volume-controlled ventilation [VCV], pressure-controlled ventilation [PCV] and pressure-support ventilation [PSV]) after ICU admission for postoperative care. METHODS: A prospective parallel randomised trialin the setting of a non-profitable hospital in Brazil. The participants were patients scheduled for cardiac surgery. Patients were randomly allocated to VCV or PCV modes of ventilation and later both groups were transitioned to PSV mode. RESULTS: All data were recorded for 5 minutes in each of the three different phases: T1) in assisted breath, T2) initial spontaneous breath and T3) final spontaneous breath, a marking point prior to extubation. Asynchronies were detected and counted by visual inspection method by two independent investigators. Reliability, inter-rater agreement of asynchronies, asynchronies incidence, total and specific asynchrony indexes (AIt and AIspecific) and odds of AI ≥10% weighted by total asynchrony were analysed. A total of 17 patients randomly allocated to the VCV (n=9) or PCV (n=8) group completed the study. High inter-rated agreement for AIt (ICC 0.978; IC95%, 0,963-0.987) and good reliability (r=0.945; p<0.001) were found. Eighty-two % of patients presented asynchronies, although only 7% of their total breathing cycles were asynchronous. Early cycling and double triggering had the highest rates of asynchrony with no difference between groups. The highest odds of AI ≥10% were observed in VCV regardless the phase: OR 2.79 (1.36-5.73) in T1 vs T2, p=0.005; OR 2.61 (1.27-5.37) in T1 vs T3, p=0.009 and OR 4.99 (2.37-10.37) in T2 vs T3, p<0.001. CONCLUSIONS: There was a high incidence of breathing asynchrony in postoperative cardiac patients, especially when initially ventilated in VCV. VCV group had a higher chance of AI ≥10% and this chance remained high in the following PSV phases.

Cell proliferation and apoptosis in keratocystic odontogenic tumors.

OBJECTIVES: Keratocystic odontogenic tumors (KOTs), also known as odontogenic keratocysts, were recently classified as a benign neoplasia due to the aggressive clinical behavior. Although several studies have shown the high proliferative activity of the epithelial lining, few studies have evaluated apoptosis in KOTs. Therefore, the aim of this study is to evaluate and compare the proliferation index (PI) and the apoptotic index (AI) of the epithelial lining in sporadic KOTs, KOTs associated with the Nevoid Basal Cell Carcinoma Syndrome (NBCCS KOTs), and dentigerous cysts. MATERIAL AND METHODS: A total of 11 sporadic KOTs, 15 NBCCS KOTs, and 11 dentigerous cysts were evaluated. The PI was assessed by immunohistochemical detection of the cell proliferation marker Ki-67. The AI was assessed by morphological evaluation of sections stained by methyl green-pyronin. The TUNEL assay was used to confirm the occurrence of apoptosis. Differences in the PI and the AI between sporadic KOTs, NBCCS KOTs, and dentigerous cysts were analyzed using the Kruskal-Wallis test. Differences in the PI and the AI between the epithelial layers of each lesion were analyzed using the Wilcoxon test. RESULTS: The PI and AI were higher in sporadic and NBCCS KOTs than in dentigerous cysts. No difference in these indexes was observed between sporadic and NBCCS KOTs. In dentigerous cysts, the PI was higher in the basal layer. In sporadic and NBCCS KOTs, the PI was higher in suprabasal layer. No difference in the AI was observed between the basal layer and the suprabasal layer in the three lesions. The AI was higher in the superficial layer of sporadic and NBCCS KOTs. CONCLUSIONS: The present study demonstrates that the epithelial lining of KOTs shows a distinct pattern of cell proliferation and apoptosis, reflecting its high cell turnover and reinforcing its classification as an odontogenic tumor.