The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial.

BACKGROUND: Based on low-quality evidence, current nutrition guidelines recommend the delivery of high-dose protein in critically ill patients. The EFFORT Protein trial showed that higher protein dose is not associated with improved outcomes, whereas the effects in critically ill patients who developed acute kidney injury (AKI) need further evaluation. The overall aim is to evaluate the effects of high-dose protein in critically ill patients who developed different stages of AKI. METHODS: In this post hoc analysis of the EFFORT Protein trial, we investigated the effect of high versus usual protein dose (≥ 2.2 vs. ≤ 1.2 g/kg body weight/day) on time-to-discharge alive from the hospital (TTDA) and 60-day mortality and in different subgroups in critically ill patients with AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria within 7 days of ICU admission. The associations of protein dose with incidence and duration of kidney replacement therapy (KRT) were also investigated. RESULTS: Of the 1329 randomized patients, 312 developed AKI and were included in this analysis (163 in the high and 149 in the usual protein dose group). High protein was associated with a slower time-to-discharge alive from the hospital (TTDA) (hazard ratio 0.5, 95% CI 0.4-0.8) and higher 60-day mortality (relative risk 1.4 (95% CI 1.1-1.8). Effect modification was not statistically significant for any subgroup, and no subgroups suggested a beneficial effect of higher protein, although the harmful effect of higher protein target appeared to disappear in patients who received kidney replacement therapy (KRT). Protein dose was not significantly associated with the incidence of AKI and KRT or duration of KRT. CONCLUSIONS: In critically ill patients with AKI, high protein may be associated with worse outcomes in all AKI stages. Recommendation of higher protein dosing in AKI patients should be carefully re-evaluated to avoid potential harmful effects especially in patients who were not treated with KRT. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov (NCT03160547) on May 17th 2017.

Saliva cortisol levels and physiological parameter fluctuations in mild traumatic brain injury patients compared to controls.

BACKGROUND: Evidence suggests that fluctuations of cortisol and physiological parameters can emerge during the course of mild Traumatic Brain Injury (mTBI). OBJECTIVE: To investigate fluctuations of cortisol and physiological parametersduring the acute phase of mTBI in hospitalized patients. METHODS: 30 participants (19 patients with mTBI and 11 controls) were examined for saliva cortisol dynamics, heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP) and body temperature (BT) fluctuations for four consecutive days. Also, the participants completed the Athens Insomnia Scale and Epworth Sleepiness Scales, in order to check for sleep problems. RESULTS: Patients showed elevated levels of cortisol relative to controls (peak at 8 am and lowest levels at 12 am), as well as for most physiological parameters. MAP was significantly higher for patients throughout the measurement period, and BT was elevated for patients relative to controls at almost all measurements of the first and second day. Mean HR tended to track at non-significantly higher levels for the mTBI group. Patients' sleepiness and insomnia values (ESS and AIS) were initially significantly higher relative to controls but the difference dissipated by day 4. CONCLUSION: The increase in absolute values of cortisol and physiological parameters measurements, indicates that in the acute phase of mTBI, a stressful process is activated which may affect sleep quality as well.Supplemental data for this article is available online at at doi: 10.1080/00207454.2021.1951264.

Characteristics and Survival Rates in Ward Patients Requiring Evaluation by Intensivist in Greece.

INTRODUCTION: Patients at risk should be admitted to the ICU if there is room for improvement. Patients who have no room for improvement or the risk of death is either too high or too low should not be admitted to the ICU. AIM: To investigate ward patient characteristics, outcomes, and survival rates after an emergency call for evaluation by an intensivist. MATERIAL AND METHOD: This is a prospective observational study of patients hospitalized at a general hospital in Greece. A data recording form was completed by the investigators in order to collect the required data. RESULTS: 115 patients (58.3%, n = 67 men and 41.7%, n = 48 women) of mean age 67.1 ± 13.8 years (range 27-92 years) were evaluated by an intensivist and were recorded. 28.7% (n = 33) were hospitalized in a surgical clinic, 67% (n = 77) were hospitalized in internal medicine clinics (oncology), and 4.3% (n = 5) of the patients were treated in the emergency department, the radiotherapy department, or the radiology department. 73% (n = 84/115) of the patients were hospitalized in the ICU. Total survival rate was 49.6% (57/115). Of the 31 patients who did not enter the ICU (out of 115 patients), 15 survived (13% of the 115 patients or 48.4% of the 31 patients not admitted to the ICU). Five (5) of them had a cardiac arrest and either died without entering the ICU or continued their hospitalization in the ward. The survival rates of the patients not admitted to the ICU who continued hospitalization at the ward was 57.7% (15/26). Of the 84 patients admitted to the ICU, 42 survived (36.5% of the 115 patients or 50% of the 84 patients admitted to the ICU). CONCLUSIONS: The survival rates of these patients are quite low and possibly multifactorial due to the severity of the disease, the unnecessary call for an intensivist due to an irreversible condition, or the delayed call of an intensivist.

Validation of the Greek Version of Comfort-B, FLACC, and BPS Scales in Critically Ill Children and Their Association with Clinical Severity.

BACKGROUND: A variety of valid pediatric pain assessment tools are used in clinical practice globally; however, none have been validated for use in the Pediatric Intensive Care Unit (PICU) in Greece. Furthermore, the association between pain behavioral responses and clinical status is unclear. AIMS: To assess the reliability and validity of the Greek version of FLACC, Comfort B, and BPS pain scales in critically ill children and to explore their association with clinical severity (Denver MOF, PMODS) and levels of sedation and analgesia. METHODS: A methodological and descriptive correlational study was performed in a 6-bed PICU. A total of 60 observations in a sample of 30 children (mean age 4.1 years; 63.3% male) were obtained by 2 independent nurses during rest and painful procedures. At the same time, the bedside nurse assessed the child's pain intensity using the VASobs. RESULTS: High internal consistency and strong interrater reliability were detected (Cronbach's alpha ≥ .85; ICC > .95, p < .001). The agreement between observers was satisfactory (0.71 ≤ Kappa ≤ 0.96, p < .001). Strong correlations were found among the scales (0.65 ≤ rho ≤0 .98, p < .05). Increased pain scores (≥moderate pain) were observed during painful procedures regardless the administration of analgesia. Statistically significant correlations were found between clinical severity and the FLACC and Comfort B scores (-0.577 ≤ rho ≤ -0.384, p < .05). CONCLUSIONS: These pain tools were found to be suitable for this sample of children in Greece. Wider application of these tools in Greek PICUs and further research regarding their association with the clinical severity and the pain responses is required for the improvement of pain management in critically ill children.

Light affects heart rate's 24-h rhythmicity in intensive care unit patients: an observational study.

BACKGROUND: Intensive care unit (ICU) patients experience two affronts to normal 24-h rhythms: largely internal events such as medication and external factors such as light, noise and nursing interventions. AIMS AND OBJECTIVES: We investigated the impact of light variance within an ICU on 24-h rhythmicity of three key physiological parameters: heart rate (HR), mean arterial blood pressure (MAP) and body temperature (BT) in this patient population. DESIGN: Patients were assigned to beds either in the 'light' or 'dark' side within a single ICU. An actigraph continuously recorded light intensity for a 24-72-h period. METHODS: Measurements of HR, MAP and BT were recorded every 30 min. RESULTS: HR, MAP and BT did not follow 24-h rhythmicity in all patients. Higher light exposure in the Light Side of the ICU (122·3 versus 50·6 lx) was related to higher HR (89·4 versus 79·8 bpm), which may translate to clinically relevant outcomes in a larger sample. Duration of stay, the one clinical outcome measured in this study, showed no significant variation between the groups (p = 0·147). CONCLUSIONS: ICU patients are exposed to varying light intensities depending on bed positioning relative to natural sunlight, affecting the 24-h rhythm of HR. Larger, well-controlled studies also investigating the effect of relevant light intensity are indicated. RELEVANCE TO CLINICAL PRACTICE: Light is a variable that can be manipulated in the constrained environment of an ICU, thus offering an avenue for relatively unobtrusive interventions.

Methadone Gastrobezoar in a Psychiatric Patient Presented in Coma.

A 43-year-old psychiatric patient was transferred in coma and hypercapnic respiratory failure at the emergency department. He was intubated for airway protection and transferred to the Intensive Care Unit (ICU). Abdominal X-ray revealed a radiopaque mass; a pharmacobezoar was suspected and confirmed by gastroscopy; one large in the stomach fundus and a smaller one in the pylorus. Gastric lavage through the gastroscope and administration of gastro-kinetic drugs and laxatives were able to dilute the bezoars. Tablets retrieved from the stomach identified as methadone and toxicological tests of the gastric fluid confirmed the presence of methadone as the only organic chemical compound. The patient was extubated on the 7th day and released from the ICU on the 10th day under psychiatric consultation having normal vital signs. Methadone gastric bezoar may lead to persistent intoxication, respiratory failure, and coma requiring ICU care. Diagnosis may be difficult and a high index of suspicion is needed.

First Peripherally Inserted Central Catheter Under Ultrasound Guidance in a Greek Intensive Care Unit: A New Role for Greek Perianesthesia Nurses.

We present a case of a 67-year-old Caucasian female who was admitted to the pulmonary clinic of a general hospital in Athens with fever and respiratory symptoms. A lung biopsy was ordered because a clinical diagnosis of interstitial lung disease was suspected. The patient was then hospitalized in the intensive care unit. Because of the fact that peripheral catheterization was impossible and the prospect of further long-term hospitalization, the patient was referred to a vascular access nursing team composed of perianesthesia nurses to advance a peripherally inserted central catheter and support the line during treatment. The peripherally inserted central catheter line was advanced with no complications, and the position of the catheter was checked using the electrocardiography method.

Nursing Activities Score as a predictor of family satisfaction in an adult intensive care unit in Greece.

AIM: To study family satisfaction with care in an Intensive Care Unit (ICU) and its association with nursing workload estimated by the Nursing Activities Score (NAS). BACKGROUND: Few previous studies have investigated the association between workload in ICUs and family satisfaction. METHODS: Family Satisfaction ICU 24 (FS ICU-24) questionnaires were distributed to 161 family members (106 respondents). Questionnaires' score, NAS measurements and Simplified Acute Physiology Score II (SAPS-II) data were analysed. RESULTS: The mean total level of family satisfaction was equal to 80.72% (± 9.59). Family members were more satisfied with the level of care compared with decision making. NAS values revealed a shortage of nurses in the morning shift. Moreover, there was a statistically significant positive correlation between NAS and total satisfaction after adjusting for age, length of stay and SAPS-II. CONCLUSIONS: Improvements in clinical practice require the measurement of care quality which particularly includes family satisfaction. Our results indicated that family members were less satisfied with decision making. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should plan for the successful involvement of family members in the decision-making process. Higher levels of nurse staffing might improve the care provided.

The Effect of Pilates on Quality of Sleep, Aerobic Capacity and Anaerobic Power in Premenopausal Women.

Pilates is a holistic exercise focused on respiration, body control, and accuracy of movements, and it improves respiratory muscle strength, balance, quality of life, and overall physical performance. However, little is known about the effect of Pilates on sleep quality. The purpose of the present prospective observational study was to evaluate the effect of four months of Pilates training on the quality of sleep, aerobic capacity, and anaerobic power in premenopausal women. The sample consisted of 53 premenopausal women: one experimental group ( n = 40) and one control group ( n = 13). Participants in the experimental group received at least three one-hour sessions of Pilates exercise per week for 16 weeks. The two groups were similar at baseline. After 4 months of Pilates, the intervention group had significantly lower scores on the Athens Insomnia Scale, Epworth Sleepiness Scale, and autonomic arousal index compared to the baseline scores. The intervention group presented significant improvement in aerobic fitness, muscle strength, flexibility, balance, abdominal muscle endurance, as well as in the general health and social functioning subscales of the 36-Item Short Form Health Survey (SF-36). Pilates workouts appeared to improve sleep quality in premenopausal women, as well as the basic parameters of fitness and quality of life.

A higher tidal volume may be used for athletes according to measured FVC.

We investigated whether professional athletes may require higher tidal volume (Tv ) during mechanical ventilation hypothesizing that they have significantly higher "normal" lung volumes compared to what was predicted and to nonathletes. Measured and predicted spirometric values were recorded in both athletes and nonathletes using a Spirovit SP-1 spirometer (Schiller, Switzerland). Normal Tv (6 mL/kg of predicted body weight) was calculated as a percentage of measured and predicted forced vital capacity (FVC) and the difference (δ) was used to calculate the additional Tv required using the equation: New Tv(TvN) = Tv + (Tv × Î´). Professional athletes had significantly higher FVC compared to what was predicted (by 9% in females and 10% in males) and to nonathletes. They may also require a Tv of 6.6 mL/kg for males and 6.5 mL/kg for females during mechanical ventilation. Nonathletes may require a T v of 5.8 ± 0.1 mL/kg and 6.3 ± 0.1 mL/kg for males and females, respectively. Our findings show that athletes may require additional Tv of 10% (0.6/6 mL/kg) for males and 8.3% (0.5/6 mL/kg) for females during general anesthesia and critical care which needs to be further investigated and tested.

Quality of Life and Wellbeing Parameters of Academic Dental and Nursing Personnel vs. Quality of Services.

Quality of life (QOL) is based on one's perception of one's position in life with respect to one's goals, expectations, standards, and concerns. It is also influenced by one's culture and value system, workflow, and workplace situation; in turn, QOL influences the quality of service one is able to provide. In this study, we aim to report on dental and nursing academics' QOL and wellbeing at the end of the third year of the COVID-19 pandemic. There are several studies on the impact of the COVID-19 pandemic on health professionals (nurses and dentists), but it is important to investigate their quality of life three years later; furthermore, knowledge about academic staff is very limited. The World Health Organization Quality of Life-BREF Scale (WHOQOL-BREF) tool, recording the physical, psychological, social, and environmental dimensions of QOL, was used. The WHOQOL-BREF was modified using a spiritual coaching/mentoring approach in a two-step design and validation procedure. The modified SHQOL-BREF (Spiritual Healthcare version) designed for this study was uploaded and filled in online during April-June 2023. The staff (N = 120, 75% female) of the Departments of Dentistry (44.2%) and Nursing (55.8%) of the National and Kapodistrian University of Athens participated anonymously. QOL in terms of physical health was reported at a higher level (M = 72.2 points) compared to social relationships (M = 69 points), psychological health (M = 65 points), and environment (M = 59 points) (scores reported on a 0-100 scale). Overall, QOL was rated at 66 points, while satisfaction with one's health was at 72 points. Job satisfaction (M1 = 3.2) and spirituality (M2 = 3.0) were reported at a medium level on a five-point scale, while personal beliefs and values were reported at a high level (M3 = 4.0). The four areas of QOL are associated with job satisfaction, personal beliefs, and spirituality. Participant age presented a significant moderate-strong effect on physical health (F (3.97) = 2.89, p < 0.05, η2p = 0.08) and on the environment (F (3.97) = 2.80, p < 0.05, η2p = 0.08), and marital status had a significant effect on social relationships (F (1.97) = 9.66, p < 0.05, η2p = 0.09). Married participants reported consistently higher levels of QOL compared to single participants, for all age groups. The department had a significant moderate effect on social relationships (F (1.97) = 5.10, p < 0.05, η2p = 0.05), and education had a significant moderate-strong effect on psychological health (F (2.97) = 3.74, p < 0.05, η2p = 0.07). PhD-level participants in both departments presented higher levels of psychological health compared to those with lower educational levels. Also, participants from the Department of Dentistry reported higher levels of social relationship QOL in all educational groups compared to the Department of Nursing. Overall, according to our findings, PhD participants generally had better psychological health. Those under 40 years of age had higher levels of physical health and environmental quality of life, while married participants and those from the Department of Dentistry had higher levels of social interactions than those from the Department of Nursing. Strategic planning on sustainability and QOL initiatives should be introduced after the COVID-19 pandemic for dental and nursing academic personnel to promote resilience and QOL scores. Enhancing the QOL of academic staff is essential for developing health promotion activities at universities and can help boost performance among staff and students.

Aerosolized Antibiotics to Manage Ventilator-Associated Infections: A Comprehensive Review.

BACKGROUND: Ventilator-associated lower respiratory tract infectious complications in critically ill patients cover a wide spectrum of one disease process (respiratory infection), initiating from tracheal tube and/or tracheobronchial colonization, to ventilator associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). VAP occurence has been associated with increased intensive care unit (ICU) morbidity (ventilator days, as well as length of ICU and hospital stay) and ICU mortality. Therefore, treatments that aim at VAP/VAT incidence reduction are a high priority. AIM: The aim of the present review is to discuss the current literature concerning two major aspects: (a) can aerosolized antibiotics (AA) administered in a pre-emptive way prevent the occurrence of ventilator-associated infections? and (b) can VAT treatment with aerosolized avert the potential evolution to VAP? RESULTS: There were identified eight studies that provided data on the use of aerosolized antibiotics for the prevention of VAT/VAP. Most of them report favorable data on reducing the colonisation rate and the progression to VAP/VAT. Another four studies dealt with the treatment of VAT/VAP. The results support the decrease in the incidence to VAP transition and/or the improvement in signs and symptoms of VAP. Moreover, there are concise reports on higher cure rates and microbiological eradication in patients treated with aerosolized antibiotics. Yet, differences in the delivery modality adopted and resistance emergence issues preclude the generalisability of the results. CONCLUSION: Aerosolized antibiotic therapy can be used to manage ventilator-associated infections, especially those with difficult to treat resistance. The limited clinical data raise the need for large randomized controlled trials to confirm the benefits of AA and to evaluate the impact on antibiotic selection pressure.

The Impact of Care Bundles on Ventilator-Associated Pneumonia (VAP) Prevention in Adult ICUs: A Systematic Review.

Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We aimed to identify the combined interventions that have been used to by ICUs worldwide from the implementation of "Institute for Healthcare Improvement Ventilator Bundle", i.e., from December 2004. A search was performed on the PubMed, Scopus and Science Direct databases. Finally, 38 studies met our inclusion criteria. The most common interventions monitored in the care bundles were sedation and weaning protocols, semi-recumbent positioning, oral and hand hygiene, peptic ulcer disease and deep venus thrombosis prophylaxis, subglottic suctioning, and cuff pressure control. Head-of-bed elevation was implemented by almost all studies, followed by oral hygiene, which was the second extensively used intervention. Four studies indicated a low VAP reduction, while 22 studies found an over 36% VAP decline, and in ten of them, the decrease was over 65%. Four of these studies indicated zero or nearly zero after intervention VAP rates. The studies with the highest VAP reduction adopted the "IHI Ventilator Bundle" combined with adequate endotracheal tube cuff pressure and subglottic suctioning. Multifaced techniques can lead to VAP reduction at a great extent. Multidisciplinary measures combined with long-lasting education programs and measurement of bundle's compliance should be the gold standard combination.

Practices and educational needs of Hellenic Police Officers in providing first aid/cardiopulmonary resuscitation: A cross-sectional survey.

BACKGROUND: It is well known that police officers (POs) are expected to be the first responders in emergency cases requiring First Aid (FA) such as cardiac arrest. OBJECTIVE: Description of practices and educational needs of Hellenic POs in providing FA/Cardiopulmonary Resuscitation (CPR) in case of medical emergencies and description of the equipment of professional FA kit. METHODS: An anonymous cross-sectional survey was conducted from January 1, 2016, to December 31, 2017, using a self-administered questionnaire designed to serve the purposes of this particular survey. The instrument consisted of 53 questions (multiple choice and open-ended questions) administered in a convenience sample of 700 POs of the Attica prefecture. RESULTS: A sample of 520 POs (constables and lieutenants) completed the questionnaire (response rate = 74.28%). Among the participants, 248 (47.7 %) declared that they had provided FA/CPR in the past, while among those declaring that they had never provided FA/PCR (n = 248), 153 (61.7%) said that they had experienced FA/CPR needs, but did not know what they had to do. Moreover, only 18.1% (94/520) of the POs answered that they have FA equipment in their professional equipment, which mainly includes bandages (54/94, 57.4%), while 29.7% of POs provided answers about their educational needs (313 in total) declared that they would like to be educated in bleeding control. CONCLUSION: There is a need to educate and train Greek POs in first aid and CPR in an organized and mandatory way in order to meet emergency needs.

Using Machine Learning to Predict Antimicrobial Resistance-A Literature Review.

Machine learning (ML) algorithms are increasingly applied in medical research and in healthcare, gradually improving clinical practice. Among various applications of these novel methods, their usage in the combat against antimicrobial resistance (AMR) is one of the most crucial areas of interest, as increasing resistance to antibiotics and management of difficult-to-treat multidrug-resistant infections are significant challenges for most countries worldwide, with life-threatening consequences. As antibiotic efficacy and treatment options decrease, the need for implementation of multimodal antibiotic stewardship programs is of utmost importance in order to restrict antibiotic misuse and prevent further aggravation of the AMR problem. Both supervised and unsupervised machine learning tools have been successfully used to predict early antibiotic resistance, and thus support clinicians in selecting appropriate therapy. In this paper, we reviewed the existing literature on machine learning and artificial intelligence (AI) in general in conjunction with antimicrobial resistance prediction. This is a narrative review, where we discuss the applications of ML methods in the field of AMR and their value as a complementary tool in the antibiotic stewardship practice, mainly from the clinician's point of view.

Rare roentgenologic manifestations of pulmonary edema.

PURPOSE OF REVIEW: Unilateral pulmonary edema (UPE) is an unusual manifestation of pulmonary edema that is frequently confused with other causes of unilateral alveolar and interstitial infiltrates. Until now limited data existed regarding the prevalence, cause, and outcome of patients presenting with cardiogenic UPE. The purpose of this review is to give insights into this rare entity. RECENT FINDINGS: In a recent retrospective study, the prevalence of UPE was 2.1% of all cases of cardiogenic pulmonary edema. UPE was right-sided in 89%. All patients with UPE had severe mitral regurgitation. In patients with UPE, blood pressure was significantly lower, whereas noninvasive or invasive ventilation and catecholamines were used more frequently compared with patients with bilateral pulmonary edema. In-hospital mortality was higher for patients with UPE (39 vs. 8% for bilateral pulmonary edema) and UPE was independently related to death (a 6.5-fold higher risk of death). Delayed treatment of UPE could be one of the explanations for this increased mortality. SUMMARY: UPE is not that rare as considered to be and is mostly related to severe organic or functional mitral regurgitation. Probably because of initial misdiagnosis and delayed appropriate treatment, UPE is related to increased mortality. History, absence of signs of infection, and elevated serum cardiac markers such as B-natriuretic peptide may help to differentiate UPE from other diagnoses. The key examination remains bedside transthoracic echocardiography, although transesophageal echocardiography can also provide additional information regarding the severity and mechanism of mitral regurgitation and documentation of the differential pressure between the right and left pulmonary veins.

Increased blood troponin levels in ICU patients.

PURPOSE OF REVIEW: Cardiac troponins in serum have become the biomarkers of choice for the diagnosis of myocardial infarction. Yet, troponin can also be elevated by a multitude of causes in the absence of overt myocardial ischemia. Such nonspecific elevations are particularly common in the critically ill. This article aims to provide information on the significance of troponin elevations in unselected critically ill patients and in patients with sepsis or septic shock. RECENT FINDINGS: Recent studies reconsider the possible association of troponin elevations with myocardial infarction in unselected critically ill patients. There are also more data on the prognostic significance of troponin in this population. In patients with sepsis, recent studies suggest that troponin may be a reliable index of sepsis-induced myocardial dysfunction, although the implications of this finding in the management of sepsis remain unclear for the time being. Troponin also appears to be a predictor of short and possibly also long-term outcome in septic patients. The advent of newer assays with even higher sensitivity, may lead to further redefinition of the role of troponin in the ICU. SUMMARY: Troponin is frequently elevated in critically ill patients. More research is needed on the diagnostic and prognostic significance and possible clinical applications of troponin measurements in patients with sepsis and critical illness.

Validity and reliability evidence of the Asthma Control Test--ACT in Greece.

BACKGROUND: The dimensionality of the Asthma Control Test (ACT) was examined in two counterview studies. Up to now, the ACT has not been validated for the Greek asthma patients. OBJECTIVE: The present study was designed to examine the validity and reliability of the ACT responses in Greek asthma outpatients under a specialist's care. STUDY DESIGN: Following evidence for sample-specific validity, the ACT (n = 100) was examined through construct, cross-sectional, convergent, and discriminant validity as well as internal consistency and test-retest reliability [root mean squared error of approximation (RMSEA)]. RESULTS: A one-factor solution fit the data [χ(2) (chi-square) = 3.899, df (degrees of freedom) 5, ns, RMSEA <0.001]. The ACT showed a high internal consistency (Cronbach alpha = 0.72) and a high 2 months test-retest reliability (IR = 0.85) for the total sample. Significant differences were found between the five categories of asthma control patients (not controlled at all, poorly controlled, somewhat controlled, well controlled, and completely controlled), according to the specialists' rating, for the ACT (p < .001). Significant differences were found between patients with and without asthma control (p = .001), patients of different gender (p = .05), educational status (p = .05), mean year income (p = .01), body mass index (p = .05), follow-up visits (p = .01), as well as among patients of different age (p < .001) and severity (p < .001). An ACT score of 19 or less provided optimum balance of sensitivity (98.46) and specificity (88.57) for screening 'not controlled' asthma. Cross-sectional validity testing showed moderate correlation of the ACT score with FEV1% predicted (r = 0.57, p < .001) and disability (r = -0.42, p < .001) and moderately high correlation with dyspnea (r = -0.71, p < .001). Convergent validity testing showed that the ACT score was correlated with the specialists' rating (r = 0.89, p < .001). CONCLUSION: The ACT is valid and reliable in Greek outpatients with asthma under a specialist's care.

The effect of physiotherapy-based breathing retraining on asthma control.

BACKGROUND: The mechanism of the breathing retraining effect on asthma control is not adequately based on evidence. OBJECTIVE: The present study was designed to evaluate the effect of physiotherapy-based breathing retraining on asthma control and on asthma physiological indices across time. STUDY DESIGN: A 6-month controlled study was conducted. Adult patients with stable, mild to moderate asthma (n = 40), under the same specialist's care, were randomized either to be trained as one group receiving 12 individual breathing retraining sessions (n = 20), or to have usual asthma care (n = 20). The main outcome was the Asthma Control Test score, with secondary outcomes the end-tidal carbon dioxide, respiratory rate, spirometry, and the scores of Nijmegen Hyperventilation Questionnaire, Medical Research Council scale, and SF-36v2 quality-of-life questionnaire. RESULTS: The 2 × 4 ANOVA showed significant interaction between intervention and time in asthma control (F = 9.03, p < .001, η(2) = 0.19), end-tidal carbon dioxide (p < .001), respiratory rate (p < .001), symptoms of hypocapnia (p = .001), FEV1% predicted (p = .022), and breathlessness disability (p = .023). The 2 × 4 MANOVA showed significant interaction between intervention and time, with respect to the two components of the SF-36v2 (p < .001). CONCLUSION: Breathing retraining resulted in improvement not only in asthma control but in physiological indices across time as well. Further studies are needed to confirm the benefits of this training in order to help patients with stable asthma achieve the control of their disease.

COVID-19-Associated Pulmonary Aspergillosis (CAPA).

Invasive Pulmonary Aspergillosis (IPA) has been recognized as a possible secondary infection complicating Coronavirus disease 2019 (COVID-19) and increasing mortality. The aim of this review was to report and summarize the available data in the literature concerning the incidence, pathophysiology, diagnosis, and treatment of COVID-19-Associated Pulmonary Aspergillosis (CAPA). Currently, the incidence of CAPA is unclear due to different definitions and diagnostic criteria used among the studies. It was estimated that approximately 8.6% (206/2383) of mechanically ventilated patients were diagnosed with either proven, probable, or putative CAPA. Classical host factors of invasive aspergillosis are rarely recognized in patients with CAPA, who are mainly immuno-competent presenting with comorbidities, while the role of steroids warrants further investigation. Direct epithelial injury and diffuse pulmonary micro thrombi in combination with immune dysregulation, hyper inflammatory response, and immunosuppressive treatment may be implicated. Discrimination between two forms of CAPA (e.g., tracheobronchial and parenchymal) is required, whereas radiological signs of aspergillosis are not typically evident in patients with severe COVID-19 pneumonia. In previous studies, the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria, a clinical algorithm to diagnose Invasive Pulmonary Aspergillosis in intensive care unit patients (AspICU algorithm), and influenza-associated pulmonary aspergillosis (IAPA) criteria were used for the diagnosis of proven/probable and putative CAPA, as well as the differentiation from colonization, which can be challenging. Aspergillus fumigatus is the most commonly isolated pathogen in respiratory cultures. Bronchoalveolar lavage (BAL) and serum galactomannan (GM), ß-d-glucan (with limited specificity), polymerase chain reaction (PCR), and Aspergillus-specific lateral-flow device test can be included in the diagnostic work-up; however, these approaches are characterized by low sensitivity. Early treatment of CAPA is necessary, and 71.4% (135/189) of patients received antifungal therapy, mainly with voriconazole, isavuconazole, and liposomal amphotericin B . Given the high mortality rate among patients with Aspergillus infection, the administration of prophylactic treatment is debated. In conclusion, different diagnostic strategies are necessary to differentiate colonization from bronchial or parenchymal infection in intubated COVID-19 patients with Aspergillus spp. in their respiratory specimens vs. those not infected with severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). Following confirmation, voriconazole or isavuconazole should be used for the treatment of CAPA.