Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxemic respiratory failure (PRONELIFE)-protocol for a randomized clinical trial.

BACKGROUND: It is uncertain whether awake prone positioning can prevent intubation for invasive ventilation in spontaneous breathing critically ill patients with acute hypoxemic respiratory failure. Awake prone positioning could benefit these patients for various reasons, including a reduction in direct harm to lung tissue, and prevention of tracheal intubation-related complications. DESIGN AND METHODS: The PRONELIFE study is an investigator-initiated, international, multicenter, randomized clinical trial in patients who may need invasive ventilation because of acute hypoxemic respiratory failure. Consecutive patients admitted to participating ICUs are randomly assigned to standard care with awake prone positioning, versus standard care without awake prone positioning. The primary endpoint is a composite of tracheal intubation and all-cause mortality in the first 14 days after enrolment. Secondary endpoints include time to tracheal intubation and effects of awake prone positioning on oxygenation parameters, dyspnea sensation, and complications. Other endpoints are the number of days free from ventilation and alive at 28 days, total duration of use of noninvasive respiratory support, total duration of invasive ventilation, length of stay in ICU and hospital, and mortality in ICU and hospital, and at 28, 60, and 90 days. We will also collect data regarding the tolerance of prone positioning. DISCUSSION: The PRONELIFE study is among the first randomized clinical trials investigating the effect of awake prone positioning on intubation rate in ICU patients with acute hypoxemic failure from any cause. The PRONELIFE study is sufficiently sized to determine the effect of awake prone positioning on intubation for invasive ventilation-patients are eligible in case of acute hypoxemic respiratory failure without restrictions regarding etiology. The PRONELIFE study is a pragmatic trial in which blinding is impossible-however, as around 35 ICUs worldwide will participate in this study, its findings will be highly generalizable. The findings of the PRONELIFE study have the potential to change clinical management of patients who may need invasive ventilation because of acute hypoxemic respiratory failure. TRIAL REGISTRATION: ISRCTN ISRCTN11536318 . Registered on 17 September 2021. The PRONELIFE study is registered at clinicaltrials.gov with reference number NCT04142736 (October, 2019).

Automatic summarization of soccer highlights using audio-visual descriptors.

Automatic summarization generation of sports video content has been object of great interest for many years. Although semantic descriptions techniques have been proposed, many of the approaches still rely on low-level video descriptors that render quite limited results due to the complexity of the problem and to the low capability of the descriptors to represent semantic content. In this paper, a new approach for automatic highlights summarization generation of soccer videos using audio-visual descriptors is presented. The approach is based on the segmentation of the video sequence into shots that will be further analyzed to determine its relevance and interest. Of special interest in the approach is the use of the audio information that provides additional robustness to the overall performance of the summarization system. For every video shot a set of low and mid level audio-visual descriptors are computed and lately adequately combined in order to obtain different relevance measures based on empirical knowledge rules. The final summary is generated by selecting those shots with highest interest according to the specifications of the user and the results of relevance measures. A variety of results are presented with real soccer video sequences that prove the validity of the approach.

Is port-site resection necessary in the surgical management of gallbladder cancer?

INTRODUCTION: Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry. METHODS: Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival. RESULTS: Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age > 70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision. CONCLUSION: In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.

Rendimiento neurocognitivo y funcionamiento de una cohorte de adolescentes con trastorno bipolar: dos años después del diagnóstico / Neurocognitivie performance and functioning of an adolescent bipolar disorder cohort: outcome two years after diagnostic

Durante las fases eutímicas de adultos, adolescentes y niños con trastorno bipolar (TB) persisten déficits en memoria verbal, atención y funciones ejecutivas. Datosde seguimiento de pacientes bipolares pediátricos medicados mostraron mejoría al comparar estados iniciales de inestabilidad con seguimientos de estabilidad clínica,pero los déficits se mantuvieron entre pacientes y controles sanos en estas funciones y tareas visoespaciales. El objetivo fue comparar 20 pacientes jóvenes con trastorno bipolar tipo I o II estabilizados, después de al menos dos años de tratamiento, y 20 controles sanos, apareados por edad y sexo. La evaluación incluyó evaluación clínica (YMRS, BDI, ADHD-RS), funcionamiento (nivel académico, situación laboral, consumo de tóxicos) y evaluación neuropsicológica (estimación intelectual, atención, memoria de trabajo, aprendizaje verbal, memoria visual, habilidad y velocidad visoespaciales, fluencia fonética, funciones ejecutivas). Se usó prueba chi-cuadrado para variables categóricas y t-test para las numéricas. No se observaron diferencias significativas en nivel de estudios cursado, situación laboral, consumo de substancias o sintomatología maníaca. Las diferencias aparecieron en sintomatología depresiva y de TDAH y algunas funciones neuropsicológicas (cociente intelectual y memoria visual), peores entre los pacientes con TB. Se dan tendencias no significativas hacia un peor rendimiento en habilidades visoespaciales, aprendizaje verbal, memoriade trabajo y flexibilidad. Son necesarios más estudios de seguimiento (AU)

Deicits in verbal memory, attention and executive functions persist within euthymic phases in bipolar adults, adolescents, and children. Outcome data of medicated pediatric bipolar patients showed improvements comparing unstable baseline status with stabilized follow-up, but deicits remained between patients and healthy controls in executive functions, verbal memory and visual-spatial tasks. The main aim of this study was to compare the performance of 20 young stabilized type I or II bipolar patients, diagnosed and medicated for at least two years, and 20 healthy controls matched in age and gender. Evaluation included clinical symptomatology (YMRS, BDI, ADHD-RS), functioning (studies level, labor situation, substance use) and neuropsychological battery (intellectual estimation, attention, working memory, verbal learning, visual memory, visual-spatial skills and speed, phonemic luency and executive functioning). Chi-square test was used to compare categorical measures and t-test for numeric measures. No signiicative differences emerged in current level of studies, labor status, substance use nor manic symptoms. Signiicative differences appeared in depressive and ADHD symptoms and some neuropsychological functions, as intellectual quotient and visual memory, worse in EOBD than HC. Trends but not signiicative deicits were shown in visual- spatial skills, verbal learning, working memory and set-shifting. Longitudinal studies are needed (AU)

Limitación del esfuerzo terapéutico en Cuidados Intensivos. ¿Ha cambiado en el siglo XXI? / Limitation of therapeutic effort in Intensive Care: has it changed in the XXI century?

Fundamento. La limitación del esfuerzo terapéutico (LET) es la decisión meditada sobre la no implementación o la retirada de terapéuticas médicas al anticipar que no conllevarán un beneficio significativo al paciente. Objetivo. Conocer la frecuencia con que se decide la LET en la práctica diaria, y si ha cambiado al inicio del siglo xxi. Pacientes y métodos. Durante el año 2003 incluimos en el informe de alta de cada paciente del Área de Críticos una pregunta de obligada respuesta sobre si hubo o no LET. Se registró la mortalidad en el Área de Críticos y la mortalidad hospitalaria. Resultados. Durante el período de estudio ingresaron en el Área de Críticos 1.510 pacientes, con una edad de 61 ± 17 años. La LET se reconoció explícitamente en una minoría de pacientes (10%) y se asoció a una alta mortalidad hospitalaria (88%). En el 55% de los pacientes que fallecieron en el Área de Críticos hubo algún tipo de LET. Los pacientes con LET tuvieron mayor riesgo de muerte predicho por APACHE II (37 ± 27 frente a 22 ± 22), mayor frecuencia de enfermedades crónicas previas (26% frente a 10%), mayor edad (72 ± 12 frente a 60 ± 18 años) y mayor estancia en el Área de Críticos (10 ± 14 frente a 6 ± 8 días). Describimos un nuevo grupo de pacientes (1% del total) que ingresan en Críticos ya con alguna LET. Conclusión. En el día a día, aunque aún escasa, la LET está aumentando y se asocia a una muy mala evolución. Se decide más frecuentemente en pacientes mayores y con co-morbilidades

Background. The limitation of therapeutic effort (LTE) is the meditated decision on the non-implementation or withdrawal of therapeutic measures due to anticipating that they would not entail a significant benefit for the patient. Objective. Know the frequency with which LTE is decided in the daily practice and if it has changed at the onset of the xxi century. Patients and methods. During the year 2003, we included a question with required response on whether or not there was a LTE in the discharge report of each patient of the Critical Area. Mortality in the Critical area and hospital mortality were recorded. Results. During the study period, 1,510 patients, aged 61 ± 17 years, were admitted to the Critical Area. LTE was explicitly admitted in a minority of patients (10%) and was associated to high hospital mortality (88%). In 55% of the patients who died in the Critical area, there was some type of LTE. Patients with LTE had greater risk of death predicted by the APACHE II (37 ± 27 versus 22 ± 22), greater frequency of previous chronic diseases (26% versus 10%), older age (72 ± 12 versus 60 ±18 years) and longer stay in the Critical Area (10 ± 14 versus 6 ± 8 days). We discovered a new group of patients (1% of the total) who were admitted in the Critical Area with some LTE. Conclusion. Although still scarce, LTE is increasing and is associated to very poor course in everyday work. It is decided more frequently in older patients with comorbidities

Carcinoma adenoescamoso gástrico en un paciente de raza caucásica / Adenosquamous gastric carcinoma in Caucasian patient

No disponible

Las unidades de cuidados intensivos y la atención integral del enfermo crítico / Intensive care units and integral care of the critically-ill patients

No disponible

Valor pronóstico de los receptores hormonales, índice de proliferación celular (Ki-67) y factores clinicopatológicos en el carcinoma ductal infiltrante de mama. estudio inmunohistoquímico de 192 pacientes / Prognostic value of hormonal receptors, cell proliferation index (Ki-67) and clinicopathologic factors of invasive ductal carcinoma of the breast. An immunohistochemical study of 192 patients

Objetivo. Valorar la relación entre los factores pronósticos clínicos, histológicos e inmunohistoquímicos en el carcinoma ductal infiltrante de mama. Material y métodos. Se estudiaron variables clínicas e histológicas, receptores hormonales e índice de proliferación celular (Ki-67) en 192 pacientes con carcinoma ductal infiltrante. Los receptores de estrógenos y progesterona fueron medidos de acuerdo con la intensidad de la tinción (I), con valores comprendidos entre 0 y 3, y el porcentaje de células positivas (P). Se calculó un histoscore para la fórmula (I + 1) × P (rango: 0-400). Los casos con un valor de histoscore por encima de 100 fueron considerados positivos. El índice de proliferación celular (Ki-67) fue medido contando 500 células, expresando el número de células positivas en porcentaje. Resultados.En 64,24 por ciento de los tumores se encontró tinción positiva para los receptores de estrógenos, mientras que el 49,12 por ciento fueron receptores de progesterona positivos. En 21,87 por ciento de los pacientes se encontró un índice de proliferación celular alto (> 25 por ciento). El tamaño tumoral, el número de mitosis, la presencia de necrosis y el estado ganglionar fueron factores pronósticos independientes en nuestro estudio estadístico. Conclusiones. Los receptores hormonales y el Ki-67 no son factores pronósticos independientes para la recidiva y la supervivencia global en nuestro estudio. Sólo los factores histológicos clásicos se han mostrado como factores pronósticos independientes. (AU)

Low-dose, fractionated radioimmunotherapy for B-cell malignancies using 131I-Lym-1 antibody.

PURPOSE: This trial was conducted to assess the toxicity and efficacy of 131I-Lym-1 in patients with either malignant B-cell non-Hodgkin's lymphoma (NHL) or chronic lymphocytic leukemia (CLL) using low-dose, fractionated radioimmunotherapy (RIT). MATERIALS AND METHODS: Thirty adult patients who had advanced B-cell malignancies (25 NHL and 5 CLL) had progressed despite standard therapy; 12 patients entered the trial with Karnofsky performance status (KPS) of equal to or greater than 60. Patients were treated with a series of intravenous doses of 131I-Lym-1 with a goal of reaching a cumulative dose in each patient of at least 300 mCi. All patients were Lym-1 reactive. Clinical responses and immediate toxicity were evaluable in all 30 patients and delayed toxicity in 26. RESULTS: Toxicity to Lym-1 antibody occurred with 28% of the 176 doses and was transient. Human antimouse antibodies (HAMA) were generated in 30% after a mean of 4 doses, but interrupted therapy in only 10% of the patients. Thrombocytopenia was dose-limiting; there were no deaths due to toxicity. Tumor regression occurred in 25 (83%) of the patients and was great enough, and durable enough, in 17 (57%) to qualify them as responders; 13 NHL patients and 4 CLL patients. Advanced disease often interrupted therapy prematurely. However, 18 patients received at least 180 mCi of 131I-Lym-1; 17 (94%) of these responded to the therapy. CONCLUSION: Although advanced disease often interrupted therapy prematurely, the results from 131I-Lym-1 therapy are clearly promising and warrant additional trials.

[Mortality and hospital stay adjusted for severity as indicators of effectiveness and efficiency of the care provided to critically ill patients. European and North American Study of Severity Systems]. / Mortalidad y estancia hospitalaria ajustadas por gravedad como indicadores de efectividad y eficiencia de la atención a pacientes en estado crítico. European and North American Study of Severity Systems.

BACKGROUND: Hospital mortality and length of stay, both adjusted for severity of illness, have been used as indicators of effectiveness and efficiency of health care in critical patients. PATIENTS AND METHODS: 1,270 adult critical patients, consecutively admitted in 17 intensive care units (ICU) from Catalonia and the Balearic Islands, Spain, have been included. For each hospital, effectiveness has been assessed with a quality performance index (QOI) obtained by dividing the number of observed deaths by the number of deaths expected according to the MPM system (MPM II0). Efficiency has been assessed with a resource utilization index (RUI) obtained by dividing the number of observed weighted hospital days (WHD) by the number of expected WHD. WHD is a measure of resource use which weights ICU days more heavily than non-ICU days. Expected WHD have been obtained by a regression model including severity of illness and the presence/absence of surgery. RESULTS: Ten of the 17 hospitals life within one standard deviation of the mean on both clinical and economical indices. There are 3 hospitals with optimal values on both indices. There is no evidence of association between effectiveness and resource utilization. CONCLUSIONS: Clinical and economical performance of hospitals can be quantified with simple indicators which allow to compare centers. Hospitals can be effective and efficient at the same time.

[Mediastinal non-Hodgkin's lymphoma: atypical presentation diagnosed with bronchoscopy]. / Linfoma no hodgkiniano mediastínico: presentación atípica con broncoscopia diagnóstica.

Primary mediastinal non-Hodgkin lymphoma is a rare entity that can manifests with secondary pulmonary involvement. The case of a 37 years-old man patient with non-Hodgkin lymphoma mixed B-cell, which was diagnosed by means of bronchoscopic biopsy, is presented. His characteristics clinical and radiologic presentation, and diagnostic usefulness of fiberoptic bronchoscopy, is remarked. We revised clinical and pathologic features of interests for this lymphoproliferative disorders with thoracic involvement.

Bone bacillary angiomatosis in an HIV-infected patient.

Bacillary angiomatosis (BA) is a recently discovered multisystem bacterial infectious disease seen in the setting of immune suppression due to the human immunodeficiency virus (HIV). A case of an HIV-infected patient with osteolytic bone involvement is reported.

Quantitative HIV-1 RNA as a marker of clinical stability and survival in a cohort of 302 patients with a mean CD4 cell count of 300 x 10(6)/l.

OBJECTIVE: To analyse plasma HIV-1 RNA levels as a marker of clinical stability and survival in a cohort of HIV-infected patients whose time of seroconversion is unknown. DESIGN: Retrospective cohort study. SETTING: Retrovirology laboratory and AIDS Unit in a teaching hospital. PATIENTS: A total of 916 samples from 302 patients, most on antiretroviral therapy, were analysed. Mean initial CD4 cell counts and HIV-1 RNA were 299 x 10(6)/l (range: 0-1600) and 134,261 copies/ml (range: < 200-4,300,000), respectively. Sixty-six cases had been diagnosed previously with AIDS. METHODS: Analysis of progression to AIDS and survival, according to initial and longitudinal viral load (VL) and CD4 cell count measurements was performed by Kaplan-Meier test. Relative risks were calculated by Cox's proportional hazards model. RESULTS: During a mean follow-up of 444 +/- 309 days, 29 patients developed AIDS and 21 died. Relative risk (RR) of progression related to the group with VL < 35,000 was: 10.4 when CD4 > or = 250 x 10(6)/l and VL > or = 35,000 (P = 0.001); and 45.3 when CD4 < 250 x 10(6)/l and VL > or = 35,000 (P < 0.0001). Cumulative probability of progression was: 0%, 0% and 12.3%, at the first, second and third year respectively, for patients with all their sequential VL determinations < 60,000; and 13.3%, 34.7% and 79.3% for patients who did not maintain VL values always < 60,000 (RR = 23; P < 0.0001). The minimum value of VL that reached statistical significance for the survival analysis was 100,000 copies/ml (P < 0.0001). CONCLUSIONS: VL > or = or < 35,000 is a better discriminant for progression than a CD4 cell count > or = or < 250 x 10(6)/l. Sequential VL determinations < 60,000 are associated with a better prognosis.

Resistance-related mutations in the HIV-1 protease gene of patients treated for 1 year with the protease inhibitor ritonavir (ABT-538).

OBJECTIVE: To define genotypic and phenotypic resistance patterns following prolonged therapy with the protease inhibitor ritonavir (ABT-538). DESIGN: Seven HIV-1-infected patients, all but one previously treated with dideoxynucleoside analogues (zidovudine, didanosine, zalcitabine), were treated for 1 year with ritonavir. METHODS: Direct solid-phase sequencing of the protease gene starting from plasma derived viral RNA followed by comparison to phenotypic drug resistance data. RESULTS: The most frequent amino-acid substitutions occurring upon administration of the protease inhibitor were V82A/F (substrate binding site), I54V (flap region), A71V and L10I. Additional mutations found in more than one patient were I15V, M36I, I84V and I93L. Mutation L63P was found both in pre- and post-ritonavir samples. Phenotypic drug resistance assays confirmed resistance to ritonavir in post-treatment samples (approximately 170-fold) and showed cross-resistance to indinavir (approximately 30-fold) and partially to saquinavir (approximately fivefold). At 1 year of treatment, one patient without known resistance-associated mutations in the protease gene still showed a substantial rise in CD4 cell count accompanied by a more than 2.4 log decrease in RNA viral load. However, at week 78, mutations R8Q, E34K, R57K, L63P and I84V were detected and the treatment benefit was partially lost. CONCLUSIONS: Long-term treatment with ritonavir is associated with the emergence of multiple mutations in the HIV-1 protease gene. The mutations L10I, I54V, L63P, A71V, V82A/F and I84V correspond to known drug-resistance mutations for ritonavir and other protease inhibitors. Phenotypic resistance to ritonavir was detected in a majority of ritonavir-treated patients at 1 year of treatment. In addition, long-term ritonavir treatment selects for cross-resistance to the protease inhibitors indinavir and saquinavir. This argues against sequential therapy with several protease inhibitors. Delayed resistance in one patient was accompanied with a prolonged increase in CD4 cell count and decrease in viral load suggesting a temporary benefit of treatment.

Aerosolized surfactant in adults with sepsis-induced acute respiratory distress syndrome. Exosurf Acute Respiratory Distress Syndrome Sepsis Study Group.

BACKGROUND: Patients with acute respiratory distress syndrome (ARDS) have a deficiency of surfactant. Surfactant replacement improves physiologic function in such patients, and preliminary data suggest that it may improve survival. METHODS: We conducted a prospective, multicenter, double-blind, randomized, placebo-controlled trial involving 725 patients with sepsis-induced ARDS. Patients were stratified according to the risk of death at base line (indicated by their score on the Acute Physiological and Chronic Health Evaluation [APACHE III] index) and randomly assigned to receive either continuously administered synthetic surfactant (13.5 mg of dipalmitoylphosphatidylcholine per milliliter, 364 patients) or placebo (o.45 percent saline; 361 patients) in aerosolized form for up to five days. RESULTS: The demographic and physiologic characteristics of the two treatment groups were similar at base line. The mean (+/- SD) age was 50 +/- 17 years in the surfactant group and 53 +/- 18 years in the placebo group, and the mean APACHE III scores at randomization were 70.4 +/- 25 and 70.5 +/- 25, respectively. Hemodynamic measures, measures of oxygenation, duration of mechanical ventilation, and length of stay in intensive care unit did not differ significantly in the two groups. Survival at 30 days was 60 percent for both groups. Survival was similar in the groups when analyzed according to APACHE III score, cause of death, time of onset and severity of ARDS, presence or absence of documented sepsis, underlying disease, whether or not there was a do-not-resuscitate order, and medical center. Increased secretions were significantly more frequent in the surfactant group; the rates of other complications were similar in the two groups. CONCLUSIONS: The continuous administration of aerosolized synthetic surfactant to patients with sepsis-induced ARDS had no significant effect on 30-day survival, length of stay in the intensive care unit, duration of mechanical ventilation, or physiologic function.

[Bronchogenic carcinoma in patients with human immunodeficiency virus infection]. / Carcinoma broncogénico en pacientes con infección por virus de la inmunodeficiencia humana.

The diagnosis of bronchogenic carcinoma (BC) in patients with HIV infection is infrequent. Five cases are described and the existing references reviewed. The incidence, risk factors, clinical manifestations, histology, age of onset, diagnosis and survival in HIV positive patients with BC were analyzed. The clinical histories of 2,586 patients with HIV infection seen in the authors' center were reviewed. Five cases in whom BC was detected were found. Sixty-nine cases published in the international literature were collected in a reference search by the MEDLINE system between 1982-1994. The patients with BC and HIV infection have an early age of presentation (mean age: 42 years) and a lower survival with respect to those without infection. No differences were observed with regard to the smoking habit, procedures for achieving diagnosis or clinical manifestation. The predominant histologic subtype was adenocarcinoma. A higher incidence of BC was observed in patients with HIV infection with respect to the control groups on elimination of the bias for age and risk factors for BC. Given its low incidence, BC should be considered in the differential diagnosis of pulmonary disease in patients with HIV infection in cases presenting a history of smoking, once the most common opportunistic infections have been discarded.