Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs).

BACKGROUND: Although patients with advanced or metastatic lung cancer have poor prognosis, admission to the ICU for management of life-threatening complications has increased over the years. Patients with newly diagnosed lung cancer appear as good candidates for ICU admission, but more robust information to assist decisions is lacking. The aim of our study was to evaluate the prognosis of newly diagnosed unresectable lung cancer patients. METHODS: A retrospective multicentric study analyzed the outcome of patients admitted to the ICU with a newly diagnosed lung cancer (diagnosis within the month) between 2010 and 2013. RESULTS: Out of the 100 patients, 30 had small cell lung cancer (SCLC) and 70 had non-small cell lung cancer. (Thirty patients had already been treated with oncologic treatments.) Mechanical ventilation (MV) was performed for 81 patients. Seventeen patients received emergency chemotherapy during their ICU stay. ICU, hospital, 3- and 6-month mortality were, respectively, 47, 60, 67 and 71%. Hospital mortality was 60% when invasive MV was used alone, 71% when MV and vasopressors were needed and 83% when MV, vasopressors and hemodialysis were required. In multivariate analysis, hospital mortality was associated with metastatic disease (OR 4.22 [1.4-12.4]; p = 0.008), need for invasive MV (OR 4.20 [1.11-16.2]; p = 0.030), while chemotherapy in ICU was associated with survival (OR 0.23, [0.07-0.81]; p = 0.020). CONCLUSION: This study shows that ICU management can be appropriate for selected newly diagnosed patients with advanced lung cancer, and chemotherapy might improve outcome for patients with SCLC admitted for cancer-related complications. Nevertheless, tumors' characteristics, numbers and types of organ dysfunction should be taken into account in the decisional process before admitting these patients in ICU.

Sobre la espectroscopía vibracional en el diagnóstico de la enfermedad de Alzheimer / About the vibrational spectroscopy in the diagnosis of Alzheimer's disease

La espectroscopía vibracional de correlación bidimensional surge como una técnica alternativa para la detección de cambios relativamente pequeños en la composición y/o estructura molecular de sistemas biológicos complejos como es el plasma sanguíneo, derivados de procesos patológicos, físicos y químicos que tienen lugar en el organismo. En este trabajo se describen los principales conceptos que se consideran en el uso de la espectroscopía infrarroja y Raman en su modalidad bidimensional y su aplicación en la búsqueda de marcadores para el diagnóstico de la enfermedad de Alzheimer. Asimismo se describen algunos ejemplos de representación de marcadores espectrales en curvas ROC indicativas de un grado de exactitud en la clasificación de muestras superior al 80%

Two-dimensional correlation vibrational spectroscopy is emerging as an alternative technique to detect relatively small alterations in composition and molecular structure of complex biological systems such as blood plasma resulting from pathological, physical and chemical processes occuring in body. In this paper the main concepts considered in the use of infrared and Raman spectroscopies in their two-dimensional form and their application in the search for markers for the diagnosis of Alzheimer’s disease are described. Some examples of representation of spectral markers in ROC curves showing accuracies in classifications of samples greater than 80% are also discussed

Intensive care in patients with lung cancer: a multinational study.

BACKGROUND: Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs. PATIENTS AND METHODS: Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality. RESULTS: Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge. CONCLUSIONS: ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option.

Systematic approach for severe respiratory failure due to novel A (H1N1) influenza.

AIM: In April 2009, a novel influenza A (H1N1) virus appeared in Mexico. It rapidly acquired the characteristics of a pandemic disease. Our objective is to present a case series of mechanically ventilated patients with severe influenza, treated with a systematic approach. METHODS: Prospective, observational, single-center study in a University Hospital. A (H1N1) virus was confirmed by rRT-PCR. In this report, we only considered patients that required mechanical ventilation (MV). All patients received antibiotics, steroids and oseltamivir from the time of admission. The main strategies incorporated in the systematic approach were a lung-protective strategy, PEEP adjusted for each patient, protocol-guided sedoanalgesia, restrictive fluid management, weaning protocol, and prolonged prone ventilation and extracorporeal membrane oxygenation (ECMO) as rescue therapies. RESULTS: We studied 19 patients: age 41 ± 13 years old, APACHE II 16 ± 7 and SOFA 8 ± 4. All patients presented PaO2/FiO2 ≤ 200 before connection to MV. Their worst values within the first 24 hours for oxygenation index, PaO2/FiO2, and PaCO2 on MV were 21.8 ± 13, 98 ± 39, and 48 ± 16 mmHg, respectively. Sixteen patients achieved ARDS; three exhibited acute lung injury criteria. Ten required a prone position, and two required ECMO (one patient required both therapies). Time on MV was 16 ± 13 days. Length of stay in the ICU and in hospital was 18 ± 12 and 28 ± 17 days, respectively. Mortality was 21%. CONCLUSION: Severe hypoxemia and a high rate of rescue therapies were observed among our patients. Nevertheless, mortality was lower than previously reported in comparable populations, which may be related to the management by a critical care team and the use of a systematic approach for ventilatory and non-ventilatory therapeutic strategies.

Efectos de la ventilación en posición prono extendida en SDRA secundario a influenza A(H1N1) / Impact of extended prone position ventilation in patients with severe ARDS secondary to influenza A(H1N1)

Introducción: Durante la pandemia por influenza A(H1N1), Chile alcanzó una de las tasas de casos más alta del mundo. Nuestro hospital recibió numerosos afectados el 2009 y 2010. Evaluamos el impacto de ventilación en posición prono (VPP) extendida, en las variables respiratorias de pacientes con SDRA grave secundario a influenza, y comparamos estos resultados con los obtenidos en otras series de VPP. Métodos: Estudio prospectivo, intervencional en UCI. Los pacientes recibieron oseltamivir y antibióticos y fueron manejados según protocolos (ventilatorio y no ventilatorio). Aquellos con criterios de SDRA grave fueron pronados hasta un índice de oxigenación <10. Se registraron parámetros de intercambio gaseoso, ventilatorios y desenlaces clínicos. Resultados: 12 pacientes con SDRA grave (edad 46+/-12 años, 7 hombres, APACHE II 17+/-6, SOFA 9+/-3) requirieron VPP, que se instauró a las 14(7-39) horas de ventilación mecánica (VM) y se mantuvo por 72(54-96) horas. Ningún paciente experimentó complicaciones mayores. La PaO2:FiO2 mejoró de 82(63-101) mmHg a 145(138-223) mmHg, (p<0.001). El tiempo en VM fue 20+/-13 días y en UCI 22+/-13 días. La mortalidad hospitalaria fue 25 por ciento y no cambió en el seguimiento de más de 8 meses. Este comportamiento con VPP fue similar al observado en otras series de SDRA grave. Conclusión: Los resultados obtenidos sugieren que la VPP resultó segura y se asoció a mejoría del intercambio gaseoso en pacientes con SDRA por influenza A(H1N1). Aunque el número reducido de pacientes no permite sacar mayores conclusiones, la VPP extendida podría ser de utilidad en los casos más graves causados por esta nueva influenza.

Introduction: During pandemic for influenza A(H1N1), Chile achieved one of the highest rates of infection worldwide. On 2009 and 2010, our hospital received a large number of infected patients. We evaluated the impact of extended prone position ventilation (PPV) on respiratory variables from severe ARDS patients secondary to this influenza. We also compared these results with those obtained with PPV in other series. Methods: Prospective, interventional study, performed in a mixed-ICU. Patients received oseltamivir and antibiotics, and were treated according to protocols (ventilatory and non-ventilatory). Severe ARDS patients were proned until oxygenation index was < 10. Oxygen exchange, ventilatory parameters and clinical outcomes were registered. Results: 12 severe ARDS patients (46+/-12 y.o., 7 men, APACHE II 17+/-6, SOFA 9+/-3) required PPV, which was started 14(7-39) hours after mechanical ventilation (MV) initiation, and it was maintained for 72(54-96) straight hours. No major complication was described. Three patients needed two periods of PPV. PaO2:FiO2 improved significantly with PPV from 82(63-101) mmHg to 145(138-223) mmHg, (p<0.001). Time on MV was 20+/-13 days, and LOS in UCI was 22+/-13 days. Hospital mortality was25 percent and remained unchanged for at least 8 month of follow-up. PPV had the same effect than in other severe ARDS series. Conclusion: Our results suggest PPV is safe and it was associated with improvement in oxygen exchange in ARDS secondary to A(H1N1) influenza. Although the small number of patients does not allow drawing any major conclusion, we believe PPV can be useful to treat severe ARDS cases due to influenza infection.

Método para la evaluación de la confusión en la unidad de cuidados intensivos para el diagnóstico de delírium: adaptación cultural y validación de la versión en idioma español / Confusion assessment method for diagnosing delirium in ICU patients (CAM-ICU): Cultural adaptation and validation of the Spanish version

Objetivo: Realizar la adaptación cultural y la validación del CAM-ICU (Confusion Assessment Method for the Intensive Care Unit «método para la evaluación de la confusión en la unidad de cuidados intensivos») al idioma español para el diagnóstico de delírium. Diseño: Población de validación. Ámbito: La unidad de cuidados intensivos de un hospital universitario de tercer nivel con 600 camas. Pacientes: Veintinueve pacientes críticos que reciben ventilación mecánica. Edad: 70 años (58-77), APACHE II: 16 (13-21) y SOFA: 7 (4-8). Intervención: Aplicación del CAM-ICU en idioma español por 2 operadores independientes y del DSM IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Revised) por un psiquiatra. Variables de interés principales: Concordancia (índice κ), consistencia interna (alfa de Cronbach) y validez (sensibilidad y especificidad) del CAM-ICU en idioma español en relación con el estándar de referencia (DSM IV TR). Resultados: El proceso de traducción y adaptación cultural se desarrolló de acuerdo con las recomendaciones internacionales actualmente vigentes. Se realizó un total de 65 evaluaciones en los 29 pacientes. La concordancia entre los observadores alcanzó un índice K de 0,91 (IC del 95%: 0,86 a 0,96). La consistencia interna del instrumento fue adecuada y alcanzó un alfa de Cronbach de 0,84 (IC del 95% unilateral: 0,77). La sensibilidad del CAM-ICU versión española para el observador A (médico) fue del 80%, con una especificidad del 96%. En tanto que para el observador B (enfermera), la sensibilidad fue del 83%, con una especificidad del 96%. Conclusiones: El CAM-ICU en idioma español es un instrumento válido, confiable y reproducible, que puede aplicarse satisfactoriamente para el diagnóstico de delírium en pacientes de habla hispana (AU)

Objective: To adapt the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium to the language and culture of Spain and to validate the adapted version. Design: Population validation. Setting: Intensive care units in a 600-bed university hospital. Patients: We studied 29 critical patients undergoing mechanical ventilation. Mean age was 70 years (range 58-77 years), mean APACHE II score 16 (range 13-21), and mean SOFA score 7 (range 4-8). Intervention: Two independent operators applied the Spanish version of the CAM-ICU and a psychiatrist applied the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Revised (DSM IV TR). Main outcome variables: Concordance (kappa index), internal consistency (Cronbach's alpha), and validity (sensitivity and specificity) of the Spanish version of the CAM-ICU were compared to the DSM IV TR, which is considered the current gold standard. Results: The translation and cultural adaptation was carried out in accordance with current international guidelines. A total of 65 assessments were performed in 29 patients. The interobserver concordance was high: kappa statistic 0.91 (95% CI: 0.86-0.96). The internal consistence was adequate: Cronbach's alpha=0.84 (unilateral 95% CI: 0.77). For observer A (a physician), the sensitivity of the Spanish version of the CAM-ICU was 80% and the specificity was 96%. For observer B, (a nurse) the sensitivity was 83% and the specificity was 96%. Conclusions: The Spanish version of the CAM-ICU is a valid, reliable, and reproducible instrument that can be satisfactorily applied to diagnose delirium in Spanish-speaking ICU patients (AU)

[Confusion Assessment Method for diagnosing delirium in ICU patients (CAM-ICU): cultural adaptation and validation of the Spanish version]. / Método para la evaluación de la confusión en la unidad de cuidados intensivos para el diagnóstico de delírium: adaptación cultural y validación de la versión en idioma español.

OBJECTIVE: To adapt the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium to the language and culture of Spain and to validate the adapted version. DESIGN: Population validation. SETTING: Intensive care units in a 600-bed university hospital. PATIENTS: We studied 29 critical patients undergoing mechanical ventilation. Mean age was 70 years (range 58-77 years), mean APACHE II score 16 (range 13-21), and mean SOFA score 7 (range 4-8). INTERVENTION: Two independent operators applied the Spanish version of the CAM-ICU and a psychiatrist applied the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Revised (DSM IV TR). MAIN OUTCOME VARIABLES: Concordance (kappa index), internal consistency (Cronbach's alpha), and validity (sensitivity and specificity) of the Spanish version of the CAM-ICU were compared to the DSM IV TR, which is considered the current gold standard. RESULTS: The translation and cultural adaptation was carried out in accordance with current international guidelines. A total of 65 assessments were performed in 29 patients. The interobserver concordance was high: kappa statistic 0.91 (95% CI: 0.86-0.96). The internal consistence was adequate: Cronbach's alpha=0.84 (unilateral 95% CI: 0.77). For observer A (a physician), the sensitivity of the Spanish version of the CAM-ICU was 80% and the specificity was 96%. For observer B, (a nurse) the sensitivity was 83% and the specificity was 96%. CONCLUSIONS: The Spanish version of the CAM-ICU is a valid, reliable, and reproducible instrument that can be satisfactorily applied to diagnose delirium in Spanish-speaking ICU patients.

[Characteristics and impact of sedation, analgesia, and neuromuscular blockage in critical patients undergoing prolonged mechanical ventilation]. / Características e impacto de la sedación, la analgesia y el bloqueo neuromuscular en los pacientes críticos que recibieron ventilación mecánica prolongada.

AIM: To describe use of sedatives, analgesics, and neuromuscular blockers (NMB) in patients undergoing long-term mechanical ventilation and to assess factors associated with their use and their association with mortality at 28 days. DESIGN: Prospective observational multicenter cohort study. SETTING: Thirteen intensive care units (ICU) in Chile. PATIENTS: Patients undergoing mechanical ventilation for more than 48h. We excluded patients with neurological disorders, cirrhosis of the liver, chronic renal failure, suspected drug addiction, and early no resuscitation orders. INTERVENTION: None. MAIN MEASUREMENTS: Proportion of use and dosage of sedatives, analgesics, and NMB. Level of sedation observed (SAS). Variables associated with the Sedation Agitation Scale (SAS), use of sedatives, analgesics, and NMB. Multivariate logistic regression of variables associated to mortality at 28 days. RESULTS: A total of 155 patients participated (60+/-18 years, 57% male, SOFA 7 [6-10], APACHE II 18 [15-22], 63% with sepsis, and 47% with acute lung injury/adult respiratory distress syndrome. The drugs most frequently used were midazolam (85%, 4 [1.9-6.8]mg/hr) and fentanyl (81%, 76 [39-140]microg/hr). NMB were administered at least 1 day in 30% of patients. SAS score was 1 or 2 in 55% of patients. There was an association between NMB use and mortality at 28 days, but it was not consistent in all the models of NMB evaluated. CONCLUSIONS: Sedatives were frequently employed and deep sedation was common. Midazolam and fentanyl were the most frequently administered drugs. The use of NMB might be independently associated to greater mortality.

Características e impacto de la sedación, la analgesia y el bloqueo neuromuscular en los pacientes críticos que recibieron ventilación mecánica prolongada / Characteristics and impact of sedation, analgesia, and neuromuscular blockage in critical patients under going prolonged mechanical ventilation

Objetivo: Describir el uso de sedantes, analgésicos y bloqueantes neuromusculares (BNM) en los pacientes con ventilación mecánica (VM) prolongada y evaluar los factores asociados a su empleo y asociación con la mortalidad a los 28 días. Diseño: Estudio multicéntrico, prospectivo y observacional de cohorte. Ámbito: Trece unidades de cuidados intensivos (UCI) en Chile. Pacientes: Pacientes con VM superior a 48h. Excluimos los pacientes con enfermedad neurológica, cirrosis hepática, insuficiencia renal crónica, sospecha de adicción a drogas y limitación precoz del esfuerzo terapéutico. Intervención: Ninguna Variables de interés principales Proporción de uso y dosis de sedantes, analgésicos y BNM. Nivel de sedación observado (SAS [sedation-agitation scale 'escala de sedación-agitación']). Variables asociadas al nivel de la SAS, y el uso de sedantes, analgésicos y BNM. Regresión logística multivariada de variables asociadas a la mortalidad a los 28 días. Resultados: Participaron 155 pacientes (60±18 años, el 57% eran varones, SOFA 7 [6-10], APACHE II 18 [15-22], el 63% con sepsis y el 47% con lesión pulmonar aguda/síndrome de distrés respiratorio agudo. Los fármacos empleados fueron midazolam (85%; 4 mg/h [1,9-6,8]) y fentanilo (81%; 76 μg/h [39-140]). Un 30% de los pacientes usó BNM al menos un día. El 55% de la SAS fue 1-2. Existe una asociación entre el uso de BNM y la mortalidad a los 28 días, pero ésta no fue consistente en todos los modelos de uso de BNM evaluados. Conclusiones: En el grupo estudiado fue frecuente el uso de sedantes y la presencia de sedación profunda, el midazolam y el fentanilo fueron los fármacos más usados. El uso de BNM podría asociarse de forma independiente a una mayor mortalidad (AU)

Aim: To describe use of sedatives, analgesics, and neuromuscular blockers (NMB) in patients undergoing long-term mechanical ventilation and to assess factors associated with their use and their association with mortality at 28 days. Design: Prospective observational multicenter cohort study. Setting: Thirteen intensive care units (ICU) in Chile. Patients: Patients undergoing mechanical ventilation for more than 48h. We excluded patients with neurological disorders, cirrhosis of the liver, chronic renal failure, suspected drug addiction, and early no resuscitation orders. Intervention None. Main measurements: Proportion of use and dosage of sedatives, analgesics, and NMB. Level of sedation observed (SAS). Variables associated with the Sedation Agitation Scale (SAS), use of sedatives, analgesics, and NMB. Multivariate logistic regression of variables associated to mortality at 28 days. Results: A total of 155 patients participated (60±18 years, 57% male, SOFA 7 [6-10], APACHE II 18 [15-22], 63% with sepsis, and 47% with acute lung injury/adult respiratory distress syndrome. The drugs most frequently used were midazolam (85%, 4 [1.9-6.8]mg/hr) and fentanyl (81%, 76 [39-140]μg/hr). NMB were administered at least 1 day in 30% of patients. SAS score was 1 or 2 in 55% of patients. There was an association between NMB use and mortality at 28 days, but it was not consistent in all the models of NMB evaluated. Conclusions: Sedatives were frequently employed and deep sedation was common. Midazolam and fentanyl were the most frequently administered drugs. The use of NMB might be independently associated to greater mortality (AU)

Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients.

BACKGROUND: Delirium (acute brain dysfunction) is a potentially life threatening disturbance in brain function that frequently occurs in critically ill patients. While this area of brain dysfunction in critical care is rapidly advancing, striking limitations in use of terminology related to delirium internationally are hindering cross-talk and collaborative research. In the English literature, synonyms of delirium such as the Intensive Care Unit syndrome, acute brain dysfunction, acute brain failure, psychosis, confusion, and encephalopathy are widely used. This often leads to scientific "confusion" regarding published data and methodology within studies, which is further exacerbated by organizational, cultural and language barriers. OBJECTIVE: We undertook this multinational effort to identify conflicts in terminology and phenomenology of delirium to facilitate communication across medical disciplines and languages. METHODS: The evaluation of the terminology used for acute brain dysfunction was determined conducting communications with 24 authors from academic communities throughout countries/regions that speak the 13 variants of the Romanic languages included into this manuscript. RESULTS: In the 13 languages utilizing Romanic characters, included in this report, we identified the following terms used to define major types of acute brain dysfunction: coma, delirium, delirio, delirium tremens, délire, confusion mentale, delir, delier, Durchgangs-Syndrom, acute verwardheid, intensiv-psykose, IVA-psykos, IVA-syndrom, akutt konfusion/forvirring. Interestingly two terms are very consistent: 100 % of the selected languages use the term coma or koma to describe patients unresponsive to verbal and/or physical stimuli, and 100% use delirium tremens to define delirium due to alcohol withdrawal. Conversely, only 54% use the term delirium to indicate the disorder as defined by the DSM-IV as an acute change in mental status, inattention, disorganized thinking and altered level of consciousness. CONCLUSIONS: Attempts towards standardization in terminology, or at least awareness of differences across languages and specialties, will help cross-talk among clinicians and researchers.

[Cholecystectomy in young women from the south-oriental area of Santiago: comparison between 2 periods]. / Colecistectomía en mujeres jovenes del area suroriente de Santiago: comparación entre dos períodos.

The aim of this study was to know if cholecystectomy rates have decreased in young women, considering that these rates have decreased in the last years in the general chilean population. The frequency of previous cholecystectomy was compared in 1582 women aged 23.9 +/- 5.8 years admitted to a maternity for delivery between 1985 and 1986 and 4943 women aged 24.6 +/- 5.9 years admitted between 1989 and 1990 for the same reason. There was a reduction in cholecystectomy frequency from 4.7 to 2.5% specially among women 21 to 35 years old. Cholecystectomy was performed at a mean age of 23 years in both groups and 42.6% of the procedures were done before the first pregnancy. An unexpected finding was a lower body weight among women studied in the second period (62.5 +/- 9.1 vs 67.7 +/- 8.4 k).