Driving Pressure-limited Strategy for Patients with Acute Respiratory Distress Syndrome. A Pilot Randomized Clinical Trial.

Rationale: Evidence from observational studies suggests that driving pressure is strongly associated with pulmonary injury and mortality, regardless of positive end-expiratory pressure (PEEP) levels, tidal volume, or plateau pressure. Therefore, it is possible that targeting driving pressure may improve the safety of ventilation strategies for patients with acute respiratory distress syndrome (ARDS). However, the clinical effects of a driving pressure-limited strategy for ARDS has not been assessed in randomized controlled trials.Objectives: To evaluate the feasibility of testing a driving pressure-limited strategy in comparison with a conventional lung-protective ventilation strategy in patients with ARDS and a baseline driving pressure of ≥13 cm H2O.Methods: This was a randomized, controlled, nonblinded trial that included 31 patients with ARDS who were on invasive mechanical ventilation and had a driving pressure of ≥13 cm H2O. Patients allocated to the driving pressure-limited strategy were ventilated with volume-controlled or pressure-support ventilation modes, with tidal volume titrated to 4-8 ml/kg of predicted body weight (PBW), aiming at a driving pressure of 10 cm H2O, or the lowest possible. Patients in the control group were ventilated according to the ARDSNet (Acute Respiratory Distress Syndrome Network) protocol, using a tidal volume of 6 ml/kg PBW, which was allowed to be set down to 4 ml/kg PBW if the plateau pressure was >30 cm H2O. The primary endpoint was the driving pressure on Days 1-3.Results: Sixteen patients were randomized to the driving pressure-limited group and 15 were randomized to the conventional strategy group. All patients were considered in analyses. Most of the patients had mild ARDS with a mean arterial oxygen tension/fraction of inspired oxygen ratio of 215 (standard deviation [SD] = 95). The baseline driving pressure was 15.0 cm H2O (SD = 2.6) in both groups. In comparison with the conventional strategy, driving pressure from the first hour to the third day was 4.6 cm H2O lower in the driving pressure-limited group (95% confidence interval [CI], 6.5 to 2.8; P < 0.001). From the first hour up to the third day, tidal volume in the driving pressure-limited strategy group was kept lower than in the control group (mean difference [ml/kg of PBW], 1.3; 95% CI, 1.7 to 0.9; P < 0.001). We did not find statistically significant differences in the incidence of severe acidosis (pH < 7.10) within 7 days (absolute difference -12.1; 95% CI, -41.5 to -17.3) or any clinical secondary endpoint.Conclusions: In patients with ARDS, a trial assessing the effects of a driving pressure-limited strategy using very low tidal volumes versus a conventional ventilation strategy on clinical outcomes is feasible.Clinical trial registered with ClinicalTrials.gov (NCT02365038).

Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Importance: The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. Objective: To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. Design, Setting, and Participants: Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. Interventions: An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. Main Outcomes and Measures: The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. Results: A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. Conclusions and Relevance: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. Trial Registration: clinicaltrials.gov Identifier: NCT01374022.

Colesterolosis Bulbi ou Sínquise Cintilante na câmara anterior: relato de cinco casos e revisão bibliográfica / Cholesterolosis bulbi or synchisis scintillans in the anterior chamber: report of five patients and review about this ocular abnormality

Objetivo: Este trabalho relata as histórias clínicas de cinco pacientes com colesterolosis bulbi "ou sínquise cintilante na câmara anterior chamando a atenção para as principais características destes casos e para o aparecimento desta situação em olhos previamente traumatizados ou na presença de cataratas de longa duração. O objetivo dos autores é atualizar os oftalmologistas a respeito da sínquise cintilante na câmara anterior uma vez que poucas descrições existem na literatura científica sobre esta situação, bem como comentar sobre algumas hipóteses a respeito da etiologia da formãção dos cristais de colesterol e do seu aparecimento na câmara anterior. Local: Curso de Especialização em Oftalmologia do Hospital Banco de Olhos de Porto Alegre. Métodos: Estudo retrospectivo de casos com análise dos prontuários dos pacientes portadores do diagnóstico de sínquise cintilante na câmara anterior que foram atendidos no Hospital banco de Olhos de Porto Alegre, no período entre 1987 e 2002. Comentários: A sínquise cintilante ou colesterolosis bulbi é um processo degenerativo caracterizado pela deposição de cristasi de colesterol tanto na cavidade vítrea como na câmara anterior ou ainda no espaço sub-retiniano. Usualmente secundária a trauam ocular, inflamação ou hemorragia intra-ocular recorrente essas opacidades, multicoloridas e brilhantes, são suscetíveis à ação da gravidade, tendendo a decantar-se inferiormente. A ocorrência dos cristais de colesterol no vítreo é bem mais frequente de ser encontrada tanto na clínica diária quanto em publicações na literatura científica, mas a sínquise cintilante da câmara anterior é de aparecimento bem mais raro no dia-a-dia do oftalmologista.

Fotodocumentaçäo em oftalmologia / Opthalmic phogography documentation

Neste trabalho, os autores procuram fazer uma análise das possibilidades atualmente existentes para a fotodocumentaçäo de patologias na área da Oftalmologia chamando a atençäo para a existência de equipamentos simples e pouco dispendiosos que podem ser utilizados por todos com excelentes resultados práticos. Este trabalho contém consideraçöes em quatro áreas específicas a saber: fotografia ocular externa ou macrofotografia, fotografias em lâmpada de fenda, goniofotografia e preparaçäo de slides didáticos para apresentaçöes.

O olho vermelho na prática médica / The red eye in medical praxis

Os autores, através deste trabalho, pretendem orientar o médico clínico geral sobre o exame de um paciente com " olho vermelho", de maneira simples, destacando os aspectos mais importantes para o diagnóstico diferencial. É feita também uma breve descriçäo das principais causas do "olho vermelho": conjuntivites, uveíte anterior e glaucoma agudo