Smoking is a predictor of worse trabecular mechanical performance in hip fragility fracture patients.

Clinical risk factors (CRFs) are established predictors of fracture events. However, the influence of individual CRFs on trabecular mechanical fragility is still a subject of debate. In this study, we aimed to assess differences, adjusted for CRFs, between bone macrostructural parameters measured in ex-vivo specimens from hip fragility fracture patients and osteoarthritis patients, and to determine whether individual CRFs could predict trabecular bone mechanical behavior in hip fragility fractures. Additionally, we also looked for associations between the 10-year risk of major and hip fracture calculated by FRAX and trabecular bone mechanical performance. In this case-control study, a group of fragility fracture patients were compared with a group of osteoarthritis patients, both having undergone hip replacement surgery. A clinical protocol was applied in order to collect CRFs [body mass index (BMI), prior fragility fracture, parental history of hip fracture, long-term use of oral glucocorticoids, rheumatoid arthritis, current smoking, alcohol consumption, age and gender]. The 10-year probability of fracture was calculated. Serum bone turnover markers were determined and dual X-ray absorptiometry performed. Femoral head diameter was evaluated and trabecular bone cylinders were drilled for mechanical testing to determine bone strength, stiffness and toughness. We evaluated 40 hip fragility fracture and 52 osteoarthritis patients. Trabecular bone stiffness was significantly lower (p = 0.042) in hip fragility fracture patients when compared to osteoarthritic individuals, adjusted for age, gender and BMI. No other macrostructural parameter was statistically different between the groups. In hip fragility fracture patients, smoking habits (ß = -0.403; p = 0.018) and female gender (ß = -0.416; p = 0.008) were independently associated with lower stiffness. In addition, smoking was also independently associated with worse trabecular strength (ß = -0.323; p = 0.045), and toughness (ß = -0.403; p = 0.018). In these patients, the 10-year risk of major (r = -0.550; p = 0.012) and hip fracture (r = -0.513; p = 0.021) calculated using only CRFs was strongly correlated with femoral neck bone mineral density but not with mechanical performance. Our data showed that among fragility fracture patients active smoking is a predictor of worse intrinsic trabecular mechanical performance, and female gender is also independently associated with lower stiffness. In this population, the 10-year risk of fracture using CRFs with different weights only reflects bone mass loss but not trabecular mechanical properties.

Elevated Extravascular Lung Water Index (ELWI) as a Predictor of Failure of Continuous Positive Airway Pressure Via Helmet (Helmet-CPAP) in Patients With Acute Respiratory Failure After Major Surgery.

INTRODUCTION: NIV is increasingly used for prevention and treatment of respiratory complications and failure. Some of them are admitted to the PACU with advanced hemodynamic monitors which allow quantification of Extravascular Lung Water (EVLW) by transpulmonary thermodilution technique (TPTD) and Pulmonary Vascular Permeability (PVP) providing information on lung edema. AIM: The objective of this study was to ascertain if EVLW Index and PVP Index may predict failure (intubation) or success (non-intubation) in patients developing acute respiratory failure (ARF) in the postoperative period following major abdominal surgery, where the first line of treatment was non-invasive continuous positive airway pressure via a helmet. METHODS: Hemodynamic variables, EVLWI and PVPI were monitored with a transpulmonary thermodilution hemodynamic monitor device (PiCCO™) before and after the application of CPAP. RESULTS: Avoidance of intubation was observed in 66% of patients with Helmet-CPAP. In these patients after the first hour of application of CPAP, PaO2/FiO2 ratio significantly increased (303.33±65.2 vs. 141.6±14.6, P<.01). Before starting Helmet-CPAP values of EVLWI and PVPI were significantly lower in non-intubated patients (EVLWI 8.6±1.08 vs. 11.8±0.99ml/kg IBW, P<.01 and PVPI 1.7±0.56 vs. 3.0±0.88, P<.01). An optimal cut-off value for EVLWI was established at 9.5, and at 2.45 for PVPI (sensitivity of 0.7; specificity of 0.9, P<.01). CONCLUSION: In this type of patient the physiological parameters that predict the failure of Helmet-CPAP with the greatest accuracy were the value of the EVLWI and PVPI before Helmet-CPAP institution and the PaO2/FiO2 ratio and the respiratory rate after one hour of CPAP.

La elevación del índice de agua pulmonar extravascular como factor predictivo del fracaso de la presión continua en la vía aérea con casco (CPAP-Helmet) en pacientes con insuficiencia respiratoria aguda tras intervención quirúrgica mayor / Elevated Extravascular Lung Water Index (ELWI) as a Predictor of Failure of Continuous Positive Airway Pressure Via Helmet (Helmet-CPAP) in Patients With Acute Respiratory Failure After Major Surgery

Introducción: La ventilación no invasiva (VNI) se utiliza cada vez más para la prevención y el tratamiento de las complicaciones y la insuficiencia respiratorias. Algunos pacientes ingresan en las unidades de reanimación postanestésica portando monitores hemodinámicos avanzados que permiten cuantificar el agua pulmonar extravascular (EVLW) mediante la técnica de termodilución transpulmonar y la permeabilidad vascular pulmonar (PVP), parámetros que permiten obtener información sobre el edema pulmonar. Objetivo: El objetivo de este estudio fue determinar si el índice de EVLW y el índice de la PVP pueden pronosticar el fracaso (intubación) o el éxito (no intubación) en pacientes que desarrollan insuficiencia respiratoria aguda (IRA) durante el período postoperatorio de una intervención quirúrgica mayor abdominal y cuyo tratamiento de primera línea es la presión positiva continua en la vía aérea (CPAP) administrada mediante casco (CPAP-Helmet). Métodos: Se monitorizaron las variables hemodinámicas, el índice de agua pulmonar extravascular (EVLWI) y el índice de permeabilidad vascular pulmonar (PVPI) mediante un dispositivo de monitorización hemodinámica de termodilución transpulmonar (PiCCO(TM)), antes y después de la aplicación de la CPAP. Resultados: En un 66% de los pacientes con CPAP-Helmet se evitó la intubación. En dichos pacientes, el cociente PaO2/FiO2 aumentó de forma significativa (303,33 ± 65,2 vs. 141,6 ± 14,6, p < 0,01) tras la primera hora de aplicación de la CPAP. Antes de iniciar la CPAP-Helmet los valores de EVLWI y PVPI eran significativamente inferiores en los pacientes no intubados (EVLWI 8,6 ± 1,08 vs. 11,8 ± 0,99 ml/kg de peso corporal ideal (PCI), p < 0,01 y PVPI 1,7 ± 0,56 vs. 3,0 ± 0,88, p < 0,01). Se establecieron unos valores de corte óptimos de 9,5 para el EVLWI y de 2,45 para el PVPI (sensibilidad de 0,7; especificidad de 0,9, p < 0,01). Conclusión: En este tipo de pacientes, los parámetros fisiológicos que pronosticaron el fracaso de la CPAP-Helmet con mayor precisión fueron el EVLWI y el PVPI previos al inicio de la CPAP-Helmet, el cociente PaO2/FiO2 y la frecuencia respiratoria tras una hora de CPAP

Introduction: NIV is increasingly used for prevention and treatment of respiratory complications and failure. Some of them are admitted to the PACU with advanced hemodynamic monitors which allow quantification of Extravascular Lung Water (EVLW) by transpulmonary thermodilution technique (TPTD) and Pulmonary Vascular Permeability (PVP) providing information on lung edema. Aim: The objective of this study was to ascertain if EVLW Index and PVP Index may predict failure (intubation) or success (non-intubation) in patients developing acute respiratory failure (ARF) in the postoperative period following major abdominal surgery, where the first line of treatment was non-invasive continuous positive airway pressure via a helmet. Methods: Hemodynamic variables, EVLWI and PVPI were monitored with a transpulmonary thermodilution hemodynamic monitor device (PiCCO(TM)) before and after the application of CPAP. Results: Avoidance of intubation was observed in 66% of patients with Helmet-CPAP. In these patients after the first hour of application of CPAP, PaO2/FiO2 ratio significantly increased (303.33 ± 65.2 vs. 141.6 ± 14.6, P < .01). Before starting Helmet-CPAP values of EVLWI and PVPI were significantly lower in non-intubated patients (EVLWI 8.6 ± 1.08 vs. 11.8 ± 0.99 ml/kg IBW, P < .01 and PVPI 1.7 ± 0.56 vs. 3.0 ± 0.88, P < .01). An optimal cut-off value for EVLWI was established at 9.5, and at 2.45 for PVPI (sensitivity of 0.7; specificity of 0.9, P < .01). Conclusion: In this type of patient the physiological parameters that predict the failure of Helmet-CPAP with the greatest accuracy were the value of the EVLWI and PVPI before Helmet-CPAP institution and the PaO2/FiO2 ratio and the respiratory rate after one hour of CPAP