RESUMEN
OBJECTIVES: Prone position ventilation is a potentially life-saving ancillary intervention but is not widely adopted for coronavirus disease 2019 or acute respiratory distress syndrome from other causes. Implementation of lung-protective ventilation including prone positioning for coronavirus disease 2019 acute respiratory distress syndrome is limited by isolation precautions and personal protective equipment scarcity. We sought to determine the safety and associated clinical outcomes for coronavirus disease 2019 acute respiratory distress syndrome treated with prolonged prone position ventilation without daily repositioning. DESIGN: Retrospective single-center study. SETTING: Community academic medical ICU. PATIENTS: Sequential mechanically ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. INTERVENTIONS: Lung-protective ventilation and prolonged protocolized prone position ventilation without daily supine repositioning. Supine repositioning was performed only when Fio2 less than 60% with positive end-expiratory pressure less than 10 cm H2O for greater than or equal to 4 hours. MEASUREMENTS AND MAIN RESULTS: Primary safety outcome: proportion with pressure wounds by Grades (0-4). Secondary outcomes: hospital survival, length of stay, rates of facial and limb edema, hospital-acquired infections, device displacement, and measures of lung mechanics and oxygenation. Eighty-seven coronavirus disease 2019 patients were mechanically ventilated. Sixty-one were treated with prone position ventilation, whereas 26 did not meet criteria. Forty-two survived (68.9%). Median (interquartile range) time from intubation to prone position ventilation was 0.28 d (0.11-0.80 d). Total prone position ventilation duration was 4.87 d (2.08-9.97 d). Prone position ventilation was applied for 30.3% (18.2-42.2%) of the first 28 days. Pao2:Fio2 diverged significantly by day 3 between survivors 147 (108-164) and nonsurvivors 107 (85-146), mean difference -9.632 (95% CI, -48.3 to 0.0; p = 0·05). Age, driving pressure, day 1, and day 3 Pao2:Fio2 were predictive of time to death. Thirty-eight (71.7%) developed ventral pressure wounds that were associated with prone position ventilation duration and day 3 Sequential Organ Failure Assessment. Limb weakness occurred in 58 (95.1%) with brachial plexus palsies in five (8.2%). Hospital-acquired infections other than central line-associated blood stream infections were infrequent. CONCLUSIONS: Prolonged prone position ventilation was feasible and relatively safe with implications for wider adoption in treating critically ill coronavirus disease 2019 patients and acute respiratory distress syndrome of other etiologies.
Asunto(s)
COVID-19/complicaciones , Evaluación de Procesos y Resultados en Atención de Salud , Posicionamiento del Paciente , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/terapia , Insuficiencia Respiratoria/terapia , Centros Médicos Académicos , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Posición Prona , Síndrome de Dificultad Respiratoria/etiología , Insuficiencia Respiratoria/etiología , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
Studies often rely on medical record abstraction as a major source of data. However, data quality from medical record abstraction has long been questioned. Electronic Health Records (EHRs) potentially add variability to the abstraction process due to the complexity of navigating and locating study data within these systems. We report training for and initial quality assessment of medical record abstraction for a clinical study conducted by the IDeA States Pediatric Clinical Trials Network (ISPCTN) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) using medical record abstraction as the primary data source. As part of overall quality assurance, study-specific training for medical record abstractors was developed and deployed during study start-up. The training consisted of a didactic session with an example case abstraction and an independent abstraction of two standardized cases. Sixty-nine site abstractors from thirty sites were trained. The training was designed to achieve an error rate for each abstractor of no greater than 4.93% with a mean of 2.53%, at study initiation. Twenty-three percent of the trainees exceeded the acceptance limit on one or both of the training test cases, supporting the need for such training. We describe lessons learned in the design and operationalization of the study-specific, medical record abstraction training program.
Asunto(s)
Errores Médicos , Registros Médicos , Indización y Redacción de Resúmenes , Niño , Humanos , Almacenamiento y Recuperación de la Información , Proyectos de InvestigaciónRESUMEN
Intravenous drug use has become the principal route of hepatitis C virus (HCV) transmission due to the sharing of infected needles. In this study, we analyzed the distribution of HLA-KIR genotypes among 160 Puerto Rican intravenous drug users (IDUs) with HCV infection and 92 HCV-negative Puerto Rican IDUs. We found a significant association between the presence of different combinations of KIR inhibitory receptor genes (KIR2DL2 and/or KIR2DL3, pC=0.01, OR=0.07; KIR2DL2 and/or KIR2DL3+KIR2DS4, pC=0.01, OR=0.39) and HLA-C1 homozygous genotypes (HLA-C1+KIR2DS4, pC=0.02, OR=0.43; HLA-C1+KIR2DL2+KIR2DS4, pC=0.02, OR=0.40) together with the activating receptor KIR2DS4 (HLA-C1+KIR2DS4+KIR2DL3 and/or KIR2DL2, pC=0.004, OR=0.38) with protection from HCV infection. Our findings in HCV-infected and non-infected IDUs suggest an important role for KIRs (KIR2DL2 and KIR2DL3) with group HLA-C1 molecules, in the presence of activating KIR2DS4, in protection from HCV infection. These results support the hypothesis that activator signaling, mediated by KIR2DS4, plays a determinant role in the regulation of NK cell antiviral-activity.
Asunto(s)
Antígenos HLA/genética , Hepatitis C/genética , Receptores KIR/genética , Abuso de Sustancias por Vía Intravenosa/genética , Análisis por Conglomerados , Frecuencia de los Genes , Genotipo , Antígenos HLA-C/genética , Hepatitis C/virología , Humanos , Receptores KIR2DL2/genética , Receptores KIR2DL3/genética , Abuso de Sustancias por Vía Intravenosa/virologíaRESUMEN
An outbreak of encephalitis occurred in the equine population in the Republic of Panama in 1962 during the months of July through Novembers, or the peak of the rainy season, when many pastures are flooded. This is the same time of the year in which the large outbreak of 1946 occurred. The 1962 outbreak extended from the Canal Zone area westward, following the coast of the Gulf of Panama and the Gulf of Parita. The highest incidence was in the lowlands of the Gulf of Parita. The 1946 outbreak occurred in the same geographic area. The virus of Eastern encephalitis was isolated from the equine brains on three occasions, and there is also a small amount of serologic evidence to support the identification of the etiologic agent. Histologic findings in the brains examined further support the virologic and serologic findings. The concomitant occurrence of cases of Venezuelan encephalitis in the human population in the same geographic area was discovered by workers of the Middle America Research Unit. The virus of VEE was not isolated from equines during the outbreak. An estimated 200 equines died during the outbreak, and very few recovered cases were encountered