Immunoglobulins IgG1, IgM and IgA: a synergistic team influencing survival in sepsis.

OBJECTIVE: The impact of endogenous immunoglobulin isotypes on the prognosis of patients with severe sepsis has not been sufficiently explored. The aim of this study was to evaluate the association between immunoglobulin levels in plasma and survival in patients with this condition. DESIGN AND PATIENTS: A prospective multicentre cohort study was conducted. A total of 172 adult patients admitted to the intensive care unit (ICU) with severe sepsis or septic shock were recruited. Patients were classified based on deciles of immunoglobulin concentrations at diagnosis of sepsis. Categorical variables were created and tested for their association with survival during hospitalization in the ICU. RESULTS: Overall, 42 patients died in the ICU during the study. Kaplan-Meier analysis showed that immunoglobulin concentrations below 300 mg dL(-1) for IgG1, 35 mg dL(-1) for IgM and 150 mg dL(-1) for IgA were associated with shorter survival times. Multivariate regression analysis showed that IgG1 < 300 mg dL(-1) was a risk factor for mortality [odds ratio (OR) 2.50, 95% confidence interval (CI) 1.04-6.03; P = 0.042]. The combined presence of IgG1, IgM and IgA levels below the described thresholds had a synergistic impact on mortality risk (OR 5.27, 95% CI 1.41-19.69; P = 0.013). A similar effect was observed for combined low levels of IgG1 and IgA (OR 4.10, 95% CI 1.28-13.12; P = 0.018) and also of IgG1 and IgM (OR 3.10. 95% CI 1.13-8.49; P = 0.028). CONCLUSIONS: The combined presence of low levels of the endogenous immunoglobulins IgG1, IgM and IgA in plasma is associated with reduced survival in patients with severe sepsis or septic shock. Assessment of the concentrations of these immunoglobulins could improve the results of treatment with exogenous immunoglobulins in patients with sepsis.

Static and dynamic experimental analysis of the galloping stability of porous H-section beams.

The phenomenon of self-induced vibrations of prismatic beams in a cross-flow has been studied for decades, but it is still of great interest due to their important effects in many different industrial applications. This paper presents the experimental study developed on a prismatic beam with H-section. The aim of this analysis is to add some additional insight into the behaviour of the flow around this type of bodies, in order to reduce galloping and even to avoid it. The influence of some relevant geometrical parameters that define the H-section on the translational galloping behaviour of these beams has been analysed. Wind loads coefficients have been measured through static wind tunnel tests and the Den Hartog criterion applied to elucidate the influence of geometrical parameters on the galloping properties of the bodies under consideration. These results have been completed with surface pressure distribution measurements and, besides, dynamic tests have been also performed to verify the static criterion. Finally, the morphology of the flow past the tested bodies has been visualised by using smoke visualization techniques. Since the rectangular section beam is a limiting case of the H-section configuration, the results here obtained are compared with the ones published in the literature concerning rectangular configurations; the agreement is satisfactory.

Evaluation of indexes predicting the outcome of ventilator weaning and value of adding supplemental inspiratory load.

OBJECTIVE: To assess the diagnostic accuracy of several measured and calculated indexes for early prediction of weaning outcome, and to study the value of supplemental inspiratory load in improving the accurate prediction of successful weaning. DESIGN: Prospective study. SETTING: ICU of a University Hospital. PATIENTS: Thirty consecutive patients under prolonged mechanical ventilation and without chronic obstructive pulmonary disease (COPD). INTERVENTIONS: Forty weaning trials were performed. Data were recorded at 15, 30 (adding inspiratory flow resistance), 60 and 120 min. MEASUREMENTS AND MAIN RESULTS: The threshold values and the accuracy of three indexes were determined: Inspiratory airway occlusion pressure at 0.1 sec. (P01) to maximum inspiratory pressure ratio (P01/MIP), inspiratory effort quotient (IEQ), and the ratio of respiratory frequency to tidal volume (F/Vt). All three were useful predictors for weaning success with a diagnostic accuracy between 82%-87%. At 15 min of spontaneous breathing, a P01/MIP ratio < 0.14 predicts weaning success with a sensitivity of 82% and specificity of 83%. In our group of patients no reintubation was necessary. The application of mechanical inspiratory load significantly increased P01 values (3.16 +/- 1.22 to 3.60 +/- 1.19, p < 0.001). The degree of the P01 increase did not provide prediction of weaning outcome. CONCLUSIONS: a) P01/MIP, IEQ and F/Vt ratio were accurate, early predictors of weaning outcome. b) The addition of a moderate mechanical inspiratory load did not enhance the diagnostic accuracy of P01 measurements. c) In our patients, a period of two hours seemed to be sufficient for development and detection of weaning failure.

[The evaluation of lung vascular compliance by the dobutamine stress test in patients who are candidates for extensive lung resections]. / Evaluación de la compliancia vascular pulmonar mediante prueba de esfuerzo con dobutamina en pacientes candidatos a resecciones pulmonares amplias.

This prospective descriptive study evaluated the utility of dobutamine in studying pulmonary vascular compliance in patients with lung neoplasms who are high risk candidates for lung resection. Seventeen consecutive patients meeting one of the following inclusion criteria were enrolled: FEV1 < 60% of theoretical value, FVC < 65%, residual volume > 130%. postoperative predictive FEV1 < 1,000 ml or PaO2 < 70 mmHg breathing room air. A Swan-Ganz catheter was inserted in the right side 24 h before surgery. The following data were recorded: heart rate (HR), mean pulmonary artery pressure (PAP), cardiac output, pulmonary vascular resistance (PVR) and arterial blood gas readings. Measurements were taken as follows: a) with the patient at rest breathing room air; b) after infusion of dobutamine 10 micrograms/kg/min; c) 30 min after breathing room air, and d) after surgery. Eleven of the 17 patients underwent pneumonectomy (5 left sided and 6 right sided). Bi-lobectomy was performed in 3 patients, segmentectomy was performed in 1 and lobectomy in 1. One patient did not undergo surgery because PAP was over 34 mmHg at baseline and did not decrease after oxygen administration. Dobutamine administration was associated with a significant increase in cardiac output (p < 0.001) and PAP (p < 0.05), with a significant decrease in PVR (p < 0.05), indicating good pulmonary vascular reserve in our cohort. No patient suffered serious complications in the postoperative period and all were released from the hospital. There were no complications related to dobutamine perfusion. We conclude that the study of pulmonary vascular function with dobutamine in high risk candidates for extensive lung resection may be a simple method for evaluating pulmonary vascular compliance before surgery, although its possible usefulness still remains to be determined.

[Recording effective capillary pressure: a useful technique in post-pneumonectomy edema]. / Registro de la presión capilar efectiva: una técnica útil en el edema posneumonectomía.

Three cases of postpneumonectomy edema, in which hemodynamic stability was monitored with a Swan-Ganz catheter, are described. Measurement of pressure in the pulmonary capillary was based on the pulmonary artery occlusion curve. High capillary pressure and normal wedge pressure were observed in all 3 cases, suggesting that the rise in net filtration pressure as a consequence of excess flow is the pathogenic mechanism that triggers edema after pneumonectomy. We emphasize that measurement of effective pulmonary capillary pressure allows for more accurate assessment of the hemodynamic status of such patients than does the measurement of wedge pressure.

[Subarachnoid hemorrhage: electrocardiographic, left ventricular wall motion abnormalities and mortality analysis in 14 cases]. / Hemorragia subaracnoidea: anomalías electrocardiográficas, de la contractilidad del ventrículo izquierdo y análisis de la mortalidad en 14 casos.

BACKGROUND: Electrocardiographic (ECG) changes have been frequently observed in patients with subarachnoid hemorrhage (SAH). Their association with wall motion abnormalities of the left ventricle (LV) have not been well established. PATIENTS AND METHODS: Sixteen patients with SAH were included; 2 patients with previous history of heart disease were subsequently excluded. We studied the neurological damage (Hunt-Hess grading scale), ECG (ST segment, T wave) and echocardiography (LV regional and global contractility) of 14 patients. RESULTS: The ECG was abnormal in 11 patients (T wave: 6 patients; ST segment: 5 patients). Echocardiography showed alterations in 5 patients, all of them with ECG changes (T wave: one patient; ST segment: 4 patients). The neurological lesion was higher in patients with abnormal echocardiogram (Hunt-Hess mean grade: 4.6 vs 2.7 in patients with normal echocardiogram; p < 0.001). An intravenous infusion of dobutamine in a 23 years old male, improved the LV ejection fraction, which was severely depressed at baseline. Mortality, in all cases secondary to the neurological damage, was higher in patients with abnormal ECG (91% vs 0% in patients with normal ECG; p = 0.01) and when the echocardiogram showed alterations although in the last case no statistical differences were found. CONCLUSIONS: Echocardiography abnormalities in patients with SAH and without previous history of heart disease are more frequently related to ECG changes affecting ST segment, and to a higher cerebral damage.

[Evaluation of the reproducibility of the data collection for the APACHE II, APACHE III adapted for Spain and the SAPS II in nine intensive care units in Spain]. / Evaluación de la reproducibilidad de la recogida de datos para el APACHE II, APACHE III adaptado para España y SAPS II en 9 Unidades de Cuidados Intensivos en España.

OBJECTIVE: To assess reproducibility in data collection and its influence on the calculation of the severity scoring and mortality risk in APACHE II, APACHE III adapted for Spain and SAPS II. DESIGN: Multicenter, prospective, observational cohort study. SETTING: Nine Spanish Intensive Care Units (ICUs). PATIENTS: 1,211 consecutive patients admitted during the study period were included. Those patients under 16 years of age, those with a stay in the ICU of less than 24 hours, those admitted for scheduled pacemaker implant and those readmitted to the ICU within the same hospital admission were excluded. INTERVENTION: None. ENDPOINTS OF INTEREST: The data needed to calculate the severity and mortality risk scores were collected. A total of 10% of the patients were chosen by simple random sampling and the same data were collected by an independent group of intensive care physicians. Finally, the data obtained by the two groups of intensivists were compared. RESULTS: Significant differences were detected in the acute physiology score (APS) and severity score used for the calculation of APACHE III and SAPS II, and the predicted risk of death calculated for SAPS II. The percentage of agreement on admission diagnosis to the ICU was 50% for both APACHE II and III models. Nonetheless, in most of the patients (76.58% for APACHE II and 79.82% for APACHE III), the difference in the predicted risk of death due to the different assignation of diagnoses on admission to the ICU was less than 10%. CONCLUSIONS: In this study, APS was the most influential factor on the reproducibility of severity scores and risk of death prediction. Admission diagnosis assignment had no significant impact on the reproducibility of the predicted mortality risk.

Epidemiology of acute carbon monoxide poisoning in a Spanish region.

BACKGROUND: In Spain, as in most of the world, the incidence of acute carbon monoxide poisoning is probably underestimated. METHODS: During an eighteen-month period we studied, by means of a standardized data collection form, all the cases of acute carbon monoxide poisoning that were diagnosed in 2 university hospitals. RESULTS: During the study, 154 patients were diagnosed with carbon monoxide poisoning. The mean age was 32.2+/-15.5 years. The two principal exposure sites were the kitchen (43%) and bathroom (23%). The majority of the cases related to malfunction of the water heater (30%) and of the central heating (23%) and 68% occurred in the home. Improper combustion of butane (31%), propane (13%), and natural gas (12%) were most frequent. The most prevalent clinical manifestations were headache (94%), dizziness (56%), nausea (45%), loss of consciousness (38%), and weakness (34%). Five patients died. In 14.4%, symptoms suggested delayed neurological syndrome. The largest number of cases of poisoning occurred during the months of December and January. CONCLUSIONS: Compared with previous Spanish series or with the antecedent year, acute carbon monoxide poisoning has a high prevalence in our region. Two factors appear to be essential to the accurate diagnosis of acute carbon monoxide poisoning: 1) the ability of emergency room physicians to recognize the clinical symptoms of carbon monoxide poisoning and 2) access to a carbon monoxide-oximeter.