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The aim of this study was to evaluate the effect of transcutaneous neuromuscular electrical stimulation (NMES) on muscle strength in septic patients requiring mechanical ventilation (MV). Sixteen septic patients requiring MV and having 1 or more organ failure other than respiratory dysfunction were enrolled within 48 hours from admission to the intensive care unit. Neuromuscular electrical stimulation was administered twice a day on brachial biceps and vastus medialis (quadriceps) of 1 side of the body until MV withdrawal. Blinded investigators measured arm and thigh circumferences, biceps thickness by ultrasonography, and muscle strength after awakening with Medical Research Council scale. Two patients died before strength evaluation and were excluded from the analysis. Neuromuscular electrical stimulation was applied for 13 days (interquartile range, 7-30 days). Biceps (P = .005) and quadriceps (P = .034) strengths were significantly higher on the stimulated side at the last day of NMES. Improvement was mainly observed in more severe and weaker patients. Circumference of the nonstimulated arm decreased at the last day of NMES (P = .015), whereas no other significant differences in limb circumferences or biceps thickness were observed. Neuromuscular electrical stimulation was associated with an increase in strength of the stimulated muscle in septic patients requiring MV. Neuromuscular electrical stimulation may be useful to prevent muscle weakness in this population.

Objectives The aim of this study is to explore the effectiveness and safety of high dose dexamethasone treatment for Acute Respiratory Distress Syndrome secondary to SARS-Cov-2 pneumonia. Trial design Multicentre, randomized clinical trial, controlled, open label, parallel group, to evaluate the effectiveness and safety of high dose dexamethasone in adult patients with confirmed COVID-19, with Acute Respiratory Distress Syndrome. Participants We will include patients with SARS-Cov-2 pneumonia who develop acute respiratory distress syndrome, in several intensive care units (ICU) in Buenos Aires, Argentina (CEMIC, Clinica Bazterrica, Sanatorio Sagrado Corazon) Inclusion criteria: Men and women, age ≥ 18 years old. Confirmed diagnosis of SARS-CoV-2 infection, by RT-PCR. Diagnosis of Acute Respiratory Distress Syndrome (hypoxemic respiratory failure not explained by cardiac disease + PaO 2 /FiO 2 ratio < 300 with a Positive End-Expiratory Pressure ≥ 5 cm H 2 O + bilateral pulmonary infiltrates) Length of mechanical ventilation of at least 72 hours Informed consent (next of kin / legal guardian) Exclusion criteria: Pregnant or breast-feeding women. Terminal disease (advanced cancer; under palliative care; cardiovascular, respiratory, or renal disease with a life expectancy less ≤ 1 year). Therapeutic limitation (advance directives or do not resuscitate order) Severe immunosuppression (HIV infection, long-term use of immunosuppressive agents, active cancer). Patients under chronic treatment with glucocorticoids for other diseases (≥ 8 mg prednisone, or equivalent) Participation in another randomized clinical trial. Intervention and comparator Eligible patients will be randomized to receive standard ICU patient care (group 1) or standard ICU patient care plus high dose dexamethasone (group 2). Group 1: dexamethasone up to 6 mg/24 hours for up to 10 days + ventilatory, hemodynamic, nutritional, and antimicrobial support according to international guidelines. Group 2: dexamethasone 16 mg/24 hours for 5 days followed by dexamethasone 8 mg/24 hours for 5 days + ventilatory, hemodynamic, nutritional, and antimicrobial support according to international guidelines. Main outcome The main result is ventilator-free days at 28 days (Days without ventilator support in the first 28 days following randomization). Secondary outcomes are 28-days and 90-days mortality, frequency of nosocomial infections in the first 28 days after randomization, Sequential Organ Failure Assessment (SOFA) score variation and prone position in the first 10-days, viral shedding 28-days after randomization, and delirium and muscle weakness at ICU discharge. Randomisation Treatment will be assigned according to site stratified randomization by permuted random blocks sequence 1:1 generated with a table in R language concealed in a randomization tool in REDCap (Research Electronic Data CAPture) platform. Blinding (masking) This is an open trial, so no masking of treatment assignment will be used. Numbers to be randomised (sample size) Assuming a 3 days difference in ventilator-free days between treatment groups, with a mean of 9 days, and a standard deviation of 9 days; the necessary sample size would be 284 subjects (142 per group), with a power of 80% and a two-tailed alpha error of 0.05. Trial Status The protocol with code 1264, version 3.0 on date: May 13, 2020 is approved by the local Ethics Committee. The trial is in the recruitment phase. Recruitment began May 22, 2020 and is anticipated to be complete by the end of December 2021. Trial registration The trial was registered under the title “Dexamethasone for COVID-19 Related ARDS: a Multicenter, Randomized Clinical Trial” with ClinicalTrials number NCT04395105, https://clinicaltrials.gov/ct2/show/NCT04395105 , registered on 20 May 2020. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1 ). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

The purpose of the study was to compare gas exchange and lung mechanics between different strategies to select positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS). In 20 consecutive ARDS patients, 3 PEEP selection strategies were evaluated. One strategy was based on oxygenation using the ARDS network PEEP/fraction of inspired oxygen (Fio2) table; and two were based on lung mechanics, either PEEP titrated to reach a plateau pressure of 28 to 30 cm H2O as in the ExPress trial or best respiratory compliance method during a derecruitment maneuver. Gas exchange, airway pressures, stress index (SI), and end-expiratory transpulmonary pressure (Ptpe) and end-inspiratory transpulmonary pressure (Ptpi) values were assessed. Data are expressed as median (interquartile range [IQR]). Lower total PEEP levels were observed with the use of the PEEP/Fio2 table (8.7 [6-10] cm H2O); intermediate PEEP levels, with the Best Compliance approach (13.0 [10.2-13.8] cm H2O); and higher PEEP levels, with the ExPress strategy (16.5 [15.0-18.5] cm H2O) (P < .01). Pao2/Fio2 ratio was lower with the PEEP/Fio2 table. Oxygenation with Best Compliance approach and ExPress strategy was not different with lower plateau pressure in the former (23 [20-25] vs 30 [29-30] cm H2O; P < .01). Paco2 was slightly higher with the ExPress method than the others 2 strategies. Negative Ptpe was observed in 35% of the patients with the PEEP/Fio2 table, in 15% applying the Best Compliance, and in only 1 case with the ExPress method. Higher SI and Ptpi, with lower lung compliance, were obtained with ExPress strategy. Using a best respiratory compliance approach resulted in better oxygenation levels without risk of overdistension according to SI and Ptpi, achieving a mild risk of lung collapse according to Ptpe. Impact of 3 strategies of PEEP selection in 20 ARDS patients on Ptpe (C), Ptpi (B), and SI (A). In 35% of the patients, PEEP selection according to ARDS network PEEP/Fio2 table induced negative Ptpe, suggesting alveolar collapse. On the other hand, the ExPress strategy (PEEP level to reach plateau pressure of 28-30 cm H2O) induced SI greater than or equal to 1.1 in 30% of the patients, suggesting alveolar overdistension. The Best Compliance approach (PEEP selection in the decremental PEEP curve after a recruitment maneuver) did not induce increase of the SI, and there was mild risk of lung collapse (only 3 patients had negative Ptpe). [Display omitted]

To the Editor: Although Talmor et al. (Nov. 13 issue) 1 observed an improvement in oxygenation in patients with acute lung injury that was managed by estimating transpulmonary pressure, there was an extrapulmonary (i.e., abdominal) cause of the acute respiratory distress syndrome (ARDS) in a high proportion of patients in their study (39%). To our knowledge, this feature has not been observed in any previously published randomized studies involving patients with ARDS. 2 – 4 The respiratory mechanics in pulmonary ARDS and extrapulmonary ARDS are different. 5 The elastance of the lung is higher in pulmonary ARDS, and the elastance of the chest wall . . .

Introduction/BackgroundOver the last years, minimally invasive surgery was advancing as the preferred approach in many cancer centres for the treatment of early-stage cervical cancer, as it offers advantages against open abdominal surgery in in-hospital and short-term outcomes. However, results from a recent randomized trial suggested lower rates of disease-free survival in the follow-up of patients operated with the minimally invasive approach.The aim of our study was to compare, in our tertiary centre, the rate of disease-free survival at 3.5 years between both surgical techniques.MethodologyRetrospective single-centre study including patients who underwent total laparoscopic radical hysterectomy (LRH) or open radical hysterectomy (ORH) due to early-stage cervical cancer (IA1-IIA1) between 2005–2017.ResultsA total of 63 patients were included (39 LRH and 24 ORH). Baseline characteristics are described in table 1. Mean age was similar in both groups 47.5 ±13.3 vs. 48.3 ±12.6 (p=0.8). The prevalence of high-risk HPV was similar in both groups with a higher rate of prior conization in the LRH group 22 (56.4%) vs. 5 (20.8%) (p=0.006). There were no significant differences between both groups in terms of parametrial involvement, histologic subtypes and stage of disease. In almost half of the patients in the LRH group the uterine mobilizer was used during surgery, with 1 case of uterine perforation. There were no significant differences at 3.5 years follow-up in terms of recurrences [LRH 4 (10.3%) vs. ORH 2 (8.3%) (p=0.8)] and overall death (being secondary to their oncological process in all cases), 2 (5.1%) vs. 1 (4.2%) (p=0.87). Kaplan-Meier analysis revealed a similar rate of disease-free survival at 3.5 years in both groups: LRH 87.2% vs. 87.5% (p=0.95) (figure 1). The rate of disease-free survival in patients in which the uterine mobilizer was used was 100%.We hypothesized that, in experienced hands and with appropriate patient selection, a minimally invasive approach via laparoscopic surgery can be as effective as conventional open surgery. However, the results must be interpreted with caution given the potential risk of bias derived from the relatively small sample size and the single-centre, retrospective nature of the study.Abstract 154 Figure 1Abstract 154 Table 1ConclusionIn the present study, we did not find statistically significant differences between LRH and ORH for the treatment of early-stage cervical cancer in terms of disease-free survival and overall survival.DisclosuresNothing to disclosure.

Non-technical summaryGlobal sustainability challenges and their impact on society have been well-documented in recent years, such as more intense extreme weather events, environmental degradation, as well as ecosystem and biodiversity loss. These challenges require a united effort of scientists from multiple disciplines with stakeholders, including government, non-government organizations, corporate industry, and members of the general public, with the aim to generate integrated knowledge with real-world applicability. Yet, there continues to be challenges for these types of collaboration. In this commentary, we describe processes of collective unlearning that serve to decenter academia in collaborations leading to a more equitable positioning of practitioners engaged in collaborative global sustainability research.

Global sustainability challenges and their impact on society have been well-documented in recent years, such as more intense extreme weather events, environmental degradation, as well as ecosystem and biodiversity loss. These challenges require a united effort of scientists from multiple disciplines with stakeholders, including government, non-government organizations, corporate industry, and members of the general public, with the aim to generate integrated knowledge with real-world applicability. Yet, there continues to be challenges for these types of collaboration. In this commentary, we describe processes of collective un learning that serve to de center academia in collaborations leading to a more equitable positioning of practitioners engaged in collaborative global sustainability research. Increasing attention to transdisciplinary (TD) sustainability science has shaped the joint work of researchers and practitioners currently addressing pressing global sustainability problems. In this short commentary, we describe and discuss an international TD collaboration and draw upon the authors’ experiences after 5 years of ongoing collaborative work in the realm of global sustainability research in the Americas. Our collective experience illustrates that processes of un learning serve to de center academia in TD collaborations leading to a more equitable positioning of practitioners engaged in TD research. Participating in social un learning practices that aim to deconstruct and disrupt institutionalized scientific norms and challenge entrenched institutional structures may hold the key to mobilizing TD research for solution-oriented placed-based social-ecological research.