Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxemic respiratory failure (PRONELIFE)-protocol for a randomized clinical trial.

BACKGROUND: It is uncertain whether awake prone positioning can prevent intubation for invasive ventilation in spontaneous breathing critically ill patients with acute hypoxemic respiratory failure. Awake prone positioning could benefit these patients for various reasons, including a reduction in direct harm to lung tissue, and prevention of tracheal intubation-related complications. DESIGN AND METHODS: The PRONELIFE study is an investigator-initiated, international, multicenter, randomized clinical trial in patients who may need invasive ventilation because of acute hypoxemic respiratory failure. Consecutive patients admitted to participating ICUs are randomly assigned to standard care with awake prone positioning, versus standard care without awake prone positioning. The primary endpoint is a composite of tracheal intubation and all-cause mortality in the first 14 days after enrolment. Secondary endpoints include time to tracheal intubation and effects of awake prone positioning on oxygenation parameters, dyspnea sensation, and complications. Other endpoints are the number of days free from ventilation and alive at 28 days, total duration of use of noninvasive respiratory support, total duration of invasive ventilation, length of stay in ICU and hospital, and mortality in ICU and hospital, and at 28, 60, and 90 days. We will also collect data regarding the tolerance of prone positioning. DISCUSSION: The PRONELIFE study is among the first randomized clinical trials investigating the effect of awake prone positioning on intubation rate in ICU patients with acute hypoxemic failure from any cause. The PRONELIFE study is sufficiently sized to determine the effect of awake prone positioning on intubation for invasive ventilation-patients are eligible in case of acute hypoxemic respiratory failure without restrictions regarding etiology. The PRONELIFE study is a pragmatic trial in which blinding is impossible-however, as around 35 ICUs worldwide will participate in this study, its findings will be highly generalizable. The findings of the PRONELIFE study have the potential to change clinical management of patients who may need invasive ventilation because of acute hypoxemic respiratory failure. TRIAL REGISTRATION: ISRCTN ISRCTN11536318 . Registered on 17 September 2021. The PRONELIFE study is registered at clinicaltrials.gov with reference number NCT04142736 (October, 2019).

Automatic summarization of soccer highlights using audio-visual descriptors.

Automatic summarization generation of sports video content has been object of great interest for many years. Although semantic descriptions techniques have been proposed, many of the approaches still rely on low-level video descriptors that render quite limited results due to the complexity of the problem and to the low capability of the descriptors to represent semantic content. In this paper, a new approach for automatic highlights summarization generation of soccer videos using audio-visual descriptors is presented. The approach is based on the segmentation of the video sequence into shots that will be further analyzed to determine its relevance and interest. Of special interest in the approach is the use of the audio information that provides additional robustness to the overall performance of the summarization system. For every video shot a set of low and mid level audio-visual descriptors are computed and lately adequately combined in order to obtain different relevance measures based on empirical knowledge rules. The final summary is generated by selecting those shots with highest interest according to the specifications of the user and the results of relevance measures. A variety of results are presented with real soccer video sequences that prove the validity of the approach.

Quantitative HIV-1 RNA as a marker of clinical stability and survival in a cohort of 302 patients with a mean CD4 cell count of 300 x 10(6)/l.

OBJECTIVE: To analyse plasma HIV-1 RNA levels as a marker of clinical stability and survival in a cohort of HIV-infected patients whose time of seroconversion is unknown. DESIGN: Retrospective cohort study. SETTING: Retrovirology laboratory and AIDS Unit in a teaching hospital. PATIENTS: A total of 916 samples from 302 patients, most on antiretroviral therapy, were analysed. Mean initial CD4 cell counts and HIV-1 RNA were 299 x 10(6)/l (range: 0-1600) and 134,261 copies/ml (range: < 200-4,300,000), respectively. Sixty-six cases had been diagnosed previously with AIDS. METHODS: Analysis of progression to AIDS and survival, according to initial and longitudinal viral load (VL) and CD4 cell count measurements was performed by Kaplan-Meier test. Relative risks were calculated by Cox's proportional hazards model. RESULTS: During a mean follow-up of 444 +/- 309 days, 29 patients developed AIDS and 21 died. Relative risk (RR) of progression related to the group with VL < 35,000 was: 10.4 when CD4 > or = 250 x 10(6)/l and VL > or = 35,000 (P = 0.001); and 45.3 when CD4 < 250 x 10(6)/l and VL > or = 35,000 (P < 0.0001). Cumulative probability of progression was: 0%, 0% and 12.3%, at the first, second and third year respectively, for patients with all their sequential VL determinations < 60,000; and 13.3%, 34.7% and 79.3% for patients who did not maintain VL values always < 60,000 (RR = 23; P < 0.0001). The minimum value of VL that reached statistical significance for the survival analysis was 100,000 copies/ml (P < 0.0001). CONCLUSIONS: VL > or = or < 35,000 is a better discriminant for progression than a CD4 cell count > or = or < 250 x 10(6)/l. Sequential VL determinations < 60,000 are associated with a better prognosis.

Resistance-related mutations in the HIV-1 protease gene of patients treated for 1 year with the protease inhibitor ritonavir (ABT-538).

OBJECTIVE: To define genotypic and phenotypic resistance patterns following prolonged therapy with the protease inhibitor ritonavir (ABT-538). DESIGN: Seven HIV-1-infected patients, all but one previously treated with dideoxynucleoside analogues (zidovudine, didanosine, zalcitabine), were treated for 1 year with ritonavir. METHODS: Direct solid-phase sequencing of the protease gene starting from plasma derived viral RNA followed by comparison to phenotypic drug resistance data. RESULTS: The most frequent amino-acid substitutions occurring upon administration of the protease inhibitor were V82A/F (substrate binding site), I54V (flap region), A71V and L10I. Additional mutations found in more than one patient were I15V, M36I, I84V and I93L. Mutation L63P was found both in pre- and post-ritonavir samples. Phenotypic drug resistance assays confirmed resistance to ritonavir in post-treatment samples (approximately 170-fold) and showed cross-resistance to indinavir (approximately 30-fold) and partially to saquinavir (approximately fivefold). At 1 year of treatment, one patient without known resistance-associated mutations in the protease gene still showed a substantial rise in CD4 cell count accompanied by a more than 2.4 log decrease in RNA viral load. However, at week 78, mutations R8Q, E34K, R57K, L63P and I84V were detected and the treatment benefit was partially lost. CONCLUSIONS: Long-term treatment with ritonavir is associated with the emergence of multiple mutations in the HIV-1 protease gene. The mutations L10I, I54V, L63P, A71V, V82A/F and I84V correspond to known drug-resistance mutations for ritonavir and other protease inhibitors. Phenotypic resistance to ritonavir was detected in a majority of ritonavir-treated patients at 1 year of treatment. In addition, long-term ritonavir treatment selects for cross-resistance to the protease inhibitors indinavir and saquinavir. This argues against sequential therapy with several protease inhibitors. Delayed resistance in one patient was accompanied with a prolonged increase in CD4 cell count and decrease in viral load suggesting a temporary benefit of treatment.

A distinctive cytologic pattern for diagnosing tuberculous lymphadenitis in AIDS.

Tuberculous lymphadenitis (TL) is a very common infection in human immunodeficiency virus (HIV)-infected patients. We performed fine-needle aspiration biopsy (FNAB) of enlarged lymph nodes in 57 HIV-infected patients to evaluate its usefulness in this population. We observed three cytologic patterns in 21 patients diagnosed as having TL: granulomatous lymphadenitis (GL) in 4 FNABs, necrotizing granulomatous lymphadenitis (NGL) in 7 FNABs, and necrotizing lymphadenitis (NL) in 12 FNABs. GL and NGL are already well-known and considered to be highly suggestive of TL. Our results support the idea that NL should have the same diagnostic value as GL or NGL. In the group of 12 patients with NL, TL was confirmed in 11 by microbiologic methods (7 by a positive Ziehl-Neelsen stain and 4 by a positive Löwenstein culture) and in the remaining patient by a biopsy that showed NGL with acid-fast bacilli. We conclude that FNAB is a useful, inexpensive, and safe technique for diagnosing TL in HIV-infected patients. The finding of a NL pattern is suggestive enough of TL to start antituberculous treatment.

Requirements for a treatment planning system for radioimmunotherapy.

Cancer-seeking antibodies carrying radionuclides can, in theory, be very powerful agents for the radiotherapy of cancer. However, as with all radiotherapy, the undesired dose to critical normal organs is the limiting factor that determines success or failure. The distribution of radiation dose in cancer and noncancer tissue is highly dependent on choices the therapist can make: choices of the antigens to be targeted, choices of the antibodies or antibody fragments to be used, choices of radionuclides, of amounts, of timing, and other electives. New technologies, especially of monoclonal antibody production, make the options myriad. Optimization of this therapy depends on a foreknowledge of the radiation dose distributions to be expected. The necessary data can be acquired by established tracer techniques, in individual patients, for particular treatment selections. These tracer techniques can now be implemented by advanced equipment for quantitative, tomographic radionuclide imaging and strengthened by dynamic modeling of the physiological parameters which govern radionuclide distribution, and hence radiation dose distribution.

Critical evaluation of hepatic scintiangiography for neoplastic tumors of the liver.

Dynamic hepatic scintiangiography increases the specificity of diagnosis of space-occupying lesions of the liver seen on hepatic scintigraphy. The purpose of this study was to evaluate and compare critically this procedure with histologic and radiopaque diagnosis in the evaluation of suspected hepatic neoplasms. Ninety-two patients had hepatic scintiangiography, scintigraphy, and histologic certification. In ten of these patients the findings of radiopaque arteriography were compared with those of hepatic scintiangiography. In all ten patients with hepatoma, the scintiangiographic and histologic observations correlated; nine of these ten patients had a "tumor stain." Fifty-one of 59 patients with metastases to the liver had scinitangiograms that showed "tumor stain." In 2 of these 59 patients, scintiangiography revealed tumor vascularity whereas the results of scintigraphy were normal. In two of four patients with metastases and two of six patients with hepatomas, scintiangiograms revealed "tumor stain" that was not evident on radiopaque afteriography. Conclusions from this study are: (A) neoplastic arterialization or "tumor stain" is more readily detected by scintiangiography than by radiopaque arteriography; (B) a normal scintigram and a "tumor stain" on the scintiangiogram in a patient with a known primary neoplasm outside the liver is suggestive of hepatic metastases; and (C) a normal scintigram and scintiangiogram make neoplastic involvement of the liver improbable. Dynamic hepatic scintiangiography is a simple, clinically useful method for increasing the specificity of diagnosis of diagnosis of space-occupying lesions of the liver and should be part of the evaluation for possible neoplastic involvement.

Pulmonary embolism in patients with upper extremity DVT associated to venous central lines--a prospective study.

We performed a prospective study in 86 consecutive patients with central vein catheter-related deep venous thrombosis (DVT) of the upper extremity, to evaluate the prevalence of pulmonary embolism (PE), and to identify clinical variables that would increase the likelihood of developing PE in an individual patient. Since upper-extremity DVT was established, all patients received intravenous heparin therapy. Then, a ventilation-perfusion lung scan was obtained within 24 h of DVT diagnosis, whether respiratory symptoms were present or not. Six points of clinical information were recorded on entering in the study, and then compared with the scintigraphic findings: age, sex, the underlying disease, the catheter material, the character of the infusate, and the duration of cannulation. Thirteen patients were considered to have PE. Sixty-six patients were finally classified as having a normal lung scan, and 7 patients were excluded from the study (because of indeterminate lung scan 6; because of femoropopliteal thrombosis simultaneously present 1). Two out of the 13 patients with PE subsequently died because of recurrent, massive embolism, despite adequate heparin therapy. PE was more commonly present in patients with polyvinyle chloride or polyethylene catheters (10/38, 26%) as compared to patients with either polyurethane or siliconized catheters (3/41, 7%; p < 0.05, Chi-Square test; Odds Ratio = 4.52, 95% CI 1.01-23.07). We conclude that PE is not a rare event in these patients, and it may be life-threatening even despite adequate heparin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Hormonal receptors, cell proliferation fraction (Ki-67) and c-erbB-2 amplification in breast cancer. Relationship between differentiation degree and axillary lymph node metastases.

In view of the limitations of conventional prognostic factors such as differentiation degree, metastatic lymph nodes, hormonal receptors and others, especially when early lesions are found, additional new markers have been studied, such as gene amplification and cell proliferation index, in order to choose the appropriate treatment. Primary breast carcinoma tumors from 97 patients were examined for differentiation degree, metastatic lymph nodes, hormonal receptors, c-erbB-2 amplification and cell proliferation index (Ki-67). A negative relationship with hormonal receptors and c-erbB-2 amplification, Ki-67 and differentiation degree was found, whereas the relationship between c-erbB-2, Ki-67 and differentiation degree was positive. No relationship was found between these factors and metastatic lymph nodes. The concurrence of high cell proliferation index, c-erbB-2 amplification and negative hormonal receptor presence would indicate a subpopulation with a high risk of recurrence. But a larger survival study is necessary to correlate these factors with clinical outcome.

Low-dose, fractionated radioimmunotherapy for B-cell malignancies using 131I-Lym-1 antibody.

PURPOSE: This trial was conducted to assess the toxicity and efficacy of 131I-Lym-1 in patients with either malignant B-cell non-Hodgkin's lymphoma (NHL) or chronic lymphocytic leukemia (CLL) using low-dose, fractionated radioimmunotherapy (RIT). MATERIALS AND METHODS: Thirty adult patients who had advanced B-cell malignancies (25 NHL and 5 CLL) had progressed despite standard therapy; 12 patients entered the trial with Karnofsky performance status (KPS) of equal to or greater than 60. Patients were treated with a series of intravenous doses of 131I-Lym-1 with a goal of reaching a cumulative dose in each patient of at least 300 mCi. All patients were Lym-1 reactive. Clinical responses and immediate toxicity were evaluable in all 30 patients and delayed toxicity in 26. RESULTS: Toxicity to Lym-1 antibody occurred with 28% of the 176 doses and was transient. Human antimouse antibodies (HAMA) were generated in 30% after a mean of 4 doses, but interrupted therapy in only 10% of the patients. Thrombocytopenia was dose-limiting; there were no deaths due to toxicity. Tumor regression occurred in 25 (83%) of the patients and was great enough, and durable enough, in 17 (57%) to qualify them as responders; 13 NHL patients and 4 CLL patients. Advanced disease often interrupted therapy prematurely. However, 18 patients received at least 180 mCi of 131I-Lym-1; 17 (94%) of these responded to the therapy. CONCLUSION: Although advanced disease often interrupted therapy prematurely, the results from 131I-Lym-1 therapy are clearly promising and warrant additional trials.

Prospects for radiolabeled monoclonal antibodies in metastatic disease.

Many monoclonal antibodies are now available that bind to human cancer cells with varying degrees of specificity. These antibodies can be labeled with various radionuclides, permitting tumor sites in the body to be imaged with scintillation cameras. SPECT, the emission counterpart of x-ray computed tomography, provides both qualitative and quantitative information in three dimensions about antibody distribution. We have detected a metastasis as small as 5 mm in a patient, and the theoretical limit of detection size is less than 1 mm. Tumors that are imaged with radiolabeled antibodies can be effectively treated with the same substance (radioimmunotherapy).

Cytologic study of renal angiomyolipoma by fine-needle aspiration biopsy: report of four cases.

Four cases of renal angiomyolipoma (AML) diagnosed by fine-needle aspiration biopsy (FNAB) are reported. One case was associated with the clinical complex of tuberous sclerosis. The tumors were solitary in two cases and multiple and bilateral in the fourth. The cytologic features of the four cases were similar to those described in the literature: smooth muscle cells intermingled with mature fat cells and blood vessels, together with a lipoidic background. These tumors are currently considered benign although they may present characteristics accepted as criteria of malignancy in other tumors: pleomorphism and atypical smooth muscle cells, vascular invasion, capsular rupture, and lymphatic involvement. We conclude that it is important and possible to establish preoperative cytologic diagnosis, since treatment of these tumors is conservative and obviates aggressive nephrectomy.

Leishmania lymphadenitis diagnosed by fine-needle aspiration biopsy.

A case of Leishmania lymphadenitis which presented clinically as an isolated left laterocervical lymph node is described. Diagnosis was made by fine-needle aspiration biopsy (FNAB), as in other cases previously reported. The material obtained yielded abundant histiocytes, multinucleated giant cells, and epithelioid microgranulomas with Leishman-Donovan pathognomic bodies in the cytoplasm of cells, together with free forms of the parasite. This paper comments on the main differential diagnoses to be considered in our region when faced with granulomatous adenitis and the role of FNAB in the identification of this parasite in endemic areas.

[Mediastinal non-Hodgkin's lymphoma: atypical presentation diagnosed with bronchoscopy]. / Linfoma no hodgkiniano mediastínico: presentación atípica con broncoscopia diagnóstica.

Primary mediastinal non-Hodgkin lymphoma is a rare entity that can manifests with secondary pulmonary involvement. The case of a 37 years-old man patient with non-Hodgkin lymphoma mixed B-cell, which was diagnosed by means of bronchoscopic biopsy, is presented. His characteristics clinical and radiologic presentation, and diagnostic usefulness of fiberoptic bronchoscopy, is remarked. We revised clinical and pathologic features of interests for this lymphoproliferative disorders with thoracic involvement.

[Use of mortality probability models (MPM II) in the evaluation of the effectiveness of care of critically ill patients. European and North American Study of Severity Systems]. / Utilización de los modelos probabilísticos de mortalidad (MPM II) para evaluar la efectividad de la atención a pacientes en estado crítico. European and North American Study of Severity Systems.

BACKGROUND: The performance of the Mortality Probability Models (MPM II) has been assessed in Intensive Care Units (ICUs) in Catalonia and the Balearic Islands. The MPM II system has been customized to that geographic area and quality performance has been evaluated in each ICU. METHODS: 1,270 adult critical patients, consecutively admitted in 16 ICUs from Catalonia and 1 from the Balearic Islands have been included. Probability of dying in the hospital has been calculated at admission in the ICU and at 24 hours using the models MPM II0 and MPM II24. Goodness-of-fit of the MPM II system in the overall group of 17 ICUs has been analyzed. Logistic regression has been used to customize the MPM II system to all the ICUs together. A Quality Performance Index (QPI) for each ICU has been obtained by dividing the number of the observed deaths by the number of deaths expected by the MPM II system. RESULTS: The overall QPI was 1.15 when using the MPM II0 and 1.17 when using the MPM II24. The QPI in the 17 ICUs ranged from 0.58 to 2.05. Three ICUs showed excess of mortality and 2 ICUs had less deaths than expected. The process of customization of MPM II to the 17 ICUs as a group improved the estimation of expected mortality. CONCLUSIONS: The use of severity indexes allows to compare the outcome of patients in the ICU and provides an indicator of quality of care. The excess of mortality observed in some ICU should produce a watchful follow-up of outcome. Risk factors for excess of mortality should be studied.

[Cardiac tamponade and Kaposi's sarcoma]. / Taponamiento cardíaco y sarcoma de Kaposi.

The case of a 31 year-old intravenous drug addict female patient with infection by the human immunodeficiency virus who had recurrent cardiac tamponade and who was diagnosed by pericardic biopsy as Kaposi's sarcoma is reported. The patient demonstrated involvement by cutaneous, mucosal, lymph node and probably pleuropulmonary Kaposi's sarcoma. Thoracic radiography, computerized tomography and echocardiography only showed the presence of pericardic effusion. Neither did the pericardic fluid obtained by pericardiocentesis provide any significant ethiologic data. Only the pericardic biopsy showed the typical lesions of Kaposi's sarcoma in this localization confirming diagnosis. This is the first case of pericardic Kaposi's sarcoma described in an alive patient and the difficulties of achieving the diagnosis of the cardiac involvement by Kaposi's sarcoma in AIDS patients are commented upon.

[Mortality and hospital stay adjusted for severity as indicators of effectiveness and efficiency of the care provided to critically ill patients. European and North American Study of Severity Systems]. / Mortalidad y estancia hospitalaria ajustadas por gravedad como indicadores de efectividad y eficiencia de la atención a pacientes en estado crítico. European and North American Study of Severity Systems.

BACKGROUND: Hospital mortality and length of stay, both adjusted for severity of illness, have been used as indicators of effectiveness and efficiency of health care in critical patients. PATIENTS AND METHODS: 1,270 adult critical patients, consecutively admitted in 17 intensive care units (ICU) from Catalonia and the Balearic Islands, Spain, have been included. For each hospital, effectiveness has been assessed with a quality performance index (QOI) obtained by dividing the number of observed deaths by the number of deaths expected according to the MPM system (MPM II0). Efficiency has been assessed with a resource utilization index (RUI) obtained by dividing the number of observed weighted hospital days (WHD) by the number of expected WHD. WHD is a measure of resource use which weights ICU days more heavily than non-ICU days. Expected WHD have been obtained by a regression model including severity of illness and the presence/absence of surgery. RESULTS: Ten of the 17 hospitals life within one standard deviation of the mean on both clinical and economical indices. There are 3 hospitals with optimal values on both indices. There is no evidence of association between effectiveness and resource utilization. CONCLUSIONS: Clinical and economical performance of hospitals can be quantified with simple indicators which allow to compare centers. Hospitals can be effective and efficient at the same time.

[Bronchogenic carcinoma in patients with human immunodeficiency virus infection]. / Carcinoma broncogénico en pacientes con infección por virus de la inmunodeficiencia humana.

The diagnosis of bronchogenic carcinoma (BC) in patients with HIV infection is infrequent. Five cases are described and the existing references reviewed. The incidence, risk factors, clinical manifestations, histology, age of onset, diagnosis and survival in HIV positive patients with BC were analyzed. The clinical histories of 2,586 patients with HIV infection seen in the authors' center were reviewed. Five cases in whom BC was detected were found. Sixty-nine cases published in the international literature were collected in a reference search by the MEDLINE system between 1982-1994. The patients with BC and HIV infection have an early age of presentation (mean age: 42 years) and a lower survival with respect to those without infection. No differences were observed with regard to the smoking habit, procedures for achieving diagnosis or clinical manifestation. The predominant histologic subtype was adenocarcinoma. A higher incidence of BC was observed in patients with HIV infection with respect to the control groups on elimination of the bias for age and risk factors for BC. Given its low incidence, BC should be considered in the differential diagnosis of pulmonary disease in patients with HIV infection in cases presenting a history of smoking, once the most common opportunistic infections have been discarded.

Is port-site resection necessary in the surgical management of gallbladder cancer?

INTRODUCTION: Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry. METHODS: Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival. RESULTS: Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age > 70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision. CONCLUSION: In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.