Altamiro Costa-Pereira

Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema – a systematic review and meta-analysis

IntroductionContinuous positive airway pressure ventilation (CPAP) and non-invasive positive pressure ventilation (NPPV) are accepted treatments in acute cardiogenic pulmonary edema (ACPE). However, it remains unclear whether NPPV is better than CPAP in reducing the need for endotracheal intubation (NETI) rates, mortality and other adverse events. Our aim was to review the evidence about the efficacy and safety of these two methods in ACPE management.MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials on the effect of CPAP and/or NIPV in the treatment of ACPE, considering the outcomes NETI, mortality and incidence of acute myocardial infarction (AMI). We searched six electronic databases up to May 2005 without language restrictions, reviewed references of relevant articles, hand searched conference proceedings and contacted experts.ResultsOf 790 articles identified, 17 were included. In a pooled analysis, 10 studies of CPAP compared to standard medical therapy (SMT) showed a significant 22% absolute risk reduction (ARR) in NETI (95% confidence interval (CI), -34% to -10%) and 13% in mortality (95%CI, -22% to -5%). Six studies of NPPV compared to SMT showed an 18% ARR in NETI (95%CI, -32% to -4%) and 7% in mortality (95%CI, -14% to 0%). Seven studies of NPPV compared to CPAP showed a non-significant 3% ARR in NETI (95%CI, -4% to 9%) and 2% in mortality (95%CI, -6% to 10%). None of these methods increased AMI risk. In a subgroup analysis, NPPV did not lead to better outcomes than CPAP in studies including more hypercapnic patients.ConclusionRobust evidence now supports the use of CPAP and NPPV in ACPE. Both techniques decrease NETI and mortality compared to SMT and none shows increased AMI risk. CPAP should be considered a first line intervention as NPPV did not show a better efficacy, even in patients with more severe conditions, and CPAP is cheaper and easier to implement in clinical practice.

Evaluation of interobserver agreement of cardiotocograms.

Objective: To evaluate interobserver agreement in visual analysis of each cardiotocographic event. Methods: Three experts independently divided 16 antepartum and 17 intrapartum cardiotocograms into baseline segments, accelerations and decelerations, according to the FIGO guidelines. Baseline segments were further classified as having normal, reduced or increased variability and decelerations as early, late and variable. Uterine activity was divided into tonus and contractions. Agreement was assessed by the proportions of agreement (pa) with 95% confidence intervals. Results: Reproducibility in assessment of baseline segments with normal variability, accelerations and uterine activity was acceptable (pa = 0.56–0.71) whereas that of other segments was not (pa = 0.14–0.45). Conclusions: Analysis of most cardiotocographic events is poorly reproducible, even when experts use the FIGO guidelines. This may be explained by some still ambiguous guidelines, by eyeball limitations in evaluation of subtle events, and by the incapacity of busy clinicians to assess complex and multiple cardiotocographic events in a systematic and disciplined fashion.

Meta-analysis on the validity of pepsinogen test for gastric carcinoma, dysplasia or chronic atrophic gastritis screening

Aim: To assess the validity of the measurement of pepsinogen I and II as a screening test for gastric cancer and pre-malignant lesions, namely low-grade dysplasia, both in the general population and in selected groups of patients. Methods: A meta-analysis of sensitivity and specificity results from individual papers on the use of the pepsinogen test. An intrinsic cut-off effect was assumed and a random effect model was used for pooling. Results: Forty-two data sets were included: 27 (64%) population-based screening studies (n=296,553) and 15 (36%) sets of selected individuals (n=4385). Homogenous sensitivity and diagnostic odds ratio (DOR) estimates were found in studies using both pepsinogen I levels and pepsinogen I/II ratio calculations. Pooled pairs of sensitivity and false positive rates (FPr) for pepsinogen I ≤ 70; pepsinogen I/II ratio ≤ 3, pepsinogen I ≤50; pepsinogen I/II ratio ≤ 3, and pepsinogen I ≤ 30; pepsinogen I/II ratio ≤ 2, were sensitivity 77%/FPr 27%, sensitivity 68%/FPr 31%, and sensitivity 52%/FPr 84%, respectively. Positive predictive values (PPV) varied between 0.77% and 1.25%, and negative predictive values (NPV) varied between 99.08% and 99.90%. In selected groups, pooling was only possible when considering pepsinogen I ≤ 70; pepsinogen I/II ratio ≤ 3: giving sensitivity 57%, specificity 80%, PPV 15% and NPV 83%. As for the diagnosis of dysplasia, studies considering pepsinogen I <50; pepsinogen I/II ratio <3 obtained sensitivity 65% and specificity ranging from 74%–85%, both with NPV >95%. Conclusion: Pepsinogen test definition should include pepsinogen I/II ratio as consistency was obtained, both in population based studies and in selected groups for those studies that used pepsinogen I serum levels together with pepsinogen I/II ratio for screening for gastric cancer in high-incidence regions other than Japan. Further studies of this test in the management of high-risk patients seem to be worthwhile.

Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision

Inter‐observer agreement in the interpretation according to the FIGO guidelines of 33 cardiotocographic tracings by experts and subsequent clinical decision was evaluated, using the kappa statistic (K) and the proportions of agreement (Pa). Overall agreement in the classification of tracings was fair (K = 0.48) and was better for normal (Pa = 0.62), than for suspicious (Pa = 0.42) or pathologic tracings (Pa = 0.25). Overall agreement on clinical decision was slightly higher (K = 0.59), but mostly was centred on the decision to take ‘no action’ (Pa = 0.79). Experts especially disagreed over the decisions to ‘monitor closely’ (Pa = 0.14) or to ‘intervene immediately’ (Pa = 0.38). These limitations should be taken into account in clinical audits and in medical jurisprudence.

Understanding posttraumatic stress disorder-related symptoms after critical care: the early illness amnesia hypothesis.

Objective:To assess the factual and delusional memories reported by intensive care unit survivors and its relationship with the development of Posttraumatic Stress Syndrome (PTSS). Design:Multicenter observational cohort study. Setting:Nine Portuguese intensive care units, as part of a multicenter study. Methods and Patients:Between January and June 2005, 1,174 patients were admitted across the nine intensive care units. Two hundred thirty-nine patients were excluded, 14 with <18 yrs old and 225 with a length of intensive care stay ≤48 hrs. Thus a total of 935 patients were included in the study. One hundred ninety (20%) patients died in the intensive care unit, 90 (12%) patients died on the ward (30% in-hospital mortality rate), and another 56 (9%) died in the next 6 months after intensive care unit discharge. Results:From the 599 survivors at 6 months, 313 patients answered the questionnaires (52% response rate). From the 313 respondents, 58% (n = 183) were men, median age was 59. The median Simplified Acute Physiology Score II was 37, median intensive care unit length of stay was 8 days, 57% (n = 177) of the patients were admitted for medical reasons. Forty percent (n = 116) of the respondents did not remember their admission to hospital, 48% (n = 142) did not remember the time in the hospital before intensive care unit admission, 73% (n = 220) had factual memories and 39% (n = 118) had delusional memories. Twenty-three percent (n = 66) stated that they had had intrusive memories. A higher number of “adverse” experiences were significantly associated with a higher PTSS-14 score. Eighteen percent (n = 54) of patients had a PTSS-14 score >49, indicating a higher risk of developing posttraumatic stress disorder. A PTSS-14 score >49 was significantly associated with not remembering the hospital stay before intensive care unit admission. Conclusion:Amnesia for the early period of critical illness (early amnesia) was positively associated with the level of posttraumatic stress disorder-related symptoms, which may be a proxy for severity of disease at the time of intensive care unit admission.

Epidemiology of Chronic Pain: A Population-Based Nationwide Study on Its Prevalence, Characteristics and Associated Disability in Portugal

UNLABELLED A cross-sectional nationwide epidemiological study was performed in a random sample of the Portuguese adult population, aiming to describe the prevalence and impact of chronic pain (CP). The 5,094 participants were selected by random digit dialing, between January 2007 and March 2008, and estimates were adequately weighted for the population. Prevalence of CP was 36.7% (95% confidence interval [CI] [35.3-38.2]), based on the definition of the International Association for the Study of Pain. Recurrent or continuous pain was present in 85% of those with CP, and moderate-to-severe intensity and disability were present in 68 and 35%, respectively. Highest CP prevalence was observed among the elderly, retired, unemployed, and less educated. Highest disability was found in relation with family/home responsibilities, recreational activities, occupation/work, and sleep/rest; 13% reported a diagnosis of depression and 49% reported interference in their job. The main factors associated with disability were sex, pain intensity, and depression or depressive symptoms. CP is highly prevalent, causes high personal and social burden, and affects particularly the most vulnerable subgroups. Portugal, depending on CP definition, could be placed in the lower prevalence group in Europe. Improvement in pain intensity management and special attention to affective components of CP are recommended. PERSPECTIVE In this cross-sectional nationwide epidemiological study, we showed that chronic pain is a significant problem that is present in 37% of the Portuguese adult general population, is associated with high personal, family, and social burden, and affects in particular the most vulnerable subgroups of the population.

Pulmonary Function Electronic Monitoring Devices: A Randomized Agreement Study

STUDY OBJECTIVES To compare in a clinical setting the within-session reproducibility of two pulmonary function electronic monitoring devices (PiKo-1; Ferraris Respiratory Europe; Hereford, UK; and Spirotel; MIR; Rome, Italy) with one mechanical device (Mini-Wright Peak-Flow Meter; Clement-Clarke International; Harlow, Essex, UK), and to evaluate the accuracy of these devices using as reference an office pneumotachograph. DESIGN, SETTING, AND PARTICIPANTS After detailed instructions, adults without airways diseases and patients with stable asthma attending an outpatient clinic performed four sets of expiratory maneuvers, one set for each device, in a strictly random order. Each set comprised three maneuvers with 2 to 3 min of rest between them. MEASUREMENTS Reproducibility of FEV1 and peak expiratory flow (PEF) was assessed by a coefficient of variation (CV) and intraclass correlation coefficient (ICC), and accuracy was assessed by ICC and limits of agreement. RESULTS Of the 38 participants evaluated, 71% were women and 61% had asthma. Ages ranged from 18 to 58 years, and FEV1 ranged from 1.2 to 4.8 L. In all monitoring devices, CV was < 6% and ICC was > 0.94 for the reproducibility of both FEV1 and PEF measurements. The accuracy of the PiKo-1 device was better for FEV1 (ICC = 0.98) than for PEF (ICC = 0.90). The Spirotel device had similar results for FEV1 and PEF (ICC = 0.95). The Mini-Wright device had the lowest accuracy (ICC = 0.87), particularly for PEF values < 500 L/min. CONCLUSIONS These low-cost and easy-to-use electronic monitoring devices showed a very good reproducibility and were in agreement with the pneumotachograph. Therefore, the PiKo-1 and Spirotel devices seem adequate for both screening and monitoring. However, prospective studies are still needed to assess their long-term reproducibility and usability and, particularly, the effects on the improvement of respiratory care.

Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: A plea for periodic basic life-support training programs

Objective: To evaluate whether the introduction of a program including a medical emergency team responding to widened criteria together with the institution-wide training on basic life support of all hospital staff would decrease cardiac arrest prevalence and mortality in patients at risk, in the immediate and long-term periods after the program. Design: Before-after design. Setting: Urban general hospital with 470 beds. Patients: All patients admitted in the hospital between 2002 and 2006 were eligible. All patients with a medical emergency team activation were included. We compared cardiac arrest prevalence and mortality and in-hospital mortality before (2002), after (2003–2004), and long term after (2005–2006) the program implementation. Measurements and Main Results: There was a significant (p = .037) decrease of 27% (95% confidence interval, 2%–46%) in cardiac arrest occurrence, 33% decrease (p = .014) in cardiac arrest mortality (95% confidence interval, 8%–52%), and a nonsignificant (p = .152) decrease of 17% (95% confidence interval, −7%–36%) in in-hospital mortality associated with the program implementation. No significant differences were found for any of the outcome variables between before and long term after periods. The main factor associated with in-hospital mortality was cardiac arrest. Factors affecting cardiac arrest were age, comorbidities, measures started before medical emergency team arrival and the intervention/program. The effect in the prevention of cardiac arrest has an adjusted relative risk, 0.646 (95% confidence interval, 0.450–0.876) and an absolute risk reduction of adjusted relative risk, 18% (95% confidence interval, 6%–29%). The program prevented one cardiac arrest for every five medical emergency team activations. Conclusions: Widening criteria for hospital emergency calls together with an integrated training program may reduce cardiac arrest prevalence and mortality in at-risk patients. Program effectiveness was critically related to the staff education, awareness, and responsiveness to physiologic instability of the patients. Long-term effectiveness of the program may decrease in the absence of periodic and continued implementation of educational interventions.

Quality of life 6-months after cardiac arrest

BACKGROUND Evaluation of outcome after cardiac arrest focuses mainly on survival. Survivors of cardiac arrest end up in different states of health and survival alone may not be a sensitive measure for successful cardiopulmonary resuscitation (CPR). OBJECTIVES To evaluate health-related quality of life (HR-QOL) of cardiac arrest survivors with EQ-5D, a generic instrument developed by the EuroQol group. PATIENTS AND METHODS From April 1997 to December 2000, all cardiac arrest adult patients admitted to an eight-bed medical/surgical (ICU) of a tertiary care hospital were enrolled. At 6-months after ICU discharge survivors attended a follow-up interview and answered EQ-5D questionnaire. A match-control group was created choosing for each survivor of cardiac arrest two controls, with similar age range (+/-5 years) and similar Apache II (+/-3 Apache II units), that were randomly selected among other ICU patients. RESULTS From a total of 1106 patients, 97 (9%) patients were admitted after cardiac arrest. Forty-seven patients (48%) were discharged from ICU. Of these, 11 patients died in the ward. Thirty-six (37%) patients were discharged from hospital. Twelve patients died after hospital discharge but before 6-month evaluation. Five patients were not evaluated, three because they were living in distant locations and two for unknown reasons. Nineteen patients attended the follow-up consultation. Eight of these patients were actively working and six of them had managed to return to their previous activity. Eleven patients were retired and seven of these managed to return to their previous level of activity while four patients presented with anoxic encephalopathy: one with mild and one with moderate neurological dysfunction, two with severe anoxic neurological dysfunction. Although a higher percentage of cardiac arrest survivors reported more extreme problems in some dimensions than other ICU patients, no significant differences were found on HR-QOL, when evaluated by EQ-5D. CONCLUSIONS When evaluated with EQ-5D at 6-months after ICU discharge, survivors of cardiac arrest exhibit a HR-QOL similar to other ICU survivors. These results agree with previous reports stating that CPR is frequently unsuccessful but if survival is achieved a fairly good quality of life can be expected.

Early extubation does not increase complication rates after coronary artery bypass graft surgery with cardiopulmonary bypass

BACKGROUND With the evolution of anesthesia and surgical procedures, fast track extubation has gained an increased interest, mainly based on the possibility of reducing health costs seemingly without compromising patient care. AIM To compare two groups of patients submitted to a non-fast track extubation and a fast track extubation protocol after coronary artery bypass graft surgery with cardiopulmonary bypass, regarding their times of ventilation and intubation and their complication rates in the postoperative period. METHODS During the year of 1998, 323 sequential patients scheduled for isolated coronary artery bypass graft surgery with cardiopulmonary bypass were enrolled in the study. Fifty-nine patients were excluded due to preoperative use of emergent mechanical and/or inotropic hemodynamic support, low body mass index (< or =18-20 kg/m(2)), reoperations for acute surgical complications, off-pump coronary artery bypass graft surgery, severe respiratory disease, recent myocardial infarction (< or =7 days) and absence of relevant data. Previous myocardial infarction (> or =7 days), prophylactic intraaortic balloon pump and use of postoperative vasoactive drugs were not exclusion criteria. We compared 76 patients sequentially submitted to anesthesia by one of the authors with a fast track extubation protocol and 188 patients sequentially submitted to anesthesia by others in the same period and using a conventional anesthetic protocol. RESULTS Demographic data, previous medical and cardiac history, preoperative medication and operative data were all similar between the two groups. The mean ventilation and intubation times were significantly shorter in the fast track extubation group than in the non-fast track extubation patients (30 min vs. 7 h and 50 min vs. 8 h, respectively). Forty-two percent of patients in the fast track extubation group were extubated on arrival at the intensive care unit. Morbidity and mortality were similar in both groups. CONCLUSIONS The study shows that a very fast track extubation protocol may be safely implemented in patients submitted to coronary artery bypass graft surgery with cardiopulmonary bypass.