BACKGROUND Survival of patients with acute lung injury or the acute respiratory distress syndrome (ARDS) has been improved by ventilation with small tidal volumes and the use of positive end-expiratory pressure (PEEP); however, the optimal level of PEEP has been difficult to determine. In this pilot study, we estimated transpulmonary pressure with the use of esophageal balloon catheters. We reasoned that the use of pleural-pressure measurements, despite the technical limitations to the accuracy of such measurements, would enable us to find a PEEP value that could maintain oxygenation while preventing lung injury due to repeated alveolar collapse or overdistention. METHODS We randomly assigned patients with acute lung injury or ARDS to undergo mechanical ventilation with PEEP adjusted according to measurements of esophageal pressure (the esophageal-pressure–guided group) or according to the Acute Respiratory Distress Syndrome Network standard-of-care recommendations (the control group). The primary end point was improvement in oxygenation. The secondary end points included respiratory-system compliance and patient outcomes. RESULTS The study reached its stopping criterion and was terminated after 61 patients had been enrolled. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at 72 hours was 88 mm Hg higher in the esophageal-pressure–guided group than in the control group (95% confidence interval, 78.1 to 98.3; P = 0.002). This effect was persistent over the entire follow-up time (at 24, 48, and 72 hours; P = 0.001 by repeated-measures analysis of variance). Respiratory-system compliance was also significantly better at 24, 48, and 72 hours in the esophageal-pressure–guided group (P = 0.01 by repeated-measures analysis of variance). CONCLUSIONS As compared with the current standard of care, a ventilator strategy using esophageal pressures to estimate the transpulmonary pressure significantly improves oxygenation and compliance. Multicenter clinical trials are needed to determine whether this approach should be widely adopted. (ClinicalTrials.gov number, NCT00127491.)

Background-Statins have anti-inflammatory properties that are independent of their lipid-lowering abilities. We hypothesized that statin therapy before the onset of an acute bacterial infection may have a protective effect against severe sepsis.

Increasing levels of pharmacologic acid suppression are associated with increased risks of nosocomial C difficile infection. This evidence of a dose-response effect provides further support for the potentially causal nature of iatrogenic acid suppression in the development of nosocomial C difficile infection.

ARDS seems to be a common and fatal syndrome in a hospital in Rwanda, with few patients admitted to an ICU. The Berlin definition is likely to underestimate the impact of ARDS in low-income countries, where resources to meet the definition requirements are lacking. Although the Kigali modification requires validation before widespread use, we hope this study stimulates further work in refining an ARDS definition that can be consistently used in all settings.

Importance: Adjusting positive end-expiratory pressure (PEEP) to offset pleural pressure might attenuate lung injury and improve patient outcomes in acute respiratory distress syndrome (ARDS). Objective: To determine whether PEEP titration guided by esophageal pressure (PES), an estimate of pleural pressure, was more effective than empiric high PEEP-FiO2 in moderate-to-severe ARDS. Design, Setting, and Participants: Phase-II randomized clinical trial conducted at 14 hospitals in North America. Two hundred mechanically ventilated patients aged ≥ 16 years with moderate-to-severe ARDS (PaO2:FiO2 ≤ 200) were enrolled between October 31, 2012 and September 14, 2017; long-term follow-up completed July 30, 2018. Interventions: Participants were randomized to PES-guided PEEP (n = 102) or empiric high PEEP-FiO2 (n = 98). All participants received low tidal volumes. Main Outcomes and Measures: The primary outcome was a ranked composite score incorporating death and days free from mechanical ventilation among survivors through day 28. Pre-specified secondary outcomes included 28-day mortality, days free from mechanical ventilation among survivors, and need for rescue therapy. Results: Two hundred patients were enrolled (mean [SD] age 56 [16] years; 46% female) and completed 28-day follow-up. The primary composite endpoint was not significantly different between treatment groups (probability of more favorable outcome with PES-guided PEEP: 49.6% [95% CI 41.7% to 57.5%]; p = 0.92). At 28 days, 33 of 102 patients (32.4%) assigned to PES-guided PEEP and 33 of 98 patients (30.6%) assigned to empiric PEEP-FiO2 died (risk difference 1.7% [95% CI −11.1% to 14.6%]; p = 0.88). Days free from mechanical among survivors was not significantly different (22 [15-24] vs. 21 [16.5-24] days; median difference 0 [95% CI −1 to 2] days; p = 0.85). Patients assigned to PES-guided PEEP were significantly less likely to receive rescue therapy (4/102 [3.9%] vs. 12/98 [12.2%]; risk difference −8.3% [95% CI −15.8% to −0.8%]; p = 0.04). None of the seven other pre-specified secondary clinical endpoints were significantly different. Adverse events included gross barotrauma, which occurred in six patients with PES-guided PEEP and five patients with empiric PEEP-FiO2. Conclusions and Relevance: Among patients with moderate-to-severe ARDS, PES-guided PEEP, compared to empiric high PEEP-FiO2, resulted in no significant difference in death and days free from mechanical ventilation. These findings do not support PES-guided PEEP titration in ARDS. Trial Registration: ClinicalTrials.gov identifier

Purpose The effect of advanced age per se versus severity of chronic and acute diseases on the short- and long-term survival of older patients admitted to the intensive care unit (ICU) remains unclear. Methods Intensive care unit admissions to the surgical ICU and medical ICU of patients older than 65 years were analyzed. Patients were divided into three age groups: 65–74, 75–84, and 85 and above. The primary endpoints were 28-day and 1-year mortality. Results The analysis focused on 7,265 patients above the age of 65, representing 45.7 % of the total ICU population. From the first to third age group there was increased prevalence of heart failure (25.9–40.3 %), cardiac arrhythmia (24.6–43.5 %), and valvular heart disease (7.5–15.8 %). There was reduced prevalence of diabetes complications (7.5–2.4 %), alcohol abuse (4.1–0.6 %), chronic obstructive pulmonary disease (COPD) (24.4–17.4 %), and liver failure (5.0–1.0 %). Logistic regression analysis adjusted for gender, sequential organ failure assessment, do not resuscitate, and Elixhauser score found that patients from the second and third age group had odds ratios of 1.38 [95 % confidence interval (CI) 1.19–1.59] and 1.53 (95 % CI 1.29–1.81) for 28-day mortality as compared with the first age group. Cox regression analysis for 1-year mortality in all populations and in 28-day survivors showed the same trend. Conclusions The proportion of elderly patients from the total ICU population is high. With advancing age, the proportion of various preexisting comorbidities and the primary reason for ICU admission change. Advanced age should be regarded as a significant independent risk factor for mortality, especially for ICU patients older than 75.

OBJECTIVE-The study evaluates lipids profile changes during gestation in pregnancies with and without preeclampsia and/or gestational diabetes.STUDY DESIGN-Lipid profiles were assessed between year prior and after pregnancy in 9911 women without cardiovascular comorbidities.RESULTS-Lipid levels during gestation varied substantially with a nadir following conception and a peak at delivery. Compared to preconception levels total cholesterol levels increased from 164.4 mg/dL to 238.6 mg/dL and triglycerides (TGs) from 92.6 mg/dL to 238.4 mg/dL. The composite endpoint (gestational diabetes mellitus or preeclampsia) occurred in 1209 women (12.2%). Its prevalence increased with levels of TG-from 7.2% in the group with low TGs (<25th percentile adjusted for the gestational month) to 19.8% in the group with high TGs (>75th percentile), but was not associated with high-density lipoprotein levels. In multivariate analysis higher TGs levels, but not low high-density lipoprotein, were associated with the primary endpoint.CONCLUSION-Lipid levels change substantially during gestation. Abnormal levels of TGs are associated with pregnancy complications. Keywords adverse outcomes; gestation; lipidsA number of diseases affecting the cardiovascular system emerge during pregnancy. Gestational diabetes mellitus is a risk factor for the development of type 2 diabetes and gestational hypertension is associated with an elevated risk for developing subsequent systemic hypertension. 1-3 Gestational diabetes and hypertension can contribute to maternal and fetal risk of developing peri-and postpartum complications. 4,5 Reprints: Victor Novack, MD, PhD,

Delays in surgery for hip fracture are associated with significant increase in short-term and 1-year mortality. Variation among the hospitals was substantial and calls for prompt quality improvement actions.