A comparative assessment of small-head metal-on-metal and ceramic-on-polyethylene total hip replacement.

Large-head metal-on-metal (MoM) total hip replacements (THR) have given rise to concern. Comparative studies of small-head MoM THRs over a longer follow-up period are lacking. Our objective was to compare the incidence of complications such as infection, dislocation, revision, adverse local tissue reactions, mortality and radiological and clinical outcomes in small-head (28 mm) MoM and ceramic-on-polyethylene (CoP) THRs up to 12 years post-operatively. A prospective cohort study included 3341 THRs in 2714 patients. The mean age was 69.1 years (range 24 to 98) and 1848 (55.3%) were performed in women, with a mean follow-up of 115 months (18 to 201). There were 883 MoM and 2458 CoP bearings. Crude incidence rates (cases/1000 person-years) were: infection 1.3 vs 0.8; dislocation 3.3 vs 3.1 and all-cause revision 4.3 vs 2.2, respectively. There was a significantly higher revision rate after ten years (adjusted hazard ratio 9.4; 95% CI 2.6 to 33.6) in the MoM group, and ten of 26 patients presented with an adverse local tissue reaction at revision. No differences in mortality, osteolysis or clinical outcome were seen. In conclusion, we found similar results for small-head MoM and CoP bearings up to ten years post-operatively, but after ten years MoM THRs had a higher risk of all-cause revision. Furthermore, the presence of an adverse response to metal debris seen in the small-head MOM group at revision is a cause for concern.

Secreted phosphoprotein-1 directly provokes vascular leakage to foster malignant pleural effusion.

Secreted phosphoprotein-1 (SPP1) promotes cancer cell survival and regulates tumor-associated angiogenesis and inflammation, both central to the pathogenesis of malignant pleural effusion (MPE). Here, we examined the impact of tumor- and host-derived SPP1 in MPE formation and explored the mechanisms by which the cytokine exerts its effects. We used a syngeneic murine model of lung adenocarcinoma-induced MPE. To dissect the effects of tumor- versus host-derived SPP1, we intrapleurally injected wild-type and SPP1-knockout C57/BL/6 mice with either wild-type or SPP1-deficient syngeneic lung cancer cells. We demonstrated that both tumor- and host-derived SPP1 promoted pleural fluid accumulation and tumor dissemination in a synergistic manner (P<0.001). SPP1 of host origin elicited macrophage recruitment into the cancer-affected pleural cavity and boosted tumor angiogenesis, whereas tumor-derived SPP1 curtailed cancer cell apoptosis in vivo. Moreover, the cytokine directly promoted vascular hyper-permeability independently of vascular endothelial growth factor. In addition, SPP1 of tumor and host origin differentially affected the expression of proinflammatory and angiogenic mediators in the tumor microenvironment. These results suggest that SPP1 of tumor and host origin impact distinct aspects of MPE pathobiology to synergistically promote pleural fluid formation and pleural tumor progression. SPP1 may present an attractive target of therapeutic interventions for patients with MPE.

Intermittent recruitment with high-frequency oscillation/tracheal gas insufflation in acute respiratory distress syndrome.

In acute respiratory distress syndrome (ARDS), recruitment sessions of high-frequency oscillation (HFO) and tracheal gas insufflation (TGI) with short-lasting recruitment manoeuvres (RMs) may improve oxygenation and enable reduction of subsequent conventional mechanical ventilation (CMV) pressures. We determined the effect of adding HFO-TGI sessions to lung-protective CMV on early/severe ARDS outcome. We conducted a prospective clinical trial, subdivided into a first single-centre period and a second two-centre period. We enrolled 125 (first period, n = 54) patients with arterial oxygen tension (P(a,O(2)))/inspiratory oxygen fraction (F(I,O(2))) of <150 mmHg for >12 consecutive hours at an end-expiratory pressure of ≥ 8 cmH(2)O. Patients were randomly assigned to an HFO-TGI group (receiving HFO-TGI sessions with RMs, interspersed with lung-protective CMV; n = 61) or CMV group (receiving lung-protective CMV and RMs; n = 64). The primary outcome was survival to hospital discharge. Pre-enrolment ventilation duration was variable. During days 1-10 post-randomisation, P(a,O(2))/F(I,O(2))), oxygenation index, plateau pressure and respiratory compliance were improved in the HFO-TGI group versus the CMV group (p < 0.001 for group × time). Within days 1-60, the HFO-TGI group had more ventilator-free days versus the CMV group (median (interquartile range) 31.0 (0.0-42.0) versus 0.0 (0.0-23.0) days; p < 0.001), and more days without respiratory, circulatory, renal, coagulation and liver failure (p ≤ 0.003). Survival to hospital discharge was higher in the HFO-TGI group versus the CMV group (38 (62.3%) out of 61 versus 23 (35.9%) out of 64 subjects; p = 0.004). Intermittent recruitment with HFO-TGI and RMs may improve survival in early/severe ARDS.

Rohrer's constant, K2, as a factor of determining inspiratory resistance of common adult endotracheal tubes.

The aim of the study was to calculate the in vitro inspiratory resistance (R(ETT)) of adult endotracheal tubes (ETT), via the end-inspiratory occlusion method, and to apply this method in vivo in order to estimate R(ETT) value in real time. By plotting R(ETT) over inspiratory flow (V) and calculating Rohrer's coefficients of linear and nonlinear resistance, K1 and K2 respectively, we determined the resistive behaviour of each ETT. Peak and plateau pressures were recorded at both proximal and distal sites of the ETT after applying a three-second occlusion under constant flow. Distal pressure was obtained via an intraluminal catheter R(ETT) was calculated as (P(peak) - P(plateau))/(V), at both sites. R(ETT) value resulted from the difference R(proximal) - R(distal). Graph R(ETT) over (V) was plotted and Rohrer's constants were calculated by the method of least squares. For ETTs with inner diameter 9.0, 8.5, 8.0, 7.5, 7.0 and 6.5 mm, K2 was 2.42, 3.05, 4.65, 6.01, 9.17 and 12.80 cmH2O/l/s, respectively. The intraluminal catheter increased R(ETT) No.7.0 by an average of 49%. Finally, ten patients with partially obstructed ETTs were tested and K2 in vivo constants found to be higher than their corresponding in vitro values (P value 0.00012). Therefore, knowing the performing size of an ETT may help the clinicians identify ETT obstruction and deal with weaning problems.

Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification.

Nasal continuous positive airway pressure (CPAP) can cause undesirable nasal symptoms, such as congestion to obstructive sleep apnoea (OSA) patients, whose symptoms can be attenuated by the addition of heated humidification. However, neither the nature of nasal symptoms nor the effect of heated humidification on nasal pathophysiology and pathology are convincingly known. 20 patients with OSA on nasal CPAP who exhibited symptomatic nasal obstruction were randomised to receive either 3 weeks of CPAP treatment with heated humidification or 3 weeks of CPAP treatment with sham-heated humidification, followed by 3 weeks of the opposite treatment, respectively. Nasal symptom score, nasal resistance, nasal lavage interleukin-6, interleukin-12 and tumour necrosis factor-α and nasal mucosa histopathology were assessed at baseline and after each treatment arm. Heated humidification in comparison with sham-heated humidification was associated with decrease in nasal symptomatology, resistance and lavage cytokines, and attenuation of inflammatory cell infiltration and fibrosis of the nasal mucosa. In conclusion, nasal obstruction of OSA patients on CPAP treatment is inflammatory in origin and the addition of heated humidification decreases nasal resistance and mucosal inflammation.

Carbapenem-resistant versus carbapenem-susceptible Acinetobacter baumannii bacteremia in a Greek intensive care unit: risk factors, clinical features and outcomes.

BACKGROUND: There has been an increasing incidence of carbapenem-resistant Acinetobacter baumannii (CRAB) infections in recent years. The objective of this study was to determine specific risk factors for and outcome of bacteremia due to CRAB isolates among our ICU patients with A. baumannii bacteremia. PATIENTS AND METHODS: Among 96 patients with ICU-acquired A. baumannii bacteremia, 30 patients with CRAB were compared with the remaining 66 with carbapenem-susceptible A. baumannii (CSAB) isolates. RESULTS: Recent ventilator-associated pneumonia (VAP) due to CRAB (OR 16.74, 95% CI 3.16-88.79, p = 0.001) and a greater number of intravascular devices (OR 3.93, 95% CI 1.9-13.0, p = 0.025) were independently associated with CRAB bacteremia acquisition. Patients with CRAB bacteremia had a lower severity of illness on admission than those with CSAB. Although, by univariate analysis, patients with CRAB were more likely to have had exposure to colistin, carbapenems and linezolid, multivariate analysis did not revealed any significant association. The mortality was not different between patients with CRAB and CSAB bacteremia (43.3 vs. 46.9%, p = 0.740). Severity of organ failure (OR 1.42, 95% CI 1.20-1.67, p = 0.001), and increased white blood cell (WBC) count (OR 1.09, 95% CI 1.01-1.19, p = 0.036), at bacteremia onset were independently associated with mortality. CONCLUSION: VAP due to CRAB and excess use of intravascular devices are the most important risk factors for CRAB bacteremia in our ICU. Severity of organ failure and WBC count at A. baumannii bacteremia onset are independently associated with mortality.

Effect of pulmonary rehabilitation on muscle remodelling in cachectic patients with COPD.

It is known that non-cachectic patients with chronic obstructive pulmonary disease (COPD) respond well to pulmonary rehabilitation, but whether cachectic COPD patients are capable of adaptive responses is both important and unknown. 10 cachectic and 19 non-cachectic COPD patients undertook high-intensity cycling training, at the same relative intensity, for 45 min x day(-1), 3 days x week(-1) for 10 weeks. Before and after rehabilitation vastus lateralis muscle biopsies were analysed morphologically and for the expression of muscle remodelling factors (insulin-like growth factor (IGF)-I, myogenic differentiation factor D (MyoD), tumour necrosis factor (TNF)-alpha, nuclear factor (NF)-kappaB and myostatin) and key components of ubiquitin-mediated proteolytic systems (muscle ring finger protein (MURF)-1 and Atrogin-1). Rehabilitation improved peak work-rate and the 6-min walk distance similarly in non-cachectic (18+/-3% and 42+/-13 m, respectively) and cachectic (16+/-2% and 53+/-16 m, respectively) patients, but quality of life only improved in non-cachectic COPD. Mean muscle fibre cross-sectional area increased in both groups, but significantly less in cachectic (7+/-2%) than in non-cachectic (11+/-2%) patients. Both groups equally decreased the proportion of type IIb fibres and increased muscle capillary/fibre ratio. IGF-I mRNA expression increased in both groups, but IGF-I protein levels increased more in non-cachectic COPD. MyoD was upregulated, whereas myostatin was downregulated at the mRNA and protein level only in non-cachectic patients. Whilst rehabilitation had no effect on TNF-alpha expression, it decreased the activation of the transcription factor NF-kappaB in both groups by the same amount. Atrogin-1 and MURF-1 expression were increased in cachectic COPD, but it was decreased in non-cachectic patients. Cachectic COPD patients partially retain the capacity for peripheral muscle remodelling in response to rehabilitation and are able to increase exercise capacity as much as those without cachexia, even if they exhibit both quantitative and qualitative differences in the type of muscle fibre remodelling in response to exercise training.

Non-invasive assessment of the microcirculation in critically ill patients.

Sepsis is associated with abnormalities of muscle tissue oxygenation and of microvascular function. We investigated whether the technique of near-infrared spectroscopy can evaluate such abnormalities in critically ill patients and compared near-infrared spectroscopy-derived indices of critically ill patients with those of healthy volunteers. We studied 41 patients (mean age 58 +/- 22 years) and 15 healthy volunteers (mean age 49 +/- 13 years). Patients were classified into one of three groups: systemic inflammatory response syndrome (SIRS) (n = 21), severe sepsis (n = 8) and septic shock (n = 12). Near-infrared spectroscopy was used to continuously measure thenar muscle oxygen saturation before, during and after a three-minute occlusion of the brachial artery via pneumatic cuff. Oxygen saturation was significantly lower in patients with SIRS, severe sepsis or septic shock than in healthy volunteers. Oxygen consumption rate during stagnant ischaemia was significantly lower in patients with SIRS (23.9 +/- 7.7%/minute, P < 0.001), severe sepsis (16.9 +/- 3.4%/minute, P < 0.001) or septic shock (14.8 +/- 6%/minute, P < 0.001) than in healthy volunteers (35.5 +/- 10.6%/minute). Furthermore, oxygen consumption rate was significantly lower in patients with septic shock than patients with SIRS. Reperfusion rate was significantly lower in patients with SIRS (336 +/- 141%/minute, P < 0.001), severe sepsis (257 +/- 150%/minute, P < 0.001) or septic shock (146 +/- 101%/minute, P < 0.001) than in healthy volunteers (713 +/- 223%/minute) and significantly lower in the septic shock than in the SIRS group. Near-infrared spectroscopy can detect tissue oxygenation deficits and impaired microvascular reactivity in critically ill patients, as well as discriminate among groups with different disease severity.

Predictors of residual sleepiness in adequately treated obstructive sleep apnoea patients.

Some patients with obstructive sleep apnoea syndrome (OSAS; respiratory distress index (RDI) of >5 events.h(-1)) experience residual excessive daytime subjective sleepiness (Epworth Sleepiness Scale (ESS) score of >10), despite adequate use of continuous positive airway pressure (CPAP) therapy. The aim of the present study was to identify clinical and polysomnographic predictors of this sleepiness. Clinical and polysomnographic variables and ESS score were evaluated in 208 OSAS patients with an ESS score of >10 before (initial assessment) and after > or =6 months of adequate (> or =4 h.day(-1)) CPAP use. Following CPAP treatment, 114 (55%) patients showed an abnormal ESS score (>10; CPAP nonresponders), whereas 94 (45%) showed a normal ESS score (<11; CPAP responders). Of the CPAP responders, none had a history of depression, whereas the converse was true for 38.8% of CPAP nonresponders. In addition, multivariate logistic regression analysis revealed that the independent predictors of residual excessive daytime sleepiness following CPAP therapy were a history of diabetes and heart disease, and a higher ESS score and lower RDI on initial assessment. In conclusion, predictors of residual excessive sleepiness in adequately CPAP-treated OSAS were a history of depression, diabetes and heart disease, and a higher ESS score and lower RDI on initial assessment.

Effect of heliox breathing on flow limitation in chronic heart failure patients.

Patients with chronic heart failure (CHF) exhibit orthopnoea and tidal expiratory flow limitation in the supine position. It is not known whether the flow-limiting segment occurs in the peripheral or central part of the tracheobronchial tree. The location of the flow-limiting segment can be inferred from the effects of heliox (80% helium/20% oxygen) administration. If maximal expiratory flow increases with this low-density mixture, the choke point should be located in the central airways, where the wave-speed mechanism dominates. If the choke point were located in the peripheral airways, where maximal flow is limited by a viscous mechanism, heliox should have no effect on flow limitation and dynamic hyperinflation. Tidal expiratory flow limitation, dynamic hyperinflation and breathing pattern were assessed in 14 stable CHF patients during air and heliox breathing at rest in the sitting and supine position. No patient was flow-limited in the sitting position. In the supine posture, eight patients exhibited tidal expiratory flow limitation on air. Heliox had no effect on flow limitation and dynamic hyperinflation and only minor effects on the breathing pattern. The lack of density dependence of maximal expiratory flow implies that, in CHF patients, the choke point is located in the peripheral airways.

Use of extracorporeal circulation and selective renal perfusion during the surgical correction of abdominal aortic coarctation.

Coarctation of the abdominal aorta is a rare pathology. Stenosis of visceral and renal arteries may present together with coarctation, which requires specific operation techniques. We present the case of a patient with coarctation of the abdominal aorta associated with stenosis of the celiac trunk, the superior mesenteric and the right renal arteries. Distal aortic perfusion by extracorporeal circulation and selective right renal perfusion techniques were used during the operation to protect the spinal cord and kidney against hypoperfusion and ischemia.

Exercise-induced skeletal muscle deoxygenation in O-supplemented COPD patients.

This study was designed to assess quadriceps oxygenation during symptom-limited and constant-load exercise in patients with chronic obstructive pulmonary disease (COPD) and healthy age-matched controls. Thirteen male COPD patients [FEV(1): 43 +/- 5% predicted (mean +/- SEM)] and seven healthy male controls performed an incremental exercise test at peak work rate (WR) and a constant-load test at 75% peak WR on a cycle ergometer. Quadriceps hemoglobin saturation (StO2) was measured by continuous-wave near-infrared spectrophotometry throughout both exercise tests. StO2 is the ratio of oxygenated hemoglobin to total hemoglobin and reflects the relative contributions of tissue O2 delivery and tissue O2 utilization. Oxygen was supplemented to all patients in order to maintain arterial O2 saturation normal (> 95%). The StO2 decreased during symptom-limited exercise, reaching the nadir at peak WR. The decrease in StO2 was greater (P < 0.05) in healthy subjects (from 74 +/- 2% to 38 +/- 6%) compared with that in COPD patients (from 61 +/- 5% to 45 +/- 4%). However, when StO2 was normalized relative to the WR, the slope of change in StO2 during exercise was nearly identical between COPD patients and healthy subjects (0.47 +/- 0.10%/W and 0.51 +/- 0.04%/W, respectively). During constant-load exercise, the kinetic time constant of StO2 desaturation after the onset of exercise (i.e., equivalent to time to reach approximately 63% of StO2 decrease) was not different between COPD patients and healthy subjects (19.0 +/- 5.2 and 15.6 +/- 2.5 s, respectively). In O2-supplemented COPD patients, peripheral muscle oxygenation for a given work load is similar to that in healthy subjects, thus suggesting that skeletal muscle O2 consumption becomes normal for a given O2 delivery in COPD patients

Risk factors for and influence of bloodstream infections on mortality: a 1-year prospective study in a Greek intensive-care unit.

To determine the incidence, risk factors for, and the influence of bloodstream infections (BSIs) on mortality of patients in intensive-care units (ICUs), prospectively collected data from all patients with a stay in an ICU >48 h, during a 1-year period, were analysed. Of 572 patients, 148 developed a total of 232 BSI episodes (incidence 16.3 episodes/1000 patient-days). Gram-negative organisms with high level of resistance to antibiotics were the most frequently isolated pathogens (157 strains, 67.8%). The severity of illness on admission, as estimated by APACHE II score (OR 1.07, 95% CI 1.04-1.1, P<0.001), the presence of acute respiratory distress syndrome (OR 3.57, 95% CI 1.92-6.64, P<0.001), and a history of diabetes mellitus (OR 2.37, 95% CI 1.36-4.11, P=0.002) were risk factors for the occurrence of BSI whereas the development of an ICU-acquired BSI was an independent risk factor for death (OR 1.76, 95% CI 1.11-2.78, P=0.015). Finally, the severity of organ dysfunction on the day of the first BSI episode, as estimated by SOFA score, and the level of serum albumin, independently affected the outcome (OR 1.44, 95% CI 1.22-1.7, P<0.001 and OR 0.47, 95% CI 0.23-0.97, P=0.04 respectively).

Thoracoabdominal motion in ankylosing spondylitis: association with standardised clinical measures and response to therapy.

OBJECTIVES: To assess the relationship between thoracoabdominal motion during quiet breathing and standardised indices of disease severity in patients with ankylosing spondylitis (AS); also to evaluate whether thoracoabdominal motion improves after institution of biological agents in these patients. METHODS: Displacement of the rib cage (RC) and abdomen (Abd) during quiet breathing in the sitting, standing and supine position were recorded by impedance plethysmography in 60 patients (mean (SD) age 41 (10) years, 56 men) and 21 healthy men (mean (SD) 36 (7) years). x-y plots of RC versus Abd displacement during quiet breathing were constructed, and the angle of the slope of the RC-Abd loop was calculated and averaged for five consecutive breaths. In 13 patients treated with anti-tumour necrosis factor alpha (TNFalpha), measurements were made before and at 3, 6 and 12 months after the start of treatment. RESULTS: In the entire AS group, the angle of the slope of the RC-Abd loop correlated with Bath Ankylosing Spondylitis Functional Index (BASFI) in the sitting (R = -0.50, p<0.0001), standing (R = -0.36, p = 0.004) and supine (R = -0.47, p = 0.0001) position, but not with Bath Ankylosing Spondylitis Disease Activity (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI) or the modified Schober's test. In 13 patients treated with anti-TNFalpha, the angle of the RC-Abd slope improved significantly (35-69% over baseline at 3 months) in all body positions and in a nearly parallel fashion with the improvements in standardised clinical measurements. CONCLUSIONS: The pattern of thoracoabdominal motion during quiet breathing correlates with BASFI, and its response to anti-TNFalpha treatment is large. This variable may be an appropriate target for evaluating potential usefulness in monitoring thoracic spine involvement and response to treatment in AS.

Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory failure.

Airway inaccessibility is one of the most dreaded situations in emergency medicine. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Emergency percutaneous tracheostomy (PCT) was widely regarded as absolutely counterindicated. Recently, however, a number of studies have appeared on the safety and feasibility of PCT in situations regarded as presenting relative contraindications. We describe the life-saving action of Griggs' PCT in a patient with upper airway obstruction resulting from burns, smoke injuries, and unsuccessful tracheal intubation attempts. Emergency PCT using the Griggs technique was immediately performed without aseptic care, and a 9-mm internal diameter tracheostomy tube was successfully inserted in less than one minute. Griggs' PCT is a quick technique that secures an airway when tracheal intubation fails. The feasibility - in selected cases - of using an emergency Griggs' PCT, in experienced hands, rather than cricothyroidotomy or surgical tracheostomy, is recommended.

cGMP-independent anti-tumour actions of the inhibitor of soluble guanylyl cyclase, ODQ, in prostate cancer cell lines.

BACKGROUND AND PURPOSE: Soluble guanylyl cyclase (sGC) is a receptor for nitric oxide that generates cGMP. This second messenger molecule has established roles in cellular physiology; however, less is known about its effects in tumour cells. EXPERIMENTAL APPROACH: The effects of 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) and 4H-8-bromo-1,2,4-oxadiazolo(3,4-d)benz(b)(1,4)oxazin-1-one (NS2028), both selective sGC inhibitors on proliferation, death and migration were determined in prostate cancer cell lines. KEY RESULTS: Western blot analysis confirmed the presence of alpha1 and beta1 subunits of sGC in LNCaP and PC-3 cells. Sodium nitroprusside (SNP) increased cGMP accumulation in LNCaP and PC-3, but not DU-145 cells. SNP-stimulated cGMP production in LNCaP cells was dose-dependently reduced by ODQ, with more than 90% inhibition being observed at 0.1 microM. ODQ activated caspase-3 in all three cell lines, but not in normal prostate epithelial cells, at concentrations over 10 muM. High concentrations of ODQ also promoted DNA fragmentation and nucleosome accumulation in the cytosol of LNCaP cells. Interestingly, the chemically related inhibitor, NS2028 was without effect on caspase-3. In addition, ODQ inhibited LNCaP, Du145 and PC-3 cell growth. Finally, although fibroblast growth factor-2 did not enhance cGMP levels in LNCaP cells, its ability to stimulate LNCaP motility was abolished by ODQ. CONCLUSIONS AND IMPLICATIONS: These observations taken together suggest that the action of ODQ in LNCaP cells did not reflect sGC inhibition. We conclude that ODQ promotes cell death and inhibits growth and migration of prostate cancer cells and that these actions are independent of its effects on GMP levels.

Predisposing factors for critical illness polyneuromyopathy in a multidisciplinary intensive care unit.

OBJECTIVE: To investigate risk factors of critical illness polyneuromyopathy (CIPM) in a general multidisciplinary intensive care unit (ICU). PATIENTS AND METHODS: Prospective observational study in a 28-bed university multidisciplinary ICU. Four hundred and seventy-four (323 M/151 F, age 55 +/- 19) consecutive patients were prospectively evaluated. All patients were assigned admission Acute Physiology and Chronic Health Evaluation (APACHE II; 15 +/- 7) and Sequential Organ Failure Assessment (SOFA; 6 +/- 3) scores and were subsequently evaluated for newly developed neuromuscular weakness. Other potential causes of new-onset weakness after ICU admission were excluded before CIPM was diagnosed. RESULTS: Forty-four (23.8%) of 185 patients developed generalized weakness that met the criteria for CIPM. Patients with CIPM had higher APACHE II (18.9 +/- 6.6 vs 15.6 +/- 6.4, P = 0.004) and SOFA scores (8.4 +/- 2.9 vs 7.1 +/- 2.9, P = 0.013). According to multivariate logistic regression analysis, the following risk factors were independently associated with the development of CIPM: severity of illness at the time of ICU admission, administration of aminoglycoside antibiotics and high blood glucose levels. Analysis according to severity of illness stratification revealed the emergence of Gram (-) bacteremia as the most important independent predisposing factor for CIPM development in less severely ill patients. CONCLUSIONS: CIPM has a high incidence in the ICU setting. Our study revealed the association of aminoglycosides, hyperglycemia and illness severity with CIPM development, as well as the association between Gram (-) bacteremia and development of CIPM in less severely ill patient population.

Chest wall volume regulation during exercise in COPD patients with GOLD stages II to IV.

The present study investigated how end-expiratory ribcage and abdominal volume regulation during exercise is related to the degree of dynamic chest wall hyperinflation in patients with different spirometric severity of chronic obstructive pulmonary disease (COPD) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification. In total, 42 COPD patients and 11 age-matched healthy subjects were studied during a ramp-incremental cycling test to the limit of tolerance (W(peak)). Volume variations of the chest wall (at end expiration (EEV(cw)) and end inspiration) and its compartments (ribcage (V(rc)) and abdominal (V(ab))) were computed by optoelectronic plethysmography. At W(peak), only patients in GOLD stages III and IV exhibited a significant increase in EEV(cw) (increase of 454+/-509 and 562+/-363 mL, respectively). These patients did not significantly reduce end-expiratory V(ab), whereas patients in GOLD stage II resembled healthy subjects with significantly reduced end-expiratory V(ab) (decrease of 287+/-350 mL). In patients, the greater the increase in EEV(cw) at W(peak), the smaller the reductions in end-expiratory V(ab) and the greater the increase in end-expiratory V(rc). In chronic obstructive pulmonary disease patients with different spirometric disease severity, greater degrees of exercise-induced dynamic chest wall hyperinflation were accompanied by lower degrees of end-expiratory abdominal volume displacement and larger increases in end-expiratory ribcage volume.