Differences in cerebral oxygenation during exercise in patients with idiopathic pulmonary fibrosis with and without exertional hypoxemia: does exercise intensity matter?

INTRODUCTION AND OBJECTIVES: Patients with idiopathic pulmonary fibrosis (IPF) present respiratory derangements at rest and during exercise, accompanied by exercise intolerance. Some patients may develop profound exertional desaturation even without resting hypoxemia. Evidence suggests the involvement of reduced cerebral-oxygenation in exercise intolerance. We aimed to examine (i) differences in cerebral-oxygenation during exercise between IPF patients with and without isolated exertional desaturation, (ii) whether the impairments in cerebral-oxygenation are detected at similar exercise intensity, and (iii) correlations between cerebral-oxygenation indices, disease severity, and 6-min walk test (6MWT). MATERIALS AND METHODS: Patients with IPF (n = 24; 62.1 ± 9.3 years) without resting hypoxemia underwent cardiopulmonary exercise testing (CPET) with cerebral-oxygenation monitoring via near-infrared-spectroscopy (NIRS). Βased on their pulse-oxymetry saturation (SpO2) during CPET, patients were divided into the "exertional-desaturators" group (SpO2nadir≤89% and ≥6% drop in SpO2) and the "non-exertional-desaturators" group (SpO2nadir≥90% and ≤5% drop). RESULTS: During CPET, the "exertional-desaturators" group exhibited lower oxygenated-hemoglobin (-0.67 ± 1.48 vs. 0.69 ± 1.75 µmol/l; p < 0.05) and higher deoxygenated-hemoglobin (1.67 ± 1.13 vs. 0.17 ± 0.62 µmol/l; p < 0.001) than the "non-exertional-desaturators" group. A different pattern (p < 0.01) in cerebral-oxygenation responses was observed in the two groups. In exertional-desaturators oxygenated-hemoglobin declined below baseline even at low/moderate-intensity exercise (p < 0.05), whereas, in non-exertional-desaturators cerebral-oxygenation declined (p < 0.05) at high-intensity exercise. Cerebral-NIRS indices correlated (p < 0.05) with CPET-duration, dyspnea, diffusion capacity, and 6MWT. CONCLUSIONS: During incremental exercise, patients with IPF and exertional desaturation present a significant decline in cerebral-oxygenation even during low-intensity exercise. Our findings support the implementation of longer-duration rehabilitation programs in IPF so that lower intensity exercise can be applied at the initial stages. (NCT03683082).

Chronic pain treatment with pregabalin in end stage respiratory failure patients awaiting lung transplantation on ambulatory veno-venous extra corporeal membrane oxygenator support; a series of nine cases.

Background: End-stage respiratory failure is non-treatable with mechanical ventilation and can be treated with veno-venous extracorporeal membrane oxygenators (VV-ECMO). It can also be used as a bridge to lung transplantation or recovery of lung function. This patient group can suffer from chronic pain, which is further exacerbated by painful procedures required as part of treatment. Pregabalin is licensed for chronic neuropathic pain and generalized anxiety disorder. Thus far, it has not been tried in routine analgesia protocols for pain relief of patients on VV-ECMO. Case Series: We included nine patients aged 17-54 years on VV-ECMO awaiting lung transplantation. Exclusion criteria were acute kidney injury and chronic kidney disease. All patients had morphine patient-control analgesia. In addition, pregabalin 50 mg twice daily was initiated in all patients with dose escalation as required. Pain scores and quality of sleep were evaluated daily. All patients experienced significant pain relief, demonstrated by reduced pain scores after treatment commencement. The mean visual analogue scale score was reduced significantly from 6 ± 2 to 3 ± 1. A significant increase in good-quality sleep duration was recorded from 5 ± 1.7 hours per day before to 8 ± 2.1 hours per day after pregabalin treatment. All patients except for two reported reduced anxiety levels of at least 2 ± 1 scale improvement (p <0.05). Conclusions: Pregabalin is an efficient analgesic with accompanying anxiolytic effects in this group of patients with unique characteristics such as high analgesia requirements and exacerbated psychological and emotional stress. HIPPOKRATIA 2023, 27 (1):22-24.

Nursing errors in intensive care unit and their association with burnout, anxiety, insomnia and working environment: a cross-sectional study.

BACKGROUND: In intensive care units (ICU), commonly identified nursing errors may have a negative impact on short- and long-term patient outcomes. Current data is scarce regarding nurses' burnout, insomnia, and anxiety impact on medication and several other types of nursing errors. This study aimed to record the commonness of various nursing errors, including checking patient data, medication preparation and administration, and infection control measures. It also aimed to investigate if "nurse-related" or "ICU-related" features may be associated with nursing error occurrence. MATERIAL-METHODS: A sample of nurses employed in four Greek ICUs was evaluated using the self-completed Athens Insomnia Scale, the State-Trait Anxiety Inventory Form Y, and the Maslach Burnout Inventory. Moreover, we also recorded the sociodemographic characteristics of the ICU nurses, data regarding nursing errors and common practices, and variables regarding the working environment. We conducted a multinominal regression analysis to identify the variables independently associated with each error/mistake. RESULTS: Ninety ICU nurses from the 99 addressed returned the completed questionnaires. The most frequent mistakes referred to drug preparation and administration, with 43.3 % of nurses reporting being "always/very often" distracted when preparing a drug and 90 % that "half of the times" they administer medication at unscheduled hours, followed in frequency by errors regarding the proper use of antiseptic solutions. Medication errors were independently predicted by state anxiety, satisfaction regarding training, emotional exhaustion score, number of ICU beds, and weekdays off work per month. In contrast, errors regarding infection control were independently associated with weekdays off work per month. CONCLUSION: Medication errors are the commonest type of nursing error. Although several risk factors have been identified, no universal "nurse-related" or "ICU-related" factor can predict all types of errors. HIPPOKRATIA 2022, 26 (3):110-117.

Burnout syndrome among emergency medicine physicians: an update on its prevalence and risk factors.

OBJECTIVE: Training in and practising emergency medicine are very stressful conditions that pose a significant emotional burden on physicians, placing them at high risk of developing burnout. The purpose of the current manuscript is to review the published literature on burnout prevalence among emergency medicine physicians and to identify the risk factors associated with its occurrence. MATERIALS AND METHODS: A search of MEDLINE (January 1980-March 2019) was conducted using the terms "burnout", "emergency", "physicians", "emotional exhaustion", "depersonalization" in various combinations. All studies, which assessed burnout prevalence (as primary or secondary outcome) among emergency medicine physicians and were published as full-text articles in English, were included in the review. RESULTS: Twenty-seven studies met eligibility criteria. Although the prevalence of burnout among emergency medicine physicians is high, the exact incidence widely varies ranging between 25% and 77.8%, because of the unique characteristics of each population under study, and also due to the different definitions, tools, and cut-offs used for burnout diagnosis. Several work-related parameters (heavy work-load, low job satisfaction, a problematic co-workers relationship, and difficulty in balancing personal with professional life), personality traits and stress-copying methods, life-style parameters, and other mental disorders (such as stress and sleep disorders) are associated with the establishment of burnout. CONCLUSIONS: Emergency medicine physicians are of a high risk of burnout, although further agreement is needed regarding the use of the Maslach Burnout Inventory as a diagnostic tool. Furthermore, the identification of the potential risk factors for this disorder is crucial so that high-risk groups could be early identified and properly addressed.

Rifampicin-moxifloxacin interaction in tuberculosis treatment: a real-life study.

SETTING: Rifampicin (RMP) has been reported to reduce moxifloxacin (MFX) levels, which may interfere with the effectiveness of MFX in treating tuberculosis (TB). OBJECTIVE: To study the MFX-RMP interaction in patients receiving MFX with or without RMP as part of their anti-tuberculosis treatment regimen. DESIGN: Patients with pulmonary TB followed up by the Tuberculosis Out-patient Clinic of the Pulmonary Department, Aristotle University of Thessaloniki, Greece, who underwent treatment with MFX during the periods 1 May 2012-30 April 2014 and 1 January-31 March 2015, were included in the study. MFX levels were compared between 12 patients who were receiving RMP (Group 1) and 10 who were not (Group 2). RESULTS: The participants did not significantly differ in body mass index, days of MFX treatment or MFX dose/kg. Neither the peak concentration (Cmax) nor the 24 h area under the curve (AUC24) differed significantly between the two groups (Group 1, Cmax median 3.9 [range 1.9-4.5] mg/l; AUC24 29.1 [10-47.4] mg·h/l and Group 2, Cmax 4.1 [2-6.4] mg/l; AUC24 36.5 [14.6-54.2] mg·h/l). CONCLUSION: Although a decrease in MFX exposure was observed in the RMP-treated group, the effect was lower than previously reported in a real-life setting. The large variability observed in MFX pharmacokinetics in both groups may suggest the need for dose readjustment in some patients, regardless of RMP co-administration.

Levels of inflammatory mediators in chronic obstructive pulmonary disease patients with anemia of chronic disease: a case-control study.

BACKGROUND: Although a subset of patients with chronic obstructive pulmonary disease (COPD) display anemia, the role of elevated pro-inflammatory cytokines in COPD-related anemia of chronic disease (ACD) has not been fully investigated. AIM: To examine the levels of interleukin (IL)-1ß, IL-6, IL-10, tumor necrosis factor-alpha (TNFα), interferon-gamma (IFNγ), C-reactive protein (CRP) and erythropoietin in stable COPD outpatients with and without ACD. DESIGN: A case-control design was followed. METHODS: Fifty-four patients with stable COPD were studied. Among them, 27 had ACD according to strict clinical and laboratory criteria (group of cases), while another 27 nonanemic COPD patients, carefully matched to cases for age, gender, height, lung function and smoking status represented the controls. Serum levels of IL-1ß, IL-6, IL-10, TNFα, IFNγ, CRP and erythropoietin were measured in both groups. RESULTS: Patients with ACD had significantly higher levels of IL-10 [25.6 (1.9-95.2) vs. 4.1 (1.9-31.9) pg/ml, P = 0.049] and IFNγ [15.2 (2.2-106.9) vs. 2 (1.2-18.3) pg/ml, P = 0.026] and had more frequently elevated CRP than controls. Levels of IL-1ß [26.2 (9.8-96.4) vs. 7.9 (2.1-28.4) pg/ml, P = 0.073], IL-6 [20.3 (2.1-125.4) vs. 6.2 (1.2-33.8) pg/ml, P = 0.688] and TNFα [30.1 (3.2-107.5) vs. 10.1 (3.2-50.4) pg/ml, P = 0.131] were also higher in cases, but the differences did not reach statistical significance. Patients with ACD also displayed significantly higher erythropoietin levels than controls [(21.9 (8.4-101.7) vs. 9.7 (6.3-21.7) mIU/ml, P = 0.010], indicating erythropoietin resistance. CONCLUSION: This study shows that in stable COPD outpatients with strictly defined ACD, levels of inflammatory mediators and erythropoietin are elevated compared to nonanemic controls.

Sildenafil may facilitate weaning in mechanically ventilated COPD patients: a report of three cases.

We report three cases of mechanically ventilated chronic obstructive pulmonary disease patients who were intubated due to an exacerbation of their disease and who presented with repeated spontaneous breathing trial failures. Patients were given 50 mg of sildenafil through the nasogastric tube, under close monitoring of haemodynamic and ventilatory parameters. After sildenafil, pulmonary artery pressure, pulmonary artery occlusion pressure, the respiratory frequency to tidal volume ratio and the P(a)CO2-P(ET)CO2 (arterial minus end-tidal carbon dioxide pressure) decreased. Cardiac output increased in two of the patients, while all of them were successfully extubated. This is the first report of successful extubation after sildenafil use.