Quality of life of patients with rheumatic diseases / Calidad de vida de los pacientes con enfermedades reumáticas

Objective: Health-related quality of life (HRQoL) is an important indicator of population health and can measure the impact of medical actions. The main objective of this study was to determine the HRQoL of patients with rheumatic diseases (RD) and compare it with that of the general population. Methods: Observational, cross-sectional, single-center study, with consecutive inclusion of outpatients over 18 years of age seen at a Rheumatology hospital-based outpatient clinic in Madrid. Sociodemographic, clinical variables and HRQoL were recorded. HRQoL was measured with the 5-dimension, 5-level EuroQoL (EQ-5D-5L), which includes the EQ-Index (0–1 scale) and a visual analog scale (VAS, 0–100 scale). A descriptive analysis and a comparison with the HRQoL of the Spanish general population were performed. Results: 1144 patients were included, 820 (71.68%) women, with a mean age of 56.1 years (range 18–95), of whom 241 (25.44%) were new patients. In patients with RD, the HRQoL measured with the EQ-Index and with the VAS, was 0.186 and 12 points lower, respectively, than in the general population. The decrease in HRQoL affected the 5 health dimensions, especially “pain/discomfort”, followed by “daily activities” and “mobility”. This reduction in HRQoL was observed in both men and women, and in all age ranges, although it was greater between 18 and 65 years of age. The reduction in HRQoL affected all RD subtypes, especially the “peripheral and axial mechanical pathology” and the “soft tissue pathology” group. Conclusions: Patients with rheumatic diseases report worse HRQoL when compared to the general population in all dimensions of HRQoL.(AU)

Objetivo: La calidad de vida relacionada con la salud (CVRS) se considera un indicador importante para valorar el estado de salud poblacional y medir el impacto de las actuaciones médicas. El principal objetivo de este estudio es conocer la CVRS de los pacientes con enfermedades reumáticas (RD, por sus siglas en inglés) y compararla con la población general. Métodos: Estudio observacional, transversal, unicéntrico, con inclusión consecutiva de pacientes ambulatorios mayores de 18 años atendidos en la consulta hospitalaria de reumatología. Se recogieron variables sociodemográficas, clínicas y CVRS medida con el EuroQoL de 5 dimensiones y 5 niveles (EQ-5D-5L) que incluye el EQ-Índex (escala 0-1) y una escala visual analógica (EVA, escala 0-100). Se realizó un análisis descriptico y una comparación con la población española según la Encuesta Nacional de Salud. Resultados: Se han incluido 1.144 pacientes, 820 (71,68%) mujeres, con edad media de 56,1 años (rango 18-95), de los que 241 (25,44%) eran pacientes nuevos. En los pacientes con RD, la CVRS medida con el EQ-Index y con la EVA, fue de 0,186 y 12 puntos menor, respectivamente, que en la población general. La CVRS afectó a las 5 dimensiones de salud, especialmente a «dolor/malestar», seguida de «actividades cotidianas» y «movilidad». Esta reducción de la CVRS se mantuvo tanto en varones y mujeres, y en todos los segmentos de edad, aunque fue mayor entre los 18 y 65 años. La reducción de CVRS afectó a todos los subtipos de RD, especialmente a la «Enfermedad mecánica periférica y axial» y al grupo de «Enfermedad de tejidos blandos». Conclusiones: Los pacientes con enfermedades reumáticas declaran peor CVRS en comparación a la población general en todas las dimensiones de la CVRS.(AU)

Quality of life of patients with rheumatic diseases.

OBJECTIVE: Health-related quality of life (HRQoL) is an important indicator of population health and can measure the impact of medical actions. The main objective of this study was to determine the HRQoL of patients with rheumatic diseases (RD) and compare it with that of the general population. METHODS: Observational, cross-sectional, single-center study, with consecutive inclusion of outpatients over 18 years of age seen at a Rheumatology hospital-based outpatient clinic in Madrid. Sociodemographic, clinical variables and HRQoL were recorded. HRQoL was measured with the 5-dimension, 5-level EuroQoL (EQ-5D-5L), which includes the EQ-Index (0-1 scale) and a visual analog scale (VAS, 0-100 scale). A descriptive analysis and a comparison with the HRQoL of the Spanish general population were performed. RESULTS: 1144 patients were included, 820 (71.68%) women, with a mean age of 56.1 years (range 18-95), of whom 241 (25.44%) were new patients. In patients with RD, the HRQoL measured with the EQ-Index and with the VAS, was 0.186 and 12 points lower, respectively, than in the general population. The decrease in HRQoL affected the 5 health dimensions, especially "pain/discomfort", followed by "daily activities" and "mobility". This reduction in HRQoL was observed in both men and women, and in all age ranges, although it was greater between 18 and 65 years of age. The reduction in HRQoL affected all RD subtypes, especially the "peripheral and axial mechanical pathology" and the "soft tissue pathology" group. CONCLUSIONS: Patients with rheumatic diseases report worse HRQoL when compared to the general population in all dimensions of HRQoL.

Mitral annular plane systolic excursion for assessing left ventricular systolic dysfunction in patients with septic shock.

Background: Using easy-to-determine bedside measurements, we developed an echocardiographic algorithm for predicting left ventricular ejection fraction (LVEF) and longitudinal strain (LVLS) in patients with septic shock. Methods: We measured septal and lateral mitral annular plane systolic excursion (MAPSE), septal and lateral mitral S-wave velocity, and the left ventricular longitudinal wall fractional shortening in patients with septic shock. We used a conditional inference tree method to build a stratification algorithm. The left ventricular systolic dysfunction was defined as an LVEF <50%, an LVLS greater than -17%, or both. Results: We included 71 patients (males: 61%; mean [standard deviation] age: 61 [15] yr). Septal MAPSE (cut-off: 1.2 cm) was the best predictor of left ventricular systolic dysfunction. The level of agreement between the septal MAPSE and the left ventricular systolic dysfunction was 0.525 [0.299-0.751]. A septal MAPSE ≥1.2 cm predicted normal LVEF in 17/18 patients, or 94%. In contrast, a septal MAPSE <1.2 cm predicted left ventricular systolic dysfunction with impaired LVLS in 46/53 patients (87%), although 32/53 (60%) patients had a preserved LVEF. Conclusions: Septal MAPSE is easily measured at the bedside and might help clinicians to detect left ventricular systolic dysfunction early-especially when myocardial strain measurements are not feasible.

Cardiac function in critically ill patients with severe COVID: A prospective cross-sectional study in mechanically ventilated patients.

PURPOSE: To evaluate cardiac function in mechanically ventilated patients with COVID-19. MATERIALS AND METHODS: Prospective, cross-sectional multicenter study in four university-affiliated hospitals in Chile. All consecutive patients with COVID-19 ARDS requiring mechanical ventilation admitted between April and July 2020 were included. We performed systematic transthoracic echocardiography assessing right and left ventricular function within 24 h of intubation. RESULTS: 140 patients aged 57 ± 11, 29% female were included. Cardiac output was 5.1 L/min [IQR 4.5-6.2] and 86% of the patients required norepinephrine. ICU mortality was 29% (40 patients). Fifty-four patients (39%) exhibited right ventricle dilation out of whom 20 patients (14%) exhibited acute cor pulmonale (ACP). Eight out of the twenty patients with ACP exhibited pulmonary embolism (40%). Thirteen patients (9%) exhibited left ventricular systolic dysfunction (ejection fraction <45%). In the multivariate analysis acute cor pulmonale and PaO2/FiO2 ratio were independent predictors of ICU mortality. CONCLUSIONS: Right ventricular dilation is highly prevalent in mechanically ventilated patients with COVID-19 ARDS. Acute cor pulmonale was associated with reduced pulmonary function and, in only 40% of patients, with co-existing pulmonary embolism. Acute cor pulmonale is an independent risk factor for ICU mortality.

Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis.

BACKGROUND: The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients. METHODS: Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. RESULTS: Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of -4.97 mL/kg (95% CI [-6.54; -3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. CONCLUSIONS: The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985.

Critical care echocardiography in prone position patients during COVID-19 pandemic: a feasibility study.

PURPOSE: Critical care echocardiography is a fundamental tool in the hemodynamic evaluation of critically ill patients and prone position ventilation might limit its application. We aim to evaluate the feasibility of transthoracic echocardiography to assess different measurements performed in prone vs supine position in patients during COVID-19 pandemic to answer our research question: What is the feasibility of classic echocardiographic measurements in COVID-19 patients in prone position ventilation? METHODS: Patients with covid-19 admitted to ICUs in four academic hospitals with respiratory failure and on mechanical ventilation were evaluated with critical care echocardiography. The first ultrasound assessment was compared between prone and supine patients recording feasibility of several echocardiographic measurements, using Fisher's exact test complementing with Crombach's Alpha. RESULTS: 139 patients were included. Sixty-eight (49%) were evaluated in prone position and seventy one (51%) in supine position. Most variables were highly feasible, left ventricular volumes and ejection fraction were more possible to obtain in prone position, while cardiac output was in supine position. Tricuspid regurgitation was the least feasible overall measurement. CONCLUSION: Prone position ultrasound achieved a high feasibility of measurements compared with supine ultrasound in critically ill patients with COVID-19 respiratory failure and on mechanical ventilation. REGISTRATION: Post hoc analysis of Echo-COVID study (NTC04628195, registered November 13, 2020, retrospectively registered).

Doppler Echocardiographic Indices Are Specific But Not Sensitive to Predict Pulmonary Artery Occlusion Pressure in Critically Ill Patients Under Mechanical Ventilation.

OBJECTIVES: The objective of this study was to prospectively evaluate the ability of transthoracic echocardiography to assess pulmonary artery occlusion pressure in mechanically ventilated critically ill patients. DESIGN: In a prospective observational study. SETTING: Amiens University Hospital Medical ICU. PATIENTS: Fifty-three mechanically ventilated patients in sinus rhythm admitted to our ICU. INTERVENTION: Transthoracic echocardiography was performed simultaneously to pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS: Transmitral early velocity wave recorded using pulsed wave Doppler (E), late transmitral velocity wave recorded using pulsed wave Doppler (A), and deceleration time of E wave were recorded using pulsed Doppler as well as early mitral annulus velocity wave recorded using tissue Doppler imaging (E'). Pulmonary artery occlusion pressure was measured simultaneously using pulmonary artery catheter. There was a significant correlation between pulmonary artery occlusion pressure and lateral ratio between E wave and E' (E/E' ratio) (r = 0.35; p < 0.01), ratio between E wave and A wave (E/A ratio) (r = 0.41; p < 0.002), and deceleration time of E wave (r = -0.34; p < 0.02). E/E' greater than 15 was predictive of pulmonary artery occlusion pressure greater than or equal to 18 mm Hg with a sensitivity of 25% and a specificity of 95%, whereas E/E' less than 7 was predictive of pulmonary artery occlusion pressure less than 18 mm Hg with a sensitivity of 32% and a specificity of 81%. E/A greater than 1.8 yielded a sensitivity of 44% and a specificity of 95% to predict pulmonary artery occlusion pressure greater than or equal to 18 mm Hg, whereas E/A less than 0.7 was predictive of pulmonary artery occlusion pressure less than 18 mm Hg with a sensitivity of 19% and a specificity of 94%. A similar predictive capacity was observed when the analysis was confined to patients with EF less than 50%. A large proportion of E/E' measurements 32 (60%) were situated between the two cut-off values obtained by the receiver operating characteristic curves: E/E' greater than 15 and E/E' less than 7. CONCLUSIONS: In mechanically ventilated critically ill patients, Doppler transthoracic echocardiography indices are highly specific but not sensitive to estimate pulmonary artery occlusion pressure.

Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients.

OBJECTIVES: Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population. DESIGN: A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography. SETTINGS: Medical-surgical intensive care department of two university hospitals in France. PATIENTS: Mechanically ventilated critically ill patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%). CONCLUSIONS: The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.

Fundamentos para aplicar una estrategia de cribado poblacional de la hepatitis C en España / No disponible

ANTECEDENTES: la hepatitis C, además del impacto en la salud, produce una importante pérdida de productividad, disminuye la calidad de vida y contribuye notablemente al aumento del gasto sanitario. Por estas razones, el Ministerio de Sanidad, Consumo y Bienestar Social (MSCBS) de España implantó en 2015 el Plan Estratégico para el Abordaje de la Hepatitis C (PEAHC) en el Sistema Nacional de la salud. Sin embargo, el PEAHC no incluye ningún plan de cribado. El MSCBS desarrolló el "Documento marco sobre cribado poblacional", que define los criterios que debe reunir una enfermedad para considerar la implantación de un programa de cribado. En concreto, define 4 criterios relativos al problema de salud, 4 relativos a la prueba de cribado y 3 relativos al diagnóstico de confirmación y al tratamiento. OBJETIVO: identificar si existe evidencia científica que permita afirmar que la hepatitis C reúne los criterios para ser considerada una enfermedad para la que se debe desarrollar una estrategia de cribado poblacional en España. MÉTODOS: búsqueda bibliográfica de la evidencia científica sobre cada uno de los criterios requeridos para la implantación de un plan de cribado poblacional de la hepatitis C en España. RESULTADOS: se encontró evidencia científica suficiente que justifica que la hepatitis C reúne los criterios exigidos por el MSCBS para implantar un programa de cribado poblacional. CONCLUSIONES: según la evidencia científica disponible, la hepatitis C en España reúne los criterios necesarios para que se considere la implantación de un plan de cribado poblacional

No disponible

Principles for implementing a population screening strategy for hepatitis C in Spain.

BACKGROUND: hepatitis C, besides health impairment, results in significant loss of productivity and diminished quality of life, and noticeably contributes to health expenditure increases. Because of all this, the Spanish Ministry of Health (Ministerio de Sanidad, Consumo y Bienestar Social - MSCBS) implemented in 2015 a strategic plan for managing hepatitis C (Plan Estratégico para el Abordaje de la Hepatitis C - PEAHC) within the National Health System. However, the PEAHC includes no screening plan. The MSCBS developed a framework document on population screening (Documento Marco sobre Cribado Poblacional) that defines the criteria a disease must meet in order to consider implementing a screening program. Specifically, it defines 4 criteria related to the health issue, 4 related to the screening test, and 3 criteria dealing with diagnosis confirmation and treatment. OBJECTIVE: to identify whether there is scientific evidence to support hepatitis C meeting the criteria to be considered a disease qualifying for a population screening strategy in Spain. METHODS: a literature search for scientific evidence concerning each required criterion for implementing a population screening plan for hepatitis C in Spain. RESULTS: sufficient scientific evidence was found to support hepatitis C meeting the criteria required by the MSCBS for the implementation of a population screening program. CONCLUSIONS: according to the available scientific evidence, hepatitis C in Spain meets the required criteria to qualify for consideration of population screening plan.

What is the lowest change in cardiac output that transthoracic echocardiography can detect?

BACKGROUND: In critically ill patients, changes in the velocity-time integral (VTI) of the left ventricular outflow tract, measured by transthoracic echocardiography (TTE), are often used to non-invasively assess the response to fluid administration or for performing tests assessing fluid responsiveness. However, the precision of TTE measurements has not yet been investigated in such patients. First, we aimed at assessing how many measurements should be averaged within one TTE examination to reach a sufficient precision for various variables. Second, we aimed at identifying the least significant change (LSC) of these variables between successive TTE examinations. METHODS: We prospectively included 100 haemodynamically stable patients in whom TTE examination was planned. Three TTE examinations were performed, the first and the third by one operator and the second by another one. We calculated the precision and LSC (1) within one examination depending on the number of averaged measurements and (2) between measurements performed in two successive examinations. RESULTS: In patients in sinus rhythm, averaging three measurements within an examination was enough for obtaining an acceptable precision (interquartile range highest value < 10%) for VTI. In patients with atrial fibrillation, averaging five measurements was necessary. The precision of some other common TTE variables depending on the number of measurements is provided. Between two successive examinations performed by the same operator, the LSC was 11 [5-18]% for VTI. If two operators performed the examinations, the LSC for VTI significantly increased to 14 [8-26]%. The LSC between two examinations for other TTE variables is also provided. CONCLUSIONS: Averaging three measurements within one TTE examination is enough for obtaining precise measurements for VTI in patients in sinus rhythm but not in patients with atrial fibrillation. Between two TTE examinations performed by the same operator, the LSC of VTI is compatible with the assessment of the effects of a 500-mL fluid infusion but is not precise enough for assessing the effects of some tests predicting preload responsiveness.

Diagnosis of hepatitis C virus infection in Spain: An opportunity to improve. / El diagnóstico de la infección por el virus de la hepatitis C en España: una oportunidad para mejorar.

BACKGROUND: Reflex testing of antibodies and viral load in the same sample for diagnosing hepatitis C virus infection speeds up access to treatment. However, how hepatitis C is diagnosed in Spanish hospitals is unknown. OBJECTIVE: To describe the available resources and procedures for the diagnosis of hepatitis C virus infection in Spain. METHODS: Survey sent to public and private Spanish hospitals with teaching accreditation with at least 200 beds. RESULTS: Of the 160 hospitals that met the inclusion criteria, 90 centres (response rate 56.3%) completed the survey. Two hospitals (2.2%) have no diagnostic resources, 15 (16.7%) can only test for anti-hepatitis C virus(Ab), 9 (10.0%) for Ab and viral load, 47 (52.2%) for Ab, viral load and genotype, 2 (2.2%) for Ab, viral load and core antigen, and 15 (16.7%) can perform Ab, core antigen, viral load and genotype tests. When an Ab test is positive, 28 (31.1%) hospitals perform reflex testing. When an active infection is diagnosed, some communication strategy is used in 62 (68.9%) hospitals. Approximately 44.2% of the respondents believe that all determinations needed to reach a definitive diagnosis should be done on a single blood sample. CONCLUSION: Although 81% of Spanish hospitals have the resources to perform reflex hepatitis C virus infection testing, it is only done in 31%, and less than a half of respondents believe that the definitive diagnosis should be performed on a single sample.

El diagnóstico de la infección por el virus de la hepatitis C en España: una oportunidad para mejorar / Diagnosis of hepatitis C virus infection in Spain: An opportunity to improve

ANTECEDENTES: El diagnóstico de la infección por el virus de la hepatitis C en un solo paso (anticuerpos y carga viral en una misma muestra) disminuiría el tiempo de acceso al tratamiento. Se desconoce el proceso del diagnóstico de la hepatitis C en los hospitales españoles. OBJETIVO: Describir los recursos diagnósticos disponibles y el proceso del diagnóstico de la infección por virus de la hepatitis C en España. MÉTODOS: Encuesta dirigida a hospitales españoles, públicos o privados con acreditación docente, de 200 camas o más. RESULTADOS: De los 160 hospitales con criterios de inclusión, respondieron 90 (tasa de respuesta del 56,3%). Dos centros (2,2%) no disponen de ningún recurso diagnóstico, 15 (16,7%) solo pueden realizar determinación de anticuerpos (Ac), 9 (10%) de Ac y carga viral (CV), 47 (52,2%) de Ac, CV y genotipo, 2 (2,2%) de Ac, CV y antígeno core, y 15 (16,7%) de Ac, antígeno core, CV y genotipo. Ante un resultado de Ac positivo, 28 (31,1%) hospitales hacen diagnóstico virológico en la misma muestra. Cuando hay una infección activa, se utiliza alguna estrategia de comunicación en 62 (68,9%) hospitales. El 44,2% de los respondedores cree que las determinaciones para llegar a un diagnóstico definitivo se deben hacer con una muestra única de sangre. CONCLUSIONES: Aunque el 81% de los hospitales dispone de medios para realizar el diagnóstico de la infección por virus de la hepatitis C en un solo paso, únicamente lo hace el 31%. Menos de la mitad de los encuestados cree que el diagnóstico definitivo se debe hacer con una única muestra

BACKGROUND: Reflex testing of antibodies and viral load in the same sample for diagnosing hepatitis C virus infection speeds up access to treatment. However, how hepatitis C is diagnosed in Spanish hospitals is unknown. OBJECTIVE: To describe the available resources and procedures for the diagnosis of hepatitis C virus infection in Spain. METHODS: Survey sent to public and private Spanish hospitals with teaching accreditation with at least 200 beds. RESULTS: Of the 160 hospitals that met the inclusion criteria, 90 centres (response rate 56.3%) completed the survey. Two hospitals (2.2%) have no diagnostic resources, 15 (16.7%) can only test for anti-hepatitis C virus(Ab), 9 (10.0%) for Ab and viral load, 47 (52.2%) for Ab, viral load and genotype, 2 (2.2%) for Ab, viral load and core antigen, and 15 (16.7%) can perform Ab, core antigen, viral load and genotype tests. When an Ab test is positive, 28 (31.1%) hospitals perform reflex testing. When an active infection is diagnosed, some communication strategy is used in 62 (68.9%) hospitals. Approximately 44.2% of the respondents believe that all determinations needed to reach a definitive diagnosis should be done on a single blood sample. CONCLUSION: Although 81% of Spanish hospitals have the resources to perform reflex hepatitis C virus infection testing, it is only done in 31%, and less than a half of respondents believe that the definitive diagnosis should be performed on a single sample

Validation and Critical Evaluation of the Effective Arterial Elastance in Critically Ill Patients.

OBJECTIVES: First, to validate bedside estimates of effective arterial elastance = end-systolic pressure/stroke volume in critically ill patients. Second, to document the added value of effective arterial elastance, which is increasingly used as an index of left ventricular afterload. DESIGN: Prospective study. SETTING: Medical ICU. PATIENTS: Fifty hemodynamically stable and spontaneously breathing patients equipped with a femoral (n = 21) or radial (n = 29) catheter were entered in a "comparison" study. Thirty ventilated patients with invasive hemodynamic monitoring (PiCCO-2; Pulsion Medical Systems, Feldkirchen, Germany), in whom fluid administration was planned were entered in a " dynamic" study. INTERVENTIONS: In the "dynamic" study, data were obtained before/after a 500 mL saline administration. MEASUREMENTS AND MAIN RESULTS: According to the "cardiocentric" view, end-systolic pressure was considered the classic index of left ventricular afterload. End-systolic pressure was calculated as 0.9 × systolic arterial pressure at the carotid, femoral, and radial artery level. In the "comparison" study, carotid tonometry allowed the calculation of the reference effective arterial elastance value (1.73 ± 0.62 mm Hg/mL). The femoral estimate of effective arterial elastance was more accurate and precise than the radial estimate. In the "dynamic" study, fluid administration increased stroke volume and end-systolic pressure, whereas effective arterial elastance (femoral estimate) and systemic vascular resistance did not change. Effective arterial elastance was related to systemic vascular resistance at baseline (r = 0.89) and fluid-induced changes in effective arterial elastance and systemic vascular resistance were correlated (r = 0.88). In the 15 fluid responders (cardiac index increases ≥ 15%), fluid administration increased end-systolic pressure and decreased effective arterial elastance and systemic vascular resistance (each p < 0.05). In the 15 fluid nonresponders, end-systolic pressure increased (p < 0.05), whereas effective arterial elastance and systemic vascular resistance remained unchanged. CONCLUSIONS: In critically ill patients, effective arterial elastance may be reliably estimated at bedside (0.9 × systolic femoral pressure/stroke volume). We support the use of this validated estimate of effective arterial elastance when coupled with an index of left ventricular contractility for studying the ventricular-arterial coupling. Conversely, effective arterial elastance should not be used in isolation as an index of left ventricular afterload.

Eficiencia de diversas estrategias para el diagnóstico de la hepatitis C en un solo paso / The efficiency of several one-step testing strategies for the diagnosis of hepatitis C

Antecedentes: la implementación de estrategias de diagnóstico de la hepatitis C en un solo paso contribuiría a disminuir el tiempo de acceso al tratamiento, evitando el progreso de la enfermedad y sus complicaciones y facilitando la eliminación de la enfermedad. Objetivo: evaluar la validez y la seguridad de las posibles estrategias del diagnóstico de la infección por virus de la hepatitis C (VHC) en un solo paso, así como sus costes y eficiencia. Métodos: estudio de evaluación económica de la eficiencia (coste/eficacia) mediante la construcción de árboles de decisión con análisis de sensibilidad determinista. La perspectiva del análisis es la del financiador (Sistema Nacional de Salud), que solo considera los costes directos. Se han considerado únicamente los costes diferenciales (costes de los test analíticos realizados). El ámbito del estudio es España. Se define la eficacia de una estrategia diagnóstica como el porcentaje de pacientes con infección activa por VHC con diagnóstico positivo y la eficiencia, como el coste de diagnosticar correctamente un paciente con infección activa. Resultados: todas las estrategias para el diagnóstico de VHC en un solo paso evaluadas presentan validez y seguridad aceptables como consecuencia de la elevada sensibilidad y especificidad que tienen los test utilizados. La estrategia más eficiente es Ac-Ag, seguida de Ac-Ag-CV y Ac-CV. La estrategia más eficiente es Ac-Ag debido a su menor coste por paciente testado, pero es menos eficaz que Ac-CV. Conclusión: los hallazgos de este estudio pueden contribuir a establecer las estrategias de diagnóstico más adecuadas en un solo paso teniendo en cuenta su eficacia y eficiencia

Background: implementing one-step strategies for hepatitis C diagnosis would help shorten the time to treatment access. Thus avoiding disease progression and complications, while facilitating hepatitis C virus (HCV) elimination. Objective: to assess the validity and certainty of potential one-step strategies for the diagnosis of HCV infection and their associated cost and efficiency. Methods: the study design is an economic appraisal of efficiency (cost/efficacy) using decision trees and deterministic sensitivity analysis. The analysis was performed from the payer perspective (Spanish National Health System), which exclusively considers the direct costs. Only the differential costs (diagnostic testing costs) were taken into account and the study was set in Spain. The efficacy of a diagnostic strategy was defined as the percentage of patients with an active HCV infection who received a positive diagnosis and the efficiency was defined as the cost per patient with a correctly diagnosed and active infection. Results: the one-step strategies evaluated for the diagnosis of HCV had an acceptable validity and certainty due to the high sensitivity and specificity of the considered tests. The Ab-Ag strategy was the most efficient, followed by Ab-Ag-VL and Ab-VL. Ab-Ag was the most efficient due to the lower cost per patient tested, although the efficacy was lower than the Ab-VL efficacy. Conclusion: the study findings may help to establish more appropriate one-step diagnostic approaches whilst considering the efficacy and efficiency

Reassessment of the Accuracy of Cardiac Doppler Pulmonary Artery Pressure Measurements in Ventilated ICU Patients: A Simultaneous Doppler-Catheterization Study.

OBJECTIVES: Doppler echocardiography is a well-recognized technique for the noninvasive evaluation of pulmonary artery pressure; however, little information is available concerning patients receiving mechanical ventilation. Furthermore, recent studies have debatable results regarding the relevance of this technique to assess pulmonary artery pressure. The aim of our study was to reassess the accuracy of Doppler echocardiography to evaluate pulmonary artery pressure and to predict pulmonary hypertension. DESIGN: Prospective observational study. SETTING: Amiens ICU, France. PATIENTS: ICU patients receiving mechanical ventilation. INTERVENTIONS: In 40 patients, we simultaneously recorded Doppler echocardiography variables (including tricuspid regurgitation and pulmonary regurgitation) and invasive central venous pressure, systolic pulmonary artery pressure, diastolic pulmonary artery pressure, and mean pulmonary artery pressure. MEASUREMENTS AND MAIN RESULTS: Systolic pulmonary artery pressure assessed from the tricuspid regurgitation derived maximal pressure gradient added to the central venous pressure demonstrated the best correlation with the invasive systolic pulmonary artery pressure (r = 0.87) with a small bias (-3 mm Hg) and a precision of 9 mm Hg. A Doppler echocardiography systolic pulmonary artery pressure greater than 39 mm Hg predicted pulmonary hypertension (mean pulmonary artery pressure ≥ 25 mm Hg) with 100% sensitivity and specificity. Tricuspid regurgitation maximal velocity greater than 2.82 m/s as well as tricuspid regurgitation pressure gradient greater than 32 mm Hg predicted the presence of pulmonary hypertension. Pulmonary regurgitation was recorded in 10 patients (25%). No correlation was found between pulmonary regurgitation velocities and either mean pulmonary artery pressure or diastolic pulmonary artery pressure. Pulmonary acceleration time less than 57 ms and isovolumic relaxation time less than 40 ms respectively predicted pulmonary hypertension 100% of the time and had a 100% negative predictive value. CONCLUSIONS: Tricuspid regurgitation maximal velocity pressure gradient added to invasive central venous pressure accurately estimates systolic pulmonary artery pressure and mean pulmonary artery pressure in ICU patients receiving mechanical ventilation and may predict pulmonary hypertension.

The efficiency of several one-step testing strategies for the diagnosis of hepatitis C.

BACKGROUND: implementing one-step strategies for hepatitis C diagnosis would help shorten the time to treatment access. Thus avoiding disease progression and complications, while facilitating hepatitis C virus (HCV) elimination. OBJECTIVE: to assess the validity and certainty of potential one-step strategies for the diagnosis of HCV infection and their associated cost and efficiency. METHODS: the study design is an economic appraisal of efficiency (cost/efficacy) using decision trees and deterministic sensitivity analysis. The analysis was performed from the payer perspective (Spanish National Health System), which exclusively considers the direct costs. Only the differential costs (diagnostic testing costs) were taken into account and the study was set in Spain. The efficacy of a diagnostic strategy was defined as the percentage of patients with an active HCV infection who received a positive diagnosis and the efficiency was defined as the cost per patient with a correctly diagnosed and active infection. RESULTS: the one-step strategies evaluated for the diagnosis of HCV had an acceptable validity and certainty due to the high sensitivity and specificity of the considered tests. The Ab-Ag strategy was the most efficient, followed by Ab-Ag-VL and Ab-VL. Ab-Ag was the most efficient due to the lower cost per patient tested, although the efficacy was lower than the Ab-VL efficacy. CONCLUSION: the study findings may help to establish more appropriate one-step diagnostic approaches whilst considering the efficacy and efficiency.

Moderate and Severe Acute Respiratory Distress Syndrome: Hemodynamic and Cardiac Effects of an Open Lung Strategy With Recruitment Maneuver Analyzed Using Echocardiography.

OBJECTIVES: Open lung ventilation with a recruitment maneuver could be beneficial for acute respiratory distress syndrome patients. However, the increased airway pressures resulting from the recruitment maneuver may induce cardiac dysfunction, limiting the benefit of this maneuver. We analyzed the effect of a recruitment maneuver and decremental positive end-expiratory pressure titration on cardiac function. SETTINGS: Medical ICU Amiens, France. PATIENTS: Twenty patients with moderate to severe acute respiratory distress syndrome INTERVENTIONS:: Patients underwent a stepwise recruitment maneuver with respiratory evaluation and echocardiography assessment of cardiac function including longitudinal strain at baseline, peak positive end-expiratory pressure of recruitment maneuver (positive end-expiratory pressure 40 cm H2O), and at "optimal" positive end-expiratory pressure. The patients were divided into two groups based on change on the PaO2/FIO2 ratio (nonresponders < 50%; responders ≥ 50%). MEASUREMENTS AND MAIN RESULTS: At peak positive end-expiratory pressure during the recruitment maneuver, the arterial pressure, cardiac output, left ventricular size decreased and right ventricular size increased. The left ventricular ejection fraction decreased from 60% ± 13% to 48% ± 18% (p = 0.05). Both left and right ventricular global longitudinal strain were impaired (-15.8% ± 4.5% to -11% ± 4.7% and -19% ± 5% to -14% ± 6% [p = 0.05] respectively). Fifty percent of patients were nonresponders and demonstrated a lower hemodynamic tolerance to the recruitment maneuver than responders. Optimal positive end-expiratory pressure was 14 ± 5 cm H2O (vs 11 ± 4 cm H2O at baseline), and PaO2/FIO2 ratio increased from 111 ± 25 to 197 ± 89 mm Hg (p < 0.0001). All hemodynamic variables returned to their baseline value after the recruitment maneuver despite a higher positive end-expiratory pressure. CONCLUSIONS: An open lung strategy with a stepwise recruitment maneuver permitted a higher positive end-expiratory pressure and improved oxygenation without any cardiac impairment. The recruitment maneuver was associated with mild and transient, cardiac dysfunction, with nonresponders demonstrating poorer tolerance.

Transthoracic echocardiography: an accurate and precise method for estimating cardiac output in the critically ill patient.

BACKGROUND: Cardiac output (CO) monitoring is a valuable tool for the diagnosis and management of critically ill patients. In the critical care setting, few studies have evaluated the level of agreement between CO estimated by transthoracic echocardiography (CO-TTE) and that measured by the reference method, pulmonary artery catheter (CO-PAC). The objective of the present study was to evaluate the precision and accuracy of CO-TTE relative to CO-PAC and the ability of transthoracic echocardiography to track variations in CO, in critically ill mechanically ventilated patients. METHODS: Thirty-eight mechanically ventilated patients fitted with a PAC were included in a prospective observational study performed in a 16-bed university hospital ICU. CO-PAC was measured via intermittent thermodilution. Simultaneously, a second investigator used standard-view TTE to estimate CO-TTE as the product of stroke volume and the heart rate obtained during the measurement of the subaortic velocity time integral. RESULTS: Sixty-four pairs of CO-PAC and CO-TTE measurements were compared. The two measurements were significantly correlated (r = 0.95; p < 0.0001). The median bias was 0.2 L/min, the limits of agreement (LOAs) were -1.3 and 1.8 L/min, and the percentage error was 25%. The precision was 8% for CO-PAC and 9% for CO-TTE. Twenty-six pairs of ΔCO measurements were compared. There was a significant correlation between ΔCO-PAC and ΔCO-TTE (r = 0.92; p < 0.0001). The median bias was -0.1 L/min and the LOAs were -1.3 and +1.2 L/min. With a 15% exclusion zone, the four-quadrant plot had a concordance rate of 94%. With a 0.5 L/min exclusion zone, the polar plot had a mean polar angle of 1.0° and a percentage error LOAs of -26.8 to 28.8°. The concordance rate was 100% between 30 and -30°. When using CO-TTE to detect an increase in ΔCO-PAC of more than 10%, the area under the receiving operating characteristic curve (95% CI) was 0.82 (0.62-0.94) (p < 0.001). A ΔCO-TTE of more than 8% yielded a sensitivity of 88% and specificity of 66% for detecting a ΔCO-PAC of more than 10%. CONCLUSION: In critically ill mechanically ventilated patients, CO-TTE is an accurate and precise method for estimating CO. Furthermore, CO-TTE can accurately track variations in CO.