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PloS One 2023Pulmonary expansion manoeuvres are therapeutic techniques used to prevent and reverse atelectasis; however, no randomized controlled trials have provided evidence... (Randomized Controlled Trial)
Randomized Controlled Trial
Pulmonary expansion manoeuvres compared to usual care on ventilatory mechanics, oxygenation, length of mechanical ventilation and hospital stay, extubation, atelectasis, and mortality of patients in mechanical ventilation: A randomized clinical trial.
UNLABELLED
Pulmonary expansion manoeuvres are therapeutic techniques used to prevent and reverse atelectasis; however, no randomized controlled trials have provided evidence supporting the use of this intervention among individuals on mechanical ventilation.
OBJECTIVE
To evaluate the effects of chest compression-decompression and chest block manoeuvres compared to usual care among patients on mechanical ventilation.
METHODS
The current study was a randomized clinical trial of adult subjects on mechanical ventilation for 12 to 48 hours. The control group received usual care (passive or active mobilization, manoeuvres for airway clearance and tracheal aspiration). The intervention group received usual care plus two lung expansion manoeuvres, i.e., chest decompression and chest block, while remaining on mechanical ventilation. Assessments were performed before and after usual care, immediately after the intervention and 30 minutes after the intervention. The primary outcome was static compliance. The secondary outcomes were the incidence of atelectasis, dynamic compliance, airway resistance, driving pressure, oxygenation, duration of mechanical ventilation, extubation success, length of hospital and ICU stay, and mortality.
RESULTS
Fifty-one participants (67±15 years old, 53% men, 26 in the control group and 25 in the intervention group) were evaluated. No differences in static compliance were observed between groups (intervention minus control) before and after expansion manoeuvres [3.64 ml/cmH2O (95% CI: -0.36-7.65, p = 0.074)]. Peripheral oxygen saturation differed between groups before and after expansion manoeuvres, with more favourable outcome observed in the control group [-1.04% (95% CI: -1.94 --0.14), p = 0.027]. No differences were found in other outcomes.
CONCLUSION
Chest compression-decompression and chest block manoeuvres did not improve ventilatory mechanics, the incidence of atelectasis, oxygenation, the duration of mechanical ventilation, the length of stay in the ICU and hospital, or mortality in individuals on mechanical ventilation. The findings of this study can be valuable for guiding evidence-based clinical practice and developing a therapeutic approach that provides real benefits for this population.
Topics: Adult; Male; Humans; Middle Aged; Aged; Aged, 80 and over; Female; Respiration, Artificial; Length of Stay; Airway Extubation; Lung; Pulmonary Atelectasis
PubMed: 38079432
DOI: 10.1371/journal.pone.0295775 -
JAMA Network Open May 2024Integration of pharmacies with physician practices, also known as medically integrated dispensing, is increasing in oncology. However, little is known about how this...
IMPORTANCE
Integration of pharmacies with physician practices, also known as medically integrated dispensing, is increasing in oncology. However, little is known about how this integration affects drug use, expenditures, medication adherence, or time to treatment initiation.
OBJECTIVE
To examine the association of physician-pharmacy integration with oral oncology drug expenditures, use, and patient-centered measures.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study used claims data from a large commercial insurer in the US to analyze changes in outcome measures among patients treated by pharmacy-integrating vs nonintegrating community oncologists in 14 states between January 1, 2011, and December 31, 2019. Commercially insured patients were aged 18 to 64 years with 1 of the following advanced-stage diagnoses: breast cancer, colorectal cancer, kidney cancer, lung cancer, melanoma, or prostate cancer. Data analysis was conducted from May 2023 to March 2024.
EXPOSURE
Treatment by a pharmacy-integrating oncologist, ascertained by the presence of an on-site pharmacy or nonpharmacy dispensing site.
MAIN OUTCOMES AND MEASURES
Oral, intravenous (IV), total, and out-of-pocket drug expenditures for a 6-month episode of care; share of patients prescribed oral drugs; days' supply of oral drugs; medication adherence measured by proportion of days covered; and time to treatment initiation. The association between an oncologist's pharmacy integration and each outcome of interest was estimated using the difference-in-differences estimator.
RESULTS
Between 2012 and 2019, 3159 oncologists (745 females [27.1%], 2002 males [72.9%]) treated 23 968 patients (66.4% female; 53.4% aged 55-64 years). Of the 3159 oncologists, 578 (18.3%) worked in practices that integrated with pharmacies (with a low rate in 2011 of 0% and a high rate in 2019 of 31.5%). In the full sample (including all cancer sites), after physician-pharmacy integration, no significant changes were found in oral drug expenditures, IV drug expenditures, or total drug expenditures. There was, however, an increase in days' supply of oral drugs (5.96 days; 95% CI, 0.64-11.28 days; P = .001). There were no significant changes in out-of-pocket expenditures, medication adherence, or time to treatment initiation of oral drugs. In the breast cancer sample, there was an increase in oral drug expenditures ($244; 95% CI, $41-$446; P = .02) and a decrease in IV drug expenditures (-$4187; 95% CI, -$8293 to -$80; P = .05).
CONCLUSIONS AND RELEVANCE
Results of this cohort study indicated that the integration of oncology practices with pharmacies was not associated with significant changes in expenditures or clear patient-centered benefits.
Topics: Humans; Female; Male; Middle Aged; Adult; Neoplasms; Medication Adherence; United States; Cohort Studies; Health Expenditures; Antineoplastic Agents; Adolescent; Young Adult; Oncologists
PubMed: 38780938
DOI: 10.1001/jamanetworkopen.2024.12998 -
Nitric Oxide : Biology and Chemistry May 2024Cardiopulmonary bypass (CPB) is associated with intravascular hemolysis which depletes endogenous nitric oxide (NO). The impact of hemolysis on pulmonary arterial... (Observational Study)
Observational Study
BACKGROUND
Cardiopulmonary bypass (CPB) is associated with intravascular hemolysis which depletes endogenous nitric oxide (NO). The impact of hemolysis on pulmonary arterial compliance (PAC) and right ventricular systolic function has not been explored yet. We hypothesized that decreased NO availability is associated with worse PAC and right ventricular systolic function after CPB.
METHODS
This is a secondary analysis of an observational cohort study in patients undergoing cardiac surgery with CPB at Massachusetts General Hospital, USA (2014-2015). We assessed PAC (stroke volume/pulmonary artery pulse pressure ratio), and right ventricular function index (RVFI) (systolic pulmonary arterial pressure/cardiac output), as well as NO consumption at 15 min, 4 h and 12 h after CPB. Patients were stratified by CPB duration. Further, we assessed the association between changes in NO consumption with PAC and RVFI between 15min and 4 h after CPB.
RESULTS
PAC was lowest at 15min after CPB and improved over time (n = 50). RVFI was highest -worse right ventricular function- at CPB end and gradually decreased. Changes in hemolysis, PAC and RVFI differed over time by CPB duration. PAC inversely correlated with total pulmonary resistance (TPR). TPR and PAC positively and negatively correlated with RVFI, respectively. NO consumption between 15min and 4 h after CPB correlated with changes in PAC (-0.28 ml/mmHg, 95%CI -0.49 to -0.01, p = 0.012) and RVFI (0.14 mmHg*L*min, 95%CI 0.10 to 0.18, p < 0.001) after multivariable adjustments.
CONCLUSION
PAC and RVFI are worse at CPB end and improve over time. Depletion of endogenous NO may contribute to explain changes in PAC and RVFI after CPB.
Topics: Humans; Cardiopulmonary Bypass; Male; Hemolysis; Female; Middle Aged; Ventricular Function, Right; Aged; Pulmonary Artery; Nitric Oxide; Systole; Cohort Studies; Compliance
PubMed: 38521488
DOI: 10.1016/j.niox.2024.03.003 -
Radiation Oncology (London, England) Nov 2023To report the planning benchmark case results of the POTENTIAL trial-a multicenter, randomized, phase 3 trial-to evaluate the value of internal mammary nodal (IMN)... (Randomized Controlled Trial)
Randomized Controlled Trial
Quality assurance in a phase III, multicenter, randomized trial of POstmastectomy radioThErapy in Node posiTive breast cancer with or without Internal mAmmary nodaL irradiation (POTENTIAL): a planning benchmark case.
PURPOSE
To report the planning benchmark case results of the POTENTIAL trial-a multicenter, randomized, phase 3 trial-to evaluate the value of internal mammary nodal (IMN) irradiation for patients with high-risk breast cancer.
METHODS
All participating institutions were provided the outlines of one benchmark case, and they generated radiation therapy plans per protocol. The plans were evaluated by a quality assurance team, after which the institutions resubmitted their revised plans. The information on beams arrangement, skin flash, inhomogeneity corrections, and protocol compliance was assessed in the first and final submission.
RESULTS
The plans from 26 institutions were analyzed. Some major deviations were found in the first submission. The protocol compliance rates of dose coverage for the planning target volume of chest wall, supraclavicular fossa plus axilla, and IMN region (PTVim) were all significantly improved in the final submission, which were 96.2% vs. 69.2%, 100% vs. 76.9%, and 88.4% vs. 53.8%, respectively. For OARs, the compliance rates of heart D, left anterior descending coronary artery V, ipsilateral lung V, and stomach V were significantly improved. In the first and final submission, the mean values of PTVim V were 79.9% vs. 92.7%; the mean values of heart D were 11.5 Gy vs. 9.7 Gy for hypofractionated radiation therapy and 11.5 Gy vs. 11.0 Gy for conventional fractionated radiation therapy, respectively.
CONCLUSION
The major deviations were corrected and protocol compliance was significantly improved after revision, which highlighted the importance of planning benchmark case to guarantee the planning quality for multicenter trials.
Topics: Humans; Female; Breast Neoplasms; Benchmarking; Mastectomy; Radiotherapy Planning, Computer-Assisted; Radiotherapy Dosage; Radiotherapy, Intensity-Modulated; Organs at Risk
PubMed: 38031125
DOI: 10.1186/s13014-023-02379-1 -
Pediatric Pulmonology Nov 2023Mechanisms underlying lung dysfunction after preterm birth are poorly understood. Studying phenotypes of prematurity-associated lung disease may aid understanding of...
INTRODUCTION
Mechanisms underlying lung dysfunction after preterm birth are poorly understood. Studying phenotypes of prematurity-associated lung disease may aid understanding of underlying mechanisms. Preterm-born children with and without lung dysfunction and term controls were assessed using oscillometry before and after exercise, and after postexercise bronchodilation.
METHODS
Preterm-born children, born at gestation of 34 weeks or less, were classified into those with prematurity-associated obstructive lung disease (POLD; FEV < LLN, FEV /FVC < LLN), prematurity-associated preserved ratio of impaired spirometry (pPRISm; FEV < LLN, FEV /FVC ≥ LLN) and compared to preterm (FEV ≥ LLN) and term controls (%predicted FEV > 90%). All children underwent cardiopulmonary exercise, and oscillometry assessment at baseline, postexercise, and after postexercise bronchodilator administration.
RESULTS
From 241 participants aged 7-12 years, complete data were available from 179: 15 children with POLD and 11 with pPRISm were compared with 93 preterm and 60 term controls. POLD group, when compared to both control groups, had impaired impedance, greater resistance, more negative (greater magnitude) reactance at low frequencies, and also had decreased compliance. pPRISm group demonstrated impaired reactance and compliance compared to term controls. No differences were noted between the preterm and term controls. Exercise had little impact on oscillometry values, but children with POLD had greatest improvements after postexercise bronchodilator administration, with decreased resistance and decreased magnitude of reactance, particularly at low frequencies.
CONCLUSION
Preterm-born children with obstructive airway disease had the greatest oscillometry impairments and the largest improvements after postexercise bronchodilator compared to control groups. Oscillometry can potentially be used to identify preterm-born children with lung disease to institute treatment.
Topics: Child; Female; Humans; Infant, Newborn; Bronchodilator Agents; Oscillometry; Forced Expiratory Volume; Premature Birth; Lung; Lung Diseases; Lung Diseases, Obstructive; Spirometry; Infant, Newborn, Diseases
PubMed: 37701982
DOI: 10.1002/ppul.26658 -
African Health Sciences Sep 2023Non-small cell lung cancer (NSCLC) has high degree of malignance and proneness to recurrence and metastasis. The aim of this study was to analyse the risk factors...
OBJECTIVE
Non-small cell lung cancer (NSCLC) has high degree of malignance and proneness to recurrence and metastasis. The aim of this study was to analyse the risk factors influencing the chemotherapy compliance and survival status of elderly NSCLC patients.
METHODS
The clinical data of 110 patients admitted from January 2014 to March 2018 were retrospectively analysed. They were assigned to non-chemotherapy (n=25), partial chemotherapy (n=30) and complete chemotherapy (n=55) groups according to chemotherapy compliance, and followed up until March 2021. Their clinicopathological characteristics were investigated by univariate analysis and then multivariate Cox regression analysis. The survival rates were compared by Kaplan-Meier survival curve and log-rank test.
RESULTS
Among the 110 NSCLC patients, 25 did not receive chemotherapy, 30 underwent partial chemotherapy and 55 received complete chemotherapy. Educational level, pathological tumor-node-metastasis (TNM) stage, pathological type, surgical approach, place of residence, payment mode and chemotherapy stage were independent risk factors influencing the chemotherapy compliance (P<0.05).
CONCLUSION
Particular attention should be paid to improving the chemotherapy compliance of patients with low educational level, late TNM stage, medical history of squamous cell carcinoma, history of thoracotomy, living in rural areas and no medical insurance, and those in the recurrence period or consolidation period of chemotherapy.
Topics: Humans; Aged; Carcinoma, Non-Small-Cell Lung; Lung Neoplasms; Retrospective Studies; Carcinoma, Squamous Cell; Risk Factors; Neoplasm Staging; Prognosis
PubMed: 38357160
DOI: 10.4314/ahs.v23i3.35 -
Intensive Care Medicine May 2024Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients... (Meta-Analysis)
Meta-Analysis
PURPOSE
Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients to enhance respiratory system mechanics and prevent ventilator-induced lung injury (VILI), compared to traditional methods.
METHODS
We carried out a systematic review and meta-analysis, spanning literature from January 2012 to May 2023, sourced from Scopus, PubMed, MEDLINE (Ovid), Cochrane, and LILACS, evaluated EIT-guided PEEP strategies in ARDS versus conventional methods. Thirteen studies (3 randomized, 10 non-randomized) involving 623 ARDS patients were analyzed using random-effects models for primary outcomes (respiratory mechanics and mechanical power) and secondary outcomes (PaO/FiO ratio, mortality, stays in intensive care unit (ICU), ventilator-free days).
RESULTS
EIT-guided PEEP significantly improved lung compliance (n = 941 cases, mean difference (MD) = 4.33, 95% confidence interval (CI) [2.94, 5.71]), reduced mechanical power (n = 148, MD = - 1.99, 95% CI [- 3.51, - 0.47]), and lowered driving pressure (n = 903, MD = - 1.20, 95% CI [- 2.33, - 0.07]) compared to traditional methods. Sensitivity analysis showed consistent positive effect of EIT-guided PEEP on lung compliance in randomized clinical trials vs. non-randomized studies pooled (MD) = 2.43 (95% CI - 0.39 to 5.26), indicating a trend towards improvement. A reduction in mortality rate (259 patients, relative risk (RR) = 0.64, 95% CI [0.45, 0.91]) was associated with modest improvements in compliance and driving pressure in three studies.
CONCLUSIONS
EIT facilitates real-time, individualized PEEP adjustments, improving respiratory system mechanics. Integration of EIT as a guiding tool in mechanical ventilation holds potential benefits in preventing ventilator-induced lung injury. Larger-scale studies are essential to validate and optimize EIT's clinical utility in ARDS management.
Topics: Humans; Positive-Pressure Respiration; Respiratory Distress Syndrome; Electric Impedance; Tomography; Ventilator-Induced Lung Injury; Respiratory Mechanics
PubMed: 38512400
DOI: 10.1007/s00134-024-07362-2 -
Frontiers in Pediatrics 2023Congenital diaphragmatic hernia (CDH) is a rare condition characterized by pulmonary hypoplasia, vascular dystrophy, and pulmonary hypertension at birth. Validation of...
INTRODUCTION
Congenital diaphragmatic hernia (CDH) is a rare condition characterized by pulmonary hypoplasia, vascular dystrophy, and pulmonary hypertension at birth. Validation of the lamb model as an accurate representation of human CDH is essential to translating research findings into clinical practice and understanding disease mechanisms. This article emphasizes the importance of validating the lamb model to study CDH pathogenesis and develop innovative therapeutics.
MATERIAL AND METHODS
At 78 days of gestation, the fetal lamb's left forelimb was exposed through a midline laparotomy and hysterotomy, and a supra diaphragmatic thoracotomy was performed to allow the digestive organs to ascend into the thoracic cavity. At 138 ± 3 days of gestation, lambs were delivered via a cesarean section; then, with umbilical cord intact during 1 hour, the lambs were mechanically ventilated with gentle ventilation in a pressure-controlled mode for 2 h.
RESULTS
CDH lambs exhibited a lower left lung-to-body weight ratio of 5.3 (2.03), < 0.05, and right lung-to-body weight ratio of 8.2 (3.1), < 0.05. They reached lower Vt/kg (tidal volume per kg) during the course of the resuscitation period with 1.2 (0.7) ml/kg at 10 min and 3 (1.65) ml/kg at 60 min ( < 0.05). Compliance of the respiratory system was lower in CDH lambs with 0.5 (0.3) ml/cmHO at 60 min ( < 0.05) and 0.9 (0.26) ml/cmHO at 120 min ( < 0.05). Differences between pre- and postductal SpO were higher with 15.1% (21.4%) at 20 min and 6.7% (14.5%) at 80 min ( < 0.05). CDH lambs had lower differences between inspired and expired oxygen fractions with 4.55% (6.84%) at 20 min and 6.72% (8.57%) at 60 min ( < 0.05). CDH lamb had lower left ventricle [2.73 (0.5) g/kg, < 0.05] and lower right ventricle [0.69 (0.8), < 0.05] to left ventricle ratio.
DISCUSSION
CDH lambs had significantly lower tidal volume than control lambs due to lower compliance of the respiratory system and higher airway resistance. These respiratory changes are characteristic of CDH infants and are associated with higher mortality rates. CDH lambs also exhibited pulmonary hypertension, pulmonary hypoplasia, and left ventricle hypoplasia, consistent with observations in human newborns. To conclude, our lamb model successfully provides a reliable representation of CDH and can be used to study its pathophysiology and potential interventions.
PubMed: 37744447
DOI: 10.3389/fped.2023.1236556 -
Frontiers in Cardiovascular Medicine 2023Cardiac magnetic resonance (CMR) imaging allows for multiparametric assessment of healthy pulmonary artery (PA) hemodynamics. Gender- and aging-associated PA stiffness...
BACKGROUND
Cardiac magnetic resonance (CMR) imaging allows for multiparametric assessment of healthy pulmonary artery (PA) hemodynamics. Gender- and aging-associated PA stiffness and pressure alterations have remained clinically unestablished, however may demonstrate epidemiological differences in disease development. The aim of this study is to evaluate the role of CMR as a surrogate for catheter examinations by providing a comprehensive CMR assessment of sex- and age-related reference values for PA stiffness, flow, and pressure.
METHODS AND RESULTS
PA hemodynamics were studied between gender and age groups (>/<50 years) using phase-contrast CMR. Corresponding correlation analyses were performed. 179 healthy volunteers with a median age of 32.6 years (range 11.3-68.2) were examined. Males demonstrated increased PA compliance (median [interquartile range] or mean ± standard deviation) (20.8 mm/mmHg [16.6; 25.8] vs. 19.2 ± 7.1 mm/mmHg; < 0.033), higher pulse wave velocity (2.00 m/s [1.35; 2.87] vs. 1.73 m/s [1.19; 2.34]; = 0.018) and a reduced full width half maximum (FWHM) (219 ± 22 ms vs. 235 ± 23 ms; < 0.001) than females. Mean, systolic, diastolic PA pressure and pulmonary proportional pulse pressure were significantly elevated for males compared to females ( < 0.001). Older subjects (>50 years) exhibited reduced PA elasticity (41.7% [31.0; 52.9] vs. 66.4% [47.7; 83.0]; < 0.001), reduced PA compliance (15.4 mm/mmHg [12.3; 20.7] vs. 21.3 ± 6.8 mm/mmHg; < 0.001), higher pulse wave velocity (2.59 m/s [1.57; 3.59] vs. 1.76 m/s [1.24; 2.34]; < 0.001) and a reduced FWHM (218 ± 29 ms vs. 231 ± 21 ms; < 0.001) than younger subjects.
CONCLUSIONS
Velocity-time profiles are dependent on age and gender. PA stiffness indices deteriorate with age. CMR has potential to serve as a surrogate for right heart catheterization.
PubMed: 37692049
DOI: 10.3389/fcvm.2023.1200833 -
American Journal of Respiratory and... Oct 2023
Topics: Humans; Hypertension, Pulmonary; Prognosis; Pulmonary Artery; Vascular Resistance
PubMed: 37562031
DOI: 10.1164/rccm.202306-1076LE